Operational Program

Grant Year Period Funded (direct Costs)

ALBANY
,AI bany

REGIONAL MEDICAI PROGRAMS SERVICII:

  (A Privileged Communication)

SUMMARY OF ANNIVeRSARY REVIEW AND AWARD GRANT APPLICATION

REGIONAL MEDICAI, PROGRAM EM 00004 8/71
Medical College of

July 1971 Review Committee

Union University

47 New Scotland Avenue
Albany, New York 12208

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

This Region presently is funded for its 04 operational year at a direct
cost figure of $806,001 (a twelve percent reduction from its original
04 year award of $915,910).  Although the precise indirect costs attached
to the $806,001 award are not yet known, past experience with this Region
indicates they will be in the neighborhood of $283,000, representing an
overall indirect cost rate of approximately 35 percent. The current
budget period ends September 30, 1971. This Triennial Application
requests support for:

I. Renewal support for three additional years of core.

11. Continuation with committed support of four ongoing activities

for the 05 year and renewal for three of these projects for two
years thereafter (06 and 07 years).
Developmental component funding for three years.

111.

The Region requests $1,104,790 direct costs  for its fifth year of operation,
$1,171,092 for the sixth, and $1,248,198 for the seventh.
identifying the components for each of the three years is included as
pages 3 through 5 of this summary.

A breakout chart

A STAFF REVIEW OF THIS APPLICATION HAS IDENTIFIED CERTAiN AREAS OF CONCERN
IN WHICH THE SITE VISITORS, COMMITTEE, AND COUNCIL REVIEWERS MAY BE
INTERESTED. THESE CONCERNS WILL BE OUTLINED IN A MEMORANDUM ATTACHED
TO THIS SUMMARY.

FWING HISTORY

Planning Phase

Grant Year

01

Period. Funded (direct costs)

7/66-6/67 $267,679

Future Commitment

01 4/67-6168
02 7168-9/69
03 10/69-9/70
04 10170-9/7 1
05 10/71-9/72

$1,040,458
1,237,456
1,177,809
. 806,001*

--

*Reduced from original award of $915,910 due to IMPS fibcal stringencies.

PROJECT

Core (including community info.
coordinators)

Developmental component

Two-way Radio

Postgraduate Instruction

Development Panel

/

Community Hospital Learning

Centers

CCU Training - Albany

CCU Training - Camunity

Hospitals

Intensive Care Unit

Schenectady Cancer Coordinator

Develop Community Leadership

TOTAL DIRECT COSTS

*original 04 year aw
However, the new a1

ALBANY REGIONAL IBDICAL PROGRAM

Compnrision of 01-04 year
funding & 05-07 year request.

15 mo.

01

i 509,691

--

144 , 104

102 , 608

75,833

' 125,240

55,410

25,472

2,100


--

1, 040,458
rd has bee
>cation an

- 15 mo.
   02

783 , 933

--

x,

124', 68 9

69,932

76 , 665

103,850

39,576

33 , 455

5 , 356

--

1 , 237,456
reduced t
ig project

FUNDED

03

$ 712,094

--

143 , 975

80,745

111,082

71,746

36 , 930

7 , 207

5,000

9,030

1,177,809
$806 , 001
is not ye

04

$ 687,159

--

142,97,5

--

--

71,746

--

--

5,000

9,030

915 , 91m

to RMPS

nom.

05

$ 791,460

85 , 000

154,030

--

--.

60,270

--

--

  5,000

  9 , 030

1 , 104,790

;cal constre

REQUESTED

06

$ 850,610

85,000

163,171

--

--

62,981

--

--

--

  9,330

1,171,092

tts.

,.

REGION Albany RM 00004 8/71
CYCLE July/August 1971

I OD

(Support Codes) (5) (2) (3)

CONT. WITHIN CONT. BEYOND APPR. ROT

IDENTI F ICAT I OX OF        AF'PR. PERIOD APPR. PERIOD PREV.
GOMPOhTNT             OF SUPPORT OF SUPPORT FUNDED

#DO0 - Develaomental **

Core 791.460

#1A - Communication . * 12,370

FIB - Comunication .*14l, 660

Two-way Bad io

Two-way Radio

Coronary Care Trg.


Csordinator tor

Development ot

#6 - & DeToastration Pq. * 60,270 --

   - Cancer         I 5.000

#16 - Corn. Leadershio       9.030

1
1 1

I 1

I 1

- -

TCThL 228,330 791,460

* 05 and 07 Year B&ond.Approved Beriod of Support

* Request amended to 3 years per telephone conversation by

(1 1

NEW, NOT 1st YEAR
PREV . INDIRECT TOTAL
        DIRECT
APPROVED COSTS COSTS

85.000 85.000 -0- 85,000

    791,460 322,185 1 , 1 13,645

     12,370 4,902 17,272

    141,660 25,779 . 167,439

60,270    14,441       74,721

5.000      1.445         b.445

9.030        723        9,753

1 1'

I

;.

85,000 1,104,790 369,473 1,474,265

-t--

E. Faatz and the Region 5/7/71. GEB-5/7

I
w
I

'1

CCK1WL;ATION WITHIN kONTINUATION BEYOhD MPROVED, NOT   W, NOT 3rd YIEtlR
MPRO'JED PERIOD OF APPROVED PERIOD OF PREVIOUSLY      PREVIOUSLY DIRECT

FLSqED APPROVED COSTS

I

IDhTIFCATIOK CP
c OVIP OfiE!X SLTPORT SUPPORT

TOTAL f
DIRECT COSTS 1

ALLYEM i

-

85,000

*DO0 - Developmentzl

85,C33 I -255,000 i

' Core - 914.512

$lh - L4.388

.*

1 924,512 2,556,582

14,388 40,097 1

158,730

#lB -

16 65. ,-9 1 2

--

51 3

#16 9,656

I

lbS.730 1 450,222 1.

b5,912     ia9.163 1


-i       5,000 '

I

I

I

9,656

7'

!

-

1

85,000

TEAL 9, b>b 1,153,542

1

I

f


r

1

I

1,248,198 3,524,080

__ .I ,

Albany PW -6- RM 00004 8/71

Geography nn+..hwoy.raphy

Albany Kegiona! Medical Program is composed of 24 counties in eastern

and northeastern New York, southwestern Vermont, and western Massachusetts.
Three of the counties in northern New York and the two in southern Vermont
have been deuignattd as an interface area for the Albany and Northern
New England Ms, The westernmost county of Massachusetts (Berkshire)
has a traditional socioeconomic and medical relationship to Albany.
(The AREip 6 Tri-Stbte RMP overlap in this county).
divid.ed into six scbunits.  The two maps which follow on pp.4 and 5
show (1) a geograptiic delineation of the Albany Regional Medical Program
and its subdivisions, and (2) the geographic relationship of the ARMP
to the other five FHs in New York State.

The Region has been

The approximate population served by this Region is two million,  and the
area contains one medical school (Albany Medical College of Union
University), 26 schools of nursing, eight schools of technology, and 55
non-federal hospitals with 7,461 beds. In addition, the Region has
approximately 2,302 active physicians and 8,806 active nurses.

His tory

The Albany Regions:. Medical Program - one of the first four operational
Regions - received ita initial planning grant in July 1.966.
crganization, the Albany Medical College of Union University, had a
particular strength in that it had one of the country's most extensive
postgraduate educa'zion programs 2nd had developed over a ten-year period
the two-way radio as an education medium.  For this reason, there was
initial (and untesglved) discussion among Committee and Council reviewers
relative to the degree to which RMPS should support ongoing programs.
When the initial o2erational grant application was submitted less than a
year later, the AR3P's heavy emphasis on continuing education was considered
by the reviewers to serve as a test of the c'apacity of continuing education
to provide the meas for developing broader programs and expanding into
other areas. The first operational award included funds for core activities,
roamunity information coordinators (since incorporated into core), two-way
radio netxork expaision and program production, postgraduate instruction
development panel, comunity hospital learning centers, coronary care
training and demonstration at the Albany Medical Center and two comunity
hospitals, an inteisive cardiac care unit at a small cornunity hospital,
and the part-time services of a cancer coordinator in the Schenectady area.

The grantee

In the Spring of 1369 when the entire program was up for renewal,  a site
team visited Albany because of Committee's and Council's qualms about:
the ubiquity of th? influence of Dr. Woolsey and the Department of
Postgraduate Education in the regional planning, review, and decision-
caking process;  th? small number of new activities that had been developed
outside of Albany itself; the continued program concentration on continuing
education; and the apparent lack of receptivity to (or failure to stimulate)
ideas from outside the Albany Medical Center.
concerns to be valCd and delivered an appropriate message to the Region.

The site team found the

I
(x,
I

Albany RMF'

RM 00004 8/71

The subsequent Committee/Council, in view of the site report, recommended
various periods of funding for the Albany activities. For instance, a
new program for the development of community leadership looked very
promising in terms of subregionalization and was recommended for five
years' support. On the other hand, some activities, the advantages of
which were doubtful, were approved for only one year's  support.
of funding for core activities was provided.

Two years

In September 1970, when staff reviewed this Region's application for 04 year

* continuation, the following observations were made:

1. Although the ARMP did provide $60,000 during its 03 year toward the
planning of the North End Community Health Center in a ghetto area of
Albany, that was the only evident contribution to one of the Region's new
stated goals of correcting quantitative deficiencies in the health manpower
pool and providing health services in medically-deprived areas. The
predominant emphasis of the program remained continuing education emanating
from Albany. The large amounts of money that continued to support activities
such as the two-way radio project, at the expense of the community develop-
ment program, attested to the emphasis placed on continuing education.
However, it was observed that the 4ast three projects the Region had
submitted were not exclusively in the Albany-based continuing education
mold, but each had been rejected by Committee/Council. A proposal' for the
establishment of a regional cancer program received a recommendation of
disapproval at the national level, while proposals for a community stroke
program and a regional library service project were returned for revision.

2. The influence of Dr. Woolsey, the Albany Medical College, and the
Department of Postgraduate Education on the planning, review, and decision-
making process remained a problem. Eleven of the 27 RAG members were from
the AMC, and of these eleven, seven were on the ARMP core staff. Although
Dr. Woolsey, after the May 1969 site visit, relinquished the chairmanships
of both the Preliminary Planning and Review Group and the Planning and
Review Group (subcommittees of the RAG) he still was a member of both.
Both groups, too, were almost exclusj-vLly Albany Medical College and core
staff dominated.

0

3. Subsequent to the April 1969 site visit, the Review Committee and
Council were furnished with an assurance by Dean Wiggers of attempts to
increase consumer, and particularly minority, represcntat ion on the RAG.
It had not increased. The continuation application stated that efforts
to get minority and consumer representatives met with some difficulty
because the "more talented individuals" from these groups were in great
demand.
the Commissioner of Education, and a representative from the Department of
Corrections.

The consumer membership on the RAG consisted of a civic leader,

4. ARMP seemed not yet to have addressed the necessity of the eventual
phaseout of RMP support for ongoing activities and the concomitant turnover

of projects.
to assume support in perpetuity.

The project progress reports and continuation requests seemed

0

-10-

Albany RHP RM 00004 8/71

The 04 operational year of this Region sees greatly diminished project
activity from the time of the 1969 site visit-support for the intensive
cardiac care unit baa been terminated by the Region, coronary care training
and demonstration activities at the two community hospitals received
renewal approval from August 1970 Council but Were not fpnded, and renewal
requests for the community hospital learning centers '-a the postgraduate
instruction development panels were reviewed by November 1970 Council
which recommended no additional funding.
04 year award of $806,001 is not yet known since the Region only recently
received notice of its twelve percent reduction.
relative allocalion among ongolng components, however, based on the
original 04 year award the money was distributed as follows:

The allocation of the current

To give an idea of the

Activity Percent of total award

Core 75.1%

#l Two-way radio * 15.6%

#6 CCU Training-Albany Hedical College

7.8%

P13 Cancer Coordinator-Schenectady

#16 Community Leadership

Regional Goals and Objectives:

The application states that until the

AW program has been in the field of

.5%

1.0%

present the main thrust of the
continuing education and training

I

in order- to keep physicians and allied health professionals abreast of
the latest advances in diagnosis and treatment.
addition, a more l!-mited effort in the development of health manpower.
Although it is expected that education'and manpower development will
continue to receive emphasis, the program intends to become involved as
well in efforts to improve health care delivery and to correct the
maldistribution of health manpower.
the Bpx; has approved two overall and long-range program goals and seven
shorter-range objectives, as follows:

There has been, in

Reflective of the new program direction,

Goals


I.

-

   To promote adinfluence regional cooperative arrangements for health
services in a manner which will permit the best in modern health care to be'
available to all.

II.

To assure the quality, quantity and effectiveness of professional

and allied health nanpower.

-11.-

1. To explore and encourage innovative methods of health care

delivery with particular attention to improving delivery in medically-
deprived urban and rural communities.

2. To mobilize consumer-provider participation in the identification

and solution of local and regional health problems.

4

   3.
utilization.

To recruit health manpower and improve its distribution and

4. To introduce methods to relieve overburdened health professionals.

5. To engage in the education and training of health personnel with

particular attention to continuing education and to the training of
personnel to fill recognized gaps in critical areas.

6. To promote public education in health matters.

7. To 'further the process of regional cooperative arrangements.

In addition, there has been formulated a list of ten itenis to be considered
in determining priorities within the program.

These appcar on page 21

of the application.

Regional Advisory Group

The Regional Advisory Group presently is composed of 37 members--32
regular and five ex efficio.  Of these 37 members, eleven are from the
Albany Medical College and 24 are from the Albany vicinity.  The Equal
Employment Opportunity form in the application indicates that four of the
RAG representatives are black. The current RAG composition reflects a
greater diversification of membership from the time of the last staff
review through the addition of minority members, the percentage reduction
of Albany Medical Center and core staff members,  and the increase in
non-health-oriented representatives.

The RAG meets quarterly.

The Planning and Review Group, which had been almost exc;usively Albany
Medical Center and core staff doniinated, has been abolished and supplanted
by a 13-member (ten regular and three officio) Executive Committee of
the RAG. The regular Executive Committee membership includes two Albany
Medcal College representatives. Four of the ten are from outside Albany
itself. The application does not indicate who the three ex officio members
Eire. The Executive Committee meets monthly and reports to the full RAG
quarterly.

Each project proposal submitted to the Albany Regional ML:dical Program is
processed through the review mechanism of the Executive Committee which,

-

with the advice of the appropriate Consulting Group (there are 13) assigns
a priority rating, Apparently, there are certain specified limits within

e

-12-

Albany RMP RM 00004 8/71

which the Executive Committee can act without RAG concurrence, but the
rest of its approvals miist be referred to the full RAG.
clear in the application whether projects rejected by the Executive
Committee routinely are seen by the Regional Advisory Group.

It is not made

. ..i;

An adjunct to the Regional Advisory Group is the subregional structure
developed through the Community Leadership project in the three New York
counties of the Northern Interface Division.. It is hoped that this 25-member
local advisory group and its three task forces will provide the ARMP
iJith the necessary experience or further subregionalization through the
formation of local advisory groups in other areas.

'

b

APPLICATION COMPONWTS

1. Core Activities 05 yr request

Three year renewal of core activities is requested.  The application
states that the atrength of the ARMP resides in core staff. Core is
involved in the operation of all ongoing activities and performs all
project evaluation. In addition, the core payroll contains many persons
who would usually be included in project budgets;for instance, many of the
technical personnel associated with the two-way radio system,  the
personnel from the Community Leadership Program (project &6), and the
project director for the CCU training program. There are 28 professional
staff, although many (including the Coordinator) are listed at less than
full-time.  Of the 28, the Equal Employment Opportcnity form shows that
none are black and only one is a woman. The most significant accomplishments
of core staff over the past two years are explained on pages 37-39 of the
application, and the most important areas for future core activities are
described on pages 40-41. 4'

$791,460

In terms of planning and feasibility studies, some of the major core-
supported activities during the coming triennium will be in the area of:

Continuing education for dieticians, medical technologists,  x-ray
technicians, pharmacists, and medical librarians -- many of these
studies involving the two-way radio network

Continuation of the physicians consulting panel (previously a project
activity for which renewal support was not recommended by the National
Advisory Council) without honorarkand at a fraction of its previous
cost

Planning for a physicians assistant program,

Creation of a health maintenance system for physicians offices

Determination of need and practicability of a day rehabilitation center

Feasibility of health care information centers to serve needs of
general public

RA 00004 8/71,

0

Planning for a regional kidney program

Feasibility of a pap smear program in community hospitals

Studying for training of physician's office personnel--physician extenders

Study in Rh inrmunization

Traveling Rehabilitation teams  for education and service

Training nurses or service in hospital emergency rooms

Treatment guidance for physicians based on tissue diagnosis

Study of two-way radio conference utilization

The ar.proximate cost next year for planning and'feasibilicy studies will
be $133,000 as compared to the approximately $62,000 spent for such activities
in the 04 year.

Core-supported and operated central regional services which will be
continued or instituted during the next triennium are:

Con t inued

Continuing Education Registration - record keeping activity which
provides a data base for planning and research in continuing
education

Health Data Inventory and Resources

Postgraduate Program Service - assistance in plannin,:, production,

and evaluation of continuing education programs within the Region

Registry of Continuing Education Programs for Physical Therapists

Registry of Physical Therapists

Selective Mailing System


New

Educational Resource Service - development of a cooperative

library network

Prescription Education Service - patient education aimed initially at:
medically-deprived persons

Public Information Resource Service

e

,

-

During the 04 year $33,400 was 01 located to ccntrnl regf(;nnl r+er-vlces. Uurinp:
ihc 05 year approximately $87,000 if? budgeted for lhen~  iunctions.

0

-14-

Albany RMP

RM 00004 8/71

IX. -On_eoing Activities

Continuation with committed support of four ongoing activities is requested
for the 05 year ant: renewal for three of these projects for two years
thereafter (06 and 07 years).  The application states that with regard to
the question of phasing out DfPS support for ongoing activities, there is
RO other regional agency to absorb the essential activities of continuing
current activities cannot be phased out without doing serious damage to
ARMY'S image as the regional agency most concerned with keeping health
personnel abreast of modern developments.  Since all projects have been
under core staff scpervision, consideration will be given to terminating
them as individual projects and incorporating the expense in an enlarged
core staff budget.

I

education which ha-Je been performed by the ARM'.

It is believed that

3

Project #1 - TWQ-W~Y Radio Communication System

This project initially was funded in April 1967.
radio communication system will be of assistance in health manpower
recruiting efforts, providing information to the public relative to
health and welfare services available to them, helping in the training
of new types of cormnunity health aides, and assisting in programs designed
to upgrade various types of health personnel.

05 yr. request

$154,030

The two-way

The application states that:

At this point in time, it is felt strongly that community
hospitals would not accept total financial responsibility for
the support of this project.
however, a calculated plan for gradual shifting of responsibility
for funding will be impl6mented by ARMP core staff.
that this process will take at least three .sore years.

During the proposed triennium,

It Is felt

Project #1 is separated in two parts:

#lA - This portion of the program is concerned with the expansion of the
network and the installation and maintenance of the technical facilities
used in the 8yStem.
yarticipatfon in t!ie radio conferences.
and maintaintng twJD-way as well as receive-only installations and initiate
an adult educatbn network.

Sixty hospitals now are equipped for full two-way

The plan is to continue activating

#I13 - This portion o the program deals with the actual production and
presentation of ra3fo conferences.
physical therapints, medical technologists, x-ray technicians, dieticians,
dentists and phari~acists, among others.

Conferences are planned for nurses,

06 year - $163,171

07 year - $173,118

-15-

Albany RMP RM 30004 8/71

Project #6 - Albany Medical Center Coronary Care Training

This project initially was funded in April 1967. Since $60,270

and Demonstration Programs 05 yr. request

0

February 1968, nineteen courses have been provided to 190 nurses
from 29 hospitals, and during 1970 three advanced seminars in teaching
coronary care were conducted for 28 nurses from 24 hospitals.  These
latter nurses have organized nine subregional training programs. In
addition, a demonstration training program for practical nurses was
completed. During the coming triennium, planned courses will accommodate
150 nurses, and subregional activities will involve the participation
of 600 registered and practical nurses. Individualized courses will be
designed for 36 to 54 physicians.  It is stated that "alternative sources
of support will be developed during this phasing out period." See the
attached memo of staff review for a discussion of the policy implications
for this project.

06 year - $62,981

07 year - $65,912

05 yr. request

$5,000

Project a13 - Cancer Coordinator for Schenectady Area

Only one additional year's support is requested for this project
which was initiated in January 1968. RMP support has provided the
part-time salary of a physician who has draw.loped professional and
lay cancer education programs, coordinated cancer care activities and
implemented statistical evaluation procedures regarding cancer in the
Schenectady area. It is planned that during the coming year the various ,
activities will be stabilized, strengthened, and given sufficient-
to assure their continued operation and success.
alternate sources of support will be developed to continue all the activites.

It is expected that

Project #16 - Development of Community Leadership 05 yr. request

                                   $9,030
This activitiy was favorably received by the May 1969 site team
and the subsequent Review Committee and Council. Although funds for
this program have not been awarded, the Region has supported it through
its rebudgeting authority for two years. The Director OF the activity
and the Community Information Coordinator assigned to it are on the core
staff payroll. The purpose of the project is to stirnulace community
leaders to take the initiative in the development of RMP activities of
significance to their community. Experience gained in thfs mode1 program
will be used to further subregionalize the activities of the ARMP. Since
project activity was initiated, a local advisory group and three task
forces have been formed, and there have been a number of continuing
education programs and seminars. Support is requested for three additional
years.

06 year - $9,330

07 year - $9,656

Albany RlrIp

RM 00004 8/71

111. Developmental Component 05 yr. request

nevelopmental component funding is requested for three years.
The stated objectives for use of the developmental component are:

1.  To design and conduct developmental activities which will further
the objectives of LUMP and allow an exploration of the feasibility of
specific and more extensive endeavors.

2.
and perception without the delays and other disadvantages of additional
review.

3.
relevant activities without delay, allow rapid solution of unforeseen
problems, take advantage of expertise and unforeseen opportunities as
they appear, allow participation in governmental programs withvsimilar
or complementary objectives, and assure adequate safeguards without
iinnece s s ary encumbrances .

The Executive Committee of the RAG will determine the developmental
feasibility and planning studies which will be used for developmental
component funding and the studies recommended by this group will be
presented to the RAG during July 1971 so that they will have been
specifically identified prior to approval and funding of the
developmental component.
cw the urc ase of equipment without prior specific approval of the
Executive Committee.

$85,000

.

To give the W an opportunity to utilize its knowledge, experience,

To originate an administrative process which will assure support of

The Executive Cornittee may authorize the

or to mate expenditures for less than $1,000 and not involving

06 year - $85,000

07 year - $85,000

,

RMPS /GRB/5 /12 /71

0

   Daft:
&j)ly lo
Attn of:

i subjcct:

To:

f

e,

DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE
              PUBLIC HEALTH SERVICE
HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION

4

May 24, 1971


Eileen I. Faatz
Public Health Advisor, GRB

and Identification of Is?ues for Site Visitors.

Staff Review of the Albany

Medical Program Triennial Application

Harold Margulies , M.Ddfi]
Director

Regional. Medical Programs Service

Staff nict on Tuesday, May 11, to review the Albijny application.
Discussion revolved around the following topics:

Decision-Making and Revi ew Process

-_-_

1. The composition of the Regional Advisory Group represents

a greater diversification of membership from the time of
the last staff review through the addition of four blacks,
the percentage reduction of Albany Medical Center and
core staff members, the increase in non-health-oriented
representatives, and broader geographic representation.-..

The Planning and Review Group, which had been AMC and
core staff dominated, has been abolished and replaced
by an Executive Committee of the RAG.

2.

a. The application does not explain the responsibilities
and functions of the Executive Cormittee nor the
method of appointment.  Copies of the amended By-Laws
creating this group have been requested of the Coordinator.

b. It appears that the Executive Conimittee rather than
  the entire RAG determines project priorities.
to the RTVIPS Technical Review Standards, the RAG as
a full body should rank projects.

According

c. Staff was unable to determine whether the Executive

Committee membership includes a racial minority.

3.

There are 13 categorical and disciplinary Consulting Groups
which serve in advisory capacity to the Executive Committee.
The involvcrnent of these groups is questtoned since most
have had very few meetings during the past ycnr.
eacli of the three consulting groups in the major categorical
areas of heart disease, cancer, and stroke hcld only one
niceting last year.  Where does thc leadership come from?

-

For instance,

- 2-

4.

Under the auspices of Project IC16 (Development of Community
Leadership) a subregional local advisory group has been
formed to serve and represent the interests of the three
New York counties in the Northern Interface Division.

have been generated by this group and the fate of any
such suggestions, but also its relationships with CHP.

Staff would be interested to learn not only what ideas

I

.5.

The Equal Employinent Opportunity Form indicates that of
the 128 members of the ARMP committee structure other
than the RAG, only one is black.

Both the RAG and the Executive Committee include =-officio ---
members.

6.

Do they have voting privileges?

Developmental Component

0

1.

The appiicatian includes a request for $85,000 for each
of three years for developmental Component activities.

a. `The Executive Committee will determine what planning
and feasibility studies will be supported through
developmental funding.
to be supported apparently will be made in advance
of the actual receigt of the award, thereby losing
the important flexibility the developmental component
was designed to afford.

.  b. Staff was unable to distinguish between the uses to
  which developmental funds will be put and the planning
  and feasibility studies designated for core support,

Decisions as to the activities

r*-Y,.

Core

-

1. Staffing -

a. Staff was pleased to note that the numerous clinical
speci'alists who previously had been included on the
core roster at extremely small percentages of time
are no longer listed.

'

b. There are no blacks on the core staff, and of the

29 professional and technical personnel only one is
a woffian o

c. Wi`th the exception of a physical therapist,  there
are no allied health personnel on the core staff,
although there is a vacancy for a nurse.
previous nurse coordinator died last year.

The

/

4

i

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.

. . .,

,

:. T1. ..
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.;: ..I

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, . ,. .-

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- 3-

e

d. Last year ARME' listed five vacancies on the

core staff, and this year eight vacancies are noted.
Staff wondered whether some of these vacancies
might not be built into the budget to provide
extra undesignated money for core activities.

6 2. Activities

a. A plethora of planning and feasibility studies is
proposed for support from the core budget, which
apparently is viewed as an umbrella under which
many studies relating to ongoing operational activitieg
(two-way radio, specifically) and to activities not
approved for funding at the national level (e.g.
physicians consulting panel) can be supported.

b. It was noted that last year only ten percent of the
core budget was expended for "program direction and
administration," and staff wondered what activities
were included in this calculation.

?

0

e

e. Project and program evaluation is performed by core

staff, although it is unclear exactly what is done
in this regard.  Some specific questions that have
emerged are:

1. How have the health data inventories and

similar activities been used to define total
program as well as continuing education needs?

2, How has information retrieved through registry
activities been transmitted and data interpreted
to health professionals, and what use has been
made of the data by the recipients?

I

3. Have evaluative activities for Continuing education
programs been instituted to determine whether
changes in the practices of health team members
  have resulted?

4.

Has the Region been able to document that educational
activities have been effective in the improvement
of patient care, health service delivery, diagnosis
and management of patient care problems, and/or the
management aspects of health care organizational
problems ?

e

-4-

Goals and Obj-ectives ---

1,

Tine new goals and objectives of the ARMF' are stated to
be reflective of the Region's desire to expand its program
from a concentration on continuing education activities
to include efforts in health manpower development,
improveinent of health care delivery, and correction of
the malrlis tribution of health manpower.
this triennial application proposes the initl ation of
no new operational' activities and three-year continuation
of the ?resent program, staff reviewers were unable to
find evidence of efforts to expand the program in the
new directions described in the goals. This application
presents no indication that the new regional objectives
have become operational.

However, since

Phase 6ut


  1.

-___ ----_

Although thc application mentions the qwstion of phasing
out Rp.l' support: for ongoing activities, the assumption
appears to be that some activities (specifically, the
CCU training and gwo-way radio) must 'be funded by RMP in
perpetuity.

The RMPS Natiqnal Advisory Council at its November 1970
meeting enunciated the following policy with regard to
coronary care unit training:

2.

.

Coronary care unit training projects are to disengage
Regional Medical Program funding at the end of their
current project Reriods or within a reasonable time
thereafter (no more than 18-24 months is considered
a reasonable period of time).

The followSng staff members participated in the review of the
Albany Regional Mcdfcal Program:

A. Burt Kline - Regional Development Branch
Frank Zizlavsky - Regional Development Branch
Larry Witte - Program Planning and Evaluation
Elsa Nelson - Continuing Education and Training Branch
Jerry Stolov - Kidney Disease Control Program
Paul Boone - Systems Development Branch
Eileen Faatz - Grants Review Branch

( A Privileged Communication)

SUMMARY OF REVIEW AND CONCLUSION OF
JULY 197,l REVIEW COMMITTEE

FOR CONSIDEMTION BY AUGUST 1971 ADVISORY COUNCIL

1,171,092 -0-
1,248,198 -0-

The Committee agreed with the site team that the Albany
Regional Medical Program be funded at $90(1,000 for one

time of the site visit in a year, and (2) Those areas

should give consideration, although the adoption of
s will ~ot be a requisite for continued funding.

--_________ _-_ ~ __ ~ -___ I

corning for longer than twelve
financial input for this operation
cease by September 1972.

months.

coronary care unit training can be borne by
. Other sources of support must be found .

Albany RPlP

-.

5 .

C.

D.

-2- RM 00055 8/71

-_

3'11~ IbIC and j t :: llx~~cii t ivL, Coi~..~iiI Lc.L\ iiiii:; L ~)c~c~)iiw pu1 icy-
makin[; hoclics wliich activcly  rcvi(w ,ind c~vnltinte on-
going and proposed activitics , allocJt-e funds anlong
thcm, and sei goals, objectives, and prioritics. The
fuiictioiis of these groups should include periodic reviec:s
of the Program's effort allocation including personnel
efforts.

1.

2.

3.

1

8

In this rcgard, the RAG and Executive Committee
must be educated as to their responsibilities.
A confcrence/scminar niight bc one way of doing
this.

The Planning and Revicw Subcornnittee of  the Executive
Cominittee 2s it is presently constituted (one RAG
member, trzo Executive Committee members, and three
core staff members -- plus plans for inclusion of
outside aembers) appears unnecessary if the Executive
Comiiittee is a strong group. If, however, the
Executive Committee feels the need for such a
working group it should be a true subcommittee: i.e.,
include only Executive Cormittee members.

All deliberations of the Executive Coinnittce must
be rcvie\.:c>d and considered by the full Regional
Advisory Group.

A functional rcvicw procedure must be established for all
ARXP efforts: proposed and operational projects as
well. as core-supported studies and activities. This
process must provide for a non-core technical evaluation.

I.

The preseqt consul.ting groups have been established
to serve both technical review and program
developnent functions. A means must be found
to separate these functions so the techncial
review is not performed by the same group
which developed the activitiy.

2. Efforts should be made to include in the technical

review process qualified people from outside the
Albany and Albany Xedical College area.

3. All technical review bodi.es should have specific

review criteria1 and guidelines.

The excellent data base which has been assembled by AKMP core
staff must be distributed and applied to establish new
activities and priorities of action.

i

Albany RMP

F.

G.

H.

-3- FOY 00055 8/71

Strenuous efforts must be made to fill the core position
of Nurse Coordinator which has been vacant for more than
a year.

The Albany RMP needs a set of operating objectives which
are quantified and measurab1e;tlme-dependent, and ranked
in priority order.

All individual projects must be evaluated not only with
regard to their intrinsic
contribution to program goals and objectives.

success but considering their

There must be a clear delineation between the activities
of the Albany Regional Medical Program and  those of the
Department of Postgraduate Education of the Albany Medical
Col1 ege .

2. Suggested Considerations

A.

B.

The Albany Regional Medica 1 Program should consider the
desirability of establishing itself as a separate
corporation with retention of fiscal management functions
by the Albany Medical College.

Consideration should be given to creating a position of
Deputy Coordinator.

An outside management consultant might be called in for
a formal review of goals and objectives and assistance in
sharpening them.

The Triennial application under consideration requests,
essentially, a three-year renewal of the ongoing program

for the 05, 06, and 07 years.
of core activ es, the two-way radio project, coronary care
training proj
and subregionalization. No new projects are proposed for funding, the
Region having incorporated most of its request for new activities as
planning and feasibility studies in the core budget.  It was noted
that approximately 75 percent of last year's expenditures and next

The current program consists primarily

I .and an experimental project in localleadership

request fall-within the core budget.

In reviewing Albany's Triennial application, the Committee harkened
back to its recommendation after the site visit two years ago that

ss the Region demonstrated it had come to grips with its chronic
                            And the question

, no further funding could be recommended.
ing the Review Committee, then, was whether the progress which
on has made can be said to represent a coming to grips with
lems.  It was agreed that they probably represent a step in the
rection at any rate.
but many of these are of such recent origin that new processes

Numerous changes have been made in the

untested and new ideas have not had, a chance to reach fruition.

Albany IMP -4 - RIY 00055 8/71

Perhaps the most dramatic revisions have been made in the review
process, through:
of the RAG;  the creation of a representative Executive Committee
of the RGG to replace a previous core and medical school dominated
group; and the reduction of core, Coordinator, and medical school
input in the review process.  The Executive Committee was seen as a
group with considerable potential (although presently confEsed as
to its role) which could be educated to become a true policy-making
body. And although the present review process is cumbersome, it:
was thought- that as it is tested the problem areas will surface and
be refined. The core staff represents a pool of many talents and is
tentatively moving away from the traditional ARMP focus on only
continuing education.
local ideas are being gathered through the consulting physicians
panel and the local leadership project, the community information
coordinators are doing a good job of publicizing ARMP activities, staff
is providing assistance in the hopeful development of CHP b agencies,
and core is moving into the areas of neighborhood health center and
rural medical care development, as well as physicians'  assistants
and nurse practitioners. Nevertheless, core activity in the newer
areas is characterized by an unbecoming hesitancy to upset the nedical
communi ty .

the enlargement and considerable diversification

An excellent data base has been established,

Although many concerns were voiced, and these are reflected in the
specific recommendations of the Review Committee and the site visitors
(lack of leadership of RAG, inadequate technical review, lack of realis-
tic, time-limited operational objectives, inadequate evaluation, etc.),
perhaps the aspect of the Albany RMP which provoked the most
discussion and provided the most cause for concern, centered around
the Region's inability to phase out support for activities which have
been going on since the inception of the Program (in the case of
coronary care "Laining) and for at least ten years before that
(in the case of the two-waay radio).
years ago that It mist withdraw its support from these activities.
has not. The Comn5~ree reiterated that the Program cannot hope to have
any impact in new areas as long as money is frozen in the support of
these old-line activities. The Review Committee agreed with the
site team's reconmendacion tkt only one year's terminal support
be provided for coronary care training activities, but disagreed with
the team's 18-moi1th suggestion for the two-way radio activities and
recommended that it be limited to a year as well.

The Region had been warned  two

It

In discussing funding recorrifiendations, a range of $825,000 to $900,000 was
offered for consideration,  and the Review Committee again concurred
with the site team in recorninending $900,000. It was thought that
this sum could provide, through judicious allocation, adequate support
for program maintenance and termination activities, with sufficient.
funds remaining to implement the numerous recommendations of the site
team and the Review Cormittee. The current year's ievei is $806,001
(reduced from $915,910 by the recent cut) and the request for next
year is $1,104,790,

The Review Commitcee agreed that a funding level

b

Albany RMP - 5- RM 00055 8/71

smaller than the $900,000 recommended would not permit the Region
to accomplish the things that it must if the site team next year is
to see the changes that have been recommended.
the $900,000 recommended grant is to allow the Region some discre-
tionary money to turn the organization in new directions, and at the time
of the next site visit a year from now the ARMP will be accountable to
the team for the allocation of all its resources.

Regional Medical Programs in Northern New York

It was stressed that

e point that arose repeatedly during the two-day meeting was that
         Ps in northern New York had submitted Triennial
       s review cycle, had been site visited, and all
       problems in terms of the quality and direction
       e three RMPs are Albany, Central New York (Syracuse),
        fourth RMP, Western New York (Buffalo), was

er/November 1970 Committee and Council. There was
the Review Committee that serious thought should
ning these three, or possibly four, Regions and that

a better use of limited dollars and perhaps combine
various programs.  It was recognized at the

Also, since each of the three Regions being

tically, any combination of these Regions would

s cycle was seen as being at a turning point in its

with some hope for resolution of its problems during

e reigning attitude was that now would be an
suggest any combined superstructure without
ms another year to iron out their own difficulties.
aw the need for more data before considering

mps /GRB /7 / 14 / 71

e Dab:

Repb to
Atfn 4:

SMtjdGf:

  2-0:

e

DEPARTMENT at= HEALTH. EDucPrTiaN. AND WELFARE
            PUBLIC HEALTH SERVlCE
HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION

June 18, 1971

Quick Report on the Albany Regional Medical Program Site Visit.
June 2-3, 1971 (Albany, New York)

<I

Director, -RTS /'

Through :

Acting Deputy Director 7
Regional Medical Programs Service

I.

Site Visit Team

-

*John E. Kralewslci, Ph.D. (WE'S Committee Member)
Assistant Professor and Director
Division of Health Administration
University of Colorado Medical Center
Denver,Colorado

Joseph G, Gordon, M.D.
Chief Radiologist
Kate B. Reynolds Memorial Hospital
     Also
Vice Chairman
North Carolina Regional Medical Program
Regional Advisory Group

Edward D, Coppola, M.D.
Associate Professor in Surgery
Hahnemann Medical College and IIospital
Philadelphia, Pennsylvania

James P. Harkness, Ph.D.
Deputy Coordinator
New Jersey Regional Medical Program
East Orange, New Jersey

Ro g e r War ne r
Director of Planning and Evaluation
Arkansas Regional Medical Program
Little Rock, Arkansas

* Chairman of Site Visit Team

RMPS STAFF -

Eileen Faatz A.Burt Kline, Jr.
Grants Review Branch

Regional Development Branch

Elsa Nelson Robert. Shaw
Continuing Education DIIEW Region I1
& Training Branch

Regidnal. Of f i. c e Rep res en t a t ive

Director RMPS - Page 2
Albany Quick Report

II o

111.

BACKGROUND:  The Albany Regional, Medical Program has been an

       issue of concern to staff, Conmiittee, and Council
reviewers for a long time, prirnarily because of: the ubiquity
of the influence of the Coordinator and the Department of Post-
graduate Education in the Regional planning, review, and decision-
making process; the small number of activities developed outside
of Albany itself and the small number of RAG members,  etc.  from
peripheral areas; the continued program concentration on
continuing education; and the apparent lack of receptivity to
(or failure to stimulate) ideas from outside the Albany Medical
College, A site visit two years ago counseled the Region that
it must examine the processes that contributed to the above
problems and change them. Subsequent staff, Committee, and
Council reviews uncovered no particular revisions  in the
way the Region was operating, and this,combined with attendant
RlYP fiscal stringencies ,has served to diminish project activity
in AHP (through renewal disapprovals and approvals without
funds) from eight projects two years ago to' the current
four ongoing activities.
application requesting three years support (05,06,07 years)
including a developmental component.
was requested for the first year of the Triennium (05 program
year).

GENERAL IMPRESSIONS: The general conclusion of the site team was

             that the AKMP is neither here nor there:
it's not where it should be but, on the other hand, it's not
where it had been.  It is just now (and certainly belatedly)
entering a transition phase.  The site team had the definite
feeling that the ARMP core office had been the scene of feverish
activity for the last couple of months or so, as document after
document, hot off the press and describing numerous organizational
and procedural changes of recent origin,were presented for

have just been made the site team had no way of judging their
effectiveness, Many have not yet been put into operation. There
is always the possibility that these represent a restructuring
of form without any real change in leadership.
hoped not.

Perhaps the potentially most drastic revisions have been made
in the review process, through : the enlargement and considerable
diversification of the PSiG; the creation of a representative Executive
Committee of the MG to replace a previous core and medical
school dominated group; and the reduction of core, Coordinator,
and medical school input in the review process,
RAG and the new Executive Committee have potential, they either
are unaware of, or loath to assume, their considerable rcsponsibil ities.
The Executive Committee is newly appointed and appears confused
as to its role,and the RAG seems not to exercise judgment of its
 om^ - merely accepting what is presented  to it.

The Region has submitted a Triennial

A sum of $1,104,790

spection.

Some major changes have been made, but since they

The visitors

Although the

This must change

Director W?S - Page 3
Albany Quick Report

during the coming year. Technical review of activities was found
to be deZinitely inadequate and restructuring was  recommended.

Although the Region has developed a recent set of objectives
they are:  too comprehensive to be meaningful, not ranked in
any priority order, and unfamiliar to many - expecially since
they were established by the planning group which recently has
been abolished. Further, although there is much talk of new
directions and activities and expansion into fields other than
education, considerable sums of money still are frozen through
the continued support of the two-way radio and coronary care training
activities e The Region must demonstrate its willingness to actually
do things it talks about. The present application, for instance,
essentially requests three years of continued funding for the
existing program. No new projects are proposed. The only
areas through which program change can be accompli shed are through
proposed core and developmental component -activities.

The core staff is a talented group and must work to divert. its
interests fron? the radio into newer activities. A lot of this
is happening already through many core studies which are being
carried out or planned. With proper direction, the core staff
can accomplish interesting things.

Because the Region has not demonstrated especial maturity in terms
of the review criteria, a developmental component award could
not be recommended. And since the ARMI' is just entering a transition

procedures, the site team thought a reasonable solution to its
dilemma would .be to allow the Regionone year to turn itself
around. The following reconmendation was unanimous among the
visitors. The dollar recommendation of'the site team is an
amount sufficient to provide for a core allocation adequate to
support the studies and activities necessary to accomplish the
Region's change in direction and emphasis.

I stage, and has not yet tested the workability of its new

__. RECOPMENDATION: One additional year is funding for $900,000 with

Region's progress with regard to the site visitors'  recommendations.
The only specific disapproval is for developmental component
funding.
However, the team strongly urges that the amounts set aside for
the two-way radio and coronary care training activities be of a
magnitude that will not hinder the Program as it strives to
redirect and reorganize its activities during the coming year.
The suggestions of the site team as to specific changes to be
accomplished during thenext year are presented in two categories:
(1) those changes which must be demonstrated to have occurred
at the time of the next site visit -- approximately June 1972,
and (2)' those areas to which the team thinks the Region should
give consideration, although the adoption of the recommendations
will not be a requisite for continued funding.

a follow-up site visit in a year to check the

The award is to be allocated at the Region's discretion.

..

Director, RMPS - Page 4
Albany Quick Report

1. Necessary Changes

-__I

A. Mechanisms for the phase-out of Pal' support should

be developed for the two-way radio and coronary care
training activities, with the understanding that:

.le RPP funds for the two-way radio will not be

- forthcoming for longer than eighteen months.

AMP financial input ioc this operation
must cease by March 1973.

2. No more than one year's terminal support for
the corona-ry care unit training can be borne by
RMF. Other sources of support must be found
by September 1972.

B. The RAG and its Executive Committee must becorae policy-
making bodies which actively review and evaluate on-
going and proposed activities, allocate funds among
them, and set goals, objectives, and priorities a The
unctions of these groups should include periodic reviews
of the Program's eifort allocation including personnel
  efforts.

1, In this regard, the RAG and Executive Committee

must be educated as to their responsibilities.
A conference/seminar might be one way of doing
this.

2. The Planning and Review Subcormnittee of the Executive
Committee as it is presently constituted (one RAG
member, two Executive Committee nicmbers , and three
core staff members -- plus plans for inclusioii of
outside members) appears unnecessary if the Executive
Committee is a strong group. If, howevgr, the
  Executive Committee feels the need for such a
working group it should be a true'subcomniittee: i.e.,
include only Executive Committee members.

3. All deliberations of the Executive Committee must

be reviewed and considered by the full Regional
Advisory Group.

C. A functional review procedure must be established for all

ARMP efforts: proposed and operational projects as
well as core-supported studies and activities. This
process must provide for a non-core technical evaluation.

-

Albany Quick Keport

D.

E.

F.

G.

1. The present consulting groups have been
  established to serve both technical review and
program development functions. A means must be
found to separate these functions so the technical
review is not performed by the same group which
developed the activity.

2. Efforts should be made to include in the technical
review process qualified people from outside the
Albany and Albany Nedical College area.

3.  All technical review bodies should have specific
review `criteria and guidelines.

The excellent data base which has been assembled by AaIP  core
staff must be distributed and wed.

Strenuous efforts must be made to fill the core position
of Nurse Coordinator which has been vacant for more than
a year.

The Albany Nip needs a set of operating objectives which  are
quantiicd and measurable, time-dependent , and ranked in
priority order.

There must be a clear delineation between the activities
of the Albany Regional Medical Program and those of the
Department of Postgraduate Education of the Albany Medical
College.

2. Suggested Considerations

- -

A. The Albany Ilegional. Medical Program should consider the

desirability of establishing itself. as a separate corporation
with retention of fiscal management functions by the Albany
Medical College.

B. Consideratior, should be given to creating a position of

Deputy Coordinator.

C. An outside management consultant might be called in for a
formal review of goals and objectives and assistance in
sharpening them.

KAT I ONALE FOR FUNQ IN G REG OMlilENDAT I ON -

----__lll___

The one year $900,000 recommendation was thought to represent a
sum which could provide, thrcugh judicious allocation, adequate support for

e

e

e

"

-_-_-

Albany Quick Report

program maintenance and termination activitjes, with sufficient
funds remaining to implement the nuinerous recommendations and
suggestions of trhe site team.
(reduced from $915,910) and the request for next year was $1,104,790.
The site team felt a smaller funding level would not permit the
Region to accomplish the things that it must if th'e site team

                                                                    '
next year is to see the changes that have been recommended in this
reportr and which must be accomplished if the program is to be continued.

The current year's level is $806,001

5+-

cfl(

Eileen I. Faatz
Public Health Advisor
Grants Review Branch
Regional Medical Programs Service

I

V. Rationale for Funding

Recommendation.................. 20-21

VI. Recapitulation in Terms of RMPS

Mission Statement Review

Criteria....................... 21-23

(A Privileged Communication)

      SITE VISIT REPORT
ALBANY REGIONAL MEDICAL PROGRAM
     June 2-3, 1971

Table of Contents

I. Site Visit Participants ........... 2-4

11. Background Information......... ... 5

111. Conclusions 6r General

Impressions ..................... 5-10

IV. Review Details.................... 10-20

RMPS /GRB
RM 04-8/71

-2-

I. SITE VISI'L' PARTICIPANTS

A. Site Visit 'ream:

*John E. Kralewski, Ph.D. (RMPS Committee Member)

Assistant Professor and Director
Division of Health Administration
University of Colorado Medical Center
Denver Colorado

Joseph G. Gordon, M.D.
Chief Radiologist
Kate B. Reynolds Memorial Hospital
    Also
Vice Chairman
North Carolina Regional Medical Program
Regional Advisory Group

Edward D. Coppola, M.D.
Associate Professor in Surgery
Hahnemann Medical College and Hospital
Philadelphia, Pennsylvania

James P. Harkness, Ph.D.
Deputy Coordinator
New Jersey Regional Medical Program
East Orange, New Jersey

Roger Warner
Director of Planning and Evaluation
Arkansas Regional Medical Program
Little Rock, Arkansas

*Chairman of Site Visit'Team

Regional Medical Program Service Staff:

Eileen I. Faatz
Grants Review Branch

Elsa Nelson
Continuing Education & Training Branch

A. Burt Kline, Jr.
Regional Development Branch

Rob e r t S h aw
DHEW Region I1
Regional Office Representative

., . .

.. " .

-.

t

L.!

- 3-

B. Regional Participants

0

t

Albany Regional Medical Program Core Staff:

Dr. Frank M. Woolsey, Jr. Director
Dr. W.P. Nelson, 111, Association Coordinator
Dr. G.J. Craft, Associate Coordinator
Dr. W.T. Strauss, Associate Coordinator
Dr. A.W. Pohl, Associate Coordinator
Dr. W.L. Oliver, Associate Coordinator
Dr. J.B. Phillips, Associate Coordinator
Dr. S.W. Cooper, Associate Coordinator
Dr. E.B. Howe, Associate Coordinator
Dr. M.F. Spear, Associate Coordinator and Director of Community

Miss I. J. Wilhelm, Physical Therapist
Dr. P. L. Brading, Educational Psychologist
Dr. R. Forer, Consultant in Sociology
Mr. J.C. Winslow, Administrative Assistant
Mr. R.W. O'Neill, Director of Public Relations
Mr. W.C. Batchelder, Director, Information Service
Mr. A.A. DeLuca, Director, Community Information Coordinator
Mr. H.J. Zarzycki, Community Information Coordinator
Mr. W.T. Meyers, Jr., Community Information Coordinator
Mr. R.E. Perry, Community Information Coordinator
Mr. A.P. Fredette, Coordinator Instructional Communications (2-way radio)

Executive Committee Members:

Leadership Project

Dr. James Bordley, Chairman, and President Regional Hospital Review &

Mr. Jeremiah Blanton, Manpower Development Specialist, Post Office

Dr. Stuart Ijondurant, Chairman of Department of Medicine, AMC

Miss. Majory Kennan, R.N., Associate Professor, Department Nursing,

Mr. F. Donald Lewis, Prudential Insurance Company of America
Mr. John Murphy, Administrator, Saranac Lake General Hospital
Mr. Paul R. Robinson, Associate Executive Director, NYS Health

PlannFng Council

Department

Russell Sage College

Planning Commission

Other RAG Members:

Dr. Harold C. Wiggers, Chairman of RAG and Dean, Albany Medical College
Mr. Bernard Siegal, Vice President, Business and Finance, Albany

Mr. James J. Warren, Warren & Son Plumbing and Heating
Mr. James L. White, Executive Director, Clinton Square Neighborhood Assoc.
Dr. Robert Gilston, Practicing Physician
Miss Helen Middleworth, Director, Albany Medical Center School of Nursing

Medical College

-4-

Other Representatives :

Mr. Ralph R. Betts, Administrator, Leonard Hospital, Troy
Dr. Philip Brown, Associate Administrator, Leonard Hospital, Troy
Mr. James B. Clemens, Administrator, Potsdam Hospital, Potsdam
Mr. William A. Clermont, Administrator, Alice Hyde Memorial Hospital,


Mr. George Nuffer, Administrator, Herkimer Memorial Hospital, Herkimer
Dr. John Olivet, Medical Director, Benedictine Hospital, Kingston
Dr. Arthur Applegate, Ilion, Medical Society
Dr. G. Peter Cook, Ticonderoga, Medical Society
Dr. Symour Horwitz, Schenectady, Medical Society
Dr. Arthur Howard, Johnstown, Medical Society
Dr. Franklyn Hayford, Chairman, Upper Hudson Regional Comprehensive

Dr. Peter Birk, Northend Community Health Center and Department

Mrs. Katherine Bradley, Medica2 Technologist
Dr. James Cullen, Consulting G~oup for Pulmonary Disease
Dr. Joseph T. Doyle, Consulting Group for Heart Disease
Mrs. Lynne W. Ferrari, Physical Therapist
Dr. John Horton, Consulting Group for Cancer
Mrs. John Murphy, Saranac Lake, New York
Dr. Boris J. Paul, Consulting Group for Stroke
Mrs. Dorothy Paul, Community Medical Care Program
Mrs. Ann Ruggerio, Dietician
Mr. Frederic G. Stefan, X-ray Technician

Malone

Health Planning Organization.

Community Medicine I

1

Albany Regional Medical Program -5- RM 00004

11. BACKGROUND INFORMATION

The Albany Regional Medical Program has been an issue of concern
to staff, Committee, and Council reviewers for a long time, primarily
because of: the ubiquity of the influence of the Coordinator and
the Department of Postgraduate Education in the Regional planning,
review and decision-making process;  the small number of activities
developed outside of Albany itself and the small number of RAG
members, etc. from peripheral areas; the continued program concentration on con-
tinuing education; and the apparent lack of receptivity to (or
failure to stimulate) ideas from outside the Albany Medical College.
A site visit two years ago counseled the Region that it must examine
the processes that contributed to the above problems and change
them. Subsequent staff, Committee, and Council reviews uncovered
no particular revisions in the way the Region was operating, and
this combined with attendant RMP fiscal stringencies, has served
to diminish project activity in ARMP (through renewal disapprovals
and approvals without funds) from eight projects two years ago
to the current four ongoing activities.

The Region has submitted a Triennial application requesting three-
years' support (05, 06, 07 years) including a developmental com-
ponent.  (A comparison of the Triennial request and the Region's
previous funding is shown on page 2.) The task of the site team,
then, was to discover the Albany Regional Medical Program's
conformance to new RMPS review criteria and to determine whether
the previously-identified deficiencies still existed.
developed by the Coordinator, in conjunction with the site team
chairman, was found to be particularly facilitative by providing
for both large and small group discussions,  a well-attended feed-
back session, and provision for site visit examination of numerous
documents of interest.

The agenda

111, CONCLUSIONS AND GENERAL IMPRESSIONS

The general impression of the site team was that the AMP has made
progress during the past year although it still lacks the maturity
desirable for local autonomy. It is just now (and certainly
belatedly) entering a transition phase.
definite feeling that the ARMP core office had been the scene of
feverish activity for the last couple of months or so,  as document
after document, hot off the press and describing numerous organiza-
tional and procedural changes of recent origin, were presented
for inspection.
have just been made, the site team had no way of judging their
effectiveness. Many have not yet been put into operation. The
visitors were concerned that they may represent more of a paper
operation than the actual implementation of process.

The site team had the

Some major changes have been made, but since they

Perhaps the potentially most drastic revisions have been made in
the review process through:

the enlargement and considerable

ALBANY REGIONAL MEDICAL PRDGEWM

PROJECT

re (including community info.

ordinator s)

ievelopmental component

tro-way Radio

'os tgraduate Instruction

Development Panel

:omunity Hospital Learning

Centers

ICU Training - Albany

ICU Training - Community

Bo s pi t a 1 s

ntensive Care Unit

chenectady Cancer Coordinator

levelop Community Leadership


TOTAL DIRECT COSTS

*original 04 year aw
Xowever, the new a1

/` -

. I'

Comparision of 01-04 year
funding & 05-07 year request

15 mo.

01

$ 509,691

--

144,104

102,608

75,833

125 , 240

55,410

25,472

2,100

--

1 , 040,458
-d has bee
,cation am'

15 mo.

02

j 783,933
    k..

--

124 , 689

69 , 932

76,665

103,850

39,576

33,455

5,356


--

1 , 237,456

reduced tc
ig projects

FUNDED

$ 712,094

--

143 , 975

80,745

111,0a2

71,746

36 , 930

7 , 207

5 , 000

9,030

1,177,809
$806,001 dt
is not yet

; bI

... ,

1,

04

$ 687,159

--

142 , 975

--

--

* 71,746

--

--

5,000

9 , 030

915,9101r

to RMPS f

nown .

05

$ 791,460

  85 , 000

154,030

--

--

60,270

--

--

  5,000

  9 , 030

1,104,790

;cal constrai

REQUESTED

06

$ 850,610

  85 , 000

163,171

--

--

62,981

--

--

--

  9,330

1,171,092

ts.

07

__

-

$ 914,512

85,000

173,118

--

I

65,912 7

--

--

--

  9,656

1 , 248,198

L

-

set of objectives they are: too comprehensive to be meaningful,
not ranked in any priority order, and unfamiliar to many - especially
since they were established by the planning group which recently
has been abolished. Further, although there is much talk of new
directions and activities and expansion into fields other than
education, considerable sums of money still are frozen through
the continued support of the two-way radio and coronary care training
activities. The Region has some good ideas and is involved in some
interesting things through core activities, yet this has not gener-
ated any projects which indicate an expansion or differentiation.
The present application, for instance, essentially requests three
years of continued funding for the existing program.  No new projects
are proposed. The only areas through which program change can be
accomplished are proposed core and developmental component activities

Albany Regional Medical Program _I

.7-

RM OOC04

diversification of the RAG;  the creation of a representative Executive
Committee of the RAG to replace a previous core and medical school
dominated group; and the reduction of core, Coordinator, and medical
school input in the review process. Although the RAG and the Executive
Committee have potential, they are somewhat unaware oi their authority
and responsibility and- as a result, are not functionin;+ at desired
levels.
confused as to its role, and the RAG seems not to exercise judg-
ment of its own - merely accepting what is presented to it, Technical
review of activities was  found to be definitely inadequateand .re-

structuring was recommended. Although the Region has developed a recent

The Exccutive Committee is newly appointed and nppears

The site team was impressed with the talent of the core staff and
its diverse interests, but was disappointed that core has not directed
its efforts away from old-line activities. With proper direction,
the core staff can accomplish interesting things.

Because liie tiegion has not demonstrated especial maturity in terms
of the revic.ij criteria, a developmental component award could not
be recommended. And since the ARMP is just entering a transition
stage, and bas not yet tested the workability of its new procedures,
the site team thriught a reasonable solution to its dilemma would
be to allow the Region one year to turn itself around. The dollar
recommendation of the site team is an amount sufficient to provide
for a core allocation adequate to support the studies and activities
necessary to accomplish the Rcgion's change in direction and emphasis.
The following recommeridiition WEIR unanimous among the visitors.

Recommendat*:
a follow-up site vislt in a year to check the. Kegion's progresB with

One addl tional ycaiir's funding for $900,000 with

regard to the site visFtors' rt.c*ommcndations. The only apecffic
disapproval is for developmental coniponent fundlng. 'I'he award is
to be allocated at the Regton's discretion. However, the team
strongly urges that the amounts set aside for the two-way radio
and coronary care training activities be of a iiiagnitude that will
not hinder the 'Program as it strives to redirect and reorganize
its activities during the coming year. At the time of the site .
visit a year from now the ARMP will be accountable to the team
for the allocation of all its resources. The suggestions of the

Albany Regional Medi cal Program -a- N"I 00004

ajlte team as to specfffc changes to be accomplished during the next
year are presented in two categories:  (I) Those changes which must
be demonstrated to have occurred at the time of the next site visit--
approximately June 1972, and (2) those areas to which the team thinks
the Region should give consideration, although the adoption of the
recommendations will not be a requisite for continued funding.

i

1. Necessary Changes:

A. Mechanisms for the phase-out of RMP support should be

developed for the two-way radio and coronary care training
activities, with the understanding that:

1. RMP funds for the two--way radio will not be forth-

coming for longer than eighteen months. ARMP finan-
cial input for this operation must cease by March 1973.

2. No more than one year's terminal support for the
coronary care unit training can be borne by W.
Other sources of support must be found by September 1972.

B.

The RAG and its Executive Committee must become policy-
making bodies which actively review and evaluate ongoing
and proposed activities, allocate funds among them, and
set goals, objectives, and priorities. The functions

, * :.

of these groups should include periodic reviews of the
Program's effort allocation, including personnel efforts.

* .'
.--r -. ,

_'

. i_

1. In this regard, the RAG and Executive Committee must

be educated as to their responsibilities.
seminar might be one way of doing this.

A conference/

2.

The Planning and Review Subcommittee of the Executive
Committee as it is presently constituted (one RAG
member, two Executive Committee members, and three
core staff members--plus plans for inclusion of
outside members) appears unnecessary if the Executive
Committee is a strong group. If, however, the
Executive Committee feels the need for such a working
group it should be a true subcommittee:  i.e., include
only Executive Committee members.

3. All deliberations of the Executive Committee must

be reviewed and considered by the full Regional
Advisory Group.

C.

A functional review procedure must be established for
all ARMP efforts:
as well as core-supported studies and activities. This
process must provide for a non-core technical evaluation.

proposed and operational projects

Albany Regional Medical Program -9- RM OOCO4

1. The present consulting groups have been established
  to serve both technical review and program development
  functions. A means must be found to separate these
  functions so the technical revi-ew is not performed
  by the same group which developed the activity.

2. Efforts should be made to include in tlie technical

review process qualified people from ouL';;de the
Albany and Albany Medical College  area.

3. All technical review bodies should have specific

review Criteria and guidelines.

D. The excellent data base which has been assembled by

ARMP core staff must be distributed and applied to
establish new activities and priorities of action.

E. Strenuous efforts must be made to fill the core position
  of Nurse Coordinator which has been vacant for more than
   a year,

F. The Albany RMP needs a set of operating objectives which

are quantified and measurable, time-dependent , and ranked
in priority order.

G. All individual projects must be evaluated not only with
  regard to their intrinsic success but considering their
  contribution to program goals and objectives.

There must be a clear delineation between the activities
of the Albany Regional Medical Program and those of the
Department of Post-graduate Education of the Albany
Medical College.

The purpose of the $900,000 recommended grant is to allow
the Xegion some discretionary money to turn the organization
in new directions, and at the time of the next site visit
the ARMP will be accountable to the team for the allocation
of all its resources.

H.

I.

2. Suggested Consi aerations:

A.

The Albany Regional Med-Lcal Program should cons-lder the
desirability of establishing itself as a separate corpora-
tion with retention of fiscal management functions by
the Albany Medical College.

B. Consideration should be given to creating a position of

Deputy Coordinator.

Albany Regional Medical Program -10- RM 00004

     C, An outside management consultant might be called in for

a formal review of goals and objectives and assistance I

in sharpening them.

IV. REVIEW DETAILS

A. Goals, Objectives and Priorities

Findings : The Albany Regional Medical Program has developed two

long-range program goals and seven shorter-range objectives
as follows: .

Goals

I. To promote and influence regional cooperative arrangements

for health services in a manner which will permit the
best in modern health care to be available to all.

11. To assure the quality, quantity, and effectiveness of

professional and allied health manpower.

Objectives

1. To explore and encourage innovative methods of health
care delivery with particular attention to improving
delivery in medically-deprived urban and rural communities. { - . .. =' i I

_. e_. -

_-

I. , ,

--

2. To mobilize consumer-provider participation in the

identification and solution of local and regional
health problems.

3. To recruit health manpower and improve its distribution

and utili zat i on.

4. To introduce methods to relieve overburdened health

professionals.

5.

To engage in the education and training of health
personnel with particular at tent ion to continuing
education and to the training of personnel to fill
recognized gaps in critical areas.

6.

To promote public education in health matters.

7. To further the process of regional cooperative arrangements.

Since the objectives were promulgated by the predecessor of the newly-
created Executive Committee of the RAG (the Planning and Review Group
which was almost exclusively Medical College and core staff membership),
they were unfamiliar to the members of the Executive Committee with whom

the site team talked. The objectives are not prioritized and are con-
sidered by the Program to be comprehensive enough to cover just about

1'

\ .-,

-_ -

any contingency and, if they are not, new objectives will be added.

Albany Regional Medical Program -11- RM 00004

Although the program objectives  are not ranked in order of importance
or need, an instrument recently has been deseloped by the core educational
psychologist and sociologist which will permit a numerical rating of
project proposals. This ten-page rating device has just emerged from
the testing stage (on core staff) and has not yet been put into operation.
It is anticipated that a composite numerical rating for each project
will be calculated on the individual evaluations of- t'cwlve to fourteen
core staff, five to ten consulting group members, and 1.11~ ten members
of the Executive Committee of the RAG--a total of approxli:itely 30
separate evaluations. The priority rating of each projec! will be
presented to the RAG, and this score will be one of several ,onsiderations
in determining approval, funding allocation, etc. The new hxecutive
Committee had not been exposed to this complicated rating scale prior
to the site visit.

--- -

Comments: The site team thought that recent efforts in the development

more than continuing education were indicative of Albany's desire to
expand its programmatic interests. However, it was explained to the
Region that non-prioritized objectives, which were broad enough to
include everything, lost their value potential for determining program
direction within certain limitations. It was suggested that the Region
develop measurable operating objectives which are  time-limited and
ranked in priority order. The recently updated data base should be
considered by the Executive Committee and the RAG in establishing
these objectives. The visitors also were apprehensive about the
relative benefits of such a complicated activity rating scale, particu-
larly in light of the limited use to which the final. composite numerical
rating will be put, and with the heavy core staff input.

of objectives to emphasize the Region's participation in

B. Organizational Effectiveness

_.---.-. Core Staff Composition:

Findings: Of the 28 professional and technical core staff, ten are

          physicians who devote between 40% and 95% of their
time to ARMP and the remainder to Albany Medical College pursuita.
All core staff have AMC appointments and operate under the College's
personnel policies, Nine of the physicians are designated as Associate
Coordinators and have responsibilities for overseeing the implementation
of AW activities in the subregional geographic areas. Except for
Dr. Spear, who directs an experiment fn subregionalization and local
planning in three northern counties, all the Associate Coordinators
are located in Albany. The site team had difficulty understanding
the precise nature of the Associate Coordinators' operating spheres,
as well as their division of effort between RMP and AMC. In fact
the team was concerned about the allocation of time between RMP and
AMC and asked the Dean to investigate. His reply is attached to this
report.

In addition to the Associate Coordinators' work in the field, AJMP
employs four Community Information Coordinators who carry information of
the RMP to the practicing physicians and hosp-itn1.s nnd generally serve

Albany Regional Medical Program -12- RM 00004

as good-will ambassadors.
with the establishment of CHP "b" agencies.
people maintain daily logs of their contacts, they report to no one
on the core staff.

Other core staff positions include fiscal specialist, educational
psychologist, sociologist, public relations, administrative assistant,
and physical therapist.
for a year since the previous nurse died, and Dr. Woolsey has been under
some pressure from the Nurses Consulting Group and others to fill it.
The site team reinforced that suggestion.
core staff deal exclusively with the two-way radio activities,  and
almost all staff are involved with the radio to some degree. There
are, in addition, three physician vacancies for which the site visitors
could find no rationale (beyond that of probably creating a slush
fund) and which the team considered unnecessary.

They are involved peripherally in assisting

Although these field

8

\

The position of Nurse Coordinator has been vacant

Six other positions on

Comments:

health interests are represented by only the physical therapist.
is very little administrative talent--the administrative assistant is
not involved in running the program. Also, an overwhelming amount
of core effort is channelfld into the two-way radio. The visitors,
therefore, recommend that a search begin immediately for a qualified

With regard to the composition of the core staff, then,
it is obvious that physicians are predominant and allied

There

Nurse Coordinator, that the Region consider the possibility of creating
a position for Deputy Coordinator to assist Dr. Woolsey in the manage-

                                                                      ,. ' -. >
ment of the program, and that ARMP involvement in two-way radio activities'.:,-'

r ,&?

cease in at least eighteen months.

Core Staff - Internal Management:

Findings: The ARMP staff appears to

     sensus management via the
sional staff) which meets weekly for

operate primarily through con-
core staff assembly (all profes-
the purpose of discussing progress

and problems and providing a continuous feedback on core activities.
Fourteen core members report directly to the Coordinator, and some
report to no one, except through the mechanism of the core staff
assembly.

Thorough and up-to-date fiscal services are provided by the grantee
organization, and the personnel policies of the Albany Medical College
guide core staffing.

Comments: Overall, with regard to the organizational aspects of

management is a functional mode of operation,
cumbersome by the large size of the group.
of the core staff in this respect is that there are a lot of good,
competent people working under the general direction of the Coordinator
but with no specific guidance.

the program, the site team thought that although consensus

it is rendered rather

And the primary problem

Albany Regional Medical Program -13- RM 00004

Regional Advisory Group--Planning and Review Structure

Findings: The composition of the Regional Advisory Group has

0

diversified and greatly improved since the site visit two

years ago: there are two black members (compared to none a year ago) ,
fewer Albany Medical College and core representatives and more non-
health-oriented members. The present membership is 32., which the
Region intends gradually to increase to 40, primarily through the
addition of more consumer representatives and non-physj cians from
various geographic areas. There are, as well, five ex-offi'clo members
(the VA Hospital Director, the Director of the AMC Hospital, the ARMP
Coordinator and two Associate Coordinators) and it was emphaa i zed
that these are non-voting representatives who act in an advisory capacity
only.

The Regional Advisory Group meets quarterly.

Harold 'diggers, Dean of the Albany Medical College, has been the RAG
Chairman since the inception of the program. He is concerned over
his role in the organization and wonders whether he should step down
as Chairman. The team replied that this was not a decision they could
make, that the situations varied with the individuals and institutions
involved, but that generally speaking the loyalties of a dean would
lie first with his school.

Until a couple months ago, the primary force in the planning and review
process had been the Planning and Review Group--heavily dominated
by core staff and Medical College membership. However, the ARMP's
recent moves to shift the focus of power included the abolition of
this group and the transfer of its functions to a ten-member Executive
Committee of the RAG. The Executive Conunittee is composed of five
physicians (two with the AMC), a nurse educator, the Director of the
CHP "A" agency, a hospital administrator, a black consumer, and the
Chairman--the President of the Regional Hospital Review and Planning
Council. There are also three non-voting ex-of ficio members. Four
of the ten representatives are from outside the Albany area, Unfor-
tunately, thi-s group is so new, and knows so little about its respon-
sibilities, that it could not provide the site team with much information
about its functions. In fact, four of the members were just added
to the RAG and have little or no knowledge of the ARMP. The Executive
Committee meets monthly and reports to the full RAG quarterly.

e

The Planning and Review Subcommittee of the Executive  Committee is
still in the formation stage.
two Executive Committee members, and three core staff members, and
there are plans for inclusion of outside members Plans are that this
group will be the real working arm of the Executive Committee and
will meet weekly. The site team could not quite grasp the need for
this subcommittee.

It presently consists of one RAG member,

Technical review is supposed to be in the province of the thirteen
consulting groups , which also are responsi-le for program development.
The question arose as to how active these groups have been in per-

forming either function.
ranged from six for the dieticians' group to one apiece for the groups

The number of meetings during the past year

0

Albany Regional Medical Program -14- RM OOOOG

on heart disease, cancer, and stroke. Those groups that are relatively ~
active seem to be concerned mainly with two-way radio pursuits.  It
appeared that most consulting groups (which contain primarily Medical
College people) were desultory in their approach,  and a random look
at the minutes of meetings revealed a tendency toward discussion of
AMC as well as fL"Ip business.
minutes,- one would gather that  the cancer consulting group was a medical
school cormnittee, on the basis of &e topics discussed. The consulting
groups have no specific technical review criteria other than the
general RMP guidelines.

L

For instance, from a perusal of the

an operational proposal was inappropriate because it duplicated existing
resources and was not feasible. A feasibility study of training nurses

Although a visual presedted to the site visitors depicts the review
process as beginning with "community originatidn" of an idea,  the
team gathered the impression that community originated ideas are few
and far between--most activities being initiated by core, and to a
lesser extent, the consulting groups. Each project, afterppropriate
core staff assistance, is assessed by the Planning and Review Subcommittee,
with a concomitant technical review by the proper consulting group
(each member of which completes a ten-page rating scale)  and an
administrative review by approximately 12 to 14 core staff (each of
whom completes a rating scale).
reviews are forwarded to the Executive Committee (each member of
which completes a rating scale), The Executive Committee, on the
basis of these three assessments, its own judgment, and program guide-
lines, develops a specific recommendation for the project and sends

The recommendations of these three

.- -.

. ..

it (along with a composite rating) on to the full Regional Advisory    i. .- , ---
Group for consideration. There is no requirement that disapprovals =.

be sent to the RAG for review, and the evidence was that they
generally are not.  What happens when project proposals reach  the
RAG is questionable. A review of recent minutes indicates that little
discussion takes place or, if dissenting opinions arise, they are not
reflected in the minutes.

,I

I

..

..

i . ,'.

v

.. .

for service in hospital emergency rooms was reviewed by the physicians'
but not the nurses' consulting group. The Regional Advisory Group
does not receive the minutes of the consulting groups.

Comments: The site team found the broadened RAG representation and

encouraging first steps away from AMC and core domination and toward
a program more responsive to the Region's needs.
encouraged, in its search for the eight additional RAG members,  to
concentrate on genuine consumer representatives, and it was suggested
that church groups, labor unions, etc. might be good sources. The

the demise of the old Planning and Review Group very

The Region was

Albany Regional Medical Program -15- RM 00004

main and overwhelming difficulty with the RAG and with its Executive
Committee is that they apparently do not understand their responsibilities.
They must be educated to the necessity of their beoming policy-making
bodies which review ongoing and proposed activicies, allocate funds
among them, and set goals, objectives, and priorities. The RAG
appears, in the past, to have forfeited these functions to others -0
mainly the core staff. However, with the infusion of new blood, the
diversification of the RAG and the creation of an Executive Committee,
the site team thought the potential and ingredients existed for the
assumption of a directing and decision-making role by these groups.
Furthermore, immediate steps must be taken to ensure that &L
deliberations of the Executive Committee are reviewed and considered
by the full RAG, It was explained by the site team that a complacent
RAG is not the hallmark of a strong Region.

As mentioned before, the site visitors could discover no particular
rationale for the existence of the Planning and Review Subcommittee of
the Executive Committee, A strong Executive Committee should obviate
the necessity for the Planning and Review group. If, however, the
Executive Committee feels the need for an information-gathering and
preliminary work group, it should be a true subcommittee and include
in its membership only Executive Committee representatives.

The Region must revise its review procedure to provide a review of
all ARMP efforts: proposed and operational projects as well as core-
supported studies and activities. These procedures must include
non-core technical assessment by groups other than those who
developed the activity, and technical review bodies should be
furnished specific review criteria and guidelines. Further efforts
should be made to include in the technical review process qualified
people from outside the Albany and AMC area.

Subregiona Ii. za tion

Findings:  The primary subregional effort has been through Project #16 -

     Development of Community Leadershi2 - in three northern
New York counties. The purpose of the project is to stimulate community
leaders to take the initiative in the development of KMP activities
of significance to their community. This experiment is in its second
year, but the Region feels the results are not yet all in. The local
advisory group was rather slow-starting. So far it has submitted no
ideas to the RAG but has developed some local continuing education
activities. It also is involved in local efforts to form a CHP "b"
agency.
don'ts for similar efforts in other subregions -- although the Region
has not established a timetable as to when the problems of other
geographic subregions will be tackled.

The experiences of this group will identify the do's and

Another emerging approach to community organization involves  the
use of approximately 30 practicing physicians from throughout the
Region to design programs to meet local needs relative to health
care delivery, health manpower, and public education. These
physicians are from the Consulting Physicians Panel, a project

Albany Regiona 1 Medica 1 Program -16- RM 00004

activity which operated for three years before the November 1970
Council recommended no additional funding, The physicians now are
serving as ARMP consultants without honoraria and will  be used as
community leaders and organizers. The group now is working with
the idea of establishing medical outposts using primary care nurses  --
something that the core staff or the medical school group could not
accomplish, The idea is that emergency outposts would be established
in rural areas and that highly trained nurses would be able to take
care of the emergency needs of patients until a physician became
available. It is hoped to expand the panel to include consumer
groups and use it to educate consumers and producers about  the need
for changes in health care systems.

I

Comments:

without financial remuneration. They can be valuable community
resources for subregional organization and local ideas and should be
used in conjunction with techniques developed in the experimental
community leadership project. If the Albany Regional Medica 1 Program
is to move in new directions, the support and participation of local
areas are imperative.

The site team was pleased to see the number of physicians
from the consulting panel whose services have been retained

C. Involvement of Regional Resources

Findings: The involvement of health agencies and providers of health

through RAG membership and programs sponsored by multidisciplinary
groups. The RAG has representation from the State Health Department,
Medical Society, Hospital Association, Model Cities program, Russell
Sage School of Nursing, University, Hospital Facility Planning Council,
and the State Comprehensive Health Planning Agency, Joint RAG member-
ship has been developed with bordering RMPs. It appears that these
groups have ilot been-overly active in ARMP activities in the past, but
the reorganization of RAG and the formation of the Executive Committee
provide the framework for active participation.

services in the Albany RMP activities has occurred mainly

The ARMP also brings agencies and providers into cooperative programs
through its operating activities. The two-way radio, for example,
has successfully brought drugstore pharmacists into the hospital
setting for radio programs and has brought doctors, nurses, dentists
and many allied health groups into similar contact with the hospital
and with each other.
example of a joint activity among ARMP, OEO, the University, and, to
a degree, the Health Department. With regard to OEO, the ARMP has
provided data for the Model Cities planning effort, has incorporated
Model Cities representation on the RAG, and has developed, through OEO,
an education program for consumers.  The physicians consulting panel
(discussed in this report under the section on subregionalization)
is still another tie with the Region's physician community.

Also, the Neighborhood Health Program is an

The program has acted as a catalyst to get CHP "b" agencies off the
ground, and this no doubt will serve to further the relationships of

k-. '

Albany Kegiona 1 Medica 1 Program -17- RM 00004

the various providers of health  services through the Region in the
future and furnish more opportunities for RMP field representatives
to act in an integrative manner. These field agents (Divisional
Coordinators and community information coordinators) have developed
a strong network throughout the Region and have established good
contacts with local communities. For instance, one of the subregions
lost its last practicing physician through an automobile accident,
and RMP was extremely helpful to the community in re-thinking its
needs for health services before attempting to solve the problem.
Some of the more positive benefits of this process included the
discussion of why doctors settle in rural areas, the positive and
negative aspects of building a hospital to attract another doctor,
and recruiting techniques  that are most effective in bringing physicians
to these areas.

Comment: The site team noted the increased activity in terms of

to health care for the poor, planning for rural areas, and assisting
rural areas in developing medical care programs,

involvement with other agencies, particularly with regard

D. Assessment of Needs, Problems, and Resources

Findings: The AW has a very good and comprehensive three-volume

its original preparation in 1966.
characteristics of the Region and the resources available to meet
health care needs, and appears to surpass that developed by most of
the Regional Medical Programs.
it, however, in terms of analysis, distribution, and as a base for
the development of activities. The needs, problems and resources
exhibited in the data base are reflected in the Region's objectives
only to the extent that the objectives were designed to be nearly
all-encompassing. The old planning and review group apparently did
not work with this information in establishing Regional objectives,
nor did core staff in devising its activity rating scale for priority
determination.

data base which recently has been completely updated from

It deals with the demographic

Not much seems to have been done with

Comments: The site team was impressed with the data base which has

     been developed and thought it could become a real planning
resource. The Region was encouraged to widely 'publicize the existence
of this information; to make it available to many groups such as CHP,
medical society, hospital association, health departments, communities;
and to encourage the RAG and its Executive Committee to use it as a
reference for planning and decision-making functions.

E. PROGRAM IMPLEMENTATION AND ACCOMPLISHMENTS

CORE

-

Findings: The bulk of activity (outside of the two-way radio) is

conducted under core auspices and so a lot of what they

do is discussed in other parts of this report. As mentioned before,

Albany Regional Medical Program -18- RM 00004

the Region has submitted no proposals for new projects -- all new
endeavors are included as planning and feasibility studies or central
services to be funded from the core budget.
suspicious from a fiscal standpoint, the review process is by-passed
for many activities, and it vests the control of projects in core staff.
The plethora of studies appears to be random bits and pieces that do
not add up to a coordinated whole. The various activities which are
carried out seem to dictate what the program will be rather than the
other way around,

Not only is this practice

A great deal of core time has been consumed by two-way radio activities,
However, it appears that perhaps the core staff is looking hesitantly
in other directions,

One of the primary illustrations of this is ARMP's support of the
Community Medical Care Program. In its development of the North End
Community Health Center in a black ghetto area of Albany, this program
encountered a funding hiatus which probably would have spelled its
demise had not ARMP provided interim holding support until OEO grant
money was approved. Consequently, in 1970, $60,000 of core money was
diverted to the planning for this ghetto health center. Dr. Woolsey
now is chairman of the policy council of the Community Medical Care
Program and the ARMP core staff is working with the program to identify
two rural sites for which OEO has agreed to provide funds.

The core staff in addition is planning a physicians' assistant training
program and studying the feasibility of nurse practitioners as assistants . ---'
to the physician.

, ..

(2-

. -.*

Core also is assigned the responsibility of monitoring ongoing projects,
although none of these appears  to have much in the way of specific
evaluation methodology.  Presumably, progress and problems are discussed
at the weekly core staff assembly.

Comments: The site team saw the core staff as a potentially powerful

      force in this coming transition phase to a more community-
oriented program and hope that some of the studies which are to be
conducted will come to fruition in the development of project proposals.
The Coordinator and the core staff are particularly (and perhaps overly)
sensitive to the feelings of the physicians in the area, The program
people characterize these physicians as "conservative" and go out of
their way to do nothing to destroy the physicians'  faith in ARMP -
maybe to the point of undesirable inactivity in the face of opportunity.
Dr. Woolsey, for instance, appears rather cautious about core involvement
in the development of rural health centers beyond assistance in
identifying sites. The visitors thought it likely that the core staff
has not kept pace with the changes that are occurring among physicians'
attitudes throughout the country, and that Albany physicians might
not, on re-examination, be as "conservative" as they were some five
or ten years ago. At any rate, the core staff should be encouraged
to be adventuresome in its activities. And, as mentioned earlier, all
core activities, other than routine, should be submitted through the
review process.

+

Albany Regional Medical Program -19- RM 00004

Operational Projects

FindinF:s: There presently arc four ongoing operational projects, The

      two major activities in terms of time, money, and effort
are the two-way radio and the coronary care nurse training, neither
of which represents any new directions for the Region. Both have been
operational since the 01 year and are now requesting renewal support
for three more years -- through the 07 year. And there are ominous
signs that the projects might be expecting RMP support in perpetuity.

The two-way radio was the base on which the ARMP was built cri~d is the
activity through which the program became known throughout the Region.
In fact, many physicians and hospitals seem to think of ARMP and the
two-way radio as synonymous. Many ARMP staff appear to have the same
problem. The radio really has gained a large degree of acceptance for
the ARMP and apparently is tremendously successful. The site visitors
were practically inundated by obviously sincere testimonials to the
radio's effectiveness. The site team two years ago urged the Region
to seek ways to phase out RMP support of this activity through the
increase in hospital contributions or some other means.
behind this suggestion was that the two-way radio had served its
purpose as a launching vehicle and had been demonstrated an effective
means of education. It was time for someone else to pick up the bill.
RMP could not continue to tie up its resources in this activity. In
the intervening two years, RMP support ha6 not diminished and, in fact,
the annual requests for each of the next three years represent increases
over previous years' allocations for the radio.  It was explained to the
site team that there was no other organization in the Region which
could support it. The close and continued involvement of the ARMP,
too, further muddies distinctions between ARMP and the Department of
Postgraduate Education which sponsors the overall radio system,  to the
extent that key ARMP core (including the Coordinator) are identified
in publications as full-time staff of the Department of Postgraduate
Education.

The rationale

The project for coronary care nurse training, likewise, is requesting
fifth, sixth, and seventh years of support. Dr. Woolsey said that he
has a plan for ARMP withdrawal from this project, although he disclosed
neither his timetable nor the precise nature of his plan.

The only other two project activities, which are miniscule in the
overall scheme of things, are the program for the development of
community leadership (described in this report in the section describing
subregionalization efforts) and a project which provides the part-time
salary of a cancer coordinator in the Schenectady area.
activity is requesting support for only a year longer, and then it
is hoped that alternate sources of support will be found to finance
the cancer coordinator's activities.

This latter

Comments:

care training projects.

The site team agreed that the AMP absolutely must phase-out
its contributions to the two-way radio and the coronary
       A Region which is trying to turn itself around

Albany Regional Medical Program -20- RM 00004

cannot afford to have so large a chunk of its resources tied up in
the same activities year after year. Consequently, it is recommended
that no more than 18 months support be provided for the two-way radio
and that only a year's termination funds be provided for coronary care

must make the decision as to the amounts to be allocated to these
two activities. The site visitors hope, however, that the money
diverted to these projects will not be of sufficient size to belie
the Region's avowed aim of traveling the new road of health care
delivery, etc. Furthermore, there is definite need to more clearly
distinguish between RMP and the Department of Postgraduate Education
involvement in the radio activities. The efforts of the RMP staff
must be clearly identified with the program and not with the Medical
College.

training. Of course, out of its total funds for next year the Region

P

F. Eva lua t ion

Findings: Each project is assigned a core staff monitor. And in the

      two-way radio project each subspecialty series of programs
is assigned a separate staff person. There appears to be no particular
mechanism for relating project evaluation to program planning, beyond
the feedback and exchange in the core staff assembly. Since there is
really no cohesive program as yet, there is nothing that legitimately
can be termed program evaluation.

Comments:

From what the site team could see, however, they have been bogged down
in the past by refining too much on exceptionally complicated techniques
of comparative rating and the use of sociometric devices to chart group
dynamics, which all seems somewhat beside the point. The Region should
develop more formal evaluation methods, establish links between results
of effectiveness and future planning, and provide the RAG and its
Executive Committee with understandable results for planning and
decision-making purposes.

There are on core two educational psychologists and sociologists-
who likely are capable of spearheading evaluation efforts.

'

V. RATIONALE FOR FUNDING RECOMMENDATION

The one year $900,000 recommendation was thought to represent a sum
which could provide, through judicious allocation, adequate support
or program maintenance and termination activities, with sufficient
funds remaining to implement the numerous recommendati!ins and
suggestions of the site team.  The current year's level is $806,001
(reduced from $915,910) and the request for next year was $1,104,790.
The site team felt a funding level smaller than that recommended would
not permit the Region to accomplish the things that it must if the
site team next year is to see the changes that have been recommended
in this report which must be accomplished if the program is to be
continued.

Albany Regional Medical Program -21- RM 00004

VI. RECAPITULATION IN TERMS OF RMPS MISSION STATEPENT REVIEW CRITERIA

A. Performance Criteria

1. Goals, Objectives and Priorities. The Region has established
goals and objectives which are so comprehensive as to cover
any potential activity. Priorities have not been set among
the various objectives. The site team recommended to the
Region  that it develop measurable operating objectives which
are time-limited and ranked in priority order. Refer to the
section on Goals, Objectives, and Priorities, page 10.

2. Accomplishments and Implementation. The activities undertaken
to date appear to have been reasonably successful in terms of
the specific ends sought. The problem lies with the fact that
these specific ends have been, in the past at least, in the
area of continuing education almost exclusively. The Region
  just now is branching out into other areas.

3. Continued Support. Activities stimulated and initially

supported by ARMP are, for the most part, still being supported
by ARMP rather than being absorbed within the regular health
care financing system.
phase out RMP support of these long-term projects so it can
invest its money in innovative activities designed to assist
the Region in its proposed change in direction. Refer to the
section on Operational Projects, page 19.

It was suggested to the Region that it

E. Process Criteria

1. Organizational Viability and Effectiveness. With regard to the

organizational effectiveness of the ARMP, the primary problem

appears to lie with the advisory, review, and decision-making
structure -- which is new and untested. During the coming year
the Xegion must concentrate on seeing that the RAG assumes a
program directing role. See section on Organizational
Effectiveness, page 11.

2. Participation. The involvement of the health-related interests

of the Region is provided for primarily through RAG membership --
and this involvement should be strengthened as the role of the
RAG is strengthened. In addition, two-way radio programs and
the activities of the core field representatives garner con-
siderable local interest and support. See section on Involve-
ment of Regional Resources, page 16.

3. Local Planning.

CHP "b" agencies are non-existent in the Albany

area, although ARMP staff have provided assistance in initial

efforts to establish such agencies. The experiment in sub-
regionalization in three northern New York counties, plus the
services of the physicians on the consulting panel, have
potential for providing for excellent local planning and input

Albany

4.

5.

Regional Medical Program -2.2- RM 00004

But this is not yet a reality. See section on Subregionali-
zation, page 15.

Assessment of Needs and Resources, The ARMP has an excellent
and current data base, but has not yet used it in the most
productive manner possible, and there is evidence that it was
given scant attention in the development of objectives.
Refer to the section on Assessment of Needs, Problems, and
Resources, page 17.

Management and Evaluation.
still is nascent. See section on Evaluation, page 20.

The Region's evaluation process

C. Program Criteria

1.

2.

3.

,

t

Action Plan. Past activities have centered around continuing
education programs which reflect a provider-action plan of
needs to the extent that they were developed in response to
(a) needs expressed by an 80-man physician panel representing

the general geographic area, and (b) the health professionals
in and around the 56 hospitals tied to the two-way radio
network. Current activities indicate involvement (in terms
of dollars and planning assistance) in health care delivery
problems through the means of a University-sponsored neighbor-
hood health program health planning through two Model Cities
programs, and the investigation ot medical care changes through
the physician panel. It is expected that during the coming
year, as the RAG and its Executive Cornnittee assume more of a
program directing role, the AM's developing activities will
be reflective of providers' high-priority needs and in
congruence with RMP mission and objectives.

-- --

- -_

c -.
.

Dissemination of,Knowledge. The two-way radio continuing
education program appears to be a very effective means of
disseminating knowledge of new and improved techniques to a
large number of professional practitioners, including doctors,
dentists, pharmacists, nurses and other allied health personnel.

Utilization of Manpower and Facilities. With respect to increased
utilization and effectiveness of community health facilities
and manpower, although there had not been as much progress
as the site visitors had hoped to find the program has nonetheless
made a contribution through the following efforts: (a) the
neighborhood health effort (to which ARMP is contributing
dollars and planning assistance) is providing health care to a
medically deprived urban area, is experimenting with new
types of manpower, and plans to expand to rural areas; (b)
the physician panel is exploring the possibility of group
practices and the use of allied health manpower in their
practices in the various subregions within the regional area;
(c) the RMP is studying the feasibility of nurse practitioners

as assistants to the physician.

\y.

-_

Albany Regional Medical Program

-2 3-

RM 00004

4. Prevention. The areas of health maintenance, disease

prevention, and early detection are addressed in the continuing
education program and through the neighborhood health program.
Proposed core activities in this area include a Pap smear
program and the creation of a health maintenance system for
physicians' offices.
a strong effort in health maintenance to date, but this
probably will develop as the program progresses.

Overall, the program has not demonstrated

5. Ambulatory Care, Activities involving ambulatory care and
out-patient treatment are covered in the above discussion.
However, the primary push in this direction probably will
result from ARMP involvement with neighborhood health center
and Model Cities planning efforts.

6-8. Continuity of Care, Short-Term Payoff, and Regionalization,

With regard to the relationship between primary and secondary
care, accessibility, quality, and cost moderation and the
linking of multiple health institutions, the program has not
demonstrated a strong integrative function nor has it affected
to any large degree the improvement of the health care delivery
system. The program fields a strong team of information
coordinators and geographic area coordinators, but unfortunately
they have few tangible results in terms of how their efforts
have actually resulted in improvements in health services in
these various regions,
the plans to expand this program into the rural areas is one
exception and stands out as the highlight of their activities.
They believe their field representatives have been successful
in changing attitudes in the region and believe that eventually
this will lead to changes and improvements in the organization
of health services. This is, at the moment, still speculative.
However, the site visit team was impressed with the fact that
they have established working relationships with the community.

The neighborhood health program and

9. Other Funding.

The ARMP is supportive of other Federal efforts

to the extent of their support of CHP, OEO, and Model Cities
planning activities. However, in terms of tapping local,
state, and other funds, the program appears not to have tried
this, at least with respect to current long-term RMP funding
of ongoing projects.

-24-

.

The Albany Medical College of Union Univers'

           Albany, New York 12208

Area Code 5 I8 462-752 I FOUNDED IN 183p

1

Office of the

Executive Vice President and Dean

June 11, 1971

Dr. John E. Kralewski
Assistant Professor and Director
Division of Health Administration
University of Colorado Medical Center
4200 E. Ninth Avenue
Denver, Colorado 80220

Dear Dr. Kralewski:

   As suggested by you, I have completed a very careful study of the
requested salary budget on pages 33 and 34 of the ARMP application.
The major purpose was to ascertain whether the percentages of salaries
of the core staff charged against ARMP were truly realistic.   In this
review, I fully anticipated that I might find significant changes to
recommend on the basis that some of the time charged to ARMP activity
might be clearly chargeable to non-ARMP performance--i.e., perhaps
Medical College programs per se.

After extremely careful review and discussion of the activities

of the core staff, including secretaries, I am truly convinced that the
percentage of effort desig,nated for each employee to ARMP functions is
as close as it is possible to estimate.

There is no question that those assigned 100 percent to ARi'i' acti-

vities are fully justified.
35 hours (non-administrative and non-faculty personnel are paid overtime
for work in excess of 40 hours), the key administrative personnel of ARMP
are expected and do usually work a longer week in order to fulfill
satisfactorily their assigned tasks and obligations.
100 percent ARMP salaried individuals do hold Medical School faculty
appointments--and like other (voluntary) "clinical" faculty--do make
minor contributions to various Medical College programs-in physical
diagnosis or in O.P.D. programs.
cases as 36 hours per year--but usually less than 24 hours.  We could
not have recruited these very competent physicians for the core staff
without offering faculty appointments--and the latter require this minimal
degree of teaching.

Although the formal College work week is

A number of these

This might amount to as much in some

  In evaluating the proposed ARMP funding of the "less than 100 percen-
tees", the percentage estimate of effort toward ARMP as compared to other
activities seems justifiable.

-25-

@ Dr. John E. Kralewski

June 11, 1971

If it seems to the uninitiated that too much time is charged to

1

ARMP activities and not enough to other sources for other responsibili-
ties, I would point out that the College has provided free to ARiW
innumerable hours of effort on the part of many department chairmen and
other faculty.
wants  to see the ARMP fulfill its catalytic obligations to the region
and the ARMP needed the expertise and judgment of professionals such as
these who are only available at the Medical College,
Eckert, Horton, Paul, Hawkins, Doyle, Barron, as well as Mr. Siege1 and
I, have spent an inordinate amount of rime and effort in trying to
strengthen the planning and implementation of ARMF' activities and will
continue to do 60.

It has done so willingly because the College very much

Doctors Bondurant,

I might add--thanks to suggestions from the site-visit team--that

the RAG and its Executive Committee will strive for clear visibility,
identification and greater control of all activities of the core staff.
We have a better idea than we were able to convey at the time of the
site visit but will exert much effort to strengthening this particular
aspect.
and will be worked upon and implemented as rapidly as possible.

Other suggestions made by the site-visit team were excellent

In conclusion, I believe the budget as outlined on pages 33 and 34

                              In my view, it

represents a realistic assignment of staff activities to ARMP functions.
I see no place where a glaring error has been included.
is by no means padded in favor of Medical College functions--including
specific operations of the Department of Postgraduate Medicine.  Thank
you for inviting these comments.  They are sincere and I hope helpful.

Sincerely,

&&w.&t c Ldiy,

Harold C. Wiggers, Ph.D., Sc.D.
Executive Vice President and Dean

I

o

c

8

I A developmental component

I1 The third year continuation of core

1

I11 The renewal of core for two additional years

IV Continuation of five ongoing activities

V  Three-year renewal of one ongoing activity

VI

The implementation of four new approved unfunded activities

VI1 Funds for one approved unfunded activity to be initiated on

9/1/73 with the sixth and seventh years to  follow in the
next triennial application.

The Region requests $1,449,269 (D.C.) for its third year, $1,247,099
(D.C.) for the fourth and $1,587,983 (D.C.) for the fifth year of
operation. A breakout chart identifying the components for each of
the three years follows on Pages 3, 4 and 5.

-

REGIONAL MEDICAL PROGRAMS SERVICE

SUMMARY OF AN ANNIVERSARY TRIENNIUM GRANTAPPLICATION

(A Privileged Communication)

Bi-State Regional Medical Program
607 N. Grand Boulevard
St. Louis, Missouri 63103

RM 00056-03 8/71

July 1971 Review
Committee

Program Coordinator: William Stoneman, 111, M.D.

The Region is currently funded at $875,083 (Direct Costs) for its
second operational year which ends September 30, 1971. The Region
currently receives indirect costs of $272,23lwhich is 31 percent
of the direct cost award.  It submits a triennial application that
proposes :

The Region is not scheduled for a site visit during this review cycle.

On May 27, 1971 staff conducted its preliminary review of this applica-
tion.
and recommendations is attached.) Briefly, staff recommended that
the application be approved for one additional year of support instead
of the three-year program requested. Dollar support was recommended
at the following level:

(A memorandum to the Director, WS, covering staff '8 findings

Total direct cost support at $924,113. This total represents the
projected 1972 fiscal year level of $689,113 plus new funding of
$235,000. Since this Region is potentially faced with a 28~ reduction
for its third year of operation,  staff believed that the increase
recommended would provide a more realistic funding base and could

P

Bi-State RMP -2- RM 00056-03 8/71

be used for:  1) maintaining essential core staff needed for the
development of program activities which will specifically implement
pertinent national health priorities, 2) provide the Region with
some additional funds so that they may become more actively involved
in the provision of catalytic functions, 3) for implementing Project
if16 - To Develop a Model for Testing Effectiveness of Physician
Continuing Education Programs in Terms of Patient Management and
for providing a portion of the renewal request for Project #9 -
Health Surveillance, Health Education and Health Care Accessibility
for a Low Rent Urban Housing Project which is, of course, contin-
gent upon satisfactory review by the August 1971 Council.   In addi-
tion, staff recommended that a management assessment visit be conducted.

Grant Year

01


02

01


02

FUNDING HISTORY

Planriing Staee

       Period

4/1/67 - 10/31/68 (19 Mo.)

11/1/68 '- 10/31/69

' OPERATIONAL 'PROGRAM

7/1/69 ,- 10/31/70. (16 Mo.)

11/1/70 - 9/31/71 (11 Mo.)

Funded (Direct Costs)

$495,39S

443,625

1,094,077

m,om *

*

Reflects 12% reduction imposed on all Regions

. .

(Support Codes) (5) (2)

                 CONT. WITHIN CONT. BEYOND
IDENTIFICATION OF UPR. PERIOD APPR. PERIOD
COMPONENT OF SUPPORT OF SUPPORT
Core - 589,742*

DOO - Developmental

$2-Coop.Reg. Rad. Therapy

t4-Compreh. Diagnostic

45-Nursing Demon. Unit in

98-Coop. Regional Inf.

#7-Establish a Radiation

Therapy Facility
f12-Coronary Care Trg.
   for Nurses
#13-Rehabilitation for

  Myocard. Infarc. Pats
fl4-Clinical & Cyto. Det.
  of Cancer-Indio. Femal

B9-Health Surveillance

#15-EdUcation on Harmful

Develop. & Support 124,885

Demon. Unit for Stroke 47,684

Early Inten. Care(Stroke) 63 -831

System-Health Prof. 13,881

58,902

-2Trban Housinp; Project 232.652

    Effects of Smokine
' B16-Effectiveness of .
   Physician Cont. Educ.

1 I

REGION   Bi-State
CYCLE   RM 00056 8/71

(3)

APPR. BOT
PREV.
FUNDED

-~

**

-

73,800

60.000

35,390

16,750

BREAKOVT OF REQUEST O3 PROGRAM PERIOD

TOTAL

* 04 &05

898,925 232,652 185,940

Beyond Approve Period of Si.pport

PREV.     DIRECT
APPROVED   COSTS

      589,742

131,752 131,752

      124,885

      47,684

63,831

13,881

I

-

58,902

73,800

60.000

232,652

35,3*0

16,750

I 1

INDIRECT COSTS' I TOTAL 1

253,146 842,288

131,752

11,959 I 75,790

I

390,605 1,839,874

nniurs

I
W
I

.

RE;GION Bi-State RM 00056 8/71
                  04
BREAKOVT OF REQUEST PROGRAM PERIOD

COl7l'lNUATION WITHIN CONTINUATION BEYOND

IDEKTIFICP-TION OF ' >,\.PROVED PERIOD OF APPROVED PERIOD OF

COMPONENT SUPPORT SUPPORT


Cor e

DQO - Developmental

#2 -

a4 -

627,740

I

APPROVED,NOT  NEW, NOT     2nd YEAR
PREVIOUSLY    PREVIOUSLY    DIRECT
FUNDED       APPROVED      COSTS

       627,740

237,&6R 137.468

-

-

- #8 -

#7 -

812 -

#13 -

I.

P

i .621 I J , 621

I

**

- -

61,471 61,471

                                          64,140

64,140

114 -

c9 - 25L.831

815 -

#I6

hn 000 I h'1pao

                  251,821

                 20,988
20,988

15.850 15,850

TOTAL 69,092 879,561 160,978

+*Fuh;s requested for 05 pear only with 06 & 47 to fallow ih

137,468 1,247,099

next trienbium -I

- CONTINUATION WITHIN CONTINUATION BEYOND APPROVED, NOT NEW, NOT 3rd YEAR TOTAL P

IDEhT IF IC ATION OF APPROVED PERIOD OF APPROVED PERIOD OF PREVIOUSLY PRBVIOUS LY DIRECT ALLYEARS '

(SUDDOrt Codes)

COMPONEhT

Core

DO0 - Developmental

42

#4

f5

$8

t7

#12

613

614

f9

81 5

616

TOTAL

(5) (2) (3) (1 1 h

-

SUPPORT SUPPORT FUNDED APPROVED COSTS DIRECT COSTS

I

663 , 992 1,881,474 [

663,992

141,764 141,764 410,984

t'

~

-  124,8P5 I

-     47,684 j

-    63,831 1

i

i

21,502 j J,

:I

365,681 365,681 365,681 !

5

120,373

-

67,167 67,167 205,107 3

           60,000 60,000 180,000

258 , 529 258 , 529 743,002

15,000 . 15,000 71,378 I

15,850 15 , 850 48,450

f

1

I

i

922,521 523,698 141,764 1,587,983 4,784,151

-- ---_

Bi-State RMP

-6-

HM 00056-03 8/71

GEOGRAPHY AND DEMOGRAPHY

The Ri-StstE Regional Medics1 Program centers around the St. Louis
metropolitan area.

The Region served by the Bi-State Regional Medical Program is complex
in that it (1) is based on patterns of medical service rather than
on geographic state-defined boundaries and (2) is bi-state as the
name of the Program implies, bridging the Mississippi River to cover
parts of Missouri and Illinois.  The medical service area is that
surrounding the institutions whose joint action brought the Program
into being on April 1, 1967: St. Louis University School of Medicine
and Washington University School of Medicine in St.  Louis and Southern
Illinois University, with major campuses in Edwardsville and Carbondale,
Illinois, then planning and now initiating a medical school In
Springfield, Illinois. The area is roughly described as southern
Illinois, covering 66 counties, and eastern Missouri, covering 43 counties.
(See map, page 7)

.

d

In this area live more than 4,500,000 persons who look, or whose
physicians look, in varying degree to these medical centers for medical
advice, consultation, treatment and health--related education.

The metropolitan St. Louis area has a population of 2.5 million at
least 10 percent of which are estimated to be the urban poor.  Only four
other communities in the region have a population of more than 30,000.
About 260,000 persons live in these commmitiee; the remaining 1,740,000
of the region's population live in smaller towns and rural areas.

In the metropolitan St. Louis area (comprising eight Missouri and
Illinois counties), there are, as might be expected, the most numerous
and most sophisticated health resources:  two medical schools, 52
hospitals with a total of 20,000 beds, 17 educational institutions,
including junior and senior colleges and universities, and more than
3,000 physicians.
cation dot the rest of the region.

Clusters of resources of varying levels of sophis ti-

- 7-

Bi-State RMP - 8- RM 00056-03 8/71

Regional Devclojrncnt

During December 1966, the St. Louis University School, of Medicine,
Southern Illinois University and Washington University School of
Medicine submitted an initial planning grant application.
several neetings, the firat planning award was made during Apri.1 1967.
Washington University was approved as the applicant agency.
Danforth and Felix (St. Louis and Wash. Univ.) were named as co-program
coordinators.

I'ollowing


Deans

i

During February 1968, the Region submitted an application for 02 year
planning support.  Because progress in the Region had been extremely
slow due to a number of factors and events, the 01 year was extended
from 3/31/68 to 10/31/68. Dr. William Stoneman was appolnted planning
director during August 1968.
momentum.  During Xovember 1968, a second-year planning award was made.
Dr. Stoneman was promoted to program coordinator. The pre-operation
site visit was conducted during April 1969.
operational application contained six proposals.
concurred with the site visitors and the Review Committee and recom-
mended three of the six projects for approval; three were to be
returned for revision.  On July 1, 1969 the Region became operational
with three activities:  Project #2-Cooperative Regional Radiation
Therapy Development and Support Program; #4-Comprehensive Diagnostic
Demonstration Unit for Stroke and 115-A Nursing Demonstration Unit
in Early Intensive Care of Acute Stroke.  Third year continued
support is requested in this application for these activities.
During the Region's first operational year three additional proposals
were submitted.
conditions :

At this time the Region began to gain

The Region's original

The May 1969 Council

The August 1969 Council approved the projects with

Project 17 - Establish a Major Radiation Therapy Facility as Part
of a Center for Comprehensive Care - (Hold RMP Dollars for equipment
pending further justification); Project f8 - Establish a cooperative
Regional Inforr,iation System.  (Fund for 3-years at 112 the requested

level. )

Project #9 - Health Surveillance, Education and Care Accessibility
- for Residents of Low Rent Urban Housing Project (fund for one-year
to allow time for further planning).
tinued support fer 118, deferral of funding until the 5th triennial
year for 117 and Renewal of project 119 which has been supported for
one year.

This application requests con-

The July 1970 Coucil recommended approval of Project #12 - C.C.U.
Training for Nurses.
the activity for the period 11/1/70 - 9/30/71.

Carryover funds were authorized to initiate
              Two years of con-

tinued support are requested in this application,
review cycles the Region currently has four projects which are approvedl
unfunded.

From various

Bi-State RMP -9- RM 00056-03 8/71

The present application reflects the Region's decision to submit
a triennial application on its anniversary rather than an applica-
tion geared only to its plans for the next year.
of the developmental component, no new activities are proposed,  The
following chart displays the Region's funding status at the time
this application was developed; the level of fundinK for thr. con-
tinuing life of onp,oing projects and specific new/i~pprovcd-hutllot-
[nitlnted activitles plus the develoDqg& component:

With the exception

Present Projected for Triennium

Fun ding 1st Year 2nd Year 3rd Year

Core

Developmental
Component

Ongoing Projects,
Continuation or
Renewal.

- New Projects
and their continuation

(11 /1/ 70-9/ 30/ 71)

$447,116 $589,742 $627,740* $663,992

None 131,752 137,468 141,764

427,967 541,835 320,913 258,529

None 195,940 160,978 523,698

$875,083 $1,449,269 $4 247,099 $1,587,983

Totals

-

* Core Renewal

Rf--Stste RMP -10-

ORGANIZATIONAL STRUCTURE AND PROCESSES

RM 00056 8/71

Regional Advisory Group: On August 15, 1970, the Bi-State Regional

wa8 increased from 55 to 77 members. While the original group contained
2 minority representatives and 3 consumers, the reorganized RAG contains
22 minority representatives and 14 consumers or public representatives.
The number of representatives of medical 8choo1s was reduced and geographic
representation was broadened. Although the actual total membership in
the Greater St. Louis area was increased from 38 members to 44 members,
the increased membership is cauaed by more inner-city and non-provider
community representation.
21 former members were dropped. According to the application, the
reorganization has created a RAG which has greater potential  for broad
Regional in-put and decisionmaking and a potential from more effective
advocacy of the RMP aims from the varied interests and geographic areas
represented.

The Regional Advisory Group meet8 approximately every three months and
has approximately 75% attendance.

Group was reorganized. The total membership

In arriving at the total membership of 77,

Executive Committee: The function of the Executive Committee is to study

to the Regional Advisory Group on basic planning, direction of develop-
ment and other policy matters.
approximately six times a year.  The original committee was composed of
12 members (1 Black). The committee ua8 recently reorganized and the
membership increased from 12 to 15 (3 Blacks). The new membership
includes: three University Medical Center representatives: three
representative8 of the public; three practicing physicians: two allied
health representatives; and four representatives from the public and
private health administrative interests.

the program in depth, develop and make recommendations

The committee meets between RAG meetings

Committee Structure:

education, communications and public education, stroke, demography and
statistics and 8 committee on health care delivery.

The Region ha8 eight standing committees on heart
disease, health manpower, cancer, continuing

There is also a Scientific and Education Review Committee which is
composed of the chairmen of the eight program committeee  listed above
and members of the Administrative Liaison Committee. The responsibility
of the Scientific and Education Committee 6 to review all proposals
submitted by the several program committeee beforesubmission to the
RAG. Approved proposals are ranked according to priorities.

Bi-State RMP -SI- RM 00056 8/71

The Administrative Liaison Committee, appointed by the Deans of the
Medical Schools has responsibility for overseeing the administrative
aspects of the Region's program, including review of salaries and
expenditure of funds.


Review Process: At the first indication of fnterest, a prospective

director (in the medical school) or an associate director on core staff
(example - Allied Health) who will assist him in the development of
the proposal, if the de. appears feasible. The completed proposal ir
first reviewed by the sppropriate program committee. If the review fr
positive, it goer to the recond level of review, the Scientific and
Educetional Review Committee. If the proporal is ruccerrful at thir
level, it then goer to the Regional Advirory Comnittce.

Evaluation:

full-time planning director has been employed who is to have primary
responsibility for both planning and evaluation. Also, the Region her
designed B standard form evaluation type questionnaire which is to be
used in all activities.  RMPS Staff, in its review of the application,
believed th8t rome method should be developed whereby information
derived on the progress of the ongoing program can be reviewed (snd
used) by the appropriate committees and by the RAG.

applicant is put in contact with an appropriate associate

During the past year the Region has made some progress in
trying to develop a more adequate evaluation procesr.

A

Data Collection 8nd Analyrir

Data collection is the third highest priority set by the Regional
advisory Committee and is one of the areas in which developmental  funds
would be ured.
Federal agencies 8nd other interested groups in the six-county area
comprising the Metropolitan St. 'Louis community to develop sumnury
census dat8 center.

Currently the Region 8 cooperating in a consortium of

Program Priorities:

Committee on March 22, 1971.
munpower and "to develop programs aimed at correcting the lack of
physician manpower services in parts of the region."
relates to allied health manpower and is "to develop programs to makr
snnropriste health manpower available throughout the region."

On page 23 appears a listing of program objectives
with priorities assigned by Bi-State Regional Advisory

Objective Priority #1 relates to physician

Objective #2

Objective prfority ranking has been assigned to 21 activities identified
under ninp problem areae.

RM 00056 8/71

Bi-Stete RMP -12-

Staff noted in its review of the application that on September 1, 1970,
the Bi-State RMP Region' Advisory Committee adopted the following state-
ment of general program priorities:

I.

Improvement of health care delivery


a.

1

Improve systems for delivery of health care services to
thp medically disadvantaged.

,

b.

Extend and increase availability of improved scientific
end technical modalities in health care,

c.

Delivery of service-systems by development of center-
sub-center cooperative relationships.

XI. Education, including continuing education of the medical,

nursing and allied health professions, especially in support
of aims expressed above.

111. Prevention of disease and its complications.

The Deve 1 opmen ta 1. Component

The Region requests developmental fund8 of $131,752 for the first
triennial year; $137,468 for the second and $141,764 for the third year.
The ability to move expeditiously to solve problem8 and gain coopera-
tion, using ~rnall amounts qf funds, has been cited by the Region as
one factor in its program growth.  The application lists, by order of
nriority. how the proposed developmental funds will be utilized in
the areas of manpower, health care systems. data base, cantfnuing
education for primary care personnel, cornnrehensive strategy for primary
care, medical information (patient management), availability of medical
resources, and strategy for utilization of secondary and tertiary
sources. In general, the approaches are described 88 plarining studies,
specific investigations, demonstrations, and ''seed" money.

Developmental requests of $10,000 or less will be allocated by the
program coordin8tor with spproval of the Executive Committee of the
Regional Advisory Committee.
and allocation made upon approval by the R.A.C. following recommendations
from the progra coordinator.
of Developaente? funds appeared to be in line with the region's problem-
priority ranklngs.

Requests for larger 8umi will be reviewed

RMPS Staff noted the the proposed use

:

RI-State RMP

-13-

RM 00056 "- 8/71

*._&_

Requested (D.C. .

- Core Third Year

Core is presentfy supported at the $447,116 (d.c.)
level for thr. (02 year) eleven-month period, 11/1/70 - 9/30/71. Support
for the Region's 4th and 5th yeadare requested which is beyond the
approved period of support for this activity.

$589 , 742

The current staff consists of 26 full and part-time personnel,
Program Coordinator is supported for 977. time or effort. One full-time
field coordinator position is vacant along with four half-time associate
director positions. Three of the latter positions are budgeted for
the new Southern Illinois University School of Medicine.  Uncertainty as
to the'wisdom of retaining categorical emphasis along with budget cuts
have delayed recruitment. The core budget escalates due to the limited
staff additfons, salary increases end normal inflation of equipment
costs, travel, etc. The application describes a busy core staff
operation which moves in the areas of planning, support in identifying
needs, assistance with project development, evaluation in operational
effectiveness, data collection, developing cooperqtive relationships,
and public relations. The application describes several core-supported
feasibility and planning studies which are in progress or are being
developed.
stemmed from feasibility studies using core funds or by using core
staff capabilities. RMPS Staff believed that Council may favor an
increase for core during the (03) year provided the funds would be
utilized by the region to develop program (project) activities leading
to a new three-year look for next year's application.

The

Several of the projects which are currently awaiting funds

Fourth Year
$62 7.740

Fifth Year
$667,992

.Continuation of Projects within approved
Periods of Support

Staff, in its review of the triennial application, found it difficult
to relate these activities to the newly evolving national health
priorities. However, it was realized that as this application was
being developed, the national health strategy was changing. Staff
concluded this would require a fair "turn-around or re-direction
period. "

Project t2 -

Mall Znckrodt

This project
is supported

Third Year
$1 24,885

Radiation Therapy Development and
Support Program - Washington University
Institute of Radiology

wee initially supported during August 1969. Currently it
at the 11-month, through 9/30/71 $108,064 (d.c.) level.

Bi- State RMP

-14-

RM 00056 8/71

Requested (D. C. )

One year of support is requested to further pursue the original objec-
tives of:
2) develoninp: a cooperative radiation physics center; and 3) providing
radiaton-therapy technology enrichment and training to advance skills
in technology.

I) extending a dosimetry communication system (telecopiers);

The project plans to continue and expand its telecommunication net-
wrk (presentIy 23 hospitels) through which hospitals and medical
groups are connected to the Mallinckrodt Institute for consultation
an treatment plena. Plans are to continue both physician and tech-
nicfen refresher courses (30 physiciane - 30 technicians participated
during September-October 1970).  Training components for professional
and paramedical personnel are to continue.

Phese out to institutional, local or other grant mechanisms support
is expected.

Fourth Year

- 0-

Fifth Year
  - 0-

This project v8s initially funded during August 1969.
being supported for the eleven-month yeer, 11/2/70 - 9/30/71 et the
$42,037 (d.c.) levbl.
pursue the orginal objectives which were to demonstrate the best
techniques for stroke diagnosis to physicians, nurses and technicians
and to encourage establishment of similar units throughout the region.
Lectures and demonstrations have been presented to 1,275 physicians
and medical personnel either at the home base or in "circuit-riding"
units. This total represents 128 hoapitels - 78 medical spcieties.
Regiondl units are now being planned for several towns and cities in
both Missouri and Illinois.
center end community hospital support following withdrawal of RMP
funds.

It is currently

One year of continued support is requested  to

Phase out is planned in terms of medical

Fourth Ye8r

--

- 0-

Fifth Year
   - 0-

Bi-State RMP

(I)

-15-

RM 00056 8/71

Requested (P. C. 1

Third Year
$63,831

Project #5 - Nursing Demonstration Unit in Early

St. Louis City Hospital

Intensive Care of Acute Stroke -

This project was initially supported during April 1970.
currently supported for an 11-month year (ending 9/30/71) at the
$55,690 level.  One year of continued support is requested to help
solve three basic problems which were identified during the project's
planning period. These are: 1) lack of intensive care facilities
for the indigent stroke patient; 2) a lack of nur8es trained in the
necessary specialized techniques; and 3) a need to determine the
effect of early intensive nursing care of the kind a modest-sized
hospital can provide, A six-bed unit was proposed.
alterations and renovation problems, opening of the unit waB delayed
until 12/70. Since that time and through April 1971, 71 patients have
been admitted. (947. occupancy rate, 21 deaths.) To date, 15 nurse0
have received special training. The project is receiving regional
as well as national inquiries. Phase out plans are not firm at thir
time.

It is

Due to the usual

Fourth Year

- 0-

Fifth Year
   - 0-

Third Year
$13,881

Project #8 - Cooperative Repional Information

St. Louis University - Medical Center Library

System for Health Professions -

This project was initiated during June 1970.
supported for the 11-month period, 11/1/70 - 9/30/71 at the $30,278
level. Two years of continuing support are requested. The prtmary
objective is to make av8ilable up-to-date medical information to
hospital libraries.  Since the program was initiated 87 hosvitala
have joined the network, one workshop has been conducted (attendance
40). a field librarian has been added to core staff to coordinate
the activity. evaluation techniques are to be developed. Phase out
is planned in terms of charges, on an arcending scale,  for sub-
scriptions, photocopy service and tuition for workshops.

It is currently

Fourth Year
$7,621

-16-

Bi-State RMP RM 00056 8/71

Project #12 - Coronary Care Training Program

for Nurses - St. Louis University

Requested

Second Yr.
$58 902

This activity was initiated during December 1970
utilizing $64,293 of carryover funds.
been reduced to $60,293.

This amount has since

The Region now requests two continuing years of support.

Since December, and through the time this application was prepared,
the program has been staffed, equipment installed and a classroom
has been renovated to simulate a mock C.C.U. Three courses which are
to train a total of 30 nurses are scheduled for April, June and
August 1971.  This activity is related to the Region's second priority -
to develop programs to make appropriate allied health manpower available
throughout the Region.

The November 1970 Council policy as it relates to CCU's and training
for CCU's is quoted:

"Coronary Care units:
units are now established conanunity resources, Regional Medical Program
funding units may be desirable when such units make important contributions
to regionalized improvement in medical care, including overall efficiency
and cost and when projects are planned to disengage from Regional Medical
Program support promptly.  To qualify for Regional Medical Program assis-
tance coronary care unit projects must also meet the following conditions:
(a) An organizational structure and staff capable of implementing a high
quality system must be present; (b) the mechanisms for entry into the
system require development; and (c) RMP funding does not finance established
technology, equipment, or patient service operations.

Council affirmed that although coronary care

Training for coronary care units: Council requested RMPS to instruct
all Regional Medical Programs having coronary care unit training projects
to disengage Regional Medical Program funding at the end of their current
project period8 or within a reasonable period thereafter as noted above."

Third year - $61,471

Continuation of Projects Beyond Approved
Periods of Support (Renewals) Second Year

Requested

$232,652

Project #9 - Health Surveillance, Health
Education and Health-Care .Accessibility for
a Low-Rent Urban Eousing Project - Pruitt - ICOE
Men's Progressive Medical Action Program Inc.

This activity is currently funded for one year (11/1/70-9/30/71 -
11 months) at the $131,605 (D.C.) level. This application requests
renewal for three years.

-17-

Bi-State RMP RM 00056 8/71

The proposal was originally reviewed by the July 1969 Review Committee
who believed that while the project represented an area of great
health needs, more planning was needed.
recommended disapproval, with encouragement to revise and resubmit
the application. However, the August 1970 Council, while recognizing
the validity of the Committee's questions and reservations,  felt
approval of one-year funding equal to that requested ($143,492),
would enable the Region to pursue the planning necessary for  the
submission of another proposal for its operational support.

The Review Committee

Also, staff in its review of this application as a part of their total
recommendation to the Director, RMPS partial funding contingent upon
the August 1971 Council's review and approval of the renewal request.
This recommendation would provide Council with the opportunity to
again review the activity with reference to the Region's total program.
The activity has the approval of the Executive Board of the Model Cities
Agency.  The original objectives of the program were to make better
medical care available to the residents of a low-income housing
development and to raise their health education and awareness  levels.
Also, the activity is to be an attempt to introduce the population
into the existing health care system.  Pages 97 and 98 contain both
a progress report and triennial plans for the project.  The budget
escalates arproximately $100,000 second year over first.  Personnel
accounts for $179,726 of the total second-year request of $232,652.
The project is included in the Region's second highest priority ranking
to develop a comprehensive strategy for the delivery of health care,  etc.

third year - $251,821

fourth year - $258,529

N.A.C. Approved Projects GJhich Have Not Previously Been Funded

Project 813 - Rehabilitation for Patients Who Have Had a

First year

Myocardial Infarction - Washington University
School of Medicine

$73,800

This activity was approved during the July 1970 Council.
of support are requested. The objectives are to: (1) Provide patients
(in the St. Louis area) who have had a myocardial infarction, with
rehabilitation services which will help them return to an active
productive life;  (2) Educate members of medical and lay communities
regarding the benefits patients can derive from coronary rehabilitation
procedures. Approximately 250 patients (physician referrals) are
expected during the first year, 300 for each of the following two years.
The program is to provide initial patient evaluation, diet therapy.
First-year costs include $55,659 for personnel: cardiologist - director,
exercise physiologist, medical technician, physical therapist and
secretary .

Three Years

second year - $64,140

third year - $67,167

Bi-State RMP

RM 00056 8/71

Project #14 - Clinical and Cytological Detection
       of Cancer in an Indigent FemalePopulation
        St. Louis University

First Year
$60,000

The Region was notified by letter on January 20, 1971, that Council's
original policy to not fund cancer programs which had formerly been
funded under 314(e) had been reconsidered. Therefore, this program .
is now being held as approved/unfunded.  Three years of support are
requested.
not only screening or cervical cancer but also for breast and rectal
cancer.  Screening clinics are to be held three ti& per week In
St. Louis University Hospital and in St. Louis city and Homer G. Phillips
Hospitals four times a week. Additionally, the DePaul, St. Louis Chronic,
St. Louis State Hospitals and St. Mary's Health Center Mobile Unit
will provide screening for indigent neighborhoods in St.  Louis and
East St. Louis.
year period.

4

The proposal merges two discontinued projects and provides

*

I1

>

As estimated 60,000 are to be screened over a three-

The three-year direct cost total is $380,000.
progress to split- the costs among several agencies (model cities)
with Bi-State RMP's share projected at $180,000 over the 3-year period.

Negotiations are in

second year-$60,000

third year - $60,000

Project #15 - Coordination for Public Education Programs

First Year
$35,390

on the Harmful Effects of Cigarette Smoking
Bi-State Inter-Agency Council on Smoking
and Health

This project was reviewed, and not disapproved but considered of low
priority, by the May 1971 Council.
The project has a single objective which is to improve coordination of
the Bi-State Metropolitan Area (a total of six Missouri and Illinois
Counties) efforts in public education on the haraiful effects of smoking.
The 3-year descending scale budget includes initial full support for a
coordinator and secretary plus the usual expenses.  During the 3rd year,
support is requested only for the salary of the coordinator.

Three years of support are requested.

Basically evaluation will be in terms of local support recehed.

second year - $20,988

third year - $15,000 '

Project #16 - Develop a Model for Testing Effectiveness of

First Year
$16,750

Physician Continuing Education Programs in
Terms of Patient Management - Bi-State RMJ?

This project was reviewed and approved by the May 1971 Council as an
especially interesting rroposal.
The !.rogram 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

and (2) test the usefulness of such patient mnagement analysis to
faculty and local physicians in planning education programs.

Three years of support are requested.

Bi-State W

-19-

RM 00056 8/71

The RAG regards this project as possibly one of the Region's important
achievements. In addition to having a low dollar cost, this activity
represents to the local review body acceptance of the RHP as competent
to exert leadership among professionals, in this instance, the physician
staff of three hospital areas.

The project was voted the highest priority of any Bi-State proposal
to date. The state medical societies of Missouri and Illinois have
approved and/or comnended the innovative character of the activity.
The project has a good potential of becoming a complete regionalized
activity .

second year - $15,850

third year - $15,850

Project #7 - Establish a Major Radiation Therapy Facility

First Year
$365,681

as Part of a Center for Comprehensive Cancer Care

Included in the application is a request for support ($365,681)
during the fifth year (third year of triennium) for this project.
The August  1969 Council approved this project with the following
conditions and recommendations. "The Council was concerned about the
use of large amounts of RMP funds  for the purchase of expensive equip-
ment and other costs of establishing patient service facilities.
Especially because of the large amount of radiation equipment known to
exist in the St. Louis area the Council would like to be reassured
concerning the need for this new installation in serving the poor
residents of the immediate area and in teaching and demonstrating
good radiation therapy practices.  Expenditure of RMP dollars  in the
equipment category is to be held until some further details and
assurances can be submitted and reviewed by the St. Louis
University is to construct a $6 million building to house the facility
and the expanded cancer treatment program.
be completed in 1973.
funding of the program until October 1973 which will come during the
third triennial year or the 5th year.
Of this total, $254,135 is for equipment.
accelerator, X-Ray therapy simulator, tomograph and programmed console).

The request is further complicated by support requested for a second
and third year which would occur in the Region's next Triennium.

            It is anticipated this will
Therefore, the Region requests approval to defer

The total request is $365,681.

(Principal items are linear

In its review of this application members of staff believed that the
Region should re-apply for this project at or near the time the
facllity is completed.
to reconsider the program and satisfy its concerns regarding the
original submission (equipment, etc.).

This would provide Council with an opportunity

6/17/71

8
b

0 Date:

   to
Arts of:

suytc;:

To:

THROUGH :

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

c

              PUBLIC HEALTH SERVICE
HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION

o

n

Junc'l7, 1971

Staff Review and Action on May 27, 1971 of Tricmnial. Apffication
subnlitted by Bi-State kegional Medical Program, I?? 00056 8/71

Director
Regional Medical Programs Service

Acting Deputy Director
Regional Medical Programs "Service

1 /'P

-<

.*- Y? 1

Chairman of the Month'

Chief, Grants Revitiw I I

I bq

t ik

Chief, Grants Nanagement Branch

A. ',

Acting Chief , Regional Development

-/-e'

Recommendation: Staff recommends that the IZi-State Triennial. Application
dated 5/7/71 be approved for one additional year of support instead
of the three-year program requested. Dollar support is recommended at
the following level:
represents the projected 197.2 fiscal year level of $689,113 plus new
funding of $235,000. Sixe this Region is potentially faced with a
28% reduction for its third year of operation, staff believed that the
increase recommended t70Uld provide a more realistic funding base and
could be used for: 1) maintaining essential core staff needed for the
development of program activities which will specifically implement
pertinent national health priorities, 2) provide the Region with some
additional funds so that thev may become more actively involved in the
provision of catalytic functions, 3) implementing Project #16 - To
neve19 a Kodcl for Testing Effectiveness of Physician --- Cont5nuiilg
Education Programs in Terms of Patient Management -- I__ and for provi;ling
a portion of the renewal request for Project 419 -- Ilcalth Survcillance, --- __
Health Education and Health Care Accessibility --_ for --__-I_--- a TAW Kent Urban
- Housing Project -- w1ii ch is, of course, contingent upon satisfactory revie
by the .August, 1971 Council. In addition, staff reconunended that a man-
agement assessment visit: be conducte'd.

Staff Participating --- in Review

I_----- I

total direct cost support at $924,113.

This total

-- -___I__-

-___-- ---

1) Xr. Robert Chambliss
2) Hr. George Kinkle
3) PIr. Joseph Jewel1
4) Dr. Marian Leach
5) Mr. Spero Houtsatsos
6) Mr. Miclincl Posta

'I

w

Director, NE'S

o

Current Funding

-

. ...

I,

r,

2

The Bi-State WIP is currently funded at $1,147,314 (total costs), for
its 02 year which terminates September 30,  1971.  This tftal includes
the 12% reduction which was imposed on all Regions during April 1971.
This amount, for an eleven-month period 11/1/70-9/30/71, represents
new funding of $681,858 and an unobligated balance of $465,1156  from
the first ycnr of the operational grant,
are included in tliese figures.

Indirect costs of $272,231

Much to the surprise of the majority of staff attending the meeting,
the Region has subiriit ted an application reqhesting three-year support,
Members of staff had been expecting a one-year pplication wbich would
cover only the 03 year of the Region's initial three-year operational
program.

Based on this belief, no site visit had been plcmned.

The current application requests $1,449,269 (d.c.) for the Region's
next year operating level.

. with the exception of the request for a developniental component. A
$100,000 increase in core is essentially to provide for the present
staif in addition to filling part-time associate director positions
in the medical schools. (1/2 time-stroke-Washington University, 3-1/2
tine associate directors in the fields of continuing education, health
care system, and community health,  at the new Southern Illinois University
School of Xedicine) and' a full-time Regional Field Coordinator.

On October 20, 1970, staff conducted its review oi the Rcgi.on's appli-
cation for the(02) year,  During the Revicw, a list of ten general.
concerns regarding the Bi-State RIYP devclopcd.

There are no new project ac,tivities included

Thcsc wcre :

1)  The "turf" problem between the Bi-State, thc Nissouri and the
Illinois Regional Medical 'Programs.
2)  The assignment of a Bi-State field coordinator to the Springfield,

Illinois area in view of the jurisdictional and geographic problems.
3)  At what levels in the local review process,vetoes may be
imposed-appealed.

4)  The number (and types) of proposals which have becr, disapproved
in the local review process.
5)  The Regioil's evaluation methodology and the uses which are being

made of. the information.
6)  Eow the proposed data collection'system would actually strengthen
thc plannizg efforts of the Region.

7)  The actml contribution toward thc goals and objectives whi.ch was
being mad? bjr the discasc catcgoricnlly assigned associate directors
in the two fiiedical scliooLs.
8)      of reported jiiipact that the currently funded operational

projects fiavc> (or may have) on the. improvcillcnt of thc dc!l.ivcry of .
health care. */

_I

A lack

t

i.

3.

I, t

Director, DIPS 3

*

9) .How (and why) some oE the minimal requests for carryover ($200-$350)
were processed through the local review systm.
10)  The Region's stipend level was not in line with Council's July,
1970 policy as it relates to stipends, travel, etc:, for-hort-term
traineeship.

During its review of the current application,  staff believed that the
Region had satisfied some of the above concerns.
has employed a full-time planning director who is to be responsible for
program evaluation.
a beginning,  staff believes the Reg-ion will need additional time to
develop a nethod of self determination and seek answers to the following
questions :

For example, the Region

While it is obvious that this individual has made

6

1)
2) Have projects (or studies) been terminated or returned
as a result of the evaluation process?
3) At what point does evaluation come into plan in the
operation of the program?
4)  What is the relationship of the core staff responsible for

evaluation to the Regional Advisory Group?

How is evaluation used by the RAG in decision making?

Also, the Region has made an effort to "solve" the Illinois-Ei-State
RMP turf problem by describing a seven-county area surrounding Springfield,
Illinois (site of part'of new S.I.U. Medical School) as a local determina-
tion area, The Region reaso&is this should leovc reasonable flexibility
to conununities which are uncertain of their position and still proyi.de
sufficient definition to allow each KMP to plan for allocation of limited
resources.

Staff was aware of the fact that during the time the anniversary appli-
cation was being prepared redirected Natidnal Health goals and priorities
were emerging.
(03) year continuation rather than consideration of the three-year
program requested.

On September 1, 1970 the Bi-State PAG adopted four general program
priorities.

of health care services to the medically disadvantaged.  On March 22,
1971 the program objectives and priorities were modiied (or changed),
and objective priority Rank #I. was assigned to _Physician Manpcoxes with
the regional objective "to develop prograins aimed at correcting the
lack of physician manpower serviccs in parts of the Region!'
#2 was assigned to allied health manpower with a regional objective

available throughout the Region!' While thc Regional Advisory Group
now has designated health manpower as thc.yain thrust for the RMI?, this
application does not reflect this priority.

This was one of the factors upon which staff recommended

The highest priority, at that time, was "Improvement of

Health Care Delivery" which included improved systems for delivery .*

Similarly,

to develop programs to make appropriate allied health manpower

It

It appeared to staff that

,-

Director, RMP 4

o

the IplG has failed to operationalize its priorities. 'This then raised
a question of on what basis does the RAG estzblish priorities?
connection the recently reviewed supplemental proposals (May, 1971 Council
#I5 - Smoking and Health and #16 - Physician ContTnuing Bducation Program)
do not appear to concern themselves with meeting manpower shortages or
improving the accessibility and availability of health services within
the Region.
time-to translate priorities into project proposals concerning explicit
criteria against which project proposals are reviewed.

In this

It appeared to staff that the Region has not had sufficient

Staff, again realizing this application was prepared during a period
of transition, noted the heavy categorical emphasis of the associate
directors who are supported (all 1/2 time) as a part of Core in the
Washington University and St. Louis University Medical Schobls. Three
associate directors in heart, cancer and stroke are currently supported *
at the St. Louis Uiiiversity School of Nedicine while Washington Univer-
sity has two associate coordinators in lieart and cancer.
position at Washington University is vacant.
requested for all these positions.

'

The stroke

Continued support is

,

In arriving at its recommendation,  staff believed that the Region might
wish to utilize the one-year period to realign and recast  some of its
personnel to more accurately reflect the current mission of TcI"IP.

While there was some confusion as to how one would relate the Bi-State
goals and objectives to the "1971 Philosophy", there was a general agree-
ment that the budget request had "missed the marld'
approach appears to remain evident in the numbers of core staff requested
for the three medical schools.  The projects which have been approved
but not funded and those programs for which continuation is requested
appear to lack innovation and to be more of the "same old thing!'   While
it is known that the Regioti'has strived for and gained consumer partici-
pation in its program, evidentally more time is needed for this group
to have an influence on the program.  Most of the funds requested are
destined for institutional rather than community ventures where a large
major8ty of health services gaps appear to exist.

After a long contentious period of review, the majority of staff believes
that the B$-State RMP is not, yet ready to "pass the test" for triennial
status,
increased level from the present book commitment forecast for this Region
which now stands at 28% below the current (02) year funding level.

Staff further recommends that Project #9 - Kalth Surveillance,  Health
Education and Health-Care Accessibility for a low-rent urban housing
prcject be considered for renewal during the August, 1971 meeting of
the National Advisory Council.
for one-year by the August,l970 Council.
the Region to pursue the planning of such 3 program preparatory to the
submission of another proposal for its operational support.

A categorical,

-a

Rather, staff recommends continuation of one more year at an

This project was recommended for approval

The one-year period was to enable

The Region

Director, RMP 5

o

has supported the project through 9/30/71 ($131,605 d.c.) with Model
Cities earmarked funds which were obtained fwm the (01) year unobli-
gated balance.

Staff singled out this project for special consideration

for the following reasons: ,#-

e

1) .It is based in a commuxity rather than institutional setting.
2) It is in line with the current mission of increasing availability

the organization of services and delivery of care more efficient.

,of care, enhancing its quality and moderating its costs--making

In summary, Staff believed that the one-year continuation period will
provide the Region with the opportunity to objectively reconsider and
restructure itself more in line with the national health goals.  Staff
believes that its recomnicndation fol.lowri an honest and thorfughly
thought-out appraisal ad is based on a bclicr that the Region contains
the necessary strengths and talents to make a visible impact in improving
the health care system.  The continuation in time, coupled with the
new funds recommended, may provide the necessary catalyst to enable
the Region to present a "new Look'' triennial applicatidn in May, 1972.

.

f ,-->/

Jos h T. Jewel1
Pu lic Health Advisor
Grants Review Branch

Action by Director

Initials

-u/J-

0

(A Privileged Communication)

SUMMARY OF REVIEW AND CONCLUSION OF

  JULY 1971 REVIEW COMMITTEE

BI-STATE REGIONAL MEDICAL PROGRAM

RM 00056 8/71

FOR CONSIDERATION BY AUGUST 19 71 ADVISORY COUNCIL

RECOMMENDATION:

The Review Connnittee concurred with staff's
recommendation that this triennial application be

d for one additional year instead of the three years requested,
t additional dollar8 be provided to the Region.

The request

for Developmental Component Funds was not approved.

OPERATIONAL RE COMMENDED

YEAR REQUEST (D.C.) FUNDING (D.C.)

03 $ 1,449,269 $ 924,113

1 , 247,099 -0-

TOTAL

$. 4,284,351

$ 924,113

:

The Review Committee noted that the Region has one additional
year of committed support remaining fron its initial opera-

onal program period.

It was agreed that the submission of this

ennial application was premature; a one-year continuation application
Id have been more appropriate.
Connnittee considered and agreed with the review and recommendations
staff in its review of the triennial application.

In arriving at its recommendation,

                                 "Staff believed
he one-year continuation period may provide the Region with
portunity to objectively reconsider and restructure itself more

national health goals.
in time, coupled with the new dollars recommended,

Staff further believed that

necessary catalyst to enable the region to present

a 'new look' Triennial Application next year."

he reviewers believed that the,Bi-State RMP has many strengths such

ood committee structure (although their real involvement in
    an apparently well balanced rather strong Regional
     and qualified leadership.  However , they suggested

Bi-State RMP -2- RM 00056 A,

that the Region be advised of their concerns in
following problem areas and deficiencies :

1)
Missouri RMP's.
area which is tom between the Illinois and the Bi-State RMP.

relation to the

!

The fragmentation of the Region in relation to the Illinois and

A perfect example of this is the Springfield,  Illinois

2)
newly established program priorities.

The continued categorical emphasis of the program in view of its

3)
need a very close review.
of expensive radiology equipment was particularly cited.

The Committee suggests that the Region's operational projects

The heavy emphasis placed on the provision

4) The Committee was concerned about the actual contributions to
the RMP effort being made by the three categorically (Heart, Cancer,
Stroke) assigned associate directors who are currently supported for
50% of their time or effort in both Washington University and St.  Louis
University Schools of Medicine.
the Region has requested support of three additional half-time associ-
ate directors in Continuing Education, Health Care Systems and Community
Health in the new Southern Illinois University School of Medicine.
It was suggested that the Region establish RMP related job descriptions
for all of these individuals.

This is particularly important since

5)
evaluation could be strengthened if more emphasis were placed on

While not unique to this Region, the reviewers believe that its

outcome" methods and procedures.

11

6)
for the future of the program.
contained no new proposals with the exception of a request for a
developmental component.

The reviewers noted the vagueness and lack of detailed planning

For example, the triennial application

7)  The committee strongly suggests that the Region immediately take
whatever steps are necessary to insure local (or other support) for
the continuation of its operational projects.

Ration ale f o r Funding Re co irrnen da t ion

The Review Committee concurred with staff's funding recommendation
and recommends one additicnal year of support instead of the three-
year funding requested.  Dollar support is recommended at the fol-
lowing level: Total Direct Cost support at $924,113. This total
represents the projected 1972 Fiscal Year level of $689,113 plus new
funding of $235,000.
28% reduction for its third year of operation, it was believed that
the $235,000 increase recommended would provide a more realistic
funding base and could be used for:
staff needed for the Development of Program activities which will
specifically implement pertinent national health priorities;
provision of sufficient funding to permit more active invo'lvement

Since the Region is potentially faced with a

1) Maintaining essential core

2)

b Bi-State RMP

- 3-

RM 00056

in their catalytic functions; 3) Implementation of Project #16 - To
Develop a Model for Testing Effectiveness of Physician Continuing
Education Programs in Terms of Patient Management and for partial
support of the renewal request for Project 119 - Health Surveillance,
Health Education and Health Care Accessibility for a Low Rent Urban
Housing Project.
for special consideration.  The innovative and unique qualities,
at a modest cost of the continuing education program were cited.
Project 119 is based in a community rather than in an institutional
setting and, more important, is in line with the current mission of
increasing availability of care, enhancing its quality and moderating
its cost--to make the organization of services and delivery of care
more efficient.

The Review Committee singled out these two projects

member of the Committee had questions about the physical fate

of the Pruitt-Igoe Housing Project in St. Louis, the site for
Project {IS.

On a recent television program (First Tuesday) it was

ated that the housing project might be tom down because of
me vandalism. Staff has contacted both the H.U.D. offices in
ngton and the St. Louis F.H.A. area office.  It was learned

that although the City of St. Louis has requested that the housing
project be demolished, the request has been denied,
currently being developed to restore the units."
600 famiilies are still housed in the project.

"Plans are

Approximately 500-

       REGIONAL MEDICAL PROGRAMS SERVICE
SUMMARY OF AN ANNIVERSARY TRIENNIUM GRANT APPLICATION

(A Privileged Comunication)

CALIFORNIA MEDICAL EDUCATION AND RM 00019 8/71

RESFARCtl FOUNDATION Review Committee

693 Sutter Street
San Francisco, California 94102

PROGRAM COORDINATOR: Mr. Paul D. Ward

maul

     'l'liis Region is currently funded at direct costs. Of this amount,
1994:0F3 <<- * reauthorized unspent funds from prior years. Its current level

0

of support is $6,292,065 and this level is expected to prevail as a maximum
far the upcoming fourth operational year unless additional RMPS  funds become
available. At the time overall fiscal constraints required budget retrench-
ment by all regions, this Region was operating at direct costs.

