ALBANY -_--- Regi.on : o t *a jI Site Visit - Review Cycle: October 1972 TvDe 'of AnDlicat ion :- Triennial -_ .I& LA Rating: 303 RECOMMENDATIONS FROM - /x/ Review Committee I!/ Council 7 RECOMMENDAT I ON The National Review Committee concurred with the site visitors in recommending three year's funding (triennial status) for the program's 06, 07, and 08 years, approval of the developmental component for three years in the reduced amounts of $30,000 (06), $45,000 (07), and $60,000 (08), continuation of program staff and seven ongoing pro- jects, and the implementation of 13 proposed projects. The Committee, paralleling the recommendation of the site visit team, recommended that Project 1/23, Health Career Incentive Program, have ARMP support terminated by December 31, 1973, because it is counter to WS policy to support health careers recruitment projects. Further, the Committee advises, as did the site visit team, that iZRQ carefully review projects #24, f31, and 643. In the case of project 124, further refinement and integration with other health activities are suggested. specifically directed at the health needs of the Albany region. Project #43 was looked upon as too expensive on a cost/benefit basis and possibly duplicative of work which has already been done in other RMPS . The total request and recommendations are as follows: Project #31 was viewed as too global in nature and not Direct Costs . Year 06 07 08 - Requested $2,426,921 $2,646,254 $3,060,317 Recommended* $1,618,000 $1,783,090 $1,940,725 '* The recommended amounts include Developmental Component monies in the amounts of $30,000, $45,000, and $60,000 for the 06, 07,and 08 years respectively. CRITIQUE The ARMP has made substantial progress since last year's site visit. The RAG has been expanded and restructured in a manner which insures greater community and less university participation in the program's decisionmaking process. representation. The new RAG Chairman, Dr. James Bordley, 111, was identified as a particularly capable and dedicated man who made a major contribution to the program's rapid development. The RAG now includes greater minority Further, the Committee concurred with the site visitors that the appointment of Dr. Girard Craft to the position of Deputy Director provided the impetus required to coordinate the large and program staff into a cohesived unit capable of administering an enlarged program. The Committee shared the site visitors' concerns about the program staff's lack of fiscal management competence in light of the program's many projects. a fiscal specialist in the interim period between the site visit and the Committee's review. iveness to site visit recommendations and assured increased staff competence in an area which had been seen as a deficient. They were pleased to note that the ARMP had hired This tended to reflect the program's respons- The Committee shared the site visitors' emphasis that the AR-MF"s excellent projects should be converted into a more integrated program. There was a consensus that this would be done in light of the com- petence of Dr. Craft, Dr. Bordley, and Mr. Robert 11. Briber, Vice Chairman of the RAG. In summary, the Committee accepted the report and recommendations of the site visitors as expressed in the site visit report. EOB/DOD 9/26/72 Component PROGRAM STAFF CONTRACTS DEVELOPMENTAL COMPONENT OPERATIONAL PROJECTS Kidney EMS hs/ea Pediatric Pulmonary Other TUTAL DIRECT COSTS COUNCIL RECOMMENDED LEVEL COMPONENT AND FINANCIAL SUlWARY TRIENNIAL APPLICATION I i Committee Recommendation for Current Annualized . Requ Level Year 1st year 774,592 I 768,230 ,~ 90,000 75,314 I 1,568,691 I 2,426,921 900,000 900,000 ;t for Tri 2nd year 787,563 X 90,000 1,768,691 nnial Council-Approved Level 3rd year -- 1st year I 2nd year 1 3rd year 731,225 I X X X x 30,0001 45,000 1 60,000 90,000 I I Site Visit Report Albany Regional Medical Program August 1-2, 1972 Site Visit Participants Consuit ants John Kralewski, Ph,D., Chairman, Associate Professor and Director, Division of Health Administration, University of Colorado Medical Center, Denver, Colorado, RMPS Review Commi,ttee Member Adelbert L. Campbell, Acting Coordinator, California Regional Medical Program, Area 9 Granville W. Larimore, M.D., State Director, Florida Regional Medical Program John S. Lloyd, Ph.D., Associate Coordinator, Program, Area 5 Alton Ochsner, M.D., Ochsner Clinic,New Orleans, Louisiana Robert C. Ogden, President and General Counsel, North Coas California Regional Medical Insurance Company, Spokane, Washington, WAC Member WS Staff Thomas C. Croft, Jr., Financial Management Officer A. Burt Kline, Jr., Public Health Advisor, Eastern Operations Branch Frank Naeh, Acting Chief, Eastern Operations Branch Miss Elsa J. Nelson, Senior Health Consultant, Division of Professional Mr. Robert Shaw, Program Director for Regional Medical Programs Service, and Technical Development Region 11, DHEW Regional Advisory Group c James Bordley 111, M.D., Chairman, Executive Committee Robert M. Briber, Vice Chairman, Brecutive Committee, Executive Director Peter Crawford, Director, Community Medical Care Program, Executive Robert A. Dyer, Executive Committee Member Marjory A. Keenan, R.N., Associate Professor of Nursing, Russell Sage Hudson-Mohawk Association of Colleges and Universities Committee Member Colhge, Bcemtive Committee Member Ccmmlttee Member Department of Health, ]Executive Committee Member Planning Commission, Executive Committee Member F. Donald Lewis, President, Heart Association of Eastern New'York, Executive Daniel P. McMahon, M.D., Regional Health Director, State of New York Paul F. Robinson, Associate Executive Director, New York State Health 0 -2- Regional Advisory Group (continued) Eitgene H. Bohi, General Manager, WAST Television, Menands, New York Ruth Buchholz, R.N., Directorof Nursing Service, Columbia Memorial Hospital, Hudson, New York Charles Eckert, M.D., Professor and Chairman, Department of Surgery, Albany Medical College, Albany New York Elizabeth B. Haile, Schenectady, New York Thomas L. Hawkins, Jr., M.D., Executive Vice President and Director, John C. Marsh, Vice President-Treasurer, Blue Cross of Northeastern Thomas W. Mou, M.D., Provost for the Health Sciences, State University John Murphy, Administrator, Saranac Lake General Hospital, Saranac William H. Raymond, M.D., Johnstown, New York Bernard Siegel, Vice President-Business 6 Finance, Albany Medical College, The Rev, John R. Sise, Cooperstown, New York Seth W. Spellman, D.S.W., Dean, James E. Allen, Jr. Collegiate Center, Jerome C. Stewart, Executive Director, St. Clare's Hospital, Schenectady, Marie N. Tarver, Executive Director, Model Cities Program,' Poughkeepsie, David E. Wall, Hospital Director, Veterans Administration Hospital, Harold C. Wiggers, Ph.D., Executive Vice President and Dean, Albany Albany Medical Center Hospital, Albany New York Hew York, Inc., .Albany Mew York of New York, Albany, New York Lake, New York Albany, New York State University of New York, Albany New York New' York New York Albany, New York --- Medical ---- College, Albany,.New York Director Michael A. Nardolillo Nathaniel McNeil Lawrence N. Fuchs Peter Jones Harold A. Rodgers Ursula Poland Bernard H, Rudwick Donald C. Walker, M.D. Bette Hanson Henry Tulgan, M.D. Mary C. Bromirski, R.N. Freyda M. Craw John A. Olivet, M.D. Donald E. Schein PROJECTS Title South End Community Health Center Carver Comprehensive Community Health Center Training for the Delivery of Home Care Health Career Incentive Program Migrant Health in Columbia County Medical Library and Information Service Community Health Education Service Design and Development of a Comprehensive hergency Health Care System Rural Community Health Guides County-wide Cardiac Monitoring System An Expanded Concept of Home HFalth Care To Have a Voice -- Post-Laryngectomy Rehabilitation Cooperative Training Program for Allied Health Professionals lhis Week in Health 1. 1 - ./ - 3- Catherine Harwood Jane6 Heron Glster Anne lswlor Dorothy Paul Leo J. Roy Capital Area HMO Planning Council Upper Hudson Regional Coalprehensive Health Schoherie County Comity Action Program Council of Conununity Service6 Haria College Community Me6Ical Care Program Heart Assmi8tion of Befern Hew York Plenning Organization Frsnk M. Uooleey, Jr., M.D. Oirsrtl d. Crsft, W.D. J. Clrrk Winslow Byron E. Eowe, Jr., M.D. William P. Xeluon, 111, W.D. Ward L. Oliver, M.D. John Be Phillig~, M.D. &OM We POhly W.D. Paul L. wad-, Ph-D. Robert J. Ambrasino, Ph.D. Raymond Forer, PhA Anne 14. Anzols Ilrrpa Wilheh, R.P.T. Arthur A. DeLtloa Jeremiah Blantan DBte L. Morgan Roy E. Perry Henry J. Zarzyckl William C. Batchelder Robert W. O%eill Albert P. Irfredette Robert B. blershall Crrl merle wily IC. ROrebawh, R.1. Director Deputy Mrector Aaainiefrative Aselstant Associate Coordinator, Morthern Mvieion Aeeociate Chrdinstor, Eastern and A680~late Coordinator, Western Mvision A8sociarte Cootdinator, Southern Mvislon Ehrelaation SpeciaUat , Educational Paychologist Evaluation Speciallet, Sociolaglet Coordlnator, Comaaunlty Health Education Coordinator of flhysical Therapy Acting Coordinator, Hurrbg Mrector, Copeolunlty Affairs Cormmrnlty Affairs Specialist Community Affairs Specialist Community Affair8 Specialist Community Affaire Specialist Mrector, Information Service Mrector, Public Reutione Coordinetor , Inatructlonal Conpnunicat ions Flocal Specislist Fiscal Spcclalirrt Interface Divieiona A86ocbte &omdinatW, Central mVi8iOll fi8ltStia s@eChli8t , EdUC8timli PBychOlogiSt -4- INTRODUCTION: The Albany Regional Medical Program was site visited in June 1971 and at that time the site team was concerned over the program's rather narrow and unimaginative thrusts, baaed largely on a two-way radio contlnuing education program. structure of the program in terms of minority representation, the lack of a deputy director and indeed the lack of any depth in admin- istration, a weak RAG, and a dependent relationship on the Medical School. These deficiencies were called to the &W"s attention when their grant was awarded last year and they immediately began to restructure their program to implement these suggestions. As the current site visit report will indicate, the ARMP supcessfully restructured the RAG and involved it in the program's development, strengthened the program staff, attracted the interest of the region's health professionals and, in all, met with considerable success in overcoming moat of the deficiencies noted by the site visit team of 1971. specific events which highlighted the activities of the past; year. h The team was also concerned over the , The turnabout in the program$ direction can be traced to some September 1971 - A meeting between the Directorj RMPS, and the ARMP Coordinator, the RAG Chairman and four members of the RAG'S Executive Committee. At this meeting, the Director, RMPS, provided specific guidance to the key personnel of the ARMP and outlined what they would need to do to enhance their succc~s as an RMP. . September 1971 - Mr. Jeremiah Blanton is appointed as the AM's first black professional program staff member. In his role as a Community Information Coordinator, Mr, Blanton begins to provide an important link between ARMP and the region's black communities. In retrospect, it is possible to see that the ARHP involvement in improving the availability and accessibility of health care in the region's black commu- nities can be traced to this appointment. , December 1971 - Mr. Roger Warner, Evaluator, Arkansas RMP visits the ARMP to advise on matters related to the program's organizational structure, review process, and project development. . 3anuary 1972 - Dr. James Bordley assumes the post of RAG Chairman following the resignation of Dr. Harold Wiggers, Dean, Albany Medical Coll.ege. Chairmen since it began operation in 1966. This was the program's first change in RAG Dr. Girard Craft Is officially appointed as Deputy Coordinator to Dr. Woolsey. INTRODUCTION (CONTD) Dr. Bordley, former Chairman of the RAG Executive Committee, and Dr. Craft, former program staff member, as a result of their past experiences, brought outstanding competence to their new positions, in two vital areae and the major ingredients for radical change had been added, At this juncture, the ARMP had gained strength . January 1972 - The W, at Dr. Bordley's urging, votes to meet nine times per year instead of four rimes per year, , January 1972 - The entire RAG membership, now expanded from 27-37 members, is broken into four "goal oriented" task forces to more closely involve each member in the review process rand program development. . February - June 1972 - The RAG Task Forcee meet times per month; the RAG Executive Committee meets twice monthly, and the full RAG meets monthly. is as follows: two to three The product of these meetings , 52 project proposals reviewed and ranked relative to ARM€"s $oals, objectives and priorities . 47 project proposals approved with varying degrees of priority . 23 projects voted for inclusion in the June 1972 appli-' cation for triennial support During thie period of furious activity, Dr. Craft coordinated, 'channeled, and guided the program staff energies while, at the same time, Dr, Bordley motivated the BAG, its Executive Committee, and its Task Forces to successfully meet the tremendous work load being forced upon it by the need to review the projects being developed by the ARHE' program staff , , , April 11, 1972 - Roger Warner, at the request of the ARMP, Visit8 the region to review and comment on the progress made since his December consultative visit. ceived significant progress. His report reflects that he per- INTRODUCTION (CONTD) . April 30, 1972 - All ARMP support for the Two-way Radio and Coronary Care Unit terminates. At`thie point,.all vestiges of past project efforts ends and the ARMP entered into a new era which involved only projects which had I been developed since the previous year'e site visit. December 1971 - July 1972 - Throughout this extended period, the ARMP staff worked in a dedicated fashion to assist the 52 project applicants to refine their original concepts into sound project proposals. . The following site visit report will document the impact of the changes reulting from the above events and will attempt to point out aome residual deficiencies and some of the problems that remain to be resolved. RMP: ALBANY PREPARED BY: A, Burton Kline DATE: 10/72 1. Gw~s, ObJectlves and Rrioritle~ (8) At the tinre of the June 1971 eite visit AFiMP was found to have two long-range program goal8 and oeven short-range obJectives as follows: aoSlS 1. - To promote and influence regionel cooperathe arrangements for health rervicerr in 8 =mer which wlll permit the best In modem health care to be available to all. 2, To assure the quality, quantity, an8 effectiveness of profesriaarrl and allied health mpower o 1. To eqlore and encourage Innovetlve methods of health care delivery with particular attention to improving delivery In abdically deprived urbrrn and rw51 do~ticer. To mbilize conomr-provider participation in the identi- fication and oolution of local and regional health pgoblems. lo recruit health IBalDpwer snd Iralprave lto dietrlbution and utilization. 2. 3. 4. To Introduce methods to relieve overburdened health profss- siaarls o 5. To engage in the education and treinlng of health peraonnel with particular attention to continuing educaticm and to the fraiabg of personnel to fila Eeo0(plised gap$ In aritfcal To promte pub110 education in health errtterrr. To further the process of regional cooperative arranlgementr. At thrt time the rite virrit team felt that the i@MP needed "a aet of operating objectlvelr which are quantifiable and maeurable, tine- dependent, and r8nked la priority orders" This rtcoaaarendation -8 capoeyed to the Coordlrator vis the Rw[F1s Advice Letter. W-8 o 6. 7. At the time of the August 1972 eite visit the following goals and obJectives for &BiiP wre gre0eDted: aaAL It To ilnprove the delivery of health care. OWTIVE A: health care vlth parflculss attention to medically deprived urban and rural collmuu3itlee. 0- B: of health care dellvery through the utilization of personnel In new roles. To improve the acceesibility of comprehensive To design and implement Innovative methods OBJBlcTIvE C: OBjBcTIvE 0: IC: OBJECTIVE A: tralniw program for members of the health team. OBJBXIVE B: the quality of health care delivered. To imrove emergency healtb eervlces. To increase public ay~reness in health nrstters. To monitor and Improve the .quality of health care. I To plen, promote and conduct educational and To design and develop mchanlsms for evaluating GOAL III: To belp eolve the health manpower problem. 0- A: OBJECTIVE B: OBJECTIVE C: of health -power . To recruit health manpower. To lncreaee the efficiency I, of health manpower. To iqprwe the dlstrlbution and utilization WiL IV: To further the process of regional cooperative ar#~ngenrcnte. OBJECPIYE At To mobilize conaumr and provider p&ticipation in the identification md eolution of local and regioaal health problem. -9- .....*-..-- The goale ana lanprange objectives were prioritized 88 follows: Very Bigh Priority I -A I11 - c High Priority Average Priority nr - B I1 - A I -c 111 - A I -B I -D IV -A 11 - B Projected activities end elreaw funded prodects were listed under each of the goals amd objective6 to which they pertained and the aiistribvticm -6 a6 f0-Z Very High Priority ObJectlve8: 7 proJect8 46$ or proJect funds High Priority Objectives: Average Priority ObJectlvee: In sm, the goale sad obmtlves have been restated and prioritized eince the 1971 site visit end the progrese be been eignificant. As the program mturer, there should be a continued effort to further refine these goals and obJectivee in terma which can be -re easily quantified and mesoured and mre specifitslly rebted to the identi- fied health Deed0 of the Albany region. The current gwls and obJectlvee were developed by thb ARMP program staff and approved and prioritized by the 1w). !hey bave been publlllrhed throughout the region vie their newsletter, the Albany Regional Medical Program Report o 10 proJectrr 6 projeofe 3546 of project funds 1% of project funds Recomeaded Action 8ce pages 27-30. RWD: ALBARY PREPARED BY: A. HJRTON KLIXE WTE: 1O/T 2. Aacomplishments and Implementation (15:) The change in the goal8 and objectives of the RAG has been reflected in the change in activities and emphasis of the program staff. The program staff now ha8 mre direction and enthusiasm to operate within that direction. The reault has been the stimulation of 52 new pro- posals and the development of new and fruitful relationships between ARWP and several community organfzatiane which had not previouely been 8 part of the ARMP process. A significant accomplishment of ARMP has been the phasing out of old proJects and the development of ngr funding support for the continu- ation of successful programs. Schenecta is now supported by Ellis Hospital. The Coronary Care d Program hae made a great contribution to the menpower pool of the region and continues at a reduced level under the auspices af the Heart Associatdon and a coneortitun of community hospitals with some ARHP program etaff support as faculty. ARMP'b olderst project and most successful in terms of regional impact and acceptability, is being continued as a program of the Albany Medical College. The program staff is proud to have been able to phase out of 6uCce6Sful projects and direct Its energies into new activities. Pruvider groups have Long looked to the ARMP for technical and professional assistance, now as the program Btaff broadens Its spectrum of activities in conjunction with its new directions, con- 8umer groups are also becoming acquainted with the ARMP and are eeeking aseistancedn the development of new programs. The Cancer Coordinator Project for The Two-Way Radio Project, See pages 27-30. - 11- 0 3. Continued Support (10) At the time of the June 1971 eite visit it was recommended that "meehanislpl for the phase out of RMP support shoula be developed for the ItPo-Way Radio an8 Coronary Care Training activities with the underetanaing tbt: 1. RMP funds for the TWo-Way Radio wfll not be forthcoming for longer than 18 months. ARW! financial input for this operation mast cease by March 1973? lilo more tban one year'^ terminal support for coronary care unit trsining cm be borne by RMP. Other 8ourcei of ~~pp~rt murt bo found by September 1972: " 2. Tbeae reconrmendations were mpde in the Advice Letter of August 1971, with the exception that the Two-way Radio operation was to ceaeer by September 1972, rather than March 1973. Both of theee prodects were phscred out in an oraerly faehlpn and each is now sustained, In whole or in part, rlth fund6 provided by sources other than RMpEi. This was acc~li6hed by April 30, lgp, welb in advance of the aeedline given in the Aitoice Letter. 'Phe region% propoml review criteria aontaln items which refer to the need for cmtinued support after RMP funding. progoslsl addresses this pointc The ARMP poUcy is to reduce or terminate funding to aay prodect which cannot produce adequate assurance of continues support by the en8 of the flret'par of AMP Xu adaition, each fWdfi3gs ... . ,. AMP;. ALBANY PREPARED BY: A, XIRTON U,INE INTE: lo/$ 4. Minority Interests (7) Objective I-A, "To improve the RCCeSt3ibi1ity of comprehensive health care with particular attention to medically aeprived urban and rural comnunltles", ha6 four top priority projects. themselves to the health problems of minority groups and minority comunities. relationships with minority communities is reflected by 80me of the uneasy alliances which exist between the provider8 and consumers who are Involved in BOW of the projects. Until the minority community, l.e., those involved in the direction of projects and those who are the recipients of the benefits of these activitiee, have worked with the MMP for eome period of the they will retain some degree of skeptieism with respect to the ARHP's sincerity In Its efforts to help them. their confidence. Tf;ey should bear this in mind in all their future effofEs with projects involving minority members who have becbme conditioned to being suspicious because they have been the victims df insincere efforts in the past. The progI%ttustaff has only one black professional and one blsck eecretary. Staff need6 mre buck professionals as .well as support staff. The Coordinator seems most anxious to get more minority representation on ataff, but needs assfstance in this regard. Three of these address The fact that these project8 grow out of the new me . ApMp will need to work closely and faithfully with these groups to Kin Since the top priority proJects of ARMP address themselves to minority interests, considerable effort should be made to Increase minority representation on the RAG. The site visit team acknowledges and lauds the efforts mde to date to improve minority representation on the RA6; hcwever, it is Important tbt the trend be continued beyond its present status. minority professional involvement in the RMP process. He my need to seek outside consultation in this regard; however, he may find it poesible to use sone of the gooa people he has already involved. ldinorlties need to be involved, particuzSsly on hi8 Executive Committee, and In working on prodect development. instrumental in assisting other providers in the region to Improve their services to and their relationships with minority groups. The Coordinator must seek innovative approaches to lche program staff could be See pages 27-30. - 13- 2. Coordinator (10) Although Dr. Woolsey, the Coordinator, is not what one would consider to be an outstanding Administrator, he has built a capable organization and hss proven his leadership capabilities by re-orienting the program from the categorical projects previously developed and displayed last year to a totally new program thrust designed to strengthen the health care delivery system. tation, appear to be solidly behind the program and the aaministration and appear to be functioning 86 a cohesive unit, even though the organization lacks clear cut job descriptions and well defined lines of authority and responsibility. Dr. Woolsey's succes8 in this regard has, in part, resulted from the efforts of Deputy Mrector, I?$-. Girard Craft, who wae appointed by the RAG last January. great deal of organizational experience and has provided a focal point for staff direction and coheeion. greatly aided in his attewtto restructure the program by his close working relationship with the RAG and the leadership which has been displayed by Dr. Jams Bordley, the Rf# Chairmsn, as well as the Executive Cormaittee. The prcgram staff is conunltted to this re-orien- I)r. Craft has a Dr. Woolsey has also been Reconmended Action See pagee 27-30. 6. Frogram Staf'f (3) Although som program etaff changes have taken place during, the past year, much remiins to be done. The staff is currently overweigheed with physician talent and lacks skills in other areas such as finan- cial mnagement and general program administration. Similarly, the lack of well defined job descriptions and work assignments still allow the perpetration of wh8t appears to l% at least some duplication of effofi, especially between the community affairs staff and the area health coordinatws. The program staff provides a good basic full- time resource with diversified talents and the site visit team felt that Dr. Craft herd =de substantial progress in developing the staff into a cohesive production unit. The team also felt that I&. Craft's - 14- 6. mgram Staff (Conti%) . plans,for future program staff reorganization were sound and that he Will continue to strengthen the organization as he Implements these plans. 7. Regional Advisory Groug (5) The RAG has been greatly expanded within the last year and is now far more representative of the region. Membership from the Albany Medical College hss been neduced to a reasonable percentage, and program staff m~mbere no longer serve on the RAG. usual frequency (monthly) aver the past nine months with an excellent level of participation and dedication during a period of great change and redirection of the prcgram. decline now that the puah is aver. The RAG has met with more than The attendance and attention my The R4G has playea an effective role in establishing objectives and priorities and Its Executive Colmnittee has, Wring this period, exampled true leadership. ite Chalrmn spend8 one day a week in the ARMP office. call for adequate representation of the interests, institutions and groups in the region. It has met twice a month, and, in addition, The RAG bylaws .. . ,.., . . ..:..: : ~. .. . .- I. . .. .. ./ .. . -. 8. Grantee organization (2) Albany Medical College, the Grantee Organization, provides adequate and effecttve fiscal administrative support. All of the prqram staff of ARMP are employees of the Albany Medical College and participate! in its fringe benefits including Insurance and retire- ment programs* The physicians on the AR#p staff hold faculty appointments and are expected to give some teaching time to Albany Xedical College. freedoes on programmtic action without restraint or veto. The grantee appear8 to have given the ARM€' full Albany Medical College hae a mandatory retirement age of 65, but we were told that this would not apply to employees of W; although at 65, thoee with faculty status would laere it unless an exception (1 year) vas granted or emeritus rstatus vcrt;ed. See pages 27-30. 0 9. Participation (3) Asrticipation of professional and voluntary health agencies in ARMP is Juaged to be quite satisfactory. involved in the program are: of Sew York, whoae two District Branches 111 and IV within the region are represented on the RA5; (2) Hospital$, while the Rew York State Hoapital Aseociation is not represented officially there are three hospital administrators on the RAG together with a VA hospital adndnletrator who serves in an ex-officio role. Nursing homes are also represented; (3) Official Health Agencies both State and local are represented in the mambership of the RAG3 (4) Educational representation Including the State Univereity eystem is included on Amry the agencies and groups (1) the Medical Society of the State Bursiing and Allied Health are also well represented on The Model Citiee Rwrarn. Catholic Charities, the Albany council-of) Community hrvicee ala; piticipste in ARMP; (7) voluntary - 3.6- RMP: ALB!UY PREPARED BY: A. BURmR KLRPE: wm: 10/72 1' 9 o Participation (Contd) Health Agencies: on the RAG 8118 the TB and RD Association as well as other voluntary health agencies are included In the-membership of ARMP's consultant groups o The Hew York State Heart Aseociation is represented See pagee 27-30. 10. Local Phnning (3) For reasons, which are described as "political" In a broad sense, there are no ClW "b" agencies vithin the area encompassed by the &IMP. by Ita Associate Mrector who also serves as a member of' the RAG'S Executive Committee. ARMP mintsine workin& relationships with several councils of social agencies within its area and with the State and local health departments. These groups have enhanced local health planning input because of the absence of CHP "b" agencies in the area. ipation in local planning activities is considered to be satisfactory. The State CHP "a" agency is, however, repreeented on the RAG In view of the circurnstsnces, ARMP'n partic- - 17- . 11. Assessnrent of Resource6 and Needs (3) The AR#p has ha8 a history of compiling an excellent data base upon which to plan and implement its program. Ironically, as of 1971, this data base was extensive; however, the program had not &eveloped in such a way that it could meet the need6 the data brought to light. In 1gP when a program developed to meet the needs which had been previously iaenfified by the data base, it tl&6 learned that the pro- gram was no longer maintQining the data base as current as it had been done in the past. Eowever, it was iadicated that it had been mrintained at a level eufficient to guide the program in its emphasis and priority estebliehmcnt. Unlike the situation 8 year ago, thi6 excellent 6ouTce of data is being ursed by the ARMOP for project devolopm?nf and Is being shared with other agencies in the region. Generally, the ARMP programmatic efforts are consonant with the identified need8 of the region and the current development is being guided by a taLcntet!l and representative RAG which, as a body, has a firm hand on the health pulse of the region. Recommended Action See met3 27-30. 12. Management (3) The Coordinator directs the prcgram staff in a style which might be described as somewhat "over participtlve management". belief is that one who expresses an interest and desire to do a specific task is more likely to be swccessful at that task than one who receives it as en arbitmry assignment. accounts for the extremely high morale exhibited throughout the program staff. to a specific task which needs to be done to further the prcgram's etated goals and objectives when there le no program staff member who expresses a willingness to undertake the task. There wag evidence that the question ie academic, since the etaff ha6 a great loyalty to the Coordinator, is made up of long-term profeesionale, has high morale, and appears dedicated to the enhanceaent of the ARMP program. The scape of the efforts put forth by the program ataff in the past Hie essential This approach, in part, However, 8 valid question would be to ask what happens - 18- 1.2. Hansgeinent (Contd) year are testimony to the fact that, in this instance at leaet, the Coordinator's etyle appear8 to work well for him, Since the BRMP, now embarking on the fiscal mnagement and surveil- Wce of projects scattered throughout the region, needs to modify its program etaff competencies in a mnner consistent with the programtic change which be recently taken place. The ARMP needs to eupplement its current staff competencies wlth people having skills in fiscal administration and .in ''in house" personnel management. For a progrsm which has grown as large and complex 88 the ARMP, there is a need for more formslized direction of program staff efforts snd an Increased utilization of prodect data and surveillance infor- m%tlon for mkbg enlightened decisions with respect to reducing eupport, terminating eupport, and rebudgeting of funds to support new initiatives which my be required to accelerate the accomplishment of program's etafed goele. Identified by the key &IMP people and they are currently taking steps to enhance the staff's competency in these areeta. The need for these competenclea has beer, - Recommended Action See pages 27-30. 13. Evaluation (3) There is 8 Regional Program Staff Planning and Evaluation Section cunsisting of three part-time evaluation specialists, one of whom is the Cbeirmn of the Sectim. results of evaluation bve been used in the region'e decieionasklng procese. While the reconnnendatiane and suggeetions of the Planning snd Evaluation Section are built into the ARMP'e proposal review procedures, it appears that their recommendations and suggestions do nat have 88 much Impsct on the final declsicm as they should. The &IMP should consider placing more eqhasla on the skills these people briag to the programand utilize their talents in program planning. F'urthermore, the RAG and Coordinator should make use of the efforts It is difficult to diecern how the - 19- 13. Gvaluatlon (Contd he PLanniag and Evaluation Section in their determinations rding the extent to which ARWP funded sctivlties to the attalnmnt of the region's goals and obJectivetr. Recoramended Action See pages 27-30. 14* Action Plan (5) As previously indicated, the region *has stated its goals and objectives, oritized them, and they are congruent with RMPS directions. oposea and actually funded operahianal projects, piarming and lity etudies, and central regional semice activities have lateti to the region's goals and objectives. Although the AMP appears to be on course at the moment, it is suggested that they could enhance the probability of staying on ram develops if they Were to carefully asses8 sad e n'a current and prodected needs and, from this, develop a short- plan to serve 8s 8 guide to enlightened decisionmking. Each proJecf, as It passes through the local review procees, could be assessed from a technical standpoint, buJ; could sleo be sstreesed in light of how it fits lato the overall plan the ARMle" has developed to insure that it continuofa to address the ref3lon's real problem. The hazard associated with sw.h a plan le that it my beconre outdated and, as Lsuch, ineffective. If 6uCh a. plan were de@igned, provIBlon8 ahould be mde to insure that It reraains current. wbich lies wlthln the competencies of the ARMP program etaff and its RAG 8nd should be seriwsly considered nhce it will tend 'bo insure arzximum involvemrnt of many of these people in the pursthft of an even more effective program aurveillance. for the conduct of monitoring and of the prodect activl Lo be a sound beginnfog for an effective and systemtic This appears Or, be 8 task The preliminary plan developed -20- - RMP: NLBAIOY PREPARED BY: A. IWRTON KLINE wm: 10/p 14. Action Plan (Contd) progrese. The ARMP should be complimented for its awareness of the problem and for taking the initial steps which Will insure a good orientation for project directors. 15. Dissemination of Knawhdjxe (2) The --has alwaye been heavily involved in the dissemination of new knowledge and technical mterial for providers through its Two- Way Project. It alao Beem to have a good communicatlms relation- ilhip with other educational inetitutims In I the region. @e of its top new projects, being eponsored by &!W York State EdUcatiOn Department, Will disseminate new knowledge sbout health' occupations to secondmy school educators and counse1ors. The public informtion officer on the program staff reports high "pickup" of new6 releasee to local media. target group^, considerable time and effort should be given to developing ways of dieseminating information to these groups. There , is a need to be able to Identify the cornunity health education component in a11 proposals. -- I With new emphasis on new Wfth colllmunity underetanding and appropriate utilization of new resources generated by the new proJects, better health care should result for people who previourrly had been neglected and deprived. Consideration ehould be given to widening the distribution of the fine ARMP Reweletter o The ARMP should be applauded for having a Health Educator on its -21- I- RW: ALBARY PRFSAREDBY: A. 33URLWm MTE: lO/p 15. Dissemination of Knowledge (Contd) staff. These special skills and talents should be utilized in program stecff development activities as well ae community activities. See psgee 27-30. 16. Utilization of Msnpawer and Facilities (4) Several of the high priority projects encourage the better utilization of existing rcsourcee. will develop a satellite type ambulatory care center etnd more fully utilize the resources of St. Peter8 Hoepital. sharing should be encouraged. Several proJecte and activities of the program staff are directed at training and utilization of allied health mnpower. should have closer monitoring and evaluation to insure effectiveness of training and proper utilization after training. The South End Community Haalth Center ProJect This kind of regource These projects 0 Recommended Action See pagee 27-30. Rwp: A1;BABY PREPARED BY: A. BURT08 gLIloE WTE: 1O/P 17. Imrovement of care (4) The grogram currently being conducted by the ARMP places heavy emphasis 011 the improved access to health c8re for people who are underserved. The low Income groups in the inner city areas of Albany and Schenectedy have had the availablllty of health care enhanced by the eetabliehment of cornunity health centere in the area. These centers have been mde goseible by the coordhmtlon and mobilization of exletlng resources in the community. The ARMP did the coordln8tlng and provided partial sygport to the conduct of these activities. satellites of established hospitals, will fend to strengthen the relationships bertween prinary care and specialty care. In the rural area of Chateaugay (Rranklin County) the ARMP prcgrsm staff provided the needed profes8ional competence to secure a physical plant, state llceases, etc., so that the Ilation8l Health Service Corps was able to place two pbyelcians, a dentist, and a dental hygienist into (L remote cornunity which, up until this time, had not had access to health care services. In a Joint project with the OEO, the ARMP helped develop the curriculum, underwrote 50$ of the cost8 ($10,000) for the training of Primry Care lursee. After their training ha8 been completed, the ARMe Will a8sume the role of proper placement of these highly trained nurses, i.e., they wlllattelqpt to locate the communities which have the most critical need for the nurses and which expreae a willingnee8 to accept them In this rather new role. In all, the recently implemnted proJects, the projected activities, the program ebff servicee, and the program staff feasibility studies reflect a recognition of the need to inrprcme the quality and quantity of health care throughout the region. The reccgnltim of the need appears to be accompanied by the development and implementation of efforts which will help meet the needs in the Albany region. Theae activities, as , i Recommended Action See pages 27-30. -23- RMP: ALBAloy PREPARED BY: A. BURTOR KLINE wm: LO/V 18. Short-Term Payoff ( 3) It fa apparent that nrany of the activities currently in progress or projected will bring immediate relief of those who currently require health services. There are plans to enhance the effectiveness of the monitoring and surveillance of projects to feedback the infor- Pgticm required to gauge prospective payoffa from each of the activities. This procedure is in its infancy at present; however, 8s the the syietemtill imprave since there appears to be a. great sensltivity 8pfong the key people In the program to the need for such monitoring. becolaes more sophisticated it le reaeonable to expect that See pages 27-30, 19. Reg1 onallzat I on (4) One of the primary concerns voiced by the site visit team of 1971 was the region's fallure to regionalize its activities. enough, one of' the prinrsry concerns of the site team of 1972 is that the program's activities are so geographically spread out that there is a need to consolidate BODE related aetlvities under a multi-project umbrella to siqplify their administration and fiscal control. ALUIP, if anything, mer reacted to the need to regionalize and must nm look tmrd the orderly assembling of projects by loglcaf grouping to insure that it Is possible to relate the program's goals and obJectives to the effort8 underway, and those which can be expected to be introduced Into the system na? that there is widespread interest in the ARMP throughout the region. tralized Its bae of opersrtionsl from Albany to points scattered throughout the region, mat beein to pay cbaer attention to improving linkages and to 8 more comdimted approach to the prwision of health care on a regiawide basis. This problem is perceived by the key people in the program an8 as the program settlee Into 8 mre routine course of Cpoing bU6i~e8S it le reasonable to assume that the "shot-gun" region- allzation Kill give way to a more tightly knit program conducted on a regionwide baee. Recom-nded ActIan gee pages 27-30. Interestfngly 0 !be The MUP, now that it had decen- ~-I----------------I---o------"--I------"----- - 24- - PREPARED BY: A. BUR'JBN KLINe DATE: 10/72 RMP: ALBANY J. 20. OTHER FUNDING (3) The current group of projects reflects an excellent input ftom funding sources other than RMPS. Approximately 30X.of the total request for project support (or $800,000) has been acquired from other community agencies or charities. This can be attributed to a sensitivity to the need for this type of outside support and to the administrative skills of the Deputy Coordinator in negotiations which involve the input of dollars from sources other than the ARMP . -25- RMP: ALBANY PREpAp,I;;D BY: A. B1RTON KLINE I DATE: 10/72 SUMMARY The ARMP has made substantial progress since last year's site visit. me RAG has been expanded and restructured in a manner that wi1-2. insure greater community and less university participation in the program's activities and provisions have been made to include more minority groups. and energy to the program and has been instrumental in creating excitement and enthusiasm over the program among the entire RAG membership. It is clear that RAG now establishes priorities for the projects and assumes responsibility for the program's activities. In addition to these changes at the policy making level, substantial changes have taken place at the organizational level. Dr. Craft, a physician with considerable experience fm medical group practices, has been appointed Deputy Director of the program and under his leadership, the program staff is being restructured and reformulated into a strong operating group. the program has been completely reoriented from what could at best be described as unimaginative to a new array of "interesting" projects o It is evident, however, that these projects have been hastily conceived and do not as yet fit together 'into a coordinated effort. Similarly, the program staff, although strengthened since last year's visit, still remains somewhat lacking in their ability to monitor, evaluate, and, in general, manage- these projects. It was also noted that some of the proposed projects must be excluded from the program due to RMPS' policies. The site team, therefore, recommends that project numbers 23, 31, and 43 be excluded from consideration and that the budget be accordingly reduced. Furthermore, in order to force the organization to rethfnk and restructure the remaining proposed projects, we recommend that the project budget be reduced from the requested $1,653,329 to $950,000 for the first year, $1,045,000 for the second year, and then $1,249,500 for the final year, RAG will have to again review the projects and reformulate them to a program scheme. The RAG Chairman is devoting considerable time As a result of the above changes, Under thio funding scheme, the In terms of the program staff budget, we recommend that the program be funded at the present levels with a 5% increase per year for the second and third year and a $20,000 one position increase in the second year to be carried also through the third year. This will allow some program expansion but will encourage a reallocation of the present budget and a reorganization ofr the present staff. -26- I RMP: ALBANY PEEPARED BY: A. BURTON KLINE DATE: 10172 . The site team recommends.that, as part of their total funds, the ARMP has a developmental component identified for th,ree years in the reduced amounts as follows: 01 $30,000 - 02 7 $45 , 000 03 - $60,000 We also recommend that the university be requested to furnish space for the program in return for the 52% overhead that is being charged, and that the space rental funds requested in this application therefore be removed from the budget. above budgets be accompanied by the following advice and recommendations to the program. The site team further recommends that the 1. -27- RECOMMENDATIONS The site visit team recommends that the ARMP be funded for three years in the reduced amounts as follows: 01 operational year $1,618 000 02 operational year $1,783,090 03 operational year $1,940,725 Specifically, the site visit team makes the following recommendations and suggestions. 1. Project #23 is a health careers recruitment activity and is not permitted under RMPS policy. A Special Report to the National Advisory Council--Regional Medical Programs Service (dated May 11-12, 1971) it states "RMP grant funds are not to be used for direct operational health careers recruitment projects." ARMP support during the next 12 months. On pagb 38 of a booklet entitled It is recommended that this activity be phased out of 2 . The program development appeared to be hastily conceived and, as a result, there emerged a general feeling among the site visit team members that the program now faces a need to consolidate their project activities, to integrate those activities which, on a region- wide basis are interrelated, and to, insofar as possible, reduce the fragmentation of efforts resultant when activitieslprojects are conducted in a somewhat autonomous fashion. 3. Project %24, Design and Development of a Comprehensive Emergency Health Care System, appears to need additional developmental work. It is suggested that, prior to initiating this project, the advice of competent people with specific expertise in the area of emergeecy medical care be obtained. Physicians to Clinical Practice, was viewed as too global in nature and not sufficiently directed at the priority health needs of the Albany region. benefit standpoint and possibly duplicative of similar work done by other RMP programs. what is available before venturing forth too far in the production of visual materials. Project 631, Orientation of Non-Practicing Project #43 was considered too expensive from a cost/ It is strongly recommended that ARMP explore -. 4. The ARMP is becoming extensively involved in the management of grants to support the conduct of many projects. This is a relatively new function for the program and will require increased program staff -28- - RMP: ALBANY PREPARED BY: A. BURTON KLINE UTE: 1O/P I 5. 6. 7. 8. competence in the financial management discipline. size and the increasing complexity of the tasks to be performed by the program staff brings about a need for additional expertise in orgaaizational structuring and personnel management. It is recom- mended that future recruitment activities place high priority on securing staff members who will increase the fiscal, administrative, and personnel management competencies of the existing staff. The Albany Medical College (AMC) expects that llRMp program staff members holding faculty appointments will spend 10% (approximately four hourslweek) of their time teaching for the college. It is recommended that this mutual understanding be documented in the form of a written agreement between the AMC and the ARMP. the site visitors viewed this arrangement to be mutually beneficial; however, there was a feeling that a written agreement should be prepared to serve as a safeguard to protect the interests of both parties. This agreement should clarify any misunderstanding which could develop in the event there are changes in the administrative hierarchy of either the college or the program. The significant !\ Most of The ARMP faces a need to update and revise the current RAG bylaws. At present they are silent on the RAG'S role in hiring/firing/ appointing the ARMP Coordinator and they empower the grantee to appoint RAG members. to reflect the recent RMPS policy statement which defines the roles of the grantee, the RAG, and the program staff, was sent to all Coordinators on June 13, 1972, as part of highlights of the June National Advisory Council meeting. It is recommended that the bylaws be updated This statement It is recommended that a document which defines the relationship between the AMC and the ARMP be prepared to guarantee a clear under- standing on the part of both parties with respect to their roles in the conduct of the ARMP. against misunderstandings of this relationship which could potenti- ally arise and also will provide guidance for the actions of new people which come into the system when there are administrative changes in the hierarchy of either party. This document will be a safeguard The site visitors, as a group, perceived a need for the ARMP to more specifically identify its operational objectives, to delineate the tasks necessary to achieve these objectives, and to assign the conduct of these tasks to particular job classifications. Specif- ically, it is recommended that the program staff be tailored to the ._ -29- RMP: ALBANY i needs of the program rather than gearing the program,to the com- petencies and interests of the existent program staff. 9. The site visit team noted that the ARMP Coordinator and four other staff members were quartered in the AMC while the remainder of the program staff had their offices in a nearby aff-campus building. This arrangement was questioned from an administrative standpoint in light of the difficulties it imposes on the Coordinator and the program staff in terms of communication, management, supervision, etc. to consolidate its offices in one location. 10. The site visit team expressed concern over the high overhead rate being charged by the AMC. belief that the college was providing services which could not be purchased at a lesser cost, it is recommended that a cost analysis study be conducted to document these statements. Force which recently studied the current relationships between the AMC and the ARMP concluded that the current arrangement was, "at this time" the best arrangement for the program. However, this report made no apparent reference to a costbenefit analysis and this leaves the conclusion open to question in this particular It is reconrmended that the program attempt to find a means Since the program staff expressed a , The RAG Task 0 aspect. 11. There was an expression of concern over the future development of the program from the standpoint of monitoring, surveillance and evaluation of interrelated activities. It is recommended that the RAG designate a subcommittee of its members to maintain close watch on the course followed by the program during its upcoming imple- mentation period, The subcommittee should be responsible for the evaluation of the impact of all funded activities (i.e. Program Staff, Planning and Feasibility Studies, Central Regional Service Activities, Operational and Developmental Component projects) on the regional goals and objectives. The subcommittee should work closely with the Planning and Evaluation section, vide a mechanism for continuous programmatic evaluation Is? viewed as a matter of high priority since the program is in the early stages of its development and attention to these important matters at this time could prevent difficulties in the future. The need to pro- 12. The site visit team recommends that the rental money from the ARW program staff budget be removed and that the AMC be informed that they are expected to provide quarters for the ARMP staff in light of the overhead monies they are currently receiving from the program. RMP: ALBANY PREPARED BY: A. BURTOE nm MTE: io/^ - h The report of this site visit team would not be complete unless it was clearly pointed out that the ARME', complied in fact and in spirit, with the recommendations forwarded in the Advice Letter following the 1971 site visit. Further, it should be noted that although the ARMP still has problems to resolve, that it has, in fact, been successful at bringing about a dramatic tuqabout in the program's direction and thrust. operating on the inside, looking out at the region's health pro- blems; this year it is operating throughout the region and is looking at its own inside administrative problems which have been brought about as a result of the many health activities that have been initiated throughout the region. healthy one. While a year ago it was This type of change is a :. . REGION: Albany RMP -'. /J OPEIWi'lONS B&U'CII: Eastern NUIBER: 00004 COORDINATOR: Frank M. Woolsey, Jr, M.D. LAST RATING: -.. TYPE OF APPLICATION: 3rd Year I_. I_ 1 Triennial /. - 1 Triennial - 2nd Year - / / Triennial / - / Other - Regional Office Representative: Robert Shaw Management Survey (Date): c- Conducted: 1970 w/" Scliedul ed : .. or Last Site Visit: June 2-3, 1971 (List Dates, Chairman, Other Committee/Council Members, Consultants) ' Chairman - John E. Kralewslci, Ph.D, (NRC) Consultant: - Joseph G. Gordon, Vice Chairman, North Carolina RMP RAG) Edward D. Coppola, M.D., James P.Harkness, Ph.D., Deputy Coordinator, New Jersey RMP, Roger Warner, Director of Planning 6r Evaluation, Arkansas RMP. ' t Staff Visits in Last 12 Months: Ocr. 1971 Nbv. 1971 Dec. 1971 (List Date and Purpose) c April 1972 !status. 4 To provide staff assistance to the region in its efforts to develop clearer goal8 and.objectives which would ultimately ,lead to a more viable program which could acquire triennial Recent evcnts occurring in geographic area of Region that are affectin u1"' program: The region currently does not have any CHP (b) agencties andgthere are movements at this time to getlhem established in one or two areas. The ARMP is assisting in their dtbvelopment with the thought that, in so doing, they will have good warking relationships with che emerging complementary agencies, The National Health Service Corps recently 'designated the town of Chateaugay in the Northwest corner of Franklin County (one uf the ARMe's Interface Division's counties) as a location for the placement of three health prof+siondls, The ARMP staff provided the required expertise and staff time required to secure the operational .headquarters for these workers', ,the licenses and certificates Isequired by New York State law,etc,,to permit this placement to take place effectively. This early placement is the A ion brought forth good workinx rela tionsnips between. $he .W. and .representative in the Region 11 office and, indirectly, enhanced ratn's working relitionship with a number of Region 11's regional offi .r SOUTHERN DiV. . -- e e -3- Demographic Information Population of the Region: 1,993,261 Population densiryigis 20l-jper -squarecmike. Population of Albany County: 285,618 Population of Albany: 114,873 Rural population: 46.72 of total Urban population: 53.3% of total Minority Facts % of entire region's population: X in Albany County: % in Albany: 12.5% (14,359) 4.3% (85,710) 5.4% (15,423) Region: Albany Review Cycle: 18/72 $ 774,592 $ 768,230 -- -0- 90,000 . I 75,314 1,568,691 I $ 900,000 $2,426,921 I I 90,000 '* 1,768,691 $2,646,25, I 90,000 .. 2,158,691* c i f -I ! ! i ! i i i i i I' I i 1 . I I I i I t $3,060,317 I I i , The division cannot be COU?:CIL RECOMMENDED LEVEL be in the program staff and project art reliably forecasted . .. . . ... , ,., .,.-- XPENT YflC1T ION 0; COMPONENT __ mL .. 15) 11) (4) (11 CONT+ hlTHIhl CGh'l. BEYChDf PPPR. NOT I )uE(rc kO1 I mpa. PERICDI BPPR. PERICCJ PREVIDUSLY 'I PPw1nust-r I CF SUPPOPT 1 CF SUPPORT I FUNOED I APPROVtO I 1 I I I I I 1 I ,' ! , . ;:. ', ,. , .. v , I ., .. ,. IQW 1 coco DOCC - I' 8RfPKOU,T OF RFNt 51 07 PRCGPAP PERXLD IFICATION OF COWPOLENT 1 CONT;-iITHIh/ CChT. BEYGROI LPPU;-NOT I NEW# NOT I ZND YEAR I b &PPR. PERlCCl APPR. PERIOCI PREVlOUSLY I PREVIOUSLY I OIRECT 1 CCSTS ! i OF SLPPC )RT I CF SUPPCRT I FUIYOEC I AFPRCVEO I t I I I 1 ! I I I I I I I I I .. . -. PkGICN - bLI.AT HI4 oooc4 10/?2 PLC€ 4 nw s-u 5rt- J t ULW 2- I 45) 42) t 4) (1) IOWTlFICATION OF COMPONENT I CCNT. )tITHIh( CChT. BEVChOf APPR. hOT I NEW* hCT I 2N0 YtAR I I APPP. PERICtl bPPR. PERIOCl PREVIOUSLY I PREVIGUSLY I OIRtCl 1 I OF 'SUPPORT I CF SUPPORT I FUNDEO I AFFRCVEO I CCSTS I I 043 THIS Y€EK IN HEALT). 1 ESTIWTED GRObTH FbhDS I I I I I I I I I I I I I I I -_- 1 ____ ~lI?LJ~-L-,-U5L~~kL------ I I I I -------- s710.9nn. I 7 . . - - __-_ - - - I ' ----+---Oo I ' I I 1 Slr798r142 I S2~958r651 I - __ TCTAL 1 _, . I $lr160t509 I-. . __ ___ 1 .^..__. c- i. :. .. . -. . .- . . -: . .. . . .-I .%.. .... IDEN1 IF ICATI Gh CF CCPFChCRf @REAKOUT OF RI.PUEST 08 PPCtPbP PERlCC I , REGION - ALBANY klr COO04 10172 PP6E 5 I PPPS-CSW-JIOGPZ-1 BREAKCUT CF REEUEST 013 PPOGPLH PFRftlk REGlDN - ALBANV RU QOOOI 10172 PAC€ 6 1 PUPS-OW-JTOGRZ-I I r, cr I -- -22- Region: Albany RMP Review Cycle: 10/72 - HISTORICAL PROGRAM PROFILE OF REGION The Albany RMP received a planning award in June 1966 and its operational award in April 1967. The program's Coordinator from the outset has been Dr. Frank M. Woolsey, Jr. and his orientation and background experience, prior to becoming a part of RMPS, was in the field of Continuing Education for Physicians, specifically he believed in the use of two-way radio communication for this purpose. The program's single-minded approach to the improvement of health care for the residents of the Albany region began to cause concern to RMPS by May 1969, At that time, the National Advisory Council expressed concern about the over concentration of this aspect of the region's program which they believed was retarding the program's overall development. Further, there was a feeling that this activity was too closely linked to the Albany Medical College's Department of Postgraduate Medicine and that this close relationship obscured the accomplishments of the ARMP. out projects after the three year support period was also a matter of concern at this time. The region's apparent inability to phase In September 1970, subsequent to a site visit, there was continued concern about the program's failure to develop new activities, to phase out activities, i'.e., the two-way radio network and to regionalize the program's operations. conducted outside the confines of the Albany area and this was in its embryonic stages with little visible progress. It was noted that the RAG met only four times per year and that 11 of its 27 members were associated with the Albany Medical College and seven were on the ARMP's program staff. not representative of the community at large and, as a result of its composition, doomed to a myopic vision of program development. During this period in the region's history the goals, objectives and priorities of the program were somewhat diffuse, global and, generally, not indicative of an organization that had given serious thought to where it: was going or how it intended to get there. At this time, there was only one activity Thus, it was apparent that the RAG was somewhat inactive, Subsequent to the site visit of June 1971, the AEUQ began to enter into a new era. of the entire region (see RAG Chairman's report submitted with the current application), i.e., the program staff participation was eliminated, the Albany Medical College members were reduced to two members, the meetings were increased to nine times per year and the RAG Chairmanship passed from Dr. Harold Wiggers, Dean of the Albany Medical College to Dr. James T. Bordley 111, a practicing physician from Cooperstown, N.Y. During this recent period the ARMP concentrated its efforts in several identifiable areas, e.g,, goals, objectives and priorities were developed and clearly articulated and the RAG was subdivided into four Task Forces ' which were assigned the task of studying, developing, reviewing, and implementing activities which would assist in the accomplishment of a specific goal. The program staff and RAG members worked together to solicit, develop, review and initiate projects and activities which would generate a broad-based, viable, regionalized program. The RAG was expanded to 37 members who were representative i Y -13- , HISTORICAL PROGRAM PROFILE OF REGION (Continued) To speed up the review process and to provide additional RAG involvement, the RAG Task Forces met twice each month to review projects for submission to the Executive Committee of the RAG and, ultimately, to the full RAG for final ranking (prioritisation) and funding. An ARMP program staff member was given a prlmary responsibility to follow through and assist in the development of each potential project. assistance and continuity of communication between a potential project director and the ARMP. As a result of this intensive effort, the program was able to develop and review (prior to the submission of the current application) a total of 47 projects. projects, 23 are included as part of the current proposal. This approach provided Of these 47 developed It is of interest, in light of past criticism about the program's failure to phase out old activities, that all previous projects have been phased out. The phasing out was done in an orderly fashion and all the old activities are still being conducted in whole or in part with financial support from sources other than RMPS. In summary, this brief history indicates that there are two identifiable periods in this region's history, the period from June 1966 - June 1971 and the period since June 1971, i.e., the era of transition which has . seen the two-way radio phased out and 23 new activities developed throughout the entire region and submitted foL coneideration with the present application. -14- STAFF OBSERVATIONS Principal Problems The program is entering a new era and is somewhat inexperienced in grants management. They are working on agreements of affiliation; however,%at present they are not sophisticated. planning a method of project surveillance, monitoring etc. but it has not yet been tested thoroughly. The program staff, essentially unchanged from past years, needs increased administrative competencies which are consistent with the current and projected program. They need to squarely address the problems and techniques of rebudgetting. Most all of the aforementioned deficiencies are potential problems and may not develop since the ARMP Director and Deputy Director appear to recognize them and are in the process of taking steps to prevent the program from encountering these types of problems which arise when there are many projects being conducted simultaneously, The region is The ARMP, in order to permit all pbtential project directors to have a chance to acquire funds, has extended project development assistance (using program staff) to everyone who has applied, i.e. they have done no preliminary screening except for a few cases in wfiich the project was completely out of the program's area of activity. This has placed a tremendous load on staff and reviewers which has been made possible only by efforts above and beyond the reasonable call of duty, Admini- stratively, this mementurn and workload cannot be carried on indefinitely screening of all potential projects to save work on the part bf all parties involved. Testimony to this approach is illustrated by the fact that (in the current application) support is being sought for only 23 of the 47 projects which were completely developed and evaluated by the RAG. . __ and the ARMP will have to develop a suitable technique for initial In summary, the ARMP faces the problems associated with coming to an accomodation with the new approaches they are using in the imple- mentation of a new program, Thecoordinator and his deputy are cognizant of these problems, are attempting to resolve them, and, in time, will probably do so. retrench because they have, in fact, come too far in too short a time period. However, at present, the ARMP faces the need to Issues Requiring the Ateention of Reviewers Most of these were brought out under the category of problems; however, the reviewers should probably be aware of this regionts need and desire for guidance for future development. carefully scrutinizing their past efforts, detecting deficiencies, and then pointing out means by which these oversights or errors might be corrected in the future, Otherwise, the problems the region faces and the issues the site visitors may wish to pay close attention to are those which may arise out of the development and implementation of a sophisticated program by a group of highly skilled and dedicated professionals who find themselves engaged in an activity which is somewhat new to them. This can best be accomplished by 0 , f Region: Albany Review Cycle 10/72 Principal Accomplishments 1. The RAG has been revitalized. the membership to 37 to include new members who would provide broader representation of the region's health interests. RAG member involvement each new member was carefully selected, was provided an orientation to the role he was expected to play, and was then assigned to one of the RAG'S four task forces. forces are set up to initiate, develop, and review activities or projects which would tend to advance the grogress in the goal area the group was assigned to pay close attention to. forces met twice per month and the full RAG, which evaluated the reports and recommendations of the task forces, met monthly. In the past there were no task forces, only quarterly RAG meetings and rather casual RAG member involvement. In the current situation each member is kept well informed and immersed in program activities. This has included an expansion of To increase individual The four RAG task Each of the task 2. Through the revitalized RAG, the ARMP developed four clearly stated goals, set their objectives and prioritized each of the four major goal areas. 3. which reached into all areasof the region. in terms of the new goals and objectives. With increased assistance from the RAG, 4. All past projects were phased out in an the objectives within a new program was developed The projects were evaluated orderly fashion and each is now sustained in whole or in part with funds provided by sources other than RMPS. This was accomplished by April 30, 1972. 5. able to assist potential project directors in the development of effective projects. Dr. Girard Craft was officially appointed the Deputy Director and has been instrumental in providing the ARMP with more directed and coordinated staff efforts. was assigned primary responsibility to follow through on the develop- ment of a project from its inception to its submission to the RAG for a funding decision. the staff member was then assigned to the role of monitoring its progress and providing eontinuous feedback to the ARMP on its status. This approach permitted greater staff involvement and better communications with project directors and potential project directors. The program staff was realigned and enlarged (slightly) to be better Each program staff member * In the event the project was approved and funded, 6. development and permitted it to be the beneficiary of project support. This was accomplished, in part, by adding a full time black professional staff member who could and did relate to the minority community and assist in the development of projects which would serve these undev served residents of the region. Beyond this, the ARMP was successful in attracting an outstanding black to participate as a RAG task force chairman. The ARMP has successfully involved the black community in the program -tb- ,- - 7. were studied by a subcommittee of the RAG and was found to be complementary and mutually supportative. The subcommittee reported that each understood its respective role and the interests of the ARMP program development could best be served by continuing to have the Albany Medical College serve in the role of grantee. The relationship between the ARMP and the Albany Medical College Review Committee e r"7 Site Visit REQUEST: requested support in the following amounts: Review Committee considered BSKMP's triennial appl ication which 04 - $1,387,'617 05 - $1,463,310 06 - $1,567,610. __uII RECOMMENDATIONS: to award tri enniat . status and provide funding at the following level: 04 - $l,lSO,dOO Comrni ttee concurred with the site vis.i tors I recommendation to disapprove the devel opmental component, 05 - $1,23'3,500 06 - $1 ,316,600. Committee also recommended that a thorough evaluation, including a site visit, be held at the end of the 04 year, to assess the Region's progress toward rneeti ng the reviewers program concerns and to determi ne the 1 eve1 of Funding for the 05 and 06 years. REGIONS STRENGTHS: The review of the Program began with a report of the site visitors' findings which delineated the RMP's accompl istiments, program p?ans and organizational problems. ments are a strong and dedicated Coordinator, a highly capable program staff, a well-developed and relevant set of goals and objectives, and a new approach to program development. promulgation of the program goals and objectives to the health providers and .institutions of the Region through the distribution of a prospectus to 8,000 individuals and agencies. Their program plan, which solicited sinal 1 ($25,000) proposals around the goals and objectives, appeared to revjewers to present a realistic method of developing activities whose resu'l ts can be evaluated at the end of one year to enable the RivlP to focus its resources on the most pramising activities for future expansion and development. The site visitors also reported that the RMP, through Dr, Stoneman's involvement as a faculty member and his ability in relatfng to university representatives, has maintained the original interest and Among the Region's accomplish- This approach involved the Region Ri-State RM 00056 Review q8%-%3]-72 - Page 2 backing of Washington, St. Louis, and Southern I11 inois Universities in the program. The St. Louis-based medical sclioals have been brought closer together as-a result of the RMP's categorical projects. Reviewers also noted that the BSRMP's Emergency i4cdical Systein`proposal in St. Louis and two health service/education activities build on existing relationships of the RMP with groups such as an interagency council on allied health in St. Louis, the Southern Illinois University, and local hospitals. The Committee observed that while the original projects were highly categorical the proposals in the present subiiiission reflect a trend toward more comprehensive activities. are more concerned with heal th care del ivery problems in underserved areas, both rural and urban. CRITIQUE: serious problem which adversely affect ids program operation at the present time. southern Illinois area. The 1llino.is RtP hss not. until recent extended much program assistance to the aiva under question. within the last tcjo months, the Illinois RMP leadership now appears desirous of assuming the entire state as its service area. of these develop:ne.nts, some Committee members questioned the need for a Bi-State RM). The response frorn those Committee rncinbers who visited the RMP Sndicat`cd that both the medical referral-patterns in the southern part of the State, which relate to Sb. Louis, and the relationships of the three medical schoo'ls which originally substantiated the need for a separate Region still exist. WIP now has developed an organization which is strengthening the relationships among the providers, rnedic;ll schaol s, and community groups, and which cannot be easily discounted. Comifiittee that the issue be resolved by bringing the two KMPs together and declaring areas of primary and joint concwn. Committee recomrriended that additional prograin staff funds be provi ded in order to permit the Coordinator an opportunity for promoting catalytic activities in the southern Illinois area. In acldition, the newer proposals Despiie all these positive points, the BSRMP has several One is the threat to the BSRMP from the Illinois RMP in the However, In the light In addition, the Bi-State It was suggested by In the nieantime, The second major probl em area i s organization. the RAG is large, overly provider-oriented and inactive. working cownittees and had delegated much GT its responsibility to the university-dominated Scientific and Educatiorral Review Committee (SEKC) and Administrative Liaison Committee (ALC). It was recommended by both the site vis~itors and Review Committee that 1) the ALC be made advl'sory to the RAG in fulfilling its fiscal responsibilities; 2) the SERC should be abolished and the Program Review Cominitttcc cha.irmen and the Executive Committee, join to determine how the proposals fit into the overall program. The RMP should also decrease the size of the RAG, establish working committees of the RAG around the Program's objectives and give the RAG membership greater responsibility. is concerned, Committee agreed that a formal structured process should be established, records of review be consistently maintained and the inanagetnent of the process by staff be improved. Comini ttce agreed that It has few As far as the review process The management style of the Coordinator vias also discussed. Dr. Stonemix? is a strong and able 'IeacloiA, his effectiveness is reduced because of the tim he dcvotcs to a palAt--tine private practice in plastic stirgcryo his occasiunLil teach.i!q and a cumhersome progi*inm staff organization in which practica'l ly evciryone reports, diwctly tu him. The fact that hc bas no effect-ive deputy and does riot appear to have the conTidunce in his staff to dc'ieyate -iiuich of the "inside" responsibility is a further drain on h-is tiix ilnd eriergies, agreed that an ii:iportant qual'ity of a guod Coordinator is delegating to and developing a staff others rep1 ied that Dr. Stoneman's strengths in other dress made him a" capable Coou.d.inaLolA. Hovever Committee fel t strongly thac the Coordinator hc a full-i,ime position and also reconwnded that a deputy coord i nil. tor w i th strong riianngemen t ski 1 1 s be hired. he1 d by facu'l ty of each of the three un-ivws-i Lies Cuiiimi ttee agreed with the site visitors that if the RiQ w3ni;s the111 to continue to be involved that full -tim posi t.ions woul d be WiBre val ~db'l e t.o tire RMP. The last area of mjor conccrii of review was the highly provider and categorical-disease orientation of the program. objectives are riioi'e cornpreheii.jive in na1;ui-e (iiianpowcr health care del ivery systems `etc. categor i cal rnedi ca7 care is sti 11 7 i sted fourth in a rarrkjni; of seven prugra:n areas. Some of the associate coordinators cotitl'nue to have categorim1 titles. The Pruitt Igw project has been the only project funded uiitil thfs year which addressed the health care nseds of the undcrscrvcd vrbsn papu'lat-ion and it has not been wc'i 1 -managed Committee recoinmended that in I .igI.it of RNPS' deeiiiphasis of traditional categorical it-ltwests and the KMP's pressing needs -in the urban and rural underserved i!wiis3 that the RVP should yr've greater at teriti on to more coiiiprelicnsive p'iq~ranis . Consumers and ii1.i riori ty members have not been involved in the development or" goals and objectives and are generally under-represented on decisionmaking and review groups. Commi ttee fel t strongly that minority, wim and Consurner participation needed to be more actively integrated in the Program. Special assistance should be given to orienting time ineinburs and to bringing the community group: and institutions with ~h21( 640 ,OO( OB 744,000 - 133,610 690,000 1,567,610 Counc 1st year 03 1 ,l 50 ,OOC 1 - Appove d 2ild year -I YaLIlyPul 05 $1 ,230,500 .eve L 3rd year 06 ->.-- ;I ,316,601 COUNCIL RECOM4ENDED LEVEL . e 0 KEGION: &-.ate * I 1 NUMBER: ZJ! 00056 COORDINA'I'OR: Wiiliam Stoneman, 111, P1.D. LAST TWTING: 266 TYPE OF APPLICATION: /m/ Triennial / - / Triennial 3,rd Year - - - 2nd fear Triennial / - / Other - 1- / OPCRRTIONS BMNCfI : id -Cant i n?nt -.- Chief: YIichael J, Posta Staff for RMP: Dona E. Houseal, Operations Officer : , C- Bar-11- PR F' R- Office Prcgraa Djrector Regional Office Representative: Ray Maddox Management Survey (Date) : La'st Site Visit: (List Dates, Chairman, Other Comniittee/Council Members, Consultants) April 10-11, 1969 Storm Whaley, Chairman; Luther Ekady, Jr,, M.D.; John F. Stapleton, M.D.; Maurice Van Allen, M.D. ,? Staff Visits in Last 12 Months: (List Date and Purpose) May 18-19, 1972 - Orientation of RMPS Staff to the RMP and Technical Assistance for the RMP, Ray Maddox, Regional Office Pr0gra.h Director - August 20, 1971; October 26-27, I 1971; January 17-20, 1972; March 17; 1972; May 30, 1972 (W Site Visit) fkcent events occurring in geogrnphi c area of Region that are affecting MlP jrograrn: --- -_I_p II_ I&. David. Derge recently appoint& President of Southern Illinois University at Carbondale. agreement with Washington and St. Louis Universities. A $1,040,000 Experimental Health Services Delivery System award grqted to Health Delivery Systems Inc. of St. Louis. Gubernatorial electiors will be held in both'rjllssouri and Illinois in Southern Illinois University reaffirms its consortium Nove~er . RM 00056 I -2- ,. .. Covering 31 counties and City Of St. 'Louis - Missouri;j-overlap cith -8lo.Ri.I -1 50 counties in Illinois ; some interface and overlap with Xllinois RNP -3- Demographic Information Population Characteristics: The Region centers around the Missouri and Illinois area around metropolitan St. Louis. but the Region encompasses mre than 30 adjacent Missouri counties and about 50 counties in the southern half of Illinois. Missouri and Illinois RMps account for an additional 30 counties and population of about 650,000. The following is a sunn~lry of population distribution: Definite boundaries have not been established, Overlap With the Missouri St. Louis county and city 8, 9, 10 (30 counties) Congressional Districts Less overlap 1,573,600 Illinois Congressional Districts plus scattered other areas 20, 21, 23, 24 (50 counties) 1,852,300 240 500 mem Approximate combined population 4,130,800 @ Selected Population Characteristics : State of Missouri Total. Pop. % Urban $ Rural % White % Non-White Density Average Per Capita* 4,677.5 m. 64 36 91 11 68 State of Illinois Total Pop. % Urban % Rural % White % Non-White Density Average Per Capita# 11,114.0 m. 80 20 86 14 198 iygE 1,882,900 80 20 4,088 m St, buis Metropolitan Area Total Pop. % White $ Non-White Density Average per Capita* Springfield, Illinois Total Pop. X White % Non-White Density Average Per Capita* 120,800 93 7 3 D 606 @Average for U. S, is $3,680 -4- Page 2 - Demographic Ir$omtion Average Age Distribution Missouri Illinois St. Louis U.S. 55 10 5 $ Under 18 33 34, 32 35 56 53 10 15 $18-64 55 % 65 + 12 Health Education Institutions Medical Schools : St, Louis University Washington University Southern Illinois University (developing) Dental Schools: St, Louis University Washington university Southern Illinois University (students will enter Fall 1972) Pharmacy : Nursing Schools: 15 Professional St, Louis College of F'harmacy 4 Practical .v Approved Allied Health Schools : 26 _. -. * -_ (includes cytotechnology, medical technology, radiologic ~ -, -_ technology, physical therapy , and medical record librarian) Pertinent Health Data Hospital Facilities (Cornunity General) Missouri 46 (includes 1 VA Hospital) St. Louis 26 Manpower Other Counties Illinois 20 80 Physicians (active, non-Federal; includes 0.D.s) : 4,627 Licensed Practica; Nurses (active): 3,822 Graduate Nurses (active) : 9,920 _. . Component OPERATI ON.4.L PROJECTS Kidney . EXS hs/ea Pediatric Pulmonary , Other TWAL DIRECT COSTS - COWCIL RECOXMEXD~D LE~EL COMPOXEiT A..DTIXAVCIAL SU!=>V3Y TRIEWIAL APPLICATICS Current Annualized Level ,- Year $ 517,962 .. 49,392 356,759 .'r X $ 924,113 $ 924,113 $1,412,617 dd- t for Trieimial , 2nd year 1 3rd year. t $1,463,31 $1,567,610 c0ur.c 1st year i \ - !-ApDroved 2nd year 1. - -- . .. VI JULY 21r1572 OREAKCUT CF RECUEST 04 FRCGRdH PER100 -- I 4 I JULY 2191972 '1 APFR. P€RICC I Of SUPPOUT I COO0 PRCGRIN STAFF I DO00 CEVELCPRENTAL COYPChthT I I OC8 CGCP REG IhFCRb'dTICh SYSl CCS PEALlk SLRV Et CAPE fCR I 012 CCPChAPY CAFE TRLIhlhC PI - - ILI!FCPibLlLUGt;t-I AI;!?R-l!5LLeESJ_I Eu?ukl!mm- CEBIhPC.€!LEL;P-I 014 CLIh Ah0 CYIC CETECT CAN1 BREAKCUT CF REQUEST 05 PROGRAM PERIOO REGIC~ - ~I-STATE RU COO56 16/72 PAGE 3 RLPS-CSP-JTCSP2-1.- (21 (4) (1) CChT. BeYONDI APPRO h0T I NENr hOT I ZNO YEAR I APPP. PERICE1 PREVIOUSLY I PHEVIOUSLY I OIRECl tf SCPPCRT I PWOEC I I I I BREAKCUT CF PEOUEST 05 PRCGRAP PERIOD JULY 21~1972 REGICN - eI-STATE un ooosb 1c172 PFPS-C PAGE SC-Jl 4 CGPZ- 1 (51 ti?) (4) tlt lOENl1FICbTION CF CWPOHENT I CCW. WITHIkl Cthh BEYCNOI LPPR. ha7 I ~EYI NOT I 2(iC YELR I I APPR. PERICDl APPR. PEPtCCl PPEVICGSLY I PREVICUSLY I CIRECI I I CF SLPPCRT I CF SL'PPCPT I FChCEC I APPRCVEO I CLSTS I I I I I I I I W I JULY 21~1972 IOENTIFICdfION OF CCPPCbEhT COO0 PACCRAH STLFF ---- C2F USE CF SlC btC RCC TC AC BRE~KOUT tF REQUEST 06 PHCGPLk PERlOC REG~CN - El-SlAtt RP 00056 ic/tz PdCE 5 R J4 P S - C L P- J t C** C 2- 1 JULY 21.LS72 BREbKtUT CF REOUEST 06 PRGGRLC PERICO (5) (2) 14) (1) IEENTlFICATfOh CF CCWPCLEhT I CCNTo WITHfkl CChT. BEVChlDl IIPPR. hOT I hEWa BOT' 1 3RC YEbR I 1 APPRO PERlCOI LPFR. FEiiIOCl PREVICUSLY I PREVIGLSLY I DIRECl I I CF SirPPCRT 1 CF SCPPGRT I FUNCEC I APPRCWD I COSTS I I I I I I f B I-SflIE 1Ct72 )&E 6 PCPS-CI~-JlLCP2-1 I 1ClAL I I ALL TEAPS I lGIREC1 CCSTS I I I I I .-_ I -.i--u&LL- I SU.W~B~CZ~~~-~A~-L-- 034 SYS IPR CEAlH CEPT OAIA I I' I I I -ELrErLr I -I.