ALABAMA 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) ALABAMA REGIONAL MEDICAL PROGRAM RM 28-03 (AR-1-CSD) 2/71 The University of Alabama in Birmingham January 1971 Review Committee The Medical School Center 1919 Seventh Avenue South Birmingham, Alabama 35233 PROGRAM CO RDINATOR: S. Richardson Hill, Jr., M.D. REQUEST FOR NEW FUNDS (Direct Cost Only) REGIONS OPERATIONAL YEAR 03 04 05 Total I. Core (Renewal) 558,061 790,921 839,284 2,188,266 II. Approved Unfunded Projects (5) 243,669 163,770 -0- 407,439 111. Renewal Requests (Projects) (2) 173,827 172,323 177,858 524,008 IV. Developmental Component (3 yrs.) ioo,ooo 100,000 100@000 300,000 V. New Projects (10) 800,852 762,914 457,971 2,021,737 Total Request 1,876,409 1,989,928 1,575,113 5,441,450 (Project #26 -Nutrition Project, Tuskegee, Alabama (Model Cities-RMP) an approved 6nfunded project will be funded with earmarked funds for model cities activities, per recommendation of the Acting Director of RMPS) Funds re@uested for this project have been omitted from the total request for approved unfunded projects (Item 11). RMPS Staff Review of Non-Competing 03 Year Operational Continuation Grant Application (December 17, 1970. Recommended Award Commitment REGIONS OPERATIONAL YEAR 03 Year 04 Year I. Core (Sub-Regionalization) tl78,658 -0- II. Ongoing Projects (2) 61,342 -0- Total $240,000 -0- FUNDING HISTORY (Direct Cost Only) Grant Year Period Funded Planning S@e 01 1/l/67 - 12/31/67 $ 247,250 Alabama Regional Medical Program -2- RM 28-03 (AR-1-CSD) 2/71 Planning S@e Period Funded 02 1/l/68 - 12/31/68 $ 286,750 02S 6/l/68 - 8/31/68 11,695 02S 9/i/68 - 12/31/68 113,392 03 I/l/69 - 3/31/69 131,526 opeiational.Stage 01 4/l/69 - 3/31/70 Core 542,369 Pro.jects 192,509 Total 734,878 Ol(S) 4/l/70 - 3/31/71 Core 101,492 Projects 39,365 Total 140,857 Ol(S) 4/l/70 - 3/31/71 Core 160,490 Projects 40,145 200,635 CEOGRAPHY AND DEMOGRAPHY: Alabama ranks 29th among the states with 51,609 square miles of land. The most recent population estimate (.Health Department's Bureau of Vital Statistics, 1967) is 3,562,850. It has a large rural population with a large Negro component (30'/.). In per-capita income Alabama ranks 47th among the states. In this state there are 67 counties - 35 northern counties are in the Appalachian development district. Trade, industrial and transportation patterns group the counties into areas similar to the seven used as the geographic framework for planning the Alabama @IP. The Alabama Region, as presently defined, represents some admixture of interest and health service functions between the extreme southeastern part of Alabama (especially the Dothan area) and adjacent parts of Georgia and Florida. The similar admixtures at Phoenix City, Alabama, with Columbus, Georgia, and in a few places along the Mississippi broader. The several interfaces across the political boundaries do not present problems and Alabama Regional Medical Program works compatibly with those that surround it (Mississippi, Florida, Georgia, Memphis and Tennesee Mid-South). The single Medical Center located very near the geographic center of the region contains the only complete constellation of medicalldental and nursing and allied health sciences resources for teaching research and service in the state. In an economic sense Alabama lies in the center of the cotton belt of Alabama RMP -3- RM 28-03 (AR-1-CSD) 2/71 the old South. Although agriculture remains a vital part of the states economy, a rapid increase in manufacturing and diversified industries have given the area a more balanced economy in recent years. Live stock, especially poultry, has become quite important to the economy. Alabama ranked second in the nation in pulp wood production. Additionally, lumber, furniture and wood projects are important. Bituminous coal, iron and bauxide are among the national resources of the state. - There are a total number of 67 counties in Alabama and there is a 64 person per square mile density in population distribution throughout the state. The major portion of the population of Alabama is Iodated in the Metropolitan areas of Birmingham, Columbus, Georgia,- Alabama Catsden, Huntsville, Mobile, Montgomery,, and Tuscaloosa, Alabama. Approximately 55% of the population of the state is urban. The medium age of the population of Alabama is 26.0. Approximately 70'/. of the population is white and 30'/. of the population is Negro. There is only one medical school in the state of Alabama, the University of Alabama Medical Center, which has an enrollment of 300. There are 14 schools of nursing of which two are collegiate institutions; 12 schools of medical technology of which 9 have a college affiliation; one school of cytotechnology at the University of Alabama; eight of x-ray technology with three having colige affiliation; and a total of 140 hospitals of which nine are federal and 131 are ndn-federal. The total number of hospital beds available in Alabama are 26,553 of which 4,1 0 are federal facilities and 22,413 in non4federAl facilities There are a total of 2,842 physicians and there are four osteopaths in the state of Alabama which is approximately a rate of 86 per 100,000. There are a total of 7,150 nurses in the state of which 5,272 are presently active which is a rate of 159 per 100,000 population. HISTORY OF REGIONAL DEVELOPMENT: On July 17, 1965, the Medical Association of the State of Alabama appointed an Ad Hoc Committee to investigate the recommendation of the Presidents Commission on the treatment of stroke, heart disease and cancer. After careful study the Ad Hoc Committee recommended that all programs of the Regional Medical Programs be centered in the Medical College, University of Alabama but should be operated with the approval and guidance of the Medical Association of the State of Alabama and the State Board of Health. On April 9, 1966 in anticipation of action under Public Law 89-239 the Governor George Wallace, appointed a State Advisory Regional Medical Program Committee. The members of this committee were nominated by the president of the Medical Association, State of Alabama and the Dean of the Medical College and included representatives of the Allied Health Professions, Voluntary Health Agencies and Consumers. The group recommended that t'he University of Alabama Medical Center be designated as the responsible agent for planning for the Alabama Regional Medical Program. Alabama RMP -4- RM 28-03 (AR-1 CSD) 2/71 The'region's initial planning grant was awarded for a 2k-year period beginning January 1, 1967. A total of $247,250 d.c. was awarded the first year. A second year award plus two supplemental awards which provided support for a subregional planning office in Mobile made available $411,83'@ for planning during the second year. During this planning phase the program coordinator for the region was Dr. Joseph F. Volker, Vice-President for Health Affair-% University of Alabama Medical Center. In the initial review of the planning application the National Advisory Council expressed concerns that the Regional Advisory Group of the Alabama Regional Medical Program did not have representation of the consumer public minority interests, dentists and nurses (and there appeared to be token representation from the state hospital associations The application also made no specific reference to an analysis of the overall medical needs of the region. There was inadequate allocation of administrative responsibility including failure to define the mechanism for coordinating the planning among the professional staff, the Advisory Committee, and the State Board of Censors. There was no systematic analysis of resources; no reference to work that had already been done in this field; no specification of cooperative arrangements among institutions to be involved, and no consideration for planning the most effective allocation of existing resources and personnel. On the basis of this criticism from the National Advisory Council the- region revised their planning application at which time the National Advisory Council did approve the planning grant which essentially satisfied earlier concerns. On November 1, 1968, Dr. John Packard was appointed director of the Alabama Regional Medical Program succeeding Dr. Benjamin M. Wells who then became Coordinator replacing Dr. Volker. The region submitted its first operational application on August 27, 1968, requesting $1,928,327 for the first 12-month period to begin January 1, 1969. It included 12 operational projects. A site visit was conducted on December 5, 1968 to determine the readiness of the Alabama Regional Medical Program for operational status. In reviewing the operational application the National Advisory Council indicated that the Alabama Regional Medical Program was in the early stages of maturity. The Council expressed the hope that the Regional Advisory Group would become more active in a leadership role under the direction of its new chairman. Also required would be an addition of a full-time program director in evaluation c-f personnel, and the role of Core staff was expected to be strengthened. Council did note that the site visit team found the staff to be generally competent and under effective leadership. The role of the staff in establishing links of communication and in capitalizing and channeling ideas and ongoing activities was noted as a major strength of the program. In conclusion, the Council concurred with the recommendations of tile site visit team which approved four of the eleven projects considered and recommended a total first year direct cost award of 734,878. In March 1970, Council approved a Core supplement for subregionalization of the Alabama RMP which involved the establishment of seven subregional ;::@ I ... f. , I I @".. .;@ Alabama RMP -5- RM 28-03 (AR-1-CSD) 2/71 offices. The region proposes through the core supplement to accomplish regionalization and coordinate RMP activities in Comprehensive Health Planning in the region. This region is unique in that the Alabama Medical Society is the official health agency at both the state and local level. This organizational framework gives the Medical Society responsibility for administering activity under title 18 and 19, "the partnership for health" (PL 89-749). In May 1970, a site visit was conducted to this region to take an in- depth look at the region's core and projects. The impression of the site visitors was that the Alabama RMP could eventually have one of the strongest health care programs of any state, if its overall scheme for integrating the strengths of the University, the Regional Medical Program, the State Medical Society and Comprehensive Health Planning is made to work. The RAG has been increased from 42 members to 62 members. The increase in membership has been directed toward expansion of consumer representation on the RAG. Each of the seven subregions were asked to appoint two candidates and six additional members were selected at large. In order to increase minority group representation on the RAG, each subregion will be required to select a minority group member as one appointee. With this increase in consumer representation on the RAG, the majority of advantage previously held by the Alabama Medical Association and the University of Alabama will no longer exist. The increase in involvement of the local community representatives on the RAG facilitates the regionalizatibn process of this region. Dr. Robert Ross McBride present chairman of the RAG has indicated that the RAG will continue to select aschairman a practicing physician from communities away from the Medical Center. The region believes that this will improve the relationship of the ARMP with community physicians throughout the region. PRESENT APPLICATION: This is the triennial application in which the ARMP has requested a Cote renewal of 2 projects, a dvelopmental component, supplemental funding of ten new projects, and continuation of a core supplement ( subregionalizat.ton) and two projects. The ARMP's proposed activities for the next twelve months are identified as follows: 1. Core Staff (a) Program Planning and Development - to implement plans for program direction as determined by long-range planning an executive committees,, Regional Advisory Group, and key staff members. (b) Project Development and Review - Try to develop a method of project development with increased involvement of RAG members Alabama RMP -6- RM 28-03 (AR-1-CSD) 2/71 and less staff time. To develop a more impartial project review process. (c) Program Management - To maintain and improve management methods of programming projects in areas of personnel and physical procedures. (d) Education - A three year plan for.involvement in the education of' Health Manpower in Alabama. To help and assist in the implementation of an overall regional plan of basic and continuing education for health workers in Alabama in order to improve the Health Care Delivery System to the people. (e) Communications - To increase the awareness of ARMP activit,ies within the region, especially the need for program consistency. To improve communications systems with core staff. (f) Program in Project Evaluation - To design evaluation methods for each ongoing project and to assist in writing new project proposals so that they include a cleaner and measurable set of objectives with a design for evaluation. To evaluate means and methods to achieve maximum utilization of ARMP dollars spent in the region. Continue to evaluate future medical needs of the community and determine what steps the providers of care must take immediately to meet these needs. To prepare a statement of health base ine data for the region which can be utilized as a comparison for future program evaluation. (g) Consultation - Key staff members, i.e., those in Associate Director and Assistant Director positions, will be responsible for consultation activities for the programs constituency. Consultation will be based upon the staff members role in the program, however, all consultation activities will be sensitive to the health needs of the state. 2. Subregional Offices The Birmingham and Montgomery subregions have established lists of objectives and priorities for the 314 (b) agencies. The ARMP-funded health planner in the Birmingham office, Mr. Al Rohling, will be involved in implementing these under the direction o Mr. George Rice (Executive Director, Community Service Council), while acting as liaison with ARMP by attending meetings with core staff and RAG. In M6ntgomeryMr. David Carter has been named Executive Director of the state approved bu unfunded 314 (b) agency. Be will be involved in further community development, identification of possible local sources of matching funds for the time when federal funding is available, and in identifying project proposals which would alleviate local needs and be appropriate for ARMP funding. Activities of the other four subregional health planners, all of whom have been appointed for less than four months,will center about the involvement of local providers and consumers into a viable health planning council which can qualify for 314 (b) Alabama RMP -7- RM 28-03 (AR-1-CSD) 2/71 status and which can identify local needs, set realistic objectives and arrange most of@the next grant period. The following years will be utilized to implement the plans. Two regions (Tennesee Valley Area in Northern Alabama and the recently delineated Selma Area) have not yet been able to identify mutually satisfactory health planning councils. Core staff will continue to be involved, with representatives of the 314 (a) Agency, in encouraging the formation of such councils. This will probably be accomplished during the early part of the next grant period for the Tennessee Valley Area, and funds for hiring a seventh health planner Are contained in the Continuation Application portion of Core staff. The Selma Area will probably not be in a position to use a health planner until.the period 4/i/72 - 3/31/73 and funds are being requested for this position in that and the succeeding grant period. 3. Grantee Institution The Executive Committee of RAG recommends that part-time salary support to faculty members and support to staff be constantly reviewed to insure that effort and time expended on ARMP duties be probably compensated. Full-time staff will probably reduce the need for part-time staff with consequent benefits in management. They are further strongly recommending that the grantee institution appoint a full-time coordinator in line with their previous actions. Committee also recommended that data collection be purchased on a contract arrangement. The ARMP explains that office space for Core staff needs expansion, which cannot be effected in their present location. They indicate that during the next few months the Core staff must move into adequate quartets. 4. Regional Advisory Group At their June 1970 RAG meeting the members and Core staff identified the following as major issues needing work or improvement if the ARMP is to fulfill its potential and has recommended actions which have been started and will continue during the next twelve months: 1. Inadequate communication between RAG and Staff. 2. RAG involvement in project development And review. 3. Relationship between RMP, RAG, and UAB to be clarified. 4. Confused relationship between CHP and RMP. 5. Inadequate consumer involvement. 6. Decentralization - what and how much? 7. Programs versus projects The RAG also reviewed the following major program areas: 1. Consultation and resource service. 2. Continuing Education 3. Manpower development 4. Medical Services. RM 28-03 (AR-1-CSD) 2/71 Alabama RMP In addition, the RAG is undertaking a reassessment of ARMP goals, objectives and priority setting which will be a continous-process occupying at leIsat the next grant period and will probably continue throughout the next three years. The categorical committees of RAG will be assisted by staff and outside consultants to reassess the planning goals established earlier and set priorities. A in depth study of the advantages and disadvantages of changing grantee institutions will be undertaken by an Ad Hoc Committee authorized by the Executive Committee of the Regional Advisory Group which appreciates the problems which arise from too close an identification of ARMP with the University of Alabama and which may become more acute when the proposed medical school in Mobile opens in 1973. ORGANIZATIONAL STRUCTURE AND PROCESSES The Regional Advis rou The size of the Regional Advisory Group has been increased to include more allied health personnel as well as consumers. This growth is responsible for a broader geographical representation which is in part responsible for the change in program emphasis from continuing education to manpower development and delivery of medical services. The RAG has been concerned with establishing a separate identity for ARMP to sity of Alabama in Birmingham (UAB). In set it apart from the Univer June 1970 the recommendation was made that a full-time coordinator be appointed by Dr. S. Richardson Hill, Jr., Vice-President for Health Affairs at UAB. Dr. Hill assumed the title of Coordinator without salary support in January 1970. In October 1970, the Executive Committee of the RAG authorized appointment of a committee to study the advantages and disadvan- tages of changing grantee institutions in light of plans by the University of Alabama, Mobile, to open a new medical school by 1973. The Regional Advisory Group is named by the applicant with the advice of the Chairman of the Regional Advisory Group. The membership of the Group shall be composed of members representing each of the following institutions and organizations, in number indicated, together with thirteen members at large representing the general public interest. Medical Association in the State of Alabama 8 University of Alabama Medical Center 8 Alabama Dental Association I Alabama Hospital Association 4 Alabama State Nurses Association 2 Alabama Heart Association 4 Alabama Division of the American Cancer Society 2 State Health Department 2 Vocational Rehabilitation Services I Veterans Administration I Subtegional Advisory Group (2 each) 16 Members At large 13 Total 62 Alabama MV -9- RM 28-03 (AR-1-CSD) 2/71 Executive Committee: An Executive Committee composed of no less than five nor more than ten members shall be electedby the Advisory Groupt The Executive Committee is authorized to act for the Advisory Group between meetings subject to subsequent approval of the Advisory Group. The Executive Committee has bIeen composed of representatives from the offices of RAG, the Presidents of the Medical Association of the State of Alabama, the Alabama Hospital Association, a Chairman of the Board of Censors of the Medical Association, the Dean of the UAB School of Medicine, the Vice-President for health affairs of the UAB, the State Health Officer, and the Coordinator of ARMP, and thus involve the responsible officers of the most significant health providers and educators In the state. Recognizing the desirability of having n smaller committee, to include consumer representation and with the majority of members living in or near Birmingham, the 1970 [LkG elected a six member Executive Committee comprised of the officers of RAC, the President of the Medical Association, and two laymen, one of whom is a past President of the Community Service Council (local 314 (b) Agency) and still serves on their Board of Directors. In addition,the Chairman of the Board of Censors, the Vice President for Health Affairs of UAB (who is also Coordinator of ARMP), Coordinator for Research Grants of UAB and the Director of ARMP are ex officio members. Education Committee: The Eduaation Committee has been composed of faculty members of the UAB School of Medicine, Dentistry and Nursing which represented the resource for education of the providers The committee has been expanded to include representation from propective students, junior and senior colleges, the Alabama Hospital Association, guidance courneLlors, and from vocational education. The Project Review Committee: This (,oiiimi.ttee,witti membership from the 7A(7, UAB and Core staff @tis t8stimed n portion of the functions of the Development Committee In review of proposals and of the final draft of project application before RA(; review. Long-Range Planning Committee: This Committee with membership from RAC,, CHP, Appalachian Regional Commission and Core staff, assumes the remaining function of the development committee, including making recommendations for short and long-range goals, objectives,, and priorities, evaluation mechanisms and methods of implementing the programs. Developmental Component Committee: This Committee with members drawn from RAG, the Office of Grants Administration, UAB and Core staff, will review and act on proposed expenditures from the developmental component. Allied Health Advisory Committee: ]'his Committeest membership represents 13 different categories of nursing and other allied health personnel ind it provides a forum for discussions of Inter-disciplinary nature, focusing on common health problems. The Committee recommends stidies to determine education needs of practitioners and encourages projects related to improving the expertise of these practitioners based on these identified needs. Major attention is given to allied health manpower needs and the Committee addressses itself to manpower distribution problems RM 28-03 (AR-1-C8D) 2/71 Alabama RMP -lo- Categorical Committees: These Comittes continue to be responsible for planning, screening and evaluation of proposed activities in their field of interest. There are categorical committees in the followi ng areas: 1. Heart Disease 5. Diabetes 2. Cancer 6. Dentistry 3. Stroke 7. Rehabilitation 4. Renal Disease Each of the above committees, by its membership contributes to cooperative relationships, and each contributes in one fashion or another to planning and-project and program review. Sponsor Review Committee: This is the Committee of the grantee institution serving As an Advisory Committee to the Vice-President for health affairs and the Director, ARMP.' The committee reviews all ARMP proposals, both Core and affiliate based, from the point of view of the grantee institution, to determine that no ARMP sponsored activities are in conflict with state laws, UAB policies or institutional objects. Following is the A@14P Organizational Chart. A L A A N! A r: G I C"e.1 A L N@,, I.