This application is the "second chapter" of the Region's triennial application.
It focuses primarily on the matrix the operational activities form in the I
Region's total program.  The first chapter of the triennial application was
submitted to the January/February review cycle.
request for an expanded Core activity (for staff to coordinate with CHP and
Model Cities) and a Developmental Component.
RMPS budget constraints prohibited their funding. Therefore, the Region has
had to redesign both the Core activity portion of the triennial plan and its
former design for an operational activity matrix in order to retrench  to a
$6.2 million level. The refashioned Core activities are included in this
application to show their redesigned, complementary functions under California's
retrenched funding.

It presented primarily a

Although increases were approved,

The application includes:

I. Progress reports on 10 terminating projects. (These are not terminal
  reports covering the entire life of these activities--they will be
  ongoing until August 1971.)

*

11. A redesigned plan and budget for continued funding of the nine Area

Cores and the Central Office.

111.

Requests for continuation within the approved period of support for
12 operational activities.

fV. Requests for continuation beyond the approved period of support for

two operational activities.

A request to activate 17 previously approved but unfunded operational
activities.

A request for the approval of ten new operational proposals.

V.

VI.

VII.

A new Central Office activity far a Regional Kidney Disease plan.

CALIFORNIA RMI?

-2 - RM 00019

Grant Year

01
02

Grant Year

FUNDING HISTORY (Direct Costs Only)

Planning S tape

Period

11/1/66 - 12/31/67 (14 mas.)
1/1/68 - 2/28/69 (14 mas.)

   Opera t iona 1 Program
(Overlaps with planning stage)

Per iod

Funded (d.c.0.)

$1,368,137
$2,613,500

Funded (d.c.0.)

    01 7/1/68 - 6/30/69 $2,9 17,144
              7/1/69 - 8/31/70 (14 mos.) $8,012,055
     02
     03
*An award statement reducing this amount to $6,292,065 plus $703,509

.. - ,. . - 9/1/70 - 8/31/71 $7,548,457 *

reauthorized unspent funds will be issued shortly.

GEOGRAPHY AND DDIOGRAPHY:

are "shared" jurisdictionally with the Mountain States and Intermountain RMP.

The Region is divided into nine Areas,  each centered around a medical school.

The total land area is 156,573 square miles, with a population of 1.9,953,100
(1970).
racial distribution is 89% White, 7% Negro and Other 4%.

The Region is coterminous with the state,  excepc
for the Reno and Las Vegas,  Nevada areas which

--I

The population spread is 80% urban, with a median age of 30.

The

The Region has nine medical schools, and one of the most recently established
was a result of joint efforts of the Drew Medical Society (the NMA affiliate
in this area of Los Angeles) ,and the UCLA and USC Schools of Medicine
(Areas IV and V).
collegiate.
a total of 138,722 beds. The majority of these are non-federal, short-term
hospitals.

There are 62 nursing programs, including 42 that are

There are 20 medical technology programs and 615 hospitals with

There are approximately 35,224 physicians in the Region,  including all but
about 100 Osteopaths, and about 91,961 nurses, of whom 57,700 are active.

HISTORY OF REGIONAL DEVELOPMENT:
were appointed at UCSF, UCLA, Stanford and USC to study the legislation.

With the passage of PL 89-239,  committees

The California State Department of Health organized the "California Coordi-
nation Agency for Training, Research, Education, and Demonstration in the
Field of Heart Disease, Cancer, Stroke and Related Diseapes."
inc luded represen ta t ives from the Ca 1 if ornia Med ica 1 As socia t ion,  the
California Hospital Association, and the Deans of the eight schools oC
medicine.
all plan" for cooperative medical arrangements throughout the State.

This agency

The Agency was organized wi.th the purpose of dcveloping an "over-

l'lanniug

CALIFORNIA RMP -3 - RM 00019

for developing regional medical programs was to proceed at each of the
participating medical centers.  The Coordination Agency would "develop
suggestions" to delineate geographic areas of responsibility for each
of the medical centers, and would coordinate and mediate other questions.
The proposed method of operation relied heavily on systems analysis techniques.

0

<*

The Agency submitted an application outlining its structure and goals,  as
described above. At this time, the Agency Chairman was Dean Robert Glaser
of Stanford, and the Project Director was to be Dr. Nemat Borhani of the
State Department of Public Health.

Reviewers criticized the proposal, feeling that it was "poorly tied together",
had a vague chronological plan for development, and overemphasized systems
malys is.

The major question raised by the application was the creation of a "mega-
region" -- a question not discussed in PL 89-239.

The Office of Legal Counsel advised against RMP creating a central agency
unless it were to coordinate a group of "subregions".  The Region decided
on this kind of structure and UCLA withdrew the planning application it had
independently submitted.
at a later date whether to break up into several regions--perhaps before
receiving operational grants.

A revised application, incorporating the recommendations of the site visit
team and the National Advisory Council, was submitted. The coordinating
agency became a nonprofit corporation and changed its name to California
Committee on Regional Medical Programs (CCRMP). The grantee became the
California Medical Education and Research Foundation (CMERF),  a second
nonprofit corporation, the fiscal arm of CCRMP, with its own staff.

The Region's first Planning grant in the amount of $223,400 was made in
November  1966 and Mr. Paul Ward was appointed Program Coordinator in
February 1967.

The various medical centers agreed to reconsider

Another site team visited the Region in Februa$y 1967 and expressed concern
about the apparent lack of cooperation among the sub-regions and little
evidence of overall planning.

The Region organized along the lines of its original plan and a site visit
team went out in March 1967 to review progress and the "revised application".
The full year award for planning included the Areas of UCSF, UCLA, USC, CMA
and CKA. Three supplemental planning grants during the first year added the
Areas of Davis, San Diego and Stanford.

The first operational application indicated that each Area had begun  to
forge meaningful cooperative relationships within the community it served.
There seemed to remain a lack of interaction between Areas, and total regional
planning and direction were had  to discern.

CALIFORNIA RMP -4 - RM 00019

The Region's first operational grant was made effectivc July 1, 1968,
including nine projects out of a total of 21 submittcd.
included a new planning area for the Northeast San Fernando Valley.

In April 1969, a special site visit to each of the Areas, for a total of
five days, was organized for the purpose of evaluating progress  of the
overall program and to review in depth the individual Core staff requests.
The site team was impressed with most of the Areas, particularly Areas I,
111, IV, V, VII, and VIII.  Most impresive was the evidence of true peri-
pheral involvement.
of the possibility of making each Area a separate Region;  there was little
support for this position outside of Area IV.

1;

The same awardr

'\

'>

During the visit Area IV (UCLA) raised the question

Subsequent review cycles have included supplemental project requests  from
this Region, resulting in several program and technical site visits.

With the award of the continuation for the third operational year, on
September 1, 1970, the Region is supported at the direct cost level of
$7,548,457, which includes a carryover from previous years unexpended
balance of $480,168.

The current base level is $7,068,289.

THE REVIEW 6 DECISION-MAKING PROCESS:
stages: (1) determination of Area need (by the Area); (2) technical review
(conducted by a panel responsible to CCRMP; and (3) regional consideration
and priority setting.

The review system has been operative for sometime and evolved from a great
deal of study by the Cmittee on Organization and Procedures.  The process
begins when the Area Core Offiice notifies CCRQ that a proposal is in  its
final stages of development.  A Staff Consultants Committee then recommends
the precise categories from which an ad hoc review committee is established
for the proposal.
Panel, composed of individuals from each Area in various categories -- heart
disease, cancer, stroke, etc.

The CCRMP review process has  three

The latter is drawn from the Regional Technical Review

The ad hoc Review Committee meets with the Coordinator, his staff and the
author of the proposal. The proposal is examined from the standpoint of
overall appropriateness in terms of personnel, facilities, relationships,
etc., and if found to be technically sound, it goes to the Area Advisory
Group for approval, then to CCRMP, with a summary of the technical review.
Only if there is conflict between the Area Advisory Committee and the
Technical Review Committee will the CCRMP be expected to bring additional
considerations into its decision to approve or reject. Normally, CCRMP will
only examine how the proposal fits into the regional design, and what priority
it should be given.

The Evaluation procedures were developed through the joint efforts of CCRMP
central staff, headed by Dr. Jack Thompson, and an Evaluation Committee of
the RAG. This committee has been responsible for pointing out ways in which
evaluation can take place, including how program objectives can be crystallized

planning from the inception of a project, with assistance and guidance provided
by the CCRMP central staff.

by utilizing evaluation techniques. Evaluation is now an integral part of . I hi

.

CAI, LFOKN JA KM I' -5 - RM 00019

IN'I'ER-AREA PLANNING ACTIVITIES: Stimulated by Review Comittec and Council

0 concerns and questions about this element of communication between Areas,

region-wide committees are appointed as required to assure coordination

and serve as forums for planning. b addition, there is planning between
given groups--i.e., nurses, stroke activities, etc. Another example, the
Coronary Care Unit Committee meets about every six weeks  to assure non-
duplication of effort, sharing of educational programs, priority systems
for participation and cost-sharing a comon registry, etc. Ther& is increasing
evidence that sincere, coordinated, statewide efforts are addressing common
problems throughout the Region, with a resultant lessening of Area autonomy.

*e between Areas and projects. Monthly meetings of Area Coordinators are held

           : This Group is called the California Committee on
ional Medical Programs (CCRMP). It is a heterogeous body including the

Deans of the nine medical schools and two schools of publich health, the
Director of the State Department of Health, and representatives of the
Ca 1 if ornia Medical Association, the Ca lif ornia Hospita 1 Association, the
California Heart Association, the California Division of the Cancer Society,
TB and Respiratory Disease Association and represefitatives of the public.

Dean Clifford Grobstein of the University of California San Diego Medical
School,  serves as Chairman of the Committee on Organization and Procedures.
As an outgrowth of this committee's studies, the CCRMP, through the Coordi-
nator's staff, has assumed a more active role in assisting the Areas  in
developing local objectives and priorities.

The question of whether California should be one Region or several has been
discussed many times by CCRMP, and agreement continues that a confederacy
of Areas creates a statewide cohesiveness and coordination not easily
obtainable otherwise.  This position has always been supported by spokesmen
from the Heart Association, Hospital Association and other public repre-
sentatives on CCW. It is also generally agreed that any administrative
difficulties can be adjudicated.

The CCRMP has turned greater attention during the past year to activities
organized to help provide a service function for the public. Manpower
development and means of developing services where they do not exist are
concerns receiving more concentrated attention. Health provider interests
give strong support to CCRMP, but RMP activities have been increasingly
influenced by representatives of the general public.

BACKGROUND: The anniversary date of the California RMP is September 1.
Under the RMPS anniversary review system, this Region's single, annual
application is scheduled for the July/August review cycle. However, during
the year of transition to the anniversary system, regions with anniversary
dates of September, October, November, December and January were permitted
to submit an additional application to one of the earlier review cycles.
The California Region opted to submit an application to the January/February
2971 review cycle.

0

CALIFORNIA RMP

-6 -

RM 00019

I

The main feature of the optional application vas  that it constituted the
Region's triennial plan for the Core portion of the entire program.
Californids Core support was in its final year of commitment, and the
Region's rationale for its early proposal for Core renewal basically wa-s-
two-fold: -,

8.

c., .

1.
and
for

Under its option,
an expanded core
the last half of

''

California was requesting a Developmental Component

funding. If approved, it hopefully could be funded
the ongoing year as well as the succeeding triennium.

And, because the expanded Core requests were for funds to increase staffs
for coordination with local CHP agencies and Model Cities programs,  the
Region presented a 3% year design.

2.  As the Region stood at the time it submitted the optional application,
its level of funding was $7.5 million and its commitment for the next year
dropped to $1.7.  It had amassed such a large pool of approved but unfunded
activities (and had 21 additional proposals in its own review process)  that
advice from national headquarters on a total program level was needed.

Staff responded with the decision that the Region should be site visited
for the following purposes:

1.


2.

3. to assess the request for renewal of the nine Area Core staffs

to determine the Region's readiness for triennial review

to examine the proposal for a Developmental Component

and the Regional headquarters.

to develop a recommended level of total program support for
the next 34 years.

4.

The visit took place Deceinber 7-9,  1970 and the site visitors' recommendations

were:

03 - $8,363,994*
04 - $9,044,526
05 - $9,451,752
06 - $9,879,340

The Review Committee was not comfor 3ble with the site visitors' recommenda-
tion, Some members were reluctant to set a program level for future years
that included committed funds for operational projects not to be submitted
until the following review cycle. However, some Committee members pointed
out that the program level would set a maximum and not a minimum and that the
Region already had approved but unfunded activities that nearly matched the
figure proposed by the site team.
the Developmental Component be approved at an annual rate of $400,000,  that
Core be renewed at the increased level recommended by the site visitors

Finally the Committee recommended that

Whe team recornended this for the annualized amount realizing tliat tlic

increase would operate only for the last half of the ycar.

CALIFORNIA RMP -7 - RM 00019

($3,878,346), that the level for operational activities be continued at
the then current amount of $4,085,648; and that this total program level
($8,363,994) be continued for 18 months which would allow for review of
the second portion of the Region's program (the operational activities)
at the July/August review cycle.

Council's action differed from Review Committee's recommendations in the
number of years of iunding recommended. Council concurred with the site
visit team that this Region needed guidance from Council regarding overall
level of funding to bc. anticipated before submitting an application for
thrce-year funding to the July/August cycle. Council approved the $8,363,994
Irvcl for the Rqion's 04, 05, and 06 years.

11 April 1971 all regions were notifed that retrenched funding was required
due to overall fiscal constraints. This Region was advised that its current
level of funding must be reduced to $6,220,094 for its ongoing third opera-
tional year and  that the retrenched funding would continue into its upcoming
fourth operational year if fiscal 1972 RMPS budget allotments are not increased.

This Application

The California Region has responded by submitting two designs--one presenting
their plan for operating on a $6,220,094 budget, and another requesting
approval of a $10,043,175 plan from which the Region would select activities
to be funded within the Council approved $8,363,994 level should additional
RMPS funds become available.

Tlw $6.2 proposal shows decreasing budgets for the future years of the
triennium. It is presumed that portions of the $10 million plan would be
activated in future years to maintain the $6.2 level. This is a point
the site visitors miglit want clarified.

The Region's goals, objectives and priorities, as well as its Area and
regional review processes, were studied during the December visit. Also
considered in December was the Region's concept of expanding its nine Area
Core staffs for coordination with local CHP and Model Cities offices and
the proposed use of Developmental Component funds.

The portion of the program to be reviewed at this time basically is the
operational activities proposed and the resulting program matrix these
activities form. However, Core activities are again included in this
application for two basic reasons;  many of the operational activities  the
Region had planned to undertake requiring funding in excess of $6.2 million
must now be redesigned and shifted to the Cores; conversely, many of the
activities described  in the former optional application based on expanded
Core staffs must be either redesigned or abandoned.

In arriving at its decisions on the selection of activities both for the
$6.2 million and the $10 million plan, the Region made choices for funding
both from its pool of approved and unfunded activities and from proposals

0

approved by the RAG at its last meeting.

Generally, the decisions may be grouped as follows:

0

CALIFORNIA RMP -8 -

RM 00019

1. Continuation of ongoing activities:

In order to retrench to the $6.2 level, the 12 continuing projects have

than the $1,739,000 level for which the Region has a commitment. The
reduction was not achieved through an across the board cut;  selective
reductions were invoked.

been selected for funding at a direct cost level of $1,456,549 rather

.

-.

Under the $10 million plan,  the 12 continuing activities have been partially
restored to a $1,515,657 direct cost level.

2. Renewal of terminating activities:

Of the 12 terminating activities,  two have been selected for renewed support
requests at a combined direct cost level of $456,000 under the $6.2 plan.
the $10 million design requests a $475,000 level for these two projects.

3.

The $6.2 plan proposes the activation of SPA such projects at a total direct
cost level of $264,000.
approximately 25.
at levels below Council approved amounts. One is an alternate to a renewing
project (C25) which is also being considered for funding by OEO.

Activation of previously approved but unfunded proiects:

These six projects were selected from a pool of

All of these projects are being proposed for activation

,

-*

The $10 million design proposes the activation of 17 approved but unfunded
projects at a total direct cost level of $1,888,098.

_- ~

<.

4. New proposals submitted for approval:

Three new proposals are submitted under the $6.2 plan requesting a combined
direct cost level of $229,440.
activities approved by the last RAG.

Ten new proposals seek a combined direct cost funding of $1,094,091 under
the $10 million plan.

They were selected from a group of  12

2-

5. Core support:

No previously approved increases for the nine Area Core staff expansions or
to the Central Office are allocated under the $6.2 million plan.
Central Office and the CMMERF Office are to be supported at a combined direct
cost level of $3,380,185.

All cores, the

Tile $10 million design provides increases for all Cores, the Central Office
and a small increase for the,CMW Office. The combined level of direct
cost support under the $10 million plan is $4,548,409.

6. The Developmental Component:

The $6.2 plan reduces the Developmental Component to $384,000 while the
$10 million plan restores it to $400,000.

t., .
-. ._;:

. . ..

CALIFORNIA RML' -9 - RM 00019

7. The Regional Kidney Disease Program:

Both plans propose a direct cost budget of $121,920 for the support of this
activity.
and only portions of it will be possible under both designs. The kidney7
ptoposaf will be reviewed by an ad hoc panel at the national level prior
t6 Cht: YdyIAugust Committee/Council meeting.

The following chart compares the total Regional proposal under the two
plans and groups the activities by type of request. The remainder of this
summary will attempt to describe the application vLa an Area by Area approach
in order to place the operational activities in a local setting with the
individual Core staffs. The agenda for the June 10-11 site visit has been
structured in a Southern California/Northern California fashion with a
portion of both the first and the final day scheduled for total regional
discussions.

The original renal proposal was based on a $760,880 total plan

Tplcr/

-&

Beginning on page 36, there is a fiscal breakout chart showing the Region's
$10 million plan for their 04, 05 and 06 years.

CALIFORNIA RMP -10- RM 00019

The total Regional Proposals (under both the $6.2 and $10 million plans,)
are charted below grouped by type of request:

$6.2 Plan $10.0 Plan

Continuation within approved

period of support

Central Office
Regional Kidney Plan
CMERF Office
Developments 1 Component
Area Cores

Area I
Area II
Area I11
Area IV
Area V
Area VI
Area VI1
Area VIII
Area IX

All Cores,.Centraf Office, CMERF ti Dev. Comp.

- ...

Continuation within approved

period of support

Opera t iona 1 Act ivi t ies

815 - Area I Cancer
#23 - Area V Chronic Respiratory
#25 - Area I Rehab & Continuity
1/27 - Area I Rural Hospitals
828 - Area VIII Comprehensive Stroke
#30 - Area VI1 CCU
1/37 - Area I11 Stroke
1/43 - Area I Stroke
#45 - Area I1 Stroke
1/46 - Area 111 San Joaquin
1/50 - Area V Pacemaker
852 - Area VI Perinatal

All continuation projects

Continuation beyond approved

period of support

i;6 - hrea IX Drew Sc.hool
824 - Area IV N.E. Valley

$ 391,090
121,920
  49,003
384,000

538,404
2 14,435
264,893
705,149
575,481
157,456
149,536
181,344
153,394

$3,886,105

$ 234,864
  78,112.
143,246
  66,562
230,8 74
  75,982
100,794
172,598
  72,000
153,655
  56,390
  71,472

$ 457,426
121,920
  53,596
400,000

666,712
334,288
433,450
888,497
743,771
244,526
256,8 18
284,767
184,558

$5,070,329

$ 244,650

149,215
69,335
240,494
79,148
105,000
179,790
75,000
160,000
57,208
74,450

81,367

$1,456,549

$1,515,657

$384,000 $400,000

72,000 7 5 ,000

-_I

$456,000 $475,000

All renewing projects

CALIFORNIA RMP

-11-

RM 00019

$6.2 Plan $10.0 Plan

Approved but Unfunded Proiects

*-

#27S - Arcn I F;itiiily Prncticc
P41R - Arca I Rtsgiootinl Monitoring
#44R - Area I Oticology C.E.
854 - Area VI11 Kopicl Ilospitolization
#56 - Area VI11 CRIS
#60 - Area VI Medical Information Service
#62 - Area VI1 CE for MD's

"" 863 - Area IV Perinatal
#64 - Area IV MD's CE
#/66 - Area VI1 REACH
#67 - Area I Respiratory Disease
#68 - Area 11 Compendium
1\69 - Area VI1 Respiratory Disease
#70 - Area I1 Allied Health
#71 - Area IV Respiratory Disease
4/72 - Area VI11 Radiology
1/73 - Area I11 Oncology

All Approved/Unfunded activities

Now Proposals :

875 - Area I Indian llcalth
#76 - Area I Hypertension

0

#77 - Area I Iniensive Care
#78 - Area I11 Oral Health
#79 - Area IV ECF
1/80 - Area V Computerized ECG
4/81 - Area V Indian Health
//a2 - Area V & IX Intensive Care
#83 - Area V Free Clinic Coordination
884 - Area VI11 Neonatal IC

All new proposals

Sub Total

Grand Total

-0 -
-0-
-0 -

19,200
-0-
-0 -
72,000
-0 -
-0 -
-0-

52,800
62,400
-0 -
-0-
-0-
9,600

$264,000

.$ 48,000

$120,000

-0 -
-0 -
-0-

60,480
-0 -
48,960

-0 -
-0 -
-0 -

$229,440

$6,292,094
- 72,OOWJ~

$6,220,094

.$ 55,740
35,4/+6
184,09 1
50,000
20 , 000
39,388
120,416
96,232
68,892
23 1,O 14
266,240
55,000
65,000
50,400
177,159
71,957
301,123

$1,888,098

$12 7,409
190,133
190,000
105,2 10
62,321
95,334
51 , 000
81,000
80,000
111,684

$1,094,091

$10,043,175

WcThis project is an alternate to project #24.

CALIFORNIA RMP -12 - RM 00019

The $6.2 million plan will hereinafter be designated Plan A and the $10
million plan will de Plan B.

Central Office

Executive Director: Mr. Paul D. Ward

Deputy Director:

John A. Mitchell, M.D.

Total Population - 19,953,100

Present Funding (includes CMERF)

$492,956 (includes $69,945 carryover)

Requested Funding Plan A Plan B

Central Office
Regional Kidney Plan
CMERP Office
Developmental Component

$39 1,090      $457,426
12 I, 920        12 1,920
49,003        53,596
384,000        400,000

Total $946,013 $1,032,942

The Regional Advisory Group in this Region is known as CCRMP (California
Committee on Regional Medical Programs).
CMERF (California Medical Education & Research Foundation) a subsidiary of
the California Medical Association, is the grantee organization. There is
also a very active Committee of Staff Consultants, which in many ways operates
as a Steering or Executive Committee,
each of the Area Coordinators, and a representative from each of the member
groups on the RAG.  This committee has 24 members and met eleven times  last
year,  The Region operates 23 standing committees or sub comittees.

It is composed of 35 members.

It is composzcl of a Chainnan (Mr. Ward),

The Central Core staff operates with 14 full-time employees.
the Director and Deputy Director, it includes three Associate Directors
and Coordinators for Evaluation, Planning and Review, and Administration. '

In addition to

The development of integrated staff relationships and effort with CHP and
Model Cities,  the contribution of RMP staff to the development of a California
State Plan For Health, the strengthening of its regionalized staffs and
advisory groups, and the development of the role of an impartial facilitator
are highlighted as significant accomplishments of this staff.
of the Central Office are described on page 14

The activitics

of this application.

The Regional Kidney Plan will be reviewed by an ad,hoc technical panel prior
to the July Review Committee meeting.
available at the Review Committee meeting.

A copy of the panel review will be

CALIFOKNTA RMI' - Area I -13- RM 00019

0

,

0

0

The $6.2 million plan will hereinafter be designated Plan A and the $10
million plan will be Plan B.

University of California - San Francisco -- Area I

Acting Coordinator: Elliot Rapaport, M.D.

Geographic coverage - 11 counties

Population - approximately 3,029,800

Present Fund ing

Core
Pro j ec ts

Tnta 1

$ 491,337

1,239,502 (including $54,985 carryover)

$1,730,839

R-

Core Staff

Continuation

#15 - Cancer - Phase I
1/25 - Rehab and Continuity of Care
1/27 - Rural Community Hospitals
1/43 - Stroke - Area I

Renewa 1s

Approved /Unfunded

1127s - Family Practice Program
#41R - Regional Monitoring
f44R - Medical Oncology
1/67 - Respiratory Disease

New Activities

1/75 - Indian Health
1/76 - Hypertension
1/77 - Intensive Care

Plan A

$538,404

234,864
143 :, 246
66,562
172,598

$617,270

-0-

-0 -
-0 -
-0 -
-0-

$120,000

-0-
-0 -

$120,000

All totals including Core $1,275,674

Plan B

$666,712

244,650
149,215
69,335
179,790

$642,990

-0-

$ 55,740
35,446
184,091
266,240

$541,517

$127,409
190,133
190.000

$507,542

$2,358,761

CALIFORNIA RMP - Area I -14- RM 00019

The Area has a local Advisory Group composed of 36 members and approximately

,~

       es and Boards involving 1,000 persons.  The Area Core staff
     full-time pployees and 21 full-time equivale-
the significantlcore staff's accomplishments begins on page 215 of the

A summary of

, . .:..

.. I

..

.- .

, . .;

. ..

.. ,..
..._..-

Progress Reports on four terminating projects are submitted.

,

Project #I - Coronary Care Training - This project is completing its third
year of support. Its objective is to improve skills in management of myo-
cardial infarction in Coronary Care Units.
with eight separate activities and is a federation of approximately 100
community hospitals.
standard reporting format which begins on page 246.
ation funding has been developed for this project. However, the experience
gained through this operation has moulded the design of several new proposals.

It is' a multi-faceted project

Progress on each activity is covered in the Region's

No alternative continu-

Project #18R - Intensive Care Training - This project is completing its third
year of support.                                            This
project has been funded by "carryover funds held in escrow" and is not re-
flected in the total estimated expenditures reported. Progress on this
activity is covered in the Region's standard reporting format which begins
on page 297. This activity trains physicians in skills of cardiopulmonary
intensive care.

It is presently funded at $50,000 direct costs.

Project #20 - Regional Hypertension Promam - This project is completing its
third year of support,  Two of the participating institutions have agreed  to
take over the demonstration activities of the project. Progress on this
activity is covered in the Region's standard reporting format which begins
on page 302. The project provides education, consultation referral and
follow-up, planning and registries.

Proiect #26 - Emergency CPR - This project is completing its second and final
year. Funds from other than RMPS sources have been contributed to the project
this year, and it is anticipated that the same sources will continue the
activity after RMPS support terminates:
in the Region's standakd reporting format which begins on page 348.

Progress on this activity is covered

The Continuing; Projects:

~. .

,.

. ..

... >
..:

..

.'i

.. I

..

. . .1

Project #I5 - Regional Cancer Program - This activity has been ongoing for two
years and continues for one more. It Includes four activity components and
its progress is described beginning on page 279. It builds on a cooperative
arrangement between the University of California, San Francisco, and Mt. Zion
Hospital and Medical Ccntcr, building on the base of cancer teams. It fnc1udt.s
Crasultation Service, radiological physics service, data retrieval and an
educa t iona 1 program.

0

c

0

0

Project 1/25 - Rehabilitation and Continuity of Care - This activity has
been ongoing for two years and continues for one more. It includes three
activity components identified as the Alameda-Contra Costa Project, the
Sonoma-Mendocino-Lake Project and the Humboldt-Del Norte Project.
progress is described beginning on page 327.
toward the development of discharge planning systems, education programs
for staffs of extended care facilities and hospital  staffs.

                Its
The activity is directed

Project 1/27 - Rural Community Hospital Demonstration - This activity has
been ongoing for two years and continues for one more. It is a cooperative
effort between the Community Hospital of Sonoma County, in Santa Rosa and
the University of California San Francisco Medical Center. Its progress is
described beginning on page 353. The project is beamed at the medical
student , the resident, and the practicing physician to enhance Family Practice.

Proiect 1/43 - Stroke Program - This activity is just completing its first
year of operation and continues for two more.
activities and was activated in June 1970. Its progress is reported beginning
on page 370. Its purpose is to provide the community with the means to develop
a more effective health care delivery system for persons with symptomatic
cerebrovascular disease.

It is composed of six sub-project

Approved/Unfunded Activities:

No approved but unfunded activities are proposed for activation by Area  I
under Plan A.

Proiect 8278 - Family Practice Program - This activity builds on Project #27
and was originally submitted to the November 1970 Council. The Council
deferred action to the site visit team (December 7-9). On-site inquiry
disclosed that the proposal was a logical Phase I1 of the parent activity
and that its extension to the indigent population of Sonoma County augured
well for addressing the Region's priorities. The site visitors recommended
its approval and the February 1971 Council agreed. This activity is proposed
for activation only under Plan B. Form 15 covering this proposal is on
page 239.

Project #41R - Patient Monitoring System - This activity was first submitted
by the Region in August 1969, was returned for revision and has been submitted
through three review cycles since, each time with a deferral action. Imple-
mentation of the changes required by the deferral actions was delayed by the
illness of the proposer and necessary negotiations with the Lockheed Corporation
on the circuitry aspects of the project.
met the revision requirements and May 1971 Council deferred action to this
site visit team for a recommendation as to whether this activity should be an
approved component of the Region's program.  It is proposed for activation
only under Plan B. Form 15 covering this proposal is on page 240. The pro-
posal here is to test a patient monitoring system and a program of education
and training of hospital staff to use the system. RMP support is in the area
of the educational benefits.

Four are proposed under Plan B.

They are:

The Area proposers appear  to have

CALIFORNIA RMP - Area I

- 16- RM 00019

Project #44R - Medical Oncology Program - This is Phase I1 of the ongoing.
Area Cancer Program (project 1/15) wLth a primary emphasis on continuing

education and c&unication for health professionals as they relate to the
total care of cancer patients.
December 1969 and is proposed for activation only under Plan B.  Form 15i,8
covering this proposal is on page 241.

Project #67 - Respiratory Care - This proposal concerns respiratory teaching
teams from communities throughout the Area to be trained in thc Bay Area by
a faculty of specialists.  It was approved by the Fcbruary 1971 Council and
is planned for activation only under Plan B.
is on page 242.
MI. Zion and Children's hospitals are the primary action bases.

The proposal was approved by Council in

..

Form 15 covering this proposal

San Francisco General, Presbyterian, Moffit, St. Mary's,

The New Proposals:

Project #75 - Indian Health Program - This activity is proposed for funding
under both plans - $220,000 under Plan A and $127,409 under Plan B.   It
constitutes a plan to identify those resources alreqdy available in the
community (Northwestern California) and provides for their maximum utilization.
The proposal is an-outgrowth of a feasibility study begun in April  1970.
brief description of the proposal is on page 243.  Expanded information begins
on page 401. ,

A

Project f76 - Hypertension and Preventive Cardiology - This activity is pro-
posed for funding only under Plan B at a level of $190,133.

hospitals inter-tied to Area-wide educational and planning activities.
brief description of the proposal is on page 244 and expanded information is
on page 444.

.1)

It aims to

- ..

establish a web of patient care demonstration programs in local community

-- .

A

Project #77 - Intensive Care Propram - This activity is proposed for funding
only under Plan B at a level of $190,000.  It will integrate into a new
approach the resources of two projects currently ongoing in this Area, but
terminating this year (projects #l Coronary Care and 18R Intensive Care
Training).
OR page 461.

A brief description is on page 245 and expanded information begins

CALIFOFNU RMP

Area Ii

- 17- RM nnni? 5/71

'Ihe $6.2 rnillion 1jI;iri will kicreinaf'ter be designated as Plan A and the
$10 rnillion plan will bc Plar~ I:.

ilavis - Sacramento -- Area I1

Coordinator: Neil C. Andrews, M.D.

Geogmphic Scope - 20 counties

Population - approximtely 1,448,200

Present Funding

  Core
Projects

Total

Requested F'umling

  Core Staff

  Continuation

#45 - Stroke

Renewals

:b 210,670 (including 11,800 carryover)

273,81.3

4; 484,4t13

Plan A

$214,435

72,000

-0-

Approved/Ur&mded

#68 - Compendium of Extended Learning  52,800

                          -0-
Allied Health Personnel and
Health Careers Counselling

#70 - Continuing Education for

New

'i'otal including Core

  -0-

$333,235

Plan B

$334,288

75,000

-0-

55,000
50,400

  -0-

$514 ,G%%

-1 8-

`lI-11:; Area submits progress reports on two ongoing activities (H2 aid #45).
'Ine project (H2) terminates this year and the other (H45) continues for
two more years.

It has an Area Advisory Group composed of 45 members and five Comnittces
or bards involving approximately 75 P ersons.

Its core staff is composed

vZZKEXG3- ers and 9-l/2 fill-time equivalents2

A report

I-

fro.jmt #2 - Kusevillc Pilot Project - This activity is In its tliird
srxl final *[ear of IW :;ur)mrt.

It is a multi-faceted activity tkiat

..

S.riclirlr=s c~mrrmity suiveys, multiphasic screening, tumor corifewnces ,
?grjtiriuing ducat ion for physicians and dentists, clinical conferwices
2m-3 seminars and intensive coronary care training.
is iiicluded on Form 15 (page 506) arid expanded information on its progress
begins on page 510.

Its progress report

The Continuing Project :

Project #45 - Stroke - This activity is proposed for funding at a $72,000
level under Plan A and a $75,000 level under Plan B and will continue

, --

for two more years. It was activated late in 1970. It is a dual .,

activity project composed of patient evaluation efforts and continuing

1-. -

education/training.
in mre detail in the Region's standard reporting beginning on page 535.

It is briefly described on Form 15 (page 507) and

IJo renewiw activities are proposed for this area under either plan.

Approv&/Unfunded Activities:

moject if68 - Corrperidium of- Extended Learning - This activity was approved

by the February 1371 Council and is proposed for activation under. Goth I'lans
($52,800 under Plan A and $55,000 under Plan B).  It proposes to establish
a recizanism for the planning, development and implementation of a cohesive
prcLqam of educatimal activities for the Area's health professions.
is briefly described on Form 15 page 508.

It

Troject #70 - Continuing Education far Allied Health Personnel and Health
Careers Counselling - This project was approved by the February 1971 Council
and is proposed for activation only under Plan B at a level of $50,400.  The
proposed mltidisciplinary continuing education programs will be carried
out in three phases:  (1) planning and development; (2) operational in
several selected sites with evaluation; and (3) extension of phase 2 with
modified programs (based on evaluation) in new sites.  Form 15 describirie
the activity is on pace 503.

! Jr, clew pr.ooo:;;i I ;; ;lw; I rjc 1udr:rl f`or thj z &*(:a inrJ(ir* eil,!ic:r* p 1:~).

--

0

0

e

CAT,TFORNTA RMP -19- RM nflOlY PI/'
T~IC? $6.2 million plan will hereinafter be designated Plan A and  the $10
million plan will be Plan B.

Area 1x1

Stanforti School of Medicine - Area I11

Coordiniitor: John L. Wi 1 son, M.D. (Acting Dean, Stanford School of Medicine)

William Fowkes, Heart Coordinator (Acting Coordinator of Area TLK)

Ceograpiiic Scope: 11 counties

Population - approximately 2,644,100

Y res en t Fund in g

__

Core $260,654 (including $40,000 carryover)

Projects           153,417

    Total        $414,071

Requested Funding

Core Staff

Continua ti on

t37 - Stroke Program
1/46 - San Joaquin Multiphasic Screening

Renewals

Ap p roved/Un funded

873 - Cancer Program

New Activities

1/78 - Oral Health Care Program

All totals including Core

Plan A

$ 264,893

100,794
153,655

-0-

9,600

-0-

$ 528,942

Plan B

$ 433,450

105,000

160 , 000

-0 -

301 , 12 3

  105,210

$1,104,783

(#37, 1\38

This Area submits progress reports on three ongoing activities
and 1/46). (he project (1138) terminates this year. Each of the remaining
two will continue for two more years.

It has an area Advisory Group composed of 23 members and 16 other District
Committees, Subcommittees or categorical committees. Its core staff is
composed of 18 full-time people.
begins on page 557 of the appli / ation.

The Terminating Project:

A report of the significant core activities

w774 b
-d/&*-i:

Project 1\38 - East Palo Alto Multiphasic Screcniny - Its purpose is to

introduce citizens of a Black urban ghetto (East Palo Alto - Menlo Park)
to the existing health care system.  It established a Screening Center in

CALIFORNIA RMP - Area 111 -20- IIFI 00019

the Neighborhood Health Center (an OEO project),
funded in 1970 for a two-year life, its activation was delayed due to a
number of reasons revolving primarily around strife in the comniunitv and
changes of staff at the Center.  Form 15 describing the project briefly

Although the project was

_-

is on page 582. ->

The Continuing Projects:

Project 1/37 - Stroke Program - This activity continues for two more years
and is proposed for funding at $100,794 &vel under Plan A and $105,000
under Plan B.  It is a project with six sub activities:  (1) Organization;
(2) Physical Therapy; (3) Prevention and Assessment; (4) Management Demon-
stration; (5) District programs; and (6) Teaching and Consultation. Its
progress is briefly described on Form 15 (page 581) and in more detail  in
the Region's standard reporting format beginning on page 586.

Project /I46 - San Joaquin Multiphasic Screening - This activity continues
for two more years and is proposed for funding at a $153,655 level under

'

Plan A and $160,000 under Plan B.
with referral and folloy-up is in this project and it is aimed at urban
poor and migrant agricuitural workers.
on Form 15 page 583, and expanded information
standard reporting format beginning on page 613.

The element of a mobile screening unit

  Its progress is briefly described

is included is the Hegion's

So renewinp activities are proposed for this Area under either plan.

Approved/Unfunded Activities :

Project #73 - Cancer Program - This activity was approved by t:he February
1971 Council and is proposed for funding under both plans.
been allocated to this project under Plan A; $301,123 under Pian B.
is a four-part program; (1) dosimetry; (2) consultation; (3) education in
community hospitals in San Jose; and (4) a staff person for the Stockton
Tumor Board. Plan A activates only part 4 of the project. Plan B activates
all parts.

$9,600 has

It

The project is 5riefly described on Form 15 on page 584.

New Activities:

Project #78 - Oral Health Care Program - This activity is proposed for
funding only under Plan H at a level of $105,210.
establishment of a "board of consultants" to revfew complex oral ~>ilthol.ogi~t~l
problems needing multidiscj plinary care.
the board,
in iirore detail beginning on page 623.

It proposes the

The cases wi 11 be re Cerrc.tf to

The activity is briefly described on Form L5 on page 585 and

0

<-

e

--"-.KR fl(JIJ1 Y FI / J

" _-

CALIFORNIA -L 1-

-

-

The $6.2 million plan will hereinafter be designated Plan A and the $10
million plan will be Plan B.

University of California - Los Angelcs -- Area IV

Coordinator: Donald Brayton, M.D.

(kograpliic Scope: 7 counties

Population: approximately

<-JQ6 749

Present Funding

Co re          677,647
Projects       496,421

   Total    $1,174,068

Requested Funding

Core Staff

Con tinuat ion beyond approval period

824 - The Northeast Valley Project

Plan A       Plan B

$705,149    $888,497

72,000 75,000

ApprovedIUn funded

1/63 - Perinatal Crisis Training              72,000 96,232
864 - Continuing Education for Physicians        -0- 68,892

#71 - Respiratory Care Training              -0- 177,159

in South Bay

New Activitv

#79 - Extended Care Facilities

60,480

62,321

All totals including Core $909,629 $1,368,094

This Area submits progress reports on three ongoing activities (/t24, 87
and 11.4). Support for all three terminates this year. Renewed support
project 1\24 is requested under both plans.

This Area has a local Advisory Group composed of 71 members and approxi-
mately 5 Committees and Boards,  The Area core staff numbers 41, 27 of whom
are full time.
begins on page 658.

A summary of the significant core staff's accomplishments

The Terminating Projects:

Project 87 - Medical TV Network - This activity is in its third and final
year of support.  It produced, distributed and evaluated audiovisual media
programs for the continuing education of health professionals.
is planning for sources other than RMP to continue its activities but they
are not specified.

                                 The network

Form 15, briefly describing the project is on page 690.

RM 00019 8/71

CALIFORNIA RMP - Area `fv

-32-

Project 1/4 - Physicians Training in Coronary Care - This activity is in,
its third and final year of support.  It has trained physicians who will

,

occupy positions as directors or associate directors in coronary care
units in community hospitals.
Form 15 on page 691.

Renewing Activity :

Project 824 - The Northeast Valley Project - This activity has been ongoing
for three years and the Area requests its continued support  for an additional
three years.
a pool of 12 terminating activities that request renewal.  The Region planned
for its renewed support at a $72,000 level under Plan A and $75,000 under
Plan B. The research activity of this project has generated interest in
the plight of the community by Los Angeles County (which has qualified
the area for a Neighborhood Health Center) and other groups such as Kellogg
Foundation.
should such funds materialize the Area proposes project W63 as an alternate.
The progress of Project 1`124 is briefly described on Form 15 (page 689) and
in more detail in the Reginn's standard reporting format beginning on page 718.
The activities to be pursued in the next three years are described bginning
on page 723.

Progress on this activity is reported on

t I. .\

It is one of the two projects selected by the Region from

The project also is being considered for funding by OEO and

ApprovedlUnfunded Activities:

. -_

One project (1163) is proposed for activation under Plan A, this being the
alternate to project 824.
Plan B (#63, #64 and #71).

Three projects are proposed for activation under

__

Project 1b3 - Perinatal Crisis Training -  .This activity was considered by
November 1970 Council and deferred to the December site visitors. Based
on the site visiturs' recommendations the February 1971 Council approved it.
The project proposes to develop physician and nursing manpower and to
stimulate services for the treatment of severe medical and surgical ail-
ments in newborns. It is scheduled for activation at $72,000 under Plan A
(as an alternate to Project #24) and $96,232 under Plan B.

Form 15 describing

the project is on page 692.

Project 864 - Continuing education for Physicians in South Bay - This
activity was also deferred by November 1970 Council to the site visitors
and February 1971 Council approved it.
to participate in half-day clinical experiences each week on a two-month
basis.
Form 15 describes the project on page 693.

                  Its protocol enables physicians to

It is planned for activation only under Plan B at a $68,892 level.

Project 811 - Respiratory Care Training - This activity was submitted to
and approved by February 1971 Council,
in respiratory care in hospitals where specialized units are not appropriate.
It involves a nine-county area.  Funding is proposed only under Plan B at
a $177,159 level.

It proposes to train key personnel

Form 15 covering the activity is on page 694.

CALIFORNIA RMP - Area IV

New Proposal :

-23-

RM 00019 8/71

Project #79 - Extended,Care Facilities - This activity is proposed for
funding under both plans - $60,480 under Ptan A and $62,321 under Plan B.

It provides for a coordinated continuing education program for nursing
home and extended care facility administrators and directors of nursing.
Form 15 briefly describing the proposal is on page 695.  Expanded infor-
mation begins on page 745.

CALIFOWIA RMP - Area V -2 4 RM 00019

-*.

..

The $6.2 million plan will hereinafter be designated as Plan A,the $10
millioa will be Plan B.

University of Southern California (Los Angeles) -- Area V

-. J

Coordinator: Donald Petit, M.D.

Geographic Scope: 1 county

4oSs1, rn

I,

Population - approximately

Present Funding

Core $55 1,399

Projects 443 9 453

Tot a1 $994,852

Requested Funding

Core Staff

Continuation

1/23 - Physician Education in Early Chronic

if50 - Pacemaker Registry

Respiratory Disease

No Renewing Activities

No Approved/Lbfunded Activities

New Activities:

Plan B

Plan A

$575,481 $743,771

78,112

81,367 -*:

1 . I-

- . ..

.r

56,390 57,208 -

2

1/80 - Computerized ECG for Community Hospitals      -0-
#8l - Urban American Indian Health Needs 48,960
1i82 - Intensive Care of the Critically I11         -0-
#83 - Free Clinic Coordination -0-

95,334
51,000
81,000 *
80 000

All totals including Core $758 943 $1,189,680

* Also includes resources of Area IV and IX and involves populations of
Areas IS and IX.

Progress reports on three ongoing activities are submitted (111, f23, and
#SO). One project (Sll) terminates this year. Project 1/23 continues
for one more year and Project #50 continues for two.

The Area has a local Advisory Group composed of 34 members and approximately

other Cornittees or Boards are listed.

The Area core staff numbers@

(.

ll-time employees and 29 full-time equivalens A summary of the signifi- 'tL, A'

c -I

t co're staff's accomplishments begins on page 776.

i'

CALIFORNIA RMP - Area l! -25 - RM 00019

The Terminating Project;

Project 11 - Coronary Care Unit Training Program = This activity is in its

third and final year of support.
Its progress  is covered briefly on Form 15 on page 806.

No alternative funding has been developed.

I-

The Continuing Projects:

Project #23 - Physician Education in Early Chronic Respiratory Disease -
This project  is in its second year of a three-year support period.
support is planned at a $78,112 level under Plan A and $81,367 under Plan B.
The Los Angeles TB Association Breathmobile refers individuals with abnormal
rcspirntory symptoms to this project. Its progress is briefly reported
on Form 15 (page 807) and in more detail in the Region's standard reporting
format beginning on page 822.

Its

Project #50 - Pacemaker Registry - This project was activated in September
1970 through funds rebudgeted from project bll, Although it was approved

--

by Derembe; 1969 Council-for a period of three years, funds have not been
awaried for its support.
year as described above, and allocated funds to support it under both Plan A
($56,390) and Plan B ($57,208). The project aims to determine the extent
to which mortality and morbidity in patients with pacemakers may be due  to
pacemaker malfunction. It is briefly described on Form 15 (page 808) and
in more detail beginning on page 828.

No new renewing activities are proposed for the Area under either Plan.

The Region activated the project for its first

0

No approvedjunfunded projects are proposed for activations under either plan.

The New ProDosals:

Project 880 - Computerized ECG For Community Hospitals - This activity
is proposed for funding only under Plan B at a $95,334 level. The project
will undertake: (1) taking ECG's for computer interpretation; (2) assuring
accuracy of the computerized interpretation;  (3) setting up computerized
ECG interpretation for private offices;  (4) obtaining appraisals from physi-
cians for improvement of services; and (5) determining optimal cost benefits.
The activity is briefly described on Form 15 (page 809) and in more detail
beginning on page 832.

Project #81 - Urban American Indian Health Needs - This activity is proposed
for funding under both Plans - $48,960 under Plan A and $51,000 under Plan  Y,.
This proposal is an outgrowth of activities sponsored by the Area's invest-
ment last year of seed money and technical assistance.  A church in Compton
was made available for a health center and an incorporated group, The American
Iridian Free Clinic, Inc. serves as the clinic's administration. Volunteers
average about 12 professionals and 8 non-profcssionals.
able as a result of this application and a similar application to the Economic
Youth Opportunities Agency of Los Angeles, the clinic will expand its ser-
vices and referrals, both in scope and hours offered.  The proposal is briefly
described on Form 15, page 810 and in more detail beginning on page 842.

With funding avail-

e

-

i.f 4

CALIFORNIA RMP - Area v -26- RM 00019

-3

Project 182 - Int&nsive Care of the CriticaIfy I11 - This activity is
proposed for funding only under Plan B at a level of $81,000.
will cover some of the po$ulation and resources of Areas IV and IX.

specialized intensive care units are noted as the resources and the project
aims to train app?oximately one half of the 600 nurses currently in direct
care positions in the specialized care of the critically ill.  The project
is an outgrowth of, the Regional experience gained through its coronary
training efforts.: It is briefly described on Form 15 (page 811) and in.,,r

JePT

The projddt

Tw6

hundred thirty seven general acute care hospitals in these areas with

-1

more detail beginxhg on page 861.

Ctr

Project 1/83 - Free Clinic Coordination - This activity is proposed for
funding only under Plan B at a level of $80,000.
functinns of the Southern Caliqorn'a Corrncil of Free Clinirs by providing
professional and supportive staff to help organize new clinics and assist
existing ones.  It is briefly described on page 812 and in more detail on
page 879

It aims to enhance the

..

-27-

The $6.2 million plan will hereinafter be designated Plan A and the $10
million plan will be Plan B.

0

Lorna Linda School of Medicine -- Area VI

Coordinator: Richard T. Walden, M.D.

I-

Geographic Scope: 4 counties

p opu 1 n t i on :

1 ,162,8 00

Core         $144,335
Projects         65,516

   Total       $209,851

Requested Funding

Core Staff

Continuing Activities

       1/52 - Perinatal Monitoring
e Approved/Unfunded Activities

Plan B

Plan A

$157,457 $244,526

7 1,472 74,450

060 - Medical Information Services           -0 - 39,388

       Total including Core         $228,929 $358 , 364

Tltis Area submits a progress report on one activity, project #52, which
will continue for two more years.

The Area has a local Advisory Group composed of 34 members and lists  13
additional committees or task forces. Its Core staff numbers 10 full-time
employees.
on page 904.

A summary of the Core staff's significant accomplishments begins

This Area has no terminating projects.

The Continuing Project:

Project #52 - Perinatal Monitoring - This project is completing its  first
year of activity.  It is proposed for continuation under both Plans  - Plan A
at a $71,472 level and Plan B at a $74,450 level. Its objectives are to
lower perinatal mortality, to reduce the number of defective infants and to
reduce the number of caesarian sections required by fetal distress. Its
progress is briefly described on Form 15 (page 925) and in more detail

beginning on page 928.

e

,-

CALIFORNIA RMP - Area VI

-

5.

-28-

RM 00019 ,\)I1

Approvgd/Unfunded Activities:

- -7

Proiect 1/60 - Medical Information Services - This project is proposed for""
activation only under Plan B at a $39,388 level.

and services to practicing physicians and other health professionals.
builds on a pilot study underway for 14 months.
Form 15 (page 926).-

It was approved by the

July 1970 Council and it proposes to expand and improve literature search

..

It

It is briefly described on

No new proposals are submitted for this Area.

CALIFORNIA RMP - Area VI1 -29- RM 00019

The $6.2 million plan will hereinafter be designated Plan A and the $10
million plan will be Plan B.
San Diego - Area VI1

Coordinator: Michael B. Shimkin, M.D.

Geographic coverage - 2 counties

Population: approximately 1,432,400

Pres en t Fund ing

Core $177,324 (including $37,200 carryover)
Projects 69,201

   Tota 1 $246,725

Requested Funding

Core Staff

Continuation

#30 - Coronary Care Unit Training

Plan A       Plan B

$149,536    $256,8 18

75,982 79,148

No renewals are proposed

0

Approved/Unfunded Activities

862 - Continuing Education for Physicians -0 - 120,416
#66 - R.E.A.C.H. -0 - 231,014
#69 - Respiratory Care 62.400 65,000

No new activities are proposed

Total including Core $287,918 $752,396

This Area submits a progress report on one activity which continues  for
two more years.


The Area has a local Advisory Group composed of 2-9 members and 15 c-onnittees
or task forces.  The Core staff number-11-time employees and 7.85 fup

w-

Project #30 - Coronary Care Unit Training - This project is completing its
first year of activity.

Its continuation is proposed at a $75,982 level

-30-

CALIFORNIA RMP - Area VI1 RM 00019

under Plan A and $79,148 under Plan B.
CCU duty, provide consultation on CCU design and equipment and to train
rescue personnel ip emergency cardiopulmonary resuscitation. Its progress
is briefly described on Form 15 (page 964) and in more detail beginning on

It proposes to train 360 RN's for

*.

page 968. .-

No renewals are proposed.

ApprovedhJnfunded Activities:

One approved/unfunded activity (1169) is proposed under both P lans.
addition, two previously approved projects (#62 and #66) are proposed for
activation under Plan E.

In

-

Project !169 - Respiratory Care - This project was approved by February  1971
Council and is proposed at a level of $62,400 under Plan A and $65,000 under ,

Plan E. Both levels are requesting budgets significantly less than the
origina 1 proposal. Through educational programs in respiratory care for
physicians, nurses and other allied health personnel the project aims to
upgrade and expand the diagnostic and therapeutic capabilities of the Area.
It is briefly described on Form 15 (page 967).

Proiect f62 - Continuing Education for Physicians - This activity was
approved by the November 1970 Council and is proposed for activation only
under Plan B at a $120,416 level.  It aims to provide coordinated continuing
education programs for physictans in San Diego and Imperial Counties.   It
is briefly described on Form f5 (page 967).

Project #I66 - R.E.A.C.H. - This proposal was approved by the Fcbruary  1971
Council and is proposed for activation only under Plan B at a $231,014 level.
It proposes supplementary staff in six general hospitals in Sail Dicpo Couuty
to establish multidisciplinary teams in each; a slightly modifjcd Leam in
two Irnperial County liospitals; methods for MD's to assume active Iwdership
roles for follow-up care under their direction; and advice for allicxi hca1Lh
professionals.

It is brief19 described on Form 15 (page 966).

Irvine -- Area VI11

Coord inn tor : Robert C . Combs, M .D.

GcoSrapIi i c covc'ragc: 1 county
populnt ion: approxiinatcly 1,420,400

1' r es en t Fund ing


Core
Projects

Tota 1

$178,600

439,178 (including $35,000 carryover)

$617,778

Rcques ted Funding,

Core Staff


Con t inua t ion

1/28 - Comprehensive Community Stroke Program

Approvc*d/Unfunded Activities

#54 - Rapid Hospitalization for Acute Myocardial

f56 - C.R.I.S. (Community Referral & Information

a72 - Radiation Therapy

Infarction

Service)

New Activity

/I84 - Neonatal Intensive Care

Tota 1 including Core

Plan A

$18 1,344

230,874

48,000

19,200

-0 -

  -0-

$479,418

Plan E

$284,767

240,494

50,000

20,000

71,957

111,684

$778,w~2

This Area submits progress reports on two ongoing activities (/I21 and //28).
Project #21 terminates this year; project #28 continues for one additional
year *

Tlle Area has a local Advisory Committee composed of 31 members, five standing
committees and two ad hoc committees.

The Area Core staff numbers(m9

ployees and 9.12 full-time equivalew A summary of Core staff's

lcant acc omplishments begins on page 993.

-32-

CALIFORNIA IU@ - Area VI11

RM 00019

5'
1. b

The Terminating Proiect:

Project 1/21 - Pediatric Pulmonary Center - This activity is  in its final
year of a three-year period of support.
professional's knowledge and skills in pediatric inpatient and outpatient
care,

The Continuing Project:

Project 4/28 - Comprehensive Community Stroke Program - This proposal was a
part of the California RMP's original operational application.
to Regional funding limitations, this proposal was not activated until the
Region's second operational year.  It proposes to increase the quality of
care of stroke patients by integrating all aspects of such care.
continuation for one more year is proposed at a $230,874 level under Plan A
and a $240,494  level under Plan B.  Form 15, briefly describing the project
is on page 1005.

11

Its aims are to increase the health

The progress made is briefly described on Form 15 (page 1004).

81 1

However, due

Its

No renewing activities are proposed

Approved/Unfunded Activities:

Two such projects (154 and 1\56) are proposed for activation under Plan A
and an additional one (4172) ynder Plan B.

Proiect 4/54 - Rapid Hospitalization for Acute Myocardial Infarction - This
proposal was submitted to the March 1970 Council. It was essentially a two-
component proposal dealing with public education and niodcs of transportation
of victims of myocardial infarction. The original project proposed two study
areas and included the involvement of a mobile unit. Tltc proposal here
confines the activity to a study of the value of public education in one
controlled population segment (Leisure World, Laguna Beach) and the mobile
unit aspects have been deLeted.
both plans - Plan A at $48,000 and Plan B at $50,000.
siderably below the Council approved level of $200,000.
1006.

This project is proposed for activation under

Both levels are con-
Form 15 is on page

Project #56 - C.R.I.S. (Community Referral & Information Service) - This
proposal was originally submitted to the March 1970 Council and received a
deferral action primarily because an earlier, similar proposal (CHAIRS) from
California's Area V had been funded by HSR&D for a five-year period at
approximately $700,000 and Council wanted a more indepth consideration of the
relative merits of both proposals.
1970 Council and received approval.
of Comprehensive Health Services established that the methodologies of CHAIRS
and CRIS are different, the former being concerned with the application of
computer technologies whereas the latter will employ standard techniques in
developing a new service. CRIS is a seed activity for an essential component
of a ccmprehensive health program in one of the fastest growing counties in
Ihe U.S. The project was approved at a $77,307 level. Jt is proposcd for
actiVJation under Plan A at $19,200 and Plan B at $20,000.
described OR Form 15 on page 1007.

The project was again submitted to July

Interim investigation by a staff member

It- is hrivKly

-33-

CALIFORNIA RMF' - Area VI11

RM 00019

Proiect #72 - Radiation Therapy - This proposal was approved by February 1971
Council and is planned for activation only under PLan B at $71,957.

It is

aimed at improving through continuing education for physicians, nurses, and
technicians, the quality of radiotherapy. It is briefly described on Fom. 15
on page 1008.

The New Proposal:

Project 1\84 - Neonatal InLcnsivc Care - This project is proposed only tinder
~'I<III 1% at a $111,684 level. It is a four-faceted proposal -- (I) training
of niirsc's for intcnsive care OF newborn infants; (2) training of physicians
(,rncl tra~r~s of MD's and NN's); (3) mobile intcnsivc car(' lor critically ill
inirints; (4) ;i consultation program. IL is briefly described on Fonn 1.5
(i-.igc 1009) atid expanded information begins on page 1076.)

-34-

CALIFORNIA RMP - Area IX RM 00019

The $6.2 million plan will hereinafter be designated Plan A and the $10

million plan will be Plan B.

Watts-Willowbrook - Area IX

Coordinator: M. Alfred Haynes, M.D.

-3.8

.

Geographic Scope: 1 county

Population: 526,700

Present Funding

Core $159,785
Projects 470,366 (includes carryover)
  Total $630,151

Requested Funding

' Core Staff

Continua t ion

Continuation Beyond Approval
Period of Support

Plan A       Plan B

$153,394    $1.84,558

  -0 -          -0 -

#6 - Charles R. Drew Postgraduate Medical School 384,000

Total $537,394

400,000

$584 , 558

This newly created Area grew,from the Watts-Willowbrook District jointly
sponsored by Areas IV and V. Drs. Brayton and Petit had developed a combina-
tion planning-operational proposal to coordinate the development of a Watts-
Willowbrook District of RMP with the development of the Charles R. Drew Postgraduate
Medical School.  Its genesis was a $220,000 RMP grant to assist in the
planning for and development of the faculty of the School.
emerged from the overall Watts-Willowbrook District activity as project #6.

This activity has

The current funding of Project #6 is $470,366.
described by the Region as falling into the following categories: 1) Department
of Community Medicine Activities; 2) Institutional Program Planning and
Development; 3) Institutional Resources Development; and 4) Faculty Recruitment
and Retention.

It is a four-faceted activity

May 1969 Council approved a site visit team recomendation that the Watts-
Willowbrook District he declared Area IX. Tlic new status of the District was
the subject of correspondencc between the California RMP Coordinator and
Dr. Mitchell Spellman, Dean of Drew Postgraduate Medical School. Dean Spellman ~

                                                                           <\
Dr. Haynes is Chairman of the Department of Community Medicine, Drew School.

..

named M. Alfred Haynes, M.D. the Coordinator for Area IX in October 1970. .%

'z. I

-35-

CALIFORNIA RMP - Area IX RM 00019

Tlw Drew School is the academic ann of the Martin Luther King, Jr. General
llospitn 1 (under construct ion). Uepartmcnt heads at the school accrue
appointittents as chiefs of service at the hospital and the credibility of
thv sclrool Lo attract and retain able, motivated faculty--lacking a facility--
has becii an obstacle.


When the King Hospital becomes operational, a contract with the Los Angeles
County Department of Hospitals is scheduled fdr activation, thereby providing
the school with additional financial assistance.

This proposal from Area IX requests the continuation of support for the
Area Core staff and renewed support for Project 86.
submitted, it is difficult to determine where one leaves off and the other
begins.

From the information

Apparently, similar areas of question arose during the Region's own review
process.
application includes the proposal originally submitted by Area  IX to CCRMP
as well as the responses of the proposers to requests for clarification
stemming from the Region's review process.

In an effort to develop a clearer picture, this portion of the

The materials concerning the Area IX Core activities are included on pages
1096-1117 in Volume 11.  The materials concerning Project #6 begin on page
1119 in Volume 11. Each requests support for three years.

i

CONT. WITHIN COhT. BEYOXD UPR. WI WZW, NOT 1st YEA3

DPR. PERIOD APPR. PERIOD PREV. PREY. DIRECT IKDIRECT

IDENTIFICATION OF
coMpomNT OF SUPPORT OF SUPPORT FUNDED APPROVED COSTS COSTS

(Page 1)

Page 2 of 2

TOTAL

20. ?26

REGION California

CYCLE R?.i r)r)r)19 8/72

BREAKOUT OF REQUEST 04 PROGRAM PERIOD

                    t
#A2 -(VII)CE for Y.D. 's I 120,416 I3n. 41 6
                     I

#56 - (V1ii)CRIS 70,000 20, wn
                                   I 19.788 '9.788
#GO -(VI)Yed. Info. Serv. I

JW,~ - (IV)PPrina tal C-isis 1 06,772 96.272

725

10.550 t4 978

       I
75, Q35 1 L5.253
15,6':! 111 ,h44

I

W I

d
I

#6& -(LV)Phys. C.E.                    I 68,892
              I         1

$66 - (V1I)REAACH I 231,014

68,892 . 13,113 82. on5

231.014 16,924 247,938

I

#67 - (1)Resn. Disease I 266,240 I 266,240

I I

108,224 374,464

$69 - (V1I)Reso. Disease

d/' - (1V)hsn. Care Trainjng
#72 - (VII1)Rad. Therapy
873 - (1II)Oncoloey
875 - (1)Indian Health

F73 - (1I)Alliec' Health

I 65,0001 65.000 I 29,235 94,235

177.1 59 I 277,159 I 50,386 22 7,545
             71 , 957 30,492 102,449
          I 301.123 lld,100 419,223
301,123                27,&23 154,832

1 50,4no) 50,400 1 ' 17,920 68.90

1

I

__

71,9571

127,409 127,409

I I

190,133 190.133

876 - (1)Hypertension

f 2 70,850

80.726

I 1on,ooo

$78 - (T1I)Oral Health Card I i 105,210
                                        62,321
                                            95,334

O// - (1)Intensive Care '1

879 - (1V)Ext. Care Fac.  I

190,003 a. < 279 - 243,239
105.210 I 21.000 126.210
62,321 I 1S,134 .eo, 455
95.334 1 10.418

105,752

1

I

$80 - (V) Cornuterized ECGl
#,SI - @)Urban Indian
A82 - (V 6 IX) Care of

   the Critically 111 '
If83 - (V)Free Clinic
    Coordination
$84 - (V1II)Neonatal
    Intensive Care

TOTAL 6,585,986 475,000

                         58,647

81,000 ' 81,000 2,778 83,778
80,000 80,000 18.260 9a,m

51,000 51,000 1 7,647

163,240

111,684 111,684 51.556

.t

12,688,709

1 .888,098 1,094.09l  1 0.043.1 75

2~6~5, 534

(Page 2) Page 1 of 2

I I

I I

I

I

0

*::

(Page 2)

Page 2 of 2

I
w
W
I

IDEhT IF ICAT ION OF

184,091
50,000

I
CI
0

.. ,.

(Page 3)

Page 2 of 2

          COiTi'I?TCATION WITHIN CONTLVUATION BEYOND AP?ROVED, NOT NEW, NOT
COPrSOhihT StlPORT SUPPORT FLlNQED APPROVED

IDE?XTFICATIOX OF APPROVED PERIOD OF APPROVED PERIOD OF PREVIOUSLY PREVIOUSLY

F56 20, no0
                                              79.788

i

$62 I 120,415

REGION Cel ifornia
BREAKJUT OF REQUXST 06 PROGRAM PERIOD

3rd YEAR    TOTAL


COSTS    DIRECT COSTS +

DIRECT ALLYEARS 1

39,388 1. 118,166 '.
120,416 11 351.248

20, no0 60.000 i-

tic;? I
454
J. F,
$67 1

I

f

I 96.232 1 96,232 11 258,696 1

1 266,240 I 795,720 I

68.892 I 68,892 11 206,676 693.042

1 231,014 231.014 11

266,240 1

368 r- ~ ~ I 55. no0 55.000 I 165.000 !

869 I 65,000
#70 50.400

65,000 I
50,"QO I

195,000 151,200 ' '

