1 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 2 PUBLIC HEALTH SERVICE 3 II jl) 4 a 5 G HEALTH RESOURCES ADMINISTRATION THIRTY-FIRST MEETING OF THE NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS I I - - - Executive Session Converence Room M Parklawn Building 3600 Fishers Lane Rockville, Maryland Monday, November 26, 1973 The meeting convened at 3:20 b'olock, p.m., or, Herbert Pahl, Acting Director, Regional Medical Program Service, presiding, COUNCXL MEMBERS PRESENT: : 0 c 22 23 24 HOOVER REPORllNGC0,INC. 320 MassachusetfsAvenu?,N.E. Washington,D.C.20002 MRS.AUDREYM.MARS GEORGE E, SCHREINER, M.D. MR. EDWIN C. HIROTO DR. LAWRENCE FOYE JOHN P. MERRILL, M.D. BUlND W. CANNON, M.D. MRS. MARIELS, MORGAN RUSSELL B, ROTH, M.D. BENJAMIN W, WATKINS. D.P.M. MR. SEWALL 0. MILLIKEN MR. C. ROBERT OGDEN 2 3 0 4 0 5 G 9 10 11 12 -I) 13 15 lli 1-i 1E l! 2( 0 21 0 22 2: 21 2, ` , HOOVERREPORTiffiCO,INC. 320 Massachusetts Avenu?, N.E Washiwton. D.C. 20002 CONTENTS -------- Projects Northland Motion 16 vote 17 Hawaii Motion Vote Arizona Motion Vote LouisFana Motion Vote South Dakota Motion Vote Colorado-Wyoming Motion Tri-State i Motion Motion vote 2 Page 11 18 33 35 37 40 43 43 47 47 47 51 52 52 55 59 66 78:: * * 0 1 2 3 4 5 G 7 a 9 10 11 12 13 14 15 1 (i 15 16 l! 2C 21 pi 2; 2f 2: HOOVERREPORTltiGCO,I~. 32t) Massachusetts Avenu:, N.E Washington, D.C. 20002 3 PROCEEDINGS ------mm--- DR. PAHL: May we reconvene the Council, please. At this point I would like to turn the meeting over to Mrs. Silsbee, who will lead us through what we have been trying to get to for sometime today, and she has it well -' organized, which 3-s no mean matter in view of the clrcU& stances that a number of people have rearranged schedules I ar: so forth. So without further ado? I would like to have Mrs. Silsbee conduct, if you will, our session here on the actual review of applications and discussion of those areas that we think are important for you to consider. Judy. MR. OGDEN: I want to enter a complaint on behalf c one minor member of this Council in that I desperately miss the existence of the review committee. I thfnk a great deal what we are facing from here on out in this executive sessior is something that the Council shouldn't be doing. And a gooC deal of what Judy is doing of necessity is being brought to I at sort of a last minute situation. Much of the discussion that we had this morning abc the thrusted purpose of this program is what we ought to be spending our t%me on. That is what we should be doing. Not trying to review ten applicatrons which are Ln a somewhat im- perfect state and make value judgments individually, which wf hope other people will accept. 0 e *- , " 0 0 6 7 8 9 11 12 13 14 15 Iti 17 18 1!8 20 21 22 23 25 HOOWERREf+ORTlRCO,INC. 320 Massachusetts Avenu:, N.E. Washintion. DC. 20002 4 I hope that this is the last time that we function without an effective review mechanism before these things get to the Council. DR. PAHN: Thank you. I appreciate that statement more than I think you can possibly realize. We undoubtedly have the opportunity now, if what we discussed this morning holds true, of reestablishing such a committee. And ft is our interest and we know it is yours to have such a group. In fact, if we cannot formally reestab- lish the committee, we have a fall back position of trying to constitute an ad hoc group, if you will. But we sorely feel the need to give both you and our' selves that kind of professional assistance and overview, and we have sorely missed it. So I appreciate that statement and I am sure we didn't really bring it up as an agenda item. I think it is most appropriate. MRS. Mms: Under the current legislation, can it be reestablished? DR. PAHN: It is not a matter of the legislation, It is a matter of Departmental policy, which is in part govern* ed by a federal policy now for reducing and eliminating rhere possible those kinds of review groups that don't seem to be necessary, Ken has his hand up, but I believe It is promulgated by the Office of Management and Budget and is being enforced 5 1 by them across the federal government. And, of course, HJ3W4 2 apart from Defense Department perhaps, has more review 3 commlttees, study sections and advisory panels, I suspect, thar. 0 4 any other department, a 5 It is very much in the OMBls purview to look at the 6 functioning and need for such groups. 7 Now, the reason that the review committee was term- 8 Fnated, of course, was that there was a phase out of RMP, In 9 all honesty, with other matters pressing, we did not try to 10 revise the Department 1s impression on that point, because we felt we had some .higher priority issues to bring to their attent.ion. We have not had the opportunity even to get those : full attentioned by the Department. But at, this stage, with what seems to be the future of the program, however tenuous, we already have, as I say, dis- cussed not &ly our interest but our need for and are making the kinds of plans internally to see iif we can't reestablish a standing ..committee and failing that j ff we can't call together groups that are functioning in the same fashion anyway. 20 MR. OGDEN: We have excellent staff people, those 0 21 who remained I think are highly experienced people who can do 0 22 a great deft 1 of this themselves . 23 You certainly have regional people who can give us 24 this kind of input prior to the time it gets to Council-. 