-= D RCGPA,'vl Ot,GAi%'IZATIO'@,VAL CHART Regional Advis" Gro!.!p UNIVERSITY OF ALABA@AA I,% BIR@Alr4GHAI%,l (Policy & Di.-.-cton) '%"CO,'RD I NATOcl Fi:.:ca! n I S. Pic;,-,)rdson Hill, jr.,,,,vi.b. c @ibilit,/, R. R. @i',c:')ryde, IND., Ch@-irry,,in S. Richardson Hill, Jr., tA.D. Vice-President for Heaith Affairs 1, LO: h P s L c n Robert P. Glaze, Ph.D. (CHP, Appalachia, VA 'tC'.iicf Pxect.,tive Office-) Coordina+,or of Research Grants M@odel Cities, tiil!-Pur-to'n) join P@-cka'rd, @A.D. Lester H. Buryn Office of Grants Administration Dc@Llty Director i%4. D. P'io@vden A@ciate Director F-Acting A,-3ciate Director 13te Dim--tor, Preeram D;mntcr Plarni!lft ard ?rc-,ram Ec!ucarion Deve:oprnent Manage@nt & Cer,-.rnuni@-atiIons Associate Director Evaluation Profc--@ons' Li.-ison 'a Laurene Gi.@re rres Robe@son L),-vid Cusic J. 0. Finri--v, %@.D. Assistant Director C@inater Community Pro.W Director - ons Associate D@or, nt Director, %Ittrst..v Research & Development OPOF ti I Donald Pi ince perational ProlLcts John Gillespie John Durant, V,.D. ld3 ?,A. Reed As!irant Director Associate Director, He3rt Assistant Director Health Planners L Cor-.municat',ons Su,-t,3t Analyst Stro!-e AudiovisuBIs Suhrecional O'fices J,- a n m n Virgir.',a Suryn Harold Sc,inaper, M.D. Robert Siavi OQ m A=nci,-!e D'..cclor fo- A."oc;ate Di -@tor, Kier" P, owptrs V.A. Thor,-os E. Andre@!i, !,4.D. (2@ V.A. Birmingliam October, 1970 -12- RM 28-03 (AR-1-CSD) 2/71 Alabama RMP Core Staff Organi2;ation: ram has 56 The Core staff of the Alabama Regional Medical Prog employees, 40 at 100'/. time. and effort. Following is a chart which indicates the percentage of personnel costs as applied to the categories of ARMP proposed activities: 15% Program Planning and Development 14'/. Project Development and Review 1 V/. Program Management 21% Education 12% Communications 13'/. Program and Project Evaluation ir/. Consultation There are two parts of Core which have to be considered in this application, (1) the Core basic, (2) Core subregionalization4 Core basic represents a renewal request which must be reviewed by the National Advisory Council and Core sub-regionalization is a continuation request for funds committed and authorized last year as part of a two year RMPS grant award. Although the Core subregionalization project was reviewed and approval was recommended by staff,this activity should be taken into consideration when reviewing the request for Core renewal because in 04 and 05 operational years of this region,the amounts necessary to continue this activity have been included in the total request for Core. (!ore basic budget of $558,061 direct costs compares with the current budget of S576,109. This represents anincrease of slightly less than $32,000. The region indicates that this is a minimum increase in the light of expanded proposed activities. The ARMP Core staff will in the next twelve months be engaged in multiphased programs as outlined in the proposed activities segment of the application. It should be noted that the program management phase includes administrative and supportive activities required to issist in the establishment and operation of subregional offices. The personnel category accounts for approximately $17,000 of the requested increase for Core basic. This increase is influenced by two major items: (1) the grantee institution (UAB) will expand its benefit programs requiring an increase from 13'/., to 18'/. on all 1971 Federal Grants to reflect a planned increase in Social Seciirity Payments, Unemployment Compensation, TIAA, State Retirement and Health Benefits which will take place during the fiscal year 1971 - 1972, and (2) a minimum merit raise (5%) has been included on all filled personnel positions. The following is a list of the Core staff members of the AR@IP including the staff utilized in the Core Subregionalization Program. Alabama RMP -13- RM 28-03 (AR-1-CSD) 2/71 % Hours Name Job Title or Function Time or Effort (Basic) V. Buryn Budget Analyst 100 C. Calvert Secretary 100 C. Crooks Adminis. Secretary 100 D Cusic Assoc. Dir. Planning 100 J: Finney, M.D. Assoc. Dir 0 . Prof. Liaison 63 J. Gillespie Ass't Dir. Operations 100 L. Gilmore Assoc. Dir. Education 100 W. Green Secretary 30 D. Hall Secretary 100 I. Harper Secretary 50 R. Hernandez Resident & Staff Ass't 75 M. Hunt Research Assoc. 33 S. Johnson Secretary 33 C. Joiner, Ph.D. Research Analyst Advisor 30 M. Klapper, M.D. Con't Med. I?duca. Advisor 10 A. Lamb Adm. Ass't l@nnifly Serv. 100 M. Lee Ass't Director Nursing 100 M. mccool Secretary 20 P. Osborn Senior Secretary 100 J. Packard, M.D. Director ARMP 100 D. Patterson Acting Assoc. Dir. Eval. 100 J. Pigman Research Analyst 80 MO Plowden, LLB Deputy Director 100 D. Prince Ass't Dir. Graphic Arts 100 I. Reed Coord. Comm Res. & Dev. 100 J. Robertson Assoc. Dir. Prog. Mgt. ioo H. Schnaper, M.D. Ass't Dir. Heart & Stroke 25 S. Sentell Secretary 100 R. Shaw Administrative Ass't 100 'I'. Sheehy, M.D. Medical Service 10 L. Sheffield, M.D. Medical Service 10 L. Shield Secretary loo E4 Sigler Secretary 100 G. Slattery Senior Secretary 100 r4. Snow Senior Secretary 1.00 .J. Watson Ass't I)ir. Commtjnicntioi-is 100 C. Whitman Secretary 100 TBA Program Dev. & Eval. Spec. 100 TBA it 100 TBA Secretary 60 L. Wilson Secretary 50 (S-(.ibregionalization) C.',,. Porter, w4.D. Director Medical Education 50 D. Carter, Adm. Health Planner 100 G. Mosley, Adm. Adm. Assistant 100 J. Brown, MHA Health Planner 100 M. Payne Secretary 100 W. Moore, MHA Health Planner 100 G. Calhoun Secretary 100 E. Cleino, Ed. D. Health Planner 100 P. Culley Health Planner 100 A. Rohling Health Planner 100 TBA (2) Health Planners inn Alabama RMP -14- RM 28-.03 (AR-1-CSD) 2/71 The day-to-day operation of the ARMP activities are supervised by the Director John Packard, M,.D. and the Deputy Director M. D. Plowden. The Corelstaff of the ARMP is quite involved in project development, implementation and monitoring of activities supported by the ARMP. These activities of Core in relationship to project are clearly identified in section III-B page 43 of this application. PROJECT REVIEW PROCESS The Region indicates that the project review mechanism at the Alabama Regional Medical Program is presently undergoing some positive changes. The program is placing u!ore emphasis on the following: (1) Crystallization of policy and initiative upward rnther than being imposed from above; (2) There is maximum participation by the voluntary and private sector at the grass roots level. The feeling at Alabama Regional Medical Program is that consumers must play a stronger part in establishing policy and making major decisions effecting the delivery of health care and determining the needs in the community in which they live. The ARMP indicates that project proposals originate from a variety of sources and from many sectors within the region. Assistance in project design and evaluation, methodology is provided by Core staff elements. If the proposal originates from a subregion with a functional area Advisory Group and is applicable to that region, it is reviewed and approved by the area Advisory Group before submission to ARMP in su mmary form with a tentative budget. The concerned County Medical Society (ies) review all project proposals prior to submission to ARMP. Upon receipt, the AIOIP Core staff reviews proposals to assure conformance with overall program objectives nnd provides initial administrative screening. At this time the Medical Association of the State of Alabama and their Board of Censors are Informed. The region identifies a checklist form which is on page 17 of Section ITI-I@ that will be utilized during the 1971 fiscal year by tile ARM]' staff for review of I)ro.ject proposals. Under the coordination of the Core gtaff,projcct proposals @ire retired to the following standing committees: (1) To the Categorical Committee for professional and scientific review. (2) Project Review Committee - for technical review, feasibility determination and for delineation of evaluation mechanism ' This committee may also measure the project proposal against the regional framework or planning matrix of the Region. (3) Sponsor Review Committee - This committee for the grantee institution reviews the proposal to assure conformance with University fiscal policy and procedure and coordination with existing efforts of plans of the university in related fields. The APJIP Core staff is responsible for coordination of all planning and operational activities with the Comprehensive State Health Planning Alabama RMP -15- RM 28-03 (AR-1-CSD) 2/71 Agency (PL 89-749) and other major planning groups in the region such as; CHP (b) Agencies, Appalachian Regional Health Planning Commission, etc. The Comprehensive Health Planning Agencies (both (a) and (b)) as well as the Appalachian Regional Health Planning Commission Review and comment on ARMP projects before submission to the RAG. Favorably considered proposals are then presented to the RAG for final review and approval or disapproval action or disapproval action. A checklist form has been developed for utilization by the RAG in their review of projects. This form can be seen in section III-D Page 19 of the application. ANNUAT REPORT OF THE REGIONAL ADVISORY GROUP @G The RAG identifies in its report the following Regional objectives which were modified in Jurel970: (1) to increase and improve total community involvement in both the problems in modern health care and their potential solution; (2) to stimulate and support the creation of new health service manpower and to improve their distribution and utilization throughout the region- (3) to provide remedial and continuing education for the entire health service team in relevant categories. The RAG indicates that progress toward each of these objectives is essential to viability of ARMP and its service to the people of Alabama, but first priority must go to that area where the need is demonstrativel)lgreat, long- range benefits are likely to be most important when there is community involvement achieved througisubregionalization, liaison, and promotion of cooperative arrangements. The RMPS has characterized its relationship with Comprehensive Health Planning as outstanding. Individual RAG members and Core personnel are continuing to work toward even more effective arrangements with CHP, and at the same time are developing support and cooperation involving many other organizations concerned with hea th. The RAG explains that subregionalization is the key mechanism W-iere y total community involvement and cooperation may be accomplished. They indicate that this is progressing well with area offices established and competently manned In five of the subregions, with prospects good for early establishment of the remaining offices despite reorganization of the region to increase the number from seven to eight subregions, conforming to the planning and development districts recently established by the Governor of Alabama. They explain that subregionalization facilitates continuing development of cooperative arrangements with the Medical Associa- tion of the state of Alabama, the Alabama Heart Association, the Alabama Charpter of the American Cancer Society, the Alabama Hospital Association, and may other state, professional, and voluntary health organizations. They believe that subregionalization is an important means for pursuit of all program goals because it functions at the "grass roots" level and enables close contact with the consumer. Tn order to increase still further the communication with the subregions, the IIA(; at the Ttii-ie 1970 meeting voted to increase its membership from 40 to 60 by adding two consumers for each of the subregions and additional members at large. Alabama RMP -16- Rm 28-03 (AR-1-CSD) 2/71 Through representation on the RAG and through the plannned eff:ort of staff, virtually all significant health-oriented organizations have effective liaison with ARMP. This is accomplished at state-wide and to an increasing extent, at county and local levels. Core personnel include an Associate Director for Professional Liaison, Dr. J. 0. Finney,Sr., and a Community Service and Development Office, staffed by Miss I. M. Reed. In addition.core staff members are active in a variety of professional associations. The secondARMP objective improvment in supply and use of health manpower has been pursued by initiating projects such as the medical information service by telephone, nursing utilization studies and a state-wide coopera- tive mechanism involving the states junior colleges and the Regional Technical Institut6 in training allied health personnel. In addition, ARMP has supported development of the Division of Family Practice and Ambulatory Medicine at the School of Medicine, training programs various types of assistance and exposure of medical school faculty and students to community hospitals. The l@G indicates that health career recruitment also is an objective of ARMP effort directed toward the goal of alleviating serious health manpower shortage in Alabama. The staff of the ARMP has invested many hours with the Health Careers Council of Alabama, the Alabama Hospital Association, and other groups developing ways to educate career guidance councilors concerning health careers an to irect the attention of young people to the satisfaction of work in the health field. Work toward the third objective to provide remedial continuing education has been approached through continuing medical education which has been the primary objective of several ARMP projects and an important aspect of several others. A RAG committee is concerned with a supplemental education and a staff member devotes full time to regional and subregional educational programs and educational consultant services in the health field. The ARMP cooperates with the UAB School of Medicines Division of Continuing Medical Education and with the Medical Association of the State of Alabima to provide educational services. Audiovisual and other educational materials are available through ARMP and more will be offered as they become available. @AC- explains that a significant but lower priority aspect of the A@-l-'-P t.tirust which requires, nevertheless, a good proportion of staff time and effort, is consulting and resource services. Here again an important function of the program is as a catalyst, to encourage cooperation among various agencies and to force their activities by others for improvements in both the nature and availability of health care. Position papers for Comprehensive Health Planning, consultation on Appalachian Regional Health Planning Commission Projects, provision of Audiovisual materials in guidance in health curricular technology are examples of this service. The Regional Advisory Group indicates that they had much difficulty Alabama Rt4P -17- RM 28-03 (AR-1-CSD) 2/71 in setting priorities within a specific program area and even greater difficulty in setting priorities between program areas. The RAG has however, submitted a priority listing of projects which is located in Section II page 7 of the application. The ARMP indicates that formal endorsements and letters of support have been given to the ARMP from all major health organizations within the region. They claim excellent rapport exists between the ARMP and the other two large Federal health planning programs within the region - Comprehensive Health Planning and the Appalachian Regional Commission. In addition to joint sharing of staff with the State CIIP Office In Montgomery, an(] the Appalachian Regional Commission In Decatil,ir, the recently funded stibreglonnllzatloii program provides a health pl.anner In each of the seven subregions In titi(, State who are responsible for assisting In the development and Inltlntlon of a 314 (b) agency for his subregion. The RAG indicates that one of the most serious challenges facing Alabama today is how to provide medical services to poor people in both t e rural and urban areas of the State. They identify subregio6alization as an activity which concentrates attention at the site of the problems in health care for the poor. The Alabama Regional Medical Program as been instrumental in setting up the Lawrence County Project, which is about to get under way with the Appalachian Commission,and to some extent, Blue Cross funds. ARMP will be a consultant for this project which emphasizes ambulatory care. A nutrition project aimed at areas of national priorities Including Decat4'i'r has been submitted and approved and plans are to implement it by April. 1, 1971. RA(; explains halt although health needs of the poor i.n AlibirriA are indisputably seri,otis, specif'ic ,it,,itistics are not available to document those needs. basic information Is being gathered, however, on a county by county bnsis by several organizations in cooperation with APMP, The data will be available to ARMI) foe analysis in rel.ation to Income levels and other factors and will be a valuable guide in the development of future projects. Two areas which the RAG indentifies as ready for early consideration in developing activities that would be beneficial to the poor are: (1) extending hours of patient clinics, and (2) providing transportation to clinics for the poor people. The RAG believes that the ARMP has made a significant impact on the delivery of health care to victims of heart disease, stroke, cancer and related diseases during its first year of operation. The ARMP is largely responsible for preparing a statewide plan for the management of cancer. PROGRAM EVALU)VI"f.ON: The Alabama Regional Medical Program recently instituted a systematic and fndepth evaluation of all projects. Continuous evaluation of projects will be the responsibility of a full-time acting associate director for RM 28-03 (AR-1-CSD) 2/71 Alabama RMP -18 1, 1970, In addition to his evaluation who was hired by ARMP on June employment, a number of-other significant developments Occurred in the, .area of evaluation of ARMP projects during the past year. Some of these are the following: 1. The development of a written statement of the evaluation process and an evaluation model to be applied to Alabama RMP projects. 2. A similar development of the concept of evaluation as an integral part of project management. Evaluation is not an end in itself, but it is regarded as means to improve the effectiveness of project management. 3. The development of the concept of the positive contributions of an evaluation process. The positive contributions will be stressed by project directors. In addition to the necessary function of determining how well goals and objectives are being met, evaluation of ARMP projects will be used tp permit early determination of serious departures from goal directed action, to disclose unrealized opportunities and to provide the basis for public or institutional support for projects. 4. The upgrading of the evaluation skills of the ARMP Staff throuw,'ri the attendance at conference, meetings with key individuals at the national,regional and local levels and through other means. 5. Prelimary planning for program evaluation. The evaluation process used for ARMP projects consist of six steps. Following is a chart which illustrates the steps in the evaluation process which has been developed by this Region: RM @8-03 (AR-1-CSD) Ltli Alabama mmkl -19- C@IART 1 -i'ION PROCESS EVALUA -4 o,- P,-,ojc(,,,r GOALS ERP-,A]@@IATICj t- Step No. 1 (Broar-I S;"14L."-'ITiOi-ItS) DERIVAI-ION O'f- PF,,Oj"L:Cl' OBJECTIVES F,-, 0 i%4 P,'-IO J'7- %-,T GOALS Stei No. 2 DETEP,i'.,'-Iil']ATIO4@ O'- P@@--A@)URES OF O[),,.JECI'IV'r_- A-i"I'AIN@ili-:NT St"@ NO. 3 ',JT OF STANDAriDS ESTAI',LIS@IM,Ei Step No. (in terms of At-t:lli;iment stated tiiiits-co,,'t-b@iiefit ratios, etc.) '4 07 COL.LECT10i - DATA ON PEPFOrl@AANCE Step No. 5 COMPARISON 0-r NO. -A, A@-ID NO. 5 Step No. 6 (Actiial vs. Dc.,iirecl) SATISFACTORY UNSATISFACTORY Pvlorlif-I No. 2 Satisfactory rncllrjr Nc). 