ALABAMA

          0                                                  0


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

             ALABAMA REGIONAL MEDICAL PROGRAM                       RM 28-03 (AR-1-CSD) 2/71
             The University of Alabama in Birmingham                January 1971 Review Committee
             The Medical School Center
             1919 Seventh Avenue South
             Birmingham, Alabama 35233
             PROGRAM CO RDINATOR:  S. Richardson Hill, Jr., M.D.

                               REQUEST  FOR  NEW  FUNDS  (Direct  Cost  Only)
             REGIONS OPERATIONAL YEAR           03            04            05             Total
             I.   Core (Renewal)              558,061      790,921        839,284          2,188,266
             II.  Approved Unfunded
                   Projects (5)               243,669      163,770          -0-            407,439
             111. Renewal Requests
                   (Projects) (2)             173,827      172,323        177,858          524,008
             IV.  Developmental
                   Component (3 yrs.)         ioo,ooo      100,000        100@000          300,000
             V.   New Projects (10)           800,852      762,914        457,971          2,021,737

                  Total Request               1,876,409    1,989,928      1,575,113        5,441,450
             (Project #26 -Nutrition Project, Tuskegee, Alabama        (Model    Cities-RMP)
             an  approved  6nfunded  project  will  be  funded  with  earmarked  funds   for
             model cities activities, per recommendation of the Acting Director of RMPS)
             Funds re@uested for this project have been omitted from the total request for
             approved  unfunded  projects  (Item   11).

             RMPS Staff Review of Non-Competing 03 Year Operational Continuation
             Grant Application (December 17, 1970.
                                            Recommended Award        Commitment
             REGIONS OPERATIONAL YEAR           03 Year               04 Year

             I.    Core (Sub-Regionalization)  tl78,658                  -0-
             II.  Ongoing Projects (2)               61,342              -0-

                   Total                           $240,000              -0-

                                               FUNDING HISTORY
                                              (Direct   Cost   Only)

             Grant Year                   Period                    Funded

             Planning S@e
             01                   1/l/67 - 12/31/67                $  247,250


            Alabama Regional Medical Program         -2-           RM 28-03 (AR-1-CSD) 2/71

            Planning S@e                    Period                 Funded

            02                      1/l/68 - 12/31/68            $ 286,750
            02S                     6/l/68 - 8/31/68                 11,695
            02S                     9/i/68 - 12/31/68              113,392
            03                      I/l/69 - 3/31/69               131,526

            opeiational.Stage

            01                      4/l/69 - 3/31/70            Core  542,369
                                                           Pro.jects  192,509
                                                           Total      734,878

            Ol(S)                   4/l/70 - 3/31/71            Core  101,492
                                                            Projects    39,365
                                                           Total      140,857

            Ol(S)                   4/l/70 - 3/31/71            Core  160,490
                                                            Projects    40,145
                                                                      200,635

            CEOGRAPHY AND DEMOGRAPHY:

            Alabama ranks 29th among   the states with 51,609  square  miles  of  land.
            The most recent population estimate (.Health Department's Bureau of Vital
            Statistics, 1967) is 3,562,850.  It has a large rural population with a
            large Negro component (30'/.). In  per-capita  income  Alabama  ranks  47th
            among the states.  In this state there are 67 counties - 35 northern
            counties are in the Appalachian development district.  Trade, industrial
            and transportation patterns group the counties into areas similar to
            the seven used as the geographic framework for planning the Alabama @IP.

            The Alabama Region, as  presently  defined,  represents  some  admixture  of
            interest and health service functions between  the extreme southeastern
            part of Alabama (especially the Dothan area) and adjacent parts of
            Georgia and Florida.  The  similar  admixtures  at  Phoenix  City,  Alabama,
            with Columbus, Georgia, and in a few places along the Mississippi
            broader.  The several interfaces across the political boundaries do not
            present problems and  Alabama  Regional  Medical  Program  works  compatibly
            with those that surround it (Mississippi, Florida, Georgia, Memphis
            and Tennesee Mid-South).

            The single Medical Center located very near the geographic center of
            the region contains  the  only  complete  constellation  of  medicalldental
            and nursing and allied  health  sciences  resources  for  teaching  research
            and service in the state.

            In an economic sense Alabama lies in the  center  of  the  cotton  belt  of


            Alabama RMP                          -3-        RM 28-03  (AR-1-CSD)  2/71

            the old South. Although agriculture remains a vital part  of  the  states
            economy, a rapid increase in manufacturing and  diversified  industries
            have given the area a more balanced economy in recent years.  Live stock,
            especially poultry, has become quite important to the economy.  Alabama
            ranked second in the nation in pulp wood production.  Additionally,
            lumber, furniture and wood projects are  important.  Bituminous  coal,
            iron and bauxide are among the national resources of the  state.  -

            There are a total number of 67 counties in Alabama and there  is  a
            64 person per square mile density in population  distribution  throughout
            the state. The major portion of the population of  Alabama  is  Iodated
            in the Metropolitan areas of Birmingham, Columbus,  Georgia,-  Alabama
            Catsden, Huntsville, Mobile, Montgomery,, and Tuscaloosa,  Alabama.
            Approximately 55% of the population of the state is urban.  The
            medium age of the population of Alabama is 26.0.  Approximately 70'/. of
            the population is white and 30'/. of the population is Negro. There  is
            only one medical school in the state of Alabama, the University  of
            Alabama Medical Center, which has an enrollment of 300.  There  are
            14 schools of nursing of which two are collegiate institutions; 12 schools
            of medical technology of which 9 have a college affiliation;  one  school
            of cytotechnology at the University of Alabama; eight of x-ray technology
            with three having colige affiliation; and a total of 140  hospitals  of
            which nine are federal and 131 are ndn-federal. The  total  number  of
            hospital beds available in Alabama are 26,553 of which 4,1 0  are  federal
            facilities and 22,413 in non4federAl facilities

            There are a total of 2,842 physicians and there are four osteopaths
            in the state of Alabama which is approximately a rate of 86  per  100,000.
            There are a total of 7,150 nurses in the state of which  5,272  are
            presently active which is a rate of 159 per 100,000 population.

            HISTORY OF REGIONAL DEVELOPMENT:

            On July 17, 1965, the Medical Association of the State of Alabama appointed
            an Ad Hoc Committee to investigate the recommendation of  the  Presidents
            Commission on the treatment of stroke, heart disease  and  cancer.  After
            careful study the Ad Hoc Committee recommended that all programs  of  the
            Regional Medical Programs be centered in the Medical  College,  University
            of Alabama but should be operated with the approval and guidance  of  the
            Medical Association of the State of Alabama and the State Board  of
            Health. On April 9, 1966 in anticipation of action  under  Public  Law
            89-239 the Governor George Wallace, appointed a  State  Advisory  Regional
            Medical Program Committee. The members of this  committee  were  nominated
            by the president of the Medical Association, State of Alabama  and  the
            Dean of the Medical College and included representatives of the Allied
            Health Professions, Voluntary Health Agencies  and  Consumers.  The
            group recommended that t'he University of Alabama Medical Center be
            designated as the responsible agent for planning for the Alabama
            Regional Medical Program.


             Alabama RMP                           -4-         RM 28-03 (AR-1 CSD)  2/71

             The'region's initial planning grant was awarded for a  2k-year  period
             beginning January 1, 1967. A total of $247,250 d.c.  was  awarded  the
             first year. A second year award plus two  supplemental  awards  which
             provided support for a subregional planning office in Mobile made
             available $411,83'@ for planning during the second year.  During  this
             planning phase the program coordinator for the region was Dr.  Joseph
             F. Volker, Vice-President for Health Affair-% University of Alabama
             Medical Center. In the initial review of the  planning  application  the
             National Advisory Council expressed concerns that the Regional Advisory
             Group of the Alabama Regional Medical Program did not  have  representation
             of the consumer public minority interests, dentists and nurses  (and  there
             appeared to be token representation from the  state  hospital  associations
             The application also made no specific reference to an analysis  of  the
             overall medical needs of the region. There  was  inadequate  allocation
             of administrative responsibility including failure to define the
             mechanism for coordinating the planning among the  professional  staff,
             the Advisory Committee, and the State Board of Censors.  There  was  no
             systematic analysis of resources; no reference to work that had already
             been done in this field; no specification of  cooperative  arrangements
             among institutions to be involved, and no consideration  for  planning
             the most effective allocation of existing resources  and  personnel.  On
             the basis of this criticism from the National Advisory  Council  the-
             region revised their planning application at which time  the  National
             Advisory Council did approve the planning grant which essentially
             satisfied earlier concerns. On November 1, 1968, Dr.  John  Packard  was
             appointed director of the Alabama Regional Medical  Program  succeeding
             Dr. Benjamin M. Wells who then became Coordinator replacing Dr. Volker.

             The region submitted its first operational application on August 27, 1968,
             requesting $1,928,327  for the first 12-month period to begin January 1,
             1969.  It included 12 operational projects.  A site visit was conducted
             on December 5, 1968 to determine the readiness of the  Alabama  Regional
             Medical Program for operational status. In  reviewing  the  operational
             application the National Advisory Council indicated that  the  Alabama
             Regional Medical Program was in the early stages of maturity.  The
             Council expressed the hope that the Regional Advisory Group would become
             more active in a leadership role under the direction of its new
             chairman. Also required would be an addition of  a  full-time  program
             director in evaluation c-f personnel, and the role of Core staff  was
             expected to be strengthened.

             Council did note that the site visit team found the staff to  be  generally
             competent and under effective leadership. The role of  the  staff  in
             establishing links of communication and in capitalizing  and  channeling
             ideas and ongoing activities was noted as a major strength of the program.
             In conclusion, the Council concurred with the recommendations of  tile
             site visit team which approved four of the eleven  projects  considered
             and recommended a total first year direct cost award of  734,878.

             In March 1970, Council approved a Core supplement for subregionalization
             of the Alabama RMP which involved the establishment of seven subregional        ;::@ I
                                                                                            ... f. ,
                                                                                           I I @".. .;@


             Alabama RMP                       -5-            RM 28-03 (AR-1-CSD) 2/71

             offices. The region proposes through the core supplement  to  accomplish
             regionalization and coordinate RMP activities in Comprehensive Health
             Planning in the region.

             This region is unique in that the Alabama Medical Society is the official
             health agency at both the state and local level.

             This organizational framework gives the Medical Society  responsibility
             for administering activity under title 18 and 19, "the partnership  for
             health" (PL 89-749).

             In May 1970, a site visit was conducted to this region to take an in-
             depth look at the region's core and projects.  The impression of the
             site visitors was that the Alabama RMP could eventually have one of
             the strongest health care programs of any state, if its overall  scheme
             for integrating the strengths of the University, the Regional Medical
             Program, the State Medical Society and Comprehensive Health Planning
             is made to work.

             The RAG has been increased from 42 members to 62 members.  The  increase
             in membership has been directed toward expansion of consumer representation
             on the RAG.  Each of the seven subregions were asked to appoint two
             candidates and six additional members were selected at large.  In  order
             to increase minority group representation on the RAG, each subregion
             will be required to select a minority group member as one appointee.
             With this increase in consumer representation on the RAG, the  majority
             of advantage previously held by the Alabama Medical Association and  the
             University of Alabama will no longer exist. The increase  in  involvement
             of the local community representatives on the RAG facilitates the
             regionalizatibn process of this region. Dr. Robert Ross  McBride  present
             chairman of the RAG has indicated that the RAG will continue to  select
             aschairman a practicing physician from communities away from the  Medical
             Center. The region believes that this will improve the  relationship  of
             the ARMP with community physicians throughout the region.

             PRESENT APPLICATION:

             This is the triennial application in which the ARMP has requested a  Cote
             renewal of 2 projects, a dvelopmental component, supplemental funding
             of ten new projects, and continuation of a core supplement ( subregionalizat.ton)
             and two projects.
             The ARMP's proposed activities for the next twelve months are  identified
             as follows:

             1. Core Staff

                (a) Program Planning and Development - to implement plans for  program
                    direction as determined by long-range planning an executive
                    committees,, Regional Advisory Group, and key staff members.
                (b) Project Development and Review - Try to develop a method of
                    project development with increased involvement of RAG members


           Alabama RMP                          -6-      RM 28-03 (AR-1-CSD) 2/71

                    and less staff time.  To develop a more impartial project
                    review process.
               (c)  Program Management - To maintain and improve management methods
                    of programming projects in areas of personnel and physical
                    procedures.
               (d)  Education - A three year plan for.involvement in the education of'
                    Health Manpower in Alabama.  To help and assist in the implementation
                    of an overall regional plan of basic and continuing education  for
                    health workers in Alabama in order to improve the Health Care
                    Delivery System to the people.
               (e)  Communications - To increase the awareness of  ARMP  activit,ies
                    within the region, especially the need for program consistency.
                    To improve communications systems with core staff.
               (f)  Program in Project Evaluation - To design evaluation methods for
                    each ongoing project and to assist in writing new project proposals
                    so that they include a cleaner and measurable set of objectives
                    with a design for evaluation.  To evaluate means and methods
                    to achieve maximum utilization of ARMP dollars spent in the region.
                    Continue to evaluate future medical needs of the community and
                    determine what steps the providers of care must take immediately
                    to meet these needs.  To prepare a statement of health base ine
                    data for the region which can be utilized as a comparison for
                    future program evaluation.
               (g)  Consultation - Key staff members, i.e., those  in  Associate
                    Director and Assistant Director positions, will be responsible
                    for consultation activities for the programs constituency.
                    Consultation will be based upon the staff members role in the
                    program, however, all consultation activities will be sensitive
                    to the health needs of the state.

            2. Subregional Offices
                    The Birmingham and Montgomery subregions have established lists of
                    objectives and priorities for the 314 (b) agencies.  The ARMP-funded
                    health planner in the Birmingham office, Mr. Al Rohling, will be
                    involved in implementing these under the direction o Mr. George
                    Rice (Executive  Director, Community Service Council), while
                    acting as liaison with ARMP by attending meetings with core  staff
                    and RAG. In M6ntgomeryMr. David Carter has  been  named  Executive
                    Director of the state approved bu unfunded 314 (b) agency.  Be
                    will be involved in further community development,  identification
                    of possible local sources of matching funds for the time when
                    federal funding is available, and in identifying project
                    proposals which would alleviate local needs and be appropriate for
                    ARMP funding.
                    Activities of the other four subregional health planners, all of
                    whom have been appointed for less than four months,will center
                    about the involvement of local providers and consumers into a
                    viable health planning council which can qualify for 314 (b)


             Alabama  RMP                        -7-     RM 28-03 (AR-1-CSD) 2/71
                     status and which can identify local needs, set realistic
                     objectives and arrange most of@the next grant period.  The
                     following years will be utilized to implement the plans.
                     Two regions (Tennesee Valley Area in Northern Alabama and the
                     recently delineated Selma Area) have not yet been able to
                     identify mutually satisfactory health planning councils.  Core
                     staff will continue to be involved, with representatives of  the
                     314 (a) Agency, in encouraging the formation of such councils.
                     This will probably be accomplished during the early part of  the
                     next grant period for the Tennessee Valley Area, and funds for
                     hiring a seventh health planner Are contained in the Continuation
                     Application portion of Core staff.  The Selma Area will probably
                     not be in a position to use a health planner until.the period
                     4/i/72 - 3/31/73 and funds are being requested for this position
                     in that and the succeeding grant period.

             3. Grantee Institution
                     The Executive Committee of RAG recommends that part-time  salary
                     support to faculty members and support to staff be constantly
                     reviewed to insure that effort and time expended on ARMP  duties
                     be probably compensated.  Full-time staff will probably reduce
                     the need for part-time staff with consequent benefits in
                     management.  They are further strongly recommending that the
                     grantee institution appoint a full-time coordinator in line with
                     their previous actions.  Committee also recommended that data
                     collection be purchased on a contract arrangement.
                     The ARMP explains that office space for Core staff needs expansion,
                     which cannot be effected in their present location.  They indicate
                     that during the next few months the Core staff must move into
                     adequate quartets.

              4. Regional Advisory Group
                     At their June 1970 RAG meeting the members and Core staff  identified
                     the following as major issues needing work or improvement if the
                     ARMP is to fulfill its potential and has recommended actions which
                     have been started and will continue during the next twelve months:
                          1.  Inadequate communication between RAG and Staff.
                          2.  RAG involvement in project development And review.
                          3.  Relationship between RMP, RAG, and UAB to be clarified.
                          4.  Confused relationship between CHP and RMP.
                          5.  Inadequate consumer involvement.
                          6.  Decentralization - what and how much?
                          7.  Programs versus projects

                     The  RAG also reviewed the following major program areas:
                          1.  Consultation and resource service.
                          2.  Continuing Education
                          3.  Manpower development
                          4.  Medical Services.


                                                              RM 28-03 (AR-1-CSD) 2/71
             Alabama RMP
                   In addition, the RAG is undertaking a reassessment of ARMP goals,
                   objectives and priority setting which will be a continous-process
                   occupying at  leIsat the next grant period and will probably continue
                   throughout the next three years.
                   The categorical committees of RAG will be assisted by  staff  and
                   outside consultants to reassess the  planning  goals  established
                   earlier and set priorities.
                   A in depth study of the advantages and disadvantages of changing
                   grantee institutions will be undertaken by an  Ad  Hoc  Committee
                   authorized by the Executive Committee of  the  Regional  Advisory
                   Group which appreciates the problems which arise from  too  close
                   an identification of ARMP with the University of Alabama and which
                   may become more acute when the proposed medical school in Mobile
                   opens in 1973.

             ORGANIZATIONAL STRUCTURE AND PROCESSES
             The Regional Advis     rou     The size of the Regional Advisory Group has
             been increased to include more allied health personnel as well as consumers.
             This growth is responsible for a broader geographical representation which
             is in part responsible for the change in program emphasis from continuing
             education to manpower development and delivery of medical services.  The
             RAG has been concerned with establishing a separate identity for ARMP to
                                          sity of Alabama in  Birmingham  (UAB).  In
             set it apart from the Univer
             June 1970 the recommendation was made that a full-time  coordinator  be
             appointed by Dr. S. Richardson Hill, Jr., Vice-President for Health Affairs
             at UAB. Dr. Hill assumed the title of Coordinator without salary support
             in January 1970. In October 1970, the Executive Committee  of  the  RAG
             authorized appointment of a committee to study the advantages and disadvan-
             tages of changing grantee institutions in light of plans by the University
             of Alabama, Mobile, to open a new medical school by 1973.

             The Regional Advisory Group is named by the applicant with  the  advice
             of the Chairman of the Regional Advisory Group.  The membership of the
             Group shall be composed of members   representing each of the following
             institutions and organizations, in number indicated, together with
             thirteen members at large representing the general public interest.
                   Medical Association in the State of Alabama                 8
                   University of Alabama Medical Center                        8
                   Alabama Dental Association                                  I
                   Alabama Hospital Association                                4
                   Alabama State Nurses Association                            2
                   Alabama Heart Association                                   4
                   Alabama Division of the American  Cancer Society            2
                   State Health Department                                     2
                   Vocational Rehabilitation Services                          I
                   Veterans Administration                                     I
                   Subtegional Advisory Group (2 each)                         16
                   Members At large                                            13
                     Total                                                     62


                 Alabama MV                          -9-         RM 28-03 (AR-1-CSD) 2/71
                 Executive Committee:  An Executive Committee composed of no less than
                 five nor more than ten members shall be electedby the  Advisory  Groupt  The
                 Executive Committee is authorized to act for the Advisory Group between
                 meetings subject to subsequent approval of the Advisory Group.  The
                 Executive Committee has bIeen composed of representatives from the offices
                 of RAG, the Presidents of the Medical Association of the State of
                 Alabama, the Alabama Hospital Association, a Chairman of the Board of
                 Censors of the Medical Association, the Dean of the UAB School of  Medicine,
                 the Vice-President for health affairs of the UAB, the State Health  Officer,
                 and the Coordinator of ARMP, and thus involve the responsible officers
                 of the most significant health providers and educators In the state.
                 Recognizing the desirability of having n smaller committee, to include
                 consumer representation and with the majority of members living in or
                 near Birmingham, the 1970 [LkG elected a six member Executive Committee
                 comprised of the officers of RAC, the President of the Medical  Association,
                 and two laymen, one of whom is a past President of the Community Service
                 Council (local 314 (b) Agency) and still serves on their Board of Directors.
                 In addition,the Chairman of the Board of Censors, the Vice President
                 for Health Affairs of UAB (who is also Coordinator of ARMP), Coordinator
                 for Research Grants of UAB and the Director of ARMP are ex officio  members.
                 Education Committee:  The Eduaation Committee has been composed of
                 faculty members of the UAB School of Medicine, Dentistry and  Nursing  which
                 represented the resource for education of the providers  The committee
                 has been expanded to include representation from propective students,
                 junior and senior colleges, the Alabama Hospital Association, guidance
                 courneLlors, and from vocational education.
                 The Project Review Committee:  This (,oiiimi.ttee,witti membership from the
                 7A(7,  UAB and Core staff @tis t8stimed n portion of the functions of the
                 Development Committee In review of proposals and of the final draft
                 of project application before RA(; review.
                 Long-Range Planning Committee:   This Committee with membership from RAC,,
                 CHP, Appalachian Regional Commission and Core staff,  assumes  the  remaining
                 function of the development committee, including making recommendations
                 for short and long-range goals, objectives,, and priorities, evaluation
                 mechanisms and methods of implementing the programs.
                 Developmental Component Committee: This Committee  with  members  drawn  from
                 RAG, the Office of Grants Administration, UAB and  Core  staff,  will  review
                 and act on proposed expenditures from the developmental component.
                 Allied Health Advisory Committee:   ]'his Committeest  membership  represents
                 13 different categories of nursing and other allied health personnel ind
                 it provides a forum for discussions of  Inter-disciplinary  nature,  focusing
                 on common health problems. The  Committee  recommends  stidies  to  determine
                 education needs of practitioners and encourages projects related to
                 improving the expertise of these practitioners based on these identified
                 needs.  Major attention is given to allied health manpower needs and
                 the Committee addressses itself to manpower distribution problems


                                                              RM 28-03 (AR-1-C8D) 2/71
             Alabama RMP                        -lo-

             Categorical Committees:  These Comittes continue to be responsible for
             planning, screening and evaluation of proposed activities in their
             field   of interest.  There are categorical committees in the followi ng
             areas:
                    1. Heart Disease                 5. Diabetes
                    2. Cancer                        6. Dentistry
                    3. Stroke                        7. Rehabilitation
                    4. Renal Disease

             Each of  the above committees, by its membership contributes to cooperative
             relationships, and each contributes in one fashion or another to planning
             and-project and program review.

             Sponsor Review Committee:  This is the Committee of the grantee institution
             serving As an Advisory Committee to the Vice-President for health affairs
             and the Director, ARMP.' The committee reviews all ARMP proposals, both
             Core and affiliate based, from the point of view of the grantee institution,
             to determine that no ARMP sponsored activities are in conflict with
             state laws, UAB policies or institutional objects.  Following is the A@14P
             Organizational Chart.


                                                                   A L A     A N! A      r: G I C"e.1 A L N@,, I.-= D        RCGPA,'vl Ot,GAi%'IZATIO'@,VAL CHART

                           Regional Advis" Gro!.!p                                                                                                              UNIVERSITY OF ALABA@AA I,% BIR@Alr4GHAI%,l
                               (Policy & Di.-.-cton)                                                          '%"CO,'RD I NATOcl                                                                     Fi:.:ca!           n           I
                                                                                                      S. Pic;,-,)rdson Hill, jr.,,,,vi.b.                                                                             c @ibilit,/,
                      R. R. @i',c:')ryde, IND., Ch@-irry,,in
                                                                                                                                                                                 S. Richardson Hill, Jr., tA.D.
                                                                                                                                                                             Vice-President for Heaith Affairs

                                                                                                                        1, LO:
                                                   h P             s L      c n                                                                                                       Robert P. Glaze, Ph.D.
                                            (CHP, Appalachia, VA                                       'tC'.iicf Pxect.,tive Office-)
                                                                                                                                                                              Coordina+,or of Research Grants
                                           M@odel Cities, tiil!-Pur-to'n)                                 join P@-cka'rd, @A.D.
                                                                                                                                                                                           Lester H. Buryn
                                                                                                                                                                               Office of Grants Administration

                                                                                                             Dc@Llty Director
                                                                                                              i%4. D. P'io@vden

                                                                                                             A@ciate Director                                                                                      F-Acting
                                                                A,-3ciate Director                                                                                13te Dim--tor, Preeram
                              D;mntcr                                                                     Plarni!lft ard ?rc-,ram
                                                                     Ec!ucarion                                 Deve:oprnent                             Manage@nt    &    Cer,-.rnuni@-atiIons                        Associate Director
                                                                                                                                                                                                                            Evaluation
                 Profc--@ons'   Li.-ison                                                                                                                          'a
                                                                 Laurene Gi.@re                                                                                     rres Robe@son
                                                                                                                 L),-vid Cusic
                 J. 0.  Finri--v,  %@.D.

                                                                                                                                                                                                                       Assistant Director
                                                                                                         C@inater Community                                                          Pro.W Director                              - ons
             Associate D@or,                                       nt Director, %Ittrst..v               Research & Development                                                                                            OPOF   ti
                                                                                                                                          I         Donald Pi ince                   perational ProlLcts                 John Gillespie
                 John   Durant,    V,.D.                                                                        ld3 ?,A. Reed

                                                                                                                                                 As!irant Director
              Associate   Director,    He3rt                    Assistant Director                            Health Planners
                                                                                                                                          L       Cor-.municat',ons
                                                                                                                                                                                                                         Su,-t,3t Analyst
                          Stro!-e                                  AudiovisuBIs                            Suhrecional O'fices
                                                                                                                                                    J,- a n  m    n                                                      Virgir.',a Suryn
               Harold Sc,inaper, M.D.
                                                                   Robert Siavi

                                                                                                                                                                                                                                           OQ
                                                                                                                                                                                                                                            m

                                                                                                                                                 A=nci,-!e
                                                                                                                                                    D'..cclor   fo-
             A."oc;ate   Di   -@tor,   Kier"
                                                                                                                                                        P, owptrs V.A.
             Thor,-os  E.  Andre@!i,  !,4.D.
                                                                                                            (2@ V.A.
                                                                                                                                                          Birmingliam
                                                                                                                                                                                                                        October, 1970


                                                                            -12-           RM 28-03  (AR-1-CSD)  2/71
                 Alabama RMP

                    Core     Staff      Organi2;ation:

                                                                                              ram has 56
                    The Core staff of the Alabama Regional Medical Prog                                        employees,
                    40 at 100'/. time. and effort.   Following is a chart which indicates  the
                    percentage of personnel costs as applied to the categories  of ARMP
                    proposed activities:
                           15%                       Program Planning and Development
                           14'/.                     Project Development and Review
                           1 V/.                     Program Management
                           21%                       Education
                           12%                       Communications
                           13'/.                     Program and Project Evaluation
                           ir/.                      Consultation
                    There    are two parts of        Core which have to be considered in this application,
                    (1)  the Core basic,  (2) Core subregionalization4   Core basic   represents
                    a renewal request which must be reviewed by the National Advisory Council
                    and Core sub-regionalization is a continuation request  for funds committed
                    and authorized last year as part of a two year RMPS grant award.
                    Although the Core subregionalization project was reviewed and approval
                    was recommended by staff,this activity should be taken into consideration
                    when reviewing the request for Core renewal because in 04 and 05 operational
                    years of this  region,the amounts necessary to continue this activity have
                    been included  in  the total request  for Core.
                        (!ore basic budget of $558,061 direct costs compares with the current
                    budget of S576,109.           This  represents anincrease of slightly less  than
                    $32,000.   The region  indicates  that  this  is a minimum increase in the
                    light of expanded proposed activities.   The ARMP Core staff will in the
                    next twelve months be engaged in multiphased programs as outlined in the
                    proposed activities segment of the application.   It should be noted that
                    the program management phase includes administrative and supportive
                    activities required to issist in the establishment and  operation of
                    subregional offices.   The personnel category accounts  for approximately
                    $17,000 of the requested increase for Core basic.   This  increase is
                    influenced by  two major items:  (1)  the grantee institution  (UAB)  will
                    expand its benefit programs  requiring an increase  from 13'/., to 18'/. on
                    all 1971 Federal Grants  to reflect a planned  increase  in Social Seciirity
                    Payments, Unemployment Compensation, TIAA, State Retirement and Health
                    Benefits which will take place during the fiscal year 1971 -  1972,  and
                    (2)  a minimum merit raise  (5%) has been included on all filled personnel
                    positions.
                    The  following is  a list of the Core staff members  of  the AR@IP including
                    the staff utilized in  the Core Subregionalization Program.


                  Alabama RMP                                  -13-        RM     28-03 (AR-1-CSD) 2/71

                                                                                             % Hours
                  Name                      Job Title or Function                        Time    or Effort
               (Basic)
                  V. Buryn                  Budget     Analyst                                 100
                  C. Calvert                Secretary                                          100
                  C. Crooks                 Adminis. Secretary                                 100
                  D  Cusic                  Assoc. Dir. Planning                               100
                  J: Finney, M.D.           Assoc. Dir  0 . Prof. Liaison                      63
                  J. Gillespie              Ass't Dir. Operations                              100
                  L. Gilmore                Assoc. Dir. Education                              100
                  W. Green                  Secretary                                          30
                  D. Hall                   Secretary                                          100
                  I. Harper                 Secretary                                          50
                  R. Hernandez              Resident & Staff Ass't                             75
                  M. Hunt                   Research    Assoc.                                 33
                  S. Johnson                Secretary                                          33
                  C. Joiner,   Ph.D.        Research Analyst Advisor                           30
                  M. Klapper, M.D.          Con't Med. I?duca. Advisor                         10
                  A. Lamb                   Adm. Ass't l@nnifly Serv.                          100
                  M. Lee                    Ass't Director Nursing                             100
                  M. mccool                 Secretary                                          20
                  P. Osborn                 Senior Secretary                                   100
                  J. Packard, M.D.          Director ARMP                                      100
                  D. Patterson              Acting Assoc. Dir. Eval.                           100
                  J. Pigman                 Research Analyst                                   80
                  MO Plowden, LLB           Deputy    Director                                 100
                  D. Prince                 Ass't Dir. Graphic Arts                            100
                  I. Reed                   Coord. Comm Res. & Dev.                            100
                  J. Robertson              Assoc. Dir. Prog. Mgt.                             ioo
                  H. Schnaper,    M.D.      Ass't Dir. Heart & Stroke                          25
                  S. Sentell                Secretary                                          100
                  R. Shaw                   Administrative Ass't                               100
                  'I'. Sheehy, M.D.         Medical    Service                                 10
                  L. Sheffield, M.D.        Medical    Service                                 10
                  L. Shield                 Secretary                                          loo
                  E4 Sigler                 Secretary                                          100
                  G. Slattery               Senior Secretary                                   100
                  r4. Snow                  Senior Secretary                                   1.00
                  .J. Watson                Ass't I)ir. Commtjnicntioi-is                      100
                  C. Whitman                Secretary                                          100
                  TBA                       Program Dev. & Eval. Spec.                         100
                  TBA                          it                                              100
                  TBA                       Secretary                                          60
                  L. Wilson                 Secretary                                          50
               (S-(.ibregionalization)
                  C.',,. Porter, w4.D.      Director Medical Education                         50
                  D. Carter, Adm.           Health    Planner                                  100
                  G. Mosley, Adm.           Adm.     Assistant                                 100
                  J. Brown, MHA             Health    Planner                                  100
                  M. Payne                  Secretary                                          100
                  W. Moore, MHA             Health    Planner                                  100
                  G. Calhoun                Secretary                                          100
                  E. Cleino,  Ed.   D.      Health    Planner                                  100
                  P. Culley                 Health    Planner                                  100
                  A. Rohling                Health    Planner                                  100
                  TBA (2)                   Health    Planners                                 inn


              Alabama RMP                         -14-         RM 28-.03 (AR-1-CSD) 2/71
              The day-to-day operation of the ARMP  activities  are  supervised  by  the
              Director John Packard, M,.D. and the Deputy Director M. D. Plowden.
              The Corelstaff of the ARMP is quite  involved  in  project  development,
              implementation and monitoring of  activities  supported  by  the  ARMP.  These
              activities of Core in relationship to  project  are  clearly  identified
              in section III-B page 43 of this application.

              PROJECT REVIEW PROCESS
              The Region indicates that the project  review  mechanism  at  the  Alabama
              Regional Medical Program is presently undergoing some positive changes.
              The program is placing u!ore emphasis on the following: (1) Crystallization
              of policy and initiative upward rnther  than  being  imposed  from  above;
              (2) There is maximum participation by the  voluntary  and  private  sector  at
              the grass roots level.
              The feeling at Alabama Regional Medical Program is that consumers must
              play a stronger part in establishing policy and making major decisions
              effecting the delivery of health care and determining the needs in
              the community in which they live.
              The ARMP indicates that project proposals  originate  from  a  variety  of
              sources and from many sectors within the region.  Assistance in project
              design and evaluation, methodology is provided by Core staff elements.
              If the proposal originates from a subregion with a functional area
              Advisory Group and is applicable to that  region,  it  is  reviewed  and
              approved by the area Advisory Group before  submission  to  ARMP  in  su
                                                                                     mmary
              form with a tentative  budget.  The  concerned  County  Medical  Society (ies)
              review all project proposals prior to submission to ARMP.
              Upon receipt, the AIOIP Core staff reviews  proposals  to  assure  conformance
              with overall program  objectives  nnd  provides  initial  administrative
              screening.  At this time the Medical Association of the State of Alabama
              and their Board of Censors are Informed.  The region identifies a checklist
              form which is on page 17 of Section ITI-I@ that will be utilized during
              the 1971 fiscal year by tile ARM]' staff for review of I)ro.ject proposals.
              Under the coordination of the Core gtaff,projcct  proposals  @ire  retired
              to  the following standing committees:
                  (1) To the Categorical  Committee  for  professional  and  scientific
                     review.
                  (2) Project Review Committee  -  for  technical  review,  feasibility
                     determination and for delineation of evaluation mechanism    '
                     This committee may also  measure  the  project  proposal  against
                     the regional framework or planning matrix of the Region.
                  (3) Sponsor Review Committee - This committee for the grantee
                     institution reviews the proposal to assure conformance with
                     University fiscal policy  and  procedure  and  coordination  with
                     existing efforts of plans of  the  university  in  related  fields.
              The APJIP Core staff is responsible for coordination of all planning and
              operational activities with  the  Comprehensive  State  Health  Planning


                Alabama RMP                            -15-       RM  28-03  (AR-1-CSD)  2/71

                Agency (PL 89-749) and other major planning  groups  in  the  region  such  as;
                CHP (b) Agencies,  Appalachian  Regional  Health  Planning  Commission,  etc.
                The Comprehensive Health Planning Agencies (both  (a)  and  (b))  as  well  as
                the Appalachian Regional  Health  Planning  Commission  Review  and  comment
                on ARMP projects before submission to the RAG.

                Favorably considered proposals are then  presented  to  the  RAG  for  final
                review and approval or disapproval action or disapproval action.  A checklist
                form has been developed for utilization by  the  RAG  in  their  review  of
                projects.  This form can be seen in section III-D Page 19 of the application.

                ANNUAT REPORT OF THE REGIONAL ADVISORY GROUP    @G

                The RAG identifies in its  report  the  following  Regional  objectives  which
                were modified in Jurel970:  (1)  to  increase  and  improve  total  community
                involvement in both the problems in modern health care and their potential
                solution; (2) to stimulate and support  the  creation  of  new  health  service
                manpower and to  improve  their  distribution  and  utilization  throughout
                the region- (3) to provide remedial and continuing education for the entire
                health service team in relevant categories.

                The RAG indicates that progress toward each of these objectives is essential
                to viability of ARMP and its service to  the  people  of  Alabama,  but  first
                priority must go to that area where the need is demonstrativel)lgreat, long-
                range benefits are likely to be  most  important  when  there  is  community
                involvement  achieved  througisubregionalization,  liaison,  and  promotion  of
                cooperative  arrangements.  The  RMPS  has  characterized  its  relationship
                with Comprehensive Health Planning as outstanding.  Individual RAG members
                and Core personnel are continuing  to  work  toward  even  more  effective
              arrangements with CHP, and at  the  same  time  are  developing  support  and
                cooperation involving many  other  organizations  concerned  with  hea  th.

                The RAG explains that subregionalization  is  the  key  mechanism  W-iere  y
                total community  involvement  and  cooperation  may  be  accomplished.  They
                indicate that this is  progressing  well  with  area  offices  established
                and competently manned In five  of  the  subregions,  with  prospects  good
                for early establishment  of  the  remaining  offices  despite  reorganization
                of the region to increase the  number  from  seven  to  eight  subregions,
                conforming to the  planning  and  development  districts  recently  established
                by the Governor of Alabama.  They explain that subregionalization facilitates
                continuing development of cooperative arrangements with the Medical Associa-
                tion of the state of Alabama,  the  Alabama  Heart  Association,  the  Alabama
                Charpter of the American Cancer Society, the Alabama Hospital Association,
                and may other  state,  professional,  and  voluntary  health  organizations.
                They believe that subregionalization  is  an  important  means  for  pursuit
                of all program goals because it functions  at  the  "grass  roots"  level  and
                enables close contact with  the  consumer.  Tn  order  to  increase  still
                further the communication with the subregions, the IIA(; at the  Ttii-ie  1970
                meeting voted to increase its membership from  40  to  60  by  adding  two
                consumers for each of the  subregions  and  additional  members  at  large.


             Alabama RMP                            -16-         Rm  28-03  (AR-1-CSD)   2/71

             Through representation on the RAG  and  through  the  plannned  eff:ort  of
             staff, virtually all significant health-oriented organizations have
             effective liaison  with  ARMP.  This  is  accomplished  at  state-wide  and to
             an increasing     extent,  at  county  and  local  levels.  Core  personnel
             include an Associate Director for Professional Liaison, Dr. J. 0. Finney,Sr.,
             and a Community Service and Development Office, staffed by Miss I. M. Reed.
             In addition.core staff members  are  active  in  a  variety  of  professional
             associations.

             The secondARMP objective improvment  in  supply  and  use  of  health  manpower
             has been pursued by  initiating  projects  such  as  the  medical  information
             service by telephone, nursing utilization studies and a state-wide coopera-
             tive mechanism involving  the  states  junior  colleges  and  the  Regional
             Technical  Institut6  in  training  allied  health  personnel.  In  addition,
             ARMP has supported development of the Division of Family Practice and
             Ambulatory Medicine at  the  School  of  Medicine,  training  programs  various
             types of assistance and  exposure  of  medical  school  faculty  and  students
             to community  hospitals.  The  l@G  indicates  that  health  career  recruitment
             also is an objective of ARMP effort directed toward the goal of
             alleviating serious  health  manpower  shortage  in  Alabama.  The  staff  of
             the ARMP has invested many hours with the Health Careers Council of
             Alabama, the  Alabama  Hospital  Association,  and  other  groups  developing
             ways to  educate  career  guidance  councilors  concerning  health  careers
             an to irect the  attention  of  young  people  to  the  satisfaction  of  work
             in the health field.

             Work toward the third  objective to provide remedial continuing        education
             has been approached  through  continuing  medical  education  which  has  been
             the primary     objective of several  ARMP  projects  and  an  important  aspect
             of several others.  A  RAG  committee  is  concerned  with  a  supplemental
             education and a staff member devotes full time to regional and subregional
             educational programs  and  educational  consultant  services  in  the  health
             field. The ARMP cooperates  with  the  UAB  School  of  Medicines  Division  of
             Continuing Medical Education  and  with  the  Medical  Association  of  the
             State of  Alabima  to  provide  educational  services.  Audiovisual  and  other
             educational materials are available  through  ARMP  and  more  will  be  offered
             as they become available.

                 @AC- explains that a significant  but  lower  priority  aspect  of  the
             A@-l-'-P t.tirust which requires, nevertheless, a good proportion of  staff
             time and effort, is consulting  and resource services.  Here again an
             important function of the program is as a catalyst, to encourage cooperation
             among various agencies and to force their activities by others for
             improvements in both the nature and availability of health care.

             Position papers for Comprehensive Health Planning, consultation on
             Appalachian Regional Health Planning Commission Projects, provision
             of Audiovisual  materials  in  guidance  in  health  curricular  technology
             are examples of this service.

             The Regional Advisory Group indicates that they had much difficulty


                 Alabama Rt4P                             -17-       RM 28-03 (AR-1-CSD)  2/71

                 in setting priorities within a  specific  program  area  and  even  greater
                 difficulty in setting  priorities  between  program  areas.  The  RAG  has
                 however, submitted a priority listing  of  projects  which  is  located  in
                 Section II page 7 of the application.

                 The ARMP indicates that  formal  endorsements  and  letters  of  support
                 have been given to the ARMP from all major health organizations within
                 the region.  They claim excellent rapport exists between the ARMP and the
                 other two large Federal health  planning  programs  within  the  region  -
                 Comprehensive Health Planning and the Appalachian Regional Commission.
                 In addition to joint sharing of staff with  the  State  CIIP  Office  In
                 Montgomery, an(] the Appalachian Regional Commission  In  Decatil,ir,  the
                 recently funded stibreglonnllzatloii program provides a health pl.anner In
                 each of the seven subregions In titi(, State who are responsible for
                 assisting In the development and Inltlntlon of a 314 (b) agency for his
                 subregion.
                 The RAG indicates that one of the most serious challenges facing Alabama
                 today is how to provide medical services  to  poor  people  in  both  t  e
                 rural and urban  areas  of  the  State.  They  identify  subregio6alization
                 as an activity which concentrates attention at the site of the problems
                 in health care for the poor.  The Alabama Regional Medical Program  as
                 been instrumental in setting up  the  Lawrence  County  Project,  which  is
                 about to get under way with the Appalachian Commission,and to some extent,
                 Blue Cross funds. ARMP  will  be  a  consultant  for  this  project  which
                 emphasizes ambulatory care.  A  nutrition  project  aimed  at  areas  of
                 national priorities Including Decat4'i'r has been  submitted  and  approved
                 and plans are to implement it by April. 1, 1971.
                    RA(; explains halt although health needs of the  poor  i.n  AlibirriA
                 are indisputably seri,otis, specif'ic ,it,,itistics are not available to
                 document those needs.        basic information Is being gathered, however,
                 on a county by  county  bnsis  by  several  organizations  in  cooperation
                 with APMP,  The data will be available to ARMI) foe analysis in rel.ation
                 to Income levels and other factors and will be a valuable guide in the
                 development of future projects.
                 Two areas which the RAG indentifies as ready for early consideration in
                 developing activities that would  be  beneficial  to  the  poor  are:  (1)
                 extending hours  of  patient  clinics,  and  (2)  providing  transportation
                 to clinics for the poor people.
                 The RAG believes that the ARMP  has  made  a  significant  impact  on  the
                 delivery of health care to victims of heart disease, stroke, cancer and
                 related diseases during its first year of operation.  The ARMP is largely
                 responsible for preparing a statewide plan for the management of cancer.

                 PROGRAM EVALU)VI"f.ON:
                 The Alabama Regional Medical Program recently instituted a systematic
                 and  fndepth evaluation of all projects.  Continuous evaluation of projects
                 will be the responsibility of a full-time acting associate director for


                                                              RM 28-03 (AR-1-CSD) 2/71
            Alabama RMP                           -18

                                                       1, 1970,  In addition to his
            evaluation who was hired by ARMP on June
            employment, a number of-other significant  developments  Occurred  in  the,
           .area of evaluation of ARMP projects during the past year.
            Some of these are the following:

                1.  The development of a written statement of  the  evaluation  process
                    and an evaluation model to be applied to Alabama RMP projects.
                2.  A similar development of the concept of evaluation as an integral
                    part of project management. Evaluation is not  an  end  in  itself,
                    but it is regarded as means to improve the effectiveness of
                    project management.
                3.  The development of the concept of the positive contributions of an
                    evaluation process. The positive  contributions  will  be  stressed
                    by project directors.  In addition to the necessary function of
                    determining how well goals and objectives are being met, evaluation
                    of ARMP projects will be used tp permit early determination of
                    serious departures from goal directed action, to disclose unrealized
                    opportunities and to provide the basis for public or institutional
                    support for projects.
                4.  The upgrading of the evaluation skills of the ARMP Staff throuw,'ri
                    the attendance at conference, meetings with key individuals at
                    the national,regional and local levels and through other means.
                5.  Prelimary planning for program evaluation.
                    The evaluation process used for ARMP projects consist of six steps.
                    Following is a chart which illustrates the steps in the evaluation
                    process which has been developed by this Region:


                                                                       RM @8-03 (AR-1-CSD) Ltli
               Alabama mmkl                         -19-
                                                 C@IART 1

                                                   -i'ION PROCESS
                                              EVALUA

                                                   -4 o,- P,-,ojc(,,,r GOALS
                                        ERP-,A]@@IATICj       t-                           Step No. 1
                                             (Broar-I S;"14L."-'ITiOi-ItS)

                                   DERIVAI-ION O'f- PF,,Oj"L:Cl' OBJECTIVES
                                           F,-, 0 i%4 P,'-IO J'7- %-,T GOALS               Stei No. 2

                                    DETEP,i'.,'-Iil']ATIO4@ O'- P@@--A@)URES OF
                                          O[),,.JECI'IV'r_- A-i"I'AIN@ili-:NT              St"@ NO. 3

                                                    ',JT OF STANDAriDS
                                      ESTAI',LIS@IM,Ei
                                                                                           Step No.
                                     (in terms of        At-t:lli;iment stated
                                                   tiiiits-co,,'t-b@iiefit ratios,
                                                                   etc.)

                                                       '4 07
                                           COL.LECT10i     - DATA
                                             ON PEPFOrl@AANCE                              Step No. 5

                                      COMPARISON 0-r NO. -A, A@-ID NO. 5                   Step No. 6
                                              (Actiial vs. Dc.,iirecl)

                SATISFACTORY                                      UNSATISFACTORY

                                                 Pvlorlif-I No. 2
                          Satisfactory           rncllrjr Nc). 4      lrnprove
                                                                     Efficiency          Reconiroie,-@d
           Continue      Con-clusio,-i of                           (in,3ff icient     Discontinu-,),ic,3
                            Project              object or        us-. of rpsources)


              Alabama RMP                             -20-         RM  28-03  (AR-1-CSD)  2/71

              Overall evaluation  strategy  is  continually  being  developed  and  improved
              upon by the A104P.  Changes in project development are taking place
              (that are in  objectives,  that  are  measurable  for  effective  evaluation)
              because of improvement in evaluation techniques.  It is Indicated in the
              application that evaluation is important in ARMP because of the management
              control it provides for funded projects.  The Region believes that effective
              evaluation techniques will improve project development, increase control
              over funded projects, and lead to a more sophisticated program.

              DEVELOPMENTAT COMPONENT

              The ARMP has requested three years support for a developmental component
              at an annual level of $100,000.

              The Region explains that the plan for utilization of developmental component
              funds will be based on  two  principles:  1)  close  control  and  involvement
              of the RAG in seeking improvement  in  the  quality  and  delivery  of  health
              services, and  2)  rapid  implementation  of  worthy  proposals.  Thus,  the
              participation of RAG members should  be  maintained  at  a  high  level,  and the
              loss of interest on the part  of  the  proposer  -  sometimes  causing  apathy
              or occasionally antipathy  now  experienced  with  the  present  project  review
              mechanism, should be avoided.

              The AP14P proposes a two-step  review  procedure  for  requests  submitted  to
              them for developmental funds.  First, one of the RAG categorical committees,
              if appropriate, will assign  priority  rating  to  the  proposal,  in  reference
              to the goals of  the  specific  category.  Second,  the  final  decision  on
              each expenditure will be made by a developmental component committee
              consisting of two RAG members, one of whom must be a member of the
              Executive Committee, and will  act  as  Chairman;  a  representative  of  the
              Office of Grants Management  of  the  University  of  Alabama  in  Birmingham;
              the Director, Deputy  Director,  and  Associate  Directors  for  Planning  and
              Program Development and for Program Management of ARMP.

              In case of doubt on the  part  of  Development  Component  Committee  as  to
              the appropriateness or level of funding request, a proposal will be
              referred to the Executive Committee for recommendation with final
              action determined by the RAG.

              In all cases, RAG will approve the expenditure of funds of the
              developmental component at the first opportunity and will forward to
              F14PS a summary of ttie proposal, a description of its developmental review,
              in relationship to area wide  ARMP priorities.

              The Region indicates  that  the  availability  of  the  developmental  component
              will strengthen inmeasureably the Implementation of their subregionalization.
              It is proposed to retain approximately  75%  of  those  funds  for  ARMP  to
              use for funding proposals which  have  a  regional  wide  impact,  similar  to
              the study to determine the need  for,  acceptance  of,  and  best  method  to
              implement  statewide  dosimetry  for  radiotherapy  cancer,  which  resulted
              in Project #27 being submitted in  this  application.  The  remaining  25'7.,
              of the funds will be a apportioned to each of the eight subregions.
              I%Illile the RAG and the Core staff will not define for each subregion,            .,:,,-; @%

                                                                                                     I


               Alabama RMP                          -21-           RM 28-03 (AR-1-CSD) 2/71

               the procedures to be used in determining  subregional  needs,  assign
               priorities, or propose review mechansisms, it will  assure  that  the
               subregion has developed an acceptable procedure  and  that  proposals
               for funding have been approved by the Area  Advisory  Group(AAG)  before
               submission to the Developmental  Component  Committee.  Core  staff
               consultation and advise will be available,  especially  during  the
               formation months of the Area Advisory Groups, and  assistance  will  be
               given in project development if the proposal  warrants  such  action.
               Should subregions not submit acceptable -,Droposals, funds will  be
               distributed by RAG as they see fit.

               'Ff)e region sees many advnntages to tli(., iil.loc@iti,on of funds to each
               subregion, such As the fo[ ow ng examples

                  (a)  For the "mature" subregion, such as tile five counties in  tile
                       Birmingham area served by an approved and funded  314  (b)  agency
                       which has published a list of needs and  priorities,  and  which
                       has an effective project review  mechanism  for  implementation
                       studies or projects for which funds are anticipated  but  not  yet
                       received, and for activities which are  desirable  but  not
                       fundable by other agencies and which could  be  conducted  with
                       such a small expenditure that formal project is not justified.
                       Top priority in this subregion is improvement in health services
                       to the poor.

                   (b) For the subregions which have been organized and staffed (Northeast,
                       Southeast, Northwest, Mobile, and Montgomery),  these  funds  should
                       expedite the process of assessing needs,  setting  priorities  and
                       developing a decision-making routine, should  overcome  any  feeling
                       that deserved support has not been forthcoming, and  will  help  the
                       RA(; and core staff communicate ARMP goals, priorities and
                       accomplishments to the subregions so that a better perspective
                       is obtained.  Also, we hope such funds will make the planning process
                       more fruitful. For example, one subregion has submitted a proposal
                       to study the need and cost of providing hemodialysis service for
                       the area.  No evidence is submitted to show this is a high priority
                       item for the area, nor that It has been reviewed by  the  local  314
                       (b) agency.  The budget seems higher than necessary.  Local
                       determination of the best way to spend limited  funds  might  we
                       result in a different or less expensive proposal.

                  (c)  For the Tennessee Valley subregion, which has not  yet  found  a
                       common ground on which an areawide health  planning  advisory  group
                       (AAG) call be formed, and for the newly created  Selma  district
                       which has not had time to organize, the funds in ad ition to t e
                       available salary Developmental Component from persons In these
                       areas will not be considered until an areawide  idvisory  group  has
                       been formed and found acceptable to  ARMP.  Although  these  funds
                       combined will be less than $30,000, even  smaller  amounts  have
                       proved to be an effective lever in the  formation  ofcther  Areawide
                       groups. If, in addition, the  available  funds  are  diminished
                       quarterly until an acceptable AAG is formed, the  incentive  may  be
                       greater.


             Alabama RMP                               -22-       RM  28-03  (AR-1-CSD)  2/71

             The reg ion explained that they cannot overemphasize  the  value  of  bei  g
                                                                                       n
             able to spend limited amounts of money  in  actions  which  have  high  local
             priority and which are Compatible with  the  objectives  and  goals  of  ARMP.
             This true decentralization allows  local  citizens  to  determine  needs,  and
             the availability of funds  to  implement  approved  proposals  without  many
             months delay which in turn  will  sharpen  the  priority-setting  mechanism  and
             insure more active and interested participation.

             As ARMP reviews the proposals from the subregions,  it  will  give  RAG  a
             clearer constantly updated view  of  local  resources,  needs,  and  priorities,
             and will enable Core staff  to  disseminate  (inovative)  and  functional  ideas
             to other subregions.

             TheRAGheartily supports  this  concept  of  the  developmental  component.

             SUUPLEMENTAL PROJECTS:
                                                                                  First Year
             Project ik27 - Regional Radiation Therapy Cooperative Treatment      Request
                            Planning and Dosimetry Project.     Through the       $122,791
             Llniversity of Alabama Cancer Research and Training Program this
             project proposes to provide an accurate  systematic  and  rapid  means  to
             determine readiation dosage  through  a  computer-telephone  system  and
             through expert personal consultation  visits  to  the  requesting  site.
             In addition, a physics support  system  is  provided  through  on-site
             consultation.  This provides advice and technical expertise to
             determine accurate radiation output.

             It is explained that this is a  regional  project,  and  Initially  will
             provide services  to  seven  geographically  distributed  hospitals  through-
             out the state and will  serve  patients  throughout  the  region.  The
             project will provide through personal consultation another excellent
             medium for on-site continuing education,  which  will  occur  through  the
             consultative process.

             It is explained that the ARMP goals  and  objectives  are  enhance  by  t  is
             project and that the Core intent  is  to  disseminate  advanced  medical
             knowledge to the local practitioner.

             In the priority rating of projects  the  region  has  ranked  this  activity
             as their eighth priority item.

                   Second Year:  $167,587              Third Year:  -0-

                                                                              I-'ir.,;t Yeiii-
             Project #28 - Continuing Medical I-'dtication within the         Regiiest
                            Office of the Medical Association of the            $73,034
             '@tate of Alabama.   The purpose of this project is to
             develop an office of continuing medical education with the @ledicil
             Association of the state of Alabama.  Since this association is,in
             essence, the voice of the  Alabama  physicians,  this  project  is  designed
             to identify and be responsive to  the  continuing  education  needs  of  these
             health professionals.  The  new  and  creative  instructional  strategy  will
             be explored in conjunction with ARMP  and  the  Division  of  Continuing
             Education at the School of Medicine.


              Alabama RMP                        -23-           RM 28-03 (AR-1-CSD) 2/71

              The Comprehensive l@lealth Planning Agency for the  Birminham  area
              stated that the project represents  a  constructive  approach  to
              Continuing Medical Education for Physicians within the state of Alabama
              with the anticipated results of improving  health  care  for  the
              citizens of Alabama.

              The ARMP indicates that thi-s project will  further  strenthen  the
              relationship between the School of  Medicine,  Medical  Association  of
              the State of Alabama, the Regional Medical Program and participating
              community hospitals.

              The Region in its priority rating of F)ro'ec@t.,,i his i-,Ii)ked this Ictivity
              13th as a priority Item.

                          Second Year: $75,806           Third  Year:   $81,929

              Project #29 - Improving the Life of the Ostomate.               First Year
                            This project proposal is essentially a             Request
              continuing education program for Allied Realti) Profes-         $21,130
              sionals and supportive hospital staff and concerns the
              physical and emotional care to be provided to the ostomate.
              The purpose follows closely the ARMP objectives of improving patient
              care through continuing education endeavors.

              It is to be implemented through  physicians,  a  registered  nurse,
              and ostomotherapists who will  provide  continuing  education  programs
              for health manpower within the region.  In addition,clinical instruction
              to ostomates will be provided and will concern areas of physical
              management of ostomies.  'I'Iiis patient tlierapist's interaction will
              lead to a close interpersonal environment so that the eiiterostomal
              therapists can provide vitally needed emotional @,tippol-t for these
              Individuals.  The long term gains of the proposal wll.'I. be the establish-
              ment of a program to train enterostomal therapist  for  the  region.

              This project in the regions priority rating of  projects  Is  ranked
              20th as a priority i.tein.

                     Second Year:  $25,304              Third   Year:   $26,217

              Project #30 -  Intermediate Coronary Care (Jnit Instruction  --      First Year
                             Mobile, Alabama. The 13kirpose of  thi.s  proposal     Request
              is to reduce the hospital mortality of the newly discharged           $72,535
              coronary care unit patient by providing  a  mobile  infirmary,  a
              training program for hospital staffs and the teci)[Ii-CiLie.9 of
              intermediate coronary care.   These t(!cliiil.(Ities Are based upon @i
              firm understanding of CCIJ procedure as well as social  "(Encounter"
              or sensitivity training sessions.

              The culmination of training ,.ind mobile Infirmary wi-11 be realize
              in health manpower who are  both  technically  and  psychologically
              prepared to care for the coronary care patients.  The region
              explains that this proposal is compatible  with  ARMP  goals  and


             Alabama RMP                            -24-         RM 28-02  (AR-1-CSD)  2/71

             ob4ectives and that advanced knowledge is disseminated locally,
             manpower will be developed, and improvement in the care of the
             coronary patient will be realized.

             In the regions priority  rating  of  projects  this  component  ranked
             21st as a priority item.

                     ,Second Year:  $62,794
                                                                                  First Year
             Project #31 - Physicians Assistant.  Alabama is very short of          Request
                            physicians.  There are many areas in the state        $206,781
             where physician availability and accessibility le, critical or
             non-existent. For example, in  one  county  with  the  region  with  over
             10,000 population there are no physicians, and in other county there
             are three physicians for a population under 30,000.

             Through the provision of the physicians assistant training program at
             the University of  Alabama,  Birminham,  this  proposal  represents  a
             viable step in increasing the  availability  of  medical  care  in  "physician
             poor" areas.  It is compatible with the ARMP goal of "facilitating the
             delivery of health care" and enhances an ARMP objective of "stimulating
             and supporting the creation of new service manpower' to be available
             for distribution in areas of critical need.

             T@ii.s project in the regions priority listing of projects is ranked
             second as a priority item.

                     .second Year:  $210,726           'I'Iii.rd Year:  $221,034

             Pro-'ect 2@34 - Closed Chest Cardiopulmonary Resuscitation          First Year
                            Program.  The purpose of this proposal is             Request
             to increase the accessibility of knowledge in CCCR in the            $93@480
             region by providing to Alabama Ileart Association field
             directors the necessary assistance required for them to perform      t  e
             following  task.
                 (1) Facilitating the establishment of  a  CPR  Committee  in  each
                     hospitals which will provide a "Core" for inservice education
                     for CPR training.
                (2)  Facilitating the establishment of CIIR  teams  In  each  hospital
                     which will be responsible for idiniiiistering, (;Ill@ techniques
                     in cardiac arrest- crisis on a 24 hour basis.

             'r@ie region explains that cil.-3seminition of idvinced ]Knowledge 19 I
             primary objective of the Alab,3in;i l@(@illoiial Medical Ili-o@,,i-am and that
             trils proposal is compatible with this objective.

             In the regions priority listing  of  projects  this  activity  is  ranked
             fourth as a priority item.

                     Second Year: $60,791


               Alabama RMP                             -25-         RM 28-03 (AR-1-CSD) 2/71

               Project  #35  -  Northwest  Florida  and  Southwest   Alabama       First   Year
                              @S   itals   Coordinated   Services   Program.       Re4uest
               The  Coordinated  Services  Program  has   been   operational       $37,830
               on  a  limited  basis  in  Northwest  Florida  and  Southwest
               Alabama for one year.  The program is designed to enable member
               hospitals to effect economy, increase patient services to share in
               health  manpower  and  to  provide  continuing   education   for   institutional
               manpower.  Several accomplishments have been realized in the short
               one-year  period.  For  example,   through   coordination   and   cooperation,
               an  x-ray  company  has  reduced  prices  for  participating   hospitals.
               Arrangements  have  been  made  with  housekeeping  companies  to   serve
               some  of  the  smaller  member  hospitals  when  previously  the  company
               would not serve hospitals of under 100 beds.  This type of action has
               resulted in t cost savings in,  tl)ose  hospitals  and  has  provided  ftiridi
               for education.

               In Malay of 1.970, tl)i.@ project was reviewed by the  IZMPS  Site  Visit
               It appeared that the team was favorably Impressed with the scope of
               the proposals since they encouraged that it be submitted.

               This proposal is compatible with ARMP goals and objectives in that
               remedial and continuing education is provided for the health services
               team and that  there  is  a  lowering  of  patient  costs  with  an  improvement
               in 'Services incorporated within the program.

               In the  regions  priority  rating  of  projects  this  project  is  ranked  #5
               As a priority item.

                       second Year:  $27,107               'I'Iiird Year:  $16,080
                                                                                         l,'l r.9 L Ye.@j r
               Project /@36 -  Instrtictioiiil 1'roi(.!ct In        Care   -              l@(!fltles t
                              't',illa(lega C(-)tinLX.  The purpose of Lliis project lq     $57,068
               to reduce hospital death due to heart disease I-liroti@!,Ii  ,]  two-fold
               approach  to  improve  the  care  of  patients  In  Sylacauga,  Talladega
               Coiinty, and other counties adjacent to Talladega County.         The   two-fold
               approach  concerns  provision  of  Coronary  Care  Educational  llrogram   and
               a (coronary Care unit teaching facility.

               This  program  Is  regarded  to  be  compatible  with  ARMP  objectives   concerning
               continuing education and development of health manpower.  This region
               has not had  this  type  of  educational  program  in  a  rural  setting.

               In the regions priority listing of the projects this activity is ranked
               19th as a priority item.

                        Second Year:  $25,153
                                                                                         l,'i r a t Y ei i,
               Project #37              the li(I ol I"' Lij(@ l,iceii,4(@(i I"-kiet fell II ", (@ (I t I es t
                                Nurse.  The region explains that In essence                 $70,307
               the li.fe of the lincensed practical ntirse has been "boxed in"
               by educational and personnel career "deadends."  This proposal
   0


              Alabama RMP                              -26-         RM 28-03 (AR-1-CSD) 2/71

              is a new and innovative approach to "taking the lid off" for this health
              worker. It is the first  approach  by  the  Regional  Medical  Program  to
              lend support to closing the knowledge gap between the LPN and RN by more
              formal, but needed and  innovative  approach  to  the  LPNs  continuing
              education.

              Recent studies indicate that 1,232  (20.8%)  of  the  -states  licensed
              practical nurses  practice  in  this  area.  Furthermore,  this  nurse
              population exhibits a younger age and  less  career  ability  due  to  the
              unavailability of instruction  courses  leading  to  an  Associate  Degree
              liilr,.qfng Program for the vocational school I.PN graduates.  M@iny
              interested groups in the state  have  expressed  a  great  interest  In
              developing an education program  that  would  allow  college  credit  for
              their vocational  training  as  licensed  practical  nurses.  By  allowing
              this college credit, vertical  mobility  to  become  a  registered  nurse
              from a junior college program is facilitated.

              This effort provides a  demonstration  for  the  region  in  producing
              a type of manpower drawn from a new source.  It will stimulate
              the establishment of  a  regular  associate  degree  nursing  program
              to insure a continuing pool  of  registered  nurses  in  this  community.

              In the regions priority listing of projects this project is ranked
              10th as a priority item.

                    Second Year:  $65,150                 Third Year:  $70,215
                                                                                  First Year
              Project #38 - Continuing ]education In 1',Iindness Ilrevention..    T@egliest
                            'I'lie region explains that In 1960 the estimated      $44,996
              number of legally bl.Ind In the linited  States  was  385,000.  I'his
              figure represents  a  prevalence  rate  of  2.14/1,000  population.  rn
              the 1960 study, Alabama was the fifth highest ranking state with a
              Prevalence rate of 3.08/1,000  or  10,000  cases  of  legal  blindness.
              Alabama is again ranked number 5 in  the  United  States  with  an  incidence
              rate of 20.7/100,000 (680 new cases).

              7'he region explains that preventive measures directed at the cii-ty
              detection and treatment of the four major causes of blfi-idiiess((,'Iaticoma,
              Diabetes, Senial  Cataract  and  Vascular  Diseases)  can  potentially
              produce a 51.4/, reduction or delay in  the  incidence  of  blindness  In
              the United States.

              I'herefore, the purpose of this project is to upgrade through a program
              of continuing edtication,tlie knowledge and  skills  of  the  optometrist
              of Alabama In the detection ind Identification of potentially blinding
              conditions.  Noting that  vascular  diseases  and  diabetes  are  among
              the leading causes of blindness,  the  purpose  of  this  project  Is
              compatible with ARNII objectives.

              'I'lifs project In the regions priority listing of projects is  ranked  Iltli
              as a priority item.

                   Second Year:   $42,496                 I'lilrd Year:  $42,496


              Alabama RMP                       -27-          RM 28-03 (AR-1-CSD) 2/71

              RENEWAL REQUEST:
                                                                                  First Year
              Project #4R - Health Manpower in Junior Colleges.  This  project    Request
                            is submitted to continue to improve the quality        $76,974
              of health care in the region by assisting the Jr. Colleges in
              attracting and holding qualified faculty, to continue to  maintain
              and demonstrate innovative and creative health education  programs,
              and to increase the supply of and to improve the education of selected
              kinds of health manpower.

              This program has enjoyed some success and some  failures.  Some
              difficulty has been experienced In recruiting and retraining  faculty
              members. The evaluators contributed much of this to  the  accute
              shortage of qualified nursing faculty In Alabama and to the instability
              often inherent in a young and rapidly expanding institution.

              All faculty positionshave now been filled for the fourth  quarter,
              including a qualified instructor for medical records  technology.
              A nursing curriculum has been developed which incorporates a number
              of innovative features4 The Jefferson State College  is  designated
              as the logical institution to assume an administrative role  in
              the development of such a curriculum at the Jr. College  level.

              This program was designed to appeal to older students, to male  and
              black students. The percentage of students over 30 years  of  age
              in the program does indicate its attraction to the older  student.
              The percentage of black students is increasing and is significantly
              higher than the state average for nursing program.

              A total of 86 students have graduated from the nursing program  and
              another 105 are enrolled in the summer quarter, a doub ing of t  e
              number of students enrolled within the two-year period seems to be  a
              realistic objective.

              In the regions priority rating of projects this project is  ranked
              number one as a priority item.

                    Second Year:   $80,737            Third Year:  $84,686
                                                                                   First Year
              Project #5R - Training Program - Reality Orientation  Techniques.     Pegliest
                            This application requests renewal for  continuation     S96,853
              and expansion of the reality orientation program which has  been
              carried out at the V.A. Hospital, Tusculusa, Alabama, since  April
              1969. This was the first, and to the region's  knowledge  remains
              the only, RMP project physically located in a V.A. Hospital.

              The project provides an educational service through a  training
              program for all levels of health care personnel In Alabama  and
              other states in order to improve the care of patients who are
              confused and disoriented from stroke, arteriosclerotic  disease,
              or other causes.

              The region explains that this project has attracted national  and


            Alabama RMP                          -28-    RM 28-03  (AR-1-CSD)  2/71

            tnternational attention and it has done an outstanding job of training
                                         ma, but throughout the country as evidenced
            personnel, not only in Alaba
            by the evaluation report which is included in appendix 5 of the application.

            The project has improved the utilization of health manpower in Alabama,
            has enhanced the team concept of delivering health care, and has improved
            the care received by individual patients.

            In the regions priority listing of projects this project has been ranked
            16th as a priority item.

                 Second Year:    $91,586             Thi.rd Year:  $93,172

            APPROVED [)NnJNDEI) PROJECTS:

            Project #14 - (,ontinijitig, I-dtication for Medical Laborntoriqj-ls. f,irst Yeir
                          This project proposes to lend assistance to            $48,930
            help personnel who wish to deepen, broaden and update their
            knowledge in skills as they relate to the Medical Laboratory an(]
            thereby assistance in giving better patient care through better
            accuracy in diagnosis.

            The project is consistent with the ARMP overall objective of providing
            retraining and continuing education for the entire health team.  This
            is the kind of specialized effort that the Regional Advisory Grouo
            tees as an essential contribution of the region's only medical school.

            Other funding sources have been carefully explored.  This program for
            continuing education for medical laboratorians  was  discontinued  this
            past year because RMP was unable to fund this project.

            This program was Initiated by the Department of Clinical Pathology
            in the Medical College of Alabama and was funded by the Cronlc Disease
            Control Center for three years ending May 1969. 'I'lie l@egion believes
            that the experience gained and the equipment purchase(] (Hiring the first
            three years of operation will be valuable In the fLittii-e.  ']'lie University
            has developed an excellent base for Continuing Education of Technologists
            which presents an opportunity to expand the offerings to other categories
            of laboratory personnel.  A program in which 100 Medical technologists,
            40 physicians and scientists, and 31 technicians can  be  trained  each
            year is projected.

            In the regions priority listing of projects this project is ranked
            22 as a priority Item.

                   Second Year:  $46,028

            Project #15 - Medical information @',ervice by                  First Year
                         This project was originally submitted In            T?eqtjest
            November of 1968 and the'original budget request was for         $52,451
            97 451 (d.c.).  The project was disapproved by the Division
            of Regional Medical Programs on December 1968.  The project
            was resubmitted by the region in July of 1969.  The Regional


               Alabama RMP                           -29-       RM 28-03 (AR-1-CSD) 2/71

               Medical  Programs  approved  the   project in  December  1969,but  approved
               funding at a level of $52,451.

               The Region initiated a pilot project     In July 1969  by  rebudgeti.ng
               of Core funds.. The acceptance has been  so  great  tliat,,oqdi.tional,
               14ATS Lines and operators@.@have beenlreqtiired, a McBee .9y.q-tem method
               of collating calls has been installed and further employees are needed
               to abstract the tapes.

               The activity Is designed primarily to provide continuing education to
               the  practicing  physicians  through   the mechanism   of   consultation.
               The best teaching opportunity arises at the moment when the practitioner
               encounters a problem or a  question  in  the  course  of  his  day-to-day
               activities in  patient  care.  Person  to  person  consultation  is  made
               available to him by telephone at this instant.  Only when it is
               necessary and appropriate,  reference  will  be  made  to  the  medically
               injured.  However, upon this request the medical school library will
               provide him with a copy of the appropriate article or a Medlars
               Bibliography for reinforcing his learning.

               This project was reviewed by  a  site  visit  team  from  the  Regional
               Medical Programs Service on May 26-27, 1970 at which time the visitors
               encouraged continuation of this activity.

               Tn the regions pri.ority  listing  of  project  components,  this  project
               Is ranked sixth n.,3 a priority item.

               Following are four projects whi.cli were reviewed by the November 1970
               (council.  '['he Af@Ml@' has included these four components as a part of this
               application and has re(Itiested support to Initiate these activities along
               with the other previously approved and unfunded projects.

               The projectsinvolved are as follows:

               Project #23 -  Guidance  Counselor  Continuing  Education  in  the  Health
                              Field. (revision)     In the regions priority listing
               of projects this project is ranked 18th as a priority item.

               Project #24 - Birmingham Community Medical Television Network.
                              Tn the regions priority listing of projects this
               project is ranked 50th as a priority item.

               Project #25 - Production of' Audiovisual. Materials for Real.Ltl
                              Orientation Training Program:  In the regions priority
               listing of projects this project  is  ranked  23rd  as  a  priority  item.

               The Nationals Advisory  Council  recommended  that  additional  funds  be
               provided to the Alabama RMP In the amount of 01-year $246,950,
               02-Year $185,924, 03-Year $127,421 to support projects #23, #25  and
               #26.  Council did not believe that project #24 had sufficient regional
               outreachand recommends that a local source of funds be utilized  to


           Alabama RMP                          -30-       RM 28-03 (AR-1-CSD) 2/71
           support this program if it is considered a priority program by the
           RAG.  The level of fundi-ng requested for Project #24 has been omitted
           from the total requested for approved and unfunded projects in the front
           of this summary.
           Project #26 - Model Cities - RMP Nutrition, Project in Tuskegee.
                         In the region priority listing of projects this project
           is ranked 12th as a priority item.  The Acting Director of Regional
           tiedical Programs@has approved an award for this project utilizing
           @IPS earmarked funds for Model Cities related activities.  The level
           of funding requested for this project has been omitted from the total
           requested for approved and unfunded projects in the front of this summary.

                                                     RMPS/GRB/ 12/31/70


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

            Dal.*: December 21, 1970
         Rtp"v to
          Aitn of.

           Subject: Staff Review of Non-Competing Continuation Application from Alabama,
                 Regional Medical Program, 5 G03 RM 00028.
              To.
                 Acting Director
                 Regional   Medical   Programs    Service

                 Through:    Chairman  of  the   Montli@-

                             Chief, Grants Management Branch
                             Acting Chief, Regional Development Brac@@,@-@
                             Acting Cl-iief, Grants Review Br@irich

                 This  continuation application is a part of the regioti's Triennial
                 Application which reqvest support for the following:  the coiitinLiAtion
                 of two projects an(I a core supplement (sub-regiotializati.on) ($240,000
                 d.c.); renewal of core ($553,061 d.c.); renewal of two projects ($173,827
                 d.c.); activating five approved and unfunded projects; a developmental
                 component ($100,000 d4c.); and for a supplemental grant of ten new
                 projects ($800,852 d.c.).

                 Staff believes that this continuation application should be reviewed
                 as part of the total. Triennial Application, especially the core
                 sub-regionalizati.on when reviewed by Committee and Council.

                 Core Syb-P,(.y                             supplement  was   approved   by   Council
                         _ Ional,izatio.iii  This Coro          p
                 In  March  1970.  It  is  an  activity  which  is  consistent  with   the   original
                 Alabama RtfP proprani objective or deceiiti.-;.il.ization.   The region sees this
                 project as a coalition of their staff functions with major community
                 groups.

                 Staff believes that this program is accomplishing regi.onalization and
                 is coordinating @IP activities with C@IP in the Region.

                 Project #16 and #20:  Both of their projects were approved for a two
                 year  period  and  are  now  completing  their  first  year   of   operatiob4   Both
                 projects appear to be progressing toward achievement of their stated,
                 goals and objectives.

                 Recommendation:  Staff  recommends   approval   for   continued   funding   at   the
                 committed level of $240,00 d.c.

                                                        Ismael B. Morales
                                                        Public Health Advisor
                                                        Grants Review Branch


            Page 2 - Acting Dil7ectcr
            Sul)ject:  Staff.Review of Application from Alabama Regional Medical Program,
            5 C03 RM 00028
            Action by Directorli

            Initials
                               17
            Date


                                                                    (A Privileged Communication)

                                       SUMMARY OF REVIEW AND CONCLUSION OF
                                           TANUARY 1971 REVIEW COMMITTEE

                                         AIABAMA REGIONAL MEDICAL PRO(@RAM
                                               RM 28-03 (AR-1-CSD) 2/71

                             FOR COiNS!Dr-PkTION BY FEBR:LTARY 1971 ADVISORY COUNCIL

                  REC    F.LND,,%TIO@T:  Additinal funds be provided for this triennial application,
                                                                                           U I - 'ng  be'  delayed
                                       but that the decision o  developiiiental.f rdi.
                  for a site visit.

                       Region's-                                                                Recommended
                          onal Year                              Request                        Fand in
                          03                                    $2,116$409*                     $1)665$557*
                          04                                     1,989 928                    1  554,2   5
                          05                                     1,575,113                       1,273,606

                                                                $5)681,450                  $4,1@93
                                    Total

                  %-Inclttdes $240, 000    commitment  for  Core  suppli-eiiIE,.tit  and  2  6ngoit-t-,  projects.

                  CP,l   QUE:   The    Committee    reviewed    tiiis-triennial    application    in    relation
                             y  1970  program   site   visit   findings   -",hich   indicated   that   the
                  Alabama  RIMP  was   at   a   critical   point   in   its   development.   The   written
                  PP.Licati,on  conveyed   the   impression   that   the   Region   hall;   made   rapid   strides
                  n @t e directa'.6nof a cohesive, broad program ai-riied at basic health care
                  probler.i,,i;  the  PAC-  appears  to  have  taken   r'esporsibility;   the   Core   staff   has
                  been strdrtcthen6d by strong subregionali7ation staffing- and Driorities'
                  Are    6tging.   The Committee had no hesitation in recomiiiendirto a level of
                  support  for   the   Coro   and   projects   which   would   pronoto   program   g
                                                                                                   ro-,7tli  but
                  felt  it  could  .lot  make  a'decis4lon  on  the   Region'8   readin6ss   for   O'evc@lc",)-
                  mental funding, on the basis of the written application.  While tried
                          seems to be. on the'threshold of good development,  the Committee
                  felt that  ta  site  Visit  was  needed  to   evaluate   what   is   really   tai-i@lig   place.
                  @Pare   helically,   Alabama's   remarkable   change   in    development    was    cited@
                  7
                  In g@ tiera@l  Committee  discussion   as   an   exampl6   of   why   three--year   looks   at
                  eg   nls'mav   -not   tbvide   the   Committee   and   Council    with    adequate    on-site
                                       p
                  ata  with which to evaluate program development.

                  he   ommittee@-,,as intrigued with possible. reasons            for      Alabama's    apparent
                  tre  5-,th,,In dev iopir6nt.  The Region is unique in           that   the    Alabama    Medical
                  @Soci ty i!s the  official  agency   at   both   the   State   and   local   levels   and   has@
                  es   0   sivilitv   for   administering   both   Titles   18   and   19   And   Comprehensive
                     ai   P@annin,,,.   The University of Alabama at Birmingham administers the
                  edi  a! denttr, a complex consisting of the hospital clinics   dental @-chool
                  aid@   full spectrum of resources for health education  health care and
                  biomedical r6seArth4   There are no similar resources in the State.
                     t ermore,      e prac
                     t    from its inception.   The Regional l@6dital Program has been su'ported
                                                                                                         p
                        h  the  Medical   Society@and   the   University   as   t   e   oroan   zation   to
                       d continuing medical education and the development of community health

                  e    ces.


              AL&MM& RIMP                        -2-             RM 28 03 (AR-1-CSD) .2/71

              The Regional Medical.Program works cooperatively with  Comprehensive
              Health Planning, at both the State and local levels.   The "A"  agency  has
              looked to the ARMP for leadership in statewide planning in  cancer  and
              heart diseases.  The ARMP has-taken an active role in  the development  0
              the CHP tlblf Aaencibs in the Region through the subrogionalization Core
              staff.

              The Committee felt that all of these aspects have  helped prograni@develop-
                    The role of the staff in establishing links  of  communication,  in
              capitalizing on and in channeling ideas, as well a's the projects, were
              noted as major strengths in bringing these forces together.

              In conclusion, Committee believes that during the past year  many  events
              have taken place which indicate that this Region has.made  great  strides
              in developing a mature RMP. The RAG has begun  to  exercise  its  influence
              in the development of the total program.  It seems that the ARMP has
              acquired the respect, support and participation of most of the major
              lf6alth facilitators in the Region and involved the provider in its scheme
              for developing an effective health care delivery  system.  Through  it"
              subregionalization program the AP@IP has extended the outreach of Uiiivbrsity
              resources into the comunity; has strengthened the role of  CHP  in  the
              Region and is fostering visibility of the A@IIP in the rural community.
              Committee has deferred action on the developmental component pending a site
              visit to determine if this Region is headed in the  direction  it  proposed
              to the May 1970 site visit team and has developed the  level  of  maturity-
              @which is indicated in this application. The impression  of  site  visitors
              was that the Alabama RMP could eventually have one of the strongest health
              care@programs of any state, if its overall scheme @or  integrating  the
              strengths of the University, the Regional Medical Program, the State Medical
              Society and Couiprenensive Health Plannina is made to work.

                                                                          RMPS/GRB
                                                                           1/20/71


       akmribaz)

             0                                                          0                                                          0


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

              Arkansas Regional Medical Program                  RM 00052 2/71.1 (S)
              500 University  Tower  Building                    January 1971 Review Committee
              12th at University
              Little Rock,  Arkansas  72204
              Program Coordinator:  Charles W. Silv'erblatt, M.D.

                                        Request (Direct Costs)

                                             03           04          05    -Total.

              Committee/Council Review
                Two new projects          654,052      592,119     667,059      1,923,230

              ---------------------  I--------------------------------------------------

              RMPS Staff Review
                Commitment                887,506            Currently in
                Catryover                 112,982            staff review
                Total Request           $1,000,488

                                            Funding History

                                            Planning Stage
              Grant Year             Period                         Funded (d.c.o.
              01                     4/67 - 3/68                    $341,846
              02                     4/68 - 1/69                    $341,846

                                          Operational Program
                                          Council                                 Future
              Grant year     Period       Approved 1/      Funded (d.c.o.)     Commitment
              01           2/69-1/70      807,487          687,506
              02           2/70-1/71     1,818,045       1,001,306 2/            -----
              03        3/ 2/71-12/71    1,595,820                              887,506
              04           1/72-12/72     6599623                                106,596


                                              2                RM  00052  2/71.1  (S)
            Arkansas RMP

            1/ Also includes Council.recommended  amounts  for  all  approved/unfunded
              projects

            2/ Includes $113,800 carryover
                                          the request of RMPS to   facilitate   transfer
            3/ Change in budget period at
              to anniversary reviiaw system - Figures for 03 year, however,   are
              calculated on a 12@.u6nth period.
            HISTORY,  Arkansas received its first planning grant ($341,846    d.c.o.)
                     on April 1, 1967 and its second, for the same amount,- on
            April 1, 1968.
            A site visit was conducted in September 1968  to  examine  the  Region's
            readiness for operational status. The site  team  had  some  reservations
            about the lack of a continuing education component on  the  core  staff  and
            the rather weak financial condition of the medical  school,  but  on  the
            whole, they were impressed with the community  involvement,,  the  active
            participation of the Regional Advisory Group,  and  the  directions  planned
            by the director and core  staff.  Following  Council  approval  in  November
            1968, an 01 operational award ($687,506 d.c.o.) was issued on February 2,
            1969, including support for core and ten projects.
            A second site visit was made in July 1969 for  the  twofold  purpose  of
            reviewing Arkansas' progres in developing  its  program  and  evaluating  ten
                                        s
            u                    proposals.  The site team concluded that considerable
            s pplemental project
            progress had been made since  the earlier visit,  especially  when  consider-
            ati6n was given to the limited resources the Region  had  to  work  with.
            One area of concern was Core staff's  non-involvement  in  planning  and
            administration, but concentration  on  project  direction.  On  February 1,
            1970, the Region was awarded an 02 continuation award of $801,306
            ($687,506 commitment plus $113,800 carryover)  supporting  Core  and  11
            projects.  In June 1970, the release to RMPS of funds that had been placed
            in administrative reserve by the Bureau of the Budget permitted an award
            of $200,000 for support of six additional projects.
            November 1970 Council, in recommending  approval  of  supplemental  funds  or
            additional core personnel, commented  favorably  upon  the  Region's  planned
            evolving shift from project to program development  wit  a concomitant
            increase   in RAG involvement  and  diversification)  and  strengthening  of
            core technical assistance and service functions.
            The current annual support to the  Arkansas  Regional  Medical  Program,
            exclusive of carryover, is $887,',06 direct costs  ($304,425  for  core  and
            $583,081 for projects).  (See  history  supplement  following  this  summary
            for a listing of.projects.) The  03  year  continuation  application  was
            submitted to RMPS on December 15, and is currently under staff review.


              Arkansas                           3                  RM 00052 2/71.1  (S)

              Present Application:  The present application requests supplemental support
                                    for two new projects.
              Project #36 - Continuing Education for Nursing Home             Ist Year
              Personnel in Heart Disease, Cancer, Stroke and Related          $111,925
              Diseases
              This request is for the continuation of workshops for nursing home per-
              sonnel previously funded by the Community Health Services of the U. S.
              Public Health Service.  A sample survey of nursing homes has indicated
              that Approximately 1,200 employees would participate in these programs.
              The proposed activities will address themselves to three facets of the
              problem:
              1.   Establishment of workshops -- twelve two-day presentations annually
                   in various areas of the state are planned.
              2.   Development of an in-service education program which will follow the
                   workshop presentations in each area.
              3.   Development of a family training program designed to assist family
                   members, gain an understanding of adjustment to the nursing  home
                   environment and avoid disengagement of families from patients  --
                   will be presented through two one-day workshops during the  first
                   year and as needed thereafter.
              It   is expected that after three years of operation the program can be
              continued with multiple support from interested agencies.

              Second Year                            Third Year
              $113,734                               $122,884

              Project #37 - A Comprehensive Program for Kidne)r Disease       lst Year
              Control for Arkansas                                            $5421127
              A comprehensive and statewide kidney disease program is planned which has
              as its objectives:
              1.   To augment and improve the existing statewide cooperative  transplant
                   program at the University of Arkansas Medical Center.  Facilities will
                   be established to provide for handling a maximum of eight  transplant
                   patients, a tissue typing capability will be developed, an  organ
                   procurement team will be provided, and the project will participate
                   in an existing organ donor program and a kidney recipient pool.
              2.  To develop and present home dialysis training programs.  This pro-
                   gram will be based primarily at the Arkansas Baptist Medical  Center,
                   but will use personnel and facilities of the Little Rock VA Hospital


                                               4                 RM 00052 2/71.1 (S)
           Arkansas RMP

               as well.  It is hoped that this program will  train  40  patients  and
               their assistants during the first year, 60  during  the  second  year,
               and 100 per year thereafter.
           3.  To develop and present programs of  continuing  education  to  physicians
               and paramedical personnel.  A two-week course for physicians (at UAMC)
               and an eight-week course f or paramedical personnel (at ABMC) are
               plAnned,l and although all interested personnel will be encouraged to
               attend, priority consideration will be given those who will be working
               at the nephrology centers  at  the  subregional  community  hospitals.
           4. To develop a network of subregional  satellite  centers  for  the  preven-
               tion, diagnosis, and treatment of renal  disease  and  to  expand  the
               dialysis capability of this network.  Eight  of  the  major  community
               hospitals throughout the state have  been  chosen  for  this  purpose.
           Steps are being taken so that at the end of three years  there  will  be  the
           necessary organization and lo cal support to sustain the  program  under  the
           leadership of the Arkansas Association for Kidney Disease and the Arkansas
           Kidney Foundation.
           The Arkansas Regional Medical Program  considers  this  project  the  most
           ambitious, significant and comprehensive exercise it has undertaken thus
           far.  It is stated that the project demonstrates more cooperation among
           health-providing groups and provides more  opportunity  for  an  effective
           impact on health care
                                 in the Region than any past activities.  It is
           viewed as a program from which many  other  total  regional  programs  can be
           built.  A letter from the Vice President for  Health  Sciences  states  that:
                     In view of the significance of this  program  and  the  services
                     it will provide within the State  of  Arkansas,  the  University
                     of Arkansas Medical Center will, in addition to other con-
                     tributions, contribute one-half of the  amount  of  money  which
                     it would ordinarily receive as a result of the federally
                     determined indirect cost rate charged for grant awards of
                     this type. This is a  major  departure  from  policy  that  must
                     be considered as a unique exception  rather  than  as  a  change
                     in principle or of accepted guidelines.  We believe that this
                     program is so important that we can justify this contribution.

           Second Year                            Third Year
            $478 385                               $554,175

                                                                GRB/RMPS     12/21/70


                                                                                                                                      2/71.1   (S)

                                                                  l-'@TSTCj'Y

                                                                                                                                                              -'on
                                                                                                                 C   -fi: j@- r-, n

                                                 cote    Stipport

                           2
                                                         ci.-i   c
                                                                  T
                                                                                                                     '-i 7 514 5                   2 -

                                                                             C@l,-c  Training                         G-O)I@03                      2.- 69

                           4                               Si:@I'A'y
                                                 Assistaoce   @o  Ca          ("I-:ac
                                                 Care                                                                        d

                           5                     Ca   1-
                                                 "roi,                                                                29,533
                                                        ra"n
                           6                                                                                               2 5 2                         9.

                           7
                                                                                                                               0

                                                                                            C@ 1:

                           I   0                  Tile 1    r                                                                                           5
                                                                                                                            9 0

                           I-  2                       t o I: ci  -I: a "I s

                           13
                                                                            1.
                                                  C i  i@

                           14-19

                           20

                                                                                  i                                    1 8 , -4,/ 7


                                                                                           6                                                                  2/71.1 (S)

                                                           continued.
                                                                                                                                                                              Init
                                                                                                                                  Currc-rit
                  P ',7                              Ti tle                                                                       Ye@ir'li Stir,,,)ort                          Dcte

                         22                          North        Central   Ar@,in@a,-,
                                                     StrOl'IC                                       Cc,iit:c-r                    $      31.,538                              6-70

                         23                          Revised  as   Project   Ir34

                         24
                                                     to                           Phys-;.cl.,,@!-,7i,                                    16,500

                         25                          CE  for  Pllyf;icians                                                                     100,000                        6--70

                         26                          CE  for  Pharrnaci.sts                                                       Approvc-d/Uriftin@led

                         @7                          Refrosher  Traini.i-!,,                     fo,7
                                                     Tecltiicylo@,ists  and                                                       Approve(]/Un.lit@iri@e@

                         28                          CE  in  Cardiol6oy  J'or  Physicians                                         Approvcd/lJr,)'u.@jdc-c,

                         ,2.9                        Model  Cardinc  C037C  Uni.t  -  Stutt,u,art
                                                     @lereorial  Hospital                                                                10,000                                 -.'7  0

                         30                          Area-14ide  Intensiv-1,  C;irc  U-ni@t  Zinc]
                                                           3 -i  C:or(iriziry  C,-irc   for  "riyl;ici,,ins
                                                     CE
                                                     and     I,.Iur s c 9                                                         App i. ove (.L                 r] c

                         3  1                        In-t-l-Ll(,t:iO!l in iNoLl-iolo@i.c
                                                     of      St-.rolc(,-,      I;riin       'ftirfior          C,)nc(,r

                         32                          Deuioyistr.-ttioi-i  inri  T)7.@i-Clil.,",  in  C@;CC
                                                     and  Illqndl.irt@,,  oil  St-coi(c-  Piti.c-nts                                     16,58)                               6-70

                         33                          CE i-,i X-,-,-4y Teclirjolc),,,,y
                                                     R,-I@-.tc-ei  l@ie'Lc7is                                                     Ap-i)roved/Unfurieiccl

                         34                          Reil.onil  Lal)otatory  Quality
                                                     Con-Lrol.                                                                           23p5OO                               6--70
                         35                                                                        fo:  Di.c,@iciiilF,
                                                               @e,-iltli  Ficility  Food  Servicc-
                                                     Supervisors

                      'fho  02  yeni-  P.N4nrd  included  $  11.3,@;00  c@irryovc:r  funcl[,   fcji.-  t@ic
                       ol'  the  projects

                                                                                                                                         GRB/RMPS                      12/21/70


                                                                 (A Privileged Communication)

                                  S@RY OF REVIEW AND CONCLUSION OF
                                      JANUARY 1971 REVIEW COMMITTEE

                                   ARKANSAS REGIONAL MEDICAL PROGRAM
                                        RM 00052  2/71.1 (S)

                         FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

             RECOMMENDATION:   Additional   funds   be   provided    for    this,application.

                                                                                      Committee
             Ye4t                            Request                            Recommendation
              03                              $654,052                              $111,925
              04                             592,119                                113,734
                                             667@,059                               12@2  884
             TO                             $1,913,230                               $348,543

             C   ITI     The Review Committee observed that the Arkansas             Regional
                         Medital  Program  will   submit   its   first   Anniversary   Review
                 lipatidn'for   consideration   during   the   Oct6ber/November   1971    review
             c  le,@  d that the current supplemental proposal results            from    the
                gio-n!  exer6ising  A  transitional  year   option.   It   was   further   noted
                a                                                  lar   @    (Arkansas    is
             a  the  Vottom  of  the  heap,with  regard  to  the   presence   of   skilled
             mE  power),  48%  of  current  funding  flows  into   training   and   education
             a  iv  ies.  The  reviewers   agreed   with   the   previous   Committee   and
                                              its  new  coordinator   Dr.   Silve   b
             Co  nci  that  the   ARMP   under                                    r   latt,
             seems effectively to be turning       itself around with respect to increasing
             core   4pabilities;lin6r6asing   RAG   involvement,   And   bringing   about   a
            @@s ift from proj6tt-to program development and emphasis4

             Project  #36   -   Continuing   Education   for-Nursing   Home   ersonne   in    r-
                              Disease,  Cancer,   Stroke   and   Related   Iiseases.   This
             a   ivity was th6dRht    to  be   well   planned   and   comprehensive.   It@meets
            @@a   ed@6f@t@e  Region,  is  designed  to   reach   nursing   home   personnel
            Li   ev    the  hinterlands  appears  to  fit  in  with   the   ARMP   overall
             p  ogr  @appr6ach, and has planned phaseout of RMP support.  As a side-
             1    t@ the reviewers wondered whether this program         might   not    6&tve'to
            @s  abliie  the  ubi6uit6us   turnover   among   nursing   home   personnel.   There
             w  i3  n  doubt  tha@  inclusion  of  this  project  into  the   Arkansas   program
             was   wii warranted.

             P'Oje     lt37   A  Comprehensive  Program  for   Kidney   Disease   Control   for
                              Arkansas.  The   reviewers   agreed   that   this   proposal
             i@   a   perb b            e, but had difficulty in evaluating only the written
             ,y   d.  It was  noted  that  the  Kidney  Disease  Control  Program   of   RMPS
             t  siq   red   the                                         an
                               proposal aa ex6ellent one,based'on              identification of
             needs    nd a logical and comprehensive plan to meet those needs.  Arkansas
             vrese    ly@has  a  minimum  of  renal   activities   -   some   trdh8Dlahtati6n


           Arkansas RNP                      2                  RM 00052  2/71.1

           but virtually no dialysis.  And so the main problem with which the
           Committee wrestled was whether the Region actually possessed the
           capabilities to carry out the fine program it has designed.  There
           is considerable evidence of good community support and the reviewers
           also saw in this proposal the strong possibility of the programs
           -extending outside Arkansas and becoming An inter-regional resource.
           After lengthy discussion, the Review Committee'referred this project
           to,a s ecial ad hoc renal panel in order that the program be
                 p
           considered in the cont6xt of national needs as well as@oth6r
           renal applications that have been submitted.  The reviewers did want
           to stress the excellence of Arkansas' regional kidney plan, but
                     as well that a technical site visit be considered.

                                                           1/18/71
                                                           GRB/RiMPS


     CALIFORNIA

            0                                                  0                                                   0


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

                CALIFORNIA REGIONAL MEDICAL PROGRAMS             RM 19-03 (AR-1 DS) 2/71
                Room 600                                         January 1971 Review Committee
                655  Sutter   Street
                San Francisco, California 94102

                                           REQUEST (Direct Costs Only)

                      Region's
                Operational    Year       03           04              05                06
                Core                   407,967       4,548,409       4,766,304        4,988,71@O
                                  (Supplement for     (renewal)      (renewal)        @(renewal)
                              remaining 6 Months
                                  of 03 year)

                Developmental
                 Component             406,720         834,759          857,140          880,642
                                   (For remain-
                                ing 6 months of
                                    03   year)

                9  New   Activities
                    (Projetts)         -             1,414,007       1,591,910         1,406,315
                    Total              814,687       6,797,175       7,215,354         7,275,697

                --------------------------------------------------------------------------

                                       FUNDING  HISTORY  (Direct  Costs   Only)

                                               Planning_S@e

                        Grant   Year                 Period                 A-unded (d.c.o.)

                            01            11/i/66 - 12/31/67 (14 mos.)      $1@,368,137
                            02             I/l/68 -  2/28/69 (14 mos.)        2,613,

                                               Operational     Program
                                           (Overlaps with planning stage)
                        Grant   Year                  Period                  Funded (dc.o.)

                            bi                  7/l/68 - 6/30/69              $2,917,144
                            02                  7/l/69 - 8/31/70  (14 mos.)   $8,012,055
                            03                  9/l/70 - 8/31/71              $7,548,457
                                (current)


           CALIFORNIA RMP                   -2-                RM 19-03 (AR-1 DS) 2/71
                                        0                                                 .4- 0
           GEOGRAPHY AND DEMOGRAPHY:   The region is coterminous with the state,
                                       except for the Reno:and Las Vegas, Nevada
           areas which 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 18,293,000 (1965). The population spread is 80'/. urban, with  a
           median age of 30. The racial distribution is 92%  White,  6%  Negro
           and Other 2/..

           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 o'- Los Angeles) and the UCIA and USC
           Schools of Medicine (Areas IV and V).  There are 62 nursing programs,
           including 42 that are collegiate. There are  20  medical  technology
           programs and 615 hospitals with a  total of 138,722  beds.  The  majority
           of these are non-federal, short-term hospitals.

           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: With the passage of PL 89-239,
           committees were appointed at UCSF, UCIA, Stanford and USC  to  study  the
           legislation.
           The California State Department of Health organized the "California
           Coordination Agency for Training, Research, Education, and Demonstration
           in the Field of Heart Disease, Cancer, Stroke and Related Diseases.'.'
           This agency included representatives from the California Medical
           Association, the California Hospital Association, and the  Deans  of
           the eight schools of medicine. The Agency was  organized  with  the  pur-
           pose of developing an "overall plan" for cooperative medical arrangements
           throughout the State.  Planning for developing regional medical programs
           was to proceed at each:of the participating  medical  centers.  The
           Coordination Agency world "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.
           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 Borhanl
           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 analysis.


              CALIFORNIA  RMP                     3-            RM 19-03 (AR-1 DS) 2/71

              The major question raised by the application was the  creation  of  a
              limega-re     --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 UCIA withdrew the planning
              application it had independently submitted.  The various medical centers
              agreed to reconsider 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  fisca  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.

              Another site team visited the region in February 1967 and expressed
              concern about the apparent lack of  cooperation  amoung  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, UCIA, USC, CMA and CHA.  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 hard to discern.

              The region's first operational grant was made effective  July  1,  1968,
              including nine projects out of a total of  21  submitted.  The  same
              Award 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, III,IV, V, VII, and  VIII.  Most  impressive
              was the evidence of true peripheral  involvement.  During  the  visit
              Area IV (UCLA) raised the question of the possibility  of  making  each


           CALIFORNIA RMP                    -4-              RM 19-03 (AR-1 DS) 2/71

           Area a separate region; there was little support for this position
           outside of Area IV.
           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 year's unexpended
           balance of $480,168.  "'he current base level is $7,068,289.  Staff review
           of the continuation ap-?Iication is attached to this summary.
           THE REVIEW & DECISION-MAKING PROCESS:  The CCRMP review process has three
           stages: (1)d6termination 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 Committee on Organization and Procedures.  The
           process begins when the Area Core Office notifies CCRMP 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.  The latter is drawn from the Regional
           Technical Review Panel, composed of individuals from each Area in various
           categories -- heart disease, cancer, stroke, etc.
           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 over-
           all 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 brihg 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 by utilizing  evaluation  techniques.
           Evaluation is now an integral part of planning from the inception
           of a project, with assistance and guidance provided by the CCRMP
           central staff.
           TNTER-AREA PLANNING ACTIVITIES:  Stimulated by Review Committee and
           Council concerns and questions about this element  of  communication
           between Areas, region-wide committees are appointed as  required  to
           assure coordination between Areas and projects.  Monthly meetings of
           Area Coordinators are held and serve as forums for planning.  In


              CALIFORNIA RMP                    -5-               @l 19-03 (AR-1 DS) 2/71

              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 common registry, etc.  There is increasing evidence that
              sincere, coordinated, statewide efforts are addressing common  problems
              throughout the region, with a resultant lessening of Area autonomy.

              REGIONAL ADVISORY GROUP: This Group is called  the  California  Committee
              on Regional Medical Programs (dCRMP).  It is a heterogeous body including
              the Deans of the nine medical schools and two schools of  public  health,
              the Director of the State Department of Health, and representatives
              of the California Medical Association, the California Hospital Association,
              the California Heart Association, the California Division of the
              Cancer Society, TB and Respiratory Disease Association and representatives
              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 Coordinator'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
              confederacyof 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 representatives on CCRMP.  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.
              DEVELOPMENTAL COMPONENT In the view of the CCRMP,  such  funds  awarded
              under this component should be snent in the implementation  of  nation-
              wide goals for nersonal health services announced by  DHEW,  and  funds
              allocated for Area Core activities should continue to be  used  in  the
              imnlementation of the HSHHA goals that emphasize  the  disease  processes
              of heart   sease, cancer, stroke and  related  diseases.  Indeed,  this
              was the recommendation of the Objectives Committee and  endorse.  by  the
              RAG.
              CCRMP may wish to select certain of the national priorities to coincide
              with known needs in California. For the first  year,  the  region,  has
              decided to apportion its priorities as follows:  Fifty percent of
              Developmentat Component funds will be  earmarked  for  the  achievement
              of National Goal 11 - to stimulate efforts to improve  and  increase  the


         California RHP                 -6-                   RM 19-03 (AR-1-DS). 2/71
         health manpower pool, focu-sing on the professional and allied health
         personnel.  Fifty percent will be allotted to National Goal 10 - to
         stimulate changes in organization and delivery of health services,
         particularly for the urban and rural poor, with priority to:  preventive
         measures, prepaid group practice, use of allied health personnel,
         ambulatory care services and neighborhood care delivery units.  In
         connection with services for the urban and rural poor, attention will
         also be given to the following: migrant farm workers,  Indians,  children
         under five years, and women of childbearing age.
         The general purpose of Developmental Component funds in California  will
         permit the Areas, through their own collective professional capability and
         decision-making process, to move rapidly and expeditiously in  responding
         to the identified national health priorities.
         The objectives envisaged by CCRMP are twofold:  (1) development of projects
         that will serve the national priorities that are, in format  an  content,
         ready for submission to RMPS and other sources, and (2) development of
         ongoing community activities such as organization of methods or mechanisms
         for augmenting the delivery of health care to the high priority target
         groups.
         The region will emphasize the following elements for projects planned for
         Developmental Component funds:
           1.  acceptability - by the user and provider of the health care  sytem.

           2.  accessibility - to the health care system by the user.
           3.  availability - of personnel and facilities to provide needed  care.
           4.  quality care - both individual acts of health care and the  health
                              care system within which those acts are  performed,
                              must meet accepted standards of excellence.

           5.  reasonable cost - cost of care must be within customary and
                                 prevailing costs to the individual user and society.

         The review process of the Developmental Component funds will be the
         responsibility of the Organization and Procedures Committee of CCRMP.
         Howev6r, the Objectives Committee offered two recommendations in this
         regard:  first, it appeared important that Development Component funds
         should be used for projects which increase the     tit  of care, and
         second that such funds be awarded on the basis of a  competitive  review
         in rel;tion to goals and objectives, with not less  than 25% to be
         awarded to Areas presently at a staffing disadvantage.


             California RM-P              -7-                RM 19-03 (AR-1-SD) 2/71

             New Supplemental Projects                                       Requested
                                                                             lst Year
             Project #66 - R.E.A.C.H. - Area VII  This project will          7231,014
                                                 provide for: (1) supplementary
             staff in six general hospitals in San Diego County to establish
             multidisciplinary planning teams in each; (2) a slightly modified team
             in two hospitals in Imperial County; (3) encouragement for physicians to
             assume an active leadership role for follow-up care under their direction;
             and (4) continuing advance training for all allied health professionals
             currently involved in multidisciplinary planning in Area VII.
             Four discharge teams will be established in San Diego County the first year
             in Mercy, University, Sharp and Scripps Hospitals.  Each team will have
             eight members:  a coordinating nurse and family counselor at full-time,
             a physical therapist and dietitian as needed, public health nurse,
             rehabilitation counselor and occupational therapist half time and a
             full-time secretary. Each hospital will provide four members  and  RMP
             will provide four.
             The project was conceived as the result of studies of the San Diego
             Area Planning Committee, composed of representatives of numerous health
             organizations and voluntary agencies.  The committee recomended that RMP
             give consideration to planning for the development of discharge  teams
             planndd along the lines of the Heart Patient Project for all local
             community hospitals.  R.E.A.C.H. will build on the experience of the
             three-year pilot demonstration'project--Heart Patient Project--sponsored
             by the San Diego County Heart Association and General Dynamics Convair
             Employees Contribution Club.
             Over the three-year period of this project, the hospitals will be
             contributing a total of approximately $249,495 in salaries for personnel
             they will assign to it.  In addition, these participating hospitals will
             provide office space, equipment and other administrative support.
              Second Year - $344,131               3rd Year - $134,784
             Project #67 - Respiratory Care - Area I  Respiratory             First Year
                                               ,teaching teams from           $266,240
             communities throughout the Area will be trained in the Bay Area
             by a faculty of respiratory care specialists.  Such training will
             include specialized medical and teaching skills as well as the  health
             team approach to comprehensive patient care.  A preceptorship for physicians
             and a special course for junior college nursing faculty, combined with
             team training experience, will help to ensure the leadership needed for
             continued development of respiratory care practices in the  community.
             The basic team program will be two weO-ks, And include small group sessions
             in the classroom, laboratory and at the bedside with expert teaching on
              ont-to-one basis.  Students and faculty will function as team members
             during all teaching rounds, seminars, and case presentations.


           California RMP              -8-                       R14 19-03 AR-1-SD) 2/71
           A special program has been-developed for the junior college faculty.
           An eight-week course includes study of the pathophysiology  of  respiratory
           disease as well as general intensive and home care of  the  respiratory
           patient.  In order to create a liaison between the junior college
           faculty member and the community team, the faculty member will spend a
           portion of her time with the team from her community.
           A one-week physician preceptorship will be available for two  or  three
           physicians six times a year in the Bay' Area.  Prerequisite for participation
           in this component of the program will be prior attendance  at  sessions
           carried out by the team in the community.
           The program has been designed to meet the requirements  of  all  Areas.  The
           composition of the teams will vary from District to District, depending
           on existing health manpower resources. Ideally, it  will  consist  of  eight
           members:  aphysician, an intensive care nurse, a hospital inservice
           educator, ahome care nurse, a physical therapist, an inhalation therapist,
           and a pulmonary function technician.  Seven teams (49 individuals) are
           to be trained during the first year, and will increase to 28  teams  in
           the second and third.
               Second Year - $316,710         Third Year - $325,727
           ProAect #68 - A compendium of Extended.-Learning - Area II        First Year
                        This project proposes to establish a mechanism         $90,207
           for the planning, development, and implementation of a cohesive
           program of educational activities for members of the health professions
           in Area II.  The authors believe that an educational program, to be
           realistic, must address the entire continuum of health care as well as
           the entire range of professional skills.  A foundation of two years of
           experience with several planning and experimental studies is cited.

           The program will address the gap in the various medical service areas
           between a reasonable or acceptable level of  continuing  education,for  all
           health professionals and the actual esistence of such programs.  The gaps
           are believed to be not so much in content but rather in the design and
           delivery of such rrograms.  Factors contributing to this situation are:
           (1) only the large hospitals in Sacramento and Reno have appointed
           Directors of Medical Education; (2) in some instances, the energies of
           the Director have been consumed by the demands of recruiting and training
           interns end residents with little time to serve the professional staff;
           (3) most small hos-itals cannot afford the salary of a D.M.E., nor can
           they in the future; and (4) some hospitals do not feel the  need  for  such
           a resource.
           The Area II Advisory Council has endorsed the concept that continuing
           Education for health professionals should be the highest priority item.
           As a consequence, significant participation in the planning process has
           been provided by the Advisory Council, together with Area II staff,
           health professionals, hospital staffs, medical societies, voluntary
           agency staffs and representatives of the "Bl' CHP Agency  have  contributed
           to the planning of this proposal.


              California RMP                  -9-                 RM 19-03 (AR-1-SD) 2/71
              Five objectives are spelled out to deal with heart disease, cancer, stroke,
              renal disease and respiratory diseases.  The ongoing Roseville pilot
              project will serve as a living laboratory for the  development  and
              testing of improved patient care and continuing education within a
              single community hospital.
                        Second Year - $86,002            Third Year - $86,967

              Project #69 - Respiratory Care - Area VII    The project          Requested
                            was developed as a result of a detailed             First Year
              survey of respiratory care facilities and personnel in             $172,356
              Area VII.  The survey established both the priority needs and        -
              the resources within the Area which could be mobilized to meet them.
              Such information has led to the design of a multifaceted project which
              integrates Area resources to meet the most critical needs.  Nine sub-
              programs are included in the project.
              The geographic location of the Area, in sharing an active border wit
              Mexico and seaport for servicemen and civilians returning from the Far
              East, makes tuberculosis a continuing problem.  Two recent pilot skin-test
              programs at San Diego City College and University Hospital, disclosed
              positive tuberculin skin tests in more than 20% of the 3000+ persons tested.
              Also, there is in this Area a remarkably high incidence of pulmonary
              tuberculosis and pulmonary coccidiomyosis in children.  There have been
              more than 48 admissions in children with severe tuberculosis  in  the  last
              ten months at University Hospital. Many  of  these  children  had  received
              inappropriate diagnosis and therapeutic management prior to their admission.
              Each sub-program will be responsive to a  different  Area  need.  Education
              of physicians and allied health professionals is the primary  goal  of  the
              project as a whole,, although some sub-projects will serve as models,
              pilots, or demonstrations in addition to their educative function.
              An outpatient rehabilitation program will be subcontracted to  the  TB  and
              Health Association of San Diego and Imperial Counties.  A Home Inhalation
              Therapy ?rogram will be subcontracted to Scripps Memorial Hospital and the
              other sub-programs will be carried out by the cooperative efforts of a
              "core" of experienced personnel based at University Hospital, plus
              qualified personnel recruited from other  Area  health  facilities.
              The planning, organization, and content of the project has been developed
              in a manner that should permit most of the sub-programs to become self-
              sustaining in multiple Area facilities during the next three years.
              The project is envisaged as a means to upgrade and  expand  the  diagnostic
              and therapeutic capabilities of Area VII by establishing effective
              educational programs in respiratory care for physicians, nurses and other
              allied health personnel.
                  Second year -  $176,702               Third year - $188,540


          California RMP              -10-                 RM 19-03 (AR-1-SD) 2/71
                                                                 Allied
          Project #70 - multidisciplinary Continuing Education fo             First Year
          TFealth Personnel and Health Careers Counsell
                      The proposed continuing education programs              $50,400
          will be multidisciplinary in approach for allied health personnel
          in Area II.  They will be carried out in three phases:  (1) planning
          and development, (2) operational in several selected sites within the
          Area and with continual evaluation; and (3) an extension of phase
          two with programs modified on the basis of evaluation during phase two,
          and in new sites.
          The target area is primarily rural with two urban centers, Sacramento
          and Reno. The data acquired by a survey made by the Office of  Allied
          Health Sciences soon after its establishment on the Davis Campus in
          April 1969, served as the basis for the First Institute of Allied Health
          Science Education in Northeast California, as well as a basis for indicating
          the need for new programs, especially in continuing education.  Planning
          has been developed by representatives of the Office of Allied  Health
          Sciences, Area II RMP, the two Comprehensive Health Planning Associations)
          and various people from educational institutions.  The resultant consensus
          was that such a project should be multidisciplinary, coordinated, and a
          conjoint program for all these groups, with the primary responsibility
          and sponsorship to reside in the Office of Allied Health Sciences at the
          University of California, Davis.
               Second Year - $69,220             Third Year   $69,560
          Project #71 - Respiratorv Care Training - Area I.V             First Year
                       The project is based on cooperative               $177,159
          arrangements between the Tuberculosis and Respiratory Disease
          Association, practicing physicians, allied health personnel, and
          hospitals to encourage the development and improvement of respiratory
          care units in suitable hospitals, and to train key personnel in respiratory
          care in hospitals where specialized units are not appropriate.  The program
          will involve a nine-county area.
          Based on a team approach, the two-part program will train physicians and
          allied health personnel in the theory and practice of respiratory care.
          The team will be a physician, nurse, inhalation therapist,  pulmonary
          function technician, and physical therapist.
          The training will require a total of four weeks for each visiting team
          from outlying hospitals. The first two weeks will be  spent  at  UCLA
          attending a didactic educational program. The second two  weeks  will
          consist of assistance at the outlying hospitals.  The course cycle will
          be repeated every three months, and there will be four complete course
          cycles each year.
          A ten-bed intensive respiratory care unit at UCLA will serve  as  the
          educational setting for demonstration and practical experience.  During
          the first year, 55 (50 physicians and 5 allied health) trainees will be
           articipating.  Each year thereafter, 120 (15 physicians and 105 allied
          p
          health) trainees will attend.


               California RMP                -11-                     RK  19-03  (AR-1-SD)  2/71
               The Area V (U.S.C.) RMP, in cooperation with olive View Hospital and the
               Tuberculosis and Respiratory Disease Association of Los Angeles, are
               beginning a teaching project directed toward the problems of the chronic
               respiratory disease patient.  The RCU Training Project will serve a
               complementary function.
               The Los Angeles  County  Tuberculosis  and  Respiratory  Disease  Association  as
               pledged $10,000 t-award the implementation of the project and an additional
               $5,000 will assist in the promotion of the various educations  components.
               Also, it is planned to charge tuition, and income so generated will be
               used to offset expenses.incurred.  It is estimated that $1,500 will be
               received in the first year and $3,375 in each of the succeeding years.

                 Second Year - $183,140               Third Year - $196,071
               Project #72 - Radiation Therapy - Area VIII      Funds            First Year
                             are requested to provide continuing                   $71,957
               consultation and continuing education  for  all  personnel  in  the
               field  of  radiotherapy.  These  activities  will  include:  weekly seminars,
               demonstrations,  conferences,  workshops  for  physicians,  nurses, technicians,
               and students.  These will be rotated among the participating hospitals.
               The needs of hospitals vary and the training and educational services
               provided will be tailored accordingly.  The concerned personnel of each
               hospital, including the patients' attending physician will be encourage
               to participate in  weekly  tumor  conferences,  including  patient  presentation,
               review of all  clinical  radiographic,  pathological,  and  laboratory  findings.
               Each of numerous problems pertaining to radiotherapy of cancer will be
               discussed in one-hour sessions.  Participating will be radiologists,
               surgeons, pathologists, chemotherapists, and specialists from other
               disciplines.
               Many institutions are in great need of technical assistance from a
               competent physicist to aid in complete treatment planning, to assist
               in the development of better techniques, and to provide a standard of
               uniformity in dosimetry.  The radiation physicist requested for this
               Program will be responsible for the calibration and maintenance of
               radiotherapy equipment, measuring instruments, and shielding devices.
               It is hoped to be  able  to  establish  uniformity  of  terminology,  techniques,
               definitions,  dosage  scaltsl  And.a Descriptive classification o  tumors.
               In addition, tumor boards will be organized in larger hospitals before
               which cases from neighboring small    hospitals  will  be  presented.
               This project has been in  preparation  since  December  of  1968  and  represents
               the radiotherapy section of an Area-wide comprehensive cancer program.
               At the time of its original preparation, it requested funds for costly
               equipment, and for this reason, the radiological section was removed
               by the Area VIII Offitt.  The present request is a modification and
               more modest version.                                   I

                   Second Year - $64,761              Third Year - $58,284


                                      -12-                  RM 19-03  (AR-1-SD)  2/71
         California RMP
                                                   This project           First  Year
                                          ea III
         Project #73.- Cancer Prograth - Area III-
                      builds on planning efforts in Area III                $301,123
         over.-the past two years.  The program consists of four
         interrelated activities which represent the first stage  of  implementation
         of the long-range plan described as follows:  (1)  radiotherapy  services
         (radiologic physics); (2) district tumor board; (3)  oncology  unit;  and
         (4) consultative-teaching services.
         The purpose of this project is to fill the gaps in the Ar6a-wide
         comprehensive cancer program, giving special attention to peripheral
         Districts 3, 4, 5,and 6. where the need is greatest.  Both ongoing
         screening projects in Area III include  screening  examinations  specifically
         for breast, cervical and lung cancer.  In addition, the San Joaquin
         Medical Society sponsors both the screening project and the District
         Tumor Board in San Joaquin District; the Health  Facilities  Foundation  is
         responsible for the screening of cannery workers in the  San  Joaquin  Valley
         and elsewhere in Area III. All elements of the  Area  have  been  brought
         to bear in the planning for the cancer project.  Also, Area I Cancer
         Coordinating Committee has assisted with planning in Area III, and to further
         coordinate their efforts, join't committees have been formed, with  a  view
         to pooling of resources of both Areas with  respect  to  ideas,  procedures
         and personnel.
         The organizational structure han already been developed as  part  of  the
                    RMP District Cancer l,omm           e) will be  responsible  for
         planning.                           ittees (fiv
         coordination of the program.
         For each of the four components--Radiothetapy  Services;  District  Tumor
         Board; oncology Unit; and Consultative-Teaching  Services,  there  will  be
         a project director. The first component  is  concerned  with  provision  of
         radiologic physics services by the Stanford  Division  of  Radiotherapy  to
         radiotherapists in the Area. This program will be  located  in  the  Stanford
         Medical Center, but supported by other  physics  resources.  Services  will
         include calibration of radiation sources, and other supportive consultations,
         as well as transmission of treatment planning  information  via  wirephoto.
         The District Tumor Board will provide consultative  services  to  physicians,
         an educational program on cancer for physicians and other health personnel,
         a data base acquired through a cooperative  hospital  tumor  registry,  and
         an annual report on status of cancer detection and management in the
         District, including recommendations.
         The Oncology Unit will sponsor the development of  a  model  oncology  unit
         in a community hospital; extend resources and  methods  developed  in  this
         unit for establishment of other units in Area  III;  and  improve  knowledge
         and upgrade skills of professionals involved in the care of cancer patients.
         The Consultative-Teaching Services will be implemented  by  the  creation  of
         an Area Cancer Team consisting of a Cancer Coordinator (medical oncologist),
         an Associate Coordinator (radiotherapist),  and  a  Nursing  Coordinator.  As
         an Areawide team these persons will  participate  in  District  Tumor  Boards
         on a scheduled basis and will assist  in  consultative  service.  They  will         I


              California RMP               -13-                         RM 19-03 (AR-1-SD). 2/71
              also conduct or assist in planning educational programs (such as preceptor-
              ships and short-term training) sponsored by the District Til-or Boards
              and the RMP District Cancer Committees.
                 Second Year - $296,698              Third Year - $287,396
              Project #74 - Blood Banking - Area V   This Project will            First Year
                           train 1,000 blood bank technologists from              $53,551
              Los Angeles and Orange Counties in the six subject areas (ABC
              Groupingi the Antiglobulin Test, and Rh Testing) over a three-year period.
              Technologists will be followed after training to determine of  changes
              in performance due to the workshops persist2.
              There are a few postgraduate training opportunities for blood bank
              technologists in this Area., but the applicant feels these are not adequate
              to meet existing demands.  The commercial serum companies workshops are
              felt to be somewhat slanted, others are held yearly by the American Society
              of Clinical Pathology, but are primarily for pathologists and not techno-
              logists, Aid all are held too infrequently to supply local demands.
              The program would conduct workshops in blood banking on a full-time basis,
              directed by a Teaching Supervisor and one Assistant Teaching Supervisor,
              Another Assistant Teaching Supervisor will be responsible for the day-to-day
              preparation of specimens and other technical details.  Other personnel
              requested Are a Research Assistant (half-time) and a Shipping Clerk
              (half-time).
              The proposal has been coordinated and cooperatively planned by Areas IV,
              V and VII as a collaborative effort and would serve all three.  A
              willingness to participate in the program has been indicated by 169 of the
              223 hospitals in the two.-county area.
               Second Year - $54,546                     Third Year - $58,986
              NOTE:  Action on a supplement (11/70.1) was deferred from the last review
              cycle pending the findings and recommendations of a site visit scheduled
              for early December.  The concerns expressed by reviewing bodies dealt
              with an apparent lack of any overall regional  priority  system.  Some
              of the proposals appeared to be attempts to develop linkages from stronger
              Areas to others that are moving more slowly.  However, the total application
              failed to indicate how the region had arrived at its choices of submission
              or to furnish background to ongoing activities which would  allow  the
              reviewers to assess the projects in their true context.  These points were
              explored extensively by the site visit team, and are included in the site
              visit report which accompanies this present "package" from California.

                                                             DRMP/GRB 12/17/70


                                                                       A  PRIVILEGED   COivViUl:\ICATION

                                       SUMMARY OF   REVIEW   AND   CONCLUSION    OF
                                          JANUARY   1971 REVIEW'CO'MMITTEE

                                       CALIFORNIAO   REGIONAL MEDICAL PROGRAM
                                              RM 19-03 (AR-1 DS) 2/7i

                             FOR CONSIDERATION BY      FEBRUARY    1971    ADVISORY    COUNCIL

                Recommendation:   That   a   developmental   component   be    approved    at an    annual
                                     rate of $400,000 to become effective for the           remai  riing
                6  months  of  the  03  year;  that  Core  be  renewed   at   the   increased amount
                recommended for the 03 year ($3,878,346) to become effective -for the
                remaining    6months  of  the  03  year;  and   that   the   level   for,operational@;
                acti itieg be continued At the current rate.($4 085,648.)@.

                committee  recommends  that  these   levels   should   prevail   for   a   period   of
                18  months  covering  the  last  half  of  the  03  year  and  the   entire   04   year,
                and 'further, when the region's triennium application is submitted to
                the  july/Augiist  review  cycle  covering  the  04,  05  and   06   years,   the   04
                -eai@level should be within these limits.  Funding for the 05 and 06
                years@will   be determined when the entire triennium application is.
                considered.

                The    effect of these recommendations      is:

                                                                                          Recommended by
                                      Requested    By             Recommended by
                                       Region                     Site Visit Team           Committee

                03   Year
                    Core              $4    263,325                  $3,878,346             $3,,878$346
                    Dev.    Comp.        813',440                       400,000                   400,000
                    Oper.,'Act.        4,085,648                      4,085,648                085    648
                                      $9@162    413                  $8,363,994*            $8,363,994*

                 4  Y  ar
                    Core              $4,476    491                  $4,072,263             $3,878,346
                    Dev,   domp.         834,759                        400,000                   400,000
                    Oper.,'A,,t.      To  be   submitted   in         4  572   263           4,085    @4@
                                      July/Aug.   Review             $92044,526              .@$8,363,994
                                      Cycle

                05  Y  r
                       re             $4,700,315                     $4,275,876             To be determined'
                      e    @OMP.         857,140@                       400    000          in July/Aug.@.
                            'A        To be   submitted    in         4,775,876             Review Cycle
                      per    ct.
                                      July/Aug.      Review          $9,451,752
                                      Cycle
                06   Year
                        e             $4,935,330                     $4,489,670@            To be determined
                       V.  comp.         880,642                        400,000             in July/Aug.
                      per.   Act.     To  be   submitted   in         4  989   670          Review Cycle
                                      July/Aug.     -Review          $9,879,34@O
                                      Cycle
                            an  annual  figure*  The  actual   increase   for   the.   last.'6 months  of    -
               @ @ T-h @   is
              @   t@p ni   vpat   is   9407.168   ($200.000 Developmental    Component     And   $207,768.       I-


          '-California RMP                     -3-            RM  19-03  (AR-!-DS) 2/71

            California  represents a testing ground of  national  significance  in
            6,ub-tegionalizatiot of medical planning:, which, in turn,  affects  a
            wide variety of educational institutions and people of diverse ethnic
            backgrounds and varying economic circumstances.

            The Watts-Willowbrook activities, in which approximately $1 million
            of RMP investment has generated approximately  $50  million  of  other
            funds, has captivated national interest and enthusiasm.  It is
            believed that this activity should serve as a model of reorganization
            and redirection of  medical,care  in  economically  disadvantaged-and'
            medically isolated regions.

            A                                                 -e me8hing.and
             nothet important innovation in California is   th
            d finiti6n of the roles  of-RMP.and  CHP.  While  there  was  n6tmuch
             e@
            evidence of coordination of CCRMP and the A  Agency,  there  is  some
            combined representation of personnel, both in CHP and CCRMP.

            Also, California has given thoughtful attention to the health needs
            of Indians, Black and Mexican-American communities and has given
            support for planning of OEO health centers in the Model Cities
            Progkam.

            The reviewers discussed at length  the  regional  evaluation  system.
            The site team had some misgivings about its effectiveness as well as
             ts relationship to the regional priority system.  This,led to
             urther consideration both pro and con of the efficacy of the
             ogi6n's aDDroa6h to evaluation and its  capacity  to  judiciously
             ick@and choose among its operational projects     The  magnitude  of
            the f ndinr level of California tends to inhibit objective examination.
            The ana logy of residency accreditation visits was cited, and one
            membe, pointed out that the Review Committee has not, as yet, evaluated
            limega-d6llars" regions in terms of "accreditation."

            Evaluation as A " rocess", in the o  inion  of  the  reviewers  should
                              p                  p
            include ongoing,, independent audits of segments of the program, i.e.,
              neer in Area I,, N6urology in Area VIII,  with  firm  documentation
            presented as to cost., accessibility, availability, etc.

            in sumarv. it was agreed that while  California  is  difficult  to
            j dge@@6n a total Drop-ram basis, it does claim to be one  region.
             beref6te  ,t e rationale of diversity  must  be  questioned  49.woll
             s      fo e of the thrust of the central  staff  to  monitor  ongoing
              og
                t MSO@@ T e Committee was reminded  that all site visits from the
              ce@ ion of RMP in  California  emphasized  evaluation.  The  region
              s @een - aution6d to build in a methodology from  the  beginning
             f Proiect  planning  c6ntinuing@through  its  operational  experience
             nd u iimat-e termination.  This, in turn, should lead to a realistic
             nd meaningful "total -program evaluation.11  If California is to be,
              dge  as a laboratory, then.it must test, modify,,redesign,
            discard  evaluate.


                                                                           AR   1-DS) 2/71
             California RMP                         -4-          RM 19-03

             Developmental   Component

             There was consensus that the  region has the resources an     ecis on-
             making ability for res onsible use of such  an  award.  The  region  has
                                     p
             proposed a strategy which will utilize  such  funds  for  specific
             objectives to maximize new opportunities and capabilities in
             responding to regional health priorities.  The  nine  Area  Core  staffs
             have@demonstrated program capabilities in a variety of activities
               nerat6d by these staffs ih  community  outreach,  coordination  with
               P, volunteer agencies, utilization of  manpower  and  resources  and
             other local health planting efforts.

             Review procedures for such proposals will be considerably simplified.
             Projects will be  more  m.od6st in scope and will  have  greater  regional
             implications, A special Review Panel  is  in  process  of  appointment
             with representation from all voluntary, as  well  as  public  health
             agencies.

             The RA:G membership views the autonomy  inherent with  Anniversity
             Review status as a real challenge for  CCRMP.  It  recognizes   that
             some tough decisions lie ahead. The  reviewers  believe  there  is
             ,strong evidence that, in the face of  reduced financial  support,
               is responsibility will be equated with  local  (Area)  progress,
              ocal needs and qualifications for such funds.
              t is apparent that California is  already  experienced  in  principle
             in Developmental Component techniques, and the region can be expected
             to be discriminating and sophisticated in  its  choice  of  activities
             for such funds.  The region feels that such programs should yield@
              arly returns with good spin-off value.
             In addition to sub-regionalizatfion at Area  levels with  visible,
             active  local decision-making, the California RMP has shown
             $ubstAntiAl,d&vel6pment toward even  greater  depths  of  regionali-
             zation4  The Committee noted that Areas are   divided into Districts$
              hich in turn, have Advisory  Councils@  representative  of  local
             health interests.  Each Area conducts planning studies, exchanges
             Information to av6id.unnecessary duplication and share experiences.

              ore Renewal

             in discusai g this segment of the application, Committee had
             difficulty in assessing a Core Renewal  request  in  isolation  from
             its ongoing 6 eratioftal projects    It noted'the  impressive  produc-
                          p
             r-ivity of SOM6 6f@@@tb6 more advanced Areas and a lesser degree  in
              he underfunded Areas* However, in  some  of  the  late  starters,
             limitation of Core funds has probably encouraged a certain
             creativity in planning and  utilization  of  available  resources.
             The reviewers agreed with the findings of the  site  team  that  the
              equest for additional funding to  equalize  Core  support  throughout


             California RMP                         -5-        RM 19-03 (AR-1-DS) 2/71

             all nine Areas  is valid.  It recalled that   such support was limited
             initially in a  somewhat arbitrary fashion,     There was also  agreement
             that  California's-expanding  interest  in  Comprehensive  Health  Planning
             and its extensive  inter-relationships with other types of'state and
              oluntary health agencies  make  it  impossible  for  Coordinators  with
             smal  staffs to stay abreast of regional linkages.to further planning,
             as well as  develop  active  operational  programs.

             Tb6 Review Committee agreed with site visit findings that Core
             budgets of less than $250,000 for Areas of a 1.5 million.population
             are unrealistically low.  Further, the distribution of awards
              angi g from 4/. to one Area and 25%  to  another,  with  an  even'wider
              ango in the per capita  distribution  of  funds,  presents  a  handicap
              o smoothly working relationships of the various Core 8taffs.

             Howdvor, the Review Committee  discussion  was  fraught  with  many  concerns
             ok ih reviewers in  their  inability  to  assess  realistically  such
              equ&bts in relation  to  ongoing  operational  activities.  The  reviewers
             were reluctant to accept the  site  visit  team  recommendation  which
             would., thby@felt, have the effect of  establishing  a  program  level
              or a@complete triennium prior  to  the  submission  of,the  complete
              riennium request.

               stead, the Committee voted to approve certain,increases     for  an
              8-month period with the provision that the levels would be
             re examined At the time the operational activity portion of the
               og m is  considered  in  the  July/Aqgust  review  cycle.  Committee
             Agreed that a more realistic  assessment  of  the  "total"  California
              ioRram could be made At that time,

              he dollar implications   of their recommendation are shown  on  t  e
              irst@page of this Summary of Review.

                C  SIONS: A number of  issues  emerged during and as  A  result  of  the
                           most@@recent site visit.  These ate outlined below:

                 The Executive Director raised  the  question  of  whether  RMPS  and
                        t;'Lonal,Advisory Council, ift--effect, delegates its  authority
                        the Anniversary Review system, by authorizing expansion of any
                        ed operational activities  into  other  areas  or  institutional
                        gs@with6ut review and approval by, Council.  This does change Council's
                        omewhat, which has  precedent  for.delegation  of  various
                 !a thorities,  The extent (how far) of such delegation needs
                    be examined.  in  the  case  of  CalifbtniA4 reviewers at the national
                   vel, have en6ouraR6d  the  region  to  refine its review and evaluation
                   stem in order to  promote  a  more  cohesive, integrated regiona  program.
                    s has included  the  extension  of  planning techniques  and   programs
                   Om Area to Area  and  DistFicts  to  maximize available tesourcest

                   e disposition of a large  backlog  of  Council  approved  but  unfunded
                 p ojects. some of which have been dormant for almost two years raises
                   e question of how long  do  approved  but  unfunded  activities  retain
                    ir.Coun6il approved  status.  The  site  team  believes  that  CCRMP


               California RMP                                                  RM   19-05   (AR@l-D   '/71
                                                     -6-                                          S) 2

                    has   adequate   ca  ility to@r:eview these projects, and       to   activate.,
                                      pab
                  -them  within  the   limitations   of   the   operational   budget, provided
                                      their technical.r&,V.,iew after a p@ojipc@.has been
                    they catty out
                    inoperative     for.from -twelve to eighteen months.  If a,second.local.
                    review attests to its pertinence and-viability., such projects could
                     -e  ov
                    b  m  ed intfo;a status where they      could  be   considered   for support
                    along  with   other more     current proposals.

                                                                                        MP
               30   The   site   team   identified'some potential    long-term    policy i  licationg
                    in  using  RMP  funds  to   support CHP   activities   as   proposed by
                    California.  -Does @, the "relationship", as -envis@ged provide.- aii@
                    avenue   whereby.CHP@avoids   its   statutory   mandate   requiring    consumer
                                          lahainR boards  etc.?                     -e
                    representation on    p.                          Or,  are    th6r other    more
                                             -th                               f B        ie
                                                                                            S?
                    subtle suggestions in,   e    use,,Of RMP  funds    to@sitaf        c
            N   13  ])octors Spellman and   t@ss@on..were  in@ited"to   r-'-e@a in in th@
              @-@---room   during   the                                   n         ec       ati6nd
                                      delib'erations@'sinc6-thO--findi g8'and r  ommend
                     f th     te  vi   it@team   were'd'             e  can id.1   'with r(4gion
                    0    e si         s               18.cuss@d 'qfjlt     d'  y                 al
                    representatives.     Doctor   Besson   remained;   Doctor   8p6llman joined
                    the Committ6e for    the last    few minutes.

                                                                    1/20/71
                                                                   GRB/RMPS


                         NW

            0                                                              0


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

               COLORADO-WYOMING   REGIONAL   MEDICAL    PROGRAM        RM  40-03   (AR-1-CDS)   2/71
               2045 Franklin$ Street, Suite 410                                        Review Committee
               Denver, Colorado 80205                                              1171

               Program Coordinator: Paul Hildebrand, M.D.

                                           REQUEST  (Direct   Costs   Only)

                                                   03 Year       04   Year        05 Year        All Years
                                                    1/71-12/71   1/72-12/72       1/73-12/73

               Continuation Commitment             1,103,772        98,415                      11202,187
               (Core)                               (483,697)         --                           (483,697)
               (12 projects)                        (610,875)    (98,415)1/                        (709,290)
               (6 month extension of
               project   to   terminate   12/70)    (    9,200)                                    (    9,200)
               02 Estimated Unexpended Funds           73,002         --              --            73,002
               Additional Components                  .508,843   204,922          218,732          932,497
               (Developmental)                      (109,000)    (   0   )        (  0  )          (109,000)
               (3 new projects)                     (370,777)    (174,333)        (184,792)        (729,902)
               (I approved-unfunded project)        (   299066)  ( 30,589)        ( 33,940)        (   93,595)

               TOTAL                               1,685,617     $303,337         $218,732         2,207,686

               *Staff Action on Continuation
                  Approved   Cont.   Committmp-nt    1,103,772       98,415                        1,202,187
                  Disapproved    Unexpended    funds   47,428                                           47,428
                  Deferred   Unexpended    funds       25,574                                           25,574
               Committee Action Required               508,843      204,922        218,732             932,497

                                                  FUNDING HISTORY

                                                  Planning Stag@

               Grant Year                           Period                           Funded (d.c.o.)
               01                              I/l/67-12/31/67                       $297,678
               02                              I/l/68-12/31/68                         366,723

                                                OPERATIONAL      PROGRAM
                                                          Council            Funded           Future
               Grant Yr.         Period                   Approved           (d.c.o.)         Cotmnitment

               01                1/l/69-12/31/69       1,079,853             976,854
               02                I/l/71-12/31/70       1,466,995         1,282,815    I/


                                                              RN  40-01  (AR-1-CDS)  2  71
            COLOR,ADO  --WYOMING RMP
                                               -2-                  Funded          Future
                                                  Council                           Commitment
                                                       oved           c.o.)
                                                                      -C 0
                            Period                                                         I
          Grant Year                                                               1,094,572
          03              1/l/71-12/31/71       1,472,782                              98,415
                          1/l/72-12/31/72          98,415
          04

          1/   Includes $106,533 of   ol Carryover

                                               GEOGRAPHY

               The initial planning grant set the boundaries of the proposed region
               as co-terminal with  those  of  the  States  of  Colorado  and  Wyoming.
               The rationale  for-this  proposal  was  that  the  University  of  Colorado
               Medical Center along with other referral facilities and health services
               of the greater Denver area  serves  as  a  nucleus  for  most  of  Colorado
               and Wyoming.  However, since 90% of the population of the region resides
               in Colorado the boundaries  of  this  state  will  be  followed  for  data-
               gathering purposes.  The adoption of political boundaries of the state
               of Colorado simoffies the collection of data and coordination of the
               Regional  Medical  Program  with  other  state  health  programs.   Another
               factor in this decision is that portions of the state of Wyoming fall
               under the influence of three Regional Medical Programs:  Intermountain,
               Mountain  States  and  Colorado-Wyoming.  Studies  have   shown   that
               patient  referral  patterns  in  some  Wyoming  communities   reflect allegiance
               to  all  three  regions.

               Land Area
                                   Square               Population                 Number of
                                   -Miles               Per  Sq.  Mi.              Counties-

               Colorado:           97,400                   17                        63
               Wyoming            104.000                    3                        24
                                  iOl,400                                             87

                                                 DEMOGRAPHY

                   lation:      Colorado - Roughly 2 million
                                Wyoming  - Roughly.3 million

                                            Population        Percent
                      Urban: Colorado        1,480,000           74%
                                Wyoming        171,000           57%

                      Rural:  Colorado         520,000           26%
                                Wyoming        129,000           43%


              COLORADO-WYOMING RNP             3 -              RM 40 (AR-1-CDS) 7/71

                                                   Population          Percent
                         Race:   Colorado           1,940,000          97%  -  White
                                 Wyoming              294,000          98%  -  White

                                 Colorado              60,000           3%  -  Other
                                 Wyoming               6,000            2%  -  Other

                  Median Age     Colorado      27.9    -
                                 Wyoming        27.3

               Health  Statistics:  Mortality   Rate

                 Rate  for  Heart  Disease: Colorado  -   285/100,000
                                            Wyoming    -269/100,000

                 Rate for Cancer:           Colorado   -114/100,000
                                            Wyoming    -115/100,000

                 Rate  for  CNS  Vascular:  Colorado   -84/100,000
                     Lesions                Wyoming    -84/100,000

               Facilities Statistics:

                   1.  University of Colorado Medical School

                   2.   In the state of Colorado, there are three nursing schools
                        with a baccalaureate program, four with diploma programs and
                        five giving associate degree programs.

                        In the Wyoming area,  there  is  one  baccalaureate  program
                        presented at the University  of  Wyoming,  and  two  nursing
                        schools with associate degree programs.

                   3.   There are 13 schools of Medical Technology located in Colorado
                                                                                    i
                        one of which is university based.  In Wyoming there is one
                        school  of  Medical  Technology.

                   4.   There is one cytotechnology facility located at the University
                        of Colorado Medical School.

                   5.   There are 18 X-Ray Technology facilities located within this
                        region, 16 of which are found in Colorado, all hospital based.

                   6.   There is a total of 92 hospitals in Colorado, the majority
                        being non-Federal, with 16,655 beds.  In Wyoming, there are
                        34 hospitals, again the majority being non-Federal, with
                        3,982 beds.


                                  - 4 -                RM 40- 01 (AR-tCDS) @/71
     COLORADO-WYOMING RMP

            Personnel-S.tat-is-t-cs:
            There are 3,201 M.D.'s (176/100,000) and 240 D.O.'s (13/100,000)
            in the state of Colorado
            In Wyoming, there are 322 M.D. is (99/100,000) and 16 D.O.'s (5/100/000).

            The number of active nurses in Colorado is 7,080 (389/100,000); in
            Wyoming,there-are 1,082 active nurses (321/100,000).

                                HISTORY AND DEVELOPMENT
            The Region submitted its first planning application in September 1966
            and was funded at $297,678 d.c. the first year (1/l/67-12/31/68) with
            a commitment for the 02 year in the same amount.  Although Committee
            and Council both recommended approval in their review they shared the
            concern that the Region's geographic overlap in Wyoming with two other
            Regions (Intermountain and Mountain States) might present a significant
            problem in the future.
            In December 1967 Staff reviewed the Region's request for the continuation
            of its planning grant into the second year (1/l/68-12/31/68).  The
            request for expanded support of $414,112(d.c) was considered very
            ambitious particularly in view of the slow progress and a reduced
            amount at the level of the first year (297,678 d.c.)was awarded.  In
            its review Staff noted recruitment had proceeded slowly and only one
            planning activity had been developed very far.  Staff was optomistic
            that the appointment of a new program director (Dr. Doan replaced Dr.
            Elsele)may accelerate planning.  It was noted, however, that the Director's
            salary at $32,000 is in addition to the existing Program Coordinator's
            (Dr. Hildebrand) salary at $35,000.  This was considered a heavy executive
            salary for a small inactive program such as Colorado/Wyoming.
            In June 1968 a supplemental award of $49,615 (d.c.)was made for the
            expansion of existing facilities and capabilities of a Pediatric Pulmonary
            Program at U.C.M.C. (with two additional years of committed support
            this program was later to become Project #13).
            Also in July 1968 the Region submitted a request for $133,973 (d.c.)
            supplemental planning funds along with an operational application consisting
            of five projects.  These requests along with a three project supplemental
            request submitted in August were all deferred by Committee and Council
            for a site visit.
            A pre-operational site visit was conducted in September 1968.  The
            team consisted of Dr. William Mayer, Dr. Mack Schanholtz, Dr. Robert
            Metcalf, Martha Phillips and James Beattie.  The visitors expressed
            their confidence that the concept of regionalizationwas developing
            well.  There was substantial evidence of involvement outside of Denver
            into Wyoming and interregional relationships were satisfactorily being


               COLORADO-'WYOMING R14P                                 RM 40-01  (AR-1-CDS)  2-171
                                                5

                  worked out, in spite of earlier concerns. There appeared to be good
                  understanding and cooperation between the Regional Medical Program
                  and practicing physicians as  well  as  with  voluntary  agencies,  the
                  medical center, the official health agencies of Colorado (and to a lesser
                  extent of Wyoming) and  the  local  CHP  agencies.  It  was  noted  categorical
                  standing committees not  only  review  project  applications  but  each
                  was charged with developing a  region-wide  approach  in  its  area  of
                  concern.  The Region saw itself as moving from a project approach"
                  to a "program approach.' The  RAG  appeared  deeply  involved  in  the  program
                  and was beginning to develop a more formal approach to its functions.
                  The representation on the RAG was felt to be somewhat less than
                  satisfactory.  Allied Health representation was limited to two nurses
                  and the only minority representative was the Executive Director of
                  the Ur@an League.  The large contingent of Spanish-American physicians
                  had not been contacted and consumer representation had not been considered.
                  Although an "administrative committee" of the RAG had undertaken the
                  establishment of a method of priority-setting, no such system was applied
                  to the first projects included in the first operational application
                  or the supplemental request.  (See Report of 1968 Site Visit).
                  As a result of the site visit, and Committee and CouncilA acceptance
                  of the recommendations, the Region was awarded $25,331(d.t.) as
                  a supplement to its 02 planning award which brought the total award
                  for the 02 planning year to $366,888 (d.c.).  Later the Region was
                  also awarded $849,053 (d.c.) for the 01 operational year (1/l/69-12/31/69),
                  for support of Core and seven operational projects.  This award was
                  later revised upward by $127,801 d.c. to include two additional projects,
                  bringing the total award for the 01 operational year to$976,854 d.c.
                  In December 1969 Staff reviewed the 02 year (1/l/70-12/31/70) continuation
                  application from the  Region.  While  it  was  agreed  the  program  appeared
                  to be moving along much as  anticipated, concern was expressed that
                  the progress reports  were  vague  in  many  respects.  Three  projects  were
                  cited as particular examples of this weakness.
                  The requests for use of carryover funds were also found to be vague
                  and poorly justified. As  a  result  of  this  review  the  Region  was
                  awarded $1,082,881 (d.c.) for the 02 operational year with the
                  option of submitting new requests  for  use  of  01  year  unexpended  funds.
                  In addition the Region  was  required  to  submit  revised  progress  reports
                  on the:three weaker projects.
                  In February 1970, Staff reviewed favorably a single request for the
                  use of $33,016 of 01 unexpended funds to contract with Trans-Century
                  Corporation  to  continue  community  planning  in  Pueblo,  Colorado  directed
                  toward developing an improved health care system for the Spanish-
                  American Population of Southern Colorado.  An award in the amount
                  requested was made.