2s DR. PAHL: That's right. HOWfR REPOi?TlNGCD,INC. 320 NlassachusettsAvenu3,N.E. Washington,D.C.20002 1 2 3 4 5 ii 7 8 9 10 11 12 a 13 14 15 16 17 18 f!b -0 23 24 Is there further discuss-ion? MR. HIROTO: Inasmuch as there are many vacancies on the Council at the moment, perhaps those vacancies might be filled with people who have a review ca'pacity and they could become a subcommittee, something of that nature. DR. PAHL: We have taken into account that very point in making nominations for the Secretaryls consideration, and if our nominations were to be accepted, a number of individuals would already have first-hand RMP experience.;, because they co not only from former review committee members and possibly former Council metiers, and ones who have served local RMP Is in 25 various capacities, so we are very hopeful that the Secreta.ry HOOVfRRfPORltNGCO,INC. 320 MassachusettsAvenu?,N.E. Washinntan.D.C.20002 MR. OGDEN: And they need to be coming around review ing th1.s with each of us before it got down to this point in discussion. MR. MERRILL: I think policy matter, you could make-- a review committee would save a lot of time. I am sure the eight to ten hours I spent reviewing this were absolutely wasted, could have been saved for toher matters if you had a review committee go over the leg work. DR. PAW: There is every good reasonp and I would say we are in accord with your statement and understandlng, and the only problem we have is a federal overview one, which is even beyond the control of the Department. But we will do what we can because we certainly are in accord with it. 3 Well, thank you very much, I do appreciate that. 11 12 13 14 0 4 * 5 (i `i 8 9 10 a 0 * HO~VfRRfP~Tl~CD,lNC, 320 Massachusettsdvenu?, IKE Washington, D.C. 20002 15 l(j 17 18 1 2 7 will help us move ahead quickly by accepting some of the nom- ina tions . MRS. MORGAN : Do you think we should go on record on the fact we do have a quorum of the members who are on Council present, although mybe not a quorum of the total number who should be on Council due to the Secretary's lack to appoint members to the National Advisory Council? DR. PARL: Yes) I think it is perfectly appropriate, because we hawe investigated this with the Department and I wouldntt want to leave you under any misunderstanding. We do have a quorum of the members who are actually serving on Council and it is Departmental policy, which we have looked into and discussed with the Department's Committee Management Office, that this does in fact constitute a quorum for this Council and we can conduct the government's business. Mr. Baum, in fact, has conducted this inquiry and ha confirmed this Departmental policy in writing, so we are not operating without a quroum. All right, Judy, would you please take over. MRS. SIURRR: I am beginning to feel like RI@ coordinators t trying to do the flipflops to keep up with this review. This is the first time we have had 53 applications -j one meeting and we had to take a choice bebeen allowing the 1 : I 4 t T 8 9 10 11 12 13 14 15 Iti 1.7 1E 2a 21 217 24 25 HOOVERRfPORliNGCO,INC. 320 Massachusetts Avenu?, N.E. Washington, D.C. 20002 8 regions more time to prepare their applications when we sent out the September 7th instructions, the choice was between the regions and staff and Council. And we felt that under the circumstanceg the regions probably needed the time. So we apologize for the fact these green sheets had to be here wait- ing for you rather than set to you at the tlm the applicatior went out, but we were undergoing a review at the same time the were being mailed to you. Just as a little background along this 1Xne # there k a staff group within RMPS that looked over all 53 of the applj cations, This included the four Operatfons Branch chiefs, Mr. Peterson, Mr. Ott, I!&, Chambliss, and Br. Pahl. The latter two were not present all the time, but as they could be This step of an overall group served to identify and develop some uniform type considerations of the problems and t issues that these applications presented; For example, the kidney projects, the fact that som regions Indicated that the technical review had been completei but the RAG was not going to have a chance to look at everythj until after the applicatin was sent forward to us. The requests that were over the a 1 located amounts for which regions were instructed to apply. Negative CHP comments if there were some. CHP comments to come, because not all regions were able to get the comments in with the application. "1 HOOVER REPORTIffi CO, INC. 320 Massachusetts Avenu? N.E. Washingon, D.C. 20002 .__l. _~__"__ 9 The status of the review verification of the region, The lack of full-time direction. And then some tougher problems. This overall staff review tended to screen out the problems which needed attention immediately. These were regic that we felt needed some attention with regard to these partic lar applications. Then in addition, this process screened out those regions which might need attention if additional dollars are forthcoming or mandated by court. The actual analysis of each application was decen- tralized to the operations officer who is responsible for that RMP. The green sheets that we gave you this morning for the regions that you were asked to review and are also include in these four books in front of you reflect the above consider ations for the most part. The discussion today may bring out others which are n& reflected. Time has been very short and staff has worked hard. The operations officers, the branch chiefs, the support staff, and the coordinating staff have worked overtime I think in terms of effort and deliberatfon. I would like to call attention particularly to some support staff who often have the unglorious job of making sure that pieces of paper are available and on hand in time, but 1 2 