4 lrnprove Efficiency Reconiroie,-@d Continue Con-clusio,-i of (in,3ff icient Discontinu-,),ic,3 Project object or us-. of rpsources) Alabama RMP -20- RM 28-03 (AR-1-CSD) 2/71 Overall evaluation strategy is continually being developed and improved upon by the A104P. Changes in project development are taking place (that are in objectives, that are measurable for effective evaluation) because of improvement in evaluation techniques. It is Indicated in the application that evaluation is important in ARMP because of the management control it provides for funded projects. The Region believes that effective evaluation techniques will improve project development, increase control over funded projects, and lead to a more sophisticated program. DEVELOPMENTAT COMPONENT The ARMP has requested three years support for a developmental component at an annual level of $100,000. The Region explains that the plan for utilization of developmental component funds will be based on two principles: 1) close control and involvement of the RAG in seeking improvement in the quality and delivery of health services, and 2) rapid implementation of worthy proposals. Thus, the participation of RAG members should be maintained at a high level, and the loss of interest on the part of the proposer - sometimes causing apathy or occasionally antipathy now experienced with the present project review mechanism, should be avoided. The AP14P proposes a two-step review procedure for requests submitted to them for developmental funds. First, one of the RAG categorical committees, if appropriate, will assign priority rating to the proposal, in reference to the goals of the specific category. Second, the final decision on each expenditure will be made by a developmental component committee consisting of two RAG members, one of whom must be a member of the Executive Committee, and will act as Chairman; a representative of the Office of Grants Management of the University of Alabama in Birmingham; the Director, Deputy Director, and Associate Directors for Planning and Program Development and for Program Management of ARMP. In case of doubt on the part of Development Component Committee as to the appropriateness or level of funding request, a proposal will be referred to the Executive Committee for recommendation with final action determined by the RAG. In all cases, RAG will approve the expenditure of funds of the developmental component at the first opportunity and will forward to F14PS a summary of ttie proposal, a description of its developmental review, in relationship to area wide ARMP priorities. The Region indicates that the availability of the developmental component will strengthen inmeasureably the Implementation of their subregionalization. It is proposed to retain approximately 75% of those funds for ARMP to use for funding proposals which have a regional wide impact, similar to the study to determine the need for, acceptance of, and best method to implement statewide dosimetry for radiotherapy cancer, which resulted in Project #27 being submitted in this application. The remaining 25'7., of the funds will be a apportioned to each of the eight subregions. I%Illile the RAG and the Core staff will not define for each subregion, .,:,,-; @% I Alabama RMP -21- RM 28-03 (AR-1-CSD) 2/71 the procedures to be used in determining subregional needs, assign priorities, or propose review mechansisms, it will assure that the subregion has developed an acceptable procedure and that proposals for funding have been approved by the Area Advisory Group(AAG) before submission to the Developmental Component Committee. Core staff consultation and advise will be available, especially during the formation months of the Area Advisory Groups, and assistance will be given in project development if the proposal warrants such action. Should subregions not submit acceptable -,Droposals, funds will be distributed by RAG as they see fit. 'Ff)e region sees many advnntages to tli(., iil.loc@iti,on of funds to each subregion, such As the fo[ ow ng examples (a) For the "mature" subregion, such as tile five counties in tile Birmingham area served by an approved and funded 314 (b) agency which has published a list of needs and priorities, and which has an effective project review mechanism for implementation studies or projects for which funds are anticipated but not yet received, and for activities which are desirable but not fundable by other agencies and which could be conducted with such a small expenditure that formal project is not justified. Top priority in this subregion is improvement in health services to the poor. (b) For the subregions which have been organized and staffed (Northeast, Southeast, Northwest, Mobile, and Montgomery), these funds should expedite the process of assessing needs, setting priorities and developing a decision-making routine, should overcome any feeling that deserved support has not been forthcoming, and will help the RA(; and core staff communicate ARMP goals, priorities and accomplishments to the subregions so that a better perspective is obtained. Also, we hope such funds will make the planning process more fruitful. For example, one subregion has submitted a proposal to study the need and cost of providing hemodialysis service for the area. No evidence is submitted to show this is a high priority item for the area, nor that It has been reviewed by the local 314 (b) agency. The budget seems higher than necessary. Local determination of the best way to spend limited funds might we result in a different or less expensive proposal. (c) For the Tennessee Valley subregion, which has not yet found a common ground on which an areawide health planning advisory group (AAG) call be formed, and for the newly created Selma district which has not had time to organize, the funds in ad ition to t e available salary Developmental Component from persons In these areas will not be considered until an areawide idvisory group has been formed and found acceptable to ARMP. Although these funds combined will be less than $30,000, even smaller amounts have proved to be an effective lever in the formation ofcther Areawide groups. If, in addition, the available funds are diminished quarterly until an acceptable AAG is formed, the incentive may be greater. Alabama RMP -22- RM 28-03 (AR-1-CSD) 2/71 The reg ion explained that they cannot overemphasize the value of bei g n able to spend limited amounts of money in actions which have high local priority and which are Compatible with the objectives and goals of ARMP. This true decentralization allows local citizens to determine needs, and the availability of funds to implement approved proposals without many months delay which in turn will sharpen the priority-setting mechanism and insure more active and interested participation. As ARMP reviews the proposals from the subregions, it will give RAG a clearer constantly updated view of local resources, needs, and priorities, and will enable Core staff to disseminate (inovative) and functional ideas to other subregions. TheRAGheartily supports this concept of the developmental component. SUUPLEMENTAL PROJECTS: First Year Project ik27 - Regional Radiation Therapy Cooperative Treatment Request Planning and Dosimetry Project. Through the $122,791 Llniversity of Alabama Cancer Research and Training Program this project proposes to provide an accurate systematic and rapid means to determine readiation dosage through a computer-telephone system and through expert personal consultation visits to the requesting site. In addition, a physics support system is provided through on-site consultation. This provides advice and technical expertise to determine accurate radiation output. It is explained that this is a regional project, and Initially will provide services to seven geographically distributed hospitals through- out the state and will serve patients throughout the region. The project will provide through personal consultation another excellent medium for on-site continuing education, which will occur through the consultative process. It is explained that the ARMP goals and objectives are enhance by t is project and that the Core intent is to disseminate advanced medical knowledge to the local practitioner. In the priority rating of projects the region has ranked this activity as their eighth priority item. Second Year: $167,587 Third Year: -0- I-'ir.,;t Yeiii- Project #28 - Continuing Medical I-'dtication within the Regiiest Office of the Medical Association of the $73,034 '@tate of Alabama. The purpose of this project is to develop an office of continuing medical education with the @ledicil Association of the state of Alabama. Since this association is,in essence, the voice of the Alabama physicians, this project is designed to identify and be responsive to the continuing education needs of these health professionals. The new and creative instructional strategy will be explored in conjunction with ARMP and the Division of Continuing Education at the School of Medicine. Alabama RMP -23- RM 28-03 (AR-1-CSD) 2/71 The Comprehensive l@lealth Planning Agency for the Birminham area stated that the project represents a constructive approach to Continuing Medical Education for Physicians within the state of Alabama with the anticipated results of improving health care for the citizens of Alabama. The ARMP indicates that thi-s project will further strenthen the relationship between the School of Medicine, Medical Association of the State of Alabama, the Regional Medical Program and participating community hospitals. The Region in its priority rating of F)ro'ec@t.,,i his i-,Ii)ked this Ictivity 13th as a priority Item. Second Year: $75,806 Third Year: $81,929 Project #29 - Improving the Life of the Ostomate. First Year This project proposal is essentially a Request continuing education program for Allied Realti) Profes- $21,130 sionals and supportive hospital staff and concerns the physical and emotional care to be provided to the ostomate. The purpose follows closely the ARMP objectives of improving patient care through continuing education endeavors. It is to be implemented through physicians, a registered nurse, and ostomotherapists who will provide continuing education programs for health manpower within the region. In addition,clinical instruction to ostomates will be provided and will concern areas of physical management of ostomies. 'I'Iiis patient tlierapist's interaction will lead to a close interpersonal environment so that the eiiterostomal therapists can provide vitally needed emotional @,tippol-t for these Individuals. The long term gains of the proposal wll.'I. be the establish- ment of a program to train enterostomal therapist for the region. This project in the regions priority rating of projects Is ranked 20th as a priority i.tein. Second Year: $25,304 Third Year: $26,217 Project #30 - Intermediate Coronary Care (Jnit Instruction -- First Year Mobile, Alabama. The 13kirpose of thi.s proposal Request is to reduce the hospital mortality of the newly discharged $72,535 coronary care unit patient by providing a mobile infirmary, a training program for hospital staffs and the teci)[Ii-CiLie.9 of intermediate coronary care. These t(!cliiil.(Ities Are based upon @i firm understanding of CCIJ procedure as well as social "(Encounter" or sensitivity training sessions. The culmination of training ,.ind mobile Infirmary wi-11 be realize in health manpower who are both technically and psychologically prepared to care for the coronary care patients. The region explains that this proposal is compatible with ARMP goals and Alabama RMP -24- RM 28-02 (AR-1-CSD) 2/71 ob4ectives and that advanced knowledge is disseminated locally, manpower will be developed, and improvement in the care of the coronary patient will be realized. In the regions priority rating of projects this component ranked 21st as a priority item. ,Second Year: $62,794 First Year Project #31 - Physicians Assistant. Alabama is very short of Request physicians. There are many areas in the state $206,781 where physician availability and accessibility le, critical or non-existent. For example, in one county with the region with over 10,000 population there are no physicians, and in other county there are three physicians for a population under 30,000. Through the provision of the physicians assistant training program at the University of Alabama, Birminham, this proposal represents a viable step in increasing the availability of medical care in "physician poor" areas. It is compatible with the ARMP goal of "facilitating the delivery of health care" and enhances an ARMP objective of "stimulating and supporting the creation of new service manpower' to be available for distribution in areas of critical need. T@ii.s project in the regions priority listing of projects is ranked second as a priority item. .second Year: $210,726 'I'Iii.rd Year: $221,034 Pro-'ect 2@34 - Closed Chest Cardiopulmonary Resuscitation First Year Program. The purpose of this proposal is Request to increase the accessibility of knowledge in CCCR in the $93@480 region by providing to Alabama Ileart Association field directors the necessary assistance required for them to perform t e following task. (1) Facilitating the establishment of a CPR Committee in each hospitals which will provide a "Core" for inservice education for CPR training. (2) Facilitating the establishment of CIIR teams In each hospital which will be responsible for idiniiiistering, (;Ill@ techniques in cardiac arrest- crisis on a 24 hour basis. 'r@ie region explains that cil.-3seminition of idvinced ]Knowledge 19 I primary objective of the Alab,3in;i l@(@illoiial Medical Ili-o@,,i-am and that trils proposal is compatible with this objective. In the regions priority listing of projects this activity is ranked fourth as a priority item. Second Year: $60,791 Alabama RMP -25- RM 28-03 (AR-1-CSD) 2/71 Project #35 - Northwest Florida and Southwest Alabama First Year @S itals Coordinated Services Program. Re4uest The Coordinated Services Program has been operational $37,830 on a limited basis in Northwest Florida and Southwest Alabama for one year. The program is designed to enable member hospitals to effect economy, increase patient services to share in health manpower and to provide continuing education for institutional manpower. Several accomplishments have been realized in the short one-year period. For example, through coordination and cooperation, an x-ray company has reduced prices for participating hospitals. Arrangements have been made with housekeeping companies to serve some of the smaller member hospitals when previously the company would not serve hospitals of under 100 beds. This type of action has resulted in t cost savings in, tl)ose hospitals and has provided ftiridi for education. In Malay of 1.970, tl)i.@ project was reviewed by the IZMPS Site Visit It appeared that the team was favorably Impressed with the scope of the proposals since they encouraged that it be submitted. This proposal is compatible with ARMP goals and objectives in that remedial and continuing education is provided for the health services team and that there is a lowering of patient costs with an improvement in 'Services incorporated within the program. In the regions priority rating of projects this project is ranked #5 As a priority item. second Year: $27,107 'I'Iiird Year: $16,080 l,'l r.9 L Ye.@j r Project /@36 - Instrtictioiiil 1'roi(.!ct In Care - l@(!fltles t 't',illa(lega C(-)tinLX. The purpose of Lliis project lq $57,068 to reduce hospital death due to heart disease I-liroti@!,Ii ,] two-fold approach to improve the care of patients In Sylacauga, Talladega Coiinty, and other counties adjacent to Talladega County. The two-fold approach concerns provision of Coronary Care Educational llrogram and a (coronary Care unit teaching facility. This program Is regarded to be compatible with ARMP objectives concerning continuing education and development of health manpower. This region has not had this type of educational program in a rural setting. In the regions priority listing of the projects this activity is ranked 19th as a priority item. Second Year: $25,153 l,'i r a t Y ei i, Project #37 the li(I ol I"' Lij(@ l,iceii,4(@(i I"-kiet fell II ", (@ (I t I es t Nurse. The region explains that In essence $70,307 the li.fe of the lincensed practical ntirse has been "boxed in" by educational and personnel career "deadends." This proposal 0 Alabama RMP -26- RM 28-03 (AR-1-CSD) 2/71 is a new and innovative approach to "taking the lid off" for this health worker. It is the first approach by the Regional Medical Program to lend support to closing the knowledge gap between the LPN and RN by more formal, but needed and innovative approach to the LPNs continuing education. Recent studies indicate that 1,232 (20.8%) of the -states licensed practical nurses practice in this area. Furthermore, this nurse population exhibits a younger age and less career ability due to the unavailability of instruction courses leading to an Associate Degree liilr,.qfng Program for the vocational school I.PN graduates. M@iny interested groups in the state have expressed a great interest In developing an education program that would allow college credit for their vocational training as licensed practical nurses. By allowing this college credit, vertical mobility to become a registered nurse from a junior college program is facilitated. This effort provides a demonstration for the region in producing a type of manpower drawn from a new source. It will stimulate the establishment of a regular associate degree nursing program to insure a continuing pool of registered nurses in this community. In the regions priority listing of projects this project is ranked 10th as a priority item. Second Year: $65,150 Third Year: $70,215 First Year Project #38 - Continuing ]education In 1',Iindness Ilrevention.. T@egliest 'I'lie region explains that In 1960 the estimated $44,996 number of legally bl.Ind In the linited States was 385,000. I'his figure represents a prevalence rate of 2.14/1,000 population. rn the 1960 study, Alabama was the fifth highest ranking state with a Prevalence rate of 3.08/1,000 or 10,000 cases of legal blindness. Alabama is again ranked number 5 in the United States with an incidence rate of 20.7/100,000 (680 new cases). 7'he region explains that preventive measures directed at the cii-ty detection and treatment of the four major causes of blfi-idiiess((,'Iaticoma, Diabetes, Senial Cataract and Vascular Diseases) can potentially produce a 51.4/, reduction or delay in the incidence of blindness In the United States. I'herefore, the purpose of this project is to upgrade through a program of continuing edtication,tlie knowledge and skills of the optometrist of Alabama In the detection ind Identification of potentially blinding conditions. Noting that vascular diseases and diabetes are among the leading causes of blindness, the purpose of this project Is compatible with ARNII objectives. 'I'lifs project In the regions priority listing of projects is ranked Iltli as a priority item. Second Year: $42,496 I'lilrd Year: $42,496 Alabama RMP -27- RM 28-03 (AR-1-CSD) 2/71 RENEWAL REQUEST: First Year Project #4R - Health Manpower in Junior Colleges. This project Request is submitted to continue to improve the quality $76,974 of health care in the region by assisting the Jr. Colleges in attracting and holding qualified faculty, to continue to maintain and demonstrate innovative and creative health education programs, and to increase the supply of and to improve the education of selected kinds of health manpower. This program has enjoyed some success and some failures. Some difficulty has been experienced In recruiting and retraining faculty members. The evaluators contributed much of this to the accute shortage of qualified nursing faculty In Alabama and to the instability often inherent in a young and rapidly expanding institution. All faculty positionshave now been filled for the fourth quarter, including a qualified instructor for medical records technology. A nursing curriculum has been developed which incorporates a number of innovative features4 The Jefferson State College is designated as the logical institution to assume an administrative role in the development of such a curriculum at the Jr. College level. This program was designed to appeal to older students, to male and black students. The percentage of students over 30 years of age in the program does indicate its attraction to the older student. The percentage of black students is increasing and is significantly higher than the state average for nursing program. A total of 86 students have graduated from the nursing program and another 105 are enrolled in the summer quarter, a doub ing of t e number of students enrolled within the two-year period seems to be a realistic objective. In the regions priority rating of projects this project is ranked number one as a priority item. Second Year: $80,737 Third Year: $84,686 First Year Project #5R - Training Program - Reality Orientation Techniques. Pegliest This application requests renewal for continuation S96,853 and expansion of the reality orientation program which has been carried out at the V.A. Hospital, Tusculusa, Alabama, since April 1969. This was the first, and to the region's knowledge remains the only, RMP project physically located in a V.A. Hospital. The project provides an educational service through a training program for all levels of health care personnel In Alabama and other states in order to improve the care of patients who are confused and disoriented from stroke, arteriosclerotic disease, or other causes. The region explains that this project has attracted national and Alabama RMP -28- RM 28-03 (AR-1-CSD) 2/71 tnternational attention and it has done an outstanding job of training ma, but throughout the country as evidenced personnel, not only in Alaba by the evaluation report which is included in appendix 5 of the application. The project has improved the utilization of health manpower in Alabama, has enhanced the team concept of delivering health care, and has improved the care received by individual patients. In the regions priority listing of projects this project has been ranked 16th as a priority item. Second Year: $91,586 Thi.rd Year: $93,172 APPROVED [)NnJNDEI) PROJECTS: Project #14 - (,ontinijitig, I-dtication for Medical Laborntoriqj-ls. f,irst Yeir This project proposes to lend assistance to $48,930 help personnel who wish to deepen, broaden and update their knowledge in skills as they relate to the Medical Laboratory an(] thereby assistance in giving better patient care through better accuracy in diagnosis. The project is consistent with the ARMP overall objective of providing retraining and continuing education for the entire health team. This is the kind of specialized effort that the Regional Advisory Grouo tees as an essential contribution of the region's only medical school. Other funding sources have been carefully explored. This program for continuing education for medical laboratorians was discontinued this past year because RMP was unable to fund this project. This program was Initiated by the Department of Clinical Pathology in the Medical College of Alabama and was funded by the Cronlc Disease Control Center for three years ending May 1969. 'I'lie l@egion believes that the experience gained and the equipment purchase(] (Hiring the first three years of operation will be valuable In the fLittii-e. ']'lie University has developed an excellent base for Continuing Education of Technologists which presents an opportunity to expand the offerings to other categories of laboratory personnel. A program in which 100 Medical technologists, 40 physicians and scientists, and 31 technicians can be trained each year is projected. In the regions priority listing of projects this project is ranked 22 as a priority Item. Second Year: $46,028 Project #15 - Medical information @',ervice by First Year This project was originally submitted In T?eqtjest November of 1968 and the'original budget request was for $52,451 97 451 (d.c.). The project was disapproved by the Division of Regional Medical Programs on December 1968. The project was resubmitted by the region in July of 1969. The Regional Alabama RMP -29- RM 28-03 (AR-1-CSD) 2/71 Medical Programs approved the project in December 1969,but approved funding at a level of $52,451. The Region initiated a pilot project In July 1969 by rebudgeti.ng of Core funds.. The acceptance has been so great tliat,,oqdi.tional, 14ATS Lines and operators@.