            COLORADO-WyoMlNr- R14P    - 6

            @n May 1970 Staff revi -           als for use of $132,450 and recommended
                                  ewed 15 propos
            approval of ten totaling $73,517, but with on -proposal restricted
            pending a site visit.  In addition Staff also reviewed the revised progress
            reports on the three projects for which such reports were requeste . -
            These were found to be basically weak, failing to relate to the  questions
            posed in the advice letter.  Many questions were not spoken to while
            others were answered in vague generalizations which characterized the
            original progress reports. The educational programs  appeared  unstructured
            and void of good educational design.  Evaluation was obviously lacking
            and apparently no assistance in this area was being given by, or
            had been requested from Core staff or other competent people who are
            qualified in this area. Lack of coordination between  related  educational
            projects was also evident.  Staff concluded that fnview of the
            substantial difficulties in the education and evaluation aspects of
            the projects, and the apparent reluctance of Core staff to over-see
            and assist, the Continuing Education Branch of RMPS should take  immediate
            action to offer assistance.
            The Continuing Educaticn Branch has since had extensive communications,
            including personnel meetings,.with Dr. Doan and the Continuing
            Education people of CNRNP.  As a result,the Continuing Education
            Branch of BMS reports that the problem which was a. breakdown in
            communication between the Continuing Ed)ucation people and the Administrative
            staff, has been for the most part resolved.  It appears relationships
            have been improved markedly with the Coordinator and the Executive
            Committee having a more favorable attitude toward the Continuing
            Education staff.  Continuing Education staff now participates
            actively in staff committees  dealing with project ideas rather  than
            serving in a passive role as an occasional reviewer of projects
            after they were already designed.
            As a result of Staff's recommendation forapproval of ten proposals
            for use of 01 unexpended funos and the Director's willingness to
            grant a special supplement of $100,000 to the Region for support of
            four approved but unfunded projects, a new amended award in  the  increased
            amount of $1,282,815 for the total program was granted in June 1970.
            A breakout of this award is presented on the last page of this summary.
            On November 25, 1970, staff reviewed the Continuation Component, the
            Region's first Anniversary Re@iew Application.
            The Acting Director concurred with staff's recommendation which was:
            1) approval of the request for $1,103,772 of committed support for
            Continuation of Core and 13 projects; 2) disapproval of a  $47,428  request
            for use of 02 year unexpended funds in eight projects and 3)  deferral  to
            the site visitors a request for use of $25,574 of unexpended funds to
            extend project #13.
            A site visit will be conducted on December 8-9, 1970 and a report  will  be
            presented to Committee at its January 1971 meeting.


          COL(RADO-VTOWNG RMP          - 7 -                ItM 40-01 (AR-1-CDS) V7t

                                      PRESENT APPLICATION

                Core Organization:

                                      Coorulinator's -- Directorts Office

                Paul R. Hildebrand, M.D.                    Coordinator
                Howard W. Doan, M.D.                        Program Director
                Rex D. Stubblfield                          Executive Assistant
                Elaine Deters                               Secretary

                                      Fiscal & Administrative Services

                Mildred Schnittgrund                        Administrative Assistant
                Kay Jones                                   Steno-Secretary
                Sylvia Meek                                 Telephone Receptionist

                                      Communication & Information Office

                J.P. Smith                                  Public Information Officer

                                      Profess 4onal Activities Division

                Richard E. Boyle,  M.D.                     Associate Director
                Anne Gough, R.N.                            Chief of Nursing & Allied  Health
                Rogene Dilley                               Steno-Secretary

                      Pr                   n & Health Information Svstems Division

                James C. Syner, M.D.                        Associate Director
                W.C. Morse, Ph.D.                           Chief, Project Administration
                F'R. Normile                                Chief, Project Development
                Hubert Brandon                              Health Administration  Specialist
                Gerald F. Fournier                          Health Administration  Specialist
                William 0. Hastings                         Chief, Project Audit & Control
                Norman S. Holt                              Wyoming Liaison Officer
                Heinz Mueller                               Health Administration  Specialist
                Dee Trees                                   Steno-Secretary
                Peggy Oliver                                Steno-Secretary

                                      Continuing Education  Division

                James E.  Dyson,  Ph.D.                     Associate Director

                                    ,,Cardiovascular Disease Division

                Robert C.  Jones,  M.D.                     Associate Director
                M. Lynn McCracken, R.N.                     Health Services Education Specialist


                                        8
    COU)RADO-WYOMING RNP                                     RM40-03 (AR-1-CDS) 1/71

           Regional Advisory Group Structure:

           Physicians  and  Dentists                4            1           5
           Medical Center Representatives           4            0           4
           Hospital   Administrators                3            2           5

           Society  and  Association
           Representatives                          4            1           5

                                                    2  Nurses Association

                                                    2  State  Medical  Society

                                                    1  Osteopathic Association

           Voluntary Agency - Representatives       2            1           3

           Public  Health  Officials                1            1           2

           Public                                   11           1           12

                                                    1  Spanish Sur-name

                                                    1  Negro

           Other                                    4            0           4

                                                    1  Nurse

                                                    1  Head   Start

                                                    1  Model   City

                                       TOTAL        33           7           40

           Program Analysis Memo shows three meetings were held during 1969 with
           an average attendance of 29 (62%) members.


                                                    DIVISIC,N OF   ',RI':GIONAL @@DICAL Fr,.CGr@"',S

                                                             '.REGIO.NAL ADVISO.RY Groy@T?

         ST-A.@DMNG CO@l"rLTTE!I!S
           Cont'-nu4-ng @-ducnv'_ion
                                                                                      T@z
                                                                 NISTL@TIVZ  CO@-!-L
           S't @o.@c

             "Cer
                                                                                                                                                 cli

                                                                                                                             REVT-l.:,N, co
                                                                                                                     STAF
                EVA,J@,  O,\'  CO.\-Nrr

                   & An@ll\'TST
               A                                                                                                            OF17TCE
                          07.'-T'LCE

                                                                                       @STON OF   CON
                                                          or PRO.,,rCT               V                TINUING               DIVT@SIO.N' C'T
               D,,rllis@ON cr         i            L -                           I                                                                  I
                                      i    'I A-n%!'@,N"-S-Li",ATION @ !!EALTI!             ::!)'JCATION             'CA:MIOVASC'-T'@-k--",
                                                        Tlo\ SYS@LE,,"-g


       COLORADO-WYOMNG RMP              10               RM 40-03 (AR-1-CDS) 2171

              The Goal or "Grand Ideal" of cwRMP is stated as follows:
              Reduce the adverse impact of heart diseare,cancer, stroke, related
              and other diseases, and thereby improve the quality of life for all
              citizens."

                                 to the practicing physician to            expansion
              (1) Provide support                               achieve an
                 of his productivity.
              (2) Assist in providing forti-ii!, immediate health service needs of the
                 poor in both urban and rural areas.
              (3) Provide quality care as geographically close to the patient as
                 is consistent with the most economical allocation of scarce health
                 resources.
              (4) Accomplish a continuous evaluation of progress towards program
                 objectives.
              (5) Coordinate closely with the community hospital as a primary entry
                 point for CWRMP influence in each health service area, to assist
                 in transforming them into community health centers.
              (6) Develop an improved working alliance with Comprehensive Healt
                 Planning based on cooperative arrangements for project development
                 utilizing the Community Comprehensive Health Planning Council, i.e.,
                 the 314 (b) agency.

                           in  strate
              e ion's WWoorrkking Strategy
              The basic working strategy utilized by CWRMP to accomplish its objectives
              is through the establishment of cooperative arrangements in project
              planning, design, and implementation with the health resources of the
              region.


          COLORAD@WiOMN(; RMP                                              RM-40-03 (AR-1-CDS)         71
                          PRO-@l.-"CT  REVIFW  PROCESS

                                                                 prOJFC"c
                                                               PROL)OSAT,
                                                                   to
                                                                  ctliulp

                                                        etc-rr,iination  of  me  it,
                                                     IUFP    Guidelines    relevance
                                                      by kiioi.:lcdgea ble Cl-,IPJ.IP
                                                     Staff    and/or    Consultants.

                                                        CWPI-IP liaison       qssists
                                                     originator    in    development
                                                     for presentation  to  C14P,'-IP
                                                     STAFF RFVI@,!,! CO,'-U,@IITI'EE.

                                                   Ori-inator  and  C@-1pjlp   Staff
                                                 presents   Project   Proposal    to
                                                     appropriate         categorical
                                                     Cormnittee    for    Scientific
                                                     Merit  and  @-!P  rel.(,v@ince.

                        IIEART
                                                                                                            'ITS
                                                                                                           A,,

                                                     Revised    Project     Proposai
                                               presented to the Administrative
                                                     Committee  of  RAG   in   broad
                                                     abstract   and   budoet   form.

                                               - - - - - - - - - - - - - - - -
                                                     Project    Proposal     revised
                                                       into   detailed   form    for
                                                        presentation to RN(,.

                                  A  Primary and Secoticlar  Pcvl-ci,ier Dc@,,;!-nated from PAG
                                                              y
                                     for presentation to the Rcgioiiil A(Ivlsory Group.
                                         "Blue Slieet" sent to eicli RAG nioril)cr prior
                                                   to P,.ccti.n-  wliicli  contains:
                                                   1.  Proposal objectives
                                                   2.  Review cycle action,
                                                   3.   Stiff co-,iir-,ir-,nts on rierit.

                                             RAG Pritiliry aiid Secondary R(,vie,,.Yers
                                            present fiii@ili7.e,(l project proposil to
                                             RAG iiient)(,rs.  Cl-ilt'.IP Stiff assists ill
                                                 presentation t,,Iien  reqLIO.StC(l.
                                               ;ATI approved Projec't Proposal is
                                                      f o rl4,1 r(I @. LI 1) l@ L- I Pfor
                                                                   LO


     COLORADO-W'YOMNG RMP               - 12                RM 40-03 (AR-1-CDS) 7/71

            New Operational.Projects!                                    Requested
                                                                         First Year
            Project #22 - Rural Health Services for Migrant and           $164,466
                         Seasonal Workers. The Colorado Migrant Council
            with the assistance of Core Staff, drafted this  proposal  to  help
            eliminate fragmentation of resources, and coordinate the existing services to
            the rural poor who are to a large degree, migrant  workers  who  have
            settled permanately in the region. Five  teams,  each  consisting  of
            one area coordinator End two indigenous family contact workers, supported
            by the project will work to accomplish three basic objectives:
              .1.  Develop health and supportive  resources  when  they  o  not
                   exist in impact areas.

               2.  Educate the farmworker and his family to utilize health
                   services that are available.

               3.  Develop rural health "coalitions" in the impact areas to serve
                   as the coordination bases  for  farmworkers,  growers,  agency
                   efforts.
            The proposal is founded upon the basic working strategy of establishing
            cooperative arrangements among providers and  consumers  of  health
            services and is no direct support of the CWRMP  objective  to  provide
            health care services to the poor.
            Second Year:  $173,333                     Third Year:  $184,792

                                                                              Requested
                                                                              First Year
            Project #23 - Comprehensive Community Neurological Service for      $59,244
                          Denver.  Request is being made by the Denver
            Department of Health and Hospitals for one year support of  a  project
            which was initiated on October 1, 1967 with 314 (e)  funds  and  will
            terminate on December 31, 1970.  The project provides comprehensive
            neurologic services to the patients of Denver  General  Hospital  and
            the Denver Neighborhood Health Centers.  Most of the patients are
            urban poor, medically indigent, and include a  high  percentage  of
            Hispanos, Blacks, drug and al6cohol abusers, the aged, and the
            chronically ill. Their most frequent  diseases  are  stroke  siezures
            of varying causes, and degradive disturbances related  to  alcoholism.
            The project encompasses an in-patient neurology  service  and  consultation
            service at Denver General Hospital, an out-patient  neurology  clinic,
            an electroencephalogram laboratory, and an intensive training program
            in clinical neurology for medical students, intern residents, and various
            other physicians affiliated with Denver General Hospital  and  the  Univer-
            sity of Colorado School of Medicine. Support is  requested  for  a  project
            director, an EEG technician, a secretary, and a resident in
            neurology from the training program in neurology of the University.
            The Department of Health and Hospitals of Denver will assume financial
            responsibility when RMP support abates.


          COLORMO-WYOMNG RHP                  - 13               40-03 (AR-1-CDS)  ?/71

                                                                                   Requested
                                                                                   First Year

               This project provides services to the urban poor, a group whose
               health care has been declared a high priority  both  nationally  and by
               the CWRMP.
               First Year:  $59,244       Second Year: - 0 -          Third Year:  - 0 -
               Project #24 - Family Health Workers as Agents of Change of         $147,067
                             Primary Preventive Care -- 1971.  This project
               is sponsored by the Tri-County Health Department (Adams, Arapahoe, and
               Douglas).  It proposes a dual approach to removing barriers which impede
               access to the stream of health care for the consumer.  It is an attempt
               to (a) initiate a family health worker training program and (b) introduce
               additional screening tests into a mobile unit program currently operating
               with a singular focus on uterine  cancer  detection.  This  proposal
               is intended  to demonstrate more effective methods of utilizing manpower
               and facilitating access to health care resources.  Expansion is
               intended to proceed only after rigid assessment of each element
               introduced to insure that the system proposed is,  in  fact,  dealing
               appropriately with consumer requirements.  The training program for
               family health workers has as two of its  objectives  gaining  program
               certification and defining more clearly the tasks  to  be  performed
               by the trainee.  Once these tasks are clearly defined, more realistic
               career patterns can be established.  Detailed and flexible job
               descriptions which include guidelines for  continuing  education  as
               well as for performance expectations, for four levels of family
               health workers have been prepared. The agency  has  a  job  appraisal
               system which emphasizes the superviser'8  participation  in  setting
               job-related goals. The objectives to which this project relates most
               closely are:  dealing with the problems of the urban poor, providing
               health care services to females with cervical cancer, addressing
               itself to the health manpower problem and improving provision o
               preventive care.
               First Year: $147,067          Second Year: - 0 -      Third Year:-  0


        COLORADO-WYOMNG RMP                                RM 40-01 (AR-1-CDS) 7/71

                                         -14-

                                     Developmental Component

            The overall rationale for Developmental Component funds is to  test
            the feasibility and potential of spontaneously occurring opportunities
            to further CWRMP objectives.

            The basic strategy to be followed in determining allocation of funds
            will proceed as follows:

              (1)  Maintain and enhance in CWRMP core staff a state of "sensitivity"
                   for new and potential "targets of opportunity," which hold promise
                   of contributing to overall program goals.

              (2)  Assure that CWRMP core staff are available to assist the
                   "innovators" of ways to effect improved health care delivery.

              (3)  Gather data and promote interpersonal relationships at
                   community levels to establish a realistic definition of needs.

              (4)  Encourage the involvement and the development, of cooperative
                   arrangements among institutions, agencies, and  organizations
                   which can serve as resource functions in resolving  problems.

              (5)  Utilize the CWRMP Evaluation Committee to document, organize,
                   and process information.
              (6)  Coordinate all involved parties (innovators, community citizens,
                   cooperating agencies, and CWRNP staff) to react to total imputs,-
                   and finalize an output which constitutes that action scheme
                   designed to resolve the problem and, thereby, serve as a valuable
                   contribution to the grand goal of CWRIIP.


         CO        WYORING RMP                                  RM 40-01 (AR-1-CDS) ?/71
                                            15

                      Funde@     ation

                      #1    CORE STAFF

                            objectives: This project is to  support  core  planning  and
                                         evaluation activities of  the  Colorado-Wyomina,
                            Regional Medical Program.  Staff is divided into four offices
                            and three divisions: (1) Professional  Division;  (2)  Division
                            of Continuing Education; (3) Project Administration and
                            Health Information Systems.  Full-time equivalent staff are
                            requested as follows: Office  of  Coordinator  (1),  Office
                            of Director (2.2), Office of Executive Assistant (13),
                            office of Communication and Public Information  (3),  Divi.sion
                            of Professional Acti-vities (7), Division of  Planning  and
                            operations (7.75), and Division of Health Data and  Pr,-)gram
                             valuation (6).

                      #2    COLORADO STATE CANCER REGISTRY

                            Objectives: The basic objective of this  project  is  to  develop
                                         a computerized statewide  cancer  registry  to
                            improve follow-up to as near as 100% as  possible  and  through
                            utilization of registry data, to provide  the  cancer  patients
                            of Colorado with the best care and earliest diagnosis possible.
                            Improved follow-up of (1) treatment failure,  (2)  second  .
                            primaries in Kansas Cancer patients,  and  (3)  determination
                            of need for treatment changes in those  patients  known  to
                            have cancer.  Extension of registries to all hospitals  '
                            improved continuing education and constant  evaluation  arc,
                            also goals. This project relates to the third  NaL!ot@il  Cancc-r
                            Institute Survey of Cancer Incidence and  Prevalence  and  a
                            proposed six-state Rocky Mountain Tumor Registry.  The
                            Colorado Department of Public Health i,7ill be the headquarters
                            for this activity.

                      #3    MULTI-MEDIA EDUCATION

                            Objectives:  This continuing education project will develop
                                         pa prototype system for videotape  exchange  and
                            closed-circuit TV involving first, the  Denver  Medical  Society,
                            the University of Colorado Medical Center, Presbyterian
                            Hospital and St. Joseph's Hospital of  Denver,  and  later,
                            seven other Denver hospitals. The TV system will  be  cop,.,erted
                            to color later and if CCTV is  extended  throughout  Colorado
                            and Wyoming,'(1) will be  extended to hospitals throt-i@,h -jut


     COLORADO-WYOKING  RMP-                  JLO               RM 40-01 (AR-1-CDS) 7/71

                          the Region, (2) produce and distribute videotapes to
                          hospitals in the Region, (3) produce and distribute     single
                          concept'films, slides and film-strips to Regional hospitals.
                          A catalog of existing educational materials and staff con-
                          sultation to local hospitals are other features of the
                          project.  The Office of Audio-Visual Education in the Health
                          Sciences of-the University of Colorado Medical Center is
                          headquarters for the project.

                          HOME DIALYSIS TRAINING PROGRAM
                          Objectives:  This project is to improve understanding of
                                       health personnel and the public in the treat-
                          ment of kidney disease and of the problems experienced by
                          renal patients, to enhance community  involvement  in  the
                          rehabilitation of patients undergoing  home  dialysis,  to
                          provide consultation to community health personnel, to
                          provide highly specialized laboratory services when required,
                          and to develop the capability to provide emergency services
                          for home dialysis patients.  Training plans include:
                          (1) three-day orientation for 30 physicians and 25 public
                          health nurses; (2) five-day orientation for five physicians;
                          (3) ten-day training for five physicians from hospitals  .
                          planning home dialysis service; (4) two-week training session
                          for seven nurses and for technicians from hospitals planning
                          a service program, three-day training for ten dieticians,
                                       -day conference of 20 social worker
                          (5) one  three                                    s and
                          rehabilitation personnel; (6) one three-day orientation for
                          five clergy, welfare workers,  pharmacists  and  community
                          leaders; (7) five one-two day conferences  for  50  health
                          related and community-oriented.,,individuals; and (8) six-week
                          training for family members of patients.  Travel and per
                          them is requested for all these groups.
                   #6     TRAINING AND APPLIED RESEARCH FOR INI'ENSIVE AND T,',T@!iAJ,'I!,ITATIV--,
                          RESPIRATORY CARE
                          Objectives:  To (I.) finiiliarizc, physicians and paraiiiecli.cal
                                       personnel of the magnitude of the emphysema-
                          chronic bronchitis problem; (2) disseminate knowledge on
                          the latest advances in the Treatment of the problem;
                          (3) to promote and assist in the establishment of respiratory
                          care-progranis in local. communities; (4) obtain greater know-
                          ledge on the effectiveness of home oxygen for both hypoxeinia
                          and non-hypoxemia individuals; and (5) intreasc the effective--
                          ness of therapy through the development of improved ventilators
                          and nebulization devices as well as the ad4ition of humidi-
                          fication de-vices to existing oxygen equipment.


                                           - 17 -              RM-40-03  (AR-1-CDS)  2/71
        R-OLORADO-WYOMNG RNP

                      #7 -- RADIATION THEKAPY AND NUCLEAR MEDICINE

                             Objectives: Technology Training.  To  reduce  the  acute
                                          shortage of well-trained radiation therapy
                             and nuclear medicine technologists by  establishing  Associ-
                             ate Degree two-year training programs in  radiation  therapy
                             and nuclear medicine technology. The  programs  will  be
                             offered by the Denver Community College in conjunction with
                             nine hospitals in the Denver area: (1) Colorado General,
                             (2) Denver General, (3) Fitzsimmons General,  (4)  Lutheran,
                             (5) Mercy, (6) Presbyterian Medical Center, (7) St. Anthony's,
                             (8) St. Luke's and (9) General Rose Memorial.  It is expected
                             that at least forty students per year will graduate from
                             the training programs.

                      #8     COLORADO INTERAGENCY COUNCIL ON SMOKING AND  HEALTH  PROGRAM

                             Objectives: To continue support of  an  Interagency  Council
                                          on Smoking and Health.  The prime source of
                             funding for the Council (which paid the salary of a coordina-
                             tor and a secretary) has been through a Special Project Grant
                             from the Public Health Service. This source  of  funding  is
                             no longer available due to budget limitations.  The general
                             objectives of this proposal are: (1) coordination of Council
                             member activities pertaining to smoking and health and pro-
                             motion of more efficient communication  between  Council
                             agencies; and (2) continuation of efforts  on  a  long-range
                             program aimed at permanent financing of the  Council  within
                             the State of Colorado.

                      #9     CONTINUING EDUCATION CORE PROGRAM FOR NURSES
                             Objectives: Based at University of Colorado  School,  of
                                          Nursing, would provide integrated  training  in
                             intensive nursing care.

                     #10     CONTINUING EDUCATION STAFF
                             Objectives:  Develop continuing E@ducation staff in Colorado-
                                          Wyoming RMP to counsel with communities interested
                             in developing local  continuing  education  programs.  Staff
                             teams woul.dprovide consultation to local hospitals.
                             Development of local consultation teams would also be encouraged
                             with RMP staff assistance provided to fill gaps in local.
                             expertise.


                                                               RM-40-01 (AR-1-CDS) 2/71
       COLORADO-WYOMING RMP
              #13    PEDIATRIC PULMONARY

                     Objectives:  Expand existing -facilities and capabilities of
                                  pediatric 'pulmonary program at University of.
                     .Colorado Medical Center.  Program will seek to familiarize
                     the medical personnel in New Mexico, western Kansas, western
                     Nebraska, Colorado, Wyoming, Montana.and Utah with the
                     facilities at this Center to attract more and earlier
                     referrals.  Will concern itself  with comprehensive management
                     and training programs of all acute and chronic neonatal and
                     pediatric pulmonary diseases.

              #14    THE STATISTICAL DIAGNOSIS AND PROGNOSIS OF CANCERS

                     Objectives:  Involves a retrospective study of approximately
                                  300 patients at the Penrose Cancer Hospital
                     to determine the results of 15 routine diagnostic procedures
                     or observations.  An aspect of this proposal involves con-
                     tinuing education of the physician.

              #15    A REGIONAL PEDIATRIC ONCOLOGY CENTER FOR RESEARCH AN]i  TRAINING

                     Objectives:  Assist the Children's Hospital of Denver develop
                                  as a regional center for pediatric oncology.
                     Involves application and evaluation of new approaches in
                     the treatment of cancer, continued evaluation of currently
                     supported research projects, correlation of data with other
                     research centers, and a continuing education, training and
                     fellowship program.                                                     r

             #16     COMPREHENSIVE CARDIAC CARE PROJECT

                     Objectives:  Project is to be administered by the Colorado
                                . Heart Association through an affiliation
                     agreement with the Colorado-lqyoming &"IP.  The overall ob-
                     jective of improving the delivery of health care to patients
                     with cardiac disease is to be accomplished by a stq)by step
                     plan.

                #18 -- I@IRROVED CARE OF THE PATIENT WITH ADVANCED CANCER

                       Objectives:  This proposal is sponsored by the American Medical
                                    Center, a non-profit eighty-five bed hospital
                       which provides care to cancer patients from all over the United
                       States. The purpose of the proposal is to establish  a  train-
                       ing program for nurses in the care of the advanced cancer
                       patient, and to cultivate in these nursing personnel the  more
                       hopeful and challenging aspects of oncological nursing.

                #19    CHRONIC DISEASE EVALUATION AND MANAGEMENT PATIENT CARE

                       Objectives: This project, sponsored by the University of
                                   of Colorado School of Nursing, Continuing
                       Education Services, is designed to train nurses and other
                       health workers in long-term care and rehabilitation of
                       patients with chronic conditions such as diabetes,  orthopedic
                       and neurologic problems, cancer, cardiac disease and other
                             --- Tll ------


                  COLORADO-WYWiAl'kgp. RMP
                                                                                           RM 40-01 (AR-t@CDS) ?/71

                                      SMIARY OF      OPERATIONAL PROJECTS CURRENTLY
                                       BEING SUPPORTED BY COLORADO-14YOMING @ID

                                                              Future Years of                      Funded (d.c.)
                  Project Title and Number                    Commit. Support                    1/l/70-12/31/70

                  Core                                                                             $489,451
                  Sub-Contract (Pueblo)                                                               39,576
                  Total Core
                                                                                                   $529,027

                  #2    State   Cancer        Registry                   1
                                                                                                   $    50,340,

                  @#3   Multi-,Media         Education                   1                            34    739

                  #4    Home Dialysis Training             Program       1                            39,,719

                  #6    Training and Applied Research                                                   120,738
                        for Intensive and Rehabilita-
                        t.ive     Respiratory     Care
                  #7 - Radiation Therapy and Nuclear                                                  58',275
                        Medicine Technology Training
                  #8    Interagency     Council     on     Smoking       1                            25,294
                        and Health

                  #9    Continuing     Education     Core     Pro-       1                            70,91.2
                        gram for Nurses
                  #10     Continuing      Education      Staff           1                            90,687
                  #13     Pediatric      Pulmonary      Center           0                            75,956

                  #14   - Statistical Diagnosis a-Lid                    I                            13,317
                          Prognosis     of     Cancers

                  iII5  - Pediatric Oncology Center                     1                             733727

                  #16   - Comprehcnsive      Cardiac      Care          0                             42,798

                  ,#18  - Improved    Care    for    tht*,PaLi.ent      2                             15;@700
                          with     Advanced     Cancer
                  #19   - Chronic      Discese      Evaluation          2                             41;582
                          and MnnageinenL of Patient Care

                                                                            TOTAL                  $1,2.82,81.5


         COI,ORADO-WYOMING KMP                                       RH      03 (AR- I -tt;Uzi f I L
                                               20---                   -@40

                                 STATUS OF UNFUNDED PROJECTS

         Project Title & Number              Approved Project                 Status
                                                    Period

         #5  Multiphasic Screening                   0                     Not   Approved
                                                                           for   Funding

         #11   Facilitation   of Lear ning           0                     Not   Approved
                                                                           for   Funding

         #12   Continuing Education Workshop         0                     Not   Approved
                                                                           for   Funding

               A Training Prograin for the
                                                   1 2                     Approved   but
               Development of Ultrasonic                                   Unfunded
               T'echniques in Community Ilospitals
         #20   Daily Update of Laboratory            0                     Not  Apprrived
               Reports                                                     for  Fundirig
         #13R   Diagnosis and Treatment    of        0                     Returned   for
                Pediatric Pulmonary Problems                               Revision
         #21   Radiation Therapy Planning in         3                     Approved   but
               Community Hospital. by Time-                                Unfunded
               Sharing Computer


                                SUMMARY OF REVIEW AND CONCLUSION OF
                                   JANUARY 1971 REVIEW COMMITTEE

                            COLORADO/WYOMING REGIONAL MEDICAL PROCRUL
                                     RM 40-03 (AR-1-CDS)   2/71

                        FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

                Recommendation4 No additional funds be provided for this application.

                Year                     R&quest           Recommended Funding

                ist  Year                $508   843              -0-
                2Ad  Year                $204,922                -0-
                3rd  Year                $218,732                -0-

                @Total                   $932,497                -0-

                @r        Committee concurred with the si.te visit report which concluded
                          that this Region has not obtained the degree of sophistication
                   ch might be expect6d after two years of planning And two
                                                                                   years
                6f@opetational status.  At this point in time, it still remains project
                or   ted and little thought has been given to the expanded responsibilities
                @of  e  RAG  in  setting  specific  oals,  objectives,  and   riorities
                                                  9                        p
                whi  @would represent a'total program.  A ong the same lines,
                there is little  evidence  that  the  numerous  data  resources  within
                ihe,Rpgi6n are being  used  for  the  assessment  of  needs.  Also  the
                Region has not taken it upon  itself  to  lead  the  way  in  stimulating
                projects related to a  specific  program,  but  rather  has  tended  t)
                ser   more@as a broker for projects spontaneously generated by.
                various health organizations.  Based upon these observations Committee
                agreed additional support for projects and the developmental
                component were not justified  at  this  time,  but  that  the  Region
                sh6 ld take its upcoming  03-year  of  operation  to  put  its  house
                in  rder for its Triennium Application.  It was noted that this
                wil be a critical  @ear  for  CWRNP  and'hotd  decisions  will  have  to
                be ade in order  to  turn  from  being  project  oriented,  to  which  it
                is  omewha@ io6ked,   to being program oriented.  Committee concluded
                s did the  site  visitors  that  talented  resources  exist  within  both
                @the RAG and Core staff to  make  the  desired  transformation,  but  it
                was aRreed  expansion  of   funding should be-reserved until sutb
                transformation   is   demonstrated.

                @Although Committee was a!dare of the fact  that  the  site  visit  team
                had sD6nt  considerable  time  discussing  its  observations  with  the
                regional personnel, it emphasized the need for both written and
                otal feedback by @IPS  staff.  While  it  was  agreed  the  site  visit
                report should not be made  available  to  the  Region,  it  was  felt
                th  written feedback should  carry  the  same  basic  message  and  tone,
                  c   ing Committee  and  Council's  input,  and  should  be  interpreted
                and com-D em nted by the verbal message.


              Coloiado/Wyoming RMP              -2-                  RM 00040  2/71

              Two troiects (#23 & 2-4) were given minor consi eration in that
              each were pick-ups of other federal grants which are terminating.
              The site visitors believed RNPS support of these projects was
              inappropriate in view of the National Advisory Council's recent
              policy re-affirming "Regional Medical Programs funds are not to,
              replace Rrant6 lost through discontinuance or reduction of other
              grant program8.11  Committee felt the site visitors were being
              too strict in their interpretation and pointed out that such pi6k-ups
              are appropriate so long as they: " (a) respond to a recognized
              need for local regibnalization and improvement; and (b) demonstrate
              that they ate integrating into the Regionvs health care system in a
              way that will Dormit disengagement of Regional Medical Program
              funding within a short time."

              Dr. Kralevski was not present during Committee discussion or action
              on the application

                                                         GRB/RMPS
                                                         1/13/71


          0                                                              0                                                              0


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

                   CONNECTICUT REGIONAL MEDICAL                   RM 00008 2/71.1 (CS)
                   PROGRAM                                        January 1971 Review Com7nittee
                   272 George Street
                   New Haven, Connecticut 06510

                   Program Coordinator: Henry T. (@lark, Jr., M.D.

                                       REQUEST (Direct  Costs)
                                                                              03  Year
                                                                            (1/71-12/71)

                   COMMITTEE/COUNCIL REVIEW:

                         Renewal for CUPISS                                   $60,496
                         New Project - Newborn Program                          26,270

                             TOTAL REQUEST                                      86,766
                   -------------------------------------------------------------------

                   RMPS STAFF REVIEW:

                     Continuatio      uest
                         Commitment for Core                                  381,000
                         Commitment for ongoing activities                    939,750
                         Carryover                                            133,860

                     TOTAL CONTINUATION-REQUEST                              1,454,610
                     ----------------------------------------------------------------

                     Action on Continuati       uest
                         Approval of total commitment                        1,320,750
                         Disapproval of carryover request                      -0-

                     TOTAL 03 YEAR AWARD                                    $1,320,750

                                                FUNDING HISTORY
                                                (Planning Stage)

                        Grant  Year            Period              Funded (4.co@.

                           ol                7/66-6/67                 $344,796
                           02                7/67-12/68                $31.3,000
                                             (18 months)


               CONNECTICUT RMP                      2 -                  RNi 00008  2/71.1

                                      Operational Program

                                            Council        Funded            Future
               Grant Year      Period       Approved        (d.c.o.)        Commitment

                 01          1/69-12/69     $1.,633,978   $1,320,750        -------
                 02           .1/70-12/70   $2,372,333,, $1,650,937-1/      -------
                 03          1/71-12/71-    $2,693,58@/, $1,320,750         -------
                 04          1/72-12/72         137,96@/                     None
                 05          1/73-12/73         145,4471/                    None

               I/ Includes carryover funding    of $330,187
               2/ Includes recommendation of    November 70 Council

               HISTORY: The Connecticut Regional Medical Program began its two-year
                        planning phase in July 1966.  Transition to operational
               status was  a  lengthy  process  requiring  multiple  Committee/Council
               reviews and two site  visits.  The  major  areas  of  concern  revolved
               around: (1) The Region's  emphasis  on  a  comprehensive  approach  with
               almost complete absence of categorical considerations, (2) Cooperative
               arrangements with, and support  for  the  program  of,  groups  upon
               which  implementation  would  depend,  specifically  the  practicing
               physicians ( as represented by the Connecticut State Medical
               Society).  The  reviewing  bodies,  after  considerable   deliberation,
               accepted Cl@P's Grand Design, with its intermingling of RMP and
               CIIP activities.  Further,  although  CRMP's  differences  with  the
               Connecticut State Medical Society were not resolved, it appeared that progress
               was being made toward resolution and that the rest of the Region
               was solidly behind the Program.  An 01 year operational award
               of $1,320,750 was made in January  1969,  calculated  on  the  basis  of
               100% funding for core and 75% funding of the Council-approved amounts
               for projects.

               Staff review of the 02 year continuation application and a subsequent
               request for the use of carryover resulted in an 02 year operational
               award of  $1,650,937,  representing  the  commitment  of  $1,320,750
               for core and twelve  projects  and  carryover  funding  of  $330,187
               for expansion of four ongoing projects and initiation of six
               others. Although  these  six  activities  did  not  receive  Council
               review, staff felt that CRMP's original operational application
               spelled out the broad thrust  of  emphasis  and  that  these  activities
               were covered well by the umbrella of Connecticut's grand design.

               A proposal in the October/November 1970 review cycle, which requested
               supplemental funding for seven new activities, resulted in approval
               in the reduced  amount  of  $183,348.  This  amount  was  calculated
               on the basis of the requested  funding  for  two  projects  --  Planning
               Neighborhood Services  in  Hartford  and  Southern  Connecticut  Kidney
               Disease Program.  Neither activity has been funded.


              CONNECTICUT RMP                    - 3 -                 RM  00008   2/71.1

              Coiinecticut's 03  year continuation request recently was reviewed by staff.
              The  proposal  received a favorable review, and it was,agreed that the Region
              had done a  superb  job of explaining the grand  design  itself  and  relating
              all activities  to  the overall program objectives.  Although the continuation
              application   requested the use of  approximately  $130,000  carryover  (with
              the promise  of  future carryover requests  totaling  around  $60,000)  the
              recent RMPS policy prohibiting awards  of  carryover  resulted  in  CRMP's
              receiving an award in the amount of the 03 year commitment only --
              $1,320,750.  It was suggested, however, that when procedures are
              developed for Regions to apply for new money on a competitive basis,
              a request for some additional funding  for  the  University  and  Community-
              based faculty at the University of Connecticut  would  be  looked  upon
              favorably by staff. Th& funding history at  the  end  of  this  summary
              sheet provides details on the distribution of the Region's funding
              level of $1,320,750 among the various segments  of  the  grand  design.

              Connecticut Regional Medical Program  will  submit  its  first  anniversary
              application on August 1, 1971 for review  by  October  /November  1971  Com-
              mittee and Council.

              PROGRAM EMPHASIS: CRMP's grand design  was  spelled  out  in  the  original
                                  operational grant application  and  has  remained  con-
              stant. The program objectives focus  on  quality  of  care,  provision  of
              service, and economy of delivering  health  services.  The  Region  has
              been divided into ten health service  areas  for  grass  roots  programming
              and planning, and within this context  the  community  hospital  is  viewed
              as the primary entry point for CRMP influence in each area.  Five
              categories of program emphasis have been  identified  as  necessary  to
              reach the Region's objectives:

                   1.  Research and Evalution --  primarily  directed  toward  research  on
                       health conditions and practices.

                   2.  Health Service Area  Program  Assistance  --  channeling  research
                       findings into planning at the local level

                   3.' University-Community  Hospital  Partnerships  --  revolving  around
                       the theory that each community  hospital  will  require  a  small
                       cadre of full-time professional  staff  to  provide  the  necessary
                       leadership in implementing  planning  results  and  in  developing
                       educational programs, to be aided in turn by a cadre of
                       university-basled faculty oriented toward the problems and
                       needs of the community.

                   4.  Clinical Services --  charting  more  effective  statewide  clinical
                       services.

                   5*  Health Profession Education  --  stimulating  and  assisting  health
                       education activities which have statewide implications.


        CONN],"CTICUT ITMP                     4                      ItM 00008  2/71.1

        PRESENT REQUEST: The portion of the 03-year application for which Committee/
                          Council review is required  consists  of  a  renewal  request
        for one additional year's funding  for  CUPISS  and  a  supplemental  request
        for support for a regional newborn program.

        Project #lR - Connecticut Utilization Patient Information and        Requested
                       Statistical System (CUPISS).  This renewal            03  Year
        request is for a third year of funding for CUPISS.  The system       $60,496
        is described as a new  approach  to  the  collection  and  utilization
        of basic health data on a large population  group  which  can  be  used  to
        promote quality and efficiency of  health  services,  to  help  measure  the
        effectiveness of various  therapeutic  programs,  and  assist  in  planning
        new facilities and  services.  RMP  provided  partial  funding  for  this
        program in 1969 and 1970 totaling $173,161, and the main thrus,t of acti-
        vities during those two  years  pertained  to  research  and  development
        concerning the  provision  of  institutional  services  through  utilization
        review reports, institutional performance indices, and operating statistics.
        Initially it was expected that  these  services  would  be  operational  in
        several hospitals by the  end  of  1970.  However,  the  ambitiousness  of
        the design and the difficulty  of  its  initial  implementation  have  slowed
        progress so that the full system has been installed in only three,
        hospitals, although installation has begun in 17 others.

        The third-year support requested in this application is for       analysis
        of data which is Accumulating through the expanding system.       This
        analysis is expected to provide basic  data  with  which  to  evaluate  the
        overall performance of CRMP as well  as  to  provide  guides  to  agencies
        concerned with the future  development  of  the  health  delivery  system
        of Connecticut.
                                                                           Requested
                                                                            First  Year
        Project #33 - Yale-New Haven Regional Newborn Special Care           $26,270
                       Unit. The primary purpose of this proposal is the
        improvement of care of critically  ill  new  born  infants  in  Connecticut,
        through the development of more effective cooperative arrangements
        between the Yale-New Haven Hospital  and  the  general  hospitals  of  the
        state. Specifically, funds  are  sought  to  develop  a  model  ambulance
        service, to purchase  additional  monitoring  equipment  for  the  existing
        newborn special care unit, and to complete the equipment of a radiological
        suite so it can be used  for  the  cardiovascular  investigation  of  newborn
        infants suffering from congenital heart disease.

        This request originally was submitted in May 1970 for funding from
        carryover monies. Although  the  general  idea  was  viewed  favorably,  the
        fact of the proposal's being heavily an equipment request prompted staff
        to act negatively on the carryover  request  and  return  the  proposal  to
        the Region with the suggestion that it be resubmitted for Committee/Council
        review4

        The proposed activities relate to  the  portion  of  CRMP's  grand  design
        pertaining to  University"Community  Hospital  Partnerships,  and  it  is
        hoped that this  program  will  encourage  greater  collaborative  planning


              CONNECTICUT RMP                          -5-                    RM 00008 2/71.1

              between pediatric specialists at Yale and physicians in community
              hospitals.  The request is for one year's funding only.

                                        FUNDING HISTORY

                                                                       03   YEAR
              Project & Sponsoring Institution                         SUPPORT           DATE
                                                                     (1/71-12/71)     INITIATED
              RESEARCH AND EVALUATION

              #1    Connecticut  Utilization  &   Patient              Renewal in        1/69
                    Information  Statistical  System   -               Review
                    CUPISS (Yale)

              #13    Inventory of Health Resources (Yale)              $11,250           1/69

              #17    Financing  of  Health  Care  (Yale)                18,750           7/66

              #19    Research  Program  Planning   (Yale & U. Conn.)    36,831           1/69

              #20    Regional Blood Bank (U. Conn.)                     49,365           6/70

              #2B    Research Program Activities (Yale)                 39,966           6/70

              HEALTH  SERVICE  AREA  PROGRAM   ASSISTANCE

              #2A - Health Service Area Planning (Yale)                 24,850           1/69

              #3 - Continuing Care Demonstration (Yale)                 93,000           1/69

              #21  -  Stroke  Coordinator   Demonstration
                      (Gaylord Hospital)                                32,000           6/70

              UNIVERSITY-COMKUNITY HOSPITAL PARTNERSHIPS

              #5  -  Community-based  Regional   Faculty               157,500           1/69

              #6  -  University-based  Regional   Faculty              2825707           1/69
                      (Yale & U. Conn.)

              #23  -  Gastroenterology  (Yale  &  Others)               42,073           6  70

              #24 - South Central Diabetic Consultation (Yale)          25,194           6/70

              CLINICAL SERVICES

              #7 - Regional Coronary Care (Hospital of St.              32,172           1/69
                                                   Raphael)
              HEALTH PROFESSION EDUCATION

              #11 - Nursing and Allied Health (Yale & U.Conn.)          32,000           1/69

              #12 - Regional Library Service (Yale & U. Conn.)          62,092           1/69


            CONNECTICUT RMP                   6                   RM 00008   2/71.1

            (Funding History Continued)

            CENTRAL CRMP STAFF
            #18 - Core                                          381,000         7/66
                                                  Total       $1,320,750

            PROJECTS NOT FUNDED BY THE REGION

            Patient Care Workshops
            Study of Physician Office Practice
            Patient Status Study
            Organization and Delivery of Medical Care

            PROJECTS WITHDRAWN FROM CONSIDERATION

            High Energy Radiation Services

            DISAPPROVED PROJECTS

            Regional Clinical Reference Laboratory
            University of Connecticut School of Nursing, Regional Faculty
            Regional Reference Laboratory
            Regional Nuclear Medicine Program
            University of Connecticut Planning for School of Allied Health Professions

            APPROVED/UNFUNDED PROJECTS

            Planning Neighborhood Services in Hartford
            Southern Connecticut Kidney Disease Program

                                                        RMPS/GRB
                                                        12/16/70


                                                              (A Privileged Communication)

                             SUMMARY OF REVIEW AND CONCLUSION OF
                                JANUARY 1971 REVIEW COMMITTEE

                             CONNECTICUT REGIONAL MEDICAL PROGRAM
                                       RM 00008 2/71.1 (CS)

                     FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

              RECOMMENDATION: Additional funds be  provided  for  this.application.

                                                              Recommended
                  Year                 Request                  Funding

                   03                  $86,766                $70,496

              CRITIQUE:  The reviewers noted that the Connecticut Regional Medical
                         Program will submit its first Anniversary Review Application
              for Octobet/November 1971 Review Committee  and  Council.  With  the
              current submission, the CRMP is exercisitg its option to present
              an interim application.  'This proposal discusses  the  relationship
              of@the request to ongoing activities and the overbill Regional plat.
              The Review@Committee observed that Connecticut is one of the
              Regions which has had a "grand design" and specific Regional
              thrusts since the beginning of  its operational experi6nce,.and
              although it occupies a somewhat pioneering position among the MQs on
              that count, it seems sometimes to fall short  in  its  identification
             @of regional needs.

              Another issue which was discussed was the recent  resolution  of  the
              Connecticut State Medical Society that the CRMP limit its activities
              to "disseminating scientific knowledge and  improving  patient  care
              in the fields of heart disease, cancer, stroke and related diseases
              through the medium of education, research and  demonstration  and
              tha  CRMP "is not authorized by statute to advocate policies and
              fund programs which promote restructuring  of  established  patterns
              of providing  a.nd financing health care se@vices.11 It  was  noted
              that Dr. Margulies reply to this condemnation was  an  eloquent  one
              and stressed the@fact that the Medical Socleiy's criticisms w6r@
              not on firm ground, not being based on the most recent legislation.
             @-However, the Review Committee did agree that since this is the
              second time CRMP has had a public dispute with  the  medical  society
              (the first be'ng it 1968 during the first application for operational
               tatus), the RMP might have been derelict in not  having  exerted
              major efforts over the last 2-2 years toward healing the  woutds.


                Connecticut @IP                      -2-                       RM  00008

                Lack of communication between the  two  groups  appeared  to  be  a
                foremost tause.  Although this issue had no particular bearing on
                the current application,  the  Review  Committee  suggested  that  it
                be investigated at the anniversary site Visit next fall.

                The.overall recommendation for the current application was for
                approval at a reduced  level.  The  basis  on  which  the  Approved
                amount was calculated is discussed below.

                Pro ect  liR   Connecticut  Utilization  Patient  Information   and
                               Statistica-L  System.(CUPISS).  The  reviewers  thought
                tha an additional  year's  support  for  CUPISS  was  a  reasonable
             @@@request since the project is one which is closely related to
             @@.Re onal goals and  one  which  is  absolutely  necessary  to  provide
                  -9
                a data base upon which CRMP  can  plan.  The  report  of  the  CRMP
                Rev'@7 and Evaluation Committee, which was included in the application.%
                was'thought to point  up  problems  and  offer  suggestion  which  the
                 t6ject personnel should heed:  i.e...  the  empliasis.upbn  dialogue
                                                                               h pot nt'
                wi   medical staffs.  the  need  for  better  communication  wit    e  ial
                us rs,  an d convincing hos itals and physicians that the system is
                                           p
                suf ic3,-enti  worthwhile to support it.  Parenthetically the
                dit  icu  ties the Region has hadlin  gaining  the  Active  support  of
                ho   tals caused the reviewers  to  question  the  success  of  the
                    ers t  - Community hospital thrust of    the C@ip.
                         y

                Howe 6ti the need for this type of  data  by  the  Region  and  the
                pot ntiai offered by the project  . insured a recommendation that
                the activity be funded for one additional year in the amount
                re4 ested.
                Project  #jj   Yalb-New  Haven  Regional  Newborn  Special  Care  Unit.
                                 e     ew  ommi  ee cons
                of   model ambulance  service  to  be  legitimate  activity  for two
                reasons:

                         1.  Demonstrating  whether  adequate  transportation   actually
                                   "fa ts' lives.
                             saves in  n
                         2.  Bui ding bridges between Yale-New Haven and the Deiibher
                                                                                          y

                oweve
                    seen to  be the,responsibility of Yale.  'Therefore, the@reviewers
                th6 ght  the CRMP should seriously  consider  limiting  its  support  to
                    approximately $10,,OOO necessary for  the  development  of  a  model
                    lance service.

                Mr. Thompson was not  present  during  Committee  discussion  or  action
                on   e application.

                                                GRB/RMPS
                                                1/15/70


                                                                                                                                             0


                                 REGIONAL MEDICAL PROGRAMS SERVICE
                      SUMMARY OF AN OPERATIDNAL SUPPLEMENTAL GRANT APPLICATION
                                     (A Privileged  Communication)
                 Florida Regional Medical Program           RM 00024 2/71.1  (C&S)
                 1 Davis Boulevard)  Suite 309              January 1971 Review CoTnmittee
                 Tampa, Florida  33606
                 Program Coordinator:  Granville W. Larimore, M.D.
                                        Request (Direct Costs)

                                                                  ReRional Year

                                                            03             04              05

                 For CommitteeLc-ouncil Action

                  New Funding
                   Four  New  Projects                $  735,651        $753,968         $801,838

                 For Staff Action
                   Continuation                        1,540,808
                     Core                                 (692,645)
                     9 Ongoing Projects                   (848,163)
                 TOTAL REQUEST                        $2,313,862         $753,968        $801,838

                                             Funding     Hi@r

                                             Planning   Phase
                     Period                          Award                    Comitted
                  11/l/67  -  10/31/68               $245,600
                  11/l/68  -   2/28/70                778,744
                   16 months

                  3/l/69 - 2/28/70                $   706,688
                  3/l/70 - 2/28/71                  1,721,648
                  3/l/71 - 2/28/72                                             $1,535,568


            Florida RMP                    -2-             RM 00024 2/71.1 (C&S)
            Background on Region:  The Florida Regional Medical Program, covers the
                                   State of Florida with  67  counties.  In  the
            core section of the application, an excellent summary is given with
            charts showing the dif faculties that the State of Florida'has with the
            wide variations.  Four counties report less than half  the  United  States
            average income of $3,421 a year.  Twenty-two counties are above the
            half mark but below the average income.  Thirty-six counties are   near
            the average and five are above-average.  The unique characteristics of
            the population of Florida relate to the number of  retired  people  and
            their location throughout the State, the large migrant work force, the
            larg6 agricultural work force which has somewhat the same kinds of
            health problem as the migrant work force,  displaced  Cubans,  urban
            centers with big   etto areas, rural poor,  an  uneven  distribution   of
            medical resources both physicians and hospitals, the descalation of
            space employment, and the large influx of vacationers.
            History of Grant: The Region received its  initial  planning  funds  on
                               November 1, 1967, after submitting tliree.applications.
            Three areas were established, based at the University.of Florida.in
            Gainesville, Tampa, and the University of Miami  in  Miami.  The  North
            Florida area moved rapidly ahead in the development of projects, while
            the other two areas were experiencing  staffing  and  organizational
            difficulties.  Shortly after the Region received its planning funds, a
            hypertension screening project was initiated  from  earmarked  funds.  The
            present coordinator was appointed in the Fall of 196.8, and  charged  with
            coordinating the three area programs.  Council approved operational
            status for the Region in February 1969 and funding  for  nine  operational
            projects.
            A program site visit was made in January 1970 and the team reported a
            number of problems seriously hampering the program -  the  function  of
            the RAG in relation to the Board of Trustees, representation of the
            RAG, the need for effective working committees, the.secessionist
            moves on the part of North Florida and program  imbalance  among  three
            FP-4P areas. The March Council accepted the team's recommendations:
            to maintain Florida as a single program, to give priority funding for
            the central and southern areas of the state, and to advise the Region
            that the RAG should be strengthened and the  review  process  improved.
            In the past year, a number of organizational changes have been effected.
            Ten district offices have been organized under  the  coordinator  in
            Pensacola, Tallahassee, Jacksonville, Daytona  Beach,  Orlando,  Tampa,
            West Palm Beach, Fort Myers,  Miami-BrowArd  and  Miami-Monroe.  The
            medical school staff have been relieved of area programing development
            responsibilities.  Project monitoring has been strengthened.


               Florida RNP                    -3-               RM 00024  2/71.1  (C&S)

               PRESENT APPLICATION

               Regional Advisory Group Report: The Regional  Advisory  Group  report
                                                includes a  fairly  extensive  descrip-
               tion of the Region's plans, priorities, organization  and  hopes.  The
               RAG feels that this year has seen the opportunity to build  the  program
               on an established base of part-time physicians, medical schools,
               hospital educational programs, junior colleges, and  voluntary  health
               organizations. The by-laws call for an executive  committee  but  it  is
               felt that ad hoc committees requiring varied groups of RAG members
               will keep the executive committee from impeding the  RAG  in  developing
               its role As an effective decision-making body.  A  major  organizational
               change resulted from the report of a Conference Committee on the
               responsibilities and relationships between the Board 6f  Directors  of
               the Florida Regional Medical Program, Inc., and  the  Regional  Advisory
               Group. The statement agreed to by all parties is  delineated  in  the
               RAG report.
               The reorganization of the core, the RAG feels, was a  critical  develop-
               ment this year; ten district offices have been set up to be  staffed  by
               part-time physicians, superseding the three areas centered in the medical
               schools. This will not only enable the RMP Core  Staff  to  service  all
               areas but will provide for functional participation of the medical
               schools without having to be responsible for  area  development.  The
               RAG report indicates that this change which has  been  supported  within
               their committed funds has created funding problems.

               The district offices will share offices with the CHP (b) agencies where
               possible, a move which is expected to enhance Comprehensive Health
               Planning interrelationships. On the state level, the  RMP  and  the  (a)
               agency have had one joint project, a statewide health  insurance  study;
               one member of the Florida RAG is Chief of the Florida  State  Bureau  of
               Comprehensive Health Planning and the Director of the  Florida  Regional
               Medical Program is a member of the Florida Health  Planning  Advisory
               Council.

               The Ad Hoc Committee on Directions and Priorities -  seven  people  from
               the RAG, representatives from the Department of Health,  labor,  nurse
               association, dean of allied health school, Florida Hospital Association,
               the Bureau of Comprehensive Health Planning, and a practicing physician
               have outlined the following priorities:

               1.  Continuing education on a interdisciplinary basis.
               2.  Improvement in health care delivery.
               3.  Identification of health manpower needs.
               4.  Development of cooperative relationships with other planning groups.
               5.  Personal health education.
               Six categorical task forces and task forces on continuing health educa-
               tion have outlined Priorities in their respective areas as well  as  the
               planning that must go into meeting these priorities.


            Florida RMP                     -4-            RM 00024  2/71.1  (C&S)

            The Regional Advisory Group report relates the new  proj_cct8  contained
            in this application to the regional  objectives  and  priorities.  The
            .Iuntor College Model will strengthen inser-vice education and  inter-
            cliange.of students among cooperating hospitals.  The Post-graduate
            Intensive Service Education for Physicians wi,ll..allow  the-physicians
            to return for study at the University of Miami.  The..Statewide
            Cervical Cytology Program will@ build on a  program,that'has  been.
            supported by the State Health  Department  and.the  Statewide.Renal
            Dialysis Program will build a transplant network.
            Core Progress Report: There are only six core  staff  members  in  the
                                   central office. The  Task  Forces  have  been.a
            major problem in developing a program approach because of their
            categorical project interests and clinical orientation. The
            categorical versus the disciplinary approach  has  been-a  problem.for
            the Task Forces. It is felt that better  staffing  for  tbe@Task  Forces
            will help them develop a program outlook.
            Project Development and Review: The Committee on Directions and
                                             Priorities sets-the  tone-through  the
            priority framework for the Regional Medical Program. A Task Force
            reviews each proposal and calls on special. consultants as needed,
            either to make site visits or to  review.  The  Regional,Advisory  Croup
            Ad ltoc Project Review Committee then  re'views the  project;  the.lioard
            of Directors of FRMP, Inc., looks at it from the  standpoint  of  fiscal
            soundness and the affiliation agreements needed, and  finally  the  RAG
            looks at it. The two CIIP (b) agencies in the state  will  be  brought
            into the review process early in the project review process.
            Evaluation: The Core report on Evaluation  cites  several  examples  of
                         how the Region is going  about  its  evaluation.  Site
            visits were set for early December on  two  projects,  Multi-phasic
                      and the Computerized EKG Processing Center,  as  a  result-of
            staff evaluation (the Region has not submitted a request for continuing
            funding of these projects until the site visit reports are available to
            the RAG). Apparently a very hard look is being  given  to  the  ongoing
            projects to see whether they are accomplishing their purposes.  In
            the Coronary Care Unit Training, they found the use  of  vignettes  from
            students was a useful type of evaluation, more  meaningful  than  some
            of the ore and post training that had  been  originally  planned.  The
            Evaluation Section indicates that the RAG is  utilizing  evaluation
            studies as guides for allocating the funds available  to  the  Florida
            Regional Medical Program.

            Nl-"W PRO-Jf,'CTS
            Project #37 - Florida Communitv JLini.or College Extended C   us     I,'irst Yezir
                          Concept.  This project under the direction of
            Philip A. Frederickson from St. Petersburg Junior College, has       $36,358


               Florida RMP                    -5-            RM 00024 2/71.1 (C&S)

               been conceived to assist community hospitals and nursing  homes  to
               improve the quality and availability of their inservice educational
               programs.  It proposes an extended campus concept which develops
               cooperation between health care institutions and a community junior
               college through association with the project staff located  at  the
               college. The project has two segments, only one of  which  will  be
               funded in part through funds from the RMP.
               The improvement of inservice education, it is felt, will favorably
               effect health care by: 1) improving skills and increasing the know-
               ledge of individual healthjworkers in the community health care
               institutions; and 2) making the employees' tasks  more  interesting
               and personally more satisfying thus leading to greater staff stability.
               The objectives are: 1) to develop a guide that will  outline  the  steps
               and changes in administrative policy and structure in the Junior College
               and community health agencies that are needed to bring about a
               flexible relationship that utilizes community manpower, mindpower,
               hardware, software more efficiently.  The guide will include suggested
               policy and procedure revisions relating to such areas as enrollment,
               attendance requirements, educational credits, tuition and fees, lending
               and borrowing of educational equipment and materials, etc.;  2)  to
               develop a system whereby inservice directors, community health agencies,
               and the community junior college faculty can combine their talents
               and efforts to more effectively teach health workers basic "for the job"
               skills and continuing "on the job" skills.  This will Include joint
               development of teaching materials and shared manpower, hardware and
               software; 3) to develop a pattern of continuing  education  whereby  the
               directors of inservice education in the community  health  agencies  are
               able to assist health workers to meet their continuing education
               needs. This mechanism will also provide the junior  college  with  feed-
               back regarding community needs in continuing education and establishing
               other resource agencies and personnel outside the  immediate  area.
               The first year's activities will be directed toward the hospita s  n
               Pinellas County, Florida, each of which has a functioning inservice
               education activity. At the beginning of the  second  year,  nursing
               homes in Pinellas County will be encouraged to participate  In  the
               program.  The third year will be devoted to consolidating experience
               gained and relationships developed in order to expatnd the  concept
               throughout the region.  The State Department of Education (Division of
               community Colleges and Division of Technical, Vocational and Adult
               Education) will be primarily responsible for the regionalization phase
               of the project.
               This project was approved by the Continuing Education Task Force,  tll(@
               Board of Directors, and the Regional Advisory Group.
               02 Year - $53,803                           03 Year - $56,710


             Florida f@MP                   -6-            RM 00024 2/71.1  (C&S)
             Project #38 - Florida Statewi e Svstem for the Care of the       First Year
                          Patient with End Stage Kidney Disease - The             ert
             purpose of this project is to establish a kidney transplant      $240, 260
             network in Florida.  This cooperative effort will: 1) provide
             a training curriculum of high quality for dialysis and trans-
             plant personnel to maintain and enlarge a recipient pool; 2)
             maintain an automated matching program with full information
             about each patient and the results of each matching effort in
             each transplant; 3) develop and implement a rapid and reliable
             transportation system for movement of donor organs among the
             participating centers; and 4) standardize and sustain the quality
             of tissue-typing throughout the system.
             Long-term hemodialysis is offered to chronic renal disease patients
             in Miami, Tampa, and Gainesville at the present time.  In addition,
             Miami and Tampa provide home-dialysis teaching.  Two  smaller  hemo-
             dialysis units are opening in the near future at Clearwater and
             Lakeland, both of which will relate to Tampa.  At Jacksonville, a
             major population center in the State, efforts have  been  underway
             for a year to initiate dialysis service.  In Pensacola there is some
             dialysis equipment which may be developed into a center.  There are
             approximately 114 patients undergoing dialysis in Florida  at  the
             present time of which 75 or 65% are thought to be suitable transplant
             candidates.  By combining these persons in one recipient pool, each
             time a donor is available, it is estimated that there is a 48% chance
             for a match with any available recipient as compared  to  respective
             chances of 37% at Miami, 22% in Tampa, 16% At Gainsville,  if  these
             centers operate separately.
             Under the auspices of this project, four transplant  centers  will
             operate in Tampa, Miami, Gainesville, and  Jacksonville.  Each  will
             have a tissue-typing technician, trained in the same techniques who
             will test all recipients at regular intervals and all donors as they
             appear.  I The existing computer-based system will monitor the potential
             recipients.  When a donor organ is to be sent to another center, the
             transportation will be arranged by the transplant coordinators from
             the locations involved.  Every active major dialysis group in Florida
             is involved in this project.  The geography of the State is covered
             completely except in the Pensacola area which will be joined in the
             second year as the physician manpower becomes trained and available.
             Every surgical team that has done a transplant in the State is
             involved also.
             To supervise each center at representative network meetings, there
             will be a physician who possesses the full authority of  his local
             colleagues to reach decisions and actions.
             A large recipient pool can be maintained only  with  an  efficient
             dialysis facility, and it will be necessary to train the nursing


             Florida RNP                    -7-              RM 00021',@ 2/71.1 (C&S)

             manpower.  This project will. teach at least 36 nurses and technicians
             per year at a projected total cost of about $25,000  annually  or  less
             than $700 per trainee.  Training will take place in Miami with 24
             students and in Tampa with 12 students.
             The project budget includes a small amount of money to  assist  in  the
             establishment of dialysis activities  in  Jacksonville.  The  equipment
             will be donated by a local hospital and space will be provided by
             another insititution.
             An essential partof an organ transplant program is public education
             activity to create a Positive atmosphere toward  donation  -immediately
             upon death.  A study done by the Florida Regional Medical Program
             staff indicates that the majority of people questioned agreed that
             they would sign a legal document giving the physician permission to
             remove the kidney to be transplanted to another person in the event
             of sudden death.  Different messages are planned for the older popula-
             tion, the younger population, hospital personnel, physicians, and
             funeral d-irpctors.
             The application states that a Board of National Consultants were asked
             to review this project who sent mail evaluations and conducted a site
             visit in Miami on October 9.  The individuals involved in this review
             were not named.  The Board of Directors of the Florida Regional Medical
             Program reviewed it from the standpoint of fiscal  feasibility;  an  ad
             hoc RAG Review Committee looked at it from the  standpoint  of  program
             priorities before the final RAG approval.
             02 Year -  $256,541                     03 - $266,746
             Project #39 - Florida Statewide Cervic                     - This First Year
                           project to detect early cervical cancer among             est
             the young, indigent, and medically indigent females over the        $271,533
             age of 20 has as its objectives: 1) the detection  and  necessary
             follow-up of treatment of cervical cancer; 2)  the  demonstration
             to hospitals and physicians of the feasibility  and  benefits  of
             screening large numbers of women, utilizing  residents,  interns,
             and paramedical personnel; and 3) improvement  of  communications
             between the local health departments and  hospitals  and  between
             the Pathology Department, the Out-Patient Clinic  and  the  Tumor
             Clinics of these facilities.

             Salaries for nurses and clerks in the  County  Health  Department
             and the respective county hospitals as well as three cytotechno-
             logists, for Dade County are requested.
             The patients will be from high, densely populated centers in
             Jacksonville. Miami, Pensacola, Tallahassee, Tampa, and West Palin
             Beach.
   0


             Florida RMP                      -8-               RM  00024  2/71.1  (C&S)
             The project hopes to "plug" the gap between the present health
             department network and the hospitals.  The health department program
             has been supported from  cancer  control  and  314(e)  funds  since  early
             1960.
             02 Year - $281, 06 1                  03 Year - $290,794
             Project #40 - Postgraduate Introductory Intensive Inservice            First Year
                           Education for Physicians in Miami - This project              est
             is designed to establish, investigate and determine the value            $42,810
             of sliort-course continuing education for private physicians,
             using preceptors techniques and student curriculum selection.
             It will utilize the  personnel  facilities  of  a  major  medical  complex
             In South Florida,  including  the  major  medical  school  teaching  hospital
             (Jackson), a Veterans Ilospital.  (Miami),  and  two  prestigious  private
             hospitals  (Cedars  of  Lebanon-and  Mt.  Sinai).  This  diverse  environment
             will offer a broad  selection  from  which  physicians  may  choose  their
             ideal  training  circumstances,  ranging  from  an  academically  oriented
             medical school to  a  private  medical  office.  Subject  matter  will  be
             equally comprehensive, extending from common practice problems to
             emerging complicated technology.

             Questions to be answered by the project are:
             1.  What type of physician is  attracted  to  and  takes  advantage  of  this
                 type of education?
             2.  What special  features  make  itsusefulness  popular  (away  from  home,
                 medical  school  center  environment,  preceptor  teaching,   personally
                 selected curriculum, course length, etc.)?
             3.  Do persons seek this kind  of  training  when  they  have,  participated
                 in noctlier types for several months or years?
             4.  What effect on  medical  practice  habits  and  attitudes  is  mediated
                 by the training program?
             A special information program  will  be  used  to  announce  the  continuing
             education opportunity,to Florida physicians.  There will be no
             emphasis on speciality  or  geography  so  that  an  evaluation  of  total
             impact can be conducted.  The Journal of the Florida Medical
             Association  will  be  used  along  with  announcements  and  descriptions
             placed in  bulletins  of  the  40  constituent  counties  or  multi-county
             medical societies.
             Personal mailing to each practitioner will be made also.         Enrollment
             will be accepted on a first come, first served basis, but this practice
             may be altered subsequent  to  accumulation  of  experience  in  the  first
             12 months.   It is expected  that  50  persons  will  be  trained  in  the
             first year.  The limit to the number of people to be trained is
             preceptor availability and trainee interest.


              Florida RMP                         -9-                RM 00024 2/71.1 (C&S)

              There is no salary  support  or  reimbursement  for  the  preceptors,  the
              faculty members,  and  physician  teachers.  The  budget  requests  an
              amount of $250 for each trainee to be placed in a special fund for
              the use of the  preceptors  in  furthering  their  training  purposes.
              This money may be used to purchase audio-visual aides, special
              books and teaching material and similar materials which will strengthen
              the program and develop a  foundation  for  sustaining  the  work  in  the
              future. The monies will  be  under  the  control  of  the  coordinator  at
              each of the cooperating institutions,
              No stipends or replacement reimbursement is requested for L@ic@ physicians:
              per them expenses of $25 a day are requested.

              02 Year - $66,975                       03 Year - $48,200
              Project #41 - A Hospital Based Program for Cardio          nar        First Year
                             Resuscitation - This project is a revision of            Request.
              an earlier proposal which was  reviewed  by  the  July  1970  Advisory   $144,690
              Council. During earlie-.1- review, the  one-day  training  period  was
              questioned, the support after RMP support is terminated was
              questioned; information on the pilot study that led to this
              proposal was lacking, information regarding the coordination of
              personnel, utilization of consultants, teaching methods, selection
              of trainees, and follow-up was also lacking.
              Under the direction of the Chairman of the Florida Heart Association's
              CPR Committee, this  program  is  designed  to  reduce  premature  mortality
              arising  from  cardiovascular  and  respiratory  arrest.   Educational
              training and modern cardiopulmonary resuscitation techniques are the
              means of attaini.n@, this objective.   ')'he community hospital w     serve
              as the base of the operation for development of  liosl)iLa.1-o@rf.(.,rited
              programs.   'riic-- ob,j(-@ctl.ves are as follows:

              1.  To train and retrain key physicians and registered i.-iur::3es  who
                  will  assume  responsibility  for  training  other   hospital   personnel.

              2.  To encourage and assist hospitals in establishing emergency
                  resuscitation measures.

              3.  To establish uniform standards of training of hospital personnel
                  according to the recommendations of the National Research Council.
              4.  To provide training  for  the  future  Instructors  tn  CPR  at  the
                  community  hospital  level  through  a  decentralized   delivery   system.
              Information is presented in  this  application  relating  to  t,:Iie  Specific
              concerns raised in  previous  Council  review.  The  I)il.ot  stuciv  findings
                                                                              I
              are delineated, the personnel and the functions of the various personnel
              are itemized,  the  type  of  consultants  and  their  functions  are  listed,


           Florida RNP                  -10-              RM 00024 2/71.1 (C&S)
           and the evaluation protocol is outlined.  The course has been changed
                                                                            The
           from a one-day course to three one-day visits to each hospital.
           trainees will,be hospital personnel with medical or nursing backgrounds
           since it is expected that only such individuals can establish  and
           conduct CPR and re-training programs in the hospitals.  These  teacher
           trainees will receive the three visit CPR training, will be provided
           with guidelines for the development and content of CPR training
           programs, and will conduct CPR training under  supervision.  Each
           hospital will be requested to select trainees from the  following
           personnel categories:
           1.  Nursing supervisors, head nurses, and assistant head  nurses.
           2.  Inservice directors.
           3.  Representatives from Inhalation Therapy Department and
               Anesthesiology Department.
           4.  Chief Residents especially on medical and surgical  services.
           Others to be invited include the Chief Physician in the  Emergency
           Room, all members of the Hdspital's Cardiopulmonary  Resuscitation
           Committee and members of Heart Association Cardiopulmonary Resuscitation
           Committees.  No class should include more than 20 trainees.
           02 Year   $95,588                    03 Year   $98,288

                                                    RMPS/GRB
                                                    12/30/70


                                    SULMMARY OF REVIEW AND CONCLUSION OF
                                      -January 1971 Review Committee

                                      FLORIDA REGIONAL MEDICAL PROGRAM
                                           @l 00024 2/71 (C & S)
                         FOR CONSIDERATION BY FEBRUARY 197i ADVISORY COUNCIL

                          I     Committee  recommended  that  this  application  which   requ6sts
                                support  for  five  supplemental  projects  be@supported  as
               foll@ows:

                AR                            REQUEST                         RECOMMENDATION

               03                               $735,651                      200,000
                                                 753,968                      160,000
                                               801   838                      145,000

               OEA                             2,291,457                      505,000

                          When the site visitors reviewed the Florida @IP     a  year  ago,  they
                          found a Region  in  serious  trouble.  An  impasse  was  developing
               00 qon the Regional Advisory Group and    the  grantee   agency, which had us?arped
               ome  of the W.G's authority and responsibilit       The  RAG's  operation  had
                                                              y .
                                                                    e and
               --en hamp6r6d@by the lack of an Executive Committe,        other    subcommittees.
               Ther@-vias inad66uate representation on the RAG of consumers, minority
                      mbets and  professional  individuals  familiar  with  Floridal@  healtb,
               n      Relationships  were  strained  with  the  North  Florida  Area  Coordinator
               n      D6an,of the University of Florida at Gainesville  who fostered the
               0        of area  cooperative  arrangements  rather  than  those  to  enhance  the
                                                    C,
               e       nt of a statewide IU4P, and spearheaded moves for secession of the
               No t  Florida area from FRK.IP.  Some of the ongoina    projects were   running
                t6@s;erious: tec nical and  organizational  problems,  and  new projects   were
                     en quaiit .  In addition  because of the ambitious efforts of
               o@ unev
               i-              y
                e   rtb ii6iida area.dur)'n,,, the early part of  the  program,  an  imbalance
               n
                 t e number of projects and  amount  of  money  invested  among  the  three,
               a, ea6 had developed.

                n=i tee noted that the  present  application  addresses  most  of  the  above
                 c  rns   As a.re--ult of a Conference Committee, relationships and
               c
               esp nsibilities between the RAG  and  the  grantee  agency  have  been  delineated
                    reed to bv both parties.  Goals and objectives, while general,
                ve   en  set.  An  Executive  Committee  and  various  other  subcommittees  have
                en     ed.  Membership on the RAG has been broadened  Core has been
               6or   ized'to take the responsibility for area development out of the dontrol
                     medical schools. At  the  same  time,  secessionist  moves  on  the  part
                 t   Unive sity personnel  in  North  Florida  have  reced6di  The  RAG  has
               arra  ea site v sits to two of the   ongoing projects and@is Presently
                n@  ering'phasin3z them out.  The   Region is  also  submitting  more  statewide,
               as w   as 1-ild and South-Florida-sponsored projects,

                e   ojeqts in the present application received a'mixed response frqm:the


                           RMP
                FLORI'DA.                                   -2                       RM 00024 2/71 (C         S)

                reviewers.      Committee found      interesting   and    unusual,    the    concept    of
                  ett  g juniorcollege@and community hospital and nursing home representatives
                    e                  inservice educational program's; however,
                  oo*  her to   Plan                                                         th6v    were    unable
                to   determine   exactly   how   this   should   be    carried    out.    It    was,,recounended
                that   the   Region   invest   some   funds   for   further   planning   in    this    promitin
                                                                                                              9
                                               n project #38.,              ri,da State                  @for the
                   t   ity.     Adecision      o                  The     Flo            wide  Sy@-te;u  @
                Care   f   Patients   wiih-tnd    StaRe    Kidney    Disca',ge,@was    deferred    until,lit o=uld@
                         at@by a national Rrou           although    Cowmitt6e    believed    it     ihoul
                ag'si  aool a   lower   piciority,iii   relation   to   other   projects    in this     app
                                                                                                         li  a :.on,
                    a      Of    e     r o         d6quacie         discussed
                       se  CDntrol Program.        While the Statewide Cervical  ly
                        would reach migrant        and other indigent women, t6vi6            rs      txpresse t e
                       that after ten years        of  funding   by   the   PIIS   other   @geiicies   would
                       e    its    support.    Project    #40.    Postf,,raduate-Introductor    Intens     e
                                                                                             y
                  ni     ce.Ed      tion     for    sicians   in.lliarii. was ent u iastica@lly            or.sed
                                         7ell as   involving physicians in the South Florida area,
                the           t   presents   A   unique   way   of    budgeting    the    educational@expense@s.
                   t            p  0  fdir,&,   sal@ary   support   for   the   preceptor,   faculty   me   bars
                   d          rs,  the  budget   requests   $250   for   each   trainee   be   Placed   in   a
                @'Se          nd   for t'nd  use of preceptors in furthering their training
                         si   i.e., b6ok6i a-tidio visual -.iids or other special tea  in
                p
                ma             With  reg6rd    to   the   os   ital@as-d   Pr@,liram   for   C
                     s               he reviewers questioned the 6xt                      invo             all
                                                                              e     @@C'     -
                           vi            te             note             ver,   a  s                  Al   le   aer
                         t field from    Florida, Vab had not been involved in the earlier
                        Al   are   how   listed   as    participants.    They    tonclud-,d'that    while    the
                           ,is  iairiy-,@4611  organized,  it  could   be   supported   at   a   lower   le   el
                         quested,

     AM


                                                                                                                       NW

            0                                                              0                                                              9


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

               Greater   Delaware   Valley   RMP                 RM 00026  2/71.1 (CS)
               551  West   Lancaster   Avenue                    January 1971 Review Committee
               liaverford, Pennsylvania
               Grantee    Agency:     University City Science    Center

               Program   Coordinator:   George   R.   Clammer,   M.D.

                                            Request (Direct Cost.-.),

                                                 03 year            04 year       05 year
                                                 4/l/71 -           4/l/72 -      4/l/73        Total
               Purpose                              1/72            3/31/73       3/31/74       All    Years

               Continuation Commitment*          21-109,357                                     2,109,357
               Continuation     Request          2,142,503   I/      33@926                     2$1761,429
               Core                              (111603,620)                                     (1,603,620)
               6 Projects                         (5-@18 31  883)   (33,926-                      (572,809)
                                                                    one    project)
               Additional Components                 565$946        1740416       164,259            904,621
               4 new Projects                       (270,591)      (174,416)      (164$259)       (609,226)
               5 previously approved
                 activities                         (295,355)                                     (295,355)
               Totals                            231   708,449      208,342       1645259       3$081,050

               *Staff Action on
               Commitment                        2,109,357           33,926        -----        2,143,283
               o@mmittee Action Required            5651,946        174$416       164,259            904,639
               1/ Continuation Request $33,146 over Commitment.

                                               Funding     History

                                               Planning Stage
               Giant Year             Period                                    Funded     (d.c.o.)
               01                     4/l/67     11/30/68                         $10358 31 270
               02                     12/l/68    3/31/69 (4 mo.)                     256,152


           Greater Delaware Valley RMP           -2-            RM 00026 2/71..] (CS)

                                          Operational Program

                                              Council                               Future
           Grant Year    Period               Approved       Funded   (d.c.o.)      Commitment

           01                                 $2,215,967     Core    1,628,336 1/   -------
                                                             Proj.     596,201

           02            4/l/70  -  3/31/71    2,248,070     Core  1,628   336      -------
                                                             Proj.     815:150 2/

           03            4/l/71  -  3/31/72    2,289,691            ----            $2,109,357

           04            4/l/72  -  3/31/73        33,926 (#13 only)  ----              33,926

           I/  Includes $155,478 carryover funds from 02,planning grant year.

           2/  Includes $317,387 carryovee funds from 01 year.

           Geography:   This Region covers eastern Pennsylvania, all of Delaware, and
                        southern New Jersey.  Discussions to explore issues of mutual
           concern  are held with the six adjoining RMP'S:  New York Metropolitan,
           Albany, Susquehanna Valley, Maryland, Central New York and New Jersey.

           Demography:

           A.  Population:  8.5 million (1965)
               1.    White       92%
               2.  Non-white      8%

           B.  Facilities
               5 Medical Schools (Philadelphia)
               1 School of Osteopathy

           C.  Physicians     12 31 214 (medical)

           D.  Osteopaths      1,090

           Program Priorities:
           1.  Improvement of health care delivery systems with special emphasis on
               the   poor.
           2.  The continuing education, primarily of physicians but with attention to
               nurses and other allied health personnel.
           3.  The development of program activities, primarily for heart disease,
               cancer, stroke, kidney and respiratory diseases.


           Greater Delaware Valley RMP        - 3                 RM 00026- 2/71.1  (CS)

           Review Procedure:

           A revised review procedure has been developed and  recommended  by  the  Grants
           Review Committee of the RAC. If the  recommendations  are  adopted,  the  Grants
           Review Committee of the RAG will be replaced by the Regional Review Committee
           which includes members of the RAG. The RAG  itself  will  remain  the  final
           reviewing committee.

           Review will be initiated by three paralled review committees:
           1) Administrative Review Committee.  Staff  members  to  include  the  Executive
               and the Deputy Executive Director, the  Associate  Director  for  projects
           and members of his staff will review  proposals  individually  and  subsequently
           will meet to prepare a report of recommendations.

           2) Technical Review  Committee.  A  fifteen-member  technical  review  committee
                'll be appointed. A member of the  staff  will  be  appointed  Executive
               wi
           Secretary without vote. Recommendations for  nomination  will  be  made  by
           the Executive Director and appointments (for one year) by the Board of
           Directors. The chairman will also be appointed for  a  one-year  term  by  the
           Board of Directors. Meetings will be held at least  once  a  year,  more  often
           according to the number of proposals to be considered.

           3) Area-Wide Committee.  Each  area-wide  committee  will  review  proposals
               originating from its respective area whenever  the  activities  of  the
           project directly involve the area.

           A Regional Review Committee will be appointed to  recommend  approval  or  dis-
           approval to the RAG. The Committee will  consist  of  a  representative  from
           the Board of Directors, who will act as  Chairman,  a  representative  from
           the Coordinating Committee, the Chairman of  the  Technical  Review  Committee,
           the Chairman or representative of the area-wide  committees  and  a  represen-
           tative from the RAG, and a member of  the  Executive  Director's  staff.  In
           reviewing proposals the Committee will receive  reports  from  the  Administra-
           tive, Technical and Area-Wide Committees. The  RAG  will  take  final  action
           on all proposals approved by the Regional Review Committee  and  may  act  on
           any disapprovals at its own discretion or  upon  appeal  for  reconsideration
           by the sponsor.

           Regional Advisory Gr@u .  The RAG has been expanded to 53 members with
                                      representation from 17 counties  of  the  Region
           and is representative of the broad spectrum  of  health  interests,  resources,
           and socioeconomic groups within the Region.  The  RAG  meets  four  times  a
           year.

           Four committees appointed by the  Chairman  (Evaluation,  Membership,  Nomlna-
           ting and Grants Review) holdindividual meetings throughout the year.

           Board of Directors. The new 1970 Board of  Directors  has  been  expanded  from
                                 6 to 17 members (all members of the  RAG)  and  includes:
           6 representatives of  medical schools, 5 representatives  of  health  agencies
           and 6 representatives of subareas. The Board  is  designed  to  function  as


          Greater Delaware Valley P4P
                                              - 4 -            RM 00026 2/71.1 (CS)

          the policymaking body of the GDVRMP.

          Standing Committees and Local Action Gto"-S.

          1.  Health Care of the Poor
          2.  Continuing Education
          3.  Categorical Disease (Heart Disease, Cancer, Stroke, Respiratory Disease
              and.Kidney Disease)
          4.  Coordinating Committee
          5.  Project Review includes the  Technical  Review  and  Regional  Review
              Committees.
          6.  Committee on Planning Methods (staff).

          General Concerns of DRMP Staff regarding Greater Delaware Valley RMP

          During March 1970, staff reviewed the Region's  second  year  operational
          continuation application for the year April 1, 1970 - March 31, 1971.  The
          continuation of the operational projects evoked little concern  and,,  in
          general, were recommended for approval at their committed level4  However,,
          staff had very serious concerns regarding the basic organization of the
          Region and the functions and activities of the large core staffs both in
          the Executive Director's office and in the medical schools.    Staff  recom-
          mended that a program site visit be made to the Region to explore the inter-
          relationships of the Core staff with the projects, as well as the degree of
          coordination among the various staffs of the Core components.  The site
          visit was conducted on June 18, 1970, and was composed of the acting
          director of RMPS and senior staff members. The major  concern  of  the  site
          visitors regarding the GDVRMP was that the Region  lacked  a  coordinated
          planning effort between the Medical Schools, subareas and the Central Core
          staff. How funds were budgeted and administered was  viewed  as  a  major
          problem.  A reflection of the inadequacy of fiscal procedures was the large
          amount of unexpended funds accrued during the 01  year.  The  site  visitors
          were in agreement that a ltliough the various activities reported on by  the
          medical schools were perhaps well conceived and  implemented,  they  were
          neither coordinated nor related to any long-term planning effort by the
          Region.  The site visitors believed that each school had developed its own
          plan and activities based upon the interest of the staff at each school.
          The Coordinating Committee, made up of the Chiefs of RMP units based at the
          Medical Schools, reportedly functioned as a central planning, coordinating,
          and advisory committee to the Region and specifically  to  the  Executive
          Director.  However, it was concluded that it was more of a liaison group
          than anything else.

          The site visitors questioned the role and the primary focus of the grantee,
          the University City Science Center.  It was pointed out to the site visitors
          that the UCSC was a non-profit stock corporation (established in 1965) and
          consisted of 23 owners (institutions).  Membership is made up of the medi-
          cal schools, colleges, and teaching hospitals in the  Philadelphia  area.


             Greater Delaware Valley RMP         - 5             Rm   00026 2/71.1   (CS)

             It was indicated that the primary emphasis was  in  research  and  development
             but that they are beginning to get more involved  in  community  service  pro-
             grams. The overall impression of the site  visit  team  regarding  the  GDVRMP
             was that it did not truly represent a regional program - a program that had
             assessed its resources and problems in a  systematic  fashion,  developed  a
             plan, established priorities,, etc. The Medical  Schools  and  especially  the
             staffs of the RMP units have initiated many  excellent  activities,  but  most
             do not fit into a total plan for the GDVRMP.  The Central Core staff   '
             especially the area coordinators, are  primarily  concerned  with  servicing
             the various sub-regions.
             Expansion in the membership of both the Board of Directors and the Regional
             Advisory Group was viewed positively by the site visitors.  It was felt
             that with the leadership of these two groups, the  GDVRMP  has  the  potential
             to build a regional program that will be visable and responsive to the
             problems of the  Region.
             Currently, the Region has the following appr6ved/unfunded projects:  Com-
             munity Health Coordinator, Wilmington  Medical  Center;  Regional  Radiation
             Therapy Network; Develop-.nent of Tumor Control Centers in Delaware Medical
             Society; Thera-Flicks Delaware Curative Workshops; and Coronary Care Train-
             ing Program, Underwood Memorial Hospital; Coronary Care Training for Nurses,
             Crozer-Chester Medical Center and Fitzgerald-Mercy Hospital.
             Listing of Current Funding Status of Core and Operational Projects in GDVRMP.

                                                                      Amount supported
             Project Number        Title                              through 3/31/71

             00                    Core
                                   1) Executive Director                  $753,890
                                   2) Bahnemann                           153,814
                                   3) Jefferson                           142,332
                                   4) Philadelphia Osteopathic            106,860
                                   5) University  of  Pennsylvania        164,363
                                   6) Temple                              113,297
                                   7) Women's Medical                     119,404
                                   Subtotal (Core)                      $1,553,960

             *1                    Coronary Care Training
                                   Wilkes-Barre  General  Hospital       $  91,338

             *2                    Coronary Care Training
                                   Reading Hospital                         81,804
              3                    Ceneral Intensive Care Courses           94,278

             *4                    Philadelphia  Regional  Chronic
                                   Pediatric  Pulmonary  Disease  Program  242,447


          ('.reater Delaware Valley RMP        - 6 -           RM 00026  2/71.1 (CS)

                                                                    Amount supported
          Project   Number       Title                              through 3/31/71

            5                    Retraining  Program  for  Women
                                 Physicians, Women's College of
                                 Pennsylvania                             759884

            6                    Coronary  Care  Training  Units
                                 Wilmington Medical Center                729600

            8                    Centers  for  Respiratory  Care
                                 Hahnemann, Allentown, Wilkes-Barre       719179

          10                     School of Radiotherapeutic Technology
                                 at Six Cooperating Philadelphia
                                 Hospitals                                379  150

          13                     Renal Disease Patient Support
                                 Program                                  489470

          14                     Improving Patient Care in Hospitals
                                 Through Self-Evaluation                  59,963

          15                     Development of Three-Dimensional
                                 Models for Cancer Detection              14,413

                                 Total                                 $2,4439486 (d.c.)

          Carryov er included above:
          #1       $173,391
          #2        209964
          #4        98,103
                  $136$458
          The Region plans to submit its Triennial Application during fiscal 'ear 1972.
                                                                                  y

          Present Application

          This application contains requests for:
          1)  One year continuation for support of Core activities and the following
               on-going operational projects:  Coronary Care Training - Wilkes-Barre;
          Coronary Care Training - Reading; Intensive Care Training; Chronic Pediatric
          Pulmonary Disease Program; Retraining Women Physicians; and Renal Disease
          Patient Support.  Staff will act on the continuation request for Core and
          the above projects.
          2)  A request for funds for five previously approved activities funded
               from Coro and carryover,

          3)  Four new operational projects.


             Greater Delaware Valley RMP          - 7 -        RM  00026  2/71.1  (CS)

             On-c@oing Projects

             Project #6 - Coronary Care Training - Wilmington, Delaware

                                                  03
             Requesting                     4/l/71 - 8/31/72
             Direct Costs                      $69,600

             The purpose of this project is to train graduate nurses in all respects of
             coronary care so that they will be able to assume responsibilities in caring
             for coronary patients in intensive care units, coronary  care  units,  or
             related medical facilities.  To date four four-week courses have been con-
             ducted and a total of 32 nurses from the first two  courses  were  trained.
             At the time this request was submitted, information relative to the numbers
             of trainees completing the last two courses was not available.

             Project #8 - Respiration Care Centers, Wilkes-Barre General Hospital,
                          Wilkes-Barre, Pennsylvania

                                                  03
             Requesting                    4/l/71 - 3/31/72
             Direct Costs                      $71,179

             The purposes of this project are:  (1) to provide excellent acute respira-
             tory intensive care at the three participating institutions .(Wilkes-Barre
             General, Hahnemann and Allentown Hospitals); and (2) to train physicians,
             nurses and inhalation therapists capable of providing good respiratory care
             by giving training programs in different areas of the Region four times A
             year.

             During the year from April 1, 1971 through March 31,  1972,  four  formal
             workshops in respiratory intensive care will be held.  One  will  be  given
             in both Allentown and Wilkos"Barre and two  in  Philadelphia.  Each  course
             will train a minimum of 15 physicians, nurses  and  inhalation  therapists.
             The course will offer both formal lectures and bedside participation in
             the care of critically ill patients and each course will  last  two  weeks.
             In addition, each hospital will use their respiratory  care  facilities  as
             part of their in-service training programs.

             In May 1970, a 12-bed intermediate respiratory care unit  was  opened  in
             Wilkes-Barre General Hospital.  The unit is intended to provide skilled
             medical and nursing care to patients with severe  respiratory  disease  who
             are recovering from an episode of respiratory failure '  Also, in May 1970,
             a five-bed respiratory intensive care unit was opened at Hahnemann Hospital
             to treat patients who are acutely ill with  pulmonary  insufficiency.  Tile
             unit has served as a training facility for medical students, interns,
             nurses and residents and to date, 39 medical students  have  completed  a
             training program in respiratory care.  In an attempt to increase the


          Greater Delaware Valley RMP           8 -          RM 00026  2/71.1 (CS)

          number of medical personnel who are trained in respiratory care, a two-week
          workshop has been developed.  The first workshop was given at Allentown
          Hospital during March 1970.  Five physicians, three nurses and one inhala-
          tion therapist were trained.  The second workshop held at Hahnemann Hospital
          during July 1970 trained 17 students.  Included were 8 physicians, four
          nurses and five inhalation therapists.  Three additional workshops have
          been scheduled and to date 15 students have already been accepted.

          Project #10 - School of Radiotherapeutic Technology at Six Cooperating
                        Hospitals

                                               03
          Requesting                     4/l/71 - 3/31/72
          Direct Costs                      $373,150

          The objective of this project is  to develop, through quality instruction,
          a technologist who will be fully  capable of assisting the  therapeutic
          radiologist in the examination, treatment and follow-up of  the  cancer
          patient.  The training program involves the University of Pennsylvania
          Hospital, Hahnemann Medical College and Hospital, Jefferson Medical College
          and Hospital, Temple University Hospital, Mesericordia Hospital and the
          American Oncologic Hospital.

          It has been the intent of the program to train no less than 12 technolo-
          gists each year, however, due to recruiting problems, only about 50% of
          this quota has been reached.  In June 1970, five students completed the
          prescribed twelve months training course and have passed  the  National
          Registry Examination. All are currently employed  in  Cancer  Treatment
          Centers.  Six students are currently in training.

          The applicant states that, at the present time, they are unable to identify
          any agency from which future funding might be secured.

          Project #14 - Improving Patient Care in Hospitals Through Self-Evaluation -
                        Chestnut Hill Hospital, Philadelphia, Pennsylvania

                                              03
          Requesting                    4/l/71 - 3/31/72
          Direct Costs                      $845,846

          The overall purpose of this project is to develop a self-evaluation approach
          for continuing education in six of nine hospitals to improve patient care
          based on a process of quality of medical care review.

          The project is proposed in three phases.  Phase I would involve a two-day
          seminar to be held for the representatives from community hospitals -- 11
          member of the board of trustees, at least two of the medical staff leaders,
          a member of the administrative staff, and a physician designated by the


              Greater Delaware Valley RMP         - 9 -         RM 00026  2/71.1  (CS)

              hospital as the person responsible for the educational  programs  of  its
              attending staff. The purpose of the meeting would be  to  get  a  commitment
              from the hospitals that measurement of patient care in  their  hospitals  is
              essential. Each hospital wanting to continue in this  program  has  to  agree
              to give to two of its physicians a mandate to evaluate patient  care  in  the
              hospital. In return for the commitment, the  GDVRMP  will  share  equally
              with each hospital costs for the personnel needed for  patient  care  evalua-
              tion and for the educational programs designed to meet the verified patient
              care needs. Phase II will determine needs.  Through  a  series  of  meetings,
              each hospital will select a system of data retrieval,  probably  PAS-MAP,
              since most of the hospitals now have this service.  Once  this  decision  has
              been made, six months will be allotted for the  self-selection  of  criteria
              and the collection of data and at least three high  priorities  of  patient
              care needs. Phase III will be the  educational  program  an  eva  uation.
              The educational coordinators at the hospital (the two  physicians  who  have
              the mandate to establish the evaluation of medical care  in  that  hospital)
              will construct the medical education programs designed to meet  at  least
              two of the three needs. Joint meetings among the  hospitals  will  be  held,
              and consultation will be available for this  phase.  Evaluation  will  be
              dependent upon the data or lack thereof supplied  by  each  participating
              hospital.  If improvement of patient care is documented., the activity would
              be considered a success in that hospital. If it is  not  documented,  the
              proposal is considered to have failed in that  hospital.  The  final  evalua-
              tion of the success of the program would be the decision  of  the  hospital
              board of trustees to assume full cost of the program  after  two  years.

              Project #15 - Development of Three Dimensional Models  for  Cancer  Detection
                            Trainingi Temple University Health Sciences Center

                                                  03
              Requesting                    4/l/71 - 3/31/72
              Direct Costs                     $32,580

              The overall purposes of this proposal are:  (1) to develop three-dimensional
              models which closely simulate the normal human rectum,  female  pelvis  and
              female breast,, in respect to sight and touch; (2) to develop methods  by
              which simulated pathologic "lesions" can be  incorporated  into  the  models
              (breast lumps, rectal and pelvic masses, and so forth);  (3)  to  develop
              models which could be produced commercially and sold at low  cost;  (4)  to
              field@test each model to determine its reliability and  validity  as  an
              evaluation tool of physical examination skills important  in  cancer  detec-
              tion programs; (5) to test the effectiveness of the  models  as  learning
              -devices for the development of physical examination skills; (6)  to  deter-
              mine the feasibility of acting as the clearinghouse for  the  GDVRMP  in
              disseminating information about three-dimensional models useful in training
              phys icians in allied health personnel.


                                                                 RM 00026 2/71.1. (CS)'
            Greater Delaware Valley RMP           - 10

            New Projects
            Project #25   Greater  Delaware  Valley  Regional  Dialysis  Training,  Project
                          Crozer-Chester Medical Center

                                 03                04               05
            Requesting,     4/l/71-3/31/72  4/l/72-3/31/73  4/1]73-3/31/74        All Years
            Direct Costs       $661,487          $49,612          $53,568         $169,667
            The thrust of this proposal is to provide effective training in       home
            dialysis to physicians, registered nurses, licensed practical nurses,
            technicians and social workers in the Region.
            The physician course will be limited  to  a  maximum  of  four  physicians  and
            will be scheduled in a flexible but structured manner each requiring a
            period of  three  consecutive  days.  The  courses  are  designed  for  physicians
            having had little or  no  first  hand  experience  with  a  hemodialysis  program.
            The Nurse course will be six weeks  in  duration  and  will  be  repeated  four
            times yearly.  Each course will be restricted to a maximum of eight students.
            Candidates will be referred from interested and cooperating hospitals.
            Candidates for the Dialysis Technician Training course must be referred
            from interested and cooperating hospitals and will be restricted to a maxi-
            mum of four  students.  The  classes  will  be  simultaneously  with  the  classes
            for nurses.
            A one-week course given to provide overall orientation to hemodialysis will
            be held for community  nurses.  Each  course  will  be  restricted  to  a  maximum
            of four  students.  The  five-day  orientation  period  will  include  three  days
            in the training center and two days of field trips visiting dialysis
            patients in their home.
            The long range plan for this training program would be that it becomes self-
            supporting, relying upon tuition and contributed services.

            Project #26 -  Demonstration  and  Evaluation  of  a  Dialysis  Training  Program,
                           Thomas Jefferson Universi@

                                  03               04                05
            Requesting      4/l/71-3/31/72  4/l/72-3/31j@3  4/l/73-3/31/74        All Years
            Direct Costs       $75p725           $63,271          $650657         $2043,  653
            The goals of this proposal  are  three-fold  in  that  training  programs  are  to
            be directed toward additional nurses and dialysis     technicians   for   staffing
            intermediate care facilities, training patients and families of patients in
            hemodialysis care, and continuing education of nurses and physicians
            specializing in care and treatment of kidney diseases.


              Greater Delaware Valley RMP         - 11 -          RM 00026 2/71.1 (CS)

              One of the objectives is to provide training of personnel  to  staff  inter-
              mediate care centers to provide dialysis care for patients who  do  not  have
              facilities or capabilities for home care and who do not need hospital care.

              It is proposed to train about 27 nurses, technicians  and  assistants  each
              year. Evaluation of the project is expected to be  developed  on  the  basis
              of production of qualified technicians and assistants, as well  as  a  better
              understanding of the needs of kidney disease patients by  nurses  and  physi-
              cians.

              The proposed plan carries the endorsement of  highly  qualified  specialists
              in several hospitals in the Region who have indicated a  desire  to  partici-
              pate in the training program.

              Project #27 - Director of Medical Education for Downstate Delaware Hospital
                            Belford Memorial Hospital, Inc., Milford, Delaware

                                  03              04                05
              Requesting     4/l/71-3/31/72  4/l/72-3/31/73  4/l/73-3/31/74     All  Years
              Direct Costs      $561,175         $37,693          $20JI058       $113,926

              This is a proposal to provide coordinated continuing  medical  education  for
              physicians, nurses, technicians and other  paramedics  personne    n two
              lower counties of Delaware '  The plan calls for employing a Director of
              Medical Education to coordinate the medical education efforts between
              three hospitals (Milford, Beehe, and Kent General) in the  area  serving  a
              population of about 175,000 people. The three  hospitals  have  a  combined
              bed capacity of 446 and a total of 90 medical  physicians  and  osteopaths.

              The primary responsibility of the Director of Medical Education will be
              for continuing education of staff physicians.    He will be  responsible  for
              the following Activities:
              1)  Evaluation of educational needs
              2)  Organization of educational activities
              3)  Organization of inter-hospital educational activities
              4)  Organization and implementation of continuing medical education
                  activities for health professionals other than M.D.'s
              5)  Evaluation of educational programs and activities.

              The Director of Medical Education will also utilize part  of  his  time  to
              become familiar with educational programs and concepts  being  developed  or
              utilized within the GDV Region and in other parts  of  the  country.  Evalua-
              tion of the program will be along several lines: (1)  the  number  of  educa-
              tional activities implemented in comparison to  preceding  activities,  (2)
              the willingness of the hospitals to continue to support  the  coordinator  or
              director of medical education on their own and the extent to which educational
              needs are defined and programs to fulfill these needs are implemented.


         Greater Delaware Valley               12           RM 00026 2/71.1 (CS)

         It is proposed that, the cooperating hospitals will assume full financing
         after three years, if the position proves to be of value to the hospitals.

         Project #28   First Care Cardiopulmonary  Resuscitation  Training  Program
                       Delaware Fire School, Dover, Delaware

                             03               04              05
         Request@n      4/l/71-3/31172  4/l/72-3/31/73  4/l/73-3/31174     All Years
         Direct Costs       $72$204         $23,840         $2410976        $121,020
         The goal of this  proposed project is to provide training  on  a  statewide
         basis for persons who  are likely to be confronted with such situations in
         methods of emergency  care for victims of heart attacks and/or stroke.
         Training in cardiopulmonary resuscitation techniques would be provided for
         specially trained lay personnel, paramedical personnel  and  medical  per-
         sonnel.
         The training programs will be specially designed to fit the  needs  of  the
         various groups and the capabilities of the individuals taking the training.
         The program evaluation is to be developed on the basis of written examina-
         tions at the close of each training session. A  substantial  part  of  the
         first-year request is for equipment, particularly a  Mobile  Coronary  Care
         Training unit to be used in the training program covering all trainees in
         all areas of the state.  $49,500 of the total $72,204 request is for
         equipment.

                                                                GRB/RMPS'   12/17/70


                                                                         (A Privileged Co,-,,@iiiiic.@tioct)

                                     SLU4MARY  OF   REVIEW   AND   CONCLUSION
                                     OF  JANUARY   1971   REVIEW   CO@ZIITTEE

                           GREATER   DEI,A@4A'IZE VALLEY REGIONAL MEDICAL PROGRA@!
                                             R,@4 00026 (S) 2/71.1

                          FOR CONSIDERATION BY FEBRUARY 1.971 ADVISORY COUNCII,

              Recommendation:  The Committee recommends that this application which
                                  requests three-year support.for four new projects b@-
              partially supported as follo,:qs:

              YEAR                           REQUE,;T                       RECO@@TENDED    FUNDIF(@

              Ist Year                       $270,591
                                                                              @$50,000 I/ 2/
              2hd'Year                           174,416                           -O-

              3rd Year                           164,259                           -0-

                      TCFFAL                 $609,266                          $50.,Ooo

              I/ Support  of   Project   #28 - First Care Cardiopulmonerv Resuscitation Tr@-,Inin@
                 Program,  Delai@lare   Fire ScTool,   Dover, Delaware may be precluded hv ITT
                 policy which limits support to        training   activities   which   Pre   directed
                 principally to medical -and allied health personnel who are epiplo-,7(,et in
                 hospitals and in other inpatient facilities, or in out-1)@t-lr,,nt
                 emergency  facilitie@.operated  by  or  directly  related   to   innti.ti-itio-,-@s
                 in  which  folloT,?-Up  care   is   immediately   available.

                 Projects  llr25  -  Greater            Va],LN,@R @i q L@!. Ii        Tr.)inifi@r. Pro'ie'c-t
                 and Project lr'26 - Deni,)rtstrqtf.on and EViF.Itlltioll Of q p
                                                                                            Tr,@i.ning
                 Erogr  @i,  Thomas   Jefferson   Uri'varsity  are  to  be  further   consirFeTe-   @y
                 special Renal Com.,Tti-ttee which is to be COTIVelle6 before           February 3971
                 Council m(,Pti.ii(y.

              LIEI-C"L@round.:  The Committee ,,as @.-T,7are that staff on January 4, 1971 had
                             revicT,,eO the continuation component of this                         Tii e
              request was for $2,142,503 for t@e (03) year continuation of Core ?ct-ivities
              .and  six  projects  and  a  supplemental  request@for  support   of   five   approvf2d
              but unfunded projects ($295,355 d.c.) @)liich have been supported out of
              carryover  funds   or   throuah   rebudgetin-   of   core.funcls.   Staff   recommended to
                                           C,             C,
              the  Actin-  Director,  RITPS  approval.  of  continued  funding  at  the   (03)   year
              committed  level  of   $2,109,357   rather   then   the   requested   $2,437,858.   It
              was  agreed  that  the  five  projects  which   have   been   previously   supported   out
              of  carryover  funds  or  through  rebud-etin-   could   be   supported   within   the
              committed level of support.   ('he Acting Director has not tal@en action on
              this recommendation.)  Therefore, the R(-vie-r,) CoTzi,-,iittee
              interested  in  how  the  four  new  proposals  were   to   interdigitate   with   the
              Region's total program.


              area ter Del.aware Vall.ey RMP               -2-                RM  00026   (S) 2/71.1

              Critique-  This Region has many built-in strength        s and much, as yet, untapped
                           potential.  Their objectives     .are extremely  broad  s.o  th-at "almost 7@
              anything will fit into them."  On this basis, the RAG obviously has difficulty
              in  project  scl.ection  and  approval  in  relation  to  the  Region's   goals and
                                                                                         0     'he
              6bi6ctivos.  The  Region  has  large  core  components  supported   in   b   th t,
              Execi-itive Ditec-tor's office and five of the six medical schools (approximately
              1.6 million per year).  In spite of this, the regional input for most of the
              projects is not clear.  This was made evident in this application for the
              stoport of tl@?o, almost identical dialysis training projects.            Project lr@25
              Regional Di6lysis Traini        Proect - Crozr-,r-Chest-.r Medical Center and
                       #26 - D6m.6@ist@ation and Evelunti6n of a.@DI-81.ysis
                omas@ Jefferson U-Lliveksity were reviewed simultaneously.           ile both
                  a proposals w re referred and are sch doled to be rOviciiod b,         y@a special
                nal@Committee, the Review Committee recommended that they be returned to
               he  Ogton so that they may consolidate the prooosels and more 'important,
               escribe  hoiqthis  type  of  activity  wil.1  fit  into  the  Reglbn's  plans   for
                nal diseas@e.

                     vi@7 Committee did@ riot di!gcLi.,-@ Project li@28 - Fire@t C re Co@ diOT4ulm@)tlar
               esupoi.tatibh TK6iniiig Program in any depth         In  addition  to  a   possible
                nf fct@with  @l'@'S  policy,  this  -,p7as  considered  an  equipment  proposal
               $50,@ 00 of  Ist  year  budget  of  $72,000  is  for  Van,).  The  needs  were  not
               ocumeoted  and  the  proposal  failed  to'describe  how  this   type   of   program
               ould  fit  the   Repi6nis   priorities.   Once-again   the   Committee   questioned
                ,w   is type of@pronosal gets through the local review process.

              The    nimitt66 bellev6d that this program, #27 - D.M.F,.  Fnl;,  Do@,7n,,5t.,ite
              D la@. re Hospitals:  1) related to the broad goals.-and objectives of the
                               i@iould@initiate an important continuation education activ ;y-"
                   on  an                                                                        i
               n a    rni-rural area far removed from the medical, sthool.  The Cc.)mmi tee
               Plieved that the R@IP should consider providing the "seed" money to initiate-:@
                                    it has good potential.. for con        e
                e program, since i                                    tinu d support from local.
               ourcos.

                                                                                       RNPS/GRB
                                                                                    1/18/71   -


              0                                                      @ 0                                                                    0


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

                 HAWAII REGIONAL MEDICAL PROGRAM                    RM  01-03  (AR-1-SD)  2171
                 Harkness Pavilion                                  January 1971 Review Committee
                 1301 Punchbowl Street
                 Honolulu, Hawaii  96813

                 PROGRAM COORDINATOR:  Masato Hasegawa, M.D.

                                         REQUEST  (Direct  Cost  Only)

                 REGIONS OPERATIONAL YEAR           03          04          05           Total

                                                            (Anniversary Review Package Due
                                                              on  May  1971)
                  I.   Developmental    Component   92,314                                92,314
                 II. @4=New Proiects               412,647     381,675     @385,220   1,179,542.

                      Total                        504,961     381,675     385,220    1,271,856

                 RMPS Staff Review of Non-Competing 03 Year Operational Continuation
                 Grant Application on 8170

                                                Awarded             Commitment       Commitment
                 REGIONS OPERATIONAL YEAR        03 Year             04  Year          .05 Year

                  I.  Core                      382,781                  -0-               -0-
                 11.  Eight Ongoing Projects    563,158             149,909           96,647
                      Total                     946,539             149,909           96,647

                                                FUNDING HISTORY
                                              (Direct Cost Only)
                 GRANT YEAR

                 PLANNING STAGE            Period                    Funded

                 01                  7/l/66-6/30/67                  108,006
                 02                  7/l/67-6/30/68                  122,297

                 OPERATIONAL STAGE

                 01                  9/l/68-8/31/69             Care- 362@872
                                                            Projects- 475,031
                                                               Total- 837,903


                OPGRATIONAL STAGE (continued)
                                     Period                           Funded
                01               5/l/69 -   8/31/69              Pacific Basin Planning
                                                                         30,000

                02              10/l/69   9/30/70                Core   336,101
                                                           Projects-   471,503.
                                                             Pacific
                                                               Basin-  17
                                                                          .,082
                                                                Total 824,686

                02               6/l/70   9/30/70            Projects    90,000

                03              10/i/70   9/30/71               Core  365,511
                                                             Projects 563,758
                                                             Pacific
                                                             Basin-   17,270
                                                             Total    946,539

                Georgraphy and  Demographp.  The Regional Medical  Program   of Hawaii (RMPH)
                                             is responsible not  only  for  the Hawaiian
                Islands, but also for the Pacific Basin--Trust Territories (Micronisia),
                Guam, American Samoa.  The State of Hawaii includes a long chain of
                islands almost exactly in the middle of the Pacific.    It stretches
                from the Island of Hawaii to tiny Kure Island, approximately 1,500   miles
                to the northwest. The populated part of the state includes the seven
                major islands:  Hawaii, Maui, Molokai, Lanai, Oahu, Kauai, and Niihau.
                These seven major islands are relatively close  to  each  other.  Hilo,
                Hawaii, is about 200 miles from Honolulu.  Both Kahului, Maui and
                Sihue, Kauai ar6 approximately 100 miles  from  Honolulu  airport.  The
                .Molokai Airport is about 54 miles from Honolulu.  Lanai and Molokai
                are only eight miles apart at their  closest  point.
                Honolulu, the state capitol and largest city of Hawaii, is located
                on Oahu, as is Waikiki, the major tourist destination area.
                The resident population of Hawaii, according to  the  preliminary  1970
                census count, is 748,182 persons, including 41,362 military personnel.
                The population has increased 18 percent since 1960 and is expected to
                reach more than  one  milli on by 1980.  In addition to the resident
                population, Hawaii has approximately 1.4 million  visitors  each  year.
                This number Is expected to double by 1975.   Medical needs of these
                visitors have a distinct bearing on medical planning for the state.
                Ethnically, the population of the Hawaiian Islands is 67 percent
                oriental and/or 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:  sugar, pineapple, military
                expenditures ard tourism.


            Hawaii RMP                           -3-             Rm 01-03  (AR-1-SD)  2/71

            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.

            There 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 residents.'

            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. The community  college  system  provides  training
            for licensed practical nurses and other allied health workers.

            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
            application received from any region) for establishment of  a  RMP  consisting
            of Hawaii, Trust Territories, Guam, and American Samoa.
            In June  1966,, the Region received its 01 year planning award at a funding
            level of $90,005 d.c. Very little progress was made in  the  first  year.
            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  RMP  was  conceived
            mainly as a means of supporting the new medical school.
            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 be chosen.
            In April 1968, Dr. Masato Hasegawa  was  appointed  Program  Coordinator,
            Dr. Hasegawa, a pediatrician, was a prominent member of the medical
            community, with great interest in community medicine."
            In October,1968, the Grantee changed from the  University  of  Hawaii  to
            the Research Corporation of the University of Hawaii.


              nilwilLiL

              The RMPH submitted its first operational application  consisting  of
              continuing core support and 10 project proposals in September  1,  1968.
              The major thrust of this application was in continuing  education  using
              Region Wide (Ilawaiiin Islands only) resources, in the absence of  a
              fully-developed medical school.

              The application also stated that RMPH 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
              with the leadership of Dr. Hasegawa. In the few months he  had  been  with
              RMPH, 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 developing well.

              In April 1969, this RMP received a $30,000 award for  planning  activities
              in the Pacific Basin-Trust Territories, Guam,, Samoa.  In making this
              award, Council sharply reduced the $100,000 requested out of concern
              that RMPH might "spread itself too thin" and not concentrate  its  efforts
              sufficiently on building RMPH in Hawaii.

              During 1969, the Core staff expanded beyond the approved  total  level,
              and this posed A problem for the Region in terms of continuing support.
              The fiscal elements of the continuation application  were  particularly
              confusing, despite r6preated inquiries to the Region.  Finally, the
              Division asked the Region's fiscal officer to meet with  Division  staff
              in Bethesda, where the difficulties were ironed out.

              In January 1970, a site visit was conducted to the Region  (Dr.  Millikan,
              Dr. Bessonl Dr. Zippen, Dr. Komaroff, Mr. Morales).  The  visitors  were
              encouraged by the increasing involvement of the Medical Society, hospitals,
              and paramedical personnel; Core staff had grown stronger; the  RAG  had
              become more broadly representative;  and planning activities in the
              Pacific Basin had been initiated.  The visitors were disappointed at  the
              diminishing involvement of the previously vigorous RAG chairman, Mr.  Cannon.
              They also believed that the KFPH had progressed where Dr. Hasegawa required
              administrative assistance.

              Staff reviewed on September 28, 1970 the @IPH 03  year  continuation
              application and believes that this RMP has made  remarkable  strides  in
              the past year.  The RAG's role and strength is still not clear,  but  an
              ad hoc evaluation committee and established policies and procedures
              provide hope that the RAG effectiveness will be improved.   The
              Executive 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.


                                                                                        I
               Hawaii KIP                           -5-            RM 01-03 (AR-1-SD) 2/71

               Core staffing has been strengthened,  both  organizationally  and  with
               additional positions of an Associate Director,  and  the  Chief  of  Con-
               tinuing Medical Education filled by  Dr.  Alexander  Anderson  (from  George
               Mill-er's operation). The  Region's  responsibility  for,  and  commitment
               to the ]'rust Territory has been expanding, and  is  a  continuing  source
               of concern to Dr. Hasegawa because of his limited resources of personnel,
               time and funds.  The operational projects appeared to be well on
               schedule towards meeting their objectives.

               Organizational Structure and  Processes:  The  Regional  Advisory  Group  of
                                                          the RMPH is composed  of  45
               members, 36 from Hawaii, 3 members each  from  Guam,  American  Samoa  and
               the Trust Territory-

               The members from Hawaii are  appointed  by  a  Nominations  Committee  or
               three-year terms. The members from  Guam,  American  Samoa,  and  the  Trust
               Territory are designated by their respective chief executive.  The
               membership of the RAG includes physicians (20), Registered T,',-,rses (2),
               Hospital Administrator (1), Social  Behavioral  Scientist  (2),  consumers
               (18), labor official (1) and a high chief  from  Samoa.  The  RAG  activi-
               ties have centered around project  review  and  approval.  Other  major
               activities of RAG during the past year included the following:

                   Establishment of appointment procedures and functions of RMPH,
                   RAG and other Committees as appended.

                   Recommendation for a change in  grantee  institution  to  RMPS  which
                   was approved.  The new grantee institution is the Research
                   Corporation of University of Hawaii.

                   Recommendation for the use of  project  summaries  to  facilitate  the
                   review process.

                   Selection of the ad hoc Evaluation Committee  of  RAG  of  RMP-Hawaii.

                   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 twenty-one employees, twenty at 100'/. time
               or effort, The Core staff organization  has  been  reviesed  to  include  an
               Associate Director and a Chief of Continuing Medical Education. Exclusive
               of the secretaries, the Core staff  consist  of  thirteen  presently  active
               members plus an Associate Director and  a  Chief  of  Continuing  Medical
               Education.


                    Hawaii RMP                                              -6-                   RM 01-03  (AR-1-SD)  2/71
                    Following is a list of the core staff members  and an organizational chart.
                    NAME                                             JOB TITL'G                                    TIME OR EFFORT
                                                                                                                       % HOURS

                    Masato Hasegawa,  M.D.                      Program Coordinator                                    50%
                    TBA                                         Associate Coordinator                                  100%
                    Alexander Anderson, M.D.                    Chief of Continuing Medical
                                                                Education                                              1000/.

                    Satoru Izutsu          Ph.D.                Chief of Planning & Operations
                                                                Pacific Areas                                          100%
                    Omar A.  Tunks                              Chief of operations                                    1007.
                    Rosie K.  Chang                             Chief of Allied Health Services                        100
                    Ruth N.  Denney                             Chief of Planning & Research Ser.                      100%
                    Norman S.  Kuwahara                         Comptroller                                            100%
                    Paul E.  Cook                               Assoc.  Chief of Operations                            100%
                    Nancy     C.      Fowler                    Assoc.  Chief-Planning and
                                                                   Research Services                                   100%
                    Clyde J. Winters                            Medical Librarian                                      100%
                    Paul     T.      Okumota                    Audio-Visual Specialist                                100%
                    Nancy     B.      Crocco                    Asst.  Chief-Cooperative
                                                                 Comm.  Health Services                                100%
                    Patricia     S.      Coe                    Researcher                                             100%
                    Thelma T.  Fujisawa                         Bookkeeper                                             100%
                    Vicki A.  Johnson                           Executive Secretary                                    100%
                    Ethel     F.      Kawano                    Secretary                                              100%
                    Lynda Armstrong                             secretary                                              1001/.
                    Elizabeth K. Medeiros                       Secretary                                              1 0 OP/@
                    Elizabeth M. Munoz                          Secretary                                              I 0 (r/.
                    Verna May S.  Okano                         Secretary                                              1001/.


                                          1-4
         Hawaii RMP RM 01-03                                                       W  Eo
                                   F--
           Ar(-I-SD)   2/71                  >1 cn                   tn              o@,
                                                                     0             0        0
                                                                                     p   0  o
                                                                     rJ4 E--i
                                                                     1-4           0  W     -4
                                                                     :t r4         U)       :s
                                                                     0P'4 $4                tu
                                                                     0co

                                             0
                                             xr-
                                          E-40
                                          En
                                          1-4
                                          (n -,4

                                             u
                                             ..4

                                             rn
                                             &4

                                             co
                                             S-4
                                             co                      0                                       0
                                                                     U)                                      4i
                                             Cd                      14                                      0
                                          P4                r4       U               E-4                  E4 r=
                                                                                        rn  0             to :I

                                                                                   0
                                          C> C:                                         F4 -A   <      :;  @
                                             co                      x                  >   M   .       . "  41
                                             r=                      ;040          r4 lm C4 0   x         0  z
                                                                                     r4 w   C4            r4 co
                                             $4
                                             0                                                            P4
                                             z

               60

                           CZ
            C4 co
                           E4

                           r4

                                                                     i4
                                                                       co
                                                                     C> M 4J

                                                                       tQ
                                                                     F4

                                                                     F-40S4
                                                                       0
                                                                       -W
                                                                       co                       O'
                                                                       E/)
                                                                                    fy4     0   0
                                                                                       1.3  H   so
                                                                                         >4 >
                                                                                         H.  C4
                                                                                         1-4 14 >1
                                                                                            U)  U

                                                                                       r4
                                                                                    uo PL4
                                                                                    @   0

                                                                                                           0

                                                                                                           4J
                                                                     U) Cf) 0)                             cu
                                                                     wwV.                                  P4
                                                                     C-)
                                                                     F4
                                                                     >                                   C4
                                                                     r4                  E-,,              L4
                                                                     r4                  En                z
                                                                     rj)               F-4 1-4
                                                                     P4                i-4
                                                                                       En

                                                                     P4 14
                                                                                            co

                                                                                            co
                                                                                       F4


                 Hawaii RMP                           -7-          RM 01-03 (AR-1-SD) Z//l

                 I'lie Region indicated in the continuation application that previously the
                 leverage in influencing the health care system was by "project grant
                 mechanisms.  They believe they are now ready for new dimensions in their
                 strategy which will involve RMPH central staff.  The central core staff
                 will provide resources for consultation in medical core systems, in
                 continuing medical education, in health services research  and  development,
                 in health data acquisition and retrieval systems, and in health education
                 of the public.  They will not be considered merely as overhead to operating
                 projects.
                 Following are the names and functions of the Committees of RMPH:

                 Executive Committee:  Acts  as the policy-making body for the overall
                 operation of RMPH.  It consist of ten voting members representing the
                 University of Hawaii School of Medicine, the Hawaii Medical Association,
                 the Hawaii Hospital Association and the consuming public.  In addition,
                 the chairman of the categorical disease advisory committees, the chair-
                 man of the Advisory Courriittee on Continuing Medical EducaLlon, representa-
                 tives of the grantee institution and the RMPH Direcotr serve  as  ex-officio
                 members without vote.

                 Finance Committee of Executive Committee:  Studies and advises on the
                 total fiscal maters of RMP-Hawaii.

                 Personnel Committee of Executive Committee: Studies and advises on the
                 functional organization of the Central Core staff.
                 The Long-Range Planning Committee: Appointed by the Executive Committee
                 its members develop long-range goals, objectives and priorities of RMPHO
                 Technical Review Committee:  The Director nominates for the consideration
                 of the Executive Committee, the chairman and members of this committee.
                 These members will technically review all operational proposals prepared
                 by RMPH for funding4
                 Categorical Committees (Heart, Cancer, Stroke) Appointed  by  the  Executive
                 Committee the members encourage development of new projects and review
                 all proposed projects in their subject areas.

                 Other Committees:

                 Advisory Committee for Allied Health Services
                 Cooperative Community Health Program Advisory Committee
                 Continuing Medical Education Advisory Committee
                 Advisory Committee for Guam, Samoa & Trust Territory
                 Hawaii County Advisory Committee
                 Kauai County Advisory Committee
                 Maui County Advisory Committee
                 Project Review Process:  Each project proposal begins the review process
                 as a letter of intent submitted to the Director of RMPH.  Ideas for
                 project proposals are generated by individuals, agencies or organizations:@:@',
                 in the health field.  The Director and Core Staff assess the revelance


               Hawaii RMP                           -8-          RM 01-03 (AR-1-SD) 2/71
               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.  The development of the project often
               takes several months.  The Core staff works closely with the applicant
               organization,throughout to construct a proposal which follows RMP
               Guidelines.  After the final draft of a proposal has been completed, it
               is channeled through the appropriate Categorical and Technical Review
               Committees, then through the Executive Committee and the Regional
               Advisory Group.  At any point, the proposal may be returned for revision,
               deferred, recommended for approval or disapproved.  Upon final approval
               of the RAG, the proposal is sent to RMPS for national review.
               All proposals are reviewed in terms of:
               (1) Relevance to the overall plan of RMPH and the degree to which the
                   proposal furthers regionalization and cooperative arrangements,
                   to improve our present health care system in Hawaii.
               (2) Identification of needs and opportunities within the region.
               (3) Definition of objectives in clear, measurable termso
               (4) Assessment of resources, including the identification and use o
                   existing resources, avoidance of duplication,, and the initiation
                   of cooperative arrangements and closer linkages between the
                   available resources.
               (5) Involvement of individuals, organizations and institutions within
                   the region.
               (6) Indication of the priority level of the proposal in relation to the
                   overall goals and objectives of RMPH.
               (7) Implementation, including strategy, methodology and techniques for
                   accomplishing the stated objectives.
               (8) Evaluation protocol developed to measure achievement of the objectives
                   and assess the overall effect of the proposal.
               Although there is no formal review relationship with CPH, 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 power of any one review committee.  Clarification
                 is required with respect to the effect of one review committees veto on
                 the continued progress of a proposal through the local review mechanism.


               tiawaii mr                                     @l VI-VI it&L%-L-Olij

                                      PROJECT REVIEW FLOW CHART

                                          GRANT APPLICATION
                                        (any agency, planning
                                             Staff RMPH)

                                        ADNINISTRATIVE OFFICE

                                         PROGRAM COORDINATOR
                                           (for.relevance to
                                            overall plan)

                                           PLANNING SECTION
                                    (when grant comes from a encies
                                                           .9
                                    other than RMPH for review by
                                     staff with expert advice as
                                                needed)

                                   CATEGORICAL ADVISORY CONMITTEE
                                         (for subject matter
                                           and excellence)

                                           TECHNICAL REVIEW
                                              COMKITTEE

                                            EXECUTIVE COMMITTEE

                                             REGIONAL ADVISORY
                                                   GROUP

                  DRNP
             Washington, D.C.                                     RESEARCH CORPORATION
                                                                       OF U OF H
                                                                  (copy of project--
                                                                   for information only)


               Hawaii   RMP                           -10-            PM  01-03  (AR-1-SD)  2/71

               Annual Report of the Regional Advisory Group       The  Regional  Advisory  Group
                                                                  of  the  @IPH  expressed
               in their report their satisfaction of progress made by the RMPH to
               meet goals and objectives set  fo--th  for  the  past  year.  In  an  item-
               by-item review, the  Committee  members  felt  that  progress  was  satisfactory
               in continuing medical education, expansion of RMP into the Trust Territory,
               stimulating new  projects,  providing  practitioners  access  to  latest  knowl-
               edge, expand electronic data  processing  and  develop  pools  of  health  data
               information. Two  areas  they  indicate  need  continued  and  greater  attention
               relate to public education and staff assistance to hospitals and health
               care institutionsin  evaluating  their  needs  for  facilities  and  service
               programs.

               The RAG was impressed but somewhat concerned with the broad but imaginative
               new perspective set forth for the  03  year.  There  was  a  question  of  staff
               capability and availability  of  funds  to  achieve  the  expanded  goals.  There
               was concern that a broad  gauge  approach  could  either  duplicate  or  dilute
               the effectiveness of  projects  and  activities  which  should  be  pointed
               toward meeting specific and big'fi priority  health  needs  in  R14PH.  With
               this advice, the RAC members approved the new perspective goals and
               objectives of RMP]I which broadly set  forth  the  major  areas  of  activities.

               As indicated in this application  the  new  perspective  and  strategy  of  the
               RMPH is to improve the health care system of Hawaii by instituting the
               following:
                     1.   Continuing Medical Education
                     2.   Demonstration projects for improving patient care
                     3.   Health services research and development
   0                 4.   Involvement in assessment of the quality of medical care
                     5.   Health education of general public
                     6.   Data acquisition and retrieval system

               Evaluation:  The Region indicates that for the purpose of proper
                             evaluation  of  operational  projects,  increased  effort  has
               been made to state project objectives  clearly  in  every  case  so  that  per-
               formande can be effectively measured.  The Evaluation Report by the RAG
               ad hoc committee is an important aspect of RMPH program evaluation.  In
               order to further develop techniques for evaluation, the staff has con-
               ducted inservice workshops and sought the use of consultants.

               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.   Feasibility and utilization study projects
                     C.   Staff development training programs


              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.  The Region
              believes that instituting organizational change  in  the  present  hospital
              system is the most economical and feasible way  of  insuring  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:
                    (a)  Studies of hospital emergency care departments
                    (b)  Shared services with hospitals joining together for the
                         operation of certain basic facilitative and supporting
                         services, clinical and non-clinical in nature
                    (c)  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.
                    (d)  The operation of one or more sub-units of patient care by
                         one central parent hospital corporation
                    (e)  Study of the feasibility  of  training  doctor's  assistants  in
                         hospitals,
                    (f)  Development of health manpower pools,
                    (g)  Investigation of the possibility of establishing an all-inclusive
                         hospital rate
                    (h)  Promotion of an identification program related to designating
                         routes and publicizing availability of hospital and emergency
                         care services to the public.
              The Region is requesting a funding level of $92,314 for the developmental
              component which is an amount equal to 10% of the annual direct cost funding
              level (not including carryover) o f the Region at the present time.

              Supplemental Projects
                                                                                Requested
              Project #23 - Mobile Coronary Care.  The primary purpose        First Year
                            of this project is to provide treatment              $138,661
              outside the hospital for acute, potentially lethal
              arrythmias by the utilization of a Mobile Coronary Care Unit.
              The Region explains that the two ongoing projects,   the    Cardiopulmonary
              Resuscitation Training Projects and  the  Coronary  Care  Training  Project
              for Physicians and Nurses are preparing for expanded activities as
              approved their 03-year of operation.  The Region believes that this
              project for Mobile Coronary Care will significantly extend the acute
              care capability in Hawaii and that these three projects inconcert should
              have an impact on death-rates from acute  coronary  attack  in  the  State.
              The Region also indicates that this  project  will  also  provide  training
              for allied health personnel, a high-priority component of most RMPII
              projects.
                     Second Year                          Third Year
                     $96,493                              $100,101


               Hawaii RMP                           -12-       R4 01-03 (AR -1-SD) 2/71

                                                                            Requested
               Project #24 - Hawaii Smoking Withdrawal Clinic Project.     First  Year
                             The broad goal of this  project  is  to        $32,950
               bring to the citizens of Hawaii an,  opportunity to reduce
               or discontinue existing smoking habits as an important step
               toward the reduction of heart disease, cancer,  stroke  and  related
               diseases.  Withdrawal clinics will be established to assist cigarette
               smokers in their ddaire to break the habit of  cigarette  smoking  and
               to combat recidivism among those who have  discontinued  the  habit.

                         Second Year                       Third Year
                         $42,000                            $52,000

               Project #25 - Establishment of Health Appraisal Units in      Requested
                             Hawaii. The  major  objective  of  this        First Year
               proposal is to define the health of the Individual in          $139,510
               the community through multiphasic  screening  and  to link
               this appraisal closely to the medical care system.  The Region
               indicates that this project is designed to maintain multiphasic
               screening as close as possible to the mainstream of   medical care  in
               Hawaii.

               The Region believes that this proposal for establishment of Health
               Appraisal Units in Hawaii incorporates several of the areas within
               RMP-Hawaii's strategy and focuses on health-care  costs  as  well.  The
               Straub Medical Research Institute of Hawaii, Inc.,is the applicant
               organization for this project.

                        Second Year                      Third Year
                        $172,866                            $160,585

                                                                                 Requested
               Project #26 - Improvement of the Intensive Care Unit-American     First Year
                             Samoa.  This proposal is requesting three years      $37,857
               support for the improvement of the Intensive Care Unit of the
               Lyndon B. Johnson Tropical Medical Center, the only hospital in
               American Samoa. Although an 8-bed Intensive  Care  Unit  now  exists
               at the Lyndon B. Johnson Tropical Medical Center,  the  medical  staff
               recognize that it is not fully operable because of inadequate trained
               staff an an incomplete list of equipment.

                        Second Year                       Third Year
                         $6,280                            $5,965


                naWall I\L'IE
                Project #27 - Im@rovement of DietarV Management and Dietary    Requested
                             Counseling in Hawaii.  The goal of this           First Year
                project is to improve.care to patients with diabetes,          $63,669
                cardiovascular, renal-, and other diet-related diseases by
                increasing dietary knowledge of medical and allied health
                professionals through discipline oriented seminars and to  increase
                community services by establishing a dietary counseling service.
                The Region explains that the relation of this project to RMPH
                strategy is that it renders continuing medical education of physi-
                cians and allied health personnel, education of the public in self-
                care and the use of demonstration projects.

                          Second Year                      Third Year
                          $64,036                           $66,569

                                                                       Present Year
                APPROV D AND FUNDED PROJECTS                           of Operation
                Project  #2  Training in Rehabilitation
                             in Catastrophic Disease                        3rd
                Project #3  -Home Care Training Program                     3rd
                Project #4  -Continuing Education of                     RMP support
                             Nurses in Patient Settings                  Phased out
                Project  #7  Cardiopulmonary Resuscitation
                             Training                                       3rd
                Project #8  -Coronary Care Training
                             (Queens Medical Center)                        3rd
                Project #9  -Coronary Care Training                      RMP support
                             (Hilo Hospital)                             Phased out
                Project #10 - Coronary Care Training                     RMP support
                               (Wilcox Memorial Hospital)                Phased out

                Project #11  - Region Pediatric
                               Pulmonary Program                             3rd
                Project #13  - Rehabilitation in Catastrophic
                               Disease (Guam, and Trust Territory)           2nd

                Project #15  - Region Cooperative
                               Chemotherapy Program                          2nd
                Project #20  - Guam Memorial Hospital
                               Constant Care Unit                            2nd


             Hawaii RMP                           -14-          RM 03-01 (AR-1-SD) 2//l

             APPROVED AND UNFUNDED PROJECTS                         Council Approval

             Project lfl2 - Program for Treatment
                            of Cardiac Arrest (Saipan)                 December  1969

             Project #17  - Hawaii. Mass I;creeni-ng
                            of Children for Heart Disease                March   1970

             Project #18  - Anti-Smoking Education Project
                            for Hawaii                                   March   1970

             Project #21  - Cervical Cancer Program
                            for the Trust Territory                       July   1970

             Project #22  - Training of Health Aides
                            in the Trust Territory                        July   1970

             PROJECTS DISAPPROVED

             Project #5 - Continuing Education Program
                          in Pathology

             Project #6 - Hawaii Tumor Registry
                          Expansion Program

             Project #14 - Cervical Cancer Program
                            for Trust Territory

             Project #16  - Hawaii Tumor Registry

             Project #19  - Continuing Health Education
                            Council of Hawaii

                                                        RMPS/CRB/11/19/70


                                                                     A PRIVILEGED COMMUNICATION

                                      SU@RY OF REVI.,M@l AND CONCLUS!Oii OF
                                         Jk'LIIUAI@Y 1971'REVIEW CO',%ii%i!TTEE

                                       HAWAII REGIONAL MEDICAL PROGRAM
                                            @l 01-03 (AR-1-SD) 2/71

                          FOR CONSTDERATION BY FEBRUARY 1971 A.DVISOP@Y CO'LJNCIL

              Recommendation:   Additional   funds   be   provided   for   this   application.

                 Region's                                                           Recommended
              @e a@t 2nal Year                         Request                      Fundin@

              03  Year                              $   504,961.                    $366,300
                 (Developmental Component)             ( 92,314)                    (   92,314)
                 (Five New Projects)                   (412,647)                    (273,986)

              O-/4  Year
                  (Five New Projects)                   381,675                      285,182

              .05 Year
                  (Five New Projerts)                   385,220                      285,119

                 Total                                  @71,856                     $936,601

              ritiqllt:   Committee conct:rs with the site visit te@i-n that        there   has
                          been considerable progress made       by the  H@)wai_i  R@IP  toward
              developin- the general principles of regionalization.  The Re-,ion has
              developed  a  framework  for  planning  the  ach,,,-,vemen-t  of  goals and
              objectives I.  %Ietliods for evaluation are bei-ng developed.

              The KIPH  has  developed  a  good  worli@i-Lig  relationship  with  the Hawaii
              Medical  Associatioi,  University  o-@  Hawaii,   St@@,te   Health   Depirtment,
              Comprehensive Health Planning, Ilo!E-,pital Association, e-Lc.  These
              relationships  are  discussed  in  a  report  of  a  site  visit  to   this
              Region conducted on December 3-4, 1970.

              The Program Coordinator, Dr. Masato Hasegawa, appears to           have     done
              a good job in pulli.og together the program since becoming Coordinator.
              Committee'  however,  believes  that  Dr.  Hasegawa  has   built   such   a
              large organization          so  many  complexities,   that   he   now   requires
              the assistance of a full-time deputy to help him administrate the
              day-to--day  operations.  This  would  free   Dr.   Hasegawa   to   spend   more
              time  in  developing  the  philosophy  and  direction   of   the   program.


             Hawaii- RMP                           -2-        RM 01"03 (AR-1 SD) 2/71

             This question was discussed in detail with both the  Chairman  of  the
             RAG, Cbairmaft of the Executive Committee and with tb& Coordinator
             himself during the December 3-4, 1970 site  visit.  It  was  indicated
             to the visitors that steps are being taken to modify the existing
             situation by appointment of a deputy coordinator at this time.

             The Core staff has been strenthened by the addition of Dr. Alexander
             Anderson, who has assumed the position of Chief  of  Continuing  Medical
             Education.  The core staff appears to be generally competent and
             seem to work very well together.  With the addition of the deputy
             coordinator the core staff should receive top   level  administrative
             direction for their activities

             The RAG has not assumed full responsibility in  giving  direttion  to
             the RMPII and has  played a minor role in stimulating project
             proposals. It is evident however, that the power  group  of  the  RMPH
             is the Executive Committee of the RAG, which has  adeqtidte  representa-
             tioii of the major provider institutions and significant insight into
             the health distribution problem and-the problem of the cost of
             health tare in Hawaii.  This Committee is attuned to the general.
             thrust as well as the problems of the RMPH.

             In the.Pacific Basin the @IPH has been coordinating its efforts with
             @CHP bec ause they have been active for several years in health planning
             throughout the Trust Territory 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 East-W6st Center.
             It is apparent to the visitors that the R14PH 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 Guam during the past year, the present proposal
             requesting the development of an intensive care  unit  training  proaram
             at the L.B.J. Tropical Hospital in American Samoa will give
             visibility to Pd4PH with other existing institutions in Guam.

             DeV61Q]2mental Coiiiooiient

             While pro'r68s has been slow for this region, it has been in the
             direction of a.broadening and deepening involvement of RMPH with@
             the provider of health services and the community*

             The long-range goals of the developmental  component  involves  three
             major items: a) a focus on hospitals as a major mechanism for the
             delivery of co  rehensive health care; b) the use of continuing
                           MP
             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'ptbjetts proposed for implementation  of  long-range  plans
             regarding the relationship between RMPH and the hospitals in
             the community appear to be well thou-tit out and implementation  could
                                                  0


                 0
                                                                               a


                                       REGIONAL MEDICAL PROGRAIMS SERVICE
                         s      Y OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                         (A Privileged Communication)

                Illinois Regional Medical Program, Inc.              RM 00061-02 (AR-1-SD) 2/71
                122  South  Michigan   Avenue                        January 1971 Review Committee
                Room 939
                Chicago, Illinois
                Grantee Agency: Same

                Program Coordinator:  Executive Director - Morton C. Creditor, M.D.

                                              Request (Direct Costs)

                                          02 Year        03 Year           04 Year
                                          2/l/71 -       I/l/72   -        1/l/73  -
                Purpose                   12/31/71       12/31/72           12/31/73         All   Years-

                Continuation Commitment   1,525,192         427,122                          1,952,314
                 (Core  and  2  studies)    (947,460)    (112,722)                          (1,060,182)
                 (7 projects)               (577,732)    (3   proj.
                                                           314,400)                              892,132)

                Renewal Components              -0-     1,443,608**     1,851,190***         3,294,798
                 (Core and 1 study)

                Additional    Components  1,586,835       1,641,597     1,063,314            4,291,746
                 (Developmental)            (158,564)       -0-              -0-                (158,564)
                 (2 new projects)           (633,704)    (772,882)         (141,016)        (1,547,602)
                 (2    approved/unfunded
                    projects)               (275,155)    (477,181)         (518,821)        (1,271,157)
                 (2    approved/deferred
                    Renal)                  (519,412)    (391,534)         (403,477)        (1,314,423)
                2 Supplements                 407,258                                           407,258
                  Ongoing Activity
                   (Core)                   (394,190)                                           (394,190)
                   (1 Project)              (  13,068)                                            13,068)

                Committee Action
                 Required                  $3,519,285    $3,512,327    $2,914,504         $9$946,116

                   Includes  $191,247  Renewal  request  for  Educational   Resource   Study.
                   Includes $201,000 request for Education Resource Study.

   40


               Illinois RMP

                                                 Fundin    tor

                                               Planning Stag@
               Grant Year            Period                                  Funded -(d.c.o.)
                   01                 7/l/67 - 6/30/68                          $304,629.
                   02                 7/l/68 -  10/31/69  (16  mos)             976,341
                   03                  il/l/69  1/31/70  (3 mos)                357,840

                                             Generational   Program

                                             Council     Funded                 Future
               Grant
                                                                                Commitment
               Year    Period                Approved    D.C.O.

               01      2/l/70    1/31/71     1,585,643   855,097*   Core        -------
                                                         730,546**  Projects

               02      2/l/71    12/31/11    1,532,333   --------               1,532,333
               03      1/l/72    12/31/72       427,122  --------                 427- l@2

               * Includes Educational Support Resource   Study  $174,500
               ** Includes,Hypertension    St. Lukes  $145 600


               Illinois RMP                     -3-                   RM 00061-02 (AR-1-SD) 2/71

               Geogr@h :
               The borders of the Illinois region are, like those of other regions, not
               defined.  in the initial planning grant application the Illinois region
               was defined as encompassing the State.  All of Illinois' five schools of
               medicine and the School of Osteopathy were located  in  Chicago.  It  was
               .felt that these institutions, working together could cover the requirements
               of the state better than could be done by apportioning parts  of  the  state
               to each school. However, the Bi-State Regional  Medical  Program,  based  in
               St. Louis, Missouri, also designated approximately the southern half of
               Illinois as, in their view, being in that region. As  time  has  passed  and
               both regions have matured this "turf" problem, which  remains  unsolved,  is
               taking on greater dimensions.  On the west, Moline, Rock Island, and other
               coumaiities of that area are a part of a metropolitan  area  which  includes
               Davenport, Iowa. In health services, some  relationship  with  Iowa  City
               exist.
               Along the northern state line of Illinois there are no areas  with  'very
               strong ties to Wisconsin. The state line appears  to  be  an  appropriate
               boundary.  Based on present health service patterns, there are sharp
               differences of opinion in northwestern Indiana (Gary, etc.) as to their
               most appropriate region. The area is a  part  of  the  Chicago  Metropolitan
               Area, but has substantial loyalties to Indiana.

               Demorraphy
               A.   Population:  Approximately 11 million
                    1.  Roughly 81% Urban
                    2.  Roughly 89% White
                    3.  Median Age: 31.2 years
               B.   Medical Schools: at present seven, (including one College of Osteopathy)
                    soon to be expanded to eleven.

               C.   Hospitals:  Approximately 300-350
               D.   Physicians:  14,000 medical and 363 Doctors of Osteopathy

               History of Regional Development
               On March 9, 1965, a committee of the five Medical  School  Deans  in  Illinois,
               members of the Illinois Division of American Cancer  Society  and  the  Chicago
               Health Department, was appointed by Dr. Morris Fishbein, President of the
               Chicago Heart Association, to discuss the possibilities of a RMP in Illinois.
               During July 1965, Mayor John Daley and Governor Otto Kerner appointed separate
               Advisory Committees for RMP which subsequently (January  1,  1966)  were  fused
               to form an original Regional Advisory Committee.  Appointment, responsibility
               and authority of the membership to the RAG was vested  in  the  Governor  until
               changed on November 25, 1968.  on that date the RAG appointment authority
               became vested in the RAG.  From July 1, 1965 until July 1, 1969, the
               Coordinating Committee of Medical Schools and Teaching Hospitals of Illinois


              Illinois RMP                   -4-                   RM 00061-02.,(AR-1-SD)
              served the function of Trustee, with the University of Chicagp,@i@g the
              grantee agency and fiscal agent.  The Coordinating Committee was7 comprised
              of the six deans of the schools and the administrators of some 1.6 major
              medical school hospitals.  It had, and exercised,,the responsibility  for
              the policy decisions relating to core staffing and administration,  and  to
              both planning and operational components of IRMP.
              The August 1966 National Advisory Council considered the  initial  planning
              application submitted by the Coordinating Committee of Medical  Schools
              and Teaching Hospitals of Illinois for implementation of RMP in Illino,;Ls.
              Council rejected it, feeling the proposal was "superficial and  inadequate."
              It'contained no description of the local Advisory Group or its  method of
              procedure and there was no appearance of involvement of  community  medical
              faciliti
                     es.
              A revised planning application was submitted and approved by May 1967 Council
              at areduced level  for a two-year period 7/67 through 6/69.  Several  concerns
              were still present'.  These were:
                  Administrative structure appeared cumbersome.
                  Heavily medical-school oriented with minimal   involvement of other
                  health-care areas.
                  Advisory Group is  physician-oriented; the only Negro member  is elderly
                  and out of touch with the regional planning.
                  Lack of information about involvement of the   central.part of the state.
              During September 1968, the Illinois Regional Medical Program submitted its
              original operational application.  Subsequently, this was withdrawn by the
              Regional Advisory Group following a November 1968,  DRMP  staff  assistance
              visit.  The visitors concluded that the Region contained the following
              weaknesses and strengths.