871 t 1 177,159 177,159 I
1:72 71,957 I I 71,957 I
      i I 1 301,123 1

I i                       190,133 190,133

P78 I 105,210 105,210
s79 6?, 000 63,000
          I
#80 95,334 95.334 I

301,123

127,409 ' 127,4P9 '

~~~

873
$7 5
P76
877

---

I

~

~

531,477
215,871 I
903,369
382,227
570,399
370.000 i
315,670 I

* 188.321
286.002 ,

F81
#82
#83
834

1

I

I

51,000 51,oiio --- 152,001)

--- 1~1,000 I

         --- 80,000
111,684 711,684 335,052

t

r'

5,510,760 388,784 1,796,912 743,770 8,440 , 206

I GR5 6/4/71

TOTAL

27,616,411

-. ..- -_

(A Privileged Communicii ti on)

SWRY OF REVIEW AND CONCLUSION OF
   JIJLY 1971 REVIEW COMMITTEE

CALIFOkVIA REGIONAL MEDICAL PROGRAM
       RM 00019 8/71

FOR CONSIDERATION BY AUGUST 1971 ADVISORY COUNCIL

c

o

Recommendation: (1) The $6.2 Million plan the Region has developed in

          order to reach its retrenched funding level is viable
and represents good decision-making. (2) The $10 million plan the Region
has developed should funds become available proposes the activation of
some previously approved activities which the site visitors do not view
CIS being wise to initiate at this time in view of the Region's new directions.
(3) With much the same selectivity that characterized the development of
the $6.2 plan, the Region certainly could mount an effective program at
the previously Council approved level of $8.3 million which would be
consistent with national priorities and the Regionas new directions.
(4) The site visitors concerns regarding the relatively ineffective
program administered by Area VI1 should be relayed to the Region with
the advice that CCRMP must address itself to these deficiencies. Also
Areas VI and VI11 are in need of intensive assistance with planning for
the future.
by assistance from Areas I, IV and V. (5) The issues and questions
identified by Committee and Council during the JanuaryIFebruary review
cycle concerning the Area I proposal (project #85)  for a cooperative
effort with the Bay Area Model Cities Agencies (San Francisco) were
satisfactory clarified.
its submission to and approval by the ad hoc Kidney Disease Panel prior
to Council Xc~ting ($8,364,000 minus $121,920); (7) the region must include
more realisttc evaluation data in its Progress Reports for assessment by
mPS staff and the confidentiality impediment must be overcome.

They are below the Regional RMP effort and might profit

(6)The regional Kidney plan to be deleted pending

REQUEST Recommended

Year Component Plan A Plan B Funding

04

Core $3,380,185
Kidney 121,920
Developmental
Component 384,000
Operational

    Activity      1,456,549
' Renewal         456,000
  Approved/unfunded   264,000
   New Projects      229,440

$6 , 292,0945~

Recommended

$4,548,409
  121,920

400,000

1,515,657
  475,000
1,888,098
1,094,091
$10 , 043 , 175

Allocationsto be
made by the
region.

$8,364,000
-121,920 Kidney
$8,242,080 (d.c.)

Year Funding

-.- 1.

05 $9,SOO,~~ Allocations to be made by the region.

06

I1

California RMP

-2-

RM 00019 8/71

The Review Committee member who participated in the site visit
introduced the discussion of the second part of the two-part request.
Also present and participating in the review was one of.the
consultants to the site team of June 10-11, 1971. A secondary
reviewer also shared in the review of the application.

& - .-

-

As background, the Committee was reminded that the purpose of the
recent site visit was to assess the operational matrix of the region.
Part I of the application covering the region's goals, objectives,
Developmental Component request and an expanded Core renewal, were
reviewed by the December 1970 site visit team,  the Review Committee
in January, and the National Advisory Council in February. The region's
new objectives were discussed at that time. These objectives, established
primarily to guide the use of developmental funds, also reflected the
direction in which the region is beginning to move-that of stimulating
changes in the organization and delivery of health services.

CCRMP's administrative management is considered to be outstanding,
especially in terms of the development of objectives, first published
in 1970 with the most recent updating including the Developmental
Component. The opinion of the reviewers was that the Program Evaluation
Committee, headed by Judge Landreen is impressive with a good grasp of the
concept of Regional Medical Programs. It has developed sound procedures
which are well defined.

It is also believed that CCRIIP reflects small but strong Core staff
expertise with specific strength of coordination and political know-how.
There is a good feel for the national scope of RMP and this is reflected
in the various program activities.

The evaluation component of the Core staff activities leaves room for
improvement. Thus far, the region's efforts at evaluation seem to be
limited to the task- of digesting a mass of information that its reporting
system generates.  Rased upon data collected by project directors and
channelled through the Areas to the central office,  the California RMP
is maintaining information that gives a good overview of the emphasis
of its activities.

It was reported that CCRMP evaluation staff believe it will have to rely
on a self-reporting system because of the confidential nature of the
data. The reviewers agreed with the site visitors that this position
is unacceptable.

The Review Committee is of the opinion that more evaluation data should
be included in progress reports, and further, that it will require
continuing contacts between project and CCRMP staffs.
feels that much good data is available, but it is admittedly hard to
extract.
and "outcome" assessment. As an example of evaluating a stroke program,
some very basic questions could be asked,  such as:
been able to reduce length of hospital stay? What is the significant input

Committee also

Notably missing from the California approach is the "output"

Has the stroke program

California RMP -3- RM 00019 8/71

on the productivity in the care of stroke patients? And so forth.
Addressing such questions should give some indication of the effective-
ness of a program, in the opinion of the reviewers.  Certainly it would
afford an excellent example of what to use as a bench mark.

ntinuing an extensive discussion of California's evaluation

methods, the reviewers felt that it is commendable to refer to both
'good'and 'bad' projects. At the same time, they feel that the region
should be reminded that CCRMP has spent a lot of money in some hard
areas, and such an investment should yield some hard results. It was
the feeling of some of the reviewers that perhaps RMPS could develop a
parallel effort to the review process that would, in some way, produce

cross-cut of project activities. How well a region has performed, in
e long run, should be another valuable criterion of the total review

11 in all, it appears that California has developed a good technique
r collection of dataonwhich to make regional decisions, along
  miological" lines. However, it would seem that the present
aluative process does not provide the necessary assistance to Area

project personnel in appropriate techniques for determining the
itical elements that contribute to the project's "success" or "failure."

as discussion of the various Core staff activities in each Area, with
us that the three strongest continue to be Areas I, N and V, based

nd USC, respectively. Areas I1 and IT1 (Davis and Stanford)

a VI in need of a thorough "overhaul".

be "Good" Areas VI and VI11 (Loma Linda and Irvinel are

for Area IX at TJatts-Willowbrook are heavily involved
01, which is a unique departure from the traditional
. The Review Committee heard from the site visitors about

      ed for assistance in this area, particularly in terms of
expectaticl.,m of the Watts community in that it continues to look to
King Hospital as a source of employment.

Many factors have presented

umental problems to Doctors Spellman and Haynes: the financial
       . County (reported to be over $50 million in debt), the
        3,200 positions orig9nally announced for the King
       0 by L.A. County, the recent earthquake, which has
       00 unemployed, trained ,hospital workers. Also, the Depart-

ty Medicine has been eliminated from the County budget, not-
revious agreement with the County that when the King

support would emanate from that source.

going, six of the ten Department Chairmen for Drew
recruited.

of Health Manpower and Markel Foundation funds are
as are Model Cities funds, reported as $35 million.
ts Area has not, as yet, been able to totally utilize
rces to their best advantage. The Committee agreed
am that the operations of Area IX, the Drew School,
1 are so irrevocably inter-related, that it is

The Medex program and a $250,000 grant

California RMP -4- RM 00019 8/71

most logical at this time to channel available financial resources  from

directions. In addition, other forms of assistance were discussed in the

form of professional consultants. This appears to be a very realistic
means of an interim alleviation of an urgent manpower need.

.--.-.

-_

@$$j

.; .=-

WPS for Area IX and the Drew School (Project #SI in the same general e 7-

The Reviewers were interested to hear about the newly established CCRMP
Program Review Committee under the Chairmanship of Judge Kenneth Andreen.
This body is charged with the function of program overview authority,
reporting directly to the RAC, and may, at its option, perform regional
site visits. This group is a potent performance evaluation mechanism.

The California RMP, in arriving at a $6.2 retrenched level of funding
request, had many hard decisions to make in terms of its developing new
directions. It was able to salvage its $400,000 Developmental Component,
which was`approved during the JanuaryjFebruary cycle. This, in the
opinion of the region, represents the best available means for change to
new directions. The only two projects requesting renewal--the DJ-ew
School and the Northeast San Fernando Valley project--from twelve
terminating programs, were selected as being commensurate with current
objectives. Also, three new proposals, two addressing crucial needs in
Irldian health problems and one with extended care facilities, were
selected in lieu of many approved but unfunded projects. The choices
were made in an attempt to retain visibility in each of the Areas,
and to maintain a capability to shift to objectives more in line with
the new mission.
does not evidence this selectivity and the reviewers failed to approve
it. The reviewers concurred in the recommendation of the site visit
team that the proposal to activate some previously approved activities
up to $10 million would be unwise at this time in view of the region's
new directions. However, there was consensus that the California RMP
could effectively mount a program at the previously Council approved
level of $9.3 million, consistent with national priorities and in line
with the stated objectiyes of CCRMP.

The plan R proposed under the $10 million request

It should be nc,ted that the issues and questions identified by Committee
and Council during the JanuaryfFebruary 1971 cycle concerning the
Area I proposal (project #85) for a cooperative effort with the Bay Area
Model Cities Agencies (San Francisco) were satisfactorily clarified.
There was positive evidence of a legitimate need and there was agreement
that this program can fulfill the needs in a manner not possible from
an orher source of health planning.
the Richmond program is more than adequately planned and is ready for
implementation.

The reviewers agreed also that

In discussing the Kidney Disease request) Committee was reluctant
to approve the planning proposal without its review and concurrence
by the ad hoc Kidney Disease Review Panel.
(approximately $121,000) was therefore deleted  from the recommended
amount, pending such a reviewwifi direct reference to the National

. Advisory Council. The plan is an outgrowth of a conference to organize
a program that will realistically provide planning for kidney disease
problems for the entire region. An attachment to this critique is a
short version of the Panel's evaluation of the `(idncy Disease Planning progralll.

The requested amount

-5-

SUMMARY OF REVIEW AND CONCLUSIONS


AD HOC PANEL ON RENAL DISEASE

of the July 16, 1971

Project: CCRMP Regional Plan for Kidney Disease in California

The CCRMP submitted a Region-wide plan as a guide  for the developing
renal disease activities in California, The plan addresses four
areas or components for action:

1. Information System Component
2. Clinical Nephrology and Dialysis Training Component
3.  Renal Transplantation and Organ Procurement Component
4. Pediatric Nephrology Component

s pleased with the organizational structure which was
reasonable and workable provision of direction toward
of renal disease problems in the Regipn. The Panel

difficulty, however, with a lack of definition in each
ibed components.

that the need for a computer data system was not set
arly with respect to how such a system would advance

nt were explained with respect to the need  to be met
ent which would be made of the proposed data output.
that a number of the stated objectives were already

hed. Comparatively, the Panel noted the absence of
oint, such as a "Funding Desk" concept (developing
RMP) which could apply patient needs as a guide  for
n and processing. It is doubted, however, that an
m is needed to relate available facilities to patients.

ents. It was expressed that neither the goals or objectives

ng was discerned in an implication to continue the
related tissue typing and referral activities now
y UCLA through activities directed hy Dr.  Paul Teresaki.

-6-

_-

.* .

h:: ;'.
@&@

.e %:;*

Project: CCRMP Regional Plan for Kidney Disease in California - 2 - - --

of a nephrology program may have merit when clearly charted.

The Region's interest in training is not buttressed by recognition
of training now being accomplished, nor the specific unmet needs
to which programs should be addressed.  The Component advises as
to the desirability of training, but stops short of clarifying
_I_ what training, for and by em, and   it might be instituted
to resolve named shortcomings.  With respect to the scope of proposed
formal courses, the Panel felt that the proposal was ambiguous.
While it was agreed an implementation schedule might not yet he
stated, the Panel believed that the results to he achieved should
be definable.

The Panel felt that the sophisticated state of the art  in California
negates the need for training in dialysis beyond that which normally
proceeds within existing dialysis programs.
consultants meeting with private physicians poses particular problems
regarding the consent of private physicians, and the per-patient
cost of such activities. The Panel believes that there is both waste
and potential danger in bringing innovative diagnostic techniques
outside of research centers where their application and interpretation
is practised as a highly skilled and developing art.
at the present time, little direct benefit to patients from such
sophisticated procedures.

A concept of teams of

There is also,

Rura 1 Tra nsp la nt a t ion and Organ Procurement Component

This section reflects a desire to improve transplantation, improve
inkunosuppression through a program for ALG and imorove organ
procurement.
to do. It could not assure itself from the plan of the need for
additional renal traisplantation units in view of the 14 which
presencly exist in California.
the budget for this Component as reflecting a money-sharing outlook
among California institutions, rather than support of programs to
satisfy precise needs.
good third party payment opportunities which exist in California.

The Panel could not. identify what the Region proposed

Dissatisfaction was expressed with

The budget also fails to reflect the unusually

Pediatric Nephrolopy Component

This Component is addressed to two salient problems: poor communications
and fcllowup; and non-systematic treatment, and evaluation of treatment.
Current pediatric nephrology facilities, of which there are two, are
stated to be adequate for the relatively small number of patients  in
need.  The Panel was puzzled by this portion of the proposal as  the
sense switches from general pediatric renal disease to chronic uremia

to contradict a statement that no further facilities are necessary,
and the Panel was left unsatisfied in terms of specific details.

in children; implications of community-level care in the plan seem

I

-7-

project: CCRMP Regional Plan for Kidney Disease in California - 3-

This proposal requests largely computer facilities and staff, and
does not seem to bear upon the specific delviery of care to children.

Dr. Kountz was absent from the room during the consideration and

t voting on recommendations.

        - The Panel recommends that the CCRMP kidney disease
lan be accepted with advice to the Region.  The organization
stablished appears reasonable and workable, and capable of defining
nd responding to the particular needs of the Region. Recognizing

the stricture of time and the scope of areas to be considered by the
lanners, the Panel felt that it could endorse the concepts of
ome parts of the initial plan, and that the proposed allocation of
121,920 can be utilized effectively in the development of those

he Panel noted that the plan does not reflect the operational status

of several kidney disease activities in California as well as the
Panel knows that it exists. In this context, the Panel recognizes
the present incompleteness of the plan with respect  to lack of
methods, procedures and timing. The Panel urges that California
be instructed to continue with clarification of goals and objectives

future applications should clearly provide an orderly

to achievement.

At its present stage of development, the plan seems less directed to

patient needs than it is ta the various  interests of institutions
     gators. The Panel felt that this was most apparent in
      ransplantatian and Organ Procurement Component,  but
      acet was observable throughout the plan.

The Panel recormnends approval of the allocation of $121,920 in the
first year, as a necessary vehicle for continued planning, and as
a means to effect some non-insignificant operating progress within

f the plan. It is proposed that $26,500 be approved for
ork of the planning committee as requested. It is
at the balance of $95,420 be flexibly employed  in areas
he opinion of the Panel, promise early results given the
ate of renal disease activities in California. These

are :

1. Increase the Region's capacity to procure and distribute

cadaver organs toward increasing graft surgery.

Investigate the development of one or more central supply
sources for the provision of ALG to transplanters.

>

/T-

-8-

e-

- x- ._*.
e'. %

?$+

Project: CCRMP Regional Plan for Kidney Disease in California - 4- ---- -z

3.

Consider continued support of the UCLA tissue typing
and donor-recipient record and referral service directed
by Dr. Paul Teresaki.

P

The Panel suggests that these areas be dealt with flexibly in that

i

continued pursuit of any area presenting significant problems be
deferred, with increased effort extended in those more amenable
to quick resolution.

1

The Panel did not find in the plan either immediate need, nor adequate
procedures for patient oriented activities with respect to broad
information programs, pediatric nephrology, or training.

June 30, 1971

DEPARTMENT OF WFALTH, EELICATION, AND WELFAKE
              PUBLIC HEALTH FERVICE
HEALTH SERVICES AND MENTAL FiEAL7i-I ADIVIINIStRA'fION

Quick Report on the California Regional. Medical. Program Site Visit
June 13-11., 1971.

I)i rector, %.IPS
THROUGH: Acting Deputy Director I

Regional Medical Programs Service

*Clark El, Mil I.il:en 13. D

nber, Naicional Advisory Council
iisultant in Keurology

Mayo Clinic
Rochestel-, Minnsoia

Joseph W. HF~SS, ,X.D*

Mewher, Revirm. Commi'itce
rector, Offi ce of Research
in Medical Educat,ion
yne State University

School of I4edicine
Detroit Michigan

Heiiry 14. Wood, Director of
Urban I:eal.th Planning
New Jersey Regional- Medical Program
East Orange, Neb7 Jersey

James A. Rock, M.D.
Chairman, PdLG Western Pennsylvanj a P\MP
Lee Hospitai
320 Main Street
Johns town, Penrisylvania

rarcl Davcns , 1.1. D.

Co o r d in a to r
Maryland Regional Medical Program
550 North Eroadr.Jay
Ealtimore Maryland

* Chairman of Si-te Visit Teain

PPIP S  S T A FF

- l"l___ ~

Jessie E'. Salazar, Grants Review Sra:ich

Page 2 - Director, DIPS

Lorraine 31. Kyttle, Grants Review Branch
Cleveland R. Chambliss, Office of.0rganizatisnal Liaison
Marian E. Leach, Ph.D., Continuing Education and Training Branch
Ronald S. Currie, ROR, DEIEW Region IX

BACKGROUND

This site visit was arranged for the purpose of assessing the opera-
tional activity rnatrjx of the Region.
two-part application. Part one, covering the Region's goals, objectives,
a developmental component request and expanded Core renewal, were
assessed by a December 1970 site visit team.
Region's new objectives were discussed. These objectives, established
primarily to guide the USE of developmental funds, alsoereflected the
direction in which the Region is begiilning to Inove----that of stiriiul ating
changes jii the organization and delivery of heal th services.

---

.It was the second part of a

At that time, the

As the agenda for the June '1971 visit- unfolded,  the team found itself
again engulfed by Core activities  as well. as the operational project

trix. Probably, this was inc~scapable becaiise retrenched funding,
nounced in the intcrin betweeu the tt;o appI.icatkoiis recluirccl re-
design of the Region's total program. The lict result. was' a highly

compressed prescntatian by each Area Coordinator of h3.s total program
activity,

The visit was conducted in two geographjc locations. The first day
in Los Angeles, we met with Dr. Spellmcln and some 01 his staff, in
Watts at the OED Multipurpose Health Centcr. Area IX activity and the
status of Project ii6,  the Charles R. Drew Postgraduat-e Medical School,
were presented. The remaining southern California Regions (IV UCLA;
V USC; VI1 San Diego; andVIII: Irvine) werc iiscussecl in the afternoon.
The second day, in San Francisco, the .northern California Areas
(I UCSP; I1 Davis; IT1 Stanford; and VI: Loma Liiida) were preseilted.
Portions of both days also were devoted to total Regional matters.

In an attempt to keep this mini report brief, T have selected only
the following items for highlighting which I believe are the most
crucial.

GENEFULL LMPRFA3 S IONS

(1) Watts needs help--of several kinds. The King Hospital already
about 14 months behind schedule, has .suffered additional setbacks,
These probably are attributable to several things, one of which is
certainly the financial coriditioii of Los Angc1c.s County (reportedly over
$50 mill-ion in debt). The recent earthqiiakes, thci complication of the
State Civil Service System, sild comrsun-i ty ferrncnt , all contribute to
monumclntal problems with which Drs. Spcllma . and Hayrics are f-ryJring to

pe. Approximately 50 area rer,idm ts at tendctl the three-houi- moT-ning,

Page 3 - Director, RMPS

session hosted by Dr. Spellman in the OEO Center and the proceedings
Eecame somewhat vocal. The team requcts Led that Mr ., Ward make arrange-
ments for a meeting with Drs. Spellman arid Haynes the next day in
San Francisco. A previous commitment precluded Dr. Spellman's
participation,  but the team had an opportunity to explore in depth
the problems with Dr. Haynes. The followin& alarms were sounded. A
commitment has been made  to the cornmunity that King Hospital would be
not only an outreach by the County to provide health weds, but an
employer as well.  However, the 3,200 posi tions ori ginal ly announced
ifor the hospital have been cut to 3,1100 by the County as part of a
drastic attempt to reduce its overall health budget.  Also, as part of
a health budget redesign, Dr. Hayiies ' Department of Coinrnunity Medicine
has been elirninated from the County budget (and there goes a previous
understanding  that when the King IIcspital opened, suppoet for this
D~~partmerit ~oulci bcg-in.) T'iiis is a coiillJ%icai.cd sei: of circumstances
which scern to turn on the ultimate point thac Los Arigeles County has
decided it will not break a precedent by providing salary support
for physicians not direct1.y engaged in thc provision of  services.

It is estimated that between 3,000 to 4 000 t rained hospit-a1 workers
(mostly State civil servants with rc:rmployinr.nl: rights) arF on the
employmnt market as a result of the recent earthquakes.
this makes the conimunity in lJatts sucjpic-i ous of the inact.ivicy to begin
the hoped for programs .to train area resident-s for positions in the
hospital.

Dr. Spellman has recruited six of the ten Departmental Chairmen for the
Drew School. To attract Chairmen in the absence of a facility and in
the face of obvious financial dif f iculties has been a tremendous
obstacle.
Health Manpower are visible stimu1ant;s as well. as Markle Foundation
funds. The team believes that the succc.ss of Area IX, the Drcv7 Sc-hool,
and the King Hospital are so entwined that it is logical at this point
in time to channel. the financiaf resources provided by P?PS for Area IX
and projccr: 116 in the same general cli-rectioiis.

However, the team feels that assistance, over and above financial
resources could be provided here in an elfort to help Drs. Spellmail
and Haynes at what we belive is a crjtical trirne.
School must be able to do more than hold the ljne until thc King
Hospital opens (tentatively scheduled for Febi-uary 1.972).

Help ;.n the form of professjonal assistance to move in ncw ways during
the interim is jnrli-cated and I believe Mr. Clrian~bliss has covered some

Knowledge of

The Medex program and a $250,000 grant from the Bureau of

Area IX and tlie Drew

datiocs along these lines wit11 you.

) The team was unanimous in its concerns aboui- Area i711 San Diego,
both its leadership and the oper2iion::l proGram it displays, A1 though
it is based in a very conservaiive area of tlie State,  nevcrtheless it
must be vi.ewed as a part of a Rrgiov ertibn~:k-ing on new dii-ecLions

Page 4 - l)irector,KI.TI'S

and probably requires a "slippered foot" kind of innovative 1 eadership
that the team feels is not present. Tf Area VI1 were not covered by
the protective umbrella of'the California total Region and had to
compare and coinpcte nationally,  it would not clo well at all.
Irvine, left the visitors with bland impressions of its operational
matrix that is disappointing. Area VI, Lonia Linda, was also viewed
somewhat negatively by most of the team. The vastness and remoteness
of its geography were considered as wel.1. as  the fact that the Medical
School does not represent a resource primarily dedicated to local
activities. It considers itsell: a nattonal I^CS~UI-CC for the Seventh
Day Advrntist Church.  However, because the Area base has a close
proximity to Los Angeles, the teain concluded that its leadership could
have developed innovative inter-Area approachcs to problem solving.
Some of the site visitors felt tliat a second look at the boundaries of
this Arca might br: wise, The iiexi. rak;ng of coizccrns were Ayeas TK
Diivis, aiid TILStanford, Total -impre.s:~;5ons recoi.dec1 by VfSitOIYS or1
these Areas wei-e arr8ivalent:- they probal) ly arc the gray areas. Areas
I , UCSP, IV, UCLA and V USC again conic thi ough as iiialcing the greatest
favorable j mpressioris in terms of bo 131 03' gan-iza tional effectivencss
and. operational achievements. Area 1 prescnied an excellent Core
developed guideline for activitj es covering the next two years. The

Area VIIS,

p of I these Arcas has good vision and even though Dr. Rapaport
usual staterncnt of concern regarding qual-ity versus cluantity,

he is moving in real ways to reach out to the six ~Ioclel Cities Agencies
in his Arca as well as the United Indisn Health Service, Inc. These
Areas could coinpare quite avorably in natioiial competiti on and the
Region ~iJl continue to benefit from the dircctions these Areas pursue.

(3)
by Judge Kenneth Andrecn and ves;t/?(]
in the area of ICegional strengths and wcaknesses has the potential of
a potent interml mechanism to assess perforiiiance. It reports directly
to the Mf2 and may at its option sitc visit. If j.t does what it says
it will do, it should prove interestirig

(4) The visitors attempted to record their inipressiorr, in a fashion
compatible with the new ssion statcriicnt" rcview criteria, Some of
the consultants had not be ore participatcd in a site visit for RWS,
while for others it was a first visit to the Caliornia FJfl'. The
reaction OS: your staff on the team v7as that given this diversity of
team mcnibcrship and in the face of a deluge of liighlightcd prcsenta-
tions in the Region, the basic cornpatihiljty of most of the rat-ings of
K~E'W team nmnbers with those of the "old California watchers" was
significant

The newly es tablisiied Il-mcrrlber Program Review Cnmnj ttee ,  &ail-ed

:?it11 program overview authority

..

(5) Finally, a word about the dcc-isj.ons thjs Region had to make in
order to retrench to a nei.7 level and at the sime tiuic salvage so:i?.e"iij.ng
for the development of its new dircctions.
level, the Regton has almost e;it irely salvagcrl its approved $400,000

In arriving at a SG,2

Page 5 - Director, @IPS

Developmental Component wl-~ich j s seen by them as "representing the
best available avenue for change in new directions."
for renewals (the Drew School and the NortheasZ Valley project)  out of
twelve terminating projects were selected, both clearly in line with
current objectives'.
Indian Heal th and one concerning extended care facilities , were selected
at thc cost of many approved/unfunded projects.
struck in an effort to retain vjs;ibility in each of the Areas and to
maintain a capability to shift to objectives more in line with the new
mission.
hence the reviewers ' failure to approve it.

KECOMENDAT ION S

(I) The $6.2 i~iIl.ion plan the Riygio!i has dc2ve1fJpcd in order to
reach its rctrcnched fundring level -is v-i able and represents good
d cc i. s ion--ni alr in g ,

(2) Thc $1 0 nil.Li on plan the 2kgi 011 has developed should funds
become availal>le proposes  the activation of soiiic previously approved
activities vliich the site visitors do not vi.cxv tis being wise to ini tiatc
at this tin2 iir view of the P.egjon's YILV dircctions,

(3) With much the same selectivity that characterized the devel opnent
of the $6.2 plan, the Region certainly could rnoiint an effective pro-
gram at the previously Council approved level of $8.3 mill.ion which
would be coi-isis tent with national priorities and the Region's hew
directions.

(4) The site visitors concerns regarding the rel-atively ineffective
program adrninis tered by Area VIL shoul.,cl be relayed to the Region with
the advice that CCPJQ rnust address itself to these deficiencies. Also

eas VI and VIXI are in necd of intensive assistance with planning

Only two requesfs

The three nev7 proposzls, two in the area of

A delicate balance was

The $10 million plan doe; not evidence this selectivity;

_I"-- ---_-__

4

or the future.

          They are below thc Kegional RIfP effort and nlighL
profit by assistance froni Areas I, IV and V.

(5) The issues and ques ti oils -identified by Coriirnittee and Counc i 1
during the January/Pebruary revicw cycli. coaccrning the Area 1 proposal-
(project #8S) for a cooperative c:-Efort wi.tli t-hc Bay Area Model Cities
Agencies (San Francisco) were sati sfacL-oi-iIy c?nrifi ecl.

,/yf-*A XII i_..,J

i --2 .07--~,

c.

Lorraine PI. Ky Ltle
Froeraill hnalg$jt
Grants Revicw Branch

(A Privileged Communication)

       SITE VISIT
CALIFORIYIA REGIONAL
     JUNE 10-11, 1971

DRAFT

REPORT
MEDICAL PROGRAM

I. SITE VISITORS ..

Clark H. Millikan, M.D., Chairman, Member, National Advisory
Council, - Consultant in Neurology, Mayo Clinic

Joseph W. Hess, M.D., Member, Review Committee, Director, Office
of Research in Medical Education, Wayne State University

'Henry M. Wood, Director ef Urban Health Planning, New Jersey
Regional Medical Program

James A. Rock, M.D. , Chairman, RAG Western Pennsylvania Regional
Medical Program

Edward Davens, M,D., Coordinator, Maryland Regional Medical
Program

REGIONAL MEDICAL PROGRAMS SERVICE STAFF

Jessie F. Salazar , Public Health Advisor, Grants Review Branch
Lorraine M. Kyttle, Program Analyst, Grants Review Branch
Cleveland R. Chambliss, Office of Organizational Liaison
Marian E. Leach, Ph.D., Continuing Education and Training Branch
Ronald S. Currie, ROR, DREW Region IX

CALIFORNIA NQ - STAFF

Mr. Paul D. Ward, Executive Director, CCRMP
John A. Mitchell, M.D., Deputy Director, CCBP
Jack E. Thomson, Ed.D., Coordinator of Evaluation, CCRMP
Mr. Acton W. Barnes, Associate Director, CCRMP (1
Mr. Richard Sasuly, Associate Director, CCRMP
Mr. William Boquist, Associate Director
Mrs. Patricia McDonald, Coordinator of Planning and Review, CCRMP
Mrs. Chris Roberts, Coordinator of Administration, CCRMP

Elliot Rapaport, M.D., Acting Coordinator, Area I - UCSF
Dorothy Moga,  Area I - UCSF

Virginia Greer, Area I - UCSF
Neil Andrews, M.D., Coordinator, Area I1 - UC Davis
Charles White, Ph.D., Area I1
William Fowkes, Jr. M.D., Acting Coordinator, Area I11 - Stanford
Virginia Hunn, CCU Nursing Coordinator
Donald Brayton, M.D., Coordinator, Area IV - UCLA

>-.

..

Sarah Mazelis, Area I - UCSF .I,

.r

I

William Markey, Area IV-UCLA

m

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California RMP Site Visit -2-. RM 00019

e CALIFORNIA FXP STAFF (cont.)

Richard Walden, M.D., Coordinator, Area VI - Loma Linda University
Mr. Derek Price, Associate Coordinator, Area I11 - UC iSan Diego
Robert Combs, Coordinator; Area VI11 - UC Irvine

Mitchell Spellman, M.D., Coordinator, Area IX - Dean,lkarles R. Drew
Alfred Ilaynes, M.D., Chairman, Community Medicine Area IX - Watts-Willowbrook

I

Postgraduate Medical School, Watts-Willowbrook

I

OTHER REGIONAL REPRESENTATIVES


Mr. Cliff Cole, Project Director, South Central Multi-Purpose
Mr. Ray Eden, Executive Director, Los Angeles County Heart Association
Judge Kenneth Andreen, Member, CCRMP and Chairman, Program Review

Health Service Center

and Chairman, CCRT.Ip Objectives Committee

Commit tee

'.

California Site Visit Report -3- RM 00019

BACKGROUND

This site visit was arranged to respond to the second part of a two
part application. Part one of the application (covering renewal of
Core at an expanded level to coordinate programs with CHP and Model
Cities; a Developmental Component; and new projects) vas considered
in the JanuaryIFebruary review cycle.  Part two of the application,
covering essentially the project activity matrix, was scheduled for
review in the July/August 1971 cycle.  The recommendation of the site
visitors in response to the first application was that'a total program
,level should be established at that time to guidc: the Region with
funding limits for the second part of the application. The Council of
February 1971 approved a total program level of $8,363,994 for the
Regiona's 04, 05 and 06 years.

In April all regions were notified of retrenched funding require by
overall budgetary constraints. At that time, the California EWP
was operating at $7.5 million with a commitment for the next year
that dropped to $1.7. Council approved a level of $8.3 and the region
had been notified that its reduced level would be $6.2. It also had
amassed a large backlog of Council approved but unfunded projects.
California responded by submitting two plans (A and B). Plan A
reduced the programs to the $6.2 level and Plan B was presented at
a $10 million level in the hope that additional funds might become
available.

At the pre-site visit conference, the team agreed that the decisions
the Region had made to retrench to a $6.2 level were well-grounded.
The Developmental Componet request was not reduced appreciably. This
is important to a region beginning significant moves in a new concept
with the Developmental Component offering an early opportunity to
implement timely programs in line with their new directions. The
selectivity process that restricted' requests for renewal to the NE
Valley Project (l'i24) and the Drew School (116) from a total of 12
terminating activities led the team to the conclusion that some
thorny decisions had been made. The team also agreed that the
assessment of the Region's operational activities must take into
account.that a part of the program is still
devoted to the originally'established objectives, while some of it
is molded along the lines of national priorities. At this point,
the CCRMP operational activity is described by Mr. Ward as "going in
a least two different directions, at different levels, and different
speeds. I'

- -.

,- _.

..

The team devoted most of its pre-visit meeting in Los Angeles in ..

discussing Area IX and the Drew School. A. general framework
of questioning was developed but it was agreed that the strategy
for the morning session in Watts would be one of listening.

V

The disparate degrees of organizational effectiveness and program
accomplishment among the Areas reflec'ted in the application also
discussed. There was agreement that the review criteria would be
applied Area by Area.

..

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California Site Visit Report -4- RM 00019

GEHERAL IMPRESSIONS

The California RMP in anticipation of changes in RMPS program directions
began to develop a new emphasis some time ago. This Region, a federation
of nine areas, some of which are larger in population and geography than
other single Regional Medical Piograms has required an ailiance of
leaderships was not easily accomplished. The 35-member California
Coinmittee on FNP (RAG) on which each of the nine Area Coordinators serve,
approved a new set of objectives preparatory to submittihg a triennial
application, It was inevitable that new funding decisions emerged in .
directions quite different from the objectives that attracted so many
members to the program initially. These new objectives also had to
receive the approval of nine Area Advisory Croups as well.

Having adopted the new concepts, California found itself with a program
evolving into two thrusts -- a portion of it committed to ongoing
projects developed under categorical objectives and another portion
molded in the new concept. Parts of the early categorically based
program are in agreement with the new objectives. While a de-emphasis
of the earlier concepts is obviously increasing the newly adopted
thrusts are accelerating. Some representatives of the Region resisted
this change. During this evolution, the Region was required to reduce
its budget. The current site visitors agreed that the decisions that
evolved struck a delicate balance in the $6.2 Plan A. The $10 million
Plan B does not evidence this degree of selectivity. The team noted that
it proposes the activation of some projects, which have been approved
at the national level within the last 18 months. These are probably
not as relevant now to regional or national priorities, and it might
be unwise to begin them now.

As past site visit teams have noted, the current team agreed that the
on'site visit mechanism offers an opportunity for understanding the
real essence of the region's activities. Catifornia, in its attempt
to reduce paper quantity, does not always present its case well. This
is a perennial problem, and is probably due to the mass of data it
attempts to synthesize for each submission. For example, this
application reported on 86 ongoing activities and Core activities of
nine Areas!  Also contributing to the problem, in the opinion of the
visitors, is the fact that the best available evaluation data is not
usually included in the summaries. Each of the last three applications
submitted were on the revised form. This has undoubtedly mitigated against
the region's ability to "tell its story" to best advantage.

Also, it

has been noted that the region appears to have difficulty in developing.
an application which reflects consistency of preparation from all Areas. 1"

L ..

Y

The matrix formed by the operational activities when viewed regionally
reflects a bifurcated program and Mr. Ward made no attempt to sidestep
this issue. Rather, he spoke to it, ,both in Los Angeles and San Francisco
in terms of total regional matters. The visitors believed that the
spread of the operational activities in this Region is the logical
ext'ension of 'ongoing changes and, in all probability, reflects the
status (or future status) of most regions, attempting such shifts in
program thrusts.

S

California Site 'Visit Report -5- RM 00019

The Region's' review process
intra-regional site visits, is excellent and activities initiated
since its promulgation are sound.

which includes outside consu1,tants and

When viewed Area by Area the matrix loses some of its appeal and the
balance becomes distorted. These concerns will be spoken to under .
Section IV, Program Accomplishments.

REVIEW DETAILS

8-

A. Goals, Objectives and Priorities:

The assessment of the Region's goals, objectives and priorities
was one of the missions of the December 1970 visit and the
February Council accepted the team's recommendation of approval.
The new objectives, which will apply to all developmental

, . component funds and ultimately pattern the program, are clearly
stated and are entirely consistent with national priorities.

B. Organizational Effectiveness

Although this portion of the program also was the subject of the
December 1970 site visit, it was again reviewed for the following
reason: The December team was assessing an application that
proposed increases to Area Core staffs in order to coordinate with
CHP activities and to provide the "underfunded" Areas (11, 111,
VII, and VIII) an opportunity to increase their staffs, There
is a correlation between the productiyity of Areas and their funding
levels. However, the December visitors were not convinced that this
was the only validdeterminant and because the approved, overall
increases were never funded, the December team believed the
problem of disparate levels of core support had to be re-examined.
The team's conclusions are as follows:

' Central Staff

California's Central Office has a role that is singular. It is small

it guides nine much larger bodies that in some ways are replicas
of itself. Itmust be the introducer, the modifie.r, or the transformer,
influencing the directions of the Areas who themselves have governing
bodies vested with local decision-making. The Central Office has
demonstrated its capability to fill this role.

Regional Advisory Group is strong.
system that provides for local determination; yet those determin.ations
are subject to expert consultant review.
necessary for the formation of a federation of nine Areas; yet it
has established a Program Review Committee to monitor the effective-
ness of the Area's programs.

Much of the Central Office effectiveness is a reflection of the
leadership of Mr. Paul Yard.
be well balanced in terms of professional training and skills.

. (8 full time professionals and 6 secretarial/clerical employees) and

For example, it has

.- _I

created anatmosphere fostering collective leaderships; yet the

4.

It has developed an interna1,review

It has developed the tenets

The Central Office staff appears to

*

California Site 'Visit Report -6- RM 00019

They appear to function in a cohesive manner. .The Executive
Director enjoys a very positive ,relationship with the Area Coor-
dinators in anxnusual capacity of being a gentle, but firm, '
administrator.

.

. CRMP is faced with the problem that some Areas are below regfonal .

,-

standards of performance. Areas I, IV and V have established
excellence that could favorably compete nationally. The
below standard" Areas are receiving much the same,kind of
message from the central governing body that the national review
process employs--rejection of proposals or such low priority
rating as to compress funding.  On the other hand, decisions
have been made to "earmark" one-fourth of the developmental
component for some of these Areas IF they produce quality
proposals designed to meet the new objectives. Some reevaluation
of the various Areas leadership must be employed if these remedial

. . measures are not effective, and feedback from this site visit will
  speak to that point.

I1

.

Area I - San Francisco

This group has performed effectively consistently, It has developed
an excellent guideline for its Core activi-ties for the next two
years. The basic premise is that efforts should be directed not
only where community need is greatest, but also where there is
significant potential for change. They have addressed themselves
to the self sufficiency of activities so that changes made will
have continuing impact and RMP resour.ces can be shifted elsewhere,
Work plans to achieve the Area's objectives have been developed
and two-year goals have been specifically identified. They are
aware of the need to continuously inspect their own activities,
to be aware of changing priorities, and to continue to update
their own reaction'and interaction to RMPS objectives. A
redistribution of Regional funds which would constrict the Area I
budget is a matter of serious concern. Area I was the only one
with concrete evidence of in-depth continuing planning activity,
including planning concerning the semantics of the changing RMPS

0

. objectives.

An extraordinary number of cooperative arrangements have  taken
place, such as: an extensive network of KMP advisory committees
covering all 12 counties in Area I and involving hundreds of health
professionals and consumers. Also, interrelationships have been
established between major functioning groups, such as CHP, County add
State organizations, social agencies, etc. v

The excellence of the staff and the programs developed by the staff
under aggressive leadership is unquestioned. Further, the team
believed that Area I is probably one of the two or three most
outstanding RMPs in the nation. There is great emphasis by Dr. Rapaport
and his staff of "planning as the community sees it." Significant
community participation has been achieved through its 800 volunteers
on various committees, including seven District committees, each
of which meets monthly. I

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California Site Visit Report

-7-

RM 00019

Area I1 - Davis

From the information presented, this Area did not demonstrate'
the significant planning found in some Areas. Activities generally
labelled "continuing education" and "bridging or c-onsultation"
were presented as the planning base. The latter represents the
Area's attempt to supply personnel to create 1iaLsons with the
CHP and other agencies. The development of health manpower and
the Organization and delivery of health services are seen by
this Area's leadership as being a future expansion of their activi-
ties. Some of the visitors rated this Area higher than others on
organizational effectiveness because they felt the Area Coordinator,
Dr. Neil Andrews, who has occupied the position for approximately
18 months,is attempting to increase small  staff at a time when it
is difficult to attract good people to the program, will get the

. Area moving.

Area I11 - Stanford

This Area's track record bespeaks good organizational effectiveness.
The rather traditional emphasis on continuing education must be
viewed also in light of the Area's early involvement in activities
'that require effective and cohesive staff liaisons. Its Core is
funded at less than $250,000 and it serves 2.5 million people.

From the information presented at the site visit, Area 111 appears
to have  laid the goundwork for an Area Health Education Center.
There is also a readiness in this Area to pursue new approaches
to health care delivery and is a likely opportunity for the forma-
tion of an HMO.
a type of clerkship of medical students who deal with problems
of rural med.icine.

Another example is the program "Action Associates",

During the visit questions were asked about the,apparent fact that
many Committees of the Area Advisory Group have never met;  nor do
they reflect adequate minority groups representation.,,
Dr, Fowkes, promised the visitors to present additional information
on these two points. ,

The Coordinator,

Dr. Fowkes made the point that Area 111 is very much interested
in attempts to contain expanding costs of medical care.
as an example of the success of their .efforts,  the limitation ofl
number of colbalt therapy isnits going into a certain portion
of the area. This limitation is being brought about by liaisons
established with RMP personnel to CHP and' other agencies.

He gave

Calitornia Site Visit Report

-8-

m1 uuo19

Area IV - IJCLA

e

This group embarked on a formalized planning process to identify
the health needs, resources and priorities of its teq districts
some time ago.
to'be taken, revitalized to a considerable degree thq district
committees, and generated a systematic identificatiod of problems
and solutions. Its early cosponsorship with Area V df the Watts/
Willowbrook district is evidence of its foresight.
staff, well distributed throughout the Area, characterizes its
organizational effectiveness.  This Area has generated 61 projects;
15 were approved by the Area Advisory Group; 13 were approved by
the Regional Advisory Group; 10 were approved by the National
Advisory Council. However, only four have been funded. Several
of the approved but unfunded activities have been partially activated
through Core personnel and funds.  In all,,118 activities have been
initiated, all characterized by joint support.from Area Core funds
and community sources.  Some receive support from contiguous Areas.
The Area was rated "excellent" on these items by the team. Program
planning on health manpower and health care delivery  is  formalized
and involves both providers and consumers and all Core staff. A
mechanism has been established to educate staff and volunteers
regarding HMO legislation, guidelines and strategy and an "HMO
Development Founcation" has been established.

Over four million people reside in the territory covered by this
Area. It was obvious that Area IV is operating a program comparable
to a "region" and in the opinion of the visitors is probably one
of the half dozen, nationally outstanding ones.

Its Community Task Force has clarified the routes

A very effective

.

Area V - USC

/

Late in 1970, Dr. Donald Petit, the Airea Coordinator, appointed
three task forces to begin a projection of activities for the next
three years.
Group members, Committee Chairmen and Core staff members. The
task forces formed were: Health Care Delivery and Organization;
Manpower; and Target Groups.

The principal purpose of the Groups was to bring the planning process
for Area V in tune with the general change in national priorities,
and the reports of these Task Forces presented to the January 1971
meeting of the Area Advisory Group give insight to the Area's work.
plans.

These were composed of a combination of Area Advisory

.e*-. ,

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California Site Visit Report -9- RM 00019

This Area has long been and continues to be an instigator of
inter-Area arrangements. Drs. Petit and Brayton were early '
framers and supporters (both with financial and personnel assistance)
of the Watts-Willowbrook District.
another example.
as CHP)is another. One such activity is the development of a
"profile" evaluation method to apply to ,health servide plans
including heal-th maintenance organizations.
strategy is the building of a profile for comparing aspects of
these organizations with existing phenomena.
felt the organizational effectiveness of this Area is second only
to Area I in its capacity to produce programs appropriate to local
socio-political movement.

The Regional Kidney Plan is

Countyywid'e planning (with Area IV and IX as well

I

The essgnce of this

Some site visitors

-

Area V programs, although small as well as numerous, appear to be
directed toward improving the quality and methods of health care
rather than involvement of health providers for the sake of
involvement alone.

Area VI - Loma Linda

A very low level of organizational effectiveness was detected in
this Area. Dr. Walden, the Area Coordinator, described the vastness
and remoteness of the geography encompassed by his boundaries. A
glance at a map certainly substantiates his  statement but also
suggests that the northern portion of Area VI could be logically
related to Area 11. Dr. Walden emphasized the %act that Lorna Linda
University does not form a good base  for local action because of
its very objectives -- to train selected physicians from all over
the world and have them go back to their place of origin. In his
opinion, should an Area Health Education Center be developed, it
should not be in the University but in Riverside or San Bernadino.

Another item that Dr. Walden brought out (and which in the opinion
of the site visitors, identifies a need to re-examine'the
boundaries of this Area) is that 75% of the population in Area VI
is located near Los Angeles. The team concluded that some
adjustments may be necessary, especially since the Area's leadership
has not, thus far, exhibited innovative approaches.

-.

1. .

.I

__

This appears to be a very weak Area. If it were being looked at
nationally, in comparison with all regions, it probably would
fall in the lowest 20 percent from a quality standpoint. \
_- .. ~

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California Site Visit Report

- 10 -

RM 00019

Area VI1 - San Di.ego

The$ visitors were unanimous' 'in their conclusion that this Area is
operating ineffectively.  The Area is known as being the territory
of cOnservative providers. However, present program activities do
not lend themselves to the introduction of more creative and
innovative programs.  The master design was described as continuing
education and Mr. Price, the Deputy Coordinator, (who presented the
Area's program in Dr. Shimkin's absence) stated they are just
beginning to learn the initials HMO. A reevaluation of Area
leadership and direction is needed and CCRMP should be advised

' that it must address ., this problem.

Area VI11 - Irvine

This is an Area with a small Core staff that encompasses a territory
'in which approximately four million people live and which left the site
team with bland 'impressions about its organizational effectiveness.

Core is supported at $178,000.
a very successful Comprehensive Community Stroke activity.

The essence of the program is

0

It

has made a significant contribution regionally and is outstanding.

Some of the visitors felt that with careful selection of full-time
staff the Area might make a meaningful contribution to the regional
effort. This is complicated by the fact that the allocated Core
positions are all filled (nine professionals, only three of whom
are full-time).
problem.

There was some feeling' that the Area Advisory croup may have
potential for being led into more innovative programs.

Decisions must be made by CCRMP regaFding this

Area IX - Watts-Willowbrook

This Area was an outgrowth of a District sponsored jointly by
Areas IV and V until early 1971. This change in administration
has been accompanied by some resentment and dissatisfaction,
particularly with the enlarge Area Advisory Croup, now 50 members
including 20 providers and 30 consumers. . Seventeen of the original
group are still on the new Advisory Body.

..

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California Site Visit Report

- 11 -

RM 00019

This portion of the site visit took place at the OEO Neighborhood
Health Center in r:ratts, with Mr. Clifford Cole, the Director,,
reviewing the origin of this health center which was made possible
by support through a grant by the University of Southern California.
The facility includes 53,009 square feet has a varieqy of sources
of funding, including third party sources, a seconda2y grant from
Model Cities and another from HEW. Under development is an J3fO
plan, as well as relationships with the King
Drew Postgraduate School of Medicine.
dentists and 19 physicians, serving 16,000 patients in 1970, with .

Hospitdl and the

The staff has1 9 full-time

a service area of 40,000 people. I

Dr. Mitchell Spellman, Dean of the Drew School, pointed out that

cont;act with the L.A. County Department of Hospitals which spells
this out. Also, the Markle Foundation assisted in funding of the
Department of Community Medicine faculty. .The Commonwealth Foundation
has provided $170,000 for development of the master plan of the
School, and the Bureau of Health Manpower is providing $250,000 to
support the development of the Master plan.

Cthe School will be an arm of the King Hospital, and there is a

The feasibility of proceeding in the development of an undergraduate
medical school is under study, and there is pending in the California
State Legislature which may produce funds for such planning, There
is a contract under negotiation with L.A. County to train allied
health personnel.
Education Center.

Dr. Spellman's presentation was interrupted a number of times by a
privite citizen attendee who represents a dissident view in the

have emphasized the academic side to the neglect of a populace
languishing without medical care. In her oplnion, the Drew School
is too high in its concept, and "it needs to get out where the people
are. 'I

This may be a potential  for an Area Health

. the community to express her feeling that the overall efforts in Watts

Compounding the problems have been the continuing delaysin the opening
of King Hospital, which is now scheduled for completion between
December 1971 and February 1972. Originally there was a budget for
3,200 positions, now reduced to 1,800. These are County Civil Service
positions, and examinations are taking place. The site team heard a
great deal of criticism from representatives of the community that
these examinations are held "downtown", some miles from the Watts .
area. Some insecurity was expressed about the impact of the unempl'oy- *
ment of some 3 or 4,000 hospital workers which was occasioned by'the
recent earthquake. The site team learned later in executive session
that there is an employment office in a trailer at the hospital
construction site, but RMP Core staff is reluctant to start training
until they can be assured of the actual number of jobs.

. permission was requested of the County to open temporary outpatient
facilities before completion of the hospital, but that was denied.

*. -.
*.

Also,

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California Site Visit Report - 12 - RM 00019

e

The site team was concerned about the lack of emphasis on an outpatient
department, as well as a seeming lack of liaison with various neighbor-
hood health clinics, such as OEO, and the three Model Cities which
exisit in the Watts Community. It was learned, howevqr, that such
inte,rrelationships are developing in all of these areas.

will have King Hospital privileges.

Dr. Alfred

Haynes pointed out that all physicians Practicing

atts-Willowbrook

Dr. Haynes also described the manner in which he beliives health and.
welfare will operate jointly as an organization of "Regional Medical
Programs Health Care Administration."  Some of the Area's accomplish-
ments he listed were: the development of a health careers program;
a Medix project with 21 persons at UCLA (corpsmen) on duty; an allied
health prcgram; planning and organization of health care; continuing
education; library facilities; and community medicine in the hospital.

A woman physician employed by the County to assist in Watts contributed
several very reasonable comments during the morning session,
particularly with reference to the training of technicians and allied
health personnel.
Van Nuys School of Technology cannot be licensed or registered
because the AMA does not recognize the legitimacy of the curricula
of the school.

As an example, she cited that graduates of the

The site team agreed that the organizational structure of Area IX
is presently so enmeshed with the Drew School and the King Hospital

8

that it is difficult to separate out the various functions.
Dr. Haynes, appointed Area Coordinator late in 1970,  is also Chairman
of the Department of Community Medicine of Drew. His efforts have
,been fragmented by explosive community problems, recurring delays in
completion of the King Hospital, recruitmeot of faculty, etc. He
has had very little time to develop an effective organization.

The status of the Drew School activity (Project #6) which has a direct
bearing on Area N is discussed in another section of this report.
However, the team was glad to learn that a Search Committee has been
appointed to recruit a Coordinator for Area N, after which time, the
professional positions will be filled. There is a need to activate
some Core staff activity apart from Drew School in order to strengthen
the coordination of efforts and liaison with other health activities
throughout the Watts community.

'l: ~

a.

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v

-.

t

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California Site V.isit Report - 13 -

RM 00019

C. Iiivolvement of Regional Resources

The following is,a synopsis of an assessment of the Region's us'e
of its resources and was made on the basis of information included
in the application. The full document will be forwarded to the
Office of Planning and Evaluation.

If "involvement" is used in the context of the impact of involvement
to influence the mission, and if "resources" is broadly considered
as meaning people and institutions, then the involvement of
California's resources presents somewhat of a paradox.

e

,"

The composition of the Area's Advisory Groups, when viewed collectively,
is about 80% traditional. The rate varies among the Areas, but the
range is not so great as to distort the average.

. The institutional resources involved in the program also are pre-

dominantly traditional when viewed on the very general classification
division of those institutions generally related to the categorical
restraints of the original legislation and those agencies embracing

                                                                          '

direct approaches to reorganizing the delivery of health care.

Areas with predominantly "traditional" advisory groups are sponsoring
non-traditional activities with an institutional action base clearly
embracing direct approaches to health services reorganization and

delivery.

The analysis suggests the need to have more than occupational classi-

fication for representation or institutional affiliation classes.
For clearly, some individuals slotted into stereotyped categories
based on the milieu with which they are associated, must be influencing
the framework in which they operate as well as the decisions made
by the Group, in ways not associated with their "label."

Also, by label, the involvement of minorities and the disadvantaged
is very low which would indicate that critical resources are- not well
tapped in the decision-making processes. * Greater involvement of
this resource could assist in the smooth and effective transition
to the new objectives.

For this Region which is beginning to move in the direction of
stimulating the reorganization of health care delivery systems,
a continuing analysis of the composition of its advisory groups,

influence on the Region's success in its new direction is certainly

the Region's resources creates the strange but productive atmosphere
of a traditional group producing non-traditional decisions.

l' .

the impact of the involvement of its memberships, and the groups' ,.

indicated. Clearly though, the impact of the involvement of ..

D, Assessment of Needs, Problems and Resources

I

3.

During the December 1970 site visit, a review was made of the
Region's ability to assess its needs,. identify problems and muster

J

California RMP Site Visit Report -14 - RM 00019

the appropriate resources for meeting these needs. The
Region's performance in this area was judged to be excellent.  ,

E. Program Implementation and Accomplishments

_I. 'CCRMP - as a Whole: The Region is operating effectively as a federation

           of nine units. A system has been developed that
generates initial local autonomy and decision-making but it provides
for total Regional overview via the priority for furiding mechanism.
There are Areas in this federation that do not meet regional
standards of performance. CCRMP is aware of this. However, these
Areas are funded at a level considerably below the national ratio
when viewed in terms of Area geography and residents. The California
RMP has dedicated onelfourth of its Developmental Component in the
upcoming year to funding activities in these Areas if they pursue
.the Region's new objectives. For some Areas, however, the team
believes that assistance beyond the infusion of developmental
funds is needed.

Area I - San Francisco

Of the eight separate'ongoing projects (many with distinct sub-project
activities) four are terminating this year. Each has developed
a degree of self-sufficiency so 'that either community  resources

will continue the effort or the activity has pursued its goal to
comple t ion.

For the upcoming year, Area I will continue four of the ongoing
activities and will implement one new one--the Indian Health
project.
balance for the transitional year.

The operational matrix of this Area displays good

Also proposed by Area I is the proposed plan for a cooperative effort
with the Ray Area Model Cities Agencies. It was submitted to the
last review cycle and deferred to the site visit team for recommenda-
tion. On-site inquiry developed information that indicates that this
.proposal is a logical link in the relationships of RMP and the Model
Cities Agencies. It outlines a plan for the School of Allied Health,
and is part of a long range amalgamation of the ModeLCities project,
existing OEO health centers, the new OEO Outpcltien't Improvement grant,
and the Commmity Health Service,  into a rational health network to
provide health services in the San Francisco community. Three projects

are already operational: a health care outreach program utilizing . 1. .

indigenous health workers with professional supervision; a health ' *,
planning team to focus on organizing consumer input into planning;
and a learning diagnostic center to improve the learning performa'nce'
of children. All of these activities are supported by funds other
than RMP.

The proposal submitted by Area I will provide  for a different kind
of staff--one that will assist both the School and the Model Cities
Agencies in determining the feasibility of a new resource for the

,-

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California Site Visit Report - 13 - KM UUUlY

training of allied health professionals and, to develop plans for'
implementing a program using present or newly developed resources.
This proposal is not specified for funding at the $6.2 level ,
because it was not an approved activity at the time t'ne $6.2 plan
was framed. The site visitors view this activity as one that should
receive a high funding priqqity.
The' new Indian Health proposal which will identify the resources
available in the Area and assfst Indians in their utilization
of these resources, has all the ingredients for sudcess. With
the assistance of the Indian community, two health aides have
already been hired under the feasibility study that preceded this
project proposal.

Area I1 - Davis

Under Plan A, this Area will continue its Stroke activities and
will implement a previously approved project entitled "Compendium
of Extended Learning." It is proposed as a cohesive mechanism
to plan, develop, and implement a program of education for the
Area's health professionals. Area I1 has provided some type
of education service, relating to one of the categorical diseases,
in 72 of the 73 hospitals in its territory.

The Roseville project will not be renewed. A number of the elements
of the activity will be continued under local support. The Region
is currently negotiating with the community on the matter of
continuing the activity.

The activities proposed by this Area for its next year are, at this
time, an extension of its present concepts based on education. Its
movement in new dir'ections depends on developmental funds.

Area 111 - Stanford

Two projects will be continued in this Area, the Stroke Program and
the San Joaquin Multiphasic Screening,
traditional emphasis on continuing education, to the point where
five hospitals are act'ually coming into an affiliation with Stanford.

There was discussion of the San Joaquin Multiphasic screening for
rural and urban poor.  A total of 4,580 persons were screened and
60% of these needed to be seen by a physician.  An OEO Neighborhood
Health Center provides space for follow up and care. This was
accomplished through local financial support. As a result of '
this screening activity the Board of Supervisors has requested
the development of two more neighborhood clinics.  A number of
interrelationships with the RMP have evolved: The project is
now being coordinated with Project Identity (federally funded)
to help in combating drug abuse.
has established a referral mechanism and also continues in'the
staffing of the health center itself.
really a comhunity affair - the Southeast Improvement Center (OEO)

There has been a rather

The San Joaquin Medical Society.

The health center is

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California Site Visit Report - 16 - RM 00019

is responsible for community relations; the Nedical Society is
supplying professional staff; and the County Board of Supervisors
is providing medical supplies and financial support. This project
is a model of how multiphasic health screening can become the
pivotal point in the development of a new approach to health care.

Another multiphasic screening project (East Palo Alto - Menlo Park)
has not been as successful. Although it was funded In 1970 for two
years its activation was delayed.
extended six months beyond the original request sinch experience
indicates that multiphasic screening has a very definite role in
the development of the whole neighborhood health center concept.
This project revolves around what is called the Charles R. Drew
Neighborhood Health Center which was established under an OEO
grant in November 1968. The target population includes 80 per
cent Black Citizens of an estimated 26,000 persons with more than
half in the low income category and eligible for ambulatory primary
health care at the Center. Multiphasic screening is now working
into the program in a way to increase the community utilization of
the comprehensive health care services. During March 1970, a total
of 126 patients were screened; in April the number was 153 and in
May 142. Progress has not been as fast as originally planned due
to repeated changes of project director, late completion of
laboratory facilities and difficulty recruiting trainees from the
local community to perform the tests. It is anticipated that the
number of patients screened, after June 1, 1971, will approach 150
per week. The multiphasic screening is an integral portion of a
complete plan and there is follow up consultation and examination

e

1

8.

Area I11 requests ~ that it be

. if indicated.

0

The Stroke Program consists of the Santa Cruz County Stroke Project,

- operational now'for 11 months and the Stroke Program at the Santa
Clara Valley Medical Center which began in October, 1970, pulling
together earlier programs begun at the Santa Clara County Heart
Association and Deanza College. Thus far, there have been some
retrospective comparisons with studies on stroke care in Santa
Clara Hospital in 1966, Stanford Hospital in 1967, and by the
California RMP in 1968. Data initially shows improvement in all
levels of stroke care. It is said that early prompt workup to
define the etiology of the stroke; quick assessment of the degree
of disability; extension of a therapeutic program throughout the
nursing day because of the adequate training in the stroke unit
and specialty training of stroke personnel; increased use of
consultation; a nurse coordinator acting effectively in liaison
between hospital services and between extended care services as
well as community resources. All have been accomplished by the
Stroke Program. The plan is to extend a variety of activities
to all portions of Area 111. The development of the pilot
program will continue at Santa Clara Valley Medical Center  for
formal patient-family instruction to reduce long-term dependence

'on allied, health professionals, and promote case finding and
treatment of hypertension, particularly in disadvantaged communities
to reduce stroke morbidity.

*" . ,

s

Qlifornia Site Visit Report - 17 - RM 00019

In addition to the two mentioned above,there is a stroke program

of the stroke program have all been achieved to some extent during
the first six months of its existence. Study of comparison groups

that more patients have had'rehabilitation services, have achieved
a degree of self-sufficiency and ability to function independently
and more have gone directly home, by-passing the extended care
facilities,  than was true during the same calendar.period before
the stroke program got underway.

Area IV - UCLA

One of the two renewing- activities selected throughout the Region
is this Area's Northeast Valley Project.
director was appointed to a regional post by OEO and Dr. Brayton
stated that negotiations for a replacement are going on.
activity represents one of the several projects initiated earlier
by the California bfP that is clearly on target and in line with
the Region's new objectives.
community of Mexican American and Black residents and its research
has generated widespread interest and assistance to the community,

. The matrix of this Area's program was viewed by the visitors as
excellent.
delivery has been instituted in all ten Districts of Area IV.

at Stanford University Hospital. The feeling was that purposes

c

of patients before the stroke program and since its inception indjcate

The former project

,

This

It is beamed at a disadvantaged

Formalized program planning on manpower and health care

The Northeast San Fernando Valley Project has been  funded for three
years and has been given high priority as a request  to continue
funding for another three years. This project exhibits extensive
community involvement and community health education. A grant for
establishing a health services network is on the verge of being
approved by. OEO.

Doctor Brayton pointed out that from November 1967 to March 1971,
61 projects were initiated by personnel in Area IV; 15 were approved
by the Area IV Council; 12 of these were approved by"CCRMP,  and sub-
sequently 10 were approved by the National Advisory Council.  However,
only 4 have been funded! In order to make the funds stretch as far
as possible, several approved projects have been partially implemented
with core funds. These include: 1) medical information communication
services, 2) decentralized coronary care unit nurse training and
3) primary physician continuing education.

.. . ~
14 . .

Doctor Brayton has initiated program planning concerning manpower '
and health care delivery in a formalized fashion in all district's
involving 575 volunteers (providers and consumers) and all Core
staff. In addition, the mechanism has been established to
educate staff and volunteers regarding HMO legislation, guide-
lines and strategy. An "HMO development foundation" has been
est ab1 ished .

.

\

California Site Visit Report - 18 - RM 00019

..

Area V - USC

Through the planning efforts of this Area and the professional
leadership it provides the Eest Los Angeles Experimental Health Care
Delivery System project came .into being.  It has been selected by
MCHS-R&D for funding.
free clinic concept and under the $10 million Plan IS, proposes an
activiEy to develop coordination through the Southern California
Council of Free Clinics the Area's efforts to support existing clinics
with professional staff and to develop new clinics.
"Urban American Indian Health Needs" scheduled for activation under
the $6.2 Plan A is another example of its ability to operate
effectively within the Region's new objectives.

e

-

This Area also is an early instigator of the

Its proposal on

,Area V spearheaded the San Fernando Valley Health Consortium, a
college-community endeavor
and implementing the training of allied health personnel.
Fernando Valley and Pacoima Health Planning project was also focused
on this suburban area for low income and indigent families.

to meet the needs-of the Valley by organizing-

The San

The pacemaker project funded May 1970, became effective November
1970. As of May 1, 1971 a total of 451 patients with pacemakers
have been identified and 267 fully registered. All are being
followed by the Registry. The objective to recover pacemakers
is working out well. Also, third objective to provide an
information center regarding the use and function of pacemakers
is moving along satisfactorily as is the fourth objective which
is to provide professional education in the use and function of
pacemakers.

The Respiratory Training Institute, originally housed at Olive
View Hospital, had to be relocated following the earthquake in
February 1971. The courses are now presented at Barlow Sanitarium
and the staff is housed at the Los Angeles TR Association Office.

A very interesting activity is the demonstration in integrated health
care for senior citizen; in East Los Angeles.
proceeding under a $40,000 contract awarded to the County Health
Department by Area V, CRMP. Senior citizens will be screened
in facilities adjacent to the East Los Angeles Health Center.
The focus of the project will be on 1,000 selected older patients
"case managers" to insure continuity of care and total followup.

The Area V stroke rehabilitation liaison nurse program, implemented
by Area V Core effort (no operational funds involved) has worked
with and utilized community resources in training 6 stroke
rehabilitation liaison nurses representing a total of 1700 acute
beds. The system is well established in each of these
participating'hospitals, and plans are underway to expand the
program into many more acute hospitals.

c

This activity is

of the total group who will receive the services of special *" *

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California Site Visit Report

- 19 -

RM 00019

Area VI - Loma Linda

e

Under Plan A,  the Core for this Area will be supported at approximately
$150,000 and one operational activity will continue--the Perinatal
Monitoring project.

                                 I
f I

*.

Dr. Walden described Core staff efforts in the following fields: the
self supporting coronary care training project in San Bernadino County
Hospital; a library awareness program; conkinuing education with
visiting experts coming in twice a year; and a remote computer terminal
for ECG and respiratory monitoring. Some Loma Linda students have
worked in South Colton centers with Mexican American communities. Dr.
Walden also described an activity associated with health problems  of
the American Indian, but this was not fully described as an RNP Core
activity .

There are two Mexican-Americans and one >lack on the Area AdvisGry
Committee. Hopefully more minority representation will be added.
Some attempt is being made to bring the University of Redlands
and the University of Calfironia - Riverside - into a relationship
with Loma Linda to assist in producing additional health manpower.
However, this does not sound like a very effective effort at
linking these educational agencies together.

Doctor Walden commented that some of the students have gone into
a disadvantaged area of Mexican-Americans to work in three treatment
centers. There was a small amount of RMP support for this activity,
but this has been discontinued. There are some activities associated

'with the problems of American Indians but these were very hazily defined.

Area VI1 - San Diego

Under Plan A, the Core for this Area will be supported at approximately
$150,000; one operating activity will continue and one previously
approved project will be activated.

~ Six "mini-projects" include: (1) Stroke resocialization; (2) Pulmonary

rehabilitation; (3) Mercy Hospital - public health education through
community outreach clinic (Mexican); (4) Continuing Education of
physicians by using a medical audit with four hospitals banded

the community college; and (6) School nurse practitioner program
working with model cities (Mr. Price said this was actually not
underway but they wanted to do it.  When asked whether they were
attempting to stimulate the public health department to do this,
he said "no we're not"!)

together; (5) Health Science education ability (core curriculum) in

I

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California Site Visit Report - 20 - RM 00019

This Area's record of accomplishment 'was far below the Regional
effort. CCRIIP plans to infuse the Area with selected developmental.
funding but in the opinion of the site visitors,  intensive assistance
with future planning is needed as well as a reevaluation Of its
leadership.

I.

Area.VII1 - Irvine

This Area will continue its Comprehensive Community Stroke Program.
This activity is increasing the quality of care of the stroke patient
and integrates all aspects of such care. The team heard an excellent

. presentation concerning the project's volunteer follow-up after
discharge activities. However, it was concluded that no formalized
planning for future engagement of the Region's new objectives is
underway.

.

Perhaps selected developmental funding will improve this Area's
overall performance, but it will require assistance in its future
planning.

Area IX - Watts

Approximately 50 area residents attended the three-hour morning session
hosted by Dr. Spellman in the OEO Center.
Mr. Ward make arrangements for an executive meeting with Drs. Spellman
and Haynes the second day in San Francisco. A previous commitment
precluded Dr. Spellman's participation, but the team had an opportunity
for an in-depth discussion of some of the problems with Dr. Haynes.
A commitment was made  to the Watts community that King Hospital would
be not only an outreach by the County to provide for health needs, but
would be an employer as well.  However, the 3,200 positions originally
announced for the hospital have been cut to 1,800 by the County.
Dr. Haynes' Department of Community Medicine has been eliminated from
the L.A. County budget.

The team feels that assistance, over and above financial resources
could be provided in an effort to help Dr's. Spellman and Haynes at a
critical time. Area IX and the Drew School must be able to do more
than hold the line until the King Hospital opens.

The team later requested that

0

NOTE: Since the site visit, staff has learned that the County of

Los Angeles has agreed to provide support for the Community

I. . .

Medicine and Community Outreach Programs for the King Hospital.
This will support an additional 150 positions in the amount of' d,

_.

'-

$655 , 895. 7

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California Site Visit Report - 21 -

RM 00019

F. Evaluation

The evaluation efforts of the California RMP come to a focus at
the CCRMP Central Office level.
directors, and channeled through the Areas to the Central Office,
CCRMP is currently maintaining information that gives la good over-
view of the emphasis of its activities. The methods And procedures
utilized are designed to provide management information--in other
words--information for administrative decision-making:
enable staff to present data which reflects percentages of budget
expenditures by:: (1) purpose of activity (quality of acts of
medical care, accessibility, availability, etc.); (2) aspect of
care (prevention, detection, diagnosis, etc.); (3) activity site
(university medical center, teaching hospital, mixed community
hospital, etc.) ; and (4) activity method (continuing education,
training, data collection, planning, etc.).

Based upon data collected by project

Such results

The site visit team had some difficulty in understanding the application
of these data as they were summarized in pie charts. For instance,
the chart illustrating "activity site" could lead one to assume
that CCRMP is almost exclusively occupied with university medical
center dominated hospitals (61%) with other community sites shown
as representing 13%. The team felt that this is not really repre-
sentative of the CCRMP effort.

The entire program review process, from Districts within the
nine Areas, through the CCRMP (RAG), is designed to operate in
a consistent manner, with the CCRMP Core Evaluation staff providing

. consultation. This has produced an operative program of review
and evaluation from the time a project activity is developed at
the Area leve1,through the time it is submitted and reviewed at

procedure as designed "to apply to the totality of project activity
as a unified program, and is not limited to project-by-project
evaluation."

e

. the CCRMP level.' The Evaluation staff members described this

The following criteria are imposed by CCRMP on all data collection
efforts for evaluation:

1. The information must be useful in the decision making process;
2.  The budget for data collection must not exceed 5% of the  total
  budget ; -

3. The data must agree in format with the CCRMP integrated information -1
  system to foster comparison among projects on a regionwide basis,:
  and ; I

..~ -

t-

4. It must be capable of surveillance.

There was somefeeling on the part of the site team that CCRMP
evaluation staff (or the process of evaluation) does not provide
adequate assistance to Area or project personnel in evaluative
.techniques or modalities necessary to ascertain the project or
program's critical elements. On the other hand, consultation is

e *

California Site Visit Report - 22- RM 00019

available to assure compatibility of data collection, form and "
reporting methodology, based on the CCRMP model.

Thus far, the region's efforts at evaluation seem, in the opinion
of the site team, to be limited to the task of digesting the mass
of information that its repgFting system generates. Thiis was discussed

undertake the evaluation of the impact of certain efforts common to most

impact value of training nurses in coronary care.

>- .

'with the regional representatives

who expressed the hope that RMPS 'would

' regions. As an example, they cited the very long chain in linking the

'

It appears thatCCRMP is moving in directions that may defy a
realistic appraisal or development of a data base capable of
conversion to a base for evaluation. An example of this is a free
clinic. CCRHP evaluation staff feels this will have to be self-
reporting because the participants have been pledged to complete
confidentiality.

The team saw some correlation of the evaluation function to the
difficulty the region seems to experience in "telling its story''
through the application. This may be due to the fact that their
evaluation reporting is poor. The team noted, in a few isolated
instances (and after extensive questioning), some fairly decent
project evaluation is being done. Unfortunately, this was not
reflected in the material submitted with the application. The
team feels that all of these reports should be reviewed by the
Evaluation staff in the Central Office, who should insist that
the Area and project personnel submit the very best evaluation
data available with their summaries. The team views
as part of the central management  function an awareness of
available evaluation data in each Area.

e

All in all, the visstors believe that the region has developed
a good technique or the collection of data on which to make
certain regional decisions. Present efforts seem to be an
epidemiological approach, with the "political" approach still to
be developed.

G. Conclusions and Funding Recommendations

(1) The $6.2 million plan the Region has developed'in order to reach
  its retrenched funding level is viable and represents good

(2) The $10 million plan the Region has developed, should  funds
  become available,proposes the activation of some previously
  approved activities which  the site visitors do not view as
  being wise to initiate at this time in view of the Region's
  new directions.

of the $6.2 plan, the Region certainly could mount an effective
program at the previously Council approved level of $8,3 million
which would 'be consistent with national priorities and the

dec is ion-making . .1

1. -
c .I

' I.

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(3) With much the same selectivity that characterized the development

e Region's new directions.

&

California Site Visit Report - 23 -

RM 00019

(4) The site visitors'concerns regarding the relatively ineffective '

program administered by Area VI1 should be relayed to the Region
with the advice that CCRMP must address itself to these '
deficiencies. Also, Areas VI and VI11 are in need of intensive
assistance with planning for the future. They-are below the
Regional RMP effort and.might profit by assistance from Areas I,
IV and V.

(5) The issues and questions identified by Committee and Coucil

during the January/February review cycle concerning the Area I
proposal (pr0jec.t $185) for a cooperative effort with the Bay
Area Model Cities Agencies (San Francisco) were satisfactorily
clarified.

RMPS /GRB / 7 /26 /7 1

e

0

REGIONAL MEDICAL PROGRAMS SERVICE

  (A Privileged Communication)

SUMMARY OF AN ANNIVERSARY TRIENNIUM GRANT APPLICATION

CENTRAL NEW YORK REGIONAL MEDICAL PROGRAM
State University of New York
750 East Adams Street
Syracuse, New York 13210

PROGRAM COORDINATOR: Richard H. Lyons, M.D.

RM 00050 8/71
July 1971 Review Committee

This Region currently in its third year of operation,  is funded at a
level of $645,080 direct cost.  In addition, the Region has received
$250,534 of indirect costs which represents an average indirect cost
on-campus rate of 67.8% and an off-campus rate of 34.3%.

In this triennial application, the Region has requested for its fourth
year of operation
activities :

$1,413,928 direct costs for support of the following

I. The continuation of Core and two ongoing projects ($490,865)

11.

The implementation of two previously approved/unfunded projects
($55,48 1)

111. The implementation of four new projects ($867,582)

(Attached 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 representation on the RAG from the lower economic
consumers, Model City Program, OEO program and the neighborhood health
center of the Region.

2. The need for RAG to assume leadership and give direction to the

CNY/RMp.

3.

    The program is overly oriented toward the continuing education of
nurses, it needs to broaden its scope of activities to meet the health needs
of the Region. r

4. Unable to identify what the eleven liaison physicians on Core are

contributing to the program.

5.

The membership of the RAG Board and RMP local advisory groups are

physician oriented with little if any allied health personnel representation.

  6. There appears to be little organized interrelationships between RMP
Committees, nor do they identify an established operating procedure.  These
committees appear to be project oriented with little involvement in program
planning and operation.

Central New York RMP - 2- RM 00050 8/71

7.

There doesn't appear to be a regional plan to which operational

activities can be related.
ship between projects.

There also appears to be little interrelation-

8. The evaluation process is unclear.

(Attached is a copy of the memorandum of staff's review of the continuation
application.)

FUNDING HISTORY
(Direct Cost Only)

Grant Year

Planning Stage

01
02
02s

Operational Stage

01
02

03

Period Funded

111167-12/31/67 $192,408

6/1/68-12/31/68 138,268

1 / 1/68 - 1213 1/68

211,000

Period Funded

711168-6130169       $  372,355
7/1/69-9/30/70       Core  462,500

Projects 607,262
Total $1,069,762

10/1/70-9/30/71 Core 389,789
           Projects 339,302
          Total $ 729,091

/'

03 (After 12% across the board reduction) Core 344,385
                        Projects 300,595
                       Total 645,080

Geography and Demography

The Central New York Regional Medical Program is comprised of 15 counties
in Central New York, plus two counties in adjacent northern Pennsylvania.
The boundaries were determined by Medical Trade Areas, Medical Education
and part graduate educational patterns and to conform with the boundaries
of the State Health Department regional efforts. The Region is approximately
96 miles wide in its East-West perimeter and 271 miles long from the
Pennsylvania State Line on the south to the Canadian Boarder on the north.
Geographically, it is one of the larger but relatively thinly populated
Regions in New York State.

Population: Approximately 1,800,000
       Approximately 60% Urban
       Approximately 97% white
       Median age approximately 30

I

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m Central New York RMP

*3-

RM 00050 8/71

Land Area: 26,016 square miles

Mortality Data:

(Rates for New York State - 1964
Mortality rate for heart disease - 437.4/100,000

Mortality rate for cancer - 186.4/100,000

Mortality rate for CNS Vascular lesions - 99.8/100,000

Facilities

State University of New York, Upstate Medical Center, 4 year,

medical school, enrollment approximately 406.

There are 19 schools of nursing, 6 of these collegiate affiliated

There are five college and institute based schools of Medical Technology
There are 48 (short-term) hospitals, (1 federal) with 7,654 beds

(488 federal).

Personnel

0

There are approximately 2,700 M.D. s (133/100,000 and approximately
55 D.0.s

There are approximately 15,000 registered nurses of which only about
9,000 are active.

There is a marked difference between the number of physicians residing in
some counties and the number who have designated themselves as being in
private practice.  The marked differences reflect in some instances the
presence of large State Psychiatric Hospitals (Broome, Oneida,and
St. Lawrence) or major medical and general educational centers (Onondaga
and Tompkins).

Xn 1965 there were 48 hospitals with general medical and surgical beds or
a total of 7,564 acute care beds and four hospitals with extended care
facilities with 472 beds, in the Central New York region.  It is signi-
ficant that more than 60 percent of these institutions have less than a
125-bed capacity, 20 percent are less than 50 beds--again reflecting the
extensive rural character of the area and the need for small hospital
units to serve large geographic areas.
beds is, of course, predominately in the group of hospitals which have a
larger than 200-bed capacity.

During the post-war
hospital facilities throughout the Central New York region but many presently
utilized beds and some entire institutions are in need of modernization or,
indeed, complete replacement.

The largest portion (60%) of

period there has been extensive new construction of

Central New York RMP

-4 -

RM 00050 8/71

The physicians in Susquehanna and Bradford Counties in northern Pennsylvania
expressed a desire to join the Central New York Regional Medical Program.
This area interfaces the southern tier of the Central New York Regional
Medical Program as well as the Greater Delaware Valley and Susquehanna
Valley Regional Medical Programs.
referral between the Southern Tier of New York and Bradford and Susquehanna
Counties in Pennsylvania have been established for many years and in the
recent past, Sayre, Pennsylvania and Binghamton, New York medical communities
have been cooperating in the development of training programs.  This request
was presented to the Regional Advisory Group on October 22, 1967, and it was
the consensus  that a reasonable and productive affiliation could be worked
aut.

Patterns of medical education and patient

The population of this area is approximately 88,911 (Bradford County - 54,925
and Susquehanna County - 38,886).  There are 60 physicians in Bradford County
and 14 in Susquehanna County.
total number of beds of 475.
Robert Packer Hospital has 305 beds.

There are five hospitals in the area with a

.Four of these have under 50 beds' and the

There is associated directly with the

Robert Packer Hospital the Guthrie Clinic
full-time practicing physicians organized

His tory:

In March 1966, the Upstate Medical Center
of New York,. selected .a 15 member RAG and

which has approximately 50
in a group practice.

Council, appointed by the Governor
approved the Research Foundation

of the State University of New York as the Fiscal agent for the applicant
institution. Dr. Richard H. Lyons, was appointed as acting Program
Coordinator.

In December 1966 the Region's planning grant application was approved for
two years support at the amounr requested.

In November 1967 the Region submitted its continuation application for
02 year of planning and requested additional funds to expand Core and
Planning activities. In addition, the Region requested three years support
for 4 projects: Project 1 - Continuing Education in Nursing, Project 2 -
Rehabilitation Consultation Service, Project 3 - Oneida County Tumor
Conference, and Project 4 - Family Practice Pnogram.
application and the four operational activities were approved and an award
granted.

Both the continuation

At the recommendation of the RMPS Committee,  a site visit was conducted
to this Region in March 1968, by Dr. Edwin L. Crosby, Dr. Stanley W. Olson,
Dr. Dan A. Mitchell, Dr. Philip A. Klieger, DRMP, Dr. Veronica L. Conley,
DW, and Mr. Robert E. Jones, DRMP. In their assessment of,the Region
the site visitors had difficulty in determining the overall strategy of
the Region which appeared to consist of identifying preceived needs, especially
those of physicians and hospitals, to take steps such as epidemiological
surveys and meetings that would identify the most critical needs,  and then
to call upon the resources of the State University of New York to meet
those needs. The RAG seemed to be representative of the Region and the
medical professions endorsed the regional medical program concept.

e Central New York RMP

.5- BM 00050 8/71

It was evident that the Region had not sufficiently developed an
organization which was iddependent and established an identity separate
from the Medical School.

Dr. Hughes, President of the New York State Medical Society, described
for the site visit team the efforts of the State Medical Society to study,
plan and implement improved health services, particularly in the rural
areas of the State. Dr. Hughes stated that the Society had received.
one million dollars from the Empire State Fund to do programming in
continuing education. He indicated that the Society most likely would
need supportive assistance from such resources as the regional medical
program when educational as well as other activities were appropriately
related to its mission.

Dr. Winning reviewed the medical care problems of northern New York,
especially those of St. Lawrence County where the active physician-pop-
ulation ratio is about 1:3,600 as compared to the generally accepted
ratio of 1:750. Continuing efforts to attract physicians to this area
have not met with success.  He discussed tentative plans to organize a
diagnostic and treatment center in St. Lawrence County in cooperation
with a 200-bed cornunity hospital.  Dr. Winning described his partial
success to date in attracting a significant number of the physicians planned
for this 24-man group practice.

The site visit team expressed interest in the work accomplished by Dr. Winning
and advised that planning activities appropriately related to heart disease,
cancer, and stroke might be supportable by the Regional Medical Programs.

e

The Region submitted in August 1968 a renewal planning grant application
requesting support for core and planning activities for a five-year period.
At the recommendation of WS National Advisory Council a site visit was
conducted to this Region in January 1969, by Dr. Henry Lemon, Dr. M. J. Musser
and Mrs. Sarah J. Silsbee, DW. During this phase of development it
appeared that the RAG was representative of the medical needs and interests
of the Region. The visltors, however, believed that representation from
the 34,000 underprivileged people of Central Syracuse should be added to
the RAG from the Neighborhood Health.Center Council. By-laws for the RAG
were being developed and a study of the practice of making the Upstate
Medical Center President the RAG Chairman had been requested by
Dr. William Bluemle, President SUNY Medical Center.

The visitors believed that a mgjor defect in RAG organization was the lack
of a functional executive committee that could help the RAG develop policy
guidelines and act on behalf of the RAG on decisions requiring iunnediate
attention by the Coordinator.  Procedures for the review of grant proposals
and defined responsibilities in the review and decision-making process had
not been well developed.  Although a large number of RAG subcornittees had
been organized, few were active. It was apparent from the operational
projects submitted that there had been insufficient coordination to date.
There did not appear to be a regional plan or an obvious strategy for
further development of programs in the Region.

The visitors found difficulty

0

clearly identifying those physician continuing education activities

Central New York RMP -6- RM 00050 8/71

related to the Upstate Medical Center from those of the RMP.  There
also appeared to be little integration between the nurse in-service
training program at the center and the RMP's nursing continuing education
project.

The visitors recommended that the University Medical Center (U.H.C.)
give priority to the recruitment of physicians for core staff (there
were none other than the coordinator).  The UMC responded that until
vacant departmental head positions were filled it would be difficult
to interest physicians in faculty appointments.
departmental head positions at the Center are filled, top priority would
be given to filling the Regional Medical Program positions.

That once vacant

In June 1969, the Region was granted an award combining the planning and
operational grants which consisted of Core and 8 projects.
an additional project (#I12 - Prevention and Effective Recovery from
Cardiovascular Illnesses Through mowledgeable-Nursing Instruction).

Support for

Present Application:

This is a triennial in which the CNY/RMP has requested funding for
continuation of core and two projects, two approved not previously
funded projects and four new projects.

Core Staff

The Core staff has been increased from 25 to 33 positions and consists
of 16 full-time and 17 part-time employees. Of the part-time employees,
11 are liaison physicians appointed as consultants at 1o"L time or effort,
3 evaluators at 20"A time or effort, 1 assistant nurse coordinator at
50%, 1 secretary at 60%, a phjrsician at 80%, and the coordinator at 90%
time or effort. Of the full-time positions, 11 are professionals, 4 are
secretarial positions and one a business director, Of the 17 full-time
core staff members there are 10 females and one minority.

Core staff activities have, in general, been directed toward reinforcing
the operational projects that have been approved and funded, and reviewin;:
the problems of health care in the region so that new or different projects
might be developed to meet these needs. In addition, they have been
involved in obtaining statistical information in the categorical diseases,
evaluation of core and projects, establishing liaison with communities,
and educational activities.

The core staff has also been very active in establishing cooperative
relationships with federal, state and local organizations involved with
the health system. (Ref: Application p. 36-54.)

Core Supported Feasibility and Planning Studies include:

- Central New York RMP

7- RM 00050 8/71

m PHASED OUT

1, Medical Library MEDLAP and Health Mobile (Appl. p. 55)

3. Lay Education Lectures (Appl. p.56)
4. N.Y.-Penn. Health Education Program Directory (Appl. p.57)
5. New Careers Workshop (Appl. p. 57)

I 2. Central New York Health Education Program Directory (Appl. p.56)

NEW ACT IV IT IE S

6.

7.
8.
9.
10.
11.
12 ..
13.
14.
15.
16.

17.
18.
19.

20.
21.
22.
23.
24.
25.

Continuing Education for School Nurse Teachers and Health
Educators (Appl. p. 58)
Health Educator Symposium (Appl. p. 58)
Leadership Training for Developing the Developers Workshop (Appl. p.59)
Leadership Training or Communication Workshops (Appl. p.59)
Home Health Aides (Appl. p.60)
Human Conservation Display (Appl. p. 60)
Food Service Managers (Appl. p. 61)
Diabetic Program (Appl. p. 61)
Guidance Councilors Upgrading (Appl. p. 62),
Combined Surgical Staff Conference (Appl. p. 63)
Workshops in Developing Communication Skills for Nursing and Allied
Health Personnel (Appl. p.64)
Regional Cancer Registry (Appl. p. 64)
Library Service (Appl. p. 65?,
Acquisition and dissemination of professional educational materials

Comprehensive Regional Contiming Education Calendar (Appl. p. 66)
Radiotherapy Clinic (Appl. p. 67)
Enterostomy Consultation Services (Appl. p.67)
RMP Bulletin (Appl. p. 68)
Addressograph and Mailing Service (Appl, p. 69)
Consultation on Instructional and Managerial Problem (Appl. p.70)

@PPI. p. 66)

Attached is an organizational chart and follminq is a listing of
Core Staff.

1 Time and

Name Job Title or Function Effort

R. H. Lyons, M.D.
P. R. Aronson, M.D.
C. T. Case, M.D.
A. M. Decker, M.D.
H. K. Ensworth, M.D.
S. R. Mason, M.D.
D. T, O'Brien, M.D.
A. J. Smith, M.D.
L. H. Smith, M.D.
I. K. Stone, M.D.
J. T. Walters, M.D.
E. M. IJyso, M.D.

Coord ina tor
Liaison Physician

II

I1

I1

II

II

I1

11

II

I1

I1

90
10
10 .
10
10
10
10
10
10
10
10
10

Central New York RMP -a- RM 00050 8/71

Name Job Title and Function "/,Time and Effort

.1. J. Murray, 13. A.
M. Jordahl
Id. L. Curry, B. S.
J. Kulakowski, M.A.
R. Schneider, M.A.
N. Allen, M.A.
S. H. Murray, M.S.
W, Rothstein
J. Martin
H. Stevens
M. Galka
C. Gregory
TRA
TBA
I,. Porter, Ph.D.
R. Philips, M.S.
R. Mullnne, M.S.
Hen 1 th Mob1 le
7'RA
7'BA
TBA
TEA

REG IONAL ADVISORY GROU P

Ass is tan t Coordinator
Admin. Ass't
Teaching Coord.
Health Educator
Instr. Corn. Coordinator
Ass't. Nurse Coord.
Library Coord.
Ostomy Tech,
Research Ass't
Research Worker
Steno
S t en0
Steno
S t eno
Evaluator
Evaluator
Evaluator

llealth Educator
BUS Driver
Reference Librarian
Clerk Typist

100
100
100
100
100

50
100
100
100
100
100 I
100
100
100

20
20
20

100
100
100
100

The RtZG reports that during the past three years the Central New York
Regional Medical Program has done a great deal to overcome the initial
fear of government intervention in the care of patients and in the
education of physicians, nurses and other hospital personnel.
enough in 1950 when the State took over the medical school from a private
university, Syracuse University, but now to have the government "move in''
and help the medical school, a State institution, to help hospitals,
nurses, and physicians was an almost impossible concept for the local
health vendors.  Those in larger communities were less disturbed than those
in smaller communities and the nurses in any communj.ty could hardly believe
that somebody would be interested in their education.

It was

The strong emphasis on nursing education through the Continuing Education
in Nursing project has done more than perhaps any other single effort
to win recognition for the Central New York Regional Medical Program and to
stimulate other educational activities throughout the region.

Other factors that have led to further recognition of the CNY/RMP has
been the Mobile Stroke Rehabilitation,  the Bulletin
and the effort to improve the teaching of family practitioners at St. Joseph
Hospital.

of the CNY/KMP

The RAG Indicates that with the change impetus by the RMPS the region
has widened its      The new Foals are to reach more people through
innovative educational methods SO that the people may institute better
individual health cnrc and to reach orit into areas where health care is
nor rit nrcsent iinderstoocl.

goals.

e

e

e

Central New York RMP -9-

The RAG in its reporr outlines the strategies the
during the past 3 yenrsfor meeting its goals,  and
nrrnngements it trns established. (Appl. p, 14-19)

The CNY/RMS Advisory Group recently increased its

RM 00050 8/'71

reg3 on has ut 1 ized
the cooperatjve

membership to 45 with the

addition of allied health and consumer representation. These new
members included educators, communication specialist, lawyers, nurses and
consumers.

It has also developed Regional Advisory Group By-Laws, which were printed
October 1969. Nominations are made by the RAG to the Council of the
Upstate Medical Center who will select 42 members not including ex-officio
members.
terms.
time by the group.

Members of the RAG may serve two consecutive full three-year

The RAG meets at least six times a year at times to be set from time to

The present membership of the RAG include:

14 Practicing Physicians

6 Hospital Administrators
1 Nurse
2 Government personnel
5 University representatives
2 News Media personnel (T.V. & Radio)
2 Charity organizations
9 Members of the public
1 VA
1 Dentist
1 Osteopath

RAG Boards/Committees and RMP Local Advisory Groups

Executive Committee (6 Members) - Helps to set goals and priorities; advises
coordinator on major expenditures which are not part of on-going
reviews committee reports; makes committee appointments.

operations;

Nominating Committee (6 Members) - Maintains list of potentially interested
individuals in the region who might serve on the RAG as replacements or
new members; npminates new members of RAG.

Community Health Education Committee (9 Members)  - Determines the need and
best way to continue to promote health educationin different areas  of

society or of the region; reviews proposals in area of health education
and mades recommendations to RAG.

Continuing Medical Education and Special Programs (8 Members)  - Reviews
requests for support of educational programs for physicians and allied
personnel in region as well as project proposals for educational programs
and make recommendations to RAG.

Evaluation of Services Committee (7 Members) - Evaluates activities of Core
as well as the effectiveness of projects and makes recommendations to RAG.

Central New York RMP -10- RM 00050 8/71

Health Manpower Committee (6 Members) - Works with Committee on Continuing
Education in efforts to recruit more people into the health field.

Hospital Committee (8 Members) - Determines regional hospital needs and how
they may be met; reviews and mades recommendations to RAG on project
proposals dealing primarily with hospital activities.

Primary Patient Care Committee (9 Members) - Concerns itself with the
extension of the physician in offering a wider variety of patient care
either through the physicians or other mechanisms; reviews project
proposals in this area and makes recommendations to RAG.

Categorical Committee on Cancer (11 Members) - Reviews requests for support of
education programs in cancer and project proposals in the area of cancer and
makes recommendation to RAG.

Categorical Committee on Heart Disease (5 Members) - Reviews requests for
support of educational programs  in heart disease and project proposals
in the area of heart disease and mades recommendations to RAG.

Categorical Committee on Stroke (5 Members) - Reviews requests for support
of education programs in stroke and project proposals in the area of stroke
and makes recommendations to RAG.

Nursing Steering Committee (17 Members) - Advises project director of
Continuing Education in Nursing project.

PROJECTS

It is indicated in the application that there are written procedures for
the review of project applications, however, these are not described in
the application.

Specific Core staff members are assigned to monitor or provide supportive
services to the individual projects which involve responsibilities  in the
area of accounting, technical or professional consultation, etc. Each
project director is required to submit an expanditure report once a month and
a progress report once every two months.
activities undertaken during the past year include visits by staff,  reports
to the evaluzition committee and direct reports from the field.

Project-related evaluation

The region has established the follwing priority ranking of projects:

1.
2.
3.
4.
5.
6.
7.
8.
9.

Area Health Education Centers
Home Dialysis Training Program
Pulaski Model Rural Ambulatory Care Center
Dial Access
Nurse Clinician Training Program
Health Mobile (Core)
Medical Library and Information Service
Regional Bio-Medical Electronics Safety Program
Feasibility Study for Establishment of a Computerized
Central New York Regional Cancer Registry

I

Cent ral New York RMP -1.1- RM 00050 8/71

Continuation of Projects Beyond Approved Period of Support

m Requested

Project #6 - Home Dialysis Training Program - This project

First Year
$53,757

was initially funded in July 1970 during the

regions 02 year of operation.
of $14,590 direct cost and has a remaining commitment of $27,022 for its
03 year.

It is presently funded at a level

The region is requesting in this application funding beyond the approved
period of support in the region 05 and 06 year.

Progress reported by the region consist of the following:

1. Unit site identified at A. C. Silverman Hospital, Syracuse, N.Y.
2. Negotiatfons completed with Onondaga County for support for

continuing expenses, dialysis supplies etc. and supportive
services (estimated at $45,000 per year).

3. Renovation of unit completed.
4. Equipment and supplies purchased.
5. All personnel positions filled.
6. Development plan completed.
7. Training manuals and teaching aids in process of development.
8. Patient evaluation is proceeding for potential trainees.

The activity is to serve as a model in delivery of kidney  treatment and
rehabilitation in this region. It proposes to train 20 home dialysis
patients per year, train six-to eight hemodialysis nurses per year and
serve as a focus for organizing a system of  health delivery care in the
area for renal disease. Phase out of this program is anticipated bv
1974with Onodaga County taking over total administration of the unit at
A. C. Silverman Hospital.

Second Year: $59,339

Third Year: $64,379

Requested

Project 89 - Dial Access -

region is now requesting three-years of additional support to continue the
activity.
to purchase the equipment and install the equipment and phone was seven
months (7/69-2/70). In the year 2170-2/71, 2865 calls were received.
In addition to the original 80 tapes purchased from Wisconsin RMP,
40 tapes were purchased later in the first program year and six tapes
were produced locally.

Two user's surveys were conducted with return of 84.7%. The survey indicated
that 94% of the respondents found the information was worth the time to
make the call, 82% indicated they received the information they were
calling for, 52% of the users were general practitioners.

Financial support of $5,000 was received during this program year from
the Susquehana Valley RMP. Although the service is paid for by the

This project was initiated First Year

in July 1969 and has no commitment remaining. The $20,740

Progress reported indicates that the lead time necessary

Central New York RMP -12- RM 00050 8/71

two ItMI's, tt is :il.so mailable to the followlny: RMPs: Albnny, Iletropolltan
New Yot-k, Niiswiii-Suffolk, New Jersey, (:renter Delaware Vnlly and Maryland.
It hns not been promoted in those areas since we do not have the hardware
nor stafi to properly service the number of physicians who would be covered.

The primary objective of this project continues to be to inform physicians
with specific and current information on an immediate access basis.

Second Year: $21,580

Third Year: $22,504

Approved Not Previously Funded Requested
Project 1/15 - Medical Library and Information Service - This project

July 1970 Advisory Council at a reduced level (01-$40,000, 02-$50,000

03-$53,000), however, because of existing fiscal restraints  funds for
its support were not awarded.

First Year
$32,704

was initially approved for three years siipport by the

The activity offers to 57 hospitals and 117 nursing homes, and individual
health professionals up-to-date information on lastest medicdl advances
needed for better patient care through supplementary library service from
the Upstate Medical Center Library.

Second Year: $35,271 Third Year: $37,944

                                         Requested /:*.. , -;
Project #17 - Regional Biomedical Electronic Safety Program First Year .-

-_ .

This project was deferred by the November 1970 Advisory

$22,777

Council because it had much difficulty relating this program to the
categorical objectives of this region. They also believed that the
activity needed to be regionalized to include other hospitals in the
region.

The present proposal has responded to one of the previous concerns of
Council in that the program has been regionalized.

Second Year: $36,368 Third Year: $36,947

New Projects (Application Pages 97-107)
Project #I8 - Area Health Continuing Education Centers

Requested

This project is an outgrowth of previously Firs t Year

funded Project #1 - Continuing Education in Nursing. It $599,547
proposes to establish Area Health Contining Education Centers
for medicine, nursing and allied health personnel in five strategic
locations of the region.
continuing education at the local level. Each center will be the home base
of a staff comprised of professional health education specialists. Each
center will be under the direction of an executive committee. The basic
structure of this executive committee exists presently in the subregional
nurses steering committee which will expand into a multi-disciplinary
policy-making organization capable of incorporating.

These centers will promote, initiate and coordinate

Second Year: $574,547 Third Year: $574,547

Central New York RMP -13- EW 00050 8/71

Project #I19 - Pulaski Model Rural Ambulatory Care Center -

Requested

This project is an evaluation of the First Year

St. Joseph's Family Practice Program presently supported by
CNY/RMP, This activity is an effort toward resolving the
problems of decreasing numbers of doctors in the rural areas.

$144,475

The proposal is to demonstrate a model rural ambulatory care center,
expose Family Practice residents to rural practice and teach the
efficient use of a health team.

Second Year: $144,475

Third Year: $144,475

Re ques t ed

$3,404

Project #20 - Computerized Regional Cancer Registry -

Center proposes to record detailed information concerning
cancer patients to allow statistical evaluation of treatment
and survival so as to upgrade the delivery of care for cancer.

Through this project the Upstate Medical First Year

Second Year: $3,544

Third Year: $3,691

Project 821 - Traininp of Nurse Clinicians

nurses from geographic areas or from patient care
agencies with a poverty of health care delivery.
These nurses will be trained to become physician associates &.e.,
evaluate patients and manage minor health problems - refer major health
problems - control crisis situations until the physicians arrives.
is expectdd that the nurse trainee upon completion of her training will
return to her functional area where the proverty of health care delivery
exists. The effectiveness of this program will be evaluated.

Requested

$120,156

This project proposes to select 32 First Year

It

Second Year: $120,156 Third Year: $120,156

RMPS /GRB/6 /I 1 /71

REGION  Central Nev York
CYCLE  RM non50 8/71

0
0
1
n

BREAKOUT OF REQUEST 94 PROGRAM PERIOD

CONT. WITHIN CONT. BEYOM) MPR. NEW, NOT 1st YEAR

IDENTIFICATION OF       APPR. PERIOD APPR. PERIOD PREV,    PREV. DIRECT       INDIRECT       TOTAL



Core               $416,368*                        $ 416,368   $161,117     $577,485

COMPONENT OF SUPPORT OF SUPPORT FUNDED APPROVED COSTS COSTS

Home Di8l vsis

53,757e                      53,757 13,431 67,188

       $20,740               20,740 2,401 23,141

              $32,704        32,704 11,708 44,412

.#6 - Tr8inin.q Proeram

f9 - Dial Access
   Medical Library 6
815 - Information Service
   Regionel Biomedical

   Area Health Continuing
818 - Education Centers
    Mndel Rural
819 - Ambulatory Care Center
    Co mpu t e r i zed

I

I

817 - Electronic Safety k 22,777 22,777 3,918 26,695

$599 , 547   599,547 .  130.087      729,634

144,475    144,475    30,012      174,487

-

(Support Codes) (5) (2) (7) (1 1

                                    3,404 3,404
#20 - Cancer Registry
    Nurse ClinfcLan
.#21 - Training 120, I56 120,156

I

I

1,625      5,029

11,581      131,737

1

n

(5) (2 1

(Suoport Codes)

CONTINUATION WITHIN COhTINUATION BEYOND

IDENTIFICATION OF J3PROmD PERIOD OF APPROVED PERIOD OF
COHPOEIEKT SUPPORT

SUPPORT

Core $372,075

86

t9

P15

#l7

P18

#I 9

t2 0

#2 1

59,339

21,580

I

$452,994

TUTAL

.

(3) (1)

APPROVED,NOT NEW, NOT 2nd YEAR

PREVIOUSLY   PREVIOUSLY    DIRECT
FUNDED      APPROVED     COSTS

$ 372,075

  59,339

  21,580

$35,271 35,271
36,368 36,368
               574,547
      $574,547 .
     144,475 144,475
      3,544 3,544

~

120,156 120,156

$71,639 $842,722 $1,367,355

REGION Central New York
BREAKOUT OF REQUEST   05 PROGRAM PERIOD

z
m
c

4
0
c(
A

B

rd

1

e
ul
1

B

0
0
0
ul
0

REGION Central New York
BREAKgm OF REQUEST 06 PROGRAM PERIOD

          C016IEIUATION WITHIN CONTINUATION BEYOND APPROVED, NOT NEW, NOT
CWOh~Nr SUPPORT SUPPORT FUNDED APPROVED

IDENTIFICATION OF APPROVED PERIOD OF APPROVED PERIOD OF PREVIOUSLY PREVIOUSLY

Core $384,720

' #6 64,379

59 22,504

81 5 $37,944
#17 36,947

41 8

-

L

$574,547

TOTAL

3rd YEAR TOTAL
DIRECT ALL YEARS
COSTS

DIRECT COS=

$ 384,720  $1,173,163

  64,379    177,475

  22,504     64,824

  37,944    105,919

  36,947     96,092

574,547 1,748,641

(Supoort Codes) (5) (2) (3) (1)

#19 144,475 144,475
82 0 * 3,691 3,691
82 1 120,156 120,156

I
w
'o\
I

n

433,425

10,639

360,468

I

$471,603 $74,891 $842,869 $1,389,363

,

$4,170,646

--

- --

Throughout Region

COORDINATOR

Associate Coordinator 1 1

I

& ecretaries

I

-

I

> 3 Physicians

Primary Patient Care

lzzrz-l Cancer Appointed

L

JI

*.

5.QRGAMZATION CHART - .CORE STAFE:
CENTRAL NEW YORK REGIONAL MEDICAL PROGRAM

+,/Ha.pltal

Technician

Admini s t rat0 rs

i2

0
0
0
VI
0

-18- RM oo050 8/71

DEPART UT OF HEALTH, EDUCATION, AND V FARE

W PUBLIC HEALTti SCHVICE 4

HEALTH SCFIVICCS AND MENT41- HEALTH ACJAiINISTRATION

Datt: I!RY 21, 1971
'/!)I lo
!ill I$:

Staff R\~vjew of Triennial Application from the Central New York
Rl~gional llcdical I'rctgrnin for Augtint 1971 R(?vic:w Cycle.

I?! jcif:

r `I

Chief, Grants Iicview Branch :!`. I 1

I

it!;?

Chicf, Grants Management Branch [I .$ <-+.

*_..I_ - -

Acting Chief , Regional Development Brw

*A

The region has requested in this application, funding for the following
activities: (Direct Cost Only)

Core

9~04 year 05 year 06 year Total

-.

.+ -

".*> -

$516,368 $372,075 $384,720 $1,173,163

. -.

Continuation Projects 1/6,#9 74,497 80,919 86,883 242,239

Previ ousl y approvcd/unfunded

.

..

Projects 815, 1/17 55,481 71,639 74,891. 202,011

Xew Projects 1\18, 1/19, 1/20

"

and #21 867,582 842,722 842,869 2,553,173

Total Request *

$1,413 , 928

$1 I367 , 355 $1,389 , 363

$4 , 170,646

*There is a remaining comrnitment of $397,022 for Core and Project G6 in

the 04 year.

In the review of this ap2lication staff concerned itself with overall
program issues and the ident2fication of concerns for the upcoming
site visit on June 3-4, 1971, Major issues discussed by staff were:,

RGGIONAT, ADVISORY GROIJP

The CNY/lWP Advisory Group recently jncreased its membership with the
addj tioil of 31 licd hcalth and consumer representation. `l'liese new
members inclded cducntors, communication spcciallst , lawyers, nurses

`L-. .

-19- RM 00050 8/71

and consumers. Staff bcli eves this increase in allied health and
consunrer reprcsentati.ves has strengthened the ILAG, however , consumers from
tlie lower economic population, Model Cities programs, OEO, and the
ncighborhood health center are not represented.

It is the general impression of staff that the RAG has not assumed the
leadership role of the CIiY/RMP.
continues-to be oriented toward the continuing education of nurses. It
has not placed enough empliasis in stimulating the health resources  of
the region to evaluate and attcmpt Lo resolve the health problems of
rhc rcgion.

The program has always bccn and

In additiou they oppcur to he projcct or.icntcitl anti liavc not assumed the
rcsponsibilj ~y for developing a regional p1.m.

Staff recorninends that the site visit team tal<(: an in depth look at the
lUG operating proccdurcs and how the RAG views its rcsponsibilities with
CNY/RME'. (1) Appointment of RAG numbers; involvcmcnt of Prcsidcnt of
the College of Pledicinc; (2) Attendance at KAG meeti.ngs50Z.

CORE

_.__

The Core staff has been increased from 25 to 33 positions and consist
of 16 full-time and 17 part-time enployecs.
I1 arc liaison physicians appointed as consultants at 10% time or
effort, 3 evaluators at 20% time or effort, 1 assistant nurse coordinator
at 50%, 1 secretary at 60%, a physician at 802, and the coordinator at
90X time or effort.  Of the full-time positions, 11. are professionals,
4 are secretarial positions and one a business director.

Staff believes that although the Core staff is small. in nulnber,  it is
a capable staff and has established a goocl relaLionship with the
CHP "b" ageiicies i.n the region.
medical staff to support. Dr. Lyons with the adininlistration of the
p r og ram.

Of the part-time employees

They necd, howevcr, to have additional

Ocher than the 11 part-time liaison physicians (-lo%), the only other
physician on Core is the Coordinator, Dr. R.11. Lyons.  Dr. W. Leavcll
the only other physician that was on Core has left the ChrY/RMP and is
now a Dean at: the University of Syracuse.

It is the general impression of staff that Dr. Lyons has not given the
CNY/RW the leadership chat it needs.  It has been recommended in
previous site visits that an associate coordinator with administrativc
capabiLitics be appointed to' assist Dr. Lyons with the day to day
operations of the CNY/I<MP.
taken into considcrclt%on again by the upcoming sitci visitors.

I)r. 1,yons 1)clieves that it Is difficult co pJn the parLicipatlon of
physicians in continuing education activities and so 11c c~mpl~asincs tlie

Staff sul:gcst that this recommendation be

" 20- RM 00050 8/71

It could bc because of this philosophy that the region is fleavily
oriented t.oiJord the continuing education of nurses. Of the efght
projec ts proposed in this application five are involved with
continuing ~diicatioii of nurses: (/,by R11, //17 #18, #21). Project P17 -
Arc3 Ilcal t.11 Continwing 1;rlucation Centers has emerged from Project ?1 -
Contiiiui 11" I'ciuccit-:i.on in Niirsinl; and lias a Iiudgct rcquc'st for 3 years
of $1 748, G/r3., approxiinately 4 7X of chc total. funding requested by the
region.

.--- ---- ~..__..._..-_-__-I_--__-

-__ -.- .-- L.L ____.-_._______-_-

Staff 1-econrincnds that tlic site visitors discuss .wit11 thc region what
iinpacl past continuing cxducation act ivitics  for nurscs have had in
jmprovin;: the hcalth care delivery systcin of tlic region and how
the proposed activities in this application are expected  to meet the health
carc nceds of this region.

Staff also suggest that the visitors have the region indenti fy what
is the ro1.e of thc eleven liaison physicians in identifying local health
needs and stii1iu1atin.g activities to meet these needs. '

____-_ b4.G Bosrds/Commit.tees and LPP J,ocal. Advisory -...
                        L- Groups:

. 5 -__

.-

The membership of these committees consist primarily of physicians with *- .
little if any representation of all icd health personnel. Staff believes -, -

that allied health personnel can contribute ant1 should have an opportunity
to participate in these committees.

It appears to staff that there is little organized interrelationships
between the committees, nor an established operating procedure which
would stiniul.ate an integrated program effort between the  comrnittees
RAG, and Corc.  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 thcsc groups into the

CNY/IWI?.

The general impression of staff is that the committees have been
project oricnted and have not assumed che responSihility for developing
a regional plan of act.i.on for each of the categorical areas they represent.
This I.ack of regional planning is apparent in the projects which have
been submitted. There is no mention of h0.w each activity interrelates
with others .in the smc. categorical area. There is also little cention '
of how each activit.y fits into a regional plan. Several of the committees
have met: less than 3 times and do not appear to' be functional.

Staf 1 reconirrrcnds tliat (luring tllc upcolning s.i.1:~ visit thcsc concerns
of staZf be included 8s a topic for dlscussioil'.

..

.. .

.. .

. II

-- .

-21-

RM 00050

Staff had difficulty ident7ifying the interrelationships between projects,
particularly those involved with the continuing education for nurses.

In general staff's primary concerns are what involvement the RAG,  committees
and core have with the projects, how these projects relate to a'regional plai:
and what is the expected impact of these activities in the health care
delivery system of the Region.
Area Health ContinuinmEducation Centers from the Continuing Education
and Training 13ranch of WS.

Attached is a memorandum on Project /I18 -

EVALUAT 1 ON

Staff was unable to determine how the three part.-timc evaluators (20%)
on Core who arc "education specialists" from Syracuse. Universi ty
participate in the cvaluntion o Core and projccts.
to detcrmina what intcrrc1;itionship exist in tile cvaluation process
between the part-time evaluators, the RAG EvaluaLlon Committee , other
Core staff, and the- project director.

-

It was also difficu1.t

Tile evaluatioii report subinitted by the evaluation committee gives
addj tional information regarding proposed activities but does not
really present a regional plan for the categorical areas and does not
sufficiently evaluate the cffectiveness of activities in meeting the
health needs of the region.
Planning and Evaluation Branch of the WS.

Attached is a memorandum from the Program

GENERAL

It is apparent that thc CNY/PM has continued to follow the initial
concept of Regional Medical Programs which was to provide a vehicle by
whj ch scientific knowledge could be more readily transferred to the
providers of health services , (with emphasis in nursing). They
have not altered their course to the cvolving mission of HMPS which is
to Increase the availability of health care while maintaining its quality.

Participants of Typc V Mccting:

Bob Morales ,  Grants Kcview Branch
Joanne O'Malley, Office of Systems Management
Burt Kline, Regional Devclopmcnt Branch
Lawrence \ditrc, Office of Program Planning and Evaluation
Frank Nash, Regional Development Branch
Jerry Stolov, Division of Kidney Disease Control
Roger Miller , Grants Management Branch
Veronica L. Conley, Ph.D., Continuing Education and Training Branch

\+~7.1~ri(; 7 /$? 2??(:Li,&

' (-21smac1 I). Morales

Pu1)I.i~ Ilcalth Advisor
Grants licview IZranch

RMPS /rRR /6 /11/71

I-

Initials

(A Privileged Communication)

SUMMARY OF REVIEW AND CONCLUSION OF

    JULY 1971 REVIEW COMMITTEE
CENTRAL NEW YORK REGIONAL MEDICAL PROGRAM
      RM 00050 8/71

FOR CONSIDERATION BY AUGUST 1971 ADVISORY COUNCIL

RECOMMENDATION:
projects with stipulated conditions:

Additional funds for one year for core and operational

RECOMMENDED

$ 1,413,928

05

1,36 7,355 -0-

1,389,363 -0-

$ 850,000

$ 4,170,646

rrent funding level is $645,080 direct cost and the
he recommended funding level is as follows:

$400,000
450,000

$850,000

-

sociate coordinator M.D. to direct a progrhrn of health

o both rural and urban areas be e~ployed. The

who is a strong executive and can bring together
this area to cooperativcly resolve the health
11. Positive steps certainly should be taken to

e leadership of this program.
xecutivcn Coilmi ttc:c* cxpaiid its rnc-oibc.rslrjp to

froill t 11~s .I owct--r.cc)r~o~~~i c c~nsri~nc~r.c; , rural
vist physicians, allied health personnel %and
ura3 artn of thc region. T1ic.y riced to 11nvc
s on the Rr:gional Advisory Group and thc -
recoimentlcd actdlng two mmlical students and
rhaps as nun-voting niembc>rs.

r

Central New York RMP -2- RM 00050 8/71

e *,c *

.*- G--<

'r 2

3. 'j'li:!t ~lic. 1-cgioii tlc.vc-]o~> ;I progr-ini plait wlrjcli iricl iiflc*s :i riicLllotl
  for prioi it y estnbl i:slinic.i>t , a tlc.cisinri-nrakln~: pruce:;s, progronr
  planning and evaluation. Tlic visitors believe Lliat this is a basic
need fos this region because they found it difficult to get any
  feeling that c'vcn the RAG or the coordinc:cr had any sense of
what the CNY/D'IP expects to be three years from now.

4. That the prograin establish a balance in the developmcnt of

activitics in relation to their prioritics; the contintling education
activitics for nurses have out-stripped sonic of tile other activities

-- in the region.

5. The visitors also believe that the region should put into action

the recoiiin:cnclations documented in Cr. Huglies'cvaluacion report,
especially paragraplis 3 and 4, of the rcport.

/

6. That the region consider hiring for Core' staff a full-time evaluator

rather than continue to utilize the present three part-time evaluators.

7.

That operating procedures and responsibilities OF the lUI? cominittees
be clearly defined with emphasis in involving them in the program

planning and operational activities of the program. - 1

8.

The visitors recoaxend a regionalization planning approach in
health services; that program activities be integrated as part of
a total program plan which can b2 measured in terms of acconplishacnt
at specified periods of time.

9. It is Iccowniendzd that not more than 20% ($120,0r?O) of the> requested
fuocljng level for Pr$ject /I18 - Area Health Continuing Education
Center be utilizcd for supi>drt of this projcct by tlie region. The
region was Ciicm~r~-gcd to carry out a derronst-r,?! ion project irl oc? of
  the sub-,-~.;;ir~~is ratiic11- tbail begi.n wit11 3. regj on-wide prograin a5
  proposed in the application.

10. Support Project 86 - Home Dialysis Training Program wCth R? funds
                                        Committee conciirs

for only one more year for. additional planning.
with the findings of the Ad Hoc Panel on Renal Disease.
of the evident disjointed approach to its needs, a trajning coordin-
ator'at $15,000 , with travel funds of $1,000 could app-opriately
be recommended for one year to obtain a more orderly and cohesive
approach to its personnel problems.

In view

4

Central New York RMP

3- RM 00050 8/71

The Region has been using some of their core funds for support of
feasibility studies and central core activities.  Committee doesn't

  ourage these activities but recommends that the activities be
funded only when approved by the Regional Advisory Group.
be considered on the basis of what they contribute to the objectives
and priorities of the Region as described in the Region's program
plan.

utilized to develop activities that will help improve delivery
health services to the urban and rural poor. These appear to be
two real priorities for the Region and this additional funding should

be able to provide some progress in these two areas.

They should

The Committee suggests that the additional $200,000 recommended

The Committee recommends a staff follow-up visit six months following
the award of this application to evaluate progress in implementing
the above recommendations and to provide assistance if necessary. It
also recommends a site visit to the Region when they submit their
next anniversary review application in May 1972.

CRITIQUE:  Committee believes that the CNY/RMP needs to strengthen
        its described goals, objectives and priorities because

they are not clearly stated in terms of health needs of the Pegion.
   jectives are described in terms of activities rather than antici-
   accomplishments.

RAG is a viable entity with fairly good leadership.

icularly from the inner-city, rural communities, model cities,

It, however,

fers from a lack of allied health personnel and consumer representation,

and the Neighborhood Health Center. Committee believes that the
eeds to assume a greater role in giving leadership to the planning

   vities of the program. They appear to be project
have not assmed responsibility for developing a regional

he Executive Committee of the RAG also needs to expand its membership

resentatian from the low-economic consumers , rural

activist physicians, allied health personnel and

rom rural areas of the Region.

certainly needs to enhance its involvement in the planning

activities of the RMP, and by doing so rendering the

leadership needed by the program.

ed concerns over the membership of the Rlvg committees

n the committees. Also, there does not appear to

rfly of physicians and the little interrelationships

operating procedure that would sti
etween the committees, RAG, and Core

ate an integrated

health personnel and rural representatives need

ommittees and that the operating procedures and
the COmftteeS need to be clearly defined.

Central New York RMP -4- RM 00050 8/71

The committees should be involved in total program planning and
operational activities, rather than being project oriented and
having a very narrow degree of responsibility within the program.

Although the present core staff is small in number, it is a capable
staff and has established a good working relationship with many
community health related organizations.

Committee believes that the program coordinator, Dr. Richard H. Lyons,
has done an unusually good job in pulling together the program since its
inception. It does appear, however, that he is somewhat impatient
with some of the newer trends in the organization of the Health Care
Delivery System and undoubtedly has seen continuing education,
particularly of the professionals with whom he has had great contact
namely physicians and nurses,  as the major responsibility of RMF'.

Committee agrees with the recommendation of the June 1971 site visit
team that the region hire an associate coordinator, M.D. to direct
a program of health service extension into both rural and urban areas.
In view of Dr. Lyon's age and history of illness,  the associate should
be chose with the consideration that he might succeed Dr. Lyons when
he retires. Committee believes that in any case positive steps
should be taken by the region to insure strong effective leadership
of this program.

It appears to Committee that there exists little if any interrelationships
between projects particularly those involved with continuing education
of nurses.
based on need and a regional plan, but rather are spontaneously
developed and submitted to the program by independent groups of individ-
uals. In most instances, activities previously funded by the CNY/RMp
have not been absorbed into the local health system with the exception
of the home health aid program which was really a peripheral development
of the program.

It seems that projects are not stimulated by the program

Committee observed that there has been a tremendous organization of
nursing resources under Mr. Margaret Sovie, Nursing Coordinator, but
that this effort has been pretty much divorced from the School of
Nursing at the University of Syracuse as well as from nursing schools
at Cornell, Utica and elsewhere.
Education Centers is an outgrowth of these nursing activities and is
primarily directed toward continuing education of nurses  rather than
multidisciplinary approach as projected by the Carnegie  renort which
recommends Area Health Education Centers rather than Area Health
Continuing Education Centers for all health disciplines.   Committee
believes the region should carry out this project by doing a
demonstration in one of the subregions rather than begin with a
region-wide program.
($120,000) of the requested funding level be utilized for support
of this project by the region and that a multidisciplinary approach
be utilized.

Project /I18 - Area Health Continuing

It is recommended that not more than 20%

b

Central New York RMP -5- RM 00050 8/71

f

Committee concurs with the site visit that the region should place
priority on training nurse clinicians or physician assistants which
could help meet the needs for medical manpower identified in the
inner  city and the northern counties where a great physician
shortage exists rather than on general continuing education for nurses.
Committee does not believe that there is a coordinated effort between
the three evaluators on core, the evaluation committee and core.
They also found it difficult to understand how the three part-time
evaluators on core staff functioned within the organization. Committee
suggested that the region consider hiring a full-time evaluator to
carry out a continuous evaluation process by working closely with
the evaluation committee. In addition, they suggested that the region
seriously consider the recornendations of Dr. Edward C. Hughes in his
summary report, as Chairman of the Evaluation Committee. Although
Committee is encouraged by the region's interest in evaluation activities,
it has difficulty in determining how the region will implement evaluation
activities without first identifying a regional plan with specific
objectives that project expected accomplishments and are measurable
in terms of evaluation.

Repional Medical ProgrAms in Northern New York

One point that arose repeatedly during the two-day meeting was  that
three of the four RMPs in northern New York had submitted Triennial
applications for this review cycle, had been site visited, and all
found to have basic problems in terms of the quality and direction
of the programs.
and Rochester. The, fourth RMP, Western New York (Buffalo), was
reviewed by October/Noveml)er 1970 Conimi t tee and Council.
some3 sentiment on the Review Committee that serious thought should
be 'given to combining these three, or possibly four
this would represent a better use of limited dollars and perhaps combine
the strengths of the various programs. It w3s recognized at the
same time that, politjcally, any combination of these Regions would
be quite difficult. Also, since each of the three Regions being
reviewed this cycle was seen as being at a turning point in its
developinent , with some hope for resolution of its problems during
the coming year, the reigning attitude was that now would be an
inopportune time to suggest any combined superstructure without
giving the programs another year to iron out their own difficulties.
The Committee also saw the need for more data before considering
any possible merger.

The three RMPs are Albany, Central New York (Syracuse),

There was

Regions, and that

RMP S /GRB/ 7 /16 / 71

I

*I

T 4

DEPARTMENT OF H~ALTH. EDUCATION, AND WELFARE

               PUBLIC HEALTH SERVICE
HEALTH SERViCES AND MENTAL HEALTH ADMINISTRATION

Rcpb to

Attn uf:

su&l: June 3-4, 1971 (Syracuse, New York)

Quick Report on the Central New York Site Visit

To: Director, RMPS

Through: Acting Deputy Director

I.

JX

Regional Medical Programs Service

Site Visit Team

Effie 0. Ellis, M.D. (Review Commirtee
Special Assistant to Executive

Vice-Pres ident
American Medical Association
Chicago, Illinois

Henry Lemon, M.D, (Review Committee)
Professor of Medicine
Nebraska Medical School
Omaha, Nebraka

Alfred L. Frechette, M.D.
Commissioner of Public Health
Massachusetts Department of

Boston, Massachusetts

Public Health

*Chairman

RMPS Staff


Ismael B. Morales
Grants Review Branch


Frank Nash
Regional Development

o

Branch

..

I?. M. SimmonS Patterson, M.D,
Executive Director
North Carolina ?Pip
Durham, North Carolina

William Lawrence, M.D.
Chairman RAG, Alabama DIP
Internal Medicine-Cardiology
Birmingham, Alabama

Miss Jean Schweer, R.N.
Director of the Division of
Continuing Education
U, of Indiana School of Nursing
Indianapolis, Indiana

Cecilia C. Conrath
Continuing Education and
Training Branch

-

Robert Shaw
DNEW, Region I1 ROR

,II.  .The region has requested $1,413,928 direct cost, a total of $768,848

above their current level of funding ($1545,080). The visitors
recommend approval of this triennial application at a level of
$850,000 wibh the following conditions:

1)

That the. regibn obtain an associate director who can serve as
backup to the coordinator and assume responsibility for planning

I

.I

Page 2 - Director, RMPS

S

and operational activities, particulary those related to the extension
of health services in the region;

2) That the RAG and its Executive Committee expand`its membership to
  include representation from the low economic consumers, rural
  physicians, young activist physicians, allied health personnel,
  and representatives from rural areas of the region;

3) That a program priority establishment and decision making process

is developed ;

That Project $118 - Area Health Continuing Education Centers be
implemented on a demonstration basis in one of the five Sub-regions
and an interdisciplinary approach utilized rather than L'srniting
it to the nursing profession. The visitors recommend that funding of
this activity by the region be restricted to 20% ($120,000) of the
amount requested for its support.

L

4)

5) That the Core staff hire a full-time evaluator rather than continue

wjth the present 3 part-time evaluators;

That operating procedures and responsibilities of the RMP committees
be clearly defined with emphasis in involving them in the program
planning and operational activities of the program.

That the region develop a program plan which can be measured in
terns of accomplishments at specified periods of time.

6)

7)

I

The site visitors recommend a staff follow up visit six months following

the award of this application to evaluate progress in implementing  the

recommendation and to provide assistance if necessary,

111. Brief Sumrnary of Findings

The goals, objectives and priorities of this program are not clearly
stated in terms of the health needs of the region, The objectfves
are degcribed in terms of activities and not as anticipated accomplishments. I

RAG has been strengthened by the recent addition of allied health and

I

consumer reprcsenta tion, however,  the visi tors believe that coiisumers
from the inner city, rural comrnunitie?, Model Cities, OEO, and the

hood health center need to be represented.

The visitors believe that the RAG needs to assuiiie a leadership role in
the planning and operations of the program.
been and continues to be, primarily oriented toward the continuing
education of nurse;.  In addition, they appear to be project oriented
and have not assumed responsibility for developing a regional plan:
The visi tors discussed these concerns with the coordinator and the

The program has always

chairman of the RAG.

t, *J

Page 31- Director, RMPS bI

The visitor: believe that although the present Core staff is small
in number, it is a capable staff and has established a good relationship
with the CHP "b" agencies in the region. They need, however, to have
additional medical staff to back up Dr. Lyons.with the administration
of the program.

The membership of the RMP committees consist primarily of physicians
and there exists little organized interrelationships between the
committees.
procedure that would stimulate an integrated program effort between the
commiktees, RAG, and Core. The visitors recommended that allied health
personnel and rural area representives be added to the comrDittees and that  the
operating procedures and responsibilities of the committees be clearly
defined. In addition the committees should be involved in pr,ograni planning

There also does not appear to be an established operating

and operational activities of the CNY/RMP.

*

The visitors had clif ficulty identifying the interrelationships between
projects particularly those involved with the continuing education of
nurses. It appears that projects are not stimulated by the prograin
based on need and a regional plan but rather arc developed and  submitted
to the program by independent groups or indivjduals.

The visitors believe that Project #lS - Area Health C'ontinuing Education
Centers needs to include an interdisciplinary approach rather than
limiting it to nurses in its first year of development.

also suggest that priority be placed on training nurse clinicians

  hysician assistants which can help  to meet  the needs for medical
manpower in the inner city and the northern counties where a great
physician shortage exist rather than on general continuing education
for nurses.

Activities in the region which impressed the visitors were the home health
aid program, the neighborhood health center and the study on rural health
planning by Dr. Edward C. Hughes. Although none of these activities are
supported by PaPS funds the Core staff has been greatly involved in their
planning and operation.

The visitors had difficulty understanding how thk three part-time evaluators
on core staff functioned within the organization. There did not appear to
be a coordinated effort between the three evaluators, the evaluation
committee and core. The visitors recommended that a full-time evaluator
on core, staff would be more effective in carrying out the evaluation process
by working closely with the evaluation committee. In addition, the visitors
suggested that the region seriously consider the recommendations of
Dr. Edward C. Hughes in his summary report, as chairman of the evaluation
commit tee.

The general impression of the visitors is that the region has continued
to follow the injtial concept of Regional M&ic:a1 Programs and has not altered
i.ts course to the evolving mission of !&MI'S. The program appears to have
the potential of having a posj tive'-influence in the health care delivery

*

of this region. @$$/& ~~~,~~~~~~~~

Tsmacl B. Morales
Grants Review Branch

&&>L ;j9 4

../

A.

Rpsponses by the Site Visi: Team to thcl RI4.P ProLrom Review Criter:a
of May 10, 1971 on the Site Visit to the Central New York Regional
          14edical Progran of June 3-4, 1971

I 'I

1. The activities of the Central. New York'RFfP represent an
opportunistic '2pproach rstlier than thFough a carefully planned
and coordinated approach to aiiswer regional needs, which they
have identified. The objectives alCh6ugh non-specific, are
congruent with the overall niission $nd objectives of RMP
na t ion all y .

2,
by Hrs. Margaret Sovie, it is'obvious that the region has been
very active In reachtng the majority of the 17,000 nurses in the
region and indirectly thereby reaching rmiy of the doctors and
into most of the hospitals i,u the area. It should also be noted
that the State Ikclical Assodiation is involved in planning and
evalua"iion activities concerning the growing deficiencies in
rural zeciical care. The visitors believe that the background is
now well established for the developnicbnt of real advances in
health care in t$e srea.

Through the Nurse Continutng Education Training Program headed

..

*A

3. The activities of which the(71\TY/RIQ are capable of could indeed

lead to improved utilization of existing health care rcsources,
particularly by developing additional health manpower,  such as
nurse practitioners and physician assistants. The Neighborhood
Health Center offers a particularly favorable resource in
Syracuse for advances in health care delivery to an inner city
population of about 33,000 which is  in need of health care services.
The Syracuse Medi.ca1 Center will be taking over the sponsorship
of this health center as of this Fall because of the failure of
administrative support from the regional health department in its
budget and operational activities. This should stimulate a closer
re1ationsIii.p between the center and the CNYIFOW.

4. Health l?aintenance, Disease Prevention, and early detection are
only minor components of the activities which the CNY/RNP has developed.

5.
diagnosis and treatmerit planncd other thn of coiirsci the superbly
designed and equ; ppcd Neighborhood Ilealth Center ;leveloped in
Syracuse by Ds. 3:om l4ou. The center, however, has been undcr-
utilized because of inadequate medical. stafF and due to local
consumer pre juciS.ces, resident and medical stvdent assistants from
the medical centier has not been accepted at this center.

There is no major expansion of ambulatory care or out-patient

It seems 1il:ely that ECCCS   j 1ity of iiiec';-cal cafe coulcl be improved
Lhat there could be irrlprov   nt in the re3 at:lo~-rshKp bet-ween prliUary

and secozidary medical csre 1 f the region can develop answers to their
ogiiized and idc?ntifisJ defi-cicncies j 11 mcdicnl carc in the area.

1

To really accomplish this, the region must alter its direction from
continuing education to accessibility of health care for the region.

7. There is no immediate pad-off seen in accessibllity, quality,
cr cost moderation in medicdl &re, although the Ndighborhood'
Health Cencer in Syracuse obviously offers a better source of
assesr;i.bJe mcd1cal care than the urban popcllation has had in the

,

1.

r1

past. /;

I/

8.  The Cen.tra.1 New York RTlP has had, gome success in linking and
strengthening the ability of multip,$e health institutions in groups
to work towards better health care. This has been particularly
attributed to Hr, Murray the Assistant Coordinator, who is involved
with many neighborhood groups, and, sits on the Syracuse City Council.
Also, Mr. Currie of the core staff has been very effective In this
regard a
exist, tiwcvev the commitrncnt to work in a cooperative effort may
need strengthening. I

The relationship betrrertn the F:IIP and othcr health agencies

I

The Centre1 Ih.7 York EW has been supportive of a number of other
funded pro jcc ts , such as the Cormuni ty Ilea.lth Center in Byi-acuse.

They have also been able to tap othcr sources of funds for some of
their planning agtivitjes, including private funds for thc survey of
rural health fieeds by Dr. Hughes.

E. PerformscLGriteria'

1.  The region has succeeded in establishing its own goals, objyctives,
and priorities in general terms on the basis of individual agreement
by RAG menbcrs as to the major objectives. There is, howevzr,no
clear statement of the basis for priority in selecting budgetary
support of projects, and.the visitors view this as a weakness in their

   of activities and not as anticipated accomplishments which
clearly relate to the health needs of the region. In addition, there
is no time table related to the accomp1ishmcnt of the rcgionsobjectives.

2. The previous activities which the region has engaged in, although
few in number, have been productive, for example, a survey of health
needs in rural arees , the developiizenl. of a neighborhood conmmlty
health center by the former associate coordinat.oi-, the devel opinent
of an excellent region-wide continuing education program for nurses,
the dcveloprmit of a mobile rebabilitaLion unit md the establishment
ol a pattern of cooperative arraiigenicrits,

3. The Centrd New York rLMP activities have not been absorbed into the
regular heai.th care system in most instances WJ til the cxception of the
hone health aides activity which wa:: rcally a pcriyheral. activity of
the C~=/~WJ?.

rniance capability.

The object:lves are primarily described in

Process Criteria

1. The Regional

Advisory Groclp of the Ceniral New'kork R~~ is on the

verge of becoming a viable aetide entity of the CNY;IpfP.
hotaevei-, believe that the RAG.needs to assume a greater leadership .
role in the planning and operational activities of the CNY/KMP.
The group has been strengthened by the, recent addition of allied
health and consumer representatives, ,hpwever, the visitors bel-ieve
that the rural comnunities, model cities, 0130 ancl consunicrs from
the inner city (neighborhood health ;;enter) need to be represcnted.
In addition, the RAG needs to add yAunger activist members representing
the rural and urban medically deprived areas. The Executive Conunittee
of the RAG needs to assume a more active role in giiring direction to
the program and its membership; should be increased to indude allied
health personnel and consumer representation. A difficulty which the
region posscsscs is the severe Wintc2r.c; of the northern area for at
least five moiiths of the ycay, whicii makes it relatively impossible
for representatives on the RAG from the area to participate during
that season of the year.

The visitors'

,

*

2.  There are 'prpbably between 100-200 health related agencies who
have relations in one way or another with the Central New York FMP,

reflecting the very Complicated history in development of Public
Health Activities in the State of New York. The visitors believe
that this is one of the virtues of the CNY/P@fP,  it has been able
to make some headway without too niuch agency interference, in spite
of the traditlonalisrrl of the provider elenleiits arid the multiple
agencies ~hfch overlap and duplicate in some cases.
to be active relationships betwecn the CNY/IUP and other health-
related agencies of the region, however, it was difficult to
determine the ainvrnnt of commttment and active participation of
these agencies to CNY/PS.IP.

There apvears

3.
agencies at the "b" level in this arer7, are carried out chiefly
through having the same small nunher of very excellent provider
workers sittlng on committees for both agencies. It also seemed
apparent that the CNY/Tu"lP was not fully mare of all of the activities
that were going on undsr Comprehensive Health Planriing in the area,
particularly the plans for a yre-paid insurance program in the
Syracuse Area, so that there cculd be a lack of cross-over on the
informational level.

4. The vist.oss believe that there is no real systematic ongoing
operational pla.ilning that would coordinatc? plamiLvg and operational
activities to77ards specific progi-a~~ objectiv? >. It was because of
thjs rcasrln a major receinncndation of the visitors IJRS  that the
region hCre an associate director 3.t the. M.D.  lcvel. for health
services e4ttcnsion to suppleiiienI. aci-lvl tfes of Dr. Lyons and

The coordination of ?PIP activsltlcs with comprehensive health

.

14r. Murray and the rest of theicore and to bring spme focus to
their activities. /*

5.
Evaluation cormnittee did a very fine job in identifying in the
evaluation comdttee's report the deficiencies of the Regional
Advisory Group and other deficiencies 'within the RIP.
other hand the three 20% evaluators 64 core staff from the
University of Syracuse represent dieferent disciplines and have
done their evaluation independentlyj'with very little effective-
ness.
evaluator on core staff who can carry out a continuing evaluation
process and work closely with: the Evaluation Comittce of the
Central Mew York P,Mi.'. In addition, the visitors believe that the
region should sei:iously consider follo.i~ing up on the 1-ecommendations
of Dr, Edward 6. Hughes outlined I in his report.

b i'

The visitors believe that, the Dr. Edward C. Hughcs' Chairman,

On the

It is believed that the Region& needs to hire a full-time

o

**

.

A PRIVILEGED CObIMUNICnTION
RN 00050

DMFT

I. Site Visit Tmz

e

e

Effie 0. El.lis, M.D. Chairnian; Speckil. Assistant to Executive Vice-

Pres j.d en t , Bc::: i ic a n Mcd ic n I A s s oc i.a t ton ;  Plernb er  of
l?.$IP Rev-iel~ ConimIttee.

Henry Lemoil, H.D. I lilember of RiW I?CV!CW Coriimit.tee,  Professor of Medicine

Alfred L. Frechette, NeD. , Coirmissioncr of Ir'ubj.ic Health, FSassachusetIs

F. Pi. Sirmotis Patterson, M,D. , Executive 9i.recLorY Assoication for the

I.!ill.iarn J,ai:!rence, 'Cr,.D. Chair1na.n !%G, Alabama 1 , Internal P1cdic.ine-

Mi.ss Jean Schweer, R,N. ~ Director c?f the Df.v-ks:ion of Continuiiig Education,

Nebraske Medical School.

Departmnt of Public Ibalth

    Worth Caro1i.m FL\iP, Durharn, North Carolina

Card io Io gy , B i rrxi ngh a rci )  A 1 a 11 a.m

University of 1ndi.ana Scliool of Nursing

RMPS Staff

Isnacl E. E.ioraLes, Public Fiealth AdV;i.sor, Graiit.s J3.pview Branch
Frank Kash, Operations Officer, EiegLonal Developnctnt Rra.nc!ii
C~cilia C.' Conrath, ChiLC, Continui.ng Education and Trai.nf.ng Branch
Robert Shaw , Regional Office Representnti.ve, DIK\,?, Region II

-__IC_-

Participants from the CiL'YlWP

K. 11. Lyons, 16.D. , Coordinator
John Murray) Assistant Coordinator
L. W. Bluemle, Jr. , M.D. , President, Upstate Ileclical Center
R. Fcl-lmidt, I-I.D., Dean of Faculty, Upstate Medic.,il Centcr; Member of US
Clarke T. Case, N.U., Chairman, Regioi-ial Advisory Group
Bruce E, Chazberlin, M.D. , Vice-Chaii-r-ian of the Regional Advisory Group
E. C. Hughes, PI.]). , Upstate Medical Center, Past-President of the Medical

             Society of the Staic of New Yorlc
Gordon J. Cuminjngs, Ph.D., Piember of the P&G
Herbert K. Ensworth, EI.D., Member of the RAG; Chairman of Categorical

C. A. Keeler, Jr., Fteember of RAG; Chairman of RAG Nominating Coimnittee
C. F. Jacobson, Ph.1). , Menher of the iUC
Thomas Mou, 15.13. , University Dean for Health Sciences, State University

of Eew Pork; Formally Director OZ Neighborhood Health

Coninittee or! Stroke

. Center

Central Kew York EWJ Site Visit -2- Iw 00050

Part j.c iyan ts (cont .)

Mi-. James H. AbSot , Vice-Pres ident for Uospi tal Ai'fairs , SUNY , Upstate

Medical Center; Meii;ber of IiZG

Robert Sagernan, N.D. ~ MeniScr of Caccc5r Conxn1.ttee 1

Robert Enich, H.D, , Plernber of the 11ea1-i: Disease Coiixnittee
E. A. Aksel, 1.I.U. , Executive Secretary Central Neia- York E;lospital.
                                                   I
            Associat2.on ~ 1.lcrc'Ier of !:AG
I<. W. Hacorn, M.D. , Regional. l~iealth Director, Stare of New York Department

Mrs. Virginia NcAllister, Chairman of Uep:irtni.cnt of Health Technology, SUWY

I

of Heal.tl,; l~!erIlbel- OK RAG I

Ag and Tech. Col leg: , Canton, NeYe ; Ncnher of
RAG and men?l>er of Comiit:ec+ on Contf.nu:ing Piedical
Ed 11c a t i. o 11 a rid

S p e c iil I. 1' 1' OS ra XI) s

Dol.ores Leonard, Director of I'hrsing, Faxton I-Iospj.ta1, IJ1:ica New York;

Sister Ann Morari, Director of Nurstng, Our Lady oT Lourdes Hospital

Pfeeniber of Kursing Steeri.ng Comi~i< (.tee of liS.11)

Binghamton., N.Y. ; ii.iember of Eursi.i-ig S teeri.ng Cormittee

Mrs @ Margaret Sovie, Nursing Coordinator
Plr. Val ter Curry, 'reaching Coordinator
Nrs Jean Kulakc?uski Heal th Educator

    Miss Suznnnc ihrray , Library Coordinator
    Mr. Robert Schneider, lnstruc tus-a1 Coqlmunicati one
e 1Ir. Anthony Parisi, Instructural Commnications

Plrs. Sandra /ir?glund, Pub1 ic Reletions
James 'Ijaldrog, Ph.D. Assistat Professor, Educational Commnications,

Plr. Porter, Evaluator (20% Time and ETIort)

SlNY Upstate Medical Center

11. INTRODUCTIOB

The site visit team arrived in Syracuse, Kev York on Wednesday, June 2,1971,
and had a pre-site visit meeting at 0:30 in the evening to discuss
appropriate ftrategy for the meeting on Thursday June 3rd.  Tlie visitors
reviewed their responsibilities in detei-mining the credibility of the
CI<Y/IziPrP decision-making and review process, administrative capabili tics ,
and its overall ability to carryout the proposed plan. The site visit
meeting was conducted at the State University Hospital where 1)r. K. H, Lyons,
Coordinator of the CNYIIWP has his office. This sit<> visit was initiated
by Dr. Effie 0. Ellis,who clearly indicated to Dr, Lyons, the 1:pgional
Advisory Group members present
of the site visit and its relative significance to the total review
process , including Coinmittee and Council seview, o the triennial
application under consideration. Dr. Ellis explained how tlic site
visitors hoped to acquire a clear understanding of the organizational
structure and processes of the Central New York 1WP and their effectiveness

and others who participated, the purpose

in reaching the goals, objectives and priorities which the region has set
forth .

e

Central Net7 York P$fP Site Visit -3- RM 00050

The Central. New York PSI? demonstrated sonic iiiiprc!ssi.ve strengths in
J.ts Regiotiztl 1.iedical. Program, as well as a nunher of weaknesses wh-ich
hnve persisted since the January 1969 Si te 17isi.i:. The visj-tors believed,
however, that the Regional Advisory Croup althoii;;h provi.der dominated
particularly bj7 physicians, has begun to assi:rr.c 1 eadersliip separate
from the, SyracLse ib'lcdical Cctiter and has demoiist-rr!.tecl a airly effective,
altlhough not ideal degree of control over the direction OC Clic program,
The New York State bledical Assoclation is c!ui.tc_ involved wi th the planning
and evaluation of the Central Ncij York thr~i~gli Dr I Edward Hughes,
who serves as Chairman of the EvaluaCion Con:tn:!.t-.t-c?e of the Regrionni
Advisory Group and whose su inary report of April 26, 1971, demonstrates
a degree of sophisticatSon nd sel....r.va:iiation wliich the lU,G is competent
to sssurne, The site vi-sitors at the concIu:;ioii of the second day believed
that Dr. Huglies ' report adequately pin po.intrttl a niliribcr of the most
sei-ious weaknesses no;$ existing in the Central. TU'YRMP program. The
visitors believe that the Executive Cc:l?;iiittee OT the PSiG sliould be
increased in n.uriber to contain befter representation from allied healLh
persoilllel ancl consuiiiers and assume inore responsib<.I.ity in tlie planning
and operational activities of the Regioilal I4edical Program. The site
v i s i tor s 11 n a n i! usly recomiended that the program he funded at a level
of $850,000 ~a7f.i:h condi.tions later identified and the provisions that
there be appropriate statf f013.0i~-~p and ;? technical. site visit after
a year of operation.. Thjs foll.o:~-up could he1.p assure that at least
so:ne of the major recoii?r,..c-ndatioi~s of the Hughes' lleport and of the si.te.
visit teaui are iraplemented into the prograin.

The rcgion has succeeded in establ isliing its OWII goals, objectives,
and priorities in general terms on the basis of individual agreement
by ]JAG members as to the major objecijves. l'hcy arc, howcvc>r, not
clearly stated in terms of the health needs of thc region and are
described as act-ivities and not as anticipatd accoi~iplishm~iits. Because
of this, the visitors believed this to be one of the weaker parts of
the Region's performance capability.

The site visitors bad an opportunity to n~ect witl: most of the Core staff
and thought thcai to he generally compctenL, The vj sitoi-s believed that
the Program Coordinator, Dr. Richard H. Lgoiis, has clone an unusually good
job in pulling together the program since its inception. Tt did appear,
howcver, that hc js somewhat impatient witli rom of the nwcr trends in
the organization of the Health Care Delivery System and undoubtedly has
seen continuing education, particularly of the proressionals with whom
he has had great contact namely physicians and nurscs, as the major
responsibility of Pap.

It appeared to the visitors that Dr. ,Lyons has had little involvement
with the development of the Neighborhood Health Center and that since

RTJ. 000050

Central New York P24P Site Visit -4-

Dr. Mou, the former Assistant Director for the ILv,P had IcTt, the
RMP and the center be operated quite inde~)endcntly. An Associate
Coordinator, I1,D. to direct a progrrm of health service extension into
both rural and urban areas is ohviously Iieeded, Thcy necd someone who
is a strong exccutivc and can put topcthei- the iiinny resouices in tlir region
into a multidiscjplinary program. In view of Di . Lyons' nt;c and history
of illness, the Associate sliould be c11o:en witl, thc considerat-jon that
he inight succecd Dr. Lyons \:hen he retires.

The Core stalf of the Cif\.y/i:~!IP is saall in timber and docs not havc the
broad range of professiondl and discjpliiie rcprcsciltatiorl that is
present in oihpr 3;Ps bGt ic is conipei ent and has adequpie ndministrative
and management capbili ties, The Corc sLafi licis been qui active
and successful in estab1 j sh ing a good working rcl ationhh ip wi th the
mulr iplici ty of health insti tutjons in the iegioii. This is particuI.,~ry
at1 ributed to Pii-. Hurray, the I;ssisLhnt Coordin3tor, who is involvccl
in may neighborhood groups and is a member of the Syracusc Ciiy Coulicil.
This type oLT conrmnity participation is also :rue of Nr. Curry who has
been very ef fective in uorlti ng with otller heslth organizations of the
region. In addition, tlirough the nur3e continuaiioa pro61 arn headed by
Mrs, llargaret Scivie, it is obvious that they 1-1,ivc~ been vcry effective
in reaching the majorj ty oT the sevclltccn thousand nurses jn the region
and indirectly thereby reaching into mo.ct of the 11ospit:ils and to
many of the doctors in the area. Thc visitorr 1135 sor~le difficulty
understand Lng how the three-part t imc evaluators oniCore staff
function within the organization. `Ihcre did not tli)p<2ar to be a
coordinated ef ort between the three e\!aluator,c, the Evaluation
Corninittee and the Core. It is Lecause of tliis that the visitors
recornrrieuded that n full-time evaludtor on Corcl staff would he more
effective in carrying out the evalsa tion process by workLng closely with
the Fval uation Cotrimittee.

I

,

The visitors believe that during the early development of the CNY/RblP
it may have Looked and in fact, may have hcen' a uiiiversity operation.
It appears, however, that the Kegioilal Advisory Croup, although
provider dominated particularly by physicians, has assuincd I eaclership
separate fron the Syracuse Idedical Cent-er and is beginning to take
control over the operations of the The Regional Advisory Group
is a highly viable active entity with good leadership. It, however,
suffers from lack of alljed heal th personnel and consuiner representa-
tion particularly from the inner-city, rural comirlonities, Model CiLies,
OEO, and the H'eighhorhood Health Center. The visitors believe that
the NAG can assume a greater role in giving leadership to the planning
and operational activities of the program. They appeared to be project
oriented and have not assumed responsibility for developing a regional
plan. It should be taken into consideration, liowever, that due to
severe winters in the area for at least five months of the year it is
relatively impossible for certain members of the RAG to participate
during this season of the year. The visitors suggested that the region
consider the telephone conference device which they have used for
educ a t ion a 1 . p u r p o s ed t o ex t end c ommu n i cat i on s d u r i 11 g t h e w i 11 t e r month s

e

Central New York KQ Site Visit -5- RM 000050

with RAG rneabers from the northern area. The. Executive .Committee
of the RAG needs t? expand i.ts membership to i-nclude representation
from the 3.oa-economj.c consuncrs , rural physicians , young artivfst
physicians, allied Iiea.1 th personnel and representatives from rural
areas of the region. This c:o;nmittee as the representative group

.. . of the &IC, can certain! y enhance its invol.vement in the planning
   arid opcrntiona.1 actLv:I.tics of the P&;P, and by doing so rendering the

. top l.evel leader sli ip n:.eded by the p:-ogr:?in.

The membership of the IT-ip coxnittees consist primarily of physicians
ancl there is little organized intr?ri-elai-.j.onsilS..l', between the coirlrni.ttees e
There also does not npptar to be an established ope.ratirig procedure
that vould stinulate zin j ntegrated prograni effort between the
conwittees, RAG, aiid C~i:.e, The vis-itors reco!ilii,cnd that allied
1ieal.t.h persr>nn~l and .;u-ral area i:cp::escni-atives be added to the
c oinxi t t e e s  and tlia t the opera t i ng proc ec! u re s  arid res p ons ill i 1 i t i. e s

should be involved in total psograx p1.anriing and operational activities
of the CS'f/F;XP. It is apparent that the cormittees have been project
or-iented and have assunzd a very narrow degree of responsibility within
the progrern,

ttces be cl-early def j lied. In acld3.tion., the comittees

The CNY/I';lP has been su-cessful in establishing c2 relationship with
a rnultfplicf ty of health instj tut-ious and groups, liowevr~r,  this relatioti-
ship has com about in an inforlnnl natincr such AS overlapping oi
comxittee ;nFi::berships aqd through piclciiig up 11 its of inforination Ilcrc
and there 2:d incorporating such inFa:-ii,atj oil iiito plans 01" programs.
Activities t117ich he.,e coiitributed t 0;-ai? vlcibil ity of tlie CEY/P$IP
and have helped in iry)rcvirig relatiot-ships between the PiClP and other
health organizations on the susvey of healtli necids in rrirnl areas,
developmerit oT a cowwnity health center by the former associate
coordinator, the developnent of excellent continuing education program
or nurses, tbe mobi le rnhabilitation unit activity which has been phased
out and in the estab1isl:uent of apattern of coopcrative nrrangemcnts.
These estab? ishpd relar Lonchips can certainly be considered one of
the strengths of the region, hoivever, ther? js little evidence that
these relationships ha\>c stimlated active involvement- in planning and
operational activities, psrticularly in dcvelopment of a regional plan
for improvc>ment of hezlth services. OR the other hand, a virtue of the
RE? is that; 3 t has bezn able to naI:; some hcdway wjthout too niuch
agency incerfercncc in spite of the traditiocmlism of the provider
elements arld the multiple agencies .r+~liich overlap and duplicate in some
cases.  The coordination 017 plana; ng wi th Co,nprchensive Health Agencies
at the B level in this area are csi-ricd out chiefly through having the
same small number of very excellent provider workers sj tting on committees
for both agcncjes. It was , however , apparent that the rcprescbntativcs
of' the CNY/RIfP were not fully aware of all of the activities that are
going on under comprehensive health p1 anning in the area particularly
the plans for a pre-paid insurance program in the Syracuse Area,  SO
that there could be coxe lack of cross over on the informational level

with these agencies, The vi-sitors believe tliat operational commitments

e

Central New YoiIk K>lP Site Visit -6- REI 000050

from other agencies could be enhanced if the RTIP vould develop a
systematjc origoing operational planniiig system t 0 coordinate plans
and programs toward specific prograz objectivcs. It is for this
reason that one of the major recoimer,dations is that they hire an
Associate llirector for Health Service extension at thc M.D. level
t9 supplement the activities of Dr. Lyons, Fir. TIurray and thc rest .
of the Core 2nd bring about a coordinated effort in progrm activities.

The Central. Xew Yoi:ir iW?, during its planning phase, conducted a
de ri1Og ra ph i c  survey c one e 1-11 i ng  the p o pu 1. at i on and  t CI t a I nunb e r s of
physicians c.oc!;;arcd to those in private prac ti:ce. The hospital
bed capacity tias determined along wi.th a . svinniary of the resources
for heart cancer and stroke patient care. These rriecti.iigs and studies
helped familtarize the people of the legion with ihe fntent of CNY/RMP
and gave the program some rough estiaatc as to the needs of the various
conmunities withtn the region. Dr. Ed\.iard C. I-Iuc$es, past-presiden~

.of the Xew Yor!: State Nedical Lissocla~ion i.s prf+scntly directing
a study' in rural medical care i~hich was initially funded at a level
of $75,0Oc) by the hvolon Foundation. Dr. JIughes is a pi:actic.ing
physician with considerab1.c depth and great interest in the
distribution of health services in the State of Kew York and aplx~ars
to be a. major asset: to the RAG. The visitors were, howevei-, informed
that the grant from the Avaion Foui~datiail was termina,tiog so that
Dr. Hughes wLll be unable to continue this study ilii1.e~~ lie is able
to locace support from other sources. The prj y areas where there
is a desperate need for improved riricdic~l. care :'.iE the 34,000 tinder-
privil-eged people of Central. Syracuse and thc northern countj.es of
the region of Si:. Lawarencc Frankli.n, n:>d Jefferson. The Nei.ghborhood
Health Center 1.ocated in this central. Syracuse uiir;r?i:privi.leged area
offers a particuLarlp favorable focus on Syracuse for advance in health
ca re de 1 iv er y s erv ice a 1 th ou gh  it is pr e s en t I y s e :rv i ng approx ima t e 1 y
only 8,000 of the population. It is expected tliar when the Syracuse
Hedical Center 'cakes over the sponsorship of this health center chis
Fall and ut-ili-zes its medical manpower r~~sources to help staff the
center it than can be more. responsive to the l\Ledical Care needs of the
35,000 population in the area. The basic health problems of the
northern area of the region are the limitefi number of physicj.ans and
tkie age of- the physicians which are available because they are retiring
at a much faster rate than they can be replaced, Dr. Rluemle,-President
of the l4edical Center, sees 'this as the number one p.roblei11 in the
regi.on, The ZQiP through its field staff has been vorliing with consumer
groups in St, Lavrence County and hop?.fL:lly out of this consumer
activity will cone a program to provide more health care for the
people of that area.

e

The region has continued to follow its initial concept of Regional
Eledical Programs; it has not altered its course to the evolving
mission of RfiIPS. it continues to view its role in the area of
continuing education and riot placing the needed eciphasis on access
of care to meet the needs identified in the provertp pocket of
Syracuse and the Northern Counties of the Region.

e

' Central New York FJ5P Site Visit -7- RM 00050

In program implernentation, the activities of the Cn'k'fu"Q represent an
opportunistic approach to feasible objectrues as determined by local
opportunities rat1:"r khan tlirough carefully pl snned. and c.oordirlated '
answers to regional needs, which thry Seelii to be quite well aware of,
Availability of health care was mentioned :jev(<i-:!I. ti.mcs hy represetitxi-
Lives of the region as a major health problem, hc~~ever,  there was
little evidence of a pl.annec1 effort: to develop a program in this
area. The activities .of the Central New York 32 have not been absorbed
i.nto the regular health care systen in most .i-rrstnnces wi tli the exception
of the honw health aide program which T,GT?S really a pei:iphi!ral. dcvel opment
of the program.
education resoii.rc~s under Plrs
that this effort has been pretty i!iuch dlvorccd from the School of
Rurshg at the University of Syracuse as ve1I as from ocher nursing
schools at Cornell Gtida and elswiiere.

There has been a ti-cinendoi:~ organization of nursi.n.g

?.iar:;aret SOV?'~ i brit i.t should be emphasi.zed

The region has formed a cOordinatLi1;; co    t t ci e w i. t li rep re s en t n t %on
froni the CWf/EX', Health Department, Hospital Association, OEO and
other health related organizations so that they could keep each
other inforimd acid avoid duplication atiioilg zgencies , particularly
the four agencies nentioned.
this commLttee to establish a coordinated pl.ailiii.:~g effori- for health
care delivery servi.ces in the regj.on rather than just to oversee what
each other is doing, This is something that th2 region could explore
for future program plan.ni.ng and develapnent.  The activities of which
the Central New York RNP are capable , corilcl indeed lead to improved
utilization of existing health care ~csources part j-cularly in developing
additionai manpower such as nurse pract itiancrs which tlie. region is
just now beginning to co:;sider. Although few in number, the Central
Xew York RMP as been successful with roan]: of its activities in meeting
it.s objectives. The nursing coronary care trfiining acti-vi. ty in Utica
is meeting the needs of two con-nunity hospitals by having them pool
their talents to provide training for s~~.aIlei- outlying hospitals in the
area and has been able to continue this actS.vity with much success.

The visitors ba;icve the CNY/RI"JP could use

A very impressive activity in cormunity health education is now in
process under the direction of EIr. Horace :T:ey: who is utilizing the
Mobile Unit previously of the ?lobile Stroke Prograin which has been
phased out to carryout community health education activities. Mr. Ivcy,
has requested that PJ4P support a fezsibilicy s~cdy in whicli the >lobile
Unit can be uti1 ized for conxiunity health education,' immunizations,
lead poisoning, survey, screening and bringing an awareness to the
comniunity of the health resources vhich are available  to them in the
comnuikity. The visitors believe that the 1-iobile Reliabilitation Stroke
Unit Program which was phased out ~las one of the better activities
in this region; one which was giving the CSY/RIIP much visibility. The
visitors were also quite impressed by the l!o;ue Health Aide Program, the
Keighborhood Health Center in Syracuse and the study of rural health
planning by Dr. Edvard C. Hughes. Altho~gh nGne of these activities are
supported by CNY/PMP funds the cor? staff Fas hccn great-ly involved
in the planning and operational activities of their programs. It appears

that the R34P is beginning to develop a good rclz-ltionsliip with the
medical groups of the region and loosening its Lies with the University.

Central New York IWP Site Visit

-8-

24 000050

Pso j ec t re 1.a t ed eva lrra t j on ac  iv i ties wh i cl? have been undertaken
by the regi..on during the [Jsst year include visits by stnEf, reports
to the Evaluation Cnmmittce 3rd di.rect: reports from the field. It
is, however evi.deiit that tiie basic evali.mtlj.o:i activiti-es implemented
by t-lie regi.on have been to\:?,rd cvaluat-inn of each pruject componsnt
in relation to i.ts own objcctives. Tilere appears to liave been' very Little
effort -in evaltiat.i-iig each OT these components in re1 stion to wliat they
have acco:i~pli.S!)Cd in meet-inj: regtonal. objectives and nieeting the health
care nc:r-ds. of the region. The re::ieT.7c+rs bel.ieve that: it will be difficult
for this region to carry out R thorougli c:valuati.on plan wttliout fi.rst
outl%ning specific objfctives on the 1iasi.s of expected accornpli.shments
and re1 ated to a ti-ine table. `ilticd evalu.:.ti.oii. process should also
be one that is d.onc COiltinUGilS1.Y throughoul: the year and can be
utili.zecI to adjcist prograiii dii-ection as nieded rather tlran the once a
year evaluation of the progra::il.

The visitoi-s recoiimend the Follo;-i.ng funding 1 eve1 in direct co.c,t I
which is appro>'imtltely $200,OO0 above their present level of funding
with the folloving conditions:

1 s t Year
2nd Year

$1 , 4 1 3 3 2 8
1,367,335

$ 850,000
  150 'f 000

8-50 000

-2---- 1 389.363 --.-- -..._---I-_-

3rd Year

Total. $4,170,64G $1. ,550,000

1. That an associate coord2iiator M.U. to dircct a program of health

service cxtention into borh rural and uri)an are,is be employed e The
region needs someone wlio is a strong cxrcutive and can bring together
the many rpsources in this ares; to cooperatively resolve the health
probleras of the region.

2. That the PAG and its Executive Corriri:it.tee expand its membership to

include representation rrom tlie lower-econumic consuniers , rural
physicians, young activist physicians, allied health personnel -and
representatives from rural area of the region. They need to have
younger represcntatives on the Regional Advisory Group and the
visitors specifically rcjconnended adding two mi-dical students and
oiie nursing student, perhaps as non-voting members

3. That the region develop a program plan which inclucles a method
  for pr.ioriLy establishmcnL, a decision-rnaking process, program
  planning and evaluation. The visitors believe that this is a basic
  need for this region because they round it difficult to get any
  feeling that even the RAG.or the coordinator had any sense of
  what the CE!Y/P,XP expects to be threc years from now.

4. That tlie program establish a balance in the development of

activities in relation to thei I- priorities; the continuing education

activ3 ties . for nurses have out-stripped some of the other actj-vities
in the i-egiori.

Central. New York lillP Site Visit -9- RM 000050

5.

6.

7.

8.

9.

The visitors also believe that the region shou1.d put into actj-on
the recomrnendat?oos dociliilented in ?lrm I'iugtzes evaluation report,
especially paragraphs 3 and 4, of the report. (Copy of the evaluation
report by Dr. JJughcs is attached.)

That the region consider hiring for Core staff a ft11 l.-tiii~ evaluator
rather than continue to utilize the present three part-time evaluators

That operating procedures and responsibilj ties of the RMP conmi-ttees
be clearly deiined wi th Eniphasis in involving theui in the program
planning and operaLional actjvit ies of the program.

The visitors rcconirnend a regional.ization planning approach in
health services; that program activities be iiitegrated as part of
a total. prograin plan which can be iiieasurcd in terms of accomplishment
at specified peri.oc':s of tlme.

It is reco:meded that nc'i mGrc than 20% ($170,090) of the requested
funding level for Project i'l8 - Are2 licalth Coiitinuine; Educatjon
Center be utiljzcd fcr support or this projcct by the regior,. The
region was encvttraged to carry out a denonstration project -In one of
the sub-regions rather than begin with a regj oil uide prograni as
proposed in the applicacjon,

The region has been using sor.>2 01 their core funds for support of
feasjbility studies and central core activj tes. The visi tors do not
discourage these activj ti cs bdt recom:~et~cI that the activities be
funded only when approved by the Xegion?.l Advj sol-y Group. They should
be CoI7Sidered on tlie basis of yai'tlat they coiitribute to the objectivcs
and prjoritjes of the region as described jti the rc>gion's program plan.
The vj sitors suqgest that the additional $200,000 recommended be
utilized to develop activities that will help improve delivery of
healtli services to the urban and rural poor. Ihcsc al~peal- to be two
real priorities or the region and this additional unJing should
be able to provide some progress in these two ai-~as,

The sjte team members recorrm?nd a staff Follov ip-visit six months
following the award of this application to evaluate progress in
implementing the above recornmendat? ons and to provide assistance
if necessary.

IMPS /CRB / 6 / 2 9 / 7 1

Responses by the Site Visit Team to the PWIP Progrzm Review Criteria
of Hay 10, 1971 on the Site Visit to the Centra?. New York Reglonil
          Medical Program of June 3-[1, 1971

A. Intendc-d-TEults of i tr*-Erocrram:

1. The actlvt'sies of the Central New Yorlc WP represent an
op p or tun i s t i c a pp I- o ac 1 i  r ; t lie r  t I.1 an  r 1; r o u I1 a c n r e Lu 1 1 y p 1 ann e d
and coorclJ  fed approach to az~~dcr resivnnl nceds , whl ch they
ham idcntl: fied. Tile objective: ,,ltl.otigh non- specific, are
coi?~rucnt with thc ovcrall ~uissioii cLnd objectives of REP
nationally.

2 +
by Mrs. 14arg;iret Sovie, -it is obvious th.at the region has been
very actj-ve in rcachin.g ths majorit.y of the 1.7,OOO nurses in the
region and i.i~directl.y thereby rpac;ii.ng many of the doctors  and
into most of the hospitals in the area. It should also be noted
that the State bfedical kssociation is iirvolwd in pXaniiing and
eva 1 ua t i on GC t 'LVF t i e P c o nc e r n i 1-13  the  YO wF ng d e f i c I eiic 2 e c  i. n
rural medical care, The visitors believe that t:he hczckground is
now well established for the development oE real. advances in
health care in the area.

Through tlie Nurse Continuing Education Training Program headed

3.  The activities of t;!iich theClE/I:F-rS ere caj>abl c of coul d Indeed
lead to ir;jjroved utiliz;ti on of ex; c;ting he3J ih care L'CBOUI'C~S,
particul arl y by devcl oping aJ:dit! ctix1 Ileal i71-L tt.dnpcwr, such as
nurse prae iitioners ai-A pitysici PI; assi statit s   The I'Tcighborltood
Health Center offers a particularly fa\roi-;tb2~ resource Ln
Syracuse or advances in health cart! tlclivc~ry to ;:II inner city
population oE :;bout 38,000 whi-ch is in ricer1 or' health core services.
The Syracuse IJledical Ccnteer will be taking over the sponsorship
of this health center as of this Pall bccaiise of the failure of
administra'ive support from the regional health departincnt in its
budget and operational activities This should stimulate a closer
relationshkp between the center and the CNY/RL;IY.

4. Health Plaintenance, Disease Prevention, and es?rly detection are
only minor components of the actlvtties xrliich the C:NY/I?MP has developed.

5. There is no major expansion of ambulatory care or out-patient
diagnosis and treatment planned otlier than OF cotrrsd" . the superbly
designed and equ; pped Neighborhood Health Center 3ev21 oped in
Syracuse by Dr. Tom Mou. The center, however, has been under-
utilized because of inadequate medical staff and due to local
consumer prc judices, resident and iiieclical student assls tants from
the medical center has not'been accepted at ~bis center.

6.
and that there could be improvement in the relationship between primary
and secondary medical care if the region can develop answers  to thci.r

It seems likely that accessibility of medical care could be improved

recognized and identified deiicieiicic-:: in rnedi'.cal care in the ares.

0

- 21 -

To really accoinplish this, the region- mist alter its direction from
continuing educ;rtion to accessibility of health care for the region.

7. There is no irrnnediat-e pa,y-off SPPD in accessibility, qnallty,
or cost noderati on in medical care, a1 tltough the K:\`e%ghboi-hood
Health Center in Syracuse obviously offers  3 bet T~T source of
assc.ssible medical care tha the urban population 1125 lind in the

past. 1

8. The Central Kev Pork ET' has had some success in linking and
strengthening thc ability of rnultiplo health ir)stitutioiis in groups
to work towa-rdc better health cxe. I hLs hac been par~icularly
attributed to Yr. Murray the Assistant: Coordinator, \~Ezo is involved
with iix,ny nejgTrlmrhood groups, and, sits on the Sgracuce City Council.
Also, Mr. CurrSc of the core staff has bee11 wry erfective ia this
regard. The relationship between the IW? and oilier Iiealt-h agencies
exist, 1icx:ever the comiitmcnt to work in a cooperative erfort may
need strengtAielling.

PI

9. The Central Rew Pork RFIP itas been supportive of a number of other
Et? funded projects, such as the CCxIEJUnffiy lka1 th Center in Syracuse.
They have also hecn able to `cap otlicr :,ources of funds for some of
their pl anntng activities, including private funds for the survey of

rural health needs by Dr. Hughes.


Per f o ma nc e C r i t e r i a

I3. ----^----__.-.--.-_I

e

1. The region has succeed.ed in establishi.nji; its own goals, objectives,
and priorities i.n general ternis on the basis of individual aqreeirlent
by RliG members as to the major ol)jec`ii.ves. There is, huwevctr,no

` clear statenent of the basls for priority in selecting budgetary
support of projects, and..the visitors vi6vir.j. this as a weakness in their
performance ca.pability. The objectives are primsrily described in
terms of activities and not as entlclpated accomplishments wiii".ch
clearly relate to the health needs of the region. In addition, there
is no time table related to the accoci,plishment of the regionsobjectives e

2. The previous activities which the region has engaged in, 21-though
few in number, have been productive, for example, n survey of health
needs in rural areas, the development 01 i: nei::Iiborhood coimunity
health center Ly the former assocint e coordiiiator, tlic development
of an excellent region-wide continulng education prcgrain for nurses,
the developrlient of a mobile rehabilita~ion unit and the establishment
of a pattern of cooperative arrangeinents.

3. The Central New York RMP activities have not been absorbed into the
regular health care system in most instances with the exception of the
home health aides activity which was really a peripheral activity of
the CP?Y/IlrlP.

- 12 -

Process CrLteria

1. The Regional Advisory Croup oE the Central New Yorl: is 011 the

verge of becoming a viable active entity of the CXY/f?.TW.

I hov~ever, believe tflat the ILrG needs to c~sstt~le c? greciter leadership.
role in the plarining and operational nctivi tics of the CW/RW?.
The group has been strengthened by the rccent ;~ciditioii of r?llied
heal th rind COllSuiner reprcsent:&tives, liowcver the vi-sitors believe
that the rural corimunities, nodel ci tics OEO and consuiilers from
the inper city (neighborhood health cent cr) need to be reprcsentecl.
In addition, tlic WS needs to add younqcr ~ct ivist iacmhers representing
the rufal and urban nzclically clcrprived areas . The 1:r;i~cu tive Comnj ttee
of the PK needs to assuine a morc active rolc ir: givliig directio~i to
the program and its meu5ercliip sliciuld l)c incrcascd to irlclude a13 icd
health persorinrl and consuwr representation. A difficulty which the

. region possesses is the severe Uinters of the ncrthcrii area for c+t
  least five n.lionrhs of the year, which xaices it relatively impossible
  for sepreacncativcs on the RAG fro111 thc ~WCR to participate driring
  that S~TSO~ of the year.

Tlie visitors

2.
have relatForis Fn one way or 3;3CitiLCr idth tile Centrdl New Yorli lW!',
reflecting the very complicated liis~ory 111 dc-:-elopmmt of Public
Health ActivitScs in the State of ;:e17 Yorlc. The visitors belicvc
that this is one of the virtues of the Ci::'/T(;+2, it has been able
to make sore head1.7ay withoiit too r,ucIi agcncy Flxterferei1ce , in spite
of the traditionalisci of the provider elt-~ierii s and the multiple
agencies ditch overlap and duplicate in som ca5es. 'There apnears
to be active relationships Letveen the ClX/ 2nd other hcalth-
related agencies OX the region, howeveL, it wcs dilficult to
determine the amount of commitncnt and active participation of
these agelicies to Cl?Y/RKP.

There are probably betiqeen  300-20Ci hc>al th relat~d ageiicies who

3.

. agencies at the "b" level in this area, arc carried out chiefly
through having the saine small nuaber of very excellent provider
workers sitting on cornnittees for both agencies. . It also sceiiied
apparent chat the ClE/iZIQ was not fully aware of all  of the activities
that were going on under Comprehensive Iieolth Planning in the area,
particul-arly the plans for a prc-paid insurance program in the
Syracuse Area, so that there could be a lack of cross-over on the
informational level.

4. The visitors believe that there is no real systematic ongoing
operational planning that would coordinate planning and operational
activities towards specific proSrc;ill objectives, It was because of
this reason a major recormendation of the visitors 1.73s that the

The coordination of PJQ activities t~i.l:Ii coziprehensive health

region hire an associate director at the N.D. level for health
services extension to sii?pler,ient ectj_vfI:ic:; of Dr T,yoris and

Mr. Murray and the rest of the core and to bring some focus to
their activities a

a

6'

'7 o

' 6,

Centers .

e

f

I.

1-

     REGIONAL MEDICAL PROGWS SERVICE
SUMMARY OF AN ANNIVERSARY TRIENNIUM GRANT APPLICfiTION

(A Privileged Communication)

Georgia Regional Medical Program
Medical Association of Georgia July 1971 Review Cycle
938 Peachtree Street, N.E.
Atlanta, Georgia 30309

RM 00046-04 8/71

Program Coordinator:  Charles Adair, M.D.
Program Director:    Gordon Barrow, M.D.

. This Region is currently funded at $1,779,862 (d.c.)  for its
                       Core is supported at

third operational year ending 8/31/71.
$648,435 (d.c.) and 23 projects at $1,131,427 (d.c.). Indirect
Costs of $203,227 are provided representing 11.42 % of Direct
Costs.  The Region has submitted a triennium application that
proposes :

I. A Developmental Component

11.
111.

Continuation of Core and six projects into the 04 year
Continuation of 10 projects beyond the Council-approved

period of support.

5 projects for three additional years
4 projects for two additional years
1 project for one additional year

IV.

The implementation of 15 new activities

V. The termination of 12 activities

The Region requests $3,920,034 (d.c.) for its fourth year of
operation, $4,349,497 (d.c.)for the fifth year and $3,942,724
(d.c.) for its sixth year. A breakout chart identifying the
components for each of the three years is presented on pages 2-4 of
this summary.

A site visit is planned for this Region. Staff has conducted
a preliminary review of the application, and has identified the
following as areas which need further clarification by the site
visitors.
attached to this summary.

These are covered in greater detail in the staff review

1. Goals and objectives
2.
3.
4. Committee structure and its relevance to the new program
5.
6.

Core staff positions and functions
RAG - its composition and its control over policy

Practical functioning of the 140 Local Advisory Groups
Development and review of projects

0

7. Project and program evaluation

REVISED 6/7/71

(SUQPOrt Codes)

CONT. WITHIN CONT. BEYOND MPR. HOT bTgw, NUT
OF SUPPORT. OF SUPPORT FUNDED APPRaVED COSTS COSTS

1st YEAR

MPR. PERIOD APPR. PERIOD PmV. PREV. DIRECT INDIRECT TUTAL

IDENTIPICATI(XI OF
COMPONENT

#18 - Core $ 683,430 * $ 683,430 $ 81,750 --- i $ 177,986 765,180

                              I
DO0 - Devel onmen tal ** $ 177,986 177,986

--- 1 60,000

#I - Clinical Training .$ 60,000 60,000

I

30,500 2,369 1 32,869

REGION  Georgia
Cycu  RM 00046 8/71

BREAKOUT OF REQUEST 01 PROGRAM PERIOD

I

#3 - Visiting Cons. Prog.
Ob - Comaunication Network, 161,200 161,200

#13 - Statewide Cancer Prdg. 450,257 450.257
               86,250 86,250
814 - Ped. Rem. Center I
#20 - Area Fac. for C.E. ' 267,700* 267,700

"22 - Physiology for    30,970* 30.970
   Nursing Instructors                                183,323
#27 - Communitv Hypertensjon 183,323***
        32,365 32,365
C30 - Fac. Plan. & Devel.  202,960 202,960
#31 - CV Area Facilities

30,500

I

#32 - Stroke Area Fac. 126,850 I 126,850

    I 161,200
16.017

      I   466.274
20,040 I   106,290
      I   267.700

1

---

I I

5, a43

21,125


---

---

36, ai 3
204,448
32,365 I

I
ra

202,960

                       I
836 - Kidney Disease

837 - Fac. for Resn. Dis. I

839 - Health Yaintenance

#41 - Electrfcal Hazards

#?R - Emerpency Cere I

840 - UNASSIGNED

4,,170 1 29.370 1

$4,178,197

-

$258,163

I 211,584 211,588 '
I 75,94q 75,940


     I
I 7,290

7,2901
   1

---,
51,646

---

126,850
263,234