3 e 4 * 5 6 7 8 9 10 11 12 e 13 14 15 lfi 17 18 19 20 0 21 0 22 23 24 25 HOOVERREPORllNGCO,INC. 320 Massachusetts Auenu:, N.E. Washington, O.C. 20002 10 don't have the public recognition that the operation staff has in being able to talk with you and to talk about the specific RMPgs. So I would like to publicly thank Mrs. Edith Leaven- thau, Mrs. Filimina Green, Mrs. Joan Williams, and Mrs. Shirl Sfmon, This staff has done a tremendous job. Friday afternoc we made it. We didn !t think we were going to, but we did, We started out with the plan today, that is why we have these four books, we were going to go through each of the books by operations branch with having an opera- tions branch chief identify those regions which staff elt need ed some attention, and then to give you a briefdescription. Becausg Mr. Ogden, we are concerned too that we don't have the review commit tee, nor does this Council at this point have very much first-hand experience with the 53 regions. Then our plan was to go first with the South Central then with the Western Operation, then with Eastern Operations, and finally with the Mid-Continent, Well, the plan was slightly changed when we knew that Dr. Cannon and Dr. Merrill would only be with us for today, and added to that was Dr. Roth, so that plan went out the window. So we started with another plan. (Laughter) But I want to call attention to these books, because unfortunately, with that plan, that is the way we put material Y 0 0 5 11 12 13 14 15 1 ti 6 7 8 9 10 e 0 0 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu:, N.E. Washineton. D.C. 20002 17 18 1!4 20 21 22 23 24 25 1 2 3 4 11 together, so we are going to be jumping from one color to the other. But the way we are going to do It this afternoon is to identify those regions by branches that we think -- we think -- might need some attention, ard then we are going to ask Dr. Roth, Dr. Cannon, and Dr. Merrill if among the other regions -- and I will read them out -- that they have been ask to review, that they feel need special discussion, or whether we can hold this off until tomorrow. We would like to have what we have identified as the problem regions looked at by this larger group if that is all right with you. So we will start out with the South Central Branch, that is blue. The region which we identified that needs some speck attention is Northland. Mr. Van Winkel will give a brief over view and then we will ask Dr. Cannon and Mr. Ogden if they hav any discussion or any action they would like to propose. MR. VAN WINKU3: Well, if I could, I would like to start off by saying the staff review was done by looking at all the things Judy mentioned, I think all of us. The staffing, the review processing, liability of RA CHP review and comment, their ability to find other sources of funding, their ability to respond to new initiatives, we flag- ged kidney as a special part of the review, we looked at their 1 2 3 Now, what I would like to do is not make a lot of cc l- 0 * 4 ments about each of these and go only by exception and if you 5 13 14 15 6 li 8 9 10 11 12 e a e HOOVER REPORTING CO, INC. 320 Massachusetts Avenu?, N.E. Washington, 5.C. 20002 12 past performance, and we looked at it in terms of whether they were in accordance with Council and RMPS policy. don't hear of those things , you know that they are fully cov- ered In the application, if I might. Our concern with Northland I think was the fact that when they phased down, they really phased down, They wound ug with one professional Staff and a couple of secretaries, Mr. Wilkins who had been the Deputy Coordinator under Dr. Miller, Now, when they got word that they had some new life breathed into them, they didn't have the to recruit new staff nor could they possibly have recruited new staff for that time period. So what they have done, they have used RAG and board members as staff to develop projects, part of their contract offerings, this sort of thing. So on the one hand, these people are developing projects ) doing the staff work on them, and then sitting on the other hand in the process of reviewing their own work, so to speak. Now, we have checked this out with management in terms of paying these people and we find that there is nothing Illegal aboLt this. I suppose what we are raising is a moral issue or possible conflict of interest as to whether this should be dor and Lt is the staff's feeling that the Northlands RMP should !? 1 recruit needed program staff so as to elminate any possible i criticism on the use of board members and RAG members as paid staff. 11 5 G 7 a 9 10 HOOVER REPORTING CO, INC. 320 Massachusetts Avenue, N-E. Washington, D.C. 20002 There is a kidney project in here where the region, will have to be. alerted as to the new regulations that Mr. SPY tr discussed this morning. They have requested their full allocation of $458,586 to support ten activities, and we recommend approval of this application as submitted with advice on the staffing, and we have some difficulties with their bylaws. They are not totally in accord with the NIB that went out with reference 12 to bylaws that was sent out by this Council. 13 MRS. SILSXEE: Mr. Milliken. 