grant CN - Connecticut Regional Medical Program//// TI - CRMP's seven-year march toward medical regionalization/G : special grant request for May-June 1973, "phase-out: grant 1973-February 15, 1974 - / Connecticut Regional Medical Program. IM - New Haven :/The Program,/l973- CO - v. ::ill. CA - WA 540 AC8 C8ca:O2NLM EL - FULL LEVEL IT - BOOK IN PARTS MT - CORPORATE NAME MAIN ENTRY DA - 760815 UI - 7609246 request for July 1, . Connecticut Regional Medical Program . . Connecticut Regional Medical Program 272 George Street New Haven, Conn. 06510 (203) 772-0860 CRMP'S SEVW-YEMMARCHTOW~MEDICAL REZIOI'L4LI~TIOlV SPECti GRANT RE&UEST FOR MAY - JUNE 1973 "PHASE-OUT" GRMJTREQUESTFOR JULY1,1%'3 - FEBRUARY15,1974 March 15, 1973 VOLUME I SuMMARYEDITIrn VOLUME II DETAZUZDBUDGETRFQUEST A companion volume to the Summary Edition which contains detailed program and budget information Connecticut Region&L Medical Program 272 George Street hew -yen, Connecticut 06510 . (203) 77200860 TRANSMITTALS PROGRAM DEVELOPMENT BUDGET REQUESTS PROGRAM EVALUATION . VOLUME I SUMMARY EDITION CONTENTS Statement of Advisory Board Grant Application Forms CRMP's Seven-Year March Toward Medical Regionalization Special Grant Request for May-June 1973 Introduction Summary Budget "Phase-Out" Grant Request for July 1, 1973 - February 15, 1974 Introduction Summary Budget Approach to Recent Review Activities Panel Reports: An Assessment of CRMP Programs - University Medical Center Regional Activitik - Community Hospital Full-Time Chiefs Program - Research and Planning Activities The Impact 'of CRMP on: - The Medical Practitioner - The Community Hospital - The University Health Center 5 11 15 37 39 43 47 49 51 Us 55 58 63 65 68 I~He, MIUULC I UWN rmC33 The home newspaper of the Southern Connecticut Valley 472 MAIN STREET MIDDLETOWN, CONN. 06457 0347-3331 Russd G. D'Oench, Jr Editor March 15, 1973 Harold Margulies, M.D. Director Regional Medical Programs Service Health Services and Mental Health Administration Parklawn Building 5600 Fishers Lane Rockville, Maryland Dear Dr. Margulies: I am writing to comment on the functioning of the Connecticut Regional Medical Program (CRMP) since my last letter of November 1, 1972; to discuss the reaction of the CRMP Advisory Board to President Nixon's budget message of January 29, 1973, which calls for a rapid phase-out of Regional Medical Programs; to describe CRMP's tentative plan of ac- tion in the circumstances; and to transmit two grant requests to "phase-out" CRMP which have been developed in the context of your instructions of February 1 and 22, 1973. One of these grant requests covers activities during May - June, 1973 and a second covers terminal activities during the July 1, 1973 - February 15, 1974 period. With regard to the functioning of CRMP since our report of November 1, 1972, it is pertinent that the Advisory Board has met three times since that date and the Executive Committee four times. The last meeting for both bodies occurred on March 8, 1973. In addition, all members of the CRMP Executive Committee and many other members of the Board participated extensively in the two-day site visit by RMPS which was conducted on December 13-14, 1972, at the request of CRMP. Furthermore, all of the approximately 60 program elements currently being supported by CRMP sub- mitted written progress reports on January 29, 1973, and an up-to-date evaluation of the effectiveness of those activities has been carried out. That evaluation was 'made by the CRMP Review and Evaluation Com- mittee, augmented by fourteen members of the Advisory Board (including five CHP (b) Agency designees), during February 1973. The detailed ap- proach to this evaluation is set forth in a letter of March 6, 1973 to me from Chairman Howard Levine which is contained in this Report. The full results of this month long evaluation process were presented in a preliminary form to the Advisory Board on February 27 and in a final form on March 8. They contributed heavily to the official Board de- cisions which are- reflected in this Report. 5 liarold Margulies, M.D. March 15, 1973 In summary, the recent CRMP review activity confirmed the fact that the vast majority of CRMP-supported activities are -king outstanding con- tributions to the health and welfare of the citizens of Connecticut. A few need some fresh stimulus and help from CRMP and three were recom- mended for termination of CRMP support on April 30. As a part of the discussion at the Advisory Board meeting of March 8 six members of the CRMP Review and Evaluation Committee--all prominent members of the Con- necticut health community--made statements about the impact of CRMP on the Connecticut health scene. Their observations were considered so cogent that they are included in this report. . CRMP is convinced that Connecticut needs a continuing coalition agency of health providers and community spokesmen which has the expertise to recommend health policy and which has the capability to stimulate and help activate programs across organizational lines to meet the larger health needs of the people of the State. CRMP is fully prepared, therefore, to continue and grow as a major con- structive influence in the health affairs of Connecticut during the whole of 1973-74, through the implementation of the plan-of-action set forth in its grant request of November 1, 1972. That over-all plan was strongly reaffirmed by the recent round of CRMP review, since the modi- fications proposed related to details, not to the basic program. In this connection, too, CRMP was pleased to receive, on February 22, 1973, a "draft advice letter" from RMPS, stemming from the RMPS December site visit and subsequent review. Your letter gave, overall, strong endorse- ment to the CRME' program, offered suggestions as to priorities of program implementation, and indicated that the National Advisory Council had ap- proved a funding level of $2,332,820 (direct costs) for 1973-74. This would be a substantial increase over the current level of funding. Against this background, CRMP has felt dismay at President Nixon's budget message of January 29, 1973 calling, among other things, for a rapid phase * out of Regional Medical Programs. Our dismay has deepened with the passing weeks as the dialogue between the National Administration and Congress on the role of the federal government in the health field has unfolded, re- vealing a dichotomy in points of view and an inadequate plan on the part of the Administration for meeting the health needs of the American people, I have been instructed by the CRMP Board "to make a vigorous protest to Mr. Caspar Weinberger, Secretary of HEW, and to the Regional Medical Pro- grams Service on the plan and on the time schedule for phasing out Regional Medical Programs." I make that protest now to RMPS and wish to stress the following points: A. CRIQ cannot judge to what degree the 56 RMPs across the United States have been ineffective, as charged by the Administration. CRMP is well aware, however, that the functions assigned to RMPs by the Administration have often been vague and have undergone repeated revision since enactment of PL 89-239 in 1965; that the fund& made available to RMPs have been constantly fluctuating and 6 Harold Margulies, M.D. March 15, 1973 uncertain; that the problems in health care delivery which are now being addressed by RMPs are the most central and difficult health issues facing the American people; and that the leadership needed to staff and guide RMPs did not exist in 1965 but had to develop through experience. In the light of these circumstances the per- formance to date of many RMPs across the country has been commend- able and the performance of some RMPs, including CRMP, has been outstanding. B. In the CRMP view, the national Administration has not suggested any realistic leadership force as an alternative to Regional Medical Programs to work for top quality medical care to all citizens in an efficient way. No convening agency, other than RMP, has been proposed to bring together the various components of the health delivery system to work collectively for the ends mentioned. Per- haps the federal Administration is looking to state governments to fill the vacuum--drawing, possibly, on revenue sharing funds. If this be so, there are many uncertainties relating to the facts that legislation in this field has not been developed; that revenue sharing funds assigned to the states may not be large enough or made available for the task; that to date few states have shown any inclination to assume responsible leadership in this field; that there is a dearth of leadership in state governments to develop and guide such programs; that the tooling up phase would take several years; and that the Administration's plan of action to phase out RMPs would eliminate the only real source of expertese, forthwith, rather than preserving it as a resource on which to build a new approach, c. CRMP is deeply concerned with the precipitous phase-out for RMPs called for in the Administration's present time schedule. CAMP has an outstanding record in stimulating new programs which have become permanent fixtures on the Connecticut scene. CRMP staff have con- tributed greatly to securing matching money and sources of permanent financing for many projects L-as set forth in detail in the "Summary Edition" of the CRMP Progress Report of November 1, 1972. Yet'many yz program activities have to reach a point of maturity, or "proving themselves", before sources of permanent financing are willing to invest. The short time between President Nixon's announcement of a planned phase-out of RMP support and the date of stopping funds is not sufficient for some CRMP supported activities to gain'an alternate source of financing- though CRMP staff will make a valiant effort in coming weeks to be helpful in this regard. Yet the net effect of the precipitous "phase-out" may well be substantial waste of public money through the demise of some activities which are not mature enough to survive.. D. There is another reason to be concerned about the rapid phase-out plan. Most CRMP supported programs have emerged from study and planning activities in local communities which often cover a period of months, occasionally years, before the program itself gets under -ye The study and planning time is used to develop local under- standing of a health problem and a consensus about a solution. 