75,940

20,120
---
---

83,160
85, on0

87.700

842 - High Risk Maternal

b Infant

63,040 63,040

85, oon 85, 000

-~

543 - Pat. & Famil'y Educ.
$44 - Comouterized Dieter9

87.100 87,700

33,575

                I

848 - Shared Allied Healtq

#45 - C.E. in !lursing
846 - Learning Resources 1
547 - Consultant Dietitiah

#49 - Health Car. CounselflR
P50 - Phys. Assistant
851 - CE Health Prof. in

Optimal Diabetes Ore

33,575

70,9161   30,936
68.1 on]   68,100
23,9171   23,917
228,147   228,147

25,200 25,200

I 42,0601 42,060

-

7,740
--- ,
---

13,360

38,676
68,100
23.91 7
241,507

REGION Georgia
BREAKOVT OF REQUEST 05 PROGRAM PERIOD

TOTAL

$220.100 $2 , 283,655 $1,845,742 i $4,949,497

REGION Georgia
BREAK9W OF REQUEST .06 PROGRAM PERIOD

IDEMTIPICATION OF APPROVED PERIOD OF D PERIOD OF PREVIOUSLY PRF~IOUSLY DIRECT 'ALLYEARS I

CWONEhT SUPPORT FUNDED APPROVED COSTS DIRECT COSTS ;

#18 - Core $ 753,481 $ 753,481 $ 2,156,511 1-
Dnfl - Develanmental .kit I 177 986
fl 60 I 000 60,000

1 -7 171,986 577 958
                                180. on0

I

#7 30.500 \ I 7n. 50L.
#6 I 161,200 161 1200
41 3 332,884 I 332,884
81 4 I 84,250 84,250 \
820 I 267,700 I I 267,700 1

                    25, a73 I 25,873 I
R27 I 191,765 I 192.765

I

I

I

R2 2

#lo
831 360,197 360,197
832 257,345 I 257,345 1

         396,426    396,426 1
. .- 139,687     199,687 1

836
#3 7
#38 147,400 147,400 I

F39

--- ---

I

16,320 16,320

Ln-- I I I

1 4,140 4,140 .
I 1
I I 1

---

$41

---

142
R43
144

#45 -
846
#47
F48
c49
850
#51

I

a5, 000

85,000

--- ---

33,575 33,575 I

I I

I

53,360     53,360 11
41,074     41,074 11
68,100     68,100 11

I

                204,300
--e --- 64,-015
     194,461 11 725,958

I                              I

I                             I
                    --e      --- 25,200 1'

194,461

I 1

I

t
I

I I I 1 I \I

1 $2,525,195 I $1,427,529 ] $3,942,724 11 $12,212,255

TOTAL

** Reiueat amended to 3 yeaha per telephone

I
*
I

,.

(..

.. .

'. .

.. .

codversatian W. Rliat and Region 1112/71

_. -.-

Georgia RMP -5-

RM 46-04 8/71

8. Relationship of projects to objectives
9.

Method for priority-ranking of projects

10. The need to request continued funding of 10 projects
   beyond the Council-approved period of support.
11. Minority involvement in GRMP

5

mTNDING HIS=

o (Planning Stage)

Grant Year

01
02

Period

1/1/67 - 12/31/67

1/1/68 - 3/31/69

Funded (d. e. )

$208 , 781

$589 , 066

Grant Year Period

01 7/1/68 - 6/30/69

(Operational Program)

Future

Funded (d. c. ) Commitment (d . e. )
$1 , 427 , 810 - 1/

------

------

..

02 7/1/69 - 8/31/70       $2,470,103
03 9/1/70 - 8/31/71       $1,779,862
04 9/1/71 - 8/31/72        ----- $1,096,536
05 9/1/72 - 8/31/73        --e-- $289,902

- 1/ Includes only 3 months of Core

e

GEOGRAPHY 6 DEMOGRAPHY

The Region encompasses the entire state;  interfaces with Alabama to
the west and with northern Florida to the south.

Counties : 159

Congressional Districts: 10

Population: (1970 Census) - $4,589,000

Urban: 60.3% Density: 79 per sq. mile

                                       U.S.
Age Distribution: Under 18-37% 35%
          18-64 yrs . -55 %             55%
            65 6 over -8% 10%

Average per capita income - $3,040 (compared with $3,680 for U.S.)

Metropolitan areas: (4) Total population - 2,040,700

Atlanta - 1,373.6     Columbus,  Ga. 234.3
Augusta - 249.8      Savannah      183.0

Race: White - 3,395,860 74%

Non-White - 1,193,140 26%

Vital Statistics

Mortalirv - deaths per 100,000 pupulation, 1967

Heart Disease
Malignant neoplasms
Vascular lesions

All causes

(aff. CNS - stroke)

-b-

Age specltlc

death rates/100,000

State of Georgia U.S. (all causes)

288.1 3x43-    45-64 yrs. 1380.8 -*
122.5 157.2      65 & over 5839.1
122.0 102.2     compared with U.S.

853.9 935.7 65 ti over - 6042.5

45-64 yrs. - 1143.5

1969/70

Resources and Facilities Enrolled Graduate

Medical Schools - Emory University School of Medicine 333 75

Atlanta

Medical College of Georgia, Augusta 418 98

Dental School

Pharmacy

- 2 Emory and Medical College of Georgia
                         Southern School of
- 2 University of Georgia, Athens; Pharmacy,Mercer Univ.

Atlanta

Professional Nursing Schools
27-(18 of them based at Colleges

and universities)

Practical Nurse Training
44 - majority are

vocational schools

Other Programs

CHP - A agency -$315,000 (10 professional staff)
(2) - B agency -$400,000 (15 professional staff) Atlanta, Brunswick

Allied Health School -- University based: Georgia State University,
School of Allied Health Services, Atlanta; Emory University School of
Medicine,Division of Allied Health Professionals.
Accredited Schools : Cyto;echnology -2

Medical Technology - 15
Radiologic Technology - 23
Physical Therapy -------
Medical Record Librarian - 2

Community and Junior Colleges: Eight Jr. Colleges

Hospitals: Community General and V.A.  General

                  Beds-
Short te& 141- 15,198

_--

a

--

(special) Long term 1 120

1 VA incl. long-
term care unit 1,450

V. A. (General)      2 917


Units          24 1,146


Homes         203 13,184

Long-term Care

Skilled Nursing

Georgia RMP

-7-

RM. 46-04 8/71

ManDower :

Physicians*- Non-Federal M.D.s (1967)

Active - patient care 4,106
     other professional activity 364
Inactive 258

Osteopaths (D.0.s) - 66

Ratio of active (per 100,000 pop.) 93 (U.S.132)

Medical Specialty - 23%; surgical specialties -33%

*Percent by specialty:

General practice -22%

Ratio

Graduate Nurses, 1966 /I Per 100,000

Actively employed in

nursing 6,956 156 (U.S. 313)

Not employed in nursing 3,111 ---

Licensed Practical Nurses

Total employed in nursing(adj)3,912
Not employed in nursing 1,046

HISTORY AND DEVELOPMENT: The Region's initial planning year began

$208,781 (d.c.).

Three awards totaling $589,066 (d.c.) were made for the second

year of planning 1/1/68-3/31/69.

on January 1, 1967 and was supported at

A pre-operational site visit was conducted to GRMP in June 1968 by
Stanley W. Olson, M.D. who was then Coordinator of the Tennessee
Mid-South RMP, Mack I. Ghanholtz, M.D., Lionel Bernstein, M.D., and
RMPS Staff Ira Alpert and Peter Clepper.
there was evidence of careful and thoughtful planning by GW
and substantial involvement of large groups of people in every
section of the state. The involvement of the Medical Association
of Georgia as applicant agency was felt to insure the full support
of the organized medical profession and the selection of Dr.  Barrow

as full-time Director represented a wise move in that he brings  to
the position substantial organizing ability and experience in
public health, in academic medicine and as a hospital director of
medical education.

The site visitors agreed

While the major criticism of the application was  that the conceptual
strategy guiding the RAG was not explicit,  the visitors made a
substantial effort to explore this matter and were statisfied a
reasonably well defined "strategy" did exist which was described
as follows.  The applicant seemed well aware that implementation
of a RMP would involve participation by all hea3th professionals
and lay persons interested in health matters, but that the primary
group which could either stimulate the program or inhibit its development
was the medical profession. The Medical Association of Georgia,
by assuming a leadership role, had assured the widest level of support

Georgia RMP

-8-

RM 46-04 8/71

by the physicians of a state which traditionally has had strong conser-
vative leanings. The two medical schools, sensing the importance of
having full support from the practicing medical profession endorsed
the proposal that the Medical Association take the lead.
in fact produced a certain freedom on the part of the schools  to
participate to the extent they feel they can do so without interfering
with what are considered their primary responsibilities of teaching
and research.  The plan for GRMP envisioned that the resources of
the two medical schools would be made available to health personnel
and health institutions of the state and that physicians and other
health professionals would look to the medical centers for training
and assistance. GRMP would assist in establishing throughout the
state a series of area facilities of excellence for heart and cancer.
As a result of this visit and subsequent action by Committee and
Council, GRMP was awarded support of $1,427,810 for 14 projects
for the year 7/1/68 - 6130169 and Core support for the period
4/1/69-6/30/69.

This

A second site visit was conducted to the Region in July 1969
following GRMP's submission of a supplemental application in early
1969 which consisted of 14 projects and a core supplement.
The team consisted of Philip White, M.D., of Committee, Glen Turner,
M.D., Edmund McTernan, M.P.H., and RMPS Staff, Jessie Salazar,
Frank Nash and William Reist. The visitors were convinced the
Region had active plans for the improvement of health care for
the disadvantaged and poor.
between GRMP and the Office of Comprehensive Health Planning and
a Joint effort was being made to develop a project for a health
information system. The general structure of the GRMP appeared
good and local involvement was considered adequate as evidenced by
the establishment of 100 Local Advisory Groups which would
interdigitate with the five subregional offices. It was difficult
for the team to conceive the degree of participation of the individual
members of the large 60 member RAG until it was explained that the
Steering Committee serves as the major decision-making body, but
that the RAG does maintain veto powers. Concern was expressed
regarding representation of minority groups, particularly at
the local level; however, it was felt at that time that there
were realistic problems which might prevent more adequate
representation, the most significant being the fact there were only
a few black physicians in the state and most of them practiced in
Atlanta. It was also felt there was inadequate representation of
the Schools of Nursing at the Universities. While the length of
time, 9 to 15 months , involved between the initiation of a
proposal and the review of it by the HAG was viewed by the visitors
as too long, the Region believed it did not create any excessive
problems.
format and system for writing and developing project applications.
GRMP had been very effective in stimulating the interest of
doctors and getting community hospitals to contribute and participate.
There was no apparent conflict betweentheRAG and the Medical Association
of Georgia, and the administrative set-up seemed to be quite adequate.
With the addition of Dr. Gullen to the staff, the Evaluation Division
was considered to be strengthened appreciably. Methodology

There appeared to be close cooperation

The visitors saw a need for the Region to develop a standard

Georgia RMP -9- RM 46-04 8/71

permitted a built-in mechanism for assessment from the inception
of each project,
on all existing projects to assure consistency $n all evaluation
procedures.
appropriate and adequate.

  Staff was also in the process of "back tracking"

All in all, evaluation techniques were believed to be

,

The Region was awarded $2,623,512 (d.c.) for support of Core and
23 projects during its 02 operational year.

In August 1970 Staff reviewed the kgion's continuation application
for the 03 year of operation.
the program appears to be well organized, under strong leadership,
and functioning well, the interrelationships of the projects were
not always clear, nor was it possible to fullunderstand how a
particular project relates to the total program.  Staff found the
evaluation aspect of numerous projects extremely weak and the Region
was requested to submit additional evaluation information on a number of
projects.
was recommended for a technical review. The technical review group
recommended the project be phased out, however,  in consideration
of the Regions concerns and objections it was agreed the project
should receive a technical site visit.

While staff concluded that as a whole

Project 116 was cited as having severe weaknesses and

In September a technical site visit team visited Project #6.
team consisted of Winston Miller, M.D., Gordon Titus, Rhoda Bowery,
and Elsa Nelson and Frank Nash of RMPS.
plagued with deficiencies, poor program planning and inadequate
evaluation. The team concurred with the technical reviewers" findings
and the Region was requested to submit phase-out - budgets, which it
did.

The Region has been awarded a total of $1,779,862 (d.c.)  for its
03 operational year 9/1/70-8/31/71.

The

The project appeared

PRESENT APPLICATION

Goals and Objectives:  The overall goal of GRMP is to "Improve regional

                health resources and enhance the capabilities
of providers of care at the community level in a way that will
influence present arrangements for personal health services to
permit maximum availability, accessibility, and use of the best in
modern medical care for heart disease, cancer, stroke, kidney
disease and related diseases."

More specific objectives are :

1. To increase the availability and efficiency of health manpower

in Georgia through:

a. The provision of the new types of health manpower
such as physician assiatants.

b. Training all types of health manpower in new skills
to allow each of them to expand his role and effectiveness.

Georgia RMP

-10-

RM 46-04 8/71 'I

c. Making scarce types of health manpower and their

skills more widely available, particularly in rural

areas.

d. Encouraging disadvantaged students as well as others

to enter the health field.

2.

To improve the quality of medical care in Georgia, including
prevention, diagnosis, treatment, and rehabilitation through:

a. Assisting the medical care institutions in meeting

the highest existing standards for facilities, construction,
equipment, and maintenance.

b. Providing health professionals with opportunities for

new skill development and continuing education.

c. By making new and improved methods quickly available

from the laboratory to the practicing health professional.

3.

The improvement of the availability and accessibility of
of primary medical care and of specialized diagnostic, prevention,
treatment, and rehabilitative services to all persons in
Georgia through :

a. The promotion of innovative models of primary care

for rural areas without adequate services.

b. The promotion of innovative models of primary care

for urban ghetto areas without adequate services.

c. Encouraging community screening, casefinding, and

prevention programs which may provide an entrance into
the health care system.

d. Promoting the regionalization of certain primary care
services such as emergency and ambulance services
which cannot economically be provided without such
regionalization.

e. Providing area facilities of excellence in the mafor

categories of disease.

f. Improvement of the skills of personnel in these area
  facilities to allow them to serve more effectively
and more efficiently .

g. Developing regional cooperative arrangements for the

more effective and efficient use of these specialized
facilities and services.

Georgia W

. -11-

RM 46-04 8/71

,

e

0

Requested

04 Program Year

$683,430

COKE: Core Staff consists of 27.6 (full-time equivalent) professional

   and technical personnel and 13.5 (FTE) secretarial and clerical
personnel.
each sub-divided into smaller units:

Core organization is divided into three major divisions

I. Administrative Division

Staff Services Section
Budget & Fiscal Section
Communications & Information Section

Facilities & Services Section
Continuing Education & Manpower Sectdon
Categorical Diseases Section
Program Assessment Section

North Area
East Central Area
Southwest Area
Southeast Area
West Central Area

11.

Program Planning & Development Division

111. Area Programs Division

Liaison is maintained with the universities through a Medical Colleges
Staff Services Division, under which an epidemiologist and biometrician
at the medical college are each supported at 50% and an Associate
Dean at Emory is supported at 33%.

Of the 27.6 (FTE)professional staff 8.5 are female and 2 are Black.

Of the 13.5 (FTE) secretarial staff 13 are female and 2 are Black.

Core activities fall into eight general areas:

1.
2.
3.
4.
5.
6.
7.
8.

professional consultation
subreglonalization
planning and feasibility studies
central regional services
project development & review
program assessment
program management
administrative management

Significant accomplishments of Core staff over the past year have been:

1,

Strengthened aubregionalization and decentralize certain program
management functions to the area program staffs in subregions.

Strengthened administrative and grants management functions
of staff.

2,

3.

Strengthened program assessment capability of core staff and
building in the continuing evaluation of the ongoipg program
as an integral part of program planning in the future.

Georgia RMP -12-

RM 4G0.4 4, 8/61

*.

!*

4. The de-emphasis of the categofizalsnature b'f'the prdgrah $,
  and planning ways to assist the providers to ffip-Pove the
  health care delivery system.

The most important area of core activity over the next Triennium
will be ''to contince to explore ways in which this GRMP can assist
the providers in improving the system in line with the priorities
of this Administration. 'I

GRMP has no active feasibility or planning studies supported through

Core.

Requested 05 Program Year

$717,602

Requested 06 Program Year

$753,481

REGIONAL ADVISORY GROUP: The RAG which consists of 65 members appears

of the key resources and interests in the Region, and is equally
balanced geographically, Physicians influence is strong with a
contingency of 32 of which 12 represent the Medical Association
of Georgia and 4 fepresent the Georgia State Medical Association,
a Black organization.  While the CHP "A" agency is represented on
the RAG, neither of the two "B" agencies have such representation,
nor is there representation of the Appalachian Program or the
66 practicing osteopaths of the State. Of the 65 RAG members, nine
are female and six are black.  All of the eight public or consumer
representatives are professional executive types.

for the most part to have representation

Like most RAGS of this size, it does not appear to be particularly
strong, but rather out of necessity relies heavily on the Steering
Committee, the Task Forces, and Core. Attendance at the tri-annual
meetings which was 37%, 52% and 61% last year, is about average for
a RAG of this size.

COMMITTEES: The committee structure consists of a Steering Committee

      (Executive Comlttee) six Task Force Committees and
approximately 198 standing and ad hoc committees. (There is some
contradiction in the application regarding the standing,and
ad hoc committees?)

The Steering Committee consists of five RAG members elected by the
RAG, and the RAG Chairman.  1ts.primary function is to oversee the
day to day administration of the program.

There are six major task forces, each consisting of 12 members
elected by the RAG, two of whom are RAG members.

"hey are:

1.  Task Force on Continuing Education.
2. Task Force on Facilities and Services.
3. Task Force on Cardiovascular Diseases, Diabetes and Hypertension
4. Task Force on Stroke and Renal Diseases.
5. Task Force on Cancer.
6. Task Force on Chronic Pulmonary Diseases

Each Task Force is responsible for recommending to the RAG the goals,
objectives, priorities and strategy in its area of competence.

Each

Georgia RMP -13- RM 46-04 8/11

also serves as a technical review group for the project applications
which are within its area of competence.

Ad Hoc committees are appointed from time to time by each task force.
Current ones are:

,

1. Committee on Black Manpower
2. Committee on Nursing Education
3. Maternal and Child Health Committee
4. Multiphasic Screening Committee
5.

Committee on Patient and Family Education

(These committees are identified as Standing Committees on Form 85
of the application

Other Ad Hoc Committees are:

1. Cancer Care in Atlanta
2. Board of Directors for a Cancer Facility in Augusta
3

Board for Project #6 - Communications Network

Black representatives serve an four of the six task forces and on
six of the eight Ad Hoc Committees.

Staff felt it would be interesting to know if the Region foresees
any alteration in committee structure in view of new trends and de-emphasis
of categorical disease, and continuing education aotivities.

SUBREGIONALIZATION: Local Advisory Groups (LAGS) have been established

in 140 hospitals (representing 93% of beds)

throughout the Region, their function is to:

1.  Advise GRMP on local problems
2.  Assist in planning and developing a local program
3. Provide communication between GRMP and the community
4. Coordinate local activities in accord with Task Force reports

While in theory each LAG was to consist of a physician, a hospital
administrator, a nurse and a member of the public, the number
of representatives varies among the LAGs  from two to seven.
have some black representation.
by 88LAGs last year.
varied from 1 to 11.
LAGs.

Four

      A total of 233 meetings were conducted
The number of meetings conducted by the LAGs
Areawide meetings are held annually for all

Staff gels it would be interesting to learn more about  these
meetings and about significant contributions they have made to the
total program.
ization can encourage cooperative planning and activities among the
LAGs when, aside from annual meetings,  there is no indication that
the individual groups meet or exchange ideas.
noted, the LAGs in most instances are overwhelmingly hospital

It is difficult to see how this form of subregional-

Also, it might be

e oriented.

Georgia RMT -14- RM 46-04 8/71

Reauested 04

DEVELOPMENTAL COMPONENT: Proposals for use of develop-

Program Year

mental funds will originate $177.986

from the RAG, Task Forces, LAGS, other agencies,  institutions
and individuals.  They will be considered in relation to both national
and regional objectives,  A tentative agenda of opportunities  that
are likely to present themselves over the next three years are:

1.

Assist in extending health services to the poor and blacks
of the rural and urban areas by increasing the availability
and accessibility of primary medical care.

2.

Utilize unique working relationships with health organizations
and health professionals in the region to assist them in
the careful development and implementation of health-maintenance
organizations.

3.

Support and promote the development of key elements related
to establishing the area health education centers.

4.

Assist providers to develop better health delivery systems
in the regions, and to study alternate approaches for
necessary modifications.

The review procedures for developmental applications will follow
the established procedures for project development, review and
management.  The review process for proposals is not expected to
exceed 90 days.

Requested 02 Program Year

$177,986

Requested 03 Program Year

$177,986

REVIEW PROCESS: The Review Process is briefly stated as follows:

.I

1.

Suggestion for a s6ecifi.c operational activity originates
from the RAG, a Task Force, LAG, other agencies or
institutions, or from an individual and is summarized in
a brief narrative.

2,

The proposal is acknowledged and referred to the appropriate
Staff Coordinator, who proceeds to work with the proposer in
its development.

3.

The proposal then undergoes preliminary review at the next
categorical section staff meeting, at which time, a staff
recommendation is prepared.

4,

The proposal is referred to the appropriate task force for
technical and program review.

5.

Proposals approved in principle begin a phase of staff
development which may take varied forms depending on its

functional.

naivete and the degree of sophistication required to make it

-._

Georgia RMP -15- RM 46-04 8/71

6. As the proposal reaches final draft stage each task force
  chairman appoints several members of his task force to
.provide an in-depth review. There is also in-depth staff
review by the Program Director, the Planning Director, the
Program Assessment Coordinator, and several other key staff
  members. A recommendation is sent on to the task force.

-

'

o

7. The task force ratesthe proposal for its technical merit

and gives it a priority based on its potential contribution
toward meeting the task force goals.

8.

Prior to review by the RAG completed elements are sent on
to the Office of Comprehensive Health Planning for its review.

9.

The proposal is then reviewed by the Steering Committee and
RAG.

Using a checklist designed to assist in the assessing of the
appropriateness of each proposal, the relative importance, and the
potential contribution to the overall program balance,  the RAG
assigns each approved proposal a priority placement of either
Crucial, Very Important or Important.

Of the eleven projects identified as Crucial seven are ongoing,

and four are new.

Of the nine identified as Very Important, three are ongoing,

and seven are new,

Of the six identified as Improtant, one is ongoing, and five
are new.

Georgia RMP

-1 6-

RM 46-04 8/71

PROPOSED PROJECTS

The Region's proposed

I Cancer

I1 Cardiovascular

roject

111 Continuing Education

IV Facilities and Services

VI Stroke and Hypertension

V Respiratory

I Cancer Element

are divided into six Program Elements:

I

Project #13 - Statewide Cancer Program - Medical

Association of Georgia

Priority - Crucial

Requested

Fourth Project Year

$450,257

This proposal requests continued support of the ongoing program, which
consists of 12 area cancer facilities, and extension of eight additional
facilities to provide treatment in the vicinity of the patient's home.
Also requested is the development of a computerized treatment planning
program, continuing education and physics support for high voltage
radiation therapy equipment, and to provide standardization and quality
control in its use.
The personnel are utilized in developing, coordinating and maintaining
the area facilities and tumor registries.
coordinate all cancer activities in their medical trade area to improve
treatment facilities, referral procedures and training of health pro-
fessionals.

Progress - This project was previously supported for 3 years:
$174,500; 02 - $401,276; 03 (current)-$234,095.
12 area cancer facilities during the past year, each with a tumor
registry element.
seminars and workshops.
during this period and programs have been developed for three addi-
tional statewide cancer workshops.
registry personnel and two additional workshops are planned.
workshops or allied health are planned.

Major budget items are for personnel and travel.

The facility directors

01 -

This program supported

All facilities participated in tumor conferences,
  Two workshops for physicians were conducted

Two workshops were held for tumor

Two

Fifth Year - $446,479

Sixth Year - $332,884

Project 830 - Facility Planning and Development -

Reques t e d
Second Project Year

Augusta Radiation Therapy Center

$32,365

Priority - Important

Georgia RMP -17- RM 46-04 8/71

e

The purpose of this proposal is  to continue the initial planning and

development of an area cancer treatment facility in Augusta which will
provide for major radiation therapy support wherein proper patient
referrals can be made.

Progress: This project which was previously approved for three years
is currently in its 01 year.  However,due to late allocation of funds
and budget cuts, staff will not be hired until July 1, 1971.

Third Year: $34,820

I1 Cardiovascular Element

Project #31 - Cardiovascular Area Facilities -

Requested
Second Project Year

Medical Association oE Georgia

$202,960

Priority : Crucial

This project is designed to expand and extend patient services  that
cannot be provided by local physicians in hospitals which are potentially
capable of serving as referral facilities for the smaller satellite
hospitals. This will be accomplished by providing services, education
programs and screening activities.  Nine additional fac6fitias will be
phased in at a rate of 3 a year.

Progress: This project which was previously approved for 2 years is
currently in its 01 year of operation (59,984), during which time five
cardiovascular area facilities have received funds. No other progress
is reported.

Third Year - $284,006

Fourth Year - $360,197

Project #27 - A Community Hypertension Program -

Requested
Second Project Year

Georgia Department of Public Health

$183,323

Priority: Very Important

The purpose of this project originally was to investigate methods
for identifying asymptomatic hypertensives in an urban indigent  com-
munity and the methods for achieving good blood pressure control.  In
the second year it is planned to explore the effect of having a resources
center for education of the majority of patients, follow-up of all

'

patients, and diagnosis and therapy for the more severe patients who
have no source of medical care. It is hoped that the study will show
various factors that deter a patient from seeking care and what can
be done to motivate more patients to comply with therapy.

Progress:
is currently in its first year of operation ($84,000).
statistical run of program data indicates the prevalence of unrecog-
nized, untreated hypertension in the study population.

This project which was previously approved for three years

The first

Of 3,809

Georgia RMP

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RM 46-04 8/71

interviews completed, 1,096 (28.8%) persons were hypertensive, 305 (27.8%)
hypertensive subjects were totally unaware of their conditions and of
those who were aware, only 468 (59.2%) were under medical care.  Pro-
grams on education were geared toward the lay community.
number of women with no previous medical experience have been trained
to become blood pressure technicians.

An unspecified

Fourth Year - $191,765

Third Year - $185,280

Project #51 - Educating Health Professionals in

Requested

Model Diabetes Care - Emory            First Project Year
University                      $25,200 '

Priority: Very Important

This project is part of a plan to develop a center designed to provide
optimal care, education, and follow-up for 8,000 diabetic patients
who are dependent on Grady Hospital (Metropolitan Atlantic City Hospital)
for their primary care.
fessionals from throughout the Region will be taught optimal patient
care techniques and methods.  GRMP support for one year will be applied
toward:  the salary of a computer programmer, who will develop a system
of computer program need instruction on the nature and treatment of
diabetes; consultant services necessary in video tape production and
editing; purchase of projection equipment to be utilized in the teaching
program; purchase of a collection-of pertinent books; computer time and
supplies necessary for programmer and supplies for the education plan.
No support is requested for second and third year.

Physicians, nurses, and allied health pro-

111 Continuing Education Element
Project #l - Clinical Training Conferences for

Health Professionals - Medical

Association of Georgia

Requested

Fourth Project Year

$60,000

Priority: Critical

This project is designed to provide continuing education conferences
for physicians, nurses and allied health personnel of the Region so
they might acquire new skills in clinical medicare and patient care.
It is intended that those people trained will then serve as resource
consultants when they return to their own environment.
be given at either of the two medical schools in the state, profes-
sional schools, teaching hospitals or other suitable institutions.
The budget request is for tuition of 30 physicians based on $1,000 for
each 10-day conference and for 60 nurses or other allied health per-
sonnel, $500 for each 10-day conference.

Training will

Progress:
01 - $47,795; 02 - $106,985; 03 (Current) - $41,000.

This project was previously supported for 3 years at:
                         During the

Georgia RMP

0

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RM 46-04 8/71

current year, 88 clinical days were spent by physicians from the Region
at medical schools.  The Medical College of Georgia devoted much of  its
time reorganizing so the department of continuing education could become
more directly related and responsive to these special needs.
clinical participation at Emory was apportioned as follows:
69 days; Pediatrics, 11 days; and Surgery, 8 days.

The

Medicine,

Fifth Year - $60,000 Sixth Year - $60,000

Project #3 - Visiting Consultants Program for

Community Hospitals - Medical

Association of Georgia

Reaues ted

Project Year

$30,500

Priority: Crucial

This project provides a flexible mechanism to provide rapid technical
consultation and education programs to many and varied requests for
such activities arising in the Region,  Support is requested for 50
visits from each of the 2 medical schools, 50 visits from M.D.'s in
private practice and 30 visits from nondoctorial level consultants.

Progress:  This project has been supported for the past 3 years at:
01 - $16,800; 02 - $24,500; 03 (Current) - $21,000. During the first
2 years more than 125 visits were made to 36 community hospitals.
During the current year 27 hospitals requested and received visits
from a total of 84 consultants. Consultant contacts were made with
1,546 M.D.'s, 168 dentists, 474 R.N.'s and 531 allied health personnel.
Topics ranged over a wide spectrum.

e

Fifth year - $30,500

Sixth Year - $30,500

Project #6 - Communications Network - Medical

Association of Georgia

Requested

Foirth Project Year

$161,200

Priority: Crucial

This project proposes the production of 80 one-inch videotapes by
Emory University and 12 such tapes by the Medical College of Georgia
in each of the next 3 years.
60 hospitals equipped with video tape recorders.
will also be broadcasts by Emory to medical institutions in Metro
Atlanta are via the 2500 Megahertiz/AM system.

These tapes will be made available to
            Most of the tapes

Progress:
01 - $616,662; 02 - $355,882; 03 (Current) - $148,561. At the end
of its 02 operational year it was reviewed by RMPS Staff and was site
visited by a technical review group.
the project be phased out during the 03 year and the Region submitted
revised reduced budgets designed to carry out the recommendation.

This project was previously supported for 3 years at:

Both review groups recommended

0

Georgia RMP

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RM 46-04 8/71

Since September 1968 Emory University produced and broadcast 900 hours
(1100 programs) of programming time on the Metro Network and 28 additional
one-hour programs (over public television) throughout the Region. On
12/7/70 Statewide broadcasts were discontinued in favor of a tape-lending
library .

I

Fifth Year - $161,200 Sixth Year - $161,200

Project 1/20 - Area Facilities for Continuing

Education - Medical Association
of Georgia

Requested

Third Project Year

$267,700

Priority: Crucial

This project proposes supporting two levels of continuing education
area facilities.
school.  Faculty assistance is given by the medical school to the
hospital in developing the usual medical divisions of hospital
services and in securing and training chief-of-service to monitor
these services and to coordinate continuing education. The second
level is the area facility located in a hospital which relates to
smaller hospitals in the area.

The first is the hospital affiliated with a medical

Progress:
01 - $95,900; 02 (Current) - $68,110.

This project was previously supported for two years at:

Five first level area facilities have been established and educational
programs have been initiated:
Athens General Hospital, Athens; Macon Hospital, Macon; Memorial
Medical Center, Savannah; Pineview General Hospital, Valdosta.

Columbus Medical Center, Columbus;

In its 3rd year it is incorporating in its Project 15 - Affiliation

for Teachinb - Columbus Medical Center which was previously supported
for 3 years:

01 - $42,691; 02 - $42,843; 03 (current) - $28,000.

Fourth Year - $267,700

Fifth Year - $267,700

Project l/22 - Physiology for Nursing Instructors

Requested
Third Project Year

and Practitioners - Emory University

$30,970

Priority: Very Important

This project provides six three-week courses, two per year for three
years, to update and expand knowledge of nursing instructors and
clinicalpractitioners, with priority given to instructors.  The
cardiovascular physiology training courses will be concluded during
1971 at which time the program will be extended into neurophysiology.

Georgia RMP

0

-21-

RM 46-04 8/71

Progress:
01 - $26,116; 02 (Current) - $14,084. In the last year, instruction
in cardio vascular physiology was provided to 26 nursing instructors
at Emory University.  In one group of 10 instructors it was found that

to the full group of participants,  this would mean about 1,580 students
would benefit from the project each year.

This project was previously supported for two years at:

I

each instructor taught an average of 58 students per year.  Extrapolated

Fourth Year - $25,873

Fifth Year - $25,873

Project #45 - Continuing Education Program in

Requested
Fir s t Pro3 e c t Year

Nursing - Medical College of

Georgia $33,575

Priority: Important

The School of Nursing proposes, with additional instructors supported
by RMP funds, to take unspecified courses into geographically distributed
smaller communities across the state. This is intended to bring high
caliber continuing education to nurses remote from larger medical
centers and teaching hospitals.  The courses will have basic care
caatent as well as clinical application and orientation.
be given to nursing personnel at the area facilities.
tion of GRMP support the Medical College will extend the program.

Priority will

At the terrnina-

Second Year - $33,575

Third Year - $33,575

e

Project #47 - Strengthening the Role of

Consultant Dietitians - Emory

University

Requested
First Project Year
   $30,936

Priority:- Important

This project proposes supporting a 5-day short course for dietitians
of smaller hospitals, at Emory University, each year of the project.
Each course would be followed by 2 visits to participants during the
succeeding 6-month period.  Participants would then return to campus
for a 2-day evaluation and summary session.
the participants will serve as consultants to the smaller hospitals
providing similar services to those provided by GRMP area facilities.
Priority will be given to the dietitians or nutritionists from hos-
pitals who have GRMP area facilities in CV, cancer, stroke, kidney and
pulmonary diseases.

After the training program

Second Year - $40,172

Third Year - $41,074

Project #46 -

Learning Resources Services -
Medical Association of Georgia

Requested
First Project Year
   $42,060

Georgia RMP

-22-

RM 46-04 8/71

Priority: Important

This regionwide activity proposes to increase the effectiveness and
outreach of education efforts through a centralized learning resources
service designed to provide stimulation, education, training,
consultation, production assistance and coordination of regional
resources and the application of education technology , audiovisual
media, and programed instructional materials. This project has been
planned to meet many requests for assistance that are coming to GRMP
and to encourage the use of practical media applications to learning
problems.
activities, increasing yearly until the project becomes self-supporting
at the end of five years.

A fee-for-service mechanism will be developed for all

Second Year - $64,850 Third Year - $53,360

Project #49 - Health Career Counseling to

Requested
First Project Year

Disadvantaged Students - Medical
Association of Georgia $23,917

Priority - Very Important

This project proposes to utilize high school counselors to encourage
disadvantaged high school students with potential to enter the health
career field. As this is a pilot study a select number of counselors
and students will participate.  Ten counselors will each select ten
students who possess the potential to become a health professional.
Through the counselors and project coordinator the students will be
exposed to a broad view of the health field and professionals.
is requested for a project director, payment of counselors for extra
time, and workshop expenses.
such efforts in the future if the project proves successful.

Support

It is expected that hospitals will support

Second Year - $20,168

Project 1/48 - Shared Allied Health Program -

GRMP

Requested
First Pro-iect Year

$68 , 100

Priority: Very Important

This project is the outgrowth and expansion of a feasibility study
supported by GRMP which initiated a program of shared physical thera-
pist activity in N.E. Georgia.  GRMP proposes that services be expanded
to include nurse anesthetists, clinical nurse specialists, pharmacists,
inhalation therapists, social workers, occupational therapists, speech
therapists and radiation physicists.
allied health professionals will become self-supporting within 12 months,
however, until they do a percentage of the net income will be returned
to GRMP.

It is anticipated many of  the

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Second year $68,100 Third Year - $68,100

Georgia RMP

-23-

RM 46-04 8/71

0

C

e

e

Project f50 - Physician Assistant Development

Program - Medical Association
of Georgia

Requested

First Project Year

$228,147

Priority: Very Important

This project is an expansion of Project 1/15 - Medical Specialist
Assistant and, as such, contains 3 component programs. Emory University
will continue its Medical Specialty Assistants Program or an additional
3 years.
initiated new developmental programs to train physicians assistants.
The Medical College proposes a one-year feasibility study prerequisite
to an operation program.  Georgia State anticipates an enrollment of
30 students during the first year and 30 during the second year. Emory-
Grady anticipates an enrollment of 20 students during the 2-year period.
GRMP support will be used by the institutions to pay faculty, supplies
and stipends.
mobility for the graduate.

Progress:  A forerunner to this project is the training of Medical
Specialty Assistants Program at Grady Memorial Hospital (Project ,115).
This activity was initiated to create a new type of individual who
would be trained in the delivery of specialized treatment techniques
to patients with myocardial infarction.
who have graduated or are in training during this reporting period
is 19.

The Medical College of Georgia and Georgia State University have

The programs will provide college credit offering career

The total number of students

Second Year - $303,350

Third Year - $194,461

IV Facilities and Services Element

Project 638 - Emergency Care for South Georgia

and North Florida - Pineview General
Haspi t a1

Requested
First Project Year

$336,460

Priority: Crucial

This project proposes an emergency service network which designates
two county hospitals as central emergency facilities, manned around-
the-clock ER physicians, equipped with intensive care ambulances for
transporting critically ill patients and backed by full hospital  ser-
vices and specialists.
dispatch of ambulances and to facilitate consultation with ambulance
attendance and with hospitals that do not have around-the-clock physicians.
The project will support salaries of ER physicians and intensive care

A communication network will provide controlled

ambulance attendants in the central facilities.  Ambulances
cations equipment will be procured under the Highway Safety

  Second Year - $294,800 Third Year

and cornmi-
Act.

- $147,400

Georgia RMP -24- RM 46-04 8/71

Project #39 - A Health Mainteaance System for

Stephens County -* Stephens County
Hospital

F!!ques ted

First Project Year

$107 , 290

3

Priority: Crucial

The Stephens County Hospital and a large physician multispecialty
group are prepared to undertake a project to improve health delivery
through a health mainetenance center, to be located in a vacant wing
of the old Hill Barton Hospital, in Toccoa. It will provide the
mechanism to determine the health profile of the community and to
treat detected abnormalities.
during the first two years to insure establishment of the medical
profile and to create interest in yearly health maintenance examina-
tions. Test results will be forwarded to family physicians or to an
assigned physician for those who do not have a physician.
will call in patients who require treatment regardless of ability to
Pay o

There will be no fee charged for testing

Physicians

Second Year - $138,560

Third Year - $16,320

Project #41 - Detection and Elimination of

Ezectrical Hazards - Emory
University

Requested

1 --\.

~-

First Project Year _.

,. -

~ .-

$7,290

Priority: Very Important

This project will support salaries to develop and conduct training
programs in electrical hazards for representatives of hospital staffs
throughout Georgia.  User personnel and those maintaining equipment
will learn how to detect hazards,  correct them and to verify the
reliability of equipment.
reliability of equipment has on the frequency of accidents due to
electrical malfunctions.

A determination will be made on what impact

Second Year - $4,140

Third Year - $4,140

Project #42 - Statewide High Risk Maternal

Infant Services - Medical
Association of Georgia

Priority : Impor tant

Reque s t e d
First Project Year

$63,040

This project is the first phase of a plan to develop a network of
intensive, intermediate and primary care centers for care of high
risk mothers,and critically ill infants.  This project is requesting
support for twoyears,the time requested to develop the plans for a
statewide system.
will be accomplished by follow-on projects.
project planning personnel and training of health professionals at
Emory and the Medical College in the care of critically ill infants
and how to operate within the system.

Implementation of the plan into a statewide system
               The project will support

' ..IJ

Georgia RMP

-25-

Project #43 - Patient and Family Education -

e

Medical Association of Georgia

RM 46-04 8/71

Re que s t e d
First Project Year

$85 ,000

Priority: Very Important

This project will support demonstrations of a patient and family educa-
tion system in various settings (rural and urban; hospital and public
health agency basid health education coordinators, etc), salaries for
education coordinators, education expenses, and cost of teaching mater-
ials will be supported by GRMP.
for developing procedures for communication of all health professional
input to the patients'education,  Development of educational programs
designed to effectively communicate information to patients will con-
stitute the project output.

Coordinators will be responsible

Second Year - $85,000

Third Year - $85,000

Project f44 - Computerized Dietary Service System -

Requested

Georgia Hospitals Computer Group First Project Year

$87,7ao

Priority : Import ant

This project will demonstrate in a two-year period the feasibility and
cost effectiveness of a shared, automated menu-planning service with
remote access for hospitals that cannot support their own computer.
Existing dietary and nutrient computer programs will be combined with
hospital dietary profiles into an integrated data-base to produce menu-
planning, special diet, inventory control, and food purchase services
that is tailored to the local situation at each hospital. If the system
proves to be cost effective, the Hospitals Computer Group,  Inc. will
6ffer the service to the other hospitals on a fee for service basis.

Second Year - $94,072

V Respiratory Element

Project #37 - Area Facilities for Respiratory

Diseases - Medical Association
of Georgia

Priority: Crucial

Requested

First Project Year
  $75,940

The Task Force on Chronic Respiratory Diseases  recommended area
facilities as the most feasible approach to increase and expand
respiratory services.
will be given to community hospitals where some respiratory services
are already offered and who have qualified personnel to direct  the
facility.  Service components in each area facility will include:
1) continuing education, 2) serving as a planning center for case

Five locations will be selected and priority

Georgia RMP

-26-

RM 46-04 8/71

funding and prevention, 3) providing special diagnostic services,
4) laboratory facilities, 5) coordinating home health services for
respiratory disease patients, 6) serving as out-patient referral centers
and 7) serving as acute care in-patient centers.

Second Year: $155,634 Third Year: $199,687

Project #14 - .Regional Pediatric Respiratory Center -
        Medical College of Georgia

Requested

Priority: Very Important

Fourth Project Year

$86,250

This project proposes to continue defining the health needs for
respiratory diseases in children and young adults and will provide
and further develop health care services and training opportunities
relating to Chronic Respiratory Diseases in the state.  The project
will support the development of a "2-platoon system:"
allow the addition of a "circuit riding team" to rotate through
selected hospitals.
examine selected patients and present case conferences, demonstrating
techniques, teaching exemplary care, and expanding the awareness of
upgrading the knowledge concerning Chronic Respiratory Diseases.

This will

This team will consult with local physicians,

Progress:  This project has been supported the last 3 years at:
01 - $143,980; 02 - $170,810; 03 (Current) - $114,098. The program
at the Medical College is one of several specifically developed
centers developed nationally and one of the few with primary emphasis
on out-of-hospital patients.  During the eight-month period ending
2/28/71, 552 patients from 73 counties were seen--a total of 2,432
out-patient visits. Direct physician involvement totalled 130. Ninety-two
physicians were involved in 5 meetings and workshops.
program for nurses was initiated.

A clinical training

Fifth Year - $84,250

Sixth Year - $84,250

Vi' Stroke, Hypertension, Renal Element

Project #32 - Stroke Area Facilities - Medical

Association of Georgia

Priority: Crucial

Reques ted
Second Project Year

$126,850

A total of nine additional area facilities for stroke are planned for
the Region.
to the surrounding community hospitals through a cooperative management
to be established by the base hospital and participating smaller hospitals
within the medical trade area.

The overall goal of the project is to provide services

Service components that will be developed

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-27-

RM 46-04 8/71

e

L

4

Georgia RMP

include:
other radiologic services, 3) provision of special diagnostic consultation
services, 4) serving as coordinating centers for home health services,
5) serving as planning centers for case finding and prevention programs,
6) offering laboratory facilities, and 7) serving as
centers for indigent patients. Fees will be charged for services so the
facilities can become self-supporting after an initial support period.
Progress:
to begin 1/1/71.

1) continuing education, 2) provision of angiographic and

outpatient referral

The allocation of funds to support one facility was approved

There is no progress to report.

'Yhird Year - $206,045

Fourth Year - $257,345

Project #36 - A Ktdney Disease Program for Geornla -

Medical Association of Georgia

Requested

First Project Year

$211,588

Priority: Critical

This project is divided into three components.
incorporates existing projects 623 and 824 to retain the highly
sophisticated teaching capabilities at the two regional centers at the
medical schools.
and transplantation to selected medical students and M.D.'s as well
as to their supporting staff. The second component is for development
diagnosis and treatment of patients with kidney disease.
be definitive diagnosis and follow-up , patient education, continuing
education for community M.D.'s and nursing personnel, and prevention
and screening programs. The third component is a demonstration of.
computer assistance with diagnosis and management of electolyte and
acid base imbalances.

The first component

These centers offer taining in nephrology, urology,

Area Facilities for Kidney Disease throughout the state for specialized

Services would

Second Year - $301,523

Third Year - $396,426

,

.. .- ..

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SdhiARY OF PROJIkTS CuRREKlzY 'BE&'
SUPPORTED IN THE 03 OPERATIONAL YEAR

- 28-

mom

-

PROJECTS

# Title

1 Short Term Training for Physicians - Emory University 41,000'

2 Ped. Card. & Hypertension Ren. Die. - Medical College

of Georgia C Emory University

20,000

3 Visitjng Consultant Program to Comm. Hosp. -Emory - MCGA 21,000

. 4 . Inter-Library Copying Service - Emory - UCGA 1,850

5 Columbus Medical Center Cont. Ed. & Med. Library

College of Medicine Center & Emory

28 , 000

6

,-8.

Comunications Network for the Region - Emory - XCGA
Improvement and Coordination of Facilities or

148,561

* -__

    Cardiovascular Diagnostic Services - Med. Assoc. of Ga. 12,600

10 Cardiopulmonary Resuscitation - Ga. Heart Association 72,702

118 Coronary Care Feasibility Study - Med. Assoc. of Ga. 10,000

13 Statewide Cancer Program - wd. Aasoc. of Ga. 234,095

14

Pediatric Chronic Pulmonary Disease Center

Uedical College of Georgia

114,098

15 Specialist Assistant Program - Grady Meuqrial Hosp. 44,297

18 Cora - Medical Association of Georgia 648,435

20 Area Facilities for Cont. Ed. - Med. Aasoc. of Ga. . 68,110

21 Coronary Care Training - Med. Assoc. of Ga.          52 , 145

22 Cardiovascular Physio. Med. Surg. Nursing

,.(

   Tag. - Ga. State University 14,084

23 Renal Failure - Medical College of Georgia 29,364

24 Hypertension & Nephrology Program - Emory Univ. 36,422

27

84,000 ~

Community High Blood Pressure in Atlanta -

Georgia Department of Health

' 28 Statewide Stroke - Ued. hsoc. of Georgia 14,075

29 *

Chronic Pulmonary Disease - Athens' General Hospital '

8,805

30

Area Cancer Facilities - Augusta Rad. Therapy Center

5 # 735

31 Cardio. Area Facilities - Atlanta Med. Ctr. Columbue 59,984

32 Stroke Area Facility - Kennestone Hosrital,Chandler 10,500

General Has. itel & University Hospital

TOTAL

1,779,862

-29-

DEPARTMENT OF HFALTH. EDucATioN. Arm WELFARE
              PUULlC I.lLIACTH SCRVICC
HEALTH SERVICCS AND MIZtJTAL HEALTH AOMlNlSTHAf ION

Do&: Hay 25, 1971

e

Rtph to
At& qf:

SuGcct: Regional Medical Program for Consideration During the August

Staff Review of the Triennium Application Submitted by Georgia

1971 Review Cycle

,..._

To:

Regional .Medical Programs Service

Request:

requesting the following consolidated budgets (direct costs).

Georgia RMP which is currently in its 03 operational year
(9/1/71-8/31/71) has subnij tted a Triennium Application

Total

-__I

06 Year

--

04 Year 05 Yeas

II_-

Core        $653,4z    $686,095    $720,402   $2,059,922
Projects (26)    3,058,618    3 ,4 5 8,9 3 9    3,011,257    9,523,784
Deve I.opinenta1   ---d- 377 986   --L-- 177 986   --- __ 177,986     533,958

Total $3,890,029 $4,317,990 $3,909,645 $12,117,664

---

Georgia's initial award for the current year was $725,828 (d.c.) for
Core and $1,296,743 (d.c.) or 23 projects, totaling $2,022,571. As
G rcstLlt of recent iniposed cuts on all Regions, Georgia RMY support
has been reduced to $648,435 for core and $1,131,427 for projects,
totaling $1,779,862.

Review: In view of the fact GRMP is scheduled for a site visit in

the application should be considered in relation to the total

June, the Reviewers agreed the continuation component of

program and no recommendation regarding support would
at this time.

The Reviewers felt a more appropriate course would be
make observations for the site visitors regarding the
as it is presented in the application. Following are
questions and concerns raised by this review.

be appropriate

for them to
Georgia Program
observations,

- Goals and Objectives: The "specific objectives" are consistent with
             RIQS trc?nds,in fact, they appear to read like

direct excerpis from current HEW literature. \*!hi le each objective
is somewhat specific in itself, when taken collectively thcty
represent a very broad and all inclusive program. This Is particularly
true when considering the Region has given them no priority ranking,
nor has it identified sonie for special emphasis. In addition none
are stated in measurable terms or related to tirnrt-frames for accomplishment.
The linkage between the objcctivcs and the ongoinp, and new projects is
not clear. It fs iriiplicd that the various Task Forces arc' rcsponsiblc for

. :.

..

..

;%

Georgia RMP -30- . *'

dcvcloping the objectives, however no specifics are provided on the
process involved.
process, how needs are assessed, and what resources are used in
this assessment.

The visitors will want to learn more about this

Core Staff: Core Staff which consists of 27 professionals and 12

      secretarial types appears to be logically organized
for the program as it currently exists. However,'it is difficult
to understand the need or the large six-member continuing education
staff, particularly in view of what appears to be reduced emphasis
on continuing education as indicated by the objectives and the
new projects.

~

While part-time positions at Emory and the Medical College are
"to coofdinate and supervise BP activities at the universities",
it would be interesting to learn specifically what these people are
involved in and whether in fact they are justified.
number of discrcpencies within the application- that should be clarified:

There are a

1, It is stated that all Core Staff arc full time yet three

positions arc s~.rowii ai' less than 100%.

2. One person (Hallman) shown at Emory Unj.versi.ty on the

Organization chart does not appear on Core Personnel
Forms (as).

3. There are position discrepencies between the Organizational
  Chart and Core Personnel Form (#6) on the positions of
  Drury, Ross, Willcins and Usher.

4. In addition the organization chart omits an accountant

(Wilson) and a sixth person in Continuing Education (Brown).

Regional Advisory Groue: The RAG which consists of 65 members appears

            for the most part to have representation'
of key resources and interests in the Region, and is equally balanced
gcogrnphically.
32.  It appears the RAG might: be strcngt1;ened by including sonic
.reprt>sentation of the CHI? "B" Agencies, the Appalachia Program and the
66 practicing osteopaths of  the state.  It worild be interesting
to learn how active the bl.ack representatives on the RAG are and
of their impressions of GWY. Like most RAGS of this size, it does
not appear to be particularly strong, but rather out of necessity
it relies heavily on Steering Committee,  the Task Forccs and Core.
It is difficult to determine to what degree it exerts policy control.
Attendance at the tri-annual meetings, which was 37%, 522, and 61%
last year, is about average for a RAG of this size, However, it
would be interesting to learn what constitutes a quorum.

Physician influence is strong with a contingency of

Conimittees: The committee structure consisting of a Steering Committee

      (Executive Committee) , six major Task Forcc Comrnittecs ,
and various Ad Doc Coniini ttms appears well. taiJ.oret1 for the current
Georgia Prograiii. 11owcvcr, Given the objectives as stated, whI ch
appears to de-emphasize categorical diseases , it would be intercs ting

Georgia RMP -31-

to learn how the four disease oriented committees will relate, and/or
if the Region envisions any need for committee alteration in the future.

e

-.. Subrtgi onalization:  GRMP has established Local Advisory Groups

            in 140 hospitals throughout the Region, whose
function it is to: advise GRMP in local problems, assist in planning
and devcloping a local program, provide communication between GRMP
and the community, and coordinate local activities in accord

subregionalization is impressive, in practical application it
appears it might be quite cumbersome.
on the 233 meetings held by 88 of the LAGS it would be interesting
to learn what of significance has resulted, It is difficult to
see how this form of subregionalization encourages cooperative
planning and activities between the LAGs, when asside from annual
meeting of LAGS sponsored by GfiP, there is no indication that the
individual Groups meet or exchange ideas. Also it might bc
noted, the LAGs in inus t ins tanccs are over-whel-mj ngl y hospital-
oriented, in that, they consist of a physician, a tiospital. adminis-
trator, a nurse, and ii riicnibcr of the public,

Project Dcvelpment and Revisx:  'i'hcre appc!ors t.o be no Staff effort

                    to stimulate projects related to
specific objectives, rather project ideas appear to be spontaneously
generated. However, once an idea is presented, Staff does give
extensive advice and assistance in the development of a project,
even to the point of writing it up. There appears to be a well
organized and thorough review process designed to take less than
120 days, which involves Core, the Task Forces and the RAG.

I with the task force reports. While in theory such elaborate

In the absence of information

e

Guidelines have been developed for the RAG to assign priority
placement of Crucial, Very Important or Important to each approved
project.
numberd program objectives to which it will make a contribution.
While this may be a valid mechanism for project ranking it probably
in many instances encourages potential project directors to develop
broad all inclusive proposals which,in fact, may not be desirable
or appropriate,  Might it not be more valid to give some priority
ranking to program objectives and then det(armirie the importance of
projectsbased on its contribution to meeting the more important
objectives?  The priority ranking of program objectives would also
provide more positive and identifiable program direction.

A project is given priority placement primarily on the

It would be interesting to learn how many.proposals havc been
submitted to GRMP by applicants, how many were rejected, and at
what stages of the review process were the rejections made. How
many were appealed?

..

Georgia RMP

-32-

Evaluation: It is difficult to make any assessment of the effectiveness

      of the project evaluation process based OR the brief
information provided on this subject, and OR the project progress
reports.
this area, this aspect of the program whould receive considerable
attention by the site visitors.
the precentage of ongoing projects which are periodically evaluated,
the frequeiicy of evaluation, by whom is the evaluation done and once
completed how is the evaluation used, including examples of project
changes due to such eval-uations.

However, in view of the Region's history of weaknesses in

Clarification needs to be made of

.

Program evaluation is conducted by measuring the extent of which
activities contribute to overall program objectives. While this
is the logical approach; it is difficult to see that it is
effective in that the objectives as stated are open-ended and
provide no frame of reference.
specifically the roles of Core Staff,  the Task Forces and the RAG
in the program evaluation process.

Projects: Although all of the projects representing the Georgia

objectives, it is difficult to see how those other than the area
facilities relate to, and compliment, each other toward achieving
a specific goal.  Many projects appear randomly designed to serve
some isolated need.

It would be of interest to learn

program in some way related to one or more program

While it is understandable that the Region has generated a certain
amount of momentum in certain program areas, and it probably cannot
make any sudden shifts at this time, it would be of interest to
learn why a large number of ongoing projects will need support
beyond the council-approved period of support.

Keeping in mind the Region's authority for choosing projects it
cares to support and establishing project priority ranking,  the visitors
will want to learn how the Region justifies the large request for
support beyond the Council approved period for one project in
pa.rticular, #6 - Communications Netwog.
for three years at $585,829, $355,882 and $148,561. At the end of
its second year of operation a technical site visit team visited
the project and determined the project did not justify continued
support.  In accord with this determination the Region submitted
phase-out budgets.  This project could also serve as a case-study
to determine how the Region: assesses needs; plans for continued
support; establishes priorities for projects ; conducts project evaluation
and coordinates related projects and activities.

'his project has been funded

l'hc Area Facility Concept is designed to provide centers of excellence
in categorical diseases throughout the Region, however,  the number
and location of these facilities is not clearly specified nor is
it clear how those facilities which have continuing education components
will relate to the facilities for continuing education. Since the
area facility aspect represents a significant part of the program,
Region should be asked to elaborate on it, at the time of the site visit.

the

\

Georgia RI@

Public Health Advisor
Grants Review Branch

Minority Involvement: Of the 27.6 (FTE) prof&ssionals on Cd&*3taff,

two are black and of the 13.5 (PTE) secretarial

o

staff two are black.

Of the 70.33 (FTE) Professional on Project Staff 10.50 are black
and of the 38(FTE) secretarial staff 3 are black.

Of the 65-members of the RAG 6 are black.

Of the 744 members on other planning groups and committees 22 are
black.

There are no Indians, Orientals or persons with Spanish surnames
represented in GHIP in any way.

Based on these observations and the fact that approximately one
quarter of the Regions population is black thg site visitors will
want to learn to what degree the GRMP is attempting to involve
more blacks as voluntary participants in committees, etc.,  and if
there is any plan to hire more blacks on Core Staff or to encourage
their employment as project staff.

-

RMPS Staff participants were:

Veronica Conley, Ph.D. - Allied Health Section
Lyman Van Nostrand - Program Planning and Evaluation
Glinter Johnson - Office of Systems Management
Prank Nash - Regional Development Branch

* Larry Pullen - Grants Management Branch
William Reist - Grants Review Branch

GRB /RMPS

5/27/71

(A Pliivileged Communication)

SUMMARY OF REVIEW AND CONCLUSION OF
  JULY 1971 REVIEW COMMITTEE

GEORGIA REGIONAL MEDICAL PROGRAM

RM 00046-04 8/71

FOR CONSIDERATION BY AUGUST 1971 ADVISORY COUNCIL

Committee recommended that the Region be awarded
$2.8 million (direct costs) for each of three

years, including developmental funding.

DIRECT COSTS ONLY

              REQUEST RECOMMENDED

         $ 683,430 $ 717,602 $ 753,481 $ 683,430

Developmental 177,986 177,986 177,986 177,986

3,316,381 3,453,909 3,011,257 1,938,584 21

3,920,034 $4,349,497 $3,942,724 $2,800,000

roject #49 - Health Careers Counseling - is precluded

cy which prohjlbits fundings of direct operational

Health Careers Recruitment projects.

owever, that Council give special consideration to see
some way in which Project 1\49 might be funded without
olicy.  There is a desperate need in Georgia for all
alth professionals.  Further , there is an urgent need

The Committee

bring members of disadvantaged populations into health

careers fieldr.)

Project 839 - Health Maintenance Program for Stephens

County - is precluded by RNPS policy which prohibits funding of
new multiphasi
those current1 being supported through RMPS. Since Committee

health testing projects pendfng evaluation of

at the project was basically designed to conduct

ic screening, a detailed examination of the proposal by

a multiphasic health testing proposal.)

requested.

Staff has concluded that the project is,

e Review Cormnittee member who chaired the June 1971 site
sit presented the findings and recommendations of the

on, another site visitor  was present to reinforce the
ong program, with exceptional management and organizational

ips.  The team reported that cooperative relationships

medical schools can to a large degree be credited to

The Conanittee shared the team's conclusion that

tanding leadership, involved and committed state and

GEORGIA RMP

- 2-

RM 00046-04 8/71

GRMP efforts. The relationships with other Federal programs (CNP,
Model Cities, Appalachia and OE0)-, however, consist primarily of
cross-representation on advisory groups and cross-review of appli-
cations.
staff resources to help these agencies develop their health program.

The Committee believes that Georgia should extend its

h

1

The Committee questioned the representation of Blacks on tbr. RAG.
The visitors reported that the Black physicians on the RAG are
deeply involved and highly supportive of the program.  They also
reported that the few Black staff members were the result of low
turnover of staff and lack of additional positions; the Region is
prepared to employ more Blacks as funds permit.

The visitors reported that the six-man Steering Committee,  the locus
of real work, included only physicians. The Committee felt the
Region should take steps necessary to broaden the representation on
this group.

The Committee's primary concern related to three areas: 1) the lack of
phase-out of projects; 2)the lack of program development to serve the
health needs of the ghetto population, particularly in Atlanta; and 3)
the high costs of new project proposals.

In answer to the first concern, the visitors explained that the Region
has phased-out some projects; in fact, the CPR project is now entirely
supported by other funding.  Furthermore, while it may seem that an
area facility project is being renewed, it is in actuality changing
either its function or its locus.  The visitors empathized with Committee
members whs only had the application to guide them, but explained that
the on-slte presentations and discussions had clarified the area facility
program pla~ v3ich is the foundation upon which the whole program is built.
The visitors cited evidence of changes resulting from the support of  the
Columbus ai-sa facility which have far reaching impact on health care:
24 new physicians have moved into the community,  5 new clinics have been
opened, which by the GRX? contract clause have to be open to all patients.
This facility is no longer supported by RMP; the project is still proposed,
but for another area of the State.

With respect to the secmdconcern, the visitors also explained that the
developmental fund plans were primarily directed toward the health
problems of the poor; one example is the store-front facilities to be
developed.  The Committee, however, felt the Region should exert more
effort in this direction.

The visitors were unable to provide information to the Committee's
satisfsction concerning the reason for the high costs of new proposals
such as emergency health care.
that the team had recomznded funding at a reduced level.

The visitors did, however, point out

'\,eq

!

GEORGIA

RMP

-3- RM 00046-04 8/71

1.

2.

3.

4.

FUNDING RECOMMENDATION: Committee concurred with the site visitors'

funding recommendation.

The rationale for this reduced level is not based on any serious
deficiencies of the Georgia program or the technical review of projects.
Rather it is based on the exclusion of, or only giving partial support
to, projects which:

were thought to have little or no relationship to the
overall program;

are not likely to have viable independent support in the

future;

could be incorporated with another project;

would be more appropriately funded from other sources of support.

The Committee concurred with the conclusion of the Ad Hoc Panel on Renal
Disease that Project 1/36 - A Kidney Disease Program for Georgia - did not
merit support.

In view of the sophistication of end-stage kidney activities

n the Georgia Region, the proposal is disappointing. The
as considered extravagant, and seemed to ''share the pie" and

transplantation program.  It appeared that existing dialysis
e capable of meeting the Region's needs if they are
ith a functioning transplantation program.
oca1 funding efforts are reflected in the request for physician

icate facilities rather than seek to organize a cohesive, efficient

Inadequate or

y element is lacking in the failure to demonstrate deeply
a1 interest, particularly in view of the organs which
en procured.  The Region's capability to mov

at this time was 'seriously questioned in vi
e of the physician and head nurse whq heretofore,  have

provided the central momentum to these activities.

se Control Program provided grant support for 1966 - 1969
the dialysis unit at Grady Memorial Hospital to be established
e Program has funded a cadaver organ procurement project,

and final year, negotiated in June at $32,000,
received funds from the Southeast organ procurement

This

ed at Richmond, Virginia.
ow to have established a well-functioning transplantation
h could have reduced, if not eliminated, the Region's backlog
patients.
viewed as without merit, and the Area Facilities were termed

There seems to have been sufficient

The computer-aided diagnosis and consultative

curred with the site visit team's recommendation, including
opmental funding. Staff was asked to make certain that

erns as well as the site visitors' concerns be conveyed to

RMPS/GRB

--

,1: 'I

--I-_- BACiCGROUND: --I_ Ge0rE;J.a RIQ is curr'qntly in its 03 operat$onaS year

      (9/70--8/71) and fun,ded,!ar $1,779,862.  ,It has
submitted a Triennium appl icatiofi requesting support fo~ three
years at 04--$3,920,034; 05-$4,349,497 and 06-$3,942,724.
Each year includes a request of $177,986 for Developmental Component,
1__---.__ GEENERAL 1FP'RESSI:ONS --I-__- : It vas tile general $mpTession of the site visitors

,e:

that Georgia is a +strong viable Region;

  e some aspects of the program appedr weak and in need of
strengthening, they are riot, for the iuost part, of a significant
nature and in most instances corrective nieasures are being planricd
or employed,
probI.erns and resources within the region and a specific plan in
the "area facility concept" to ernp3.oy some of the resouxces in
resuJ.vinZ seine of the problems.

The visitors 17eic highly i~iip~cs~ed with the lnaiiagenicint and organizatlonal

strengths of Ehc Reg Lon am1 the outstandin;: lccdership provided by
  i~cctor and Key members of Core Staff. The involvement and
  trucnt of state anGI locel rc1sou~ces is very strong and the
  rs?tive rclatioashjp betwee:i the two iriedical school s , which
  large degree "cn be credited to G!UP r-ias considered somewhat

iiamenal. The visitors were disappointed to learn that while
ooperative" relationslips have been establ%shed with other variouc
deral programs (CHP, Model. Cities Appalachi a and QEO) these
la tionships consist of Little more than cross-representation on I
visory groups axid cross-revietj of appli.cs*zions. It WES felt that

GP?4l' does appear to have a good concept of the#

I

r

given the strong leadership and management qualities  of GRPP it
should feel an obligati.oii to extend itself and lend assistance to
these other a.gencies in the development of their health programs.

ilc the visttors initially had some reservations about the
mposition of the RIiG, they were pleased to learn that black

                            are deeply involved
d are highly supportive of the program. In addition the liegrion has
ans to include representatives of other federal programs on its

physicians, who represent the black communities

was not clear to the visitors the extent of the participation of
individual members of the PdG in 'the decision.-niaking process
cxample, in the esr-ablishinent of priorities 01- the i-ev-ler~ of
ects.  It appeared that niuch of the decisi.on-n>uklng occurred

the Steering Corriniittc.e 1-cvel and al.though the RAG had a11 opportunity
discuss or disagree with dacisions reached by the Steer-ing Conimittee,
fact, this did not often OCCIIT. The visjtcrs expressed concern over

e size of the six--riian Steering Cornmitt(:<?, and the fact that only .on
c occasion has a non-physi c,iari ever sei-vecl on tli-is hody .

Georgia Quick Repc,-c t

.! .

Whil e the visitors were 2avorzbly kriip1-essed wi~h thc rcgionalisation
conccpt 6s it is being dcvelqed thLoiigki aiea facii ities, which
are designed to provide educai-iun and improve pat-ieni: ,s&rvices,
they were disappointed theL Gl@1Pt has dciconstrated 1itifJ.e  concern for
the primary care problems of thc ghettos.
by the Kegioii's intentioii to sup1)ort , with devel.opmeilfd funds ,  the
medical schools efforts to develop sti.re-.front type facilities
for provision of siich services to tile poor.

The visitors retained scrioiis qucsti-ons $E to the extent and
worthiness of the evaluation aspect of ,the prograin. However, it was
observed that while the evaluation proc?'css pcr se may be weak at the
present time, a fairly stringent effordr is beiilg inade to lcecp
abreast of progress of individual projects I
has been acquired recently and up'on maminirig his credentials and
talkjng with hi;a the visitois were optirr4isti.c that an eifective
evczl rmtj on process TT i 11. evo 1 ve .

~hc visi.tors initi a: C~i~cer:L r&:,arcI i rig tlre ftiLictj c2ning of the ~oca.1
Advisory Groups was So: izt;lii. I conf! r-i,icd i.ii th; 1' soiiic rarely met or
fulIctiolied* 1:vcn :5<i3 thkj7 form oi sub-icgioiial--
j.zatlcm illdeed rii If: of .acti\7ily represcniatives of
locnl areas arid t h;<vc htm actf.vc, &:id specific
projccts have kcc: hy the concerns of these gro~ips. The
Region adlviittlcd to*l'lot stimulati.ng act,ivity aL the LAG level at this
time when funding possibilities are j:wioi-e.

Ifowever, they were heartened

/'
/

A ncw evaluateon specialist

I

OW: _I byiilc the Region is rcquceting support for thrcc?

        years at 04- $3 , 9 2 0 034 ; 05- $4 ,34 9 4 9 7 ; 06- $3,94 2,7 2 4,
the site vjsitors recommend a reduced lc:vel of $3,1136,293 or each of
three years which incl-udes a Developmental ,Component of' $177 ,PIG for

e rationale for this seduced level -is not babed on any serious
fi ciencics of the Georgia progi-nm or the teclini cal revicw of any

projects.
giving partial support to, projects-which:

Rather it is based pririiari1.y on Lhe excl-usion of,oi- only

1.
2.
3.
4. Could Fa incorporated with another pi-ojcAci..
5.

Are inconsistent with pol icy.
Have little or no 1;elationslr':ip t.c thc ovcrall- program.
Are not 1fkely to have vjabJe ind,cq>e.ilclcnt- s*:ppnrL in the future.

Cominittee and Council are still deliberati.ng the role of KMPS.

A Privileged Communication

      SITE VISIT REPORT
GEORGIA REGTONAL MEDICAL PROGRAM
     June 23-24, 1971

Table of Contents

I. Site Visit Participants .................. 2

11. Introduction............................. 5

111. General Impressions ...................... 6

IV. Review Details........................... 9

V. Conclusion and Recommendations...........13

VI. Recapitulation In Terms of RMPS Mission 17

S tatemen t Review Cr i ter fa

Georgia RMP Site Visit

- 2-

RM 00046

I. Site Visit Participants

A. Site Visitors

(Chairman) Philip T. White, M.D. (National Review Committee)

1:

Associate Dean,Medical College of Wisconsin
Milwaukee Wisaonsin

John R. F. Ingall, M.D.
Program Director, Western New York RME'
State University of New York at Buffalo
Buffalo, New York

W. Lester Henry, Jr:, M.D.
Professor and Chairman of the Department of Medicine
Freedman's Hospital
North West Washington, D.C.

Jurij Savyckyj, M.D.
Intern, St. Johns Hospital
Yonkers, New York

B. Regional Medical Programs Service Staff

Veronica Conley, Ph.D.
Head, Allied Health Section
Continuing Education and Training Branch

Rhoda Abrams
Assistant Branch Chief
Planning and Evaluation

Frank Nash
Operations Officer
Regional Development Branch

,.

Ted Griffith
Regional Representative
Office of the Regional Health Director
DHEW Region I11

Carl Taylor
Assistant Budget Examiner
Office of Management & Budget

William Reist
Public Health Advisor
Grants Review Branch

R

Georgia Site Visit -3-

RM 00046

C. Review of the GRMP Organization and Res-ationships :

Louis L. Battey, M.D., RAG and Steering Committee
A. Jay Bollet, YL9 RAG and Steering Committee
Louis C. Brown, M.D., President Georgia State i.ledica1 Association
- Robert L. Brown, M.D., RAG and Steering Coinmitter'
Curtis H. Carter, M.D., Associate Dean, School 01 Itcdicine, Medical

-~- F. William Dowda, M.D., Chairman, RAG and Steering Lr mittee
J.B. Ellison, M.D., RAG and Steering Committee
Eugene J. Gillespie, M.D. , l)irector,"A" Agency and MC Y.c>mbcbr

I!ernard L. Hallman, X.2. , Regional Advisory Group and Steering Committee
Glenn M. Hogan, Executive Director and RAG Member, Georgia liospital

J. Willis Iiurst, M.D., RAG and Steering Committee

Boisfeuillet Jones, IUG Member representing Public Interest,

Jacquelyn E. Keese, Program Director, Georgia Heart Association,

James C.Metts, Jr., MA, Chairman, Candler General Hospital LAG,

Elton C. Osborne, Jr., M.D., Deputy Director, State of Georgia Department

Arthur P. Richardson, M.D., Dean, Emory University School of Medicine

Evelyn Rowe, M.N., RAG Member representing State League  for Nurses

Jack G. Whelchel, Health Advisory Council, Inc., Northwest Georgia

College of Georgia

Comprehensive Health Plannlng

Association

Consumer Groups

Voluntary Health Agencies

Savannah Local Advisory Groups

of Public Health, Official Health Agencies

Allied Health Professional Groups

R. Rexiey of GRMP Program:

- J. -C;i - I r _. -12i-k - - Barrow, M. D. , Director Georgia Regional Medical Program
Morris >I, Sradley, Director Division of Planning and Program Development
~-- Don J. Tiraiitcw, Program Assessment Coordinator, Georgia RMP
James J,
    Cbi~l~~ Director, Division of Administration and Coordinator

Facility and Service Section,Medical Association of Ga.

E. Increase AvaGabiLity and Efficiency of Health Manpower:

William E. Fackler, M.D.,(Chairman) Continuing Education and
Health Manpower Task Force
Raymond C. Bard, Ph.D., Vice President for Academic Affairs &
Acting Dean, School of Allied Health Sciences, Medical College of Ga.

Alda Ditchfield, H.S.N., -- M.A., Professor of Nursing, School of Nursing
Medical College of Georgia (in charge of Continuing Education
for Nurses)

Continuirig Education and Health Manpower Task Force

Area Facility, Athens

the Medical College of Georgia; Member, Continuing Education and

Health Manpower Task Force

Luther G. Fortson, Jr., M.U., (Private practice of medicine) Member,
Shelby J. Lacy, R.N. Nurse Coordinator, Continuing Education,

Glen E. Garisson, M.D., Coordinator for Continuing Education at

Georgia RMP Site Visit -4- RM 00046

Bernard L. Hallman, M.D., Associate Dean and Coordinator for

Stephen H. King, M.D., Director, Continuing Education Area Facility,

GRMP Programs, Emory University School of Medicine

Athens

!

F. Improvement of Quality of Medical Care:

John D. Watson, Jr,, M.D., Cancer Task Force
Charles R. Hatcher, M.D., Chairman, ,Cardiovascular Disease, Hypertension

Walter S. Dunbar, M.D., Chairman, Chronic Respiratory Diseases Task Force
Joseph A Wilber, M.D., Chairman, Stroke, Renal Disease Task Force
Frank P. Anderson, M.D., Pediatric Respiratory Disease Center
Gerald F. Fletcher, M.D., Director,Cardiovascular Area Facility,

James C. Metts, Jr., M.D., Director Stroke Area Facility,  Candler

Gladys names, R.N., Coordinator of Nurses Training Program in

Elbert P. Tuttle, Jr., M.D., Kidney Program

R.J. Weinzettle, Hospital Administrator, Memorial Medical Center,

and Diabetes Task Force

Georgia Baptist Hospital, Atlanta

General Hospital , Savannah

Coronary Care, John D. Archbold Memorial Hospital, Thomasville

Savannah

G. Improvement of the Availability and Accessibility of Primary
  and Preventive Medical Care:

Harold E. Smalley, Ph.D., Facilities and Services Task Force
Paul Boumbulian, Coordinator Model Cities Evaluation Project, Athens
Bernard Hallman, M.D., Associate Dean and Coordinator for GRMP Programs,

Emory University School of Medicine
Robert E. Reynolds, M.D., Associate Dean, Health Care Programs
and Coordinator for GRMP Programs, Medical College of Georgia

Mary F. Woody, M.N., Dirtktor-of Nursing Service, Grady Memorial
Hospital, Atlanta; Member, Facilities and Services Task Force

..

..

. ...

..

? . .., .
i. T- '

-.-

Georgia RMP Site Visit -5-

I1 BACKGROUND INFORMATION

0

I

RM 00046

Georgia WP is currently in its 03 operational year (9/70-8/71)
and is funded at S1,779,862. It has submitted I Triennium
application requesting support for three years at: 04-$3,920,034;
05-$4,349,497; 06-$3,942,974. Each year includes rt request of $177,986
for Development Component

The visit was conducted in accord with routine procedure Tor
evaluating the readiness of a Region to be reviewed on a I_ +ennium
basis and to receive developmental funds. The applicatiort iird the site
visit report will be considered by Committee in July 1971 and Council
in August 1971.

Tt might be noted that Georgia RMP has always been considered by
Committee and Council as one of the better managed and more pro-
gressive Regions. It has encountered no serious problems and the
only significant, and somewhat persistent weakness has been in
the area of evaluation, which might also be cited as a
characteristic of most Regions.

An executive meeting was held the evening prior to the site visit,
at which time the indivldual members of the team were asked to
express their views as to what they saw as problems or areas that
needed exploration. While numerous observations and questions
were raised it was agreed the major emphasis would be placed on
the areas of concern that had been raised by Staff review of the
application. As a result of that review, it was believed explanation
and clarification was needed on the following points:

1. T!)e method for establishing goals and objectives, the assessed
needs L', 7Ihich they based , their priority-ranking and the time-
frame 1 r)r r heir accomplishment.

2. The organizati.on of Core staff and identification of the
functions or" til? part-time positions at Emory and the Medical
University.

3* The relationsliips with other federal program and plans for
cross-representation on governing bodies.

4. ?he committee stri~cture and its relevance to the program.

5. 'l'he functions of the Local Advisory Croups and their significance
to the program.

6, The process by which projects are generated and the method
for giving them a priority ranking.

It was also agreed that each individual member of the team would have
the privilege of addressing himself to the GRMP representatives for
answers to specific quesrions.

Georgia RMP Site Visit

-6-

RM 00046

111. GENERAL IMPRESSIONS

Tt was the general impression of the site visitors that Georgia is b
a strong viable Region. While some aspects of the program appear
weak and in need of strengthening, they are not for the most part, ,
of a significant nature and in most instances some corrective measures
are being planned or employed. However, the visitors did feel two
weaknesses which were identified do warrant immediate attention by
the Region, they are; programming for primary care in medically
deprived areas,and developing broader representation on the
Steering Committee.

GRMP does appear to have a good concept of the problems and
resources within the region and a specific plan in the "area
facility concept" to employ some of the resources in resolving
some of the problems. Early in the history of the Region a task
force spent a considerable amount of time developing the back-
ground material which was required for their recognition of problems
and for the development of programs which,would attack these problems.
They had at that time, their own epidemiologist and data expert. In
the meantime other sources of information have developed, as for
example the CHP "A" agencies, hospital associations,  state medical
societies, state board of health and voluntary health agencies. GRMP
now sees no need for continuing the accumulation of data since
much of it is available from other sources.

The visitors were highly impressed with the management and
organizational strengths of the Region and the outstanding leader-
ship provided by the Director and key members of Core staff.  They
were pleased to learn that each of the two part-time coordinators
which are assigned to the medical schools do indeed seem to serve
the appropriate functions for GRMP, rather than for the medical
schools per se. In /addition, they have been instrumental in
helping the Region develop outreach programs in conjunction with
programs legitimate to the interests of the medical schools. The
involvement and commitment of state and local resources is very
strong and the cooperative relationship between  the  two medical
schools, which to a large degree can be credited to GRMP, was
considered somewhat phenomenal.  The visitors were disappointed
to learn that while "cooperative" relationships have been established
with other various federal programs (CHP, Model Cities, Appalachia
and OEO) these relationships consist of little more than cross-
representation on advisory groups and cross-review of applications.
It was felt that given the strong leadership and management qualities
of GRMP, it should feel an obligation to extend itself and lend
assistance to these other agencies in the development of their health
programs.

There is a clear demonstration of an organizational structure which
permits strong inter-regional medical program relationships with
thirteen other surrounding Regions.

Georgia MIP Site Visit

RM 00046

Vile the visitors initially had some res+>, v~tions about the
composition of the RAG, they were pleased to learn that black
physicians, who re reser.? the black cornmunit1 E are deeply involved
and are hjghly suppcrlive of the program. I dfj ition, the Region
has involved more iibries and all icd health personrli.1 oil the RAG.
Each of Ihe tho Appalachia programs which serve iir f Georgia
are to become CUP "B" agencies. Once this occu~s,
include them on the Mi;.

are to

It was not clear to the visitors the extent of participai I of the
individual members of the RAG in the decision-making prot*e:sr  for
example, in the establishment of priorities, GI- the review tf projects.
It appeared that much of the decision-making occurred at the
Steering Committee level and although the RAG had an opportunity
to discuss or disagree with decisions reached by the Steering
Committee, in fact, this did not often occur. The visitors expressed
concern over the size of che six-man Steering Committee, and the
fact that only ori one occasion has a non-physician ever served
on this body. It was observed that the by-laws call for four
of the six positions to be filled by the R4G Chairman, a
representative of the Pkdical Association of Georgia, and a
representative from each medical school, so that the NominatCng
Committee have the option of appointing non-physicians to only two
other positions. It was apparent in the discussions with GRMP
staff that they recognized the visitors concern and might attempt
to take corrective measures.

Vhile the visitors were favorably impressed with the regionakization
concept as it is being developed through area facilities, which
irt designed to provide education and improve patient services,
the! wnrc- disappointed that GRMP has demonstrated little conceLn
for +:E ;:-imary care problems of the ghettos, It was interesting
to lparlr A Dr. Barrow does not see GRMP stimulating or support:-~g
,-- .e!-i:eed cts in the Model Cities areas. His rationale being,
the n~ec:~ oi ,'74-h areas are so great GRMP could put all of its
support in thest aceas and still not fill the needs. He sees other
rederai arogran: as resources designed to serve these needs. The
visi tors werP heartened by the Region's intention to support, with

(approximately $15O,GO'J) drv~lopmental funds, the medical schools
effol ts to develop store Lront type facilities for provision of
primary care to thP 7 ,or, ,Iiile this plan is somewhat contradictory
to Dr. Barrow's statevents ~ the visitors did not have the opportunity
1 o explore the apparerit inconsistency.

Tkie visicors retained serious questions as to the extent and
worthiness o the evaluation aspect of the program. On the
previous site visit, a new man had recently been hired with the
thought that he would strengthen the evaluation process. Apparently
he left or for other reasons the process was not strengthened. A
similar situation currently exists in which a new education
specialist has been recently acquired and the visitors are again
hopeful that this will lead to strengthening of the evaluation

Georgia RMP Site Visit

-8-

RM 00046

process for the whole region. Upon examining this individuals'
credentials and talking with him, the visitors optimism was
heightened. Although, the evaluation process per se may at the
present time seem weak, a fairly stringent effort is being made
to keep abreast of progress of individual projects.
involving central core staff and area representatives are scheduled
so that there is a fairly continuous review of activities and the
opportunity to change the direction or alter these activities,
provided proper evaluation processes evolve.

Veekly meetings

The visitors expressed concern as to what appears to be a fairly
subjective method used for determining priorities and  for selective
funding based upon program priorities. This may reflect a weakness
in the decision-making process. On the other hand, perhaps it is
justifiable to consider that, by having this rather subjective
methodology, it permits some flexibility to take advantage of
opportunities which might arise from implementation of certain
projects, even though they might not be of the highest priority.
The visitor's initial concern regarding the functioning of the
local advisory groups was somewhat confirmed in that some rarely
meet or function. Even so, they were convinced that this form of
subregionalization indeed does permit an avenue of activity for
representatives of local areas and that some of them have been active,
and specific projects have been generated by the concerns of these
groups.  Some of the apathy and inactivity on the part of these groups

might be a reflection of the limitation of funds, which have been
disappointing to some of the local groups and the fact that some

*-

4-
`..-.

of the projects which they have felt were pertinent  to the local
needs have not been activated. Dr. Barrow admitted reluctance
to stimulate activity at the LAG level at this time when funding
possibilities are remote.

It was noted that there was a great emphasis on continuing education
activities and that a significant proportion of the budget proposed
was related to projects underwriting such nctivfties. It might be
viewed, however, in the context o nn immense shortage of physicians
in the state of Georgia and that perliaps certain types of continuing
education would at least produce better and more efficient services
by those physicians available. Ilopefully, the continuing education
activities proposed would not just be the traditional types of
post-graduate courses, but rather aimed at making physicians have a
greater awareness of different methods of care, as for example,
in the use of allied health personnel, thereby leading to increased
productivity. In addition, this seems pertinent to the concept of
area health education and care centers, and that only through the
development of an education center is it possible to attract quality
physicians and other professionals into such an area health facility.

It should be pointed out that the central theme of the GRMP relates
to the concept of the development of area health facilities.  These
facilities have both service as well as an educational function.
They are of two types.
hospital or hospitals which would relate closely to one of the

._

The one type would be fairly major community

i,'

`c_- '

Georgia RMP Site Visit -9- RM 00046

two medical \chools in the development of frill-time faculty members,
thc development of residency and internship training programs, the
dcavclopment of inqprvice and community trailling programs and the
development of additional services in that area,, Many of the
projects proposed relate closely to area faciljt-ie.; concept and
should be viewed in t.hat context rather as simple .,('parnte projects.
Comment was made many times that this concept seemed iu he in
keeping with the natioaal view of health problems, anii
Carnegie Commission report on the need of area health e
facilities. Beyond the type I facility was envisioned
facility which would be a smaller hospital with more lirrii
of expertise.. Through the creation of the medical schools of type
I and type11 relationships, a network of care would evolve which
could help meet all of the objectives outlined by the RMP which
relate to increasing availability and efficiency of health manpower,
the improvement of the quality of medical care in Georgia, and the
improvement of the availahility and accessability of the primary
medical care with specialized diagnostic procedures for a11 persons
in Georgia, including the medically indigent.

Discussion was held with the Director and Core staff in reference
to the funding for the Area Facilities for Continuing Education.
The discussion did point out the need for hcing aware of the
availability of other funds for these types of activities and
that when these became available they should be sought and that
requested money freed up for other purposes in the region.

IV . REVIEW DETAILS

Goals -I and Objectives: The Region's objectives are stated as follows:

I. 70 ivrrease the availability and efficiency of health manpower
  in <,c 01 gia.
2. lo improve the quality of medical care in Georgia, including
  pr:-/i it diagnosis , treatment and rehabilitation.

3.  Z"fle improdelrent of the availability and accessibility of
  primarilymedical care and of specialized diagnostic, prevention
  treatment ani rehabilitative services to all persons in Georgia.

'Jhil~ these are stat& fairly explicitly, and sub-ob jectives elaborate
somwhat on them, they seem to lack a great deal of specificity or
direction. However, on the basis of the information provided they
appear to have some relevance to the problems in the State of
Georgia, and have been established after a somewhat subjective
assessment of regional needs, problems and resources. The Director
contends that the needs identified by GRMP are obvious, and
indepth studies would only be a waste of time, money and effort.
The visitors found no inconsistencies between the Regions objectives
and the national prlorities. The objectives appear to be relatively
well understood and accepted by members of the organizations associated
with GRMP, however, their usefulness in determining the funding of
operational proposals was unclear. In the absence of priority-ranking

Georgia RNP Site Visit - 10 - RM 00046

of objectives, they are used more as a general guide which allows
the flexibility of shifting funds from one project to another,
on other bases. In part, this is related to the time-frame and
consideration as to whether other sources of support might be
available. While the visitors were somewhat skeptical of this
method of procedure,  it was obvious the program did have certain
emphasis in that those projects relating to the establishment of
area facilities were given the highest priority rating, Crucial,
while most other projects fell into the Very Important or
Important categories.

o

Organizational Effectiveness

The Director is indeed effective, he lends a strong sense of
direction to the program and seems effective in developing close
relationships between core staff members and their counterparts
at the medical schools, on the RAG, and in other agencies around
the state. While he is strong-willed and at times gives the
impression he might dominate the program,he appears to be
responsive to the desires of the RAG and moving the program
accordingly.

The quality of the Core staff, who were visible to tne visitors,
was exceptional and there was obviously good morale and a high
degree of esprit de corps. They reflected a broad range of
disciplines and demonstrate an adequate administrative and
managerial capacity.
who are assigned to the medical schools for liaison purposes, do
not represent an over-balance of institutional influence and infact
appear to be satisfactorily fulfilling their function.
organization of Core appears to serve the Georgia program well
and there is reasonably good balance between central and field
workers.

The two part-time members of Core staff,

The

The Medical Association of Georgia  is the grantee organization and
functions primarily as a fiscal agent. Although it strongly
influences program direction, it does not appear to interfere
significantly with the functioning of the Director or the Core
staff. Dr. Adair, who is the part-time Coordinator of GRMP, has
responsibility for fiscal matters and serves as "financial watchdog"
over the program.

The Committee structure which consists of six standing committees
and some five ad hoc committees appears adequate. While the
standing committees play a significant role in the setting of
objectives, it is the 6-man Steering Committee which appears to be
the real decision-making body.
while the by-laws call for five members of the Steering Committee
to be elected, they also call for three of these five to be
representatives of the Medical Associat ion of Georgia and the
two medical schools. The RAG Chairman serves as the 6th member.
It was felt this vastly limits participation of the other interests.
This was reflected by the fact that only on one occasion has a
non-physician served on this body.

The visitors questioned the fact that

J

C;eorgia IMP Site Visit - 11 - RM 00046

While final authority lies with the FAG,  it appears this body
relies heavily on the Steering Committee for guidance. The

KAG does not appec. to always function as effectively as might
be possible, howevec, it does seem to have reasonable control
over the establishment of policy and is concerned with the
credability of the EM? within the Region.

Involvement&t:egional Resources

As observed previously there appears to be fairly strong I ition-
ships and involvement with local and regional resources, ai for
example, the medical schools, physician associations, the hospital
association and voluntary medical groups. Involvement of these
resources and their expertise is found either at the RAG, LAG
or Task Force levels. Uhile some have served as sponsors of projects,
others serve more as resources for data and as consultants in the
devel opmen t of the various GRMP componen ts.

The visitors expressed concern tlin t the relationships and the use
of resources as represented by other federal agencies was not as
c;trong as migbt seem possible. 'Jhile nirrch was heard about
t'coordiriationl' and "cooperat ion" between CRMP and other federal
programs there is little evidence that much of significance has
evolved. Apparently Dr. Barrow's philosophy that GRMP will only
provide administrative and planning assistance to the Model
Cities programs, also extends to other federal programs. It
appears unlikely that any co-sponsored programs or projects will
result from GRMP relationships with other Federal programs.

WilL the Medical Association of Georgia does not appear to
         t must be recognized as the most influential

evidenced in the direction the program is following

s of projects which have evolved. It is also evidenced
  t Dr. Barrow feels he must proceed with caution in
"ertion of GRMP in order to preserve relationships

which hav~ b~t.1~ cTiltivated within the more conservative elements
t)f the medical -~mrnunit-y. The visitors felt he may be too cautious
;ind that he might '?e more agressive in his attempts to move this
practical element .

Assessment of Needs,- 'I iibiL,r?s and Resources

--

?be averall needs of the Region, while not based on an analysis
nt collected data, are systematically identified by the RAG in a
subjective manner.
Georgia, which are identified by the RAG, and to which program
objectives relate, are so obvious as to make any studies based
on data irrelevant and a waste of time and money.

The Region argues tha t the major needs In

In the development of program and projects it does appear that
data obtained from relevant resources are used in determining
approaches and in giving priority to certain aspects. In reviewing
applications from hospitals to become area facilities,related data
plays a significant role.

Georgia RMP Site Visit - 12 -

Program Implementation and Accomplishments

RM 00046

Core activities have resulted in action-oriented planning and
the development of 140 Local Advisory Groups whose function it is
to plan at the local level and through one of the five field
representatives coordinate plans and activities with GRMP.
While only some 80 of these LAGS appear to be active, the visitors
saw some logic in the Director's reluctance to stimulate the
slow-comers at a time when competition for RMP support is so
keen. The cooperation and coordination of these LAG'S is probably
best reflected in their support and contribution to the area
facility concept which is designed to provide centers of excellance
and education in ma.jor hospitals, to which the smaller hospitals
can relate. However, it should also be noted that a number of projects
have originated with the LAG'S.

The visitors found it difficult, in the absence of project review,
to judge the quality and productivity of ongoing projects. However,
on the bases of the somewhat subjective testimonies by Core staff
and other participants, the visitors did get the impression that
the projects are moderately productive. Some skepticism of such
testimony was raised by the fact that projects have not been
intensely evaluated.

In response to the visitors concern that slightly under half of
the Regions ongoing projects are requesting renewed support,
Dr. Barrow argued that while most of these projects retain the same
titles, they in fact are substantially altered and represent new
activities. He sees those projects related to area facilities to
be of a ever-expanding nature, so as to always require GRMP support.

Evaluati on.

There is little evidence that any extensive evaluation activities
have taken place in Georgia. Most of the projects have not received
intensive scrutiny to date, although a few head counts have been
done in some of the educational projects. This can be attributed
to the lack of a full-time director of evaluation which was
remedied by the hiring of Mr. Don Trantow last Octoher. His
credentials are icpressive and, given time, he may construct
an effective evaluation activity. He has spent his first several
months in Georgia building evaluation protocols into all ongoing
projects by visiting and meeting with project directors.   Ile
contributed significantly to the application under review by
developing an internal system for project directors to specify
objectives and develop self-evaluation protocols. It is
anticipated that pmject evaluation will be done for the most
part by the project director himself and that a monitoring
function will be performed by the subregional field staff who
meet on a weekly basis with the Coordinator, the Evaluator, and other
senior staff. Mr. Trantow expects to evaluate specific activities
on a selected basis. Since he is the only evaluation staff person
right now, he will probably hire consultants  to aid him.

./

Georgia RMP Site Visit - 13- RM 00046

In addition, Mr. Trantow has met with the Regional Advisory Group
and the core staff and conducted essentially ai11 education process
on the significance al:d character of evaluation. Hopefully, by
the next site visit, the evaluation activity will he producing
data useful to the decision-making activitiea of the dq;ioiial
Advisory Group.

Review Process: The review process in Georgia has evolvrc `-Ier

          the past three years into an extensive but "ficient
system involving staff consultation and assistance, written ,cedures,
and broad community involvement. Proposal review has been icd::ced to
90 days.

Project proposers submit brief outlines of proposed projects to the
Core Staff which revi.ews the activity internally and develops it
further with the proposer. If there is agreement that the outline
should be developed into a proposal, the project director, with a
written set of guidelines, writes up the proposal which is reviewed
again by core staff. Recommendations are developed and the proposal
referred to the appropriate one of six task forces. The task force
decides to accept or reject the core staff recommendation. If the
proposal is disapproved by the task force, official documentation of
the action is made. Otherwise, it is reviewed, with written guidelines,
for technical adequacy and relevancy to the RMP program and given a
priority (Crucial, Very Important, Important). It is then referred to
the Steering Committee where it is again reviewed, If rejected by
the Committee, it does not go to the RAG, (however, the proposer may
appeal the action, although this has never been done.) The Regional
Advi;o?cy Group then reviews the proposal and the recommenda tions of
the Steering Committee and makes its own decision. It has on occasion

3 decision of the Steering Committee, although apparently
  tly, The RAG also assigns priorities (Crucial, Very
  :?ant) using a standard set of written guidelines.

----..A, Fundinv Eesnnuen~_la?.~on: -..A.--!--..--.-.%--

While the Region is requesting support for
three years at 04-$3,920,034; 05-$4,349,497;

06-$3,942,724, the site visitors recommend a reduced level of $2,800,000
or each of three years -~hi~i-i includes a Developmental Component of
$177,986 for each year. (This recommendation takes into consideration
the Kidriey panel's recorriiiieadation of disapproval of Project #36 A Kidney
Program for (;eorgia, whic-h was reviewed after the site visit.)

Rationale: The rationale for this reduced level is not based on any

review of any projects. Rather it is based primarily on the exclusion
of, or only giving partial support to, the following projects:
(Note: The following recommendations would reduce the recommended level

serious deficiencies of the Georgia program or the technical

to below $2,800,000, however, the visitors rounded it off to $2,800,000.)

0

Georgia RMP Site Visit

- 14-

RM 00046

Project #6 - Communications Network

The site visitors had difficulty aeeing how this project related
directly to the Georgia program and failed to understand how it
received a priority rating of Crucial.
recommendation to phase out this project was warranted.
following the site visitors review of this project in March 1970 was
well stated.
encumbered from other continuing education projects within the program,
but this should be very carefully weighed by the Region, especially
in relation to the market demand for video-tapes and the measured use
of them.

It was felt the previous Staff

The advice

Support for this project could legitimately be

Project #I3 - Statewide Cancer Program

Request : 04-$450,257 ; 05-$446,479 ; 06-$332,884

The site visitors were concerned that the activities in this area to
date had not demonstrated that these were likely to have viability
independent from support of the RMP.
projecting the establishment of additional centers. In addition,
there was concern expressed about the value of the registries as used
by these programs.

sources. While this did reflect the part of the area facility concept, I..--..

continue functioning and seek other sources of support for ongoing
activities devoting most of the new monies into the development of
new projects,
$200,000 each year.

In spite of this they were

It appeared to the visitors that support for the

_.
I. .

registry portion could legitimately be borne by hospitals or other

nevertheless, it would appear that this particular program could

ai

. -2

Therefore, it is recommended that this project be funded at

Project 1/14 - Pediatrd Respiratory Center

Reques t : 04-$86,250; 05-$84 3 250 :

06-$84,250

Project #37 - Facility for Respiratory Disease

Request: 04-$75,940; 05-$155,634; 06-$199,687

The visitors felt that these projects were closely related and indeed
might profit from being operated in conjunction with one another.
It was recognized that these projects were important to the area
facility concept, but that they perhaps should not be developed
independently of each other and that certain types of teaching methods,
personnel and resources could be used conjointly thereby permitting a
lower level of funding, a total of $100,000 each year.

Cccrri;Fa KMP Site Vl.sit -15- ICT? 00046

Project 1/22 - Yhysio1oj:y for Nursing Instrucek*x.

Request: 04-$30,970; 05-$25,873; 06-$25,873

It was difficult for the site visitors to see the releai,arice of this
project to the total goals and objectives of the Region- "his focus
on neuro-physiology for nurse instructors seemed to reall) ave one
of the remotest connection with increasing the availabill i'j ~rrd
accessability of care. No attempt was made to judge the me: c: of
this project but it would be recommended for no funding.

Project #43 - Patient and Family Education

Request : 04-$85,000; 05-$85,000, 06- $85,000

Project 1/46 .. Learning Resources Services

Request: 04-$42,060; 05-$64,850; 06-$53,360

It appears that there is some commonalty of efforts in these two
projects. Both tend to be developmental projects without specllfic
areas of activity being defined. It would appear that these could be
developed in conjunction with one another. Accordingly it is
recommended that these be combined into a single project and funded at

the level of $50,000 each year.

Project #49 - Health Careers Counseling

Request: 04-$23,917; 05-$20,168

sion of this particular project the site visitors were

riy feature of this which was not in conflict with

the policy i.t;sicerncnt of the National Council. This appeared to be
directed dt rite recruitment of disadvantaged students into health
careers and relater! to health career councils. It would appear
therefore, that ihjs %?as inappropriate for funding at this time.
The visit.ors would Like tc being to council's attention however the
desperate need of r_he State of Georgia  for all kinds of health
professionals and aLso the urgent need for ways in which the dis-
advantaged can be brought into  the health career fields.
wish to consider this soyiewhdt unique project in relation to the
desperate need to see if there is some way in which it may be funded
and yee not be in opposition to its present policy.

Council may

Project 1/50 - Physicians Assistant

Request: 04-$228,147 ; 05-$303,350; 06-$194,461

In the discussion of this project it appeared that the Medical College
of Georgia is really in the planning stages of operations and not
ready for a full-fledged operational educational program, Further,

e

Georgia RMP Site Visit -16- RM 00046

the Emory Medical School is also in a planning stage.
they had had a physician assistant training program they are now
planning on changing directions and training generalists rather than
specialists. It was noted that funds may be made available for such
programs through the Bureau of Health Manpower. In addition it was I
observed that in previous deliberations by Committee and Council
there has been some question as to the legitimacy of Regional Medical
Programs involvement in the development of a physicians assistant
concept since other agencies were involved and that ongoin;; studies
as to the value of physicians assistants were underway. Consequently,
it might be of value to consider reducing the funding of this project
SO that it can support planning but not operations until we have more
information as to the value of physicians assistants and the avail-
ability of funds from other sources.  It is our recommendation there-
fore that this project be funded at the level $100,000 for each of
3 years.

Even though

I

. -Project#36 - A Kidney Disease Program for Georgia

Request: 04-$211,588; 05-$301,523; 06-396,426

The visitors accepted the Ad Hoc Kidney Disease Panel's recommendation
of disapproval for this project, and subsequently recommends no funds.

*.

,\

Project $39 - Health Maintenance Program for Stevens County

.-

Request: 04-$107,290; 05-$138,560; 06-$16,320 .-_.

While the title of this project would indicate it relates to a system
of health care,  the visitors believed it in fact is little more
than a project which would provide for multi-screening of residents.
They were sympathetic to the needs for ways to improve health care
to the rural disadvaqtaged,  but felt in view of policy regarding
multi-phasic screening, funds should not be provided  for this
project.

Project #44 - Computerized Dietary Services System

Request: 04-$87,700; 05-$94,072

The visitors were somewhat skeptical of the need to use the gagetry
of a computer to provide this service.
difficult to understand the relevance of this project to the Region's
goals and objectives, and its relationship to the total program.
They would recommend no funds for this project.

Developmental Component:

They also found it

Request : 04- $177,986 ; 05- $1 7 7,986 ; 06- $17 7,986

In reference to the developmental funds it appears that some thought has _--
been given to the legitimate use of such funds. One major sphere of i ~
activity would probably be in relationship to the development of store-frhr?'
facilities in core areas of cities, to provide residents with greater access
to primary care.  This is an area of activity which'is not heavily emphasized

Georgia KMP Site Visit -17- RM 00046

by this X.egion at  this time and might be well served by the use of develop-
mental funds, The manaTement leadership and organizational strengths
of this Region are good and the visitors wo~Id therefore assume that
developmental funds would be used legitmatelg ?rid well. It is therefore
recommended that the dcur lopmental component be iunded at the level requested
for each of three years.

VI. RECAPITULATION IN TEiMS OF RMPS MISSION STATEShEIJr-~~~L~~lEW -I CRITERM

A. Performance Criteria:

1.

Whether a Region has succeeded in establishing it,
goals, objectives and priorities - The
lack specificity and have no priority ranking.
do not provide certain direction to the program, they do
serve as a general guide, which allows some flexibility or
shifting funds from one project to another.

  , j~

While they

goals and ooject;ives

2.

The extent to which activities previously undertaken ha-s
been productive in terms of the specific end6 sought - Core
activities appear to have resulted in action-oriented planning.
In the absence of project review.  The achievement of such
activity is difficult to evaluate, however, much testimony
by regional personnel would suggest projects have been
moderately productive.

3.

Whether and the degree to which activities stimulated and
initially supported by RMP have been absorbed within the regular
health care financing system - Of twenty-two projects currently
supported 12 are to be phased out and 10 are requesting
renewal support.
?-mewed support, while retaining the same titles, do in fact,
.i ,*:)resent new activities.

The Region argues that those requesting

1.

The wj;iu&y and effectiveness of an KMP as a functioninq
orgariiratiiln,_staff, and advisory structure - The organization
and cormittee structure appears to serve the GRMP well.
WliiLe the tc46 does exert policy control it relies heavily
on the six--lna4*L S~eeri~g Committee.
by physician. ana the visitors would suggest efforts be made
to include non-physicians.

This committee has been dominatec

2.

The extent- to which all the health-related interests institutions
and professions oE a region are committed to and are actively
participating in the program - Relationships and involvement
with local and regional resources appear strong.

3.

-GLV or in coniunction

The degree to which there is an adequate functioning planninp,
organization and endeavor, developed t
While the GRMP and CHP Directors serve as representatives on

-. -,

--

I

each others advisory group and review each others applications,
little in the way of cooperati.ve endeavors has evolved. To
a-+Q rPlatinnShinS with the two CHP "B" Agencies has been

Georgia RMP Site Visit - 18- RM 00046

insignificant, however, plans are to strengthen cooperation,
first by establishing cross-representation on each others
advisory groups.
and there does not appear to be immediate plans to strengthen it.

Coordination with Model Cities is remote

~

- ---- -_ - ___ . ___ __-

4. The degree to which there is a systematic and onpoinq

\

identification and assessment of needs,problems,  and
resources; and how these are being translated into the regions
continuously evolving plans and priorities - The Region
feeling its needs are obvious, does not base them on
analysis of collected data.
projects designed toward the subjectively established
objectives do take into consideration data analysis
and resources.

However, programs and

5.

The adequacy of the region's own management and evaluation
processes and efforts to date in terms of feedback desipned to
validate, modify, or eliminate activities - As with most
other regions GRME' has had a persistent problem with
evaluation, While there is evidence that the Region does
monitor activities fairly closely and has occasionally
modified and rebudgeted projects, there is also evidence
that evaluation may be overlooked in the consideration
of some "petf' projects.

C. Program Criteria

...

..
..

,. .-
. ..

+ ..

1. The extent to which they reflect a provider action plan

-_

of high priority needs and are congruent with the overall mission
and objectives of RMP -  The Region's goals and objectives, while
they are broad and subjectively determined, do represent a guide
for the program to which providers endorse, understand, and adhere.
Although consistent with RMP's mission much of the Georgia
program take9 an indirect approach to achieving these goals.

2.

The degree to which new or improved techniques and knowledge
P are to be more broadly dispersed so that large numbers of people
will receive better care - Much of the Georgia program continues
to relate to continuing education and increasing the knowledge
of health providers who do not have easy access to major
learning facilities.

3.

The extent tG-which the activities will lead to increased
utilization and effectiveness of community health  facilities
and manpower, especially new or existinp kinds of allied
health personnel, in ways that will alleviate the present
maldistribution of health services - Georgia's Area Facility
Concept and the continuing education projects which relate
to it have the basic components to increase the efficiency of
personnel and effectiveness of community health facilities.

4. Whether health maintenance,disease prevention, and early detectio-.

I

activities are an integral component of the action-plan -

1. -

1-

Forthe most part the Georgia program only relates to these
activities in an indirect way.
direct relationship.

Only one project has any

Georgia RMP Site Visit - 19- RM 00046

5.

The degree to which expanded ambulat:i.;Eare and out-patient
diagnosis and treatment can be expectei to result - It can be
assumed that  y increasing and improving services of area
facilities anc by increasing the efficien-.j rJf health
providers, ambulatory care and out-patient .ie;vices will be
considerably increased.

6. Whether they will strengthen and improve the reia.l inships

between primary and secondary care, and thus greait, j.ontinuity
in and accessibility of care will result - Again, i   .? assumed
the area facility concept will have a direct influenic on greater
continuation and accessibility of care, particularly fox the
indigent.

7. The extent to which more immediate pay-off in terms of accessibility,
  quality, and cost moderation, will be achieved by the activities
proposed - These factors will be influenced by the degree to
which the area facilities can expand services and through the
related continuing education program improve the competence
  and efficiency of health providers,

8. The degree to which they link and strenpthen the ability

of multiple health institutions and/or professions (as opposed
to single institutions or groups) to provide care .. The area
facility concept has genuine regionalization qualities and is
designed to improve the quality and provision of care,  in both
the major hospitals and smaller hospitals
This will be accomplished by strengthening the relationships
between the medical schools and the larger hospitals, and the
larger hospitals and the smaller ones.

throughout the state.

9.

=-::?tent to which they will tap local, state and other
frrtid. sr, conversely, are designed to be supportive of
ot1-1~~- Federal efforts - While a substantial number of
Gemgta3-: programs include non- Federal support, they see
a need for ehe continuance of Federal support, in the area
acil:.cy program, for many years to come. Unfortunately
the Georgia prozrarn fails to relate well to other Federal
efforts e

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

HAWAII REGIONAL MEDICAL PROGRAM
Harkness Pavilion
1301 Punchbowl Street
Honolulu, Hawaii 96813

RM 00001 8/71
July 1971 Review Committee

PROGRAM COORDINATOR: Masato Hasegawa, M.D.

This regiotl in its third year of operation, is funded at a level of
$835,762 direct cost.  In addition, the region has received $101,523 of
indirect costs which represents an average of 12.5 percent.

In this anniversary application the region has requested for its fourth
year'of operation $1,658,831 d.c. for support of the follming activities:

I. The continuation of core and 5 ongoing projects ($849,186)

  Funding for a previously approved unfunded developmental
  c ompone n t ( $7 8,8 9 7)

11. Funding for nine new projects ($730,748)

111.

(Attached on the back of the Summary is a chart identifying the components

involved with the above items p.20-22.)

Following are the key issues identified by  staff in their review of
the cont inuat i,on application.

1.
2.

3.

4.

5.

6.

e

7.

The need for specificity in the region's objectives and priorities
The need for the RAG to develop its By-Laws and assume the
responsibility for directing the planning and operational activities
of the RMPH.
The need for a deputy or associate director to help administrate
the day to day operations of the RMPH.
The RAG Technical Review Committee and Categorical Committees '
need to be given an opportunity to have input in the planning and
operational activities of the RMPH.  The operating procedures and
responsibilities of these committees need to be clearly defined.
The need to relate evaluation efforts to specifically identified
objectives.
Development of a feasible plan of action or the PacificBasln
The need for a feasible regional plan of operation to be
developed.

HAWAII RMP

-2- r RM OOOOl'8/71

GRANT YEAR

Planning Stage

01
02

Operational Stape


01

01

02

02


03

03

FUNDING HISTORY
(Direct Cost Only)

$

PERIOD

7/1/66-6130167
7/1/67-6130168

9/1/68-8/31/69 Core
         Projects
            Total

FUNDED

$108,006
122 , 297

362,872
475,031
837 , 903

5/1/69-8/31/69 Pacific Basin Planning

30 , 000

10/1/69-9/30/70 Core 336,101
         Projects 471,503
      Pacific Basin 17,082
          Total 824 , 686

6/1/70-9/30/70 Projects 90,000

10/1/70-9/30/71 Core 365,511
          Projects 563,758
       Pacific Basin 17,270
          Total 946,539

10/2/70-9/30/71 Total 835,762

0

(After RMPS4 12% across
the board reduction)

-- _.

Georgraphy and Demography:

The Regional Medical Program of Hawaii (GPH)
is responsible not only for the Hawaiian

Islands, but also or the Pacific Basin--Trust 'I'erritories fMicronisia) ,
Guam, American Samoa. The State of I-lawail includes a long chain of
islands almost exactly in the middle of the Pacific. It stretches
rrom the Tslnnd of Hawaii to tiny Kure Tsland, approximately 1,500 miles
to the northwegt.
major islands: Ilawaii, Mau:, Molokai, Lanai, Oahu, Kauaf, and Niihau.
These seven major fslaiids are relatl.vely close to each other. Hilo,
llawaii , is about 200 miles from llonolulu. Both ltahului, Maui and
Sihue, Kauaj ax&' approximately 100 miles from Honolulu airport.  The
tiolokai Airport is about 54 miles from Honolulu. Lanai and Molokai
are only eight miles apart at their closest point.
Ijonolulu, the state capitol and largest city of Hawaii, is located
on Oahu, 3s is Waikiki, the major tourist destination area.

The populated part of the state includes  the seven

HAWAII RMP

-3-

RM 00001 8/71

_.

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_-

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'1'11~ resident poprllatlon of Hawaii, according to 1 he preliminary 1970
c-etisiis count , is 748,182 persons, lncludlng 41,362 mjlitary personnel.
'rhc. poptlliition has increased 18 percent since 3960 and IR expected to
~-e%:~rli more than one million by 1980.
popfilntion, llnw~ll hn.s npproximately 1.4 mill lun vifilrors each year.
'I'ltis ntimhcxi- Is expected to doiible by 1975.
visitors hnve a dlstinc~ bearing on medical plannlng for the state.
Etllnically, the population of the I-lawa.ian Islands .is 67 percent
oriental and for Polynesian, 32 percent Caucasian and 5 percent Negro.
The median age is 24.3.

The economy of Hawaii has expanded tremendously in the past two decades
and is based on four major industries:
expenditures ad Lourism. .

In addition to the University of Hawaii which has approximately 20,000
students in undergraduate and graduate programs, there are five small
Private colleges and five two-year public community colleges within the
state.

In addition to the rc.rident

Medical neade of these

sugar, pineapple, military

-

-

I -_-

-

l'tiere are thirty-three hospitals in the State of Hawaii. Nineteen of
these are accredited by the American Hospital Association and eight
have approved training programs for interns and reoidents.

The University of Hawaii's College of Health Sciences includes a two-year
School of Medicine, a School of Nursing, School of Public Health, and
School of Social Work.
for licensed practical nurses and other allied health workers.

The community college system provides training

The Trust Territories include 2,100 islands (700 square miles of land)
spread over 3,000,000 square miles of Pacific Ocean-an expanse greater
than the territory of the continental United States.  Guam is a single
island (209 square miles) 3,300 miles southwest of Honolulu. American
Samoa includes seven islands (76 square miles), 2,300 miles south-south-
west of Honolulu.  There are 92,000 Micronesians in the Trust Territory,
76,500 mixed Chamorro in Guam and 26,000 Polynesians in American Samoa.

History of Regional Development:  The Region submitted its initial planning
                     application in September 1966 (the first
applicaton received from any region) for establishment of a RHP consisting

of Hawaii, Trust Territories, Guam, and American Samoa.

In June
level of$90,0@5 d.c.
the Coordinator, Dean Cutting, has been unable to spend much time on RMP
and the Deputy Coordinator, Dr. Graham, has apparently not stimulated
either planning efforts or community involvement.  Only $20,000 of the
$90,000 award was spent. Concern was expressed that RIP was conceived
mainly as a means of supporting the new medical school.

2966, the Region received its 02 year planning award at a funding

Very little progress was made in the first year.

HAWAII RMP -4- RM 00001 8/71

.I____...-

In June 1967, Hawaii was awarded its 02 year planning award at a level
of $91,978 d.c. In July 1967, a staff visit was made to Hawaii (Dr. Sloan,
Dr. O'Bryan, Mr. Anderson).  Staff was impressed with the enthusiastic
and strong leadership of the RAG. The medical school did not appear to
dominate the RMP; as a result, the physician community appeared to be
warming up to the program. It was decided that the RMP offices would be
moved out of the Leahi Hospital (next to the Dean's office) and into a
"neutral" building at the Queens Medical Center.  It became clear that

a new program coordinator would he chosen.

J

In April 1968, Dr. Masato Hasegawa was appointed Program Coordinator.
Dr. Ilasegawa, a pediatrician, was a prominent member of the medical
community, with great intereat in "community medicine."

in October.1968, the Grantee changed from the University of Hawaii to
the Research Corporation of the University of Hawaii.

The RMPtl submitted its first operational application consisting of
continuing core support and 10 project proposals in September 1, 1968.
?'he major Lhrust of this appllcation was in continuing education using
I{t-gion Wide (Ilnwaiinn Islands only) resources, in the absence of a
Itilly-develolwd niedtcal school.

- -.

'i'l)e application also stated that KMPH goals included development of
"advanced health systems" which would improve the delivery of health
care.

A site visit was conducted to the Region in September 1968 (Drs. Millikan '
and Slater, Mr. Lewis and Mr. Jones). The site visitors were very impressed
wfth the leadership of Dr. Hasegawa. In the few months he had been with
R?%lPH, Dr. Hasegawa had clearly begun to involve diverse elements, over-
come earlier hostility, and develop a separate identity for RMPH. Also,
the visitors were profoundly impressed with Mr. Wilson Cannon, Chairman
of the RAG, and with the vigor of the RAG as a whole. The visitors believed
that the Core staff was dtkeloping well.

*I 1

-,

L-

In April 1969, this RMP received a $70,000 award for planning activitles
in the Pacific Basin-Trust Territories, Guam, Samoa. In making this
award, COURC~~ sharply redwed the S100,OOO requested out of concern
that RMPH might "spread itself too thin" and riot concentrate it6 efforts
sr~fficicntly on building lWPH in Hawaii.

lhiring 1969, the Core sta T-E expanded beyond the approved total level,
and this posed a problem Cor the Region in Lerms of continuing support.
'Tile fiscal elements of the continuation application were particularly
confusing, despite 1-epreated inqciiries, to the Ref;ion. Finally, the
Division asked the Regim's fiscal officer to meet with Division staff
ill Betliesda, where the difficulties were ironed out.
f11 January 1970, a site visit was conducted' to the Region (Dr. Millikan,
Dr. yesson, Dr. Zippen, Dr. Komaroff, Mr. Morales).
encouraged by thc increasing involvement of the Medical Society, hospitals,

The visitors were

-

HAWAII RMP

-5-

RM 00001 8/71

and paramedical personnel; Core staff has grown stronger; the RAG had
become more broadly representative; and planning activities in the

e

Pacific Basin had been initiated.
diminishing involvement of the previously vigorous RAG chairman, Mr. Cannon.
They also believed that the RMPH had progressed to the point where Dr. Hasegawa
required administrative wsistance.

The visitors were disappointed at  the

o

1

Staff reviewed on September 28, 1970,the RMFTI 03 year continuation
application and believes that this RMP has made remarkable strides  in
the past year.
hoc evaluation committee and established policies and procedures
provide hope that the RAG effectiveness will be improved.
Committee of the RAG is the strong force; two of its members also
serve on the RAG. Also strong forces are the categorical committees,
which appear to have veto powers that vitiate the RAG's role.

The RAG's role and strength is still not clear, but an ad

The Executive

In December 1970, a site visit was conducted to the Region (Dr. Besson,
Miss Conrath, Mr. Gardell, Mr. Morales, Mr, Spain and Mr. Currie).
The visitors were impressed with the considerable progress made by the
Hawaii RMP toward developing the general principles of regionalization.
The region had developed a framework for planning the achievements of
goals and objectives. Methods for evaluation were being developed,
The visitors did not review projects but rather focused the review on the
established organizational structure andan administrative process of the
HRMP,  its interrelationships with the health care system of Hawaii and
its capabilities to implement the program in accordance with stated
goals and objectives.

In many respects the region appeared to have made little progress since the
previous site visit in January 1970.
in January still persisted in the December visit and are similar to those
identified by staff in their review of this application. (Copy of
staff$ memo and  the December Site Visit Report are attached p.23-38.)

Organizational Structure and Processes

The Regional Advisory Group of the RMPH is composed of 42 members,
33 from Hawaii, 3 members each from Guam, American Samoa and the
Trust Territory.

Many of the problems  that existed

The members from Hawaii are appointed by a Nominations Committee for
three-year terms,
Territory are designated by their respective chief executive.
membership of theRAG includes physicians (20), Registered Nurses (2),
Hospital Administrator (l), Social Behavioral Scientists(Z), consumers
(18), labor official (1) and a high chief from Samoa. The RAG activities
have centered around project review and approval.  Other major
activities of RAG during the past year included the follawing:

The members from Guam, American Samoa, and the Trust

The

Establishment of appointment procedures and functions of RMPH,
RAG and other Committees as appended.

,

HAWAII RMP

Recommendation
was approved.
Corporation of

-6- RM 00001 8/71

I

for a change in grantee institution to RMPS which
The new grantee institution is the Research
University of Hawaii.

for the use of project summaries to facilitate the I

Recornendation

review process.

Selection of the ad hoc Evaluation Conunittee of RAG of LIMP-tlnwsii.

Discussion about regional priorities and input from specific health
professions.

An ad hoc Evaluation Committee of RAG is presently doing a study to
determine how the RAG can function as a policy and decision-making body.

The core staff of the RMPH has nineteen employees, all at 1002, time or
effort. The core staff organization has been revised to include an
Administrative Manager and a Consultant in Medical Education, Exclusive
of the secretaries, the core staff consistx of eleven presently active
members plus an Administrave Manager and a Consultant in Medical
Education.

Following is a list of the Core staff members.

Name Job Title X Hours

Time or Effort

_. .

^I

.i

_- . :

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Program Coordinator 100
Consultant/Med. Education 100

,D.

Masato Hasegawa., M.D.
Alexander Anderson, M,
Vacancy
Vacancy
Satoru Izutsu, Ph.D.

Omar A. Tunks, MBA
Rosie K. Chang R.N., M.S.
Kanae Kaku, M.D.
Norman Kuwahara, CPA
Nancy Crocco, MA.

Clyde Winters, MLS
Martha Kaplan, BA
Pa ii 1 Okumo t o
Ethel Kawano
Elizabeth Munoz
Elizabeth Medei ros
Verna May Okano
Jeanne Tucker
Thelma Fu jisawa

Medical Economist 100
Administrative Manager 100
Chief of Planning and Operations

  Pacific Areas 100
Chief of Operations 100
'"Chief of Allied Health Services  100
- Biostat./Epidemiology 100
C omp t r ol 1 er                 100

Ass't. ChiefICoop. Comm.
Health Services 100
Medical Librarian 100
Administrative Ass t 100
AV Technician 100
Exec. Secretary 1 Or)
Secretary 100
Secretary 100
Secretary 100
Secretary 100
Bookkeeper 100

. ...

- ...
I. ..
.. ..

_.

'< --- . : .
,, ' ... , , ..

.

I

HAWA I1 RMP -7- RM 00001 8/71

Following are the names and functions of the Committees of RMPH:

Allied Health Committee - Facilitates community liaison with allied health
groups. Identifies needs, proposes projects to meet needs and evaluates
ongoing allied health activities.

Cancer Advisory Committee - Encourages project development and community
coordination in cancer area, isolates needs, determines priorities and
recouxnends projects to Technical Review Committee, Executive Committee,
Long-Range Planning Committee, and R.A.G.

Executive Committee - Reflects community's interest in on-going programs
and guides core staff activities in coordination with new directions
and new priorities as well as revfews project progress monthly.

Heart Advisory Committee - Encourages project development and community
coordination in heart area, isolates needs, determines priorities,
and recommends projects to Technical Review Committee, Executive Cornittee,
Long-Range Planning Committee & R.A.G.

Kauai County - Facilitates regionalization of projects throughout the
county, assesses county health needs and reviews and encourages proposals
with these in mind. Works in close cooperation with the county CHP advisory
committees; In some cases memberships are identical,

Hawaii Cot'nty - Facilitates regionalization fo projects throughout the
county, assesses county health needs and reviews and encourages with these
in mind.
In some cases memberships are identical.

Cooperation Community Health Programs - Did not elicit desired input  from
proverty area residents, as it was too structured;  therefore it has been
dissolved and other mechanisms for obtaining proverty cornunity involvement
that are more informal are sucessfully being used.

Maui County - Facilitates regionalization of projects throughout the
county, assesses county health needs and reviews and encourages proposals
with these in mind. Works in close cooperation with the county CHP
advisory committees.

Works in close cooperation with the county CHP advisory committees.

In some cases memberships are identical.

Regional Advisory GrouE - Provides overall advice and guidance the the
RMP-H through policy setting and priority establishment; fosters cooperative
efforst on part of community agencies and grouns in improving health care
equity of access, maintenance of quality in health care and in the constraints of
cost in health care. It also aims to influence improvements by providers
towards the economLca1 regionalization of health care. It reviews all project
proposals before submission to the NAC of RMPS.

RAG Evaluation Committee - Provides independent assessment of overall
program development.
to goals and priorities and proposes recommendations for the future of
the program.

Informs R.A.G. haw activities are functions relate

HAWAII RMP -8- RM OOOQl 8/71

Stroke Advisory Committee - Encourages project development and community
coordination in stroke area, isolates needs, determines priorities and
recommends projects to Technical Review Committee, Executive Co:mittee,
Long-Range Planning Committee & R.A.G.

Finance Committee - Reviews expanditures and budgets; guides and advises
Executive Committee and staff through fiscal policies.

Operational Support Team - Monitors operating projects and through evaluation
and feedback improves the ongoing projects' ability to achieve their
objectives more realistically; provides comments, assistance and specialized
consultation to Operations Branch.

- Continuing Medical Education Advisory Committee -  Membership overlap with
Continuing Health Education Council, Inc., therefore, meets only when RMP

physician education projects need community guidance.

Long-Range Planning Commfttee - Identifies ne.eds, assesses resources , suggests
improvements in organization patterns, establishes priorities, recommends
evaluation procedures.

Technical Review Committee -'Reviews all project proposals, making specific
recommendations for changes and improvements in the proposals with respect
to substantive conent, adequacy of supporting materials,  relevance and
accuracy of technical data and general quality of the document  text.

Selections Committee - Nominates members and Chairmen of the categorical
disease committees for appointment by the Executive Committee to maintain
the high caliber and broad representation of the membership.

Pacific Basin - Acts as liaison between its assessed health needs and
project proposals to make the latter effect the former in Guam, American
Samoa and the Trust Territory.

, ,'

Personnel Committee - Recommends employment of supplementary and replacement
personnel to augment core staff strengths as new directions emerge.

Nominations Committee - Nominates members of Regional Advisory Group and
Executive Committee to replace those members whose terms expire to keep

membership broadly representative.

Project Review Process:
as a letter of intent submitted to the Director of RMPH. Ideas for

Each project proposal begins the review process

project proposals are generated by individuals, agencies or organizations
in khe health field. The Director and Core staff assess the revelance
of the idea, proposed in the letter of intent, to the overall plan of RMPH.
If it seems relevant, the Director assigns an appropriate staff member
to assist in further development of the project with the advice of the
committee set up for this.
takes several months. The Core staff works closely with the applicant
organization
Guidelines.

The development of the project often

throughout,to construct a proposal which follows RMP
After the final draft of a proposal has been completed,  it

..

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. ., .-

I .

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.. * , i

Hawaii RMP -9-

is channeled through the appropriate Categorical and
Committees, then through the Executive Committee and
Group. Upon final approval of the RAG, the proposal
national review.

. --

proposals are reviewed in terms of:

Relevance to the overall 'plan of RMPH
proposal furthers regionalization and

RM 00001 8/71

Technical 'Lleview
the Regional Advisory
is sent to RMPS for

and the degree to which the
cooperative arrangements,

to improve our present health care system in Hawaii.

Identification of needs and opportunities within the region.

Definition of objectives in clear, measurable terms.

Assessment of resources, including the identification and use of
existing resources, avoidance of duplication, and the initiation
of cooperative arrangements and closer linkages between the
available resources.

Involvement of individuals, organizations and institutions within
the region.

Indication of the priority level of the proposal in relation to the
overall goals and objectives of RMPH.

Implementation, including strategy, methodology and techniques for
accomplishing the stated objectives.

Evaluation protocol developed to measure achievement of the objectives
and assess the overall effect of the proposal.

Although there is no formal review relatonship withCHP, projects are
often discussed with CHP personnel during the preliminary stages of
project development.

A problem encountered with the present review mechanisms is the difficulty
attendant upon the veto pawer'of any one review committee.
is required with respect to the effect of one review committee's veto on
the continued progress of a proposal through the local review mechanism.

Clarification

HAWAII RMP

- 10 -

PROJECT REVIEW FLW CHART

GRANT APPLICATION
(any agency, planning
  Staff RMPH)

1

ADMINISTRATIVE OFFICE

PROGRAM COORDINATOR
(for relevance to
overall plan)

RM 00001 8/71

    PLANNING SECTION
(when grant comes from agencies
other than RMPH for review by

staff with expert advice as

needed)

(for subject matter
and excellence)

4,' TECHNICAL REVIEW

COMMITTEE

EXECUTIVE COMMITTEE

    GROUP
REGIONAL ADVISORY

I

DRMP /

Washington, D.C.

m-omn An CH CORPORATION

FUOFH

Kn3LAN

0

-_

(copy of project--

for informetion only) ' '

HAWAII RMP

- 11 - RM 00001 8/71

Annual Report of the Regional Advisory Group

The Regional Advisory Group of the RMPH report their satisfaction of

progress made by the- RMPH to meet goals and objectives set forth for
the past year. The RAG indicates its awareness of the new direction
of RMPH and acceptance of the present national priorities on improving
health care delivery. While supporting this innovative potential for
changing the health care system, the committee continues to support
continuing education for providers, general public education and
provision of technical and professional assistance in the development
and implementation of new concepts, standards and practices with
particular attention to the evolution of health care delivery,  reform
and eventual constraints in cost. The Regional Advisory Group proposes
the following future goals and objectives:

,

1, Concur in shift in direction of RMPH to improvement in health

care system, particular accessibilityand quality of care.

2. Activities should relate to identification of needs, assessment

of resources, improve organization patterns, develop cooperative
arrangements, establish priorities, institute evaluation
procedures and improve communications.

3. Specific proposals to reach objectives include: studies and

research; study groups and workshops; activation of county
advisory committees; organization of Honolulu Hospital Committee;
funding of part-time county and hospital M.D. coordinators;
work to catalyze and establish cooperative arrangements  among
health interest; and development of new techniques of continuing
education.

The RAG sesthe core staff members playing a more active and dominant
role by assisting in the development
improving the health care sytem related to greater accessibility, and
quality of care.

of new and innovative methods of

The RAG reports that the RMPH works cooperatively with other federally
sponsored programs such as Model Cities Cities, Community Action Programs,
and Comprehensive Health Planning, and others. In addition, the RMPH
has good relationship with professional associations, health agencies,
educational institutions and groups interested in categorical diseases.

Following are a list of recommendations which the RAG has approved  for
implementation for the issuing year:

a) Each RAG member should be assigned  to a Committee.
b) There should be an educational workshop annually for all RAG members.
c)  There should be a manhal published for each RAG member setting forth

the goals and objectives of RMPH with an outline of the duties and
responsibilities of each RAG member.

d) The Director, Chairman of the Executive Committee, and Chairman of the
RAG should meet personally with each new RAG member at  time of
appointment.

HAWAII RMP - 12 - RM 00001 8/71

The Director and designated members of the core staff should meet
periodically with all RAG members to review RMPH activities from
time to time.
The RAG members should receive a copy of the minutes of each Executive
Committee meeting immediately following meetings of the Executive Committee.
Communicate frequently, regarding RMPH program and activities, to RAG
and committee members for their information.
A RAG Evaluation Committee should be established as a standing committee
to meet regularly during the year to evaluate RMPH programs and activities
rather than once a year on an ad hoc basis.
Continue to strengthen the evaluative process and procedures for the
qualitative aspects of the Regional Medical Program of Hawaii and the
individual operational projects and activities.
directed toward determination of behavioral changes in health professionals
as well as the real influence on morbidity and mortality  rates of health
care. Establish specifically, evaluation tools and measurements for
each project and significant core staff activity.
A representative of the Hospital Association of Hawaii and the Nurses
Association of Hawaii be appointed to membership on the Executive
Committee. This Committee recommends that action be taken to
implement this Executive Committee membership as soon as possible
but not later than June 1, 1971.
An Associate or Deputy Coordinator be employed or designated.
RMPH continue active involvement with core-staff activities and
demonstration projects in the Pacific Basin with the maximum limits
that the budget will allow.

*

Attention to be

-

m) A clearly defined process for all ideas and proposals for RMPH projects
and activities should be established. This should include the
mechanism for continuing feedback to individuals and agencies proposing
projects in order that they may know the exact status of a project
at any time.

n)  Provide extention of training and education to health personnel in
extended care facilities, nursing homes, and care homes to strengthen
programs related to rehabilitation and out-of-hospital services.

be charged with the responsibility to carry out the foregoing
recommendations as expeditiously as possible.

0) The RAG Evaluation Committee recommends that the Executive Committee

Evaluation

The RMPH has an Emhadon Committee which provides independent assessment
of overall program development.
how activities and functions relate to goals and priorities and proposes
recommendations for the future of the program. The region indicates that
the activities and achievements in operating projects and by core staff
members are measured and evaluated in terms of the stated RMPH goals
and that final evaluation of results rests with the Director, Executive
Committee and ultimately the RAG.

The Evaluation Committee informs RAG

I..

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I -. .

,

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e

e

HAWAII RMP - 13 - RM 00001 8/71

Developmental Component

The Developmental Component  of the Regional Medical Program of Hawaii
will follow the presently working review cycle and monitoring.

The Region states that the Developmental Component provides the needed
opportunity for RMP-Hawaii to establish innovative activities in
continuing education as pilot studies; to test their feasibility,
palatability and productivity on a limited experimental basis before
extending their scope and insuring their longevity through the formal
mechanism of project proposals.

These educational programs will include:

A. Demonstration Projects of innovative patient care systems
B.
C. Staff development training programs

Feasibility and utilization study projects

The Region believes that the availability of the Developmental Component
will provide an immediate opportunity for the Regional Medical Program
of Hawaii to influence the need for organizational change of individual
hospitals and in the overall hospital system of Hawaii.
believes that instituting organization change in the present hospital
system is the most economical and feasible way of insuting that compre-
hensive care is accessible to every citizen that is in need of medical
care. Activities which are being considered for improvement of the
hospital system under the Developmental Component include:

The Region

Studies of hospital emergency care departments
Shared services with hospitals joining together for the
operation of certain basic facilitative and supporting
services, clinical and non-clinical in nature
Educational seminars for board members, hospital administrators
and medical staff in understanding the role changes that are
necessary in the organizational structure to provide compre-
hensive medical care
The operation of one or more sub-units of patient care by
one central parent hospital corporation
Study of the feasibility of training doctor's assistants in
hospitals
Development of health manpower pools
Investigation of the possibility of establishing an all-
inclusive hospital rate
Promotion of an identification program related to designating
routes and qublicizing availabillty of hospital and emergency
care services to the public.

The Region is requesting a funding level of $78,897 for the developmental
component which is an amount equal to 1077 of the annual direct cost
funding level (not including carryover)  of the Region at the present
time.

Core Central Repional Service Activities

Medical Library:
medical community in the Region through this activity have included

Services which have been extended to members of the

HAWAII RMP - 14 - RM 00001 8/71

literature searches, translation, book selection, consultation, and
data collection.

Audiovisual Services: The core staff includes an audiovisual specialist
who provides community service and consultation to hospitals, physician
group, voluntary health agencies,government agencies as well as RMP
projects .

Consultant Service in Medical Education: Core staff members provide a
variety of consultation services to health-related organization in the
community .

._

Health Maintenance Organization: RMPH core staff are meeting actively
with interested hospitals, medical groups and other agencies who have
expressed an interest in the development and organization of an HMO.
Future involvement will include assistance in the feasibility decision,
resource review, subscribes market, systems for performance monitoring
and evaluation alignment of resources to deliver HMO services, health
systems design, record keeping system, medical and paramedical education,
development of monitoring system for internal management and external
audit.
and involvement in discussing the development an HMO.

To date four specific groups have requested RMPH assistance

Cooperative Community Health Services: The purpose of this core service
is to act as a resource and provide assistance to citizen groups in
disadvantaged areas iil order to improve the health status of this
community. Target groups for this service are primarily the two
Model Neighborhood Areas and Community Action Program target areas.
The nature of the assistance provided by this RMPH service includes:
familiarizing the cornunity with the health care system and its
effective utilization, identifying community resources, identifying
problem areas and needs, increasing the accessibility of health
services, assisting in planning programs to fill the need and problem
areas, providing back-up health statistics and research material, and
facilitating assistance from+ appropriate agencies.

Projects

The region indicates that specific core staff are assigned to monitor
and evaluate progress of all projects  to determine if they are meeting
objectives on a qualitive and timely basis.
requlred for each project includes:
monthly progress reports; and periodic documentary of mainland travel;
employment of consultants and utilization of project faculty members.
All reports are reviewed by the core staff,  executive committee and the
Director.  Following are the projects for which the region has requested
support .

Periodic reports which are

monthly expenditure reports;

Continuation Within Approved Period of Support

Project #15 - Regional Cooperative Chemotherapy Program - This project

04 year $110,000; 05 year $73,333.

was initiated June 1970 and has the remaining commitment:

HAWAII RMP - 15 - RM 00001 8/71

The region has requested support to continue operation of this project:
04 year $110,000 and 05 Year $73.333.

The objectives of this project continue to be to provide improved care
for cancer patients; evaluation and/or treatment of patients in the units;
improved data collection, storage and feedback to the physicians; improved
education for physicians and dissemination of information in use of
chemotherapy.

The program reports that it has organized a regional oncology therapy
program (6 active chemotherapy units)  established an educational
program on oncology and progress has been made in establishing a computer
program and a Telephone Task Force to aid in consultation.

Project #20  - Constant Care Unit - Guam Memorial Hospital - This project

was initiated in June 1970 and it has the remaining

commitment:
in this applicaticn support to continue operation of this project:
04 year $39,909 and 05 year $23,314'.

04 year $39,909, 05 year $23,314.

The region has requested

The primary objectives of this project continue to be to improve the
delivery of intensive and coronary care to 71,696 Guamarians and
referrals from the Trust Territory.

It is reported that two physicians, six nurses and one engineer have
been trained in Hawaii and the mainland U.S. in the cooperation of the
constant care unit, Guam Memorial Hospital. In addition, an existing
ward was renovated and put into operation. Equipment has been ordered
from the mainland U.S. with installation and maintenance services
furnished by an authorized subsidiary of the American manufacturers located
in Japan.

Continuation Beyond Approved Period of Support

Project #3 - Promotion and Extension of the Home Care Concept

no remaining commitment. The region reports that through this $52,800
project,workshops and training of health personnel  in Home Care
Services and techniques have involved 425 physicians, nurses and allied
health members. The caseload of home care patients was 330 in 1970 and 275
a year earlier or an increase of 20"/, in Hawaii,
consultation visits and several audiovisual training films have been
developed to publicize the home care program and train health personnel
in home care service procedures and techniques.

Third Year
Requested

This project was initiated in February 1969 and has

There have been 11 site

The region has requested 3 years of additional support  to continue
this project.
the home health services among providers and consumers through trained
staff and educational media and to gather and present evidence that
expenses are saved by insurance companies which subsidize home care
without previous hospitalization and that home care service in general
reduces acute and long term care facilities expenditures.

The primary objectives of the project are to popularize

Fourth Year: $39,875 Fifth Year: $40,004

HAWA IT RMP - 16 - RM ooooi 8/71

Project i/


commi tmen

7 - Cardiopulmonary Resuscitation - This project was
  initiated in February 1969 and has no remaining
t.  It is reported that this project has met the

Requested
Third Year
$35,000

objectives of: 1) retraining and stabilization corps of 300
instructors; 2) initiating In-service training programs in 31 hospitals;
3) getting eight hospitals to require CPR certification to maintain
staf privileges; and 4) developed a standardized report form. The
objective of training 20,000 people was not obtained; only 9,581 have
been traine'd in CPR and 1,275 retrained.

The region has requested two years of additional support for this project
which would provide about five years of funding through RMP. It proposes
to conduct 12 instructor workshops, train 12,000 hospital, rescue ,
paramedical and high risk industry people; to provide consultants for
related training programs; to achieve and improve first contact care and
transporative care for victims of respiratory and cardiac arrest.

Fourth Year: $19,700

Project all - A Regional Approach to Pediatric Pulmonary Care
       This project was initiated in Feburary 1969 and

Requested
Third Year

has no remaining commitment. The region reports that since $94,853
the Pediatric Pulmonary Center opened, 218 infant patients
have been treated at the center. The education program in Pediatric
Therapy and Care has involved 286 physicians and 554 nurses and
allied health personnel in training sessions and organized hospital
in-service training programs.  An education program has begun for
family members to care for children at home who labor under
respiratory distress. In addition, an ambulance service has been
developed and equipped to transfer sick babies between hospitals
and from neighbor island hospitals through the Honolulu International
Airport.

The region has requested iorthis application an additional three years
support to continue this activity.

The project proposes to;:l) train 36 nurses, 18 physicians, 36 paramedicals
and 18 administrative personnel; 2) to evaluate 17 key areas in the state
for chest clinics; and 3) to develop air evacuation-transfer of critically
ill patients.

Fourth Year: $82,285

NElJ PROJECTS

Fifth Year: $77,335

Project #28 - Medical Library Information Network -

to improve and expand library facilities of the 33
medical institutions in the Pacific Basin through augmentation
and cooperation, including library personnel training and medical
forces education.  It provides for a network coordinator who will

Reques ted

$78,021

The primary objective of this proposal is First Year

HAWAII RMP - 17 - RMOOOOl 8/71

be responsible for service development, data collection, user surveys,
resource evaluation studies, and will effect cooperative agreements
among libaries for the most efficient and economical means of
satisfying identified needs.

0

-

Second Year: $41,756

Third Year: $41,506

Project #I29 - Intensive Care Nursing -

ing programs to become qualified members of intensive care $75,610
units.  Activities planned during the first year will train
two classes of 12 nurses each in a six-week educational program based
at the University of Hawaii with clinical practices at the Queen's
Medical Center, St. Francis Hospital and Kuakini Hospital. Two
courses will be taught each year.  Annually24 nurses will complete
the course.

This project proposes

Requested

to train 72 professional nurses in six-week train- First Year

Second Year: $67,718

Third Year: $67,718

Project 830 - Waianae Coast Comprehensive Health Center

Requested

The Waianae Coast has a multi-ethnic First Year

pepulation of 25,000 and is characterized by high

$267,300

unemployment, lack of local employment opportunities,
low income, low educational levels, limited transportion, inadequate
job skills, inadequate and substandard housing and  limited and
uncoordinated health services. The area is a target for Model Cities
and Community Action Program.

There is an immediate need for health, medical and related social
services in the target area. Since 1965 the community has been
working toward improving health services. The Waianae District
Comprehensive Health and Hospital Board, Inc.,has been working with
various public and private agencies to implement their program concept
for comprehensive health services in the area.
tive planning have been RMPH, CHP, Governor's Office, Model Cities,
Departments of Health, Social Services, and Accounting and General
Services, Schools of Medicine and Public Health, Hawaii Hospital
Association, Dental Society, Medical Society, Health and Community
Services, OEO, Honolulu Home Care, and Human Services Center.

RMPS support is being requested for coordination and administrative
personnel, some diagnostic equipment for screening and early detection,
computer and da&a processing costs for the Medical/Environmental Data
System, and consultant services for evaluation.

It is indicated that program evaluation will be conducted in
three primary areas of concern, accessibility, quality of care, and cost.
The Region believes that this program has great potential for conversion

e

Included in the coopera-

to a Health Maintenance Organization.

Second Year: $248,857 xhird W $257,049

HAWAII RMP - 18 - RM 00001 8/71

Project #31 - Upgrading of Bedside Nursing Care in Rural Community

the sponsoring agency for this project, with Dr.  Jack Humbert as

project director. The primary objective is to provide bedside
instruction to nurses on the lastest medical concepts in practical
application of modern nursing care in 5 rural hospitals on the
island of Hawaii.

support for this ac tiv it y

Requested
First Year

Hospitals - The Hawaii Community College will be $29,250

This program will be evaluated on an on-going basis

I
L

for both quantity and quality. The region has requested only one year

Project #32 - Monitoring of Physiologic Data From Outlying Community

The Queen's Medical Center is the affiliate institution for First Year
this proposal. Alfred Morris, M.D. and Philip Foti, M.D. are $77,811
co-project directors. Participating hospitals in the project are
Fiaui Memorial, Wilcox Memorial, Kauai Veterans, Hilo, Kona, Wahiawa,
Castle, Kahuku, St. Francis, Kuakini and the Queen's Medical Center.

Hospitalsat Medical Centers in Honolulu. Requested

The primary objective of this proposal is to connect electronically
8 coronary care units fromllcighboring fslands and remote rural areas
to 3 medical centers in Honolulu so that physiological data can be
monitored and rapid consultation education to coronary care professional
and allied health personnel can be provided.

Implementation of this program will be accomplished in four distinct
phases: 1) installation of a DATATEL monitoring system; 2) initiation
of inanediate consultation services to outlying islands; 3) didactic
electrocardiographic monitoring training courses; 4) weekly conferences
utilizing DATATEL hookup. Evaluation has been built into the program.

Second Year: $63,178 Third Year: $65,176

Project #33 - Community Involvement for the Physically Retrained -

is the sponsoring agency for this proposal and Dr. R.F. Shepard
is the Project Director. The primary objective is to teach or
educate key people of 20 community agencies to develop realistic
approaches in the utilization of the energies of 500 retrained handicapped
and assist them to develop skills and interest,  find social contacts and
to use their time and residual abilities to give purpose to their life.

Requested

$79 , 109

The Pacific Institute of Rehabilitation Medicine First Year

Second Year: $76,629

Third Year: $75,958

Project #34 - Cardiac Disease Detection and Rehabilitation -

health agencies will participate with the Queen's Medical
Center in this proposal.  Jack Scaff, M.D. will be the Project
Director. The primary objective o this proposal is: 1) early
detection of 600 potential heart disease patients; 2) administer
prevention care to 300; 3) rehabilitation of 200 'patients with
cardiovascular disease to prevent recurrence; and 4)  to train 100

Requested

$61,221

Nine hospitals, Central YMCA, and various First Year

IVlWAII RMP - 19 - RM 00001 8/71

health professionals, including new types of allied health and

lay personnel.

Second Year: $52,131 Third Year: $53,683

Project #35 - Respiratory Therapy Traininq - The affiliate

Community College in Honolulu. This is a three-year project $26,900
to upgrade the capabilities and accessibility of respiratory
care in Hawaii, Guam and American Samoa. The primary objective of
the activity is to train 60 selected nurses and allied personnel
each year in 2 fourweek training programs and two physicians in
2 three-day preceptorship training programs in the special techniques
of respiratory care.

Requested

institution for this proposal is the Kapiolani First Year

Second Year: $26,900 Third Year: $26,900

Project #36 - Improving the Accessibility of Care to Stroke Patients Requested

are to train eight multidiscipline (RN, OT,I?T, SW, Dietitian, $35,526
Speech Therapist), stroke teams; five on Oahu, and one each of the
outer islands: Maui, Kauai and Hawaii.

in Hawaii - The primary objectives of this proposal First Year

Second Year: $43,428

e

Third Year: $39,088

RMPS /GRB /6 / 17 A7 1

REGION Hawaii

CYCLE RM 00001 8/71

BREAKOUT OF REQUEST 04 PROGRAM PERIOD

  (Support Codes)        (5) (2)

IDENTIFICATION OF        APPR. PERIOD APPR. PERIOD

COW. WITHIN CONT. BEYOND

COMPONZNT OF SUPPORT OF SUPPORT

DO0 - Develonmentsl

t1 - Core

$51 6,624

Reg, Coouerstive I

#I 5 - Chemotheraay Prog. $1 10,000

39,909

C20 - Constant Care Unit

#3 - Home Care ,

#7 - CPR Training

ill - Ped. Pulmonary Prog.

#28 - Med. Library Info.

629 - ICU Nurse Training

   Compreh. Health
630 - Center (Waianae Coasl)
   Bedside Nurse Care
8.31 - in Rural Hospitals

52,800

35,000

94, a53

(7) (1 1

MPR. MOT BEW, NOT   1st YEAR
PREV, PREV .    DIRECT INDIRECT TOTAL
FUNDED APPROVED  COSTS COSTS

$78, a97 $ 78,097

                     $ 78,897

       516,624 516,624
1 I I 137,800

39,909       ---        39,909

52,800    20,048      72 , 848

---

iio,ooo $ 27,800

1

35,000       ---        35,000

94,853    26,369      121,222

$ 78,021 78,021 --.. 78,021
75,610 75,610 --- 75,610

               --- 267,300
29,250 29,250 -*- 29,250

267,300

267,300

u

H

Physiological Data

Corn, Involvement fo

Cardiac Detection 6 I

132 - Monitoring System

#33 - the Phys. Retrained

834 - Rehabilitation

#35 - Resn. Thersny PrOj.

   Iwroving Access to
436 - Care for Stroke Pat.

I

'd

                      98,634
77,811 77,811 20,823

                         101,101
79,109 79,109 21,992
61,221 61,221 24,640 85,861
26,900 26,900 7,478 34,378

35.526 35,526 -.- 35,526 .

i

1
h)
0

I

TOTAL

0
0
0
0
I

I

$699,277-: /$78,897 I $730,748~$1,658,831 I $149,150 ' $1*807,981

1 GRB 15 11 7 171

$1 49,909

OJ
\
v
c

o

..--

(Suoport Coder)

ISEKIIIFICATION OF
CCBYPONENT

DO0 - Develonme ntel

#I - Core

-

t20

:ONTINUATION BEYOND
VPROVED PERIOD OF
iUPPORT

$533: 457

f3

APPROVED,NOT  NEW, NOT
PREVIOUSLY    PREVIOUSLY
FUNDED      APPROVED

$78,897

#7

#I 1

$78,897

$67S, 31 7

f28

$620,597

#2 9

f30

f31

132

f33

f34

f35

#36

--

TOTAL

REG ION Hd i~
BREAKOm OF REQUEST 05 PROGRAU PERIOD

(5)

COIRINUATION WITHfl
&PROVED PERIOD OF
SWPORT

$73.333

23,314

$96,647

39.875

19,700

82,285

$ 41,756

67,718

248,857

63,178

76,629

52,131

26,900

43.428

2nd YEAR
DIRECT
COSTS

$ 78,897

533,457

* 73,333

  23,314

  39,875

  19,700

  82.285

  41,756

67,718

248,857

---

63,178

76,629

52,131

~ ~-

26.900

43,428

$1,471,458

o

REGION Hew8 i i
BREAK3UT OF REQUEST 06 PROGRAM PERIOD

          . CQT'QIRUDION WITHIN CONTINUATION BEYOND APPROVED, NOT NEW, NOT
IDENTIFICATION OF APPROVED PERIOD OF APPROVED PERIOD OF PREVIOUSLY PREVIOUSLY
COKPONE&NT SDPPORT GUPPORT FUNDED APPROVED

DO0 $78,897

3rd YEAR   TOTAL
DIRECT     ALLYEARS
COSTS    DIRECT C@TS ,

-

$ 78,897 $ 236,691

I
?a
N
I

* (Supoort Codes) (5 1 (2) (3) (1 ) 6

Care $555,332 555,332

                                                                           ---

#l5

820 t ---
5.3 40,004 40,004

67

61 1 77,335                           77,335

P28                                      $41,506 41, SO6

829                                         67,718 67,718

#30                                       257,049 257,049

#31
f32 65,176 65,176
133 75,958 75,958

                                                        53,683
f34 53,683
135 26,900 26,900

I 1

I

I

..

---

#36 39,088 39,088

$78,897 $627,078 $1,378,646

TUTAL $672,671

8'

4

1,605,413

183,333

63,223

132,679

54,700 '
        r

254,473

161,283

21 1,046
773,206 1

206,165 1

231,696 i
. 167,035 i

80,700

29,250

+

-

f

t

-.

118,042 '

I

I

$4,508,935

Y

A PRIVILEGED COMMUNICATION
RM 00001

page 23

SITE VISIT REPORT

DECEMBER 3-4, 1970

HAWAII REGIONAL MEDICAL PROGRAM

Chairman

Gerald Besson, M.D., Member RMPS Review Committee

ReRional Medical Programs Service Staff

rsmael B. Morafes, Public Health Advisory, Grants Review Branch
Daniel Spain, Operations Officer, Regional Development Branch
Gerald T. Gardell, Chief, Grants Management Branch
Cecilia C. Conrath, Chief, Continuing Education and Training Branch
Ronald S. Currie, Regional Office Representative, DHEW Region IX

ReRional Advisory Group

Mr. E.E. Black, E.E. Black and Company
Mr. Edward C. Bryan, Vice Chairman, Chairman Executive Cornittee
Mr. Masaichi Tasaka, President-elect, Hospital Associationcof Hawaii-

Neal Gault, M.D., Chairman, Evaluation Committee , Associate Dean, School

Richard K. C. Lee, MOD,, (ex officio), Research Corporation, Executive Director
Mrs. Sylvia Levy,
Harold Sexton, M.D., Straub Clinic
Mr. George Sumner, Jr., Vice President, Blythe and Company
Bernard J. 8. Yim, M.D.,
of Executive Committee
Mr. Harold Ajirogi, Member Executive Committee, Sr. Officer, East-West Center
llnogi Goto, M.D., Member Executive qommittee, /Honolulu Medical Group
John Lowrey, M.D., Member Executive Committee, President-Elect, Hawaii

William R. Coops, (ex officio member, Executive Committee)
Plrs, Kazue K. McLaren, Assistant Chief, Public Health Nureing Branch
Senator George Mills, M.D., Medicine Director, Kamechamehu School
Walter B. Quisenberry, M.D., Director, Department of Health

representing Mr. Ollie Burkett

of Medicine, University of Hawaii

Comprehensive Health Planning Officer

Chairman of Long-Range Planning Committee

(member

Medica 1 As soc fa t ion

tlWP Categorical Disease Committees and Technical Review Committee

Cancer Advisory Committee
James Banta, M.D.
Mr. James Bunker
Mr. Richard Hager
2.  v ing 9 ton Wong ,M . D .

Heart Advisory Committee
Miss Charlotte Dennis, R.N.
H.H. Chun, M.D.
Mrs. Ruth Iwata, R.N.
Miss Janice LacosE, R.N.

Hawaii Site Visit Report

Page 24

Stroke Advisory Committee
Elizabeth Anderson, M.D. ( Vice Chairman)

Abraham Kagan, M.D.
David Lee Pang, M.D.

'Technical Review Committee
Reginald Ho, M.D.
Donald Leton, Ph.D,
Ming Pi Mi, Ph.D.
Robert Weiner, M.b.
Drake Wili, M.D. (Chairman)

-

tlowa i i Ilea 1 th Aprenc ies

Mr. James Bunker , Executive Vice President , American Cancer Society--
Mrs. Mary Lee Potter, Executive Director, Hawaii Nurses Association

Vilbur S. Lummis, Jr., M.S., M.D. Deputy Director, Department of

Edward O'Rourke, M.D.,
Mr. Donald Stapp, Executive Director, Hawaii Heart Association,

Raymond Corsini, M.D.,
Plr. Richard Hoag, Executive Director, American Cancer Society --Oahu Unit
Clifford Straehley, M.D.,  President, American Cancer Society--0ahu Unit
Harlan Cleveland, President of the University of Hawaii

I-?nwaii Dfvislon

Health, State of Hawaii

Mawa i i

Dean, School of Public Health, University of

American Cancer Society--Hawaii Division-Consultant

Grantee Tnstitution Research Corporation of the University of Hawaii

Richard K. D. Lee M.D., Executive Director, Research Corp.
Mr. William R. Coops, Administrative Officer, Research Corp.
Mr. G. C. Dfxon, Comptroller, Research Corp.

Hawaii RMP Core Staff

Masato Hasegawa, M.D., Director
Alexander Anderson, MOD.,
Mrs. Nancy Crocco, Assistant Chief of Cooperative Conanunity Health Services
Mrs. Rosie Chang , Chief of Allied Health Services
Mr. Paul Cook, Associate Chief of Operations
Mrs. Ruth Denney , Chief of Planning and Research Services
Satoru Izutsu, Ph.D., Chief of Planning and Operations for American Samao,
Kanae Kaku , M.D. , Rfostatistician/Epidemiologist
blr. Norman Kuwahara , Comptroller
Mr. Hobert Murranka, Administrative Assistant
EIr. Paul Okumoto , Audio-visual Technician
Plr. @mar Tunks, Chief of Operations
Flr. Clyde Winters ,Medical Librarian,

Consultant in Continuing Medical Education

Cliiam, and the Trust Territory of the Pacific Islands

Hawaii Regional Medical

Program Site Vieit

-25 -

RM 00001

Background: The previous site visit to the Hawaii Regional Medical
      Program took place January 26-27, 1970, and its primary

-

purpose was to review program development. In general, it was
the opinion of the site visitors that, considering problems involved,
regionalization was moving forward. Problem areas at that time
revolved around the following issues:

I. Mr. Ollie Burkett, a member of the RAG, and Executive

Director of the Hawaii Hospital Association,  did not believe
that hospitals were involved enough in the decieion-making
process and planning phase of the RMP.

2. No representation for the 22 osteopaths in Hawaii on the
  RAG or committees.

3. Core staff lacked strong top-level administrative direction

for their activities.

4. The visitors believed Dr. Masato Haeegawa required the
assistance of a full-time deputy or associate director
to help him administrate the day-to-day operations, so
  that Dr. Hasegawa could be free to spend more time in
developing the philosophy and direction of the program.

5. The visitors believed that the Region needed staff in

certain categorical areas; such as a Specialist in continuing
education.

e

$L

6. The RAG played a minor role in the Regional Medical
Program, compared to the Executive Committee which appeared
to be the emerging powerful force in directing the Regional
Medical Program.

7. The visitors believed that there was needed representation
on the RAG from organized labor and low-level consumers.

8. It appeared that the RMP core staff was only belatedly
identifying the problems of urban and rural, disadvantaged
communities in their Region.

9. The visitors found it very difficult to consider the

question of Hawaii RMP's role in the Pacific Basin.  It
was obviously a question that has perplexed the Region.
The site visitors agreed with Dr.  Satoru Izutau that
operational projects would serve as a tool by which the
W of Hawaii could help introduce a better system of
health care in the Pacific Basin.

.-

Wawaii Regional Medical

Program Site Visit

- 26- RM 00001

C:unccrnu of thie Site Visit: To determine the maturity of this
Region and its readiness for a developmental component award
by focusing on:

--- -

1. A review of program development to date, with particular
regard to the development of core staff activities, the
Regional Advisory Group, categorical disease committees,
and the relationship among the key institutions in the
Region, including the medical school, hospitals, State
Health Department, and the Medical Society;

2. The relationship of the development component request with
total program development.

- General Comments: Dr. Gerald E. Besson clearly indicated to Dr.
Masato M. Hasegawa, HRMP Coordinator, the Regional Advisory Group
members present and each group of committee members as they participated,
the purpose of the site visit and its relative significance  to
the total review process, including Committee and Council review
uf the application under consideration.

It was evident to the site visitors that there has been considerable
progress made by the Hawaii RMP toward developing the general
principles of regionalization. The Region has developed a framework
for planning the achievement of goals and objectives. Methods
for evaluation are being developed. The visitors did not review

_-

c  `1
/.    .;

,. e--

....
. _I

projects but rather focused the review on the established organizational
structure and administrative process of the HRMP, its interrelationships

.u-

with the health care system of Hawaii and its capability to
implement the program in accordance with stated goals and objectives.

Statement of Accomplishments of Regionalization: It is easy to
recognize that this Region has significant problems created
by the mixture of ethnic groups, the dispersion of the counties
(islands) of the State by distances as great as  200 miles (with
all inter-island travel being essentially by air >,  the absence of
a fully-developed four-year medical school, and the loyalties
created by affiliation with a single hospital, which make  it
difficult for people to think of the community problems at large.

`The relationship of the Hawaii Medical Association to the Hawaii
Kcgional Medical Program as described by John Lowery, M.D. appeared
to be satisfactory. He stated that the Hawaii Medical Association
wants to cooperate with the Regional Medical Program beaause it
believes that it can relate better to the Regional Medical Program
than it can to the Comprehensive Health Planning or other Federal
he3 I th programs.


Dr. Neal Cnult, Jr., Associate Dean, Univeruity of Hawaii School
of Medicine, was present and explained that the relationsliip
and spfrit

of cooperation between the University School of Medicine

Le/

and the IiKbtP is good.  The visitors, however, believe that tfic ~ I - .>
Nledfcnl ScliooL has an extremely limited capacity to play a slgnificant ."
role in attempting to actually get a four-year medical school

..

>

.._.__ "

. . .- _. . . .

._ .. . . .

___

k

.

Hawaii Regional Medical

Program Site Visit

-27 - RM 00001

underway. Dr. Gault expressed interest in the hospital-oriented
activities to which the developmental component is directed. He
would like to see these funds utilized to integrate hospital
service8 and believes the University Medical School could be
utilized as the coordinating point for its implementation.

Deputy Director of Health was present during the site visit and
tie indicated that the relationship between the State Health Department
and the Regional Medical Program is satisfactory. The RMP and
the State Health Department have exchanged planning data,  and
participate on committees which have a common interest, and the
Health Department is represented on the Regional Advisory Committee.

Mrs. Sylvia Levy, Director, Comprehensive Health Planninpl, explained
that the State of Hawaii has a 314 (a) Agency operating out of
the State Health Department and reporting directly to the Governor
of Hawaii.
It appears that the relationship between the Regional Medical
Program and Comprehensive Health Planning is of a positive nature
and that Mrs. Levy will be asked to join the Long Range Planning
Committee of HRMP,  The HRMP and the CHP have been jointly doing
a study on the distribution of health manpower in Hawaii:  Mrs. Levy
believes that the CHP and RMP should merge if possible to facilitate
utilization of manpower available rather than compete for it.
The activities of the CHP are restricted because it only has
a staff of three professionals. The general agreement seemed to
be that Regional Medical Programs could and should work more
closely with CHP.

There are no "b" Agencies in the Hawaii Region.

Mr. Ollie Burkett of the Hospital Association was not present
at the meeting, which was a disappointment to the site visitors:
however, the spokesman for the Hospital Association indicated
that the relationship between the RMP and the Hospital Association
has been gradually improving.
Mr, Burkett has had a great influence on the HRMP since becoming
a member of the RAG and the Executive Committee of the RAG. This
is certainly reflected in the strategy outlined by the region
which gives primary emphasis toward improving the health of
Hawaii through better and increased utilization of hospital facilities.

The School of Public Health at the University of Hawaii has been
involved with the Regional Medical Program since its early development,
The primary contribution that the school has made to the Regional
Medical Program, both actual and potential, involves its relationship
with the Pacific l3asin and its epidemiology competence. The School
of Public Health has also been very active with OEO, Model Cities,
and Comprehensive Health Planning with whom it has a training
grant. Dr. Edward O'Rourke, Dean, School of Public Health
emphasized the interests of the School of Public Health in making
its resources available to the Regional Medical Program. He
anticipated and encouraged a close working relationship witti
RMP in the future.

The visitors believe that

..

Hawaii Regional Medical

Program Site Visit

Dr. O'Rourke explained how
seminar on National Health

---

-- .. _"_

-38 -

RM 00001

as a result of a special student
Insurance held in April 1970, in Honolulu,

a technical proposal was developed and submitted by the School
of Public Health to the National Center for Health Services Research
and Development.
the feasibility of developing a broadly representative community
organization which will take responsibility for development
and the implementation of desirable and acceptable modifications
in the present health services system in Hawaii.  The overall
goals are stated 8s (1) improving the quality of health care,
(2) moderating health care costs and (3) increasing accessibility
to services for all member8 of a community. Hawaii is the Setting
for this project to develop a program which can be used as a
model for ultimate statewide health insurance on a national basis
if the model proves successful.
appointed a seven-member board, a new administrative and organizational
unit to set health policy.
health institutions among which the Kegional Medical Programs,  the
School of Public Health, the Hawaii Medical Association and the
State Department of Health

The purpose of this proposal is to explore

The Governor of Hawaii has

The Board represents several major

are members.

A great deal of concern was expressed by the constituent institutions
of RMPH that this Governors committee would duplicate the functions
of RMPH as well as CHP.
the vesting of authority for staffing this Board under the auspices
of the School of Public Health might tend to undermine the credibility
of RMPH as the focal point for institutional linkages of the
health care provider and health related consumer interest.
has been one meeting of the Board at which RMPH was present.
great deal of concern was expressed that the political development
at the Governor's level might impose a political plan for the
creation of a new health care structure without direct involvement
and concurrence of the maj& health lnetitutions.

Furthermore, there was concern that

There
A

Ln a meeting with Harlem Cleveland, President of the University
the site team members discussed with President Cleveland the
School of Public Health proposed plan for a "Model National Health
Insurance Demonstration Program".  President Cleveland explained
that the proposal was still in the primary stages of development.
The visitors explained that the proposal was stillin the primary
stages of development.
Cleveland the significant role the HW can assume as the coordinator
for the development and implementation of the model program with
the providers of Health Services. President Cleveland 8ppeared
interested and receptive toward the visitors commentaries.

The visitors explained to President

The visitors elso briefly discussed with President Cleveland
community involvement of the University in the health field ,
particularly in continuing education.
that he foresee6 agrester involvement in the future of the University
with the community in the field of health.

President Cleveland indicated

Following this ineeting the site ream members suggested to Dr. Hasegawo

Hawaii Regional Medical

-29 -

Program Site Visit

RM 00001

for his consideration the idea of appointing a member of  the
Board of Regents of the University to the RAG of the HW. Dr.
Hasegawa appeared very receptive to ais suggestion.

L

Mrs. Kazue McLaren, member of the Regional Advisory Group and
Assistant Chief of Public Health Nursing Branch indicated that the
nursing profession is now fairly well represented on the RMFH
committees and that the cooperation between the nurses and the
Regional Medical Program has improved much during the past year.

There are 22 osteopaths in Hawaii, and these individuals are
still not represented on the Regional Advisory Group. Dr. Hasegawa
stated that the osteopaths have been contacted and will be
drawn into some of the FWPH activities.

The allied health personneld of the Region have been actively
joined together by the Regional Medical Program.

Core Staff: Similar to the previous site visit team of January 1970,
the site visitors expressed concerns over the effectiveness of
the Coordinator who is salaried on a 50% time and effort. The
limited administrative capability of the present part-time Coordinator
creates a serious impediment to the realization of the goals
outlined by the RMPH. The visitors re-emphasized last year's
recommendations to the Coordinator that he employ a full-time
deputy or associate director to help him administrate the day-to-day
operations, so that he could be free to spend more time in
developing the philosophy and direction of the program.

The question was discussed in detail with both the Chairman of
the RAG, Chairman of the Executive Committee and with the Coordinator
himself. It was indicated to the visitors that steps are being
taken to modify the existing situation by appointment of a deputy
coordintor at this time. The Core staff has been strengthened
by the addition of Dr. Alexander Anderson, who has assumed the
position of Chief of Continuing Medical Education.

The site visitors believed the the core staff is generally competent
and seem to work very well together, however, they have lacked
strong top-level administrative direction for their activities
in the past.
deputy coordinator may remedy this situation.

Regional Advisory Group: Mr. Richard Davi, present Chairman of
the Regional Advisory Group, was not availabae at  the site visit
meeting because he was on the mainland. It was apparent to the
visitors that the RAG was not assuming their responsibility in
giving direction to the RMPH.
in stimulting project proposals, and have not assumed responsibility
in the review of applications.
member of the RAG about the Developmental Component it was
highly disappointing to discover that almost none of them was
aware of what was included in the developmental component. They

The visitors believed that the addition of a full-time

They have played a minor role

When inquiring to each individual

Hawaii Regional Medical

Program Site Visit

-30 -

RM 00001

seemed also unaware of any long-range goals of the RME'H.
spite of their unfamiliarality with the developmental component
they had given it a stamp of approval.  Close scrutiny of this
approval revealed a degree of reservation by RAG members, leading
the visitors to believe that the Region may not be fully ready
for a developmental component award.

In

It is apparent that one of the weaknesses of the RMPH is the
poor communication with the RAG and non-involvement of the RAG
in the decision-making process.

c

*8

DiHcusuions with Mr. Edward C. Bryan, the Chairman of the Executive
I:omuiittee who is a consumer reprcsentntfve and a very competent
businessman and other members Lndicatc the I!xecutlve Committee haa
~dequote rcpresentation of the major provider institutions and
they have slgnificant insight into the health distribution problem
and the problems of the cost of health care in Hawaii.
Amnittee is tuneti in with the general. thrust as well as the problems
of the RMPtI. Realizing the managerial deficiencies in the RMPH,
the ICxrcuLive Colnmittee has contracted with the Hawaii Education
Coiin(:11 Incorporated to do a study of RMI'II.
will study the total operation of the RMPI-I and will make recommendations
for development of policies, performance and the organizational
structure of the RMPH that may increase its administrative efficiency.

I_ Categorical Committees:  The communications between the Technical
Review Committee, Categorical Committees and Core staff have been
very poor.  The committees have not been involved either in identifying
the health needs of the Region nor in having an input in program
Jirection of the RMPH. The members of these committees have
been nierely passing judgement on projects which are presented to
them without knowing how they relate to RMPH goals and priorities.
The visitors recommended that core staff input be built into the
meetings of these committees to keep them abreast of total program
activities and to encourage committee input into the RMPH.  They
ilso recommended that guidelines delineating committee responsibilities
and ;unctions should be made available and discussed with all
corim~.ttee members.  Many committee members seemed surprised and glad
to kilow tliat they can have an input into the total program operation
~f the Ichfl'lf. It was obvious to the site visit team when meeting
ciiLh these committees that there is a wealth of brainpower ready
to be explored on these committees, and that if utilized properly
by the RIPH its program will be strengthened.

This

This organization

-- Pacific Basin: Dr. Satoru Izutsu, Chief of Planning and Operations
for the Trust Territory (Micronesia), American Samoa and Guam,
explained Regional Medical Programs in the Pacific Basin.   The
team was impressed with the capability of Dr. Izutsu in creating
the initial linkages and the progress made by the RMPH in this
diversely culturally isolated area.
its efforts with CHP in Micronevia bccauue CHP has been actlvc
tor several years in health planning throughout the Trust Tcrritory

The RMP has heen coordinating

Hawaii Regionn I Medical

Program Sfte Viait

- 31.-

RM 00001

'L

and has come up with a comprehensive health plan for the area.
They have also coordinated their efforts with the Hawaii School
of Public Health and the EastWest Center.

The RMP has also established ties with the Department of Interior,
the Micronesian Businessman's Association,  and other local
community action groups. Three representatives from each of the
areas (Trust Territory, Guam, American Samoa) have been appointed
to the Hawaii Regional Advisory Group. It is apparent to the
visitors that the RMPH needs to have visibility in these areas,
prior to establishing linkages with local health institutions.
Just as the Cervical Cancer Project served to createvisibility in
Guam during the past year, the present proposal requesting the
development of an intensive care unit training program at the L.B.J.
Tropical Hospital in American Samoa will give visibility  to RMPH
with other existing institutions in Guam.

The concern of Dr. Izutsu expressed in the past and again this
time is that the needs of people in the Pacific Basin are so
overwhelming and the funds for RMPH so limited that there has
been a reluctance to become extensively involved in program and
project development in the Pacific Basin.

The added travelexpenses required for travel of the nine RAG
representatives of the Pacific Basin with the limited budget
awarded($17,270) does not allow the Coordinator any flexibility.
He would like to have the fiscal flexibility to travel to the
Pacific Basin when advantageous situations occur and when the
occasion presentg itself to support the travel of persohs from
the Pacific Basin who want to participate in a training program
conducted in Hawaii. It will also allow him to utilize the services
of other core staff members in the Pacific Basin such as Dr. Alexander
Anderson, Chief, Continuing Education and Mrs. Rosie Chang, Chief,
Allied Health. The site team believes that funds awarded to the
Pacific Basin should be earmarked so that if the Coordinator of
the Pacific Basin wishes to rebudget funds from activities supported
in the area he will not infringe on funds allocated to Hawaii proper.

- DEVELOPMENTAL COMPONENT: The primary area of concern for the site
visitors was the Developmental Component and it was obvious to
the visitors that a great deal of thoughtby the Region coordinator
and his staff went into this application. The long-range goal of
the developmental component involves three major items: a) a focus
on hospitals as a major mechanism for thedelivery of comprehensive
health care; b) the use of continuing education programs; c) and
the development of a data acquisition system that will help  to
assess the quality of health care in Hawaii. The technical projects
proposed for implementation of long-range plans regarding the
relationship between RMPH and the hospitals in the community appear
to be well thought out and implementation could do a great deal
towards realization of the articulated goals. The review procedures

Hawaii Regional Medical

Programs Site Visit

-32 -

RM 00001