              Weaknesses
              1.  Little evidence of real commitment of leadership by the medical schools.
              2.  inadequate representation from outside of Chicago on the various committees
                                d the advisory group
                  task forces an
              3.  Core staff is much too smal 1 for such a large and complex region.
              4.  Need for aggressive leadership by the power structure.
              5.  IRMP is too passive;should be more active.
              6.  The foundation of IRMP, its core staff and  its planning leadership capa
                  is not ready for the superstructure of an operational program.
                                                                                                I  I
                                                                                             ".-.j II @
                                                                                                   i
                                                                                                   I
                                                                                                   i

                                                                                                   I
                                                                                                   11


              Illinois RMP                   -5-               RM 00061-02 (AR-1-SD) 2/71

              StrenRths
              1. The obvious interest and talent of many task force committee chairmen
                and members.
              2. The beginnings of hospital networks related or  Potentially  related  to
                medical schools.
              The revised operational application was submitted for  consideration  during
              the July/Aiigust 1969 review cycle.  The application contained a two-year
              request for support of planning and Core activities beginning November 1,
              1969 (the grant period had been extended from July 1. 1969 to November 1, 1969)
              and support of three to five years for 8 new operational projects. A  pre-
              operational site visit was conducted during June 1969. The members of  the
              site visit team were impressed with the amount of planning and maturation
              that had taken place since the original operational application and the
              November 1968 staff assistance visit.  Members of the site visit team
              recommended that on the basis of the evidence presented of cooperation
              between Medical schools, hospitals, councils, voluntary and public agencies,
              the region was now ready to mount an operational program.  Seven of the
              eight operational proposals were recommended for approval.  The team further
              recommended that the request for additional funds for core not be approved,
              until a new program coordinator could be appointed.  The site visit team further
              recommended that if the IRMP was approved as an operational program, the
              Region should be made aware of the program recommendations of the team@
              These were:
              1.  That the Regional Advisory Group, Boards, Task Forces, and Committees
              contain minority group representation, both professional and lay consumers;
              2.  That there be broader distribution of allied health and health manpower
              involvement;
              3.  That there be a more realistic relationship established between the Board
              of Trustees and the RAG pertaining to application review;
              4.  That concrete efforts be effected to solve the upstate versus the Down-
              state cast of the Region;
              5.  That a more organized, realistic approach to the collection and collation
              .of data be obtained;
              6.  That the aims and objectives of contract arrangements be continually
              reviewed in relationship to their history, ready availability of any particu-
              tar information sought, and the real, proposed effect on the future of the
              Region's Program;
              7.  That a 'lan be developed and a policy established and agreed upon between
              agencies and institutions to provide for an auditable accounting procedure
              for any fees or funds earned in or as a result of any project -  supported
              activity And;


             Illinois RHP,                        -6-                RM 00061-02 (AR-I-SD) 2

             8.  That the Region appoint and establish a Region-wide representative
             Stroke Committee.
             Both the July Committee and August  1969  Council  concurred  in  the  re@ ommendation
           ..of the site visit team.  During February 1970, the Region     was awarded opera-
             tional funds to support Core and the seven new projects.      A breakdown is
             provided.

             Project                                                       Amount Supported (D.C.)
             Number      Title                                             through 1/31/71

             00          Core (Basic)                                          680,597

                         Hypertension Study-St. Luke's Hospital                145,600

                         Education Support Resource Study                      174,500
                                                  CORE TOTAL                 $1,000,697

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

             2           Multiphasic Screening iii Chicago Area
                         Industrial Plants to Detect Coronary-
                         Prone Persons and Individuals with Sub-
                         clinical Heart Disease                                199,826

             4           Regional Coordinated Cancer Program                   108,950

             5           Radiation Therapy Treatment Planning Center            24,300

             6           Macon County Stroke Coordination Program               33,790

             7           Comprehensive Stroke Rehabilitation Program           111,225

             8           Comparative Endnoscopic Study and training
                         program in the Early Diagnosis of Gastric
                         Cancer                                                 71,330
                                                                   TOTAL     $1,585,643

             Following the recommendations of a June 1970 technical site visit team, the
             August 1970 Council recommended approval  of  four  new  operational  projects;
             two in renal disease, one in cancer and one  Utnified  Health  Information  and
             Counseling Service.  Currently these are approved but unfunded projects.

             Review Process

             Review is carried out in two stages. The  first  is  a  technical  review  done
             by either a standing committee or task force,  or  an  Ad  Hoc  committee.  The
             reviewers may recommend approval, disapproval  or  may  recommend  revision  of
             the application.  The second review is conducted by the RAG.


               Illinois                         -7-             RM 00061-02 (AR-1-SD) 2/71

               Regional Advis    rou
               The Regional Advisory Group is a 40-member body with representation from a
               broad spectrum of people involved throughout the Region in health care
               and health planning. Members are nominated by a committee composed  of
               representatives from the Board of Directors, the RAG, the Heart Association,
               Cancer Society and State Medical Society.  Members are elected by the Board
               of Directors with ratification by the RAG.  The members are elected for
               five-year terms with one-fifth of the membership rotating each  year.  The
               group meets on a bi-montly basis and a five-member Executive Committee
               of the RAG meets on alternate months. The Executive Committee  of  the
               RAG prepares the agenda and considers matters requiring immediate
               attention, subject to approval'by the group. The B@-Laws of the  Board
               of Directors and the RAG were revised on May 25, 1970 which provide for
               two major changes:
               1. The membership of the RAG was expanded from 30 to 40 members  in  order
               to provide for broader representation of consumer and allied health interest
               from other areas outside of Chicago.  Eleven new members were added most
               of whom represent minorities, consumer and Allied health groups.  Since
               the last election of members to the RAG, some of the original  members
               have resigned, leaving a present membership of 36  individuals.  Potential
               members are presently being sought from among minority and consumer
               groups, especially from the downstate area.
               2.  The RAG is now officially designated as the body responsible for overall
               policy and guidance for the IRMP in planning and operational programs.
               They conduct final project and grant application review.  The  revised
               BY-Laws have relieved the Board of Directors of both project and application
               review responsibilities.

               Board of Directors
               This is a 22-member body which meets monthly (3 members also serve on the RAG)
               and has corporate responsibility for the financial and other affairs of the
               not-for-profit organization.

               Executive Committee of @oard of Directors
               This is a 9-member group composed basically of the Deans of the Medical
               Schools which may act for the Board should it become  necessary.  This
               group met in the last year.
               The IRMP has recently reorganized its Committee and Task Force  structure,
               and now contains the following:

                 1.  Task Force - Health Information
                 2.  Task'Force -,Manpower and Education
                 3.  Task Force - Continuing Education
                 4.  Task Force - Evaluation and Research

               1.  Heart Committee
                   a.  Sub-committee Myocardial Infarction


           Illinois RMP                      -8-              RM 00061-02  (AR-1-SD)  2/7

           2.  Cancer Committee

               a.  Sub-committee,,Chemotherapy

               b.  Sub-committee on Radiation Therapy

           3.  Stroke Committee

           4.  Screening Committee

           5.  Nursing Committee

           6.  Public Relations - Public Information Committee

           7.  Medical School Coordinators

           8.  Kidney Disease Committee (just forming)

           All committees and Task Forces are engaged in making policy recommen at ons
           and have advisory responsibilities.

           Major Changes in IRNP

           July 1, 1969 - applicant organization - fiscal agent changed  from  University
           of Chicago, College of Medicine to a separate not-for-profit organization,
           the' Illinois Regional Medical Program Inc., June 1, 1970 - Morton Creditor, M.D.
           assumed full-time duties as Executive Director of IRMP.  Dr. Creditor Replaces
           the now retired Dr. Wright Adams who was IRMP's original full-time coordinator.
           Dr. Creditor has been responsible for creating a "new look" and  emphasis  for
           the Illinois Region.  The RAg. committees, task forces and staff are now
           engaged in the setting of new program priorities.  A site visit is to t;-- conducted
           on December 3-4, 1970.  The report will be available during the January/
           February 1971 Review cycle.

           Present Application

           This is a pentagonally structured 3-year renewal request.  It contains requests
           for:

            A.  Renewal of Core and continuation of seven on-going operational projects.

            B.  A rather large supplement to the basic core component plus a supplement
                to one of the on-going projects (Home Health Services).

            C.  A Developmental Component,

            D.  Funds to implement four previously approved  operational  activities  and

            E.  Two new operational proposals
           While the Region has one additional 12-month period (2/l/71-1/31/72) of
           committed support for core and its seven projects, they have opted to
           request a total program renewal for three years.


              Illinois RMP                          -9-              RM 00061-02 (AR-1-SD) 2/71

              A.  Core and Operational Projects

              The Region presently has a commitment of $947,460 for the core component
              which includes terminal year support for a Hypertension Study.  This
              application includes a request for first year $394,190 supplementation to
              this amount.  If approved, the previous $887,137 (excluding Hypertension
              Study) would be increased to  $i,281,327  for  basic  core  support.
                                 (Core only)                         (2/l/71-1/31/72)
                                  Committed-       First Year            Requested_
              Basic                 712,637                              1,106,827

              Educational
              Resource Study        174,500                                174,500
              Hypertension Study     60,323                               60,323:
                                   $947,460                             $1,341,650
              The second year request of $1,556,330 includes $112,,723 committed funds plus
              $191,247 for the continuing Educational Resource Study at the University of
              Illinois.  The third year request of $1,851,190 includes $201,000 for
              continued support of the Educational Resource Study.  The three-year total
              request for core component is $4,749,170.
              The increases requested in the core component are to provide for continuation
              of efforts to obtain the Region's previously presented broad objectives
              (at this point, it should be noted that the present Executive Director,
               Dr. Morton C. Creditor  assumed his position full-time, on June 1. 1970,
               and has inherited a vrop"ram which was developed under a previous
              administration. Doctor C@editor has caused a shifting of emphasis, particularly
              in terms of strategies to be employed and recognizes that limited financial
              resources will require application of efficient managerial practices to
              maximize the impact of each demonstration.  The Region's new strategy is
              designed to facilitate the generalization of innovation and will capitalize
              upon the mutual interests and resources of other agencies.
              The additional core funds requested Are to be used primarily to fill gaps
              in the present core staff by;l) employing a physician who will serve as
              primary assistant to the Executive Director' and 2) upgrading coordinators
              assigned to medical schools  from  part-time  ;o  full-time  status.
              The application requests continued support at the committed level for the
              seven operational projects listed on page 6.      in addition, $13,068 is
              requested as a supplement to project #1, Home Health S@rv           This project
              was funded for $35,525 (dc.) on February 1, 1970 for the first year of
              an approved two-year project period.  If approved, the supplement would
              raise the second year funding from the currently approved $35,577 to
              $48,645.  The additional funds are to be used to support a full-time
              services organizer whose duties would be to handle the detailed arrangements
              with a great number of potential provider agencies.  Details of duties
              as well as how this project fits into the Region's plan are listed under


              Illinois RMP,                    -10-                 RM 00061-02 (AR-1-SD) 2/

              Tab OGI-S in Volumbe II-.

              B.  Developmental Component
              The Region requests $158,564 for one year only to support a Developmental
              Component.  The major purpose for use of developmental funds will be the
              exploitation of opportunities  for  acceleration  of  the  rate  of  fulfillment
              of the established objectives of the  IRMP  and  as  a  corollary,  rei nforce-
              ment and enhancement of the techniques and methodologies employed in
              fulfillment of those objectives.  The application lists under Tab IV,
              Developmental Component in Volume I, many examples of the intended
              utilization of these types of funds.  Some of these are:
              1)  Appearance of new areawide planning Council requiring Developmental
                  support for survival.
              2)  Unexpected opportunity for new medical school'to appoint associate
                  Dean for RMIP.
              3)  Opportunity to establish liaison relationships with allied or associated
                  resources.
              The application also lists  specific  restrictions  for  which  these  types  of
              funds will not be used.  Example-funding of proposals which had been disapproved
              by any IRMP or RMPS Review process.
              C.  Request  for  Funds  to  Initiate  Previou          d Operational Activities
              Following the recommendation of a June 1970 technical site visit team, the
              August 1970 National Advisory Cguncil recommended approval (with conditions)
              of four new operational  projects.  Currently,  these  are  being  held  in  the
              region as  approved  but  unfunded  activities.
              The Region now requests funds to initiate these approved/unfunded projects:

              Project                                            Amount               Council
              Number        Titl!i                              Re    ted                 oved
              #10           Continuing Education in        01  Yr. 134,982            162,257
                             Nephrology                    02 Yr.  146,550            181,948
                                                           03 Yr.  156,300            191  883
                                                 #10   Total     $ 437,832          $ 536,088
              #11           Regional Transplantation       01 Yr   384,430            1503,000
                             Program                       02 Yr   244,984            150,000
                                                           03 Yr.  247   177          150  000
                                                 #11   Total     $ 876,591          $ 450,000


                  Illinois   RMP                                             RM 00061-02 'kAR-1-SD) 2/71
                  Project                                                      Amount              Council
                  Number       Title                                         Requested             Approved
                  #12          Cancer Education                       01   Yr. 37,096             49,155
                                                                      02   Yr. 24,348             12,289
                                                           #12    Total        61,444             61,444
                  #13          Unified Health Info.                   01   Yr.   238,059           226,000
                               and Referral                           02   Yr.   452,833           317,000
                                                                      03   Yr.   518,821           -0-
                                                           #13    Total     $1,,209,713           $543,000
                  All Ye'!ars Total Requests and Council Recommended Amounts for Projects
                  #10, #11, #12 and #13
                                                   Current Request        Council Previously Recommended
                  ist   Year                        $?,94,567                      587,412
                  2nd   Year                          868,715                      661,237
                  3rd   Year                          922,298                     341,,883
                                 T(YTAL        $    2,585,580                $   1,590,532
                                                                                                Requested
                  D.  Summary of New Operational Proposals                                     First Year
                  Project  #14  -  Valley  Prolect  -   A   Community   Health Center         $482,612
                                  The Board of Trustees, University of Illinois
                  requests through the Illinois Regional Medical Program $482,612 (d.c.)
                  for the first year of a two-year project request to support a community
                  health center for residents of the "Valley" Community, a health-ppverty
                  area of 10,1000 people.  This proposal is the result of a $71,400 IRMP
                  supported planning study.
                  The primary objective is to design a system which will deliver family-
                  oriented,  comprehensive  health  care   and   to   initiate   those   activities
                  required to insure full-scale program implementation on or before the
                  beginning of fiscal year 1972.  The achievement of the primary objective
                  is dependent upon the attainment of a series of interrelated goals as
                  envisioned by the Valley Community representatives in defining perceived
                  community needs and developed in concert with the Medical Center Campus
                  representatives.
                    A.  To  provide  a  wide  range  of  health  services  for  the   residents   of   the
                         Valley Community include:
                         1.  Diagnosis and treatment of acute and chronic illness
                         2.   Development of programs concerned with disability limitation
                              and rehabilitation
                         3.   Design and implementation of programs for the detection and
                              management of asymptomatic disease
                         4.   Development of programs for the promotion and maintenance of
                              health and prevention of disease


               Illinois RMP                       -12-               RM  00061-02  (AR-!-SD)   2/1
                     5. Emphasis  on  health  care  for  infants,  children,  and  pregnant  women.
                     6.  Coordination of the program with other agencies involved in
                         health services affecting the community
                B.   To provide health-related jobs for community residents
                C.   To identify, develop, and encourage health training programs and health
                     career opportunities for community residents
                D.   To increase the application of existing knowledge and techniques
                     of health care at the community level
                E.   To develop new  approaches  to  health  care  delivery  and  health  education
                     that are appropriate and acceptable to the community and the University
                     and which may  serve  as  models  for  other  communities  and  institutions
                F.   To explore new dimensions for professionals and non-professionals
                     within the health care team
                G.   To explore ways with the community to afford opportunities for staff,
                     undergraduate  and  graduate  health  professionals  from  the  University  of
                     Illinois Medical Center to participate in the activities of the
                     Community Health Program in order to create sound educational
                     experiences,  better  understanding  of  community  health  matters,  and
                     additional resources  for  present  and  future  community  health  needs
                H.  To  utilize  existing  methods  and  develop  new  techniques  of  evaluation
                     as an ongoing part of the total program
               The achievement of a Comprehensive Health Care System is to be pursued in
               3 phases. The first phase is  to  be  the  provision  of  clinic  services  for
               diagnosis and treatmen t  of  episodic  illness  and  accidental  injury.  Phase  II
               and III are projected for less acute patient services, coordination and planning.
               A specifically designed evaluation  mechanism  will  be  developed  to  measure
               the degree-of improvement in delivery of family-oriented, comprehensive
               health care.  The application describes plans for RNIP phaseout.  $385,652
               of the first year total budget is for I)ersonnel services.

                    Second Year - $654,039
               Supplement to Pr  ect I#Pl4  This is an unusual                   Requested
                                            request.  The Region asks         First Year
               in addition to the basic application for Project #1.4,           $64,736
               that the reviewers consider a two-year request (#149)      at a
               reduced ldvel.  This two-year request should be considered as both
               supplementary to and separate from the basic project.  An amount of $64,736
               (d.c.) is requested for the first year to support a history-taking
               technique for the community health center.  They propose to at first, use
               a Medequip TM Automated Testing System adapted especially for residents
               of the Valley Community.


              Illinois RMP                   -13-             RM 00061-02 (AR-1-SD) 2/71
              Personnel of the Educational Resource Study, funded as a part of IRMP
              core activity, would be utilized in evaluation of the history-taking
              techniques.  The applicant states that the successful introduction of
              the history-taking component alone would make an important contribution
              to the developing health system at the Valley Clinic.
              A total of $26,336 for personnel in this supplemental (#14s) is also
              included in the batic project. If both basic project (14)  and  the
              supplement (#14s) are approved, the combined total request of $547,350
              could be reduced by $26,336 for a net requirement of  $521,014.
              Project #1@ - A Proposal to Establish a Program for the         Requested
                            Development of Nursing Resources in Illinois      First Year
              The Illinois Nurses Association requests $112,690 (d.c.)        $112,690
              through the Illinois Regional Medical Program, for the first
              year of a three-ytar project period to initiate this program.  The
              funds will be used to finance a program whose purpose would  be to initiate,
              promote, facilitate and coordinate activities designed to  meet the nurse.
              manpower needs in Illinois in accordance with the report of the Illinois
              Study Commission on Nursing and subsequent studies and  reports.

              The specific objectives of the proposal are:
                1.  Initiate a plan of action for a crash program designed  to
                    accelerate the movement of experienced registered  nurses
                    into and through baccalaureate and masters programs in  order
                    to meet present and future needs for nursing  leadership,
                    particularly teachers, administrators and specialists.

                2.  Establish a statewide network for selective  recruitment,
                    counseling and guidance in order to increase the  present
                    proportion of high school graduate (male and female)  who
                    choose careers in nursing; direct prospective students into
                    appropriate educational programs; encourage and enable mature
                    individuals and those from minority groups to enter nursing
                    in greater numbers; assure full utilization of all  available
                    class spaces.
                3.  Promote the development of the career ladder for mobility  so
                    that competent practitioners will be available on a continuing
                    basis at each level and in each area of practice.

                4.  Seek increased financial support and assistance for nursing
                    education through both public and private sources at federal,
                    state and local levels.

                5.  Initiate and take leadership for statewide and  community
                    planning to assure orderly transition, expansion and
                    development of nursing schools as recommended by ISCON  and
   is               to meet the changing health care needs of society.


             Illinois RMP                  -14-         RH 00061-02 (AR-1-SD) 2/71
             The Illinois Counittee-on Nursing Careers (jointly sponsored by the
             Illinois Nurses' Association and the Illinois League for Nursing) will
             serve as the steering committee for the proposed program.
             In addition, a broad based advisory committee will be formed  to  provide
             representation for the various health related organizations, consumer
             groups and other concerned agencies and individuals.  The  present  staff
             of the Illinois Committee on Nursing Careers will form a  nucleus  around
             which the proposed program can be built.  The staff will, in some
             instances be activators and initiators. At other times,  they  will  serve
             as advisors, consultants, conveners, resource persons, and as liaison
             for other groups. The committee and staff will plan  and  implement  those
             programs that fall within their purview, and will work with  and  through
             local, regional and statewide groups, lending impetus and  assistance  to
             programs developed by others, encouraging or persuading others to
             develop needed programs, and coordinating the various activities to
             assure optimum results.
             The total program will be developed and implemented over a three-year
             period, with certain ongoing activities extending beyond  that  time.  An
             integral part of the program will be continued research and data collection
             which will provide a basis for evaluation of progress toward  meeting  the
             goals. At the conclusion of the third year, a detailed  anaylsis  will  be
             made of the supply of nursing manpower in Illinois.  ISCON recommendations
             will be reviewed and updated on the basis of changing needs and trends
             Goals and objectives will be reviewed and a new plan of action formulated
             as need and circumstances dictate.
             The applicant believes that this proposal is related to one of  the  basic
             IRMP goals--to assist in making health resources available  to  patients.
             Data will be compiled for evaluation purposes., among others, which  will
             focus on measuring progress toward the overall goals to assure  that  the
             needs for nursing leadership and manpower in Illinois are met.
             $70,000 of the first years' total budget of $112,690 is for personnel.
             During the second and third years personnel requests increase to
             $95,000 and $99,000 respectively.  The second and third year personnel
             increases will provide support for a counselor and a secretary in the
             downstate area.
                 Second Year -  $137,204          Third Year - $141,016

                                                             DRMP/GRB 12/15/70


                                   SUMMARY OF REVIEW AND CONCLUSION OF
                                        JANUARY  1971  REVIEW   CO@IMITTEE

                                   ILLINOIS  REGIO'iiAL  MEDICAL   PROGRAM
                                           RM  61-02   (AR-l-tSb)   2/71'

                          FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

            B  KGROUND.  This    is an unusual request.  It contains a request for
                           continuation. supplemental funding for an ongoing project
            an   Co  e,.and  a  request  for  renewal  support  with  a   developmental   component.
            @T        n:'scu'rrent  budget  period  has  been  extended  for  two  months
            @(2      3/31/71) without additional funds.  The Region has one additional
            1           eriod (4/1 71-3/31/72) of committed support ($1,525il92) for
                      p
            the  r  c  e  activities  and  7  operational  projects.   Staff   considered   the
            @6 tinuation Portion of the application but due to a number of difficulties,
            @vo@  d   defer@any fur  er ac  on un            e si e  v  s          0
            mine-w  ch avenue, (continuation and supplement, three-yeat renewal, etc.)
            t  @@Region wis ed@to take.  During the December 3-4  1970 site visit, the
            Pr  gr  @Coordinator,  the  Chairman  of  the  RAG  and   the ChAikman@of- the
            B  ar  of  Trustees  advised  the@team  that,  after  due  consideration.   it   was
            de   ide @that  the  application  be  considered  a   three-year   renewal   request.

                               The  Committee   recommended   that   this application,     which
                  7@-                   8:  1)  three-year  renewal  support  at  an  inc  eased
                                request                                                 r
             e                ctiviiies including an Educational Resource Stud
                                                                                        y
            o   e@ e@         ati6n  for@7  projects  and  second  year  continuation   for   3
                 hese  projects;  2)  4  developmental  component  program;  3)   support   for
                                                                                       pp     d/
                              A supplemental request to an      ongoing project;          partially.
            SU      ed for  2,000,000 for a one-year period.  Included as - part of the
            ree         tio  is  that.  1)  The  amount  requested  for  a  developmental   66m-
                     $i58,564)  for  the  first  year  not  be   approved.
            2        2,000,666 is.predicated that any carryover funds will not be
            a    1   e to the Region as an additional amount.

                                             REQUEST                         RECOMVNDED      FUNDING

            ;I    e                            $3,519,285                       $2,000,000

            @2nd  Ye                        @3    512,327                            none

          :@3rd   Year                        2   194i5O4                            none

                      ALS                   $9,946,11   6                       $2iOOOlOOO

                         In       e          n
                 IQ         its d  libetati6  ,  the  Committee  considered  the  Site  Vis@it,@
                         Report,  Illinois   Regi6nal-Medidal   Program,   December   3-4
                 e   he 5tte  isitots recoimdended'triennial s-up :rt'b  provided for dire t
                                                                     Po     e                      c
                  runai6g in the Amount of $2,000                 ch of three years, momberq@of
                                                      .000 for ea
                  t  elwhile  concuring  W3,.t'h  the  amount,  recommended  that  support   be


           Illinois:Regi6nal  Medical   Program                     RM 61-02 (AR-1-CSD)2/71

           A ember  of  the  Review  Committee, who was also  a member of the-Decembet 3-4,,
           1970 s te  visit-team,  related  the findings of the  team  to'the  Committee.
           He reported the overriding positive factor in -this RMP is-@@the-  new  program
           coordi ator who assumed full-time leadership on June 1, 1970.  In his
           short tenure, he has caused the IRMP to assume a new personality,, has
           st@arted@@the process of turning the program around  and  is  definitely
           ch ngin the program eippha@is. He went  on  to  state  that  Illinois  already-
                   9
           @ha -th  necess.ary@@streagths-and-potenti6l to enable i@t to become  one  of
           iti leading Regions in the country.

           Bo h  t e Composition, to include more  minority  members  and  consumer
              erests, and'the role of the Regional  Advisory  Group  has:bee-n  changed.
               e  as little doubt that-this                 @becom'ng de ply  involved
                                              group is@now              e
           as t-he@@primary determiner of goals, objectives, priorities And Policy
           @f  th  Resion@.  Core activities,have,been reo g@anized@into a    four-
           ho  ed  tru6t&rd which now includes regionali.-ation, core functional
           4c4@i ities,, administration and management, and re
                                                                gional program
           development.

           The Com  ittde was encouraged to  learn  that  since the  last  total  program
            e  ev   June 1969). in addition to  an  attempt  to improve  the   otkAniiAtion
           and ca  ab 1 ties of both the RAG  anct  C6re@Staff, there  are-now  much
           @st ng  r ties and@relationshipt  with  the  medical centers and other
           a   ci  s,and institutions within the Region.

           @@s re  ionaliza ion has always been a  major-problem  in  this  Region,@as
           it  s I  similar Regions,  with a historical  upstate  versus  a@downst:ate;.
           Ca         ently., the Region has been working closely @,7ith-several  sub@
            e         ealth viannink a enci6s (exam le - S  ringfield)  in  an  effort
           to b      to solve this perennial drawback to an effective program.

           T   C    ittee was  on        that a rather larg
           r    stea. A large portion of this  was  to  increase  support  of  the  time
               ffo t of the resent  5  pArt-timO  coordinators  assigned  to  medica@.
                             p
           s     s@from  vakttime  to  fulltime.  Additionally,  support  for  full-time
           coorctil t-ors li requested for the two other alre6dv established
                          s                                                      schools
            n t e@Region-P Us 4 new medical schools which are    in the process of being
           es             (S Kingfield,  Peoria,  Rockford,  and hampaign).   Both   the
                            P.
           at          r's'@4nd members of-the Cbmmittee,qu'estioned the value  oftthese
                      s without some medical  school-M4P Oritten  plans; expectati;onsL@@
                      in.es.

                   ion spec a ist.  In  line with this, members  f Commi  e  conun
                      the evaluation expertise that is already available in this
                    there is no excuse for evaluation of poor qualit.y.@  In  the  future-
           h  9  r    rem6 is for the activit  are to be expected.
                                              y

           @@As'    cted'in the site visit-repprt, the Committee.,was@in a@reement wi@th,


                                                                 RM 61-02 (AR-1-CSD)  2/71
          Illinois Regional Medical Program      -3-
          the team regarding the priority to   which new projects should  be supported,.

          In arriving at a recommendation, the Committee   .generally  agreed with   the
          observations and conclusions of the site  visitors  that  the  Illinois  RMP
          is obviously in the process of turning  around  and  should  be  encouraged.
          While they also agreed with the yearly level of funding recommended by
          the site visit6rsl they believed that $2,000,000 should be awarded for one
          year instead of the three years  requested..  The  sitr-.visit6rs  considered
          this to be a "new" Region in spite of its being in operational status for
          almost one year (since February 1970).  Therefore, the Committee reasoned
          that the Warding of funds for a one-year period would provide the
          opportunity for the Region to prove-its maturity  and  also  allow  time  for
          the Regibnls planned total program renovation.
          In conclusion,, the Committee recommended that the total program as presented
          in@this application be partially supported  at  $2,000,000  for  aone-year
          per' d, rather than for  the  three-year  period  request6d,  This recommendation
           .ill cause the R 5zion to reapply for triennial  support  in  time for the
          w
          january/r-etruary 1972 Review Cycle.

                    as a part of the reconLmendAtion is that:

              The amount k6qu6sted for a developmental component    not  be approved.

          2) The $2,00031000 is predicated that  any  carryover  funds  not be made
          av iiabie to the Region as an additional amount.

          Fu   eri the Review Committee strongly recommend that staff convey to
           h @Region its concerns regarding the necessary planning which should
          t    pl 66 before full-time IU4P medical  school  coordinators  are  assigned
          and@its concerns  regardin  the quality of evaluation which will be
          ex  cted@from-fhis Region.

         @Drs@. Schm dt and Ellis were not in the room during the deliberation    on
               application.

                                                     DRMP/GRB  1/15/71


                         NW

            0                                                              0                                                              0


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

              INDIANA REGIONAL MEDICAL PROGRAM               RM 43-03 (AR-1-CSD) 2 71
              1300 W. Michigan Street                        January  1971  Review   Committee
              Indianapolis, Indiana 46202

              PROGRAM COORDINATOR:  Robert B. Stonehill, M.D.
                                       REQUEST (Direct Costs Only)
                                       03                04            05            All
              Purpos                                                   1973         Years
              Continuation        1,256,308            -0-             -0-          1,256,308
              Core & 3  Feasi-
              bility   studies        422,573)         -0-             -0-        (  422,573)
              (5 projects)         (833,735)                                      (  833,735)
              Renewal Components   671,122           517,891         559,673        1,748p686)
               (4 projects)
              Additional Components 136,005            -0-             -0-             136,005
                 (Development)       (127,000)         -0-             -0-          (127,000
              (1 new project)          91005)          -0-             -0-              9,005)

              Sub-Total              2,063,435       517,891         559,673        3,1  0,999

              Supplemental Appi.
              Deferred   11/70
              Council 2 projects       120,576         68,188           69,389         258,153
              Total                  2,184,011       586,079         629,062        3,399,152
              Staff Action  on
              Continuation           1,256,308         -0-             -0-          1,256,308

              Committee & Council
              Action                   927,703       586,079         629,062        2,142,844
              Note: 1)  The  continuation  request  includes  the  commitment  $1,121,411  and
              carryover $134,897 to support core and seven projects.  Three of t!ie
              projects have been ongoing for two  years;  three  were  funded  one  year  from
              carryover; and one approved for three years is to begin.
              2)  In addition, carryover was requested for continuation of #5 and #6.
              Subsequent to submission of the application, Grants Review Staff informe
              the IRNP that these two projects were approved and funded for one year
              only and must now be considered as renewals by February 1971 Council.
              Meanwhile, staff will consider extending their current support for three
              months with additional funds until the renewals are acted upon.


       INDIANA   RMP                       -2-              RM 43-03 (AR-1-CSD) 2/71

                               FUNDING HISTORY (Direct Costs)

       Planning          01       1967               $384,750
                         02       1968              592,106
                         03       1969              217,473

       OPERATIONAL

       Grants   Year           Period       Council Approved       Funded        Commitments

       01 1/                   1969          $1,363,571           $1,363,571
       02                      1970           1,271)411    2/      1,513,690
       03                      1971                                                1,121,411

       I/ Merged  with  03  planning
       2/ Includes $242,279 carryover

       Demography

       A.  Population:  Approximately   5,000,000   in   1969

              1.  65%   urban
              2.  93%   white
              3.  median age 28.9 years (U.S. average       29.5)

       B.  Land:  36,185 square miles

       C.  Mortality per 100,000

              1.  Heart   373
              2.  Cancer 156
              3.  CNS vascular lesions 126

       D.  Facilities

              1.  Indiana University School of Medicine
              2.  38 Schools of Nursing (12 of which are affiliated with colleges
                   and Universities and 5 grant B.S. degrees
              3.  Allied Health Programs:
                   17 schools of Medical Technology
                   2 cytotechnology facilities
                   18  X-ray  technology   facilities
                   IUMC has a Division of Allied Health Sciences with programs in
                    10 professions, i.e., health education, P.T., O.T. and inhalation
                      therapy
                   139  hospitals  with  36,335  beds


            INDIANA RMP                       -3-           RM 43-03 (AR-1-CSD)  2/71

               Manpower (1966)

                 1.  5,111 M.D.s and D.O.s - 100/100,000
                 2.  13,769 active nurses - 275/100,000

            History of Regional Development: During September 1965, the Dean  of  the
                                              Indiana University Medical Center appointed
            a Study Committee which included representatives from the State Medical
            Association, State Health Department and Medical Center.  After  extensive
            preparation, the first meeting of the Regional Advisory Group was held  in
            July 1966 followed by submission of a planning application to RMPS in
            September 1966.
            The Region received a three-year planning grant beginning Januaryl, 1967.  The
            current coordinator joined the staff in July 1967 and was named  successor
            in his present position in January 1968.

            A site visit was made September 1968 to determine IRMP readiness for operational
            status.  Impressed by the Region's leadership, community involvement and good
            working relationship with the university, the site visitors strongly recommended
            approval of the operational application.  The November 1968 Council recommended
            approval for three years. The third planning year merged with  the  first
            operational year during which time $1,363,571 (d.c.o.) was awarded (03
            planning - $152,295 - and 01 operational - $1,211,276) for core staff  and
            five projects.

            On reviewing the second year continuation application, staff believed  the
            IRMP was progressing satisfactorily. The amount of $1,513,630  (d.c.o.)  was
            awarded for core and ten projects (3 continuing and 7 new projects  approved
            by Council). The award included $242,279 use of carryover funds,  most  of
            which was for support of three approved and unfunded projects for one year
            with no continuing commitment.

            The current Application for third continuation support was reviewed by staff
            November 24, 1970 and a summary of their comments is appended.

            Goals and Objectives: The overall goal remains to  make  available  improved
            patient care through cooperative arrangements including continuing education
            and demonstrations in the areas of heart disease, cancer, stroke,  kidney
            and related diseases.  Original emphasis was in the area of expanding
            Continuing Professional Education, increasing manpower and stimulating
            appropriate research. Increased emphasis will now be placed  on  stimulating
            the delivery of needed patient care.  Within the broad objectives, the
            RAG assigned priority ranking to all projects; 1 to 13.

            Ranking order:
                      REGIONAL ADVISORY GROUP PROJECT PRIORITY DETERMINATION

            Priority   #     Project
            (1)  2.89  4     Coronary Care  ................... (Funded until December 31., 1.971)

            (2)  2.79  3     Stroke ..........................  (Funded Until December 31, 1971)


                                                                   RM 43-03 (AR-1-CSD) 2/71
         INDIANA      RN?                     -4-

         Priority            Project
         (3)    2.67    13   Nursing in Coronary Care Units      ... (Funded  until   December   31, 1970)
         (4)  2.58      2    Multiphasic Screening        .......... (Funded  until   December   31, 1971)
         (5)  2.55      16   Chronic Pulmonary Disease        ...... (Funded  until   December   31, 1970)
         (6)  2.50      18   N.W. Indiana Community Coronary Care..(Approved-Unfunded)
         (7)  2.27      11   Nursing    Continuing     Education....  (Funded until December 31, 1970)
         (8)  2.19      21   Radiation Therapy    .....    (Deferred for site visit by 11/70 Council)
         (9)  2.10      22   Respiratory Care Technician ( "           it     11    it   11  to  of  11
         (10) 2.06      14   Library       .....................   (Funded  until  December   31,   1970)
         (11) 2.00      5    Health Manpower       .............   (Funded   until   December 31,   1970)
         (12) 1.95      9R   Neighborhood Health Centers           (Funded   until   December 31,   1970)
         (13) 1.72      6    Health Hazard       ...............   (Funded   until   December 31,   1970)
         ?     ?        23   Smoking Program       .............   (To be considered by 2/71 Council)i.!..-,..t
         During the     latter part of the year, the Regional Advisory Group turned its
         attention to the development of a long-range plan.  Accordingly, a special
         committee  the  Long-Range  Goals   and   Objectives   Committee,   was   formed   to   consider
         this  matter.  With  assistance  from  Core  Staff,  the   following   set   of   goals   and
         objectives was approved and recommended to RAG.  These objectives are not
         intended  to  outline  a  set  of  programs  that  would  be  supported   from   Core   Staff
         funds,  but  are  intended  rather  to  reflect  patient  care   needs   in   the   Indiana
         region  and   to suggest  the  kinds  of  activities   and   projects   which   the   Regional
         Advisory  Group  would  be  likely  to  view  favorably  if   they   were   submitted   for
         approval.  The document is perceived to be dynamic rather than static, and
         will  likely  be  modified  to  reflect  changing   needs   within   the   region;   however,
         it should serve as a guide to those who will be submitting proposals for
         funding through IRMP.
         The  goals  and  objectives   below   fall   into   five   categories:   prevention,
         detection,   treatment,   rehabilitation,   and   a   general   category   for   objectives
         that overlap two or more of the first four categories.

         1.  PREVENTION

              A.     Goal
                        It is the goal of IRMP to lower mortality and morbidity by
                   means of strategies to prevent the occurrence of illness.

            B.  Long-Range Objectives
                 1.     To make it possible for every Indiana citizen to live in an
                    ____z - - - - - -              t-n ce-.nri hpql t-h -


           INDIANA   RMP                    -5-            RM 43-03 (AR-1-CSD) 2/71

                  2.    To enable every Indiana citizen to avail himself of every
                  feasible prophylactic strategy, from personal health habits to
                  immunization, to avoid disease and disability.

               C. Short-Range Objectives

                  1.    To enlist the citizens of Indiana in attempts to deal with the
                  the problems of pollution and environmental controls.

                  2.    To increase the availability of  proven  immunization  techniques,
                  particularly for low-income citizens.

                  3.    To increase the dissemination of preventive medicine information.

           11.   DETECTION

               A.Goal

                       It is the goals of IRMP to lower mortality  and  lessen  disability
                  by means of early detection (and subsequent treatment) of treatable
                  disease

               B. Long-Range Objectives

                  1.   To provide opportunity for periodic health screening for every
                  Indiana citizen.

                  2.   To educate every Indiana citizen concerning  those  danger  signals
                  of disease which he can himself detect.

               C. Short-Range Objectives

                  1.   To increase the number of Indiana communities having free or
                  low-cost health-screening facilities.

                  2.   To increase the number of Indiana residents  who  receive  periodic
                  health-screening.

                  3.   To increase the incidence of disease-detection at a treatable stage.

           III.   TREATMENT

                A.   Goal

                       It is the goal of IRMP to reduce mortality and morbidity by making
                    quality medical care available to every sick Indiana citizen.

                B.  Long-Range Objectives

                    1.   TIo provide opportunity for treatment of  illness  and  disability
                    for every Indiana citizen.

                    2.   To provide means for bringing the latest developments in medical
                    knowledge and practice to the attention of physicians and medical
                    Dara-Drofessions and technicians.


       INDIANA  RMP                    -6-             RM 43-03 (AR-I.-CSD) 2/71

            C.   Short-Range objectives
                 1.   To increase the availability  of  medical  care,  particularly
                 for residents of low-income areas.
                 2.   To encourage and support programs  intended  to  increase  the
                 efficiency of health care delivery systems.
                 3.   To encourage and support the continuing education of physicians
                 and allied health personnel.

       IV.  REHABILITATION

            A.   Goal
                      It is the goal of IRMP that rehabilitation services be available
                 to every Indiana citizen, so that  the  handicaps  and  limitations
                 resulting from disease and disability be mitigated as much as
                 possible.

            B.   Long-Range Objectives
                 1.   To make it possible for every Indiana citizen to receive
                 professional help to offset and  compensate  for  the  debilitating
                 sequelae of disease and disability, in order to allow each citizen
                 to pursue as productive a life as possible.
                 2.   To prolong the longevity and productivity of the elderly
                 as much as possible.
                 3.   To enable those born with physical defects to function
                 normally and effectively in society.

            C.   Short-            tives
                 1.   To increase the number  of  rehabilitation  therapists  (S.T.,
                 P.T., O.T.) practicing in Indiana.
                 2.   To increis(! the number of students In r(!Iiabillt.,ition tr,-ilrilri,@
                 programs In Indi;ina.
                 3.   To increase the availability of reliai)ili.tition -i(.-rvic(!s Lf) Ltic
                 rural and urban poor.

       V.  GENERAL/RESIDUAL

            A.   Coal
                      It is the goal of IRMP to enhance the health program in Indiana
                 by all ancillary services consistent with RMP guidelines.

            B.  Long-Range Obiectives
                 1.   To bring Indiiiia to or above the national median in per c;il)iti
                 etintiiv nf          and allied health persotii)(@l .


           INDIANA  RMP                   -7-          RM 43-03 (AR-1-CSD) 2/71

                    2.   To provide Indiana medical personnel with competence to
                    utilize newly developed equipment and apparatus necessary in
                    medical practice.

                    3.   To stimulate systems for the delivery of health care  most
                    effective in utilizing resources and manpower to meet health needs.

                    4.   To enhance a high degree of cooperation among the  various
                    groups concerned with health:  practitioners, consumers, voluntary
                    agencies, educators, governmental units, health insurance agencies,etc.

                    5.   To encourage redefinition of medical practice patterns  of
                    physicians, nurses, and allied health professionals in order to
                    permit more efficient and effective utilization of skills and manpower
                    (i.e. broaden responsibilities of allied health  professionals;
                    develop new health disciplines).

                    6.   To reduce the relative cost of quality medical care.

              C.    Short-Range Obi6ctives

                    14   To maintain a state-wide health data bank, including  data
                    regarding health facilities and manpower, morbidity, and mortality.

                    2.   To support efforts to recruit medical manpower,

                    3.   To extend to remote parts of the state, rural and urban, health
                    care systems which have been demonstrated to be effective in local
                    pilot projects.
                    4.   To inaugurate and support community action groups concerned
                    with health.

                    5.   To develop continuing-education centers at the proposed regional
                    campuses of I.U. School of Medicine.
                    6.   To support the introduction of proven medical practice
                    innovations to Indiana medicine.

                    7.   To encourage changes in the Indiana legal code so as to re  ect
                    changing medical practice.

                    8.   To study ways of utilizing available health manpower  more
                    effectively.
                    9.   To study ways of developing new manpower in the light of
                    emerging needs.
                    10.  To enlarge the representation on, and increase the activities
                    and effectiveness of, the Regional Characteristics Committee.
                    11.  To develop cooperative relationships for data collection and
                    utilization with CHP, the Indiana State Board of Health and other
                    agencies.


        INDIANA  RMP                   -8-              RM 43-03  (AR-1-CSD)  2/71

                12.   To develop methods for determining  the  cost-effectivenesn
                of medical programs.

                13.   To increase the efficiency of health care systems.

                14.   To increase utilization of facilities and  reduce  per-unit
                cost.

                15.   To train technicians to perform tasks now performed by
                physicians and nurses.

                16.   To extend the availability of medical care  among  minority
                groups and the poor.
        Organization:  The RAG consists of 49 members (22 physicians) provides
                       overall advice and guidance to IRMP and considers  all  projects
        as well as the core staff budget. It elects its  own  officers,  Chairman,
        Vice-Chairman and secretary. It also elects a  12-man  Executive  Committee
        to function in the name of the RAG in the interim  between  meetings.  Minority
        representation includes 2 blacks. Consumers number nine  and  allied  health
        is represented by 6. Sixteen Regional Committees have a  membership  of  150
        and four area committees account for 118. The RAG meets 3  times  each  year.
        The Executive Committee meets two weeks prior to RAG meetings and  at  other
        times when necessary.
        According to the narrative, the committees and local groups  are  actively
        involved in planning program development, and project review.  The
        fabrication reflects interweaving of cooperative efforts.

        The state is divided into 14 sub-regions for purposes and are the  same  as
        those for CHP. Because travel time from the central office  is  minimal,  no
        sub-regional offices are planned. Plans include the use  of  field  represen-
        tatives. Sub-regional programs are being  created  through  CHPB,agencies
        (4 now in existence, 6 campuses of Indiana and Purdue  University,  hospitals
        participating in the graduate and continuing medical education  system  of
        the Indiana University Program for state-wide Medical Education and 7
        Indiana University Centers for Medical Education).
        The project planning development and review process begins with the
        originator forwarding a summary to the Coordinator. If the  idea  is  within
        the scope of IRMP, a team (1 central staff, I member of an  appropriate  IRMP
        committee and I representative of an appropriate health agency)  are  appointed
        to assist the applicant in the development of a proposal. If  there  is  an
        active CHPB agency in the area, a representative is invited  to  participate
        in the development and review of the proposal. The  completed  proposal  is
        reviewed by the Scientific Advisory Committee, after which a  formal  site
        visit is made. With the benefit of the reports from  the  Scientific  Committee
        and site visit team, the Executive Committee reviews the proposal  and  makes
        recommendations to the RAG.  The RAG makes the final decision based on their
        review including comments and recommendations of the three  prior  review
        including comments and recommendations of the three prior  review  groups.
        The project proposer appears before both the Executive Committee  and  RAC.


                                               DIVISION OF REGIONAL
                                                MEDICAL PROGRAMS

                                                 INDIANA REGIONAL

                                                 ADVISORY GROUP

                                                                          EXECUTIVE
                                                                           COMMITTEE

                        p      NG-RANGE GOAIS                                           PLANNING and EI)UCATIOI- ;r
     RULES and MEMBERSIII                                  TAFF
                               and OBJECTIVES
          COMMITTEE             COMMITTEE                                                    COMMITTEE

                                                                   SCIENTIFIC ADVISORY
                                  ET
                                   0                                   COMMITTEE

                                                    STANDING
                                                   COMMITTEES

       CORONARY
          CARE

                               MA@

                                                                                                       10-1-70


         INDIANA RMP                     -10-            RM 43-03 (AR-1-CSD) 2/71

         Core staff is divided into four distinct budgets:  the Coordinator's Office
         (central core), and three feasibility study core groups (Cancer Committee,
         Regional Characteristics Committee (data) and Continuing Education and
         Technical Support)

         The Central staff consists of 10 professionals and 4 secretaries.  Pro-
         fessional personnel includes 3 new positions;2 field representatives and
         a staff assistant.  The staff assistant's role is geared to pro.ject control
         and evaluation (progress reporting, financial status and evaluation
         including determining costs effectiveness).  Initiation of developmental
         component activities will add to existing staff responsibilities.  Three
         positions are currently unfilled:  the epidemiologist, one field
         repres ntat.ve an  one secretary.

         The Cancer Committee Core consists of a full-time physician and two
         secretai-te8.  Tie Regional Cancer Committee and staff have established
         13 sub-regional committees.  The Regional Characteristics core (3
         professionals and 3 clerks) is a data gathering group, including continuing
         studies of hospital discharge and related morbidity and mortality data.
         The Continuing Education and Technical Support staff's (3 professionals
         @ 25% time and 2 secretaries @ 50%) most significant contribution is
         apparently the, planning And implementation of 10 postgraduate courses
         annually co-sponsored by IRMP and the Indiana University School of Medicine.

         Following is a list of core staff budgeted for the 03 operational year (1971)
         and the organizational chart.

                                    COORDINATOR'S OFFICE
                                        (Core   Staff)

                                                     Institution           % Time
                                 Title               Affiliation          Effort
         Professional

         R. B. Stonehill, M.D.  Coordinator          Ind. University      100% - 12 mo.
         R. A. Hagstrom         Dir. Program
                                Management
         H. C. Smith            Dir. Nurs. &
                                All  Hlth.  Sc.
         C. F. Leamnson         Dir.  Community
                                Relations
         J. Svaan, Ph.D.        Dir. Educational
                                Services
         C. R. Hudson           Dir. Admin.
                                Services
         To be Appointed        Epidemiologist
         J. B. White            Field
                                Representative
         E. Ferguson            Staff Assistant
         To be Appointed        Field Rep.


             INDIANA RMP                          -11-           RM 43-03 (AR-1-CSD) 2/71

                               CONTINUING    EDUCATION AND TECHNICAL SUPPORT
                                       (A  Portion  of Central   Staff)

             Personnel
                                                         Institution
                Name  &  Title                           Affiliation          Time

             J. Royer, M.D.       Assist. Dir. of
                                    Postgrad. Ed.             iusm            25%

             To be   appointed    Conference
                                    Coordinator               iusm            25%

             To be   appointed    Education
                                    Evaluator                 iusm            25%

             Sharon Bowers        Secretary                   iusm            50%

             To  be  appointed    Secretary                   iusm            50%

                                              CANCER COMITTEE
                                        (A Portion of Central Staff)

             William M. Loehr, M.D. Project Director
                                        Cancer   Committee   Indiana
                                        Activities           University     100%

             Mary Chitwood              Secretary            Indiana
                                                              University    100%

             Carolyn Henry              Secretary            Indiana
                                        (South   Bend)       University     Part-Time
                                                                             (Hourly)

                                     REGIONAL CHARACTERISTICS SECTION
                                                 (Core   Staff)
                                   RMP Job Title            Institution Affiliation     Time or
             Name & Discipline     or Function              (Includ. Subunits, i.e.,  Effort
                                                            Depts., Schools, etc.)      % / Hours

             D. Parrott            Research Associate       Indiana   University          IOO'A
                                             Reg. Char.

             F. Brown              Analyst  -  Reg.  Char.  Indiana  University           100'7.

             M. Hensley            Clerk - Reg. Char.       Indiana  University           100%
             R. Valentine          Clerk - Reg. Char.       Indiana  University           100%
             C. Hensley            Clerk - Data Bank        Indiana  University           100%
             S. Graves             Analyst - Data Bank      Indiana  University           100%


                                                                   INDIANA REGIONAL MEDICAL PROGRAM                         CENTRAL STAFF ORGANIZATION

                                                                                                                                   u

                                                                                                                                    OF             CANCER                                  DIR E
                               ASST. I                                                                                                                                                      EDUC
                                 POSTC                                                                                     SER     s   E        COORDINATOF                                  SEE
                               AND  C,
                                   EDL                                                                                     C. Hudson               Dr. Loehr                                  Di
                                   Dr.

                                       ri
                                       13

                                                                                                                                                                                        IUNIC RESEARCH
                                                                                FIELD
                                                                             REPRESENTA-                                                                                                  CONIPI-'TATIO-N
                                                                                 TIVES                                                                                                       CENTER

                                                                                             STANDING COMMITTEES

                                                                                                                                                                                              10-1-70


             INDIANA RMP                        -13-                   RM  43-03  (AR-1-CSD)   2/71

             Annual Report of the Indiana Regional Advisory Group:

             The IRMP RAG addressed goals  and  objectives  as  outlined  in  that  part  of  this
             summary.

             "This report covers year 02 of the Operational activities of the Regional
             Medical Program and  sufficient  data  do  not  exist  relative  to  cost  effective-
             ness of such  programs.  Such  information  will  emerge  as  more  data  are
             accumulated and more detailed program evaluation are made."

             Relationship to other programs concerned with planning and improvement
             of the organization and delivery of health services.

             "Direct  participating  relationship  exists  between  the  State  and  area-
             wide  Comprehensive  Health  Planning  Programs  (P.L.  89-749),  for  the  Director
             of the State Comprehensive  Health  Planning  Program  is  a  member  of  the
             Regional Advisory Group and is Chairman of the Committee on Regional
             Characteristics of the Regional Medical Program.  Equally there is direct
             participating of the Regional Medical Program and Model Cities Planning
             through the activities of the standing Committee on Neighborhood Health
             Centers.  Metropolitan  Health  Council  of  Indianapolis  has  submitted   a
             project  request  to  Model  Cities  for  funding  of  Neighborhood  Clinics.  Until
             recently, Indiana has not had  a  state  OEO  office.  Plans  will  now  be  de-
             veloped  to  integrate  appropriate  OEO  programs  into  Regional  Medical  Program's
             goal and objectives.  Cooperative relationships exist with Medicare, Medicaid,
             welfare, Hill-Burton, atmospheric pollution, radiation health, manpower
             development,  and  various  HEW  programs  involved  with  professional   education,
             stipends, and continued education."

             Impact of the Program
             "It was suggested that  the  Regional  Advisory  Group  evaluate  the  impact  of  the
             program in:  (a)  quality  of  individual  care  provided;  (b)  more  efficient
             utilization  and  organization  of  resources;  and  (c)  improved  distribution  of
             services so as to be  more  readily  available  and  assessable  to  all  within  the
             Region.

             At the moment it would  be  more  difficult  for  the  Regional  Advisory  Group
             to evaluate, items (a), (b),  and  (c)  listed  above.  The  program  has  not  been
             operational to the point in time that would permit such qualitative evaluation
             by the  Regional  Advisory  Group.  Evaluation  will  require  a  related  and  mean-
             ingful  system  of  data  collection  and  analysis.  The  Regional   Characteristics
             Committee is  currently  in  the  process  of  developing  techniques  whereby  such
             data can be accumulated.'

             Without the obvious  advantage  of  quantitative  and  qualitative  data  it  is  the
             impression of the  Regional  Advisory  Group  that  the  impact  of  Regional  Medical
             Program on the quality of individual care provided has been most positive.
             This is based on the activities of the following operational programs:
             Coronary Care,  Stroke,  Nursing  in  Coronary  Care  Units  and  Chronic  Pulmonary
             Disease.


       INDIANA RMP                    -14-            RM 43-03 (AR-1-CSD) 2/71
       it is further felt that there-is sufficient utilization and organization
       of resources as demonstrated in the Flanner House Multiphasic Screening
       Program, and Health Hazard Appraisal Program.  Improved distribution of
       services can be reflected in the activities of the Neighborhood Clinics
       of the M6tropolitan Health Council, Stroke and Coronary Care Units."
       The RAG further reported that the IRMP is an excellent program under strong,
       efficient administration and with a staff which exhibits an unusual sense
       of pride in its organization.  The grantee institution is the Indiana
       University Foundation, a non-profit organization chartered in 1936.  The
       Foundation is a separate and distinct entity and does not come under the
       supervision of Indiana University.  However, key officials of the University
       serve on the Board of Trustees of the Foundation. The  relationship  of  the
       Foundation to IRMP is essentially that of a fiscal nature.  The  IRMP  staff
       reports directly to the RAG which has administrative authority over the
       program and is responsible for the development of overall IRMP policies.
       The RAG Acts in a stewardship role as well as advisory.
       The IRMP staff are employees of Indiana University and are, therefore,
       subject to all rules and regulations of the University.  Salaries  of  staff
       are based on a survey of wage structures in and out of the  Region.
       Evaluation:  As indicated in the application, an effort is being made to
                    strengthen this aspect.  A staff assistant has been employed
       and will concentrate on this area.  The "Regional  Characteristics"  section
       of core also plans to aid evaluation.
       Developmental     onent:  The IRMP has requested $127,000 which is an
                                 amount equal to 10% of the current level of
       funding, excluding authorized use of carryover funds.  The  Region  believes
       that it has the capability of administering these funds that will permit them to
       move rapidly and effectively into new programs and activities.  Mucti of
       this activity will be based on current and continued studies  by  Long-Range
       Goals and Objectives Committee.  Potential areas: Rural Health Care,
       extension of health centers, disease prevention, studies of health care
       delivery systems, feasibility studies, coronary care programs, health
       manpower studies, leadership development, community information and
       referral programs, home  health care, and program planning and development.
       The process of review and management is adequately described.  Requests for
       more than $10,000  must be acted upon by the RAG.   Applications for less than
       $10,000  may be approved by the Executive Committee without review by the
       RAG.  Requests for less than $5,000 may be acted upon by the Program
       Coordinator (chief executive officer of the RAG).

       Supplemental Projects:
                                                                         Requested
       Project #23   Cigarette Smoking Deterrent Program                 First Year
                     This is a pilot program that will try to            $9,005
       develop a unique anti-smoking program at the high school level.
       The program will be carried out by a group of students in one  high  school.


            INDIANA RMP                  -15-            RM 43-03 (AR-1-CSD) 2/71

            A similar school will serve as a control.  The project effectiveness
            will be evaluated by assessing behavior and attitudes of random samples
            of students in the two schools before and after the program.
            The special student group (council) will be selected by the project
            director in consultation with the school administration and faculty.
            No restrictions will be placed on the student council  in  the  development
            of program.  However, the project director and an Advisory Board will
            be available to consult and assist the students.

              Second Year                             Third Year
                   -0-                                   -0-

            Renewal Projects:
                                                                              Requested
            Project #5R - Health Manpower Recruitment    This is a           First Year
                          request for renewal of  a  project  submitted      $25,000
            with the initial operational application  for  three  years
            support at an approximate annual  level  of  $316,000.  The September 1968
            site visitors recognized the project director's enthusiasm about the
            proposal but did not believe the protocol was sufficient.  The program
            was already ongoing supported by an annual budget of  $60,000  provided  from
            numerous community organizations, and there was no evidence of effectiveness.
            As recommended by the site visitors, the Review Committee  and  Council,  the
            project was approved and funded in the amount of $25,000 for one year only.
            The current application indicates that the project is presently budgeted at
            $60,000, $25,000 from (5/12) IRNP, and $35,000 7/12 from CHP and the Indiana
            State Health Department with 314-D money.
            The purpose remains to be the motivation recruitment and admission of students
            And adults to education/training for  health  professions.  The  objectives
            and methods are unchanged.  Much of the activity is devoted to dissemination
            of literature and responding to requests for information.  Wor  is a so
            carried out in the core city program through schools, i.e., consultation,
            in school programs, and workshops  for  guidance  counselors.

               Second Year                                 Third   Year
                  -0-                                         -0-
                                                                              Requested
            Project #6R - Prospective Medicine  This is also  .a  request     First  Year
                          for renewal of a project  which  was  submitted       $20,734
             'th the initial operational application for three years' support
            wi
            at an approximate annual level of $370,000.  The September 1968 site
            visit team noted the enthusiam among  practitioners  for  the program and  the
            concept of the health hazard  approach  seemed  educationally stimulating.
            However, several deficiencies in the proposal were note .

            The small number (40.1 of physicians receiving the continuing education
            reflected its high costs.  The health hazard concept was innovative but
            the teaching techniques were traditional.  No plans were outlined for
            evaluating the effect of the program in improving health care.  As


        INDIANA   RMP                     -16-            RM  43-03  (AR-1-CSD)  2,/71

        recommended  by the site  Visitors,  the  Review  Committee  and  Council,  the
        ,project  was funded for one year only in the amount of $20,734.      The   pro-
        ject also has received a grant  of  $73,830  for  the  period  July  1,  1970-
        July 31, 1971 from the Indiana State Board of Health (314-D funds).
        The objectives of this project are concerned with the performance of
        health hazard appraisal in three different medical care situations; a
        small community  hospital,  the  family  physician's  office  and  two  neighbor-
        hood  health  centers.  Accomplishments  include  a  manual  for  the  practice
        of medicine and  exhibits  at  State  and  National  medical  meetings  resulting
        in appraisals on 1000 physicians.

           Second Year                                  Third Year
                -0-                                         -0-
                                                                             Requested
        Project #9R - Neighborhood Health Centers  This is a request         First   Year
                       for renewal of a project which first began            $584,827
        as a feasibility study during the planning and received
        one year's support in the amount of $169,550 for one year during
        the 01 operational period.  The site visitors (September 1968) found
        this to be an impressive endeavor directed by capable people.        It was
        noted that RMPS support was  only  about  one  third  of  the  anticipated  costs
        and funds from other sources, i.e., local groups, Flanner House an  O.E.O.,
        would be sought.  The visitors had no hesitation.in recommending its
        support, but believed it to be the type of activity that could be
        supported in the future by Model Cities  CHP, O.E.O. etc.
        Renewal for one year was  requested,  approved  and  funded  in  the  amount  of
        $169,550  for  one  additional  year.  The  reviewers  were  somewhat  uncertain
        as to the relationship of  the  project  to  the  goals  of  RMP  legislation.
        It was believed that an  additional  year  would  allow  the  centers  to  become
        firmly established and provide the necessary time to be brought under
        funding agencies for these purposes, i.e., Model Cities.
        Two companion  activities  serve  the  Indianapolis  Model  City;  #2  "Multi-
        phasic Screening" and #9R "Neighborhood Health Centers".        According   to
        information received  from  the  RMPS  representative,  HEW  Region  V  Office,
        the projects qualify for Model Cities certification.
        The three health centers, each operated  by  a  hospital  ,  are  sponsored  by
        the Metropolitan Health Council.     The aim of  the  project  is  to  provide
        high  quality  continuing  medical  care  to  the  disadvantaged.  130  patients
        were screened at the Southeast and Central Avenue Centers.        The Martindale
        Center has seen 376 of 453 patients referred there from the         multiphasic
        project. One or  more  diseases  were  diagnosed  in  291  of  their  patients.

          Second Year                                Third Year
             $477,280                                $524,058


                                                               RM  43-03  (AR-1-
             INDIANA RMP                     -17-                              CSD) 2/71
             Project #16R -,Chronic Pulmonary Disease      This is a           Requested
                            request for renewed support of a project           First Year
             originally proposed, approved and funded for one year.             $40,561
             The support was to provide a five-day conference for individuals
             trained Ipreviously and newly identified physicians.  The RMPS Con-
             tinuing Education and Training Panel recommended disapproval on
             technical grounds stating that past progress had not been well docu-
             mented.  Since the Region had already been authorized to use unexp6nded
             funds to begin the activity, the Committee believed it should be allowed
             one year to complete the program; the basis for it's approval and
             funding.
             The major aim of the current proposal is to improve education in Pul-
             monary Disease through the development of sub-regional centers by:
             1)  Training and continuing to train increasingly larger "target groups"
             of physicians from hospitals geographically representative of the various
             communities within the state; and
             2)  Maintaining continuous contact with    these "trainees',',', (a) providing
             them with guidance and supervision, and    with the teaching techniques,
             material and aids necessary to promote and encourage in their own
             institutions teaching activities intended to divulge information in
             this field to a larger group of community practicing physicians, and
             (b) Assisting them in making available in their respective communities
             diagnostic and therapeutic facilities and services, such as pulmonary
             function laboratories, rehabilitation stations and respiratory care units.
             The applicability of this educational model was evaluated and tested in
             the past two years, during which time the program was considered as a
             pilot and feasibility study.  From all the information available it
             can I$e inferred that this educational system has been very successful
             Beginning with 9 participating hospitals from large geographic areas
             within the state and with 12 "trainees," the various activities were
             gradually expanded to include at present 16 hospitals and 29 "trainees".
             At least 10 of the sub-regional "centers" so developed are now participating
             very actively within the functions of the IRMP.
             At this time it is felt that the scope and the operational scale of this
             program are ready to be expanded and it seems most desirable to have it
             supported over the ensuing three years.

                Second Year
                $40,311                                 Third Year
                                                         $35,615


       INDIANA RHP                       -18-               RH   43-03.(AR-1-CSD)    2/71@
       Prolects  Approv  d-Unfunded'of  Partially  Funded   With   no Commitment  for
                         e
       Whic       ort              ested.

                                          Project Years
                       01                                 02                        03
                Approved       Funded          @pproved        Commit@     AP12roved    Commit

                         '2/'$51  450
       #11    $   82,036                         $88,850         -0-          -0-
       #12     31109,003        -0-             69,702           -0-       $72'375       -0-
       #13        40,428      40,428.           36,947           &.0-        38,720      -0-
       #14        27,497 2/    26,197           29,064           -0-         30,026'     -0-
       #18        41,966       -0-              309050           -0-         32,390      -0-

       Total    $191,927     $118,075           $254,613         -0-      $173,511       -0-

       Footnotes:
       2/ supported from carryover funds in the       2nA operational     year
          approved with no additional fundd4

                                                              GRB/RMPS  11/25/70


                                  DEPAIRTI/IENT 0'7 IIEALTH, EDUI::.@"ITIOr-4, Ai,4D 1,VELFARE
                                                  ['U't'tLIC I-IEAL.Ti-i C,@@?VICF-
                                   HEAI-'T'Vi SERVICE.3 AND MLr4-rAL ti@-,',LTii ADMit-41CTF@ATION

                  December 15,    1970
          Rep@ to
          Alln of. Staff review   November 23, 1970, of In(li@i-,ia REgioiiil Medical PI.-o,,,ramf,,3
                  Continuation    Application r@l 00043-03 (Af.@-l-CDS) 2/71.

              To: Actini, I)jrcctoi-
                  regional Medical. Programs Service

         Tlii-ii: Cliii.riiiin of the Itontli

                  Cli.iL@f, Gritit,; liiii.,igenic-nt Br;.iii(@lt

                  Act@ili@,

                              The continuation rc!(Iuest is part     of the
                              ti@oi-i for $2,184,0-Ll (d.c.o.) for    their 03 c)l)(!i-atioTiil-
                  This amount includes their supplemental. ippl.ic,-,tioli (1-1-Yo I)roj(-(@t:,;) co-,n-
                  sidered by the November 1970 Council and deferred for the                       1, 1.970,
                  site visit.

                  The  continuation  request  is  for  $1,302,042  ($I.,]-2.]-,411  commitment  jrt(l
                  $180,631 carryover) for core and seven approved pro-.         ects.  Three of the
                  projects il)l)roved with three year commj-.t,.i-@entc@ have be(@n onpoir)g t-i-7o years,.
                  Three of the approved projects (two for three years tnd one for t@.7o yc@;irs)
                  wc@re begun durint@, the current y(.@,ir from c@irryovc@r funds with if() coirii-iit-
                  in(--nt. One approved for three years  is  to  commence  during  the  O')'  vc-,-Ir
                  with support froii both the                 lev(-@l and (--zirryr)v(--r.  C(-)ijtiiiiiiL-or
                  of 1)roj(.!ctc. #5 and 6 from cirryover was ;also                  blit@
                  advised the l,',c-.i,!.on that      were ,j.l)pi-ov(@(i ;jj-i(I fiiii(.1c@(I for on(@ oiily
                  and w@i.11 now lizivc@ to be              a@:           I)y tlj(.@ l,(,I)rLi,.iry '11)/l.
                  (.'ounce.'[.             an              for         inont@ii..,; wi.tl:j i(Jcii.t-ioti:jl fail(].,;
                  Should be considered until renewal ctatus is acted itj)on.
                  Reconim(@n(lat Lon: Approval in the amount of $1,175,,591 cl.c.o. i.jicl.u@irip,,
                                      the use of (,arryover or new funds in the amount of
                                      $54,180..

                                           Basis for level recommended:

                                                     Committed     Carr
                                                   l,ev(!l          New Pounds               Total.

                  Core                                $422%573                               $422,573

                  #4 CCU                               157,250                                157,250

                  #3 Stroke                            271,000                                271,000


              Harold Margulies, M.D.              2                   December   15,   1970

                                           Committed         r 0 -"r              Total
                                              Level        New Funds
              #2 Multi Screening              225pOOO                               22@,000
              #11 Nursing Allie                     i         42p747                 88,335
                  Health Cont, Ed.             45.,588
              #5 Health Manpower            (3  mos.)          60250               6 5-    250
                                                               5,183                  5,183
              #6 Prospective Med.               MOS.)
                                           $lpl2l,411        $54,180             $1,175,591

              The attached summary of 01 and 02 iwards and 03 request ind rc!co7cnendati-ons
              may be helpful.           I
              This recommendation is based on staff review and site v'    Lsi-t  information
              attained duri,iig the Deceribc,-r 1, 1970, site vi.sit.         #1.1.,
              and Allied Itealtli Continuing Education , is I statewide progra7ii  of  vast
                                                                  cd a groat  deal  of  time
              importance to the Region.  Core staff has invest
              in  its  development  and  necessary  cooperative   arrangements.   Continued
              support would allow completion of the two year activity.  The site
              visitors agreed to recommend approval of renewal     of projects  #5  and  6.
              This then is the reason for staff's recommendation for their extension for
              three months until renewals are acted upon.
              Support is not recommended for  project  #18  (N.W.  Indiana  CC)  because  it
              is a three year project and there is no assurance of continuation.  Also,
              like most projects, there  would  be  some  time  required  for  tooling  up.
              Projects #1-3 (Nursing in CC) and  #14  (Library  Program)  were  funded  from
              carryover funds with the understanding that no further B14P support would
              be required.
              A group recommendation iiis not i@.-,rc@ed upon by ,taff dtirii),,, ti)(@ir
                                                                             2
              November review. The above  recommendation  is  based  on  the  review  all(]
              subsequent site visit - December 1, 1970.  Messrs Says, Cl@B, and
              Robertson, ltDB, were members of the team.
              Staff reviewers' comments prepared prior to the site visit are attached,
              including Mr.  Teets',  GMBL  who  recommended  approval  at  the  commitment
              level.
              Note:  A site visit was made December 1, 1970, and a report will- be pre-
                      sented to the  January  1971  Review  Committee.  Tile  site  visitors
              believe that in the absence of a meaningful- specific data based statcwide
              plan, the I%"IP is not ready for a developmental component.  Ilowever, the
              team expressed  confidence  in  the  coordinator  and  staff  leadership,  as


             Harold Margulies, M.D.              3 -                 December  15,  J970

             wc,l.l is general speculation of pre,@ent projc@c-t activities. The visitors
             will support @i recommendation for approval. of three nc@w and four renewals
             ($927,703 d.c.o.).
             The site visit confirmed staff's concerns about the need fo   r better
             evaluation.  Some effort has been made to strengthen this aspect, iT)Cj-ud-
             ing the employment of a  staff  assistant.  The  regioiiil  characteristics
             section of core (health data unit located at the Indiana State Board of
             Health) seems to be a fragmentc-d.effort  from  planning,  development  and
             evaluation.  Outside consultation might be beneficial.  Also, IRMP
             should explore cost sharing of data service.
             The IRMP letter December 9, 1970, to you is an accurate accounting of the
             site visitors' feedback and recommendations.  Hopefully, the Im4P
             consider the scope of work required prior to their next submission of
             August 1, 1971, and necessary rebudgeting.

                                                          Saran J.
                                                          Acting Chief
                                                          Grants Review Branch
             Ac t ion by D ir ec t or   v td

             Initials
             Date            c,,  0

             Attachments:
             1.  Summary of 01    02 awards and 03 request  and  recommendation  by  GRB
                 and RDB
             2.  Recommendation by CMB
             3.  Review comments by GRB a-nd'OPPE staff
             4.  Copy of IRMI)'s letter December 9,  1.970.

             @IPS staff who Attended this continuation re-view meeting:

             L. J. Says, GRB
             Lee Teets, GMB
             Dale Robertson, RDB
             Leah Resnick, OPPE
             Mary Asdell, CETB


                                                                 A PRIVILEGED CO@MNICATIOI

                                   SU@RY OF REVIEW Al\'D CONCI",USION OF
                                     JANUARY 1971 REVItl@ COLN@ TI'EE

                                    I-T\TDIANA REGIONAL MEDICAL PROGRAINI
                                   PIA 43-03 (AP,-l CSD) 2/71.1 & 2/71.2

                        FOP, CONSIDERATIO@N BY FEBRUARY 1971 ADVISOI-',Y COITNCIL

              6@cormend&tibn-  The Committee considered the supplemental portion of the
                               application for support of four renewal projects  one
              ew pt6jett and the d6velopmental.component.  The supplemental application
               r sup-p6rt of two new projects deferred for a site  visit  by  the
               vember 1970 Council was also considered.  In  View  of  the  site  visit
              indi gs, the Committee  recommended  disapproval  of  the  developmental.
              owever. contrary to  the  site  visitor's  recommendation  the  Committee
                    I                                                 It
               co   nds.additional funding in the amount  of  only  $150,000  for
               et  Tonal activities.

             Note,   The Continuation portion of  the  application  was  reviewed  and acted
                     upon bv stakt., An.award in  the  amount  of-the  committed  level
               1, 1,411) for core activities  and  six  projects  was  being  processed
             i  co  6nsurate with !RMP's grant period beginning January,l, 1971.

                        A d aft report-of the December 1, 1970 site visit
                           r                                                 was presented
                        findings of which were highlighted by a...Comft@ittee member of
                          @t te
             broad@generai objectives and lack of a data  base  by  which  goals  could
                r  u66d to Dribri.ty-oriented specific work to meet defined deficits
             in t e ReRibn.  This problem coupled with the array of projects precluded
               pro t4m Pr spectiveo  Evaluation was cited as another weakness.
               qp  6 thes @PrA!ems, the visitors believe that the IR'i'4P has strength
                   t6fttial capability. The  organizational  structure  is  basically
               @n    There was evidence of competent staff  leadorshiv,  as  well  as
               G involvement.  The review process including technological input
              eems@ adectiai6. AlthouRh ttiereare no  formal  geographic  subregions,
                                                                          it
                ess ry to viable 6p6rations were apparent.  The site visitors,
             co c . ed that in the absence of  a  meaningful  and  specific  data-based
               At  id& plan,,tho !PIIP is not ready for a developmental component
              nd  id not tecomme6d its approval.  The te4m, however, did express

             p       act'v ties.  The team recommended approval of t e@pr6posed
             t      ew projects and four renewals ($800,103).

             T e i plicati6n and the site visit findings  prompted  a  r6at  deal  of
                                                                       9
             d set sion and debate about  appropriate  action  t6,be  taken.  The
             d    tomy between the written descripti-ons,and what has actua IY  '


                                                 -2-        RM 43-03 (@R-1 CSD) 2/71.1 & 2
             Indiana RMP

             been done was recognized and one of the  values  of  site  visits  is  finding
             out reality.    Concernwas expressed  about  disa  proving  the  developmental
                                                               p
             c@dinrkon6ftt approximately 10'/. increased funding), and on the other 'hand
              pptoving all new and renewal projects (60'/. increase).   There was
             agreement that the site visitors found sortie good projects  in  the  Region
             that just did not happen.  They were nurtured by !R@IP.  The problem is
             that the activities are like stepping stones that lead no place.       There
              as  6,olidar'lty in the opinion that the word must g6t  to  IRMP  that  their
             next Anniversary Review Grant Application reflect the suggestions made
             to them bv the-site visitors. There  was  disparity  in  reaching  a  decision
                r 6omrfl6lAdati
             on   e          01-1 of the funding level6 The Coiiinittee questioned  whether
               e Region had taken any positive action since the site visit.  In response,,
              taff@advised that the IRMP got the site visitors message and that they
              eem@ o understand the scope of work to be undertaken prior to their
              ext@submission in August 1971. A retreat  for  Core  staff  and  RAG  was
              nticipated in January 1971.
             Befo e reaching, agreement on a recommendation two  moti.obs  did  hot  carry.
             The first r(ioton for "disapproval of  the  developmental  and  additional
              466,000 for one year for projects  with  a  clear  message"  was  defeated.
              he second motion "a proval in the  amount  requested  for  one-year  with
                                  p
             a cl6 r mbssAge4', was not seconded.
              n conclusi6ft- the Committee recommended additional funds    in the  amount
              f $ 50,000 d#C.O    with   s.trong advice to the R6gioni 1) that funds be used
              n t e,necessary  planning to move the program  forward  as  recommended  by
             the, ite visitors; 2) future proposed  activities  be  based  on  scientific
              iud of needs And Priorities;  and  3)  evaluation  include  patient  care

                                                                           GRB/RMP8  1/19/71


           0                                                             0                                                              0


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

                 INTERMOUNTAIN REGIONAL MEDICAL PROGRAM            RM 15-05 (AR-1 CDS) 2/71
                 50 North Medical Drive                            January 1971 Review Committee
                 Salt Lake City, Utah  84112

                 PROGRAM  COORDINATOR:  Hilmon  Castle,  M.D.

                                     FOR CO @ TTEE/COUNCIL REVIEW

                                             05 Year        06  Year     07  Year      Total

                 Developmental             $ 75  000                                $    75,000
                 Two Renewal Projects        321:022        $328,336     $351,673     1,001,031
                 Three New Projects          367,014        368,508      389,194      1,124,716

                   TOTAL                    $763,036        $696,844     $740,867   $2,200,747

                                         FOR RNPS STAFF REVIEW

                                                                      05  Request

                 Core                                                 $   973,090
                 11 Projects                                            1,489,034
                                                                      $2,462,124
                 Committed                                              2,446,230

                 See attached Summary of Staff Review.

                                                FUNDING

                                                            05  Year     06  Year      07  Year

                 New                                        $763,036     $696t844      $740,867
                 Ongoing                                      15,894
                 Now Committed                            $2,446,230  $2,417,167         -0-

                 TOTAL DIRECT COSTS                       $3,225,160  $3,114,011       $740,867

                                            FUNDING   HISTORY

                 Planning Year                                            Awarded

                    01                                                   $    456,415
                    02                                                        350,294

                 Operational Year

                    01                                                    1,832,760
                    02                                                    2,267,074
                    03                                                    2,445,193
                    04                                                    2,986,791

                 Commitment
                    05                                                    2,446,230


         Intermountain PM                    -2-             RM 15"05 (AR-1 CDS) 2/71

         GEOGRAPHY AND DEMOGRAPHY:

         The region encompasses an area of 564,000 square miles,  including  the
         State of Utah and parts of Nevada, Montana, Idaho, Wyoming  and  Colorado.
         The greater portion of the land area is arid or  mountainous  and  is
         sparsely populated. Approximately one-third of all  the  people  reside
         in a small irregular rectangle some 80 miles -long by 1 to 25 miles  wide,
         centered in Salt Lake City. Most of those remaining, live in  13  'cities
         of 20,000 to 50,000 population and 25 smaller towns of 5,000  to  20,000
         persons.

         Some uncertainties relative to boundaries probably attend  all  areas
         except the State of Utah.  Salt Lake City is the approximate geo-
         graphical center of the region, and it also represents the  trade,  educa-
         tional, religious, cultural, social, as well as medical center  for  all
         of Utah, southern and eastern portions of Idaho, western Wyoming, northern
         Nevada, southwestern Montana, and the area in Colorado which lies  on  the
         western slopes of the Rocky Mountains. Salt Lake City  is  the  well-
         established center for all methods of transportion.

         The population numbers roughly 2.25 million for the region,  with  about
         50% urban.

         In addition to the University of Utah School of Medicine, there are seven
         institutions of higher learning, each with a  pre-medical  program  and
         training for allied health personnel. Four have  nursing  degree  programs
         and two provide advanced studies in nursing. The University  of  Utah  has
         a Bureau of Community Development experienced in conducting  surveys  of
         health needs.

         The region contains a total of 87 hospitals, with 10,230 beds.  There are
         2,100 physicians (94/100,000), and 7,000 registered nurses, 5,200 who are
         active (231/100,000).

         HISTORY OF REGIONAL DEVELOPNENT:

         The University of Utah School of Medicine began planning for  a  Regional
         Medical Program in mid-1965. In October 1965 a  fulltime  Coordinator  was
         appointed.   Numerous meetings throughout the region were conducted during
         this pre-@lanning period.

         The region based its planning on five areas:  community and p ann ng
         resources; manpower; inservice training programs;  continuing  health
         education; and hospital facilities and equipment.

         The Intermountain Regional Medical Program was one of the  first  programs
         to submit an application for operational grant funds. A  site  visit  was
         made to the Region in November 1966, and the site visitors  reported  the
         program was ready for operational status, the RAG was prepared  to  assume
         responsibility for priority setting, and that the  proposed  activities


                Intermountain RNP                 -3-                RM 15-05 (AR-1 CDS) 2/71

                would extend existing expertise from the University of Utah Medical
                Center to hospitals throughout the five-state area.  The proposed
                operational program was weighted toward continuing education  and  cardio-
                vascular disease activities.  The inclusion of a physiological monitoring
                research and development project, under the direction of Dr. Homer Warner,
                was also proposed, and a special technical site visit  was  recommended,
                and later carried on to appraise this aspect of the proposed program.

                The first operational grant was awarded in April 1967 for  a  three-year
                period.  During the next three years,, new activities were added in stroke
                and related diseases areas; the initial thrust in the cardiovascular field
                was continued and heavy emphasis was placed on continuing education and
                training. In 1969 the region requested renewal support for  Core  and  all
                ongoing projects, and a site visit was again made to the region in October
                1969 to study the results of the three-year funding and the region's
                plans for the future. The 1969 site visitors were  much  impressed  with
                the accomplishments that had ensued in the past three years.  Patient
                care services and trained personnel existing throughout the region were
                direct   results of the Regional Medical Program.  The region had developed
                a capable core staff, apparent good working relations with physicians
                and nurses in hospitals and was beginning to think in non-categorical
                programming terms. The site visitors commended the core  staff  and  the
                RAG for the accomplishments of the past three years, but urged  them  to
                consider turning the program in other directions away from the concentra-
                ti6n in categorical diseases diagnosis treatment, and toward  prevention
                as well as un-met health delivery problems existing throughout the region.
                The site visitors also urged the region to concentrate more on developing
                   @le relationships and less on technology as the primary  vehicle  for
                peop
                regionalization.
                In the Spring of 1970, the region submitted a request for funding to
                develop multi-phasic screening activities for a 314(e) Neighborhood
                Health Center in downtown Salt Lake City for the urban  poor.  This  was
                approved and funded.
                The application for the fifth operational year at the commited  level  was
                reviewed by RMPS Staff in November 1970.  A copy of that review is
                attached.

                REGIONAL ADVISORY GROUP,,

                Three new consumer representatives have been added during the  past  year.
                An effort to involve members in identification of high  priority  problems
                and in feedback is being attempted.  Three new Task Forces on Health
                Manpower Problems, Health Services for Medically Impoverished, and Program
                Impact Evaluation have been organized.  Membership on all such groups
                always reflects personnel from outside the Salt Lake City area.  Some
                members of the RAG are also members of the Health Planning Council (314b).


       Intermountain RNP                  -4-                 RM 15-05 (AR-1 CDS) 2/71

       The region is reported to have developed a very comprehensive review
       process which was time-consuming but apparently responsible and mature.
       The RAG was involved in several stages of 27 steps in project development.

                     PRESENT APPLICATION FOR ADDITIONAL FUNDING

       DEVELOPMENTAL COMPONENT:.

       The amount requested is $75,000.  These funds will be invested in pro-
       Jects that can become self-supporting quickly.  Not less than ten such
       activities will be ready for implementation  by  April  1,  1971.  Priorities
       will be aimed at health services to both urban and rural poor, and studies
       to improve productivity of physicians and health personnel for more
       efficient use of health resources. The  RAG  will  allocate  such  funds  and
       will analyze the proposals in light of needs, resources and program
       priorities.

       RENEWAL AND NEW PROJECTS:

       The application requests renewal  support  for  two.on-going  projects,  #16R
       Endocrine Program and #18R - Model Stroke  Program,  and  funding  for  three
       new projects, #30 - Chronic Respiratory Disease Project, #31 - Diabetes
       Education, #32 - Head, Neck, and Oral Cancer Detection Training.  A
       comparison of the types of activities supported now in this fourth
       operational year with the request in regard to the portions allocated
       to various areas follows;

       Components by Disease Category               Present          Proposed

       Heart                                        19.5%              17%
       Cancer                                          6%                 8%
       Stroke                                          4%                5%
       Related Diseases                                9%              17%
       Multi-Categorical                               32%             22%
       General                                      29.5%              31%

       Components by Type of Activity

       Training and Education                       21.1%              25%
       Demonstration of Patient Care                33'8%              30%
       Research and Development                     15.5%              15%
       Administration and Planning                  29.5%              31%

       Thus, it can be seen that the Region  is  making  aslight change in
       direction. The above figures  do  not  include  the proposed developmental
       component of $75,000, which will  be  utilized  for venturing into new
       areas of programming.

                                                      RMPS/GRB
                                                      12/l/70


                            DEPA[ITMENT OF FIEAL_-ri-1, EDUCATION, AND WELFARE

                                           PUI.IL.1r: @t@izvicF-
                             iiFAt-I'll t.;f.I?VICLS Af,4f) @,11.'N,rA[- til-ALTH AV)MINI'-]'f?A'['IOF4

                 Noveiiil)cr  27,  1970
        Reply to
         Atin of.

         Subject: Staff Review of Continuation Portion of Application  -  Intermountain
                 Regional Medical  Program RM  -15
            To:
                 Acting Director
                 Regional Medical  Programs  Service

                 Through:  Cliiirm.4n of the Month
                           Acting Chief, Regioni@Development Branch <t-

                                          r
                           Acting Chief, G ants Review Branch

                 General.:  The request for continuation of eleven ongoing projects,
                 renewal of two, three new (supplemental) projects, one pre-termination
                 project  Core staff activities and a proposal for a Developmental
                 Component comprised the Anniversary Review app ication  rom IRMP.
                 This memorandum will deal with the request for continuation of Core
                 and existing projects and staff discussion and recommendations  about
                 the region.

                 There were questions raised and some differences of viewpoint relative
                 to how the region attempts its evaluation.  In general, the staff
                 agreed that it is an outstanding RMP, with agressive and dynamic
                 leadership, and exhibits in the present application many  examples'of
                 efforts to improve and balance its health planning. These  were  noted
                 in the newly developed Planning Guide which was designed as a  working
                 document for staff and R.A.G. to deal with accessibility, qua ity,
                 efficiency and comprehensiveness of health care and services.

                 The region has increased its sub-regionalization efforts through  the
                 delegation of some responsibility for project development and management
                 to the Medical Education Coordinators (9).

                 The Core staff has been reorganized into three Divisions, each  headed
                 by an Associate Coordinator:  Operational. Pro ects Division, Administrative
                 Services Division, and Program Development Division, the latter as yet
                 largely unstaffed. Total Core staff (exclusive of  project  personnel)
                 numbers 52 FTE.  An additional. fifteen full and part-time are being
                 recruited which will bring the FTE total to 63.

                 The Coordinator continues in an Acting capacity. Ile has assumed  the
                 chairmanship of the Department of Community and Family Medicine at
                 the University of Utah School of Medicine. A Search Committee  of  the
                 RAG is seeking a full-time Coordinator.


                                                                      Se
            Page 2 - Acting Director, Regional Medical Programs         rvice

            Rci,ional Advisory Gr tNtip:  -Three  new  Consumer  representatives  have   been
            added during  the  past  year.  A  former  Chairman  of  the  R.A.G.  now  serves
            on  the  Review  Committee  at  the  national  level.  An  effort  to  involve
            members in identification of high priority problems and in feedback
            is being  attempted.  Three  new  Task  Forces  on  Ilealtli  Manpower  Problems,
            Health Services for Medically Impoverished, and Progrini Impact Fvaluation
            have  been  organized.  Membership  always  reflects   personnel   from   outside
            the Salt I,,ike City  irea,  but  there  wis  some  concern  expressed  by  staff
            about lack of repi.,6's@'entaL!-oii from organizations such  as  the  American
            ite,irt Associiti.on -tnd  other  voluntary  groups.  Some  members  of  the  RAG
            are also members of the Ilealth Planning Council (314 b).

            Evaluation':  There was a dif f erence of  opinion  as  to  the  range  or  scope
            of  the  regionis  evaluation  methodologies.  Staff   who   participated   in
            the.renewal site visit  of  a  year  ago,  recalled  that  the  team  had  felt
            that,  while  the  educational  evaluation  was  scholarly  and  effective,   the
            region  had  not  broadened  its  evaluation  process  sufficiently  to  zero  in
            on problem areas of individual projects.  On the other hand, the
            representative of P  &  E,  who  has  worked  closely  during  the  past  year
            with  Dr.  Schoraw,  feels  that  IRMP  has  developed  one  of  the  outstanding
            systems in the country for project evaluation, which includes a mechanism
            for building in evaluative methods from the beginning of project development,
            and involving R.A.G. members throughout the process.
            Financial                 The  region  has  a  good  record  of  sound  fiscal
            management.  The  Director  of  Budgetary  Services  trains   and   assists
            project managers in preparation of budgets; monthly        financial    reports
            are prepared  and  the  financial  status  of  all  projects  is  monitored  by
            the  Associate  Coordinator  for  Administrative  Services   and   periodic
            reviews are provided to the R.A.G.  There is an unresolved questi.oR
            of balances  accruing  from  previous  years,  for  which  the  region  has
            submittedctequest for re-budgeting.  The request coincided with the I:U4PS
            Director's memo dealing with carryover funds, and a request was submitted
            for  a  "special"  consideration.  This  was  approved  and  a  letter  is  in
            preparation which will  allo@q  the  region  to  request  the  amount  that  they
            would  repro-ram  to  remain  unexpended  at  the  remainder  of  the  04  budget
                        0
            year.  This  would  permit  the  funds  to  be  reauthorized  for  their  use  in
            the 05  period  in  addition  to  the  committed  fund  level  of  $2,446,230.
            Coopei-ative Planning and Involvement:  The.Comniunity Health Centers
            Foundation  organization  was  the  result  of  IRMP  stiff  involvement   with
            the encolii-,igeniciit of a R.AIG. Task Force on Poverty Problems.  This
            has resulted in the funding from  PIIS  and  OEO  of  $953,739  for  a  new
            ambulatory  care  unit  at  the  University  ilospitil,  and  improvements  in
            rural  health  care  for  Utill.  IRMP  involvement  is  gradually  phrasing  out
            as the FoLinditi.on hires its own staff.     The  establishment  of  the   31   B
            agency was al.so the result of li@@IP staff efforts.
                                       ,ist  misunderstandings   with   neighboring   regions
            The region referred to p,
            and cites several examples of cooperative efforts to improve understanding.


                Page 3 - Ac-titig I)irector, Regional M(-dic@ll Programs Service

                IR@ill and Mountain States are jointly funding a Medi.cal Education
                Coordinator for Pocatello and the Southeastern Idaho area, and the
                two RilPs will jointly sponsor a stroke rehabilitation workshop and an
                Allied Ilealth Manpower Conference during the coming year.  Regular
                meetings of IP,@IP and Colorado-'4yoming staff members have helped to
                strengthen lines of communication.  The IRMP and Colorido-T,%Tyoniing M.,'Ps
                are developing jointly a program in continuing education for Tqestern
                Colorado and Eastern Utah.
                DeveloL)ill,-@ -i@l CLoaone t: The amount requested is $75,000.  These funds
                will be invested in projects that can become quickly self-supportiTli,,.
                Not less than ten such activities will be ready for implementation by
                April 1, 1,9,jl. Priorities will be ii.ried at  tio@ilth services to both
                urban and. rural poor, and sti-idi-es to i.mprove productivity of physicians
                and health personnel for more efficient use of health resources.  The
                RAG will allocate such funds and will analyze the proposals in light
                of needs, resources and program priorities.
                Questions:  While there was consensus on the excellence of the applica-
                tion, progress of the region and its operational projects, there were
                several questions which should receive the attention of the site visit
                scheduled for December 3-4:  Audiovisual- plans for the future--how long?
                Department of Community and Family Medicine support now being inaugurated
                via KIP funds--what happens after RMP?  What about activities emanating
                from the medical center--clarification of who (out in the region) receives
                program output and how it is translated into action?  P & E needs more
                information regarding priority setting and plans for involvement of
                voluntary agencies at the RAG level?  What will Intermountain do with
                level funding?  Estimate of timing of present dual role of Coordinator?
                Core Administration (Project #19) - ($973,090) - Will provide for
                10'/. salary increase to cover employee benefits and merit increases
                consis-tent with U/U.policy.  Will recruit several budgeted positions
                including Coordinator.
                Pro_iects: #2  Network for Continuing Education ($260,480).    Has
                good sub-regionalization aspects and also cuts across regional lines.
                Has plans for placing a Medical Education Coordinator in each area.
                Ir'5 - CCU Trai-ning for M.D.s ($109,044).  Also has enlisted other
                PIIP cooperation:  Mountain States, California (Ren@, Colorado-Wyoining
                and Grand JLICtion, Colorado.
                #6 - CCU Training - R.N.s & Cardiopulmonary Resp. ($100,321).  New
                Pilot to train LPNs and will also compare two methods of InsLructi.on
                and applications.
                #7 - Clinical Cardiology Training ($64,348).  Plans for making partially
                self-supporting In three pliases: (1) elimination of stipends; (2) charge
                of fees for 1-week training and elimination of short term stipends;
                and (3) charging of fees for long term training.
                #8 - Community Cardiovascular Review ($103,340).  No concrete plans
                for turnover.
                #10 - Computer Based Physiological Monitoring ($192,901) - Has added
   0


          rage 4 - Rcuing i)irecuor, regional ricuicai rrograms service

          one hospital (VA now in -- Total of five).  Plans for this  upcoming
          year will initiate a charge schedule (inontli'charge per terminal
          attachment) beginning April 1971--evenutally self-supporting by  end
          of grant period (April 1973).
          #11 - Cancer Training & Continuing Education ($32,574).  Adds an
          Operations Manager for six-state tumor registry, each state to pay  a
          portion of his salary.  Project viewed as an evaluation tool for
          physicians in cancer care.
          #20 - Radiology ($37,722).  They have now recruited a certified radiologi-
          cal physicist, part-time, who has begun his training program which will
          qualify him to conduct safety surveys and calibration visits.
          #21 - Myocardial Infarction Data System ($171,812).  Adds Research
          Assistant and more time for System Research Assistants.  Grant-related
          income anticipated in future.
          #25 - Chronic Renal Disease ( $87,009) - Dr. Lawrence Stevens  named
          Executive Medical Director, and Dr. Gary Maxwell as Education Director.
          Efforts to obtain a neplirologist and nurse continue.  Funded July 1, 1970.
          #26 - Ilultiphasic Screening ($229,483) - Funded September 1, 1970.
          Remodeling of facilities underway, automated systems being  designed,
          and project will start screening target population by April 1970.

          Note- If Intermountain does not obtain an increase to their $2,446.,230,
          they will have to reduce their continuation support to provide for
          renewal projects and any approved but unfunded activity they would support.

          Recommendation:  Approval in amount requested ($2,462,124) to continue
          Core staff activities and above projects (#14 requests one year only in
          order to terminate). Amount committed is $2,446,230,  which  reflects
          a difference of $15,894, attributable to the fact that two  projects
          (#20 and #21) have always been awarded one year at a time with no
          future committed support. Rebudgeting has been and will  continue  to
          be necessary for these'two programs.  Site visit team to clarify the'
          issues raised in the staff review.

                                           Jessie F.salaz'ar
                                           Public Health Advisor
                                           Grants Review Branch

          Action by Director

          Initials

          Date

          RMPS Staff Present at Continuation Review

          Harold O'FlahF-.rty                Dale Robertson
          Rod Mercker                        Jessie F. Sa.azar
          Elsa Nelson                        Sarah J. Silsbee
          Edward Tapper, M.D.


                                                                          INTERMOUliTAIN
                                                                         RM 00015  2/71
                                                                         Staff Observation

             There were a number of questions    and concerns r@iised  about  the  Medex
             project at the last review cycle    in Oc'L-ol)er/14ovzmber.  In view of the
             region's emphasis of its  significance  to  the  overall  program  as  well
             as clarification of  issues  that  had  been  raised,  additional  comments
             were submitted in a letter of December 17, 1970, which is attached.
                                       see S'te visit report.
             For additional details,

                                                                     CRB/12/28/70


                         50 t@ort'n    Drivc    Siit L@ilr-,C City, Uti@i Ol I 1 2

                                                             18011322-7901

                                                             .December 17, 1970

           II-Eirc)ld Dfiargul.ies, M.D.
           Acting Director
           Regional iV,:Ddical. Procrarcis Se@-,/Ico
                   Services and iVic.-iLal 1-@TeE,,I-Lh Ad m.i n j@. s l@ rci t i on
                     Bitildi-nrj, Room I.I.--O,'-D
           -5600 F@i-shcrs Lane
           Rocl,@ville, Viarylland 20852

           Dear Dr. Margulies:

                      We understand   from inL@Or-,-,ial conversations with som, e of the
           Rc(jionr-il Medical Progrcims'. Sa,-v,'@ce staff and with riem'@oers of the teE,,rii
           vii-t.-Lci'l conducted Ei site visit oil the !R@v',P on i-Dece,-nr@er "II and 4, that
                                                            Proposal to Train P' ys@ciE,,,@
           Questions have been raised regarding the                            r, L
           Assistants (Pi-ojec" No. 29). Since 'the proposal was. strongly  encIiorsed by
           our r@egional Advisory Group and was -a-L-ed necir the top of all IRV,,P oper-
           atioi-i,al projects and pending proposals  'a recent priorit@7 review by -a
           p,--nel of RAG and staff me,-,,ibers, ,-,7e should li.',,e to respond to the cluest-iors
           which have been mc ised.

                      The cori-@ment his been made that the IlZi\4P proposal. is pa'L.ene@..
                              J.                                                  -ed ',Q
           on the University o' Washington VED-r,'X Program and r,)ay not be EdapL
           ttic situation in the Intermountain Region.  It is true that our pro, Dse,!. %ve.@
           based on a careful s-Ludy of 'the MEDE',X Program. Conditions in the in -Le
           rfloun'Lain Region are very similar to 'those in rural Washing,-L-on, with great
           need to provide prompt assistance to badly overwor,<ed rural general
           practitioners. A survey of soi-rie 36 rural physicians, and physician meT.1-
           bers of our RP@G revealed ci strong consensus in favor of a ivlEi@EX type
           project. It is noted in tire proposal that the Physician Assistcint Project
           could also relate closely 'Lo the IR.LVi-P's continuing education activities
           and would also complement ef-,orLs to improve      accessibility of hea'Lth
           Care for urban populations ('Liie OEO/Ci-L -1 '10 fund d Neighborhood i@,ie,21@th
           Contc-r in Salt 1,@!-,e City) .The Physician zllssisLEint Proposc-i'@ cont@.,@'ns a
           vc@i-@i,earoi@ully designated C-, Ff r L'
                                          to C!VE:L].!'EI'Ll@ its erreC'C!,V,@l- eS@, ' r '!-le EiSS'SLE'@n'
                                                                        10 L

                 I-,  f


               li@irol CL D,,riargLIliE@ SiV,. D. Acting Director
               Regioi-l,-i'i Mcclic,,c@l Programs, Service
               Dccor,,il-)or 1-7, 1970
               Page 2

               the  physician  and  his  patients  and  would  be  carri.ed-o-@t  in   p@,rEill.ol.   wi4l-h   a
               graiiL to the University of Utah D-cparcment of Cortiniian-i.ty and Fcimily
                                                          -in irri)r-o                 L
                            'Lo develop a model 'or c                vc)d rural health care system.
               Evc,li-tc-tt@lo@-i C'Iz@4L-a be shared w-i.ii -Lhe University of Washington
               Program and other physician assistant training activities, in order lo
                                                                                                    @  L
               b f o a cl en "L he base 4'@,,- decision making a-id  any  appropriate  M,  odii'icati.o,-i  01-@
               activities as the pro-ect progresses.

                             The  UniversiLy  of   Utah   College   of   Medicine   is   currently   ad.-,-.-LL-
              .ting additional students and as pointed cut in the proposal (Page 16), is
               planning for rf-axii-nur@-,  ex:Dars,.o,-i  oi@  its  p-,-ograrii.  The  P,iys-I.cian  Assi.s@anc
                                   i                             '@or'                           L
               project is therefore supplementary to e,,i  Ls to provide more pr-'i-,ic-lr-v
               physicians and is ,iot jus@ a poor substi'i               I 0
                                                L                  L -i-Le ' r riiore docLc)-es in rLi '-e, cc)-
               niL7@ni'LIC,'S

                             The ques4Lion of acceptance by Inte.-mouncain physicians                  o7.-        the
               services of a M'LD @-X 'type assistant has also been r@qised.  As noted or.
               page.  18  -of  the  proposal,  a  sarr@ple  b4,7  rural  physicians  in  Utah   was   vis"-@@-cd
               by   IRVIP   staff   members   and   asked   to   respond   to   a   questionnaire   reca-rcl,nc,
                                                      Twenty o-' the 'wen'@y-.@our -C)i
               interest -in a V                                   L      L
                                 ,,.ED"'x project.                                        iiysici.ans
               respr,)iicied indicated 'LhF-@ t 'they would utilize     a physician assistant i -.Lr a
               training pl-ogi-r-irn were imple,-,10n-Led  in  '.his  Reg,Loi-i.  I'he  number  o-.'  doc-,,oi7s
               reached -Ln t'nis preliminary survey is P,-Oi-,ably less than 15% o@ 'Lh e ru r&.'
               pi-a c'Litioners  in  'the  'tZe,@ion,  yet   the   favorable   responses   'Lotaled   more   than
               the r@,,i,-,iber watch can be accommodated          in the first class proposed for
               project.

                             We have no-, sol-ici-ted letters of application           -,'ro,-ri physicians,
               since conrai!L- r,-, e n'L oi' funds for a IVLED-'X p@-ogrerri    has    been    uncertain.    We
               have had several. physicians as'-, a'.)oi-it       the i;f-ogress of our- effort, ho@vever-,
               including inquiries as @Lo whether we could provide training -.'Or paramedical
               people already empioyed in sorce capacity by the physician.  One Unsolicited
               lo, tLer of application has recently boon received and a copy is attached.  A
               letter   from   IRIVIP   inviLIng   physicians   applications   has   been   pre   are    .    in
               view  of  the  high  priority   which   this   projecL   has   been   given   in   our   prograri
               planning, we intend to r@-iail this IcLL'c,- @Lo c@ limited nuriber of rural ph-,/s,'-ci.ans
               as  soon as a method for selecting t'ne most                     potential   prece,,pto.-s    has
               been agreed upon.

                                                                                    h
                             Since submission of 'the proposal, t,,)e                   Cate iViec,,c@,l
               Association Bo,-ird of j'rus'L-c-,,c,,s has                        'C'@-,E'


                Ffzlrolcl lviEtrgLilics ', i@/i. D., Acting JDjrec'@or,.
                Regio,-i@il. i\./i'cdicc-il Programs Service
                Docoi-,ql)cr 3.7, 3.970
                Page 3

                established  a  coi-.ririi'L,teo  to  provide  liaison   between   IRIVP   and   the   Assoc@1-1
                atioii.  This  committee  has  i-,ie-@  'Lwice  and  hcis,  recommended   that   the   U,@.E-,Ii
                Scate   Medical   Assoc!ip-,'.-ion   assist   in   development    of    legislative    proposals
                to facilitate criiplc)yii-eq-L- of physician assistants.  The Psiocl,,Itio-.,,,'s
                mec7@ico-locjal. coristil'La n'Ls  are  drai@@.-ing  such  proposals  .  Acfu-J'.on  favoring  the
                estabi'-igiiriient of a ViEDII:,'X Pj:ogi-ar,,i has also been tclken by the state -Iied,.cal
                sociE,@ti&s    in    i@evada,    Montana    and    Wyoming.    Afte,-    several     discussions
                with  representatives   of   the   nursing   profession,   --igreement   with   'the   proj(30-'L-
                has    eon  expressecl-  by  'Lhe@-f-,,  with   the   understanding   that   expanded   rol.c-,s
                for  nurses   be   supported   also.   This   the   I,'ZVIP   is   doing.   Plans   are   nearly
                complete for a woi--,shop IL-o develop training 'or nurses in care of
                                                           is jo4
                accidc@n@,@,! t-.-aun-@a v.'Lc-Lirfis.  This 1   Ln'cly sponsored by if),,-ViP and the
                Uta'Ll  State   NLirses   Association.   Other   studies   o-if   utilization   of   nurses   in
                rural health care are pr-o@ectecl,, if a Develop,@-ienLEl Co,-r..ponen'L is
                approved and @unded for IIZ-.ViP.

                             We have been 'Lold thaL the curriculum lo,- this program was
                considered s@,el@-chy and                 in coverage     of   Certain   subject    matter    such
                as training in drug reactions.  The curriculum outline contained in
                Appendix  71  o-l'  'the  proposal.  was  stated   to   be   preliminary   and   IL-entatlve.   As
                                                                             Coi_,,Irni@Lee Will Se'- Ob,eCl,-iVeS
                the proposal i@-idica-,es,        Curi-ict,,Ii-trn Advisory           L       L@    L    i
                fo  i-  'the  learning  procram,  based   on   ci   careful   assessment   of   the   needs   of
                physicians pa,-Licip&,t-i.,-i@i and the                  will,  be  designed  to   Feet   t'l-lese
                objectives.  The  'Le  n-Lative  outline  sub.-i-iit-Lecl   was   developed   by   an   ad   hoc
                comr,liittee'of College of iVied-i.cinc-- faculty and potential physician p@.-ec@--p-L-o.-s .
                The r@iEitLer,- oil drug reactions was rc.,entioned as I-Le,,n D 3 ci i n IL-he oi:t'-Llii-.e  and
                                               - El pp@O  i  L
                would certainly be given                pr-'-a'e emphasis.  In this connection we
                                                          TR.@VIP is aSSjSlLii-,g
                should like to point out @Lha'L- 'the     i                       the Un4.versi-L-y of U'-Lc-il,'
                College  of  Pharmacy  in  a  Workshop   for   pha,-rf,,EicisLs   and   p'@-iys-Lc,,ans   while,
                is intende@ to develop new roles 'or the pha             rn,,ac-i.st  and  -iio@-e   cooperation
                between pharmacist and physician in such @iatters as counseling on
                potential  "irug  reactions  and  devc-lopr,,ien,@-  o@   patient   cornplicince   bc-hav4-o@,-.
                                                                                -ant Pi7oposal is
                This is another way in wh-i.ch the @hysician Assist
                with   other   IRiViP   activities.    EvEtlitation    procedures    proposed    include    spa-
                ci fic    asseIssrf,.ent o'L the praCti Etli.ty oi' the training curriculum and the
                                                I     c
                identification of any gaps at an early enough point to allow -Ov@si-o,-,
                the training is completed (see page 29).

                                              j
                                                'CLiVo
                             A specific            L    of the proposal is to clevolor--) ')cs"t@v@
                @@titudes c-ir,,,onrT the pEiti.c)n@- pot),Li I Ei t -Lo,-i in each          wiL I-,, @,- a 3 0
                                                                                  @ o - i    i r, -L C; - v
                -:iccol)L'anr-;e. oj' t@ic, iVij-ODI@,'X in his plz,,nnoci. role.  Ap-@D,(-.),


                               17, 1970
                PEige 4

                qi-iosti.onnaire techniques will @)c till-il.i@Z.2ct       @Lo Ov@-ilu@,to                   o@,
                objc,,c'c'ivc.  Potential pi-o"-)Ie:-I-,s in
                the physicians wiiO @L@00,'@ Part in Li-,C SURVOY P!7iO- to                             ol@
                proposal.  Doc-o,,-I'i,:)ntc@ti.on on this was not                         siric:,,L., the
                COi-ISiSLC--Cl OrL SILII'Djec-11-ive opinions.

                               The potential ior                    in such E,,t-eaF    @.s
                fee schedule to service                       by        physicist ass,;.sca,,-,L, vv-l.liiii@-i-iess oi@
                for@icile patients to be se-an by tl,IE,, assistant and tiae -c,,IciL.,,oi7ishil) bc,-ween the
                MEDEX --nd nurses or other paramedical personnel was recognized.  I'L- is Lhe
                general consensus 'that these pi-(5b!e,-ns can  he  met  by  cEre.L@ul  delegation  o-i
                duties by the physician and by emphasizing  the  -Lnci-ecise  in  'Lo'L-e.1  service
                  I '                                                                                                @ @. cs
                                                                                              the
                wlij-ch the physician's ol-@.ice can @)rovicia through use oi'

                                                                                          I
                .who express a wish 'Lo see the doctor  h-i@-,isolj'  will  always  be                             'Lo do
                so.  A report o@L di.sc-Liss-oi,@s o.L@ an ad hoc Sc-Len-Lf3c, Z@.dvisory C-roup 0.
                'EvalLiE,,t'on oi@ the iVlid-TeVel
                          I                          -L @,Vel-',Ii-cal-       ,,.,Ets cor,lpil.ec',, by tire,
                Center -Lor Health Services 'Zesea-,,-ch a.-,         C, Develop.,-.,ic,@t, jt,,nc,, I and 2, -970.
                                                                                                                 -L
                It states that "In several past                            (Di@ the n-,icl--levc,'L rlCdiCE@IL WC)!7'Kel-
                there  seems  to  have  been  no  pro,D'Lern  w.'Lth.patiol-It  Ecc;optence  ....  C  o   :,,i   n,,Ll   Y
                                                                                     -'-h o@ the practice.
                acceptance seats most dependent upon the s@rengL

                              As                                              Lo
                                  .you no            know,   a   proposal   '   r    a    VLD7X    pojec'@    has    ec@n
                subm@ i'L"Leci by the Uni'-vers,L@Ly o 1-@ U -Lah Col',@,--ge o@L Ved,"clne , Deper@L-r,,ie:,.-L o
                Co,-n,-,-,u,-i-Lty -inct Fat-,iii-y          to 'the Na-Lionc-,]. Cen-Le@- -@o,- Fecili'-Lh  Ser\l.-Lc  s
                Research and                            It is an Ed@.p-L-a'Lio,-i o,-' @Lhe IR.Vi'13 p-lopos-.1.  to  t-e
                forrnat desired by the Center.  We vioti'LCL be pleased 'Lo have.app,-oval                       a - @,
                funding from either 1-'\.iViPS or -the                  or jointly -error ho'-,h .  There Ls crea-L
                interest in, and we              E,@ great riee-' roi-, t,                    n c o,-l,'u n c -Li-C, 7
                                                                           .iis pro@ect.  T
                other  efi@OrLs  and  as  a  par-"-  of  a  planned   program   l@oi-   i,,Iiprov-,ng @Liie s@
                                                                                                              s      s,
                ,ol' rural health care in 'this region, it will help to reduce                      crisis      i-ieal@,Lh
                manpower @Lhroug'@i training and c-riiployi-n-er-@'L oi E,@ I.arc,,el.y unused
                resource,, the                                 corps,-rie.-i.

                             We would be pleasek'l 'Lo respond to any @Ll-Irther @.-uestions                  or   'Lo
                visit with meriibors of your s'La-ir'L about details           of   'this    project.

                                                                Very sincerely yours,

                                                                C. Hilr,-,on Castlc,, M.D.
                                                                Coordinator
                C 1-1 C p'n

                                                      C-


                                                                                                        F'ROI\,i WASITINC-,TON M@ED'F"X
                                                             I L F 0 i-- D                    D 1,C A I-

                                                                   4r.>S SOUI'fl ,,AI!J --Tt@F:L'F'

                                                                                    25, 19-i'O

                                                                                                                      c)n


                                       July 11, 1-970

            University of @lla s 11-1 i ig'L. o n
            SeEi'Lae, Was'iairlgEon

            Doe-ir Sirs:

            I am a Genorc@l Practicionei-, doing 10cimily Practice in the small, rache@- iso-
            latcd co,-i-iniurii-'cy of Milford, Utah.  My practice is active and busy, and
            deriizinding.  If I don'!L- need some help now, I certainly will'. in the very near
            fUL-Ll,--e, , as my v.,o.-k load has increased year',\,,, 'or the last 15 years.

            I have read of your          i@or        Physici-a-,q's Assist@ii-i'cs Lf -@il-@@n-@
            Care, April 30, 1970') .  I believe     my community would be
                          'u.-'Iizinc ',Ohysician AssistEin-L- .
            accep'L,@" n g a ri j- Lia

            In nay practice I have a young man who is an Ex-Corps,-nan,   wife has
            completed his 4 years oil college, has a small 'La,-riily and is marf-'te(ft -L-o
            a young         oi' 'this community.  This young man thoroughly en,oyed his
            wor.< as a "riiedi--" and has expressed very real interest in the
            Prograr1q.

            I also have  an o-L@ 'Lice, assistant, who has wo,-'-Iec,' for roe as my C)i@'Lice -.\--ui-se
            for the past IS years.  She is vigorous and healthy and co,-rlDeLent and
            intelligent.  She -is E, Registered LFb -in(ft X-,i@ay Techricia,-@.  She has al.so
            exp--resseci sincere interest in pursuing the "iVL-,.7!DEX" Progcam, if it would
            be available to hc@ r

            I:i'cher oj' th s c-, p,-- o p I ewould he we'll qual.i.Fied, dedicated, sensi.k@i.v-@
            iridivid.uE@.Is in the capacity of a P,-iysician's Assisl@-@inc, and I would be
            delighted to carry on 'the 9 months on-the-job  training, in nay office for
            e i'L-1-ier o-F

            I would appreciate any information you can send ri@e, thaLwoLild help me    in
            my goal c)i'.Obtciining effective, corflp,-Lc-,nt help.  Plecise coiiirf,,ent specifically
                                                   (f, 4
            as -to th  s liability of the above Can lclc@tes 'or the MEDEX
                   e  vi

            T"nanks very much for your help.

            Yours sincerely,
   I*                                                                                             I-

            D. A. Sy-,iio.,-id, Nrl.lD.


                          INTEPiNIOUN'fAIN REGIONAL @DICAL PROGRAM

            STAFF OBSERVATION:

            Mr. Daniel Webster, Pegional Office Representative, RMPS, Denver,
            Colorado, called to report the.following about the.Intermouritain
            Regional Medical Program:

            1.  Robert Satovick, M.D., has been appointed coordinator.of the
                Intermountain Ple to replace Dr. C. Hilmon Castle.  Dr. Satovich
                has served on the IFIM core staff, with special responsibility
                for developing the teteb-,t6V6@cula-r- program.

            2.  Mrs. Irene Sweeney has retired.  Her responsibilities for sub--
                regional development will be assigned to Artnur Anderson, a
                member of the IRMP core staff i-Those'former duties were in'the
                renal program area.


                                                                    A PRIVILEGED COMMNICATION

                                        SUMRY OF     REVIEW AND   CONCLUSION OF
                                           JANUARY   1971 REVIEW CONMITTEE

                                      INTERMOUNTAIN REGIONAL MEDICAL PROGRAM
                                            RM 15-05 (AR-1 CDS) 2/71

                               FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

               Recommendation:  Award  of  $75,000   for   a   Developmental   Component   and
                                 $150,000 for operational activities.

                                                                                   Recommended
                      Year                           Request                        Funding

                       05 (Developmental
                                                  $    75,000                       -75,000
                             Comppftent)
                           2   Renewal    Projects    321,022
                           @3 N w Projects            367,014                       150,000

                          Total                      $763,036                   $225    000

               6riti4ue:  The Chairman of      the site visit team repcrrt6d on the visit
                           made on December.3-4. 1970.  The findings and recommendations
                  th  team  confirmed  the  previous  visit   of   November   1969   which   was
               0 ganized for an extensive      program  review   and   renewal.   IRMP,has   a
                ell-tra.-ned and'competent     Core staff,  o d cooperative relationships
                 th    soital6 and a well-developed review process.

                 e  6view  Committee  discussed  the  implications  of   the   search   for   a'
               c      nator, with Dr. Castle now Chairman of the Department of
               @C     itv Medicine     For   instance,   the   University   resources    or
                ost   aauate  education and-family medicine have been placed in the-.
                   a         0    amun
               posti   doate    6cati6n4, This@may     create problems for the new
               cooro   at6i.  particularly when it     is realized that:the IRMP has a larger
                 dg,   than the Department of Community Medicine.  The hew Coordinator
                 11     designated  as  Associate.Dean   of.   the   M6dical   Sdhool-,'ahd   it
               w       e
                 rec    ns    t ide  the sphere.of the Department of Community Medicine
               w  i@    a   te 1  challenge.  (Note:  since   the   meeting   of   the   Review
               C   i@  ee.   R   has been formally advised b              hairman of the !RMP
                                                                  y the c
                          h    p                                              IRMP Coordinator.)
                        t e     ointment of Dr. Robert M. Satovitk as

                he   C   mittee was in agreement that-the IRMP has: exhibited the
               nec@es   .ry@mat ritv  and  decision-making  ability,  both   on   the   part   of
               the I    and  Core  staff.,  to  justify.an   award   of   Developmental   funds.


           _,@--Intermountain  RMP                 -2-            IM 15-05 (AR-1 CI)S) 2/71

               As further demonstration of good judgment on the part,of the RAG,
               a very modest D.C. was deliberately requested to allow the region
               to first gain experience in this direction.

               The reviewers noted the important step in sub-regionalization efforts
               through the appointment-of ten Medical Education Coordinators in  ten
               'hospitals throughout the re ion  but also noted an apparent lack
                                         9
               of understanding of the community organization nedessaty for such
               ub-regionalization.  There is no cleat strategy for Accommodating
               e M,E.Cs with the:University of Utah in   order to expand education,
               training and health manpower. The Core staff,needs to  be  encouraged
               to utilize and seek the assistance of the resources of local  organi-
               tdtibns  rather than d6pendin  entirely on Core staff.
                                           9

               The plan for M.E.C.s is a laudable first step  away  fr6m@technically-
               oriented pr6'ects that !RMP has consistently emphasized, but the
                         i
               reviewers noted that this region will probably  always use a
               technological approach in view of its geographical and weather
               characteristics.

               The reviewers loatned that the Physiciant
                                                       s Assistant  Project,  which
               had been looked upon negatively by the Review Committee in October
               as a very important element of high priority for IRMP..  The  degree
               f physician involvement in the planning And development  of the
               togt m is i  tepsive.  The RAG, as well as Core staff, has indicated
               ev  eel it is critical for IRMP to contribute to this program, even
               if@funding for the educational portion emanates from the National
               Center for HP41tb Services Research and Development.

               he RevieW Committee discussed the question of the IRMP RAG representa-
               Ion.  it was noted that the Pr6sident of the University of Utah
               poi ts members of the RAG, and while the very intricate relationships.
               at  XiSt between IRMP and the RAGs of Colorado/wyomiftg and other
               pighb6ri@g tegions are excellent, minority and consumer participation
               s mi@ imal@.

               The reviewers feel that regional r6soutces are well utilized, although
               ha  necessarily depended on a variety of "multiple represettation".
               ere many, of the same people appear on all committees.

               be COmmit,'.tee questioned the tegion's failure to come  to  grips  with
               e@p obl@m 6f@seeking other sources of support and phasing out projects
               ere was $0   feeling that such a monolithic structure motivates
                                                                                  of
               in t a@fle luility of such-action.  Further, the review pr cess
                     arentl  does not@allow evaluation that would provide for such
               P   app     y
               rnov6r Or phasing out.  Committee would be interested in demonstrated
               id6  te of accomplishments of its various programs with  an  aftalvsis
               fexpetienc6 tdgultihg from  funds  invested.

               Ithe opinion of the reviewers, the IRMP  needs to  develop  criteria
               or ntinuing ongoing programs,  with  scientific  documentation  which


             Intermountain RMP                   -3-             RM 15-05 (AR-1 CDS) 2/71

             will measu re output of programs, their ability to "sel,f-renew" or
             obtain dollar support elsewhere.  Also, they should try to develop
           .a local process designed to eliminate projects that fiave (or have not)
             accomplished their regional goals.

             In a discussion dealing with an appropriate dollar recommendation for
            .IRMP, the reviewers addressed a per capita  approach.  The  site  team
             had recommended aft additional $150,000 to support  .new projects,  and
             noted a lack of enthusiasm about the Endocrifte Laboratory an  stro e
             programs.  The matter was discussed by the site team with the region,
             and there was agreement that the program has not fulfilled its
             expectations.

             The Committtee's deliberations on the Developmental Component    award
             elicited the opinion on the part of some of the  reviewers  that  such
             an award should be provisional upon the receipt by  RMPS  of  adequate
             data-on the progress of ongoing programs, particularly those that
             have had large investments of funds.  This, in turn, led to an-
             examination of the current level of funding and the site team's
             recommendation of $150,000 to be awar e    or projects.

             Th ere was consensus that the region'is adequately funded for its
             site., population, etc.  The maturity of the region, the.capa6ity
             of RAG for responsible decision-making, and indications of
             ,objectives and priorities justify such an Award.  Also, these
          ..,funds should enable the region to move more rapidly away from
             project orientation.  There was also agreement that the management
             of grant funds is well-designed and efficient.  Core staff has ability
             to develop a more imaginative thrust, but  will require new funds
             since the'present grant fundsare tied up in ongoing activities.

             Sist6r Ann'Josepbine was absent from the room during the discussion.

                                                        RMPS/GRB/l/22/71


                 0                                                              0                                                             0


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

        LOUISIANA REGIONAL MEDICAL PROGRAM                 RM 33-02 (AR-1-CSD)  2/71
        Suite 401                                          Januarv 1971 Review Committee
        2714 Canal Street
        New  Orleans,  Louisiana   70119

        PROGRAM COORDINATOR:  Joseph A. Sabatier, Jr., M.D.

                               Request  (Direct  Costs  Only)

                                   03                 04                05          All
        Puri)ose             3/l/71-2/29/72    3/l/72-2/28/73    3/l/73-2/28/74     Years

        Continuation
          Com@ttment            $628,369                                          $   628,369
        Core                   ($346,777)                                           (346,777)
        4  Projects            281,592)                                             (281,592)
        Adeitional
          Components        $1,678,644            $1,214,216       $1,193,121     $4,085,981
        Developmental        (    62,837)                                           (  62,837)
        6  Projects         (1,400,096)          ($1,080,577)     ($1,065,597)    ($3,546,270)
        4 Approved but         215,711)              133,639)         127,524)      (476,874)
          Unfunded
          Projects
        Total               $2,307,013            $1,214,216       $1,193,121     $4,714,350
        Scaff   Action         628,369                                                628,369
          Commitment

        Committee           $1,678,644            $1,214,216       $1,193,121     $4,085,981
          Action Required

                                      Funding Ilistory

                                       PLANNING STAGE

                     Grant  Year             Period                Funded (d.c.o.)
                         01             I/l/67-2/28/68                $490,448
                         02             3/l/68-2/28/69                454,445
                         03             3/l/69-2/28/70                425,300

                                    OPERATIONAL PROGRAM

                                         Council             Funded             F'i-iture
        Grant  Year       Period         Approved              (d.c.o.)       Connitment
            01        3/l/70-2/28/71    $821,628               $673,887
            02        3/l/71-2/29/72     705,611                                $628,369
            03        3/l/72-2/28/73     211$043                                 1-31,701


      LOUISIANA RNP                                           KM JJ-UZ @AK-1-Ubi))  L//i

      Geography and  Demography

      The Louisiana  RMP serves the entire state of Louisiana, which has  a  population
      of approximately 3.7 mill,-'on.  It has interfaces with the Texas, Arkansas
      and Mississippi RMP'S.  B,r national standards, Louisiana is an economically
      poor state.  In 1966, 29 of the 64 parishes were poorer than 90% of the
      counties in the U.S., and 15 other parishes were poorer than 75%  of  the  U.S.
      counties.  Thus 69% of the parishes are at a high poverty level.  Much of
      this poverty is concentrated in rural areas of the state and  is  reflected  in
      poor health status.

      There are three medical schools in Louisiana - Tulane University Medical
      School and the Louisiana State University Schools in New Orleans and Shreveport.
      The major teaching hospitals in the state, serving the  three  medical  schools
      are charity hospitals, which treat the indigent  patients.  Louisiana  has  a
      legislatively fragmented health care delivery system, divided  among  the  state
      charity hospital system, the private care system, and the  State  Department  of
      Health. There are 156 hospitals in the state  with  approximately  26,637  beds.
      This number includes eight federal hospitals and ten state-operated charity
      hospitals with 4,898 beds. A total of  4,194  non-federal  physicians  practice
      in Louisiana and 8,370 nurses are actively employed.

      Regional Development

      The original planning application, submitted by the  Louisiana  State  Department
      of Hospitals as the grantee agency in Jurie 1966, was returned  for  revision
      because reviewers thought it represented more of a pre-planning  than  a  planning
      effort. The revised submission was approved in late  1966  with  the  condition
      that the Region: 1) clarify how the program would cover areas outside-,  metro-
      politan centers; 2) identify the person or organization adminstratively
      responsible for the program; 3) reduce the budget; and 4) clarify how the
      systems portion would fit into the overall aims of the program.

      After a National Advisory Council site visit by Drs. Peeples  and  Hurst,  funds.
      were awarded in December 1966. About the same time,  Dr.  Joseph  Sabatier  was
      appointed Coordinator. During the first planning  year,  the  Region  requested
      and received permission to use planning funds to implement  a  coronary  care
      unit program in Lafayette, Louisiana, with the purpose of  testing  the  concept
      of RNP as a catalyst for development of an  adequate  community-wide  structure
      for long term community health planning. This  experiment  turned  out  later
      not to have been very successful.  After    second year planning  funds  were
      awarded, the LRMP began work on its operational  application,  which  contained
      a request for core funds and two projects - Health  Careers  Recruitment  and
      Delineation of Medical Service Regions. In  reviewing  this  application,  Council
      stated that, while the LRNP had made progress in planning, they  did  not  believe
      the application reflected readiness for an operations  I program.

      The Region's second operational submission was approved-by  the  August  1969
      Council, following a site visit in June, which indicated that  the  Region  had
      been particularly successful in bringing together the  important  health  institu-
      tions and organizations in the state. At the time the  Region  was  beginning  to


       LOUISIANA RMP                             -3-          RM 33-02 (AR-1-CSD)  -'@/71

       examine its organizational structure and to  take  steps  to  change  the  grantee
        gency to a nonprofit corporation.  The Regional Advisory Group appeared to
   &be  dominated  by  physicians  and  lacked  adequate  consumer  representation.   The
       site visitors expressed the hope that the Region would begin looking at Droject
       activities in terms of the total Louisiana area, not just the New Orleanc
       Medical Center Complex. The  operational  application  included  funds  for  -@@ur
       projects:

             i@l - A Training Program for Tumor                       $116,956
                  Registry Secretaries

             #2  -A Proposal for Teaching Conferences                   25,000
                  for Diabetic Patients

            Y@3 - Proposal to Establish an Office of                   106,954
                 Research and Development in Educational
                 Renewal (ORDER)

           '#4 - Audiovisual Lecture Demonstratiorts in                 24,791
                 Radiology and Radiologic Techniques

                                                                      $273,701

       Funding of the first operational year was delayed until March 1970 due to
       federal fiscal constraints.  Consequently, the Region is still in its first
       operational year.  During this year the Region has submitted two supplemental
   Applications.  The  first  requested  $535,747  for  project  #5,  Development  of   a
   @egional Medical Center Coronary Care Training Unit.  This proposal, which
       would have established a 19-bed coronary care unit at Charity Hospital, New
       Orleans, was withdrawn by the Region after the November 1969 Review Committee
       meeting and has been resubmitted in the present application as Project Y@18.
       The second supplemental application included these projects with the following
       action:

             @A8  Cardiopulmonary Resuscitation                  Revision Required

             #9 - Metropolitan Organ Bank                        Funding deferred
                                                                 pending development
                                                                 of Guidelines

            #10 - Study of Health Care Delivery
                  Patterns of the Medically Indigent             Approved

            #11 - Lymphomatous Tumors in
                  Louisiana                                      Approved without
                                                                 funds

            #12 - Telemetry  of EKG's                            Returned for Revision

            #13 - Continuing Education Program for
                  Physicians of Ruston, La.                      Approved  without  funds

         Since none of the approved projects have been funded, all but project #12
         have been included in the present application to be reconsidered for funding.


        Louisiana PMP                  -4-                    RM 33-02 (AR-1-CDS) 2/71

        Regional Objectives

        The Region has identified three critical health issues, which gave rise to
        the Region's objectives.  These critical health issues are 1) health care needs
        of the disadvantaged, 2) methods of improving the productivity of the health
        care-deliv6ry system, and 3) health care costs. The following are the objectives:

        1.  To improve and expand the "data base" and systems of data management
            for health planning in the region.

        2.  To develop planning aids (models and tools) to increase the effectiveness
            of the region's health planning related to achieving LRMP objectives.

        3.  To implement regional programs through "subregionalization" of the
            health services and delivery systems of the region:

            a.  Contribute to the upgrading of medical care for those people in
                the region who have been found to be disadvantaged in terms of
                health care received.

            b.  Promote efforts to make quality health care more.accessible.

            c.  Encourage the provision and utilization of comprehensive health
                care (e.g., prophylaxis, adequate patient follow-up  and,continuous
                care).

            d.  To promote efforts to contain or reduce the cost of quality  health
                care.

            e.  To promote efforts which are directed at improving the capacity
                of the health service and delivery systems (e.g., improving the
                number and utilization of health manpower and other resources).

        These regional objectives will be achieved within the framework of a regional
        conceptual strategy. This conceptual strategy includes the  following  five
        principles:

          1) region-wide perspective
          2) catalytic role
          3) collaborative involvement
          4) utilization of existing resources
          5) involvement of a limited duration

        Organizational Structure and Processes

        At the time the grantee agency was changed to a nonprofit corporation,  the
        Regional Advisory Group was reorganized by incorporating more groups with
        a central interest in RMP and by increasing consumer input.  The  36-member
        RAG now consists of 9 ex-officio members, 21 elected representatives of
        organizations and institutions, and 6 public representatives.  In  addition
        to Its project approval function, the RAG also considers program statements


         OUISIANA                          -5-                   RM 33-02 (AR-1-CDS) 2/71

         from and offers guidance to the  planning  committees  and  receives  progress
         reports on core.
          The LRMP employs the following  committees  in  its  overall  process:
            a) Program Planning Committees (Heart Disease, Cancer, Stroke,
               Epidemiology and  Statistics,  and  Continuing  Education  and  Health
               Manpower) are responsible  for  determining  needs  and  developing
               programs within their assigned specialty.
            b) Ad Hoc Program  Development  Committees  are  temporary  committees
               formed to aid in the development  of  specific  projects  and  at
               the request of the project proposer.
            c) Ad Hoc Project Review  Committees  are  established  to  evaluate
               the technical, scientific  and  operational  excellence  of  each
               project. Consisting  of  experts  in  appropriate  fields,  these
               committees are usually from outside the region.
            d) Areawide Planning  Staff  Liaison  Committee,  composed  of  representa-
               tives of CHP b agencies and  the  a  agency,  provides  liaison  between
               CHP and RMP; it does not make official recommendations on projects.
            e) The Executive Committee of the  RAG  composed  of  the  RAG  Chairman,
               Vice-Chairman and four other  members,  represents  the  RAC,  between
               its regular meetings and reviews continuation requests.
         The LRMP review process comprises  three  steps:  1)  administrative  review
         by Core staff, 2') technical review by the Ad  Hoc  Review  Committee  (copies
         of which are included with each project),  and  3)  final  evaluation  by
         the RAG.

         For a discussion of Core structure and  function,  please  refer  to  the
         continuation section of application component of the summary.

         PRESENT APPLICATION
         Developmental Component                                           $62,837
         The Devel.opmental Component funds will play an important role   in   the
         three major activities of LRMP  activity:  1)  development  and  improvement
         of health planning and decisiori-inaking systems (including evaluation);
         2) development of programs designed to meet  specific  needs;  and  3)  imple-
         mentation of programs.

         Examples of these activities could include:
          a) data gathering processing, interpretation and utilization;
          b) acquisition of authoritative information and advice;
          C) limited experimental studies  in  health  care  delivery  systems  or
              applied clinical research;
          d) dissemination of information; and


        LOUISIANA RMP                     -6-                RK 33-02 (AR-1-CDS) 2/71

          e) development of certain -unusual operational projects key to the
             implementation of high priority programs.

        The Coordinator will submit a detailed explanation of the proposed
        activity to the RAG, who will then approve or disapprove ilt.   Upon
        completion of the activity, the Coordinator will report its results to
        the RAG.

        Continuation Component:

        These components have been reviewed by staff.  Their program and funding
        recommendations are in a supplementary memo.

        Core                                                         $346.,-77.@-,

        Medical School                   Coordinator
        Advisors                            Dr. Joseph Sabatier
                            I                        i
                  Deputy Director
                  I             I
        1. Planning        2. Evaluator                  4.  Assistant  Director  for
            Section                                         Administration
                    r-                                   I            i             1
        3.  Project Development                       Staff      Secretarial     Business
            Section                                   Writer     Staff           Manager

        1.  The Planning Staff will coordinate and implement activities in data
        gathering, resource planning and delivery systems planning.  Examples of
        these are a feasibility study of developing  a  hospital  discharge  abstract
        system, an assessment of the region's radiation therapy facilities, and
        an evaluation of models to improve the quantity and quality  of  health  care
        delivery to rural and urban poor.

        2.  The newly employed Evaluator will develop methods of program evaluation
        and refine the program's priority setting mechanisms.

        3.  The Project Development- staff will stimulate and develop those projects
        specifically related to specific regional purposes.

        4.  The proposed activities of the Administrative staff include revising
        the regional guidelines and improving the  regional  communications  systems.

        The LRMP has assisted health groups in other then project development.
        For instance, the RMP provided a panel of experts to investigate the
        current status of the Louisiana Hospital Television Network, a study
        recommended by the pre-operational site visit team.  LRIM also provided
        assistance to the Cancer Commission of the State.Medical Society in
        assessing problems of establishing a statewide cancer registry,  as  well  as
        to several other organizations. Core staff also  uses  subcontract  funds  to
        conduct planning and feasibility studies.

        The LRMP has no subregional office staff of its own.  It has, instead,


                                    -7-                  RM 33-02 (AR-1-CDS) 2/71
  LOUISIANA RHP
  fostered the developmnt of local CHP agencies.  Financial and planning
  assistance has been offered to the six areavide health planning councils
  by LRNP.  These agencies, in turn have been asked to comment on R14P
  projects in their areas-
  All of Core staff's 17 positions (15.5 F.T.E.) are filled.
  Continuation support in the amount of $281,592 is also requested for four
  projects:
     #1 - Training Program for Tumor Registry Secretaries
     #3,- office of.Research and Development in Educational Renewal
                     'n --Of iki&ical Service keiions in Louisiana
     #6 - Delineatio
                      ofr'-li6c ui nt@ -#to@'gr'am
     ,#7.--,-,@Health Care  r
     Approved but Unfunded Pro ects
     These projects fall into two categories: 1) Those which had funds approved
     by Council, but which RNPS, due to funding constraints, was unable to fund;
     and, 2) Those which received a recommendation of approval without additional
     funds from Council.
@committee   and    Cou.ncil consideration of these projects is needed in determining
     a funding level for the next year and not for approval of  the  activities.
     1.  The Region has assigned both of these projects a high,priority.
                                                                       lot  Year
     Project #9 - Metropolitan Org n Bank                               $102,035
     Sponsored by Tulane University School of Medicine, this proposal would
     conduct a feasibility study on the development of An organ bank for the
     methodical procurement, preservation and supply of vital organs for purposes
     of renal transplantation in New Orleans.
             Second Year                            Thi d Year
                $77,242                              $79,342
     Proiect #10 - A Pilot Project to Establis a  Method  of  Evaluating  Health
     Care Delivery Patterns of'            ndigent witn Hea         se,  Cancer,
     Strok            ad Diseases
     The Louisiana Capital Area Health Planning Council,  a  314b  agency,  will
     initiate a pilot study to determine  health  care  pattern  characteristics
     of low income residents in Baton Rouge, Hammond, and  New  Roads  and  form
     an Ad Hoc Committee on Comprehensive Health Services for low income citizens
     which might help evolve a plan for comprehensive health delivery system in
     an urban target area.


         LOUISIANA RMP                      -8-                    RM 33-02 (AR-1-CDS) 2/71

         II.  Both of these projects were assigned a relatively low priority
         rating by the Rbgion.
                                                                        lst year
         Project #11 - Lymphomatous Tumors in Louisiana                 $56,921

         The major purpose of this proposal is to establish a statewide surveillance
         system for identification and histologic classification of all newly-
         diagnosed cases of Hodgkin's disease occuring within a two-year period
         and to coordinate  resources  for  treatment.  The  Tulane  University  School
         of Public Health and Tropical Medicine will sponsor the project.

              Second year                             Third year
                $46,994                                $48,192

         Project #13 - A Proposal to  Establish  a  Continuing  Education  Program  for
         the Physicians of the Lincoln General Hospital                 Ist year
                                                                        $7,258
         The physicians of Ruston, Louisiana, in conjunction with
         the development of a plan to supply health care services to the medically
         indigent, seek to develop a structured program to upgrade skills in their
         respective specialties.  Physicians from Lincoln General will spend two
         weeks in appropriate specialty  departments  at  Baylor  College  of  Medicine
         in Houston following individually designed programs in their specialty.
         Conditions regarding the description of the courses, the parish-wide plan
         for comprehensive health care, and the ORDER's (project #3) involvement in
         evaluation, have been discussed by the project director.
                                                                 2nd  yr.
         Supplemental Projects                                  $9,46-3

         Committee and Coundil  action are required  on  the  following  six  projects,
         which the Region has grouped into roughly three priority groups:

            1) High

                  Project #18 - CCU Training at Charity Hospital

                  Project #17 - Regional Pediatric Pulmonary Center

                  Project #15 - Health Data Information Center

            2) Middle

                  Project #16 - CCU Nursing in the Capitol Area

            3)  Low

                  Project #14 - Nurses Continuing Education

                  Project #19 - CPR


      LOUISIANA RMF                  -9-                    RM 33-02 (AR-1-CDS) 2/71
    @Project #14 - Coordinated Continuing Education Program  for  Nurses  in
      Louisiana                                                    lst  Year
                                                                    $156,487
      Proposed by the Louisiana State Nurses' Association, this
      project would develop a statewide coordinated continuing education
      program for professional nurses and other nursing personnel.  The
      program would be incorporated into the L.S.U. Adult Education Division.
      Because the intent of the project is to show relevance to the particular
      needs of the nurses in the subregions while upgrading the nursing manpower
      of the region, the project would serve the Region's third objective of
      implementing regional programs through subregionalization.

              Second Year                          Third Year
                $252,005                            $249,331
                                                                      i-@t Year
      Prolect #15,- Louisiana Health Data Information Center          $63,348

      The objectives of this proposal are @hree-fold:
        1) Establish and operate an information resource for users of health
           and related data.

        2) Stimulate studies in data acquisition and identify needs for
           data not currently available.
        3) Develop an inventory which can be monitored over  a  long  period
           and at a minimal expense.
      The proposal, sponsored by the Louisiana State  Department  of  Health
      fulfills the primary project objective of establishing a data base for
      health planning.

             Second Year                       Third Year
               $53,580                          $54,383
      Project #16 - Ongoing Training for Cardiac Care  Nursing  Personnel  in
      the Louisiana Capital Area                               Ist Year
                                                                  ,5

      The Louisiana Capital Area Health Planning Council  proposes  to  adopt
      the ROCOM system to construct a teaching program of 120 hours for
      participants in the CCU nurse training.  Courses will be held in three
      hospitals in the Baton Rouge area.  The project addresses the objective
      of improving the capacity of health services and  delivery  systems  by
      increasing available manpower resources.

             Second Year                          Third Year
                $30,738                            $31,646


        LOUISIANA RMP                     -10-                    RM 33-02 (AR-1-CDS) 2/71
        Project #17 - Regional Pediatric Pulmonary Center'                $460,331

        The Tulane School of Medicine Department of Pediatrics seeks funds
        to establish a  multidisciplinary  pediatric  respiratory  care  unit  in  the
        children's ward, Charity Hospital, to deliver modern quality respiratory
        care to indigent children  by  establishing  a  four-bed  special  care  unit,
        an inpatient ambulatory  treatment  unit  and  a  teaching  demonstration  unit.
        Since the project is directed  toward  those  who  are  disadvantaged  in  terms
        of having and paying for health care, it supports one of the Region's
        high priority objectives.
                        I

             Second Year                            Third Year
              $548,765                              $565,247

        Project #18 - Development of a Regional CoronaEX Care Training Unit at
        Charity Hospital of Louisiana at New Orleans
                                                                         $509,381
        This project, sponsored by the Charity Hospital in New Orleans
        which serves the  medically  indigent,  would  attack  the  regional  priority
        of providing  medical  care  to  the  disadvantaged.  Although  the  application
        states that LRNP recognizes RMPS' reluctance to approve funding of CCU
        hardware and architectural renovations, this two-year project requests
        funds from RMP primarily for alterations and renovations and equipment
        because state tax funds cannot be stretched to provide the same.  The
        proposal intends to establish a model CCU with a 19-bed capacity.  The
        LSU School of Nursing and LSU and Tulane Medical School would then
        provide three-week courses for  nurses  and  one-week  courses  for  physicians.
        This proposal was previously submitted  to  RMPS  in  1968  and  withdrawn  by
        the Region after the Review Committee Meeting to strengthen the proposal.

             Second Year  -  $36,536

        Project #19 - Cardiopulmonary   Resuscitation Program           $177,016
        The Louisiana Heart Association as the sponsoring organization seeks
        funds to determine the extent of CPR training and the current level of
        competence of individuals' involved in CPR programs in the state and      then
        to establish a statewide program to train and retrain at periodic intervals
        such groups as  physicians,  registered  nurses,  licensed  practical  nurses,
        dentists and general  hospital  personnel.  This  proposal  was  returned  for
        revision by the July 1970 Council because the proposal had not adequately
        delineated certain aspects of the training program, the previous experience
        with this activity in the state or certain items in the budget.       This
        proposal would promote subregionalization of health care services (objective
        #3).

             Second Year    $158,953              Third Year    $164,990

                                                               DRMP/GRB 12/9/70


                            DEPARTMENT OF HEALTI-I, EDUCATION. AND WELFARE
                                          PU13L[C HEALTH SERVICE
                             HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION

          Date: December 14, 1970
       Rel)ly to
        Atitiof.- Staff Review of Non-Competing Continuation Application from the
        Subject: Louisiana Regional Medical Program, 5 G03 RM 00033

           To: Acting Director
              Regional Medical Programs Service

              THROUGH:  Chairman of the Month

                        Acting Chief, Regional Development, Branph

                                                      nch
                        Chief, Grants Management Bra
                        Ac'ti'@Cl@ief, Grants Review Branch
              The Louisiana Regional Medical Program is requesting continuation
              support for its 02 operational year for core and four projects.  Since
              Louisiana's budget year does not start until March 1, 1971, and the
              45-day estimate of expenditures is not due until mid-January, requests
              for use of carryover funds have not been included in the present
              application.  Therefore., the discussion was limited to general program
              issues and the following continuation request.