14 MR. MILLIKEN: I think this is related to something 15 some of us are concerned about, have talked about. This Ls Iti the ability of the staff, this staff, as spa.rse as it is, 17 to provide the kind of surveillance necessary to assure this 18 Council and staff that lf at any point in time there is evi- 1!4 20 21 22 23 24 25 dence of an inability to deliver on these in the right way, tl: 1t this be brought to proper attention, MR. VAN WINKLE: Could I respond to that? Certainl: in any areas where we thought we had difficulties, we are in touch two or three times a week by telephone with these regSons. We also had an opportunity to visit a great number of these regions on the EHS iss :;ie and also on the health 13 0 e 0 e 10 MR. VAN WINKLE: That is absolutely true. 11 12 13 14 1% MRS.SIISBEE: Mr. Milliken, we shared some concern 1 terms of this particular period of time, this process is try- ing to identify those,we feel may need some special attention. We also recognize that we aren't really on top of all 53 and we have been able to identify those that don't have the review I (i process. We have some that have been identified as having 17 18 l!) 20 21 22 23 24 25 known management problems. We will be trying to bring that out as we go along. But we too feel we have a lot of spade work to do to assure you as Council that these regions are on top of things. But in terms of this particular application, Dr. Cannon had to go out and make a phone call, but, Mr. Ogden* do YOU have any comments? MR. OGDEN: I would just read you my notes, which we] based largely on the yellow sheets which came out,, which I HOOVER REPORTING CO, INC. 320MassachwettsAvenu?,N.E. Washington,D.C.20002 education activities, So we did have first-kand knowledge 2 of many of these problems. 3 I think we stayed up with them fairly well. 4 5 These will be revisited under the schedule that Dr. Pahl mentioned to you this morning, we hope to bring back to 7 8 you at the March Council or whenever that happens to be. MR. MILLIKEN: I think even more, I am thinking about certain questionable regions would get more attention 9 if they are running on a .more questionable basis. 14 1 agree are useless, being what they had before. On the back 01 f 11 12 13 /I c 0 4 e 5 6 7 a 9 10 e e e HOOVER REPORTING CO. INC. 14 15 I li 17 18 l!) 20 21 22 23 24 25 320 Massachusetts Avend, N.E. Washington, D.C. 20002 the material sent out. This I felt was a well presented application and I thought it demonstrated considerable advanced planning, which has been typlcal of Northlands all along. MRS. SILSBEE: Mr. Ogden, could you speak up? MR. OGDEN: My notes simply read this is a well presented application demonstrating considerable thoughtful advanced planning typical of the Northlands effort. Again, Northlands has used a contractual approach in what appears to me to be both constructive and a successful manner. After review by the HAG and allocation of perspec- tive funds to the several categories, the funds for Em activi ties were negotiated for five CHPB agencies for implementation to state plans and Minnesota State Department of Health for state@ide .coordination of the EMS effort. Funds also were allocated to seven community based groups for health education and to two CHECls, at University of Mknnesota clinic; 15 contractees, who have potential statewide impact, same situation. Kidney hyper te ns ion. Application indicates if additional funds are avail- able on January 1s t, a similar technique will be followed. My opinion, this Fs an application well deserving of full funding, but I would recommend that the HAG needs to 1 2 3 4 5 G 7 8 9 10 11 12 13 14 15 l(i 17 18 19 20 21 22 23 24 2s HOOVER REPORTING CO, INC. 320 Massachusetts Avenu 2, NE Warhinotnn II C. 20002 evaluate the cohesiveness of ti-e program. MRS. SILSBEE: Dr. Cannon, as I mentioned, had to make a phone call and before he left, he whispered he would go along with approval as requested. Do you want to make a motion, Mr. Ogden? MR. OGDEN: I will move that the application be --.- .--_ I ,__._ I"^ _.,..,._.. _,^".l.l. .--`.*.--.---" _,/ _-,,_ -IIII-I.C~-I,I.-I ,...e-=*-- -'*-1-"1'" approved for the funds requested. -,-- ,%-rs""*---'--. I_.. _' ,_ (, .-. ..,. , .,-_ MRS. MORGAN: I second it. MRS. SILSBEE: For the record, the funding that is being requested by Northlands is $458,586. There is a kidney proposal and there will be follow- up with regard to the staff and the bylaws. Before we go on to another applfcation, it is pro- posed, when we mentioned kidney here, that there will be a statement made that the RMP may not release funds fortidney project X, which is being identkfied, to support a new facility, a new or expanded services. in an ongoing facility, until the facility receives interim approval or exception from the Bureau of Health Assurance, Social Security Administration Now, the other regions that either Dr. Cannon, Dr. Roth, or Dr. Merrill have been asked to review, as one reviewe in the South Central Operations Branch, are Florida, Georgia, Memphis, Michigan, Mississippi, North Carolina, and Ohio Valle If you have any points that you would like to bring up or would like to have those regions brou@;ht forward now, 1 2 3 4 5 6 8 9 DR. ROTH: Also parliamentarian. 10 11 12 MRS. SICSBEE: Opposed? 13 {No response.) 14 15 lfi 0 0 HOOVERREPORTINGCO,INC. 320 Massachusetts Avenus, N.E. Washington, D.C. 20002 17 18 I!) 20 21 22 23 24 25 would you speak up. DR. PAHL: Pardon me. Judy, in the press of time, I thinftalthough they did move and second, we are just moving little too rapgdly. We should take a formal vote, all in favo say "aye, " just for the record, [Laughter) I know I talked too long this morning, but you shouldn't feel that pressed for time. MRS. SILSBBE: All in favor? __"__... .-. _,__------- (Chorus of "ayes.") MRS.SILsBBE: Motion is carried. Motion that was ----.....-- -_-_ - _______ a-.----^-.. --- ______. -. .._._ - __.,._ _--.- .