normally used for project review will also be utilized for review
of applicaclons requestlng developmental component funds.  The
visitom, however, expressed concern over the lengthy procesu
(4 to 5 months)  utilized for these reviews.
that they intend to rnake changes in their review process that would
reduce the time span.

The Region indicated

In many respects, this Region appears to have,made little
progress since the previous site visit in January 1970.
of the problems outlined in the background section of this memorandum
still persist o

Many

m.

inere seems to be however an increased sophistication which allows
them to now look at program rather than project and to more realistically
consider program priorities.
has been in the direction of a broadening and deepening involvement
of RVIi with the provider of health services and the oommunity.   It
is on the basis of this evident maturation that the site visit
teain was inclined to encourage the process by recommending approval
of the developmental component in spite of the managerial short-
comings previously discussed.
will become better prepared with the developmental component to
assume a leadership role with the implementation of new major
health programs in Hawaii, such as the model National Health Insurance
Demonstration Program in Hawaii referred to by Dr.  O'Rourke.
The ffiNPI-1 as the representative organization of the health provider
mast be involved with the development of such programs.  It will
give flexibility to the RMPH to implement with greater facility
cmtinuing education programs stimulated in the community by Dr.  Alexander
Anderson. Dr. Anderson has in a short time become greatly involved
in marly continuing education activities, as a consultant. The
developmental component will also give the RMPH the flexibility
it needs to implement its plan for coordinating and expanding
the availability of hospital services to the people of Hawaii.   The
site visit team members are convinced that the hospitals have
been and will continue to be the major providers of health services
in Ilawaii.

While progress has been slow it

The visitors believe that the RMPH

11; Sencral, the major concerns of the visitors which the RMPH must
resolve are as follows:

a.


b.

C.

d.

Greater involvement of the RAG in the planning, operation
and decision-making process  of the RMPH.
Identification of responsibilities, establish operating
guidelines and involve all committees of the RMPH in planning
and operations af the WH.
Employment of an Associate Coordinator with management
and administrative skills to run the day to day operations
of WH.
Better communication between the Coordinator, Core Staff, RAG
Executive Committee and other committees of the RMPII. Conimunic,iclor
between the KMP and other hcalth organizations must also
be improved.

1.

\.

_-

s:.w..~*..*.,, ..._ I ,... ,.. , *. .. .._ .....,. .. .... -...........-.-.... ~

Hawaii Regional Medical -33 -

Program Site Visit

REI 00001

e. Clarification of the commitment of the RMPH to the Pac%fic

Basin area consisting of American Samoa, Guam, and Micronesia.
Consideration should be given toward earmarking funds awarded
for this program.

f. The RMPH must assume a leadership role in the developmerit
and implementation of the Model National Health Insurance
Demonstration Program being negotiated for Hawaii by the
School of Public Health, University of Hawaii with the
National Center for Research and Development, HSMHA, USI'HS,HIIW.

RECOMMENDATION: It is recommended that the developmental grant

level of $92,314 and that Projects 824,#25,#26 and 127 be funded
at the requested level in 01 year of $273,986, 02 year $285,182
and 03 year $285,119. Project #23 is not recommended for funding
with KMP funds because of Council's decision not to fund new mobile
coronary care projects. The total funding level recommended for
three years is as follows:

be funded for one year to the WH at the requested

TOTAL

----

03 04 05

-I__

KEGIONS OPEKA'rIONAL YEAR

I Developmental Component $92,314 $92,1314

                $366,300 $285,182 $285,119 $936,601

11 Six New Projects a986 I_ $285,182 $285,119 -844,287

GRR/KMPS
12/ 28/70

., .,. LA...& .....,..-. _. .

. ~,-~ .. .. , .--.

.. .

.. ._....__.l_.......... .... .. . ... L 1 a*.: ..\.*.- :-,I ............,. L.

I

- 34 -

!.

t ''

DEPARTMENT OF WEAL.Tl-I, EDUCATION. AND WELFARE
             PUUI .IC t It~AI-TI 1 6I:RVICE
HEACTtI Sf:I<VIC.ES ANI) MEN-TAL t4EAL'Tt-l ADMIN:S7'f:/iT'ION

o

.!.)a.'c': June 10, 1971

'dy lo
tfll oj: fl

Staff Review of Trlennial Application from the llnwalj. Rc!p,jonol
Mcdjcal Program 5 GO3 RM 00001

uljcct:

To: Director

Regional Medical Programs Service

..

~ic rc.?,ion lias requested funtling in tliis trjcnnih~ application for
tlic lollowing activities: (1)irec.t Cost Only) __

-

.

- . .-.

06 Year Total kk. '

*04 Ycar 05 Year

Core $ 516,624 $ 533,457 $ 555,332 $1,605,413

Devclopiiiental Component 78,897 78,897 78,897 236,691
(Previously approvcd/Gnfunded) d' ,
Con 1: i ncia t i on P ro j e c t s 332,562 238,507 111,339 6 88,4 08

4/15, #20, #3, a7, ill1

#37 ,#3? ,/;33,m ,#34,836 ---.-

Ne:? Projccts #28, 1/23, 930 730,748 620,597 627,078 1,978,423

-

I'ot:11 $1,658,831 $J ,471 ,1158 $1 ,378,046 $!t,505,435

In rcvicw of thls appljcation, staff concrrnctl 3tse'lf wj th overall program
d (1 v c 1 o pic n t .

On tlic basis of Lhis review and because thc region has failed to follow
t-ltroirgli on past recommendation from the RMPq staff suggest to Conrni ttce
and Coimcil for thckir consideration thc ioYlow3ng rccornmcndation:

-

Approve one year of funding for core and operational projccts and

i qnnnrovc Dcvcil opmcntal Coinponc.nt support ontil tlic foll o,iing

- 35 -

Director, Wll'S

RM 00001 8/71

!.

e 1. l'he regioi! identify spcci fic objectivcs arid priorities that rclatp

7. That a fcasible regional plan of operat ion 1)c devqlopcd tliaL wil 1

meet the hcalth nceds of the region, based on mcasurablc accomplisli-
mcnts at specifjc periods of time of prograiii devc>l opincnt.

It is sirggcstccl thaL staff conduct a follow-up visit six niontlis following
noti ficntion to the region of thpse conditj oris to determi ne progress
and provide assistance it necessary.

Goals, Ou-cxives and Priorit%%

Program goals arc described, however spccific objectives and priorities
are not clearly stated in term of the health veeds of the region.
The objectives arc clcscribed in tcrms of act iv-ities and not in ternis
of an 1: j c i pa I ed acc onipl i shmen t s .

Rcgioi~aJ Aclvj sory Group (RAG)

In a January 1970 site vfsit, it appcnred to the visitors that the
Cool-diiintor was the sole autho.ri ty in the decision-making process. Tlic
RAG had not assumcd their responsibility in giving dirchctjon to the `d.I*IPlI.
Tiicy hacl played a minor role in stiniulating project proposals,  and hacl
not assumed responsjbility in the review of applications. It was
apparent that one of the weaknesses of the IIMPlI was the poor co:n:niinicatjon
of Core with the RAG and the non-involvcment of tlic I?AG in the decision-
niakjn:: process.
encouI-a;;ed tlicni and [-heir Executive CoiiiniiI-tc>c to assiime thc I eadc.rshjp
of til<' IiEIrlI.

111; visitors discussed this 111 uiJl<*m with thc IUC, and

-

. i

- Director, KMPS

o

:

36 -

RM 00001 8/71

1i;if. lx*c*ii :;(JIM* i idicat~ion tiiat tlic. IuZC rnay Iinvc bwn nlot ivatcd by the
siLc. vjsj1oi-s to as;iiiiii~c grcnter rc1sporlr:ibi JiLy. Jt is, howcwar,
ap~~:ii-c~iil to staff Lllnt at tl~e prcsertt Llic RAG Iiax had little, if any,
input into tlic! development of plans or in the operations of the
progmni. For example, during the December 1970 Site Visit the visitors
discovcrcd that the JMG tint1 li~tlc. if any i.nvolvement with the planning
of the developmental component and few membcrs had reviewed the application.

Staff suggests that a message should be sent from Council to the Coordinator
and IW Chairman of the RMPH that future funding of this region may be
inrluenced by the degree to which the RAG assumes greater responsibility
for direction of this program.

I

Tn both tlie .Tantinrp and I)c~ccmbc~- 1970 xitc: vi.$: Ls the visitors c:xprcr;sc:d
Ct)iit't'I-iIS o\'c'L' CIIC '~clii~jni:;~ r-;iLjvc cfftxLjvpi)<~::s of ~lir: Corirdinaic)r wl c)
<*:I:- s:i7;Tri(>cl 011 ;I 50'7 t-iii,L> ,qnJ (#[r(irt , 'I'hr- v7z.i I or'; oi' 1)nIli r~c~cn*:jons
I-CY t)it~,~l'-ii~1~4 I o L~C? CoorJ j II;I 101- I 1i;i t ]I(. c.iiq,l ojr ;I rl17 1 - L ii:,,. dcpti I y or
n:;::(ic.icltc. djl-i.ctoi.
so lhnl tlic CoordinaVoi- coiild bc frccs to spciid III~I-c' finic in clc.vclopfn::
tltc. phi 1 osophy aiitl clii-cction of tlic prof;raig.
in clctail with both the Chairman of the ICAG, Chairman of the Executive
Cori:iaittcc and with the Coordi.nator himself. Both thc Chairman of the RAG
and the Executive Committee explained that they did not care to see Dr.
Hnsc~gowa assume work on a 1OPk time and effort.
thc Coordinator remain on a part-time basis and that a deputy coordinator
wSth administrative capabilities be hired to carry cn the clay-to-day
operations of the program.  It is, however, indicated in this application
that the Coordinator will be dorking on 100% time and effort.

Staff has been informed that Dr, Hascgawa is consi.dcring giving up
his private proctice and that the region intends to hire an
specialist  rather ttinii hire a deputy coordinator.  A position for a
dcputy Jircctor has not bccn inclrrtlcd in the rcxpest for stlpport of

I (J help hini ;i~liiijnjs[(~i- ~11r. d:iy-~o-,d:iy opcrnI ions,

This concern tias been discussed

They preferred that

administrative

col-c st;m-.

I

M tw pos i t i OIIS ;idd erl to c oi-c\ i nc 1 ttdc? , Mpd i ca 1 Ikononii li t , Ad ii~i ni :: t rat f vc!
lIai,ny,:. I-, 1\ j 0:: I ;I 1- -j s ti ci;i 11 /1;pi dciiii 01 0;: j s L' , nnd Adnii ni s t rn 1 I v C_ 12:; :, i :; tan t .
Pasi tioiis onii ( Lecl fi-cm Co1-c. arc Iltc. Associntc Coordinators, Chiclf of
Pl;!nning, Associate Cliic!F oi: Opcrntions, Associal-c Chicf for Planning
ant1 Kcsearch, researchers and a secretary. Staff believes that the
prcscnt core pci-sonncl arc cor~ipctc:nt and S~CIJI to work very well togetlicr ,
h o..;c.vei-, bccnusc tltcy hnvc lacked strong top-level  ndrni nis trntivc
dircclion for tlizir activities, each appc!ars to go his own separate
way in carrying out RMPH activi tics,

ad

I

- 37 -

very poor.  The ~ol~lilljttecs have not
vc pot had jnput in planning and
Tnstecd the conmi t tcc rncrnbcrs hnvi~
ut of coiltext or c1.cnr untlc.rstniidji~

sed and glad to know of tlie possibility

   total program operation of the KMPH.
onunittees represented a t7ealth of untapped
   y by the Rf.IPU, would strengthen the

the 1)c.cenihcr 1970 slLc vlsit'

oniruendations of si te vi6i.t team that
eetings of these committees to keep
ties and to encoilrage

th- IW'H, Thcy also recornmcndecl that guiclclincs delineating COT
                        be mnclc: avai lablc and di scur:sed

i Ltcc members.

                    970 si re visi 1 tc
            tlie I:PI1'11 for n lkvel opmc
cause of e a1 restraints additj.0
             he region has request

he developmental coniponen
  n should be authorized
  recorninended approval

existing managerial sho
blenis would be resolved and

oiient were in line
taff that the manage
s not reached the 1
anagement of developmental funds.

rite rr c:la t ion sli .j p be tween pro j cc t
d into a program plan that would

care needs of the rcgjon.

re wlin t i nvol vcment tlie RAG,

e with the projcxts, how these pro
lint is the expccted impact of thes

y system of the Region.

lie new activities proposed in
rd access of care arid reach
of the region.

-/

appljcation to c:vaIunt c projccts and tota
io11g1i rsncorirny,cd hy ';ni vr#!::t in cvalrintj~i~i

t RM 00001 8/71
                     -38-

- Dir'ector, RMPS ..

Public Health Advisor
Grants Review Branch

Attendance at Hawaii Type V:

t

Tsnt.it1. F. M~i-alcs, Grqnts Review Dranch
Elni-y E.' Hurphy
1,orc.n H~ll ic.l:son 70ff5cc of Systems l4magcmcnL
Nancy 14cCuirc  Office of Systems Nanagenlcnt
Cecil ia Coni-atli, Continuj.ng Pklucation and Training Branch 1
Clcvcllarid K. Clia.nibljss7 Off ice of Organizational. JLiaison
Eorlncy C. Ilcrckcr, Grants Mnnagcmcnt Branch
Spencer Colburn , Regi.ona1 Uevclopment Branch
Rhoda Abrams, Office of Program Plnnni.ng and Evaluation

Kidncy llj smse Control

,: . I

I

e.

i

I 1

Action by Dircctor ' ' ' ' --

I,

I

I

..

. .. +.

'. .. .

... .

., .\.

... ...

.. .

_I

--

/

Tthe .region reflects a providcr action pI.c?n of hi$ priority nc&s
-tlbich appears congruent with the overall mission and obfectives as ' .
described in Dr. l*!il.son's memo of ?fay 12, 'i97i. (Referznce .made'
to pzges 2-4 of the appllcation.)

Past pcrfornianc-e has not demonstfated .quccess, hoxc?ver, the reg,ion
has 'now built this into its planned cote staff zictivities 3rd
prop'osed projects.
zppl ica t ion, )

*

I

(Reference is nade to pages 2-3 of. the

same respmse as ip YO, 2. . ..

Lhcre. Ts no actjon plan for ir.;ple:!natat5o;l. oi such acttvit5as, ho~tvcr.,
the '&Cion fs conscious of thest- zctiv? ties nnc! has submittg3ci project
#32 which involves scree'nr'ng.

The proposed opcrational projects, to a large degrez are ex~ccted
to demonstrate expanded.aixbul.atory Fare and out-patient diagnosis
and t rea tmn t;'

b

*.

PI

,

successful in accoxplishing proposed activrtics in tbis area
is expecteh that acii.vities in the direction of anhulatory care

11 be expcznded by the region.

Several of the regions proposed ac tivitics could enhance grn,F,,ter
cont'inuity of care. The potential is there,

re is .no regional plan to rne'asure thc impact bf PJfP actlvites in
ess of care, quality and cost mod,eration for health carc. It is
\.?ever, menticrnecl in Project 1/30 that its evaluation will include
ec. primary areas of concern, accGssibiIity, quality of care and

-

-

o

~ 7. ".

. cost.

-

1

pioposed program goals and objectives (Core and projects) need .

Iiavc a t'imir: schedule for accompl~shm-c'n~ so that a rr.ore  inmediate

. @.

-01: c+n be achfevecl.' #.

*1

(.. .

,.

..

.... .. . . . .Page 2

..

+c

.. *. '

a. .

..

i- .. ../

.

,.

.-

--

,-

. '* I

..

..

.1_

..

. ?e r f o ma nc e' . t..

-

b

* *.

..

1, ' Goals are described, however sp'cific ob jzciives 2nd priorities


2. Eecause the rcgion's prozran objectiv'rs are non-specific . -/-----.

/-

2re not clearly stated.
but not stated in terms of what is to be accomplishe'c!.

kctivlties are des,cribed 'as obrjecf'i'ves

'

L

.

i -,

I

prduitivity in terms of program accomplishments cannot be
. miasdred. It is,however, posSible ;to measu;Te productivity

{iithin the 1irni.ts of each project, 4

a.

,-

.@ ..

. 3, Very little evidence bf this in this-region,

-.

..

C, Process .I

..

1,
-*

At present, the vSability aiic! effectivcn2ss oi thc F2iP is less
tlian efiective.
reports de~ecl Jzriuriry 1970 2nd. Dccc.r%~r 1.970.
rectiiy the situation has been very 3101.~;

Active pafticipation exist, but the level of corrulitnierit is
questionable.

Referencc is r.mdt to the trio previous site visit 0

ProGrcss to

2,

KO real common objective or efiort to meet health

CIS of the region?

s kind of participation by the EWPH vith CHP is functionin
better in the Facific Basin Islands than inthe Matiaiian Islan s.
(Reference is Eade to the regions last continuation application.)

x

.

(A Pr1v Lleged ComunLca t io,?;

HAWA 2 1 KEG IGNAL MED ICAL PRGGRAK

&l 0001 8/71

FOR COhSTDERATICS BY AUGUST 1971 ADVISORY COCL\C_,

Xecornmendation:

until .the stipul

Additional Surds fGr one year for core and opd --Lon&i
projects and aisapprovai of the aevelopnenLa; ,c;l7oilent

ated conditions are met.

G4
05
06

$1,658,851
1,471,458
1,378,646

$: ,07 2,000
   -0-
   -9-

Total $4,508,935 $i,072,000

The region's current funaing level is $835,762 direct cost and the

/- rationak for the above recomxended funding level is as follows:

Core               $400 000
Projects  (continuation

   renewals, new) 672,000
Developmental Component -0-
             $1,G72,000

?;I specific objectives and priorities tnat relate
a:; c;f the region. That the objec-cives delineate
      ts in terms of a realistic tine schedule.

1"

3. That the K4G Techt7icai :<.<view Caxmit:ee and Categorical Commi'itees
  be give3 ar, opportunity to Lave inpt Ln :he planning and operational
  activities of ?he S;PFLa Cle~rly defined operating proceuures
  and responsi'billties oT zncse corialtzees should be deiinca.ied a

P

Hawaii RMP -2- 222 00001 8/71

Tf

5. That the XMPH clearly identify its coraitaent to =;?e Pacific Basin

and develop a feasible plan of action for this area from which RMPS    [e.,>
can determine future funding needs. .n..-.'--s

*

-&%El,*

6.

That a feasible regional plan of operation be developed  that will
meet the health needs of the region, based on measurable accomplish-
ments at specific periods of time of program development.

Committee suggested that staff conduct a follow up visit LIX months
following notification to the region of these conditions  to determine
progress and provide assTstance if necessary. In addition, r. site
visit is recommended to the region when it submits its anniversary
review application in May 1972.

Critique: The Committee reviewed this triennial application in relation

      to the January and December 1970 site visics to this region.
it is apparent that the RMPH continues to have a gcod working relationship
with the Hzwaii Medical Association, University of Eawaii, State Health
Department, CHP, Hospital Association, etc.
discussed in a report of a site visit to this Region conducted on
December 3-4, 1970.

These rslationships were

It was noted that core staff of the program has been strengthened with
the addition of Dr. Alexander Anderson who has assuned the position
of consultant in Medical Education. The staff appears to be generally
competent and seems to work very well together,  but ?,as not received
sufficient leadership. In past reviews of this regio;?, the RMPS
Council has recommended that the coordinator hire a full-time deputy
to help him administrate the day to day
in response to this recommendation the coordinator is presently
considering full-time employment with the &YPH and >as moved Mr.  Oniar
Tunks, C?iieZ of Operation into the Adriiinistration %;lager position.
The Cozmitzee ;lopes that these steps will help the 7rogram develop
the effecttve leadership it requires.

The.iiAG still con'clr,~?es to have a passive influence i;l the development
of pkns and irt i3e o7erational activities of the program.  The
ExecutLve Coriimittze 2s .;?..a dccision-making body for :he program
but functions indepe;zly G^C ::-Le RAG rather than as a:! extension
of FAG leadership.  r,rher: ic=s: site visiced in DeceK3ez i970 the

the problems of tne KYTY.

The goals, objectives and `;.T~G.Z~,:;ZS 05 ::-.e progran Ere descrlbed,
however, they are not c1ezrl.y state6 Lr, reia'iion to z:ie specific
health ceeds of the region. In additlcni they are lescribed in
terns of activieies rather tnsn in ter,-.s G? anLiciFated acconpllshments.

operations of the program.

#'

. Executive Coamltilee was ef-tuned 'io the gezeral  thrust as well as

The corcmnications 2a011g the MG, Tectnicai Review Czmittee , Categorical
Coinnittees and Core ssaff have been very px-. The: cxmittees have not
been involved in the planning ana havc- r.02 had inpi: in Flaming and

S Hawaii RMP -3- 00001 8/71

L

operacional ncLi vitics of <he RMPH.
have been passing judgement on projects out of context 01- cieas under-
standing of RMPH goals and priorities. During, the December 1970
site visit rrany committee members seemed surprised and glad to know of
the possiblity that they could have input into the total program
operation of the RMPH. The visitors felt that these committees
represented a wealth of uncapped brainpower which if utzlized properly
by the RMPH, would strengthen the program.

Instead the coinmirtee members

Committee re-emphasizes the previous recommendations of site visit
team that core staff input be built into the meetings of the%:
committees to keep them abreast of total program activities am to
encourage committee input into the FNPH.
guidelines delineating committee responsibilities and unctions should
be made available and discbssed with all committee members.

Garnittee had dffficulty identifying the interrelationship between
projects and how each of these activities fitted into a program plan
that would have an iilfluence in meeting the health care needs  of
the region.

They also recommendeci that

ittee's primary concerns are what involvement the RAG, committees,

ore have with the projects, how these projects relate to a
nal plan and what is the expected impact of these activities
e health care delivery system of the Region, Committee was

encouraged,however, in that some of the new activities proposed
in this application have an emphasis toward access of care and
reaching out into the rural low economic areas of the region.

The region proposes in this application to evaluate projects and
total program effectiveness.  Although encouraged by interest in
evaluation activities, Committee has difficulty in determining how
the region will implement evaluation activities without first
identifying a regional plan with specific objectives that project

-;lshments and are measurable in terms of evaluation.

dvice of the December 1970 site visit team, the February

1971 Advisory Counc:l approved rhe RMPH for a Developmental Component
award but because of existing fiscal restraints additional funds for
this purpose were  no^, relec,sed,  The region has requested  in this
application fundrj for support of the developmental component, however,
Committee doesn'ir believe that the region should be authorized a
developmental component auard  The committee took into consideration
th2t previous approval of rhe
Courrcii in spite of existing managerial shortcomings bccause it
believed that these problems would be resolved and that the long-
range goals iil the developmental component were in line with regional

developmental componet was given by

is, however, evident chat the managerial problems stili

that the region has not reached the level of sophistication

required for proper managenrent of developmental. fuids

3

In the Pacific Basil; the kYPH has been coordinating its efforts
with CHP because they have been active for several years in health
planning throughout the Trust Territory and has come up with a
comprehensive heaith plan for the area,  They have also coordinated
their efforts with the Nawaii School of Public Health and the East-
West Center. It is apparelit to the visitors that the BfPH needs to
have visibility in these areas, prior to establishing linkages with
local health institutions. Just as the Cervical Cancer Project served
to create visibility in GUZE: during the past year, the present proposal
requesting the development of: an intensive care unit: training ,nogram
at the L.B.J. Tropical Hospital in American Samoa will give vFsibility
to kVH with other existing institutions  in Guam.

It is recoriunended by Committee chat the hXPd develop a. plan for the
Pacific Basin
accozplishments and iixiudes grojection of funding needs.
fashion KvlPS can consider the needs of the Pacific Basin and Hawaii
independently when reviewing its request for support of program
activities.

which identifies specific objectives based on expected

In this

REGIONAL MEDICAL PROGRAMS SERVICE

SUMMARY  OF AN MTVERSARY TRIEMI~IM G-UT APPLICATION

(A Privileged Comunic at i on)

MAINE'S REGIONAL MEDICAL PROGRAM
295 Water Street
Augusta, Maine 04330

RM 00054 8/71
July 1971 Review Committee

Program Coordinator: Manu Chatterjee, M.D.

This Region was awarded $842,636 for its third operational year ending
September 1971.  The 03 year award included indirect costs of $5,417
which represents an average indirect cost rate of 15G.  Originally the
03 year award,was for $904,473 but due to RMPS fiscal restraints was
reduced. The current application is a Triennial one which requests the
following :

I. Developmental funds which were approved by the November Council

but not yet funded.

11. Core for three years at an increased level; one year of commit-

ment remains and two years are requested beyond that.

111. Support for three operational objectives, based on projects
   prevfously approved and funded and now extended and project
   approved but not yet funded.

A breakdown of the funding requests follows this page.

This Region was site visited in October 1970 to assess its readiness
for a developmentdl component.
describes the team' s aesessment succinctly.

An excerpt from the site visit report

"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 the
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 community at large. 'I

Because of the October 1970 site vf.sit findings and Council's recommenda-
tion that Maine receive a developmental component,  another site visit
was not scheduled to review its triennial application.  Staff has
reviewed the application in relation to its past and their comments
are reflected in the summary following.

MAINE RMP

                   CONT. WITHIN CONT. BEYO;D APPR..
XNTIFICATION OF @PR. PERIOD APX. PEXIOD PEV.
3XPO5ENT OF SUPPORT OF SUPPORT FUNDED

C O2E $567,786 1/

DO0 - Developmental $ 78,653
%21 - Health Serv. Del. 1 105,192 2/ 205,631

                                 163,671
$22 - New Health Manpowe

New Methods for

I

116,138 -21

Public & Profes- .

4

HEW, NOT 1st.YEAR ,. 1 , i

PREV. DIRECT INDIiiECT TOTAL
APPROVED COSTS COSTS

                      1 $ 567,786

3/ 78,653 --- 78,653
      $ 6,521 I 317,344

310,823

279,809 3,833 283,642

1

$567,786 ---

!

EGION   YAINE
CYCLE   RM 00054 8/71

$23 - sional Eealth Ed.

96,.377 21

I

~crr;A~ $885,493 I

BREAKOUT OF REQUEST 04 PROGRAM PERIOD

170,424 266, 80c' 5.948 272.749

I

i

$1 6,11)2 $1,520,174

$61 8.379 $1.503.872

- 1/ 05 and 06 year are Continuation Beyond Approved Period of' Support.

- 2/ Maine has allocated funds previously assigned to projects into operational objective budgets designated
as 121, #22, and 823. Several former projects, such as the Kennebec Valley Development, Continu-hg
Education and Coronary Care Training have one more year of commitment.  Two additional years of support
are requested in this Triennium Application.

Other projects were approved but unfunded.

- 31 Maine was approved or 2 years developmental funding in December 1970, and is requesting a third year

of funding per telephone conversation by Mr. Spencer Colburn and the Region 5/17/71.

MAINE RMP

4 -

RM 00054 TR 5/71

REGION MAINE
BREAKOUT OF REQUEST 05 PROGRAM PERIOD

[DEW IP ICAT I ON OF

D PERIOD OF

I
w
I

I I

I $1,6461394

TOTAL $974,043 $672,351

RM 00054 TR 5/71

MAINE RMP

Grant Year

01
02

Grant
Year


01
02

03
04
05

-

Period

!

-5-

FUNDING HISTORY

Planning Stage

  Period

5/67 - 4/68
5/68 - 4/69

Operational Program

  Funded
(Direct Cost 8)

7/68 - 6/69 $ 428,106
7/69 - 9/70 (15 1,229,634
        mos. )
10170 - 9/71 842,636*

10171 - 9/72 ---
10172 - 9/73 ---

RM 00054 8/71

Funded (Direct Costs)

$193,909
358,170

Future Commitment
(Direct Costs)

---

$637,642
57,333

*Reduced from original award of $904,473 due to RMPS fiscal constraints.

Includes $50,693 in carryover funds used for planning Maine Medical
School and three feasibility studies.

GEOGRAPHY AND DEMOGRAPHY

The Maine Regional Medical Program includes the entire State of Maine.
The character of the area is similar to northern New Hampshire and Vermont,
but poor transportation connections among these sections was one of the
considerations in the original establishment of MRMP boundaries to
include Maine only.  The RAG feels the present Region is valid and a
workable one, and no redefinition of boundaries is contemplated at present.

Maine is a rural and geographically isolated state, and its population
of almost a million is concentrated in the southernpart of the state
on the Atlantic coastline. The largest city, Portland, has 70,000
residents. As was mentioned before, interstate transportation services
are limited.

In addition to the University of Maine which has an enrollment of
approximately 18,000, there are several small liberal arts colleges
throughout the state.
for one as part of a "health science" education center.
efforts of the Maine RMP are directed toward the successful estaqlishment
of amedical school.

The Maine Medical Center is the Region's largest health faciliiy (573 beds),
and there are four other voluntary hospitals of over 200 beds.

There is no medical school, but there are hopes

Many of the

A total

MAINE RMP -6- RM 00054 8/71

of 4,266 beds exists in the 61 voluntary acute general hospitals,  and


state.

There are 3,856 active nurses.

there are nearly 5,000 long-term and chronic care beds throughout the

c-

The physician population of Maine is 1,078 MDs and 221 DOs.

HISTORY OF REGIONAL DEVELOPMENT

When early interest regarding Regional Medical Programs was generated,
the possibility of Maine's becoming part of a New England RMP was
discussed. Maine, however, chose autonomy and a search was begun for
an appropriate grantee organization.
considered were found to be unacceptable to some segments of the medical
community, so Medical Care Development, Inc., was formed -- it had no
pre-existing health complex affiliation and was regarded as an acceptable
component of the medical care system.  The Bingham Associates Fund and
the Maine Medical Center were particularly active in pre-planing phases.

Existing organizations which were

In December 1966 the first planning request was submitted to the
Division of Regional Medical Programs.
Development, Inc., as the application organization; Bingham Associates
Fund as the fiscal agent, and the Field Director of Bingham Associates
(on loan 100% to Medical Care Development) as planning coordinator.
The Committee and Council reviewers thought that the plan was unique
in that although there was no medical school in Maine, Tufts University
in Boston was actively involved and a number of its medical faculty
were on the MRMP staff.  Although the planning application proposed
the appointment of hospital coordinators to serve as liaisons between
the community hospitals and the RW, there was no evidence of favorable
community hospital reception of this idea.
formation of a committee of practicing physicians to advise the MRMP
staff in policy and program matters.
reviewers about the exact relationship between this group and the
Regional Advisory Group. In general, the planning grant application
was thought to be a good one, and an 01 year planning award was made
in May 1967.

It designated Medical Care

1.

\-

   The plan also proposed the

There was some concern among the

Under the planning grant the program's professional staff was assembled
and Dr. Manu Chatterjee was appointed full-time program coordinator.
Periodic meetings with regional health and education agencies became
established practice, hospital coordinators (or acting coordinators)
were appointed in 56 hospitals and held
were initiated, the RAG membership was compietely divorced from the
grantee organization to eliminate the possibility of legal problems
and overlap of membership, and an operational proposal was developed.
The first operational request was submitted in February 1968.
May 1968 site visit team was satisfied as to the Region's readiness
for an operational award; many concerned individuals and groups in the
Region felt that MRMP could help overcome the problems and were willing

mee.tings, two feasibility studies

A

L

MAINE RMP -7- RM 00054 8/71

to work toward the Region's success.  It was noted that, initially,
cmphnsls was given to development of the regional medical. program
rather than to estiib1Lehinent of priorities among unmet needs. The
program lind developed around activities which were already started ,
and the RAG had not yet been confronted with the need to select among
several activities. The site team suggested that the RAG develop a
mechanism for Regional priority setting.  The hospital coordinators
were considered an effective group in expressing community hospital
needs. The site team recommended that MRMP investigate the possibi-lity
of developing a data collection program.
received an operational award for support of three projects:  Visiting
Guest Resident Project, Kennebec Valley Regional Health Agency, and
Smoking Control Project. A fourth activity, Physician Seminar, was
not considered an appropriate use of RMP funds.
MRME' assumed fiscal responsibility for its own program and operational
projects.
March 1969 for support of a Coronary Care Project and the Physicians
Continuing Education Program

0

In July 1968, the Region

At this juncture,

A supplemental award tothe 01 operation year was made in

During the 02 year the Region continued to fund core and the original
projects. In addition, the Region rebudgeted and utilized unexpended
funds to initiate new projects for which supplemental funding
available:  the Directors of Medical Education activity and the Regional
Library project.  During this same period of time, the Region had
submitted several project proposals relating to its objectives #5 and 6,
which called for a heavy investment in equipment, not having specific
project objectives or design.

During the third year, the Department of Community Medicine proposal
was resubmitted and approved for partial support by the Council.
staff review for the third operational year, the Region requested
continued funding for core and six ongoing projects and developmental
funding. Staff recommended approval of funding at $934,473 (direct
costs) of which $42,693 was carryover. Since that time, the Region
received an 03 award of $904,473, and subsequently a reduced award of
$842,636.

was not

These were returned for revision.

During

The Region is presently supporting the following activities:

Core
Guest Resident Program
Kennebec Valley Regional Health Agency
Smoking Control Program
Coronary Care Program
Physicians' Continuing Education
Regional Library

TOTAL COSTS

$429,542
20,551
150,644
36,138
133,744
50,128
21,889

$842,636

The November 1970 Council approved developmental funding for Maine.
The May 1971 Council approved a program in Family Nurse Associate
Training which would have impact on a Model Cities areas of Portland
and Lewistown.
No additional funds have been provided to the Region for either of these

This was approved by Council at a level of $27,896.

0 activities.

MAINE RMP -8-

PROGRAM OPERATIONAL OBJECTIVES

I '..

.. . ,
. ..

, . . "..

.

RM 0'0054'8/71

Since 1968 the Maine RbP has been defined by six operational objectives.
When the October 1970 Site Visit Team visited Maine, the site visitors
described the six program objectives as reflecting an emphasis on the
development of an integrated system of medical care, which provided
access to medically depressed people, as well as improvement of the
availability of care to the community at large. The visitors felt the
objectives reflected the national priorities but were equally geared to the
unique needs of Maine itself.

i

Since then the RAG has decided that the first three operational
objectives should be given priority as far as the Maine program is
concerned: (1) To conduct experiments in new methods for delivering
health care to disadvantaged areas and for evaluating their potential
for positively influencing present arrangements for the practice and
financing of services; (2) To develop new health manpower for quality
distribution and organization of the full range of medical services to
all of the people of this region; and (3) To improve and update the
level of medical knowledge of the health professionals and the public
at large through continuing education progrznm .

Former objective #4 "to develop a capability in the five subregions
for areawide health planning and the delivery of health services'' is
a central strategy for achievement for all objectives.

Objective 115 "to maximize the capability for the delivery and
distribution of quality medical-care to the community hospitals" and
#6 "to maximize the capability for providing specialized diagnosis,
treatment, and medical educational leadership and the referral
hospitals in each of the five subregions," the RAG feels %t cannot now
justifiably be singled out for priority consideration because of
the present funding available to the Regional Medical Programs Service
and to Maine.

Therefore, the first three objectives are now the program priorities;
the Chairman of the RAG appointed subcommittees to serve as technical
review bodies for indepth analysis of project activities 2s they relate
to these operational objectives.
RAG to continue the development of the program by organizing both
ongoing projects and those approved but not funded in relation to the
first three operatiansl objectives.
that this change clarified the klaine program approach.

It was a unanimous decision of the

In its review, RMPS staff felt

The chart on page 9
three program objective's.

describes how each of the projects relates to the

REGIONAL ADVISORY GROUP

The RAG bylaws calls for 33 members; 30 other individuals serve on
the Board of Directors. There are six new members on the RAG. When

MAINE RMP

F
u
I4
D
E
D

N
0
T

F
U
N

D

E

Q

PERCENTAGE EFFORT OF APPROVED PROJECT COMPONENTS BY OPERATIONAL OBJECTIVES

ti II

OPERATIONAL OBJECTIVES

APPROVED OPERATIONAL
PROJECT COMPONENTS
Kennebec Valley Regional
Health Agency
Physicians Continuing
Education
Coronary
care
Regional
Library
Regional Directors of
Wdical Education
DeDartment of Community
Mekcine-Yaine Medical Center
Interactive Television-
Bangor, Blue Hill, Stoningtor:
msing and Allied Health
Continuing Education
Regional Cancer
program

Family Nurse Associate*

(Modei. Cities)

TOTAL

      111
PDATE LEVEL OF ME&

PROFESSIONALS AND

I1

DEVELOP NEW

I I

CONWCT EXPERIMENTS '

IN NEW METHODS FOR 1 HEALTH MANPOWER ICAL KNOWLEDGE OF

DELIVERING HEALTH

SERVICES

11

j

310,823 279,809

11 ' 266,801

APPROVED
FUNDING
LEVEL

114,666

54,728

148.312

42,828

27,500

50,000

191,864

124.217

75,422

- 27,896

857,433

MAINE RMP -10- RM 00054 8/71

the site visitors studied the RAG, they suggested that the Region
take steps to: (1) change the character of consumer representation
on the RAG, to include non-medically oriented consumers and those
of modest means; (2) develop:-a subcommittee in task force structure
for the RAG; and (3) clearly separate the functions of the Board of
Directors from those of the RAG.
made in this direction, although there appears to be only one new
member from the low income consumer groups. The Board of Directors
is completely separate from the RAG and their functions are completely
separate.

Staff feels that steps have been

Since October 1970 site visitors, and subsequently Council, recommended
that the Maine decision-making process and the function of the RAG
was sufficiently mature to utilize developmental funds, the RAG
functioning does not seem to be a major area of consideration now.
A chart on decision-making process as it appears in the application
appears on page 11 of this summary.

Developmental Component - The Region has outlined First Year

studies and activities that they intend to undertake $78,653
with developmental funds. These are related to the three
major objectives of the Region and are spelled out in considerable
detail, including an estimate of the staff time that is to be
involved in their development.
follows :

a number of specific Request

A listing of the types of studies

Health System Organization including definition of Health Maintenance
Organization - $15,000.

Subregionalization - Health Manpower - experimental activities for new
types of management personnel and development of evaluation procedures
for studying their irnpGct - $20,000.

New Technologies in Communications and Transportation - $5,000

Area Health Education Centers - $30,000

Community Organization for those areas that have a shortage of health
manpower and must depend on citizen organization - $25,000.

Peer Review Mechanisms - peer review on a subarea basis among a
number of small community hospitals - $10,000.

Speciality Care Projects - information and referral in cancer - $5,000.

.. .

.. .

! '.
1. . .
.:,-

. ..

Health System Components - small feasibility program in health service
delivery staff education and manpower utilization for small hospitals,
nursing homes and ambulatory centers - $20,000.

RM 00054 8/71

MAINE RMP -12-

Subregionalization Related to the 314(b) Development - $15,000.

Health Care Financing - $10,00Q.

Problem-Oriented Medical Records - to help expand the demonstratdon
project at Augusta General Hospital'- $15,000.

i

Public Education in Smoking - $10,000                                     r,
Interregional Communications Utilizing ETV and other technologies - $15,000 '

Rehabilitation Workshop - $5,000

These developmental actlvities have been chosen because they can be
implemented, they contribute toward the achievement of the operational
objectives and they have potential as expanded projects. The review
process for the developmental funding and the management procedure for
allocation of funds is carefully outlined in the application.

02 Year - $78,653 03 Year - $78,653

Core Staff - At present there are 14 individuals on the First Year

equivalency of 9.4. Of the ten professional.positions, $567,786
four are female. No minority groups are represented on the
core staff.
$255,000.
employees and an equivblent of two full-time trainee positions at
a total cost of $413,112.

core staff representing a full-time

Request

Core personnel are now budgeted at approximately
The projected personnel budget calls for 23 full-time

Staff had some questions about the rate of increase in salaries and
the rationale for the projected full-time support of the Associate
Coordinator for evaluatipn, if he continues to spend approximately
half-time as Director of the Health Council of Maine. The objectives
of the two organlaations are closely intertwined however, and MRMP is
credited by the RAG as having been responsible for the revitalization
of the health council which has a primary role in health career development.

Cooperative arrangements are described in the application with the
Comprehensive Health Planning Agency, Department of Health and Welfare,
the Interagency Council on Smoking and Health, Health Council of Maine,
the Maine Medical Association, the Maine Osteopathic Association, the
Maine State Nurses Association, Model Cities, OEO and the University of
Maine.

Core supported feasibility studies are described: a student program has
completed surveys on patient flow and nursing manpower and inthe future
will be working on HMO development and peer review development.  Another
feasibility study describes student research activities conducted by the

MAINE RMP

-13-

$34 00054 8/51

Antioch students which has pravided data on emergency care and physician
and hospital costs.
education, cancer clinics in which about 1200 women received detection
examinations at the hospitals and a physician manpower inventory.

The one central resource described is the Planning Reference Library
which provides materials to community hospitals. Performance sites
listed for the ongoing activities in Maine show that project and core
activities now reach 34 different health care institutions in the
State of Maine.

Completed feasibility studies include personnel

The October 1970 visitors were impressed with the sincerity and
effectiveness of the coordinator and his core staff and the fact that
the MKMP hag developed productive relationships with many organizations
in the State and with the surrounding Regions.  Staff in its review
felt that the Maine core staff may have increased its effectiveness
in the past year.

02 Year - $624,565 03 Year - $687,022

Projects

Two projects have been phased out this year; the Smoking and Health
and the Guest Resident Program.
core activity.
limited scale by Tufts with the Maine RMP as the coordinator. One
of the reasons for phasing out MRMP support of this project was the
failure to attract enough residents.  Only 30 residents a year were
willing to come up and serve in the hospitals. About 10 hospitals
were serviced in this fashion.
ongoing projects in Kennebec Valley, Coronary Care, Physicians'
Continuing Education and the Regional Library, but the triennial program
proposed is described in terms of the operational objectives, rather
than in projects.

Smoking education will become a

The Guest Resident Program will be continued on a

Progress reports are given on the

1/21 - Objective Number I - To conduct experiments in new methods for
delivering health care. $310,823

Eighty percent of the rural poor are 20 miles from the nearest
hospital.  The community's studies to date show major difficulties
in seeing a physician, in transportation and in distance.  The per
capita income in Maine is $2,477 - the lowest in New England.  The
study to date indicates that 50% of the low income women have never
had a pap smear, 30% of low income families have never had a chest

First Yea1

1d.c.)

X-ray. Five
over have had
is less that
means for the
introduce new

times more family members whose income is $6,000 and
physicial examinations than those families whose income
$3,000. Objectives of these activities are: (1) to develop
rural disadvantaged to enter the medical care system;  (2)
communication technology in three areas; (3) to experiment

MAINE RMP -14- RM 00054 8/71

with new health system organization format in five locations; and
(4) to expand the health system component staff interrelationships
via organization and communication system usage.

Details on the locations of these activities are not included.

02 Year - $ 341,965 03 Year - $376,095

822 - Operational Objective I1 - New Health Manpower

Program objectives for this activity are: (1) to define and Request
evaluate the use of physicians' assistants in seven varied $279,809 (d.c.)
practice settings;  (2) to develop and expand home health/
ambulatory care teams in three locations; and (3) to continue
the development of nursing and technician capabilities in the
Region for coronary, intensive, family and cancer care.

1

1

First Year

Maine has approximately 100 physicians for 100,000 civilian
population compared to the 160 in New England,  130 in:the United
States.  The distribution pattern for the physicians varies from
one to every 668 people in Cumberland County to 1 to 2,000 in
Washington County.
population have difficulty in seeing a physician and additional
25% feel they cannot get an appointment.
that the feasibility studies for developing the types of personnel
projected have already been carried out by the Maine RMP in conjunction
with area hospitals, community groups and the University of Maine.

Studies in rural Maine indicate 30% of the

The application states

- ..

.:

,' .. ,..
i :

j.. .. .

<, ...

. ..

..

Staff noted that the coronary care training which has been supported
for three years should be phased out according to Council policy.
The Region does not seem to be planning this phase-out.

03 Year - $338,569

./

02 Year - $307,790

#23 - Objective 111 - Public and Professional Health
Education. Program objectives are: (1) to establish Request
regional directors of medical education; (2) to develop $266,801 (d.c.)
practice models in primary, family and community medicine;
(3) to continue the physicians' continuing education program
and initiate full scale operation of the nursing and allied
health education program; and (4) target expanded public health
education to the schools and community health councils throughout
the Region.

First Year

02 Year - $295,481

03 Year - $322,830

RMPS/GRB
6/18/71

(A Privileged Communication)

SUMMARY OF REVIEW AND CONCLUSION OF

JULY 1971 REVIEW COMMITTEE

MAINE REGIONAL MEDICAL PROGRAM
    RM 00054 8/71

FOR CONSIDERATION BY AUGUST 1971 ADVISORY COUNCIL

RECOMMENDATION: The Review Committee recommended that Mair
years and that developmental funding be approved.

triennial funding at a graduated level for tkl4ch three

                 DIRECT COSTS ONLY
YEAR REQUEST RECOMMENDED

$1,503,872

$1,100,000

5 1,646,394 1,200,000

1,803,169 1,300,000

TOTAL, $4,953,435 $3,600,000
Since the principal Committee reviewer had participated in

the October 1970 site visit to study the Region's application
ntal component funding, she was able to relate tht! written
lication to firsthand,recent experience in Maine.
ication reinforced the site visit team's appraisal of the

                                She felt
Region with demonstrated ability, a superior Coordinator

Core staff. She felt that the RMP staff were effectively
a "brokerage" function in providing staff help and small
ey to other agencies and in finding non-RMP sources of

ities that are in line with Maine's program priorities.

as somewhat concerned about the lack of specifics in
ear program proposal.
oved and sometimes funded projects into broad program
the Committee had difficulty relating this to previous
Both the principal and secondary reviewers, however,

The Region has broken up its

ange was a forward step in program development, develope

committee with staff assistance but that careful
required to appraise the effects.
ated to the increase in Core staff, both in size
Staff was asked to determine the rationale for

It was agreed that the Maine RMP has moved ahead with
use of developmental funds in line with the three program

Another concern

vels.

.

MAINE RMJ? - 2- RM 00054 8/71

After considerable discussion, the Committee finally arrived at a
recommendation to provide funding at a reduced graduated level for
each of the three years, to include developmental funds.  Staff was
advised to keep close scrutiny of the salary levels, specffic
program activities and accomplishments during the triennial period.
The Region should be advised that certain of the former pr--jzct
activities, .particularly in the coronary care training area, could
not be continued indefinitely because of Council policy.

RMPS/GRB

7/16/71

REGIONAL MEDICAL PROGRAMS SERVICE

EUMMARY OF AN ANNIVERSARY TRIENNIUM GRANT APPLICATION

(A Privileged Communication)

Memphis Regional Medical Program
1390 Medical Center Towers
969 Madison Avenue
Memphis , Tennessee 38103

RM 00051 8/71

July 1971 Review Committee

Program Coordinator: James W. Culbertson, M. D.

The Region's current third year award for core and 13 projects is $1,371,916
($1,086,048 direct costs and $285,868 indirect costs).
year supplemental award for 16 months in the amount of $701,344 (,q;655,172
direct costs and $46,172 indirect costs) included support of 2 projects
during the third year.  The estimated current level of support for direct
Costs is $1,668,144.
In a reduced amount is in process. The present application proposes:

In addition, a second

In keeping with funding restraints,  an amended award

1)

Authority for a developmental component  in the event new funds
become available for this aspect.

Continuation 02 5 projects (14, 17, 18, 19 and 25) within the
currently approved periods, 2 for two years and 3 for one year.
Support is also requested for one additional year beyond the
current approved period for projects Nos, 19 and 25.

Three years additional funding for Core and 7 projects ( 1, 2, 3,

2)

0

3)

5, 6, 7 and 8).

4)

5)

Three-year funding for 12 new projects (29-40).

Termination support of 3 project8 (4, 10 and 24).

- _.. _--I

, --

~he Region, rewests
$2,549,008 the fifth ,397,991 the sixth year. A breakout chart

direct .c?stS) for its fmrth ~ear,

identifying the components for each of the three years  and a list of core
activities follows:

_-

I

PJ

I

u- 0

TOTAL

282,588 1,379,214 887,206 2,549,008

1

CC~I!.z'%TIOS WITHIN COhTINUATICX BEXONI P.PPRG\TD, MX
SLTPOPT S CTPGRT FUh3ED

PL'P3.OE:ii PEBXOD OF APPROVED PERIOD OF ??..EVIOUSLY

799,5L8

I

IDEXTZPICATXO?; OF
CGWPO~ZXT

NEV, NOT
PILC'JIOUSLY
APPROVED

_I_

2,397

118,720

Cwe
$1
s 2 53,746

                           33,431
                             74,605
#3
i'i 5

i

I

I

I

$6

-

141,940

1 I

#a
k14
ii17

--

1

k 18

I

I

33 1

29,555

I

$32

834
#3 5

833 I
                            I

3 7 6,4 ,00L 00

54,026

-

$36 ~

ii3 7

I
I

563,358
52,960

I

-

P38
83 9 i
iKt 0

I

29,669
47,120
44 3 194

t

991

1

7,701,232

_- -_-.

TUTAL

969,964

I --

1,428,027

-4A-

Page - Project

92 Central Cancer Registry

Y2

HRKP Hospital Nursing Services Survey

93

93

  34

- 94

95

95

96

96

97 '


97


98

98


99


99

Physicians Survey on Continuing Education

Memphis Household Health Survey

CommunLty Iknlth Welfare Services Inventory

Family Plannine Survey

Mid-South Hospital Inventory

I

Health Delivery System

Regional Iienlth Delivery System Survcy

Subregional Divisions Study

Informal Comkiunications System Survey

Identification of Problems Among Region's

I *I

Aged

r.

Regional Medical Manpower Analysis

Nutrition Study

Inventory of References Used by Regional Physicians

Rehabilitation Needs Survey

100 Calendar of Continuing Education Courses in Dentistry

100

101

Regional Research Information Services

Medical Lkbrary Information Network

I01 Regional Clinical Nursing Conference

102 ROC014 Service

102

I03 Emergency Air-hbulancc Program

103 Regional Conbputcr Service

Advanced C 1 in ic a 1 Co 11 Le r e nc es

Organizatl onal Assistancn for Hcatth Relatc!d Conferences, Seminar*
and Workshaps

Memphis RMP -5- RM 00051 8/71

RMPS staff reviewed this application, particularly the continuation
portion and their comments in a memo to the Director are appended.

0

FUNDING HISTORY

Grant Awards Total
Year

4

Date Period Amount

-

No.

-

-

Planning
01 ~302-01 4/10/67 4167- 3/68 $173,119

02 5GO2-02A1  10/47/68       4168- 3/69        183,443

03 5GO2-031  6/20/69 .      41 69 - 91 69        249,490

3GO2-02S1 9/23/68 9168- 3/69 192,397 ,

Opera t ional

01 1GO3-01A1 1O/7/68 7/68-6/69 $663,746
                   7/69-8/70 755,859
                  lO/69-8/70 599, 767

02 7G03- 02    6/27/69


03 5W3-03  11/2/70 91 70- 8/71 1,371;-916

3GO3-0251 1/30/70

* 3cO 3-0251 6/16/ 70 5/70-8/71 701,344

*overlaps the 03 year

Commitments (direct costs)

04

-

05

$395,342 (projects 14, 17 and 18)

$250,030 (projects 17 and 18)

GEOGRAPHY AND DEMOGRAPHY

This Cegion encompasses twenty-one counties centered around Memphis in
southwest Tennessee overlapping 25 counties in norkhern Mississippi, 13
counties in Arkansas, 5 Kentucky counties and 3 in Missouri.  The total
population of the area served is 2,393,000 (59% urban).  There are only
two metropolitan areas, Memphis, Tennessee (767,100) and Pine Bluff,
Arkansas (83,400).  The negro population is 1-9 in Tennessee and 37% in
Missisoippi.
Mlssissippi ($3680 - U.S. ).

Average per capita Income: $2,810 - Tenneaeee and $2,192

Mortality rates per 100,000 population:.

U.S.

Tennessee MissiGsippi 7

Heart
Malignant
Vascular
All Causes

336.0 311.8
140.5 132.8
128.8 126.8
919.7 963.8

364.5
157.2
102.2
935.7

Manpower training facilities include the University of Tennessee (College
of Medicine, School of Dentistry, and School of Pharmacy).
there were 764 students enrolled in the College 3f Medicine and 165 graduates.
Other schools:

In 1969/70

5 professional nursing, 1 practical nurse, 1 cytotechnology,

Memphis RMP -6- RM 00051 8/71

4 medical technology, 4 radiology technology, 1 physical therapy and
1 medical record librarian.

Medical manpwer includes 1518 physicians (ratio 130/100,000 in the
21 Tennessee counties),
the Regional ratio of physicians was 95/100,000 and 153/100,000 for active
graduate nurses.
V. A. (1,256 beds).

8

According to the initial planning application

\

Hospitals in the Region 87 (13,319 beds) including the

REGIONAL DEVELOPMENT

Planning for a better health care system in Memphis began in 1946 when
the Commission Government of Memphis, in collaboration with the University
and hospitals of that City, employed a firrn to survey patterns of referrals,
medical facilities and future needs of the area. Among the recommendations
carried out was the formation of the Mid-South Medical Foundation to
function as the planning agent for the Memphis Medical - Center. -__-
la a five block area which includes two general (2,438,bedqr the VA hoepital
R tuberculosis hospital, a state psychiatric hospital, a children' s
hospital, a rehabilitation center, children's heart out-patient facility,
a speech and hearing center, child development center, Memphis and Shelby
County Health Department, University Medical Units, cancer out-patient
clinic and the Campbell Clinic,
County Medical Society established the Mid-South Medical Center Council
for Comprehensive Health Planning, Inc. (MEICC). The first Board was
appointed in 1966 when the state charter was obtained.  Since that time
the membership has been expanded to include representation from the Region
outside of Memphis and Shelby County.

-.f The r. Center * -------

Beginning in 1965, the Memphis and Shelby

By common consent and by resolution of the Memphis and Shelby County
Medical Society, the University of Tennessee College of Medicine was
designated and continues to be the applicant organization for the Memphis
Rekional Medical' Program. +,'

The Mid-South Medical Center Council for CHP "B" also serves as the MRMP
Regional Advisory Group,
and six months, April
merged with operational activities in the second planning year.
awards were received for three years ending August 31, 1971.

The Region was site visited June 1968, April 1969, and July 1969.
the last site visit it was noted that program development during the first
operational year had been set back by at least nine months due  to a  series
of problems resulting from the sanitation employees' strike, the assassi-
nation of Martin Luther King and the hospitals' personnel strike.
visitors found the gsals and objectives vague and broad.
n3 clear relationship between Regional goals and project components.  The
visitors informed Regional representatives of BW's concern that a majority
of operational projects appeared to be oriented to further development of
the medical center, rather than to involve the Center in outreach activities.
An attempt was being made to develop programs in the periphery through local
advisory groups; fifteen had been established at local hospitals,  two in

The Region received planning awards for two years

1967 through September 30, 1969.

Planning was

Operational

During

The

There was also

Memphis RMJ!

-7-

RM 00051 8/71

Arkansas, five in Mississippi, three in Missouri and five in Tennessee.
Evidence of attempts to develop rural area activities was two projects
in northern Mississippi, #18 Mobile Multiphasic Screening and #19 Cardio-
vascular Clinics.
community including the health department were good. Some problems in
alterations and renovations within operating projects in the City of Memphis
Hospitals had been solved.  A new hospital authority,  a fifteen-member board'
was being established for administration of city and county hospitals.
visitors gave considerable attention to clarifying the MMCC & MHMP relation-
ships.  The 100-member Board of MMCC heads CHI? "B" and served as the MRMP
FUG.  Although the arrangement might be expected to provide good inter-
facing relationships, some cornplicationa had arisen, The role, functions
and Interrelationships of the two staffs had not been clarified. It also
appeared that IW staff was not working directly with the RAG.
cations with the RAG, including proposals, had to be processed through the
MMCC staff which caused some hangup. The MMCC board was heavily weighted
with Shelby County representatives,  and the visitors did not believe this I
was the desired equitable  membership for a RAG.  There also seemed to be
a power struggle between the Medical School and MMCC. The visitors expressed
some concern about core staffing patterns. Some staff had been employedrfor
operational projects proposed, which were not approved.  Also, there were a
significant number of part time personnel.  The visitors believed that MRMP
might develop faster utilizing full-time personnel to concentrate efforts  on
generating outreach programs and supervising project developnent. Too many
projects were improperly designed and lacked Regional implications.

On review of the third year continuation application during August 1970,
WS staff noted program development was  still slow.  The MMCC Board had
expanded to 134 members,
were still not clearly defined. The organization structure appeared diffuse
and the problems in the CHP-RMP relationships enumerated by the site visitors
were still apparent.  Although progress in the peripheral areas had improved,
the main thrust continued to be medical-center focused. A move in the right
direction, the Region planned to relocate its quarters off campus. An
innovation in organization wa~ the development of an RMP Review and Nlicy
Committee, a group through which it was thought RMP could better communicate
to the MMCC (also the RAG).
Region was to assemble a central core staff with appropriate expertise.
Progress was poorly presented.
advised that it should begin planning for phasing out support of projects
after the duration of current funding.

According to testimony, RMP relationships with the medical

*

The

MRMP communi-

e

The overall goals, objectives and priorities

It was recognized that a major effort of the

It was also recommended that the'Regbn be

ORGANIZATION STRUCTURF:

The application includes a list of 156 members of the RAG and Steering or
Executive Committee.  The legal voting body of the RAG is 44 persons, the

mlkdations to the RAG.  An MMCC-MRMP Evaluation Committee of nine members
develops annual reports of the RAG.  A Planning Board (Program Committee)
of fifteen advises coordinator on policy, administration and applicability
of project proposals,  and meets jointly with the Policy and Review Com-
mittee. There are also twenty-one other Committees including disease cate-
gories.

+m-C Board.

The MRIJP Policy and Review Committee, 37 members, makes recom-

The total membership of the Board and all Committees is 338 (may be

0

Memphis RMP -8- RM 00051 8/71

some overlap of members),

An organizational chart is appended.

Initially projects were submitted directly to the Central Committee at
which point they were referred to technical reference committees if neces-
sary.
turned them-for revision or approved them.
tions were submitted to RAG.
Committee, final action was taken by the RAG.

The current review structure (chart attached) now includes assistance in
the development of proposals by a staff team.
to a Consulting Panel, then to the Planning Board and the Policy and Rediew
Committee for review and rating before final action by the RAG.
does not determine priority ratings of components until after the National
Advisory Council action.

The Central Committee - - __ either held proposals for further study, re-

Approved and rated applica-

After review and comment by the Health Services

o

Final propsals are submitted

The RAG

A joint CHP-RMP task force has been formed to develop an Experimental Health
Management System for coordination of the delivery of health services.   A
contract has been proposed to HSMHA.
future role of MRMP as aiding operational planning and evaluation research
of the new experimental health services planning and delivery system.  The
MMCC CHP "B" Agency is responsible for @icy planning for health services,
facilities, manpower, and health needs research.  The operational activity
cf the system will be the responsibility of a new corporation of MMCC to be
formed and named Health Systems Management, Inc. Its function, under the
direction of a Management Board,will be to negotiate linkages of a con-
tractural nakure between segments of the delivery system, develop and coo+-
dinate grants for health services, promote new developments, and manage
evaluation data acquisition process.

New directions describe the immediate

GOALS, OBJECTIVES, PRIORITIES AND STRATEGY

These are fully described in Volume I of the application pages 115-119.

The MRMP goal is improving the level of health care; . ~ including -.- prevention,

diagnosis, treatment and rehabilitation for <the ,. . Regions' pa@bt'ion.

Objectives:

2'

1.

2.

3.

4.

To stimulate the provision of optimum health care to the entire popu-
lation of the Region, with priority to the economically poor,  the near
poor and the medically indigent.

To promDte continuity of care for all patients, particularly those
with stroke, heart disease, cancer and kidney disease.

To emphasize rehabilitation as a necessary comp!Tl.eiiL of the spectrum
of comprehensive health services to return individual:; -to maximal
functioning.

To prom3te continuing education for physicians, dentists, nurses, and
allied health professionals in order to assure the consumer of the
benefits of the latest knowledge and skills.

Memphis RMP -9- RM 00051 8/71

5.

To promote health education for the public with the aim of enabling
all individuals to participate in and make effective use of the health
care system.

6.

To stimulate the expansion of the health manpower pool and to make more
effective use of all levels of health manpower.

7.

To increase andimprom local involvement in both the problems of health
care and their solutions, by assisting providers.

8.

9.

To assist sub-regional areas in defining their health needs.

To develop closer working relations with DHEW Region IV Officials,  State
and areawide CHI? agencies, and other existing Federal,  State and local
heaith and health-related organizations.

10. To perform continuing evaluation on the various components of the MRMP

in an effort to assure maxim program effectiveness.within a framework
of limited resources.

_.

- -..

Special priority will be placed on activities -which mihesize:

1.

Effectiveness and quality of service (preventive, diagnostic, therapeutic,
and rehabilitative).

Health education for consumers,  as well as for providers of all pro,-
' festi iomi tj-pei .

Active local involvement of both consumer and provider groups  in the
planning process.

Efficient use of total comunity health care resources.

2.

3.

4.

5.

6.

Placement of patients at appropriate levels of care.

Development of mechanisms for stable financing.

7. New kinds, or improved distribution, of manpower.

8. Program components, projects, and activities which can be shown to have

a high benefit-to-cost ratio.

9.

An improved system of primary care with appropriate access, outreach,
and referral to other levels and sites of' health care and to supporting
services (such as nutrition, education, welfare, and family planning),
as well as appropriate follow-up procedures.

Memphis RMI) - 10 - RM 00051 8/71

LO,

Development of an improved functional data profile of the health care
needs of the region's population; the social, attitudinal, political
and financial constraints; and the efficiency and capacity of the

I

delivery systems throughout the region. \

PROFILE OF ONGOING ACTIVITIES

A T-(IYIPG-MIS computer printout December 31, 1970, reveals the folloving fund inq
p,il;terii cl~arcicterists of 15 operotiorinl projects nupportecl I);/ Lhe Idemp?i is
li(hril minJ. Medicril Trogram contraated wtth 1;hc n~grefplx: of 579 trctivitlc,.a  for
OLL 54 region::.

Sponsoring Agency

Medical School
bled. Sch. Univ. Hosp.
Univ. Affiliated Hosp.
Univ. Health School
Public Health Ag.
Vol. Health Ag.
Gther Hospital
Health Prof. Society
Combination
Other

Physicians

Training Health Prof.

RNIS
Allied Health Pers.
Technicians/Aides
Combined Phy. & RN's
Other Combinatioria
Other
Not Applicable

Disease Category

Heart
Cancer
Stroke
Kidney
Other
Mu 1 t i - cat ego r i ca 1

- Target Population

A, Minori.ty

n1n c I<
M inor1 ty
Other f'oor.
Not Applicable

IJercen t of Dollars

MRMP All Regions

3
0
37
0
2
0

0
22
2

34

13
4
22
0
9

22
0
30

41
2
3
;4
5
7
16
2
7
5

26
5
12
0
6
52

15


85

8

26
12
13
3
8
39

'I

8

85

..

..

. :- .
\..

\ : .

I.. . .

...-.

Memphis RMP

0

Spnsoring Agency (cont 'd)

I3. Age

C hi i Id re n
29- 39
40-65
ever 65
Zen Pop.
Other
Not Applicable

Health Care

Prevention & Screening
Diagnqsis & Treatment
Rehabilitation
Comprehensive
Combinations
Not Re levant

Primary Purpose

(-'ontinued-Fd.
Train Existing Health Pers.
Train New Health Pers.
Patient Services
Half Training & Half Pt. Service
CDord. Health Services
Research & Develop.

- 11 - RM 00051 8/71

Ge Qgra ph y

Reg i orial
Subregional
Rural
Inner City
Interregional
Not Applicable

Percent of Dollars

MRMP All Regions

0
0
16
0
84
0
0

47
34



19

0
1


0

0
13
0
61
1
3
22

40
9
29
0
0
22

5
0
6
1
71

1
16

11
34
6
26
16
7

21
22
2
24
14
8
8

55
27
6
8
3
1

PRESENT APPLICATION

-

The application iiicludes a RAG report in three parts, from the points gf
view of the Chairman, the Policy and Review Committee and Evaluatim Committee.

Eqiinl opportunity data:  of 22 1/2 Core full-time professionals, 11 3/5 are
frmale, 110 minority staff; of 13 core support-personnel, all are female and
5 represcant minorities; or 41 3/4 project professionals, 10 3/4 are female
ai~i 7 ore mirtor-ity members;
and 68 are minority members.

of 386 RAG and Committee members, 48 are female

e

A ininority report by Dr. C. 0. hugherty, private practicing physician
and a member of RAG is included in Volume I1 p. 114.  The report deals
with lack of evaluation data by MRMP.

- Continuation of Core

The amount requested for core reflects an increase
of 45%.
and 5 support positions at $23,304).

Fourth Year
Request
$799,548

Vacant positions account for $127,504 (6 professional at $104,2C)O

Twenty-five (25) feasibility and planning studies and central service
tictivities are listed on page lC a of this summary. These are
described in Volume I pges 92-104.

Accomplishments :

1.

2.

3.

4.

rL .

M3bilization and organization of individuals and groups concerned with
nursing, allied health professions, and rehabilitation; regionaliza-
tion of a program of conferences and workshops on rehabilitation in
cornunity hospitals; development of two project proposals for
increasing numbers and effective use of non-physician members of
the health team.

Development of new concept and format of continuing education for
physicians in their own community hospitals through the organizing,
scheduling, and conducting of Advanced Clinical Conferences, using
their own patients for discussion of problems and topics of their
own choice by visiting specialists from the private practice sector.

Ir auguration 3f a central regional library and medical information
semice for all physicians and other health professionals in the
region;  development of a model learning center project proposal
frm a large community hospital serving a 13-county subregional
referral area, to serve as a prototype for a regional network of
fifteen area learning and referral centers.

Development of an audiovisual studio with basic cinephotographic
and other equipment providing capability for production of teaching
material especially pertinent to our peculiar regional needs, designed
to assist all professional staff members and project directors in
their work.

Completion of surveys and publication of directorics ?>f health,
edacation, ar,d welfare services in southeastern Mis:;oari and in
enstern Arkansqs (second and third volumes in a series);  study of

Memphis IiMp - 13 - a? 00051 8/71

6.

7

8.

9.

subregionali zation patterns in southwestern Kentucky, western
Tetiiiessec., :ind northern Mississippi; extension of liaison contacts
wi t,h n wide variety of community agencies and organizations, bth
rnetrip,,lItnn and rural - with special efforts in the fields of
fhi1.y planning, nutrition, and pgvertjr.

CcJnduct of the Memphis Household Health Survey (1100 metropolitan
houceholds) to study accessibility and utilization of health services
and to define socioeconomic and attitudinal characteristics of
respondents; a compaiiion study of accessibility of health care in a
rural population (Lafayette County, Mississippi - collaboration with
Mississippi Regional Medical Program); a study of birth cantrol
attitudes and practices among 500 Memphis mothers in collaboration
with the Memphis Planned Parenthood Association; tabulation, analysis,
and editing of Memphis Regional Hospital Inventory,  in collaboration
with our areawide comprehensive health planning agenky (Mid-South
Medical Center Concil); analysis of 900 physicians ' responses to pre-
ferential questionaire regarding continuing educational content and
metktodology;  a ztudy of motivation for entering fin allied health pm-
Pc~::,;iori (rlrtntnl h.ygienc2); und D. continuing program of long range
cr)lLrnc 1; i or) of hc:alth data to demonntrnte changer; from ba:;eline char-
act,c.rl:;t IC:;.

Iriitj A t icJri ~f' studies by 8 cjo int task force with areawide comprehensive
health planning agency (MMCC) which led to the development of pre-
applicatim trJ the National Center for Health Services Research and
Development for a grant to establish a Health Services Management Corp-
oration for tri-county metropolitan Memphis and after a slte visit,
the further development of' a proposal for contract to establish the
corporation as an operational agency development of active liaison
with all agencies in metropolitan Memphis dealing with problems or
interests of disadvantaged citizens; liaison with personnel of the
neighborhood clinics operated by the Memphis and Shelby County Health
Department, as well as the voluntary (Wesley House) clinic for primary
health care operated by the North Memphis Community Health Organization;
arranging for meetings with representatives of the Welfare Rights Qrgani-
zation and other groups in a vigorous effort tq identify and becrJme vel1
acquainted with the indigenous leaders amoriFr, low incgme gr3ups in metra-
politan Memphir: and elsewhere in the regirin.

Establishment c>f a 3ection of 1l:valuatiCm staffed by R nystem ana1y:;t
and a demographer, with an epidemiolo[r,ist (M.D., M.P.H. ) as a con-
sultant, to develop a complete and dehiled program of evaluation of
both central staff' efforts and project accomplishments - with appro-
priate consultation service to project proponents during the evolution
of the initial project application.

Considerable expansion of the Information Services' program, with acqui-
sition of the full-time services of an Assistant Information Officer,
who has versatile skills as an artist-illustrator; publication of three

Memphis RMP - 14 - RM ooogi 8/71

0.

1.

2..

issues of the Memphis RMF newsletter CURRENT in an attractive new format;
publication of proceedings of a health care symposium at the 1970 Annual
Meeting of the Regional Advisory Group; design and printing of the program
fx (a) the 1971 Annual Meeting and Scientific Session of the Tennessee
Heart Association, (b) sympsium on the counseling role of the therapist, and
(c) a symposium on malnutrition; printing of a new descriptive booklet on
The University of Tennessee Medical Units and the Memphis Medical Center;

radio and three television interview programs,preparation of two exhibits,
multiple new latern slides, and various other educational and informational
graphics.

five press releases, thirty news stories, and eight feature stories, two 0

Formaticln of a committee on community medicine comprising public health
officers and practicing physicians to study means of strenghtening out-of-
hdspital services offered by health agencies in the region; development of
a project propDsal to augment the primary care services now provided in
conximi ty clinics operated by the Memphis and Shelby County Health Department
staffed by nursc practitioners, to provide more active physician supervisory
and consultative participation, in order to broaden the health services offered;
discussions with health officers in rural counties lo3king toward development
of a regionwide network of' such facilities, based on the Memphis prototype
model.

Exploration by the Communications Officer and the Automation Committee of
services - bDth administrative and clinical - which can be offered by the
staff of The University of Tennessee (Memphis) Computer Center to community
hospitals in the region and to emerging comprehensive primary health care
organizations; study of possibilities for pooled clinical data from City of
Iternphis Hospitals, Shelby County Hospitals, Memphis and Shelby County Health
Department, and private community hospitals in the Memphis medical center.

Active collaboration with the Tennessee State Office of Comprehensive Health
Planning and local areawide :314(b) agency (MMCC) in organizing new 34(b)
c~mittees in sguthwest Tenl--ssee (District 8) and northwest Tenmszee
(District'7); exploratory meetcngs at the Mississippi State Office CJI" Coa-
prehensive Health Planning looking toward organizing a 314(b) agency for
nnrtheast Mississippi, including local meetings with two interested local
~rc>ups; transmission of our survey data on comrnuriity resources in southeast
Xissnuri to the chairman of the 314(b) committee there,wh%ch had been
orcanized under the auspices of the Mizsouri State Office for Comprehensive
Health Planning, and continuing liaison with that committee; liaison with
existing 314(b) committees in eastern Arkansas;  offer ~f r,l;af'f services. to
ai3 in organizing the eight counties of southwest Kentucky (the "Jackson
i'uchase Are") for areawide comprehensive health planni rig.

Pi*>;ects next year include continuation of the ari  JC with expansions based
311 availability of RMPS funds. A propsed new dir:c.ri.:i?n is pro:ect evaluation
0% alluded to in Volume I page 49.

TI s application includes statements on core cooperative arrangements t7itJh
:n_ :'e than 15 organizations (Volume I pages 60-85).
c:!wunity relations and liaison activities are described in Volume I riages
cs-91.

Core consultakion,

Sixth Yea3 $799,54%

Mempbis RMP

0 Developmental

. . . .. . . ..

- 15-

RM 00051 8/71

Fourth Year - 0 -

Decnuse ,)f t,he MFNP's understanding that no new funds are available to
::i~pl~)rt, 1,~if~sf~ nctivities, no fund; are requested. However, authority to
iirdr:rtnkr. I,lie~;~: type!; of act ivj 1; Li.,:; in reque::t,ed i.n the event additional

:ilizrltion t,:f nsscist,ing in the establlshment of' CHP "B" agencies throughout
the Region;
Learning centers; 3) cooperative public education programs; 4) assistance
in Health Maintenance Organizations.

+ JmC avtiilatile. Areas to bc :; tqh ted in on Include: 1) subregion-

2) establishment of a network of satellite information and

Continuation of Projects Within Currently Approved Periods
#14 Coronary Care Unit - St. Bernard's Hospital Fourth Year $20,343

This project now in its second year was approved for three years and was
funded fqr $54,380 the first year, $26,884 the second year and $20,342 was
committed for the third year (4th MRMP operational year).
provided equipment  for a four-bed Coronary Care unit at a hospital in
Jonesboro, Arkansas.  The construction of the unit was provided by other
sources. The unit is utilized to train registered nurses in coronary care
techniques with the understanding that these trainees pyramid their learning
to other hospital personnel.

The activity

In addition to patients now being cared for in the unit, 129 have been treated.
The project reports adequate reception by professional staff and an increase
in trained personnel. No significant change, however, has been noted in
corona ry mort a lit y .

Fifth Year -0-

Sixth Year - 0 -

#I7

Prevention Services Heart, Cancer, Stroke
- and Related Diseases             Fourth Year $19 3,500

This project is now in its first year with authorized funds of $269,470
(16 months). Commitments: 2nd year, $180,000 and 3rd year, $120,000.

The project is an adjunct to the previously existing ChrQnic D' sease Screeriir&g
program, a cooperative effort of the University of Tennessee Medical Sck:cml,
the City of Memphis Hospitals and the Mempbis and ahelby County Health
Department. In addition to screening for glaucoma;-diabetes syphilis, cancer
9f the cervix and tuberculosis; additive procedures were to include bbod pr@ssu
spirmetry, EKG, hemoglobin, urinalysis and occult blood. The project antici-
pated screening 20,000 patients annually drawn upon the City of Memphis Hospital
Out-patient Clinic and recipients of the Tennessee Welfare Department.

The July 1969 site visitors were impressed by this project and the competence
of the Director.  However, there was some concern that the anticipated case
load might be unrealistic.

Memphis RMP - 16 - l?M 00051 U/?l

Ileiays were encountered in tooling up (recruitment, developent of facilities,
1,iJrC:hase of equipment etc. ).
prsms were screened.

During nine months, July 1970-March 1971, 7,200

Fifth Year $129,000 Sixth Year -0-

lilt3 Mobile Multiphasic Health . Fourth Year $181,507 b

Tlii:; pr*o,jcct wns approved frJr throe years and $312,633 was authorized fr/r
it:- f'ir&;t year. Commitments:  2nd year, $195,000 and 3rd year, $l3O,OOO.
Zpo:ieJrtd by two northern Mississippi Hospitals, a mobile trailer screening
xuit serves the five-county trade area of these two hospitals.  Annual case
load predicted was 20,000.  Procedures include a short history, measurements
.)f' blood pressure, height and weight; chest X-ray; EKG; spirometry; cervical
cymlogy; urinalysis; blood chemistry; tonmetry; and self breast-examination.

The July 1969 site visitors recognized that this was a community-generated
activity from a part of rural Mississippi where there is great need for
i:r.proved health care.                     1) anticipated
mse load overly ambitious;
resclting pathology; and
oriented area.

Some problems foreseen by the team:

2) ability of the two hospitals to deal with
3) referral patterns in a general practicimer-

3ill scale screening did not begin until April of this year due tr, delay in
developjng the trailrr unit. Meanwhile mmc screening was done ty using B
Xicr,issippi State Boord of' Health hobile Medical Clinic.
:;eT'teml~cr-r)ecerritJ~r  1gr/O, 2792 children were :;crccncd wj t,h a yic Ld of 1355
~il~tv~mi~l i'indirqw. During the three-month period Januury-March 1971, 182
nciults we~e screened leading to the detecti!)n 01' 1386 abnormalities.
Liiird of the abnormal findings warranted referral to their family physicians.

Diiririg fQur month:;,

One

- F~IW Year $121,000

Sixth Year - 0 -

el9 Cardiovascular Clinics in Northern Mississippi Fourth Year $38,046

Tris project, approved for three years, was begun in the second operational
;.-ear and received $25,752 for seven months from carryover funds.
$lj,OOO for a second year in the'Region's third operational year with no
xmnitment for its continuation. Support is requested for an additimal
\-c.r:r and six months to complete the three year project period.

It received

.'p >tisored by the Mississippi State Board Qf Health, this project, pmpzez
I-.xj)Ciiiditit: 8 network of diagnostic nrid consultative he0r-t clinics which ha3
il~:c11 c:;tubli:;lied in forty-six locution:;. The reEirLar1.y scheduled cliriicc are
i::iniied by physicians i'rom the Mj :s:;i::ippi Stnte i: ~*ir~? of Jlealth, the Univtr-
-i 1,iC.s oi' Tentiecsee i3nd Mississippi, and the privu',c . i chr. The project
-x 111 ~::ed broaden5 ng the  cliriic Gerviccs by increasing tric. frequency or clinics
i'rouj twice each month to weekly.  Post graduation educati 4 jiLL< L  programs were
n~o to Gc conducted for physicians, nurses, and other health personnel.

?fie July 1969 site visitors believed this to be a worthy project. They were
satisfied with adequacy of follow-up and of University consultative assistance.

- .

'\

I

Memphis RMP - 17 - RM 00051 8/71

During the past ten months, 42 clinics were held in 12 locations.
patients worked up, 198 were diagnosed as having some form of heart disease,
One hundred and fifty patients seen in the clinics were referred by private
physicians.

Of 466

Fifth Year. $16,468

Sixth Year - 0 -

j$25 Home Care in a Hospital %sed Agency Fourth Year $27,657

'i3iis proJect was approved for three years, 01 - $20,600,

02 - $23,972,

03 - $27,657.

I

&ginning iit the Regions second operational year, ZWS authorized $10,443
(6 mmths) to begin this project.  The Region's third year award included
$12,630 to continue the project for a second period with no cmmitment for
future SUxJpOrt. The Region is reques-iing funds for one year and six months
to complete the project period.

This is a home care project based in an Arkansas hospital to serve as a
demonstration to other hospitals in the area where this service is not
available;
to economic usefulness.  The activity is responsible for nursing care,
physicial thereapy, dietetics, as well as as coordination of other
available services.  It was anticipated that 1200 home visits would be
made the first year.

The project aims to shorten hospital care and return patients

During the first seven months of operation, 552 visits were made (23Q
professional nurse visits and 322 by trained nurse aides).
readmission has not been necessary in a significant percent Cjf the patients
Serv ed because of successful horae care programs.

Hospital

ffl Ctroke Center

Fourth Year $84,200

This is a request for support for an additional three years. Previous
funding:

Specific objectives continue to be:
for stmke management including intensive care; 2) development of a
training program to provide the necessary medical skills; 3) dissemination
of information by a multi-disciplinary stroke team: 4) expansion of
medical center training facilities for physical therapists; 5) developmer,t,
of facilities for psychometric evaluation of stroke patients; and 6) improve-
ment of rehabilitation techniques and facilities.

01 - $81,606,

02 - $148,522 and 03 - $68,546.

1) establishment of a model center

Construction of the new six-bed stroke intensive care unit at John Gs:;tori
lIc.>npital is almxt complete. Meanwhile R temporary unit is operated at the

Hemphis RMP - 18 - RMOOO~L-. 8/71

City gf Memphis Hospitals,
nurses in the unit and has precluded offering short term courses for physi-
cians and nurses. "he stroke team is described as moderately.successfu1 in
continuing education.
k retrospective study is being done to aid in evaluation of stroke intensive
care. 0

A major problem has been the understaffing of

A professional education film is being developed.

Fifth Year $102,350 Sixth Year $118,720

//2 - Gostrointestinal Mucosal Suction Laboratory Fourth Year $41,595

Support is requested for an additional three year:;. Previou:: funding:
01 - $18,000, 02 - .$23,325 and 03 - $24,821.

The project was developed in the Memphis area to serve the entire Region
charging private patients who are able to pay and processing biopsies
i'rom indigent patients without charge.  In addition to its functional
service, the laboratory also serves as a teaching facility for
~echnicians, medical students, interns, and residents.

3Lrir.g the past year, 158 biopsies of 141 patients were processed.
Xring the same period, five second-year residents of the University
,;f Tennessee, Department of Medicine and five technicians received
training in the laboratory.
technologists and students at Memphis State University and one
n3spftal. Physicians from outside of Memphis have not utilized the
laboratory to the extent anticipated.

The project Histotechnician lectured

Fifth Year $51,824 Sixth Year $53,746

- Prevention and Early Treatment of Skin Cancer _I

Fourth Year $29,340

7

ikLi: is a request for support o$ this project for an additional three
jeers. Previous funding: 01 - $29,590, 02 - $34,998 and 03 - $25,435.

0i~;ectives are to demonstrate methods of detecting and providing early
niaiiegement of skin cancer in rural populations of the Region;  and tc)
eci',cate health professionals and lay yublic. Nurses trained in cliniral
cietection 01' skin cancer and actinic Keratosis, gtither data by hrirne

orviews and examinations in a rural Tennessee County. Ilur-cti5nnaire:
+a-~ 31s~ Seen sent to appropriate physician specialists. ir! tmperstir,n
?;i th a pharmaceutical firm, field trials nave also been conducted in
11 - 1116 5 13uorouracil" in Lreatiny, zkin lesions. The project reports
its study has revealed a significant number of unkreated skin cancer
anti substantial solar Keratosis. The findings have Lead project staff
L ) prgpocing an educational campign to educate physici:lrir. and others
!ii  'ihe use of "5 Fluorouracil" fur control of solar Ker*atj$ i:;,

. It

Sixth Year $33,431

c

Memphis liMp -19- RM 03051 8/71

0

if') - Intcnsi ve Cnrdio-pulrrionary Care Training Unit

Fourth Year .$67,6'jO

;;I~I)/) )r.t f'or three: udtii t,ioriul year:: in requezted. previcJIIf3 furiding:
01 - :~l30,000, 02 - $106,2Ctj and 03 - $100,000.

As result of' the project, a twelve-bed intensive cardiopulmonary care
unit is in operation at the Menphis Medical Center. Training has
lncluded the University of Tennessee College of Medicine house officers
and fifth-year medical students, Forty nurses received six weeks of
training. The circulatory care clinic serves as the treatment unit
fw the City of Memphis Hospitals and has admitted 327 patients since
opening February 1970. The Project Director serves as coordinator for the
Northeast Mississippi Cardiac Clinics aich serve northern Mississippi
health departments.
The greatest problem has been the shortage of nurses at the City of Memphis
Hospitals,

4

Visiting physician teams consulted on 729 patients.

Sixth Year

$74 , 60 5

Fourth Year $115,694

This is a request for support for an additional three years. Previous support
(direct costs): 01 - $59,928, 02 - $69,144, 03 - $35,605

The goals of the project have been to set-up a chest clinic within the
University Medical Center to provide consultative services and ongoing care
for patients with chronic pulmonary disease; as well as to provide a post-
graduate and graduate teaching facility.
been that this activity is University oriented with almost no outreach,  and
the need Tor at least 50% time by a project director.  A clinic for diagnosis
and treatment of patients with chronic obstructive lung disease has been
established.  A viral and mycoplasma laboratory has been implemented to carry
out special research studies to improve clinical management of patients.
About 35 patients have been enrolled in the studies. Educational activities
have included the training of medical residents, physical therapy ntudents
and senior medical technology studentc.

@

Previous concerns -of RMPS have

Under a ncw project director, the program ariticipaters. expansion of the clinic
to a regional diagnostic facility. Projections include training more allied
health personnel. Additional facilities and staff are also planned,

Fifth Year $130,210 Sixth Year $141,940

#7 - Streptococcal Disease Center Fourth Year $123,230

Support is requested for an additional three years to include a new component

(7A - Memphis Shelby County Health Department).
01 - $103,252, 02 - 101,310 and 03 - $110,648.

Previous funding:

e

Memphis RMP

- 20 -

RM 00051 8/71

Tlie goal of this proJect has been to establish a streptococcal disease
control center at the Memphls City Hospitals to provide:  1) a service
laboratory; 2) clinical services; 3) a registry for follow-up arLd epidmi-
ology; and 4) continuing professional and public education.

Reported accomplishments:
house staff of two large Memphis hospitals, Arkansas physicians, medical tech-
nologists, and medical students; 2) bibliography and library service; 3) public
education and information; 4) in-service training for nurses of county health
departments; and 5) research and development studies.
patients under surveillance or treatment.

1) continuing education for nurses, nursirlg stxdents,

The project has 4.50

The proposal includes a new component (7A) to fund two additional nurses for
the health department program and to furnish prophylactic medication.
application indicated that research and service aspects of this project are
almost all funded from other sources.

The

Fifth Year $133,201 Sixth Year $143,035

$ - Regional Electrxardiographic Diagnostic

Center

Fourth Year $62,575

This is a request for support for an additional three years.

IJrevious

fatiding:  01 - $108,687,  02 - $87,158, 2 03 - $72,985.

The gDal of this project has been to provide centralized University-based
eiectrocardiog&phi,- recording and interpretation services.
re-iised to include for the eventual incorporation of computer aided diagnosis.

interpretations would be improved.

With the exception of some telephone transmission with some hospitals,  the
centralized EKG system, including the computer is operational, Because of
conflict with private medicine (competitive aspects) the approach is now
limited mainly to tke servicing of emergency electrocardiogZ&hic
of coronary care units in the Region.
two hospitals, one in Tennessee out of Memphis and another in Mississippi.
Educational Activities consist of an annual course for physicians.

Plans were

Thrbughcontinuing edilcation programs, it was hoped that the quality of EKG

situations

Transmitting units have been place  in

TI. LO 1 i c th Year $59,796 Sixth Year $63,002

- 3ev Projects

-

(described in the application, Voliime 11, ~)il~es 154-1_77)

,$"29 Productioii and Zistribution of RadLopharrnaceuti (::i ; :I


'fiiis is A proposal to improve the fac-ilities for producl; )I. of short-lived,
~*ndi~pl-iar~r~aceuticals in the University of Tennessee laboratories,  and to

Fourth Year .w7,6l5

Memphis RMF - 21 - RM 00051 8/71

develop means for their distribution to the Regir)n's hgspi-tals within
r-m:;~ ~imk)Lr? timc: and at, low costs. This lab,)ratory premritly produces these
~adit)pharrnace~rt, lcalv for uze by the City of Memphls H jcpitals, but not in
!;iifi'itient, quantity to supply other hospitals.

-- Fifth Year- $54,830

Sixth Year $30,192

,f30 - Comprehensive Kidney Di sease Program   Fourth Year $81,9g-- -

A two-phase program, the first year will be spent in surveying Regional
renal needs to  serve as a basis for program priorities for the remainder of
the project period.  Needs will be approached hy:  1) continuing education
seminars at local hospitals and short term courses for physicians and allied
health personnel at the Memphis Medical Center; 2) home dialysis training
pragrazns for physicians, nurses and paramedical personnel; 3) establishment
of regional satellite hemodialysis units for home dialysis patients; 4)improved
renal transplantation facilities and establishment of a coordinated system of
harvesting and preserving organs, tissue typing and consultative facilities
and 6) establish screening programs for early detection of Kidney disease.

Fifth Year $60,242 Sixth Year $63,608

#31 Peripheral Vascular Clinic

Fourth Year $10,711

This is an apparent recast: of disapproved projects 4 and 27.
awarded to #4 for further planning.
provide the general public with an understanding of the disease processes
and the resources available for medical and rehabilitative services and to
disseminate current information in an up-to-date fashion to physicians,
nurses, and rehabilitation personnel by clinic visits and educational work-
shops presented at the outlying hospitals.

Funds were

The objectives of this proposal are to

Throughthe Peripheral Vascular Clinic faciltties, this project will attempt
to educate the public and medical professionals on the diagnosis, prevention
and control of peripheral arterial disease.
through pamphlets explaining the causes, warning signs and possible compli-
cations of vascular diseases.
buted to such areas as hospital lobbies, county health departments and mqbile
x-ray units. Professionals will be presented with the latest information
through lectures and conferences, with nurses and allied health personnel
participating.in in-service training programs.

The public is to be reached

Approximaterly 10,000 pamphlets will be distri-

Fourth Year $11,697

Sixth Year $11,882

$32 Model Hospital Learning Center Fourth Year $37,922

This project, based in the Jackson-Madison County General Hospital, is
expected tis demonstrate the desirability and need for improved and available
medical library services to physicians and other health professionals within
a 13 - county area of West Tennessee.

It is anticipated that this facility

- 22 - RM 00051 8/71

will serve as the first of approximately five similar facilities to be
developed later, establishing the basis for an information/comunications
network in this region.

Fiftii Year $27,999

Sixth Year $29,555

Fourth Year $47,211

Thc f-tb,ject;ives of this propma1 are to develop and determine post-mortem
tests uhich if available to physicians will improve their accuracy of death
certification, to develop those techniques which can be used in lieu of an
a~t2psy and at less cost than performing the autopsy, - and -- to disseminate to . ~ ---
8r.d - -- encourage - _____ the - . utilization - - of - these techniques by all physiciansin the
region.

1~;~s project is expected to provide for a maximum degree of accuracy in
death certificates with a minimum expenditure of profeesional time,  to
prsvi.de a far more accurate base line to measure the benefits of all
-prDgrams within the MRMP, to.institute a greater awareness on the part
3f.the physician of the true value of mortality data and thus lead to
greater caution on their part incompleting death
develop a model protocol. and plan which could, with relative ease and little
~Gst, be instituted in other 'regions.

r'ifth Year $52,211 Sixth Year $7,000

i-1:

certificates, and to

--I_

$34 Leadership in In-Service Education I_ Fourth Year $42,756

In response to need indicated in a 1969 regional survey, the project
-,.:iil assist individual institutions and agencies to upgrade care and
services available through the further development of present in-service
nersonnel.
'ze developed for the region.

In addition, a poor of future in-service educators will

.Six subregions having potential as teaching centers have been identified
as willing to work'collaboratively with the project director.  It is
a:iticipated that much of the first year of the proposed project will be
::erded to establish a common baseline for in-service - education 1- persmnel.
Par-cicipantz will be assisted in identifying the -&hcation and training
~cwfis of henlth workers in their institution or agency.
t,c-~sions will then be designed to equip in-service personnel with tools
i,') meet tlie self-identified needs.

The ellsuing

3ii'th Year $36,550

p:, Laborat3ry Evaluation of Clinical Tests in Patient; -I--- wi<, I

Fc7urth Year
$58,030

Endocrine and Met a boli c ---I_ Di s t urbance s

TliE. objectives of this project are to educate and acquaint physicians T c- -
allied health personnel of this region with the recent advances

..

..

..

..

..

'

Memphis RMP - 23 - moo051 8/71

in the area of clinical endocrinology and the recent advances in the
performance of clinical testing in patients with endocrinologic and
metabolic disorders; and to apply a series of more relevant and precise
techniques in the field of endocrinology and metabolism for the diagnosis
of endocrinologic disorders,

This proposal calls for a pilot study in the region that would utilize
tests to determine regional diagnostic patterns.
Ghese new techniques will be made available to medical personnel in the
region.
promoted by the use of the Veterans Administration Hospital laboratories
8s teaching facilities.

The results of applying

The dissemination of recently gained knowledge will also be

In order to achieve the above objectives, the following methodology ia
yro-pr;sed for this project:

1.

2.

3.

IC o

Lectures and demonstrations will be given to physicians and allied
health personnel and hospitals with lOO+ beds in this region.
is anticipated that at least one hospital will be visited each month.

It

A short seminar course and workshop of one week's duration in the
VA laboratory will be offered to selected and interested individuals
who are in charge of hospital clinical laboratories or physicians whose
practicejustifies such an educational exposure.  It is anticipated that
eight to ten allied health personnel and three o@'four physicians will
attend such workshops per year.

-

__ - -.,- -..- -

i

Relevant tests for large numbers of the p9pulation will be used to
evaluate the normal pattern in the Memphis Regional Medical Program
region.

An educational pam'phlet will be published for 8 readily available
source of reference for all the hospitala in the region.

Plf'th Year $51,702

Sixth Year $54,026

if36 Eqansion of Servlces in ExisJing Neighborhood Health Centers Year

in Memphis -&373--

This project proposes to expand the role of registered nurses by
developing a training curriculum with the University of Tennessee
College of Nursing and College of Medicine to upgrade nurses from
generalists to nurse specialists within certain fields, and to expand
preventive services offered in four existing Tdcnighis health department
facilities by implementing primary care.

The project proposal encompasses activities beyond the confined scope
of present Regional Medical Programs Service legislatlon therefore,
MINI? proposes to act as a "broker" for services not applicable under

Memphis RMP - 24 - ~~00051 8/71

Regional Medical Program legislation - (e.g., dental services are an
integral part of the total propsal),. Funds requested exclude dental
service monies.  In its pmition as broker Memphis Regional Medical
Program will seek funds from other federal agencies for partial support
for the project.

'

E

The primary objective of the project is to improve the general health
Df the comunity by providing continuing medical care, comprehensive
in nature, of good quality and economical, by building upon existing
public health services of four decentralized health centers in Memphis,
Subsidiary 9bjectives include the provision 3f decentralized health and
rr,edical care for ambulatory patients, the expansion of the present clinical
ntirsing Zrogram t3 include ambulatory patients with chronic pulmonary
disease, certain surgical conditions, psychiatric and chronic cerebral
dysrhythmias end the creatign of mwe direct lines of patient referral.
Other objectives include the effective utilization 3f nurses and other
sllied health personnel in the prm~ioion gf this care; alleviation of
3vercr3wding 3f medical center diagnostic cmsultative facilities by patients
receiving maintenance care; the conservation gf physician time for ectzvities
requiring his degree of skill and expertise;  the cmrdination of medical
services with other cmmnity health resmrces: the pmvisi9n of dental
cervices t3 an extended segment of the pDpulati9n, and prwisim gf ongroing
srientation
Ideaphis medical area.

and in-service training programs for nurse clinicians for the

._

- --

-

Adult health services offered will include the clinical nursing Program,
home care activities, anti-partem and post partem activities , medical @idanee
alld and the development of primary care services. Preventive ~edi-
atric senices   include a history, a Screening Physical, and prwrY pdi-
5tri.c care for treatment of specific conditions c_- such 8s ga6trOintesti-l Up-
sets, up-pr respiratory infections, and minor mi~Tjxct <..- -r..*..-*--+

disorders*

-

-.?..%!I Year $430,295
$37 Strerigthen and Improve Utilization
  gf Existing P Nursing Manpower

-

Sixth Year

$563,358

Fgurth Year .$48,378

Addrexing the nurse manpower shortage, the pr3ject's objectives will be
ayprmched from two angleo.
",m nursing $&cialists -.one in chronic disease and the otl-
.:cdical-surgical area,
+c~-Jc<pltals in the region in the areas of consuLtation and education.
chronic diseaee nurse will assist health workers in the management and re,H
habflitation of chronic disease patients, with e!; emhasis on the improve-
nent of continuity of care.  Her position will gi\e --er the opportunity to
Lssess the current situation concerning continuity oi'
c~d to work to overcome existing deficits.
sFcialist will be primarily concerned with establishing criwria for quality
=f' care End e-xamfning current nursing utilization patterns ard roles, especially
ir regard to the roles they are expected to perform in emerging care delivery
s:istens.

The fimt approach entails the utilization of'

Both will work with the various heelth agencies and

The

         in the region
The rnedical-.~,i~~,~i-cal nursing

Memphis EiMp

- 25 -

m 00051 8/71

The second approach introduces a nursing audit - a method of nursing care
evaluation by nurses - by which nurses can evaluate the quality of nursing
care being given.  The two approaches are expected to result in the delin-
eation of deficiencies in current patterns of nursing utilization,  the im-
provement of nursing service through the expansion of skills (through con-
ferences and workshops and consultation), the development of education and
training programs that are more relevant to newly defined nursing roles,  and
a better overall view by nurses of their expanded functions.
ore to receive continuous feedback from patient, medical and administrative
mrces in regard to their effectiveness and be further evaluated by the
measurement of improvements ii the care of the chrmically ill.

Fifth Year $50,372 Sixth Year $52,960
#38 A Combined Program fm- Postgraduate Training Fmrth Year $30,592

i

The programs

of Phvsicians. Nurses and Allied Iiealth

Persgnnel in Intensive and Coronary Care

Thrjugh the cooperative arrangements of three hospitals in different  com-

munities, two in Arkansas and one in Missouri, separate courses in cardia?
care will be 3ffered registered and licensed practical nurses,  and cgmblned
fcdlow-up courses In intensive care.
be offered at one hospital.

A conjunct program for phyeiclans will

This project will be an attempt to achieve quality educational programs in
cardiac and intensive care at the subregional level.
endeavors will be toward the appropriate health professionals in eight
counties. The rationale for the approach is that it is felt that optimal
participation can be achieved by offering these continuing education programs
in the close proximity to the work and home setting of the participants.

The outreach of these

Fif'th Year $28,032 Sixth Year $29,669

#39  Continuing Education for Tennessee Physicians

Fourth Year $48,320

The continuing education programs in the state of Tennessee are administered
by various agencies--medical schools, Regional Medical Programs, medical
societies and others--and no one peraon or organization is responeible for
coordinating these,
actual needs and few include procedures to evaluate the3r effectiveness.
Eglsting programs are carried out in the traditional manner, and fregmentation
makes the introduction of innovative education programs impossible. In
addition, no central record office exists to aid physicians in getting certf-
fication on the basis of their postgraduate studies.

Many programs are inatilxted without regard to physicians'

This proposal calls for the coordination by 8 ctuLLralized office of all con-
tinuing medical education in the state. Although this organization would
not be directly involved in the conduct of education,  it will serve as a
catalyst, identifying needs in continuing education arid teaching resources,

The project is to assess the needs and desires of physicians in the are
determine how present programs meet these.
inventory available continuing education resources.  Physicians will be
encouraged to utilize self-asaessment methods to determine areas requiring

r-- ---+-

The project will also entail

0

Memphis IiMp -26- RM 00051 8/71

strengthening.
bution of the programs and also establish some type of state certification
to provide recognition to those participating in postgraduate programs.
An investigation of innovative educational programs will be undertaken.

The project will analyze the current geographical distri-

Fifth Year

$44,804

Sixth Year $47,120

BO Hypertension Control Demonstration ' Fourth Year $37,177

This project proposes to screen persons in three north Mississippi counties
for hypertension.
will be provided by Mississippi Department of Health nurses with the assist-
ance of medical personnel from The University of Tennessee Medical Units.  A
consumer education program will be developed.

Ob jeatives: 1) develop a model demonstration hypertension control program
for selected county health departments in north Kississippi; 2) demonstrate
the ability of public health nurses and allied health personnel to conduct
ti hypertension screening and control program with a minimum of physician
support; 3) increase the awareness of the general public to hypertension and
its complications to a pint where they will seek care; 4) make treatment
resources available at the local level for the majority of medically indigent
hypertensives; and 5) assure the continuity of care for the hypertensive
patients .

Diagnosis, treatment, and follow-up of these patients

Fifth Year $38,472 Sixth Year $44,194

Previously Funded Projects for which Continuing RIG' Support is not Requested

# Peripheral Vascular Disease

IGfien this project was originally reviewed.by RMPS,  it was believed that the

proposal was over-budgeted and.'underplanned.  It was not approved but funds
were awarded for further planning (01 - $23,936, 02 - $18,454).

A revised proposal (#7) was submitted and disapproved by Council.
of two community clinics was questioned.  The regionalized professional and
public education aspects and the peripheral clinics were not well developed.
The value of the referral center was recognized, b.& Council questioned the
appropriateness of RMI? funds for its support.

The value

#lo  Combined Attack on Certain Forms of kart Diseese, Cancer and Stroke


This project has received funding for three years, 31 - $20,000,
(23 - $24,465.

02 - $23,332,

Wxis proiect fo'r the Kenneth (Missouri) Pargould (Arkansas) Area is now in
its third year. As a result of the activity three operatio:, ,?oposals were
r;itL:rlftted to MRKP during the last two years, 1) HoEe Health Care(#25 finded),
2> Regional Cancer Center, and 3) Combined Program lor Care of Cardiac and
Stroke Patients Through Intensive Care.

The continuing education pnase of the project is reported to be successful.

Memphis RW

- 27 -

RM 00051 8/71

Postgraduate education programs at two hospitals have been integrated and
expanded,
Registered nurse course consists of 96 hours of didactic and practical train-
ing.

Training has been for registered nurses and para medical personnel.

A series of training is planned for physicians.

fi4  Feasfbility Study of HQspital Infection Control

As recommended by the July 1969 site visit team and Review Committee, Council
approved this two-year project without additional funds.
that the study was poorly designed.  The progect was funded ($5,092) for four
months in the Region6 second operational year from carryover funds.
ceived $10,181 for continuation ig the current third year.

It was believed

It re-

Accomplishments include:

A registered nurse has been trained and has had six months experience in
surveillance of hospital acquired infections.  Three selected wards in the
City of Memphis Hospital have been studied over six months, October-March.
Overall rates of hospital associated infections were 3.1% and 5.5% for two
medical wards and 9.5% for a surgical ward.

A computerized bacterial report retrieval system was developed within the
City of Memphis Hospitals as a model of what could be done in any community
hospital.  A computer program was written and developed to produce a series
of reports designed to answer pertinent questions of great value to the
practicing physicians and to the control of hospital associated infections.

Project members cooperated in a catheterization study done by Dr, Allan Bisno
and his staff of the Section of Infectious Diseases of the Department of
Medicine.
greatly overused considering accepted indications for this procedure and
b) showed that compared to scalp vein needles, intra-catheters were three
times more prone to be contaminated with potential pathogenic bacteria,

This study a) confirmed the fact that intravenous catheters are

_- -.

Both the principal investigator and nurse employed on this study have made
special efforts to become more expert in the field and hospital-associated
inrections.
of the problem and are frequently consulted in matters pertaining to hospital
infection control.

Both have attended special conferences devoted to various aspects

A reference library of literature dealing with hospital-associated infections
has been developed and is growing.

Through this project, there has been established at The University of
Tennessee College of Medicine a nucleus of people interested and experienced

in the problem of hospital-associated

#g Obion County General Hospital

This project was fhnded for two years
Operational year, 01 - $20,000 and 02

infections.

beginning in the Region's second
- $23,332.

The purpose of the project

Memphis FU@ - 28 - RM 00051 8/71

was to apgrade some of its facilities to develop its capability in heart,
cancer, and stroke,
apparently expired because of its inability to recruit appropriate personnel,

No funds were expended in 02 year when the project

Previously Disapproved Projects

$4

Peripheral Vascular, Disease (Funds were approved for Further planning)

#ll Regional Medical Technology School

Radiological Diagnostic Equipment at Crittenden

#13 Demonstration in Preventative Services
#l5 Regional Program for Education in Medical Technology
xi6 Improved QuFjlity and Services of Medical Laboratories
#20 Kidney Failure Training Center
#21 Care of High Risk Infan-ks
#$22 Buclear Medicine Research and Training Center

Regional Blood Banking and Transfusion

{E6 Biomedical Information Network
#27 Peripheral Vascular Clinic
#28 Regional Blood Banking and Transfusion

GFB 6/8/71

MEMPHIS REGIOXA L MEDICAL PROGRAM
ORGAhiZATIOKAL CHART, APRIL 2. 1971

A DXINISTRA TIOX

Li7

1 DIVISIOX OF ?ROGRXX DEVEWPMENT

I1 r

Program Management Branch

r

I ?

Xursing . Aliied

Branch & Rehabilitation Branch

i `7-

Community Evaluntion

Records Services Services Services Design

Re f ercx 2
Cormit t tes

I
'LJ

?

(A Privileged Communication)

e

SUMMARY OF REVIEW AND CONCLUSION OF

JULY 1971 REVIEW COMMITTEE

MEMPHIS REGIONAL MED ICAL PROGRAM

RM 00051 8/71

FOR CONSIDERATION BY AUGUST 1971 ADVISORY COUNCIT,

Recommendation: Additional funds be provided for core and projects
         and disapproval of developmental componet request.

$2,754,233        $1,627,000
2 , 549,008         1,627,000
2,397 I 991         1,627,000

Total $7,701,232 $4,950,000

Current funding level of the Memphis RMP is $1,512,795 direct cost
and following is the rationalefor the recommended funding level.

Core $ 600,000
Projects (continuation 1,027,000

renewal , new)

Dev e lopmen t a 1 Component

-0 -

Total $1,627,000

the site visit team's recommended $2,000,000

t requested and during its deliberations

egion at the above recommended level for
er, of the potential of the Memphis RMP ,
d mission it was decided to recommend

In addition, committee concurred with
June 1971 site visit team that the MRMP
r Project #39 - Continuing Education for
The support of general C.E. activities
see Medical Association was not considered

quired by increasing the dues o
s also recommended that the region not

of RMP funds. It was suggested

        0 for Project #36 - ExDansion of Neighborhood

     n the activity. Regarding the seven ongoing
     rt is requested for an additional three years

jects, it should not be for more than one additional year.

nce the National Center of Research and Development

at if the MKMP chooses to continue its support

Memphis RMP

-2-

RM 00051 8/71

In addition, Committee believes that RMP funds should not be
utilized for Project 120 - Comprehensive Kidney Disease, because
it was found to be unacceptable on a technical basis by the Ad Hoc
Panel on Renal Disease. It seems that this project was developed -,
with little or no considerations of existing facilities in
surrounding areas.

Critique: The Committee considered this triennial application in .*

1

r4

3

relation to the June 1971 program site visit. Since a

Review Committee member did not participate in the site visit, the report It
to the Committee was given by a consultant who participated  in the
site visit and it was reported that the Memphis RMP was at a critical
point in its development. The region has responded to some of RMPS
past concerns by moving awary from a medical center oriented core staff
and establishing a better working relationship with the Mid-South Medical
Center Council (MMCC).
relationship with the Medical Society, University? Health Department,
CHP Hospital Association, etc.

The region also continues to have a good working

The complexity of the organizational structure in which the MRMP is
situated, has not been clearly understood in past years and has been
a concern of RMPS.
hdghtened by a recent contract awarded to the MMCC for an Experimenbal
Health Planning and Delivery System. Now, however, there is a
better understanding of the Organization by RMPS. (See Organizational chart)

While the potential exists through this organizational approach for
melding RMP and CHP activities, the June 1971 site visit team questioned
the legality of the MMCC Board of Directors serving for the MMCC as
the RAG.
of Directors membership is representative only of the  14 counties
or which the CHP "b" agency is responsible and not  the 75 counties
of the MRMP. The Committee was informed that in the near future
RMPS will be studying the'decision-saking processes of a number of
RMPs, including the Memphis RMP, and that it will not be necessary
to seek advice from the Atlanta REI; Regional Office General Council,
as recommended by the site visitors.

The complexity of this organization has been

The legality question arises primarily because the Board

Committee discussed the Policy and Review Committee which has been
in existence for only six months is appointed by the coordinator and
has met only twice. This conunittee was established to serve as an
informal KAG because the MitYF needed a policy and decision-making
body that would be representative of the region.  It is obvious,
however, that until this group gains experience and maturity the
Planning Board of the MRMP will continue to be the decision-making
force of the MRMP. The Planning Board is also appointed by the
Coordinator and was established to advise the coordinator in planning
and operational activities of the program. Committee believes that
if the Policy and Review Committee assums its intended responsibility
the MRMP organizational process could be greatly strengthened.and suggest
that RMPS should maintain close observation of this development.

-3-

RM 00051 8/71

Other MRMP committees appeared to have limited input into the
planning and operational activities of the program and many are
Ron-functional. Committee believes that the MRMP can be strengthened
by developing a resource of knowledge through the committee structure
and establishing a process that will ensure active participation of

hese committees in program activities. Representation on these
omittees should include physicians, nurses, allied health personnel,

and consumers (industry, minorities).

The core staff of the Memphis RMP seems to spend a vast amount of
time and effort in helping other health organizations locate resources
for funding activities generally related to the umbrella - like goals

f the MRMP and the MMCC. In addition, core has been involved with
     mber of planning studies, some that have been productive
      that do not appear to be consistant with the RMP's goals
      ties. Committee believes that these core activities have

resulted in winning good will and giving visibility to the MRMP, however,
their focus appears very diffuse. For better coordinator of activities
and to assure that core feasibility and planning activities are in

ogram goals and objectives, Committee suggested that
es be reviewed and acted upon by the Planning Board and

Review Committee.

appears that the various sections of core were pursuing independent

jectives and not coordinating their efforts toward a common goal:
is fragmented approach could be the result of Dr. Culbertson, the

ng the only physician on core staff other than

only 20% of his time to the MRMP. Committee
mmendation of the site visit team that the

e a full-time deputy with administrative experience

on the day to day operations of the program.

h needs of the region involve the Black population
to almost no Black professional employees on
committee structure. Although the MRMP reported

m that there have been concentrated efforts
oyees for professional positions, committee
eased effort is warranted.

ectives and priorities of the MRMP are described,

not: clearly stated in relation to the specific

he region nor in terms of anticipated accomplishments.
  e MRNP should be more specific in their state-
  ives and priorities.

pressed difficulty in identifying the in rrelationships

ts and how each of these activities fitted into a program

ave an influence in meeting the ealth care needs of
  rs that past emphasis in the program has been
  ously appearing projects that would improve
  rather than stimulating the opment of
  ased on identified needs.

Memphis KMP -4- RM 00051 8/71

Committee'sprimary concerns are the involvement of the RAG, committees,

to a regional plan and what is the expected impact of these activities
on the health care delivery system of the Region. Committee did
express encouragement that a few of the new activities proposed in
the application have an emphasis toward access of care and reaching
out into the rural low economic areas of the region.

.. a.

~ _-

and core with the development of projects, how these projects relate :-

Conunittee also expressed concerns over the region's inability to
adequately phase out its support of projects after three-years of
support. There is a tendency on the part of the MRMP to pass the
responsibility for saying no to Regional Medical Programs Service.
Of the amount requested in the present application for projects
26.8% is for the continuation of 7 projects for an additional
3 years past the original period of approval. Committee recommends
that the region phase out RMPS support for these 7 projects by the
end of their fourth year. Continuing Education has encompassed a
major portion of this region's activities, however, they have not
been reaching the Black physician. The reason given to the site
visit team was that because Black physicians have inadequate educational
qualifications, they do not have hospital affiliations where the
training is rendered.
aware of this problem and hopes to do something about it.

_.

The visitors were informed that the MRMP is

The region proposes in this application to develop a mechanism for
evaluating projects and total program effectiveness. Although
encourage by interest in evaluation activities committee has
difficulty in determining how the region will implement evaluation
activities without first identifying a program plan with specific
objectives that project expected accomplishments and are measurable
in terms of evaluation.

The MRMP has rzquested in this application developmental component
authority withour additid';lal funds.
of this request uiitil the region has resolved its exisitng
organizational and administrative problems.

Committee recommends disapproval

RMPS (GRB /7 / 161 7 1

.

a.

9RCANIUTIONAL ReLAnONSBIPS EElWEW MID-SOUTR MeDIcAL CENTER, MEMPHIS WP, CW, AND NCKSRD

AS PERCEIVED EY SITE VISIT TEAM ON JUNE 16-17,  1971

- 156 Kfmbcrs with 51% consumer
- Meets annually

DEPARTMENT OF HEALTH, EDUCKrl?N, AHD WELFARE
             PUBLIC HEALTH SERVICE
HEALTH SERVICES AND MENTAL HWLTH ADMINISl~!tATION

June 28, 1973.

Quick Report on the Memphis Regional Medical Program
June 16-17, 1971
Director, FJPS
Through: Acting Deputy Director

Regional Medical Programs Service

I.

Site Visit: Team

Paul Dygert, M.D. (Chairman)
Private Practitioner
21 02 E
Vancouver , k?a shi iigt o n 9 85 6 1

McLougIilin Blvd .

Mrs. Florence `Jyckoff (Council

Watsonvi 11 e, Californj a 95076

43 Corrali tos Foad

P&ltlPS Staff

Isrnael E. Morales
Public Eealth Advisor
Grants Review Branch

--

Bruce W. Everj s t , M. D . (Council

Chie of Pcrlriatrics

Ruston, LouisLma 71270

Robert ZZ. Carpenter, M.D.

Regional Medical Program

I) Menib er)

Grc!cil Cl i11i c

Memb cr )

Director, Western Pennsylvania

3530 Forbes Avenue
Pittsburgh, Pennsylvania 15213

Richard Russell
Public Health Advisor `
Grants Revlcw Branch

Eugene NeLson T. W. Grififith
Program Analyst . Regional Office Representative
Planning and Evaluation RTanch      DIIIZW Region IV

                         50 -_ 7th Street, N.E.
Frarik Mash Atlanta, Georgia 30323
Operations Officer
Regional Development Branch

II.
Triennial Application which included a developmental-type requcst .
The team was extremely pleased with, the structure and' conduct of the
visit.
interests involved in the Program participated.

This two-day meeting was held in Memphis to review the Program's

Appropriate representatives of a large majority of the various

III, Summary of Finclings

The team was ab1 e to elicit specific infoimation which helpcd

cl.ari fy the enigmatic orgailizcitioilal. structure wh'ch has historical 1.y
characterized the Memghis PJiP I

..

*

i)

,  age - L - uirecror, mi'b

The organizational relationship between the Mid-South Medical Center
Council and the Memphis PdG' are recognized'by hoth groups to be curnber-
some and complicated.  The compI.exity has been heightened by the recent

contract awarded to the NMCC for an Experimental Health Planning and
Delivery System in the Memphis area.  In spike of thi.s complex situa-
tion, it appears that these organizational relationships present an
excellent opportunity for the groups to take full advantage of the .
interface between &PIP and CHI?.
izational relationships.

The attached chart shows the basic organ-

While there is a potential for successful%y melding the activities
of/&? and CHP, the question arose as to whether the current decision-
making process for the RT4P meets legal requi-rements regarding the
authority of the Regional Advisory Group.
serves as the MPMP RAG, is not the filial authority for the organization
it serves.  The power of final authority is vested in the IjMCC's 45-
member Board of Directors. Although mail ballots are solicited from
the ~~~-TTI~D~~XIS of the CounciI on 3iIPJIP app1.i cati oils, the utilizat-i 011
and the influence of these ballots by the Board of Directors v7as not
clearly discernable, Also, there vas no indication that a specified
number of ballots were required before ac'iion could be taken on an RVP
applri cation.
issue f ram General Council in the Atlan ta Regional. Office. If
General Council finds the current procedures legal, the team members
would not recommend any changes. I, however, the General Council
responds negatively, a restructuring of the MPNP would be mandatory

The 156-member MMCC, which

The Lean recomincnded tlia t the ?lI%IP gck a ruling on this

*

e RMP is to continue.

It was obvious that since the last site visit in July 1969, the working
relationships between the ME4CC and MRMP have greatly improved.
applies to both the staffs of the two groups and their primary committees.
The development of the Experimental Health Planning and Delivery System
control was a joint CHP-WfP effort.

This

Also in response to the previous site visit team's recommendations,
the IW has made a definite move away from a medical center oriented
core staff.

The general impression

the visitors had of the MRYP were:

1. As with most Regional Medical Programs, the MRtW's goals,

objectives and priorities are global and so broadly stated that they
are relatively meaningless

2.

The organizational concept is probably excellent, but the

manner in wliich it functions is open to question.
Review Committee of the Pap appears to be a rather light stamp of the
Planning Coirmittee, rhich is the mjor voluntecr seginent in decision-
making power.
Coordinator.
to that retained by core staff.
to operate independently of the Planning Conuni ttee,
that varioxs sections withjn core staff also operate on an individual

The Policy and

The Planning Coimittee was es tabl-ishecl to advise  the

The decision-makjng power of this group seeiiis to be equal

In some areas thc core staff seemed

Further, it appeared

m

'r,

e

Page 3 - Director, WS *\ I'

basis.
assessing the value and decussation of the Memphis WI?.
Directors' effectiveness in policy detennination is questionable. The
M%X or RAG appears to be a public relation 'facade, and if not illegal,
certainly ineffective in the review process.

The Board of Directors of thr: PICC is probably cffectivc in

The Board of

3.

Involvement of regional resources seemed complete, probably

due to the strange organizational arrangement with the MMCC.
ment is greatest: with CHP and the University of Tennessee,  and less
in depth with other resources.
ness with and among other Regional Medical Programs in the area.

                      Involve-

There seem to be amazing cooperative-

4.

    Assessment of needs, problems and resources has been
adequately determined by RMP and CIP workiiig cooperatively with the
MSMCC. The assessment, however, has not iiecessaril-y led. tg solutions
to rhe findings of need.  This is probably inevitable with the past
emphasis on accep i5.g spontaneously appeal-ink; pi*Oj(?Cts to improve
regional cooperai ion. This apparciitly is hegimjag to change as
staff is reaching out to stimulate the k.inds of projects that are
need cd.

5.

Program ir~!plemeiztation and accompl ishactits have a qotty history.

The Jackson Hospital's Learning Center would seem to be a case in poiilt
for excellence; and yet, in other areas, such as the studies on family
planning and the effectiveness of health care in Oxford, Mississippi,
appear to be an unnec9ssary expeztditure of funds.  The MRNP also seems

ve succumbed to the excitement ar!d satisfaction of delivering ser-

in at least two areas.

                       Plans for phasing out projects are less
       Their continuing education program does not seem tb be
eeting the needs of the most incompetent physicians in the area.

than optimal.

6.

     Evaluation is in its infancy.
be very effective and, if implemented in the early planning phases of
projects,  should be one of the best.
out projects appears unsatisfactory for program assessment.

IV. Recommendat-:

The MPP's projected plan should

Eval-uation of ongoing and phased-

Requested

$2 , 754 , 233
2,549 0 08
2 , 357,9 91.

Recomriien ded

-

$2,000,000
2,000 , 000
2,aoo,ooo

$G , 00 0,000

----

(Current level of direct cost support $1,512,795)

There was some conEusion over whether or not a Developmental Component
was actually requtsted.
tional core staff Lunds were made avai 1 able, a developmental. award would
not be necessary.
recormend approvc?l_ of a Developmrn tal Award  Fur Lher , the Learn rccoill-

The MPJP coordinator inclicatcd that if addi-

The team bcl.ievcc1 it ~honlil report that it c.ould not

Page - 4

1.

2.

3.

4.

5,

6,

- Ilirector, PdPS

Efforts to recruit Hldc employees for p~-oicssional posit-ions
on core staff be incrmsed.

Core staff ac~ivities be cooz-dii?atcld to justiiy the time and
personnel involved and to assure that the activities are
worthy and consistant vith the 1WP's goals and priorities

The Planning Coinniittee be more involvecl in dec-icling which
core staff activities should be p)~rsueci.

The Reference Comniittees have more input into the total
prograni planning and operational process as well as project
evaluation.

In arriving at the ecioclnt of funds recoimeiidi~d, the te~i~i rcli cd 112,
on tl'ic Program's potential.
effori: sincc its j-nceptio'i, and with its 11c:'i.i dircicl?.on aitd sense oE
rnission sliould be encouraged.

Thc! i%??P has s1ic)'I.m s-igns oi lifc aizd

Public EIcalth Lidvisor '
Cran ts Review llranch

*

Page 2 - MP?P

is that the MEW operates in an /opportunistic manner rather than in an
organized well-planned approach bascd on expected accomplishments .

2,
except to those who are most in peed.
to access of health care basc"d on identifieti needs. ,

3.
increased utilization and effectivenesq of community health facilities
and manpower.
the present maldistribution of health, Services can be expected to be

.1 .

i

The MEli.IP appears to bP dispersing improwd techniques and kEOw1edge,

The emphasis"is not directed

It appears that sone of the FIRPIP activities will lead to some

     The extent to which the, /program activities will alleviate

e

minimal. I4

4. Health maintenance, disease provention, and early detection activities
are an integral part of the ~133~'s proposed prograin,' as reflected in
six projects,
establishing a Ikalth Systcms Mannp~entent program which is to involve
the IfPXP,

5.
The exte:it to rihich these activiti E'S trill have an impact in the heal-th
care delivery sysi:en is qucst-ionable.

6.
ship between p'r.il;.i.,ary and secondary  care,
these activities will improve continuity and accessibility of care will
be rd.iiimal.

In addition, the Nid-South Medi-cal. Center Council. is

I

The MRMP proposes thrw dctivities whic1) wi'L1. expand ambulatory care,

To som degreg the act-ivities of the PlJ'JV could improve  the relation-

IIowevci-, the degree to wlij ch

7. The MP,"/IF activities will have limited impact of immediate pay-off
in terms of accessibility, quality, and cost moderation.

8. There are some, but very few, joint efforts stimulated by MPdP
activities that facilitate the provision of health care.

9. The MMP will tap local, state, and other funds when possible and
is supportative of other F2deral .cf forts in the University.  There
has been, however, very litk1e success by the FIILhP in locating other
sources of funding to pick up activities For which MIXPIP support has
t enn-ina t ed .

DRAFT

Mrs. Florence 1:. Myckoif, (Council PIcml)er), IJatsonville, California
Uruce '7. Everist, M.D., Chief of Pediatrics, Crecn Clinic, Ruston

Robert li. Cai-penter, N.3., Director, TJcstcrn Pennsylvania R1P
Paul Dygert, fI.13., Provate Prbctitioner, Vancouver, Mashington, Chairman

Lou is i il na

lsniael B. Korales, Ptiblic liealth kdvi $or, (`rants Ileviev Eranch
Eugene Nelson, Program Analyst, Planrling arid Evaluation
Frank Wash: Operations Officer, Regj OIIF 1 Develcil:incrit Branch
R i ch a rd Ru zi s e 1 1. ,  Pub 1 ic Hca 1 t 11 Ad v i L` o I- ~  G ran t s
T. 11. Griffitli, Icegional Oificc Representative, L)!iFN Region IV

v i e!? 1'1 rail ch

James il'. Culbertson, M.D., Coordinator
James b!. Patc, PI.D., Chairmaii, Pla:!ning Poard
A. Iiussell Clack, Jr., E.S., Executjve Assistanct
Jonfane F. Ra~linson, E.F.A. , Assist-ant Lnformation Officer
Levis E. Ami:: 9. Ph.D. Assistant Director, Pianning Erancli
Haty K. Taylor, Chief Secretary Coui.-l!iunity Servjces
Patricia Vander Schaaf, Interagency Liaison Officer
Joyce Eiarrell ~ Chief Secrttary Project Design
Pauline Stone, Staff Librarian
Margaret B. Cherr~7, Assistant in Sociology
James G. Couch, Research Psychologist
Richard K. Thomas, M.A o , Sociologist
Came t te Sapping t on,  Re  ea rch Ass j s tarlt
Edward Miller, Chief, Secretary Evaluation
Mark Kashgarian, PI.D., Consultant Epidemiology
Chris F. Drago, Assistant- Evaluation Officer
Helen C. A.i>sI~ii>b, Rerearch Assistant
E. Vm. Rosenberg, I.I.D., Assistant Director Education Branch
Bonnie Kunzel, Health Educator
Sara J. Jackson, Regional Librarian
John T. Vincent, Jr., Coiwiunication Officer
Ruth 11. Bryce, Assistant Director Nursing, Allied Ileal th 6: Rehab. Branch
Mary S. Templeton, Health Educator
Norma Long, Psychiatric Nurse Specialist
Rachael Taylor, Nurse Specialist-Stroke
Judith Thoxpson, Eurse Specialist - Cancer

Hekrtn Plarshal 1, Chief, Sec. Office Services

I?] 1 Fli P, PlcnC1.rr~j 1 , ChicrK, Sec. Busin.-: s i:ccor3s

e

1Valt.er Dlggs

Aiidrenr Lasslo, I%, D.

John D. Youiig, Jr. , PIT. D.

A s si si ant Pde s E: or of Comiii unity Ne di ciiic
Assjstant Wrccior for 11c;~lth Cnrc Program
Gco@;t. Mcciicz~l Collcgc

Cillic DicI;crsou, I<. N.

Harry Cosby, Jr, , M. D.

Jess E. Porter, I\'ia,z370r

,'

, Eo]-man L. Cascy

Memphis lUW
J.M. hJoore, Ji:. , D.0.

Jack E, T'i'c.11 s, D. D, S,

David J;liiies, Xf. D.

Christoplicu illartin

-5-

It was eiicoursging to the visitors that since the last site visit in

July 1969, the MMP has responded to some of F@PS p~st concerns.

The

working rala tionship:; between the staffs and CommitLczcs of the ?lid-South

Hedical Center Council and the TW3? have greatly improved, md the MRIYIP

has made a dcficite mve zway from a rr:ccli.cal center oriented core staff.

The Regton zfco cont? nues fio h~~e a goad aorlcing relLtionship ~ith the

Medical Society, University, Heal th I?epartTl>cii!t, CIIP, Hospital Association,

etc.

Althougfi the- program still  coi-itains ma joi- \~C!~!<IICSS~S which need  to

be corrected, the site visitor:; were encourzgetl The Mei'1ph-iI; R>W hac

the potential of becoming one OL tlic betrev ZPs, in terms of atidre: :ing

e the broad issues of the provision of heal th car?. Fui-ther, strcng:thmFxg

of the l4PJtP organizational and adn~inistrative proccss slrould pci-nit it to

take Pull advantage of the unique opportunity of working closely with Cii?

and the recently approved Experimental Heal th Planning and Delivery Sys tern

program in Memphis.

,

In recomnending $2,000,000 for each of thc programs next 3 years,  the tem

relied heavily on the program's potential,

The PfRIIP with its new direction

and sense of mFssi.on should be encouraged to develop a program which, can

bring together the health resources.to meet heal.th needs of the Region.

A. Goals, Objectives and Pr!orities

As is the case with many Regional 1.fedical Programs, the Memphis RIG' has

established goals, objectives and priorities which are rather meaningless.

e The Program's aims arc broadly stated iii terms of activities rather than

-6-

Memphis RICE' Drt?ft RM 00051'

anticipated accomylishments within a specified period of timc.

As a result

the I4R4P has no diffjculty relating 811 of Its project ectivities  to its

priorities.

The only priosity for which these is no relaced project is the

1

development of mechanisms for stable ftnancing. I

I

The organizationzl concept under wtrich the NJW' operates is probably excellent

The manner in rz.hich the PRMP functions, ho-wcvcr, is open to iimerous questions.

As indi.cated by the attached chart, the organize t:l.onal relationship between

the p.-----IIIcI---I- Mid-South Kedical Center Council and ti,e lilX\iP arc recognized by both

groups to be cuicbersome and complica:cd.

by the recent contract awarded to the W4CC for an Experirhental Health Planning

The complexity has been hightened

and Delivery System in the Memphis ares,  In spite of this organizational

labyrinth, there appears to be an excellent opportunity for the groups to

take full advantage of the interface between 1IkE' a1-d CBP.

Mliiie the potential exists for the melding of RW and CHP activities,  the

site visitors questioned the legality of the MWP's decision-making process

in terms of the Regional Advisory Groub authority. The 156-member MCC,
which meets only once a year, is officially designated as the RAG for the

Memphis RMP. The MWC, however, is not the final authority for its own

organization.

The power of final authority is vested in the- E\f.ICC's 45-member

Board of DirectoE, which meets 10 times a year. It is the Board of

Directors who acts on RMP matters. Although mail ballots are solicited from

the 156 members of the Council on MRMP applications,  the utilization and

inflpence of these ballots was not clearly discernible.  Further, there was

no indjcation of assurance that a specificd number of ballots were required

-7-

Memphis RMP Draft RM 00051

to insure a majority vote by Council nlembers.

The priinary issue is that the

Board of nirectors membership ic representative only of- the 14 counties

for which the CHP "b" age~icy is responsible aid not the 75 counties of the

F4IUvfP. It appears that the RAG is a public relations facade, ineffective

in the ?TiIP review process, and perhaps Filegal. The visitors' concern

of the 1-ega1i.t.y of the RAG ~7as shared by tlic Excut.ive Ilircctor of the PDfCC.

The team advised the MRKP that it should get a ruling on the legality of Fts

RAG froin General Council in the Atlanta EEIJ 13e~:ional Office. If General

Corincil finds the current proccdurcs 1 egal, tlte team rc70uld be satisfied

If however, General Council responds riegnti\frly, a res tructuring of the

EGNF would be mandatory if the RxP is to conti-nue.

The PfL?MP Policy ----- and Review Coixmit_LGg, whicli has been in cxisteme Sor only

six months is appointed by the Coordinator and 113s met only twice. This

Coxranittee was established to serve as an informal PIG bccause the MWAP

needed a policy and decision-making body that hrould be representative of

the Keglon and deal primarily with lLWP business. This Corcmittee reports

directly to the i44CC regarding DIP matters.

the Policy and Review Committee has the widest ].attitude with no restraints

in dealing with policies and technical advice concerning project review,

it presently appears to be rather light stamp of the Planning Board.

Although it was reported that

The Planning Board, which also appointed by the Coordiiiator was established

to advise the Coordinator,  and is the major segment in the MNQ's dec-ision-

making power. The Planning Board . not only scyeens potential project

proposals for applicability, but advises the Coordinator as to which

applicants sliould or should not be given Core stoff asslst-ame %n developing

a proposal.

The Plaunlng Board meets jolntly with the Policy and Review

-8-

Memphis RMP . RM 00051

Comittee on a monthly basis. There is limited representation on the

Planning Board from the f.fE.IP's  13 Reierence Committees.

The I Reerenc~~~~~t~~y some of 17hicli are categorical, appear to have

limited input into the total propan plmni n:;? operational and project

evaluation processes. Based on the frequency with xP7hicfi these Comiittees

meet, it appears that many of then have be Inactive. It was reported that

the limited funding situarion had dampened thc enthusiasm of many of the

key Cormittee rficmbers .

The Core staff seem to have retained, in sme areas, decislon-making power

equal to that of the Planning Board. This is reflected primarily by the

number and types of activities which are stimulated, initinted, and conducted

by staff members. It appears that the varioss sections of the core organization

e

are pursing lndepcndent and unrelated objectlves and simply reporting to

the Coordinator, The Coordinator is over cxtcnding himself in an attempt

to fill two positions: his own and that of a r:uch needed administrator. There

has been a concentrated effort to fill the adninistrat:ive void by recruiting

a specific candidate as Assistant Director o,F Program Management, however,

because of the candidate's experience he is being considered for Ira position

in Program Development..''

There is some question as to when the core

administration might be strengthened.

It seems that the Core staff is overly anxious to please too many groups

and interests, all at the same timc.  There is a reluctancy to say "no,"

as evidenced by the HbXP's tendency not to phase out its support of projects

-9-

Menphis REP RM 00051.

Core staff sceras to devotc a vast ai:?ount of tiiiie and effort to assist other

health orgznizations apply for funds for many and varied services and

programs generally related to the broad goals of MiMp and NCC.

this develops good will 2nd builtis a ~7ider uriderstanding of the K.ii"JZ, the

focus of the approach is extrerely diffuse. Khcther or not the costs,

including the time aid effort of pcrsoiLricI. involved, are justified is

While

qucs tiortable, Jn ternw of the KW's goals mid priorities.

Many of the health needs of the Region involve the Black population.

Yef: there appears to be almost no Ulsck professional ciyloyees on

the NPW? Core and Cormittee structure, Although the F1rofP reported

to the site visit team that there have been concentrated efforts to

recruit B1 ock employees for professlnnal posi tiuns, Corrini ttee believes that

an increased effort is ~~arranted.

Involveinent of resources seemed coxplete, primarily due to the organizational

arrangement with the HHCC. Involvement is greatest with CIIP and the

University of Tennessee and less in depth with other resources. There

seems to be amazing cooperation with and among the adjoining Regional Medical

Programs.

RIP and CHP relationships seem to be part of the difficulty in clarifying

the MMGC and MMP admf-nistrative. processes.  There are 5 state "A" agencies

and several    agencies which must be consultad and/or involved in varying

degrees.

"Ei"

The PP%P appears to have been quite active in developing a data

base, and also devotes considerzble cffort ir, the basic orgmizational

development of the "Btl agencies in the Region.

HE?HP Core staff is currently

helphz to plan a model health system in Northern Mississippi which is

e

e

e

Memphis W


envisioned as

now supported

Development .

-10- IW (jOO.51

part of a IO-county hcm.iIig and urban devel.cjpment program

through a grant froin the DepartrneLit of Housing and Urban

MIUQ Core staf is involved with or maintains liaisons with approximately

40 civic and service cjrganFzations. There is, ho.r,.ever, a lack of conmitment

from many of these groups which might bc attrib11Led to the independent

pursuits of core staff rncrnbe3-E; arid the tendency of the 1212PfP to operate in

an opportunistic mar!ner rather thsn in at: organized well-pl anried approach

based on expected acconplishrients as a result of its involvement with these

other resources.

D. Assessment of ?<c@s, Problcms ~~)_--P~sotl~ces

The assessment of needs, problems and resources has been adequately determined

by the l\PM and CHP working cooperatively LTith  ti,c ItMCCC.

however, has not necessarily led to solutions based on needs. This gap in

The assessment,

programing is probably inevitable since past emphasis has been on accepting

spontaniousl-y appearing projects to improve regional cooperation. This

situation is apparently beginning to change as core staff is attempting to

stikulate the type of projects that are needed.

There is a need for the F!iRl"lp to strengthen its use of allied health resources

throughout Fts program and to place some emphasis on stirnulatins activities for

allied health personnel.

,.

E. Program Implementation

Accomplishments in this area have been spotty.

The Jackson Hospital's

-11-

Ke mp I1 i s

WlP

coawunity hospitals. Specialists fron the private practice sector, are

invited by other physicians to partici2ate in Advanced Clinlcal Conferences

in whicti patients of the Invlcing physici.ans arc thc subject of discussion.

Although this is a well designed contiuuing education provam for practictng

srccinlists aiid general pr??.ctj.tioricr:, which serve a network of sinall and

mcdtitni sized hospitals, it does not reach any Black physicians.

g.i ven is that si rice Black physicians have inadcquatc cducacional qualifications

P

The reason

they do not have hospital affiliation. It is hoiavcr, obvious that: to

improve educational qualities these physicians mist have access  to these

continuing education activities which happen to bc centered in a hospital

setting. In other prograin areas, however, there appears to have teen an

unnecessary expenditure of funds.

attleudes and practices ainong Elefiphis motherr:, and thc effectiveness of the

health delivery system of (kford-Lziayette Coanty, Mississippi. The MR7M.P

also seems to hsve succunbed to the czcitement and satisfaction of

delivering patient services for example, the Mobile P1ultiphasi.c Health

Screening Project in Northeast lilississippi. The team was concerns that the

MW nay not: be giving adequate attention toward phasing out its support o

these types of activities, as well as other projects.

Cases in point are a study of birth control

The MIW plaiis for phasing out its support of projects are less than optimal;

as evidenced by the current application.

projects, 26.8% Is for the continuation of 7 projects, for an additional

3 years, past the original period of approval, Tlic decision by the MKMP

to continue the projects is done so without adequate evaluation of effectiveness

of thc activities to date. As noted earlier, there is tendency on part of

the MRHP to pass the responsibility Cor saying no to Rcgional Medical Programs

Services revietr process.

Of the total amount requested for

This tendency has been noted in the review of

-12-

RM 00051.

previous applications.

0

,.

In the past, tlicre has cot been an effective cvaluation process for core

staff and project activities in the HK3-P. The Xcgion, however, proposes

in this app3 ication to develop a nlcchanism for $?valuating projects and

total prograni effectiveness. Although enccura:;e by intcirest in evaluation

activities the tern h;d difficulty in determining i.im the Region will

iwplerrrent evaluation activities witliout first identifying a program plan

with specific objectives that project expcc:ed accomplishmtnts and are

measurable in term of evaluation.

It is anticipated that the core staff evalunticn section wi.11 be deeply

involved in the E.b:CC's Health Systein M2naze-ent. A.ithough pians are not

clearly defined, the FUXl? is to he responsible for the surveillance of

e

HSM activities and the evaluati.on of the qriality of care HSM provides.

The contract between IECC and NCIISIID in its cope of work calls for MRItfP in-


vo lvenen t .

Health Sys terns I."lar,agemcnt Contract

This contract has just recently been signed and is for $728,000 as follows:

$358,000 Planning EWPDS

120,000 Development of Pediatric Nurse Program

-.--...-2- 250 000 Evaluation

$728,000 Total

- Rationale for Funding Recommendations --

As noted earlier, the amounts recommended are based primarily on the

Hemphis HQ -13-

Tenn e s see Ked i c a1 I: s s oc ia t ion was MI t cons i d e J- e d app 1" op I i a t e uti I. i z at i on

of lU4P funds. It was suggested that support of tbese activities be

acquired by illcreasing the dues of mc:s?bcrs of the assoclation.

It is also recormended that the Region not invest mor? than $ 318,710 for

Regarding the seven ongoing pro ject-s for ivbich support if; requested for at1

continue its su?port of these 7 projects, it should not be for more thnn one

additional year.

The MIiElP has requested in this app! ication devrlopnientnl component

authori t`y without additional funds

request until. the Region has resolved its existing organlzational and

Conimit- tec: recorilmcnd s disapproval of this

admi n i s t r at i ve p 1-0 b 1. ems .

(Note:

On June 24, the PJ4PS lid Hoc Panel on Renal Disease reviewed the

MRYP Project #20 Conprehensive Kfdney Disecsc ProsAq,  and found it

unacceptable in 8 technical basis.

and seemed to be developed witli little or no consideratf-on of existing

The proposal w;1s iouncf to be ambiguous

facilities in the surrounding areas.)

- 14-

DRAFT

1 The F1lU-Q'. has estahlisi~ed its own gGals, oh j ectives and priori ties.
Tiley are, Imwver, generzlly stat:cd and ' in terins of ac:t:ivities rather
than anticipated aceom71 islnxents within ,a specified peri.od of time.

2.
they meet the anticips tecl objectives of individual acti.vities.
2s very little indication, hox.evcr, that these activitj.cs have been
produeti-ve in meeting tlie health needs of thc T.lEfP and facilitating
thc accessiLi.li ty of health  care.

Activities previous1.y undertaken have bep.11 product-j.ve to the extent

.

Thcre

3. Activities stjnulztcd and initially su;mortcd by the> MXIIP have
not adequate1 y been absorbed wit.hLn  tfic regu1,ir heal tti cam financing
system.
beyorid the approved period of support:.

An indication ~f this is the WPII' request to continue 7 projects

Pxoc!: s s :

I. N?~ilc the current state of the M1W is vi.ablcJ and effective, the
manner in whicli it functions is questic\i;abl.c.

~__

2.
institutions md professions. 'ihcrc3 is c? need, IICT,-;?VCL, to increase
the clcgree
in the Progr27n.

The lfP?+~~ has good relationships witli other health i-c?lated intercsLs,


      oL coIrmiin:cnt and actjve partici;jstion of these groups

3.
in the developnent of CIP "E" Agencies in the Region.

The 1."s,P is currently directing nuch 0.f its effort in assistiitg

4.  The assessrznt of needs, problems and resources has bccn adequately
determined by the FWP and Cl3' worlcing cooperatively iiith the Mid-South
Medical Center Council. This assessment, ho:,rwCr, has not wcessari ly
led to solutions as determined by needs.  This is probably inevitable,
since in the past enphasi s has been placed on accepting spcntaneously
appearjng projects to improve cooperation. Tliis i s .?pparentI\r bcf7inning
to change as core staff is atteixpting to stimulate the type of projects
that are needed.

5.                               The projected
plan should be very eifective, if iniplerncnted in the early planning
phases ot projects.
would seem to be unsatisfactory for program asscssmcnt.

PROGRA.3:

The >G?P's evaluation program is 5~. its infancy.

The evaluation of ongoing dnd phased-out projects

.

is that the XRIP operates in an opportunistic nanner rather than in an

organ ize d ti.e!.I--p 1.anne d app ro 2 ch bas e d o:~ e>?e c I: d accoiq~li s hmn t s ,

2. The Xl~?W app2ars to be dispersing i.n?r-oved techniques and knowledge,

these activities xill improve contLnrii t:: and acccssibilit-y of  care wi 11
be iiinimnl.

7. The EiT<,Ll3 ectivities will .have I.imi..ted i.::.;?cct of irnmcdiate pay-off
in ternis of accessibility, quality, and cost i:iodc:ratiol-i.

8. There are scze, but very fex, joint er'fcrts stli.mnlated by MFWP
activities tkt facilitate the provision oi ii2altil care.

9. The M?XP will tap local, state, w.6 otjier funds t.4icn possible and
is supportative of other Federal efforts $11 the Universi ty.  There
has been, ho.:;ever, very little success 37 t3Ei >RE' in locating other
sources of funding to pick up activitics for ~.:hich 12QlP support has
terminated.

o

DaGANIZATIONAL RELATIONSHIPS EEMW MID-SOUTH MXDICAL CPNTER, EKPHIS RMP, CHP, AND NCHSRD

AS PERCEIVED BY SITE VISIT TEAX ON JUNE 16-17, 1971

- 45 Members (18 providers - 27 oonsumers)
- Meets 10 times a yeer

I

ittee of HMICC

I

WPHIS RM?

           - Staff Proposed:
21 in Tennessee 34 Frofessional
27 in Mississippf 18 Clerical
16 in Arksnsas Current:

- 75 Counties 'iota1

5 in Kentucky    38 professional
6 in Missouri     11 clerical

!. '-

s (2 proGiders - 8 con-

sumers). - Act on

CHP matters. - Chairman sits on

5 clerical

I

- Appointed by HMCC Board of
- 19-35 Members(l/3-ertt~~~ minorit

- 9 Members

- Funded as EHPDS by h'CH8RD at:

$478,000 for Planning

$728,000 Total

6/23/71:RlG'S"XB

  REGIONAL MEDICAL PROGRAMS SERVICE
A SUMifARY OF k SUPPLEMENTAJ, AF'FLIChTICIN
   (A Privileged Cormnuni. cation)

P

Metropolitan Washington, D. C. RM 00031 8/71
Regional Medical Programs

July 1971 Review Committee

2007 Eye Street, NTJ
Washington, D. C.

Program Coordinator:

Arthur Wentz , M.D.

0

The Region is currently in its fourth year of operation and is funded
at $887,681 direct costs, and $328,998 indirect costs which-repre-
sents 37% of direct- costs.

The Region is reqwsting this supplemental application, $2,047,869
for three years support of Project #49 - A Comprehensive Kidney
Disease ControlProgram for Metropolitan F!ashington.  This project
is the outgmwt'h of three kidney projects which 'Liere co'nsi dered as
part of the Region's Triennium Application in the February 1971
review cycle but which were denied support because they represented
a "shotgun approach", lacked planning and a common thread drawing
them together into a total program.

Project #49 - A Comprehensive Kidney Disease ~

#

Requested .
First Project Year

Control Program for Metropolitan ---
Washington - Medical Society of

$749,167

the District of Columbia

The overall goal of the proposal is to improve the survival and
quality of life of kidney disease patients in the Washington, D.  C.
Metropolitan area.

The goal will be met by pursuing the following objectives:

4.  Establish a community-oriented cooperative centralized
organ retrieval and tissue typlng center to effectively
organize, expand, and utilize the existing transpl-antation
capabilities.

2. Coordinate, expand and improve dialysis capability to
meet community needs:

a. Establish out-of-center home dialysis training programs.
b.  EstalJlish a community home dialysis training center at
  D. .C, General Hospital, which services an indigent

population.

c. Establish low-cost neighborhood dJ alysis centers to
provide an alternative to homh'dialpsis or patients
  wj th poor home envimnments .

3.

Improve dialysis capability to prcjvidz supp~rt for

transplmtations.

r

e

e

e

Metro . Washington, D . C. RMP -2- RM 00031 8/71

4.

Educate medical and paramedical personnel in the necessary
procedures associated with transplantation and dialysis and
educate the public in the importance of organ cbntribution.

Reduce the incidence of renal disease through early detection
and treatment of bacteriuria and hypertension.

5.

6.

Establish a representative organizational structure that will
assure coordination of community resources, thereby avoiding

. duplication of efforts.

7.

Provide for third-pary insurance carrier cost retr:eval,

thereby establishing a self-supporting program.

..

Second Year - $672,344

Third Year - $626,358

GR13-6 / 17 / 7 1

(A Privileged Communication)

          SUMMARY AND CONCLUSION OF
         JULY 1971 REVIEW COMMITTEE


METROPOLITAN WASHINGTON D.C. REGIONAL MEDICAL PROGRAM

RM 00031 8/71

FOR CONSIDERATION BY THE AUGUST 1971 ADVISORY COUNCIL

Request Recommendation

Year (Direct Cost) (Direct Cost)

1st $749,167 - 0-
2nd $672,344 -0-
          $626,358 - 0-
         $2,047,869. -0-

The Committee concurred with the observations and recommendations
of the Ad Hoc Panel on Renal Disease.

The proposal should

not be supported. Further, if requested by the RMP, a staff visit

hould be made to discuss and explore how to expand transplantation

ng the care which the Washington patients need.

re that the problems of meeting renal disease
ere very likely not unique to kidney
ole problem of coordination in the MWRMP be

  ssions are invited. It is useless at this time
sion of dialysis, which is already being conducted
asis, without resolution of an effective way to develop

ient transplantation site.

sideration of this proposal is the pointed need for

    g for such capability.  The presumption set

        on that provision of a tissue typing laboratob
organ procurement would stimulate interest in transplantation is
           le (over 70 in non-Federal Hospitals) patient

ility and the Region's omission of in-depth

ists in the Region,  The Panel noted four tissue
es already in the area and the fact that Federal
ange the organ donor population which has heretofore

f only 1.25 organs per transplanting medical
fronts a dialysis bottleneck because there

effective transplantation capability. In the
lantation capability, it seems futile to consider
osals.
considered the apparent lack of patient-support
MWW but questioned the true magnitude of this

The application does not define the specific

Metro D.C. RMP -2- nl"1 UUUJS Of II

.problem in view of the large existing dialysis population.
'large proportion of indigent patients was seen as a strong basis
,for moving quickly into transplantation, especially if organs could
be made available to keep the waiting period to 4 months, or less,
and thus preclude the expense of carrying out home training.

The

The reality of a lack of transplantation interest was underscored
by reviewers both as a key to understanding why full-blown
transplantation is not already underway, and why there is no
observable nerve center on which to exert influence to stimulate
progress.
transplantation was the limiting factor in the Region, with an appropriate
transplantation prograq, initiation of any one of the four dialysis
proposals would be acceptable.
more than one transplantation activity, one such activity must be
established before there can be more.

If there were clear recognition in the proposal that

While there might be interest in

e

The proposed bacteriuria screening project seemed to have little
merit in view of its research nature and the magnitude of the Region's
end-stage problems.

The Reviewers expressed a desire that the Region have a transplantation
capability.
or institution at which a fruitful approach could be made.
was hoped that consultative conversations on this point with key
Washington authorities might be organized by the MWRMP.
persons in the xeviewers'estimation would include the Chief of Medicine,
Chief Surgeon, and Chief Nephrologist of each of the applicant institutions.

But it could not identify the appropriate point

It

..

Key

GRB/RKPS

7/14/71

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

Michigan Association for

RM 00053-04 8/71

1 Regional Medical Programs July 1971 Review Committee

Suite 200, 1111 Michigan Avenue
East Lansing, Michigan 48823

t'

Program Coordinator: Albert E. Heustis, M.D., M.P.H.

(Note: Dr. Heustis had resigned effective May 1, 1971. However, he has
agreed to serve as Program Coordinator at least through the period of the
June 9 and 10, 1971 site visit;)

The Region is currently funded at $1,898,936 (Direct Costs) for its third
operational year which ends 8/31/71.
direct costs of $393,094 which is 20.7% of the Direct Cost award. Total
RMP funding in Michigan is equivalent to approximately Ite cents per resident.

The Region has submitted a triennial application that proposes:

The Region currently receives in-

24

I A three-year developmental component.

I1 The continuation of six ongoing activities. Five of

these projects request a 6th year of support which is

one year beyond the Council-approved support period.

I11 The renewal of Central Core and 3 subregional planning
   units for three years plus renewal for varying periods
   of time for five ongoing activities.

IV Support for four previously approved but unfunded projects

for three years.

V Three year support for two new proposals.

An overview of the Michigan Regional Medical Program

The Michigan Association for Regional Medical Programs (MARMP) is about to
complete its third full year of operation. The most significant accomplish-
ment during the past year was the adoption of "Program Priorities."  These
were designed to respond to  the most pressing needs of Michigan, as a whole,
as well as to the understanding of the major national health concerns. To
add to the Guidelines for Stroke, Cancer, and Educational Projects developed
earlier, the last year saw the completion and approval of "Heart Program
Guidelines," and "Criteria for Cooperative Efforts. 'I
was a cooperative agreement with State and Areawide Comprehensive Health
Planning Agencies.

Approved in principle

Further, a policy for the handling of small pilot,

feasibility, or demonstration studies was adopted.

e

Michigan RMP

-2 -

i I,I

RM 00053-04 8/71

.-

In addition, the Michigan Diabetes Association, the Michigan Tuberculosis
and Respiratory Disease Association, the Comprehensive State Health Planning
Commission and the Wolverine Medical Society were each invited to be repre-
sented on the Corporation.  This increased the membership of the Corporation
and provides additional advice from individuals representing a wide range
of professional health oyganizations, voluntary heaJth agencies,  state
government, universities, geographic areas, and the public-at-large.

Involved also have been health professionals and other volunteers who
advised the Corporation through a Task Force on Continuing Education and
Professional Advisory Councils in the fields of Cancer, Heart Disease,
Stroke, and Chronic Respiratory Diseases, Ambulatory Care and Kidney Diseases.

4

EXISTING CORE AND PLANNING PROGRAM COMPONENTS

The Michigan Region
staff for program promotion, planning, facilitating, and/or coordinating
activities of concern to the Regional Medical Program (RMl?).
these are Michigan State University, University of Michigan, Wayne State
University, and Zieger/Botsford Hospitals.

supports agencies in addition to the Central (Corporation)

Currently

Michigan State University

The principal areas of concern are coordinating intra-university RMP activi-
ties; developing an extra-mural program to facilitate cooperative programs

,

outside of the academic community;

to test new ideas.

University of Michigan

The Secretariat was established to

in grant administration, planning,

and conducting limited feasibility studies

-

ass is t the University ' s pro j ec t directors
and evaluation. It also encourages and

assists the faculty in developing feasibility and demonstration studies.

Wayne State University
accessibility of medical care to the Detroit Model Neighborhood;  the evalua-
tion of the educational needs of health professionals and auxiliary workers;
and the deprivation in health services utilization.
ZiegerlBotsford Hospitals were selected by the Michigan Association of
Osteopathic Physicians and Surgeons and the Michigan Osteopathic Hospital
Association as the primary group to work with MARMP to plan principally
but not exclusively for the osteopathic profession.
included contracting with the Professional Examination Service of the American
Public Health Association to develop and conduct examinations for pbysicians ;
the development of a teaching program based on identified needs; the evalua-
tion of behavioral changes resulting from the educational programs; and
the provision of assistance in the development of a neighborhood health
center in Pontiac.

is concerned with increasing the availability and

Activities to date have

- 3-

RM 00053-04 8/71

Central (Corporation) Staff is the arm of the Board of Directors and Regional
Group in carrying out established policy and implementing Corporation pri-
orities and goals. It assisted with the development of the categorical
and educational program guidelines, the "Program Plan" and "Program
Priorities."  It also provides assistance on request to both university
and non-university personnel in the development of new program components.
It is responsible for the implementation of the RAG program component review
system, for the overall management of the grant, and for promoting coopera-
tive efforts among health providers. Additionally, it serves as liaison
between the Corporation and Federal Regional Medical Programs Service and
between the Corporation and State and Areawide Comprehensive Health Planning
Agencies.

The Region requests $3,815,394 Total Costs for its fourth operational
year; $3,322,516 Direct Costs for its fifth and $3,328,220 DYrect Costs
for its sixth operational year.  A chart identifying the components  for
each of the three years follows on pages 4, 5 and 6. The Region is to be
site visited on June 9 and 10, 1971.

FUNDING HISTORY
  PLANNING

Grant Year Period Funded (D. C. )

e 01 6/67 - 7/68 $1,040,6 39

                    OPERATIONAL PROGRAM
                                        Council Funded
Grant Year Period Approved (D.C.)

01


02


03 *

7 11/68-61 3016 9    1,495,330     721,763 Core **

7 / 1/6 9-8/ 31 / 7 0    2,054,020    849,814 Core **

9/11 70-8/31/ 71     2,031,533     683,293 Core **

773,567 Projects

1,134,863 Projects

1,215,643 Projects

* Reflects 12% reduction imposed on all RMPS programs.

** Includes central core and subregional planning agencies.

GEOGRAPHY, DEMOCRAPHY AND HEALTH STATISTICS

Geography -The boundaries of the Michigan Regional Medical Program are
the same as the state borders. Physically the Region is composed of two
peninsulas - an upper peninsula which is separated from the more densely
populated lower peninsula by the Straits of Mackinac. The total land
area is 57,019 square miles.

I 133.148 I 36.030 I 163,1,78 1

I \ 26,865 I ~ 5,000 ! 31,865 ' i

I I

133.148

1 I 116,17& I 24.225 I 140.39? .

1

26,865*

=,?; 6 R-Jurve i 11 ance of
Slectric Equipment
::l;-Stroke Base Center
z-lc-3etrcit General Stroke 116,174*

:-;C-Coxzre. Stroke jz,j(i& I 10,3iO 82,93L
=2l-?uu'clic Ed. for Stroke 58.95C 58,950 1 5,715 I
                       ! 16,530
.:'-Cardiovascular Center I
--,-?mi. _. - :, Wdical Ed. I 66,050
:::z-csnt. ECI. for Inner- 1

I I 99,990 I 117,568
                I I-

17,558

.:Z--Stroke Deno. Unit 99,990k !

I I

I

I

                 t        1                  I
,5-?rro-d xcspital       72,564*                                             I

6G.655 ,

06.720 !

I 16,530 I 4,794 21,324 _.

10.670
171595 108,932

532,155. .

Ciiy 3ospital~ I 97,337*

I 505,269 I 505,269 76.885

-2~-x:.:i.~are -Ur:>an POOX 1 I I.

=23-Care or' Stzcke .in 1

I

i I 120.530 131,818
                                            259,225

Geieral Hospital

Eezlth Services Coord. 207,353

- Deliverv Svsten
+33-Stroke Day Care

c-32-Eealt'n Services j

Center

I

I

TEAL 471,880

*06 year beyond Bpproved period 'of support.

. ,-: . * 1 - *,, I

c

I

TOTAL 1 445,638

I

WGICX Flichigan
BEAKO'JT OF FZQUEST 05

PXCGWCY PERIOD

I I

1,391,326 484,000 3,322,516
          1,001,552

I

I

I
vt
I

il

3rd YEh? \I TOTAL

CO:~TJ3UATIOX WITdIN COITIHUXION BEYOSD APPROVED, NOT AX:?, SOT

ID~h"\TIFICMIOS OF APDRVJED PERIOD OF ld?TROVHD FERIOD 03 PS3VIOUSLY P"VI0!2S LY D1"CT ALL YEAX
- c 2: :?cx3T- SU??OZT SLrpPOXT FUXIED * APPROVED CCSTS 11 DTXXT COSTS
COO- Developmental 180,000 180.000 if 540 000

is1 - Core I 320.400 I 320,LOO !I 893-

.

..

I
I

m

i

-7- RM 00053-04 8/71

The vast land area coupled with centers cf medical excellence and decentralized
health resources, its relatively self-sufficient pattern of obtaining care,
and its array of health manpower argue well for the one state - one region
concept in Michigan.

A. Demography and Health Statistics

1. Population (1970 Census) - 8,875,100

Density of population -- 156 per sq. mile
Metropolitan areas, population in thousands:

Ann Arbor 230.1 Jackson 142.4
Bay City 116.6 Kalamazoo 199.3
Detroit 4,163.5 Lansing 373.5
Flint 493.4 Sa gin aw 217.8
Grand Rapids 535.7

9

SMSA'S -- total population of 6,472,300

% Urban - 74

% Negro 11
% Other nonwhite 1

2. Income -- average personal income (per individual) 1969

Michigan
E. No. Central

$3,944 U.S.

3,937

B. Facilities and Resources

1. Medical Schools

Univ. Of Michigan, Med.Schoo1, Ann Arbor
Wayne State Univ. School of Med., Detroit
Michigan State Univ. College of

Human Med. (2 yr.) E. Lansing

Osteopathy - Michigan College of

Osteopathic Medicine, Pontiac

Professional Nursing Schools - 39

22 are college or university-based

$3,680

1969/70

En roll men t     Graduates


  8 12         189
  537         132

--

85

-- --

(1967)

5,666 1,463

Michigan RMP

-8-

2.

Accredited Allied Health Schools

Cy t o t echno io gy
Inhalation Therapy
Medical Record Librarian
Medical Technology *
Physical Therapy
Radiologic Technology

t

3
2
1

37
2
40

-

RM 00053-04 8/71

* Includes 1 school at V.A. Hospital, Allen Park

Student Capacity

14
60 (commun. colleges
38 affil. with hosp)

32 (univ. based)

365


752

,. Federal Health Programs

CHP "A" Agency - Lansing

CHP "B"' Agencies :

Battle Creek
Detroit
Grand Rapids
Lansing
Marque tte

Funds

$520,000

110,000

500,000

125,000
165,000
60,000

$960,000

Prof.
Staff


5

4
10
4
5
'2

25

OEO Neighborhood Health Centers

#'

Baldwin
Detroit

Model Cities

1st Round Planning Grants
Detroit
Flint (Genesee County)
Hghland Park
Saginaw

2nd Round Planning Grants

Ann Arbor
Benton Harbor
Grand Rapids
Lansing

Michigan RMP

D. Manpower

Physicians (non federal)

      patient care)

*Active (providing

Inactive
Osteopaths

Total active MD's & DO'S

Professional Nurses (1966/67)

Employed in nursing
Not actively empl. in nursing

*Physicians by specialty

-9-

Total in general practice
Total in medical specialties
Total in surgical specialties

Others

RM 00053-04 8/71

#      Ratio per
(1967)   100,000 pop.

95 90 --

11,522 134

23,441      - 277
13,212           --

% of.

Number Total

2600 27
22 75 24
3310 35

14 05 14

Regional Development

During November 1965 the Governor's Council on Heart
Stroke met at the Wayne Couqty Medical Society Headquarters in Detroit
to discuss P.L. 89-239 and its implication for Michigan. Dr. Albert
Heustis served as chairman of the group. Following this, during December
1965, Dr. Marston from N.I.H. met with members of the staff of the
Department of Public Health, members of various local medical societies
plus representatives of the State Medical Society and various agencies to
further discuss anR.M.P. in Michigan.

Disease, Cancer and

During June 1966 the Michigan Association for Regional Medical Program,
Inc. was incorporated. Following this, during December 1966, the original
planning application to support a central planning staff of MARMP was
submitted. This was immediately followed, January 1967, by a supplementary
request to support Core planning activities at the Department of Public
Health, Michigan State and Wayne State Universities. During the January-
February 1967 review cycle the planning application and supplemental re-
quest were recommended for approval with the comment "In its entirety
the applications reflect a comprehension of what a Regional Medical Program
should be and makes clear the needs and objectives of the Region."

Michigan RMP -1 0- RM 00053-04 8/71

The Region's first planning award of $1,040,639 (D.C.) was issued during
June 1967.
September 1967.
during February 1968.

Dr. Heustis was appointe? full-time Coordinator during

The Region's first operational proposal was submitted

Following a positive June 1968 preoperational site visit, the Region
became operational July 1, 1968.
$721,763 supported a Core/central office and 4 subregional offices plus
10 operational projects.
it submitted two separate operational supplementary requests.  The sup-
plements requested support for nine new activities plus a renewal request
for Project ill5 (Survey of Physician Continuing Education - Zieger/Botsord
Hospitals),  The Region's application for its second year operational
funding requested $1,676,824 (D.C.) as compa.red to a second year 100%
commitment of $1,626,398 plus a request to use $127,782 of a projected
$470,344 balance from first year funds ($69,118 of the total of $127,782
requested carryover was approved).  Staff's review of the progress reported
on  the first year of operations and the plans described for the second
operational year led to a conclusion that the Region (with some minor prob-
lems) had exhibited growth and maturity under excellent leadership and
that the RAG was on top of things with a review system,  both at the tech-
nical level and RAG level which appeared superb.
effective 7/1/69,  a 14-month award (which realigned the ending of its
budget period from July 1 to September 1) was issued for $1,862,244 (D.C.).
On August 17, 1970, staff considered the Region's application  for its
third operational year (no carryover funds were requested).  Briefly,
as in the 02 year application, staff continued to believe that the Region
was on target.
$4,504 less than the $1,560,170 previously committed for the third year.
Also, in this application the Region reported an estimated !8.9% expendi-
ture rate of its second year funds.
Acting Director RMPS signed an award totaling $1,601,367 (D.C.) in
addition to funds previously awarded on a 16-month basis and still
available for expenditure. The actual direct cost funds available for
the period 9/1/70-8/31/71 totaled $2,091,100 (D.C.). This amount was
later adjusted in line with the HSMHA director's letter of April 7, 1971
which reduced the current level to $1,898,936.

The following chart shows the Region's funding at the time this appli-
cation was developed, the levels of funding for the continuing life of
ongoing projects and specific new and previously approved activities.

Of a total of $1,495,330 awarded,

During the Region's first operational year

Based on this Review,

The third year request was for $1,555,666 which was.

Based on staff recommendation, the

Michigan RMP

-11- RM 00053-04 8/71

Core

Central Off ice

Subregional Planning Offices
Michigan State
Wayne .State
University of Michigan
Ziegerl Botsford Hospitals

Core and Subregional
  Planning Subtotal
Developmental Component

Core and

Projects for Triennium

(Direct Costs )

Present
Funding 1st 2nd 3rd
                             Year

-

Year

(Direct Costs) - Year -

$ 283,706 279,234 294,200 320,400

163,107   172,798    170,000    170,000
148,160   221,387    2 76,800    299,500
23,480       --            --           --

64,840 116,500 123 , 072 129,629

683,293   789,919     864,072    919,529
  0     180,000    180,000    180,000

Projects

Ongoing Projects, Continuation $1,215,643 1,052,490 972,892 841,091

and/or Renewals

e

Approved Projects

New Projects

Not Initiated

1,053,872   1,001,552  1,075,423
262,350    304,000    312,177

Totals $1,898,936 3,338,631 3,322,516 3,328,220

Organizational Structure and Processes

Board of Directors

The Michigan Association for Regional Medical Program is an incorporated
not-for-profit corporation.
board of directors (all board members are also members of the Regional
Advisory Group) under specific rules as outlined in the corporation
by-laws. The Board meets monthly.

The corporation is managed by a seven-member

Regional Advisory Group

The Region currently has a 35-member Regional Advisory Group (membership
on RAG is synonymous to membership in the association -- members of RAG
are automatically members of the Association and vice versa);the RAG
meets quarterly with an average 75% attendance.  (The by-laws allow for
proxy participation and vote)  The group presently has representatives
from some 22 organizations or institutions plus six representatives from
the Public-at-large and one representative from each of six districts
recognized by the corporation. There are three black members. New

Michigan RMP -12- RM 00053-04 8171

members to the group are nominated and elected by current members.

In addition to the Board of Directors mentioned above whose function
is to be in charge of the corporation property, manage and control
the corporation affairs and funds, appoint the Coordinator, establish
regulations for corporation conduct, accept all grant applications,
recommend to the RAG action on all reports and requests and approve
all studies under $8,000,
of standing professional Advisory Councils. These are in the fields
of: cancer, stroke , heart disease, chronic respiratory disease, kid-
ney, ambulatory care, continuing education plus an ad hoc project
review committee.
last year (Board of Directors) to a minimum of 1 meeting each for the
stroke and heart disease.

i <,

the Region has a rather comprehensive casting

These groups have met from a high of 11 meetings

Professional Advisory Councils

All Professional Advisory Councils are advisory to the RAG in that they:

1)

Develop written guidelines relative to RMP effort in a specific

area - the following programmatic guidelines and reports have been or
are being developed:

2) Assess

A Regional Cooperative Cancer Management Program

Report on the Diagnosis and Management of Four Neoplasms

Regional Cooperative Stroke Education Program

Heart Disease Program Guidelines

Guidelines .for the Preparation and Review of Proposals

for Educational Programs

Proposed Chronic Respiratory Disease Program Plan

Charge to the Professional Advisory Council on Ambulatory

Care (Ambulatory here refers to Health Services rendered
to all those who are not in-patients)

progress being made by such efforts

.'I

3)

Serve as additional Review Committee to that of a formal

Project Review Committee

4)

Recommend specific implementation of applicable MARMP Priorit,ies

that will accomplish the most with limited funds

Ranking

1st Highest

Review Procedure

A prospective applicant has many avenues of proposal development assistance
in this Region.  These will include MARMP staff and may include the four
universities having full-time planning capabilities, professional advisory
councils, voluntary health organizations, hospitals and other health and
educational institutions.

The Ad hoc Project Review Committee has a potential of 64 members, met
8 times during the past year and has the function of recommending approval/
disapproval to the RAG of all requests over $8,000.  An Ad hoc Project
Review Committee is appointed to review each completed proposal and make
its report and recommendations to the RAG. While it is known from previous
experience with this Region that the Local Review Process is thorough and
comprehensive, the upcoming site visitors will have an opportunity to
inquire into the specific processes of the system. Inherent in the review
process is the right of appeal. Members of the RAG have established an
individual rating system which aligns each proposal with a priority listing
numerical place and relates it to a program priority.

Program Priorities
on March 13, 1970 the Reg,fonal Advisory Group approved and ~~nked new Program
priorities for MARMP briefly,these are:

- - - -- -__

Obj ec t ive

Immediate health service needs of the
poor (both black and white) in the
major metropolitan centers and in
designated areas inhabited by rural
poor

2nd Highest

3rd Highest

Next to Lowest

To increase the delivery of health
services

To prevent disease and its complications

General professional Continuing
Education to improve the quality of
treatment services

Lowest

All other things compatible with
Public Law 91-912

. Michigan RMP

-14-

RM 00053-04 8/71

The total Regional program for the first year of the triennium and related
to these priorities is shown on the chart,(pg.l5).Included in the RAG
report portion of the application, the RAG outlines some Regional strat-
egies.
difficulty in establishing a realistic time frame in which the Region
planned to implement its priorities.
not appear to reflect any new approach but simply a continuation of the
"same old thing."  Staff also realized that as this application was being
prepared, new national health priorities were being established and these
would require a fair "turn around" period.

However, staff in its review of the total application had some

               Some of the proposed program did

PRESENT APPLICATION
THE DEVELOPMENTAL COMPONENT

The Region requests developmental funds of $180,000 for each of three
years.
approved program strategies and thus its priorities through the use of
developmental funds.  Specif3c ideas are included for the use of these
funds to implement actions suggested by the Region's several Professional
Advisory Councils as most.important in improving the availability,  acces-
sibility, and acceptability of quality health care services. Then too,
the special funds could be used to quickly respond to new requests within
the Region's top three program priorities,
Michigan Region has developed an excellent record for using small amounts
of funds in problem solving and in gathering necessary information to add
strength and promote growth of its program.

The Region cites examples of how it plans to implement the newly

Down through the years the .

The RAG has developed (and approved) a method of procedure for adminis-
tering these funds.
meeting six other stated criteria may be handled by the Board of Directors.
Other requests will be considered in the Region's usual peer review system.
A specific contract will be,.negotiated with each organization funded.
Allocation of funds are to be on a reimbursement basis requiring monthly
fiscal and periodic program reports.

Briefly, any component costing $8,000 or less and

Go re

-

Requested (D.C. )
Fourth Year

$279,234

(First year of Triennium)

Central core activity is currently supported in the Region's third
operational year for a total of $283,706 (D.C.)
a staff of nine full-time personnel plus the necessary and usual expenses.

This amount supports

This application requests two new field representative positions in the
first year of the triennium.
of personnel from the present two to a total of four field representatives.

If funded, this would increase this type

I

HlCHICAN RECIOSAL XEDICAL P REQUEST AS OF MAY 1, 1971

CJJIECfiRIZED BY PROGPAY Pil

FOR 04 YEAR -

Core

Ird HighesL
'revent disease
nd its complice-
ions

Continuations
beyond approved
period of support
(Renewal)

Next to Lowest
Cenral professiona All other things
continuing educa- compatible vith
tion to improve P.L. 91-912
the quality of
treatment services

1 :or Rated

proposals

I

133-Strohe Day
are Center-
.tartin Place D/O
3ospltals

S102,350

Developmental

Componeu

7-77!

I

TOTALS $279,23

$614,694 $478,030

___- -_

ghest Priofitv Illghcst
mediate health Increase the
rvice needs of U
or (both black L health services
lite) in tkmajor i
tropolitan centem
d in designated

delivery of

edical Education
rogram-Blodget t
spital, Grand

I

3evrIop~stsl 1ao.ooo

compsnen t

$150, w3

S35.?,V% $3.338.631

-__

i

rmit Memrial

$120.530

21-Comprehensive
ealth care for
rban poor-Wayne
ounty General
ospital
31-cornunity
ealth services
aordinators-USU

$112,622

32 -Lake si de
mprehrns ive
salth care for
le poor-Zieger/
Jtsford OsteoprtH:
>spital

$160.000

$I ,096.OO9 $519,866

-_

Prepared by GRB

DIRECT COSTS ONLY

I I I

#I8 - Comprehensi
ttack on problems
f stroke-W.S.U.
(21 - stroke
2ucat ion Program-
ichigan mart Ass

$115,124

:

e

.&&an State

Il5-Subregional P3-Data Collection
planning-Zieger/ Dept .of Pqb .Bealth
Bocsford Bospitalr 84-Model CCU-Mich.

$116.500 Heart Assn..

116R-Surveillance
of electronic
equipment-Michigan
Heart Assn.

s47a.o~) .

#30-Southeas c
Sichipan Regional
Cancer Program-
V.S.U.

$220,720

133-Strohe Day
are Center-
.tartin Place D/O
3ospltals

S102,350

,1251 71


Total
request

,310,529 .

,053,812

262,350

The application describes a small but energetic and productive core staff
operation which moves in the areas of planning, support in identifying
needs, assistance with project development and in evaluation of opera-
tional effectiveness.
for either continued or new support for several core-supported feasibility
or planning studies. Example: nursing survey, Detroit General Hospital.
The core budget escalates in the 5th and 6th year due to the new staff
additions and normal salary increases.
for central core.

Also the fourth year request outlines support

No indirect costs are requested

Michigan RMP -16- RM 00053-04 8/71

Request
Fifth Year
$294,200

Request
Sixth Year
$320,400

Also, the Region currently provides support for four Subregional Planning
Agencies (on contract) which are located in 3 medical schools and an
osteopathic hospital (s).

These are:                                       Pe rsonne 1
Institution Current , Full-time

Support (D.C.) Equivalents

Michigan State University ' $163,107 7
University of Michigan 23,480 3
Wayne State University 148,160 5
2 ie ger / Bots f o rd 110 sp i tal s

. 64,840

2

Fmds to these four agenqies are provided for the planning, promoting,
facilitating and/or the coordinating of activities of concern to the
Regional Medical Program.
discussed below.

Project #5 - Subregional Planning Offices Requested (D.C.)

Tf!ese subregional planning offices are

Michigan State University Fourth year

$172,798

.. .

.. -.-

.. . .

..

. .... '.

; . -i.- --_
.:... ;.
- .., , ,
. \. ..-
' '.... .

..

This project is currently supported for $163,107 (D.C.). Continued
support is requested to assist local health providers to expand and im-
prove health services to medically and economically disadvantaged rural
poor in Central and Southwestern Michigan.  The progress report briefly
describes seven small pilot scale programs which have been initiated.
For example, a community Health Aide Program was instituted in conjunction
with the Cansing Housing Commission. Since October 1970, 58 patients
have been referred to the project nurse.(?)Plans for the future are geared
more toward the Region's priorities rather than on categorical emphasis.
Also, MSU-RMP fe working with the C.H.P. 3144 Agency in an experimental
Health Services Planning and Dellvery System grant.

The MSU-RMP has been supported by MAW since 1967.
requests three additional years of support.
estimated approximately $67,000 total unexpended funds for the current

     This application
The applicant originally

Michigan RMP -1 7- RM 00053-04 8/71

year. This amount may change due to the. recent budget compressions.

In its review of the request for continued support, the local Project
Review Committee believed that the MSU has a greater potential for con-
tributing to the KMP effort than was reflected in this application.
Therefore, the Review Committee recommended to the RAG that the University
completely restructure its request and identify a specific area upon which
it could concentrate its efforts. The RAG concurred. If this request
is
able program plan.

funded,

the funds will be held by the corporation pending an approv-

Re ques te d
Fifth Year (D.C.)
$170,000

Project 514 - Wayne State University

Requested
Sixth Year (D.C.)
Sl70,OOO

Requested (D.C.)

Fourth Year
$221,387

This program is currently supported at the $148,160 level. Three years
of continued support are requested to enable WSU-RMP to increase the
capacity of the Health Care Systems to provide expanded and more rele-
vant care directed especially toward primary patient care. The primary
thrust of the University program is directed toward the Metropolitan
Detroit.area.  The WSU-RMP has participated with OEO, CHP and HUD in
the design and implementation of a comprehensive health care (HMO)
delivery model for Model City residents where family oriented care is
being provided to an enrolled,
and children on a capitation basis.
effort be expanded to include other defined population groups.  Also,
WSU-RMP have developed several other major projects which have been approved
and are currently being funded. In fact, several of the professional
staff, which are supported under the WSU-RMP planning office,  are also
listed (without compensation) as individual project directors. These
WSU projects will be discussed individually later in this summary.
Wayne State University Subregional Planning Office was ranked number two
priority in this application.

prepaid population of 10,000 men,  women
   The application proposed that this

The

Reque s te d
Fifth Year
$2 76,800

Project 115 - Zieger/Botsford Hospitals

Requested (D.C.)
Fourth Year
$116 , 500

This program is currently supported during its third year at the $64,840
(D.C.) level. Continued three-year support is requested. Geographically

e

Michigan RMP -18- RM 00053-04 8/71

this is a two-pronged program aimed at the osteopathic physician (1900
D.O.'s in Michigan) in the Greater Detroit, Lansing-East Lansing area.

The objectives are:

1) To identify items of clinical behavior for specific diseases
to be recorded and serve as an index of care.
2) To program the above for computer analysis.
3) Application in eight osteopathic and three medical hospitals
to obtain base line data and comparative data on treatment received
by the "poor" and "near poor".
4) To improve care through indicated intervent ion.
5) To evaluate progress through measurement of altered clinical
behavior.

A self-administered eurvey-examination to determine physician knowledge
involving some of the osteopathic physicians in Michigan was conducted
under project support.
Physician knowledggaps were identified and remedial educational pro-
grams based on these gaps have been or are being instituted and evaluated.
The Subregional Planning Office is working closely'with the Michigan
State University RMP Office to involve the university medical hospitals
in these activities.  The budget request escalates almost 100% fourth year
compared to the third year funding.
professional position (Evaluator-Statistician) and would allow for normal
salary increases and provide $30,000 subcontract funds to be entered
into with the Commission on Professional and Hospital Activities.
program was awarded a number three priority in the total application.

(1700 examinations distributed - 31% completed).

The current request would add a new

This

Fifth Year (D.C.)

Request
$123,072

Staff in its review of
concerns regarding the

Sixth Year (D.C.)
Request
$12 9,629

the triennial application had the following
Subregional Planning Offices:

1)
and independent units? ,
2)
to the central core staff?
3)
clarify the relationships to RMP and to each other of the planning
offices. Staff further noted that the University of Michigan sub-
regional planning office is not requesting support in this upcoming
triennium.
application was too meager to enable the Project Review Committee
to make any determination.
the University may wish to restructure its request which could

Are these in reality subregional planning offices or separate
What are the relationships of the subregional planning offices

Staff believes that some statement is indicated which will clearly

It has been learned that the University of Michigan

The RAG concurred and suggested that

I

Michigan RMP -19- 3.M COO53-04 8/71

then be considerea on its merit. Also, the RAG recommended that
an amount of funds be retained in the corporation budget which could
be available for any such program receiving

RAG approval.

Requests for Continuation of Projects Within Approved
Periods of Support

Project /117 - Stroke Base Center - Wayne State

This project is currently supported at the $16,000 (D.O.) level. As
noted on the enclosed fiscal break-out sheet, funds for the Region's
sixth year are requestpd which is beyond the approved period of support
for this particular project. Continued support is requested to provide
professional. consultation to the cooperating stroke centers and stroke
information proeran. assist in the design of professional educational
opportunities to meet their needs, and be responsible for the overall
evaluation of the Region's stroke program.

The Program was approved during June 1969 and funded during June 1970.
A part of this was due to the relocation of the original Project Director
(Dr. John Meyer). The progress reported thus far is in futuristic terms.
An evaluation protocol has been developed which excludes surgical pro-
cedures and measures of patient status. The evaluation tool is to be
tested at the Lapeer County General Hospital by a recentlv employed
Record Analyst. In approving the project, the RAG conditioned the ap-
proval on the project including information on surgical procedures and
measures of patient status. This project was awarded a priority ranking
of sixth in the total application. It is related to program priority
Category I1 - Prevention of Disease and its Complications.

- Requested (D.C.)
Fifth Year

$33 980

Requested (D.C.)

Sixth Year
$38,293

Project #l8 - Comprehensive Attack on the

Problems of Stroke - Wayne State Univ. Requested (D.C.)

4th Year

I $116,174

This project is currently supported at the $80,000 (D.C.) level.
noted on the enclosed fiscal breakout sheet, funds for the Region's
sixth year are requested which is beyond the approved period of support
for this project.
7/11/70, under a new Project Director (Dr. John Gilroy rather than Dr.
Meyer).
opening of a 6-bed demonstration unit was delayed until 12/70.
is reported in terms of a multi-disciplinary conference which is being
hcId weekly for those involved in the care of patients from the departments

As

The project was approved on 6/21/69 and funded on

Due to renovation and reorganization at Detroit General Hospital,

Progress

Michigan RMP -20- RM 00053-04 8/71

of Neurology and Physical Medicine.
tion purposes to Project 817 - Stroke Base Center - Wayne State,.  The
objectives of the program are to enable practicipg phystcians, R.N. 's
L.P.N.'e, P,T,'s and Social Workers to gain the pecessary knowledge,
skills and attitudes to function optimally in the prevention and man-
agement of stroke patients.,
involve these professionals from seven inner-city hospitals.

i 1

This project is related for evalua-

,~.,

In the future years, the project hopes to

Personnel accounts for $112,224 of the total 4th year reauest of $116,174.
As of February 1971 recruitment efforts were continuing for a nurse
supervisor O.T., social worker and a pharmacy consultant.
RAG in its review of the project, conditioned its approval on the sub-
mission of an approvable training program (course outline, class size,
bibliographv, etc.)

b

Also, the

This project was awarded a prioritv ranking of fifteenth in the total
application.  It is related to Program Prioritv I11 - Prevent Disease
and its Complications.

Requested

Sixth Year
$138 , 95 0

Project #19 - Stroke Demonstration

Unit - Detroit Osteopathic Hospital Requested (D.C. )

-

Fourth' Year

$99,990

\

This project is currently supported at tqe $84,775 (D.C.) level.
are requested for the Region's sixth year which is beyond the approved
period of support for this&project.
June 1969 and funded during June 1970.
unit became operational on 9/15/70.
prepared, 55 patients had been admitted to the unit - 48 with acute stroke
and 7 with T.I.A. investigation.

Funds

The project was approved during
  A 16-Bed stroke demonstration
At the time this application was

Continued support is requested "to improve the quality and develop more
uniform standards of care provided patients with stroke in Michigan  by
utilizi'ng the center to train physicians and allied health professionals
from participating hospitals!'  The project is receiving good cooperation
from other Michigan osteopathic hospitals.
funded stroke cooperating centers in the Region.
Detroit General and Sparrow Hospitals).
the Project Review Committee noted the apparent-greater progress in this
program as compared with the other two cooperating centers.
tional phase of the project is expected to be fully operational by March 1,
1971.
of students, etc.

This is one of the three

(Detroit Osteopathic,

During its review of this request

The educa-

For this reason, no informatinn is available as to number and types

Michigan RMP -21- RM 00053-04 8/71

The Project Review Committee recommended aDproval subject to the programs
submitting by May 1, 1971 to the WP Board of Dirpctors,  a formal course
outline including educational goals for each of the disciplines involved.