                    Continuation Requested                              Amount

              Core                                                       346,777

              Project #1 - Training Program for Tumor
                            Registry Secretaries                          731447

              Project #3 - Office of Research and Develop-
                            ment in Educational Renewal                  140,867

              Project #6 - Delineation of Medical Service
                            Regions in Louisiana                           3,303
              Project #7 - Health Career Recruitment Program              63,975
                                         Sub Total Projects             $281,592

                                              Total Request             $628,369

              Besides the continuation request, the Region has included in its AR
              application, a request for a one-year developmental component, funding
              of four approved but unfunded projects and six new projects.  The Region


           Acting Director, PkiPS - Page 2

           was supported by a funding level of @673,887 during the 01 year.

           Recommendation: Approval of the committed  amount  of  $628,369  for  core
           and four projects.   Staff also strongly urges, that in  light  of  the
           Region's present constricted funding level and the quality of core staff,
           that serious consideration be given to increasing this Region's commitment
           for next year.

                The following staff members attended the December 4 meeting:

                   Miss Dona Ilouseal, Grants Review Branch

                   Mr. Michael Posta, Regional Development   Branch

                   Mr. Lawrence Pullen., Grants Management Branch

                   Dr. Alan Kaplan, Continuing Education Branch

                   Miss Mary Asdell, Continuing Education Branch

                   Miss Joan Ensor., Planning and Evaluation Branch

                   Miss Loretta Brown, Planning and Evaluation Branch

           General Comments

           Staff was impressed with the present  application  and  surprised  that for
           a Region which has been operational for less than one  year,  it  had  begun
           to address a program concept so well.    The regional goals  and  objectives
           are described, as is the regional conceptual strategy and critical health
           issues.  Staff noted that the Region is attempting to address soine of
           the health care problems of the disadvantaged  through  its  projects  based
           at Charity Hospital.

           The LRMP has reorganized its RAG during the last year and has     added
           consumer and black representation.  The  Region  provides  orientation  to
           each new RAG member. Staff believes that  with  the  new  grantee  agency,
           a nonprofit corporation, and  the  new  guidel'ines and bylaws,  which  states
           that each RAG member votes on each project, a  more  democratic  and  active
           RAG should develop. Because of  the  recent  reorganization,  however,  it
           is too early to tell just how strong it will be.  At  this  point  in  time,
           it shows more promise than progress.

           The regional review process up to the RAG   level is strong.   Core  staff
           provides administrative review and Ad Hoc   Keview groups  composed  of
           expert consultants generally from outside   the Region provide  a  technical
           assessment of the proposals.   The Region has included these assessments
           with the projects, as well as the reasons why  the  proposals,  which  the
           RAG disapproved, were turned down.    One suggestion RMPS staff  would  make


                Acting Director, RMPS - Page 3

                is to advise the Region to describe how the approved projects were
                changed as a result of  the  review.

                Core staff appears hig]-il-y qtiilificd. Although  program  evaluation
                efforts are still in the  "to  plin"        tlic, c@v@iltiitor has only just
                recently been empl.oyed and a methodology has been formal.tz(@(l.  As
                far as data collection is concerned, core  in  conjunction  with  the
                Ref;ion's Epidemiology Committee, has been ver@, idroit in using
                outside resources and in avoiding duplication of effort.  The proi,ram
                has excellent fiscal guidelines and  monitors  its  expenditures  closely.
                RMPS staff is concerned in the case of  Projects  #17-,'The  Regional
                Pediatric Pulmonary Center, and #18, A  Regional  Coronary  Care  Training
                Unit at Charity Hospital, which contains large 'equipment and  A  and  R
                requests, that LRMP staff is either weak in allowing the project
                applicants to include these items or else  is  flaunting  national  policy.
                In its introduction to one of these projects, however, LRMP states
                that it is aware of the national trend away  from  funding  such  items,
                but that local need for such units to  serve  primarily  the  disadvantaged
                is so urgent, that the Region wishes it to  be  considered.  In  fact,  the
                RAG has assigned the coronary care training project the highest priority.

                                                                                          i.
                The progress on the ongoing projects appeared satisfactory.  As for
                the tumor registry secretary training, project  #1,  staff  was  concerned.
                that the project may be emphasizing tra.l.ning tumor  registry  secretaries
                without considering the need for producing  better  output  data  for
                tumor registries.  The Office of Research and Development in Educational
                Renewal, project #3, seems to be operating as  a  genuine  resource  for
                project proposers, as well as for  institutions  and  agencies  throughout
                the Region. Staff was curious about  the  relationship,  if  any,  between
                the project's Advisory Council and  the  Region's  Continuing  Education
                Committee.

                Conclusion: The committed amount of  $628,369  is  recommended  for  the
                Region's second operational year.

                                                   Dona E.  Houseal
                                                   Public Health Advisor
                                                   Grants Review Branch

                Action by Director

                Initial

                Date


                                                                                (A Privil.eged Communication)

                                       Sli,@,,MARY OF PEVIET@ t,,@@;D CO@ICI,USIOj4 OF
                                           January   1971   Review   Co,-,iTittee

                                       LOUISIANA REGIOINAL LNE@DICAL PROGRAM
                                                RM 33 (AR-1-CSD) 2/71.

                             FOR CONSIDERATION BY FEBRUARY 1971. ADVISORY COUNCIL

                RECO,@NDATION:   Committee recommended approval of $400,000 i.b new funding
                                      for one year only.

                                                             ui--Si

                YEAR                    CO,@TIFENT                 NEW FUNDS                 TOTAL

                lst    Year               $628,369                 $1.,678,644               $@,307,013

                2nd   Year                    ---                      1,21-4,216               1,214,2,16

                3rd   Year                                             1,193,121.              1,1-93,121.

                  TOTAL                   $628,369                 $4,085,981.               $4,714,350

                                                     RECOI@^,IENDATION

                YEAR                       STAFF                        COMMITTEE                       TOTAL

                ist    Year               $628,369                 $400,000                         $1,028,369

                2nd    Year                                        Contingent    on
                                                                   results     of
                3rd    Year                                        site     visit

                CRITIQUE:@,   Committee thought that the LR@IP he(l@accompl.ished            much during.its
                              first operational year.   It has established liaison with a wide
                variety of    groups in the Region involved with planning for or delivering
                health cake.   It has added black and consumer representation to the RAG and
                is in thi-@@process of reorganizing ongoing Committees which serve the RAG.
                The revip:v7 process, which utilizes exoerts from outside t              he Region to
                technically review the projects, operates effectively.  Goals and objectives,
                while somewhat vague, are well stated and in consonance with the general,
                dire  ction of R@.

                Reviewers found,several areas of weakness Lo which they believed the ReRion
                should devote their attention and efforts during their second operational
                year.


              Louisiana RMP                       -2-                 RM 33 (AR-l.-CSD)  2/71

              Regional goals and objectives need  to  be  further  delineated  as  to  how  they
              would improve patient care, and the planning strategy should be developed
              on the basis of hard data which will show how regional activities will
              improve patient care. At  the  present  it  appeared  that  the  generality  of
              the goals and lack Of Systems analysis in establishing goals would make
              it difficult for the Region to  select  or  reject  as.wel.1  as  evaluate  program
              and  nrojcct  activities.  The  efforts  of  the  Region's  Epidemiology  Committee
              in dealing with the collection of data and the proposed project 15, Louisiana
              Health Date Information Center, which would C*oordinate date already collected
              by various agencies in the Region, will help overcome this

              A cloF.@ y related issue is  the need to strengthen the planning and evalu-
              6tion capabilities of Core   staff.  While planners and an evaluator have
              recently been added to Core stAff, Committee noted that their specific
              bacl,,groun(,IF are not in tli(-, health care delivery or health planning and
              administration  areas.  Reviewers  suggested  that  their  exnerience  be  suo-
              ,Dler,irnted by outside consultants.  Pro  ect as well- as  pro-rem  evaluation
                         buttressed.

              In conclusion, Committee recommended that $40r),OOO be a(3d,c.,@rl to the  Region's
              funding level for the next year, and tcey stated that these funds could
              be used to supplement Core, includin- pl.anning and feasibility activities,
              or fund projects. Whil.e no  funds  were  recommended  for  future  years,  the
              Committee stated that funds iioul.d  be  approved  contingent  on  a  satisfactory
              showing of progress at  a  site  visit  when  the  Region's  triennial  application
              is submitted.

              Projects were  not           individually.    Committee  recommends  that  Council@
              look at Project lk9, the  Metropolitan  Organ  Ban!<  which  has  been  previously
              approved by Council but not yet futi(lorl,  with  the  kidney  projects  submitted
              by other Re-I.ons,

                                                                           RMPS/GkB
                                                                           1/1,5/71


             's                                                              9                                                              0


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

              Maryland Regional                                    RM  00044-03  (AR-1  CSD)  2/71
              Medical Program                                      January 1971 Review Committee
              Suite 201, 550 North Broadway
              Baltimore, Maryland
              Grantee  Agency:   Johns   Hopkins
                                 University

              Program Coordinator:  Edward Davens, M.D.

                                         03  year       04 year         05 year
                                         3/l/71 -       3/l/72          3/l/73       Total
              Purpose                    2/28/72        2/28/73         2/28/74      All Years

              Continuation*              $2iO77,883      -----           ----        $2,077,883
               Commitment
               (Core    including
                Epidemiology    &
                Statistical Unit)           (808,161)    -----           ----            (808,161)

                16 Projects              (1,269,722)     -----           ----        (1,269,722)

              Additional Components        10363,149    $1,045,401      $1,062,775      3,471,325
               (Developmental)              (1009000)     (100,000)       (100,000)      (300,000)
               (4 New Projects)          (1,263,149)      (945,401)       (9629775)    (3,171,325)

              Totals                       3,441,032     1,045,401       1,0629775      5,549,208

              *  Staff  Action   Commitment2,077,883

              Committee    Action
              Required                     1,363,149     1,045,401       1,0629775      3,4719325

                                                Funding History

                                                Planning Stage

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

                  01                     I/l/67 - 12/31/67                       $438,106

                  02                     1/l/68 - 2/28/69                          678,182


        Maryland RHP                      -2-                 RM  00044-03  (AR-1  CSD)  2/71

                                      Operational Program

                                           Council                               Future
        Grant  Year   Period               Approved       Funded  (d.c.o.)         Commitment
          01          3/l/69 -   2/28/70   $2,294,177        724,360  Core        -------
                                                          $1,208,523 Projects

          02          3/l/70 -   2/28/71      2,314,535      784,556  Core        ------
                                                           1,420,101 Projects)
          03          3/l/71 -   2/28/72      2,350,115         ------             $2,077,883
          04          3/l/72 -   2/28/73        145,000         ------                145,000
                                               (#19 only)

         Includes $251,417 Carryover funds

        Gpograpby: The  Maryland  Region  includes  the State of Maryland without Mont-
                    gomery County  (where  the  patient flow is traditionally into the
        District of Columbia) and York County, Pennsylvania.

        Demography:

        Ponulation              @.4  million

          a. Uri@an             71%
          @.  White             91%
        Facilities:  a. Johns Hopkins University School of Medicine      Enrollment 150
                     b. University of Maryland School of Medicine - Enrollment.367

        Physicians:  a. Medical Doctors     5,450 (1965)

                     b. Doctors of Osteopathy - 20 (1965)

        Program Priorities
        1.  Continuous determination of needs through a well established RMP
        Enidemiology and Statistics Center.
             a.  Consumer needs - extent and characteristics of di.seases and health
                  nrolilems.

             b.   Providers of service - adequacy and distrittition of facilities and
                  health manpower to deal with consumer needs.


           Maryland RMP                        -3-                  RM 44-03 (AR-1- CSD)  2/71

           2. Review and encouragement of innovative. models for  health  care  delivery,
               including primary heal.th care.

                9, To identify promising experimental  efforts  and  disseminate  knowledge
                    about collaboration among the directors of the new orogrems.

                b.  To identify geographic gaps in health care service and encourage
                    development of organized services to fil.1 the gaps.

               Strengthening of Central RMP Core Unit, as well. as support  of  innovative
               projects in the del-ivery of health care will be necessary  to  accomplish
               the priorities above.

           4.  Continuing Education

           5.  Expansion of inter-agency and inter-institutional cooperation.

           6.  Review and evaluation of ongoing operational and new projects.

           Review Process

           The review process includes:  review by staff; examination by the Epidemiology
           and Statistics Committee to assure that objectives are clearly defined,
           methods of achieving these objectives identified, the  data  collection  process
           is appropriate and the methodology for directly evaluating each project in
           terms of its achieving its own objectives and in terms of its relationship
           to the overall Program is established.  Following this, the review of the
           Epidemiology and Statistics Committee is passed on to  the  scientific  Advisory
           and Review body. When finally approved, the project will  pass  on  with  both
           the evaluative and the scientific Advisory and Review  Committee's  review  to
           the Regional Advisorv Group for final approval.

           Regional Advisory Group

           The ?.@-v6ting member Regional Advisory Group has been broadened by  adding  six
           new membprq to fill. vacancies. Three of these are llack one  from  the  field
           of ntil-lic hpalth, an obstetrician and one is involved in the field of  social
           services for the disadvantaged.  Three vacancies were filled during the
           October 16, 1970 meeting.  These include the Director of Baltimore Model
           Cities Agency, a consumer representative from the Eastern  Shore  of  Maryland,
           and the Executive Director of the Maryland Compr(@hensive Health Planning
           Agency.  Two medical students (one from each School of Medicine) have been
           added at non-voting members.  The RAG meets ten times a year.

           Administrative Committee - This Committee is composed of the following ex-officio
                                       members: Deans of the two  medical  schools;  Dean,
           Johns Hopkins School of Hygiene; Commissioner of Health;  Coordinator  of  RMP;
           and Chairman of the RAG (without vote). The functions  of  the  Committee  are
           to: 1) appoint the Coordinator; 2) make final  decision  on  all  administrative
           matters; 3) appoint members of the RAG; and 4) establish policy for administrative
           operation.


                                                                 Rm 4*.,Ol (AR-1 CSD)  2/71
         Maryland RMP                       -4-

         Other Committees -The RegioTf has seven categorical committees:    Heart,
                           Stroke, Cancer, Epidemiology and  Statistics,  Continiiin,@,
         Education, Kidney and Pulmonary.

         History of Regional Development
         Based on a series of preliminary planning conferences during 1966, Dr. William
         Peeples, State Commissioner of Heal.th, Dr. Thomas B. Turner,  Dean  of  Johns
         Hopkins lAndical School, and Dr. William Stone, Dean, University of Maryland
         School of Medicine, a Regional Medical Proaram  Steering  Committee  was  fo rmed
         composed of three representatives from the Johns Hopkins Medical Institutions,
         the University of Maryland Medical School and the Maryland State Department of
         Health.  This Committee served as the overall Coordinating Committee for the
         Maryland RMP.  The representatives on the Steering committee of each cooperating
         institution were selOcted I,-v and served at the nleasure of the Gox,ernin?,
         'Boards of their respective institutions   This Committee appointed  a  6  man
         Fill--committee on Planning, oho was given the responsibility  for  developing
         the application for a planning grant.
         An advisorv Group, composed of representatives of the official and voluntary
         health agencies, the public at large, medical  society,  etc.,  was  formed.
         Dtiring 8eptemlier 1966, the Maryland Regional Medical Program  submitted  its
         first planning grant which was approved with the following conditions:
             1.   Clarification of fiscal. responsibility for the grant;
             2.   Assurance from applicant of legality of the responsibility of
                  administering the program;
             3.   Clarification of the responsibilities of the hospital administrators
                  and staff, as well as the  listed  eleven  professional  people;  and
             4.   Statements as to how the integration of the components of the three
                  participating organizations will be effected and managed.
         The first year planning award was for the period of January 1, 1967 - December
         31, 1967.  During the initial planning stages of the Maryland RMP, Dr. William
         J. Peeples, Chai-tman of the Steering Committee was the Program Coordinator.
         In March 1967, Dr. Thomas Turner, retiring Dean of the Johns Hopkins     University
         School of Medicine was appointed as Program Coordinator.
         In March 1967, staff considered a request from the Region for the second
         year to continue Core planning activities.  Staff felt that although overall
         progress in this program during its first year had been modest, definite
         accomplishements had been Achieved in the areas of (a) recruitment and
         organization of Core staff, (b) the  development  of  a  functional  decision-
         making process which involves the  RAG  and  appropriate  planning  Committee,
         (c) the stimulation of Coonerative relationships with Community hospitals,
         and (d) the delineation of regional boundaries.  Staff recommended approval
         for a second-year planning grant for the period January 1, 1968 - December 31,
         196P.  Also, during the second year of planning the Region received approval
         to initiate six feasibility activities in the following areas:  Epidemiology


           Maryland RMP                       -5-                 RM 44-03 (AR-1 CSD) 2/71

           and Statistics, Evaluation of Continuing Education or Medical Care, Heart,
           Stroke, Cancer and Continuing Education.
           Dr. William S. Spicer Jr., was appointed Acting Coordinator during January 1?6?.
           In August 196P. the Region submitted a planning renewal request for the sunno-t
           of A Central Core Administration and seven other planning units.  Also s,i--
           mitted was the first year operational grant application which inclueer; 1,
           operational projects.
           A site visit was made to the Region in December 1968, to review the planning
           to date as well as the request for operational funding.  The site visit team
           was impressed with the "vigorous" leadership which the program coordinator
           had provided, and had r?cruited and organized what appeared to be a very competent
           staff.  It was the recommendation of the team that the Core planning renewal
           be maintained at approximately the current level funding.  The teams impressions
           of the operational application were generally favorable although there appeared
           to be a significant service orientation.  In addition, some of the activities
           sponsored by the medical schools did not clearly refl.ect active or intended
           outreach to the broader community.  The team concluded that this was a viable
           region prepared to mount an operational program.  The team recommended approval
           of $1,511,81.2 for 14 of the proposals.
           The January 1969 Review Committee recommended a level of funding at approximately
           half the amount recommended by the site visitors.  Because of the disparity
           between the recommendations of committee and the site visit team, Council
           appointed a special Council referee committee to restudy the entire back-
           ground and application materials and recommend a level of funding.
           Following negotiatio@with the Region in March 1969, the Region received an
           award which included $742,360 (d.c.o.) Core activities and $1,208,52? (d.c.o.)
           for 11 of the operational proposals, a total of $1,932,8P3 (d.c.o.).
           In November 1, 1069, Dr. William S. Spicer resigned and Dr. Wm. Peeples
           former commissioner of the Maryland State Department of Health was appointed
           Pro,-,ram Coordinator.
           During February 1970, staff considered a request from the Region for the
           second operational year for the continued support of Core Staff activities
           and 1.@ ongoing projects.  The request was composed of a total of $1,93/-,FS2
           from Committed funds for support of Core staff activities ($7?P,521) and
           $1,20/4,@5q for the 11 onvoing projects, and a portion of funding ($?I,"iti2)
           to initiate approve but unfunded project #19 - Tisstic Typing Laboratory.
           Alro included in the request T,7as a total of $]P,7,656 from unrxnen(led ftintlg
           foi- the extension of two projects and additional funds for Project #19
           (al-.Ove). Staff was Disappointed with the Region's nrofress and expressed
           the following concerns:
                 1.  The anplication itself was uncoordinated and did not reflect
                    any degree of organization.
                2.  The progress reports were prepared at an early date by the Region
                    and as a resul.t, reflect meager resul.ts.


         Maryland   RMP                       -6-                   RM 44WD3 (AR-1 CSD) @/71

               3.  it appears that little coordination exists between the various
                   institutions with dore staff, and less coordination exists among
                   the projects and their staff.
         As a result,. it was difficult to arrive at a firm judgement about how much
         progress had been accomplished during the Region's first seven months of
         support.  However, no information was presented within the application which
         would justify disapproval of any of the components.
         Staff recommended approval as requested and further      recommended that a program
         site visit be scheduled in early June 1970 with a member of Committee and
         Council and DRMP staff to explore the intrarelationships of the core staffs
         with projects, as well as the degree of coordination among the various core
         components.

         Listing of Current Funding Status of Core and Operational Projects in Maryland
         RMP.
         Project                                                         Amount supported
         Number                       Title                              through 2/28/71

            no        Core and Administrative Staff
                      Central- Unit                                           $218,960
                      Johns Hopkins University                                98,271
                      University of Maryland                                   123,751
                      State Health Department                                 34,011
                      Epidemiol.ogy and Statistical, Unit                      239,092
                      Clinical Cancer Program                                  3,220
                      Continuin- Education Feasibility Study       York       17)946
                      Cancer Feasibility Study                                1-2,000
                      Oral Cancer Detection                                   12,392
                      Symposium on Pulmonary Disease                           I,  013
                      Pulmonary Function Study                                16,400
                      Conference on Delivery Medical Care                      1,500
                      Maryland Hospital Education and Res. Education           6,000
                                              CORE SUB TOTAL                  $784,556

             1        Continuinp, Educational Program for Peninsula
                      General Hospital                                        17,550
             2        Development and Eveluat+on of a Comprehensive
                      Technical Screening Program for School-age
                      Children of Low-income Families - University
                      of Maryland                                             76,816
                      Early Detection of Cardiac and Malignant Disease
                      in Pre-school Children - Mercy-Hospital                 24,173

             4        A Program for Mass Detection of Heart Disease
                      in School Children - Baltimore City Hospital            22,54"

             1)       Early Detection of Heart Disease in the
                      Newborn - Johns Hopkins                                 20,000


              Maryland RMP                             -7-                       RM 44-(.)3 (AR-1 CSD) 2/71

              Project                                                                Amount supported
              Number                       Title                                     through 2/28/71

                  7        Coronary Care Program
                             A) University of Maryland                                    79,700
                             B) Baltimore City Hospital                                   21,846

                  P'.      Closed Chest Cardiopulmonary        Resuscitation
                           Maryland Heart Association                                     38,000

                  0        A) Acute Stroke Unit - Johns        Hopkins                   118,618
                           B) Chronic Stroke Unit - Baltimore City
                               Hospital                                                  179,821

                10         Acute, Intermediate and Long-term Stroke
                           Care - York Hospital                                          145,596

                11         A) Proposal on Stroke - University of Maryland                138,8lq
                           B) Pronosal on Strol@e - Nursing Education
                               University of Maryland                                     42,555
                           C) Proposal. on Stroke - Rehab. Nursing
                               Montebello Hispital                                        61,714

                12         Proposed   Coordinated    Discharge    Pl.anning    Program
                           for Wicomico and Somerset Counties - Wicomico
                           County Health Department                                       15,083,

                13         Regional   Medical   Program   for    Outpatient    Strokes
                           Deer's Head Hospital - Salisbury                               1,8,51)tt

                14         Demonstration and Training Program in                         163,653
                           Rehabilitation of Stroke Patients - Sinai Hospital

                16         An Ambulatory Program for Comprehensi-v(, Pulmonary
                           Services - Maryland General Hospital                           90,0')O

                           A) Tissue Typing - Baltimore City - Johns
                               Hopkins                                                    83,1/@7
                           B) Tissue Typing - University of Maryland                      l')],r)53

                                                             TOTALS                  $2,204,65@
                Incltj,'e8 $251,417 Carryover

              March 1970 Committpe/Council recommended that action on a November 196P
              Supplemental Operational Application be deferred pending the site visit.

              This November Application contained the. following proposals:

              #2'i - Position of Director of Continuing Education - Anne Arundel General
                     flogri ta I .
              it?5 - Comnrphpnsive Sti-ol.,r, Prol,,.ran - Prince Geor-ge's General. Hospital


        ,Maryland RMP                                          RM 44-ni (AR-1 CSD) 2/71

                                                                                 els
        #26 - Stroke Rehabilitation Program in the Home and in  the  Prince  Georg
             County Health Departmetit Rehabilitation Clinic
        #27 - Management of Intestinal. Stomas - Baltimore City Hospital.s (The site
             visit was conducted on May 11-12, 1970)

        The site visitors found that the RMP had bumped along, grown and evolved
                                                                            schools.
        largely through the strengths that pre-existed in the two medical
        It was apparent to the team that there are too few ful.1-time neople on the
        Central. Core Staff and that they have found it difficult to guide, or in
        fact, counteract the strengths of the schools.   Recommendations both  to  add
        funds and rebudget funds from institutional cores were made  by  the  site
        visitors, and accepted by the July 1970 Council, which should strengthen
        the central core, not in an attempt to subjugate the Medical  Schools  per  se,
        or to destroy their roles in the creation of more programs, but  to  help  give
        the schools directions which may be something other than the traditional ones
        the schools Osually take.   Also, whil.e large core staffs are partially supported
        in both Hopkins and Maryland, these appeared to the visitors to be little
        concern for developing interrelationships between the various program
        components.  One of the overriding probl.ems in this region is the rapid turn-
        over of program coordinators.   The present coordinator, Dr. Edward Davens
        who'bep,an on July 1970, is the fifth Coordinator since this Region  @egan  its
        plannina phase during January 1967.
        The Region has received approval (unfunded) for  the  following  nrojects:
        Projects #25 and #26 Combined - Comprehensive Stroke Program, Strol,-p
        Rehabilitation; #27 - Management of Intestinal Stomas; and, #."I - RheijrTintic
        Fever Prevention.

        Present application:   This is a reqtipst for four new proposals qn(i a
                               developmental component.

        Nct@l Proposals
        #12   Contindine Education Program for Hartford Memorial Hospital
                             03
        R(,qti tin           I/l/71 - 2/28/72
          Direct Costs           $33,909
        The Hartford Memorial Hospital, Harve de-Grace, Maryland is requesting a
        ,;t,lpnlemental salary to employ a full-time Director of Continuing  Education
        in addition to a secretary to assist him in his duties.  The Director of
        Continuinc, Education will. participate in the Maryland RMP  seminars  and
        forLinis for Directors of Continuing Education in order to lead  the  hospital
        more effectively to an expanding standard of excellence,  become  acqt.tqintpd
        Keith expert consultants in various fields, and establish  channels  for  rapid


            Maryland RMP                         -9-                 RM  44-03  (AR-1  CSD)   2/71

            acquisition of materials and  advice.  He  will  have  an  active  role  in  the  many
            functions related to  quality  of  care  review,  and  will.  assume  responsibility
            for coordinating  various  programs  within  the  hospital  in  consultation  with
            the chiefs  of  Service,  relating  these  programs  to  the  individual  physicians
            and servina as liaison officer with the teaching Medical centers and
            surrounding health care facilities.  He will arrange and moderate conferences,
            lectures,  scientific  sections  of  staff  meetings,  and  assist  with  departmental
            meetings. In  addition,  the  DOCE  will  assist  the  staff  with  specific  Problems
            regarding diagnostic  and  therapeutic  procedures  an(]  will  orvanize  seminars
            for nursing  and  other  paramedical  personnel  with  emphasis  on  updating  their
            education.  He will have the resnonsibility for developing appropriate tpachin"-
            loarning materials where none exist  and  in  cooperation  wi.tti  the  librarian,
            u,ill supervise the needs of the Library.

            By employing a Director of Education, the applicant states that the Hospital
            will have a more direct method  of  assuring  itself  that  good  health  care  is
            being rendered to its patients.

            The DOCE will be  responsible  professionally  to  the  medical  staff  and  its
            Executive Committee,  and  Administratively  to  the  Board  of  Directors  and  the
            Administrator. The  Objectives  of  the  project  will  be  to:  1)  assist  the
            Staff, Administration and Board through the development of structured
            Continuation and Reparative Education activities as part of the physician
            and hospital daily activity; 2) continue to arrange for cooperative educational
            health care activities with surrounding smaller community hospitals, clinics
            and extended care centers;  and  3)  provide  for  inservice  training  for  the
            Directors of Continuing Education as well as continuing education for the
            Staff.

            #33 - Comprehensive  Regional  Approach  to  Education  and  Therapy  for  Chronic
                   Renal Failure
                                 01                    04                  05
            Requpsting       I/l/71 - 2/2,8/72  I/l/72 - 2/2?,/73  '1/1/71 - 2/2P/714  All years
            Direct Costs       $1,101,662            $850,178             $P68,002      $?,Iz,20,042

            The Primary purpose of this program is to expand existing facilities        to
            provi(!e an effective form of therapy for Patients with irreversible renal
            failure.  Currently, some 10 patients are being maintained on dhronic (Ii.alysis
            through four hospitals, and only 12 renal transplants have been Performed in
            three of these institutions.

            The objectives of the project will be:

            1)  increased  dialysis  and  transplantation  capabilities  within  the   cooperating
            institutions as a demonstration of patient care.       Wi.th current  staff  and
            space, maximum Iialv,;is facilities are:     Baltimore City (10),Jolin,,q  Hopkins
            and University of Maryland  (4),  the  total  number  of  Patients  on  dialysis  at
            one time t-eini@ 22. Thi.s project calls  for  expansion  of  facilities  in  some
            hospitals  and  initiation  of  program  in  others.  Home  training  programs  will
            be (levfloperl at Baltimore City, Maryland Ceneral, and Sinai Hospitals.


         Maryland RMP                         -In-                  RM 44-03 (AR-] CSD)    1  2/71

         Anticipated facilities are:     Baltimore City (10), Good Samaritan (16),
         Johns Hopkins (8), Maryland -General (6), Montebello State (4), Sinai (4),
         and Maryland University (8).     The  total  number  of  patients  on  dialysis  (in-
         patient) at any one time would be 56.       It  is  also  estimated  that  25   natients
         could be moved to home dialysis during the first year.  The Programs at
         Baltimore  City,  Univ6raity  of  Maryland,  and  John  Hopkins  will  accept   patients
         from other institutions for Renal transplantations.        Montebello    will    provide
         a service for patients from inaccessible areas of the Region awaiting Cadaveric
         transplantation.
         2)  Development   of adequate  referral  systems  for  patients  in  need  of  treat-
         ment.  Referring  @hysicians  may  contact  any  of  the   cooperating   institutions
         for evaluation of their patients.  Based on the availablity of an opening
         the  patients  will  be  accepted  for  evaluation  directly  or   referred   elsewhere.
         1)  Training of physicians, nurses, and technicians in the referred specialized
         technique  for  care  of  individual  patients  locally  and  throughout   the   Region.
         Training  opportunities  will  be  provided  for  full-time  physician  trainees   in
         the  Departments  of  Medicine,  Surgery,  Urology  or  Pediatrics  of  the  various
         hospitals, and for part-time community physician trainee who can acquire
         srecial skills  in  patient  management  which  will  be  applicable  in  their  own
         "ractice. Fellows  will  be  assigned  to  the  program  from  one  to  three  years
         end will be given major clinical responsibilities as their skills an(] knowled?,e
         arlv@ince.  Experience will be provided in the management of patients on chroni.c
         fien)o(lialvsis, and during all phases of renal transplantation.       They  will   also
         be trained in renal Tihysiology and transplantation immunology.         Ilurses  will
         receive  training  in  the  basic  principle  of  disordered  renal  physiology  and
         the  management  of  chronic  renal  disease  along  with  the  management  of  clinical
         nroblems  specifically  related  to  dialysis  and   renal   transplantation.   This
         will  be  eone  through  lectures  and   practical   clinical   experience.   Technicign
         traininginvolved through familiarization with the central dial.ysete dispensing
         Equipment  individual  delivery  systems  and  maintenance  of   all   dialysis   equip-
         mpnt.
         A)  Encouragement  of  the  development  of  additional  facilities  in   other   insti-
         tLItions throughout the Region by means of an Educational Program.
         ';) Evaluation  of  the  economics  and  efficacy  of  the  various  treatment  forms
         used and the feasibility of the entire program.

         @lethotis of evaluation inclutle mont'nly Pt-etinps of (iiqlysis directors and
         transplantation team members to evaluate  the  status  of  each  p@itient  in  track
         nroc,rem and to discuss educational progress.       An the home program
         momentum and as physicians, nurses and technicians enter the cent(.,rs for
         trainin?, periods, their liro,(,,ress will l,e evaluated.   Economic factors and
         therapeutic  results  will  be  periodically  evaluated  and  comparison  made  amoni.,,
         type of  treatment.  The  Region  states  that  this  program  in  Renal  disease  is
         FL111V congruent  with  thp  Maryland  RMP's  objectives  an(]  will  be  the  framework
         for the Region-wide system of continuing education.


           Maryland RMP                       -II-                  Rm 44-01 (AR-1 CSD) 2/71

           #14 - Regional Oncology Affiliation
                                 03
           Requesting              3/l/71 - 2/28/72
           Direct Costs                $6F,905

           The nurnose of this proposal is to establish a continuing association between
           the Johns Hopkins Oncology Center and  an  increasing  number  of  Community
           Physicians and hospitals to  provide  a  clear  demonstration  of  modern  multi-
           disciplinary care of  cancer  patients  and  continuing  post-graduate  training
           in clinical oncology oriented about existing patient management problems.
           A basic goal of this Proposal is the  creation  of  an  organization  throuch
           i4hich Physicians can work together in a cooperative  way  to  improve  their
           capabilities in caring for patients with cancer.  Full-time telephone coverage
           ioill be provided so that patient problems can be  handled  as  they  arise  and
           questions can be considered while they are  fresh  in  mind  and  clinically
           pertinent.  Rapid access will be provided to ambulatory patients for compre-
           hensive diagnositic evaluation and multidisciplinary consultation.  A specific
           Panel of specialists will serve this  purpose.  If  treatment  is  require(]  and
           cannot be administered by the referring  physician,  this  will  be  provided  by
           the Center staff.
           Where required, prompt admission will be provide() for patients needing @'najor
           diagnostic and treatment procedures.
           Continuing Education is also a basic goal of this proposal.  The Johns Hopkins
           Oncology Center will provide  the  organization  and  supervision  necessary  to
           create a Productive program. The  major  emphasis  will  be  directed  toward
           clinical application. The  initial  thrust  of  the  professional  education
           proq     'll be directed  along  the  channels  of  Patient  referral.  Inquiries
              ,,ram vii
           about specific problems will be answered promptly, but later will be repeatedly
           followed up by brief newsletters or references to new developments in the
           specific area of inquiry.
           Regtjlarl!v scheduled visits to affiliated community hospitals will be marle
           for the purpose of clini.cal consultation of Tiost@raciiiate  education.  The
           Stan(-Iar(i methods of bedside teaching, presentations at staf f ro(inrlr an(] @pecia
           seminars will be employed. An  annual  two  or  three-day  oncolopy  course  will
           be provided bv th,- Center.  A fully automated comTiijter-I)aserl rpco-rel
           and communications will be Ieveloned at the  center  for  the  purposes  of:
           8) cli-niral-(,(Iitcatioiial communication; b) evaluation of current  management
           I%ractices7 c) Program evaluation; and d) program planning.

           The applicant states that it is expected that the  annual  Course  Will  IleCOM('
           largelyself-sut,porting after the first 3 years and some future support of the
           educational acznect@ of the program can be expected from the participating
           hospitals. Wnenever possible professional  fees  will  be  collected  by  the
           University from patients in the program and will  be  applied  to  the  costs  of
           the Troject.


        Maryland Rig                          -12-                     RM 44-03 (AR-1. CSD) 2/71

        #35 - Home Care Program communi@Health Center - Bon Secours Health  Center
                                    03                     V.+                     UD
        T'@eqtlested         3/l/71 - 2/28/72       3/l/72 - 2/28/73        3/l/73   -    2/28/74
        Direct Costs             $66,673                 $66,673                 $66,673
        This proposal for a Home Care Program,an activity of the Bon Secours
        Community Health Center,will be under the auspices of the Bon Secours Hospital
        Inc.
        The principal objective of the Community Health Center is to provirle the
        basis for a more efficient way of delivering health care - botn quantitatively
        and  qualitatively  to  a  Population  of  over  20,000  persons   in   West   Baltimore.
        Initially, the Community Health Center will tal,.t- care of 5,000 persons.             It
        is proposed that  the  Community  Health  Center  will.  try  to  develop  a  stron;,,  and
        @,r@r,i broad aml,ulatory an(] home care program to aim at:       a) avoiding unnecessary
        hospitalization  b)  implementing   early   hospital   discharges-,   and   c)   practicing
        Preventive  medicine  to  improve   the   community   health   standards.   Thd   Community
        health center will provide comprehensive heal.th services based on family
        iinits  and  will  try  to  coordinate  all  the  heal.th  facilities  fbi-the  area  for
        the t-enefit of the community.  It is estimated that about 33% of the nopulation
        of  the  Bon  Secours  Hospital  area  is  under  age  15,  and  approximately   11%   is
        over  age  65.  Based  on  these  figures  and  on  the  experience  of  other  home   care
        nro-rams.  it  is  estimated  that  for  a  population  of  5,000   the   Health   Center
        will  make  annroximately  80  nursing  visits  per  month   for   reasons   of   chronic
        sicl<ness,  The  community  health  nurse  will  make  about  16  of  these   visits   per
        month  in  addition  to  24  visits  per  month  for  acute   illnesses.   The   community
        airles  will  make  about  64  visits  per  month  for  reasons  of   chronic   sickness.
        The  Community  Health  Center  will  util.ize  as  much  as  possible  residents  of  tbr-
        ei-e,q for the purpose of assisting patients at home in administering medications,
        cool(ing , etc. These  Community  Health  workers  will  be  under  tl-ie  flirert  super-
        vision  of  the  Communi,ty  Health  Nurse  and  will  receive  a   short-term   training
        course for their activities.       A training program  is  currently  bein,,,  rleveloT)e(I
        for this purpose.     The  Community  Health  Center  will  also  use   the   T)rrsonn(,l
        ant' facilities of the city Health Department as much as possi.l,je to avoirl
        duplication  of  effort  and  to  economize  resources.   It   is   expected   that   the
        Center  will  have  the  part-time  services  of  the  Public  health  Nurse   who   covers
        the Bon Secours Hospital Area.

        Developmental          onent
                                  03                         04                    05
          - liestell         3/l/72 - 2/2P@/71       3/l/72  - 2/28/73       3/l/73   -   2/28/74
        Direct Costs             $1.00,000                $100,000               $100,000

        Use of D6velonmental Funds
        The  Region  intends  to  use.  the  development  funds  to  Provide  a  means  for   the
        Core  Unit  to  carry  out  its  central  function  and   responsibility   of   executing
        a l@roa(i strategy to improve the quality and distribution of health care
        services  in   the   Region. The  method  of  use  may  be  through  small   short   term
        contracts,  investigations,  date   collection   or   intensive   exploration   of   broad
        collaborative      projects. Any itnpedi(nent or obstacle to achievement of improved


             Maryland K@                                               RM 44-03 (AR-1 CSD) 2171

             regionalization, comprehensiveness, availability and accessibility of health
             services will be a fitting target in using Developmental Component ftin,-!,-;.
             An example of the use of Developmental funds might be to enable the RMP Cancer
             Committee to conduct a series Of discussions around a collaborative, -luiti-
             disciplinary effort among the several highly specialized teaching cancer
             centers and primary health care physicians in bringing expertise to -.ne@4icallv
             nee(ly,high priority population groups utilizing existing resources in the most
             efficient manner with each center relating to a defined geographical area of
             the Region.  The Central Core unit with the assistance of Developmental funds
             would attempt to serve as a catal.yst in this enterprise.

                                                                RMPS/(',RP, /1 2 /1 0/70


                                                                                                                        cation)
                                                                                         (A Privileged Coqmiuni

                                               SUi)2,iAR.Y OF Ri@:VIE@l   t.@TP CONCLUSION OF
                                                     JAI@IUAPY 1971  nEVJ@E'vT Co'rRIITTEE

                                                MARYLT@TD REGIONAL MF,,DICAL PR(RRAM
                                                      P   44-03  (AR-1-CSD)  2/71-
                                   FOR CONSIDERATIOI@T BY FEBRUARY 1971 ADVJSORY COUNCIL

                         I,v 'DKC-rON:   The Coi@iifilttee rE,-co-,i-@nanded that additional  funds not be
                   RE (,'O" U,' l@
                                           provided for this application which requests:  1)  develop-
                   mental component        funding for three years;  and 2)                      three years  support
                   for 4 new projects.
                   YEAR                                       REQUEST                               R F,, C   N IJE-1 DIFLZIDING
                   03 Year                                       $1,363,149                                     -O.-
                   04 Year                                        1,045,401                                     -0-
                         ar                                  1      062,775                                     -0-
                   05 Ye,

                                        TOTP@                     31471,325                                     -0-
                                  The reviewers noted that this Region has a history of the. lack
                                  of strong and sustained leadership.   It also pointed out that
                   the strengths of the Region have historically evolved and grown largely
                   through the stre-a-ths  that pre-existed in the two Medical Schools.   The
                   Region lacks a sl,;i.rit of cohesiveness  and, in reality,  insofar as its
                   present  coifLc,.,,iLtees  and RAG are structured,  it is  a "Baltimore" program.
                   in    its    deliberation    the    Coii-n@ittee    considered    the    May     1970     Site     Visit
                   Report and with reference to the weak Core Staff and were disappointed
                   to note that  little visible change has occtirecl since the time of the site
                   visit.   Also,  the Corif-@iittee learned that Staff in its D6cember Review of
                   the continuation application,  could find little                                     of progress or
                   improvement   on   ,,hich   to   base    a    favorable    contiiltiat@io-,It    ]:.,@lcorr,,Dendatioii.
                   Along with this,  me@7ibers of the Committee                                 that           applications
                   from   this   Region   appear   to   have    a    futuristic    tc,-,isr@.    I'@Iiiile    the    Region
                   has received PDIP support since January 1,  1967  (Plarti-iing and Operational)
                   it.is difficult         Ito determine exactly what has been accomplished over the
                   years.   A portion of this may be attributed to the rapid  turnover of
                   ProgramCoqrdinators.      (The      present      Coordinator      is       the       fifth).       There
                   was also a@;doubt raised as  to,whom these individuals owed their allegiance,
                   the Medical       Schools or the RMP.
                   Another problem noted by the Review Committee was that the collection of
                   individual projects appeared to be the results of interests of the two
                   medical schools or of individual  interes Ls rather than a concerted
                   program effort.   The projects  appear to be isolated and unr                               elated to each
                   other   and   do    not    seem    to    fit    into    any    organized    plan.    Because    of   the


          Maryland Regional Medical Program         -2-        M4 44-03  (AR-1-CSD)  2/71

          problems associated with the 1,11'@IP, the Review Committee believed that  no
          new funds should be awarded for the  support  of  new  operational  activities.
          Therefore  review of new projects was minimal.

          The reviewers were encouraged, however, to learn that the    Region has
          partially complied with one of the recommendations of the     site  visitors
          and are beginning to include more minorities, consumers, and representatives
          from outside the Baltimore area. In spite of  this  one  ray  of  hope,  the
          Committee expressed disappointment in the RAG',s failure to show their
          strength in becoming a viable group  capable  of  determining  the  overall
          goals., objectives and priorities for the Region.

          The Epidemiology and Statistical Unit at Johns Piopkins was believed to be
          a major strengt h of the Region. The  Review  Committee  believed  that  this
          group has the potential to assist the  Region  by  providing  the  necessary
          date on which to start to build a Regional program.

          In conclusion, the reviewers believed  that  from  the  information  presented,
          while the 19,MP may be a potential vehicle for the improvement of the
          Dell@ve-i.ylof Health Care Services, it is rambling around without direction
          now. On the basis of the above, the  Committee  concluded  that  the  Region
          should not be awarded additional funds for either new projects or a Develop-
          mental Component at this time  rather, it should again    be advised  of  the
          deep concerns of the Review Committee and staff  with  regard  to  its  Core
          Staff, its lack of regibnalization and most important., of a clear cut
          plan which will assist in solving some of the  health  care  needs  of  the
          Region-. Further, the Committee recommends that  staff  convey  to  the  Region
          that this action should not be considered punitive against the new
          Program Coordinator, but rather should  provide  him  with  an  opportunity
          to reconsider and develop a more  realistic-plan  for  the  organization  and
          manage.i,,ic-nt of the Region. The Cormmittee reinforced  the  recommendation
          of the 1970 site visitors that a method be found to enjoin the rather
          large staffs supported from PL@IP funds in the two Medical  Schools  under  a
          more productive, more manageable system.

          Dr. Scherlis was not present during the.deliber-ition.

                                                        RMPS/GRB  1/19/71


              0                                                              0


                                     REGIONAL    MEDICAL    PROGRAM     SERVICE
                     SUMMARY   OF   ANNIVERSARY   REVIEW   AND   AWARD    GRANT    APPLICATION

               METROPOLITAN WASHINGTON D.C.
               Regional Medical Program Service
               2007  Eye   Street,   North   West                                RM 31-04 (AR-1 CDS) 2/71
               Washington,     D.C.     20006                                    January'1971 Review Committee

               Program Coordinator: Arthur Wentz, M.D.

                                            REQUEST   (Di-rect    Cost)

               PURPOSE                       04   Yr.        0.5    Yr.     .06 Yr.           ALL
                                           3/71-2/72      3/72-2/73       3/73-2/74          YEARS
               Continuation                $1,008,728      $189,082         - 0 -           $1,197,810
                Commitment
                 (Core)                    (571,201)           (0)            (0)         (571,201)
               (4 Projects)                (437,527)       1(189,082)         (0)         (626,609)

               Renewal ComDonents            240,727            964,609   1,018,635       2,223,971
                 (Core)                       (0)          (B.-?O,Ooo)     (870,000)     (1,690,000)
               (2 Projects)                 (240,727       (144,609)       (148,635)      (533,971)

               Additional     Components     3,161,406    2,848,680       2,743,458       8,753,544
               (Developmental)              (97,067)       (110,000)       (140,000)         347,067
               (10 New Projects)           (2,172,674)      (2,259,630)  (2,278,512)     (6,7'LO,816)
                 (Core)                    (195,068)           (0)            (0)         (195,068)
               (7 Approved-Un-
                 funded Projects)          (368,302)       (245,803)       (190,796)         804,;Ol

               (1 Deferred Project)        (328,295)       (233,247)       (134.11--;O)      695,692

                      TOTAL                $4,410,861     $4,002,371     $3,762,093        $12,175,325
               Staff Action on  - No final determination was             made  on   the continuation
               Commitment                rec"uest. It was the Acting     Directors decision
                              to defer all requests to the site          visit team for consideration. A
                        copy of Staff's review of the continuation component is attached to
                        this summary.
               Committee    Action
               Required                    $3,402,133     $3,813,289     $3,762,093        $10,977,515

                                                  FUI,MI'ING    HISTORY
                                                (Planning Stage)
                      Grant Year                     Period              Funded (d.c.)
                          01                 1/i/67-2/28/68               $188,000
                                             (Operational        Stage)                               Future
               Grant    Year            Period         Council      Approved         Funded          CommitT-,ent
                    01             3/l/68-2/28/69                7                  $592,148
                    02             3/l/69-2/28/;O                -                 $1,400,416
                    03             3/l/70-2/28/71         $1,883,320               $1,489,772        S'L,008,72--@


                                                                               KM JL-U4 (AR-1 CDS) 2/71
                                         REQUEST   -    BREAKOUT    BY    COMPMM  Jan. 1971 Review Comittee

      Continuation      Commitment                           04                       05       All Years
                                             04   Year     Committed'  05   Year   Committed  Request
      CORE                                   571,201       571.1201    --------    --------      571,201
      #lR    -FrecdT[ialis  Hospital         203,677       203,677        39,510     29,850      243,187
             Stroke Station
      #19    -Reaional Cancer Registry          40,000     40,000      --------    -------        40,000
      #20    -Peripheral- Vascular
             Facility                           501000     50,000      --------    --------       50,000
      #25    -Cancer Radiotherapy Unit
             Education, Consultation
             Service                         143  850-     14@3 85Q    149,5Z2     149,572      '293,422
                              TOTAL          1,008,728    1,008,728    189,082     179,442  1,197,810
      Renc@qal Request                                                             All   Years
                                             04    Year    05  Year    06   Year     Request
      CORE                                                 820,000     870,000     1,690,000
      #2R    Cerebrovascul.ar  Disease  9/  lliO,  727     144,609     148,635       433,971
             Follo@q-up & Surveillance
             System
      #12R   @lobil.e Coronary Care          100,000       -------                   100,000
             Unit                                  727     64,CC@    I-,O-l-8,635    2,223,971
      Additi nal  Co    ne@s

      CORE                                   195,068                                 195,068
      #17 -  Heal.th Careers  Council@l      35,200        '53,825     55,368        144,393
      -#'@9- Cancer Registry-z/              29,445        -------     -------          29,445
      20  -  Peripheral Vascular  3/
             Facility                        43,608        -------                      43,608
      #23 -  School of Inhalation-4/         86,490        ------- -   ---------        86,490
      #26 -  Community Hospital Stroke
             Program 5/                      80,611.       91,000      86,000        257,611.
      #28 -  Coronary  Care   Nurse
             Trainiii g 6/                   54,471-       55,860                    11,0,331.
      #31 -  Area flen-.odialysis 7/         3'28,295      233,247     134,1.50      695,692
             Training Program
      #37 -  Earl.y Detection of@'/          38,477        45,118      49,428        133,023
             Chronic    Obstructive
             Pulnionaary   Disease
      #39 -  Exercise Stress Training
             Referral. Serv--ces             77,724        72,120      74,827        224,671
      #40 -  Pediatric   Pulnionary
             Program                         200,205       230,845     285,31@O   716,360


                 METRO           DC                                                        3                                     RM  31-04  (AR-1  CDS)  2/71.
                                                                                                                                 January  1971  Review  Comittee

      #41.    -  Physicians  Assistants
                 Program                                              3.72,71.7            240,,959               246,1,05            659,7PI,
      il42    -  Hypertension  Clinics  in
                 Economically  Depressed
                 Areas                                                185,181              174,1@54               178,982             538,317
      #-43    -  Cervical.          Cancer           De-
                 tection                                              150,000              125,000                125,-OOO            400,000
      #44     -  Interstitial                     Cancer
                 Therapy                                              174,400                       78,449                58,691      311,540
      #45     -  flome-based  Care  of
                 Chronic                     Obstructive
                 Lung  Disepse                                                42,720                53,650                58,880      155,250
      #46     -  Mobile  Dialysis  Center                                     39,527                18,668                19,443              77,638
      #47     -  Regional                     Nephrology              718,867              586,945                617,107                    1,922,919
      1/48    -  Nurse@Midwife,  Maternity
                 Nurse  Clinician  Program                            411,333              678,840                614,3@67                   1,704,340
                 DEVELOPMENTAL                                         97        067       110,000                4@tkQO                347        067
                                                                          1
                                                   TOTAL                   3,161,406      2,848,680                    2,743,458             8,753,544
                                  GRAND            TOTAL                   4,410,861     4,002,371                     3,762,093            12,175,325

                                                                PREVIOUSLY  REVI@,VED  PRO.JECTS
      0

      L/Project         7'r'17    - Approved          with          no          funds          recommended
      :?/Project        #19       - Approved         and         funded         -         but         requests         supplemental          support
      @/Project         #20       - Approved         and         funded         -         but         requests         supplemental          support
      @/Projc,ct        1'r'23    - Approved-funded  first  and  second  years  with  carryover
      5/Prbject         i"'26     - Approved         -         but          unfunded
      S/Project         7',@28    - Approved-funded  first  year  with  carryover
      @/Project         i'r'31    - Deferred  pending  further  study  of  supporting  such  renal  projects
      @/Project         #37       - Approved  -  but  present  request  exceeds  02  and  03  years  approved  level
                                    02  Year:                   $40,618                     03          Year:           $Z@4,928
      )/T,Iroject       YA2R      - Deferred           for        site         visit


                     ii Lo
                                                                                                                                January  1971  Reviev Committes

                               Tli('                                                                                                 Ilrograii         is                          o---
                                                                   of  Col-tiliil@lia
                                                 OtTle                             e'                  c
                                        on t:          r     Lill(I                         o t          oLinti.t-s     'of     ',,,')Iylaril
                                      Arlin@,,t-.on  and  Fiirfix                                           of         Vi)@-ginia
                                      The     (:!.ty     of     /,!(!/,@indri.a,      Vir@rin,.La
                               Tli(-,                                (.his       1),c,gLo-ii    i,,as  "i-itlltleiicccl              1) r i m,.t)- i I. y 'l-,'y@,    ,Thai      1 C!
                                                                                                            I c      F@ t-- ni
                                      ,-)i tal     11    I
                               110 'Ii
                               on  tlje.  T[l,,@))  On        t. 11 (2  II,(,.            (2         PrC)jLC'i,t@4(i                                 J,1170@t@ll,     T)t t             I
                               distril)tltjon  ,ii)d  m(.!dlcil-                                                                                       aj     so  i r- f I      I t
                               i3-L

                               I                                                                                                           the  Pi@-iii(,c          C-. c-- o       s       i
                               CC,I,nty                                                              d 'ai.)  i.-niti.nl.                          Lb                                        t II
                                                                                          Prc)@riT,.i..
                                                                          in    tll(.-     J)istr-ict-        of,                        1-11;111.;in
                                              Cc@cjri,,(--     @i      (,OilTi@Y7                    to                    @@Lii
                                            A17. t7 li C! @ S @IT;ICI  I-  il-,iC! '@I.L             and      is  till(!(@l7@t 0              1)@,  a) 1,       "tliit
                                                                                          p  I:r-jciplt(.
                                                                                 r  m     wi ti) i @i@- tli (? j.  r
                               as                ,ir,  :Lri:  V.Fie  I)rc)p,  i

                               The                        @ociet-y            of   tli(,t       T)i.strict        of                                                L,:
                               oi-ganj.ziitioii.                 'I'llis     (I(...,Cj.sioIl     i,,,as      base(i    on  ti   I   C-   1 @3 C Li F: L; (,II   S 1)
                               wif,:Ii                                           of              of     the      t-.I)r(?c-
                                                                                                                           T
                               CCC,17J,C                                @trid                        the, 1).(.    ).calti)                                       aii(I
                               iii(@nibc,r,-        of        the        medical        Soci-ety.


                                                         5
          METRO D C                                                       RN 31-04 (AR-1 CDS) 2/71
                                                                          January 1971 Review Committei

                                                                 1)  c

                         FAI

                                                 I T
                                           @@yp@   A

                                                      Jr

                      1,11@'TROIIOI,T]'AN'


                                                                                         January 1971 Review Committed

                        I,and    Arci    -    ]-,483

                        District    of     Col.iiifjl)ia           61                  Alexandria City,  Va.             15
                        @lorLtE,on)c@ry Co., Md.               493 iiii.1c@t,          Arlini,,t-.on     Co.
                                   G(---orpe's Co., 14(l.         485                  Falls  (:Iitirch  Cit,,)          24
                                                                                       Fairfax City                    405
                                                                                       Fairfax Co.

                        Iloptil.zition:      (in  thousands)                           1960

                        Total                                                          2001

                        Dist.i.-ict    of     Col.untbia                                 764
                        l,lon,t@rt)jiio-ry    County   )                                 341
                        Prince                   Co.)    Md.                             357
                        Alc,>-,,iiidri.,i     (city)                                        91
                        ArljitE,,to,-i Co.,  Va.                                         163
                        Fall,,  (;Iilircli  City,    Va.                                    10
                        Fairfax      Co.,      Va.                                       275

                        Percent U):I-)an:        I.,Tnf,,Iiingtoii,   ]).C.
                                                 Alexandria,  Va.
                                                 Falls  C,,iurch,  Va.                       iooz,
                                                 Fairfax      Co.,      Va.                  7 8/,
                                                 Ifoiitgoitir--ry CC). , Md.                 8 6/@
                                                 Prince  CLoroe's Co., Md.                   83-/,

                        Ap,e o      o tiLitioi-i:  (1960)
                                                                        Maryland                                       Virginirt
                        Median        U.S.         D.C.         Mont.  Co.            Pri-ncc-          Al  c!x.    Arl.       ],-aii- f ax.
                        Age           29.5         32.2             28.1               25.2             28.0        30.8         2zi. 5

                                                                   I\Iumber                             PC-,],Ccllt
                                                           (in thousands)

                            Total                                   12                                     6.2
                            65    yrs.    of     age
                              and over
                                 D.C.                               7                                      9.1
                                 Mont.     Co.     &
                                   Pr.  Gco.  Co.                   3                                      4.4
                                 *Vii-,,),i.nia                     2                                      4.1
                            *Represents Alex.,  Arl.,               Co.   &   I.,airfa@:   Co.


                                METRO DC                                                                                                                    7                                                   RM 31-04  (AR-1 CDS)  2/71
                                                                                                                                                                                                                January 1971 Review Committee

                                                      Tot,al                                                                          498                                   25.2
                                                             C.                                                                       419                                   ')4.8
                                                      l,'@ont,            C(".                                                           13                                    3.9
                                                                                              Co.
                                                                                                                                          32                                   9.1.

                                                                                                                                             9                                 5.6
                                                                                                                                                                               5.4

                                                          @l(,,7,  (,7'/  of poj)ii                                     L   (-)-ii ()j'-        1).                                                                                                              oi'-

                                                           1  1-1    I   tj  I i -i                                                       271.,(@)0,0                                           111-@)(I                               01                                         el

                                                                                                                        i  c:     1,   S cl      C) o I                                     Eii       o I I i ii, t ii      i   li
                                                                                                                                                              (I            cl I .              II        1. I @l! if@! i-j      'i@  0
                                                                          G    o r,,     e                                          tjlliv.
                                                                                                                                                                                                                                    8

                                                                                                7                                   3                                                   Y
                                                                          led.  -           I w 11)                     i         c o         c@           @,i i'.             @'L      c@ (@l
                                                                          Tot-zil.          Are 'I                    II.
                                                                                                                        4
                                                                                                                      3

                                                                          1).C.                 @i    of                             2

                                                          Otli(:r                               of
                                                                          Cy       o      c@(@iiiio       I        op,.@,         J)    C.        I    ,)Ii i (@l i    i s    tlnj.v(t 17@; -1.1-y    af.fi. I

                                                            i  tiA I @, :
                                                                                                                                                                      II o n - I @'e (I (, r @ i I                                                          'i,ot, I 1.
                                                                          S h C) -r                 J,O)-I""                                                    S  I  I  o  r             l,o3i'@-,
                                                                                                                                                                                                                                                            No ii -

                                               1)     C.
                                               @l@l                              2                  1                             3                                   8                         3                    1      1
                                               V"A                                                                                                                    @4                        -                           4                                                 5
                                               11,   C)  Li                                                                                                        23                           5                          28


                                                                January 1971 Review Columittee
          PROGRAM HISTORY AND DE-VELO @,\T
            The Regionts first year of planning was a 14 month period 1/l/67-2/28/68
            and was supported at $188,000 (d.c.).

            In February 1968 a pre-operational site visit was conducted to the
            Region.  The site visit tean consisted of George Miller, M.D.; Leonidas
            Berry, M.D.; Mieczyslaw Preszcynski, M.D.; Martha Phillips, RMPS Staff;
            Patricia McDonald, RNPS Staff and Dr. Thomas Bodenheimer       '@S     Staff.
            The site  visitors  were  impressed  with  the  wide  range  of  individuals,
            groups and practicing physicians that appeared to be actively interested
            in the  program  and  who  attended  and  participated  in  the  opening
            session ot the visit.     The D.C. Medical Society appeared to be
            coffimitted- to regional systems.   Representation  of   Allied   Health
            groups and nursing groups  on  the  RAG  was  lacking  and  it  was  noted
            the Region had difficulty getting individuals who are not in
            medically-related fields to participate in the program.         The   site
            visitors commended the active involvement of the RAG and the extensive
            guidance and review it has given to the development of the program.
            It was felt the Region was aware of the.need to cooperate with adjacent
            Maryland and Virginia R@Ts.      Concern  was  expressed   @hat'plan'ning
            was  being  done  for  individual  projects  without  interaction   among
            them.   It was noted, ho@,:ever, that this was probably due to insufficient
            staff to provide the necessary coordination.        Although    organized
            planning for the Region, local priority setting, and identification
            of regional strengths an---'  needs  had  not  been  yet  approached,the
            site visitors  concluded  tle  D.C.  program  was  moving  in  the  direction
            of truly  regional  coordination  and  that  it  would  continue  to  be
            strengthened by the time t-e program was reviewed at the close         of
                                        The site visitor
            the first grant period.                       s  endorsed  the   readiness
            of the Region  to  move  into  the  operational  phase  of  the  program.

            Committee and Council co.-c-,:rred with the site visitors recommendation
            and the  Region  was  awarded  $241,642  (d.c.)  for  planning  and  $350,506
            (d.c.) for support of three operational projects, both for the period
            3/l/68-2/28/69.

            On September 1, 1968 A@-t'iiur 14entz, @NI.D.  replaced  Thomas  Mattingly
                                        7
                                         L-                                     -year
            as Program Coordinator        i February 1969 Staff reviewed 02
            continuation application.     It was noted  that  some  stage  in  the  local
            management process caused    an unexplained delay in notifying project
            directors that they cou'Ld   start their projects.     In addition other
            severe administrative difficulties were evident from some questionable
            handling of other fiscal- aspects of the program. It was also recommended,
            in addition to  staff's  --@-co-,mendation  to  continue  support,  that
            appropriate staff  visit  -.-e  Region  to  review  its  procedures  for
            program administration.

            On March 6, 1969,Grants Management     Personnel  of  It'@S  visited  the
            Region and succeeded  in  resolving  many  of  the  fiscal.  and  policy
            problems which were noted in the February Staff Review.


                Metro  D.C.                         9              RM 31-04 (AR-1 CDS) 2/71
                                                                   January 1971 Reviev Committee

                During the 02 year of operational status, 3/l/69-2/28/70 the Region
                was awarded a total  of  $1,400,416 (d.c.), of this,  $554,908  (d.c.)
                supported Core and $845,508 (d.c.) supported nine operational projects.
                As a result of concerns expressed by Committee and Council, regarding
                supplemental  applications,  during the August 1969 review cycle,
                a site visit was conducted  to  the Region in October 1969.  The
                site visit team consisted  of  John Thompson, Chairman; Russell Roth, M.D.;
                Victor Vertes, M.D.; William DeMaria, M.D.; Walter Hangen, RNPS staff, and
                Michael Posta, RMPS staff.  The visitors observed that the
                Washingtoq program had not as yet achieved any  real  statement  of
                goals and 'objectives, and consequently was unable to set priorities
                in any ki'nd of rational fashion. They found it  difficult  to  judge
                the projects in light of the overall problems of the  Region  or  the
                projected program of the Region.  The only way tt@le goals (which
                were really"areas of concern) were used, was to classify the individual
                projects as they were submitted into one grouping or another.  Concern
                was expressed with regard to the separate  organization  of  a  post-
                graduate medical "faculty" within Core and outside the formal
                university setting. This activity was  actually  being  carried  on
                under the Hospital Council and there was no  indication  of  how  the
                educational effort of the projects would relate to the organization
                or center. The team concluded the D.C.  RMP  was  moving  slowly  and
                continued to have ver  real problems in establishing its own identity.
                                      y
                It was felt,however, the reorganization and  formalization  of  the
                RAG will assist them to do better planning.
                In February 1970 Staff reviewed the  Region's  continuation  for  the
                03 operational year (3/l/70-2/28/71).  Staff agreed the application
                was the best yet submitted by the Region and that it seemed to reflect
                the leadership provided by the coordinator and his struggle to accept
                advice from RMPS and outside sources.  The  following  issues  were
                raised and the Region was asked to respond to them.
                      1.  A plan of action for coordinative RMP planning and operations
                          with health programs for inner-city populations, including
                          model city, comprehensive health planning, health department
                          and OEO programs.
                      2.  A plan of action for increased  involvement  of  inner-city
                          representation in RMP planning.
                      3.  An outline of procedures and time schedule of RMP priority
                          committee.

                      4.  A substantive description of activities of Continuing Education
                          Staff working with the Hospital. Council, including a list
                          of hospitals for whom DME support is provided and the basis
                          for support.
                      5. A plan of action for approach  to  overall  health  manpower
                          planning.


                                                                  L%r& -)L-Vl+ kAn-.L %,UO) ZI/L
           Metro D.C.                                             January 1971 Review Committe4

           In May 1970 the Region responded to the questions posed to them.  In
           its review Staff observed that this Region has not made a
           significant contribution to planning for inner-city.  With the
           exception of a number of funded RMP projects, few  examples  of  specific
           achievements or plans could be cited.  Although  the  Associate  Coordin-
           ators at the universities were apparently charged 'with the responsibility
           of cooperative planning, they saw their role as being more " involved
           in the structuring of projects which reflect  the  institution's  concept
           of their appropriate role in RMP activities"; a philosophy  which  is
           more consistent with the type of program that has evolved  from  this
           Region.  T.he Region also cited as evidence of inner-city involvement
           and cooperative planning, the fact that twelve agencies which theoretically
           represented the inner-city were represented on the RAG.  Staff
           questioned the degree to which these representatives were active
           participants, noti-.ig none served on RAG sub-committees.

           This review re-emphasized a second concern which various  numbers  of
           staff had harbored for quite sometime, namely the  almost  complete
           separation of the Center for Continuing Education with  the  Hospital
           Council from Core staff activities and management.  It  was  noted-
           the Center's activities closely coincided with those of  the  Council
           in that they were hospital-oriented and for the most  part  catered
           to short-term needs, with little thought of cooperative planning
           on a long"ter-m basis with various kinds of education  institutions
           at all levels. This observation was borne out  by  many  activities
           and in particular the manpower surveys reported by the  Region  which
           focused just on employment needs of hospitals.  Another concern
           of Staff was the fact that there was evidence the Center was instituting
           educational programs which were not only of questionable value, but also
           served to undermine established programs.

           In view of the concerns expressed regarding both the  planning  for
           the inner-city and the course pursued by the  continuing  education
           center, it was agreed some kind of strategy to help the Region change
           these aspects must be employed by Staff before the  Region  submits
           an application for Anniversary Review.

           The Regionlas a result of RMPS Staff's efforts to  assist,  has'taken
           steps to re-organize Core so as to strengthen the continuing education
           aspect of the progra,-,i.  Attempts to improve the staff concerns about
           the inne-r-city have resulted in the formulation of the Health Care
           Delivery Planning Committee which serves as a horizontal  group  composed
           primarily of Blacks who have specifically dealt with the immediate
           health needs of the disadvantaged in the center-city.  Further,
           attempts to improve the organizational structure have  resulted  in
           the proposed Office of Program Planning, Office of  Community  Health
           and Program Activities and the Office of Program Appraisal.


            Metro.    D.C.                                         r@,T@t 31,-04 (AR-1-CSD) 2/71

                                                      ION

              CORE  STAI'F

                  total amount requ sted for       fir@t year of the triennium
              The                   c                 I
              beginning March 1, 1971 for           of Cc)r@., activities is  $766,269.
              This total represents a  continuation  req,,ie@@t  for  $571,201  committed
              support and  a  supplemental  request  for  $195,068  of  additional  funds
              which would provide su-port for 10 new professional. positions to Core
              staff.

              In addition to this first 7)7e r          the Region is also requesting
              renewal of Core for the          f,"?'@1)20,000) and third ($870,000) years of
              the Triennium.

              The 10 new positions being requested would raise from thirty t@ forty
              the total number of Cor@--@ Stzq.,!'f positions,  Of the present 30 positions
              allocated to Core, 24 arc-,,

              STRATEGY AND GOTI,S

              The Region's overall pro,@E,Iram objective ]@s "'co           on increasing
              the Region's capability f@,@r @jc,ovi(iing outpatient, and preventive health
              and medical care services in liecirt-         cancer, stroke, kidney
              disease and related disease to all. the citizens of the ReE,,ion."

              Each categorical planning ti-@,tmiiittee hills certain identified areas  of
              emphasis:

                1.  Heart Disease Plinaing Committee:

                    a.  Program emphasis should be directed toi,,ai-d keeping private
                        physicians          of developments in the cardiopulmonary area.

                    b. Out-of-hospit,,! progrE@.i,,i,,, for the patient aimed at  primary
                        and second,,iri;, prevention through early recognition and
                                     I
                        improved diagnosis should be supported.

                2.  Cancer Planning Cr,@,@,itL:ee:

                    a.  Start activities in fields of public information,
                        patient ediicati.or-@ Hand prc)fcss,(.c)n 1, I:ral.ning.

                    b.  Promote early screenir.@g and detection procrams
                                                                    r@
                        for those tumor sites which lend themselves to
                        this approach.

                3.  Stroke Planning C,o-r,,uittee:

                    a.  Institute a placement center to assist patients
                        and physicians in locating e@cterded. care, ambulatory
                        and rehabilitative services.


                                                                RM 31-04 (AR-CDS) Zfll
    METRO DC
                                                                January 1971 Review Comittee
                                           SOCIETY OF THE
                                   MEDICAL
                                    DISTRICT- OF-COLUMBIA

                                    POLICY AND STEERIFIG
                                       ..-CotlniTTFF
                                   PLROGRAM COORDINATOR

         MEDICAL DAT
     intelligence oi  egion's                       xpressions of Need..
     Health Car

                                                      ANNING COM

                                    Assessi           ds

                 PR[  ORITIES
                 COMMITTEE
              Areas of Emphasis
                                      PROGRA@ GOALS
                                            f
                                   Criteria  or Activities

                                       EGIONAL
                                       DVISORY
                                       R(IIIP
                                             Evaluation of Goals
                                                 erms of Region's Needs

                                                 als Do Not Meet Needs
               Goals, Meet Needs      Goals Partially
                                      Meet Needs

           REGIONAL  MEDICAL
           PROGRAMS  SERVICE

             Federal  Review


       METRO  DC                               12                 RM 31-04 (AR-1-CDS) 2/71
                                                                  January 1971 Review Comittee

                   b.  Establish consultative services based on cooperative
                       relationships among local institutions to upgrade
                       the quality of stroke care in hospitals and extended
                       care facilities of the region.

               4.  Renal Disease Planning Committee:

                   a.  Coordinate dialysis facilities within the Region
                       to evaluate the capacity of the coordinated facility
                       in delivering this therapeutic modality.

                   b.  Develop financial coordination to provide permanent
                       funding for services through third party carriers
                       and publJ.c assistance.

               5.  Other Major Diseases Planning Committee:
                   A.  Improve diagnostic and screening centers which would provide
                       broad support for comm6nity health act v t es.

                   b,  Develop a lead poisoning control prog-.c,,3m.

               6.  Education and Training Planning Comm).tte@,,,

                   a.  Coordinate existing educational pyopr,-ms.

                   b.  Improve efficiency and effectiveness of in-service
                       education and training.

               7.  Health Care Delivery Planning Committee:

                   a.  Make effective use of existing and acquired facilities, funds
                       and personnel.,
                   b.  Design programs to improve quality of tteal.tq cL@re delivery
                       in the Region.


                                                                                                                                      0.

                                                                    HE14, Ptl-,, li@',-P.SA                                                    0
                                                          Regional Medical Programs Service                              0                     C9

                                                                                                                          >

                                                                                                                          N
                                                               Medical SOC4ety o' the
                                                                                    L
                                                                T)istrict of Columbia
                    Regional    Advisory
                             Group
                                                                Policy and    Steerin
                                                                       Committee

                      Plann
                  Pr4-oritv   Com-mi@tee
                            ing,   and
                                        S
                                                              ,%ft.@'14P Program Coordinator
                       Admini-s@ra t4   ve                   Deputy Program Coordinator                           Coordinators @'or
                           an
                                                                                                           Categorical Disease -Irozra7,s
                           F4,scal

                                                                                                       Assoc. Coord'Lnators for
                       Co=un-'@cat4ons                                                                 I.'Jtl-L. Depts. and LiosT)ital Co@-'!C"@
                           and
                  Piibl4.c  information
                                                                                                                             'Ith
                                                                                                             Olfce of Hea
                                                                                                             Development:
                                                                                                          Continuing Educ. foi@ P'.ivsic-'-ans
               Office c.
                                                                        Office of                           Conti uin- Educ. for
               Program                           e ot
                                           Of -ILic                                                               n
                                           conmullitv                   Program
               Planning                                                                                    Allied Hlth. Educ. & Tri@'
                                           Healtl,i ane                 Appraisal
                                                                                                            !'o;7ereiice Resotii-ce
                                      Progri-q Act'     4 es

                                                                                  Policv

                                                                                                                                          0


      KETRU Du                                - L-V -                           %---- ---, -, @ -
                                            .REVIEW OF ACTIVITIES     jasuary 1971 Review Committe

                                                      STATED
                                                PROGRAM  G0ALS

                HEALTH
              COMMUNITY
                                               STATED CRITERIA
   )Iicited             Unsolicited             FOR ACTIVITIES
   roposals             Proposals

               PROGRAM
             COORDINAT

                CORE                                                                     NNING
                 STAFF                                                                  IAMITTEES
                                                  GUIDELINES
                 A
                                                       I I
                                           EVALUATION, OF PROJECT,

                                Rejection                           Meets Goals
                                as not  meeting  the                Fulfills Criteria
                                RAG Program

                                                TECHNICAL
                                                ASSISTANCE
                                                COMMIITEE
                                               Te hnical Review
                                                                        li Technically Adequate
                                Needs
                                Technical
                                Revision                          PRIORITIES    COMMITTEE

                                                                Ordering       ctivities in Terms c
                                                                Goals, Criteria & Funding

                                                                     TOTAL PROGRAM

                   00
                                                              IREGIONAL  ADVISORY   GROUP

                                                                REVIEW 0  TOTAL   PROGRAM
      Difference    of       Not Financially       Program
      Opinion   with         Feasible              Does Not
      Committee   on                               Meet Goals        Program  goals  met,
      Recoiiimc.nded                                                 Priorities Approved,
      Priorities                                                     Pro  am Financially Feasible

                                                                    REGIONAL MEDICAL
                                                                    PROGRAMS SERVICE


                                                 - 15 -
              Metropolitan D.C.                                       Rm 31-04 (AR-1-CSD) 2/71
                                                                               1971 Review Comittee
              RF,NF,WAT, PROJECTS
              Core:  As c't@-@-d under the previous section on Core                 '@@,-@q@-sted
                     the Region is requesting $571,20i committed. stip-,)ort        First Year
              and $195,068 supplemental support for the first triennium             $820,000
              year.  It is also requesting renewal support in the f6rm of
              a commitment, for the se,:@ond and third triennium years.  The
              purpose is to have Core and project suppo@-t  in  phase,  at  least  for  the
              most part.

                        Second Year - $870,000
              @ro@ct il,2R                   Disease Follow-tip aiicl Si.irveillan  e@yAtem
                            This renewal   request has previously   submitted      Requested
              to the Noiember 1970 rev4LLw cycle.  Comraittee ard   Council        First Year
              returned it for the upcoiLing site vi.,-iL.                           "el4O,727
              Request is made for 36  months  additional  support  for  this  project
              sponsored by Georgetown University.  The    project  was  initiated  in  1968
              to acquire information on stroke occurrences in the Washington Region
              which can be used to pro-vide better care for the stroke patient, planning
              for needed facilities (bads, rehabilitation centers) and eiientiially
              control and prevention o'Ll stroke.  The goals of the project are:

                   1. To maint.@,in a continuing renort@L@.-ig system for  evaluating
              medical@ care for str,olr6 patients in the Region ane,, to provide a means
              for measuring the effectiveness of the Regional Metiical Program.  The
              reporting system will provide co@@unity-wide ii-iformation on stroke
              incidence,,  surviia).,  rehabilitation,  geographic  distribution,  hospital
              stay, demogranhy and epidemiology.
                   2.  To provide a source of information for carrying out epidemiologic
              or demographic studies by providing a basic patient population upon which
              special studies could be, based.  These studies will. provide the information
              necessary for control and prevention.
              Information on strok(@ patients is to be                  hospital   records,
              private physicians and offer pertinent sources.  hT',,uring the initial two
              years of operation,  the  Stroke  Surveillance  System  has  established  the
              basis for a Regional reporting system by concluding cooperative arrange-
              ments with 29 hospitals in tile Region.  The Sys@'.-em will attempt to expand
              to all hospitals through the local Medicz,,l Societies.  Other information
              sources are also Laing @.,xplorod.  Successful implementation of this
              program on a continuing basis will provide information an the extent of
              the stroke problem in the area as well ag a mechanism for evaluating
              the Regional Medical  Program  stroke  program.  A  counkrehen,sive  progress
              report is provided on the project's activities and success to date.
                 Second Year - $144,609                Third Year - $148,635


                                                               January 1971 Reviev Co@i
          Metropolitan D.C.                                   RM 31-04 (AR-1-CSD) 2/71
          Proiect #12R - Mobile Coronary Care Unit  Renewed support       Requested
                         for one year is being requested for the          First Year
          Mobile Coronary Care Unit in Montgomery County.  The            $100,000
          purpose of the unit is to demonstrate that mortality from
          heart attacks can be reduced if the patient received care  during  the
          crucial period immediately following the attack.
          The mobile van, or heartmobile, provides the same services an
          equipment that can be obtained in a hospital coronary  care  unit.  An
          important feature of the project is that it is staffed by paramedical
          personnel.  A volunteer physician communicates with the team via a
          telemetry system.
          Preliminary evaluation as of July 14, 1970, shows that 59  percent  of
          the total number of patients transported by the van were  admitted  to
          coronary or intensive care units   More extensive evaluation is being
          conducted in conjunction with the Department of Health, Education, and
          Welfare, Fed6ral Heart Disease Control Program.


       METRO DC                                  17             RM 31-04 (AR-1 CDS) 2/71
                                                                January 1971 Review Comittee

             PREVIOUSLY REVIEWED PROJECTS FOR WHICH SUPPORT IS,,BEING RE2UESTED

             Project #17 - Health Careers Council

                           Approved with no funds recommended.
                      01- $35,200         02 - $53,825        03 - $55,368

             Project #19 - Cancer Registry

                           Approved and funded, has committed support of $40,000
                           for upcoming year.  Request supplemental support of $28,445

             Project #20 - Peripheral Vascular  ,cilit

                           Approved and funded, has committed support of $50,000
                           for upcoming year.  Request supplemental support of $43,608

             Project #23 - School of  Inhalation  Therapy

                           Approved and funded first and second years with carryover funds
                           Request - Third year support at $86,490

             Project #26 - Community Hospital Stroke Program

                           Approved and unfunded

                 Request 01 - $80,611    02 - $91,600    03 - $86,000

             Project #28 - Coronary Care  Nurse  Training

                           Approved and funded first year with carryover

                 Request  02 - $54,471     03 - $55,860

             Project #31 - Area Hemodialysis Trainin& Program

                           Deferred pending further study of supporting such
                           renal projects

                 Request  01 - $328,295   02  -  $233,247   03 - $134,150

             Project #37 - Early Detection of Chronic Obstructive Pulmonary Disease

                           Approved and unfunded.
                 Request   01 - $38,477    02  -  $45,118  03 - $49,428
                           (Second and third year request exceeds approved level
                             of $40,618 and $44,928)


                                                              January 1971 Review Comittee

           NEW OPERATIONAL PROJECTS                                    Requested
                                                                       First Year
           Project #39 - Regional Exercise Stress Testing              $77,724
                         Referral Services. This project sponsored
           by George Washington University proposes the  establishment of
           exercise stress units in three hospitals or clinics.  The objectives
           are to evaluate coronary disease status and support multifactoral
           approaches to coronary risk reduction and post-myocardial infarction
           rehabilitation. The units will be located so  as  to  provide
           equitable availability to all citizens. After  one  year  the
           equipment will be moved to other sites to start similar activities.
           Referrals will be made by physicians and patients will be
           returned to the referring physician for  followup.  The  stress
           test will be a multi-stage, progressive submaximal test  to
           the "Target Heart Rates" recommended by the Scandinavian Committee
           on Exercise Electrocardiography.

           Tests will be conducted by highly competent  personnel  who
           will educate others to assume the continuing operation  of  the
           programs at each site. Evaluation will  cover  the  attitudes
           of both physicians and subject patients at or just  after  the
           testing, and what influence the results had on  living  habits
           and coronary risk factors in follow-up studies.

           The project relates to the program goals in that it  emphasizes
           disease prevention.

           Second Year: $72,120                    Third  Year:  $74,827

                                                                        Requested
           Project #40 - Metropolitan Washington Pediatric Pulmonary    First Year
                         Program. This project sponsored  by  Georgetown $200,205
           University Hospital has as its major goal,  improved  standards
           of care for children suffering with chronic asthma,  cystic
           fibrosis and other severe respiratory  illnesses.  Under  this
           plan, the outreach work benefit 92% of all children in the Washington
           Area. This proposal would:

                1) Maintain the organizational framework of the  Pediatric
                   Centers now operating so that the evaluation  of  this
                   initial effort can be completed.

                2) Maintain the current computer based pulmonary  registry
                   for in-house patients. Modify  the  current  automated
                   system to include pulmonary outpatient data  from  the
                   three university Pediatrics Hospitals Programs (Georgetown,
                   George Washington and Howard).

                3) In the second year, establish a specialized  outpatient
                   clinic for children with pulmonary disease at Providence
                   Hospital which would serve as a model for the implementa-
                   tion of similar facilities on a regional basis.


         )MO DC                                 19             RM 31-04 (AR-1 CDS) 2/71
                                                               January 1971 Review Comittee

                   4) Extend the             based pediatrics p@@.-og.,rams to other
                       affiliaLE--.,-! tioi,i-jl@.tals such as D.C. Genei-, @,,@)spital and
                       Fairfax Hospital in the third year.
                   5)  Continue training programs at the undergraduate, graduate
                       and fellowship levels in order to meet the critical shortage
                       of trained physician in the area of Pulmonary diseases.
                   6)  Numerous ol@@portuni.ties for paramedical and allied medical
                       training of personnel could be provided.
               Second Year:  $230,845                    Third Year:  $285,310
               Project #41 - Tra           am: Cardiovascular 'technicians and    Requested
                             Physicians Assistants.  This project sponsored       First Year
               by the Washington Hospital Center is a revised version  of  the     $172,717
               ongoing project ik3 - TraininR for Cardiovascular  Technicians,
               which will terminate at the end of the current year.  It proposes
               the:
                    1) Continuation of the Cardiovascu!-ar Technicians Training Program
                       in its present form to teach two 18-weel.@ classes a year.
                    2) Introduction of an extension of the above one-yea-r- program in
                       order to produce a more highly trai.@ied individual capable of
                       increased responsibility in the cardiovascular field.  On
                       graduation he receives a certificate representing one year of
                       college work, approximately 28 credits.  This "advanced program"
                       is planned in conjunction with i,ic)ntgc)m(-,ry College.
                    3) Introduction of an associate degrce @)rogra-in in conjunction
                       with Montgomery College to train iTioro. bro@-.-Adly based pliysi.cian's
                       assistants.  This program will be ericei--@ed Directly by a candi-
                       date who elects to do so.  Candidates who have completed the
                       basic and/or advanced Cardiovascular Technicians Training
                       Program will be able to apply credits obtained in those programs
                       to their associate degree.
               Second Year:  $240,959                        Third Year:  $246,105
                                                                                 Requested
               Project #42 - Establ ishm -,i : of Seic-c.Le(i -@l, -Ie,:te-,".ISlon Clinics First Year
                              in Fcotioipica       ssc@d Areas, This project      $185,181
               sponsored by the Hospital and Medical  Care  Administration  of
               the Department of Humane Resources is designed to improve health
               care of patients with hypertension within the Region by establishing
               a reference and control center tying together five clinics.  The
               District of Columbia General Hospital, WastiingiLon Hospital Center,
               The Anacostia Neighborhood Clinic, Freednians Hospital and Columbia
               Hospital for Women.


       MTRO DC                                  - 20 -         RM 31-04 (AR-1 CDS) 2/71
                                                               January 1971 Review Committee

             The referral center would be staffed to provide a community
             education program; (Addendum I'll a referral system based on
             patient needs and staffed 24 hours a day; a central research element
             to bring together data generated by the separate clinics with
             the objective of improving preventive measures and providing continuing
             data for better patient management.  It would coordinate the use
             of paramedical personnel furnished by the D.C. Department of
             Health.

             The clinics at all five locations would be coordinated to  meet
             the needs of all patients within their respective  areas.  Special
             procedures would be developed at the Washington Hospital  Center
             to provide home and clinic care on a reasonable cost basis  for
             the economically marginal group residing in the areas served  by
             these hospitals.
             The concept developed here is to reduce clinic visits by  patients
             by providing scheduled home health visits in conjunction with
             scheduled clinic visits. The care of patients will be  based  on
             the physician's Health Management Plan. The major  concerns  of
             many inner city patients with transportation, travel time, waiting
             time, and frequency of attendance will be reduced by at least
             one-half the demand of the present system.
             Second Year:  $174,151@                   Third Year:  $178,982

                                                                      Requested
             Project #43 - Cervical Cancer Detection.  By means of   First Year
                           this project, the District of Columbia    @150,000
             General Hospital and Howard University Collefe of Medicine
             is requesting support to continue ongoing programs of  cervical
             cancer detection currently funded through section 314 (e).
             The primary objective of this proposal is to increase the
             number of women who are protected from cancer of the cervix  by
             supporting and extending the services of the Cervical Cancer
             Protection Center at D.C. General Hospi-@al,.with particular emphasis
             on serving women who are not already under supervision by a private
             physician.
             A secondary objective is to increase physician skills in the
             early detection of cancer of the cervix.  Joint gynecologist-
             pathologist conferences sponsored by the Project Staff  provide
             a learning opportunity for medical students of Howard,  Georgetown
             and George Washington Universities; the Project prepares an
             annual Metropolitan Symposium with the Cancer Society and  Medical
             Societies.  Special health education staff are requested to
             increast patient understanding.
             This project receives support from the American Cancer  Society.
             Patients screened by the project staff include those who are
             not dependent upon D.C. General Hospital and who are referred
             for follow-up at other community hospitals. Referrals  will  be


                                                               January 1971 Review Committee
       METRO DC                               - 22 -           RM 31-04 (AR-1 CDS) 2/71

           lieinodia@Lysis unit to provic@c- i-,Leans for managing patients with
           kidney failure @@iiio do riot-. have adequate facilities for home
           dialysis.  It represents one part of the developing program in
           the Metropolitan Washington Region for the care of kidney disease
           and is a part of the present dialysis program at The George
           Washington University Medical Center.  Stich a mobile unit will
           be established in a truch or trailer and will be moved from patient
           to patient.  It will be available to any deserving patient in the
           Metropolitan Washington Region previously trained in the use of
           the artificial kidney and can serve to  support  existing  dialysis
           training centers at Georgetown University Hospital and Veterans
           Administration Hospital, as well as the one at The George
           Washington University Medical Center.  The unit will initially
           be supported by tl-ie present request, but subsequently will derive
           support through fees and donations.

           Second Year:-  $18,668             'Third Year:  $19,443

                                                                         Requested
           Project #47 " A Regional Neplir  ogy Prop-ram.                First Year
                         This proposal sponsored by the   Georgetown       $718,876
           University Medical Center would be the first   systematic  approach
           to integrating an extension of present facilities  and  cominglina,
           patient care, training, and research.  It would take advantage
           of the existing facilities of the Georgetown University Nephrology
           Division which are outlined in a detailed organizational chart.
           These resources consist principally of the D.C. General Neplirology
           Section(ix trained personnel including one physician and two
           nurses), the Metropolitan Washington Dialysis  Center  (10  trained
           personnel including two additional physicians and  three  -nurses),
           the Georgetown University Nephrology section (14 trained personnel
           including four physicians and two  nurses),  the  Nephrology  Fellowship
           program (7 physicians), and an administrative staff (four trained
           personnel including one nurse) and an editorial office (2 trained
           personnel).  The proposal would integrate these facilities in a
           systematic way to provide an organized approach  to  the  treatment
           of renal failure in a major segment of this region.  It will do
           this by providing additional individuals required by the plan,
           by supplying some new facilities such as the one  at  the  D.C.  General
           Hospital, provide the basis for planning an out  of  the  hospital  home
           care facility, and provide an administrative-social worker unit
           as a resource for screening patients for dialysis and transplantation
           which in turn could bernade available on a fee for case-service
           basis to any hospital in the region having a dialysis facility.
           This could interdigitate with the existing 12 university contract
           program for tissue typing and exchange or donor kidneys on a "best
           match" basis.

           Second Year:  $586,9z@5                    Third Year:  $617,107


                                                                         .-. - @ -- %-- x %.,Vol 41 r L
                                                                         January 1971 Review Comittee
             encouraged from D.C. agencies and the community.  A         community
             Advisory Committee wil-L be established.

             Second Year:    $125,                        Third Year-:   $125,000

                                                                                  Requested
                                                                                  First Year
             Project #44                                                          $174,400
                                                                            ge
             proposed the development of a-La Inter-Regional Program of Inter-
             stitial Cancer T'ileriiDN,.  S,@)ecifically, a program would be set
             up  to  manufacture  Iridium  192  seeds  and  package  them  in  such
             form  as  to  make  implantation  a  more  safe  and  convenient   procedure.
             Special instruments and improved after-loading techniques will
             also  be  developed  and  made  available  to  all  hospitals,   tumor
             surgeons,  and  radiotherapists   in   the   Washington   Metropolitan
             area and the other 13 regions in the Southeastern Regional
             medical  Program  consortium  who  are  qualified  to  use  the  same.
             Consultation to user groups will be available on a request basis.
             Iraining in interstitial radiotherapy will be provided for visiting
             i--vldi.ologists, radiation physicists radiologic residents and technicians.
             Second Year: $78,449                              Third Year:  $58,691

                                                                                  Requested
                                                                                  First Year
             1-Iroject #45 -- Home -Base Care of Crronic Obstructive Lung         $42,720
                            i@sea-se. The Pulmonary Disease Division of
             Gec--aletown University S--hool  of  '4edicine  proposes  the
             development of a three-year program oriented to improve the delivery
             of care in the home  and  in  outpatient  fac4-l4-t-ies  for  patients
             with chronic obstructive  lung  disease  (COLD)  in  Mell-r,Dpo'Lita@n
             Washington.

             To  accomplish  this  goal  requires  the  development   of   adequate
             facilities and personnel in the community geared to -orovide expert
                       care bv:       training Vis@; ling 'lur.ces and   ublic Health
             Nurses in basic aspects of COLD including therapy applicable in
             the  home;  (2)  training  physicians  in  comminitv  clinics  in  the
             performance and interpretation of pulmonary function testing; (3)
             education of patients  with  COLD  and  their  fa7,,ilies  on  those  aspects
             of COLD which they can control and manage; (4) team visits from
             Phil  applicant  2Lnstitut-Lon  of  pulmonary  nurses,  physician  therapists
                        L
                inhalation therapists..

             Second Year:  $53,650                               Third    Year:    $58,880

                                                                                  Requested
                                                                                  First Year
             Project #46 - Mobile Dialysis Cen@(-,r.    This proposal             $39,527
                           cir)or,,;t,)red bv the George Washington University
             Itedical Center seeks co demonstrate the feasibility      of a niobile


                                     - 23 -       RM 31-04 (AR-1 CDS) 2/71
       MMO  DC                                    January 1971 Review Comitte,

                                                         Requested
                                                         First Year
             Project #48 - Nurse-Midwife Maternitv Nurse Clinician $411,333
                       program. In order to meet the acute health
             manpowere needs of the metropolitan area this "doctor-
             multiplier" program sponsored by District of Columbia Department
             of Human Resources will produce two new careers for registered
             nurses:
             The maternity nu se practitioner who expands the nurse role to
             provide total medical supervision to well maternity patients and
             certain gynecological patients in an out-patient setting as
             delegated to her by a physician.
             The classic nurse-midwife who in addition to the above functions
             also manages labor and performs delivery, wor'fing on a team with
             a board certified obstetrician.
             The proposal has a number of components. These include a service
             program which provides a setting to train and return midwives
             to active practice, an educational component in conjunction with
             Federal City Collegeblhpartment of Continuing Education,and
             a preceptorship placement service to provide on-the-job experience
             in private, voluntary and public institutions.
             Second Year: $678,840         Third Year: $614,167


        METRO DC                            24 -              RM 31-04 (AR-1 CDS) 2171
                                                              January 1971 Review Comittee

          DEVELOPMENTAL COMPONEN'T

          The Region is requesting three years of developmental support:  first
          year - $97,067, second year - $110,000,, third year - $140,000.  The
          Region proposes to use the developmental funds to support  the  following
          studies:

          1. The creation and staffing of a committee composed  of  Medical  School
              Departments of Community Medicine, members of the Department of
          Publit Health of the District of Columbia, staff of the Office of Eco-
          nomic Opportunity, neighborhood health centers and consumers  to  explore
          means of stimulating the development of neighborhood health centers.

          2. The use of formal instruction to improve the  effectiveness  of  plan-
              ning committees.
          3. The feasibility of establishing a clearing house  to  identify  educa-
              tional employment opportunities for medical students iwishing to  become
          involved in innovative health care activities designed to  improve  delivery
          of health care to inner city populations.

          4.  The feasibility of developing a computer-based clearing house to
              locate patient care resources for stroke patients needing "after the
          acute phase" care at home,  in extended care facilities, or in outpatient
          rehabilitation resources.

          5.  The development of a pilot study in patient education to improve the
              after-care portion of medical treatment by getting the patient to
          understand the nature of his particular disease and what the  patient  needs
          to do to improve the management of his continuing treatment after dis-
          charge under a physician.
          6. Exploring the most suitable ways of expanding,  up-dating,  and  coor-
          dinating multiphasic screening activities in the Region with initial
          emphasis on early detection of major diseases i-.i people of limited economic
          resources.

          The developmental funds will be expended under the following set  of  rules:

          1.  Studies must be completed and result in a proposal for an activity
              consistent with the program goal for the triennium.

          2.  Funds for any single study proposed may not exceed twenty percent of
              the total sum made available in the year for development of activities.

          3.  Core staff will be assigned to each study and will be responsible for
              completing the study within the approved budget and within  the  time
          framework established.


                               MLMMO DC                                                                   25                              RH 31-04 (AR-1 CDS)  2/71
                                                                                                                                          Jamary 1971 Review Cmmittee

                                                                                                                                                 RM 31-04 (AR-I.-CSD) 2/71

                                                                                                                                                 --------------

                                                                                                                                                                     3 /1     -'O-.-    2

                                                                                                                                                                            $551:1031i

                                                                                           st.-@c),.@c: St,,:tlo,,i                                                           139   296

                                                                                                                                                                                121,812
                                  4.@3                                                                                                                                            49,600

                                  11-5                                                    of Ov,-4rl,:i@

                                                                                    C,  C. r    il     C. IL
                                                                                                                                                                                  37,500
                                 @,-'l 2                      Cc)r(,)ci,,;-@-y Ccir--@      Urtit                                                                              8 5

                                  .. -IC                                     r  P,      i
                                                                                            t: -Cy

                                                                                                                                 Fa c         t y
                                                                    "' i 1 ri  C) i-I  i  -C         -r  I  V       C, LI I I
                                 ii 2              t I'C)

                                              Schc-,,,)! or                                                                                                                       22,600

                                                                     ,I,      cl;                                                                                          2

                                #28          Coronary Care Nurse Training                                                                                                        49,438

                                   2 9                                        'j'r c:, i t i. n   @i i-i (i  -c z, e,c        ri,

                                #35


                S  -  --I   t   Li 0 f  P r 2j -!@r FLI  C, (I

                Project TiLle and ',iuriber                                                                      Status

                1/4 - liome Telecasts  of Medic.@l                  Suryical      Conferences                    Disapproved

                #6 - Coriisrc-ii(@nsive ilospitil  and tioae Cire                 of    Strol-,c    llatic-.iiL.,; DI..iz!l)rrovc-(]
                #7 - Puerperal Hemi.pl.egia                                                                      Disapproved

                           -  1,od(,]  ';crc)k(,  for: L@ictro.  D.C
                                                                                                                 Di--approvc(,'

                                         -cry D4.se.-!.,4c:     The    r,,ole of    Ey,
                           -         Ari                                               C. r c
                           its

                           -',,I()bille Coroiiiry Care Unit  for l,@cti.-o.         T). C.                       Di.sap;)rov(.c',
                #13        -Mobile Coroi-iiry     Care Unit -' Georgetown Uni%;c.-i.-,,;ity                      Disapproved
                f@14       -Home Telecast  of Yiedic.,.41-Surpic@l Cardiovascular                                Funde@ &
                           Conferences                                                                           T6rininated
                #16        -. Paramedical lletrzining by Video Tipes
                                                                                                       (No  fun o  -cconmc-nF@e(.)

                #17        -Health Careers  Council                                                              Approved
                                                                                                       (No  funds  recor;7.11-,reicd'

                #18        -Application of Technological  Advances  to
                           Education  in Cnncer                                                                  Dis&pprov(-('@
                                                                                                                                           Ir
                i@21       -Applying Conir.-,uiiity Health Research Findings  in  tne
                           Region                                                                                D i

                #22        Pediiit'ric Coii-,,,-ii.inity '\idney Dis@ase PrevQntion Center                       App::c;v(--,i

                #24        ALteript  to Ir@i,,-xrove Cire an(]  Patient Cooperation                              Rettir,-t  for
                           in Hypertension                                                                       Revisioli

                i@2        7Contiiiu-Iri-, Eeii.,c.F.,tion inei  Socin]  Services  for
                           Pediatric Or-Lcolo.yy                                                                 Di.,;Pnprc)ved
                                                   C>

                11!30      -Cori.,.iunity Re.-al  Diar,-,iosis  Service Us'inc.'
                           floure.scence                                                                         Dispppi-oved
                3    1     -Ilemodi@-lysis Triirii,-ig Progrrri                                                  Approved      -      Unfunded
                #34        -Filr@i':on  "Care  of the Colostociiy Patient"  for                                  DefL-ri-c-(i  for
                           Pat'@'ent Instruction                                                                 Additic),7t,-!  Inilormaticin

                3          6
                           -Diob(,t(@s and  Obesity      EvLiluitioyi and Prevention                             Nl o 1)@,  L@'t i n r] i n
                                                                                                                 Re c       cl e r@

                ..3        7-    Detcctic,,-i    ox'     C,iroi)ic     O'@)structivc-                            tppi-OV,2d      U-,IfLlndC'6

                           3C. r (I o vs c i,i 1, @, r  D j. i-  @ 0 1 1 C)-. LI (I  C; I I- V   I-, C                           Uri
                                                                                                                   T
                           C c 0 C,,C t oi,,,i

                #26        Comprehensive Hospital Stroke Program                                                 Approved        Unfunded


                                                    27
                             DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

                                            PUBLIC FIEALTH SERVICE
                              HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION

          Dal.,:   November 27, 1970
       ,Reply to
        A.tin of.
         Subject:  Staff Review, November 23, 1970, Metropolitan Washington, D. C. RMP
                   Triennium Application
            To:    Acting Director
                   Regional Medical Programs Service
                   THRU: Sarah J. Silsbee, Acting Chief, Grants Review Branch

                   Backgrodnd:   The Metro Washington RMP, currently in their     03  operational
                   year,  hIas submitted a Triennium application requesting $4,410,861 (DC)
                   for its initial year scheduled  to  begin  March  1,  1971.  The  total  budget
                   request for the next three years is $12,175,325 (DC).

                   The current projected commitment to this Region for its 04 year is
                   $1,008,728 which consists of $571,201 (Core) and $437,527 for four
                   program (project) activities.

                   The subject application  requests  approximately  $195.,OOO  additional.  funds
                   for Core Staff with the balance earmarked for two renewals, ten new
                   activities, a developmental  component  and  approximately  six  supple:,iental
                   activities either not yet  funded  or  initiated  with  carryover  funds  with
                   drastically reduced expenditures,  (or budgets).

                   Purpose of Staff Review.@

                   Participants were advised that a  site  visit  has  been  scheduled  for  Dec-
                   ember 7-8, 1970.  Dr. Ellis (National Advisory Committee) and Dr. Hunt
                   (National Advisory Council) will be the principal leaders.  Therefore,
                   the two purposes for the Staff Review were to:
                        A.  Make recommendations to the Acting Director, RMPS, regarding
                             the commitment for the 04 year.

                        B.  Identify issues for the site visitors.
                                                I

                   General Observations about Nr@4/Bl4P:

                   Up until this date, the Region had place   d most of its  emphasis  in  stitnu-
                   lating individual project activities utilizing the Associate Coordinators
                   placed at Georgetown,  George  Washington  and  Howard  Medical  Schools,  and
                   at the D. C. Department of Public Health and the Washington Hospital-
                   Council. The Regional. Advisory Group had  been  quite  busy  at  each  of  its
                   quarterly iiiectin,-s with "project" review.  Until. recently priority
                   rankina was accomplished only on those activities being revi-c@t.7(! at  trick
                   particular RAG session.. Very little  evidctncl-  of  planning  or  evaluation
                   including surveillance had been demonstrated by the Core Staff.


                           Acting Director

                 Most of these short comings were adequately spelled out to the Region
                 by the site visit team this past year (October 1969).
                 The Coordinator and staff have been quite active in attempting to
                 alleviate many of these apparent problems' and have responded to them in
                 the subject application.
                 Key RME% staff who were willing to rank  this  Region  in  the  lowest
                 quartile based on past progress and RAG involvement, are now suggesting
                 that it could be given a higher grade based on future potential.  Assets
                 include:
                      1.   The establishment of seven planning  committees  of  eiaht
                           members each. Thus, all 57 members  of  the  RAG  (including
                           its Chairman) will be more actively involved.
                      2.   The establishment of a  priorities  committee  composed-of
                           chairmen of the seven planning committees.
                      3.'  The proposed additional offices  for  Planning,  Community
                           Health and Program Activities, and  Program  Appraisal  to
                           the Core Staff.
                      4.   A better delineation of program objectives.
                      5.   A good Fiscal Policy and competent staff.

                 Staff Recommendations:

                 A.  For   the Actini Director, RMPS:
                      1.   Regarding the commitment for the 04 year, staff recommends
                           the decision concerning the Core  continuation  be  deferred
                           until after the site visitors'  findings,  especially  since
                           $195.,OOO additional funds are requested to  supplement  the
                           $571,20). currently earmarked for this function for  the  04
                           year. Specific reasons for  this  recommendation  are  found
                           below under the heading "Issues for Site Visitors."
                      2.   Regarding four projects to be continued:
                           a.  #IR - (;troke, Freedrens Hospital) - Staf f  reconuncnds
                               approval at the requested amount - $203,677 (DC)
                           b.  #19 - (Cancer Registry - D. C. Dept. of Publ.i.c Health)
                               Staff recommends approval at the committed amount of
                               $40,000.  The site visitors might wish to fiirtll(.'.r
                               investigate the request for additional funding for this


                                                 29

                         Acting Director, RMPS

                              activity.  Progress denotes minimum "output" to date.
                              Most of the operation has been directed in  gat  ering
                              material for computer tabulations.

                        C.    #20 (Peripheral Vascular -  George  Washington)  Staff
                              recommends approval of the committed amount of $50,000.
                              A recent change in Project Directors might lead the way
                              for the establishment of satellite clinics which were
                              originally proposed but not yet implemented.  Again
                              the site visitors might wish to inquire about the need
                              for supplemental funding requested for this activity.
                        d.    #25 (Radiotherapy Program - Howard  University)  Staff
                              recommends approval at the committed and requested
                              amount of $143,850. This activity  was  just  recently
                              funded under the earmarked funds for modelcities.
                              Because of the time factor, a progress report was.not
                              expected.
                        6.    In addition to the recommendation for  the $437,528 (DC)
                              included in items eta" thru "d" above, it is  suggested  that
                              additional committed funds be considered for activities
                              previously funded with Carryover Funds.  Specific reference
                              is made to'Projects #12, #23 and #28 which  are  included  in
                              this application.  It should be noted that eight project
                              activities were funded this past year  from  carryover.  T  e
                              Region might be commended for such action; yet many problems
                              have arisen in spite of getting more institutions on boar
                                          ended that the next  three-year  program  exclude
                              It is recomm
                              carryover financing for activities scheduled for more than,,
                              one year's duration.
                              Since Projects #12 (Mobile Coronary Care Unit)"an-d t2
                              (Inhalation Therapy Training) have one more year remaining,
                              carryover could be considered for partial  funding  of  these
                              activities.

                              Staff recommends $55,000 additional  commitment  for  Project
                              #28 (Coronary Care Nurse Training -  Howard  University)  for
                              a two year period.
                 B.  Suggested issues to be raised by the site visitors:
                     1.  There is some question as to the need for ten additional profes-
                         sional positions on Core Staff.  The  application  indicates  that
                         some of the presently employed Associate Coordinators will assume
                         new roles (or @ual rol.es),in manning three of the new proposed


                                               30

                         Acting Direc tor, RMPS

                        offices (Planning, Program  Appraisal  and  Community  Health
                        and Program Activities).  The  Organizational  Chart  (Volume  1,
                        page 63) should include the  necessary  positions  under  the
                        respective Sections so that the budget  sheets  can  also  be
                        compared with the "new look".

                   2.   The Office of Manpower Development should  also  be  examined  so
                      ,that Continuing Education activities can be more clearly
                      .'defined.

                   3.   With reference to items 1 and 2, the reviewers  wish  to  know  if
                        the Region wants to get Iaway from  the  institutional  approach
                        (phasing-out of some  of  the  Associate  Coordinators).  The
                        Region's report on Core's Stewardship seems  to  be  an  extended
                        apology. They recognize the  need  to  restructure  the  organiza-
                        tion and suggest sweeping changes  in  over-all  philosophy  and
                        more involvement of its RAG.  Yet,  through  its  apology,  they
                        seem to be suggesting necessary changes in -the Program irrespec-
                        tive of whether they may be receivi ng additional funds.  In
                        short, the Region may have stated its case better by submitting
                        two plans for reorganization instead of the  one  which  poses  so
                        many questions. After reading  the  position  descriptions  to  be
                        included in the new organizational  structure,  it  becomes  even
                        more difficult to see who is  oing to be at what helm.
                                                      9

                   4.   Monitoring, surveillance and evaluation  have  been  rather  weak
                        in this Region. The new look  suggests  that  the  Office  of
                        Appraisal should alleviate these problems.  What about RAG
                        members? Can they become more  involved  in  these  kinds  of
                        activities?

                   5 .  Staff notes that a large portion of the  RAG  is  from  Virginia
                        and Maryland.  Site visitors may wish to pursue the composition
                        of this body even though funded activities in Virginia and
                        Maryland have been quite limited.

                   6.   Expenses of RAG and Task Force members  should  be  further  ex-
                        plored. Perhaps a budget figure  would  reveal  these  costs  are
                        not, in fact, too extravagant (Page 134).

                   7.   A pictorial chart depicting the  review  process  would  further
                        clarify the narrative presentation.  It is suggested     that
                        evaluation be included in the chart.

                   8.   Some staff members were concerned about the first two mentioned
                        firules" under which the developmental component  is  slated  to
                        operate.  The first rule appears unvorkable'and the second seems
                        unwise.


                         Acting Director, RMPS    - 31

                       9.  Questions concerning two renewal requests should be
                           pursue

                           a. Mobile Coronary Care Unit -  This  activity  was  approved
                              for a two year period and actually got underway in
                              Match 1970 with carryover  funds  although  limited  funds
                              were used for to6ling-up prior  to  that  time.  In  view
                              of recent Council action regarding Mobile Units,
                              should another $100,000 be allowed for the further
                              evaluation of this activity as proposed for one
                              additional year?

                           b. Stroke Registry - This renewal (#2R) was deferred
                              by the National Advisory Council  which  met  in  November
                              1970, pending further investigation by a site visit
                              team.  Principal questions centered on future use
                              of the material being gathered.

                      10.  Of the ten new proposals to be considered, two points
                           should be clatified:

                           a. of the three kidney proposals,  can  the  Region  identify
                              one of them which can be considered priority?

                           b. Can the Cervical Cancer Detection Program be considered
                              in view of the  recent  Council's  'recommendation?  This
                              proposal combines two previously funded 314 (e) grants.

                           What is the amount of expected  carryover  for  the  current
                           03 operational year!

                                     SUMMARY OF REQUEST AND RECOMMENDATION

                                                                          Recommendation

                        Conimitt@d     ort
                                                                         (Deferred for Site
                          Core                        $571,201           Visit Consideration
                          Projects IR,19,20, & 25      3   IL7                @43@  2@7
                                                    $1,008,728                 $437,527

                          In addition  to  the  recommendation on
                          committed support, Staff also recommends
                          project #28,which is funded in its first              $55,000
                          year from carryover,be awarded $55,000 additional
                          commitment for its second  and  third  years  of
                          operation.
                                                                     TOTAL     $492,527

                                            Michael  J.  Posta
                                            Operations Officer
                                            Regional-  Development  Branch


                                             HAROLD MARGULIES@ iki.D.

               Action Z.
                                        c       'O v

               Date

               Signatur(

               Listed below are RMPS members who attended this Type V meeting:
                             Dr. Marian'Leach - Continuing Education Branch
                             Margaret Mullins - Planning and Evaluation Branch
                             Rod Mercker - Grants Management Branch
                             Lorraine KyttlO- - Grants Review Branch
                             William Reist - Grants Review Branch
                             Michael Posta - Regional Development Branch

                                                                 GRB  12/24 70


                                                                       (A    Privileged    Communication)

                                    SUMMARY OF REVIEW AND CONCLUSION OF
                                       JAIQUARY   1971   REVIEW   CO@IITTEE

                         METROPOLITAN WASHINGTON D.C. REGIONAL MEDICAL PROGRAM
                                            RM   31-04   (AR-1-CDS)   2/71

                          ]FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

               Lt       NDATIO@iS:.  (1)  Continuation support be ptov ded in the amount
                                          committed  for  the   04   year. l@

                                     (2)  Additional  support  in  a  reduced   amount   be   provided
                                          for the core renewal and new projects in this
                                          application.
                                     (3)  Developmental funding be denied at this time.

                         Committed     Committed        Additional       Additional
                         Support       Support          Support          Support             Total
               Year      Requested     Recommended      Requested        Recommended       Rec   rmuended
               Ist         @1,008,728  $1,008)128       $3,402,133       $    574,623        @1,533@351
               2nd           189,08.2        189,082        3,813)289     1,095,824          11284,9Cr6
               3rd            -0-            -0-         3    762,093     1,041,353         1   041,353

               Tot  1      $1,191,810  $1,107,810       $
                                                         _.10,971,515    $2,711,800          $3,909,610

                   Staff     reviewed the  continuation  com  onents  (core  and   four   projects)   of
                                                             p
                                                          The Acting Director deferred these
               this   application   in   November   1970.
               components  to  the  visitors  of  the   upcoming   site   visit   for   consideration.
               The   site    visitors in turn recommended approval of the contuation components
               in the amount committed.  Commi      ttee   after   consideration   of   the   application
               and'the site visitors'report concurred with this recommendation.

               CRITI                               the site visitors   I observation that this Regioli.
                     -QUE:    Committee    accepted                                                     I
               hap made substantial progress in the form of reorganization duritio the n@ist
               year and that while progress program-wise is not as evident, organizational
               weaknesses have been strengthened to the ext6nt the Region now shows greater
               potential.  This new potential can also be attributed to what was considered
               the high caliber of key members of Core StAff.  The restructured RAG
               committees  were  considered  a   significant   change   which   should   bring   about
               greater  involvement  in  program   development;   hbwever,   it   was   recognized   it
               will  take  time  for  them  to  demonstrate  progress   towards   a   total   program.
               While   the   reviewers   had   reservations   regarding   the   minority   representation
               on the RAG, it was noted most of the funded activities appear to be centered
               in  the  lower  socioeconomic  areas   of   the   District.   The   review   process   was
               considered satisfactory-, however, there is a need for mote emphasis on
               program  review  and  use  of  outside  e-4zperts  on  the  planning   and   priorities
               committees.'  Although   there   appears   to   be   considerable   cooperative   effort
                ith   other   community    organiza                                   e  Region   might
               w                                  tions, the reviewers agreed th
                                                                                 land   and   Virainia
               Vant to delineate further priority pocket areas in.@lary                        a
               and  consider  future  programs  for  theri.-  It  was  also   suggested   closer   ties
               be developed with the Health Departments in these states.


             MF4TROPOLITAN WASHINGTON D.C. PMP           -2-      RM 31 04 (AR-1-CDS) 2/71

             While the site visitors believed the  Reg:Cbn needs to develop a system.
             of utilizing the data being collected and to establish  sharper  criteria
             in identifying specific needs  some Committee members were more highly
             critical of the entire programming process, from assessing needs to
             evaluating achievements. They cited the expensive  Cam  rehensive  Kidney
                                                                    p
             Program as an example of how the Region has given priority to  a  program
             upon which the need appears relatively insignificant when  compared  with
             ot .6r needs of the community. Along the same lines it was  believed  the
             new projects represent a "shotgun approa@ch" and lack a common thread
             dra ing them together into a total program.  Concern  was.also  expressed
             over what appears to be the strong dominance of the medical schools as
                'ht be ief! cted by the fact that a majority of the projects are sponsored
             mig          e
             by these institutions. It was also noted that none  of  the.projects  are
             co-sponsored or represent a cooperative endeavor or effort by the Medical
             Schools.

             After considerable discussion and debate Committee concurred with the
             site visitors that while program progress does not  ustify additio al
                                                                                n
             support, potential based on the reorganization does and the Region should
             be given@additional project support.for each of three years  and  renewed
             support of Core for the second and third years.  With respect to the
             D6velopmental Component, however, Committee did not concur with the site
             visitors recommendation of $75,,O.00 additional funds, but rather took the
                'tion that support of this component should not be granted on the
             posi
             basis of potential but should be withheld until such time as  the  Region
            ,'has demonstrated its potential in the form of program progress.

             In addition to these recommendations  Committee  concurred with the visitors
             observation that the three projects, which compris,e.the Comprehensive
             Kidney Disease Program, lack planning, contain too much  overlap and fail
             to utilize all available@resources.  It also agreed with the recommendation
             that no additional funds be provided for these proposals, but that @15,000
             Core supp?rt be provided to develop a comprehensive plan for kidney dis'ease
             control.

                                                                      RMPS/GRB
                                                                      1/20/71


                                      REGIONAL   MEDICAL   PROGRAMS    SERVICE
                                 SUMMARY OF SUPPLEMENT@AL GRANT APPLICATION
                                         (A Privileged Communication)

             Michigan       Association                            RM    00053 2,171.1 (S)
             Regional Medical Program                              January 1971 Review Committee
             Suite 200, 1111 Michigan      Avenue
             East tansing, Michigan
             Grantee    Agency:    Same

             Program Coordinator:  Albert E. Heustis, M.D., M.,":.I.@

                                            Request   (Direct    Costs)

                                      Ist   yr.       2nd   yr.       .3rd   yr.      All    years_

             Direct Costs             $428,073       $426,098         $448,274        $1,302,445
             Indirect Costs             38,505,          41,971           45,748          126,224

             Totals                   $466,578       $468,069         $494,022        $1,428,669

                                                 Funding    History

                                                 Planning Stage

                           Grant Year            Period                Funded    (d.c.1
                               01                6/67  -  7/68           $1,040,639

                                              Operations       Program

                                                   Council                                Future
             Grant Year      Period                Approved       Funded (d.c.)           Commitment

                  01         7/l/68   -  6/30/69   1,495,330         721,763  Core        --------
                                                                     773,567  Projects
                  02         7/i/69   -  8/31/70   2,054,020         8491814  Core        --------
                                                                  10134,863   Projects
                  03         9/l/70   -  8/31/71   2,031,533         822,136  Core        --------
                                                                  1,164,961   Projects
                  04         9/l/71   -  8/31/72     501,255            -------              385,730

                  05         9/1,/72  -  4/30/73     360,940            -------              281,727
                                      (8   months)


          Michigan  RMP                      -2-            RM 00053     2/71.1 (S)

          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 densly populated lower peninsula by the straits of Mackinac.
          The total land area is.57,019 square miles.

          The vast land area coupled with centers of medical excellence and decen-
          tralizod 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.

          Demography

          ,Populatio@i (1968)        8,800,,OOO (Estimate)

            a.  Urban                      73%

            b.  White                      91%

          Facilities   a. University of Michigan Medical School    4 year   enrollment
                                                                              780
                      b.  Wayne State University School of Medicine    enrollment 516

                      C.  Michigan State University College of Human Medicine

          Physicians   a. Medical Doctors - 9,625 (1962)
                      b.  Doctors of Osteopathy - 1,691  (1962)

          Program Priorities - (Listed in Order of Importance)  (Approved by RAG March 13,
                                                                  1970)

          1.  Immediate health service needs of the poor.

          2. Concerns for younger  age  groups

          3. Increasing the delivery of health services

          4. Prevention of disease and its complications

          5. Improving the quality of medical services

          Review  Process

          Staff - Prepares a summary to generally highlight the project's objectives
                 and technical approach.  Additionally, any staff "concerns" are
          surfaced to the technical review committee for their consideration.

          Technical ]@eview Committee - (Generally an Ad Hoc Committee of outside
                                       consultants)  Meets with the applicants, and
          makes a comprehensive review to determine the project's merit, its benefit
          to the community, the significance of the disease pressure, the fulfillment


            Michigan RMP                       -3-              Rm 00053      2/71.1  (S)

            of an actual need, the mechanism of effect,  the  competence  of  the  technical
            approach, evidences of cooperative arrangements, and its concern toward
            fulfilling a MARMP priority concern.

            Board of Directors - (7 members - all  members  of  RAG)  Reviews  the  complete
                                  project, the staff summary, and the report of the technical
            review committee from the standpoint of the intent of RMP legislation, devel-
            opment of cooperative arrangements, and  applicability  of  the  program  plan.

            Regional Advisory Group - (34  members)  Receives  the  Board  of  Director's
                                       recommendations as well as the other material which
            has been considered by the board.  At  this  time,  the  RAG  either  approves
            the proposal for submission to RMPS or returns th,2  proposal  to  the  sponsor.
            The right of appeal is available.

            Program Coordinator - Albert Heustis, M.D.  was  chairman  of  the  Governor's
                                   Advisory Council on Heart  Disease,  Cancer  and  Stroke
            when it first met during November 1965  to  discuss.the  implications  of  RMP
            to Michigan. During June  of  1966  the  Region  was  incorporated.  During
            September 1967, Dr.  Heustis  was  appointed  fulltime  program  coordinator.

            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)  On  October  9,  1970,  during  the
            annual-meeting of the members of the MARMP  Association,  new  members  of  the
            Regional Advisory Group were elected.  The  RAG  currently  has  34  members.
            New Organizational memberships  include  representatives  from  the  Michigan
            Academy of General Practice, the Michigan Association of General Practitioners
            of Osteopathic Medicine and Surgery, a  member  of  the  Comprehensive  Health
            Planning Advisory Council, the Kidney  Foundation  and  the  Health  Planning
            Council of Michigan. A  group  of  six  representative  Public-at-large  Members
            was also  elected.

            Michigan's triennial application is due for  submission  in  May  1971  for
            consideration in the July/August 1971 Review Cycle.

            Listing of Current Funding Status of core and operational projects in MARMP.

                                                                            Amount Supported
            Project Number                   Title                          Through 8/31/71

                                        CORE

            #1               Central Planning                               $   326,381

            #5               M.S.U. Planning                                    189,975

            #7               U. of Micbigan Planning                             63,480

            #14              Wayne State Planning                               177,460

            #15              Ziegler - Botsford Hospitals                        64,840

                                                  CORE subtotal                 822,136


            Michigan RMP                        -4-               RM 00053      2/71.1  (s)

                                                                               Amount Supported
            Project Number                  Title                              Through 8/31/71

                                       Generational Projects

            #3               Coordinated Data Collection (Dept. Public
                             Health)-                                               231,656
            #4               Model CCU Michigan Heart Association                   109,856
            #8               Postgraduate Nurse Education                           102,707
            #9               Drug Information and Therapy.Analysis
                             University of Michigan                                 79,489
            #12              School of Dentistry - U. of Michigan                   31,636
            #16R             Surveillance of Electronic Equipment                   45,701

            #17              Stroke Base Center - Wayne State                       10,196

            #18              Comprehensive Attack on Problems of Stroke             115,314

              19             Stroke Demonstration Unit -.Detroit
                             Osteopathic Hosoital                                   91,633

            #20              Central Michigan Comp. Stroke Program                  82,857

            #21              Stroke Education Program                               62$216

            #22              Develop CVR Center Benton Harbor Mercy
                             Hospital                                               35,720

            #25              Western Michigan Medical Education Program
                             (Blodgett,Memorial Hospital)                           801250

            #26              Inner-city Cont. Education Program                     85,730

                                                   Total Core & Projects          $1,987,097

            Summary of Existing Michigan Regional Medical Program Components

            The Core component of the Michigan Region hag four agencies in addition to
            the central staff for which it provides funds for promoting, planning,
            facilitating, and/or coordinating activities of concern to the Regional
            Medical Program.  These ire Michigan State University, University of Michigan
            (which includes a Dental Section), Wayne State University and Ziegler/Botsford
            Osteopathic  Hospitals.  Clarification  of  relationships  between  these   have
            been the concern of a Regional Advisory Group (RAG) committee which has been
            studying the Situation since the first of the year.


             Michigan RMP                                        RM 00053      2/71.1 (S)

             Operational  Proiects

             A.  Heart Disease

             1.  Western Michigan Continuing Education Program, Blodgett Hospital, Grand
             Rapids; #25 - Physician Training in Satellite Hospitals.  The larger general
             hospitals in Grand Rapids are cooperating with each other and with ten smaller
             surrounding hospitals in developing and implementing a physician education
             program in Cardiovascular Diseases.  The staffs of smaller hospitals are
             helped to identify their own needs, make their needs known to visiting
             specialists, and receive appropriately tail.ored individual help in their own
             hospitals. The project also  provides  for  the  services  of  a  replacement
             physician to enable local practicing physicians to attend educational programs.

             2.  Physician Training in Cardiovascular Care; #22, Mercy Hospital, Benton
             Harbor.  This program is developing a cardiovascular center with facilities
             for cardiac catherization And, angiograpoy.  It is also developing and carrying
             out an educational program in C/V Diseases for the physicians in the surround-
             ing three-county areas through visiting consultants, inter-Hogpital Conferences,
             and monthly clinics.

             3.  Cuoronary Care Unit Training Program;  #4,  Michigan  Heart  Association.
             This program offers two-week courses for nurses and one to three-day seminars
             for physicians throughout the region who function in coronary and intensive
             care units.  Programmed learning texts to be used with teaching machines for
             hospitals with (or planning CCU'S) are being developed.

             4.  Survey of Electronic Equipment in Special Care Units- l@16R, Wayne State
             University.  This program surveys hospitals in the Metropolitan Detroit area
             to assess personnel practices with respect to the electronic equipment used
             in their coronary and intensive care units and in emergency rooms.  The
             program is also determining the potential hazard in the use of such equipment
             and providing pertinent safety data about specific equipment.

             B.  Stroke

             1.  Regional Stroke Base Center; #17, Wayne State University.  This Program
             will provide professional consultation to the cooperating stroke centers and
             the stroke information program, 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.

             2.  Cooperating Stroke Centers; #18, and #19, and #20.  This is a three-horned
             program involving Detroit General Hospital, (Wayne State), Detroit Osteopathic
             Hospital and Sparrow  Hospital  (Michigan  State  University).  Acute  stroke
             units established in these institutions are to serve as demonstration an(]
             training centers for physicians and alli.(!(l health p(!rsonnel.. New(@r methods
             of diagnosis, treatrti(@@nt ano rehabilitation of patients with acute  stroke
             will be demonstrated.  Cooperative  arrangement  ire  to  be  developed  with
             surrounding hospitals, and  f@s  of  experts  from  the  centers  will  visit
             cooperating facilities for the purpose of conducting consultation, teaching
             rounds and seminars.


        Michigan RMP                      -6-             RM 00053     2/71.1 (S)

        3.  Stroke Education Program; #21, Michigan Heart Association.  This program
        is designed to impress people regarding the predisposing factors and symptoms
        of early stroke and to motiva.te them to take advantage of what they and
        physicians can do about them.

        C.  Multi-Ca@orical - Heart, Cancer, Stroke
        1.  Continuing Education for Nutses; #8, University of Michigan.  This program
        is to develop and implement continuing education programs in heart, cancer
        and stroke for nurses throughout the region.
        2.  Drug Information; #9, University of Michigan.  This program provides drug
        information on a 21rhour basis to physicians and allied health professionals
        throughout the region.  Drug therapy patterns are analysed.
        3.  Continuing Education Program for Small Inner-city Hospitals; #26, Wayne
        State.  This program is for a continuing education program for physicians
        and allied health personnel in three, small inner-city hospitals.  Technical
        assistance is offered through Wayne State.  It involves self-study programs,
        'identification and assessment of factors contributing to any health care
        gap and the development of programs to overcome the gaps.

        D. Evaluation and Data Collection; #3, Michigan Department of Public Health.
        This program is concerned with the development of methods to assist in the
        definition of target populations needing care and to measure the performance
        of the health care delivery system.

        Of a total of 29 new individual project requests, Michigan RMP has had one
        ne,,i operational proposal not approved at the at the Federal level due to
        programmatic considerations.  A revised version of that request is included
        in this application.

        Currently the region has two operational projects which are approved - unfunded.

        These are:

        1.  Comprehensive Health Care for the Urban Poor - Wayne County General
        Hospital.  This program, designed to serve an urban poor population, will
        establish a modern and comprehensive screening, diagnostic, and treatment
        center using the facilities of the out-patient and in-patient departments
        of the Wayne County General Hospital.

        2.  Demonstration and Teaching of Specialized Care of Stroke in a Generalized
        Hospital.  This proposal will add another unit to the Michigan Regional
        Stroke Program.  It is to serve as a demonstration an(] training center for
        physicians and all.ied Health personnel Initially from five Detroit hospitals,
        Alexander Blain, Jejiniiig Memorial, Evangelical Dea(-oniiess, Detroit Memorial
        (Center), and the South Macomb Hospitals.
        Present Application: This is a request for two individual projects. One
                            proposal is in the field of cancer, the second is to
        provide community health service coordinators for model neighborhood compre-
        hensive health programs. Direct costs only are shown in the following descriptions.


            Michigan RMP                        -7-           RM 00053.     2/71.1 (S)

                                                                                   Requested
                                                                                   First Year
            Project #30 - The South Eastern Michigan Regional Cancer Program.       $220,720
                          This is a revised request of the  original  proposal  which
            was reviewed during the June/July 1970 review  cycle.  The  critique  and
            recommendation of the June Review Committee which was supported  by  July  1970
            Council was:

            "Critique: This is the Region's first cancer proposal and  is  to  improve  the
                         care of cancer patients in a tri-county area by providing a
            clearly identified and publicized network of cancer  consultants  in  nursing,
            medicine and social service. A survey indicated that  the  level  of  practice
            regarding cancer management is outmoded by about ten years.

            Members of the Review Committee believed that the concept  of  training  cancer
            consultants is naive (if a physician is an oncologist, he  is  a  cancer
            consultant). It was difficult for the reviewers to  understand  why  he  should
            be paid a per them to do what he should or probably would  do  any  way.
            Additionally, it was believed the requirement that  all  hospital  admissions
            have "pap" smears appeared to be an expensive  duplication.  A  question  was
            also raised regarding the value of establishing cancer  guidelines  for  this
            small geographic area. There was concern about  the  experience  the  proposed
            project director has had as an educator.

            In recommending non-approval, the reviewers believed that  the  proposal  should
            be recast to include much more planning of the educational aspects  as  well  as
            concrete phase-out plans, with a greatly reduced budget.  Phasing of the
            program was also suggested. It was suggested that  the  Region  utilize  medical
            education evaluation consultation at Wayne State University and  that  the  RMPS
            Continuing Education and Training Branch staff provide assistance in this
            effort.

            Recommendation:  Non-approval II - revision required."

            Summary of proposed program: Wayne State  University  requests  $220,720  through
                                           the Michigan Regional Medical Program  for  the
            first year of a three-year proposal which is to improve the  care  of  cancer
            patients in a tri-county area, by providing a clearly identified and publicized
            network of cancer consultants in nursing, medicine  and  social  service.  This
            is the Region's first cancer project.

            The project proposes to establish cancer consultants  throughout  the  tri-county
            area (Wayne, Oakland, and Macomb Counties) to increase the availability
            expertise in cancer management to practicing  physicians.  A  Central  Teaching
            Group of Cancer Experts from Wayne State University will serve as faculty
            for training the cancer consultants and for developing                for
            management of patient wi.t@@li malignant

            The cancer constjlt;irit:,,4 will 1)(@ i.(Ientifi(,(l tin(] r(,nppoirit@t,(] I)y Lli(, ilro)(,(,t@
            Director annually iii(i will have the responsibility of:  I.. I.mpl(,mc,r)tin,,,, i
            monthly tumor board in their hospitals; 2. implementing an(]  attending  clinical
            teaching conferences in their own hospitals; 3. attending the monthly conferences


         Michigan   RMP                       -8-            RM 00052     2/71.1 (S)

         of the Central Teaching Group; and 4. providing    consultation (on a fee-for-
         service basis) to physicians and furnish information on current management
         and evaluation standards and therapy recommendations.

         ,An area-wide cooperative program among radiation therapists will be developed
         to provide needed services and to improve the scope and quality of the therapy
         offered. @All pathologists in the tri-county area will be given an    :opportunity.
         to become active participants in pathology slide seminars to be held at two
         hospitals (St. John and Wayne State).

         A two-week cancer educational program will be provided (maximum of two per
         year) which will enable key nursing personnel throughout the tri-county area
         to gain the necessary knowledge and skills to effectively provide cancer
         nursing care and to teach other nursing personnel.  The establishment of
         hospital nursing units primarily devoted to the care of cancer patients
         requiting aggressive nursing care, will be encouraged.

         Each tri-county area hospital will be encouraged to work toward the establish-
         ment of a mandatory Papanicolaou cervical smear requirement for women admitted
         to the hospitals.

         The project proposes to demonstrate the feasibility of cooperative utilization
         of social workers in hospitals with less than 250 beds.

         A referral center telephone service will be made available to answer such
         questions as where to go for financial assistance in purchasing costly drugs
         or where to obtain a bed for home care.

         On page 32, the region outlines the changes in the proposal and budget which
         are in reply to concerns raised during the initial committee/council review.

         The region states that the cancer program is fully congruent with the MARMP's
         regional cooperative cancer management plan which "seeks to promote maximum
         utilization of existing resources and to expand general cancer facilities
         and services only as needed."

         Additionally, it meets the qualifications to be ranked highest and second
         highest priorities of the recently passed program priorities.  The revised
         budget shows an approximate 1/3 reduction per year:

                   Year            Original Budget           Revised Budget

                    01                $346,852                   $220,720

                    02                 357,530                    229,433

                    03                3211,, 01) /                251,000

                    TOTAI,S        f,; I , O',@ 3,0 /9           $701,702

         Second Year                 Third Year

         $229,433                     $251,609


            Michigan RMP                        -9-           RM 00053     2/ 71.1,  (S)

                                                                                  Requested
                                                                                  First year
            Project #31 - Program for Community Health Services Coordinators      $207,353
                          The Detroit Model Neighbor@ood Comprehensive Health
            Program, Inc., a non-profit organization developed by the Detroit Model
            Neighborhood Agency, requests $207,353 for the first year  of  a  three-year
            program which is to help provide comprehensive health  services  for  model
            neighborhood residents. The proposal was developed  by  the  MARMP  financed
            Wayne State University Planning Staff and with the help  of  the  MAR@  financed
            Planning Office at Wayne State University.  This proposal specifically addressed
            itself to the implementation of specific items i,,-!.-;.thi.n tht-- regions two highest
            priority areas.  If approved, and funded, this program would interdigitate
            with the regions approved/unfunded project Comprehensive  Health  Care  for
            the Urbin Poor, providing, of course, that program is funded.

            Funds ate requested for the development, testing and evaluation  of  a  new
            system of providing comprehensive health care services to the residents of
            the Detroit Model neighborhood. The project is to  be  integrated  into  the
            ongoing operations of the applicant organization which  is  presently  providing
            comprehensive care to a prepaid population of  approximately  10,000  model
            neighborhood residents under contractual arrangements with  the  health  Council
            of the model neighborhood.  At present, general and speciality medical-
            surgital-health services, for enrolled model  neighborhood  residents,  are
            provided directly by or through the comprehensive  health  care  group.  The
            goal is to increase physician, nurse, and other health professional utilization
            and to increase patients acceptance and utilization of  health  services  by
            the development of a manpower program generating community health workers.
            A new type of trained health worker, the health services  coordinator,  is  to
            be trained.  He will, in fact, become the family broker for health services.
            Program activities will be designed to focus on three systemic  points  w  ich
            are planned to:

            1.  Increase effective utilization of health care providing personnel.

            2.  Increase utilization of available health care services.

            3.  Increase impact of comprehensive health care services.

            The Health Service Coordinator will assume the  roles  of  interpreter,
            negotiator, advocate, advisor, instructor, counselor and helper to the
            disadvantaged population. Evaluation is to be performed  on  the  basis  of
            specific criteria which include before and after  comparisons  and  various
            assessments.

            The Program is so structured that if it proves successful, it  will  not  only
            become self-supporting (funded by corporation) but it would have a good
            potential of being copied elsewhere.  $162,000 of the first years total budget
            is for personnel.. Purchase of four vehicles are requested  during  the  first
            year.  This is a one-time expense.


       Michigan RMP                                       Rm 00053i   2/71.1 (S)

       Second year                     Third year
         $196,665                       $196,665

       2nd and 3rd year funding is projected at continuing levels since sufficient
       takeover by the applicants is projected to compensate for increased costs.

                                                        RMPS/GRB/12/2/70


                                    SUNL4ARY OF REVIEW AND CONCLUSION OF
                                      J@nuary 1.971 Review Committee

                              MICHIGAN ASSOCIATION REGIONAL MEDICAL PROGRAM
                                       RM 00053 2/71.1 (Supolement)

                          FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

              Recommendation:  The Committee recommended that this application, which
                                 requests support for two new operational projects be
              p6rtially supported as follows:

              YEAR                        REQUEST                         RECO@-2,TENDED FUNDING

              l,st Year                   $    428,073                         $    368,073

              2nd Year                         426,098                            366   098

              3rd Year                         448,274                            388, 2 74

                   TOTAL  (d.c.)           $1@,302,445                           $1,122,445

              @it@ut,:  The   Committee   noted   that the Michip,,an R?, IP will submit its
                          triennial application for consideration in the July@/@ug,,ist 1971
              Review,Cvcle as noted in previous reviews of this Region.  The committee
              reviewers commented on the qu-zl-i.ty of local review,

              Since this optional application included only two projects,         the   Committee
              did not have an opportunity to study their potential impact         on  the  entire
              programs   lioi-2ever, as noted on the pink component sheet, only 2% of the
              Regioh's current funding floTi into cancer activities, and the Cominittee
              believed the Southeastern Mi h@icln Cincer Pr(l,,r@erLi (Proect #30) would
              add needed  balance  to  the  total  programs  In  addition,  the  Committee  fel.t
              that Project #31 - Program for Community Health Service Coordinators would
              help alleviate identified needs  of  the  urban  poor,  ,2ill  develop  @)  nucleus
              of traine.d health service coordinators, has outreach, involves many health
              resources and represents good     coordination between two federally-funded
              programs, the RMP and Model. Cities.  The-Committee understands earmarked
              funds are available.

              The Southeastern Michigan Regional Cancer      Pro-ram (Pro4ect IA30) has been
              revised; in line with Councils suggestion regarding the earlier -version,
              the budget has been reduced, educational aspects strengthened and phate-
              but plans are included.

              Dr. Hess e7as not present durina Committee discussion or       action on the
              application.

                                                                                  GRB/RMPS


                                                   RE(@lO@4A],                  PROCitAMS
                             SUI,@IA]tY  01@'  ANi4l-Vi-I'l,@,A]tY           A@@ll) Al@@All,l)           APPL'FCAJ.'IO@4@
                                                     (A Privil.c,g(!d  Coqii@iunicaLiori)

                NLI%' JERSEY REGIONAL MEDICAL PROGRAM                                        RM 42-0    2   (AR-1-CSD)            2/71
                7  Glenwood Avenue                                                           January  1971 Review Cornniittee
                East- Orange,  New Jersey

                PROGI@@L COORDINATOR:   Alvin A.  Florin, @I.D.

                                                         REQUEST (Direct Costs Only)

                                                            03                     04                       05                     Al],
                I'Ljrl)ose                      4/l/71-3/31./72             4/l/72-3/31/72                       4/l/73-3/31/73    Years

                C011ti.IlLiaLioji
                 Coniiititiii(,.iiV.             $1,236,1@76                                                                    $1,236,176
                Core                                  656,931-)                                                                      656,931.)
                6 Projects                            579,245)                                                                       579,245)
                Rc,nc,i,i,il Coi-npc)ri(,.rits   $          54,216                                                              $         54,216
                1 Project                             (54,216)                                                                       (54,216)
                Additional Contponents           $3,490,515                                                                   $11,770,391-@',-
                Dev(,Iop7,,c,ntal                     123,500)                                                                           (123,500)
                15 T,)tojects                          ($3,367,015)                $3,300,621@                 $3,299,625   (@ll.,646,891)*

                Total                            $4,780,907                         $3,300,624                 $3,299,625     $13,060,783
                taff Action Com-                         1,236,176                                                                     1,236,176
                mitmc,-it
               Os
                Conirnittc!e Action
                Requ@Lred                        $3,544,731                         $3,300,624                 $3,299,625     $11)824,607
                -(Prc
                @,       ect @r'18 has requested  support  for               a  fourth  ($832,21@2Ta  cl  fi   h  ($847,'85
                     years.)

                                                             Fuildi,]L,@l L-,La@y_
                                                               PI-ANNI!,T(; SJ'A-(;I-',.

                                   Grant Yc!@,ir                        Per 1 c)d
                                          01.                     7/l/6Y-6/30/68                            $271@,/il7
                                          02                      7/l/68-6/30/69                            $614,1@62

                                                         OPERATIONAT,         PIIO(,Ib@Yt

                Grant                                        Council                     l'undc,d
                Year             Period                    @Lr o@@ cl                      d (L-@

                           4/l/69-3/31@/70                       $1,306,273             $   979,705
                02         4/l/70-3/31/71                    1,415,891,                 $1.,306,906       2-1
                03         4/l/71-3/31/72                    1,623,?97                                                @1,236,2'j5
                01@.@      4/l/72-3/31/73                        197,833                                                   97,000

                I./(9                          for         nii(i  I?             ;iL ,,t        ](,v@-i
                                $68,22-'j of                             01  yc,,,ir.)


            Nhl4 JERSEY RMP                         -2-                 RM  42-02   (AR-1-CSD)

            (;(@oi?raphy and D  ri h     The New Jersey  Region  is  coterminous  with  the
                                         state.   IL  has  interfaces  with  the  Metropolitan
            Nciw ;ft)rk an(] tile Creater Delaware Valley RMPS.  There is over lapping
            _@ltiris(licLion, however, in the southern seven counties of  New  Jersey  with
            Llic (;reaL(!r Delaware Valley RMP.  A special liaison committee has been
            organized to help deal with this problem.
            New Jersey is  a  very  densely  populated  state,  with  approximately  7,100,000
            people, as of the 1960 census, in its 7,521 square mile area.       The  New   Jersey
            Region is served by 8,531 M.D.s,  523  D.O.s  and  23,758  active  nurses  as  o
            1962) and  has  54,960  hospital  beds.
            New Jersey  has  two  medical  schools: the New Jersey  College  of  Medicine  and
            Dentistry in  Newark  and  the  Rutgers Medical School  in  New  Brunswick.  As  of
            July 1, 1970, legislation was  signed  by  the  Governor,  establishing  a  single
            Board of Trustees for  the  two  medical  schools.  A  steering  committee  has
            been formed and will  serve  as  the  Department  of  Continuing  Physician  Education
            of the medical school of  the  state  as  the  new  administrative  arrangements
            are determined (p. 178).
            Regional D evelopment: The  New  Jersey  Joint  Committee  for  Implementation  of
                                     P.L. 89-239 was incorporated in  early  19.66  to  draw
            together the appropriate groups to begin planning for all RMP.      The   first
            planning application, received  in  September  1966,  was  returned  for  revision
            because of the 1) lack of a strong medical school (one was under development
            and the other was  undergoing  extensive  reorganization),  2)  the  vagueness  of
            the proposed plans and  3)  the  lack  of  definition  about  existing  resources.
            The revised submission was  approved  in  July  1967  with  the  following  comments:
            1) indication that the role of  the  two  medical  schools  has  been  diminished  in
            favor of a separate group  of  professional  people  who  will  spear-head  the
            planning was viewed as an improvement; 2) the program methodology and evaluation
            were not clearly stated; and 3) the  region  will  have  to  consider  disposition  of
            staff and equipment if  future  planning  dictates  dividing  the  area  into  new
            regions for the operational phase.
            During the planning phase, Dr. Florin, on loan from the State Health Department's
            fIeart Di.sease Control Program, was  appointed  Coordinator  and  18  other  Core
            staff  personnel  were  also  employed. Urban health  planning  was  becoming  a
            strong feature of the program: the Urban Health Task Force was organized and
            three staff were employed t.o work with  the  three  Model  Cities  Programs  in
            tile state.
            'File operational application was reviewed  and  approved,  following  a  site  visit
            in September 1968.    The site visitors pointed  out  that:  1)  the  medical  schools
            problems of reorganization and early growth  has  forced  the  @IP  to  draw  on  the
            skills and abilities of the more highly developed hospitals and other facilities;
                full information about the portion of  medical  needs  of  New  Jersey  being  met
            in New York and Philadelphia is not available; 3) individual New Jersey hospitals


            NEW JERSEY RMP                              -3-             RM  42-CP  (AR-1-CSD)

            have developed  independently and may  have  less  experience  in  cooperative
            efforL than in  areas where medical school  affiliations  have  been  in  effect;
            ,,iti(I li) the historical separation between the northern and southern parts  of
                 state @,,i.ves way slowly.  Approval was given to three coronary nurse
            training proposals,  an  external  cardiopulmonary  resuscitation  program,  a
            training program in coronary  cineangrography,  an  evaluation  of  the  status
            of implanted pacemakers, tumor  conference  boards  in  hospitals,  a  medical
            tape and fall library, and a hemodialysis training program.

            f)uring the first operational year, a  supplemental  project  request  to  detect
            high risk atherosclerosis in an  industrial  setting  was  submitted  and  dis-
            approved, and Core was renewed  for  three  years.  Problems  arose  during  this
            time between the Camden County Medical Society and the proposers of the
            West Jersey Hospital ambulatory  care  project,  which  would  have  attempted
            to evaluate a new,pattern of health care  for  an  indigent  population  in  an
            urban ghetto area. Since there  were  feelings  among  certain  forces  that  the
            proposal would disturb the existing  patterns  of  delivery  of  service,  the
            proposal was withdrawn from RAG consideration.