-- I I 1 I I I t I I 1 UNSPECIFIEO GRCYTH FUNCSI I i 1 S3r24CrllS I I I S60.006 I $101.632 I $lrC209f?Z I 1 Sf5'3.COO I I TClbL I . . -. '. I i I F 10 I a PAGE 1 REPUEST CCTOEER 1972 REVIa CYCLE R)IPS-O SR- JTUGRS-3 JULY 24.3932 P 6 1 C.hJ.U!! EQIO_CPBQW-R3lG SUIJHARY BUOGET BY TYPE CF SUPPORT REGION 56 BI-SYA1E PRP SUPP YR 04 cEsa H IC-CU~TINENT RnPS RPPS RVPS RRFS TOTAL 0 I DEQ INC IR ECT TOTAL OIRECT OLRECT DIRECT 3RC YR ALL 3 VRS CLICC#LIT tic. ' TITLE SUPPORT YE& 1Sf YP 1ST YR IS1 YR 2ND YR CORPOIIENT 10.850 c -CCkTIhUEO CI ,NEXT-P46€- _- .. JULY 24wlF72 REGLCkAL WED IC& PROCRAHS SgRV ICE LISTIN6 CF ADOITICLAL FUHES PA6E 3 RWPS-OS+ JTOGRB-3 pwp SUPP YR 04 RE-1 CCTOBFR 1972 REVIEY CYCLE REGION 56 81-ITA7E DESK WIC-COhlINENT OTHER OTHER TOTAL GRANT RELATED INC_OCE SlLTE LCCL FEQE-RLL MON-C tOERAL DIRECT TOTAL f!!-f IhT EREST 07bEk FWlrDS FWDS f UNO S FLhDS ASSISTANCE TkIS PEPIOG UlVPONENT RRPS hLCr6ER TCrPL -I__- .' LEU RCT PPEVlOUSLY APPROVED R 115 .513 - DCCO 115.513 999 hEW SUE-TCTlL 115.513 119 9513 CONTINCATION BEICNO APPRCVED PERItO CF SUPPCRT COO0 985.816 9e5.816 015 35.390 35.390 0 16 is. esc . 15.850 14.729 14.729 oia I 019 22.094 22 ~054 vi +J I --- - 0 20 221451 221491 ? 02f 33 e366 33 e366 ~-* 3,-~ ~ - - - . -_.- 022 2t.345 023 25,000 25.000 2 377% __-_ ~ --- - 024 22.734 - 25.1665 -- I__--- -- 025 211t65 OZb 21 e620 2ima P -7 7 JULL2_41197 2 LISTING OF ADDITIONAL FUNCS ,:?'*. --- - '> J:, Ru;1 ---_ REGION - 56 ------ 61-STATE RHP SUPP TR C4 DESK PIliCChTlhthT 'AGE 4 YEST OCTOBER RM lSUW€.kC-!. PS-OW-JTO GRB- 3 - -- - ____ __~ _________ CTHER CT PER TOT AI. _I__ CCtPthE)tT RPPS CAdhT PELCTEC LhlLOPIE S?b?E CQcA 420€R A_L.NT)_h-EE-DE PAL 01 RE C T T CT AI. HI_NQS NUWBLR TGTAL I LTEREST CTHER FUhOS FUNDS FUhCS FUN c s-- ASSISTANCE THIS PERJOO 26 s399 53,326 53r320 033 26 s3S9 034 CChT. BLYCNC SUe-fCTdL 1.41E.Slt i .45e *Sib APFPCYEC NGT PREVIGUSLY fUNDED 60 rOOO 014 6CvC00 - c_ I F NOT PREV SUB-TOTAL -- a\ 60.000 I 6QiQQ0 - CCNTIhbATIOh LIlHIN AFPRCVEC FEPICO CF SUPPCPT 5s 366 lllr6lO 72,428 008 5.3.5.5 009 111 1610 012 12142e ? - - CChT. UITHIk SUE-TOTAL 189 e4G- ie5,466 REEION TOlALS I 1.823.833 1,623733 d e 1971-72 BI-STATE WVIP ALLOCATION OF DOLLARS AND STAFFING RESOURCES 1972-73 Region: EH..;S@te m 00056 lh1.W~ % Of Total &Om staff $542,083 58.7 Projects 382,030 41.3 Developmental Component - - $924,113 100.0 Total Dollars % of Total $ 650,126 46.9 621,978 44.8 115 513 8.3 $1,387,617 . 100.0 Positions (F.T.E.? Dollars % Of Total Central Field Positions (F.T.E.) Dollars $ of Total 19 (18.00) $264,865 61.1 6 ( 5.25) 60,256 13.9 19 (18.25) $295,726 61.1 6 ( 5.25) 67,300 13.9 Total University 10 ( 6.50) 108,373 25.0 (29.75 $433,494 100.0 35 (29.75 $484,326 100.0 F.T.E. ) F.T.E.) 35 10 ( 6.50) 121,100 25.0 -18- Region: Bite - Review Cy c 1 e : HIS'I'ORICAL PROGRAM PROFILE OF REGION The BSRMP began its planning in an area rich in pedical resources and complex in government structure and inner clky,problems. The initial planning a& was made in April 1967, (Washington University and St, Louis University respectively) acted as co-coordinators until Dr. William Stoneman, a plastic surgeon and faculty rnember at St. Louis University, was appointed Coordinator in November 1968. A consortium of the Region's three universities (Washington, St, Louis and Southern Illinois) delegated the grantee - responsibillties to Washington University. Early concern of reviewers dealt with 1) the need for more minority members on the RAG, 2) the question of meaningfMinput from a RAG whose membership was so large (56 members), and 3) the heavy categorical emphasis. latter, the RMP had structured its planning and proposal development utilizing a mechanism of eight program cormittees and associate categorical directors on Program Staff. Drs, Danforth and Felix With regard to the ' University people were heavily involved in the Scientific and EZiucationdl Review and Administrative Liaison Conrmittees. .r.iXlring its second planning year the RAG'S Executive Ccaranittee developed recamnendations which sought to involve its members mre directly in the planning and direction of the program by increasing its mership, holding more meetings and studying the RMP in depth. After a preoperational site visit, the RMP applied for and received, operational status in 1969. Director, Dr. Stanley Olson,to St. Louis L_-- to meet . -- with -- Rlvrp representatives __ - -_ - He foGd intense se aration of the two St. his medical-schools which had shared a !&tory of not being particularly ifi€ei%s€GB-in serving the comunity. It was hoped that the IMP might serve as a catalyst in getting the schools to pull together in an attempt to improve the health care delivery system. Program Staff and five prajects for its first operational year, activities included: Problems in getting the RMP going took RMPS The program received an award of $881,387*for Project #2 Radiation Support #4 Comprehensive Diagnostic .Demonstration Unit for Stioke #5 Nursing Demonstration UnLt in Early Intensive Care of Acute Stroke #8 Cooperative Regional Infomtion System for the Health Professions .n #9 Health Surveillance, Education 9 Care for Residents of Pruitt Igoe 0 -19- Page 2 - Historical Program Profile of Region Region: Bi-State Review Cycle: Sept/Oct 1972 The new Southern Illinois University School of Medicine appointed a Dean and plans were made.to add.associate coorWiators fram S. I. U. to the. staff. ~o~l~-_-~.~-_to~surface in 1970 with the S. I. Ua Medical School in Springfield where both Il&& and &-State €U@s pianned to establish subregioml offices in the area. The IUnois RpBp placed a Subregional Coordzna'cor ;in Springf"l;S$d for a time, but neither RMP presently has staf'f in that area, In reviewing the FW1s application for its second operational year, RMPS staff was concerned that the projects proposed had minimil impact outside the existing system and did little to inprove the existing inequities. Reviewers noted that minority and consumer input on RAG had been increased, the Executive CorrPnittee was reorganized, and evaluation arad outreach capabilities were added to Program Staff. The following projects were funded: #2 Radiation Therapy #4 Diagnostic Demonstration Unit for Stroke #5 Nursing Dmonstration Unit for Stroke #8 Regional Information System for the Health Professions #g Pruitt Igoe #12 CCU Nurse Training The RMF' is presently in its 03 year. triennial support last year, Council believed that an additional year was needed in order for the RMP to realign itself in order to develop a propam more in line with the RMPS mission. While Bi-State had gained increased consumer participation in its program, most of the f'unds in the application were destined for institutional rather than conanunity ventures. In addition, continuation and approved but unfmded projects appeared to be more of the "same old thing'.'" Reviewers were also concerned about the continued categorical emphasis and the actual contrlbution of the categorical associate directors based in the medical schools. reconmended that the RMP give further attention to the f'ragpntation of' the Region in relation to the Illinois RMP. time the Coordinators of the Wo programs have met with Southern Illinois University and Dr. Stoneman prepared a statmnt concerning BSRMP involvement in this part of the Region. As a result of this, S, I. U. has reaffirmed its corrpnitment to the consortium, The BSRMP is actively recruiting for the two S. I. U. associate aoordinatorsMps and the positions rmy be filled by the end of September. Dr. Stoneman also has s&neom in mind for the regional field coordina'cor position for the SpringfiWi area. Although the RMP requested It was Parenthetically, since that -20- Page 3 - Historical Program Profile of Region Region: Bi-State Review Cycle: Sept/Oct 1972 - A managent assessment vlsit was held in April1972, The team found the RAG and Executive Conrmittee to be inactive and its members Uninf'omed. The powerful comittees created by the consortium of the three medical schools appeared to have assumed almost total au$hority for both the program and administrative aspects of the RMP. team's-recam&dations included: program staf'f, 3) improving fiscal repwting procedures, ard 4) developing a property management system. The RMP's response to these recommendations is expected before the time of the site visit, r 1) giving the RAG more decisiormking authority, 2) reorganizing The RMP was awarded $1,450,757 for a 15-month budget period ($1,160,604 on an annualized level). groups of activities: This figure includeq'ms for the following A, ProgramStaff B. St. Louis EMS project C. Tho health services/education activities (Casbondale and ,St, Louis) D, #2 #4 #5 #a #9 #12 #I5 #16 E. Other approved projects Radiation Therapy Comprehensive Stroke Unit Nursing Demonstration Unit - Stroke Regional Information System Pruitt Igoe CCU Nurse Training Sanoking and Health Physician Continuing Education for Patient Management Three-months of support for 17 new one-year activities included in the triennial application, ,-,. - ._ ._ .- . .. : . -I .- . - .. ., ..- .- . -21- DEPARTMENT OF HEALTH, EDUCATION, AND \\'ELFARE MEMORANDUM PUBLIC IIEALTII SEKVICE HEALTH SERVICES AND MENTAT, HEALTH ADMINIbTRATI TO ECT: DATE: The Site Visitors of the Bi-State RMP August 15, 1972 b Operations Officer Mid-Continent Operations Branch SWf Review of the Bi-State Triennial. Application, lnvr 00056 A staff,review of the Bi-State Triennial Application was held Monday, July 31, and was attended by the followilyj; people: -lene Hall, Office of Planning and Evaluation Loren Hellickson, Office of Systems Managerent Dona Houseal, NLd-Continent Operations Branch Margaret Hulbert, Division of Professional am't Technical Jennie Peterson, Mid-Continent Operations Branch Pat Schoeni, Office of Comnunications Me Stubbs, Grants MansySement Branch Jone Williams, Mid-Continent Operations Branch Developmnt StaEf mt to discuss the RMP's accomplishments, problems and issues for the visit. The EnVIP's request for the triennium includes: 04 05 core 650,126 696,100 Projects 621,978 640,000 Developmntal Component 115 3 513 127,210 ma $1,412,617 $1,463,310 Staff noted that the request for the developmntal ermisslble amount of $92,400 (computed on the t of the 03 year direct cost ftmd$ng level). 06 744,000 690,000 '133,610 $1,567,610 component exceeded * basis of ten A. Accomplishments The Bl-State RMP has taken a new approach to program development which found noteworthy. als around ideas generated by the RAC, appeared to present a Their plan, which sollcited small ($25,000 range) realistic method of developing activities which would be relevant to eglon's goals, objectives and priorities. In addition, some of the - 22- Page 2 - ?he Site Visitors of the Bi-State RMP I projects address regional health care delivery problems in ways which are more innovative and which may have mre immediate payoff. Examples include primary health care progm for children and an urban populatioquse of the pediatric.nurse practitioner, and an investigation of techniques of iqroving ambulatory care. , In addition to those examples of program staff assistance described in the RAG Report (pp. 42-45) and in the Core Activities sm (p. 137), RMPS staff noted that the Bi-State RM?? provided staff assistance in developing the Experimental Health Services Delivery System application, which was recently approved and hded by the National Center for Health Services Research and Development, HSIWA. . I B. 'Problems and Issues 1. in two parts. The f'irst response has been submitted by the grantee agency and was included in the site visit packet. The second to be sent from the Coordinator and the RAG, will be available to you at the time of the site visit. In regard to the first, members of the . management assessment team reiterated their belief that the problem basically lies in a difference of philosophy betweenqRMPS and the , Bi-State RMP as to who should control the program -RAG or grantee (the Consortium). While the RMP maintains that the Consortium reviemprojects only to assure good stewardship of federal funds, the management assessment team's observation was .that thek fiscal control overlaps into program areas. schools would recornend f'urding only for projects which suit their special interests and that the RAG would be either Unwilling or too weak to oppose the medical establishment. Fom 14 indicated minimal involvement of RAG in project monitoring. The Region's response to the management assessment report will be ' .- The team feared that the Staff also noted that Staff noted that of the 23 projects in the application, ten are university-sponsored ard another five are associated with university- affiliated hospitals. 2. Staff examined the goals and objectives and concluded that the RMP needs a clearer understanding of the separation between goals, objectives and activities. The rationale behind the matching of goals, objectives and a.ctivities with each other, as well as the progression from one year to the next (with some goals and objectives being added or dropped) was unclear. I 3. problem will be to gather more information md possibly make sugGestions to RMPS staff as to how this might be handled. responsibility of the team to settle this issue. "he charge to the site visit team with regard to the turf It will not be the Incidentally, staff W.' -23- e o Page 3 - The Site Visitors of the Bi-State RMP lev& that Dr. Creditc . Coordinator of the Illinois RMP, had sent letters (copy attaclA) to the Illinois CHP "b" agencies requesting their impressions on the boundary problem. Of the 74 RAG members, 46 are from St. Louis, five frm Missouri and 23 f'rom Illinois. 4. Staff thought there was a need for more minorities on program staff and the RAG, the RAG (8) and Executive Committee (2) to be low. They also found the representation of women on 5. It was noted that Dr, Stoneman is President-Elect of the St. buis Medical Society. Since Dr, Stoneman also carries out a part-tkne practice in plastic surgery, staff thought it imperative for,him to consider both hiring. a strong Deputy Director and reorgmizing staff to allow him more time for overall program direction and development. Planning. Attachment 6. Staff was also concerned with the categorical emphasis as exhibited in the categorical associate directors on program staff, the program ccPnmittees and a number of the projects. Some staff members indicated a need for mre projects which would provide the consumer with information on how to better enter and use the health care system. consumer involvement on the health care delivery comdttee,as well as the amount of collaboration with CHP ''b" agencies in subregional They were also curious about the extent of DonaE. Houses Component LOGRAN STAFF INTRACTS iVELOPMENTAL COMPONEh! 'ERATI ONAL PROJECTS 4 Kidr.ey EXS hs/ea Pediatric Pulmonary Other )TAL DIRECT COSTS - COMPOXENT ANDFINAXIAL SWY TRIENNIAL APPLICATION , o I Rcgion: l%-St%>e c 1st year Current Annualized Level c3 Year I $ 517,962 . 49,392 I 650,126 I_- 115,513 621,978 .. 1 $ 924,113 ;t for 2nd y - inial, 3rd year $i 744,000 133,610 ' 690,000 e. '. . * Committee Secomendotion for Counc 1st year i c 1 -Approved 2nd year \ .. -4 . * I Ld 1 1 JULY 21r1572 OREbKCLJl CF RECUEST 04 FRCGRLd PER120 JULY 2191'577 BREPKCUT CF REOUEST 04 PFCGRPM PtRlCO 12) (4 1 (1) I I CF SilPPCQT I CF SUPPCRT I FLNCEC I APPRCVED I CCSTS 1 CCSTI I I I 1 I I I I I I (5) IEENTXFIC4TICh CF CCPPChEhT I CCNT. WITHIhl CChT. BEYCNOI LPPR. hCT I hEbt. ACT I 1ST YEPR I 1S7 YEbH I I 4PPR. PERZCDI APFP. PERfCCl PliEVICUSLY 1 PREVICUSLY I OIPECT I IhCIPECT I ICTLL f ', j 1 JULY 21.1972 c (51 ICENTIFICPfIOh CF CCWFGNLlrT 1 CChT. WIlHIhl I 4PFR. PCRlZCl I CF SLPPCRT 1 I I 034 SYS LPR CEA7h CERT CATA I I BREIKCUT I:F Pc9UfST 05 PRCGPhP PERIOD PEGlCN - PI-STATE HU COG56 1C/7i PACE 4 . RPPS-C SP- J? C'i i- 1 I2 1 (4) (1) CLh7. BcYCNDl LPPR. IsCT I hEW9 hU7 I ZhC YFbR I APFP. PfPICCl PDFVICLSLY 1 PREVICUSLY I CIOEC? I CF SUPPCRT t FLhCET. 1 APPPCVEO 1 CCSTS I I I I I 1 I I I I u? I JULT 21,1972 IOENTIFZC~~lON OF CGHPChEkf 1 I I COO0 PlCCRbM STAFF I tSl CCWr Utfklk( I I APFR. PFRtGO CF SLPPCRT 1 BREAKOUt C'F REOUfSt 06 FRCGPLM PERIOD RE6ICN - &l-StAtt RC 00056 1C/tZ PACE S RMPS-CSC-JlCCR2-1 JULY 2191572 EQEbKCUT CF REOUESI 06 FRCCHIIC PERICO (51 121 (41 (1) ICEHflFICATlth CF CCCPCkEhl I CCNT. UlfPIhI CChl. BEYCkDI 6PPH. hCf 1 hEW* hCT I 1 APFR. PERlCCI b1.FH. FEPIOCI PREVICUSLY 1 PREVLCLSLY I I CF SLPPCRT I CF SLPPCRT I FUhCEC I APPRCVEO I I I 1 1 I 3RC YEJH I ClRECl t CCSTS I I I I ICldL I I PLL YELGS I ICIfiCCT CCSlS I I I I I I .. 4 cd I I- h) I (I E 6 I CE &LED IV_CSRQCf!!2LSLR_VICf --- PAGE 1 REGION 56 61-STATE PWP SUPP YR 04 REPWST CCTOBER 1972 REVXEY CYCLE RUPS-0 S?l-JTEGAB-3 CESK U IC-CON1 IkEhT F? JVUI_z411~-77 .P.\ SUMMARY BUOGET BY TYPE CF SUPPORT - @ ____-- RHPS RCPS RPPS RPFS TOT& DIRECT OIRECT DIRECT C&RPCNLAT O@~~~ INCIRJCT TOlA-L 3RC YR ALL 3 YRS COUPONEN1 hC. TITLE SUPPORT YEAR 1ST YP 1Sl YR 1ST YR ZND YR UNSPECIF 1EO GRCYTH FUhOS c22 68.C22 86.044 02 25.CCC 25.000 - - 25.000 ICv85C __ 3.472 14~322 -. 10.850 . I -CChT IhUEO Ch RFXT-PPGE- .- --- CChT IhliPT lCR h ilk IN PPPRCVED PER IGD CF SUPPORT . L-7A.1 603 5* 3tC I . ! _.._._._ ____ - . - . - ___ . . . __ __ ... __ _____-._..~-----------.-.------ T ___ __._-.- . . . .. . - .- . . - ---.. .- - .- .. . .- . . ,- . .. . . . . .. - .. - - .- . . 1 7 .. - . . . . - . - . -. .. COORDINATOR : Mr . Paul Ward Staff for RMP: ~a-8 S&th. Ralic Health Advisor - - 3rd Ycar Triennial / __. J Triennial Triennial / - / Other - Chainnnn, Other Cormnittee/Council M Clark W. MiLlikan, M.D., ChactlFlDBht Joseph W, Hess, M.D., ReWI Henry M. Wood, Director of Urban Rock, MOD,, Cha&rmn 6u\ avens, MOD. I Cadfdl.Wtnr Regional Office Representative: Ronald Curria Management Survey (Dare) : Conducted: , ' c- S ch edul ed : - or tants) RMP participate in AH to meet with Califor e and t~ eattend CALI FORNlA kAND PACNALLY -2- ST'&l'@E COUNTY OUTLINE MAP SIZC 8% x 11 ,Total Population r19,953,100 Population Density s 128 per $4. mi. WTROPOLfTAN AREAS ' t $, Urban8 91' * ' I Il+bRural 9% .. al i nas-Mont erey anta Barbara tockton (San Joaquin) San Bernadino State and County # Califohia - Sub Areas Population and Counties (1970 Census) , Cmerf - Calif. RMP comprises 9 sub areas, 3 in the Northern part and 6 in the Southern part, each centered around a medical school or develop- ing center. Northern Areas Counties Area I - San Francisco 11 I1 - Davis-Sacramento 20 111 - Stanford (Palo Alto) 11 42 Southern Areas Area IV - UCLA 7 ' v - usc (LOS Angeles) 1 VI - Loma Linda 4 2 j VIII - Imine 1 j PX - Watts-Willowbrook 1 I I 1 VII - San Diego 16 Totals 58 - 3,029,800 1,448,200 2,644,100 7,122,100 1 I 1 1 1,406,700 6,882,000* 1,162,800 1,432,400 1,42O,400 526,700 ' 12 ,.831,000 19,953,100 I 1 , Total population since the Census is probably over 20 million. *Parts of Los Angeles County overlap with other areas. I -5- California - Sub Areas Population Iq' County (1970 Census) (in thousands) 290.2 13.6 22.2 . '6.0 104.6 194.5 fU64.7 123.8 250.1 556.2 18.2 2644.1 of 42 Counties (Nor thera) Area 11 - Davis-Sacr~~Q,to - (20 Counties) ' S is k i y on Modoc Shasta Teh ma Las swn Glenn Butte Colus a Plumas Sut ter YO10 33.2 '. - -7.5 77.5 29.5 15.0 17.5 102.0 12.4 11.7 41.9 91.8 __ Solano sacr amento Yuba Sierra Placer Amador Alpine El Dorado Nevada 169 . 9 631.5 44.7 2.4 77w3 11,s *5 43.8 26.3 1448:2 31c-. -6- i California - Population by County (1970) (in thousands) Southern Areas Area IV - UCLA-L.A. (7 Counties) Madera 41.5 Tulare 188.3 Freeno 413.1 King A- 64.6 Kern 329.2 San Luis Obispo 10%7 264 3 Santa Barbara .I 1406.7 Area VI - Lorna Linda (4 Counties) Mano 4.0 Inyo 15.6 San Bernadino 684.1 Rivers id e 459 . 1 1162.8 - Area VI1 - San Dieao (2 Counties) Sari Diego 1357.9 Imp e r i a1 74.5 1432 o 4 - Area VI11 - Imine ' Orange County 1420.4 Area IX - Watts - W. Ventura County 376.4 (part LOA.) + 150.3 (e) 526.7 . , I Total of 16 Counties (So. Calif.) I- I. '1 r: I i i 7\ REGIONAL CHAMCTERTSTICS __L- FACILITIES MID RESOURCES s CHOOLS (Cont'd) - - - - - Enrollment G r ad ua t e s (1969 /70) (19 69/70] Lo cat ion No . . Schools ." -. - -_ - - .-. -and-- - (8) -hmtl Linda U.-Sch-of Ned .-'-' ' 381 -- ' - -=- '--._a- -i...--.- rr- - - ~ '89 Lomi- Linda 69 Palo Alto Stanford Univ. Sch of Med. 342 . Univ. of Calif. Col. of Med 445 78 Los Angeles Univ. of Calif. Col. of Med 254 58 Lrvihe Univ. of Calif. Sch of Med. 5 16 . 126 Unfv. of So. Calif. 302 72 Los Angeles Uniy. of Calif. Sch. of Med. 99 ..I Oavt s Charles C. Drew .. Postgraduat;-Sch.m of Med. Developing. Watts-W. L.l San Francisco . Univ. of Calif. Sch of Med. 101 -- San Diego -- - Dental . - (5) Loma Linda, U. of Calif,LA, Univ. of Sout liern Ca 1 if . , San 'Franci sco MC . , Pharmacy (1967/68J- (3) __ , Coll. of the Pacific, SF Schools o_f.Public Health (3). . U. of Calif. Berkalw; 0. of Cal. LA, . Loma Lidda. Nursing Schools o Professional Nursing c. I-. o -. 1 -- _- I .. i Practical Nursing Number 67 The rrw anh . I I' Junior Colleges. - Allied Health SchOols - (Approved Programs) * ~ -_ Cytotechnology 6 Number 6 7 .. Medical technology - 65 ( 2 at VX hosp. Long Beach'& LA) .. Number $\ Radiologic Technology Numb e r 110 ( 2 at VA hosp. &os Aogeles !nd(SP) - Physical ther,apy 7 - Number c---- - . &--- ' I. Medic81 record Librarian - 2 ------*, . - .. ?X..&. .- Note; See Manpower Table for sources - page 8, .. 1. -7 ' Soul.ces:* Directory of ~pprdvcd Allied Medical Educetional Program Council on Medical Education, her. bled. Assoc. Chicago 1971. 6 .- .. &LZTIES _*I__ ., .* .--- .- AND RESOURCE,S (Cont 'd) ..... . 'I. . . *- .. ._._ ... -.. .. .. , .:. - , .. ... .. .......... . 1. -.. . .' , .. ' , -.-.. .. ... ... ... .. I.' ' HOSPITALS- ...... ..' , - ... *. . .. ,. .. * , .* .. . ,.. . ., '7 : , ' .I I. . f. .. .." ... .. ... ., ... Skilled Nursing Ho!nes Personal care Ho!tlcs with Nursing Care tOng-terrn &re. Units Source: NCHS - 1148 17,354 45 1 16,015 ' 108. 5,991 A Plss t er J?ac i 1 i 1: i es Inventory County and Metropolitan Area Data Boo!: Pi-IS- Number 2043 - Section 2, Nokmbcr 1970 *Thrre are approximately 35,224 ph';sicians in the Region, includff.ng all but about 100 Osteopaths and" about?. 91,961 nu.rses oe whom 57,700 are active, 7 COMPONENT AND FINANCIAL SUMMARY ANNIVERSARY APPLICATION DURING TRIENNIUM Component ent ic Pulmonary Ctirrent Annualized Funding TR Year 01 04 operatlonal year $ 4,313,532 859,896 586,692 3,196,786 $10,043,175 r I $10,043,175 r Council- Approved Level For TR Year -~ $10,043,175 Region's Request For TR Year 02 05 operational yeas ( 377,930 1 Recommended Funding For TR Year - /-/ - SARP I-/ - Review. Committee Recornend - d Level For Remaindez. of TrieMiar! I LUIPCEC - - LWbXCEC AWAPCEO ** PEOLESTFn _R~OCESTEDREXQUFSfEO REOgESTEC * C9/Y IylL/72 TCI'JL __ ** 01/73-12/13 01/14-12/74 01/75-12/75 TOTAL IO s bYAP CEC AYAPCEC - __ 06 Cl C! c '1 ** 05 - CC W PCh EN I-"-- hC TlTLE c1----- -- c2 - it o c-- .- 281 O? 22284 42974 122 STPCLE PEStCIbl -123-SfRnKE-VOLkRTEE *3- le173 *I 2267G 34972 574C2 124 STCCKE VCLLNT€€ -12E-VCl Ih PESCCIbL 1'1 65870 10ai22 1735f2 1487-51 126 VOLUNTFER STRUK +* TfS-73 5 1 0 ** , e7144 122551 209695 ~~~~~~E Cb **-4b1?9~17358 1278 LA CO EH "FD CA 51698 C-127C LA CC EM MEC CA IC r)tse 12e EP PED CARE PLb 129 EYEP CAQE CRITI +* 193258 26429 3 457551 130 CUP 1bCY CF CUh 102645 Yl7P At-F P CGCCJJP +c 27300 75345 *+---- 14 94 2 P- 152219 2S6648- .. 132 CCwPPEVEHSIVf C -133--PtitS SPEC IdL IS----- --- ** 5c49c 52023 1c2522 ++- 152 171704672 356843 134 PARAMEDIC EM CA 156022 ** 77852 78 110 135-1 CCL f 5 C EL1 hUFS * l3C AtJTRIlIOh AhC C .* 122327 124436 24t 763 -n bREb V > 138 PECIdTRIC LLPSF *+ t3754--- - b7454 '-TTT-CCPP10N-flCKCE--------------- -- --- - ----- o *- -1 C233C lC7943 *e 21561 C23E1 120 VClLhTEEPI Ih 5 I ** zeio3 lzlP0 KE-VOCUYTEE ZUBlO L* tooso 18173- -* *- ltSL4- 1766334 6 17- 0 2t 3 5 3 7- $1, '. . *- IN -- 13418 5 -7-132 35-266 I3e- ** liSiSOTU18i%527 1 . w --__- -_- - ~ --- -- - -- - -- - - 131208 210273 . -0 ... ...... ._~ ........ . .. ... - .. .... .... I . -. ..... _-_- L? 0' -___ 0. RE6ION - CUIMRNIA aR oooi~ iom PAGE 4 __ . _. __ . .- --- AHPS-CSM- J:OGR2-1 , I .- I CURRENT I I I INOIPLCT I TOTAL I I .- __ 0 I COSTS 1 U L24r980 ~ $26.875 - $1 81173 . $27 152 I I .-- I I _-- I I-- [ _--- I S17.381 I __ I_L I 281.381 I I. - I $96.786 I f $92.286 1 i 1173.171 I.____, 3362.2431I I $63.122 I I $178.195 I I :$212.258 i $141.962 $30 -576 .- Q Q $2001991 1 I $64.944 I I $157.607 I 1 I J143.123 I I t ~ 594.969 I' sa7.537 I . _- .- I i I ! I r-' OI t I i i 0 0 0 a 0 -- - I c 0 0 0 0 0 0 0 0 'I" 0 0 0 ;o '0 , ~,. 0 0 0 .. .' . 0 0 0 Q 0 .-. .I 0 0 0 0 0 . .... . ........ ...... . . -. -- ...... .. ... -. -- c. .- i .- ,. ---- .! i3 - - --?-- - 0. I I Ih) Q ,I 1' ..... - 21.- P.L. 89-239 in 1965, the California State Department with the active participation of representatives of the California Medical Association, the California Hospital Association, the deans of the eight scbools of medicine, and voluntary health agencies and resources, organized a "Coordination Agency'' for the purpose of developing an overall plan for cooperative medical arrangements through- out the State. a1 programs proceeded at each of e Coordination Agency developed ic areas of responsibility for each of the medical centers, and ated other questions. of cooperation relied heavily on systems analysis dinating agency submitted an application to RMPS e and goals as described above, s criticized the proposal, feeling that it was "poorly tied e chronological plan for development, and question raiaed by the -regton"--a question not , el advised against RMP creating a central coordinate a group of "subregions .I' The Region tructure and UCLA withdrew the planning eceiving operational grants.' appltcatioa it had Ladependently sub'mitted. The vrtriou8 medical centers ther to break up into several corporating the recommendations of the site a'nonprofit corporation and changed its ee on Regional Medical Programs (CCRMP), 1 Education and Research Foundatton (CMIERF) , u a1 Advisory Council, was submitted. The nonprofit corporation, as the grantee. area offices were organized and baaed with the administrative eight medical schools. Area a, the most eration" is based at the Drew Postgraduat grant in the amount of $223,400 was made 1 Ward was appointed program coordinator her site visit team visited the region in February 1967 and eased concern about the apparent lack of cooperstion'amng the agion and little evidence of overall planning. - 22 - Historical Program Profile of Region (cont.) 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." of UCSF--Area I, UCLA--Area IV, USC--Area V, and California Medical Association and California Hospital Association. planning grants during the first year added the areas of Davis--Area 11, San Diego--Area VII, and Stanford--Area 111. The region's first operational grant was made effective July 1, 1968, including nine projects out of a total of 21 submitted, which included planning for the Northeast San Fernando Valley. - The full year award for planning included the areas Three supplemental In April 1969, the CCRMP was site visited for the purpose of evaluating progress of the overall program and to review in depth the individual program staff requests. The site team was impressed with most of the are68, particularly Area I--San Francisco, Area II--Davis, Area I?-- Los Angeles, Area V--UCSA, Area VIJ--San Diego, and Area 'VIII--1rvine. Most impressive was the evidence of true peripheral involvement. During the visit, Area IV (UCW) raised the question of the possibility of making each 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 2, 1970, the region was supported at the direct cost level of $7,548,457 which included a carryover from previous years unexpended balance of $480,168. The base level at that time wa6 $7,068,289. In April 1971, all regions were notified of national funding constraints which would require reduced budgets. designated A and B. A, reduced the programs to the $6.2 million level and plan B was presented at a $10 million level in the hope that additional funds might become available. , California submitted two plans In June 1971, the site visitors and the Review Committee t2 J - ,LIS felt that the $6.2 million plan A was viable and represented good decisionmaking, The $10 million plan developed, should funds become available, proposed the activation, of several previously approved, but unfunded activities which would require careful screening in vi&w of the region's new program direction in response to new ._ RMPS _- priorities. The Council, however, recommended a level of funding at $10,043,175 on the basis that the CCRMP and its subdivisions had demonstrated a high level of competency in decisionmaking. .- - The CCRMP 04 operational year originally Sept. 1, 1971, through August 31, 1972, was extended four months to Dec. 31, 1972, due to STAFF 0 13 S [i RVA'I' 1 ON S - princii)al Prob lenis : 1. 2. Continued support to t..e weak areas fo; the purpose of s-rengthening and raising the areas to CCRMP standards, has been made with this problem and only Area VI--Lom Linda, Area VII--University of California--San Diego, and Area VIII-- University of California--1rvine--are considered weak. Although the CCRMP has made a great improvement in preparing budget sheets (forms' 16's), there appears to be an administrative problem at the central office with regards to budget. Considerable progress ___I - .- - -_ - -.- - - - __. Princiual Accomplishments: 1. 2. 3. The CCRMP central office has undergone an organizational reorganiza- tion which has permitted the provision of a much broader range of technicak asslstance to area offices in the first year of anniversary review status. A regional kidney disease program plan with speciffc component objectives has been developed, and' priorities have been established among these objectives. One of the new program emphasis of the CCRMP is on manpower assessment. regional health services/educational activities p€an. They have been sponsoring programs to develop a Issues Requiring Attention of Reviewers: It might be well to keep in mind the CHP/RMP controversy. FUNDING H ISTORY (Direct Cost Only) Planning Stage Grant Year Period Funded (d.c.o.) 11/1/66--12/31/67 (14 ~8,) $ 1,368,137 1/1/68--2/28/69 (14 mos.) 2,613,500 Operational Stage (overldps with p stage) Period Funded (docoo.) 7 /1/68--6 130169 $ 2,917,144 7/1/69--8/31/70 (14 mos.) 8,012,055 9/1/70-98/31 /7 1 7,548,457 * 9/1/71--8/31/72 8,956,936 o 9h1/71--12/31/72 (16 mos.) 12,180 , 123 ** & award statement was issued reducing this amount to $6,292,065 plus $703,509 react thor ized unspent , This amount includes HS/EA and EMS supplementala funded at $1,9&0,153 and $100,000 respectively, -. Region: Ca1ifori:j.a TWP RM 00019 Iieview Cycle :-OsJoher 1972 .---. / X / SARP Type of Application : Anniversary _.I_ during trieiitiium Rating : 355 7- -- - / j Site Visit I/ Council The Staff Anniversary Revi.e:.;r Panel recoinrnends a $9,351,175 direct cost funding level for the CCRTiJ' 02 year anniversary application (I-/I/73-12/31/73). The above figure includes $800,000 €or the developmcntal funding request and $322,000 direct cost earmarkecl. funds for kidney disease activities. The SAP2 recoininendation does not exceed the National Advisory Council approved funding Level of $10,043,175 for the 02 year. This reconmendation was reached from the following conclusious - Althoagh the CCPJIP has made good progress during the past year it was the e consensus of the reviewers that the program did not merit an increase over -. the ihtional Advisory Council approved .funding level. Also, an in depth discussion of the problems related to the region's kidney disease activities resulted in the following recomnendations: 1. 2. Projects 87K, 87L, 8751, and 87N, which are new proposals to begin in FY 73, have not received appropriate technical review utilizing outside consultants as prescribed in the guidclines. Therefore, the region is to be notified that these proposals cannot be considered and approved for funding at this time. If the region wishes to have them reviewed locally by outside technical consultants, WIPS will supply the region with a list of consultants. If these projects are reviewed by outside technical consultants and approved, the region may then resubmit them according to the method outlined in the guidelines for consideration for supl;lemental funding. Projects 875, 88C 88D, 88E and G8F did not receive appropriate preclearance and technical review prior to approval by CCT;MP RAG, although the region was informed of the necessity of such action in the May 3, 1972, Guidelines, However, since these projects are currently operational, this requirement will be waived. The region is to be notified that it may choose to continue support of these projects by appropriating monies from its operational budget, but no earmarked kidney monies have been approved for support of these projects , 3, 4 `I Project-s 86, 878, original projects California Kidriey th a t c on 1: i nu a 1: i o 11 -2- C7D, 8712, 87F', 87G, 87k1, 87L, and 89 are trhe begun in FY 72 Tollowjiig Council. approval of the Disease proposal. The region is to be notified of these projects j'Li approvecl for FY 73 at a funding level of $322,000, Any greater st1Fpoi-t of these projects is inappropriate in that we have received no justification for an increased funding level when guiclel incs cull. for a decremental funding pattern in the 02 and 03 years. Because of tile coiifusion regarding tlic cui-reiit status of the CCiS\IP's kidney activities staff from F$WS will mcike a consultation visit to assess the situatjoii on Octobcr 2 and 3, 7he $9,951,175 fundjn;: recomencla?ion 17a:; dccjdccji on when SAlIP anticipated that CCWP wor?Ld resubiliit t-he LIW lcidncy proi)o::al s 87K, 87L, 8717, oiid 87h7, and deductcd 592,000 (requeqtcd amouiit for these acrjvitics) from the I':atiori?l Advisory Council. approved levcl of $10,043,175. This maneuver wil 1. keep the CCZPIP with-in the Couric i 1. opprovcd level €or the 02 anniversary year Other spectfic conceriis noted by Slip2 relative to severa~ of the nine CCRhiP area programs wcrc: 1. 2, 3. 4 . 5. 6, Areas 1, Til, and VI, are not requiring writtcn assurances from program sponsors of conformance f.o Title VI oi the Civil Rights Act. Area 'IrIl has a half-time coordinator. SAPV believes the coordinntor's position should 3e a full-time job. SARP yues fLoned the practice of salaried chai.rmen €or consultant panels i.n Area V. Area I11 has a 12-menber faculty advi.sory cornrnittce which reconinlends approval or disapproval of all DIP proposals for funding and advises the coordinator. SAW believis that thi.s corriinittee is functioning in the same capacity as the Arca Advisory Group, Additionally, it was noted that tlie dean of the medical school appoints new Area Advisory Group members. Because of these two factors, it appears that the medical scliool may be dominating the program, Several of the areas are not following proper review and matiageinent procedures; i.e., failure to distribute review and procedure criteria to applicants andlor failure to review expenditure reports from operational activities, Evaluation procedures are weak or nonexistent in Areas 111, IV, V and VII; i.eo, Area TI1 has no overall program Area IV, V a.nd VI1 do not have FAG involvement evaluation, and in program evaluation. - 3 -, 7. Area I oplxars to be in violation of 1;illPS policy guidelines by supporting basic i.ierlicnl education training; i .e., the Area is sirpportiiig medical residents in a faiiiily practice prop-am. 8. SAW nc,Yd t-he sickle ccll request froill Area LX. Although there i.s no clearly clc€ined 1rt.iPS poli-cy rcgarrljng support of this kind of activity, it was noted that siniiltlr pr'ojcct-s €rom otlier IIIlPs have been advised by tlic Xational Advisory Councfl to seek Eunding frorii tlic Sickle Cell Anemia PI-ogram, National Center for Family Planning Services :JSPiIYi. IWPS /WOE 9/6/72 ney e2 iatric Puhonary .er DIRECT COSTS Current Cccncil - $ 4,313,532 859,896 586 ,G9.2 < 3 , 195 , 786 I 8,956,906 _. $10,043,175 i?egion s Rcrjxcst For TI: Ycar 02 (05 operational year) $ 4,112,556 800,000 4,814,402 ( 6?3,&14 ( 492,457 ( - ( 110 000 ... ( 1 1' 1 1 1 11,022,559 $ 4,112,586 4,114,132 ( 322,000 1 >'<( 4.92,457 ) - c 1 $<( 110,000 ) ( 1 9,351,175 %ARP gave no specific recommendztions on these projects e Region Central Eew York Review Cycle 10/72 Type of Application : Anniv er sar y b e f o r e Tr i ennium SARP a Site Visit lbting 779 Recommenda tions From /x/ Review Committee /i' Council RECOMMENDATION: The Committee agreed with the site visitors in recommending approval of the anniversary request for the 05 year in a reduced amount of $889,000. This amount includes the continua tion of Project #6--Home Dialysis Training Program with no increase in funding above its 1972 level. The Committee paralleling the recommendation of the site visitors and outside technical reviewers disapproved Project #38--Coopera tive Organ Bank with advice to follow the Kidney Guidelines and develop a regional plan for renal disease. The recommended funding level would permit the region to actively recruit a well qualified staff and at the same time not permit the program to be overburdened by a large number of projects. Committee also recommended the scheduling of a Management Survey visit to evaluate and strengthen the region's fiscal capabilities. The total request and recommendation are as follows: Year &quested Recommended 05 $1,420,349 . $889,000* Critique - The SNkEWP has made a valiant effort during the past year to remedy the deficiencies noted during the 1971 site visit. the year the program worked arrangement for him and an even greater handicap to a program making an attempt to bring about required changes. The region has established new goals and objectives which are consistent with national goals, but still fail to directly reflect the local health needs. but still needs to strengthen its representation to insure additional imput from young providers, minorities, nurses and allied health members. *Includes $16,000 for koject #6--Horne Dialysis Training For most of with an Acting Director which was a difficult The RAG has been expanded to include more consumer representation, $429,000 for recruiting and hiring an adequate program staff $469,000 for support of project activities. . II e c e -2- . Unquestionably, the program's highest priority is to fncrease its program staff size. health planners, nurses, fiscal managers .and workers in the allied health areas. In the area of fiscal management, the program has an overriding need to. strengthen its competencies in light of the unexpended funds accumulated during the past year. The Management Assessment visit will help the program to identify its problems in more specific terms and will provide guidance to the implementation of possible solutions. It requires competencies which can be provided by physicians, In summary, the program did well during the past year in light of the circumstances; however, it faces a need to correct many deficiencies if it is to become a mature RMP. It must abandon its emphasis on the "mini-contract" mechanism and place its faith on acquiring a program staff which is capable of generating and implementing a plan which will address some of the region's pressing health needs. seen as a year in which the CNYRMP acquires a program staff which is capable of developing and implementing an integrated, coordinated group of activities which will result in a solid RMP program in the Central New York region. ?%e recommended funding level has been carefully scrutinized and was broken into two distinct categories, i,e., program staff and project support. The Review Cownittee felt strongly that the CNYRPIP wouJd be well advised to place its priorities in the coming year to these two categories in the proportions indicated and to view the nepr future as a "staffing up and planning" period. Implementation should be relegated to a point in tine which comes after the program has acquired a program staff with a wide range of competencies and has developed a sound plan for the future programmatic efforts to be undertaken by the CNYPaP. In so far as possible, they should avoid the "piecemeal" approach which charaterizes the mini- contracts efforts . The year ahead is There was considerable discussion by the Committee concerning the site visitors recommendations. EOB/DOD 9/25/72 COMPONENT AND FINANCIAL SUMMARY ANNIVERSARY APPLICATION BEFORE TRIENNIUM Component '04 Year 05 Year 05 Year /-/ SAW /y/ Review Committe f $489,102 PROGRAM STAFF I ' $444,908 DEVELOPMENTAL COMPONENT OPERATIONAL PROJECTS 1 Kidney $889,000 combined EMS hs/ea Pediatric Pulmonary Other r TOTAL DIRECT COSTS - ~. $850,000 *Committee does not specifically discuss these projects . CENTRAL rn PORK c REGIONAL MEDICAL PROGRAM SITE VISIT REPORT August 9-10, 1972 I. Site Visit Participants Consultants Dorothy E. Anderson, R.N., M.P.H., Site Visit Chairperson, Review George E. Scheiner, M.D., National Advisory Council, Professor of F. M, Simmons Patterson, M.D., Executive Director, Association for Committee, Associate Coordinator Area V, California RMP Medicine, George town University North Carolina RMP , RMPS - Frank S. ksh, Acting Chief, Eastern Operations Branch Robert Shaw, Program Director, DHEW Region I1 Nicholas Manos, Emergency Medical Service Task Force, Division o'f Jerome J. Stolov, Public Health Advisor, Eastern Operations Branch Professional & Technical Development Central New York RMP John J. Murray, Coordinator Ernest Carhart, M.D., Medical Advisor Sandra Anglund, Public Relations Marjorie Jordal, Assistant Director for Administration Walter Curry, Bnergency Medical System, Coordinator Robert Wheeler, Ph.D., ENS Consultant Nicholas Collis, U.D., Director Health Service/Education Activities Ottilia Nesbit, Health Planner Robert Schneider, Evaluator Lawrence Polly, Audio Visual Maintenance John Koch, Technical Assistant, Eearmtag Resource Center Suzanne Murray, Librarian Larry Rummel, Community Coordinator (Fast) Micheal Reich, Administrative Assistant Trainee CNYRMP Executive Committee Clarke T. Case, M.D., Chairman, Physician (Surgeon) Private Practice* Gordon J. Cunrmings, Ph.D., Rural Sociologist, Cornel1 University* Horace S. Ivey, M.A., Director of Social Service Department, Upstate Bruce E. Chamberlain, M.D., Physician (Surgeon) Private Practice* * Central New York RAG Members Medical Center* -2- . -2 Barbara Bates, M.D., Consultant, University of Rochester Irwin K. Stone, M.D., Physician (Gen. Prac.) Jhergency Room * Virginia McAllister; B.S., SUNY Agricultural 6 Technical College, - Gertrude Cherescavich, Project Director of Nurse-Clinician Program Betty Katona, Acting Nurse Coordinator Helmon Rubinson, M.D., Physician Coordinator Sister John Nicholas, lbrse-Clinician Student Maryanne Miraglilo, Nurse-Clinician. Student Benjamin Levy, M.D., Preceptor, N. Y. Telephone Co. Robert F. McMahon, Preceptor, General Practitioner, Syracuse Professor & Chairman, Department of Health Technology * CNYRMP Primary Patient Care Committee McDonald Dixon, Foreman, Revere Copper & Brass, Inc. * Herbert K. Ensworth, M.D., Physician (Internist) Private Practice/Ithaca * Robert Gelder, M.D., Physician (Surgeon) Private Practice in Sidney, Jerome Wayland Smith, Oneida Ltd., Silversmiths, Secretary of Company * Robert Westlake, M.D., Chairman, Physician (Internist) Private New York * Practice - Syracuse * __ CNYRMP Regional Kidney Disease Meeting B. A. Bernstein, M.D., Physician Private Practice - Syracuse Dorothy Bruno, staff - Senator Lombardi - Albany Paul Bray, staff - Senator Lombardi - Albany Thomas Flanagan, M.D., Physician, Private Practice * Ron Fonda, Syracuse-Onondaga Planning Office John Harding, M.D., Binghamton Bucky Helmer , NY- Penn Gerald Hoffman, Legislative Assistant - Senator Lombardi Edward C. Hughes, M.D., RMP, Chairman Planning & Priorities Committee A. 0. McPherson, Upstate Medical Center Stephen Kucera, M.D., Johnson City Otto Lilien, M.D., Department of Urology, Upstate Medical Center Honorable Tarky Lombzrdi, ChiAirman, Senate Health Committee Jason Moyer, Medical Director - Binghamton General Hospital Ms. Harriet Morse, Executive Director - Senate Health Committee Zahi Nia Makhul, M.D., Department of Urology - SUH Richard Schlesinger, CHP, ALPHA, Syracuse Richard Schmidt, M.D., Dean, Medical School, Upstate Medical Center * Edward T. Schroeder, M.D., RMP Project Director, Home Dialysis Ronald D. Smith, M.D., Utica CNY RAG * Training Program * Central New York RAG Members -3- 11. INTRODUCTION The Central New York Regional Medical Program (CMTSRMP) site visit was conducted following the receipt of their application for one year's support in the amount of $1,420,349 direct cost. application requests support €or the continuation of six projects and ten new activities. ously been funded as nine separate projects and are now administra- tively merged under two new project numbers. The Of the ten new projects, two had previ- The charge to the site visit team was: 1. To review the region's overall progress since the last site visit in June 1971. 2. To determine the newly appointed Director's role in program direction. 3. To determine how regional needs and resources are identified and analyzed. 4. To evahate the monitoring and surveill.ance of ongoing program activities. 5. To study the roles of RAG and its committees in program direction and to relate them to the recently published RMPS policy governing these relationships. 6. To review the region's mini-contract activities and obtain progress reports on those projects which have recently been initiated as supplementary activities. 7. To arrive at a funding recommendation which would include the region's kidney activities as well as its general programmatic activities. 111. Conclusions and General Impressions The site visit team was fortunate in having three members who took part in last year's visit. had made many positive changes since the last site visit. The site visitors noted that the region The region has established new goals and objectives which are c.on- sistent with national goals, but still fail to directly reflpct the local needs. The RAG has been expanded to include more consumer representation,but still needs to strengthen its representation to include more input from young providers, minorities, nurses and allied health members. The Becutlve Committee has also added consumers. The team found the RAG Chairman to be dedicated and knowledgeable about the total program. -4- - The recently appoint,ed Director has generated a new enthusiasm within the RMP and has been successful in achieving a greater visibility for the program throughout the entire region. The program staff needs to be expanded. It requires competencies in the physician, nursing and allied health personnel areas. The region has made a sincere effort to comply with the recorn- mendations set forth in the 1971 advice letter. However, a .?hysician Associate Birector has nut been appointed. The team was favorably impressed with the CNYRMP's ability to involve CHP "b" agencies as an aid to the program in its project review and program planning. While the site visitors noted the program's progre.ss and its new direction, the following deficiencies and concerns were reported to the region during the feedbacklsession. 1. large enough to effectively implement a successful RMP program. The following positions and competencies are recommended. The site visitors Felt: that the present program staff is not a. b. C. d. e. A full-time physician in the role of an Associate Director. In the recruitment process the program should attempt to attract an individual who would bring strong administrative and public relations competencies to this position. It \:- ,$' - -. - '\ ! . ,I was noted that the CNYRMP has successfully recruited a Medical Consultant; however, his primary value is as a family practice consultant and, as such, does not fill the program's needs for strengthening its administative and public relations capabilities. There is a need for the recruitment of program staff in the roles of Assistant Director for Operations, an Assistant Director for Administration, and an Assistant Director for Program Planning and Development. I There is a need for a Nurse Generalist to aid the Manpower Coordinator in the planning and development of health service/education activities. The utilization of community resources could be enhanced by the hiring of a Community Coordinator for each of the area's subregions. Evaluation is an important aspect of a successful RMP and although this is currently being done, there is a need to enhance this apect of the program's operations, Consideration should be given to the recruitment of an experienced full-time Evaluator. t 2 I. i _, \ -5- In summary, there is a need to enlarge the staff in a manner which will provide the competencies outlined. there should be an attempt to recruit minority candidates who can provide the balance and insights which will be helpful in program development. communication link with the minority groups in the CMlRMp area who have a-need for the benefits which can be provided through the auspices of the RMP. In the recruitment process In addition, minority staff members can provide a 2. The site visit team recommends that no additional mini-contracts be initiated. It was noted that these contracts required an excessive number of program staif man-hours to monitor and evaluate. In light of the small program staff, the efficiency of manpower utilization must be optirnal and in using the mini-contracts approach, the manpower/dollar administrative costs appear unwarranted. 3. specifically reflect the local needs of the region. that the program systematically identify the needs of the region, develop short and long term objectives to meet these needs and, in the process, redefine its goals and objectives in a manner which more specifically addresses the region's pressing health problems. 4. There is evidence that a programmatic thrust is developing in one of the subregions; however, there is a need to coordinate the relationship between program planning, operational projects, and program staff activities to capitalize on these positive developments. The CNYRMP's goals and objectives are broad and fail to It is recommended 5. from various sectors of the region. Specifically, there is a need for greater representation from young providers, minorities, women, and allied health personnel. The RAG membership needs a greater balance to provide insight 6. CNYW grant application packet. scheduled for a complete analysis at a later date; however, there should be the immediate implementation of a formalized appeal procedure for all grant applicants. There is no formalized appeal procedure provided in the current The region's review process is 7. Project 1/38, The Cooperative Organ Bank is disapproved. The project, as presently conceived, demonstrated a lack of coordination and integration with other renal activities and fails to meet the region's total needs for a kidney program. 8. for continued support at its present level. It was noted that the goals of the training unit are not clearly stated and that the project will not attain maximum efficiency until such time as this has been accomplished. Project 86, Home Hemodialysis Training Program is recommended -6- 9. New York. In its present form the agreement of affiliation is to be with two private phpicians rather than with a nonprofit corporation or institution as required by grants management policy. 10. The CNYRMP Bylaws fail to comply with the RMPS policy which sets forth the respective roles and responsibilities of the grantee, the RAG, and the program staff. the form of a News, Information and Data (NID) publication on August 30, 1972 and has been sent to all regions. the Council of the Upstate Medical Center is given the authority to appoint RAG members upon the advice of the RAG. The Bylaws require modification to turn the authority for RAG member appointment over to the RAG, thus making the RAG a self-perpetuating body. Project #40, Satellite Clinics Serving Rural Areas of Central I .C This project is disapproved on administrative grounds. This policy was formally issued in Under the current Bylaws, 11. capabilities. future to evaluate the situation and to provide constructive guidance. of expenditures and the resultant lapsing of funds. The region has a need to strengthen its fjscal management A Management Survey Visit will be scheduled in the The site visitors expressed concern over the low rate Funding Recommendation The site visit team recommends approval of the anniversary request for program staff and projects in a reduced amount of $889,000. The team recommended $429,000 for program staff salaries and $460,000 for project activities. amount would be sufficient to permit the active recruiting of a well qualified staff and, at the same time,' not permit the program to be overburdened by a large number of project activities. The site team is impressed with the program's need for an enldrged staff which will increase its competencies to develop a solid program. This must be the region's highest priority in the upcoming year. __ It was believed that this W: Central Bew Yak PREP. BY: Jerow stolov WTB: 10/p 1. GOALS, O-TIYEG, ABD PRIORITIES (8) The region'e new goals and objective8 represent a new direction which le consi6teat with the RUPS lat8S1011 statement; however, as noted earlier, they do not reflect local health needs. The objective8 were developed by the Planning & Prioritlee Comdttee created in December 1971. The Conrmittee waa chaired by I&. IMwarBp Hughes, Director of Counnunity Medical Service (Hen York Medical Society). Other mmbere of the ComPaittee were choben because of their personal knowledge of the region's health needs. The Committee had repreeenLativc8 from both coneumere and providers. The CEP "13" and the CHP "A" agencies were also invited to participate In the formulation of the region's new goal8 and objectives. The Planning &Priorities Committee wed the foll0~1~ basis for the formulation of the gosla an8 objectives: 1. The data arrde available at the RAC) meting of December 2, 1-971. 2. The stated goale and priorities of the CHP "A" end Crrp "B" agenciee. 3. Mini-contract proposals which had been submitted by health pro- fessionals. In the region perceived to be their problem areas. This procedure enabled the region to see what people 4. Tbe Elwps d80iOn statement. 5. Data provided by the Community Medical Servicee (New York Medical society) o On bfarch 2, 1.972 the following goals and objectives were approved: 1. "Improvement in the eystem of health care del.ivery by asslating in the evaluation of existing health systems and in the develop- ment and evaluation of potentially effective alternative health care Byatenre with p8rticuLar attention to the rural, inner city, and elderly medicelly dleadvantaged . " 2. "Increasing the aVt%llabllity, efficient utilization and capacity of health care permanel while providing for their continuing competency. '' "Strengthening regional cooperative errrallgements in order to make mximmn we of available resources." 3. RMP: Central Hew York RW?ARED BY: Jerome Stolov DATE: lO/P Although these objectives are listed in priority order, the Planning and Priority Committee hopes to formalize explicit priorities by the end of the calendar year. In addition to a lack of explicit priorities, the site visit team found no evidence that the program had establiehed short or long, tem goals. The final statement of the goals and objectives was mailed to 5000 health professionals in March 1972, at the time the requests for grant applications for 1973 were circulsted. of intent were submitted. the CIYRMP's goals and objectives. health providers had Under8tOod and eccepted the region's program and 8 further indication of the broad nature of the stated objectives. Approximtely 57 letters This was an indication that the Of these, only 15 failed to fall within h examination of the CayRMp grant application reveals that 52% of the region I s requested operational activities 8163 directly related to their highest priority objective of improving primary patient care for the medically deprived rural, inner city and elderly _- __ t. * - --- residents of the region. The region has msde an honest attempt to revise its goals, obJectives, and priorities; however, it has been handicapped by the resignation of' ita former Coordinator, operstlng for the better part of the year with an interim Coordinator, a smll staff, a RAG which requires restructuring and a number of other disadvantages which have combined to mke progress difficult. Now that the new Coordinator has been named, the situation should begin to stabilize and the coming year should see the evolution of more specific and more meaningful goals and objectives. Once this h8s been accomplished the program should begin to take on a more positive outlook. Recommended Action -3- IYI u RMP: Central Hew York PRBARED BY: Jerome Stolov DCITE: lo/= It should be recognized that this program had only three professional. stPrff members for most of the year abee the Last site visit; however, the site visitors were able to daentify BOW noteworthy accomplishments. 'phe RbfP's new Spanish-speaking Eealth Qhmer worked closely with the H-Perm EX) Coordinator and Model Cities: staff in Bingbmton. work resulted in tire: development of 8 proposal to Mode1 Cities to fund an Ambulatory Care Clinic. Her The Library Coordinator stbulated hospital8 to apply for library improvement grants. each received $3,000 $rente. As a result of her efforts, three hospitals The Emergency Medical System Consultant developed an Icforlmation Guide to be used in working with the New York S=k€bte Bureau of Emergency Service8 and the CEPs in the development of local and regional plans for the delivery of Eaerrgency Health Services. IPhe C!RYRMP program staff gbnned and tmplemented two training programs. "he purpose of the first progrcbrn, &dieation Education Program, to update nursing home personneL with respect to the proper utilization of recently developed medicationfie in Beptember l9'/", and will address itself Lo the training of nursing honu? personnel to enhance their skills as activities Leadere. Som? activities initiated by the CNYRMP have been extended or repli- cated throughout the region. Pulaski Model Rural Ambulatory Care Center, operated tn conjunction with the Family Practice program at St. Joaeph's Hospital in Syracuse, is being replicated by the C. S. Wilson Hospital. in Johnson City, New York. hensive rural health care system at Baoner-Keseon Hospital in Susquehanna, Pennsylvania. Thisp development is a tribute to the efforts of the QJYRMB to move its expartbe to areas outside Syracuse. The second program will take place 0 The etts visit team noted that the This hospital has submitted a proposal to create a compre- The Nurse-Clinician program @rrovides another example of a project being extended throughout the region. of the first class were from Syracuse while less than ona-fourth (22%) of the participante in the second clam came from Syracuse. regionalization aspect of this program effort was viewed positively by che dice visitors. Two-thirds of the participants The - 10- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 2. ACCOMPLISHMENTS AND IMPZEMENTATION (15) (Contd) In addition, the region plans to work with the other New York State RMPs in such joint efforts to enhance its activities in public relations, program evaluation, and cancer registries. A unique coordinating board has been developed in which the RMP program staff and members of the NY-Penn Health Management Corperation work together to insure integration and cooperation of all planning and implementation of programs in that subregion. CNYRMP is fulfilling, in part, its role as a coordinating health agency. I In this way the A mini-contract has been given to the Neighborhood Health Center in Utica. to inner city residents and in moderating health costs by providing primary care outside of a hospital emergency room. only other alternative left to theae inner city residents. This has resulted in making health care more readily accessible This had been the The Pulaski Rural Ambulatory Care Center has increased the availability and accessibility ot care for people living in Northern Oswego County. Many of the 200 patients per week which are seen in this center had formerly been patient8 of a Pulaski general practitioner who is now ret ired. The Librarian, EMS Consultant, and Health Planner have given pro- fessional aseistance to those people in the region who have requested their help. For example, the Medical Consultant, who recently joined the CNYRMP, is providing professional assistance and consultation to those engaged in family practice care. Up until now, the CNYRMP has not been involved in peer review mechanisms and has not specifically examined the quality of health care being rendered in this region. However, the minutes of the Executive Committee meeting held on May 25, 1972, states the following: Executive Committe directed the staff to consider the problem of quality of care as a priority for the next program year and to direct efforts of the program staff in the establishment of means of measuring quality care and upgrading that care when it is found inadequate." In light of this mandate, the program can be expected to address this aspect of health care in the near future. "The -------------- Recommended Action -11- RMP: Central New York mPARED BY: Jerome Stolov DATE: 10/72 3. CONTINUED SUPPORT (10) All proposals submitted to the ClDYRMp must give evidence of possible sources for continued funding. In the course of examining the projects preeently being funded, the site visitors observed that during the evaluation of the Nurse-Clinician project, the phasing in of tuition was strongly emphasized. The Model Rural Ambulatory Care Center is expecting that patient fees and local fund raiaing will aid in phasing out RMP support for this activity. of funds i8 being accomplished and the need to accomplish this is recognized by the region. Thus, the recycling On the negative side, the site visitors noted that the Dial Access project will not be self-eustaining since it is having problem in finding sources of continued support. find alternate mans of supporting this activity or will need to accept the fact that it has failed to demonstrate its value to the uiera. The region will be forced to The St. Regis Reservation Clinic, Project #31, has not shown evidence that the CNYRMP staff has adequately negotiated formal agreements with funding institutions which define the extent of their present and future participation. avoid problems which can arise when there are misunderstandings of responsibilities and authority. A major problem which ha8 confronted the Home Dialysis Training project has been its lack of 8ucce8s in locating financial support for each patient . %is must be done if the region is to Of the sixteen proposals submitted for funding, very few had realistic plans for continued support. reviews. For this reason, the region faces a true need to recruit a full-time staff person who is skilled in administrarive negotiations which will result in the acquisition of continued support for the worthwhile activities initiated in the region by the RW. This was a mjor factor in several CHP - 12 - - RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 4. MINORITY INTERESTS (7) As mentioned in the section on goals, objectives and priorities, the number one priority of the CNYRMP relates to improving the system for health care delivery to rural, inner city, elderly medically disadvan- taged, and etc. To accomplish this, the region will need to add minority members to ita ataff who necessary to work wtth the mQnority groups. will bring the insights and Linkages The population of the entire 17 county region is about 3% minorities. The site team observed that only three out of 17 mini-contracts were targeted to the inner city populations, while the majority of projects appear to serve rural residents. The CNYRMP has not significantly improved the quality of care delivered to the black minority populationa. priority project was the St. Regis Reservation Health Clinic for Indians. However, the region's highest An example of RMP supported activities that resulted in training members of minority groups was the funding of the training of a nurses aide and a LPN for the Utica Neighborhood Health Center. The St. Regis Reservation Clinic, Project #31, also has a training component far local manpower development from among the local Indian population. In January 1972, a Spanish speaking Health Planner was added to the CNYRMP program staff. model city agencies, community action programs, and the Spanish Action League. She has also made contact with the Mohawk Nation which resulted in CNYRMP funding a mini-contract to this group. is fair to assume, baaed on her early accomplishments, that this staff member will make a significant contribution to the future efforts of this program. Her assignment was to work with consumers, It As of June 1, 1972, the Central New York professional program staff had three females and three male members. One of the females represents the Spanish speaking minority group. -13- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 The present Director has been with the CNYRW since 1968; however, he has only been in hi8 new position since July 1, 1972. October 1, 1971 through July I, 1972, he waa serving as the region's Acting Director. While he was the Acting Director he was successful in expanding the W's minority membership and in gaining the appoint- ment of the directors of the region's three clpp "by' agencies to the RAG. He employed a management consultant to help him develop an organizational chart which was consistent with the new CWYRMP direction. In this process the duties of program staff membems were! redefined through the development of job descrfptions. for several of the staff memhers and provided ti guide to the type of competencies the program needed to seek in ice future recruitment effort 8. From This resulted in changes A paragraph in the annual report of the RAG statea, "John Murray, Assistant Coordinator, WBI named Acting Coordinator and hrre done a remarkable job in adapting our program ro the evolved E;zpzR national mission, as well as local neede. He ha8 instilled in ell of us a new enthusiaem for IMP.*' It was apparent that he had acquired the respect of the local health community and, on this basis, was appointed to the role of Director in July. The stte visitors were concerned because he has failed to establish an effectively functioning program staff. authority and his etrategy in not filling the Associate Director, Assistant Director for Program Planning and Developant and the Assistant Director for operc3tions positions. The Director planned eo consider existing program staff aw potential candidates for the above positions. The team felt that the program needed these positions filled with well qualified health profesaionale in order to establish an effective staff. On the basis of the Coordinator's viws toward the delegrrtion of authority and hie failure to seek highly experienced health profeesionele for the key program positions mentioned, the site visitors believed there is a need for the Director his approach and to attempt to strengthen the progxam through improved adminis tre t ivo pracedurtnr The visitors questioned the Director's failure to delegate The Director's good working relationship with RAG la actested to by the fact that the RAG'S Ad Hoc Selection Committee nominated him to be the program's DireCtorv, and the full RAG utieaimusly voted to approve this nomination. In summary, the site visitors viewed the kb3ctoFL. with ambivalence. -14- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 r 5 COORDINATOR (10) (Contd) They perceived him as a man who related well with people, groups, and institutions throughout the region and, in so doing, represented the CHYRMP in an excellent fashion. On the other hand, they saw him as a man who lacked the managerial skills to recruit and properly utilize the program staff. Assistant Director for Operations who could effectively build and properly utilize the staff. This reinforced the need for an "in-house" 6. PROGRAM STAFF (3) The former Director and many of the staff have left in the past year. This has left the program vastly understaffed. Both the new Director they have carried in recent months. it is impossible for them to continue at this pace. the top priority this program faces is the enlargement of the program staff with qualified individuals to fill the key staff vacancies which have been mentioned repeatedly throughout this report. The site team nored that a physician associate director has not been appointed' as recommended in the 1971 Advice Letter. =.. _i . -4 and his remaining staff are to be commended for the heavy work load _. _x It is also quite apparent that Unquestionably, The team learned that at the present time a member of the program staff has been designated to serve in the dual roles of Assistant Director of,Operations and Coordinator of Emergency Medical Services. This practice is contrary to RMPS policy and is obviously too much for one man to handle effectively. In addition to those positions requested by the region, the site visitors recommend that consideration be given to hiring a well qualified nurse and an allied health pro- fessional to balance the range of competencies of the program staff which is expected to carry out a bcoad-based public health program consistent with its stated goals and the overall mission of the RMPS. Recommended Ac t ion -15- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 7. REGIONAL ADVISORY GROUP (5) The present CNYRMP RAG breakdown is as follows: 13 practicing physicians, 14 members of the public at large, 7 hospital admin- istrators, 5 educators, 4 government officials, 3 CHP "b" agency directors, 2 lawyers, 2 nurses, 1 dentist, and 1 head of a social service organization. The RAG has good geographic representation. There are five minority members on the CNYRMP RAG. program goals, there needs to be greater representation from these groups. fifth member is a representative of the Spanish-speaking community. There are no Indian representatives and this must be corrected in light of the program's need for input from this segment of the population. The site visitors also noted that there,were only three female members on the RAG and felt that this should be increased. The Binghamton Model City Agency, the Oswego County Migrant Health Care Committee, and the Community Action Program of St. Lawrence County each have representation on the RAG and this was viewed as an excellent means of getting inputs from throughout the region. In light of the Four out of the five minority RAG members are black; the Four of the five minority members serve on CNYRMP Technical Review Committee Minority representation on the Executive Cornittee needs to be increased. and one minority member serves on the Executive Committee. With the establishment of a new Planning and Priorities Committee, along with a new Review and Evaluation Committee, more RAG members are going to be more directly involved in the decisionmaking. increased involvement and dec ent ra li za t ion of the dec is ionmaking process was viewed as a step in the right direction. This The Executive Committee meets bi-monthly and not less than one week prior to each RAG meeting. The recommendations of the Executive Committee are presented to RAG and are subject to questioning and reversal by the RAG. in the program and, as such, is an aid to enllghtened actions which will strengthen and coordinate the program's activities. The RAG Chairman is knowledgeable and involved The site visitors learned that the RAG exercised its authority in at least one instance by approving a project which had not been recommended for funding by the Executive Committee. The site visit team was unable to determine whether the RAG provides guidance to the program staff. man of the RAG is in telephone contact with the CNYRMP Director. Hywever, it was noted that the Chair- -16- e-...*- - RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 .-. 7. REGIONAL ADVISORY GROUP (5) (Contd). on a weekly basis. and the Director established a bridge beeween two segments of the CWRHP which will enable them to work in a more coordinated fashion. This close communication between the RAG Chairman was viewed- as constructive in the sense that it .. The reorganization of CNyRMp's EUG resulted in the establishment of the following standing committees: Nominating, Executive, Planning and Priority, Evaluation, Manpower, Primary Patient Care and Coordi- nating Eoard for the NY-Penn area, In addition to the standing committees there are Ad Hoc Committees on matters related to kidney disease, emergency medical services, and cancer. In'summary, the RAG has undergone some dramatic changes during the past year and has made some prcgress; however, there is still a long way to go to acquire a KAG which can effectively fulfill its mission as defined by RMPS. the News, Information and Dara (NID) bulletin issued by RMPS on August 30, 1972 should serve as the guide to the future efforts to revitalize this body Tfie process of restructuring must continue and -I -_ ------- 8. GRANTEE ORGANIZATION (2) The Research Foundation provides support through the Upstate Medical Center Business Office in the areas of purchasing, personnel, and grants administratton. They kave also assisted the region by giving special assistance in areas stich as mini-contrac t formulation and negotiation. Office more for additional legal advice, personnel recruitment, preparation of salary schedules which are consistent with the job descriptions which have emerged on the new organization chart as a result of the management consultation which had been contracted to study this aspect of the program. "lie region plans to utilize the Upstate Medical Center's The bylaws, however, need t:, rake into account the recently formalized relationships required by RNPS between the grantee and RAG. has been forwarded to all regions in an August 30, 1972 issue of News, Information, and Data (NLD). According to the RMPS policy, the RAG has . . the responsibility of selecting and appointing its own members. The current bylaws specifically give the Council of Upstate Medical Center tht.-, ' responsibility to appoint RAG mvnbers and this must be modified. %is policy r. --------------------_____________^_____ -17- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 9. PARTICIPATION (3) The CNYRMP Program Director meets with staff and board members of the four CHP organizations in the region on a monthly basis to discuss program activities and plans. Both the Binghamton and Syracuse Model Cities agencies electedme delegate each as members to the CNYW RAG. Board of Directors of the Community Action Programs. Many CNYRMP RAG physicians serve in official capacities in various committees of the New York State Medical Society. Still another indication of participation is the 134 applications which were requested for the mini-contracts and the 57 letters of intent which were actually submitted to the CNYRMP. In previous years, proposals numbered from 5 to 10 per year. contracts, although they have many drawbacks, do serve to involve and interest more people in the activities of the program. In addition, there are also members from the The use of mini- Although four out of seven members of the Executive Committee are from the Syracuse area, the mini-contracts and proposed projects which were approved for funding resulted in a prograrc with geographical balance. No major interest group appears to be exercising arbitrary control over the program's activities. e .............................................. Recommended Action 10. LOCAL PLANNING (3) When the RMP receives an inquiry or letter of intent for a proposal the CHP is immediately contacted. both the RMP and the local CHP planning groups to further develop the proposal, the representative CHPs for them to review in light of their role in regional health planning. In the past this procedure was carried out in the month preceding the submission of the CNYRMP's annual application; however, the CNYRMP is currently attempting to give the CHPs and their om RAG more time to act on CHP comments by having the proposals reviewed on a continual basis throughout the year. Joint: meetings are then held with When the proposals are completed, the request is sent to -18- c - RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 10. LOCAL PLANNING (3) (Contd) The CNYRMP plans to work closely with the local CHPs on a major project for gmergency Medical Services. recently been provided to the CNYRMP to conduct such an activity. The current plan is to contract with the local CHPs for setting up EMS councils and hiring local EMS Coordinators. It is interesting to note that the region hopes to utilize this project effort as a vehicle for the establishment of a CHP "b" agency in an area which does not have one at this time. Supplemental funds have There is evidence to suggest that the CNYRMP has been successful in its attempts to gain participation from other health agencies in the region. c. . ..< -r -_ .". I ' Recommended Action -1 .F , ' ... . . . . ...,. . . , ~. i,' : .. . :.<.a , .-, ..>,- - 19- RHP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 11. ASSESSMENT OF NEEDS AND RESOURCES (3) As cited in the section on goals and objectives the region uses five sources to identify its regional and subregional needs. the site visitors failed to see haw these sources of identifying needs could be integrated to provide the information required to generate a well directed programmatic thrust. In addition, the site vieitors found only a few examples of present program staff activ- ities which were in anyway related to the health care problems which had been identified by the five input sources. the recently established Planning and Priorities Committee will be able to synthesize this information in such manner that they will be able to establiah priorities and refine the objectives in light of the current information. ThLs is crucial to the CNYRMP if it is to be successful at re-orienting ita program SO that it can effectively implement activities which will alleviate the region's amst pressing health needs rather than continue to pursue the path of doing "good works" in a fragmented, isolated, and uncoordihated f ashion. However, It is hoped that The region also plana to recruit four cornunity coordinators for its dysignated subregions and also a health system planner. It is hoped that the above personnel will help in the assessment of needs and in the identification of resources, so the program can develop a rne&ingful plan of action for the program's future activities. 12, MANAGEMENT (3) With the small staff that has been available to the Director, CElyRMp ha8 bean engaged in an impressive number ot ectivities. the sire visit team obaerved that program staff activities did not appear well coordinated. It was observed that the Learning Resource Center personnel and the Librarian were people who could have been used to assist the manpower coordinator in hi8 tasks. There were no indications that such a working relationship existed or was developing. the However, -20- RMP: Central New York PBEPARED BY: Jerome Stolov DATE: 10/72 12. MANAGEMENT (3) (Contd) As was mentioned in the section related to the Coordinator, the proper utilization of staff appears to be one of his major weaknesses. It is hoped that experience and confidence will help him to improve his management skills. The region requires a monthly financial report and a bi-monthly progress report. and semi-annual progress reports. aid the program to have current fiscal data which can be used for effective rebudgeting and enhancing its capabilities to capitalize on opportunities to move rapidly into activities which will advance the program. balance of $417,339 which speaks to the management capabilities. In the past they required quarterly financial reports This procedure should eventually However, at this time, the region has an unexpended need to improve its fiscal Each project and mini-contract has been assigned to a program staff member. contract when the initial letter of intent was received. In addition, the staff member arranges for technical review and is also required to give the results of the technical review back to the project director and to assist him in making changes which are required as a result of the review process. This approach places a heavy work- load on each staff member and prohibits him from utilizing his time to assist in program planning and development. It is on this basis that the mini-contract approach is viewed as an ineffective approach to project development by this region at this time; It reduces staff to a role in which they are forced to react rather than act on matters related to program planning and development. Further, the volume of contracts under review results in a workload which tends to delete staff time to the point that activities can become fragmented, disjointed, and uncoordinated rather then syntherieed into a solid program which addresses the region's needs. The program staff member was assigned to the project'or Job descriptions have been developed without stating the requtred qualifications, It was noted that the Assistant Director for Administration was appointed to this position and there are indications that she does not have the qualifications and abilities to perform effectively in this role. This is evidenced by the fact that the program has accrued $417,339 in unexpended funds during the past year. The team consequently recommended that a Management Survey Visit be scheduled early next year to provide the region with constructive assistance in the handling of its fiscal management activities. -21- RMP: Central New York, PREPARED BY: Jerome Stolov DATE: 10172 .13. EVALUATION (3) The site visitors observed that the region followed last year's advice and designated a program staff person as its evaluator. However, the training and experience of the evaluation director was in the field of education and not in analysis. The CNYRPIP RAG report recog- nizes the program's weakness in this area by stating the following: "Evaluation has been an extremely difficult problem for this W, although we believe that the problem is shared by many others through- out the region. We are hopeful our two-pronged effort to correct this problem will bear fruit: (1) Reorganize our Evaluation Committee along subregional CHP area lines and involve RAG members on site visits; (2) Institute an interregional RMP effort in evaluation, spearheaded by our organization, to bring standardization and more expertise to all of the evaluation efforts in the Upstate New York's The site visitors expressed concern that only one project had been evaluated prior to the RAG'S approval of the submission of the CNYRMP's annual application to RMPS. Although, the visitors recog- nized the evaluation of the Nurse-Clinician project, it was felt this procese should have been done prior to the deadline for submission, The evaluation of this activity was viewed as quite superficial and, in fact, was no more than pzogress reporting and discussion. 