@have beenlreqtiired, a McBee .9y.q-tem method of collating calls has been installed and further employees are needed to abstract the tapes. The activity Is designed primarily to provide continuing education to the practicing physicians through the mechanism of consultation. The best teaching opportunity arises at the moment when the practitioner encounters a problem or a question in the course of his day-to-day activities in patient care. Person to person consultation is made available to him by telephone at this instant. Only when it is necessary and appropriate, reference will be made to the medically injured. However, upon this request the medical school library will provide him with a copy of the appropriate article or a Medlars Bibliography for reinforcing his learning. This project was reviewed by a site visit team from the Regional Medical Programs Service on May 26-27, 1970 at which time the visitors encouraged continuation of this activity. Tn the regions pri.ority listing of project components, this project Is ranked sixth n.,3 a priority item. Following are four projects whi.cli were reviewed by the November 1970 (council. '['he Af@Ml@' has included these four components as a part of this application and has re(Itiested support to Initiate these activities along with the other previously approved and unfunded projects. The projectsinvolved are as follows: Project #23 - Guidance Counselor Continuing Education in the Health Field. (revision) In the regions priority listing of projects this project is ranked 18th as a priority item. Project #24 - Birmingham Community Medical Television Network. Tn the regions priority listing of projects this project is ranked 50th as a priority item. Project #25 - Production of' Audiovisual. Materials for Real.Ltl Orientation Training Program: In the regions priority listing of projects this project is ranked 23rd as a priority item. The Nationals Advisory Council recommended that additional funds be provided to the Alabama RMP In the amount of 01-year $246,950, 02-Year $185,924, 03-Year $127,421 to support projects #23, #25 and #26. Council did not believe that project #24 had sufficient regional outreachand recommends that a local source of funds be utilized to Alabama RMP -30- RM 28-03 (AR-1-CSD) 2/71 support this program if it is considered a priority program by the RAG. The level of fundi-ng requested for Project #24 has been omitted from the total requested for approved and unfunded projects in the front of this summary. Project #26 - Model Cities - RMP Nutrition, Project in Tuskegee. In the region priority listing of projects this project is ranked 12th as a priority item. The Acting Director of Regional tiedical Programs@has approved an award for this project utilizing @IPS earmarked funds for Model Cities related activities. The level of funding requested for this project has been omitted from the total requested for approved and unfunded projects in the front of this summary. RMPS/GRB/ 12/31/70 DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Dal.*: December 21, 1970 Rtp"v to Aitn of. Subject: Staff Review of Non-Competing Continuation Application from Alabama, Regional Medical Program, 5 G03 RM 00028. To. Acting Director Regional Medical Programs Service Through: Chairman of the Montli@- Chief, Grants Management Branch Acting Chief, Regional Development Brac@@,@-@ Acting Cl-iief, Grants Review Br@irich This continuation application is a part of the regioti's Triennial Application which reqvest support for the following: the coiitinLiAtion of two projects an(I a core supplement (sub-regiotializati.on) ($240,000 d.c.); renewal of core ($553,061 d.c.); renewal of two projects ($173,827 d.c.); activating five approved and unfunded projects; a developmental component ($100,000 d4c.); and for a supplemental grant of ten new projects ($800,852 d.c.). Staff believes that this continuation application should be reviewed as part of the total. Triennial Application, especially the core sub-regionalizati.on when reviewed by Committee and Council. Core Syb-P,(.y supplement was approved by Council _ Ional,izatio.iii This Coro p In March 1970. It is an activity which is consistent with the original Alabama RtfP proprani objective or deceiiti.-;.il.ization. The region sees this project as a coalition of their staff functions with major community groups. Staff believes that this program is accomplishing regi.onalization and is coordinating @IP activities with C@IP in the Region. Project #16 and #20: Both of their projects were approved for a two year period and are now completing their first year of operatiob4 Both projects appear to be progressing toward achievement of their stated, goals and objectives. Recommendation: Staff recommends approval for continued funding at the committed level of $240,00 d.c. Ismael B. Morales Public Health Advisor Grants Review Branch Page 2 - Acting Dil7ectcr Sul)ject: Staff.Review of Application from Alabama Regional Medical Program, 5 C03 RM 00028 Action by Directorli Initials 17 Date (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF TANUARY 1971 REVIEW COMMITTEE AIABAMA REGIONAL MEDICAL PRO(@RAM RM 28-03 (AR-1-CSD) 2/71 FOR COiNS!Dr-PkTION BY FEBR:LTARY 1971 ADVISORY COUNCIL REC F.LND,,%TIO@T: Additinal funds be provided for this triennial application, U I - 'ng be' delayed but that the decision o developiiiental.f rdi. for a site visit. Region's- Recommended onal Year Request Fand in 03 $2,116$409* $1)665$557* 04 1,989 928 1 554,2 5 05 1,575,113 1,273,606 $5)681,450 $4,1@93 Total %-Inclttdes $240, 000 commitment for Core suppli-eiiIE,.tit and 2 6ngoit-t-, projects. CP,l QUE: The Committee reviewed tiiis-triennial application in relation y 1970 program site visit findings -",hich indicated that the Alabama RIMP was at a critical point in its development. The written PP.Licati,on conveyed the impression that the Region hall; made rapid strides n @t e directa'.6nof a cohesive, broad program ai-riied at basic health care probler.i,,i; the PAC- appears to have taken r'esporsibility; the Core staff has been strdrtcthen6d by strong subregionali7ation staffing- and Driorities' Are 6tging. The Committee had no hesitation in recomiiiendirto a level of support for the Coro and projects which would pronoto program g ro-,7tli but felt it could .lot make a'decis4lon on the Region'8 readin6ss for O'evc@lc",)- mental funding, on the basis of the written application. While tried seems to be. on the'threshold of good development, the Committee felt that ta site Visit was needed to evaluate what is really tai-i@lig place. @Pare helically, Alabama's remarkable change in development was cited@ 7 In g@ tiera@l Committee discussion as an exampl6 of why three--year looks at eg nls'mav -not tbvide the Committee and Council with adequate on-site p ata with which to evaluate program development. he ommittee@-,,as intrigued with possible. reasons for Alabama's apparent tre 5-,th,,In dev iopir6nt. The Region is unique in that the Alabama Medical @Soci ty i!s the official agency at both the State and local levels and has@ es 0 sivilitv for administering both Titles 18 and 19 And Comprehensive ai P@annin,,,. The University of Alabama at Birmingham administers the edi a! denttr, a complex consisting of the hospital clinics dental @-chool aid@ full spectrum of resources for health education health care and biomedical r6seArth4 There are no similar resources in the State. t ermore, e prac t from its inception. The Regional l@6dital Program has been su'ported p h the Medical Society@and the University as t e oroan zation to d continuing medical education and the development of community health e ces. AL&MM& RIMP -2- RM 28 03 (AR-1-CSD) .2/71 The Regional Medical.Program works cooperatively with Comprehensive Health Planning, at both the State and local levels. The "A" agency has looked to the ARMP for leadership in statewide planning in cancer and heart diseases. The ARMP has-taken an active role in the development 0 the CHP tlblf Aaencibs in the Region through the subrogionalization Core staff. The Committee felt that all of these aspects have helped prograni@develop- The role of the staff in establishing links of communication, in capitalizing on and in channeling ideas, as well a's the projects, were noted as major strengths in bringing these forces together. In conclusion, Committee believes that during the past year many events have taken place which indicate that this Region has.made great strides in developing a mature RMP. The RAG has begun to exercise its influence in the development of the total program. It seems that the ARMP has acquired the respect, support and participation of most of the major lf6alth facilitators in the Region and involved the provider in its scheme for developing an effective health care delivery system. Through it" subregionalization program the AP@IP has extended the outreach of Uiiivbrsity resources into the comunity; has strengthened the role of CHP in the Region and is fostering visibility of the A@IIP in the rural community. Committee has deferred action on the developmental component pending a site visit to determine if this Region is headed in the direction it proposed to the May 1970 site visit team and has developed the level of maturity- @which is indicated in this application. The impression of site visitors was that the Alabama RMP could eventually have one of the strongest health care@programs of any state, if its overall scheme @or integrating the strengths of the University, the Regional Medical Program, the State Medical Society and Couiprenensive Health Plannina is made to work. RMPS/GRB 1/20/71 akmribaz) 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) Arkansas Regional Medical Program RM 00052 2/71.1 (S) 500 University Tower Building January 1971 Review Committee 12th at University Little Rock, Arkansas 72204 Program Coordinator: Charles W. Silv'erblatt, M.D. Request (Direct Costs) 03 04 05 -Total. Committee/Council Review Two new projects 654,052 592,119 667,059 1,923,230 --------------------- I-------------------------------------------------- RMPS Staff Review Commitment 887,506 Currently in Catryover 112,982 staff review Total Request $1,000,488 Funding History Planning Stage Grant Year Period Funded (d.c.o. 01 4/67 - 3/68 $341,846 02 4/68 - 1/69 $341,846 Operational Program Council Future Grant year Period Approved 1/ Funded (d.c.o.) Commitment 01 2/69-1/70 807,487 687,506 02 2/70-1/71 1,818,045 1,001,306 2/ ----- 03 3/ 2/71-12/71 1,595,820 887,506 04 1/72-12/72 6599623 106,596 2 RM 00052 2/71.1 (S) Arkansas RMP 1/ Also includes Council.recommended amounts for all approved/unfunded projects 2/ Includes $113,800 carryover the request of RMPS to facilitate transfer 3/ Change in budget period at to anniversary reviiaw system - Figures for 03 year, however, are calculated on a 12@.u6nth period. HISTORY, Arkansas received its first planning grant ($341,846 d.c.o.) on April 1, 1967 and its second, for the same amount,- on April 1, 1968. A site visit was conducted in September 1968 to examine the Region's readiness for operational status. The site team had some reservations about the lack of a continuing education component on the core staff and the rather weak financial condition of the medical school, but on the whole, they were impressed with the community involvement,, the active participation of the Regional Advisory Group, and the directions planned by the director and core staff. Following Council approval in November 1968, an 01 operational award ($687,506 d.c.o.) was issued on February 2, 1969, including support for core and ten projects. A second site visit was made in July 1969 for the twofold purpose of reviewing Arkansas' progres in developing its program and evaluating ten s u proposals. The site team concluded that considerable s pplemental project progress had been made since the earlier visit, especially when consider- ati6n was given to the limited resources the Region had to work with. One area of concern was Core staff's non-involvement in planning and administration, but concentration on project direction. On February 1, 1970, the Region was awarded an 02 continuation award of $801,306 ($687,506 commitment plus $113,800 carryover) supporting Core and 11 projects. In June 1970, the release to RMPS of funds that had been placed in administrative reserve by the Bureau of the Budget permitted an award of $200,000 for support of six additional projects. November 1970 Council, in recommending approval of supplemental funds or additional core personnel, commented favorably upon the Region's planned evolving shift from project to program development wit a concomitant increase in RAG involvement and diversification) and strengthening of core technical assistance and service functions. The current annual support to the Arkansas Regional Medical Program, exclusive of carryover, is $887,',06 direct costs ($304,425 for core and $583,081 for projects). (See history supplement following this summary for a listing of.projects.) The 03 year continuation application was submitted to RMPS on December 15, and is currently under staff review. Arkansas 3 RM 00052 2/71.1 (S) Present Application: The present application requests supplemental support for two new projects. Project #36 - Continuing Education for Nursing Home Ist Year Personnel in Heart Disease, Cancer, Stroke and Related $111,925 Diseases This request is for the continuation of workshops for nursing home per- sonnel previously funded by the Community Health Services of the U. S. Public Health Service. A sample survey of nursing homes has indicated that Approximately 1,200 employees would participate in these programs. The proposed activities will address themselves to three facets of the problem: 1. Establishment of workshops -- twelve two-day presentations annually in various areas of the state are planned. 2. Development of an in-service education program which will follow the workshop presentations in each area. 3. Development of a family training program designed to assist family members, gain an understanding of adjustment to the nursing home environment and avoid disengagement of families from patients -- will be presented through two one-day workshops during the first year and as needed thereafter. It is expected that after three years of operation the program can be continued with multiple support from interested agencies. Second Year Third Year $113,734 $122,884 Project #37 - A Comprehensive Program for Kidne)r Disease lst Year Control for Arkansas $5421127 A comprehensive and statewide kidney disease program is planned which has as its objectives: 1. To augment and improve the existing statewide cooperative transplant program at the University of Arkansas Medical Center. Facilities will be established to provide for handling a maximum of eight transplant patients, a tissue typing capability will be developed, an organ procurement team will be provided, and the project will participate in an existing organ donor program and a kidney recipient pool. 2. To develop and present home dialysis training programs. This pro- gram will be based primarily at the Arkansas Baptist Medical Center, but will use personnel and facilities of the Little Rock VA Hospital 4 RM 00052 2/71.1 (S) Arkansas RMP as well. It is hoped that this program will train 40 patients and their assistants during the first year, 60 during the second year, and 100 per year thereafter. 3. To develop and present programs of continuing education to physicians and paramedical personnel. A two-week course for physicians (at UAMC) and an eight-week course f or paramedical personnel (at ABMC) are plAnned,l and although all interested personnel will be encouraged to attend, priority consideration will be given those who will be working at the nephrology centers at the subregional community hospitals. 4. To develop a network of subregional satellite centers for the preven- tion, diagnosis, and treatment of renal disease and to expand the dialysis capability of this network. Eight of the major community hospitals throughout the state have been chosen for this purpose. Steps are being taken so that at the end of three years there will be the necessary organization and lo cal support to sustain the program under the leadership of the Arkansas Association for Kidney Disease and the Arkansas Kidney Foundation. The Arkansas Regional Medical Program considers this project the most ambitious, significant and comprehensive exercise it has undertaken thus far. It is stated that the project demonstrates more cooperation among health-providing groups and provides more opportunity for an effective impact on health care in the Region than any past activities. It is viewed as a program from which many other total regional programs can be built. A letter from the Vice President for Health Sciences states that: In view of the significance of this program and the services it will provide within the State of Arkansas, the University of Arkansas Medical Center will, in addition to other con- tributions, contribute one-half of the amount of money which it would ordinarily receive as a result of the federally determined indirect cost rate charged for grant awards of this type. This is a major departure from policy that must be considered as a unique exception rather than as a change in principle or of accepted guidelines. We believe that this program is so important that we can justify this contribution. Second Year Third Year $478 385 $554,175 GRB/RMPS 12/21/70 2/71.1 (S) l-'@TSTCj'Y -'on C -fi: j@- r-, n cote Stipport 2 ci.-i c T '-i 7 514 5 2 - C@l,-c Training G-O)I@03 2.- 69 4 Si:@I'A'y Assistaoce @o Ca ("I-:ac Care d 5 Ca 1- "roi, 29,533 ra"n 6 2 5 2 9. 7 0 C@ 1: I 0 Tile 1 r 5 9 0 I- 2 t o I: ci -I: a "I s 13 1. C i i@ 14-19 20 i 1 8 , -4,/ 7 6 2/71.1 (S) continued. Init Currc-rit P ',7 Ti tle Ye@ir'li Stir,,,)ort Dcte 22 North Central Ar@,in@a,-, StrOl'IC Cc,iit:c-r $ 31.,538 6-70 23 Revised as Project Ir34 24 to Phys-;.cl.,,@!-,7i, 16,500 25 CE for Pllyf;icians 100,000 6--70 26 CE for Pharrnaci.sts Approvc-d/Uriftin@led @7 Refrosher Traini.i-!,, fo,7 Tecltiicylo@,ists and Approve(]/Un.lit@iri@e@ 28 CE in Cardiol6oy J'or Physicians Approvcd/lJr,)'u.@jdc-c, ,2.9 Model Cardinc C037C Uni.t - Stutt,u,art @lereorial Hospital 10,000 -.'7 0 30 Area-14ide Intensiv-1, C;irc U-ni@t Zinc] 3 -i C:or(iriziry C,-irc for "riyl;ici,,ins CE and I,.Iur s c 9 App i. ove (.L r] c 3 1 In-t-l-Ll(,t:iO!l in iNoLl-iolo@i.c of St-.rolc(,-, I;riin 'ftirfior C,)nc(,r 32 Deuioyistr.-ttioi-i inri T)7.@i-Clil.,", in C@;CC and Illqndl.irt@,, oil St-coi(c- Piti.c-nts 16,58) 6-70 33 CE i-,i X-,-,-4y Teclirjolc),,,,y R,-I@-.tc-ei l@ie'Lc7is Ap-i)roved/Unfurieiccl 34 Reil.onil Lal)otatory Quality Con-Lrol. 23p5OO 6--70 35 fo: Di.c,@iciiilF, @e,-iltli Ficility Food Servicc- Supervisors 'fho 02 yeni- P.N4nrd included $ 11.3,@;00 c@irryovc:r funcl[, fcji.- t@ic ol' the projects GRB/RMPS 12/21/70 (A Privileged Communication) S@RY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE ARKANSAS REGIONAL MEDICAL PROGRAM RM 00052 2/71.1 (S) FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL RECOMMENDATION: Additional funds be provided for this,application. Committee Ye4t Request Recommendation 03 $654,052 $111,925 04 592,119 113,734 667@,059 12@2 884 TO $1,913,230 $348,543 C ITI The Review Committee observed that the Arkansas Regional Medital Program will submit its first Anniversary Review lipatidn'for consideration during the Oct6ber/November 1971 review c le,@ d that the current supplemental proposal results from the gio-n! exer6ising A transitional year option. It was further noted a lar @ (Arkansas is a the Vottom of the heap,with regard to the presence of skilled mE power), 48% of current funding flows into training and education a iv ies. The reviewers agreed with the previous Committee and its new coordinator Dr. Silve b Co nci that the ARMP under r latt, seems effectively to be turning itself around with respect to increasing core 4pabilities;lin6r6asing RAG involvement, And bringing about a @@s ift from proj6tt-to program development and emphasis4 Project #36 - Continuing Education for-Nursing Home ersonne in r- Disease, Cancer, Stroke and Related Iiseases. This a ivity was th6dRht to be well planned and comprehensive. It@meets @@a ed@6f@t@e Region, is designed to reach nursing home personnel Li ev the hinterlands appears to fit in with the ARMP overall p ogr @appr6ach, and has planned phaseout of RMP support. As a side- 1 t@ the reviewers wondered whether this program might not 6&tve'to @s abliie the ubi6uit6us turnover among nursing home personnel. There w i3 n doubt tha@ inclusion of this project into the Arkansas program was wii warranted. P'Oje lt37 A Comprehensive Program for Kidney Disease Control for Arkansas. The reviewers agreed that this proposal i@ a perb b e, but had difficulty in evaluating only the written ,y d. It was noted that the Kidney Disease Control Program of RMPS t siq red the an proposal aa ex6ellent one,based'on identification of needs nd a logical and comprehensive plan to meet those needs. Arkansas vrese ly@has a minimum of renal activities - some trdh8Dlahtati6n Arkansas RNP 2 RM 00052 2/71.1 but virtually no dialysis. And so the main problem with which the Committee wrestled was whether the Region actually possessed the capabilities to carry out the fine program it has designed. There is considerable evidence of good community support and the reviewers also saw in this proposal the strong possibility of the programs -extending outside Arkansas and becoming An inter-regional resource. After lengthy discussion, the Review Committee'referred this project to,a s ecial ad hoc renal panel in order that the program be p considered in the cont6xt of national needs as well as@oth6r renal applications that have been submitted. The reviewers did want to stress the excellence of Arkansas' regional kidney plan, but as well that a technical site visit be considered. 