7 Harold Margulies, M.D. March 15; 1973 When this local 'base building" is done thoroughly, the launching of the program itself usually proceeds smoothly and the success of the program is reasonably assured. The precipitous curtailment of HMP which is proposed by the federal Administration means that many plans-in-the-making, some near maturity, will not be implemented. This represents, again, waste of time, emotional input and money of many people and the dashing of hopes for a resolution to long existing health problems. In view of the total situation being discussed here, the CRMP Board re- cognizes three possibilities in charting current CRMP activity. First, the Board recognizes that, despite President Nixon's present plans to phase-out RMPs, Congress may well pass legislation and authorize ap- propriations to continue RMPs beyond the terminal date currently set and that, for various reasons, there may be an acceptance of this continuation by the Administration. In that event, as previously stated, CRMP has a complete plan of action ready for implementation during 1973-74. Second, the Board recognizes that President Nixon's plan for phase-out may well prevail and it has taken action to "authorize and support a full exploration of ways to continue CEWP through special funding from (a) foundations, (b) state government, (c) various federal agencies or (d) some combination thereof." After the current period of program review and decision making are complete and this report is submitted CHMP will turn :to that exploration. Third, the Board recognizes the need to comply fully with the HMPS re- quests of February 1 and 22 for a complete phase-out plan. This report is devoted largely to the presentation of such a plan, though, as has been true of all other CRMP Progress Reports to RMPS, it is also designed to serve the additional purpose of an official report to over 2,500 people who represent the primary constituents of CRMP throughout Connecticut. ,c The following pages, therefore, focus on four topics: A. There is a presentation of 'CRMP's Seven Year March Toward Medical Regionalization." This discusses the developments to date of CRMP's central thrust, which has been to create two networks of interlocking institutions and programs in Connecticut, with each of the two univer- sity health centers serving as hubs. In the CRMP view if these two systems are fully activated a high probability exists that top quality ,health care can be made available to all the citizens of Connecticut in an efficient way. B. There is a presentation of CRW's "Special Grant Request for May - June, 1973" which is designed to extend CRMp's present fiscal year ending April 30, to the end of the federal fiscal year, which Ferudnates June 30. CRMP has been advised by RMPS that a sum of $264,157 (direct costs) is available for the May - June period. 8 Harold Margulies, M.D. March 15, 1973 This is substantially less than the level of funding currently avail- able and also substantially less than the level recommended by the National Advisory Council for 1973-74-so, all CRMP supported ac- tivities are programmed for reductions, looking toward the completion of CRMP support on June 30 with very few exceptions. (C) There is a presentation of CRMP's "Phase-Out Grant Request for July 1, 1973 - February 15, 1974" which projects a step-by-step plan for termination of all RMPS support for CRMP activities. (D) And, as previously mentioned, there is a summary of the recent ac- tivity of the augmented CRMP Review and Evaluation Committee, along with assessments of CRMP's impact on the Connecticut health scene by six prominent citizens of Connecticut. One program and funding situation deserves special mention here. On June 8, 1972 you notified CRMP that RMPS was giving "three year approval, in the amounts requested" to assist in the operations of the Connecticut Institute for Health Manpower Resources, Inc. Subsequently the funds to cover the three years were transferred to Connecticut. CRMP feels it made a firm commitment to that agency, that funds are on hand to cover that commitment and, thus, CRMP is making no special request for that agency in this report. As you can tell from the above, CRMP faces a very busy schedule in the weeks ahead. We hope the federal Administration's plans to phase-out RMPS, as described in your telegram and letter, will change but we re- cognize that any change that occurs may not come until late spring. In the meantime CRMP staff and Board leadership will be seeking funds from a variety of sources to keep the central elements of CRMP alive and to finance many of the ongoing program elements on a permanent basis. In this connection, you will recall that prior to President Nixon's budget message of January 29 Dr. Henry Clark resigned as Director of CRMP ef- fective May 1, 1973. At that point Mr. Edward Morrissey, Associate o Director, will become Acting Director. I am pleased to report that Dr. Clark has agreed to remaid with CBMP as a Senior Consultant for a three-months period beginning May 1 in order to assist in the critical transitional activities of that period. If you have questions about any of this report, Dr. Clark, Mr. Morrissey and I will be pleased to comment. Chairman CRMP Advisory Board /lP . 9 ' DEPARTMENT OF HEALTH, EDUCATION, AN0 WELFARE Public HcJlth Service mlth Servicrs arid hlrntal Health Administration LEA'JE C!.AFIK - FOR HS!.tHA USE ONLY Plojcct Idcrrtikltion Number GRANT APPtlCATlON REG'IONAL r.:EDICAL PROGRAM Administrativa Codes ProSfan OJta . ,I, ffTLE OF ?WJECT lOR PRCGRAW (Ltmtr to 51 spores) CONNECTICUT REGIONAL MEDICAL PROGRAM 2. MA!,lE AN0 ,1'0!XEjS OF f~=Llc,\?1T ;s1rcct .\5rmhcr, SIrerr ,sarnc, CIIJ.* COUlll)`, 5: ::c' or cw7rr;`. ZlP Co&) Yale University 155 Whitney Avenue New Haven, Connecticut 06510 C3UG. 0lSTRk.r 3 May 1;1973 I June 30, 1973. I 7. PSIOUNT RECkJESTED F013 a. BUDGET PER:06 s 330,078 a EkWLOYER'S IOENTIFICATIGN MJMBER Uncludt lndircct Costs) $is #o6-06469-n 4. OlRECTOR OF FRCJECT ,`~%,:rzr,-nt or Cz,trer Director, . ChwiJtta~or or Autcig?:l irrscrtt~3or) : ka NAME (&XI. Fir:t. JliJJlc htrria/j Cl "'* .CLARK, HENRY T. JR.; M.D. 0 tsPtcl:Y~ . TITLE DIRECTOR DEGREE SOCIAL SECURITY NUMBER M.D. I ADDRESS (StrccI ,\iiJ?tbFr @ib.~ StIJJttw). SMW xumc, City. `Slorr fi I Cotttttryj, ZIP Code) 272 George Street' Hew Haven; Connesticut 06510 I 5. PROJECT PER100 (TRIEIUNIUhl) FRO!.1 (.\lo..,D.$. Yr.} 1 THHCUtiH (.!lo.. C+V. i'r.) I January 1, 1972 I December 31, 1974 I 6. BUDGET PERICO FROM pro., I>J,. Ji.) i THROUGH 1.110. firt.lv. .i'r.) I 8. FINAMXAL hlANAGE!.lENT OFFIdlAL TITLE Manager., Grants 8 Contractg Financial Administration . ADlXtESS (Street A'ttttther (or Box ,\`trttrbsr), &reel .%w:c. CiIy, Stan (or Courttry.!. ZIP Code) Yale University 155 Whitney Avenui New Haven, Connecticut 06510 ASSURANCES AND CERTIFICATIONS BY APPLICANT The following assurances and certifications are part of tl1e project gr3nt application and must be signed by an official duiy authorized to commit and wure tl1nt the applicant will comply witjl the provisions of the applicable I~ws, regulatidns, arid policies rcl3ting to'the project, The applicant hereby assures and certifies that he 11.3~ read and will comply.with the following: Title VI-Civil Rights Act of 1964 (PL 88-353) and Part 80 of Title 45, Code of Federal ReguMions, so th3t no person' will be cxcludcd from participation in, bc denied tl1.e benefits of, or be othekise subjected to discrimination on the grounds of r3ce, coJor, or nation31 origin. Patents and inventions (Current PIIS Policy Statement) under which all inventions made in tl1c course of or under any grant. shall be promptly and fully rcportcd to HEW. Specific assursnces, policies, guidelines, rcgul3tions and requirements in effect at the time the r;ranl a\v;\ld is made 3nd zppkablc to this project (including the making of reports ai required and the msintcn3nce of : necessary records and accounts. which will be made 3vail3blc to the Department of HEW for 3udit purposes) which are contnined 3nd listed in the grant application psckage and made a part hereof. I ~NATURES - Use Ink. Autographic signature of Official authorized to sign for ap$icant and Project Directorbr other person(s). author&d to sign in their behalf. FPLICANT NO, 1 (Name only) Yale University : .,: DIR ECTOR OF PROJECT OFFICIAL ~AUTHORtZED TO SIGN FOR APPLtCANT COMPLETE .FOR R'Mt% Oi\l LY ---- I I .- kiwis` Thomas, M.D. Dean, Yale University School of Medicine ISFC~Vti.,~~_~ . . . . . . ----L- .--I-- SiliNATjjJRE OF CHA!RMAN OF DRY GROUP j &,:*j'l:*.~ "/ A&;; *Russeli G. D'Oench,' Jr. --- --.____. -_, .---...---I- ----- DATE (MO., Day, Yr.) March 15, 1973 DATE (hfo., Day, Yr.) ` -iit%%= 1p71 M.D. --- DATE fMo, Day, Yr.) March 15, -1973 ; ---.-- GRANT. APPLICATION REGlOFJAL KCDICAL PROQRAZ~l New Rave& .ConneCticut . T:J. .\`o.. Ex;,w:~:ri mu Hn. CLARK- HF!NRY 3lTl.E I : DIREXTOR ii; p,-;`..> r h MGREE SOCIAL SECURITY NUMSER ,I. ,? i M.D. I I I 1 h-en-h1 30 --- -- .--/ `nESS. .___ * fi I cOlu1tryJ, %{p C&i e---V- _..- .`.`-.,, "..__. ..-...-, --.,, 272 Geohze Street Adminktrs:ivc Codes 5. PRO:ECI PERIOD (TRIENNILW FRO!.1 (Jlo.. DJ)`, yf'r.) ! TMHCUGH (!.!o.. I%;?.. rr.) January 1, 1972 I December 31, 1974 I 6. BUDGETP33ICD FROF.1 {.Vo., I?,,; j-f.) 1 THROUOH IS/o. C.W. y.-.) July 1, 1973 February 15,. 1974 I `1. E,\lOCNT.REQ~JESTED FOt4 o . BbDCETPER:OD $ 459,782 1 Utretude Indirect CorsJ TITLE Manager, Grants 0 Contracts Financial Administeation Yale University 155 Whitney Averiue New Haven, Connecticut 0651io 1 PROJECT lDENTIFICATION NO. ASSURANCES AND CERTIFICATIONS BY APPLICANT Thc.follorving assurances and ccr!ifications are part of the project grant application and must be' signed by an official duly authorized to commit and nssure thnt the applicant will comply with the provisions of the applicable laws, regulations, and policies rclnting to the project. The applicant hereby assures and certifids that he has read nnd will comply with the following: Title VITCivil Rights Act of 1961 (PL 88.353) and Part SO of Title 45, Code of Federal Regulations, so that no person will be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination on the grounds of race, color, or national origin. Patents and inventions (Current PIIS Policy Statcmcnt) under which all Inventions nr3de hi t!ic course of orundcr any grant shall be promptly and fully reported to HEW. Specific assurances, politics. guidelines. Tcgulations and requirements in effwl ill ihZ liw tili: $ihlit award iS I&irk! JiiJ ~pp~icablc to t!iiS I;iOjCC: (including the making of reports 3s required and the msintenzwe of : nccesssry records and accountsr which will .be n;sde available to the Dcpartmcnt of Hl?