0 The new charge to the Review and Evaluation Committee is to eite visit each project twice during a 12-month period. jects, the Committee must also assees program staff activities and RAG functions. A task and a timeline plan for the Review and Eval- uation Committee has been established. In addition to the pro- The region is to be encouraged to implement the plan of the Evaluation Committee as portrayed in the task end timeline chart given to the site visitors. There is also to be involvement of total staff in the evaluation process, so that all proposals can be conrtnuously evaluated for continued funding or termination. is quite poor; however, there are signs that the future will see a substantial improvement if the current plan is successfully implemented. The track record for evaluation -22- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 t 14. ACTION PLAN (5) As stated earlier, 52% of the project requests are related to the CNYRMF's first objective, to improve the health care delivery of the rural, inner city and the medically disadvantaged, but there is a need for greater community involvement and commitment. The site visitors felt that the newly proposed activities were not realistic in view of the types and numbers of program staff presently on board. They further felt that theutilization of the mini-contract approach was unrealistic at this time and, in a sense, placed the cart in front of the horse. In this approach the RMP was asking the region-at-large to develop its program rather than developing its own program which it could present to the region's residents for their ratification. program is viewed as rightfully originating from the RAG members who should represent the region's health interests and not directly from people in the region seeking financial support to "do his thing" through a mini-contract. In view of the region's iequest to recruit ten key program staff members and recognizing that their planning and evaluation committees are undergoing reorganization, the CNYm's application which requests funds to manage 16 projects and 20 mini-contracts appears to be more than they can successfully accomplish during the next program year. on "Projects'' and does not involve the implementation of a coordinated, integrated program. The region's involvement in the formulation of the - Most of the current action plan is focused In summary, it appears the region needs to find a new approach to program development and it is hoped that new staff will alleviate the need to look for short-cuts and will permit the development of a well constructed action plan which effectively and methodically attempts to alleviate the health problems of the region. Recommended Action 15. DISSEMINATION OF KNOWLEDGE (2) An example of program staff disseminating skills is represented by the work of the Library Coordinator. Requests for inter-library loans were increased to 5,127 or 56.5% over the previous year. The Biomedical Communications Network handled 343 computer searches or -23- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 15. DISSEMINATION OF KNOWLEDGE (2) (Contd) or 64.9% more than last year. throughout the region some of the means they might employ in order to obtain additional funding to enhance their operations. Three hospitals have received National Library of Medicine improvement grants as a direct result of the work and training done by the CNYRMP Librarian. She also taught hospital persounel 16. UTILIZATION OF MANPOWER AND FACILITIES (4) Increasing the availability, efficient utilization, and capacity of health care while providing for continuing competency is a major objective of the CNYRMP. Several projects, namely, the Generalist Nurse Practitioner Training Program, health service/education activities, medical emergency technician training and Health System North directly address this objective. These projects represent 34% of the total requested project funds. Examples of approved mini-contracts for the current funding year which include the utilization and/or training of allied health personnel are: 1) Creation of a Neighborhood Health Clinic (an LPN and a community worker/nurses aid was hired with RMP funds). 2) Training professionals and paraprofessionals to work as a team in remotivation and reality orientation. 3) Geriatric Day Care Center. 4) Homemaker service for the Madison Company. 5) Establishment of satellite medical centers. 6) Expansion of Volunteer Childrens' Clinics to rural areas. 7) Comprehensive Home Care as a follow-up to Pulmonary Rehabilitation. -24- - RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 ; 16. UTILIZATION OF MOWER AND FACILITIES (4) (Contd) It is difficult to determine how much these activities will benefit the population in underserved areas. In an attempt to reach the underserved areas, the region is setting selectivity standards €or applicants to the Nurse-Clinician Program, applicants from rural and ghetto areas wifl receive high priority in terms of being the beneficiaries of the training provided in the Nurse- Clinician Program. The region through its health service/education activities is attempting to involve the health education institutions. The site visitors learned that CNYRMP is involving the Maxwell School of Government by having its Masters Public Health Administration candidates participate in evaluation and planning studies. School is commendable, providing the staff can adequately supervise this endeavor. These standards will attempt to insure that The idea of training interns from the Maxwell A bibliography on geriatric patients with chronic respiratory disease has been assembled by CNYRMP staff. Overall, the region is making a sincere attempt to utilize existing manpower and facilities and, in this instance, the mini-contract approach may have been somewhat helpful to them in their efforts. On the other hand, the approach to this problem is handicapped by the shortage of program staff and the need for a more systematic approach which a larger staff could make possible. 17. IMPROVEMENT OF CARE (4) The CNYRMP has utilized studies and data supplied by the CHPs. ALPHA CHP "b" agency, for example, has established improved ambulatory care as its main priority. Both proposals, #19 - Pulaski Model Rural Ambulatory Care Center and P40 - Satellite Clinics Serving Rural Areas, address the problem of improving ambulatory care which the CHP agency, from its vantage point, recognizes as the area's major health problem. The -25- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 17. IMPROVEMENT OF CARE (4) (Contd) Attempts to exploit transportation services are best shown by the CNYRMP mini-contract to the Geriatric Day Care Center in Canton. This proposal has enabled the contractor to bring patients to and from the day care center. this area. resolved by the CNYW intervention. on this effort. There is no public Transportation in Thus a simple, but highly significant problem has been The CNYRMP should be commended 'Jhe CNYRMP is currently working with a Neighborhood Health Center in Utica, the Pulaski Model Rural Ambulatory Care Center and the Rural Urban System of Health Care in an attempt to amplify the capabilities of each of these programs to being better ambulatory care to the areas they are serving. 18. SHORT-TERM PAYOFF (3) The St. Regis Reservation Clinic appears to promise early access to improved health services within the next year. already making additional services available to its rural population and is receiving assistance from the CNYRMP in this effort. It is too early to evaluate the impact the Nurse Practitioner Training Program will have on moderating costs of health care; however, it appears that this effort will add to the efficient utilization of personnel and result in an increase in the accessibility and availability of health care services in the region. There is reason to believe that the EMS project will enhance the availability and quality of health care in the next two or three years. The region has already begun activities which are designed to attract individuals and agencies to participate in its Bnergency Medical Service (EMS) project. It is hoped, that through involvement in the EMS activity, the people and organizations in the region will develop linkages with the CNYRMP which will result in additional activities which can be worked on in cooperative fashion. The Pulaski Clinic is In the overview, the CNYRMP has been making a contribution to the improvement of care in the region; however, this contribution will become more significant as the program continues to restructure and -26- - RMP: Central Mew Pork PREPARED BY: Jerome Stolov DATE: 10/72 , 18. "SHORT-TWM PAYOFF (3) (Contd) increases the size and competencies of its program staff. riding problem faced by the CNYRMJ? is the shortage of program staff and, until this is resolved, the programmapic efforts will suffer. Under the staffing circumstances this program has faced during the past year, the accomplishments in this area are commendable. Recommended Action The over- ~~~__~~__~~~_~~~~_~~____,,,,,,,,,,,,,,,,~'~~~~~ -27- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 19. REGIONALIZATION (4) Both the EMS project and health services/education activities are examples of activities aimed at multiple provider groups, the Nurse-Clinician project is located in a single provider insti- tution, the students come from all parts of the region. Although The CNYRMP plans to assign program staff to each of the four CHP subregions. will be in a position to encourage sharing of facilities and manpower on a regionwide basis, These coordinators, by proper exchange of information, The Health System North project is an example of how new linkages are being established with the University Health Science Center in Syracuse by providing for an on-going rotation of medical students, interns, and residents throughout the CNYRMP's northern area to provide health care in a section which is particularly short of physicians. This has proven to be an effective means of providing health care services to the underserved residents of this isolated portion of the region. New linkages between northern Oswego County and St. Josephs Hospital Health Center in Syracuse, and between the rural Susquehanna County in Pennsylvania and C. S. Wilson Hospital in Johnson City, New York are also being established. The region believes these preliminary negotiations will assist it to extend its program more effectively throughout the region in the future. The EMS project is expected to create a regionwide and ultimately a statewide network for communication and transportation for the enhancement of Emergency Medical Services and Ambulance Transportation Centers throughout all of New York. The region appears to be making headway in the extension of the benefits it can bring to the Central New York area. RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 - 20. OTHER FUNDING (3) The CNYRMP has attracted other funds when planning Project #46, Health System Notth. summer fellowship program because RMP funds could not be used to pay for this type activity. As mentioned earlier, three hospitals have received National Library of Medicine improvement grant funds as a result of assistance provided by CNYW staff. The E. J. Noble Foundation paid for the The team, however, was disappointed to note that several of the new projects being proposed appear to be mere extensions of activities normally conducted by other agencies. In spite of this, the CNYRMP approved them for RMP funds. For example, Project t28, The Well Baby Clinic and Project 845, A Coordinator for the Spanish Speaking Coummunity, appear to be services that should be provided by the County Health Department and the County Mental Health Board respectively. be in need of closer contact with RMPS and to become more familiarized with the specific nature of the RMPS mission. The Dial Access project is being terminated in September 1972. from the CNYRMP staff indicate that the hospital is exploring other governmental or commercial sources of funding; however, it does not appear that this program will be able to become self sustaining. Once again, it is possible to speculate that this project could be sustained if the CNYRMP program staff was sufficiently large and had the competencies required to provide the necessary assistance to the project director to help him find alternate sources of support. has apparently been a useful service to the region and may be the victim of inadequate RMP staffing. Thus, the CNYRMP program staff and the RAG appear to ___ Reports This The Nurse-Clinician Training Program, which is entering its second year of CNYRMP funding, has been encouraged to charge tuition for the training being rendered and thus become independent of the need for RMP support. It is hoped that this can be done successfully so the activity will not collapse when RMP funds are withdrawn. The development of the St. Regis Reservation Clinic gives no evidence of having generated funds from any sources other than W. Dialysis unit is also failing to meet its funding needs because there has been no success in having the A. C. Silverman Hospital incorporate the expenses of the unit into its per diem rate. The CNYRMP, in light The Home -29- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 20. OTHER FUNDING (3) (Contd) of the failure to secure the backing of the A. C. Silverman Hospital, is attempting to organize a Dialysis Buyers' Cooperative as an aid to renal patients. There is concern over the Pulaski Rural Model Ambulatory Care Center which has been funded by the CNYRMP for one year. to generate patient fees. It is encouraging to note that a local fund raising program has provided some funds and that five acres of land have been donated to it. major funding problem still remains unresolved. It has been unable These are temporary steps and the The mini-contracts, on the other hand, as a precondition to funding, have been generating other private, local, state and federal dollars. For example, one mini project is utilizing National Health Service Corps personnel to provide family centered primary medical care is also receiving CNYRltP support. Overall, the CNYRMP has not been successful at acquiring other sources of funding for projects they have initiated. program addresses the need for administrative/fiscal competence and is successful in bringing this expertise to bear on the development of projects in their formative stages --- the ability to sustain activ- ities will be limited, as is now the case. Until such time as the Recommended Action , -30- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 o Renal Disease Activities The CNYRMP has funded the Home Dialysis Training program, Project #6¶ and two feasibility studies which are currently in operation. requesting support to initiate Project 822, Cooperative Organ Bank of Central New York. It is The Dialysis Buyers' Cooperative feasibility study was found to be lacking specific objectives. working relationship between the patients and a local Kidney Foundation. At this time, the region lacks a Kidney Foundation and an effort should be made to encourage the establishment of such an agency which once established, could be helpful to the region's entire kidney program. The study also lacks evidence of a The Comprehensive Areawide Kidney Service feasibility study for the NY-Penn area appears to dovetail its objectives with those of the Dialysis Buyers' Cooperative feasibility study. objectives that could be measured at the end of one year. could also benefit if it were able to work with a local Kidney Foundation. Since most of the region's proposed activities are directly related to the functions conducted by the Kidney Foundation, they would be well advised to place high priority on efforts to get the placement of a local Kidney Foundation activity in their area to supplement the entire kidney program. The Home Dialysis project goal of training 12-15 patients per year appears to be non-specific. New York is in the range of 60 to 75 patients per year. capacity of the Home Dialysis two-bed unit and the stated number of personnel far exceeds the anticipated number of patients who need to be trained. In addition, the training facilities are now located in high cost, high overhead hospitals. region should take cognizance of cost factors in all future decisions. It too has no specific This group The end stage renal population of Central The training The site visitors believe the The goals of the Cooperative Organ Bank, Project 122, are too general. It was reported that only six tu nine transplants will be done in the first year. be a far larger number of organs potentially available and therefore it follows that a greater number of transplants should be possible. The past year only three transplants were performed and only 14 trans- plants have been done in the past four years. Unless the goals are elevated and unless the numerous organizations who are involved such as the Hemodialysis Committee, the Transplant Committee, the Consumer The project proposal leads one to believe that there would -31- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 Renal Disease Activities (Contd) Cooperative Committee and the Organ Retrieval Committee are coordinated, the region will be unable to care for its renal failure patient pop- ulation. this type of fragmentation. It was therefore recommended that a Regional Kidney Proposal be developed with a time goal that is realistic and related to the com- munity needs. Any future kidney planning should include provision for care of patients throughout the entire Central New York region and not be limited to the urban areas, i.e., Syracuse, etc. The Central New York area is uniquely suited for Home Dialysis and for this reason this aspect of the region's kidney program should be expanded. No kidney program can expect to be successful in light of With regard to the Organ Donor Program, it was suggested that this program needs to relate to other CNYW programs in the region. As an example, the Organ Transplant Center should utilize the Emergency Medical Care program to relate to communications and transportation of the organs. The trauma surgeons and neurosurgeons working in emergency services represent the greatest resources for donor kidneys. They must be included in the planning for the program in order to capitalize on the advantages they can bring to increasing kidney donations. The Organ Donor Program needs to develop a procedure list, permission forms, develop sterile containers for organ trans- portation and develop a perfusion device which can be placed in a centralized location and in a location which is well known to all potential users. developed. donation which will further increase the supply of organs needed for the region's renal failure patients. A cost and recovery schedule should also be Lastly,there needs to be lay education in regard to organ -32- - RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 SUMMARY The sense of the site visit team was that this program made a valiant effort during the past year to remedy the deficiencies noted during the 1971 site visit; however, the obstacles which they faced were insurmountable. with an Acting Coordinator and this was a difficult arrangement for him and an even more severe handicap to a program making an attempt to bring about required changes. Under the circumstances, the Director (now officially appointed) and his small staff must be cornended for their personal commitment and sacrigices made during this period to improve the program. The future for this program is viewed as promising in light of some positive developments noted during this visit. First and foremost, Mr. John Murray has won the confidence of the RAG and has earned the role of Director and, in this sense, can now begin to operate more effectively. Although the site visitors are convinced that Mr. Murray needs to sharpen his administrative skills, they share the respect and admiration of the local officials who selected him for this new role. Time and experience will bring him confidence and his dedication and determination to generate an outstanding RMP in Central New York will, in all probability,be realized to the benefit of the 'region's residents and RMPS. For most of the year the program was forced to work The program has added three new staff members and they will certainly reinforce the efforts of the currently overworked small staff. region is requesting ten new professional staff members and, in this request, the site visit team lends a strong endorsement. recruiting program should bring the competencies Mr. Murray needs to build the effective program he desires. The A selective There is little doubt that the program needs to enhance its planning. It must specifically identify where it wants to go and determine the best way to proceed. To effectively accomplish this, the.Director must receive help from the established Priorities Committee, Evaluation Committee, his RAG, and from the new staff he is planning to recruit. It ie essential that he make maximum use of these resources to develop a sound plan. In the area of fiscal management, the program faces a definitive need to strengthen its competencies. matter which needs to be addressed and resolved at the earliest possible moment. deficiency. This must be recognized as a priority Effective planning will be an aid to the resolution of this -33- RMP: Central New York PREPARED BY: Jerome Stolov DATE: 10/72 SUMMARY (Cont d) In all, the program faces a challenging year ahead; however, the site visitors feel the potential for success is on hand and are optimistic that the CNYRMP will have success in their efforts. ______-__._.-- -_- NTJKEIEX: 0050 COORDINATOR: Mr e John Mtir LAST PATING: 226 I-^ ---__.- Regional Office Representative: Robert Shaw TYPE OF APPLICATEON: 17 I_ Triennial -- i-7 Tri.ennial 5- t Last Site Visit : June 3, 1971 -. Effie 0. Ellis, M-D., Survey (Date) . ?, None \i I Presidents Amerlc.an Medical Association; Member of RHP Review Committee Henry Lemon, M,D., Member of W Review Committee, Professor of Medicine Nebraska Medkal School Alfred L. Frechette, N.D., Conmissioner of Public Health, Massachusetts Department of Public Health F. M. Simons Patterson, M.D., Executive Director, Association for the North Carolina RMP, Durham, North Carolina William Lawrence, M.D., Chairman RAG, Alaba RMP, Internal Medicine- Cardiol.agy, Bjmningkam, Alabama ELSE Jean Schweer, R.N., Director of the Division of Continuing Education, University of Indiana School of Nursing Chairman TRMP RAG Committee Staff Ykits Ln Last 12 Months: June 13-16, 1972 - Jimy Roberts, M,D.and Jerome Stolov June 8, 1972 Robert Shaw CW@P RAG Meeting April 12, 197? Marian E. Leach, P.Hu, DPDT, Staff Assistance regatiding health March 22-21r. 2.972 J. Stolov, Executi.ve Committee Meeting February 2-5, to December 1971-J. Stolov RAG meeting and Staff Assistance followup of advice Staff assistance regarding health service/educational activities service /education acttvitfes observe mini. cont.ract negotiation letter Recent event;& r~xm-ring in Aeograp1g.c area of Region that are affecting I. : July E, 1971 Experimental Health Services Delivery System Funded for the Ny Perm Area (southern tier of CNY) $275,000 -2- 2. Approved National Health Service Corps Sites (Cato Meridian, Chenago, Transfer of Neighborhood Health Center transferred to Medical Center Maxwell School in Public Administration offers degree in Public Health Memorial, Barnes Kasson, W. Winafield [Little Falls Hospital] Faxton Hospital Chateaugay, N.Y.) (Upstate Medical Center) Program 7/72. 3. 4. 4 -4- DEMOGRAPHIC INFORMATION Population characteristics: age distribution rural, urban, minority, income level, Health education institutions Pertinent health data Geography: The Central New York Regional Medical Program is comprised of 15 counties in Central New York, plus two counties in adjacent northern Pennsylvania. The boundaries were determined by Medical Trade Areas, Medical Education and part graduate educational patterns and to conform with the boundaries of the State Health Department regional efforts. The Region is approxi- mately 96 miles wide in its East-West perimeter and 271 miles long from the Pennsylvania State Line on the south to the Canadian Border on the north. populated Regions in New York State. square miles. Geographically, it is ore of the larger but relatively thinly The total land area is 26,016 Population: Approximately 1,800,000 Population density 68/square miles Approximately 60% Urban Approximately 97% white INCOME - Average Income per Indlvidual, 1969 United States $3680 State (of RMP) $4421 (NY)*--SMSA - $3154 AGE DISTRIBUTION - Median Age Approximately 30 Percent of Total by Specified Age Group, 1970 Age Group State U.S. Under 18 yrs. 33 35 18 - 65 yrs. 57 55 65 yrs. & over 10 10 METROPOLITAN AREAS Name of SMSA Population (in 000's) Total 1,263.0 Binghampton NY-Pa. 298.0 Syracuse, NY ** 629.2** Utica - Rome, NY 335.8 ** - 197G Census for Metro area - increased City of Syracuse - 197,000 total population; from 564,000 in 1960 incl. 21,000 Negro (about 10.8%) ., . .. .. .. . :. . . ,. , ... ... ,. '. .. i ". . .. . . .. Y -5- FAGIL I T I ES -__I_ 1 1.n New York State there are 48 hospitals with general medical and surgical. beds or a totai of 7,564 acute care beds and four hospitals with extended enre IacilCties with 472 beds, in the Central New York region. tions have less tliari 1.25-bed rural character of the area, and the need for smaller hospitxl units to ser've large geographic areas. The largest portlor! (60%) of beds is, of course, predominately in the group of hospitals which have a larger than 200-bed capacity. It is sipnlficant that more than 60 per cent of these institu- In Pennsylvania there are five hospitals in the area with a total number of beds of 475. Four of these hhve under 50 beds and the Robert Packer Hospital hac 305 beds. Packer Hospf td, die Gurhrie Clinj c which has approximately 50 full-time practicing ptryaicions organized in a group practice. 'There is associated directly with the Robert Personnel Physicians - '2here are approximately 2,700 M.D.s (133/100,000 and approximately 15 D.0.s Nurses - There arc 2pproximately 15,000 registered nurses of which only about 9,OOc) are active. Peptinent Health Data MORTALITY RATES, CY 1967 MORBIDITY - ILLEIESS RATES (1965 - 1967) Deaths per 100,000 Population --.-1- Rates per .l??qersons, by $e Group Cause RMP (State) U. S.196 Pera:,ns w, X with 364.5 Age Group act1 te cond. chronic cond. Heart Disease 437.4 -- -.-. -_------ I Age 14, EaSL N.East Group Ge%a5-,G$L IJ . S . Eeog .Reg. U. S. Cancer 186.4 157.2 All Ages 1'94.9 190.2 47.0 49.5 Vasc. lesions 88.8 102.2 45-64 yrs, 119,9 124.5 64.5 71.1 All causes, 1019.4 935.7 (aff. CNS) --c 65 & over 107.9 103.4 80.6 85.6 all ages 45-64 vrs. 1143.9 1.143.5 65 & okr 6168.8 6042.5 -6- HEALTH EDUCATION INSTITUTIONS COUNTY-INSTITUTION St. Lawrence Clarkson College St. Lawrence University SUNY ** College at Potsdam SUNY Agriculture & Technical Institute at Canton Had is on Colgate University Hamilton College SuMl Agriculture & Technical Institute at MOrrisVf1le Cazenovia College Tompkins - Cornell University Ithaca College Broome SUNY University Center at Binghamton Broome County Technical Institute Onondaga LeMoyne College Syracuse University Onondaga Community College SUR Upstate Medical Center PROGRAM (Special note of paramedical programs) Technical Institute Liberal Arts Liberal Arts Nursing (2-year program) Lib era1 Arts Liberal Arts Nursing (2-year program) Practical Nursing Medical Laboratory Technology Nursing (2-year program) Sloan Institute of Hospital Administration Graduate School of Nutrition Physical Therapy Health professions programs in planning stage Medical Technology Dental Hygiene X-ray Technology Liberal Arts School of Nursing, Special Medical Dental Hygiene, Medical Laboratory Medicine, Nursing, X-ray Education Programs Technology Technology, Medical Laboratory Technology, Graduate School -7- Cor t land SUNY College at Cortland I. Oswego SUNY College at Oswego Health Education Liberal Arts Oneida Utica College (of Syracuse University) Mohawk Valley Technical Institute Nursing Medical Technology Cayuga Auburn Community College Associate Degree Program Jefferson Jefferson Community College Associate Degree Program Hospital Schools of Nursing (Three-Year Diploma Programs) CITY - COUNTY -HOSPITAL 0 - St. Lawrence A. Barton Hepburn St. Lawrence State l-r Cayuga Auburn Memorid. Broome Binghamton General Binghamton State Charles S. Wilson Onondaga C rous e- Irving St. Joseph's Oneida lrlarcy State St. Elizabeth's Utiea State Jefferson Mercy House of Good Samaritan Ogdensb ur g Ogdensburg Auburn Binghamt on Binghamt on Johnson City Syracuse Syracuse Marcy Utica Utica Water town Water town -,IC L:. .> hi./e2 Pedi Zt ri c Pu lxonary GI ECT COSTS 04 Year * c_-- S 341,745 . 196,000 \537,745 / - .-- s 850,090 * - per award dated 12/3/` `05 Year 653,205 ( 44,660 ( 91,062 (- ,142,320 ( ' -- ( -- " - ~~ 1,420,349 c /--/ so - I I 3 I 1 .. ._. _. . . , 8 -_ --- PYPS=CSt'-.? ,.( i..' ._. 1 .L . _. I. e .. . ..- -.._ - -...- ._ .. .. - . --. ~ -.- - - . - -. - .. REGION - BREAKCUT CF REQUEST RH 00046 - 06 PRoGRkr PERtQO -- -- - .- .. 1 TOTAL I 1 1- 1 ALL WLRS 1 lotR€CT COSTS I I -.- -a ..- BREAKCUT OF REWEST-- ,_ . .. 06 PROGPIH PERIOO (2) I43 ir, CCNT. BEYONO1 APPR. *Of I NEY. NOT APPR. PERICCI PREVICUSLY I PREVICUSLY OF SUPPORT I PWDED ___ I APPROVE0 I I I I . __-_ ._ . . . .__..- -.-- .. ... . .. . .. .-_. . .-. ^.. . . . , ., . *. , .... -- . . . _- . -. .. ., .- _I_--- --_.--. I~ _-_. . ____.._._.__. - 1 i i I k. 'i 1 t I I i ! 1 i I I , , t I I I I AMs StPVICE ____I____ -I__ KMPxLoS*-JTCFh, S ALL RECUEST bhC bhbRCS AS Cf JbLE 30, 157 R CEtlCIbL tEOICOl -. - -.---_ - _I FUhOlhC HI>., LIST REGlOh 4b CEOFGIl, FUp SLPP YP 04 CPEPPT IChIL CPbNl--!CIR€CT COSUNLV) b WARDED AkAfiOtO AIybPOEO AhPRCEC ArARCEC __ ** >€CU€ST€C RECU-E~EC RFouEST€O REQUESTED b v 7WFt h EN t 01 02--- - 0, c4 ** 05 CC or - - NO TITLE - - --- - 09/71-12/12 TCTbL ** -0J/'733Z/l3 C1174-12/14 C1/7+12f75 fCTbL IO - CCCC ___ PRCGFAP - - ._ __ SlbFt 770000 761 300 64R400 8€~C7 3cc_s1c7 ** 1C.lC4 734107 1440401 la ci90 CEV AREA PRG tis CttCC m700 ** 21284 ** - DO02 b hUFSE MlCYIFE *+ o ** (1 120506 i205000 ** 117986 177906 355972 .-- 0000 C€bELtFIEhTbL F - DO01 IUPP OLEO Pi2 IWAC 2?281 OCC3 irFPcu% FPIW~R 1os7e iom *+ I 0004 IVPQOVFD PP I'AR 10530 10.S30 ** 7920 79zC ** DO06 I~PROkEO PQ IPAR cos a0 - fcicc c --- 4 1 CC- 25731 238231 *+ 001 - CCAFEFENCfS- fCR 0015 COhF FCR IHPPOV OOlC CCPF FCP IPCPCV -13 ocS.-tcr y L F. I TTS 3 L 7 931s -._-_ 931s ** - - OClA .CCM FCP IIPPOV -. - **- lCCOC LOO00 20000 ** 10000 10000 2OOCC I . ** 10000 10000 2000e 002 POST RES10 TR P io 400 20000 fO400 *- C034 VI 51 11 hG CChSLL ** 3COOC 30000 60000 c_ -- - - - -- - 003 ~ISIT~G cnNsu - qaao_- __ -_ 245CC 2lCCL _____ 43333 91833 +*- . ,- - 00.8- V 1s IT ING CONSbL ** ______ 15000 * 15000 3oacc 004 IhrEeiie sEw t 23100- 23?00- ieoc 4e2cc r 4 /. t I i OC5 COLURLS UC EYtR 367CC 42_POO 21300~ 10750 ** cce crcao c\r& tb0 E 86800- I_ 105100 - 3 067 C k' I U h3- f 1 ON S 522SCC 359scc 14PtCC !O27000 ** z04500 I*- 12600-- __ 5 - 011 CC ECUlP SR HCS 19700 34200 - lO0OC t3tCC ** i& t9bCC 1A37CC 1270C 256000 ** gyl f 2-010 CPPf PPG SThDE - _I- - -___ -- 013 SIAIEIIOE CINCE - tZ55CC - 40 1300 234100 219 133. 1080033 ** - 013~-STbTthlEE CANJE ** 122550 122550 24:JCO i - 0131 STLD CA FPOGPbC - -- - - -- - __ 5ooc 5cco - 013L SThC -_ Cb CPrCPPC ** fa 0-c scqo . 10000 0131 SThC C4 PROG6AP ** scoo 5COO lCOC0 OL3E SThG Cb F?CG&AP ** ..act 5000 10000 - 013F SThtFWlCE CdWCE 0136 STbC Cb FPCC A6 14CCC . 10000 __ - ** 1000 taco - ** 5000 5000 10000 * -- I - -- --- ** I- 5000 5000 tocco j.. , 013J STUI: CI PPOCPPM ** 5650 __ ._ 5450. 109CO 10000 ICCCC * - ~ __ - *+ - --- I *I -_ 5000 - soco - __ ___ - - - 013b STbC Cb FPCC bF - 0132 SThC CC PPCC bP -_ 014C-REC-PFCl~~RIC R %* 333cc 13332 466?2 C13Y ZTtO C4 FPCG 4P ** COO0 50CC 014 PEG FEClalPIC P 133600---- 170800 015 TPhG PFG MFC SP 387CC 685CO 44?CC 151500 ** 1 Olt Plbh ClT HSP S 017 COWC PUB INFO A ictcc 23ccc 43600 ** OZCB 4PEA FACILITIFS ** 153CC 19 3CO 11410C- 733?? 451eP3 ** .-- - 28200-- I__ -- __-_ - - 28200 ** ~ _____- - - --- -- - 396COP . - -_- - 020 AREA FACILITlES - 84200 t8lCC - 249564 4ClEC4 ** ___ - 023C_CPE~.@tC ll_!TtES *I 1_57GO 1_5_700 314CO la O'CE C?FP FACILJIIFS ** 5170C 51 700 ' 103400 ** lC60CO 10 02CG bPEb FACILITIES ** 53000 53000 -- -- - --I----- -_ - __ -** 12zcc lzzac- 24400 704CC . - -- 352CC ?520C L -- - II_.OZCF AREA FACILITIES - - - 9 - G2Cl 4REA FACILITIES 6 021 CEV SYS CF cc 1 13600 13600 272CO L 4CZCC -+L. I L - o 020s LPEC FICILITIES . ** seoc * - OZCV - APE* --__ FlCILtllES ** MOO 11600 9 -~__ 022 PHvsroicuLcR. __ ..-.-2610o - 14JCC 531CC WO5C A02750 I* I .I I- - - It ! I i -' !' 023 S€N FAIL TRN DE 3moo 79400 67200 SOZOO-* o --mncfiriorrm CY 43ECC ?64c7--- 217333 ** **67600 6'ICCC 027 CCCPLNITI HYPER 64000 133333 __ 028 CEV CCCPP STATE moo l4lOC 511cc ** --027RFCOPWUNITY H'tP -0 2 9 7 COP- ED -S ER V-CFi4O-b -19 80 0-* * 030 FAClCITY PLANNI 51cc 3242C 38120 ** -C3 CTf 8C I L-I TV-CI A h-b -0llA CVd 4REd fbCfLf 0310 CVA APFI FACILI -0 3 1 F - CV b bR EA- F AC I L I 031G CLA bPEb f4Clll O3lP CVb dPEb FACILl -03lP CVd-4PFA FACfLl 0315 CVA APE4 FACILI -032 STeOKE 4RFb fAC 0321 STPOKE ARE) FbC 73 2N7 T FdlTTm n-Fb C C3ZT STPCNE AFEC FPC L 25040 I ** 2:coo 27600 552CV ** 27606 ** lJFOG 19800 39600 * *- (r16003160C 632CO- 34800 *c lTC00 ** r: dq05C 379560 2.IU10 ** . 031 CAPC IOV4SCbL4Q. - _- - --- 17400 415 6-72) C E o ** SC~OO i L 3400 13400 26800 c: 73 TJTbL-IUTFTCI11 - **tlCOC- 2190b *MOO- .* 12500 125CO 25qa 11200 556CC 1 53200 Ii 325CO i 35oco mi00 ** -- -13400 ~ 13406 ** i4oac L40CO 28000 *I -- 15000- 15000 3CCCO. c ' 10 t 7 6 39 76.644 7 6-* *-- - ** 56CC 5toc 278CO ** 27800 zoccc 266CO *t 22161 10333 ** 35000 I -~ - I I IZ?Q---f 13 2y9-* *-- E-036 --a KICNEY CIISEAS--- $ 0368 FECICNLL NEPI-PC _--...-- - ** - 2 2 1 t 7 -0 3 f 332 5 00- k ** 3 too0 e -C!G PEtlChAL hEPtiPC 03t~ PE~AL iaEt FICI -0 3 t X-6 E h A 13R T-bF A C I 037 AREA FACILITIES -037E PES CIS IAEA FA 0375 PEZ 015 /REA FA -0371 RESP 015 AREA 7 -63e-E vE fiGV7. LPETUU 03614 EWEPC CbPE FOR -C41' CETECT AhC ECfM -042 FLbh SlUC SYS c---- C42R PLAh ZlkC 5YSTE -0 4 20-F L A N-S T W TSV 51 E 043 PAfrEFT bhC FA? 0436 PAllENf AND PAY 043F FATIEhT tNC fbH -C43C PlilIEhl AhC FbP 043'4 PATIENT AVO FAH .* 13000 -- \. 268CO- 41291 ** 41291- - _--_-....-- - -. __._-_-- ** 17600 16400 34000 ** 93000--. 93000 186455 ** I * 1860CO 1~64~s 037x UESP crs APE& F 102SC- --- lO2S0 ** --- 4e2ec ** -- .- 482ac-- -- _--I_ ---._ ** 55oc __I__ ___- . 9?.C$-.-- 0418 cftec AND ELI~~ 3998 * ** 170CC 17390 .L 5 570 0 29255 e4555 61100- 11600 10000 1600 16300 3 13ccc 50?3-2--*__-lrC332 ** ___ 461CO \ 150cc- 12oco-- 2 ** ** *+ -- ----- -- 2300 L -- ---I__ -- -..____ _-- 82-04 5-PP CG-T C--F X P P h C- I4CCC IIICCC ** ! ~ i. i -4 .. , j J 1 -18- Rcgion : Review Cycle: IW/L /- 11IS'TORICAL PROGRAM PROFILE OF REGION Georgia Regional Me'dical Program's initial planning year began on January 1, 1967, the region became operational on July 1, 1968 and it obtained triennial status on September -1-',- L971, GRMP includes the largeet geographic River, and is characterized by large rural areas sparsely populated with small hospitals and generally inadequate health facilities and services. This region is looked upon as one of the more progressive regions, and has a good concept of the probleuis and resources existing within its boundaries. No really serious problems have plagued this region, area east of the Mississippi -I One concern during GRMP's early stages of development was its weak evaluation process. The region responded extremely well to this concern and now has an excellent evaluation process. An evaluation specialist wag added to the staff. New directions now allow each approved program element to have a specific evaluation'plon drawn up by the program assessment coordinator and the project director at the time of pro3ect design. Implementation of the plan occurs shortly after funding. Last year, program involvement with other Federal programs (CHP, Model Citkes, Appalachia and OEO) was rather limited and consisted of cross-representation on advisory groups and cross-review of applications. GRMP is now participating with these agencies in developing their health program in addition to reviewing their applications and serdng on the advlrsory groups. The primary, care problems of the underserved urban population was one area Of concern that GRMP has not, until recently, addressed to any degree. Developmental component money is now being channeled into projects centered around health care delivery to the rural and urban poor. Four access stations make use of allied health professionals to assist physicians to better serve patients in their geographic areas that are remote foom the physicians' office. Originally, the Steering Committee consisted of six members of which only one was a non-physician. In order to correct this situation, the Bylaws Committee recommended that the membership be increased from six to nine members with at least four of the nine being non-physicians. This recommendation will become effective in the fall of this year. Lack of stimulation of activities at the Local Advisory Group level is a problem that the region dealt with through its subregionalization process. GRMP developed the "area facility" concept which basically provides-miRimal , financial support to selected larger community hospitals for the purpose of expanding and extending appropriate health services to the smaller -19- ale and health professionals in their area. Thirty area facilities ntinuing education and categorical diseaee are presently supported. aa Facility Concept is explained on pages 1 thru 7 of the present the week of August 14-18 and will be available to report on this cation. Staff, at the request of GW, plans a visit to the region of the total program along with the region's health access stations, tc,, when the application is considered. elve projects have successfully been terminated by either receiving rt from other sources or having had elements that were absorbed into rojects o The Phyeiology for Nurisng Instruc tors Course (Project 522) minated by Council because it was difficult to see the relevance project to the goals and objectives of the program and how it could relate to increasing the availability and accessibility of health care. The duration of most of the terminated projects was two and three years. GW has been considered by Staff, Committee and Council to be a strong program with good management and organizational strengths, excellent leadership, involved and conrmitted State and local relationships, Excellent ation exists between the two medical schools. e emergence of Emergency Medical Service activities through $100,000 supplemental funds to provide the planning for a total EMS system June 8-9, 1972 visit. -20- Region : Georgia Review Cycle: 10/72 STAFF OBSERVATIONS Principal Problems: Recommendations from last year's review cycle revealed GW's problems to be those of a weak evaluation process, lack of program development to serve the health needs of the underserved urban population, the need for broader lay representation on the Steering Committee and lack Of staff assistance to other Federal programs in developing their health programs. Principal Accomplishments GRMP has the capacity to adjust readily to changing priorities. present application reflects definite response to the specific recommendation,s in last year's advice letter. force reorganization to allow greater responsiveness to the new mission of RXP and reflect the three lirajor program areas of interest to GRMP, additions to and change in the Steering Committee structure, and some slight reorganization of program staff to permit the setting up of an operations division. The There has been a task GRMP has matured to the point where emphasis is now being placed upon working with larger community groups responsible for local and area planning, such as CHP(b) agencies and Area Planning and Development Commission of which there are 18 in the state instead of working with the Local Advisory Groups. National Health Service Corps in site selection and in obtaining medical and dental society approvals for placement of health professionals in areas where health services are inadequate because of medical personnel shortages. GRMP staff is cooperating with the Three program areas which reflect GRMP's thrust for meeting local and national priorities are manpower development and ultilization, specialized services, and primary health services. Taek forces in these areas of competence develop goals, objectives and priorities. recommend. appropriate strategies for reaching these goals and objectives. GRMP should be noted for the rapidity with which it was able to move into primary health care by ultilizing developmental component money for planning and implementing the access shation concept, a regional midwife service and pbnning a multicounty rural primary care system. They also Overall, GRMP is characterized as being one of the better managed and organized regions. No previous problems have existed to decrease its funding during the past year. . - ._ I .. .. . -_ -2 1- Issues Requiring Attention of Reviewers GRMP has an approved triennial program of which it is requesting the second year funding. The request does not exceed the N.A.C. level. is to fund the region at the approved level for its second triennium year. Staff '8 reconnuendation after reviewing this application SCOB/DOD/RMPS 8/10/72 ~ .a I- > n P fD u. 0 0 n, n 'd l-t l-t 0 n, a a 8/ rt fD W 0 ?tl e i 1 .. .. . .. . .' i 1 F. ... ,' .: r. I; 1, ~ _,. .... -*. 7 5, , 1; 'j c r: i r' .- J 1 .Region HAWAII RM 00001 Reivew .Cycle October 1972 Type of Application Triennium Rating 309 Recommendations From rn Review Committee .- - SARP Site Visit Council endation: The Committee agreed with the site visitors and recom- mended, that the RMPH's triennial application be approved. Funding Levels 05 Year 06 Year 07 Year (1/1/73--12/31/73) (1/1/74--12/31/74) . (1/1/75-42/31/75) $1,805,488 $1,689,213 $1,670,577 -.. 0- I/ 150,000 150,000 $1,805,488 $1,839,213 $1,820,577 request for the 05 year was not approved. Total funds recommended for RMPH include earmarked funds for kidney project #47 and the Pacific Basin Area. recommended for the kidney project W47 is $15,000 less than the site visit recomendations. The fundiiig / Because the RMPH has not completely satisfied the management and review process requirements of RMPS, .the developmental : levels in the following amounts for the Pacific Basin Area. Committee endorsed the site visitors recommendations that KMPS earmark funds from the RMPN's three-year recommendea 05 Year $299,700 06 Year $288,221 07 Year $299,110 e was impressed with the site visitors' favorable report on the progress of the R4PH during the past year. change in the direction of the progfcam along with increased productivity. There has been a significant The Conmittee com,endcd the increased Insolvcraent of the F,7iPH in the PaciLi.c Basin, The gosls, ob,ject:.ives and priorikics of the Basin are reflected by the €unded prctjec Ls a /\iso, the represcntatives of the Basin are beginning to consider themscLlves a part of the FNPI-I, and are atteixpting to see hos: the Basin can relate to tlie program of lawaii, Areas of concern requi.ring IW'S at tenticin during the conling ycnl- are: Region: Hawaii RM OOe' ' Review Cycle: Octobe Component GRAM STAFF & PROJECTS LOPMENTAL COMPONENT, EMS hs/ea Pediatric Pulmonary Other TAL DIRECT' COSTS COUNCIL RECOMMENDED LEVEL ._ COMPONENT AND FINANCIAL SUMMARY TRIENNIAL APPLICATION Current Annualized Level 04 Year $1,405,185 $1, 102,000 Requt 1s t year (05) $1,886,223 . 287,583 ( 90,488) c 1 c 1 ( 1 c' " $2,264,294 ,t for Triennial . 2nd year I 3rd year (06) (07) j1,780,150 $1,420,276 287,583 287,583 39,213 20,577 Committee Recommendation for Counc 1st year 0 ,730,000 -0- 75,488 , 80 5,488 .-Approved 2nd year (06) I , 650 , 000 150 , 000 39,213 1,839,213 ,eve 1 3rd year (07) . , 650,000 >SO , 000 20,577 . , 820,577 JcIncludes $1,470,645 direct cost.for EMS project. These funds are for two years but were totally awarded during the 04 year for RMPS administrative purposeso t VI t SITE VISIT IiEPORT REGIONAL MEDICAL PROGRAM OF WLWAZI, GUAM AND THE TRUST TERRITORY OF THE August 7-8, 1972 AMERICAN SAMOA, PACIFIC ISLANDS , Site Visit Participants: Leonard Scherlis, M.D., Chairman; Member of the Regional Medical Programs Review Committee; Professor of Medicine and Head, Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland Mr. Edwin C. Hiroto, Member of the National Advisory Council on Regional Medical Programs; Administrator, City View Hospital, Los Angeles, Ca 1 i f ornia Mr. Kenneth Barrows, Bankers Life Company; and Chairman, Regional Advisory Group, Iowa RMP, Des Moines, Iowa William I. Holcomb, M.D., Private Practitioner; and Member, Regional Advisory Board, Oregon RMP, Eugene, Oregon - -c--. .- . _._ ._ RMPS Staff: Mr. Richard L. Russell, Acting Chief, Western Operations--Branch, DOD &. Calvin Sullivan, Western Operations Branch, DOD Mr. Ronald S. Currie, Program Director, RMP, Office of the Regional Edward 5. Hlnman, M.D., Director, Division of Professional and Technical Health Director, DHEW Region IX, San Francisco, California Development RMP of Hawaii Staff: Masato Hasegawa, M.D., Executive Director MrW3*Chnar A. Tunks, Deputy Director Alexander Anderson, M.D., Consultant in Medical Care and Quality of W,riClyde Winters, Consultant in Medical Information System Miss Susan Chandler, Assistant Director, Community Health Mrs, Rosie K. Chang, Assoc. Director, Allied Health Manpower Miss Manolita DeJesus, Office Manager Satoru Izutsu, Ph.D., Assoc. Director, American Samoa, Guam & Trust Territory Kame Kaku, M.D., Biostatistician/Epidemiologist Mr. Ross Ramelmeyer, Assoc. Director, Planning and Systems Analysis Miss Florence Katz, Assistant Health Planner Mr. Michael Rodolico, Assistant in Systems Analysis and Evaluation Mr. Norman Kuwahara, Assoc. Director in PPBS and Comptroller Medical Care Page 2 - RMPH Site Visit Report, RM 00001 RAG Members in Attendance: 51 4 Mr. Edward C. Bryan, Chairman, RAG; Executive Committee Member; Castle 9 Mr. Ollie Burkett, Vice-Chairman, RAG; Executive Committee Member; William M. Peck, M.D., RAG Representative fromMicronesia5 Trust t; Cooke, Inc., Honolulu, Hawaii * Hospital Association of Hawaii, Honolulu, Hawaii Territory of the Pacific Islands, Office of the High Commissioner, Saipan, Mariana Islands Public Health, Agana, Guam ., Mrs. Betty S. Guerrero, RAG Representative from Guam; Department of Hn. Curtin A. Leser, RAG Member; Hawaiian Electric Company, Honolulu, Hawaii Mr. Stanley B. Snodgrass, RAG Member; Administrator, Convalescent Center Mr. Albert Yuen, RAG Member; Admin. Vice Pres., Hawaii Medicai Service Mr. Harold H. Ajirogi, Sr., RAG member and Executive Committee member; Mr. Ligoligo K. Eseroma, RAG Representative from American Samoa; District #l of Honolulu, Honolulu, Hawaii Association, Honolulu, Hawaii Program Officer, East-West Center, Honolulu, Hawaii House of Representatives, Legislature of American Samoa, Fagatogo, American Samoa Herbert Y. H. Chinn, M.D., RAG member, Alexander Young Building, Honolulu, Hawaii . .-- .- - pthers : William E. Iaconetti, M.D., President, Hawaii Medical Association, Mrs. Sylvia Levy, Officer, Comprehensive Health Planning, Department of Miss Edith Anderson, Dean, U. H. School of Nursing, Honolulu, Hawaii Mr. David Pali, President, Waianae Coast Comprehensive Health & Hospital Mrs. Claire Ho, President Elect, Hawaii Dietetic Association, Nutrition Mrs. Mary Lee Potter, Executive Director, Hawaii Nurses Association, Terence Rogera, Ph.D., Dean, U. 11. School of Medicine, Honolulu, ,Hawaii Mr . James Bunker, Exec. Vice Pres iden t , American Cancer Society, Hawaii Livingston Wong, M.D., Alexander Young Bldg., Honolulu, Hawaii Mr. Jerrold M. Michael, U. H. School of Public Health, Honolulu, Hawaii Mr. Mark Sperry, Assistant Director, Health & Community Services Council of Hawaii, Honolulu, Hawaii Mr. George Moorhead, Assoc. Director, Health & Community Services Council of Hawaii, Honolulu, Hawaii Mr. Pat Boland, Asst. CHP Officer, Comprehensive Health Planning,, Hono lu lu , Hawa i i Miss Margaret Makekau, Asst. CHP Officer, Comprehensive Health Planning, Honolulu, Hawaii Honolulu , Hawa i i Health, Honolulu, Hawaii Board, Znc., Waianae, Oahu Branch, Department of Health, Honolulu, Hawaii Honolulu, Hawaii Division, Honolulu, Hawaii , 0 Page 3 - RMPH Site Visit Report, RM 00001 Others, Cont.: H. Tom Thorson, Exec. Director, Hawaii Medical Association, Honolulu, Hawaii Mr. Raymond Lilly, Administrator, Waianae Coast Comprehensive Health Center, Waianae, Oahu Mr. Robert W. Rhein, Asst. Administrator, Waianae Coast Comprehensive Health Center, Waianae, Oahu Mr. Alexander Charter, Project Director, RMPS; Vice President, -Syracuse University, Syracuse, New York Miss Jane Arakaki, Consultant Dietitian, Hawaii Dietetic Associatibn, Maunalani Hospital, Honolulu, Hawaii Mr. William Coops, Administrative Officer, Research Corporation of the University of Hawaii, Honolulu, Hawaii INTRODUCTION The main section of this report follows the RMP Review Criteria and concerns primarily the activities of the RMPH in the State of Hawaii. A separate section is included on the RMPH activities in the Pacific Basin. 1. GOALS, OBJECTIVES, AND PRIORITIES (8) The current goals, objectives and priorities were established in 0 1971 and represent a change from an emphasis on categorical diseases to the development of a program to assist in the improvement of the health care delivery system. flexibility in programming. The criteria for setting priorities on projects and staff activities are in line with the State's CHP efforts, especially those relating to the accessibility of better health service to the medically underserved areas of the Region. reevaluate the current goals and objectives and update them if necessary. The goals are broad and allow the RMPH considerable The RMPH RAG plans to The team was extremely encouraged by the current program direction of the RIQH. There was, however, concern that the RMPII might well find , itself werextended in terms of its organizational capabilities. The team emphasized that the RMPH must realize its full responsibility for successful programs, a responsibility which includes more than financial support and RMPH goals. RMPH grant recipients 8hould be made aware that their projects are part of the RMPH and must conform to the established RMPH procedures and reviews. This concern will be discussed further under the Action Plan. Page 4 - RMPH Site Visit Report, RM 00001 Recommended Action: should be realistic in terms of what can actually be accomplished rather than what it would like to have accomplished. In reevaluating its goals and objectives, the RAC 2. ACCOMPLISHMEWTS AND IMPLEMENTATION (15) Tbe RMPH's efforts of past years are now resulting in concrete program The RMPH has definitely established its own separate identity results. as a cammrnity leader in an extremely complex social environment, In the process of development, the program has gained support and involvement of the community's power structure, or t8establishment,t8 and the conanunity itself, or the %onestablishment." staff has been developed. of all key staff in some of the major program areas. The change in' direction, enthusiasm, and productivity of RMPH is impressive. considerable progress has been made by the RAG in taking corrective measures in response to the Review Process Verification and Management Survey Visits conducted by RMPS staff in May 1972. A competent, dedicated and.enthusiastic There has not been, however, adequate involvement Further, Recommended Action: The RMPH be encouraged to continue to build on its experiences and successes thereby strengthening its administrative and review processes to develop a fluid and adaptable structure so that the RMPH is able to be flexible to achieving its goals o 3. CONTINUED SUPPORT (10) The team found this to be and could not identify a clear meet the different needs that arise in a particularly weak segment of the program RMPH policy aimed at developing other sources of funding for successful activities. evidence that decremental funding had been considered in reviewing proposals. It is expected that the cancer chemotherapy project will be funded by the American Cancer Society and the National Cancer Institute upon completion of its fourth and last year of RMPH support. Further, there was no The Medical Care Review Organization project has been supported since June of 1971 by the NO, HSMHA, as an experimental project. discussing long-term funding of this project, RMPH representatives reported that eventually the participating hospitals would share the cost. or not the private physicians would be willing to share the costs is not clear at this time. In Whether Recommended Action: The RMPH should require grant applicants to incorporate plans for developing other sources of funding for successful activities from the inception of the project. the possibility of applying decremental funding to the projects in the triennial application. FLlrther, consideration should be given to L I * Page 5 - RMPH Site Visit Report, RN 00001 0 4. MINORITY INTERESTS (7) It is difficult to address "minority interests" in Hawaii as the term is defined on the mainland. Of the 750,000 people of the State, 150,000 are Hawaiian or part Hawaiian, most of which are at the bottom of the social and economic scale. Other minorities include descendants of the people brought in from China, Japan, Puerto Rico, Portugal, and the Philippines to work in the plantations. but unable to obtain land. The team believed that the RMPH is addressing the r'minority interests" by placing high priority on making better healtb care accessible to people in medically underserved areas, as evidenced by the RMPH support of the Waianae Coast Comprehensive Health Center project. The Waianae District historically has had one of the poorest health profiles in the State, according to standard measures of health, including incidence of serious commtnicable diseases and chronic health conditions, incidence * of restricted activity and bed days, lack of prenatal caE,e, and incidence of infant mortality. These minorities are land oriented Recommended Action: The RMPH should be encouraged to pursue its interest in addressing the problems of the medically underserved areas. 5. COORDINATOR (DIRECTOR) (10) There was no doubt of Dr. Masato Hasegawa's dedication to the RMPH. A significant amount of the program's accomplishments was attributed to the strong leadership he provides in the community and his ability to bring together diverse groups, Further, Dr. Hasegawa relates well with the RAG, especially its chairman, with whom he has regular and frequent meetings. Prior to the visit, one of the concerns of the team was that the Director was not allowing his deputy to function in an effective manner. RMPS staff members noted a marked change in the degree of responsibility the deputy had assumed in implementing changes in response to the manage- ment survey and review process verification visit conduct of the site visit. Dr. Hasegawa openly admitted that in the past he had not delegated appropriate authority and responsibility to the deputy. Further, he stated that he realized appropriate delegation was necessary. While the team was encouraged with the Director's change in attitude, there was some evidence that it might be some time before the deputy's responsibilities and authority would be fully established. conflict, apparently one of personalities, exists between the deputy and comptroller. Further, the deputy, in a private session with RMPS staff, reported that he does not have access to fiscal information from the RMPH comptroller. The arrangements are that if the deputy needs fiscal 0 reports, and in the A - Page 6 - RMPH Site Visit Report, RM 00001 information, he must ask Dr. Hasegawa who in turn gets it from the comptroller. separate meeting which will be discussed later, also voiced concern about not being able to get information from the RMPH comptroller. The withholding of information by the comptroller appears to be condoned by the Director as a way of controlling the type of information he wants released to various individuals. 7 Representatives of the Hawaii Medical Association, in a L Recommended Action: to use more effectively the deputy and for recognizing the need to delegate more responsibility and authority accordingly. deputy's role be fully clarified and documented for the RAG and program staff. cmications between RMPH staff and the RAG and strengthening coordina- tion of effort and communications among the program staff. The Director should be complemented on his decision It is recommended that the The team sees an effective deputy as a mechanism for improving 6. PROGRAM STAFF (Formerly known as CORE STAJ?F) (3) The team found a competent, dedicated and enthusiastic staff. Although it was reported that the staff consulted with one another on individual projects and program areas, the team did not believe that staff involvement was adequate in a number of key projects, especially the Emergency Medical Service System, Hawaii Medical Care Review Organization, Waianae Coast Comprehensive Health Center, and the Pacific Basin Program. In view of the nature and significance of these programs, there is a need for total commitment of much of the staff. wondered if Dr. Alexander Anderson, Project Director of the Hawaii Medical Care Review Organization, was or would be actively involved in other RMPH activities. involvement of the deputy, and believes that he should be able to assume greater responsibility in the coordination of staff activities in program development. meetings should be held so all staff members have a general idea of the total RMPH program. Along these lines, the team As noted earlier, the team was pleased with the increased If not already being done, perhaps periodic formal staff Recommended Action: A concentrated effort be made to commit staff efforts in a coordinated manner to further strengthen the RMPH program development as reflected in all its major project activities. 7. REGIONAL ADVISORY GROUP (5) The team was extremely impressed with the RAG chairman, Mr. Edward Bryan. There is no question of his commitment to and involvement with the program. RMPH is fortunate to have his leadership. The discussions with Mr. Bryan and other RAG members convinced the team that the RMPH RAG is well aware that it should have the responsibility for setting the general direction of the RMPH and formulating program policies, objectives, and priorities. e Page 7 - RMPH Site Visit Report, IiM OOOOZ Confusion exists, however, about the role of the Executive Cornittee, especially in the RMPH's review process. Executive Committee may be relieved of its current responsibility of review and approval of applications. the RMPH process plans for early involvement of CHP. was impressed with the willingness and ability of the RAG to assign relative funding priorities to projects. Mr. Bryan indicated that the The team was pleased to note that Further, the team The team reaffirmed the findings of the management survey visit and review process verification visit. The reports of these visits included the recamnendation that the RMPH revise its bylaws and strengthen its review process. RAG had been formed and had drafted a revised set of bylaws. efforts to strengthen the review process had already begun. The team was pleased to learn that a committee of the In addition, The revised draft of bylaws will require additional work, and the need for advice from someone knowledgeable in bylaw preparation was evident. The visitors realized, however, that this first draft had been prepared in a short period of time. There was evidence that the program staff is increasing its efforts to keep RAG members better informed of the overall administrative and program operations. that all RAG members have access to an adequate system of two-way conummications. As the body which has the responsibility for setting program direction, policies, and priorities, the RAG must have access to an effective mechanism to comnmrnicate its decisions to the program staff. Also, and equally important, there must be an adequate mechanism by which the program staff transmits to the RAG and its committees the information they need to make decisions. The team stressed the need to continue this effort so 0 A major concern expressed over the composition of the RAG was a lack Of the 37 RAG members from the of adequate allied health representation. State of Hawaii, 34 are from Oahu and the remaining three represent the Maul, Hawaii and Kauai county medical societies. of the State of Hawaii representatives on RAG are hospital administrators or serve on the board of a major hospital. In addition, most of the physicians on RAG have at least one hospital affiliation. Kuakini Hospita1,for example, appears to be represented by at least four RAG members, including three members of the Board of Trustees and the Chief of Surgery. health interests are not represented and there appeared to be minimal consumer representation. the RAG and the increased involvement of the Council is commendable. Approximately 25 percent As a result, In contrast, voluntary health agencies and allied The acceptance of the Pacific Basin Council by Page 8 - RMPH Site Visit Report, RM 00001 Generally, the team was pleased with the strength, inv6lvement and codtment of the RAG and was extremely encouraged with the administrative and programmatic changes which have occurred since the last site visit. There was evidence that the RAG as a whole is assuming some of the authority previously held by the Coordinator and Executive Committee. which the RMPH is taking can only be commended and encouraged. Recommended Action: The direction a. The RMPH be encouraged to continue to refine its revised bylaws, giving close attention to the issues raised in the management survey and review Verification reports. clarifying the role of the Executive Committee to insure that it acts in behalf of and not instead of the RAG. seeking professional guidance in the wording and structure of the bylaws. Perhaps legal council could assist. Special attention should be given to Consideration might be given to b. The RMPH review process should be finalized with special attention given to the issues raised in the review process verification report. Attention should also be given to eliminating unwarranted duplication in the process. c. d; Additional allied health personnel be added to the RAG. The adequacy of representation by voluntary health agencies and ." .. - %* , -j consumers be explored. *. e. The RMPH continue its efforts in strengthening communication between the RAG and program staff. 8. GRANTEE ORGANIZATION (2) Dr. Richard K, C. Lee, Executive Director, Research Corporation of the University of Hawaii, the grantee, was not present during the visit. team assumed that he was heavily involved with two major Federal site visits to the University's Medical School. Mr. William Coops, the grantee's administrative officer, however, actively participated during most of the visit. RMPS of its favorable acceptance of the management survey report and a willingness to work with RMPH in implementing the report's recommendations. The primary concern of RMS was that the RMPH Executive Committee had usurped some authority of the grantee. grantee since Dr. Lee served as an ex officio member of the Executive Committee. The Prior to the sire visit, the grantee had notified This had been sanctioned by the be in During the visit, Mr. Coops stated that the grantee finds the RAG to a very active and concerned group and, as a result, feels comfortable permitting the RAG to do some of the grantee's work. e Page 9 - RMPH Site Visit Report, RM 00001 The team found no widence that the issues raised by the management survey report would not be satisfactorily settled. The clarification of the role of the Executive Committee, as noted earlier, should further clarify the relationship between the RMPH and the grantee. Recommended Action: Advisory Group Responsibilities and Relationshipsf1 should be considered by the aMpH in revising its bylaws. The recent "RMPS Policy Concerning Grantee and Regional 9. PARTICIPATION (3) With the exception of allied health interest, the key health interests, institutions, and groups appear to be actively participating in the program. The team believed that Dr. Hasegawa had been instrumental in bringing these many groups into the program. Representatives of a number of professional, voluntary, governmental, and consumer groups attested to their involvement with the RMPH. Association of Hawaii; Hawaii Nurses Association; The University of Hawaii's Schools of Medicine and Public Health and East-West Center; the American Cancer Society; the Health and Community Services Council of Hawaii, a private agency which represents 115 public and private groups; Waianae Coast Comprehensive Health Center; and the Health and Community Services Council of Hawaii. As indicated earlier, the team believed that the RMPH' has involved the "es tablishmentl* and ffnmestabliehment .I' Recammended Action: There should be more active involvement of the allied health groups in the REPPH. Included were the Hawaii Medical Society; Hospital 0 10. LOCAL mANNING (3) As reflected in the Review Process Verification Visit Report, the area of cooperative endeavor with Hawaii CKP agency is one that requires increased attention. basis. CHP early in the review process as recommended by the review process verification visit report. CHP rcAt' a gency docls have county committees on all but two of the Hawaiian Is lands. Planning to date appeared to be on a fragmented The team was encouraged, however, by the RMPH plans to involve Although there are no CHP W' agencies, the CHP in Hawaii is preparing a budget proposal for the next fiscal year which, if funded, will more than double the existing CHP agency staff of three professionals. be part of the A agency staff. As presently proposed, all personnel will i I Page 10 - RMPH Site Visit Report, RM 00001 !&e proposal would add me full-time staff person, a research - associate, to Mrs. Levy's imnediate staff. would establish what are being termed as State Assisted B agencies. Under this concept, full-time planners will be assigned to the counties of Hawaii and Maui, the windward side of Oahu and a half-time planner would be asskgned to Kauai. This staff will assist with the development of a statewide health plan for Hawaii. that the State Assisted B agencies will develop into full-fledged independent B agencies, In addition, the proposal . ' I Over a period of years, it is anticipated In May 1972, RMPH employed and Associate Director for Planning and Systems Analysis for the purpose of developing long and short-range plans. The systems approach at this time is in the embryonic stage, and appeared rather confusing. of CHP and other appropriate connmrnity groups, and the coordination of RMPH program staff in program development will result in an effective planning mechanism. Hopefully, this approach coupled with the involvement Recommended Action: The RMPH be encouraged to continue its increasing efforts to develop an effective planning mechanism. Future staff and/or site visits to the RKEW should pay special attention to the systems approach. 11. ASSESSMENT OF NEEDS AM) RESOURCES (3) --. Dr. Hasegawa reported that the data available from CHP had been gathered primarily by the RMPN. While there was no evidence of a scientific 1 approach to assessing needs and resources, the team noted that the RMPH seemed to know what needs to be done. in the Management Reporting and Evaluation System (MRES) being conducted by the University of Washington through a RMPS contract, should strengthen the RMPH's planning and assessment practices. MRES is a group of processes that serve as mechanisms for directing, planning, monitoring, and reporting the effects of a =...its personnel, its efforts, its resources. The major output of the system is the productiori of timely and practical information which enables coordinators and Regional Advisory Groups to effectively apply the decisionmaking processes. Recommended Action: RMPH should continue its efforts to work more closely with CHI? in assessing needs and resources, The participation of the RMPH 12. MANAGEMENT (3) In view of the recent Management Survey Visit, the team did not .believe it necessary to question the fiscal management of the program. The need for better coordination of program staff in programs and project development has already been discussed. appeared adequate. The monitoring of projects e Page 11 - RMPH Site Visit Report, RM OOQOY. 13. EVALUATION (3) i Evaluation was considered to be a serious deficiency of the program. The new Associate Director for Planning and Systems Analysis is also responsible for evaluation of project and program activities. recruiting for a medical economist to insure a relationship of the RMPH to the total economic system of Hawaii and provide measures of cost effectiveness and cost benefit to insure that the delivery system has a measurable ecrmomic component built-in. An evaluation subcommittee of the RAG has been established and is currently in the developmental stage. Another subcommittee of the RAG, also in the developmental stage,' is the Implementation Connittee, which about five months ago initiated the site visit mechanism to ongoing and potential projects. the program staff to provide project progress and expenditure reports to the RAG and its committees at each of their respective meetings to a,td in the evaluation of projects. RMPH is There is a need for Recomnended Action: to evaluate project activities and to assess how they will contribute to regional goals and objectives. providing information on progress and evaluation results to program management, the RAG, and other appropriate groups. The RMPH should continue to develop new techniques Special attention should be given to 14. ACTION PLAN (5) 0 The RMPH has established priorities for project funding. First priority is given to ongoing projects and second priority to the new projects. While all of the projects have a sense of reality to them and are in keeping with both RMPH and national objectives, the team believed that the magnitude of the program proposed would seriously tax the current capability of the RMPH. Also, priorities have been set within each of the two groups. Some of the RMPH's key projects, such as the Emergency Medical Service System, have been rapidly thrust upon the RMPH, which has responded admirably. adequate time to evaluate the significance of their potential involvement with the EMS, Waianae Coast and Pacific Basin activities. Although these individual programs represent different types of joint involvement with a number of other agencies, they are the primary responsibility of the RMPH, and, therefore, will require the total commitment of much of the program etaf f. There was a question, however, as to whether RMPH had had The EMS program at this point is only a "paper system," and the full impact of RMPH's responsibility of making it il truly comprehensive system may not be fully realized. The RMPH ha6 a responsibility of seeing that the EMS Advisory Council must be broadly represented to incZude those interests which are necessary to the successful development e Page 12 - RMPH Site Visit Report, RM 00001 of a quality operational system. elements. '. Society Ccnunission for Heart Disease report on myocardial infarction. Also, the relationship of the Physiological Data Monitoring System project to the EM3 project should be carefully examined and coordinated. The overlap between the two projects must be compatible. The RMPH plans to fund the EM5 project, which is sponsored by the Hawaii Medical Association through a contract. Currently, the HMA and RMPH are having some difficulty in negotiating a contract. The morning following the site visit, RMPS staff was asked to meet with the following representatives of the HMA: Herbert Y. H. Chinn, M.D., Member of RAG, Past President of the Hawaii Medical Association and Chairman of the HMA-EMS Executive Committee; Thomas Y. K. Chang, M.D., Assistant City and County of Honolulu Physician, Director of the City-County Ambulance System, and Assistant Director for Equipping Ambulances in the EMS Project; George Mills, M.D., Member of RAG and Executive Committee of RMPH, Past President of HMA, and Hawaii State Senator; and H. Tom Thorson, Executive Director, HMA. problems seems to be that the HMA is hesitant to be placed in a position of having to answer to the RMPH. concerned that the RMPH plans to hire a physician on its program staff to "keep an eye on him.'' information from the RMPH comptroller regarding the RMPH fiscal policies. There was much discussion as-to who would resolve the differences between the HMA and RMPH in contract negotiation. would have to be worked out between the HMA and the RMPH Executive Committee. RMPH should assure that the system- gives appropriate attention to the trauma, drug, psychiatric, and medical t Regarding the latter, advantage should be taken of the Inter- h Livingston Wag, M.D., Project Director, EMS Project; One of the Dr. Wong, the project director, is MVIA representatives said they were unable to get Dr, Mills suggested that this Although the RMPH will support about 15 percent of the Waianae Coast's total program, the team believed that the RMPH has a major responsibility in working with the development of the total program. The future of the Waianae program can be potentially exciting, or potentially troublesome, for the RMPH. President, Waianae District Comprehensive Health and Hospital Planning Board, Inc., the RMPH has been an exceptional stimulus and catalyst toward the development of the total program. The role that RMFH has played seems to be well recognized and appreciated by the community. the project continues to develop successfully, WH, no doubt, will receive much of the credit. should be thwarted and the provision of health services should be delayed, the community may look to RMPH for explanation. It seems, therefore, that the RMPH would want to provide close surveillance and assistance to the other segments of the project, absorb a considerable amount of program staff's time, the team believed the investment would be most beneficial to the community and, therefore, the RMPH. Based on the testimony of Mr. David Pali, If On the other hand, if the progress of the project While support of this nature may well Page 13 - RMPH Site Visit Report, RM 08001 Another concern of the team was the lack of any clear relationship of It Review Group pointed out the'need to the Hawaii Medical Care Review Organization project to other projects. appears that many of the MCRO activities might be applied to the other projects. relate MCRO to the Oahu Patient Origin and Utilization Study. It was noted that the CHP In discussing the RMFB's plan for renal disease, the team noted that there seemed to be a problem of two competing hospitals, each wishing to perform identical functions. team that the problem had been solved and there would be no duplication. The RAG chairman assured a member of the Reconanended Action: a. The RMPH carefully reevaluate the magnitude of its triennial plan, giving special attention to the RMPH's full responsibility to its major program components to determine how best to utilize organizational resources, especially program staff. b. A mechanism be developed to utilize the Report of Inter-Society Commission for Heart Disease Resources in establishing the Emergency Medical Service System. e. That the RMPH and RMPS provide close surveillance and assistance as necessary on the progress of the EMS project. d. The relationship of the Hawaii Medical Care Review Organization to other RMPH activities, and the relationship of the Physiological Data Monitoring System project to the W project be explored further. 15. DISSEMINATION OF KNOWLEDGE (2) The team expressed no concerns over this segment of the program. Provider groups and institutions and education and research institutions have been contacted and involved. 16. UTILIZATION MANPOWER AND FACILITIES (4) Existing health facilities will be more fully utilized through projects such as the EMS, and Monitoring of Physiological Data projects. Productivity of physicians and other health manpower should be more fully utilized as a result of projects such as Manpower Utilization and Restraint of Costs in Hospital System, Hawaii Medical Care Review organization, and Upgrading Bedside Nursing Care in Rural Connmrnity Hospitals. allied health personnel is demonstrated to some extent in the Dietary Counseling and Outreach Service and the Waianae Coast projects. The use of The team Page 14 - RMPH Site Visit Report, RM 00001 believed that there was a need for greater allied health activity in the program related directly to Hawaii. (The use of allied health persdTink1 in the Pacific Basin program is clearly demonstrated.) In addition, the manpower programs of the RMPH could be strengthened through a better integration of programs. Reconmended Action: in its programs as related to the State of Hawaii. tion of manpower programs for physicians, nurses, and allied health personnel should be explored. 17. IMPROVEMENT OF CARE (4) r The RMPH should reevaluate allied health involvement Further, the coordina- All of the projects, in various ways and degrees, are aimed at the improvement of care. 18. SHORT-TERM PAYOFF (3) It is reasonable to expect that some of the projects will increase *_ the availability of and access to services. The Waianae Coast project is a prime example. The Medical Care Review Organization is to establish an ongoing system for quality of medical care review. medical economist is being recruited to address the economic component of the delivery system. As noted earlier, a 19 o REGIONALIZATION (4) In view of the geography of Hawaii and the fact that the majority of the population is in Honolulu, the team elrpressed no concerns over this aspect of the program. . coordination is the Waianae Coast Health Center Project. The membership of the Regional Advisory Group and its standing cormittees indicate regional involvement. Major health, business, labor and educational organizations are represented. application, 13 are outside of Honolulu. Further, there are program staff activities and operational projects which are specifically directed to Hawaiian Islands other than Oahu. The Pacific Basin program, of course, is an example of successful regionalization under most unusual circumstances. 20. OTHER FUM)ING (3) One example of joint effort and multi-agency Of the 24 performance sites shown in the The only two concrete examples of other sources of funding were the American Cancer Society's intent to support the chemotherapy project and the support of the Waianae Coast project by state and Federal funds. team was disappointed, as noted earlier, that there was no clear RMPH policy aimed at developing other sources of funding. The Recommended Action: continued support which could be used in the review and evaluation The RMPH should develop a clear policy regarding processes. Page 15 - RMPH Site Visit Report, RM 00001 PACIFIC BASIN The team was extremely pleased with the increased involvement of the RMPEI in the Basin which by its very nature presents an unique challenge. The Basin covers a geographical area of mer three million square miles, is populated by 228,000 people who speak ten languages and live on 105 of the 2,147 islands. distinct and separate in regards to people, culture, and government. More than 50 percent of the population have no ready access to health care. Guam, American Samoa and the Trust Territory are The goals, objectives and priorities of the Basin are reflected by the funded projects, Constant Care Unit on Guam, Health Assistant Training, Improvement of Health Services through Otology, and Health Information System on Guam. specific health needs, availability of resources and the problem of vast distances were taken into account. In developing priorities for project selection, the Perhaps the most significant accomplishment to date, excluding the results of individual projects, is that the representatives of the Basin are beginning to consider themselves as a part of the RMPH, and are attempting to see how the Basin can relate to the program of Hawaii. Mrs. Betty Guerrero, the RMPH RAG representative for Guam, for example, wanted to know if Guam could become part of the Hawaii EMS program. Dr. Wong, the Em project director, said "we will have to talk." funds by RMPS as part of the RMPH award, has definitely helped close the credibility gap between the Basin and RMI?H. planning." The earmarking of The Basin was "tired of The RMPK is supporting operational projects. The team commended the enthusiastic leadership provided by Dr. Satoru Izutsu, Associate Director for the Pacific Basin. His ability to provide program direction and to identify with the cultural diversity of the area is impressive. spend between 10-25 days a month in the Basin. The vast territory Dr. Izutsu covers requires that he The RAG for the Pacific Basin is the Pacific Basin Council which is composed of ten RMPH RAG members from Guam, American Samoa and the Trust Territory and 12 members of the now disbanded Pacific Basin Advisory Committee. health organizations are represented. Key Deliberation of Pacific Basin matters are solely the prerogative of the, Council and its representatives in the RMPH RAG are the primary contacts for Dr. Izutsu. Because of the cost of travel, one member from each area of the Basin is designated, by fellow Council members, to attend RMPH RAG meetings in Honolulu. Page 16 - RMPH Site Visit Report, RM 00001 The three representatives from the Basin, Mrs. Guerrero from Guam, Dr. William Peck from Saipan, and Mr. Ligoligo K. Eseroma from Amerfcan Samoa indicated that the Pacific Basin Council had adequate input in the RMPH. possibility of changing the RMPH title to "Regional Medical Program Area." He said such a change would satisfy the Government of American Samoa. The Council finds meeting in Honolulu a practical and desirable arrangement. It is intended that Council members will convene a day prior to RAG meetings so that RAG members from Guam, American Samoa, and the Trust Territory may attend both meetings. Travel costs per Council meeting are $5,500. becoming actively involved in the program. Comprehensive Health Planning is established in each area of the Basin. A CHP plan has been completed for Guam. really activated-there have been three CHP planners in the last three years. Just recently, American Samoa got a new planner who previously was the assistant to the CHP planner on Guam, Mrs. Guesrero, Mrs. Guerrero believes it will take American Samoa about three years to develop its CHP plan. Dr. Izutsu is actively involved with the Comprehensive Health Program Council for the Trust Territory which involves representatives from all consumer, provider, and governmental groups. In general, the site visitors were highly impressed with the development of the Pacific Basin Program, and believed much had been accomplished with. limited staff and budget. - Mr. Eseroma, in a note to the Chairman of the team, questioned the It appeared that the key health interests of the Basin were American Samoa's CHP is not The team recommended that the Pacific Basin Program be approved in the amount requested ($299,700). Further, the team endorsed the specific identification of funds by RMPS for the Pacific Basin Program. ' CONCLUSIONS AND RECOMMENDATIONS The team was favorably impressed with the change in direction, enthusiasm, and productivity of the RMPH. is capable of managing a three-year plan, they were concerned with the magnitude of the proposed plan. transitional stage of organizational as well as programmatic development, and the proposed program might overextend the present capabilities of the RKPH. The team believed that during the coming year the RMPH will have adequate opportunity to demonstrate that it has developed the efficiency and strength required of a mature and stable organization. has not completely satisfied the management and review process requirements of RMPS, it would have been inappropriate for the team to consider a developmental component request for the 'initial year of the triennium. While the team believed that the program The RMPH is currently in the midst of a Since the RMPH . f e. Page 17 - RMPH Site Visit Report, RM 00001 The team recommended that the RMPH be approved for triennium status, including the Developmental Component, for the second and third year of the triermium, provided: c I. 11. 