- -. before I talked too much. (Laughter) MR. OGDEN: Incidentally, before we leave that, I should have mentioned in reading through this material, I lookt on RAG, board member, staff, purely as emergency measures and : can't imagine they looked on it any other way. MRS. SILSBEE; Okay. In the absence of anyone want- ing to bring up those other regions at this particular time, we will bring them up when we get through with this other groul In the Western Operations Branch, two regions that were Identified as needing some discussion were Arizona and II 18 I 1 II Hawaii. Mr. Russell. MR. RUSSELL: Do you have any preference which one 0 6 jj MR. RUSSELL: The Hawaii regional medical program 7 presents some very special and serious issues. Just in the w 8 II of background for those of you who haven't had an opportunity to 9 read the yellow sheet and green sheet, both of which are quit 10 lengthy, when Council reviewed the Hawaii application in 11 II October, the program was approved for triennial status. How- 12 ever, Council chose not to award the developmenta. component 4 or 13 the first year since the program had just recently revised it 14 review and management processes and Council felt, rightly so, 15 that the program would need at least a year to really-test 1 fi their new procedures. 17 As a result of an EMS visit, site visit in June, we 18 found the program had deteriorated substantially since we had 1!4 last looked at it, when we site visited It and had taken it 20 through Couno&l Peview; we were encouraged through the regu- 21 II lar processes, a review, staff assistance following review, * -I) 22 that we could have continued to asstst the program. "7 it The basic problem as we see it is a lack of leader- 24 II ship in the area of management. Specifically, the director 25 is on a YO-hour basis. However, hSs 40 hours are not HOOVER REPORTING CO, INC. 320 Massachusetts Avenu?, N.E. Waehinotnn nfl 7llM)7 0 1 2 3 4 5 10 15 The director has two sets, at least two sets of manage- ment philosophy. One is that in the presence of RAG members, as best we can remember, he readily admits recognized management practices should be used Ln the conduct of a regional medical practice. However, when, under local pressure in the decision. making process, he reverts to other than sound management f(i practices. Quite frequently he will point out to RMPS staff 17 18 20 e 21 0 22 23 2.4 25 tiOOVERREPORTINGCO,INC. 320 Massachusetts Avenu?, N.E. Washingtcm,D.C.20002 19 coterminous with the regular office hours. Therefore, he is 1 not literally available to his own staff or to RMPS staff. The director seems to place more emphasis on the fndividual staff members standing in the community rather than on professional competence. I do not mean to imply there are not competent program staff members in most cases. The program staff has limited rapport as far as management goes with the director. Those who do choose to question him wish they hadn't, that the multi-ethnic background of the people in Hawaii precludes obJectlve management practices. It appears to us that the director gets his power from the amount of money available to the program, rather than from his Regional Advisory Group. We have worked with him quite closely on this to try to get him to use his RAG as the buffer between the decis otx that are made and the community. t Due to the absence of the director during regular I 11 12 13 14 15 7 8 9 10 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu?, N.E. Washington, D.C. 20002 17 18 19 20 21 22 23 24 25 I off ice hours, we have to rely very heavily on the deputy 2 director, whom we haven't had the opportunity to really watch 3 him in a situation which demonstrates his effectiveness. 4 As a result of the inadequate management of the 5 very large emergency medical services project, RMPS. with Burt 3.U approva 1, chose to transfer that project from the regional medical program, pull the administratlon back to the central level, and with coordination of the Emergency Medical Service: Branch have gotten that branch now to direct It from a pro- grammatic standpoint of view. And the EMS Branch visited the Hawaiian Medical Association shortly after the transfer and he saLd already the improvement was very, very noticeable. So the point I am trying to make is the Hawaii R&P really failed to adequately handle a very large segment of the program. The next issue, critical issue, at the local level, national level and regional level, being HEW regional level, is the Uommunlty Health Services project in the W,aianae. , coast area, which is an underprivileged area. We have pointec out fn the paper here that the Community Health Services out ( San Francisco, after months of negotiating with the Waf$na.e. -1, Board, that Board is responsible for administering pro- jects not only from RMPH but other federal funds, @smmunity %eaIth Services has laid out specific conditions on the farnil! !I 20 1 2 3 4 5 G 7 8 9 10 11 12 e 13 14 15 l(j 17 18 1!9 20 0 21 0 22 23 24 25 HOOVERREPORTlNGCO,INC. 320 Massachusettsftvenu?, N.E. Washington,D.C.20002 21 Health Center project. If the board does not accept these conditions, then the Community Health Service will have to terminate its support. The board has had, oh, 15, maybe 20 days in which to respond. They had to respond within 10 as of Friday. We unde; stand that the LMaianae 1.:. 