            The second operational year saw the approval and funding of six Urban Health
            Coordinators for Model Cities areas, the approval and funding (from carryover)
            of A cancer care course for nurses and continuation of  Core  and  six  of  the
            original nine projects. The  Region's  present  level  of  funding  is  $1,306,906,
            $69,125 of which is carryover  '  The Region has  allocated  $872,956  to  Core
            (including the Urban Health Component) and $433,950 to projects.

            Regional Objectives

            Determination of the NJRMP's objectives came as a result of the reorganization
            of the RAG. While some members  apparently  felt"that  the  law  should  be  inter-
            preted literally," others looked upon  the  legislation  as  a  general  guideline.
            The Regional Advisory Group reports  that  its  many  new  members  (including
            several consumer and minority group  representation)  urged  that  the  program  be
            concerned with improving the accessibility, quality and quantity of health care
            for the disadvantaged. As  these  consumer  interests  emerged,  they  received
            support from some of the provider representatives.

            Three general. goals have evolved:

                1) improving accessibility, quality and quantity of hc-al.tfi servi.ces  for
                  the urban disadvantaged;
                2) increasing the effectiveness and efficiency of existing health
                  facilities and services; and
                3) increasing the skills and knowledge of health practitioners.

            The Region has discussed each of its  program  components  as  they  relate  to
            these objectives and has also assigned a  priority  rating  to  each  new  project.

            Organizational Structure and Processes

            Ttiiti,ill.y the NJRMP RAG had 57 members with a  15-member  Executive  Committee
            composed of representatives of the  medical  profession,  medical  schools  and
            ;tat:e and voluntary health  agencies.  Following  a  major  reorganization,  the


             N EW J ERS CY @T                         -4-               RM   42-@   (AR-1-CSD)

             25-member RAG  now  includes  13  members  at  large  and  12  permanent  members
             who  continue  to  represent  the  major  health  interests  of  the  Regioq.  With
             the  13  general  members,  consumer  representation  was  added.  The  RAG  is   the
             major priority setter and decision-making body.  They review ongoing
             (,I)erations, Core staff activities and the activities of the councils and task
             forces.  Rather  than  reviewing  individual  proposals  on  their  own   merits,   the
             RAG now  considers  each  in  the  context  of  the  three  regional  objectives.

             'I'lic following councils and  committees  have  been  established  by  the  RAG:

                  Executive Committee
                  Nominating   Committee
                  Council   on Ifeart and Related Diseases
                  Council   on Cancer
                  Council   on Cerebrovascular Disease and Stroke
                  Council   on Continuing Education for Physicians
                  Council   on Continuing Education for Allied Health Personnel
                  Urban Health Task Force
                  Council on Communications
                  Committee on Information and Library Services

             Each  council  develops  areas  of  priority  and  suggests  project  activities   to
             be deve loped  by  staff.  Following  approval  of  a  specific  project  concept,   it
             is  then  discussed  by  the  RAG  and  approved  for  project  development.  After
             staff development,  when  the  project  is  written,  it  is  reviewed  by  the  appro-
             priate  council  and  referred  to  the  RAG  with  the  council's   recommendations.
             The councils' technical review criteria have not be discussed in the applica-
             tion.

             Fc)r a discussion of Core structure and function. please refer to the
             continuation section of the application components.

             Developmental Component                                                    $123,500

             Developmental funds will be used to explore new areas and test new
             concepts  related to the three regional goals.

                  1.   Improving  Urban  Health.  The  Region  will  explore  group   practice   in
                       the  ghetto  area,  new  health  career  opportunities  and  career   ladder
                       opportunities  for  the  utilization  of   community   health   consultants,
                       and the  concept  of  the  liospital-based  family  health  care  center.

                  2.   Increasin-  Existing  Health  S(--rvices.  Ideas  the  Region  would   like
                       to investigate under this objective are a method for collecting
                       health  information  on  facilities,  service  and  manpower,  the   need
                       and acceptability for a comprehensive treatment service for patients
                       with chronic obstructive lung disease, and a plan for the procurement,
                       storage and utilization of human organs for transplantation.

                  3.   Improving  the  Skills  and  Knowledge  of  Health  Practitioners.  A(@-ti@-
                       vi.ties planned under this objective are programs to encourage
                       Physicians  Lo  increase  their  diagnostic  skills  in   early   recognition


           NE4 JERSEY -PMP                       -5-                RM 42-02    (AR-1-CSD)

                    and  treatment  of  coronary  heart  disease,  the  establishment  of
                    community  centers  designed  and  equipped  to  identify  high  risk
                    heart disease patients, and programs in stroke education and
                    management.

               allocation of funds will be determined jointly by staff, councils and
           RA(;, with t[ic- RAG giving final'approval of each activity.

           Present Application

           Continuation  -  These  components  have  been  reviewed  by  staff.  Their   program
           and funding recommendations are in a supplementary memo.

           Core                                                                $656,931

                                             Coordinator
                                         Dr. Alvin Florin
                                                  I
           Fiscal Office ---------------- Deputy Coordinator    ------------- Communications
                                        Dr. James Harkness              Statistical
                                                                        Services
                                                                        Administrative
                                                                        Assistant
           Dirlector of                                                           I
           Continuing                    Program Director                  Director    of*
           Education of                               Heart Disease        Urban    Health
           Physicians              Associate          Program Coord.       Planning
               I                   Coordinator        Cancer               and
           Project Coordinator*                       Program   Coord.*    Urban    Health
                                   Field Coord.7-      &  Asst.  Coord.    Coordinators*
                                   NJCM&D          -,Stroke      Program
                                   2 Field Coord'@.    Coordinator
                                     South Jersey -- 2 Nursing &
                                                        Allied   Health
                                                        Coordinators

           *Funded by operational projects.

           Each funded and proposed project is assi.gn(@d ,i Core staff I.iaisoii officer
           who assists the affiliated institution in achieving i.Ls goals, relating  the
           activities of one project to others and monitoring the  project's  progress.
           During project development, fie assists with wording purposes and  objectives,
           suggests funds required to achieve stated objectives and  develops  evaluation
           methods.  In addition, a large number of the new projects in this application
           resulted from feasibility studies, in whicfi staff participated.  These activi-
           ties form the documentation upon which evaluation of program  achievement  is
           made.

           Staff also are expected to be familiar with developments in the  region  and
           the nation in his substantive area. Each senior Core staff  member  has  major
           responsibility for staffing a council or task force.


             NI;14 JERSEY DIP                             -6-                     Rm    42-0,'    (AR-1-CSD)

             Salaries  of  several  of  the   Core   staff   members   are   funded   by   projects.   The
             Urban Health Coordinators-are one example.  This project was written to
             provide  each  of  the  nine  Model  Cities  with   a   senior   health   planner   to   help
             p 1,'iii,  develop  and  implement  the  health  component  of   the   DIIUD   Model   Cities
             @)ro,,,ram.  They have also operated,in many instances, to obtain technical
             @issistance  and  categorical   funding   for   the   health   plan   and   related   projects.
             Tn addition to the.Urban Health Coordinators (Project #12), the cancer
             program coordinators are assigned to the tumor conference board program and
             a physician will be detailed to assist with the first year's development of
             Project   #14,   Regional   Program   for    Continuing    Physician    Education.    Other
             staff members are assigned to the New Jersey College of Medicine and Dentistry,
             the  SLate  Health  Department   and   the   Southern   District   Health   Office   of   the
             SLate  Health  Department  for   development   of   an   application   to   establish   a   CHP
             (b) Agency.
             As  far  as  relations  with  CIIP  are   concerned,   there   were   some   suggestions   that
             @IP and CHP staffs be combined.  A joint committee studied a plan for possible
             merger,  but  after  a  new  Director   of   CHP   was   appointed,   plans   were   dropped.
             Subregionalization   activities   in   the   NJRMP   have   been   coordinated   with   the
             development of b agencies.

             Core staff members have been involved in numerous other activities which
             facilitate planning in the region.  They have been responsible for such
             activities   as   arranging   for   systems   analysis   consultation   for   a   statewide
             mobile screening service, assistance to a local hospital in developing a pro-
             posal for psychiatric aspects of patients with coronary artery disease
             organizing subregional cancer conferences and facilitating project dev;lopment@@',@,               .
             in funded Model Cities related to other federal and state agencies.

             There are 28..5 full-time positions budgeted; all but one are filled.

             Continuation    support is also requested for six ongoing projects:

                   Project   #4   -External Cardiopulmonary Resuscitation
                   Project   #6   -Evaluation of the Status of Implanted Pacemakers
                   Project   #7   -The Establishment of Tumor Conference Boards in
                                   New Jersey Hospitals
                   Project   #,9  -II(-modialysis Training Program
                   Project   lkil- Cancer Care Course for Nurses
                   llrt-ii cc ti'r' IUrban ][earth Component

             @'(,iiewat
             ilroject 7-,@'-3R - Ro,,,,ioAal 'rraiiiin@;      for Cardiac Nursing.                  $66,252
             @ile visit, Committee and Council action are required for this one-year
             rc,ii(-,w,il  request.  The  project  requests  a  third  year   of   support   to   continue
             to meet the needs of the Region's community hospitals for registered nurses
             trained in intensive coronary care until the transition to NJRMP                is  goal   of
             decentralized   nurse   training   is   achieved.   The   Newark   Beth   Israel    Medical
             Cc,nter will train an additional 80 nurses in the four-week course.


            NE14 JERSEY RMP                         -7-              RM 42-0?    (AR-1-CSD)

            Supplemental Projects.

            Site visit, Committee and Council actionarerequired in the following
            1.5 projects.

            Project /r'1.3 - Hospital Based Family ft(,alth Care Service, Middlesex      $235,066
                           General Hospital, New Brunswick.

            This project establishes  a  three-year  demonstration  program  to  evaluate
            the effectiveness, acceptability,  quality  and  cost  of  a  family-oriented
            comprehensive ambulatory health care service provided by a comunity
            general hospital representative of  the  majority  of  community  hospitals  in
            the region. The service  is  designed  to  strengthen  existing  community  re-
            sources for the disadvantaged with  a  formal  mechanism  for  direct  community
            participation in the planning and operation  of  the  service  (objective  #I)..

            This experience will provide the  New  Jersey  Regional  Medical  Program  with
            guidelines for the establishment and operation of hospital-based ambulatory
            services to meet the health  care  needs  of  the  disadvantaged.  These  NJR4P
            guidelines will be available  to  community  hospitals  throughout  the  region.
            As the Regional Advisory Croup reviews the availability of health care
            services for the disadvantaged  throughout  the  region,  they  will  recognize
            gaps in services, establish priority communities and promote the adoption of
            community hospital-based ambulatory services,  and  be  able  to  recommend  a
            tested mechanism for the organization and delivery of service.

            The Regional Advisory Group will  promote  the  establishment  of  a  statewide
            committee to make recommendations  for  securing  new  financial  resources  in
            order to insure the continuation of this  service  and  its  adoption  in  other
            community hospitals.

            Second Year:  $223,670                                Third  Year:   $237,647

            Project l@14 - Regional Program for Continuing Physician Education.       $70,758

            This project proposes to provide  all  practicing  physicians  in  the  region
            with an opportunity to become aware of all phases of medical knowledge
            and development through a  medical  school  organized  program  of  continuing
            physician education in order that the hi.ghest  quality  of  medical  care  can
            be delivered through a coordinated and supervised system.  The Medical
            College of Now Jersey at  Newark  will  organize  a  region-wide  educational
            program for practicing physicians involving community hospitals and specialty
            societies.

            'this project addresses the goal of increasing  the  skills  and  knowledge  of
            health practitioners (#3) by coordinating educational programs for physicians
            sponsored by hospitals, medical schools, the Academy of Medicine and specialty
            societies.

            Second Year:  $108,062                             Third Year:  $151,649


           NEW JERSEY RNP                                            RM 42-02 (AR-1-CSD)

                                      e'                                                3,973
                         Comprehensiv  Stroke Car  and Educational Program.
           Project #15                             e                                  $15
           'File purpose of this project is to encourage the staffs of six local
           hospitals serving a population of 616,640 in  a  two-county  area  to  parti-
           cipate in a cooperative educational and clinical program designed to increase
           their knowledge'@and effectiveness in the  care  of  patients  with'transient
           Lscliemic attacks and completed strokes.

           'file Council on Cerebrovascular Disease and Stroke  established  a  regional
           plan for the development of  comprehensive  stroke  care  services.  After  ayear
           and a.lialf of detailed planning and building cooperative working relation-
           ships, an application for a  two-county  program  was  designed.  Project  #15
           provides new services and facilities (objective #2) for stroke care.  It wi
           also encourage physicians to refer  patients  to  these  services.  This  project
           will coordinate the resources of six hospitals  to  insure  that  all  stroke
           patients in a subregion receive the full  range  of  services  required.
           Second Year:  $132,971                            Third Year:  $138,911
           Project,#16 - Professional and Patient Stroke Educational Program.        $73,873
           The a.im of this project is to encourage and stimulate the staffs of
           ten community hospitals in Bergen County  (population  one  million)  to
           strengthen the management and prevention of cerebrovascular disease by
           participating in cooperative  demonstration  education  programs  designed  to
           increase the knowledge and effectiveness of physicians, 'nurses, allied health
           personnel, and families of patients.  Developed on the basis of recommendations'-",..-,.'
           of a feasibility study, this project attacks objective #3 by improving patient
           care through the education of physicians,  nurses  and  other  allied  health
           personnel.  It also helps to achieve a balanced categorical program for the
           region, promotes subregionalization  and  involves  the  practicing  physician
           in planning.
           Second Year:  $77,091                             Third  Year:   $76,174
           Project #17 - Regional Blood Freezing Program.                         $63,720
           This project hopes to increase the opportunities for all patients     in  New
           Jersey to have access to a frozen blood program so that they will      receive
           the advantages of newer and safer  methods  of  blood  replacement.  It  will
           accomplish this aim by expanding the Essex County  Blood  Bank  to  a  region-
           wide system, educating health professions about the  use  of  frozen  blood,  and
           increasing the emergency supply of blood in the region.
           '-riiis. project serves the region's second objective by decreasing the  risk
           invofved in multiple transfusions and increasing the effectiveness of organ
           transplants. It also provides an  additional  source  of  blood  for  emergencies
           and rare blood type needs.

           Second Year:  $54,021                             Third  Year:   $18,185


           NEW JERSEY RMP                       -9-              RM 42-OL> (AR-1-CSD)

           Project #18 - Model Cities Community Health Improvement Program.         $824,929
           ']'lie. Model Cities Community Health Improvement Program has been formulated
           to provide health planners with the requisite information for designing
           ii(ic,ded improvements i.n the health care delivery system for ghetto residents.
              Program wil.l. Identify and describe the scope of major health problems,
           the utilization of existing health services and  the  spectrum  of  obstacles
           to utilization - information, motivation, availability, accessibility,
           facilities, and financing.  Through a large-scale mobile screening service,
           employing Model Cities residents, the proposed program will include inter-
           views, health examinations, referral and follow-up services, and provide
           a limited funding mechanism for the medically indigent.  It will permit
           entry into the health care system, and give impetus  to  the  improvement  of
           local health care delivery through specific recommendations to Model Cities
           agencies resulting from the analysis of.program operations.  This project is
           designed to offer screening and referral  services  until  the  comprehensive
           health centers are more widely established.
           Second Year:  $954,084                          Third Year:  $967,820
           Fourth Year:  $832,242                          Fifth Year:  $847,385
           Project #19 - Comprehensive Family Health Service, Newark Beth Israel  @51,21r),59f,
                         Medical Center.

           This project would establish a tiiree-year demonstration program to evaluate
           the effectiveness, acceptability, quality and cost of a family-oriented,
           group practice,comprehensive health service in an urban community hospital
           setting.  The service is designed to fill the physician deficit in a central
           city area serving disadvantaged and medically indigent families, and to
           provide for direct consumer decision-making in the planning and operation of
           the service.

           This experience will provide the New Jersey  Regional  Medical  Program  with  the
           ,necessary information on personnel and facility and funding needs for deliver-
           ing acceptable and adequate medical care  to  this  population  through  community
           hospitals.  The information will be used to develop guidelines for the
           establishment and operation of a hospital-based ambulatory care service with
           recommendations for the funding required to provide this  type  of  care  for  the
           entire region.
           High priority has been accorded by the.Region to  this  project  and  Project  #13
           as ways to test the concept of providing compreheiisiv(-! heal.th services to  the
           disadvantaged (objective #I) through the existing hospital facilities of the
           region, rather than tliroupli the establishment of new, co,@ti.y free-standing
           centers.

           Second Year:  $1,150,513                          Third Year:  $1,193,249
           Project #20 - Decentralized R.N., L.P.NI Cardi,ac Nurse Training.        $84,405
           Tile aim of this proposal is to improve the care of patients with cardiac
           conditions by increasing the capability of local hospitals in a four-couhty


          NEW JERSEY RMP,                        -10-            RM 42-02 (AR-i-C@D)

          subregion to conduct their own training programs for nurses, and by
          establishing a new'role and training progrqm for Licensed Practical   Nurses
          in intensive cardiac care.

          The project resulted from a feasibility study of multimedia instructional
          systems which determined that, when utilized under the supervision of skilled
          faculty, this teaching method can be effectively and  economically  employed
          in local hospitals to train'their own staff. The proposal  furthers  the  aim
          of objective #3 by improving the knowledge and skills of R.N.s  and  L.P,N.s6

          Second Year: $70,496

          Project @k2l - Nursing Education for Leadership and Clinical Teaching.  $41,579

          Proposed by Rutgers University, Extension Division, this project would
          attempt to meet the region's continuing need for leadership and  teaching  of
          hospital nursing'staff in specialized clinical areas by  inaugurating  an
          educational resource within Rutgers, to develop the leadership  skills  of
          iiurses and prepare them as clinical instructors in  cardiovascular-cardiopul-
          monary patient care in the first year, and additional clinical areas  in  the
          second and third years.

          Second Year:  $48,598                                Third  Year:  $50,168
          Project #22 - A Regional Radiation Automated Dosimety Project.        $184)082

          Project #22 is grouped under the objective of increasing  the  effectiveness
          and efficiency of existing health facilities and services.  It  will  link
          the resources of major medical centers of the area to the community hospitals
          by establishing a mechanism to program radiation  doses.  Radiotherapists  and
          physicists will be freed to extend their services to  hospitals  treating
          patients with megavoltage equipment, but without qualified personnel.  Directed
          by the New Jersey College of Medicine and Dentistry, the project  will  make
          available and accessible optimal radiation therapy for cancer patients through-
          out the region by providing radiation therapy consultation  and  automated
          dosimetry for patient radiation therapy departments having megavoltage radia-
          tic)n therapy equipment. The project developed as a result of  a  regional
          radiation therapy survey undertaken by the NJF14P Cancer Council.

          Second Year:  $96,116                              Third  Year:  $100,955

          Project #23 - A Cervical Cancer Screening and Education Program.      $162,825

          Originally funded as a 314e grant, this project provides a means of
          delivering the benefits of a cervical cytology program  (referral,  screening
          and follow-up) to increase the early detection of cervical  cancer  among
          females at high risk in low socioeconomic groups in a  sub-region  of  New
          Jersey (Middlesex County: population 560,000 people); and also provides a
          demonstration program for other sub-regions of the state.  The  proposal  is
          also expected to increase the region's knowledge about the extent  of  disease
          among the disadvantaged (objective #1).
          Second Yoar:  $174,469                            Third Year:  $197,686


             Ni@'w JPRSI-l'y l@P                                       RM 42-02  (AR-]--CSD)

             Project IP24 - A Training Course for N.J. Tumor Registry Secretaries      $19,140
             Sponsored by the NJRMP, this proposal will organize courses and workshops
             to train tumor registry secretaries.  It was generated from the activities
             of the ongoing Tumor Conference Board project, which saw the need for
             comprehensive and up-to-date records of cancer patients to insure follow-
             up and suggest the location of specialized  facilities  for  cancer  treatment.
             As such, it addresses the goal of improving the knowledge and skills of
             health practitioners (objective l@3).
           Second Year:  $19,142                                 Third Year:  $19,778
             Project #25 - Primary Rheumatic Heart Disease.                            $66,517
             This project's purpose is to reduce the  incidence  of  rheumatic  heart  disease
             through the early identification of  streptoccoccal infection by providing
             free throat cultures to all school children with symptoms of sore throat
             in a subregion, utilizing school nurses; by outlining and conducting an
             educational program on the importance of this procedure; and by providing
             a home follow-up mechanism for children failing  to  maintain  penicillin  treat-
             ment. IL will increase the  effectiveness  and  efficiency  of  existing  health
             services (objective #2) by utilizing the services of the school nurse,
             Second Year:  $59,035                                Third Year:  $56,792
             Project #26 - Regional Medical Library and Information Network.          $122,608
             Sponsored by the New Jersey College of  Medicine  and  Dentistry,  this  project
             is designed to strengthen the capability  of  the  region's  community  hospital
             libraries to provide  readily  accessible,  comprehensive  medical  information
             for patient care by creating  a  regionallibrary  network,  training  personnel
             and expanding information services.  The capability of community hospital
             libraries and their staffs will be increased  and  made  more  effective  through
             this network, which will link all hospitals to  the  existing  regional  li-brary
             resources at the medical schools.
             Second Year:  $92,790                                 Third Year:  $63,842
             Project #27 - New Jersey Consumer Health Radio Program Series.            $52,950
             This project will call. upon the resources of all 49 local radio stations
             within the region for disseminating specially prepared programs for the
             disadvantaged and the general public.  The project @7ill be organized and
             directed by the Communications Division of the New Jersey College of Medicine
             and Dentistry working with the scientific faculty.  Thus, the project utilizes
             existing radio facilities and various  departments  and  resources  within  the
             college, as well as informing the disadvantaged about  good  health  practice,-,,
             answering questions about special  health  problems,  and  providing  information
             about access to available services (objective  #].).  The  College  conducted  a
             pilot experiment in the use of radi-o to  answer  consumer  questions  concerning
             health and medical care with a grant from the  flunt  Wesson  Corporation,  which
             produced exceptional results: an increase in registration  iL  tl@ic  Pre-Natal
             C'li-nic, Drug Abuse Clinic and Family Health Care (,enter and, some  decline  in
             the use of the Emergency Room for optional services.
             Second Year:  $39,256                                 Third Year:  $26,769


                             DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE
                                             PUBLIC HEALTH SERVICR@
                               HEALTH SEFTVICES AND MENTAL T-IEALTH ADMINISTRATION

          Date: December 1, 1970

            to
          ,in Of.

         Subject. Staff Review of Non-Competing Continuation Applicati on from New Jersey
             .  Regional Medical Program, 5 C03 RM   00042

                Acting Director
                'Regional Medical Programs Service

                THROUCII:  Chairman of the Month

                                                a]. Development Bra
                          Acting Chief, Region                     nch

                The New Jersey Regional Medical Program i.s requesting   continuation
                support for its 03 operational year for core and six projects.  Since
                New Jersey's budget year does not start until April 1, 1971, and the
                45-day estimate of expenditures is not due until mid-February, requests
                for use of carryover funds have not been included in the present
                application.  It should be noted that the Region has no approved and
                unfunded projects.  Therefore, the discussion was limited to the following
                continuation request.

                     Continuation Requested                               Amount

                Core                                                     $656,931

                #4 -.External Cardiopulmonary Resuscitation               50,545

                #6 - Evaluation of :the Status of Implanted               68,104
                     Pacemakers

                #7  -Establishment of Tumor Gonference Boards            150,02
                     in New Jersey Ilospitals

                #9  -Hemodial.ysis Traini.no Program                      40,144
                                           C)

                #II- Cancer Care Course for Nurses                        61)414

                #12- Urban Hoilth Component of Core                       209@01.6

                             Total   Request                          $1  236,176

                Besides the continuation request, the R(@gi.on has included i,ii its AR
                application, a request for a one-year devclopiiletital component, one
                renewal and 15 new projects.  The Region was supported by a funding
                level of $1,306,906 during the 02 year; this amount included $69,1.25
                in carryover.


                 Acting Director, RMPS Page 2
                 Recommendation:  In view of the progress evidenced by the projects (some
                 have exceeded their objectives) and the apparent competence of core staff,
                 approval of the committed level for the 03 year is recommended.
                 The following staff members attended the November 23 meeting:
                     Miss Dona Houseal, Grants Review Branch
                     Mr. Lee Teets, Grants Management Branch
                                'tte, Planning and Evaluation
                     Mr. Larry Wi                             Branch
                     Dr. Veronica Conley, Continuing Education and Training Branch

                 Gene al Comments and Site Visit Issues:
                 Staff found the application well-presented.  Three regional objectives
                 are outlined, and throughout the application, past, present and future
                 activities are related to these goals. The regional objectives are:
                     1) improving the accessibility, quality,and quantity-of health
                        services for the urban disadvantaged;
                     2) increasing-the effectiveness and efficiency of existing health
                        facilities and services; and
                     3) increasing the skills and knowledge of health practitioners.
                 The application informs us that the Regional Advisory Group's responsi-
                 bility is to establish priorities and review proposals based on these
                 objectives, while the Task Forces and Councils provide technical review
                 of the projects and recommend policy in their special. areas.  Core staff
                 involvement includes assisting with development of projects, conducting
                 feasibility studies and staffing the Councils and Task Forces.  Based on
                 this information, staff raised the following concerns for the site
                 visitors' attention:
                  -  Review C i-teri-a.  The Region has not included its review criteria
                 used by its Task Forces and Councils for technical review of projects.
                 Since this type. of review has now been transferred to the Regions, it
                 becomes very important for national reviewers to have some judgment of
                 this process.  Therefore, the Region should be asked to discuss this
                 during the site visit.  Staff was also interested in knowing how ideas
                 for feasibility studies for proposed projects are selected.
                      Reorg:aiiizati.on of RAG.  Following a major reorganization , the RAG
                 now includes 13 general and consumer members, five of whom are blicks.
                 As a result of this change, certain objectives have been set for the Region..
                 Staff wonders what problems have occurred and how the PI@IP --- Corr-,
                 review groups and involved organizations -.-- have coped with them.  The
                 -question  f Medical @ociety involvement is crucial here-
                          0


               Acting Director, RMPS    Page 3

                    Evaluation. Who on  Core  staff  is  responsible  for  coordinating
               evaluation efforts, both project and program evaluation?

                    medical School Involvement.  Medical school development is in a
               state of flux in New Jersey.  Staff is concerned about the degree of
               medical school involvement in RMP as a result of this change.

                    Status of Board for Grantee Agency_. In November 1968, the RAG was
               reduced from a 57-member to a 25-member policy-making body which was to
               serve as a Board of Directors for the  governing  body  of  the  grantee
               institution, the New Jersey Committee for Implementation of P.L. 89-239o
               Staff is concerned about this overlapping membership and that the RAG,
               by serving as the board for the grantee agency, may be advising itself.
               Staff would like the site visitors to explore this situation and
               determine whether such a conflict of interest exists in guidance of the
               program.

                    Support of Proposed Projects  Without  RMP  Funds.  The  Region  is
               requesting  approximately $11,500,000 in supplemental project activities.
               Given the'apparently bleak prospects for a significant increase in the
               national  vailability of funds for such activities in the next year,
               staff wondered if the Region had any  plans  for  alternate  sources  of
               funding.

               Conclusion:: The committed amount of @1,236,176 is recommended for thta
               Region's  third operational year.

               Sarah J. Silsbee
               Acting Chief
               Grants ReTiew Branch

               Action by,Director

               Initials

               Date


                                                                                                                                                    @l, 11 C.!   c@ 4,@

                                                              ST-                   T  @,v7      A. @@t)
                                                                                                           Co

                                                                              42-02               1- CS!))     2 /7 1

                                                                                                                                      cp-17J
                                                                                  13'Z                    1971.

                                                                                                                                             t
                                                                                                                                                    2)                t
                                                                                                                         C,
                        for  15             projects,  arLl  3)  zi                                                                 1):! partially
                        sttp,@,@.rtr@et  z,!;   f c, 1 107 7@@,

                        y

                                                                                                                  $         I , 2  3  1

                                                                                                                              3,300,624             3 ,  3 "D     2  l@

                                                                                                                             3,299,@625             3,,299,625
                                                                                     $123,5f.')O                        70   1,   I,-,7         $ 1 3    0      7   3

                        Yi l@R                     A

                                                                              1) a, v -a Ir,@  "Ii                          c t s

                        03                     $1,236,176                        -1 2        @Do                                2   5                     $2,9S9,50'L

                                                                                                                   1   31,17   75,@',               1,357
                        05                                                                                                                          1,276,466
                        Tb,.r.,@ L                                               1 2 3   5  0  0                          @4,264,041.                     $5,623,7.17

                                                                                          tioiis
                           Ba,,ie  es  site  visit               recon@i@@Lid@.
                                             Iii  its  del5.bei7,iti@c)ii,  tl.,c@             Cr)nii@.ii.ttee       vccc-,-)ted        ttie        report of       thc-
                                              site  visit  to  the                                     P..t@-,-I,on  on                             10-11,      19700
                        Ti-ie  visitors                            on                                  of  this                       -@)@ic2  tl@ie     1,i 5 t


                    NEII J@",SEY RZ-IP                                       -2-                                -Ml 42-02 (AP,-I-CSD) 2/71

                    site visit.            Pic    reo::-a.,iized Regional Advl,,,--oy-y                            Ipp@@,ir's  to  be
                    functioning very              effectively   as   a    poli6y-makiii@    body,    The    PAC,    has
                    established tlire@@.a                                      goals                                for     Lllc--     o-r),-r-,tionil
                    projects  ;,;hicli  have  been  developed  by   a   proceeds   of   r!ecrotiatioiis   knIrnoLIrr
                    the  PA-r, merib rt;.           Althou-b  not very  sy,,3teTY.,.@tic,  title process
                    because  the  L,%-ro'  is  quite  active  and  involved.                                      and  lotir,
                    o jectives  should  be developed,  however,  to  insure a  plan of action  that  is
                    consistent and measurable.                        Vie  Itt@i-P has  not                             @t     data     bise,
                    although  they I,-.tve li  (I available d,-it,-  collected                                    other       a@e@icies        and
                    has  collected                             to  SLIDPOrt  ne@-,J3  fo-r                   call    the     pr,-),ject:s.
                    T    c    Region    sh,),,lld     devote,     rp-.3re     attention     to     ejt,4blis'tlinr,     a     (lita     base,
                    which      t..7ould      mainly      involve      the      synthesis       of       data       from       otber,a,.,encies*
                        e proj@ct  re-viel,7 procedures  are i,7ell  devcloi)@e,                                  appear to effectively
                    etteen      projects,,      set      priorities      aiid      r,,onitor      the      -success       of       already
                    f     nded      projects.      The      team      reccri-inended      and      Co,-,,ni.ttee      concurred      that      the
                    r      visa,)      process@should@inclticip-       an       idversnry       r@vie-@q       step       conducted       by:
                    l@  di-%Ii@Cluals OtIfic-@r              those.  if;,ib b@ave @-2ork,@O  on  tla--  dev6').o                       o@:

                    -Ci@     j                    ic)@i Mechanics              Iiia or,,,: -i- ti.n-n is 1,7elj.                              Vri(i
                        1,@@-o Oct eV          @t
                                 bly i@l; iiiisle.-@.red.                                tii@c  cl@@@.oi@iat  c)f n@7,i                tlie
                        O,, ic@  receivers,                                core stafl                      I,."@lly   be   ve@'d@d    to Al--IE)r.11le
                    t  I   c-@    a     11-Orkloc7d     (Since     on@-     of      the      present      Core      staff      Positions I,,,Ill
                    be     funded     out     of     a     project     budget     in     the     future,     this      position      could      be
                    de     ic  tei  to  t             efforts).

                    Al     far     as     iiiiple,,l,,erLt@,tion     ot     the     program     is     concerned,     this     Region,      has
                    ria    --  r,@ i-,ie  important  achievemc@xits.              In  ttie                  o,.f  stroriz" radical  schools
                           affiliate('. m6dical  centers,  tinny  coril,@iunity hospital,-,  ire                                                the
                           "I  i,,-i  sporso  its            continuing  education  ind patient  care detionstration
                                               c  @
                    a  tiv-"-tieb.   A                            education                           is     bel,n3     dc!Nelnntd     i,@,-.-ich
                    v        the  co @ unity                          as  the                         education  and  training  locus
                    for    p   sicignsi  nurses  and otlier health personnel.                                      IP    has    also    been     a
                    f  rc-e  n   getting   groups   of   hospitals   together   to   pl.LiK-i   region,--illy,   such   at
                    @i6i  &6tbk6  care  progrcl,@s and radiation                                           ficilit.1.6s.                RevieTiers
                    v;    re    iticularly  intri-yited  by  the  proposed                                             to   be    ri,@-in-tecl    by
                           lu  ity hospital.-,  (in tl,-i-7ark  and                      BrunswicIF)     i.;Iiich      7,70uld      test      the
                    c      t,      acceptance      an      overall      feasibility      of       the       co@,,ritinity       hospital       based
                    comprehensive                        care  center  in  a  large  and                           hospital             setti@n"7

                           0      i      pressiv6      wore      the      ReRion's      efforts       in'the       urban       hEllalth.6ector.
                           RO'liog has  s6.v6t6l vocal black consu  erscn  the-.   G                                       n      active       urban
                           It    'Taslt    Force     and'r4i     Urban     -lif,.alth     component     of     'coie     -..10hich     places
                    s      aff in    the     n     ne     tioddl     Citi6s     to     assist     with     the     development     of     the
                    h      it      part      of      the      l@-,del      Cities      npplicationo      These       urban       health       planners
                    h      e:als6     provdd     viluAble      in      seeking      other      sources      of      fun      ng      for
                    various       progta,-,i6,       increasing       the       awareness       of       residents        about        health
                    Ine  d6.@@ind  influcncit-trr  the overall  level  of                                         for       6tiier        aspects
                    of     th'e;@ladel Cities  prorram.

                           Re;ion has been  effective  in  involving  other                                state@1.1--@@Cl--    croLi-,DS     such
                    ci  s  thin I-IP-dicr@.1  Socic-,t,,,,  the                      tissociatioii         and  th,.- ly@iiriDes A6s6ciation.


                          IIE@L  JER@SLY   PdAll                                                    -3-                                   RI-,I 4,?-@iO2  (A-R-1-CSD)  2/71

                                   c                                                                                                                           0
                          )!T..di      I-Scliool              nnl             involvc@,t,--,nt   -.t   the    prec,,-rt                               is     c     nditionvj@,
                          by    tite@Lr    probl              :,is or                    and                      @,,c               iile ti:ie colitelill
                                            tl,.e  Gre  ter   Pc-lw,@iare   Va   Iley-                              a-nd t-li@. I,,L-w- -.Ters,@.y F-,4p 'over
                          tille te@ri  sout'@,i,@rn                                  in             Jer             is                  co-@,itrol,
                          agreed          w2lt,@ the  site  visitors                                     it      slio'tiliA      c-oi:.ttirtuc!      to      be      -r,@.,7nitoreLI(I.7

                                                                                                                                   attcntioii  til@  possibility
                          @Ono            mo@@,bee of  Co@@il!-Iittee  brou-tit  to                      the  groLp
                          of       conflict       Of-       iritelt:est       in       the       orgaiii@z@,itio@@i       iii       iF@-i3ch       the-,       'iloard        mciitbers-
                          of-               t,- tr, t  c-,    ri @.ttic@y,    't'-I-C                          Ci@.L--r@-,-it--Lo,@-:   for  t  :e  Ir@i)l
                                    PL.   8o-g39,             @l:'c  all@ litic,                             I:,   '01c,  tlic,  site  visitors                         liL-Vad
                          t   t   t'@i   i    p  sitttntibli  cio-c,.@n't@iccessarily  clictnte  ci  conflict  of  interest,
                          c             tee                        ttiet.in       order       to       obvi.,,@tte       ariy       cloubt       in.       the        futt@re,        it
                          should             be  rec-c        'L@eiided       that       the       I-Ieaion        ad            he       Boar(,Ils        mefrb-@        sh@il     in
                                                                                                                    just t                                                    p
                                                   -o
                                   t    w@,y,  p  ssi@bIN,@by  @dlinjz                                v@n-R.AG  me,@bei8   to  tliip-  Board

                          In-@co        r-Iiisiort,           t@ie reviewers I,erc                                                                                       pro
                          tc.)@      date      ,-aid                                            is                  to                    tl,i,@ incr@-i c.,cl
                                        .j:,L I i  i  it                 tl.,,-@  Anni@,@-rse..zy                                                         Rr@vici@7          rs
                          1)        :,Le,     bo                          'this      c,7)tiitl       b,-.@                              at  i@                          lo    .2.L'
                          f i.@    i   ri          level                                                            t
                          l@y      til      Cr@i      itt;    c  re    ,iltecl  fr   -I  Llie                                  of
                          c@mllr3  atinsz  fro                -ij4ot                   6L",6,anl.zritional cottin-s         sucl"@          as          hoipitals          an(i
                          ni    1-C    I      school         .   Piif-Is for a devol.or,@,A-Ac-.,4ital                      co.-.@,poncnt    vi@re    included,    in
                          @t     ic     i 4irig  16-vel.               tec@,,use  tili@,@                           has      ,t  good  rc-@co',.d  of  tAsiElz   Ef.'Iall
                          a  hunts,,   of   T"66              v  Spiac,in@-ttively,  as   t,7ell   ar:   tisii%cl   furi(Is   to   initiate
                          activ.@      ies                    e                   other  -,otircc-s  of  sopp,ort,                                                 @,&Trec@d   that
                          this            gion      r,,6ritecl  the  privilege  of  h@.vin@,,                                           fle:,,ib3.e  Money..


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

                New Mexico Regional Medical Program             RM 00034  2/71.1 (S)
                University of New Mexico Medical School         January 1971 Review Committee
                920 Stanford Drive,, Northeast
                Building 3-A
                Albuquerque, New Mexico  87106

                Program Coordinatot6  Reginald H. Fitz, M.D.

                                         Request (Direct Costs)

                Committee/Council Review:   03          04          05         Total

                Project #16             $45,188      $55,558     $575,069    $157,815
                (formerly #12)

                Note:  This project was presented to Committee and Council review at the
                       February-March 1970 cycle.  The Committeels recommendation for a
                "Return for revision and resubmission to include clarification of certain'
                concerns was endorsed by the National Advisory Council.  This present
                application represents these efforts.

                In order to keep the program active and in phase with the New Mexico
                school year, $16,000 was granted from unspent balances from the 02 year
                with the 03 year award, for six months only (September 1-February 28, 1971).

                RMPS Staff  Review:

                             Continuation Support for
                             Core Staff and 11 ongoing            $1$1036 ,719 (commitment)
                             activities

                             Carryover                               133,452

                             Total (d.c.)                         $1,170,171

                                            Funding History
                                          (direct costs only)

                                             Planning Sta&e

                Grant year        Period                               Funded

                01                10/l/66-9/30/67
                                 (grant extended from                  $384*317
                                  10/l/67-11/30/67)
                02                12/l/67-6/30/68                      $252,379
                                  (7 months)


            New Mexico RMP                      2                RM 00034 2/71.1 (S)

                                      operational Program
            Grant year          Period                              Funded
            oi                  7/l/68-6/30/69                        $965,305
            02                  7/l/69-8/31/70  (14 mos.)          1   252,911
            03                  9/l/70-8/31/71                      191703,171

            HISTORY OF PRESENT APPLICATION:
            This project was originally  submitted  for  the  February/March  1970
            cycle and returned for revision in view of certain deficiencies.
            The reviewers felt that New Mexico is an almost ideal area to carry
            out a PhonoCardioScan screening program, and moreover noted that it
            was an indication that New Mexico had established an appropriate
            set of priorities.
            The primary concern about the application was that a program of
            this scope could not rely completely on volunteer technicians as
            was planned.  Also  it was unclear how the computerized registry
            would be used for follow-up, and there were no other indications
            of such measures to be utilized.  There were no plans presented for
            phasing out RMP support, nor a statement  of  how  the  state,  county
            health departments or school boards, would eventually be called
            upon to provide support for the program.
            There were other technical and budgetary concerns which were
            communicated to the region, as well  as  the  suggestion  that  NM/RMP
            should seek assistance from other similar programs that are
            functioning well, such  as  Baltimore  and  Metropolitan  District
            of Columbia.
            At the time of the submission of  the  request  for  continuation  for
            the 03 year, RMPS staff gave special attention to a request for
            carryover funds (for one year only) to continue the salaries of
            physicians who had piloted certain demonstration activities.      Staff
            agreed to this proposal, in order to  keep  the  project  operational,
            and the continuation award of September 1, 1970 granted the amount
            of $16,000 to continue the program, but with the last six months
            funds restricted pending the  receipt  of  an  Anniversary  Review
            package on November 1, 1970, to include  a  revision  of  the  project
            in line with Committee/Council suggestions.
            NM/RMP decided to delay submission of the A/R application until
            February 1, 1971, which made it necessary to revise and update      this


           New Mexico RMP                        - 3 -         RM 00034  2/71.1  (S)

           project request for three years, for submission to the JAnuary/February
           1971 cycle.

           PRESENT APPLICATION:
                                                                                   First Year
           The revised application has followed very closely the suggestions  Recluested
           and concerns of the Review Committee and National Advisory Council. $45,188
           The objectives are:

                1.  To detect  previously  undiagnosed  organic  heart  disease
                    in school children.
                2.  To provide initial evaluation and, if needed, long term
                    follow-up for children who are found to have unrecognized
                    organic heart disease.
                3.  To establish the prevalence  of  previously  known  and  unknown
                    congenital and rheumatic heart  disease  in  New  Mexico  school
                    children.
                4.  To "delabel" children who have been previously diagnosed
                    as having heart disease, and are  found  to  be  free  from
                    cardiac disease by the screening physician.
                5.  To utilize these and  other  epidemiologic  data  to  establish
                    a registry for  congenital  and  rheumatic  heart  disease.
                6.  To acquaint health professionals in New Mexico with this
                    program, and to conduct education programs (e.g., in
                    association with screening clinics) for practicing physicians
                    and nurses.
                7.  To develop educational programs for children and parents
                    related to the nature, prophylaxis, and treatment of
                    heart disease.

           This proposal has been approved by the State Medical Society and has
           received favorable review  by  the  Comprehensive  Health  Planning  "A"
           Agency Council.    Community acceptance  has  been  excellent  and  many
           localities have requested  the  program  on  their  own  initiative.
           There have been no problems in recruiting volunteer technicians.

           In Los Alamos, an  educational  program  for  practicing  physicians  has
           been conducted in association with the local cardiac clinic.
           All communities requesting  heart  sound  screening  must  obtain  local
           medical society approval for  one  of  the  following  two  alternatives:
           (1) local medical society appoints one physician to conduct secondary
           screening in the school setting, or (2) requests the services of the
           Project Director or Assistant Director, or other physicians designated
           by   them.

           The PhonoCardioScan  Registry was established in order to facilitate
           accurate data collection and storage  and  to  provide  a  means  of
           continuing, regular follow-up of patients.  An elaborate computerized
           system will not be necessary since the anticipated number of new
           cases will probably not be greater than  150  -  250  per  year.  It  is
           possible that  ultimately  that  the  PhonoCarioScan  data  will  be
           incorporated into the region's Health Information System which is


           New Mexico RMP                       - 4 -         RM 00034 2/71.1 (S)

           planned.  Data collection and storage will be manual but will be
           designed for adaptation to computer systems if needed later on.

           The Project will be staffed by a Director, Dr. Robert F. Castle,
           assisted by Dr. Jonathan Abrams, (20'/. and 15%), a full-time  Nurse
           Coordinator and full-time Assistant PCS  Program  Coordinator,  plus
           ti4o part-time clerical staff.

           Three PhonoCardioScan computers have already been purchased, one by
           the N.M. Heart Association and two by the NM/RMP.  The Heart
           Association has also allocated $1,350 for travel expenses and provides
           office space and part-time  additional  secretarial  assistance.  The
           Heart Association has thus far absorbed telephone costs  as  well  as
           office supplies, and has pledged from $10,00-$15,000 in 1974-75 with
           modestincrements thereafter.

           Cost of individual case detection will be computed periodically.
           Direct costs vary inversely with numbers screened,  since  the  major
           outlay has been for the PhonCardioScan computers.  Costs will be computed
           with respect to grade and socioeconomic levels, although data collec-
           tion to date has not been so analyzed, but will begin with the
           appointment of the full-time Coordinator.  The registry, when
           established, will provide efficient cost analysis, as well as preva-
           lence rates from different socioeconomic and geographic areas.

           It is hopedthat the screening will become routine in most New Mexico
           school districts and some locally autonomous programs may be functioning
           by the end of the third year.  In most school systems the program will
           include pre-school (Head Start) children, as well as  4th  and  10th
           grade students.

           Direct costs for the program from February 1969 through  August  1970
           totalled approximately $19,780. Cost per child  screened  was  $1.20
           (through June 1970).  The cost of detecting each child with previously
           undiagnosed heart disease was $1,312.  The latter figure reflects the
           large initial cost of the screening devices.  These costs will
           decrease with more screenings per machine.

           During the academic year of 1971-72 an expansion of the  program  is
           projected.  By this time, a group of physicians and trained volunteers
           should be established throughout the state conducting the program in
           many  communi'ties.  Some long term support will be requested from CHP as
           well as state and local health budgets.

                    03 Year:  $55,558                 04 Year:   $57,069

                                                 RMPS/GRB/12/22/71


                                                          A  PRIVILEGED  COMMUNICATION

                                S@RY OF REVIEW AND CONCLUSION OF
                                  JANUARY 1971 REVIE7@ CO@a',IITTEE

                                NEW MEXICO REGIONAL MEDICAL PROGRAM
                                          I00034 2/71.1 (S)

                       FOR CONSIDERATION BY FEBRUARY 1971.  ADVISORY  COUNCIL

            RecoLn,iiendation:  Additional FunJs as requested to be provided with emphasis
                              on the importance of follo@,7-up data to be provided  to
                              the  registry.

            Y@ar'                    Request                     Recommended Vund'n

            03                       $45,188                          $45,188
            04                        55,558                           55,558
            05                        57,069                           57,069

              Total                 $157,815                         $157,815

            r@i@@e:  Project #16 (formerly#12).  The Review Committee was impressed
                       with the improvement in this revision,  but  still  had  reser-
            vations about part"time.physician personnel.  It  was  felt  that  the
            region'should be encouraged to enlist additional assistance from
            volunteers in order to maximize progress made thus  far  to  maintain  its
            momentum. The project is believed to  be  realistically  planned  for  the
            needs of New Mexico children.  The involvement of the Heart  ssociation
            is noteworthy as is the interest of the Department of Public Health
            which will eventually take over the program.

            The reviewers questions d the Consultant costs ($10 000)  in  lieu  of
            full-time staff, which will provide a fee of $50.00 per half-day for
            the secondary screening.  It was noted, however, that such physicians
            would be local, qualified, specially  trained  individuals,  or  fu  -time
            faculty of the University of New Mexico Med,ical  School.  In  the  latter
            case, the $5OoOO honorarium will be paid to the Faculty of Medicine
            Fund and not to the individual physicians.

            The other concern expressed was in reference to the documentation of
            cases detected.  Committee wondered if the registry will provide the
            means for continui@  follo-v7-up of these children, how they will
            be identified, etc.  The emphasis here was on the importance of
            the registry being kept in an "active" status  and  not  allowing  the
            data to lie dormant without appropriate follow-up.  The region should
            be cautioned about developing an excellent system, which without
            careful monitoring along the way, could fail  the  children  for  whom
            it was designed.

                                                        Pi,TT).q Ir-pp,II 8 /71


                              REGIONAL MEDICAL PROGRAMS SERVICE
                  SUMKARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                  (A Privileged Communication)
              New York Metropolitan                    RM 58-02 (AR-1-CDS) 2/71
                Regional Medical Program               Janaury 1971 Review Committee
              2 East 103rd Street
              New York, New York  10029

              Program Coordinator:  I. Jay Brightman, M.D.

                                     Request (Direct Costs)
              Committee/Council Review                 02               03             04

                Developmental Funds                    329,000)
                Four New Projects                      811,686)      $647,943       $760,512
              Total New Funds                      $1,140,686        $647,943       $760,512

              RMPS Staff Review

                Core                               ($1,146,791)
                10 Projects                          1,538,061)

              Total Continuation Funds             $2,684,852

              TOTAL REQUEST                        $3,825,538        $647,943       $760,512

              Staff Recommendation:  Continuation Funding at Committed Level

                $2,539,887
                ( 1,146,791) Core
                ( 1,393iO86) Projects

                                          Funding Histor_y

                                          Planning Stage
              Grant Year                       Period                        Award
                01                        6/l/67 - 5/31/68              $  967,000
                02                        6/l/68 - 9/30/69                1,688,875
                03                       10/l/69 - 1/31/70                  516,000


               New York Metropolitan RNP          -2-             RM 58-02 (AR-1-CDS) 2/71

                                        Operational Stage

               Grant Year           Period               Award               Commitment

                   01           2/l/70 - 1/31/71       $2,163,744
                   02           2/l/71 -12/31/71                              $2$539,887
                   03           1/l/72 -12/31/73                               1,932,320

               Background:  The New York Metropolitan Regional Medical  Program  covers
                            the five counties of New York and the  contiguous  counties
               of Westchester, Rockland, Orange and Putnam. It  serves  nine  million
               people, including 35,000 physicians, 223 hospitals, 43,000 nurses and
               a multitude of other professionals.

               Seven medical schools are located in the Region:  New  York  University,
               Columbia University, Albert,Einstein, SUNY Downstate  Medical  Center,
               Mount Sinai, New York Medical College and Cornell University.

               The Associated Medical Schools of Greater New York is the grantee agency.
               This organization was set up for the Regional Medical Program and includes
               the seven medical schools and the New York Academy  of  Medicine.  The
               Trustees are the seven deans and the director of  the  Academy.  Nominees
               for the Regional Advisory Group are recommended by a  Regional  Advisory
               Group (RAG) Committee and appointed by the Trustees.

               The New York Metropolitan RMP was first awarded planning funds on
               June 1' 1967.  Two projects were funded during the planning phase
               from earmarked funds for a mobile coronary care unit and  a  pediatric
               pulmonary diseases program.  Dr. I. Jay Brightman was appointed
               coordinator in January 1969.

               The Region applied for operational funds in May 1969, and a  site  visit
               was made in July 1969 at which time the team was impressed with the
               organizational changes that had been made under Dr. Brightman's
               direction:  broader representation of the RAG, the emergence of a
               Planning, Priorities, and Evaluation Committee, closer supervision of
               the medical school core staff and project operations by  the  Directors,
               and broader functions for the Technical Consulting Panels.  Council
               approved operational status and funding for five of the  eight  proposed
               projects in August, but due to funding restrictions, the first operational
               grant was not made until February 1, 1970.  Still, in its first year the
               Region has 10 on-going operational projects.
               Technical site visits were made to the Region in February 1970  and  July
               1970.  A site visit to study the Region's readiness for developmental
               funding was made in December 1970.


             New York Metropolitan RNP         -3-            RM 58-02 (AR-1-CDS) 2/71

             PRESENT APPLICATION

             Regional Advisory Group Report: The report describes the changes  that
                                              h'ave been made in the organization  of
             the Regional Advisory Group. The rules were'revised in 1969 by  an  Ad
             Hoc Committee on rules which has since been appointed a  standing  co@
             mittee.  The Steering Committee was increased to a 35-member Committee
             on Planning, Priorities and Evaluation. A Screening  Subcommittee  was
             organized as well as a Subcommittee on the Developmental Grant  and
             Priorities, a Subcommittee on Renewal Applications (which not only looks
             at renewal requests but continuation requests) and a Subcommittee  on
             Evaluation.

             Considering the geographic impact of the Regional Medical Program  to
             date, the RAG report indicates that the Northern counties,  especially
             Orange and Rockland Counties, are still behind in their  organization.
             Queens County will now have a County Committee.  There is cross
             representation with the New York City Health Services  Administration,
             the Health Department, the Westchester Health Department, the  Health
             and Hospital Corporation and the Hospital Council of Southern New York.
             The Comprehensive Health Planning (b) Agencies have not yet been
             established although there is cross representation with the  statewide
             CHP.

             The categorical disease planning groups completed regionalized  plans
             in heart disease and cancer.  Stroke, diabetes, and renal disease
             regionalized plans are well along the way in draft form.

             The RAG report indicates that the contribution and involvement of
             the medical schools faculties is still a problem.  They found that the
             Associate Director positions had not worked out as well as expected and
             a Medical Allocations Committee has been set up, composed of two
             trustees, two members of the RAG, and the director, to look over  the
             12-month plans of medical school for budget and program.
             Manpower is considered an important problem in the region and there
             is an interdisciplinary committee on allied health education as  well
             as an ad hoc committee on personal health services.  The RAG report
             states that a project in Bedford-Stuyvesant was turned down in  the
             technical review process; an appeal was made to the RAG indicating that
             the needs in that area were so great that this project was  greatly
             needed; the RAG approved the activity and decided a different set  of
             criteria was needed to look at these projects.

             The RAG report also states that the developmental component is
             considered an important element that would enable the region to  go
             ahead with activities and not have to await national review or a  turn
             down by the national review processes for things that they know are
             important locally.


                                                                                      /71
              New York Metropolitan RMP           -4-           RM 58-02 (AR-1-CDS) 2
              Following is the number of people from various categories that are  on
              the RAG and on the Committee on Planning, Priorities, and  Evaluation:
                Membership                        RAG                   CPPE
              County Medical Society               9                       6
              Dental District                      5                       0
              Nursing District                     5                       0
              Other Societies                      7                       2
              Voluntary Health Agencies           12                       6
              Hospital Administrator               8                       2
              Planning Groups                      5                       2
              RMP County Committees                5                       2
              Public Health Agencies               8                       0
              Educational Agencies                15                       8
              Public Members                      16                       3
              Core Staff:  The progress report on core staff activity indicates t at
                           the organization and central office has  proceeded  along
              lines recommended by the Management Assessment Team that  visited  the
              region last summer.  A new position has been established for Assistant
              Director for Field Services and the planning and evaluation activities
              have been separated and will be an Assistant Director for Planning and
              an Evaluation Specialist.  An office in White Plains will be set up
              through the New York Medical College and an office in Harlem is staffed
              by the Columbia University Associate Director.  Queens County will  have
              a staff representative as well as a County Committee.
              The application states that plans to have the Comprehensive Health
              Agency review the applications have been delayed because  the  Mayor's
              Task Force on CHP is not in a position to review applications now.
              The core staff is helping the Mayor's Task Force on CHP.
              A data book has been published and is available to  groups  throughout
              the region.  A number of studies have been made through the core staff
              operation which enable the region to involve new geographic areas and
              program areas. Following is a list of the studies:
              1.  Intensive CCU Training with the Orange County  Community  College.
              2.  Epidemiology Survey of Cerebrovascular Diseases by the King County
                    Medical Center.
              3.  Study of Facilities Services for Respiratory Diseases and Disorders.
              4.  Coronary Care Training Surveys.
              The medical school staffing for which about half of the budget has been
              allocated in the past, is now being studied and evaluated by a Medical
              Allocations Committee.  While still a problem area, the application states
              that the medical school faculty is becoming more involved in the program.


             New York Metropolitan RMP        -5-              RM 58-02 (AR-1-CDS) 2/71
             Developmental Component.-  The subcommittee for developmental grant and
                                      priorities has fairly well'-rounded
             representation; three medical doctors, one doctor of Osteotrophy,
             and three consumers, including the RAG chairman.  The application
             for the developmental component speaks to the need to build on the
             categorical disease planning that has taken place.  The  region-wide
             plans on the categorical diseases will serve as guidelines for
             priorities for program development.  The region anticipates using
             developmental component funds primarily for pilot project-type
             activities which will determine feasibility, identify the  problems,
             determine methods of overcoming the barriers and develop  evaluation
             indices so that a major project can be developed.  Each pilot pro-
             ject will be looked at from these criteria:  will it serve more
             people, will it provide better service and will it help increase  the
             manpower pool. A number of suggested ideas that might  be  considered
             for developmental funding are identified in the application.

             New Projects

             Project #25 - After Care Center for Chronically Ill Patients at    First Year
                           Montefi,)re  Hospital -  The project proposes to      Request
             demonstrate the impact of a new modality of medical care through   $164,310
             the development of a Montefiore After Care Center for nursing
             home and home patients throughout the Bronx.  Comprehensive
             diagnostic, theraputic, and rehabilitative services will be
             provided to the patients who are transported from their nursing
             homes or homes to the hospital.  An estimated 300 patients would
             be served each year by the center.
             It is anticipated the project will provide better, more comprehensive
             care for more patients and that it will result in better  utilization
             of scarce professional personnel by eliminating the travel time  and
             single patient service now necessary for the home care  service.  It
             is also expected that the patients will benefit from the socialization
             and interaction with patients and hospital personnel.  The project has
             the backing of all the major medical care institutions in the  Bronx,
             the Visiting Nurse Association, Medicaid and the Bronx Medical Society.
             Based on current patient loads, it is expected that about 70  percent
             of the patients will be on Medicaid and/or Medicare and the  services
             can be reimbursed. The project is expected to be  self-supporting  in
             two years.
             Cost effectiveness of the After Care Center Service  and  comparison
             of the program effects with additional home care  programs,  nursing
             homes, and extended care facilities will be studied.
             The project builds on a pilot study made by the Montefiore Home  Care
             Service and the Department of Physical Medicine which indicated  that
             six patients per hour could be served by a pbysicial therapist  with
             the help of a physical therapy aides in the hospital setting, compared
             with six patients a day served by the home care service.


              New York Metropolitan RNP          -6-          RM 58-02  (AR-1-CDS)  2/71

                                                                     Medical   Director
              The project will be directed by Dr. Isadore Rossman,
              of the Montefiore H6me Care and Extended Services.  Experienced
              personnel from Home Care Service and other Montefiore Hospital de-
              partments will be utilized in the project.  The review history
              indicates that the Home Care Technical  Consulting  Panel  reviewed  and
              approved this project with  certain  modifications  regarding  possible
              methods of self-support.  The estimated third party reimbursements
              have now been deducted from the full cost of the  project  and  RMP  is
              expected to provide only those funds that are not reimbursable.
              The project was reviewed and approved by  the  Committee  on  Planning,
              Priorities, and Evaluation and the Regional Advisory Group.

              02 Year - $73,891
              Project #26 - A  Commur,-ity Model for Early Care of Heart Attack       First Year
                            Suspects - This demonstration project is designed          Request
              to make changes both in the usual behavior, at the onset of a           $150,650
              heart attack, of patients and their families in a large defined
              population in Queens and in the responses  of  the  medical  care  system
              serving this population.  It represents the combined effort of
              the Health insurance Plan and two of its Queens' medical groups
              serving a population of 100,000 (50,000 age 35 to 74 years) and
              LaGuardia Hospital.  The goal  is to effect more rapid requests
              for medical care after the onset of a heart attack, And to
              institute a system capable at all times  of  a  rapid  and  appropriate
              response which fully utilizes medical knowledge.  The end goal is
              the reduction in the present high rate  of  sudden  deaths  from  coronary
              heart disease.
              The project will be built around the HIP medical record which indicates
              those patients at high risk, those  with  prior  coronary  heart  disease,
              hypertension, hyperglosterima; patients will be urged to visit
              their doctors once a year at  which  time  the  physicians  will  explain
              the program to them and the importance of calling into the system early.
              In addition, quarterly mailings of material will  be  sent  to  all  the
              HIP clients in Queens.  There will also be mailings of special project
              materials after they have been field tested.  The project was
              originally conceived as having four main elements: 1) patient education;
              2) centralized telephone screening at LaGuardia Hospital by physicians
              of calls from all possible coronary  suspects  will  take  place  24-hours
              a day, seven days a week, to  reduce  communication  delay  in  bringing
              the patients!symptoms to medical attention; 3)  a  mobile  team  of  para-
              medical personnel trained in  necessary  techniques  for  emergency  care
              of patients  experiencing  mild  myocardial  -infarction  complications
              with telephone and radio  communication  with  the  project's  physician
              based at LaGuardia Hospital; 4) the operation of a special pre-coronary
              care area at LaGuardia Hospital for the observation of patients in two
              defined categories: (1) persons who do not meet the usual current
              criteria for hospitalization but who may be in  the  early  stage  of  an
              acute myocardial-infarction not  yet  recognizable;  and  (2)  patients


              New York Metropolitan RMP           -7-           RM 58-02 (AR-1-CDS) 2/71

              who might be experiencing an ischemic episode not destined to lead
              them to a mild myocardial-infarction  but  capable  of  inducing  a  fatal
              arrhythmia.

              After the original proposal was  reviewed  by  technical  review  process,
              the mobile team aspect  was  eliminated  from  the  project.  The  project
              director felt while this would  be  a  positive  contribution,  he  agreed
              with the site visitors assessment  of  the  less  relative  importance  of
              this particular component. The  project  director  intends  to  make
              arrangements with  existing  community  transportation  facilities  to
              assure rapid response to calls  from  the  centralized  coronary  screening
              physician. The KT  site  visitors  also  recommended  that  a  separate,
              distinct, and well-staffed coronary care unit be established at
              LaGuardia Hospital; the project  director  gave  definite  assurance  to
              the RMP that modifications would be made  in  the  present  coronary cake
              unit to restrict it to coronary patients but  it  was  not  possible at
              this time to have the CCU located in close  proximity  to  the  pre-
              coronary area.

              Long-range effects of this  demonstration  program  are  anticipated  once
              the results have been  evaluated.  The  project  advisory  committee  is
              seen as the mechanism for  disseminating  results  throughout  the  region.
              The American Heart Association has  indicated  an  interest  in  supporting
              the field testing of materials.  Information on the RMP review indicates
              that the project received careful review  which  resulted  in  changes  in
              scope and costs.

              02 - $178,840     03 - $189,575     04 - $190,140     05    $168,550

              Project #27 - Ambulatory Care Nurse Training Program      This   project
                             is proposed by the Bronx Medical  Center  Hospital  -
              Jacobi, Albert Einstein School of Medicine  and  will  also  involve
              Morrisania, Lincoln, and Fordham Hospitals in the Bronx.  The
              project is based on four years  home  care  experience  which  indicated
              a need for the home care,patients to  have  one  person  in  the  hospital
              to whom they could relate for needed medical care.
              The project is designed to  expand  nursing  practice  in  the  ambulatory
              care clinic. It will make maximum use  of  the  registered  nurse  in  the
              setting of the ambulatory care nurse  clinic;  each  patient  will  be
              assigned to a nurse after he has been  seen  In  a  diagnostic  clinic
              or the emergency room.  The nurse will follow her patients in
              subsequent clinic visits to  see  if  therapeutic  regimen  prescribed
              by the physician is being carried out, to  look  for  any  changes  in
              the patients' clinical status and  in  general,  to  provide  a  mechanism
              whereby the patient can avail himself of  any  hospital  service  he  needs
              at any time.


                                                                            DS) 2/71
               New York Metropolitan RNP      -8-         RM 58-02 (AR-1-C
                                                          expand its nursing
               The Albert Einstein College of Medicine will
               training program to develop this type of ambulatory care nurse.  A
               didactic program of 302 hours has been planned which will focus on
               nursing and medical care, and specific diseases, with strong emphasis
               on detecting changes in a patient's condition that will require the
                      I                              ill also spend a  total  of
               physician s intervention.  The trainee w
               52111 hours in supervised clinical practice. The entire program will
               be six-months in duration. Eight ambulatory care nurses will  be
               trained in the first year; 40 will have been trained by the third
               year.  Each nurse, when fully trained, is expected to be able to handle
               a panel of 300 patients per year (or some 2,000 clinic visits per year);
               one physician will be available to work with a group of four or five
               such nurses.  Trained nurses will also serve as perceptors for new
               trainees.  The,project will be evaluated by an independent group of
               evaluators who will compare patients of the project nurses with the
               control group of patients with respect to each of the objectives of
               the program. The tooling up period is expected to take one  year.
               The first eight nurses trained will be expected to go to four municipal
               hospitals to set up ambulatory care nurse clinics.
               A review history of this project, indicates that funding was found for
               the trainees' salaries through the New York Health and Hospital Corpora-
               tion.  The RMP staff apparently did considerable work to emphasize the
               importance of the close collaboration between the nurses and physicians,
               and the applicant has accepted the New York Metropolitan RMP adopted
               principles relating to the expanded role of the nurse.
               02 - $90,078                            03 - $109,700
               Project #28 - Earl           of Breast Cancer - This  project  calls   irst Year
                            for establishing two breast canc r  screening  programs       est
               in conjunction with cervical cancer screening programs at the         $413,701
               Metropolitan Hospital and Maimonides Medical Center in New  York.
               The project will be directed by the Guttman Breast Diagnostic
               Institute, which has been established through support by the Guttman
               Foundation and the American Cancer Society to study, develop, and
               promote mass breast cancer screening on a  practical  basis.  An
               estimated 20,000 women will be examined each year.
               At the present time, the Guttman Institute is performing 60 to 70
               examinations a day to women over the age of 35, at fee of $15.  A
               new type of mammography equipment (Senograph machine) is used for
               the mammography.  The use of this machine has enabled the Guttman
               Clinic to speed up the process and  reduce  costs.  Thermography
               is also used for selected patients.
               A mammography project has been conducted since 1963 with the Health
               Insurance Plan of Greater New York through the  National  Cancer
               Institute funding.  It involved 60,000 women divided into two equal


             New York Metropolitan RNP        -9-         RM 58-02 (AR-1-CDS) 2/71
             groups, one of which was periodically screened and the other, control
             group, not screened to test the effectiveness of mammography as  a
             screening @thod.  The result showed a significant difference in
             mortality from breast cancer among the women screened (31  deaths)
             as compared to those in the control group (52 deaths).  During  the
             latter part of this period, the Guttman Breast Diagnostic  Institute
             was established to experiment with more efficient methods of  breast
             screening including mammography, thermography, clinical  examination
             and history taking. This project will attempt to  incorporate  the
             methods utilized by the Guttman Institute into ongoing hospital
             procedures.  Both Metropolitan Hospital and Maimonides Medical Center
             have had projects (no longer funded through 314(e) funds) to examine
             women for cervical cancer and have carefully established  follow-up
             procedures.  By adding breast cancer to the screening procedure, the
             follow-up procedures already functioning can be utilized.  The cervical
             cancer screening will:continue to be done by the gynecology department.
             The mammography will '7)e done by the radiology department but the
             mammograms will be read by the Guttman project director and his
             associate.  The Guttman Institute will set up the project, will provide
             the equipment, train technicians and clerks, arrange for processing and
             interpretation of the films, supervise the follow-up and keep  the
             records.

             The East Harlem Screening Clinic is also mentioned in the application;
             apparently the project director will be providing consultation to the
             center which has its own equipment.
             The budget request funds for a radiology clinician and techn c an at
             each of the hospitals as well as two health aides and a  half-time
             program coordinator.  Senograph mammography machines are requested for
             each of the two hospitals as well as thermograph machines.  It  is
             expected that this project will become self-supporting in two years.
             Not as much information is presented concerning the review of  this
             particular project. It was reviewed by the Committee  on  Planning,
             Priorities, and Evaluation and the Regional Advisory  Group.  There
             do not seem to have been any changes as a result of the review.
             It is stated in the application that screening for breast cancer  is
             considered a high priority activity developed by the cancer region-wide
             planning group.
             02 - $205,134                           03 - $102,567
             Ongoing Pr   cts, (See attached November 30, 1970 memorandum on staff
                                review of continuation application.)
             Ten operational projects are now funded by the New York Metropolitan
             Regional Medical Program.  Four of these projects have been functioning


               New York Metropolitan RMP         -10-         RM  58-02  (AR-1-CDS)  2/71

                                                                            f Practicing
               only since July 1970.  Project #11 - Continuing Education o
               Physicians at Brooklyn-Cumberland Med-ical Center and Project #12 -
               Development of an Area-wide Program of Continuing Medical Education for
               Physicians in Upper Manhattan Area at St. Luke's Hospital are both aimed
               at the physician unaffiliated with  any  hospital  or  without  membership
               in education-oriented professional societies, of  which  there  are  about
               3,000 in Manhattan, Brooklyn, and  the  Bronx.  The  Technical  Consulting
               Panel on Continuing Medical Education and the RMP Associate Director
               for Continuing Education are studying these projects.
               Project #13 - Regional Program for Treatment  and  Investigation  of  End-
               Stage Renal Disease :- provides home dialysis  training  for  professional
               personnel and for patients and families in the upper Manhattan and Bronx
               areas. Project #14 - Coronary Care  Nurse  Training  Center  -  fits  well
               into the region-wide plan for heart disease.
               Project #17 - Harlem Region Stroke Program - has not  yet  begun,  but  is
               designed to serve as a prototype of the entire region with its
               inadequate stroke service.
               Five of the older projects are being monitored by the following pro-
               cedures: bi-mnthly observation by RNP  staff,  review  by  its  respective
               Technical Consulting Panel during the  ast part of the fiscal year,
               fiscal control, evaluation procedures t                       core   staff
                                                        o be developed with
               and special presentations before the RAG or  its  Committee  on  Planning,
               Priorities and Evaluation.
               Project #1 - Mobile C ronary Care Unit -  St.  Vincent's  Hospital  -  The
               Technical Consulting Panel - Heart Disease -  would  like  to  see  mobile
               unit coverage extended to all of lower Manhattan, but no action is being
               taken in this direction until an RMPS National study is completed.
               Project #9 - Educational Program in Rehabilitation of Allied Health
               Personnel at Barbe Fo-in ation Rehabilitation Center - Providing
               continuing education opportunities for rehabilitation personnel
               and developing career ladders for less skilled employes are high
               priority areas for the  RMP.  Cost-benefit  analyses  will  be  instituted
               in the second year.
               Project #2 - Pediatric Pulmonarv Disease  Center  at  Babies'  Hospital  -
               has developed a more regional-type of  program  this  year  as  contrasted
               with its  early  institutional  bias.  Self-support  possibilites  are  to
               be fully explored during thp third year as well as cost-benefit studies.
               Project #6 -                        am - Memor      ospital  -  While  the
               region has no                       ity of this continuing education
               activity, the  need to broaden its  focus to the whole field of rehabili-
               tation is being studies.  In addition, core staff reports difficulties
               in getting a clear cost picture of this project since it is closely
               intertwined with other hospital activities.
                                                             GRB/@S
                                                             12/29/70


                                              [)I PAI','@ f@,l      ()I,  I I f7,' 1. 'r I I                  At      V  -L --A"

                                                                        pt,liit-l(, I11 AI .-III f,
                                                IIE/@i 'I 1-1 f';I- I?VIC /,,J I) r@A L.( I             IA() tl

                                        30, '1970

          At@@;

                c 1:                          of  iNoi-i--C;o[iil)cti.iig  Cont@i-iiu,-.iti.oi-i  Appl-.i.citi.oii  frc)lrl ',NC@.%,7  York
                                                                              Pro(,r@ini

                      Act iLi,,  1)         t
                                                      Pi-o,@rain  S(@rvi.cc@

                                        Ae t@: 1  ng  Cli-i-(@f

                                        Acting        Ciii.cif
                                        (:r,,ints     llc@%, i     Pr,@incli

                                        Ch-i.c,f
                                        Grz-@tits     M,.iiiac,,eiii(.,iit  Brari(-Ii

                      I'Iijs         i!)plicat--L.on  is  a  part  of  the                             fi.rE,,I-  A@-in-lvctr@,ary  Revi(!@,!  ;-aid
                      a@@!z-i-r(I  ipplic@it.i.on  xilk@i,ch  requests  -til-)y)orL  for  tlj(--                                           of  tc.---l
                      prc)jects       atid       co-r,@ ($2,684,852        d.c.),        i        dcvelopri).,?iit@tl.        co,-jipon@@,it                    d.c.)
                      an(!     for      a                        gr@iit       consi@tj-n,,       of       four       I)rojc@rt,@       ($811.,686        e,.c.,).
                      Staf,"s  review  of  tlic,  cont@!rLtiiL!,o[i  ai)i)l.ica@.-loti  coticcy-iLr@itc@.d  OLI  OVOL'al.1
                      p r o   r@ @-i isF@ues  rather  than  on  individual  T.)roj(,cLs.

                      '@,',ajor  issues  discLts@l;c@d  by  the                                   staff  Were:
                              (1)       Al.tiiou,@li  LI)E@  Rec,!.ori  staLe@,  tl-),qt                            dLirli-t,l  the  pasL  ycar  his
                                        been  on  toLal  Drograiii                                       ttiCl,                        reflc@.cts          nioi:c
                                        of  a  project  or-LcLLLed  tyl)c,  of  op,-@r@i@iori  by  sLiff  Ets  well  as  c(:)ill(lli.t-
                                        tc,-es.       Concurrently,      it      appears      Lti,,iL@       projecLs       are,       develo[)C,(.1       wit'ti
                                        RMPS  as  the  T)ri-nci.pal  so@ircc-  of  @LLpliot-t.                        Staff  concluded  tliir.  Llic!
                                        RegioLi  should  [)lace  additional  ci,@pliisi@,,  on  Llie  catalytic  ai)proac.ii
                                        and  that  joint  funding  of  qcLivities  should  be  eiicoura-ed.,
                                        Planning  activities  dL@scribed  are  tt)p-  rc@sults  of  the  iari@,oi.,,;
                                        Technical  'niisulting  Panels.                         Stalf  fel-t  that  the
                                        slioul.d      be      niore@      revolved      in      there      pl-iL-ini-iic,      activities,;.

                                                                                                                            1
                               (3)      C@iitral    Core     St-aff     cap,,il)il..-ity     in     Cc)nt..ii-itil.rig,     I.,Idkic,-ttioti
                                        needs  to  bi,  strerictfic,@tic@,fl.

                               (It        t  w @ i @;  ;@t @', ri:, (I  L h,7 L  II y@- .  1, I- 1 i-, I I tI I  Ii d  iii,-i (I t-  c t) I I:; (I i- i 1) I.
                                        ill                                    @fO@t-,  fol-

                                                                    them
                                        prc),,,rt-,r,f@  at:  tlij.@,  T,)niiit  i-,21  s o iii  !I !,'I t la      II    ill  til(@


             Page 2 - Dr. Margulies

                 (5)   An accountant has been added to the central  office  staff  as
                       was recommended by the Management Assessment site visit team
                       in July, 1970.  Staff questioned whether the contract for
                       fiscal services had been revised as a result of  this  and  of
                       equal importance, has the contract been reduced.  Possible
                       .payment for duplicative services prompted this discussion.

             In summary, staff believed that this Region, now applying for its second
             year of operational support, has made significant progress but that
             much iniproveiiic!iit is needed in the development of the total program
             especially in regards to additional- output from the medical.  schools.
             Recomnic@iidatioii: Approval- of continued funding at the committed level
             of $2,539,887 d.c. rather than the requested $2,684,852 d.c.  The
             difference in the requested and committed level- of support iF, due  to
             the fact that the Regi.on elected to request the National Advisory Council
             approved level for Project #17, Harlem Re-ioiial Stroke Program, rather
                                                           Q
           .than the committed level..  Since the region will be given a twelve month
             budget for an eleven month year due to a change in anniversary dates,
             staff was of the opini.on that funds would be available for this project
             if the Rdaion believes additional support is necessary.

             Dan M. Spain
             Operations Officer
             Regional Development Branch

             Approved:

                                                      Da Le
                        ector, RL!IPS

             The followiii- staff members participated in the reviei.; of this Conti.nuation
             Application:

             Mr. Morales
             Mr.   Teets
             Yir.  Spain
             Miss Morrill
             Mr.-  Witte

             Mr.    Baum (Observer)
             cc:  Mr.  Gil.v-ior                                Mi.ss liorril-1.
                  Mrs. Silsb(-@e                                Mr. Witte
                                                                Mr. Spain
                  @Ir. Morziles
                  Nlr. Teets


                                                                                                         (A Privileged  Coiiii)it-inicatic)i-t)

                                                  SUNFiAs.RY  OF  l@EVIEVT Al@D CONCLUSIO!I OF
                                                        JANUAP,Y  1.971 REVII@'@4 C01@,11'1!TEE

                                          NFI,! YOPV@ @IETROPOI,ITAQ RT'@GTO,,Ti@L @!Ei)IC@Al,  Pi'lloGtl"4@l@ll
                                                             RM        58-02        (AR-1,CDS)        2/71

                                     FOR  CONSIDL,'!,'-@TIO@%T  t@Y F'EBRIJAPY  1.971 ,',!)VISORY  COUJN(,TL

                      PECO@tl,!EDIDATION:      Additional       funds       be       provided       for       this       application       fo@-
                                                   for  the  02  year  only.

                                                                                                                             R E,@'        2) 17.
                      YFAR                                                                                                       FUNDING
                      02                                                       @1,140,6@)6                                 @200,000
                      03                                                           647,943                                       -0-
                      04                                                           760,512                                       -0-

                                                 Total                       $2,5@9,i:!,]-                                  $2003000

                      The T-I,O'@l'-on will  be  subf@,iitti-fi@,  its Aiir,'i-,,,@rsary r@                      Apl'
                                0                                                                       c@           )lic. @ic)TI@
                                  1,  1971.,                     tire    P(Icliti-o@!al,      fLiii.cliiig         be   c(,,iis
                      Tli@ Rc-g-i-oii has  a.                       l@,vcil-  of  "-@,2F,@-,320                         fc,-,:
                      03  o  crat-.:Onal-  year  (core and  1.0  proj,@,c-:ts).

                                                    rn
                              _UjLl:    The  Co@n  ittec believes  thnt  the NYP,-o,@IP  is  becci-o,-,ii,,,, a mpt-Lire
                      P,c-gion.      Several     changes     have      occurrcei      ii@      tlic-@      c)rg,.irki.zatiop,,il      structure
                      a r, dnieTbershi.p  of  the  central-  core  stuff,  all.  of which  are vi@2@,/C',Cl
                      favorably.      A,dditions      to      the      staff      include      an      Assistant      Direc      or       or
                      Planning,  Evaluation Specialist,                              an  accou.-it,,.iiL.   I,!itli  the
                      iii,,    of    core    staff    plans    qrc,    for    their    grc-@t't-.e)-     1),iri:i.cipiti.o.@     in        @.r)g
                      with     cofTLTunities     in     the     devclopine-@it     of     projects     and      oLl-te-,c
                      '.Ulie Associate  Directors  of  the Medical-  School.,-,@  are                                            to
                      thc-ins--lves morc- with  stirroui-Ldi-ci@  conL-GiLir@-L.ties  an.,J  rre- wt:)rkinQ @,ii.11-h  Icc.,).I.
                      planning  coniTnittc-es  designated  by

                      The.  Cbiiii-n-i-ttee believes  that  the              Cc)oi-dictlit@c-.i@,   )r.  1.  j@,y                         his
                      been doing a  good  administrative  job.                           lie  is              ,, off the pos i!L)ili-i--y
                      of     the     NYI;d-@LP     becoming     a     medical     sc,!'.IOOI     program      by      establishing
                      objectives,  guidelines,  and  categorical  plans  for                                       Region.        Ili.s
                      strategy    appear's    to    be    to    work    around    the    @robleir,     of     the     @ic@dicil     SC     1C)o
                      and  keep  thcia  involved  in areas where  there  is  little  ciiiiice  for  cc)llli,)Iic.@l-@
                      tions.       Dr.  Brightipctri  is  planning,  hu,,.,Tovcir,  to  obtain  greater  in-17.ol.vei,len',,.-
                      and     output     fi-oLi     the     iftedical      schools      tl).rough      the      Associate
                      located  at  the various  schools.                       In  'ILine  19C-9  a  no@,,7 procedure was  itiit'i,-tecl
                      by which  each Associate Director would  propose.  a  12-rriolith  proc,3:a-c:,  de@vc-.,-,op-.
                      rqent  activity  in  his  area  to  fit NYk@TPi@i'll  plans.                       These        proposals         were
                      reviewed  by a  nc:r,.7ly  established @Ic!di.c..il. Al.1t:-)cpti-ons
                      of,two representatives  of  the  Bo,7,rd  of  Trustees  and  two                                              of  the R@-G,
                      ,,7ith@tne Director.   Allocations  of  funds  to  cover  t'l-i   costs  of  acceptable,


               NEW YORK METROPOLITAN @,IP                      -2-                    .-RM 00058

               protocols are to be made to the medical schools.  A quarterly review
               of the progress of the proposals will be conducted by the Mcdic@il.
               Allocations Committee and reports will be made to the P@.

               The acceptance of these medical school            programs   is   very   recent   and.tlie
               value  of  the  new  approach  has   yet   to   be   proved.   Ilowever,   the   RAG   members
               are hopeful that dc-.noiistr@,iti.o-iis and studies                  f-rom   this    approach
               will   increase   the   visibility   of   N@ll@   and   offer   a   return    commensurate
               with the dollars expended.

               The Committee is E,,ncoLtr@iged' by ti-ic@ maturity  which  @.1-ie  RAG  of  this  Rec,@i-oii
               has developed.       It appears that they are                    a rubL)z,,a.- stamp  type
               operation   but   rather   have   assumed   their   responsibility   in    giving,t    is
               Region leadership and direction.

               Mr. Robert L. Popper is the Chairman of the RAG and appears                  to  be   very
               active in the Program.         He was highly                       to-@,?arcl the core
               staff and especially,  the D-i-rectot, Dr. Brightman.

               Cat@egori,cal program              i-ticludiiicy priorities are generated by
               Technical consulting Panels and a-ce beiii- used by the Reg@lonil Advisory
               .Groups and Sub-1--c--ioTIL-,l cof@@Llnittees as guiec!l..in,-2s  for  the  generalization
               and review of projects.                                of those.
               Panels reflect the new goals and objectives of the               Region       particularly
               in   the   area   of   paramedical   education.   The   question   of    setting    priorities
               from within the various categorical and functional committees to arrive
               at overall P,L4P priorities has not been completely resolved.                 The.    Committee
               believes  that  the  true   test   of   the   priority   setting   procedures   out   iiio
               would take place with the awarding of developmental funds.

               D',PVELOP,,IEtl@TAL CO@IPOi'.,TT7NT: The Committee believes that the developriiental-
               component is necessary for the continuing progress of the N'DI,I"@"!P and
               recommends  a  reduced  amount   of   $200,000,   'based   on   the   present   level   of
               maturity   of    this    Recion.

               The application for the        developmental   component   speaks   to   the   need    to
               build on the categorical disease plan-,iiii- that has taken place.  The
               Region-widb  plans  on   the   categorical.   diseases   wil.l.   serve   as   guidelines
               for priorities for pr      ograi-,i development.    Tlie.regioit    anticipates     using
               developmental   component   funds   primarily    for    pilot    project-type    acti",Ii:ti6s
               which will detbrmine.fe,,Isibility- ideiitify.the problems               determine      methods
               -of  overcoming  'the'barriers  and  deve-lop   Evaluation   ind-ic'es   so   that   a   major
               project  cart  be  developed.-  Each  pilot   project   wili.   be   looked   at   from   these
               criteria:   will   it   serve   more   people,   will'it   provide   better   services    and
               will it   help   increase   the   manpower   pool..   A   number   of   suggestecl'idca's that
               might be considered for devel6pmental funding are identified in the
               application.

               SUPPLIMENTAL     FUNDING:   The Committee recommends that no additional funds be
               provided for     the following activities because they do not clearly relate to
               the present objectives and goals of the NYRT,,IP and they have little relation-
               ship   to   the   developmental   component.   They   appear   to   be    activities    which


              NEt4 YORK METROPOLITAN @-IP                  -3-                  RM 00058

                    iri, the systE-in prior to the Region's dcvelop@,iient of present
              were
              priorities, goals aiid objectives.

              Project-. @,@25 - After Care Center for Ch-(-oi-iical.ly 11.1 Patiorits it
                              Moiitefiore--,Ilos-pi-Lal

              Project 141-@26 -A           @lodel- for Eirly Ci-t@c, of Ile,,a3-L Attack

              Project IF'27 - Apibi-ilatorv Care Niirse Traii-i

              Project l@28 -  EarL@,,_@6t.c-ction of Ilr@ii,,t Cai:tccr

                                                                                RMPS/GRL,


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

                NORT H DAKOTA REGIONAL MEDICAL PROGRAM        RM 60-02 (AR-1 CD) 2/71
                University of North Dakota                    January 1971 Review Committee
                1600 University Avene
                Grand Forks, North Dakota  5  01

                PROGRAM COORDINATOR:  Theodore H. Harwood, M.D.

                                         REQUEST (Direct Costs)

                COMMITTEE/COUNCIL
                   REVIEW:                02          03           04        Total

                Developmental           $31,482                              $31,482
                 Component

                RMPS STAFF
                REVIEW:

                Core                   $295,640
                4 Ongoing Activities     90,444
                Carryover                23,038
                    Total              $409,122

                                         FUNDING HISTORY

                Planning                 Period                 Funded

                01. Year           7/l/67 - 6/30/68            $188,010
                02  Year           7/l/68  -  12/31/69           257,100

                Operational

                01  Year           1/l/70  -  12/31/70          325,946

                Future Commitment

                02                  I/l/70 -  12/31/71          310,683
                03                  I/l/72 -  12/31/72          255,942 (Core only)


          North Dakota RMP                       -2-             RM 60-02 (AR-1 CD).2/71

          GENERAL:

          The present application is composed of a request for  continuation  for
          the second operational year, a Progress Report, details about Core
          Staff activities, a request for a.Developmental Component,  and  budgetary
          information.  With the exception cof the Developmen tal Component, all
          these elements Are dealt with in the Staff Summary of December 15,
          which is attached.

          DEMOGRAPHY AND GEOGRAPHY OF THE REGION:

          The geographic boundaries of @he region are conterminous with the state
          boundaries. In planning for the region,  other  possibilities  were
          considered, including portions of Minnesota, South Dakota  and  Montana.
          These arrangements were not acceptable to the North Dakota  State  Medical
          Association, and the decision was made to remain autonomous  within  the
          state boundaries.  The region's headquarters is at Grand Forks.

          The population is estimated at 632,,446 for a land area of 70,665 square
          miles.  There is a two-year basic medical science School of Medicine
          at the University of North Dakota located in Grant Forks with an
          enrollment of 83.

          There are nine schools of nursing, three which  are  university  affiliated
          and one which is degree granting.    There are seven schools of  medical
          technology, all of which are college affiliated. There  are  seven  schools
          of x-ray technology, four of which are affiliated with  the  University
          of Minnesota.  There are noschools of cytotechnology, physical therapy,
          or medical record librarians.

          There are 68 non-federal hospitals, two are long-term and  66  short-term.
          Beds total 3,811 in the short-term and 1,907 in  the  long-term.  There
          are within the state five.short-term federal hospitals with a total
          of 476 beds.

          'There are 594 physicians, 13 Doctors of Osteopathy, 2,138 active  nurses,
          33 physical therapists, 33 occupational therapists, 284 dentists  and  3
          medical social workers.

          HISTORY OF REGIONAL DEVELOPMENT:

          North Dakota Regional Medical Program re-states its objectives  in  its
          request for a Developmental Component. These have  not  varied  appreciably
          since the inception of the program:   (1) "To develop medical  care
          facilities with a reasonably wide range of services  in  recognized
          service areas. (The main factor of importance is not  the  actual  distance
          in miles to be traveled, but whether or not having  traveled  these
          miles, the individual receives prompt and efficient care.), and (2)
          To make the most efficient use of each professional individual's
          training and capability, utilizing his time and talents at  his  highest
          possible achievement level."


             North Dakota RMP                  -3-           RM 60-02 (AR-1 CD) 2/71
             NDRMP represents the providers of health care in the state of North
             Dakota, since the North Dakota State Medical Association assumed the
             responsibility for bringing RMP to the state and for its continued
             direction.  Accordingly,Core staff development and function revolves
             around this concept--that in order to develop a sound basis for a
             continuing overall program,extensive participation by physicians is
             an essential element.  The region states this premise as the backdrop
             for the development thus far of: (1) a capable and dedicated staff;
             (2) a physician Board of Directors; (3) a Regional Advisory Group with
             predominantly physician representation; and (4) a committee structure
             with a high degree of physician representation.
             The region has attempted to develop a "total program concept" rather than
             individual and unrelated projects.  As a consequence, a strong staff and
             technical committee function has emerged.  Generally, program activities
             develop as a result of a combination of committee and staff action,
             with representatives of organizations where a potential to pursue the
             program is evident.  The Core staff of ND/RMP has made a wide range of
             contacts with people, and institutions, and has a good knowledge and
             understanding of existing capabilities.  Early in the development of a
             program, the appropriate committee of the RAG is involved, together
             with representatives of the sponsoring institution, and final development
             and planning of all aspects involves all three groups.  When the completed
             proposal is presented to the Regional Advisory Group and the Board of
             Directors for their review and approval, they are usually familiar with
             it.
             The major responsibility for continuing evaluation of details of the
             program rest with the technical Committees.  This has strengthened
             the interaction of the committees, staff and the RAG.  Committees keep
             the full membership of the RAG informed of activities through a formal
             report at each meeting, plus frequent communication in the interim
             periods.  In the development of new programs for North Dakota, this
             method of active staff participation in all stages of development has
             proven to be the most effective.
             North Dakota has tapped the resources of a plan developed by the Extension
             Division of N.D. State University in Fargo to identify representative
             consumer groups in and around recognized medical service areas of the
             state.  It was found that in some areas there was an existing organization
             which conducted studies and was planning for needed services.  The
             general trend in such communities has been to develop a method of
             cooperation between existing institutions and individuals, leading toward
             the development of a single hospital system.  In some instances this
             means a move toward total coordination of all health care and social
             services.  Two examples of such planning are underway in Grand Forks
             and Rugby.  The former city has under development the concept of a total
             medical center.  Administratively, the two existing hospitals have united
             already, and are planning for a completely new medical center which
             will involve all elements of the medical community, including the
             University of North Dakota Schools of Medicine, Nursing, Allied Health


           North Dakota RMP                     -4-            RM 60-02 (AR-1 CD) 2/71

           Sciences and the Rehabilitation Hospital.  other cities  in  the  state
           are planning similar moves and the ND/RmP has stimulated  and  assisted
           in these efforts.  '
           The Rugby community proposes to connect the existing clinic group, which
           consists of seven physicians and a single hospital of about  100  beds,
           with an additional structure to provide new and much needed facilities.
           These will include extended care, rehabilitation, etc.  In addition,
           the new building will include all the various social and  community
           services such as welfare, mental health, social services and related
           activities.  The intent is to Icoordinate and facilitate the use of all
           medical and social services by locating them under one roof.  A Federal
           planning grant has been awarded to Rugby for development of the scheme
           and other related research studies are evaluating its progress  and
           ultimate implementation and operation.  The Core staff of ND/RMP has
           assisted in a variety of ways, and will be an active component  of  the
           research project presently being developed by Dr. James Cummins  of
           Brandeis University.

           The data obtained by the collaborative efforts of the N.D. State
           Extension Division and the ND/RMP staff, will be furnished  to  Compre-
           hensive Health Planning and other interested groups as an  accurate
           base for health planning.
           There is a strong trend toward group practice by physicians in the state,
           and 353 physicians are presently practicing in groups of three or more.
           In the larger urban centers there are well-developed functioning
           multi-specialist groups with a wide range of services.
           There is little, if any, organized out-patient service provided  at
           hosptial centers, and for all practical purposes, no free  clinics  for
           indigents. Approximately 65,000 people are eligible  for  Medicare,
           and approximately 46% of the population are enrolled in Blue Cross-
           Blue Shield, with another 25% under other forms of commercial health
           insurance.  Further details concerning the region's development and
           progress are contained in the attached RMPS Staff Summary of the
           Continuation Request of 12/15/70.

           REGIONAL ADVISORY GROUP:

           The Board of Directors of the North Dakota Medical Research Foundation
           (Grantee) which is identical in membership with the Council of  the
           North Dakota State Medical Association, serves as the Board of Directors
           of the Regional Medical Program.  The Regional Advisory Group has been
           expanded to include consumer representation, and while not actively
           involved in committee deliberations, the interest of  various  consumer
           groups and organizations appears to be developing and  promises  to
           expand. (See attached staff review(memo 12/15/70) for  further  details
           concerning the RAG.)


              North Dakota RMP                        -5-      RM 60-02  (AR-1  CD)  2/71

              DEVELO M NTAL COMPONENT:

              The proposed Developmental Component Activities  are  broadly  based  and
              proposed to serve as an instrument whose major role  is  to  assist  in
              the development of any and all methods for making  it  possible  for  the
              populace to receive the highest possible  quality  health  care.  At  the
              same time, the region points to the difficult factors concerning supply,
              distribution  and  financing.  Specific  developmental  activities  proposed
              include:

                      1.  Improved undergraduate educational opportunities.  In
                          particular, the School of Medicine at the University
                          of North Dakota is studying the  feasibility  of  expanding
                          to a four year school, and the  ND/RMP  is  making  significant
                          contributions in planning.

                      2.  Development of a scheme for bringing  the  rural  populace
                          in contact with health services, patterned somewhat along
                          the lines of neighborhood health centers  and similar
                          to previous efforts of the Indian Service.  This would
                          utilize the efforts of the Medex  program,  with  variations)
                          such as other types of physicians assistants..

                      3.  Development of an academic continuing education activity,
                          not only for the School of Medicine, but for other educational
                          institutions in the region.

                      4.  Collaboration with planning groups  for  closer  coordination
                          of efforts with a view of  the  centralization  and  elimination
                          of duplication of health planning activities.

                      5.  Development of the Team Teaching  and  Care  Concept,  beginning
                          with the organization of teams for  Stroke.  The  RAG  Stroke
                          Committee has been active in this development.

                      6.  Concentration of efforts to elevate  the  health  standards  of
                          Indians living on reservations, to  include  training  and
                          general education programs for health aides  on  a  variety
                          of subjects such as nutrition,  obesity,  diabetes,  etc.,
                          in a collaborative effort with  the  USPHS  hospitals.  The
                          ND/RMP will act as the coordinating  agency  and  clearing
                          house for such services,  developing  the  communication  device
                          and opportunities for better  utilization  of  existing  facili-
                          ties and services4 This will build  on  the  experience  of
                          feasibility studies already initiated by  the  Core  staff
                          in Tuttle Mountain Reservation.

              SITE VISIT - DECEMBER 7-8, 1970:

              This is a separa te document which will be supplied later.

                                                                          GRB    12/18/70


                           DEPARTMENT OF HEALTVI. EDUCATION, AND WELFARE
                                                  4.
                                           PUBLIC HEALTH SERVICE
                            HEALTH SERVICES AND'MENTAL HEALTH ADMINISTRATION

        Date:    December 15,  1970
   Rcp@ to
    Att;i of.'
     Slibject:   Nortli Dakota Conti.nuati.on AI)pli.catioi-i Staff Review, December 1, 1970,
                 5 C03 l@l -60
        7'o:
                 Acting Di.i.-ect.or
                 Reg,i.onal Medical. IlroL!,Yiiiis Serv@ice
                 Thrdugh: Chairiii@in of the Month

                          Chief, Grants Management Brai)c
                          Acting Chief, Regional Development II)ranch
                          Acting Chief, Grants RcZ)e 7@Brancli

                 General:  Staff consideration was directed to the request for continua-
                 tion  for  the  secordand  final  (committed)  year,   the   unexpended   balance
                 and evaluation of progress of the region, and in broad terms, the
                 request  for a Developmental Component.
                 The region was supported for its first       operational  year  in   the   direct
                 cost amount of $325,946, wi.tli an amount of $3iO,683 r(--coiiii-iien,](!(l for
                 the second (final) yeir.      In both the planning and operational.
                 applications, the region requested two year support only.
                 The present application is composed of a Progress Report, details
                 about Core  staff  activities,  a  request  for  a  Devel.opniontal  Coitiponent,
                 a  request  for  continuing  support  for  four   operational   projects,   and
                 expenditure and budget information.
                         rv  and  Fiscal  Status:  The  region   estimates   an   unexpended   net
                 balance  of  $23,038,  and  requests  the  use  of  such  funds  to   implement
                 two Council -Ipproved but unfunded projects, and expansion of Core
                 staff support ii-id other ongoing operational activities.  Extensive
                 staff discussion resulted in a consensus to hold in abeyance a
                 final recoiiliflciiclition  for  the  carryc)vcr  request  pending  the  findings
                 and recommendations of the sit(, visi.t scheduled for Deceiiil)cr 7-8, 1970.
                 This act-ion did not. i.nc]Lldc a re-bud@,oti.ng request which wi@; pI-cs(!Ilte(I
                 a few days following the Noveiiil)cr 1, deadline.
                 The regi.oti his budgeted its funds wel.1 and efficiently, and is
                 11 cost-coiisciou-;" to the extreme.    They  have   never   requested   indirect
                 costs  until  the  pist.year  when  they  were  permitted   to   use   indirect
                 costs amounti.n,, to $12,590 to finance the salary of a nurse.             This
                 was the result of a recommendation of the site visit team of June             1969,


                                                      .7

                            Acting Di.rcctor, ]@MI'S

                   that a nurse at a Masters Degree level be recruited for the
                   Rehabilitation  Nursing  Program.  The  region  had  been  unsuccessful   in
                   its search for a qualified  candidate  until  this  past  year  and  autliori-
                   zation was given by RMPS  to  rebudget  indirect  costs  funds  for  her
                   salary for the balance of  the  01  year.  This  action  did  not,  of
                   course,  carry  a  commitment  for  the  project's  second  year.  Continued
                   support of this postion from carryover funds i-s part of staff recommend-
                   ations.

                   The  Grants  Management  representative  expressed  concern  about  the
                   fact that the.region had subm-'@tted its request for continuation based
                   on the application of two  years  ago,  rather  than  the  level  funded
                   (recommended)  amount  of  $310,683  for  its  second  year  support.  This
                   was apparently a misunderstanding on  the  part  of  the  region,  and  a
                   visit to RMPS by  the  Arsociate  Director  last  week  has  clarified  this
                   issue. New budgets  will  be  submitted  at  once  which  will  reflect
                   allocations in agreement  with  Council  committed  amounts  for  the  02
                   year,

                   Regional. Advisory Group-. The RA.C@ is  concerned  and  interested  in  the
                   program, although they seem to rely on Core staff for ideas and project
                   develo mei-it.  A sy steni of project review  has  been  developed  which
                   involves the entire Group, rather  than  a  Task  Force  or  Commi.ttee
                   approach.  North  Dakota  feels  this  works  best  for  their  Group.  The
                   site visit report to  follow  should  shed  light  on  the  present  organi-
                   zation which has always appeared somewhat duplicative and over-structured.
                   The report does not specify  the  criteria  used  by  the  Croup  for  program
                   and  project  review  or  decision-making.  Twelve  new  members  have  been
                   added during  the  past  year,  including  five  physicians,  six  representa-
                   tives from the general public  and  one  Indian,  who  is  a  Hospital
                   Administrator.  The  Group  also  includes  the  lieutenant   Governor.

                   Rep;ional Progress a@id               o i e@n t :The   operational   activities
                   of  the,N.D.  @IP,  which  are  almost  exclusively  continuing  education,
                   appeat"to have been shaped and  directed  to  a  large  extent  to  gain
                   the confidence  and  cooperation  of  the  physicians  of  the  region.  There
                   appears to be no  .overall plan  to  identify  and  meet  the  continuing
                   education needs  of  physicians,  nurses  and  allied  health  throughout  the
                   region'.  Rather, continuing education activities seem to be conducted
                   primar@ly in response  to  an  interest  by  health  professionals  to
                   cooperate with the N.D. @IP, thus establishing lines of communication
                   where   one  existed  before.  A  further  characteristic  of  the  region's
                   continuing education  activities  is  that  they  have  been  provided  for
                   nursesipredoniinantly, yet there is  little  or  no  involvement  of  the
                   nursing profession in  the  regi.on's  planning  or  decision-niaking.
                   For example, the @IP Continuing ECILtcati.on  Committee  is  composed  of
                   physicians exclusively!
                   Although there appears to be  interest  by  N.D.  RMP  in  establishing,
                   improved  relationships  with  the  nursing  profession,  there  continLICS
                   to be an Unfortunate schism between N.D. RMP  and  tlic,.  nurse,  education


                         Acting Director, PKIPS

               leadership.  Both  groups  are  sensitive  to'this  situation  but   there'
               appears  to  be  an  impasse  at  present,  which  precludes  significant
               improvement.  Efforts  to  involve  the  nutrition   profession   is   reflected
               in  the  Diabetes  project  which  is  apparently   functioning   effectively.
               However,.there appears to be little involvement of the dietetic
               profession in the N.D.  RMP  structure.  As  yet,  outreach  to  ot:ljei-
               allied health  personnel  is  al.most  non-existent.  Al,tlioLigii  there  are
               small numbers of  alli.c!d  health  practitioners  in  the  region,  there
               are programs  in  the  state  to  educate  physical  tlicril)ists,  occupational
               therapists,  medi.cil  technologists,   and   radiologic   technologists.

               There  are  Indications  that  the  continuing  education  activities   may
               reflect greater innovation in the future.  The region Is experimenting
               with multiprofessional education in the project "Diabetes and
               Nutrition".  On  the  basis  that  those  who  learn  together  are  more
               likely  to  function  more  effectively  as  a  team,  physicians,  nurses
               and  dietitians  are  instructed  together  in  some  classes.  Also,   the
               important role  of  the  region  in  making  possible  the  development  of
               a Medex program in conjunction with the Department of Co@nmunity
               Education  at  the  University  of  North  Dakota  is  significant.   North
               Dakota is one of  the  four  centers  in  the  country  which  is  funded
               by the;  National  Center  for  Health  Services  Research  and  Development  in
               its ef forts  to  develop  a  uniform  evaluation  protocol  for  physician
               assistant  type  programs.  N.D.  Pd4P,  and  its  Director   in   particular,
               have  largely  been  the  stimulus  to  encourage  the  medical  profession  to
               extend beyond  its  boundaries  to  become  involved  in  this  study  of
               national  scope, funded by a federal agency, and in       a   controversial
               beaitb'nianpo@qcr area.   Invicw of the deficiencies of  N.D.  RR.IP  i.n
               its  evaluation  activities,  perhaps  the  close   relationship   between
               N.D. @IP and NCIISRD in this Medix study will be reflected in an
               increased  interest  and  emphasis  on  evaluation  in  the  program   itself.

               The  representative  of  the  Program  Eval.uation  Bxanch  expressed   concerns
               which were, for the most part, generic.  These elicited much discussion
               about ;the "unusual" characteristics of this region.        ,then  measured
               agains't  regions  that  have  developed  sophisticated   evaluation   systems
               and strategies for planning and decision maki.ng, N.D. RMP undoubtedly
               falls ;short.   if N.D. @IP  is  judged  in  terms  of  wliit  existed  before
               RMP as : compared with wliit  his  been  accomplished  to  date  with  a  very
               modest,investment,  N.D.  @IP  represents  a  new   and   accelerated   effort
               to mee,t the health needs of the peopl.c of North Dakota.
               The re;gion should be  encouraged  to  develop  a  Core  staff  focus  for
               both  planning  and  evaluation.  This  need  is  supported  by  the  fact
               that the application  does  not  delineate  the  nature  of  the  regioil's
               plannf.ng process; what role planning pl.@iy in decisi.oli-mal,,iiig;  who
               is responsible for implementing pliiinii)g activities; and how
               evaluation is built i.nto projects.

               If there is agreement that North Dakota should not be excluded
               from  national  programs  simply  because  they  have  not  achieved   optimum
               results, in  three  yeirs,  in  heil-tli  planning  in  a  traditional  sense,


                   then there must r)c@c@@,,3sarily follow an acceptance of the way
                   that North Dakota P\@IP is going about developing lines of communication
                   upon which to build a program.  It is probably the only way, at the
                   present time.

                   Recommendation:   Continuation for the second year in the committed
                   amount of $310,683 direct costs, plus $12,590 from carryover funds
                   for a Council approved (currently appointed) position in Project #2.
                   The balance of c@-irryovcr funds ($20,000 approximately) to be granted
                   based on the rc@coriiincnclati.ons and advice of the si.te visit te,@im.

                                                     Jessie F!. Sal.a/,ar
                                                     Public Ilcaltli Advisor
                                                     Grants Review Branch

                   Action by Director

                   Ini.tials

                   Date


                                                              A PRIVILEGED CO@IMUNICATION

                                         Ol:'         COi':4CLUSIO14 OF
                                          ].g-ll 1,@EVT
                                  JANUARY         -Li,-14 CO@ZIITTEE

                               NORTH DAKOEA REGIONAI, IIEDI@CAL PROGRki%l
                                     RM 60-02 (AR-1 CD) 2/71

                      FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

            Recommendation:   Additional funds to be provided.

              Year 02                      Request               Recommended  Funding

            Developmental                 $31,482                     -O-
           *SupplementAl Funds              -0-                     $30,000

              Total                       $31,482                   $30 000
              Not requested by region    but recommended by  site i!isit team.

            LzILt  u :  The present application is a reqliest,for continuation   for
                       the second operational year, a Proaress Report, details
                                                          C,
            about Core staff activities, a request for  a  Developmental  Component
            and budgetary and fiscal information.

            The critique is addressed to the results of site  visit  team  findings
            (Dia6ember 7-8, 1970) and recommendations concernin the proarai@l as  a
                                                                9        0
            whole, and in particular, the request for  a  Developmental  Component.

            The Chairman of the site v4-s@;t team reported on the findings and recori-
            mendatioiis of his group. Its purpose was to  determine  the  readiness
            of the North Dakota @IP to embark on a course of  independent  decision-.
            making, as well as to assess  ,the region's ability to utilize developmental
            f tilids.

            Core Staff

            The Program Director is. in ef f-ect, the Pro-ram.  Ile exerts strong and
            forceful leadership and speaks effectively for ND @IP.  He has been
            the moving force-in initiating and stimulat@i-ig necessary liaison  for
            the successful operation of the program thus  far.  He  enjoys  effective
            personal relationship with the medical community who hold him in e.steem,
            and has been the primary reason for a general acceptance of the ND/@IP.
            This has been aided by the Core staff which has continued to be committed,
            hard working and loyal to the program. It is  notable  that  since  the
            inception of the program, Dr. Wright has attracted competent people
            who exhibit high motivation and enthusiasm.

            Tbe'staff has been very active in project development, reinforcing,
            relationships and strong in initiating public and provider education.
            Staff has also provided leadership to fill the void caused  by  the  lack
            of involvement of the North Dakota University Medi.c-.L@l @c'fiool, Nursing


             North Dakota RMP                         -2-              RM 60-02 (AR-1 CD) 2/71.

             School or the voluntary and  public  health  agencies.  Despite  this  lack
             of support, the Core staff has  adroitly  implemented  projects  to  deal
             with the community as sole functionary  and  without  the  active  support
             of those agencies.

             Even though the ND/@IP staff has exemplified regional cooperative ventures
             in initiating their activities, and have done so with remarkable economy,
             the region does not consider one of its  major  functions  as  a  supportive
             influence in planning,  integrating  aid  coordinating  such  developments.
             The concept of program planning with coordinated project parts,
             complementing and maki-.ng up the whole seems to be unfamiliar to the
             staff. The staff apparently  does  not  view  these  movements,  concepts,
             activities, etc., as its role and this is a major deficiency in the
             growth of the program.

             @@@@tional Program Activities

             A wide variety of activities have been  undertaken,  and  include  appi-oxi-
             niately 120 se,-,iinars and workshops.  There  as een @i movement to
             improve patient care, especially  in  stroke  and  diabetes.  The  region
             is providing support and encouragement for the new North Dil,,ota  Medc,.%
             Program.  While this will not be funded frciii R@ill@S funds, the implelyl(-2rita-
             tion has been dependent on the background              of the  Core  staff,
             especially in regard to providers  and  opportunities  for  preceotorsliips
             and training possibilities.

             Another interesting proposal under development will    provide   expertise
             and assistance in a grant proposal for the Ileart of   American Hupian
             Services Center.  This is an innovative project to provide comprehensive
             and integrated delivery of health and social services to a rural
             Cacbement Area of Rugby, Nortl Da ota.

             Progress was noted in the region's building of bridges to the University,
             particularly in the Department of Continuing Education, the newly created
             Department of Community Medicine, the  Computer  Center,  and  for  arrange-
             ments with students in the School of  Medicine  for  a  Summer  preceptor
             program.

             e@velopniental Component

             The North Dakota Regional Medical Program has not yet clearly and
             concisely described its regional objectives.  There is a lack of
             movement toward an overall long-range plann-ing process or a
              program conc6pt" with project components utilized as building
             blocks in the program.

             There is very little evidence of a  transfer  to  a  programmatic  approach
             from a project approach, and this has  tended  to  fragment  their  efforts.
             The region needs to plan for projects  that  are  congruent  with  national
             as well as regional  priorities.  This  latter  observation  was  pointed
             up by the lack of evidence of a systematic approach to identifying


            "VLLil LJt@UL41 XWlr                                   Ni@l ov-vz      tV) Lill

            program for the nutritional management of persons with diabetes arid
            other chronic diseases, which was approved at $33,506 direct costs.
            All revi,(,--,,iers noted the enthusiasm this project generated throughout
            the region.  It is well designed, under very capable.leadership and
            ,shows potential for further development of a team approach for patient
            care.  This is a much needed concept that is becoming increasingly
            acceptable to the medical community of Nortli Dakota and will benefit
            by further de iaor-Lstrat-!,ori immediately.

            The region needs to give some thought to project planning which is con-
            gruent with current national priorities. Alsb, a more systematic
            approach to identifying local needs is called for, with broader input
            from areas other than Grand @-ori-s and Fargo.

            The RAG piemberslil-p would benefit by a more diverse representation to
            include representatives of labor, health insurance and allied health
            professions.

            Core staff should be increased, at minimum, to the level of an
            Associate Coordinator.  There is also a need for Core staff to develop
            skills in proc-r@11[i Planning and development, in delineating program
            objectives and definition of priorit@l-c@s, as N,7cl.l as establishing
            evaluation procedures.

            Some thought should be given to development of a review process to.all.@,,
            for a technical review with advice and collaboration on evaluation of
            program components.  Careful measures should be taken to insure that the
            ,needs of all local areas are considered.  The design of a method of
            evaluation should include review of progress to provide information to
            determine modifications, etc.

            The reviewers urged that the region initiate a long-range "regional"
            program with appropriate iritecyrated components.  This should begin
                                         C,
            immediately so that it can be included with the Triennial application.

                                                 RMPS/GRB/l/18/71


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

                NORTHLANDS REGIONAL MEDICAL PROGRAM              RM  21-03  (AR-1  CSD)   2/71
                375 Jackson Street                               January 1971 Review Committee
                St. Paul, Minnesota      55101

                PROGRAM COORDINATOR:  Winston R. Miller, M.D.

                                  REQUEST FOR NEW FUNDS (Direct Cost Only)

                REGIONS OPERATIONAL YEAR           03            04             05            Total

                1.   Core                      $    99,082  $  990,400         $1,045,685    $2,135,167
                II.  Ongoing Projects     6)     236,366          -0-           -0-             236,366
                III* Approved Unfunded
                           Projects (3)          144,602,        58,690            60,418       263,710
                IV.  Renewal Request (1)            34,330       34,495            35,950       104,775
                V.   Developmental
                       Component                 131,500        131,500           131,500       394,500
                VI.  New Projects (4)            270,238        361,194           362,726       994,158

                     Total                     $916,118     $1,576,279         $1,636,279    $4,128,676

                RMPS  Staff  Review  of  Non-Competing  03   Year   Operational   Continuation
                Grant Application (December 10, 1970).

                                             Recommended     Award     Commitment         Commitment
                REGIONS OPERATIONAL YEAR           03 Year               04 Year             05 Year

                I.     Core                      839,053                    -0-               -0-
                II.    Ongoing   Projects   (7)    476,315             $49,441                .0-

                     Total                      $1,315,368             $49,441                .0-

                                                 FUNDING  HISTORY
                                                (Direct Cost Only)

                GRANT YEAR                 PERIOD                     FUNDED

                Planniny, Staize

                01                    1/1167  -   12/31/67             $344,998
                02                    1/l/68  -   12/31/68              549,643
                02S                   7/l/68  -   12/31/68               27,849
                02S                   1/l/68   -   6/30/69                6,838


              Northiands RMP                     -3-             RM 21-03 (AR-1 CSD) 2/71

              The Region had  established good  relationships with the  practicing
              physicians and  the State Medical Association.  The allied health
              professionals were minimally involved,  as  was the School of  Public
              Health at the University of Minnesota  and  the State Division of
              Rehabilitation.  Representatives  of  community hospitals were  very
              reticent about their involvement and  needed  a lot of encouragement and
              work to bring them into the program.

              Better liaison was developed with the  Comprehensive  Health  Planning
              (A-Agency) with whom the NRMP coordinated  data  gathering  efforts,
              than with the voluntary area-wide planning agencies.

              The reviewers discovered that the ad hoc committees have not generated
              projects in needed areas, but rather screened  proposals  which  were
              developed prior to the formation of the committees.

              The National Advisory Council for RMP's approved in  March  1969  the
              operational grant application at a funding level of $1,189,964 (d.c.o.).
              The Northlands RMP Inc., became the official grantee and fiscal agent
              for the program with the award of the  operational  grant  succeeding
              the Minnesota State Medical Foundation and the Mayo Foundation.

              During the year of 1970 the Regional Advisory  Group  was  reorganized
              (three more consumer representatives and osteopaths  were  added)  and
              the new members were oriented by the NRMP core staff.

              All of this regions twelve operational projects are in the area    of
              continuing education and manpower development.  Following  is  a  list
              of the planning and feasibility studies which core staff has activated:

                 1.  Core Curriculum for  Continuing  Medical         L. D. Stauffer, M.P.H.
                     Education                                        University of Minnesota

                 2.  Standards of Medical Practice                    W.H. Trow, M.D.; MSMA

                 3.  Video-tape on New Physician-Patient              B.F. Fuller, M.D.
                     Interviewing T6chniques                          University of Minnesota

                 4.  Regional Laboratory Facility:                    GiG. Stillwell, M.D.
                     Feasibility Study                                Mayo  Clinic

                 5.  Rural Health Care:  Feasibility                  E.T. Carter, M.D.
                     Study                                            Mayo  Clinic

                 6.  Regional Consultation Service of                 J. Minott Stickney, M.D.
                     Mayo Clinic                                      Mayo  Clinic

                 7.  Albert Lea-Austin Health Services                B. Dornblaser, MIH.A.
                     Regionalization Study                            University of Minnesota

                 86  On-going Inventory of Practicing                 R.N. Hill, Ph.D.; NRMP
                     Physicians  ;


         Northlands RMP                     -4-            RM 21-03  (AR-1  CSD)  2/71

             9. Changing  Dimensions of Physicians                 R.  N. Hill, Ph.D.; NP.IIP
                Manpower

           10.  An Analysis of Group Practice in                   R.  N. Hill, Ph.D.; NRMP
                Minnesota

           11.  Patient Orgin Study                                R.  N. Hill, Ph.D.; NRMP
           12.  Cancer Mortality Study                             R.  N. Hill, Ph.D.; NRMP
           13.  Physician Migration Study                          L.  F. Cole, M.A.; NRMP
           14.  Metropolitan Physician Mobility                    T.  J. Litman, Ph.D.;
                Study                                              University of Minnesota
           15.  A Collage:  Selected Allied Health                 M. J. Deschler, R.P.T.,
                Manpower Statistics                                M.P.H.; NRMP

         Present  Application:  In  this  application  NRMP  is  initiating the
         Triennial Review System and requesting a Developmental Component Award.
         Also, support is  requested  for  the  Core  Component,  twelve  continuation
         project components, one  renewal  project  component  and  four  new  project
         components. The complete  system  of  NRMP  is  described  in  this  applica-
         tion to facilitate a "zero-based" review.

         NRMP is organized with subdivisions into three functional areas of
         concern(l) Continuing Education, (2) Manpower and (3) Health Services
         Development.  The three Planning,Review and Management Committees charged
         with coordinating responsibility in these areas, oversee all program
         components. The core  component  of  the  program  is  structured  in  detail
         under three broad  goals,  (1)  Administration,  (2)  Facilitation,  and  (3)
         Problem Definition and Solution.

         All activities of NRMP  have  been  reorganized  into  a  composite-whole
         consisting of the three functional areas of concern and the three broad
         goals of  the  core  staff.  The  specific  administration  and  facilitation
         responsibilities of the core  staff  overlap  the  functional  area  sub-
         divisions, but problem definition and solution activities are completely
         subdivided.  Facilitation activities include research studies, and
         planning coordinating activities in each of the three areas.  In the
         revised system of NRMP all project component staff will be integrated
         with core staff into the broad staff of NRMP.  Activities of both
         groups will be coordinated through accountability to the three Planning,
         Review and Management Committees and through them to the entire RAG and
         Board.

         In the initial development of NRMP, like most RMP's    '  heavy  emphasis
         was  placed  on  Continuing  Education  components.  Recently  more  emphasis
         has been placed on  Health  Manpower  and  Health  Services  development,
         especially in core activities, in  order to produce A better balance


              Northlands RMP                    -5-           RM 21-03 (AR-1 CSD) 2/71

              in the whole endeavor. In addition, the expanded  Continuing  Education
              Program has permitted a more complete program in this area..

              The Developmental Component will be utilized by the NRMP to initiate
              appropriate and timely feasibility studies, short-term pilot  programs,
              statewide conferences and special research studies, under direction  of
              the RAG.  The three Planning, Review and Management Committees have
              suggested many areas of activity which will be the basis for  soliciting
              specific developmental activities.

              ORGANIZATIONAL STRUCTURE AND PROCESSES

              The Board of Trustees:  The group consistsof representatives  from  what
              is called the nine sponsoring organizations of the  incorporation.  They
              are as follows:
                              Minnesota State Medical Association
                              Minnesota State Board of Health
                              Minnesota State Medical Association Foundation
                              American Rehabilitation Foundation
                              Regions of the University of Minnesota
                              Minnesota Heart Association
                              Minnesota Hospital Association
                              American Cancer Society, Minnesota Division Inc.
                              Mayo Foundation

              The Board has corporate responsibility for the operation,  administration
              and fiscal control of all the activities of the  program.  All  members
              of the core staff are accountable to the Board through the Program
              Director (Coordinator).  The Board appoints four to eight members at
              large of the RAG, and all members of Planning and Review, and  Advisory
              Committees.

              The Regional Advisory Group (RAG):  The constituency of the RAG was formed
              by Asking 34 organizations in Minnesota to select a  representative.  In
              addition, four to eight public members are selected by the  Board.  The
              Regional Advisory Group presently is composed of 36 members, (9 sponsoring
              organization representatives, 9 Minnesota State Medical Association
              Councilor Districts representatives, 7 consumer representatives  and  9
              members from other organizations).
              The RAG has authority and responsibility for program development and
              management.  Three members of RAG are on each of the Planning and Review
              Committees, which review all applications in detail.  The  RAG  members
              on those committees present committee recommendations to the entire
              RAG.  The RAG also receives progress reports on all core and demonstration
              project component activities. The RAG exerts it program  authority  and
              responsibility by voting on all program components in every  application
              for funding.

              Under the new Anniversary Review System, the RAG has elected to act as a
              committee-of-the-whole to authorize use of Developmental Funds.  The
              group has agreed to meet as often as necessary for this purpose.


               Northlands RMP                                         -6-                          RM 21-03  (AR-1 CSD)  2/71

               Planning     and     Review     Committees     (P     and     R     Committees):     There      are      three
               P & R Committees with  the responsibility for development of program
               goals     and     objectives,     and     for     detailed     review     of     all      program      component
               applications.     The     three      P      &      R      Committees      are:      Continuing      Education,
               Health Services Development,  and Health Manpower.   These  three
               committees made  their recommendations  to the RAG.   Each P & R Committee
               includes    a     chairman     and     ten     other     voting     members     (one     or     two.from
               each       Medical       Center,,       three       non-medical-center        members from the RAG,  and  two
               to four members at  lar,,e).

               Advigory Committees:                NRMP has appointed advisory committees  in various
               areas of expertise  to advise the three P and R Committees,  as well as  the
               Board and  the RAG concerning program development.   The  following committees
               are currently active:

                                (1)Heart Disease and Stroke                          (7)Communications
                                (2)Cancer                                            (8)Intensive         Coronary         Care
                                (3)Nursing                                           (9)Dial-Access               Library
                                (4)Dentistry                                       (IO)Diabetes
                                (5)Radiation Therapy                               (11)Mayo Postgraduate Education
                                (6)Rehabilitation

               Staff Organization:   The Core  Staff of the NRMP has  forty-six employees,
               twenty-nine     at     100'/.     time     and     effort.     The     core     staff     organization     and
               functions have been changed  to reflect  staff responsibilities  toward
               three     program      goals:      (1)      Administration,      (2)      facilitation      and      (3)
               problem     definition     and      solution.      Overall      direction      is      provided      by      the
               Program      Director,      and      three      Associate      Directors,      (The       Deputy       Director;
               the      Associate      Director,      University      of      Minnesota;      and      the      Associate
               Director, Mayo Institutions.   The Director and  three Associate Directors
               constitute  the Executive Staff.

               The    following    is     a     list     of     the     core     staff     membersand     an     organizational
               chart:
                                                                                                                 Time or Effort
                      Name                                           Job Title                                        % Hours

               W.  R.   Miller, M.D.                             Program Director                                     100*/@
               R.  J.   Wilkins, M.H.A.                          Assoc.  (Deputy)  Director                           1001/.
               J.  M.   Stickney, M.D.                           Assoc.  Director                                       70%
               W.  R.   Fifer, M.D.                              Assoc.  Director                                       80'/.
               L.  B.   Stadler                                  Program Management Director                          100*/.
               L.  G.   Berglund                                 Project Management Coord.                            1001/.
               E.  D.   Leyasmeyer                               Cont.  Educ.  Coord.                                 1001/.
               D.  A.   Lee                                      Fiscal Director                                      1001/.
               K.  A.   Kiley                                    Communications               Coord.                  1001/.
               R.  N.   Hill                                     Evaluation Officer                                   1001/.
               J.  @l.  Schowalter                               Nursing Coordinator                                  100%
               @t. J.   Deschler                                 Rehabilitation               Coord.                  1001/,
               R.  D.   Place,  D.D.S.                           Dental Coordinator                                     5 O'/,
               T   B  A                                          Health        Care        Economist                  100%


                         Northlands            RMP                                          -7-                   RM  21-03  (AR-1  CSD)  2/71

                                                                                                                                          Time  or  Effort
                              Name                                                     Job  Title                                                % Hours

                         M.   J.  Ryan                                              Liaison  Librarian                                           1001/.
                         G.   Foreman                                               Ext.  Librarian                                               41.5%
                         J.   Lorrig                                                Ext.  Librarian                                               41.5%
                         L.@  F.  Cole                                              Research  Sociologist                                        10(r/.
                         L.   A.  Sonderegger                                       Research Assistant                                           100%
                         R.   P.        Buckley,        M.D.
                         0.   M.        Heiberg,        M.D.
                         R.   Schnabel,  M.D.
                              J.  Ballantine,  M.D.                                 Comm.  Coordinators  (25%  each)                             1001/@
                         R.   Axness                                                Bookkeeper                                                   1001/.
                         11   personnel                                             Secretary/Assistant                                          1001/,
                         T   B    A  (2           half-time)                        Secretary             (Mayo)                                 100%
                         T   B    A  (3           half-time)                        Secretary             (U.  of M.)                            150'/,
                         M.      B.  O'Sullivan,  M.D.                              Reg.         Lab. Dir.    (Mayo)                              50%
                         G.      C.  Wollner                                        Reg.         Lab. Admin.  (Mayo)                              50'/,
                         G.      M.  Needham                                        Reg.         Lab. Coord.  (Mayo)                              30'/,
                         T   B    A                                                 Lab.         Tec. Coord.  (Mayo)                              50%
                         E.      T.  Carter,      M.D.                              Rural  Health  Dir.  (Mayo)                                   40%
                         T   B    A                                                 Phys.  Asst.                (Mayo)                            50'/.
                         T   B    A                                                 C.M.E.              (U.  of M.)                               50%
                         M4      K.  Cragun                                         C.M.E.  Coord.  (U.  of M.)                                   50'/.
                         T   B    A                                                 (5)  DCME's  (20'/.  each)                                   1001/.


                            Northlands RMP                                         -8-                           RM 21-03  (AR-1 CSD)  2/71.

                                                        T A B L E       0 F     S  T A  F F       0 R G A N I    Z A T I 0 N

                                                  F 0 R    N-R M P    P R 0 G R A M    A D M I N I S T R A T I 0 N

                                                                                   6 R A i'@  T  E

                                                                                    NRMP,      Inc.

                                            ARD  FF -TRUSTEESI                                                       REGIONAL ADVIS(RY GR@P
                                                                                                                                        I

                                                                                PROGRAM DIRECTOR
                                                                             *W. R. Miller, M.D.
                                                                             R. J. Wilkins, M.H.A.
                                                                                            ii,ector

                                       INTERNAL        SERVICES                                                     EXTERNAL SERVICES
                            Communications            -   K.   A.   Kiiey                         '@ursing                 -  J. M.  Schoaiter,T\ti,M@'d
                            Evaluation                -   R.   N.   Hill,                         Library                  -  iv. J. R,:2n,
                            Fiscal Management         -   D. A. Lee,                              Rehabilitation           -  M. J.  :;schler, RPT,I/.!'!!
                            Sociology & Data          -   L.   F.   Cole, I-IA                    Eentistry                -  R.  D. Place, DDS
                                                                                                  Economist                -
                                                                                                  Community     Cooi,d.    -      (5

                                CONTINUING         EDUCATION                    HEALTH    tiANPOWER                        HEALTH SERVICES
                                        SECTION                                       SECTION                           DEVELOPT;ENT        SECTION

                                 *W.  R.  Fifer, I.iD                         *k. J. llilkitis, ti@IA                    *J. t,l.  Stickney, IID
                                Associate Director                            Associate Director                        Associate Director

                                CCI@'TT@
                                                                                HEiLT.-,
                                      COI.;14!TT.@                                        COMMITTEE
                            Lee    D.    @taur@fer,    Chairman                                   Chairman
                            E.D.   Leyasmeyer    -    Coord.            L.G.Berglund     -      Coordinator*'-,    L.B.Stadl,2r@
                            ,.J.  Frey,  flD  -   Bd.   Rep.            J.W.Rivall, MHA - Bd.

                                                       PTOJECTS             EIE.140"iSTRATIOI@ P@@OJECTS                                     3j7CTS
                                Diabetes - Etzwiler                         Nurse        Refreshp-r
                                led.  Card. - Lucas                                               Stryker
                                'LC,:U - Lee                                (Ophth.   Tech.'."':':*                     (Cone-.  I:Q     --i'-seise***-
                                Stroke - Er,-ith                                                    Hi Z Z)
                                      Access    -     BelgZzird
                                Clin.   !,utr.   -   Ve2,strate
                                !.!ed. Tech. - I-lerritt
                                (M,aY,o;P.G.E@*** -                           PROBLEY3
                                                                                         DEFINITIOIN'                      PROBLEY,            'iO'
                                                    Osmi@idson)                   AND      SOLUTION                          AND SCL,'@
                                (Univ. Ped. Educ.'@                        Manpower       R.  HIZZ
                                                                           Itudies                Cole
                                           Educ.:'.'**                                                                        P@g.  L

                                                                                                                       Mayo Rural Health
                                                                                                                                             Carter
                                                                                                                       Vital StatisticE,
                                  F.@OBLEM    '@EFlj'IITIOli
                                      AI;D SOLUTION
                                                  (2)
                                                   Leyasineyez,
                                Library - .,.,@an                                             'I'l@e         D@-rec4@,i,,   together   w-l@:@   the
                                I-le@c!icai Audit -  Fi,,"cr                                                       .!),.",(jtors,   co-pr@lse   the

                                                                                                             !,,,,"t7iout i)ote
                                                                                                                    ui2funded.


              Northlands RMP                       -9-         RM 21-03 (AR-1 CSD) 2/71

              The total core budget  of $938,135 in direct costs for Fiscal Year 1971
              requested by the NRMP  exceeds both the level of commitment for core and
              the level approved by  the National Advisory Council for  the  03  year
              operation.
                               03    N.A.C. Recommendation     $923,830
                                03   Commitment                $839,053
                                03   iZequest                  $938,135

              The Region explains that since this is  a  triannual  application  with
              inclusion of a developmental request, no attempt  was  made  to  tailor
              the budget to the 03 year NAC  authorized  level.  They  indicate  that
              the core budget in this application was developed to support the com-
              pletely revised program of Nortblands Regional Medical Program.

              The increased budget request over the 03 year  lies  in  the  personnel
              and travel categories.  The increase in the personnel buget is due to
              a slight shift in the types of personnel and a projected average salary
              increase of 6/. for NRMP employees.  The increase in the travel category
              reflects principly the increase in RAG and Committee meetings planned
              for the next year.

              The Region explains that in response to  the  stimulation  provided  by
              the new Anniversary Review System, the  NRMP  has  undergone  extensive
              self-renewal of its.entire program.  In this application the NRMP
              system is described in full. It has documented its integrated
              development, its readiness for greater autonomy and its capacity for
              administrating a developmental award.

              The fundamental philosophy has been retained for emphasis on the three
              general functional areas - Continuing Education, Health Manpower, and
              Health Services Development.  The three com  parably designated Planning,
              Review and Management committees have developed more specific policy,
              statements which provide guidance not only for project component review
              but also for design of work programs for Core activities.
              Project Review Process:  The new and preferred procedure for development
              and inclusion of new project components is as follows:

                    1    A proposer interested in submitting a proposal for inclusion in
                         the program will first contact the Program Director.
                    2.   The Program Director will assign a member of his staff to prepare
                         A two page abstract or outline of the  roposal to be developed
                                                                p
                     3.  The Core staff member will present the abstract or outline,to
                         the appropriate Planning and Review Committee for its tecom-
                         mendations.
                     4.  Upon approval of the P & R Committee, the staff member and the
                         proposer of the new component will proceed with project
                         development.
                     5.  The costs required for development of the project may be paid
                         out of Core funds. This may  include  reimbursement  to  the
                         sponsoring organization for time and effort and other costs.
                         (Board approval required)


          Northlands RMP                         -10-       RM 21-03  (AR-1  CSD)  2/71

                6. As. soon as the proposal is completed  in  final  form  it  will  be
                     processed through  the  local  review  mechanism.  Expert  budget
                     and program consultants may  be  employed  to  provide  unbiased
                     technical assistance.  The P & R Committee will then conduct its
                     review.  Proposers  desiring  to  have  their  application  included
                     in the next Anniversary Application  will  be  well  advised  to
                     complete applications for a  first  time  review  several  months
                     before the July lst deadline for final review.  This will allow
                     time for revisions which are frequently  required  by  P  &  R
                     Committees before final approval.
                7.   After approval by the P  &  R  Committee,  proposal  applications
                     will be reviewed by the Regional  Advisory  Group  and  the  Board
                     of Trustees.
                8.   Approved project components will be included in the supplemental
                     portion of the next annual composite application.
                9.   Deadline for'inclusion will be July 1, each year.

          Although not preferred, an alternate procedure will be accepted if
          circumstances  warrant.  Project  proposers  may  submit  component  applica-
          tiong in completed form to the Program Director.  If applications
          meet NRMP standards they will be submitted to  a  P  &  R  Committee  for
          review.

          Proceedings of  review  committees  meetings  are  regarded  as  privilege
          communications, prepared only for use by Consultants, Centra  Sta
          and Board of Trustees. A summary  of  the  Review  Committee  s  report  on
          an individual project will be submitted to members of the      Regional
          Advisory Group when this is appropriate.  The Committee members,
          individually, do  not  advise  applicants  of  Committee  recommendations.

          To avoid situations of  possible  conflicts  of  interest,  members  of  Review
          Committees absent themselves  from  the  meeting  room  when  applications
          submitted by  their  own  institutions  are  being  discussed.  Individual
          Committee members recognizing  other  conflicts  of  interest  are  expected
          to voluntarily request the  same  action.  In  such  cases,  the  individual
          Committee members do not prepare a personal report of his recommendation.

          The Committee recommendation is made  by  majority  vote  of  the  members.
          The chairman of the review committee  prepares  a  summary  report  of  the
          Committeels appraisal and recommendation of each project proposal
          considered. This report  follows  the  same  outline  as  the  individual
          reports from  Committee  members.  The  average  numerical  rating  scale
          of all Committee members is included.

          The Committee approves,  disapproves,  or  defers  each  project  proposa
          considered. When a  project  is  disapproved  or  deferred,  the  Committee
          specifically lists the deficiencies  which  were  the  basis  for  the  action,
          particularly  important  when  projects  are  deferred.  The  Review  Committee
          provides the staff with a very  clear  and  detailed  statement  of  what
          it wants changed.   The report  includes  concrete,  constructive  cr  tic  sm.


               Northlands RMP                       -II-        RM 21-03  (AR-1  CSD)  2/71
               Each member of the Review Committee  includes  in  his  report  a  numerical
               rating as indicated on the  attached  format  page.  The  five  point  scale
               rating is applied to each project with regard to:
                             A. Intrinsic Merit
                             B. Relevance to NRMP Goals
                             C. Priority for Inclusion in NRMP.
               Each rating is independent of the other two.  Averages of the individual
               Committee meember ratings have a  semblance  of  objectivity  to  the  total
               Committee recommendation.  Each member comes to the Committee meeting
               with a complete  typewritten  report  emphasizing  the  following  points:
               Description:  Give a concise description of the proposal, including
               aims and procedures as each is  appropriate  to  a  clear  understanding  to
               the project proposed. Are  the  objectives  concise  and  specific  enough
               for results to be evaluated:  Discuss the strength and weakness of
               various aspects of the proposal.  Are the aims logical?  Is the approach
               valid and adequate?  Are the procedures feasible?  What is the significance
               and pertinence of the proposed study with  regard  to  the  state  of  the
               field and importance of the objectives?
               Personnel and Resources:     Discuss the competence and background of the
               investigators and the adequacy of  other  personnel  and  facilities  to  be
               employed, Is continuity  assured  for  the  duration  of  the  project?
               Evaluation:  Comment on the adequacy of proposed self-evaluation
               methods4 Is the project planned  in  phases,  so  it  can  be  effectively
               reviewed at periodic intervals?  Is there an evaluation method covering
               each stated objective:
               Regionalization:  Is there adequate proof that cooperative arrangements
               are firmly established?  Does  this  project  have  the  potential  for
               statewide improvement in the delivery of health services?
               Budget:  Is it realistic in terms, and aims, and methodology?  Are
               all items justified on the  basis  of  the  approach,  procedures,  and
               analysis of the  data  proposed?  Itemize  and  provide  specific  reasons
               for reductions in time or amount of funds which you recommend.

               Annual Report of the Regional AdvisM Group (RAG):  The RAG has a
               deep sense of responsibility for t  s program, and at the same time feels
               almost overwhelmed with the magnitude and scope of the activities.
               It expresses a genuine desire to  become  more  involved  in  planning  of
               program components, and specific direction of activities and in
               facilitating a more extensive  outreach  to  peripheral  areas  of  the
               state.

               The date the RAG has approved  what  it  considers  to  be  mertiorious
               projects.     They recognize that these projects serve particular
               problems, and while relatively narrow in their scope contribute to
               the whole. In reviewing  the  projects  and  programs  funded  to  date  and
               in considering protential future activities the RAG has become


        Northlands RMP                     -12-          RM 21-03 (AR-1 CSD) 2/71
        increasingly aware of the totality of the health care problem.
        Together with trustees, the staff and the committees of the  NRMP,  the
        RAG is planning to define problems that exist in greater  depth  and
        attempt to establish more detailed methods and priorities  in  solving
        identified problems.
        Program goals, policies, and guidance developed by three  Planning  and
        Review and Management committees have been unanimously adopted  by  the
        RAG.  Individual members expressed some concern over the magnitude and
        rapid growth of the program,, fearing the growing pains  might  impede
        successful progress.
        In approving the continuation components in this application,  the  RAG
        felt that all of them had a significant achievement  and  should  be
        continued. In order to maintain  program  momentum,  the  continuation
        components should have priority for funds if they  are  insufficient
        funds to cover the whole program.
        The RAG believed that special consideration in  priority  for  funding
        needs to be given to one renewal and one new project component  in  the
        application. The dial access information system (Project #10  R)  is  a
        continuation and expansion, with specific orientation to Minnesota, of
        the previously funded dial access project component  conducted  in
        conjunction with Wisconsin.  The RAG believes that the Diabetes
        Edutation Center Component (Project #20) will provide  the  basis  for
        continuation of projects #5 and #15 and represents a  renewal  of  the
        emergency funding provided this year for project #18.  The  second  and
        third years of this project component will  amalgamate  components
        #5, #15 and #20 into one unit.
        The Regional Advisory Group believes that this NRMP should do
        everything possible to develop strong relationships with other
        Regional Medical Programs adjoining Minnesota.  The  members  were
        impressed with the five or six specific examples of interregional
        activities between Minnesota, North Dakota, Wisconsin and Iowa.
        The RAG has frequently emphasised the need for  strengthening  the
        health system in sub-regional areas of the state.  It  has  endorsed
        the activities of community Coordinators and staff in project component
        activities which seek to develop strong outreach to  peripheral  areas.
        It was impressed with the Core staff presentation of 16 core activities
        and 7 project component activities which are designed  to  stimulate
        improved cooperative arrangements in sub-regional areas  to  strengthen
        the health care system in the periphery of the state.  Some  of  the
        members were distressed with the feeling that they have not moved fast
        enough in this direction and that no great  accomplishments  have  yet
        been achieved.
        The RAG of NRMP feels a deep sense of responsibility  for  the  program
        but at the same time feels a frustration  with  the  organization.  In
        the minds of many of the members, this frustration increased when they
        became aware of the magnitude of their responsibilities, the


              Northiands RMP                     -13-      RM 21-03 (AR-1 CSD) 2/71

              difficulties in understanding the multiple components of the  program,
              and the time and effort necessary for them to execute their  responsi-
              bilities. The RAG has never the less expressed  its  confidence  in
              the competence and diligence of the program leaders and wishes
              sincerely to see the program succeed.
              Program Evaluation:  The Northlands RMP's approach to  evaluation  has
              been multi-dimensional, employing a variety of techniques and  methods
              to appraise progress toward the three broad goals of the program  as
              well as accomplishments of the objectives of individual projects.
              Thus far, considerable stress has been placed on the use of  evaluations
              as the intitial step towards self-improvement with emphasis  given  to
              self-appraisal and self-assessment of activities and  achievements.
              As Northlands RMP reaches maturity, greater emphasis will be  placed
              upon an evaluation process which calls for hypotheses testing
              proceeded by some exploratory study and descriptive and  diagnostic
              investigation. The major dimension of the evaluation  process  thus
              far has included self-evaluation with internally  developed  criteria,
              scientific evaluation of program and project accomplishments and
              external appraisal more at processes than at  ov.tcomes.  The Region seems
              to be taking an overall look at their program as well as  individual
              projects in developing a plan for evaluation.
              Developmental Component: The Northlands Regional  Medical  Program  is
              applying for a developmental component award of 10'/. of the total 02 year
              operational budget an amount of $131,500.  The Board of Trusteesi
              Regional Advisory Group, and RMP Staff indicate their confidence  that
              the NorthlAnds RMP has developed specificity of program goals,  strength
              of core staff organization, and strength of program fiscal  management
              sufficient to demonstrate its readiness to receive  the  developmental
              award.

              The NRMP explains that they have had fairly extensive experience with
              program activities and analogous to those which will be  conducted  with
              the developmental award.  During the planning phase, nine such component
              activities were conducted, four by specific re-allocation  authority  of
              RMPS, and five by the employed core staff. Three  of  these  studies
              resulted in demonstration project component applications.

              During the operational phase, NRMP has conducted twelve  more  such
              short term studies.  The Developmental award however, will make it pos-
              sible for NRMP to fund activities under the local authority  of  the
              RAG without waiting for special RMPS approval as was necessary  n t e
              seven activities carried out previously by this method.

              The NRMP will utilize developmental funds to conduct special
              feasibility studies, short term projects, or special research
              activities, appropriate to NRMP goals which are not already a
              part of Core or project component activities.  They  indicate  that
              developmental funds will not be used to provide support for
              operational projects, either those previously submitted or those
              pending review. Neither will they be used  for  initiating  long  term
              activities or for purchase of equipment.


          Northlands RMP                  -14-         RM 21-03 (AR-1 CSD) 2/71
          The submission and review of request for developmental funds will
          follow the presently working review cycle and monitoring system estab-
          lished'by the Region.

          Broad Goals of the NRMP
                 1.  To develop and maintain a flexible organization capab le
                     of administering an  ongoin@ cooperative program involving
                                                9
                     the multiple health care organizations and personnel in
                     Minnesota.
                 2.  To stimulate existing health care personnel,institutions
                     and programs to commit their talents and their resources
                     to cooperative efforts to develop more optimal health
                     care services for all the people of Minnesota.
                 3.  To characterize and attack specific problems in a coordinated
                     program to improve health care services to the people of
                     Minnesota.

          SUPPLEMENTAL PROJECTS
                                                                         Requested
          Project #20 - Diabetes Education Center   This project will     irst Year
                       provide the basis for continuation of Project     $135,210
          #5 and #15 and represents a renewal of the emergency funding
          of $81,62i provided this year for Project #8 - Diabetes Detection
          and Education Center.  The RAG gave top priority for funding this
          program.
          The objectives of this program are to (a) improve health care by
          stimulating patient interest in and knowledge of their  disease;
          (b) provide continuing education for physicians and allied health
          professionals; (c) serve as a res@ource center for practicing  physicians;
          (d) develop and make available to other programs,educational materials,
          techniques, and systems; and (e) stimulate and coordinate development
          of health education programs,
          The NRMP believes that this'program interrelates with Core, other
          project activities, planning and review committee policies.
                   Second Year                      Third Year
                   $247,113                         $254,473
          Project #21 - Minneso a Congenital Heart Dise                  Requested
                        This proposal is to establish a congenital       First Year
          heart disease registry in Minnesota to facilitate a multi-     $20,448
          disciplinary approach to this disease entity.  Data obtained
          from an optically read registry form will be used to coordinate
          and improve the currently available health care system for afflicted
          children.  The Minnesota Heart Association allocated $5,000 for
          research and development of the  optically-read  form.  The  participating
          agencies have contributed staff and clerical time for planning and
          development.