\V for audit purposes) which are contained and listed in the grant application p3ckage and made a part hereof. GNATURES - Use Ink. Autographic s;gnature of Official authorized to sign for applicant and Project Director ir other person/s) authorized to sign in their behalf. PPiJCANT NO. 1 /i\`on,c orrly) Yaie Ul niversitv D!RECb3R OF PROJECT OFFICIAL -AUTt4ORIZED TO SIGN FOR APPLICANT COn;lPLETE FOR RUPS ONLY School of Medicine ---e--e- -"--y 5 ROUP DATE (,Wo.. Day, Yr.) .March 15, 1973 DATE @lo.., Day, Yr.J March Is', 1973 DEGREE M.& DATE (-MO, Duy, Yr.) M&ch 15; 1973 -,---i. 14 CONNECTICUT REGIONAL MEDICAL PROGRAM 272 George Street New Haven, Connecticut 065 10 Telephone: 772-0860 Henry 1. Clark, Jr., M.D. Director March 15, 1973 CRMP'S SEVEN-YEAR MARCH TOWARD MEDICAL REGIONALIZATION Introduction and Brief History The basic objective of the Connecticut Regional Medical Program (CRMP) is to promote the delrvery of the best possible medical care to all 3,000,OOO citizens of Connecticut in the most efficient wsy. In order to reach that objective CRMP developed in 1968, as a first step, a clear set of program goals and a detailed plan of action to reach those goals. This "Grand Strategy" has been set forth in each of recent CRMP Annual Reports to the Regional Medical Programs Service (RMPS). It was last presented in the introduction to "The CRMP Story', a 250-page volume which was a part of the November 1, 1972 Annual Report to RMPS and was widely distributed throughout Connecticut. It is important here, however, to present again a brief history of CRMP and a statement of its central thrust as background for special grant requests to RMPS for May-June, 1973 and for July 1, 1973- February 15, 1974 b This should also be useful information for other agencies which may consider take-over of either the financing or the further promotion of activities which have been catalyzed by CRMP. The Connecticut Regional Medical Program was activated on July 1, 1966 under the joint sponsorship of the Yale and University of Connecticut Schools of Medicine. In 1968 its program direction was delegated to the Advisory Board, which is currently composed of 48 members who are broadly representative of the public and health interests of Connecticut. o Yale *' University remains the grantee agency. CRMP stems from the "Heart Disease, Cancer and Stroke' legislation of 1965 (P.L. 8g-239). CRMP leaders felt from the outset that the only effective approach to attacking these scourges was to address some basic problems in the organization and delivery of health care in Connecticut. e.g., proper care for residents of the inner city; proper care for the aging, especially in the 250 nursing homes of the state; better linkage between preventive and curative medicine; greater availability and better distribution of health personnel; and attentSon to the problems created by the high cost of health care. 15 The issues enumerated are matters in which no single agency or organiza- tion - then as now -- has prime responsibility for leadership. In 1966, therefore, CRMP convened spokesmen for the whole health establishment of Connecticut and organized an 18-month study of the deficiencies in the health delivery system. CRMP provided staff support to nine task forces which involved about 200 Connecticut citizens. Research backup was pro- vided by faculty of the School of Public Health at Yale. The plan of action which resulted was submitted to Washington on March 1, 1968 as CRMP's first "Request for an Operating Grant'. The Central Thrust The overall strategy of this plan was relatively simple. Based on studies conducted at Yale, the state was divided into 10 health service areas in order to promote local planning and problem-solving. This division of Connecticut was adopted by CRMP, Hill-Burton, Comprehensive Health Plan- nirig, the Connecticut Hospital Planning Commission, and other key state- wide health planning agencies. CR!@ recognized that a local coalition of health and consumer interests in each health service area is desirable to attack various local health problems. It recognized, further, that the CHP (b) agencies, when fully developed, should help serve this purpose, and it proposed to work with and through those agencies when they were well established. CFMP expected that it would take several years to establish effective CHP (b) agencies in all 10 health service areas (several of the [b] agencies are still in an organizational stage in lg'j'3), and felt that some interim mechanisms should be established which could work on selected local problems and which could feed into and support the (b) agency concept as that concept is fulfilled. In order to stimulate local planning, CR@ challenged each of the 33 short-term general hospitals of Connecticut to look outward from its four walls; to work closely with neighboring general hospitals and other com- munity health agencies and practitioners; to consider community-wide health problems in the inner city, in long-term care, in education of health person- nel, in prevention, and in rising costs; and to serve as leadersh+p forces ,~ in studying these problems and implementing programs to correct them. Beginning in 1968, therefore, CFMP proceeded to implement its overall pro- gram goals in the following ways: 1. Through the mechanism of CRMP staff visits and small and large con- ferences - and with the aid of spokesmen from other key Connecticut agencies and especially the Connecticut Hospital Association - CRMP sought to persuade the leaders of the medical staffs, trustees and administrators of the 33 short-term, general hospitals of Connecticut to consider transforming their hospitals into true community health centers with significant local outreach activities. 2. Once there was local hospital acceptance of this idea, CRMP helped to make available faculty experts from the Yale and the University of 16 3. 4. 5; Connecticut Schools of Medicine to assist local communities to identify and study local problems and to plan solutions. The early consultations by individual faculty members evolved over time into the creation of the CRMP-assisted Community Studies Units at the two universities. In keeping with the CR!@ overall plan, too, those community hospitals which met certain criteria became eligible for affiliation with one of the two University Health Centers of Connecticut. These affilia- tions were designed to foster top quality educational and patient care programs at the community level in a variety of ways. They established the framework for the regional coordination (regional- ization!) of many,health specialty programs such as high energy radiation, open heart surgery, emergency medical services, kidney dialysis and organ transplant services, library services, blood services and many others. In addition, they presented the universities with valuable new sources with which to round out and expand their own educational and research programs. One central feature of the affiliation agreements has been the joint appointment of full-time chiefs of key clinical services in the com- munity hospital. In the CRMP view, these men should provide needed medical leadership to foster expanded programs of education in the com- munity hospital, to oversee the quality and acope of the hospital's patient care programs, and to develop the hospital's outreach activities. They should aLso serve as local leaders to help plan and implement programs to coordinate many medical specialty programs on a regional basis. In order to stimulate the development of the two university-community hospital affiliation networks, CRMP has devoted much of its staff time and grant funds to programs which link physicians based in the two settings. However, taking advantage of the expanding affiliation networks, CRMP has also sponsored programs which have linked nurses, pharmacists, dentists and allied health personnel in the university d and community settings, looking toward expanding program activities in those fields which will improve the quality, accessibility, and ef- ficiency of patient care for the citizens of Connecticut. In addition, CRMP is currently stimulating some community hospitals and local health departments to coordinate many of their activities toward these same ends. The Current Stage of Implementation In early Summary Editions of its Annual Reports to Washington, CRMP dis- cussed program developments on each aspect of its "Grand Strategy". By 1972 this was not feasible since program activities stimulated and/or supported by CRMP had become very extensive and complex. Instead, on 17 November 1, 1972 CHMP published a 250-page volume - "The .CHMP Story" - which is a compendium of 91 weekly Newsletters that present detailed pro- gram developments from May 1970 to September 1972. Sotie of the program developments since that time are set forth in Volume II of this March 15, 1973 report. A revised and expanded version of "The CHMP Story" is anticipated for 1974 as one product of a sabbatical year which is in prospect for the present Director of CHMP. It is pertinent, however, to comment briefly here on the current stage of implementation of the Central Thrust of CHMP. Since 1968 over 150 studies have been carried out by university Community Studies personnel and other CHMP-supported researchers to assist local heslth leaders in Connecticut to analyze local health problems and to plan action programs to overcome them; furthermore, the demand and capacity for such studies is growing. Prior to 1968, there were no affiliations between the 33 community hospitals of Connecticut and the two University Health Centers; today 29 community hospitals are affiliated and discussions are in process involving three others. In 1968 there were six full-time chiefs of clinical service in three community hospitals; in March 1973 there were 57 additional chiefs at work (30 being supported, in part, by CHMP) in 20 hospitals. Furthermore, in March 1973 there were 21 joint university- community hospital search committees seeking new chiefs, with seven of these to fill positions in hospitals which had not previously had a full-time chief. The January 1973 progress reports by the 30 CPMP-supported chiefs - and the subsequent site visits to seven hospitals - indicated that re- markable progress is occurring in converting community hospitals in Connecticut to true community health centers. And these same reports, plus others from regionally-oriented faculty based in the two University Health Centers, indicated that extensive joint educational, patient care and research activity is developing in many settings in the context of the af- filiations. Altogether, a solid base has been built for medical regional- ization in Connecticut - and this represents a very significant accomplishment of CHMP's 1968 program objectives. Attention should be called at this point to the charts which appe& at " the end of this statement. They depict the annual growth in the develop- ment of the two affiliation networks and in the appointment of full-time chiefs from 1968 to 1973. Some Other Accomplishments Several other "accomplishments" of CHMP are less tangible and less subject to measurement. However, they are no less real, and they are very important to the continuing improvement of health services to all the people of Con- necticut. The following paragraphs indicate the nature of those "accomplish- ments". 