Detroit Osteonathic Hospital expects to maintain the unit and all project
personnel as a regular cost of qperation upon termination of RMP funding.
Requests for personnel is $83,360 in the first year $99,990 request.

This project was voted a priority ranking of eleven out of the total
application.
of Health Services.

It is related to Program Priority I1 - Increase the Delivery

Requested (D
Fifth Year
$107,870

Project #20 -

Requested (D.C.)
Sixth Year
$107,870

Central Michigan Comprehensive        Requested (D. C. )
Stroke Program                        4th Year

$7 2,564

The project is currently supported at $88,655 (D.C.) level. Funds for the
Region's sixth year of support are requested which is beyond the approved
period of support for this project.
and funded dur8pgJJune 1970.
established adjoining the rehabilitation unit of the Sparrow Hospital.
the period 1/20/71 to 3/24/71, 18 patients were admitted to the unit.
were 4 deaths.
patient progress reports are sent regularly to attending physicians for
modification of care or for additional diagnostic studies. A Stroke Committee
has developed routine diagnostic, laboratory and nursing procedures and
developed charts for graphic reporting of patient progress. Evaluation is
being coordinated by the Wayne State University Stroke Base Center.

The project was approved during June 1969

                      During

A 4-bed Stroke Demonstration Unit has been

There

A weekly multidisciplinary conference is held and written

Continued support is requested for this activity with the hope that by
demonstrating gobd patient care learning will follow by osmosis. This project
was awarded a priority rating of eighteenth in the total application.
is related to Program Priority I1 - increase the delivery of health services

It

Requested (D.C.)

Fifth Year

Requested (D.C.)
  Sixth Year

$78,451 $78,451

Michigan RMP

-22-

RM 00053-04 8/71

Project #21 - Stroke Education Program - Michigan

Heart As so cia t ion Requested ('D.C.)

Fourth Year
$58,950

This project was initiated during September 1970 and is currently sup-
ported at the $57,216 (D.C.) level.  Two years of continued support is
requested to provide a public education program regarding stroke risk
factors.
severity of prematiire stroke.

The objective of the project is to reduce the incidence an.l/or

Radio and T.V. spot announcement scripts have been developed and will
be produced dririnq Aprjl 1971.
printed material for public distribution, speaker outlines and printed
media material are being developed.
materials are aimed at providing public information regarding:

The air target date is June 1971.

Also,

Both the mass medi& and individual

1) Predisposing stroke factors and their avoidpnce
2) Symptoms of incipient stroke so that medical advice is sought
early enough to either avoid, postpone or modify an impending stroke.
The concept was originally submitted as part of the Wayne State
University stroke project.

Evaluatian will consist of random sample interviews with the public and
with selected groups of physicians.
will be used.
in the development of the evaluation instrument.
financial take-over of the activity

The Project Review Committee raised a question regarding the $36,000
out of a total request of $59,001) which is requested for sub-contracts
in view of their non specificity.  If this project is funded this con-
cern will be satisfied.

The project was voted a priority listing of seventeenth out of the
total application.
Disease and its Complications.

An out-of-state control community

The University of Michigan Research Center is cooperating

               are not firm.

Phase out plans and

.f

It is related to Priority Category #I11 - Prevent

Requested (D.C.)

Fifth Year
S60,550

-23-

Project #26 - Continuing Education Program

for Inner-city Hospitals -
Wayne State University

RM 00053-04 8/71

Reques te2 CD. C. .I
Fourth Year
$97,337

This project is currently funded at the $80,219 (D.C.) level. The
initial funding began on July 1,  1970.  Funds for the Region's sixth
year of support are requested which is beyond the approved period of
support for this project. Continued support is requested to achieve
the project's objective which is to improve care provided to patients
with heart disease, cancer, stroke and related diseases in Detroit
Inner-city Hospital.  Full staffing has almost been accomplished with
the exception of a medical school physician coordinator.
was identified as the first patient care problem.  All hospital medical
staffs (Detroit, Boulevard, Kirwood and Lakeside General Hospitals)
have approved criterion practice for hypertension; actual practice data
has been collected, reviewed and evaluated; initial intervention has
been designed and implemehted and post-intervention monitoring is in
process. It is expected that two additional patient care problems will
be defined and standards of care agreed on during the current year.
Plans for the triennial period include the establishment of 12-15 patient
care problem areas. Also, additional inner-city hospitals are to be
brought into the project.

.

Hypertension

Personnel request for 71-72 is $88,000 of the total direct cost budget
of $97,000.

A part of the evaluation methods  are to analyze pre and post-intervention
data.

Plans for continuing the program following withdrawal of RMP funds are
not specified.

Requested (D.C.)
Fifth Year

$97,337

Requested
Sixth Year

$97,337

Michigan RMP -24-

RM 00053-04 8/71

Project Continuations Beyond Approved Period
of Support (Renewals)

Project 13 - Health Sehices in Six Michigan Costies -
      Data Collection- (formerly called E. C. H.O. )
      Michigan Department of Public Health

Requested
Fourth Year
$197,982

This project is currently supported at the $227,490 (D.C.) level.   It
was initially funded as a part of the Region's planning grant and has
been supported for three years under the Region's operational phase.
In the Region's operational phase, funding has come from various sources,
but the initiating and primary source has been MARMP.
1970 MARMP has provided over 60% of the funds ($518,886).
continued support is requested "to produce and stimulate the use of timely
information on population, environment, health needs and services and to
measure changeover time to develop the use ofthe extended vital statistics
system. 'I

Through June 30,
  Two year RMP

Progress is reported in terms of vital statistics extension and health
survey demonstration.
methodology has been developed, continued RMP support is requested (50%
first year - 25% second year - third year, none) for 2 years of a 3-year

According to the application, now that a basic

. -:

program to demonstrate the utilization of the data generated in six
defined localities (Adrian, Detroit, Flint-Genesee County, Grand Rapids, ._,

*. _-

Lansing and Muskeegan).
nine-concern refinement of st,?tistical proceduye, relating mortality and
environmental data to geographic local
of non-professional community health analysts and alternative ways on
how to finance the survey process.
related to MARMP,

The 1970-71 request had 11 objectives.

The first

dissemination of data, the use

The remining two objectives are

  1) To produce information on heart disease, cancer, stroke and
related diseases as contributory causes of death in relationship to
total causes of death.

21 To provide technical statistical consultation to MAW and MARMP

Projects.

The project is related to several federal programs:
Mgdel cities, NCHSFtD and OEO.
its approval upm assurance Qf availability of both local ($225,000)
and state ($14-3,000) funds.

Tke pr.s;ect vas voted a priority of twenty-one in the total application.
It -,.-as cocsidered to be related to Program Priority I11 - Prevent Disease
and its Cmplicatims.

C.H.P.

(A) (B) (D),

In approving the request the RAG conditioned

Requested (D.C. )
Fifth Year

-

$100,000

Sixth Year

None

e Michigan RMP

-25-

RM 00053-04 8/71

RMP Staff in its review of the Triennial application, had great
difficulty in trying to relate project #3 to the Region's priorities.

Project #4 - Model CCU - Michigan Heart Association

Requested (D . C. )
Fourth Year

$146,900

The project is currently supported at the $103,000 level.
was initially funded during September 1968.
is requested to:
acute coronary disease; (2) offer nurses training in patient management
in coronary care units.  Since September 1968 and through January 1971,
this project conducted 12 community centered courses attended by 632
physicians from 149 hospitals and 34 community centered courses attended
by 742 nurses from 135 hospitals, 73% of which had CCU's.
a programmed instruction system for use by institutions wishing to train
CCU nurses.  All courses have been held in accordance with-the proposed
schedule.  The physicians' courses we're taught by 75% local faculty and
the nursing, courses by 100% local faculty.

The program

Three-year continued support

(1) offer physicians training in the management of

It has developed

The request for continued support is a RAG directed combination of  the
University of MLchigan School of Nursing and the Michigan Heart
Association effort to draw omla single program component based on the

e improvement of patient care.

Council policy as it relates to CCU's which was adopted at its November 9-10?
1970 meeting, is quoted:

"Coronary care units : Council affirmed that although coronary care

units are now established community resources, Regional Medical Program
funding units may be desirable when such units make important contributions
to regionalized improvement in medical care, including overall efficiency
and cost and when projects are planned to disengage from Regional Medical
Program support promptly.  To qualify for Regional Medical Program assis-
tance, coronary care unit projects must also meet the following conditions:
(a) An organizational structure and staff capable of implementing a high
quality system must be present; (b) the mechanisms for entry into the system
require development; and (c) RMP funding does not finance established
technology, equipment, or patient service operations.

   Training for coronary care units: Council requested RMPS to
instruct all Regional Medical Programs having coronary care unit training
projects to disengage Regional Medical Program funding at the end of their
current project periods or within a reasonable period thereafter as noted
above. "

The program was voted a priority ranking of 20 in the total application.
It was considered to be related to Program Priority IV - General Professional

-

Continuing E$ucation to improve the quality of treatment services.

Requested (D.C.) Fifth Year Requested (D.C.) Sixth Year

$142,006 $150,042

Michigan RMP A-26- RM 00053-04 8/71

Project #16R - Surveillance of Electronic Equipment

Requested (D.C.)

Michigan Heart Association Fourth Year

$133,148 I

This project is currently supported at the $53,044 (d.c.) level.  The
project was initially funded for one year on May 1, 1969, through the
Wayne State University.
one additional year.  During the operation of the project,  it became
clear to the Region that a key element in the MARMP goal of promoting
replacement financing of projects would and could be served by collecting
service fees from hospitals.
University policy. Therefore, and by mutual consent, the project has now
been transferred to the Michigan Heart Association.
the transfer was based primarily on making the project self-supporting.

The July 1970 Council iecommended approval for

This procedure conflicted with Wayne State

RAG approval of

Three years continued support is requested in this application. The
primary objective is to establish effective preventative maintenance
practices and programs for electronic equipment in critical care areas.
Since May 1969, and until the time this application was prepared, a
total of 13 initial hospital surveys and two re-surveys have been
completed.  The progress report indicates this is far below the original
estimate because of technical difficulties and the fiscal problem out-
lined-above.
national publicity, i.e. national and regional meetings, seminars and
publications.

The results of the program evidentally are receiving

Project personnel are continuing to work through the Intersociety
Commission for Heart Disease Resources to develop guidelines for optimum
use and maintenance for electronic equipment throughout the nation.
Evaluation is proposed in terms of questionnaires being sent to partici-
pating hospitals to determine action on the recommendations of the team.
The local reviewers obviously had difficulty in arriving at a recomenda-
tion. For example, the Project Review Committee members were unanimous
in acknowledging the value of the program but believe that such activities
might be more effective and appropriate for an agency capable of enforce-
ment and long-term service.
the three year triennial request of $133,148 is for personnel.
this would add a second full-time engineer plus a %-time secretary.
project was voted a priority listing of 22 out of the total application.
It is related to Priority Category IV - General Professional Continuing
Education to Improve the Quality of Treatment Services.

An amount of $100,374 of the first year of

If funded,

This

Requested (D.C.) Fifth Year Requested (D.C.) Sixth Year

$133,148 $133,148

e Michigan RMP

-27-

RM 00053-04 8/71

Project 11122 - Cardiovascular Center - Mercy Hospital Requested (D.C.)

Benton Harbor Fourth Year

$16,530

This project is currently supported at the $28,920 (D.C.) level. The
program was initially funded during October 1969.  One terminal year
support is requested. The project involves eight area hospitals. A
moclerqcardiac catheterization and angiography laboratory has been
established in the base hospital;  a referral clinic has been established;
a teaching program attended by 30 nurses has been com pleted with
additional courses planned; CCU units (total 20 beds) have been established
in seven of the eight participating hospitals;  a seminar was held on
"acute emergencies and their management" (attended by SO M.D.s and 25
nurses); and in a three-month period, eleven persons were resuscitated
by people trained in this program. Plans for the future are to expand
and make more effective the work that has been developed.  The project
was voted a priority listing of seven out of this total application.
It is related to Priority Category I1 - Increase the Delivery of Health
Services.

No support requested for the fifth and sixth years of operation.

Project %25 - Western Michigan Medical Education Requested (D.C.)

Program - Blodgett Memorial Hospital, Fourth Year
Grand Rapids $86,050

This project is currently supported at the $73,429 (D.C.) level.
initially funded (from carryover funds) during March 1970.

Three-years continuing support is requested.
program is to extend to physicians in smaller hospitals expert knowledge
to improve the diagnosis and treatment of the cardiac patient.
medical staff self-study methods, cardiology consultants from three
medical schools have visited ten community hospitals (total 125 visits).
The Kellogg Foundation is assisting three of the smaller hospitals in
establishing CCUs.
has made a measurable impact on the beginning of regionalization.
plans are for expanded outreach activities to include five additional
hospitals and adding new activities.
Detailed subjective and objective evaluation methods are utilized.

It was

The objective of the

Using

The project has provided reciprocal benefits and

Future

(Arteriosclerotic Heart Disease)

The 71-72 request of $86,050 includes $61,000 for personnel and $14,400
for consultants.

The project was voted a priority listing of ninth out of the total appli-
cation. It is related to Priority Category I1 - Increase the Delivery

of Health Services.

Requested (D.C.) Fifth Year Requested (D . C . ) Sixth Year

$91,550 $97,000

Michigan RMP -28- RM 00053-04 8/71

APPROVED PROJECTS NOT PREVIOUSLY F'UNDED

Project 1/27 - Comprehensive Health Care for
       the Urban Poor - Wayne County
      General Hospital (1st Year Triennium)

Requested (D.C.)
Fourth Year

$505,269

This project grew out of a planning study which was supported by
MAW from Jusle 1967 through August 1970 for $61,000.
allowed the Region time to recast the original request following the
recommendations of a technical site visit team.  The revised project
was approved during the July 1970 National Advisory Council.
In the period since this application was submitted, the Region has
rebudgeted $69,941 (D.C.) to partially support the program through
8/31/71.  The project was voted number one priority out of the total
application.
immediate health service needs of the poor in the major metropolitan
centers.

This period

It is related to the Region's highest priority -

The program is being conducted in cooperation with O.E.O., the University
of Michigan School of Public Health (for evaluation), the State Health
Department and five voluntary health associations.

The objectives are to: (1) Demonstrate increased effectiveness of
comprehensive health care compared with episodic care; (2) Improve
patient care with available health professionals and to decrease
costs by training sub-professional health workers.

Requested (D.C.) Fifth Year Requested (D.C.) Sixth Year

$454,574 $477,459

4-

Project #29 - Cooperating Stroke Center

Requested (D.C.

(1st Year Triennis)

Detroit Memorial Hospital Fourth Year

$120,530

This project was approved by the November 1970 National Advisory Council.
During the interim since this application was submitted, the Region has
rebudgeted $39,811 (D.C.) to initiate and carry the program through
8/31/71.
application and is related to the Region's second highest priority -
increase the delivery of health services.

The program adds a fourth major hospital to the Region's cooperative
stroke program. It is to operate under the cooperative guidance of the
Wayne State Stroke Base Center.  In addition to providing continuing
education for M.D.'s and paramedical personnel at Detroit Memorial, it
will provide the same service in five other community hospitals.   It

It was voted a priority rating of sixth out of the total

-29-

RM 00053-04 8/71

is to involve a specialty team, clinic facilities and a 25-bed stroke
unit at Detroit Memorial. Teaching sessions are to be conducted at
the participating hospitals.
of diagnostic procedures and evaluation criteria; will establish
screening clinics and will strive for early patient transfer to rehabi-
litation care facilities or to home.

The project will involve the establishment

Requested (D.C.) Fifth Year Requested (D. C. ) Sixth Year

$120,880 $149,690

Project #30 - Southeastern Michigan Regional Requested (D,C .I-

Cancer Prpgram - Wayne State           Fourth Year
University                  (1st Year of Triennium)

$220,720

This project was originally submitted to RMPS in January 1970.
returned for some revision. The revised application was approved, at
a reduced level, by the National Advisory Council during its-February
1971 meeting.
was voted a priority rating of fourth in the total application.
related to the Region's second highest priority - increase the delivery

It was

Currently it is not receiving any RMP funds.

The project

It is

I

of health services.

This is the Region's first cancer program.

Its objectives,in cooperation

with a model neighborhood program,  are to:

(1)
(2) Demonstrate feasibility of five small inner-city hospitals

Improve cancer patient care and hospital facilities.

utilizing one medical social worker.

To accomplish these objectives the program is planned to:

(1)

(2)
(3) Train in-service nurse educators.
(4)

Provide inservice training to physicians whom other physicians
look to for advice.
Increase existing radiation therapy capability.

Evaluate the three-year impact of these activities.

Requested (D.C.) Fifth Year

$229,433

Requesljed (D.($.) Sixth Year

$251,609

Project t31 - Model Neighborhood Comprehensive

Requested (D.C.)

Program Inc. - Community Health Fourth Year
Service Coordinators (Developed (1st Year Triennium)
by Wayne State University Staff)

$207,353

This project was approved by the National Advisory Council during its
February 1971 meeting.

During the interim, since the time this application

Michigan XMP -30- RM 00053-04 8/71

was submitted, the Region has rebudgeted $16,000 (as stipend support)
to support two trainees into the program.
priority rating of eighth in the total application.
related to the Region's highest priority -
of the poor in the major metropolitan centers.
of the project is to demonstrate, test and evaluate the use of new
personnel (Community Health Service Coordinators) who are to assist In
providing comprehensive health care services to a defined, prepaid
population.  An amount of $161,172 is requested for personnel out of
a first year request of $207,353 (D.C.).  If funded, this project would
interdigitate with Project 127 - Comprehensive Health Care for the Urban
POOL
a cooperative effort between an RMP and a %del Cities Agency.
for gradual local bakeover are described.

The project was voted a

The project is

immediate health service

The primary objective

Also, the project appears to represent an excellent example of
                                             Plans

Requested (D.C.) Fifth Year

$196,665

Requested (D.C.) Sixth Year

$196,665

NEW PROJECTS

Project #32 - Lakeside Comprehensive Health Care

Requested (D. C . )
Fourth Year
(1st Year Triennium)

for the Urban Poor - Michigan College
of Osteopathic Medicine - Zieger/
Botsford Hospitals $160,000

This proposal. requests three-year support to assist in the development
of a comprehensive health care delivery system for a low income area.
Its geographic scope will be the low income area of the city of Pontiac.
The program is a part of a cooperative effort between the MARMP, O.E.0,
CHP(b) and Vocational Rehabilitation.
operation, on a limited basis, and is funded through the Michigan State
University Department of Cdhunity Medicine, Pontiac Housing Commission
and the O.E.O. (Headstart) program.
$646,700.
share.
objectives of the program are to:

The program is presently in

The total first year budget is

An amount of $200,000 total costs is requested as MARMP's

The remainder is to be provided from other sources.

The primary

(1)
(2)

(3)
(4)

Provide an entry point into the health delivery system.
Demonstrate the value of a three-level preventive and ambulatory

Provide for continuity of care through two family practice teams.
Develop an adequate pre-payment mechanism over the three-year
period.

Frogram.

Personnel requests include a gamut of 24 full-time, three part-time
personnel (physicians to typis t/reception%sts) o

This proposal was voted a priority listing of tenth in this application.
It is related to the Region's highest priority - immediate health service
needs of the poor in the major metropolitan centers.

Requested (D.C.) Fifth Year Requested (D.C.) Sixth Year

$200,000 $200,000

Michigan RMP -31- RM 00053-04 8/71

Project 133 - Comprehensive Stroke Day Care Center

Requested (D . C. )
Fourth Year
(1st Year Triennial)

Martin Place Hospital - East

$102,356

Three-year support is requested for this new proposal which is to become
the fifth component of the MARMP stroke program.
State, Detroit General, Detroit Osteopathic, Detroit Memorial (not
funded) and Sparrow Hospital in Lansing.)

(Base center - Wayne

Martin Place Hospital-East (269 beds) and Martin Place Hospital-West
(154 beds) in Detroit have a common administration and each hospital has
a four-bed acute stroke unit.
osteopathic physicians which includes specialists in neurology,
psychyiatry, neurosurgery, vascular and cardiosurgery and internal
medicine.

They have a single medical staff of 219

The primary objective of the proposal is to reduce health care costs
and aid in the return of the stroke patient. The proposed method to
accomplish the objectives are to establish a day care center at Martin
Place Hospital-East.

The program is specifically designed to reduce the health care costs of
stroke patients and to more quickly re-integrate them in normal life.
The center, when appropriate, will strive for a "day in the hospital,
night at home" program.

A special modified bus, supported and staffed by the center, will be
used to transport patients.
complex of medical and allied services which will be individually planned
based upon the number of patient visits to the center.

Services to be provided will consist of a

The program is expected to become self-supporting through third-party
payment 8.

The proposal was voted priority listing of fifth in this application.
It is related to a program Priority Category 111 - prevention of disease
and its complications.

Requested (D.C.) Fifth Year r-

$104,000

Requested (D.C.) Sixth Year

$112,177

RMJ?S/GRB
5/27/71

I

(A Privileged Communication)

SIJWIARY OF REVIEW AND CONCLUSION OF ..

JULY 1971 REVIEW COPNITSEE
MICHIGAN KEGIONAd MEDICAL PROGRAH
     RM 00053 8/71

ONSIDERATIOS BY AUGUST 1971 ADVISORY COUNCIL

NDATION: The Review Committee recommended that the Region be

awarded $2,100,000 for each of three years including

.

onent .funds

DIRECT COSTS ONLY

igan RMP

-2-

RM 00053 8/71

   oncern was that while the Region's priorities are very well
ted, and consistent with the mission and objectives of IMPS, their
1s and objectives need t~ be expucitly stated, ip terms of being

nd related to a time frame for evaluation of proire'ss

ievement.

The reviewers learned that a 3-day retreat is planned

to accomplish this,

        The reviewers noted that four of
vities proposed for the first year of the
der its number one priority--"Immediate Health
or (both black and white) in the major metropolitan
ed areas inhabited by rural poorol'

reed that the Michigan program has demonstrated

.maturity to receive approval of a developmental

  lan or study new and innovative ideas.
  e to utilize developmental. funds to continue

as a long history of prudent use of small amounts

During

n to program priorities.

   did the site visitors, beilieved that the Region
d to continue its effarts related to the amalgamation
e subregional planning officesv

wledged that the Region's review process meets the
centralization,
ations 2nd suggcstio.ns as outlined in the site,visit

The Reviewers agreed with the site

I

doc. funds per year.

laming offices are to be considered and

6

Michigan RKP

31 00053 8/71

the $2,100,000 to ensure orderly termination of WP support,
have already been funded for three-ypr periods - Project #3 - -.- Data
Callection - Department of Public Health and Project*#4 - Coron3r.y

of Electronic Equipment, Michigan Heart Association (which has already
been renewed once); and will require termination of RIG' support for
four stroke projects and Project E26 - Continuing Education Program for
Inner-City Hospitals, Wayne State University, upon completion of the
two remaining years of Council-approved support rather than three more
years of support as requested,

Included in the recommended $2,100,000 level are funds to.initiate
project #27 - Comprehensive Health Care for the Urban Poor .. who reside
in the imiiediate area of Wayne County GEKEKZ~ Hospital,
voted this project as the number one priority activity in the total

This

action will reqcire disengagement of PX@ sa-- rrort for two projects that -

- --.

. 'I

e

Michigan Heart Association; and for Project ?/16 - Surveillance

The MARMP/PAG

application.

Dr, Hess was not present.during the discussion of this qpplication.

e

c

I

t

June 23,

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
          PUBLIC HEALTH SERVICE
HEALTH SERVICES AND MENTAL HEALTH ADMlNISTRATlON

1971

Quick Report on Michigan Regional Medical
Program Site Visit - June 9-10, 1971
                       J6

Director, RMPS
THROUGH: Acting Deputy Director .J/,,;y
degional Medical Programs Service

Site Visit Team

Alexander M. McPhedran, M.D., Chaiman
Emory University Clinic Coordinator
Atlanta, Georgia

Jack, H. Hall, M.D., Practicing Csrdiologist
Director of Medical Education
Methodist Hosyital
Indianapolis, Indiana

8

Robert W. Brrown, M.D.
Kansas Regional Medical Program
Kans3s Sity, Kansas

RMPS Staff

Jeanne L. Parks
Grants Review Branch

George Hinkle Eugene Piatek

s Manageinent Branch

Office of Program Planning

and Evaluation

Maurice Ryan
Regional Representative

n Education and Training Branch

isitors identified several areas of concern, but were in agreement

RW is an energetic, effective Region with a well directed

group of people who have developed maturity in the decision-making process

in developing a program to solve health care problems.

The visitors

particularly impressed with the strength and competence demonstrated

by the small, but cohesive central core staff and its capability in
  ing excellent leadership and direction to the program.

gional Advisory Group vhich represents many of the health interests
state and a wide geograThic area is quite effectively carrying
s responsibilities; it clearly demonstrated to the visitors that

it is a strong arm of the MAW; and it is in control over the review
and planning process of the Region.

c

Page 2 - Director, RMPS

Through the activities of the Regional Advisory Group and its technical
review cominittees, the Region apparently has engaged the interest of
many physicians and osteopaths in the State and has involved the
activities of the three medical  schools and an emerging School of
Osteopathy.
the community and county hospitals. However, there was little evidence

It has also gained cooperative arrangements with some of

ive roles or involvexent of the nursing or other health professions.

The Region has also made psitive efforts toward shifting program planning
and development from the earlier focus on the categorical diseases to
attacking problems of the health care delivery system, as evidenced by
the request for funds to support project #27 - Comprehensive Health Care
for the Urban Poor, Wayne County Hospital, which is related to the Region's

highest priority - immediate health service needs of the pooy in the major

-.

olitan centers.

   gion's priorities are very well stated and are consistent,  if not
congruent, with the mission and objectives of RMP.  The visitors expressed
concern, however, that the Region had not given sufficient attention to
explicitly stating program goals and objectives that might be quantifiable
and related to a time frame for evaluation of progress and achi.evement.
The visitors believed that the Region tras well aware of the need for
specificity in program goals and objectives and were advised that this

receive major attention during a 3-day retreat to be held in the

   uture. The need for an identifiable process in the area of
evaluation vas another concern of the site visit team and was discussed
at great length with representatives of the Region,
be a somewhat sensitive matter, but the visitors got the impression
that the Region is searching for ways to carry out its evaluation process,

This appeared to

ajor concern was the impending resignation of the present program
  rdinator, and what effect this would have on the present program.
The team realized that funding levels to be recommended for the next

3-year period would be administered under new leadership,
visitors met with the search committee and were advised that currently
four qualified applications are being considered.
advised that, members of the committee believed that at this point
in time, the MARY' is mature enough and so structured as to enable
a new coordinator to assume and carry out the mission of the program
without interruption.

The Region is currently funded for its third operational year, through

The site

The team ins also

.

, for $1,898,936 (d.c.).
ion has reiuested $3,338,631 direct cost for its 4th year;

$3,322,516 for its 5th year; and $3,328,229 for its 6th year.  The
site visitors recommend approval of the triennial application at a

\ /

Page 3 - Director, R@S

level of $2,100,000 for each of the three years.
believe that this level will enable the Region to:

The site visitors

Support a developmental component.

Continue core activities at their current level.  All
subregional planning offices are to be considered and
supported as a part of c3re activity.

Provide sufficient funding to support all projects which
have been rated as the Region's top ten priority activities.

Provide funding to renew project #25 - Cdntinuing Medical
Education .

#

I

The site visitors do n2t recommend renewal funding for the other projects
beyond the approved support period.
allowed to allocate one year funding from xithin the $2,100,000 to ensure
orderly terrninetion of R!l' support.
of @P suppgri; or ti73 projects that have already been funded for thrze-

and Project #4 - -- Coronary Care - Michigan Heart Association; and for
Project #16 - Surveillance of Electranic --- Equipment, Michigan Heart
Association (which has al-ready been renewed 's; and will require
termination of E@ supFort for four stroke
Continuing Education Pmgram for Inner-City Hospia, Wayne State
University, upon completion of the tvo remaining years of Council T

However, the Region should be

This acti on vil-1 rzquire idisengegenEnt

eriods - Project #3 - Dsta Collection - Department of Public Health

projects and Project #26 -

approved support in lieu of three more years

support as requested.

,' /--"-I

  Jeanne
i/: Public
Grants

Health Advisor
Review Branch

\

A P 1' ivi 1 cg, ed Cormuni c at ion

The first day of the meeting was held at  the
Hospitality House, East I,r?nsinz. The, second
day, the group met in the Council Room at the

Piichigan .State Medical Society in East Lansing,

Table of Contents

I. Site Visit Partixipants ........................... 1

IT.. Introduction ...................................... 5

111. Conclusions and General Impressions ............... 5

IV. Review Details .................................... 7

V. Rationale for Funding Recommendation .............. 14

. VI. Summary of Suggestions and Recommendations

of the Site Visit Team ...........................

16

VII.

Recapitulation in Terms of ILVS Mission

Statement and Reviev Criteria ................... I7

lvlichigan Site Visit

-1-

WA 00053

B.

C.

D.

E.

Alexanckr 1%. McPhedran, M. D. - Chairman
Emory Univer s i t y C 1 iriic
At 1 ant a Georgia

Robert Id. Brown, M.D.
Consultant
Coorcll nator , Kansas Reglonal Medical Program
Kansas City, Rmsas

Jack H. Hall, K.D. -
Cons u 1 tan t
Methocll: st Ho:;pital
Indiana.polis, Indiana

George Hiiikles Cranes Management Eranch
Joseph .leitiel 1 Grants Revie:J Bral-Lch
bliss Elsa Wt:1soti, Continuing Education and 'Training Branch
Mrs. Jeanne Parks Grants Review Branch
Eugene Piatck, Ofiice of Program Planning and Evaluation
Maurice C . Ryan, Regional Office Representative




Albert E. Heustis, M.D, Coordinator
Gaetane 15. Lorocque , Ph. D. , As coc istc Coordinator
Theodore ,Lopushinsky, Ph .D. , Program Representative
Martin I, Pastor, Assistant Prograin Coordinator for Finance
David E. Eaton, Field Representative

Sub-Regional 'I'lannhg Off$ c-e Dj rectors

/I

Leonard Cohen, Ph,D. Zieger/Botsford ILospirals
Dr. Gcorgc Suhrland and Mr. Jim Lyons, Michigan State University
Mr. Ralph Lewis, University of Michigan
Mr. Marvin Meltzer, Wayne State University

Rep r e s en t a t ive s o f the M ic h i an Reg i 02-

Regional Advisory Group Members ,

Dr. Michael J. Brennan, Chairman, MRMPIRIIC Michigan Cancer Foundation
4811 John R. Detroit, Michigan, 48201 (Michigan Cancer Foundation)

Miss Verna 30 Astley, R.N., Director of Nursing Service,
Butterworth Hospital 100 Michigan, N.E., Gd. Rapids, Michigan 49503
(Michigan Nurscs Associatkxi)

Michigan Site Visit -2- IIM 00053

Dr. Bernard Eercu, Wayrie State University, Detroit, Michigan

Dr. Gerald 11. Bonnette, Professor of Oral Surgery, School of

Dentistry, Unlversity of I\lichi.gan: Ann Arbor, Michigm 48104
(Michigan State Dental Associati-on)

I

Mr. Harold 17, Eyers, Director, Vetersns Administration TIospital.,

2215 Fuller Road, Ann Arbor, tfichigan 48 LO5 (Vcterans Hospital)

9: Dr. Dorothy Carnegie, 840 E. Eft. Hope, Lansing, Michigan 48910
(Michigan Association of Osteopathic Physicians and Surgcons)
( Presidartt, Board of Directors, I.il.ir;L.la)

* Dr, Ethelene Crockett, 1327 Nicolet Place, Detroit, Michigan 48207

. (KO 1 ver ine Kedi c a 1 S oc i e t y )

* Dr. John Gronvall , Dean Piecllcal. Scliool, University of Nfchigan,

1335 Catherhe St., Ann Arbor, MLchigan 48104 (University of Michigan)

Dr. Bonta liiscoe, 2909 E. Grand River, Lansing, Michigan

(Michigan State Medical Society)

* Dr. Andrew D. Hunt, Jr., College of Human I*fedicine, 103 Giltner Hall,

Michigan State University, East Lansi-ng, Miclil sari 48823
(MLchigaa State University)

* Mr. Tt'illiam S. McNary, Exec. Eir., Comp. Health Planning Council of

Southeastern IJLicXigan, 921 Penobscot Cuildirrp,, Detroit, Michigan 48226
(Southca t Geographic krea)

Dr. Reuben lk.yer, Head of Cormnuriity Medicine, Wayne State University

Detroit, Michigan (14Jayne State University)

Dr. John C. Peirce, St. Mary's Hospital, 201 Lafayette, S,E.,
                (West Central Geographic Area)

Grand Rapids, Ffichigan 43503

Mr. Ronald Yaw (Former RAG Member), Rlodgett Memorial HospLtal,

1840 Wealthy St. , Grand Rapids, Piichi.gan 49506 (Michigan Hospital Assoc.)

* Dr. Allan Zieger, Eotsford General Hospital, 28050 Grand River Ave.,

Farmington, Hichigan 48024 (Michigan Osteopathic Hospital Assoc.)

Mr. Victor Zink, Directorj Personnel Research Section, General

Motors, General Motors Bldg., Detroit, Michigan (Public-at-Large)

* Dr. R. Gerald Rice, Chief, Bureau of Maternal and Chief Health,

Michigan Department of Public Health, 252 IIoIlister Bldg. , .
Lansing, Michigan 48914

(Michigan Department of Public Health)

4 Members, .Board of Directors, Michigan Association Regional Medical Programs

e

Piichigan Site Visit -3- P\M 00053

P r o f e s s i ona 1 kd w 1. so 7-~qmr312

-..-----*_

Dr. Harold I3oimanY Chairn.;iil, Dcpa-t-rnent of Pat-Iiology, St. Mary's Hospital,

201 Lafnyette S .E. , Gd. Rapids, Michigan 43503 (Chnirn:.rul. of: Cancer PAC)

Dr. Robert P. Locey, Chairman, Proj. Director, Pri!n::ry Care Study,

517 Ship St.y Room 4, St. Joseph, I4ichigan (Chairman oE Ambulatory Care PAC)

Dr. Yoshikazti Mori.ta, 3535 W. 13 llile Kd., Royal Oak, Michigan 48072

(Chairman of I<Fdney PLC)

Elr. Irvin Nichols, Michigan TI3 and Respirztory Disease Association,

403 Seymour, Laisiilg, Michigan (Kember of Chronic Respiratory Disease PAC)

Mr . Abralmn Iliriclcner Executive Director, MLch.tga~i Heart Association,
16310 W. Twelve $file Road, PO Eo,: LV-160, Southfield, Michigan 48076

Elr . Ted Ervin , Chief, Bureau of llanagernent Services , Miclii gan Depar tmeiit

of Public Health, 3500 N. Logan St. LansiL1g, Michigan

Dr. Stuart IIarkness, Detroit OsteopathFc Hospital, 12523 Third hve.,

Hi.g:hland Park, Piichigan 423203

Dr. James Boward, Director of Hea-lth Care Planning and Professor of

Community' Medicine, Kichigan Col Lege of Osteopathic Ffedicine ,
900 Auburn Road, Poiitiac, Michignn 48057

0

Dr. Robert Lewis , Chief, Center for Health Statistics, Department of

Public Health, 3500 N. Logan, Lansing, Michigan 48914

Dr .


Dr .


Mr .

PO


Mr .

Cooper , Comprehensive Health Planning "13" Agency , Bangor, Michigan

Dorain, Blodgett Menorial Hospital Grand Rapids, Michigan

Lacy, Michigan Heart Association, 16310 W. Twelve Mile Road,
Box LV-160, Southfield, Michigan 48076

u

Andrew Pattullo, Kellogg Foundation, Eattle Creek, Michigan

Miss E. Peterson, Michigan Heart Association, 16310 W. Twelve Mile Road,

PO Box LV-160, Southfield, Nichigan 48076

Dr. L. Rentz, Detroit Osteopathic Hospital, Detroit, Michigan

Miss Reynolds, Elichigan Heart Association, 16310 TJ. Twelve Mile Road,
PO Rox LV-160, Southfield, Michigan 48076

Miss Geraldine Skinner, School of Nursing; University of Michigan ,

Ann Arbor, Michigan

e

Michigan Site Visit

-4-

RM 00053

Miss Joan Wallace, Wayne State University, Detroit, l\'iichigan
Dr . Melvin Reed, Wayne State Urriverslty, Detroit, Michigan

e

Dr, Frank Bunker, Mercy Hospital , Bcnton IIarbor, Michieart
Dr . S . Katz , Michigan State University, East Lansing , Michigan
Dr. W. Livingston, Wayne State University, Detroit, Michigan
Mr. Ted Martin, Wayne State University, Detroit, Michigan

Mr. Oliver Wendt, IILchigzn Kcart Association, 16310 W. Twelve Mile Road,

S out h f ie 1- d , El. chi g an 4 8 07 6

Dr . Coppula, lvlictiigan Statc University, East Lansing , Michigan 48823
Dr. Maurice Reizen, Djrector, Michigan Department: of Public Health,

3500 N. Logan St. Lansing, Michigan

Michigan Site Visit -5- RM 00053

INTRODUCT LON

11- -__I--

e The site visit was conducted iolloving suliid.ssion of the Michigan PWP's

application for three years of continued funding. On August 31, 1971 the
Region will have completed its iniLial 3-year operat ioAal prxiod.

Under the new anniversary and award systretli, the purposes of the site
visit were to: 1) review the Region's ovcrali progrcss; 2) to exainine
in depth the experience and acliievements oi the ongoing program;
3) how this experience has (or will) uiodi fy prograili goals, objectives
and pri.orities; it.) to consider the Rcgicn's prospects foi- the next three
years and 5) then to arrive at it funding rcconrr:,cridal.ion based GTJ the
intrinsic qualities of the program.  The Lealri met the even in:; before the
meeting began and, based on tlte writtcn information prcvidcd, agreed that
the f4fchl gan Regional Medical Program appGrei1tl.y hnd already reached a
point of self-determination and deci!:kon-rcalting capdbili 1 ics that should
permit them to have an established amount of money and to develop priorities
in the spending of these funds according io the local needs.

111.

The site visitors were in unanimous agreement that %he PIARMP is a viable
region,  and that it is doing an extremely effectfve job with a sophisticated
awareness of the aims of the Regional Eledical Prog,rmi and have fostered
exemplary cooperative arrangerncnt s in virtually cvcry conceivable way as
opportunity has allowed to dischargc its res~ionslbilitics .  In addition,
the team was satisfied that there is adequate evi dcncc of rcgionnlization,
with ex tens ive co opcr at ion with other c orimun i ty pro f't. s s ional  and cons mer

groups; and that the MAKXf' has a high level of competency and dedication
in its operation. The team believed that thc ful.CF1lment of the National
aims of tlie Reginnal Medical Programs is being developed to a high degree
of excellence in Hichigan.

CONCLUSIOKS AND CEhTXL ---.---------- IMPRESSIOK3 -

Based on the various coments made by the broad variety of people who
represented the Region,  it was the opinion of members of t,he site visit
team that this Regional Medical Program is already having a major impact
in the improvement of the entire health care system in the State of Michigan.
The team was impressed with the Region's singular determination to improve
the health care of the people in Michigan and believed that
as the vehicle to do so.

is evolving

The visitors were particularly impressed with the strength and competence
demonstrated by the small, but cohesive central core staff and its capability
in providing excellent leadership and direction to the program.

The Regional Advisory Group,which represents many of the health interests
in the State and a wide geographic area,is quite effectively carrying out
its responsibilities; it clearly demonstrated to thc visitors Chat it is a
strong arm of the MAIIMP; and it is in .control over the review and planning

process of the Region.

e

Michigan Site Visit -6- I34 00053

Through the activitirs of thc Regional Advisory Group and its t.cchnical
review cormtit tees, tlie Region has at tric tcd the in1 pres t and encouraged
the activc parricipation of both the ailopathic and ostcopatllic physicians
in the State. It lias a1 so involved the nctivities o ttic three mdical
schools and an e:ncri;jng School of Osteopathy. It has also gained
cooperative arraizgernmts with many of the comnunity and county hospitals.
While there was little evidence of activL. roles i)r irivolveirrent of the
nursinz or other health professions ,the rt?i>lon recently
employed a full-time nurse consultant r.~lzo is to be based at Eerris
State College, Big Rcrpids, Michigan. The Region has also made postive
efforts toward shifting program planning and development front 1-he earl ier
focus on the catesorical diseases to attacking problcnrs of the health
care delivery system, as evideilced by the request for funds to support

project #27 - ~:;~x>J!~Rs ive I~~~-~h-~~~~~~-~~~-.~~~~~~~~~~~Q~,
County Ilospital, which is related to tlie iegion's 1i;i;liest priori ty -
imcdiate health service needs of the poor in the major metropolitan
centers.

'

Nayiic

The Region's priorities are very well stated and are consistent, if not
congruent I with the mission and objectives of FJWS. The visitors expressed
concern, however, titat the Regi on had not given sufficient attention to
explicitly stating program goals and objectives that might be quantifiable
and related to a time frarile for evaluation of progress and achievemcnt.
The visitors believed that the Region 1.7~~ well aware of the need for
specificity in program goals and objectixrcs and were advised that this
was the major topic to be discussed dusitrZ a planned, 3-dey retreat to
bc held during August 1971. The need for an idcntifiable process in tlie
area of evaluation was another concern of the site visit team and
discussed at great length with representatives of the Region. This
appeared to be a somewhat sensitive matter, but the visitors got the
impression that the Region is searching for ways to carry out its evaluation
process.

A major concern was the impending resignation of the present program
coordinator, and what effect this would have on the present program.
The team realized that funding levels to be recoinmended for the next
3-year period would be administered under 'new leadership.
met with the search cor'mittee and were advised that currently, four
qualified applicants are bei-iig considered.
that, members of the cormittee believed that at this point in time, -t&
KAIWP is mature enough and so structured q-GLenable a new coo?--dinator
to assii~~e and carry out the mission of tlie proGmkitliout i.errnption.

The site visitors

The team was also advised

Michigan Site Visft

-7-

RFI 00053

IV. REVfP\;I DCTATT,S -____-

A. Goal s O?ijec Lives ad Pr ior3 tics

-- _------ ..- -

e --

The Regional kdvicoi-y Group adopted the present pr.og3-a~~ priorities during
March 1970. Five major healch priorities were adopted which appcar to be
sulistantivcly cocnd aid addre:;.; the Reg loll's iilnjor houlth needs.
example, the first highest priority aiid its rclated objfActivc is "to
improvc the imwiliate health service nceds of the poor (both black and
white) in the major metropolit-an ce:iters 2nd ii: desigiioted areas inhabited
by rural poor." IIovcver, Lhc: Kegion's objwLivcs a~id goal arc not
specific in term of beiiig yuantifiablch ~1or in 3.cfcrcnce to a time frame
for evaluation of progress and achievement. The site visit-ors \(acre
advised that the Region was alreLdy airare of the necd Lo strengthen its
goals and ob jec tivtxs and have, in fact, sclieduLet1 a thrce-day retreat
wliic'n will be directed prlciari ly to idwt-ify sp'ccific ~OG~S and olijectives
related to the priorities and with a propG:,ed the frame. The site
visitors realized that when this applicgtion was in preparation, the
national health goals and priorities had yet to be aimouriced .

For

Mcrnbers of the site visit team cormended the Region on its oresightedness
and wre impressed that the ReZion recognized the necessity for establishing
r e a son ab 1 e t ime - ptia s cd go a1 s  Io r the i rilp 1 fiiiicii t a t io ti o f the e s t ai:, 1 i sh ed
priorities and for the establistment for syecific criteria by which the
process and the ac.complishment will be inzasurcd.

Representatives of the Region cited cxariyl es of how it plans to implement
the newly approved prozram strategics and its priori ties through the use
of developmental funds. Specific ideas wcrc cited to implement actions
suggested by the Professional Advisory Courzcils as most important in
improving the availability of quality hezlth care service. For example,
the securing of improvement o the care of pat-icnts with the four selected
malignancies (hodglcins disease, carcinoma of the ccrvix, carcinoma of the
uterus and carcinoma of the breast) selected by the Cancer Professional
Advisory Council as being thosc in which the health of the people of the
State would have the greatest chance of improvement through the application
of existing knowledge. In addition, the developmental funds, could be
used to quickly respond to new request within the Region's top three
"program priorities"; in seeking ways to extend the process of regionalization
to the northern pzrt of Michigan's lower pcninsu1.a and to Michigan's
northern peninsula; in supplementing University efforts by promoting the
linking of larger cormunity hospitals arid their stnfs to satellite
institutions; in facilitating the callaborative workjng together of the
four university medical schools in improving the accessibility and
availability of health services. in accordance with I4ARHP priorities;  and
in working with those who are interested and able to improve the effectiveness
of existtng health professionals and health-care services.

B. Organizational Effectiveness

It was obvious that the EIARMP is made up of a wc~l 1 -directed groiip of

e people who have developed maturity in the decision-making proccss and

Nichigan Site Visit -8- Pa 00053

e

e

e

in developing a program to solve hea,l_th care problems.
the MG alonz wFtli the entire Board of Di.rwtors were quite candid in
accredi ting the siiccc!ss of impleneritlnS the lkgion's program to the firm
and adroit leadership of the Prograx Coordinnfor who has been successful
in leading the Region "out of the wilderness". Re is supported by an .
extremely small central core staff r.hFch is composed of 5 professionals,
highly capable and well-qualified individuals e
in June 1967 I the. Region hcts provided. support to four subregional
planning offices locatecl in the three medical schools and selected
os teopathic hospitals.
supported as separate operationa~ projec.ts, mel!;ixrs of RNP staff of the
various ins titutions 17ere quick to addt that they vere in reality,
performing ftlnctioris as extensions of core in their vsrioris institutions.
Accepting this, the site visitors belfcved that the Core staff of the
PLegLon is actually composed of a brond raiige of both professional and
d.iscip1.ine competence. The group of people who are working in the
medical schools and their affil.iated reaching hospitals provide the
necessary credentials and are necessary and critical (considerin.g that
the Program Coordinator has a Public Kcalth background) to capture the
interest and support of academicians involved in the Region's program
activities. In order to provide the RE~~OJI with nore fl.exibility in its
core component, the site visFto1rs recc:lmeilded that an agreement be
established whereby specific "core f~nctfons" which are to be carried
out in the subregional planning offices are identified mder the core
budget allocation rsther than as separate oper:!.tionai projects which
is their current method of listirig theilt i.n the app1.icati.nn. It was the
opi.nion of the site visitors that this recon::s?endation vi1.1 serve to
separate core activities from operational  activities while at the same
time allowi.ng additional financial flexibility in the core component.

The chairrran og

Since it!$ inception

:Jhile the subregLona1 pl-mning offices have been

The site visitors believed that the administrative functions and services
provided by the grantee organization i-n this Region is commendable and
perhaps could be used as a model for other regional medical programs.
The grantee agency is a not-for-profit independent corporation which
requests no direct costs.

The' local review process in the Michigan Region was considered to be of
excellent quality. Since the Region iias establlshed, they have had one
application which was riot approved at the federal level, n'uclear Medicine
v Teclin-ician Trainir*p, Pros=.
prepared, Council established its policy with reference to support for
this type of training.

During the time that application was being

Also, down through the years, approximately one half of project proposals
which have been presented to the local review groups have received negative
actions. The "not recoomendcd" are not confincd to any one disease or
area of health care but rather cover a broad spectrum of both categorical
and other types of proposals.

The MARMP/RAG currently is a 35-member body. OE this total, 5 are female,
3 arc black. It. was interecting to the Lcm tli:it 17 members attended Ehe
site visit meeting. AI SG, the corporation by-latis restrict consumer

Michigan Site Visit -9- RM 00053

representatives to six. IJhile these positions arc all currently filled,
the Region out1 iried its past, alniost futile efforts to locate consumers
(with a small "c") who could or ~rould malic a contribution to the I?egFon's
program.

e

The site visitors spent quite a bit of time in trying  to determine the
involvement of the CTIP agencies and tlw Rli4P. The "A" ogcncy is presently
located in the Goveri2or (E office where It is allocatrd a very low priority.
The team was advised that any progress which had been achievcd with the
five funded ''fir' ageKJcies in the state has becn made on a direcr relation-
ship basis  and has been made in spite of the ''A1' agency arid not because
of it.  The CIZP in the Detroit area where, oric--half of the Region's
po'pulation reside in a three-coiint~7 area was described as a "mess !I'
While the Region currently has five funded CilP "E" Agencies, wlth minor
exception, the NP is, in fact, carry-Lng 0u.r z'i least the CZIP "A" agency
mission throilghout the State, partially by default. It is FMRMP's inrent
to support the ultimcite development of a strcrig Michigan CHP "A" agency
at which time they will assume a Tilore appropriate role for an He.
Repeating for emphasis, it was obvious from the variety of talent present
during the meeting that the Region has involved the activities of tile
thee major schools of medicine and an ewrgin:, school of osteopathy.
It has gaincd cooperative arrangem~n~s between tlicsc schools; between the
os teopatliic nidi cal proiessiori and the allopathic medical profession;
is working with both comaunity hospital s and county hospitals;  and
voluntary agencies, consrimer and co~~i~it~lllty groups, The Rc&i.on indicated
that it had lost some of its early categorical- supporters in its in-
sistence on program activities which did involve regional resources
rather than single investigator institution-type activities.

The Region is currently actively involved in coordinative and col-labora-
tive efforts in the Detroit area (for example, assisting in an emerging
Model Cities H.M. O.), with the Saginaw Hospital organization (a corporation),
and with related health and planning programs in Grand Rapids, Fl..int,
Lansing and Pontiac.

The team noted that with the possible except-ion of the currently funded
coronary care program, the Region did not appear to be placing any great
emphasis on involving the nursing and allied health professions.
However, indications are that nursing has played an active role in the
development and conduct of the M4TNP program. Allied health is a major
consideration in the development of programs tro meet Michigan health
needs. Conversely, the ability of the osteopathic physician (2,000 in
Michigan) to work with the medical doctor in solving health problems
throughout the state was amply demonstrated. In fact, and partially as
a result of RMI' involvement, hospital privileges are being exchanged.
The team believed that almost anyone who is anything in the provision of
or the planning for health services in lower Mlchigan has had some exposure
to the Regional Medical Program, the Region is prc:scntly making a concerted
effort to extend the availability and the types of specialty health care
needed in the upper portions of the lower pennlnsula, Traverse City,

Mchigan Site Visit - 1.0- R1.I 00053

Grayling and points itorth. Incidentally, this area contains a iiumber

e of remote Indim populat-ion areas

However, these arc di scretc f-rom rescrvaLio;i--hype Indian sc_ttlemci~ts a
Previously, because of limitations within el:e V, A. hospital system,
there has beer! littl c iorrnal relationship bctween thc V. A. hospit-ols
and W42flP. I:oit.ever, wi.th recent revised a1 lowances wicliin the V. h.
medical system, this is now being looked at or future incorporalion
as a resource toward responding to local health nceds in selected
nedical scarcity areas.

Also, the visitors leaned of the Regions beginning efforts to provide
improvement in rural health care in scwe of tile Re~ions 63 counties, three
fourths of which are considered rural. The Flichlk;an Sezte University
Subregional Planning Office is currently working in Casu County and
the two counties surrounding it (total pop:ilati.on - 250,000) to wtablish
an II.1iI.O. without prepayment type activity. The progrcmi is funded
conjointly with $125,000 of migranl health funds, $93,000 of CRP 314 e
funds plus a public health service donated building. The university is
to be responsible for the evaluation and appraisal of the total progrsm.

D.

Assessment of Necd,~ Problem and R~s?i~r$~

---I___-

The State of Michila is believed to have one of the best and most
complete data collections cystens. Although fucds lime cone irom a
variety of sources, t-he initiating and prircary source of funding has
been the p.z4PXP.

The data collection efforts are now concentrating on demonstrating the
utilFzation of data that has been generated in six defined localities -
Detroit, Adrian, Flint-Genesee County, Grand Rapids I Lansing and Muskeegan.

Members of the site visit team were inFormcd that the data generated is
being utilized to a large extent by the Region through its various study
groups , the Professional Advisory Councils, Pro jcct Kevi ew Committees ,
the Regional Advisory Group and a number of other agencics in the state,
in establishing and changing the goals, objectives arid priorities as they
relate to the health care needs of the Region.

The visitors heard reports from representatives of the Region on the
types of data which has collected and how this information is being
utilized by the various groups in the Region.  The data which has been
collected provides iniormation on health care and health needs  the
availability of health manpower and data on the extent and manner of
how various kinds of health services are being met in the State.

Representatives of the Region indicated that
collected to date was the data on Detroit which provided a current
picture of the deterioration going on in the'area, population shffts,
shifts in social and medical needs etc. It was pointed out that while
this kind of data is nor particularly attrnctivc! to thc politicians it

e serves to answer crritical questions regardf ng the program required to

the most significant data

M-ichigan Site Visit

-11-

KM 00053

e answer the health and social nccds of a corrinirliity. In addition, it

has played a major role in obtainir,i; funds from the Department of
IIousing and Urban Development for t-lie developnen t of a >:ode1 Citj-es
Neighborhood Heal th Center  in Detroit

Although the site visitors believed that ttic data collection systc.,n is
necessary and is providing useful ii1formztio;l they also believed that
those individuals or agencies reqEesting information provided by the
health d2tn system, should be responsible for supportin2 it. The
representatives of the ProTessional Advisory Cormc i Is which are advisory
tu the RAG and also serve as review bodies lime been extremely effective
in assessing the needs and problems of t.I:e KcZion relative to their
particular specialty area. They have been xtively establishing goals
and objectives bascd on what is needed to upgrade the quality of care
being provided in their respective arcas. In addition, it was reported
that an "articulated set" of written guid~line and reports are in fhnal
stages of development relative to PWP effort:; in specific areas. For
example, a guideline establishing rniniinura criteria for the early
detection, treatment aid diagnosis of cancer-, is Eci~ig developed;
a Regional Cooperative Stroke Educatjon Progrsa; Hea~t Dl sease Program
Guideline; Guideline for the Preparation and E;cvieir of Proposals Cor
Ed uc a ti on a 1  p r og ZT am: ; 1% op os ed Clir on i c Rc s p ir ;1 tory I) 1. s e as c Pr ogr am P 1 an ;

and Charge to the Professional Advi sory Coiincfl on Ambulatory Care.

E.

Program T,mpxln-en,tation and Acccnpl ir,Firnents_

As previously stated in this report, the site visitors believed the Core
staff to be rather Sifiall in size but appears to be composed of highly
capable and well -qualified individuals. It was agreed that, for the
most part, the TMP assigned core type personnel in the Piedical schools
and ZiegerlBotsford Eospitals have, or will in the near future, "turn the
corner" and become more intirnately involved in working tovard MkP3fP
priorities, goals and objectives. A case in point is Michigan State
University. Due to a number of internal organizational type problems I. e.,
placement of lW activities in the school, faclc of new innovative approach,
and' the normal growing pains of a new consolidated total IIealth Science
school, the ff&1'3?P/PdG disapproved the institution's request for continued
funding. I4.S .U. has been supported since the Region was established.
In turning down the PfSU Subregional Office continuation application, it
was the FAG'S intent to reorient the MSU effort toward the problems of
rural health care and through using PISU's existing strengths as a land
grant school, with an extension service, to begin to answer some of those
very pressing problems of rural Michigan.

The area discussed by the RAG in which it was believed that PISU could
best use its vast and unique resouces in making a real and needed con-
tribution to improved health care of Michigan was "Iiow can high quality
care be delivered to the sural poor?" (This was not seen as precluding
the University's responding to for irzstance, a specific request for
help from ttrz wdcl citics are23 withiri thclr geographic area of intcrest.)

e Within this broad theme it was believed that E.ISU could provide real

Michigan Site Visit -12- KM 00053

leadership in looking at the process of sccwing coimiiunity invo1.vcment
and particJpation within specific areas, in lookin,"; at ilecds and TCSOUTC~S,
atrd in assisting with the establislirilent of a sys tern of "Comprehensive
Health Care which wm1.d be accept able to both providers and coixsumers.
It was envisioned that the College of IItmmi licdicine and other University
resources might then develop prograins to support this rather than the

"vice-versa emphasis" seen in tbc past activities.

~

A good portion of the cite visitors time was used In hea:-'iug testinony
of how the collective core staffs had tried, scmetirric successfully, to
coordinate xi.th CHP azencies througLout thc states. The visitors also
learned the Kegion 17~s involved in establishing and irnpl eaenting programs
wFth several other egencies such PS housing Lcmiljssioris, 0.E.O. Hodel
Cities, State Official and voluntzry heal til agencies. 3'wo examples of
these kinds of program activities are the Wayne County Central IIospital -
Coqxchensi E ."- Care for .I_y.-- the I---d-- Urbm 1'00~ Project (related to 0. E. 0. )
which is currently ~1,proved - unIu~i,ded aiid .sz_alic'..S;;cleCf!!il_r,rPhenr;~vc Heal th
-. Care for the --- Poor which is a new proposal,  iii a housiii;; project in
Pontjnc, Michigan. The latter program, if approved, is to be a con-
joint activity which is related to O.E.O., CffP (b) and SRS (Voc<?tional
Rchabi 1 it a tion) .

The site visitors noted that the Eegion is currently requesting continlied
renewal or new support of 16 pure operatioxal prograifis arid a developiner~tal
component. Four of 16 projects arc- essentially Tor stroke patierit -
service type prograius.  It was noted that the 4 stroke projects had
two remaining years of council approval, Tile appl icafioiz contained
a request for one addit3.anal year of support beyond Council approval.
The team recomicnds that these 4 prograins be continued for the two-year
approved period but that the request for 1 year renewal- be denied.

F. Evaluation

The suggestion of the- site visit team, during the feedback session, that
the Region add an evaluator to the coi-e staff, proved to be a sensitive

. point with the Region. It was pointed out by the Coordinator that
Dr. Larocque, the full-time Associate Coordinator, has both the
academic background and the experience credentials necessary to provide
leadership in this area and it is the Iicgion's belief that individuals
must be employed and then given as much in-service education as possible
to strengthen their skills. The Region also pointed out to the visitors
that they have a close association with Dr. George Elillerrs evaluation
workshops, The Region has also encouraged the use of evaluative expertise,
and strength which are available from the universities, such as,
Dr. Jason Hilliard, Dr. Katz, and others. However, it was reported that

the tremendous demands on these individuals time. The Region also rein-
forced the fact that there is a nation-wide shortage of persons qualified
to do evaluation. In addition, the cost of conducting ideal evaluation

* there were difficulties in utilizing the services available because of

-

was'discussed and whether an N4P could afford such costs.
gave an exaiiip3.e of a project with a total mst of $C7,CCO b$hich wzs

Dr. Larocque

t4icliigan Site Visit

.13-

REI 00053

submitted to one of the universities for an esti.mate of the cost of
evaluating the activity.

The pri-ce quoted was $iOO,OOO.

It was obvious to the menhers of thc Learn that the monitoring and
surswilliance of all activities is good. This opinion results from the
performance uf the Core staff, the many Professional Advisory Councils,
the study groups, and especially the Regional Adlvisory Croup.
present evaluation strategy begins t7Fth the conception of an idea wliicli
while it may be considered adequate, is not idc%al. For example,
sufficient "evaluation handles" arc incorporated into cacti proposal to
allow the Region at any given time to extrapolale what is needed, what
will be done, Ly whzn and possibly by who:n. 'iiici site visitors recomiciided
that with ehe incre&sed akttention now being giw~ to evaluative erforts
at the DXIEN & ?L14UA levels t1xa.t a more syste:natLc evaluation system would
be in order. The need was seen to sl rezgth2.n the evaluation capabilities
~4 the Region which may fake the form of additiionzl staff assistance.
ThLs would serve to provide and give potential and prospective partici-
pants in the WXtP aid in the development of more specific program ob-
jectives and more specific evaluation criteria c?nd methods. It was
later learned that this recoomendation is in line with the triennial
plans for the Region. ?he recent addition of Theodore Lopuskinsky, P1i.D. ,
who is a full-time Core staff member, oray lead to more effcc.tive planning
and evaluation in the future.

The Region's

Mi.chFgan Site Visit -14- RM 00053

discussions and tlic rcspouscs to qtlcstloiis posed to rcprescntatives
of the FIFcliigan Rc(:ional Nediczl Prograni, the site visitors judged
tliis Region to have achievcd a very high level of organizational. and
program strength rind maturity.
experiences (combined witti its futrirc pizns) in the prudent use of
small amounts of funds for the plannjng, promotLon arid "sect1 Ing" of
new ideas and concc?pts, the team bel ieves that a devclopinciital component
should be approved for this I).eglon.

E-scd on the Region's successful past

The Region is current1 y funded for its third operatlonal year, through
8/31/71 for $1,898,936 (d.c.).

The Region has requestied $3,338,631 dijqcct cost or its 4th year;
$3,322,516 for its 5th year; and $3,328,220 for Lts 6th year.

The site visitors reconmend approval of the triennial application at a
level. of $2,100,090 for each of the three years.
believe that this level will enable the Region to:

The site visitors

a) Support a developmental component

b) Continue core activities at the3-r current le~rel All
  subregFonal planning offices  are to be considered and
  supported as a part of core activity.

0

c) Provi.de sufficient funding to support all projects which

have been raced as the Region's top ten priority activities.

d)

Provide funding to renew project 1/25 - Continu5ng Medical
Education. ..-

The site visitors do not recorninend renewal funding for The other projects
beyond the approved support period. Ilomiver, the Kcgion should be
allowed to allocate one year funding from wit-hin the $2,100,000 to ensure
orderly termination of W support- This action will require disengagetnent
of WiP support for two projects that have already been funded for three-
year periods - Project #3 - Data Collection - Department of Public Health
and Project 1'4 - =?nary Car% - Michigzn Heart Association;  and for
Project #16 - ~xil.1ance of Elec;ron_J_-~~~guLpment, 'I\Iichigan Heart
Association (which has already been renewed once) ; and will require
termination of F&P support for four stroke projects and Project #26 -
-1 Continuing Education 1'rogra.m For Inner-ci-ty l:ospitals, Wayne State
University, upon completion of the two remaining years of Council -
approved support in lieu of three more year's of support as requested.

Included in the recommended $2,100,000 lcvcl are funds to initiate project
827 - mrehenLi-xe Jlcalth Care ----..^ll-l-l_l for thc Urban --.-.----- Pooi- - who reside in the
immediate area of T'ayne Count-y Cciir~ral JJospi 1-9 I ,  7'11e ?!APW/RAG vol-ed
this project as the number one priority activity in the total application.

0

Michigan Site Visit -15- RM 00053

It is currently in the approved/uniunded status.  This project: was
initially su.hmitt6d as a multiphasic sc.reeiil.nz pirograiri and WAS
reccmmended for deferral to i~iclude ;-i technical site visit, by the
May 1'369 Council.
the July 1970 Council expanded the scope of the project to the extent.
that the nultipliasic screening aspects have been dcempliasJ.zed. Staff
and the site vFsif:oi-s rciricw and discussions with representatives of
the Region have est:ablishcd that this project no longer meets the
criteria  for classif icatJl.on as a. "mu% tiphasic screening project" as
defined by the i$ay 1971 ZI'AC. ErFefly, the ov?rall objectives of the
'program are :

.

The revised appll.cation ~.rhicti vas approved by

,. -

to demonstrate the increased erFrct iveness of the Cocprehensive
Health Service as compared to tlre trndit!o;ral episodic care

to test the efficiency of the two health systems with respect
to costs, physicians time, spec-ilic socio-economic and
envirormr-ntal factors contributing to fhe Izcalth needs of a
medically indigent population, etc.

to test the feasibili ty of covqjensat:in~ for the shortage of
physicians and nurses by traLning a new category of health
workers to perform routinized types of procedures.

Michigan Site Visit

-1.6-

DI 00053

Sub-re&nal Plar~gg- Offices

The team recommends : 1) that a concrete method be establi.khed whereby
MAPJ*fP staff supported in these offr'Fces will be %dcntified with the
E.tfilU4P and, more inportrant, t~i.11. be identified with -progratns and nctivities
which are d.irect1.y in 1.ine With and/or complcnient the goals  objec.tivcs
and priorities as estab1.i shed by the ~egional Advisory C;roup; 2) that
the bu.dgcttirtg of Core personnel and functiolis which zi-e carried out in
these offices be coinplctely sepzrate from opcratiocai pi:o~rnms r~hicti
may be carried on simultaneously i-n the institution or its affi1int:es
and 3) that the I'iegioi?.'~ organizational chart be modified so as to show
a line of- authority 1xtween. the npproi>riate individua.1 3.n tbe central
office and approprkave HAPW? supported staff in each sub-regional office.

.

pro gr am Vi s abi lLz/ P u b 1 ic Re 1 i! tiA.nL

The team believed that the Region should give careful consideration as
to how Lt ir,ight inprove its Lrnsge and visahilitp both to its professional
and lay constituency.

C omp r e hens ivcxe?&th P 1 ann in&

The team strongly suggests that the FfAL"I'/K!!G take the lead ill an
attempt to clariEy the respcictiw missj.ons of these t-wo agcncies through-
out Michigall. The picture was unclear as to the value of C.H.P to R.M.P.

Goals and Oblixtlves

--...--u

The team recorimends that the Region address itself to redefining its
long and short term goals and objectives in the sense of being quanti-
fiable and related to a time frame for evaluation oE progress and
achievement in intplementing Its priorities.

Eva 1- u a t ion

The team recommends that the YdRHP strengthen its efforts in the area of
evaluation. It was suggested that this might he accomplished by the
addition of qrrallficd core staff to assisc the individual who presently
conducts the evaluation functions of the program.

Grant Adrn in i s t r a ti o n

Because of its history of having relatively large unexpended balances

' in the face of unmet needs, the team recommends that the Region continue
  to establish and refine its mechanism to ensure the actual use of dollars
  allocated to MAN@ participating institutions.

Datti Collection --

iJhile the team u!rderstood the value to IXP (arid others) for the continued
collection of hard data, it was suggested that a greater emphasis might

e

. Michigan Site VisiC

-17-

he included 3s to i.,hat happen:; to the actual or potciit-ial pa~ient. The
am recownends that the I"Y?JC(lP .rrithdrnw `,s the primary fiscal si~pport
or tlic: collection of data aiid that support jor thic; art-ivity be spread

among the variouz, agenci~~~linstitutions which utilize the results.


Core Staff

.-

-I_

1.

Thc Region has established excel I ent priorj ties wlrLch ~,re very well

stated and ~7hich appear to be substantlvclg SC)L~IIC~ armcl address the Region`s
major health necds. Long and sliort term goals hzvc 11ot been clearly stated.
The site visit tcec;! reco tended that the Region address i rsclf to redefining
its goals and ohjectivcs in terms of being quantifiable and related to a
time frame for ttie iifplemntation of its prioritics. See t-1~ scction on
Goals, objectives and priorj tics I page 7.

2, The Region's previous activities hnve been successful $11 teriiis of
specific ends sought. These specific ends 113~~~ b~en largely iu activities
t rere categorical in nature. The l~egio~i is ~GW isaking positive efforts

toward shifting its program pl annirig and development to attacking problems of
the heal tli care delivery system.  See page 6.

3. The activities stimulated and initially supported by FZAF@fP are or the

most part still being supported by PlAHI.SP rsthcr than being ahsorbed within
the regular health care financing system. Although the success of some of
these activities in promoting cooperative arrang;cnientc has been notable, the
site visitors believed it might he too early to expect that tliey should have
been discontinued.

See page 14 - Rationale --- For Furding Recommendation.

Pr oc e s s Criteria

1. With regard to organizational effectiveness the MAICIQ is a strong and

viable organization made up of a well-directed group of people who have been
successful in the planning development and implementation of a progran which
addresses itself to solving health care problems. Refer to section on
Organizational Effectiveness page 7 through 9. ,

  2. With regard to the involvement of the health-related interests, the
Region has a very strong inclusion of the allopathic and osteopathic
physicians, through their involvement with the three medical school s and an
emerging school of osteopathy. There is little evidence of an active role or

nvolveimnt of the nursing arid othcr health professions e

kk~~~ver, the I<c:;ion's

iennial plans include the invol vemcnt of other heal th professionals.

A

Michigan Site Visit -18- Rk 00053 .

full-tlxie nurse consultant has been employed and will  bc based at
Ferris State College, Big Rapids, Michigan. See section 011 Involvcriient
of Regional Resogrccs, page 9 t:hroug;h 10.

  3. The Region has five funded CIiP "E'' ngcncles. The "A" agency,
1.0cated in the Governor's office is a very weak and ineffective program.
The E@@ is currently carrying out the CIiP "ba" &elicy at which the they
will assume a more appropriate role for an NIP. Scc section on lnvolvement
of Regional Kesource,page 9 through 10.

4. The MA1W.P has one of the best and most complete data collection

systems, and is currently being utilized to a. large extent by the Region in
establishing and chznging the goals I objectives and priorities as they
relate to the health care needs of the Regjon- Refer to the secti.oii on
assessment of Needs, Problems and Resources, pages 10 through 11.

  5. The Region's evaluation process needs strengthening. The site
visit team stJggested that the Region might accoii~ylish this by the addition
of a qualified core staff ineniher to assist the individual who presently
conducts the evaluation functions of the program. See section on Evaluation,
pages 12 through 13.

C. Program Criteria

1. The Region is rapidly changing its program emphasis from a purely

categorical yrogrzin to one which will reflect a provider actiun-plan of
high priority needs arid which are congruent with the overall mission and
objectives of R.M.P. For exangle, the Region's top four priority activities
are to increase the availability of CBSC, enhancing its quality and making
the organizatiou of services and delivery of care more efficient. In
addition, the seven activities listed under the Region's second highest
priority (increase the delivery of health services) are exactly in line
with the PXP mission.

2. With regard to increased utilization and effectiveness of comiunity

health facilities and manpower, the Region is making extensive inroads in
the Model Cities Neighborhoods and in the future plans to institute both
urban and rural health care delivery system, designed to use new and
existing kinds of health professionals.

4.

The Wayne County General Hospital project, which is currently

approved, unfunded, is an excellent example of the Region's attempt to
completely revamp the health care system to a large medically iridigent
population. The plan calls for health maintenance, disease prevention
and early detection activities as a part of action plan.

5-8

   One of the Region's new activities, %Toke Day Care Center, while
categorical in nature, includes a plan to provide ambulatory care, out-
patient care, diagnosis treatment, and rehabilitative services on a cost
efiective basis. The Region's "push" in the areas of Keighhorhood Health

Center and Eiodel Ckties efforts are based on primary care as opposed to

e inpatient care-

Michigan Site Visit -19- RH 00053

The Region is directi.ng its efforts toward providing bot.11 primary and.
secondary care for the urban poor In Pont.iac ni~d Detroit. These two
proposals alone shou1.d have i.m!
quality arid cost moderation.  'The LzkcsFde Comprehensive Heal. th Care
project, a n.el.7 proposal, will bring together the 14icl-ii.gan College of
Os teop a ti-, ic Medic i ne
Housing Co;nmission and the O.E.D. Headstart program in a conjoint funding
and provis'ioq of servl.ce effort.

dkate payoff in terms of accessibility,

?.'is U Dep $1 L' tnien t o f C cn~nr! ni t y bled i c in e ,  Pon t i a.c

9. The t4AF:P is highly supportive of oLl~c!i- Fcdcral efforts, as mentjoried

above, of Ciicir SUjl1,Ol't oF CIIP, OK0 znd 1Iodcl Ci tics Plnrmiliy, activities.
The RAG be! i eves the ?<AP.i$P program priorilsies in obrailiiug requests which
total in dollar valuc to approiriniztely t:wo tines the amount: of Funds which
are currently available to the Kegion.

         REGIONAL ME!)ICAL PROGRAMS SERVICE
SUMMARY OF ANNIVERSARY XEVIEd AND ,AWARD GRANT APPLICATION
        (A Privileged Communication)

N EW MEX IC0 REC IONAL MEDICAL PROGRAM ' RM 00034 8/71

A1 buquerque, New Mexico 87106

c The University of New Mexico July 1971 Review Committee

PROGRAM COORDINATOR: Reginald I{. Fftz, M.D.

0~76c

lhe region is currently funded at $f&43+74-(03 year) which includes
$133,452 of carryover funds.
future years. The triennium application contains the follawirlg:

The region has no committed funds for

I. Developmental Component

11. Renewal of Core activities

111. Renewal of 9 ongoing projects; 3 continuing !

activities; 1 revised (new); and 1 approvedl
unfunded project (04 year)

IV. Termination of 2 projects (05 year)
V. Termination of 3 projects (06 year)

_L_ - ___- ___--I__-.- - I- - - -__I_- _.-- I

--

A site visit is scheduled for June 8-9, 1971. RMPS staff's preliminary
review of the application has identified issues and concerns  for the
team's consideration and exploration with regional representatives,
The review is a part of this summary.

0

Grant Year

01

02

01


02


03

FUNDING HISTORY
(Direct Costs Only)

Planning Stage

Period

10/1/66 - 9/30/67
(grant extended from
10/1/67 - 11/30/67)

12/1/67 - 6/30/68

(7 months)

Funded

$384,317

$252,379

Operational Program

7/1/68 - 6130169 $ 965,305

7/1/69 - 8/31/70 (14 mos.) 1,252,911

9/1/70 - 8/31/71 1,170,171

5

IDENTIFICATION OF

COMpOliENT

*DO0 - Developmental

81 - Core

#lA - Registry

82 - Cardiac Care Unit

X
n
0

r(
5

U

CONT. WITHIN CONT. BEYOND APPR. BOT NEW, NOT   1st
APPR. PERIOD APPR. PERIOD PREV. PREV.     DIRECT INDIRECT TOTAL
OF SUPPORT OF SUPPORT FUNDED APPROVED   COSTS

COSTS 'il

91,200 91,200 91,200

252,533 252,533 83,247 335 ,7'80

                                        1 22,720
94,037 .94,037 28,683

36,282 36,282 8,108 44,390

   Coronary Care

  Unified Laboratory

    Stroke and
lt5 - Rehabilitation

83 - Kuiurse Training

p4 - Sciences Tranng

39,927 39,927 9,514 . 49,441

49.950 49.950 1-7 66.837

103,531 103,531 35,504 , 139,035

$6 - Emergency Med. Servide

#7 - Continuing Education


   Information Center
#8 - Health Sciences

+9 - Center __
  Ped iatric Pulmonary

   Cerdiopulmonery
#lo 'Evaluation Center 8.500

67,700                67,700    21,181 '       88 I 881

24,983                 24,983     4, ria        29,101

17.395                    17.395     6,631        24,026

70.150                  70.150     25.561         95.711

8.500 2.146 10.646

1

814 - Remote Coronary Carl

67,463

24.950

Streptococcal Throa:

815 - Culture

816 - Soend & Mar. Sreenq.
    vorrerly G13)
817 - Leukemia-Lycphoma

. (Formerly g12)Hoart

-

100,913

TOTAL

+Request amended to 3 years per. telephone

67.463     4,090        71 353

24.950     3,783        28.733

23,302     6,717        30.019

31.600 31.600 12,033 43.633

23,302

-

756,488 23,302 122.800 1,003,503 268.203 _c__ 1, 271.706

7

I GRB-5/6/71

conversation by J. Salpzar and the Region 5/4/71 -

REGION New Mexico RM00034
BREAKOVT OF REQUeST "5 PROCRAH PERIOD

CONTINUATION WITHIN CONTINUATION BEYOND

IDEFJ!IFICATION OF XYPROVED PERIOD OF APPROVED PERIOD OF

COHPONEKT SWPORT SUPPORT

DO& Developmental
#I - Core 265,319

f1A 94,037

82 - -

13 - 41.387

-

APPROVED,NOT  NEW, NOT      2nd YEAR
PREVIOUSLY   PREVIOUSLY    DIRECT
FUNDED      APPROVED      COSTS

91,200 92,200

        265,319

         94,037

~

41,387

I

54 - 52.540

#5 - 108,663

1

iw

I

52,540

108,663

(5)

(Support Codes)

86 -

87 -

f8 -

f9 -

110 -

#14 - 68,485

#15 - 25,498

816 -

f17 -

TOTAL, . 93,983

(2 1 * (3) (1)

I

70.880

70,880

25,573 25.573

21,955 21,955

62,450 62.450

               68,485

               25,498

24,274 24,274

      33,342 33,342

985.603

742,804 24,274 124,542

o

z

X

124,248 i
326,297 f 1
212,831 1, ' I

157,776 i

.'.

P

76,754 1,

62,538 i

        I
188,464 ,

8,500 * :

c

9

135,948

  0

5' w
  P

50,448 ' 0

47,576

100.130

ca
\
-I
r

   (Supoort Codes)

. IDE~IIPICATION OF

' CoNPOEiE~T

DOO-Developkntal

81 - Core

(5) (2)

COXPINUATION WITHIN CONTINUATION BEYONI
APPROVED PERIOD OF
SUPPORT SUPPORT

APPROVED PERIOD OF

8

278,873

89,886


-------

3rd YEAR

PREVIOUSLY

APPROVED

91,200 91.200

278,873

89,886

8lA v

82 -

~

. '*

'42,934

55,286

114,103

74 , 251

26,198

d3 -


84 -

I 55,286

85 -

114,103

26,198

#b -

87 -

~

23,188

#8 -

P9 -

$10 -

814 *

23 , 188

55,864

-

55.864

**i

81s -

816 -

$17 -

35, 188 3S, 188

I

I ' 760,583

1 126,388

I ' 886,971 kf76,07j_-]

1

TOTAL

.- t.

..

NEW MEXICO KMP -5- RM,00034 8/71

GEOGRAPHY AND DEMOGRAPHY

The region is coterminous with the state, with some established patient
flow patterns into Colorado and Texas. The population numbers a littl-e
over one million one thousand, with 66% urban based. The median age is
22.8; 90% white, 2% Negro and 6% Spanish American and Indian.

There is one School of Medicine located at the University of New Mexico
in Albuquerque, and three Schools of Nursing, all of which are based
at the University of New Mexico. There are 44 hospitals, mostly
short-term, non-federal with approximately 4,262 beds. As of 1967
there were 970 active M.D.s and D.0.s and 2,511 actively employed
graduate nurses, with 1,095 inactive. There are also 712 employed
licensed practical nurses.

HISTORY OF REGIONAL DEVELOPMENT

The University of New Mexico School of Medicine was designated by the
Governor to plan and operate a Regional Medical Program, and a planning
grant application was submitted to DRMP on July 1, 1966. Planning
was to be carried out by disease-oriented committees, set up by the
Regional Advisory Group. The same approach was envisaged for the
Evaluation and Continuing Education Committees. The Dean of the School
of Medicine was appointed RMP Director,  as well as Chairman of the
Executive Committee of the RAG.

The initial planning grant in the amount of $449,736 was awarded for
the period of October 1, 1966 to November 30, 1967. Seven-month
planning funds in the amount of $108,048 were made for the second-year
planning continuation (December 1, 1967 to June 30, 1968). This
phasing was due to the Region's submission of its first operational
request, which was disapproved by the National Advisory Council  in
May 1967.

The Progress Report submitted with the 02 continuation application
indicated very slow progress in planning, and also that considerable
confusion existed among NM/RMP personnel concerning goals and methods
for meeting the needs of the state in the categorical diseases.
Dr. Fitz continued to act as Dean of the Medical School, Coordinator
of the RMP and Chairman of the Executive Committee of RAG.

An Associate Director was appointed on June 1, 1967 and DRMP staff
became aware of some increase in NM/RMP activity. The RAG met only
twice during the first year, and descriptions of planning activities
for the 02 year were vague and seemed to be operational in nature.
No justification for expenditures of 01 year funds was included.

Staff review of the continuation planning application was uniformly
critical and a decision was reached to extend the 01 grant for 60 days,
during which time the grantee was asked to justify expended grant funds,
and completely revise its proposed budget (66% above the 01 year level).

NEW MEXICO RMP

-6-

RM 00034 8/71

A major criticism of the application was the over-commitment of Dr. Fitz,
the Coordinator. In October 1967 the Director and Associate Director
for Operations, DRMP, discussed the administrative problems with the
Coordinator and the continuation application was subsequently approved
in November 1967.

A four-part operational application was submitted in April 1967, and
requested support for (1) a Medical Information Network for Albuquerque
hospitals; (2) Itinerant Cardiac Clinics; (3) CCU Training Program and
(4) Rheumatic Fever Registry.  Disapproval of the request was voted by
Council, based upon poorly planned projects which seemed unrelated to the
original planning grant, inadequate conceptualization of an RMP, weak
evaluation procedures, and lack of involvement of organizations and  .
agencies outside the Medical School.
a new application.

The region was urged to submit

An improved application was submitted in December 1967, desctibed as
"Phase I" program with five operational projects, although descriptions
of future phases were not included.

The Review Committee (January 11-12, 1968) identified weaknesses
similar to those observed in the original operational application and
recommended deferral and a site visit for the purpose of exploring,
with NM/RMP personnel, ways and means of determining the real needs of
the region with appropriate translation into a unified, comprehensive
proposal with a truly regional orientation.

'

The reviewers believed that the application would have been more compre-
hensive as Phase I, if Phase I1 had accompanied it.
weaknesses readily apparent which had been identified in the previous
proposal.

There were many

Prior to the Site visit of April. 8 and 9, 1968, the NM/RMP submitted
a "phase I Supplement", which included a number of changes in the
proposal.

The 'site team explored with the region the ways and means of moving
from planning into an operational phase. The team also attempted
to reach a better understanding of regional needs and resources.
Seven projects were reviewed with the program personnel who were
articulate and -responsive to questions and discussions concerning
their implementation.

.r

Also, the team, because of the changes in the administrative structure
of the Medical School and the NM/RMP, discussed with the Core staff,
as well as the Chairman of the RAG, the concerns and organizational
and administrative complexities. The team was impressed with the
competency of this individual, but the discussjon with the Coordinator
did not clarify where the program "control" was.
seem to focus on major problem areas and failed to provide for continuity
in planning, evaluation and a natural transition into operational projects.

The program did not

NEh' MMlCO KMP -7- fiM 00034 8/71

The site team had difficulty irl separating the Regional Medical Program
as an entity from activities of the medical school.

0

The seven projectdreviewed were:

111 - Model Coronary Care Unit
112 - Training Course in Coronary Care Nursing
#3 - Laboratory Sciences in Allied Health Professions
84 - NMRMP Stroke Program
f5 - Emergency Health Services (Related diseases)
f6 - Educational Programs
f7 - Health Information & Communication

The National Advisory Council of May 27-29, 1968, recommended approval
in a reduced amount, and a grant was made, effective July 1, 1968, in
the amount of $965,305 (D.C.), for Core activities and seven projects,
one of which was from earmarked funds for a Pediatric Pulmonary Center,
in Lovelace Clinic (Project #8).

During the first operational year the region submitted two supplemental
projects, $/lo - Cardiopulmonary Laboratory at St. Vincent's Hospital
in Santa Fe and all - Rural-Urban Linkage for Improved Health Services
(Estancia). Both were viewed favorably by Committee and Council,
although the Estancia program was funded by NCHSR&D. Project #lo
was funded from unexpended 01 monies, in the amount of $14,963.

Tile Progress Report for the first year indicated some organizational
improvements, with a notable shift away from the medical school
orientation.
and was granted $1,252,911 (D.C.) for a fourteen month period. This
amount represented 9077 of the previously approved level for projects,
and Core at loo"/,. Authorization was also granted to continue the
two projects that were funded from carryover in the 01 year.

The Region identified $355,612 in unspent balances,

Project #12 - Heart Sound &Murmur Screening for N.M. School Children
was reviewed at the FebruaryIMarch 1970 cycle and was returned for
revision. Submitted for the July/August 1970 cycle was a three-part
supplement for three new programs: 1/13 - Leukemia - Lymphoma Program;
W14 - Monitoring of Decentralized Coronary Care Unit;  and #15 -
Streptococcal Throat Program. Project #14 was presented to staff in
March 1970 as a request for rebudgeting of funds to support n pilot
phase. Because the proposal involved many technical and clinical
complexities, and indeed presented a new dimension to the N.M. program,
it was agreed by staff that approval of rebudgeting to implement this
study before submission to the Review Committee and National Advisory
Council was inappropriate.

Reviewers of the Leukemia - Lymphoma (f13) program returned it for
clarification of the personnel budget, its relationship to the overall
regional cancer program and a statement concerning the therapeutic
and clinical backup.

.

*With subsequent applications, all projects have been renumbered.

NEW MEXICO RMP -8- RM 00034 8/71

The continuation a.pplication for the 03 year requested:

Core and 9 projects
Carryover balances

$1,053,537

174,902
$1,228,439

The carryover request was to fund for one year projects 12, 13, 14,
15, all of which were pending Council recounnended revisions and to
permit the region to place $44,000 in escrow for three pilot studies
in kidney disease planning, expansion of project 1/5 and multiphasic
screening for Indians and Spanish Americans.

Staff discussed at length the advisability of allowing Dr. Fitz tQ
utilize unspent balances for continuing pilot activities which would
expire (and whose staff had threatened to resign  without a year's
salary commitment).
from carryover balances to continue, salaries of physicians who
inaugurated the pilot studies would circumvent Committee/Council
authority since Council had returned them for revision.
had submitted new protocols for #I2 and 1/13 witfi the continuation
request.
RMPS of the following:

Staff thought that commitment of one year's funds

The region

There was agreement by staff and approval by the Director,

--Approval for one year only (with last 6 months restricted)

pending a revision to be reviewed at January/Feburary cycle

as components of the Anniversary

  1/12 - Heart Sound and Murmur
  #13 - Leukemia-Lymphoma

Review application for:

$16 , 000

24,675
$40,675

updated projects to be

--Approval for one year only, with

submitted as components of A/R request:

$114 - Monitoring oZf,CCUs

$68 , 127

$90 , 227

1/15 - Strep Throat Culture 22 , 100

--D i sa pprov a 1 of "esc row" carry ov e r

($44 , 000)

Total Direct Cost amount of carryover - $130,902

Staff agreed that the region needed assistance and encouragement  to
spell out details of a "regional design" in the forthcoming Anniversary
Review package.
was urgently needed.

There was further agreement that a program site visit

Staff was unable to get a real feeling about progress in the region,
an almost complete turnover of Core staff was noted,  as well as
Dr. Fitz'expressed intention to leave from time to time.
discussed was the region's inability to budget its funds well with

Also

NEW MEXICO LiMP

-9-

RM 00034 8/71

I

a recurring balance at the end of each year.
not concern itself with the region's administrative affairs. The '
region included revised By-laws, but staff noted the RAG continues
with limited representation,  i. -e. one Spanish American.

The RAG seemingly doe$

0

The continuation award for the third operational year was macle,
effective September 1, 1970 for twelve months with direct cost
amount of $1,170,171. This award carried the restrictions for
projects referred to above.

The region submitted a revision of the Heart Sound and Murmur
Screening Program, now re-numbered as #14. The reviewers were impressed
with the revised program, which appeared to have improved with additional
planning. The involvement of the Heart Association was commended, as
well as the interest of the Department of Public Health which will
take over the program eventually.

THE NM/RMP ORGANIZATION

The Regional Advisory C'roup is comprised of 41 members, with an eight-
member Executive Committee, all but one of whom, are physicians. The
Executive Committee serves as the nominating committee for the election
of officers and new members of RAG. It reviews all applications
for technical and fiscal soundness and recommends in writing all
applications presented to the full body of RAG for approval. It
frequently meets on a weekly basis.

There are also categorical committees of RAG--Cancer, Heart, Stroke,
Continuing Education, Kidney Disease and Cardiopulmonary, all relating

0

to projects.

The full RAG meets quarterly, approximately three weeks prior to the
RMPS deadline for application submission. Review procedures were
modified in October 1970 to include review by State and Areawide
Comprehensive Health Planning agencies. The review procedures will
be revised and updated prior to September 1, 1971, and will apparently
be correlated with priorities and criteria for funding.

REGIONAL GOALS

The basic strategy for the accomplishment of NM/RMP goals  lies in the
cooperative relationships that have evolved between the Regional
Medical Program, Comprehensive Health Planning Agencies, the medical
profession, commu?ity hospitals , and the University of New Mexico
School of Medicine and other institutions of higher education in the
state.

The region sees the relationships referred to above as permitting
a flexibility and capability for program development relating to
manpower training, the logistics of health care delivery,
qualitative aspects of medical care, and the pooling of health
service information appropriate for health planning in the agencies

0

NEW MEXICO RMP - 10 - RM 00034 8/71

and organizations with health planning responsibilities. The next
Triennium will utilize the region's categorical projects and sup-
portive resources at the Core staff and project levels to coordinate
and complement the basis on which to move toward the achievement of its
goals.

DEVELOPMENTAL COMPONENT

First Year $91,200 Second Year $91,200 Third Year $91,200

b

The NM/RMP RAG has approved four activities to be implemented under
such a component:

1.

2.

3.

4.

Management of renal disease in New Mexico. A 3-year developmental
and demonstration will request approximately .'j150,000,
NM/RMP Renal Disease Planning Committee was formed in July 1970.
Establishment of satellite dialysis centers and home dialysis
training programs are the preferred activity areas.

An

In-service Educational Program: Local Community Hospital Involve-
ment. Expansion of the Presbyterian Hospital Center in Albuquerque
so that it may serve such a function for smaller hospitals  in
other areas.

NM/RMP and Model Cities Involvement. The Santa Fe Model Cities
Program, in conjunction with the North Central New Mexico
Comprehensive Health Planning Council, has developed a
preliminary proposal to provide locally situated health
maintenance services to residents of the Santa Fe Model
Neighborhood Area.

Training new Types of Allied Health Manpower. NM/RMP has
been asked to assume the catalytic role in establishing
training programs for "physician assistant" equivalents.
The University of N.ew Mexico School of Nursing is examining
potential resource; which could be linked to establish a
curriculum and other quidelines for a "nurse practioner"
program. Such training, on a pilot basis, is currently being
conducted by the Department of Epidemiology and Community
Medicine (Estancia Project). Also, the Bataan Memorial
Hospital in Albuquerque and the Presbyterian Medical Services
of the Southwest, Inc., in Santa Fey have also expressed
i nterest in developing a cooperative arrangement to establish
this type of training program.

The region anticipates that it will eventually submit all of the
four proposals outlined above as operational projects.
addition, early planning is expected to get underway in the area
of hypertensive disease.

In

The review process for developmental component proposals will he the
same as for other operational project applications. A preliminary

<

N i<W MEX TCO TIMI' - 11 - HM 000'34 8/71

proposal wlll I)c reviewed by the Director and Core staff to determlne
the p,r:nernI Fensthility and merit of the proposal. Tf the proposal
receives approval in a preliminary review by the Executive Committee,
the proposal originators and Core staff will develop a course of
action to prepare a formal project application. An ad hoc advisory
committee may assist in this task, if necessary.

When the application is completed, it will be forwarded to the appropriate
Professional Advisory Committee (e.g. Cancer) for technical review.
The Executive Committee will then consider all recommendations and
make its own critique and return it to origniators for the final
version. The Director will then submit the completed application,
together with documentation that the review process has been follow&d,
to the RAG for approval.
and/or state Comprehensive Health Planning authority will be obtained.
The application process may be intecrupted for revisions at any step
along the way. If a decision is made at any level that the proposal
is not feasible or acceptable, the initiator may request, a special
review by the RMP Executive Committee.

Administrative procedures for the allocation of such funds will be
in accord with existing fiscal management procedures employed by
the University of New Mexico, the grantee.

0

Before this last step, appropriate areawide

PRESENT APPLICATION Fourth Year

                                        Request
- Core $94,037

The most important area of Core activity for the next Triennium will

e

be to 1) upgrade the State`s health care delivery system by employing
RMP resources to supplement various existing capabilities within smaller
community hospitals; 2) provide basic and upgrading training capabilities
to meet New Mexico's ancillary health manpower needs; 3) coordinate
NM/RMP activities with State and areawide Comprehensive Health Planning
agencies and with Model Cities  programs in SanCa Fe and Albuquerque
to develop a health information system capable of clearly defining
New Mexico's health needs; 4) lend support to the possible development
of an experimental health services planning and delivery system
project in the Albuquerque area; and 5) cooperate in exploring the
potential for health maintenance organizations and area health
education centers in New Mexico.

`Ihe New Mexico State Planning Office, Comprehensive Health Planning,
in collaboration with NM/RMP, developed the multi-agency development
of a State Health Information System or New Mexico. 7he system
has not matured beyond a relatively informal structure due to
restricted funds.

The region is supporting the salary of one Health Planner working
with the State ClW Agency. This salary will be assumed by the
State Planning Office beginning July 1, 1971.

NEW MEXICO RMP - 12- RM 00034 8/71

The Mid-Rio Grande Health Planning Council,Inc., was a member of
the initial inter-agency group, together with NM/RMIJ and other
agenci.eu, tliat attempted to develop a State Health Information System
for New Mexico.
bodies and the Mid-Kio Grande HPC and NMEWP share health data
resources (personnel and processing capabilities) in current efforts
to utilize the Health Planning Council's Patient Origin Study and
to refine inputs to the cornunity health profiles.

Cooperative arrangementsstill exist among these

The Director and Core staff undertook a primary role in the development
of an organizational structure entitled "The Albuquerque Area Health
Coalition" which was developed in order to become the applicant
organization for an
Delivery Systems Program. This organization, functioning within
the Middle Rio Grande Health Planning Council umbrella, and with
the assistance of RMP and HPC staffs, developed the proposal submitted
to the National Center for Health Services Research and Development.
The region provided staff for the development of the Northern New
Mexico Comprehensive Health Planning Agency "NORCHAP" to facilitate
its transition from organizational to planning status.

Experimental Health Services Planning and

The region will assist during the coming Triennium in developing
CHP agencies in the four blaming districts of the state where such
organizations have not yet developed.

Fifth year - $265,319 Sixth year - $278,873

Project 1-A NMRMP Repistry Program - Fourth Year

Funds are requested for three additional years to provide
(1) data handling capability; (2) follow-up of medical
care for more than 5,000 registered cancer patients; (3) tumor registry
services for 45-50 hospitals; (4) data on cancer incidence, morbidity,
mortality, stage of diseasq at diagnosis, treatment, survivial, etc.;
and (5) regular reports td'more than 1,000 physicians.

Request
$94,037

About eight more hospitals will be added for a complete statewide
network.  Interested hos?itals will develop appropriate clinical
activities to meet requirements of American College of Surgeons.
It is hoped that the registry services will be supported entirely by
local hospitals or other sotrrces by July 1974, with NM/RMP continuing
to fund other parts of the data handling.

Fifth year - S94,037

Sixth year - $89,886

Project 1-B - Health Information Mini System

This projec,t is terminating on August 31, 197.1.
instrumental in examining internal heal th information capabilities
and needs of the NM/RNP. It focused on the development of health
information from census data, the promotion of appropriate use of

The system was

NEW MEXICO RMP - 13 - RM 00034 8/71

such information, and the conti.nuation of efforts to develop a plan
and necessary inter-agency cooperation to implement the developmental
phases of a State Health Information System.

Fourth Year

Request
$36,282

Project 2 - Model Cardiac Care Unit

This program is requestirg renewal-for one
additional year, with the Bernalillo County Medical Center ansuming
the major financial responsibility by August 31, 1972. `[he CCU
is a home base for many activities of the CCU Nurses `[raining Project
(#3) and serves as a central monitoring and teaching unit for the
Remote Monitoring Project (#14). NM/RMP support of the project
for the requested fourth year is limited to professional salaries,
which assures teaching resources and facilities for both projects
#3 and 1/14.

Project 3 - Coqonary Care Nurses Training Project Request

The project emphasizes the relationship between training
of personnel in cardiovascular care and their functions in the
Central Monitoring Units and remote stations. It will continue
the four-week course and accelerate the teaching of personnel who
will be working in the Remote Stations (one-week courses).

Fourth Year

$39,927

The Remote Monitoring Project will establish eight Central Units
and 23 remote units to provide quality care in local facilities.
The plan encompasses approximately one-ha1 of the small hospitals
in New Mexico. 1'0 this end, this project will train 21 registered .
nurses for the central monitoring units and 73 nurses to work in
the remote units. Also, il six-week course to train monitoring
technicians is planned, and will correlate activities of the CCU
Project and the CMJ Remote Project.

0

     Fifth year - $41,387 Sixth year - $42,934

Proiect 4 - IJnified Laboratory Sciences Training Program Request

Three additional years are requested for this project, which

addresses the lack of training facilities, supporting personnel and
great distances to provide continuing education for laboratory
personnel in an essentially rural population. In addition to present
staff, a medical technology educator will be recruited and it is
planned to direct some attention toward specialized laboratory
orientation or training for other categories of personnel such as
cancer recognition and management, heart disease management,
kidney diseases, disorders of blood.-forming tissues, etc.

Fourth Year

$49,950

Fifth Year - $108,663 Sixth Year - $55,286

NEW MEXICO RMP - 14- h 00034 8/71

Project 5 - Stroke and Rehabilitation Project

Fourth Year

Request
$103,531

The goal of this project aims at setting up a
definite structure of personnel with suitable
rehabilitation skills in various regional community hospitals and
smaller satellite centers around the state. It is hoped to bring
expert stroke and rehabilitation consultation to medical and allied
health personnel in selected urban and rural communities.

Nnjor urban centers with satellite rural commrinities within New Mexico
hnve been selected as target areas for this project . 'J'his will
p t-ovide t-be setting for formal educational programs preeented in
the urban center, with a home base in Albuquerque.

The training of substitute specialists in rehabilitation will be an
important new component of this project and will foster subregfonalization.
These specialists will bring new rehabilitation services to rural and
urban communities, with RNs and LPNS trained in basic rehabilitation
nursing techniques and some in occupational and physical therapy.

As physicians, urban community health leaders and substitute specialists
gain expertise and capability in planning for patients,  a reduction
in project activity will begin.
of the subregions will be self-sufficient by the end of the triennium.

.-

It is anticipated that at least five

Fifth Year - $108,663

Sixth Year - $114,103

Proiect 6 - Emergency Medical Services Project Fourth Year

Ad additional three years support is requested to $67,700
continue educational programs designed to improve the
knowledge and delivery of skills of physicians,  allied health
professionals and related occupations.

The curricula of educatidal programs have been developed and tested
over the past two years.
for Rio Arriba County based  at the Espanola Hospital with mobile
components at Chama and Tierra Amarilla.
arrangements have been established with the hospital,  the State
Highway Traffic Safety Commission, the Medical Association, and the
Rio Arriba County Commissioners to implement the program.

Request

Also, a pilot project will be developed

Cooperative working

A school for Emergency Medical Technicians developed from the N4P
Training program for ambulance personnel.
months and curriculum was prepared by Dunlap Associates.

Training requires three

Fifth Year - $70,880

Sixth Year: $74,251

. .. .

. .... . .

A-

n . -

I

t

Other aspects of the program include radio communications, categorization
of hospital emergency departments, expansion of first-aid training
nnd evaluation of educational programs--pre-test, post-test, demonstra-
tion of learned skills, attitudes, cost trainee ratio, reciprocating
benefit, attendance, student evaluation, etc.

- 15 - HM 00034 8/71

Pro ieet #7 - Continuing Education Program Fourth Year

Three additional years are requested to provide $24,983
support for opportunities for health professionals,

Requ est

0

working in institutional settings and private practice, to update
skills and knowledge.

Circuit programs have fostered the development of workshops and other
types of programs for allied health personnel in outlying areas. For
instance, the Stroke Rehabilitation Team has been involved as well
as the Coronary Care Nurses Training and Pediatric Pulmonary Center
programs.

The program is viewed as a continuing activity, particularly the
circuit riding program, which provides presentations that are timely
and convenient to remote practitioners. One important spin-off effect
is the organization of workshops by local people, utilizing local
resources and facilities.

Another principal thrust of the project will be the presentation of

symposia and ~ ,-- seminars --- . . in Albuquerque. The staff with cooperation of
Core, m&$l guide and coordinate-otGer~pWgYamT
for close interaction with program goals.

-'

Fifth year: $25,573 Sixth Year: $26,198

Project 8 - Health Sciences Information Center Fourth Year
                                         Request
This request is for three additional years, and the $17,395

region states that it does not expect it to terminate as long as
RMP exists.
impact will be phased out during 1972 and 1973.

By means of a VATS telephone service, literature and bibliographic
searches are requested. The project assists smaller community
hospitals in upgrading health and medical informat ion for local

aries.
ew Mexico provides reference services and has absorbed some

However, aspects of the project that are not demonstrating

The Library of the Medical Sciences of the University

of the overload from the project. The Dial Access audio-tapes
will
service will become a function of RMP Core staff, although the
project and Library staff will continue to house the equipment
and provide an answering service.

not be emphasized during the coming year and the VATS telephone

Fifth Year $21,955 Sixth Year - $23,188

--

Proiect 9 - Pediatric Pulmonary Center Fourth Year

The request will fund an additional, three year
support but on a diminishing scale.
a comprehensive health center for all children with chronic
pulmonary disease.

Request

$70,150

The funds provide

The Pulmonary Center is housed in the Bataan Rehabilitation Center
with associate laboratory facilities in the Lovelace Foundation and
teachin:. facilities in the Bataan Hospital-Lovelace Foundation Medical
Center. The staff will be decreased from 15 to 13 for the next three-
year period.
the present year and further decreased to 7296 and 66% during the followinP
two years.
Cystic Fibrosis Research Foundation and fellow-ships are being requested.
Traininp, and educational programs will continue as presently set for externs,
residents, fellows and student nurses. In addition, community visitation
traininR programs are planned to continue with visitations to 4 major and
2 smaller communities.

The budnet requested for the fifth year will be 80% of

Other sources of fundin? have been located through the National

Fifth Year - $62,450 Sixth Year -$55,864

Project #lA - Cardiopulmonary Evaluation Center

For the final year of RMP support, the program will

expand its activities into exercise testing and will
continue sponsoring lectures and other educational activities for physicians
and nurses in northern New Mexico. The New Mexico Division of Vocational
Rehabilitation wilt buy some necessary equipment to assist in expansion of
laboratory capabilities. The primary activity will continue to be the pro-
vision of cardiopulmonary evaluation services, and responsibility for con-
tinuing the Center will be fully assumed by St. Vincent Hospital after
August 31, 1972.

Fourth Year
Request
$8,500

Project #16 - Heart Sound and Murmur Screening Program      Fourth Year

                                            Request
This project (formerly 812) was initiated originally with $23,302
funds from 02 year balances as a pilot program for six
months only.  Committee/Council reviewed a revised protocol  in
Jsnuary/February 1971, and approved without funds for three years. The
region now requests funds at a reduced level to continue this activity for
two more years, with emphasis shiftinR from kindergarten groups  to third
grade children in Title I ichools and fourth and tenth nrades in rural and
pueblo or reservation settinas.  Plans are underway to reach children in
the Navjo reservation area this year.  An additional computer is requested
which' will dve them three PhonoCardioScan computers. Project activities
will be coordinated with those of the Streptococcal Throat Culture ProRram
(#l5) and will continue to work closely with the NM/RMP Registry Program to
refine registry procedures to track New Mexico children with organic heart
disease.

Fifth Year - $24,274                       Sixth Year - r) -

Project 817 - Leukemia-Lymphoma Propram                    Fourth Year

- Request
                              $31,600

This proErem (formerly &l3) will mobilize and coordinate
physicians and facilities throughout the state to provide
the most current effective investigative and therapeutic tools in a more
uniform manner. During the pilot phase (first year) 21 physicians, mostly
private practitioners, committed their support to this program. Groups
have been established in chemotherapy, radiotherapy,  infectious disease

NEW MEXICO RMP

- 17 - RM 00034 8/71

and blood services. Protocol8 developed by expert chemotherapists were
established to provide a more uniform approach to therapy.

The blood services proup will develop more effective means of providing
the intensive platelet transfusion support, and an oncolopy patient review
conference will be established. This will coordinate activities between
these various groups and utilize the expertise of physicians with major
interests in cancer, including the surgeon, the pathologlet, the oncoloa,y
nurse and the social worker. Training for oncology nurse8 will be undertaken
and teaching programs will be developed for major hospltala. A central
information bank will be actively followed.

During the last two years of this Triennium, the project will seek support
from the Cancer Memorial Research Fund, the New Mexico Leukemia Lymphoma
Society, Inc., and the National Cancer Institute. One NCI Rrant ha8 already
been approved o

Fifth Year: $33,342 Sixth Year: $35,188

Project #I4 - Remote Coronary Care Project

Fourth Year

Re q ue s t
$57,463

This project was approved by Council in July t970 for
three years without additional funds. It was implemented
from 02 balances for one year only. The present application requests two
years funding. At present the University Heights Hospital, Albuquerque,
and the Cihola General Hospital in Grants (70 miles away) are tied into
the Bernalillo County Medical Center by remote monitorina.
Los Almos Hospital is monitored by Bataan Memorial Hospital in Albuquerque,
and the latter hospital will now become a central monitoring point for
hospitals in Santa Rosa (120 miles)and Tucumcari (160 miles). During the
first year it is anticipated that eight small community hospitals will be
incorporated into 3 networks for remote monitoring. A training program
for monitoring technicians is ongoing in coordination with other heart
disease projects.

The second and third years of the program will establish units in Las Cruces,
Santa Fe, Clovis, Farmington and Raton. When this is accomplished, nearly
one-half of the 52 small hoepitars in the state (90% of the state's general
hospital system) will be able to provide quality care  for acute heart
patients. The central monitoring and its remote stations will be used as
a nucleus for continuing educational programs for physicians and nurses, as
well as a regional information center, data collecting unit, etc.

Since April 2971,

Fifth Year: $68,385 Sixth Year: - 0 -

Project #I5 - Streptococcal Throat Culture Program Fourth Year

Request

As a companion to project #I4 above, this promam $24,950
was similarly inauwrated, and requests two years
support. The proqram will be extended to southern New Mexico by mid-june 1971

IJEW MEXICO RMP - 18 - RM 00034 8//1

and the physicians' otfice program will move into northern New Mexico
by earty-August 1971. Physicians receive reports at two month,intervals
and further refinement of the reporting procedure is expected. The \
New Mexico Heart Association ia co-sponsor of this propram.

Fifth Year -. $25,498

Sixth Year Z-0 -

RMPS/GRB 6/4//L

DEPARTMENT OF b1EALTH. LUUCATION, AND WELFAKt
            PlJi3L.IC HEALTH SERVICE
HEAL111 SEf3VlCES ANI.) MENTAL HEALTH ADMINIST RATION

Staff Review of the New Mexico (RM-34) Triennial Application
May 10, 1971.

Sub jet::

!

0

e

liarold Ilargulies, M,D.

Director, RNPS

Through: Chairman of the Month

I

. ,,'.

- Chief, Grants Review Branch,

Chief, Grants Management Branch i. I

*I.

Acting Chief, Regional Development

.

Staff in attehdance: Jessie F. Salazar, Grants Review Branch

Rodney Mercker, Grants Management Branch
Cecilia C. Conrath, Continui.ng Education and

Joan Ensor, Program Planning and Evaluatlon
Michael Posta, Regional Development Branch
Joseph Ott, Office of Systems Management

Training Eranch

Staff review dealt with overall program issues, and was based upon
an awareness that a site visit (the first in three years) is scheduled
for June 8-9, 1971, From the general discussion, a list of impressions
and cancerns emergedo It is hoped that clarification and a better
understanding of the NM/RMP can be gained by the cite visit team, Miss
Conrath, who will participate,was a member of a visi tine team organized
by the Experimental Health Systems on April 1.
participant in the RMPS Management Asse-ssment visit on May 5-7, 1971,

It was generally agreed that the NM/RMP is a "one man program."
There appears to be a lack of communication not only among staff,
but particularly from Core staff to project staff and to community
hospitals.

The Nurse Coordinator is believed to be imaginative and competent, but
is apparently stymied in implementation of allied health training
programs due to the Coordinator's reluctance to del epte any
rcsponsjbility in these areaso

Dr, Oseasohn, who was responsible for much creative plannl.ng in the
early days .of the program, has left the RMP to head up the Medical School

Mr. Mercker was a

-..

Page 2 .. Dr. Margulies

Depnrtincnt of Cormininity Medicine.
R gap in the planning aspects of the NM/RXI! as well as continuing
program evaluation.
or portions of projects being evaluated,.but no real data on program
evaluation.

Dr. Oseasohn's departure has left

There is some evidence of individual activities,

1

The operational projects all appear to be provider-oriented, with

aware of existing minority problems, yet the application does not
indicate that the NM/BlP (as a program objective) is giving any
attention to such problems.
A very high percentage (over 5074 of the population pays for its own
health services. New Mexico 3.s probably the only state in the union
that does not cover at least one-half of its population through
group health insurance.

There is some evidence of a reluctance on the part: of the NM/RMP to
turn away from the categorical (heart, cancer, stroke) approach.
The Cooreinator differentiates Core staff as "categorical" and
"administ rat ive. 'I .I

very little, if any, consumer representation. C.ore staff is quite

$i I

D

Staff believes that Cornprehensive Health Planning invdlvement by the
NM/RMP is a plus. An IWP Health Planner is stationed in the Santa
Fe CHP Office, and his salary will be picked up by CHP beginning
July 1.
councils" in four districts throughout the state. There is an
Area Health Coalition in Albuquerque, which is the applicant
organization for the Experimental Health Services and Delivery Systems.

He has been assisting in the development of "interim

The New Mexico Comprehensive Health Planning Council (NORCHAP) was
.assisted in its formation as a 314 (b) agency by the Coordinator of
h?f/RMP, Dr. Fitz. Mr. Thomas I. Harnish, the Executive Director,

is the sponsor of NORCHAP', is a member of the RAG.
that even though there is a lot of planning talent in the Albuquerque
area, no real leader in the existing agencj.es has emerged.  There is
a tendency to organize a new agency about: every six months,  or
whenever a new program appears on the horizon.
feeling, either in the application, or in staff awareness, as to
the involvement of the State Department of Health in health planning,

,

of the Presbyterian Eledical Services of the Southwest, Inc., which

It was noted

There was no real

*

The RAG has been broadened to include some minorities and lay
people, although the Executive Cornmitree (mainly physicians)  is believed
to be the power group (and decision-making) of this body. Program.
activities are largely medical school centered and provider oriented
rather than patient (people) oriented. Staff is of the opinion th,at
New Plexico clings to the "colonialism" of the past, with no apparent
attention given to ancient communication problems between its "Anglo"
population and the Spanish American and Indian citizens.
member RAG., 37 are males.
attempt at sub-regionalization.

Of the 41

The region does not seem to be making any

I '. .'

. ....
. , ..-
. ..I../

.. I

I 5 ,I :.:. .;

uy

\

,

- 21 -

was no~.ed that. thc:rc have Lccn rto stiJtc$wide confcrcmco:; in pi-nmoting

ssistlints. si;ifE felt this i>i sigrii rjc;int for a11 arrha
uCe rii;iripc)wcAi- prul>leiiis. Also, tIi(.t-c w:is no jntlicntion

or involveincnt by thc Ilurcau of Inclinn AKfairs jii J<MP health planning.

alillo County Hospital is the only hospital in Albuquerque providing
patient services, or services for indigent patients. This. is the
hing hospital for the Medical School. This pointed to the

observation that  there is a great deal of emphasis on the Presbyterian
  ita1 Services and it was noted that a number of RAG members are
  esentatives of that institution.

e staff did not deal in depth with the request for Developmental

.._

..

Eunds, questions were raised as to how th-e various components  fit
into a total package.
for approving Developmental funds, and the reasons for such broad areas
they propose.

The site team should explore the region's plan

orm 16 for projects 3, 4 and 9 request stipends which are believed

in conflict with Council policy.

idney Disease KMPS staff have visited the NM/IIMP with a view

to attaining some knowledge of local management resources  for renal

asc. It has been reported that the Dr. Condon (a lady physician)

thc Veterans IJospital who was named by Dr, Fitz as thc person

responsible for planning a kidney program in New Mexico,  has  left
the VA Hospital and moved to Iowa.
new kidney plans.

P seems to have "dropped the ball" relative to the Estancia
t, which received much national acclaim, planned under RMP
es and funded by NCHSR&D.
roject as a pilot for replication in other parts of the state.

as some opinion that the region may he tending to "drop the

The visiting team needs to explore

The original plan proposed to use

ball" in the planning for Health Services Planning and Delivery
Systems as well.  Dr. Fitz appears to view the IIMP as a broker,
utilizing IWl' funds to generate the interest, then once the program is
underway, moves on to greener pastures.
completely negative, but staff thinks that the program sufiers from a lack  of

eeling of continuity or cohesiveness in planning.

?his is not believed to be

Previous fiscal and budgeting problems appear to have been corrected.

region has a history of large carry-over balances.

The Grants

agement Branch reports that this should not be a problem this year '
in the future.

I

The region-has submitted a budget request based on

  Dr. Vernon Wilson letter of April 7, 1971 which limited the
support for this region at $912,313 based on it present funding
level, will be needed for the Triennium.
and GMD with Dr. Fitz, who will submit an alternative plan,  for an
expanded request.

This was discussed by GRB

The present budget request is unrealistic,  should

itional funds become available.

rage 4 - iir. rmrgiiiltza

- 22 - I.. .,

. ,?

Equipment aid computer costs requests need exploration by the site team.
There are sone existing iederal sources that may be able to provide
these more economically.

In summary, the RMPS staff found the application well written and
adequate in its presentation. It raises many questions, however,
(not alleviated by the new format) and concerns outlined in the
foregoing which need to be explored in greater depth by the
site visit team.

Public Health Advisor
Grants Review Branch

0.

r.

Action .-by Director

.L I .-~d--/

. :.

. ...

'. * ,

New Mexico RMP

- 2, -

RM 00034 8/71

Core staff is still organized around the categorical diseases, with
Assistant Coordinators responsible for a group of projects in these
areas.
pursue its primary goals, its objectives of sub-regionalization, and
to link together all of the planning and projects into an integrated
program. The Coordinator referred to this as a "vestigial categorical
structure." Core staff has been actively involved with other federal
agencies, especially Comprehensive Health Planning. It is also
involved in developing community organization and planning in the Four
Corners area. Staff would like to assist in developing Area Health
Education Centers, but there does not appear to be this expertise on
Core staff at present. It was reported that planning for such centers
is being explored by the Dean's office and not by NM/RMP staff.

This emphasis appears to inhibit the region's attempts to

The region has apparently not considered how the Emergency Health
Personnel Act might be implemented in New Mexico, although there was
an indication that this could become a future function of NM/RMP.
This might be the source of physicians for the Model Cities activities
in Albuquerque,  Santa Fe and Rio Arriba County.

The reviewers received the impression that the NM/RMP sees itself
in the role of "broker" of RMP funds. However, once the RMP funds
are allocated for the various activities such as Model Cities, there
does not appear to be much coordination of effort or follow-up on
the part of Core staff.

While the NM/RMP has enjoyed close cooperation with both A and B agencies
of CHP, and Model Cities, there is an absence of a firm program of action.
These agencies are eager to participate in RMP affairs  and would  like
to organize a Neighborhood Health Center.  There was uncertainty, however,
about the source of necessary funds.

The Committee was impressed to learn that the NM/RMP has excellent
relationships with other health agencies in the state.. There are
some town/gown projlems wjth the State Medical Society, but the RAG,
through its Executive Committee, appears to have credibility, at
least in the Albuquerque and Santa Fe areas. Although decentral-ization,
regionalization and peripheral dissemination are stated major objectives
(by the RAG) for the future, the representation from peripheral areas
is minimal. The RAG does represent well the areas where care is available,
as it also represents some areas of need. It would appear, however, that
more RAG input as to other :oca1 needs would seem desirable, and possible,
if active representation can be  found for other high need areas.  The
RAG appears to function more as a "board of approval" rather than an
active policy-making body.

There is little evidence of capability on the part of Core staff in
evaluation procedures, and this segment of the NM/RMP needs attention
and strengthening.
planning in this direction, no formal plan or strategy was presented.

Although there is adequate staff to begin some

The Review Committee recalled that in initial stages there was
an excess dependency on the resources of W/RMP on the part of the

-3-

1. There now appears to be a clear separation
istrative responsibilities.

tional activities seem to be proceeding

    titularly appropriate to Ne Mexico. Based
     uate resources, interest a
  subregional center, whrlch coul
      of the state.

rvices Project (#6) enjoys impressive leader-

ect (#lA\ has been successful in abstracting
epresenting 90% of the region's b
f the leukemia-lymphoma program (

m, or to link it with the co

Mini-System (#lB) was disappointing to the

as not led directly to operatio
for action seem to have been by-passed.

operational activities in gener
three years ago are requesting ad
    t plan for phasing out s

prognosis for the NM/RMP

ood climate at the present time

new and stronger leadership. Vhi
    een the region's goals an
the turn-around process in a st
be slower. The Review Committe

h expressions of good will on the

e visit which took place

eed that it is important
cation and strengthening

p. Also, the appointment of the new Coordinator,
ollowing the site visit as the resul of the immediat
Committee by the Executive Committee

ers. The former Coordinator, Dr.
tant to the NM/RMP on an interim
the region ' s leadership.

f the possible jeopardy in which
 the NM/RMP should withdraw its investment.
ort is essential, therefore, for an effective

tion of the RMP. Committee noted that
tention to the site team to phase out

opportunities, as well as problems exist,
9'' and "have nots," About 25% of the
n, Indian or Mexican-American,

given specific attention to the heal

sible the Medical School dependency. There was

e

New Mexico RMP -4- RM 00034 8/71

In considering the request for a Developmental Component, the
reviewers agreed that the region has not demonstrated the
necessary maturity or organizational development to administer
such funds. Also, the triennium application under review was
believed to be about one year premature. Committee expressed the
hope that reports issuing from the present review need to be
strengthening,andid and supportive.
and unanimously approved the conclusions and recommendations of
the site visit team.

The Review Committee endorsed

RMPS IGRB 17 /14/7 1

..

,. :

..

-... .

DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE

PUBLtC HEALTH SEg;lCE

HEALTH SERVICES AND MENTAL HEAiTt4 ADMINISTRATION

; June 25, 1971

Mini Site Visit Report of the New Mexico Regional Medical

Su4ec1: Program, June 8-9, 1971

To: Director

Regional Medical Programs Service

ugh: Acting Deputy Director

Regional Medical. Programs Service

of Participants : Sister Ann Josephine, Chairman '

hlr. Arthur 21. Rogers
John Gramlicli, M,D,
Morton C. Creditor, MOD,
Anthony Lo Komaroff, MOD,
George E. Schreincr, MOD,
Mr, Clevelaricl Ciiafizbliss
Mrs. Jessie I?, Salazar

I: met with Sister Ann Josephine in Albuquerque at 11 aDmD on June 7,
at her request in order to brief her on the program, and particularly
with reference  to the issues and concerns we had previously identified,
and with which you are familiar, Actually, some of the issues turned
out to be more sensiti.ve than we had anticipated, At the outset, I
would like to record that much of the sensitive areas of the site
visit were skillfully guided and channelled into what will, hope-
fully, result in a "positive and constructive message'' (Dean Stonets
description).
leadership as well as a sympathetic understanding and awareness of

Sister brought to the Chairmanship of the team a superb

strengths and weaknesses of the New Mexico Regional Medical Program.

Fitz is leaving the prograni in September to join the Commonwealth

The site visit team found the MNRPIP goals to be reasonable and
relevant, considering the general assessmznt of New Mexico as a
"have not'z region,
objectives are the result of a specific assessment of needs, problems
and resources, Certainly they are congruent with national priorities,
but are being ioipleniented less successful~ly.

It was unclear however as to whether goals or

Core staff is still organized around the categorical diseases, with
Assistant Coordinators responsible for a group of projects in
categorical disease areas,
ernphasi s i-nhibtts the region's dttempts to pursue its primary

The site visitor.s believed that this

.

_e

Page 2 - Director, RMPS

*

non-categorical goals, its objective of subregionalization, and to
link together all of the planning and projects into an integrated program.
The regional representatives referred to this as a "vestigial categorical
structure," yet Erppears not to have attempted to divest itself of this

The Core staff (particularly the Director) has been involved with other
Federal Health Agencies, especially CIIP, since the beginning of the
NM/EMP,  NM/RMP has paid the salaries of one community planner to
work with the A agency, and to help plan for the establishment of
B agencies. Another RMP staff man is delegated full-time to work
with the B agency in Santa Fe (NORCHAP) and with the Santa Fe Model
Cities, Since the A agency staff consists of four people and the
B agency staff of three, the EZMP contribution is substantial. RMP
is involved with developing community organization and planning in

t of the core staff activity in pi-ogram ji?ipl-rmentati.on is

rners" area of the state. The site team felt khat this

The region would like to assist in developin: Area Health Education
Centers, but the teain could identify no one on the core staff
conqetent to prirsue this task. The only possibility thus far is
at the New PIexico State University in Las Cruces, This possibility

as been explored by the Dean's office, but not by RMP staff.

here was no evidence that the region has considered how the'Eniergency

Health Personnel Act might be implemented in New Mexico, although
there was an indication that this could become a function of DIP.
Apparently no thoughthas been given to the possibility that the
Emergency Health Personnel Act niigh t help supply physicians  for the
Model Cities activities in Albuquerque, Santa Fe and Rio. Arriba County.

The site visitors had very little time to evaluate individual project
activities.
System has not directly led to operational activities. Rather,
opportunities for action seem to have been by-passed. Another concern
was that most of projects begun three years ago are requesting
additional three-years funding. This seems to not be in keeping
with the policy of phasing out support Fn order to create turn
around money.
is a region of limited resources with fewer possibilities for
financial support from other sources. The individual project
activities are apparently uncoordinated. Rather, they seem to be

,the cancer registry which has been successful in abstracting records
from hospitals with 90% of the region's beds, is not being used as
part of the Leuk'emia-Lymphoma program to 71 313 an overall cancer
program or, to link it with the continuing education program in cancer,

The Emergency liedieal Services Project, under the vigorous leadership
of Dr. Hendryson is impressive.

We were disappointed that the Health Information Mini

On the other hand,  the team realized that New Mexico

' a group of "good deeds" rather than a cohesive program.

For instance,

This progrartl seems particularly

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Page 3 - Director, RMPS

appropriate in view of the/mortality from accidents is greater than
mortality from any of the categorical. diseases  in New Mexico.  This
Espanola-based program exhibits the appropriate resources and
environment for the development of a subregional concept. It seems
likely that Espanola will be able to serve as a regional center for.
a large geographic area in the northern area of the state,

The New Mexico Regional Advisory Group appears to represent well
the areas where care is available. It represents some areas of
nekd, but more WIG input as to other local needs would seem desirable
and possible if active representation could be found for the other
high need areas.
1970, twelve from Albuquerque, four from Santa Fe and one each from
Espanola, Las Vegas and Carlsbad.  It appears that this ch,ange was
intended to increase the number rather than extending representation.
Throughout the sTLe visit presentation it was clear that policy is
mad6 and controlled in the Core staff and ISxecutive Committee of the

fact that

Nineteen members were added to the RAG in December

. The team believes that the PtG is in fact a "board of approval"
her than a body organized for active participation in policy nialting.

TZw program has gcid credibility and an understanding re1ationshi.p
with the Medical Society.

There was little evidence of capabilj ty in evaluation and this segment
of the program certainly needs attention and strengthening,  . There is
no formal evaluation plan or strategy, although there is adequate staff
to begin to plan in this directtoil.

Although there appears to be a clear separation of the grantee and
administrative responsibilities the site teain was aware that in
the initial stages of the program an excess dependency of the

edical School on the resources of NM/RMP existed, Dean Stone
acknowledges this and stated his intention to phase out this depen-
dency as quickly as possible.

Conclusions and Recommendations of the sits visit- team:

1. The region should be complimented on the good relationships
that exist between the NFI/PaP and other professional groups,  and
the Dean for the Medical School support of the NN/RMP.  The team
was cognizant of the possible jeopa.1-cly to the Medical School by
a severe cut-back to the program.

2, It was agreed that another year will be required to prepare
an appropriate triennium document which would be capable of
approval and implementation.

The l?Pf/RMP has not demonstrated the

ram maturity for a Developmental Component..

Core staff is in great need of strengthening.

unding kn the amount of $850,000 for one year only is recommended

in order to allow the region to establish a plan of action which
will emp1iat;ize a more positi.ve approach  to a viable RMP.

'3 .e

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- Director, RplPS

Search Cornnittee should be appointed as soon as possible

to find a new Program Coordinator.

6.  The membership of the Executive Cormnittee of RAG needs better
representation and orientation for its role in policy guidance of

hrough indirect means (through CHI? and Model Cities
e HM/RMP appears to not have addressed the specific heal

needs of minorities.

  he "constructive, positive message" which was the pie? from
  Stone to the site visitors and his to-the-point criticisms of
the program in general require carcful and serious consjderation

]&J& OL4f /----

gssie F, Salazar
Public Health Advksor
Grants Review Branch

1

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DRAFT

       SITE VISIT REPORT
NEW MEX IC0 REGIOXAL MEDICAL PROGRAII

June 8-9,1971

Sites visited were:

Albuquerque and Santa Fe

I. Site Visit Participants:

Sister Ann Josephine, Chairman; Member of Review Committee; Administrator

Holy Cross Hospital, Salt Lake City, Utah

George E. Schreiner, M.D., Member of National Advisory Council; Chief,

Nephrology Section, Georgetown University Hospital, Washington D.C.

Anthony

Morton C. Creditor, M.D., Coordinator, Illinois RMP, Chicago, Illinois

L. Komaroff , M.D. , Beth Israel Hospital, Boston, Massachusetts

Arthur M. Rogers, Chairman of RAG of Connecticut RMP, Scovill Manufacturing

Company, Waterbury, Connecticut

John Gramlich, M.D., (Mountain States - WICHE), Practicing Physician,

Cheyenne, Wyoming

RMPS Staff:

Jessie F. Salazar, Public Health Advisor, Grants Review Branch

Cleveland R. Chambliss,, Office of Organizational Liaison

New Mexico Pap Staff:

\

Reginald H. Fitz, II.D., Program Coordinator
William Weeks, Assistant to the Director for Administration
Loyal L. Conrath, M.D., Assistant to the Director for Heart
A.G. Greenhouse, N.D., Assistant to the Jlirector for Stroke
Charles K. Key, M.D., Assistant to the Director for Cancer
I.E. Hendryson, N.D., Assistant to the Director for Related Disease
Dudley Griffith, Assistant to the Direccor for Planning and Evaluation
Nary Pozorski, Nursing Education Specialist
Elizabeth Barnett, Paramedical Education Specialist
Anthony Mares, Ph.D., Health Planner
Helen Potter, Health Information Coordinator
Gar Elison, Information Services Officer

Regional Advisory Group:

Hugh B. Woodward;M.D., Chairman, Executive Committee; Medical Director,

Robert S. Stone, X.D,, Executive Committee; Dean, University of New Mexico

I4ountain Bell Telephone Company

School of lledicine .

New Mexico RMP Site Visit -2- RMO0034

Regional Advisory Group (cont.)

e

Vaun T. Floyd,M.D., Executive Committee; President Elect-New Mexico

Mr. Richard Heim, Executive Director, New Mexico Health and Social

Alonzo C. Atencio, Ph..D., Assistant Dean/Student Affairs and Assistant

Mr. Sidney Hertzmark, Hertzmark-Parnegg Realtors, Albuquerque, New Mexico

Mr. George Olson, Director, State Comprehensive Health Planning Council

Bruce D, Storrs, M.D., Executive Committee; Director, Health and Social

Julius L. Wilson, M.D., Private Practice, Santa Fe, New Mexico

Medical Society, N.M. Cancer Society and X.M. Heart Association

Services Department, Santa Fe, New Mexico

Professor/Biochemis try, University of New Nexico

2.

Santa Fe, New Mexico

Services Dept. .(Medical Services Division) Santa Fe, New Mexico

, Others

Pfr. George Olson, Director, State Planning Office, CHI? Division
Mr. John Glass, Director, NorCHaP
Mr. Thomas I. Harnish, Executive Director, Presbyterian Medical

Services of the Southwest, Inc.

- __. Mr. Roger Brumley, Santa Fe Model Cities Staff Liaison for NorCHaP -- -

Mr. Rudolf Pendall, Executive Director, Mid-Rio Grande Health Planning

Eva Wallen, M.D. , Director, Health Unit, Bernalillo County, Albuquerque
Mr. Jeff Meyer, Health Planner , Albuquerque Piodel Cities Program

Council

r

11. , BACKGROUND INFOPNATION

This was the first program site visit to New Nexico Regional Medical
Program since April 829, 1968, when a site team explored with the
region ways and means of moving from a planning into operational
status.

The current visiting team was charged with-an evaluation of the
program generally, and especially:

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the region's readiness for a developmental c-omponent;
the experience and achievements of ongoing programs;
regional. goals, objectives and priorities
involvement of health interests throughout the region;
the roles of Coordinator, Core staff and the RAG and
its committees;

organization and process of the technical review of programs;
the region's evaluation processes;
the decision-making methodology;
an examination of the region's interrelationships with other
health planning agencies.

status of the regionalization concept; ..

New Mexico RMP Site Visit -3- RM 00034

The team met on the evening of June 7, 1971, to discuss the
application in general, and the concerns and issues previously
identified by staff and members of the team. It was recognized that
there was a great deal to be covered in the two days allotted for the .
visit, and that some of the areas might prove to be qui-e sensitive.

'r

REVIEW DETAILS

I

Goals, Objectives and Priorities I

I

The recognition that New Mexico is a "have-not" Region, with
deficiencies in both the absolute numbers and distribution of
health personnel and facilities, has conditioned the Region's goals
from the outset. The goals remain pretty much unchanged: Emphasis is
on the improvement of access to and quality of health services, disease
prevention, correcting the manpower shortage, and lastly the categorical
disease..

Restatement of these goals is found in a letter from the RAG to
the Director, RMPS. None of the goals is accompanied by specific
objectives or priorities, nor are the proposed operational activities
identified as to che goals they are implementing. In another part of
the RAG letter, a series of new objectives are listed, which will be
discussed subsequently.

The site visit team felt that the goals were reasonable and relevant,
considering the general assessment of New Mexico as a "have-not" Region.
It was less clear whether any goals or objectives had been born out of
a more specific assessment of the needs, problems, and resources of
the Region.

The team felt that the goals and objectives were congruent with national
priorities as stated, but were being implemented less successfully.

Spokesmen'for the medical school, medical society, state department of
health, and other federal agencies all acknowledged their agreement with
the general goals of the program. Implementation of specific objectives
to carry out these goals had proceeded slowly enough to,raise the
question whether the established health forces in the Region really
supported these goals; there was no hard evidence to justify this
skepticism, however.

The Region appeared torn between its rhetorical emphasis on broad,
non-categorical activities, and what appeared to be its actual continuing
strong emphasis on the categorical diseases. The Core staff is still
structured around the categori-cal diseases, with assistant coordinators
for each disease area. Each assistant coordinator has responsibility
for a group of projects in his categorical disease area. The site
visitors felt that this emphasis on the categorical diseases inhibited
the Region's attempts to pursueits primary non-categorical goals, to
puisue its objective of subregionalization, and to link together all

New Mexico RMP Site Visit -4- RM 00034

of the planning and projects into an integrated program'. Futhermore,,

e the Region seemed .to realize this dilemma: It described as "vestigial"

its persisting structure oriented toward the categorical diseases. Yet
the Region had not chosen to divest itself of this "vestigial" structure.
Perhaps this was because many on the Core staff had been chosen for .
their competance in the categorical diseases, and held medical school
appointments, and thus' could neither be easily replaced nor asked to
accept non-categorical planning and organizational responsibilities.

,.

Some of these responsibilities were among the new objectives outlined
in the current application. The objectives were all fully congruent
with current Federal priorities. They include: 1) The development
of new types of allied health manpower; 2) The development of area
health education centers as proposed by the Carnegie Commission
report; 3) Implementation of the Emergency Health Personnel Act;
.and 4) The developaent of Health Maintenance Organizations. The
site team felt that these objectives had been chosen more because
of signals from Yashington than from a spontaneous interest arising
in the Region. As will be discussed later in the site visit report,
little thoughthad apparently been given as to how these objectives
would be pursued and implemented.

3. Organizational Effectiveness

1. Coordinator

e*

A major defect of the program is the failure on the part of the Coordinator
to exercise a leadership role.
of the operational framework within which the program goals and objectives
were to be accomplished. He cannot be identified with a particular strategy
which gives "character" to NMRPlP. It is the feeling of the site visit
team that he has similarly failed to characterize hWRMP to his constituency-

He failed to provide clear understanding

On the other hand, Dr. Fitz appears to have developed excellent personal
relationships with CHP agencies and medical society, but this may
well be related to lack of the usual presstire exerted by agressive
RMP leadership.

Dr. Robert Stone, Dean of the University of New Nexico School of
Medicine, the grantee agency, inferred some lack of confidence in the
leadership ability of the Coordinator.

*

2. Core Staff

The core staff is
in the absence of
words, individual
the functions are

    The competency of
e and competency of

small and th'eir effectiveness is difficult to assess
an understandable programatic framework. In other
functional effectiveness can't be evaluated if
not wel.1 defined and organized.

core staff was difficult to judge. The background
a few were well demonstrated in terms of specific

New Mexico RElP.Site Visit -5- RM 00034

targeted responsibility (e.g. for tumor registry, health information
system and categorical activity) but one sensed a lack .of cohesiveness
associated with good management.

,,

The fact that the management assessment team criticized certain
auditing lapses on the part of the grantee, lapses which in fact
do not exist, suggests a wide hiatus in terms of grantee-staff
administrative relationships.

There is little evidence of capability in evaluation or at least
use of the capability if such exists.

The categorization of core staff is highly artificial and based on
admittedly "vestigial" categorical (heart, cancer, stroke) considerations,

One member of core staff who is obviously a plus is Dr. I. E. Hendryson.
He is creative, understanding .- and well-organized.

C. Assessment of Needs, Problems and Resources .-

Although there is a stated commitment to subregionalization and change
in program direction, there is little evidence of intent to modi-fy
staff composition and responsibility rin acknowledgement of new program
directions.

The core staff, particularly the Director, have been admirably involved
with other federal health agencies-"especially CHP--since the beginning
of the NM/RMP.
planner") to work with the A agency 2nd to help plan or the
establishment of B agencies. Another RMP staff member is designated
full-time to work with the B agency in Santa Fe (NORCEIAP) and with
the Santa Fe Model Cities Program. Since the A agency staff consists
of four people, and the B agency staff of three, the RIP contribution
is substantial. The DIP representative is involved also with developing
community organization and planning in  the Four Corners  area of the
State (described elsewhere in this report). The site team commended the
NM/RMP on this aspect of Core staff activities in program implementation.

Several questions clouded the evaluation of program implementation.
It appears that the hX/RXP has not decided whether it should serve
as a "doer", directly instigating activities, or, as. a "broker" to
encourage others to do so.
the "broker" role. This raised two questions: (1) Is the RMP an
active broker, perceiving opportunities to bring disparate groups
together, ol; is it a passive broker, available only if other health
groups, on their own initiative, sought REP assistance? It appeared.
to the site team that NN/RMP has been too passive in the broker role. .
(2) Is the NM/RMP seen as an independent organization whose staff
has special planning and implementing resources, or is it seen merely
as another source of dollars which other health agencies could tap?
It appeared to the visitors that the NIP has been viewed by the
Medical School, Medical Society, State Department of Health, etc., as
a source of funds. The team recognized the problem of creating a
sophisticated and independent organization in a "have-not" region, but
felt that the BIP leaderyhip has not done enough to develop such an

RMP has paid the salaries of one staff man ("community

It seems that the NM/RNP is playing mainly

' organization.

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New Mexico RMP Site Visit Report -6- RM 00034

The visiting team was concerned by a disparity between the region's
stated new ohjectives and its readiness to pursue those objectives.
For instance, it was stated that the continuing education function
would be enhanced by recent legislation making New Mexico the
second state to require continuing education for physician reliFensure.
Yet,  there was no indication as to the role NM/RMP might play in
assisting the State Medical'Society to develop these mandated continuing
education activities.

The Region indicated a strong interest in the developmedt of new types
of allied health personnel. Indeed, the NM/RMP directly supported the.
initial development of a nurse-practitioner program in Estancia.  This
program was subsequently funded by the National Center for Health
Services R6.D. There was no evidence that staff of the NM/RMP is
currentl-y involved in seeking other opportunities to expand the use
of this model for health care delivery. NM/RMP supports 50% of a
secretary's salary to assist the Hospital Association in its physician
assistant (MEDHIC) program. However, overall, GYP'S efforts in experi-
menting with the development of new types of health personnel are only
token at this point.

The Region expressed an intention to assist with the development of Health
Maintenance Organizations. The site visitors could not identify anyone
on Core staff with the kind of expertise and available time necessary
to stimulate interest in, and plan for FMOs. The Dean specificially
doubted the capacity of RMP to help develop HMOs. In fact, the only
HMO in New Mexico which has been seriously considered thus far is
the joint venture of the Lovelace Clinic and Presbyterian Pledical
S.ervices; hW/RMP has not been involved in the planning.

The Region stated that they would like to help develop Area Health
Education Centers, 'as recommended by the Carnegie Commission. Again,
the site visitors could identify no one on the Core staff who could
pursue this task. The only possibility thus far is the Las Cruces
(New Mexico State University) area, and this possibility has been
explored by the Dean's office, and not by RMP staff.

The site team found no evidence that the.Region had considered how

the Emergency Health Personnel Act might be implemented 'in New Mexico,
'despite their indication that this could become a function of RMP.   In
the proposed Model Cit-ies activities in Albuquerque and Santa Fe,  and

in the Emergency Health Care proposal for Rio Arriba County, apparently
no thoughthas been given to the possibility  that the Emergency Health

Personnel Act might help supply physicians.

..

The visitors were concerned about the approach that New Eiexico F@fP
has taken in stimulating an application for an Experimental Health
'Systems grant from the National Center for HSR&D.
rejected direct RMP leadership of this effort, and chose to form a new
planning body--the Albuquerque Area Health Coalition.
RMP had participated in the development of an Experimental Health
Systems proposal (consistent with its recently developed objectives)
it did so in an indLrect and possibly ineffectual manner.

'

The RAG specifically

Thus, although

New Mexico RMP Site Visit Report -7- RM 00034 .

Although the Region claimed to place a high priority on the
development of a program in kidney diseases, the only progress in this
direction was to form a committee twelve months ago which has "not
developed any plans to the point of maturation." In fact, no plans
of any sort were described
none of the four nephrologists in the Region has been seriously
involved. The site team believed that opportunities do exist
for preliminary planning for a renal program, and notedithe
especially critical needs in the Four Corners area as one place to

to the site visitors, and iti appeared that

begin. 1

1, Grantee Organization

The grantee organization provides adequate support, in fact some
unrecognized as noted above. Although there appears to be a clear
separation of grantee and administrative responsibility, there was
developed at the beginning an excess dependency of the medical school
upon the resources of NM/RMP. This is acknowledged by the Dean who
promises to phase out this dependency as quickly as possible (but
not abruptly) and who acknowledges that the school has greater
obligation to RMP in return for the investment.

Early-on the New Mexico University School of Medicine took vigorous
note of the need to separate its policies and philosophies from the
NM/RMP, in spite of the heavy dependence of the NM/KMP on the Medical
School for professional resource people. In fact, the lack of strong
leadership by the RAG Executive Committee is likely the result of a
conscientious attempt to avoid an appearance of co-opting the hM/RMP
by a single major interest. In 1968, Dean Stone criticized "too much
Medical School involvement .'I

e

It is the feeling of the present site visit team that reinvolvement
in the RAG by key Medical School people would strengthen RAG lead.er-
ship.
Medical School should be closely involved.

2, Regional Advisory Group

Certainly in the selection of a new Coordinator for NM/RMP  the

.I

The New Mexico Regional Advisory Group currently  consists of 41 members.
24 are located at Albuquerque, 7 in Santa Fey and one each from ten other
locations. The group well represents the areas where care is available
and represents some areas of need, but more Regional Advisory Group input
as to other local needs would seem desirable and possible if active,
representation could be found for the other high need areas.
Appointment is initiated as a result of individual expression of
interest and there has been little apparent attempt to seek out members
in an effort to create appropriate balance.

. -- .

New Mexico Site Visit Report -8- 00034

Nineteen members were added to the Regional Advisory Group in December
1970.
Las Vegas, and Carlsbad, so it would appear that this change in the
membership was intended to increase its size rather than for the prime
purpose of extending representation.

12 reside

in Albuquerque, 4 in Santa Fe, and one each in EspgEola,

The Executive Committee, which is obviously the key policy making
group wh.ich wields the power, is inappropriately constituted in that
all of the members but one are physicians. In the RAG itself there
is little representation from the allied health professions other
than physicians and nurses. Participation by institutions of higher
education is limited to the University of New Mexico, there being
no other colleges or junior colleges participating.

The present Chairman has served in this capacity since the beginning
of the program.
provide for rotating Chairmanship with an election each year,  there
appears to be a reluctance on the part of the membership to elect a new

chairman .

Throughout the site visit presentation it seemed clear that policy
was made and controlled in the staff and Executive Committee. There
was little reference to the Advisory Group in any of the presentations
or discussions. One would conclude that the Regional Advisory Group
is in fact a board for approval ratlier than one for active participation
in policy making.

The site visitors noted that although the By-Laws

As the New Mexico KMP goes forward to programming, it would seem
necessary for the Regional Advisory Group to take a stronger role
in the policy discussions of'the program.
contribution expected of each member of the Regional Advisory Group
could lead to moving the group in this direction and if necessary,
to some change in the makeup of the group.

An evaluation of the

Wide use of interlocking board memberships appears 'to have established
good working relationships with other related health planning agencies
and should continue. Reciprocal lnvolvement on the NM/RMP RAG is not
so apparent. There is no OEO representative; there is one Community
Action Program member on the present RAG.
tive of the Bureau of Indian Affairs is striking. In the selection
of a new Coordinator, his ability to achieve broader delegation of
responsibilities and to activate representation of presently uninvolved
health agencies and ethnic groups should be considered.

The absence of a representa-

The RAG, through its Executive Committee, appears to have policy control
over the program and seems to have credibility, at least in the
Alburquerque and Santa Fe areas. The team had very little opportunity
to assess the perceptions of other areas of the state.
that although decentralization, regionalization and peripheral
dissemination is stated as a major objective of.the future, the
representation from the peripheral areas is minimal. Also, there is a

It was noted

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New Mexico Site Visit Report -9- RM 00034

technical review structure and process outlined in the application.
However, it appeared to the team that very little objectivity is used
in such review since the approval of activities does not seem to be
consistent with the priorities as stated by the RAG itself.

Involvement of Regional Resources

The IQl/R.IP seems to be quite effective in its support of other health-
related interests, institutions and professions in New Mexico. It has
been particularly active at the planning level and it is anticipated
that this activity will contribute to achieving regional goals.
Presumably effectuation of ongoing projects of significance should be
forthcoming . e

Comfortable relationships have been established with practicing
physicians, and organized medicine in New ?lexica seems to look

-

favorably on N?I/E?.?lP as a whole. . __

Community hospitals are well-represented, but because of the population
"distribution, they -are predominantly from Gcrnalillo County (Albuquerque).

Alvleson beam facility is being built at Los Alamos. It is anticipated
that the facility will be finished by 1973. The possihlc application

of a Meson beam for delivering radiotherapy at specified depths has
therapeutic implications which are being pursued by the N14/RMP Cancer
Coordinator.
There seems to be amicable association wj th other health agencies ,
especially at the planning level. However, little direction has been
achievd toward interesting other agencies in taking over projects as
part of a planned phase-out.
with other planning groups--i.e. assignment of a Core staff employee
to CHP in Santa Fe seems to be useful at the planning level. Consumer
and community groups have not yet been extensively involved in the RMP.
The Espaxola project may prove to be an outstanding exception.

-.

. .. -

NM/RMP has developed good cooperation

Some support of New Mexico poli.tica1 power structure seems to have
been received through the State Health Department. However, there was
no evidence of close working relationships at the -program level.

In terms of subregionalization, much was said about future intentions,
although up until now, RPIP progrm activity has been virtually limited
to Albuquerque and Santa Fe. There appears to be some disagreement
between the Coordinator and theDean concerning the most logical
targets of initial subregionalization attempts. There is no evidence
as yet of participation by people intheproposed subregions in the a
planning for such regionalizacion, except in Santa Fe.

Part of the site team visited the Espazola Hospital, which is about
23 miles northwest of Santa Fey to look at the Emergency Medical
Services program, under the direction of Dr. Hendryson.  It appears
that the resources are appropriate and the individuals involved
in this institution are ready and anxious to cooperate in the

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New Mexico RMP Site Visit

- 10 -

'131 00034

development of a subregional concept.
team that Espanola will be able to serve as the regional center for .
a large geograhic area in the northern region of the State.
there seemed to be a genuine understanding on the part of those with
whom this was discussed, of the organizational needs and requirements.

It appeared to'the visiting

Further,

Program Imp 1 erne n t a t i on and A c c omp 1 ish me tit s

1. Core Activities have been covered under Organizational Effectiveness,

page 4.

\

2, Project Activities and Evaluation

The site visitors had very little time to evaluate the individual
project activities, and our comments here will be necessarily brief.

The site visitors felt that the planning effort (the Health Information
Mini-System) had not directly led to operational activities,  Rather,
opportunities for action that fit the general goals and objectives of
the program had been "grabbed up" -- there was no evidence that the

Region had used its planning data to specify areas of greatest need,
and then instituted operational activities to meet these needs. The '
site team realized that this type of approach had characterized many
RMPs,  and were hesitant to be too critical on this point.

Most of the project activities seemed appropriate to the Region's
apparent and stated goals and objectiv'es -- dealing with improved
access to health care, disease prevention, and particularly the manpower
shortage.

Most of the projects appeared to strengthen linkages among the Region's
health institutions.

Tliere is little evidence of capability on the part of Core staff in
evaluation procedures, and the team noted that this segment of the
New Mexico program needs attention and strengthening. Although

. there is adequate staff to begin some planning in thissdirection,
no formal plan or strategy was presented.

The site team was bothered by the fact that almost all of the projects
which had begun three years ago were requesting an additional three
years funding. This seemed not in keeping with the policy of phasing
out support for given activities as soon as possible, in order to,create
"turn-around money." On the other hand, the team realized that New
Mexico was a region of limited resources where the health sector was
less liable to be able to pick up and financially support RMP-initiated
activities. Nevertheless, it was felt that more support from non-RMP
resources could be found for those projects which clearly provided
services to comnunity health facilities, such as the Stroke and
Rehabilitation Project ~ and the Unified Laboratory Science Training
Program.

New Merico Site Visit Report - 11 - RM 00034

The site visitors .felt that the individual project activities were not
as well integrated as they might have been. They appeared to be

"a group of good deeds"  rather than the implementing arms of a cohesive
program. For instance, the cancer registry has been successful in
abstracting records from hospitals with 3o"L of the Region's beds, and'
yet the registry data were apparently not being used as part of the
Leukemia-Lymphoma program, to plan an overall cancer program, or to tie
into a continuing education program in cancer. As another example,
the three coronary care projects were described in the application as
separate activities; despite assurances of thei-r integration by the
heart disease coordinator, evidence in support of that assurance was
lacking. It was felt that the three projects should be combined,
with probable savlngs iri both quality and cost,
meaningful integration, the site team was pleased to note the
intention to coordinate the streptococcal throat screening and
'phonocardiogram screening programs.

One project which site visitors found very impressive
was the Emergency I4edical Services project. Under the vigorous
leadership of Dr. Hendryson, this project has completely surveyed
emergency medical services in the Region, has led to the establish-
ment ofa Governor's Advisory Commission on Emergency Medical Care,
and has trained 400 ambulance attendants and essentially all of the
state highway patrolm2n in basic emergencv medical care procedures.
This project seemed particularly appropriate in. view of the fact
that mortality Krom accidents is greater thzr! nortality from any of
the categorical diseases in New Plexico, and emergency care is greatly
complicated by widely dispersed health personnel and facilities.

As one example of

e

It is difficult to see the Plew Mexico RJIP as a unit. It exists as
a number of separate projects not yet tied into a composite whole.
Assessment of the overall program and evaluation of projects must
wait on the establishment of a system of progran and detail evaluation.

There was no evidence of any feedback mechGnism relating to program
and project  evaluation of the Regional Advisory Group.

TV. Conclusions and Recommendations of the Site i'isit Team

1.
exist between the hP.I/RI$P and other professional groups, and the
Dean for the Medical School support of the XX/XP. The team was
cognizant of the possible jeopardy to the Hediczl School by a
severe cut-back to the program.

The region should be complimented on the goafrelationships that

Although there appears to be a clear separation of the grantde and
administrative responsibilities, the site team vas aware that in the
initial stages of the program an excess dependency of the Medical
School on the resources of hYl/RMP existed.  Dean Stone acknowledges

this and stated his intention to phase out this dependency as quickly
as possible.

e

New Mexico Site Visit Report

~.

RM 00034

2. It was agreed that another year will be required to prepare an
appropriate triennium document which 1iou1.d be capable of approval
and implementation. The hqf/RMP has not demonstrated the program
maturity of a Developmental Component.

3. Core staff is in great need of strengthening. i

i

4.
in order to allow the region to establish a plan of action which will
emphasize a more positive approach  to a viable DIP.

5. A Search Committee should be appointed as soon as possible to
find a new Program Coordinator,

Funding in the amount of $850,000 for one year only !is recommended

I
I

6. The-membership of the Executive Committee of RAG needs better
representation and orientation for its role in policy guidance of
the program.  Consideration should be given to some modification
in its leadership ar:d direction in order that this body can more
adequately representand steer the larger body.

7. Except through indirect ineans (through CI-IP and Model Cities
outreach) the NM/RIP appears to not have addressed the speci.fic health
needs of minorities.

.e

8, Finally, the team was disappointed at the lack of progress in the

e kidney disease area. It is believed that opportunities do exist for

preliminary planning for a renal program, and the consultants noted
the especially critjcal needs in the Four Corners area as one place
to begin. The team's recommendation for this component of the
program is that an amount of $30,000 be specifically earmarked for this
hea3,th problem.

RMPS I7 I? 7 I71

a-

,.

REGIOML IGDICAL PROGRANS SERVICE

b

#

0

e

"9 10 I' App I $ca t ion
(Special Action)

NATIOWAL KIDNEY FOirNDI?TTON
3L5 Park Avenue, South
Nev York, New York 10010

Project Director: Edward 3. Mitchell

Direct Corts $3G'7,0lO $350,17G $341,870 Si, 05?,05 I!

Indirect Costs - 0- - 0- - 0- - 0-

TO%'A L $367,010 ' $350,170 $341 e7G $: * 35 9 G5C

(Special Act. 1 8/71

"9 10" Kidney Ap p 1 i ca ti on

-2-

"he project is divided into two areas of concentration: the first is
a national project r~ihich is an expansion and development of the existing .
public and professional program of the Wational Ridn'ey Foundation; the
s&ond is a local pilot .project in a state or major metropolitan area
and is designed for a more controlled and intensive effort than is
proposed on the national level.

Of the $367,010 requested from RMPS for the first year 28.6% is for
personnel; 7.4% for consultant services; 2.5% for equipment; 2.6% for
supplies; 3.2% for trsvel; 55.5% for "other." The major "otIicr" costs
are Postage arid Shipping, Euilding Occupancy, and Printed and Audio-
visual iIateria1 s.

-4

T;-,e Pznel found this pro~rosel to be s.:ittiout innowtion and believed it
reyresri,tcc' essentia1l.y the contir,u,?tion of es tzbl i shed Xst.ior:aI Kidney
Pounc!atFon activity. Tlie proc?durcs ;re nor clca+J y tlci'incd no+ is
the process for evsluation, such -1s ?;'e- ari(I pbst- publjcity action,
spelled out. Thc p:oposal misses an ir+oi-tnr,i point in riot being ilerected
at tiic i?entificaticFL of the po;,l2-~ti0:1 vhu should Lc ~~oor!*ccl r:ith i2
specific areas to p:-ocure orgz!is .i:!.icy, cor 1- ~vi!Xllc7bIt. TIie Panel believed
';hat such of this work is being periorncd on the :",e:ional level, and that
the Foundation rq:ould Ez riel1 advised to coordinate or coopcrzte with-
Regional activities.
might perform zri intermediary role .c.:here ap?I icationr: are knorrn to be
under dcvelopmnt. It seem that the Foundatjcin could efectively
accomplish munch of its task, without Fedel-a1 funds, by coordinating its
funding riith its af fi?lated chapters.

1t was recognized

that the Fciindaticn aEd its affiliates

1-

-- Rccornnrendatj.or1:

The Pgnel recooxended that the "KLdncy Donor Program"
not be supported.

Subject:

TO:

DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE

             PUBLIC HEALTH SERVICE
HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION

June 17, 1971

Pre-Triennial Assessment

The Reviewers of the Northern New England RMp

The llorthern Nev England &lP is entering its third operational year
during which it ;rill be preparing its triennial application. This
Region has pursued a *data collection and anal-yeis approach to program
developrr,ent unique among most R@s.
has been an unusually small number of operational projects.

+has not submitted any projects since its initial operational.
application (vhich contained four} was revieled two years ago.
were the supplemental proposal (project #6) included in this applicailon
to be approved and funded, the Region muld still have only three ongoing
operational proJects.
Project in Continuing Education, will be in their. last year. Applications
from this Eegion have experienced conti;iiting difficulty in review at the
national level since the Program's p1am;ng days.
explained its systems approach well, nor Justified its requests for
funds as completely as it should have.

Concomitant with this approach

The Region


  Even

Projects #2, Progressive Coronary Care, and #+,

It has not always

In staff's review of the appl-ication in L:ay lc)7J, they were similarly
unable to get a grasp of vnat the Region hzd zccomplished and what  its
future plans might be. Regimal goals, objectives and sirategy seemed
to be absent from the RAG report.  'While the application forms  did not
ask for an Explanation of the data base,  staff L~YS djsappginted that
the Region did not tzke the opportunityto describe its program or to
discuss possible implementation of the technic81 site visit recomnien-
dations in December 1970.

For these reasons, winen staff reviewed the application they recomnended
'to the Director, WJPS, that Committee and Council be requested to assess
fts program approach beore the Region began preparation of its three
year Look. Additional information was requested from the Region. The
memo containing staff'k review and recoirmeniia-tions can be found at the
end of the suirmary.

In conclusion,  staff would Like sone guidance on how to work with this
Region while it is preparing its triennial a-pplication.

..

Dona E. 1Iouseal
Public Health Advisor
Grants Review Branch

REGIONAL MEDICAL PROGRAMS SERVICE
(A Erivileged Comunfcation)

SUMMARY OF AN ANNIVERSARY GRANT APPLICATION

-

Northern New England RMP
University of Vermont
College of Medicine
25 Colchester Avenue
Buslington, Vermont 05401

e

RM 00003 8/71
July 1971 Revfew Committee

c

1'r~)grarn Comdiriator: ,John E. Werinberq, M. D.

`I'his Region Is currently funded at
operational year wkiich ends August 31, 1971.
request of $971,708 for continuation of core and two projects (staff action
Jriiy) and a new project dealing with kidney disease (Committee and Council
actign required).

599/9G

(dlrect costs) for its second
The application includes a

A breakout chart identifying the compments follows,

                    FUNDING HISTORY
                    Planning
Grant Year Period - Funded (d.c.9.)

OL

$208,807
577,775
459, 581

Operational Program

Grant Year Period Funded (d.c.0.)

01
02
03

s/1/69-8/31/70
9/1/70- 8/ 31/71
Future Commitment

$915,703

670, 677
590,196 L/'

This amount is reduced from the bmitredlevel of $670,677 as a result
of RMPS funding cuts.

GEOGRAPHY AND DEMOGRAPHY

Although the Northern New England RMP was originally envisioned to include
New Hampshire, Maine and Vermont, this Region now encompsses only the State
of Vermont and three northeastern New York Counties.  The population of this
total area is 595,700.
University of Vermont College of Medicine at Burlington.  There are also
five professional nursing schoo18, three practical nurse training and four
B Llied health schools.

The State of Vermont has one medical school - the

Vennorit is served by 621 active physicians, 31 of whom are osteopaths.
are t836 active and 955 inactive nurses.
presently actively employed.
20 hospitals with a totall,961-bed capacity.

There

956 licensed practical nurses are

In addition to a V. A. Hospital, there are

e

ORGANIZATIONAL STRUCTURE AND PROCESSES

Northe,rn New England RMP

-2 -

r

m 00033 8/71

Comprehensive Health 'Planning have been merged into a 32-member group dhring
the past year.
in a subsequent section.

The new relationship between these organizations is described

The Regional Advisory Board component of the Joint hard has 25 voting members,
including seven consumers.  The purposes of the RAB are to advise and guide
the RMP in its planning and operational programs; to be actively involved
in developing regional objectives;  and to be continually concerned with the
relevance and effectfveness of the RMP's programs to its otJectives.

d

1

A Stiir1.y Corrmij 1,tcc: or' tlic lv\B :serves a:; an Executive C.wnaj ttee to tfie 1lAl.l.
14,z x-J':n rrmribf:r:; revicw end make rec~orr~~neridations on proposed progr'ain,:; to
',:.e PAE, monitor f'unded programs, ratify candidates for. disease iriariaheineiIi,
cvmictees and function as the Regional Health Management Committee of the
Ztate Health Planning Council of CHP.

This Region has organized disease management committees to bDth manage  clinical
activities and recommend investment of resources for a delineated nhber of
specific health care problems, usually in a particular categorical disease
area. Membership of the committees includes physicians, nurses, hospital
administratiors and representatives of other health interests. More speci-
fically, such groups are charged by the Advisory Board with:

1. Accountability for the establishment of the standards and

guidelines for the clinical management of preventive, early
detection and therapeutic and rehabilitative services vithin
the region.

2.

Recyonsibility for rrmking operational decisions on the allocatlon
of health rlystems resources under their control and influencing
deci:;ionc on resources that are not directly under their control.

3.

Responsibility foq. establishing a quality control inforfiation
system and exercising audit functions for the ,disease area under
their pllrview.

An operatisnal disease management program for coronary artery disease
caficer currently exist.
respiratsry disease, stroke, and kidney disease, as well as maternal and
chilrl problems, trauma services and infectious disease. Six Intersociety
Task Groups in Heart Disease have also been formed to read and review
Intersociety Reports on Heart Disease, review data from Vermont and make
recommendations fvr programs to the Coronary Care Management Committees.

and

There are plans to develop similar programs  in

CORE
Core staff's prim8r.y sphere of activity appears to be the data system. Its

-

'</'

Norl,hern New England RME' -3 - RM 00003 8/71

-

a

accomplishment:; during the pafit year included working with the disease
management reports, completing data base developnent, establishing outlets
for data, and completing a study of primary care in Cavendish,  Vermont.
Other efforts included work to achieve the merger of the CHP and RMJ?
Advisory Boards and providing organizational support to disease management
groups and CH?"b"agencies.

Its plans for next year are listed as follows:
data to develop the State Health Plan, 2) provide organizational support to
develop disease management committees in respiratory disease and kidney
disease; 3) provide organizational and technical support to developing
CHP "bff agencies; 4) develop new Phase I1 reports on major health problems;
and 5) continue to update the data base.

rLhe staff includes 17 members hth expertise in administration, medical
coding, systems analysis, survey research, urban planning;, education, library
work, mathematics, social work, engineering and medicine. All but two are
full time.

1) provide basic planning

Core staff has completed reports on cancer, respiratory disease, end-stage
kidney disease, stroke, prepared phns of medical care, and primary care
management in rural practice.
Core staff will be funded at approximately a $389,157 level during the 03 year.

THE DATA SYSTEN

The NNE RMP has a comprehensive, population-based information system con-
taining: 1) hospital, nursing home and home health agency abstracts for all
institutions within Vermont and neighboring portions of New York and New
Hampshire; 2) health manpower and facility inventories for a similar area;
3) corresponding demographic data; and 4) survey research capability.
ing to the RMP, this data base permits the establishment of population based
utilization, disease, admission, procedure and mortality rates on a small
geographic base.  Differences between individual institutions can therefore
be observed. It also pernits cross tabulations with physician characteristics,
estimations of per capita resource investments including personnel, dollars and
facilities.

Accord-

In addition to the special reports in particular categorical areas, the Region
is providing data to CHP for its planning uses and to the State Medical Society
for its Peer Review organization.  Other users include the Connecticut Valley
Compact, the Northern Counties Comprehensive Health Planning Council, PLanned
Parenthood of Vermont, the Vermont Hospital Association and two HMO activities
(fn Abnaki and Black River).

RMP-CKP RELATIONSHIPS

During the past year the FNP Regional Advisory Group effected a merger with
Vermont's State Health Planning Advisory Council (CHP A Council) to form a
new State Health Planning AdvSsory Council (SHPAC).

On Cecember 9, 1970,

Northern New England RMP -4. - RM 00003 8/71

the organizaing meeting of the combined RMP-CHP Boards was held.
board has retained within it the Regional Advisory Board (RAB) membership
and it:; ability to function as a separate board when necessary.
other hand, come F3P bard members are not full voting CHI? Board members.
Members from the RAB serve on all six of the Council's standing committees.
In addition, in order to retain continuity in decision making, the Study
Cmmittee of the F3P has been retained intact as the Committee on Regional

The meeged

On the

Health MaEaagement for the State Health Planning Advisory Council.

I

Yith regard to RMP-CHP staff cooperation, the two staffs are collaborating
3n devehpent and implementation of the data base.  One interestinc note is
the fact that Mr. David Miller, the CHP A Agency Director, is organizationally
above milp by virtue of his position of assistant dean at the Medical School.

A recent NNE RMP newsletter discusses the differences between RMI? and CHF' in
the following way:

The purpose of the Regional Medical Program is to develop
regional disease management programs.  The purpose of the
Comprehensive Health Planning Program is to create planning
councils to analyze problems, set priorities, and establish -
plans concerning the most comprehensive aspects of health.
Without the Regional Medical Program, Comprehensive Health
Planning lacks sufficient specific resources for technical
skills in problem definition, program design, and program
evaluation. The Regional Medical Program, with its Univer-
sity base, provides a technical skills resource which can
respond rapidly and efficiently to the needs of Comprehen-
sive Health Planning for technical assistance.
done either with the Regional Medical Program resources or
by using the Program as a technical advisor in evaluating
other technical resources.

This can be

Without Comprehensive Health Planning, the Regional Medical
Program lacks context. Comprehensive Health Plahning pro-
vides local and State level planning organizations. Through
these organizations, it expects to achieve a planning process
which will determine the problems, the priorities, and the
actions necessary to achieve comprehensive health.
Regional  Medical Program's information and technical skills
can be used mxt constructively in support of this planning
process. kmprehensive Health planning, therefore, provides
the mechanism for deciding whether or not the Regional Medical
Program's propsed alternatives are feasible solutions either
ir, terms of public acceptance or interagency cooperation.

The

Nqrthern New England RMP

.5 -

m 00003 8/71

I
J

r--- - ---
I
I

I

r- -1

I
I

VERMONT KMI'/(:HP
OH(;ANI%ATIONA I, CHAKT

MVET(\OR

I

REGXONAL DEVELOPMENT
PLAI?NING PRoGBAM

--

Plaririing for regiDnal medical programs in Vermont began in June 1965 wi.th
the appintment by the Governor of an Advisory Board for IleaLth Programs.
Early planning eff9rts appeared to center in the University and were
directed by Dr. RDbert Slater, then Dean of the Medical School.

Early in the planning process, a systems approach to definition and analyses
of needs vas outlined.
to develop, in collaberation with the professional health personnel of the
University Medical Center, alternative organizational patterns within which
the most effective use of professional talent could be made.
attention was paid to developent of basic models of patient care.
national reviewers had questions about the practicality of such an approach
to the complex problems in medical programs, a national ad hoc committee of
systems analysts was convened and developed guidelines for Regions who
wished to take the systems approach.  Funds for the TRW contract were omitted
in the initial planning award.  Progress w8s slow because of change in direc-
tion (Dr. Robert Coon replaced Dr. Slater) and the lack of Core staff.

the change in Coordinator, the Region did not veer from its original emphasis

The engineering assistance of TFW was contracted

Particular

Since

With

on systems analyses.

Although some of the systems analysis proposals were

e

Northern Mew England

6- RM 00003 8/71

deleted frm the qriginal applicatim, an attempt was made t,.> include
similer services by making use of University resources.
:;5ipc were tlevelqxd with the C.,lley,e of Engineering, bioen@ rweri t1f:
persQnrd and management erlgi rieering f:rmps,
$62,000 t:, supprt a survey of' heart disease in Chittend9t1 C:?unt,y was ::1111-
rnitted during the first planning year.
first, attempt to relate baseline data to treatment, approval was recommended
and the study funded at a reduced amount.

Planning during the 02 year continued to emphasize the systems analysis
fraEewgrk:  a supplement was submitted requesting additional Core staff
positions, a subcontract for systems engineering consultation (TRW) , service
charges for a Professional Activity Study (PAS) and additional personnel
time from the College of Technology.
was to develop a Model of Patient Care by a Committee which would define
objectives, identify evaluation criteria, review progress and make recommen-
dations to the RMP Core group.
Disease Management Groups described below .  Because of the need for more
information about such an approach, a site visit was held in July 1967 to
r3view the merits of the application and to assess the systerns capbility.
The visitors found the systems capability modest but with the involvement of
tke University resources in technoloky, etc., they thought that it would
expirid.
the exception of' the systems subcontract with TRW and some of the bioengi-
merirtg pocitions, should be supported.

Dr. J&a Yennberg, a young physician with expertise in preventive medicine
and public health, succeeded Dr. Coon as Coordinator in May 1967.  With
Dr. Vennberg's appointment came somewhat of a change from the long-range
planning described above to short-term project development.  The Region
exbarked on certain planning activities,  some of which later evolved into
operational proposals. These studies included the heart inventory, the
PAS study and the systems contract with TRW (mentioned earlier), as well as
coronary care, emergency care, and health professions education studies, a
regional cancer project and a hospital-shared data processing system. The
RMPparticipated in the developnent of the Connecticut Valley Health Compact,
whose overall goal was to examine the possibilities for the provision of
tDt81 health care Sn the subregion. Many of these studies, however, showed
the continuinf: importance of the systems approach to problem solving and
planning in the liegj 'xi's conceptual strategy. During Tts third planninlr,
year, the Rc:c:j or1 reyue:;t;ed arid vas qranted approval to rebudget iLlndc  fl>r a
data j rif'ormtion oti:dy Lo be yerfonned under contract with I'M.  Thc stridy
pLanried to develop %he tazic plenu and opernting methods  for a  ::liared daLa
proceseing system which could be accepted by all hospitals in the Regioii.

Closer reLa1,i on-

   A supplernental requcr; 1. ('or

Since the proposal represet~ted a

The overell plan behind this request

This Committee was a forerunner of the

Eevicwere agreed with the visitors that the planning request,  with

OPERATIONAL PROGRAM

The iiegion's operat5oiial application, including renewal of core and four
yrolects ms submit!-,ed in liiid-l$&8.

The project:: included:

@ Prcgressive Coronary Care
#3 hergericy Health Care
$t
#5

Continuing Education for the Health Professions
Evaluation Protocol for Emergency Health Services

Northern New England RMP -1- Km WUWU~ U/ll

e

e

e

A pre-operational site visit was held in October 1968.
the Region's slow rate ot maturity and the lack of RAG involvement in the
decision-making process. They were also concerned by the lack of medical
society involvement in generating program ideas, the absence of a clearly
defined conceptual strategy, and apparent irrelevance of the operational
projects to the immediate categorical health needs of Vermont. On this
basis, Council deferred the application for additional information and clari-
fication. The revised submission was reviewed again in early 1969 and
approved. Core was approved at a reduced level with reservations. Reviewers
noted the continuing emphasis on systems engineering and analysis. They
questioned the desirability of such influence in the operational project
managers, who seemed to stand outside of the medical activities proposed,
and they stated that there should be no further significant increase in
Core staff support until the Region had demonstrated the effectiveness of
the staff currently employed and the existence of a plan pertinent to
Regional Medical Programs.  Project 113 was not supported because of Council
consideration in mobile coronary care units and part of the program of
pzroject #5 was consolidated into Core; Until this cycle (July-August 1971)
the Region has submitted no further project applications, although staff
learned that over 40 proposals have been in the local review process. In
May 1970 when the Region submitted its continuation request for 02 year
support, statt found the progress reporting so sketchy, the tuture plans so
nebulous and the financialreporting so unjustltied, that the application was
deemed unreviewable. There was also considerable discussion about the
Region's first year of operational experience resembling ita planning ex-
perience, i.e., concentrating on problem identification, epidemiologic
studies, data analysis, etc. There appeared to be no clear-cut operational
plan of action.  The Region submitted a revised application, which was
approved with the statt recommendation of a  site visit.  Such a visit would
investigate: 1) whether the Region actually has systems..analysis capabilities,
2) whether the Region's strategy and its incorporation into the CHP planning
structure was consistent with RMP goals and also evolving a Regional Medical
Program, and 3) whether there has been any major reallocation of iregional
resources.

The visitors noted

A staff consultative site visit was made in early December 1970. The recom-
mendations are too numerous to repeat here, but the general advice seemed to
be that although the major emphasis on data acquisition and analysis  stra-
tegies was reasonable, perhaps some of the Region's resources should be
allocated to RMF' activities which would give the RMP some visibility in the
Region.
but some glans for utilization, including a systematic data utilization
strategy, should now be developed.
problems encountered in preparing or "marketing" the data for specific organi-
zations.
of the data system among regional groups and perhaps add someone not in-
tegrally involved with the program and with expertise in preventive medicine
and public health to the Study Committee of the RAG.  Although in the early
planning days,  there was evidence of support from the Medical School and the
State Health Department, the Denember 1970 staff visitors reported problems
in cmmunications with members of these institutions. The relationship with
the practicing community was also a question.

The continuation application for the 03 year submitted in May 1970 did not
speak to many of these points. Staff, therefore, thought that in light of

The data techniques had been used effectively in some instances,

                Particular attention should be paid to

In addition, the Region should broaden the base of understanding

?hrthern New England RW -8- RM 00003 8/71

!,r& r:mcerns of earlier reviewers and the criticisms of the site visitors,
it, vwI.rl IJe prudent to bring the program before Committee and Council for
on a:;cessmc;nt of' Lhe;.r approach before the Region began to prepsre their
trierrriial application.

Project #6 1Iorthern New England RMP
Kidne-r PrG msal

Requested First Year
$126,740

This proposal would establish a program to control chronic renal disease
in the patient service areas of the major teaching hospitals serving
Vermont and portions of New Hampshire and upper New York State.  At the
present time, there are no centers providing chronic dialysis or kidney
transplantation in Vermont or New Hmpshire.
patients from these two states in outside programs is becoming critical.
A chronic renal home dialysis and transplantation program is to be
established at the Medical Center of Vermont in Burlington.  Coordinated
development phiis have been established with the Dartmouth Medical School
in Hanover, New Hampshire.  A home dialysis training program (24 patients
a year) and a kidney transplant program (10-24 patients a year) would be
instituted.  The transplant capability would be coordinated with the Tri-
State RMP propsed New England Kidney Program and the Interhospital Organ
Bank.
cost.

Decreasing ability to place

Evaluation will include assessment of access, quality of care and

Other sources of finding have been identified,  and funds have been received

monies vere obtained after passage of specific legislation Wrtaining to
the treatment of end-stage renal disease.

,' '_

from the Vocational Rehabilitation Agency and the State of Vermont.

State

_J

A Kidney Disease Management Committee has been established to analyze the
status of the health system, and to define priority problems and an
operational program by the application of health systems performance
criteria.
(RAG) for solving priority problems, establishing standards and guidelines
for the performance of the program and monitoring resources.
also serve as a focus for determination bf further resource investment
options.

The Kidney Comitiee will be respnsible to the Advisory Board

They will

Second Year
$117,404

Third Year

-3mB-

REVISED 6/11/71

CONT. BFXOND APPR. NOT NEW, NOT   1st YEAR
APPR. PERIOD' PREV. PREV.     DIRECT INDIRECT
,OF SUPPORT FUNDED APPROVED   COSTS COSTS

$389.157 $1 8i .751

(Supnort Codes)

IDENTIFICATION OF APPR. PER10

bl - CORE $389,157

7

REGION Northern New England
CYCLE RM 00003 8/71

BREAKOUT OF REQUEST 03 PROGUM PERIOD

-

126,740 $716,936 $270., 666

Progressive

82 - Coronary Care

I 19,999

11 9,999

81,040

16 - Kidney Program I

39,340

18,759

126,740

~