              Northlands RMP                        -15-      RM 21-03 (AR-1 CSD) 2/71

              The objectives of this program support the Northlands  goals  of
              improving patient care, professional education, and disease prevention.
              There will be a close and cooperative relationship with such other
              NRMP component projects as Pilot Study in Postgraduate  Education  in
              Pediatric Cardiology, Pilot Program of Regional  Postgraduate  Medical
              Education - Mayo Institutions, and Postgraduate Education In Diseases
              of Cardiovascular and Nervous Systems and Neoplastic Diseases in
              Childhood - U. of M.   This program has encouraged,  during  its
              planning phase, harmonious cooperation between independent and diverse
              health institutions and promises to continue doing so if  it  becomes
              operational.

                     Second Year                           Third Year
                      $26,088                               $28,688

              Project #22 - Continuing Education in the Radiological Sciences  Requested
                            at the University of Minnesota Medical Center:      First Year
              The dissemination of information on new techniques used  in  the   $63,886
              practice of radiology is the fundamental objective of this
              proposal.

              This program relates directly to the goals of  Regional  Medical
              Programs as well as to the goals established by Northlands.  The
              education focus of this program will provide the means  for  conveying
              the latest advances in radiology and nuclear medicine so  as  to
              bridge the gap between the existing knowledge and skills and their
              implementation. The project will link the expertise  of  the  medical
              centers to the radiology practitioner.  The upgrading of radiological
              services throughout Minnesota will permit the best in modern  care  to
              the patient.

                       Second Year                          Third Year
                        $45,715                             $46,715

              Project #23 - A Continuation Course for Nurses Care of th.e    Requested
                            Patient with Neurological Disease.               First Year
              The primary purpose of this program is to train nurses in       $50,694
              neurologic and cerebrovascular disease nursing.  The program
              will be presented by three nurse educators and one physician,
              augmented by recording and filming portions of the  course  presented
              by experts unavailable for travel to peripheral institutions.

              The Continuing Education Committee of NRMP has  established  policies
              into which the goals of this project fit unquestionably.  These
              goals stress the need to better the level of practice of health
              professionals, develop programs which advance cooperative relationships,
              provide educational opportunities at the site of the health professional's
              practice, and utilize the interdisciplinary team approach.

              This project will not conflict with the presently funded project
              entitled "Improving Stroke Rehabilitation Through a Regional Program
              of Continuing Education" which deals exclusively with the rehabilitation
              of long-term patients. Personnel from both courses  have  agreed  that
              the courses differ.
                      Second Year                       Third Year
                      $42,278                           $32,850


         Northlands RMP                      -16-          RM 21-03  (AR-1  CSD)  2/71

         APPROVED AND UNFUNDED PROJECTS

         The Region has requested in-this application new funds to activate
         the following approved and unfunded projects:
                                                                                  Requested
         Project #13    (Previously Known as Project  #9)  -  Pediatric  Educa-   First Year
                        tion: This program is aimed at,hose physicians             $38,693
         whose practice is devoted, in a large part, to the care of
         children.  It will provide an educational experience to the participants
         in (1) pediatric cardiology, (2) pediatric neurology, (3) infectious
         disease and immunology and  (4)  metabolic  disorders  and  neoplastic
         disease in childhood.    An entire day each  week  will  be  designated  as
         a postgraduate effort by ten to fifteen  members  of  the  faculty  of  the
         Department of Pediatrics.

         This project relates to the Regional Program  Plan  in  that  it  will
         enable utilization of  limited  manpower.  The  Region  has  requested
         one-year support at the' NAC a proved level for 01 year of $38,693.
                                        p

         Project #14 - Course for Medical Technicians in Opthalmology:  Requested
                        This program proposes to train selected             First Year
         individuals to perform those technical and mechanical                 $5@1,850
         determinations required in the treatment and diagnosis of
         eye disease and thus extend the time availability of the Opthalmologist.

         This project complies with the goals  and  objectives  of  the  Region
         because it provides for the development of new health manpower.

         The Region believes it has documented very well the health manpower
         shortage in Minnesota.
         The Region has requested three years support  at  the  NAC  approved  le,;el.

                 Second Year                        Third Year
                 $27,855                            $30,083
         Project #19 - Mobile Health Unit:  The objective of this         Requested
                        proposal is "to extend the arm of the             First   Year
         physician" into a rural section of Northwestern Minnesota           $54,059
         utilizing a mobile van and the services of registered nurses.

         The program relates to Regional goals and objectives in that it
         increases equity of access to a system  of  quality  health  care  and
         increases the system productivity while constraining costs.  The
         Region has requested three years support at the NAC approved level.

                Second Year                           Third Year
                $30,835                                $30,335


               Northlands RMP                     -17-      RM  21/03  (AR-1  CSD)  2/71

               RENEWAL   REQUEST

               Project #10 R - A Minnesota Dial Access Information System.         Requested
                                The Dial Access Medical Library has been           First Year
               an operational project since March 1969, in cooperation             $34,330
               with Wisconsin RMP Dial Access Program in Madison.  This
               application for a Renewal grant is for the purpose of
               establishing,  expanding  and  coordinating  a  Dial  Access  Information
               System specifically oriented to the practicing physicians in the
               State of  Minnesota.  The  Education  Committee  of  NRMP  believes  that
               this program could become an essential component of an extensive
               information network  which  eventually  could  link  the  various  health
               facilities with  the  medical  centers  throughout  the  State.  The
               RAG of the NRMP has designated  this  program  as  a  high  priority
               activity for this Region.

               The Region indicates that  this  program  relates  directly  to  the
               goals of of Northiands because  it  helps  to  make  the  latest  medical
               knowledge  constantly  available  to  all  practicing  physicians  within
               the Region.  It will further help to develop integration of information
               available from other project activities supported by RMP as well as
               information  available  through  existing  region-wide   resources.

                       Second Year                            Third YeaL
                        $34,495                                  $35,950

               SUPPLEMENTAL FUNDING OF ON-GOING PROJECTS

               Project #2 S - Multidisciplinary Improvement in Medical Care            Requested
                               of Myocardial Infarction in Minnesota:                  First  Year
               This was an approved and unfunded project which was initiated           $82,792
               with carryover funds awarded by the RMPS on July 1, 1970.
               The Region has requested new money  at  the  02  year  NAC  approve
               level for continuation of the program.

               The primary objective of  this  program  is  to  provide  practical
               courses for nurses who are directly involved in the care of coronary
               patients.
               Project #1.2 - (Previously known as  Project  #8)  -  Pilot  Program    Requested
                              of  Regional  Postgraduate  Medical  Education  (Mayo    First  Year
               Foundation).    This was  an  approvedand  unfunded  project  which     $31,002
               was initiated with carryover funds awarded by the RMP.  The
               Region has requested new money for continued support of this program
               in its 02 year. The NAC  approved  level  for  this  project  in  its
               02 year  is $69,960.

               In addition the Region has requested supplemental funding of the
               following ongoing projects:
                                                                                       Diff. in Req.
               Project         Commitment       NAC Approved level         Request     vs. Commit.
               #2              $187   500             $259,841             $259,841        $72,341
               #3                  24:917               45,161               32,018         7,101i
               #5                 481,000               66,130               66,130         18,130
               #7                  75,000              100,000              100,000         25,000


         Northlands   RMP                -18-                RM 21-03 (AR-1 CSD) 2/71

                                                              Present Year
            APPROVED  AND FUNDED PROJECTS                    of Operation
            Project #2  -Mutidisciplinary                        2nd
            Improvement in Medical Care of
            Mycardial Infarction

            Project #2S -  Supplement to
               Project #2 (above)                                lst

            Pro ject #3 - Postgraduate Education
               in Pediatric Cardiology                           2nd

            Project #5 - Diabetes Regional
               Center                                            2nd

            Project #7 - Improv ing Stroke
               Rehabilitation through a Regional                 2nd
               Program of Continuing Education
            Project #12 - (Revision of Project #8)               Ist
               Pilot Program of  Regional  Postgraduate      (carryover
               Medical Education, Mayo Foundation                   funds)

            Project #10 - Telephone Dial Access-
               Medical Library                                   2nd

            Project #15 - An Education Program in
               Clinical Nutrition                                lst

            Project #16 - Upgrading  the  Quality  of
               Clinic Laboratory Tests  by  Improving            lst
               Performance of Laboratory  Personnel  in
               Non-Urban Hosptials  through  Continuing
               Edcuation.
            Project #17 - Refresher Courses for Nurses           lst
            Project #18 - Diabetes Detection Center              lst

            APPROVED AND UNFUNDED PROJECTS                    Council Approval

            Project #13 - (Revision  of  Project  #9)
               Postgraduate Education in  Disease  of          December 1969
               Cardiovascular and Nervous  Systems  and
               Neoplastic Disease in Childhood,  llniv.
               of Minn.

            Project #14 - Course for Medical
               Technicians in Ophthalmology                    December 1969

            Project #19 - A Proposal for a   Mobile
               Health unit                                     November 1970


            Northlands RMP                      -19-           RM 21-03 (AR-1 CSD) 2/71

               PROJECTS DISAPPROVED

               Project #4 - Information Network for
                 Education and-Clinical Evaluation
                 Applied to Coronary Artery Disease

               Project #6 - Service-Oriented
                 Cancer Registry

               Project #11 - Development of a Stroke
                 Rehabilitation Management Simulater

                                                           RMPS/GRB/12/10/70


                                                                A PRIVILEGED CONMNICATION

                                   S@RY OF REVIEW AND CONCLUSION OF
                                      JANUARY 1971 REVIEW COMMITTEE

                                  NORTHLANDS REGIONAL MEDICAL 'PROGRAM
                                       RM 21-03 (AR-! C8D) 2/71

                          FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

                Recommendation:  The Committee recommended that additional funds be
                provided for this application as follows:      639, 32 - 03 @'/ear;
                $1,462,159   04 year4, and $1,378,700 - 05 year.

                                      TOTAL REQUEST AND RECOMMENDATION

                                               RMP   Request

                Year               Developmental             Other               Total
                03                  1313,500               2,099,986             2)231,486
                04                  131,500                1,494,220             1$625,720
                05                  131,500                1,504,799             1,636,279
                Total                $394,500              $5iO98,985            $52493,485

                                             Committee Recommendation

                Year               Developmental             Other                 Total
                03                  131$500                1,822,900 1/          119954,400  1/
                04                  131,500                1,380,100 2/          1,511,600   2/
                05                  13ls5OO                1,247,200             1,378,700
                Total                $394,500              $4,450,200            $4,844,700
                   (Includes  $1,315,368   of t6nnitted funds approved by staff.)
                   (Includes $49,441 of committed funds for one project.)

                critique; A site  visit  was  conducted  to  this  Region  on  December  15-16,
                            1970 and the visitors reported that they were favora  y
                impressed  with  this  Region's  development  to  date.  Concentrated   efforts
                are being made  to  stabilize  the  planning  and  decision-making  process
                and respond to  new  program  direction  as  well.  The  Regional  Advisory
                Group has assumed the leadership role and now has full responsibility


          Northlands RMP                        -2-           RM 21-03 (AR-1 CSD) 2/71

          for program direction.  While valid, the goals and objectives of the
          region were found to be general in nature.  The Region is, however,
          aware of this problem and is presently formalizing its regional
          objectives.

          The Region is in the process of shifting its program emphasis from
          continuing education to health care delivery.  As yet, the l@C has
          not dealt with the issue of setting priorities on indi.vidi.iil components
          of applications.  The RAG, however, plans to face this issue once it
          knows what level of funding will be awarded to the Region.

          Dr. Winston R.  Miller, the Program Director, is a very capable
          administrator and.he has a competent supportive Core staff.

          The Associate Director for RMP at the University of Minnesota appears
          to be a positive force of the NRMP.  The RMP Coordinator at Mayo,
          however, has had difficulty getting his institution's active participation.
          Dr. Miller has developed a good rapport with project representatives, the
          RAG, and the Board of Trustees and he skillfully manages to keep the
          latter two groups well informed of Core staff activities.

          In  view of the broad goals, Committee was concerned with the relevance
          of projects to the goals, especially in the area of continuing education.
          There appears to be fragmentation in specialized training activities.
          It was reported, however, by the site visit team that Core staff is
          making some attempt to correct this problem by working with hospitals,
          colleges and allied health associations.

          Committee's overall impression is that further program development will
          be accelerated with the increased RAG interest and involvement,
          especially when coupled with the continued support of a strong Core
          staff led by an extremely capable Coordinator.

          Developmental Component

          Committee recommends a developmental component award for the NRMP
          because it believes it will encourage continued interest and
          involvement of the RAG, and enhance program development which appears
          to be in progress.  The Developmental Component has been a primary
          stimulus for strengthening the RAG's position and the RMP appears
          to be capable of administering the Developmental Component.  Principle
          use of the developmental funds will be in the areas of manpower and
          health delivery services.  The Region should be advised that continued
          support of the Developmental Component after its first year will be
          based on an extremely critical review of the effectiveness of the RAG
          in its new leadership position.


           Northlands  RMP                    -3-          RM 21-03 (AR-1 CSD) 2/71

           Supplemental Projects (New Activities)

           Project #20 - Diabetes Education Center - In considering this project,
                         Committee had to consider the Region's total Diabetes
           Education Center Program. It is proposed that in the 02 year  of  this
           project that projects #5 and #15 will be incorporated.  The Project
           Director for all three projects is the same and has been recognized
           nationally for his competence. He is developing a model for  a  center
           which has   national as well as regional benefits. The Committee believed,
           however, that the RMP should consider phasing out, at the end of the
           Region's 04 operational year, those activities formerly  supported
           under projects #5 and #15.

           Project #21 - Congenital Heart Disease Registry -
           The Committee noted that the input into the registry would be  from
           pediatric cardiologists only, and feedback would  o to only the
                                                            9
           pediatric cardiologists, and the Pediatric Committee of the  Heart
           Association. It also appears that the cost per case  is  high.  The
           Committee believed that prior to supporting this project, the RMP should
           reevaluate it in light of the concerns expressed about registries by
           the National Advisory Council in November 1970.

           Project #22 - Continuing Education in the Radiological Sciences  at
                         the University of Minnesota Medical Center -  The
           Committee found little evidence that this project is based on an
           analysis of regional needs.

           Project #23 - Continuation Course for Nurses Care of Patient  with
                         Neurological Disease - There is no indication that
           this project is based on an analysis of regional  needs.  Further,
           this was another reflection of the fragmented continuing  education
           program of the region.  Committee also wondered why this type
           of activity was not a part of the general education program for
           nurses.

           Approved and Unfunded Projects

           (The region has requested in this application new funds to activate
           the following approved and unfunded projects.)

           Project #13 - (Previously Known as Project #9) - Pediatric  Education-
                         The Committee noted that this project is limited  in
           its sphere and is not truely a regional effort. Further,  the  project
           is not in keeping with change in emphasis of the Northlands  @IP.  The
           project represents a unilateral approach and reflects the fragmentation
           of the Region's Continuing Education Program.

           Project Y@14 - Course for Medical Technicians In Ophthalmology - This
                         program is currently being supported to a limited degree
           from local funds.  Committee believes that it should not take an
           additional three years to establish a training program.  The Committee
           believes that the RMP should consider providing funds for two years
           only at the level previously recommended by Council


       Northlands RMP                         -4-          RM 21-03 (AR-1 CSD)  2/71

       Project #19 - Mobile Stealth Unit - The Committee found tliit this pro;,r,)rii
                     clearly relates to regional goals and objectives.  It
       increases equity of access to a system of quality health care and
       increases the systems projectivity while containing costs.

       RKenewal Requests

       Project #10 (R) - A Minnesota  Dial Access Information System:  The Committee
                          noted that this program represents a high priority  item
       for this Region and was impressed that it is not only providing  educational.
       linkages, but has the potential for a much broader  educational  program.
       Supplemental Funding.of On-going Projects

       Project #2 - Multidisciplinary Improvement in Medical Care of Myocardial
                    Infraction in Minnesota - Committee noted that this basic
       program has  been progressing adequately with the amount of  funds  provided
       up to date, and believed that it would probably continue  without  additional
       RMP funds.

       Project #2 (S) - Committee believes this supplemental activity  of  Project
                        #2, initially implemented with  carryover  funds,  would
       allow the continued expansion of the current project.  Expansion of
       the basic program appeared warranted.
       Project #3 - Pilot Study in Postgraduate Education in  Pediatric  Cardiology-
                    The Committee believes that this project should  be  permitted
       to expand out of the cardiology field into the neonatology area.
       Committee noted that this project is involving a five-state area  and  is
       a good regionalization component which is involving 11  or  12  cardiologist.
       Project # 7 - Improving Stroke Rehabilitation through Regional Program
                     of Continuing Education - The committee noted that the
       American Rehabilitation Foundation has a long record in education,
       specifically in allied health.  There is a great deal of enthusiastic
       local commitment to this project which has now reached over 8,300
       people.  Its multi-pronged attack is involving nurses, families and
       clergy.

       Pro ect #12 -(Previously known as Project J@8)- Pilot Program of
                     Regional Postgraduate Medical Education (Mayo Foundation):
       This was an approved and unfunded project which was initiated with
       carryover funds.  The region has requested new money for continued
       support of this program in its 02 year.  The Committee wondered
       why the RMP wished to continue this project.  Progress has been slow,
       and apparently something is wrong. The Committee  believes  that  perhaps
       the RAG may not have had adequate opportunity to review the contintintion
       request. Further, it appears that if Mayo was committed  to  the  project
       they should be putting some of the institutions' funds into the program.

                                                        RMfl@ /CRB / I / 18 / 71


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

                 OREGON REGIONAL MEDICAL PROGRAM                        RM   00012   2/71.1    CS
                 3181 S. W. Sam Jackson Park Road                       January 1971 Review CoT=ittee
                 Portland, Oregon  97201

                 Program Coordinator:   J. S. Reinschmidtl M.D.

                                            REQUEST (Direct Costs Only)

                                          04                  05                  06
                 Purpose           4/l/71-6/31/72     7/l/72-6/30/73     7/l/73-6/30/74      All      Years

                 Continuation
                   Commitment         $311,064                                                  $311,064
                 Core                 (2291,765)                                                (229,765)
                 3    Projects         (81,299)   1/                                            (81,299)
                 Renewal
                   Components          329,210            $267,966              $229,612        $826,788
                 4    Projects        (329,210)           (267,966)           (229,612)         (826,788)
                 Additional
                   Components          317,872               196,625             191,144        $705,641
                 2 Previously
                   Approved Prj.       (85PO75)             59,147)             61,169)         (205,391)
                   New Projects       (175,356)           (137,478)           @129,975)         (440@,809)
                 i Supplement
                   to Core             (5710441)  2/                                            (57,441)

                   Total              $9581146            $464,591             $'420,756        $1,843,493

                 Staff    Action
                 Commitment           $311,064                                                  $31.1,064

                 Committee
                 Action
                 Required             $647,082            $ 464 -591         $   420@756       $.I,532,429

                 I/ (Three months     of committed support for three of the four Renewal
                     Projects     below)

                 2/  (Three  months  of  support   for   core   requested   to   change   Region's   budget
                     year  to  July   1)


                                               2 -                   RM 00012 2/71.1 CS
            OREGON RMP

                                        FUNDING HISTORY

                                        PLANNING STAGE
            Grant Year                        Period                     Funded   (d.c.o.)
                                        4/l/67 - 3/31/68                    $166,494
                01
                                                                             203,793
                02                      4/l/68 - 3/31/69                   $

                                       OPERATIONAL PROGRAM
                                                                                   Future
            Grant Year     Period         Council Approved       Funded (d.c.o.) Commitment
                01     4/l/68-3/31/69         $955,097               $522,287
                                              885  994                854,146
                02     4/l/69-3/31/70
                03     4/l/70-3/31/71         921,948                 837,328  1/
                04     4/l/70-6/30/72         3191)854                             $319,854
                                                                                     28,920
                05     7/l/72-6/30/73           28,920

            I/ Includes $107,795 in carryover.

            Geography and Demographz
            The Oregon RMP  is  bounded by the Washington,  California  and  Mountain
            States RMPS. The state has approximately  2.05  million  people  in  its 96,248
            square miles.  The major portion of the population is concentrated in an
            area between the Pacific  Coast and the Cascade Mountain Range.  The remain-
            der of the population resi Oa in widely separated cities, small communities
            and rural areas throughout the state.
            Oregon has a university medical school in  Portland  and  seven  schools  of
            nursing. There are 87 general hospitals  with  a  total  of  7,608  beds.  The
            population  is served by 2,770 M.D.'s and D.O.'s and 7,851 nurses.

            Regional Development
            The second planning application was approved  in  February  1970  after  the
            initial one had been  returned  for  insufficient  detail.  Conditions  were
            placed on the first award asking the Region to clarify the role    of the
            medical school, community hospitals,  practicing  physicians  and  the  Kaiser
            Foundation  Health  System.
            The first of four Coordinators to serve the  program  was  Dr.  Myron  Grover,
            Director of Continuing Education of the  Medical  School,  which  serves  as
            the grantee agency. Dr. Grover was  succeeded  by  Dr.  Goldblatt  during  the


               OREGON RMP                       - 3 -              AM 00012 2/71.1 CS

               second planning year.  When Dr.  Goldblatt became Coordinator, the  Region
               requested and received a modest  planning supplement for planning an
               administration costs.

               The operational application was  submitted in December 1967 and  following
               an enthusiastic endorsement from a site visit team in February 1968,
               Council approved the submissions. Shortly afterwards,  the  Region  sub-
               mitted two supplemental applications with eleven projects, which  were  all
               approved.

                  #2 - Early Diagnosis and Therapy,of Cerebrovascular Disease
                  #3 - Surgical Treatment of Vascular Lesions and  Cerebral  Complications
                       of CVA Disease
                  #4 - Diagnosis and Treatment of CVA Disease and Influence of  a  Stroke
                       Clinic on Stroke Care
                  #5 - Stroke Continuing Education Program
                  #6 - Mid-Willamette Valley CCU Training Program
                  #7 - Training Nurses for Coronary Care
                  #8 - Educational opportunities for Physicians in Diagnosis  and  Therapy
                       of Cancer
                  #9 - Central Oregon Heart, Cancer and Stroke Pilot Project
                  #10- Coronary Care Teaching Aids
                  #11- Guiding Patients with Aphasia
                  #12- Southern Oregon Diabetic Instruction and Evaluation

               The first six projects, which were awarded funds, are in their third
               year of support. Of the remaining five, the Region funded  four  out  of
               unexpended funds.  (The Region is requesting renewal support for
               Projects #1, 4, 6 and 7, and committed funds for a year of  support  for
               Project #8 in the present application.

               Site visitors to the Region in April 1969 came away greatly impressed
               with all aspects of the program, including core staff,  Regional  Advisory
               Group, and evaluation efforts.  Although the program appeared heavily
               producer and continuing education-oriented, there were indications that
               staff was Developing activities involving other groups and in other areas.
               As a result of the site visit findings, continuation of core  and  approval
               of two supplemental projects #13 - Mobile Emergency Cardiac  Project,  and
               #14 - Training Programs to Promote Better Care of the Diabetic Patient,
               were approved and funded out of carryover.

               The Region's request for continuation of core and ten projects  for  the
               third year was well-received by staff.  It appeared that the Region had
               come a long way in establishing itself as a broadly-based, ongoing program
               as opposed to a series of isolated projects.  The key to this trend seemed
               to be the RAG's increasing awareness of the meaning of  local  autonomy.
               The RAG, complemented by a capable core staff, had developed  a  mechanism
               for evaluating both incoming proposals and ongoing projects.  As  a  result
               of this evaluation, the Region had prematurely terminated one project - #3.


                                             4                RM  00012  2/71.1  CS
          OREGON RMP

          Although generation of project activity slowed down somewhat,  the  Region
          submitted and had approved the following projects:
             #15 - Physician In-residence Course in Cardiology (received  new  funds
                   from RMPS)
             #12R- Southern Oregon Diabetic Instruction and Evaluation Project
             #16 - Training Program for Personnel of Oregon Health  Care  Institutions
                    (funded from carryover)

          The third operational year has also seen two changes in coordinator.
          Dr. Goldblatt was replaced by Dr. David Johnson, who served  as  Associafe
          Professor of Public Health and Preventive Medicine at the  University  of
          Oregon.  Dr. Johnson resigned in November to become Regional Health
          Director for Region X, and has just recently been replaced by Dr.  J.  S.
          Reinschmidt, who has been with the Student Health Service for  the  past
          seven years (curriculum vitae attached).
          The Oregon RMP, then is in a state of transition.  The  new  coordinator
          has just assumed his position. The core staff's time for  the  past  six
          months has been consumed with preparing the AR application  and  therefore
          not devoted to developing the program. As the  application  aptly  states,
          "daily routine drives out planning."  The Regional Advisory Group has
          been struggling with RMP's changing role; it "has recently  broadened  its
          program beyond its conservative interpretation of public law 89-239."
          The Region is also requesting a change in its anniversary date from
          April I to July 1, because the November 1 national review  deadline  would
          require the Region to do most of the application preparation during  t  e
          summer months which imposes a hardship on the  Region.  Oregon  apparently
          has only two months of sunshine in which everyone takes  their  vacation.
          Thus, the Region is unable to get quorums for RAG and other  review  group
          meetings and project directors are not available  for  consultation.  For
          this reason and because the Region needed more time with a  new  coordinator
          to develop their triennial look, RMPS gave the Region permission  to  change
          the anniversary date.

          Regional 0-jectives
          Within the goal of improving the care given to patients with  the  categori-
          cdl diseases and the ultimate objective of reducing morbidity, disability
          and premature death by: (A) stimulating more  widespread  and  effective
          use of the latest advances in the prevention, diagnosis,  treatment  and
          rehabilitation of these diseases and (B) by  encouraging  experimentation
          with and adoption of more efficient mechanisms in the  dispensation  and
          administration of health care services, the Oregon RMP has  the  following
          more immediate objectives:

          A - 1. To encourage the development of  cooperative  arrangements  among
                   the Region's medical school, research centers, health organizations,
          medical institutions, and individuals engaged in the delivery  of  health


                OREGON RMP                       - 5 -,             RM 00012 2/71.1  CS

                services or In the  provision  of  health-related  professional  educational
                programs.

                    2. To assist persons involved in  the  delivery  of  health  services  on
                        continuing educational programs  to  transform  ideas  for  improving
                care into well-developed and  expertly  presented  operational  projects,  and
                to consult with and advise such individuals in regard to potential sources
                of funds for these projects.

                    3. To assist directors  of  operational  projects  and  affiliated  insti-
                        tutions in the efficient administration, responsible fiscal
                monitoring, and meaningful evaluation of their projects.
                    4. To provide for the continuing education  of  the  ORMP  staff  and  of
                        appropriate members of th@ RAG and  its  committee  system  so  that
                the latest and most  effective  administrative  and  instructional  methods
                are employed and so that the  volunteer  policy-making  component  of  ORMP
                can be assured that it will determine any  new  directions  for  the  program
                in an informed and meaningful fashion.

                                                  I
                B - 1.  To determine, in concercwith the RAG, a consensual set of specific
                        operational objectives for the  ORMP;  taking  full  cognizance  of
                emerging RMP legislation and guidelines; to  be  completed  by  February  1,
                1972; and to include explicit reference to the particular manner and extent
                to which ORMP can or should in the  absence  of  increased  fiscal  resources
                address itself to the issues of  distribution  of  health  care,  innovative
                use of medical personnel, relationships with CHP.
                C - 1. To prepare by February 1,  1972,  a  consolidated  AR  application  for
                        program triennium review.

                Organizational Structure and Processes
                Oregon has a forty-member Regional  Advisory  Group,  representative  of  most
                of the important health provider and  consumer  groups  in  the  state.  Its
                operation is facilitated by the following committees:
                a) a three-man Executive Committee  responsible  for  administration  of  the
                   program between RAG meetings.
                b) a Grants Application Review  Committee,  which  reviews  the  applications.
                c) a Regional Cooperation Committee,  which  studies  the  coordination  and
                   activities of the various grantees in the  state,  through  the  use  of
                   subcommittees and consultants.
                d) an Evaluation Committee is available to evaluate funded grants, as well
                   as the activities of the  terminated  projects.  It  will  also  accumulate
                   and present factual evidence of the  accomplishments  of  the  entire  RMP.
                   It may draw on the resources of consultants.
                e) the Heart, Cancer and Stroke and Continuing Education Subcommittees are
                   composed of experts in these  respective  areas.  Their  function  is  to
                   (1) evaluate project ideas  for  feasibility,  scientific  soundness  and


          OREGON RMP                          6                 RM  00012  2/71.1  CS

          applicability to RMP, (2) make recommendations  to  the  Grants  Application
          Review Committee regarding project requests, (3) determine needs to
          improve care of patients with the categorical diseases
                                                                     (4) provide
          solutions for needs, and (5) act as regional consultants.
          The grant application review schedule is attached.  If the ORMP is     not
          awarded monies to support all ORMP approved grant requests, a     priority
          rating will be assigned by the RAG in order to  determine  which  shall  be
          funded.  The rating will be made using the following criteria:
          i.  the amount of regionalization (the creation of cooperative     arrange-
              ments, avoidance of duplication of  existing  effective  efforts,  written
              support from all appropriate agencies,  and  anticipated  benefits  to
              institutions other than just the applicant organization);
          ii. its concern with the prevention and/or early detection of categorical
              diseases, and to those directed toward commonly occurring     illnesses,
              especially those tending to'affect children or adults  in  the  most  pro-
              ductive years of life;
         iii. the inclusion of some element of continuing education  either  as  a  pre-
              dominant or as an important component part;
          iv. its orientation around the problem analysis   approach, as  outlined  in
              the ORMP instructions for writing applications; and
          V.  the cost per unit of accomplishment when compared to (1) other programs
              of a similar type, or (2),alternative solutions  to  the  same  problem.
          For a discussion of Core structure and function, please refer to the con-
          tinuation section of the application componen s.

          Present A@lication
          Continuation - These components have been reviewed by staff.  Their program
                          and tunding recommendations are in  a  supplementary  memo.
                                                                            4th   Year
          Core                                                               $287,206
          The Oregon RMP has  a small core staff, which until this point  in  time,  has
          been more organized to deal with the  preparation  of  well-developed  and
          well-written project applications, than with  the  stimulation  of  program.
          The Region admits that the broader RMP programs  now  envisioned  may  require
          a staff reorganization and the addition of more members.  There are seven
          full-time professional personnel  and  four  secretaries.  The  professional
          positions include the Program Coordinator, Coordinators for Community
          Organization, Program Administration, Information and Communication,
          Nursing and Allied Health, Project Development and an administrative assis-
          tant. Evaluation services are provided through  contract  with  the  Northwest


               OREGON M@@.P                      - 7 -            RM 00012  2/'71.1  CS

               Regional. Educationi,'- La@-)r,,r@,tory.  Contract funds will al,so be utilized
               to continue a patient origir, study.  Core funds arc,. al@--,o being used to
               dr@,ielop a physicia;-i,-, assistance program in conjunction with the Medical
               School Division of Family Practice.

               In addition to their application preparation  function,  staff  provides
               assistance on request to vari-ous regional  organizations.  Examples  of
               this type of help include:  (1) providing data, special charts and reports
               to hospitals and conferring with architects and hospital consultants in
               four areas of the state; (2) serving on the Ombudsman Committee of the
               Oregon Medical Association and (3) involving many different organizations
               in the Portland area in an ii.formal planning effort to explore means of
               improving the organization and delivery of health services, particularly
               for the low-incotrie families.

               Continuation support is also requested for:
                  15 months for project #15, Physician Inresidence Course in Cardiology
                   3 months for projects #4, Comprehensive Stroke Care in. the Regional
                     Education; #6, Mid-Willamette Valley Coronary Care Training Pro-
                     gram; and #7, Coronary Care for Professional Nurses and Physicians
                      (These projects are also requesting renewal support for three
                     additional years).

               The Region also hopes to fund the following Council approved projects from
               carryover:

                  Project #9, Ifeart, Canc(--r and Stroke Pi,-ot Project
                  Project #10, Coronary Care Teaching Aids
                  Project #11, Adult Patients @qith Aphasia
                  Pro ect #14,, Diabetic Patient Care.

               Approved but Unfunded Projects

               These projects liave been previously approved by Coui@icil, but due to national
               funding constraints, have not been funded.  Committee and Council consider-
               ation of these projects is needed in determining a funding level for the
               next year and not for approval of the activities.

               Project #8 -  Educational Opportunities for the Oregon Regional Physician
               in the Diagnosis and Thera.pv of Cancer.                       Ist  Year
                                                                              $42,369
               This project will provide an intensive one-month in-resideiice
               course at the Medical Center for eight physicians per year.  The curricu-
               lum will be tailored to the physicians' needs and those of his community.

                     Second Year                                Third Year
                      $59,147                                    $61,169


           OREGON RMP                         8 -             RM 00012 2/71.1  CS

           Project #16   A Training Program for Personnel of Oregon Health Care
           Institutions                                                     let  Year
                                                                            $42,706*

           The purpose of this project is to provide informational courses to a
           multidisciplinary spectrum of sub-professional health care u7orkers.    The
           courses will be designed so that students may comprehend and carry out
           their own specific responsibilities under  formal  institutional  standards
           concerned with the control of significant  health  care  problems.

           This project has received some support from carryover funds since
           October 1970.

           *for a 15-month period

           Supplemental Projects: Committee and Council action  are  required  on  the
                                   following nine projects:

           Renewal Projects

           Project #lR   Heart, Cancer, Stroke Circuit Postgraduate  Course  for  the
           Oregon Region.                                                   4th  Year
                                                                            $1805,747*

           The purpose of the circuit course program is to provide continuing educa-
           tion for physicians, nurses and allied health personnel  at  19  locations
           in the Region.  Sponsored by the University of Oregon Medical School,
           faculty from this institution and selected private practitioners, through
           the use of video tapes and other teaching techniques,  will  bring  medical
           care advances of the research laboratory and medical center to health
           personnel in the small community.

           During the past three years of operation, the courses have reached approx-
           imatelv 1600 physicians inoverlOO presentations, 900 nurses in 23 courses
           and 70 medical technologists in five sessions.  Since evaluation appeared
           weak,, the proposers have taken steps to evaluate through  a  questionnaire
           changes in patient care practices as a result of the courses.

                  Fifth Year                                Sixth Year
                   $1362,409                                 $1332 363
           *Note:  for a 15-month period.

           Project #4R - Com2rehonsive Stroke Cate  with  Regional  Education
                                                                            4th  Year
                                                                            $52,375*

           The Cood Samaritan Hospital and Medical Center in  Portland  wishes  funds
           to renew RMP support for a strole program, which  includes  the  following
           three elements:


                OREGON RMP                           9 -                 RM  00012  2/71.1  CS

                a)  a stroke evaluation and education team at the sponsoring hospital,
                b)  satellite clinics at Bend and Astoria, and
                c)  a series of 12-day courses in care  of  the  stroke  patient  for  nurses.

                As  far as progress is concerned, the project has continued the activities
                of  the Outpatient Clinic and assisted  in  the  establishment  of  an  inpatient
                Stroke Care  Unit  at  Good  Samaritan  Hospital  and  Medical  Center.  Panel
                discussions and exhibits have  been  presented  by  the  staff,  directed  toward
                both physicians and nurses.  A  formal  12-day  course  for  nurses  has  been
                established, and a one-day  Circuit  Course  was  given  in  four  communities
                during the last three months of this fiscal year.  The  Satellite Clinic
                in Bend has been  established  and  clinical  research  is  underway.  A  cost
                effectiveness study has shown  that  the  savings  from  patients  going  home
                has resulted in a savings of almost  three  times  the  budget  for  the  project
                for a year in hospital and nursing home costs, assuming a patient with a
                major stroke is cared for only one year in a nursing home.

                        Fifth Year                                  Sixth Year
                          $54,444                                    $561-617
                *Note:  This project has three months of committed support ($14,215) from
                April 1 to June  30,  1971.  If  approved,  the  Project's  level  of  funding
                for the 15-month period (April 1, 1971 to June 30, 1972) would be $66,590.

                Project #6R - Mid-Willamette Valley Coronary Care Training Program
                                                                                    4th   Year
                                                                                      $44,113*

                A program of coronary care nurse training (four three-week courses for 32
                nurses a year), advanced training and  workshops  for  nurses,  and  a  physician
                post-graduate education  program  would  require  three  additional  years  of
                RMP support.  A total of 110 nurses have been trained and over 500 physicians
                have attended the courses thus far. A  spinoff  of  the  project  has  been  that
                all but one hospital in the state have policies governing coronary care as
                opposed to three at the initiation  of  the  project.  The  training  is  con-
                ducted by the staff of the Salem Memorial Hospital in Salem, who will
                have trained 110 nurses and 512 physicians in these courses during the
                past three-year period.

                        Fifth Year                                 Sixth Year
                         $37,438                                    $19,294
                *Note: This project has  three  months  of  committed  support  ($13,039)  for
                the period April 1, 1971 to June 30, 1971.  If approved, the project's
                level of funding for the 15-month period (April 1, 1971 to June 30, 1972)
                would be $57,352.


           OREGON RMP                          10                RM  00012  2/71.1  CS

           Project #7R    C6tondt_v Care for'Pt6fOs8ionAl'Nurs0s and Physicians
                                                                             lst  Year
                                                                             $51,775

           Nurse trainees will come from approximately 16 Oregon hospitals with
           coronary care facilities to Sacred Heart Hospital in  Eugene,  for  one  or
           all of the following courses in coronary  care  nursing:  (1)  a  three-week
           basic course held three times a year; (2) a  40-hour  advanced  course  held
           five times a year, and (3) an advanced workshop for  nurses  once  a  year.
           Over 100 nurses have been trained to  date.  In  addition,  project  staff
           will visit participating hospitals to conduct a six-hour training session
           for physicians.

                   Second Year                               Third Year
                     $39,675                                  $2Ot338

           *Note: This project has three months  of  committed  support  ($18,460)  for
           the period April 1, 1971 to June 30,  1971.  If  approved,  the  project's
           level of funding for the 15-month period (April 1, 1971 to June 30, 1972)
           would be $70,235.

           New Projects

           Project #17  -The Mid-Willamette Valley  Diabetic  Patient  Project
                                                                             lst  Year
                                                                             $17,516

           The purpose of this proposal is to train  out-patient  diabetics  and  their
           families in personal care of diabetes. The  Salem  Hospital  in  Salem  will
           provide 40 courses of 30 hours duration (ten  patients  per  course)  with
           special attention to those patients from  smaller  community  hospitals  and
           outlying doctors' offices.  Additional efforts will be directed to adoles-
           cents and deprived groups.    The project would  also  provide  additional
           information for physicians, training for paramedical personnel and
           increased public awareness of the need for patient education.

           The concept of this course is directed toward better  patient  care  in  a
           sub-regional area.  The courses will make available facilities to diabetics
           otherwise not available to them, and by improving  their  care  also  reduce
           the economic loss to themselves, the community and public agencies.

                   Second Year
                      None

           Project #18 - An Operational Service for  Remote  Coronary  Care  Monitoring
                                                                             lst  Year
                                                                             $7931   501
           Emanuel Hospital, Portland  would provide an operational
           coronary care remote monitoring system to community hospitals on a volun-


             OREGON  RMP                                         RM 00012 2/71.1  CS

             tary basis by transmitting the EKG signal via telephone lines from the
             outlying hospitals to   the Emanuel Hospital  CCU.  Project  nursing
             personnel would continuously monitor the signal on oscilloscopes.  The
             service would also offer special education for the CCU  nurse  emphasizing
             common electrocardiographic patterns, techniques of defibrillation, and
             equipment procedures.  Continuing education for physicians may also be
             arranged.

             This project stresses an operational mode for the improved  care  to
             patients with myocardial infarction residing in less populated areas of
             Oregon. The project also builds on the successful  pilot  programs  demon-
             strating the feasibility of the larger central hospital's  monitoring  the
             coronary patient in a rural hospital.

                     Second Year                              Third Year
                       $67,758                                 $70,142

             Project #19 - Pendleton Region Stroke Rehabilitation Project    lst Year
                                                                             $23,592

             The Pendleton Stroke Education Group (PSEG), an unofficial group repre-
             sentative of the agencies and institutions involved in stroke care in
             Pendleton, was formed as part of one of the initial stroke projects.

             St. Anthony's Hospital in Pendleton, in conjunction with the PSEG, intends
             to improve the level of stroke care in the area by:

                                   I
                       1.  Identify4ng local problems in providing stroke care,,
                       2.  Improvin,, the continuity and coordination of stroke care
                                   C,
                       3.  Providing continuing education in stroke rehabilitation
                           for members of the health care team in the  subregion,
                       4.  Developing a home health program, and
                       5.  Educating the public about the effectiveness of rehabili-
                           tation for the stroke patient.

             The project contributes to ORMP goals by building cooperative arrangements
             among health personnel and institutions, improving patient care  and
             utilization of resources and skills, as well as providing continuing
             education and developing innovative approaches to treatment.

                    Second Year                              Third Year
                       $18@874                                $14pl56

             Project #20 - CommunitV Coordinators of Continuing Medical Education
                                                                            Ist YeaL
                                                                            $22,344
             ORMP support is requested by the Oregon Medical Association to
             subsidize an integrated system of 17 volunteer coordinators of  continuing


                                              12 -              RM 00012 2/71.1  CS
           OREGON RMP

           medical education for Oregon  physicians.  Practicing  physicians  would  be
           trained to determine needs in their communities  and  in  educational  tech-
           niques in order to enable them to act as part-time Directors of Medical
           Education for their communities.  Coordinated by a central administrative
           information and resource jnit, the physicians would also coordinate state
           educational resources and short  preceptorship  experience  for  physicians.
           The project relates to ORMP goals of utilizing existing resources more
           effectively, and of innovatively using mainly volunteer personnel to deal
           with the provision of adequate continuing education opportunities to
           physicians.

                   Second Year                               Third Year
                     $22,494                                  $15,650

           Project #21 - A Drug Information  Service  for  the Health Professions
                                                                             Ist Year
                                                                             $329403
           A drug information center will  be  established  at the School   .
           of Pharmacy, Oregon State  University,  which  will serve as a central
           reference source collection with the capability for aiding all health
           practitioners in exercising a rational approach  to  drug  therapy.  A  drug
           information specialist will answer specific  requests  for  information  and
           publish a bulletin containing drug information of general and current
           interest.   The Drug Information Specialist  will  also  encourage  utiliza-
           tion of the Drug Information Service by seeking  contact  with  health  pro-
           fessionals through participation in local  and  regional  continuing  educa-
           tion activities of the various professional groups.
           The proposal contributes to improvement of patient care  and  represents  a.
           cooperative effort of health professions to identify and meet local needs.
           It also increases the economy of health care delivery by sharing available
           resources.

                   Second Year                               Third Year
                     $2810352                                 $30,027

                                                                GRB/RMPS  12/17/70


                         CURRICULUP! VZTAE  FOR J. S.  R-PIk,SCffl,!IFff bl. D.

                                                                          -throuSh hi
            Born  in Pensacola, Florida,   1925, and  received education             gh
                school. there.'

            Military Service   World War II,  U.S. Army

            Pla@ed, 2   children

            Education:,
                A.B. Vanderbilt University  1950
                M.D.-Vanderbilt University 1953

            Ilost-radtiate Tt-airii.nL,:
                Internship (i.-o'Llatin-) Colorado General Hospital, Denver, Colorado
                                   L>
                Cone@,l Surc@ery Residency University of Colorado  ?,Iedical. Center
                1954-1956 and 1959-1962 included one year in research.  Teachin-
                -of interns, residents and  nurses  part  of  responsibilities.

            Experience:
                General Prac'Llice  Tekoa, Washin-.ton, 1956-1959
                Surgery and General Practice  Pullman,  Washin-ton,  Igo'2-1963 (Student
                Health Se--vice Washin-ton State University)
                Student Health Service University of  Orevon  Eugene,  Ore,-on, 1963 to
                -present.  Directok since 1966-1967.
                Plem'oer and current chairman of i@ledical Education Committee and member
                of Library and Publications Cor..,jiittee Sacred  Heart  Hospital Yiedical
                Center, Eu-ene, Ore-oni
                Served as P- moderator in clinical seminars of the annual scientific
                session of American Academy of  General  Practice  1968  and  invited  to
                t-erve in like capacity for 1970.

          'Organ'-zationst
                Araerican Academy of General Practico
                Lane County i@',edical Society (Secretary 1970)
                Ore-on L'-Iedical Association (Dele,ate to House of Dele-ates  and member
                of Venereal Disease CorrLmittee and. Ad hoc Subcommittee)
                American Mrjdical Association
                American Colle-e Health Association (L',Iember of Council 1068 to present)
            -Pacific Cop-St Collec-e Health Association (President 19'9
                                  C>                                   o   -1970)
                Staff Sacred 'rfcart Hospital Eu-ene
                Eugene Sur-ical Society
                Lane County Corbiunity Health Council

          Publications:

                                                                                        D.
                "Traumatic Pancreatitis, An Incre@.sin- Problem", Henry C. Cleveland,,
                Julian S. Rcinsch@,iidt, @t. D.;  William R. Waddell, 14. D.:  @r Ical
                Clinics of Iforth APerica  Vol, 43, No. 2, April,   1963


                                            14
                                   oll
                                   S. Reinschraidts go'Do

        Publications: (continued)
          l'Infectious Mononucleosis in American Negroid Students". R. J.
            Carson, II. D'. ;  J. S. Reinschmidt, @l. D. ;H. C. Lemon, 1-1. D.
                                   -n College Health Association Vol. 16,
            Journal of the Americ@
            No, 2, December, 1967
          "History  and Physical Foria for Student Health Services",
            J. S. Reinschmidt, @I.D. ; R. A. MacHaff ic, M.D.;  S. Carlson, PhD.;
            James Tomb.OLI-hs  Northwest Medicine Vo
                                                    1, 67, 110. 11,
            NoveDibcr, 1968


                                                                        ATTAC@  -, IT G
                                                          OREGON REGIONAI @Ac:,:)ICAL PROGRAM
                                                                                   L

                                                           GRANT      APPI-I@CATION      REVIEW       SCHEDULE

        Fc@:ASIB!ILITY     REVIEW
        IDEA Pi@-Crr-iV=-D          STAFF REVIEW-Mq-ET',NIG WITH APPLICAINT- GRANT DEVCLOPMENT-TO REVIEW CYCLE
              i                                                    i                                         I
        Reccr'a'ed                        I                        I                                         i
        Filed
        Acknowledged                reasib,@l,"I-Y         SLcc:es@ to Co-nplete or                Deadline Set
        Xeroxed                     Sugg--st,ons           Low Pricril-y
                                    to Appliccrit

        REVIEW CYCLE
                                                                                  EXECUTIV   .E                                      DIVISION OF REGIONA]
            A                                                                                                PAB                     MEDICAL PROGRAMS SEI
                                SL,)IBCOMMITTEE                C- A,-@ C

                                u                                                       w                    view
                                i;
        Xe rox                    e                             ev,@)             KeVie
          @c,.Cll                                                                          d                 c. and
        Si i. @/@eeting         Ccncer                          ec. cnd           Rec. an
        SI- r'                  S+roKe                          @c.,cT' Recor"    Staif Report            Stcff Repo,-t
          Ic-@ 7
            ,led 'i-o Sj'o.                                                                              Dec  on
        Mc'                                                                                                   is!
         cnd Appliccnt          L-volucl,-Ion
                                Com;-niltee
                                                                      Applicant and                      Applicant cnd                    f Report to Applicant
                        r,   Work                                           Working                            Working                     Subcc,-nrnittees
                                                                                                                                           imposition of Grant


                                                                                   (A Privileged Cor,@@nunic,-ti-on)

                                                  SU'-%r@LkRY OF                                   01?
                                                      JA',,FJArLtY 1971  RI,,VIEW  CO",@',@'ITTi7E

                                                      O,",EGO"'l REGIO"Z'IL IMDICA'@- PiloGlvq%l
                                                          RI--I 00012  (CS) 2/7L

                                      CO@"iSIDERATYO'@'i BY FEBRUARY 1971 ADVISC,RY COUki@lt

                                                Co,, ittee                     ,ipro- Li    o      thi    ),,Jlicnti.on
                                              icl,   ircllldes   reqcests   for,'   1)    rezi@,,i@7il for   three,-
                   for four-I)rojzcts azicl, 2)                                                  Y,@ars for fiv,,
                   projects; 3) fu@nd,, for ti7o previously ap-proved but u@iifurkded projects; and
                   4)  a  supplenierit  to  Core,   at'tlie   following   reduced   vr.,iouittso.

                                                                              g;T
                                                         REGIO'41     RE

                                                                                                    -JEST
                                                                            SUPPL-c,.',,Til,@i@l'@ ro                TO@'RAL
                   ol                    $311,061.,                                 $614  7  08  2             $    953,146
                   02                                                                     464,591                   464,591
                   03                                                                42Ot7@6_                       420.756
                   T(Yf Al.                $311,064                              $1,532     Z@29                     $1,843,493

                                 STAI,'P RE                                                                          TOI'AL
                   01                      $391,128                                       $613,986                   $1,005,114
                   02                                                                      54,444                        54,444
                   03                                                                       56.617                       56.617
                   TOTAI,                  $391,128                                       $725,047                   $1,116,175
                         Inclt@tac@s 3 t-Ilot'ittis extens-,oti for Core and Project             @rl5.
                    -r t i (i      Cotyr,)ittee reviei-,,@d the probic--e3s bcsp-ttin-           this R.?c,io-n in tile,
                                   dev,@lop.,eLit of tiie present application:
                          1.    'rne Oregon lVvIP has find three Coordinators                duriti@ the pnst year,
                   Dr. Reinsc'nnidt ba,4,in@. L-maii appointed De6criber 1, 1970.   Revie@iers recog-
                   ni@zed that t@,,ith tiis unasual tu.-novar, program develoi;-,Pent has been in
                   abeyance.
                          2.    K*cause of difficulties iii getting @ipproi)rinte groups and pro-
                   ject directors tog@attic@r during the                                    the Region requested a
                   change  iii  their  P.@.iiiivarsary  dates  frot,,i  A-,r)ril  I  to  July  1.        This chance
                   will -@iot only -Ilow the Regicti to submit                                            in Fel)rLit4ry


                  OREGOII  PtF[l                                     2                          PYi 00012 CS 1/71

                  frorn no;,7 on, but durin,- the prp-:5@tit ye@2,," it                 give the
                  net Coordinator additional tinia in @!liich to plan its                            A? application.

                          3.  The             lp, attei-Illptincy to reei3fin,,@ its priorities in terin3 of
                  the net? perception of R@lli@.          T"ne p@-es.-@nt application reflects this
                  ri-I th@-- la"-',, of                            Set of goals;           objective    with     I)-Coj(,-Cts
                  developed -..ccordiri,,Iy.

                  As a recult of               ttincr--rtaint'Les,                                       to ippro@,,r-,
                  funls  fc)--  ciore  than  t'@ic   current   year   uLitil   rcvJ.(,T,;@,rs   could   see   evidence   of
                                                 Tt-i:! e-xc@@pt-!Lo-,)    P-L'OJcct                               St
                  Care with acgioti@ll Elucntion, @-;nicli has s'iowii that the savings                       from      patients
                  going          has reat.,Itcd in 6 savings of alr@lost tfirce tiT,',@-s the                 budget for
                  the project for a year in hospital and niirsiric, ho-.-,c costs,  as5;ir,,iin- a
                  patient with a Trajor stto!<e is cared for silly one year in a nirsing home.
                  The Co-@,.nlittee i7an iiiprez-,s4@2d          a, project @,7'hic'ii der,,,,,,)z).-traterl such a cost
                  SSVit)gS,  13 17;?Il CS -In irCTe@,-,c air tli,@                         of ctivicit
                  O,i-           of tlis@ co-li.fi@,@ttoe           a                                 to -7:) t(,)      Rn-@oi
                  for tlli-- p@,oj"ct, left t@i,@ otlier fli@                          tll:2 r@,@@,3ults           to bc
                  veri-@4Lr-.(.i before tal,,:inc, such an --ic!-ioi.      Tticy                 th@)t  tire   results   1)0,
                  pUbliSil2a and             L'11,2! C,-'@a7,;?I(2 'i)@-                                      tlcia- I),ZoJL-ct
                  c,ff ects Stich * cci-: @l-der,-ible Coot                                                   tliit      Council
                  T)Olicy regardin-, phase-ott of                       projects   b,:,   @7aiv--d   for   thin   project    air
                  ore,e-z  to keep t'll@- p,:o-rar,@i mobile.

                ,The rei,.,iainitig              projects,  @IR,  6'@'@  and   7i',   .7@,re                  for pli,-@se-out
                  in their fourth ycnr.           The  core  supplc,,.-,@nt  t7,-ib   app,,-o,,,cd   in   o,-der   to   provide
                  for    the         ir,            ye-nr.    F-,,,nO-s fare lncitir@,ccl  for  the  rppr(-)-v@,d  but,:  u,-i-
                  fu-,@idf--a projects ntid for tti-a rei,; l@rojecto at: a re(lr-,cetl
                  tiorl  t@,   tli(-- Region to better c(:)o-:eir..7tc, their projccc.,-,,
                                                                                                              ,ic l,y tj
                  rie@7 stroke project                                      on2

                  IIOTE:   'rie             of tire sll-;iff revic,..,y of          continuation co.-.Ipofi@nt were
                  not available in ti-,@,2  for Cov,-.Iittc-,e to coDsider it in reco,-4i,-nonding all
                  overall            of @[Li-,i et l@? for the                The Director
                  support for core, project .@-,15 and thr@c.,                       sul@po-et for p-coj,@cts
                  and    7R.  Since staf@L vac,, unable to                        npl)i-oval of the rcegioi s request
                  for use of@@91,530 of                          funds   for    pro,,-2c'--s           9,  10,  11,  -iiid    14,
                  the   Fegio,-i@requests   that   Council    con3laer    approviii-    nevy    funds    in    that    ar-@ou-nt
                  to co plete the third year activities of                           projE,@cts.     Trie follo-i@7iri@D,  is
                  a list of    the projects:

                                                  Project      i@9             Ciii(-,er    and    Stroke    Pilot    Project
                                                  Project     PelO   -    Coronary    Care    Teacnin,,    Aide
                                                  ProjLct     I'll    -    Adult    Patients            @phasta
                                                  Project     414 - DieLietic Patient Care

                                                                                                          1/13/71


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

              SOUTH DAKOTA REGIONAL MEDICAL PROGRAM            RH 00067  2/71.1
              School of Medicine                               January 1971 Review Committee
              University of South Dakota
              216 East Clark street
              Vermillion, South Dakota  57069

              Program Coordinator (Acting):  Henry M. Parrish, M.D., Ph. D.

              Requested
               (3 years beginning January 1, 1971)

                                   lst  Year      2nd  Year      3rd  Year        Total

              Direct Costs         $597,700       $662,588        $689,123       $1,949,411
              Indirect Costs         1889537        237,059        251,282          676,878

                TOTAI,             $786,237       $899,647        $940,405       $2,626,289

              Geography and Demography:

                                               Mobridge                Aberdeen

                                                                                  Watertown
                                                                                    0

                                             Opierre                            Brooking

              Rapid City

                                                                   Mitchell       Sioux  Fa

                                                  'Winner
                                                     0

            Pierre   State Capital                                                           illion
            Vermillion - University of South Dal,,ota
                          SDRMP Headquarters  ,


        South Dakota RMP                 -2-                RM oon67  2/71.1

            ation:                (1-960)     690,514

          Urban-                                  39%
          Racial-                                 96% white
                                                  27.7 years (U.S. average  29.5)
          Median Age-
        Land Area:                            76,378 square miles

        Mortality Rates:  (per 100,000)

          Heart-                                 355
          Cancer-                                143
          CNS vascular lesions-                  118

        Facilities:

          University of South Dakota, School of Medicine
          Seven schools of Medical Technology
          Six schools of X-ray Technology
          75 hospitals (6,854 beds)

        Personnel:

          564 physicians (82/100,000)
          45 osteopaths
          1977 nurses (288/100,000)
        Historical Development:  The development of the Nebraska-South Dakota
                                 Regional Medical Program began in the Fall of 1965
        and a request for planning was submitted in October 1966.  The application
        renresented individual planning programs by the Nebraska State Medical
        Society, University of Nebraska Colleges of Medicine and Dentistry,
        University of South Dakota Medical School and Creighton University School
        of Medicine.  The November 1966 Council recommended approval with an
        exoression of concerns about interrelationships of the five parties involved
        in planning and the apparent cumbersome administrative framework.
        The Nebraska-Sotith Dakota Regional Medical Program was initially approved
        for two years of planning beginning January 1, 1967.  A site visit was
        made in September 196f' to assess the Region's capability for operational
        St                     ro
          atus (core and four p. iects). The site visitors  observed  the  Region
        was in an early stage of regionalization.  Two deterrent factors were the
        inability to complete major staffing until June 1967, and the need to
        create a new organizational structure to function as  a  whole.  Planning
        also seemed to be by intuition rather than by design. There  was  a  lack
        of adequate data needed to support project planning.  Cooperative organization
        between the three medical schools (University of Nebraska College of
        Medicine, Creighton University School of Medicine and the  University  of
        South Dakota) was noted.  There seemed to be good participation by Nebraska
        physicians, but much less involvement of South Dakota physicians.   It was anparent


              South Dakota RMP                     -3-                  RM  00067  2/71.1

              that the Nebraska  State  Medical  Association,  the  grantee  institution,
              played a dominant role in Regional affairs.  The site visitors believed
              that although the rate of progress in program planning and development was
              slow, there were beginning signs of regionalization.  It was also agreed
              that continued development of the Region would depend upon the initiation
              of some operational projects to provide visibility and a focal point for
              the high degree of enthusiasm displayed.  In view of the site visitors'
              report, the Review Committee and Council concluded that operational status
              was premature and recommended approval for continuation in the planning
              phase.  Accordingly, the three-year operational application was funded
              as a renewal planning grant.  Summation of the planning funding:

                                  1/67-12/67     1/68-12/68     1/69-12/69
                                   Ist  Year      2nd  Year     2/ 3rd  Year       Total.-

              Direct  Costs         $289,350       $281,450     I/  $440,375     $1,011,175
              Indirect Costs          60,989         67,917     I/    70,831         199,737

                TOTAL               $350,339       $349,367     I/  $511,206     $1,210,912

              I/  The planning renewal award (3rd year    of planning) included   $107,800
                  ($102,520 d.c.o. and $5,360) for one    year of more planning   of  two
              projects, Audio Visual Continuing Education Services and Coronary Care
              Program.  Stroke Rehabilitation Technician Training was disapproved

              2/
                  The planning renewal award carried subsequent years recommended commit-
                  ments (d.c.o.); 04 year - 1/70-12/70  -  $350,239  and  05  year  -  1/71-12/71
              $@7P,812 for Core staff.

              The Region applied for support for four operational projects in May 1969.
              A site visit followed in June 1969 to assess progress and to review the
              projects.  Changes in the bylaws seemed to have influenced progress toward
              regionalization.  Major  changes  included:  (1)  designation  of  the   Presidents
              of the two State Medical. Associations to serve on alternating years as
              Chairman of the RAG; (2) Presidents Elect of the two medical associations
              to chair the Executive Committee alternating annually; and (3) RAG reore-
              sentation was broadened to include minority group representation, volunteer
              health organizations and nurses  (70  RAG  members,  35  from  each  state).  South
              Dakota, which previously was less enthusiastic about joining with Nebraska
              as a Region, appeared to have adjusted  and  was  participating  on  a  more  equal
              basis.  The three medical schools continued to maintain cooperative relation-
              ships.  Planning also seemed to be on a more sound footing.  Concurring
              with the site visitors, the August 1.969 Council recommended qpproval for
              operational status.  T e Cotinci ,  owever, remained uncertain as to th(@,
              real involvement of South Dakota in this  program  which  seemed  to  be  a
              carefully balanced arrangement between the two Nebraska m(@(lical cir@ntc@rs.
              Staff discussed this with the Region representatives in negotiating the


       South Dakota RMP                    -4-               RM 00067  2/71.1

       award, emphasizing the ne.ed'for real program outreach - not  simply  repre-
       sentation on various committees. The Region  has  received  $1,162,224
       ($1,024,239 direct costs and $161,.729 indirect costs) for core and  four
       projects in the current first operational year.

       The first concrete evidence of South Dakota's immense  dissatisfaction   and
       possible breakway was in the spring of 1969 when Governor  Farrer  of  South
       Dakota wrote the Secretary, H.E.,W., requesting permission to merge the
       South Dakota CHP and RMP efforts. A year later, Dr.  Robert  Haye6,  then
       RMPS Associate Coordin'litor for South Dakota, in a letter (February 20,  1970)
       to the Director, RMPS, formally announced South Dakota's intention  to  with-
       draw from the current two-state RMP and establish  its  own  Region.  Subse-
       quent dialogue between RMPS staff, Dr. Hayes, and the  Region  Program
       Coordinator lead to South Dakota's submission of a  preliminary  draft
       application in May 1970.

       A staff team visit was made July 15-16, 1970, for the  purposes:  (1)  assess
       the possibility of keeping the two states together in a  mutually  acceptable
       functioning program and necessary mechanics; (2) if South Dakota still
       desired separation, obtain clarification and elaboration of  their  draft
       pronosal, which was very general and inadequate; and  (3)  provide  appropri-
       ate assistance. Part of the team visited key core staff  and  a  past  chairman
       of the RAG in Lincoln, Nebraska, and joined the rest of the team in Vermillion,
       South Dal(ota. Dr. Robort Hayes had recently become the  State  Health
       Officer and Dr. Henry Parrish, Associate Dean of the  University,  was  serving
       as Associate Director for South Dakota and was to be the  Acting  Coordinator
       for the proposed SDRMP. South Dakota had  a  three-step  agenda:  (1)  separ-
       ation from Nebraska, (2) setting up its own RMP, and (3) "merger"  with  CHP.
       South Dakota's intent to separate was clear and Nebraska seemed  ready  to
       acquiesce. RMPS staff reactions to the draft  application  were  discussed
       in detail. The amount proposed (more than $1 million  the  first  year)  was
       extremely high. It was also pointed out that most Regions  fall  short  of
       expending funds in the first year due to tooling up  and  recruitment  problems
       and delays. The application was long on general  background  and  history,
       but short on specificity about actual planning and projections  for  each
       y c-,,q r.
       The July 197n Council preferred not to consider  South  Dakota's  separation
       and the establishment of their own Region in advance of  a  formal  application
       and the regular review process. For this reason,  Council  did  not  address
       a relevant question, whether or not South Dakota  might  assume  administration
       of parts of the existing three funded operational projects  to  Nebraska-
       South Dakota RMP.

       A 'Funding Summary" is appended.
       Present Application: Upon receint of this  anplication,  the  applicant  was
                             advised that the issue of separation had  to  be  taken
       tin by the November 1970 National Advisory Council following a visit  by  two


             South Dakota RMP                    -5-              RM 00067  2/71.1

             of its members October 27. They were advised that the  application  would
             then be processed through the regular review process, Review Committee  in
             January 1971, possible site visit and final consideration by the
             February 1971 Council.
             To provide interim support for Nebraska-Soutti Dakota Regional Medical
             Program's core staff and three projects (beginning date January  1),  the
             current first-year award is to be extended for six months until June 30, 1971
             at the current level of support.
             Oh the basis of the visit of two of its members, the November 1970  Council
             approved the separation of Nebraska and South Dakota;  each  beginning  n
             the planning phase.  The report and recommendations approved by the
             November 1970 Council is appended. As requested by  the  visitors,  SDRMP
             provided the following addition information: (1) letters of  endorsement-,
             (2) Core staff job descriptions; (3) biographical sketches for RAG members;
             and (4) South Dakota health study.  Nebraska plans to submit an application
             for their separate RMP for review by the April 1971 Review  Committee  an
             May lq7l Council.
             This is a formal request from South Dakota for support for three years  of
             planning, at which time they plan to separate from the present  Nebraska-
             South Dakota RMP. The decision was approved February 197n  by  the  South
             Dakota members of Nebraska-South Dakota RMP. Nebraska members  approved  a
             resolution expressing their desire for a separate Region.  The  resolutions
             was enclosed with a letter August 19, 197n, to RMPS from the NSD/RMP.
             As proposed by the Governor, the South Dakota RMP proposes -q merger of
             their functions with those of CHP. The applicant organization  for  SDRMP
             will Ir the School of Medicine, Univprsity of South Dakota.  The  grantee
             for SDRMP will be the Office of the Governor. Both agencies will  have  a
             common RAG consisting of 41 members (21 consumers and 20  providers).  The
             providers include members of medical, nursing and paramedical  professions,
             and representation from the medical school, hospitals, nursing homes,
             university, voluntary health agencies and official health  organizations.
             Al] projects and grants are to be acted upon by the RAG and must  conform
             to the State Plan and objectives also decided upon by the RAG.  The  bylaws
             provide for a Chairman, Vice Chairman, and Secretary. The latter  two  will
             be elected by the RAG. The President Elect of the  South  Dakota  Medical
             Association shall serve as the Chairman of the RAG and the Executive
             Committee. The Executive Committee shal.1 consist of  nine  members:  the
             Chairman, Vice Chairman and Secretary of the RAG; a representative of  the
             School of Medicine, designate of the Dean; and five consumer members of the
             RAG.  At least one of the providers shall represent the South Dakota Hospital
             Association and one consumer shall represent the Indian  population.  The
             Chairman shall ippoint the consumer members of the Executive Committee.  The
             RAG will meet at least three times annually.  The Executive Committee shall
             meet monthly to carryout business in the interim of RAG meetings.


       south Dakota RMP                      -6-                 RM  00067  2/71.1

       According to the bylaws, the-Program Director shall be a  physician  graduate
       of an AMA School of Medicine; one who is licensed or eligible for license in
       South Dakota.  Demonstrated leadership qualities are also a requirement, and
       experience and/or training in administrative medicine is desirable.    The
       Director shall be an employee of the grantee organization.   His  appointment
       and dismissal shall be the prerogative of the Medical School.   However,  the
       advice and consent of the Executive Committee will be sought.

       In the framework of six subregions] areas, planning will be done by staff and
       approved or disapproved by the RAG. Ad hoc committees will  be  utilized  as
       necessary to provide technical assistance.  SDRMP and SDCHP will work
       cooperatively in planning. SDRMP will be responsible  for  planning  relative
       to heart diseases, cancer, stroke, continuing health education,  and  health
       manpower. SDCHP will be responsible for planning in the  areas  of  health
       services, heal.th facilities, environmental health, Indian health and  mental
       health.. Cost sharing will be considered beginning with the  six  subregions]
       representatives. Planning for better health care  being  the  major  thrust,
       goals d@al with health manpower, professional continuing  education,  medical
       care facilities (includes in-service education and transportation), screening,
       communications among providers and consumers, prevention, early diagnosis and
       treatment, rehabilitation and public education.  Objectives formulated by the
       NSD/RMP's categorical disease task forces will be utilized in  the  planning
       process.

       Although a three-year planning grant is requested, it is implied  operational
       status might be possible in one or two years.   Objectives during the  first
       year include evolving administrative procedures; recruiting core staff; devel-
       oping working relationships with CHP; recruiting health manpower and developing
       a supporting project; initiate and expand continuing education  for  health
       personnel, including the development of one or more operational support projects;
       begin six subregion activities including assistance in the  development  of
       CHP 314 B area planning grants; and train ambulance drivers in emergency health
       care.

       Much of the application addresses the history of the Nebraska-SOLItti Dakota RMP
       and reasons for South Dakota's request to separate from Nebraska to establish
       their own Region.  The University of South Dakota, the applicant organization,
       is described as being established in 1862 with a present enrollment  of  five
       thousand students in its two colleges and six schools.  Academic units:
       College of Arts and Sciences, School of Law, School of Medicine,  School  of
       Education, School of Business, Graduate School, College of Fine  Arts  and
       School of Nursing. As one of the major research centers  in  South  Dakota,
       the University has received grants from 15 agencies including  the  Atomic
       Energy Commision, the National Science Foundation, Health Manpowr.r Edtication,
       the Bureau of Indian Affairs and the National Institutes of Health.

       Or the $597,7nO requested the first year, $372,650 (61%) is  for  personnel.
       Sixteen ftill-tim(-, professional positions qr(, btidi-,Ptcd (a Director, 3
       assistant Directors, Administrator, Statistician,  Epidemiologist,  Sociolo-
       gist, Medical Care Planner, Community Developer, and six RMP representatives).
       Toti other full-time positions are budgeted (Administrative Assistant  and


              South Dakota RMP                   -7-                  RM 00067  2/71.1

              and nine secretaries).  oher categories:  consultant services - $5,0',C,
              equipment - $62,550, supplies - $48,000, travel for RAG  and  staff  -  $6S,50'
              publications - $10,000, other (rent, telephone and computer time) - $25,,-),')O.
              The budget reflects no costs sharing by CHP.

                              NEBRASKA-SOUTH DAKOTA FUNDING SUMMARY
                                              RM 00047
              PLANNING
              Council - November 1966
                        November 1968
              Site Visit   September 1968

              lst  Year                        1/l/67  -  12/31/67

                                Direct  Costs       $289,350
                                Indirect  Costs       60,989
                                          Total                      $350,339

              2nd  Year                        1/l/68  -  12/31/68

                                Direct  Costs       $281,450
                                Indirect  Costs       67,917
                                          Total                      $349,367

              3rd  Year                        1/l/69  -  12/31/69

                                Direct  Costs       $440,375
                                Indirect  Costs       70,831
                                          Total 1/  2/               $511,206

              Total 3 years                    1/l/67  -  12/31/69

                                Direct  Costs     $1,011,175
                                Indirect  Costs      199,737
                                                                   $1,210,912

              1/ The Region was initially approved and funded  for  two  years  of  planning.
                  I!pon review of the three-year operational application, the Review Com-
              mittee and Council concurred with the site  visitors  that  operational  status
              was premature.  Accordingly, the three-year operational application was
              funded as a renewal planning grant carrying commitments (d.c.o.), $350,239
              the second year and $378,832  the  third  year.  TheIRegion  became operational
              beginning January 1, 1970, and continuation of core,  reviewed  by  staff,  was
              funded for one year with a commitment the second year;  core  support  must  be
              renewed for the third operational year prior to January 1, 1972.

              2/  The renewal award for the third year of planning included $107,880
                  ($102,520 direct costs and $5,360 indirect costs) for one year additional
              planning of two projects, #2 - Audio Visual Continuing Education Services
              and #3 - Coronary  Care  Program.  Project  #4  Stroke Rehabilitation Tech-
              nician Training - was disapproved.


                                                                         RM   00067-'   2/71.1
         SOUTH DAKOTA RMP

                                               1/l/70     12/@1/72
         OPERATIONAL
         Council - 1969 August and December
         Site visit - 1969 June                                           Direct Costs
                                                                                       Approved
                                              Approved
                                               Period               Funded            Future Level

         Core                                1/ 2    years       (01)    $443,647     (02)   $425,903
                                                                                  1/  (03)        -0-

         #1                                    3    years        (01)     313,138     (02)   313,138
             - Coronary Care                                                          (03)   367,871

         #2  - Facilit  Communications         3    years        (01)     132,715     (02)   132,715
                       y                                                              (03)   -@71,390

         #3  - Stroke Education                Approved     Not  Funded
         #4  - Neoplastic Disease              3    years        (01)     134,739     (02)   1280739
                                                                                      (03)   128,739

                                                                                                    495
                                                                                      (02) $1,000,
         TOTALS                                                 *(ol) $1,024,239
                                                                                      (03)    $668,000

         *Note:  01 year award includes       authorized use of carryover $23,744 ($17,744
                   Core-and $6,000 mobile     unit    #4)

                                        Approved   Not Funded
         #3 - Stroke Education         01               02              03              Total
         Direct Costs              'TI87,350        $187,350         $187,350         $562,050


             South Dakota RMP                  -9-                 RM 00067  2/71.1

                                    RNPS Vist to South Dakota

                                     Vermillion, South Dakota

             Date:  October 27, 1970

             Place:  School of Medicine, University of South Dakota (Vermillion

             RMPS Visitors:  Bruce Everist    National Advisory Council, RMPS

                              Clark Millikan   National Advisory Council, RMPS

             Personnel from South Dakota:

                              Dr. Henry Parrish, Acting Director (Program Coordinator)
                              South Dakota Regional Medical Program

                              Dr. Robert H.  Hayes  State Health Officer

                              Dr. J. Patrick Steel, Radiologist, Yankton, South Dakota;
                              Member, National. Advisory Council, National Institute of
                              General Medical Sciences

                              Earl B. Scott, Ph.D., Professor of Anatomy, University of
                              South 'Dakota, School of Medicine

                              Dr. Robert Quinn, Past President, North Dakota State
                              Medical Association

                              Mr. William Murphy, Executive Secretary, State Hospital
                              Association

                              Dr. Warren L. Jones

                              Mr. Richard Erickson, Executive Secretary, South Dakota
                              State Medical Association

                             Mrs. Bertha Damm, Executive Director, South Dakota State
                              Nurses Association

                              Mr. Peter Zwier, Executive Secretary, American Cancer Society,
                              South Dakota Division

                              Dr. Bruce Lushbough

                              Mr. James R. Nordstrom, SDRMP Staff, 20 per cent


        South Dakota RMP                 -10-                 RM 00067' 2/71.1

                       Mr. G. Halter-, SDRMP-Staff,100 per cent

                       Mrs. Schwab, SDRMP Staff, 100 per cent
                       Mr. Don Brekke, SDRMP Staff, 50 per cent (SDCHP Staff,
                       50 per cent)

                       Miss Gloria Hansen, SDRMP Staff, 100 per cent

                       Executive Assistant of President Richard L. Bowen, University
                       of South Dakota
                       Dr. George W. Knabe, Jr., Dean, University of South Dakota,
                       School of Medicine

        General: The Nebraska-South Dakota  Regional  Medical  Program  apparently
                 began amiably in 1966 with what appeared to  be  a  rational  approach
        to rogionalization involving two adjacent  states.  Enthusiasm  was  apparently
        high in both states. Some of the difficulties described  at  the  time  of
        our visi t were:
        1. The meetings were apparently held in Nebraska,  and  the  South  Dakota
        representatives had to spend considerable time traveling to and from Om6ha.
        Without adequate airplane service, this meant a tiko-hour drive each  way  at
        a bate minimum.
        ?.  Ideas were germinated in South Dakota and come to  fruition  in  Nebraska
        with little substitute change.
        3.  Principal core personnel were placed in the two universities in
        Net-raska witl)out simil.ar attention or recognition at the Univers ity of
        Sout Dakota.
        4.  As South Dakotans see it, they were treated as country cotisins; made
        to Fer@l that they were lacking in sophistication, and  therefore,  having
        to attempt to make up for this with sincerity, enthusiasm and dedication.
        5. The South Dakotans believe that there was  inequity  in  the  distribution
        of funds.
        6.  A variety of other items described in detail on pages 18, 19, 20, and
        21 of the printed new planning grant application for a  South  Dakota  Regional
        Medical Program.

        New application:
        RMP-CHP relationship. There is described an  attempt  to  partially  merge
        these two organizations.  This was initiated by the Governor  with  a  letter
        to H.E.W. and was concurred in by the power structure of  medicine  in  South
        Dakota. This change (from the traditional arrangement)  is  that  the  Regional
        Advisory Group will be identical for both organizations and that certain


              South Dakota RMP                                       RM  00067  2/71.1

              individual employees may receive partial stipending from CHP and  partial
              stipending form RMP (Mr. Don Brekke). There will be  separate  offices  and
              separate directors for the two organizations. In a state with  a  limited
              number of professional people, this arrangement would seem to make  good
              sense, save time and allow for greater cooperation among all involved 'Persons.
              Currently, there is an A agency (annual budget 140,000 dollars) and  one
              B agency that has not been funded (Rapid Cit@. In the budget  for  the  RMP
              planning grant application, it is proposed that six  representatives  be
              paid from the RMP budget but act as RMP-CHP representatives in  the  six
              regions of the state and that they initiate, as part of their  job,  the
              development of more B agencies. There is precedence for this  in  West
              Virginia and Alabama. There need not be any specific  difficulty  arising
              from this arrangement; the cooperative undertaking might well be an inter-
              esting experiment.

              Bylaws of the Regional. Advisory Group of the South Dal<.ota Regional Medical
              Program. On the face sheet of the application, it is stated  that  the
              recipient of the grant will be the School of Medicine, University of South.
              Dakota, Vermillion, South Dskota. This should be a  bit  more  carefully
              defined in the body,of the application as on page 23 "the University  of
              South Dakota" is mentioned rather than the medical school as  well  as  the
              matter on page 28 of the appointment and dismissal (Director  of  the  RMP)
              shall be made by the University of South Dakota" being of concern to  the
              Dean of the medical school who wants to be certain that the  distinction
              between the over-all university And the medical school is absolutely clear.

              Proposed Core.  The prospective use and activity of the core staff, for which
              budget support is requested, is impossible to evaluate from the  document
              given us. At the time of our visit to Vermillion, the Authors  of  the
              application stated that they had originally planned to write a much  more
              elaborate and detailed grant proposal but had been advised by  staff  to
              delete all extraneous material. The result is a synopsis of  a  synopsis
              and gives merely a listing of 16 professional staff people plus ]@O other
              employees. We tried to discuss the duties of each  of  the  professional
              people and it became more and more evident that this list  constitutes
              an attempt to bring a basic staff of public health professionals  into  the
              state. The list includes: a  biostatistician,  an  epidemiologist,  medical
              sociologist, and a community developer.  It appeared obvious that if these
              people can be found and employed, they probably would wear  "many  hats"
              but would share a basic dedication to improving the health of the  people
              of South Dakota. It was obvious that the acting director  of  the  proposed
              South Dakota RMP (Doctor Parrish) is public health oriented and has  had
              experience in the mechanics of developing a foundation for health planning.

              We asked that the job descriptions of these 16 professional people be sent
              to th@ staff (in another document) prior to the National  Advisory  Council
              meetinF November 9 an(] ].O.


        South Dakota RMP                     -12-                  RM   00067   2/71.1

        University of South Dakota Medical School relationship     with   RMP.   There
        apparently has been some  uneasiness  between  the  medical  school  and  the
        Nebraska-South  Dakota  Regional  Medical   Program. Dr. George  W.  Knabe,  Jr.,
        the current dean, has had  some  interest  but  littl-e,participation  in  the
        Nebraska-South Dakota RMP and has been  annoyed  by  the  RMP  demands  on  the
        time of the medical school personnel.     Now that  the  associate  dean,  Doctor
        Parrish, is the acting director of the    South Dakota RMP, the.dean is further
        annoyed by the amount of time demanded    of Doctor  Parrish  in  developing  the
        new RMP. Communication  between  the  RMP  personnel  and  Doctor  Knabe  has
        been faulty.  Doctor Knabe has not been privy to the development and
        content  of  the  current  proposa'1, and is somewhat uncertain about some aspects
        of the document but does  endorse  the  participation  of  the  medical  school
        in carrying out the  objectives  of  the  proposal.  The  dean  is  particularly
        interested in getting a full-time director of the proposed South Dakota RMP
        so that Doctor Parrish may  return  to  full-time  activity  in  the  University
        Medical School. As we  review  the  discussion  in  Doctor  Knabe's  office,  w6.
        feel there was more pique than substance in his uncertainties.

        Projects: The  South  Dakota  group  of  the  Nebraska-South  Dakota  Regional
                   Medical  Program  has   apparently   lost'interest in the,communications
        project and the canter project  but  they  continue  to  be  vitally  interested
        in the coronary care project which  has  approved  funding  for  a  period  of
        three years.   The share of this project  going  to  South  Dakota  is  $120,000
        a year of which $50,000  funds  activities  centered  in  the  University  of
        South Dakota Medical. School and $70,000 funds the activities centered      in
        Sioux 'Falls, South Dakota, and Rapid City, South Dakota.  From their
        description of the project's success so far, it would seem that they        have
        made a significant beginning  with  outreach  to  the  smaller  hospitals  for
        continuation and with courses  of  two  days'  duration  at  the  University.
        So far the instruction is primarily directed toward physiology, pharmacology
        and anatomy. The  activities  centered  at  Sioux  Falls,  South  Dakota,  under
        the direction of Doctor Woods appear  to  be  more  clinically  oriented  with  a
        demonstration type coronary care facility.  The entire group wi      th whom  we
        visited were unanimous in  their  hearty  recommendation  of  need  to  continue
        this project as they refer to it as the first tangible eviience of "action"
        by RMP in South Dakota.  In  discussing  the  future,  it  appears  that  South
        Dakotans do not have any  projects  ready  for  immediate  submission  but  do
        have a portfolio containing 22  project  ideas  in  various  stages  of  develop-
        ment. These  have  previously  been  discussed  by  the  Nebraska-South  Dakota
        RMP Regional Advisory Group.

        Recommendations:

        1.  South Dakota be designated as an independent RMP

        2. Arrangements be made to  supply  "core  support"  of  at  least  $40,000  per
        year to the new South  Dakota  RMP.  If  further  written  description  of  plans
        and of functions of the expanded  core  personnel.  requested  by  South  Dakota
        is forwarded to the RMP  Washington  office,  the  staff  and  National  Advisory
        Council consider  increasing  the  $40,000  annual  core  support  immediately.


              South Dakota RMP                 -13-                  RM 00067  2/71.1

              3.  Funding of the coronary care project in South Dakota be continued;
              $120,000 per year -- total time three years.

              4.  South Dakota RMP be moved to "operational status" as soon as an acceptable
              operational grant application is received and processed.

              5.  Details of the separation of Nebraska-South Dakota RMP into Nebraska
              RMP and SDRMP be constructed and carried out by the Washington RMP staff
              being certain that the Nebraska RMP receives appropriate funding in the
              new arrangements.

                                                                  RMPS/GRB  12/8/70


                                                           Si

                                                     SO'tTl.'Il  r)A"O'.CA   P,
                                                            IU,l 00067                      2/71.1

                                                                              D."                  1971

                                                                                                                Ic@:E
                                                     application     to     beco:ii@-.     a     se-parpt@e     Pei-ion     6tid      to      begin
                      plannin,!,.         The  reduced  ariount of  @943,000  for  three  years  is                                recc)a,,i-net)@ed
                      for       core       (01-.$2!-)9,@50'3,        02-$313,030        end                          'In  icldition,  $120,000
                      is                         for     one     year     for     support     of      tied                co:,-oi).@,ry        care
                      p  oject  ill  tbref."                   r-l,@ot.1 tio,-,,T)   t L)  I     To'@@il    I.c@v@-il     of     stippo@:t     reco
                      is  as

                                                                          Di i ",IC   Ck@s

                               01                              0                                        n3

                         $379,503                           $313,orjo                            @376,00@)                          si,o-us,500

                                                                      -nd    ti:i-.    rer@r)y-t of  ttLic                  27,  1970 y@-@i@t  by
                                          Cour.c,..l    mc@rbtxs     i7     i:c                                              ,Iso           benefit
                      l@@,7  ii.,pLiL  front          of  its r,,cr@-,@barr-,
                      stated,.          The                                        t,,)  b-,,  IoLic,  c@ii
                      details             rc@,,ardiiig                                           etc..                 rer,@)rtc,@,l     tliet-
                      additional                                                 I)Y  t:@e     v   1. i:                      Of
                      job (lesf-riptic)ii--                                                              f                tied
                      had    been    provided,,    -s     i@P-11     e,,;     a

                      ill,-le  Co-r.@-@littee  believed  tl-5zt
                                                     c@,-ri   be   srz-.@v,.d   task'    by
                      coi,,cepl- of coordi ioti,,ig  S.'fl                                                              P@@IC @iticl  tile  ti,-c  iT-l
                      to  the  Cov,-rriorIL" office  i,-,                                                                 St-ite      lie,-,iltll
                      I)irector,
                      residual.  carry ove7: of  1"4'            @IP.     Ti-te                                 t,,)   h-@v@,n    the    z.,ctive
                      support of  the  S.  D.                                  Sc-li-I)OI  of 'ti@,licin@,  St@itc@
                      Association                   Fosiitc.1             I,--ion  aiicl  ot',ie-;:   I,.@y                                   are
                      hopes    for     a     four     yez-Lz-                               T.tic  Cor,-@"Pittc@c,  '2@@,rc@"cd  ttiat  Sout'Ll
                      Dakota i-nay  lac@,  so-,n,@                        b?.@.,@-   they   i:.e                     akil  the  clit@iate iL.,Cy
                      be      right      to                                               to    t,,c            tl,,-.ir  ideas  into

                      !lie budget  is liic,,Ii,  p,-,@irt        icialarl.y  personnel,  eqiiiF                        @-,ni
                      need  for all of  ti.@t,                                                                is  not
                                                                                                   I @@                       -@ f f 1.7 @;
                      if recruitratit  capability fare  prc,.-jent.                            b.                         St!?         -tti
                      combi.n@itic),@is     of     @-@pert'.Isc@     anrl     a     field     stnfj'             s?.,ifice.        'Ili  e  bti   c t
                      does  not  secnl  to  all.o-,,  for  "tool  tip"                             b-@!t               i@s   fLill    blo@,,.ri f i:oa
                      day one,          In                    -i  rc@c,-k                                              consi.dlr(,,d-       tl-@e


              SOUT@-I Dkl',O'.CA B-1,@IP                                   IUl 00@067 2/71.1.

                                                            o-                       d ,y       f.
              The current aL@riLial rEllIe Of SL!Pport for Core activities    i- @111,700 atid
              itici,ti.ti,@s five, ful)@                              ni.irse, lilinnin@
              and t,,lo                                       (A'i@!lr!
              assistant co3rdi.nator 30%, aiid plaiinitia assistant 5%).  The Comriittee
              bbli6@ies that t?2.50,C,@.0 d.c.o. for sti,)port of core tire  first year i,?itli
                                   :ifi    seco,-Id vrd tiiiire, year        be z,lcl@quite-

                  torrent corctin
                                  ,,-y care project                                yi,@').
                    s ed.  The proj@,ct includes three
              discit s                                      Sotit:',i DaKcts hospit,-,).Is ctirreiitly
              budo.eted'at $120,OCO d.c.o.  'Ihe Co.@-,riii@ttee a@r6ed that South Dakota
              should be nwzirde,'j fL' @(IS for oac yea  .1  the current level to proNI.clc-
              Continuity of this pro<,ran. i-ki,-il tr-eir projected plans are more cryst@-ilizcd.
                       tire activty            be funded is ci@i                project or a Co-,-O,
                                               b  b
              staff feasibility                         b@  ,!-t         'i@); star
              TLIL, Co@-il,-i-l-tte---                                     firft,@ effort          br@
                                                                                     a t i c@ Tli
                     be  :Icc           loy     o- P- CCP@.@l".)."@r@@
              in                                             -@tik@CL o'
                                         of
              of    troiner, uLi.                          convinces,      vis.".Ls to

                          i@

                          I
                          I
                          I                                                     JAN I 9 I"

                          i

     0


                                                                                                  i-RVIC:
                                                                                               S'
                                                    ,,E(,'10i\,TAT, !,,EJ)ICAI@ PP@OGP@1,1@,
                                      SU@2,fArY OF ANNIVERSA',',Y REVIEI@T AND AWARD APPLICATION
                                                          (A Privileged Coiimuf,,!.c@,-ition)

                      SUSQUEI;ANNI@      VALLEY      PEGIO,@"Pl,       IIEDICAL       PROGP@L        K@4      00059       2/71.1             CSD)
                      3806    @i-arket     Street,     P.O.     Box     541                           iaftuary 1971 Revi-f@,@,i CoirLi@-ttee
                                                                                                                                              L
                      CaDip T-lill,  Pc-ansvlvania   17011-

                                  Conrclipator:   Richard B.  @IcKenzie

                                                          LIF@K-IS@T      (Direct       Costs Only)

                                                   04                           05                            06
                                           4/]-/71-3/30/72              4/l/72-3/30/73                4/l/73-3/30/7/i.            All       Years
                                                      -----------
                      Contintiatioii
                         COMTC,itrieiit             $545,9-1-5                                                                    $545,9@l--',
                      Core-                           (469,700)                                                                   (@69,700)
                      3        Projects           (76,215)                                                                            -(76,2-1@5)
                      1),enewal
                         L@m@@e@ts                $29,425                           $31,551                                             $60,976
                      I       Project             (29,425)                           (31,551)                                            (60,976)
                      Add-i.tional.
                         r@o@ts                     $1,503,780            $1,482,065                    $1,592,377             $4,578@222
                      4         Previously
                      Approved         Projs.         (184,044)                     (158,387)                (98,534)             (@,40,@,65
                      7         New         Pro'ects(1,319,736)           (1,323,678)                   (1,493,843)            (4,137        257)
                                      @al
                                                  $54,596                           $54,596                  $     i@-@6
                                                                                                        $1,646,973             $5,348,901
                         Total                    133,716                 $1,568,212

                      Tt-af:F   A-ct-i-o-n
                         Coir,niitri ent              $545,915
                      Coriir,iittee.@
                         Action
                         Required                   $1,587,801            $1,568,21-2                   $1,646,973             $5,348,901

                                                                   FUNDING            HISTORY

                                                                   Planning           Staae

                      Grant        Year                   Periorl                                               Funded  (dt,o.)

                      01                                  6/l/67--5/31/68                                       $253,530
                      02                                  6/1@/68-3/31-/69                                      $250,056


               SUSQUEHANNA VAI,LEY l.U@IP                2                      RM 00059 2171.1 (AR-1 GSD)

                                              ODerLtional. Pr
                                                                                                     Future
                                                                            'Funded                    tT)!Cnt
               Grant Year       Period             Cbuv.cil,appi-ovo-d               dc.o.'       Cblilrfll

               01           4/l/69--3/31/70               $698,052             $532,444 1/
               02           4/l/70-3/31/71               666,495                671,997 fl
               03           4/l/71-,-3/31/72             695,333                                  $545,91@5
               04           4/i/72-3/31/73               650,075                                   497,644
               05           4/l/73--3/31/74              483,294

               1/ Represents    75%    funding of projects

               2;/ Includes $124,390 in carryover

               E(Lo,- --a 'h-

               This Region consists of 38 counties in the cent3.-al- corridor of Pennsylvania
               bordering on Maryland in the south and 'New York in the north and separated
               from the  I,,Iesterii  Pennsylvania  arid  Greater  Delaware  Valley  @lPs  by  nioun-
               tainous  terrain..  The  total  population  of  the  Region   is   projected   to   be
               2,323,751 (1970 Census).  Much of this population is centered around the
               three urban areas, but the Region also contains large rural and forest
               areas   with   low   population   concentrations   and   underdeveloped    facilities.

               The  Milton  S.  Hershey  Ilp-dical  Center  of  the   Pennsylvania   State,   University
               was established in 1-963.  The first class of 40 medical students was
               enrolled in 1.967.  The Region also has 55 hospitals.  It is served by 1,776
               bl.D.'s and 218 D.O.'s.  There are 8,909 active nurses.

               L-'@iorLal Developident

               In  1966  the  Susquehanna  Valley  Committee  on   Heart   Disease,   Cancer   and
               Stroke,presided  over  by   the   President   of   the   Pennsylvania   Medical   Society
               (PMS),  met  to  plan  an  PMP  for  the   central   Pennsylvania   Region.   The   first
               planning  grant,  submitted  by  the  PMS,  was  approved   in   June   1967   pending
               clarification  of  the  role  of  the  new  medical  school,   the   state   health
               department   and   administrative   and   staffina,patteriis   and   assurance   of
               allied  health  involvement,  The  Executive   Director   of   the   PIMS,   Mr.   McKenzie,
               was appointed Coordinator in August 1967.

               During  the  second  pl-ai-in.in-  year,  the  Region  encountered  a  number  of   problems
               w.ith the completely lay Core staff and the grantee agency, which             considered
               the P14P  Core  staff  as  another  branch  of  the  P@IS.  There  was  stroii-  senti-..
               ment among Core staff regarding the degree of control the PMS maintained
               over  routine  office  matters   and   the   relatively   low   salary   scale.   Several
               stiff members resigned as a result.  There was also some confusion about
               the  relationship  between  the  RAG  and  the   PIIS   Board.   A   management   consulting
                                                                                      LI
               firm  was  retained  to  study  the  entire   program   and   recommended   certain
               staffing chances, some of which have gone into effect.


             SUSQUEHANNA VALLEY P@T@-            3              RM 00059 2/71.1- (AP,-l CSD)

             The Reoion beoaii work on its initial- operational  application  which  would
             contain five coronary care unit proposals and  a  request  to  train  coronary
             care unit nurses. A site visit was helci in  Deceitiber  1968.  The  visitors
             recommended operational status to convince the  local  physicians  that  P@4P
             would actually help them improve  patient  care.  While  leadership  from  the
             RAG was sl.o@,7 in developing, the Region had an impressive amount of  physi--
             ciaii involvement at the grass roots lE@vc-,-I- tlirotic,h the Area Committee
             structure. In fact, the bywords for the SVRL@IP in those, earl-y  days  became
             11 grass roots involvement and I'coronary care."  Council approved the
             Region's request with the understanding that  the  CCU  projects  were  pilot
             project@ for-the Region with evaluation  of  the  results  before  additional
             projects are funded and with the stipulation that 50 percent of the equip-
             mpnt funds be made  available  for  physician  training.  Shortly  afterwards
             three more proposals were submitted, approved and funded.  They were a
             stroke care unit, a home health care -Droject and a rec,i.onal medical ii-ifor-
             nation service.

             New projects submitted durivo, the second year, however, continued to
             emphasize coronary care-.  Reviewers fouii.cl thcpi, on the @,7h'ole, to be a
             disparate group of projects, attacking the problems of coronary care in
             an isolated fashion. They disapproved the projects and  recom-  eiide  t  at
             the Region establish an overal-1 plan involving greater coordination  coop"
             eration and consolidation. Core and  the  coronary  care  training  proposal
             at the Geisinger Medical Center were renewed.

             A site.visit held in February 1970 reviewed the overal.1 progress of the
             Region and four new projects.  They concluded that the Region. should:
             1) consider broadenin,- the base of its grantee agency to insure  that  al.1
                appropriate groups feel represented. A  change  to  a  nonprofit  corpora-
             tion was seen as a possible solution-,

             2) Utilize consultants fro-in both inside and outs!-de the Region to  improve
                efforts in data gathering and epidemiology;

             3) appoint a liaiso@ member of the Hershey Medical School faculty part-time.
                to the @,IP staff to both improve relations with the new  -medical  school
             and involve physicians on Core staff;

             4) white continuing to encourage grass roots involvement, devote more
                attention to developing a regional decision-making process which selects
             projects on the basis of a regional plan, rather than just on a community's
             needs.

             Projects funded during this past year include:

             1) an extension of the ori.ginal five CCU's with carryover funds for an
                additional year,
             2) the CCU nurse training project,
             @3) the second year of the SV@IP library information. services


               SUSQUEHANNA VALLEY R'@l@-              4                @l 00059 2/71.1- (AR-1 CSD)

               4) project #7, the Stroke  care  Unit  and  #S,  the  Home  lic@,tlth  Service,  out
                  of carryo,7er, and
               5) projects #16, the Radiological 'Health Trai-ni.ii- Program and #17, Coll-imbia-
                  Montour Home Health Services.       Projects  @tl-8,  a  Rheumatic  Fever  Control
               Program, and #19, a CPR project were approved but unfunded.

               The  Recion  submitted  one  further  applicatioii.-durinc,  its  second   operational
               year.   Only the Eriterostoipal. Trai.v-inu Procrani and the CPR and CVA Transport
               Vehicle,  York,  were  approved.   Council   requested   additional   information   on
               the CCU. 1,Turse Training  Program  at  the  Altoona  Hospital  before  it  could
               be  approved  (this  information  has  been  received  and  will  be  forwarded   to
               the  February  1971  Council).  The  remaining  four   projects,   including   an
               emphysema  program,  a  stroke  rehabilitation  and  tral.ninc,  program,  a   cart-
               ridge viewin- system pilot project and a supervisory CCU nurse training
               program, were turned down.

               The Region's present  level  of  funding  for  its  second  ope-@ratiortal  year  is
               $671,997.

               Note    A site visit was not planned  for  this  Pe@i.on;  on,,!  had  been  held
                       during the past year; and the Re-ion informed IU,IPS only a week
               before  the review deadline of its decision to include a request for a
               developmental component  in its AR application.

                 i@@a L@l e c tfiv e s
               The SV@IP  frankly  adini-ts  that  its  centralized  program  planning  to  date
               represents a disconcerted effort and that the P,.ecion does not have a
               specific plan ,Tb.ich details specific objectives that result in specific
               applications.  Interest  in  the  past  has  happened  to  center   on   heart   dis"
               ease and coronary units.

               At  its  fall  1970  meeting,  the  RAG  established  formal  goals  which  set  the
               stage for development of primary goals and specific objectives.
               The primary  goal  is  to  "improve  the  quality  of  patient  care-  working  with
               and throuch the  providers  of  health  care  as  they  function  in  the  existi-n('
               health  care   sys.teRi;  and  by  influencing  the'present  arrangements   for   health
               services  and  by  concentrating  maximum  effort  on  those   activities   which
               have the highest local, regional and national priorities."

               The primary goal is approached through specific goals in three  asic areas -
               organization, strategy and program.

               P-rgani7atioTial Structure and Processes
               The SVPJ;IP has  organized  a  30-mepiber  RAC,  with  representatives  from  each  of
               the four  Areas  and  fro-in  various  health  organizations  an.d  institutions  of
               tlie Region.   The  RAG  has  Executive,  By-Laiqs  and  Noriinatin-  Committees  and


              SUSQIJEIIA,@'@'@IA VAT@l,,[,Y @IP      5             R14 00059  2/71.1  (AR-.  CSD)

              is in the process of selecti.i-i(, Plaiinin@, and reevaluation. Committees.  The.
              @'4P has divided the Peg-i.on into four Arc-,as, each  of  which  is  served  by  a
              Committee ran(,iri- from  60  to  l@15  members.  Each  Committee  has  appointed
              subcommittees  to  serve  as  study  aroups  and  an  Executive  Committee.   To
              provide  review  and  planning  at  the  regional  level  in  specific   functions,
              Councils formerly Task  Forces)  have  bz.-cn  es-Lal)]-ished  in  the  categorical
              areas, as well as in  Facilities  and  Services  -and  Continuing  Eclucati.OYL.
              Each Council also sets goals  and  objectives  in  it-,  resp-cctivc-@  interest.

              The review procedure consists of the following steps:
                                                                 0
              1.  Consideration  by  the  volunteer  Area  Comm--i.ttees  through  their  Executive
                   Committee and specialized subcommittees.

              2.  Consideration by the members of categori-cal- councils who supply spec-
                   ial-ized professional technical review on a regional scale.

              3.   Considerati.oi-i of the relevance  of the prop(Dsal.to regional goals and
                   objectives by the PAG.
              At each step, staff members provide administrative assistance.            Formal
              review procedures, i-Licludirio a  set  of  criteria  and  a  numerical  ranking-
              system, which assigns all new projects a priority number, have been devised
              for the RAG.  Plans are underway to develop a similar system for the
              Councils and Area Committees.

              PI.I@ESENT APPLICATION:
              R@v ]@p@e-.I@@_Lo-.Ii-rone-Lit                                           $54,596
              Activities  initiated  through  developmental  component   funding   "will   seek
              to improve the  quality  of  patient  care  by  working  with  and  through  the
              providers of health care  as  they  function  in  the  existi-nc,  health  care  sys-
              tem,  by  influencing  the  present  arrangements  for  health  care  services,   and
              by  concentrating  maximum  effort  on  these  activities  which  have  the   highest
              local, regional and national priorities."  An example mi-ght be. an explora--.
              tion  of  appropriate  methods  and  means  for  developing  improved  patient   care
              techniques and systems in kidney disease prevention and control.

              The review mechanism described tinder organizational structure and processes
              above will   apply to the developmental component as well.

                        $54 596                                      $54,596

              Continuation Component

              These  components  have  been.  reviewed  by  staff.  Their  program  and   funding
              recommendations are in a supplementary memo.


                                                                                p@i 00059 2/71.1- (A]>,-]. CSD)
                 SUSQUEIIA@@,;"L,'A VAT-,LEY PT,,-I.'         6

                                                                                                    $469,700
                 Core
                 The SVP,'@IP Core staff is completely ]-ay.          Its   Coordinator   was   the    former
                 Executive   Director   of   the   Pennsylvania   Medi-cal-   Society,   which   serves    as
                 the   grantee   agency.   An   organizational   chart   for   Core   staff    is    attached to
                 the stiTiin, iry. The f unctio-,is can be brief ly cli-f ined is f ollox,Ts:
                 1.   Techi-i--!-cal- Services - plans, establishes and directs the technical ser--
                      vices for:     appl-icaLioii@;                   grants TPai-ia@c-,,@neiit,  research  and
                 evaluation   services,   development    and    operation    of    library    activities    and
                 general office management.
                 2.   Cop)Ttluni.cations   -   directs   the   production   of    communications    material
                      and provides liaison with the news media.
                 3.                               provides   staff   services   to   coauliittep-@,,    councils
                      and  pl-anp-in@,   groups,   coordinates   ecL,-lcati.oiial   activities   and   programs,
                 assists with the establishment of regional goals, objectives and priorities,
                 and provides personnel recruitment services for staffing.                   In addi-t-io-L-i.,
                 Field Services are included in this.braiicli.             A field represeiitati     ve   is
                 assigned  to   each   of   the   four   Areas   to   provide   regional   coordination   and
                 staff services to all volunteer committees and groups in the Region.
                 With   the   assistance   of   the   field    representatives,    various    Area    Committees
                 or   subcommittees   have   developed   standards   for    coronary    care,    sponsored    a
                 cancer   detection   clinic   survey   and   conducted   a   cancer   incidence    and    mor-
                 tality survey.
                 The  SVR@MP  Core  budget   last   year   included   funds   for   "progr@-Lm   related   acti-
                 vities."  These  are   funds   in   the   magnitude   of   $50,000,   which   t   e   Reulon
                 used  for   various   purposes,   such   as   to   conduct   pilot   studies   of   various
                 proposed project activities, hold conferences, and supply educational mater-
                 ials   to   health   professionals.   Types   of   activities   for    which    these    funds
                 will be used next year include a conference for re,.-ional directors of
                 coronary   care   units,   an    audio-tape    cassette    scientific    program    service,
                 data   collection   and   a   consultation   program   for   tumor   clinics   and    tumor
                 registries.
                 The  budc@e@t  for  1971-72  includes   funds   for   25   full-time   positions,   22   of,
                          0
                 which have been filled.   The new positions           .would be a Systems Coordinator,
                 Nursing      eciali-st and receptionist.
                           @p
                 Continuation support in the amount of $76,215 is also                 requested    for    three
                 projects:,

                 if'9  SVMIP Information Service
                 #16     Radi-ological- Health Training Program
                 #17     Coluinbia-llontour Home Health Services

                 Reneiial_Lr@  -@ts
                                                                                                     3rd    Year
                 Project #611      C    narv Care N,,jrse@,'               Pro@r@i-m, Gpj-sint-E!t      $29,425
                                       The Geis-i-il,-,er @lledical Center will. conduct


               SUSQUYIlb@TIU,, VAI,I,li'y JUJII                       RM 00059 2/71.1 (Al'\.-,I CSD)
                                                      7

               four  four-@qeel& coronary care courses per year.       Each  class  wil-I  admit
                   .4
               ten traii)ees., who are principally recent diploma graduate nurses.           The
               curriculum  includes  lectures,  laboratory  work,  and   cli-ni@al-   experience
               in special nursing techniques for the cardiac patient.

               Community hospitals tlirou@,lio-Lit the Susquehanna  Val-ley  Region,  as  well  as
               border areas, may  use  this  traininc,  pro,rrim  to  staff  their  coronary  care
               units with qualified nurses.

               This project was submitted with the      Region's initial operational applica-
               tion  and  applied  for  and  received  one-year  renewal  support  last   year.
               Since its inception, it has trained 42 nurses.

               Fourth Year
               $31.,551@

               Ap
                 p,LbVE@d but Un'i-inded Projects
               These projects have be-en p5@ovibus]-y'approved by CriL@iicil, but due to     i-i.ation--
               al funding constraints, have not been funded.  Committee and Council con-
               siderations of these projects is,needed in determining an overall funding
               level for the Region for the next year and not for approval of the
               activities.
                                                                                       I.st  Year
               Project ill-8 - P@heiili-,,@@itic Fever Control        This project     $75,217
               will impress upor.. physicians and the public the necessity for
               throat  cultures  in   diagnosing   streptococcal   infections.   Hospitals   and
               physicians in 16  of  the  Region's  27  counties  iiill-  receive  free  throat
               culture kits. The kits will be  used  on  people  bet@,7ceii  the  a.-es  of  two
               and  forty-fivb  who  have  upper  respiratory  infection  or  a  sore   throat.

               The  participating  hospitals  will.  interpret  the  cultures  and  send   reports
               to the attending physicians.      The physicians will fc)llo@,T--up with appropri--
               ate treatment.

               .Although  this  project  involves  the  demonstration  of  patient  care,   the
               aspects of  continuing education are also present.

               In addition,  the  promotional  efforts  of  the  Heart  Association,   who   will
               participate  in  the  program,  will  increase  the  publi.c's  awareness  of  the
               value of  the procedure.

               Second Year
               $64il4l7
                                                                                       let   Year
               Project #19 @'Cardiopolm6i!atV Re-susCi.!:atiOn Ttdini-@,.              $16$693
               Sponsored  by  the  Heart  Association,  the  purpose  of  this   project
               is  to  establish  an  emergency  cardiopulmonary  resuscitation  team   in   every
               hospital in the Susquehanna Valley Region.


               SUSQUEfLk@T@q'A Vi@LLI@"Y P@IP           8                RM 00059 2/71.1 (AR--I CSD)

               First, the InstrLictor's    Traiiij-n,-, Center  at  the  Harrisburg  Hospital   @qil-l
               be expanded to include a special      training course in emergency clirdio-
               pulmonary  resuscitation.'  Each  year,  teams  from  18   hospitals   wil.1   complete
               this course.  Then, u8iiia the organizational- framework of the PeiinE;yl-vania.
               Heart Associati-on  and  its  chapters,  these  i-ie@@ly  trained  teams  will  traip-
               other hospital- teams.
               The  wide  geographical  distribution  of  emergency  teams  will   be   ideal   for
                             0
               training  local-  ambulance  crews,  rescue  squads,  and   other   health   personnel
               throughout the Region.

               Second   Year                                           Third Year
               $).5,481                                                @16,066
                                                                                         I-st  Year
               Project  #21-   El-iterostOTal Ther,@p-V Trainin,@    The Harrisburg      $9,934
               Hospital  will  conduct  twelve,  four-iicsek  courses  in   onlerostor,,al
               therapy per year.  One student will be trained in each course.
               Training  will  included  bedside  instruction   and   practice,   medical   lectures,
               technical lectures  and conferences.

               The  graduate  therapists  will  be  able  to  provide  patients  with   stomal   care
               and management, therebyfreeinc, nurses and physicians for other work.             In
               addition,  the  therapists  will  instruct  patients   in   self--care   and   teach
               allied health personnel the principles of stoeial management.

               Second   Year                                           Third Year
               $10@439                                                 $10,920
                                                                                         lst   Year
               Project #26 - Cardiopulriionarv and CVA Transport       Vehicle,          $82,200
               York  Hosp  t@al.  This  pilot  project  will  determine  the   effect   of
               a  specially  equipped  and  staffed  transport  vehicle  in  reducinc,  the  conipli--
               cations and deaths associated with heart attack and stro@e.

               The  custoic,-designed  van  which  will  contain  a  resuscitation  unit,  a   respir-
               ator,  a  two-way  radio,  drug  --tora-e  facilities,  and  other  emergency   eqtiip-
                                                     0
               ment, will be on call 24 hours a day, staffed by a physician or coronary
              ,care nurse, orderly, and driver.

               Second   Year                                           Third Year
               $68@050                                                 $71,548

               New    Prolects
                                                                                         ist   Year
               Project #27 - Nurse DiAl- Access.  Robert Packer Ilbspi.t@il,             $29,969
                    re,@eniL--
                             .y         Dial-  Access  for  Nurses  wil.1  cover   Central
               New York State and the entire state of Pennsylvania.  It is a special
               telephone information system for R@l's, LPN'S, student nurses, and others
               particularly those practicing in an isolated setting --'@.7ho do not have the
               resources-available for their continuing education            Availe.bl.e on an around-


                SUSQUEI:IAI,,R@A VAT,LEY                9               RM 00059 2/71.1 (AR-1 CSD)

                the--clocl-I basis from any telephone, it provides the caller with free,
                five-to-six minute taped messages on a variety of subjects, such a-,
                (1) nursing care for specific conditions,  2) new procedures an  Equipment,
                (3) availability of community resources, (4) nursing care in emergency
                situations, and (5) legal aspects of nursing situations.

                The  Central  New  York  @4P  is  presently  funding  a  Physician   Dial   Access   pro-
                gram out of the Sayre Hospital.        S V l,'.'L'IP Core funds are being used to  extend
                coverage of the physician program to their Reaion.

                Second   Year                                            Third Year
                $29,453                                                  $3-J,224
                                                                                           Ist    Year
                Project  #28 - Autor@,.,ated Coiii)uter--Assisted Analysis of the          $294,470
                @PG, Pennsylvania State University.  Four participatiiic, hospitals,
                located  in  three  areas  of  the  Region,  will   send   computerized   EEG   signals
                to   Penn State's Hybrid Computer Laboratory.  The information will be
                interpreted  by  computer  at  Penn  State  and  the  dialonosi-s  returned  -to  the'
                sendinc, hospitals.  Each  computer  diagnosis  will  be  coi,,if),,ired  to  the  phy-
                siciants  final  diagnosis.  The  purpose  of  this   project   is   to   install   and
                further  develop  this  computerized  EEG  system,  and  at   the   same   time,   deter-
              ,mine  the  feasibility  of  providing   all   hospitals   throughout   the   Region   with
                rapid and valid electroencephalogram interpretation service.

                Since January 1968  the Geisi-tiger Medical Center and the Pennsylvania
                State University have been conducting research on automatic computer analy-
                sis of EEGS.

                Second   Year
                $82@062
                                                                                           lst    Year
                Project #29 -   @m Literized EKG Pil-ot PrSn, @i@.  This project           $300,186
                would establish a computerized EKG transmission and analysis
                system which woul-d link 13 hospitals in a 27-county area to a computer
                center at@l@larrisbur  Hospital.  EKG's would be transmitted to the center,
                                      9
              ..processed and the interpretation transmitted to the originating hospital..
                A  formal  training  program,  conducted  by  a   cardiologist   from   the   Hershey.
                Medical  C'P-nter  is  planned  for  physicians  and  technicians   involved   in   the
                project. ithe'project resulted from a pilot program at the Harrisburg
                Hospital.!;

                Second   Year                                            Third Year
                $300   186                                               $300 186
                                                                                            'l,@t'Year
                Project   #30   Coordinated Home Care      Ptpgtain of Lancaster           $1.06,128
                L@@t                                                  Lancaster County
                     y.  The Coordinated Home Care Agency         of T
                will  arrange  quality  medical,   nursing,   social,   and   related   services   for
                patients in their homes.  The central        administrative   Coordinated    Home    Care
     0
                Agency wi'Ll:


                                                                                                   -i  Cs]))
                SUSQUETIANNA VALLEY I-,TIP                   10            R@.-I 00059 2/71...[.

                1.   Coordinate   community   resources   in   the   delivery   of   optimum   home    health
                     care services.

                2.   Act as the one sourcc-.of referral for the physicians.

                3.   Serve  as  a  center  for  coiTi,)rchc-,-nsivc-  planning,  evaluation,  and   fol-l-owup
                     of home care services.

                4.   Act   as   an.   information   service   for   physicians,   patients,,    participating
                     agencies, and the public.

                5.   Hold   periodic   joint   conferences   with   physicians,   other    professional-    or
                     allied   persons,   and   consumers   of   service   to   determine   how    effectively
                     the program is functioning.

                Second Year                                                  Third   Yei.r
                $106,367                                                     $11-5,400
                                                                                                Ist    Year
                Project #31 - Fa,7@iilv and CoTnii-ilii-tv Ileal.tli Service  I?ro-2:@,@l,      $145,630
                Lancaster General Hospit      '      The main objective of the Family
                Health   Service   Program   is   to   deliver    comprehensive    faraily-oriented,    pri-
                mary health care as part of a community hospital-.   The new system also
               "seeks  to  create  a  structure  @7hicii  casts  a  physician  as   a   health   a   vocate-
                for  his  patient.  Home  health  aides   will   be   used   to   provide   health   e   uca-
                tio-@i and develop cornnunication with the clients.            Residents of the low
                income  areas  will  serve  on   a   board   to   review   and   analyze   the   effectiveness
                of the delivery system, which includes Family Practice Residents and
                T@urse Practitioners.

                Second--Year                                                 Third    Year
                $145.$724                                                    $159 086
                                                                                                lst    Year
                Project #32 - Central P@     n@q Iva@a @.in@. -@if Eclucati.on and              $296,1.78
                Treatment,Ceriter, Al-toona Ilos-pital.   This project w 11 provide
                physical facilities  equipment, and personnel. to conduct a cancer education
                and   treatment   center.   It   wil-1   utilize   cobalt   therapy,   deep   therapy,   and
                isotopes  for  diagnosis   and   therapy   and   provide   a   firm   basis   for   continuin-
                educationlfor   physicians   in   cancer   detection   and   treatment.   It    will    a]-so
                provide a':super-voltage facility in an area geographically and economically
                separated;'from  the  nearest  similar   facility   by   more   than   50   miles,   as   well
                as   allow   tor   continuity   of   treatment,   detection   of   recurrences,   and   new
                primary tumors, while maintaining identity with the patients personal-
                physician.  The  Pegion's  Ad  Hoc  Coatriiittee,  on  Radi.i.t-.Lon   Therapy,   which   is
                studying the Regionis radiation therapy resources, has re-viewed the project
                and endorses the need for a facility in Altoona.

                Second Year                                                  Third    Year
               -$2021,075                                                    $210@050


               StTSQ'tiFITAI"ITl@ Vlil,LEY r,'-IP                         P,Lq 00059 2/71..].. (AR-1. CSD)

                                                                                          lst Year
               Project It'33 - ilaf--!.I.ton Health Cenucr.  The 11,@iiai.ltol-L Health   $147,1@75
               Center,  Inc.,  a  nonprofit  organization   directed   by   a   group of
               coiisL,,,@ie,rs and  representatives  of  providers  of  health  care, requc@st
               support to establish a  cc)mi3rc@hc--nsi.vc-  health  care  system  in a disadvantaged
               area of Harrisburg.  The neighborhood health center will be served by a
               f,q,ial..Iy heal-th    @,@nicl- inc-l-udes corpiiitinit-ly health    rec-i.-Lil.ted froi-c.
               the, nei@cbl)orliood.

               Second Year                                              Third    Year
               $Z,,57,811                                               $678,897


                                                                                                                                                               @Asst  D4-rec,'.or
                                                 f
                                                                                                                                                                            0-
                                                                                                                                                                'Dro,
                                          echn-i

                                                                                                                                                                                               F
                            r,@ n   S                                                                                                               on-1
                                                               yslers                                 CoT-,,,iun-                      Ac-'U-4-vit-'@es                                           -rv-'Lc--
                                       cn@                                                                       ic

                                                                                                                 no,  0-
                            o c r   4- n   o r               Cc)ord-'Ln@-'Vor,                        C oo--,-d4-     u        I       coor(fL@4.nt-'-Ior                                      l.o or      n   u o r'

                                 .,es cEt,-,ch
                                                                                                                                                                                                            7-;
                                                        A       n                                                  lic
                                                                                                                                                              Lield

                                                                                                                                              a
            @2 C                                                                                                                    'S  e c                                          eo,,esen
                                     'C@                        -   ---S                                     c  o,,', i @L                      list@     i  Pc,,oresen
                                    C:.         s

                                            S@
                                                    L
                                            A.,3 s t
                                            11-@'.br   Sen,                                                                    i

                                                                                                                             e.L
                                                                     Secre@va--y,                                   "",Secr  ua--y  i          @Secre'uary@

                                                                                                      i@ S c c,-- elu rlry
                                                                                                                                                                                                 Secreta@,,

                                               Mach-'@n'                                                                                                                      Z. - ":,7 C.@@
                                                       e
                                                                          @Recept
                                           op er       o--


                                                       13-

                                                                        -i-10@,4; A,',!D
                                         @-I JENI' O'@
                                  L) EP'A,                        EDUCI@

                                                     PUI',L.IC
                                    FIEAI-Tti S:7%F@VICLT, A,'AD

          1)(;t,-:            23,  3@970

         .AI?71 of.
                  Staff Pevici,7 of                      Continuation Appl.:Lc.,iLic)!-t    front tlll@
                  u s uelianna  valley  regional.  i@ledical  Pro-raiii,  5   C03   IZI@T   00059

            To:
                  AcLi.r,,- I)i.roctor
                              ,odic.il Pro-ra@ms Service

        Ttii--i-i: Chii.riti-in of- the itor,.th
                  Acting Chief, Re"ional Developnt'ent            Branc@,

                  Chief, Crants @lanag,-@-iient Branch

                  Acti-n- Cliicj', Grants Pevic-.k.7 Branch

                  The                 Valley Re-.ional ',Ieclical Pro-,rE,iii is requ,,e,-;tijic, coiitinlia-
                  tion support for its 03 operational year for core and tliiee.projetts.
                  Since Susquehanna Vallev's bud-et year does not start until April I.,
                  and tile 45-day estimate oL' expavditures is not clue. until. itij.d-Fe-bi-uary,
                  requests for use of carryover funds have not been incl.uded.in the present
                  a 1) 0 1 -'t ci t i. on. Therefore, the discussion was I.iriit:ccl to ceneral pro-,rant
                  issues and the foll-o@7i-tia     continuation request.
                                                C,

                  Conti-Tittatio-.i RecLtested                                             Amount

                  Core                                                                   $469,700
                  Project #9, SVR-'-LI? Inforniati-on Service                              45,614

                  Project  1'f'1-6,   Radi.ol6@ical   Health   Trai-niii-
                  Pro-raiLi                                                                17,501

                  Project   #17,    Colu[qbia-i!'ontour    Home    Health
                  Services                                                                    10Q

                                   T'Otal                                               $545,91.5

                  Besides the continuation request             the. Pe-,ibn has included in its rkR
                  application  a request for a developmental component, fundi.n,@, of 'our
                                 5                                             1                  C,     1.
                  ,approved but unfunded projects, a renewal- and seven ne,,,! projects.   The
                  I'@egion was supported by a fundiii-. level of @Y671.,997 during the 02 year.
                  R6coFtniendation:     Approval- of the coii-,Tqittc@d @-ii7iouit of $545,91.5 for core
                                        and three projects.


                                                          -14-

                Harold                                                            Dc@cc!iiil)ci: 23. 1-970

                The  following  staff   ric-,ii,)ers   attended   the Doce-ri,il)cr 17 iiiecL.iii,-:

                                          Miss Dona Ilouseal,, CRB
                                          Mr. Dale Robertson, RDB
                                          Mr. Georce Ilinl-lo, GMB
                                          Miss  Mary  Ascle-1-1,   CEB
                                          Mrs. Patricia @ii-il-I.ins, P'j" f'3
                                          Miss Loretta Broi,"In, PEB

                Gener@il' Comments

                                                       C,40nlS                    C, the  past year.      TMile
                Staff was pleased with this Rel@                progress    dtirin.,
                this  Region  is  only  bo('Iinning  to  deal   with   the   settil-l"   of   more   specific
                goals and objectives and is just           st.-Lrtirl- to  co]-I.c-cll-  needed  data,  its
                efforts in co@)in-- ri7ith sr-,-e of the problems identified by the site visitors
                a-,id  reviewers   last   year   were   encoura-:i.na:

                .I-.   The   evaluation   reports   by   a   physician               of the-five termj,.na
                     tirLj   coronary   care   Drojects,   which   have   been   sorely   needed,   have    been
                included    in   the   application.   The   evaluation    reports    included    with    the
                terminate   on   reports   appeared   tliorou,,h   and the    criteria    developed    should
                prove  valuable   to   the   other   non-TV-@IP   funded   units   developed   around   the
                -Region.

                2.   The SVP@,'P core staff      including   the    Coordinator    is    completely    lay.
                     While  tnis   type   of   core   can   function   with   imagination   and   work   very
                capa'ol-y, in the past this has not al.@,,,ays been the case,             Several.   kinds    of
                capabilities were missi-iia       from   the   staff   and   this   weakened   the   program.
                For   example,   the   conti-TiuinQ   education    se -i@ent  has   been   marked   by   frag-
                                                                    C)
                mentation and a lack of awareness of what has been done elsewhere.   Some
                of   this   may   be   solved   by   getting   outside   consultation   (to   be   discussed
                belo@@i),  but  Core   staff   is   also   adding   needed   expertise   in   continuipc,
                education:and    allied    health.    A    proc7ram    development    director,    syst.ems
                coordinator   and   a   research   and   evaluation   specialist   are   also   beinc,    em-
                pi.oyed.   Problems   with   the   Recional   Advisory   Group   caused   by   poor   coiii-
                MUD-ications have prompted the staff to spp-n-@-more time. personally                 advisin,@
                                                                                                               C>
                .the PAC members of SV@1.0 activities and changing the presentation                   of
                written material ooinc, before the PAG.

                3.   As   a   result   of   site   visit   recommendations   in   February    1970,    the-Region
                     has   s6u,,   t   consultation   in   plannin-.   A   group   including   @larshall-
                Raffel,   PE'!nn   State   Universit   -   Dr.   Joel   Nobel,   Emergency   Care   Research
                            i                       y@
                Insti.tute@   as   well   as   state   health   department   and    Buck-nell    University
                personnel   was   called    to-ether    toaavise    on    the    structure    and    composition
                                               LI
                of  a  proposed  Pl@abning   Co,-,unittee,   There   is   a]-so   evidence   that   the   Region
                has @oticht outside expertise in various technical areas.

                4.   The review process       is bEiii@ streLi@t@he-,ic@d.   Formal    review     procedu res
                     including a set of criteria          and a numerical                syste.,ci @,Th-i.cn -ives


                                                    15-

              Harold Marcul.j-es  II.D.
                                                                      Deceiitl)cr .23, 1970

              all- ric@i@ projects a priority number, have. been devised for Lli e rAG.
              Plaiis are underlay to develop a sii,@il l@ir -systei,,i for the CoLiticii-s and
              Area Con,-riiittees.

              5.   The relationship bcti7con the INIP Barrel the cr@Liitee'aceiicy, the PoliLlsyl-
                  vania Medical Society, has improved slightly. 'Thc, Medical Society
              still considers the PL@IP as a branch of their orcat-Li-/,ati.oti ivcl ma:Lnt@l.,-L.ns
                                                                  c-,
              a degree of control consistent with this concepts        Discussions have been
              held with the       and @r@i.ntee acency concerit-@.ii- the              of a
                                       C,        0
              nonprofit corporation, but at the present its estEiblj-sl-tilient seems a lonc,
              way o.L'f,

              Conclusion:   Approval of   the committed amount of $545    91.5 is reconmiended
                            for the Pegion's third operational year.

                                                            Dona E. lIoLiseal
                                                             Public Health  @dv:i.sor
                                                             6ranLs Revic@q Braiich

              Action by Director

              Initials

              Date


                                                                                         REVISED

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

                 SUSQUEHANNA   VALLEY   REGIONAL    MEDICAL    PROGRAM      RM  00059  2/71.1   (AR-1   CSD)
                 3806  Market  Street,   P.O.   Box   541                   January 1971 Review Committee
                 Camp Hill, Pennsylvania  17011

                 Program Coordinator:  Richard B. McKenzie

                                           REQUEST (Direct Costs Only)

                                      04                    05                    06
                 Purpose        4/l/71-3/30/72        4/l/72-3/30/73        4/l/73-3/30/74       All   Years
                 Continuation
                   Commitment          $545,915                                                  $545,915
                 Core                 (469,700)                                                  (469,700)
                 3    Projects        (76,215)                                                      (76,215)
                 Renewal
                   Components         $29,425                  $31,551                              $60,976
                 1 Project            (29,425)                (31,551)                              (60,976)
                 Additional
                   Pro_iects         $1,503,780         $1,482,065           $11,592,377       $4,578,222
                 4    Previously
                 Approved   Projs.    (184,044)              (158,387)           (98,534)        (440,965)
                 7   New    Projects(1,319,736)         (lp323,678)          (1,493p843)       (4,137,257)
                 Developmental
                   Component          $54,596                  $54,596             $54,596       $163,788
                   Total             $2pl33,716         $lp568,212           $lp646,973        $5p348,901

                 Staff    Action
                   Commitment          $545,915
                 COL=I t tee
                   Action
                   Required          $1,587,801         $lp568,212           $1,646$0973       $4,802,986
                 #26 Deleted       -     82,200          -      68,050         -    71,548      -   221,798
                 REVISED    TOTAL     1,505,601              1,500,162           1,575,425       4,581,,188

                                                   FUNDING     HISTORY

                                                   Planning      Stage

                 Grant    Year                 Period                             Funded (ti.c.o.)

                     01                        6/l/67 - 5/31/68                         $251,530
                     n2                        6/1,/68  - 1/31/69                       $250,056


                                            - 2                   RM 00059 2/71.1 (AR-1 CSD
          SUSQUEHANNA VALLEY RMP

                                    Operatiotal Pro& a@m
                                                                                    Future
          Grant Year    Period           Cou@cii',,'approved  Funded d.c.o.     Commitment

          01         4/l/69-3/31/70           $698,052           $532,444
          02                                  666,495             671,997
          03         4/l/71-3/31/72           695,333                            $545,915
          04         4/l/72-3/31/73           650,075                             497 644
          05         4/l/73-3/31/74           483,294

          1/ Represents 75%  funding of projects

          2/ Includes $124,390 in carryover

          Geography and Demography
          This Region consists of 38 counties in the central corridor of Pennsylvania
          bordering on Maryland in the south and New York in the north and separated
          from the Western Pennsylvania and Greater Delaware Valley RMPs  by  moun-.
          tainous terrain. The total population of the Region  is  projected  to  be
          2,323,751 (1970 Census).  Much of this population is centered around the
                                                      ains large rural and forest
          throe urban areas, but the Region also cont
          areas with low population concentrations  and  underdeveloped  facilities.

          The Milton S. Hershey Medical Center of the  Pennsylvania  State  University
          was established in 1963.  The first class of 40 medical students was
          enrolled in 1967.  The Region also has 55 hospitals.  It is served by 1,776
          M.D.'s and 218 D.O.'s. There  are  8,909  active  nurses.

          Regional Development
          in 1966 the Susquehanna Valley Committee on Heart Disease, Cancer    and
          Stroke,presided over by the President of the Pennsylvania Medical    Society
          (PMS), met to plan an RMP for the central  Pennsylvania  Region.  The  first
          planning grant, submitted by the PMS, was approved in  June  1967  pending
          clarification of the role of the new medical school,  the  state  health
          department and administrative and staffing patterns,  and  assurance  of
          allied health involvement. The Executive Director  of  the  PMS,  Mr.  McKenzie,
          was appointed Coordinator in August 1967.
          During the second planning year, the Region encountered  a  number  of  problems
          with the completely lay Core staff and the grantee agency, which considered
          ,the RMP Core staff as another branch of the PMS. There  was  strong  senti-
          ment among Core staff regarding the degree of control the PMS maintained
          over routine office matters and the relatively  low  salary  scale.  Several
          staff members resigned as a result.  There was also some confusion about
          the relationship between the RAG and the  PMS  Board.  A  management  consulting
          firm was retained to study the entire program  and  recommended  certain
          staffing changes, some of which, have gone  into  effect.


                SUSQUEHANNA VALLEY RMP            - 3 -            RM 00059 2/71.1 (AR-1  CSD)

                The Region began work on its initial operational  application  which  would
                contain five coronary care unit proposals and a request  to  train  coronary
                care unit nurses. A site visit was held  in  December  1968.  The  visitors
                recommended operational status to convince the local  physicians  that  RMP
                would actually help them improve patient care,  While  leadership  from  the
                RAG was slow in developing, the Region had an impressive  amount  of  physi-
                cian involvement at the grass roots level through the Area Committee
                structure. In fact, the bywords for the SVRMP in  these  early  days  became
                ligrass roots involvement" and "coronary care."  Council approved the
                Region's request with the understanding that the CCU  projects  were  pilot
                projects for the Region with evaluation of the  results  before  additional
                projects are funded and with the stipulation that 50 percent of the equip-
                ment funds be made available for  physician  training.  Shortly  afterwards
                three more proposals were submitted, approved and funded.  They were a
                stroke care unit,, a home health care project and a regional medical infor-
                mation service.

                New projects submitted during the second year, however, continued to
                emphasize coronary care.  Reviewers found them, on the whole, to be a
                disparate group of projects, attacking the problems of coronary care in
                an isolated fashion. They disapproved the  projects  and  recommended  that
                the Region establish an overa   p an invo  ing greater coordination, coop-
                eration and consolidation. Core and the  coronary  care  training  proposal
                at the Geisinger Medical Center were renewed.

                A site visit held in February 1970 reviewed the overall progress of the
                Region and four new projects.  They concluded that the Region should:
                1) consider broadening the base of its grantee agency to  insure  that  all
                  appropriate groups feel represented. A  change  to  a  nonprofit  corpora-
                tion was seen as a possible solution4,

                2) utilize consultants from both inside and outside the  Region  to  improve
                  efforts in data gathering and epidemiology;

                3) appoint a liaison member of the Hershey Medical  School  fatuity  part-time
                  to the RMP staff to both improve relations with  the  new  medical  school
                and involve physicians on Core staff;

                4) while continuing to encourage grass roots involvement, devote more
                  attention to developing a regional  decision-making  process  which  selects
                projects on the basis of a regional plan, rather than just  on  a  community's
                needs.

                Projects funded during this past year include:

                1) an extension of the original five CCU's with carryover funds for an
                  additional year,
                2) the CCU nurse training project,
                3) the second year of the SVPIQ library information service,


          SUSQUEHANNA VALLEY RMP           4              RM 00059 2/71.1 (AR-1 CSD)

          4) project #7, the Stroke Care Unit and #8, the Home Health Service, out
            of carryover, and
          5) projects #16, the Radiological Health Training Program and #17, Columbia-
            Montour Home Health Services. Projects #18, a Rheumatic  Fever  Control
          Program, and #19, a CPR project were approved but unfunded.
          The Region submitted one further application during its second operational
          year.  Only the Znterostomal Training Program and the CPR and CVA Transport
          Vehicle, York, were approved.  Council requested additional information on
          the CCU Nurse Training Program at the Altoona Hospital before it could
          be approved (this information has been received and will be forwarded to
          the February 1971 Council).  The remaining four projects, including an
          emphysema program, a stroke rehabilitation and training program, a cart-
          ridge viewing system pilot project and a supervisory CCU nurse training
          program, were turned down.
          The Region's present level of funding for its second operational year is
          $671,997.
          Note:  A site visit was not planned for this Region; one had been held
                during the past year; and the Region informed RMPS only a week
          before the review deadline of its decision to include a request for a
          developmental component in its AR application.
                                                                                         t7

          The SVRMP frankly admits that its centralized program planning to date
          represents a disconcerted effort and that the Region does not have a
          specific plan which details specific objectives that result in specific
          applications.  Interest  in the past has happened to center on heart dis-
          ease and coronary units.
          At its fall 1970 meeting, the RAG established formal goals which set  the
          stage for development of primary goals and specific objectives.
          The primary goal is to "improve the quality of patient care working  with
          and through the providers of health care as they function in the existing
          health care system; and by influencing the present arrangements for health
          services and by concentrating maximum effort on those activities which
          have the highest local, regional and national priorities."
          The primary goal is approached through specific goals in three basic areas
          organization, strategy and program.

                     nal Structure and Processes
          The SVRMP has organized a 30-member RAG, with representatives from each.of
          the four Areas and from various health organizations and institutions  of
          the Region.  The RAG has Executive, By-Laws and Nominating Committees and


                 SUSQUEHANNA VALL17Y RMP                          RM 00059 2/71.1  (AR-  Cc,D)

                 is in the process of selecting Planning'and Evaluation Committees.  The
                 RMP has divided the Region into four Areas, each of  which  is  served  by  a
                 Committee ranging from 60 to 135 members.  Each Committee has Appointed
                 subcommittees to serve as study groups and an Executive Committee.  To
                 provide review and planning at the  regional  level  in  specific  functions,
                 Councils (formerly Task Forces) have  been  established  in  the  categorical
                 areas, as well as in Facilities and Services and Continuing Education.
                 Each Council also sets goals and objectives in its respective interest.

                 The review procedure consists of the following steps:
                 1.  Consideration by the volunteer  Area  Committees  through  their  Executive
                     Committee and specialized subcommittees.
                 2.  Consideration by the members of categorical councils who supply spec-
                     ialized professional technical review on a regional scale.
                 3.  Consideration of the relevance  of the proposal to regional goals and
                     objectives by the RAG.
                 At each step, staff members provide administrative assistance.  Formal
                 review procedures, including a set of criteria and a numerical ranking-
                 system,, which assigns all new projects a priority number, have been devised
                 for the RAG.  Plans are underway to develop a similar system for the
                 Councils and Area Committees.

                 PRESENT APPLICATION:
                 Developmental Component                                            $54,596
                 Activities initiated t',qrough developmental  component  funding  "will  seek
                 to improve the quality of patient care by working with and through the
                 providers of health care as they function in  the  existing  health  care  sys-
                 tem, by influencing the present arrangements  for  health  care  services,  And
                 by concentrating maximum effort on these  activities  which  have  the  highest
                 local, regional and national priorities."  An  example  might  be  an  explora-
                 tion of appropriate methods and means  for  developing  improved  patient  care
                 techniques and systems in kidney disease prevention and control.
                 The review mechanism described under organizational structure and processes
                 above will apply to the developmental component as well.
                          $54*596                                   $54,596

                 Continuation Component
                 These components have been reviewed by staff.  Their program and funding
                 recommendations are in a supplementary memo.


           SUSQUEHANNA VALLEY RMP             6             RM 00059 2/71.1 (AR-1 CSD)

           Core                                                             $469,700
           The SVRMP Core staff is completely lay. Its  Coordinator  was  the  former
           Executive Director of the Pennsylvania Medical Society,  which  serves  as
           the grantee agency.  An organizational chart for Core staff is attached to
           the summary.  The functions can be briefly defined as follows:
           l.-  Technica  Services - plans, establishes and directs the technical ser-
               vices for:  applications development, grants management, research and
           evaluation services, development and operation of library activities and
           general office management.
           2. Communications - directs the  production  of  communications  material
               and provides liaison with the news media.
           3.  Program D             provides staff services to committee.$, councils
               and planning groups, coordinates educational activities and programs,
           assists with the establishment of regional goals, objectives and priorities,
           and provides personnel recruitment services  for  staffing.  In  addition,
           Field Services are included in this branch.  A  field  representative  is
           assigned to each of the four Areas to provide  regional  coordination  and
           staff services to all volunteer committees and groups in the Region.
           With the Assistance of the field representatives, various Area Committees
           or subcommittees have developed standards for coronary care, sponsored a
           cancer detection clinic survey and conducted a cancer incidence and mor-
           tality survey.
           The SVRMP Core budget last year included funds for "progra7m related acti-
           vities." These are funds in the magnitude of  $50,000,  which  the  Region
           used for various purposes, such as to conduct pilot  studies  of  various
           proposed project activities, hold conferences, and supply educational mater-
           ials to health professionals.  Types of activities for which these funds
           ..will be used next year include a conference for regional directors of
           coronary care units, an audio-tape cassette  scientific  program  service,
           data collection and a consultation program for tumor  clinics  and  tumor
           registries.
           The budget for 1971-72 includes funds for 25 full-time  positions,  22  of
           which have been filled.  The new positions would be a Systems Coordinator,
           Nursing Specialist and receptionist.
           Continuation support in the amount of $76,215 is also requested for three
           projects:

           #9   SVRMP Information Service
           #16   Radiological Health Training Program
           #17   Columbia-Montour Home Health Services

           Renewal Projects
                                                                              3rd Year
           Project #6R - Coronary Care Nurses' Training Program, Geising@r  $29,425
           Medical Cpnter,  The Geisinger Medical Center will conduct


               SUSQUEHANNA VALLEY RMP           - 7 -           RM 00059 2/71.1 (AR-1 CSD)

               four, four-week coronary care courses per  year.  Each  class  will  admit
               ten trainees, who are principally  recent  diploma  graduate  nurses.  The
               curriculum includes lectures, laboratory  work,  and  clinical  experience
               in special nursing techniques for the cardiac patient.
               Community hospitals throughout the Susquehanna Valley Region,,  as  well  as
               border areas, may use this training program to  staff  their  coronary  care
               units with qualified nurses.
               This project was submitted with the Region's initial operational applica-
               tion and applied for and received one-year renewal  support  last  year.
               Since its inception, it has trained 42 nurses.

               Fourth Year
               $31,551

               Approved but Unfunded Projects
               These projects have been previously approved by Council, but due to nation-
               al funding constraints, have not been funded.  Committee and Council con-
               siderdtions of these projects is needed in determining an overall funding
               level for the Region for the next year and not for approval of the
               activities.
                                                                                 lst  Year
               Project #18 - Rheumatic Fever Control Program.  This project      $75,217
               will impress upon physicians and the public the necessity for
               throat cultures in  diagnosing  streptococcal  infections.  Hospitals  and
               physicians in 16 of the Region's 27 counties will  receive  free  throat
               culture kits. The kits will be used on people  between  the  ages  of  two
               and forty-five who have upper respiratory infection or  a  sore  throat.
               The participating hospitals will interpret the  cultures  and  send  reports
               to the attending physicians.  The physicians will follow-up with appropri-
               ate treatment.
               Although this project involves the demonstration of  patient  care,  the
               aspects of continuing education are also present.
               In addition, the promotional efforts of the  Heart  Association,  who  will
               participate in the program, will increase the  public's  awareness  of  the
               value of the procedure.

               Second Year
               $641,417
                                                                                 18t  Year
               Project #19 - Cardiopulmonary Resuscitation Training.             $16,693
               Sponsored by the Heart Association, the  purpose  of  this  project
               is to establish an emergency cardiopulmonary  resuscitation  team  in  every
               hospital in the Susquehanna Valley Region.


         SUSQUEHANNA VALLEY RMP            - 8 -             RM 00059 2/71.1 (.kR-1 CSD)

         First, the Instructor's Training  Center at the  Harrisburg  Hospital  @@ill
         be expanded to include a special  training course in emergency cardic-
         pulmonary resuscitation. Each year, teams from 18  hospitals  will  ;@-ompi-ete
         this course. Then, using  the  organizational  framework  of  the  Pennsvlvania
         Heart Association and its chapters, these  newly trained teams will     train
         other hospital teams.
         The wide geographical distribution of emergency  teams  will  be  ideal  for
         training local ambulance crews, rescue squads,  and  other  health  personnel
         throughout the Region.
         Second  Year                                       Third Year
         $15,481                                            $16,066
                                                                            lst  Year
         Project #21 - Enterostomal Therapy Trainin&.  The Harrisburg       $9,934
         Hospital will conduct  twelve,  four-week  courses  in  enterostomal
         therapy per year.  One student will be trained in each course.
         Training will include bedside instruction  and  practice,  medical  lectures,
         technical lectures, and conferences.
         The graduate therapists will be able to provide  patients  with  stomal  care
         and management, therebyfreeing nurses  and  physicians  for  other  work.  In
         addition, the therapists will  instruct  patients  in  self-care  and  teach
         allied health personnel the principles of stomal management.
         Second  Year                                       Third Year
         $100439                                            $10,920
                                                                            lst  Year
         Project'#26 - Cardiopulmonary and CVA Transport    Vehicle,        $82,200,
         York Hospital. This pilot  project  will  determine  the  effect  of
         a specially equipped and staffed transport  vehicle  in  reducing  the  compli-
         cations and deaths associated with heart attack and stroke.
         The custom-designed van which will contain  a  resuscitation  unit,  a  respir-
         atori a two-way radio, drug storage facilities,  and  other  emergency  e(iuip-
         ment, will be on call 24 hours a day, @taffed  by  a  physician  or  coronary
         care nurse, orderly, and driver.
         Second  Year                                       Third Year
         $6810050                                           $71,548
         DELETED  PER REQUEST FROM REGION, SEE LETTER OF  JANUARY  4,  197]f  ATTACHED.

         New Proiects
                                                                            lst  Year
         Project  #27   Nurse Dial Access,  Robert Packer Hospital,         $29,969
         Sayre, Pe nsylvania. Dial  Access  for  Nurses  will  cover  Central
         New York State and the entire state of Pennsylvania.  It is a special
         telephone information system for RN's,, LPN'S,  student  nurses,  and  others
         particularly those practicing in an isolated setting  --  who  do  not  have the
         resources available for their continuing education.  Available on an around-


               SUSQUEHANNA VALLEY RMP             - 9 -            RM 00059 2/71.1 (AR-1 CSD)

               the-clock basis from any telephone, it provides the caller with free$
               five-to-six minute taped messages on a variety of subjects, such as
               (1) nursing care for specific conditions, (2) new procedures and equipment,
               (3)  availability  of  community  resources,  (4)  nursing  care  in  emergency
               situations, and (5) legal aspects of nursing situations.

               The Central New York RMP  is  presently  funding  a  Physician  Dial  Access  pro-
               gram out of  the Sayre Hospital.  SVRMP  Core  funds  are  being  used  to  extend
               coverage of  the physician program to their Region.