1. Prom its beginnings CHMP has sought to transform community hospitals from dormitories in which skilled technical services can be rendered 18 to the patients of community physicians to social instruments con- cerned with planning and implementing prcrams, in conjunction with health practitioners and other health agencies, to meet the total health needs of their communities. In the CFW view, there has been a remarkable attitudinal change in this direction in about three- fourths of the general hospitals of Connecticut, and some progress in this respect in the other one-fourth. 2. From the beginnings, also, CRMF' has sought to persuade the two Uni- versity Health Centers to become the central elements in an integrated health delivery system serving all the people of Connecticut and, furthermore, to expand some of their teaching and research activities into various community settings. In this undertaking CRMP had strong support from a few faculty members at each university center. How- ever, many more faculty members were wary of the "burden" the univer- sities would be assuming and fearfulthat the new relationships would produce responsibilities which would dilute the effort of the univer- sities in their traditional roles as teaching and research centers. During the last few years the early faculty advocates of greater uni- versity involvement in the community have been joined by many colleagues who have discovered that the community setting, when properly developed, offers expanded opportunities for research and for the training of university students. Other university faculty members have either not been willing to venture into the community or remain skeptical of the benefits to their departmental activities. Overall, however, there has been a substantial attitudinal change toward greater university involvement with community elements. 3. The constructive influence of the individual full-time chief in his hospital and in his community is discussed extensively in other sections of this report. It is interesting to speculate, however, what the collective impact of the chiefs will be, in'time, on the medical affairs and medical politics of Connecticut. The Connecticut State Medical Society (CSMS) has, officially, strongly opposed CRMF in its efforts to promote the establishment of the full-time chief system in the com- munity hospitals of Connecticut. In contrast, the majority ofathe practicing physicians of Connecticut seem to favor the CRMP point of view, in that they have helped to implement various CRMP goals in their own communities, have voted to establish the full-time chief system in 27 hospitals and have participated in the selection of the new chiefs. These chiefs have medical competence, leadership ability and, collec- tively, a more liberal point of view than that represented by the Council of CSMS. Hopefully, CSMS will involve these men in its affairs and listen to their advice. In any event, CRMP has helped t.o create an additional source of medical leadership in Connecticut. 4. During the past three years CRMP has created a review mechanism which has proved very competent in assessing the effectiveness of the pro- grams it has supported. Many governmental agencies and foundations have good mechanisms to judge the "promise" of a given program, through . ln a combination of reviewing a written grant request and of conducting site visits by peers. Few governmental agencies and foundations con- duct adequate follow-uy! examinations, however, to determine if pro- grams are being implemented effectively. Since early 1971the CRMP Review and Evaluation Committee, made up of 24 distinguished members of the Connecticut health community, has reviewed progress reports from CRMP delegate agencies on at least an annual basis and has sent over 200 site teams to visit programs in operation in their local settings. This overall review has resulted in a few early terminations of CRMP program support, some changes in program direction, and a great deal of stimulus and constructive suggestions to promote more effective program development. 5. Psrticulsrly heartwarming to CRMP leadership as an "accomplishment" has been the progressive recognition, since 1966, of CRMP as a creative force on the Connecticut health scene and growing acceptance of its leadership by most local and statewide health agencies. This point is amplified by several of the panelists whose statements of March 8, 1973 are contained in this Report. 6. Perhaps the greatest "accomplishment" of CRMP has been to demonstrate that medical regionalization can work in the United States despite the limited success of past ventures in this ff&ld. Using the "carrot and stick" technique and with a great deal of dedication and hard work, a relatively small group of professional and lay leaders, functioning in the public interest, launched a program in 1966 to overcome vested interest, inertia and institutional pride and build the framework for a more effective health care system in Connecticut. Their initial suc- cesses brought new converts to help with the task. The collective results of their effort are presented in this report. Potentials for the Next Three to Five Years The CRMP Triennial Application which was submitted to Washington on August.l, 1971 projected program developments through 1974. Thus, the following comments, which suggest potentials for program development 4 through 1978, are unofficial and represent only a fragmentary and topical presentation of what "might be". Yet, the examples cited build on the existing program base which CRMP has helped to establish and they are, for the most part, logical extensions of existing programs. ': " For the months immediately ahead, one objective should be to extend uni- versity health center affiliations to the four community hospitals that do not have them now. A corollary of this is to gradually expand the col- laborative effort between the University Health Centers and each of 33 community hospitals in the fields of patient care, education of health personnel and research. The presence of two University Health Center- community hospital affiliation networks in Connecticut provides the "skeletal" framework on which to build qualfty, accessibility and ef- ficiency of health care to all citizens. As collaboration between specialty services in the university centers and their counterparts in the community goes forward, the program "substance" is added to the "skeletal" framework. The prototypes of these linkages are already developed in the fields of gastroenterology, diabetes, kidney disease, blood services, library services and newborn care. But these systems need to be more fully developed - and systems involving many other medical specialties have hardly been started. Another early objective should be to increase the number of full-time chiefs of service in several of the 20 community hospitals in which chiefs are currently functioning; to extend the full-time chief concept promptly to seven additional hospitals where the policy has been approved and search committees are at work; and to stimulate the adoption of the full- time chiefs program in the six remaining general hospitals which have not yet approved the policy. Working with and through the chiefs of service, CRMP should put more emphasis on peer review and the establishment of local standards of quality of care. In this connection, too, CRMP should assist the chiefs of service and, where appropriate, the CRP (b) Agencies to study local health care problems and, in turn, assist the community hospitals or other appropriate local agencies to implement programs to overcome those problems. In a related field, CRMP should promote the functioning of the Connecticut Institute for Health Manpower Resources and the Yale Office of Allied Health Manpower to the end that the needs for health personnel in the various health service areas will be determined and local educational con- sortia developed to train those personnel. During the next three to five years CRMP should also.develop greater liaison with a number of voluntary health sgencies in the fields of heart disease, cancer, respiratory diseases, etc. which are well established organizations with a noble history of service in Connecticut. Greater participation in the development of medical regionalization in Connecticut would likely give new purpose to some of these agencies. And part of the costs of some local "outreach" programs could probably be provided&by u: these agencies. Since 1966 the Connecticut State' Commissioner of Health has been intimately involved in directing CRMP affairs. Since 1968 the Commissioners ,of Mental Health, Welfare, snd Community Affairs and the Chancellor for Higher Education have also been members of the CRMP Board. The relation- ships between CRMP and the several State departments have always been cordial - but joint program activities between CRMP and those departments have been limited, with a few notable exceptions. CRMP has focused to date mostly on stimulating program developments in the voluntary sector where indeed, most of health care to citizens is given. During the next three to five years, however, CRMP should undoubtedly develop more pro- grams in collaboration with