111. IV. The amounts requested for each year be reduced. for detailed amounts.) The RMPH be site visited prior to the beginning of its next operational year. RMPS provide close surveillance and assistance to the EMS program. The following advice and recommendations be relayed to the RWH. (See page 18 A. B. C. D. E. F. G. H. I. In reevaluating its goals and objectives and the magnitude of its triennial plan, special attention should be given to the RMPH's full responsibility to its major program components. The RMPH is encouraged to continue building on its experiences by strengthening its administrative and review processes. Consideration be given to developing other sources of funding for successful projects, and decremental funding of projects be applied where appropriate. RMPH be encouraged to pursue its interest in addressing the problems of the medically underserved areas. The Coordinator be complemented on his efforts to more effectively use his deputy. A concentrated effort be made to commit staff efforts in a coordinated manner. RMPH be encouraged to continue to refine its revised bylaws and in doing so, consider the RMPS Policy Concerning Grantee and Regional Advisory Group Responsibilities and Relations. The review process be finalized with special attention given to the issues raised in the RMPS review process verification report. Efforts to strengthen communications between the RAG and program staff should be continued. 05 sv Request :?ecammend s I 06 sv Request Recouraends Initial Appllcetfon Ri dney GRAm, TOTAL $2,173,806 $1,730,000 $2,067,733 $1,800,000 90,488 90,488* 39,213 39,213* $2,264,294 $1,820,488 $2,106,946 $1,839,2 13 07 sv Request Reconmen& $1,420,276 287,583 1,707,859 20,577 $1,728,436 $1,121,166 1,408,749 20,577 $1,429,316 287,583 $ 114,219 184,901 $ 299,110 $1,707,859 $1 , 800,000 $1,650,000 150,000 1,800,000 $1,820 , 577 20.577* 41,350,890 1,500,890 $1,521,467 150 000 20,57 7* $ 114,219 184,901 $ 299,110 Ini tial App licstlon Program Staff 8nd Projects Develop-tal component -Subtot8 1 .M&ey WAND mAL $1,886,223 $1,730,000 . $1,780,150 $1,650,000 287,583 -0 - 287,583 150,000 2,173,806 1,730,000 2,067,733 1,800,000 90.488 90,488* 39,213 39.213* $2,264,294 $1,820,488 $2,106,946 $1,839,213 * Pendfhg RMPS acceptance"af RMPH technical review of kidney application, see page 20. , t. .r. c Wwaii Program Program Staff and Projects Developmental Camporient Kidney -Subtotal TOTAL Pacific Basin Administration Projects TOTAL Rovaii (Excluding Kidney) Pacific Basin Kidney TOTAL GRAND TOTAL $1,586,523 $1,&30,300 $1,491,929 $1,361,779 287,583 -0- 287,583 150,000 1,874,106 1,430,300 1,779,512 1,511,779 $1,818,824 ' $1,550,992 90,488 90,488* 39,213 39,213* $1,964,594 $1,520,788 $ 107,700 $ 107,700 . $ 110,880 $ 110,880 177,341 177,341 192,000 192,000 $ 299,700 $ 299,700 $ 288,221 $ 288,221 2,173,896 1,730,OCO 2,067,733 1,800,000 $1,874,106 $1,430,300 $1,779,512 $1,511,779 288,22 1 299,700 299,700 288,221 39.213* 90,488 90.488* 39,213 $2,164,294 $1,820,488 $2,106,946 $1,839,213 I $1,408,749 299,110 1,707,859 20,577 $1,728,436 $1,500,890 299,110 1,800,000 20.577* $1,820,577 Page 19 - RMPH Site Visit Report, RM 00001 0 1 J. RMPH be encouraged to continue its efforts in developing an effective planning mechanism, including closer association with CHP . K. Continue to develop new techniques to evaluate project activities and to assess haw they will contribute to regional goals and objectives . L. A mechanism be developed to utilize the findings of the Inter- Society Cananission for Heart Disease Resources in eatablfshing the EM3 system. M. The relationship of project activities be further explored. N. Additional allied health personnel be added to the RAG, and reevaluate the allied health involvement in programs relating to the State of Hawaii, and explore the coordination of man- power programs for physicians, nurses, and allied health personnel . 0. The adequacy of representation of voluntary health agencies and consumers on the RAG be explored. P. Develop a clear policy on continued support of successful projects which could be used in the review and evaluation 0 processes. RATIONALE FOR FUNDING As noted earlier, the team believed that the Pacific Basin program should be funded in the amounts requested. The team could not endorse a developmental award for the first year of the triennium, but believed that in a year's time, the RMPH will have reached a stage of maturity which would justify a developmental award. The recommendation for support of a "Triennial Award" is believed necessary to encourage the RMPK to continue in the direction in which it is moving. the team believed a second rejection could hinder the progress being made. In view of the rejection of the previous triennial application, For the Hawaii segment of the RMPH 05 year, the $1,730,000 recommended for program staff and projects represents a $842,445 over the current $887$555 for the same purpose. The team had to consider that the RMPH has already been awarded $1,470,645 for the two-year EMS project; the administration of the EMS project will require considerable RMPH staff effort. Page 20 - RMFH Site Visit Report, RM 00001 In arriving at the total amount of $1,730,000 it wae understood thZt the ;r amount requested €or the kidney project woul be added, if RMPS accepted the RMPH technical review of that project. 8 The amount reconmended was not based on the deletion of individual project budgets. team did specifically include in the 05 year Llmount,funds for the Pediatric Pulmonary Center at the suggestion of RMPS staff, in view of the history of Pediatric Pulmonary funding by RMPS and its effect on the RMPH. J However, the' The amount recommended for the 06 and 07 years permits an $80,000 increase over the 05 year, and includes $150,000 for a developmental component. - .--------I -._I--_.._C&__ __ - - - _- (Project #47--Dialysis and Transplant Center Since the site visit, RMPS staff has determined that this project conforms to the Kidney Guidelines, received favorable outside renal technical review and has supportive RMPH RAG and CHP comments. The RAG, however, did not resolve differing recommendations of the renal technical reviews regarding the procurement of a liquid scintillation system. potential of mixed leukocyte culture as a retrospective measure of incompatibility, largely in a living related donor population, but doubted that this procedure is essential to the overall success of the cadaveric transplant program. systqwhich would be principally used for leukocyte culture studies was r econrmended. Two of the technical site visitors recognized the research Deletion of the liquid scintillation The third technical site visitor recommended funding of the liquid scintillation system, on the basis that from the use of some equipment there will result direct service-related advantages for patients with respect to both donor/recipient selection and post-transplant management . RMPS staff noted the existence of liquid scintillation equipment at the University of Hawaii. project is about $15,775. conflict regarding the reluctance of Kuakini Hospital, which has done only two transplants since 1971, to agree to support St. Francis Hospital as'the only PHS funded tertiary center for the treatment of end-stage renal disease on the Islands. the relationship of both hospitals to the project should be clarified.) The amount budgeted for similar equipment in this Further, it was noted that there has been some Before funds are made available RMPS /WOB 9-19 -7 2 ----- Review Cycle: OC;T. 1p~2. REG I ON : HAWAII OPERATlONS BRANCII: NUMBER: 00001 COORUINA'rOR: Masato Hasegawa, M.D. &lef: Richard Russell Staff for mp: Calvin L. Sullivan .. -- - LAST RAT IN(; : TYPE OF APPLICATION: - 2nd Year - / / Triennial / - / Other - - 3rd Year Regional Office Representative: /r/ - Triennial / / Triennial Management Survey (Date) : May 15-18, 1972 Conducted: or Scheduled: Last Site Visit: -- (List Datcs, Chairman, Other Comr,iittee/Council Mmbers, Consultants) August 7-8, 1972 Mr. Edwin Hiroto Leonard Scherlis, M.D. Mr, Kenneth Barrows William I. Holcmb, MmD. RMPS Advisory Council RMPS Rek.ew Committee Consul tan t Cons ul tan t Staff Visits in 1,3st 12 Nonths: -- (List Dtt$ and ) 1- ose Dr. Haro Mr. Richard Russell and Mr. Ron Currie - Met with WH Program Staff, November 1971. Management Assessment Visit - May 15-18, 1972 Review Verification Visit - May 15-18, 1972 DPTD site visit to limited care facility of St. Francis Hospital, Honolulu Margu!LYeg - Jet with RMPH RAG, November 1971. seases. *AULA > a. HllllAU 2 , PART , / .. .. .. . c. , ., .. / HEW Regional Office - . .. / .> HAWAII IX Regional Delineation: State: `Hawaii, American Soma,c.Guam and Trah Territory Counties: 5 (Hawaii) Congressional Districts : 2 Subregions : Territories Overlap/in terf ace DEMOGRAPHIC INFORMATION 769, 900 Population Hawaii GW 86,900 American Samoa 27,800 Trust Territories(approAmate 97, 600) approximately 900,000 Age Distribution Percent of Total by Specified Age Group, 1970 U.S. Age Group Hawaii - Under 18 yrs. 38 35 18 - 65 yrS* 56 55 6% 10 65 yrs. & over INCOME - Average Income per Individual, 1969 & 1970 1969 19 70 State (of RMP) $3882 $m5* United States 36 80 39 10 *State of Hawaii ranks 6th MORTALITY RATES, CY 1967 & 1968 Population Density 104 per sq. mile % Urban - 83 % Non-White - 61 Metropolitan Area Populatic *Honolulu - 613.1 (mainly p olynes i an) Deaths per 100,000 population ** Caw e Heart Disease Cancer Vasc. lesions - - RMP (Hawaii) 196 7 - i968 - 168.3 162.8 U.S. 364.5 98.5 98.5 157.2 - 46.3 44.2 102.2 (aff. CNS) All causes, all ages 45-64 yrs. 65 & over ** Utes generally population). &mica% because of age distribution (mu& younger 519.4 935.7 827.6 1143.5 5102.6 6042.5 RMOOO 01 -4- KEGIONAL CHARACTERISTICS (Cont'd) FACILITIES AND RESOURCES SaiOOLS Schools No. Enrollment Medicine (and Osteopathy) (1) (19 69 / 70) University of Hawaii 75 Graduates Lo cat ion (1969/70) Sch. of Medical Sciences -- (2 yr. school of basic med. sci.) 1970171 86 -- Nursing Schools Professional Nursing -- Honolulu Number Practical Nursing Number Allied Health Schoola Cy to technology Number Medical Technology Number Radiologic Technology Number Physical Therapy 2:l at Univ; 1 at community college. 3:l at community college. (Approved Programs)b --- 5 (incl. 1 at Army MC-Tripler) 2 (Honolulu --- .. :. .., . .... . .. .. ~ .. - .. ._ Medical Record Librarian --- RM 000 01 L-, - I. REGIONAL CHARACTERISTICS (Con t ' d) FACILITIES AND RESOURCES (Cont ' d) HOSPITALS Nan Federal Short and Long-term general hospitals, 1069 & 19 70 Number'of Beds Number 19 70 21 22 2384 245 3 872 1969 1970 - 1969 - - Short term Long term (and special) 7 6 9 32 V.A. General hospitals 0 Number of Hospitals with Special facilities # of facil. Intensive CCU 8 Cobalt therapy 3 Isotope facility 6 Radim therapy 7 Renal Dialysis 5 in patient Rehab-in patient 3 Source: her. Hospital Assoc. 1970 Guide Issue August 19' NURSING AND PERSONAL CARE HOMES, 1967 Nmber Skilled Nursing Homes 12 Personal care Homes with Nursing Care 24 Number of Beds 909 178 8 5 41 Long term care units Source: NCHS - A Master Facilities Inventory County and Metropolitan Area Data Book PHS - Number 2043 - Section 2, Nov. 1970 - I> - I. REGIONAL CHARACTERISTICS (Cont'd) FACILITIES AND RESOURCES (Con t ' d) MANPOWER profession Nmber %Tot a1 RM 00001 - Ratio per 100,000 Physician - active (pt. care) 9 34 100.0 general practice 20.0 medical specialties 21.0 other (active) 82 130 s urgi cal spe ci a 1 ties Physician - inactive Osteopath Total active MD & DO 27.0 Professional nurses active 2 334 32 1 . ;Inactive 204 Lic. Pract. Nurses actively empl. in nurs. 1319 176 not enpl. in nurs. 2 44 Medical techno logis ts Radiologic technologia ts Physical therapists Medical record librarians GROUP PRACTICES Sources: Distribution of physicians, Hospitals, and Hospital Beds in the U.S., 1969; American Medical Association, Chicago, 1970. Health Manpower Source Book, Section 20, PHS-NIH-BEMT, 1969 Conponent 1st year Current hnual ized 01; Year Level - I I $ 513,297 $ 692,244 (107 , 100) 24,705 0 207,523 537,553 - 3XTMCTS b EVELOPWTAL CO~&ONENT IUXAL PROJECTS Kidney (90,425 I./) EMS ( 21 1 hs/ea I -O- 1 Pediatric Pulmonary ( 32,285 ) (192,007 ) Other I I . $1,079,555 $2,26&,294 OTAL DIRECT COSTS OWCIL RECOAMHEKEED LEVEL I 1 jt for Tri 2nd year $ 717,456 0 (110,&80) 287,593 1, 101,907 (39,213) (77,335 j $2,106,9&6 1 COUR nnial 1st yljar $ 743,929 0 (114 , 219) 287,513 ' *. 696,924 (20,57 7) i c $1,728,436 JX yez -7 AUGUST 18r1972 - ........ -. . _- BREAKOUT OF REOUEST OS PROGRAM PERIOD REGION - HAWLII RM 00001 10/72 PAGE 1 RRPS-CSM-JTCGRZ-1 I I APPR. PERIOOI APPR. PERIODI PPEvxnusLv I PREVIOUSLY I DIRECT I INDIRECT I TOTAL I I APPROV€D COSTS I COSTS I I 15) It1 I41 (1) IDENTIFICATION OF COMPONENT I CCNT. WITHIN1 CONT. BEYOND1 APPR. NOT I NEUI NOT I 1ST YEAR I 1fT YEAR I I OF SUPPORT I OF SUPPORT I FUhDED I I -1 I I -- I -_ I I I I I -- I COO1 PACIFIC BASIN AOHlNISTR*l I I I I S5flAd54 I I I S5E4IY I I I -_ COO0 PROGRAM ADRINISTRATION I TlON I SlplrlpD I ItlOf.lOO1_211.3921L I I1 S69-I I I1 S69L.2441 I1 59OdUJ I I I'lRZlU,lfiz)I, I _. I I 1- I I I I I I 982r285.I sat7as I ~21.677 I I I I I I I I I $66046 I Suf946 I SlZJLQs I II I I I I I I I UPg2LSZ€iU=L -_ DO00 DEVELGPfiENTAL COCPONENT I 011 A REGICNAL APPRObCH TO Pi 015 COOPERATIVE CHEMCTHERAPYI 020 CONSTANT CbRE UNIT st- I s2- I I I SZ6-3 I I - AQlAm- I I ,,lWXiRAB -- - -047 REGIONAL RENAL 011 I I I I I I I I I I .J -. ..... - ............. .... ........ ....... - ... WGUST lee1972 - . __- - - - - - . IOENTIFICATlON OF COMPONENT - COO0 PROCRAP ACUINISTRATICN IS) CONT. WITHIN1 APPR. PER1001 OF SUPPORT I I I OREAKOUI OF REOWST 06 PROGRAM .PERIOD I21 141 (11 CONT. BEYONO1 APPR. NOT 1 NEW* NOT I APPR. PERIOOl PREVIOUSLY I PREVIOUSLY I OF SUPPORT I FUNOEC I APPROVE0 I I I 1 I I I REGION - WAYAIl RH 00001 lot72 PA6E 2 RIPS-OW-JTOGRZ-1 - ZNO WAR I OIRECT I COSTS I I I BREAKOUT OF REQUEST 07 PRCGRAW PER100 REGION - HAWAII RM 00001 10112 PAGE 3 - RIPS-OSW-JTOGRZ-1 (1) I I I I I I I I I t COO0 PROGRAM ADMINISTRATION I I I I I I I sbzplllo I s1.Bzp.By) I I I I I slbu.4aw I s3u- COOL PACIFIC BASIN AOMINISTRAI I I I I I II 2 I It s743&911 I1 s-11 I t I $W I I AB- I OThL 15UL2lL- __ DO00 OEVELGPCERTAL COCPGNEkT I I 1 I I- c-1 011 A REGIONAL APPROACH TO PI I I I I I I I s-0 I 1 I I I I I -JRlATRII:PULntblAPrRE I I s4fdmr 015 COOPERATIVE CHEMCTHERAPYI I 029 CONSTANT CARE UNIT I I I I I I ! ! (2J ( 4) I OF SUPPORT I OF SUPPORT I FUNDEO I TOTAL I ALL YEARS I I APPROVED I CCSTS I IOIRECT COSTS I IS1 IOENTIFICATION OF COMPONENT I CONT. WITHINI CONT. BEYONOI APPR. LOT I NEW. NOT I 3RO YEAR t 1 APPR. PERlOOl APPR. PERIOOI PRFVIOUSLY I PREVIOUSLY I DIRECT I I I . run -- ' PR[)C;RIIIL J _- I I I I I I I s21.866- 027 KOOLAULOA DIETARY COUNSEl I I I I I I I I I I I I I I s21.866- 027 KOOLAULOA DIETARY CoUNSEl I I I I I I I rsl+kO I $55- I Sl+fL477 I 028 HEALTH INFOPMATICN NETWOI I I I I I I I AAkuu!m-l --029 INTENSIVE CARE NURSIkG I I I I I I I 1 _RI[l€THEc 030 WAIANAE COAST COMPREHENSl I I I I I I I 1 I s3 RI I I 031 UPGRADING OF RURAL NURSII I I I' I JYJLtlLWWFR I 1 S12W9 I 032 PHYSIPLOGICAL DATA HONITl I I I 1 I I 031 IMPRCVEMENT OF HEALTH CAI I I I I I I I DRIYCL run I $24348 1 sie.444 I I 1 I I I 039 HLTH INFO SYS FCR COWPREI I I 1 I I-. I 1 1 s(16.6341 041 HAYAII MEOICAL CPRE REV11 I I I I I I I 1-145 I HENsIULXBY $75&&0l 1 11 $291.338 I I I I -tuL- 042 HEALTH SCREENING FOR THE1 I I I I I .ELOERI_Y f CE I rw I s-1 1- 043 WOLOKAI HORE HEALTH SERVl I I I I I 044 OAW PATIENT ORIGIN AND I I I I I I I I IAL I I I I I I I -Jml.uAucLmJnY 045 IMPROVEO HANPOYER UTILIZl I s9ao I $9-0 1 s-0 1 I I -LxEn 947 REGIWL REkAL DIALYSIS I I I __ I I I. -- I I I I I 1 I I 12- I S86.464 I -1 NC w s14dML SlW 1 Sll&j.l9 1 mal *- TRiiNiNli I I I sY AMI --- s-1 SW7I I I rsl+kO I I $55- I I Sl+fL477 I 028 HEALTH INFOPMATICN NETWOI I I I I I I I AAkuu!m-l --029 INTENSIVE CARE NURSIkG I I I I I I I 1 _RI[l€THEc 030 WAIANAE COAST COMPREHENSl I I I I I I I 1 I s3 RI I I 031 UPGRADING OF RURAL NURSII I I I' I JYJLtlLWWFR I 1 S12W9 I 032 PHYSIPLOGICAL DATA HONITl I I I 1 I I 031 IMPRCVEMENT OF HEALTH CAI I I I I I I I DRIYCL run I $24348 1 sie.444 I I 1 I I I 039 HLTH INFO SYS FCR COWPREI I I 1 I I-. I 1 1 s(16.6341 041 HAYAII MEOICAL CPRE REV11 I I I I I I I 1-145 I HENsIULXBY $75&&0l 1 11 $291.338 I I I I -tuL- 042 HEALTH SCREENING FOR THE1 I I I I I .ELOERI_Y f CE I rw I s-1 1- 043 WOLOKAI HORE HEALTH SERVl I I I I I 044 OAW PATIENT ORIGIN AND I I I I I I I I IAL I I I I I I I -Jml.uAucLmJnY 045 IMPROVEO HANPOYER UTILIZl I s9ao I $9-0 1 s-0 1 I I -LxEn 947 REGIWL REkAL DIALYSIS I I I __ I I I. -- I I I I I 1 I I 12- I S86.464 I -1 NC w s14dML SlW 1 Sll&j.l9 1 mal *- TRiiNiNli I I I sY AMI --- s-1 SW7I I 0 I - . I __ - - __ - -___ _-___-_ - - -. __ __ - - - - - i f I' RUQS-OS~TCIF~~W I I. ____---- aECIEhtL YEGICIL PPOCRICIS SERVICE -. __ __ ALGEST ir1972 __. ----- FUhDIhG HIClCPY LIST PEGIOR 01 rswrrr PYF SUFP YR 04 CPFRITIONIL CRANT lOIRECT COSTS ONlI) ALL RECUEST bhC bWbRtS AS CF JUhF 30, 197 6 T AwAPDEO_ Ah A P C E-G AWIP CEC IhbRCEC-- __ AUAPCEC ** ~EQIlESlEC_-REOLESTEO REOb€STEO RECUESTEC 6 m CCYFChi%T Or c2 O? c4 ** E5 Ob- 07 -- NO TITLE 10/71-12/72 TOTAL- ~ ** 01/73-1_2/73 01/14-12174 C1/75-12175 TClrl 10 _____ __ - _____. - __ . . - - __ *I I, COO0 PPCGRBP STIFF 3F29CC 3e35cc 3ecccc 5777-1 i 1734112 ** 584544 606576 62971C is20a30 12 ~ -__ .___ CEO1 PACIFIC eASiN A 5016C 55i60 ** l0770C ii08e0 114219 332759 0000 CEVElCFwEYTCL C 003 Panwoirok AWO E lC0CC CC7 CAnOIC-FlL"C4bF 487CO ZOOOU 5560G 174LOO ** -i508---rE-n- PDYTiJE E 53CCC 12c3cc 97 1OC 270400 ** 2c79e? e6zt49 287583, **-- 287583 ____-I__- .-CCZ--lRhG PEHae -CbST-<0300 761 oo--- t2CCC i7escc ** 45eoc ** --0O4 -- (EL E C LUFS WU d I(---- i55CC XiCC 457cc ** ,_-________I_--- W3CC 1650C - _I . --_I_ 47tCC ** -01C --CCL EOCIP TRh 14---`---38?00- 446CC 1lCCC 55tOC ** 2 100 3700 5800 ** 9600- ___- ____ ___. . 005 CCl: €CLIP AhD 1 15962C 77335 ______.. 011 PECSCICL IFFFCA 2109co 114tCC E27CC--- - S4RC? LC3C53 ** -- 8ZZ8E- - 013- -RHILB CA TZTRPHC 015 REG CCCPERLTIVE 377crc 92ccc 123375 253079 ** 64CC46 t.4csc___ C2C CCLSTALT CAPE L 50200 4tlCC 5F114 155414 ** tiett 21866 __ __ - -_ _- _- - . ____ . . ....... - -- -26848(_. . _ ?be48 ** -. - CEP 1CA1. C*hCER _____~ ______ -. - 022 kELLTk tSS1STW 23~62 23862 ** 027 KCCLALLCd 51ET4 OZd CECICAL LIPRPPY 029 IhTFhSlVE CIRE 030 h4l4NIE COAST C 415ei 4.735~ 55540 144477 __ ** -. _- 46eoe 46808 I* 62831 41581 104412 o @?el= E5C15 ** 43232 43232 86364 . 14115 14715 **_ 14300-_-- __ 143CO i 1'5252 15252 ** 2C148 - 26 14 29 1 4_e___ .. 70444 i f -- 154593 154593 ** 1tSFIC 178412 348324 _-___-____ iiezi9 031 UFCPICINE OF RU ___ - "-032 PtcrSlCfCGlCrL-C--------- -- 47274 47274 ** t317E 65Cil 5 037 WPRCVFYENT nF . -. O~R --M@AC~F ASSISTA~ __-- - COCCC ccccc ** 1Cl695 106780 112119 320594 C3S HLTH IhFO SYS F 25300 25000 ** 4me 44413 46634 133345 040 EVERCEhCY YECIC 147C645 1470645 ** C41 IJAhAII PECICdL ** 24200C 249457 . 2568A 1 751338 042 PEALlk SCREEhlN- I* 68196 70895 73575 2130Ct -- 13820 044 CllHU PITIENT CR ** 1382C 262 150 045 IWFPCVEC WIffPOY ** 85050 137050 900 5 G __ - - - ..043-- rctc_rII I-CCE FEL- - - 48531 - 25009- - - 1500P_ 88531 _____ 047 --Kidney ** -9- -392T3-----70577- 5494110 ** -2264294 2106946 1728436 6099676 - .. ** I____--- - TflTAL - E67SCO 914700 83570C - 28 75 e 30 -_ - ... ........... 3`. .. - . ... .... ..~ .. -. .- - - __ - -- - _- __ . . r __ . __ .. .- _____.~ .......... __ ...... ............ __ . .- ... __ .... - ~--. . . .. ~ ........ .... .. - ... - - . - - ... ......... - - 12 - The RMP of Hawaii, Trust Territories, Guam and American Samoa was established with a planning grant under the University of Hawaii School of Medicine in July 1966. Little progress was made in the first year as the Coordinator, Dean Windsor Cutting, was unable to spend time on RMP activities. During the 02 planning year, the RMPH'pffices were moved out of the University's Leahi Hospital and into a "neutral" building at the Queens Medical Center. for a new Coordinator became apparent. Dr. Masato Hasegawa became Coordinator. trician and prominent member of the medical community with an interest in community medicine. The need Dr. Hasegawa is a pedia- In April 1968, In October 1968, the grantee changed to the Research Corporation of the University of Hawaii , since the developing school of medicine did not have the staff and time to devote to establishing a fully operative RMPH. The RMP became operational in September 1968, and had continuing education as its major thrust, using regional resources in the absence of a fully developed medical school. The RMPH goals also included development of "advanced health systems" which would im- prove the delivery of health care. Dr. Hasegawa, in only a few months, began do involve diverse elements , overcome earlier hostility and develop a separate identity for RWH, ment of the medical society, hospitals and paramedical personnel had been accomplished. Further, program staff had become stronger, but it was evident that the Coordinator required administrative assistance. The RAG had become more representative, however, there was diminishing involvement of the previously vigorous chairman. Planning activities in the Pacific Basin had been initiated as a result of a $30,000 award specifically for activities in the Basin. -_ At the end of the first operational year increased involve- During its first two years of operation, (9/68-9/70}, the RMPH made considerable progress. The RAG'S role and influence, however, was stillnot clear, Established policies and procedures plus an Ad Hoc Evaluation Committee provided hope that RAG effectiveness would be improved. categorical committees which appeared to have veto powers that weakened the role of the RAG. The Executive Committee was the strong force, as were the Progress continued to be made toward developing the general principles of regionalization. the achievement of goals and objectives. being developed. allowed the RMPH to look at program rather than projects and to real- istically consider program priorities. There appeared to be a broad- ening and deepening involvement of RMPH with providers of health The RMPH had developed a frame work for planning Methods of evaluation were Also, there was increased sophistication, which ,. 1. . .- . I. .. .. =_ . 2. : .. .- - 13 - services and with the community. In 1971, however, RHPH appeared to be making little progress toward the solution of problems noted during the previous year. It appeared that the RMPH had failed to follow through on past recommendations from RMPS. In August 1971, therefore, the LGational Advisory Council recommended that the RMPH not be approved for triennial status. program staff and operational projects. component had been approved for the previous year, the Council believed it should not be approved again until the following conditions were met: Funding was approved for one year only to support Although, a developmental 1. The region identify specific objectives and priorities that relate to the health needs of the region. anticipated accomplishments in terms of a realistic time schedule. The RAG develop its bylaws and assume their responsibility for directing the planning and operational activlties of the RMPH. That a deputy or associate director to help administer the day- to-day operations of the RMPH be employed. That the objectives delineate 2. 3. 4. That the RAG Technical Review Committee and categorical committees be given an opportunity to have input in the planning and operational activities of the RMPH. procedures and responsibilities of these committees should be clear 1y delineated . Clearly defined operating 5. That evaluation mechanisms to be implemented to relate to projected accomplishments indicated in specifically identified objectives. That the RMPH clearly identify its comitment to the Pacific Basin and develop a feasible plan of action for this area. That a feasible regional plan of operation be developed that will meet the health needs of the region, based on measurable accomp- lishments at specific periods of time of program development. 6. 7. In November 1971, as a result of a visit by the Directlor, RMPS, the RAG baane more aware of its role and new directions and responded by re- budgeting some of its funds to provide greater support to activities more in keeping: with its goals and priorities. In May 1972, RMPS staff conducted a Management Survey Visit and a Review Process Verification Visit to the RMPH. the review proeess and the management process would require considerable strengthening before they could be fully certified by RMPS. , Staff found that both . . . . . -. - 14 - There was a clear need for revised bylaws which would spell out the duties and responsibilities of the RAG and each of its codttees, in- cluding a clear statement on the role of the RAG as the policy and decisionmaking body of the program. In June 1972, the RMPH was awarded $1,470,645 for support of a two-year Emergency Medical Services System Project to be conducted by the Hawaii Medical Association. The RMPH may participate in the testing and evaluation of the Management Reporting and Evaluation Sys tern (MRES) developed by the WashingtodAlaska RMP. and plans; evaluation and fiscal and technical procedures. MRES is designed to aid the RMP in identification of health needs The RMPH submitted a kidney proposal to RMPS on August 1, 1972. extended deadline was granted for this submission. An - '15 Region 00001 Keview Cycle : October lo Historical Profile: Pacific Basin By invitation of the RME'H in 1968, the governments of Guam, American $moa and the Trust Territory joined Hawaii in creating a Pacific Basin Area. A chief of Planning and Operation was added to program staff in January 1969. The proposal to implement RMPH in the Pacific Basin was not totally funded by RMPS, instead $30,000 was earmarked for planning purposes. With a small budget and a staff of one, the thrust during the first three years was to ascertain whether the Pacific Basin areas could utilize RhF' programs. Five project proposals were submitted. One was funded, Constant Care bit-Guam. The project "Rehabilitation in Caleaatrophic Mseases" was extended to Guam and the trust territory. In 1971 the RMPH RAG approved fbnds unfunded projects (#21,22) . 1972 for the Pacific Basin Area. the Pacific Basin will be to improve total health care services. Problems areas might be seen as the level of funding and how this money is shared by the sub-regions of the Pacific Basin, recruitment of qualified personnel for funded projects and the distance between the island units. part of the RMPH RAG to allocate funds for the Basin. relationships on Guam are strained. In April 1972, the Pacific Basin Council was created. directors and priorities are made in eonsultation with this group. for two previously approved, but $156,412 were made available in April The future thrust of the RMPH in Further, there appears to be some reluctancy on the CHP-RMPH Program - 1.6 - 1) Management and REView a) Bylaw revision b) Definition of role Process needs considerable strengthening: of RAG and of committees (see reports) i 2) Cooperation with CHP agencies I Principal Accomplishments : Increased programing in Pacific Basin Coordination of the development of an EMS system Strengthening of Staff compentencies Changing emphasis of program from categorical to a total health care system6 I. Strengthening RAG Zssues Requiring Attention of Reviewers: 1) Issues of concern per MSV and RW reports '/ . 1 I. .". ._, ." Prior to . Triennium September 30 7 October 1, 1971 Alexander Schmidt, M.D. - Chairman C. H. Adair, Jr., Ph.D.- Consultant Luther G. Fortson, JK., M.D. - Consult W. Fred Mayes, M.D. - Consultant .. - Member of Conkittee DATE - . 4-5, 1972 2-3, 1972 y 27-28, 1972 - PURPOSE Staff t&s%stance ant . Staff Assistance Staff Assistance ., - I&. Stonehill, Coordinator, resigned, effective April 30, 1972 Dr. Steven Beering became Acting Coordinator May 1, 1972 Acceptance and growth of the AAGs (Area Action Group) around,the State. This has incorporated many kinds of health providers throughout the region. -2- - Formalization of the Tuberculosis relationship with the 5 existing CHP(b) agencies, and Respiratory Disease Association and the Eidians Heart Association. - Formation of 2 new CHP(b) agencies with IRMP assistance. - Expansion of Statewide plan for Medical Education to include new center around the State Increase acceptance of Il" by various Health agencies, especially the Indiana State Medical Association. A large influx of health dollars in Indiana (several million) especially in Indianapolis and Gary. (an increase from 7 to 9 with the 10th projected), - - - Transfer of large funded projects to local funds, e.g., coronary care and stroke projects. r z -3- DEMOGRAPHIC INFORMATION *e l%e region encompasses the entire state; interfaces with Ohio Valley to the south; Counties: 92 Congressional Districts: 11 Population: (1970 Census) - 5,193,700 Urban: 65% Density: 143 per sq. mile Rural: 35% U.S. Age Distribution: Under 18 - 36% 35% 18 - 65 yrs. 54% 55% 65 & Over 10% 10% Average per capita income - $3,691 (Compared with $3,680 for U.S.) Metropolitan Areas: (8) Total Population - 3,061,000 Anderson - 137.5 Laf ayet te - 108.3 Evansville - 230.7 Muncie - 127.9 D - 629.0 South Bend - 277.9 Gary Hammond East Chicago Indianapolis - 1,099.6 Terre Haute - 172.7 Race: White - 4,830,141 93% Non-White - 363,559 7% - 19 69 ,/ 70 Resources and Facilities Medical School - Indiana University School of Medicine 885 2 14 Enrolled Gradute- Ind i anap o lis Dental School - Indiana University School of Dentistry Pharmacy - Purdue at Lafayette and Butler at Indianapolis 39 1 89 Allied Health School - Indiana University Medical School, Division of Allied Health Sclences Indianapolis Accredited: Cytotechnology -2 Medical Technology - 20 Physical Therapy -1 Radiologic Technology - 26 Medical Record Librarian - 1 Professional Nursing Schools Practical Nursing 28-(17 are University of College Based) 17-(Mostly Vocational and Technical) ? -4- .* IhDIANA Current Annualized Level Roviaw Cyclo: Sept. /Oct. 1972 ' Request For Cocponent Pir,OGRri\l STAFF Kidney EEIS hs/ea Pcdiatric Pulmonary Other TOTAL DIRECT COSTS COLJKCIL-APPROVED LEVEL , i- 04 Year 379 ,4.42 100,000 --e- 641,969 . 4 1,121,411 1,100,000 !.I Fy 71 annualized level n5 Year 417,890 505,000 603,806 ( 11,532. 1 ( i ---- 1 (.. ; ---- 1 ( ---- .I( 1 1,526,696 -c Request Funding For Year .. I /-/ Yes - /-/ No - 1 1 lb I 1. ' i , BREAKOUT OF REQUEST 05 PROGRAM PER130 REGION - INDIANA RN 00013 10/T2 PAGE 1 RUPS-OSt4-JTOGRZ-l-- - 11) I I APPR. PERlOOl APPR. PER1001 PREVIOUSCV I PWEVIOUSLY I DIRECT J INDIRECT I TOTAL I I 15) I21 (4) lDENTIFICATJON OF COMPONENT 1 COM. WITHIN1 CONT. BEYOND1 APPR. NOT I NEW* YOT I 1ST YEAR I 1ST YEAR I I OF SUPPORT I OF SUPPWT I FUNDED I APPROVED I COSTS I COSTS 1 I I -I- -- I I I COO0 PROGRAN STAFF I I I I I I I 009 NElGH6ORHOOO HEALTH CENT1 I I I I 1 I I f I ----,--,~1,,,19ZZ1SP~l,,-- U?.LBPD-Irrl6rUIP-l,A.LQS3.a2neL--- v i -9- Region : Indiana Review Cycle: Sept/Oct. '72 HISTORICAL PROGRAM PROFILE OF REGION AND PRINCIPAL PROBLEMS Indiana Regional Medical Program's initial planning grant was awarded January 1967. January 1969. The region requested triennial status to begin January 1972, but was denied this request by the Oct./Nov. 1971 Committee and Council. The application submitted had been written before the region had developed its data base and a set of objectives. The action plan for subregionalization had not been described and discrete activities could not be evaluated. There was a lack of overall planning and the activities and projects proposed did not constitute a sound program. The operational grant was awarded The region is currently funded at $1,121,411. The region has always been weak in the areas of planning and evaluation, and this weakness still remains. There has been a Lack of involvement by IRMP with other health agencies in Indiana receiving federal funding. There is concerted effort by the staff to rectify this situation. The program staff has been small and very fragmented, but RMPS staff feel confident this will. be resolved by the new leadership of IRMP. The RAG has never been as committed to or involved in SRKP as is required. The RAG needs to be restructured. Proposed activities and projects were never based on a scientific' study of needs and resources. i I The region has always r lied on the "bubbling up" of activities and projects. f There has been a lack of strong leaders'liip and supervi$ion for the program staff. IRMP has, in the past, been dominated by the Medical Syhool. The region's review process is inadequate and does notimeet all of the RMPS minimum standards and requirements. However, the staff has already begun to revise and update the review process. The region submitted a triennial application for this kurrent review cycle. RMPS staff reviewed the application that it did not present a 3 year plan. Staff Dr. Margulies that the August 1972 site visit that the region triennial, they that would lead -10- be advised that instead of going with a weak should resubmit a strong anniversary application - up to a much stronger triennial request next year. Dr, Margulies concurred with staff`s recommendations and the region was so advised. that the triennial application was prepared without the direction of a coordinator.) accepted our advice and resubmitted an anniversary application. (It should be noted, however, IRMP and the Indiana Regional Advisory Group Accomplishments : - The subregionalization effort is taking Indiana RME' out from Medical School domination. - The region has begun to move from being a categorical program to activities addressed to health care delivery and regionalization. - A new and much stronger working relationship with the State Medical Society is beginning to develop. - Appointment of Dr. Steven Beering as Acting Coordinator. - Reorganization of program staff, currently underway. Issues Requiring Attention of Revicwers: The region is requesting continuation funding for one year based on RMPS staff recommendations. $1,121,411which is the NAC approved level. $1,526,696 which includes an increase for program staff salaries, continuation of three projects and request for funding of eight new projects. Contractural services in the amount of $505,000 in the program staff budget for feasibility studies, and planned programs to support the subregionalization activities and to build for a strong triennial application next year are also requested. They are currently funded at The region is requesting central region services - RME'S staff feel that the region should not have funds to support sickle cell projects other than small amounts for planning and feasibility studies. - An increase is needed in program staff salaries to hire staff to fill some key vacancies. - Staff recommends a funding level of $1,200,000 for the one year continuation. A suggested breakdown is: $500,000 for salaries and wages, fringe benefits etc. 300,000 contractual services 200,000 for continuation projects 200,000 for new operational activities licvj ew Cyclc: October 1972 ---- RflPS STAFF BKIEFlKG DOC1JMENT OP~-R.~'~IO.YS BIWXII : Eastern -_ *e Chief: Frank Nash R: Manu Chatterjac, H.D. Staff for RW: CoWtanc@ Woody Spencer Colburn Lyman Van Nostrand char 181 ~arnes I_ 3rd Year Regional Office Representative: William McKQnas - ennial / - / Triennial Management Survey (Date) : Conducted: Scheduledt or Chairman, Other Committee/Council Members, Consultants) '* Sinter Ann Josephine, Review Comnittee, Chlirwoman It. Wchael BICOLILUL~, Council Dr. Willfam V~W, Coruultant ification Review Process area of: Region that are - affcctj?l: College of Physicians terminated e granted an additional $72,000 inue the Program until the University of Maine takes complete Lubec activity was funded at $20,000 as a dewzlopteental component" funded ut a lave1 of $85,000 for the firrt year of planning. BANGOR -3- Popufatfon: The estimated 1970 population is 992,048 a) 512 urban b) Roughly 99% white c) Median age: 31.6 (U.S. average 29.5) Land area: 31,012 rquardi milao Health lrt~tirticlr: a) b) Rata for csncer--182/100,000 (high) c) Rate for CNS varcular lesionr--l26/lO0,OOO (high) PaCtlLtie6 statietico: Mortality rate for heart lliseaa --463/100,000 (high) a) No medical schools b) Sewn Schools of Nursing,, one is univarsfty-bared and one is broed at a junior college. Three Schools of Medical Technology c) d) No Schools of Cytotechnology e) Eight Schools of Xray Technology E) There are 58 horpitals, five are federal and 53 are non-federal. Of the non-fadaral horpitels, 45 are lrhort term with 3,508 beds and eight are long Lerm with 4,802 beds. The five federal hos- pita18 hsve a tot81 of 1,189 beds. Perronnal sratirtico: a) There are 1,078 HIIS (ll0/lOQ,OOO) and 221 DO8 (22.5/100,000) in Mine. b) There are 3,856 active nurses (393/100,000) in Maine. Per Capital Income! (1970): $3,257 1970 Population 992,048 203,211,926 Currcnt Cocponent G ? 2 Ri, -1OXAL i PROJECTS Kidney . ZJS t.s/ea V I Peziztrlc Pulmonzry ICT.4L DIRECT COSTS ' . ...,a n7.r iizcd Fmding TR Year 04 960,000 78,653 416,855 1 1,503,872 Council - ~pproved Level For TR Year - 05 Region' s 'Request For TR Year 05 *. ~ $785,720 (75,ow 96,000 - $1,676,096 $1,646 394 gc comcnd ed Funding For TR Year - ;-/ SARP /-/ Review I -. C0m.i t t e e '1 1 L lei526 181576 ** it 1 7 5C?& -u3?8-FS mm?rTC C 1-2 5 7 cc d. D31B bftb FLHlLV NCP ?17F1 ** 0338 )SEA TEAY NUPSI 31191 91 6 6-93 C f l-** C3LC HfEA ~4F~ClTH Ir 31CtC 31t60 +* 2 0 38 4 52'038 4 5-* * 734C' bFCI ChbL-lPPPO3 -036C- +SfA-kEAlTG EIlU 7 3 KTt VPCTFDFPLCRL 0398 PEklPIL ITbl ION C405 INkPLATIPN THER 0418 CEDICAl IAIEKSI ' O43L PFCJfCT kP)rCCCK 0+5& FIPILY PLALhILt I* z2ooc 42 - mua 1G0174 .I 500R3 500s 1 I *- f co 0 c-500 9-10 0 0 9 2- ** 36579 35526 72lC5 * *--12 3 3 2 -10 5 1 1-1 338 3 d 341 1 'cECICLC-'IYTEhSl 211413 *e 1CCSOt llOS1l ** (ciao 40010 IQQP~O a72FTF1mTTB -** --- 330CC- 363CC c93cc 7442-UP En? 1 ZOtuHE ALT 037C CSEb FEAtTk ED. 51210 51250 ** - - . -C~~C-RE~.L~~CIT~TIC~ ' I+ 460 r5-9 6 c 74 ** Zifbi 24764 ir ..- .I- . .- RREAKUUT OF REOU€Sr 06 PROGRAM PtPlOO REGl#U - MAINE RH 00054 10172 PAGE 2 I RHPS-OS+JTOGRc-L . .. -9- . _. .. -..-. . - lity of Mine's becoming part of a New England RMP was dircussed, interest regarding Regional Medical Program was generated. ae chose autonomy and an appropriate grantee organization was formed, ical Cure Development, lac. ical Center were particularly active in pre-planning phases. The Bingham Associates Fund and the Mlna, 6 first planning request wao submitted to the Division of Regional Medical amr in December. cant orgaaieation; Bingham Associates Fund as the fiscal agent, and ield Director of Bingham Aseociates (on 108n 100% to Mdical Care opmnt) ar pl ning coordinator. It designated Medical Care Development, Inc., as the the 01 planning grant the program's professional staff was assembled r, Manu Chutterjee was appointed full-tiam program coordinator. ngs with regional health and education agencies became establiehed ice, horpital coordinatom (or acting coordinators) were appointed in Periodic nd held imetings, two feasibility studies were iaitiated, the was completely divorced from the grantee organitation to eli- e porrribility of legfiproblems and an overlap of membership, and rational proposal wan developed. fst operational requert was submitted in February. as ratisfled as to the Region's readiness for an operational award. notsd that, Initially, emphasis was given to development of the 1 mdical program rather than to establishment of priorities among A Hey site visit the 02 year the Region continued to fund program staff and the orlginal The Region rebudgered and utilized unexpended funds to initiate new the Pirectore of Medical Education activity and the Regional Library ~ts, ~ or which rupplemental funds were not available. The Region re- continued funding for program staff and six ongaing projects and opmntal funding for the 03 operational year. t -10- 1970 - - The Region was site vieited in October to assess its readiness for a developmsntal component. Developmental funds were approved by the November Council. The site visit team considered, the evolution of , Maine's Regional Medical Program was being co~utstent with that of the program at the national level. The RMP started with a categorical emphasie &ut expanded to include a comnitment to the development of an integrated system of medical care to provide access to medically dcprassed populations, as well as Improvement of availability of care to the comnunity at large. emphasie, and are also geared to the unique needs of Maine itself. The six program objectives reflect this 1971 The August Council recornended triennial status for the RMP and develop- mental funding be approved. The increase in program staff was a concern of the Revlew Committee and Council. I_ RAG decided that the three broad operational objectives should be given prlority as far as the Maine Program. 1972 The RMP submitted an emergency medical services and health servicee/ education activities (MEHEIA) proposals for supplemental funding. The EM proposal developed, which is regionwide in scope, as a result of the Cl06e working relationship between CHP Ageneies and the program staff. the University of Maine. - The program staff stimulated the MEHElA project by working with The June Council approved both of these Proposals for supplemental funding. The VA has supplemented partial funding for the MEHEIA Proposal. During the verification review visit on Nay 2, the team found the Maine RMP Review Process exceed8 the mi.nimum standards in some areas, but there are others in which it does not meet them. The RMP's review process was conditionally certified until the areas of concern have met the requirements: (1) The bylaws of the RAG be revised to reflect the responsibility of the Board of Directors of the Medical Care Development, Inc. in the review process as being limited to fiscal and admini- strative affairs, and the RAG being fully responsible for program policy and decisionmeking; (2) A more specific outline of the review process be developed and made available to applicants, and 8 conflict of interest state- ment be developed which coincides with Federal pblicy; -12- * ])rijicipal I'i-ohl~~~~: . I.. The RAG byhwe are to be revised to reflect the responsibility of the Board of Director8 of the Madical Care Development, Inc, in the review procaos ae being limited to fiscal and sdminiotrativa affaire; and the RAG being fully repponaible for program policy and decioionmaking. The grantee hae been requeetad to provide thca rationale €or the projected staff increase. The RMP should establiah a priority ranking and funding system. The RAG needs to aetabliah a conflict of interest policy. I Priiic i ])a 1 ,\ccoiitl> 1 i :;Iiw~~nts -. . _..- As a result of a cloee working relationship with VA, Model Cities, CHP AgUnCi88 and the University of Maine; the RMP developed (1) MEHEIA, (2) EM, (3) Kannebec Valley Regional Health Agency, (4) Lubec, (5) Com- munity Action Program, and (6) The Sutnmer Student program €or further deoalopmcnt of primary care in urnnierserved areas. The RMP was completely involved in the study of the College of Physicians until March 1972. The MRMP received $400,000 in funds from other sources to help develop these activities. The negotiated contract with Harold Keairnee, M.D. for evaluation supervision. Jsst~cs ri'cl~i ring attcntj 011 of rcvi c\;(\rs Maine's RKP should continue rystematic studicns of the interest, use, and adap- tation of problem oriented medical records. There art no minorities involved in the program in any capacity. . There ie no sptcffic policy in the application delimating a XRKF policy or long- term euppor t . ~Iio\f . C ircctor, Regional M-.dical. Programs Service _- I__-- -- Re j cc ted (date) Region Maine Review Cycle 10/72 .B r) COblPCINENT mTD FINIZNCIAL SUMMARY AN'NIVE2SARY APPLICATION DURIKG TRIENNILDI Current Counci 1 - Component PROG?AM STAFF COXTRACTS 6 DEVE LOPXEXTAL COW . . 0 ?E ?,AT I CX4L PROJECTS Kidney EKS -2 hs/ez Pediatric Fulmonary Cther TOTAL DIRECT COSTS . GCGN C 1 L - APPROVED LEVEL Annualized Funding TR Year 01 $ 462,492 2'; 000 '78,653 416,855 $ 960,000 - -~ $1,503,872 Appl-ovcd IACVCl For TR Year 02 $1,646,394 Rcgion s Rcqucst For TR Year 02 $ 785,720 (75,000) 96,000 794,376 - $1,676,096 R c comcn de d Funding For TR Year 02 /s/ _. SARP /-/ Review - C om,i t t e e < 3 ( 3 3 ( ( 3 c $1,200,000 . Rec.ommendations From /-Tf Review Conimittee 'Ilic mtrrrbcrs of the 3Laf.i Anniversary Review Panel reconiwnded t1iat ffnine's Rcgiondl Iledical Program be supported at the 1 cvel of $1,200,000 direct costs for the seccnd year of tricnpiurn. Thcsc: funds will provj de support for program staff, operatiopa: activities and a devcl-opmerital. component. This repr~sciits an increase over the Region's current. annualtzcd J eve1 of funding. An increase was considered justified by the SARP because of Llie Region's current stage of development. "he Staff Anniversary Review Panel was impressed with thc Regjon's continuing t-o refjne its objectives to: (I) conduct ej.:perimeiits in new riicthods for deliv- ering health services; (2) develop new health nianpowrcr; and (3) update level of medical knowledge for health proiessional- and public e The objectives are directed tor67ard solving $kine's uiiique problems, and yet are still in IrceTiing k7j th national priorities. realistic assessiiieni of needs and appeal- to be functional as guidelines Lor operating the progrsin. These reflect input from providers, consumers, and low-income members of the TUG. HRHP has continued to cstablish its leader- ship role througliout the State. services to undcirserved, urban and rural areas of the State. A substantial anount ($1,666,465) was awarded during the latter part of the current year to support supplemental activi ties in erner3cnc.y iiiedi cal services and health servicesleducation activiti cs over a three year period and although this was a plus for the Region, reviewers were somewhat concerned about the capability of program staff to adequately manage such a tremendous increase in the Region's overall budget, Although their fears '117ere sornerdw t relieved by the information that one nicmber of the staf€ would bc responsible For the administration of the hs/ea (l.IEIIEIk), stafF was urged to express this concern to the Rcagion. Somewhat paradoxically, there vas concern about the large projected starf increase fi-om 25 to 32 positions; arid rhe lack of inforination supporting the rat ionaLe for the projccted increases The SARP showed concern for the one to one ratio of proFessional and clerical positions; and the Coordinator 's salary as being clispropor tiona tc to the remainder of staff, RMPS Xanagement Assessment Unit wjll work wi th the Region to resolve The priori ties reElect a The I'rogrm has been successful in providing these issues. e c EOU: 9/7/72 , . . .. . . . .I I Ted Griffith --- ---- - Collductcd: none os early' 1973 S ch e du 1 c (1.: *. d st Site Visit: .June 1971 (in response to triennial application) Mrs. Florence R. Wyckoff [National Advisory Council) Brudt? Evxz4.st, M.D. kb$% p. Carpenter, M.D., Director, Western Pennsylvania RMP Paul Dygert, M.D., private practitioner, Vancouver Washington (National Advisory Council) Staff Visits: to clarify the geographic relationshi , Mississippi anl Western Tennessee ing the grbgrams s W) is der by ms. Silve&Et4tt, Lamptofl and cur MID-SOUTII POl'ULh'l'TON CEN'I'BRS AND h4 ED 1 C A L ?' R A I N I ?.:G F' R OG R A Ms Comprehensive Health Planning B Agencies Comprehensive 1 leal th Planning B Agencies The Bootheel Council (Missouri) : as well as the funded CHP(b) agency. program stafE subsidy, MItllp assisted with identification of needs and development of priorities. 'I'his is MRW's Area Advisory Council Through contract funds and The Jackson Purchase Council (Kentucky): as this council was forming. MRMP provided data base NW Tennessee Council: MRMP prepared portions of this council's application; did the leg work to start the office; presently is budgeting contract dollars to assist in identification of needs. WCC: Council has excellent overlap; products of joint efforts have been outstanding and are expected to continue under new arrangement. Formerly W's Regional Advisory Group; new Regional Advisory District #I Council (Mississippi) : WMP did leg work in establishing; budgeted $15,000 contract dollars through A agency to catalyze. Not yet funded for operations-- District 42 Council (Mississippi) : Still in process of organization. Activities under requested Developinental Component include completion of work in this area. District #3 Council (Mississippi) : MRMP contributed $4,000 f or survey work; included in hW's EMS plans. Funded through Appalachia- - NE Arkansas Council: of data base. kRMP assisted riith planning funds and development ./ -- IO Ak IC C3 AlrARDEO bW4RCEC E? c4 CCtPChFhT c1--- 02 --.-- '! ``E __ . - ._ 09/70-08/71 04/_11-1217? _- TPIPL ** 01173-12/73 _____-__-_ 01/74-12/74 C1/75-12/75 TCTbL It la ** I NO 39 1092 2 162700 325400 1CEz4C 21'17174 ** 20lC922 1900000 COCO FPCGFbY STCFF 5357CO s~e234 7) 162700 c E1AL 592 100 L654tCC 15128 6 127980 ** b195964 32t7e23 zesais3 - - 96 22 mar c Region: Memphis Review Cycle: October 1972 Demographic Inforrnat ion I. The Region's Coverage: Consists of parts of five states traditionally known as the Memphis trade area on the basis of hospital referral patterns. Made up of 75 counties: 21 in West Tennessee 16 in Arkansas 27 in Mississippi 6 in Missouri 5 in Kentucky IT. The Region's Population: Contained 2,560,032 people in 1970 Most populous subregion is the Tri-County area containing Shelby County, Tennessee (Memphis) ; Crittenden County, Arkansas ; DeSoto County, Mississippi with 802,000 residents--nearly one-third of the region' s population. The other subregions contain the following population : North Mississippi 662,559 West Tennessee 459,404 SE Missouri Kentucb 329,626 East Arkansas 374,909 Although there is a shift from rural to urban areas, the region remains essentially rural, characterized by an agricultural economy. @%?%e exception of the city of Memphis, with a population of 624,000, the largest city has a population of less than 50,000 (Jackson, Tennessee). The East Arkansas subregion has the lowest population density; even Western Kentucky, the most densely populated subregion, falls below the national average. Only 13 of the 75 counties in this region have as much as half of their population residing in towns of 2,500 or more persons. Race mof the region's population is Negro; there is a small American Indian and Oriental population. Black population within subregions and by county is significant. However, the distribution of the Blacks comprise 73% of the population in Tunica County, Mississippi while the Ozark area makes a striking contrast to the rest of the Arkansas subregion with a very high white and elderly population. Nine of the 27 counties in the Mississippi subregion have populations of more than half Black. Ae dk subregion with the highest ratio of persons over 65 is Kentuchy; the lowest is North Mississippi. instance, has a 12.9% under age 5 average as compared to the national average of 8 o 6%. Tunica County, Mississippi, for Infant Mortality The infant mortality rate of the region is 28.9 compared with the national average of 21.7. subregion have rates at least twice the national average. Seven counties in the Mississippi Distribution of Physicians: In tlus region there is one physician for every 1,206 people. The Benton County, Mississippi ratio is 1/7,505 and DeSoto County, Mississippi has a total of 5 physicians--1 for every 7,177 people. ," - ' Income - Thessissippi subregion has the lowest income level. 4 counties in the MHMP territory with a family income of under $4,000, -- -. 0. Of the 3 are in Mississippi. 0 I Region : Memphis Review Cycle: Oct. 1972 HISTORICAL PRCXXAM PROFILE W's early years were spent under the watchful eyes of its parents-- The University of Tennessee Medical Units (the grantee) and the Mid-South Medical Center Council (the board of which served as the MEiMp Regional Advisory Group), As the program developed, its relationship to WCC evolved into an exceedingly fruitful partnership; UT has proven to be an excellent grantee- -vigilant but without co-opting tendencies. This region first received operational funding in 1968, activating 10 projects basically representing an extension of the medical center rather than a deliberate pursuit of regionalization. One of the 10, however, was a linkage and sharing of resources between hospitals in Paragould, Arkansas, and Kennet, Missouri. Reviewers of the second operational year application kept in mind that MRW had developed its operational plan under considerable pressure from DRMP to assume operational status and realized it had submitted readily available, attainable proposals for its debut. Initially, the second year continued the ongoing activities with the addition of an ICU project in Jonesboro, Arkansas. Supplemental funding in the second year (June 1970) allowed the region to activate 5 new projects and Memphis' regionalization was underway. was begun; cardiovascular clinics, operated by the Mississippi St. Board of Health, received funding; a demonstration program in home health care seated in Paragauld, Arkansas was started; and the expansion of the geographic bases of West Tennessee activities beyond Memphis/ Shelby County lines began. of events occurred that created a crisis for MRMP, its grantee, and MC--a sanitation employees strike, a hospital employees strike (both of which were of very long duration), and the assassination of k.. Martin Luther King. The majority of the Memphis medical center manpower was devoted to keeping the complex operational under great stress and RMP expansion temporarily took a back seat. The question of other continuing sources of funds after W support terminated arose in the review of Memphis'3rd year operational and MRMP went into its 3rd year with the message to start building continuity for its successful activities elsewhere. The triennial application submitted by the region the following year was a combination of: A mobile health screening activity in Northeast Mississippi Also during this operational year, a series cation. Staff felt the region had not really addressed this - . A requested Developmental Component authority . The continuation of 5 projects for their previously specified life . 3 additional years of funding for Program Services 'and for 7 . The termination (at the specified time) of 3 projects o 12 new proposals projects beyond their previously specified life The application requested $2.7 for the 04 year; site visitors recommended $2.0 for each of the 3 years; Committee and Council recommended $1.6 €or each of the 3 years; the Uirector, WS allocated $1.3 €or the 04 year. mental component authority . The site visitors, Committee and Council assessed the following pluses and minuses: None of the reviewers recommended approval of the develop- +The working relationships between MICC and RMP had indeed created a unique interface between Comprehensive Health Planning and Regional Medical Programs and both organizations were taking full advantage of the opportunities. -The organizational identification of the.EuiRMP Regional Advisory Group as the board of bNCC has created an administrative (and possibly legal) complication that needs to be clarified. of several organizations but ful activities it generated. +Mnh.Tp staff had developed a good role as "broker" for joint efforts -Paradoxically, did not have a good record of spinning off the success- -The Coordinator appeared to be overextending himself and needed RMP a good #2 man. and a replacement still has not been found.) (Ur. Charles McCall had left for the Texas +The region, nevertheless, has the potential of becoming one of Total RWS budgetary restrictions pennitted funding only at the $1.3 level. True to form, Memphis allocated these dollars to the 7 activities seeking 3 year renewals, but promised that this would be their terminal year; the 5 continuation activities were also supported; 2 of the 12 new proposals were activated. Hospital Learning Center, had strong subregionalization potential. In June of this year, Memphis received supplemental funds which brought it up to the approved $1.6 level for an extended 16 month 04 year. the better programs. One of the two, the blodel e True to its promise, it did not allocatc: any extens ion t ime or dollars to the projects schedulcd for tennination; it gave basical ly cxctcn- sion time dollars only to the continuing components; and it acti.vatccl 3 previously approved but unfunded activities a combination of 2 proposals. Collcctively, these activities display a good combination of training and service. In developing its budget for the extended current year, the region paid good attention to its future year budget needs and has not boxed itself in by activating projects that cannot reasonably be continued within the existing level. Conversely, it has learned to project turn over dollars rather well,' and it is this type of projection that will support the existing program's continuation needs. Memphis submitted an EVS proposal in April 1972, competing for $762,898 to fund for 18 months the first "year" of a 2 year activity. Memphis role had been identified in both the Tennessee and Mississippi state plans for a partnership of federal, state, community and private framework, as the lead program charged with the involvement of hospitals and medical schools to upgrade emergency room services, An award of $67,038 was granted for further planning and surveying needs. one of which represcntcd The region also competed in June, 1972 for supplemental funds for health services/education activities but the applications were not recommended for funding. COMPONENT AND FINA!!CIAL SUMMARY ANNIVERSARY APPLICATION DURING TJUEKNIW Annualized Funding 1st TR Year 04 - Current '. . I Council- Approved - Level FOT 2nd 'IR Yezr 05 - Component PTtCiGPAN STAFF b COSTRACTS DEVELOPMENTAL COMP . . \ OPER4TIOSAL PROJECTS p1 Kidney ENS (contract) ' hs/ea (contract) Pediatric Pulmonary C ther TOTAL DIRECT COSTS . COUNCIL-APTROVED LEVEL . - :.' . ..-., 1 ,,.... ,,.. . i .. .I ; .. ,. . 1,627,000 1,627,000' t Region's Reauest Forznd. 998,298 1,012,624 162,700 e. .. . . 1,094,205 i ( 506,000 ( 400,000' 1 3,267,827 Region : Memphis Reconmended . Funding For 2nd TR Year 05 - /-/ - SARP /-/ Review -- . Committee /Z;IYes 1 i 1 1 1 e Recommended - Level For Reminder of Triennium f 1 1,627,000 d I .., Princip:~I I'rob1cn:s : Please see attached staff ~neil~)r~i~dtiit~ Principal Accoinpl isluiicnt s Please see attached staff memorandurn ? Issues requiring attention of reviewers Please see attached staff memorandum .* /3 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE Dale: Re$y lo Atln 4: Subjccf: TO: From: August 17, 1972 Staff Review of the Memphis Anniversary Application Vr. Lee E. Van Winkle Acting Chief, IMPS, South Central 0 anch L/ 3s. Lorraine 31. Kyttle`f' Public Health Advis+ , - On August 3rd the following staff met to review the ?!emphis anniversary application for the purpose of identifying issues for the attention of reviewers: Mr. Larry Pullen, Grcints Management Branch F4r. Gene Nelson, Planning and Evaluation Mr. Ted Griffith, Region IV, HEW M.S. Lorraine Kyttle, South Central (Clperations Branch Remembering the concerns of previous reviewers of this region, staff elected first to consider the effects of the recently created Memphis Regional Advisory Council which is now organized as a body free- standing of the Mid-South Medical Center Council. As early as 1969, site visitors questioned the complicated organizational arrangement under which W3IP was operating vis a vis the >%KC. was officially designated as the bIRlP Regional Advisory Group, and the full membership me`; only twice a )-car. The real decision-making authority was vested in a 45-menber Board o!' Directors, which met 8-10 times a year. bMCC was and is a po:.+er-fiil and berieficial influence on health care in the Memphis inedical tr,-.de area. area covering west Tennessee; Crit tendon County, Arkansas; and DeSoto County, Mississippi, and as such i'epresents a valuable ally for RMP. The working relationships between RW md FNCC (0) are exquisite. The 151-member MMCC It is thc CHP(b) agency for the 14-county However, the 14-couity zandate vested in ?NCC gave rise to questions of the legality of that lmdy holding the decision-making authority for a program serving 75 ccuities an3 actiirely supporting (both with professional assistance and grani funds) activj tics beyond MMCC's geographic sphere. Beyond the possible legal issue, revicizrers challenged the cumbersome adniinistrativc structure such itn arrangement had spawned. A Policy and Review Committee within the RVP striicture had been created and was acting like a RAG in most ways, hut \MCC--Cffl' were important and that Memphis RhP was utilizing these opportunities we1 1, but the Region was given the message hold developmental component authority when according triennial status to this region last year. At that time it was acknowledged that the (. i<. `L- - *A- -----: ...,+;nnal at the decision-making level. c t 2 0 C)n June 28. 1972. the full membership of hMCC voted to accept a resolution presented by the'Board of Directors which disenfranchised &self as the RMP Regional Advisory Group. Memphis Regional Medical Program composed of 36 persons and vested in that body all of the powers formerly held by the Board of Directors of MCC with regard to RMP matters. It created a Regional Advisory Council for The new body is not simply a selection of 36 MMCC members (although it is difficult to assemble a group interested in health care delivery in the Memphis area and not have them be WKC members), made his first moves seeking a free-standing RAG, he proposed the establish- ment of a committee within WCC to explore solutions, and he involved Dr. Bland Cannon, a consultant to both MMCC and UT; Dr. Joseph Johnson, Chancel- lor of UT and an WCC member, and Mr. Norman Casey, Executive Director of MMCC and the CHP(b) agency. MC did create such a committee and all of the persons named above were included in the 7-member body. The committee reviewed the activities of W, considered nominations for a new RAG, and developed a working paper for guides to bylaws. When Dr. Culbertson The new membership reflects a good geographic distribution of the territory served; a 5-member overlap of WCC board members; and a Chairman, Dr. Francis Cole, who certainly knows his way around MCC, UT, 0, RGD, and the health needs and interests of the region. Dr. Cole was the chairman of the Policy 6 Review Cmittee and his confirmation by the grantee is assured. Proposed bylaws developed by the 7-member Committee mentioned above are up for discussion at the initial meeting of the new RAC on August 16. opment of revised administrative and review procedures is also on the agenda. Drafts of both documents have been reviewed by staff and the preliminary work done by MRW and the new RAC is excellent. Staff concluded that the region has satisfied the disqualifying factor concerning developmental component authority and recommends its approval for the last two years of the triennium. Goals 6 Objectives: Tn January 1972, MlMP sharpened and redefined its goals and objectives. (This need was cited by 1971 site visitors). broadly stated: (1) increasing the availability of care; (2) improving accessibility to care; (3) enhancing its quality; and (4) moderating its costs. objectives, but among the four statements MRMP has attempted to cover the full spectrum. attempting to digest the several different treatments of them in this application. Staff concluded that the pursuit MRMP had described of 3 goals did little to accomplish the fourth, but this we felt to most regions. The new goals are directly reflected in The devel- The 4 goals are still It was difficult to distinguish strategies, priorities and These are explicitly stated; our difficulty was in ecisions recently made by MRMP. AccomDlishments and Imlementation: 8 P It is in the area of program staff services and cooperative relationships with other organizations that this region probably excells in perfoimance but does not report on well. of them) there are references throughout other sections of the applica- tion to MRMP's inputs to other regional health efforts. it difficult to get a sense of the total contribution MRMP staff has made in the role of catalyst as well as architect. The expanded health care offered by Wesley House (inner city Memphis--hnded by OEO) stems from a proposal generated and partially written by MRMP staff; the experimental health care delivery system funded by a NCHS R t?, D con- tract originated from MRMP staff work; the recently awarded Sickle Cell Anemia grant from NIH had a heavy component authored by this staff; a family planning center proposal recently competed successfully for f-EMi4 funds and had its genesis in bRW. Planning groups and institutions have become quite accustomed to looking to RMP for tech- nical assistance and consultation, and MRMP has filled this role commendably. In addition to the Forms 9 (20 pages This has made Con? inued Support : This has been an area of concern for previous reviewers. year, the region evidenced only a vague concept of spinning off successful operational components. lot in a hurry, operational projects, which either have just terminated or will terminate by April 1973 resulted in the following: Until last They appear to have learned a Specific inquiry about the fate of the original 10 1 project terminated with no continuation of the activity 2 projects continued under other sponsoring but on a restricted 5 projects continued either at full range or nearly full range 2 projects (which will not terminate until April 1973) have bas is by other Cunding tentative agreements for future support, 1 of which the Mississippi State Board of Health plans to fully fund. Minority Interests: M the 36-member new Regional Advisory Council, 9 members are Black and 6 are women, Staff noted that one of the minority members is the controversial Mr. Ollie Neal, Administrator of the Lee County Cooperative Health Clinic in Marianna, Arkansas. Mr. Neal is known in the area as an outspoken proponent of the need for change in the health care delivery system. Since the submission of the Equal Opportunity Employment form 7 included in the application, the lone minority professional (a female) has resigned. for her replacement. only minority proSessional on a program staff in a region where 31% of the population it serves is Black. bW is recruiting a black, female nutritionist At this time, the replacement candidate is the .. 4 The activities MRMP supports reach the rural poor, which, in most of the subregional areas includes large numbers of Negroes, to an extent much greater than the complement of the program staff would indicate. The cardiovascular clinics supported in North Mississippi cover counties with high percentages of Blacks; the high risk infant component, which is regional, will target the minority population (it is just starting up): the proposal to expand the services of existing Memphis neighbor- hood health centers to primary care (and is a good combination of train- ing and service) primarily serves the indigent; the hypertension con- trol component operating in 3 northern Mississippi counties operates in an area where more than half the population is Black; and the arrangements entered into with the Lee County Cooperative Clinic (Mari- anna, Arkansas) for on-the-job training of nurse practitioners is an activity targeted to minorities. Grantee Oreanization: There has been no problem of grantee interference with RAG'S decision-making role in the past under the MMCC arrangement and none is expected under the new arrangement, Chancellor of UT Medical Units is an MnCC member, is a member of the new RAC, and keeps himself well-infoned on MRMP affairs. UT as the grantee is a proven partner without co-opting tendencies. Dr. Joseph Johnson, Process : Staff believes the Coordinator is overextended and whereas he gives good overall leadership, the need for specific mastership sometimes makes MRMP miss the mark insofar as responding to specific signals €ram RMPS is concerned, He needs, and has needed €or some time, a strong Program Director. time but not filled. The position has been budgeted for quite some The Forms 6 and 7 regarding the Program Staff give information that does not agree--the listing of personnel was updated later than the Equal Iinployment Opportunity report. As of August, 1972 there were loyees on Program Staff. The entire Program Staff Services budget (Salaries & Wages, Travel, Consultation, etc .) currently approximates one-half of their total program budget. When the last tally of RMP percentages was made (FY 1971) two-thirds of the regions were budgeting from 31 to 60 percent of their total funds on program staff and staff activities. to the health groups and institutions in its region--grant proposal writing being only one. The proposed Program Staff budget Vernphis submits for next year still Staff realizes that both the grantee and MMCC have informally advised Dr. Culbertson to stay below 51%. With the excep- tion of the Program Director vacancy (the needed #2 slot) staff unanamiously recommends that the region be advised no further 26 are classified professionals and 18 1 and secretarial. MRMP provides a tremendous staff resource service within the one-half mark if you delete the $1 million contract ory. expansion of program staff is deemed warranted. ?he personnel listing in the application reflects 13 vacancies and 36 filled positions, so some additions have already been effected since the application was prepared. a triennial status with certain budgetary prerogeratives, but a recommen- dation regarding no further expansion of program staff included in an advice.letter which reaches both R4C and the grantee would be potent. We realize that this is a region in Memphis KMP has assembled a staff of essentially full-time competent people who move very well in the health community. credentialed, but Dr. Cu1herl;on is the only full time M.D. on staff. They are well- Participation and Local Planning: It is this area, staff believes, in which hW has excelled, interests of the key health groups arc woven through MflW's activities (particularily its staff services) and conversely MRW is a partner in most undertakings of other organizations. Its superb collaboration with Health Systeins Management, Inc. (the organization developed to administer the NCHS - R 6 D experimental systems contract); WCC; W; UT and the Health Departments of most of the states involved in its teritory, forms a productive coalition. The Assessment of Needs and Resources: Staff resources are involved in almost a preoccupation with systematic identification and analysis of needs and resources, But this staff has developed an eminence in this region as a resource for data and analysis that has proven tio be the springboard for some excellent joint ventures. utilized by the state Department of Transportation and was one of the reasons for IW'S identification as a component in the state's emergency medical system. of data) is reElected in the activities of other health interests in the region as well as I\IRMp. For example, staff's studies on emergency rooms was Much of this type of activity (analysis Management and Evaluation: The order and scope of activities appear to be well-defined and under- stood by staff. A management assessment visit is planned for this region early next year which will provide more specific evaluation on this point. This past year, the staff has increased its vigilance, both fiscal and programmatic, over operational activities. Like many regions, the results of MRflP's evaluation efforts are still fragmented but they are aware of this and are attempting to get at the whole thing, application preparation, has been identified by staff as targets This area, as well as improved reporting via e o €or working toward with the region in the upcoming year. Since attaining triennial status, Memphis has instituted more sophisticated budgeting mechanisms to identify projected funds so that new activities may be initiated. The administrative procedures cover- ing the developmental component are in the process of revision and the work staff has done in this regard for presentation to the new R4C looks good. Program Proposal : There is a $1 million contract proposal under the Regional Staff Services portion of this application which breaks out as follows: . Inter-Regional Information Exchange Program $ 4,000 . Community Health Service Educational Activities $400,000 o Tennessee Nursing Association Manpower . ambulatory Health Care Centers . Emergency Medical Services Program $100,000 $500,000 Feas ib i 1 i ty Study $ 2,600 The ambulatory health care centers portion builds from keystone component #36, Expansion of Neighborhood Health Centers, an approved but unfunded activity of highest priority which is proposed for activation in this application. purpose of extending the Memphis/Shelby County concept of utilizing a nurse in an expanded role to the rural areas of the subregions. Endorsements of the concept have already been secured from local physicians and early implementation is promised. The community health services education component proposes the expan- sion of the model hospital learning center recently funded at Jackson- Madison County Hospital, Jackson, Tennessee (component #32) to a net- work of eight such learning centers. The expansion proposes a second center in Tennessee (at Union City), one in Kentucky, one in Arkansas, one in Missouri and 3 in Mississippi. basically as the Jackson station is, the individual programs would be determined by local conditions. the proposal seeks to: Basically, the $100,000 contract request is for the Although they would be patterned Based in an active comity hospital, . develop learning centers which provide instmctional materials, trained personnel and organized channels of corramznication with the UT Medical Center Library and the UT Audiovisual Department-- , create a MRMP regional development liaison office that can be a focus for RMP activities in the area-- . train local in-service leaders to respond to regional requests . encourage residency and intern training programs, working for assistance-- collaboratively with university medical centers - - - . improve arrangements with local vocational and community colleges to expand allied health manpower training- - . encourage quality control systems such as FAS/hW-- . initiate consumer education programs. The emergency medical services program is essentially a resubmission of an activity Memphis proposed in the spring of this year competing for supplemental funds. to further survey and plan total EMS needs. that by January 1, 1973 (the beginning of this region's next operational year) this will have been accomplished and it again requests operational monies. into this proposal, preliminary consultation should be arranged with the Division of Professional and Technical Development. At that time, $67,038 was awarded to the region The region tells us Staff recommends that should MRMP budget operational dollars Briefly, the new activities are: #41, Patient Safety and Electrical Surveillance proposes education to promote awareness of electrical hazards and safety measures; a regional pacemaker referred clinic (at UT) and registry; a regional cardiovascular health delivery team to upgrade the knowledge of the general practitioner concerning his cardiac patients. practitioners in two settings: the Lee County Cooperative Clinic (Marianna, Arkansas) carried out on a one-to-one basis with Clinic physicians; and (2) intensive sessions at the Arkansas Medical Center or at UT, whichever proves to be more expedient. This proposal has encountered some political controversy since the original clearances were secured (a local health professional who ran unsuccessfully for governor included the danger of this type of activity in his plat- form). is working with MRMP hopefully to implement the activity under the auspices of the county medical society. #43, Regional Blood Banking proposes to link the small community hospitals in the region to the Baptist Hospital Blood Bank in Memphis. 2 years, after which the project should be self-supporting. #42, The Satellite Clinic Program proposes the training of nurse (1) on-the-job training at However, the Marianna Community Hospital's new administrator The region estimates that RMP support will be needed for The descriptors covering the 15 components proposed for funding reflect: . 67% of the component dollars are in activities that combine training with patient services . 12 of the 15 offer multicategorical pursuits . 9 activities (35% of component dollars) are subregionally based , .. .. . ..: . ! : ... \. .I -3 -. -j.r S 0 . . 4 activities (56% of component dollars) are regional activities with ties to central services . 2 activities (8% of component dollars) are a network of central and satellite units , two-thirds of the activities are sponsored by other than the The $1,381,870 requested for operational component funding is comple- mented by $1,044,781 funds from other sources ($23,000 state funds, $911,781 local funds and $110,000 other federal sources). single medical school in the region. STAFF RE-TIONS : This application requests $3,267,827 direct costs for the second triennial year (the region's 05 operational year). annualized level of Eunding is $1,627,000, Staff recommends an increase in the approved level to permit funding at $2,252,000 based on the following rationale: $1,627,000- -to support current program for the upcoming year which is The current ~ rather tightly budgeted on projected turnover dollars to continue activities initiated in the extension period. $ 162,700- -for developmental component $ 237,30O--to support selected new activities including the 225,00O--to pursue selected activities under the contract request keystone component #36 $ $2,252,000 a/ b~magcrilcnt Survcy (Date) : -* process Verification Vis it cafeducted july 25, the Region was certifiad. i # dran M.D., Review Cmittee (Chairman) . Robert Brown, KD., Coordinator, Kansas R)pB Jack Hall, M.D. , %+odist Hospital Indianapolis George Hinkle, Grants Management Branch Joseph Jewell, Grants Review Branch Elsa Nelson, Continuing Education and Training .Branch Jeabne Parks, Grants Review Branch Eugene Piatek, Office of Planning and Evaluation Maurice Ryan, Program Director, Region V WS STAFF: Attended two RAG Meetings and visited the MARMP Staff once(Pgm. Dir.) ting (Program Director) tend RAG Meeting-. met Dr. Tuner [Program Director 6 SCOB Staff Rep.) /7-10/72 Attend RAC,' Retreat - Consult on preparation of anniversary application (Program Director 6 South Central Operations Brand Staff Representative. Accompany Dr. Himm, Dm, on his visit to consult with major health providers interested in developing a state kidney plan (Program Director 6 Staff Representative) -. , . ..,.-lL ---_ _- n;*ar+nr p C+aff Rpn.\ .-.- - -. - 2- <--,. 6:& 1- &-&a -.