               Second Year                                          Third Year
               $290453                                              $30,224
                                                                                    lst   Year
               Project #28 - Automated Computer-Assisted Analysis of the            $294,470
               EEG, Pennsylvania State University.  Four participating hospitals,
               located in three areas  of  the  Region,  will  send  computerized  EEG  signals
               to Penn State's Hybrid Computer Laboratory.  The information will be
               interpreted by computer at  Penn  State  and  the  diagnosis  returned  to  the
               sending hospitals.  Each  computer  diagnosis  will  be  compared  to  the  phy-
               sician's final diagnosis.  The  purpose  of  this  project  is  to  install  and
               further develop this computerized  EEG  system,  and  at  the  same  time,  deter-
               mine the feasibility  of  providing  all  hospitals  throughout  the  Region  with
               rapid and valid electroencephalogram interpretation service.

               Since January 1968, the Geisinger Medical Center and the Pennsylvania
               State University have been conducting research on automatic computer analy-
               sis of EEGS.

               Second Year
               $821)062
                                                                                    lst   Year
               Project #29 - Computerized EKG Pilot Program.  This project          $300,186
               would establish a computerized EKG transmission and analysis
               system which would link 13 hospitals in a 27-county area to a computer
               center at Harrisburg Hospital.  EKG's would be transmitted to the center,
               processed and the interpretation transmitted to the originating hospital.
               A formal training  program,  conducted  by  a  cardiologist  from  the  Hershey
               Medical Center is  planned  for  physicians  and  technicians  involved  in  the
               project.  The project resulted from a pilot program at the Harrisburg
               Hospital.

               Second Year                                         Third Year
               $30010186                                           $300,186
                                                                                    lst   Year
               Project #30 - Coordinated Home Care Pto&ram of Lancaster             $106,12T'
               County.  The Coordinated Home Care Agency of Lancaster County
               will Arrange  quality  medical,  nursing,  social,  and  related  services  for
               patients  in  their  homes.  The  central  administrative  Coordinated  Home  Care
               Agency will:


           SUSQUEHANNA VALLEY RMP;           10 -       RM 00059 2/71.1 CAR-1 CSD)

           1. Coordinate community resources in the delivery of optimum home health
             care services.
           2. Act as the one source.of referral for the physicians.
           3. Serve as a center for comprehensive planning, evaluation, and followup
             of home care services.
           4. Act as an information service for physicians, patients, participating
             agencies, and the public.
           5. Hold periodic joint conferences with physicians, other professional or
             allied persons, and consumers of service to determine how effectively
             the program is functioning.
           Second Year                                    Third Year
           $106$367                                       $115,400
                                                                         lst Year
           Project #31 - Family and Community Health Service Program,    $145,630.
           Lancaster General Hospital.  The main objective of the Family
           Health Service Program is to deliver comprehensive family-oriented, pri-
                                          mmunity hospital.  The new system also
           mary health care as part of a co
                                cture which casts a physician as a health advocate
           seeks to create a stru
           for his patient.  Home health aides will be used to provide health educa-
           tion and develop communication with the clients.  Residents of the low
           income areas will serve on a board to review and.analyze the effectiveness
           of the delivery system, which includes Family Practice Residents and
           Nurse Practitioners.
           Second Year                                    Thir   ear
           $145,724                                       $159,086
                                                                         lst Year
           Project #32 - Centra  Pennsylvania Cancer Education and       $296,178
                     enter. Altoona Hospital.  This project will provide
                                              personnel to conduct a cancer education
           and treatment center.  t will ut  ize cobalt therapy, deep therapy, and
           isotopes for diagnosis and therapy and provide a firm basis for continuing
           education for physicians in cancer detection and treatment.  It will also
           provide a super-voltage facility in an area geographically and economically
           separated from the neatest similar facility by more than 50 miles, as well
           as allow for continuity of treatment, detection of recurrences, and new
           primary tumors, while maintaining identity with the patient's personal
           physician.  The Region's Ad Hoc Committee on Radiation Therapy, which is
           studying the Region's radiation therapy resources, has reviewed the project
           and endorses the need for a facility in A toona.
           Second Year                                    Third Year
           $202 075                                        $210,050


              SUSQUEHANNA VALLEY RMP                            RM 00059 2/71.1 (AR-1 CSD)

                                                                             lst Year
              Project #33 - Hamilton Health Center. The  Hamilton  Health    $147,175
              Center, Inc., a nonprofit organization directed by a  group of
              consumers and representatives of providers of health  care, request
              support to establish a comprehensive health care system  in a disadvantaged
              area of Harrisburg.  The neighborhood health center will be served by a
              family health team, which includes community health aides recruited from
              the neighborhood.

              Second Year                                     Third  Year
              $457,811                                        $678,897

                                                               GRB/RMPS  12/28/70


                                                                           I             IRECTOR

                                                                                                                               rector
                          Asst   Director
                                 for                                                                                           r
                                                                                                                     -@oFrem De-Vel@
                          Technical Serv

                                                                                                  Education,,il
               Graits                                                                                                                       Service
                @a-na         -1                  ,s                     Corn--nunic              Activities
                                         !Syster
                                             ordinq-tor                      --rdinator
                Coordinator              ico                             Coo                      Coordinator

                    ]Research
    I-ol-'@c ---IC, i o,@ I & ',--Val Admin                                CoirLnunic          lYurs--',n          Field          ifiele-
                                                                                                         9
           -@sL,    IS-oecialist      ISpecialist                         Spec4alist,              ec-,al-s        Represpn                           2e-g e                   Sf
    ,ec- a'                                                                                    LP-

                              S4-afl
                               k,
                                s t
                              Libr   Serv

                                                secretary                                 Secretary       Secretary

                                                                           Secretary                                                                etp-ry

                                                                                                              S-,AFF' C,,-,GAPII7-A:rION
                              Machine               @ec
                              @erator
                                                                                            S'@l S t)!j q &N!,N tA VA@-  REGICNAL


                                                                             3-

                                                                     (.)F

                                                                         F,U       t IfAI .'I I  I  @;[-r

                                         23,  1.970

              Ailit oj.
                          St@@ff  pev@tek4  of  @Nori-Coripc-,tin(,  Cc,ntintiation Application  from  the
                                                                           LI
              S!I;jtci:                                                               1  Pro,-ram,  5  G03  R@l  00059
                                              Valley  Regional @ledica

                          Act-in@  Director
                          I.,OF,ioll@ll  @l(,(Iicll.  Pro(,rims  Service

             Iiii-ti:     C@ti;iir;iliii  of  the  iloiltli

                          A(-t iiii,

                          C,il i f,

                          A c, t.

                          l@tic,                      Va'l.]-ey  Rc!@.-i.onal 1,1(-clical,  Program  j,,;  re(ILte@sti.ii,,y  co,-iL!iiLi.-,-
                          tioii  sui)l)ort  for  its  03  onc-ratio[-ial  year  for  CO,-E'  --Ind  three  projects.
                          SITICC'  SI-ISC[Lieliann.a Valley's  bud-et  year  does  not  start  until Apri-I.  2,  1-971,
                          and     tti@-     4')-day     estimate     of     exponditur(--s     is     not     clue     until     Tlii.d-l-'C-'.bru@iry,
                          reqttt-,,3ts  for  use  of  carryover  funds  have  not  been  included  in  the  present
                          application.            Therefore,       the       discussion       was       limited        to        general        program
                          issues  and  tlte  followinc,  continuation  request.

                          Continitatiion Requested-                                                                         Amount

                          Cor@.                                                                                           $469,700

                          Project  #9,  SVRILIIII  Information  Service                                                    45,61,4

                          Project  #16,  Rridi.ol-ogi.cal                              Tr@Lin@iii,,
                                                                                                  LI
                          Pro@;rarii                                                                                       3.7,501

                          Project       #17,     Col.iiifil-)ia-Mont@ir      Itome      fic@,.iltli
                          Services                                                                                            010-

                                                Total                                                                    $545,91.5

                          Besides  the  continuation  requ,?st,  the  Region  his  incIL.ICIC@(I  in  it  AR
                          application,  a  request  for  a  developmental  component,  fi-in(Iiii@!  of  four
                          approved  but  unfunded  projects,  a  renewal.  and  seven  ne.,.,i projects.                                         I'h  e
                          Region @..,as  supported  by  a  fundiii-  le-zel  of  $673.,997  during  tlLc-,  02  year.
                                            L i on:     Approval,      of      the      committed      amount      of      $545,915      for       core
                                                        and  three  projects.


                                                 -14-

          11@irc)ld @tirgLiliCS,                                       December 23, 1.970

          I'lic, following staff nic@nil)crs attended the Dc,.cc-iiil)(tr 1.7

                                  Miss I)on,,i
                                  My. Dtle Pol)(-!rL.,;oii, RI)I@
                                  Mr. (;c-,orgc- lliiiklc!, Ct4ill
                                  Mi-ss Mary Asdoll, Cf,:13
                                  Mrs. Patrici-a '@lul.l.in@;, PI',']'j
                                  Miss Loretta Brown, PEB

          General Comments
          Staff was pleased with this Region's progress           ditrina the past year.      I.,Ih i 1 e
          this Region is only beginning to deal with the setti.n- of more specific
          goals and objectives and is just starting to collect needed data, its
          efforts in copin,- with some of the problems identified by the site visitors
          and reviewers last year were encouraging
                                                      C>

          1.   The  evaluation  reports  by  a  physician   consultant   of   the   five   termi.na-
               ting  coronary  care  projects,  which  have  been  sorely  nc,,c@dcd,  liavc-   been
          included in the application.        The  evaluation  reports  included  wi.tli   tiir2
          termination reports appeared tliorou-Ii and the criteria developed should
          prove valuable to the other noTi-IOIP funded units developed around the
         .Region.
          2.   The SVI@@IP core staff including the Coordi-nitor is completely lay.
               UThile this type of core can function with imagination and work very
          capably, in the past this has not all-'      ays been the case.      Severil.   kinds   of
          capabilities were nissi@ng from the staff and this weakened the program.
          For  e-.<ample,  the  continuing  education  seament  has   been   marked   by   frag-
          nii--ntation'and a lack of awareness of what has been done elsewhere.              Some
          of  this  may  be  solved  by  getting   outside   consultation   (to   be   discussed
          beloi.i), but Core staff is also adding needed expertise in continuing
          education and allied health.        A pro-ram develop-.iont director, SySt -7
                                                                                          E- ?.S
          coordinator and a research and evaluation specialist arc! also bc,3n@,
          ployed.    Problems With the  Regional  Advisory  GroLip  c@-,usc@d  by  poor  cc),I;-
          mtinic,iti.ons have prc)iiii)Lc2d the stiff to spon@ n,,oi-c times l@c.-r@;()ri:illy i(i v i1 ri,,
          thc, RAG riici!i',)c@rs of SV@,11) activities ai(I changing the prE@@;c,iiL@iL@loi-i of
          written rirteriil going before the PAC,.
          3.   As a  result of site visit recoii,:icnditioiis i.ii February 1970, the I-'Iegj..on
               has S6LIgIlt consultation in planning.        A group including @lirshal.1-
          Raffel-,  P6nii  State  University;  Dr.   Joel   Nobel,   Emergency   Care   Research
          Ingti,tLltC; as well as state health department and Bucknell Univc-.rsitv
          personnel  was  callc@d  to-ethcr  to  advi.se  on  the  structure  and  coinpo-ri   L'ion
                                       0
          of i proposed PI.,inni-og,Coiiunittec,,.   There  is  also  evidence   that   the   Region
          has Sought Otitsidc@ exp&rtise in various technical areas.
          4.   The review process     is being streiictliened.     Form@il. review procedures
               iticludi.ii,, a set of criteria and i numerical ranking --ysL(@r;i


                                                15-

              Harold Margulies, M.D.                             Deconiber 23,, 1970

              all new projects a priority number, have been devised for the RAC;.
              Plans are underway to develop a similar system for the Councils and
              Area Committees.

              5.  The relationship between the RMP and the grantee aaency,  the  Pennsyl
                     ia Medical Society, has improved slightly. 'The Medical Society
                  van
              st-ill considers the PMP as a branch of their organization and maintains
              a degree of control consistent with this concept. Discussions  have  I)Cen
              hold with the PI@IP and grantee agency conccrii,in,,,, tlic@       of a
              nonprofit corporation, but at the present iL,@, est@..])I-i@,hrncinti se(,iii@,, a long
              wily off,

              Conclusion: Approvil.. of the comiiii.tL(@d amount of $545,91-5 is rccoi:Tr!@ri(IC@d
                           for the Regi.on's third operational- year.

                                                        Dona E. Ilouseal
                                                        Public Health Advisor
                                                        Grants Review Branch,

              Act-'Lon by Director

              Initials

              Date


                                      -16-

                                                          January 4, 1971

       I,lr. Dale Robertson
       Programs Assistance Branch
       Regional Medical Programs Service
       Health Services and lvfental Health Administration
       Parklavn Building, Room 15
       5600 Fishers Lane
       Rockville, Maryland   20852

       Dear Dale:
            This is to officially inform you that we are withdrawing Pro4ect
       No. 26, Cardio-Pulmonary and CVA Transport Vehicle.  The  reasons  for  this
       Withdrawal is explained in the letter from the applicant, Robert L.    -vvans
       i,i.D. which is enclosed with this letter. We are pleased  with  the  honest
       e@@ation offered 'ov this institution and, therefore, must concur with
       the request.
            Although Project l@o. 26 has already been approved by the ,ational
                                                                             equest
       Advisory Council, it should no longer be considered a part of our r
       for funding in our Annual @'Lpplication submitted @lovember 1, 1970.

                                                Sincerely yours,

                                                Richard
                                                Director

       RBI,4: j z

       Enclosure

       CC.  tUas Dona Houses,
            Yx. George Hinkle
            ,Mr. Clyde Couchman


               C)*:'       EL)LIC-Al@10i@,l                          DEC   0

        'f  L.,  LVAN"-,.
                                                                           c@(

                  NI.D.--lt4TEi@@@'AL  N,EDICINE
   'f  H  C).,A tl.  @IAFZT. Ff%ACTICF-'
   DAVID  J.  JONES,  tl.[).--COtMMUiN[TY  MF--L)ICINF7

                                                    y i"l
        December 241,1.970

        Mr. Richard B. McKenzie
        Director, Susquehanna Valley
          Regi-6nal Medical Program
        1104 Fern%.zood Avenue
        Camp Fill, Pennsylvania   17011

        Dear Mr. McKenzi@:
        in reviewing our application for."A Cardio-Pulmonary and CVA
        Treatment Vehicle", it is our understanding that this applica-
        tion has been approved, and is awaiting  funding  through  the
        a.ppropriations bill recently passed by Congress.

        The original application for this project was  made  over  two
        and one half years ago, when it was designed as a feasibility
        study directed at special services to patients suffering from
        coronary and cerebro-vascular  problems.  in  the  intervening
        time, it has been shown repeatedly, both in the United States,
       .And abroad, that this service has questionable   .ustification.
        It is probably neither financially or professionally efficient,
        as first thought, nor a good use of over $200,000.00.
        Although we realiz e that this project has been  approved  4or
        funding, and will be funded, we should like to withdra,.7  our
        application. We si-@ply do not feel that the  project  is,  at
        this time, a justifiable use of tax  dollars  with  reasonable
        chance of productivity for our people.
        Vie hope you will understand and agree with our decision, and t@a-L,
        we may work together in the future,on a more productive
        With viaria best wishes for the Holiday season,

        ,Siricer,el  yours,

                   Evans, M. D.
         ice President - Medical Affairs

        RLP,:njh

                     tell  R-rc)@7nr-,l 1 (-r.   i,4 -   D. Secrc,,tcit: oT


                                                                          (A    P-rivileaod    Communication

                                         S@i2,IARY OF PFVIEVI AND CONCLUSION OF
                                             JANU@,RY I()'71.

                                  SUSQIJEHANF@'A VALI,[--,Y RFGIONAL l@IEDICAL PROGRAM
                                                 Rl,f 59 (AR-1-CSD) 2/71

                            FOR CONSIDERATIOIT BY FEBRUARY 1971. ADVISORY COUNCIL

               RECOI@@@'7ND,@,,TTO' Corn--,i,-ttee deferred their                     on.  all  but  the
                                    renewal  Pro  ect  #6R  (which   was   approved   as   requested)   to
               Council with the     suggestion  that  a  site  visit  be   scheduled   to   the   Ro,-ion.
               before   the   Council   meeting,   (Subsequently,   the   Director,   rd,!PS    determined
               that  a  site  visit  would  not  be  scheduled  at   this   tini6).   The   Region   has
               requested new fundit@ in the amount of $4,581,188 for renewal of one
               project, four previously approved but unfunded projects, seven new projects
               and a developmental component for a tliree-y--er period.

                     The amount recorr@r..i@nded for project          i@s:  01 - $29,1425 and 02'
               $311551.

                             The Susquehanna Valley 1)@",!P's application @,7as.dif'Licult to evaluate
               because  the  Region  is  undergoing  several  rn@ijor  changes  and   the   Cor,,Iml@ttee
               had  no  member  with  on--site  knowledge  of  tne  Po,,ion..  '  (The  member  who   had
               chaired  last  year's  site  v-Ls4.t  times  since  left  the   Con,-,iittec).   Several
               problems  were  identified  by  the  site   visitors   list   year,   and.   the   Re@ion
               is takiii  stops to alleviate tl@iciri.

                     T'ne Core staff, incltidin- the Coordinator, is          completely lay and
                                                   0
               without combined siQni.ficant experience in the  ealt  p anninz area,.
               Although lay staff ca.Li function with                       and  worl@  very  capably,   the
               .,Sus uehanna Valley F@,2SLEE needs additional capabilities in order to operate
               in this inanner..    The  low  salary  scale  which  has  been  set  by   the   grantees,
               aaency, the Pennsylv@-@,@-i-i.a lledic,--'L Soci.c@t-'y, has  been  partially  responsible
               for the difficult4c-s in aettin- largely qualified personnel.               Sever,-,I   kinds
               of capabilities, particularly in continuing education, allied healt@i,
               and bval.uatioi. vere Iclickin@ and this @,,c,,okezip-cl the program,       Durin(-   the
               past year the Region has hired  @-i  cort-.Lnuin---  oduc@it-i.on  director,  a  1)@-ograii
               development director, a systc-,,ts coordinator and a research and                evaluation
               specialist.   The   Region   has   sought   consultation   expertise   in   planning    and
               evaluation,  as  well  as   in   various   technical   areas.   A   -roup   of   planning
               6xperts from Pennsylvania State University, Bucl@nell University, and
               the State Ftealth Department, amona others,          has   been   called   together   to
               advise  on  the   structure   and   composition   of   a   proposed   Plannina   Committee.
               A  physician  has   been   retainer   as   a   consultant   to   coordinate   evaluation
               of  the  coronary  care  units  in  the  Re-!.on,   including   many   which   were   not
               funded by the SVII@'@IP.

                     Progress  has  been  made   in   the   continuing   education   segment   of   the
               program.   The   newly   appointed   Continuiric,   Education   Coordinator   on   Core   sta
               has worked with the Contint-ii-,t,@ Edi.ic.-,2tit-)n CoLincil, ,@lli.cli has  restructured
               its i.-kcmbL@rship to include                             t-ro,@'t non-riicdical professions,


               SUSQUEHANNA VALLEY RYP                      -2-

               to  look  at  the  quality  and  accessibility  of  health  care   on   a   regional   basis.
               The  staff  has  al.so  sought  consultation  in   allied   health   from   a   neighboring
               Region  and  taken  steps   to   strengthen   the   continuing   education   component   of
               ongoift(7 and new projects.

                     The heavy emphasis on coronary care during the f          irst  two  years   of   the
               program   has   been   ameliorated.   The   present   application   in@ludes    requests
               for  comprehensive   health   care   centers,   home   health   care   coordination%   nurses
               dial   access   pro -ram  and  a  computerized  EEG  proposal..   The   only   oncoinc,   coro-
                                 C,
               nary care pro OSal WOLild be the Geis@,nger i'@le(lical Center CCU Nurse         Training
                               p
               Program,  the  sole  such   resource   in   the   Region.   The   proposer of an already
               approved project (#26),, the York Hospital        .  has   withdrawn   its request    for
               a  CVA  Transport  Vehicle  beca-,se  they  believe  it   is   no   longer a wise use
               of Federal funds.

                     The  Pe-ional   Advisory   Group   has   formalized   their   review criteria and
                            C>
               developed a nuE,,er-7cal r,-tin,, system                     i rtir.-@erical  priority
                                                C@                     0
               to each project.      Plans are under consideration for ttie adoption of a
               similar system for t,ie Councils and Are.@-

                     Committee noted that only sl.i-lit  -i.mprc)vcitlL@rit  had  been  made  in  the
                                                        0
               relationships with the Hershey Medical School and the. grantee agency, rho
               Pennsylvania Medical Society.

                     Since there seems to have been much change and           redirection   of    the
               pr ogram  reviewers had difficult  in assessing a reasonable fLindina recoa,,riien-
                       .%                             y                                         C)
               dation.    Individual projects were not reviewed.

                     Several  options  were   considered   by   Committee   before   decidina   on   their
               reco,g@-nenda tion:

                     1)  that the Reaion be @unded at the present level with a consultation
               visit before next ye-@r's submission.

                     2)  that  the  Region  be  advised  to   review   and   Strengthen   the   staff
               capability  particularly  in  the  proo-rai7,1  pl@,.nnino  and  evaluation   area   and
               that 6 site   visit  be  scheduled  later  to  review   the   Re-.ion's   pro-ress   and
               determine whether further fundina should be added to the program.

                     3)  that the Region be given       approximately   $200,000,    an    amount
               comparable to the Region's request for previously approved but unfunded
               projects, for the next year, but that no funds for new projects be approved
               until a site visit is made to review the status of the program.

                     4)  that the Region be site visited before any funds be approved
               for  the  Re@ion  with  the  exception  of  the  ongoin,,   renewal   project   @F'6R.

                     Thi  last  option  was  decided  upon,  partly  in   order   to   give   the   Region
               any additional    funds  at  the  becinnina  of,  rather  tnan  later   in   the   year.
                                                   C,

                     in li.clht of the present  funding  stritir,,(,,-idies,  'the  need  for  such  urgency
     0                     u
               does   not   apply.

                                                                         RMPS/GRB 1/19/71


                                                                    SUSQUEHANNA VALLEY
                                                                    RM 00059      2/71
                                                                    STAFF    OBSERVATION

             -PROJ&CT #25, ALTOONA HOSPITAL TRAINING  PROGRAM FOR  CORORNARY CARE NURSES

                     The SVRMP first submitted this   project, the  Altoona   Hospital
            Trainin- Program for  Coronar  Care  Nurses,  for  review  in  late  1969.
                    0                     y
            'When it was returned (because Council could not as.ce@tain this project's
            part   in the Region's overall plan for coronary cars units), the Region
            revised  the proposal and resubmitted  it  for  the  June-July  1970  review
            cycles   Review Committee had additional technical concerns and recommended
            disapproval. The  technical  concerns  were:  I)-the  objectives  are  not
            stated in terms of education of the  learner;  2)  other  than  a  'eneral
                                                                              9
            reference to follow-up,, the proposal  does  not  speak  to  any  evaluation
            of the studen't's retention of  knowledge  or  employment  status  after
            training; and 3) evidence of nursina input into the curriculum is
                    a
            missing. Council,  however,  recognized  the  need  for  and  importance of
            the Project in the Recion since this  project  would  be  the  only  ccu
            nurses trainina center in I-lestern  Pennsylvania,  and  indicated  that if
            the project director submitted additional material speakina to Committeels
                                                                           a
            concerns for their review,, they would  reconsider  it,  The  Recion  has,
            forwarded the additional information  for  Council  review  and  wislieg the
            project to be considered in recommending a fundina level for this
            application.

                                                               1/12/71


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

                 TEXAS REGIONAL MEDICAL PROGRAM                            RM 00007 (S) 2/71.1
                 P. 0.  Box  "Qll                                          January 1971 Review Committee
                 University Station
                 2608 Whitis Street
                 Austin,  Texas   78712

                 Program Coordinator:  Charles B. McCall, M.D.

                                              MUEST (DireLt Cost

                 REGIONS   OPERATIONAL   YEAR     03               04           05              Total

                 Four Supplemental Projects  212,736               219,499     177,568       609,803

                                                   FUNDING HISTORY
                                                  (Direct Cost Only)

                 Planning Stage

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

                 01                               7/66 - 6/67                     969,541
                 02                               7/67 - 6/68                   1,039,295

                  Operational Stage
                                                      Council                                Future
                 Grant Year     Period                Approved          Funded (d.c.o.)      Commitment

                 01             7/68  - 9/69          1,700,000          1,615,000
                 02            10/69  - 9/70          20,580,043         2,220,891 1/
                 03            10/70  - 8/71  2/      2,097,076          1,866,044  51           --
                 04             9/71  - 8/72          1,547,870                             1,029,105
                 05             9/72  - 8/73              240,386                              214,050

                 1/ Included $444,178 carryover
                 2/ Change in budget period at request of RMPS to facilitate transfer to
                    anniversary review.  Toward is for 11 months.
                 3/ Included  $549,34.4 carryover


        Texas Regional Medical Program        -2-                  RM 00007 (S) 2/71.1

        History: Texas received an 01 planning award ($969,541) on  July  1,  1966
                  and its 02 award ($1,039,295) on July 1, 1967.

        A site visit was conducted in June 1968 to determine the Region's readiness
        for operational status and to review the proposed continuation of planning
        activities into the operational phase of TRMP's  development.  Of  major
        concern to the reviewers was the apparent lack of central  direction  and
        coordination of the program. This was illustrated by  the  uneven  progress
        made in the development of the nine subregional planning units and  by  the
        fact that operational proposals appeared to be "based  on  institutional
        interests and strengths with very little regard for community  needs  and
        goals - either regionwide or local - and only a few show evidence  of  true
        cooperative arrangements or even unilateral  peripheral  involvement."  The
        site team also observed that the Regional Advisory Group,  through  under
        stron- leadership,, had not been active in the identification of  program
        goals and the development of program plans. The RAG was  also  weak  in
        its representation of minority groups, consumers, allied health professions,
        and the practicing community.

        With these considerations in mind, the Council recommended  a  one-year
        approval of the Texas operational application, including  the  continued
        planning support, with future funding contingent upon demonstrated
        improvement in the areas mentioned by the reviewers.  Accordingly, a
        one-year operational award was issued on Jiily 1, 1968 in the amount  of
        $1,615 000 (d.c.6.), these funds to be 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 visit was held in April 1969 to judge the progress  made  in
        fulfilling the conditions laid down the year before as necessary for further
        funding, that is, strengthening central administration and  expanding  the
        RAG.  The reviewers were well satisfied that these requirements were being
        met; a new coordinator had been appointed and had presented his  plans  for
        tightening up the organization, and the RAG included nine  new  interested
        groups that had not been represented earlier.
        on thatbasis, an 02 year operational award was made, but since the
        Division considered the Region still 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 the next (03) year. Instead, the  Region  was  awarded
        and committed funds at the 01 year level. Consequently, ten  of  the  new
        projects were funded from carryover to keep the Region  from  stagnating.

        When the Region applied for 03 year continuation, the financial  bind  in
        which it found itself was apparent. From an 02  year  operating  budget
        of $2,220,891, TRMP dropped to an 03 level of  around  $1,400,000.  This
        substantial decrease resulted from a combination of the  Core  commitment's


               Texas Regional Medical Program        -3-                   RM 00007 (S) 2/71.1
               reduction because of the phasing out of planning bases and  the   Region's
               use of carryover to initiate a number of activities during  the  02  year.
               In reviewing the application, staff emphasized th;,,'- this fisczl disarray
               was not the fault of TRMP; rather it was the fault  of  circumstances  and
               past Division policies. Staff review further  emphasized  that  Dr.  McCall's
               plan appeared to be working.  The planning bases were phased out by '
               January 1970 (except for development of a subregional office in Houston)
               and for the first time the Region has a multidisciplinary  core  staff  in
               Austin. Functional differentiations between the RAG  and  the  core  staff
               have been made. The RAG has adopted a set of by-laws  and  seems  to  view
               itself in a new light as being involved in program development.  The
               five task forces, with their primary review  responsibilities,  have  been
               made agents of the RAG rather than of the Coordinator.  Financial management
               procedures have been altered with help from  RMPS.  Planning  and  evaluation
               functions ha*e been consolidated in the Coordinator's office.  There are
               obvious close relationships between TRMP and the Texas Hospital Association
               and a formal working arrangement with  CHP.  Subregionalization  is  being
               pursued actively.  There is the subregional office in Houston, and there
               are plans for establishing four additional subregional offices during
               the year and creating in Austin a Division of Community Health Organization.
               Because of the progress the Region had made during the past year, and
               because of the promise it showed for the future, the  03  year  award  was
               for $1,866,044. This figure included  $549,344  in  carryover  funding  to
               permit the Region to retain the momentum it  had  built  up.  The  funding
               history at the end of this summary lists the  projects  currently  supported.

               Re&ional G a s
               In the RAG report submitted with the August  1970  continuation  application,
               the following regional goals and program objectives were outlined:
                    1.  To assist in the advancement of the practice,, knowledge
                        teaching, and education of medicine and allied health sciences.
                    2.  To promote demonstrations and research in the delivery of
                        health care services.
                    3.  To promote and encourage cooperative arrangements among all
                        segments of the health care community--both provider and
                        consumer, official and voluntary.
                    4.  Through planning and evaluation, to analyze existing health
                        care programs, and through  cooperative  and  collaborative  efforts
                        promote the effective,  efficient  and  economic  utilization  of
                        health care services.
                    5.  To promote innovative approaches to the delivery of health
                        care services on a regional basis.


        Texas Regional Medical Program         -4-                RM 00007(S) 2/71.1

        Present Application

        The present application contains requests for supple@,.-.ital funding for
        four projects.  The projects are presented below in the priority order
        in which the Region has ranked them.  Two of the projects (#a 51 & 52)
        with slight modification, have been supported in the past by RMP, and
        two (#a 50 & 53) have been supported in the past by other agencies.

        Project #50 - Control of Hypertension and Chronic Renal Disease       Requested
                      The first three years of this activity were             First Year
        supported by the Chronic Disease Program of the U.S. Public          $1401000
        Health Service, and the current year by the Moody Foundation of
        Galveston, Texas.  Its stated purpose is the improvement of delivery
        of health services by developing the means for providing ready access to
        early diagnosis of high blood pressure and chronic kidney disease for the
        majority of the population.  This is to be accomplished through a serial
        annual investigation of a cohort of 10,000 schoolchildren in Galveston
        county and assistance to the county schools to extend similar health
        care to all school children.  Although the immediate effects of this
        project-will be limited to health care consumers in the county, the
        information and experience gained can have applicability throughout the
        Region.

        Even through the project is envisioned as requiring a total period of
        twelve years (it is now in its fourth), RMP support is requested for
        only three years, during which time the investigations of the delivery
        system will be completed.  After that, since the longitudinal studies to
        be carried out are research oriented, support will be requested of other
        sources.

        Among the four proposals in the present application, this activity has
        received the highest priority from the Texas RNP because of: the involve-
        ment of the Medical School, the County Medical Society, and the community;
        the preventive medicine orientation of the project; and its Regional
        program potential.

           Second Year  -  $144,659          Third Year  -  $149,551

        Project #51 - Helping Hospitals Organize and Strengthen       First Year
        Inhalation Thera2y Patient Care Programs.  This project      $26,900
                     is the same, except for geographic coverage,
        as Project 04 of the same title which was operational between July 1968
        and September 1970.  When 03 year continuation was requested in August
        of this year, continuation of this activity was not included.  During
        its previous operating phase the project was under the aegis of the
        Methodist Hospital, but when support resumes the Texas Hospital Association
        will assume responsibility.

        The objective of this project is to assist hospitals throughout the state
        in organizing and strengthening their inhalation therapy patient care


             Texas Regional Medical Program        -5-                      RM 00007 (S) 2/71.1

             programs.  This will be accomplished by:

                (1)  Four two-day institutes to acquaint administrators, nursing
             directors, potential inhalation therapy employees and others with ttle
             principles, organization and clinical application of an organized
             inhalation therapy program.

                (2) Four two-week periods of clinical experience  for  employees  selected
             by their hospitals so that Lhe employees may return to help their in-
             stitutions organize and strengthen inhalation therapy patient  care  program.

                (3) Follow-up training education.

             The previous two years of experience was confined to approximately half
             of the state, and the application states that as a direct result of
             project activities 20 hospitals have established inhalation therapy
             departments, 19 have strengthened their programs, and 11 are actively
             developing plans and soon.will have organized units  in  operation.  The
             two-day institutes were attended by 641 people from 103  hospitals,  and
             98 employees from 50 hospitals completed the  clinical  experience.  The
             present application seeks to extend these activities to the  other  half
             of the state.

                 Second Year - $26,500
   0         Project #52 - Education Media Instrfictional Program for          Requested
             Allied Health Educators   This project is in much the             First  Year
                           same situation as the one above, in that            $20,860
             it had one previous year of support by RMP as Project l@43,
             and ittoo, is being transferred from the Methodist Hospital to    the
             Texas Hospital Association.  It is designed to assist allied health
             educators to improve instruction through the use of educational media by:

                (1) Six one-day educational media institutes at selected sites throughout
             the state for personnel involved in allied health education programs
             in hospitals and other health care facilities as well as junior and
             senior colleges.

                (2) Six five-day in-depth workshops for allied health educators  who  will
             then be equipped to improve their instruction through better utilization
             of audiovisual media and the selection, design, and production  of  such
             media.

                (3) Supplemental follow-up education and training.
             An Evaluation method is described.

             During the year in which this program previously operated, three institutes
             were presented for a total of 108 participants from 43 institutions.
             Evaluation questionnaires indicated to the Region that the three institutes
             were successful.

                  Second Year  -  $22,250


         Texas Regional Medical Program       -6-                 RM 00007(S) 2/71.1

         Project #53 - Choricardi_,ioma and Related Trophoblastic Diseases
                       The Trophoblastic Disease Center was established    Requested
         in October 1967 under USPHS grant support which now has           First Year
         terminated prematurely.  Funding is being requested of            $24,976
         RMP so the Center may continue to provide HCGG determinations
         for all physicians who ALeed the service, to'compile and evaluate
         patient data,, and to stimulate interest and provide consultation to
         all physicians who want it.  The Center has progressed from an average
         of 30 sample assays per month during its first year of operation to the
         current level of 90 samples monthly.  To date, 439 patients have been
         assayed, of whom 246 were diagnosed and reported as having some kind of
         trophoblastic disease.
         Although this proposal received the lowest priority ranking by the
         Region of the four projects in the present application, RMPT sees its
         function here as that of sustaining a needed service through its
         period of transition to self support.

             Second Year   $26,090             Third Year   $28,017


                  Texas Regional Medical Program            -7-                    RM 00007(S) 2/71.1

                                                 History Supplement

                  Project                            Title                  Current Support  Initiation
                                                                                (d.c.o.)          Date

                       I          Medical Genetics (MDA)                        14,000          7/68

                       2          Child Welfare Workdrs Training (MDA)               Approved/Unfunded

                       3          East Texas Teaching Chain (Grad. Div.)        RMP   Support   Terminated

                       4          Inhalation Therapy Patient Care Prog.
                                  (Methodist)                                   RMP@Support     Terminated

                       5          Regional Consulation in Radiotherapy
                                  (MDA)                                         30,000          7/68

                       6          Consultation Service in Medical
                                  Physics (MDA)                                 45,000          7/68

                       7          Cancer Survey (MDA)                           RMP   Support   Terminated

                       8          Statewide Cancer Registry (Houston)           105,300         7/68

                       9          Educational Television (Grad. Div.)           Disapproved

                     10           Microwave System Development (MDA)            Disapproved

                     11           Consultation Services - Radiotherapy
                                   via Television (MDA)                         Disapproved

                     12           Dissemination of Cancer Literature (MDA)      Disapproved

                     13           Communication Study (MDA)                     Disapproved

                     14           Stroke Demonstration (Dallas)                 151,000          7/68

                     15           Area-Wide Total Respiratory Care
                                   (12 counties)                                 80,000          7  68

                     16           Rehabilitation Program A (Baylor)              72,068          7/68

                     17           Rehabilitation  Program B (San Antonio)        48,000          7/68

                     18           Rehabilitation  Program C (Dallas)             47,000          7/68

                     19           Cardiac Work Evaluation (Baylor)              RMP   Support   Terminated


        Texas Regional Medical Program           M8@                RM  00007  (S)  2/71.1
        History Supplement - cont-4.nued

        Project                        Title                    Current Support     Initiation
                                                                    (d.c.o.)         Date

          20        Eradication of Cervical Cancer
                    (San Antonio)                                   90,000            7/68
          21        Core                                            696,222           7/68

        22-30       Planning Bases - Phased out

        31          Long Distance Telephone Consultation
                     (Dallas)                                       20,000         10/69

          32        Cardiovascular Nursing Institutes
                    (Texas Wo-a,---.i's U. )                        Unfunded

          33        Coronary Care Nurse Training in Community
                    Hospitals (St. Joseph's and Riverside
                    Hospitals)                                      64,915         10/69
          '@24      Regional Coronary Care & Training By
                    Computer (Galveston)                            Disapproved
          35        Reduce Complications Following Radio-
                    'therapy (Den tal Branch - Houston)             40,986         10/69
          36        Inter-Regional Cooperetive Serial Control
                    Systems in South Central Library Region
                    (Statewide)                                     28,610         10/69
          37        Health Careers Personnel Program (Statewide)    66,862         10/69
          ':'.8     Dial Access (MDA)                               19,963         10/69
          39        Anniial Clinical Conference (MDA)               11,520         10/69

          40        CB in CVD, Coronary Care and Intensive
                    Care (Galveston)                                 Unfunded
          l@l       Social Workers' Training in Neoplasia (MDA)      Approved/Unfunded
          42        CE for Occupational Therapists (Dallas)          24,311        10/69
          43        Educational Media Instructional Program for
                    Allied Health Educators (Baylor & Methodist)     RMP Support Terminated

          44        Health Occupations Improvement (Multiple
                    locations)                                       Deferred


                                                                 (A Ilrivi.Ici@(:,(i Corn-,il-@_IE14Cat,_ril

                                     SPECIAL ACTION
                            TEXAS REGT.ONA'L I-IEI)ICAL PROGPO@-r@l
                                        Pl,l 00007

                             January 1971 Revie@,7 ColfliltiLtc-c-

              The June/July 1-970 Revie@.7 Committee and  Council  rL.@viewed  a  request
              for a three-year renewal of  Project  i'@14R  -  Stroke  Demonstration  Pro-.ram
                       e@. i@-e Patient Care, which previously had received funds as
              a  one-yLar  earmarked  supplement  to  the  planning   grant.   Subsequent
              to the original ai@7ard the project period was extended without
              additional funds  to  provide  time  for  the  completion  of  the  construction
              of the stroke unit.

                                                                              e   f  '71
              In reviewing this reouest, the Cmiimi-ttee and Council- agre d ti, t
              most of the staff for this project is now on hand ii-id seems to be
              well qualified and that the project should be continued.          Ho,,,Teizer,
             @the application itself was deficient in that-            L. --
                                                              , it Coll'-a4llc-d no
              indication of the num,Ders of physicians and nurses to be trained
              during the three years or  the  amount  of  time  to  be  devoted  to  education
              and  consultation  activities  for  community  hospitals.-   Further,   the
              proposal did not contain a   -discussion  of  the  intents  during  the
              second  and  third  years  of-the  grant  renewal  request.  There  was
              also needed a more full discussion of  g-rari@--and-hospit,.il--gei-ierated
              income.

              Consequently, the recommendation was for approval in the time and a,..iou:it
              requested, on the condition that Information be provided to contain
              answers to the aloove questions as well a    s an  assurance  that  at  the
              completion of three years, no additional grant support for the project
              will be requested frot.T,, P-'4-@DS. The Committee and Council  also  restricted
              the expenditure  of  funds  over  the  current  level  of  expenditures
              the requested information had received approval.  The amounts
              recommended (and awarded subject to approval of this material) were:

              01 Year:  $1.96,244            02 Year:  $164,344               03 Year:  $11@2,844

                                                                   CIZB /P@,TS
                                                                   12/29/70


                                                             (A Privileged Communication)

                              S@i@Y    OF REVIEW AND CONCLUSION OF
                                 JANBAPY 1971 REVIEW CO@UIITTEE

                                 TEXAS REGIONAL MEDICAL PROGRAM
                                       RM 00007 (S) 2171-.l

                      FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

               Recommendation: Additional funds be  provided  for  this  application.

                  Year                Request              Committee   Recommendation
                   03                $212,736                  $265900
                   04                 219,499                  $26,500
                   05                 177,568                     -
                  Total              $609)803                  $53,400

               @r        The Revie-@,7 Committee thought the Texas Regional Medical
                         Program had come a long way in the last  year  and  a  half,
               as is discussed in the yellow  summary  sheet.  The  Regional  goals
               appear reasonable - the mission is broad  -  and  priority  setting
               among regional components is good.  The reviewers admitted, however,
               that in order to get a complete picture of the ov-erall TRNP activity
               .we will have to wait for this Regionis  first  anniversary  review,
               application, which will be seen during the JLily/August 1971  tevie.@q
               cycle..  There was con5ensus, though, that RMPS is getting its
               money's worth in Texas.  It was noted that two of the four projects
               in this supplemental application previously  have  been  funded  by
               other agencies but support has terminated  and  financing  is  being
               sought of RiNiT.  The Review Committee thought the TRMP should
               be discouraged from sending in proposals of this nature unless
               their relation to regional goals and  importance  to  the  Region  s
               clearly delineated

               Project #50 - Control of Hypertension  and  Chronic  Renal  Disease
                             This project proposal provoked considerab e  iscussion
               Among the reviewers.  It was agreed that in'the four years it
               has been in operation, this study has don@ an excellent job of
               developing cooperative relationships between the school system
               and the county medical society.   It was alsd  realized  that  this.
               project has suffered through PHS  reorganizations  and  in@lool@ing
               .for other sources of funding has encountered the problem of
               research institutions saying the  activity is service-oriented
               and service agencies claiming it  is research-oriented.  The Committee
               .was concerned that such attitudes--Dtay spell the demise of a significant
               study - everyone's thinking someone else should support it.

               As a way out of this dilemma, Committee would suggest to Council
               that this is a potentially valuable project, but.one which requires
               nuinerou@ years of support before results can be realized.  It was


                                                                      (t, Privilege(.1 Corrritunic,-,tion)

                                      SIL,',@lMliR@@ R VI@,'Tl A@'@D          OF
                                          January 1-971 Revi-ei,2 Coriintitt-!e

                                        Texis Reg@Lon@l. Medicgl PrograiTi
                                                   2/71 (SPICIAI, A-TIC-,')
                                        Rt,l Orl'007

                            FOR CONSIDERATF.'ON   BY I'EBRUARY 1971 ADVI@')OT@Y COUNCIL

               The Rpvi@ew CoGimitt@-t-,                        'illc,@,ionil                 tilcl
               ,n(IC'qLl.-ItOl@y C,'.ISt,2C@re.'J tne   o@f.' t'ite pievi.ot-is revic-%,) g-roii,@)s corlcernitic@
               the Stroke D@lmonstratiori Procrem for Pro@,ressive Patient Care.             It
               agr(-@ed ehat the restriction on the expeti(.1il-ure of funds for this project'
               should b6 lifted.

                                                                                   RMPS/GRB
                                                                                   1/20/71


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

               VIRGINIA REGIONAL MEDICAL PROGRAM               RM 49-02 (AR-1 CDS) 2/71
               700 E. Main Street                              January 1971 Review Committee
               Richmond, Virginia  23219

               Program Coordinator:  Eugene R. Perez, M.D.

                                 REQUEST FOR NEW FUNDS (Direct Cost Only)

               REGIONAL OPERATIONAL YEAR          02             03               04

               1.   Approved, unfunded
                    projects (1)                $211,728       $263,685         $299,875
               II.  New Projects (2)             288,468       242,109           249,784
               III. Developmental    Component    40,000       100,000           125,000

                      Total                     $540,196       $605,794         $674,659

               RMPS Staff Review of Non-Competing 03 Year Operational Continuation_
               Grant Application on 11/30.

                                                  Awarded          Commitment      Commitment
               Regions Operational Year           02   Year       03 Year           0.5 Year

               1.   Core                         $475,255           -0-              -0-
               II.  Ongoing Projects (6)          442,536         $449,235           -0-
                    Total                        $917,791         $449,235           -0-

               In addition to the above, the Region requested $193,189 of carryover funds
               to supplement Core ($39,184) and ongoing projects #1,#2,#3,#4,#7, and  9
               ($59,203); to initiate the approved unfunded projects #8 - Tumor Registry
               ($83,928); and utilize $10,871 in Project #10 - Multiphasic Screening
               Program.  These request for utilization of carryover funds were disapproved
               by the Director of RMPS.

                                     FUNDING  HISTORY  (Direct  Costs   Only)

               Grant Year                     Period                Funded

               Planning Stage

               01                      I/l/67 -  12/31/67            $226,800
               02                      3/l/68 -  2/28/69            254,000
               03                      3/l/69 -  2/27/70            475,255

               Operational Stage

               01                      1/l/70  -   12/31/70    Core 375,413
                                                         Pro   ects 410.718
                                                              40tal  -786,,131


            Virginia RMP                       -2-              RM 49-02 (AR-1 CDS) 2/.71

            Geography and Demog@h

            The Virginia Regional Meaical Program which is headquartered in the State
            Capitol of Virginia services the entire State of Virginia with a land area
            of 39,838 square miles.  The population of the state is 4,692,675 covering
            96 counties (and 37 independent cities) with an  average  density  of  100
            people per square mile.

            The Virginia RMP is divided into five  district  areas  which  correspond
            to the same five regions of the Virginia Hospital Association.      Fifty-
            seven percent of the Virginia population is  urban  and  roughly  81%
            is white.  The population has a median age of 24.1 years.

            There are ten major colleges in the state  of  Virginia.  The  state  has
            two major medical facilities, the Medical  College  of  Virginia  and
            the University of Virginia Medical School.  Within  the  state  are  43
            nursing schools which offer L.P.N. programs and  33  which  offer  R.N.
            programs (including 21 diploma degrees,  six  associate  degrees,  and
            six baccalaurate degrees.)  There are eleven schools of medical
            technology, two of which are affiliated  with  medical  schools  (the
            others are affiliated with  hospitals.)  There  are  four  cytotechnology
            facilties within the state, two being  affiliated  with  medical  schools
            and the other two being affiliated with  hospitals.  There  are  20  x-ray
            technology facilities in Virginia of which  two  are  affiliated  with
            medical schools.

            The total number  of hospitals in Virginia is 156 (of which 107 offer
            general medical services) with 40,116  beds.  There  are  150  nursing
            homes within the state, (55 having  extended  care  facilities)  with
            7,879 beds.

            There are in Virginia 5,018 physicians  (123/100,000)  and  38  osteopaths
            (1/100,000) within the Region. There  are  15,883  nurses  (R.N.s)  and
            5,743 (L.P.N.) nurses.

            History of Regional Development:

            Shortly after the approval of Public Law 89-239 the Governor of Virginia
            appointed a fourteen (14)member  Covernor's  Regional  Advisory  Group
            representative of community a,-id state interests.  This  group,  under
            the Chairmanship of the State  Health  Commissioner,  coordinated  the
            development of an application for planning  funds,  which  resulted  in
            An initial planning grant award in January  1967  of  $226,800  first-year
            support. The applicant organization  was  the  University  of  Virginii
            School of Medicine in Charlottesville,  Virginia  with  the  Commonwealth
            of Virginia as the designated region, with  some  overlapping  in  the
            north with the District of Columbia.  A continuing cooperative relation-
            ship was established with the  Metropolitan  Washington  Regional  Medical
            Program. On July 1, 1967 Doctor Eugene R.  Perez,  was  appointed  as  the
            full-time Program Coordinator.  The  Regional  Advisory  Group  consisted
            of twelve physicians.   In their review of  the  planning  application,
            Council expressed concerns about the  absence  of  representation  of


              Virginia RMP                         -3-         Ril 49-02 (AR-1 CDS)2/71

              of paramedical personnel and minority groups on the  Regional  Advisory
              Group, the planning as submitted was quite non-specific and the evaluation
              plans and procedures were not emphasized.

              Early in December 1967, at the request of the Region, the planning grant
              was extended without additional funds through February 29, 11)68,  to
              permit additional time for organization and planning.  When the continua-
              tion application was submitted in late January 1968,  the  responsible
              fiscal agent was changed from the University of Virginia to the Medical
              College of Virginia in Richmond, now known asthe  Virginia  Commonwealth
              University.

              The Core staff at this time consisted only of a program director  and
              an administrative officer.  The Regional Advisory Group consisted
              of nine physicians and five laymen. There was  an  Executive  Committee
              consisting of six members drawn from the Regional Advisory  Group  to
              exercise authority  in the interim between meetings of the RAG.

              It appeared that the previous recommendations from Council  to  expand
              the RAG to include representation from Allied Health  Professions  and
              minority groups had not been met. Evidence of  a  cooperative  medical
              school commitment to the program from the two medical schools was
              not present. Planning efforts continued to remain at  a  minimum  level
              and evidence of sub-regionalization was at an  elementary  stage.  Early
              in July 1968, the Virginia RMP submitted its initial  operational  grant
              application requesting support of 16 projects for a  three-year  period
              The projects submitted included four in heart disease, six  in  cancer,
              one in stroke, four in continuing education, and one  for  expansion
              of core.

              A site visit was made to the region in September 1968, and  the  site
              visitors reported that the continuous problems with cooperative
              arrangements, regional planning and RAG membership  still beset  the
              Region. Council did not approve operational status  for  the  region,
              but did approve the continuation support of  planning  activities.
              Council urged that the region be advised that core  activities  be
              strengthened, that a regional approach be used in  project  development
              and that the new operational plan tie in with the  previous  planning
              phase. Another recommendation which was again  stipulated  by  Council
              was that the Advisory Group be increased in number and that  it  include
              representation from paramedical professions and  minority  groups.

              The region resubmitted their initial operational grant  application  to
              the December 1969 Council and a site visit was made to the  region  on
              October 1-2, 1969. The December 1969 Council  concurred  with  the
              recommendations of the site visitors and the Review  Committee  that
              this region be awarded operational status.  Of the seven projects
              in the application, Council approved five projects  and  disapproved
              two projects. The Medical College of Virginia continued  to  be  the
              responsible fiscal agent for the Virginia RMP.  Nine additional
              members had been appointed to the Governor's Regional Advisory


          Virginia RMP                       . -4-       RM  49-02  (AR-1  CDs).2/71
          Group, which brought the total present  Regional  Advisory  Group  member-
          ship to twenty (20) members.  Four standing committees on heart disease,
          cancer, stroke and related-diseases were created to  replace  Task  Force.
          members and were broadened to include dentists, nurses, hospital
          administrators  and  minority  representation.   Regional   representation
          was also taken into consideration in the formation of these committees.
          An Executive Committee,vihich  consisted  of  six  members  and  exercised
          all of the authority of the  Advisory  Group  relevant  to  its  functions
          and interim between meetings of the Advisory Group was activated.  Each
          medical school has an RMP Committee for heart disease, cancer, stroke and
          related diseases. The  chairman  of  each  medical  school  RMP  Committee
          acts in liaison capacity between the schools and the RMP Central Office
          and also as official members of the Coordinating Planning and Evaluation
          Committee.  Other  representatives  on  the  Coordiniting   Planning   and
          Evaluation Committee are two  representatives  from  the  Medical  Society
          of Virginia, Comnittee on Heart, Cancer  and  Stroke,  one  representative
          from  the  Virginia  Hospital  Association,  one  representative  chairman
          from  a  Standing  Committee  on  Categorical  Diseases.  This   Committee
          provides advice to the Regional Advisory Group and  to  the  Virginia  RMP
          Director regarding needs and resources 6@  the  Commonwealth  of  Virginia
          Region. It is also  to  determine  proper  relationships  between  program
          elements including the identification of needs, determination of
          priorities and analyze  program  performances  and  results.  In  carrying
          out these functions the Coordinating  Planning  and  Evaluation  Committee
          would designate and direct sub-committees,  review  proposals  and  submit
          recommendations to the RAG.
          In February 1970, the RMPS  Staff  reviewed  this  r.egion's  continuation
          application,  requesting  support  of  the  Core  component.  Chan@es   in
          staffing patterns were noted, which had  the  effect  of  diminisbigg  the
          number and total effort of physicians  involved  in  the  Core  operation.
          Furthermore, the region expended  only  55.1%  of  its  funds.  To  permit
          time for the region to clarify the rationale for the new staffing
          patterns and to project its  rate  of  expenditures,  an  award  was  made
          at the committed  amount  of  $475,255  (d.c.o.)  with  a  restriction  on
          the use of $100,000.  Staff believed that this action served two
          purposes: (1) assured the RMPS that funds will be available for
          program development, either for a better documented Core plan  or
          new operational projects that may be approved; (2) permit RMPS to
          maintain a degree of stewardship over  this  rather  shakey,  but  hopeful
          Regional Medical Program.
          The paramount issue currently  involving  the  time  and  efforts  of  the
          Virginia Regional Medical  Program  are  their  plans  for  breaking  away
          from the present grantee, the Medical College of Virginia, and
          becoming a  corporate  body.  They  are  presently  developing  guidelines
          for personnel policies which they hope  will  be  the  basis  for  forming
          a corporate structure. The  motivating  reason  for  the  proposed  change
          from the present grantee stems from what the staff of the RMPS believes
          to be inadequate fringe benefits.  It  seems  since  the  Medical  College
          is a state supported institution,  its  employees  are  regulated  by  the
          State  Merit  System  and  given  State  retirement  benefits.  Since  the
          VR14P employees are paid by a Federal grant  and  are  not  considered  to


             Virginia RMP                           -5-        RM 49-02 (AR-1 CDB)2/71

             be state employees, they are not eligible for these  fringe  benefits
             and consider this to be an injustice. Ccnsequently,  they  feel  their
             only alternative is to incorporate and provide their  own  fringe
             benefits. The Director of Regional Medical  Programs  Service  believes
             these reasons are not only logical but of prime importance in the
             development of a productive program for the state of  Virginia.  Witt)
             respect, however, to the By-Laws and Articles of Incorporation for  tile
             proposed corporation, the Director of RMPS has  recommended  that
             these documents be revised in order that the membership of  the  corpora-
             tion will be separate from that of the Regional  Advisory  Group.
             Indications from the VRMP at present are that if they have  to  separate
             the membership of these to groups, they may decide not  to  incorporate.

             In this anniversary review application the VRMP has  requested  support
             for the following: (1) Continuation support for core  and  operational
             projects #I, #2, #3, #4, #7, and #9; (2) a  developmental  component;
             (3) supplemental support for two new projects; (4) and new funds
             to activate Projects #10 - Virginia Model Multiphasic  Health  Screening
             System, and #8 - Tumor Registry.

             Staff review of the Continuation Application concerned itself with
             total program and not individual projects.  Generally,  everyone  was
             in agreement that the region has made some progress during  the  past
             year.  This was particularly reflected in the composition of the applica-
             tion which was a considerable improvement over  previous  submissions.
             The region has shown improvement during the past year in that  they  have
             reacted to staff suggestions regarding Core staff personnel  by  taking
             steps to strengthen the program evaluation and  administrative  sections.
             They have accepted the suggestions of staff that additional  physician
             input on Core staff is needed and are actively recruiting  for  a
             physician to fill the deputy coor inator posit on.

             Organizationdl Structure and Processes:

             The Regional Advisory Group of the VRMP is composed of 20  members,  10
             physicians, 1 registered nurse, 2 hospital administrators, I allied
             health representative, 4 non-health professionals, I  labor  official
             and 1 businessman. These-members are appointed  by  a  nominating
             committee made up of no less than 3, nor more than 5 members  of  the
             Regional Advisory Group and then recommended by the RAG  for  appoint-
             ment by the Governor. Appointments shall be for a  term  of  four
             years with the term of office of each member beginning  with  the
             March Meeting. The membership of the Regional  Advisory  Group  shall
             not be less than 20 persons and they shall be selected  in  accordance
             with the provisions of P.L. 89-239. Regular meetings of  the  RAG  are
             held on the third Thursday of the months of March, July  and  November
             of each year at a location designated by the Chairman.  The  RAG  shall
             be the final authority for approval of all activities  proposed  during
             the planning and operational phases of the program and of  all  matters
             of policies related to the program. It is indicated  in  the  application
             that RAG activities during the past year have included  the  following:
             (a) Regional Advisory Group review of goals and  priorities  submitted
             by the standing committees, and made final decisions on  the  Regions
             objectives; (b) the RAG has been involved in the  proposed  incorporation


          Virginia RMP                           -6-     RM 49-02 (AR-1 CLIS)  2/71
          of the VRMP and has been studying  and  encouraging  its  implementation;
          (c) the RAG has worked toward the establishment  of  overall  policy  and
          a framework for the functioning of Core  staff;  (d)  the  Regional  Advisory
          Group has given careful study and review  to  projects  submitted  for  their
          action; (6) the RAG has formed three committees of  the  RAG  which  are  the
          Personnel Committee, the G-oals Committee and  the  Incorparation  Committee.
          These committees were charged with  investigating  and  recommending  means
          to athieve a more effective organizational  structure  for  the  developing
          progr  .
          Following are the names and functions of the committees  of  the  RMP:
          Ad Hoc Committees: These committees  contain  expertise  from  various  cate-
          gorical health service areas and are appointed by  the  chairman  of  the
          Coordinating Planning and Evaluation Committee.  There are ad hoc committees
          in the following areas: Continuing  Education  for  Nursing  Personnel;  Man-
          power Survey; Tumor Registry; Plan  Multidisciplinary  Stroke  Programs;  and
          Radiation Therapy.
          Coordinating, Planning and Evaluation Committee:  This committee functions
          as its title indicates.  It is an essential mechanisim for program
          development, coordination, planning  and  evaluation.  This  committee
          has consultants available and has the right to  form  Ad  Hot  Committees
          as necessary for special purposes. In addition, it  can  call  on  the
          Standing Committee for advice.  The  Coordinating,  Planning  and  Evaluation
          Committee also screens and  evaluates  all  operational  grant  proposals
          and makes recommendations to  the  Governor's  Regional  Advisory  Group.
          Standing Committees: The  standing  committees'  functions  are  directed
          by the coordinating, planning and evaluation committee.  Their
          principle function is the generation of ideas that can be  used  on  a
          state-wide basis in accordance with the RMP concept of regional
          cooperative arrangements. They also serve  in  an  advisory  capacity  to
          the coordinating planning and  evaluation  committee.  There  is  a  standing
          committee for heart disease, cancer, stroke  and  one  on  related  diseases.

          Taken into consideration when  forming  committees  has  been  geographic
          distribution and representation from the  variety  of  health  professions.

          Each medical school has an RMP committee for heart  disease,  cancer,  stroke
          and related diseases. The chairman. of  the  Medical  School  RMP  Committees
          servein a liaison capacity between the schools and  the  RMP  Central  Office
          and are official members of  the  Coordinating  Planning  and  Evaluation
          Committee.

          The Medical Society of Virginia, fleart,  Cancer,  and  Stroke  Committee
          consists of ten members of the Medical Society  of  Virginia  drawn  from
          the ten congressional districts which affords broad geographical
          representation. The Chairman is an  official  member  of  the  Coordinating
          Planning and Evaluation Committee,  thereby  having  direct  representation
          and participation in a committee concerned with all aspects of the
          program; he is also an ex officio member of the Regional Advisory
          Group.
          Following is an organizational chart  utilized  for  planning  and  operation
          of the Virginia Regional Medical Program.


                                                                0

                                           Itll',GINIA REGIONAL Vi'@'DI'Al-@ PtIOGRAiM
                                  ORGANIZATION CHART FOR PLANNING AND OPERATION

                                           GOVER.NOR'S Rr-_GIO'\AL ADVISORY GROUP

                                                  P,   Executive Committee

                                                       Coordinator/ Director
        HosD4Ltal and Relate                                                                                \,,.e,4-cal School
                                                            Core Sta,.f
        Health Organizat4Aons
                                                                                                          Re-oresentatives

                                                                             Ad Hoc Committees
                                     Fiscal Aor nr- ii7

                                                                t4
                                                      Coo.-dina n-r, Planning,
                                                               and
                                                                                            Medical Society o'l' Viroinia
            Consultants
                                                                                                                                 >
                                                       r-valuatioi,, Coirnii
                                                                          .ttee        Heart, Cancer, Stroke Committee         f'@i

                                                                       li                         Re,@,,zed Disc@ises
                Fearr LIJ41sease                 Cancer                      S r o'@- e
                                                ol                                                  Cor,,,-..' 10,2
                 Con-.mittee                   C ITIMI-Ltee               Coi-,-ini;.ttee


           Virginia RMP                          -8-           RM  49-02  (AR-1  CD.S)2/71

           The Core staff of the Virginia RMP  has  29  positions,  24  at  100'/.  time
           or  effort.  The  Core  staff  organization  has  been  expanded  to  include
           an  accountant,  editorial  and  allied  health  officer  positions  and  the
           time and  effort  for  the  unfilled  positions  of  education  research  and
           evaluation officer  have  been  increased  to  100'/.,ratner  then  50%.  The
           three  positions  of  heart,  stroke,  and  cancer  consultants  have  been
           deleted  and  an  internist  has  been  proposed  instead.  The   internist
           presumably will  cover  heart  disease,  stroke  and  Dr.  Perez,  the  cancer
           field.  The  time  and  effort  for  the  two  Medical  School  representatives
           and the  epidemiologist  position  have  been  reduced  from  50%  to  25%.
           The net effect of these changes diminished the number and total proposed
           time and effort of physicians involved in core staff operations.
           During the review of the continuation application the questions troubling
           staff were how Dr. Perez could direct the continuing planning effort and
           new operational  activities,  supervise  a  staff  of  28  people,  only  four
           of whom are physicians (1.75) and five of whom are located in sub-regional
           offices,  maintain  the  institutional  and  community   relations   necessary
           for a  strong  Regiona  Me  ical  Program,  an  provi  e  ea  ersh  p  or  the. G.

           Following is a list of the Core staff members and an organizational
           chart.

                                                                         TIME  OR   EFFORT
           NAME                          JOB TITLE                          %    HOURS

           Eugene R. Perez, M.D.         Director                             100
           A. S. Cann                    Communications  &   Public
                                         Information Officer                  100
           T. Y.   Tully                 Editorial Assistant                  100
           C. 0. Martin                  Administrative    Officer            100
           A. Burton                     Project  Fiscal   Officer            100
           No L. Doeppe                  Administrative Assistant             100
           J. D. Bobbitt                 Secretary    (Clerk-Steno)           100
           D. K. Brooks                  Secretary    (Clerk-Steno)           100
           M. L. Cosby                   Secretary    (Clerk-Steno)           100
           K. F. Meyer                   Secretary    (Clerk-Steno)           100
           TBA                           Personnel  &  Payroll   Clerk        100
           TBA                           Purchase  & Supplies Clerk           100
           M. @4. Proctor                Survey Officer                       100
           TBA                           Heatlh  Planning   Officer           100
           TBA                           (Epidemiologist)                      25
           J. L.  Mason                  Educational   Sciences   (and
                                         Evaluation) Officer                  100
           TBA, M.D.                     Medical Officer                      100
           F. L. Peters,   R.N.          Nurse Officer                        100
           TBA                           Allied Health Officer                100
           B. L. Peace, R.R.L.           Medical  Record   Officer            100
           l@T.B. Hunt, Jr. M.D.         (Medical School Liaison)              25
           TBA                           Secretary                             50
           M.P. Neal, Jr., M.D.          Medical  School   Liaison             25
           TBA                           Secretary                             50
           TBA                           Chief, Community Liaison             100
           P.L.  Beamer                  Community   Liaison   Officer        100
           H. D. Kauffelt                Community   Liaison   Officer        100
           14. W. Schmidt                Community   Liaison   Officer        100
           M.P. Gray                     Community   Liaison   Officer        100


        Virginia *W                           -9-
                                                             RM 49-02 (AR-1 CD8) 2/.71

                        V).IIGINIA III.-4'GIONAI, Ml,-',]'.)ICA], l']IOG]tAM

                                         (coltL.l Staff)
                       Organization Cliart as of 30 Soptcml)cr 1970

                                         DIRECTOR
                                                                        Medical Scliool
            L-'pidci'jiiologist
                                                                        Liaison Officers (2)
                                       'PLI'J'Y DIRECTOR
                                           (Vacant)

            Comii-itiiiicatlojis ,tiicl                                 Adniiiiist-i,,itive Officor@l:
            I'Liblic Information                                              (.rcnil)orary)

                                                                              I'll.'Oject Fiscal
                          sistant                                                Offi cer

                                                                              Adiiiinistritive
                                                                                 Secretary

                                                                              Secretaries

             Survey OffiIccr                                             Medical  Officer  (Vi ci iit)

                                                                         Nurse and Allied
             Educational  Sciences                                          f-lealtli Officer
                                                                                -icaltli Vacant)
                  Officer                                              (Allied I

             Projects D&vclopinoiit
                    and"                                                 medical l@cr-ords
             Man,igciiient Officer*                                            Off i cer

             lic-,iltli Planner                                           COMMLIflity I-,iaison
                                                                             Officers (4)
               (Vacant)
                                                                             (I vaciiicy)


                                                 -10-      RM 49-02 (AR-1 CDS), 2/71
           Virginia  RMP                                                      qMA slnl@a'il'v
                    (aC[D I-,q,A) 20-e4% MA        e-
           Following is a folow chart of the project review process of the Virginia
           Regional Medical Program.
                               NfA                               A1010it(V
                       Submission of Proposal Summary to VRMP,

                       Staff  Review
                           :yo @, Q it
                       *Review  y  @')qW'I')o@rq&in'aotip-nrk,"'HK-h)nfiRA19-Nwgi%lpion
                        Committee

                         (If  Approved
                       *Review by  the        aXC)-PgTlln  and/o.- Ad Hoc Committees
                             'L- 4e
                           Th    dica           Committee

                       Developmant  of                           application with
                   -asses   ance   fro             iu Y,rtj,.,.,ici

                       *+Review by th !very                -@l:)r Ad Hoc   Committees
                       and the Medical Society  Coiimittee

      -1.0,)illo ovijr;-i       )roved)
                              p
           (X-tr.-IO(ifflOrfy-+-Review'@ trg't'   977Y-anning @nd ENdilog

                         (If-approved)
                         RevLew by the RAG

                 ill o                                                a         '10
                                                                  irir3i iaaa. fr@i  iibH
                         (If approved)
                             o   RMPS
          oviir;-ilainirriba
                                  ed back to  the  -rigina                0
                  ,c)g@may @e -eferr                    tor for  (1) not conforming
           to goals and strategies of VRMP and/or (2) revision.

                          e referred back to the appropriate review committee
           for further review, development and/or revisions..

                                      as                       Lon when
                  in the review; process.

                              ro formal review relationship with CHP,-.statfs of
                            e                                tat
                           tA)f activities ayid mttual interest.

                              i  Regional Advisor) Group

       --'-@e IWC-":rii      TT t' a s a r e s u 1 t o fa t i o n a I A d v I T6@6-uW, i, oi
                 r           n@l Advisory Group las become mo-r
           the Vi                                             e
                             J,,  Ld-@       d-pi              ibility.

           AiLte-r,,.@euiaw- t4dy of the RMPS re( onunefidations,!,.t-@.@l.@ng,.c
           were implemented: (a) the RAG was enl@ rged@with representation an
           diversified both professional and geographically; (b) the standing committees
                                                              'Ch 5'@or; -s sT'd -nf@- 7fi-
                                                                       .Ioflfl ,
                ,@y6@,@fRW)ye Task Force) were    iversified b(                 pji


              Virginia RMP                          -11-         RM 49-02  (AR-1  CDS)  2/71

              geograhically; (c) a stronger  and  more  organized  review  procedure  Tqas
              initiated; (d) the core staff was  enlarged;  (e)  the  RAG  adopted  by  laws.
              The Regional Advisory Group went on to identify its general goals
              and specific goals in  the  categorical  areas  of  heart  disease,  cancer,
              stroke and related diseases.

              The RAG indicates that the  enlargement  of  standing  committees  in  the  RAG
              provided for program  representation  of  key  health  interest  and  agencies.
              In addition the staff of  VRMP  has  worked.closely  with  many  public  and
              private health  agencies,  institutions,  and  groups  throughout  the  region
              in development of program goals activities.       They explain  that  as  a
              result of activities generated  by  the  VRMP  many  people  from  different
              disciplines and areas of interest, as well as members of the public
              have talked together about health  care  problems  in  the  region  for  the
              first time.  They identify some of these as the medical schools,
              practicing physicians, dentists,nurses, allied health groups and other
              health manpower in the region.

              The RAG indicated that it became  apparent  to  them  in  early  1968  that
              there was a need for sub-regionalization in order that the program
              might be  more  effectively  administered.  After  extensive  study  by  the
              Core staff of various possibilities it was decided to adopt the
              Virginia Hospital Association Division of five sub-regions.

              The RAG explains that in order to  relate  the  VRMP  to  the  critical  issues
              of the poor and the inter-city health problems,the Virginia RMP,staff has
              been in contact with two model cities programs in the state.  In addition
              the Model Cities Program  was  represented  and  participated  in  the  VRMP
              Continuing Education Workshop  for  Nursing  Personnel  which  was  held  in
              the Tidewater area of Virgnia in November 1969.  Rapport has been excellent
              with both the Model  Neighborhood  Programs  in  Richmond  and  the  Norfolk
              Model Cities Program. The  RAG  also  indicates  that  it  must  be  remembered
              that Virginia in contrast to many other regions, has rural health problems,
              which perhaps, supercede  the  urban  health  problems  of  this  state.  Many
              of the health problems in the states rural population are found in the
              Appalachian Region which  covers  21  counties  in  the  Southwestern  portion
              of the state.  Seven of these counties lie in the heart of the poor areas
              of  Appalachia.  The  VRMP  staff  has  concentrated  considerable  planning
              efforts into the problems of  Appalachia  and  other  rural  areas  of  the
              region.  The RAG indicates that the VRMP staff is also working very
              closely with the Virginia Council on health and medical care.  The
              Virginia Council's main thrust is a health careers program, and the
              recruiting of physicians and  allied  health  personnel  for  rural  areas  in
              the state.

              The RAr, indicates that there is  a  good  working  relationship  between  the
              RMPS and other health  related  organizations  such  as  the  Comprehensive
              Health Planning, Blue Cross-Blue Shield, Virginia Health Insurance Council,
              Virginia Department of Vocational Rehabilitation, Virginia Heart Association,
              American Cancer  Society  Virginia  Division,  and  the  Virginia  Appalachian
              Health Services Regional Health Demonstration Program.  It also states that
              there is a close working  relationship  with  the  two  medicalschools  in  the
              region as well as the Medical  Society  and  the  State  Health  Department  of
              Virginia.


         Virginia RMP                          -12-          RM 49-02 (AR-1 CDS) 2/71

         Evaluation
         The Region explains that the core staff activity in the area of evaluation
         has been largely concerned with providing technical assistance  in  the
         writing, monitoring and reporting on theprogress of operational projects.
         The reasons given by the Region for these Activities is  the  requirement
         that the RMPS sponsored activities conform to the seven  criteria  stated
         in the guidelines for RMPS.  These criteria are essential elements;
         involvement identification of needs and opportunity, assessment of
         resources, definition of objectives, setting of priorities, implementation
         and evaluation. It appears that evaluation which is  involved  will  be
         concerned with the individual component activities operational  in  the
         region.

         Virginia Regional Medical Program Coals
         1.  The overall goal of the Virginia Regional Medical  Program  is
             improved patient care through continuous upgrading of the know-
             ledge and skills of physicians, dentists, nurses,  and  allied
             health professionals so that the latest and best in modern medical
             care for heart disease, cancer, stroke, and related diseases.is
             available to all the people of Virginia.
         2.  The objective of improved patient care is to be achieved by
             establishing voluntary cooperative arrangements among  the  medical
             schools and/or medical centers, with the practicing physicians,
             dentis@s, nurses, and allied health  professionals,  primarily
             through programs of continuing education.
         3.  The mechanism of cooperative arrangements  and the essence  of
             the Regional Medical Program concept is the linkage of patient
             care with health research and education involving  the  full  array
             of available health resources and personnel on a statewide basis
             to provide a mutually beneficial interaction.
         4.  The realization of the above goals with be achieved by project
             activities and other efforts which, when taken together, constitute
             coordinated programs to reduce morbidity and mortality in  each  of
             the categorical disease areas.  These  coordinated  programs  n  turn
             represent the overall purpose of the Virginia Regional Medical Program.

         Developmental Componen
         The Region is requesting a three-year developmental component award, as
         follows: 01-Year $40,00; 02-Year $100,000; 03-Year $125,00;  a  total  of
         $265,000 for 3 years support.
         The Region indicates that this award would provide the Virginia RMP
         with the capability of initiating activities not possible without
         the developmental component; and that these funds may be restricted
         to the conduct of conferences at which concepts can be thoroughly
         discussed prior to the preparation of a complete proposal.  Funds
         may also be used to employ personnel on a short term basis  to  support
         a contractural service for the conduct of studies from which facts


            Virginia RMP                           -13-       RM 49-02 (AR-1 CDS) 2/71

            can be obtained and recommendations generated ,  Tt is anticipated th@.';-
                                                             I
            each activity requesting developmental- funds will- be reviewed and administered
            in a m t-ler similar to that of fully funded operational projects.

            Supplemental Projects
                                                                       First  Year
            Project #11 - Emergency Coronary Care:  The purpose          Requested
                           of this project is to prepare Volunteer      $92,916
            Rescue Squads  to provide optimum emergency care to acute
            coronary care  victims in the city of Virginia Beach, from the time
            of their arrival on the scene until the transfer of the patient  to  the
            hosoital emergency room.  To accomplish this goal the project will provide
            emergency coronary care training and equipment for the  ten  volunteer
            rescue squads in the Virginia Beach Area.

            Data for analyses will be collected in all phases of the  project  to
            provide information for evaluating its effectiveness.  After adequate
            review of the data by persons knowledgeable in the field,  the  design
            will be available for other communities to utilize in organizing
            similar activities.

            The region indicates that this project relates to the  overall  regional
            plan and goals established by theregional Advisory  Group.  Under  the
            strategy for heart disease, and immediate goal was approved  for  the
            initiation of a pilot study of pre-hospital neighborh6o  coronary care.
            It is the intention of this proposal on emergency coronary care to
            accomplish this goal and the proposal has been  enthusiastically  and
            unanimously approved by the VRMP standing committee on heart disease.

                   Second Year: $57,521                Third Year:  $56,207
                                                                                First Year
            Project l@12 - Procurement of-Cadaver Kidneys for Transplantation:  Requested
                           The purpose of this project is the development       $195,552
            of a mechanism by which Cadaver Kidneys may be procured to
            save the lives of patients dying of end-stage renal disease.
            The project will establish a program of  professional,  administrative
            and public education which the region believes is necessary  to  carry
            through the primary purpose of the program.

            The goals are consistent with the RMP goals as they  require  regional
            cooperation between medical schools and community hospitals  not  only
            within Virginia, but also In adjacent states.

                   Second Year: $184,588             Third Year:  $193,577

            Approved and Unfunded Projects                                         First Year
                                                                                   Requested
            Pro'ect #10 - The Virginia Model Multiphasic I-lealth Screening System.  $222,602
               i
                           The region is requesting new money to activate this
            approved  unfunded project which was approved by Council in July
            1970.

            This project proposes to establish a multiphasic health screening system
            with facilities for gathering data on patients physiological  state  and


            Virginia  RMP                     -14-           RM 49-02 (AR-1 CDS) 2/71
            the follow-up necessary for the early detection  of disease.  Primarily,'
            the project will look for non-manifest symptoms  or risk factors
            associated with heart disease, cancer, and stroke.  In  the  process,
            medical and health data will be generated which will  be  generally
            valuable to the referring physicians in the management of his patients.
            The total funds requested by the Virginia Regiona I Medical  Program  for
            support 6f this activity in 01-Year is $222,602.  It has requested
            utilization of carryover @ollars in the amount of  $10,877  and  $211,728
            of new money.  In its 02 and 03 projected revenue will be utilized
            to reduce the amount of new funds required for support  of  the  program.
            Commonwealth University has stated that it will assume full financial
            responsibility for any deficit between the funds  requested  and  granted
            and revenue anticipated in the second and third year of the program
            and subsequent  years.  The Council approved level for this project
            were as foll(xqs: 01 year $268,552; 02 year $480,479; 03  year  $433,704.
            These levels of funding were approved with the condition that the VRM
            could guarantee sources of revenue for the program.  The region has
            responded to this condition to the satisfaction of RMPS staff.
            Approved and Funded     ects                       Present Year of Operation
            Project #2  -Coronary Care Evaluation                   First  Year
            Project #3  -Cardiopulmonary Resuscitation
                         Training Program                           First  Year
            Project #4  -Stroke in a Small Rural Community          First  Year
            Project #7  -Virginia Medical Information
                         System                                     First  Year

            Project #9  -Continuing Education for Nursing
                         Personnel                                  First  Year

            Approved  and Unfunded Projects
            Project #8   State-wide Tumor Registry                  01  $113,584
                                                                    02  $  98,600
                                                                    03  $110,100
            Project   #10 Virginia Model Multiphasic                01  $268,552
                          Health Screening System                   02  $480,479
                                                                    03  $533,504

            Disapproved and Unfunded Projects
            Project #5 - Stroke Program and Training Unit

                                                           RMPS/GRB/12/21/70


                                                                A    PRIVILEGED    COMMUNICATION

                                      SUMMARY  OF  REVIEW  AND   CONCLUSION   OF
                                         JANIJARY 1971 REVIEW COI@II'ETEE

                                       VIRGINIA   REGIONAL   MEDICAL   PROGRAM
                                           RM 00049-02 (AR-1 CDS) 2/71

                           FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

               c@o @eridation:    AdditionA].  funds  be  provided  for   this   application.
                                   CoLincil's special attention is called to the
                                   Multiphasic Screening Program.

                   Region@s                                                       Recommended
              Operational Year                      Request              Additional      Funding

                     02                          $  540,196                      $211,,728
                     03                             605,794                      263,685
                     04                             674,659                      299,875

                  Total                            $1,820,649                     $775,288

              In  addition  to  the  above,  the  Region  requested   $193,189 of   carryover
                     to  supplement  Core  ($39,184)  and  ocigoing   projects #I,  #9,  #3,  #42
              '#7,  And  #9  ($59,203);  to  initiate  the  approved  unfunded project  #8  -
              rumor Registry ($83,928); and utilize $10,871 in Pro ect #].O - Mtjl.tiphasic
                                                              il          j
              Scree-nin'g Procram.  These requests for utilization of carfvover funds were
                                                                                 I
              disapproved by the Director of MIPS.  The Region was awarded only the
              committed  level  of  $917,791  for  their  02  year  of  operation  which   begins
              JAnuary    1, 1971.
              Lri@L@e:     Generally,  Committee  believes  that  this   Region   continues   to
                           have problems with cooperative arrangements and regional
              planning.'   The VMIP has not fully defined its goals and priorities;
              categotical  program  plans  are  general-and   non-specific;   and   develop--
              ment  of   a. definable regional plan of action and mechanisms for
              .establishing priorities are very vague.

              Conmiittee'expressed concerns over the reduction in medical representation
              on  the  Cote  staff.  Three  positions  of  heart,  stroke  and   cancer   consul-
              tants  have  been  deleted  and.int6rnist   has   been   proposed   instead.
              The internist is expected to cover heart disease and stroke; and Dr. Perez,
              the cancer field.

              Commit tee  was encouraged   that the core staff organization has been
              expanded  to  include  an  accountant,  editorial  and  allied   healt   6   ficer
              positions and the time and effort for the unfilled positions of education
              research  and  evaluation  officer  have  been  increased  to  100'/.  rather  than
              5 O'/@


             Virginia RMP                         -2-               RM 49-02 (AR-'I CDS) 2/71

             Committee recognized that the VRMP has established a satisfactory relation-
             ,ship with the Virginia Medical Society; however, they have not been able
             to successfully acquire the support and active participation of the
             two Medical Schools in the Region.

             'Additional Fundi

             The Dev@-lop-,n n@t@@ Component request was not recommended for funding.  The
             Region has not reached an adequate level of maturity.  The Coninittee
             believes that the Region should receive an in,depth site visit in
             relation to its Anniversary Review Application in the November 1971
             Review Cycle.

             The Committee found little relationship between the two new proposals,
             Emergency Coronary Care and Procurement of Cadaver Kidneys, and the
             stated goals and priorities of the VRMP.  The Committee noted, however,-
             that the implementation of tne approved,but unfunded Project #10 -
             Multiphasi.c Scrc@,-riinc Program, could stimulate cooperative arrangements
             and give the VRI,.TP needed visibility.  Aware of the Council's concerns
             about @lultiphasic Screening Proc,rarn, the Corimi.ttee did not know what
             effect the May 1971 report to Council on the state-of-the act would
             have on already approved niultiphasic screening projects..  There ore,
             the Committee calls special attention to the Council on this recomelida-
             .tion for additional funding.

                                                       @IPS/GRB/l/19/71


                                            RECTONAI, LNiEDI(,,AL                   SERVICi,-'
                           SIT@lA@-@Y  OF  A'@@i@IVT7RSA@'Y  REVIP@,L   A'o!D   AILKF,D   GRANT   AP-PI,ICATION
                                                 (A Privileged Coiiniiuiiicati.on)

             1-@@N-SHIN.,GTO@\'/AT,ASKA REGrLO@@Al, Z@lEi)ICAL PROG-L@IM             @l 38-0@-", (AP,-,I-CD)   2/71.1
             500 U,@tiver,(3itv District Building                                    January 1971 Review
             Se@i'L-tl.e, @,,Iasliin-to.-i.   98105

             P-P,'Dr"P,AL@l COO"DTL@@'@TOR:   Donal R.  Spar,@tian, IT.D.

                                                1', DLT @L@_CL) i r @ t- C@c),c; t s On I y

                                                                       04                           05
             P @t     e                                       2   /l/71-.12    /31/71     I/l/72-12/31/72           All@ Yt,@
             Continuation Commitment                                   $1.,503,450           $1,596,935            $3,100,.)85
                (Core)                                                (638,906)
                (1-4      Projects')                                       (664,935),              -                     -
             Two Approved Projects  - Unfunded                              79,765                    3'0,800 I/          11.6,565
                                                                                                            9/
             Ne@,i D@-velop-.nental CoTiponent                             120,000               156.000---               276.0k)o
             Total Funds       Related    to    this    Request    $1,7    3@')I,5           @1,789,735                ,3,492,95@)
             Less;    Co-,@tinuqtioii    Request     (Sta4-'           -1,503,45t)           -I-,596,935           -3,100,38-@-I

             Cominittt-e./Couricil Acti-o-, Required              $       'L99,765           $       19'),SOD      $  '-z92,5,c-@5
             I/    Not    Reflected    in    Application    Budget    -    release    of    new     money requested
              .   ( L
             2./  (Not Reflected  in Application Budget)

                                                         Funding Historv.

                                                           PIA-Lvl'-N-ILN'G ST,'@CE

                                Grant    Year                        Period                          Fu-,ided-(t.,c-.@-
                                       01.                     9/l/66-8/131/67                            $-@66,Z-48
                                        02                     9/l/67-8/31/E,8                          655,1.48
                                        03 (17 mos)            9/l/68-1/31/70                           840,518

                                                      OPEP\ATIO-@@AL PROI@'P@iM

             Grant Year                Period              Council. Appro-\7ed         Funded         (d.c.o) Future C'oiriirit,.uc@t
                   ol              2/l/6S-],/31,/691-/             $1,021,06-              $]-,021,067
                   02              2/l/69-1/31/-/O.'--/        1,490,000:--;                 1,312,740              ----
                   03              2/l/70-1/31-/71             2,441,202                      1,820,8643/
                   04              2/i/71-12/31/71.            1,945,812                     ----                $1,596,935
                   05              1/1,/7'-)-12/31/7^          1,690,618                                           1,596,935
             1,/   (Cc)re   funded   undei.-   Pi-inn4l-ng Gr,@nt@).
             2/  (Approxinia@Le)
             3/  (1ccl.udes $215,000 02 carr-vo,,7er funds)


                Washington/Al.a:7,1,@6 'Rl;,T                   -2-                       RM 38-04 (AR--l-CD) 2/71

                                              li,7 - T,iis           incltij s tti  r-' states of                     incl
                                              @loo 000 square miles.           The 3.2 million rec,
                Alaska which f-ncoiaip@,@'@'s       $                                                    idents      of
                Washitic,ton state are served by about 3,100 practicing physicians.   More than
                half   of   the   physicians   live   in   two    population    centers,    Seattle    qrid    Spokane,
                which   are   opposite    sides    of the state.   Alisl,.a's 279,000 residents ire serv@,d
                by  soilz--  200  pr@icti,clltio,  physicians,  of   wioia,   about   90   live   in   Anchorage.
                Only   two   other   Alasl-nn   communities   have    i@iorc    than    15    practicing    physicians.
              .Washington   has   about   10,234    active    nurses    -ind    Alasl@,i    about    628.    Ancliora@e
                serves the r@i;ajol- g,,@o-rc,@phic population area-, of Al;isl@,i.           The state of
                Washington, somewhat like                     is  ,eogreplil.rall.y  divided   by   11).rurttzl-.ns
                into at least t-,@,,o ri,,n-joi-- acograp'@iic            The lar-cst                 ce,@itpr     cist
                of   the   mountains   and   the   largest   population   area   is    Spokane,    located    in    the
                northeastern    corner    of    the    stite.    Tne    Spoirine    medical    facilities    draw
                patients,   not   only   from   the   northeastern   part   of    llisliingtori,    but    also    from
                areas of Western Montane and the panhandle of Idaho, which are in the
                Mountain States Rl,fP.

                    LCTl,)l  Devel.ol-)riE,,nt  -  'The  University  of  Wishinc-,tort,  School.  of  1,@'@-dicine  was
                designated as grantee a-,ency in 1965.               Ecirly  in  1906,  Dr.  Donal   R.   Spnrl-Ir-oaii
                i.,,as appointed   ti'@e Ri'@P Coordit@,qtor.    In Se-ptei@;I',)er 1966,  the
                Regional Medical Pro-,ratn was officially establisher with tl@i@                           of   a
                three-year plennin,, grant.           During tli,@            of tlie second year and folio-T-71'.119
                a  site  visit,  the   Reg@Loii   beC@lTrle   operational   with   a   pro-rz;ni   which   fell   int@;
                three categories:        1)   f_u@ption   end   Trei.i-ijnc,   -   Continuing    education    for
                physicians was ei@i@)I-iarized using different methods of -.udio@,islial instruction,
                consultation,    and    preceptorship    technique.    PtogriFis'    @@ere    ilco     designed     for
                paramedical personnel.          An    expanded    library    resource    ;7as    developed    for
                Alasl-a; 2)              Stiidics   -tid   Services   -    Activities    in    this    category    were
                concerned i@ith                                and   consultation    and    pl@@terns    of    care
                for cancer patients; and 3) 14)L@e Lo@,@@ i@@lLi@onstration
                                                                                                        were
                implemented in the field of computer aided instruction, and cy-O'Lic fibrosis.
                Reviewers of the operational           ippl.ic@-tion    noted    that    the    proposal    clearly
                fit   together   in   terms   of   the   broad   getieT-,-jl   concept   of   the   Regional    Medical
                Program.   Many of the projects emerged front local. coi,,-P.Unities far distant
                from    the    University     Center.  A  ntir@.-iL-cr  of   imaginative   individuals   froi.1   c@ut-
                side   the   Univer,.-I.ty's   framework   l@ind   been    involved.    The    coordinator    had
                collected    a    good    administrative    staff.     The     educational     projects     which
                generally    er,-ierged    free    nreas    outside    the    university,    appeared    stronger
                than   the   developmental.    or    more    narrowly    oriented    service    projects    which
                stemro@d   free   university    sources.    Ti@7o,probleri    areas    were    noted:    1)    The,
                                    staff   appeared   lacking   in    fiscal    expertis6,    and    2)    the    area
                of evaluation was i7eak for ill projects.

                Early in 1969,  the region was evain site visited to:   1) revietq the pro@ress
                                                          0                                                     1z,
                of,the Region',,, total pro,,rem; and 2) further study a supplemental operational
                grant application.        Tl,ic team was extremely impressed with the ongoing planning
                and evaluation, operating procedures                   the    accomplishments    of     the     Re-ion.
                Much of the success was attributed to the leadership provided by the Progr@-tm
                Coordinator, Dr.                    who   sconce]   uniquely    suited    for    the    position.
                During   its   first   operational   year,   efforts   Iiid   beef-,    made    to    strengthen    the


                                                                                                           PM    3.8.-04  (t@R-1-CD)  2/71
                                    /Alasl i'                                 -3-

                   role  of  ttic  Regional. Adv-sory Grotjp P-tic',                                its  r("Presentziti.oi.            A
                   sound    and     wholesc)r@,i,-@     relationship     between     the     1111;!P     and     the     University     of
                   Vlasnin-ton had  been  established.                      A    small     but     competent     stiff     li@ici     been
                   developed.          Som@e                    tio-,7c!vc@r,         stil,l noted  in  the-  are,]  of evaluation.
                   At  this  stage  of  the Rcaic)n's  devclopt,--c-iit,  its  repres@oiit@itives were  Ittemptin-.
                   to     shift     frorii     E,,eii@ral     objective-,     cet-itrcil.ly     developed,     to      specific      ones      based
                   on     need,     as     expressed     tlirouc@hout     the     l@cgion.     The     tr@irisi.tion     fror@i      one
                 .perspective      to      another       was       proving       difficult.       The       lic-,gion's       original       concept
                   was  to develop  overall  objectives                               i,o,,.ild                  t(-IE'   Plitl-lill-    Of
                   appropriate     projects.     The     fail.u-@e     of      t@ti-'Ls      strategy      was      attributed      to      the
                   R,i  ions                                                                               perio,@',  wr@en  the
                   objectives were  still very general..    In an attempt  to m@,il@  the  chift,  staff
                   was    to    dQveiop    a    five-year    plan    x@,,tiich    was    to    be    presented     to     the     RAC     for
                   its  consideration.

                   Al.8o    during    the    first    year,    the    R"'r-     had     involved     other     q-ertcl.e:-,     and     had
                   developed  stron- relations'Liips  a,--,ong  thcta.                       This           pirtieLil.-II.-ly         true
                   'fo.-  sucl-i agencies  as  OEO,  the  Rcgio-iil                             Pl,,,n,-iiri,-,    Council     and     the
                   State I-Iceltli D.@--pprLr@icrit.           The                        of cc)fii-itiztity hosi)              viis     riot
                   clearly evident,                            efforts     v.-,ere      bni.n-         to                      this       7,rea.
                                Society       involv@-,,@.,.@-,nL        slo,.@            not uiiifoi-ri,  bait
                   At  this  sta@e  of                                it-        riot4if-I  threat  tire  Core  sLo,'Lf
                   the  initiative  ir.  pro,,ra.-it                               end    -a,    ei    Ministration    of    inclividti@il
                   projects.      There      was      evidence      ho-,7cver,       that       project       development       was       being
                   stii'@,,iloted at  the  griss  roots  level.

                   DLii,in@    its    -(-fcoii(i    year    of    opLr,,ition,    the    Pcgion    expin(.',    d    its    pro@rir@is     in
                   coronary      care,      share,      and       cancer,       t'iirouc.,Ii       various       continuing       education
                   and          demonstration           projects.

                   in   October   1.969,   @-iiioti-icr    site    visit    to    the    P,T?IP    i7,is    nece@,F@ctry    to    rc@vie@7
                   the     Region's     application      for      rene@,7ed      support      of      Core      staff      pl.@nring      activ-
                   iti@eq  -iid  10 projects,  and  the  request  to  it-cpl.cipent  4 reeve projects.                                 Since
                   the    Regi6rt    ,7as    about    to    enter    its    fourth    year     of     planning,     n-@iej     third     year
                   of operational  st-itts@-,  the  over@,I.l                                of    the    site    visit     t,,zis     piiced
                   Oil prq@l l@rev-!,c.-,.@7 rather  their project  r(l-vic,,,;.                  As    a     result     of     this     review
                   it was  ].earned  that a  nu.,,,iber  of  ir@@ipres!iivc                       Vi-i.-Lificnnt                      tied
                   occurred i,7iti@iiii  the  M@l,? durin,,  it,,  socc)-iirl  operational                                The       most
                   significant     chariE,;es     were     those     related     to      the      roles      of      the      Regional      Advisory
                   ComF@.iittee    and     staff,     and     the     influence     of     th,e     consuricr.     There     had     been     a
                   r@.ajor    tr8nsitio-i     fro,-,i     staff     leader,,iliip     to     RAC     and     coiiruricr     leadership     in
                   program planninc, and  direction.                      The    chen-c    arms     most     notable     wiieii     the     PAC
                   rejected     a     thtee-ye@,r     operational     pla-L-i     which     was     the     primary      effort      of      the
                   W/AP,l@fP planninc,  staff.                The             was     not     only     undergoing     a     si@,iiific,-I-Lit
                   transiti     on    in    philosophy,    pro-rar,,i    direction     ciilO,     I,eider,,,,Iiiip,     but     was     il.fo
                   beginning  to  iriipl(,i7ierit a  pro-r@ir,.i to-,,7ard  a  set  of ne@7 goals.                               Individual
                                                                  L>
                   projects     reflected     en     attempt     to     build      on      the      philosophy      of      the      Region's
                   flo'utreac'ii" pro-i-gni.          The  philosophy .@.,@)d direction                          ut-idertnl,-,Oil          indicated
                   that- not  only was  the  proararii accepted -throuclio,,3.t  tt'i,2                                    but       its
                   direction was  being  t,@tro-igly  infltic@iiced  by  tlic,.                                  tl-,rouc--ti   the    Ri,@C.
                   The  involvement  of  the  consut-.,,cr .;.-is  particularly                                         in  tl@ie  develop-
                   n7le",,it of  the Central l@lasli-,ngt(>n                                                                      for       the
                   Spokane area                       uii-'@qu(@.   o@i  tl-i   other none!,  t]-tc.                  Prc-,@   pro    raiti


               Washington/Alast@a Rf@',P                    -4-                  RM 38-O!@               2/11

               was considered to be predo,,,Iiii@ntly                  oriented.  The gonls for that
               area were not clear z:.,sid the activities were             Cicci-iocl innovative.  Tile
               RtVt, however, ,7as  i@i@211        of             lack of resources, and the problems
               involved in pro-raiii                     The                           cc)licer-n,-,c]
               reviewers in txio  t@7,3@7s. First, the sub-regio-.-i@.il or "o,,Itre,-ich" philosophy
               vTas  not  clearly  evident  in  the  indivi-OiLi@il  projects  is  presented   in   the
               written cippl-)2.c a L ion. This                     to be due to the uiifii.@iil.iirity
               with grantsii,,@-i-iship of those individuals who prepared the proposals.  The
               second and riost important concern v7.is over the impression of the projects
               were attenLptitiy to c,-@rry out the "outreach" phil,o,@-ol-)Iiy on an individual
               basis.   This       particularly i-ioLi.c(@,@l)le in the are@i of coritiniii!@-
               It appeared tiiz@@t the core staff could help coordinate the "outreach" impacts
               of  the  individual.  projects.  Further,   RI-IPS   revic@,7ers   believed   that   the
               blendiii,-,'of these different npproaclies should be a primary concern of the
               R14P, since the conflicts of philosophies and a lack of cboriinati6               ii ariona
                                                                                                        C,
               projects were most lil,-e y to occur at the corp.,P.,,inity level.

               The reviewers were irtlprer,@,ed r.,,ost with the cardiac pro-rar.-i.       the        sub-
                           ii.i      field appeared to           a close x7orl@in@ relE,.tioi-t,-hip i,7it'ii
               the Core staff planning officer, and also                    to be very familiar with
               the operational projects.        The -tro'zce prot-,ra@ii i@)os considered to 'h-lvc- bid
               re,-3so@i,obl-c            and it,@%- pl@irniiir, efforts       e-,,pc.,ctee,@ to be ,Iccelnrated
               and strengthened by the i(lditio;,i of -i stro'i@e planning officer.           It ilai-I noted
               that the cancer program had been pr@Ltii@,,rily centered around the automated
               tumor registry.

               The continuing education pro,,rL,,m          found to be provider,       rather     then
                                                 0
               probl-er,,i-orieTitee,. Pro-,ra,-,is for physicians, nurses .iiicl allied lic@,,ilti-i all
               seemed to have adequate thrust.         It appeared, ho-7ever, that these pro,-'rat.,is
               bad different Directions.  R6vic@iers believed that spccial attention should
               be given to coordin,@)tiri- these various approaches.   Further, the itteiiipt to
                                          0
               coordinate these education programs by Core staff should have been r,.-Iucli
               greater   that   it   appeared.   Evaluation   off   educational    activities    seemed
               very good, but very SpOLLy.  1, recent reorgn-,iization of Core staff respoisi.-
               bility  indicated that the Core staff role tied been redesigned to carry out
               the R@IP plans es developed by the PAC.          Also, it appeared t't'i@it a good
               Core  staff  had  been  developed  and  i.;oul.d  be   further   strengthened   by   the
               addition of.a iie@.7 director for evaluation.

               Dr. Sparl,,tr@an, the coordinator, still remained as chairman of the            RAC, however,
               there were strong implications that a clian-c would be forthcoming.  The RAC
               was found to be .,in exLrc.,@@aely active group ind @,7os committed to the revised
               goal., "Provide optinturti health care to persons in I-lesliington-,@laslta at rislt
               of  heart  diseases   cancer,   stroke   and   related   dis6ase.1'   The   methods   by
               which  the  Region  planned  to  work   toward   this   goal   was:   1)   support   the
               development-of   cooperative,   integrated   reuional   health    care    systems    of-
               malting  comprehensive  personnel  h,,-al.th   services   available   to   al.1   people in
               the-Region; 2) support and organize continuing education pro,-ram for all
               health providers to tipcl.-te.thcir skills and services; and 3) sponsor activity
               to increase the "capacities" of providers of hciltli -ervSces.


                   Wastiirigton/Alasl-,a  Pi,iP                           -5-                         Rl,t.   38--Ol@   (Al,-I@-CD)    2/71@,

                   Tov7ard     the     end     of     its     third     operational     year,      the llce,,ioii     submitted      a
                   supplemental application i,;Llici-i reqt:,.csted                                  support  for  the.  Alis'-,',
                   @lerlical  Library and  tile 1,c-d-ical  Co@,iputcr                 .       Services Projects.      'Cilcsc      t@,,,o
                   components  %?ere  favorable revie-,7@d  by  term  1)@c-ember  1.970 Ccuncil.,  but are
                   not        funded.    In     addition,     tiir-@             -UI)Tilitt@Cl   @i-,l
                   ey,clusively -,Ii.tli                 dircise                              Tot-fi,,-d  the                    Diseise
                   Control      Progrpni,      the      proposal.      contained      el.cverL      interrelated      parts      in      four
                   major  areas:
                   Al.t@ioti-h  the                      noted  tli,@:t  the  St:,@-tc,  of                        has  a
                   rc-,,Iil               c           in S--@ttl@2                                                                  tIli2
                   coalition of proposals  fro,-,.i re-,ial  disea@es  expe-,ri",frc)@'ll both Seattle  and
                   Spoknrle,.the    only     tiqo     densely     populated     areas     to     be     served     by     the     pro@@ret-,i,-
                   it  appeared  to  the                           that    the    plan    in     tirIC
                                                                                                      application      li,-)d       been
                   developed    by    the    rerial    experts    with    little    input     frozen     the     RI-!P     Core     st:,i'Lf.
                   14o    additional    r@,2,iT'o    funds     Here,                     for  tl@,,@  I'licivicy                  Tli c@
                   Region      h@i,,                                           is                    by            and   x,.!ill. be      the
                   subject of a  separate  surt:nary.

                                     and                role      in              hc-@ilt'@i  c@@re  records,  tile
                   of  tile
                   in  some detail  the  plan  for  1969-73.                      In     light     of     pi--ogreri      experience      ducal
                   the  past year and  of                                                   of  reSicn,-il health needs  .fill(]
                   resources,     the      plan      1969-1973      i,,,as      Modified      and      Simplified      to      b(@tter_Cxflress
                   re@,,ional  objectives  -,P, noT7' preceivod.                    Priorities  hive  been  set  for  the
                   expenditure  of  tiT@ic  a,,-id  effort.               Goils  have  been                     far    relel.-ion     to
                   their    importance    and    ur-oncy    for    the     Region,     inei     to     the     li/Al,@",'@p     capacity     to
                   meet  thei@i keel)in,,  in  mird  the  p-zbbl-c-,nr@  peculiar  to  the                                and  the
                   unique  streii<,tbs  of                         The  reni@iiig  o@ pro(,ri,-n priorities  is
                   follo;.,s:

                           1.      W/t.,I'.,!P Priorities  (ProOtict)

                                   1.    Support       develon@,i-,,iit       of       cooperative,       integrated        re-ioiill
                                                    care   netiorks   ,o   that   eicli   p--itic.@nt    r,-i,@,y    ree,--@'-eve
                                         qu,nlitiy service  appropriate  for his  o7,7n pcobl.c@@liz-,  and  as
                                   -     close    to    his    home    as     is     consistent     i@itli     optittiurn     quility
                                         at reasonable  costs.

                                   2.    Support    activities     to     better     defiiiE,.     health     rii,-inpoi@7r2r     and
                                         health     services     deficiencies     and     to     @,;oi-k     to-,@,@ird     their
                                         resolution.

                                   3.    Support activities  to it.@,prove  care  for  the medically
                                         disadvantaged.

                                   4.    Support     modification     of     the     e@.istiiic,      health      cire      systet-,i
                                         airiied    at.    ir@-iproving    tne     efficiency     of     providers     in     the
                                         organization and del.ivery of  (ju,,!@i.ty 'ic@-ilth care.


                Washinoton/Alask@i  P,'                                                     RI-I  38-04  (AR-1-CD)  2/7).

                                         Prioriti,oz;   (Proc@ @"s'                tctiOlls by      @@,"ii-ch      the      Db@v      four
                               objectives  are  to  be

                               1.    Ex,,),@ii)d        's      ro'@r2      as      n      catalyst       incl       coordinator       with
                                     he@jltl-i-rel,ited  agencies             develop            closer            coor(.Iiii,nti.on
                                     v7i(:ti                                      state          lieili:li          igencieL,.

                               2.    Support an                     Continuing  Eriucat-.i.@,n   l,rcorrat,.i   for
                                                                    in  C)rde-@-   to
                                                      level of pro'L                                iithiii          the
                                     health             care                                         oil liu-cl-,4-L,
                                     and allied health personnel.

                               3.    Increase   cr@.ipha@,is    O',i    screening,    pre%,ciitioll,    early    care,
                                     rehabilitation,  ambulatory care end eiTerociicy care.
                                                                                               C,

                               4.    Assist public health                         I)ro,,,r     to
                                     better utilization aj@'                   care

                I,,Thile the                        to
                a,@c)  tl)  re  fail  be  a                   C).L'  f o c I,, F@0                  c  n c     P, t. r C)
                a-,id  related  diLea@
                                         ,'4 e 1: C  I'@l           I t .  cc)-             .0 @i c't:. i o t-i ti i@ f
                atio-,i  of              continues  to  be  an                      1)zirt of tt-ii@ goal of improving
                health care.   Examples of cooperative                                     are   offered   as    follc)@,,7s:
                1) A co[n,-,itinity coordinator group foi-rfic!d  two years ac-,c) by 11)1)ol.ntrci@ilt from
                the   State   1.1,2!dical   Association,   the   University    of    1-7@istiiiiSIL:ol    School    of
                I,'Lc,dicine and tf,.,-        has proven to be @ii                                               link
                these three orgnniz@@ti-onq;  2)                                            Ilo,@pit-.@ll t,-osociatioils
                meaningful                        of hospitals x7itli             Ri,it) h,-..r; b-.(,n         to iiiiteri,-Iize
                than was  this relationship with                                                                    but
                Progress   has   been   r@iode;   3)   Relation   to   other    I)roZr@rio    co@,,ccrcice,    ..7ith
                planning end ii4,lprcvr@,i-@-.c-iit of health                       both tlir2 Seattle lic)del, Citi.tes
                and the State and                                                                    I,,,,,oiicies are
                represented on the PAC.              Further,  crof3s                            of staff and Advisory
                con."@iiittee                                      iiid C;@-P L)'L title, St,,tr-@, Arc,,i-@2i.cle iiicl County
                levels continues          ,id        been incre@lL@ed.                is @'i 2,00@i  Cli,fl"@,,tc  of
                cooperation bt!tuc-p-n             and CIIP i.,z         t@,,o                 are, c.,          ob,,t@lclcs
                to @,ccovxpl.isltin,, @c@,)Cl joint t.-iorkiiig                     in i p-co@,i:,iri oil
                4)  I,.Iashingto,-i  State  D@p-irtr@i,2rit  of  I'@e.,ilth   -   Close   ind      productive       relations
                exist   with   the   Washir@-ton   State   Dapartir@citt   of   Health   i,71,lich   is   now    a    pnrt
                of the State Social and Health Services                                     5)     'University     of
                Washington   School   of   i.,il.@dicirie   -   joint   point   ilLs    between    the    RI,,?    and    the
                Uhiveroity School of l@l.,--dici,ne continue.               A   total.   of   93    physicians    from    the
                School of IL!edicine his participated  in                      Continuing     E:ducatiol'i     Protl,iprps
                and the close ties bet@7ce.n the                   ContinLljn(,-,, Ec]Ltcition and University of
                Waship.gton ContiiiLtin.@ 1,1,,dice.1 Education ire ini-itunlly b-@n6ficial. in many
                ways;  6) Voluntary 17'ealth t,-cncic--c - There irc- i@itiltiple croos representations
                beti,7-2c--n           of  the  F,,'LIP  and   the   two   St@,tc,,   Ilieai:t   Associations   and   five
                jointly     sponsored      @,ct-@vitier,.      The      director      served as consultant to


                                                                                   7-                           38-04           (AP-1-CD)           2/71

                   the        Rel-iibi.li.t,-@tion        Section        of        the        li,-iter-Soci'.et:y        C@)@@ziiirsicii        on         Car(liovasci-iiir
                   'Dise,nse           and   on      a         at  the
                   in ti7ovembc@r  1.970  wl-iic'p.  diicu@-rcd  x-7ays  in                    RI-i-i"E,        and        Ileirt        affiliates
                   call       work        together        to          the  ISCCV                           A     F
                                                                                                                ,c@ocl          repre@-ent,3tioi-i
                                                                                                                                        --t @- 1 ito I
                   continues  to                                                                                             t I     I,lz I rk  c,I
                   and  Alaska  divisions  of  the  P.E,.aricnii  Cancer  Societ-v.                        Evidence            of             cooperative
                                                                                                    d
                   relations      is      deiion-,,t-i:tited      by      t-.i-ic,      cclitribtitioi,i      of      both      the      I-Iisliingtoi-i       and
                   A I a c,   cl i v i E i O,.,) o  f  IC   17,  -'Lear,                         to                the  Ri,-llll

                   Boune@prif.-!3:      Both  the  states  of  l@Ial-hin-ton  and                          continue          to           agree
                   that                              of      the      t@,io      stated,       clearly       fits       into       the       regional       cciicept
                   and  is  beneficial.             The  southern  and                      borclc!i.@s      of       ttic,       IIishingtoii
                   portion  of  the  ll,eQio-.,i  have  been  the  subject  of  s(-,iTie  discussion.                        For      most
                   purposes  of  tit,,2                     the      prer@cnL      boundaries       of       the       Stp@te       of       l@,lsliiilgt@-,i
                                                     and         satisfactory         dcliiicLitio@,i         of          their          ictivitie,.;.
                   Piiysici-.ons  Arco              in                                                                             cIC2,-'!.-Ce
                   for  active                                   tL-,.@           Bond  to  eirite,  hive!                      no             desire
                   to  cl,i,@in-c         southern  bc,,iTl@'zj-!.-y.                                         ns  tried                 center
                                                                                                                                        /Al@   @"O
                   for            EasterLi                                        z,,rid  T,!,'cstc.,r@i            Inc]             @@7
                                                     Pr             spill             iiit-t7;  th,@@@.@  z@re-L7,,,
                                                          11
                   there      has      been      no      re(4u,-,It      to      incorporate      any      portion      of       Idaho       or       l@'onttit-,a
                   into I,,'/ARI@.P and  such a  step does not  seen i,,eccssi@-y  for pu-A:po@,@,es  of continuing
                   education or  to it-.il)rov,- health care  services,                        In    t@,7o    areas    of    Epstctrp.
                   Washib-ton on  the  border of Idaho ni!riLly,                                                          Le-@,7iston-
                   Cl@irt-cston,  turn  professionals  froi-..i bot:li  -t,-tc-s  hiv-@.  joined  i@-i
                                                                                                          @p                            ate.
                   activities  in French                       and  the 'fountain Stal                R"    jointly             pnrticip,

                                            'o@-L:   The  Co@@:@lunity                 Sei:-%,!.co,,-,      D'@vQ]-C)p,     art,:-'     Procretis
                   have been gi-vc!i@i prir,,sry responsibility fo@  t@-licing                              ccci:essive             steps
                   tot,,-ard  subrerlion@il- clcvelopi,,-@nt.

                   11    ,tlth    Care,of                                            Tiie   F,.AC   li,-is   decided   that:   -   1)    the
                   Region         shouted              itself  to  the hceltit                   faced,    of     all     the     citivens
                   in Washington and  Alesl@;  and  2)  slid! @7orl@  to                                      the      efforts      of
                   other    groups    seen    ns    CFO    and    li'lod,@l    Cities    @.@tiosc    pri,-Iiary    riission    is    issistii-ice
                   to  the                    needy.

                   Cotqt    of     Ecol.tli     Care:     It     is     hoped     that     appropriate     Modification     of     the
                      l@t-           s-y,s--t-e-r-i-of   @,.,hich   the   P,'rl'fl   r-,ny   properly   be   involved   such    qs    the
                   ,Yider use  df ill,-erl Health personnel  of                                           and         health            service,-
                   should  lea4 to availability of quality care at  lesser  cost

                   IL IL31 iLt y@. Ci r-c@ :    l@lc--sureable  iml)rovc-,-rc-iit  in  the         quil.ity    of    care    is     an
                   objective c!@':      @-@l  the coritini-iii-tc., education  projects.

                   13ettet lJtiliz8ti.aii  need 'Pistri.l)-Litio-Li  of                       C,.ir(-,                   The    Region     ti<.IS
                   contributed      in       the       planning,       in    the    teleran,'    of    I-li@DEX    personnel    at     the
                   University          of                      This     p-corrari     cc)-,i@ributes      to      a      better      distribution
                   of healt'n  -service-.-,  ot-d n  greit an,,-,ilabil4.ty of the  sair@,e.                     The
                   hospital autopsy rrrdj(@ct  led  !-o better                                        of      the             F,,,@neril.
                   practitioner and i-icl@Arby


                Washinotozi/Alasl,,a RIJ?                                                       P,@l 38-04  (AR-1--CD)  2/71

                                                                                         "he 1,       p      rtictil@it-ly
                through  its   El@cLitivc@   Co@,.@imittc-.e   has   i@orke(T--'c-'I---o-.-cly'   @@;,-t-h   Core   stiff   in
                irnproveriicnts  in prorii:,?,@'i                      duriii,@,  the past year.         These
                have      produced      clearer      definitions      of      staff       responsibility       better       r@icasures
                of perforni,,.nce,  ir,,,pro,,,cd co.-,.,!-.,,iiinicition          st@iff,    and    bet,,,icen    staff     and
                RAC.     The Cc-re  ctaff                                   the           d(?,,,,ire   to   serve    in    the
                "honest brol,,er" capacity to coordinate efforts  to,.I,,.ir,(,'  improving  the effective-
                ness   and   Satisfaction   of   health   provi(,'or,-,    in    their    i@7c)rl-,    nrcl    they    are    maki,n,.-
                qt3ality henlt'o. care                              te)    the              izi the   Region.  In this 17,ly,
                                             of    the            tl-@ Prcgz7,3,.n his              ttic   rerl)ect   of   thL,

                                          StriActLI-)-e

                Up@n  the impl.e.-ti--ntation of  the  '@klaii  for  the I)evel.op@-ient of W/APIIP 1969-1973"
                an                                   vn,,   ii-iitint-ceA   to   determine   -vil'ic.,ther    or    not    the
                               of                            1,7,ns suci'l stiff cc,,-ilei, by itfi Iicti.vitic@-,,
                accoui,@ll.sh the Fcials an,-l o'Dlecll-i.va.,            set forth.        1,@s  a  reL-,,,ilt,  tli,2
                was re,.ti:Llcttjrr:,@d c).-i a pi.-o-ret7i bases           a                     rel.itcc.1  groui,),,   of
                activities hav4@rL-1,                                                  The    office    of    the     Di.rector
                was rezil..'Li;ne4 for                                      pi.              Icluei.ii@
                cc)or(l@i-@,,ni--ion,                                                               @,,ervices
                adri-tiyii.,>tr,itiozi       pLi.!)Iic                      Specific prc,@,,rirns fare set Lp in C@ic
                                                                                                    -tion, d--velopiiic-ntFil
                folloi-ting al7C,,-,aS:    heart,  cancer,  stro.@e,  continuing             oe@itc@
                proc-,ram and cot,,,@-e,,-.trLity health services.          An Aclvl-sory    jCor@,@@nittre,     under     the
                              of the RAC was assigned to each procriri ire,-t.                      Tlic@              of
                Associate         Dirc,(-tor      created  for c,@cli proc-,r@@@i.        As   the   pro-i-or@,l   n@atinger,
                he    assLivies    the    usual    executive    fii-icticn,,    associated    Nitli     the     aclr.,i@.iiirt@r@itic)n
                of his prbgra@-i@,                     fiscal and                                        Ilis program
                responsibilities     @re     defined     as     ad,,-Pinisteri.ng,     pILiiiiin-      and      coordinating
                progrrtt-.q activities and projects.               A   detailed   organization   c,iart    is    sho-.@7ii    on
                page 112 of the -,ppli.cntion.
                ,E@c,-ional                                Executive, Pla-iinii@@,,  i-Lid  other  Cc),,.-,iii.ttc-.'C?s

                The   RAC   has    eeiftotis tr,-ter-I   its   willing   ,ic--ept,.ince   of    the    policy    and    decision--
                making role  ttint                   the defl.nitior,, of this body           Is      responsibilities       in
                laxq and                          That        Liricc@rt,@,icity as  to the direction of the procrii,,i
                lirigered  is sho@.,-ri by the continuation of the di.rectoz of the progr@i-cli Is
               .Cliairi@-aii   of   the   RAC   until   IIov,@-riber    1969. Oi-i@thit    date,    lir.    Robert     Ogden,
                -i   business   Haiti   fro,-,a   qr)c'@ene   and   an   npl)ointe"e   to   the   RAO   at   its   inception
                vias elected ch@iiriii@.n.        The RAC                    to  ti,-@et   every   t@7o   or   three   mo,.iths
                and the Executive Conipiittee,  composed of members of the PAC, m(@cts                              once    a
                month.   Advisory Co-@,@-Lii-ttees  for heart disease,  cancer,  stroke and continuing
                education lia@,7e existed -ince the beginning of the                                       Corr,-,Iittees  or
                the    developmental    programs    and    cor@i@,,Liriity    health    rei:-vices    hive    riore     recently
                been formed.         These   coi-ii[iitteo.,g,   broadly   repi.-t-.,-,entative   of    @ippro,@;:!..,tc
                di seaplanes and with adequate,                              di,@,;trib,,jtic)n,    have    met     re@Uinrly
                and have functioned effectively in I)I.c@iiniric,.                              staff,     revic-,@iiil-.
                applications    for    graiit@-     or     other     @ul)port      developing      guidelines      for      care
                in.the area of their responsibility arid particular corrpeifctice.                             In     the


                                                                                            9-                            Rtl 38,@04 (Al,,-1--CDN               2/71

                                                                               --cl  hc)c-                                               Ul,) C)L@
                                                                                                         T)',@j) P I,-        I:
                      of  the  RAC         nict  repeatedly  to  develop  tiif,,  IIIAL@LL                          _III        fC)        1969-1973.   Prc)visio.,-k
                                                                                                                                                by  special-
                      -of  the  Pll.'l  to                  it                        fo,,:  1971-@1974                 acco@
                                                                                    tire  P\-i@C  i@)js                          and  by  the  E-,ecutive
                      Co,,jii@,ii-ttec,  in                          for  pre@,ei,itiLioLi  of  the  revised                     I)Iciii     to      the      PAC
                      for  their

                      The  PAC  is  co,.iposed  of  42  r@ic@,,7ibers  qs  follo-,-,s:                        19      physicians      of       wilcim       t@,7o
                      represent
                                                                                                                                      Public            I'l@nit'q
                                                                                                                          f,t!r
                                                                                                       @,,ind-                   staff                rc-is-i:erco'
                      nurses  both  of  i;ltoiii  represent  schools  of  nursinr.,;  three  hospital  admiiii  t)-,qtors;
                      one  Allied  1--,,,ealth  rel)rc,,,,ientative;  t@,7o  Social  arid  ]:')Behavioral  Scientists.  one
                      of             rep-,:Csc-Lits  a  @.adic-nl  school.,  the  o,-Iie-c  a  Til@ii-in@Iric,                                                for
                      Urban  disndvi.,,nta-ed;  three  non-healt'li  professionals;  teii  business  or
                      r.,@ann,,cri.nl  of                        reprec-,cnLr,  ties  Ui-tiv@-r.7,i.ty,  three
                                                                       rely  -  c)rg,-.nizciLic;,@-i  for  t:ti,,  Urbili
                      and                                                                              'L'
                      @   i  f our        Ilt-,, 1) 1, 1 c  o-  Con c3 .i t..i@r  re 1: C., s C!,-t L,-,, t i vC,-., 2     or  0 f f i c il I       and       one
                      slot'ttc@r"  Pr

                                               7                                                                       vLry
                                                                                                       cii  p5i,,eF,  72  -  79  of  tli@,.!
                                                                                                              ' 11
                      The  proceon  is  broker,                         tt-.rec:  i.@ajor  areic,  initial                                aic!i  preliminary
                      reveal,         application         preparation,         ni-id         forr@.i--il

                                                     t 1.

                      The  T)ro,,,rari                       i@-  r@.,,netc-  up  of  a  total.  syct(-@i@ ethical
                      coi-itr,)l  -nd,                                  for                    Of         spocifi.c         prograri@:@',.cd          activities.
                      Each  specific  pro,,rii,- @-,,ithin  the  n-nster  pro,,raai  is  made  up  of  related  groups
                      ol'  acti.vit5,e@-  haiiing                         goals  and  objectives.                    the      basis      for      this       type
                      of  I)rogrir,,i  appro-,-ic,i  i.-,  Detailed  pli-,inin,                              pr6,,ii(-],js  for  the  step  by
                      step develo@pr@T!i7i'c of t:@ii operz?4tiT.-i5.-, pl.an  17i!iC't'@                                  the         results          d--,Sired
                      over  a  period  of                         Usii-ig  this  apprc,-.cli,  a                            plan  for                        iiij
                      approved  arid  pro%,ie@  s  t'-te                         )'or  tt-ic                                                        pl@in  and
                      an  operating  p@;ii  for  each  fL!,-)ctioiairt,,  project.                               These      plans      @,7ill       be       used
                      as                       4piiei  basis  for  @ictic.,ns  for   the  prc)-rir4.i  for  1971-74.                             This
                      concept                            PI.,-,II  for  the  total  prc,@,r,,ir@i,  and  ol)er,)tin,,!  plan                     for         each
                      function      and      each      project,      i7iiicti      describes      in       clet,@il       the       overall       goals       and
                      objectives,,  the  detailed  activities  anl  schedule  for  each  facet  ind  the
                      monetary  -,iiiOLI'tlt                    to  Portion  qnd  part  of  the  procr,)ril.

                      a@iiiiin,?             Peasi@bil-ity  Studies:                  To  date  Core  staff  funds  were  used  to
                      carry  out        or       participate       in       eight       planning       studies        durin-        the        1970        fiscal
                      yeari       These      (lot,),      collection      aid       analysis       efforts       were       in       addition       to       tvio
                      inforr.,iatiot-i   '-oriented         operational         projects         and         jelected         data         collection          and
                      analysi,4      activities  in  supp,,)-@-t  of  edtic,;ti..clial                                               The  eight
                                      studies  end  their                           as  of  October  1,  1970  ore:

                              1.     Spc)7f.,@ne  I-loi-fie                Cn@--(2  Aid                      to      asses,-,       interest       in
                                     resources  of                         Marc!                  service                                  concerning
                                     nc,  d  for                1-i@Eltl)                                         to                   for
                                                                                          in                                             Co[-,-ipletecl
                                     1970.


              W    ingto,.-@    IA    P                  -10-                             (A7,-I-Ci)) 2/71

                    2  . Wlii-tui,7in                                           Survey     to        select
                         i r,.-,p or t,-@ i-,iI tl t  pr co I c I'll  ri -Nice  iu r-, I I-)  ol@ i Ch  t@i e  I,"ii i ttq,,i n
                         County COP  could  bcgin  pl@-@niiiiit-  for  hciltli  care, Co.,Tip I.c-, ted
                         August  1970.

                    3.   1,@hatco@,i,      Si-,a@.,it,       Island Szin Ju,,iti  Coi.ii@l@i
                                                                                                Health
                                    S-.-ia.-vev  -  to  survey                     of  fieil.tli  care
                                for  pr-',r@-nry  )n(i  ct@,,,2rf--eicy  c@,re. cr,7plClt-e,  1-1,@ly  1970

                    4.                                                              BLirc,,iti.   o   CoL.;---ii
                         Develo,-)ti,-?-qt     Survey     -     to     assess     patterns      of      health      care      of      fqr;ii.lies
                        .predomiiintly       rural        region        concerning        the        possibility        of        being        able
                         to        supper--t  both  neiditio--,-i@il  rti-@di,cnl oiicl the  dcveloptn2lit
                         of a COT-rl)ined exte-,ided care facility and rural area clinic.

                                                                   to  identify  the   health   status   of
                         the               of tl,,e             of            I't,,irbor, resources Iricl
                         facilities available. to rti-,et tl-,@-- needs id@iiti.fi-td in re]-,..,tion,-,hip
                         to status,;, and to irt-vo'j.va @-i                 of the
                         co.-Ice-r-..is for problci-.s of                                               1970.

                    6.   Wnsni.n@to-@i State liLirsc-,,@@ A,,@t;oci,-@tion Cc;-t-itinLiin(-r,  Survf!
                         to de-terii-@n(@ pr,@ceived continuing educ,-,tio,,i need of 1-1@611,-nE,@ton
                         State v@ui-sc!s.  In process.

                    7.   lye,-,,rt Stiz@,,c2ry       - to ol)t@iin        rc,-nrdi.nL-, ex,-,,-riencL- @,7itli
                         tic-art surgery in the                         r@c.,.gion. On-oin,-,,

                         subsumed under Core staff support, the                    of  this   projoct   is:

                         (1)  to obtain baseline inforr,.atic).-i ,s to Morbidity and
                              mortality of coroi.,ary, artery disease in a selected slib-
                              region of IFI@tsliiyitc)i-i

                         (2)  the test the feasibility of P@               of obtaining such
                              inforr,intion about all- categories of disease of concern to
                              ttic@     throughout the Re<yion.

                         (3)  to  r@icasure the reliability of medical records face sheets
                              as  source docL,,i,,,,@-,,its for corollary artery disease data
                              ering.

                         (4)  to test the feasibility and desirability of extending this
                              program  throughout  the  cntire  1)@(-,gioii.  Terr@iin@@,ted June 30, 197CL.

              Evaluntio       The Rei,,ion's evaluation plans ,@re described in clc,,tail pages 84.-89.
                       -Lli
                  'd upon the overall. regional plci-ii,  9-11  cl)cratiri,,       for each function
              Base                                                         0
              and pro4ect is developed and                 t'Li@  basis  for  actual  provision   of   dita
              which is utilizers in the evaluation process.           T'iii.s  concept  of   evaluation
              culniiiintes.in    nn                  for        levc@l,' oj'
                              in a                                          the
              of data at each            of the                                   is           by  tale


                                                                                      -10-
                     l@,.Sllillgtcjn/Al@islil@,@ B'J.P                                                                 III 38--O'-  (AP,-I-C@))              2/71@

                               2
                                                                                                                                          to            select
                                                                                       inci  if;,-ties                           tho  I)Iiitpi;sn
                                      county  C@',IP  coL,.l.cl  begin  planning  fc,-c  lie@ilth  care.                           Coip@pl,@ted
                                      Aul7.,tist  1970,

                               3.                                                  nrcl   S,-i-,i                                                     Ficaltli
                                                       S@irvQ-@         to       survey.consur@icr.e:,,Lj.vllt(-',-.,       of        health        care
                                      nccdo                             end  c.-iercency  c,3re.

                               4.                                              t,-,Iij.v  rEity  of li'@,.@,-@l,ki..n@'tcii,  LurcLi i-i  0 i'L@  C c,@      ii i t
                                                            Si-irv(,,-.i  -  to  assess  patterns  of  health  care  of
                                      predo,-iiiratly               rural re-.iort       cc,,iceriiin-       the       possibility       of       being       able
                                      to     support      both      additional      rii@,dical      to,,otipo@-?er      -,nd      the      dc!vnlor)ri      nt
                                      of  a  comoincd  extended  care  facility  and  rural  area  clini.c.

                               5.                                                   Si.t             to     i.(Ic@nLi.fy      the      health      StlLuO      Of
                                      thc-                        of   the    co,-"-@l-,-o.-i,-ty of                                                   z;-i-id
                                      ficilities      avai3al)le      to      t@lloc,.t      LI-ir?       iieeO,@       identified       in       r(?Intionsni
                                                                                                                                                             p
                                      to                   'III(!  to                     lar,c-                    of   tire   cc!z@l-ii@-ir,,ity   iii
                                                                                                                                                                   C,
                                                                               of                 care  eol.iv,--ry.                                   c, I  1197

                               6.                                                                                                                    surve
                                      to      det@2-ciiiine      prcceiveei       continuing       oducitioi-t       ne--cl       of       1-:',)ohingtoii
                                      State  nurses.    In  process.

                               7.     Pe@rt                     Re5Zistrv            to  obtain  clit@i  regardi.n-  experience  xqitli
                                      heart  surc,ery  in  the                                               Rec-,ion.       0-iicoin@-

                                                       I  Infnrctio-,i  Pc@-istr                -     an     a      former      pl.annin,,      project:
                                      su.bsL,r..-t,eci  u   er      Core      Staff      Support,      the      purpose      of      this       project       is:

                                              to  o'btai-n  basclii@,c  inf  rr,-,@ntion  as  to  rf-@rbidity  Ind
                                              r,-,ort@-@lity  of  coro-@in,-cy,  artery  dise@ise  in  a  selected  su.b-
                                              region  of                           and

                                              the       test       the       feasibility       of a  ric!tl-iod  of  obi-@iiiii,.iiF,  @uch
                                                                    -bout      Call      categories      of      disease       of       concern       to
                                              the  P,'@,IP  throughout  the  Regio-zi.

                                      (3)     to      r@ic@-t,@ure      the      reliability      of      medical      records      face      sliE@et.,3
                                              as     source     etocui-,,.2-,,its     for     coraii,,,ry      ii-tcry      disease      data      gatf-l-

                                              erin,7.

                                      (4)     to       test       the       feasibility       end       desirability       of        extending        this
                                              prograrii  tlirou,c;7hout  the  ciiti.re  I'@egion.                     Terr,,iiiiated       June        30,   197Ct.

                     Evaluation:              The      r@euio-a's       evaluation       plans       are       clescrili,-@d       in       detail       pa-es 84-89.
                     Based      upon      the      overall      re-iortal       plan,       an       operating       plan       for       cacti       function
                     and     project     is     dcvelops-d      ,-@id      bccor,@,es      tli(-@            for       actual       provision       of       data
                     iqliich  is  utilized  in  tlic,  evaluation                                          This       co@-icepil-        of        evalu@3tion
                     C1,11@@.iirtates  in  v-,i                         pl,,@n  for  e  'ch  lcvol  of                               i..,il:hliii
                                              in  -,  Yil,c,@r@ii-clii-cil                    @iii0i  permits  the  systematic
                     of  date  at  each                       of  the  6rg,-,@.nizatio-,-i,                     data     i-s     Liti).izc@cl     ]:)y     the
                                                      rr",-:1--i'll,@i"pf,-@@  fn-,-  t-l-IL,            r@.'                      ii)rl


                                                                                                                  RI@l 38-04  (1@R-1--CD)    2/71

                                                                                               perforr:,,,@c.1        any  ,,ncllor  all  level,-
                                                         fc),@  c-,
                     of  the  total,  progr,-@rc,,  niad  will:                 1)  provide  for  evaluntioii  of  tried
                     'proZ;rnr@i pi:c,@,re  s;  2)  pro-qid-@  foi.-  -,,ri  effective  base  for  directing  the  progrir@i;
                     3)  provi(7,c          base!  for  a@@-i  effective  aIlL@cct:-Iori  of  funds  ind  other  resources;
                     4)  gi-ve  visibility  to  potential  problems" ire@,s  c),,i  a  ti.rr,@ly  b@l,,,-is;  5)  i,mpro-7e
                     rnc)rale  by                        @@.ii  opporLti,,iity  foi.-                           t(,i                            their
                     Icapabilities      and      ef'L'ort;      and      6)      provide       for       a       coordinated       effort       toward
                     ,a  corir@lon  goal..       This  concept h@.-  been  @nppl,ied,(:o  the
                                                                         th,--rc  -iic)@-               aii  o-cerill  plan  for  t'iie  progrnt,.,,i
                     1971-71,,                                                       o'll'i(,'  project  oT,) e r i t i i-@ @  p I;P., rt,,,3 Tile      clltq
                     buying  getieratct.'i  by  tkic,@e  pl@4ris  is  bein,@  utilized  for  evaluation  and decision-
                     makinc,       purposes       during       the       1970-71       pro@.,rain       period.

                                                                  the  early  st,-3r,es  of  the  program a  subregionnl
                     op
                                                                                     ce,                  -v?hicli  served  the  ni,-i  or
                            aLl@ll    was  established  in Ancliorar,                                                                        i
                     geographic  arid  population  area  of:  trif-it  ,Late.                            i,ater      during      1968,       a       part-
                     tirII2  ptiy,-iiciszi,  tog,-,t't-ic@-1:  i-7itli  a  @ocre'c.,iry                hired  to  z,,(Itnini@,ter  the
                                             Alc,,,"L,@@i    project    n-ne,    by    eoiz-,rl     so     ser-,,7c@d     i,@     the     coordinator     of
                                        Prc)erzi@-,l  for  SoLitlif@@@irte-cii                       Further     c,'ctidy     is      being      c,-iv-111
                     to  incrE-,@,,G@.i,g  Llir-,  size  of  the                                                                               C@.nti-@@1-
                     p,-)rtio,L'i  (tl-,,@  Iar-e  t  ircp-  of
                     operating                   its  c@Ir,  byl-@-,-,@Ic,,  li@@;  been                             i-id  is   fLiti@--tic,-Lii-i-ig
                     in      e;e'Linin-.      the      foods      of      the      populntioii.      The      Coordinator      and      the       advisory
                     cor@@,r,iittee      i7ork      cl,osc@'y      i-iitti      tlin      various      associations       ancl       iaencies       within
                                                         L
                     the  state  of Alici-a  is               does     the     Core     with      the      various      agencies      T,,itlii-ri      the
                     State  of                              Close      liaison  is  ri@,iiitziiiicd  beti,,ceii  these  representatives
                     and  the  Core  staff.               In  19'08,  an  Eastc-r,,i l-,Iastiin@-toi-i                                 office
                     established  l@7itli  I  cc@ordin,-tor  @;,id  a  -@c-crc@tpry.                        Ai-i  advisory                          for
                     that             hr.,s -been  established  snd  is  flincti.oiiin-  effectively.                                  This  coi@;,..,-iiittee
                     .represent-.  outlyin-  districts  in  the  eastern  part  of  the  state  and  is
                     presently                        the  health                    of     the     area     c3,,-icl      consideration      several
                     projects  to                   th@l,r  needs.          Ti-ii.s       subregion        also            in        close         liaison
                     with  the  8o'@-ttle  Core  staff  froni                            i-t         receives         necessary          aclr@linistrative
                     services.

                     The  rerabc@rs@      of  both  the  Alaskan Advi@,,c,,,-,y                                 inet  the  Eastern          l@'@isiiinE,,toii
                     Advisory Coni.,-iiittee  serve  as  r;teiiiberr,  of  L'LIZ,                             Rec,ional  Advisory  Cor@imittee.

                     T'ne  need  for  further  sul)-d-7-visioii  of  the                                     is           studied.                 Several
                     areas  @,7ithin                           end                 have        iiidi6itcd        interest         in         subregion,.jl
                     developr,@@nt'.         Studies  are  beir,,-  continued  @.7i.tli  the  CIIIP  "A"  and  "B"                          agencies
                     qs  to vlietl-,'P-r     or  not  it x,7ill  be  po,,,sibl(,  to delineate                                               subregion,'Il
                     arc-as  for  b;btli  progr@@i-tis.

                                                                      Present @,.rL)  ic@qtio-,i

                     As  noted  on       the  consolidated              btjdcret    request      on      page      12      of       the       application,
                     a      total      of      $1,623,li5O      is      requ.-@stc!d      for      the      Regioii's      fourth      year,       2/l/71-
                     12/31/71,      for      coi-itinu@Ci      support      of      Core      staff      activity      and      14      projects,      and
                     support  of  a  rieii  developmental  co..,If)onei-it.                      It  @l-ioul.cl  be  noted,  ho-,.?cver,  that
                     the     Rcaion     in     requesti,--     release     of     $79,765     of     nL-i-7     r@,.one-y     for     support     of     2


                                                                                                  -12-                         Rii 38-04                             2/7).

                       ai5prco-r.@e(I  L,7lt                                             T'r,i,@   t(it@l                  of                       are  to  this
                       application             i@,@              $1,703,215.    Of        this                             f.;tl.ff  Iction  is  to  be
                       ,L.il-(-,n  ovi  $1,50'1,450,                             $199,7'0',          o;i                                                                !-r,
                       reqtijr  (I.                                                    tii-,,-   ri                    014  yr-.@,,r  as  requested  by
                                                                   is  requ,@s               0
                       R@A,,PS  to  alilrii                             's  1@i-@.,-Iiversl-:ry  date                    tti2  r,,.@ijo-i-ity  of  other
                       re,,,ion.@,  in  tli@                                 cy(..-]--@.     Fc)i:           05  y@@@ir,   I/I.//2-12/31/72,  the
                       IZogioa      is      requesting      $J.92,800      for      tfic.      ,,ccoiid       yDir',q       support       of       one       of       the
                       approved/tinfij,@.d--,d  projects  and  tlie                                                      co-@,non@rit.

                                                                                O!@                                  05
                           L@l 0                                       2   71- 12      71                      1/72- 12        72                     All@    Yei   r   s

                       Direct  Costs                                     $120  000                               $156,000                                        $276,000

                       '!'he  eiii,,@uiit  rer,,uested  for                  this                      is                                      $40,00              th@,ii
                       the                            could  b.--@       funcl,.fd  u,,icloi.                           S                             The  priorities
                                                                                     @C-s              be                      tiic  1971,-197@'@
                                                                                                                                                                    been
                       pl,,3,i  v.@@                    c,-i-i pn Te       131-133       of        t',Ic          .Cq tictill.      Ilriorit-i-co            la
                       di,vi.(3,-,,,!  iiito  t@,7c.)                                                                tli2                          by              troy
                       Hill be a--@L:@Leved.                 @reas  of                                 for                                            b E@    i
                       cril-isi.r@,@,@-3:  e!  foi.                ye,.:r                         @i   c@ ii-i  five.                      1)
                       x@7itli                ci,.,e  proviclors  of  possible,  t@,,o(,lifi.cations  in  the  hen'Ltli  care
                       orE,nnization  anl  6elivzry  syoter,.l  inclLill,,-i,  tl,c                                                           I  r  rlor
                                                                                      I                  C-1                                C,                e
                       effective                                                                       2)                           of  nc,@7  ,!nd  iiiiio@,,tivc@
                       approacli@cs  to  rural  health  care  needs;  3)  exploration  of  new  and  iiinovnti.ve
                       -3@)pro,iche@,  to                                         sl-ic)rt@lf,os  @@iicl  r@iileti.,;trii)Lition;  4)
                       of  wider  and                     coordinated      use      of      holes       health       c;3i.-c       -@,icl       other
                       services   is   an,    @,ltcrii@,7cive    to                                                  and  5)
                       in  cooperatic,-@.,i  x7ith  C'@'P  (B)  3c,-)c,-tcies.

                       The  revi-c,,17  procedure  to  be  used  in  viloc@iti-cir,  fiiiieiel;  for  (Ic-velc)prr,.ot)tcal  activities
                       i.c-  cs,,@c@@ltielly  the                           treat               in  ti-ie  rec,,ul.ir  project  dc-velop,-o.@@@@nt  process
                       with    certain     i-11.@-,,'t-:Lfi.c,-,,tic,-@,r,,.    The                                  irc@  introduced  to  ensure
                       f Ie@"-i! I) i I i ty'                                       on  the I)E,,rt of  the                             while  not
                       the ri,(Z"or O@L  the r(-,vie@7 T)-cocedtii:o.                                                                           revic-@,,7 process
                       will  differ  froiii  the  procct  revi(---"7  process  as                                                       1)  for  @-ipplicatl@lis
                       requesting        lec-,r        th3@-i        $2j,000        the         Director             hav(!  authority  to  approve  an
                       e,i,.lird  with  i  report  to  the  E,@,ccutive  Coiii@-Iiitte@@  end  to  the                                              @inc',     2)     for
                       Application,.!-,      of      r,)oi-e      than      $2,(It')D      but      less      tllnn      10%      of      tot@91      dcv.eloi)cl,c-tltal
                       funds       for       aigiven       yl--L@,r       which        require               icticn         the  ],Incentive
                       slinl,l     li@-lv-@     the     -,-Utllority      Lo      cinke      @n      decision      on      appro-,:,,il      or      disappro-v.11.      of
                       an  activity'.             The                               be  r@i,,tde  by  written  bill.ot.                    A  report  will.  be
                       rcinde  to  the        PI,@G

                       The     critcri@-     specified      for      teco.-,iic;,,l      rc,,vici,,,      will      be      the      sarnL,      as      tli@,t      used
                       for   project.   rcivic@i,7   pi-c)ceFs.                 Ilo@,ever,  I)eforc, ecvel.opi@i@2ntil activity
                       the review st@ir-;c, it                         neet one or ii,,orc- of-  the (lev


                                                                                            13-                           rd,,! 38-04  (All@--I-.C]))            2 / 71.

                                                                     co-,itri.l)u';-c    to      tlti--                   ,I L..  Of
                                                               for           fi-tt,,tr(@  is                        in  tlic-  tlirec-,  year                    ni.id
                                                               -t@             @7;  land  2)  c)ff@@r                            for  pi:ovi(lin-,
                      sLtppleme,-t,iry        pol@@@@cy        ,
                      information  or                                   activities  by -(,iiiicli  tli,,-@  goals,  objcclivr@'s  and
                                       of                               kept     in      st(@,-)                                                                 III
                      ficaltli ccr(:.                                                  c-citi2ri@i                    be  zl)plicd.                        Applications
                      foi-  developTqent  I  -,ward,,,                       be    subciit@tc@d     to     the     RAC     it     any     of     its     'Lour     or
                      C"or,-,                                         yoor.        In  ot-clc.,,.  to  eii,,iii-c  tliz,.t  fu-nlo
                                    inc,   c@@-i    tc@-)    T)r-I.cr-!.ty    prc)jcct-.@,,,    no r,-.ore                               of
                                                                                                    -it     Barry                                                tl-iis
                      I.iri-tit  ni:iy   1),,2                  in  tl;e  c@,-"  of
                      or  urg(--@-icy  by  .9                                      oj'  t'ne  Li@C                      pres@,,-it.
                                                                                                        ,Yill    not     be     clissi.riil.-@r     frc),@     t'tic-
                      control  of  devel,opi.,,,.s@rttal  i7;7@irds  activities
                      tyi3iiagr,iL,nt        of        overall        prcgra,,a         accivitilc,.

                                                                                         f

                      p  r  oc- c t    9;"      A I                          T, i

                      G.    r,-, t i 0                                                   Council                                             t 13  e
                                                           R

                      Ol.-2/68-1/69                        $21,754                       $21,754                   $21,751@
                      02-2/69--1/70                            9      328             9,328                    17,299
                      03-2/70-)./?l                          28,700                23,700                      28,000                           ----
                      04-@2/71.-12/71                        31,320                31,320
                      05-1@//'2-3.2/72                          -0-

                      T,ri  I'.-nvF-lr;lber  1970,                      in       its
                              t          place                              ctaff,         t,-e         y)roject                  ciild  Llic  PAC
                      LI@is  project,                      ci,].    believed    t',    n-l-    trip.              ILI-clic;@711   Library   h-@,   p,--    -ivi    e, @'t
                      ,-all    it%r@.f)crtgn"-              to                                                            support  sli@),,ild  be  continue
                      for                                                                                       tip  the                           'Yhc,
                      of  titin  project  is  to  create  O!l                                                                                                      of
                                                                                  to     cciitribLito     to     tli2      cc@i-it:l.iiuj.tlg      cducc.@-4011      of
                      physicians  -4-itd  ial,li@eei  he,@ilth                                       in                 by       provi-din-        full        nnd
                      equal.                   to  cu@.-rent                          in      t@ic             I  @,,Cic@i7iccS.