1/18/71 GRB/RiMPS CALIFORNIA 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE 'SUNMRY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) CALIFORNIA REGIONAL MEDICAL PROGRAMS RM 19-03 (AR-1 DS) 2/71 Room 600 January 1971 Review Committee 655 Sutter Street San Francisco, California 94102 REQUEST (Direct Costs Only) Region's Operational Year 03 04 05 06 Core 407,967 4,548,409 4,766,304 4,988,71@O (Supplement for (renewal) (renewal) @(renewal) remaining 6 Months of 03 year) Developmental Component 406,720 834,759 857,140 880,642 (For remain- ing 6 months of 03 year) 9 New Activities (Projetts) - 1,414,007 1,591,910 1,406,315 Total 814,687 6,797,175 7,215,354 7,275,697 -------------------------------------------------------------------------- FUNDING HISTORY (Direct Costs Only) Planning_S@e Grant Year Period A-unded (d.c.o.) 01 11/i/66 - 12/31/67 (14 mos.) $1@,368,137 02 I/l/68 - 2/28/69 (14 mos.) 2,613, Operational Program (Overlaps with planning stage) Grant Year Period Funded (dc.o.) bi 7/l/68 - 6/30/69 $2,917,144 02 7/l/69 - 8/31/70 (14 mos.) $8,012,055 03 9/l/70 - 8/31/71 $7,548,457 (current) CALIFORNIA RMP -2- RM 19-03 (AR-1 DS) 2/71 0 .4- 0 GEOGRAPHY AND DEMOGRAPHY: The region is coterminous with the state, except for the Reno:and Las Vegas, Nevada areas which are "shared" jurisdictionally with the Mountain States and Intermountain RMP. The region is divided into nine Areas, each centered around a medical school. The total land area is 156,573 square miles, with a population of 18,293,000 (1965). The population spread is 80'/. urban, with a median age of 30. The racial distribution is 92% White, 6% Negro and Other 2/.. The region has nine medical schools, and one of the most recently established was a result of joint efforts of the Drew Medical Society (the NMA affiliate in this area o'- Los Angeles) and the UCIA and USC Schools of Medicine (Areas IV and V). There are 62 nursing programs, including 42 that are collegiate. There are 20 medical technology programs and 615 hospitals with a total of 138,722 beds. The majority of these are non-federal, short-term hospitals. There are approximately 35,224 physicians in the region, including all but about 100 Osteopaths, and about 91,961 nurses, of whom 57,700 are active. HISTORY OF REGIONAL DEVELOPMENT: With the passage of PL 89-239, committees were appointed at UCSF, UCIA, Stanford and USC to study the legislation. The California State Department of Health organized the "California Coordination Agency for Training, Research, Education, and Demonstration in the Field of Heart Disease, Cancer, Stroke and Related Diseases.'.' This agency included representatives from the California Medical Association, the California Hospital Association, and the Deans of the eight schools of medicine. The Agency was organized with the pur- pose of developing an "overall plan" for cooperative medical arrangements throughout the State. Planning for developing regional medical programs was to proceed at each:of the participating medical centers. The Coordination Agency world "develop suggestions" to delineate geographic areas of responsibility for each of the medical centers, and would coordinate and mediate other questions. The proposed method of operation relied heavily on systems analysis techniques. The Agency submitted an application outlining its structure and goals, as described above. At this time, the Agency Chairman was Dean Robert Glaser of Stanford, and the Project Director was to be Dr. Nemat Borhanl of the State Department of Public Health. Reviewers criticized the proposal, feeling that it was "poorly tied together", had a vague chronological plan for development, and overemphasized systems analysis. CALIFORNIA RMP 3- RM 19-03 (AR-1 DS) 2/71 The major question raised by the application was the creation of a limega-re --a question not discussed in PL 89-239. The Office of Legal Counsel advised against RMP creating a central agency unless it were to coordinate a group of "subregions". The region decided on this kind of structure and UCIA withdrew the planning application it had independently submitted. The various medical centers agreed to reconsider at a later date whether to break up into several regions--perhaps before receiving operational grants. A revised application, incorporating the recommendations of the site visit team and the National Advisory Council, was submitted. The coordinating agency became a nonprofit corporation and changed its name to California Committee on Regional Medical Programs (CCRMP). The grantee became the California Medical Education and Research Foundation (CMERF), a second nonprofit corporation, the fisca arm of CCRMP, with its own staff. The region's first Planning grant in the amount of $223,400 was made in November 1966 and Mr. Paul Ward was appointed Program Coordinator in February 1967. Another site team visited the region in February 1967 and expressed concern about the apparent lack of cooperation amoung the,sub-regions and little evidence of overall planning. The region organized along the lines of its original plan and a site visit team went out in March 1967 to review progress and the "revised application". The full year award for planning included the Areas of UCSF, UCIA, USC, CMA and CHA. Three supplemental planning grants during the first year added the Areas of Davis, San Diego and Stanford. The first operational application indicated that each Area had begun to forge meaningful cooperative relationships within the community it served. There seemed to remain a lack of interaction between Areas, and total regional planning and direction were hard to discern. The region's first operational grant was made effective July 1, 1968, including nine projects out of a total of 21 submitted. The same Award included a new planning area for the Northeast San Fernando Valley. In April 1969,a special site visit to each of the Areas, for a total of five days, was organized for the purpose of evaluating progress of the overall program and to review in depth the individual.core staff requests. The site team was Impressed with most of the Areas, particularly Areas I, III,IV, V, VII, and VIII. Most impressive was the evidence of true peripheral involvement. During the visit Area IV (UCLA) raised the question of the possibility of making each CALIFORNIA RMP -4- RM 19-03 (AR-1 DS) 2/71 Area a separate region; there was little support for this position outside of Area IV. Subsequent review cycles have included supplemental project requests from this region, resulting in several program and technical site visits. With the award of the continuation for the third operational year, on September 1, 1970, the region is supported at the direct cost level of $7,548,457, which includes a carryover from previous year's unexpended balance of $480,168. "'he current base level is $7,068,289. Staff review of the continuation ap-?Iication is attached to this summary. THE REVIEW & DECISION-MAKING PROCESS: The CCRMP review process has three stages: (1)d6termination of Area need (by'the Area); (2) technical review (conducted by a panel responsible to CCRMP; and (3) regional consideration and priority setting. The review system has been operative for sometime and evolved from a great deal of study by the Committee on Organization and Procedures. The process begins when the Area Core Office notifies CCRMP that a proposal is in its final stages of development. A Staff Consultants Committee then recommends the precise categories from which an ad hoc review committee is established for the proposal. The latter is drawn from the Regional Technical Review Panel, composed of individuals from each Area in various categories -- heart disease, cancer, stroke, etc. The ad hoc Review Committee meets with the Coordinator, his staff and the author of the proposal. The proposal is examined from the standpoint of over- all appropriateness in terms of personnel, facilities, relationships, etc., and if found to be technically sound, it goes to the Area Advisory Group for approval, then to CCRMP, with a summary of the technical review. Only if there is conflict between the Area Advisory Committee and the Technical Review Committee will the CCRMP be expected to brihg additional considerations into its decision to approve or reject. Normally, CCRMP will only examine how the proposal fits into the regional design, and what priority it should be given. The Evaluation procedures were developed through the joint efforts of CCRMP central staff, headed by Dr. Jack Thompson, and an Evaluation Committee of the RAG. This committee has been responsible for pointing out ways in which evaluation can take place , including how program objectives can be crystallized by utilizing evaluation techniques. Evaluation is now an integral part of planning from the inception of a project, with assistance and guidance provided by the CCRMP central staff. TNTER-AREA PLANNING ACTIVITIES: Stimulated by Review Committee and Council concerns and questions about this element of communication between Areas, region-wide committees are appointed as required to assure coordination between Areas and projects. Monthly meetings of Area Coordinators are held and serve as forums for planning. In CALIFORNIA RMP -5- @l 19-03 (AR-1 DS) 2/71 addition, there is planning between given groups--i.e., nurses, stroke activities, etc. Another example, the Coronary Care Unit Committee meets about every six weeks to assure non-duplication of effort, sharing of educational programs, priority systems for participation and cost- sharing a common registry, etc. There is increasing evidence that sincere, coordinated, statewide efforts are addressing common problems throughout the region, with a resultant lessening of Area autonomy. REGIONAL ADVISORY GROUP: This Group is called the California Committee on Regional Medical Programs (dCRMP). It is a heterogeous body including the Deans of the nine medical schools and two schools of public health, the Director of the State Department of Health, and representatives of the California Medical Association, the California Hospital Association, the California Heart Association, the California Division of the Cancer Society, TB and Respiratory Disease Association and representatives of the public. Dean Clifford Grobstein of the University of California San Diego Medical School, serves as Chairman of the Committee on Organization and Procedures. As an outgrowth of this committee's studies, the CCRMP, through the Coordinator's staff, has assumed a more active role in assisting the Areas in developing local objectives and priorities. The question of whether California should be one region or several has been discussed many times by CCRMP, and agreement continues that a confederacyof Areas creates a statewide cohesiveness and coordination not easily obtainable otherwise. This position has always been supported by spokesmen from the Heart Association, Hospital Association and other public representatives on CCRMP. It is also generally agreed that any administrative difficulties can be adjudicated. The CCRMP has turned greater attention during the past year to activities organized to help provide a service function for the public. Manpower development and means of developing services where they do not exist are concerns receiving more concentrated attention. Health provider interests give strong support to CCRMP, but RMP activities have been increasingly influenced by representatives of the general public. DEVELOPMENTAL COMPONENT In the view of the CCRMP, such funds awarded under this component should be snent in the implementation of nation- wide goals for nersonal health services announced by DHEW, and funds allocated for Area Core activities should continue to be used in the imnlementation of the HSHHA goals that emphasize the disease processes of heart sease, cancer, stroke and related diseases. Indeed, this was the recommendation of the Objectives Committee and endorse. by the RAG. CCRMP may wish to select certain of the national priorities to coincide with known needs in California. For the first year, the region, has decided to apportion its priorities as follows: Fifty percent of Developmentat Component funds will be earmarked for the achievement of National Goal 11 - to stimulate efforts to improve and increase the California RHP -6- RM 19-03 (AR-1-DS). 2/71 health manpower pool, focu-sing on the professional and allied health personnel. Fifty percent will be allotted to National Goal 10 - to stimulate changes in organization and delivery of health services, particularly for the urban and rural poor, with priority to: preventive measures, prepaid group practice, use of allied health personnel, ambulatory care services and neighborhood care delivery units. In connection with services for the urban and rural poor, attention will also be given to the following: migrant farm workers, Indians, children under five years, and women of childbearing age. The general purpose of Developmental Component funds in California will permit the Areas, through their own collective professional capability and decision-making process, to move rapidly and expeditiously in responding to the identified national health priorities. The objectives envisaged by CCRMP are twofold: (1) development of projects that will serve the national priorities that are, in format an content, ready for submission to RMPS and other sources, and (2) development of ongoing community activities such as organization of methods or mechanisms for augmenting the delivery of health care to the high priority target groups. The region will emphasize the following elements for projects planned for Developmental Component funds: 1. acceptability - by the user and provider of the health care sytem. 2. accessibility - to the health care system by the user. 3. availability - of personnel and facilities to provide needed care. 4. quality care - both individual acts of health care and the health care system within which those acts are performed, must meet accepted standards of excellence. 5. reasonable cost - cost of care must be within customary and prevailing costs to the individual user and society. The review process of the Developmental Component funds will be the responsibility of the Organization and Procedures Committee of CCRMP. Howev6r, the Objectives Committee offered two recommendations in this regard: first, it appeared important that Development Component funds should be used for projects which increase the tit of care, and second that such funds be awarded on the basis of a competitive review in rel;tion to goals and objectives, with not less than 25% to be awarded to Areas presently at a staffing disadvantage. California RM-P -7- RM 19-03 (AR-1-SD) 2/71 New Supplemental Projects Requested lst Year Project #66 - R.E.A.C.H. - Area VII This project will 7231,014 provide for: (1) supplementary staff in six general hospitals in San Diego County to establish multidisciplinary planning teams in each; (2) a slightly modified team in two hospitals in Imperial County; (3) encouragement for physicians to assume an active leadership role for follow-up care under their direction; and (4) continuing advance training for all allied health professionals currently involved in multidisciplinary planning in Area VII. Four discharge teams will be established in San Diego County the first year in Mercy, University, Sharp and Scripps Hospitals. Each team will have eight members: a coordinating nurse and family counselor at full-time, a physical therapist and dietitian as needed, public health nurse, rehabilitation counselor and occupational therapist half time and a full-time secretary. Each hospital will provide four members and RMP will provide four. The project was conceived as the result of studies of the San Diego Area Planning Committee, composed of representatives of numerous health organizations and voluntary agencies. The committee recomended that RMP give consideration to planning for the development of discharge teams planndd along the lines of the Heart Patient Project for all local community hospitals. R.E.A.C.H. will build on the experience of the three-year pilot demonstration'project--Heart Patient Project--sponsored by the San Diego County Heart Association and General Dynamics Convair Employees Contribution Club. Over the three-year period of this project, the hospitals will be contributing a total of approximately $249,495 in salaries for personnel they will assign to it. In addition, these participating hospitals will provide office space, equipment and other administrative support. Second Year - $344,131 3rd Year - $134,784 Project #67 - Respiratory Care - Area I Respiratory First Year ,teaching teams from $266,240 communities throughout the Area will be trained in the Bay Area by a faculty of respiratory care specialists. Such training will include specialized medical and teaching skills as well as the health team approach to comprehensive patient care. A preceptorship for physicians and a special course for junior college nursing faculty, combined with team training experience, will help to ensure the leadership needed for continued development of respiratory care practices in the community. The basic team program will be two weO-ks, And include small group sessions in the classroom, laboratory and at the bedside with expert teaching on ont-to-one basis. Students and faculty will function as team members during all teaching rounds, seminars, and case presentations. California RMP -8- R14 19-03 AR-1-SD) 2/71 A special program has been-developed for the junior college faculty. An eight-week course includes study of the pathophysiology of respiratory disease as well as general intensive and home care of the respiratory patient. In order to create a liaison between the junior college faculty member and the community team, the faculty member will spend a portion of her time with the team from her community. A one-week physician preceptorship will be available for two or three physicians six times a year in the Bay' Area. Prerequisite for participation in this component of the program will be prior attendance at sessions carried out by the team in the community. The program has been designed to meet the requirements of all Areas. The composition of the teams will vary from District to District, depending on existing health manpower resources. Ideally, it will consist of eight members: aphysician, an intensive care nurse, a hospital inservice educator, ahome care nurse, a physical therapist, an inhalation therapist, and a pulmonary function technician. Seven teams (49 individuals) are to be trained during the first year, and will increase to 28 teams in the second and third. Second Year - $316,710 Third Year - $325,727 ProAect #68 - A compendium of Extended.-Learning - Area II First Year This project proposes to establish a mechanism $90,207 for the planning, development, and implementation of a cohesive program of educational activities for members of the health professions in Area II. The authors believe that an educational program, to be realistic, must address the entire continuum of health care as well as the entire range of professional skills. A foundation of two years of experience with several planning and experimental studies is cited. The program will address the gap in the various medical service areas between a reasonable or acceptable level of continuing education,for all health professionals and the actual esistence of such programs. The gaps are believed to be not so much in content but rather in the design and delivery of such rrograms. Factors contributing to this situation are: (1) only the large hospitals in Sacramento and Reno have appointed Directors of Medical Education; (2) in some instances, the energies of the Director have been consumed by the demands of recruiting and training interns end residents with little time to serve the professional staff; (3) most small hos-itals cannot afford the salary of a D.M.E., nor can they in the future; and (4) some hospitals do not feel the need for such a resource. The Area II Advisory Council has endorsed the concept that continuing Education for health professionals should be the highest priority item. As a consequence, significant participation in the planning process has been provided by the Advisory Council, together with Area II staff, health professionals, hospital staffs, medical societies, voluntary agency staffs and representatives of the "Bl' CHP Agency have contributed to the planning of this proposal. California RMP -9- RM 19-03 (AR-1-SD) 2/71 Five objectives are spelled out to deal with heart disease, cancer, stroke, renal disease and respiratory diseases. The ongoing Roseville pilot project will serve as a living laboratory for the development and testing of improved patient care and continuing education within a single community hospital. Second Year - $86,002 Third Year - $86,967 Project #69 - Respiratory Care - Area VII The project Requested was developed as a result of a detailed First Year survey of respiratory care facilities and personnel in $172,356 Area VII. The survey established both the priority needs and - the resources within the Area which could be mobilized to meet them. Such information has led to the design of a multifaceted project which integrates Area resources to meet the most critical needs. Nine sub- programs are included in the project. The geographic location of the Area, in sharing an active border wit Mexico and seaport for servicemen and civilians returning from the Far East, makes tuberculosis a continuing problem. Two recent pilot skin-test programs at San Diego City College and University Hospital, disclosed positive tuberculin skin tests in more than 20% of the 3000+ persons tested. Also, there is in this Area a remarkably high incidence of pulmonary tuberculosis and pulmonary coccidiomyosis in children. There have been more than 48 admissions in children with severe tuberculosis in the last ten months at University Hospital. Many of these children had received inappropriate diagnosis and therapeutic management prior to their admission. Each sub-program will be responsive to a different Area need. Education of physicians and allied health professionals is the primary goal of the project as a whole,, although some sub-projects will serve as models, pilots, or demonstrations in addition to their educative function. An outpatient rehabilitation program will be subcontracted to the TB and Health Association of San Diego and Imperial Counties. A Home Inhalation Therapy ?rogram will be subcontracted to Scripps Memorial Hospital and the other sub-programs will be carried out by the cooperative efforts of a "core" of experienced personnel based at University Hospital, plus qualified personnel recruited from other Area health facilities. The planning, organization, and content of the project has been developed in a manner that should permit most of the sub-programs to become self- sustaining in multiple Area facilities during the next three years. The project is envisaged as a means to upgrade and expand the diagnostic and therapeutic capabilities of Area VII by establishing effective educational programs in respiratory care for physicians, nurses and other allied health personnel. Second year - $176,702 Third year - $188,540 California RMP -10- RM 19-03 (AR-1-SD) 2/71 Allied Project #70 - multidisciplinary Continuing Education fo First Year TFealth Personnel and Health Careers Counsell The proposed continuing education programs $50,400 will be multidisciplinary in approach for allied health personnel in Area II. They will be carried out in three phases: (1) planning and development, (2) operational in several selected sites within the Area and with continual evaluation; and (3) an extension of phase two with programs modified on the basis of evaluation during phase two, and in new sites. The target area is primarily rural with two urban centers, Sacramento and Reno. The data acquired by a survey made by the Office of Allied Health Sciences soon after its establishment on the Davis Campus in April 1969, served as the basis for the First Institute of Allied Health Science Education in Northeast California, as well as a basis for indicating the need for new programs, especially in continuing education. Planning has been developed