-* 7' RECENT EVENTS OCCURRING IN GEOGRAPHIC AREA OF REGION 2 Appointment by Governor Milliken of Irving A. Taylor as Director of the Office of Comprehensive Health Planning. I Coverage of entire state by CHP areawide (b) agencies. Beginning development of an emergency medical services state plan. (A cooperative effort between MAW, CHP, Department of Public Health and Office of Highway Safety Planning.) Initial meeting (June, 1972) of all individuals and organizations ' interested in the development of a state plan for the prevention, detechtion and treatment of kidney desease. (Co-sponsored by MARMP, the State Office of CHP and &e Michigan Kidney Foundation.) Development of a "State Plan for Nursing Education in Michigan, Phase 11: Planning for Licensed Practiual Nurse Education" (Provisional) . Formal incorporation of Area Health Education Centers in Grand Rapids and Flint. Passage of certificate of need legislation for acute care general hospitals. In May, 1972, Michigan became a member of the National Institutional Television Consortium in order to promote health education for 8-10 year olds. Selection of two DEtroit agencies (the Detroit Health Facilityssthe Detroit Medical Foundation) for receipt of Health Maintenance Organization Planning E unds. Michigan receiving four assignees from the National Health Services Corps. Wit3im tB4& Academic Sphere Michigan State University: 1, Formal insitution of on-campus headquarters of the College Osteopathic Medicine; first on-campus classes held; an increase from 36 to 64 students entering the 1972 class. 2. The School of Human Medicine graduated its first class of medical students. - 3- Wayne State University: 1. Entering into phase I1 in the development of a large scale ambulatory facility to be located in the Detroit Medical Center Complex where students will be able to rece training in an ambulatory and multidisciplinary setting; the opening of Scott Hall, the basic science unit for the Medical School that permits admission of 256 medical students; establishment of a Department of Family and Community Medicine under Dr. Ruben Meyer (RAG member). University of Michigan: Redesign of the Post Graduate School of Medicine to provide for community extension* ng the most recent results stemming from the consortium of the Deans the four medical schools is the capacity for a student in any of the r SC~OO~S to take elective courses for credit in anycof the other ive 8.9 MILLION PEOPLE CLUSTER MAINLY IN THE SOUTHERN ?ART OF THE STATE ALMOST 80 PERCENT OF THE POPULATION LIVE IN THE 17 MOST POPmATED COUNTIES, - 1 1. Population of Michigan Counties (1970 Census) 400,000 or Over 1. See table, No. 67 e ... .... . I' _C.__ I i .j;.;--:=. ... .... ...... ... .. . :._ ..... .... . .:. .. . ............... _I .. . .* .. - ... - \I. .. ' 1~11 s i.n y s C~I C) o 1.5; ' .. .. . ,-___IL--------- , ,i /. .. -7- .. . .AI 5% Lv. . . . , .. . f , i Michigan RMP ' COMPONENT WD FINANCIAL SUiWRY Review Cycle October/72 ANTIVERSARY APPLICATION DURING TRIERNIUM Conponent PROGRAY STAFF COSTRACTS DEVELOPMENTAL COiW . 6 OPERnTIOXAL PROJECTS Kidney ENS hs/ea Pediatric Pulmonary Other TOTAL DIRECT COSTS comer L-APPROVED . LEVEL Current . . Annualized 04 Funding TR Year 160,598 1,483,784 1,924,566 ~~ 2,100,000 Counci 1 - Approved - Level For TR Year 05 . - 2,100,000 2,100,000 ? Region s Request For .TR Year 05 - 425,940 -0- ` .192,'350 2,379,189 c -0- I ( . -0- 1 ( -0- I 2,997,479 Reconmended - Funding For TR Year 05 - /-/ Review -. Commit tee I 1 ( 1 I. I I I c Recommended Level For Remindcr of Trienniun I co 3 \ *The Region identifies two projects (#45 6 #46) as Health Service Education Activities, when in fact they do not meet RJ4P.S' definition of such an activity. ,The titles of these projects wil*'bT.? ,$.$ .* 1 ' 9**y .I 8 I` changed. < ,.> 4AL _. -~ '4 -2 . - _- AUGUSl--8~19?2 - - 8REAKC:UT OF AEQL1EST --- ~I_ -- -- 05 PROZRAM PERIUD - IS1 (21 (41 f IDEf4rIFICATION OF COMPONENT I CONT. WITHINl COW. BEYOND! APPR. NOT I NEW I I' . .. -12- . HISTORICAL PROGRAM PROFILE OF THE MICHIGAN ASSOCIATION FOR REGIONAL MEDICAL PROGRAMS Nov. '65 - Governor's Council on Heart, Cancer, and Stroke met to discuss PL 89-239; Albert Heustis, M.D., Chairman. Dec. '65 - Dr. Marston, NIH, met with health providers to discuss a RMP in mchigan. June '66 - The Michigan Association for RMP was incorporated. June '67 - The region's first planning award was granted. Sept.'67 - Albert Haustis, M.D. was appointed full-time Coordinator. June '68 - A pre-operational site visit was conducted. The region was considered to be viable, cooperative arrangements were being fonhed'and.operationa1 projects were likely to lead to desirable regionalization. (No negative findings were revealed.) June '68 - The region became operational. The first year operational program consisted basically of the Central Planning Staff, subregional planning projects (at Wayne State, Michigan Dept. of Health, Michigan State Udiv. and Univ. of Michigan) and continuing education activities, a large portion of which were sponsored by the University of Michigan. were almost entirely sponsored by major health institutions (medical schools, Department of Public Health and the Heart Association). education project which was to become, in the 03 year, identified as a subregional planning activity. no emphasis on a particular disease category. The ten operational type activities Zieger/Botsford Hospitals sponsored a continuing The overall program placed July '69 - The region was awarded 2nd year operational funding. National reviewers found the region had exhibitied growth and maturity under excellent leadership. superb. The region's review system appeared No negative findings were revealed. The second year operational program continued along the lines of the first, but with some exceptions. Department of Public Health subregional planning project was discontinued and stroke began to emerge as a major emphasis with the funding of four related projects. Spons~rshfp of projects remained with major health institutions. Support of the -13- Aug.'7O - The region was awarded 3rd year operational funding. The reviewers believed MARMP was on target. considered too small. concern regarding the contributions and the relationship to the Central office of the four subregional planning offices. Quantitative project evaluation needed strengthening. Program staff was Both the region and the reviewers expressed While the third year program remained basically the same as the second, the region took more interest in the underserved and funded a related project. than the traditional institutions were funded. The continuing education project at Zieger/Botsford was identified as a subregional planning project under the central program. Also, more projects sponsored by other June '71+A pre-triennium site visit was conducted. The region received a favorable review by the site visit team, Committee and Council, and was approved for triennfum and developmental component. Issues raised by th&s review are elaborated on in the Staff Observation Section of this document. pt. '71- The region began its 04 year of operation with an award of $1,923,509 for program staff, de$elopmental component, three subregional planning projects (University of Michigan is dis- continued) and 11 operational projects, most of which were initiated in 02 and 03 years. Additional emphasis was placed on delivery of services to the underserved with the funding of three related projects. Also, the MSU planning office took on the cew look of a project designed to improve services to a specific underserved population. I, -Albert Heustis, M.D. resigned as Coordinator and Gaetane Larocque,Ph.D., the Association Coordinator, became Acting Coordinator. , - Gaetane Larocque, Ph.D. resigned and Theodore Lopushinsky, Ph.D., a Program Representative, became Acting Coordinator. y 1, - Robert Tupper, M.D., Director of Medical Education at Pontiac 3.972 General Hospita1,became permanent Director.(Title changed from Coordinator to Director. ) 2 - The region's 04 program period was extended 4 months(9/71-12/72) and with supplemental funds the region's award is increased to $2,566,087 for the 16 month period. July 6, - Region submitted current application for RMPS review. 1972 STAFF OBSERVATIONS - 14- Principal Problems Previously Identified E Achievements toward their Solution The site visitors' concern of a year ago regarding the future of the program upon Dr. Heustis' resignation was justified. It took the Board of Directors eight months to recruit and hire a new Director, during which time the program progressed at a slow rate due to a lack of leadership, resignations of staff (at one point there were only two professionals on staff) and an accompanying morale problem. and the hiring of additional staff, 'there is a new enthusiasm and vitality throughout Michigan RMP. After being aboard only a short time, Dr. Tupper became aware of how accurately the national reviewers of a year ago identified the more significant problems of the Region which demand immediate attention. Following are concerns identified a year ago and relevant comments. Since Dr. TUpper's appointment Concern: Goals and objectives were not stated explicitly in quantifiable terms nor were they related to identifiable time-frames. The retreat scheduled for a year ago to deal with this problem never took place. The new planner/evaluator has worked out with Dr. Tupper a specific concept to deal with the problem. to and accepted by the RAG at a June '72 retreat. The RAG has identified some general areas of possible program direction. Based on these staff is presently developing a specific program, with alternatives, to be presented to the RAG for endorsement. This concept was presented Concern: A need was identified for a more systematic evaluation system. A new planner/evaluator has been hired who has an excellent background in evaluation. every roject and in cooperation with the Project Director is wor ing out an agreeable evaluation mechanism. concept for planning and the developnlent of goals and objectives has program evaluation built into it. in the areas of allied health. He is currently site visiting His Concern: A lack of depth of program staff was noted particularly Three people have been added to the professional staff which now totals five. the other three are genera1ists.h. Tupper tentatively sees a total of about 13-15 professional staff most of whom will be generalists. Specialists and allied health people will be considered in relation to the new program look once it is developed. Of these, two are. specialists, _. - I. .. ... -15- Concern: The salary structure for central. program staff should be more equitable to that of institutional program staff. Concern: Central program staff salaries have been increased in an attempt to make them more equitable. are for the most part now equitable with those of institutional positions with the exce tions of the Director at Wayne State ($32,000) his Deputy ( i 27,000) , and the Director at Zieger/Botsford at ($30,000). are comparable to those of other regions. Salaries Most salaries The relationship of CHP to MARNP was unclear. In June 1972, MARMP and CHP held a combined retreat to improve dialogue and planning efforts. time, Dr. Tupper and the CHP (a) Director have established close working relationships as have ?Ae two staffs. are working closely in the development of a state kidney plan and a state emergency system plan which will be jointly funded. which appears to be the first step in continuous dialogue. Plans include assigning staff members as liaison to specific @) agencies. The 'Iregion should refine its mechanism to insure more realistic budgeting and financial control of funds. Dr. Tupper is aware of the problem in this area, and he expresses his awareness of the need to 9requent- IY monitor program expenditures so as to use rebudgeting more fully in promoting efficient program expansion. Consideration should be given to haw MARMP might improve its image and visability to both the professional and lay constituency. New organization plans include a Director of Cmunications. Responsibilities of this position will include the publication of periodic news letter and other, wrspecif ied means of promoting NARMP and it5 mission. Staff supported in the three subregional planning offices be identified with MAfi"Mp and be identified with programs and activities which are directly related to b!ARMP goals, objectives and priorities. The budgeting for subregional personnel and functions be separate from other programs which may be carried on in the institution. A line of authority be established between the central office and the staff of the subregional offices and be so refl.ected in an organizational chart. Since that They Dr. Tupper has attended CHP (b) meetings -ID- - During the past year considerable change has occurred with respect to the functions of the subregional offices and their relationships to the central office. "his change represents a phasing out of subregional planning as it has been functioning in the past. The Michigan State University planning component has been altered so that it no longer serves as a subregional office conducting many diffuse activities, which due to overlap, confuses evaluation. While it maintains the same title it in fact is a project having the specific mission of developingt9in cooperation with 314 (e) grant; a family health center, underserved of a rural area, Cass County. will serve as a model for the rest of the state. staff includes personnel serving in the center. project is consistent with the region5 goals and objectives and will be considered as any other project including the expectation that it will terminate by 8/74. and continuing care models for the Thisfin turn, Project The With the submission of this year's application, the Wayne State Planning Component now represents a specific project designed to develop prototype family- centered, hospitalrbased, primary health care organization in Mt. Sinai Hospital, which has the potential of becoming an I-Ml capable of serving a low-income population of 10,000, As with the MSU component, while the title remains the same, the project will be subject to the same conditions and evaluation as any other operational project and will be expected to terminate by 8/ 73. The Zieger/Botsford Hospital participation activity has not undergone much change. It remains basically the same emphasizing an effort to document the quality of care being delivered to the underservecl,and through the use of PAS and peer review improve services. To date, no progress has been made to incorporate this activity as a part of program staff or completely isolate it as a separate project with a limited period of support. Dr. Tupper has a strategy for terminating the project, but it will necessitate a trade off for a smaller staffed osteopathic subregional office which will be directly responsible to him. Problems Not Previously Identified but which are Recognized and beine Resolved bv the Region. Problem: The region's bylaws are in bad disarray and are not consistent with the RNPS statement on Grantee-RAG relationships. -17- Dr. Tupper, the board and RAG are wrking together to develop bylaws which do comply with the RMPS s tatment and incorporate other suggestions made by WS staff. e Problem: Few minorities (1) and no women are employed on program staff in professional positions. Dr. Tupper is aware of the problem and intends to make special efforts to recruit both minorities and women to professional positions. Problem: MARNP activities are limited to the southern and particularly the sourtheas tern part of the state. Dr. Tupper is aware of the situation and will be making special efforts to develop activities relative to the needs of the northern mral cammunities. Issues Requiring the Attention of Reviewers e basic issue is whether or not the reviewers believe the Michigan ogram is deserving of having its NAC approved level raised YO^ its current level of $2,100,000. f the *gion is approved and awarded the amount requested, it ill allow it to continue its basic program outlined for already spoken to in this document,however, a staff review of MAR@ is scheduled for August 29 and any issues resulting from eview, not previously identified, will be the subject eparate document. e , . . ,. _I .. . -. .. ~ _" - -. . .- . . .. .. . ,. .. ....... ... .~ ~. .. . . .. . , . .. . . ___ -. __ -. . .. ~r~ c: ,. , -'. .I I 1? I. - 1,924,566 r\ - c- 1.1 i '. -0- ,. n [ -/I- _- -...- _-"_._--_I- -... . 04 Year 05 Year 06 Year 2,445,891 2,325,89 1 Re qu e s~~d- $2,34 0 6 J 8 2,439,588 Recorm:lcnded* -- -__-I---- $1,500,099 2,110,000 The Icidney project is gxcl-uded Iron. the 04 year level but is hcliG>:? in the 05 and 06 year levels. CRI'I'T(iLTE : I^. Ccimittcc accepted the reconw~ndations~ of the site visit team with the exception of the funding level for the. first year of the trFeriniujn. The 04 year €undSng ].eve1 rcflects the CO~CET?S reviewers had aboiit some of the projccts l>!lG~? has choscn to fund and tlie fact the first year budgct period for the triennial i.s only for 10 .months. Cominittee w2s aware that these projects werc deceloped i'rior to the rethinkicg of the region and thc restructuriJl:, of MG and progrzm 5-taf f and feel that th? rzgion should bc- restricted during the iiist year funding, and they should ree~izluate the prcyosed activities and be very selsctive in the ones they dacide to fur,c;. direction of MRNP and coincide w:th the nbu goals and objcctives The pi0irct.s should reflect the new t i I i I It was not.ed by the .reviewers that IlPNP has macle a sigiiificant turnaround since the September 197 1 site visir., and have answered ~1.11 the criticisms of tliat visit. prograin arid the, new staff appear to be compe-tent ail! dedi.cated. Tlie leaders11 i.p and niaiiagemm t of M3F has dramatically irriproved and it was felt by the reviewers tilit the regiou has the maturity md ability to move forvard and should be a:ia.;ded tricniiial status: The RAG has becom~: actively involved iii ilirecting the I , I i $411,097 ---- Y 485,133 $896,230 .I_.-..-_IUIIII. $1,095,428 Tsr. ycar - 1,7;p,48( ( 183,634 J 3 ( I-_.- S 666,387 250,000 . 1,529,504. (120,4G3) ( 150 3 4 1 ) I $ 513,823 $ 633,842 I i A Region requested a Tour month extension and wds a $321,U53 for continuation. year to 10/72. This extended their 03 operational ** Ten month 1S'udget SITE VISIT REPORT MISSISSIPPI REGIONAL MEDICAL PROGRAM JACKSON, MISS LSS IPPI JUNE 29-30, 1972 Site Visitors Joseph W. Hess, M.D., Detroit, Michigan, Chairman, Site Visit John P. Merrill, M.D., Boston, Massachusetts, Member of Claude E. Nichols, Jr., M.D. Harrisburg, Pennsylvania, Practicing Mr. Donald Trantow, Evaluation Consultant, Director of Assessment, Team, Member of RMPS Review Committee RMYS Hational Advisory Council Physician, Member of Susquehanna Valley RAG Georgia RMP Regional Medical Programs Service Lee Van Winkle, Acting Chief, South Central Operations Branch William Torbert, Public Health Advisor, South Central Operations Vernie Ashby, Public Health Advisor, South Central Operations Eugene Nelson, Office of Planning and Evaluation Earle Belue, Division of Professional and Technical Development T. H. Griffith, SEW Region IV Representative for RMPS Branch Branch Mississippi Regional Medical Program Staff T. 1). Lampton, M.D., Coordinator Pat L. Gilliland, Assistant Director for Administration Guy T. Gillespie, M.D., Assistant Director for Planning James B. Moore, Ed.D., Assistant Director for Community Bob Cotten, Communications Specialist Betty Zimmerman, Grants Management Officer Jack Gordy, B.S., Planning and Evaluation Assistant Tom Brooks, M.A., Health Planner Nita Gunter, M.A., Sociologist - Demographer A1 Betts, Program Specialist Carlyle Baker, Program Specialist and Evaluation Liaison and Program Development -2- - Mississippi Regional Medical Program Regional Advisory Group Lewis Nobles, Ph.D., President of I4ississippi College, Guy I). Campbell, M.D., Member of RAG David B. Wilson, M.D., M.P.H., Chairman of RAG Planning Chairman of Regional Advisory Group Committee Participants Robert E. Blount, M.D., Dean and Director, University Medical Center Charles W. Flynn, Mississippi Hospital Association Cyril A. Walwyn, M.D., Mississippi Medical and Surgical Association, Minority Group Representative Richard E. Barba, Mississippi Division of American Cancer Society Miss Lucile Little, Mississippi Heart Association Frank M. Wiygul, M.D., Mississippi State Board of Health Pxthur A. Derrick, Jr., M.D., Mississippi State Medical Mss Wynema McGrew, Mississippi Nurses' Association Alton B. Cobb, M.D., M.P.H., Medicaid Commission Representative Phil Laird, CHP "A" Agency Association -3- Purpose of the Sire Visit The site visit was to review the Mississippi Regional Medical Program's Triennial. Application request and to ascertain the progress made by the region since the previous staff assistance site visit: of September 1971. This site visit report is a compilation of observations and conclusions from all members of the site visit team and follows the outline of the RMPS Review Criteria. A. Performance Since the Staff Assistance Site Visit of September 1971, the Mississippi Regional Medical Program has taken many positive steps in developing a program that is now a major contributor and a very important leader in the rlolf77ery of health care to the people of Mississippi. The goals and objectives were expanded and delineated during a retreat of the Regional Advisory Group in December of 1971. are the basis €or the new direction MRMP is now moving. The RAG arid program staff were also restructured during that retreat which has resulted in a cohesive and dedicated working group. MRME' has not only answered and dealt with all of the criticism and recommendations of the 1971 site vlsit team, but has moved forward in the accomplishment of other goals. These The coordination between the University Medical Center and the MRMF' appears extremely good. MRMP has been instrumental in setting up a School of Allied Health at the University Medical Center for which a Dean has just been appointed. The number of midwives in the County Health Improvement Program has increased, resulting in a reduction of neonatal deaths in Holmes County. In 1968 the neonatal death rate was 28.0 per 1000 Live births. This was reduced to 19.8 in 1970 and 7.0 in 1971. Previously, the neonatal death rate was the highest in the country. Also in Holmes County, a number of pediatric nurse assistants have been trained under the auspices of MR?.? and medical care has reached out to the urban community with the establishment of a satellite medical clinic in a trailer. Renal satellite units have been set up around the state which has significantly reduced the cost of dialysis. In the University Medical Center the approximate cost per patient is $19,500 per year. In the trailer units (4 currently operational), the cost per patient dialysis has been reduced to $3,500 for units with 3 or more patients. - 4- Similarly, heart clinics have been set up which have resulted in care being given to patients outside of the hospital, again resulting in cost moderation. The initial establishment of a stroke care demonstration center has been expanded and clinics outside the hospital have now been set up where neurologists are available for consultation. An average of 100-150 patients per year are being treated. Courses have been developed for physicians and they have been invited to spend 5 days on the ward with a neurologist in the stroke care demonstration center. Some 20 physicians attended the course last year. been implemented by the development of courses for nurses. 15-20 nurses from various parts of the state attended courses last year. In addition, nursing care for the stroke patient has Some A pulmonary training program in inhalation therapy has been established and a-number of inhalation therapy aides trained, who may now function effectively nritside hospitals. trained 38 aides and was designed for the disadvantaged unemployed persons with 30 percent of the ones trained being minorities. The 20-week program has The original coronary care unit,funded by MRMP at ZMC, which at the time was the only one in the state, hzs trained 120 nurses in coronary care. of other units in hospitals around the state staffed by individuals trained at UMC. cardiopulntonary resuscitation. This has resulted in the establishment of a number Some 4,000 individuals have been trained in emergency h extremely important activity is the program for the training of dental hygienists. since there is no dental school in Mississippi. that perhaps this prograq may contribute to the establishment of a dental school. In addition, real effort has been made at establish- ing an adequate third party payment base to take over the cost of patient care when RMF' monies are phased out. There is a close rela- tionship with medicaid since the present head of medicaid is a member of RAG. This program appears to be particularly effective MRMP staff feel Another example of continued support is with the Hollandale Midwifeq' Project in which medicdd money is paid into a pool which is to help support service costs of the program; One possible drawback has been the fact that much of the effort of MRMP has been undertaken by faculty members of UMC. This has been possible through MRMP support, but since other sources of funding to support contributions to continuing education by these individuals is slim, it seems unlikely that in the future they can continue their efforts in this area. -5- There are specific goals, objectives and priorities dealing with the improvement of health care delivery for underserved minorities. MRMP activities have made primary health care services available in heart clinics, neurology, and active stroke programs in which over 50 percent of the patients in attendance represent minority and underserved groups. This type of care has improved services throughout the state bringing the health care team to the patient in settings dose to their home and only those patients who need the more extensive work up in the medical centers are referred. This has resulted in the specialty clinics not being swamped with routine patients that can be seen, diagnosed, and treated in the local area. The training of inhalation therapy aides has attracted minority groups and other project activities which have employed minority members. Minority patients have talcen advantage of all patient activity services funded by MIWE'. Dr. Lampton and staff have assisted minority professionals in obtaining hospital privileges in several instances. When the Black Hospital was closed in the Yazoo City area and patients were referred to the previowly all white hospitals, they assisted in getting the black professionals accepted on the staffs, and have also worked with the hospitals in becodng certified for medicaid and medicare programs. The program staff has one minority professional and one minority secretary. Further efforts are being made to employ Competent minorities in unfilled vacancies. One outstanding program the MRMP staff are involved in is with Black medica3. students that are attending school outside of Mississippi. Seminars are being held in which these studento are brought back to Mississippi in an effort to interest them in returning to the state upon completion of their studi.er;. The RMP has been instrumental in assisting minority groups throughout the state in obtaining access to health care services, and access to schooling that is available. B. Process Coordinator On the basis of previous visits by RMPS staff and the comments of a number of MRMP program staff and RAG members, the Coordinator has provided strong leadership and appears knowledgeable and exhibits -6- eiithuiiiasm. There was further evidence of this in the large number of organizational changes that have occurred since the September 1371 site visit. The program has developed a sense of direction and cohesion, and the Coordinator has succeeded in gathering about him a young,dedicated program staff who appear to have the potential for functioning effectively. There is evidence that some further maturity as Coordinator is yet to be developed, but there seems to be little question that Dr. Lampton has made substantial progress as a program manager. The working relationships with the RAG seem to be cordial and satis- factory as determined from the formal and informal statements of members of RAG. but has not been filled. Dr. Lampton indicated that he is concerned about finding a well-qualified pewson to fill this position. A position of Deputy Coordinator has been created Program' Staff The program staff does reflect a relatively broad range of professional and discipline competence although some of them are new and as yet untested in an RHP setting. improvement in this regard since the September 1971 site visit. A number of the older nembers of the staff have demonstrated effective administrative management capability although there is substantial room for improven?ant,particularly in the area of planning. Assistant Director for Planning and Evaluztion is a physician who is half time with W, the only half time-position on program staff, and he does not eppear to be very sophisticated in the area of program planning. master degree in Urban end Rural planning and lacks the necessary experience to provide strong support at this time. Unquestionably,there has been substantial The His C'nief Planning Assistant is a recent. graduate with a The program staff apFears to be adequate,except for the planning section. There was concern on the part of the site visitors regarding the salary level for several key members of the program staff. It was felt that the level was too low to retain competent staff for a long period of time. The new goals and objectives and the general orientation of the program staff sppear to be appropriate, but projects which have evolved out of the goals and objectives have yet to be developed. Regional Advisory Group The site visitors felt that most of the key health interest in institutions within tbe region zre represented on the RAG; and RAG nembers appear to be geographically distributed on the planning and executive cormnittees and the task forces. Jjr. Nobles, Chairran of RAG, is the president of Mississippi College and has a broad background in pharmacy. site visitors exhibited intelligence, experience, and practicality. He also has maintained contact with the State Legislature and has been active in lobbying far legislation to increase SU~~OK~ for training paramedical personnel. His presentation to the - 7- Most impressive has been the resrructuring of RAG. more involved in the activities of MRMP. The RAG is scheduled to meet 3 times per year, but in the last 6 months more frequent meetings have been held with a special retreat in December 1971, to reorient the program based cn recommendations of the September 1971 site v.lsFt and to develop the ciirrent set of goals and objectives. They have become Attendance at MG meetings have been running over 50 percent. a bylaw's requirement tha,t if a member misses more than 3 meetings he is dropped from RAG membership. as consumers out or" a total of 37. The consumers actively participate in the deliberation as shown by the RAG minutes. There is There are 11 RAG members classified Since the 1971 site visit, there has been a marked change in the role which RAG plays in the decisionmaking process. more actjvely involved in planning committee and task force work, and a system is being implemented that involves RAG members on monitoring teams est~hlished for each project that is approved and funded. The RAG is much The Executive Committee meets between RAG meetings, and the RAG has delegated to it authority for approving small projects and grants not over $2,000. tative of the total RAG, The Executive Cornnittee is geographically represen- Grantee Organization The grantee organization (University Medical Center) provides adequate administrative support and there appears to be a good working relation- ship with W. In general, it permits sufficient freedom and flexi- biiity and does not appear to be interfering wlth RAG'S policy making role. However, MRMP may need some special Consideration by the University In terms of personnel policy and the establishment of salary levels for program staff in order to assure appropriate working conditions to retain competent program staff. Participation The major health interests in the state appear to be participating and working well with MKMF'. Members of these health interests, including the Nursing Association, Medical Association, Black Medical Community, Heart Association, Cancer Society, State Board of Health, Veterans Administration and general practitioners from the rural community, were unanimous and enthusuastic about the aims and accomplishments of MU@ e Local Planning I MFMP has worked closely with CHP in developing "b" agencies. are currently 3 operating "b" agencies in Mississippi and MRMP has been involved In getting each of them operational. stated objectives for the corning year is to assist in developing "b" agencies in other local areas. There One of the program's -8- With the cooperation of MRMP, LO local planning areas throughout the state have been identified. these areas was supplied by MRMP. concerning organizations in 9 of the 10 areas and 5 of these are in the active planning stage at this time. There is an adequate mechanism for obtaining CHP review and comment, and the existing "a" and "b" agencies have input and comment on program proposals. Much of the data used in defining Active discussions are going on Assessment of Needs and Resources The MRMP has participated in and/or has available to it a rather large data base documenting the health needs and resources of Mississippi. the expertise needed to mve from available data to program develop- ment. *The needs of Mississippi are so extensive in the health area, that almost alijl Lype of project could find some rationale or justification. that a careful review and analysis of the available data be made to provide the context for an overall program plan of action which will be most cost effective and efficient in addressing the unmet health needs of the people as a whole. activity remains a weak point in MRHP at this time. , However, there has been, thus far, an apparent lack of Tfiis situation would seem to meke it even more urgent A systemtic planning All of the projects in the current trlgnnial application were developed concurrently with the rethinking of the goals and objectives and the restructuring of the RAG and program staff. Consequently, the current set of projects have not evolved as a result of the rethinking which has gone on during the last 10 months, although several of rhe projects are compatible with the directions expressed by the new goals and objectives. - Management The coordination of program staff activities has improved substantially since i" moved into its new quarters in which staff are in one location and in close physical proximity to one another. faction which characterized the progrsm in September 1971, and was rather freely voiced by prograin staff at that time, was found on this site visit. concern of the site visitors in having a half time person as Assistant Dlrector for Planning and Evaluation. weak area of the progran, it was felt that this position should be full-t.ime since new staff members working I.n this section will need guidance and consultation in directing the activities of the program. None of the dissatis- However, an exception to this general rule was the Since this is the one I. .. .. ,. , .. . -. .. , ..-, . -9- A plan has been developed for regular systematic monitoring of individual projects by both written reports and by site visits of project monitoring teamq, which include program staff, MG members, and other consultants as necessary. Periodic progress and financial reports are also required. Evaluation The program has a full-time evaluator who appears to have the potential to improve the evaluation activities of MRMP. He had been with the program only 4 months prior to the site visit. The projects which are currently ongoing, and the new projects in this application, did not have the benefit of his expertise, and the site visit team did not have R basis upon which to judge his performance, although their prognosis was optimistic. His plans for evaluating and monitoring projects, as well as for organizing total program evaluation, appears well conceived and practical. The site visit team was impressed with his presentation and felt that his input to the region will have a positlve effect. new projects, including those which are proposed in the triennial application. He plans to build more effective evaluation into A particular problem which was identified in the application is the difference in evaluative criteria between the stated objectives, project devezopment guidelines, technical review criteria, develop- mental component priorities, the FUG rating form, and the program evaluation statement form 14. This was called to the attention of the region during the site visit. C. Proposal The priorities of MRMP have been established and complement the need for health care in Mississippi. during a retreat of the Regional Advisory Group in December of 1971. The priorities are congruent with the national goals and objectives. In general, the activities proposed for the triennial application relate to the stated goals and objectives, although, for the most part, they were initiated prior to the RAG retreat. The priorities were established The methodology for monitoring and evaluating the current list of activities were olrtlined by the Program Evaluator during the site visit. The approach the region has chosen to pursue is both realistic and practical and the site visit team has confidence that the intended results proposed in the activities will be accomplished. In view of the fact that the University Medical Center is the only institution of higher medical training in the state, and with their program of continuing education, it is felt that the knowledge gleaned by MRNP will be adequately disseminated to the medical and allied health fields throughout the state. - 10- The communications specialist of the program staff has developed methods to keep RAG members, health care providers, and the general public informe6 on the various activities and the mission of MRMP. His input to the triennial application and his presentation to the site visit team is evidence that his knowledge of the region and of MRMP's mission will be a great asset to MRMP in the area of information and commication. The program staff feel that because of the paucity of manpower and facilities, the maternal and childcare facilities , which are the spin off of other projects, vi11 help to improve the utilization of manpower and facillties. ship will be a very necessary prerequisite, since 37% of the population in Mississippi is black, with 41 black physicians practicing in the state. which are not maintained on the surface but are, however, maintained in the mores and customs of the people, programs of this nature have an increasing beednp on the welfare of the entire state. The project for black physicians preceptor- In the view of the inherent problem of "separate but equal," With the Schocl af Allied Health at UMC and active recruitment of both black medical students and allied health personnel, there can be marked improvement in the number: of physicians and allied health personilel who will be serving the community. MRMP has shown, through the midwifery progrem, that individuals can be taken care of in outlying areas and that paramedical facilities will be developed, as proposed in the-currect application to increase the availability of care. There are ten planning and development districts in the state. MRMP recognizes the fact that health care generally follows trade patterns in Mississippi and that these ten districts form the basis of any approach to improving the health delivery systems, as well as the care that people receive in the region, with CHP to regionalize the health care in Mississippi. The current list of projects proposed in the triennial application is by no means the utopia for regionalization, but the site visit team believes that plans and uethods for doing this can be achieved by MRMP. KRNP is actively involved . *- . .. .. . .. . ..I .. . .:. Although the performwe generally has been socrd, there is a lack of agreexent on the part of the program staff, with the precept that: "evidence of support for continuation of successful activities in program by community organization or other Federal or State agencies after RMP funding has been phased out," should be provided. instances, staff argued that even though no evidence for continuing support is available and in all probability will not be available, the project should be launched and supported in and of itself. In many -11- A number of projects, particularly the kidney project, have been partially funded by agencies other than MRMP, and it is felt that each project will, in turn, be reviewed and evaluated with other funding sources being investigated. Re c omend a t ions 1. The site visit team recommends that the Mississippi Regional Medical Program be awarded triennial status, and that the triennial application be approved for funding as follows: 04 Operational Year $1,926,984 05 Operational Year 2,200,000 06 Operational Year 2,445,891 The triennial application includes a request for developmental component . 2. Strengthening of the Planning Staff: a. There should be a full-time director of the planning and evaluation section. b. Extensive training is needed for the new planning staff, including training visits to RMPs which have well organized and operational planning. Suggested RMPs are: Florida Georgia Northlands Ohio Valley Tennessee Mid-South 3. Emphasis should be placed, in the immediate period ahead, on the development of written program statements for each of the goals, 1 through 5, with priority and implementation schedules based on the goals and objectives agreed upon. Then these statements could be used as the basis for reevaluating currently developed projects and assessing the need for new project development appropriate to the goals and related program statements. 4. Better documentation of need, based on need assessment studies appropriate to local areas, which relate to program goals and objectives, is necessary. 5. Improved Technical Review input to the RAG and its subcommittees with greater emphasis on Technical Review in the decisionmaking process is essential to the program. -12- . .-. 6. The program staff and the planning committee of RAG should coordinate the evaluative criteria with the stated objectives, project development guidelines, technical review criteria, developmental component priorities, the RAG rating form, and the program evaluation statement form 14. the statements that should be coordinated: The following is a list of a. b. d. e. f. g* h. C. Guidelines--page 83--1st paragraph, Items 1-7 Technical Review and Rating Form--features 1-5 Developmental Component Priorities--page 100,l-5 Goals and Objectives--page 72A & B, I-V Criteria #2--page 146, "New Modalities. " RAG rating form criteria Application information for project applicants, 1-3 General Principles--page 82,l-5 7. MU-& should work to obtain CHP and State funding of ongoing health planning data collection and movement toward placing the data collection project into the State Board of Health or the CHP (a) agency. -8. MRMP program staff salaries should be reviewed with the UMC administration to see if a mechanism can be developed fur more adequate program staff compensation. an., 'William A. Torbert -, .. .. .' -. . .. .. -. , , . .. 1 ... -4.- . I_ __--_-_- --- c-~I~I)~~,~~TJI:: Theodore `D. Lampton, M.D. I,IiS`T IbY~IXG: . Eugene Nelson - P. & E. Staff ,for RFW: --- .- William Torbert - PHA - SCOB hwrence-i%Llen - Grants Mnmt . - -- I ---- --- 1% I .-. 11 1 1: 01: A1~1~1,lCA'I'ION: 3rd Ycar Regj 0113 1 Officc I\cprcr;cnYaLi\*e: - TheokJL GrCffith LI / x / Tyj.c]inj :i1 / / `l'~-icl~lli~l~ I- L1 I\l~llrl~CliIC71t SUrirc)' (Date) : - 2nd Ycar - /- / `j'rictit~ial / / Other COl1 du c t c d : Scheduled.: May 22-25, 19?2 or , I- -- ast Site Visit: - Staff Assistance rj L&K-- Chairman - Dr. Joseph Hess, Committee Dr . Anthony Komarof f , Council Dr. McCall, Consultant . Br. Levenson, Consultant . Dr. Vaun, Consultant w Staff Visits in Last.12 Months: Dec. 1-3, 1971 - .RAG Retreat and Staff Assistance - DATE PURPOSE Mar. 22-24, 1971 . - RAG Meeting of Project Review April 1972 - . Staff Assistance May 18-19, 1972 - Verificatiop of Review Process . Recent events occurring in geographic area of Region that are affecting RMP program: Highlights of activities during the past year involving MRMP program stafif: 1. In June 1972, Govergor Waller appointed Dr. Risher as head of CHP(a) agency. 2. An EMS saatewide planning council was established with 'all agencies involved in Emergency Medical Care participating. Creation of the new School of Allied Health at the University Medical Center. A new Dean was appo*nted on July 1,. 1972. L2, 3. k c 4 4. The new Riverside Psychiatric Hospital opened -- only privately owned Psychiatric Hospital in Mississippi. -..-J @$@ 'C'"J*, --a - 5. Maternal and Infant Care project in Holmes County under the County Health Improvement Program has been expanded to 3 other counties - Warren, Sharkey, Isaquena. Applachian Project became operational and was funded at $2.4 million. 6. 7. Three Regional Vocational Centers established in Mississippi that included some training for health careers. 8. A New School of Nursing established at the Mississippi State College for Women in Columbus, Mississippi. 9. Legislation has been passed and the Board of Trustees have approved a new dental school for Mississippi. 10. A'Nurse Anesthetist program was established at the University Medical Center. 11. The Legislature passed a sickle cell screening program for the public schools. 12. Moorehead Junior College, in the Delta, has initiated a new program for upgrading WNs; to RNs. Tri County Comprehensive Health Program (Yazoo, Madison and Leake Counties\- funded at $416,000 under the Experimental Health Delivery Services. 13. 14. Five National Health Corp personnel assigned to Mississippi. 15. Full-time director of family planning appointed in the State Board of Health. 16. First class of dental hygenists graduated in June df 1972. 17. New Helicopter ambulance service in Hattiesburg. the state. The only one in 18. MRMP was the sponsor of Mississippi's first "Health Expo" held during the first three days of October, 1971, which drew throngs of interested people from all areas of the state. DEMOGW PHI C I NFORMAT I ON Tota I (2 1 393.5 Biloxi-Gulfport 134.6 Jackson 258.9 . - POPULATION: (1970 Census) @a :&?$ Total Population: 2,216,912 $ Urban: 44.5 ..-Qx ' Population Density 46.9 per sq. mile $ Non-whi-I-c: 37 Age Group, 1970 Age Group State U.S. 34 Under 18 yrs. 38 18 - 65 yrs. 52 56 65 yrs. B over' IO IO ETROPOLITAN AREAS AGE D I STR I 8UT I ON Source: Bureau of The Census - PC(I)-AZG and PC(I)-B26 1970 - 1'970 Census of Population; . State and Countv ,U26 INCOME - Average Income .. per Individual, 1969 State (of RMP) $2,192 United States - $3,680 Source: State data from Statistical Abstract of the U.S., 1970 . I, (Dept. of Commerce) HOSP 1 TALS Non-Federal Short- and Lona-Term General HosDitals. 1971 Short-Te rm Long-Term Number of Beds --I---- Number I-- 115, 9,262 0 0 V :A. Genera 1 tlosp i ta 1 s 2 I ,576 (One has long-term unit) Source: Mississippi Hospi-tals With License Status and Governing Bodies, February I, 1971, Mississippi Commission on Hospital Care h- ~ Component PI\OGWV STAFF CONTRACTS 4 DFIVE LOPMENTAL COMPONENT -, OTERAT I OSAL PROJECTS Kidney . EP!S Iis/ea Pediatric Pulnonary . Other TOTAL DIRECT COSTS COWCIL RECOMMENDED LEVEL C. - - .. . . __ a COMPONENT AND FINANCIAL SUMMARY TRIENNIAL APPLICATION Current Annualized -~ Level 03 Year 7/71 - blTz* 411,097 . ---- ., 485,133 . 896,230 1,095,428 o Rcquc 1st year 95,315 C,730,480 .. 2,340,618 it for Tri 2nd year 633,842 ---e 190,600 1,555,746 (161,915) ---- (137,743) ---- ---- 2,439,588 inial 3rd year. 9' 666,387 250,000 1,529,504 (120,403) ---- 'I (150,341) Comii t t ee Recomentl n t ion fo Counc 1st year .. -.4pproved 2nd year *Region requested a 4 month erttension and was awarded 1$321,053 for contingation. operational year to 10j72. This extendkd, their 03 RECIUV - Hi55 BRtAKO RE OUE ST RM 00057 1W72 PAGE 1 - RMPS-OSM-JTL - 04 PKt PE R1 OD - - - - __ - - ... I~~E:ITIFICATI~~N CF Li;YP,kL>;T I CJXT. ~.LT.il:il CONT. DEYUNU I A???.. PL&I231 APPII. PEKIUII] PHEVIOUSLY I PREVIOUSLY I DIRECT I INDIRtLT I . IUlAL 1 I L'F SbPPOHT I CF SUPPORT I FUhDEO I APPROVED I COSTS 1 COSTS 1 ! . . .. ! .__ ! I I I I JULY 17rlP72 l3REAKOUT OF REQUEST 05 PKOSRAA PERIOD REGION - niss an 00057 io172 PAGE 2 RMPS-OSM-JTOGRZ- 1 ......... ................... _- .... - - ._ . - -- .-I .--: .. __ . 'i- ............. I ... .... - - -- REGIONAL MEDICAL PROGRA~S SERVICE RMPS-OSM-JTOFHL h6 I REGIO)(. 57'-iIss' ~~~P-jupp~.YR o.~--- -- FUNDING HISTORY LIST _-.___ m OPERATIONAL GRANT (DIRECT COSTS ONLY) AL'L AEQUEST-AND'-~NARDS~S-OF HAY 3ir 1972 ,-- JUNE 811972 AWARDED AWARDED mmom AIWAROEO 01 - 02 L3 .- COHPONElllT -- NO TITLE 07/71-06/72 TOTAL ___- COO0 PROGRAU STAFF 3C69QO 4C18CO 411097 1119797 001 conpa STPK DET 62600 1198CO 91627 274027 052 IRN OXRX CHR PU 20C30C 178000 93784 472084 MlSS PG INST IN 38500 57200 62790 158490 - 003 004 oc5 Ow6 OC 8 ,-3 7GOCO 33592 __ 93792 86000 52332 190832 81000 25210 ____ 25210 1ooo'J lOCC0 54470 328370 31 11:: 2a14io 3C218 3i12ia RECUT HLTH RNPW 70000 CYA CLNCS INOIG 29000 -. 312CG EST COORO SYS C 164605 lL932C COHPR PRG CPR T 39000 47000 RAD RX TRN CONS 2L-900 454LU REG COCPR NEURO 67503 7 1000 COUPR REN OIS T 46300 341cu EUPGY N CRTCL I ____- _. - ___ RENAL OIS PROG WP CONTL OEM A tl!i 011 ' G12 -',, e13 -, 018 617 ** ** ** - . . _- . . I - TOTAL - 1229tOO 1095400 896230 3221230 I ** .... .~ . ...... ... __ ___ - .... ..... I -. ............. - ........ .- ..... . - . . __ - - .. .. .. ................ __ .. - __ - SI' -_-__~-----.- __ _--__ .. -...--._I ...... -I --- - I .. _. ..................... ..................................................... . ~- .. .............. - ~ .- .- . . .. _. ......... ... - ... __._ .............. .- ___ ............. - ....... ..... .- ... !f ... .. .. ... - .. ... 4 .. ........... - .. - -- 4 ..... .. - ........ .- ... .... ..- . ............... ............. .......... - .......... ---~ ,_ .............. -. ...... .................... LJ LII __ - ,- .... ... ~ -.__ . -- ---. - - ..- .... .................... - - . .- . - . - ---.I .......... . . - . - - - 7 I ,- .+ .......... I _- ,a: -.I ...... -. . -. . a. ............. Jlcgion: Mississippi RMP Review Cycle: Sept/Oct. 1972 One Medical School located in Jackson serving the .entire state. For the most part, medical care is avail&'lE to ah citizens, but the. real problem is in educating the people to take. advantage of medical services. Upgrading and increasing health manpower is the major goal for this region and positive steps are being takeh to alleviate this problem. for health services/educational activities. The region was awarded supplemental funds to begin p-laming Mississippi has only one physician per 1,350 people, which is half the average for the U.S. This figure includes all urban areas. In many rural districts of Mississippi, the ratio reaches almost astronomical proportions. The region's emphasis in the past has been categorical in hear,t, cancer, and stroke, and in continuing education with activities o centering around the Medical School. The new thrust is regionalizing the activities' with the major emphasis on improving the health care delivery system access and availability to all persons. Projects being submitted by the Eegion have been designed for outreach into all areas of the state. % The regipn is requesting funds for 2 continuation projects. All other projects are new. Ten old projects are being' terminated. The developmental component is intended to provide MRMP with funds to move rapidly and elipenditiously in responding to emerging or unique program development activities. The internal problems that plagued ihe, region a year ago no longer exist. . The program Gas moved to new quarters outside of the Midical School complex. The program staff has been reorganized and new st& have been hired to fill needed vacancies. - - The RAG has been restructured and is no longer a reactionary group but now exert good leadership and strong influence on the program and are actively involved in directing the activities of MRMP. . . ~. ~- -. -. - . . I -. . .. .. . .~ .. ,' .. , .. .. .. t ,.. . .. - The Mississippi RMP, a year ago was just beginning to turn the corner in becoming a strong and important leader in the 0 development and delivery of health- services to all people of Mississippi. together" so to speak and are now a cohesive, dedicated and enthusiastic group who are looked on by the health professionals of Mississippi as strong and reliable leaders in developing programs that are innovated and challenging, but are designed to meet the health needs of the region. During the past year they have "put it all 0- Review Cycle: Sept/Oct.. 1972 STAFF OBSERVATIONS Principal Problems : Review of.the region during last year's review cycle revealed the following problems : 1. Goals and objectives were broad, giving the region little direction. 2. No Black professionals on program staff. 3. Program staff needed further strengthening in both planning and evaluation skills. 4. RAG needed to be restructured and become more involved in directing the program. The region was relying quite heavily on the "bubbling up" technique as opposed to a balance between this and a RAG and program staff stimulated system of project development. 5. 6. Evaluation had not consisted of more than progress reporting. Principal Accomplishments: 1. 2. 3. 4. 5. Program staff has moved to new facilities away from the Medical Center, resulting in a new identity for MRMP throughout the State. RAG and program staff has been restructured and reorganized and RAG ii now more involved and.is directing; the program instead of being a reactionary group. Goals and objectives have been refined and further delineated, and RAG and program staff are developing programs to meet the goals and objectives rather than waiting for activities to bubble up. Additional staff have been hired to fill vacancies in planning and evaluation. work in the program development area. A Black professional bas also been hired to Evaluation techniques have been developed for evaluating projects and overall programs. Issues Requiring Attention of Reviewers: The region is requesting triennial status and developmental component. Much of the effort of MRMF' has been undertaken by faculty members of the University Medical Center. This has been possible through MRMP support, but since other sources of funding to support contributions to continuing education by these individuals is slim, it seems unlikely that in the future they can continue their efforts in this area. MRMP may need some special consideration by the University in terma of personnel policy and the establishment of salary levels for program staff in order to assure appropriate working conditions to retain competent program staff. . c a SARP L Region New Mexico Review Cycle Sept/Oct, 191 Type of Application - Trienc Rating . 294 RECOMMENDATIONS FRO14 @ Review Committee /7 Site Visit Council RECOMMENDATION : The Review Commi ttee concurred wi th the site vi si t team's recommendati ons regarding : 1. The RMP's readiness for triennial status. The approval of a developmental component. mi ttee rejected the site vi si tors recommendations- on the total amount of funds to be recommended for each of the three years of the triennium as ding level of the developmental component. Committee uctions in both project and program staff funding requests. overall reduction are included in the critique section of ort. The following summar-izes the Committee's recommendation for tional year compared with'the Region's request and the site cornme nda t i o n : Re comme nda t i on % Program's Review Request (05) Site Team Committee $J,319,722* $ 830,000 $~,070,ooo 232,305 3 50,000" 1 138,228 120,000 $1,690,255 $1,300,000 $1 ,l5>0, f ancer registry funds were transferred from the program staff to the perational project budget category. mended totals of $1,200,000 and $1,250,000 for the sixth and m years respectively, including a developmental component of ch of these years, ing $120,000 for the developmental component for each of the Committee believed that the $120,000 recommended by the site viiit The si te visi tors had recommended $1.3 : velopmental component was too ambi tiotis for a Program that undergone so many changes throughout the past year. Even though Committ ognized the significant progress made since Dr. Gay's appointment as rdinator, which included a number of changes in program staff, the expansion the RAG from 41 to 116 members, the establishment of 9 standing committees membership, the revision of the bylaws, the development puterized financial system ,and the involvement of both provider d community groups in establishing the goals and objectives for the triennial L e Region New Mexico Review Cycle Sept/Oct, 19/ RECOMMENDATIONS FROM REVIEW COMMITTEE . Page 2 application request, they suggested that more time is needed to' concentrate on initiating comprehensive activities and programmatic thrusts, Review Committee noted that the Program has made excellent progress in increasing minority involvement on the Executive Committee, RAG and its comi ttees. The Coordinator has already responded to the site vi si tors concerns regarding the employment of mi nori ty members on program staff. It was noted that the Coordinator has hi red three additional minority staff members thus resulting in a total of six minority program staff mitlee noted that the NMRMP's program objectives are commendable. However, e proposed use of funds appeared to be a continuation of old-line activities, Concern was expressed regarding the proposed con ti nuati on of ongoing acti vi ties for a fifth consecutive operational year. In this connection, there was extended discussion concerning the request for conttriued funding for the cancer registry. trongly urged the Program as well as the project director to- seek other ources of support for this activity during the next year. Reviewers agreed 4th site visitors that the $118,000 requested should be budgeted and monitored as an operational project rather than as a program staff activity. Reviewers were made aware of several of the outstanding qualities of this particular program and were informed of the partial support being made The site visit team had dealt with this issue and had ailable from the National Cancer Institute. iewers also r&ed the request for a substantial increase in the number of personnel needed to implement project activities under program staff direction. It was felt that this strategy should'be discouraged since it would probably lead to further prolongation of activities beyond a maximum three-year time- limit. staff through the use of operational project funds rather than pursuing continued assistance through its program staff budget. eview Committee disagreed with the site visit report statement "if the They recomnended that the Region should consider supporting additional ram is interested and seriously intends to facilitate HMO planning, it ld bring onto the program staff people with appropriate experience in t gerial and financial aspects of HMO planning. Commi ttee noted that two organizations in Albuquerque have funded HMO activities and could be called upon to offer consultation to other applicants upon demand. omittee further discussed the overall staff complement and agreed that the mmuni ty Health Services Response Sys tern was parti cul arly outstanding. cognition was made of the number of demands from communities which were . ing responded to from this section. In spite of this commendable effovrt? viewers believed that this staff should concentrate more of its efforts in imulating programmatic activities rather than responding solely to the ming single, isolated project requests. COMPONENT AND FINANCIAL SUMMARY TRIENNIAL APPLICATION Current Annualized ERATIUNAL PROJECTS Pediatric Pulmonary _. ECOMMENDED LEVEL ~a'st Site Visit: (List Uatcs June 8-9, 1971 - Sister Ann Josephine, Chairman, Review Committee I II_--.- Chairinnn, Other Co:mittcc/(lounci 1 Rci!ibcrs, Consul tnilts) Anthony J. Komeroff, M. D. - National Advisory CouncitE George E. Schreiner, M. D, - Morton C. Creditor, M. D. - Consultant Arthur M. Rogers - Consultant I John Gramlich, M. D. - Consultant It I1 If 11---* Staff \'isits --_I____ in Last 12 Honths: -- I (List I9ntc and 1)urpose) October 17-20, 1971 '- Frahk G. Zizlavsky-ln~rodurtore I VlSl January 21-22, 1972 - Harold Margulies, M.D. Director' - April 19-22 ky 94-18 JufIy 25-28, 1972 - Frank Zizlavsky, Joan' Ensor, Kathy Scurlock-Verificati on of Revie17 Speech to State Medical Society 1972 - Frank G, Zizlavslcy,>Attend RAG me,eting and Technical Assistacce I -9 1912 - Edward Bloomquist - Kidne Technical pssistance 972 - Frank G. Zizlavsky - Atlend Chicano, Cultural Awareness Program PKQceSS I Itcce~~t events occurririq in gcop?-:inliic area of Kcgioll that a7.e nfri.ctilin ILfli' pYogl-nlll: ..- '.L-l-..p-- - --d- --I-_.--I ---_- 1. 2, Coordinator has completely reorganized program; hired new staff; fe% Coordinator James R.,Gay, M.D. a6 of July, 1971 enlarged RAG; increased committees; changed Program from traditional program staff and projects to Developmental Program Staff & Community response. 3, June, 1972 - National Advisory Council approved $425,675 for. 01 year and $139,046 for 02 year for project 818 - STATEWIDE EHS and $82,oOQ for project li's 19-22 for 01 year hedlth service education activiries, z e Nursing Schools Unfv. 0: N.S. Mcdi ca 1 t cchnology ___.__-I___ - I- 5 ( 1 at V.A, hospital) __- -_- - . - Numb e r ---- Rad i ci lop, i c Te chno logy 7 ( 1 at PtlS Indian MC, Gallup) Numb C' r ___-_______---__----- -..--- POTULAT IC:: : Total Population ; 1,014,000 I, Urban - 69 Population Density; 8 per sq. mile ' 7, Non-white - 10 (large proportion Indian and Sp. surname) h!ETROPGLLTA'4 AUAS i L AGE DISTREBUTLOX * Percent of Total by Spzcificd Age Group, 1970 Source: Rriyccu ol thc Census- PC ( VI Ir VZ> 1370 - I370 Census Of ~'OPLI 1 CI t i Qti ; Stcte and County i: 33 Rurc.au of the Censtts - PC (P3) .. 3, U.S9 I'opulatlon of St-aildsrd 3etro~:oliLan Statistical Axcns, 1970. . Kill 003 34 . I Medica). Greup!, in the'U.S., 1969 ; A.bl.A., Chicap,@, 1971 Sourccs: Distribution of Physiclans, `tospitals, and Hospital 'Jcds in the U.S. 1969, .her. Kedical ASSOC., Chicago, 1970. Health Manpower Soiircc Book,. Section 20, PHS-NIH-BEHT, 1969 The lkalth Professions Educatjonal Assistzncc Yrogram, Report to the ?resident and the Congress, Sept.11970 I (P9.S- RIII-REXT) -6- / - Fciion: . N:!,+ Review Cycle: L m MEXICO C onp onen t PROGW*l STAFF CONTRACTS DEVELOPMENTAL CO@OiNENT OPEPATIOX4L PROJECTS 6 Kidney * EMS hs/ea Pediatric Pulmonary Other TOTAL DIRECT COSTS COWCIL RECOWEXDE'D LEVEL COMPONENT AND FINANCIAL SUMMARY TRIEIQJIAL APPLICATION o Current Annualized Level 04 Year - ' 610,682 . 426,037* 1,036,7 19 Reqc 1st year 1,2 01,263-- 118,459 1,319,722 138,228 232,305 1 L, 690,255 st for Tr. 2nd year '. 06 1,381,452 84,825 1,466,277 158,968 135,906 ,761,151 nnial 3rd year. 07 1,441,5 15 56,550 1,498,065 165 , 974 55 , 390 1,719,429 Coun 1 1st year Comi t t e e Re coxen5 ,'i t i c.2 for I *;Includes Project $6 Emergency Medical Services funded at $61,274. L I cn h I' dULt 18. 1972 . .. . I_ _... - Review Cycle: October IY/Z HISTORICAL PR0GRh.M PiiOPILE OF REGION The University of New Mexico School oE Medicine was designated by the Governor to plan and operate a Regional Medical Program, and a planning grant application was submitted to DRMP on July 1, 1966. Planning was to be carried out by disease-oriented committees set up by the Regional Advisory group. Director, as well as chairman of the Executive Cormittee 01 the RAG. The Dean of the School of Medicine was appointed RMP Thc 2irst planning grant was awarded for the period October 1, 1966 to November 30, 1967. A seven month grant period was awarded for the second year planning continuatiori because of disapproval by the National Advisory Council of the Region's first operatiunal application. Reasons tor disapproval wcre: 1) no justification for expenditures of 01 year funds; 2) over commitment of Dr. Fitz, the. Coordinator; 3) planning activities for the 02 year were vague and seemed operational in nature; and 4) no RAG involvement. The Region resubmitted an improved operational application described a$ "Phase I" program with five operational projects. The Review Committee (January 11-12, 1968) recommended deferral and a site visit to deteriniile t\e real needs of the region with appropriate translation into a unified colnprehensive proposal with a truly regional orientation. Prior to the sire visit, the NM/W submitted a Phase I supplement - which included a number of changes in the proposal. Advisory Council of May 27-29, 1968 recornended approvi; in a reduced amount and a grant was made in the amount of $965,305 for Core and seven projects. The progress report for the first year indicated some organizational improvements with a notable shift away from the medical school. The region identified $355,612 in unspent balances and was granted S ,252,911 (D.C.) for a fourteen month period. The Mational * The cuntinuation application for the 03 year requested Core and nine ;>rclj(-ct:, ($1 ,053,537) and carryover balances in the amount of $174,902. 'The continuation award for the third operational year was made fectivc September I, 1770 for twelve mor,ths with a direct cc,st ;11I1OUIl 0 f $ 1 , 1 7 0 , 1 7 1 . ... I . ., - -. .. ,. :: '. I' . i .. . , ,. - -__- On May 1, 1971 the New Mexico RMP submitted i.ts triennial application (iricluding a developmental component) request for the @A year, S1,003,503, for the 35 year $985,603 and for the L6 year $886,97?. -12- Region: New Mexico Review Cycle: October 1972 0 0 0 On June 8-9, 1971 the NM/RMP was site visited. The site visit team identified rhe major strengths to be the good relationships that exist between the* NM/KMP and other professional groups, and the Dean of the Medical Sclioo I supportive role in the RMP. However, majvr weaknesses In the krl;lon still exifited. These were: I) an excess dependency ol the Medica; Sctiool on the resources of NM/fWP; 2) lack of a good coordinator; 3) need for strengthening of Program Staff; 4) better representation of the Executive Committee of the R4G; and 5) lack of progress in the kidney disease area. The program received $796,312 for its 04 year (only one additional year) with a follow-up site visit in a year to evaluate a revised triennial application. In July 1971, James R. Gay, M.D. became new Coordinator. During tile past year, Dr. Gay has reorganized the New Mexico RMP, hired new Program Staff, enlarged the New Mexico RAG from 41 to 116 members, increased the number of its committees, revised by-laws, and revised organizational structure from traditional mode (vertical hierarchial pattern) to matrix system where everyone is in a co-equal position on an organizational chart. In April, 1972, the budget period for the program was extended an additional four months to December 31, 1972. An amount of $1,382,288 was made available for the 16 month period (9/1/71-12/31/72). The June, 1972 RMPS National Advisory Council approved Project #18- Slatewide Emergency Medical Services for $425,675 for 01 year, and $139,046 for 02 year. Also projects f's 19-22 were approved €or $82,000 $or only one year. amount of $2,029,009 for the 04 year budget period. The Program is presently supported in the On July 1, 1972 the New Mexico RMP has submitted its revised triennial application (including developmental component) request for its 5th, 6th and 7th years of financial support. -1 3- Region: NEW ElEXICO Revieti Cycle 10/72 STAFF ORSEXVATIONS - 1. ,-i L. . 3. li I 5, 7. (i 'I . principal Problems: Program Staff budget request is large i .e, xcqticsting 3k additional staff members. Lsr,r:e proportion of Program S taf I: budget for equipment Program Staff being project directors could become conflict of interests. Other areas of contintied financial support after the withdrawal of ?2GP support . 'Tny docs NM/IQfP continue to fund Project- i/lA- Ttrmor Registry when on ?;;e. 20, j tern 9 - it states. .. continues oi)jcctions CQ Twwr Registry. .. Docs r? :hrec year plan really exist? Program did not submit any new projects as part of its triennial application P,plI'S policy prohibits more than 5 years of financtal support for projects !% and $8. . principal Accomplishments: 1. AssLsted Hone Education Livelihood Program (H.E.L.P.) to assume responstbility for the Migrant Health Program in New Mexico. 2. €,!l/'tV.u? has reorganized total Program. 3. Provided assistance to small clinics throughout New Plexico. 4. Provided excellent assistance to comunitj.es for obtaining National .5. 6. Excellent representation of minorities on Executive Board, MG, and I!eaLth Service Corps placement of assignees. Program Staff has responded to many community requests for assistance Cornmi t tees. Issues reqtriring nttentjon of reviewers: J. I+I?S pol icy, adopted in August 1969 by NlZC docs not permit support of . nrl c ! raining; in "cstahli shed hcollh professions. Therciotc training pro;:rnrns Tor dental assistants (p.45), mcdecause of t.he three different cv11rcres wi tliin the. state, namely Anglo, Chicam an2 1 ndian. P:3r t 14 - Cancer Programs T!:esc: docments are descriptions of plans and activities. evaluate their proposals 3s segments of a program one needs more information In order to -16- STAFF OBSERVATIONS (continued) about the problems they address, the alternative solutions to those prohlerns from which these approaches were chosen and the reason For the priori ties accorded these plans. For example, the ratio of annual cancer deaths to annual incidence or new diagnoses appears to be 1100 to 2500. Perhaps New Mexico already i~ approaching the American Cancer Society goal of saving 50% of cancer patients. patients with multiple cancers is .0025% of the population, perhaps smewhnt lower than the national average. A total of 2500 cases, even without correction for The forthcoming development of new untlsual radiation therapy resources and a related cancer center are calling attention to cancer in New Mexico. It is clear that these facilities will require patients and that their existence will change the patient referral patterns in the state and adjacent areas. The new centers will not reduce the State's medical resources, and they wi.11 pick up only a small fraction of the workload of the existing medical care system. For all of these reasons, one must question the Rplp priority of projects whose principal beneficiaries to date seem to be future Untvereity-related oncological activities, and drug testing. The plans for both projects appear to have been designed along admirable lines, Both are thoughtfully detailed in procedure. seems to be developing its own registry, which seems to suggest that the Statewide registry cannot serve all the needs of therapists. Both strive to involve practicing physicians and existing hospitals. The leukemia-lymphoma program The registry project seems to be rather costly, With a dozen accessions, and fewer than half as many deaths per working day, and its basic, tabu- lations and printouts designed, the organization seems over-staffed at thirteen full-time and two part-time people. program gives little information on its performance. The usability and reliability of the data collected by its field workers, the performance of hospitals in providing the records, the trends in accession and losses to follow-up would be helpful parameters for assessment of the registry's chances of success. in stage at diagnosis or patient referral patterns have occurred in the hospitals that have participated for two years or more. The account of the registry It would also be useful to know whether any changes The leukemia-lipphoma project also is costly. an unknown current annual expenditure for a patient load of 225 now It would add $90,000 to -17- STAFF OBSERVATIONS (con ti nued ) - rezisrered to an estiriated 400 or so. benefit fmm this added cost, and much of the treatment would be experi- '-:ental, with investigational new drugs. It appears that the project wist rely heavily tipon its clinical triaL and research valves to justify ~LS costs. IT t-his is true, should it not be supported by research i ntcrests, rather than by a Regional Medical Program? Not all of these patients would pari: 15 - Priority llealth Care iJo information is presented regarding several critical areas: Methods to provide conrinuin; nupport following expiration of REIP grant; Zffcclivencss of existint; model system in adclrcssine, thc tar;.,r?t IIcrtIth problem; Local verification or the acceptobili ty of the proposed approach; :.:-v~luation criteria. Part 16 - llealth Information Center - provides general information. ?art 17 - Community Rchobilitation Program T!.is program seeks to enlarge the awareness of rehabilitation among existing social and nedical workers. spectalist team whic5 seeks to impart both awareness and skills to ?oca1 mrk-forces, on a community-by-community basis. In one area the team hes demonstrated to its own satisfaction that it can improve n community's awareness and utilizaeton of consciously planned and administered rehabi- 1i;ative techniques. sjtuation the :em found and the changes that allowed it to disengage with con:*Sction that its mission was accomplisliccl. The objective is admirable. As an improvement of the performance of cxistfn:: resources, ir appears to be a legitimate RMP objective. !'s some dnubt :liar the approach employed in the experiment recounted s'ioi:ld be continued, because it seems to this reviewer to Se one tZlat 'muld ~akc 2 .ton$ i:jnc to COVC~ the State. To do this, it emnloys a five- 1 1 No before and after data are given to show t?ie Tilere TFe State-directed agencies should have bcen pcrforning chis Cunction ni.l ;?ion:. ic-7 zfFor~s cn ??lp!n~ thc State agencies tr: be more aggrassive, Could not :he 9fp reach nore localities sooner by concc2tratfng -18- t & Mr. Spencer Colburn, Public Health Advisor, Eastern Operations Branch, Division of Operations and Development SITE VISIT REPORT NORTHERN NEW ENGLAND REGIONAL MEDICAL PROGRAM AUGUST 9-10, 1972 I . CONSULTANTS William Thurman, M.D., Chairman; Review Committee Member; Professor and Chairman, Department of Pediatrics, Univereity of Virginia School of Medicine, Charlottsville, Virginia 22901 Ms. Florence Wpckoff, National Advisory Council Member, 243 Carralitos Thomas Nicholae, M.D., Executive Director, Colorqdo-Wyoming RMP, Mr. Roger Warner, Director of Planning & Evaluation, Arkansas __^I.. University -- .- Little . Rock, _Arkar;Escae 12204.. Road, Watsonville, California 95076 2045 Franklin Street, Denver, Colorado 80205 Regional Medical Program, 500 University Tower Building, 12th at RMPS STAFF Mies Cecelia Conrath, Associate Director for Continuing Education and Manpower, Divieion of Prof eaetmal end Technical Development Miss Sandy Flythe, Public Health Analyst Trainee, Eastern Operations _.- ---" __ . -, Branch, Division of Operations and hvelopnknt Mr. William McKenna, Jr., Program Director RMPS, Office of the ... - Regional Health Director, Boston, Massachusetto 02203 Lyman Van Nostrand, Acting Chief, Planning Program, Dffice of -_LI-- Plannitt a@ -@.alua$ion- Mre. Evelyn Biddle, Administrative Assistant Donald Danielson, Director NNERMP Edgar Francisco, Ph.D., Director of Planning 6 Evaluation Barbara Higgins, Community Health Reseurch Aesociate Rayburn Lavigne, Aseistant Director for Program Development Robert Liversidge, Aseistant Director €or Continuing Educat Mrs. Catherine Lloyd, Research Associate Carl MBneri, Regional Bealth Development Project Manager-Respiratory Michael Quadland, CorPwraity Haalte Development Activity Anthony Robbins, M.D., Director, Community Health Development Mrs. Mary Taylor, Manager, Cancer Proarm ion -2- Consultant to NNERMP - Milton Nadworny, Ph.D, , Chairman of Department of Economics, University of Vermont NNERMP Regional Advisory Group Members Mrs. Priscilla Allen, M.D.;Aesistant Director Public Health Nursing Richard Bushmore, M.D., Welfare Department, State of Vermont Gerald Errion, Director, N.E. Kingdom Mental Health Services Reverend William Hollieter, Consumer * Edgar Hyde, M.D., Private Practice, Northfield, Vermont * William Luginbuhl, M.D., Dean of University of Vermont Medical School, John Mazuzan, M.D., Private Physician, Chairman of RAG Hilda Packard, R.N., Director, Nursing Service Brattleboro, VeTont * Robert Richards, M.D., Private Practice, Springfield, Vermont Lois Smith, R.N., Hospital In-Service Educator, St. Albans, Vermont Barbara Taft, Housewife, Springfield, Vermont * M. Dawson Tyson, M.D., Represented RAG Member, Yasinsiki, Director, Joel Walker, Administrator, Central Vermont Hospital, Varre, Vermont Keith Wulace, Consumer for state Burlington, Vermont * JJA Hospital, White River Junction, Vermont * Members of the Executive Committee Others Sinclair Allen, M.D., Co-Director, RMP Respiratory Disease Management Joan Blankenship, R.N., Project Director, Ambulatory Pediatric Program; Richard Bouchard, M.D., Director RMP Heart Management Committee Stanley Burns, M.D., Director RMP Cancer Management Committee Garath Green, M..D., Co-Director RMP Respiratory Disease Management David Miller, Executive Director, Vermont VHSI Jan Westervelt, Director Vermont Comprehensive Health Planning Committee Executive Director, St. Johnsburg Home Health Agency Committee i . .. 5' 2. . \. Northern Hew England W - 3- RM oooO3 The aite visit was in response to a triennial application from the lolERllEp. overall progress, its current quality, ita readiness for triennium ststus and a developmental component, and to arrive at a funding recormendation for considerat ion by the Stational Review Codttee an8 the lOetional Advisory Council on Rw8. The gurpoees of the site viait were to asaess the program's Prior to January, thia program devoted 8 great majority of its time and energy to developing a data base for health planning and also in phnning 8 6lrrgl.e msnagement eryatem for RbfP and W. With the data base, problems of accreditation and utilization contlnulslly occurred. Wfth the mnagea~ent syetem cowlicated a8minietrative etructureo were considered but no admlniatrative lstructwe could be created that would allow linking the two organizations in s manner which would preserve each proaram'e inteadad purpose, at least In the oplnion of the Federal Government. To complicate the organi- zational problems even further, Vermont me the rocipient of an Lbrperimntsl Bealth Services Delivery Syotem contract In excess of ~,OSO ror a two year pertad. Rcal1zing that en acceptable management syetem could not be readily &eveloped and that continued RWS euppost far such a massive data collection effort wa~ unlikely, the program began formulating a more utradlticmal" RlIp h Janusry under the new leaderehip of Mr. Danielson. A reader of this document should keep in mind the infancy of $he new program 8% the tiere of thie eite visit snd the influence this Stage of maturity We on the fiadings, opinions, suggertlons, and recom- mndstions contained within thio report. 1. Goale, abdectivse and Psioslties Due to the infmcy of the liliaE Program as a "program", goalis, obJsctive8 and priorities have not yet been developed and explicitly atated. bylaw8 of the RAO, and the application for triennial support refer to program goals 8s being wee of Improving acceseibility to medical care, enhanciag quality of care, end increasing efficiency and efficacy of mdlcal care Belivery. These are considered as area8 of concern stated in a very broad and global genae th8t cemot be interpreted, or accepted, ae atdlndcrrde against whiah to mke polioy and funding dealrioner. The llorthern Hew England RNP -4- RH 00003 V It ie coatridered, however, that the program Is now on the fringe of making a cmrrtructive move in this area end 8 significant impact within the next 90 to EO bye should occur. which a problem list is presently being developed, the "beginningsf' of what sppcars to be necessary for the establishment of an active and effbctive RAb, and 8 program staff cognizant of the immediate need for explicit but appropriate goals, objectives and priorities. These are all positive factor8 which should lead to improvement soon in this area. This is not to say, though, that the eite team I8 not without concern for in discussing this subject during the vielt, it became apparent that RAQ, the technical committees as well as etsff In the region, do not share a common concept of how goals, obJectives and priorities ere to function. staff seem to understand haw goals, objective6 and priorities ahould be used In policymeking, decisionmeking, evaluation, etc., but some (the Chairmn of the RAO In particular) did not appear to have this 6ame understcmdlng. both during the formsland informal sessions and there Is reason to believe that 8 unanimity of uaderstsndlng will soon develop. T&ey have data from The program There was extensive diecussion about this point Even though it is mentioned above that the RAG has the "beginnings" As discuseed later in thie report under Regional Advisory Group and Ninority Interest, there la concern that the present RAG membership is not representative of all desired factions. and community group8, and allied heslth personnel are Lacking rtpresentetion. of being an effective group, It also la not an area without concern. --. , ,1 Illotably, consumer If the goals, objectives and priorities are to accurately reflect the region's needs and problems, all desired factions should be repreeented in their formulation. 2. Accompll8hmente and Implementation The mJor accomplishments have been the developwnt of the Regional Disease Management approach and the developmnt of a data b8Se for health planning. Regional Disease Managensent is a committee approach to heart disease, cancer, and reeplratory dieease. Of these three committeee, heart is the most developed, data has been collected, professionally enalyzed, and standards and guidelines have been developed for treatment far coronary care. When considering the effectiveness of the disease management commit- tees, it is encourt@ng to note the acceptance of the committee's recommcndstiona by providers as well as acceptance of "updating" changes recommended by the cormnittees through their continuing evel- uation and updating of eteadards proceas. 