official agencies. For example, CRMP should continue to assist in implementing a statewide program of Emergency 21 Medical Services, though the prime leadership should be assumed by the State Department of Health. As another example, CRMP might help to catalyze university relationships with some of the state-supported long- term-care hospitals, somewhat along the lines of the university-community hospital affiliations. Finslly, during the next three to five years CRMP should give increasing attention to the costs of health care and, particularly, to financing the basic costs of medical regionalization. A full study is needed to determine what the basic costs of medical regionalization properly are or should be, but they include at least the following: the costs of a centrsl staff (such as the CRMP program staff) which can serve as con- ceptualizer, convener and catalyst for program development; the costs of two university offices to promote the workings of the affiliation net- works; the costs of a research staff which can study the key regional or state-wide health problems; and the provision of some "challenge" funds with which to help launch selected demonstrations of new health programs. Some of these costs of medical regionalization may be obtained from federal grants; some may be obtained from local or national. phil- anthropic foundations, but the basic continuing financing should undoubt- edly come from the state. It should be recognized that the activities under discussion are those concerned with.promoting an efficient and ef- fective health delivery system for Connecticut. The costs of these activi- ties would very likely be less than one half of one percent of the total annual expenditures on health services in Connecticut. The past function- ing of CRMP is a partial indication of what "might be" for the future in this connection. What Will Remain if CRMP Phases Out? The CRMP Report of November 3, 1972 to the Regional Medical Programs Service (Volumes I and II) describes a large number of programs which CRMP stimulated and helped finance during the pretious six years, which have proven their value and which have become permanently established on the Connecticut scene through alternate sources of financing. ' & Similarly, this present report to IMPS requests mds to continue several key activities currently being supported by CRMI? for several months while permanent financing is being phased in. Included in this category are the Community Studies Unit in the two University Health Centers, the Of- fices of Regional Activities in the two University Health Centers and five "categoricalfl regional programs in the fields of gastroenterology, diabetes, kidney disease, emergency medical services and library services. In addition, and very important, CRMP anticipates most of the university- community hospital affiliations will remain in force. Furthermore, it ap- pears that all of the full-time chiefs currently on hand will be continued by their parent community hospitals. And hopefully, many of the. attitud- inal changes discussed above will continue if CRMP phases out. 22 What Will Be Lost if CRMP Phases Out? If CRMP phases out, as President Nixon proposes, most of the programs projected above for the next three to five years will probably not materialize. The CRMP review mechanism which has contributed in such a major way to program performance -- and the assurance that public funds are well spent - will cease to function. CRMP staff, who have served as conceptualizers, catalysts and consultants to many program activities, will take other positions. The common meeting ground which CRMP has pro- vided to bring together the various parts of the health establishment of Connecticut to plan and function together in the public interest will disappear. And in the absence of the catalytic effect of CRMP some of the attitudinal changes discussed above may retrogress. Concluding Comment On March 8, 1973 six prominent members from the Connecticut health scene who are all members of the CRMP Review and Evaluation Committee, were in invited to present their views to the Advisory Board on the effectiveness of programs currently being sponsored by CRMP and on the impact of CRMP as a whole. Their statements appear in this Report and they amplify the above discussion. , At its March 8, 1973 meeting the CRMP Advisory Board voted to protest to HEW Secretary &spar Weinberger the Administration's present plans to phase-out'federsl. support for Regional Medical Programs. The Advisory Board voted further to take steps to encourage Congress to continue Regional Medical Programs. The Board also voted to explore possible alternate sources of financing for continuing CRMP, including state govern- ment, foundations and federal sgencies. CRMP staff is at work on all this but will need the help of Board members, individually and collectively, in the weeks ahead. 4 ??????? o Henry T. Clark, Jr., M.D. Director . 23 I( x tr 0 > 3 z" I SHARON 0 MASSACHUSETTS PUTNAM 0 Northeast WINDHAM f--b' NEW MILFOR f Millions Middletown Southeast llcll \ 7 NEW LONDON M'LFoRo AFFILIATION AGREEMENTS-1968 Urn Corm Medical Center 0 .:@$. Yale Medical Center `o~~/\~c/ UNIVERSITY-COMMUNITY HOSPITAL 24 CONNECTICUT REGIONAL MEDICAL PROGRAM MASSACHUSETTS HARTFORO oocloo ROCK"" \ SHARON TORRINCTON 0 0 0 PUTNAM Northeast WINDHAM NEW M LFORO Y r Danbury 70 I: 0 cl m ii r 9 z u lMr fWICCC*',lQtZQ rum- I IITK ww-I 3 - IJUU o Short-term, General Hospitals On Hand *Includes Full-time Chiefs of Staff, Medicine. Surgery, Pediatrics, Ob-Gyn, Psychiatry 25 CONNECTICUT REGIONAL MEDICAL PROGRAM . K (II 0 t 3 z" I SHARON O- DANBURY I - I DERBY PUTNAM 0 V- South Central NEW HAVEN A YALE " / WINDHAM MIDOLETOWN Middletown Southeast NEW LONOON ? tkdr/)h. -' UNIVERSITY-COMMUNITY HOSPITAL AFFILIATION AGREEMENTS- 1969 2' @ .<;; .;.. ,$$$#< ter 1. 26 CONNECTICUT REGIONAL MEOICAL PROGRAM MASSACHUSETTS n rrthwmt- I NO I Lll1VU3h SHARON TORRINGTON 0 0 I U. CONN fl /s NEW MILFORD o PUTNAM Northeast WINDHAM 1 Danbury ( Waterbuy sou Southeast ~11~11~ P NEW HAVEN IEFS*-19@ o Short-term, General Hospitals Pre-existing New Positions r. *Includes Full-time Chiefs of Staff, Medicine, Surgery, Pediatrics, Ob-Gyn, Psychiatry 27 CONNECTICUT REGIONAL MEDICAL PROGRAM MASSACHUSETTS PUTNAM 0 -n HARTFORD 0 SHARON TORRINGTON -hP#- A - Wt.0 Northeast WINDHAM AFFILIATION AGREEMENTS-1970 ~ primary -1 preliminary 28 CONNECTICUT REGIONAL MEDICAL PROGRAM MASSACHUSETTS x tr 0 > 3 z" Northwest' SHARON TORRINGTON 0 0 0 PUTNAM 0 ROCKVILLE J Northeast WINDHAM A NORWICH Southeast L-TIME CHIEFS*- 19 70 o Short-term, General Hospitals , 1 New Positions *Includes Full-time Chiefs of Staff, Medicine, Surgery, Pediatrics, Ob-Gyn, Psychiatry CONNECTICUT REGIONAL MEDICAL PROGRAM 29 MASSACHUSETTS STAFFORD I Northwest TORRINGTON HARTFORD 0 SHARON ' - 0 1 DANBURY AFFILIATION AGREEMENTS-1971 u - . U. Corm Medical Center Yale Medical Center ~ primary ~ primary n Allied ni preliminary 30 CONNECTICUT REGIONAL MEDICAL PROGRAM MASSACHUSETTS 0 PUTNAN NEW LONDON R FULL-TIME CHIEFS*-1971 , o Short-term, General Hospitals New Positions 11 ff Pre-existing V New Positions Filled or Scheduled Authorized with Search Committees *Includes Full-time Chiefs of Staff, Medicine, Surgery, Pediatrics, Ob-Gyn, Psychiatry JJ 1 0 u m ii r 9 z u ^_ CONNECTICUT REGIONAL MEDICAL PROGRAM MASSACHUSETTS STAFFORO PUTNAM 1 AFFILIATION AGREEMENTS- 1972 UNIVERSITY-COMMUNITY HOSPITAL . U, Corm Medical Center m Primary ::::::::.:p..:.:.:.: :. Yale Medical Center ~ primary Ln$ preliminary :. 32 CONNECTICUT REGIONAL MEDICAL PROGRAM x rK 0 > 3 LLJ z MASSACHUSETTS Northwest o 1111' .I Uanbl m . I I WATERBURY 0 @j 70 1 0 CJ m m r- 9 z u -TIME CHIEFS*-1972 o Short-term, General Hospitals Pre-existing New Positions Filled or Scheduled 6 New Positions Authorized with Search Committees `Includes Full-time Chiefs of Staff, Medicine, Surgery, Pediatrics, Ob-Gyn, Psychiatry Professional Services, Ambulatory Services x [r 0 > 3 w Z MASSALHUSt I I S STAFFORO Northwr U. CONN // ) PUTNAM 1 DANBURY < HOSPITAL AFFILIATION AGREEMENTS-1973 March 15, 1973 U. Corm Medical Center Yale Medical Cenl ~ primary E-4 Allied ~ primary k-4 preliminary :er 34 CONNECTICUT REGIONAL MEDICAL PROGRAM x [r 0 > ? LLI z WINSTEO MASSACHUSEu s 6x4 4 4 Capitol 0 LJ -. PV..?. .._-- --_- * ROCKVILE f 88 YV I 1 1 Northeast P-l I - / NORWICH `-I'! V V V' II FULL-TIME CHIEFS*-1973 2J 1 0 XJ IT ii I- 9 7 u March 15, 1973 o Short-term, General Hospitals Pre-existing New Positions Filled or Scheduled New Positions Authorized with Search Committees 35 `Includes Full-time Chiefs of Staff, Medicine, Surgery, Pediatrics, Ob-Gyn, Psychiatry Professional Services, Ambulatory Services CONNECTICUT REGIONAL MEDICAL PROGRAM 272 George Street New Haven, Connecticut 06510 Telephone: (203) 772-0860 SPECIAL GRANT REQUEST FOR MAY-JUNE 1973 Henry T. Clark, Jr., M.D. Director Introduction mrch 15, 1973 This statement and the following summary budget data have been prepared in response to Dr. Herold Margulies ' telegram of February 1, 1973 in which he discussed the impact of President Nixon's budget proposals to Congress for Fiscal `74 on Regional Medical Programs and asked for a detailed plan to phase out the activities of the Connecticut Regional Medical. Program (CRMP). Dr. Margulies indicated that the CRMP plan was to be submitted by March 15, 1973 in two parts : Part one to cover the phase out of most program activities by June 30; part two to continue activities meeting certain criteria after June 30 "but in no event beyond February 15, 1974". This statement covers part one; a following statement covers part two. This statement has also been prepared in the context of (a) advice from Ms. Eileen Faatz, the CRMP liaison officer on the RMPS staff, of Februsry 12; (b) instructions relating to plans for phasing out RMPS which are contained in a letter of February 22 from Dr. Mergulies; and (c) program and policy position of the CRMf? Advisory Board which are presented in the statement by Chairman D'Oench that transmits this report. St is pertinent that under RMPS direction CRMP functions on a fiscal. year which ends on April 30. The first question CRMP faced on receipt of Dr. Margulies' telegram of February 1, 19'73 was whether funds assigned by CRMP to its delegate agencies for the current fiscal year should be reduced in some across-the-board or selective manner. The decision was to continue s&l of these programs at current levels through April 30, 19'73 with funds on hand for the following reasons: (a) e3.l programs needed and deserved at least three more months to work toward fulfilling their program goals and thus demonstrate their full potential-s; (b)' all programs needed and deserved at least three more months to begin to explore alternate sources of funding based on this demonstrated performance; and (c) all programs needed time to honor commitments to personnel in terms of vacation, due notice, etc. With that decision made, the next question became how to develop and imple- ment a reasonable set of program priorities and budgets, in the circumstances, for May-June 197'3, recognizing that June 30 is the end of the feder&L f5scel year and is s&so the federal target date for completion of all regular IIMP activities. CRMP obtained assistance in this splgre on February 12 when Ms. qleen Faatz telephoned to indicate that $264,152 (direct costs) was a~lable~ to C!B$P during MaJr-JLme to cover phase-out activities. CRMP was further aided in late February when Dr. Margulies' letter of February 22 arrived giting more detailed guidance on preparing phase-out plans. . 