by representatives of the Office of Allied Health Sciences, Area II RMP, the two Comprehensive Health Planning Associations) and various people from educational institutions. The resultant consensus was that such a project should be multidisciplinary, coordinated, and a conjoint program for all these groups, with the primary responsibility and sponsorship to reside in the Office of Allied Health Sciences at the University of California, Davis. Second Year - $69,220 Third Year $69,560 Project #71 - Respiratorv Care Training - Area I.V First Year The project is based on cooperative $177,159 arrangements between the Tuberculosis and Respiratory Disease Association, practicing physicians, allied health personnel, and hospitals to encourage the development and improvement of respiratory care units in suitable hospitals, and to train key personnel in respiratory care in hospitals where specialized units are not appropriate. The program will involve a nine-county area. Based on a team approach, the two-part program will train physicians and allied health personnel in the theory and practice of respiratory care. The team will be a physician, nurse, inhalation therapist, pulmonary function technician, and physical therapist. The training will require a total of four weeks for each visiting team from outlying hospitals. The first two weeks will be spent at UCLA attending a didactic educational program. The second two weeks will consist of assistance at the outlying hospitals. The course cycle will be repeated every three months, and there will be four complete course cycles each year. A ten-bed intensive respiratory care unit at UCLA will serve as the educational setting for demonstration and practical experience. During the first year, 55 (50 physicians and 5 allied health) trainees will be articipating. Each year thereafter, 120 (15 physicians and 105 allied p health) trainees will attend. California RMP -11- RK 19-03 (AR-1-SD) 2/71 The Area V (U.S.C.) RMP, in cooperation with olive View Hospital and the Tuberculosis and Respiratory Disease Association of Los Angeles, are beginning a teaching project directed toward the problems of the chronic respiratory disease patient. The RCU Training Project will serve a complementary function. The Los Angeles County Tuberculosis and Respiratory Disease Association as pledged $10,000 t-award the implementation of the project and an additional $5,000 will assist in the promotion of the various educations components. Also, it is planned to charge tuition, and income so generated will be used to offset expenses.incurred. It is estimated that $1,500 will be received in the first year and $3,375 in each of the succeeding years. Second Year - $183,140 Third Year - $196,071 Project #72 - Radiation Therapy - Area VIII Funds First Year are requested to provide continuing $71,957 consultation and continuing education for all personnel in the field of radiotherapy. These activities will include: weekly seminars, demonstrations, conferences, workshops for physicians, nurses, technicians, and students. These will be rotated among the participating hospitals. The needs of hospitals vary and the training and educational services provided will be tailored accordingly. The concerned personnel of each hospital, including the patients' attending physician will be encourage to participate in weekly tumor conferences, including patient presentation, review of all clinical radiographic, pathological, and laboratory findings. Each of numerous problems pertaining to radiotherapy of cancer will be discussed in one-hour sessions. Participating will be radiologists, surgeons, pathologists, chemotherapists, and specialists from other disciplines. Many institutions are in great need of technical assistance from a competent physicist to aid in complete treatment planning, to assist in the development of better techniques, and to provide a standard of uniformity in dosimetry. The radiation physicist requested for this Program will be responsible for the calibration and maintenance of radiotherapy equipment, measuring instruments, and shielding devices. It is hoped to be able to establish uniformity of terminology, techniques, definitions, dosage scaltsl And.a Descriptive classification o tumors. In addition, tumor boards will be organized in larger hospitals before which cases from neighboring small hospitals will be presented. This project has been in preparation since December of 1968 and represents the radiotherapy section of an Area-wide comprehensive cancer program. At the time of its original preparation, it requested funds for costly equipment, and for this reason, the radiological section was removed by the Area VIII Offitt. The present request is a modification and more modest version. I Second Year - $64,761 Third Year - $58,284 -12- RM 19-03 (AR-1-SD) 2/71 California RMP This project First Year ea III Project #73.- Cancer Prograth - Area III- builds on planning efforts in Area III $301,123 over.-the past two years. The program consists of four interrelated activities which represent the first stage of implementation of the long-range plan described as follows: (1) radiotherapy services (radiologic physics); (2) district tumor board; (3) oncology unit; and (4) consultative-teaching services. The purpose of this project is to fill the gaps in the Ar6a-wide comprehensive cancer program, giving special attention to peripheral Districts 3, 4, 5,and 6. where the need is greatest. Both ongoing screening projects in Area III include screening examinations specifically for breast, cervical and lung cancer. In addition, the San Joaquin Medical Society sponsors both the screening project and the District Tumor Board in San Joaquin District; the Health Facilities Foundation is responsible for the screening of cannery workers in the San Joaquin Valley and elsewhere in Area III. All elements of the Area have been brought to bear in the planning for the cancer project. Also, Area I Cancer Coordinating Committee has assisted with planning in Area III, and to further coordinate their efforts, join't committees have been formed, with a view to pooling of resources of both Areas with respect to ideas, procedures and personnel. The organizational structure han already been developed as part of the RMP District Cancer l,omm e) will be responsible for planning. ittees (fiv coordination of the program. For each of the four components--Radiothetapy Services; District Tumor Board; oncology Unit; and Consultative-Teaching Services, there will be a project director. The first component is concerned with provision of radiologic physics services by the Stanford Division of Radiotherapy to radiotherapists in the Area. This program will be located in the Stanford Medical Center, but supported by other physics resources. Services will include calibration of radiation sources, and other supportive consultations, as well as transmission of treatment planning information via wirephoto. The District Tumor Board will provide consultative services to physicians, an educational program on cancer for physicians and other health personnel, a data base acquired through a cooperative hospital tumor registry, and an annual report on status of cancer detection and management in the District, including recommendations. The Oncology Unit will sponsor the development of a model oncology unit in a community hospital; extend resources and methods developed in this unit for establishment of other units in Area III; and improve knowledge and upgrade skills of professionals involved in the care of cancer patients. The Consultative-Teaching Services will be implemented by the creation of an Area Cancer Team consisting of a Cancer Coordinator (medical oncologist), an Associate Coordinator (radiotherapist), and a Nursing Coordinator. As an Areawide team these persons will participate in District Tumor Boards on a scheduled basis and will assist in consultative service. They will I California RMP -13- RM 19-03 (AR-1-SD). 2/71 also conduct or assist in planning educational programs (such as preceptor- ships and short-term training) sponsored by the District Til-or Boards and the RMP District Cancer Committees. Second Year - $296,698 Third Year - $287,396 Project #74 - Blood Banking - Area V This Project will First Year train 1,000 blood bank technologists from $53,551 Los Angeles and Orange Counties in the six subject areas (ABC Groupingi the Antiglobulin Test, and Rh Testing) over a three-year period. Technologists will be followed after training to determine of changes in performance due to the workshops persist2. There are a few postgraduate training opportunities for blood bank technologists in this Area., but the applicant feels these are not adequate to meet existing demands. The commercial serum companies workshops are felt to be somewhat slanted, others are held yearly by the American Society of Clinical Pathology, but are primarily for pathologists and not techno- logists, Aid all are held too infrequently to supply local demands. The program would conduct workshops in blood banking on a full-time basis, directed by a Teaching Supervisor and one Assistant Teaching Supervisor, Another Assistant Teaching Supervisor will be responsible for the day-to-day preparation of specimens and other technical details. Other personnel requested Are a Research Assistant (half-time) and a Shipping Clerk (half-time). The proposal has been coordinated and cooperatively planned by Areas IV, V and VII as a collaborative effort and would serve all three. A willingness to participate in the program has been indicated by 169 of the 223 hospitals in the two.-county area. Second Year - $54,546 Third Year - $58,986 NOTE: Action on a supplement (11/70.1) was deferred from the last review cycle pending the findings and recommendations of a site visit scheduled for early December. The concerns expressed by reviewing bodies dealt with an apparent lack of any overall regional priority system. Some of the proposals appeared to be attempts to develop linkages from stronger Areas to others that are moving more slowly. However, the total application failed to indicate how the region had arrived at its choices of submission or to furnish background to ongoing activities which would allow the reviewers to assess the projects in their true context. These points were explored extensively by the site visit team, and are included in the site visit report which accompanies this present "package" from California. DRMP/GRB 12/17/70 A PRIVILEGED COivViUl:\ICATION SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW'CO'MMITTEE CALIFORNIAO REGIONAL MEDICAL PROGRAM RM 19-03 (AR-1 DS) 2/7i FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: That a developmental component be approved at an annual rate of $400,000 to become effective for the remai riing 6 months of the 03 year; that Core be renewed at the increased amount recommended for the 03 year ($3,878,346) to become effective -for the remaining 6months of the 03 year; and that the level for,operational@; acti itieg be continued At the current rate.($4 085,648.)@. committee recommends that these levels should prevail for a period of 18 months covering the last half of the 03 year and the entire 04 year, and 'further, when the region's triennium application is submitted to the july/Augiist review cycle covering the 04, 05 and 06 years, the 04 -eai@level should be within these limits. Funding for the 05 and 06 years@will be determined when the entire triennium application is. considered. The effect of these recommendations is: Recommended by Requested By Recommended by Region Site Visit Team Committee 03 Year Core $4 263,325 $3,878,346 $3,,878$346 Dev. Comp. 813',440 400,000 400,000 Oper.,'Act. 4,085,648 4,085,648 085 648 $9@162 413 $8,363,994* $8,363,994* 4 Y ar Core $4,476 491 $4,072,263 $3,878,346 Dev, domp. 834,759 400,000 400,000 Oper.,'A,,t. To be submitted in 4 572 263 4,085 @4@ July/Aug. Review $92044,526 .@$8,363,994 Cycle 05 Y r re $4,700,315 $4,275,876 To be determined' e @OMP. 857,140@ 400 000 in July/Aug.@. 'A To be submitted in 4,775,876 Review Cycle per ct. July/Aug. Review $9,451,752 Cycle 06 Year e $4,935,330 $4,489,670@ To be determined V. comp. 880,642 400,000 in July/Aug. per. Act. To be submitted in 4 989 670 Review Cycle July/Aug. -Review $9,879,34@O Cycle an annual figure* The actual increase for the. last.'6 months of - @ @ T-h @ is @ t@p ni vpat is 9407.168 ($200.000 Developmental Component And $207,768. I- '-California RMP -3- RM 19-03 (AR-!-DS) 2/71 California represents a testing ground of national significance in 6,ub-tegionalizatiot of medical planning:, which, in turn, affects a wide variety of educational institutions and people of diverse ethnic backgrounds and varying economic circumstances. The Watts-Willowbrook activities, in which approximately $1 million of RMP investment has generated approximately $50 million of other funds, has captivated national interest and enthusiasm. It is believed that this activity should serve as a model of reorganization and redirection of medical,care in economically disadvantaged-and' medically isolated regions. A -e me8hing.and nothet important innovation in California is th d finiti6n of the roles of-RMP.and CHP. While there was n6tmuch e@ evidence of coordination of CCRMP and the A Agency, there is some combined representation of personnel, both in CHP and CCRMP. Also, California has given thoughtful attention to the health needs of Indians, Black and Mexican-American communities and has given support for planning of OEO health centers in the Model Cities Progkam. The reviewers discussed at length the regional evaluation system. The site team had some misgivings about its effectiveness as well as ts relationship to the regional priority system. This,led to urther consideration both pro and con of the efficacy of the ogi6n's aDDroa6h to evaluation and its capacity to judiciously ick@and choose among its operational projects The magnitude of the f ndinr level of California tends to inhibit objective examination. The ana logy of residency accreditation visits was cited, and one membe, pointed out that the Review Committee has not, as yet, evaluated limega-d6llars" regions in terms of "accreditation." Evaluation as A " rocess", in the o inion of the reviewers should p p include ongoing,, independent audits of segments of the program, i.e., neer in Area I,, N6urology in Area VIII, with firm documentation presented as to cost., accessibility, availability, etc. in sumarv. it was agreed that while California is difficult to j dge@@6n a total Drop-ram basis, it does claim to be one region. beref6te ,t e rationale of diversity must be questioned 49.woll s fo e of the thrust of the central staff to monitor ongoing og t MSO@@ T e Committee was reminded that all site visits from the ce@ ion of RMP in California emphasized evaluation. The region s @een - aution6d to build in a methodology from the beginning f Proiect planning c6ntinuing@through its operational experience nd u iimat-e termination. This, in turn, should lead to a realistic nd meaningful "total -program evaluation.11 If California is to be, dge as a laboratory, then.it must test, modify,,redesign, discard evaluate. AR 1-DS) 2/71 California RMP -4- RM 19-03 Developmental Component There was consensus that the region has the resources an ecis on- making ability for res onsible use of such an award. The region has p proposed a strategy which will utilize such funds for specific objectives to maximize new opportunities and capabilities in responding to regional health priorities. The nine Area Core staffs have@demonstrated program capabilities in a variety of activities nerat6d by these staffs ih community outreach, coordination with P, volunteer agencies, utilization of manpower and resources and other local health planting efforts. Review procedures for such proposals will be considerably simplified. Projects will be more m.od6st in scope and will have greater regional implications, A special Review Panel is in process of appointment with representation from all voluntary, as well as public health agencies. The RA:G membership views the autonomy inherent with Anniversity Review status as a real challenge for CCRMP. It recognizes that some tough decisions lie ahead. The reviewers believe there is ,strong evidence that, in the face of reduced financial support, is responsibility will be equated with local (Area) progress, ocal needs and qualifications for such funds. t is apparent that California is already experienced in principle in Developmental Component techniques, and the region can be expected to be discriminating and sophisticated in its choice of activities for such funds. The region feels that such programs should yield@ arly returns with good spin-off value. In addition to sub-regionalizatfion at Area levels with visible, active local decision-making, the California RMP has shown $ubstAntiAl,d&vel6pment toward even greater depths of regionali- zation4 The Committee noted that Areas are divided into Districts$ hich in turn, have Advisory Councils@ representative of local health interests. Each Area conducts planning studies, exchanges Information to av6id.unnecessary duplication and share experiences. ore Renewal in discusai g this segment of the application, Committee had difficulty in assessing a Core Renewal request in isolation from its ongoing 6 eratioftal projects It noted'the impressive produc- p r-ivity of SOM6 6f@@@tb6 more advanced Areas and a lesser degree in he underfunded Areas* However, in some of the late starters, limitation of Core funds has probably encouraged a certain creativity in planning and utilization of available resources. The reviewers agreed with the findings of the site team that the equest for additional funding to equalize Core support throughout California RMP -5- RM 19-03 (AR-1-DS) 2/71 all nine Areas is valid. It recalled that such support was limited initially in a somewhat arbitrary fashion, There was also agreement that California's-expanding interest in Comprehensive Health Planning and its extensive inter-relationships with other types of'state and oluntary health agencies make it impossible for Coordinators with smal staffs to stay abreast of regional linkages.to further planning, as well as develop active operational programs. Tb6 Review Committee agreed with site visit findings that Core budgets of less than $250,000 for Areas of a 1.5 million.population are unrealistically low. Further, the distribution of awards angi g from 4/. to one Area and 25% to another, with an even'wider ango in the per capita distribution of funds, presents a handicap o smoothly working relationships of the various Core 8taffs. Howdvor, the Review Committee discussion was fraught with many concerns ok ih reviewers in their inability to assess realistically such equ&bts in relation to ongoing operational activities. The reviewers were reluctant to accept the site visit team recommendation which would., thby@felt, have the effect of establishing a program level or a@complete triennium prior to the submission of,the complete riennium request. stead, the Committee voted to approve certain,increases for an 8-month period with the provision that the levels would be re examined At the time the operational activity portion of the og m is considered in the July/Aqgust review cycle. Committee Agreed that a more realistic assessment of the "total" California ioRram could be made At that time, he dollar implications of their recommendation are shown on t e irst@page of this Summary of Review. C SIONS: A number of issues emerged during and as A result of the most@@recent site visit. These ate outlined below: The Executive Director raised the question of whether RMPS and t;'Lonal,Advisory Council, ift--effect, delegates its authority the Anniversary Review system, by authorizing expansion of any ed operational activities into other areas or institutional gs@with6ut review and approval by, Council. This does change Council's omewhat, which has precedent for.delegation of various !a thorities, The extent (how far) of such delegation needs be examined. in the case of CalifbtniA4 reviewers at the national vel, have en6ouraR6d the region to refine its review and evaluation stem in order to promote a more cohesive, integrated regiona program. s has included the extension of planning techniques and programs Om Area to Area and DistFicts to maximize available tesourcest e disposition of a large backlog of Council approved but unfunded p ojects. some of which have been dormant for almost two years raises e question of how long do approved but unfunded activities retain ir.Coun6il approved status. The site team believes that CCRMP California RMP RM 19-05 (AR@l-D '/71 -6- S) 2 has adequate ca ility to@r:eview these projects, and to activate., pab -them within the limitations of the operational budget, provided their technical.r&,V.,iew after a p@ojipc@.has been they catty out inoperative for.from -twelve to eighteen months. If a,second.local. review attests to its pertinence and-viability., such projects could -e ov b m ed intfo;a status where they could be considered for support along with other more current proposals. MP 30 The site team identified'some potential long-term policy i licationg in using RMP funds to support CHP activities as proposed by California. -Does @, the "relationship", as -envis@ged provide.- aii@ avenue whereby.CHP@avoids its statutory mandate requiring consumer lahainR boards etc.? -e representation on p. Or, are th6r other more -th f B ie S? subtle suggestions in, e use,,Of RMP funds to@sitaf c N 13 ])octors Spellman and t@ss@on..were in@ited"to r-'-e@a in in th@ @-@---room during the n ec ati6nd delib'erations@'sinc6-thO--findi g8'and r ommend f th te vi it@team were'd' e can id.1 'with r(4gion 0 e si s 18.cuss@d 'qfjlt d' y al representatives. Doctor Besson remained; Doctor 8p6llman joined the Committ6e for the last few minutes. 