0 Eerch cornittee le free to oa;.,ipnize itself into subcommittees and task forcw, but generally develop 8bng the lines of atanduds asld guidelines for treatment, educational sequiremnts, and Ion ayetelaa. AdBitional cormaitteee in emergency medical service systems, kidney disease, eat? other problem apeas of disecbae and health care delivery are planned. The ]RrgiomL Disease b(an&@m@nt approach ie Con6ider@d a aubstantlal lishnuent becsueo it ~trve~l at3 mechanism for stimubting fvftiea, provides 8 vehicle throqh which to replicate eucceslerful. accoxplislmmts , and f uact ions 8s a msna for promoting wM@r applfcatim of new kncrwleege and technique8 e Hawever, these codttees need a functional operating plan, bybwe, and a definite roaching their mission. In %he paat e been the influential force in the stsucture 80 it is anticipated that with their pr estpbasfs &iPPiculties will develop as aaaum itfa Leraderehilg role In formulati ai "new" RB@ now begins to a total progrsm desipcd seheneive empbsie. In the semx of 8 fun@i;SoniW Rlbo, $tees were the only way of obtalnbg "provider" bput in is iPsportant that the management co&tte@6 understand the strength and lilnitatloas of their sole in policy development obna Beciaionmkiag. 0 besbse for health planning wquestiombly holds a poteptial ling Illare rational 8ecisimw as to how the health dare system should be msged and what s%anWder and guidelines for treatment are more efficacioae. me data Wee laas been the source for nreny reports, paperm, mathe Like, published by the program evidence that the care problem such a8 COmggreh@n6l\l@ Health Planning "a" ana "b" agencies, the Experimerrtal Xealth Senices Delivery system (1Bs&), 8 that e number of parties concerned with health care delivery pro- blem are not u8erc1 of the bta and in fact fn BOW instance8 may nut even be ware of ita existence. The site vis%% team fs amre that the datca will ooon (Septemibar 1972) be funded and minCeined by a separerte independent organization; but, nevertheless, believe the RMP haa to assum some continuing; respcms- fbility in solviag the problem of deveLoging a utilization strategy for the data. (a list of which sppended to this report). Also, there it3 bawbeen used by others concerned with health , etc. Yet, in this 8am connection theye is evidence fi many ways this program le considered to be one in which Horthern Hew England RMP -6- '&!CO~l~8hiEXlt6 have been fwj there has been little effect on mnltorlng costs, and aside from the program emnating from the management committeem, there has been little impsct on the improve- ment of the quality of care. Again, hawever, the site teem is cornfortable with the lmpreesion that prugress Will be achieved in the future. % 3. Continued Support There is not a firm policy on contfnued support. continued support ie formally addressed in the tecbnical review crlkeria and there is subatantial evidence that emphseis is given to continued support during the planning, developing and reviewing 4. Minority Interests Due to the fact that there is no signfflcant ethnic minority in Vermont, the reviewers chose to use the term "minority", divested of racial connotations, and to refer to the poor and medically underserved sector of its population. (Blacks, Indians, Japanese, Chinese, and others) constitutes 0.4 of l$ of the total population. From census data it is estimated that one-fourth of the population of the State have French a6 their first and in may 68868, on3y language. Regardless of the small number of minorities, the site visit team feels that the RAG should be more representative of the total population served by the program. The issue of Of ~rOpO6818 o The total minority population Xt was indicated by the FW that the membership of the RAG will probably be increased by ten In the near future. fop?, euggeeted that these additions should be chosen with the Idea of sdequate representation of all aepecte of the population a8 we11 a8 other local intoreeta in mind. On the program staff there are no minorities anathere are no womn In top-level decislmnaklng positions o Probably mre survey8 have been done in this region than in any other to assess the health needs, problems, and utilieation of eervices of minority groups, but very few "true" consumers have been consulted in formubitfag study deslgns of interpretation of the data, or in action plans. The team, there- - 7- RM 00003 1. Coordinst or Considering the prbceee of transition through which the Northern Hew Engfand RMP hs0 been going, the new Coorainator seem to have done a commendable job. Donald Danielson VBB appointed Mrector of lU!fERbB in January of' 1972. re8lgaed to become Mrector of Research and Development of Health $yetems Incorporated, the recipient of HSNA ExperbntaL System's contract o !he prevaous Mrector, John Wennberg, During the following months, Mr. Danielson has reorgsnizedthe Regional Advisory koup to laake It a separate functianing body for Rbop, ha~p revised the program staff structure and begun to hire IOM new people, and gut together the current eppliaation. He #@ems to have developed a good working relationship with the Regional Advisory Oroyp md there mer generally goo8 interection with the Chairman of the RAFI, B. John Wazuzan. It did seem apparent to the site team that a deputy director was needed. for tluch, and that he woula b@ a health professior~al rather than a maasgement-type, SB thie seemed to be where the staff structure needed retrengthening . MI?. Danielson said he WBI in the process of' recruiting 2. Program Staff The program staff has been reorgsrnizad to reflect the movement of the large data (Iffort to Health Syeteme, Ine. The data base staff of 11 people plue recretrarlce ha8 been dissolved, with eomc moving Into ofher pouitiona in W snd oome going to E8I. 'phe reorganized structure now includes two mJor ataff fanetione end two major line functions. and evaluetion, -king u6e of the data base built by the m, and e~ucationel activities support, which will help in educatioaal dcslgn and evaluation in eupport of local project efforts. The two mjm line dlvialogrll are: Staff fwnctions include plaming (a) Health to gut System Development and Demonatration Staff - Designed together 0 comaunity heslth devslopmht support Northern New England RMP -8- RM-00003 5 capability which can work with local areas in developing coordin,?ted health services. head this division. A young M.D., Anthony Robbins, has been hired to (b) Regional Program Development Staff - Responsible for staffing. the disease management committees and task forces, which currently include heart disease, cancer, and respiratory disease. Others proposed are in emergency medical systems and kidney disease. staff is also responsible for the program management of the projects in this area. This The site team felt that the program staff at present is heavily manage- ment-oriented, and that there is a significant need for nursing and allied health personnel on the staff, to provide a broader range of professional and discipline competence. The team also thought that staff was needed in the areas of health system development and community organization, to provide a stronger alternate focus to the categorical interests. Efforts at keeping the medical com- munity and public informed of RMP activities might also be strengthened. The program staff currently employed was essentially full time. 3. Regional Advisory Group -- - The process of reshaping the Regional Advisory Group seems to be moving along well. Planning Board in December 1970, to form a single planning and manage- ment decision group for the state, This proved to be unacceptable to RMPS at the national level, so that in the latter half of 1971, WS and HSMHA specifically indicated that functions assigned to RMP, CHI?, and the Experimental Delivery System (HSI) must be separated so that each could be given appropriate attention. An RMP Study Committee then went to work to re-establish a'separate RMP Advisory Group, and adopted by;Faws for the new RAG in February 1972. The new RAG currently has a membership of about 30, with the expectation that it will be expanded to 40 in the near future, The RAG was merged with the State Comprehensive Health The site team noted that specific areas of representation that need strengthening are nursing and allied health personnel, consumers,VA Hospital and possibly 8ome of the economic and local political interests, and representation of the areawide CHP agencies. In this connection, the site team also brought up the question of the status of the three New York counties around Plattsburgh which the Vermont RMP sometimes claims responsibility for. The team stated that Northern New England RMP e -9 - RM 00003 if this area wa~ to be considered part of the NNERMP, then they should be represented on the RAG, On the other hand, if it was determined that they really related more to the Albany RMP, it might be better to make that clear, so the situation did not remain in limbo, team made it clear that from a:RMPS standpoint, there was no objection to the NNERMP releasing its partial claim to that New York area. The The RAG is structured to meet four times annually and to-date the meetings are very well attended. role in setting program policy. that both the RAG and the staff needed to initiate a much more defin- itive process of setting specific objectives and priorities. the objectives are tending to be set by the Regional Disease Management Committees, which are strictly categorically-oriented, rather than looking at the problems across-the-board, The new RAG has played a very active The site team made it clear, however, Otherwise, The RAG does have an Executive Committee which has been meeting frequently and which has a wide base of representation. 4. Grantee Organization The University of Vermont is the Grantee Institution for the NNERMP. Relationships seem to be generally good with the grantee permitting sufficient freedom and flexibility to the RMP, There was some question raieed about the policy of submitting the names of proposed RAG members to the President of the University for concurrence, especially in light of the new RMPS policy statement on RAG/Grantse relationships. The RMP, concerned about the overhead charged the program (currently 70.2% of salaries and wages), is moving its offices to an off-campus site to achieve a lower rate (46.73 of salaries and wages). supports this move. The aite team also noted errors in the method of filling out Form 15 (Operational Activity Summary) and Form 16 (Financial Data Record) of the RMPS application form. On most of these forms, the NNERMP listed the University of Vermont as the sponsor institution, and on many listed a program staff person as project director. This gives the distorted picture that most funds are flowing to the University of Vermont, which is not the case. form to show who was actually running the project. An additional question was brought up on the advisability of asking for specific medical school review and comment on project applications. This seemed to duplicate in some ways the work of the technical review committee structure. The grantee The R,MP was requested to correct these Northern New England RMP -10- RM 00003 - 5. Participation. There seemed to be evidence of close interaction with some health groups and interests, but a lack of involvement with others, was noted that particularly on the Regional Disease Management Committees, physician Influence was dominant, that these groups in particular needed a broader range of repre- sentation, including nursing and allied health interests, and possibly some public or consumer involvement, Although the volun- tary health agencies are participating, it was felt that this aspect could be'strengthened, as well as greater involvement of the State Health Department, political elements could be more significdntly involved. It It was suggested It was also felt that the economic and local 6. Local Planning The NNEW seems to have developed good working relationships with the two areawide CHP agencies that exist in Vermont: the Northern Counties Health Council (Northeast Kingdom), and the Connecticut Valley Health Compact. will be developed in the future. The large data base which RMP developed proved to be a helpful rationale in the definition of medical trade areas. patterns and utilization of services was particularly useful in defining appropriate sub-regions for planning purposes. It is expected that three more planning areas The data on patient flow There seems to be an adequate mechanism for obtaining CHP review and comment on RMP proposals. wide agencies provided comments. It is not quite certain the extent to which the RAG took these comments into account in making their final priority rankings. 7. Assessment of Needs and Resources The data base developed by NNERMP is probably one of the best in the country. The general analytical approach was the development of the following indices: population needs and characteristics; community characteristics; resource investments (manpow&, facilities, expen- ditures); utilization of services; and end regults. Both the State CHP agency and the two area- , Titis base has provided a good source for identification of problem areas and resources available. It has been particularly useful in development of categorical programs by disease management committees, particularly so in the area of heart disease. Northern New England RMP -11- BM 00003 The major concern is now that the data effort is being moved into Health Systems Incorporated, will the RMP develop a working linkage 80 that the data continues to be available for a more action-oriented approach to using it, The site team mentioned that some mechanism should be established to make certain that the data continued to prove useful to the XHE' in its planning and development activities. 8. Management A REP staff member is assigned management responsibility for each project. Each manager must work with the project director and the Director of Planning and Evaluation to develop a work schedule and the points at which project acitivity may be measured and evaluated. Periodic progress and expenditure reports are required at least quarterly for all projects. of the project, the Director of Planning and Evaluation and other staff are to provide assistance to get these solved. expenditure is low for a project, funds will be diverted to other uses. If difficulties are noted in development If the rate of It is difficult to tell at this point how well the program staff activities are coordinated. analyzed more easily after the RAG sets some more specific objectives and priorities, and after existing staff vacancies aze filled. This component of the program may be 0 9, Evaluation In addition to the management reporting process, an evaluation process has also been designed. ever, 60 it is rather early to judge it. full-time staff person for planning and evaluation, and will probably be hiring an assistant in this area. Two mechanisms are used to provade feedback on progress ta RAG and clther appropriate committees. submits a quarterly report to the RAG stating progress made concerning project ovjectives for that period, site visits which may be called for by: (a) the Director of Planning and Evaluation; (b) a disease management committee; (c) the Executive Committee; or (d) the RAG. It has not really been teated to date, how- The program does have a The first is that a project director The second involves peer review There is also an annual evaluation of each project, whether or not the project is subject to renewal during the following year. basis of the proposer's annual report and materials provided by staff, evaluations will be made by the appropriate disease management On the I Northern New England RMP "12- RM 0_00003 committee and the Executive Committee. characteristics of the project which contributed to its success or failure, will be asked to recommend whether or not such activities should be replicated in the region, and whether similar projects should be considered for future funding. These groups, after examining 3 There appears to be no line of direct responsibility from those con- ducting the overall ongoing evaluation to the Director of Evaluation. Such an organizational arrangement would clarify the responsibility for the continuing evaluation activity. Considering the reorganization of the NNERMP review process and RAG, it is too early to determine whether this mechanism will convert unsatisfactory results into program decisions and modifications,. The RMP needs to develop for both its own benefit and for that of project directors, a specific procedure relating to the phasing out of unsuccessful or ineffective activities. V. PROGRAM PROPOSAL 1. Action Plan -~ -. .~ .- The NNERMP has not, as yet, established goals, objectives and pri- orities. However, they recognize the need and understand the importance of developing a framework of goals, objectives and priorities. program related to the RMP's mission statement. Director of NNERMP, stated that ranking of priorities will occur in the very near future and that these priorities will be congruent witii The site visit team stressed the need to convert fo a Mr. Donald Danielson, national goals and objectives. +. The activities now being proposed by the region do relate to their approach toward new priorities, objectives and needs. However, the team is concerned that though the 20 proposed projects have sevetal common objectives, there is need to tie these related efforts together so that the resources have a greater potential for changing the health care system than if they are left as isolated activities. all seven cancer proposals have a high proportion of effort devoted to cancer education of the health professions and the public, but they are proposed as seven separate independent activities. Likewise, the five heart proposals have a high proportion of effort to education of health manpower and the public, but they are also independent of each other as well as of other RMP proposed activities. Infant and Mother Care which carries the top priority ranking by the region does not relate to other RMP activities. For example, Northern New England RMP -13- RM 00003 Seven discrete categorical areas are to be used as part of a coqsumer education program using the extension serivce network, but there is no consolidated approach or strategy by the health providers to use this resource to achieve maximum benefit. In four categorical areas, i.e., respiratory disease, cancer, heart, and cerebrovascular rehabilitation plans are proposed to establish and adopt procedures to improve patient care management within com- munity hospital. No interface, exchange, or strategy is suggested or considered. staff effort and its resources by its heavy concentration on cate- gorical approaches and thereby loosing the promise of a program change to improve the system of health care delivery. Attention to the whole instead of individual bits and pieces is essential if the change promised in the reorganization is going to be fulfilled. The Regional Management Committees on a categorical base must interface and inter- lock with RMP goals and objectives or there is danger of a traditional 5Ld-LinC ahraaic dimawe pugma bein$ developed. me program might welZ ewmriUer consoli8sttan of some or its propoeed sctivltiee when the actus1 program to be Implemented is deterptineb. IR summary, this RMP is in danger of fragmenting its ?ne. planned and proposed activities are realistic in view of the resources available and past performance. Abundant data exists on the region's health problems and resources so that criteria for setting priorities becomes all the more important in this region* The team was told that methods for reporting accomplishments and assess- ments have been proposed. commitment to the reporting process so that accomplishments and results can be easily measured, priorities had not previously been viewed and updated periodically, it will be done in the future. Evaluation teams plus managers have a The Director also indicated that though 2. Dissemination of Knowledge, In regard to including other groups or institutions that will benefit from data, the team finds that these groups have been targeted and that they will be further involved in the future. Knowledge, skills, and techniques to be disseminated have been identi- fied in some areas, but not yet developed in relationship to community affairs with the exception of the ambulatory pediatric program. Once implemented and developed, there is little doubt that they be dissent- inated in the region. The site visit team is concerned that the RMP seems to be operating singularly and not in conjunction with other organizations and research e Northern New England RMP -14- RM 00003 institutions in the area excepting the University of Vermont and those hospitals with coronary care units. Other health and edu- cation providers have not-ye: -become -involyed and there -is evidence that they had not really @$ep Interested in becoming 80, likely is because the past RMP strategy has been preoccupied with data gathering and not action, Improvement is expected in this area under the new program thrust. 4 'Ihis, most The team is in concordance in thinking that while the RMP has not shown any evidence of improving quality of care other than in coronary care or moderating costs, this will be a by-product as the program moves on. practical techniques is very significant at this point in time. For example, the use of referral centers has been well established and help by RMP should continue in the future. The approach to dissemination of knowledge about applicable, 3. Utilization Manpower and Facilities Utilization programs are not yet far enough along withln the regjon to comment on except to say that there are a limited number of pro- grams in a limited number of community health facilities.' are all well utilized and will most likely improve in the future. Thest' I ._ .- We saw no evidence that there has been increased produc tivity of health manpower other than physicians and possibly the utilization of nurse practitioners, The region, however, urider&tariris u tiliza tiori problems and is beginning to move in this area, although, implemen- tation has not actually occurred. ._ 4. Improvement of Care 'Ihe RMP has identified the problems of expansion of ambulatory care and the geographic areas requiring attention, ities will expand ambulatory care and other needs. In reference to communication, transportation services, and others, the RMP is doing well as can be expected. They are available but often are not well used nor do people understand how to use them. The EMS is an excellent example of what can be done. Problems of access have been identified and solutions are in project form. Current and proposed activities will strengthen primary care. Underserved areas are beginning to receive attention in one or two projects. As the RMP moves more fully.into a sesvices, more involvement of the underserved areas will occur. Current and proposed activ- There are some health maintenance and disease prevention components, but these are not yet a major emphasis in this particular RMP. We .- I. %. 1- i Northern New England RMP -15- RM 00003 can see that they will be in the very near future. ance and disease prevention components andiplam are considered realistic in reference to the present state of the knowledge, Health mainten- 5. Short-T~erm Payoff Operational activities will increase the availability and access to services over the next two to three years. to measure payoff is understood, is documented, and is well estab- lished in the new evaluation mechanism. The need for feedback It is reasonable to expect that RMP support can be withdrawn over the next three years in most instances. 6. Reaionalization With respect to regionalization, the team found that plans and activities are aimed at aasisting provider groups and institutions. Greater sharing of facilities, manpower and other resources is definitely envisioned in their planning and projects at this point in time. available to other areas. health practitioners and institutions. is also a definite part of their planning and has already'been demonstrated with coronary patients. Existing resources and services will be extended and made New linkages will be established among Progressive patient care 0 7. Other Funding There is little question but that the region has already attracted funds other than RMP and will continue to do so. Most of those have been state and federal, but some local and private funds have been involved. The region has, it was iadicated, definite plans for bringing in others. to other federally funded health program8 and have furnished the base for much of their activity to date. This is particularily evident with Comprehensive Health Planning, Experimental Health Servlce Delivery Systems, Health Maintenance Organizations, and the Federal-State-Local Health Statistic Center. RMP activities have been definitely related .. ..I ... Northern NeQ En'gland RMP -16- 101 00003 - SUMMARY ' - Taking into consideration the history of this program with' its preoccupation on data gathering and efforts to organizationally merge RMP and CHP, the site visitors were favorably pleased with developments since January when the RMP decided to devote its energy to developing a viable RMP. The site team recognized the infancy of the program reviewed, the fact that many elements of the program are untested, and that for the most part the NNERMP is a "paper" organization. the quality of the materials assembled and with an insight tu the management capabilities of the program staff, the visitors were impressed with the progress to date and believed prospects for continued development are good. Yet, based IJn In light of the above remarks, however, the site team has the following suggestions: I . The gods and priorities need to be further defined and mort accomplishment in the next 90-120 days. The Regional Advisory Group needs to expand its membership to , include better representation of youth, minorjties (as ' interpreted under Minority Interests of this report), the medically underserved, areawide planning agencies , allied health, and representatives from the bordering areas of , New Hampshire and New York if it is establishd that these areas are indeed appropriate territories of the NNERMP. i sideration should also be given to the appropriateness of the economic and local political interest having representation. ' emlicitly stated. Ideally, the time frame on this is for . Con- . ' The RAG should consider establishing a subcommittee structure i aligned with goals, once goals have been developed. . I The cbmposition of the disease management committees, ad hoc ; groups, and technical review committee6 should be examined At this time, ' there is concern for over representation of physicians, thus i limiting constructive input from other providers or I persons , , knowledgeable on health care problems. I closely to insure appropriate repreeent'ation. . !Also, measures should be taken to assure that these groups are supportive of the program's evaluation plan. The disease management comittees should have bylaws, or another similar management tool, to align their functional operation plans with the total program. I . 1 * I Northern New England RMP 0 RM 00003 , Consideration should be given to developing management com- mittees for non-disease areas of interest to RMP such as community health, . The approval and disapproval mechanisms for projects should be more clearly delineated. . The evaluation scheme should be re-examined to give further assurance that the RAG and program staff each understands its respective roles in review, evaluation, and feedback. This should minimize potential conflicts. changes should be made coordinating all program staff performing my evaluation with the Director for Evaluation. Also, organizational . The vacant program staff positions should be filled with persons that will provide the program with a broader range of professional and discipline competence, system development, and community organization are specific suggestions. Nursing, allied health, health . The program should look at all their proposed projects and relate common objectives so that the resources have a greater potential for effecting constructive change of the health care system. . The RMP still needs to assume some continued responsibilities for making the region aware in the development of a data utilization strategy. A foml policy on continued support should be established. of available data, and to assist . . The surveillance and monitoring devices of projects should include a method for prematurely phasing out unsuccessful or ineffective projects. Each of the above points were discussed at the feedback session at which: the Program Staff, the Dean of the Medical School, the Chairman of the RAG and several other RAG members were in attendance. In addition to presenting the above points at the feedback session, the following advice was given with the belief that it may serve to improve the program's presentation in future applications: , The forma 15 and 16 should each reflect the same project sponsor, and this should not necessarily be the grantee institution but the institution or agency at which the project is being coordinated and actually implemented. . Program staffs' discipline, professional competency, speciality, or area of fnteresr be identified. Northern New England RMP -18- RM 00003 - , A problem-solution chart be include$ in the program report. $ . The role clearly identified so that potential areas of conflict :or decisionmaking are handled in advance. of the project managers and the project directors 'Je RECOMMENDATION It is the site visit team's recommendation that triennial status not be granted at this time, but that the program receive two-year approval, with developmental component rights, at the level of $850,000 each year, It is further recommended that there be a site visit next year to determine progress, se-evaluate the second year funding level, and again determine the program's readiness for tri- ennial status if in fact triennial status is again requested. . With this recommendation there is one restriction and it is with the continuation request for Project #6, A Program in Kidney Disease. and third years are $37,900 ana a $25,400 respectfully; the requested levels are $78,740 and $70,000 respectfully. change of scope of the activity and there has been no re-evaluation by a technical review group that would satisfy review-of-lcidney- proposal-requirements as set forth in the May 3, 1972 NID, it is the recommendation of the site visit team that the present level of approval remain. If RMPS wishes to investigate this situation further :ind it is decided further evaluat3.m of this situation is merited, thP site visit team has no objection. The presently approved levels for this project's second Because there is ;le Morthern New EngtOdd RnP -19- APPENDIX I RM 00003 Northern New Englhdd RMP - 20- Kn UVVUJ NORTHERN NEW ENGLAND RllGIONAL MEDICAt PROGRAM PUBLLCATIONS LIST A. Published by the Program "A Comparison of Utilization of Selected Health Services by Various Age, Income and Education Groups in the CVHC Area." January 1971. A Connecticut Valley Health Compact Report. - "A Layman's Look at the Working Paper of Health and Medical Care Resources, Spring 1970. "A Report on Cancer in the Vermont Region." February 1971. "A Report on Kidney Disease insthe Vermont Region." May . 1971. 1. 2. 3. 4. A Report on Vermont Hospitals 7/71 A Report on Prepayment in Vermont A Report on Respiratory Disease in the Vermont Region 12/71 A Report on Stroke in the Vermont Region "A Report to the State Health Planning Advisory Council." April 1971. Basic demographic data. "A Working Paper of Health and Medical Care Resources. November 1969. Connecticut Valley Health Compact Report. 1. 2. An Inventory of Health Manpower in the State of Vermont 6/72 An Inventory of Health Related Educational Programs in The State of Vermont 6/72 "Background and Methodology of the CVHC Area. 1971. "Children's Immunizations in the CVHC Area." A Connecticut Valley Health Compact Report. "CVHC Results: Mental Retardation." July 1971. A Connecticut Valley Health Compact Report. "Coronary Care Network Newsletter. first issue: October 1970. August A Connecticut Valley Health Compact Report. August 1971. Published bimonthly; "Demographic Characteristics of the CVHC Area. 'I 1971. "Family Planxling Patterns in the CVHC Area." 1971. January A Connecticut Valley Health Compact Report. A Connecticut Valley Health Compact Report, August 1. 2, 3. Eighteen Individual Hospital Reports Identification of Major Health Problems and Needs in Vermont 5/72 Thirteen Individual Home Health Agency Reports' 9/71 Northern New England RMP -21- RM 00003 "Infant Mortality in the CVHC Area." August 1971. A Connecticut Valley Health Compact Report. 0 1. Inventory of Health Care Services and Facilities in Vermont llKnowledge, Need and Use of Home, Health, Mental Health and Related Services." January 1971. A Connecticut Valley Health Compact Report. "NNE/RMP Health Planning Data Base." Winter 1970. a "Northern New England Regional Medical Program" (newsletter) . Published bimonthly; first issue: February 1967. "Patterns & Utilization of Health Services and their Economic Implications in the CVHC Area.'' A Connecticut Valley Health Compact Report. "Patterns of Use of Hospitals & Preferences for Hospitaliza- tion. April 1971. A Connecituct Valley Health Compact Report. August 1971. 1. Physician Manpower in Vermont 10/71 "Projected Impact of Health Maintenance Legislation in 0 Vermont." May 1971. 1. Report on Health Care in Vermont (Layman's Version 2. Report on Vermont Home Health Agencies 9/71 of "Status Report. . ''1 8/72 Revised "Setting of Health Goals in Vermont: Problem in Political Science and Technology of Planning ,I1 presented at the 11th Annugl Institute of Management Sciences, Los Arrgeles. October 1970. "Smo&ing History and Behavior of the CVHC Population. August 1971. A Connecticut Valley Health Compact Report. 1. Standards & Guidelines: Vermont Coronary Care Network "State Health Planning Advisory Council By-Laws . 1970. Cornptehensive Health Program Boards. "Statcus Report of the Community Health Systems of (Technical Version) August 1971. "The Consumer's View of the Health Care System and Health Insurance." April 1971. A Connecticut Valley Health Compact Report. January For the combined Regional Medical Program and 0 Worthcan Hew Englhdd RMP , ;ZL- RM 00003 .+.3 "The Northern New England Regional Medical Program Health Planning Data Base." Northern New England Regional Medical Program Conference and Workshop on Evaluation, Chicago; .September 1970 . "Utilization of Dental Services in the CVHC. 'I January 1971. A Connecticut Valley Health Compact Report. "Variations in Patterns of Medical Care in the Vermont , Region for the American College of Surgeons, Regional Meeting." September 10, 1971. Burlington, Vermont. Paper presented at the B. Publi'bhed Nationally and Locally "HMO Hearings Begin ,I' Legislative Roundup. July 23, 1971. "HMO Strategy Would Increase Cost of Care in Vermont, Study Shows ,It NHT Newsletter. June 7, 1971. "How One Regional Program Looks ,'I Modern Medicine. March 1966. Review Cycle: 10172 RMF'S STAFF BRIEFING DOCUMENT , k P REGION: Northern New England OPERATIONS BRANCH: Eastern NUMBER: 00003 Chief: Frank Nash COORDINATOR: Mr. Don Danielson Staff for RMP: Spencer Colburn TYPE OF APPLICATION: 3rd Year Lm Triennial f 7 Triennial Regional Office Representative: William McKenna 2nd Year L-7 Triennial c] Other Management Survey (Date): Conducted: Scheduled: October 1972 or Last Site Visit: (List Dates, Chairman, Other Committee/Council Members, Consultants) October 1968 - (Program Site Visit) Dr. Proger, Chairman, Dr. Storey, Robert Lawton December 1970 - (Technical Assistance Visit) Dr. Mark, Chairman, Drs. DeLon, Keller, and Komeroff Staff Visits in Last 12 Months: (List Date and Purpose) February 1972 - To establish a channel of communication with the new coordinator, discuss regional development plans as well as coming site visit. June 1972 - To attend first meet:ing of new RAG, and to clarify question:;. regarding the scheduled August site visit, review verification visit and management assessment visit. Recent events occurring in geographic area of Region that are affecting RMP program: MSDS Contract F-S-L Statistic Grant (presently under consideration) -3- Region: Northern New Ihgland Review Cvcle: 10/72 POLITICAL INFORMATION Governor : Deane C. Davis (R) Senators : George D. Aiken (R) Robert T. Stafford(R) Representative: Richard Mallory (R) DEMOGRAPHIC INFORMATION Population characteristics : Total: 444,732 X Urban: 32 % Non-white: 0.4 of one percent Age Distribution (%) Under 18 yrs. 18-65 yrs. 65 yrs and over Average Income per Individual Mortality Rstes (CY 1967) Heart Diseases Cam er Vasc. Lesions All Causes, all ages Facilities and Resources: Schools Medlcine (UVM) Ikrsing Practical Nursing Cy t o techno 1 og y Medica 1 Techndlogy Radiologic Technology * * * * Hospitals Nonfederal Short Term Nonfederal Long Term V.A. General Hospital e VT. U.S. 35 35 54 55 11 10 $3,267 $3,680 435.5 364.5 173.9 157.2 117.5 102.2 . 1085.4 1143.5 Ember Enrollment (71/72) Graduates (72) -- 1 288 66 4 523 108 2 106 94 1 (Med. Center Hospital, Burlington) 1 (rn) 2 * * * * * * * Number of Beds 2,244 Number 18 3 2,325* 1 200 *Plus 42 beds in respiratory disease unit at the Med. Center Hospital, Burlington. * * * * * * * * 1 * * - 4 .. \I ,/ Special Hospital Facilities Number Intensive CCV I1 1 Cobalt Therapy 3 Isotope Facility 3 Radium Therapy 1 Renal Dialysis, in patient 3 Rehabilitation, in patient * * * * * * * * * Nursing and Personal Care Homes (1972) Number of Beds 22I.E 8 69 Skilled Nursing Home Personal Care Homes with Nursing Care 1311 Long Term Care Units 1043 * * * * * * * * * Manpower Profession - Physician - Active Inactive General Practice Medical Specialties Surgical Specialties 0 ther Osreopa th Nurses - Active LPN - Active Inactive Inactive Number 644 32 218 150 69 20 7 33 -- 2373 955 1067 316 * * .. . .-., .. .- . ..: ... . . ____ --.\ , ., -r., y.-.: . . .. ... . ;E . .. . . L_. e COMPOSEST AX9 FINA.YCXL S!J>Pi%RY TRI EKX IXL APPLICATION Coqocent Pedi at r i c7ulnonazy Gthc-r . -\ )TAL DIRECT COSTS ltn*CIL' RECO.WSNDED *LEVEL c- Current Annuzlized Level 03 Year $ 397,578 725,967 o * Region Northern New Review Cycle 10/77 V I I 462,368 $ 480,000 $ 500,000 I* I ii4 , 617 683,804 78; 740 1 1 1 114 , 6x7 114,617 '( 70,000 . 1442368 46236t 48OCCC sccccc 659978 1645878 ** 47C823 ** ,-lTRT-- 9c;261-- 70 17 61' * *,?617 11 46 1-3 857" CCCO PROGRAM STAFF 5567CC 389200 OC2 PFCCPESflbE CCP 194400 120000 156423 TOOG-CEV E CTA EhiTf6. C -UOI-PaOJECT-lY CnNTV -0C7--Eb'Z IkCEECSlhC 009 PIGH RISK INFAN -DITTECIE~sLfTEO Cf 7127PBu 1 ATPCY -FEn - 014-- PEGICNLL 12EC-R F 015 PAP lPfAC FEbSl 148740 72060 ** 5535c 4t402 172050 - 720€0--- 10000 C06 KIChFY FFCJECT t52SC 5 5 2 s c -** 78?40_ --- ** 70298 ** 57260 3e527 38440 1fOSbl I- .* n5752 85216 5341C 22431e o *- 47616 41616 ** ll0CJ 11 CSS 88558 197 14772 8531554 .+- ** 2522e 29238 -7 3 C C2 -- C C-1 t E 5 i? 10.355 o *- 24364 29725 31452 85595 -'tie -PLFLrc FCLCbTlC ** 31797 - 31797 019 EL€CTPICIL SAFE - 4*-72t4Ev2-5f6 . b 7 13'2 f32306 021 PRCFCSSIONAL €0 +* 2c030 39515. . 22959 82504 023 hEh TEChhICCES z--O 24--EGrUGk IC h f i 0% 5 - -02 6 011 REClCNALILEO RE - 013 CbhCEP PROTOCOL - I 472C4 28199 29952 21'GCCI;RhTlTt OF C +* 017 RECICPAL CAPCEF - - -O~C-EPRL~-IC-CF-C~P o 502?9 40522 4 341 b 13457_1 50920 ¶ i 1750 i Z 025-S1Rf6TCCCCCAL C ' ** 30'50 4ccc lC50 i ** 22082 29654 317FO 83556 f -- -... _- . +* sosic . ** 17 50 ** 368C 722-GPGC FCf'K+-EF€PE 3630 --_----- - C AP 0 I LC-l-FX6R 021 rEoLTr CCUCbTIO +8 2545812 ** 126Clt9 lllb3?1 IC31253 34ce379. - TOThL - 41560c 59_420().- 1040012 ~ ___- ___ .___ __ -L- .---- JULY 17*1972 KtblLW - N NtW RM 00003 10172 i I I TOTAL I 1 I I 1 1 1 a * a I 02U EAPLY IO CA2L;IACS I J I 1 .-- .I_-- 1 I I I I I )70r000 1 L480rOOO I I S566.337 I S1.116.337 I ICTAL 1 - 10 - Region : norwaii LVCW L1116-Lo11.L Review Cycle: 10/72 -- HISTORICAL PROGRAM PROFILE OF REGION 8 July , 1967 riscal Year 1968 June, 1968 - John E. Wennberg, M. D . became PrOgriIill Coordinator (100% time). Site Visit: The role of systems analysis activities in RMP is discussed. systems had helped them organize the planning process in other than planning activities. Visitors felt that but questioned its use - During Ey 68 the RMP accomplishments were: 1) Participated in development of the Connecticut Valley Health Compact whose overall goal is to examine the possi- bilities for the provision of total health care in the Connecticut Valley Healkh Compact region. 2) A physician attitude study is initiated :> ' -1 ,<..: .! 3) Heart inventory is completed. ~ . ~ _.- ,I--- 4) A survey was made of existing medical records to evaluate time involved in history taking and recording of data from the viewpoint of completeness and retrievability . 5) A state-wide education program is con- ducted in external cardiopulmonary resuscitation. 6) Possibilities of a cervical cancer screening program are explored. 7) Involvement with three projects related to information sys terns. - First Operational grant request receivL2d requesting support of four projects as follows : Project U1 - RMP office Project #3 - Emergency Health Care Project #4 - Continuing Fducation for Ilealtlt In early September a project #5 - Evaluation Protocol for Coronary Care System Inclusivt! Emergency Health Services was submitted and Project 82 - Progressive Coronary Care ., .. ,- ,-* .. &> k .-./ Professionals * 11 - October, 1968 November, 1968 December, 1968 0 February, 1969 May, 1970 - Site Visit to discuss 01 operational. request: .- Major concerns of the visitors: 1) Slow rate of maturity; 2) Lack of involvement of RAG - especially in the decisionmaking process; 3) Degree of influence of Executive Committe or RAG; 4) Lack of Medical Society involvement in generating program ideas; 5) Lack of a clearly defined conceptual strategy for the region. All projects were reviewed and visitors felt this had merit but additional planning was needed. - Council concurs with site visit team and Review Committee and 01 operational grant is deferred for additional information and clarification. - Dr. Wennberg request (granted) permission to meet with DRMP to discuss November Council's recommendation. He asked for permission to revise the operational application and be allowed to submit it for the January-February 1969 review cycle. His justification for requesting this was that a delay to the April-May cycle would be extremely detrimental to NNERMP. - Council approved operational request and authorized funding of Projects Nos. 2-- Progressive Coronary Care, and 4--Continuing Education for Health Professionals. The WS staff review of the 02 year operational request found the progress reporting so sketchy, the future plans so nebulous and the financial reporting so unjustified, that the application was deemed unreviewable. There was also considerable discussion about the region's first year of operational experience resembling its planning its planning experience, i.e., concentrating on problem identification, epidemiology studies, data analysis, etc., without a clear-cut operational plan of action. - 12 - August, 1970 December, 1970 RMPS staff reviewed a revised 02 operational request, approved it, and recommended a site visit to investigate: 1 1) Whether the region actually has systems analysis capabilities. 2) Whether the region's strategy and its incorporation into the CHP planning structure was consistent with RMP goals and also evolving a Regional Medical Program. 3) Whether there has been any major reallocation of regional resources. Site Visit: The findings and recommendations were generally as the following: The major emphasis on data acquisition and analysis strategies was reasonable, however, some of the region's resources should now be allocated to RMI? activities which would give the RMP some visibility in the region. been used effectively in some instances, but some plans for utilization, including a systematic data utilization strategy, should now be developed. Particular attention should be paid to problems encountered in preparing or "marketing" the data for specific organizations. addition, the region should broaden the base of understanding of the data system among regional groups and perhaps add someone not integrally involved with the program and with expertise in preventive medicine and public health to the Study Committee of the RAG. Although in the early plan- ning days, there was evidence of support from the Medical School and the State Health Department, these visitors reported problems in communication with members of these institutions. The relationship with the practicing community was also a qiiesticbn. The data techniques had In - 13 - e May, 1971 -- August, 1971 October, 1971 - RMPS staff was unable to grasp accom- plishments of the region and requested that the National Review Committee and Council be requested to assess its program approach before the region begins preparation of its three year application. - National Advisory Council expressed concern over the program of the region and requested a staff assistance visit to the region. - Dr. Margulies, Director RMPS, sent a letter to Dr. Luginbuhl, Dean, College of Medicine, UVM, expressing concern over the status of RMP in Vermont, the portion of RMP resources going for support of the Experimental Delivery System and conversely the portion going toward program development consonant with the Mission Statement. - Mr. Don Danielson is appointed Program Coordinator and the effort to rebuild NNERMP along "traditional" lines is started . - 14 - Region: Norther New England Review Cycle: 10/72 - STAFF OBSERVATIONS Principal Problems: The priniciple problems have been this program's failure to: 1) establish a RAG active in decisionmaking, 2) develop a clear-cut operational plan of action, 3) coordinate RMP, CHP and MSDS into one management system acceptable to both Vermont and the Federal Government, and 4) develop a systematic data utilization strategy for W or other potential data users. Principal Accomplishments: The principal accomplishments have been: 1) 2) 3) development of the Regional Disease Management approach development of a data base for health planning, and publishing of reports in heart, cancer, kidney and respiratory diseases. Issues requiring attention of reviewers: 1. 2. 3; 4. 5. 6. 7. Present and future organizational relationships between RMP, CHP and EUSDS? Relationships with the medical school with particular attention to the Medical Review and Comment provision in the review process? Correlation between the activities and the stated program's goals, objectives and priorities, and determination of which is the product of what? Composition of the RAG (CHP a and b?) and its Executive Committee? j The RMP plans for future support and/or utilization of the data base? Compliance with the CHP review and comment regulations? The plans for involvement and development of the three counties in New York State considered a part of this region? I -- 1-1 SARP ReZion: Northern New England RM 00003 RevJcm Cycle: Qctobex 1972 Type of bppl icntion: Trieniijnl Rat.in,l; : --- 2 82 __-_ ____- ----____--I__ I__--- Re comnien dat ions From . /fl Review Committee .- - Site Visit /7 Council I- - RECOMi'lENDATLON The National Review Committee concurred with the reconmendati on of the August 9-10 site visit teaill. That is, it reconiinended: (a) The request for triennial status be denied and that the program be approved for its 04 and 05 years at the level of $850,000 each year; (b) W5 thin the $850,000 a devel.opmenta1 component in the amount of 10% of the program's previous annualized direct cost level be awarded; (c) k site visit be conducted prior to the 05 year to completely reassess the program. With continuation request for Project #6, A Program in Kidr,ey Disease, it is recommended that the presently approved levels of $37,900 and $25,400 for this project's second arid third years remain. The requested support levels of $78,740 and $70,000 €or these two years should not be approved. The Total Request (d.c. ) Request -_I_. Year 04 05 06 CRITIQUE $1,260,789 $1,116,337 $1,031,25 3 Review Coninittee Re cornmen dation $850,000 $850,000 -0 - Taking into consideration the history of this program with its pre- occupation on data gathering and efforts to organizationally merge E4P and CHP, the Committee was favorably pleased with developments since January when the RMP decided to devote its energy to developing a viable RPP. -2 - The Coininittee recogqized the infancy of- the Ijrograrn reviewed, the fact that many elements of the progrr;nl arc> untested, and that €or the most part the MNISPJ-IP is a "paper" organizntjon. the quality of the materials assenrl~lcd and with an insight to the management capobi lities o€ tlie pr:~gra~~i staff, particularily the new Director, IiIr. Danielson, it is believcd prospects for continued development are good . Yet, based on The following suggestions emanat ecl from tlie review: . The goals and priorities need to be further defined and more explicitly stated. , The MG needs to expmd its membership to include better rep res en?. at i on o f you L h , the me d i.ca1I.y under sc rve d , ar eawi de planning agencies, allied health, and represciitativcs from the ;ordering areas of New Hairip2;l)ire and New Yorlr if it is established that these areas are indeed appropriate territories of the XNlXIP. Consideration should also be given to the appropriateness of the economi c and local political iiiterest having representation. - . The RAG should considcr establishing a subcomrnittee structure aligned with goals, once goals have been developed, , The composition of the disease management comrnittees, ad hoc groups, and technical review committees should be examined closely to insure appropriate representation. Also, iiieasures should be taken to aysurc that these groups are suppo~-l:ive of the program's evaluation plan. . The disease management coirimi ttees should have bylaws, or another similar management tool, to a1 ign their functional operation plans with the total program, I Consideration should be given to developing management committees for non-disease areas of interest t-o Pdzl) such as cominunity health. . The evaluation scheme should be reexamined to give further assurance that the RAG and program staff each understands its respective roles in review, evaluation, and feedback. should minimize potential conflicts. Also, organizational changes should be made coordinating all prograrr, staff performing any evaluation with the Director for Evaluation. The vacant program staff positions should be filled with persons that will provide the program with a broader range of professional Th-is t . c -3- and discfpline competence. Nursing, all.%c?cl health, hea1t:h system developnicnt, and comunity' organ:i.zati.on are specific suggestions . The 1)ro~r,rni!i.5~1ould 100k at a1 1 tlicir proposed projects and relate coimon o1,jcctivcs so that the rclsocirces Ilrive a greatcr potential for effecting constructive change of the Iicalt-11 care system. a The PXFj still needs to assume some continued responsililities for rnakjng the rsgion aiware of avaiidb3e data, and to assist in the developnicnt of a data uti lizatiori strategy. A formal policy OR continued sul)port shoulrl be established. . The survci lla-~ce and monitoring devices or Frojecls should iiiclude a liicthnd Lor preniaturely phas ing out unsuccessful 01: inef Fective projects. It was emphasjzed that tlte transitior the MNEK?P i!; presently going through is not the tradi tional projcct-to-progLnrs trznsition most RXPs experier:ce, but one of changiiip from an orgaii zation priiiiarily Inierestcd in data collection to one rrow in concert with the presci>t SPS mission sta~ement ID fact, tl-rc fer7 categor-ical activities of the program have a comprehensive flair with clefini_te considerations for broader problems. Dr, Luginbuhl of the University of: Ve?-mont was riot presznt during these deliberations. Component ___.- hslea Pediatric Pulmonary Other TOTAL DIRECT COSTS Current Annualized Level 03 Year $ 397,578 328,389 725,967 $ 462,368 114, G17 683 304 ( 78,740 ( 1 c 1 I 1 _-- ( 1,260,783 nrn i fl1 w--~- I--- ynar __. $ 500,000 114,617 416,636 i I i I 10% ~ (37,900) (25,400) 850,000 j s50,000 Region Rochester . Review Cvcle 10/72 - f7 SARP Type.of Application: Anniversary before Triennium Rating 269 Recommendations From - ./ X/ Review Comniittee - - - / 1 Council - / / Site Visit - e RECOMMENDATION: The Committee agreed with the site visitors in recommending an approved level of $935,000 for the Rochester RMP's 05 operational year. In arriving at this level it was necessary to balance the numerous and promising changes made during the year against the considerable work yet to be done. $900,000, plus $35,000 earmarked for the kidney program, was considered appropriate because it would represent an increase over the current approved level and a moral encouragement to the RegTon and would permit the RRFP a sufficient allocation for program staffing, develop- mental and planning activities, as well as an increase in project activities beyond those initiated during the 04 extension period. The base level of Requested Recommended $1,035,000 $935,000 Critique - The Committee agreed with the site visit team that over the last year the Rochester Regional Medical Program has seen dramatic organizational, functional, and programmatic changes, particularly: 1. The resignation of the previous Coordinator and the hiring of Dr. Peter Mott. 2, The dissolution of the previous large program staff in terms of functions and people and the beginnings of the new. 3. The change in the character of the program with the termination of sixteen ongoing projects and the initiation of new directions in concert with newly-established goals. 4. The change in RAG composition, interest, and responsibility. -2- 5. The closer working arrangements with the CIlP (b) agency. ' Time has not yet permitted the Region to complete the change process, however, and many areas still need a substantial amount of work; especially: 1. The further development of goals, short-term objectives, and priority setting mechanisms, 2. Completion of the organization of RAG committees and delineation of their functions, with an awareness of the need for minority representation. There is a necessity too, which the Region recognizes, to diminish the power of the Executive Committee and increase the responsibilities of the UG. ' 3. Development of program staff as a high program priority. There was the suggestion that the Region may wish to increase program staff over that now projected. 4. The immediate development of by-laws and procedures, with the proviso that these documents-must he furnished to RMPS staff for review, and that the January 1st award be contingent on their completion. It was stressed that there must be a clear definition of the differing roles of program staff and RAG. The Committee agreed, too, that the numerous other points of advice the site visitors relayed to the Region (which are contained in the site visit report) be formalized and relayed to the Region after Council consideration. EOB / DOD 9/26/72 .. COMI'OKENT A!! @ INANCIAL SUAWIARY 1 Current Annualized Level ANNIVERSARY APPLICATION ' BEF0.M TRIENNIUM " Request For Con;! one n t Year I PROGRQl STAFF COXTPuKTS IjEVELOP3:ENTAL COMPONENT . ' OPEtL'ITIONAL PROJECTS PIsdiatric Pulmonary Other o TOTAL DIRECT COSTS COUhrCIL-UPROVED LEVEL $ 259,855 -- e- 598,951 I I. $ 8581806 . I $ 871,308 05 Year $ 415,000 -0- . -0- 620 , 000 ( 35,000 ) ( -0- 1 ( ( -0- 1 1 (, . -0- ( -0- .. ) .. $1,035,000 Requesti5Funding For Year /-/ SARP /x/ Review Comnit? .. ._ ,. - $935 , 000 combined .. ' . (35,000 3 ( I i I I' $935,000 $35,000 for the Regional Kidney Program. REGION: Rochester OPERATIONS BRANCH: NUMBER: RPI 00025 Chief: Frank Nash COORDINATOR: Peter Mott, M.D. Staff for RMP: Eileen Faatz LAST RATING: WC': h I_ TYPE OF APPLICATION: 3rd Year Regional Office Representative: /I Triennial /I Triennial Robert Shaw 2nd Year Management Survey (Date) : Triennial &m Other Anniversary prior Conducted: November 1970 to Triennial-05 or Operational year Scheduled : Last Site Visit: June 1971 (List Dates, Chairman, Other CommiUeelCouncil Members, Consultants) Alexander M. Schmidt, M.D., Dean, Abraham Lincoln School of Medicine, Robert Lawton, Deputy Director, Tri-State RMP - Consultant Richard Cross, M.D., Chairplan of NJRMP RAG - Consultant Richard Haglund, Associate Coordinator for Administration, Intermountain RMP - Staff Visits in Last 12 Months: University of Illinois - Review Committee Member e Consultant (List Date and Purpose) October 1971 - Dr. Orbison (Dean, Med. Sch.) and Dr. Saward (Assoc. Dean Extra- February 1972 - Dr. Pahl, Mr. Peterson, Mr, Simonds, Mr. Shaw, Ms. Faatz - mural Affairs) visit Rockville to discuss RRMP problems with Dr. Margulies. to review the changes/progress made since the June 1971 site visit, discuss the Rochester situation with all key people involved, and recommend necessary changes for the Region in the future. and site visit . June 1972 - Ms. Faatz - review recent progress and,discuss upcoming application Recent events occurring in geographic area of Region that are affecting RMP program: All year. Continuing conflict between Blue-Cross sponsored pre-paid group practice plan and many area physicians who oppose the idea - with Blue Cross the victor. a Rochester health authority. and concomitant increase in close working relationships between CHP and Fall 1971, Unsuccessful attempt by CHP (b) agency and others to establish ng 1972. BDplopment of Assistant Director of CHP (b) agency RMP. June 1972, Tropical Storm Agnes wreaks havoc on the Corning-Elmira area - both cities inundated - possibly two of Cour community hospitals beyond repair and many private physicians' offices wiped out. Since this area has been rife with duplication and gaps in health delivery system, there -~JQ+= +ha nnaaihllitv for some restructuring of the system in the In New'York State And Detail of Rochester RMP .._, . ,. -3- Region: RnrhPatPr Review Cycle: 10/72 DEMOGRAPHIC INFORMATION o t The Rochester Regional Medical Program is composed of ten counties in the western portion of New York State. by the Lakes Area RMP (Buffalo) and on the east by the Central New York REP (Syracuse), on the north by Lake Ontario, and the south by Pennsylvania. It is bordered on the west The city of Rochester is the third largest in New York and is the industrial, commercial, educational, and cultural center of the area covered by the RRMP. More than half the city's people earn their livings in manufacturing industries. Eastman Kodak and the Xerox Corporation employ large numbers. The second largest city in the RRMP area is Elmira, a manufacturing center in the south-central part of the State. The remainder of the Region can be characterized as small townjrural, including the beautiful Finger Lakes area, and has fruit growing, truck gardens, dairy farms, and vineyards. The approximate population served by the Region is 1.2 million. statistically the population of the ten-county area is 66 percent urban, this is a result of the large urban population in the two most populous counties of the area: Monroe County (Rochester) and Chemung County (Elmira). The other eight counties in the Rochester Region are over- whelmingly rural. The non-white population of the area comprises 5.5 percent of the total, with the largest concentration in the city of Rochester where 17.5 percent of the population (52,115) is non-white. Many Blacks and Puerto Ricans in Rochester, though, feel that the census figures are considerably lower than the actual population figures. The RRMP area contains 271 registered migrant camps - one-third of the New York State total - and during the peak season there are somewhere between 12-15,000 migrants in these camps, mostly Blacks. The median age of the area is approximetely 28 years with eleven percent of the population over 65. There is a generalized out-migration in the age ranges 20-35 and an in-migration at ages under 20 and over 65. average family income in the area is somewhat lower than that of the rest of New York State and the percentage of people eligible for public assistance is higher. There are 27 general acute care hospitals4 in the Region with a total of 4,153 beds. Of these, seven hospitals and 50 percent of the total beds are in the Monroe County (Rochester) area. Elmira has two hospitals of about 250 beds each. one community hospital each. registered MDs and 10,435 RNs, with 70 percent of the physicians and 50 percent of the nurses in Monroe County. shows, though, that in the ten counties there are only 800 active, non- institutional primary care physicians (GP, internal medicine, pediatricians, and OB/GYN) under 65 years of age. The health education institutions in the area include the University of Rochester School of Medicine and Dentistry, eight professional nursing schools and three for practical nurse training, one cytotechnology and six radiologic technology programs, as well as two hospital-based programs for medical technology. Although The The remaining eight counties contain at least The Region houses 1,798 licensed and Appendix A to the RAG Report Current. Annualized Level ' Rcqucst For Kidney --- __L Rcqucst Funding Foi. ?1S/C3 Pediatric Pull7!023ry u- I 1iCTAL DIRECT COSTS C3iiXCI i -X??R3VE3 LEVEL * Only Coun ' Year $ 259,855 598,951 c $ 858,806 $ 871,308 1 approval for the 05 year j: $ 415',000 -0- -0 - 620,000 ' ( 35,000 ( 201,500 I ( I -0- (. . -0- 1 $1,035,000 * Yc3r I I I' $35,000 for the Regional Kidney Program. -. . -7- Region: Rochest er Review Cycle: 10/72 HISTORICAL PROGRAM PROFILE OF ReGION The initial planning period for the Rochester Regional Medical Program began in October 1966. By that time Dr. Ralph Parker, the former Medical Director of the Rochester Regional Hospital Council, had been appointed Coordinator and Mr. Frank Hamlin, past President of the Hospital Council, had been appointed Chairman of the Regional Advisory Group. These appointments were considered particularly auspicious since the Hospital Council is an organization which practiced regionalization well in advance of the concept's embodiment in PL 89-239. Council were impressed with the history of cooperation among the components of the medical community in the Region. When the RRMP applied for operational status in early 1968, staff and national reviewers emphasized Dr. Parker's difficulty in recruiting full-time staff (haiwas the only full-time person for the first nine months) and the lack of administrative personnel involved in the program. Despite this problem, site visitors and CoPrmittee/Council reviewers thought the Region to be well-established with good university and community support, and ready to inaugurate an operational program. Since each of the five project proposals in the original operational application, however, addressed some aspect of heart disease, the reviewers indicated that the Region needed to give attention to the development of a balanced program. The Committee and Over the next couple years as project proposals were reviewed by Committee and Council and as continuation requests were assessed by RMPS staff, the initial optimism about this Region began to wane. fact, uneven progress in the BRMP prompted a staff reduction of the 02 year commitment. There appeared to be a growing concentration of activities in Rochester (and the University Medical Center in particular) at the expense of peripheral involvement. The laissez-faire administra- tion of the Coordinator, the low rate of expenditures, and the continued dearth of full-time professional staff were seen as problems as well. The Rochester RMP appeared to lack influence on the health care system. These growing concerns spurred numerous visits to the Region. The first was a site'visit in April 1970. In general, the site team found that many of the individual projects were strong and many were promoting regionalization. was beset by the suspected difficulties. administrative deficits of the Coordinator and the passive character of the Regional Advisory Group which had relegated problems regarding program and priorities to others. This visit and a subsequent management assess- ment visit in November 1970 resulted in recommendations to the Region . that the RAG assume its responsibilities for direction and that the program hire a strong Deputy for the Coordinator and provide administrative assistance to the program. The Spring of 1971 saw the submission by the RRMP of a Triennial Application which exhibited the same chronic problem areas, and another site visit was scheduled for June. was merely a replay of that in 1970, the site visitors were optimistic about the recent creation of an interested and active Executive Committee of the RAG, and in this Committee the visitors saw a possible hope for In The Regional Medical Program itself, however, Of prime importance were the Although in many ways the 1971 visit bringing the RRMP out of the doldrums. The program still remained, though, a conglomeration of individual projects, and the primary problems identi- fied continued to be: 1. Problems in program staffing and lack of administrative leadership. 2. Lack of integration of goals and objectives into a coordinated program approach with attendant priorities for determining program activities. 3. The inadequate review and decisionmaking process and the failure of the RAG to assume its responsibilities. The many concerns of the site visitors were relayed clearly to the Region and emphasized by a recommendation to fund RRMP for only one additional year, and at a reduced level. The Region was told that there would be a follow-up site visit in a year to check progress. Within a few months of the site visit Dr. Orbison (Dean of the Medical School) and Dr. Saward (Associate Dean for Extramural Affairs) visited Dr. Margulies in Rockville for a frank disaussion of the Region's problems. For some time after this, the Region appeared to continue business as usual, stretching its 04 year award to cover all approved projects, which by this time numbered 17, primarily categorical and dominated by nurses' , and physicians' continuing education activities. Then, on January 1, 1972, Dr. Parker's resignation was announced and interim direction was assumed by Mr. Jonathan Rudolph, a young man who had come with the program only a few months before as assistant to the Coordinator. .- -. , -.e- . . I. . ,. . .! .- ..... .. ' -.s.. " A rather large team of RMPS staff members (five) visited Rochester in late February 1972 and were rather disappointed to find that other than Dr. Parker's resignation and the search for a new Coordinator, the situation was as stagnant as it had been for the last two years, spent discussing necessary changes with the numerous people involved with the program. Although the messages delivered by RMPS staff at that time were not new, perhaps the degree of receptivity was, because after the February visit, a number of things happened in rather quick succession (including the appointment of a new Coordinator). These are described briefly on the next page under Principal Accomplishments. Meanwhile, an RMF'S administrative decision to implement a three-cycle review year, caused Rochester's 04 year to be extended four months from 8/31 to 12/31/72. RRMP was asked to justify an award of $266,672 (a pro-ration of the present level of funding) with the understanding that during the four-month extension new activities could be implemented with RMPS staff approval, without approval of the National Advisory Council. submitted an application for $266,672 for the four-month extension. for program staff activities and thirteen projects was requested. thirteen projects, ten were completely new and evidenced a new trend in Rochester, away from continuing education and categorical activities. the strength of the major programmatic, functional, and organizational. changes which had occurred in the Region in the last months, and on the basis of the new look represented by these projects, Dr. Margulies and RMPS staff gave Rochester the authority and funds to implement these activities for four months, Two days were These activities, though, could not be continued beyond 12/31/72 In June, the RRMP Support Of the On -9- Region: Rochester RMP Review Cycle: 10/72 STAFF OBSERVATIONS Principal Problems: Main problem is the insufficient time since Dr. Mott became Director, for all the necessary restructuring: a. Essentially, at this point, the Director and the Assistant Director are running the program by themselves, a rather difficult task. b. The RAG bylaws and other procedures need revision. c. The RAG committee membership (selected before the new RAG members were appointed) needs to include minorities and other new members. d. In filling future RAG vacancies, the program should consider whether the present composition of seven women on the 36- member group represents adequate sexual parity. e. The RAG must continue to take on increasing responsibility and relieve the Executive Cornittee. Principal Accomplishments: In this last year there have been considerable organizational, func- tional, and programmatic changes: a. New Director - Dr. Peter Mott b. Changed composition of RAG to increase minority and consumer representation, and election of a new RAG Chairman (the second in the Region's history). 6. Establishment of goals, termination of old program, and initiation of new directions. d. Closer working arrangements with CHP and development of relationships with groups not formerly involved, such as inner-city and migrant organizations. Plans for complete reorganization and reorientation of program staff. e. Issues requiring attention of reviewers: a. Goals - Does regional experience since the formulation of goals suggest that they should be modified? 0 b. Is the review process adequate? -IO- STAFF OBSERVATIONS (Con t hued) Issues requiring attention of reviewers (continued). c. Are the Region's ideas about the organization and functions of the new program staff reasonable, and are recruitment activities meeting with success? ! d. Is the proposed evaluation process for individual projects going to be handled in a coordinated fashion? position for evaluator of program staff.) (There is no proposed e. With the change in program direction, is the previous base of community support being maintained, or is a new constituency being developed, or both? f. How has the University/RRMP relationship withstood the recent program changes? .. , .. . 1! .... ... Page 2 - Review Committee - Texas RM 00007 ' advisory groups appeared practical at this time. The visitors also believed the proposed activities reflect peripheral involvement. Expansion of more allied health representation in the decisionmaking groups has been limited, but sincere beginning efforts were noted. Of major concern to the visitorss progress in minority involvement on the program staff and in the decisionmaking process has been slow. However, attention was drawn to RMPT's written plan for recruiting minority program staff. The site visit team believed the application request to be modest for what RMPT proposed doing and recommended approval for the period of time and in the amount reauested. The <' visitors also went on record recommending a continued rating of "A" for RMPT. he Review. Committee expressed concern that the RAG is still dominated by providers of health services, and noted only minimal change in minority involvement. the projects seemed to be self-serving to producers of services. It was also believed that many of was expressed that a program which has to deal with the kindJof sues in Texas, particularly Blacks, Mexican-Americans, migrants, etc. , n only do so with the kind of experience they can get from people are involved with these problems. The Committee noted the relatively modest request submitted by the RMPT and wondered Ljhy the program wasn't bigger in view of the size On the other hand, e reviewers were not impressed by many of the proposed projects and questioned hcw much impact they would have on the health care del i very sys tem . The Committee recognized some progress in Texas and the keen ability However, it was believed that the Region should the state and the magnitude of the problems. the Coordinator. minorities and consumers, and sharpen its focus rs. Flood were not'present at the discussion of this .I B:DOD 9/ 291 72 Region: COMPONENT AND FINANCIAL SUMMARY TRIENNIAL APPLICATION R Committee Recommendation for Current Annualized Level 04 Year L -Approve< 2nd year Counc 1st year nnial 3rd year ;t for Tri 2nd year Requ t Is t year Component $ , 877,970 -- $ 754,129 $ 579,999 138,280 90,000 [ $1 58,000 $190,000) $21 0,000; 225,000 1,297,538 160,000 200,001 EVELOPMENTAL COMPONENT PERATIONAL PROJECTS 1 ,264,341 1,317,47; 771,761 ($309,640: ( 337,15j' --- 1 : $337 I1 57: (294,640) m, hs/ea Pediatric Pulmonary Other $2,400,508 ~1,900,00 $2 $1 00,oo $2,300,0( $2,178,470 $2,34023 $1,580,040 TAL DIRECT COSTS UNCIL RECOMMENDED LEVEL .. REPORT OF Rl3GIONAL MEDICAL PROGRAM OF TEXAS SITE VISIT August 1-2, 1972, Austin, Texas BY REGIONAL MEDICAL PROGRAMS SERVICE CONJXNTS Pa;? I . SITEVISIT"4 .................... 1 A . Consultants .................... 1 B . RMPSStaff .................... 1 C . DHEW VI Regional Staff .............. 2 I1 . REGIONAL MEDIC& F'RCXBAM REPRESENTATrvEs AND OTHERS . . 2 A . Executive Corrmittee and Regional Advisory Group . . 2 B . Grantee ...................... 4 c . Pro@;ramStaff ................... 4 D . Others ...................... 5 I11 . BACKGROUND INEKlRMATION ................ 7 A . Purpose of the Visit ............... 7 B . Pre-Site Visit Meeting .............. 9 IV . CONCWSIONS. GESJERAL IMPFESSIONS AND RECOIvlMENDATlON . . 10 V . WIEW DETAIL3 .................... 11 A . Performance .................... l! B . Process ...................... 15 c . ProgramPro~sal ................. 21 ATI'ACHMENTS I . Supplemental Coments ................. 25 Recruiting Plan 1973-74 ................ 23 11 . I11 . Non-RMpTF'unding ................... 33 -1- I. SITE VlSIT TEN! A. Consultants Miss Elizabeth E. Kerr (Chairman) Review Cormnittee Member Director, Program in Health Occupations Education Division of Health Affairs University of Iowa Iowa City, Iowa Ws. Mariel S. Morgan National Advisory Council Member Chief Medical Technologist Presbyterian Hospital Albuquerque, New Mexico - 1/ George E. Miller, M.D. (fomner member of Review Cormittee) Director of Research in Medical Education College of Medicine University of Illinois Chicago, Illinois - 1/ Alf'red Popma, M.D. (former Ember of National Advisory Couricil and past Director of the Mountain States RMP) Boise, Idaho John A. Lowe, M.D. Director South Dakota Regional Medical Program Vermillion, South Dakota B. RMPS Staff p- - l/Miehael J. Posta Acting Chief Mid-Continent Operations Eranch Division of Operations and Development Joseph de la Puente Acting Deputy Director Office of Planning and Evaluation JirrnTy L. Roberts, M.D. Health Consultant Division of Professional and Technical Development - l/Participated in the previous site visit June 1971 - chaired by Dr. Ifiiller Luther J. Says, Jr. Operations Officer Mid-Continent Operations Branch Division of Operations and Developmnt C. DHEW VI Regional Office Staff David Eubanks Program Representative Dallas, Teras A. Executive Committee and Regional Advisory Group - 2/ Richard T. Eastwood, Ph.D., Cham Director, Houston Medical Center Houston - 2/ Arthur H. Dilly University of Texas System (Chairman of Capital Area Planning Council - CHP(b) Austin R0bert.K. Bing, Ed.D. President, Occupational Therapy Association University of Texas Medical Branch Galveston Levi V. Perry, M.D. (Coronary Care Project) Private Practice Houston N. C. Hightower, M.D. Past Chairman, RAG Chairman of Nominating Comittee Scott and White Clinic Temple George J. Race, M.D. Chairman, Technical Advisory Committees Baylor University Medical Center Dallas - 2/ Elizabeth Jones, R.N. Chairman, Continuing Education Committee Associate Dean, University of Texas School of Nursing Houston !- i- ;; t. tt - 2/Executive Committee Members I -3- Edward L. Baker Texas Pharmaceutical Association Dallas - 2/ S. R. Greenwood Chairman, Availability Cormittee Member, Program Development Codttee Temple National Bank Temple - 2/ Jams. E. Bauerle, D.D.S. Texas Dental Associafiion san Antonio Martha N. Bobbitt, R.N.. Texas Nurses Association Amarillo Wlrton G. Hackney Executive Director, CHP (a> Austin Billye Brown, R.N. Member, Evaluation Cormittee Associate Dean, University of Texas School of Nursing Austin Vance Terrell, M.D. Program Developmnt Cormittee Private Practice Stephenville V. J. Bel& (ex officio) Director, V.A. Temple Charles Corley President, Texas Society of Medical Technologists Abilene John M. Smith, Jr., M.D. Texas Medical Association Private Practice san Antonio - 2/ Grover Bynum, M.D. Vice Chairman, Evaluation Coattee Private Practice Austin - 2/ Executive Corranittee Members -4- - 2/ J. G. Cigarroa, M.D. Private Practice Laredo B. Grantee Charles A, LeMaistre, M.D. .Chancellor University of Texas System Austin C. R. L. Anderson Comptroller University of Texas System Austin Charles B. McCall, M.D. coordinator Stanley Burnham, D.Ed. Director, Professional and Cornunity Programs Louise Miller, B.A. Chief, Administrative Services David K. Ferguson, M.S.- Deputy Coordinator Robert 0. Humble, M.A. Deputy Director for Cornunity Programs kverly Drawe, M.J. Chief, Information Service Thomas V. Sander, B.B.A. Accountant ' Hubert Reese Data Management Specidlist John Donbroski' Program Development Linda Johnson Technical. Information Specidlist - 2/ Executive Cormittee Member Program Staff .. . .... . '_. I. , , :, .., . . .l .- . , .-_ . ._ . .. . '<..i;' -5- John G. Dailey Director of Education Prograros (effective 9/1/72) Central'Office Based Operations Officers Robert L. Anderson, M.B.A. Gerald Mussey, M.Ed. (ENS Specialist) Billy D. Gwartney, M.B.A. Subregional Representatives Sumel D. Richards, Ph.D. #2 Lubbock Maria Elena Flood #3 El Paso Jarnes C. Karsch, M.S. #4 Abilene Grady Faulk, Jr., M.Ed. #7 Tyler N. Don Macon #8 Houston Sister Marion Strohmeyer, R.N., M.P.H. #10 Harlingen D. Others Floyd Norman, M.D. Assistant Regional Director for Health and Scientific Affairs DHEW Reeon VI Dallas Garabed Eknoyan, M.D. Ehylor College of Medicine (Renal. Disease Project, Director) Forrest Ward, Ph.D. coordinating Board Texas College and University System Austin Lincoln Williston Executive Director Texas Medical Association Austin Ray Hurst Texas Hospital Association (TRMP Health Careers and Electrical Safety Projects) Austin Lewls A. Leavitt, M.D. Wlor College of Medicine (TRMP Rehabilitation Projects) -6- Robert Mickey Office of Medical Health Manpower Texas Medical Association Frederick Fleming Executive Director Houston-Galveston Planning Conmission - CHP (a) Houston Velma T. Faulk, Ph.D. Project DFrector GRO Projects 54 A-E Jo Ann Hinson GRO Verma Hancock GRO -7- 111. BACKGROUND INFORMATION A. Purp ose of the Site Visit 1. To assess program progress, processes and proposed Triennial Application. constituted mor factors taken into account by the site visit team. The RMPS Review Criteria 2. As recomnded by the August 1971 National Advisory Council the site visit team was charged to provide specific infomtion on progress in the following areas which were enumerated in RMPS' Advice Letter of August 11, 1971 to RMPT. a. "The RMP of Texas needs to establish priorities under its new program direction. Although the review system appears to be satisfactory at the present time, reviewers felt that it cannot be . f'ully tested until priorities itre established. Only then can the Region expect to concentrate on funding patterns which relate to the real health needs of the Region. b. "The subregional staff members need more assistance and support from the central staff and RAG members in the development of specific programatic activities. Ucal advisory groups, either in cor@mction with CHP(b) agencies or under the auspices of RMP of Texas, would also further the enhancement of progressive action in the subregional areas. "The approval of the developmental component request should also assist the Region in the further development of mom peripheral involvemnt. e. "More representation from allied health groups is needed on the major policy making bodies, especially the Executive Cormittee and the Regional Advisory Group. Reviewers felt that those who are now serving on task forces and conanittees could/should be considered for election into policy making positions and continue to use the subcommittee structure as a "training ground" for additional nonphysician health professionals and consuITy?'I?s. -8- d. "Similarly, additional minority group mrnbers shr,ul,l be included on the RAG and Executive Cormittee. Reviewers noted the cormitmnt of FOP of Texas to the health care needs of Dhe Blacks and Mexfcar- American populations which together comprise 30% of the population of the Region. Althou& there is representation f'rom professional members on these groups, reviewers urge the Program to consider the nonprofessional's involvement in proposed activities soon enough for them to be constructive in their participation. in the subregions where activities will be planned for ghetto residents and migrant workers. By utilizing minority groups, especially those with bilingual talents, at the local level, a mre extended RW orientation could be offered whicii could provide a source for better selection or those who could be considered for election into the Regional Advisory Group o "It was noted that there were no minority representatives on four of the mJor subcommittees of the RAG or any serving in professiowl positions of Core staff. Program should strive to improve these weaknesses. Perhaps employment opportunity on the Core stzff might be improved by inserting a recruitment swestion into the operational objectives of the Administrative Service Division (note page 68 of the Triennial Application) . "In giving attention to the assessment of regional needs and problems, some reviewers felt that the process seemed to be more of a central office academic review rather than peripheral involvement and inp7-A-- a theoretical rather than przgnEtic approach. agreed that the Core staff theoreticians are most capable but mly need to have increased input r'rcm tt!e emerging subregional organizations. These statements might be considered as a corollary to item #2 found above. This would seem appropriate, especially The e. iievlcders f. "Reviewers felt that overall Program accomplishments to date have been relatively modest. that some projects, such as the Cancer Registry, have not progressed as rapidly as others. It was ncted The -9- relatively high f'unding priority given to the Registry activities was most perplexing to the reviewers. care program was cited as having had a real impact on the health delivery system. per se, were not discussed by the reviewers other than how they were ranked for funding consideration. It is assumed that this apparent short-coming will be rectified when short-term objectives and program priorities become finalized by the Regional Advisory Group. '' On the mare positive side, the corcmuy Other project activities, B. Fre-Site Visit Meeting 1. As part of the verification of' RMPT's review process, Messrs. Posta and Says visited and interviewed representatives of the CHPb) , two CHP(b) Planning Comnissions and sponsors of four projects (2 approved and 2 disapproved) July 28 & 31, 1971 in Houston and Austin. On this phase of the verification, they found RMET in compliance with the RMF'S' Review Process Requirements and Standards. 