37 March 15, 1973 In planning these programs and budget requests for Msy- June 1973 and for the July lg3-February 1974 period CRMP was favored by one fortunate coincidence. In December 1972 CR?4P requested progress reports from delegate agencies covering all CRMP-supported programs, with a submission date of January 29, 1973. Furthermore, C!R?4P had projected a complete review of each CRMP-supported program based on these progress reports and augmented by site visits during February and early March 1973. Indeed the CRI@ Review and Evaluation Committee was in session on February 1 to launch this activity when Dr. Margulies' telegrsm arrived. The contemplated review went forward in a modified form (aided by 14 Board members) and it is reported in other sections of this report. The fact that this activity was put in motion in December has meant that an orderly process could be followed in developing this report. In making judgments on funding levels for various CRMP program elements for May-June 1973 the CRMP Board was quite conscious that the anticipated $264,152 was substantially less than the lfl2-l9'73 level of grants from RMPS and also sharply below the level recommended by the National Advisory Council for 1973-74. The Board was anxious to give all programs which were judged to be proceeding in an effective way toward their program objectives as much support as possible for as long as possible -- (a) so that they could demon- strate their potential value to their communities, (b) so that as a conse- quence they could develop alternate sources of financial support and (c) so that they could make appropriate plans to continue or, otherwise, find placements for existing staff. In this total regard, the Board recognizes President Nixon's current emphasis on,economy in federal government. CRMP feels, however, that supporting selected worthy activities in the field of human service for a few weeks to the point of viability is a greater economy than terminating these activities abruptly and thereby wasting previously invested public funds. We believe President Nixon would consider this reasonable. The Board was also conscious that CRMP has an excellent record of obtaining matching money and "take over" support for its projects (as reflected in the November 1, 1972 Summary Report to RMPS) and it can continue to perform well in this regard if given reasonable time. o ??? In order to develop a budget for Mey-June 1973 based on $264,152, the CFMP Board adopted a set of 10 criteria which included but went beyond those set forth by RMPS. In applying those criteria, support for three on-going programs is scheduled to be terminated April 30; four programs which were to be activated Msy 1 have been notified there will be no RMEB support; snd all other programs are recommended for a reduced level of support, looking toward termination of RMPS grant assistance on June 30, except for the special activities described in the "Part Two Request" which follows. A summary of the CRMP Special Grant Request for May-June 1973 is presented in the attached table. The details of this request are presented in Volume II. 38 March 15, 1973 CONNECTICUT REGIONAL MEDICAL PROGRAM' ADVISORY BOARD REQUEST TO RMPS FOR MAY - JUNE 1973 . Program RESEARCH AND EVALUATION Community Studies Personnel, Yale University School of Medicine Community Studies Personnel, University of Connecticut School of Medicine Health Service Area Planning Assistance Joint Publication Series Regional Blood Bank Survey and Supporting Services Program, UConn. __ Connecticut Ambulatory Care Study HEALTH SERVICE AREA PROGRAM ASSISTANCE Community Health Services, Inc. 38,130 .21,170 21,170 Association of Community Health Service Agencies, Inc. 11,250 10,000 10,000 Shared Hospital Services Demonstration, Connecticut Hospital Association . 10,000 15,000 15,000 8334 Home Care Coordinator, Hospital of St. Raphael 12,000 39 9,000 9,000 : 1972-73 M 42,537' 42,509 42,509 7,085 38,500 48,398 5,000 36,115 --w-w -e-m- (25,000)3 --we- ---- 38,709 42,846 75,000 75,000 m-w-- ----w MAY-JUNE 1973 ADVISORY BOARD l.aRm1973 6,416 7,500 --- 3,510 1,666 7504 1972-73 P r 0 g r a m e Regiokl Hospice Development Program, Yale- New Haven Hospital Southcentral Connecticut Continuing Care Demonstration Program, Yale-New Haven Hospital The Connecticut Stroke Program, Gaylord Hospital Personal Health Services Planning Assistance, Southcentral Connecticut CEW, Inc. 22,080 65,000 30,000 22,000 Neighborhood Health Services, Hartford Citizens Health Action Council UNIVERSITY-COMMUNITY HOSPITAL PARTNERSHIPS Community Hospital Based Regional Faculty 435,000 600,000 600,000 75,000 33,750 University of Connecticut University Based Regional Faculty, UCOM; School of Medicine 150,353 196,744 196,744 25,000 University Based Regional Faculty, UConn. School of Nursing Regional Renal Diagnostic Program 10,871 24,029 Yale University University Based Regional Faculty, Yal& School of Medicine University Based Regional Faculty, Yale ., School of Nursing 135,000 25,000 40 1973-74 Budget Request From 11/l/72 Report 18,989 18,989 3,165 B---w w-v-- w---- -M-m- --- --m- 22,000 ---I -I- ---- ---w ---I 12,400 12,400 1,812 25,094 12,500 2,083 249,687 249,687 22,500 27,300 27,300 2,0834 Program Y+e Affiliated Gastroenterology Program Yale-Connecticut Diabetes Teaching and Consultation Program Connecticut Kidney Disease Program Regional Renal Diagnostic Program CLINICAL SERVICES Connecticut Regional Drug Information Service, Yale-New Haven Hospital HEALTH PROFESSION EDUCATION Connecticut Network for Medical Communications, UCOM. Health Center Allied Health Manpower Office, Yale-New Haven Medical Center Regional Library Services, Yale Medical Library Regional Library Services, UCOM. Health Center Regional Library Services, CRMP Consultation and Training Manpower Information Forecasting and Development System, Yale School of Medicine . 1972-73 w 45,554 29,055 133,533 23,192 30,000 16,000 14,000 16,000 2,333 28,104 55,000 55,000 10,083 7,333 7,333 10,083 7,333 7,333 12,164 -B-B 58,840 41 42,000 42,000 7,000 24,150 137,965 19,700 30,000 1973-74 Advisory Board Decisions March 8, 1973 29,076 118,642 19,700 30,000 MAY-JUNE 1973 ADVISORY BOARD REQUEST MARCH 15, 1973 4,025 18,261 3,250 5,000 4,684 1,222 1,222 -m--w ---we Program PIlOG& STAFF, CONNBCTICUT REGIONAL MEDICAL PROGRAM .PROGRAMS IN SPECIAL CATEGORIES Statewide Emergency Medical Services Developmental Component Regional Health Education Program, Yale New Britain Child Health Program Northern Connecticut Regional New Born Service 1973-74 477,737 477,737 57,752 19,000 208,250. -w--m 154,000 74,510 85,108 ---mm 80,000 --v-m- 31,000 TOTAL $264,152 1973-74 Advisory Board Decisions March 8, 1973 FOOTNOTES: 1. All budget figures presented in this table are direct costs only. 115,940 154,000 ---- 2. 3. 4. 5. 80,000 31,000 (3,351j5 -w-m -we-- All 16 months fiscal year budgets have been converted to 12 months to obtain a proper basis for comparison. Included in Health Service Area Planning Assistance. Support terminates May 31, 1973. Included in Program Staff, CRMP. 42 CONNECTICUT REGIONAL MEDICAL PROGRAM 272 George Street New Haven, Connecticut 06510 Telephone: (203) 772-0660 Henry T. Clark, Jr., M.D. Director March 15, 1973 'PHASE-OUT' GRANT REQUEST FOR JULY 1, 1973 - FEBRUARY 15, 1974 Introduction This request has been developed in the context of the previous discussion but, more specifically, in response to points (2) and (3) in Dr. Margulies' telegram of February 1, 1973, which are as follows: "2. Request continued support for only those activities re- quiring RMPS funds that will produce a predictable re- sult justifying the federal investment, or `3. Request continued support for those essential activities where a mechanism has been established to continue without interruption support of the activity from other resources.' In the discussion of "CRMP's Seven-Year March Toward Medical Regionalization" the central thrust of CRMP was presented in some detail. That report reviewed the creation and functioning of the~Community Studies Programs at both Yale and the qniversity of Connecticut. Faculty members from these two programs are available, on request, to study local health problems and to chart action programs to overcome them. Furthermore, these same faculty members have recently begun to evaluate the impact of various CRMP-sponsored programs on the Connecticut health scene. The report on "CRMP's Seven-Year March..." also discussed the workings of the Offices of Regional Activities at both Yale and the University of Connecticut in developing and building content into the two university-community hospital affiliation networks. Further- *' more, it discussed the expanding roles of conrmunity hospitals as leadership forces to improve health care for all citizens of their communities, and the roles as change agents being played by the growing numbers of full-time chiefs of service in those hospitals. And "CRMP's Seven-Year March..." described examples of regionalization of specialty services, e.g., gastro- enterology, diabetes, kidney disease, emergency medical services, and li- brary support programs which, in the aggregate, are designed to foster top quality medical care to all 3,000,OOO citizens of Connecticut in an efficient way. CRMP staff believe that about three more years of RMPS support is needed to carry the system of medical regionalization under development in Connecticut to that point of maturity at which its overall viability is assured. A fully established demonstration of medical regionalization in Connecticut would have major national and international value in promoting better delivery of . 