1/20/71 GRB/RMPS NW 0 0 REGIONAL MEDICAL PROGRAMS SERVICE s Y OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) COLORADO-WYOMING REGIONAL MEDICAL PROGRAM RM 40-03 (AR-1-CDS) 2/71 2045 Franklin$ Street, Suite 410 Review Committee Denver, Colorado 80205 1171 Program Coordinator: Paul Hildebrand, M.D. REQUEST (Direct Costs Only) 03 Year 04 Year 05 Year All Years 1/71-12/71 1/72-12/72 1/73-12/73 Continuation Commitment 1,103,772 98,415 11202,187 (Core) (483,697) -- (483,697) (12 projects) (610,875) (98,415)1/ (709,290) (6 month extension of project to terminate 12/70) ( 9,200) ( 9,200) 02 Estimated Unexpended Funds 73,002 -- -- 73,002 Additional Components .508,843 204,922 218,732 932,497 (Developmental) (109,000) ( 0 ) ( 0 ) (109,000) (3 new projects) (370,777) (174,333) (184,792) (729,902) (I approved-unfunded project) ( 299066) ( 30,589) ( 33,940) ( 93,595) TOTAL 1,685,617 $303,337 $218,732 2,207,686 *Staff Action on Continuation Approved Cont. Committmp-nt 1,103,772 98,415 1,202,187 Disapproved Unexpended funds 47,428 47,428 Deferred Unexpended funds 25,574 25,574 Committee Action Required 508,843 204,922 218,732 932,497 FUNDING HISTORY Planning Stag@ Grant Year Period Funded (d.c.o.) 01 I/l/67-12/31/67 $297,678 02 I/l/68-12/31/68 366,723 OPERATIONAL PROGRAM Council Funded Future Grant Yr. Period Approved (d.c.o.) Cotmnitment 01 1/l/69-12/31/69 1,079,853 976,854 02 I/l/71-12/31/70 1,466,995 1,282,815 I/ RN 40-01 (AR-1-CDS) 2 71 COLOR,ADO --WYOMING RMP -2- Funded Future Council Commitment oved c.o.) -C 0 Period I Grant Year 1,094,572 03 1/l/71-12/31/71 1,472,782 98,415 1/l/72-12/31/72 98,415 04 1/ Includes $106,533 of ol Carryover GEOGRAPHY The initial planning grant set the boundaries of the proposed region as co-terminal with those of the States of Colorado and Wyoming. The rationale for-this proposal was that the University of Colorado Medical Center along with other referral facilities and health services of the greater Denver area serves as a nucleus for most of Colorado and Wyoming. However, since 90% of the population of the region resides in Colorado the boundaries of this state will be followed for data- gathering purposes. The adoption of political boundaries of the state of Colorado simoffies the collection of data and coordination of the Regional Medical Program with other state health programs. Another factor in this decision is that portions of the state of Wyoming fall under the influence of three Regional Medical Programs: Intermountain, Mountain States and Colorado-Wyoming. Studies have shown that patient referral patterns in some Wyoming communities reflect allegiance to all three regions. Land Area Square Population Number of -Miles Per Sq. Mi. Counties- Colorado: 97,400 17 63 Wyoming 104.000 3 24 iOl,400 87 DEMOGRAPHY lation: Colorado - Roughly 2 million Wyoming - Roughly.3 million Population Percent Urban: Colorado 1,480,000 74% Wyoming 171,000 57% Rural: Colorado 520,000 26% Wyoming 129,000 43% COLORADO-WYOMING RNP 3 - RM 40 (AR-1-CDS) 7/71 Population Percent Race: Colorado 1,940,000 97% - White Wyoming 294,000 98% - White Colorado 60,000 3% - Other Wyoming 6,000 2% - Other Median Age Colorado 27.9 - Wyoming 27.3 Health Statistics: Mortality Rate Rate for Heart Disease: Colorado - 285/100,000 Wyoming -269/100,000 Rate for Cancer: Colorado -114/100,000 Wyoming -115/100,000 Rate for CNS Vascular: Colorado -84/100,000 Lesions Wyoming -84/100,000 Facilities Statistics: 1. University of Colorado Medical School 2. In the state of Colorado, there are three nursing schools with a baccalaureate program, four with diploma programs and five giving associate degree programs. In the Wyoming area, there is one baccalaureate program presented at the University of Wyoming, and two nursing schools with associate degree programs. 3. There are 13 schools of Medical Technology located in Colorado i one of which is university based. In Wyoming there is one school of Medical Technology. 4. There is one cytotechnology facility located at the University of Colorado Medical School. 5. There are 18 X-Ray Technology facilities located within this region, 16 of which are found in Colorado, all hospital based. 6. There is a total of 92 hospitals in Colorado, the majority being non-Federal, with 16,655 beds. In Wyoming, there are 34 hospitals, again the majority being non-Federal, with 3,982 beds. - 4 - RM 40- 01 (AR-tCDS) @/71 COLORADO-WYOMING RMP Personnel-S.tat-is-t-cs: There are 3,201 M.D.'s (176/100,000) and 240 D.O.'s (13/100,000) in the state of Colorado In Wyoming, there are 322 M.D. is (99/100,000) and 16 D.O.'s (5/100/000). The number of active nurses in Colorado is 7,080 (389/100,000); in Wyoming,there-are 1,082 active nurses (321/100,000). HISTORY AND DEVELOPMENT The Region submitted its first planning application in September 1966 and was funded at $297,678 d.c. the first year (1/l/67-12/31/68) with a commitment for the 02 year in the same amount. Although Committee and Council both recommended approval in their review they shared the concern that the Region's geographic overlap in Wyoming with two other Regions (Intermountain and Mountain States) might present a significant problem in the future. In December 1967 Staff reviewed the Region's request for the continuation of its planning grant into the second year (1/l/68-12/31/68). The request for expanded support of $414,112(d.c) was considered very ambitious particularly in view of the slow progress and a reduced amount at the level of the first year (297,678 d.c.)was awarded. In its review Staff noted recruitment had proceeded slowly and only one planning activity had been developed very far. Staff was optomistic that the appointment of a new program director (Dr. Doan replaced Dr. Elsele)may accelerate planning. It was noted, however, that the Director's salary at $32,000 is in addition to the existing Program Coordinator's (Dr. Hildebrand) salary at $35,000. This was considered a heavy executive salary for a small inactive program such as Colorado/Wyoming. In June 1968 a supplemental award of $49,615 (d.c.)was made for the expansion of existing facilities and capabilities of a Pediatric Pulmonary Program at U.C.M.C. (with two additional years of committed support this program was later to become Project #13). Also in July 1968 the Region submitted a request for $133,973 (d.c.) supplemental planning funds along with an operational application consisting of five projects. These requests along with a three project supplemental request submitted in August were all deferred by Committee and Council for a site visit. A pre-operational site visit was conducted in September 1968. The team consisted of Dr. William Mayer, Dr. Mack Schanholtz, Dr. Robert Metcalf, Martha Phillips and James Beattie. The visitors expressed their confidence that the concept of regionalizationwas developing well. There was substantial evidence of involvement outside of Denver into Wyoming and interregional relationships were satisfactorily being COLORADO-'WYOMING R14P RM 40-01 (AR-1-CDS) 2-171 5 worked out, in spite of earlier concerns. There appeared to be good understanding and cooperation between the Regional Medical Program and practicing physicians as well as with voluntary agencies, the medical center, the official health agencies of Colorado (and to a lesser extent of Wyoming) and the local CHP agencies. It was noted categorical standing committees not only review project applications but each was charged with developing a region-wide approach in its area of concern. The Region saw itself as moving from a project approach" to a "program approach.' The RAG appeared deeply involved in the program and was beginning to develop a more formal approach to its functions. The representation on the RAG was felt to be somewhat less than satisfactory. Allied Health representation was limited to two nurses and the only minority representative was the Executive Director of the Ur@an League. The large contingent of Spanish-American physicians had not been contacted and consumer representation had not been considered. Although an "administrative committee" of the RAG had undertaken the establishment of a method of priority-setting, no such system was applied to the first projects included in the first operational application or the supplemental request. (See Report of 1968 Site Visit). As a result of the site visit, and Committee and CouncilA acceptance of the recommendations, the Region was awarded $25,331(d.t.) as a supplement to its 02 planning award which brought the total award for the 02 planning year to $366,888 (d.c.). Later the Region was also awarded $849,053 (d.c.) for the 01 operational year (1/l/69-12/31/69), for support of Core and seven operational projects. This award was later revised upward by $127,801 d.c. to include two additional projects, bringing the total award for the 01 operational year to$976,854 d.c. In December 1969 Staff reviewed the 02 year (1/l/70-12/31/70) continuation application from the Region. While it was agreed the program appeared to be moving along much as anticipated, concern was expressed that the progress reports were vague in many respects. Three projects were cited as particular examples of this weakness. The requests for use of carryover funds were also found to be vague and poorly justified. As a result of this review the Region was awarded $1,082,881 (d.c.) for the 02 operational year with the option of submitting new requests for use of 01 year unexpended funds. In addition the Region was required to submit revised progress reports on the:three weaker projects. In February 1970, Staff reviewed favorably a single request for the use of $33,016 of 01 unexpended funds to contract with Trans-Century Corporation to continue community planning in Pueblo, Colorado directed toward developing an improved health care system for the Spanish- American Population of Southern Colorado. An award in the amount requested was made. COLORADO-WyoMlNr- R14P - 6 @n May 1970 Staff revi - als for use of $132,450 and recommended ewed 15 propos approval of ten totaling $73,517, but with on -proposal restricted pending a site visit. In addition Staff also reviewed the revised progress reports on the three projects for which such reports were requeste . - These were found to be basically weak, failing to relate to the questions posed in the advice letter. Many questions were not spoken to while others were answered in vague generalizations which characterized the original progress reports. The educational programs appeared unstructured and void of good educational design. Evaluation was obviously lacking and apparently no assistance in this area was being given by, or had been requested from Core staff or other competent people who are qualified in this area. Lack of coordination between related educational projects was also evident. Staff concluded that fnview of the substantial difficulties in the education and evaluation aspects of the projects, and the apparent reluctance of Core staff to over-see and assist, the Continuing Education Branch of RMPS should take immediate action to offer assistance. The Continuing Educaticn Branch has since had extensive communications, including personnel meetings,.with Dr. Doan and the Continuing Education people of CNRNP. As a result,the Continuing Education Branch of BMS reports that the problem which was a. breakdown in communication between the Continuing Ed)ucation people and the Administrative staff, has been for the most part resolved. It appears relationships have been improved markedly with the Coordinator and the Executive Committee having a more favorable attitude toward the Continuing Education staff. Continuing Education staff now participates actively in staff committees dealing with project ideas rather than serving in a passive role as an occasional reviewer of projects after they were already designed. As a result of Staff's recommendation forapproval of ten proposals for use of 01 unexpended funos and the Director's willingness to grant a special supplement of $100,000 to the Region for support of four approved but unfunded projects, a new amended award in the increased amount of $1,282,815 for the total program was granted in June 1970. A breakout of this award is presented on the last page of this summary. On November 25, 1970, staff reviewed the Continuation Component, the Region's first Anniversary Re@iew Application. The Acting Director concurred with staff's recommendation which was: 1) approval of the request for $1,103,772 of committed support for Continuation of Core and 13 projects; 2) disapproval of a $47,428 request for use of 02 year unexpended funds in eight projects and 3) deferral to the site visitors a request for use of $25,574 of unexpended funds to extend project #13. A site visit will be conducted on December 8-9, 1970 and a report will be presented to Committee at its January 1971 meeting. COL(RADO-VTOWNG RMP - 7 - ItM 40-01 (AR-1-CDS) V7t PRESENT APPLICATION Core Organization: Coorulinator's -- Directorts Office Paul R. Hildebrand, M.D. Coordinator Howard W. Doan, M.D. Program Director Rex D. Stubblfield Executive Assistant Elaine Deters Secretary Fiscal & Administrative Services Mildred Schnittgrund Administrative Assistant Kay Jones Steno-Secretary Sylvia Meek Telephone Receptionist Communication & Information Office J.P. Smith Public Information Officer Profess 4onal Activities Division Richard E. Boyle, M.D. Associate Director Anne Gough, R.N. Chief of Nursing & Allied Health Rogene Dilley Steno-Secretary Pr n & Health Information Svstems Division James C. Syner, M.D. Associate Director W.C. Morse, Ph.D. Chief, Project Administration F'R. Normile Chief, Project Development Hubert Brandon Health Administration Specialist Gerald F. Fournier Health Administration Specialist William 0. Hastings Chief, Project Audit & Control Norman S. Holt Wyoming Liaison Officer Heinz Mueller Health Administration Specialist Dee Trees Steno-Secretary Peggy Oliver Steno-Secretary Continuing Education Division James E. Dyson, Ph.D. Associate Director ,,Cardiovascular Disease Division Robert C. Jones, M.D. Associate Director M. Lynn McCracken, R.N. Health Services Education Specialist 8 COU)RADO-WYOMING RNP RM40-03 (AR-1-CDS) 1/71 Regional Advisory Group Structure: Physicians and Dentists 4 1 5 Medical Center Representatives 4 0 4 Hospital Administrators 3 2 5 Society and Association Representatives 4 1 5 2 Nurses Association 2 State Medical Society 1 Osteopathic Association Voluntary Agency - Representatives 2 1 3 Public Health Officials 1 1 2 Public 11 1 12 1 Spanish Sur-name 1 Negro Other 4 0 4 1 Nurse 1 Head Start 1 Model City TOTAL 33 7 40 Program Analysis Memo shows three meetings were held during 1969 with an average attendance of 29 (62%) members. DIVISIC,N OF ',RI':GIONAL @@DICAL Fr,.CGr@"',S '.REGIO.NAL ADVISO.RY Groy@T? ST-A.@DMNG CO@l"rLTTE!I!S Cont'-nu4-ng @-ducnv'_ion T@z NISTL@TIVZ CO@-!-L S't @o.@c "Cer cli REVT-l.:,N, co STAF EVA,J@, O,\' CO.\-Nrr & An@ll\'TST A OF17TCE 07.'-T'LCE @STON OF CON or PRO.,,rCT V TINUING DIVT@SIO.N' C'T D,,rllis@ON cr i L - I I i 'I A-n%!'@,N"-S-Li",ATION @ !!EALTI! ::!)'JCATION 'CA:MIOVASC'-T'@-k--", Tlo\ SYS@LE,,"-g COLORADO-WYOMNG RMP 10 RM 40-03 (AR-1-CDS) 2171 The Goal or "Grand Ideal" of cwRMP is stated as follows: Reduce the adverse impact of heart diseare,cancer, stroke, related and other diseases, and thereby improve the quality of life for all citizens." to the practicing physician to expansion (1) Provide support achieve an of his productivity. (2) Assist in providing forti-ii!, immediate health service needs of the poor in both urban and rural areas. (3) Provide quality care as geographically close to the patient as is consistent with the most economical allocation of scarce health resources. (4) Accomplish a continuous evaluation of progress towards program objectives. (5) Coordinate closely with the community hospital as a primary entry point for CWRMP influence in each health service area, to assist in transforming them into community health centers. (6) Develop an improved working alliance with Comprehensive Healt Planning based on cooperative arrangements for project development utilizing the Community Comprehensive Health Planning Council, i.e., the 314 (b) agency. in strate e ion's WWoorrkking Strategy The basic working strategy utilized by CWRMP to accomplish its objectives is through the establishment of cooperative arrangements in project planning, design, and implementation with the health resources of the region. COLORAD@WiOMN(; RMP RM-40-03 (AR-1-CDS) 71 PRO-@l.-"CT REVIFW PROCESS prOJFC"c PROL)OSAT, to ctliulp etc-rr,iination of me it, IUFP Guidelines relevance by kiioi.:lcdgea ble Cl-,IPJ.IP Staff and/or Consultants. CWPI-IP liaison qssists originator in development for presentation to C14P,'-IP STAFF RFVI@,!,! CO,'-U,@IITI'EE. Ori-inator and C@-1pjlp Staff presents Project Proposal to appropriate categorical Cormnittee for Scientific Merit and @-!P rel.(,v@ince. IIEART 'ITS A,, Revised Project Proposai presented to the Administrative Committee of RAG in broad abstract and budoet form. - - - - - - - - - - - - - - - - Project Proposal revised into detailed form for presentation to RN(,. A Primary and Secoticlar Pcvl-ci,ier Dc@,,;!-nated from PAG y for presentation to the Rcgioiiil A(Ivlsory Group. "Blue Slieet" sent to eicli RAG nioril)cr prior to P,.ccti.n- wliicli contains: 1. Proposal objectives 2. Review cycle action, 3. Stiff co-,iir-,ir-,nts on rierit. RAG Pritiliry aiid Secondary R(,vie,,.Yers present fiii@ili7.e,(l project proposil to RAG iiient)(,rs. Cl-ilt'.IP Stiff assists ill presentation t,,Iien reqLIO.StC(l. ;ATI approved Projec't Proposal is f o rl4,1 r(I @. LI 1) l@ L- I Pfor LO COLORADO-W'YOMNG RMP - 12 RM 40-03 (AR-1-CDS) 7/71 New Operational.Projects! Requested First Year Project #22 - Rural Health Services for Migrant and $164,466 Seasonal Workers. The Colorado Migrant Council with the assistance of Core Staff, drafted this proposal to help eliminate fragmentation of resources, and coordinate the existing services to the rural poor who are to a large degree, migrant workers who have settled permanately in the region. Five teams, each consisting of one area coordinator End two indigenous family contact workers, supported by the project will work to accomplish three basic objectives: .1. Develop health and supportive resources when they o not exist in impact areas. 2. Educate the farmworker and his family to utilize health services that are available. 3. Develop rural health "coalitions" in the impact areas to serve as the coordination bases for farmworkers, growers, agency efforts. The proposal is founded upon the basic working strategy of establishing cooperative arrangements among providers and consumers of health services and is no direct support of the CWRMP objective to provide health care services to the poor. Second Year: $173,333 Third Year: $184,792 Requested First Year Project #23 - Comprehensive Community Neurological Service for $59,244 Denver. Request is being made by the Denver Department of Health and Hospitals for one year support of a project which was initiated on October 1, 1967 with 314 (e) funds and will terminate on December 31, 1970. The project provides comprehensive neurologic services to the patients of Denver General Hospital and the Denver Neighborhood Health Centers. Most of the patients are urban poor, medically indigent, and include a high percentage of Hispanos, Blacks, drug and al6cohol abusers, the aged, and the chronically ill. Their most frequent diseases are stroke siezures of varying causes, and degradive disturbances related to alcoholism. The project encompasses an in-patient neurology service and consultation service at Denver General Hospital, an out-patient neurology clinic, an electroencephalogram laboratory, and an intensive training program in clinical neurology for medical students, intern residents, and various other physicians affiliated with Denver General Hospital and the Univer- sity of Colorado School of Medicine. Support is requested for a project director, an EEG technician, a secretary, and a resident in neurology from the training program in neurology of the University. The Department of Health and Hospitals of Denver will assume financial responsibility when RMP support abates. COLORMO-WYOMNG RHP - 13 40-03 (AR-1-CDS) ?/71 Requested First Year This project provides services to the urban poor, a group whose health care has been declared a high priority both nationally and by the CWRMP. First Year: $59,244 Second Year: - 0 - Third Year: - 0 - Project #24 - Family Health Workers as Agents of Change of $147,067 Primary Preventive Care -- 1971. This project is sponsored by the Tri-County Health Department (Adams, Arapahoe, and Douglas). It proposes a dual approach to removing barriers which impede access to the stream of health care for the consumer. It is an attempt to (a) initiate a family health worker training program and (b) introduce additional screening tests into a mobile unit program currently operating with a singular focus on uterine cancer detection. This proposal is intended to demonstrate more effective methods of utilizing manpower and facilitating access to health care resources. Expansion is intended to proceed only after rigid assessment of each element introduced to insure that the system proposed is, in fact, dealing appropriately with consumer requirements. The training program for family health workers has as two of its objectives gaining program certification and defining more clearly the tasks to be performed by the trainee. Once these tasks are clearly defined, more realistic career patterns can be established. Detailed and flexible job descriptions which include guidelines for continuing education as well as for performance expectations, for four levels of family health workers have been prepared. The agency has a job appraisal system which emphasizes the superviser'8 participation in setting job-related goals. The objectives to which this project relates most closely are: dealing with the problems of the urban poor, providing health care services to females with cervical cancer, addressing itself to the health manpower problem and improving provision o preventive care. First Year: $147,067 Second Year: - 0 - Third Year:- 0 COLORADO-WYOMNG RMP RM 40-01 (AR-1-CDS) 7/71 -14- Developmental Component The overall rationale for Developmental Component funds is to test the feasibility and potential of spontaneously occurring opportunities to further CWRMP objectives. The basic strategy to be followed in determining allocation of funds will proceed as follows: (1) Maintain and enhance in CWRMP core staff a state of "sensitivity" for new and potential "targets of opportunity," which hold promise of contributing to overall program goals. (2) Assure that CWRMP core staff are available to assist the "innovators" of ways to effect improved health care delivery. (3) Gather data and promote interpersonal relationships at community levels to establish a realistic definition of needs. (4) Encourage the involvement and the development, of cooperative arrangements among institutions, agencies, and organizations which can serve as resource functions in resolving problems. (5) Utilize the CWRMP Evaluation Committee to document, organize, and process information. (6) Coordinate all involved parties (innovators, community citizens, cooperating agencies, and CWRNP staff) to react to total imputs,- and finalize an output which constitutes that action scheme designed to resolve the problem and, thereby, serve as a valuable contribution to the grand goal of CWRIIP. CO WYORING RMP RM 40-01 (AR-1-CDS) ?