~~~~~~

126,740 30,816

I

.- TOTAL

99,799

157,556 1

$987,602

I

I

(Sunport Codes)

IDENTIFICATION OF

- COMPONEKP

81

12


86

(5) (2) (3) (1 1

I CONTINUATION WITHIN lCONTINUATION BEYOND1APPROVED.NOT I NEW. NOT I 2nd YEM I

-

86

I

~.

I AVPROVED PERIOD OF [APPROVED PERIOD OP IPREVIOUS~Y

1 PREVIOUSLY I

DIRECT

TOTAL

t

T

I rr
0

I

I

REG ION
BREAROm OF REQUEST 04 PROGRAM PERIOD

SUPPORT

--

SUPPORT FUNDED APPROVED COSTS

--

--

I

117,404

--

117,404

..

117,404

117,404

!

REG I ON
BREAK9I-T OF REQUEST 0 5. PROGRAM PERIOD

CORI'INLJATION WITHIN 'CONTINUATION BEYOND APPROVED, NOT NEW, NOT .3rd YEAR TOTAL

IDENTIFICATION OF APPROVED PERIOD OF APPROVED PERIOD OF PREVIOUSLY PREVIOUSLY DIRECT ALL YEARS

coMPomNr SUPPORT SUPPORT FUNDED APPROVED COSTS DIRECT COSTS +
  fl -- $389,157

  82 -- 119,999

1

-

(Support Codes) (5) (2) (3) (1 )

#4 --

#6 137,368

7

-

-

137,368

TOTAL

h 4

        81,040

137,368 381,512

   I +
*r.

I

t


I

1

I

I

I I

t

r

r

137,368 971,708

_-*

--

GRB 6/11/71 it

- LY

DEPAKTMENT OF HTALTH. EDUCATION. AND WELFARE
             PUDLIC t-ICXLTt{ SERVICC
HEALTH SERVICES AND MENTAL HCALTH hLlMINISTRATION

e

llalr: ~une 5, 1971

Ikbb f6

Attn 4:

Sut!tcl:

Staff Review of the Anniversary Application from the
Northern Ncw England RIP, RM 00003-03, May 12,  1971

TO: Harold Margulies, M.D.

Director, RfIPS

P

I

Throuzh: Acting Deputy

      Chief, Grcnts

     Chief, Grants

Acting Chic, Regiona 1 Devclopnicn t

Staff met to r'evicw the Northern New England RMP's AK application, which
included a request for continuation of core and tv~o projects.  A
supplemental project in kidney disease is expected a'fter June 1.
progress appears adequate, staff recommends approval of the $830,046
(total costs) continuztion request.
The Northern %ev England Region is unique among RMP's and for several
reasons, One is its relaticnship .t.lith Comprehensive Ikalth Planning.
A second is its almost exclusive investtricnt in thc data planning and
ana1ysi.s approach to program.
feature which sets this p;-ogram apart from rr:ni1y others is the small
i:m!)~r of projccts--this "ncgion has not had an application bclore
Corumittee nnd Council since its initial O~CI-~~~OTI reviev. Each of
these poLnts vas consic~m'cd during staff rcvicw of the nppIi.cn tinn.

Since

As a result of this cornmitincnt, a third

RM 000'3 8/71

- rL'9 -

.

- Mrcc t or, KMPS

or strategy for addrcssing these, a1 though one ,paragraph in tlie Core
scctic.-~ (form #8) describes what could be cons;dcred as tbe Region's
operational objectives for the coming year. These include providing
basic planning dato to devclop the State Health Plan, providing organiza-
tional support to further develop disease manageincnt groups, providing
organizational and technical support to devel oping CHP "b" agencies,
developing I?CT.I Phase I1 reports on major health problems and continuing
to update the data base.

The very general discussion of the data base in the RAG report also raised
doubts about the Group's complete understanding of or commitment to this
< mphnsis. A Study Committee, which serves as an Executive Cdimittec to
thc Boilrc:, seem to providc more dircction than the IUG, but it also
appears reactj-vc to Dr. WcnnberZ.

Thc Dcccrnbrr 1370 site visit team mode several reconinicnclations tihicli they
thought might bi-oaclcn thc base of understanding about thk data system
approach among rr.gionnl groups:
should bc~ nn cz-officio rncmber of each managcmcnt committee to keep the
SturJy Comrtiittce appraised of its activities; and 2) ihr Study Conunittcc
should add a mxiber with expcrtise in preventive mcdicinc and public
health, who is not a cizmber of Core staff, to provide an independent
assessment of the data base. The present application shows no evidence
that these have been implemented.

With regard to !&XP-CHP staff cooperation, the two staffs are collaborating
on development and irnplcmcntation of the data base. Along this line, it
is hopcd that the head of the state CHP program, Mr. David Mil?cr, may
be able to provide some necessary administrative and public relations
backup to thc RXP. Parenthetically, staff noted with interest that
MI:. liiiller is also an assistant dean at the Mcclical School, 17hich places
him orga~iizaticnially above F34P.

1) a meniber of the Study Committee!

Staff's discussion of the data base related primarily to the comments of
thc DecemSer site visit report and to personal knowledge of it through
special reports and visits and convexsations with the Region.  For thc
second year in a row, the application provides insuf Zicient information
on the program. The data system itself, including from v7hat sources the
data is collected and hot? it is put together, is not explained for
reviewers ,

At the time of the Deceraber site visit, the team found great: potential
cxistcd for use of the system, but no plans or its iniplcmetitation had
been delineated. Althotigh star1 lcarned that the Kcgion is now finding
users (such as the Plc~clical Socicty for rncdi'c'al audit purpores), thc-y
stil 1 Iiavc not s~el l~d out a uti1.j zation stratrgy, jnclutlin~ oflicr
pofc.nt in1 users, an implcnic~ntntion scli(:dule,  control:: on the use of tlie
data and the like, Staf 1' al~o had ndtlitioiic~l quCsttjorir, rclat i.ii;; to

- I!# - RM 0003 8/71 '

-I Director, IW?S

o

what dam would be supplied to what users and the system's use of other

.I

data rcsourccs in thc Region.
of how tlic Region had met tlic recommendations of th,c December site visit.
They though that, in order for the Region to give an adcrphtc accoiint
of its program plan to bmmittcc and Council, thc Region should submit
additional. material, incl.uding a dcrcription of the data base and thc
stratcgy for its ut5Lizntj.on.

Finally, they wished to see sonic indication

'

1

111.

Oucstion of Nced for RIP Invnlvcr~cnt in Activitjes Otlicr Than
The D3p Eosc

Vhile there vas a consensus ainong staff'about the need for more information
regarding the data studies, staff was divided as to the desirability of
the Region's continuing to invest all its efforts in the dad plsnning
and analysis approach with so few other visible activities in the Region.
As noted earlier, tlie Region would have only two projects ongoing during
their 03 year.

'The Region has.had numerous proposals in its reviev process, but has

                                        Certain staff

held back even the bctter ones, apparently because the R.iP had not yet
fully dcvclopcd its review criteria or thc data base,
rccmbcrs indicated that in viet? of the lessening availability of iunds
and the rliixed success of niaiiy Regions going the project route,  the data
analysis approach was entirely cppropriate for this Kim   In contrast
'tlith many othcr PNP's, this one, they argued, was not haphazardly
deve1opj.n~ projects, but vas actually trying to provide data  for the
Region to detertiline its nccds before developing projcct proposals. I

Othcr staff mrmhcrs, however, exprcsscd their conccrii about the progi*nm's
vj.sibi2ity in the Region, as we11 as the clesirabili.ty of RIG? being thc
sole supprt: of a resource which has a potential benefit for so many
agencies.  These staff wcr'e apprehcnsj.ve &at the stymyiny, of all. projects
in revicu, ccjuplcd with possible nisundcrstanding or iptornncc of the
dats approach on thc pzrt of many in tlie Region, wuld not only inhibit
visibility of the program, but might also alicnnte some  iiitercstcd
groups. or individual 6.
heads of the State 11c:alth Departmcnt and tlic University 's 1)Cp;lrtnlcnt of
Coniniunity Mcdicille at thc: last site visit that tliis was occurring.
tlhilc not cncoiii:agj.np, the Region to begin submitting larger ncimtcrs
of projects, staff felt that there ~cre probably certain high priority
activitics which could be uncertakcn'at thc present with Core or
project funding without waiting for a complete data collcction and
analysis of Regional needs.
might consider:  1) the addition of a health planner to Core.staff
who could assfzt wit11 tlic implcmentatlon of the data base results  in
the zedical comuiity and 2) alternate ways of financhg the data
collectioa .and ana1ysj.s resource,  (Somz people in thc Region have .
already suggested the establishment of a naprolit corporatLon with
responsibility for thc pooling of data collections.)

TIicre ms evidence from convcrsntjons with the

Thcsc staff also suggested that the Region

\

- 14 -

RM 0003 8/71

(I - Director, RMPS

Recommendations                                               0-

1. Approval of the              request for Core and

Project #2

and 94 Project in Continuing

Education.

2.

a) The Region submit an expanded RAG report with emphases on goals,
objectives, priorities and strategy; b) the Region consider expanding
the memberships of the committees as,described above.

.

3.

The Rcgion should submit additional information its data fpse for
Committee ancl Council. review. This information sho~ilcl includc:
a) a description of the data base with emphasis on soals, oI)jcct:ivcs,
priorities, utilization strategy and controls on dj ssc*minntion and
b) a progress report on and responsc to thc recommcndations of the
DeccinLcr `1370 site visit. *

4.

In view of staff's discussion regarding the proper role of RMP in
M.N.E., they belicvc the most appropriate course would be to refer
the present application with some additional materials to Review
CommSttee and Council., not for an action on funding, but to give
the Rcgion, the benefit of the reviewers ' thinking about the
appropriateness of this approach prior to the Region's preparation '
of their triennial application.

Dona E. Houseal.
Public Meql th Advisor
Granis Review Branch

1

(A Privileged Communication)

SUMMARY OF REVIEW AND CONCLUSION OF

JULY 1971 REVIEW COMMITTEE

NORTHERN NEW l3Nw REGIONAL MEDICAL PROGRAM

RM 00003 8/71

FOR CONSIDERATION BY AUGUST 1971 ADVISORY COUNCIL

RECOMMENDATION: The Committee recommended that this application

NNE RMP Kidney Proposal, be supported as follows: $55,290 for the
01 year; $37,900 for the 02; and $25,400 for the 03 year.

which requests supplemental support for Project 86,

An outline of the Region's request for their 03 year and staff and
Committee recommendations follows :

Reque s t

Re commen dat ion

Continuation of Core $590,196
and 2 Projects
(Staff Action)

Project #6 (Committee 126,740
Act ion )

$590,196

45,290

TOTAL $716,936 $645,486

In addition, for reasons outlined in the staff summary, Staff requested
guidance from Committee on how to work with the Region as it prepares
its triennial application. These comments are discussed below.

CRITIQUE:

(data collection and analysis) and poorly prepared applications have
consistently given staff difficulty in assessing the Region's progress
and program plans.

The reviewers identified six features of the NNE Program which were
probable causes of this racertainty:

Committee responded to Staff's sense of uneasiness over
the Northern New England RMP, whose unique program thrust

1.

The unique history of the program in which the systems
analysis approach (with few projects) prevailed;

__

2.


3.

The _- absence of a good set of goals, objectives and priorities;
With the only two operational projects due to phase out this
year, the difficulty of assessing what the Region has done;

Northern New England RMP

-2-

RM 00003 8/71

g*

4. In addition, the lack of information on what the NNE RMP

t,;:+.. -:

.-=e. C'

is doing for the health care problems of Vermont;

. _.

5. The lack of a data utilization strategy; and

6.

An apparent communications problem between the Coordinator
and both the Regional Advisory Group and the health
providers of the Region.

Reviewers also had concerns about the operation being primarily the
creature of the Coordinator, and the extent to which existing data
bbses within the Region were incorporated in the system.

Despite these problems, Committee was impressed with the competence
of Core staff, who appear to have the capability for developing a
meaningful data system,  They noted that the data base was a factor
in the selection of Vermont for an Experimental Health Services Planning
and Delivery Systems contract from NCHSRD.
In discussing what advice to give staff in working with the Region,
Committee was first concerned with the lack of a defined strategy
for utilization of the data. Although the capabilities and interests
on Core staff may be more oriented to collection and analysis,
reviewers stressed the importan-ce of outlining plans for using the
data. Committee recommended, therefore, that RMPS staff encourage-
the NNE RMP to seek assistance with development of a utilization
strategy from 1) the technical experts at the December 1970 site
visit, and 2) groups specializing in utilization of knowledge, such
as the Center for Researdh in Utilization of Scientific Knowledge
in Ann Arbor, Michigan.
Another recommendation to the Region was to improve the presentation
of information about the' program in the application.  For example,
reviewers could not determine from a list of twelve agencies, described
88 users of data output, just what information they were using and
for what purpose.  Since the application format does not lend itself
to an adequate description of the program, the Region needs to rein-
force the requested material with supplemental information regarding
the data system, its utilization strategy, spinoff effects, endorse-
ment of the program by other institutions and agencies,  2nd the like.

The issue of RYP-CHP relationships was discussed, While the lines
of program responsibility for the two agencies have not been defined,
it appeared to some that RMP seemed to have taken on the responsi-
bilities of a CHP "A" Agency.
that in their triennial application the NNE RMP delineate the
responsibilities of and relationship between the two agencies.

The last issue discussed was the overall question of the Region's
ability to move in a new direction, i.e., toward the improvement in
the Vermont health care delivery system.

Committee felt it important, therefore,

While its primary efforts

Northern New England RMP -3 - RM 00003

to date have been the collection and analysis of data, it is now
beginning to offer the output to various agencies and organizations
who influence the delivery of health care in Vermont.
the Region can demonstrate that RMJ? goals are being carried out,
either by the Vermont RMP itself or by the RMP catalyzing other
agencies, the reviewers stated that they were not concerned by either
the almost exclusive investment in the data analysis approach or
the small number of project activities.  Committee believed that
the results of such a unique approach, which the Region has pursued
from its early days, should provide valuable experience for many
other Regions.

As long as

The Ad Hoc Kidney Disease Control Panel reviewed Project 86, the NNE
RMP Kidney Proposal,
capability in Vermont existed and found the staff well-qualified.
The Panel recommended that "the trained talent in Vermont be utilized
to develop a program which can later be evaluated in its relationship
to the Tri-State Region, and in the size and quality of the activities
initiated."  They also requested the opportunity to review the second
year continuation application to determine the project's progress and
its relation with the proposed Tri-State RMP Kidney Program.

The Panel members determined that a need for the

Committee aoncurred with the Panel's comments and the reduced funding
recommendation of $55,290 for the 01 year; $37,900 for the 02; and
$25,400 for the 03 year.

RMPS/GRB
7/19/71

REGIONAL MEDICAL PROGRAMS SERVICE

(A Privileged Communication)

SLiY Of? AN ANNIVERSARY TRIENNIUM GRANT APPLICATION

Kochester Regional Medical Program
University of Rochester Medical

260 Crittenden Boulevard

4 Center

v+ Rochester, New York 14620

RM 00025 8/71
July 1971 Review Committet

Program Coordinator: Ralph C. Parker, Jr., M.D.

The Rochester Regional Medical Program currently is in its 03
operational year.
03 year represents an 18-month budget period for which the direct cost
award was $1,451,951 (equivalent to an annualized figure of $w.zf&-a
The indirect costs for the 18-month period were $501,418,  an overall
indirect cost rate of 35%. The current budget period ends August 31,

The original 03 budget period was extended, so the

19 71.

1.

11.

111.

This Triennial application requests support for:

Developmental Component funding for 3 years.
Renewal support for core and 12 ongoing projects -- core for
three years and the individual projects for varying lengths
of time from one .to three years.
Initiation of six new projects in the first year of the Triennium
(04 Operational Year) and three new projects in the 2nd and
3rd years of the Triennium (05 and 06 operational years).
These last three projects will include many of the activities
currently being conducted under eight of the ongoing projects
through their merger into more comprehensive groupings.

The Region requests $1,514,081 direct costs for its fourth year
of operation, $1,478,419 for the fifth, and $1,559,790 for the
sixth.  The chart on page 3 compares the actual funding levels
for the first three operational years with the request for the coming
Triennium, and breakout charts identifying the components for
each of the three years are included as pages 17 through 19of this
summary.

Staff review of this application has identified certain areas of
concern in which the site visitors, Committee, and Council
reviewers may be interested.
below, and elaborated upon in the memorandum attached to this summary.

These concerns are listed briefly

1. Problems in core staffing and apparent lack of administrative

leadership.

2. Questions about the review and decision-making process and
the locus of responsibility in certain crucial areas:  e.g.
allocation of funds, determination of priorities, etc.

0

3. Apparent lack of subregionalization.

Rochester W

-2-

RM 00025

4. General concerns regarding whether the Region has developed
a program (as opposed to individual project activities),
the amount and quality of evaluation, and the relationship
of program goals to RRMP activities.

.
5. University-RMP and CHP/RMP relationships.

F'UNDING HISTORY

(Planning Phase)

Grant Year

(J 1
0 2

    Period

10/66-10/67 (13 mos.)
11/67-2168 (4 mos.)

FunLdd (direct costs)

$246,394
$72,752

. ....

(Operational Stage)

$841 , 296

01 3/68 - 2/69
02 3/69 - 2/70 $1,008,164
03 3/70 - 8/71 (18 mos. $1,451,951

GEOGRAPHY AND DEMOGRAPHY:

The Rochester Regional Medical Program
is composed of ten counties in the

western portion of New York State.  It is bordered on the west by
the Western New York RMP (Buffalo) and on the east by the Central

-

PENbiSY LVAN IA

The map on page 4 shows the geographic relationship to the Rochester
Regional Medical Program to the other five RMPs in New York.

The approximate population served by this Region is 1.3 million, and
the area contains the University of Rochester School of Medicine
and Dentistry, eight professional nursing schools and three for
practical nurse training, nine schools of technology and 27 short-term
hospitals containing 4,258 beds.
2,049 active physicians and 5,589 active nurses in the Region.

There are, in addition, approximately

ROCHESTER REGIONAL EDICAL PROGIVYtl
Comparison of 01-03 year'funding

and 04-06 year request

PROjECT

* for 8 or 9 month periods

IN NEW YOKK

I
f.
I

..,

icocnes ter KMT

-5-

HISTORY:

Dr. Ralph Parker, the former Medical Director of the Rochester
Regional Hospital Council, had been appointed Coordinator and
IYr. Frank Hamlin, past President of the Hospital Council, had been
appointed Chairman of the Regional Advisory Group.
were considered particularly auspicious since the Hospital Council
is an organization which practiced regionalization well in
advance of the concept& embodiment in PL 89-239. The Committee
and Council were impressed with the history of cooperation among
the components of the medical community in the Region.

The initial planning peri.od for the Rochester Regional
Medical Program began in October 1966. By that time,

These appointments

When the RRMP applied for operational status in early 1968,  staff
and national reviewers emphasized Dr. Parker's difficulty in
recruiting full-time staff (he was the only full-time person for
the first nine months) and the lack of administrative personnel
involved in the program. Despite this problem, site visitors and
Committee/Council reviewers thought the Region to be well-established
with good university and community support, and ready to inaugurate
an operational program.  Since each of the five project proposals
in the original operational application, however,  addressed some
aspect of heart disease, the reviewers indicated that the Region
needed to give attention to the development of a balanced program.

Over the next couple years as project proposals were reviewed by
Committee and Council and as continuation requests were assessed
by RMPS staff, the initial optimism about this Region began to
wane. In fact, uneven progress in the RRMP prompted a staff
reduction of the 02 year commitment.  There appeared to be a
growing concentration of activities in Rochester (and the University
Medical Center in particular) at the expense of peripheral involvement.
The laissez-faire administration of the Coordinator, the low rate
of expenditures, and the continued dearth of full-time professional
staff were seen as problems  as well.
to lack influence on the health care system.
visit was conducted in April 1970 for the dual purpose of investigating
the validity of reviewers' concerns and providing guidance to the
Region.

In general,  the site team found that many of the individual projects
were strong and many were promoting regionalization.
Medical Program itself, however, was beset by the suspected difficulties.
Of prime importance were the administrative deficits of the Coordinator
and the passive character of the Regional Advisory Group which had
relegated problems regarding program and priorities to others.
In a general feedback session and in special individual consultations
with the Coordinator and with the RAG Chairman, the site visitors
emphasized the necessity of Dr. Parker's obtaining strong administrative
backup and of the assumption by the Regional Advisory Group of its
proper role.

The Rochester RMP appeared

Consequently, a site

The Regional

Rochester IMP -6- RM 00025 8/71

REGIONAL GOALS AND PRIORITIES : The application explains that; the

of the Rochester Regional Medical Program outlined the following
five goals:

original planning grant application

1.

2.

3.

4.

5.

To niake health services and facilities of highest quality
more generally available throughout the area.

To improve communication between the medical and nursing
faculty and other health care personnel with special knowledge
and skills and the staff members of all hospitals, nursing
homes ,and other patient care facilities.

To determine ways in which nurses, social case workers,
technologists and other medical aides can contribute maximally in
the provision of health services by supplementing the activities
of our limited physician manpower

pool.

To provide optimal programs of advanced training of
physicians and nurses to meet the requirements for increasingly
complex medical care.

To develop programs of continuing education in which physicians
nurses and paramedical personnel will be active participants.

Recently the Statistical and Evaluation Unit conducted a survey
of the Regional Advisory Group, from which priority ratings were
determined.
will be discussed later in this summary, the survey produced priority
ratings along two other axes.

In addition to a ranking of ongoing activities, which

1. Target populations -- inner-city residents, rural residents,

migrant workers, e<c.

2. Project functions -- organization and delivery of ambulatory
services; manpower development; administration of health
services; organization and delivery of chronic inpatient, home

health education; organization and delivery of emergency
services; and organization and delivery of acute inpatient
services.

, health, and rehabilitation services; preventive services;

REGIONAL ADVISORY GROUP:

There presently are 35 members, including 17 physicians, three nurses,
and nine public representatives.
outside the immediate Rochester vicinity. Mr, Hamlin remains chair-
man.
Opportunity form on the grounds that New York State law prohibits

The RAG gradually has been expanded to
represent a greater diversity of interests.

     Half of the members are from

Although the Region refused to complete the Equal Employment

Rochester RMP

-7-

RM 00025 8/71

racial or ethnic classification, phone conversations with Dr. Parker
indicate that two RAG members are black.

Thz former Planning Committee, which had great influence on program
directionand which was University-dominated, has been replaced
by a nine-member (plus two advisory members) Executive Cormnittee of
the RAG. The Chairman of the Executive Committee is the Chairman
of the University Department of Preventive Medicine and Community
Health.

There are, in addition to the RAG and its Executive Committee,
three Study Committees: Heart Disease, Cancer, and Stroke. The
application does not explain the review process,  so it is unclear
what the roles of the various committees are and their relationships
to and interaction with the RAG, the Executive Committee, and the
core staff.

APPLICATION COMPONENTS

Requested

I. Developmental Component

04 Year

$100,000

*.

Three-year developmental component funding is requested. These monies
will be used to carry out short projects in general or categorical
areas of primary health service but without financing actual patient
care.
allied health personnel for an inner-city health care network to
be established by Neighborhood Health Centers, Inc., developmental
activities will focus on problems of rural residents, migrant workers
and the homebound chronically ill adult.
to center around the organization and delivery of ambulatory services
and manpower development.

Since RRMP may be receiving an OEO grant for the training of

Activities are expected

Priorities and objectives for developmental funding will be established
by the RAG.
the approval of thecoordinator, with sums  In excess of that amount
needing Executive Committee sanction.

Expenditures of less than $5,000 appear to require only

05 Year: $100,000 06 Year: $100,000

11. Renewal Support for Core and Twelve Ongoing Projects
                                       Requested
Core: The full-time professional staff of the Rochester 04 Year

    Regional Medical Program consists of the Coordinator, $352,542
the Nurse Coordinator, and two Nurse Specialists. There are, in
addition, five Program Directors of Health Services, Heart Disease,
Cancer, Stroke, and Renal Disease, ranging from 27% to 71% time,
and part-time systems analyst and research bibliographer.
the Winter of 1970, Dr. Parker brought on an Assistant Coordinator,
a young man who had recently received his M.P.H.
however, resigned this month (May 1971)and Dr. Parker is recruiting
a new Assistant Coordinator. The four other professional vacancies
on core staff are for a Nurse Specialist in cancer, and three people
to work on a physicians'  assistant program.

During

This individual,

Rochester RMP - 8- RM 00025 8/71

The Region sees some of the most significant core accomplishments
during the past year as its work with the Genesee Region Health
Planning Council (the CHPWagency), particularly in the planning of
an ambulatory rural health center, developing plans for the emergency
department of a small community hospital, planning for health services
in a rural area, developing a migrant workers' health program, and
developing programs for the training of nurse practitioners and
physicians' assistants. During the past year nine percent of the
core budget was allocated to planning and feasibility studies.
There are no core-supported central regional services.  The application
states that the most important areas of core activity during the
next year will be to continue planning for rural health care,  to
help start allied health personnel training programs, to participate
with the CHP'bI'agency in an experimental health services planning
and delivery systems project, and to identify other unmet health
care needs.  In the area of consultation,community relations and
liaison activities, the application explains that limitations on
core time prohibit the seeking of new activities.
activities demand less time, "other problems will be looked for."

When present

05 Year: $377,766

06 Year: $404,059

ONGOING PROJECTS: All ongoing projects have been given priority

presented in this summary in their priority order.

Project #7 - Early Disease Detection Unit (Priority 1)

sixth years of this activity.

the project will have achieved economic independence .
1970, 7,306 patients were screened (in the central unit at
Strong Memorial Hospital abd in the mobile unit), and activities
were expanded to serve some ambulatory aged, rural and inner-city
residents, and high-risk cardiac groups in industry. In addition,
a number of evaluative studies were performed.  It is planned that
during the Triennium, a satellite screening unit will be developed
in a rural area and further liaison will be established with new
ambulatory care centers in Rochester, thereby supporting
primary health care for rural and urban disadvantaged and providing
for the collaboration of the screening program with the health  care
system.  The May 1971 Council, in examining multiphasic health testing
as a regional medical program activity,  concluded that RMPS should
withhold funding from any new multiphasic health testing projects,
but that intensive efforts should be made to gather and evaluate
the experience that will be gained in the projects already funded.

rankings by the Regional Advisory Group arid are

Requested
04 Year

Support is requested for the fourth, fifth, and $266,103

It is hoped that after that  time

During

05 Year: $215,554

06 Year: $164,918

ster

-9-

RM 00025 8/71

tivities will include three-day intensive courses,

Requested
04 Year

, This activi

ity support when possible.

Requee ted

04 Year
$29,598

oject #l5 - Neurologic and Rehabilitative Nursing (Priority 5)
        is project is requesting support fo
                  It then (in the thi
       be incorporated into proposed Project 829 - Comprehensive

of operation.

Its objectives are to develop

g practice, demonstrate

ciplinary team approach to patient care, and develop
cational media.

Intensive courses in rehabilitative nursing

been developed and conducted, along with supportive activities.

se courses have been directed primarily toward nurses in leadership posi

Rochester RMP

-10-

RM 00025 8/71

Future activities will concentrate on reaching nurses in the outlying'
northern counties.
stroke rehabilitation teaching, instruction in the various clinical
areas of diabetes, chronic renal, and neuromuscular disease.
will be done for the preparation of adult health practitioners to
fill gaps in the care of chronically ill in areas with a
scarcity of health professionals.

It also is planned to incorporate into the

Planning

0

05 Year: $30,509

06 Year: Merge with Project #29

Requested
04 Year

Project 1\16 - Physician Training in Chronic Renal

      Disease (Priority 6) This project has $7,460
received RMP funding since 1969 and is requesting money for two
more years, after which time it will merge with proposed Project #28 -
Comprehensive Postgraduate Education for Physicians.  In an effort
to coordinate and improve the care of patients with chronic renal
disease, during the past year nine visits have been made to hospitals
and medical groups for presentations and discussions of the treatment of
patients with renal disease.
years are not discussed.

Activities planned for the next two

05 Year: $8,147

06 Year: Merge with

Project /I28

Project 118 - Continuing Education for Physicians in Cerebrovascular

        Disease'(Priority 7) This project has been supported
since 1968 and will terminate at the end of the current budget period.
Its activities will meld into Project 112 - Postgraduate Cardiology
Training Program for Physicians - for the first two years of the
Triennium (04 and 05 years) and then be incorporated, along with
Project 52, into the proposed Project t28 - Comprehensive Postgraduate
Education for Physicians.

Requested
04 Year
$14,958

Project 113 - Decentralized Cancer Education (Priority 8)

project which is planned for incorpmation into proposed Project #28 -
Comprehensive Postgraduate Education for PhysiciaE - in the 3rd year
of the Trienniun.  The objectives are to increase the availability
of the most advznced knowledge and techniques for cancer diagnosis
and treatment at area hospitals.
has been established at Highland Hospital and teaching activities
have been carried out at area hospitals.

Third and fourth year support is being asked for this

An education and service unit

05 Year: $16,131

06 Year: Merge with Project

11 28

Project 1.18 - Diabetes Mellitus;  A Pro

        of Paramedical and Medical Resource Sersonnel
(Priority 9) Two years' additional support is requested for
this project which was initiated in 1969, after which time it will
be merged into proposed Project d's 28 and 29, comprehensive Continuing
Education for physicians and nurses.

04 Year
$31,367

Past activities have been

-11-

Kl"l UUULJ Of II

n the areas of continuing education for nurses,
    in patient educationand expanded roles

instructional media. During

         ities will include continued
ing of diabetes nurse specialists (some in

, physician education, continued definition
ioner role, and continued development and

Rochester), implementation of community-based

06 Year: Merge with Project

#'s 28 and 29

                             Requested
- Chronic Renal Disease Nursing (Priority 10) 04 Year
                               $24,386

This project originally was funded in 1969 and
application requests third and fourth year
he third year of the Triennium (06 year)

these

cluded in proposed Project #28, a comprehensive

on proposal.  The application explains that because
ing and the lack of a nurse specialist, activities
ed. However, there has been periodic consultation,

teaching materials has been started, a two-day
ublic health nuraes was conducted, and a regional

eeds, and problems was conducted in conjunction

A nurse specialist was appointed in March 1971

a team to plan an interdisciplinary and

ication network among established

educational programs will be

rd approach to care will be established, self-
iala for patients and nurses will be produced,
ion activities will be carried out.

06 Year: Merge with Project

829

                       Requested
cal and Evaluation Unit (Priority 11) 04 Year

                        $71,918
e maintained by RMP support for life since
critical to the core staff: i.e,,data ~

This unit, which has been operational since

ssment, project evaluation, and program evaluation.

06 Year: $84,554

Requested

$4,002

ne EKG Consultation (Priority 12) 04 Year

This project has been funded since June

onlyone more year of support.

It originally

ee-part proposal:

Part B of the original proposal

Rochester RMP -12- RM 00025 8/71

for Transmission of EKGs for Remote Computer Analysis was approved/unfunded,
and Part C - Regional Arrhythmia Detection Service Utilizing Dynamic EKG
Monitoring - was disapproved at the national level.

are now (or will be in the near future) three receiving stations
(two in Rochester and one in Elmira) and two transmitting hospitals
(in Sodus and Hornell).
primarily for emergency consultation, ultimately routine EKGs will
be sent.

Project 119 - Cancer Clearinghouse (Priority 13) This activity

is requested, and then in the second and third years of the
comming Triennium it will become part of proposed Project #27 -
General Clearinghouse.
and December 1970 the Clearinghouse received 550 calls.
65 patients were referred for consultation at the University of
Rochester Medical Center and 25 were seen in their home communities.
In addition, cancer teaching programs and conferences are being
presented.  Some problems which have been encountered include the
apparent lack of awareness of the service and the difficulty in
arranging consultation for patients unable to travel.
plans are not discussed.

There apparently

*'

Although the network is presently used

Requested
04 Year
$23,218

has received three years of support, one more

In the 21-month period between March 1969

As a result,

Next year's

05 Year: Merge with Project t27

06 Year: Merge iith Project

f27

Requested
04 Year

Project f4 - Regional Coagulation Laboratory (Priority 14) $20,000

Only one additional year's support is requested

for this project which was initiated at the beginning of this Region's
operational phase in 1968.  During the past three years,  55 health
personnel technicians have been trained and the Center has served

as the primary diagnostic and therapeutic center for patients with
hemmorrhagicor thrombotic disorders.
discussed nor is mention made of future support mechanisms  for this
activity .

Next year's plans are not

Project /I3 - Myocardial Infarct Registry priority 15)

which has received three years of RMP financing. Whether it will
continue under other financial auspices is not explained.

No further support is requested for this project

111. Initiation of New Projects (Six in the first year of the Triennium,

one in the second, and two in the third)

FIRST YEAR (04 Yr.) INITIATION

.

Project #21 - Regional Organ Procurement -LA- Sharin, 'Cr-lontation _.-_ I -__

earmarked funds. The application makes clear that if no special
funda are available, the proposal is not to be considered for support.

liqiic~stc~cl
04 YC?ilr
$107,22!#

This request is for funding from KidGeT Ilisease

-.- -

RM 00025 8/71

-13-

ordinate all resources for the purpose of

s the existing resources of the Region

end-stage renal disease by transplantation,
Specifically, the project will establish

a treatment care facility for transplantation in the Rochester
area, support a tissue typing laboratory to meet the needs of the

SONY-West, and support the coordinating
urement and organ sharing in the American

06 Year: $72,844

Requested
04 Year
$77,979

ject 1/22 - Development of a Community Research and Teaching

Faculty for Ongoing Postgraduate Medical Education

purpose of this project is to develop the research and teaching
entia1 of traditional practices by implementing a data-collection

ping system which will permit a practicing doctor to
ctice experience according to many variables: age/sex
atment success, etc.  Ten primary care practices have

rest in participating and it is hoped that as others

will want to participate.

The program is

planned for two phases:

1) setting up the systems in the individual

and 2) collecting and making use of the information
            After two years of support,
be incorporated into proposed Project t28 -

education and research.
tgraduate Educationfor Physicians - in the third

Year: $82,598

06 Year: Merge with project t28

                                   Requested
oject #23 - Family Counselor Program. Mature 04 Year

                              $18,440
as family counselors for children with chronic
esses and their families and assisting the physician

agement.
of psycho/sociologic problems experienced by these

non-professional women will be selected

It is hoped that through this program

children will be diminished and that physicians will be free to
    time and energies to other aspects of the patients'

trainee will receive an initial 30-40 hours of education,
monthly meetings during the first year of the program.

06 Year: $22,920

Requested
04 Year
$50,210

roject #24 - Consultation Service for Rural Practitioners

and Communities

This project aims at the

improvement of rural health care delivery through assistance to
rural communities and practitioners in the form of: manpower training

Rochester RMP

-14-

RM 00025 8/71

and continuing education related to local needs, and analyses and
education regarding administrative practices.
service will:
possible improvements in the efficient use of resources and where
new manpower roles can be instituted;  provide the facilities for
recruitment and education of new manpower; relate the functions
of the individual practitioner wih the health care needs of the
community; evaluate the results of changes instituted in individual
practices.

The consulting

analyze the content of practices to determine

05 Year: $54,452

06 Year: $58,920

Project #25 - Health Education and Advocacy

       In an effort to fill the gap between inner-
city patients with chronic diseases and the providers of
health services, the proposed project will train patient-
workers as health education advocates.
as the initial target disease, but as the program evolves similar
techniques will be utilized for other chronic diseases.
pilot project will recruit and train 15 diabetics in an eight-week
program,
involved.

Requested
04 Year
$62,072

Diabetes has been selected

The initial

It is projected that approximately 300 patients will be

05 Year: $66,047

06 Year: $70,248

Requested
04 Year
$121,850

Project #26 - A Chronic Neuromuscular Diasease Team Propram

and after-care planning for stroke patients, and 2) utilization
of existing health care facilities.
accomplished neuromuscular disease who are potentially salvageable
for more independent living will be indentified in any of  five
stages of illness: 1) during evaluation at the Early Disease
Detection Unit- Project #7 , 2) during acute hospitalization,
3) at point of discharge from acute hospital, 4) at point of admission
to chronic disease institution, and 5) when established at home.
Patients will be seen by the Chronic Neuromuscular  Disease Team,
recommendations will be made as to their management and care,  and
the team will document the faults of the health care system at
each of the five stages and report them to appropriate groups and
health care workers. Evaluation techniques are described.
The activities presently carried out under Project #14 - Development
of a Stroke Team - will be merged with this proposal.

This proposal describes plans for 1) prevention

Patients with potential and

05 Year: $130,680

06 Year: $140,059

-15- RM 00025 8/71

SECOND YEAR (05 Yr.) INITIATION

Requested
04 Year

Project #27 - General Clearinghouse

health care delivery by facilitating consultation in
all categories of disease.  It will include the activities of
ongoing Project 119 - Cancer Clearinghouse. Present staff will
be used to expand the clearinghouse, the present panel of

The purpose of this project is to improve -0-

linical experts will expand to cover a variety of medical areas,

d the types of questions asked will be analyzed to determine

areas for continuing education programs.

05 Year: $39,863 06 Year: $45,080

THIRD YEAR (06 Yr.) INITIATION

Project P28 - Comprehensive Postgraduate Education for

Requested

Physicians. This proposal incorporates the 04 Year

activities currently carried out under the following

-0-

projects :

112 - Postgraduate Training in Cardiology
#8 - Continuing Education in Cerebrovascular Disease

1113 - Decentralized Cancer Education
#16 - Physicians Training in Chronic Renal Disease
118 - Diabetes Education Program

and the activities proposed in a new project which will run the
first two years of the Triennium before incorporation:

#22 - Community Research and Teaching

Continuing Education programs will be developed which include all
clinical areas and will be divided between intramural programs  in
the Rochester teaching hospitals and teaching clinics in the hospitals
outside of Rochester.

05 Year: $0 06 Year: $216,572

Requested
04 Year

Project #29 - Comprehensive Continuing Education Program

activities currently carried on under the following projects:

for Nurses This proposal incorporates the -0-

86 - CCU Training for Nurses

C15 - Neurologic and Rehabilitation Nursing
817 - Chronic Renal Disease Nursing
#18 - Diabetes Education Program

I

Rochester IU4P -16- RM 00025 8/71

The proposed program will consist of three major components: A) planning
and organizational development, B) continuing education, and
C) demonstrations.  It is explained that the merger of discrete
categorical activities into a unified program will facilitate the
achievement of a common goal, promote flexibility in assignment
of staff and funds, increase the ability to respond to changing
goals and needs, and simplify administrative and organizational
activities.

05 Year: $0 06 Year: $179,616

GRB/RMPS 6/7/71

_. .

:_ ,.:-.!.
.. I :. ..
  ,I ., .:%
, I....

,

, .

.... . L .!

\. .. . . ::

BREAKOm OF REQLEST 04 PROGRhM PZRIOD

-- 31 request 06 year only

-

DO0

e

#25
1126
#27
#25

c

I 70,248      70,248      198,367 I

  45,080     45,080 . 84,343
  71 62     716-577     71L579

IkQ, 059 14Q&9 197 584 t

e

#29 179,616 I 179,616

I I

1

-

k

-~

REGION Rochester
BREAK9UT OF REQLTST 06 PROGRAM PERIOD

I

179,616 '

906,259

653,531

TOT&

I

1,559,790 4,552,230

-20-

.

DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE
            PIJF3LlC HEALTIi SERVICE
HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION

Date: June 2, 1971 .

Cbty lo

4ltn of:

Subjccf:

Staff Review of the Rochester Regional Medical Program Triennial
Application and Identification of Issues for Site Visitors

To:

Di r e c to
Regional Medic 1 Programs Service

.c

Through: Acting Deputy Director

Regional Medical Programs Service

I

Staff. met on Monday, Hay 17, to review the Rochester application.
AJ though it was noted  that the University-dominated Planning Committee
which hitlrerto had aloiost complete control of the prograin had been
replaced by   Ib:ecutive Corninittee of the MG and that the RAG had
bccn diversified along iiialiy lines,  the areas of concci:n far out-
nunbered the conimcndablc aspects of the program. Discussion
revolved around the following topics:

Core

--

1. Who provides the administrative and program direction for this

Region ?

a.

b.

C.

d.

The Coordinator appears to be the only staff person in
an administrative capacity.

Do the roles of %he program directors provide for their
input into overall program direction or are they concerned
only with project direction?

.I

'l'hc "ChrirL of Yrograni Relationships" on pagc 38 of
tlrc? applj cation prcscntr; an ei;ibroglio of coimnuni catj 011
and rcspunsibi lity chaiiiiels that appcnr to confuse
rather thitn enliarice thesc proccsses.

Is there any pcrson on core staff who deals with  fiscal
control and accountability?

2. Ifow active is the core staff in initiating activities. Does

it merely respond to requests?

Director, KEIPS -21- Rochester Type 1'

Review and Decision-making Process

Subregionalization

1.

- 2.

3.


4.


5.

What is the review process? Does it provide for technical
rcview?

What arc the respective roles of the RAG and the Executive
Coniiiiit tcc? How are the members appointed?

Who determines priorities and on what basis?

Who allocates funds and on what basis?

What  is the genesis of the projects which are being proposed
in triennial application.

1.

Is there any?
aware of local concerns, needs, and proposals for solution?
The site tcaiii a year ago urged that the approximately 35
regional physicians with University appoin tnients assume some
RMP responsibilities for subregionalization. Has anything
been done in this regard?

What mechanisms exist for the RAG to become

Goals and Program Ilirection

---

1.

2.

-3.

4.

Has RKMP actually developed a program approach or does the
merging of individual projects into more comprehensive
units during the second and third years of the Triennium
rep rcsen t its program approach?

Are the goals of the Rochester Regional Pledical Program
operational? Are they related to ongoing and planned activities?
Do the new proposed projects further the Region's goals?

What evaluation has been conducted and/or planned,  and how do
the evaluation results affect the direction of the Rochester
program? What is the Statistical and Evaluation Unit doing
in this regard?

Although thcre are threc full-time nurses on core staff and
numerous projects in the area of continuing education
or nurses, the KWF' appears not to have developed an allied
health thrust. Where in the KMI' does responsibility lie
for leadership and coordination of the continuing education
and manpower components with regard to allied health personnel?

, Director, RMPS

Rochester Type V

Relationships

1. What is the relationship between the Rochester RMP and

CHP agency?

2. What is the relationship between the KMP and the University?

Is it symbiotic or does the University play the predominant
and controlling role?

The following staff participated in the review of the Rochester
application: -

A. Burt Kline - Regional Development Branch
Larry Witte - Program Planning and Evaluation
Jerry Stolov - Kidney Disease Control
Julia Kula - Continuing Education and Training Branch
Lee Teets - Grants Management Branch
Tom Simonds - Grants Xanagcment Branch
Eileen Faatz - Grants Review Branch
Spencer Colburn - Regional Development Branch

Eileen I. Faatz

Public Health Advisor

,*' Grants R6view Branch

(A Privileged Communication)

SUMMARY OF REVIEW AND CONCLUSION OF

JULY 1971 REVIEW COMMITTEE

ROCHESTER REGIONAL MEDICAL PROGRAM
      RM 00025 8/71

FOR CONSIDERATION BY AUGUST 1973, ADVISORY COUNCIL

KECOMMENDATION :

             Request              Recommend at ion
Year (Direct Costs)       - (Direct Costs)

04
05
06

$1,514,081
$1,478,419
' $1,559,790

$8OO,OOO
  - 0-
  -0-

The Review Committee agreed with the site team in recommending approval
of one year's further funding at the reduced level of $800,000 with
a follow-up site visit in a year to check the Region's progress with
regard to the site visitors' recommendations. The only specific
disapproval is for developmental component funding. The award is
to be allocated at the Region's discretion among core, ongoing, and
proposed activities with the clear understanding, howc?vc:i- that:

1. This will be the final year of suppoL-t for Coronary Care

'raining a7.d the Early Disease Detection Unit (multiphasic screening)
to allow phase-out and data analysis support.

2. The Region will have flexibility in budget rearrangement
to build its core staff, develop a revised form of Regional leadership,
strengthen the managementprocessesfomalize the review process and
effect other changes reconunended by the site team.

3. Although the kidney project is excluded from funding within

the $800,000 level, if earmarked funds become available there is no
objection to an increased award to permit funding of this activity.
This project, however, did receive an unfavorable review from the
Ad Hoc Kidney Panel.

CRITIQUE:  The Committee noted that this year it was seeing essentially

      the same problems in Rochester that were identified by
a site tcam a year ago and by a management assessment  team in the
interim. These revolve around the continued inadequate program
leadership, a poorly organizcd and staffed core, and an under-utilized
Regional Advisory Croup. There was this time, however, a new and
optimistic dimension to the Committee's
view of the Rochester Regional Medical Program -- the Region has begun
a significant process of change.
a quarter of the way through, the Committee hoped that the momentum

and the site visitors'

And although it is only perhaps

ZC? -3 --A L- ----l ,-.+I-. CL,, nT,ml,,tinr19?-,, nrnrocq.

-. ~ - . ... .I(- *

Rochester RMP

-2-

RM 0002s

Perhaps the most important difference in the program is  the diversification
of the RAG and the recent creation of an interested and active Executive
Committee of the RAG. It vas agreed that in the Executive committee
rests the leadership potential for bringing this Region out of  the
doldrums. It already has identified many problems and possible
solutions. One of the key areas of concern discussed by the
Executive Committee is the inadequate review and decision-making
process, and the group realizes that a more complete review process
must be established, that the RAG must assume program-direction
responsibility, and that a formal technical review system must
be devised.
on its first attempts at objective and priority setting, and although
the mechanisms need smoothing, the objectives appear to be a reasonable
first step.
disparate projecrs. This is another area in which the Executive
Committee is working -- the integration of goals and objectives into
a coordinated program approach with attendant priorities for determining
activities.
being well thought of throughout the area, having brougnt about good
regionalization, having an excellent and enthusiastic nursing staff,
and having developed some interesting project activities. But most
good accomplishnents appear to be a result more of serendipity than
planning.

$39

- -. -.

.-

Aqother hopeful sign is that the Region has embarked

The program is not yet, however, more than a group of

There are also the positive factors of the program's

The relationship between the RRMP and the Medical School is good,
and the school is very supportive of the efforts  of the Executive
Committee. Likewise, RRMP and CHP seem to get along well -- there
is governing board membership overlap, there are collaborative
endeavors, and the RMP is using (and will more in the future) CHP
county coxnittees are sources for local ideas and needs.

Problems co;ltlr.:a in core staffing and administrative leadership.
Dr. Parker stiil has no deputy (as has been recommended to him
numerous ttnes: rind provides little program direction to core
staff. Althougt ih-. 2arker is effective on a one-to-one basis
and is well liked chroughout the Region, his administrative abilities
are limited ard his own passivity appears to permeate and characterize
the core approach.  The Review Committee relied on the site team's
perception that, after discussing the matter with the visitors, the
Executive ComiiitEee clearly understands the necessity for restructuring
the c6re to provide for its assumption of administrative,  financial
managemnr, planning and evjlaatlon, and certain program development
responsibilitLes and to release core staff from day-to-day project
direction duties. It agreed that there appear to be good people on
core who suffer from lack OF direction but are anxious to become
coordinated and program oriented.

The Triennial application under review by the Committee requested
for the 04 year developmental component funding, renewal of core
and 12 ongoing projects,  and initiation of six new activities.   The
attached chart compares past funding of the program with the current
request. Although the Region obviously lacks the maturity required
for a developmental award,  and the Ad Hoc Kidney Panel recommended
disapproval of the kidney proposal on the basis of its being out

Rochester RMP

-3-

RM 00025

of date, the Committee agreed with the site team that with these
two exceptions any of the application's proposals were reasonable
candidates for support from $800,000 recommended award.
recommended level represents reductions from the current year's
annualized level of approximately $895,000 (after the cut) and
the request level of $1,514,081, and was considered by thr:? Committee
to be an amount sufficient to provide for a core allocation adequate
to accomplish the recommended changes.
force the Region to make choices among various combinations of
activities for support during the coming year.

The $800,000

At the same tlme,  it will

NortknNew York Regional Medical Programs

One point that arose repeatedly during the two-day meeting was
that three of the four RMPs in northern New York had submitted
Triennial applications for this review cycle,had been site visited,
and all found to have basic problems in terms of the quality and direction
of the programs. The three RMPs are Albany, Central New York
(Syracuse), and Rochester. The fourth RMP, Western New York (Buffalo),
was reviewed by October/November 1970 Committee and Council.
was some sentiment on the Review Committee that serious thought should
be given to combining these three, or possibly four Regions,and
that this would represent a better use of limited dollars and
perhaps combine the strengths of the various programs. It was recognized
at the same time that, politicdly, any combination of these
Regions would be quite difficult. Also, since each of the three
Regions being reviewed this cycle was seen as being at a turning
point in its development, with some hope for resolution of its problems
during the coming year, the reigning attitude was  that now would
be an inopportune time to suggest any combined superstructure without
giving the programs another year to iron out  their own difficulties.
The Commirree also saw the need for more data before considering
any possible merger.

There

RMPS/GRB
7/16/71

ROCHESTER FSGIOSAZ. FEDICcC PRCGP&?f

Comparison of 01-03 year filnding

and 04-06 year request

* for 8 or 9 nonth periods

DEPARTMENT OF HEALTH. EDUCATIQN, AND WELFARE
         PUBLIC I-IEAL'IW SERVICE
HEALTH SERVICES AND MENTAL tlrEAl-7.A ADMIEVISTRATION

of:

Report on the Rochester Regional Medical Program Site Visit
4-25, 1971 (Rochester, New York)

Director, RYPS

: Acting Deputy Director

Regional Medical Progranis Service

I. Site Visit Team

4

der Pi. Schmidt, 1I.D. (Chairman Site Visit Team)
sity of Illinois Collcgc: of Mdicilie

coln School of Medj cine

Robert Lawton
Deputy Director

State Regi-onal Mcdi cal Program
cal Care znd Educat%on Foundation,
on Mass achus et ts

Inc.

Richard 3. Cross, M.D.
Professor of Medicine
Ass is tan t Dean
Rutgers Medical School
New Brunswick, Kew Jersey

Chairman of New Jersey RMP
Regional Advisory Group

Richard liaglund
Associate Coordinator for Administration
In t e rmouii t a in Region a1 Me d i c a 1 Pro gram
Salt take City, Utah

Als 0

----

Eileen Faatz

ants Review Branch

lia Kula
ritinuing Education

Burt Kline
Kc g ional I)ev e 1 o priieii t i: i^ an ch

Spencer Colbum
Regional Developinen t Crsnch

Robert Shaw
Regional Representative
New YorEC, Ncw York

IjIlEW Regioil 11

Director, WS - Page 2
Rochester Quick Report

I : This visit was viewed by the site team as the third in

a sequence of visits which evidence the growing concern

t of staff, Committee, arid Council reviewers ahnut the

Iiochester Regional Medical Program.
visits was approximately a year ago, in April 1970, and was
prompted by the apparent concentration of activities in Rochester,
the laissez-faire administration of the Coorili nator, the low rate
of expenditures, and the continuing dearth of full-time professional

f. That visit, and the subsequent Management Assessment visit
ovember 1970, resulted in recommendaYions to the Region that
Regional Advisory Group assume its responsibilities for

program direction and that the program hire ;I strong Deputy for the
Coordinator and provide administrative assistance to the program.
Staff review of the current triennial. application highlighted
problem areas consistent with past review a The purpose wf this
visit then, was to determine what efforts and progress had been made
2x1 ameliorating the Regim's chronic probl.c~ns .

The first- in the trio of

IIJ. GENERAL llPRESSIONS: __ _I Yne general. conclusioi~ of the site team was
                that initial rehabilj lation therapy has beguii

and that the Region has potential for assuining an active and

uctive role. But much remains to be clone.

t

Ire happiest change that has come about is the diversiftcation of
  egional Advisory Group and the creation of an interested and
   e Executive Committee of the RAG. It is in the Executive

ittee that the site team saw the leadership for bringing this
out of the doldrums.  It has been meeting weekly since its
tion a few months ago and can provide the dynamism necessary
change. Although the program is well thought of throughout
area, has brought about good regionalization, and has developcd

interesting projects (particiilarly in the spheres of cardiology
urses' continuing education), it does not yet hang together
program. It is more a conglomeration of individual projects.

are many factors that contribute to this lack of a coordinated

program, primarily:

1. Continued problems in core staffing and lack of administrative
leadership. The Coordinator still has no deputy and provides little
program direction to the core staff.
restructuring of core staff to provide for its assiunption of

The site team recominecded a

istrative financial management, plaiiiiing and evaluation and
n program development responsibilicies and to rel.casc core
from day-to--day project direction dut:it:s. There are some
ood people on core who suffer  from lack of direction.

2. Lack of integration of goals and objec1:ives into a coordinated

       Progress is beginning in the Executive Committee (wj th

program approach with attendant priori-ties for determining prograin
activities e
help from the Statistical and Evaluation IJntt) illid should spread

to the Regional Advisory Group.,

Page 3
Rochester Quick Report

3. The inadequate revieu and decision-making process. The

Executive Committee already had identified this as a key problem and
is working on soh tions, to incl.ude the assumption of program-direction
responsibility by the RAG, development of a niore complete review
process, a formal technical review procedure, and. the restructuring
of the current committees on heart disease, cancer, and stroke
into less categorical' groupings with relevar!ce to program ob j ectivcs.

Although it flight have been rather discouraging for this site
team to be replaying the sane feedback tape which the Region
presumably heard on the two previous visits,  t-here was a definite
note of optimism which had been absent before.
will be done---the Executive Coninlittee will take the ball and carry
it.
031 oilring recommendation. b

RECCCMf;:I\lDh'l'IQN - :

This time something

It was in this happy frame of mind that the team arrived at the

Approval of one year's fur-the]- fuildilig at the rccluced
1evc.l of $800,000 with a follow-up site visit in

81' to check the Region's progress with regard to the sitc visitors'

recoriimendations. The only specific di sapproval is for developmental
cr~~~iponc~it funding.  The award is to be ailocat:t?d at. the Region's
discretion aiyiong core, ongoing, and p~oposed activities wlt-h the
clear understanding , ho-c.7cver that : ,.

1.

This wj-11 bc the final year of support. for  coronary care

training and the Early Disease Detection Unit (multipliasic screening)
to allow phase-out anh data analysis slipport.

  The Region will have lexi.bility in budget rearrangement to'

strengthen the management processes , formalize the review process ,
and effect other changes recommended by the site team.

uild its core staff, develop a revised form oE I<egionaS leadership,

3.

   AI though thc kidney project is excluded from funding within
the $800,000 level, if earmarked funds become available the site
team has no objections to an increased award to permit funding of
this activity.

$800,000 recoirmendecl level represents reducti oils from the

current year's anniialized levcl of approximate2y $89S,OOO (after the
cut) and the requested level of $1,5%4,081 and was considered by
the team to be an amount sufficient to provide ,for a core allocation

uate to xcoiiiplish the reconimenhed changes a
ill. force the Region to make choices avnong varions combinations of

At the same time,

activities for support during the comjng year.

C*&/Ld-.-. Pi -L*>

Eileen 1. Faatz
T'ublic Heal Ch hdv: sox-

Attachment: Coinparison of 01-03 yi a f~incliiig with 04 E4 06 yr. r~:qucst.

ROCHESTER PIEGI.ONAL MEDICAL PRCKXAM .

Comparison of 01-03 year funding

and 04-06 year request

PROJECT

LO- StElist

* for 8 or 9 month periods

..

.

o

      SITE VISIT REPORT
ROCHESTER REGIONAL KEDICAL PROGRAM
     June 24-25, 1971

A. Site Visit Participants:

Alexander M. Schmidt., M.D. , Chairman; 1knber of Review Committee; Dean,
Abraham Lincoln School of Medicine, University of Illinois College
of Medicine, Chicago, Sllinois

Robert Lawton, Deputy Director, Tri-State Regional Medical Program,

Medical Care and Education Foundation, Inc., Boston, Massachusetts

Richard J. Cross, M. D: , Professor of MedLcine, Assistant Dean ,

Rutgers Medical School, Rew Erunswick, New Jersey; Chairman of
New Jersey REP Regional Advisory Group

I

Richard Haglund, hssociate Coordinator for Administration, Intermountain

RMP, Salt Lakc City, Utah

RMPS STAFF:

Eileen Paatz, Pub1 ic Health Advisor, Grants Review Branch

Julia Kula, Continuing Education and Training Branch

Burt Kline, Operations Officer, Regional Development Branch

e

Spencer Colhurn, Operations Officer, Regional Development Branch

Robert Shaw, Regional Representative, DKEW Region I1

B. Regtonal Participants

Regional Advisory Group and Executive Committce

Hr. Frank Hamlin, Chairman of the RAG
Dr. Robert Eerg, Chairman of Executive Committee (Dept,. Prev. Medicine)
Mr. Peter Warter, Executive Committee (Xerox Corp. )
Dr. Wendell Ames, RAG (Dept. Health)
Mr. lJalter Wenkert, RAG (CHP b Director)
Mks; Janet Mancc, R.N. , RAG (NYS Murses Association)
Miss Rita Chisholm, R;N.-: RAG (U. Rochester School of Nursing)
Mr. Arnold Jerome, Exec. Committee (Hospital Administrator, Elmira)
Dr. James Norton, Exec. Committee (Private practice, Montour Falls)
Dr. Christopher Parnall, Jr., Exec. Committee (1Iosp. Administrator, Rochestcr)
Mr. David Stewart, Executive Committee (Blue Cross)
Dr. Willis Weedcn, Exec. Coninittee (Private Practice, Canandaigua)
Dr. Wayne Templer, RAG (Private Practice, Corning)

--_ ---._ _-__

Rochester RMP

Regiona 1 Medica 1 Program Staff

e

-2-

RM 00025 .

Dr. Ralph C, Parker, Jr,, Program Coordinator
Dr. Barbara Bates, Director, Health Services Program & EDDU Proj. Director
Dr. Thomas Cardillo, Director, Heart Disease Program
Dr. Gaetano F. Piolinari, Director, Stroke Program
Dr. William Gavctt, System Analyst
Dr. Arthur Jacobs, Direct of Statistical and Evaluation, Unit
Dr. Mary Sears, Cancer Projects I

                                        I
Miss Janet Long, Specialist, Rehabj litation Nursing
Miss Rose Pinnco, Specialist, Cardiovascular Nursing
PZrs. Haria Smith, Diabetes Project Nursing
Dr. Eugene Farley, Project Director for Proposal for Community Research

MPs, Ginny Hansen, Nurse Specialist on Core
Dr. Rarry Pless, Project Director for Proposal for Family Counselor Program

  Naomi Chamberlain, Proj. Director for Proposal for Health Advocacy
Dr. Robert Breckenridge, Project Director, Coagulation Laboratory .
Dr. Robert Jones, Staff of Proposed Chronic Neuromuscular Disease Team

Other Participants

I

Miss Edith Olson, Coordinetor, Nursing Activities

& Teaching

I

-- MS. __

Dr. J. Lowell Or'cison, Dean of Medical School
Dr. Lawrence Young, Chairman of Dept. o Medicinc

e

MS. Eleanor HaJ I, Director of University Nursin!: Education
Fir. Donald Irish, Medical Society
Mr. Richard Hufnail, University Financial Officer
E4r. Peter Norman, h`orthern Livingston Health Center
Mx. Darwin Farber ,. Neighborhood Health Centers, Tiic.
Mr. Norbert Temple, Rochester Regional Hospttal Council
Dr. Robert Easley, Genesee Valley Heart Association
`MS`;. 1. Pulling, Geilessee Vall.ey Heart Association

11. BACKGROUND

This visit was viewed by the site team as the third in a sequence
of visits which evidence the growing concern on the part of staff,

Committee, and Council reviewers aboa the Rochester Regional

Medical Program.

I

I

The first in the trio of visits was abproximately

I

a year ago, in April 1970, and was prompted by the apparent

concentration of activities in Rochester, the laissez-faire administration

of the Coordinator, the low rate of expenditures, and the continuing

dearth of full-time professional staff. That visit, and the

subsequent Management Assessment visit in November 1970,  resulted

in recommendations to the Region that the Regional Advisory Group

assume its responsibilities for program direction and that the program

hire a strong Deputy for the Coordinator and provide administrative

a

assistance to the program. Staff review of the current

Triennial application highlighted problem areas consistent with

past reviews. The purpose of this visit, then, was to determine

what efforts and progress had been made in ameliorating the

Region's chronic problems.

111. GENERAL IMPRESSIONS

The general conclusion of the site team was that initial rehabilitation

therapy has begun and that the Region has potential for assuming

an active and productive role.

But much remains to be done.

.Tk-ie happiest change that has come about is the diversification of

the Regional Advisory Group and the creation of an interested and

e

active Executive Committee of the RAG.

It is in the Executive Coinmittee

Rochester RMP Draft

that the site team saw the leadership for bringing this RMP out of

e

-

the doldrums.

It has been meeting weekly since its creation a

few months ago and can provide the dynamism necessary for change.

Although the program is well thought of throughout the area, has

brought' about - good regionalization, and has developed some interesting

projects (particularly- in the spheres of cardiology and nurses'

continuing education), it does not yet hang together as a program.

It is more a conglomeration of individual projects.

There are many

factors that contribute to this lack of a coordinated program,primarily:

1. Continued problems in core staffing and the lack of administrative

leadership.

The Coordinator still has no deputy and provides little

program direction to the core staff. The site team recommended a

restructuring of core staff to provide for its assumption of administrative,

0

financial management, planning and evaluation, and certain program

development responsibilities and to release core staff from day-to-day

project direction duties.

who suffer from lack of direction.

There are some very good people on core

2. Lack of integration of goals and objectives into a coordinated

program approach with attendant priorities for determining program

activities. Progress is beginning in the Executive Committee (with

help from the Statistical and Evaluation Unit) and should spread

to the Regional Advisory Group.

3. The inadequate review and decision-making.process. The

Executive Committee- already had identified this as a key problem

and is working on solutions, to include the assumption of program-direction

responsibility by the RAG, development cjf a iiiore complete review

0

process, a formal technical review procedure and the restructuring

J

Rochester RMP

Draft

e

of the current committees on heart disease, cancer, and stroke into

less categorical groupings with relevance to program objectives.

,.

Although it might have been rather discouraging for this site  team

to be replaying the same feedback tape which fhe Region presumably

heard on the two previous visits,  there was a definite note of

optimism which had been absent before. This time something will

* be done -- the Executive Committee will take the ball and carry it.

It was in this happy frame of mind that the team arrived at the

following recommendation.

Recommendation: Approval of one year's further funding at the reduced

level of $800,00O~with a follow-up site visit in a

year to check the Region's progress with regard to the site visitors'

recommendations. The only specific disapproval is for developmental

component funding. The award is to be allocated to the Region's

discretion among core, ongoing, and proposed activities with the

clear understanding, however, that:

I,

1.

This will be the final year of support for coronary  care

training and the Early Disease Detection Unit (multiphasic screening)

to allow phase-out and data analysis support.

2.

The Region will have flexibility in budget rearrangement to'

..

build its core staff, develop a revised form of Regional leadership,

strengthen the management processes, formalize the review process,

and effect other changes recommended by the site team.

3. Although the kidney project is excluded from funding within

$800,000

level, if earmarked funds become available, the site team

ROCXESTER REGIGNAE EDICAL PRCGRAM ,

Comparison of 01-03 year funding

, an6 (24-06 year request

..

I

4

Rochester RMP Draft

e

has no objection to an increased award to permit funding of this activity.

I
i
r

I

IV. REVIEW DETAILS

-

A. Goals ,Objectives and Priorities
Findings: The goals of the Rochester Regional Medical P ogram remain as

stated in the original planning grant, and inhude improving

0

the availability of quality health services) improving communications

between-and among health personnel and institutions, determining

uses for new allied health manpower) and providing continuing education

and training for physicians and nurses.

The important recent

change revolves around the RAG determination of priority ratings

along three axes :

1. Target populations: ten population groups have been ranked

in priority order.

Heading the lest are inner city residents,  rural

e

residents , and migrant workers.

2.

Ongoing activities:

a rank order list of all presently operational

projects has been compiled, although this list does not include new

projects proposed for funding.

3. Project function: perhaps the most meaningful listing developed

~ is that showing the relative priorities among various project functions:

organization and delivery or ambulatory services

manpower development

administration of health services

organization and delivery of chronic inpatient, home health
and rehabilitation services

preventive services

health education

organization and delivery of emergency services

.

. .. ... r . -' .- - L-. -- c ,.A..-?T.l n..AC.

Rochester RMP Draft

The statements of target population and project function were developed

e

by the Statistical and Evaluation Unit, and the priority determinations

resulted from a simple survey questionnaire which reiuested ranking

assignments f,rom each RAG member. The lists as they appear are

composite -ratings.

Even in that respect they are imperfect because

the questionnaire drew'only a fifty percent response rate from

RAG members -- or only approximately 15 returns. Furthermore,

,the three prioritized lists have not been integrated to elicit

congruence among the three sets of priorities nor to develop

specific objectives for the future. No method had been developed

to relate the priorities  to the determination of activities to be

supported .

Although the Statistical and Evaluation Unit has done some survey

work (primarily attitudinal) and hak developed a data book (discussed

in a later section of this report), most needs assessment appears

to be more the result of perceived needs gained through informal

personal contacts made throughout the region than based ,,on actual

data analysis.

,

Comments:  The site visitors saw the Region as being in the preliminary

     stages of evolution toward the development of a set of

workable and operationally valid objectives , based on actual regional

needs, developed in priority order by the Regional Advisory Group,

and a factor in determining regional activities,

to be done.

Much work needs yet

Nevertheless, even though more by acclldent than design,

e

the present stated goals and priority project functions represent a

rpacnnahlo firct rl~t in this evolution.

Rochester RMP

Draft

b

e B.

Organizational Effectiveness:

Coordinator and Core Staff

Findings: The Coordinator has not been successful in de 1 eloping and

I

maintaining a strong sense of program direction and cohesion

I

or an effectively functioning core staff. Dr. Parker is a kindly

and well-liked gentleinan who lacks administrati.ve and management

skills.

1

In response to the urgings of both April 1970 site visitors

and the November 1970 management team that the Coordinator hove

a deputy to carry the administrative burden,  Dr.. Parker in the Winter

of 1970 brought on as Assistant Coordinator a young man who recently

had received his M.P.H. This individual, however, resigned in

May 1971 and another young man with similar background has been

chosen to replace him, starting in July.



The core staff currently consists of Dr. Parker and eight categorically-

driented people who also are project directors.

who in other Regional Medical Programs would be included on

individual project budgets rather than core. Although the core appears

These are people

to be a very talented group,  in the absence of direction from the

Coordinator,its loyalities and interests seem to lie more with the

individual projects and the Medical School than with the Rochester

RMP. Dr. Bates, or instance, who organizationally is Head of the

Health Services Program on core staff is interested only in certain

areas of health services - specifically, the Early Disease Detection

Unit (for which she is project director) kd nurse practitioner training.

She also is working for the Medical School and running the outpatient

department.

There are many areas in core left uncovered:

e

1. Administration and management - Dr. Parker is the only person

with administrative responsibilities.

2. Financial capabilities - project accounts are kept primarily by

project directors and a core secretary reconciles them monthly with

a University print-out; the fiscal management services provided by

the University are not appropriate to the needs of the program;

nobody has the responsibility for reviewing expenditure reports or

suggesting fund reallocation; the project directors develop budgets

and Dr. Parker reviews them.

3. Planning and evaluation - the Statistical and Evaluation
Unit is budgeted as a separate project and generally left to pursue

its own interests.

4.

Program development - in the absence of direction the core

e

staff has concerned itself little with what the RRMP is,should be,

8 or might become.

Comments:

The site visitors believed this Region has a phantom core

staff.

,I

It has no practice in thinking of itself as

RMP - it is not dedicated to building a cohesive program.

In a

core group discussion of possible uses of developmental component funds

the staff seemed to be exchanging ideas and discussing the future of

the program for the first time.  Each is used to doing his own thing
without consulting others and 'although some of these individual

efforts are very good, they likely are things these people would

I

be doing without RMP anyway and are not the product of either coordination

or leadership.

The site team saw this combination of a Coordinator

8 -. Rochester W . .

Draft

who fails to provide leadership and a staff whose loyalties lie

e

elsewhere as potentially devastating. It was very encouraging, though,

to see the obvious willingness of the staff members to lower their

categorical sights and become program oriented.  The team stressed

the necessity for restructuring the core to provide both for

administrative competence and a formalization. of the program aspects,

and offeredsomespecific suggestions along these lines:

1. It was suggested, first of all, in the feedback session that

* the Executive Committee take on the job of overseeing the reorganization

of core staff. It is a group which has an interest in doing this

and is, itself, acting as a substitute core with regard to thinking

in terms of a coordinated program. It also was suggested that the

Executive Committee consider bringing in a consultant to look at

core staff organization and function.

*

2. Dr. Parker must have an associate or deputy to relieve him

of the necessity of carrying the entire administrative burden.

He

can no longer be all things to all people.

3. Some business and financial management expertise must be

added to core.

4. The functions of the Statistical and Evaluation Unit should

become a part of core and evaluation expertise must become an integral

part of program planning.

5. Core staff must be released from day-to-day project routine

and become involved with the program aspects of the RIP, implementing

the policies of the RAG and developing an understanding of the potential

and opportunity of RMP.

As stated before, core is now spread out

e

and functioning with many hats, but it has shown a distinct eagerness

tn serve the core staff function of building an RMP.

9 Rochester 1W

Grantee Organization:

e

Findings & Comments:

The relationship of the University of Rochester

Medical School to the Rochester-Regional Medical

Program has raised some questions in the past.

The site visitors,

though, found the relationship to be sound and beneficial to both

parties. The University has been good to RMP.

provided matching funds for RMP activities, it supplies considerable

administrative and fiscal assistance, and the Dean spends a lot of

time on RMP affairs.

on dollar management.

It has on occasion

The University does not hold a tight rein

It is very supportive of the new and active

Executive Committee of the RAG which is struggling to fashion a

coordinated program, and it appears not to have any designs to

dominate and affords the program a considerable degree of freedom.

The Medical School feels a responsibility for core staff - most

have tenure - and in the event of a disaster befalling the RMP,

most probably would be transferred to the University payroll.

The only

cautionary advice from the site team was that in the area of personnel

development of core staff, the coming year is a critical one, and

n

the University must balance any coiicerns about the future of RIP

and the fate of its staff with the realities and necessity of

increasing certain competencies on the staff. I

Regional Advisory Group :

Findings :

The Regional Advisory Group gradually' has been expanded

to represent a greater diversity of interests.

There

presently are 35 members, including 17 physicians, three nurses,

e and nine public representatives. Two RAG members are Black. Half

10 - Rochester RMP Draft

0

the members are from outside the immediate Rochester vicinity.

A nine-member Executive Committee of the P?G recently-has been

formed, and appears to offer hope for salvation.

its creation it has been meeting weekly, and the minutes of these

meetings reveal that it has been grappling with problems vital to

this RMP. The Executive Committee consists of two University

In the months since

representatives, two public representatives, two hospital administrators,

two regional physicians, and a Blue Cross representative. Parenthetically,

the nurses are worried that they are not represented on the Executive

Committee. The three leaders of the committee appear to be: Dr. Berg

the Chairman, and Head of the Department of Preventive Medicine and

Community Health; Mr. Hamlin, the Chairman of the RAG; and Mr. Warter,

Vice President for Research at the Xerox Corporation. It is

Mr.  Warter who seems to be the driving force behind the move for

change -- he certainly is the idea man and the most vociferous of

the three. He was named to the RAG at the suggestion of Dr. Saward,

Associate Dean for Extramural Affairs (and himself a member of the

Executive Committee although out of the country at the time of the
visit) and when he learned of the Executive Co~,~mittee's'existence,

U

Mr. Warter requested membership. The three representatives stated

that they welcomed the opportunity to talk to the site visitors,

first to explain what they had been doing and second to receive

guidance and advice.

Both purposes were accomplished.

1

The present review process is nominal, at best. In preparation

for this Triennial application, a letter was circularized explaining

that the F2WP was accepting project proposals for.inclusion in its

12' Rochester RMP

Draft

annual application. Each proposal was reviewed by the Executive
Committee and then by the full Regional Advisory Group.

Although

e

the RAG receives the proposals on those projects for which the
Executive Committee recommends approval, it receives oniy project

summaries of those for which disapproval has been recomrbended.

attendant technical review procedures are presently very unorganized

1

and used only sporadically.  At present,  the Coordinator and the core

staff play a large role in what technical assessment there is. The

Executive Committee realizes this is all wrong and is gathering its

I

The

I

collective thoughts on possible solutions.

exactly what procedures will emerge, some preliminary planning has been

done. For instance, the entire study committee structure is being

Although it's not clear

reorganized. The present categorical committees on heart disease,


cancer, and stroke are being phased out to be replaced by groups with

more relevance to the program.

committees which are needed include: long-range goals and priorities,

communications and public relations, by-laws and membership, finances

and budget, evaluation, continuing education, and health services

delivery.

Some early thoughts on the types of

It is hoped that in the process of regrouping, the services

and interest of the members on the now defunct categorical committees

can be retained.

It is planned that the new committees will play a

substantial role in program development and idea generation.

the present thought that technical review will

It is

be provided on a ad hoc

basis.

Comments: The site team thought the RAG ,as presently constituted

f

was representative of regional interests, hut urged  the

Region to add members of the CHP county committees (discussed in the

12 . Rochester RMP .

Draft

next section of this report) as interested people are identified.

The RAG obvious1.y has abdicated any program directing position and

e

.

must, during the coming year, assume its proper responsibilities.

The Executive Coinmittee knows this and plans to pave the way by

developing guidelines'and procedures for the RAG,

thoughtthey probably could do it.
a promising group which is on the right track'and will  act on the

advice of the site kea. The Committee realizes that initially it

,.

            and the site team

The Executive Committee itself is

will be appropriating for itself an undue amount of power,  but as

functions and procedures are formalized, the Executive Committee plans

to delegate responsibilities to core and the RAG and its committees.

The site team thought this to be a reasonable approach. The

Committee was urged to develop a sound review process on two levels:

(1) technical merit and (2) the fit of the activity with local and

e

national goals.

Although the site teamsaw an ad hoc system of

technical review as one way of doing things, it expressed the hope

that the Region consider other mechanisms which might require less

supervision.

Subregionalization

Findings :

The Rochester program has decided against establishing any

sort of formal subregional structure for a number of reasons:

1.

The Region is a small one and no point is more than 2% hours

driving distance.

2.

The core and project staff travel throughout the Region

extensively and sound out perceived needs, at least, on an informal

basis.

3. There is neither enough time nor money to invest in

e

establishing such structures.

13

e

C.

Rochester RMF' Draft

  4. The CIZP b agency has established a network of county committees

with which RMP has informal liaison.

seven people with overlapping RMP/CHP memberships, and as particularly

interested individuals from the CHP county committees emerge and are

There are presently on the RCZG

identified, RMP will tap them for RAG membership.

Comments : The site team believed that subregionalization could be

achieved by the method the Region described, and urged a

formalization of relationships between RRFP and CHP and its county


committees.

INVOLVEMENT OF REGIONAL -- RESOURCES

The Rochester Regional Medical Program is known, well-liked,  and used

by many individuals and agencies throughout the Region

Dr. Parker's esteem with the physicians is manifest in his recent

election to the presidency of the county medical society. There was

much evidence that the regional physicians look to the RIP for help.

Much of this was brought about through the good rapport established

through the regional continuing education activities and "the friendly

way in which RMP staff wi'll respond to pleas and ga into,communities

and assist in analyzing and solving problems.  Many area physicians

now, because of RElp, are excited about physicians' assistants, and

will look to the DIP for what they want to do in this area. The

program is cooperating with and helping communities in the delivery

of care through an analysis of emergency room
the Medical Society's Monroe Plan (modeled on

Plan), promoting the development of the North

a rural ambulatory prepaid health care center

utilization, supporting

the San Joachim Valley

Livings ton Health Center -

- and involvement with a

14 . Rochester RMP Draft

recently-funded Blue Cross/Shield prepaid health care model.



was testimony to indicate R@'s substantial role in promoting facility

There

e

utilization analysis - for instance, in Elmira, two community hospitals

with cobalt facilities combined them in one institution. And the words

of praise came from the administrator of the hospital which relinquished

its capability.

Relationships with CHP are proceeding apace. There is collaboration in


studies (for instance the data book and a study of emergency departments

-

in city hospitals) and the seven overlapping RAG/CIiP memberships.

Mr. Wenkert, the CHP b director, has a rather large staff of mostly

generalists, and he looks to RtP for some technical assistance. The

two groups orginally had collaborated on an experimental health services

delivery application, but when it was drastically reduced to become no

more than an HMO, CHP became the lead agency. It probably will look to

RMP, though, for evaluation expertise. In general, then, CIiP/Wf

relationships are reas.onably good, but need formalization. Mr. Wenkert

also stated that he would find it easier to work with RMP if he were

sure of its goals and the direction it intended to take.

The Region appears to haye worked out rqasonably good but informal

relationships with many local agencies such as the heart association

and the regional hospital council.

It also is quite interested and

active in the Genesee Regional Educational Alliance for Health Personnel.

Comments: The site team credits the RRMP with turning the ten-county

area into a region which is now established and viable.

It

has managed to relate the University to the communities for the first

e time, primarily through its continuing education activities and interesting

.I5 .

Rochester RMP

Draft

the university in the problems of providing medical care.

brought about good communication between physicians and nurses and

It has

between town and gown.

The site team felt that the impact of RMP on

                                            I
the communities is substantial. i

The Region, however , has shown considerable timidity in its use of

regional resources.

1

The area health organizations are Loming to BE'

.

for assistance, but the BP, in turn, is not bold in exacting similar

requests of these other groups. The program is not strong in the

initiation and promotion of activities.

in providing assistance and responding to requests.

It is very st'rong, though,

D. ASSESSMENT OF NEEDS, PROBLEMS, AND RESOURCES

Findings: The Statistical and Evaluation Unit is budgeted and treated

0

as a separate project. It relies primarily on its own

interests and requests from others (CHP, project directors) to guide

the direction of its activities.

It has worked on some interesting

studies (e. g. emergency room utilization), has conducted attitudinal


surveys,  and has worked with the Executive Committee in the first

phases of developing an objectives and priority setting mechanism.

There is a recently produced regional data book (in conjhnction with

CHP) which contains a compilation of statistics but little analysis.

The activities of the Unit are not comprehensive. The core and project

staff, through their numerous informal contacts throughout the Region,

have gained an idea of perceived needs,  but the IWP has not yet started

planning basad on data analysis. Interestingly enough, the Region's

.objectives are reasonable - even though perhaps accidentally. However,

e core and operational activities do not reflect systematic programming

based on assessment.

' 16 Rochester RMP Draft

Comments: The activities of the Statistical and Evaluation Unit

e

must become core functions and responsive to the necessity

of data analysis as a basis for determining program direction.

9.

E. . PROGPU IKPLEMENTATION. AND ACCOMPLISHNERTS

- Findings:

It would be difficult to discuss core and project activities

separately since, like the staff, the activities overlap.

Generally speaking, core activities have been confined to responding

and reacting to requests rather than aggressively initiating activities.
But they are available to the people in the Region and have

fostered

a great good feeling through their helpfulness.

divisions into which most ongoing and proposed project activities

There are four

fit, and core is being reorganized along those lines: medical

continuing education; nursing cnntinuing education;health services;

and evaluation, management services, etc.

Medical Continuing Education

Ongoing projects for which 04 year funding is requested:

Postgraduate Training in Cardiology

Cancer Clearinghouse

Telephone EKG Consultation

Decentralized Cancer Education

Physicians' Training in Chronic Renal Disease

Diabetes Education Program

New Proposals for which 04 year funding is requested:

Community Research and Teaching

1.7 ' Rochester RMP Draft

e

Many of the ongoing continuing education activities are planned

for merger into a larger overall multicategorical physicians'

postgraduate education program in the 06 year.

Generally speaking,

the activities carried out in the field of medical continuing

education are casual and unstructured.

An adequate job of late 60's

vintage continuing education is being accomplished, with cardiology
standing out particularly.-  The process of regionalization is being

'furthered through informal consultations, circuit riding, and bedside

teaching activities in community hospitals. The Region expects pending

recertification requirements to have a major impact on its continuing

education activities. Unfortunately, there is no evidence that the

continuing education project directors/core staff have ever

met together to discuss  the future of the continuing education program

a

and how it can become part of and  Eoater

a restructured health

service system.

Nursing Continuing Education:

Ongoing projects for which 04 year funding is requested:

CCU Training for Nurses

Neurologic and Rehabilitation Nursing

Chronic Renal Disease Nursing

Diabetes Education Program

No new proposals in the area of nursing continuing education are

presented for 04 year funding. However, in.the 06 year, all of the

ongoing projects are proposed for merger in a multicategorical comprehensive

program for pos'tgraduate education for nurses.

a

Rochester RMP

This group of

. Draft

activities is possibly the best of the RRNP program.

The nurses are energetic, dedicated, and well-known thr ughout the

Region.  Largely through their efforts, there now apparkntly is an

7

I

unusually free dialogue between physicians and nurses. They are

building bridges out bo the rest of the region and between and

among community hospitals.

roles they see developing for nurses. Nthough they are speaking

in terms of career ladders upward from the diploma level, they

have not yet looked at the bottom rung and the LPN with an eye toward

upward mobility. The nurses, too, expect upcoming recertification

requirements to impact on their program. They are apprehensive

that the Executive Committee does not contain nursing representation,

They are excited about the new

but they seem amenable and willing to pursue the new look in

core responsibilities.

He'alth Services :

Ongoing activities for which 04 year funding is requested:

Early Disease Detection Unit

Proposed new activities for 04 year funding:

Family Counselor Program

Health Education and Advocacy

Physicians' Assistants Planning (through core)

Early Disease Detection Unit is entering its fourth year of operation,

and since the site visit a year ago Dr. Bates has been working on

evaluation.

effect of screening on the community and

She feels she is not in a position to evaluate the

..

has been concentrating

on how the physicians to.whom patients are referred react. The

19

e

Rochester RMP

Draft

results have been rather discouraging in some instances.

For example,

250 patients with poor hearing were referred from the unit and in

only three instances was something done about it.

The threenew proposed projects all were interesting but the site

visitors could not see- that they resulted from any health services

programming effort. They were, rather, activities that came along

.and received RAG approval.