3oard had not responded an d the scuttlebutt is that they will not accept the Famkly Health Center-Community Health Services Conditions. If that is the case, then the WaianaeLCo+St:will ._. not get the $400,000 for the Family Health Service project. Now, the RMPH involvement in the Waianae,CQ@st J has been significant. Effective as a catalytic agent, it was supposed to help with administration of the board to get it hr shape. The first conflict that we noticed w,as when the Com- munity Health Service would not accept the project director-- this gets complicated, so stop me if I lose you, please -- it has taken me a couple of years to get Lt straight -- the Waianae --* Board is a voluntary board, its administration, some of Fts aspects have been funded by the Regional Medical Program of Hawaii. Now, the board in turnappoints its adminfs- trator, who is salaried. That administrator automatically becomes the project director for the projects coming Into the Jaianae u`"_ ". ..,. . recommendation, vote favorably on the program, and they can go out as they see fit, MRS. MARS: Are you including a visit from Council? DR. CANNON: Are you going out there anyway? (Laughter) MRS. MORGAN: Just staff. DR. CANNON: I think it would be nice 9f a Council member went along, but I do not think we ought to go out thert and threaten them. We have been out there every visit I have been on, we have been saying, "Look, this is it;" I think th; doesn't work with them. I don't believe it is going to work with them. I think we need a different approach. MR. RUSSELL: I think we were trying to make the dil ference here was I see no reason why a Council member couldn'f go, it would be very helpful, just on a visit, rather than what we term as a site visit. I don't think they are ready for that. MRS. SIXZEE: How about an ex-Council member? MR. RUSSELL: Ex-Council member. MRS. MORGAN: Dr. Cannon! 41 I 1 2 91 (Laughter) MRS. MARS: You are elected. DR. CANNON: YOU know, they almc6t ran me out of 4 II town last time. MRS. SILSBEE: Dr,*~,?annon,has moved, which has been -, , ..,,~. w...-, ,~ ,,,, .,.. ._ ._ . . .~ ^.. _ . - 6 seconded, the recommendation be accepted funding as requested, ~~1 $359,623, with the condition that the region be visited to i' i 6%:; determine whether they really have changed direction and respo - 9 ded to previous concerns. DR. CANNON: That is where Ihanged it. 11 I II MRS. SIXSBEE: SO that should be amended to-- 12 DR. CANNON: I changed it to go out there with a dif 13 ferent attitude, one of-- t 14 MRS. MORGAN: Helpfulness. DR. CANNON: One of assistance. Not to change direc- 16 tfons, but see if you can't coerce them a little bit. 17 MRS. MORGAN: Take your box of candy. 18 MRS. SILSBEE: The problem is how to word them. l!) 20 (Laughter) DR. CANNON: You can't threaten them and change 21 1 them, that is what we have done. 22 MRS. SILSBEE: Be visited in a nonthreatening manner to determine how they are doing. DR. CANNON: Be helpful, consultative vis2t. MRS. MARS: Are you going to fund this program, then HOOVERREPORTING CO,INC. 320 Massachusetts Avenu?, N.E. Washifmtnn DC 20002 HOOVERREPORTlNGCO,IN( 320 Massachusetts Avenue, N. Washineton. D.C. 20002 1 2 3 4 5 6 10 il 12 :3 .4 .5 .7 .8 ,!I !O !1 !2 !!7 c4 !5 I. E. 42 before the site visit by staff? In other words, whether they change or not, they are still going to recei ve the money; is that what you are saying? DR, CANNON : That 1s my recommendation. Because the are doing a job, they still.. have the momentum, they still hav the staff, They are not going in the exact direction as RMP asks,Council would like for them to go, but they are doing a job In Arizona. MEG. MARS: You feel they are filling the health needs of the community? DR. CANNON: Yes, but they are filling the needs of some other programs, too, they shouldntt be. MEG. MORGAN : In other words, they are doing CHP. DR. CANNON: They are doing a lot of work for other organizations that other organizations should be doing. MR. RUSSELL: I think at this point, if 1 may say SC we have some indications that they are attempting to change and as has been pointed out, I think on a number of occasions, we as staff have had very little face to face contact with any of the RMPrs, and I do think we should give them the bene- fit of the doubt. MRS. SILSBEE: Motion has. b,een made and secondea to c recommend fund ing as requested, $359,623, with the condition that the RMP be visited in a consultative manner. All in favor? 0 0 4 5 MRS. SIISBEE: Motion is carried. --1-e.. (,. ". -*`,,`"-I .I%. . ...,.. ., ,, _ ,I , .j,l, NOW we are going to move-- this is a swftch, Frank o 6 to the Mid-Continent Branch, and that is red. 7 The reason for that is there are two regions in this 8 group where there will be nobody who was a reviewer here tomol 9 row ) so we have to get at it today. 10 w first. 11 MR. POSTA: Thank you, 12 I would like to note from the green sheet, Mr. 13 d i L i4 Zi,zlavsky & the operations officer. This region is brought up for problems I guess more 15 like the one that `I;ee just brought up with reference to 7 1; Northlands. 17 18 19 20 21 22 2s 24 25 We are concerned with the number of staff now on board and the staff that is proposed for the calendar year 1974 o Just a little background, the request that you are looking at now calls for $270,000, Oddly enough, another $269,000 has been approved for the region for the same amount of time for the topic of pediatric pulmonary. The grantee is a free-standing corporation. It has had good management in the past under their past grants HOOVER REPORTING CO, INC. 320 Massachusetts Avenu:, N.E. Washineton. D.C. 20002 1 2 3 43 (Chorus of "ayes. ") MRS. S ILSBBE : Opposed? (No response. ) 25 consider coming onboard 100 peroent of the time. He is now on HOOVER REPORTING CO, INC. 320 Massachusetts Avew N.E. Washington, D.C. 20002 44 management officer. RMPS has made a management visit there. They came through with flying colors. Last December, the satff also had a verification re- view process visit there, and RMES did