2. The site visit team met the evening of August 31, 1972 to review the purpose of the site visit as outlined above. At the suggestion of Dr. Miller (chairman of the June, 1971 site visit), it was weed that most of the discussions should be directed toward the concerns of the August, 1971 Council; and that little would be gained in rediscovering most of what was learned during the previous site visit. For these reasons RMFT agreed to last minute changes in the agenda to allow adequate time to get at the major issues during the first day. Also, for this reason som RAG and Cormittee members originally scheduled to attend during the second day were not present. However, RAG and Cormittee representatives present were satisfactory to the conduct of the visit. Other issues to be explored as presented by RMPS staff were: -UtiUz&ion of consmr groups in establishing Objectives and priorities. --Relationships with CHFCa) and Cb) agencies in planning and project development; particularly since only 5 of 21 (b) agencies have been funded and TRMP local advisory groups have not be activated. - 10 - ---Why are no planning and/or feasibility studies included in the application? ---What is the current status of emergency mdical services and what is ?rRMP's role? -4f those projects whei-e ?RMp support is to be phased out in the 04 year, how many Will continue? --Proposed budgets indicate only minimal support f'rm other sources. If successful, what are the assurances of their continuation after cessation of 'I" support? ---In the long range planning, what will the relation- ships be between GRO projects and Area Health Rep source Information Centers? ---With regad to GRO projects, what are the cost-sharing services other than education? ---Explore rationale of f'unding of the many new projects &' -'< for one year only, as well as unspecified growth funding~,'*..;~ - -; in the 06 & 07 years. \- IV. CONCLUSIONS, GENEXG 7MpRESSIONS AND RECOMMENDATION The Regional Medical Program of Texas has developed priorities which were the basis for the development of the proposed three year program. Objectives and priorities should be further developed in measurable terms; hence the critical need for rapid employment of a qualified evaluator, support and assistance to the subregions. Progress and projected staffing of subregions is good. and being, responsive to local CHP b) planning groups rather than formation of local RMPT advisory &roups appears practical at "vis time. The proposed programs reflect peripheral irivolvemnt. Expansion of more allied health representation in the decision- making grou~s has been Umited, but sincere beginning efforts were noted, however. also been slow in the transition md this issue must be addressed mcire rapidly. shoultl now be tested, do and approval is recmnded for the period of tine and in the amounts requested. record recommending a continued rating of A for RMPT. There was new evidence of central off-lce Their plan of cooperation with Progress in minority interest involvement has Evidence of overall progress is clear and proposed action The request is modest for what they wmt to The site visitors also strongly wished to go on - 11 - Supplemental docwnts requested from RMPT (appended to this report) are as follows: 1) a discussion of program elemnts relative to 1974 and 1975 plans for new activities; 2) Recruitment Plan 1973-74; and 3) Non-WPT Project Funding. At the request of RMPS staff RMPT also provided supplement;_il information on the renal disease project with a cover letter dated August 14, 1972. A. Performance 1. Goals, Objectives and Priorities This was one of the major concerns of the previous site visitors as stated in the advice letter. and short-term objectives have since been established. Priorities have been delineated and coincide with both RMPT and national objectives. The objectives ils evidenced by testimony during the site visit are understood by all those participating in the process. The paucity of measurable objectives inherent in the priority statements, however, was noted. The Chairman of the RAG, the Coordinator and his Deputy shared this concern and intend to develop measures of effectiveness. A Chief of Program Development and Evaluation is to be employed and more expert consultation will be sought in strengthening the E3aluation Cormittee. It is clew that the subreglonal offices axe now providing more input into the system. subregional office representatives. advisability of developing local advisory groups was discussed and the concensus was that CHP(b) oriented planning councils are being developed and that potential activities of local RPIP advisory bodies would constitute wasteful dupllcation of effort. This would also be detr-ntal to codty efforts, particularly in Texas, because not all of the potentially effective, articulate, and well-infomd consuITIE3rs have been introduced to the system. Perhaps RMPT could assist in developing more expertise in council consumer participation, as suggested by om of the subregional representatives. Specific long-term This was supported by all The issue of the consmr - 12 - A joint effort to train consumers in council participation is presently being supported by Migrant Health and RMPS. In addition, five contracts for developing an environment for Chicano Health Consmr Participation are being supported by RMPS in Texas, Arizona, Colorado, and California in the hope to alleviate this need for effective council participation. Mrs. Maria Elena Flood, subregional representative in the El Paso area has been appointed by RMPT to spearhead the latter in Texas. The site visitors believe some real progress has been made toward establlshing priorities under the EW program directions. The stated priorities, when appropriate, have been followed in the funding of operational activities. Priorities are addressed to regional needs and reflect the possibility and lnstmntality for continuous development and improvement. While their objectives and priorities reflect the result of a study process, there is little evidence that other than "studied opinions" entered into the priority determination mechanism. 2. Accomplishments and Implementation There is evidence of continued accomplishnent stimulated by Program Staf'f and RAG Committees. support of a planning effort towards a comprehensive proposaL addressed to renal disease has resulted in a promising activity. If this program is successfUlly funded and implemented, it will bring to Texas one of the first efforts addressed to comprehensive care of a particular patient group on a regional basis. Health Education Resource Programs (AHEFP) are other examples of likely successrul activities. For example, the Project GRO and their Area While "traditional" projects had been supported in previous years, these are now being terminated. of projects, as presented, promise to deliver improved accessibility. wider application of howledge is not yet visible. A new generation The thrust of these activities 'coward the Quality of care has not yet been addressed with emphasis, particularly in terms of providing opportunities to measure these objectives. . -. ... . -. .. 1 . .:. ,. .. , .. ,. . . . .,. .-..-:., - 13 - aepresentatives of various multi-disciplined professional organizations testified favorably on behalf of RMM'. Salient mng these was the Texas Medical Associatlon, the Texas Wsing Association, and the Texas Pharmaceutical Association. It was recognized that the Region is serving an effective role towards the delivery of health services by being a bridge between the institutional physician, the practicing specialist, ard the general practiuoner. is serving as a catalytic agent toward progress addressed to implementation of FiI" priorities. Here tne program The visitors saw positive potential reflected in present and scheduled accomplislmnts. 3. Continued Support In response to questioning by the visitors, the Regional representatives reviewed the continuing support status of' activities funded during 1970-72. Of twenty-two projects supported only two will continue after the close of the current period; eight will be supported by self and/or other support; seven will be discontinued; and continuance of three is questionable. It is evident that the issue of continued project support may well become an irnportant component in RMpT's decision- making progress. While FtMFT feels that past performance in this area could well be improved, the future will bring early consideration of this issue at the proposal development stage. For exarriple, an integral. part of the total perfomce plan for an integrated kidney disease program for Texas willbe identification of continued sources of support other than RMPT with particular attentior, to fee for ~ervice. 4. Minority Interests The lack of adequate minority involvement being a historical problem in FMFT, this revlew criterion was explored in depth by the site Visitors, as will be recognized throughout this report. on the F'rogram Staff, one professional and two clerical (Spanish summed), one of whom was added during the past Wre are only three minority representatlves - 14 - year. A recruitment effort has been underway for somethe for a qualified Mexican-American to head the San Antonio subregion. Employment of Black subregional representative in Dallas is also a consideration. out that Sister Strohmyer, subregional representative in the Rio Grande Valley, though of German ancestry, identifies extremely well with the Mexican-American in that area. is expressed in the following table: It was also pointed Minority and female representation on the RAG MINORITY AND FEMALE IXPIESmAflON ON RMPT RAG 1968 1969 1970 1.971 --__I- SPANISH SURNAME - 1 1 2 BLACK 1 2 3 3 1 3 5 6 FEMALE 11 50 ---- TOTAL OF RAG 32 33 % OF RAG immmsrn~ -6.3 18.2 Although there is clear evidence 'ICTAL OF ABOVE 2 6 9 44 20.5 f min cons&r mum through the subregions, 1972 3 3 5 11 51 22.0 21.6 rity input by the visitors expressed-dissatisfaciion with the small number of minority members on RAG and its sub-structure. for the Reglon is the significant number of mlnority personnel on project staffs. A plus The present goals and objectives coincide with areas of minority concern, particularly those addressed to "making quality of care available in those areas where little if any is now available." Planned activities are addressed to the training of Embers of minority groups in health occupations, RbPT is not satisfied with its performance in minority involvenlent. of Texas System, Charles A. LeMaistre, M.D., advised that as the grantee institution, the University of Texas indicated awareness of their responsibility to assure compliance by the FWT. The Chancellor of the University 2. A proposed "Recruiting Plan" for 1973-74 was pt,, eEt4 to the visitors. The plan includes the hiring of Elacks ard Spanish Sunanw3d/Spanish Spealsing Americans. It wa; emphasized that the Recruitment Effort Document includes plans for constructing a talent roster. This docmntation was submitted to RMPS as a supplement to the application prior to the Review Committee meeting. Dr. Cigma, a RAG meniber and a private physician from El Paso, who identified himself as a Mexican-American, advised that all the tokenism in the world would not help without true concern for the needs of minorities. In the RMPT RAG he has clearly seen concern for the needs of the urderserved. B. Process 1. Coordinator Dr. McCall, the Coordinator, has provided strong leadership to the Texas Regional Medical Propyam during his three-year tenure. He has assembled a viable Regional. Advisory Group and has utilized the diversified talents of its membership in establishing the threeyear plan as presented in the Triennial Application. Group has been actively involved in responding to the concerns of the August, 1971 National Advisory Council as enumerated in the advice letter August 11, 1971. Dr. McCall's excellent rapport with the members of the Regional Advisory Group and with the mmy health agency representatives was overtly apparent to the visiting team. In addition to tMs task, this The Program Staff is outstarding as evidenced by their individual presentations throughout the two-day site visit meeting. major responsibilities and receives the same degree of loyalty from other members of the staff as does the Coordinator. The Deputy Coordinator, Mr. David Ferguson has Program Staff w Current FU%T staff' consists of 19 professionals. but two of them serve 100% time, and there has been very little turnover during the past two years. professional staff members are requested in next year's budget. All Six additiorlal - 16 - They include a Director of Educational Programs, a Chief of Program Developnt and Evaluation, a Nursing Eikcatcr, and three subregional representatives. believe that the additional positions budgeted (approximately $100,000 annually) in the Triennial are justified. Chief of the Program Development and Evaluation position is considered essential since Mr. Humble, who had filled this position until recently, has been appointed Deputy Director of Cormunity Programs and will now be more involved in working with the subregional representatives. The site visitors suggested that consultant services also be considered to assure that effective program evaluation plans materialhe by the RAG Cormittee assigned to this function. Aside fican program evaluation responsibilities, this Cormittee will also be expected to assess Frogam Staff activities. The site visitors The The Program Staff reflect a high quality and broad range of professional discipline competence. Particularly impressive was the quality of the subregional representatives who demonstrated thorough knowledge about their responsibilities described their active involvement with the local Council _- r I. and respective geographical assigned areas. They also -: i .. ~ 3 .- us of Govements and CHP 314(b) agencies who give additional input frm the consumer interests in the respective subregional areas. 3. Regional Advisory Group The 51 member RAG met three times during the past year. The average rate of attendance was 70%. The site visit team noted that most of the key health interests were represented on the RAG. membership was considered to be satisfactory. with many Regional. Medical Programs, physician representation is proportionately high while consumer interests remain rel- atively low. attention since the sm problem was evident when the Regj.on was assessed in 1971. "he RAG Chairman and the Coordinator responded to this concern by stating that progress had been made in the selection of one-third of the members who were replaced during the past year. clear that the progress was not as good as it should be and strongly urged that this problem be addressed as soon as possible. Dr, Eastwood, RAG Chm, responded by stating Geographical distribution of its However, as Tbe site visitors gave this deficit considerable The site visitors Fade it - 17 - that the present &ers of the Advisory Group are outstanding personalities. He also expressed his belief that there is a distinct difference in institutional and practicing physicians; and considering Texas" large population, geography and nuher of medical institutions, the nmber of physician RAG members may be minimal. this premise expanding the RAG me&ership may be the solution to involving more non-physicians. On The 16 mber Executive Cornrdttee met 4 times during the pat year and provided ample guidance to the Coordinator and staff. This Committee was particularly effective in providing leadership in the total review process and in utilizing the Regional Advisory Group.'s many (51) cormittees and task forces. Membership composition of all comittees was found to have the sam weakness as the RAG. The Program Development Conanittee assumed an active role by establishing short-term objectives and program priorities. As a result of its work, seven Program Cormittees have been fomd to identif'y general program activities relating to the seven priorities identfied. The Chairman of each Program Cornnittee is a RAQ member and serves on the Executive Cornnittee. each of the seven priority statements and funding allocations projected for use of growth funds in the second and third year of the proposed Triennial Grant Application. the Program Staff has a fairly good concept of what kinds of activities should be generated in subsequent years. The Staff will also be able to better employ developmental funds in stimulating activities which have a direct relationship to the short range objectives identified. General program activities are described for Thus, 4. Grantee Organization Dr, Charles LeMaistre, Chancellor, University of Texas System, Mr. R. L. Anderson, Comptroller, and Mr. Arthur Dilly, Executive of the UT System assured the site visit team that the grantee does provide fkeedom and flexibility to the RAG and does not interfere with the programmatic endeavors and the decisionmking functions of the RAG. The site visitors wished to be assured that compliance was being Et in equal employment practicies for minority groups and womn. When the response to this inquiry indicated that progress had not been as good as it should be, the visitors suggested the need for an affirmative action - 18 - plan which would include a recruitment practice callirsg for the advertisemnt of the job, its description, the credentials needed, records of interviews conducted and the results of them, upward mobility intents, and the implementation of an applicant file. The visitors were then presented with a recruitment plan which had been prepared by the Program Coordinator which was considered to be a "forthright" response. concern that intent should be encampassed far beyond the sole responsibility of the Coordinator and urged that the above mentioned affirmative action plan be considered for draft by the RMPT and ratified by its membership. It was apparent that the grantee also recognized its responsibility in seeing to it that the minority interest problems are resolved. However, the team expresEed the 5. Participation Many health interests, institutions and groups are actively participating in Rl"T as evidenced by the number of persons NIO attended the two-day visit. captured the controlling interests of the program. In comparing the budget request with that of last year, there is a complete turnaround with respect to funding the major universities and institutions. ment has provided more corramcnity resources but has not brought about less cooperation from the major health institutions. Although there remains a high degree of mdical society influence on program activity corsiderations, much progress has been noted. For example, an HdQ activity is being funded by HSMHA to the Bexar County Nedical Society as a direct result of RMPT involvement and staff asslstance in drafting the application. Also, the first three program priorities indicate a marked change in the philosophy of the Texas program in that access, availability md utilization of manpower have replaced the categorical emphasis of yesteryear. There remains strong Tesentrnent in implemnting new physician extender manpower programs (i.e., physician assistants) on the part of the Texas Medical Association ('IMA). This was aga.in eniphaized by a ?MA Official and progress in this area may be slow unless the four proposed AHERP's (health services/educal;ion activities) generate additional strength through the County Medical Societies. No major group has This accomplish- - 1g - The political and economic power is involved in th? 3EY program. Aside from active RMPT physician prominence on the state and national scene (i.e., cancer and heart), the CHP agencies and local Councils of Governments have given endorsements to the Region. 6. bcal Planning CW(b) planning has developed slowly. There are 21 CHP (b) state planning reglons encompassing the entire state (254 counties). almost all of the others have received state fbds ($10,000 to $20,000 each) for staffing. Nineteen (19) of these agencies now have councils. In Texas, each CHP (b) agency is associated with a Council of Govermnt. The latter are voluntary associations of local governments of which two-thirds of voting members are elected officials. All health proposals for state and/or federal support me reviewed first by the CHP Planning Agency and then by the Council of Government. All proposals applicable to the City of Houston also require review and comnt by the Mayor's Office of Planned Variation, one of approximately twenty federally supported proparm. RMpI'has defined 10 subregions covering the entire state and six of these have now been staffed. four will be staffed by the end of the current period with priority given to the San Antonio and Dallas areas. Most of the subregions relate to two or more CHP planning agencies. the central office staff. interface with local planners and consumer groups. During the last RMPT review cycle, there was ample evidence that RMPS' Minimum Review Process Requirements and Standards for local review have been carried out in a most satisfactory mer, particularly b the CHI?(%> agencies. As reported by FWS staff the CHPd agency has participated in the review of RMPT applications but only through limited staff involvemnt. The Council has not been involved because it meets only twice annually. CHP(a) staff reported and described their review and comnt workload as voluminous (49 agencies have health components); yet they believe they too should have technical review prerogatives. Its staff is limited and the lack of a complete state plan is probably because most of its $500,000 budget is used in Five have received federal funding and The remaining Unstaffed subregions are currently served by The Region has an excellent - 20 - enhancing the local (b) agency growth. by one of their officials they are more inteirsced i!i developing the players before the script. As eh?~iu3sst2Z 7. Assessment of Needs and R, Psources There was ample evidence that RMPT has conscientiously accumulated a great deal of data as evidenced by its being selected along with 6-7 other RMps to participate in the WashingtodAlaska Management Ii-Lfomtion Sys tern program. The data is utilized, but probably not to its fullest extent in identioing specific and measurable needs, The priorities, as stated, reflect the general mission statements of the national program and are not based necessarily on specific needs as docwnted by hard data obtained by the FiiWT. 8. Management The mnagement capability of RMTT continues to be excellent. well coordinated, including mnitoring by RAG members, a Program Staff person and other selected ad hoc members. Progress and financial reports are required on a quarterly and monthly basis respectively and shared services are being actively pursued by satellite hospitals participating in the five project GRO activities. Association is participating actively through its diversified activities especially in the electrical hazard project and in the shared services program being implemented in 18 hospitals. The latter propam has demonstrated a 10% savings in services provided bjj utilizing the concepts employed by better miagement techniques. Program Staff and project activities are The Texas Hospital 9. Evaluation At the present time, there is no full-time Evaluation Dlrector on the Program Staff even thoupa there is evidence of some management assessment in this specjalty. Several activities have been rightly terminated due LO evaluation and monitoring assessments by staff arid tkte RAG. Sane project activities have been evaluated fa.ii>ly extensively while others have not due to the shortage of statf expertise. Very little consultant services have . been procured to more f'ully provide evaluation to progarn development and Progran Staff activities. The site .j . . - .-. . . -,-.... ' ..I, i-. .. I ':, . .> _1-. ,? __. .:. - 21 - visitors were assured that employment of a qualifiL4 evaluator would be given hi& priority and that the RAG Evaluation Conanittee and consultants would be more highly geared to this effort during the ensuing year. More effective evaluation is critical to the Region's further program development and effectiveness. C. Program Proposal 1. Action Plan A comprehensive effort, the priorities have been thoughtfully prepared with much debate and review, and are clearly congruent with national goals and objectives. The proposed activities relate to stated priorities and objectives, wlth increasing attention to needs. Though modest in terms of identification of areas of highest need, the proposal is much more realistic in light of available resources and past performance. The goals are amable, but are stated in such a general way, it will be difficult to quantio; and is one of the weakest parts of the program proposal. Methods of reporting accomplishmnts and assessing results are proposed, but address individual activities more than program achievement. are planned, Periodic review and updating of priorities 2. Dissemination of Knowledge Most programs have a focus on appropriate provider groups and/or institutions that will benefit. Knowledge, skills and techniques to be disseminated have been identified to varying degrees in some projects, degree of imolvemnt of health education and medical institutions as evidenced in their widespread support of program proposals. Better care to more people is the goal to which mst projects are directed; but some solid masurement of results remains to be seen. Moderation of costs of care is addressed. address management of most f'requent health problems, those to which attention is given are significant and not rare. There is a remarkable While RMPT does not necessarily 3. Utilization of Manpmer and Facilities The Region's intent to utilize cornunity health facilities is apparent in most projects. At this stage increased productivity of health manporsrer does appear to be an - 22 - objective in most of the projects. allied health personnel has improved. types of health manpower is a sensitive issue, further attention is being given. Utilization of manpaver ad facilities is an identified priority and it is receivin& appropriate program focus. Underserved areas and populations is a concern of RMPT as reflected in their proposal. Utilization of Although new 4. Improvement of Care There seems to be a very limited degree of studies of ambulatory care, but this data may emerge in next year's program staff activities. other groups in attempts to improve Dnergency Medical Systems. Access to health care is their first priority and projects are addressed to this issue. Prirr-ary care and its access will probably be strengthened since this is an important element in several projects. attention is given to health maintenance md disease prevention in the proposed activities. Program staff are involved with Less 5. Short-term Payoff The proposal in part is directed more toward the availability of an access to services, than swly gathering more information about health problem; whether this goal will be achieved remains to be seen. The need for feedback to document actual payoffs is projected but not specificdlly planned. planned beyond three years and plans for transition to other sources of support are generally incluexi. Support of projects is not 6. Regionalization Support of multiple groups and institutions is a mior goal of the program as reflected in many of the activities. Sharing existing resources, and services and ne^ Linkages among provlders are indicated in the three year plan. "he concept of progressive patient care (e.g., OF clinics, hospitals, extended cpse facilities, home health services) are only minimdlly reflected in the application. '. ' -. - 23 - '1. Other Funding Contrary to the irSomtion in the application, there is ample evidence that the Region has and will attract runds from sources other than RMPT. in detail during the site visit, the RMET accountant provided RMPS staff with a document which indicates non-FD" flm3ir-g as follows: $882,372 and terminating projects - $150,380. Though not discussed new and continuing projects - 4 August 15, 1972 Harold f.larcJulies, M.D., .Director Regional Medical Proyranis Service Parklawn l$uilding, Room 11-05 5600 Fishers Lane Hockvi 11 e, Mary1 and 20852 Dear Dr. Margulies: The attached materials are forwarded in response to discussion with the site visit team on August 1 and 2, 1972. During that visit we outlined the Regional Advisory Group's work toward definitive program developxent. The reviewers asked that we reduce to writing, RI4PT's 1974 and 1975 plans regarding new activity in each short-;-.'- '. discusses each program element as it ..: ._ ' . -. range prograin area. bas been identified by the conimit3ecs of the Regional Advisory Group and as presented at the site visit. Attachment I. . Another area of discussion was the minority composition of the staff of the Regional Medical Prograni of Texas. The discussion centered around the recruiting plan presented to the tean as additional information. suggested we forward the plan as -inforination suppl enental to our appl ication. It is enclosed herein as Attachment 11. Under separate cover and letter we have sent you (August 14, 1972) additional documents in support of the Texas statewide renal proposal. was requested by J. 1. Roberts, M.D. of your staff. It idas This material We hope this information will be useful..in the prcscntatiotb of tflc RMPT Triennial Application to the review committee and council. clarification is needed or information required please let us know. If additi6nal 7 hirles B. kCall, M.D. Coordinator ,' c .. 1 . .* C BM/m j XC: Miss Elizabeth Kerr- I. Enclosure ..__.- -s. Elariel S. Morgan r. Luther Says &* n n-3 - n-I __._ ( 3) i d c 11 1' i f i cat j 011 and tl i s cu s s i. o 11 o P 11 iir t i c u 1 a r c 1 crii c n I- c; o f (;;1c1i pi-o~rant arcn €or ciiip11:~:;is 1)y tlic I{cgioi~:iI. Medical 1'ruOgr:l.n or '~'csas. 'flit coniinittees , tl~roiigli tlic lat,tcr xssi~nlnen~-, spccificd scver;il arciis of particular concern as a point of tlcpai-turc for Purtlicr program d~:vcl opi~cnt and iiiimcdi atc €oci for. stnlf cffort. Tlic timing of tlic c1cvel.opincnt process was such that thc stalf did not: have this information availnlJlc to thcin wlieii proposals and ideas iroin the coinriiunity were being solicited and evaluated in December, 1971 arid Janrrary, 972. I'liere€ore, the f irr; t opportunity to explore community interest in depth in these areas will come in the 1973 rcview Y cycle. The staff of the Regional !.IedicaI. Program of Texas is seeking cominunity interest and jnvolveinent in those elements sct out hj thc program coin~~ittecs. The €nits of this search will bc forthcoming in the 1973 review cycle. In anticipation of new activity in these specific arcas, a ~nini.muin mount of ~ funds in the 1974 and 1975 budgct have been idcntificcl. Some of tlicsc funds arc avai~ab.Ie Irom tcrminating projects. Othcrs b JI~IVC been incIudcd 011 thc basis of an cstimatcd nuiulicr and size or activity antici.pntec1, 'c TI~C a'ctual spccific activity to 1 .: F. . . .e - 26 - I ACcc!is - Public (paticnt) cd cation '- idcas for tho rcduction of bnri-icrs to health arising Crom lack of knotqlcdgc ahout ill- ness, thc licalth care system, or financing mecl~;lnis~ns. T 'r Cultural barrier reduction - tes.t methods for overco!~iin~: health barriers relating to culture from both the paticnt and pro f e s s i ona 1 v i eivp o in t s . Quality consistcl~cy - try mcchanisms to assure that the quality of care provided is consis tent. without regard to economic or social status. Coordination of reierrals - exp.7 ore ideas for coordi.naij ng paticnt referrals to reduce the conlusion and allpearancc of fragmentation in the health care system. Simplification of the entry - proccss - aside €1~0111 cost and information, seek idcas concerning the simplification of the acquisition of care. Availability - Emergency service coordination - seek activities whose purposc is tlic dcveiopmcnt of linkages and/or coordinatj 011 of scrviccs of commt~nitics involved in the delivcr)r o€ emcrgc~ncy b nicdicnl trcatnlcnt . iacilities not IION avai1:iblc. IJtili z;ition - .' ,d . , Utilization studies - encourage studies of facility and nurscs not working as nurses. Rural rcsource coordinatjon - support activitics that aiiri for cooperative interaction among rural coiiiinunj tj es in the efficicnt and ef Cectivc use of health carc resources. Health Manpower - Curriculum coordination - explorc means by which arti- culat i on and coordination can bc expanded in the region' s manpower program. C en t r a 1 r c f e r en c e s our c e d c! v e 1 o pme n t - s u pp o r t fur t 11 e r activities that will improve and expand this valuable program. Continuing Education - Professional self-asscssmcnt - seck methods for re- designing the conventional approach to self-assessmrnt. Community leadership development - encourage health professionals to becgme involved in coniinunity plannirlg and seek ways to provide some training for the assumption of that' role. Audio-visual techiiiqucs - analyze new electronj c tecliniques for potential use in refresher education. ' Rc-instruction,in disease management - test idcas for selecting the appropriate subject ar.eas' for re-instruction pi- e s cn t ;z t ions . 0 -25- * L h cncournge attcmpts to closc tlie co~iiinuni cations gap betwccn tlic ~'town'' professionals and the "go\vn" professionals . Tnvolvcn~cnt of state education agency - try idea:; whi.cli involve thc state education agency stiff in RIW~ activity. Extension - . Successful project screciiing - 'seck successPu1 idcns froin this and other RZ4P's that might bc applicable in Texas. , ~ .. , . -1 Publication of successiul effort - support the sprcncl of *=- -.! .., information regarding activitres that have successfully con- tributed to improved patient cqre. Publicize proj cct progress regularly - en'couragc eE:Eoi-ts at publicizing the progress of project effort in a11 attcirlpt to involve the intcrcst of others. Audio-visual information - maintain a kiiowlcdgc of I. , -+. , .I . ' . .. .. . ,. .. ... ... . ' .. , .. .; , ' .* At the time of the devc:lopiiicnt of this plan tile Regional I4cdical Pt-Ctljrdi; of Texas eitiployed 30.6 full time equivalent staff in seven offices tfi,-ouliirL' out the state. prczyt-diii ciiiploys no Elacks and three I~lcr,ican-Ar;rericaiis. This pldri is dc- signed to I)ring the staff of the Regional illedical Program of Texas iiito rcssanal)le parity with the 1970 censlls tabulation of rnajor iiiinori ty groups in Texas. The census identifies 12.7 percent of the Texas population as Black and 17 percent as Spanish surnamed. That staff is 44 percent male and 56 perccnt female. Tile Recruiting -- Goa7 Tne goal of the prograin regardi ny i,iiriority staffing is .presented it) the attached table. To meet this goal recruiting efforts will be organized to seek, in the next two years, five Blticks, three Mexicat7-flinericans, and two females. professional and other criteria for ci;iployiiient in this program. anticipated that this goal can be achieved by the end of 1974. Every effort will be made to find individuals who can meet the It is The following vacancies exist in the present. organizational structure of the Regional Medical Program of Texas: Available Positions --- Current Vacancies: 0 Chi eP , Program Devel opment and Eva1 uati on Nurse Education Coordinator Regional Representative - San Antonio Administrative Assistant - Houston Future Vacancies (1973): Regional Representative - Dal las-Fort l!orth Regional Representative - Aniari 1 lo Clerical positions will be created in each of the regional offices as th;) professionals are employed. This will add three half-tiilic secrct;lrics tu the staff by the end of 1374. One secretary is proyi-ai:iined for the Austin office staff in 7974. In additioti to the planned additional positions shown above there wi'11 be vacancies that occur froiii noriiial attrition. this rate will -be ayp$oxiinately two clerical and one professional per year. Recent experience itidiccitcs - 30 - b cooperation of Regional Advisory Group liK!iii!J(!r7>, i's, tire ttai:iw of sevrjral minority rccruitit,*j cutit tict: acli will ~JC tliorouyhly cxplor'cd in ttic coiaii II~J eads io .i 5 w:trc 01- quali I'icd tiionths. At1 Pxfstitl cirp'Ioyr.ient aycncy also is supplying good po te 11 ti a 1 1 y ci uil1 i fi ed i t~di vi dua 1 s . The en ti re pro9 ri:m s la ff ttic vhcancics that exist arid is alert. to the availability of p ro f c s s i on i\ 1 s. . Proqress -...I-____- atid Evaluation lhi s rcciwi ti ng plan wi 11 be eval uatcd in two areas. (1 ) fkcords w-i 11 be developed and maintained on cacti rcci-uiting contact. A file will bo c1o;c:d only when a final advice letter is written or the individual rcrx)vr-: hiw,ei f from consideration. each three montlls as a part of the quarterly adininistratS ve revi cw procc-sc.. (2) Progrcsr, toi.!drd tlic coniposi tc goal will be reci~rc~cd , Current: iilack PROGRAM STAFF MIWORITY REPRESEXTATION PLAN (1 ) ilexi can/Arr,eri can Fen!a? e Total Staff ---, G5al: Black &xi cm/Amri can Fen2 1 s Total Staff Profess i ona? itisber Fercen t 0' 0 1 5 6 31 19.6 3 13 4 17 6 26 24.6 Clerical iii ti r.ib e r .Percent 0 0 2 18 11 7 00 11 2 13 2 17 13.5 100 13.5 Compos i te ilumber Percent 0 0 I w P 3 o 10 17 56 I 30.6 5 13. '6 ' 17 79 50 38. 1 ,. , . . . '. . .. .. , FROM : SUBJECT: Operations Officer Mid-Continent Operations Branch < _- ~~&mal ~cal Progrsrm of ~xas 'a Supplemental Information to the Triennial Applicatlon < _- wg~onal ~cal Progrsrm of ~xas 'a Supplemental Information to the W-emlal Applicatlon mng the site visit to FWEC tie subject of support; fro~n other sources vim discussed. contrary to the lnf'omtion In tk Triennial dtmdon is being met. AlthougsI not discussed specifically duriw fhe hit, RMPT provided this reporter wlth a list- of r10n-M euppart of both new an8 continuing activities $882,372, as well as prqjects to be tenrdnated this period 8150,380. . . Application under review, them vias anple eadence that this T. _- \ pK RegLcn has subsequently clarified that their figures are for the figures include sennces of 0- ldrd. c-. ., - t: clne year and gre expected to increase In subseqwnt years. Also AHRIC - qricr . 2,400 T y 1 c r .- Sin i 1: h C o u n t y 5,090 I'r o j cc t IIliAClI 7,000 Family Mcdj cal. Resource 4,000 C e n t e r P 1 ann i II g I ! AIIERP - Central Tcxas 2,750 Electrical Safety Services 100,000 Cont inuiiig Medical Education Project HEARD 0 22,230 55 , 990 37,400 -- -- -- Standard Tcchniqucs for -- Home Health Care Rehab Nursing Tcchni.qties 20,500 Demo' Unit Continuing 70,415 33,137 For Small Iiospi tals Education in Medical Rehab Project GRO . 25,000 .* Proj ec t MAN0 72,800 Chi 1 d r CII s lie ar t Pr ogr aiii 43,000 W. Texas - S.E. New blcxico 6,250 -- -- AliERP - Kio Grande Valley -- 8- - -- ' 4. AIIERP - South Texas - -. 372,000 Strltcwide Cancer Registry ..$ .- itcducc C011ipl.j cat ions I:o 1 1. owing llad io 1: 11 e r apy Maxi 11 ofaci;il 1Ie;il th Cnrccys Dial. Acccss Strokc Demo Program Medical l'hysics I 1111 a 1 a t i on T 11 c r a p y Electrical IIazards o 2,400 13,500 14,500 49,832 3,500 2,000 -- 5,000 -.. -. - - Eradication 05 Cervical 14,548 Cancer PASTBX 4,000 Inter-regional Serial Contr o 1 1,100 Re 11 a b Man a g e ni e n t - 6,000 St. Elizabeth's -- -- -- -- Regional Rehab - IVharton Regioiial Rchab - Nctf )3 r ii uii f e 1 s 27,000 7.,000 7/28/72 Review Cycle: October i972 3 REGIomr Texas OPERATIONS BRANClI: Mid-Continent ?. , -., - o NUbER: 00007 Chief: Michael J. Posta C0ORDINATOR:Charles B, McCall, M.D. Staff for RMP: Luther J. Says, Jr. Operations Officer, MCOB; Jim LAST RATING: A **, de la. .. TYPE OF APPLICATION: - 3rd Year Regional Off ice Representative : e/ Triennial / / Triennial VI. Dallas. Texas) - - 2nd Year Management Survey (Date): / / Triennial /-/ Other 71 - Conducted: Scheduled; or Last Site Visit: (List Dates, Chairman, Other Committee/Council Members, Consultants) July 29-30, 1971 - George E. Milla?, M.D., Chainnan;'Alfred M. Papma, * M.D.; Joseph J.'Smith, M.D. and I. J. Brightman, M.D. .. . - 9 %e VM to TElMp Central Headqwters, Assistance to Safety and 93 _rnl@zgn and to attend RAG * Recent events occurring in geographic area of Region that are affecting RMP program: meeting, -_ 1. Seven priorities established with an ad hoc ccanmittee for each to develop appropriate programs. In addition to the folk existing subregional offices (El Paso, Houston, Harllngen, and Tyler), two me were implemented (Abuene and Wbbbck) o San Antonio and/or Dallas will soon begin. 2. 3. Five representatives. of TRMF' participated 'in t& RMPS sponsored conference on wamness of the Mexican American culture May 14-17, 1972, Abiquiu, N. M. W SP 14 15 4 TEXAS POPULATION 1970: 11,196,720 TEXAS CITI.ES with 100,000 or more population (1970) and % change since 1960 CITY POP. (1 970) % CHANGE a Amarillo 127,010 - 7.9 b Lubbock 149,101 +15.9 322,261 +16.5 c El Paso d Fort Worth 393,476 +10.4 e Dallas t I 844,401 +24.2 c; f Austin 251,808 +35.0 g Houston 1,232,802 +31 .4 h Beaumont 115,919 - 2.7 i San Antonio 654,153 +11.3 j Corpus Christi 204,525 +22.0 NUMBER OF OTHER CITIES OR'TOWNS BY SIZE POP. RANGE NUMBER 2,500- 9,999 249 ., 10,000-49,999 100 I 17 50,000-99,999 ........ ._ - ./ # 07 REGION: TEXAS - Geography and Demography Encompasses entire State; several subareas- Counties: 254 Congressional Districts: 23 populas (1970 Census) - 11,197,000 Urban: 80% Density: 43 per sq. mile Texas u. s. 37% ' 35% 54% 55% 9% 10% Age Distribution: .-c- Under 18 years 18 - 64 years 65 and over Metropolitan Areas: 17 SMSA'S Total Population 6&&&lfl.' Dallas Galveston Odessa El Paso Laredo San Angelo Skm=% Wac0 Abilene Brownsville Corpus Christi Fort Worth Lubbock Wichita Falls gouston . Denison- Sherman Texarkana Tyler Race: 87% White; 13% non-white 364.5 Heart bisease 157.2 Vascular lesions 275.3 130.2 Malignant neOp1. 92.2 102.2 (aff.CNS - stroke) 935.7 All causes 798.6 b ". .... _. . ..... ..... _-_ .. , .. ,. 8 , ..... ! _.. .. -. . -. :.-- : ._ . Age specific death rates (all causes) 45-64 yrs .-1081.4 65 & over -5518.8 0 , -5 107 Region: Texas Resources and Facilities Medical Schools - Baylor U. College of Med., Houston U. of Texas, Med. Br., Galveston U. of Texas Southwest Med. School U. of Texas So. Texas Med. School Medical School, U. of Houston Dallas San Antonio (developing ) 1969/70 Graduates Enrollment 362 88 598 147 . 426 107 2 16 33 Dental School 3 - Baylor, U. of Texas, Houston and U. of Texas, San Antonio Pharmacy 3 - U. of Texas, Austin; Texas So. U:-& U.' oi? Houston, Houston Professional Nursing Schools Practical Nurse Training 51-32 are college or University 153- majority at college or based special vocational and technical schools Allied Health School -- University based: University of Texae, Med. Br, at Galveston 'School of Allied Health Sciences, Galveston Public Health university of Texas, Houston - School of Public Health Accredited Schools Cytotechnology - 9 (five affiliated with University or Med. Sch, Medical Technology - 57 (one at VA Hospital and one at Broake Army) Radiologic Technology - 60 (one at Brooke Army Med. Center) including one at Brooke Army Med. Center) .. Physical Therapy - 4 (one at Brooke Amy Medical Center) I -6- - 5/71., - #07 Region: Texas Hospitals - Community General and V.A. General- 490 44,587 7 2,532 14 2,857 Short term Long term (special) v. A. (general) - Skilled nursing homes 441 31,587 # Hospitals with selected spec!-a1 facilities ' Intensive Care - X-ray therapy - Cobalttherapy - Isotope Renal dial (in pt.1 Rehab. (in pt.1- - Active 11,279 Inactive 481 Osteopaths @.O.'s) 721 Ratio of active M.D.'s (per 1O0,OOO POP.): 106 *percent byspecialty: General practice - 31%. Surgical spec. - 33% Medical spec. - 21% Ratio per Graduate Nurses, 1966 # 100,000 Actively employed in nursing 20,167 . ' . 188 Not employed in nursing 9,955 - 139 78 33 84 48 24 Licensed Practical Nurses (1967) Total employed in nursing (adj o ) Not employed in nursing 13,386 --- , ._ 5/71 RDB Component 1st year 2nd year I. PROGRAM STAFF COrnRACTs . L . DEVELOPMENTAL COMbYENT CPERATXOXAL PROJECTS Kidney . Ex6 hs/ea Pediatric Pulmonary 3rd year. 1st year . Other TUTAL DIRECT COSTS - CO~CIL RECON!E?;D~D LEVEL .. ~oMPoNENT AND-TINANCIAL SUMMARY TRIENNIAL' APPLICATION Current Annualized Level _ok Year I $ 579,999 138,280 Rcgion: Texas Review Cyclc: .q-+/nct 7973 I Comnittc Recornendation for 1-Approvec 2nd year Level -- Jrd yeor -- o 7. .- JULY 17~1972 - I BREAKOUT OF REQUEST -- 05 PROGRAM PERIOD REGXI3 - TEXAS Rn OOQO~ lam PAGE 1 RIPS-OS-JTOCRZ-1 _- .. . JULY 17.1972 BREAKOUT OF REUUEST - 05 PROGRAM PERIOD --.- . REGIOY - TEXAS -_ BREAKOUT OF REQUEST RM 00007 10172 PAGE 3 JULY 17~1972 RhPS-OUCJfOCRZ-&-, - -. . . - - . - 06 PROGRAM PERIOD - - -__ - I - . -, JULY 17,lf72 BREAKOUT OF REQUEST Ob PHUGRAH PERIOD JULY 18.1972 -- __ - BREAKOUT OF REPUEST P7 PROGRAM PERIOD REGION '- TEXAS RH OO'l97 1(3/72 PAGE 5 RMPS-OSH-JTOCRZ-1 _- I JULY 18'1972 BREAKOT OF REQUEST 27 PROGRAM PERIOD , REGION - TEXAS R9 o??fl7 11/72 P4GE 6 RMPS-OSM-JTOGRZ-1 component Title No Disease COO2 Feasibility of pastex c2m ~I-annimRenal C21Z FeasibiUty Stud3r ~220 planning So. Texas Med. 60,135 ~230 y- So. West Med. 62,596 C240 plannj.~ Calveston U. T 95,194 c250 ~3mnirx Dental Inv. 42,194 c260 planning Multi. *de 45,386 e270 planning Reg. Ca. WOga 37,622 ~290 pmmim Baylor Fea. ,180.117- C2U Programstaff Subtotal 755,630 $ 721,219 $ 15,000 . 3,260 4,349 11,500 9;500 27,725 792,553 596,883 26,748 12,570 DOOO Developmental Component I 001 IViecEcal Genetics 25,149 003 East Texas Hosp. Teachi% 40,164 50,000 005 Re@onalConsultation in 47,500 Radiotherapy 006 Medical Physics 28,500 007 Cancer Incidence and 76,446 Resources in Texas 008 Statewide Cancer Registry 38,000 014 Stroke Demonstration Progressive Program 014A Stroke Demonstration Chain 004 Cw. Hospital lY&B.Ution 47,500 60,000 30,000 45,000 49,584 80,000 91,123 141,045 $ 527,617 20,000 4,000 551,617 87,334 20,000 108,000 63,419 Total 9/7 2-12/72 $1,481,222 20,000 4,000 .:580,140 15,000 1,743 ' 75,135 65,856 99,543 42,194 56,886 47,122 ,207_.842 2,696,683 87,334 64,467 40,164 97,500 137 , 500 ' 143,084 141,045 63,419 page 2 - Funding History List Component 01 NO Title 7/68-9/69 014B Stroke Dmnstration $ 015 ha-wide Respiratory 174,388 016 Regional Rehabilitation 107,007 017 Regional Rehabilitation san Antonio 60,709 017A Regional Rehabilitation 017B Regional Rehabilitation 018 Univ. of Texas Dallas Co. 40,873 019 Rehabilitation Cardiac Work 41,181 020 Wadication of Cervical Cancer 80 083 030 Planning for Allied Health R-aining 51,870 031 Long Mstance Consultations 033 Extended Coronary Care Nursing Training 035 Reduce Complications j J' J 036 Serial Control System 037 Health Careers 038 Dial Access 039 Amual'IbmrClinic 042 Continuing Education for Occupational Therapists 043 Instructional Program for Allied Health Educators 045 Comnunity Action 046 Ivbxillofacial Prosthetic 046A Maxillofacial Prosthetic 046B Maxillofacial Prosthetic 046C Maxillofacial Prosthetic 02 03 10/6!3-9/70 10/70-8/71 242,915 127,063 80,000 67,708 67,607 46,185 74 , 620 g0,ooo 13,000 35 , 000 84,000 37,006 16,500 28,000 29,801 15 .) 000 24,000 17,500 160,000 100,000 45,049 86,700 19,395 62,550 38,566 28,001 65,762 19,963 11,520 22,826 90,977 106,217 04" 9/71;8/7 2 $ 36,581- 20,000 5,444 14,556 20,000 55,000 34,878 30,062 35 , 060 Total 9/72-12/72 $ 36,581 497 , 303 321,778 174 , 501 5,444 14,556 160,542 41,181 276,783 64,870 54,395 146,550 110,566 65,002 172,563 53,463 26,520 46,826 17,500 206,217 34 , 878 30,062 35,060 305,977 component No Title Total 01 7/68-9/69 $ 02 10/69-9/70 $ __c__ $2,220,891 04% 9/71-8/72 $ 26,900 75,000 68,583 $1,3909435 $ 26,900 75 Jooo 68,583 $6,934,366 I -17- Regional Medical Program of Texas 04 Yr. Extended 16 Months (9/71-12/72) Direct Costs Program Staff Planning Renal Disease $ 926,818 26,500 Sub total Developmental 120,000 06 Medical Physics 20,000 14 Stroke Demonstration 100,000 16 Demnstration Unit 20,000 17A Demonstration Unit-Registry Rehabilitation 5 3 444 l7B Demonstration Unit-Registry Rehabilitation 8,556 20 Cervical Cancer 20,000 35 Radiotherapy Complications 35,000 36 Serial Control System 9 , 001 37 Health Careers 77,000 38 Dial Access 24,555 45 C-ty Action 55,000 46 Maxillofacial Prosthetic 100,000 08 Cancer Registry Bexar Co. 131 939 51 Inhalation Therapy 48,100 54A OR0 - Tarleton State College 22,247 54B GRO - Sam Houston State University 22,247 54C GRO - Tyler Junior College 22,847 54D GRO - Del Mar College 543 GRO - Graduate School of Bicanedical Sciences 55 Electrical Safety Services 58 Area Health Education Resources Program 15,000 21,000 60 S. Texas Area Health Education Resources 15,000 Ij0,OOO 61 MAN0 - Family Health Service Program 30,000 62 Children's Heart Program 63 Area Health Resources Infonration Center 8,000 64 Standard Tech. for Hme Health Care 12 , 000 65 REACH 8,000 66 Dqonstration Unit in Medical Rehabilitation 22,270 9,009 68 Dey. Auto Area Health Resources Infmnation Center 17,712 4,992 g$i; 59 S. E. New Mexico Health Resources Program 67 Basic Rehabilitation Nursing Technician Total $ 953,318 $2,106,720 - 18- MIONAL MEDICAL PROCRAM OF WS HISTORY FUNDING (DmT COSTS): Planning Grant Period Period Amount Funded 01 02 01 02 03 04 7/66-6/67 (12 mos . ) $ 969,541 7/67-6/68 (12 mos o ) 1,0393295 Operatioral 7/68-9/69 (15 mos o 1 1,615,000 1,708,040 T/ - 5/ 10/69-9/'/0 (12 OS. 2,220,891 i/ 10/70-8/71 2/ (11 mos o ) 9/71-8/72 r16 mos. ) 2,106,720 Ti/ Included $444,178 Carryover from 01 year. Award for 11months at request of RMPS to accommodate anniversary Included $549,344 Carryover f'mn 02 year; also, includes 12% budget 04 periods extended from 9/71-8/72 $1,390,435 to 9/71-12/72 $2,106,720 Reflects a 12% budget - reduction imposed in April 1971. review scheduling. reduction placed on Texas E71 1971 appropriation. to accmodate Three Cycle Review. REGIONAL DEXELDFMJWT: In December, 1965, various academic, State and private health representatives met to discuss the potentials of the then newly enacted legislation calling for Regional Medical Programs. which later became the Regional. Advisory Group. After first attempting to establish three separate Regions, the applicants comprhised on three subregions in North Texas, South Texas, and the Gulf Coast. Seven schools in the Houston area represented the Gulf' Coast subregion, while the UTSW in Dallas represented the Northern subregion and UT San Antonio represented the Southern subregion, The University of Texas at Austin was designated the applicant organization, while the Texas Medical Center in Houston was designated the fiscal agent, In June 1970, the fiscal agency was transferred to the Office of the Compbmller of the University of Texas System in Austin. The initial planning grant was awarded in July 1966, but progress, including staff recnuitment was relatively slow. in planning for an Allied Health Waining Program and in starting a Cancer Registry; San Antonio reported resistance problems with private practitioners; A State Coordinating Comittee was formed Baylor (Houston) rewted some progress -19- Regional Medical Propam of Texas RM 00007 10172 0 while Southwestern (Dallas) reported good progress in surveying resources and personnel needs in the categorical diseases. Dr. C. LeMaistre was serving as Program Coordinator in Austin, and Dr. Spencer Thompson was appointed Associate Coordinator and was stationed in Galveston. the second planning grant year, staffs from the various institutions began joint planning meetings, task forces were created in the categorical diseases, the RAG began to develop its Review Process and the Texas Council of' Health Science Libraries was created. its initial operation applicatio&which led to a site visit conducted in June 1968. During "his planning group submitted The major concern of the site visitors was the apparent lack of central direction and coordination of the program, This was illustrated by the uneven progress made in the developnent 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 Eor comrmXnity needs and goals - either regionwide or local - and only a few demonstrated evidence of true cooperative arrangements or unilateral peripheral involvement .I' The site team observed that the Regional Advisory Group, though under strong leadership, had not been active in the identification of program goals and the development of program plans. The RAG was weak in its representation of minority groups, consumers, allied health professions, and the practicing cmty, Because of these apparent shortcomings, Council recommended a one-year approval of the Texas operational application, including continued planning support, with future funding contingent upon demonstrated improvement in the areas mentioned by the site visit reviewers. Accordingly, a one-year operational award was issued. planning activities. A subsequent site visit ms held in April 1969 to access the progress made in fulfilling the conditians laid down the year before as necessary for further f'urding; that is, strengthening central administration and exparding the RAG. The revfewers were satisfied that these reqQirernents were being met; a new coordinator, Dr. Charles McCall, had been appointed and had presented his plans for tightening up the organization. The RAG was expanded to include nine new interested @;roups. On that basis, the Region received an 02 award including carryover, as well as cormitrrients for the 03 and 04 years. The 03 continuation application, reviewed by RMPS staff, indica&&- that Dr. McCall's plan appeared to be working: out by January 1970 (except for development of a subregional office in Houston) and for the first time the Region had a multidisciplinary program staff in Austin. Functional differentiations between the RAG and the program staff had been delineated. The RAG had adopted a set of *@ylaws and seemd to be involved in program development, primayy review responsibilities, had. been made agents of the RAG rather than of the Coordinator. Financial rmnagement procedures had been altered with RMPS assistance. These fbr-ds were divided evenly between operational and The planning bases were phased Five task faces, with Planning and evalution functions had heen -20- .Regional Medical Program of Texas consolidated in the Coordinator's office. Close relationships between 'I" and the Texas Hospital Association and a formal working arrangement with CHP had been initiated. On receipt of the Region's Triennial Application for the 04, 05, 06 years, another site visit was conducted during June 1971. The visitors were convinced that TRMP had mde considerable progress during the pa5t two yews, but in the absence of specific proposed activities for flmding for the second and third years of the request, three year f'unding was not recommended. The Region was complimented on its concerted efforts to develop program activities outside the confines of the medical institutions without losing the support and conmitment of these necessary resources. It was recognized that there itre still strong proponents for the categorical medical center approach in Texas, but in the opinion of the site visitors, these interests had been neutralized by the support for a program emphasizing the needs of communfty hospitals and practicing physicians. The focus on subregionalization was also commended. inciigenous workers with firsthand knowledge of their respective worMng . Subregionalization was being pursued. The decision to employ areas indicated that action oriented planning and implementation of program activities can be initiated more quickly and be mox concentrated on the real health needs in the respective geographical areas. office staff of the RMP of Texas was acknowledged to be highly qualified, enthusiastic and well directed by its Coordinator and Regional Advisory Group, Also noteworthy was the involvement and participation of practicing physicians at both the decisiormddng level and in the area of ongoing projects, especially those which have assisted the physician with upgrading patient care. the State Health Department, the nursing association, the hospital association and voluntary health agencies are supportive of the RMP of Texas. As recommended by the site visitors, the August 1971 Council approved the Region for two years support, including a developnsental component. The central It was noted that other key health groups, including CKP, . .:- ... . .. i . __ .. , . .. -. : * , . . . :. .~ . .. , .. .. .. .. . -- -21- DEPARTMENT OF HEALTH, EDUCATION, ANI) WELFARE HEALTH SERVICES AND MENT'AI, HEACI`H A1)MINIS'I'Ith`l'IC)N MEMORANDUM PUBIJC HEALTH SERVICE e TO : THERECORD DATE: July 24, 1972 STAFF OBSEKVATIONS : Operations Officer Mid-Contlnent Operations Branch Carrpnts agreed upon at RMPS Staff Meeting July 18, 1972, regwding the Triennial Application from the Regional Medical Program of Texas and the Site Visit scheduled August 1-2, 1972. SUBJECT: Participants : * Michael J. Posta, Chief, Mid-Continent Operations Branch * Luther J. Says, Jr., Mid-Continent Operations Branch * Joseph L. de la mente, Office of Planrdng and Evdluation * Jirmly Roberts, M.D., Dlvision of Professional and Technical Development Harold White, Grants Management Branch * Denotes staff mmbers of the proposed site visit team. SWrmary: The meeting began with a brief review of the references prepared for the site visitors with particular attention to the history of TRMP, previous site visit, advice letter, Management Information System printouts on previous ftmding, breakout of tb proposed three year sperding, and descriptor sunanary. Staff noted the funding of current 04 year to be as follows: Date of Awasd Period Amount (dace) Activities 9/3/71 $1 , 274,565 Program Staff $523,081 15 Projects $751,484 9/1/71-8/31$72 9/lf71-12/31/72 $2,106,720 mtFa Staff $953 818 Developmental $120,000 31 Projects $1,032,902 6/.'W!T 2 (!mended - 4 mo. ext.) - 22- Page 2 - THE RECORD The proposed triennial funding (d.c.) plan is as follows: 05 - 06 - 07 - Program Staff Activities $ 754,129 $ 862,762 $ 877,970 Developmental Component 160,000 200 , 000 225,000 Projects (27) 1,264,341 (16) 796,960 (9) 537,538 Unspecified Growth Funding -0- 480,000 760,OdO Total $2,178,470 $2,339,722 $2,400,508 The renal disease and GRO components consists of five projects each. It was interesting to note that support of 13 projects will be phased out during the current 04 period. Continuing support for two more years is requested for the five GRO projects which began at the beginning of the current 04 period. Continuing support for one more year is requested for the Electrical Hazards project now completing its fbt year. Continuing support is requested for eleven new projects which began during the Last quarter of the current extended 04 period. Ten new activities are proposed, five of which represent the renal disease component. Of the 21new activities (11 began in the current period), ten are currently budgeted for one year only, two for two years and nine for three years. Staff was favorably impressed that most of the project sponsors are other than mdical schools and most of the activities are subregional. activities are continuing education, training new and existing health manpower, patient care and coordination of health services. Only two projects are categorical disease oriented. Mexican-Americans are the primary target population of five projects (four in the Rio Grande Valley and one in the San Antonio area). Blacks are the secondary target population of two projects. Other special target groups include: poor, 14 for rural areas, and 2 for other poor. delivery methods represented by the projects: care, home health care, in hospital care, and mobile units. include access, area health education (4), medical consultation, health team approach, joint services, patient and public education, and safety. The health professional target groups include physicians, nurses and almost all categories of allied health personnel. The primary 1 for the inner city Primary health care ambulatory care, extended primary elements Issue Requiring Attention of the Site Visitors The site visitors should specifically explore "@'s progress relative to the six constructive criticisms enumerated in the RMPS advice letter of August 11, 1971. -. ,- . .. .. . .. . .. . ~I .. e 4 -23- Page 3 - THE RECORD Other issues should include: Utilization of consmr g??oups in establishing objectives aM3. priorities. Relationships with CHP "a" and "b" agencies in planning and project develapment; particularly since only 5 of 21 'lb" agencies have been f'unded and TRMI? local advisory pups have not been activated . Why are no planning and/or feasibility studies included in the application? What is the current status of erergency mdical services and what is 9RMF"s role? Of those projects where TRMP support is to be phased out in the 04 year, haw will continue? Proposed budgets indicate only minimal support from other sources. If successfU, what are the assurances of their continuation af'ter cessation of TRMP support? In the long range planning, what will the relationships be between GRO projects and Area Health Resource Infomation Centers? With regard to GRO projects, what are the cost-swing services other than education? Explore rationale of f'unding of the many new projects for one year only, as well as unspecified growth flxnding in the 06 and 07 years. I Regkon Virginia RM 00049 r Review Cycle 10/72 '%I .' Type of Application: Triennium Rating 287 Recommendations From - / X/ Review Committee - - _- - / / Council - / / site Visit - RECOMMENDATION: The R9view Committee accepted the recommendation of -the site visitors that the Virginia Regional Medical Program be approved three years. A developmental component in the requested amount to be funded within the total $1.8 million level, 2. Critique - The Chairman of the site visit team presented the findings of the team to the Review Committee. Progress of the Program since the last site visit was illustrated both by reference to the Region's change in attihde and the favorable response by the Regional Advisory Group, the Coordinator, and Program Staff in regard to past concerns and recommendations of review groups. The site visitors' evaluation of programmatic achievements, current concerns and recommendations emanating from the August 1972 visit were presented, Committee discussion focused upon the recommended funding level for the Program. Staff budget for central staff services was provided. The Program's capability to effectively allocate and utilize the recommended funds was discussed. The Chairman of the site visit team reported that the Program had attained a maturity of judgment and a demonstration of competency (in the way it had moved and.in the way it anticipated it was going) that qualified it for triennial status at this point in time. Clarification of the requested amount within the Program 'Dr, William G. Thurman was not present during the discussion. EOB/DOD 10/2/72 Region: Virginia RMQ004 Review C-eT COMPONENT AND FINANCIAL SUMMARY TRIENNIAL APPLICATION Component Current Annualized 03 Year ' Level - RQGRAM STAFF ONTRACTS * LOPMENTAL COMPONENT PERATIONAL PROJECTS hs/ea ** Pediatric'Pulmonary AL DIRECT COSTS WCIL RECOMMENDED LEVEL $ 501,225 (41,802) -0- 536,566 $1,037,791 I $1,010,000 . * Program Staff Total Included in Operation __ ._ Requ 1s t year 1,016 , 407 (376 , 769) 80 , 000 1 , 893,136 : 136,996 :128,045 1 [ 45,660 r c 1 r j) 2 , 989,543 ;t for Triennial 2nd year 3rd year I $1,054,02 $1 , 159 , 429 `I 80 , 000 1,574,98 1,169,137 (142,675) ( 52,094) - i 80,OO Committee Recommendation for Counc 1st year ;1 , 800 , 00 1-Approved Level 2nd year 3rd yea:! I -+- $1,800,000 $1,800,0~ rejects - Total d SITE VISIT REPORT VIRGINIA REGIONAL MEDICAL PROGRAM August 3-'., 1972 I. SITE VISIT PARTICIPANTS Consultants Sister Ann Josephine, Chairman, Administrator Holy Cross Hospital, Salt Lake City, Utah Benjamin W. Watkine, D.P.M., 470 Lenox Avenue, New York, New York Morton C. Creditor, M.D., Coordinator, Illinois Regional Medical Program, 122 South Michigan Avenue, Suitk 939, Chicago, Illinois William Vaun, M.D., Director of Medical Education, Monmouth Medical Center, 300 2nd Avenue, Long Branch, New Jersey Staff, Regional Medical Programs Service Mr. Frank Nash, Acting Chief, Eastern Operations Branch Mr. Clyde Couchman, Program Director, RMPS - DHEN Region 111 Ms. Joan Ensor, Program Analyst, Office of Planning & Evaluation Ms. Marjorie L. Morrill, Health Consultant, Division of Professional Mr. George Hinkle, Public Health Advisor, Eastern Operations Brar-h Staff, Virginia Regional Medical Program & Technical Development Eugene R. Perez, M.D., Executive Director Jack L. Mason, Ph.D., Asst. to Executive Director for Evaluation Ms. Ann S. Cann, Communications & Community Affairs Ms. Tandy Shields, Assistant to Communicatipns 6 Community Affairs Officer Mr. Freeman H. Vaughn, Program Development & Operations Officer Mr. Sam Kalman, Planning C Technical Services Officer Mrs. Barbara Peace, Records and Registries Administrator Mr. Archie Nelson, Jr., Assistant Allied Health Officer General W. C. Haneke, Business Administrator Mr. Arthur L. Burton, Assistant Business Administrator Mrs. Mildred Brown, Community Liaison Officer Mr. Fred Beamer, Community Liaison Officer Mr. Henry Kauffelt, Community Liaison Officer Mrs. Wilma Schmidt, Community Liaison Officer Mrs. Norma L. Doeppe, Executive and Administrative Secretary Representatives of the Virginia Region A. Regional Adviaory Group - Members Anthony J. Munoz, M.D., Medical Society of Virginia, Private Practice, Farmville, Virginia, Chairman of the RAG and Executive Committee Virginia RMP -2- RM 00049 - Representatives of the Virginia RMP (continued) %, 8 A. Regional Advisory Group - Members (continued) Mack I. Shanholtz, M.D., Commissioner, Virginia State Health Department, Richmond, Virginia, Executive Committee of RAG, Bylaws Committee Mr. Hunter A. Grumbles, Hospital Administrator, Memorial'Hospital, Danville, Virginia, Executive Committee of RAG, Program Committee Mr. Bernard W. Woodahl, Executive Vice President, Virginia Division American C&ncef Society, "Richmond, Virginia, Cancer Commit tee, Btecutive Committee of RAG Comonwealth University, Richmond, Virginia, Ex'ecutive Committee of RAG. Frank A. Wade, M.D., Chairman, Medical Society of Virginia, Private Practice, Roanoke, Virginia, Review & Evaluation Committee R. A. Mackintosh, M.D., Private Practice, President-Virginia Academy of General Practice, Review & Evaluation Committee Thomas C. Barker, Ph.D., Dean, School of Allied Health Professions, Virginia Commonwealth University, Review & Evaluation Committee Mr. James B. Stone, Executive Director, Virginia Heart Association, Richmond, Virginia, Heart Disease Committee Robert T. Manning, M.D., Dean, Eastern Virginia Medical School, Norfolk, Virginia Mr. D. Joseph Moore, Executive Director, Tidewater Regional Health Planning Council, Norfolk, Virginia Mrs. Jane B. Nida, Director, Department of Libraries, Arlington County, Arlington, Virginia L. A. Woods, M.D., Vice President for Health Sciences, Virginia B. Board of Directors - Members Daniel Mohler, M.D., Associate Dean, University of Virginia, School Charles Tomes, M.D., Ph.D., Medical Director, Memorial Hospital, Kinloch Nelson, M.D., Assistant Chief Staff for Education, Veterans of Medicine, Charlottesville, Virginia Virginia State College, Petersburg, Virginia Administration Hospital, Richmond, Virginia C. Ad Hoc and Standing Committees John C. Hortenstine, M.D., Director of Medical Education, Winchester Memorial Hospital, Winchester, Virginia, Chairman, Heart Committee Walter Lawrence, Jr., Division of Oncology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia, Chairman, Cancer Committee Department, Richmond, Virginia, Committee on Kidney Disease James C. Pierce, M.D., Medical College of Virginia, Surgery Virginia RMP -3- RM 00049 D. E. o OrganizationslInstitutions Daniel Mohlet, M.D., University of Virginia* Warren H. Pearse, Virginia Commonwealth University (VCU) L. A. Woods, M.D.; Vice President of Health Sciences, VCU * Robert T. Manning, M.D., Eastern Virginia Medical School* Raymond P. White, D.D.S., School of Dentistry, VCU Mr. James Moore, Medical Society of Virginia Frank A. Wade, M.D.; Chairman, Medical School of Virginia * Charles Tomes, M.D., Ph,D. , Old Dominion Medical Society* R. A. Mackintosh, M.D. , Virginia Acadmy of General Practice* Mrs. Barbara Walker, Virginia Nurses Aesociation Hr. Earl Willir, Virginia Hospital Association Mr. Herbert Seal, Virginia Nursing Home Association F. B. Wiebusch, D.D.S., Virginia Dental Association Mayer Levy, D.D.B., Virginia Dental Association Mr. Keith Kellum, Virginia Pharmaceutical Association Ms. Barbara Gibson, Virginia Pharmaceutical Association Mr. James H. Stone, Virginia Heart Aesociation* Mr . Bernard Woodahl, American Cancer Society, Virginia Division* Mr. Edgar J, Fisher, Jr., Va. Council on Health & Medical Care Mies Ann McMeill, Tuberculosis 61 Respiratory Dieease Aseociation Mr. Henry.Harmon, Model Neighborhood Mrs. Poe, Model Neighborhood Mr . David Benson, R$AF' (0 .E .O . ) Mr. W. H. Brower, CHP (A) Mr. D. Joseph Moore, CHP (B)* Kinloch Nelson, M.D., Veteretrans Administration* Mack L. Shanholtz, M.D., Virginia State Health Department* Others Mr. Beverly Orndorff, Science Writer, Richmond Times Dispatch Ms. Mr . Mr. Mr . Alberte Clayborn, Richmond News Leader Gene A, Pierae, MCV, Renal Dieease Robert Youngeman, Southeastern Inter-regional Exchange Prdgram John Taylor, Congressman Satterfield'e Aesistaat *Dual Listing Virginia RMF' -4- RM 00049 INTRODUCTION: - 11. The Virginia Regional Medical Prograx will have completed its first three years as an operational program on December 31, 1972. of the August 3-4, 1972 site visit was to assess the region's overall progress, the quality of the current program and its prospects for the next three years. PURPOSES OF THE SITE VISIT The purpose The site visitors reviewed the Virginia RMP's decisionmaking and review processes, administrative and evaluation capabilities, and the current planning, involvement and accomplishments with respect to program directions of the Regional Medical Programs Service. The new review criteria and Mission Statement were used by the site visit team as a guide in evaluating the overall program and arriving at programmatic recommendation. 111. SITE VISIT OBSERVATIONS Goals and Objectives The Virginia RMP goals and objectives were developed after the newly established Program Committee had reviewed national, state, and local health priorities and received input from state and local health planning councils, the various health societies and associations, other RAG members, and the Virginia RMP staff. ives reflect the latest mission statement of the RMPS and are explicitly stated even to the extent that activities to be directed toward implementation and accomplishment of the stated objectives are delineated, They are considered to reflect regional-needs and problems to the extent that the activities identified with the goals and objectives evolved from need identifying conferences and feasibility and planning studies. It is considered that they have been accepted by the health providers and institutions of the region as signified by formal endorsement of the Program health provider groups, and membership of health providers and consumers on the RAG, the Board of Directors and various RAG committees. However, it does appear that community and consumer group participation in the development of the goals and objectives has been limited to their representation on VRMP review and decisionmaking groups. - __ These goals and object- The region has endeavored to prioritize the goals and objectives as well as proposed program activities. system has been devised for establishing relative priorities of individual projects/activities at the time they are reviewed by the RAG. Rating sheets are utilized that measure ten positive elements (need-intensity need-extent, potential benefit success probability, resource use and generation, scientifidtechnical characteristics, A very thorough numerical rating Virginia RMP -5- RM 00049 evaluation, educational strength, budget analysis, and program balance) and one negative element (adveree reaction or effects). These elements are rated on a scale ranging from 0 to 5 and adjusted by as6igned "weighing factors" that reflect the relative importance of each of the elements evaluated. objectives and prioritias established appear to be adequate, evidence was found that there is no clear plan for utilizing the ranking system in establishing funding priorities. visit team that confusion exists as to the purpose and potential benefit of priority ranking as a mechanism for funding determinations and decisionmaking, need to more fully discuss and understand the intended purpose and method envisioned for utilization of the goals, objectives and project ranking system in future funding and policy determinations. Although the procedures followed, and the goals, It is the consensus of the site It ie suggested that members of the Program Accomplishments and Implementation The VRMP is in its third year of operational activity, having been awarded operational status effective January 1970. that provider groups are looking to VRMP for consultation and assistance and that the involvement of physiciana, nurses, allied health professionals, hospitals, universities and other agencies in efforts to improve health care throughout the region is making a difference in the total health care system. Evidence of significant program staff activities was manifested by involvement directed toward improved care for stroke patients in underserved areas, development of skills in utilizing medical audit a8 an educational inetrmnt to improve quality of patient care, and activities related to rehabilitation consulting teams for nursing homes, pro- em in sickle cell anemia and many other areas. Program staff has assisted in the establishment of the Virginia Medical Information System as a Statewide Biomedical Library service which is currently planned for expansion to a subregional level. The coronary care evraUatlon project that originally began with five participating hospitals was expanded to eleven; now that RMP funding is to be discontinued, it is anticipated that the effort begun by the VRMP will continue at 8me hospitals and be discontinued at others where the original objectives have been accomplished o of successful effort8 aseociated with consultations in discharge planning, community hospital baaed physician education, and improved care for stroke patients in underserved areas. Program staff activities have stimulated or directly resulted in greater involvement of dentists, pharmacists, and allied health personnel. better utilization of manpower through the continuing &cotion efforts and dissemination of new knowledge and techniques through training programs for myocardial fnfarction, cardiopulmonary reewcitation, There is evidence 0 Current plaus provide for continuation and/or expansion Activiti@o We resulted in 0 Virginia RMP -6- RM 00049 emergency coronary care, and continuing education training for nursing -- personnel.. relationships in the five subregional districts staffed by the Community Liaison Officers. This process has been continuously evolving thrnugh- out the development of the VRMP. There is a measure of accomplishment in the building of * Areas of planned development that should have a direct effect on the quality of care and better utilization of manpower include proposed project activities associated with family nurse practitioners, career opportunities for hospital personnel, obstetric training for nurse practitioners, automatic patient history development and translation. Progress toward cost moderation is anticipated by program staff's discharge planning effort and the proposed project for development of shared services, facilities and personnel for rural health care institution of Virginia. Minority Interest It is not clear to what extent the Region has identified and analyzed existing data that could permit the RMP to assess its role in meeting health care needs of the underserved areas. However, the response in supporting sickle cell anemia education and screening activities and the measurable model cities involvement by program staff would positive action in meeting the needs of minority groups. visitors were apprised of other endeavors to stimulate a greater response for serving minority needs that were unsuccessful primarily due to this group's preoccupation with employment and housing deficiencies. was suggested that the VRMe should seek a more positive input in this area from minority members of the RAG and Board of Directors. believed that this input could result in stimulation of ideas that could then be more fully developed by program staff with continued consultation provided by these members. indicate The site It It is Minority groups are represented on the Board of Directors (2 of 12), the RAG (4 of 34) md professionally on the program staff (3 of 19). However, the representation on standing committees and on other committees of the VRMP was not viewed as favorable. Increased minority group representation should be considered, not to arrive at an equitable percentage relationship, but to reflect the magnitude of the problem and to better serve the minority group population in the VRMP area. .it. ,. . . .: .. - , * : I. .; \ :..... _. . , .. .. - _. Virginia RMP -7- 1 Continued Support RM 00049 There is an established policy for withdrawing RMP financial support at the end of the initial three year support period. reported that it is actively seeking other sources of funding upon termination of RMP aupporf, past efforts do not appear to have been very successful - a situation that is not uncomanon to the VRMP. Currently, ten projects are ongoing: year of support and without any positive indication of a future source of funding and two are being discontinued; one is being expanded on a subregional level with two of the three medical schools providing continued support for the ongoing portion, and two others are being continued either partially or completely by other funding sources; the two remaining ongoing activities are to be continued as central staff activities, only one of which has a positive commitment for continuation by other sources. The 15 proposed new projects in the triennial application relate more positively to this iearue: The VRMP is currently seeking support from the National Center for Family Planning Services for two proposes sickle cell anemia activities and addressee the issue in a positive manner for ten of the rematning 13 project proposals. Of the remaining three, one is a short-term assistance type activity without any long-term qualities, one is reported as positively selected for continuation although the source of funding is not mentioned, and the issue is not addressed in the final one. The Program is strongly advised to continue devoting this accelerated attention to all program elements (including program staff continuing activities) and to consider incrementally decreasing funding of activities over the approved support period to facilitate the use of RMP dollars for initiation of new activities directed toward accomplishment of goals and objectives. Although it was three are still in the initial 0 Coordinator Dr. Eugene Perez, the Program Coordinator, although he has a tendency to overreact must be described as a strong, competent leader that relates well with the RAG, the Board of Directors, members of his staff and other professional organizations. He has orgmized an effective and functioning etaff that appears to be well qualified and highly motivated. Even though the dminirrtrative naechanSem8 are present for effective communication with the RAG, the presence of ideal communication was questioned by the eite visitors and refinement of these processes ie considered necessary, It is strongly recomended that the Region be advised to accelerate its current ongoing effort to locate and hire an effective deputy iirector. Mot only is a deputy coordinetor considered essential to Virginia RMP -8- RM 00049 insure continuity of the program, it would relieve Dr. Perez of many of the daily time consuming routines thus permitting an even - greater involvement in overall program management and an intensif i- cation and improvement of daily communications both within and without the VRMP organizational structure. Program Staff The program staff is all full time, impressive, competent personnel with an adequate range of professional disciplines and management capabilities. with respect to duties and responsibilities and very involved in activities to strengthen relationships and foster involvement of communities throughout the area. Site visitors, although not concerned with the flexibility and dedication of members of the staff, were apprehensive about the capability of the staff to adequately absorb the increased work load with respect to monitoring, evaluation and RAG liaison that is inherent in the proposed expanded program. (It is noted that the current application positions and five other positions for a planner, assistant plri: ier, statistician, health educator and a registrar.) The site visitors were especially cognizant of substantive program activities placed under the management of program staff and encouraged the region to secure a firm commitment of the RAG for developing mechanisms for control and provision of necessary support for the management and program monitoring rcqujred of these activities. Individual employees appear to be highly knowledgeable provides for seven secretarial The VRMP plans include the opening of subregional offices ir, each of the five areas of the State delineated by the Virginia Hospital Association. Each office is to be staffed by an area coordinat-or (currently employed and designated as a Community Liaisor. Officcr) and a secretary. The responsibility of the area coordin-~',~ will be to work and plan -5th health care institutions, educatiw,il institutions, health professionals and subprofessionals and othcr interested personnel and programs 201- the improvement of the ' pa ttrh delivery system through manpower development. It is also planned to establish Local Advisory Groups within each of the five arcas to more adequately determine local health needs and methods fcr successful attainment. _i .. .. . .