                      Project          Y,-38,@                    Cc,.,z-,!)utcr          S-2rviccc@
                      Operational                                                     Cot-l!lc 1,  I                                     Future.
                            Year                           Reouested                  t-.  nroved               Funded               Co,,,i@-.,titrtient

                      03            -2/70-1/71               $145,600                 $45,600                   $35,000
                      04-2/'71-12/71@                          48,41;5                  46,/,,@t5                                            ----
                      05-1/72-3-2/72                           36,800                   36,

                      let     November     1.970,     Coi.@@L-Lcil,      in      its                           tlii2t
                      -h  d  tat",,-,a                              P,'L'D  st@,ff,                                                       tl@r--@  P,,',,C  cc)-o,,ccnrii-c,

                      c,i    Lul"eel     tii@.                   of                                                                                              to
                            p
                      regional


                                       CONTINUATION ACTIVITIES               RM 38      2/71.1

                   In addition to Core staff  activity  the  rei,,ion  is  requesting  continued
              support for 14 projects as indicated below by programs and goals:

                   COY,Tll,7JIl?,i@'i EDUC2,'rIOZl P'AOCPAL. GOI,@L: Support and engage in an organized
              Continuing  Education  Program,  in  cooperation  with  other  related  organiza-
              tions., in order to  provide  health  professionals  with  the  opportunity  of
              maintaining the hicliestoesired level of health care capability.
                                  0
              Project -IKIR Centra.1 I-"Iashington I-Ir@ct. This project is in  the  third  year
              of its five-year pro-ram period  and  its  goal  is  to  develop  a  regional
              program  of  integrated  continuin-  medical  education  for  health  profes-
              sionals in the  Central  Washington  area,  and  assist  in  the  application
              of this model program to the 1-1@ishi-ogton/Alarka 'L',eFion, as related to  the
              P,egion's goals.  Its objectives are to:  1) assist in developing the audio-
              visual aspect of an integrated continuing education program for the
              Washington/Alaska area;  2)  provide  subregion@il  cooperation  within  the  Cen-
              tral lilashincto,-i Regio-.i; 3) distribute, utilize ind evaluate  self-in-struc-
              tior,.al material; l@) promote i-,iteraction- anion- physicians and nurses  for
              diagnosis @,,ncl treatment to continuiii- c@itic.?,t.-ioll; al'll 5) promote participa-
              tion and oCner medical education.programs.

              Pro@ress  indicators  are:  1)  50%  viewer  potential  of  production  achieved
                                           I
              and 2) 750 participants in conferences.
              Primary evaluation inciiccs are: 1) 50"/'.  viewer  potential  of  production
              achieved; and 2) 750 participants in conferences.

              Project 1,@2',', - Southeastern t@laslza  This project is in the third year of its
              five-year program period and its -oal is to stimulate participation in
              continuing  medical  education  activities  by  providing  educational   programs
              for medical personnel  in  Southeastern  Alaska  for  the  purpose  of  improving
              patient  care.  Its  objectives  are  to:  1)  conduct  instructional  presenta-
              tions; 2)  offer  specialist  consultant  services  for  patients;  3)  alleviate
              professional  isolation  and  develop  patient  referral  patterns  by  providing
              opportunities for  personal  contact  among  local  physicians,  and  with  con-
              sul-tants from @@7ashin-ton State medical centers; 4) provide audiovisual
              equipment and  programs  to  health  practitioners;  and  5)  plan  alternative
              approaches  to  continuing  medical  education  in  isolated  areas.  Pro)-ress
              indicators are: 1) 12 medical  consultant  visits;  2)  4'.ZN  consultant  visits;
              3) 8Preceptorships;  and  4)  60  patients  seen  by  consultants.  Its  primary
              evaluation indices are: 1) 15  medical  consultant  visits;  2)  8  preceptor-
              ships; and 3) 10,meetings and conferences scheduled.

              Project 7'1'3 - Postgraduate Preceptorsiiips for Physicians     This  project  is
              in the third year of its five-year procrani  period.  Its  goal  is  to  sponsor
              and arrange preceptorsnips which  enable  physicians,  nurses  and  allied
              health personnel to spend a period of time in  a  medical  center  with  a
              specialist of their choice to  refresh  and  reinforce  their  knowledge  and
              learn currept methods of treatment.  Its.objectives are to: 1) match indi--.-.
              @d al physicians ,Keith a specialist or                    of


                                                        15 -

              choice in     medical center to learn new techniques or reinforce their skills
              and               2) r@,)@pind the current preceptor@,hip  program  to  include
              group short- courses and  training  in  specialty  areas:  3)  offer  i  limited
              number of  preceptorships  for  nurse  specialists  and  those  in  allied  health
              professior.s; and 4) expand preceptorship net@..,orl-. Pro-@,-,.ess  indicators
              are: I'/, 63 precep-uor-@liips; 2) 328 preceptee days; and 3)  75%  of  prc-cep-
              torships satisfyii-i-- a majority of p-zecepl--e(--'s objectives.   Pr       evaluation
              indices are: 1) 105    proceptors; 2) 485 pi-ecepler days and 3) 75'110 of
              preceptors'iaips satisfying a majority of precepl:ers' objectives.

              Project @';5!, - Inl'orr..,-,ation and Education Resource Support Unit.
              This project   is 4 n tire third year of  it.,;  five-year  pro-ram  period.  Its
              goal- is to provide e6Ltcational and  in'@ornatioriii  support  for  the  Central.
              staff and operating p-roject of 1-i7,ishirictoni'i@-lasl@a PJ,!P. Its ob ectives are:
              1) assist represeinta',-i.ve-- of health  practitioners  to  identify  needs  in
              continuing  education  and  to  impIciTertr-  ind  evaluate  continuing   education
              pro-rans; 2@ promote regional                           continuing   education    rela-
              tionships; 3) provide public information iervices for I.," 'A,'Zkll' and its
              projects;  4)  produce  printed  and  audiovisual  materials  as   requested   by   the
              Central staff and -,7a-,-ious operational projects; and  5)  ii-.ain-@aln  a  network
              for distribution of those Materials that             brin- a continuing education
              process in convenient reach of pn@ sicians, nurses ind allied health cire
              personnel principally in the two states,  -,,-ithout  Iislo--atinr  them  :Fror@l
              their field of P2-act)-ce.  Progres@, i-d,.citors are: 1) 130 production requests-,
              2) 15 audio-visual  educational  p  cla@es;  Bruce  3)  quality  is  measured  by
              response  to  need,  subjective  statements  and  exposure   rate.   Primary   e%,alua-
              tion i-,aeticies ar'e: 1) l'!'jO production requests; and 2) 13  Auclio--,risual
              educational pacL,,ages.
              Project '117 - Co-,itinLtiina Education of Labo@-,-.torv Personnel.
              This project is in the third year  of  its  fi-kie-year  pro@,r,.'Ir)  period.  Its
              goal is to  up@rade  the  techniques  of  laboratory  personnel  in  the  !"'/A,a,P
              Region.  Its objectives are: 1) maintain the established pro-raiTi of training
              center-based continuing education of laboratory personnel intact including
              a r,.utual communications net@,Tork; 2) ir., leriei-tt locuni tenens program;  3)
              increase the scope  and  cual4-ty  of  tire  training  pro-ram;  and  4)  to  support
              laboratory se,--,-inars conducted in a training center.       ro-,ress  indicators
              are: 1) 57 Trainees, and 2) 235 nLirfiber of training days.        Its  -DriTIarv
              evaluation  indi2eg  are:  1)  60  trainees;  2)  375  number  of  training   days;
              and  3)  level  of  capabilities  of  the  trainees  are  represented  by  center
              evaluation ai-ris.

              ll,'F@11,P,T PROGP@I COAL: Improve the total cardiac climate incl.udinc, prevention,
                                                                                       C>
              early  tare,  hospital  and  chronic  care,  and  rehabilitation  for   persons   with-
              in  each  community  of  the  Reaion,  with  special  attention  to  matters  of
              distribution, cost effectiveness and quality of care.

              Project 'I'@'6R - Coronary Care Unit Coordination Project
              This project is  in  the  third  year  of  its  -Five-year  program  period  ind  its
              goal is to coordinate the actions of persons involved in the care of coronary
              patients through the development and improvement of cooperative networks


                                                                  16 -

                 involving cor.-iiuniti,-s in health care provides for the benefit  of  coronary
                 care practice. Its objective are: 1) to i.-@Tprov(@, coitit@iuyii(,ations iii,ong
                 persons involved in the care of coroni-r-,, patients; 2) develop and i.i,,iprove
                 r-,",U educational programs in continuing nursina education; 3)  provide
                 support to continuing education pro-,rar@is for nurses, physicians and other
                 related to cardiac care; and 4) evaluate data, needs and technology relatinQ
                 to   coroiary   care   in   TI@7ashington    and    Alasl@a.    Pro@@rcss    indicators    are:
                 1)  judgment of the Cardiac Sub-Co-,T,-i,.ittc-e leased on quarterly reports
                 and interviews -@.tith the pro4ect staff of evidence of effective and appro-
                 priate use of project funds and personnel tirte directed to-,.7ard the ob-
                 iectives listed in (--he operation plan;  2)  300 nurses trained; 3)  20
                 courses   receiving,   coisultati.on   and   I,,%f   support;   l@)   2'0'    clinical    preceptor-
                 ships;  and 5)  60 studeits'  advanced course.                r,@ipay-v                    indices':
                 1)   loi,er   Mortality   rate   of   patients   in   Cl,U's;   2)   decrea,,@e   in    percentage    of
                 units   found   hazardous;   and   3)   'UO,O'UO   units    of    training    using    CO_u    workshop.
                 Project #28 - Subre,,@i.onal Coron,73:@, Care Educational Pro@raiii.                  (This      project
                 has been combined T@,@ith Prolect               130                                natio,,-i,   for
                 fiscal year 1971).          ','his  pro  ect  is  in  the  middle   of   its   second   -,Tear   of
                 it  s  ti-2o-year  proZra,,-.ct  period  and   its   -oal   is   to   provide   a   beginning   frarile-
                 x.,ork For e,,.evelopL,,icnt @nd ir.--.p,@ov(-,i.-,evit of cooperative net@@,,orks x,,,itli@Ln  and
                 betijeen   subreaional.   coTn7-rlinit-I.es,   tilei-r   health    care    professionals,    and
                 institutions    in    the    development     of     self-supportin-     coi@.tinuin-     nursing
                 education,  through the support iii(i coordination of                  subrecioiial        coronary
                 dare nurse education programs.              Its                  are,-  1)  develop   and   i.iTi-,orove
                 programs    and    processes    useful    in    continuing    nursir,.-    education:    2)    implement
                 meaningful   evaluation   of   the    pro@(,ct's    impact    on    the    nurses    involved    and
                 their   patient    car--;    3)    provide    support    to    conti.iiuin-    education    programs
                 for    nurses;    and    A)    encourage    cooperation    among    the    education    centers
                 in order to reduce the amount of direct                      -1@'undin,,   required   to    continue
                 project    activities.    Primary    evaluation    indices    are:    1)     300     nurses     trained;
                 2)   20   courses   receiving   support;    and    'j)    175    proceptee    training    days.

                 Project l'i'20 - Pe-iial and Adren@-il Ilyperteiision.
                 This  project  is  i-,-.  the  T--!iddle  of  the  secol-id   year   of   its   tl,!O-year   program
                 period   and   its   ob@,ective   is   to   improve   the   early    detection    and    dia(,laosis
                 of   renal   and   adrenal   hypertension   so   it   can    be    treated    -,hile    still    curable
                 a-id to' lo,@)e-,-- the- ass-@-.7 cost throu-ii --he use o.@ i.-Adio-iiiin!uno ass@.ys and
                 other assays.        Its oo-'.ectives are:  1)               the                 'for  plasir.,a   renin
                 activiL-.r as -, ccr@.7i--C;  2)  develop            establish    t,ie    cli    ical    correlation
                 of raclio-iT,lr,'@UnO assay of regain;  3)  develop alrlosteroiie assay;                       establish
                 and maintain a hypertension re-isti.-y;  ar,,d 5)  educate medical personnel about
                 the    advances    ir-    di-i-rosis    And    treatment    of    curable     hypertension.     Pro2ress
                 indicators   are:   1)   "O   additional   case   pickups;    2"    1500    tests    aiven;    and    3)
                                                                                    10               C>
                 te-,tf3 110-IC           f2l,-exjhere.    Pripiar@ evaluation       indices are:  1)  30
                 additional case pici-,ups;  and 2)  600 bi-o-,-is--,iy tests civeii..
                                                                                         0

                 Project #27 - A       Col'Eniinity   ,%Dproach   to   the   Therapy    of    i,ife-Thr--@atenin@
                                     Arr'iijthr@,,ias and Acul@p- I,,',7ocardial infarc,lion outside   the

                 This   project   is   in   the   middle   of   the   second   year    of    its    three-year    program


              period and its @,oal is to  stud,,,,  the  Feasibility  and  efficacy  of  Operating
              r;iobil.e      staffed and equipped Lo h--ndle icute, potei,.L@izilly lethal.
              ai-rliyl--hr,-,,ias anrl to fuiietio,.-i as corc,,ii,-,ry care ut-ii.ts outside the hospital. Its
              objectives are: 1) operate the s,,stel-n inci assess the  effect  of  the  I,"o.)ile  In-
              tensive,"Coron,.),r@, Care Ufnit          sNrsteri in  sudden  death  in  acute  Toyocar-
              dial infarctioii,   and in other life tLlreaf@eririg. situati-o-,is for %@hich  it  has
              been utilizecl- 2) determine the feasibility  a-,id  efficacy  of  ol3eratincr  a  @II'CCU
              @;ithout i.,,r.-.,ediate attendance of a  physician,  utilizin-  trained.,  experienced
              firer,-.en ,,ho have access to medical direction 'ijN7  radio  transtiissjoti  of  voice
              and electrocardiogram; 3) study the                    of  the  local  sudden  death  pop-
              ulation a,-,d Utilize triese data in  -in  effort  to  improve  the  @"II/CCU  operation,
                                                           -- of        I;,Cl                        lu
              and to better define the potential val.ii          this 1.1  tTJ system iTi the coning nity;
              4) continue to e::pand efforts air education,      both  at   the   professional   level
              and to the -eiieral community; and 5) secure       additional   funding   for   continued
              operation of the systei@i beyond Auc.,ust 1, 1970,  Pro,c,,,-i-ess indicators ",re.- 1) systc-,,.
              capable of operatin-          paramedical staff only- 2) lives saved;             public
              response i.iiiicacea' b-,7 increased num.)er of calls;   -,nd 4) establishment of
              quantifiable data.Pri,.-.iir-)7 Eialuatio-.i. in(.Iir-e@,: 1) system  capable   of   operating
              iqith  paramedical  staff  only;  2)  number  of  lives  saved;  3)  public  response
              indicated  by  increased  number  of  calls;  and  4)   establishment   of   quantifiable
              data.

                   r
              STP.OTIE         COE@@L: Promote  end  en  a-e  in  ictivities  directed  toi,,,ard  the
              a--hieve-,,-,eitt of cpti-P.@al health care for all persons in the P,,egion v7ho have  had
              or are at significant  risk  of  suff--riii@  'Lroin  stroke  and  related  diseases.

              Project i@21 - St3-ol-e Edtication-Personnel.
              This project is 3.n the middle of the second year of its ti,,,o-year program period
              and its coal is to proinote and Drov-i.de             modern knowledge all,-,I  skills  to
              medical,  paramedical  and  appropriate  lay  persons  in  order   to   achieve   optimal
              health care for all- persons in 1,;'ash-@n-tori and llaska  Nqlio  suffer  from  or  are
              at  high  risk  of  stroke  and""or  related  disorders.  Its  objectives  are!  1)   in-
              crease interest. and I-,noi,,-I-edge, @nd -,ilso improve and  maintain  abilities  of
              appropriate  persons  regarding  stro.@@e  and  related  ('tireases,  2)  increace  consul-
              tant availability in  areas  of  need;  3)  evaluate  needs  @ind  methods  of  ineetinc,
              these needs in  the  region-,  and  4)  promote  cooperation  and  cooperate  @,7ith  other
              P,l@iP and nor--T,.',@T projects.  Proaress  indicators;  1)  stroke  ;pecialist  nurses
              developed  and  practicing  in  1,c,,ion;  2)  iieitrop-itholo-y  technician   developed
                                                 c>                      0
              and  practicirc-  in  P@e-ion;  3)  450  nurses  trained;  Z@)  50  physicians  trained;
              5)  200  lay  people  (educational  proQraws)  trained;  and  6)  15   consultation   trips
              completed. PriT,@:e,-@v  evaluation.  monetary:  1)  300  nurses,  100  physicians,  and
              50  lay  people  trained;  2)  3  consultation  trips  completed;  3)  1  stroke   special-
              is@ nurse trained; and 4) 1 neutopathology technician trained.

              Project @,@24 - Stroke Pehabilitation rursirig Proarai-@i.
              This project is in  t,)--  middle  of  the  second  year  of  its  tllr-@e-year  program
              period and its -oal is to improve strol@e  patieLit  care  in  10,,Tashington  and  !ilasKa
              through increasi-pa knowledge  and  skills  of  IU',Ils  in  the  area  of  rehabilitation.
              Its  objectives  are:  1)  provide  instruction  in  rehabilitative   nursina   for   RN's
              at  Good  Sartiaritan  Rehabilitation  Center;  2)  support  community  action  in   stroke
              rehabilitation; 3) evaluate  ir.-.,pact  of  course  on  nurses  and  patients;  and  4)
              determine project self-support potential,          -ogress  indicators:  1)   116   nurses
              trained; 2) 5 two-i,7eek nursin<- courses held; 3) 1 @r-ollo@i-Lip course held-,
              4) four family stroke classes held;


               held; and 5) dcntonstrat:ed chan@e in patienl-    care.            evilt itior, indices
               are:' 1) 81,,. nurses trained; 2) 5,040 tr.-iirinc,  days;  and  3)  demonstrated
               change in patient care.

                        I
               Project i',@31        (,ountv Unic               State Heart Assori.atio-Li Strol-,e

               This project is in the i,,iiddle of the seco  nd year of its two-year proaram
               period and its coal. is to introduce -,.@-id develop the concept of restorative
               and rehabilitative nursing into'  the.  hospitals,  Pitrsir,,-  holes  and  homes
               of        and Thurston Coui-@l:ies.  Tts  07) iecL!.ves are: 1) develop
               s'i,:ills, attitudes and techniques in restorative and rebabi     litat4ve nursing
               for rITls, LT.'@T I S
                            t@   end 17@urses Aides; 2) proriot,-- the acceptance of Litilizina.
               the concept of restorative and rehabilitative ilursiii<,; 3) ii-,iplei-fieii'c hor,,,.e
               health ai.de pro,,rar,.--,s t@,7ith rehabilitation ind restorative nursin,@, emphasis;
               4','F develop course for families so they may better understand and case for
               tiie strol.@e patient:; and 5) evaluate ii,,pecL  of  courses  in  knowledge  and
               attitudes of students and on restorative  a-..id  rehabilitative  nursin,,  i.-Li
               the consulate,.   Pro7-rc-rs indicators: 1) 10 I-,or,-te health aides trained;
               2) 54 nursiii.,- persoi@riel trnined, 3) 72 ph@,,,;!.cia-Lis oriented-, li.) 150
               participants in ii.-i-service trai,,iin-; -@,.id 5) 500 hours iii-service trairin-
               completed.  rr4lr@.,!I-r@7         indices:
                                           _A   - .-         1) 11,4 Illou-@-s didactic instruction;
               2) 192 hours !,,,i)orcli:ory; 3) 60 nur S 4 -fl. p_ personnel  trained   4)   500   hours
               itistructioti of in-service trainin-; and 5) 1.50 in-service traininy
               participants
               C!,I,TCZR PPOC-2,IJI- COAL: Promote and en-a-@e in regionally coordinated
                                                        C',         -
               activities directed tox-7ards a balanced proiyriiii for the prevention, cure and
               optimal palliative care of cancer, @.7liere cure air not possible, for persoiis
               N,jitliln the area.

               Project -@r'12!L', - '2,ae-@iolo-ical Physics Program.
               This project is in the third year of i@s four-year program period and
               its coal is to provide a radiological physics service to radiotherapists
               through the provision of accurate physical data, modern tools and corpiiuni-
               cation of improved techniques which fill result in better care of the
               cancer patient.  Its objectives are. 1) create an effective or-anizat on
               to provide a radiological ph,?,sics service; 2) provide physical data
               essential for tire practice of radiotherapy; 3) provide services of
               benefit to               patients;  4)  provide   radiological   safety   service
               to tire radiotherapy departments; and 5) provide devices and instruments
               of general use air radiotherapy.  Pro,7,ress indicators.:   1) 80% of radiation
               therapy patients encompassed by the project; and 2) 50% enhancement of the
               quality of patient care by the use of the physics service indexed by the
               yearly increase in these services.  Prirnarx evaluation indices:   1) 75%
               of radiation therapy patients encompassed by the project; and 2) 20%
               e@nancement of the quality of patient care by the use of the physics
               service indexed by trie yearly increase in these services.
               Project 21@@32 - l,ashin@-tonIt@la3 1-a Auton-ate(i Tui.)or -e i<-tr
               This project is in ,-lie riddle of the seco-,-id year of its t@.7o-year program
               period and its aoal is to provide hospitals wife Auto@,-@iated Tumor Pegistry
                                0
               services i.,,hic,i N%iill collect, coribine, co-,Tpare a,,-,d evaluate uniformly defined


                                                                                                                   RM 38   2/71.1

                  information    on     cancer     patients     dp-si,@neet to i!,.iprove patient care and insure
                  proper                     Its   ob@e-tiveo   ira:   1)   provide   a   qu@,lity    s,,Isi:er-i    of
                  data collection a,.,.d  file T:la2ln'ce,,lance co thit i,,Ieanin@,ful reports ire
                  continuously producec-'!,  interpreted a            rid used!  2)  provide effective qu@lity
                  control   of   data   and   evaluate   iiiforiii.at4-or,   ]:)@j    continuous    trairLin,;    3)    provide
                  a fol.lo-,,l-up service for all part5.cipai@-i-ng hospitals                         can    pror!, 'o@e
                  and   e-,tpedi.te   pati.e-c@.t   'Lollo@,,-tip;   I:.)   provide   comparative   data   lists    for
                  all                      hospitals N,,,hich             n:easLire   -In(.1   coi7@p@ire   the   quality
                  of diagnocis aril effectiveness of vir4,ous tre,-iti,-Ienf@ @@@od,?,IiLies;  5)  conduct
                  training seuii-aars  -for all tuT.,@or re@ist,-r-@r secretaries                      special         training
                  for Autorated T-ti.@-or !:'c-,istry                     pro@@.74.d(-- consultation to l-,.o@,p@,-tal
                  i@:ith respec.': to                                               --oiitiiiuous 1-ul.d          Oi-illt
                  assistance slio,,il(I jz av@iil,-;!)le to aDslz-.---act ciser,;  7)  p,,7ov,'--@le da@@-e@
                                                                          e
                                            s ,  @',) - -i lu 1,            , t   C.,.   -TIOI-ir
                  for special stuiie                 s-.L       c 1.   e             .I i tj       Llllet  LT           of
                  cancer                   4Lve           of -.late in ipte-,,-I,)ret;-ve reports
                  stration                                                                   tre-ti,.eit;   'a-fiet     f 0 ry! -
                  atio-., of   a Ttir.@,,or                                                                 o q
                                             a   '@-bruar-,
                                          actu              ,    1,    1971    cases    35,000     par,-icipatir-     hospitals
                  19;  2)  p--oiected  Dr--ceT.,,iDer  'il,  l.'@71  cases  4'),OOO  p,7,rticiprttiii,-   I-lo,-7tpi-tals   21.
                                                          1)   actual   Febri-,ai.-y   1,   1970   -   cases    1.9,CjOO,
                                      ilO,';PiLal@'3  IC);  projected   Jzi,.i-,.-,ry   30,   1971   -   cases   27,/@00,
                  pai-ti-cipatin- hospitals  17.


                                Pr,:GTOI,'AL MEDT(tT., PRO'7,ItM@LS SFITVICE'
                    r)UMYil,@t@'I OT@ All OPEPATIONAL rUPP@1,EITTAL CRATIT APPI,ICATION
                                 ,(A Privileged Commnication)

          17ASIIINGTON-AIASKA REGIOtaL MEDICAL  PROGRAM                 Mvi  00038  2/71.2
          500 "Ull District Building
          1107 N.E.  45th  Street
          Seattle,Washington  9810

                                Donal R. Sparkman, M.D.
          Program Coordinator:

          Requested
          Program
          Period                   lst year              2nd year             3rd year     Total
          Direct Costs          $281,803              $279.1347            $199,016       $760,166
          Indirect Costs          489047                511,189              292494        1280730:
          Total                 $3299850              $330,536             $228*510       $888,896

          Historv: (See  History  of  (AR-1-CD)  2/71.1 also under consideration)
          Backaround:  In November 1970 Council considered a proposal from the W/A/R   MP
          termed the Kidney Disease Control Program which contained eleven interrelated
                                                                             ivni - onA  education
          parts in four msior areas:  administration; transplantation: kav       it
          The Council noted that the State of Washington has a well-known renal diseases
          center in Seattle and that the application reflected a coalition of proposals
          from renal diseases experts from both Seattle and Spokane, the only two
          densely populated areas to be served by the program.  It appeared to the
          Council that the plan in this application had been developed by the renal
          experts with little input from the RMP core staff.  In a sense, the full-blown
          plan seem to be imposed on the r44P.  The application included considerable
          detail about the eleven individual proposals, but it failed to provide any
          analysis of the options available in planning kidney service programs in
          this type of geographic area; i.e., the cost of relocating and rehabilitating
          patients in center population area as compared to diffusing services transplant
          to areas; or information on the distribution of potential receipients.
          The program proposed to serve the Mountain States RMP as well as Washington
          and Alaska and coordinators are requested for both Seattle and Spokane.  The
          Council questioned the need for the two full-time positions.  The necessity of
          a medical advisor was questioned when consultants and advisory groups are
          available.  Many of the activities have merit, some seem questionable for PMP
          support, some seem questionable from a scientific viewpoint , and several seem
          unnecessary,  The clinical training activities appeared to have merit.
          In the absence of regional alternative priorities for the renal program in
          the area, the inclusion of several debatable activities and the expectation
          that this RKP with its strong RAG, capable core staff and a well-known pool


           Page 2 - R", Summary of,an Operational Supplemental Grant Application
           of renal diseases expertise should present a more realistic funding request,,
           the Council concluded that no additional funds should be provided at this time
           The Council, however, expressed interest in reviewing a less diffuse renal
           diseases program that focused on clearly-delinaated high priority areas of
           need for the Region.
           Present Application:  This is an updated revision of theor@ginal. proposal.
           In modifying the original request, two principles have been followed.  (a) re-
           sources have been allocated only to those areas of highest priority and (b) maxi-
           mum possible use has been extracted from existingresources. Accordingly, some of
           the originally proposed activities have been deleted and others re-oriented.
           ;The budget has been reduced for each year as follows:
           el- from $858,501 to $281,803; 02- from $824,253 to $279,347; and 03- from
           $627,016 to $199,1016.  The areas of hig eat priorities have been identified
           as:  (1) the institution of capability for coordination and planning at the
           regional level, (2) the expansion of transplant resources and (3) the evaluation
           of dialysis techniques and equipment.
           A synopsis of each of the 11 parts originally proposed and major modifications
           follow. The figures in parentheses are  the  originally  requested  amounts.
           Project #41 - Regional Administration - This aspect of
                              r@ovoial would-a-ii an associate director for-Kidney    First Y@@,
           disease to the 14AR.MP core staff and a kidney coordinator for the         Request-@-...,.,
           Mountain States RIP, as well as other staff, to assure continued           ($112,170
           coordinated planning and implementation of the kidney disease program.       57,200
           Second Year -($119,232)                      Third Year - ($126,550)
                           712145                                        76)590
           .,@P41 Changes - Budget reduction.  The administrative structure envisaged as
           originally proposed with moderate reduction in personnel and operating budget.

           Project IP42 - Regional Tr ansplant Program - The four activities included in
           this area of the program are  all  interrelated.  The  Tissue-Typing,  Host-
           Graft and Professional Transplant activities are  designed  to  increase  professional
           and technical capability and distribute it among the major medical centers
           in the Region, as well as provide direct service to all ireas.  The Donor-
           Organ Retrieval System will involve ten or more Regional centers in supplying
           cadaveric organs.
           #42 Changes - The Host-Graft Project (42D) will be deleted as it is still in
           the early developmental stage and will not have assured impact on cost of care.

           Pro_iect f@42A - Regional Tissue-Typing Laboratory - This project will     First  Year
           be directed by Dr. E. Donnal Thomas at the Public Health Service ITos-     Request  .,.
           pital in Seattle.  The facility that the Public Health Service lios-       (464,20;.@',
           pital has now, is primarily intended for research and cannot provide


          Page 3 - RMP, Summary of an Operational Supplemental Grant Application

          tiss,je-typing service for an augmented transplant program.  It is necessary
          that tissue-typing capability be developed outside to provide services  for
          Seattle to extend the time coverage and to reduce the costs.  The funds
          requested would permit this facility to expand its operation to provide these
          services.  In addition, they will determine the feasibility, economics . and
          efficiency of expanding the tissue-typing capability using one of two possible
          approaches, a central typing facility or blood banks.  Four technicians will
          be trained in the course of this project each year; two from the facility at
          the Public Health Service Hospital and two from the Regional Blood Bank.
          Second Year   ($68,380)            Third Year - ($10,000)
                           7,537                             -o-
          #42A   n es    Budget reduction.  Funds requested only to maintain activity at
          its present level.
          Project #42B - Regional Organ-Donor Retri             - This aspect       First Year
          of the program will be directed by Dr. He,           ff in the Depart-    Request
          ment of Medicine at the University of Washington.  This program will      ($32,588)
          @develop a plan for Regional network for the harvesting and transportation  41,938
          of cadaveric kidneys, train one or more surgeons in cadaveric kidney
          removal And preservation techniques in each of ten major medical centers
          within the Region, operate a r6gional donor-organ retrieval system,, and coor-
          dinate development of the donor-organ retrieval system with the development
          of the tissue-typing laboratory And expansion of the transplant program.
          A start has been made on setting up this system in  Spokane.  In  addition,
          nine other medical centers will be involved in the program - Tacoma,
          Bellingham, Bremerton, Yakima, Wenatchee, Boisei Billings, Anchorage and
          Olympia.
          Second Year ($29,695)               Third Year ($1,000)
                        37,932                             631 500
          @4@42B- Changes - Budget increase.  Change in personnel.
          Project #42C - Professional Trans@arnt Capabili@ - The director          First Year
          of this activity is Dr. Thomas Marchioro from t e Department of          Request
          Surgery at the University of Washington.  Specific objectives of   this  ($589700)
          activity to increase the professional transplant capability are to         20,950
          recruit an additional full-time surgeon to work with the surgical transplant
          team, to provide one year training in transplantation surgery and to provide
          one year training program in immunology to  two  physicians.  This  project
          in interdigitated with the Professional Education Project - #44.
          Second Year (#58,995)             Third Year - ($44,606)
                          7,860                             -0-
          #42C - c@    e - Budget reduction. Original @proposal scaled down.


           Page 4   RKP, Summary of an Operational Supplemental Grant Application

           Project #42D - Determination of Host-Graft I.n.t.--rrelationship@ -     First Year
           This project will be directed by Dr. Gary Striker, Department           request
           of Pathology at the University of Washington.  As a means of            ($4.9,000)
           increasing the life of Renal  transplant  patients,  this  activity        -0-
           will focus on increasing the knowledge of  physicians  on  the  use and interpreta-
           tion of the technique for detecting the blocking serum substance.  Three
           months' training will be  provided  for  four  physician  trainees.  The  trainee
           physicians will be the surgical  transplant  trainee,  the  immunology  trainees
           and the nephrology trainees who are  enrolled  in  the  Professional  Transplant
           and Professional Education  projects.  In  addition,  technicians  being  trained
           under the Regional Tissue-Typing Laboratory Project will also receive special
           instruction.
           .Second Year  ($29,663)        Third Year  ($24,637)
                             -0-                             -0-

           ,@42D            CompletL-lY deleted.

           Project #43   Regional Dialysis Program - Five distinct activities are
           proposed to improve the quality of dialysis care and the system of delivering
           care to the patient.
           @r43 @hanges - Assessment of needs for following cases (43C) has been deleted,
            eritorial dialysis evaluation (43E) combined with Equipment Evaluation
           Project (43D)

           Project #43A - Kidney Failure.RegistIZ - This project will be directed         First Yr.
           by Dr. F. Kingsbury Curtis, Chief, Dialysis Unit,, Veterans Administra-        Request
           tion Hospital, Seattle, Washington.                                             ($62,450)
                                                                                             311700
           This will eventually collect data from all  three  -  post  -  transplant
           and dialysis patients in the Region, thus involving physicians in local
           communities as well as those in  treatment  centers.  It  will  develop  a  c6m-
           puter system to be used as a control data collection system for both transplant
           and dialysis aspects of the program.
           Second Year - ($108,695)               Third Year - ($103,2 5
                             37,870                                419257
           43A - Changes    Budget reduction  in  personnel  time,  consultation,  and  sub-
           contracts.  .

           Project #43B    Evaluation of Home Dialysis Patient Training_-          First Year
           This activity will be directed by Dr.  Tom  Sawyer  of  the  North-       Request
           west Kidney Center in Seattle.  The Eastern-14ashington/Montana/         ($110,140)
           Idaho Artificial Kidney Center in Spokane will also be involved.            432075


          Page    RMP, Summary of an Operational Supplemental Grant Application

          This activity will focus on evaluation of the present procedures  for  training
          home-dialysis patients, a revision of the curricula and testing of new approaches
          based on the evaluation and development of a final training  package.  This  is
          noted as a great need for the country as a whole.
          Second Year - ($84,155)        Third Year - (-O-)
                         40,108                         -0-
          @1,43B - Changes - Budget reduction in personnel costs, supplies and equipment.

          Project lP43C - Assessment of Needs for Follow-Up Care in the Local       First Year
          Commni@- The project-director will Be Dr. -Jerry fendras, 7)irector,      Request
          Northwest Kidney Center, Seattle.  The Eastern Washington/Idaho/Montana   ($70,663)
          Artificial Kidney Center in Spokane will also participate,                    -0-
          This activity is desig-.ied to quantify the needs for follow-up on a systematic
          and defensible basis,, to identify personnel who should deliver care and
          to design and implement a pilot project to deliver the follow-up care needed
          by dialysis And transplant patients in their local communities.
          Second Year - ($859503)           Third Year - ($93,933)
                            -0-                               -0-

          #43C - Changes - Deleted Completely.

          Project -@43D - Evaluation of New Dialysis Equipment and Techniques       First Year
          Dr. James J. Cole, a Nephrologist in the Department of Medicine at        Request
          University Hospital will direct this project.  The Eastern Washington/    ($89,950)
          Idaho/MontAna Artifical Kidney Center in Spokane, the Veterans              32,400
          Administration Hospital and the Northwest Kidney Center in Seattle will
          also participate.
          This activity will evaluate dialysis equipment in laboratory, clinical, and
          home settings, will develop performance criteria for consideration at regional
          standards, will develop pre-test for personnel to be administered before they use
          the equipment and to assist the manufacturers in improving their equipment
          design and standards of quality control.
          Second Year   ($94,845)              Third Year - ($100,230)
                          35 780                                 -0-
                            I
          Project Y@43E  Demonstration of New Eqx4iEment and Techriques for Home      First.Year-
          Peritoneal Dialysis anA-Te6ting Its Ro e in the Mnnagement of               Request
          Chronic Renal Failure.  This activity wiLl-be directed by Dr. Henry         ($94,850)
          -Tenckhoff, Department'of Medicine at the University of Washington, who        -0-
          also directs the Regional Organ-Donor Retrieval System under the Transplant
          Program.
          This activity will investigate the feasibility of long-term peritoneal


         Page 6 - lU4P, Summary of an Operational Supplemental Grant Application

         dialysis based on a newly developed home fluid supply system in a variety
         of situations on a variety of patients.  Training in the new techniques is
         also planned for physicians and,other medical personnel.
         Second Year  ($290550)          Third Year - ($35,470)
                          -0-                             -0-
         43D and 43E  ChanjXes - Budget reduction.  It is proposed to maintain evalua-
         tion activities in the Peritorial Dialysis project (43E) and combine this
         administratively with the Equipment Evaluation Project (43D)

         Project iP44 - Regional Education    ram - Dr. Christopher Blagg,     First Year
         Nephrologist from the University of Washington Hospital, will         Request
         direct the program.  It is related to the other aspects of the        ($113,790)
         program, Regional Transplant and Regional Dialysis.  It consists         47,415
         of the following parts:  (1) Clinical Traineeships - one-year
         training in transplantation surgery for one surge on each year; one-vear
         training in transplantation immunology for two physicians each year; one-year
         training in clinical nephrology for one physician each year; rotating training
         of two to six physicians each year to take a two to six month training in
         clinical nephrology; and four three-month training program in medical
         nephrology for "appropriate" urologic trainees each year.  (2) Coordinated
         Continuing Education Program for physicians, nurses and dialysis technicians
         and it will include development of ten film strips, three TV shows, a traveling
         circuit course for eight communities in Washington, Alaska, Idaho and Montana,
         distribution of quarterly bulletin, and the support of trcvel expenses for
         consultations and continuing education for all types of personnel involved.
          Second Year-($115,540)             Third Year - ($87,325)
                         41$1115                            37,050
         #44 Changes   Budget reduction.  Clinical traineeships have been eliminated.
         @lso, budget for continuing medical education activities has been reduced.
         Project will draw more heavily on the Education and Support Unit of Tel/A@@IP.

                                                                    GRB/12/29/70


                                                                                       T120 i-                 k  14  Al
                                                                                                                            7Z     All
                                                                                                                    'Rpivc@4
                                                             0 1

                                                           co@

                                                                                                                         9 9,/,4 6
                   7AL                                           5-0

                                                                                                           (90,;ZY'3)
                                                                                    @6 73@) (@3
           4) - TITAiLl S PKAAJ                                                      6
                                                                                                              0 Oa
                                                                                                 7,

                                                                                                               I- -317

                                                                                                                              7
                                                             -2,P,9  3      1.2S                   7       3.3           79.
                                                                                                                         @/, zs 7  @7@@Ill 116,i?-27
             4'3 A -                                                                                                      7 4,/f

                                                                                                                 33
                             w-u                             7L.

                       V,9

            41 -?,r- - t4r,

                                                                                   I                                                          /.Z  YFIO
                                                            I'/,/  ',9  ( @7 @/@ /  // y @',/ ",)      -,)   IF  @; @  ( 3 7, O_X61 -@'- @'@ @)
          @V41 - @                                            .3 ;"/ f )
                     ,OOCA 7-1 t) tv ?@ 0-6             ) @ -


                                                       (A Privileged Communication)

                             SUMMARY OF REVIF-VNT AND CONCLUSION OF
                                TANUARY 1971 REVIf,,Iq COI%IITTEE

                          WASHINGTON/AT,ASKA REGIONAL MEDICAL PROGRAM
                                  @l 38-0/4 (AR-].--CD), -2/71 1

                     FOR CONSIDERATION BY FEBRUARY 1971 ADVISOII@Y COUNCIL

            RECOBDIENDATION:  Committee recommended that this application be approved
                             and additional funding provided as requested.

                                    F@IDING RECO@S,',IENDATION

                              DEVELOPMEN'EAL
            YEAR                COMPONENT               OTHER            TOTAL
                                                                                   --7
            Ist                @120,000               $1@5921144      $1,712,14@.@'2
            2nd                 156.%OOO               1,633,735       1,789,735 3/

            I/ (Difference between this fi-ure and total shown on summary for 04.year
                                          Q
                represents an additional  8,929 recommended by staff as part of
                continuation application.)

            2/ (includes $1,512,379 continuation bud,-et recommended for I prov al
                                                                        p
                by staff.)

            3j (Includes $1,596,935 commitment for Core and 6projects.)

                       The Committee noted that this application had not been site
            visited since the Region had been subjected to two major site visits in
            1969.  The last site visit in October 1969 placed primary emphasis on
            program rather than project review.  In the case of each site visit,
            significant progress toward the development of a mature Regional Medical
            Program was noted. The reviewers,  inclu-ding an individual who had served
            as chairman of the last visit and as a member of two previous visits
            believed that this application substantiated the extremely positive report
            of the October 1969 site visit.  There was no doubt thit this Region has
            reached a very mature stage of development.  Some reviewers believed that
            the Committee would no longer have a function if all Regional Medical
            Programs were as strong as the W/ARMP.

                                                                    RMPS/Gl@
                                                                    1/19/71


                                                               (A Privileged Communication)

                               STJi%ZIAP,,Y OF REVIF,$L AND CON@CLUSION OF
                                   JI@NUARY 1971 REVIL@L@ COyi,@IITTEE

                            IqAS[Il@,IGTON/AIASI@ REGIO@\TAL @TEDICAL IIPOG@kL%l
                                        @'4 38--04 (S)  2/71.2

                       FOR CONSIDEfj@TION BY FEBPU,@RY 197i ADVISOE@Y COUNCII,

              RECOI@'@@IENTDATTOY@:  The Corimittee recommended additional funds for this
                               application pending a favorable revi.e-,,7 by the ad hoc
              Advisory Coiimittee on Kidney Disease Grant Applications

              YEAR                               y-')  dco.              RECOiqMENDED
                                                                                           o
              Ist                            @281,803                     $281,803
              2nd                             279,347                      279,3  7
              3rd                             199,016                       199,016

                        Total                $760,166                     $760,166

              CRITI      The Committee believed that this u dated revision of the,
                                                             p
                         original proposal adequately responded to the major concerns
              raised in Corniaittee's previous review.  It was noted that the budget
              has been greatly reduced and the revised proposal clearly delineates
             'high priority areas of need for the Region.

                                                                          RMPS/GRB
                                                                          1 19 71


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

                  WESTERN  NEW   YORK   REGIONAL   MEDICAL        RM 13-04 (AR -ICDS) 2/71
                   PROGRAM                                        January   1971   Review   Committee
                  2929  Main   Street
                  Buffalo, New York  14214

                  PROGRAM  COORDINATOR:  John   R.F.   Ingall,   M.D.

                                              Request (Direct Cost Only)

                                         04 Year          05 Year        06 Year
                  Purpose                3/71-2/72       3/72-2/73      3/73-2/74      All Years
                  Continuation                               No               No
                  Component              $1,029,472*       Commitment   Commitment     $1,029,472
                       (Core)               (379,234)
                       (4   Projects)       (650,238)
                  Renewal
                  Project                      171,516     174,304        177,236           523,056
                  Additional
                  Components                 1,078,517     869,740        646,777         2,595,034
                  (Developmental)           (118,116)        -              -               (118,116)
                  (4 Nei%,  Projects
                   Anniv. Appl.)            (495,608)     (434,990)      (291,555)     (1,222,153)
                  (2  New   Projects
                   Deferred    Appl.)       (276,885)     (234,227)      (241,957)          (753,069)
                  (3   Approved/   Unfund-
                   ed Projects)             (187,908)     (200,523)      (1139265)          (501,696)

                  TOTAL                  $2,279,505      $1,044,044     $824,013       $4,147,562

                -Staff   Action   on
                  Commitment             $1,029,459*
                  Committee    Action
                  Required               $1,250,033      $1,044,044     $824,013       $3,118,090

                  *The 04 Year Commitment for these activities is $1,029,459.

                                             Funding History
                                            (Planning Stage)

                  Grant   Year                    Period                       Funded (d.c.o.)
                      01                       12/66-11/67                      $117,026
                      02                       12/67-11/68                      $271,185


            Western New York                 - 2 -              RM 13-04 (AR-lCDS)'2/71

                                   (operational Program)
                                      -   Council        Funded         Future
            Grant Year       Period      Approved        (d.c.o.)     Commitment

              01           12/67-2/69     $615,015     $615,015         ------
              02           3/69-2/70      1,445,545,1   1,340,76        ------
                                                              92/
              03           3/70-2/71      1,663,777@/         4
                                                   ,,   1,667,67
              04           3/71-2/72       1,383,29@'                  $1,029,459
              05
                           3/72-2/73       124,78

            1/Does not include $250,000 for approved/unfunded regional dialysis
              program.
            2/Includes carryover funding of $486,512

            GEOGRAPHY AND DEMOGRAPHY

            The Western New York Regional Medical Program until recently was
            composed of eight counties (seven in western New York and one in
            northern Pennsylvania), but during  the  last  year  a  second  Pennsylvania
            county has been incorporated into  the  WNY  program,  bringing  the  total
            number of counties to nine.  The largest town in McKean County,
                      ia (the  recent  addition  to  the  Region)
            Pennsylvan                                          , is on the New York
            border, and has a  referral  pattern  dominantly  to  Buffalo.  The  Region
            is bounded by Lake Erie to the west and Lake Ontario to the north.
            The counties to the east of this Region traditionally have looked
            to Rochester for medical care.
            The approximate'population of this 8,200 square mile Region is 3,002,000,
            and it is primarily urban and white.  The two metropolitan centers
            of Buffalo, New York and  Erie,  Pennsylvania  account  for  around  750,000
            of the total population.  The area is served by 57 short-term hospitals
            with 8,800 beds, four VA hospitals with 3,100 beds, and two state
            tiospitals.with nearly 6,000 long-term beds.  There are 2,661 physicians,
            8,525 active and 4,550 inactive nurses.  Major facilities include
            SUNYAB School of Medicine and  Roswell  Park  Memorial  Institute,  as  well
            as 15 schools of nursing (four degree-granting), six schools of
            medical technology, one school of cytotechnology,.eight schools of
            X@ray technology, and one school of pharmacy.

            HISTORY OF REGIONAL DEVELOPMENT
            Regional planning was instituted late in    1965, and in the Spring
            of 1966 a formal planning application was submitted with Dr. Douglas
            Surgenor, Dean of the School of  Medicine  at  SUNYAB,  as  interim  program
            coordinator.  Generally,  the  application  was  received   enthusiastically
            by the reviewing bodies,  although  there  were  some  questions  revolving
            around the lack of program evaluation and the lack of relationships
            among the six planning projects which were proposed.  After problems
            regarding the legality of the  Health  Organization  of  Western  New  York
            (HOWNY) were resolved, a planning award was made in December 1966.


                Western New York              - 3 -               RM 13-04 (AR-lCDS) 2/71

                In the Spring of 1967 Dr. Ingall became the program coordinator.
                A planning supplement application later in  the  year  requested  funding
                for new activities and instigated a February 1968 site visit to make
                a determination as to whether the Region was entering, or should
                enter, its operational phase.  The site visit team reported that
                the concept of regionalization was recognized and accepted by
                representatives of all of the counties, that RAG representation was
                well-balanced, that cooperative arrangements appeared to be substantial,
                and that administrative procedures were being developed.  There was,
                however, little evidence of a unified approach to priority setting
                or identification of regional resources and needs.  There was agreement
                that the Region should achieve operational status and An operational
                award was granted in March 1968.
                During the nearly three years since its first operational award,
                the Western New York Regional Medical Program has submitted project
                applications with regularity. Although  there  have  been  two  technical
                site visits, program considerations were not  involved,  and  the  Review
                Committee and the Council have kept in touch with this Region primarily
                through its applications.  Nearly every review body evaluating one
                of these proposals has commented on the diversity of interests and
                the wide spread of ongoing Regional activities.  Of the four
                projects for which the national review bodies have recommended disapproval
                (in the areas of poison  control, medical genetics, mass media in ormat on
                to ghetto residents, and atherosclerotic disease) in three instances
                the negative recommendation was prompted by the questionable,categorical
                relevance of the proposed activity.  The 03 year award of $1,667,674
                (which includes $486,512 in carryover funding) is supporting the
                following activities:

                    Core Planning and Administration                   $435,902
                    Telephone Lecture Network                           181,053
                    Coronary Care                                       168,152
                    Chronic Respiratory Disease                         638,879
                    Immunofluorescen(:e Service & Training              34,590
                    Test of Continuing Education Techniques             38,190
                    Tumor Registry  '                                   63,794
                    Topical Chemotherapy for Pre-Cancerous              47,4 -)
                    Lesions and Cancer of the Skin                           54    Funded entirely
                    information Dissemination Service                   31,960 @   through carry-
                    Regional Coagulation Laboratory                     27,701/    over & rebudget
                                                                                   ing

                There is, in addition, on the books an  approved  but  unfunded  regional
                dialysis program.


           Western New York                  - 4                     RM 13-04 (AR-l,CDS) 2/71

           ORGANIZATION AND   REVIEW PROCESS

                                LIT.-'GIO,@Al, ADVISOfl@Y GIZOUP
                                                   -rS
                                   COUNIY CO't@',I'rri..

         .County Coi-.ulittec-    !BOA'.ZD 01@                    "iooil Ol.?
         :Liaison                    OF H.O. D.Y.                   S.U.N.Y.A.B.

         ,Telel,ho,.Ie L4,.cLtire

           rsonnql  a:id
                    a iarf !-,ic-Tit
         ,Bi-isiness l-'@e
                                                       [,As s-o- -c- i ae
                                                        -.'.-)Lrector

       G:I.@@i'r D--  'T
                :VI, _Jnr".
                                                                A ir) Also "V'),Cll;

                                    IC.IT.P

         The above diagram, prepared by the Region, indicates the functional
         and organizational interrelationships that exist within WNYRMP.  Solid lines
         indicate lines of authority.  Dotted lines indicate specific channels of
         communication.  The Anniversary Application states that this chart is
         intended to show:  the effort within WNYRNII that is given to maintaining
         lines of communication between the RAG and the Director; the increased
         regional responsibility for program planning and translating evaluations
         and research into grant development, manpower development, and management;
         and the specific RMP staff linkage that has been established with CHP


             Western New York                - 5 -                  RM 13-04 (AR-lCDS) 2/71

             The Regional Advisory Group (Health Organization of Western New York --
             HOWNY) is composed of nine county committees, ranging in size from
             nine to 78 members each.  The total membership currently is in the neigh-
             borhood of 300. The executive body of the RAG  is  known  as  the  Board
             of Directors of HOWNY. The Board  has  29  members:  nine  representing
             the county committees, nine the county medical societies, with the remaining
             membership representing CHP, the  health  departments,  Hospital  Association,
             the University and Roswell Park.  There are, in addition, three members
             chosen to represent the interests of  urban  minorities.  The  Board  of
             Directors is the final arbitrating body of the RAG.

             The standing committee structure has been expanded during the last year
             to include groups on rural health manpower, telephone lecture network,
             evaluation, and health happenings.  These are in addition to the previously
             existing committees on proposals,  by-laws  and  constitution,  coronary
             care, cancer, stroke, dialysis, and pulmonary planning.

             The WNYRMP sees one of theprimary benefits of  the  review  process  as
             its value as a continuing education  experience  for  all  involved.  New
             project proposals receive  preliminary review by the county committees
             before being received by the  Proposals  Committee.  The  Proposals  Committee
             (often with outside technical assistance and reviews by the State Health
             Departmenti county health officers,  University  Department  of  Social
             and Preventive Medicine and others) provides  a  technical  review  and
             forwards the project and its report to  the  Board  of  Directors.  The
             Board is vested with  final  decision-making  authority.

             The Board recently has been looking at ways in  which  it  might  alter
             its review process in light of the annual review concept, and is considering
             the institution of site visits.  It is thought that in addition to allowing
             a continuing reassessment of ongoing  activities  and  priorities,  site
             visits could involve consultants from throughout  the  Region  and  strengthen
             the regionalization process.  Other  changes  contemplated  include  the
             establishment of a chronological priority rating system And the
             introduction of quarterly review of  the  grand  design.

             The core staff includes 13 professionals,  all  but  one  full-time.  The
             Region has been unable to fill a long-vacant slot for Associate Director
             for Epidemiology, so this position is no longer budgeted.  The
             organization chart outlines current staffing patterns.  The core staff
             pictured in the anniversary application is  reflective  of  the  emphasis
             the Region places on its  role  as  broker/facilitator/enablihg  agency.

             REGIONAL   OBJECTIVES

             The Region has developed a grand design, outlined  in  the  Regional  Advisory
             Group report. It is described as a fluid  plan  which  permits  easy  revision
             in response to changing needs.  Three  overall  program  objectives  have
             been identified:
                                 1. Accessibility  to  medical  care.
                                 2.  Quality of care.
                                 3.  Economy in the delivery of health services.


               Western New York               - 6                   RM 13-04 (AR-lCDS) 2/71

               In addition, thirteen policies are described.  A policy is defined
               by the Region as a strategy for achieving program objectives.     In
               brief form, the policies deal with:    the development  of  specific
               relationships; increasing manpower resources and their effectiveness;
               correcting the maldistribution of health resources; upgrading
               abilities of health personnel; improving access to specialized
               diagnostic and treatment centers; developing ambulatory care
               facilities; developing comprehensive rehabilitation services;
               improving continuity of care within-the Region; assisting physicians
               with information and services; encouraging projects of patient
               education; promoting areawide planning and coordination of health
               services; and improving the management of health problems of
               the aged.
               As the Region moves away from project  planning  and  toward  total
               program planning, it will need constant baseline data for the
               definition and re-definition of  Regional  problems.  The  increased
               planning capabilities on core  staff,  the  hopefully  strengthened
               abilities of CHP (it is now apparently in a slump from which
               WNYRMP is helping it rise) and the information gained from the
               Information Support System (supported by an  RM?S  contract  to  the
               Harvard Center for Community Health and Medical Care) are expected
               to be of help in this regard.

               The Board of Directors apparently has not  yet  developed  a  system
               for the priority ranking  of  objectives.  Neither  have  priorities
               been assigned the new projects in the Anniversary Application
               for which supplemental support is  being  requested,  although  on-
               going activities are ranked according to  their  importance  to  the
               Program as viewed by the Board of Directors.

               PRESENT APPLICATION
               Continuation Components:  The Region is requesting its final
               year of commitment for the continuation of five components, in
               the following amounts:

                        Core                                    $379,234
                        #2-Coronary Care                         121,237
                        #3-Respiratory Disease                   439,962
                        #4-Immunofluorescence Service             35,359
                        #10- Tumor Registry                      53  680
                             TOTAL CONTINUATINN REQUEST       $1,029,472
               The continuation request will be reviewed by staff, and its recommenda-
               tions will be the subject of  a  separate  supplemental  memorandum.
               Terminal Reports:  Final progress reports for Project #6 - Nuclear
               Medicine, and Project #7 - Test of Continuing Education Tec n ques,
               are presented for information purposes only.  No further RMP
               funding is requested.


                 Western New York            - 7                 RM 13-04 (AR-lCDS) 2/71

                 Renewal Component                                   Requested
                                                                     Fourth Year
                 Project #1 - Telephone Lecture Network.  Renewal     $171,516
                             support is being requested for the fourth,
                 fifth, and sixth years of operation of the Telephone Lecture
                 Network.  Although the primary objective of the network is stated
                 to be the provision of continuing education programs to  all
                 persons involved in the delivery of health care, it has found
                 wide use by the core staff and Coordinator as an easy access
                 to the health community of the Region, especially for surveys,
                 meetings, regional conferences, etc.  It also is used for meetings
                 of the Board of Directors and various committees.  In addition
                 to the regular lecture series, the network is helpful to other
                 ongoing activities:  it is used occasionally by the Respiratory
                 Care and Immunoflourescence projects,and it is  a  necessity
                 to the operations of the Coronary Care Program and the Information
                 Dissemination Service. It has been used for presentation  of
                 courses in Spoken English for foreign medical personnel  and
                 is used regularly by a community group, Parents of  Diabetic
                 Children.  This project is considered to be the number-one
                 funding priority by both the Coordinator and the RAG. It  is
                 seen As a most successful vehicle for regionalization.
                 The Telephone Lecture Network connection has expanded from 36
                 to 60 separate locations throughout the Region and two counties
                 outside the geographic boundaries of the RMP.  Fifty-three of the
                 receiving units are located in hospitals.  Since its inception, over
                 300 specially-designed educational programs have been presented over
                 the network.  A survey is currently under way through which the
                 staff can more thoroughly evaluate the effectiveness of the program
                 and determine the extent of financial support that can be expected
                 from participating institutions (the monthly contribution now is
                 $20).  Other avenues of support for the network are being investigated
                 as well.  It is stated that the development of a self-support
                 mechanism for the network is of foremost concern to the Region.
                 Fifth Year:  $174,304                    Sixth Year:  $177,236

                                                                         Requested
                 Additional Components                                   First Year
                                                                         $118,116
                 Developmental Component: The Anniversary Application
                 explains that the developmental component  is  fundamentally
                 problem-oriented and ultimately will be shaped by the definition
                 of crucial problems in the receipt of adequate health care.  This
                 will involve an examination of new settings for the delivery of
                 health care, new organizational and inter-professional relationships,
                 and new roles for allied health personnel.
                 Although the developmental concept is of an innovative and comprehensive
                 nature, the Region already has identified certain specific areas
                 in which such monies might be put to use:


               Western New York               - 8 -             RM 13-04 (AR-lCDS) 2/71

                  1.  Definition of reasons for spiraling health care costs
                      and measures to curtail them.
                  2.  Inquiry into medical care patterns and  self-administration
                      of medicine in the area of diabetes.

                  3.  In association with other concerned agencies, definition
                      of the problems of the underprivileged.
                  4.  Work toward better communications among, and increased
                      social consciousness of, health care planners.
               The Region intends to apply its developmental monies  evenly
               throughout the first three quarters of the  budget  year.  A
               priority system will be established, and judgments on distribution
               of funds will be made by the Board of Directors at intervals
               during the year.
               This request is for a developmental award for one year only, to
               coincide with the remaining year of core commitment.
               New Projects - Anniversary Application:  This Anniversary Application
               requests support for the initiation of four new projects.  The
               application states that the RAG sees these proposals as consistent
               with current priorities viewed in relation to the grand design.
               Project #20   Regional Bone Pathology Laboratorv. The      Requested
                                                                          First Year
                             major objective of this proposal is to
               improve the care of patients with bone diseases by         $64,453
               establishing a Regional Bone Pathology Laboratory at
               SUNYAB which will facilitate the diagnosis of musculoskeletal
               disease by evaluation of the bone biopsy or resected specimen.
               The consulting service will be aimed at the diagnosis  of  a
               wide Spectrum of bone diseases, and there will be no charge to
               the patient, physician, or hospital.  In addition, training
               programs are planned for private physicians and the  house  staffs
               of hospitals for the purpose of instruction in the  management  of
               bone conditions in their patients.  The Telephone Lecture
               Network will be used for conferences and seminars.  Final y,
               a regional bone tumor registry will be established in order to
               assess and improve current treatment.  The proposal states that
               in three years, if the project has demonstrated its effectiveness,
               support will be sought from county and state  health  departments.
               Second Year:  $48,398                 Third  Year:   $49,567
                                                                          Requested
               Project #21 - Choriocarcinoma and Related Trophoblastic    First Year
                             Disease. This request essentially is for     $50,856
               RMP assumption of support for a Trophoblastic Neoplasia Center
               established in 1967 by SUNYAB and Roswell Park under a USPHS grant.
               Grant support was scheduled to continue until 1973  but  was
               discontinued prematurely in September 1970.  Although  no  charges


                   Western New York          - 9 -             RM 13-04 (AR-lCDS) 2/71

                   will be made, the project directors hope the diagnostic services
                   of the laboratory will become self-supporting within the next
                   three years by instituting a schedule of reasonable charges.
                   The purpose of the Center is to provide area physicians the
                   means for diagnosis and follow-up of patients with trophoblastic
                   neoplasia, provide consultative services on treatment, educate
                   young physicians in the management of the disease, and conduct
                   research to improve diagnostic methods and treatment.  In addition
                   the high-risk population (which is calculated to be 3,000 in
                   the WNY Region) will be screened annually.

                   Second Year:  $52,795            Third Year:  $54,830
                                                                             Requested
                   Project #22 - Comprehensive Continuing Care for Chronic   First Year
                                Illness. This project will be  located  at   $175,625
                   the E.J. Meyer Memorial Hospital in Buffalo, where a preliminary
                   and small-scale program has been in operation since 1968 to
                   develop a more coordinated approach to the care of patients with
                   chronic diseases. Building on that base, this project  will
                   develop a model demonstration program ( using multidisciplinary
                   teams) which will afford comprehensive, continuous care for
                   chronically ill patients, whether in or out of the hospital,
                   and will incorporate into the program the unique resources of
                   a major university teaching hospital.  Particular  emphasis
                   will be placed on patients who are economically deprived.
                   Educational opportunities for physicians, nurses, social workers,
                   and allied health personnel will be provided.  The program will
                   be evaluated to determine its efficiency in improving t e
                   quality of care, reducing hospitalizations, improving compliance
                   with treatment regimens, reducing disability, and changing patient
                   and health worker attitudes, as well as to ascertain the costs
                   of such a program compared to the costs of traditional treatment.
                   Second Year:  $183,587                  Third Year:  $187,158
                   Project #23 - Planning of a Computer-Based Health Data    Requested
                                 System. This two-year request is for  the   First.Year
                   development of a detailed master plan for a health data   $204,674
                   network for the Western New York Region.  Educational programs
                   will be designed to acquaint health professionals with  the
                   capabilities and restrictions of the data system.  Also, a systems
                   analysis will be conducted to determine current data handling
                   practices, standardization of these practices will be sought, and
                   the data needs of each user will be defined.  Finally, small-scale
                   field trials will involve placing experimental terminals in two
                   hospitals, one large nursing home, one health department, and
                   the offices of five practitioners.  During these trials, experience
                   will be gained as to the volume and nature of  input-output
                   requirements, acceptance by users, problems of confidentiality,


             Western New York                - 10                 RM 13-04 (AR-lCDS) 2/71

             acceptable turn-around time, cost/information  assessment,  and
             other issues which wourd affect the design of the general plan.
             Once the full-scale operation is attained, every effort will
             be made to switch from external fund support  to  a  self-supporting
             operation.

             Second Year:  $150,210

             New Projects - Deferred Application:  Two  projects  received
             recommendations of deferral from the November  1970  Advisory
             Council, although the Review Committee previously had suggested
             a recommendation of @ipproval with no additional funding, and
             with the condition that no RMP monies be tunnelled into Project
             #19 because of its inappropriateness for FM support.  In reviewing
             these two proposals, both Committee and Council had difficulty
             determining the relationship of project goals to Regional
             priorities and objectives, primarily due to an absence  of  a
             description of the Region's overall plan as well  as  the  amorphous
             nature of project goals.
                                                                            Requested
             Project #18 - A Model Program for Comprehensive Family Health First Year
                           The major objective of this project is to        $170,977
             demonstrate the efficacy of a multidisciplinary  team  approach
             to the provision of excellent primary medical care to a representative
             cross section of society. The Deaconess  Hospital  of  Buffalo,  the
             sponsor of the proposal, has established a  Family  Practice  Center
             with a director, staff, including seven  residents,  and  a  waiting
             list of patients.  FM support is requested for those portions
             of the program related to community health nursing, medical social
             work and nutrition, and to study the  application,  utilization
             and correlation of these disciplines as applied  to  ambulatory
             patients. Funding is not requested for  the  service  component
             or the residency training aspects. The  development  of  the  family
             practice model at the Deaconess Hospital will  emphasize  the
             four parameter of  demonstration,  education,  research,  evaluation
             and assessment, and service.

             Second Year:  $138,310                Third Year:  $142,406
                                                                                Requested
             Project #19 - Prevention and Treatment of Respiratory Distress  First Year
                            Syndrome Due to Hyaline Membrane Disease in         $105,908
             Infants. The proposed project will be  located  at  both  Children's
             Hospital of Buffalo and the Roswell Park Memorial Institute.
             A study has been conducted in the use of urokinase activated human
             plasmin in infants with respiratory distress syndrome.  Results of
             the study indicated that in the plasmin treated group there was
             a doubling of survival time, while in the  sub-group  consisting  of
             those whose birth weight was two kg or less, plasmin  therapy
             tripled survival rate. The purpose of  this  project  is  to  extend
             the benefits of this study to all infants in the region.
             Two independent studies are planned:


                   Western New York                              RM 13-04 (AR-lCDS) 2/71

                      1.  Prevention of respiratory distress syndrome with plasminogen.
                      2.  Treatment of respiratory distress syndrome with streptokinase
                          activated plasmin.

                   If studies are successful, plans call for the introduction
                   of these methods to all hospitals of the region which would
                   be handling such I.nfants.

                   Second Year:  $95,917                  Third  Year:   $99,551

                   Approved/Unfunded Projects: These three activities received
                   approval from previous Councils but have not been funded by
                   RMPS. This year, however, project #'s  13  and  14  were  initiated
                   by the Region with carryover funds and  project  #16  through
                   rebudgeting of basic grant funds.  Consequently, these activities
                   have no future commitment.
                                                                                  Requested
                   Project #13 - Topical Chemotherapy for Precancerous Lesions Second Year
                                  and Cancer of the Skin.  This  is  a  proposal  $49,631
                   for a program to provide  community  physicians  a  recently-
                   developed technique of topical chemotherapy for the prevention
                   and treatment of precancerous growths (solar keratoses) and
                   cancers of the skin. The program  was  planned  for  three  phases:

                      I.  Developing an operational system for implementing, co-
                          ordinating, and evaluating the program.

                      II. Professional e ucat on.

                     III. The actual operational phase during which topical    chemo-
                          therapy will be performed as a treatment method.

                   Phase I was aided greatly  by  the  Buffalo-Rochester  Dermatologic
                   Society which supported the project and formed a liaison committee
                   for this activity.  Phase II has been initiated and is progressing
                   smoothly.  Although PhaseIII will be deferred until Phases
                   I and II have been completed, a number of physicians who have
                   specialized training and experience  will  start  this  operational
                   phase on an exploratory basis.  This will provide information
                   to guide the general implementation of Phase III.

                   The two further years of support requested are consistent with
                   the second and third years of support recommended by the December
                   1969 Advisory Council.

                   Third Year:  $52,180
                                                                                Requested
                   Project #14 - Information Dissemination Service. The         Second Year
                                  objective of this program is to es-           $38,275
                   tablish an information dissemination service to prov  e
                   the physician and other  health  professionals  with  printed
                   information from a broad spectrum of medical and scientific
                   journals and books and to alert them to new developments in


                 Western New York          - 12 -           RM 13-04 (AR-lCDS) 2/71

                 their field of interest through  a  current  awareness  service.
                 The Telephone Lecture Network is  the  communication  link  used
                 in this activity.  The Health Sciences Library at SUNYAB is
                 designated as the resource medical library.
                 To date, 34 of the 53 hospitals in the telephone lecture network
                 system have received orientations as  to  the  services  offered
                 through this project; meetings have been arranged with the
                 remaining 19 hospitals.  Personnel  at  each  participating  in-
                 stitution are designated to channel  requests  to  the  resource
                 library. As of July 1970, 72  requests  for  services  had  been
                 received and filled.  It is hoped that ulitmately the information
                 dissemination services can be supported by hospitals and the local
                 medical societies. The requests for second  and  third  year  of
                 support for this project are approximately $6,000 in  excess  of
                 the amounts approved by the November 1969 Review Committee.

                 Third Year:  $39,515
                                                                                Requested
                 Project #16 - Reeional Coagulation Reference                   First Year
                              This proposal originally was submitted to         $100,000
                 the February/March 1970 review cycle as a request for
                 the establishment of a blood coagulation  reference  laboratory-
                 which would have  training,  service,  and  research,components.
                 Roswell Park Memorial Institute had  been  providing  some  free
                 services in this field, but increasing community needs and
                 decreasing funds for Roswell Park  prompted  the  submission  of
                 this proposal. After a  technical  site  visit,  the  June  1970
                 Review Committee recommended that although the  goal  of  having
                 a reference and standardizing laboratory was an  excellent  one,
                 the rest of the teaching and service aspects should be diminished
                 to concentrate only on the training of technicians from outlying
                 hospitals to perform coagulation  tests.  It  was  thought  that
                 a first year budget of $60,000 and second and third year budgets
                 of $40,000 each would be sufficient for such  an  endeavor.  The
                 subsequent Council agreed,  but  expressed  its  willingness  to
                 allow the Region to increase the funding of this  project  to  a
                 maximum of $100,000, providing such a  level  of  funding  would
                 be required to maintain this valuable regional resource.
                 In September 1970, after  assurances  that  the  laboratory  was
                 developing in the direction of training technicians  rom
                 outlying hospitals, the Region received permission  to  rebudget
                 $27,700 into this laboratory to retain trained  staff  personnel
                 until the end of the current budget  period.  At  the  time  the
                 progress report was prepared, three technicians  were  receiving
                 training, schedules were being established for  two  physicians,
                 blood coagulation studies were being carried out, and physicians
                 associated with the center had participated in 40 consultations.
                 Three years additonal support is requested.
                 Second Year:  $108,828                  Third   Year:   $113,265

                                                              GRB/RMPS
                                                              12/9/70


                                                               (A Priv4leged Communication)

                                SLTI@RY OF REVIEW AND CONCLUSIO@i' OF
                                   JANUARY 1971 REVIEW COMITTEE

                            WESTERN NEW YORK REGIONAL iqEDICAL PROGRAM
                                     RM 13-04 (AR ICDS) 2/71

                       FOR CONSIDERATION BY FEBRUARY 1-971 ADVISORY COUINCIL.

               RECOMMENDATION, Additional funds be provided for this a pl'
                                                                         .p  icatioii.

                                                                            Committee
                        Year                                             Recommendation
                       04                    $1,250,033                      $359,424
                       05                    $1,044,044                      $374,827
                       06                      $824,013                      $113,265
                      TOTAL                  $3,118,000                    $1,024,752

                   I UE,.  The Review Committee agreed  with  the  site  visit  team
                           that this Regicn has  not  yet  completed  the  transition
               from project to program emphasis;  althouah  it  does  appear  to  be
               trying.. The Committee-did  not  ac,Iree withthe site teani's recommendation
               to  provide developmental funding.  In  committee's  view  this  Reg-Lon
               is not  yet ready for this type of flexibility.  The  Rea4-orial-  goals
               are  global in nature and the  strategies  for  achievin-  them  (termed
                 policies" by the Region) even  though  more  specific,  appear  not
               to'be based on a rational assessment of Regional needs.  It
               was thougb--that the collection of projects for which furid@-Lnc,  is
               requested did not rev&Al. a sound review process so  far  as  blen  -ing
               proposed activities with overall goals of the Region.
               Although the RAG is composed of nine county committees and has
               a total membership in the neighborhood  of  300,  the  final  arbi.ting
               body is the  29member  Board  of  Directors.  'The,Board  is  heavily
               physician@riented,  and  the  Region  is  considering  the  possibility
               of expanding the membership  with  the  addition  of  nine  additional.
               non-phy8ician  representatives.  The  Review  Committee  agreed   with
               the site team that the  Region  should  be  encouraged  to  accomplish
               this expansion. It  was  also  thought  that  the  decision-making  and
               priority-settinr role of the RAG should be strengthened.  The
               .county committees were seen as having outstanding potential as
               forces for 8ubtegionalization,  and  the  Review  Committee,  and  the
               site team were in agreement that the Region should be urged to
               diversify the functions of these groups to include activities
               -beyond the mere review of projects.  The county committees
               could serve as vehicles  for  genuine  grass  rools  participation  in
               progriiii devel-OI)Tli-'Ilt.


               Western New York
                   RMP                           -2-                         RM 00013

               The extent to which the resources of the Region have been involved
               in the TAINYMV was seen as one of  the  most  exceptional  features  of
               this program. This  has  been  accomplished  by  dint  of  constant
               concentration on this goal by  the  Coordinator  and  the  Core  Staff.

               The Region is beginning to make  inroads  in  assessing  the  needs  of
               the area and developing a planning base  to  use  as  a  guide  for
               the development of a total  program  and  the  setting  of  priorities.
               Likewise, efforts are being made in the direction of program-evaluation.

               Since she WNYRMP will be  requesting  core  renewal  in  another  year,
               and RMPS will then have  another  opportunity  to  take  a  close  look
               at this Region, the reviewers thought  it  would  be  well  if  the
               Region devoted the  coming  year  to  completing  its  transition  from
               project to program orientation, with emphasis on-

                    1.  Developing a  sound  program  plan  and  priorities,  based
                        on identified Regional needs.

                    2.  Increasing the decision-making role of the RAG and
                        diversifying its membership through the proposed expansion.

                    3.  Developiiig  th.e county committees into something other t),an
                        mere project  review  bodies,  and  working  toward  realizing
                        their potential as forces for sbbregional.ization.

               Consequently, the recom@mended monies  for  the  Region's  04  year,
               .although@increasing the absolute  award,  represent  a  decrease  from
               the 03 year operating  level,  which  had  been  increased  through
               the use of large amounts of carryover.  The  03  year  basic  award  of
               $li!81,162 was expanded to $1,667,674 by carryover.  The 04 year
               suggested award of $1,388,883 represents a combination of continuation
               funding of $1,029,459 and renewal and supplemental funding of $359,424
               recommended by this Review  Committee.  Since  no  projects  in  the  c
                                                                                     urrent
               application will  be  specifically  disapproved,  the  feeling  was.
               that the recommended award  is  one  which  will  maintain  the  Region
               during its 04 year but also  force  it  to  make  decisions  about.
               exactly where the  money  will  be  applied.  The  discussion  below
               outlines the basis on which the recommended new and renewal
               funding of $359,424 was calculated.  It should be noted that
               this is somewhat different from the funding level arrived at by
               the site@team, although it was prompted by the same considerations
               and is merely a slightly different means to the same end.

               DEVELOPMENTAL CO@FPONENT:  Although  the  site  team  had  suggested
                                           one  year@  developmental  funding  on  the
               basis of this Region's potential for imaginative use of these monies'.
               the Review Committee was not  persuaded  that  this  Region  was  quite
               ready for a developmental component.  The recommendation of the
               disapproval of developmental- funding was based on all the deficiencies
               noted above as well as the RAG's not   yet  having  developed   precise
                 . . @ I  -    -


                                                                   RM 00013
             Western New York            -3-
               .RMP

             RENEWAL REQUEST: The Review Committee agreed with the site team
                             that the Telephone Lecture Network, for which
             renewal funding is requested, is one of the most exciting activities
                             It has been used in very imaginative wa s.  It
             in this Region.                                        y
             is an integral- part of many ongoing and proposed projects,  and
                                for regionalization.  There was unanimous
             is a definite force
             Agreement that renewal funds for this component should be included
             in the award, although it was suggested that if the Region were
             to increase the presently nominal financial contributions by
             participating institutions, award monies would become available
             for rebudgeting into other regional activities.
             APPROVED UNFUNDED: There are three projects which have received
                               approval from previous Councils but have not
             been funded by RKTS.  During the 03 year, however, these three
             projects were initiated with carryovet funds and through t e
             robudgdting of basic grant funds.
                     cal Chemotherapy for PrecanceroLis Lesions and Cancer of the.Ski-a
                 Information Dissemination Service
                 Re '.onail C-Lozaigulation Reference Laborator
             The Region is requesting that supplemental funds be awarded for the
             continued conduct of these activities.

             Although the site team had recommended supplemental fundin- calculated
             on the request for only one of these projects ( Information Dissemination
             S6tvice) because of the good job it does in promoting regionalization,
             the'Review Committee thought that since the projects already had
             been initiated, the entire request for their continuation should be
             recommended.  The decsions to include these funds in the calculation
             of support really was an attempt to bring the Regibn's funding
             for the 04 year to a workable level, And it was recognized that
             the Region would have the option to rebudget these monies among
             Rozi-onal components as it saw fit.
              El PROPOSALS-. The four new projects in the anniversary package
                            and the two projects which were deferred by November
             Council for the site visit, brought the total number of new proje cts
             for which supplemental funding was requested to six.

                     ional Bon
                                       el ted Tro hobllaassttli-c Disease
                                       iag Cuare for Chronic Illness
                  'Planni @ o  A  omputer-Based Health Data System
                  A Model Prog am for CulomDrehensivp Family Health
                  Prevention and Treatment of Respiratory Dis
                   Due'to Hyaline Plembrane Disease in Infants


              Western New York                -4-                         RM 00013
                 RMP

              Since the Region did not demonstrate, and the site team could
              not discover, the relationship of these individual Components
              to the overall program, and  since  there  were  no  sound  Regional
              priorities, the Review Committee  agreed  that  there  was  no  basis
              on  which  to.judge  these  proposals.  Their  technical  sufficiency
              was presumed to be adequate,  but  the  review  process  which  approved
              these activities without any mesh with the overall Regional plan
              was questioned. In the absence  of  any  basis  on  which  to  assess
              these activities the Review  Committee  agreed  with  the  site  team
              that although none should be specifically disapproved, they
              should not be  included  in  the  recommended  funding  calculation.
              This would not prohibit the  WNY@IP  from  rebudgeting  into  any  of
              these -ix activities.

                                   FUNDING CALCULATION
                                                                          First   Year
                                                                            Committee
                                                @ie@st                   Recommendation

              Developmental Component           $118  116                      -0-
              Renewal                           $171,516                    $171,516
              Three Approved/Unfunded           $187,908                    $187,908
              Six New Projects                  $772,493                       -0-
              Total Supplemental Funding                                    $359,424

              Dr. Perry  was not present at  the  deliberation  of  this  application.

                                                                       1/20/70
                                                                       GRB/RMPS


                                        REGIONAL   MEDICAL   PROGRAMS   SERVICE
                      SUMMARY OF ANNIVERSARY REV'IijW AND AWARD GRANT APPLICATION
                                         (A  Privileged  Co  ,   nication)

             WEST VIRGINIA REGIONAL MEDICAL PROGRAM                        RM00045   2/71    (C&S)
             West Virginia University Medical Center                       January 1971 Review Comittee
             Morgantown,   West   Virginia    26506

             Pron,,ram   Coordinator:   Charles   D.   Hollaud

                                              Requested   (Direct    Costs    Only)

                                   02                  03                    04                  All
             Pur]2ose             1971               1972                  1973                 Years
             Continuation.l...L/  $535,467        $515,965               - 0  -             $1,051,432
             Core           j6/    485,713             490,740           - 0  -                  976,453
             2 projects     I/      49,754           25,225              - 0  -                 74,979
             ,1/  Includes  $18,900   Carryover   ($18,000   -core ss-.aff for renovating new quarters
             and $"O for project #6 (Helicopter Study)
             Supplemental       $173,829          $186,094               $167,561           $    527,484
                Developwatal   -   0    -            - 0 -                 - 0 -                - 0
                Renewals          -  0  -            - 0 -                 - 0 -                - 0
                New             $173,829          $186,094               $167,561           $    527,484
                    3    projects
             Total    Requ*qt   $7n9,296          $7n2,059               $167,561           $1,5780916
             *Staff    Action    53,5.467              515,965              -  0  -           1,051,1@32

             Comittee     *nd
             Council     RejuireA
             Action             $173,829          $186,094               $167,561               $527,484
             *RMPS  staff   reviewed   the non-competing   02   year    continuation portion of the
             application and rec        uded approval in the amount of $534,567 including the
             use of $18,000 carryover funds for renovating new headquarters.

                                          FUNDING      HISTORY d.c.@

              Planning:          01                     1967                           $   150,798
                                 02                     1968                               350,717
                                 03                     1969                               3789045


             WEST VIRR.INIA RMP                       2                           RM45 2/71  (C&S)

             OPERATIONAL

             Grant.  Year            Period           Council Approved        Funded     Commitments
                  01                   1970               $395,048         $395,048
                  02                   1971                                               $516,567
                  03                   1972                                                515,965

                                      APPROVED UNFUNDED PROJECTS  (d.c.o.)
                                    lat yr,           .2nd  yr.      3rd    yr.           Total
             #8 Self Audit             $138,901       $184,556         $147,292           $470,759
             #9 Roop. Assistance         33,583         32,626        - 0 -                 66,209
             #10 multi-unit              50,561         42,304           42VO83            134,950
                 Comunications

             Total                     $223,047       $259,496         $189,375           $671,918

             GEOGRAPHY &  DEMOGRAPHY:

               Land Area:                                  24,079   square   miles

               Population:                                 1,811,000
                   Urban                                   38%
                   White                                   95%
                   Median   Age                            28.5

               Mortality    per 100,000
                   Heart Disease                           422
                   Cancer                                  168
                   CNS   Vascular   Lesions                115

               Facilities:
                   1)   West Virginia University School of Medicine           4 yr. school
                        (enrollment approx. 250)
                   2)   Eleven schools of nursing
                   3)   Seven schools of medical technology
                   4)   Ninety-one hospitals (5 federal) with 15,963 beds (1,396 federal)
                        Seventy-six are short-term facilities.

               Personnel:
                   Physicians             (1968)               1550              (85.6/100,000)
                   Osteopaths             (1968)               ill               (    6.1/100,000)
                   Registered   Nurses    (1966)               5011              (276.6/100,000)

             HISTORICAL DEVELOPHENT:  In December 1965, Dr. Clark K. Steeth, then
                                         Dean of the West Virginia University School of
             Nedicine,  convened  a  meeting  to  discuss  the  Statate  participation   in   RMP.
             The meeting was,attended by representatives of the State Departments of
             Health and Welfare, the West Virginia Heart Association, the West
             Virginia Division of the American Cancer Society, the West Virginia


        WEST VIRGINIA RMP                        - 3 -                RW@5   2/71   (C&S)

        Hospital Association, the West  Virginia  University  Medical  Center  and  the
        general public.  Upon  unanimous  agreement  to  participate,  the  Medical  Center
   4pwas selected  to  initiate  and  coordinate  planning  to  establish  the  WVRNP.  A
        28-member RAG was appointed and  Dr.  Steeth  was  elected  chairman.  The  RAG
        appointed a 12-member staff committee  to  prepare  the  planning  grant  application.

        This Region received a planning grant for  three  years  beginning  January  1,  1967.
        The amount awarded the second year included  a  supplement  of  $141,807  for  four
        feasibility studies; (1) Survey  of  a  Rural  Area  (Blackoville);  (2)  Nechanical
        Morbidity Reporting by Physicians; (3) Coronary  Care  'Unit;  and  (4)  Physicians
        Self-Audit. The latter three  were  also  supported  in  the  third  year.  The
        third year was extended seven months to  August  31,  1970,  and  the  Self-Audit
        to September 30, 1970, with no additional funds.

        A site visit was made in July 1969 to  assess  the  Region's  capability  to  become
        operational. It was noted that when  the  WVRHP  began,  it  had  many  obstacles
        to overcome. The State  suffered  from  critical  economical  crises,  leaving  most
        areas without adequate health care.  Small  towns,  rural  and  mountain  areas,  so
        predominant in West Virginia,  lacked  health  personnel.  The  medical  school  was
        only 11 years old and there was little evidence of effective continuing education
        into the hospitals and medical  profession.  Adding  to  these  oroblems,  Dr.  Wilbur
        the Regional Coordinator, recruited  in  June  1967,  died  in  January  1969.  Mr.
        James G. Holland, Associate  Coordinator,  was  serving  as  Acting  Program  Coor-
        dinator. Despite the dearth  of  resources  and  the  unfilled  coordinator  position,
        the site visitors believed  the  Region  was  ready  for  operational  status.  The
        West Virginia University Nedical School had taken  an  active  role  in  the  WVRMP
        and good physician and  nurse  participation  was  evident.  The  Region  had  also
   reestablished  appropriate  cooperative  arrangements.  As  pointed  out  to  the   Region,
        there was a need for much better minority representation on the RAG.  The ,
        35-member RAG had only  recently  organized  its  committee  structure,  (Executive
        Committee, Project Review Committee,  four  planning  Committees,  and  nine  Sub-Area
        Advisory Groups)  and  it  wastIoo.early to determine how  well  it  was  working.  t
        Sub-area offices based on  joint  planning  with  Comprehensive  Health  Planning
        were projected for the near future.  The August 1968 Council recommended approval
        for operational status for three years for core and four projects.  Pk. Charles
        D. Holland was  appointed  Regional  Coordinator.  To  provide  appropriate  super-
        vision of the medical aspects,  a  special  Medical  Advisory  Committee  was  con-
        stituted to assist the Coordinator.

        'GOALS AND OBJECTIVES: As originally stated,  the  overall  goal  of  WVRMP  is  to
                                 assist the nation's health resources  in  making  the  best
        possible care for patients with  heart  disease,  cancer,  stroke  and  related
        diseases. Kidney disease  has  been  added.  The  objectives  have  been  refined
        and set to a time  frame  for  management-monitoring.  (Section  III  -  Appendix).
        Objectives: 1)  Stimulate  effective  responses  to  community  and  area  health
        needs by developing and maintaining  a  system  of  area  offices.  2)  To  provide
        for description and evaluation of health care  systems  for  the  purpose  of  pro-
        gram planning and development by securing, maintaining and analyzing basic
        data concerning health related variables - focusing particularly on facilities,
        personnel and their utilization.  3)  To  enhance  patient  care  by  assisting  to
        0


          WEST VIRGINIA RMP                       - 4 -              RM45  2/71  (C&S)

          the establishment of improied methods of continuing education for physicians,
          nurses and allied health personnel.  To assist in the establishment of new
          types of health manpower programs, to expand the capabilities of,the tradi-
          tional health care providers and gain their acceptance throueh
          continuing education.  4)  To analyze current problems and patterns of emergency
          medical care and'to promote improvement. 5)  Within  the  constraints  of  limited
          health resources, develop innovative programs to support rural family health
          maintenance 6) Promote  the  development  of  necessary  cooperative  arrangements
          among health providers and related groups to improve health care.

          PR16RITY RANKING:

               lot level
                  I -  Core
               2nd level  (Continuation on-going funded ac tivitiea)
                  I - #4 Nursing Care of Stroke Patients
                  2 - #6 @licopter Study
               3rd level
                  1 - #11   Rural School Health
                  2 - #12   Cancer Education and Service
                  3 - #10   Multi-Unit Communications
                  4.- #13   Hospital Service
                  5 - #8    Self Audit
                  6 - #9    Hospital Assistance
          ORGANIZATION:  The present application includes the annual report of the RAG,
                         much of which is alluded to in this summary.
          The  organizational structure includes a RAG of 35 members which meets quarterly.
          During interim meeting of the RAG, a seven-man  Executive Committee is authorized
          to transact business.  The WVU Medical Center Staff Committee is a special Com-
          mittee to guide the Coordinator and his staff.  Other committees (40 members)
          include Planning, Review and Evaluation, Education, DemonatrationF;, and Research.
          Project applications are reviewed by the Review and Evaluation Committee, CHP
          "A" and "B" Agencies. The final review and  recommendation  is  by  RAG.  The  RAG
          is definitely not a rubber stamp group as evidenced by their change in the
          priority ranking of projects (Section III, pages 76-77).  As indicated in the
          narrative some of the reviewers tend to ignore the criteria.  Core staff is
          aware of the problem and believe promised guidelines from  RNPS  may  be  helpful*
          The number of professional core staff has increased from 16  to  20;  an  addition
          of two field staff, a physician consultant and a pediatric nurse consultant.
          Because of the required travel, efforts failed to recruit an assistant Director
          and this position has been changed to Coordinator of Field Services.  The
          Associate Director is now for Planning and Development.  Other changes includes
          the addition  of  a.Physician Consultant and Research Assistant.  Clerical and
          secretarial positions have been increased from 9 to 11.  Core progress includes
          staffing four of nine sub-regional offices.  Two additional offices will be
          staffed during the second year.  Core  studies-have  included-.  hospital  patient


       WEST VIRGINIA RMP                       - 5 -              RM45    2/71    (C&S)

       flow; medical students' choice of practice and location;  rural health patterns
        nd resources;  characteristics of users and the operation of emergency system
   On a complex medical facility.  Activities have also included working with the
       RAG, Committees and  project  applicants  in  program  development.  Three  core
       staff (a physician, nurse and secretary) will be committed for about one year
       in the development  of  a  Pediatric  Nurse  Practitioner  project.  Plans  also
       include study and necessary planning for  innovations  in  health  manpower  and
       renal disease. Efforts will  include  more  involvement  of  the  allied  health
       professions, particularly physical therapists.

       Cooperative arrangements with appropriate agencies continue.     @   t   notable are
       those with the State Medical Society and  CHP,  A  and  B  Agencies.  There  are no
       model cities programs in W. Va.i but there are numerous O.E.O. sponsored Com-
       munity Active programs of which  VVRNP  has  had  contact  with.four-significant
       mutual activities are  anticipated.  The  great  distance  between  the  central
       WVM in the northern part of the state and the Southern West Virginia Regional
       Health Council has been a deterrent to   a coordinated effort in the Appalachian
       202 multi-county demonstration@in the  southern  part  of  the  State.  Rowever,
       the two agencies continue to work toward the development of a "Guest-Residency
       Prograii" in the Appalachian area.

       Of the four approved and funded projects  during  the  first  year,  three  were
       implemented and PMS staff believe that progress is satisfactory.  One (#l-@-
       cation for CCU Staffs) was funded for one year, but will continue after cessa-
       tion of RMP support.  Continued support is requested for continuation of (#4-
       Nurit-ag Care of Stroke Patients) for its second year.  Continuation is requested
         r two additional years for  (#6-Helicopter  Feasibility  Study).  Project  #5-
          oke and its Treatment) approved and funded for one year by RMPS ($31,400 was
         t implemented because of the problems in personnel recruitment.  An unexpended
       balance of approximately $145,000 is anticipated in the current year and is re-
       flected mostly in the core budget and by not funding project #5.
       EVALVATION: The Review  Committee  has  responsibility  for  evaluating  project
            I  @    proposals and recommending a priority  ranking  to  the  RAG.  Core
       Staff is responsible for  monitoring  projects.  However,  detailed  information
       about evaluation is locking.

       NEW PRWECTS:                                                           Requested
       I                                                                      First Year
       Project #11 - Progressive School Health Programs for                     @89,366
                     Rural Commuitiol
       Sponsored by the Upshur County Board of Education at Budkhannon, the objective
       of thin project is to develop a model school health program that can be repli-
       cated within the constraints of limited financial and human resources in rural
       areas of West Virginia.  The project will have two elements:  1) education and
       2) services.  The school education aspect will be undertaken by training elem
       mentary grade teachers in curriculum  content  for  health  education.  This  ap
       proach will be carried Into higher grade levels  later  as  curriculum  develops
       and is available.  The health services aspect will be directed by a registered
       nurse assisted by a school Health Assistant.  The Realth Assistants, a new type
         manpower, will be trained (six the first  year)  to  perform  many  tasks  now


        WEST VIRGINIA RIIP                    6                 RM45 2/71  (C&S)

        done by the school nurse.  S-upplementat services of a dental hygienist, pedi-
        atric nurse practitioner and physician consultant are planned.  The difference
        from other similar school programs is the planned follow-up with family and
        community resources through the use of the school Health Assistant.      Evaluation
        is planned in terms of measuring progress in  implementation  and  ultimate  impact
        of the project. Plans include efforts to secure  other  sources  of  funding  after
        cessation of WVRNP grant support.
                         Second lear                        Third year_
                         $89,791                           $98,154
                                                                             Requested
        Project #12 - Cancer Education and Service                           First Year
                                                                             $52,956

        Sponsored by the West Virginia University School of Medicine, this   is a Cancer
        registry focused education program for 63 hospitals.  Each of the hospital's
        registries will be the educational outlet for upgrading cancer information
        resulting in improved care of cancer patients.  The  project  will  provide  avail-
        able text books, periodicals, audio visuals and  hardware  to  registry  directors.
        Efforts will be made to utilize the existing West Virginia University nurses
        Service's tele-lecture unit hook-up to 45 hospitals  (34  have  tumor  registries).
        An-9 istance will be given to registry directors to develop more meaningful
        information and follow-up programs.  In cooperation with the Liaison Fellows
        of the American College of Surgeons, the American College of Radiology Coumtittee
        on Cancer Management and the Cancer Control Division of the Wes-41. Virginia  State
        Department of Health, problem-oriented workshops are planned through the West
        Virginia Chapter of Tumor Registrars.  The current limited distribution of the
        annual report by the Central Registry is to be increased to inclade all the
        physicians in the State.
        Evaluation will be based on the end result reports - hopefully improved survival.
        Continuation of the project supported by other sources is planned after termi;-
        nation of RMPS grant support.

                           Second Year                       Tkird Year
                           $53,392                            $55,252
        Project #13 - ge@tati*oi,of Hospital Service Areas                     Requested
                                                                               First   Year
                                                                               $31,507

        The purpose of this project is to provide hospitals in the State more infor-
        me,tion upon which to base individual and regional planning decisions.
        Objectives:ll) learn more about patient characteristics;  2) learn more about
        hospital information needs;  3) develop some comparative measures of hospital
        care delivery; 4) gain better understanding of type and size of the community
        hospital planning unit most appropriate to better delivery of hospital care;
        5) sustain the impetus for regional planning by input - to effect better hospital
        care; and 6) foster additional researdh on problems of health care delivery.
        The definition and analysis of "marketing" areas will be used to assist in
        planning for expansion of services and facilities; determining areas and potential-,


           WEST VIRGINIA RNP                     - 7 -              RM45  2/71  (C&S)

           patients that are not now adequately served, physician referral relationships,
           etc.
           The project will be completed in two phases during the 29-mouth period.  The
           first phase (January - December 1971) test demonstration in a four-county,
           area which includes 5 hospitals and approximately 120 physicians.  The second
           phase beginning in January 1972 will be implementation of the project  on,;a
           state-wide basis to include 75 in-state hospitals,lt9 out-of-state hospitals
           and about 300 physicians.
           The program is one of investigation and RMP continued support after the project
           period is not indicated.

                             Second Year                       Third Year
                             $42,911                           $14,155


       WEST VIRGINIA
       UNIVERSITY

                                                                                                                REGIONAL
                                                                                                                ADVISORY
                                                                      ----------------------------------       GROUP

                                                                                                                      VE
                                                                                                                      EE

                                           TO                                INFORMAI
                                                                             OFFICER                                 ING
                                                                                                                     TEES

             COORDINATOR-                                                         ASSOCIATE DIRECTOR
             FIELD OPERATIONS                                                     PLANNING AND
                                                                                  DEVELOPMENT

   ELKINS AREA       PARKERSBURG      HUNTINGTON                               BEHAVIORAL-       STATISTIC
     OFFICE          AREA OFFICE      AREA OFFICE                              SCIENTIST
   MORG,LNTOWII      BECKLEY AREA     CHARLESTON
   AREA OFFICE         OFFICE         AREA OFFICE
                                                                                                    PHYSICIAN
                                                                          NURSE
                                                                         CONSULTANTS                CONSULTANTS


        WEST VIRGINIA
        UNIVERSITY

                                                                   STRATEGY FOR VOLUNTARY COOPERATIVE ARRANGEMENTS

                                                -------------------------------------------------------------------------------

         PROGRAM              -----------------
                    ----------                                  A D V I S 0 R Y    G R 0 U P
         DIRECTOR

   R
                                                             E X E C U T I V E   C 0 M M I T T E E

   m

   p
                                                                   PLANNING COMMITTEE

                                                  RESOURCE SUB-
   c
                                                  COMMITTEES FOR
                                                  ELIGIBLE ACTIV-
   0
                                                  ITIES
                                                                            cn
                                                                            z
   R                                                                        0
                                                                            F4

         REGIONAL
   E                      SUPPORT TO RAG                                                    PROC@@T
          OFFICE                                                            cn              OBJECTIVES
                          AND COMMITTEES                                    z

                                                                       En

                                                                       P4
   s

   T
         AREA
   A     OFFICES                                                       W     01
          x 9
   F                                                                    COMMUNITY
                           SYSTEKATIC PROGRAM                         TRUSTEESHIPS               EA
                           DEVELOPMM4T                                                       PRIORITIES

                                                L-------------------------------------------------------------------------------


                                      REGIONAL MEDICAL PR             SERVICE
                     SUMMARY OF ANNIVERSARY REVTi'@W AND AWARD GRANT APPLICATION
                                       (A   Privileged    Coumunication)

            WEST VIRGINIA REGIONAL MEDICAL PROGRAM                       RMD0045  2/71 (C&S)
            West Virginia University Medical Center                      January 1971 Review Comittee
            Morgantown,   West   Virginia   26506

            Pro.-rau  Coordinator:   Charles   D.   Holland

                                             Requested   (Direct   Costa   Only)

                                 02                  03                    04                 All
            Purpose              1971              1972                  1973                  Years

            Continuation,;,.L/  $535,467        $515,965              -  0  -            $1,051,432

            Core           i/    485,713            490,740           -  0  -                 976,453
            2 projects   1/      49,754            25,225             -  0  -                  74,979

            .I/  Includes  $18,900  Carryover  ($18,000   -core staff for renovating new quarters
            and $900 for project #6 (Helicopter Study)

            Supplemental      $173,829          $186,094              $167,561           $    527,484

               Developwntal  - 0 -                 - 0 -                 - 0 -               -  0  -
               Renewals          - 0 -             - 0 -                 - 0 -               -  0  -
               New            $173,829          $186,094              $167,561           $    527,484
                  3    projects

            Total    Requomt  $709,296          $7n2,059              $167,561           $1,578,916
            *Staff    Action     535,467            515,965               - 0  -            1,051,432

            Comitte*     mud
            Council    RejuireO
            Action            $173,829          $1869094              $167,561               $527,484

            *RMPS  staff  reviewed   the non-competing   02   year   continuation portion of the
            application  and  recommended  approval  In  the  amount  of  $534,567   including   the
            use of $18,000 carryover funds for renovating now headquarters.

                                        IMING       RISTORY    d.c.*._l

            Planninit:          01                    1967                          $ 150,798
                                02                    1968                            350,717
                                03                    1969                            378,045

                                             P4                      w


          WEST VIRR.INIA RMP                         2                           RM45 2/71  (C&S)

          OPERATIONAL
          Grant.    Yeer           Pel-iod           Council Aperoved       Funded      Comitments
              01                    1970.               $395,048          $395,048
              02                    1971                                                  $516,567
              03                    1972                                                   515A 965

                                    APPRCUED UNFUNDED PROJECTS  (d.c.o.)
                                   is                2nd   7r.      3rd   Yr.             Total
          #8 Self Audit              $138,901       $184,556       $147,292              $470,759
          #9 Hosp. Assistance        33,583          32,626          - 0 -                66,209
          #10 Multi-Unit             50,563          42,304            42,083             134,950
              Communications

          Total                      $223,047       $259,496       $189,375              $671,918

          GEOGRAPF,Y   &    DEMGRAPHY:

             Land Area-.                                 24,079 square miles

             Population:                                 1,811,000
                 Urban                                   38%
                 White                                   95%
                 @dian    Age                            28.5

             Mortality per 100,000
                 Heart Disease                           422
                 Cancer                                  168
                 CNS Vascular Lesioras                   115

             Facilities,.
                 1)   14eat Virginia University School of Medicine          4 yr. school
                      (enrollment approx. 250)
                 2)   Eleven schools of nursing
                 3)   Sever, schools of medical technology
                 4)   Ninetlv-one hospitals (5 federal) with 15,963 beds (1,396 federal)
                      Seventy-six   are    short-term    facilities.

             Personnel:
                 Pliysitions                                  1550                 (85.6/100,000)
                 Osteopaths              (1.968)              Ill.              (    6.1/100,000)
                 Registered     Nurses   (1966)               50ii              (276.6/100,000)
          HISTORICAL DEVELOP'rOiiTi  In December 1965, Dr. Clark K. Sleeth, then
                                        Dean of the West Virgi-,iia University School of
          Nedicine,  con,,reued  a  meeting  to  discuzs  the  otate's  participation   in   RMP.
          The meeting was attended by representatives of the State Departments of
          Health and Welfare, the West Virginia Heart Association, the West
          Virginia  Division  of  the  American   Cancer   Society,   the   Weat   Virginia


               WEST VIRGIUIA                                             3                                              (C&S)

               Ho a p i t a I  A Ei 4"@    i   t     Wc.,o'@-                                                          the
                            u                                                                                             Center
               gener                                                                    ci-paf:e,  t,@.
               was sel("@,cced to                  and                                                    the  WV#'@-4L,4.  A
               28- me-ofaer RAG was a                         l@,r.  Sl@c-eth was elecLi@,l chairman,,         The     RAG
               appo@@@,yt@t I a 12- eob i:, aL@ f@ counitte--@a to   rel@n@re               pl.           grant         application.

               This   Region   received   a    ?lanning    grant    for    t'rtree    years    begit@iiing    January    1,    1967.
               The   amount    awarded    the    tiecoad    year    included    a    supplement    of    $141,807    for    four
               feasibility    studies;    (1)    Survey     of     a     Ru@ral     Area     (Blackvville);     (2)     Mechanical
               Morbidity    Reporting    by    Phyef.cians-    (3)    Co:cnary    Care    Unit;     arid     (4)     Peiysicians
               Self-Audit.   The   latter   three   were    also    supported    'Lri    t    e    t-lhird    year.    The
               third   year   wag   extended    seven    @oonCli8    to    August    31,    1970,    and    the    Self-Audit
               to September 30, 1970, With no additional  fui@ads,,

               A site visit ,,ias              i..i July 1961; to a seas the Regiu@  '              capability      to      become
               operational.        It  u-as  a@otf@,cl   that   wi@ien   the   WVAMP   began,   it   'than   many   obstacles
               to    overcome.    The     State     suffered     from     critical     economical     crises,     leaving     most
               areas    without    adequate    health    care.    Small    towns,     rural     aud     mountain     areas,     so
               predominant    in    West    Virginia,     lacked     health     Personnel.     'Zhe     medical     school     was
               only 11 years old and there was little evidence of effective continuing education
               into   the    hospitals    and    medical    profession.    Addivi.,,    'zo    these    i@XoL@lems,    Dr.    Wilbur
               the   Regional    Coordinator,    recruited    in    June    i,967,    diec"I    ii    3@.@iiuary    1969.    Mr.
               James    G.    Holland,    .49sodiate    Coordinator,     was     serving     as     Acting     Program     Coor-
               dinator.      Despite    the    dearth    of    resources    ayid    the     unfil'LeO.     coordinator     position,
               the    site    visitors    believed    the    Region    was     ready     for     operational     status.     The
               West  Virginia  'Jnivers-."Lt@@@7  l@dica'.'i  Sc@iao'Z'.  had  takeL@i  an  acti@,,re   role   in   the   ;IVRMP
               and    good    physician    and    nurse    participation    was    evident.    '.,"eie    r(egion    had    also
               established     appropriate     cooperative     arranga@@its.     As     pointed     out     to      the      Region,
               there was a need for                  better    mirior.t@,    representation    on     the     RAG.     The
               35-member     RAG     had     only     recently     organized     its     ca=ittee     structure,      (Executive
               Committee, Project                    Coya-ii ttee,   four    planni,:ig    Co=it    sets,    and    nine    Sub-tLrea
               Advisory   Groups)   and   'r@,e   was@t'oo   early   to   dete,@rt,@ine   how   well   it   was    working.    t
               Sub-area   offices   based   on    joiii@@-    p@@anning    with    Car,,-kpretteLsive    'Tlealth    Planning
               were projected for the near future.   The August 1968 Council recommended approval
               for operational status for tiiree years for core avoid four projects.                              W. Charles
               D.     Holland     was     appointed     Regional     Coordinator.     To     provide     appropriate      super-
               vision    of    the    medical    aspects,    a    special     @dical     Advisory     CouQittee     was     con-
               stituted to assist the Coordinator.

               GOALS   "D    OBJECTI'rJ2S:    iiv    originally    stated,    the    overall    goal    of    WVIUIT    is    to
                                                assist    the    nation's    health    -cetiq:)urces    in    uking    the    beat
               possible   care   for   pat:@.ents    with    heart    disc@ase,l    cancer,    strol@cA@    and    related
               diseases.    Kidney    disease    has    been    added.    Ti-i;e     objectives     have     been     refined
               and    set    to    a    time-    fraim    for    managempnt-momi.toring.    (Secti@Dit    III    -    Appendix).
               Objectives:   1)                       effective     response     to     community     and     area     health
               needs   by   developing   and   w;a@Lntiiinirg    a    aystet,,a    of    arec    offices.    21    To    provide
               for   description   and   evaluation.   of   healt'@.   care   sys,@--em,@L   for    the    purpose    of    pro-
               gram planning and development oliy securing, ma,'-Tntain'Lig end analyzing basic
               data concerning health related variables - focut;in,?, @articularly o@'i facilities,
               personnel    and    their    utilization.    3)    To    enhance     patient     care     by     assisting     in


      WEST  VIRGMA   RMP                       - 4               RM5    2/71  (C&S)

      the est   ablishwnt of improved-methods of continuing education for physicians,
      nurses and  aliied health personnel.  To assist in the establishment of nev.-
      types of health manpower programs, to expand the capabilities of the tradi-
      tional health care providers and gain their acceptance throueh
      continuing education.  4)  To analyze current problems and patterns of ewrgency
      medi.--al care and'to promote improvement.  5)  Within the constraints of limited
      health resources, develop innovative programs to.support rural family health
      maintenance.  6)  Promote the development of necessary cooperative arrangements
      among health providers and related groups to improve health care.

      PRIORITY RANKING-,.

            lot level'
               I -  Core
            2nd level  (Continuation of on-going funded activities)
               I - #4 Nursing Care of Stroke Patients
               2 - #6 Uelicopter Study
            3rd level
               1 - #11  Rural School Health
               2 - #12  Cancer Education and Service
               3 - #10  @ ti-Unit Communications
               4-- #13  Hospital Service
               5 - #8   Self Audit
               6 - #9   Hospital Assistance
      ORGANIZATION:  The present application includes the annual report of the RAG,
                     much of which is alluded to in this summary.
      The organizational structure includes a RAG of  35 members which meets quarterly.
      During interim meeting of the RAG, a seven-man  Executive Committee is authorized
      to transact business.  The WVU Viedical Center Staf f Committee is a special Com-
      mittee to guide the Coordinator and his staff.  Other committees (40 members)
      include Planning, Review and Evaluation, Education, Demonstrations, and Research.
      Project applications are reviewed by the Review and Evaluation Committee, CEP
      "A" and "B" Agencies.  The final review and recommendation is by RAG.  The RAG
      is definitely not a rubber stamp group as evidenced by their change in the
      priority ranking of projects (Section 111, pages 76-77).  As indicated in the
      narrative some of the reviewers tend to ignore the criteria.  Core staff is
      aware of the problem and believe promised guidelines from RMPS may be helpful.
      The number of professional core staff has increased from 16 to 20; an ad it on
      of two field staff, a physician consultant and a pediatric nurse consultant.
      Because of the required travel, efforts failed to recruit an assistant Director
      And this position has been changed to Coordinator of Field Services.  The
      Associate Director is noii for Planning and Development.  Other changes.includes
      the addition of a Physician Consultant and Research Assistant.  Clerical and
      secretarial positions have been increased from 9 to 11.  Core progress includes
      staffing four of nine sub-regional offices.  Two additional offices will be
      staffed during the second year.  Core studier, -have included:  hospital patient


        WEST VIRGINIA RW                       - 5 -              RM45  2/71  (C&S)

         low; medical students' choice of practice and Ic)cation;  rural health patterns
    end'resources,, characteristics of users  and  ti-Ae  operation  of  emergency  system
        In a co@)lex medical. @@acility. Activities leave als@o included working with  the
        RAG, Committees and project applicants  in  torogram  develop  at.  Three  core
        staff (a physician, nurse and secretary will  be  committed  for  about  one  year
        in the development of a Pediatric Nurse Practitioner project.  Plans also
        include study and necessary planning for innovations  in  health  manpower  and
        renal disease. Efforts will Include  more  involvement  of  the  allied  health
        professions, particularly physical therapists.

        RESOURCES' Cooperative  nrrangements  with  appropriate  agencies  continue.  Most
                    notable are those with the State Medical Society  and  CHP,  A  and
        B Agencies.  There are no model cities programs in W. Va., but there are
        numerous O.E.O. sponsored Community Active programs  of  which  WVRMP  has  had
        contact with four-significant mutual  activities  are  anticipated.  The  great
        distance between the central WVRMP in the northern part of  the  state  and  the
        Southern West Virginia Regional Health Council has been a deterrent to a
        coordinated effort in the Appalachian 202  multi-county  demonstration  in  the
        ,southern part of the State.  However, the two agencies continue to work
        toward the development o a "Guest-Residency  Program"  in  the  Appalachian  area.
        CURRENT PROI-ECTS: Of the four approved and funded  projects  during  the  first
                           year, three were implemented and  RMPS  staff  believe  that
        progress is satisfactory. One (#l-Education for  CCU  Staffs)  was  funded  for
        one year, but will continue after cessation  of  RMP  support.  Continued  support
         a requested for continuation of #4 - "Nursing Care  of  Stroke  Patients"  for
         ts second year. Continuation is requested for  two  additional  years  for  #6  -
         Helicopter Feasibility Study."  Project #5 - "Stroke and its Treatment"
        approved and funded for one year by RMPS ($31,400)  was  not  implemented  because
        of the problems in personnel recruitment.  An unexpended balance of approximately
        $145,000 is anticipated in the current year and  is  reflected  mostly  in  the
        core budget and by not funding project #5.

        E            The Review Committee has  responsibility  for  evaluating  project
         VAITJATION.
             I       proposals and recomending a  priority  ranking  to  the  RAG.  Core
        'Staff is responsible for monitoring  projects.  However,  detailed  information
        about evaluation is lacking.

        NEW PRIVECTS:                                                            Requested
                                                                              First   Year
        iroject #11 - Progressive School Health Programs for                    $89,366
                      Rural Communities

        Sponsored by the Upshur County Board of Education  at  Buckhannon,  the  objective
        of this project is to develop a model school health program  that  can  be  repli-
        cated within the constraints of limited financial and  human  resources  in  rural
        areas of West Virginia. The project will  have  two  elements:  1)  education  and
        2) services. The school education aspect  will  be  undertaken  by  training  ele-
        mentary grade teachers in curriculum content  for  health  education.  This  ap-
    "roach will be carried  into  higher  grade  levels  later  as  curriculum  develop$
   Rpi,rd is available. The health services  aspect  will  be  directed  by  a  registered
        nu se assisted by a school Health Assistant '  The Health Assistants, a  new  type
        of man@r, will be trained (six the  first  year)  to  perform  many  tasks  now


        WEST VIRGINIA TO'P                  - 6                  BLv,,45 2/71   (C&S)

        done    by    the    school    nurse.    Su-p-)Iemental    services    of    a     dental     hygienist,     redi-
        stric    nurse    prk;.ctitioner    L-,.d    physician     consultant     are     plavineA.     Ybe     difference
        from other cimilzr uchool programs is the plonred follm,,-cp with family and
        ccmlnunity    resources    through    the    use    of     the     school     Health     Assistant.     Evaluation
        f:@    plann,e4    @n    tcr=.    of    wasuring    progress    in    implementation     @     ultimate     iiVact
        L    the    project.    Plans    include    efforts    to    secure    other    sources    of    funding     after
        cessation of ViViO.? grant support.
                       @CS'l@    r-ar                        Third veer
                        $89,791                             $98,154
                                                                               Requested
        Project #12 - Cance4- Educa@--ion cn   Service                         First         Year
                                                                               $52,956
        Sponeored by the West Virgin-La 'Ci-,iiversity School of @dicine,  this is    a     Cancer
        regiF.try focused education program for 63 Hospitals.     Each      of      the      hospitals
        registries will be t.ie educational outlet  for upgrading cancer information
        resulting    in    improved    carn    of    cancer    patients.    The    project     will     provide     avail-
        able    text    books,    periodicals,    audio    visuals     ard     hardware     to     registry     directors.
        Efforts    will    be    made    to    utilize    the    existing    West    Virginia    University     Nurses
        Servicets    tele-lectu-@e-unit    hook-up     to     45     @os?italc     (34     have     tumor     registries).
        Asr-s totance will 'De given to registry directors to develop more M'nningful
        information    and    fol-I.ow-up    programs.    in    coo    erat'Lor,    with    the    Liaioon     Fellows
                                                     p
        of -,he American Collece. of Su-@g--,ot!s, the Auericart C--Ilege of Radiology Committee
                                                        viuion    of    the    West    Virginia     State
        on C&Lcer Management and the Cancer Control Di
        Department     of     Health,     problem-oriented     workshops     are     planned     through     the      West
        Virginia Chapter of Tumor Registrars.   L".ie    current    limited     distribution     of     the
        annual report by the Central P%egiatry is to be incresse4 to include all the
        physicians in the State.
        Evaluation will be based on -Ilae end result reports - lio?e@Lully improved survival.
        ,-'orit@Lnuati(-,t of t.-.e  @u--,,@orted   by   o-,"4&er    gcurces    is    planned    after    termi-
        nation of IL4PS grant si;pport,

                           Secaud 4c-ar
                           $53,392                             $55,252
        -,,o                                             L"eas                   Requeste
        ?                                      I 1.1ervic
                                                                                 First Year
                                                                                 $31,507
        T'ki(-- --urpose of tl-.1@      i:o  provld@-  'Lloc,@)-'Ltals  'Ar.  t'Lle   St&te   ttore   i,.ifor-
           r
              upon   Wnicb    @L-o    b8se    individual    and    @-egio%ial    @laitrin'Y    6'ecisions.
                                                                    c
        O'ojiactive5: I')   lea@-.-   ma@-   abouf--   rLtier.@t   cL-iar@cZeri-r;tic--;   2)    learn    more    about
        hospital in;'armation         3) develop       .2cta!,n,-Ltive mr-e.Lires of I-.ospital
        care d3livery; 4) -@i2ia better               cf       t-,-rld   of      the      community
        hospital planning unit @st @,"2repriste 11--o bettei-          of   hospital    care;
        5) sustain the im?etus for re.@onal pl&nning by input - to effect better hospital
        care; and 6) foster additioiiL'S. researdh on  problaimi  of  health  care  delivery.
        The definition and analycis of- "trarketing" arer-s will be uGei to a.3sist in
        planning for ex?Lr-sion of Service Lid fc;cil4-tieG@; deterr-in.Lng areas and potential


            WEST VIRGINIA Me                       - 7                RM45  2/71 (C&S)

            patients that are not now adequately served, physician referral relationships,
            etc.

            The project will be completed in two phases during the 29-mmth period.  The
            first phase (January - December 1971) test demonstration In a four-county,
            area which includes 5 hospitals and approximately 120 physicians.  The second
            phase beginning in January 1972'will be implementation of the project on a
            state-wide basis to include 75 in-sttte hospitals,'19 out-of-state hospitals
            and about 300 physicians.

            The program is one of investigation and RMP continued support after the project
            period is not indicated.

                             Second Year                        Third Year
                              $42,911                           $14,155

                                                                     CRB 11 7, /1 71@ 70

                                                                     Rc,visrti  1115/71


     WEST VIRGINIA
     UNIVERSITY

                                                                                                                         REGIONAL
                                                                                                                         ADVISORY
                                                                          ----------------------------------           GROUP

                                                                                                                               VE
                                                                                                                               EE

                                  ASSISTANT TO                                     INFORMAT[ON
                                                                                   OFFICER                               STANDING
                                  THE DIRECTOR                                                                         COMt4ITTEES

                                                                                              ATE DIRECTOR
             COORDIN                                                                   PLANNING AND
             FIELD OPE                                                                 DEVELOPMENT

   E-KINS AREA       PARKERSBURG        HUNTINGTON                                  BEHAVIORAL            ATISTICI
    OFFICE           AREA OFFICE        AREA OFFICE                                 SCIENTIST
   ORG&NT014iN       BECKLEY AREA       CHARLESTON
   REA OFFICE          OFFICE           AREA OFFICE
                                                                                                           PHYSICIAN
                                                                                                           CONSULTANTS


   ,qEST VIRGINIA
   UNIVERSITY

                                                              STRATEGY FOR VOLUNTARY COOPERATIVE ARRANGEMENTS

                                            -------------------------------------------------------------------------------

    PROGRA,ll  ---------------------------                  A D V I S 0 R Y   G R 0 U P
    DIRECTOR

                                                         E X E C 1,J T I V E C 0 M @i I T T E E

                                                               PLANNING COMMITTEE

                                              RESOURCE SUB-
                                              CO@NITTEES FOR
                                              ELIGIBLE ACTIV-
                                              ITIES

                                                                       0

    REGIONAL
                     SUPPORT TO RAG                                                     PROGRAM
     OFFICE
                     AND CO@ZIITTEES                                                    OBJECTIVES

    AREA
    OFFICES                                                        s OP
     x 9
                                                                    COMMUNITY
                      SYSTAIATIC PROC,@L                          TRUSTEESHIPS             AREA
                                                                                         PRIORITIES
                      DEVELO@ilENT

                                           L ------------------------------------------------------------------------


                                            10

                        DEPARTT,,LENT OF' HEALTFI, EDUCATio@l, AND WELFARE
                                        PUF3LIC HEALTH SERVICE
                         HEALTH SERVIC@CAND MENTAL HEAI-Ti-l ADMINISTRATION

            Deceiiiber 17, 1970

            Staff Revievi of Noti-Coiiipeting Continuation Application froi-ii West
            Virginia Regional Medical Prograin      R[4 00045 - 2171 .1 (C&S)
      7 o:  Acting Director
            Regloii,il I-.ILdical Pt-ograiiis Service
            Th)-OLlgil: Chciiriiian of th,,-, Montil@,
                       Acting Chief, Regio.ii5-l Developiflcnt BranC

            West Virginia Pegional Medical Prog@'aiii requests continuation suppoi-'L- for
            the 02 operational year for Core and t@@io projects, plus use of $0/00.00
            cart-yover.
            Staff concurred on the following recoii,,riienda@Lions:
              1.   Support in the coinniitted aipount for  Core  and  Projects  L'4
                   and #6.
                                                                        -n Li ci I)atc
              2 .  Disapproval  of  the  $900.00  request  or  use  of  a         d
                   carryover.    (Staff concurred that the activity     planned for
                   the use of carryover tias needed and justified .       liovj(-,ver,
                   lag-tiiiie in recruiting staff for Core in the 02 year should
                   provide the  funds  necessary  for  SLInport  of  this request.)
            Sui-iii-ii;,iry Of action recorilinended:
                                            02 Year                               Staff
                                       Coniniitted Ai,,ioutit @e  ues-Lcd     R e c o r,,i;,, 1 r-. r; (-I c. @l
            Core                            $467,713          $467,713           $467,713
            Project r4                          15,054          15,054            15,054
            Short Teri,.l Training Tyson
            Ca-r@of-- t@r k@e FFaii-ent
            Project -:6                         33,800            34,700*         33,800
            lLelLtc2pl r@@ s@ibil_Lty
                   Total                    $516,567          $517,467           $516,567
               Includes recit,ic-,st for use of $900 anticipated cii-ryover.


                  Page 2   Acting Director, RMP'J

                  @lest Virginia R,!P @,,,as apl)i@oved-for operational status effective
                  January 1, 1970, with funds provided to support Core and three
                  Projects:
                         Education !@or CCU Staffs (I yr.), #4 - Nursinq Caro of Stroke
                    Pati         yrs .  and 41-15 - Stroke and I ts              I yr .    In
                    May,  1970,  Project  -Ir'6  -  Helicopter  Feasibilit  Stud  was  approved
                                                                       y-     Y.
                    and funded.
                  The present  application  was  submitted  in  the  AR  forniat  presented  at
                  Airlie [louse and contains a request for supplemental funds to support
                  three now projects  as  well  as  continuation  support  for  Core  and  t@ie
                  two projects with commitments for the 02 operational year.          No    develop-
                  mental component was requested  at  this  time;  however,  a  request  %,.,as
                  included to utilize $900.00 anticipated carryover.  Staff review did not
                  include consideration of the supplemental request as this will be
                  considered by conii-nittce and Council in the January-February, 1971,
                  Review  Cycle.  Staff  discussion  of  the  application   included   the   organ-
                  ization,  structure  and  functions  of  Core,  the  RAG,  Executive  and   other
                  Committees, Regional priorities, acconiplishi-iients, etc.
                  Staff rioted Project ',-T'5 - Stroke and Its Treatment - approved for one
                                                 e@d d7u--          of
                  year only, was never activ-a-         e -U6--lF@, '-  - v@i6 key project staff @,ii th
                  no  hope  for  replaced.i,:@nt within the one year period.  Revieviers concurred
                  progress reported  for  Core  ancl  Projects  #I,  I''4 and  @16  was  satisfactory.
                  Project llr'l was well received and provided training  for  a  greater  riur,,,@er
                  of applicants than had  been  anticipated.  As  previously  noi,,P-(!,  t@iis
                  project was approved for one year only.        The activity will coriti(iU(il  on
                  a reduced scale with non-RtIP support.
                  Staff also discussed a potential problem              developed in the
                  after  Submission  of  this  application.  The  University  of  VIC@st  Virginia.
                  Medical Center can  no  longer  assure  contiguous  space  for  new  Ri"iP  staff
                  added to Core and is negotiating viith a hotel in downtown t@iorganto%,,,ri
                  for  a  SLlite.Of  offices  for  Core  staff  headquarters.  It  is   anticipated
                  approximately  $18,000  will  be  needed  to  refurbish  this  space.   At   this
                  time funds are available  in  the  Region  to.support  thi@.  [lo,,,iever,  it  is
                  uncertain whether ary,,-tngeinents  can  be  completed  prior  to  termination  of
                  the Current grant year.      In  t@ie  event  arrangements  cannot  be  completed
                  within the current grant year, staff agreed a request -icroi;i the Region
                  for use of carryover (o)- for near funds if policy precludes use of
                  carryover) viould br-, needed, and justified particularly for this one-
                  time only expenditures


                                       12

           page 3   Acting Director, R14PS

           Staff also highly recommended that all due consideration be given to
           funding the three projects recommended for approval by the National
           Advisory Council in the November 1970 meeting.  It is the consensus
           of Staff that these activities are sorely.needed to give the Region
           visibility and to assure continued support of affiliated and coop-
           erating groups and individuals in the Region.
           The following staff members participated in the December 7, 1970,
           meeting:
             Mr. Frank Nash, RDB    Mr. Larry Pullen, GMB    Dr. Margaret Sloan
             Mr. Luther Says, GRB   Miss Carol Larson, CT&E
           Additional comments submitted by reviewers are appended.

           Frank S. Nash
           Operations Officer
           Regional Development Branch,

           Attachments

           Approved                          Date

           Disapproved

                               D.
           Acting Dir          s


                                                                        A PRIVILEGED CO,@IIJNICATION

                                        SUI,n,L,@RY OF REVIEW AND CONCLUSION OF
                                            JANUARY  1971  REVIE@@T  CO@l@-TIIEE

                                      WEST VIRGINIA REGIONAL @TEDICAL PROG@'4
                                                Rl,l 000ii5  2/71.1  (C & S)

                           FOR   CONSIDERATION   BY   FEBRUARY    1971    ADVISORY.COITNCIL

              Rdcorruiie.ndatio,-i:   The Co-tTi-@i@@tLE,,o considered opl)l-l'-catioii which includes
                                   requests:   1)   continuation   support   for   core   activities
              and  two.projects  and   2)   supplemental   support   for   three   new   projects.
              In  reaching  a  recommendation  for-  the   level   of   funding,   the   Committee
              also   considered   three   projects   previously   approved   by   Council   but
              unfunded,  and  their  program   relevance   including   ranl@   order   by   the
              WV/@IP.    Funds requested by WV/@IP and reco,iiiiiE,.nded  by  CoriiHii.ttee  are  as
              fol@  Io-"7s
                                                 Direct Cost

              Year                              Requested                 Recoi-@@Liieiided Ftir)din@
              O?                        I/     $ 932,343                 2/   $     776,567
              03                                 961,555                 2/         775,965
              04                                 356,936                 2/         260,000

                Total                           $2.12501834                     $)-,812,532
              The Co:iii,.tittee also recommends that its conceri-@.s be co@l-uli!lnica.Lt--d to the
              WV/Rt,',Il.
                                                  Direct Cost

                                               0
                 Re fight                       2 Year                 03   Year           04   Year

              Continuation
              Core & 2 projects                $535,467                 $515,965              -0-
              3 New Projects                    173@82L                  186,094                 561
                      Sub Total                $709   296               $702,059             $167,561
              Approved & Unfunded               223,04/'                 2591496              189,375

                 Total                         $932,343                 $961,555             $356,936
              2/  The second year continuation re.ciuL-st was reviewed         by   staff   and
              $516,567   d.c.o.   was   recommended.    Committee    reco,,@ended    additional funds
              in  the  amount  of  $260,000  each  year  for  three  years   for   new   projects.


             W6st Virginia RMP                     -2-            RM 00045 2 71.1 (C & S)

             Critique: The Committee noted  that  although  t.he Region has been operational
                        for only one year, the program seems to be moving forward under
            -effective leadership.  The requested level of support is modest, particu-.
             larly in view of the dearth of needs in the State.

             The Committee noted the new core staff positions budgeted and wondered if
             they could actuall  be recruited.  As reported by staff, the Coordinator
                                y
             on a recent visit to RMPS indicated he expected no great prob ems  n
             filling the positions.

             The Rural Scl-iool- Health proposal, ranl,,ed first of the six new projects
             by the RAG, is an interesting concept and worthy  of  support.  'The
             Committee, however, was concerned about the  assurance  of  adequate
             follmq-up.  The question arose as to the number of pediatricians
             available in the target area and a clearer  statement  of  follow-up
             care is needed.  Also, the amount budgeted for consultant services
             is high.

             By the nature of the goals of the "Cancer Education and Service" project,
             the current registry program appears to be only aquisition of data...
             The project is designed to  u,@ rade and stimulate utilization of
             information gathered.  Like Council, the Committee has little
             enthusiasm for  the  program.

             The Committee  believes  that if WV/@IP considers funding this project,
          ...they should be aware  of  the November 1970 Council's discussion and
             'Action about registeries.

             The Committee believed that the "segmental  ion of hospital service areas"
             'Proj6ct is a study concept that might be more Appropriate as a Core
             plannina activity and/or CHP.  It would seem that some of these data
             would have been acquired during the WV/RMP planning phase.

             The concept of  niedical-self audit as represented by project  #8  is
             recognized as a very innovative activity in WV/RMP and of great
             interest.,

                                                  RMPS/GRB/l/19/71


                                     REGIONAL MEDICAL PROGRAMS SERVICE
                       SUM14ARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION
                                       (A  Privileged   Communication)

              Wisconsin Regional Medical Program, Inc.            RM 00037-04 (AR-1-D)  2/71
              110 East Wisconsin Avenue                           January 1971 Review Committee
              Milwaukee, Wisconsin  53202
              Grantee  Agency:   Same

              Program Coordinator:  John S. Hirschboeck, M.D.

                                           Request       ct Costs)

              Purpose                   04  year  (9/l/70  -  8/31/71)

              Additional    Component
              (Developmental)                      $200,000

                                               Funding History

                                               Planning Stage
              Grant Year                       Period                                  Funded (d.c.6.)
                  01                           9/l/66   -   8/31/67                    $319,458

                                             .Operational   Program
                                                   Council                                Future
              Grant Year     Period                Approved       Funded (d.c.o.)         Commitment
                  01         9/l/67  -  8/31/68       539,366     Core     415,093        ------
                                                                  Proj.    133,773

                  02         9/l/68  -  8/31/69    1,365,463      Core     438,974        ------
                                                                  Proj.    723,707

                  03         9/l/69  -  8/31/70    1,338,194      Core     438,974        ------
                                                                  Proj.    800,536  I/

                  04         9/l/70  -  8/31/71    1,794,257      Core     438,974        ------
                                                                  Proj.   1,153,299 2/

                  05         9/l/71  -  8/31/72       499,425                             $484,120
                  06         9/l/72  -  8/31/73       442,805                              442,805

              I/  Includes  $141,080  Carryover
              2/ Includes $60,704 Carryover


         Wisconsin RIIP                                          RM 37-04 (AR-1-D)2/71
         G     h  :  The boundaries of the Wisconsin Region are coincident with
                      those of the State. The University of  Wisconsin  Medical
         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 peninsula and part of Illinois.

         Diamogr.aphy
           A.  Population:  approximately 4.5 million

               1.  Roughly 64% urban

               2.  Roughly.98% white

                   Median age 29.4 years
               3.

           B.  Medical Schools:  2

           C.  Hospitals:  Approximately 200
           D.  Physicians:  4,803 (medical)
         Region's Objectives:  The objectives fall into three categories; those
                               related to direct patient care, those related to
         requirements for effective support of direct patient care;  and  those
         related to basic research.  The objectives are as follows:
             Develop a plan to improve preventive medicine capabilities throughout
             the region in the fields of heart disease, cancer, stroke, and related
             diseases.
             Plan to improve diagnostic capabilities with the region as related to
             heart disease, cancer, stroke and related diseases.
             Plan for improvement of the capability within the region to provide
             long-term medical care and rehabilitation for patients with  heart
             disease, cancerstroke, and related diseases.
             Improve patient care through a plan to increase nursing support within
             the region.
             Plan to improve the support capability of allied health  personnel
             within the region.
             Plan to increase the number of physicians in the region and to improve
             utilization of physicians within the region.
             Improve patient care through a plan for expansion of physical facilities,
             and the more efficient use of existing facilities within the region.
             Develop plans for expanding the effort in clinical research for heart
             disease, cancer, stroke, and related diseases.
                                      -   -     . ' - J---             And


             Wisconsin RKP                -3-                  RM 37-04 (AR-1-D) 2/71

                information flow program for the region.
                Formulate a plan for the development of an optimum program for con-
                tinuing postgraduate education in fields of heart disease, cancer,
                stroke, and related diseases.
                Develop a plan which provides for the most extensive participation
                and utilization of the capabilities of such established organizations
                as the American Cancer Society, Public Health Services, Heart
                Associations, etc.
                Expand and diversify already strong basic research programs in cancer,
                heart disease, stroke and related diseases and initiate new research
                relative to rehabilitation.

             Priority Determination:  The Region indicates that the priorities are
                                      tied to points of decision related to the
             overall planning process.  At each decision point, priorities are required
             to allocate resources in the best possible way.  Six steps are outlined
             which are required to produce results for WRMP proposals.  Three of
             these steps concern decision making that concern priorities.
             In the first step, WRMP establishes what it wishes to do during a
             particular planning cycle and attempts to establish priorities among
             potential proposals.  A number of methods may be used to establish
             priorities to begin a planning cycle:  a)  progressively defining and
             redefining the organizations, goals & objectives. Ultimately, such a
             process could identify a set of manageable activities; b)  various
             data sources, such as profiles of emergency room activities, hospital
             discharge data and national health survey can be used to isolate frequency
             of ailments and identify needs; c)  a judgemental process could be used,
             presenting a decision maker with a set of possible programs and descriptive
             information expecting that he would add to this list.  The results would
             be a raking of the possible proposals identified.
             The second step of the planning process is to examine the feasibility of
             high priority potential,proposals identified in the first step.  For
             example, the staff would be concerned with the overlap of these potential
             proposals, their feasibility for development during the planning period,
             the approximate amount of resources they might require and the availability
             of these resources.  The third step requires staff and volunteer development
             of feasible proposals.
             The fourth step of the planning process is the local review.  The decision
             makers of WRNP, (the RAG) are responsible for this decision.  There are
             two basic results from this review:  establishing basic merit for each
             proposal and ranking acceptable proposals in order of local preference.
             Step five is DRMP review and rebudgeting constitutes the last step in a
             planning cycle.  Priorities during rebudgeting represent the specific
             allocation of the available resources to approved projects.


                                            -4-              RM  37-04  (AR-1-D)   2/71
           Wisconsin R14P
           R gional Advisory GroU'D  The group meets on a quart( .!rly  basis  and   is
                                    composed of 40 members representing the
           following areas:  Medical, from Clinic to individual practice:
                                                  Insurance;  Labor  Unions;   Minority
           Nursing; Dental, Medical Education;                                             ic
           group interests; ;legal;  Industry;  Finance  area-wide  planning  agencies;  Pubi
           Health and Comprehensive Planning; Voluntary Agencies; Public Relations
           and Industry  and  Mercantile  interests.  The  RAG  was  recently  reorganized
           for the purpose of  becoming  more  actively  involved  in  all  aspects  of
           the work of  WRMP.  The  group  provides  overall  advice  and  guidance  in
           the planning and  operational  program  of  WRMP;  is  responsible  for  the
           development of the goals and  objectives  and  is  involved  in  the  review
           and evaluation of ongoing planning and operational functions.  All
           Committees and study groups are subcommittees of the RAG with the        chair-
           man of each subcommittee a member of the RAG.  The duties of the      RAG have
           been combined with those of the subcommittee in ways that have effectively
           involved people of diverse skills in  many  areas  of  the  health,  health-
           related and  allied  fields  in  cooperative  efforts  toward  developing  a
           strong and viable  RMP.  The  by-laws  of  the  RAG  have  been  amended  to
           roved for  a  5-member  Executive  Committee  who  shall  act  for  the  RAG
           p
           between  the  regular  quarterly  meetings  on  matters  specifically  assigned
           by the RAG for interim action.
           .Review Process The  Project  Review  Committee  is  composed  of  six  members
                            ox  the  Regional  Advisory  Group,  representing  hospital
           administration,  nursing,  and  medicine.  The  committee  meets  before   each
           Advisory Group meeting to study the applications and provides the
           Regional Advisory Group with a detailed review of the advance or completed
           application  for  project  support  and  recommends  action  regarding   the
           applications for final  decision  to  the  Advisory  Group  and  endorsement
           by the Board of Directors.
           History of..Regional Development     In  April  1965,  both  the  University of
                                                Wisconsin  and   Marquette   University
           submitted separate  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 through closer
           collaborative  efforts  between  the  two  Medical   Schools.   During   the
           interim between April 1965 and July 1966, the Wisconsin Regional Medical
           Pro ram Inc., was  formed  as  a  collaborative  venture  by  the  Marquette
              9
           School  of  Medicine  and  the  University  of  Wisconsin.  The  Corporation   is
           controlled by  the  Presidents  of  Marquette  University  and  the  University
           of Wisconsin.  Management  of  the  Corporation  is  vested  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.  The  Program  Coordinator  is  directly   responsible   to   the
           President  of  the  corporation.  The  Board  of  Directors  also   appoints
           the Regional Advisory Committee and its chairman.


             Wisconsin RMP                    -5-                RM 37-04 (AR-1-D) 2/71
             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/i/66 - 8/31/67, ttie second year
             planning grant was merged with the first year operational grant.  The
             Region became operational following a preoperational site visit in
             July 1967.  The second year (9/l/6,7 - 8/31/68) award provided continued.
             support for Core planning and administration, plus support for three
             feasibility studies (two in dial access tape libraries, And one for single
             concept films).  In addition, funds were provided to support three
             operational projects.  These were in Uterine Cancer Therapy, Pulmonary
             Thromboembolism and Cancer Chemotherapy for adults.
             During its third year, 9/l/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 requested support for nine  new  operational
             projects contained in two separate applications.  Seven of these were
             recommended for approval.
             During its fourth year, 9/l/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 renewal support for
             Dial Access Library Service for Physicians; Dial  Access  Library  Service
             for Nurses and Single Concept Films project.
             In August 1970, staff considered a request from the Region for the
             fourth (operational) year (9/l/70-8/31/71) which  contained  requests  for
             continued support for Core ($438,,974) and twelve ongoing projects
             (see listed below).  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; #16-Medital Library Service and
             #17-Nurse Utilization Demonstration Unit.  Approval of continued support
             in the amount requested for the fourth year was recommended.
             Currently, the Region has the following approved/unfunded projects:
             Department of Health Manpower and Continuing Education;  An Education
             Program for Cardiac and Intensive Care Nursing; and renewal support,
             with no additional funds for Inactive Nurse Education.
             Listin& of Current Funding Status of Core and Operational Projects
             Project                                                    Amount Supported (D.C.)
              Number     Title                                           Throukh 8/31/71
             1           Core                                                    $   438,974
             4           Cancer Chemotherapy for Adults                               38,500
             5A          Library Service for Physicians                               16,900


                                             -6-                    Rt4 37-04 (AR-1-D)2/71
           Wisconsin R14P

                                       Table Continued
                                                                   Amount Supported .(D.C.)
           Project                                                  Thrnilah B'@l
           Number      Title
                                                                         $     19,020
           5B          Library Service for Nurses
           5C          Single Concept Films                                    20,500
           6           Radiology and Nuclear Medicine                         126,906
           7B          Coronary Angiography                                     5,800
                                                                               57,256
           7C          Pediatric C;'ardiology
           8           Cancer Chemotherapy Program (Milwauk6e)                 64,384
           11          Tissue Typing Program                                   50,950
           12          Uterine Cancer Screening Proje'ct                       50,820
                       Comprehensive Program in Renal Diseases                450,000
           15*
                                                                               16,525
           16          Medical Library Service
                                                       n Unit                 119,613
           17          Nurse Utilization Demonstratio
           20*         Detection and Management of Gynecologic
                       Malignancy                                             116.125
                                                           TOTAL        $   1,592,273

           Carryover included above:
           #16   $16,525

           #17    44,179
                 $60,704
            Not considered during staff review of continuation application.

           present Application  This application contains a request for a developmental
                                component in the amount of $200,000 for a one-year
           period beginning 9/l/70 - 8/31/71.
           Use of Developmental Funds  The Regional Advisory Group identified areas
                                        of high priority program interest and recommended
           that developmental funds be made available for feasibility studies and
           program development.  The following program areas were approved for use
           of developmental funds:


              Wisconsin RIIP                     -7-                RM 37-04  (AR-1-D)  2/71

              a.  the planning and promotion of an improved coronary artery disease care
                  system for the Region.

              b.  the planni ng and development of innovations in health care delivery
                  and manpower utilization.

              c.  the planning and development of improved hospital emergency care and
                  improved transportation of the sick and injured.

              d.  the planning and development of innovations to improve long-term patient
                  care, including home care and Nursing home care.
              e.  the planning and development of means by which education can be brought
                  to those health professionals who are not presently served.

              f.  the planning and development of continuing education which is designed
                  to develop proficiency in using new knowledge or new technology.

                  the planning and development of improved health care for isolated
                  rural residents.

              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 RKP activities.

                                                                 DRMP/GRB 12/8/70


                                                                (A Privileged Comniunication)

                               SUMMARY OF REVIEW AND CONCLUSION OF
                                 January 1971 Review Committee

                               WISCONSIN REGIONAL MEDICAL PROGRAM
                                    @M 00037--04 (AP,-l-D) 2/71

                       FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL

          Recommendation:  The Committee recommended that this application, which
          requests $200,000 for a developmental component be deferred and incorporated
          into their.triennial application.

           YEAR                               REQUEST             RECOMMENDED FUNDING

          lst Year                            $200,000

                TOTAL                         $200,000

          Critiqi-ie:  In its deliberation, the Committee considered the Site Visit
          Report, Wisconsin Re '.onal Medic                ember  8-9,  1970.  While
                              &I           al Proaraiii, Dec
          the site visitors recommended a proval for approximately $160,000 for
                                          p
          one year for the developmental component, rather than the $200,000
          requested, members of the Review Committee  believed  that  action  should
   l&,b6 deferred with advice to the Region to incorporate their proposal for
          developmental funds into their triennial application, due May 1971.

          A member of the Review Committee, who was also a member of the
          December 8-9, 1970 site visit team, reported the findings of the team
          to the Committee.  He reported that the Wisconsin PIIP has many strengths
          and much potential.  One of the positive factors is the Program Coordinator
          who has fully devoted himself to the goals and objectives of RMP and
          who has done an excelient.job through the  years  of  maintaining  control
          over the management and direction of the I%TRMP.  However, the team agreed
          and suggested to the Coordinator that he  could probably use another
          M.D. on his staff as back-up to himself and to coordinate monitoring
          of WPMP planning and operational activities. He  went  on  to  state  that
          while@the core staff appeared to be a cohesive group which has stayed
          together over.the years, they believed that  i@  lacked  sufficient  depth
          and 8frength as to its ability to evaluate total  program  as  related  to
          objectives. Physically, the Core  Staff  is  split'between  Milwaukee  and
          Madison. While the essential strengths  are  presently  in  the  Milwaukee
          Core-offices, the Region is considering a plan to  move  and  combine  the
          two offices into one Central Core office which will be located in Madisoni

          I'he'Regional Advisory Group was viei,7ed-by the site visitors as being  a
          well-balanced group, having broadened the range of professional and
         -health interests. Geographical  representation  has  also  been  improved.
          It was noted that there is currently only one  Black  member.on  the  RAG,
          ut"this may be improved through appointment to a vacancy.  The Committee


                                                              RM 00037 (AR-1-D)  2/71.
         Fage 2

         learned that the RAG has a strong role in   policy  direction  and  guidance
         of the program and has a strong input into the review pro@ess.

         The extent of the subregionalization efforts in  Wisconsin  was  one  of  the
         concerns of the site visitors, although the Region is progressing in this
         effort, the team believed that further  efforts  should  be  made  especially
         in the rural areas of the State.

         One of the major concerns of the site -visit team was the. lack of objective
         methods of evaluation. While  the  Region  has  the  expertise  available
         through the'Universities, evidental.ly this  talent  is  not  being  fully
         exploited.

         Members of the Committee learned of  the  team's  concerns  regarding  the
         large Renal Disease Project i-71iicLi is currently being funded in the
         Region.  While the Reviewers were aware of the  receri@  funding  of  this
         activity it agt6ed with the site  visitors  that  some  earl.y  technical
         assistance would be necessary if the project is expectc@(-l to  achieve  its
         objectives.

         While the site visitors agreed that the MIP.is     a we]-l-adjusted  Region
         which has demonstrated that it has  the  machinery,  expertise  and  loca
         7utonomy to successfully and prudently administer and use a developmental
          omponent as a part of their tbtal- program,  members  of  the  Committee
         believed that the developmental component was too broad and all encompassing.
         it was believed that the Region should more adequately describe and speci y
         how  developmental funds would relate to the priority needs of the Region.

         In conclusion, in spite of the site  visitors.posit@Ll@@erecommendation  on
         the request for developmental funds, the Review  Committee  a  ter  a  some-
         what lengthy discussion, believed that  the  awarding  of  a  developmental
         component at this time was not indicated.  Rather, the Committee recommended
         that action on the developmental component  be  deferred  with  the  thought,
         that the Region may wish to  incorporate  its  proposal  for  developmental
         funds in the triennial application, which will.  be  considered  during  the
         July/Atigust 1971 Review Cycle. In arriving at the recommendation to defer
         action on this application, the Committee  believed  that  the  delay  wou
         provide the Region with the opportunity to  replan  its  anticipated  use  of
         developmental fundsi Also,  the  Committee  further  recommended  that  a
         technical site visit to include members  of  MMPS  Kidney  Disease  Program,
         be made to review and assist the Region  with  the  Renal  Disease  Project..

         Dr. White was not present at the deliberation of this application.

                                                                            GRB/RMP
                                                                             1/19/71