43 health services to large population groups in many settings. The National Administration's present schedule for phasing out RMPS support eliminates some of the time needed for the optimum development of the Connecticut demonstration. Yet most of the key elements are in place in Connecticut and some of these probably can be carried to the point of permanent via- bility in the next few months. The institutional commitments are strong in this regard and CRMP's record of finding matching and take-over support for the activities it has sponsored, as set forth in detail in the Summary Statement of the November 1, 1972 Report to RMPS, is very convincing. In this general context-and particularly In the context of points "2" and "3" in Dr. Margulies' telegram of February 1, 1973,-a brief comment is pre- sented below on the programs for which RMPS support is requested for the July 1, 1973-February 15, 1974 period. The budget request for each program is shown in the table which follows this statement. Community Studies Personnel, 'Yale University School of Medicine and Community Studies Personnel, University of Connecticut School of Medicine Among the studies currently under way in these two CRMP-supported programs are the following. At Yale, community studies personnel are studying: (a) the organization of hospital-related pediatric services in Connecticut; (b) the potentials for establishing a regional health department in Darien, Connecticut; (c) criteria for determining the need for a nursing home in a given community; and (d) the desirable future direction of Connecticut's public chronic disease hospitals. At the University of Connecticut, com- munity studies personnel are examining: (a) the impact and significance of full-time chiefs of service in community hospitals; (b) the potentials for merging the New Britain Health Department with the New Britain Hospital; (c) problems involved in rendering Emergency Medical Services at Bristol Hospitals; (d) the possibilities for establishing a District Health Department in the -' Farmington Valley; (e) the potentials for establishing a primary care demon- stration in Windham County; and (f) the organization and delivery of services to the elderly through Hartford Neighborhood Senior Centers. All of these studies are being carried out for agencies capable of utilizing and/or implementing them. All should be complete--or at a point where they can be completed--by the time when CRMP's support is scheduled to terminate on January 31, 1974. The Community Studies.Units at Yale and UConn have proven their value to leading Connecticut health institutions and agencies. Their continuation after January 31, 1974 appears certain through some combination of univer- sity support, grant support , and fees for services rendered. . 44 Office of Regional Activities University of Connecticut School of Medicine and Office of Regional Activities Yale University School of Medicine The UConn Office of Regional Activities has played a major role in developing affiliation agreements between the University of Connecticut School of Medi- cine and seventeen community hospitals. The Yale office has helped stimulate affiliations between the Yale School of Medicine and twelve community hos- pitals. Within the'context of those affiliations both offices have worked to fill many full-time chiefs of service positions in community hospitals, to develop and expand more effective programs of education for medical students, interns and residents, and to promote regionalization of many specialty ser- vices. CRMP support for the university-based regional faculty and for the full-time chiefs of service in community hospitals is scheduled to end on June 30, 1973. It is essential, therefore, to keep in operation the two university offices of regional activities in order to provide stimulus and administrative support for the two university-community hospital affiliation networks. It seems clear that both of these two offices will be continued by the universities beyond January 31, 1974, when CRMP support is scheduled to end. Yale-Affiliated Gastroenterolony Program Yale-Connecticut Diabetes Teaching and Consultation Program Connecticut Kidney Disease Program Emergency Medical Services Regional Library Services, Yale Medical Library Regional Library Services, UCOM Health Center These are specialized, regionalized programs which have been discussed fully in previous reports and are discussed in some detail in Volume II of this report. Each is moving steadily toward full program development and toward financial self-sufficiency which will make it independent of CRMP assistance. In each case modest RMPS support is sought to maintain a few central elements ui of each program until early 1974. The needed "take-over" money will come from voluntary sources in the cases of the gastroenterology and diabetes pro- grams, from federal grants in the case of the kidney program, from the State and perhaps a philanthropic foundation in the case of Emergency Medical Services, and from a combination of fee-for-services and the National Library of Medicine in the cases of the twu parts of the library program. A period of time is needed in each case to finalize and phase in this 'take-over' funding. Program Staff As RMPS has noted repeatedly during recent years, CRMP has functioned with one of the smallest program staffs of any of the 56 RMPs: Nevertheless, .that staff has helped make it possible for CREiq to bring to partial fruition a very complex and ambitious program of medical regionalization in Connecticut. . 45 The broader aspects of that accomplishment are set forth in this volume; the details are given in Volume II of this Report and in the November 1, 1972 edition of The CRMP Story. The continuation of most members of the CRMP Program Staff through December 31, 1973, with RMPS support, is necessary to solidify the gains made in Con- necticut through CRMP influence, to work for take-over funds for on-going CRMP activities not mentioned above, to protite the implementation of studies currently being concluded, to help prepare final reports to RMPS and else- where, and to work for a continuing presence for RMP in Connecticut independent of RMPS financing. More detailed comments on each of the above programs are presented in Volume II of this report. In Volume II, also, there is a letter from the chief administrative officer of each agency for which funds are being requested during the July 1, 1973~February 15, 1974 period. , A budget summary table follows. More detailed budgets are presented in Volume II. . 46 CONNECTICUT REGIONAL MEDICAL PROGRAM March 15, 1973 Budget Request to Region&l Medical Programs Service for the July 1, 1973 - February 15, 1974 Period Component RESEARCHANDEVALUATION Community Studies Personnel, Ysle University School of Medicine Community Studies Personnel, University of Connecticut School of Medicine UNIVERSITY-COMMUNITY HOSPITAL PARTNERSHIPS Office of Regional Activities, University of Connecticut School of Medicine Office of Regional Activities, Yale University School of Medicine Yale Affiliated Gastroenterology Program, Ysle University School of Medicine Yale-Conn Diabetes Teaching & Consulting Program, Yale University School of'Medicine Connecticut Kidney Msease Progrsm, Yale-New Haven Medical Center CLINICAL SERVICES Rnergency Medical Services, Connecticut State Department of Health HEALTH PROFESSION EDUCATION Regional Library Services, Yale Medical Library Regional Library Services, University of Connecticut Health Center Library PRGGRAM STAFF-CONNECTICUT REGIONAL MEDICAL PROGRAM TOTALS CMCIC . 3-13-73 Direct Indirect Total costs costs costs 24,797 22,580 30,000 33,177 12,500 13,000 16,000 35,500 6,111 6,111 11,563 8,369 36,360 30,949 13,122 43,122 19,006 52,183 6,350 18,850 7,779 20,779 5,832 21,832 4,375 . 39,875 G 3,780 2,655 39,745 9,891 8,766 $337,206 $122,576 $459,782 / NEW BRITAIN GENERAL HOSPITAL BLISS B. CLARK, M.D. EXECUTIVE DIRECTOR NEW St?,-,-A,,.,. CONNECTICLIT 06050 * (203) 220-5011 March 6, 1973 Mr. Russell G. D'Oench, Jr. Chairman, CRMP Advisory Board The Middletown Press Middletown, Connecticut Dear Mr. D'Oench: I sm writing to report on the recent activities of the CRMP Review and Evaluation CoPrmittee which have culminated in (a) program and budget recommendations for May-June, 1973 and (b) program and budget recommenda- tions for July 1, 1973 - February 15, 1974. These sets of recommendations were developed in the context of instructions from the Regional Medical Programs Service (RMPS) dated February 1 and 22, which asked that CRMP develop a plan of action to phase out its operations. Furthermore, the Committee understood RMPS set a limit of $264,157 (direct costs) in available funds for the May - June, 1973 period. In discharging its current responsibilities, the full Review and Evaluation Committee met four times -- on December 5, 1972 and on February 1, February 17 and March 1, 1973. In addition, there were several meetings of sub- committees and twelve site visits. I 8111 pleased to report, too, that the work of the Review andEvaluation Committee was augmented at various levels during this round of review by the participation of 14 members of the'CRMP Advisory Board. At its December 5, 1972 meeting the R and E Committee adopted a plan to request written progress reports from all CRMP-supported programs, due Jauuary 29, 1973 and it made tentative plans to conduct site visits to each program during February - March, 1973. At its February 1, lg'j'3 meeting the Committee received copies of the agency reports which had been requested; discussed President Nixon's budget message for FY 74 which proposed a phase out of RMP; considered the contents of a telegram from Dr. Margulies which came during the course of the meeting and gave some instructions for phase out; and adopted a modified plan for Mr. D'Oench March 6, 1973 the current round of review which called for most of the review to be carried out by three panels on the written reports, with site visits to be carried out only in special situations. At its February 17, 1973 meeting, the Committee took preliminary action on the recommendations by the panels on most of the delegate agency reports but agreed on the need for 12 site visits. At its March 1, 1973 meeting the Committee considered the 12 site visit reports; developed program and budget recommendations for the May-June request to RMFS; developed program and budget recommendations for the July 1, 1973 - February $5, 1974 request to RMPS; developed recommendations on several programs with special situations; and developed recommendations on several policy matters concerning the future functioning of CRMP. I am attaching a copy of the minutes of the R and E meeting of March 1, 1973 which'gives the details of the Committee's recommendations for (a)'the special grant request for Msy-June, 1973 and (b) the I'phase-out" grant request for July 1, 1973 - February 15, 1974. I em writing a separate letter to summarize the Committee's recommendations on policy matters. I will be pleased to amplify this letter and to respond to questions at the meetings of the CRMP Executive Committee and Advisory Board which are set for March 8, 1973. I expect to have the assistance of several members of the Review and Evaluation Committee on those occasions. Specifically, I- have asked the chairmen of the three panels--John Barone, Ph.D., by Duff, M.D. &d John Glasgow, Ph.D .