certify the review process. However, I think we are concerned not with what it 1 was a year ago, but what it is going to be, what it is right now ) and what it is going to be in there next three or four months. When they came in, when Louisiana came in for their extension plan back in March, the staff went down to one grants management officer and a 25 percent program coordinator. Staff did approve nine continuing activities. A I couple of tha; e were for only two months. However, the seven that they did approve through l/31/74 was primarily under contractual arrangement and s,jlnce this is a free standing corporation, incorporation, those contracts were considered binding and there was a good chance for continuing once they had been consummated, and therefore that was primary reason why seven additional activities were approved for a small staff. Now, we have been notified by the coordinator if he did get a good review by this particular body, that he woul * * 13 13 i4 i4 `15 `15 llj llj 17 17 18 18 19 19 20 20 0 21 21 0 22 j 23 0 0 22 23 24 24 25 25 HOOVERREPORTlNGCO,INC. HOOVERREPORTlNGCO,INC. 320 Massachusetts Avew, N.E. 320 Massachusetts Avew, N.E. Washington, Washington, D.C. 20002 D.C. 20002 board 25 percent. That might be good. It might be bad. I think maybe you folks might like to discuss that a little bit further. However, upon being notified that Congress had ex- tended the program for another year, Dr. Sabatier did go back and has hired his former deputy coordinator, a dentist. And also one of his evaluators, on a part-time basis. Also the grants management person who has done a go job in the past fs available for consultation purposes with reference to grants management. We as staff, if you will, back in December 1971, had an official site visit. That was an application for triennial status. The Council and review bodies did not think that they had qualified and therefore gave them an approval for a two-year period for one million dollars each of two years. This past December, the program decided not to come in for a triennial appli..cation but to only come in for their one million dollars. Again, to reiterate,,a year ago, when staff went out and looked at this review process, we could find nothing wrong. This is a particular program that has specialized in a ca tegorica 1 approach. Most of their activities that they have solicited has been to more the leading institutions and those institutions themselves have gone about their particular job 1 2 3 4 5 7 a 9 knew what the other program was doing. 10 11 * 13 i4 15 16 17 DR. ROTH: No. I don't have anything to add on that 18 Louisiana is sort of a place apart in many of its l!) 20 21 24 25 HOOVER REPORTING CO, INC. 320 Massachusetts Avenu?, N.E. WashinPion. D.C. 20002 46 in their own individual way. In other words, what I am trying to say is that ther are net too&wfully many cooperative agreements in many of the activities that have been funded to Louisiana. A good example, this last July, staff went down and took a look at three or four VMS activities. Each of those activities were being funded by a particular fnst itution, if one progrm you will, and there was very 1Tttle evidence that So, again, I bring attention to the fact that this regfon has not been in the past one of our better ones. We are concerned because of the number of staff on board and we would recommend perhaps that you would consider a site visit to this region before fvIarch. Dr. Roth, I notice thatyou were one of the reviewers Did you have any comments? relationships and things medical, and this information about t program director Is something that I did not have available. I would support the recommendation of staff. - . DR. CANNON: If that is a motion, I second 1;: _,_II A---- -L----.-,,. MRS. SILSBEE: Dr. Merrill was the other reviewer. Did he have an opportunity to talk with you, Dr. Roth? DR. ROTH: No, I didn't talk to him about It. e HOOVERREPORTlNGCO,INC 320 MassachusettsAvenu?,N.f Wwhinntnn n i-r 7nnn7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 lf. 1-i 1t l! 2( 2' 21 2! % ` 2, Of course, in the view of my earlier comments today, I found the grant application and the track record along categorical lines as probably being on the credit side of the ledger with relatively little of th3.s other stuff, but I didn' have a chance to talk to Merrill at all. MRS. SILSBEE: The staff recommendation for2-._-- record Ls that the request for $270,323 be recommended for approval, but the program should be encouraged to recruit additional staff, particular reference to the program direc- tor+ ~gaause of the marked change brought about through planne phaseoug $ite visit to the region is recommended prior to the March Council meeting. MR. POSTA: Right. MRS. SITSEIZE: Do I hear -- DR. CANNON: So move. MRS. SILSBEE: Second? DR. ROTH: Move approval. 7-------------_ DR. CANNON: Second * MRS. SIISBEE: Any dicsussion? DR. CANNON: Question. m&s, SILSBEE: All in favor? -.. -.. (Chorus of "ayes. `I' 1 MRS. SITSBEE: Opposed? (No response. > MRS. SIISBEE: South Dakota. ~-I-.__.- .