*.. . .;.: : . , .: . ..:: . . - l,. , .. .,,, :. - . - 2: _- , .:..: ... . . ___ . ~ - ~~- ~ Regional Advisory Group The RAG is considered to be adequately representative of alL key health interests, institutions and groups within the region aid C>&IE that is actively participating in setting program policies, estab- ... Virginia RMP -9- RM 00049 lishing objectives and priorities, and providing overall guidance and direction to the program activities although the site visitors sensed that a greater degree of guidance and direction may be needed with respect to program staff activities. and the meetings are considered to be well attended, especially when one views the wide geographical diotribution of the maberehip. The RAG meets at least quarterly An Executive Committee of the RAG has been established to act for the RAG between meetings, subject to subsequant approval of the entire group, but the visitors considered this six-member group small comparison to the proposed expanded program and too provider dominated. It is recommended that the group be enlarged, preferably by the addition of consumer-non-provider type representation. in The Virginia RAG ha8 made extremely significant progresa in regard to orientation, indoctrination and active participation of its members since the last site visit. appear to be very capable and dedicated with the common goal of making the VRMP a viable and recognized health care source in Virginia. During the past year, the group's bylaws have been rewritten to (1) mre effectively state its responsibilities and the responsibflities of the Executive Director eo the group, (2) provide for more frequent meetings and (3) establieh a new Program Cornamittee, Bylaws Committee, an Ad Hoc Committee on Allied Health and an expanded role for the Review and Evaluation (NE) Committee. The RAG membership in line with the expanded role of the R & E Committee, has participated in local site visits to ongoing projects and an increase in this type of effort is planned. heading of "Management", it was the consensus of the team that the workload envisioned is too great for this five member R 6 E Committee. Improvement in this area, more effective channels for communication between the RAG and program staff as previously stated, and minor changes in the RAG composition and cormnittees (such as lay consumer interests on the Executive Comrmittee and more adequate (b) agency representation) are recommended to complement the already significantly improved RAG. Members interviewed during the visit However, as more fully discussed under the Grantee Organization The Virginia RMP is an incorporated entity governed by a 12-member Board of Directors. of 18 former RAG members who were very active and knqwledgeable concerning the purposes and working mechanisms of a Regional Medical Program. Since incorporation, three of the original Directors have once again accepted membership on the RAG, thus assuring knowledge and understanding of the eeparate functions of each of the two groups. The grantee organization was originally composed Virginia RMP -10- RM 00049 The grantee organization provides adequate administrative support, the needed freedom and flexibility, and recognizes the RAG'S policy- making role as set forth in the RAG bylaws. To further facilitate efforts to expand daily communications between the Board of Directors, the Executive Director, his staff, and the RAG, it is strongly recommended that ex-officio Board of Director membership on the RAG be provided, and vice-versa. - Participation The Virginia RMP has established close interrelationships with major health oriented organizations within the State, it is in communication with Model Cities programs in Norfolk and Richmond, Virginia, and it has demonstrated effort toward developing relation- ships with CHP (b) agencies. Although the relationships with-CHP (b) agencies have not been sufficiently accomplished, the Program appears to be to continue efforts in this direction. for adequate representation from all (b) agencies on the RAG was stressed by the site visitors, cognizant of this need and has expressed its intent In this connection, the need '-.<- Cooperative efforts and liaison with health oriented organizations are the RAG'S various standing and ad hoc review committees, and program staff. objectives of the VRMP and has once again endorsed the program. The Region has established a working relationship with the newly emerged Eastern Virginia Medical School and has continued its involvement ' and mutual cooperative arrangement with the other two existing medical schools, is actively involved with the participation of all three medical schools, CHP (a) and (b) agencies, the state and local health departments, both the Medical Society of Virginia and the Old Dominion Medical Society, Virginia Academy of General Practice, and others. exemplified by interlocking memberships on the VRMP Board of Directors, f ,- * -_ The State medical society has reviewed the new goals and It would appear that the political and economic power complex In view of the Program's interest in continuing education activities, it is encouraged to continue to improve relationships with the medical schools and the community colleges, but cautioned not to ignore hospitals in its continuing education efforts. Local Planning The VRMP has demonstrated achievement toward developing relationships with CHP (b) agencies. Although, the relationships have not been sufficiently developed, the Region appears to be cognizant of this Virginia RMP -11- RM 00049 need and has expressed its intent to continue its efforts in this direction. In this connection, the degree of success varies in each of the five subregional areas of the VRMP. ticipation by the Tidewater CHP (b) agency and memberghip Executive Director on the RAG tends to be indicative of opportunities of early planning input from this area, although the actual quality of the input could not be determined. Of the remaining five CHP (b) agencies in the region that are considered operational, positive relationships were reported by only one of the program staff Community Liaison Officers. Active project par- of its The Program has established a mechanism for obtaining CHP review and comment, but it would appear that the action is not completed with sufficient lead-time for the comments to be considered by the RAG. It was suggested to the site visitors that the "stepped-up" (one month) submission date for the current application did not provide sufficient time for receipt and consideration of comment during this submission cycle. The VRMP's plans for Subarea Coordinator Officers and the establishment of Local Advisory Groups (LAG) are envisioned as providing a workable mechanism for greater local involvement in the development of program proposals and program direction. It is recommended that the Region be advised to consider representation from these LAG'S (e.8. Chairman) ae active members of the Regional Advisory Group to enaure local input into the decisionmaking and policy determining proceas. , Assessment of Needs and Resources At the present time there is no systemmatic continuing method of identifying needs, problems and resources that has resulted in program decisions based on an analyeis of data, but representatives of the Program have stated their intent to assess needs as identified by the emerging CHP process, Goals, objectives and priorities are largely designed to be consistent with national priorities and are in agreement with the RMPS mission statement for regional medical programs. The RMP has utilized group discussions, staff visits into the area, and the activities of the Community Liaison Officers in the five subareas of the VRMP to determine the immediate needs of the population. The Virginia Council on higher education has been given the respon- sibility of compiling a complete inventory of all health care personnel and facilities within the region. The VRMP will cooperate with the Council in the survey activities and the publication of the results, and is actively collecting a data base (Central Tumor Registry) with the ultimate goal of providing better care for precaent and future cancer victims in Virgiuicr. Virginia RMP - -12- RM 00049 An improved health data base is stated as one of the goals of the VRMP. Congruent with this goal is a planned survey to determine educational needs of health professionals and health care institutions to facilitate effective planning for continuing education of health care personnel. ,- Management The management "blueprint" followed by the Virginia RMP appears to be conceptually adequate in that periodic progress and financial reports are required, provisions have been made for monitoring of projects and other activities by program staff and members of the RAG, and personnel are considered professionally qualified and competent. However, as stated elsewhere in this report and repeated here for both emphasis and quick reference, this is the area in which the site visitors believed a greater refinement and strengthening of procedures would most significantly improve the Program. a. The Review and Evaluation Committee (R 6 E) in its expanded role reviews and reports to the total RAG as to the efficiency of the various program activities, in addition to its primary responsi- bilities for (1) performing or causing to be performed all required technical reviews of new applications and (2) establishing a recommended priority for funding when reporting to the RAG. this regard, especially with escalation of R €i E Codttee members' participation on site visits, it is the consensus of the team that the work load and responsibilities should be delegated to a larger base of technical and scientific expertise. In b. Communications should be improved both within the VRMP organi- zational structure and with other health interests throughout the region. organization is placed upon the need for,more timely and complete involvement of the RAG in the day-to-day activities with possibly the program staff preparing briefs to facilitate absorption of the data by the RAG Chairman and other committees and members. In regard to other health agencies, improved communications and working relationships with the existing and emerging CHP (b) agencies are recognized for primary emphasis, especially with respect to determination of health needs in underserved rural and urban areas and for improved coordination with resultant mini- mization of duplication and dilution of health improvement efforts within the region. Emphasis for improved communications within the ' c. The Executive Committee should be enlarged and be truly repre- sentative of the RAG composition. In this connection, non-provider representation should be included. 'L Virginia RMP -13- RM 00049 Evaluation The VRMP is experiencing problems common to many RMP's in the development of an effective evaluation process. evaluation staff member, but the site visitors have concluded that it is too early to judge the evaluation progrram under way state that the techniques and evaluation data being obtained need to be improved. The evaluative syetem provides for progress reporting and review by project directors, site visits and routine monitoring by program staff and members of the RAG with provisions for feedback to appropriate groups. However, there is no indication that these evaluation efforts have resulted in program modifications or that ineffective activities have been discontinued or scaled down. Discussions with the Region in regard to it8 evsluativs efforts and among members of the eite visit team durSng executive mssions, high- lighted the urgent need for all regional medical programs to improve evaluation methods and techniques. It was the consensue of the team that a greater effort needs to be directed toward facilitating exchange of ideas, methods and even "peer" review of evaluative techniques utilized by all regional medical programs in assessing both project and program effectiveness. It ha8 a full-time except to Action Plan Since the last site visit, the VRMP has established a RAG Program Committee whose responsibility is to review and update goals, objectives, strategies and concepts for the VRMP along with the primary responsibility of providing guidance to the Executive Director for program activity and project development. The RAG has recently accepted new goah and objectives formulated by this Committee which enables them to move from a heretofore categorical emphasis. These are considered to be congruent with the national objectives and in agreement with the new REIPS mieelon statamat. Administrative procedure8 for reporting accompliehmante, monitoring the progress and aseessing and evaluating results have been established, but a greater refinement of these efforts is considered essential. 0 Dimemination of Knowledge VIRMP has been actively participating on the Coordinated Health Survey Committee with CHP and the Virginia Council on Health and Medical Care in surveying health manpower, facilities and services in the State and has assisted in the dissemination of the results. This survey will become an mpual activity to establish a ool~lpon data base e Virgfnia.RMP -14- RM 00049 eventually to be transferred to a State Ceater for Health Statistics, A Health Data Library, established in the VRMP office, provides services primarily utilized in program staff operations. these library resource materials are available to other agencies and other individuals upon request, The Virginia Medical Information System project has provided ready access to medical information obtainable from regional and national sources. It is currently planned to establish two information sub-centers at community hospital libraries that will cooperate with the ongoing system that is to be continued by the two medical school participants. It is proposed that this endeavor will be supplemented by a Virginia Drug Information and Consultative Service project during the next triennium. Provider groups and lnetitutions that will benefit from the proposed activities have been determined to some extent, although, knowledge, skills and techniques to be disseminated, in most instances, are yet to be determined and are Many of the proposed activities are to be based in health education and research institutions of the region and are designed to provide better care to more people by and dentists and by providing for the assumption of time consuming routine procedures by specially trained allied health personnel. These efforts, if successful, could result in improved availability and accessibility of health care accompanied by a moderation of health care costs. 3 4 However', included as objectives of the activity. improving the skills of physicians \ _- -- Virginia RMP -15- REI 00049 Utilization of Manpower and Facilities Improvement of the quality of health manpower and the efficiency and economy of health care services in Virginia are identified priority areas for the VIW. Activities directed tow8rd the develop- ment of shared services, facilities and personnel in rural areas, the provision for new types of allied health personnel such as the proposed obstetric and family nurse proctitimar traSning programs, and efforts toward the expanded role for pharmacists and new career opportunities for hoapital personnel will reault in increased pro- ductivity of phyeiciarce and other allied health promuel. many of the octivitiee are directed toward greater ufillzation of manpower and facilitiar in rural areaa and will undoubtedly benefit the areas in which the activity is to be conducted, the immediate overall regional benefit is viewed as me that wdd be relatively insignificant, Although Improvement of Care By intensified utilization of local workshops, group discussions, activities of the Cormamity Liaison Officers, staff visits throughout the area, and planning and feasibility studies the RMP has msde progrees in identifying problem areas and developed methode by which ambulatory care might be improved. and project activities should measurably expand ambulatory and emer- gency medical service care. components realistically based on present knowledge are included in the application. However, tin the opinion of the site vicsitors, the proposed objectives appear to be overly .rnbr5emeb pated that the activities could lead to improved ~CCQCIS to primry care and health sarvlces in underesrved rural areae, but that the improvement in undareerved urban and ghetto area# will be minimal. As stated before, repreeantativas of the VW were encouraged to increase staff efforts In the latter areas. Many of the program staff activities ' Realth maintenance and disease prevention tt a arptid- Short-term Payoff Short-term payoff is inherently a part of the continuing educational and training proposals and will be realized if these activities are successful in accomplishing their stated objectives. In addi- tion, program staff activities directed toward discharge planning, Virginia RMP -16- RM 00049 the quality of medical care assurance based on chart audit and-con- tinuing education, rehabilitation consulting teams, and improved care for stroke patients all have the quality and potential for immediate benefit to recipients of the services. If one can assume that manpower savings realized by more efficient techniques, the use of less highly skilled personnel for routine services, and improved productivity of hospital and allied health personnel by providing greater career opportunities and incentives could lead to moderation of health costs, then the proposed activities will moderate health costs. However, short-term payoff does not appear to be the primary goal of the proposed program. The VRMP did not demonstrate to the site visit team that sufficient time had been devoted to the develop- ment of short-term goals, although the policy for withdrawing support after three years is well established and indications are that it can be done successfully. 4 . Regionalization The program plan should assist in creating new linkages among health providers and institutions, and it is aimed at assisting multiple provider groups and institutions. the Drug and Medical Information network projects, the Radiation Therapy Consultant Service activity, and the proposal for Development of Shared Services in Rural Health Care Institutions are specific examples of items included in the plan that have this underlying quality. and manpower and extending the capabilities to a larger area of the population. geted and varied project activity is proposed, the site visit team was greatly concerned about the seeming absence of coordination between similar and related activities. It was suggested by members of the site visit team that consideration be given to combining some of the education and training activities proposed. The Kidney Disease proposal, Each of these is capable of insuring sharing of facilities While a wide range of health providers are tar- .. _.i . I I ." , > . :.- . -. I.._ Other Funding The Region has been reasonably successful in attracting funds for ongoing activities from local and State sources. application indicates other sources of funds totaling $198,172 or 6.6% of the total requested direct cost amount. Furthermore, the VRMP has indicated that it is actively seeking other federal funds for support of the two sickle cell anemia activities included in The current Virginia RMP -17- RM 00049 the current application. been made and more positive results are anticipated toward obtaining commitments assuring activity continuation from other funding sources once RMP funding is withdrawn. Please refer to the section Continued Support for a more detailed analyeis of this area. It is also noted that great strides have Conclueions The site visit team was generally the VRKP since the last site visit. Indoctrination of the compara- tivelynew RAG appears to have been successful in that the members are actively participating in the decision and policymaking processes. The development of this group has been further enhanced by the reappointment of three former RAG members who had resigned to accept appointment on the Board of Directorr for the VRMP. impressed with the progress of The VRMP has refined its organizational and managerial structure to provide for more frequent RAG meetings for execution of its responsibilities and greater involvement of RAG members in the evaluative and monitoring aspects of the program. The concept of using RWiew and Evaluation Committee (R&E) members for monitoring of operational activities by reviewing progress reports and participating in site visits for evaluation (with the assistance of program staff and RAG members who live in the vicinity of the project) should be &ore workable if the RbE Committee is expanded to lessen the work load on individual members. The VRMP bylaws have been rewritten to more positively state the functions of the RAG and the responsibilities of the Executive Director and his staff to the RAG. been established for regular review and modification of the goals, objectives, and priorities of the VRMP $0 that they may effectively reflect the needs of the region and still remain congruent with the mission of Regional Medical Programe a8 reflected by national needs and priori ties o The planned establishment of Subregional Area Coordinator offices of Local Advisory Groups (LAGS) to more positively determine local needs and priorities should provide an even firmer foundation for the program expaneion envisioned in this application. A new Program Committee has , in the five geographical eubdivlsions of the region and the formation While focusing on the improvements and latent potential of the VRMP, one must also consider the need for further refinement (as noted Virginia RMP -18- RM. 00049 - throughout this report) of the areas in which progress is so note- worthy __. with special consideration being given to the need for improved communications between the primary managerial components of the region: staff (including the subarea coordinators) and the Board ofgrectors. The Region needs to develop improved coordination of fragmented efforts in similar and related type activities such as those directed toward pharmacists, dentists, and other allied health personnel. need to be coordinated and developed on a regional basis with greater participation from interested groups. In this regard, since the August 3-4 site visit, word has been received from Dr. Perez, the Program Coordinator, that a meeting of representatives of health organizations and groups interested in emergency medical services was convened on August 9, preliminary to development of a Coordinated EMS System for the State of Virginia, follow-up meeting is planned. ) the RAG, Executive Director, members of the program w . bolated activities proposed in the area of emergency care systems (Progress was made and a Recommendations The proposal, as submitted, is viewed as an ambitioMundertaking administratively efficient program staff and place too great a monitoring and evaluative load on the maturing RAG and its Committee structure. ._ , that might very well overburden the small though well qualified and '_ Accordingly, the site visit team recommends that the VRMP be approved for: (1) (2) Triennial status at a $1,800,000 direct cost level for each of three years ; A developmental component in the requested amount to be funded within the total $1.8 million level. In the opinion of the site visit team, while permitting expansion and gtowth to a viable region, funding support at the reduced level will make necessary greater program coordination among the various activities (program staff ad projects) and closer monitoring of daily progress to obtain the most effective utilization of avail-able funds. .I . ,.. . . -. ,.. . i .. 7 .. .. ;. 1. , ., f .I I . .. .-'.."' Review Cycle: 10/72 RMPS STAFF BRIEFING DOCUMENT Vfl 8- fl qwq .- REGION: Virginia OPERATIONS BRANCH: East ern NUMBER: RM 00049 Chief: Mr. Frank Nash e L I COORDINATOR: Eugene R. Perez, M.D. Staff for RMP: George F. Hinkle Marjorie Morrill Charles Barnes LAST RATING: 246 Joan Ensor TYPE OF APPLICATION: - I' X/ Triennial - I' / Triennial Mr. Clyde Couchman - - 3rd Year Regional Office Representative: - 2nd Year I_ 1 1 Triennial - I' I' Other __. Management Survey (Date): Conducted: July 1971 Scheduled : or Last Site Visit: September 14-15, 1971 Sister Ann Josephine, Review Committee, Chairman Bruce W. Everiet, Council Hember Louis K. Collins, M.D., Conmltant, Private Physician William C. Fowkes, Jr., M.D., Consultant, California W, Region 111 Fred Shapiro, M.D., Consultant, Renal Disease Staff Visits in Last 12 Months: April 6, 1972 - Attend RAG meeting and discuss recent developments at the National VRMP level. (subsequently approvedlfunded) Emergency Medical Services Pro3 ec t . Application. April 17, 1972 - Provide staff assistance in resolution of a proposed June 7, 1972 - Attend RAG meeting for review and approval of Triennal Recent events occurring in geograph:Lc area of Region that are affecting RM! program: (a) In 1972 the General Assembly of Virginia amended and re-enacted legislation relating to exemption from tort liability of persons rendering emergency medical services in Virginia. After July 1, 1972, paramedics who are properly trained may perform more advanced emergency procedures such as initiating intravenous fluid therapy, administering medications to relieve pain and prevent cardiac arrest, and perform cardiac defibrillation. (b) Legislation has been passed that permits dental students entering their senior year to accept summer employment in state supported and government institutions in the community when supervision is provided by a Medical College of Virginia (School of Dentistry) faculty appointee. I. . ,, VIRGINIA REGIONAL MEL,' A PROGRAM SUB REGIONS. (FIVE) + PERFORMANCE SITE DATA ** TRIENNIAL APPLICATION, . I , P -I- DEMOGRAPHIC INFORMATION Population (1970 Census): 4,648,500; Approx. 63% urban, 19% non-white and a median age of 25.9. U.S. - State 35% 35% Under 18 years 18-65 years 57% 55% 6 5 -over 8% 10% Land area: 39,838 square miles Population Density: 117/square miles Major SMS Areas: Health Statis tics: Facilities: Population RMF (000) Sub-Region Lyn chbu 1: g 121.8 IT Newport News-Hampton 289.3 V Norfolk-Portsmouth 633.1 V Richmond 515.6 IV Roanoke 179.4 I1 (Metro DC Area) (350 .O) (111) Mortality rate per 100,000 population for Heart Disease is 312, 128 for cancer and 85 for CNS Vascular Lesions all of which are from 15-19% below the National average. for all causes is 820.9 whereas the U.S. average for all causes is 935.7. Deaths per 100,000 The State has two major medical facilities, the Virginia Commonwealth University (Medical College of Virginia) and the University of Virginia School of Medicine. Within the State are 34 nursing schools that offer Registered Nurse programs and 44 nursing schools which offer L.P.N. programs. cytotechnology facilities and 23 Radiologic technology facilities within the State. One school each in the disciplines of Dentistry, Pharmacy, and Allied Health and Physical Therapy are located within the State at the Virginia Commonwealth University, Richmond. The American Hospital Association (1970 Guide Issue) reports 102 short term hospitals and two long term general hospitals with 16,385 and 434 beds, respectively plus two V.A. General hospitals with total bed capacity of 1,493. with nursing care and 20 long term care units with respective bed capacities of 6,862, 2,873 and 925. The State of Virginia has 4,900 physicians (106/100,000) and 28 osteopaths. There are 16,487 professional nurses of which 4,975 are inactive and 5,843 licensed practical nurses of which 959 are inactive. region has approximately 949 radiologic technoligists, 2,611 pharmacists, 2,552 dentists, and 433 dieticians. There are eleven schools of medical technology, four There are 82 skilled nursing homes, 59 personal care homes The Virginia E S 1 \,.. '\ Current hnuzlized\ CO2p"Clt Level 03 Year t for Tri 2nd year - - c0ur.c .st year nial 3rd year. sequc 1st year (376,769 ,) 1,893 ~136 t ,150,429 .,054,027 S 501,225 (41,802) 89,000 -I)- 1,169,137 L,574,982 536,566 (142,675 ( 136,996) ( 128,045) ( 48,669 -- I ( 52,094 -- -- I c COEXIL RECO?-MEXDED LEVEL * Included in Pro ,,+* Earmarked - Inc f $2, P89,54 3 1 $1,037,791 TOTAL DIRECT COSTS I $1,010,000 'am Staff total d d lded in Operational Pro ects - +,?tal i J:, *a .. -I I ,l ! I 8 -c1 I c JULY lee 1972 B .. .. ' 'i , ?... , , ,' I.: .. . .. .. . .... KtlilON - VllrClNIA RM 00049 10/72 PAGE 4 I wrps-csr-Jrrr.a?- 1 JULY 18,1972 P.REIKOUT OF RFPUEST 05 PPLGRAM YLRIUI; I I JULY lEs1972 ,. .. . ' .. PEGION - VIRGIhIA RR 00049 1U/72 PACC 5 ,I,.* It.. ,*I.*.*- , (51 (2 i (4 1 (1 I LUNI. Ultl~lNI WN1. ULYUkJ] AI'JJH. hU1 I hl kr hL1 I 311D VfhR I APFR. PEPlCCl PPPR. PFRlCOl PREVIOUSLY I PRLVILUSLY 1 CIRFCT I CF SUPPCWl I 1F SUPPORT I FUhCEO I APPHUVID 1 COSTS I I I I I I I TrTN 1 I ALL YEAPS I IDlFECT CCSTS I i I BREAKOUT OF REOWEST 06 PRnGRAM PEPIWl WCGIUN - YIHGINIA 'PAGE 5 Rn 00049 :0/7z RCPS-C Sr- Jl CCP? -1 ( 51 IOENlIFICATICN CF CCI(PChEN1 I CGNT. kITFINl I APPR. YERICOI I I 036 CBSlCTR1# IRAINING PROGR I 1 1 CF SUYPCRl I (21 (4) (1 1 CCNT. BEYOND1 APPR. NOT I NEhv NOT I 3R0 YEAR I APPR. PERICCI PREVIOUSLY I PFtVlLUSLV I CiRCCT I Lt SUPPCRT I FUkOEO I APYHUUtl) I COSlS I I I I I I TCTAL 1 I I I I I ALL YEARS 1 II)IRECl CCSIS 1 I I i I A* I I S6L9fZ I UMuLi-ines,elr_r 1- 037 SHAREC SEW RURAL hEAlTk( I 1 I I I I I I +.. RMP: WEST VIRGINIA 5. * COORDINATOR (10) The Coordinator has obviously provided strong leadership in the development of the West Virginia RMP. and managerial abilities to deal with the problems with which he is faced. He relates and works well with the RAG and in the last four months has recruited an individual as associate coordinator who appears likely to provide the necessary planning and administrative' assistance needed in a larger program. coordinator the RMP has hired three program specialists, a data analyst and a field representative.) it is advantageous to have a non-medical man in this particular position since he has to relate equally diplomatically to the University and to the leadership of the State Medical Association in a manner which will generate a minimal amount of friction and a maximal amount of cooperation. 1 He has adequate administrative (In addition to the associate The site visitors feel that This has obviously been achieved. 6. PROGRAM STAFF (3) The program staff are all full-time and represent a broad range of competence with the exception of the key disciplines of medicine and nursing. established in the program staff at least as half-time positions with authority and responsibility in the areas of planning and evaluation. A physician and nurse staff position should be r. .. -9- DATE: 10/72 _- RMP: WEST VIRGINIA PREPARED BY: N0rma.n Anderson 7. REGIONAL ADVISORY GROUP (5) The RAG and its subcommittees have more than adequate representation from providers and other health interests throughout the State. The RAG itself is heavily provider oriented: including alternates, its total membership of 38 (+12 alternates) consists of 24 physicians, four hospital administrators, and five other health professionals, all together accounting for over 90% of the membership. four non-provider members, only one might be considered a "real" consumer, in the sense that she represents the poor and medically underserved population of the region. site visit team that the Regional Advisory Group composition should be modified to be more representative of consumer groups (induding racial minorities which currently have only minimal representation), the nursing and allied health professions, and community colleges. This modification may well necessitate amending the RAG bylaws, which now call for representation from a specific list of health organizations and ipterests in the State. impressed by the testimony of one of the RAG members, Ms. Brown describing her "living room" approach for stimulating consumer interest both in the West Virginia RMP and in health care in general. It is hoped that this approach will do much to foster consumer participation in the program. It was felt that the RAG has an excellent attendance and partici- pation record. Meeting of RAG subcommittees, likewise, seem to be well attended and to have garnered enthusiastic support. Of the It was the consensus of the The team was especially e While the RAG does play a role in determination of policy and overall program direction, it was the site team's impression that this role is one more of reaction than action. It seems that program staff are responsible for most of the actual planning and program implementation, although the RAG is kept informed of developments. From information presented, it appears also that RAG does not monitor or evaluate program staff activities. The RAG'S Executive Committee, like the larger body, is not broadly representative of the health and consumer interests in the State. This particular group, in fact, numbers no racial minorities or women among its members. group also needs to be expanded to provide for more input from nurses, allied health personnel, and consumer groups. It was the visitors' feeling that this 7. REGIONAL ADVISORY CROUP (5) Continued Since staff is non-medical and under great influence from the Univeristy it seems appropriate that specific mechanisms be developed to insure that: RAG expertise and perspective are utilized in monitoring and evaluating program development. conceptual. framework for revising or discontinuing specific activities. 4 This will help provide a broad 8. GRANTEE ORGANSZATION (2) The Dean of the tledical Center stated that he is the budget officer for West Virginia RMP and that he periodically meets with Mr. Holland (although there is no regular schedule for such consultation). The Dean attends most of the Executive Committee meetings. further stated that it is Mr. Holland's responsibility to keep him informed of West Virginia RMP's activities. nications are maintained between the University and the W.. There is a Hedical Advisory 'Committee to the Coordinator, composed of the Dean, the Provost for Health Sciences and a Professor of Surgery. Again, no meetings of this group are scheduled. of contractual procedures the RMP must use the University system, and as a state institution, the University must use state procedures and meet state requirements. approved through the President's office of the University. system is complex but the University is wholly committed to the RMP and its success and has made several significant efforts to eliminate procedural delays that the RMP has encountered. He Open lines of commu- In terms All contracts are processed and This Responding to site visit team questions about the informality of staff, RAG and grantee relationships, the Dean stated that "it seems to bother you people that we get along so well together." He said "we have a compatible marriage and that if the RMP did not have the support of the University it would be a disaster because they could not stand alone." other reports such as the Management Assessment Report that the Vest Virginia RW is strongly supported by the University. The site visit team was convinced that the grantee organization does provide adequate administrative support within the constraints of the state government system and permits sufficient freedom for This further substantiates - 11 - RMP: WEST VIRGINIA PREPARED BY: Norman Anderson DATE: 10/72 8. GRANTEE ORGANIZATION (2) Continued program development. The University does not swm to be interfering with RAG'S policy making role. nication and liaison between the RAG, the program staff and the University through the crucial presence of Dr. Andrews who has exerted a very strong directional influence in the past. He claims currently not to be directly involved in programs, although his influence is probably still significant in less direct ways. There is obviously very good commu- However, West Virginia RMP may need special consideration by the University in terms of personnel policy and the establishment of salary levels far program staff in order to be competitive with other IMP'S to recruit and retain competent program staff. . 9. PARTICIPATION (3) Almost all key health interests are actively participating in the West Virginia RMP and it does not seem to have been captured or co-opted by any major interest. economic power complexes are involved but the HYGEIA Foundat ion which provides a significant portion of health care in the State has not yet been brought into active RAG participation. As an example of participation Mrs. Joanne Ross, Director, Southwest Community Action Council stated that the RMP regional liaison officer has provided a great deal of assistance and that "RMP is a mover and a doer." The region's political and - 12 - - RMP: WEST VIXGINIA PREPARED BY: Norman Anderson DATE: 10/72 io. LOCAL PLANNING (3) The State Comprehensive Health Planning Agency is in the Governor's office staffed with a full-time director and a secretary. are six established (b) agencies and West Virginia RMP has been instrumental in getting each of them operational. As a result of a recent CHP study a total of eleven (11) regions have been certi- fied for planning. This means five (5) more (b) agencies are to be developed. West Virginia RMP will provide assistance in the development of h (b) agencies. The State Agency Director says he has no problems with matching funds, but the (b) agencies have a lot of problems with matching funds. The State agency provides assistance to WP staff in developing data. The comprehensive health care agencies have been slow in developing, but we might anticipate a faster growth in the future. There West Virginia ZiXT has recently developed .and. published a report entitled, Guidelines for Proposal, Review and Operations of Activities which adequately describes the review process of the region: The Guidelines specify that the proposal is sent to the appropriate Comprehensive health planning agency for its review and comment at the same time the proposal is submitted to the West Virginia RMP Technical Review Cormnittee for its assessment. From all indications very good working relationships exist between West Virginia RMP and CHP. meet the stated review requirements of applications by CHP. The Guidelines as written more than Recomxrmded Action: 11. ASSFSSMENT OF NEEDS AND RESOURCES (3) lIhe West Virginia RMP has participated with the University and CHP in data collection to identify health needs, health manpower and health resources in the State. Bealth needs in the State are many and are characterized by the State being the third most rural in the nation, by having the second highest ratio of proprietary hospitals, and by having a very high percentage of physicians who were trained in other ccuntries. The State has approximately 400 unlicensed foreign named physicians working in the State. A method should be developed to provide full accreditation for those physicians and equal participation in the affairs of the medical community. The need to establish residency training programs in - 13 - RMP: WEST VIRGINIA PREPARED BY: Norman Anderson DATE: 10172 the State is well documented. has increased nursing manpower by approximately 30 lpercent and a corresponding decrease in physician manpower by approximately 30 percent. Many of the remaining physicians will be of retirement age in the next few years. developed concurrently with the goals and objectives and the restructuring of the technical committee and program staff, the past the area liaison officers have functioned somewhat pendently in assessing the health needs in their area. Over the past few years West Virginia The current triennial application was In inde- 12. MANAGEMENT (3) The central office program staff was reorganized and expanded to support the work of the field staff. together with the field operations coordinator make up an organizational unit which is one of only two activities that report directly to the program coordinator. The other organizational unit is the Office of Program and Grants Management which is a standard administrative service organization. In view of the p-ojected program growth this office may need to develop additional strength to provide the coordinator with adequate financial monitoring and control. All three of the other program staff organizationalitunits report to the coordinator through the recently established position of associate coordinator. These three organizational components are: Office of Program Research and Evaluation, Office of Program Planning and Development, and Office of Information and Comuni- cations. The Office of Program Planning and Development is a new activity that was initiated to assist the field staff. This office is comprised of four staff specialists'in the area of Health Care Delivery Systems, Emergency Health Services, and Health Manpower and Medicine. The area liaison officers _- --------- - 14 - RYP: WEST VIRGINIA PREPARED BY: Norman Anderson DATE: M/72 12. MANAGEMENT (3) Continued Changes made following the Management Assessment visit in June, are apparently seen as satisfying personnel and organization structure needs for the future. if the projected program expansion is approved. Position descriptions are not yet available and fiscal procedures have not been written out. With the Management Assessment and site visit accomplished, staff plans to take up these tasks. This may need further review, llecomended Act ion - 13. EVALUATION (3) The Office of Program Research and Evaluation is staffed by a program evaluator, a data analyst-and a research assistant. Evaluation is in the process of transition and change and upgrading cannot be adequately evaluated in all phases as yet. West Virginia RMP does require quarterly progress and financial reporting on all operational activities. periodically meet with project directors in their areas to discuss progress of a given activity as it relates to the objectives. i I Field staff members - 15 - P: WEST VIRGINIA PREPARED By: Norman Anderson DATE: 10/7 Program Proposal The priorities of the proposed program by the region are well established and understood in terms of objectives, but their use in the selection of proposals to be funded, and in preparation of the developmental component are not spelled out in detail. The activities are highly congruent with national objectives and needs. The proposals appear soundly based and realistic in view of resources. ated, although we are not sure that enough in the review and evaluation process to insure this. The reporting methods proposed for three month monitoring of projects seem fairly subjective at present. when necessary. The results can be quantitatively evalu- sophistication has developed The region has been quick to modify its objectives A decision was made early, in view of their major objectives, to improve health care delivery but to leave to the University the major responsibility for continuing education. Some limited self-evaluation demonstration projects hairs hen developed for physicians, and a visiting physician program was instituted which was not very successful and is no longer operational. Linkages are being developed for closer cooperation in postgraduate medical education at the residency level. The emphasis is upon delivery of the common rather than rarely required facets of health care, such as emergency medical services. The program generally should have an impact on improvement of facilities for delivery of health care and utilization of present personnel (midwife and pediatric nurse physicians assistants). The planning for this began early in the program. Improvement of clinic care is a major prospect for several portions of West Virginia through the development of new clinics. emphasis deals with the development of improved access to patient care under difficult local conditions. These activities are strongly sub- regionalized and can be expected to have immediate payoffs in better patient care, with increased availability of and access to services, and improved quality of care. However, total medical care costs will probably increase rather than decrease as services are made available to areas where medical care has previously been short supply. The total program nonexistent or in very Important developments to improve categorical types of health care in the long run appear through: 1. Supporting care linkages between the general group practices in outlying communities (such as Hygeia supported clinics) and multi- specialty groups in urban areas, as in Charleston and Huntington. 2. Development of residency programs in the latter areas, which can increase physician retention in the state from a 40% level at the 0 I - 16 - RMP: WEST VIRGINIA PREPARED BY: No- DATE: 10/7 5.; - end of medical school, to a 7077, level at the end of residency training. There are no residency training programs now, although one is being started, These two factors will strengthen relations between general and specialty care and should lead to improvement in the quality of care. d The region has been outstanding in obtaining outside funding for its pro- grams. value and viability of the program plans. believe that an official letter from the State Medical Society, endorsing the program as stated in the triennial application, would be helpful. It is the site visitors' opinion that an action pattern has been established which, barring unforeseen complications, can i.mprbve the quantity 200-30(X within the next decade, This impression was substantiated by a visit to the Fairnont Clinic to determine what has been accomplished through strictly local means. This fact alone serves as the most.concrete demonstration of the The site visitors, however, Site Visit to Fairmont Clinic, Fairmont, W. Va.; August 8, 1972 'fhe site visitors terminated their work with a visit to a nonprofit clinic organized 15-20 years ago by the Monongehela Valley Health Associatian (a lay group).which now offers a full range of health services, including home care, clinic care, and hospital care. The clinic averages 500 patient visits daily from 8 a.m. to 10 p.m., with a staff of 13-14 full-time physicians, and with its own integral pharmacy, X-ray, lab, emergemy room, record room, and podiatry service. It accepts .persona? ffndnces, and operates two satellite clinics in the hills six and 31 miles distant. $20-25. embracing hospital, clinic, and home care. story building downtown housing their home health service. This is split into care grol;ps by age (over 56 and under 65), with two separate nursing staffs, and covers the surrounding rural area as well. The Fairmont clink has one of the new Family Health Center Grants thus far awarded by HSWl.A. patients, including 50% not covered by third party or The average patient visit cost runs from Records are all typed and of high standard, with a unit system There is a separate five- This clinic, and an even more extensively developed clinic at Elkins, which fnclzdes transportation facilities for patients, should at some time recei.ve careful evaluation with respect to actual costs and benefits of operating an areawide health system embracing the home and clinic (but not hospital costs, these being handled by an independent agency). At present there is little linkage between this clinic and WVU Medical Center, since third and fourth year clinical clerks have been with- drawn in favor of hospital assignments. REfP assisted materially in \ L .'! \.___I. - 17 - - WEST VIRGINIA PREPARED BY: Norman Anderson DATE: 10/72 obtaining the Family Health Center Grant, and has established an excellent working arrangement with this clinic. a tremendous demonstation project and local resource The clinic represents SUMMARY The site visit team was very impressed with the energetic program staff, the cooperation and assistance provided to other agencies, the coordinated team approach to health care, the excellent subregionalization and their resourcefulness in garnering funds from other sources. The WVW was described as a well oiled machine that is responsive to the health needs of the region. and published report entitled: Guidelines for Proposal, Review and Operations of Activities which ad-equately describes the review process of the region. Everyone agreed that this is a well prepared report and a definite asset to program development. The site visitors were pleasdwith the recently developed The grantee organization has been responsive to the needs of the WVRMP as was descri'ueci in the Management Assessment Report in April when the grantee obtained authorization from the West Wnia State Auditor to make operating capital advances to institutions that collaborate with the Regional Medical Program and do not have the capital to implement the agreed upon program activity, During the course of this site visit this continued commitment was restated. It was felt that there has been adequate flexibility established with RMP under the university structure, however, some problems still exist concerning the fiscal system, salaries, personnel qualification, and acceptance by the university personnel system which are slowly being aired. The team was a little concerned with the informality of the administrative procedure, but observed that excellent rapport has been established with the key health industry in the state. We did suggest that the administra- tive procedures be adequately described in writing. It is the opinion of the site visitors that the West Virginia Regional Medical Program has made an impact on the Health Care System. is a mature region that has performed well and has acquired the necessary skills and organization to continue to improve and influence the health care system in the wild and wonderful State of West Virginia. This RECOMMENDATIONS 1. That the West Virginia Regional Medical Program be approved for triennial status with the follming funding levels: 04 operational year $1,500,000 05 operational year $1,600,000 06 operational year $1,700,000 - 18 - WEST VIRGINIA PREPARED BY: Norinan Andersorr. DATE: 10/72 The recommended funding levels include the developmental component request. following: ment in program staff support, even though the visitors felt that the voiced concern with regard to two of the proposed operational activities: the first, V6luntary Office Self-Audit Services, because it reaches only a limited number of physicians in the state and its cost benefit relationship seem very high; and the second, the Camden- on-Gauley Medical Center, because the team felt that the Pd4P should make efforts to obtain matching funds from the Hygeia Foundation, which is sponsoring the program. - The site team made these recomendations based upon the (a) that the program is not requesting any major incre- program is slightly understafedxb) the visitors in particular I 2. That nursing, medicine, 2nd social service disciplines be added to program staff as at least half-time positions with major responsibility and authority in the areas of planning and evaluation. 3. That written policies and procedures delineating the respective admin- istrative responsi3i:iiies of the WVRMP and the grantee institution be developed. 4. That the bylaws of the Regional Advisory Group be revised to allow broader representation anu specific responsibilities of the grantee, the RAG and the program staff. allied health, nursing professions, and consumer interests should be represented on the RAG. types of representation desired, rather than specific organizations. Currently, any change requires revision of the bylaws, that addition of representatives from the rural provider insitutions (especially the UMW-affiliated Hygeia and Ephraim McDowell Foundations) was especially important, since these organizations have contributed heavily in carrying out the RMP goals for broader health care coverage. The RAG could easily reduce its representation among the categorical voluntary health agencies to a single representative member for all of the agencies currently represented. from community colleges, nursing, social service, allied health, and consumer groups o That RAG develop a procedure for applying established program priorities and criteria in project funding determinations. of a comprehensive review and funding process. Rural health care provider institutions!, Flexibility should be increased by specifying It was felt Further, RAG should increase membership 5. This should be part 6. That efforts to recruit additional female and minority personnel on program staff be continued, and that actlvities be initiated which will, impact cjn specific minority pockets. That a portion of the developmental component be used to carry out the additional planning and research necessary to develop a residency trainicg program for primary and secondary physician training 7. - 19 - PREPARED BY: Norman Anderson DATE: 10/72 * W: WEST VIRGINIA in several of the major hospitals in the State. the State Medical Society has obtained $300,000 from the State legislature to assist in the improvement of the residency training program. component was to be used for anything other than the general objectives and patterns of activfties that were described. The site visit team felt it would be appropriate for the West Virginia RMP to utilize portions of this developmental component to obtain maximal physician retention estimated at 70% through assisting in the establishement of the residency training programs outside of the medical center, particularly in Charleston, Wheeling, and other major communities in the region. It is to be noted that The site visitors did not perceive that the developmental Review Cycle: 10/72 - c REGION: NUHBER: RMPS STAFF BRIEFING DOCUMENT West Virginia RM 00045 COORDINATOR: Mr. Charles Holland LAST RATING: 358, OPERATIONS BRANCH: Eastern --.- Chief: Frank Nash Staff for RMP: Norman Anderson - I__- Eileen Faatz TYPE OF APPLICATION: /--IT/ Triennial LIJ Triennia1 3rd Year 2nd Year L-. 7 Triennial LJ Other Regional Office Representative: Clyde Couchman Management Survey (Date) : Conducted: April 24-27, 197 2 Scheduled : or Last Site Visit: (List Dates, Chairman, Other ComitteelCouncil Members, Consultants) July 8, 1969 - Anne Pascaeio, Ph.D. - RMP Review Committee Bruoe Everist, M.D. - RMP National Advisory Council Desmand O'Doherty, M.D. - Consultant Staff Visits in Last 12 Months: (List Date and Purpose) September 28, 1971 - Alan 8. Kaplan, M.D. (Staff Assistance) April 24-27, 1972 - Management Assessment (Tom Simonds, Rod Merhker,N. Anderson) April 26, 1972 - Verification of Review Process (N, Anderson, Clyde Couchman) June 23, 1972 - Staff Visit (N. Anderson) Recent events in geographic area of Region that are af f ec tin& RMP program: 1. 2. 3. 4. WVRMP has recently redefined and restated their objectives to be more responsive to the needs of theiRWon. 'Ihe Technical %vim Committee structure has been reorganized. A Technical Review Committee has been established for each of the three objectives. WVRMP has developed and published a report entitled, Guidelines for P$cuiYoral, Review and Operations of Activities which describes the review process of the Region. Management Survey team report and verification of the review process report . -_ Mr Robert Whit lex .- Mr . Gerald Humme 1 258 Stewart Street Morgantown, West Va. , I Mr. Garvey Gilaore Eishop Hill Building 203 Randolph Avenue Elkins, West Virginia -- / /- -3- DEMOGRAPHIC INFORMATION 1. 2. 3. e 4* 5. Geography Region: West Virginia Review Cycle: 10/72 - The region conforms to the political boundaries of West Virginia, For planning purposes the region has been divided into nine sub- regional areas. The boundaries of these sub-regional areas are the same as those of CHP "B" and the State Economic Development Department. Land area: 24,079 square miles. Papulation: 1970 Census a. Total: 1,744,200 b. Urban: 39% C. Rural: 61% d. Minority: 4% Income: State of West Virginia - 1969 ($2,610) - 1970 ($2,929) United States - 1969 ($3,680) - 1970 ($3,910) West Virginia ranks 46th in the U.S. per capita income Average income per individual - 1969-1970 Age distribution: Age group under 18 years 18-65 years 65 years and over Facilities and Resources: West Virginia 33 56 11 a. b, Sixteen Schools of Professional Nursing, seven of them c, West Virginia University School of Medicine college or university based. Sixteen School of Practical Nursing U.S. 35 55 10 - Allied Health Schook a. Two schools of cytotechnology b, Sevem*sehaole of Medical technology c. Twenty-four schools of radiologic technology -4- Ho s pi t als a. Short term - 74 - 9,286 beds b. Long term - 2 - 460 beds C. V,A.Gerfral Hosp. -4-1,257 beds 6. Manpower: Active * a. Physicians - 1,596 b. Osteopath - 100 c. Professional Nurses - 4,704 (260 per 100,000) d. Lic. Pract, Nurses - 2,317 (136 per 100,000) Total - 1,696 (94 per 100,000) - * From a study conducted last year, utilizing the West Virginia Medical Association Journal of new members of the West Virginia State Medical Association from 1961-1971, the following data was collected. A preliminary analysis of the data shows that, of all new members of the Stare Medical Association, a significantly high and growing proportion are foreign medical graduates (9% of these joining in 1961 vs. 65% in 1971), _- COMPOSENT iWD FXNAYCIAL SU4WWIY TRI EKN I AL APPLIC.4TION 2nd year _- 3rd ye=. Kidney E.3 * (2f , 556) hs/ea PediatricTulEonary Gther - . (24,105) TAL OIREcf COSTS** * $63,'375 **$863,375 - ._ CurreRt hnuzlized 04 Year Level - $ 57.7,086 148,466 -_ -- 222,914 .. . 800,000 ' $ 929,810 cified Growth Funds Ileac1 1st year $ 584,725 95,222 80,000 ' 1, i35 ; 15 3 25,000] 41,506 [ 49,830) $1,799,878 .. Co:!!?c 1st year I. I c d d ! . 1' i ! I I I I2 .. I co I JULY I 7, I.* r,! EM I I I I I r41JPP 1 022 PARKEkSUUcb AhtA HdRt t-tl 1 1 I I I I I 021 SAILLLITE HtALIH LtNltiiSl I - I I I i - #.?nu L-LLLrlo&QQe-lrso.oooJ 12~W I ' flLUrLl;r'Y - 10 " Region: West Virginja -- Review Cycle: 10/72 History. - In December 1965, Dr. Clark K. Sleeth, then Dean of the West Virginia University School of Medicine, convened a meeting to discuss the State's participatfon In RMB. The meeting was attended by representatives of the State Departments of Health and Welfare, the West Virginia Heart Association, the Wesr Virginia Division of the American Cancer Society, the West Virginia Hospital Association, the West Virginia University Medical Center and the general public. Upon unanimous agreement to participate, the Medical Center was selected to initiate and coordinate planning co establish the WVRMP. A 28-member RAG was appointed and Dr. Sleeth was elected chairman. The RAG appointed 8 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 geasibility studies; (1) Suivey of a Rural Area (Blacksville); (2) Mechanical Morbidity Reporting by Physicians; (3) Coronary Care Unit; md (4) Physicians Self-Audit. The latter three also were 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. had many obstactles to overcome. economic crises, leaving most areas without adequate health care. Small towns, rural and mountain areas, so predominant in West Virginia, lacked health personnel. and there was little evidence of effective continuing education into the hospitals and medical profession. Add-lng to these problems, Dr. Wilbar, the Regional Coordinator, died in January 1969. Mr. James G, Holland, Associate Coordinator, was sPrving as Acting Program Coordinator, coordinator poeition, the site visitors believed the region was ready for operational status. has taken an active role in the WW 2nd good physician and nurse participation was evident. cooperative arrangements. As pointed out to the region, there was a need for better minority representation on the RAG. KAG only recently had organized its comittee structure, and it was too early to determine how well it was working. on joint planning with Comprehensive Health Planning were projected for the near future. Council recommended approval for operational status for three years for core and four projects. Mr. Charles D. Holland was appointed Regional Coordinator and to provide appropriate supervision of the medical aspects, a special Medical Advisory Committee was constituted to assist the Coordinator. It was-noted that when the GNRMP began, it The Stare suffered from critical The aedlcal school was only 11 years old Despite the dearth of resources and the unfilled The West Virginia Univeristy Medical School .The region also has established appropriate The 35-member Subarea offices based History (continued) When Committee and Council took a brief look at the region early in 1971 when supplemental support for new projects was requested, it was observed that although the region had been operational for only one year, the program seemed to be moving forward under effective leadersfiip. Subsequently, however, the across-the-board twelve percent reduction for all RMps reduced West Virginia's 02 year grant from $516,567 to $454,579. But later on in the year the region received an additional $126,299 from unexpended 1971 appropriations to provide supplemental support for core and an ongoing project and to initiate an approved/unfunded project. supplement only, and the commitment for the 03 year remained at the reduced level of $454,579. This was a one-year - f2 - Region: West Vir.ginia Review Cycle: 10/72 HISTORY OF REGION Principal Problems since Region received first planning grant in 1 January 1, 1967. Review and Council Concerns a) The degree to which the regional activity would be expanded into peripheral areas. b) Lack of information on resources of the Medical Center. c) Relationships with other existing programs. (Appalachian Health Studies and Development.) Site Visit: July 1969 (Preoperational) - Recommended operational status 1/1/69 - 12/31/70. Concerns of Site Visitors The need for increased representation from the poor on the RAG. a) b) Recruit an educator to program staff for bringing in consultants with II - a. .- expertise in education. Review and Council recommended operational __ status . October 1971 Review Committee and Council a) WVRMP was penalized because they had not had a site visit since 1968 and very few staff visits. b) Questions concerning the reorganization of the committee structure. c) Questions concerning the review process of the Region, Recommended staff assistance be provided to the Region to clear any problems in advance of submittal of the Triennial Application. Principal Accomplishments: 1. Reorganization of the committee structure. 2. The recruitment of an Associate Director, three Program Specialists, a data analyst and a field representative. 3. Revision and simplification of the review process as spelled out in the WVRMP Guidelines which also outlines program objectives and priorities. - 13 - Region: West Virginia Review Cycle: 10/72 e Principal Problems (Based on application, since last review) 1. Relationship between WVRMP and the grantee (University of West Virginia Medical School) which was dealt with through the management assessment visit. 3 2. The Sack of poor white representation on the RAG, Committees, and few allied health representatives. Principal Accomplishments (Based on applications, since last review) 1. Reorganization of the technical review committee's structure which has been conformed to the programs new objectives. 2. The development of "Guidelines for Proposal, Review, and Operation of Activities" which describes the review process, 3. Redefined and restated their objectives, The objectives are Health Care Delivery, Health Manpower and Bnergency Medical Care and each objective has a number of sub-objectives. 4. WVRMP has filled the following positions: an associate coordinator, three program specialists, a data analysist and a field representative. Through cooperative efforts and joint funding with a variety of public and private nonprofit organizations, five rural health care centers are being established. WVRMP staff play a cruclal role in obtaining other funding, i.e., $120,000 was."matched" by other one mllllion dollars- fromisther source^. 5. e Issues requiring attention of reviewers Same as principal problem. (WVRMP bylaws are very restrictive governing RAG composdtion. the bylaws be rewritten.) Site visit team may want to consider suggesting that Recommendations From /1 Region West. Virginia $Y 00045 Review Cycle October 10172 Type of Application: Triennium Rating 336 .Review Committee Council The Review Committee accepted the recommendations of the site visitors that the West Virginia Regional Medical Program be approved for triennial status with the following funding levels: 04 Operational Year $1,500,000 05 Operational Year 1,600,000 06 Operational Year 1,700,000 The recommended funding levels include the developmental component request. Committee viewed West Virginia RMP as a viable program with a well conceived d developed planning process built around clearly defined program goals and objectives. Each proposal is directed to one of the three objectives-- health care delivery, emergency medical services, and health manpower. The goals and priorities are directed to improving access to care in the unserved and underserved portion of the region. e concerns expressed by Committee have been adequately described in the te Visit Report listed under recommendations, Committee recommended that he concerns be strongly emphasized in oncern expressed by Committee is that representation on the RAG. the advice letter. One major "poor" people should have adequate Conxp onen t PROGRAM STAFF ONTRACTS DEVELOPMENTAL COMPONEfiT PERATIONAL PROJECTS Kidney Epls hs/ea Pediatric. Pulmonary Other TAL DIRECT COSTS WCIL RECOMMENDED LEVEL COMPONENT AND FINANCIAL SUMMARY TRIENNIAL APPLICATION Current Annualized Year Level - $ 557,086 148,466 -- 222,914 $ 800,000 $ 929,810 Region: West Vi;;a * Review Cycle: & Re* 1st ,year $ 584,725 95,222 80 , 000 1,135,153 9- : 41,506) : 49,830) 1 1,799,878 $ 619,19 -- 80,OO 1,280,80 (27,556) 1,980,000 nnial 3rd year $ 656,279 -- 80,000 1,343 , 7 21 ( 24,105) 2,080,000 $1,980,000 $2,080,000 Committee Recommendation fox Counc 1s t year L, 500 , 000 1-Approved Level 2nd year 1 3rd yea -+-- 1,600,000 $1,700,01 I C001~111N,11'012: John S. Hirschboeck, M.D. staff fol. I~~~~~: Jeanne L. Parks, SCOB - William (I1Billt*) Reist, SCOB Last Sitc Visit: December 1970; Chairman Dr. Russel B, Roth, Gouncil 9 Ih.. Edmund Lewis, Review Committee Staff Visits b8`last 12 Months! June 8-9, 1972: To attend RAG meeting to get overview of review process; to see RAG in action in preparation for verification of review process visit. ,June 13, 1972: Recent Events Occurring in Geographic Area of Region that are Affecting RMP Program: Verification of review process visit I In Yay 1971, the Governor of Wisconsin created a Health. Planning and Policy Task Force to (1) study the state's health needs;TZ) d esign a comprehensive system whTch would provide the health services consumers require; (3) compile a health plan and designate health priorities; (4) reamend a legislative program; (5) suggest any necessary administrative reorganization; (6) identify the responsibility for government, the providers, the educational system and the consumer; and (7) make recmendations,on the financing of system ad the consumer; and (8) make recommendations on the financing of health care, utilizing both public and private capital, with a request for early identification of those areas demanding priority attention. ~, To accomplish this far-reaching and significant undertaking, the following Task Force work groups were established; (1) Health Service Research E Development (2) Health Financing (3) Education of Health Workers (4) Transportation (EMS) - ~ ~ ~ ____ -2- Health Planning Environmental Health Health Education of the Public Personal Health Services Evaluation of Health Services Each of the work groups have projects or studies underway which will be finalized ,within the next six months and will provide the basis for final recommendations to the Governor. 171e Governor also appointed a Health Policy and Program Council which carries, along with other duties, the responsibility for Comprehensive Health Planning under the Bureau of Comprehensive Health Planning, the state (a) agency. This Council will continue its work after the Task Force has completed its assignment and will be in a position to take action on program areas identified by the Task Force, WRMP has both staff and committee representatives on both groups, As policy develops for the State of Wisconsin, WRMP may have a significant role in the implementation of new programs which might arise out of the two bodies. 'I'hree new CHP (b) agencies have become operational; one in North Central Wisconsin, one in North Western Wisconsin and one in the Lake Winnebago District. There are now 8 operational CHP (b) agencies in the State of Wisconsin, 30 * 32* - 5- IXXXAPHIC, FACILITIES AND RESOURCES STATISTIC4L WY REGION: WISCONSIN : The region encompasses the entire State. Counties: 71 Congressional Districts: 10 Population: (1970 Census) 4,417,900 Urban: 66% Density: 81 per square mile Rural: 34% A e Distribution: Wisc . 36%- 65 years and over 11% t?knFzT 18-64 years 53 % U.S. 33T- 55% 10% 6- -total population: 2,388,000 (over 50% of State total) nn-Wisc)--262.0 Madison- -287.5 Milwaukee- -1393.3 Racine- -171.2 % (large proportion Indians); White--96% ources and Facilities Enrollment Graduates -F1s 92 Medical Schools- -M&. College of Wisc . ,Milwaukee University of Wisc . Med. Sch. ,Madison 409 Pharmacy- -1 at University of Wisc. Hospitals, Madison Dental School--Marquette University, Milwaukee PrOfe5SiOnal Nursing Schools Practical Nurse Trainin 32--all at Technical Inftitutes are based at colleges and Universities 1 Cytot.echol0gy- - 3 Medical Technology--35 incl. 1 at V.A. Hosp. Radiologic Technology--30 incl. 1 at V,A, Hosp. Physical Therapy--2 (Univ. of Wisc. Med. Sch. and Marquette U.) Medical Record Librarian- -1 (Wood) (Wood) -6- Ilospitals- -Comity General and V.A. General Beds - # LI Short term 158 21,866 Long term (special) 8 1,198 V .A. (general) 2 1,342 Skilled Nursing Homes 353 27,205 - # Hospitals with selected special faciligies Cobalt therapy- -24 Radium therapy- -41 Renal dial (inpt) - -18 Rehab (inpt) - -27 * q, Intensive Cardiac Care- -52 'i Isotope--42 ,. c Long term care units 65 3,667 I component XGNAL PROJECTS hs/ea Pediatric Pulmonary DIRECT COSTS . I L-APPROVED EL September/tktober/fS CONPONENT AND ANWERSARY APPLICATION DURING TRIENNIUM Current . . Counci 1 - Annualized Funding TR Year lst (OS year) 529,955 64:792 117,822 1,066,503 x 1,779,072 1,779,072 Approved - Level For TR Year 21b4 (06 year) 1,779,072 Region's Request For ..TR Year 2nd 625,607 * .. . . 200,898 1,350,110 ( 312,881 1 (1,265,896 1 c 3 ( 1 c 3 2,176,615 Recormended Funding For TR Year 2nd /-J ' /x Review Committee 1 1,779,072 cReconmndcd - Level For Remainder of Triemiunl 4 I I I I I 1 I 015 COPPREPEhSIVE RFhAL PRCCl I I ROY I I I I s3-$ I El I I I I I I 1' 023 .- I I cc ,. . . ,. .,... ,' I I I 1 *- I I f 1 I t I I TETAL .- - TOTAL - 548900 llC25CS lCtlFtCC lC23@15- 32425t2 7CC727E * ZLltttS 1654731 62016 393??C2 1: r -11- Mi s tosical Profile `%e Wisconsin W's initial planning year began September 1, 1966, was designated as an operational program on September 1, 1967, and. received Triennial States on September 1, 1971. The Wisconsin W Inc. was formed as a collaborative venture by the Flarquette School of Medicine and the University of Wisconsin. emompasses the entire state of Wisconsin, with the largest concen- tration of its population in the seven Southeastern counties of Wisconsin, which serve as one of the area-wide health planning agencies-- the CHPA for Southeastern Wisconsin (WASEW). nationally in the mount of money spent for higher education. Health Sciences Unit of the University Extension, University of Wisconsin in Madison has been a pioneer in the development of continuing education for resources for physicians, registered nurses, and allied health professionals, and has achieved national reputation for the excellence of its work. The W has Over the years collaborated with these resources which have resulted in the development of a number of operational program designed for nurses and physicians and other health professions in the region. It The Region ranks high The During its early years of operation the WRMP has concentrated basically on quality of care in categorical disease areas and post-graduate education programs for physicians and nurses, with principal operational foci in the Marshfield, Milwaukee, La Crosse and Madison areas, and to a much lesser extent in the Central Northeast and Northwestern portions of the state. The northern portion of Wisconsin is characterized mostly by large rural areas sparsely populated with small rural hospitals and for the most part inadequate facilities, Operational programs have recently been developed which do provide some outreach to some of these. rural areas, The region through its newly appointed field representative for Northern Wisconsin has been working with hospital administrations in this area and has assisted these hospitals in the development of collaboration and service sharing arrangements. The current application requess funds (Project #36A) for support of such an activity. Project d 30, brth Central Wisconsin, illustrates another example of an outreach program in the Northern and Central area for the small rural hospitals. These projects among others in the current application illustrate the region's emphasis on finding ways to extend services to areas out- side the Metropolitan and University centers and the large group clinic settings, and on developing methods for monitoring the quality of care and moderating the costs of quality health care. far B statewide EMS project for the State of Wisconsin also represents a program which would aid people in the Northern areas and will tie together a number of extremely scattered, smaller services. working in close collaboration with a broad spectrum of the health groups in the region and has developed a network of communication and functional activity among medical centers, hospitals, and health agencies in the region, The awarding of $1,265,810 ' WRAP is me region has successfully terminated a number of its original three year projects by either receiving support from other sources, or because of unsatisfactory results. Appendix D of the current application describes the accomplishments and sources of funding of these terminated projects. in Detection and Management of Gp ecologic Malignancy,are projects Project #16,Medical Library,& Project #20,Action Program W has improved the extent ad quality of its evaluation pyocedures responsibility for and has been actively involved in conducting project site visits and developing methods to produce "outcome" data rather than theoretical information. Evaluation is now built into projects during the initial stages of their development. The region's review process was the subject of a June 13, 1972 visit. It was found that the mechanics of the WVP review process generally meet the minimum standards ; however, it was recommended that provisional certification be given pending implementation of staff's recommendations and suggestions which relate to: (1) conflict of interest; (2) feedback letters; (3) provi- sion of review criteria to potential applican$s; of the r gionIs byelaws; and (5) provision of written review criteria to technicaf reviewers. by the establishment of a Review and Evaluation Committee which has the (7 '.-.-- .;:-;y 1 (4) re-examination The region has expanded the membership of the Corporation from its original three to a total of nine members. tW reassessed its utilization of developmental component funds in light of its present objectives, and have defined in greater detail its intent and purpose in developing program meas for developmental component funding. funded; five of these have been approved by the RAG for extended support and appaar in the project section of the current application. Areas of activity include delivery of primary health care, and monitoring the quality of health care. During the past year, seven activities were During the past year, increased efforts have been made in furthering effective comications and collaborative efforts in program plming and development with the state areawide CHP agencies. WRJP provided assistance to the Northeastern HFC in preparation of an application for a project with the Menminee Indians and has consulted with this HPC about cardiovascular surgery needs and neighborhood clinics. Consultation ad assistance has also been provided at the request of the 0 agency of Southeastern Wisconsin, on matters relating to require- ments of Cardiovascular Surgery. Foundation of Wisconsin, the WRW convened a conference to identify the components of an effect-ive community action program to ,deal with the problems of sickle cell disease, established guidelines for such a program, and have since provided consultation to the Medical Society of Milwaukee County and the United Cormunity Services of greater Milwaukee about sickle cell comity action programs. In collaboration with the Johnson Issues bquiring Attention of Reviewers: The basic issue is whether the WRMP shorrld be approved and funded at the level requested in the current application. for $2,176,615 including $200,898 for devel-o@eatal component funds. The region-is currently funded at its NAC approved level of $1,779,072. Recornended funding for the developnent component should be based on this level. The request is If the region is approved and funded in the amount requested, it will be able to continue its basic prograa-as oG-t€5i8 -iii''%e- ccfrenf application, provide salary increases for program staff &nd initiate eight new activities which for the most part will provide services and health care needs to areas of the state which have in the past been neglected. A staff review will be scheduled arid if additional issues are raised '-- *L- -th;nrt nf a SeDarate document. -13- Staff Observations Principal Problems : Prior to the submission of the W's Triennial application, a site visit was conducted which revealed problems related to: (1) the lack of objective methods of evaluation (2) the.inadequate representation of racial minorities on the RAG and a lack of minority representation on rogram staff minority program members, and only one minority (black) representative on the RAG) (3) lack of sufficient depth of the program ~taff (4) the extent of subregionalization efforts, especially in the . rural northern part of the State (5) developmental component request too broad and all encompassing, lacking specificity as to how the funds would relate to priority needs (6) The three-member corporation is not large or broad enough to govern such a large program as the WRMP, Inc, (This still remains to be a problem, as t fi ere are still no racial Principal Accomplishments: wRI4p's Triennial Application reflected a definite response to the specific problems , concern and recommendations of the reviewers. The region has added depth and strength to the program staff by the addition uf a Physician Associate Coordinator for Program Development and Evaluation (Madison WRMP office) , a Deputy Coordinator for Regional Liaison (Milwaukee WRMP office) , and a field representative who serves W as liaison in the North Central area of Wisconsin. His efforts have been directed towards promoting and providing assistance in the development o'f collaboration and service sharing irmong the rural hospitals, particularity in the rural areas of Northern Wisconsin, He has worked successfully with the hospital administrations in the area and has identified opportunities for improved cooperation among these hospitals, As a result of these efforts, seven participating hospitals, working through a non-prof it corporation are in the process of merging to share services and to combine health care services in an effort to provide more comprehensive services and to improve the quality of services that is so urgently needed in this has improved its subregional efforts by establishing cooperative relationships with some of the large proprietary clinics, namely, Marshfield and Gunderson. the Marshfi-eld Clinic have designed a proposal to establish the concept of regionalization by providing a variety of medical and laboratory senrices to the small rural hospitals in the North-Central area of Wisconsin. It is anticipated that other health care delivery systems within the central Wisconsin region will also participate in the provision of outreach services to these rural areas. As an example, WRMP and staff members of ,. .. ,_ - .-. .-,~. i.^ .- ................... ... .... ......... ... ... ....... -_ ............ ..... ...... -, .................... 529,955 63,732 117,822 1,066,5C3 1,779,072 S25,SC7 I 2,1?6-, 615 1 7.7 2,572