If there really were a functioning

core unit on health services, instead of just a box on an organizational

chart, elements of-these proposals might be integrated, perhaps with

EDDU, and a program based on objectives could be derived.

Evaluation, Management Services, Etc.:

Ongong projects for which 04 year funding is requested:

Regional Coagulation Laboratory

Statistical .and Evaluation Unit

New proposals for which 04 year funding is requested:

1,

Regional Organ Procurement, Sharing and Transpl-antation ~

Consultation for Rural Practitioners

Chronic Neuromuscular Disease Team

The projects in this category represent a mixed bag of activities

which did not fit into the other three categories.

The Statistical

and Evaluation Unit should, of course, become a part of core.

Comments: The site team found a group of miscellaneous projects


                                                 The

overall quality of these-activities is uneven, with nursing and

occasionally related to 21: unstructured program.

20

Rochester RMP Draft

cardiology continuing education winning high marks for success. The

strength of the program to date appears to lie in its consultation and
education activities and the availability of the staff tu give assistance

throughout the region.

are slated for withdrawal of RMP support next year.

One project is being phased out dnd two others

                   But,without clear

I

objectives and priorities, it is rather difficult for thk Region to

make these determinations.

One apparent problem for which the site team found no solution (primarily

because the problem never was articulated and the sources never brought

out) revolves around the status of cancer activities in the Rochester

Regional Medical Program.

There has been evidence for some time that

cancer has been getting short shrift,  but the visitors did not find

out why and Dr, Hall, the program director for cancer, was out of town

during the site visit.

F . EVALIJATLON

Findings: For the most part, project evaluation seems to be left up to

the individual project directors (with varying degrees of

sophistication and success), but Dr. Jacobs, Director of the Statistical

and Evaluation Unit, has been giving some assistance in terms of comparing

cost with units of output.

Program evaluation has not developed - and

there is no program to evaluate. Dr..Jacobs is suffering from lack of

direction and not understanding what his role is supposed to be, He

doesn't know whether he's line or staff and, in the absence of guidance,

has been following his

around evaluation as a

own interests and instincts, which seem to revolve

research activity nore thar. 88 an appliec! discipline.

21 Rochester RMP Draft

The studies  that have been done by his group seem not to be used by

0

-

anyone

Comment: The Statistical and Evaluation Unit must be fransferred to core

staff and be provided guidance as to the directions its activities

should take..

The $800,000 recommended level represents reductions from the current

year's annualized level of approximately $895,000 (after the cut) and

the requested level of $1,514,081, and vas considered by the team to be

an amount sufficient to provide for a core allocation adequate to

accomplish the recommended changes. At the same time, it will force

the Region to make choices among vari.ous combinations of activities  or

e support during the corning year.

VI. RECAPITULATION IN TEDfS OF NIPS EiISSION STATEMENT REVIEW CRITERIA

I. PERFOR~NCE .

1. Goals, Objectives, and Priorities. The site visitors saw the Region

                     as being in the preliminary stages
of evolution toward the development of a set of workable and operationally
valid objectives, based on actuzl regional needs, developed in priority

order by the Regional Advisory Group,  and a factor in determining

regional activities, Much work needs yet to be done. Nevertheless, even

though more by accident than design, the pjresent stated goals and priority

project functions represent a reasonable first cut in this evolution.

See pp. 4 and 5

22' Rochester RIP Draft

2. Accomplishments and Implementation.

The site team found a group of

0

miscellaneous projects occasionally

related to an unstructured program. The overall quality of these

activities is uneven, with nursing and cardiology continuing education
winning high marks for success.

The strength of the program to date

appears to lie in its consultation and education activities and the

availability of the staff to give assistance throughout the region.

See pp. 16-20

3. Continued Silpport.

One project is being phased out and two others are

. slated for withdrawal of DIP support next year.

But without clear objectives and priorities,  it is rather difficult

for the Region to make these determinations.

e 11. PROCESS

1. Organizational Viability and Effectiveness. This Region combines a

Coordinator who fails

to provide leadership with a core staff which is not accustomed

to think

in program terms.
the core to provide both for adninistrative competence and a formalization

of the program aspects.

The site team stressed the necessity for restructuring

'L

The RAG has been, to date, a rather passive

assembly, but with the advent of the new Executive Committee of the

RAG there is great and encouraging potential for change.

See pp. 6-12

2. Participation. The site team credits the RRMP with turning the

ten-county area into a region which is now established

and viable.

for the first time and has brought about good comnunication between

It has managed to relate the University to the communities

.23 Rochester KMP Draft

physicians and nurses and between town and gown.

impact of WP on the communities is substantial.

It was felt that the

The Region however,

has shown considerable timidity in its use of regional resources. The

area health organizations arc coming to FMP for assistance, but the &P,
in turn, is not bold in exacting similar requests of thede other groups.

i

i

The program is not strong in the initiation and promotion of activities.

I

It is very strong, though, in providing assi.stance and responding to

requests. See pp. 13-15

3. Local Planni.ng. The WIP is pursuing subrqgionalization through its

               informal relationships with CRP b agency county

committees. This seemed reasonable to the site team, but it urged a

formalization of relationships. See pp. 12-13

4, Assessment of Needs and Resources. The Gore and project staff, through

e

their numerous informal contacts

throughout the Region, have gained an idea of perceived needs, but the

WIP has not yet started planning based on data analysis.

Seep?, 15-16

5.

Management and Evaluation,

In the absence of a real program, 'any

program evaluation is out of the question.

        See PP. 26-21

Project evaluation is sporadic as to quality.

111, PROGRAM

1. Action Plan. The program has just made the first cut in what it thinks

its needs are,

It does not yet know what  its overall

mission is, so it hasn't evolved to the point where a provider-action plan

could be expected. The Region is working an it, though, and is conscious

of the necessity,

24 Rochester RNJ?

Draft

2. Dissemination of Knowledge.

The Region is getting at this through its

e

continuing education and multiphasic

screening activities.

has been involved in a model prepaid health care system sponsored by Blue

The area of manpower is a priority item. The Region

Cross/Shield which has just been funded and is planning to study general

practitioners' practice arrangements. The site team would give the

Region at least an average rating.

3.

Util.ization Manpower and Facilities.

The Region has done some work

along these lines including

working with communities on forgiveness loans for medical students;

planning for nurse practitioners and physicians extenders programs; and

a study of emergency room utilizatton throughout the Regioti.

4..

Preventton.

The Regiods primary activity in prevention is its Early

Disease Detection Unit.

5. Ambulatory Care. The extent to which the RRHP becomes involved will

depend on the development and direction of its

manpower program to a significant degree,

a high priority item.

North Livingston Health Center - a rural prepaid heal-th care center.

Anibulatory care is listed as

The RRMP was involved in the initi,ation of the

-.

6.

Continuity of Care.

It is the stroke people in the program who seem

primarily concerned in this area and some of the

education programs are dealing with secondary care.

7.

Short-Term Payoff.

Ou'tside of the involvement in the Blue Cross/Shield

prepaid plan (cost moderation), the Early Disease

$

23 Rochester RMP

Draft

Dctec tion Unit (access) and the Region's continuing education programs

(qual.ity), the site visitors could not determine much activity.  It has

e

been modest or slow on picking up on the concept. -Generally, the

Region is leaving this for others 2nd is not initiating much itself.

8. Regionalization. Quite a good job has been done. Community hospitals,

with RRMP advice, are getting together on facility

utilization; the physicians and nurses are communicatitlg well; and much

o the town/gown conflict has been ameliorated.

9.

Other Funding.

The site team felt that the Rochester IQfP probably was

     being tapped for funds more often than it was tapping

Ttiis was seen as part of the Region's syndrome of letting people

others,

come to it rather than going out and stirring up activity.

e

..

     REGIONAL MEDICAL
SUMMARY OF AN ANNIVERSARY
      (A Privileged

gional Medical Program
North Lamar Blvd., Suite 200

PROGRAMS SERVICE
TRIENNIUM GRANT APPLICATION
Communication)

RM 00007 8/71
July 1971 Review Committee

: Charles B. McCall, M.D.

ntly funded at $1,708,040 (dc) for its third operational
s August 31, 1971.
funds reauthorized as carryover into the third year.

s represent the current funding level of the 03 year

Of this amount $549,344 represents

receives indirect costs of approximately 30% of direct

r the 12% budget reduction was imposed in April 1971.

Texas RMP submits a Triennium Application that proposes:

I,

Developmental Component for three years.

ew projects for three years.

one approved/unf unded project .

ight continuation projects for one year; two projects for two years.

jects for one year.

t for "Earmarked" Kidney Disease Program Funds for

,714,244 (dc) for its initial year of its
of $120,000 is requested for the developmental
ents 10% of the current 03 year's funding level (minus
.

Component for its second and third years of the new
ut chart identifying the Components for each of the

  The Region expects the committed funding level to
the current review cycle and projects increased amounts

ears is found on the next page of this synopsis.

ed for a site visit on June 29-30, 1971.
the application has identified several issues which

ded to this Summary.

The staff's

be pursued by the site visit team.

These are included in Section C of

Geography and Demography

as Regional Medical Program covers the State's 267,000 square miles

counties.
from heavily populated urban, industrialized cities to those of

Its approximate 11 million citizens reside in areas

2nd Revision (617171)

REGION    Texas
CYCLE   RM 00007 8/71

-

BREAKOUT OF REQUEST 04 PROGRAM PERIOD

298,264 2 ,OL2, so9

*Groc;th Funding ----
   TOTAL 1,236,344 37,000 146.900 294.000 1,714,244

*see page 17 of the Summary for additional comments

..

.I

0.6 years of.request are Continuation Beyond Approved Period of Surmort.

CRB-617 /7 1 ..

**Request amended to 3 years per telephone condersation 6v M. Postd and the Region 5/12/71

,. . .
I: .

. :

REG ION Texas
BREAKOUT OF ReQUEST 05 PROGRAM PERIOD

/

I
c..

li.

REVISED -(6/7/71)

1 COYiRJUATION WITHIN CONTINUATION BEYOND APPROVED, NOT

IDEhTIFICATION OF    APPROVED PERIOD OF  APPROVED PERIOD OF  PREVIOUSLY
COHPO?ZhT          SUPPORT          SUPPORT           FUNDED

(821A - Core )
(821B - Core )
($21~ - Core )

( 86 6,853*)

I

--

~- ~

REGION Texas
BREAK9UI' OF REQUEST 06 PROGRAM PERIOD

NEW, NUT 3rd YEAR TOTAL
PREVIOUSLY DIRECT ALL YEARS
APPROVED

1/21 - Total
Developmental
t54
#36
c55

I-

866,853* -

          18~,-000


I 27,000

75,000

L

I

I

$8
c3 5

(I46A )

(846C )

(#46B )

#46 Total
945

I

I
I

__

I

5

83 7
#6
P5 1

I

$20
C38

(fl4A 1

(#14B )
814 - Total
+16 .
f#17A I
(817B )

U17 - Total - __

#5 0

*Growth Funding
*see page 17 of the summary

for additional comments

!

128,800* 128,800
75 3,000 753,000 ~ 1,204,850

I

Texas Regional Medical Program -2-

0

RM 00007 8/71

primarily agricultural and sparsely populated.
more than one million residents, while several have less than 5,000 persons.

Two of the counties have

*I

Although endowed with outstanding health educational facilities, composed
of five medical schools, three dental schools, three schools of pharmacy,
51 professional and 153 practical nurse training schools, and ample
allied health facilities, the majority of the counties do not have adequate

services according to the Texas State Health Department.

are 490 short term community hospitals with 44,587 beds.

                                              Almost 60%
of the hospitals are less than 50 bed facilities.  Two hundred, twenty-six
of the total 565 hospitals are accredited and approximately 25 are medical
school affiliated.  The Region contains two categorical research centers -
M. D. Anderson (cancer) at Houston, and the Cardiovascular Research Center
(heart) at Baylor.  There are 11,279 practicing physicians in Texas (106 per
100,000 papulation) made up of 31% general practitioners, 21% medical
specialists and 33% surgical.

FUNDING HISTORY
(Direct Coats Only)

  Planning

Grant Year

01

Period

7 166-616 7
7 /6 7-6/68

Amount Funded

$ 969,541
1,039,295

Operational

01 7 168-9/69              1,615,000
02 10169-9/70             2,220,891 1/
03 10170-8/71 2/ 1,708,040 z/

- l/
- 21

Included $444,178 Carryover from 01 year.
Award for llmonths at request of RMPS to accommodate anniversary

review scheduling.
cluded $549,344 Carryover from 02 year; also, includes 12% budget
reduction placed on Texas FY 1971 appropriation.

Regional Development

cember, 1965, various academic, State and private health representa-
met to discuss the potentials of the then newly enacted legislation

calling for Regional Medical Programs.
formed which later became the Regional Advisory Group.
tempting to establish three separate Regions, the applicants compromised
OD three subregions in North Texas, South Texas, and the Gulf Coast.
schools in the Houston area represented the Gulf Coast subregion, while

A State Coordinating Committee was

After first at-

Seven

TSW in Dallas represented the Northern subregion and UT San Antonio

Texas Regional Medical Program

- 3-

RM 00007 8/71

1

represented the Southern subregion.
designated the applicant organization, while the Texas Medical Center in
Houston was designated the fiscal agent.
was transferred to the Office of the Comptroller of the University of Texas
System in Austin.

The University of Texas  at Austin was

   In June 1970, the fiscal agency

The initial planning grant was awarded in July 1966, but progress, including
staff recruitment was relatively slow. Baylor (Houston) reported some progress
in planning for an Allied Health Training Program and in starting a Cancer
Registry; San Antonio reported resistance problems with private practitioners;
while Southwestern (Dallas) reported good progress in surveying resources and
personnel needs in the categorical diseases.  Dr. C. LeMaistre was serving as
Program Coordinator in Austin, and Dr. Spencer Thonipson was appointed Asso-
ciate Coordinator and was stationed in Galveston.

During the second planning grant year, staffs from the various institutions
began joint planning meetings,  task forces were created in the categorical
diseases, the RAG began to develop its Review Process and the Texas Council
of Health Science Libraries was created. This planning group submitted its
initial operational application which led to a site visit conducted in
June 1968.

The major concern of the site visitors was the apparent lack of central
direction and coordination of the program. This was illustrated by the
uneven progress made in the development of the nine subregional planning
units and by the fact that operational proposals appeared to be "based on
institutional interests and strengths with very little regard for community
needs and goals - either regionwide or local - and only a  few demonstrated
evidence of true cooperative arrangements or unilateral peripheral involve-
ment."
under strong leadership, hid not been active in the identification of
program goals and the development of program plans.  The RAG was weak in its
representation of minority groups, consumers, allied health professions, and
the practicing comunity.

The site team observed that the Regional Advisory Group, though

Because of these apparent shortcomings, Council recommended a one-year
approval of the Texas operational application, including cmtinued planning
support, with future funding contingent upon demonstrated improvement in
the areas mentioned by the site visit reviewers.  Accordingly, a one-year
operational award was issued on July 1, 1968, in the amount of $1,615,000
(d.c.0.). These funds were divided evenly between operational and planning
activities. This combined package included fourteen operational projects
and a number of planning efforts which included core support and support
for the nine institutional planning units.

A subsequent site visit was held in April 1969 to judge the progress made in
fulfilling the conditions laid down the year before as necessary for
further funding; that is, strengthening central administration and expand-
ing the RAG. The reviewers were well satisfied that these requirements -.

Texas Regional Medical Program' -4-

1

RM 00007 8/71

94

were being met; a new coordinator, Dr. Charles McCall, had been appointed
and had presented his plans for ttghtening up the organization.
was expanded to include nine new

On that basis, an 02 year operational award was made, but since RMPS
still considered the Region in probationary status as far as managerial
direction was concerned, support for the 12 new approved projects was not
included in the calculation of supplemental funds or of the commitment for

Instead, the Region wae awarded funds at the 01 year

The RAG

rested groups,

..

next year (03).
1.

Consequently, ten of the new projects were funded from carryover to

keep the Region from stagnatiag

When the Region applied for 03 year continuation,  the financial bind in

it found itself was apparent.
,891, TRMP dropped to an 03 level of $1,400,000.
se resulted from a combination of the Core's reduction because of the

From an 02 year operating budget of
             This substantial

phasing out of the institutional planning bases and the Region's use of
carryover to initiate a number of activities during the 02 year.

In review-

application, staff emp

ed that this fiscal disarray was not the
o circumstances and past Division practice.
k Dr. McCall's plan appeared to be working:

f TRMP; rather, it vas
eview further emphaeiz

The planning bases were phased out by January 1970 (except for development
of a subregional office in Eouston) and for the first time the Region had
a multidisciplinary core staff in Austin.  Functional differentiations be-

the RAG and the core staff had been delineated.

, with primary review responsibilities, had been made agents of the

              Planning and evaluation functions had been

The RAG had adopted a

by-laws and seemed to be involved in program development.

Five task

RAG rather than of the Coordinator.
altered with RMPS assistance.
consolidated in the Coordinator's office a Close relationships between TRMP
and the Texas Hospital Association and a formal working arrangement with CHP
had been initiated.

Because of the progress the Region had made during the 02 year, and because
of the promise it showed for the future, the 03 year award was made for
$1,866,044.
the Region to retain the momentum it had built up.
tached on the last page of this summary, lists the projects currently sup-
ported.
April 1971.

Financial management procedures had been

Subregionalizarion was being actively pursued.

This figure included $549,344 in carryover funding to permit

The funding history, at-

It reflects a 12% budget reduction imposed on the Texas RMP in

Organizational Structure and Processes

The grantee institution, the University of Texas System, is a consortium
of 17 state-supported educational institutions. Medical, Dental, Biomedical
Sciences and Nursing Schools are represented.
Regional Advisory Group are from the respective schools representing the

Eleven of the 50 member

. . . _..

Texas Regional Medical Program -5-

RM 00007 8/71

10

grantee. It should be emphasized that these 11 members represent their
respective schools and have not represented the grantee. According to

strategy has taken place.
standing services to the RMP by providing annual audits on the various
program components, exerting equipment control and purchasing good excess
equipment available from an updated inventory maintained by the Comptroller's
office.

the recent RMPS Assessment visit, no attempt to monopolize funding

..

The grantee's fiscal agent has provided out-

Both the RAG and its 17 member Executive Committee are highly provider-
oriented and appear to be well balanced geographically. Five minority
members are noted on the RAG.  Allied Health representation appears  to be
lacking in both the RAG and Executive Committee, but might be more preva-
lent in the newly created Program Development and Evaluation standing com-
mittees of the RAG or confined to the 14 member Standing Task Force on
Allied Health Programs.

The site visitors may wish to pursue this question.

The five standing Task Forces on Heart, Cancer, Stroke, Allied Health
Programs and Continuing Education and Biomedical Communications each met
three times and made recommendations to the RAG through the Program Develop-
ment Committee regarding program direction and content. Each maintains an
inventory and awareness of Regional resources in their respective program

I -. 3--'

\,:.-*

5,

elements . , . -*-

*1

The review process has been established and appears to be working well.
A chart depicting the various phases and deadline dates for the subject
application is found on the next page.

Regional Objectives

The long range objectives ediablished to meet the needs of Texas, as endorsed
by the RAG, include: 1) the improved delivery of technical skills and service
through prevention, detection, treatment, and rehabilitation; 2) the de-
velopment of programs designed to meet the real health manpower needs; 3)
to serve as an agent/broker for information that will achieve insight into
the real health problems; 4) to promote innovative approaches to the im-
proved availability of health care; and 5) continuing education. During the
past year, the full membership of  the RAG has decided to reexamine its
present project approach and pursue a "total program" direction.  However,
a transition period will be needed whereby  two  critical concerns will have
to be met: 1) ongoing activities (projects, services, etc.) must cmtinue
as planned, and 2) the shift to the new orientation must be positive but
smooth. To achieve an organized gradual change to programatic emphasis,
the application states that'la three-phase integrated approach has been
implemented.  Each segment of the existing program is being carefully
scrutinized. Priorities are being assigned to program objectives and
strategies.
toward the established goal can be estimated, measured, and documented for
later evaluation. In the three years allocated to the accomplishment of

Programs are being divided into work plans so that each step

' REGIONAL MEDICAL

PROPOSAL REVIEW PROCESS

staff for suggestions
and assis tatice .assistance, and modifica-

core staff for suggestions,

tion, if desired

Bcember 1 January 4

------------______------------

site visit task force with

Review COW

re commend a tlons

I

January 18 February 1 February 26

--- --- --- --

Regional Advisory

Regional Medical Program .Service:
Approval

mendations Conditional Approval
       3 Approval with moaifi- Returned with Advice

cation
Disapproval

___I.. ni3rtr.mk-z- 1 n 107L.

Texas Regional Medical Program -6-

RM 00007 8/71

e.

full transition from project to program orientation, RMPT will meet its
current obligations and build an operational base through which the health

professional can respond to the real health needs of Texas."

4,

Operational emphasis for 1971-72 will center around the continuation of
selected 1970-71 activities and the development of the first phase of the
long-range plan.
cognizant of the magnitude of individual problems, and ready to assist those
who want to contribute to solutions. An organization to meet these demands
has been developed in recent months.

The RAG and staff will be responsive to community needs,

Its key features are:

I.

Subregional offices have been opened in East Texas, far West Texas,
South Texas, and the upper Texas Coast. An office is planned for
the Panhandle/Permian Basin area this year.

2.

RAG has appointed a Program Development Committee to advise on
program areas, content, and priority. Staff is working closely
with this broadly representative group.

3.

The program development function has been separated from evaluation
to provide emphasis in these critical transition years.

I `.

4. Education has been organizationally separated from Professional
Programs to accommodate the potential shift in emphasis between
  areas as programmatic emphasis becomes clearer.

Present Application

Developmental Component

The Region requests devehpmental funds of $120,000 for the initial year
of the Triennium and hopes to increase this total with an expectant higher
commitment level for the second and third years. Examples of how these
funds will be used include:

1. Community hospital linkage
2. Rural health care
3.
4.

5.

Subregionalization especially on the Mexican-American border
Catalyst function for the encouragement and growth of high-
quality care outside the urban Medical Centers
Extending the resources of Coronary Care over areas not
having these services.

In addition, the Region states that the Grass-Roots Organization (Project
GRO) has the potential of creating an entire series of spin-offfs which
will further stimulate catalytic activities on the part of RAG and Core
staff.
tiQn, provides a flexible format for the introduction and testing of inno-

This project, while essentially moving into action through educa-

vative, new approaches to health care delivery.

._

Texas Regional Medical Program -7-

0

RM 00007 8/71

An abbreviated review process has been designed for the effective admin-
istration of developmental funds. For maximum flexibility, in situations
where timeliness is critical, the Coordinator has been delegated the
authority by the Regional Advisory Group to commit up to $5,000 to any
single unique activity. He must report such action to the Executive Com-
mittee at its next regular meeting following such action.  Authority for
commitments in excess of $5,000, but less than $15,000, has been delegated
to the Executive Committee based on the majority vote of a quorum of the
entire committee.
for approval of the Regional Advisory Group.

Second Year- $170,000

- CORE Requested First Year+$716,343
The request for Core personae1 for the initial year of the Triennium is
$497,794 which calls for 21 full time professionals and appropriate secre-
tarial and clerical assistance.
$666,501 which supported staff for the nine institutional bases.

Five professional positions are now vacant, three of which are Regional
representatives who will be expected to man the subregional areas operating
out of the Director's office of the Community Health Programs Division.
The other two vacancies include a Director of Educational Programs and a Chief
of Program Development. Subregional offices are operative in four of the ten
designated district areas of Texas, and other planning areas are scheduled to
be manned during the coming year.

Since Dr. McCall's appointment as Coordinator in June 1969,  the Core staff
has been increased with capable and enthusiastic employees.
established a viable program under its Division of Evaluation and Data
Management, the Division of Professional Programs, the Division of Educa-
tional Programs, and its Division of Community Health Programs.
the Divisions has outlined measurable objectives for the coming year.
June 1970,  the staff has been augmented by the addition of a nurse,  a busi-
ness graduate, an economist, a hospital administrator, a former voluntary
health agency executive, a mathematician, and a former pharmaceutical repre-
sentative.  An organization chart depicting the Core staff is found on the
next page.

Three planning studies and two of the proposed new project activities will
be administered under the supervision of Core staff.  They include a data
bank, a study to determine the feasibility of PASTEX (Texas Hospital par-
ticipation in the Professional Activity Study /FA57}, a plan for a Regional
Comprehensive Renal Disease Program, Project GR'O, and an Electrical Hazards
Proj ec t .

L

All commitments in excess of $15,000 must be submitted

                  Third Year - $185,000

This compares to the original 01 year of

The Region has

Each of

Since

Numerous cooperative arrangements have been established by the TRMP. They
can be found on pages 120-132 of the application.

COORDINATOR -------------------..I- ---_I

@cCnll)

I

DZILECI0.P - CO%L'SIIY       DIEaOR - PROFESSIONAL       DIRECTOR - EDUCATIONAL                   DIRECTOR - PZOC!UL'I .
Exra PZOS~KS DIV.         PROG?A!!S DIVISION           PROGRAMS DIVISION                      XKYACEXXT DIUISIOB

                                                  I
(XJCCn) (Burnhaz) (Burnham) * I
                                  1 DEPUTY COOXIISATOR

.

-

I I

L

OPERATIOSS OFFICER           NURSING EDUCATION
  (AnCerson)                (Lerro)

\

.

OPERATIONS OFFICEP

i2G,CSAL E?. 08

E:sIc:;;L fZP. El0

P ROC iu`2E.p

L

?.L5IC:;AI. =?.ill b 2
    (1971)

E.SICZ.u. EP. 95
   ( 19 71-72)

US: X.U. FL?.

I
L ------------------------ --

o

;ZGlOS.AJ, E?. E6
  (1972-73)

ii?cxc%L E?. 41
  ( 19 7 3- 74)

    mm1zIVLoN CBART
REGIONAL HEDICAG PmUY OF TBXAS
        1971-72

..

aThesa functions are being conducted by the indlviduala rhoun.
The positions will be filled at qualified iadfvldualr C.L) be
recruited in 1971-72.

. - ._

.. . _.

. -. . .

.`.

,I

.

.I

.

Texas Regional Medical Program -8-

e

RM 00007 8/71

o

The total amount requested for Core activities is $716,343, exclusive of
developmental component request, It includes:

Salaries ....................... $497,794
Equipment ...................... 5,670
Supplies ....................... 8,100
Travel ......................... 56,400
Space Rent ..................... 49,809
Publication .................... 25,800
Consultant ..................... 4,000
Communication .................. 27,970
Computer ....................... 12,000
Feasibility .................... 4,000
Planning for Renal Disease ..... 20,000
Other .......................... 4,800

Total $716,343 First fear
         Request of new Triennium

Second Year Request $803,219

Third Year Request $866,853

PROJECTS

Ten of the 16 project activity requests are scheduled for one more year of

--

funding; three are scheduled for two mre years and three projects ire
scheduled for three years of RMPS assistance.
have received funding priorities of ill, #3 and #lo by the Regional Advisory
Group.  These will be described first with the continuation projects
described later in order of their funding priority.
specific request for earmarked Kidney Program funds, described on Page 18
of this report, was submitted after this summary was started.

The new proposed projects

Project #50, a

New Project Proposals:

Project #54 - E (Priority #l) First Year Request $75,000

This proposal, to be administered by Core staff, was developed from inter-
est generated at the community level,
were established
Health Services Resources. The project proposes to:

Local cooperative planning groups

which has led to the request for a local Coordinator of

1.

Organize several small community hospitals into three
larger groups which would represent 32 hospitals with a
bed capacity of 1,500.
of West Cross Timbers Council, Mid Trinity Valley Council

The three groups would consist

and Northeast Texas Advisory Group.

0

Texas Regional Medical Program -9-

RM 00007 8/71?

2. Once organized, the three groups would arrange for

educational teams from medical schools to visit their
localities and offer training to physicians and allied
health personnel.

An amount of $75,000 for each of three years is requested  for salaries and
expenses.
group programs involving 60 hospitals with health professionals delivering
services associated with a 3,000 bed capacity are forecast.

Second Year Request $75,000              Third near Request $75,000

By the end of the third year of RMP support, six self-supporting

Project /I55 - Electrical Hazards (Priority 113)

First Year Request $75,000

This three year proposal, to be administered by Core staff, has established
the following objectives:

1.

To provide hospitals and their administrative and professional
staffs with information on hazards associated with medical
electronic instrumentation.

2. To demonstrate methods for meeting the need to provide appro-

priate expertise and consultation to hospitals concerning
potential and existing hazards in their critical care areas.

3. To determine health manpower needs in medical electronics.

4. To provide hospital personnel with pertinent data about the

safe use and care of specific electrical equipment in
critical care areas.

2'

5.

To determine a practical methodology for regular monitoring
and surveillance of critical care areas.

The Texas Medical Association is a strong supporter of the proposal and as-
sisted in its preparation.
program was visited prior to the initiation of this application.

The Michigan RMP, currently funding a similar

Second Year Request $56,000

Third Year Request $27,000

Project #51 - Helping Hospitals Organize and Strengthen Inhalation Therapy

Patient Care Programs (Priority #lo)

First Year Request $26,900

This project, which requests $26,900 for the first of two scheduled years,
was approved by the February 1971 Council.  It is the same project, except
for georgraphic coverage, as #4 of the same title which was operational
between July 1968 and September 1970.

resumes, the Texas Hospital Association will be the sponsoring Agency.

\a

During the previous operating phase,

the activity was administered by the Methodist Hospital.  When support

._*

0

.i

o

e

0

Texas Regional Medical Program -10-

Objectives Include :

RM 00007 8/71

1.

2.

3.

4.

5.

6.

To foster improvement of patient care by assisting
interested hospitals in developing allied health
personnel in inhalation therapy.

To establish relationships between those hospitals
interested in organizing inhalation therapy departments
and several key hospitals having outstanding inhalation
therapy departments.

To provide basic knowledge of inhalation therapy, the
organization and management of the unit, and the develop-
ment of selected inhalation therapy trainees and others
through a two-day institute.

To develop selected inhalation therapy trainees by pro-
viding their clinical resources for training in a two-week
clinical setting.

To assist hospitals in organizing inhalation therapy
departments by providing an inhalation therapy manual
designed and developed specifically as a reference and
guide in organizing and managing such a unit.

To continue to provide consultation and guidance in the
development of personnel and/or facilities to those
hospitals participating in the inhalation therapy training
program.

Second Year request $26,500

Continuation Projects:

Project /I36 - Interregional Cooperative Serial Control System (Priority 112)

This library project was supported this past year at a level of $28,001.

It is scheduled for one more year of RMP support at $9,001 and should be
self-supporting thereafter.
and improve the biomedical serial data base which was created during the
first two years. A listing, entitled TALON (Texas, Arkansas, Louisiana,
Oklahoma and New Mexico) Union list (meaning "union" of literature) has
been published.  The list include8 9,436 titles; a supplement containing
3,000 changes has been completed.
published in July 1971.

The major objective for 1971-72 is to expand

A second edition of TALON will be

Project #8 - Statewide Cancer Registry System (Priority 84)

This project was renewed and supported this past year for $87,123.
scheduled for two more Years of support at levels of $108,000 and $75,650,
respectively.

It is

The following objectives are planned for 1971-72:

Texas Regional Medical Program -11- RM 00007 8/71

1.

Test alternative methods of data collection and organ-
ization.

Develop a series of information subsystems for processing
data.

2.

3. Compile sample reports of several types appropriate to the

purposes of a Cancer Information service.

This project was site visited by a technical team in August 1970.
sponsor is the UT School of Public Health, Houston,

Its

Although organizational progress was considered satisfactory, the site visit
team may wish to explore progress in the study area (Health Planning area
#9) and plans for statewide implementation.

Project #35 - Reduce Complications Following Radiotherapy (Priority #5)

This project, sponsored by the UT Dental Branch at Houston, was supported
last year at a level of $38,566.
is requested for $35,000 to demonstrate effective methods of patient manage-
ment and to emphasize the need for oral care of head and neck cancer.
Progress denotes the project team conducted 14 meetings attended by 807 den-
tists, radiotherapists, radiologists, and head and neck surgeons. Seven
hundred other individuals from other Regions also attended.  The project
published and distributed "Refresher Course'' booklets concerning the various
aspects of oral care for the head and neck patient and effectively demonstra-
ted improved patient care through the development of a systematized program.

Continued support for one additional year

Project #46 - Expansion of Maxillofacial Prosthetic Services (Priority /t6)

,'

This project, sponsored by Baylor College of Dentistry, was supported  last
year at a level of $106,217. Continued support for one additional year is
requested at $100,000 to (1) expand service and maxillofacial prosthetic
services to three million persons as well as those residing in other areas
of the Region; (2) continue the implementation of training programs for
dentists and technicians to serve on head and neck cancer teams; and (3)
increase patient care capabilities to a level of 400 patients per year.

-

According to the Region, the project has made reasonable progress in that
it has significantly strengthened cooperative relationships and in doing
so has implemented full prosthetic treatment of patients needing removable
intra-oral and extra-oral appliances, has recruited three dentists for the
training program and has increased its monthly treatment capacity from 33
to 40 patients.
visits, 52 appliances were delivered and 71 professional consultations
were administered. The bulk of the funding requested is to be used for
salaries and stipends.

From September to December 1970, there were 234 patient

, ,.
.. .

. ..

' . .,

t

".

~... . .

--.

h Texas Regional Medical Program -12- RM 00007 8/71

I

Project #45 - Rehabilitation Management Through Coordinated Community

Action - St. Elizabeth's Hospital (Priority 117)

This project, cosponsored by Baylor University and St. Elizabeth's Hospital
in Houston, was supported last year at a level of $91,723.
one additional year is requested for $55. 000, which will be used primarily
for salaries. To date, the project has received three years' assistance.
NAC approved it for four years.

I

Support for

The activity is geared to provide rehabilitation management for patients
residing in the low income area of Houston.
mentation with 13 staff members and additional assistance from various
comunity agencies.
patients and has developed an instrument to establish the nature and
extent of residual physical impairment.  The team provides medical
evaluation, physical and occupational therapy, psychological evaluation
and therapy, social work assistance, special therapy, vocational training,
and financial assistance on an in and out patient basis.
to receive future support from other Federal sources when KMP funding is
phased out in August 1972.

Progress denotes full imple-

The project has initiated a plan to treat indigent

The project hopes

Project 4/37 - Health Careers Personnel Program (Priority #8)

This project, based in South Texas, was Supported last year at a level of
$65,762.
used for salaries of project personnel and for travel. The primary objec-
tive for next year includes an intensive effort earmarked towards recruit-,
ment of Black and Mexican-American students to the health field. This
activity is planned on a statewide basis with more concentrated efforts
placed in the Houston-Galveston area, especially since the hospital asso-
ciation in this area has requested such.

a,

Support for one additional year is requested for $77,000 to be

The applicant notes that after a relatively slow start,  considerable activ-
ity has been generated during the last five months of 1970. The Regional
Project Director, based in South Texae, has addressed 6,589 secondary
school students in assemblies, arranged hospital tours, and made visits to
homes of interested students. The Black field representative has been
active in counseling and recruiting in predominantly Negro schools. A
plan for evaluating data gathered from the project is currently being
formulated. The telephone counseling service has not been as effective
as was origindly anticipated but efforts will be continued to develop,
analyze and test this service next year.

Project 86 - Medical Physics in a Regional Center (Priority #9)

This project, conducted at M. D. Anderson Hospital and Tumor Clinic, was
supported last year at a level of $45,000.  Renewal support is request-
ed for one year at $20,000 which will be used to cover the salary of a
physicist and his travel expenses. The project is expected to be self-

E$
d2

Texas Regional Medical Program -13-

RM 00007 8/71

supporting by 1972.  Plans call for a minimum of 15 site visits to various

I*

hospitals to establish dosimetry standard8 which will enable medical
physicists to communicate more effectively with physicians.

Progress denotes that the State's medical physicists have formed their own
organization, have conducted two workshops to promote the standardization
of procedures, have developed a regional calibration facility,  have made
available thermo-luminescent dosimeters, on a weekly basis, for verifica-
tion of exposure rate of therapy machines between calibrations and have
provided other service activities within this subspeciality for 22 States
and six foreign countries.

r-

Project #20 - Eradication of Cervical Cancer in South Texas (Priority jlll)

This project, conducted at the Medical School in San Antonio (UT) was

supported last year at a level of $86,700.
:or one additional year primarily to evaluate the data on hand for the

Suppott is requested for $20,000

purpose of defining an appropriate role of the computer in cervical  cancer
screening programs.  This activity has provided for cytologic screening of
a high-risk population in South Texas and has demonstrated the importance
of a computer assisted records program.  Since 1968, an average of 40,000
smears have been taken in 33 South Texas Counties.  Follow-up has been made

been taught to administer the smear technique.
received through 314(e) funds. Additional plans for next year are outlined -%
on page 152 of the application.

effective by the cyclic computer reminder system.

Nurses and LVN's have

__

Previous support has been

Project #38 - Dial Access Telephonic Analysis: Medical Consultation Service

(Priority C12)

This project, conducted -at M. D. Anderson Hospital and Tumor Clinic, was -
supported last year for $19,963.  Renewal support is requested for one
year.in the amount of $17,000 which will be used to update 100 tapes which
are made available to physicians as. an aid in the management of cancer
patients.  The system employed renders toll-free telephone calls of six to
eight minute tape recordings of the most recent diagnostic and therapeutic
information on specific neoplastic disease problems and situations.

Through December 1970, the project has serviced 2,339 physicians who have
telephoned for information. Brochures have been mailed to 13,000 physicians
and dentists throughout Texas. Louisiana physicians have recently begun to
use the service.  The program has been endorsed by the Texas Academy of
General Practice; and an exhibit has been prepared and displayed at  the
National Osteopathic Association's Tenth International Cancer Conference.

0

.

0

0

Texas Regional Medical Program -14-

RM 00007 %/71

Project 1114 - Stroke Demonstration Unit (Priority 1/13)

This project sponsored by the Neurological Department of University of Texas
Medical School at Dallas (Southwestern) was supported last year for $141,045.

Two additional years of support are requested; $100,000 for each year.
Objectives include the training of 100 or more nurses and LVN's per year

in formal on-site workshops, one-day conferences for post graduate education
for M.D.'s, two-week courses for family practice physicians, six-month
fellowship programs for practicing physicians, evaluation of course content,
and plans to evaluate the economics of operating stroke unitsfor the benefit
of smaller hospitals.

Progress through December 1970, denotes that the project has developed a
special 22-bed stroke unit facility and has assembled a multidisciplinary
team of health specialists who have demonstrated to North Texas health
professionals the latest techniques of RX and rehabilitation for stroke
patients. Other factors include: (1) the addition of two beds to the
intensive care unit;  (2) 25 nurses have participated in the 53 day training
program; and (3) only two of 25 expected physicians have attended the one-
day conferences.
initiated.

An evaluation of the nurse workshop program has been

Project 116 - Regional Rehabilitation Through Cornunity Action - Wharton,

Texas (Priority 1/14)

This project, cosponsored by Baylor and two community hoepitals in Wharton,
was supported in the amount of $67,708 this past year.  One additional year
of support is requested for $20,000 to make available complete rehabilita-
tive services, provide training programs for hospital administrators,
physicians and allied health personnel, develop a program which can become
operationally independent and demonstrate the feasibility of providing
services of this kind to other communities.

Progress denotes that 641 patients were given services during the reporting
period, the size of the facility was increased by 8,000 square feet, program
and patient evaluation, data collection and patient follow-up was made
available, and the project has established a regional center for the im-
provement and enhancement of patient care to a community where this kind of
service had not been previously available.  Texas RMP has supported this
project for three years.

Project 1/17 - Regional Rehabilitation Through Coordinated Community Action -

Bihl Center, New Braunfels, Texas

(Priority #15)

This project
sity of Texas Medical School at San Antonio, and the Bihl Rehabilitation
Center which services a three-county area.
$46,185 was made available this past year.

is cosponsored by the Department of Physical Medicine, Univer-

RMP support,  in the amount of
One more year's support is

Texas Regional Medical Program -15-

RM 00007 8/71

0 e

requested for $20,000.
to continue the operation of the model program of the Bihl Center.

During the reporting period, 175 patients were treated which is fewer than
expected.
the difficulty in obtaining medicare funds.
presentatiohs were made to hospital and nursing home staffs.
training sessions for LVN's, attended by 150 persons.
ning to pay for services which will assist the self-supporting objective.
Texas RMP has supported this project for three years.

After then, the New Braunfels Huspital is expected

,-

The decrease in anticipated admissions was caused, in part, by

Forty formal instructional

There were 30

Patients are begin-

Terminating Projects

Eight project activities and two Core supported feasibility studies will
terminate with the close of this, the 03 year.

Project activities include:

1 - Areawide Total Respiratory Care

The project provided respiratory care in twelve counties sur-
rounding Houston and utilized the San Jacinto TB and RD Association
facilities as back-up support to the sponsoring agency at Baylor
University. It is anticipated that respiratory intensive care
units will continue through local funding now that RMP support has
been withdrawn. ,-

i-: -'.'

_I

2 - Annual Clinical Conference

This project, funded at $11,520 this past year, presented the 15th
Annual Clinical Conference on "Progress in the Rehabilitation of
the Cancer Patient',',in Houston,  Attendance totaled 372, including
52 persons from 25 other States and three foreign countries.
Anderson Hospital and Tumor  Institute was the sponsor for the past
two years.

M. D.

3 - A Beginning Program of CE for OT's

This project has been funded for two years at approximately
$24,000 each year.
Continuing Education for Occupational Therapists.  By July of
1970, 140 of the estimated 400 OT's in Texas had been located
and interviewed.  Six one-day workshops along with the Annual
TOTA Convention were held in Galveston in April 1971.
workshops are scheduled.  A new proposal with more  innovative
approaches to Continuing Education is being considered.
sources of funding will be explored.

It has created interest in stimulating

Other

Other

Texas Regional Medical Program -16- RM 00007 8/71

4 - Extending Coronzry Care Nursing Training to Community Hospitals

This program has had considerable success in that 107 nurses had
been trained in five hospitals, including one ghetto hospital in a
predominantly Black area in Houston during the first year of oper-
atioc.
together would have trained 20 nurses.
interest was stimulated leading to the training of 30 Black physi-
cians. During the second year, five rural hospitals were conducting
the program for 75 nurses.  One group of ten hospitals and another
comprised of nine hospitals have requested TRMP assistance in
pursuing this kind of activity in the immediate future.

Only two hospitals had been planned originally which,

Additionally, physician

5 - Medical Genetics of Tumors

This program has identified a number of high risk families.
noted on page 164 of the Triennium Application is noteworthy.
plan for continuation is not indicated.

Progress

A

6-

Long Distance Telephonic Consultation

This project may have served to demonstrate the lack of interest on
the part of physicians for continuing education opportunities util-
izing what was considered to be a unique project designed to provide
free consultative services via telephone to physicians within a one
hundred mile radius of Dallas.  Only three to four percent of  those
physicians eligible (1,441) actually used the services.

7 - Regional Consultation Services - Radio Therapy

Significant progress is noted in that 17,800 patients were treated
with mega-voltage irradiation therapy at the M. D. Anderson Hospital
since 1968, Hermann Hospital had had a total of 522 external beam
irradiations and 39 interstitial irradiation new patients, and St.
Joseph's had 355 external and 30 intracavitary irradiation new
patients.
design and a system for the centralization of data which provides
for access, retrieval and analysis were noted as further progress.

Improved techniques, evaluation of equipment of advanced

8 - Regional Rehabilitation Program - Kilgore, Texas

Progress has been considered above average.
continued with local support.

The program will be

Texas Regional Medical Program -17-

RM 00007 8/71

-.-.

Terminating Core Studies

The two terminating feasibility studies supported by Core included

n-

(1) the development of a physical therapy unit at the Uvalde Hospital
which accomplished its objective; and (2) a study to determine the
feasibility for developing an innovative training and educational program
directed at correcting critical manpower deficiencies which the current
educational system has been unable to alleviate.  Although the need has
been well documented in the area of training anesthesiology technologists,
it is too early for the Region to forecast prospective results in estab-
lishing a program similiar to those now conducted at Case Western Reserve
and Emory Universities.
activity, other Federal support will be sought if the educational system
chooses to pursue this need.

Since RMPS no longer will support this kind of

Request for "Growth Funding"

In the addendum material submitted by the Region, projected "growth
funding" is requested for the second and third years of the Triennium.
The budget request includes $451,850 for the second year with the assump-

National Advisory Council one year from now.

Budget projections have been made for each of the Program entities which
include Community Health, Professional, and Educational Programs in an
effort to determine a resource level for planning and development purposes.
The RAG is specifying program priorities against which these potential
resources can be budgeted.  An amount of $753,000 is projected for the
final year of the Trienn,ium.

The Regiotl stresses that Program emphasis will continue to shift from
education to demonstration of health services and community action-based
efforts. Education is expected to seek a level at which the TRMP can
disseminate knowledge and assist cooperative education efforts without
duplicating those services already being provided.

tion that adequate numbers of good proposals will be submitted

expected to be generated from the Developmental Component activities.

to the

,-
1_ -.>

These proposals are

..

.,

d

The RAG and its Committees have established the policy to concentrate on
the development of community health demonstrations and will plan to
implement them as soon as economically feasible.

Texas Regional Medical Program -18-

e

RM 00007 8/71

    Specific Request for "Earmarked" Kidney Disease Funds

Project #50 - Control of Hypertension and Chronic Renal Disease

.e

o

First Year Request $120,000

This project activity is a resubmission for specific consideration  for
funding from those sources assumed to be earmarked for kidney disease
proposals. It is understood that the request will not compete with other
proposals in the application.  Funding will not be implemented unless the
total budget request, including this activity, will be funded to the Texas
W.

The project was reviewed by the Kidney Disease &-hoc Panel in January 1971
and was referred to Council for a decision regarding the maximum length of
time which RMP support could be obligated or projected.  A specific answer
has not yet been obtained, although the Region has been advised that funds,
presently allocated to the TRMP, could be used for a short duration until
other support could be found.  In essence, this project has been considered
as approved for one year only.  The present request calls for three years
of RMP support.

The project had been supported three years by the National Center for
Chronic Disease Control and one year by the Moody Foundation.
scheduled for seven more years of operation before final results of the
study can be considered to be conclusive.

The target population in the study includes children who entered the pri-
mary school system four years ago.
an eleven year duration.

The project has been designed to demonstrate:

It is

The same children will be followed for

1.

That reduction in the number of future cases of hypertension
and chronic renal disease can best be accomplished by early
detection and appropriate therapy during the presymptomatic
stages.

2.

That since the presymptomatic stage for hypertension and chronic
renal disease occurs early in life, school-age children comprise
the ideal target population.

That incorporation into existing school health programs will
provide the most feasible and acceptable system for delivery
and early detection to that target population.

3.

4.


5.

Developing predictors of hypertension and chronic renal disease.
Investigating community responses to a program for this control.

Second Year Request $124,300

Third Year Request $128,800

         -19-
TMAS REGIONAL MEDICAL PROGRAM

Projects Funded During 03 Year

Sept. 1, 1970-Aug. 31, 1971

NO o

-

20

17


46


16


14


35


46


8

36


37

1


4


31


18


33


39


6


3a

5


15

CURRENT BUDGET AMENDED

TITLE BUDGET REDUCTION BUDGET

Coordinator's Office (Including $ 696,222 $ 96,085 $ 600,137

two feasibility studies $27,335)

Eradication of Cervical Cancer in 90,000 3 , 300 86,700

So. Texas

Reg. Rehab., UTSAMS - New Braunfels 48,000 1,815 46,185

Maxillofacial Prosthetic Services 110 , 287 4,070 106,217

Reg. Rehab. , Baylor-Wharton 72,068

Stroke Demonstration Unit 151,000

Reduce Complications Following Radioth. 40,986

Rehab. Mgmt., Baylor-St. Elizabeth's 100,000

Statewide Cancer Registry 105,300

Library - Serial Control System      28,610

Health Careers .I 66,862

Medical Genetics 14,000

Cont. Ed. for Occupational Therapists 24,311

Long Distance Telephone Consultation 20,000

Reg. Rehab., UTSWMS - Kilgore 47,000

Coronary Care Nurse Training 64,915

Annual Clinical Conference 11,520

Medical Physics 45,000

Dial Access Telephonic Consultation 19,963

Regional Consultation, Radiotherapy 30,000

Community Respiratory Care         80 , 000

UfL!-&

4,360    67,708

9,955    141,045

2,420    38,566

-.

"d -2

91,723 -.

8,277 ~ :,

18,177     87,123

  6 09    28 , 001

1,100    65,762

1,430    12,570

1,485    22,826

  6 05    19 , 395

1,951.    45,049

2,365    62,550

  0      11,520

  0     45,000

  0      19,963


  0      30,000

0 80,000 '-

$158,004 $1,708,040

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

HEALTH SERVJCES AND MENTAL HEALTH ADMINISTRATION

Subjtcf:

Staff Rcvie.tJ, Triennium Application, Texas Regional Medical Program

v May 1.4, 1971

To: Harold Margulies, M.D., Director

Regional Mcdi cal Programs Service'

TIIROIJGH: Sam 0. GiInier, Jr. Acting Chief ~ -

1

..)

# Regional l~evclopntent Branchy

f

Plrs. Sarah J. Silsbee, Chief /. . b

Grants Rcview Branch , KFiPS

i

1 ' i,

Gerald Cardell, Chief ; r*

Grants PIanageincnt Branch, RXPS

E'c.r_:;cins a'iic:udinLJ * Ei.lcrn FaaLz, Grants Ecvicw P,r,i!ich

- __ I-I__-_-____- ..-a.

Carol Larson, Coiitinujng Education 6 l'raining
Char le s Barnes , Grants Management Branch
Lee Teets, Grants Managerwnt Eraich
Harold O'Flaherty, Planning 6 Evaluation Eranch

Thomas Simonds , Managcmetit Assessment
Michael J. Posta, Regional Development Branch

A. Background

--

0

The Texas RMP is currently funded at $1,70S,04@ (d.c.) for its 03
operational year which terrnlnates August 31, 1971.. Of this amount
$549 , 344 represcnts unspent second year funds reauthorized as carryover
into the third year. Indirect costs approximatc 30% of the above
nlciitioncd direct costs. These figures represent the current funding
level of the 03 year after the 12% budget reduction was imposed in
April 1971.

The subject Tri cnnium Application requests':

1. Devcl.opn~cntn1 Coioponcnt for three ycors

2. Core and two ncw projeccs for three ycars

3. The initiaLion of one approved buL nqt yci funded project

4. I'iRlit cotitjniiat-ion projects for one* yc'ar; ~WCJ projects for two yeor:;.

5. Two rCtlCb7C11 projects for one year.

. 4f

6.

Spccific rc?qiiest for "earmarIcedff Kidiicy Lliseasc Program fuiids
for oiic year.

-21-

Page 2 - 1Iarol.d Margulics, M.D.

The Region requests $1,714,244 (dc) for its initial year of its second
Trienniuio.
Component which represents 10% of the current.03 year's funding level
(minus carryover of $549,344).

increased amounts for the Developmental Component for its second and
third years of the new Triennium.

      An amount of $120,000 is requestcd for the developmentd- .


ing level to be increased after the current review cycle and projects

Fa

The Region expects the committed fucd-

P.

5..

B. Purpose of the Review *: . ,

*, .

Since the Region is scheduled for a site visit on June 29-30, 1971,
staff  ccntered its discussion on issues ~hicli might. be .pursued by the
vj sitors .
tIici-,-! 1.:;::; iinnii iinoiis C.CJlICcI.I1 rel;fiT<Ij.ilz tIi:l rcI.at:i vcIy I.o:.7 fiinding 1 c-./rlS
forcnsl. for l'exa::. 'J'o da~~-, tlii:: Rcl;ion has yet t.0 be g;.ivcrj a f~i!dj.~-~g
bast wIl$ch woiil d ;lI ~CIW for atk!qrl;lLC!* ful. 11IC: I;] ;Ii~iliilg :!rd dC:i?C].<~p~ii~riL.
Ins.:t:c.ntl, cnrryovc~ ftind!: h:lvc: hcvrn Zrniited on ;I year to year 1,:i:;j :;,
Y1i-i s pi*ol)l mi vias disciissccl at thc: Type S nrc:c~tin;; I.a:;t ycnr , but since
thc l<i*Zion w:~:: lieatlcil lnt-o its 03 yc;!r, cnrryovc!i- g.gz3.n 17iic; rc:comir:r!c!e.d
by straff and received your approval. The April 1971, dcci:;icil to fund
I31P's on the basis of its "book conmitments" has again placed financial
pressures on this Region.
funding consideration for its new Triennial, assuming the site visitors'

Altliough a spcc5fi.c funding recor:iiicndation WQS pot attcrripted ,

Staff suggests that Texas be given special

-

reconnilendations are favorable.

C. General Impressions

Staff nicinbers , particularly those who, have visited the Region,  are
most impressed with the Program Coordinator and his enthusiastic and
qualified Corc staff. Recent stafi visits concerning eval-uat ion act-iv-
ities and management assessment reiterate the progress Lcing made by
tlie Rcbgion , especially' in the ovcrall  direct ion and in -j ts Core-centercd
activities.

-22-

o

sc'rvc: on thi~ 3 I-nlan Exccutive Committee. Sraf f is satisicd that
the grantee does not monopolize funding strategy but the site
visitors might wish to further investigate' this possibility and
suggest that the RAG and its Executive Committee reduce the number
of grantee members to the extent feasible.

2.

Consunicr and All.ied .Health representation are lacking in both RAG
and in the Executive Conunittee. Can these apparent shortcomings be
alleviated in the near future? .e

4.

5.

6.

7.

8.

9.

The application does not address the topic of priority sefting.
What can be expected in the near future, especially if the
developmental component request is approved?

The application does not contain a copy of the By-Laws.
will be obtained for each of the site visitors prior to thc meeting.

From the Organization Chart on page 92 of the. application and ttie
general discussion con-crning it, tlicrc was some cjucstion as to
the reason for both a 1)ivjsion of IJroCcr:sionnl Program:; and a Division
OF Educational Prograrns. Perhaps thc .site visi tors might. wish to
iurthcr explorc the etiology of this dcvelopriicnt ,
what are the criteria for achj cving program ha1 ance in thcse two
areas?

Although a nunibcr of good cooperative arrangements have bccn de-
velopcd , response from the CIIP agencies,  relative to the review of
this application, do not seem to indicate strong ties.
niiglit bc pursucid further by the site visitors with particular
refcrcnce to the "B" agencies already funded and  those now in the
plaiinj ng phase.

A copy

More specifically ,

(See Figure 13, page 74 of the app1ic:ation.)

This factor

-41

Page 4 - Harold Nargulies, M.D.

'1.

10. Equal employment opportunity among minority groups appears to be *a

evident in the projects funded, but is lacking within Core,
Perhaps this point should be emphasized as a function of the F
Administrative Service Division and inserted into its operational
objectives found on page 88 of the application.

.. , .. .

Recommendation to thc Director, RMPS

D* _I_--7_

With your approval, this report will be incl.udcr1 for..tlie site visitors'
information and will be attached to the yellow Sunmary Sheet made
available to members of the Review Corninittee.

*

I

Michael J. Posta
Operations Officer
Keg io II a 1 D c ve 1 o y 111 en t Br an c h

Approved ..

Disapproved

/ _.

                      I

' Harold Margulies, M.D.

; /;: ,

,-. /

1*

!/
- i,,,

Director, RMPS

.

.

(A Privileged Communication)

SUPlMARY OF REVIEW AND CONCLUSION

JULY 1971 REVIEW COMHITTEE

OF

TEXAS REGIONAL MEDICAL PROGRAM
     RM 00007 8/71

FOR CONSIDERATION BY AUGUST 1971 ADVISORY COUbiCIL

RECOMMENDATION: Approval for two years only of the Texas Re;:ional
         Med ical Program at a funding level of $1,590 )I Wr),
includinf; the use OF developmental funding.

DIRECT COST ONLY

YEAR REQUEST                RECOMMENDED

04 $1,714,244            $1,590,000

05 1,882,519             1,590,000

06 2,035,653                   -0-

TOTAL $5,632,416 $3,180,000

CRITLQUE: The findings of the June 29-30, 1971, site visit were

presented to the Committee by Dr. George E. Miller, former

member of the Review Committee. The principal discussants were the
primary and secondary reviewers who were members of the Review Committee
itself. Dr. Miller presented the team's findings in the context of the
past history of the Texas Regional Medical Program. He reminded the
Committee that the program had begun initially with the intention of
creating three Regions which were finally merged into a single statewide
region with three subregions. He said the interrelationships in the
early days were illustrated by the fact that the grantee was the University
of Texas, Austin Campus, and the fiscal agent was the Texas Medical Center,
with institutional planning staffs in each of the University of Texas
medical schools, Raylor and M.D. Anderson Hospital. He recounted that
after two years of planning, the site visitors studying the Region's
application for operational funds, reported that the program seems to
represent a loose confederation of special interests rather than a
Regional Medical Program.  The strong institutional interests did not
adequately represent minorities, consumers, allied health professions
or the practicing community.
in 1969, significant progress had been made in strengthening the
central administration, largely through the appointment of a new full-
time coordinator, who was establishing a central organization in
and planning to phase out the institutional planning units.
reported that by 1970 the strong central administration had been

At the the of a site visit one year later

Austin

Dr. Miller

established and the University of Texas system had been named both grantee
and fiscal agent.

1

f

TEXAS DE'

-2-

RM 00007 8/71

The site visitors were much impressed by what they encountered in
Texas in 1971. The visit was carefully planned, superbly organized
and nicely run by the Coordinator and his Core staff.  There was
excellent and easily understood documentation of each presentation.
In synthesizing their ideas and responding to the site visitors'
questions, the Core staff gave evidence of high professional quality.
It was also impressive to the team to have the Chairman of the Regional
Advisory Group (a former president of the Texas Medical Association)
not only present throughout the visit but an active and well-informed
contributor to the discussion. Other significant Regional Advisory
Group members were also present, some throughout the entire meeting.

The team found evidence that working relationships between the staff
and the Regional Advisory Group were excellent and the Regional Advisory
Group exercises significant influence in the policy and direction of  the
program. In addition, a number of individuals representing academic
institutions, professional associations, comprehensive health planning
groups, public and voluntary health agencies, individual practitioners,
task forces and advisory groups had come from all over Texas to give
supporting testimony to the site visitors about the importance of this
program to the health services system of the state.

The team concluded that the Coordinator had managed an impressive shift
from the institutional focus of the past to provider and community focus.
The program has won enthusiastic and widespread support in most quarters
includingnot only the medical professions but other health providers as
well. The team found that the parochial interest which appeared to impede
the initial development of the program are rapidly receding.
evident that the program is rapidly extending into a series of subregional
organizational centers.
program phase.  Four of the ten health subregions in Texas are now covered
by full-time Core staf? members who are indigenous workers with impressive
understanding of their local problems. A fifth subregional representative
would have been appointed except for the budget cutback.

It was also

This is to be the major thrust of the next

Despite evidence of significant progress,  the site visitors found that
at the decision-making level, the organization still appears over-
balanced by physicians.
as arc 12 of the 17 Executive Committee members. The only health
professionals on thc PJC are three dentists and  two nurses.
are no other health prorcssions represented on the Executive Committee.
A previous managerrent assessment visit felt that th.e grantee (University
of Texas system) was overly represented on the RAG, but the strong and
persuasive response from the Chancellor indicated that only two such
persons represented the system while the others represented individual
health education and health service institutions within the system. The
team believes there is sufficient justification for this arrangement.
Although important steps in securing minority representation on the RAG
have been taken, additional efforts seem desirable to the team. In the

Tventy-nine of 50 WG members arc physicians

l'liere

TEXAS

- 3-

F3I 00007 8/71

four major subcommittees there are no minorities represented and this
certainly requires correcting. Site visitors also noted a paucity of
minority groups on the Core staff.

While it is evident that the Coordinator and the RAG art. giving serious
attention to delivery problems in low service high demand areas, they
still seemed to the team like ad hoc arrangements at this point in time.
A program development committee of the RAG is workin:: on the establish-
ment and priorities and critieria but these are not yet available in
other than the most general terms. A good review system has been
established. It is difficult to decide which programs deserve support
and which do not. The team felt there is no question but what progress
has been made in this direction. The system has not yet been codified.
The team found this of special concern in the face of the triennium
proposal in which phase out of present project would make $450,000
available for future program development during the second year and
$750,000 during the third year.
funding during the next year were considered largely pedestrian and
routine and represent the original program approach which is now being
phased out. In the area of assessment of regional needs and problems,
the team had some feeling that the process was more a central academic
review than a peripheral involvement and input - a theoretical rather
than a programmatic approach. The Core staff theoreticians are excellent
but will need increased input from the emerging subregional organization
and staff. Dr. Miller reported that program accomplishments thus far are
rather modest; in fact, some of the projects (such as the Cancer Registry)
are described by technical reviewers as little short of disaster.
Nonetheless,there is perceptible achievemcnnt in at least one project (the
about to be terminated coronary care nursing training) ; the outcome has
been dramatic, not only in the involved institutions but also in their
impact upon other institutions.
projects as such.

An evaluation committee has been established in the RAG, headed by
Dr. Stanley Olson, with technical assistance of a widely respected senior
social psychologist at the University of Houston. The only significant
evaluation effort thus far has been directed toward the above-mentioned
coronary nursing training program. The team reported anecdotal evaluation
by practicing physicians present at the site visit which were quite
expressive of their understanding and appreciation of the program
offerings.
satisfied that very significant progress has been made in the Regional
Medical Program of Texas and that extraordinary attitudinal and
organizational changes have occurred under the leadership of Dr. McCall.
The program offers high promise of substantial impact upon access to and
delivery of health service in the Texas Region.
strong support." The team recommended, however, that the Region not
be provided three-year funding as requested in the absence of substantive
program plans for the second and third year of the triennium. The team
did feel that the developmental funding  was well justified by the review

The array of projects identified for

The team did not look at individual

Dr. Miller summed up the site visitors conclusions as "well

The team feels it deserves

TEXAS mlp

RM 00007 8/71

system developed, the Core staff available and the strong RAG. The
team recommended that the Region be awarded $1,590,000 for each of
two years including the requested $120,000 developmental component,
with the understanding that  there will be further program review at
the end of the first year at which time they may wish to again
submit a triennial application.

The Committee discussion folIowing Dr. Miller's presentation was
spirited. The Committee reviewers, having had the benefit only of
the application, were somewhat skeptical about program progress and
critical of the project proposals included in the application.
However, Dr. Miller re-emphasized the team's feeling that significant
changes had occurred in the RMP of Texas, changes that had resulted
from earlier site visit recommendations such as the change from the
institutional focus to the program focus.

The team concluded that the power structure behind and involved in the
Regional Medical Program was impressive and was in a position to effect
the change in program direction they are embarked on.  Dr. Miller
explained that it was with the help of the knowledgeable people on the
RAG, that the Coordinator had been able to function in the positive
fashion in which he had.

The Committee voted to accept the site visit recommendations which *-
included funding at $1,590,000 for two years, including the developmental
component. A site visit will be made in one year to see how the Region
is progressing in its subregional program development, in including
allied health professions on decision-making bodies, in adding
representatives of the 25% minority population of the Texas Regional
Medical Program on decision-making and other committees and in helping
them play a construcitve role in program development.

*'

Dr. Rrindley was not present at the discussion of this application.

RMPS/GRB
7/15/71

DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE
            PUBLIC HEALTH .SERVICE
HEALTH SERVICES AND MENTAL HEALTH E.DMINISIRATION

July 6, 1971

Quick Report of Texas `Site Visit, June 29-30, 1971

Director I
Regional Medical Programs Service
Acting Deputy Director
Regional Nedical Program Service 1

llowing consultants took part in the Texas site visit:

George Miller, M. D. , Chairman
Alfred Popna, M.D., Mountain States Director,

former Council member


Connecticut RAG member

Metropolitan XMP

oseph Smith, M.D., Practicing Cardiologist,

I. Jay Brightman, M.D., Coordinator, New York

Staff members on the team were: Michael Posta, Regional Development
Branch, who prepared all the site visit materials ; Miss Carol Larson,
Continuing Education and Training Branch; Harold 0' Flahcrty , Program
Planning and Evaluation; Dale Robertson, DHEW Region VI, Dallas ;  and
Mrs. Judy Silsbee, Grants Review Branch.

1

eting took place in the Texas DP offices in Austin.

Working

staff of the Texas RMP were the primary spokesmen for the Region with
members of the Executive Coniiittee, RAG, Task Forces and the Coordinator
participating as the need arose for clarification of their commitment

olvement in the process described by staff.
ntion of agenda fomat is sigriificant as an indicator of the

                       Three years ago when the
Texas RMP first requested operational status, or even two years ago
when a site visit reported that the Texas program would no longer
require a yearly surveillance by Council, the agenda had to be
presented by institutional representatives, either of the Core staff
or categorical projects.
program because the progrzm represented a loose confederation of
competing institutional interests.

There has been remarkable progress in the past two years.  The concen-
tration on institutional interests and needs has given way to a
concentration on the health needs of Texas without sacrificing the
support and conmltment of the educational institutj ons .  There are

that have taken place in Texas.

There was 'no one spokesman for the Texas

.

Page 2 - Director, WS

still strong proponents for the ckegorical medical center approach
in Texas, but these interests have, been neutra1ize.d by the support
or a program emphasizing the needs of conmunity hospitals and.

icing physicians, backed by the resources of medical centers.

ttention of the Texas UP is now focused on sub-regionalization.
reas, coterminous with CHP boundaries have been designated for

RMP development. Four of the areas are nov staffed: the El Paso area,
the Lower Rio Grande area, East Texas hnd Houston.
staff are a remarkable group of people, with only one type of
experience in common - firsthand knowledge of their areas.
El Paso representative , Mrs . Maria Elena Flood, is a Mexican-American,
mother of eight, who has worked for years in hospitals and clinics
in the area; she has no educational background but she has knowledge
of the health needs and health resources in the area. Sister Strohmeyer,
a former surgical nurse with gfaduate training in public health, has
on-site experience with the problems and frustrations of the migrant
workers and Chicanos of the Lover Rio Grmde. Nr. Faullc, a formcr
voluntary health association employee, is a native East Texan who not
only speaks the East Texas dialect but understands the pace necessary
to get down to business.  The nexest subregional staff member, Mr. Odey,
has been a drug representative in the Houston area for a number of years.
The Region had hoped tD employ another staff to work in the Lubbock area,
but RMPS budget reductions made it impossible. However, Dr. McCall, the
Coordinator, explained that plans for the Lubbock staff call for c,lose
association with the developing medical school (whose parent university
is Texas Tech rather than the University of Texas), in contrast to the

The subregional

The

her staff.

ile subregional staffing has been underway only for the past year,  the
.shift toward subregional emphasis has been evolving since Dr . McCall
became Coordinator two years ago.
most part and developed by Dr. McCall, have been responding to local
community interests in imaginative ways. For example, the coronary care
training project staff amassed for a group of Black hospitals in Houston,
has been providing consultation and training to several groups of small
hospitals in rural areas, including an East `J'exas coinbination of
predominatly white staffs. The proposed project, GRO, which was rated
the highest priority by the BAG, has, grown out of central staff efforts
to provide specialized help in in-service education for small rural.
hospitals. By assisting several hospitals to forin a corporation for
joint purchasing and other services, the central staff has enabled the
hospitals to develop funds from the resulting savings  for in-service
training. In turn, the medical institutions have been persuaded to
provide training rrlanpower for this purposc.

The team became convinced that the Regional- Advisory Group has actively

The central staff, recruited for the

cipated in the changes or' the Texas E)rograiii, and has provided

e

e

Page 3 - Director, P2PS

guridafice to the staff at critical junctures. As an example, last Fall .
when the staff proposed a maaagemeijt approach to planning based on
non- ca t egori cal p rogr ara t i c objectives , the Executive Committee urged
staff to test out the theoretical approach with practicing physicians
and community hospitals before approaching the total RAG with the
j.dea.  The positive local response resul-ted in the appointrnent of RAG
committees on Program Development and Evaluation.

I.

The staff works rwll with the RAG and $ask Forccs, providlng data and
materials needed for policy.

The team was particularly interested to see how the staff provided
data and other infoimatioii for the nev FAG cornniittees on Program
Developrent and Eval~uation, and the receptiveness of thcse groups Lo
staff contributions *

Another area of progress in thc Texas P\W is  the invol.vcment and
participation of practic-i-ng physicj ans at both the c1cc:ls-i on-making
level and at the level of thosc on -going proj ccts whi ch the physicians
feel help them with patient care.
through both its plijrsic-ian officials and executlve staff, is an active
supporter of the Regional 3ledical Program.  The fact that this has not
always becn the case is significant.

I

t

The Texas Medical Associatioii,

The team determined that a number of other key health groups, including
CHP, the State Health Department, the nursing association, the hos~ital
association and voluntary health agenci es support the program.
seems that the Regional Medical Program has provided a forum in which
occasionally dissenting groups could work together.

It

There are several areas that still need attention in Texas. The team
recommends  that the 1972 site visit pay particular attention to progress
in the following areas:

1.

The establishment of priorities under the new program
directioii .

Texas is just turning its program around froin one
based on categorical and in?tituti.onal focus to one
based on subregional. health carc ncetls.
significant progress in reaching. the turn--around  but
it is still soon to see what thc changes will niean i.iz
terns of priorities in fundh::.

Tt has made

The revie:? S~S~~TR
one, but it can't
established.

that hbs been dcvel.o~)cd seems a good
be rested uatj 1. the priori ties are

Tne approach t~ regiona:t $lm,ning thrortgh ob jeci.ivPs
is conceptiially very sound, hut it needs transiation
into subregional activities based on priorities. - : ,

The team is confident that the Tcxas RAG and core
stacf will establish prioritics giean%n2Ful for
Texas within the next few months; but the 1972 site
1risj.t team will be in a position to judge the
accuracy of thei? prediction. ;

/

1

2. Traiislatica of iriterec t iil subregional devclopmcnZ into

specific programmatic goals.

Tr3xa.s h;s reculiited an iinagi riatj group of subrsgi.ona3

' sta%: inmhers, well-vexed in local hc.nl%h needs and
resources, but these sraff need a p;;eat deal of help
and supporl. fron the ckntral staff and ;he PAG in
developing subl-ezional goais , obj E:C t:ives r-rid fjpecific
aclivil_ie& e The team ielt thai one obvLous suggltstioiz
~2s the ctevc1op;nent of local a&Ji snry groups, eithe+r
in conjunction with GI-IP (b) agencies or under PWP
aw-pices vhen that is not possible.

The team knows the Region must progress in this area
by the time oE the 1972. applicatioii nrLd site visit
because it is upon the subregic.nal program devclopment
that: the Xegion has s'calied its hopes for future.
fuiiding .

The devel~oprnental funding recoiiimer,dcd. by the tc~m shoi:ld
help in this development.

Increase of representation from allied he2.lth groups on
major policy mali-ins bodies, incl v.di.ng the Regional.
Advisory Group.

3.

.

TIic Texas MC- is heavily represent-e4 by physlciails
in oile capacity or another. Texas feel F; ihe physiciarrs
involvement has tccn a factor 111 ,acceptance of and
involvement in the prograin an4 the team-agrees tliat
this has been importsilt -

Texas f eels chat "Lie ir;volucment of a1 liccl health
representat-ivcs on coi;iln.ittec?s ?rid task Eoi.ces is
critical but th:~ tem urged th<.iLL tci place allied
hc a!. th rep re s tn t at ivczj who h nvt: s cl rvcd at ly in the 6 e
capac-i t it3s on der:isj_o:L-:na!Ein:,, bo& e:;.

Page 5

4.

i

Director, NPS

Several members of the EkeciiI-ive Conimitt:ec stated
they would be held accountable fox- changes in the
representation.

*-

./

Increase of representation fr~~ rn5norir.y groups  on
majbr policy-making bodiw . I

Texas is cominitted to tackling health care needs of the
poor -- Chicanos and Blacks in; the cities arid migrant
workers or). the farms. There is representation from
professj onart members of these groups, but the team
urged the Coordinator to provide an opportunj ty for
non-professional to become iLivol.ved in the Texas
B4P ~-~I~I-~?~~LI~~I to bc consrru~ti&-i~ jnjr~bc i r ~a~"Lic?"-
2s-+2_n.. The teaa al:;o siisqestcd that P conscious
effort on the part of ,the stail 2nd RAG Lo EI~IGW
thcLr conotrixtjve coLtributi o~s at the liAG level.

The Ceordi nator iinpliecl thzt this particular
recornmndati.on might be harder to achirvc than  the
others b~ie agreed to try.

- Recommendation:  The site visit team reconmiends tLat the Texas
RNI? Ee providz $1,590,000 direct costs for each of the two years
to iccl.ude developnental funding, brith the unders tandicg that :

1) A si~e visit will be made within the next year to study
specific program activities to bc ~~oposecl to implement
the new Focus cn subregionalization and

2) Texas may elect to request tzienriiczl fund.ing in 1972
when its three-year program, plans are more specific.

This s.~a,s a compromise evolved by the site team.
Impr&ssed with the progress made in Texas thaC ic; incllnation was
to recornnerd three year level funding for thc Pxograra -411 the   .
confidence that the RAG and "ie Core staff would use tile Funds
ixl imaginati.ve VJELYS to help the most prc~ss:ing liealth needs of
the subregions.

But in thc zbsence of either establishcd prioriLies or specific
activitj es pro?osecl for the szcoiici and third years 01 requested
frtndiDg, thc tem did r,ot feel it cuuld reccmmend threc-year Fanding.

Hence
progresc in Texas and pvvvidc motis/cit i oil for accelerating the next-
phc25cs of ;~uozil alii dc~icSny.eiif..

The teain was so

Che co;ripronii5e idiich in the teal 1's mi.nd c7i:I.l- acknowledge the

KtC IONAL P@.IE,DICAL PRIX"RAMS SE?VXCE

  (I? Privileged Communication;

('1 b

>c ITRY OF AX OI'EPATLONAL SIJPI'LICMENT SR3N'C APPLICATION

1.1 i. re c t ::o c; t s $4 63 ,2 9 2 $3613,595 $381,513 $l,2?7,,400

rr OTA I. $463,292 $368,595 $381,m $1,213,400

Uirr.ct t,i.stc $466,764 $369,880 $345 ~ 730 $1,182,374

i,istr:rv: :I, ?'overnber i47:, ~ourlcil reviewed the Region's total program

md its 'friennial application, and concurred with the favorable

0- irt Cktober 1970 site visit. Council concluded that the Region

crcloped the capacity lor self-detcrmination; had set realistic,

r, rr11y ind qcceprable goalc and objectives; and had adequate decision-
uL~iki.ng processes as well as m,?nagemcnt and evaluation capabilities.

Hc~gL;rn's Iric.nnia1 appiication diiring the next t3iir.e~~ years is $2,261,685,
$2,015,591 :~nd F2,043,035, R:.fPS fiscal restraints will only permit funding
and comni trneiit for these periods at $1 81 7 632, $1,882 $485 and $1,882,485 e

s'oirncil approvctl direct cost level of unding for the

TRI-STATE IMP -2- RM 00062 8/71

Eackxround: This application contains n single proposal which is a

Kidney Program (NERKPRO). The original proposal was reviewed in April
1971 by both the Review Committee and the Ad Hoc Panel on Renal Disease.
Since the two groups met simultaneously,  the Committee did not have
access to the Panel's recommendations. The Committee, however, was
impressed with the proposal from a program point of view and recommended
that additional funds be made available for NERKPRO, subject to a
satisfactory technical review by the Ad Hoc Renal Panel,

modified version of Project 813, New England Regional

In May Council concurred with the Panel's recommendation of deferral
with a site visit. There were serious reservations as to whether the
appropriate individuals within the six states had had ample opportunity
to review the proposal in its final  form to determine the degree of
collaboratlon and cooperation that would be required; 2) the budget
seemed extremely excessive; 3) the extent of participation by the Eoard
of Governors could not be clearly determined; and 4) due to the magnitude
nf the program, further detailed evaluation of its many facets seemed
war ranted

A site visit was made on May 24, 1371 by members of the Renal Panel
and RMPS staff.
by the hTRKPRO Scientific Advisory Committee (Providers) and members
of the Advisory Groups (third-party carriers).

The team vas impressed with the support of the proposal

Since the Xovember 1970 submission of the proposal to RMFS, a number
of important changes had occurred, including the decision of Connecticut
to cooperate only in the Inter-Hospital Organ Bank of NERKPRO.

The tczn was concerned that the proposal as originally written did
not: clearly reflect the procedures of plans for the critical segments
of the program, especially the expansion of transplant services. The
greatest need existing in the New England Area is a significant increase
in the ncimter of cadavcric kidneys being procured. Further, the team
believed that the FYI? should: 1) reexamine the need for satellite
tissuc typing facjliEies; 7) rcrvalcate the educational programs
propost-d, incltiding tcchnicei brochures 2nd films; and 3) absorb the
rcgistry as part of i5C Inter-Hospital Organ Bank,

IC ;:ac oivious th~:: thc propOS31 had stimcllated a substantial amount
of interest among providers and third-party carriers in New England.
Considerable time and effort had gone into the development of the
proposal,  The site visit team recommended further deferral DendinP
receiptand review of a revised proposal by the site visit team_pr>p_r_-
to the August 1971 Council meeting.  The visitors believed that any
other action could very well slow down, if not completely stop, the

momentum and interest
years

Present Application:

clearer dcfinition of

which has been generated during the last two

..

This revision of the original proposal more
specifically restates its goals and provides a
method e

TRZ-STATE KlIP

e

3- RM 00062 8/71

Goals and Obiectives (Restated)

1,

The goal of NERKPXO is to asstire that no patient with end-stage
kidney disease will die from lack of necessary services,

I

2, The long-range objective is to furnish to transplant ur:;ts an
  adequate supply of cadaveric organs to satisfy patient nerds,  and
  to assist in developing mechanisms for funding of services to
  pa tien ts a

9

3, The intermediary objective is to develop an organization in the
  five-state region (Massachusetts, Maine, New Hampshire, Vermont
  and Rhode Island) which will procure the cadaveric organs needed
  for transplantation, and to identify the main problems in funding
  so that programs can be developed to solve them.

As originally stated, the goal was to establish the New England Regional
Kidney Program to assure that no person will die of kidney failure
because of a lack of funds, or lack of a plan to he treated on knowledge
of what is available,

In the original proposal, support was requested for the training of:
1) Dialysis Nurses; 2) Transplant Nurses; 3) Dialysis Technicians; and
4) Tissue Typing Technicians and for continuing education: 1) Nurse
Consultants in Dialysis and Transplantation were to 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 was to be held for nephrologists, transplant
surgeons, immunologists, nurses and technicians; 3) short (up to two
weeks) individual training courses to update skills will be sponsored.

The reviser' propclsn 1 eliminates the training program for technicians,
nurses and physicians, as suggested by the site visit team. Also,
eliminated is the request for funds for audiovisual teaching materials
since film production is expensive and films along with bn~hures have
1 imi ted usefulness

The originally requestcd support for the registry is eliminated. The
MP states that registeries are records kept in a particular format
for purposcb of future reference and research. They should be an
integral part of the organ bank and funding desk and do not require
s e pa r a t e hud ge t ing .

Originally it was planned to establish three IOP, tissue typing satellite
laboratories. The NERKPRO Executive Committee has decided that each
region will make its own judgement on the necessity for tissue typing.
The request for support for satellite tissue typing is eliminated in

the revised proposal.

e

TRI-STATE RMP

t4-

RM 00062 8/71

New Items Proposed in Revised Proposal

Procurement Physicians: As suggested by the site visit team, it is

the level of assistant professor in a university hospital to increase t
the supply of cadaveric organs. Seven members of active transplant
centers in the New England region will be selected by the Executive
Committee of NERKPRO. Support is requested for 50% time of each physician.
One procurement physician will be located in each of the following:
Maine; Burlington, Vermont; Providence, Rhode Island; Massachusetts
General Hospital, Boston; Boston City Hospital; Peter Bent Rrigham
Hospital, Boston; and Boston University - V.A. It will be the function
of these physicians to formulate and initiate programs for the procure-
ment of cadaveric organs from hospitals in their area, A detailed
description, their functions are presented on pages 16-18 of the revised
app 1 i ca ti on e

proposed to use the services of physicians at

th


T

Local Coordinators: To reinforce the physicians working at the professional

is requested for 5 full-time local coordinators whoes main purpose would
be the education of the public in the importance of donating organs,
and in directing the attention of the public and lawmakers to their duty
in supporting programs dealing with kidney disease.  A coordinator would
be located in Maine, Massachusetts, Rhode Island, New Hampshire, and
Vermont.  A coordinator's job description is given on pages 20-21 of
the revised proposa 1 e

level would be a counterpart among the laity. Support

July 16, 1971 Review of Revised Proposal by Site Visit Team:

In their review of the revised proposal July 16, 1971, the site visitors
were favorably inpressed with the revised application. Its positive
reflection of most of the recommendations proposed at the May 24 site
visit results in a realistic program which can be achieved.

Recommendation: The site visitors recommend approval of the Tri-State

budget. The proposed budget is considered extravagant in some aspects,
and it does not reflect as direct 3 decremental RMPS funding schedule as
the site visitors would prefer and believe to be practical with growing
potcntial sources of future funds. The site visitors consider the
application from Vermont to be complementary to the NERKPRO program.
Should Council also approve the application from Northern New England
(Vermont), the site visitors have recommended deletion of several positions
from NERKPRO application which would be duplicative in the overall
Tri-S ta te operation.

NERKPRO application (Project #13) with a modified

?

-6-

REGIONAL mDICAT, 'PKLTRAS SERVICE

SUMMARY 0s AN 3PERATIONAL SUPPLEHEiT GRAM3 APPLICATION

( A Privileged Communication)

Direct Costs $463,242       $368,595        $381,513   $1,213,400

Indirect Costs -0-              - 0-              -0-          -0-

Total $463,292 $368,595 $381,513 $1,213,400

Ristory: In November 1970, Council reviewer! the Region's total program and
      its Triennial application, and COLXUK~~@~ with the favorable report
of an October 1970 site visit. Council coacluded that the Region had devel-

oped the capacity for seff-determination; had aet realietic, timely and accep-
table goals and objectives; and had adequate? decision-making processes aa
well as managenrent and evaluation capabiliries. Although the Council approved
level of funding for the Region's Triennial application during the next three
years is $2,261,685, $2,015,592 and $2,043,035, WS fiscal restraints will
only permit $1,722,474 funding and commitment for these periods.

Present Applixstion: The application contairre, one kidney disease project,

Renal Disease on Aprik 14-15, 1971.

which is also to be reviewed by an WS Ad Hoc Panel on

Project #I3 New England Refrionar ki~?ey Program
Submitted by the Tri-State RMP, this three-year project proposes to establish
the New England Regional Kidrrey Program (NERKPRO) to al~iure that no person
will die of kidney failure becgwe of a lack of funds, or lack of a plan to be
treated on knowledge of whet ba available. Tho proposal is in three parts.

Part I - A general introduction documenting need and resources.

As a result of a nreceiif: rreriee of meetings sponvored by the Tri-State RMP, a
group of leading ne$,rologists and other Interested persons joined to develop
IJERKPRO. (See Apendix X: Wnutes of NEKU'RO Meetings - Durham, blew Hampshire;
pp. 107-138).

There ia general agreement that NERKPaO mat meet several baaic

TRI-STATE KMP -7- 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) profeesional
training programs are needed for physicians, nurses and technicians in the
fields of hemodialysis, organ harvesting, organ transplantation, and tissue

typing. 0


cess of being developed in the region,  Transplant centers are a180 centers

Boston and Nev Raven are major transplant centers, and others are in the pro-

for professional education and training in kidney disease.
Boston is the location of the Interhospital Organ Bank (ZOB), a clearinghoure
for matching cadaver organs with potential recipients.

rz

In addition,

NEW ENGLAND FACILITIES FOR EXD-S'IIAGE KIDNEY DISEASE

Central Support:

I- Dialysis Units:

Boston

Boston City Hospital
Lemuel Shattuck Hospital
Messachusetts General Hospital
Peter Bent Brigham Hospital
University Hospital
Veterans Administration Hospital
St. Elizabeth's Aospital

'Interhospital Organ Bank
Massachusetts General Hospital
Boston, Wssachuoetts

Other Nasruaehusetts

Babcock Street Unit, kookline
Lakeville Hospital, TLaiceville
North Shore Regional. Dialysis Unit, Beverly
Springfield Hospital, Sprtngfield
St. Joseph's Hospital, 'bweii
Worcester Memorial Hospital, Worceater

Transplant Centers :

Ope ta t ive

Boston City lospltal

Massachusette General Wospital
Po ter Bent Brighem Hospital
Un ive r s i t y Kos pi t a P
Veteran Administration Hospital

Rarvard and B.U. Services

Maine

Mine Medical Center, Portland

Connecticut

Yale-Mew Haven Hosp., New Haven
Hartford Hospital, Hartford
Veterans Administration Rosp.,

Bridgeport Hospital, Byidgeport
St. Vincent's Hoap., Bridgeport
DanSury Hospital, Danbury
Waterbury Hospital, Waterbury
Hospital of St. Raphael,

New Haven

West Haven

..

' _\.
   _. .+
  .:. ,
.,, . .. : .;
.- , I:.

... ._

. ".

,.. .

..

..

-8-

TRI-STATE RPPP r\N 00062 5/71

Part 2 - An application for funds to fini:rcs! reEiona1izatjon
     of the operations 01 the Tnrer-hospital Organ Bank.

Reorwnization Of -the IfoB is a major component in the development of the
NERKPRO program. The a non-profit organization, ia actually a center
for information, expertibie, che performance of technical Eunetiono (tissue
typing), and edministratim of 0r~nn allocation. &~OK furrctdons of the IOB
include: 1) Education and infoxmation efforts, primrLly wish physicians, to
encourage the "harvesting" of cadtver o~gdrtr, suirable far trawplantation;
2) Operation of a central office:
which information on organ availability, suitability, and demand can be ex-
charged, (b) maintenance of a central registry of persons awaiting tranaplant
and of potential donors, and (c) administration of a system for d*ter&ning the
allocation of cadavar organs available among the patients awaiting tranaplant,
using information determined by central serotypiag laboratory; and 3) operation
of a central aerotyping laboratory.

\

9

(a) Berving as a comunicaeion center through

The IOB is currently supported under a contract from the Kidney Disease Control
Program, IMPS, and funds from the Massachusetts Department of Health.
has begun chargiagfees for serotyping, and is negotiating with third party
payers to mke these and related costs reimbursable.
of expanding the field of operation ta serve the entire New England region.
FinanCi81 assistance is needed to support the IOB durlng this tranritional
stage when: (1) the IOB is axpanding its physical capacities, geographic
coverage, and training activities, (2) support from the Kidney Dioeese Rogram,
RIPS is being phased out, and (3) income from fee-for-serviceo is not yet suffi-
cient to support these operations on a full or regular basis.
the application deecribe eteps to be taken to facilitate expansion of the IOB.)

The IOB

The IOB is in the process

(Pages 47-53 of

.-

A total of approximately $166,000 la requested for the first year support of
the IOB as follows: $128,289 personnel; $22,524 supplies; $15,300 equipment.

Part 3 - Describer; rhe stem to be taken in developing the reminder of the
    program components so that at the end of the y,rant period. a coor-
      dinated repional program will exist.

The development of the program will be administered by George L. Bailey, X.D.
with the advice of HER its Scientific Advisory Committee and other cam-
aittees. In addition to the IOB, other program elePDent8 will be developed as
followe:

     Development (sf Program land Standard Settinp,: NeRKpRO through its
Scientific Advisory and other committees will offer advice to any group con-
templating developant of a kidney program (Pages 28-29).

Professional Trainin?,:

Is discussed on pagea 29-35 of the application.

The applicant notes that preaant RMPS guidelinorP exclude the support of physi-
cllans fellowships. If funding becomes available, a fellow8hip training program
in nephrology or transplant surgery would be implemented.  Support is requested
for the training of: (1) Dialysia Nursee, (2) Waneplant Nurses, (3) Dialysis
Technicians, and (4) Tissue Typing Technicians.

RM 00062 5/71

-9-

"RI-STATE RH?

Continuinp, Eciiic.~, I- !.on: ..n

(1) Nurse Consultants in Dialysis and Trans-

plantation will be av.;i:able for any program in the region to assist with
specific problems, demonstrate new techniques to remte centers, and act as
adviaors to areas startisg new programs. (2) An annual two-day workshop on
new developments in dialysis and transplantation will be held for nephrolo-
gists, transplant surgeons, immunologists, nurses, and technicians.
(up to two weeks) individual training courseu to update skills will be spon-
sored.

(3) Short

   Organ Procurement: Lay and Phynician Education: As presented on pages
33-35, this would involve: (1) Training organ harvestinR teams, (2) educating
the general public to increase their willingness to be donor8 and rectpients,
and (3) increasing the awareness of the physician in general practice con-
cerning the desirability and practicability of treating end-stage kidney disease.

%ne Funding Desk (Pages 36-43): This desk would serve three basic functions:

(1) Serve as a clearinghouse for information concc-rning presently available
sources of financing; (2)
reimbureeawnt for kidney disease and other catastrophic conditions, end would
. ?velop proposale 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.

collect data on third-party payer experience with

kRistrY of NERKPRO (Pages 44-46)

The registry functions would include:

1.

Maintenance of an up-to-date registry of all potential cadaveric
transghnt recipients in order to provide the neceaaary information
for the equitable sharing of cadaver organa.

2. Registraticn of ell live related donor transplants for purpases of

follow-up on success rete, funding profile, statistics, etc.

Registration a all dialysis patients indicating whether center,
satellite or home; source of funding; location; etc.

3.

4. Registration of every physician, nui'se, or technician trained in

dialysis, transplantation or tissue typing in New England.

5.

Registration of every dislysis and transplantation facility noting
their patient capacity, training capacity and costa.

A total of approximately $257,000 is requested for this part of NERKPRO (does
not include IOB coats) iis foliows: $74,829-personnel; $5,000-consultants;
$7,360-furniture; $16,000-travel.; 4242,200-training and continuing education;
$19,27O-rent and telephone; $11,020-postage and special trenaportatfon; and
$21,500-coolputer time and fees for hqrvestlng organs.

I

:.i.

!-'. .

4 .:

.. . i
. . ..

TRI-STATE RMP

0

-

10- RM 00062 5/71

-

The Appendices of the application contain
and participation; by-laws, rosters and other information for the IOB;
Teaching Protocol for Mn-Coil Machine Dialysis; Funding of Renal Patient8
in Rev England; Minutes of NERKPRO meeting; and curriculum vitae of key
personnel.

copies of 52 letters of support

RHPSlGRB 3/9/71

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

Virginia Regional Medical Program
700 East Main Street
Richmond, Virginia 23219

'RM 00049 8/71
'July 1971 Review Committee

Program Coordinator:

Eugene R. Perez, M.D.

-

The region currently in its second year of operation,  is funded at
a level of $673,037 direct cost.
$63,718 of indirect costs which represents an average indirect cost
rate of 9.4 percent.
The Medical College .of Virginia and has become a corporate body.
region will be submitting its anniversary review application in the
November 1971 review cycle.

The region has requested in this supplemental application $795,155 for
three years support of Project #13 - A Comprehensive Program for the
Control of End Stage Kidney Disease in Virp,i&,  The sponsor is the
Medical College of Virginia and the project director is David H. Hume, M.D.

Project #13 - A Comprehensive Program for the Control of End

proposal was initially.submitted as Project #12-Procurement
of Cadaver Kidneva for Transplantation in the February 1971
review cycle.
the RMPS Ad Hoc Panel on Renal Disease the Council deferred action in
order to obtain additional information relative to commitment of
cooperating institutions, definition of budget and clarification of
objectives and methodology.

In follow up to Council's recommendation a slte visit to the Virginia RMP
was conducted by staff on April 9,  1971.  The concerns expressed by
Council were discussed wi.th representatives of the VmIP and the two
medical schools of Virginia. As a result of this meeting the VRMP has
established a categorical committee on dialysis and organ procurement.

This proposal is a comprehensive approach to provide services to patients
withendstage renal disezse.
increase the dialysis capability in the region, provide training, improve
the availability of cadaver organ's for transplants and develop a
state-wide public education program in all aspects of kidney disease.

Second Year: $264,149 --_I__ Third Year: $279,665

      In addition,. the region has received

On 3/1/71 the VRMP broke away from their grantee,

The

First Year

$251,341

Stage Kidney Disease in Virginia. This Request

Based on the technical. deficiences identified by

.,

It is expected that this program will

'GRB 6/11/71

(A Privileged Communicat ion)

SUMMARY OF REVIEW AND CONCLUSION
OF JULY 1971 REVIEW COMMITTEE


VIRGINIA REGIONAL MEDICAL PROGRAM

RM 00049 8/71

FOR CONSIDERATION BY AUGUST 1971 ADVISORY COUNCIL

1 with reduced budget. Recommended that

RMPS staff visit the project to clarify the capacity

sting dialysis facilities and negotiate RMPS

ation guidelines. The basis for patient
continuity of unit operations, and MCV backup
identified. It is suggested that no
e funded, but only personnel; i.e., 3 nurses

concepts expressed in the review and contained

uested), janitorial, and physician to assist

patients in the new limited care unit
e following recommended level of funding
ould use as a basis for negotiatio

Recommended Funding
  (direct costs)

03

-

02

6,000 --

20 , 000        12,000

1,000         1,000

27,000        13,000

-

ittee concurred with the conclusion of

n Renal Disease and noted that the Panel was
h the scope and the problems represented in the
ease program.

It generally agreed with

in the application.

ts related to cross-matching were consid

ppeared that they should be deleted from the ap
ully establish a trend to halt pie
would more properly be proposed  f

application. A recommendation was
ssible continued contract funding f
development. Consideration was giv

charging for some "service" porti
     d by the absence of Tit1
    evelopment of local sourc

Virginia RMP

-2-

RM 00049 8/71

The request for organ procurement program appeared too high and
suggests a request for support for capabilities which already
exist.  The KDCP is funding a cadaver organ procurement project
over three years, the third year recently negotiated at $109,000.
The proposed fees ($100) for private physicians as organ
procurers appeared reasonable but administrative physician
salaries were considered appropriate for support only on a
decremental basis, toward encouraging development of other
sources of support. It was suggested that these physicians costs
be included at successive levels of the requested rate for the
first year, at 50% in the second year, and excluded from grant
support in the third year. A decremental Federal support pattern
should be brought to the Region's attention.

The Panel report states that the demonstration of a new type of
satellite facility was not appropriate for grant support. It also
was persuaded to question wheter increased home dialysis training
might not be better accomplished by expanding existing facilities
at Richmond and Charlottesville. Doubt was expressed on the
suitability of developing patient self-dialysis to be performed '
in the satellitedialysfs units. The proposed increase in dialysis
patients was questioned in view of the expressed objective to
increase transplantation. While basic problems were recognized
with respect to Charlottesville, Richmond and the Norfolk area,
the proposals in the application will not resolve Regional problems
of cooperation and coordination of facilities.

The request to fund professional and paramedical personnel training
through the satellite units rather than developing patient home
training was considered inappropriate. Reviewers felt the Federal
support responsibility lay in providing for those items which
could not be recouped through other sources. To accomplish this
it was recommended that support for personnel and urging that
supply costs of indigent patients be met through charges levied
on paying patients.

The request to fund a second satellite unit for indigent patients,
while another unit is now being opened for paying patients, was
considered extravagant. It is felt that one unit could serve both
populations, with support.

RMPS/GRB/7/16 f 71

REGIONAL MEDICAL PROGRAMS SERVICE

SUMNARY OF AN ANNIVERSARY TRIENNIUM CRANT APPLICATION

(A Priveleged Communication)

Wisconsin Regional Medical Program
110 East Wisconsin Avenue
Milwaukee , Wisconsin 53202

RM 00037-05 8/71

July 1971 Review Committee

Program Coordinator:

John S. Hirschboeck, M.D.

This Region is currently funded at $1,554,640 {direct costs) for
its fourth operational year ending August 31, 1931. The Region
currently receives indirect costs of $300,488 which is 19.3 percent
of the direct cost of the award.
application that requests:

The Region submits a triennial

I. A Developmental Component
11. Renewal of Core activities
111.
IV. The renewal of three activities

V.
VI.

The continuation of four ongoing activities
The implementation of four Council approved/unfunded activities
The implementation of five new activities

The Region requests $1,917,076 D.C.  for its fifth year of operation,
$1,509,777 for its sixth year and $1,084,858 for its seventh year.
A breakout chart identifying the components for each of the three
years follows on pages 2-4.
1970 in relation to its developmental request.
another site visit to the WRMP was not scheduled at this time. Staff,
during its preliminary review of the application, noted that the Region
has made considerable progress in the areas of program planning, devel-
oping objective methods of its evaluation procedures, and is now
shifting its emphasis toward program development rather than the
solicitation and encouragement of independent projects, at3 in the
past.

It was further noted that the Region has begun to strengthen and
expand its subregionalization efforts and is moving toward further
development of collaborative relationships with the areawide health
planning agencies in the Region.  The Region is also in the process
of expanding the present three-member corporation , the povernhg
body of WRMP, to a total of nine.

This Region was site visited in December

Because of this,

Staff in its review also expressed concern regarding the following:

1. Lack of racial minorities represented on core
  and project staff.
2.  Inadequate representation from the black com-
  munity on the RAG.

3. Lack of evidence regarding sources of future
funding for certain project activities upon
  termination of RMPS funding.
Lack of information regarding income generated
  from project activity.

4.

=GI()?; WlSCOnSln

RM 00037 8/71

PROCRAM PERIOD

05

BREAKOUT OF REQUEST

(Supper t Codes) (5) (2) (3) (1 1

.

Cm. WLTRIN CONT. BmONI) UPR. ROT W, NOT
~ppx. PERIOD APPR. PERIOD PEV.
OF SUPPORT OF SUPPORT 1 FUNDED APPROVED

PREV. IhVIRECT TGUT.4

COSTS

IDEN TI F IC AT ION OF
COMPONENT
00-Bevelopment a1 t

I 495,675 80,570 576,245
                200,000

                     495,675
Core 140,000 140,000 60,000

1

1

4,364 22,964

#5B-I)ial Access-Library
FfiC-SingI e Concept
  Films Project  I 50,820 1 50,820
f6-Radiology
R12-Uterine Cytology

                             I 469,234
g13A-Inactive Nurse
-dical Library 1,525 I 1,525

#17-Nurse Utilization I 130,890
#HA-Medical College of I
Wisconsin Manpower

#22-~omunity-Oriented
Rehabilitation
323-Cardiac Intensive

Care Nursing
T24- CbRE

#26-Nurse Associates
# 27 -Una s s ign ed
#28-Diagnosis & Therapy

Criteria Review
#2WJnassigned
#30-North Central Out-
  reach
#31-South Side Health
Contact Center

Service - Nurses 18,600
             15,500

i

       21,440
39,144 134 344

15,500 I 5,940

95,200 1 I 95,200 1 !

- 17,765 68,585
  I I t. I 66,500 I 66,500 1 21,175 87,675
  I f 1,525
   I 54,341

1

I

    79,726 548,960
130.890 . 43,300 174.190
57,965 9,025 66.990
                54,341

1

I

I

#15-Comprehen. Renal I 469,234 --

I

57,965

54,341

--

__ a25-Unassigned

-_L_

I

c__

06 PROGRAM PERIOD

REG ION Wisconsin
BREAKOUT OF REQUEST

(Sunport Codes)

IDENTIFICATION OF

3

#28 I I I 23,000

W

2nd YEAR
DIRECT

COSTS

531,973
140,000

469,234

57.965

57,428

83,007
28,945

118,225

23,000

I
w
I

REGION Wisconsin
BREAK3UT OF REQUEST 07 PRCGRAM PERIOD

upnor t Cod e s ) (5)

C Om I WU AT I ON W ITH IN

TIFICATIOH OF    APPROVED PERIOD OF
'ONE'ljT          SUPPORT

*e                            571,700
Qs!s&meM a1   I

--

J I

2 I

3A I 1

23
24
25 Unassigned
26

-

27 Unassigned .-

_I P

28

-

29 Unass f gned

(3) (1)

f+

APPROVED, NOT NEW, NOT 3rd YEAR TOTAL 1

                                  DIRECT COSTS '
FUNDED APPROVED COSTS

PREVIOUSLY PREVIOUSLY DIRECT AUYEARS ,

571,700 I 1,599,348 -

140,000 J 140.000 420,000

                  18,600

I I

II

57,965 57,965      173,895

62,016 62,016      173 , 785

1

1

83,007               83,007
         28,945      28,945
          I                           I

I1

118,225 118,225 353,351

I 1

23,000 [ 23,000

1

Jn3 ORR I 310.170 I 1,084,858

0 Wisconwln ItMI'

-5-

FUNDING HISTORY

PLANNING STAGE -.

KM 00037-05 8/71

Grant Year Period Funded (d.c.)

01 911 /66-8/31/6 7 $319,458

OPERATIONAL PROGRAM

Council

Grant Year Period Ap p rove d Funded (d. c. 1

01 91116 7-8131168 $539,366 Core 415,093
                                   Proj ~83,773

02 9 / 116 8-81 31 I69 1,365,463 Core 438,974
                                   Proj .723,707

03 9/1/69-8/31/70 1,338,194 Core 438,974

                                    Proj .800,536

04 * 9/11 70-81311 71 1,794,257 Core 411,689

Pro j .l, 142,951

* Reflects 12% reduction imposed on all RMPS programs,

Geography and Demography:  The boundaries of the Wisconsin Region
are coincident with those of the State. The University of Wisconsin
Pledical School sphere of medical care influence includes parts  of
Minnesota, Iowa and Illinois; similarly, the Marquette University
School of Medicine has medical care influence in the Michigan penin-
sula and part of Illinois.
with over 50% residing in the six metropolitan areas of Duluth-Superior,
Green Bay, Kenosha, Madison, Milwaukee and Racine.
population is urban and 96% white.
29.4 years.

The Region has two medical schools - the Medical College of Wisconsin
in Milwaukee with an enrollment of approximately 416 (88 graduates)
and the University of Wisconsin Medical School in Madison with an
enrollment of 409 (92 graduates).  There is one school of pharmacy,
a dental school, 25 professional nursing schools (10 of which are
based at colleges and universities), 12 practical nurse training
institutes, 3 schools of cytotechnology, 35 schools of medical technology,
30 schools of radiology technology and 2 schools of physical therapy.

The population is approximately 4.5 million

About 66% of the

The median age is approximately

Wisconsin RMP -6- RM 00037-05 8/7

Hospital. facilities include two V.A. hospitals, 8long-term hospitals,
158 short-term hospitals, 353 nursing homes and 65 long-term care
units with a combined total of 55,278 beds.

The Region has 4,700 active (non-Federal) medical physicians and osteopaths ,
1@84 actively employed nurses and 3,996 LPN's.

Regional Development In April 1965, both the University of Wisconsin

applications which were considered by the National Advisory Council
on Regional Medical Programs, and were deferred with the suggestion
that a revised application be submitted. It was further suggested
that cooperative arrangements would be enhanced zhrough closer collab-
orative efforts between the two medical schools. During the interim
between April 1965 and July 1966, the Wisconsin Regional Medical
Program,
School of Medicine and the University of Wisconsin. The corporation
is controlled by the Presidents of Marquette University and the
UnFversity of Wisconsin.
in a 9-member Board of Directors with a broader representation which
includes the State Medical Society of Wisconsin, the Wisconsin Hospital
Association and consumer interests. Dr. John S. Hirschboeck was
elected secretary and appointed Regional Program Coordinator who
is appointed by the Board of Directors.
directly responsible to the President of the corporation.
of Directors also appoints the Regional Advisory Committee and its
chai man.

and Marquette University submitted separate

Inc., was formed as a collaborative venture by the Marquette

Management of the Corporation is vested

The Program Coordinator is

The Board

In July 1966, the Wisconsin Regional Medical Program, Inc. submitted
a revised 2-year planning grant application which was reviewed and
approved by Council for the period September 1, 1966 - August 31,
1968.  After one year of planning activities 9/1/66 - 8/31/67,  the
second year planning grant was merged with the -first year operational
grant.
site visit in July 1967.
provided continued support for Core planning and administration , plus
support for three feasibility studies (two in dial access tape libraries,
and one for single concept films).
to support three operational projects.
Therapy, Pulmonary Thromboembolism and Cancer Chemorherapy for adults.

The Region became operational following a preoperational

The second year (9/1/67 - 8/31/68) ward

In addition, funds were provided
  These were in Urerine Cancer

During its third year, 9/1/68-8/31/69 (second operational), the
Region received approval for the renewal support of Core planning
and administration.  Also during this period the Region submitted
a request for the support of nine new operational projects contained
in two separate applications.  A site visit was hela during November 11-12,
1968 to review these projects and to review the regionalization process
as it was developing in the Region.
satisfied with the development of the Region but expressed the fol-
lowing concerns :

In general, the visitors were

i. '

'.__I

Wisconsin RMP

-7-

RM 00037-05 8/71

Role and composition of the RAG.  It was suggested
that this group take a more vigorous role in the
identification of regional goals. It was believed
that the addition of more consumers would add strength
to this group.

Role of assistant coordinators in the medical schools.

The Region's emphasis on the engineering approach to
planning. It was believed that this activity should
be augmented by the addition of other groups such as
epidemiology, preventive medicine, etc.

The fragmentation of the continuing education efforts.
Seven of the 9 projects were recommended for funding.

During the fourth year, 9/1/69-8/31/70 (third operational) the Region
received approval for the following projects : a Comprehensive Program
in Renal Disease; Cardiopulmonary Resuscitation Project ; Medical
Library Service; Nurse Utilization Demonstration Unit; and two years
renewal support for Dial Access Library Service for Physicians; and
three years renewal support for Dial Access Library Service for Nurses
and Single Concept Films Project.

In August 1970, staff reviewed a request from the Region for the
fourth operational year, 9/1/70-8/31/71. The request was for the
continued support of Core ($438,974) and twelve ongoing projects.
The request was comprised of the total committed support of $965,444
and carryover in the amount of $60,704 as partial support  for two
approved projects; 816 - Medical Library Service and 817 - Nurse
Utilization Demonstration Unit. Approval of continued support in
the amount requested or the fourth year was recommended.

A site visit was conducted on December 11-12, 1970 to assess the
Region's readiness to utilize developmental funds requested in an
application, submitted during October 1970; to review the overall
program progress of the Region; and to evaluate project and core
activities in terms of their relationships to overall program goals
and objectives.
that it has the machinery, expertise and local autonomy to success-
fully and prudently administer and use a developmental component,
and recommended that that developmental component be awarded for
approximately $160,000 for one year. The site visitors also recom-
mended that the Region should:

The site visitors agreed that the WRMP has demonstrated

1) Continue its sub-regiondization efforts. The establishment

of an "RMP" desk in selected CHP Regions, Assignment or appointment
of a part-time community coordinator in the Marshfield Clinic and
the University Extension Service were seen as possible solutions.

Wisconsin RMP - 8- RM 00037-05 8/71

2) Expand and augment the three-man corporation (perhaps to a

total of nine) which might include representatives of the State
Medical Society, Hospital Association, etc.

3) Exert more effort to give the Region more professiona1.a~

well as lay visibility.

'.
...

   4) Strengthen the core staff especially in the area of an
Assistant or Associate Program Coordinator to back up the Coordinator
to assist in the day-to-day management of the program.

5) Take concrete steps to  OVBPcome the lack of objective evalua-

tion methods in the Region.

The Review Committee considered the Developmental Component request
from the WRMP during its January 1971 meeting.
visitors positive recommendations on the request for developmental
funds, members of the Review Committee believed that action on this
request should be deferred with advice to the Region to incorporate
the proposal for developmental funds with their triennial application.

In spite of the site

_,

The following chart shows the Region's funding at the time this applica-

_-

tion was developed; the level of funding for the continuing life of
ongoing projects and specific new and previously approved activities.

Core and Projects for Triennium (Direct Costs1

Pres en t Funding 1st Year 2nd Year 3rd Year

$ 411,689      $ 495,675  $ 531,973  $ 571,700
   - 0-         140,000    140,000    140,000

Core
Development a1
Component

Projects

Ongoing Projects, 1,142,951 1,277,444 469,234 - 0-

Continuation and/or

Renewals

Approved Projects (Not Initiated) 275,983 198,400 202,988

                                               170,170
New Projects 223,649 170,170

  TOTALS $1,554,640 $1,917,076 $1,509,777 $1,084,858

Wisconsin RME' -9-

RM 0037-05 8/71

Organizational Structure 6 Processes

Board of Directors - The Wisconsin RMP, Inc., is controlled by the
presidents of the Medical College of Wisconsin and the University
of Wisconsin. At present there are only three members of the
corporation, but will soon be expanded to a total of nine.
of the corporation is vested in an elected nine-member Board of
Directors (who are not members of the RAG).

Management

Regional Advisory Group - The RAG adopted several amendments  to its
bylaws on September 24, 1970, to take into account its expanding

role in

guiding the activities of WRMP:

Increased the size of membership (47 members) to assure
a broader represenbation of various health professions,
organizations, and agencies and of members of the public.

Allowed for a maximum term of six years instead of the
previous three years to provide for rotation of membership
with a sufficient continuity for carrying out the program
successfully.
and guidance and a strong input into
the WRMP.
the framework that "the ultimate purpose of all activities
of  the WRMP shall be the promotion of  the health of all
people in the Region," its strategy has been to work with
a number of groups in the state,  such as, the State and
County Medical Societies, the Nursing League and Nursing
Association of Wisconsin, the Wisconsin Hospital Association,
State Dental Society, Association of Osteopathic Physicians
and Surgeons, Blue Cross-Blue Shield, Kidney Foundation and
the voluntary health agencies.  Agency cooperation includes
all of the universities, the school of nursing and the
Marshfield and Gundersen Clinic Foundations. The WRMP has
also worked very closely with the Bureau of Comprehensive
Planning since its inception.
development of functional liaison with areawide health
planning agencies, by forming a WRMP field service with a
representative in each of the areawide health planning
agencies.

The RAG has a strong role in policy direction

the review process of

Since the RAG makes its policy decision within

The RAG is proposing further

Sub-Committees - The Regional Advisory Group, on December 3, 1970,
approved the following changes in its sub-committee structure:

  Steering Committee, formerly the Planning Committee, is charged
with the responsibility of (1) recommending goals and objectives to
the RAG; (2) recommending ways to implement the goals and objectives;
(3) identifying ,areas which can and should be developed; and (4)
recommending charges to other RAG sub-committees including the formation

Wisconsin RHP -10- RM 0037-05 8/71

of new committees; the elimination of non-functioning committees;
and the changes in committee responsibilities.

Review & Evaluation Committee formerly the Project Review Committee,
has the responsibility of recommending to the RAG: (1) approval or
disapproval of applications for WRMP funding, including budgetary
changes;  (2) discontinuation of projects or portions of projects
prior to scheduled termination; (3) establishment of evaluation
procedures which are to be carried out by the Evaluation Director
with the help of WRMP Staff and the Project Staff.  This cormnittee
also prepares periodic and terminal reports regarding the progress
of WRMP projects and programs for the RAG.

Continuing Education Cornittee which replaces the earlier Council on
Continuing Education is responsible for: (I) recomending to the RAG
and the Steering Committee goals for the educational programs and
projects of WRIW;  (2) advising the RAG & Steering Committee regarding
the development and coordination of continuing education resources in
Wisconsin; (3) advising the project staff and core staff regarding
continuing education needs, purposes, and methodology for program
and projects conducted by WRMP; (4) providing (when possible) for the
coordination of continuing education activities conducted by voluntary
health agencies, professional societies and educational institutions.

L- .

Council for the Allied Health Profession: (1) provides a forum for
discussion of problems in health care delivery and professional education -: -

i."

'_ r

as they apply io the allied health professions and to health care in
general; (2) recommends to the RAG appropriate participation of the
allied health professions in WRMP programs and projects;  (3) stimulates
the development of continuing education activities for the allied health
professions as they relate to WRMP goals; and (4) fosters programs which
improve interprofessional i educational activities and interprofessional
collaboration.

Program Priorities

On September 24, 1970, the Regional Advisory Group identified and
approved high priority program priorities for WRMP as follows:

A.

The planning and promotion of an improved coronary artery disease
care system for the Region.

The planning and development of innovations in health care delivery
and manpower utilization.

B.

C.

The planning and development of improved hospital emergency care and
improved transportation of the sick and injured.

D.

The planning anddevelopment of innovations to improve long-term patient
care, including home care and nursing home care.

, .'

Wisconsin RMP -11- RM 00037-05 SI71


E.

The planning and development of means by which education can

0

be brought to those health professionals who are not presently
served.

F. The planning and development of continuing education which IS
  designed to develop proficlency Ln using new knowledge or new
  technology.

The planning and development of improved health care? for isolated
rural reeidents.

C.

H.

The planning and development of improved health care services
for the poor and those who find it difficult to enter the health
care system.

I.

The promotion of further involvement of health profession schools
and their faculties in R%Tp activities.

Review Process

After a proposal is identified and submitted, staff will analyze and
translate it into an'"1ssue Paper" in line with the planning model
and goals of WRMP.  The written analysis is then reviewed by the
Executive Committee of the RAG for a priority decision regarding
allotment of staff time and effort for the future development of the
proposal. Once it is decided that the proposed merits further con-
sideration, it is developed and reviewed by appropriate study groups
on subcommittees of the RAG and by appropriate areawide comprehensive
planning agencies (when reaction might be contributory). It is then
prepared with a budget for final review by the Project Review and
Evaluation Committee (formerly named Project Review Committee) which
assigns priority, and then by the Regional Advisory Group itself.

Evaluation

The Region's evaluation efforts are described in this application
in three different stages: during planning and development of projects;
during the process of formulating objectives and after the activity
is completed. An evaluation team, consisting of two Review and
Evaluation Committee members, two Regional Advisory Group members,
a staff person and the ?valuation director,  conducts evaluation
reviews at least twice a year. When a project becomes operational,
the project director makes periodic progress reports to the evalua-
tion director and annual reports to the Regional Advisory Group,
through the evaluation director. The Project Review and Evaluation
Committee provides feedback to the project directors and suggests
or requests changes if the progress proves unsatisiactory. All proj-
ects are required to have an evaluation component and in some  cases
the project staff is primarily responsible for accomplishment of

Wisconsin R"FP

(..

, '.

. >'.,

..

.i *

. ..

I -. ,
%'. ...

*. .:;Li

-12-

RM 00037=05 8/71

the work.
committee may suggest that parts of the evaluation would best be
carried out by the core staff. Outside consultants are also called
in to evaluate proposals and projects.

In other cases the review by the Review and Evaluation

The Project Directors are responsible for providing a final report  to
the RAG through the Project Review and Evaluation Committee.  This
report provides information valuable to future planning by analysis
of the strength and weakness of results related to the procedures
and assists agencies in deciding on adoption of the procedures  into
ongoing programs.

The following standards are used in evaluathn:

(a) Goals and objectives as determined by the FAG and program

areas chosen to achieve them on the basis of highest priority.

(b) The degree to which WRMP programs are able to provide addi-
  tional services and more efficiently use existing manpower.

(c) The degree to which WRMP can design new and coordinate existing
  projects to form programs to meet the piorities of the Regional
  Advisory Group.

(d) The degree of professional and lay acceptance of the programs,

(e) The ability of projects to become self sustaining, cost-

effectiveness measures where appropriate, improved distribu-
tion of services, and improved Gtilizaton of existing services
and facilities will be measured.

.

: .<.:

*-- ,..
. -... i,
. . ..:
...a i

..

. ..

. I.

Present Application

The Developmental Component

The Region requests $140,000 (d. c.0.) for development funds for each

of three years.

Within the broad scope of policy and goals it has adopted, the WRMP
states that it is committed to the planning and development of pro-
grams which will improve the health caresrvices within the Region.
To improve the efficiency of the total planning and operational effort,
developmental funds will be used to initiate and test the feasibility
of proposed projects prior to their development into more permanent
projects or programs.  The Regional Advisory Group has  recommended
that developmental funds be made available or feasibility studies
and program development in the areas of high priority program interests
described under "Program Priorities. "  The following proposals are
currently under consideration for support by the Developmental Component:

0

0

0

Wisconsin RMP -13- RF' 00037-05 8/71

1,

2.

3.

4.

5.

The

The preparation of a manual and vLsnal aids for the University
of Wisconsin Extension Library Service  to be used in carryling out
the continuation of WRMP Medical Library Project No. 16. The
University of Wisconsin Extension will continue the project under
its own sponsorship.

Plan the organization and implementation of a Comprehensive Cancer
Therapy Program for Southeastern Wisconsin in collaboration with
the Comprehensive Health Planning Agency of Southeastern Wisconsin,
The Southeastern Wisconsin Medical Center, Inc., and the Medical
College of Wisconsin.

Prepare a manual for high school counselors to assist them in
health career guidance in collaboration with the Wisconsin Hospital
Association,

Plan and organize a health care delivery program for the residents
of Menomonee County (formerly the Menomonee Indian Reservation)
in collaboration with the Northeastern Wisconsin Health Planning
Council.

Assist six hospitals in Metropolitan Milwaukee in developing a
pilot quality control system for laboratory services.

review mechanism described under "Organizational  Structure and

Processes" will apply to the developmental component as well.

- Core Central Core activity is presently supported Requested (d.c.)

year. This amount supports a staff of 20 full and
part-time personnel. One existing professional $495,675
position is vacant (Director of Fiscal Management).
This application requests five new professional positions  in the
first year of the triennium, an Associate Coordinator for Program
Development as recommended by the December 1970 site visit team,  an
Assistant Coordinator, Medical College of Wisconsin and three liaison
representatives to provide functional liaison with the areawide Health
Planning Agencies.

at $411,689 in the Region's fourth operational Fourth Year

(1st year of triennium)

The application describes a core staff who is now moving into the
areas of program development, planning and in evaluating the opera-
tional effectiveness of the Region. The application also describes
two panning studies which were conducted during the previous year,
generated with assistance from the core staff.
continued support for one core-supported planning study - Southside
Health Contact Center, and one feasibility study - North Central
Wisconsin Outreach. Also, during the next year (1st year of triennium),
the core staff will collaborate with the Wisconsin Bureau of Compre-
hensive Health Planning and the Community Health Planniiig Service

The fifth year requests

Wlsconsin rcclp

.. 14-

RM 40037-05 8/71

of the APHA in the planning and development of a Comprehensive Health
Service demonstration.

Two of the five new projects included in this application are "out-
growths" of either planning or feasibility studies conducted with core
funds.

Requested Sixth Year

Requested Seventh Year

$531,973 $571 , 700

Requests for Continuation of Projects Within Approved Periods of Support

Project #5-B Dial Access J,ibrary Service

- for Nurses - Cniversity of Requested (d. c. 1
Wisconsin - One additional year

Vffth Year_

is requested (Fifth period) to provide contin- $18,600
ued support for the development of library
tapes and to provide prompt,  convenient dissemination of information
to nurses. The program, used also by inservice coordinators and in-
structors in nursing schools has created better understanding of
patients conditions and has provided confidence to nurses in isolated
practice settings.  Over 32,000 calls ha-ve-been accepted in a 28_.-10nt_h_
Deriod. Future use of the librarv Drogram vi11 also include service to

the allied health workers. It is anticipated that calls from Wisconsin
nurses will continue to be about 1,000 per month.

This project was ranked third in order of funding priority by the WRMP.

Project 15-C Single Concept Films - University Requesced (d.c.)

in 1968 is designed to provide physicians 3nd $15,500
nurses in Wisconsin hospitals acc.ess to short
teaching films to improve their skills and knowledge in order to
provide better patient care. Continued funding is requested for an
zdditional year for the purpose of producing or adapting films pri-
marily for nurses and other specialized hospital personnel such as
the physical therapists. Since September 1969, twenty new films
have been added to the library, two of which were produced in the
Segion.
in the upper peninsula of Michigan have participated in the programs.

of Wisconsin - This project initiated

Fifth Year

More than 70 hospitals in the Visconsin area and two hospitals

Requested (d.c.)
Fifth Year

$469,234

Project #15 - Comprehensive Renal Progran
        This project was activated
last year at a Council approved level of

$542,155 d.c.0. (92,155 rebudgeted from
other projects).
year period and this anplication requests funds for the remaining
two years.
Inc.
disease program in Wisconsin.

The activity was approved by Council  for a three-

It is sponeored by the Kidney Foundation of Wisconsin,

The proposal ia 'designed to develop a comprehensive renal

0 Wisconsin RMP

.15-

RM 00037-05 8/71

I

Since the project was implemented, the followfng activities are in
progress: 1) a large home dialysis training facility has been con-
structed at the Madison Methodist Hospital. The unit is presently
operational with a capacity to train 40 patients yearly.
serves as a resource to other dialysis units in the state for training
technicians and physicians; 2) a postgraduate training program for
physicians in other aspects of nephrology has been established at
the Milwaukee County Hospital; 3) tissue typing labs have been estab-
lished in Milwaukee and Madison which have allowed the development
of a state-wide cooperative program in cadaver transplantation; 4)
cadaver kidney procurement teams have been organized throughout the
state; and 5) a program in the prevention and early detection of
urinary tract infections has been initiated, and an index of catheter
care has been designed. The present components will continue their
activities on an expanded basis during the next two years. Efforts
are currently underway to obtain state legislative support and insur-
ance coverage for future support of this program.

It also

This project was ranked first in order of funding priority by the
Region.

Sixth Year

$469,234

Project #17 - Nurse Utilization Demonstration Request (d. c.)

direction of the University of Wisconsin,

Milwaukee School of Nursing in collaboration
with Marquette University Graduate Department of Nursing and St. Mary's
Hospital, Milwaukee and was initiated by utilization of carryover
funds. It was designed to demonstrate better utilization of nurs.es
and other health care personnel in a clinical setting.  The project
is divided into three phases:
and procedures; 2) implementation and evaluation of new patient care
systems and 3) actual demonstration to hospitals. Continued support
is requested to carry out the last phase of the project.
this phase, actual working experience for health teams from other
hospitals throughout the Region will be offered to assist them in
developing moreeffective patient care systems on their own. The
funds are largely for personnel who will disseminate the information
gathered during the first two phases of the project.

The initial design stage has been completed and ten of the sixteen
systems are in the process of being implemented.  Delay in the im-
plementation of the patient care system was due to the loss of the
nurse clinical specialist.

- Unit. This activity is under the m"

$130,890

0

1) development of patient care systems

During

Wisconsin RQ

-16-

The Region plans to evaluate this project on the basis of the differ-
ent types of data which have been collected,
views, personnel questionnaire, absentee rate, turnover rate, cost
accounting practice, referrals for continuity of care, etc.

sue-, aR: patient tnter-

The Health Science Unit of the University of Wisconsin Extension
Service will continue to participate in the development of the
demonstration phase of this project after withdrawal

"4,

of RMPS funds. .

This project was ranked fourth in order of funding priority by the WRMP.

Project Continuation Beyond Approved Period of Support (Renewals)

Requested (d. c.)
Fifth Year
$95,200

Project //6 - Interrelated Program in Radiology

Radiological PGics Laboratoq*. This project
was initially funded during September 1969  for
a two-year period. One year renewal support is requested to: 1)
continue the present services of computerized treatment planning,
TDL verification of deliv-red dose, radiological physics services
and radiotherapy consultation; 2) add services to reduce radiation
exposure from diagnostic X-rays; 3) sponsor workshops on physical
and clinical aspects of dosimetry and treatment ?rotoc@l; and 4)
provide dial access talks on radiation safety, Since September 1969,
the Wisconsin Radiological Physics Laboratory has provided physics
services and radiotherapy consultation to most of the hospitals and
clinics that are doing radiotherapy in the Region.  Over 100 visits
have been made to hospitals by WRPL traveling physicists to provide
calibrations and measurements which are vital to accurate radiation
dosimetry.
outside the major centers for GYN cases,  external beam rotational
cases and radium needle implant.
$75,643 for personnel.

and Nuclear Medicine - Wisconsin

A total of 66 treatment plans have been done in hospital

The 71-72 request of 95,200 includes

The project was ranked sixth in order 05 funding priority by the
Region.

The Region is currently considering applying for a three-year supple-
mental grant to extend through August 1975. The grantee has just
begun to charge for the services provided and expects that the project
will eventually become self supporting.

Project t12 - Uterine Cytology - This project Requested (d.c.)

Wisconsin State Laboratory of Hygiene became
operational on September I, 1969. The project
is a demonstration program designed to implement and evaluate a new
semi-automated technique for screening the adult female population
for uterine cancer. One year additional funding is requested to

which is headquartered in the

Fifth Year
$50,820

Wisconsin RMP -17- XM 00037-05 8/71

pursue the original objectives of: (I) the demonstration of cell
sizing as a method for mass screening of a female population for
uterine cancer; (2) definition and further refinement of the tech-
nique itself; and adaptation OF the technique of cell sizing to the
detection of other types of neoplasm, and the extension of this
method to other laboratories.

During the first 18 months of the project, 6,200 women in Wisconsin
have been screened by the size distribution method along with
simultaneous papanicolaou smears. The project involves the cooperation
of two clinics in different areas of the state and two State Board of
Health Mobile Units,  a third clinic: will be added to the study during
the next year.
size, distribution, pre-screening method is highly useful in detecting
early cancerous and pre-cancerous lesions of the uterus and will
effect more efficient use of cytotechnologists since the method re-
duces the proportion of negative smears which constitute the majority
of smears currently being read. It is anticipated that this method
of cancer screening will be incorporated into  the local clinics and
other medical service facilities. The study will also assess the
capability of paramedical personnel and patients to obtain the
specimen.' This project was ranked fifteenth in order of funding
priority by the RAG.

Project 816 - Medical Library - University

initiated in September 1969, is designed $1,525
to develop methods of providing improved
access to medical information for the health personnel in Wisconsin.
This overall objective is to be accomplished through three interrelated
programs: 1) a series of four-day courses for clerical personnel
in the operation of hospital libraries; 2)
list of serials for libraries in Wisconsin; and 3) a consultation
service to health infornation personnel upon request.

This request is for one additional year or funds to be used in pur-
chasing computor time, and the cost of printing and distributing  the
union list.  It is also planned to update and edit the initial union
list, expariding coverage by adding the scientific and psychological
holdings of several major non-hospital libraries. The applicant re-
ports that serial holdings for 46 to 48 participating hospitals have
been added to the data base.

The course material and curriculum have been developed and tested in
five areas of the State, and the University of Wisconsin Extension
Department intends to offer the course over the Educational Telephone
Network in September 1971.
material are being made for ENT programming.
available personnel to devote substantial time and effort in motivating

The results of the study have indicated that the

Requested (d. c. )

of Wisconsin - This project, Fifth Year

the development of a union

The appropriate revisions of the course

Because of the lack of

Wisconsin RM? -18- RM 00037-05 8/71

hospital
not been utilized to the extent originally anticipated.  Only fifteen
formal consultations and an unspecified number of informal  consulta-
tions have been conducted.

administrators to utilize the consultant service, it has

y.

Approved Projects Not Previously Funded

Project #13 A - Inactive Nurse - University Requested (d.c.)

application directed toward the preparation
of inactive nurses was initiated March 1, 1969. $66,500
The total project originally seen as a two-year
project was designed in three parts:

of Wisconsin - The original Fifth Year

(1st year Triennium)

1) Specially designed courses for inactive nurses in selected areas

of the state.

2) A series of telephone/radio conferences offered to inactive nurses
on a statewide basis,

3)

Individual study guides on selected nursing ta.pes.

Funding was provided to support only one aspect of the project which
was 112 - the provision of telephone/radio conferences for inactive
nurses.  The grant was made in September 1969 for one year only.

(September 1970 - August 1971) and was approved, but not funded.

This request is for the support of the second year, to carry out the
intent of the original proposal. The appliesnt  states that the program
has met an educational need among inactive nurses.  Evidence of this
has been the response and support of a total of 699 inactive nurses
who have participated in all three phases of the project.  One hundred
and two inactive nurses Gave returned to practice between September 1,
1969 and August 30, 1970, and the assumption is that this impact will
continue.                                               It
is to facilitate the return of the inactive nurse to the practice of
nursing.
the WRMP.

.-

An application was submitted for the contihuation of this project

I --

LI

./

..

L I_

The overall objective of the program remains the same.

This project was ranked 12th in order of funding priority by
No support for the sixth and seventh years is requested.

Project #18 - A Medical College of Wisconsin Manpower
National Advisory Council. The project calls for the $57,965
establishment of a Coordinating Council for Continuing

Education of the Medical College of Wisconsin. The Council will be
composed of representatives from a variety of professional groups,
consumers and planning agencies. Its major function will be to
utilize existing resources for the development of an operational
program in Continuing Education. The Council will focus on the
development of team-teaching methods, devel-opment of ongoing programs

Requested (d.c.)
Fifth Year

This project was approved by the July 1970

-__ _- - H-ealth _Educat_ion-_in the newly created Department of Continuing

Wisconsin W -19- RM 00037-05 8/71.

in community hospitals and the development of a system of continuing
consultation, Educational activities utilizing methods and content
identified by practical experiences will also be developed and
implemented.

Requested (d. c. ) Sixth Year Requested (d.c.) Seventh Year

$57,965 $57,965

Project if22 - Continuing Education in

Division of Health, Wisconsin Department of (1st year triennium)
Health and Social Services. This is a three- $54,341
year request for a project which will provide
physicians and allied health professionals an opportunity to develop
skills, increase their knowledge and will improve the coordination
of rehabilitation activities. The target area is a three-county
rural area located in Central Wisconsin. Therapy consultants will
be provided by the State Division of Health to assist in education
and consultation programs.
health agencies and physicians in the planning and development of
programs.  An information and referral service will be developed in
target areas to provide them a source of information on the care of
the patient.  Local and state advisory groups will provide general
guidance, interpretation and liaison with organizations and will be
responsible for planning the continuation activities when the project
terminates. Most of the budget ($33,989) will be for the support of
professional perscnnel and to condcct appropriate evaluation studies.
This project was ranked eleventh in order of funding priority by the
Region .

Requested (d.c.)

Rehabilitation Medicine - Fifth Year

Project coordinators will work with local

Requested (d.c.) Sixth Year

$57,428

Requested (d.c.) Seventh Year

$62,016

Requested (d.c.)
Fifth Year
  $97,177

Project %23 - An Educational Program for Cardiac

of Wisconsin, Milwaukee - This proposal was approved for
a three'year period by the June 1970 National Advisory Council.
project proposed to train 72 nurses during each of the three years.
The purpose of the program was to prepare nurses to function effectively
in a Coronary Care and/or intensive care unit by means of a six-week
educational program.
(which were supported in part by a grant  from the Wisconsin State
Board of Nursing) were offered by the Milwaukee School of Nursing
which provided training for 12 RN's during 1970-71.
that a third course will be given during the spring.

This program was ranked tenth in order of priority fund.inp, by the WIW.
Requested (d.c.) Sixth Year Requested (d.c.) Seventh Year

and Intensive Care Nursing - Universi-ty

The

In the absence of WRMP funding two courses

It is anticipated

$83,007 $83,007

Wisconsin RMP

-20-

RM 00037-05 8/71

New Project8

Requested (d.c.)

Project 124- Cancer Review and Emendation Sys tern Fifth Year

support to establish a viable decision-making        $28,945
mechanism within all Wisconsin hospitals.
objectives are:  1) to strengthen existing cancer centers; 2) develop
a multidisciplinary team approach to cancer patient care; 3) determine
the need for new centers and personnel; 4) initiate training programs
for the development and demonstration of the best methods of cancer
treatment; and 5) support and assist medical groups to assure wide-
spread use of the best available methods of early detection and cancer
therapy. The first year is devoted to training programs, providing
interdisciplinary consultation to hospitals, implementing desired
standards in hospitals and determining the viability of the project
on a statewide basis.
fees charged to the hospitals for services and through patient charges.

This proposal requests three-year

(1st year of triennium)

The specific

The project will become self-supporting through

Evaluation will be based on the degree objectives are met:
ment in treatment success or referral demonstrated by patient records,
percentage of hospitals participating with cancer evaluation and
meeting data and training requirements.

improve-

This proposal'was ranked ninth in order of funding priority.

Request (d.c.) Sixth Year

$28,945

Requested (d.c.) Seventh Year

$28,945

Requested (d. c. )

(1st year Triennium)

Project #26- Nurse Associate - University Fifth Year

Primary Care, Madison. This proposal requests $116,901
three-year support to demonstrate the capability
of the nurse aasociate and to include some tasks now performed by
physicians.  This is the first of a series of projects from the
ad hoc committee on the Delivery of Primary Care by WRMP,
the project will focus on child health care then will move fnto the
area of family health and finally to the axea of geriatrics.

of Wisconsin, Program of

Initially

The project proposes to:
consultation program for 68 RN's and physician teams; 2) place
these nurses in practice settings; and 3) evaluate the nursing role
and collaborative functioning in an office, group practice, health
center or outpatient department community setting.
consist of a series of education, field experience, follow up, con-
sultation and evaluation cycles.

1) establish a cooperative education and

The project will

Evaluation will be conducted on

Wisconsin RMP -2 1- RM 00037-05 8/71

L

an ongoing basis and will include: ;)ss;udent performance; 2) role
acceptance by physician, nurse and consumer; and 3) cost effectfve-
ness analysis.

This proposal was ranked eighth in order of funding priority by the
Region.

Requested Sixth Year

$118,225

Requested Seventh Year

$118,225

Requested (d. c.)

(1st year Triennium)

Project #28- Diagnostic and Therapeutic Fifth Year

requests three-year support to assist hospitals
in Wisconsin in selecting diseases or conditions
to be studied, setting criteria for them in the specific hospital and
monitoring the performances in that hospital against the criteria,

Criteria Review - This proposal

$23,000

Consultation and assistance will be provided by the University of

Wisconsin and WW to the hospitals in order to enable them to establish
and carryout their own programs.
four hospitals to determine its applicability In the state.

Initially this will be done in

If the method appears promising additional support of approximately
$50,000 will be proposed after the first year.  This will enable an
increase in the number of hospitals involved in the process.

Requested (d.c.1 Sixth Year

$23,000

Request (d.c.) Seventh Year

$23,000

Requested (d. c. )

(first year of triennium)

Project #30-:  North Central Wisconsin Fifth Year

          Outreach - This is a
request for one-year support for an $12,862
activity which was initially developed
as a feasibility study as a part of core staff activity.
will: 1) provide an ongoing medical consultation service between the
medical staffs of small rural hospitals and the Marshfield Clinic;
and 2) assist in the development of satellite clinics in communities
where there is little likelihood of them recruiting a physician.  It
is proposed that the clinics will be staffed by a physician for a half
day two times 8 week and a trained physician assistent the remainder

of the week.

Personnel requests for 71-72 is $11,362 of the total direct cost budget
of $12,862.

This proposal

This proposal was ranked fifth in order of funding priority by the WW.

Wisconsin RMP

-22-

RM 00037-05 8/71 I

# Request (d . c . )

Project t31- South Side Health Contact Fifth Year

outgrowth of a planning study which involved
Core staff assistance and financial support in
planning and developing the initial plans for the creation of the
South Side Health Contact Center.  The Center was founded by a group
of low-income persons in Milwaukee's South Side "Inner City."
founders established three operational goals:  1) to serve as a source
of information on medical resources to members of the local community;
2) to serve as a referral agent and health advocate; and 3) to attract
more direct health services into the community, both through coordination
of already existing services and the development of new services.

Center - This proposal is  the

(1st year of Triennium)

$41,941

Its

This request is or one-year support to expand and upgrade these
services to a comprehensive ambulatory health service, and is requested
as a program for the utilization of WRMP developmental component funds.

All of the services included in a comprehensive health service will
be provided such as: medical care, dental services, social services,
community organizations and the development of support sources.

Planning of the service will be directed toward an assessnent of the
medical services required, examination of the means through which
the necessary service could be provided and ways in which the paper
creation of the planning process might be concretely realized and
maintained.
priority by the Region.

This project was ranked second in order of funding

RMPS/CRB/6 191 71

?

(A Privilewd Communicat

SUMMARY OF REVIEW AND CONCLUSION OF
   JULY 1.971 REVIEW COMMITTEE

WISCONSIN REGIONAL MEDICAL PROGRAM

RM 00037 8/71

on )

FOR CONSIDERATION BY AUGUST 1971 ADVISORY CrJilNCIL

Committee recommended that the Region be awa
$1,5000,000 for its first and second triennial years

and that it be awarded $1,085,000 as requested by the Region ior its

d year. The Committee further recommends that the request for
lopmental component funds be approved and included in the totals as
forth above.

DIRECT COSTS ONLY

* $1,Y17,076 $1,500,000

  1,509,777 1,5OO,OOO

  1,084,858 1,085,c)OO

$4,511,7? I $4,085 000

f the Review Committee that participated in the December 1970
as unable to attend this meetin?. Therefore, the mvlewers
to benekit from his first hand information,

: The reviewers noted that the Reqion was last site visited

durTnp December 1970 with reference to its application for

support of a developmental component.

Because of the short time since

er site visit was not scheduled for this application.

te visitors recommended approval of the developmental com-
, the January 2911 Review Committee heXieved that action
ould be deferred and reviewed in relation to the total

concurred with this recommendation,

ther noted that the Ret?,Fon had responded to the advice
t the December site visitors and had:

ram proposed in the triennial application. The February 19/2 National

strength to the core staff by the addition of a
Coordinator tor Proqram development by the replace-

societe Coordinator hy a qualified individual, and by
three liaison representatives who ere to work with the
pencies and the Marshfield Clinic.

1

h

Wisconsin RHP -2- RM 00037 8/71

2)  Improved the extent and quality of evaluation procedures by the
establishment of a Review and Evaluation Committee which will be
responsible tor conducting project site visits at least once a year and
by developinz methods to produce "outcome" data rather than theoretical
in forma tion.

i

3)
rative relationships with some of the large proprietary clinics.
(Marshfield and Gundersen)

Improved their subregionalization errorts by establishing collabo-

4) Expanded the Board of Directors from three to nine members.

The Review Committee also considered and accepted the tindinqs of an
April 1971 staff site visit team report on the large Comprehensive Renal
Disease Program which is funded through the Region.

The Regional ;ldvisory Croup which has a total of 47 members (including
nine females and two blacks) appears to be a well-balanced group; it
represents a broad ra,nge of professional and health interests and a wide
geographic area; it has a very strong role in the policy direction and
guidance of the Region and a very strong input into the review and planning
process.

During September 1910, the Regional Advisory Group approved new program
priorities which are essentially in line with the National Health
Priorities. The Planning Committee of the Regional Advisory Group, during
their July 1971,meeting are to reexamine and restructure the goals, purposes,
basic program objectives and policies to bring them more in line with the
Regional and National Priorities.

.

The reviewers believed that the WRMP is now in a period of transition,
shifting its emphasis from a project to a program approach.

Most of the Region's categorical programs which have received support
for a nurnb2r of years wil4'be transferred to other than RMP support during
the first year ot its triennium.

Two of the new projects Sroposed in this application - North Central
Outreach and South Side Health Contact Center were believed to be in line
with the national priorities.

The Review Committee agreed with the December 1970 site visitors that the
Region
autonomy to successfully and prudently utilize a developmental component
in the planning and development of programs which will improve the health
care services within the Region.

has demonstrated tht it has the machinery, expertise and local

The reviewers were favorably impressed with the current small core staff's
role in this Region. The Core staff has demonstrated excellent leadership
and competence in working with both providers and consumers of health
services as well as the many agencies and neighboring Regions (Iowa and
Northlands) who have an interest in health.

Wisconsin RMP -3- RM 00037 8/71

As noted before, the application request funds to support additional core
staff members.
support was warranted.

4

1

The reviewers agreed that an increase in the level of core

The Region's review process meets the requirements tor decentralization.
The process involves staff, the Executive Committee of the RAG, appropriate
study groups or subcommittees of the RAG, appropriate areawide compre-
hensive planning agencies, Project Review and Evaluation Committee and
then the Regional Advisory Group.
sophisticated method in arriving at the ranking of program and project
proposals.

The Region appears to have a very

The recommended level of support developed and recommended by the Committee
the fifth operational year was arrived at in the following manner:
        Core Support $ 495,675

Developmental Component 140,000

Operational Activities

(new, renewal ti

                a 64,3 z5*
continuing) r ''. ' -

Total $1,500,000

e Committee believed that this amount should be sufticient to

partially support the Region's top ten priority activities.

Also,,Council's

roject #23 - An Education Program for Cardiac and
- University of Wisconsin which was approved for a
e June 1970 National Advisory Council.
er ten by the Regional Advisory Group and thus

This

would be included in the proposals recommended for funding.

this application.

RMPS/GRB 7/13/71