------ ------- 1 2 3 11 12 13 14 0 4 0 5 6 `i 8 9 10 * e 0 HOOVER REPORTIA CO, INC. 320 Massachusetts Avenu, N.E. Washington, D.C. 20002 15 l(i li 18 l!l 20 21 22 23 24 25 Y8 MR. POSTA: South Dakota. Staff had no real concerns with this particular application or with the region Again, they have a very small staff. However, the total amount requested is $120,680, $42,000 of which is earmarked for staff. As a result, you only have about $78,000 rounded off for four or five activities. We do feel that four full-time staff can handle. The reason we brim it to your attention today is 1 fact that this region has been considered a soLCal,led plannir region after its divorce with the Nevada program about a yea] and a-half ago. I think that the program has quite a bit of poten- tial, could probably do an awfully lot more with additional money, because of the fact that they were in planning status, because it fs a 9-l starting date application, meaning that when they came in for their terrenial application last March 1st s neither review committee nor the Council had the oppor- tunity to review it. As a result, their funding level of the so-called percentage of the formula is extremely small. I thfink if I am right, Judy, our main consideration today would be to consider them now an operational program? MRS. SIISBEE: Yes. This was the recommendation of staff. We felt that the planning grant was a fluke in time; whereas, its compankon, Nebraska, broke off also. It has bee IO 17 18 13 i4 15 HOOVERREPORTlNGCO,INC. 320 Massachusetts Averw, N.E. Washington. D.C. 20002 1 !4 20 21 22 23 `24 25 1 : operational for somet-ime; South Dakota hasn't. It is carry- ing on activities and we felt it would be neater if it re- mained operational. 4 5 MR. POSTA: This program is rather unique in that it has a Regional Advisory Group which serves as the council `i for the CHPA agency. So every time either one of the groups j called to order, business is conducted for both. 8 As a result, during this past year, when Regional 9 Medical Programs was in a more rather shaky status, this reglc 10 did continue to meet with its Regional Advisory Group and has 11 been quite active with things directly concerned with RMP as 12 well as with the CHP agencies. MRS. SIrSBEE: Dr. Roth or Dr. Cannon, do you have any comments? MRS. SICSBEE: Suggestions? DR. ROTH: Well, they stressed in the material I hal available that this was entirely concerned with salaries, wages, fringe benefits, and indirect costs. And no program- mic support other than what they had going. So I saw abso- lutely nothing wrong with it if they were to continue Fn RMP at all. MRS. SIISBEE: This is one of the things, the appli- cation that you have is just a portion of the program. They have money from the first award we gave this year, and then in the case of South Dakota, they had a couple of activities 49 50 1 funded during phaseout, so there is more to the program than 2 staff. @ 3' DR, CANNON: I gave it a grade one on staff and pro- 4 jects, but thought they ought to have their money and thought 51 they ought to be operational. They are just barely making it. I fi j / MRS. SItkcgEE: Any other discussion? 7 li i/ MR, OGDEN: Could I ask if the regiona,l director-- $11 do you really feel the small amount of money involved in I 9 1 these projects will do any good at all? 10 MR. POSTA: Lil, would you like to respond to that? 11 MRS. RESNICK: They had a great deal of voluntary 12' support, which hasn't come through 3_n the application, but et 13 has come through on their estimates, available funds from other 14 sources. 15 MR. POSTA: Mr. Webster, from the Regional Office 16 in Denver. 17 MR. WEBSTER: If I might, I have watched the South 18 Dakota Regional Medical Program for quite awhile., and like 1 !I both of the Dakotas, those people seem to know how to stretch 20 a dollar pretty well. They don% have that many to begin with. 0 21 Actually only I think of the total amount requested, 0 2" 1 they only have four staff right now, two professional and ~~1 / two secretarial backup. That accounts, with fringe benefits, 24 for the some 44. 25 The have tknTee major projects, which would have tiOOYERREPORTlNGCO,INC. 320MassachusettsAvenu~,N.E. Washinaton.D.C.20002 HOOVER REPORTING CO, INC 320 Massachusetts Avem, N. Washington, D.C. 20002 3 1 1 1 1 1 3 1 1 1 2 2 2 2 2 2 1 2, 3 / 4 5 6 'i 8 Ii 9 .O .l 2. 3 4 5 li 7 8 !f 10 !I 12 Ii 3 / d 3 I. E. 51 continued even had the RMPS actually terminated. One was support the EM3 program with the moneys being directed to the State Health Department, tih ich heads up that program; one to Mount Marty College for an extension health educa- tion program reaching on to Indian reserva.tions, and similar one in the northern part of the state at another university. They have in here put in a number of small starts, all of which would be to support other organizations and agencies to do their thing. They really were not trying to dc much except to coordinate and try to stimulate. They are a farming out type of operation that has been looking for good applications even though very small in money, and I think it is quite viable. DR. ROTH: I move approva 1, c ----_ .."-~~.r^n_n.nl~.--r' MR. POSTA: I think your point is quite well taken. DR. ROTH: I move approval as recommended by staff. .- -U'""-' `-' -*"`-.N-l",l-* .a-*.-- ,*Y,.,... _"~:. . . ~II;.. .lu,L . . . . ,=__lql_ ,_._, DR. CANNON: Second. .., I,. 11. ...I . ,_. _. a.7 ., ,hil,:/.< .,._ .a<.. _i .J.*";, , "`"rr,urr~~T""`"yr~~ MRS. SILSBEE: That is approval at $120,680, Does that include operations? DR. CANNON: Change to operational status. DR. RCYJJH: Yes. MRS. SIL`%EE: Change to operational status. Any further discussion? MR. WILLIKEN: Question. MRS. SIKSBEE: All in favor? 2 MRS. SILSBEE: Opposed? 3 (No response.) 4 MRS. SITLS33EE: That is carried. a 4D 5 l; 7 8 9 10 11 12 * 13 14 15 16 17 18 '1!1 2C 0 21 0 2; 2:' 24 `S 2` HOOYERREPORTlffiCO,lNC. 320 Massachusetts Avenu?, N.E Wash&ton, D.C. 20002 1 (Chorus of "ayes. ") Now I the next one is Colorado-Wyoming, which Dr. Rot ---*------4 -*- --~wrn-,.u .,.. .,.,. %.i.*.,~-,Y~~ e,,,.,.j" ,w, ,,I w.,., ,,,,. ",, , r~T( .:rr**w-,~`ic~ ./, 3.2 i __,,. -..`