--to give an assessment of CRMP programs re- viewed by their respective panels. I have also asked Joseph Smith, M.D., Willis Underwood and Paul Doolan, M.D. to comment, in that order, on the impact of CRMP on the medical practitioners of Connecticut, on the thirty- three CommunitY hospitals and on the two University Health Centers. I would like to mention, in closing, that the members of the Reviey and 4 Evaluation Committee have again functioned with high purpose and strong dedication during the recent review cycle and that it received outstanding staff support in conducting its work. Sincerely yours, Chairman CRMP Review and Evaluation Committee . OFFICE OF THE PROVOST FAIRFIELD UWVERSI-W NORTH BENSON ROAD, FAIRFIELD, CONNECTICUT 06430 = (203) 255-5411 March 6, 1973 UNIVERSITY MEDICAL CENTER REGIONAL ACTIVITIES REVIEW AND HVALUATION COMMITTEE CONNECTICUT REGIONAL MEDICAL PROGRAM INTRODUCTION The Panel on University Medical Center Regional Activities assumed a respon- sibility for the review and evaluation of eighteen (18) university adminis- tered regional programs. In eight hours of committee work, supplemented by three two-hour site visits, the panel was able to complete its assignment. Augmenting the regular R & E committee members in both program review through committee work and site visits were members of the CRMP Advisory Board, principally the CHP (b) agency designated members. The framework adopted by the panel for review of programs included a judgment as to the program's clarity of objectives, progress in achieving program goals, contribution to the overall mission of CRMP and developing prospects for alternate financial support beyond the period of CRMP pump-priming. PROGRAM ASSESSMENT AND OVERVIEW COMMENTS The central thrust of CRMP, e.g., creation of a university-affiliated hos- pital system, is successfully illustrated by the organization and range of university regional activities in research, education and patient care. The template of this arrangement, two university spheres of influence - northern half relating to UConn and southern h&f relating to Yale, offers a practical and manageable orbit permitting intensity of university-community interaction. The flexibility of this arrangement is evidenced by a range of Yale adminis- tered state-wide patient c~are/clinical progrsms which utilize Yale-New Haven u: Medical Center's enriched clinical base and which in time permitted entry of the UConn Health Center after its clinical base was well established. Regional activities which illustrate the larger framework include: Community Studies Units The Department of Epidemiology and Public Health, operating within a tradition of public service, has greatly -anded its research and planning service through CRMP support and stitiiulus. Where CRMP has identified the problem, located the regional client and created the opportunity for study, Yale has supplied faculty and graduate students. Institutions, communities and CHP (b) agencies have been beneficiaries of this service and the future promise of help is equally great. One would hope-that commun$ty hospital-pased chiefs of service would increasingly turn to this resource for help in local problem- solving thus adding further substance to their university affiliation. The UConn Community Studies unit, a more recent development, shows equally high promise&n assisting northern Connecticut communities. Particularly encouraging is the unit's emphasis on helping affiliated hospitals sort out answers in 51 primary end ambulatory care, specialty, care organization, hospital-health department relationships, and the role-impact of full-time chiefs of service. Joint participation by both units in an appropriate statewide study is one of the directions future planning should take. University-Based Regional Medical Faculty University faculty engaged in outreach, particularly with affiliated hos- pitals, is a$merstoreof CRMP's program emphasis. The awareness and interactions which have resulted from this thrust have been difficult `to report because of the range and breadth of their activities. It is clear that this is an essential component of an integrated health and educational system. Moreover, a whole style of medical care leadership has been developed which has taken firm root in the universities and the community hospitals, even if some university clinical departments and some smaller hospitals have not fully participated. The necessity for a stimulating and integrating force, such as the two university Offices of Regional Activities, will also re- main, both to build upon accomplishments to date and to offer the community hospitals a university-based "ombudsman" for future program development. University-Based Regional Nursing Faculty An effort, similar to university-community collaboration in medicine, has been made in the nursing area* Here the tradition of a university nursing school as a regional resource is recent, the potential of nursing playing an expanded role in health care delivery is evolving, snd the presence of a male chauvinism as well as modest program goals with consequent minimal funding, have led to modest efforts exclusively in continuing education. Issues such as nursing practice, new forms of regional organization of nursing service and the role of specially prepared nurses all remain, and all.needing more effective regional solutions. Therefore, much remains to be done in improving nursing education and practice, which will require extensive university nursing participation. Regional Sub-Speciality -Health and Education Programs Perhaps the areas best understood by health providers and appreciated by health consumers have been programs offering help in ,direct pati?nt care. ; Here there has been an explfcit patient care emphasis, committed and enthusiastic university faculty leader(s), a network of informal. relation- shj.p.with practitioners, and the opportunity to integrate education and patient care. Two programs' expanded with CRMP funding, the Connecticut Regional Blood Program and Yale-New Haven Continuing Care Program, now continue under sponsoring agency auspices. The Yale-led statewide Diabetes and Castroenterology Programs have established a network of community-b.ased educational and patient care activities with high promi. of pemace through alternate funding. The multi-faceted Kidney Disease program offering diagnostic, dialysis and transplant service is well on its wa~r to becoming I a model of rkpeclti-& care organization. A similar opportunity is ahead for the Conne&icut Regional Drug Information Service as it builds up the hospitti as a dynamic center of modern drug therapy. . 52 Regional Education and Communications Efforts Allied Health Manpower Coordination at Ysle has demonstrated the feasi- bility of a consortium arrangement linking hospitals, colleges and the secondary school systems for allied health education. The need and opportunity for replication elsewhere in the state is great. At UConn, with CRMP help, a School of Allied Health has been established which can now forge new alliances for interprofessional health care delivery activity and extend relationships to other community and senior colleges. The actitities in these areas in the past were most timely because there are plans for cuts in direct federal aid for such programs in Fiscal `74. Hopefully the availability of critical manpower data to guide realistic educational planning can come through the CRMP-funded Manpower Information Forecasting Systems and Regional Health Education Programs, both at Ysle. The need Yale has to rationalize its extramural education&. alliances with affiliated institutions hopefully can be guided toward solutions from these previously mentioned data collection, analysis and progrcu?l development mechanisms. The newly emerging Connecticut Institute of Health Manpower Resources can serve as a neutral convener, catalyst and source of expertise in statewide manpower planning, while being of help to CHP (b) agencies as they come to grips with local health manpower issues. The Connecticut Medical Communications System has successfully demonstrated the feasibility of linkage between university facilities and peripheral institutions. The need now is maximum utilization of communications technology and extending the number of institutional participants. The parallel effort of helping hospitals develop expertise in educational media (non-print material) has successfully dovetailed with an acknowledged "winner", The RegionaS. Library Program. The necessity for a31 Integration of library, drug information and audio-visual services into some permanent structure of university-community hospital shared services remains to be pursued. SIGNIFIWCE OF CRMP IMPACT University LlediCal center region&L activities offer an interesting plat- form both to gauge university social leadership and community need-rkponse. W On both scores, an affirmative judgment must be rendered due in large part to CRMP's stimulus and support over the past. six years. As convener, prodder and bro?