/71 15 Funde@ ation #1 CORE STAFF objectives: This project is to support core planning and evaluation activities of the Colorado-Wyomina, Regional Medical Program. Staff is divided into four offices and three divisions: (1) Professional Division; (2) Division of Continuing Education; (3) Project Administration and Health Information Systems. Full-time equivalent staff are requested as follows: Office of Coordinator (1), Office of Director (2.2), Office of Executive Assistant (13), office of Communication and Public Information (3), Divi.sion of Professional Acti-vities (7), Division of Planning and operations (7.75), and Division of Health Data and Pr,-)gram valuation (6). #2 COLORADO STATE CANCER REGISTRY Objectives: The basic objective of this project is to develop a computerized statewide cancer registry to improve follow-up to as near as 100% as possible and through utilization of registry data, to provide the cancer patients of Colorado with the best care and earliest diagnosis possible. Improved follow-up of (1) treatment failure, (2) second . primaries in Kansas Cancer patients, and (3) determination of need for treatment changes in those patients known to have cancer. Extension of registries to all hospitals ' improved continuing education and constant evaluation arc, also goals. This project relates to the third NaL!ot@il Cancc-r Institute Survey of Cancer Incidence and Prevalence and a proposed six-state Rocky Mountain Tumor Registry. The Colorado Department of Public Health i,7ill be the headquarters for this activity. #3 MULTI-MEDIA EDUCATION Objectives: This continuing education project will develop pa prototype system for videotape exchange and closed-circuit TV involving first, the Denver Medical Society, the University of Colorado Medical Center, Presbyterian Hospital and St. Joseph's Hospital of Denver, and later, seven other Denver hospitals. The TV system will be cop,.,erted to color later and if CCTV is extended throughout Colorado and Wyoming,'(1) will be extended to hospitals throt-i@,h -jut COLORADO-WYOKING RMP- JLO RM 40-01 (AR-1-CDS) 7/71 the Region, (2) produce and distribute videotapes to hospitals in the Region, (3) produce and distribute single concept'films, slides and film-strips to Regional hospitals. A catalog of existing educational materials and staff con- sultation to local hospitals are other features of the project. The Office of Audio-Visual Education in the Health Sciences of-the University of Colorado Medical Center is headquarters for the project. HOME DIALYSIS TRAINING PROGRAM Objectives: This project is to improve understanding of health personnel and the public in the treat- ment of kidney disease and of the problems experienced by renal patients, to enhance community involvement in the rehabilitation of patients undergoing home dialysis, to provide consultation to community health personnel, to provide highly specialized laboratory services when required, and to develop the capability to provide emergency services for home dialysis patients. Training plans include: (1) three-day orientation for 30 physicians and 25 public health nurses; (2) five-day orientation for five physicians; (3) ten-day training for five physicians from hospitals . planning home dialysis service; (4) two-week training session for seven nurses and for technicians from hospitals planning a service program, three-day training for ten dieticians, -day conference of 20 social worker (5) one three s and rehabilitation personnel; (6) one three-day orientation for five clergy, welfare workers, pharmacists and community leaders; (7) five one-two day conferences for 50 health related and community-oriented.,,individuals; and (8) six-week training for family members of patients. Travel and per them is requested for all these groups. #6 TRAINING AND APPLIED RESEARCH FOR INI'ENSIVE AND T,',T@!iAJ,'I!,ITATIV--, RESPIRATORY CARE Objectives: To (I.) finiiliarizc, physicians and paraiiiecli.cal personnel of the magnitude of the emphysema- chronic bronchitis problem; (2) disseminate knowledge on the latest advances in the Treatment of the problem; (3) to promote and assist in the establishment of respiratory care-progranis in local. communities; (4) obtain greater know- ledge on the effectiveness of home oxygen for both hypoxeinia and non-hypoxemia individuals; and (5) intreasc the effective-- ness of therapy through the development of improved ventilators and nebulization devices as well as the ad4ition of humidi- fication de-vices to existing oxygen equipment. - 17 - RM-40-03 (AR-1-CDS) 2/71 R-OLORADO-WYOMNG RNP #7 -- RADIATION THEKAPY AND NUCLEAR MEDICINE Objectives: Technology Training. To reduce the acute shortage of well-trained radiation therapy and nuclear medicine technologists by establishing Associ- ate Degree two-year training programs in radiation therapy and nuclear medicine technology. The programs will be offered by the Denver Community College in conjunction with nine hospitals in the Denver area: (1) Colorado General, (2) Denver General, (3) Fitzsimmons General, (4) Lutheran, (5) Mercy, (6) Presbyterian Medical Center, (7) St. Anthony's, (8) St. Luke's and (9) General Rose Memorial. It is expected that at least forty students per year will graduate from the training programs. #8 COLORADO INTERAGENCY COUNCIL ON SMOKING AND HEALTH PROGRAM Objectives: To continue support of an Interagency Council on Smoking and Health. The prime source of funding for the Council (which paid the salary of a coordina- tor and a secretary) has been through a Special Project Grant from the Public Health Service. This source of funding is no longer available due to budget limitations. The general objectives of this proposal are: (1) coordination of Council member activities pertaining to smoking and health and pro- motion of more efficient communication between Council agencies; and (2) continuation of efforts on a long-range program aimed at permanent financing of the Council within the State of Colorado. #9 CONTINUING EDUCATION CORE PROGRAM FOR NURSES Objectives: Based at University of Colorado School, of Nursing, would provide integrated training in intensive nursing care. #10 CONTINUING EDUCATION STAFF Objectives: Develop continuing E@ducation staff in Colorado- Wyoming RMP to counsel with communities interested in developing local continuing education programs. Staff teams woul.dprovide consultation to local hospitals. Development of local consultation teams would also be encouraged with RMP staff assistance provided to fill gaps in local. expertise. RM-40-01 (AR-1-CDS) 2/71 COLORADO-WYOMING RMP #13 PEDIATRIC PULMONARY Objectives: Expand existing -facilities and capabilities of pediatric 'pulmonary program at University of. .Colorado Medical Center. Program will seek to familiarize the medical personnel in New Mexico, western Kansas, western Nebraska, Colorado, Wyoming, Montana.and Utah with the facilities at this Center to attract more and earlier referrals. Will concern itself with comprehensive management and training programs of all acute and chronic neonatal and pediatric pulmonary diseases. #14 THE STATISTICAL DIAGNOSIS AND PROGNOSIS OF CANCERS Objectives: Involves a retrospective study of approximately 300 patients at the Penrose Cancer Hospital to determine the results of 15 routine diagnostic procedures or observations. An aspect of this proposal involves con- tinuing education of the physician. #15 A REGIONAL PEDIATRIC ONCOLOGY CENTER FOR RESEARCH AN]i TRAINING Objectives: Assist the Children's Hospital of Denver develop as a regional center for pediatric oncology. Involves application and evaluation of new approaches in the treatment of cancer, continued evaluation of currently supported research projects, correlation of data with other research centers, and a continuing education, training and fellowship program. r #16 COMPREHENSIVE CARDIAC CARE PROJECT Objectives: Project is to be administered by the Colorado . Heart Association through an affiliation agreement with the Colorado-lqyoming &"IP. The overall ob- jective of improving the delivery of health care to patients with cardiac disease is to be accomplished by a stq)by step plan. #18 -- I@IRROVED CARE OF THE PATIENT WITH ADVANCED CANCER Objectives: This proposal is sponsored by the American Medical Center, a non-profit eighty-five bed hospital which provides care to cancer patients from all over the United States. The purpose of the proposal is to establish a train- ing program for nurses in the care of the advanced cancer patient, and to cultivate in these nursing personnel the more hopeful and challenging aspects of oncological nursing. #19 CHRONIC DISEASE EVALUATION AND MANAGEMENT PATIENT CARE Objectives: This project, sponsored by the University of of Colorado School of Nursing, Continuing Education Services, is designed to train nurses and other health workers in long-term care and rehabilitation of patients with chronic conditions such as diabetes, orthopedic and neurologic problems, cancer, cardiac disease and other --- Tll ------ COLORADO-WYWiAl'kgp. RMP RM 40-01 (AR-t@CDS) ?/71 SMIARY OF OPERATIONAL PROJECTS CURRENTLY BEING SUPPORTED BY COLORADO-14YOMING @ID Future Years of Funded (d.c.) Project Title and Number Commit. Support 1/l/70-12/31/70 Core $489,451 Sub-Contract (Pueblo) 39,576 Total Core $529,027 #2 State Cancer Registry 1 $ 50,340, @#3 Multi-,Media Education 1 34 739 #4 Home Dialysis Training Program 1 39,,719 #6 Training and Applied Research 120,738 for Intensive and Rehabilita- t.ive Respiratory Care #7 - Radiation Therapy and Nuclear 58',275 Medicine Technology Training #8 Interagency Council on Smoking 1 25,294 and Health #9 Continuing Education Core Pro- 1 70,91.2 gram for Nurses #10 Continuing Education Staff 1 90,687 #13 Pediatric Pulmonary Center 0 75,956 #14 - Statistical Diagnosis a-Lid I 13,317 Prognosis of Cancers iII5 - Pediatric Oncology Center 1 733727 #16 - Comprehcnsive Cardiac Care 0 42,798 ,#18 - Improved Care for tht*,PaLi.ent 2 15;@700 with Advanced Cancer #19 - Chronic Discese Evaluation 2 41;582 and MnnageinenL of Patient Care TOTAL $1,2.82,81.5 COI,ORADO-WYOMING KMP RH 03 (AR- I -tt;Uzi f I L 20--- -@40 STATUS OF UNFUNDED PROJECTS Project Title & Number Approved Project Status Period #5 Multiphasic Screening 0 Not Approved for Funding #11 Facilitation of Lear ning 0 Not Approved for Funding #12 Continuing Education Workshop 0 Not Approved for Funding A Training Prograin for the 1 2 Approved but Development of Ultrasonic Unfunded T'echniques in Community Ilospitals #20 Daily Update of Laboratory 0 Not Apprrived Reports for Fundirig #13R Diagnosis and Treatment of 0 Returned for Pediatric Pulmonary Problems Revision #21 Radiation Therapy Planning in 3 Approved but Community Hospital. by Time- Unfunded Sharing Computer SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE COLORADO/WYOMING REGIONAL MEDICAL PROCRUL RM 40-03 (AR-1-CDS) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation4 No additional funds be provided for this application. Year R&quest Recommended Funding ist Year $508 843 -0- 2Ad Year $204,922 -0- 3rd Year $218,732 -0- @Total $932,497 -0- @r Committee concurred with the si.te visit report which concluded that this Region has not obtained the degree of sophistication ch might be expect6d after two years of planning And two years 6f@opetational status. At this point in time, it still remains project or ted and little thought has been given to the expanded responsibilities @of e RAG in setting specific oals, objectives, and riorities 9 p whi @would represent a'total program. A ong the same lines, there is little evidence that the numerous data resources within ihe,Rpgi6n are being used for the assessment of needs. Also the Region has not taken it upon itself to lead the way in stimulating projects related to a specific program, but rather has tended t) ser more@as a broker for projects spontaneously generated by. various health organizations. Based upon these observations Committee agreed additional support for projects and the developmental component were not justified at this time, but that the Region sh6 ld take its upcoming 03-year of operation to put its house in rder for its Triennium Application. It was noted that this wil be a critical @ear for CWRNP and'hotd decisions will have to be ade in order to turn from being project oriented, to which it is omewha@ io6ked, to being program oriented. Committee concluded s did the site visitors that talented resources exist within both @the RAG and Core staff to make the desired transformation, but it was aRreed expansion of funding should be-reserved until sutb transformation is demonstrated. @Although Committee was a!dare of the fact that the site visit team had sD6nt considerable time discussing its observations with the regional personnel, it emphasized the need for both written and otal feedback by @IPS staff. While it was agreed the site visit report should not be made available to the Region, it was felt th written feedback should carry the same basic message and tone, c ing Committee and Council's input, and should be interpreted and com-D em nted by the verbal message. Coloiado/Wyoming RMP -2- RM 00040 2/71 Two troiects (#23 & 2-4) were given minor consi eration in that each were pick-ups of other federal grants which are terminating. The site visitors believed RNPS support of these projects was inappropriate in view of the National Advisory Council's recent policy re-affirming "Regional Medical Programs funds are not to, replace Rrant6 lost through discontinuance or reduction of other grant program8.11 Committee felt the site visitors were being too strict in their interpretation and pointed out that such pi6k-ups are appropriate so long as they: " (a) respond to a recognized need for local regibnalization and improvement; and (b) demonstrate that they ate integrating into the Regionvs health care system in a way that will Dormit disengagement of Regional Medical Program funding within a short time." Dr. Kralevski was not present during Committee discussion or action on the application GRB/RMPS 1/13/71 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) CONNECTICUT REGIONAL MEDICAL RM 00008 2/71.1 (CS) PROGRAM January 1971 Review Com7nittee 272 George Street New Haven, Connecticut 06510 Program Coordinator: Henry T. (@lark, Jr., M.D. REQUEST (Direct Costs) 03 Year (1/71-12/71) COMMITTEE/COUNCIL REVIEW: Renewal for CUPISS $60,496 New Project - Newborn Program 26,270 TOTAL REQUEST 86,766 ------------------------------------------------------------------- RMPS STAFF REVIEW: Continuatio uest Commitment for Core 381,000 Commitment for ongoing activities 939,750 Carryover 133,860 TOTAL CONTINUATION-REQUEST 1,454,610 ---------------------------------------------------------------- Action on Continuati uest Approval of total commitment 1,320,750 Disapproval of carryover request -0- TOTAL 03 YEAR AWARD $1,320,750 FUNDING HISTORY (Planning Stage) Grant Year Period Funded (4.co@. ol 7/66-6/67 $344,796 02 7/67-12/68 $31.3,000 (18 months) CONNECTICUT RMP 2 - RNi 00008 2/71.1 Operational Program Council Funded Future Grant Year Period Approved (d.c.o.) Commitment 01 1/69-12/69 $1.,633,978 $1,320,750 ------- 02 .1/70-12/70 $2,372,333,, $1,650,937-1/ ------- 03 1/71-12/71- $2,693,58@/, $1,320,750 ------- 04 1/72-12/72 137,96@/ None 05 1/73-12/73 145,4471/ None I/ Includes carryover funding of $330,187 2/ Includes recommendation of November 70 Council HISTORY: The Connecticut Regional Medical Program began its two-year planning phase in July 1966. Transition to operational status was a lengthy process requiring multiple Committee/Council reviews and two site visits. The major areas of concern revolved around: (1) The Region's emphasis on a comprehensive approach with almost complete absence of categorical considerations, (2) Cooperative arrangements with, and support for the program of, groups upon which implementation would depend, specifically the practicing physicians ( as represented by the Connecticut State Medical Society). The reviewing bodies, after considerable deliberation, accepted Cl@P's Grand Design, with its intermingling of RMP and CIIP activities. Further, although CRMP's differences with the Connecticut State Medical Society were not resolved, it appeared that progress was being made toward resolution and that the rest of the Region was solidly behind the Program. An 01 year operational award of $1,320,750 was made in January 1969, calculated on the basis of 100% funding for core and 75% funding of the Council-approved amounts for projects. Staff review of the 02 year continuation application and a subsequent request for the use of carryover resulted in an 02 year operational award of $1,650,937, representing the commitment of $1,320,750 for core and twelve projects and carryover funding of $330,187 for expansion of four ongoing projects and initiation of six others. Although these six activities did not receive Council review, staff felt that CRMP's original operational application spelled out the broad thrust of emphasis and that these activities were covered well by the umbrella of Connecticut's grand design. A proposal in the October/November 1970 review cycle, which requested supplemental funding for seven new activities, resulted in approval in the reduced amount of $183,348. This amount was calculated on the basis of the requested funding for two projects -- Planning Neighborhood Services in Hartford and Southern Connecticut Kidney Disease Program. Neither activity has been funded. CONNECTICUT RMP - 3 - RM 00008 2/71.1 Coiinecticut's 03 year continuation request recently was reviewed by staff. The proposal received a favorable review, and it was,agreed that the Region had done a superb job of explaining the grand design itself and relating all activities to the overall program objectives. Although the continuation application requested the use of approximately $130,000 carryover (with the promise of future carryover requests totaling around $60,000) the recent RMPS policy prohibiting awards of carryover resulted in CRMP's receiving an award in the amount of the 03 year commitment only -- $1,320,750. It was suggested, however, that when procedures are developed for Regions to apply for new money on a competitive basis, a request for some additional funding for the University and Community- based faculty at the University of Connecticut would be looked upon favorably by staff. Th& funding history at the end of this summary sheet provides details on the distribution of the Region's funding level of $1,320,750 among the various segments of the grand design. Connecticut Regional Medical Program will submit its first anniversary application on August 1, 1971 for review by October /November 1971 Com- mittee and Council. PROGRAM EMPHASIS: CRMP's grand design was spelled out in the original operational grant application and has remained con- stant. The program objectives focus on quality of care, provision of service, and economy of delivering health services. The Region has been divided into ten health service areas for grass roots programming and planning, and within this context the community hospital is viewed as the primary entry point for CRMP influence in each area. Five categories of program emphasis have been identified as necessary to reach the Region's objectives: 1. Research and Evalution -- primarily directed toward research on health conditions and practices. 2. Health Service Area Program Assistance -- channeling research findings into planning at the local level 3.' University-Community Hospital Partnerships -- revolving around the theory that each community hospital will require a small cadre of full-time professional staff to provide the necessary leadership in implementing planning results and in developing educational programs, to be aided in turn by a cadre of university-basled faculty oriented toward the problems and needs of the community. 4. Clinical Services -- charting more effective statewide clinical services. 5* Health Profession Education -- stimulating and assisting health education activities which have statewide implications. CONN],"CTICUT ITMP 4 ItM 00008 2/71.1 PRESENT REQUEST: The portion of the 03-year application for which Committee/ Council review is required consists of a renewal request for one additional year's funding for CUPISS and a supplemental request for support for a regional newborn program. Project #lR - Connecticut Utilization Patient Information and Requested Statistical System (CUPISS). This renewal 03 Year request is for a third year of funding for CUPISS. The system $60,496 is described as a new approach to the collection and utilization of basic health data on a large population group which can be used to promote quality and efficiency of health services, to help measure the effectiveness of various therapeutic programs, and assist in planning new facilities and services. RMP provided partial funding for this program in 1969 and 1970 totaling $173,161, and the main thrus,t of acti- vities during those two years pertained to research and development concerning the provision of institutional services through utilization review reports, institutional performance indices, and operating statistics. Initially it was expected that these services would be operational in several hospitals by the end of 1970. However, the ambitiousness of the design and the difficulty of its initial implementation have slowed progress so that the full system has been installed in only three, hospitals, although installation has begun in 17 others. The third-year support requested in this application is for analysis of data which is Accumulating through the expanding system. This analysis is expected to provide basic data with which to evaluate the overall performance of CRMP as well as to provide guides to agencies concerned with the future development of the health delivery system of Connecticut. Requested First Year Project #33 - Yale-New Haven Regional Newborn Special Care $26,270 Unit. The primary purpose of this proposal is the improvement of care of critically ill new born infants in Connecticut, through the development of more effective cooperative arrangements between the Yale-New Haven Hospital and the general hospitals of the state. Specifically, funds are sought to develop a model ambulance service, to purchase additional monitoring equipment for the existing newborn special care unit, and to complete the equipment of a radiological suite so it can be used for the cardiovascular investigation of newborn infants suffering from congenital heart disease. This request originally was submitted in May 1970 for funding from carryover monies. Although the general idea was viewed favorably, the fact of the proposal's being heavily an equipment request prompted staff to act negatively on the carryover request and return the proposal to the Region with the suggestion that it be resubmitted for Committee/Council review4 The proposed activities relate to the portion of CRMP's grand design pertaining to University"Community Hospital Partnerships, and it is hoped that this program will encourage greater collaborative planning CONNECTICUT RMP -5- RM 00008 2/71.1 between pediatric specialists at Yale and physicians in community hospitals. The request is for one year's funding only. FUNDING HISTORY 03 YEAR Project & Sponsoring Institution SUPPORT DATE (1/71-12/71) INITIATED RESEARCH AND EVALUATION #1 Connecticut Utilization & Patient Renewal in 1/69 Information Statistical System - Review CUPISS (Yale) #13 Inventory of Health Resources (Yale) $11,250 1/69 #17 Financing of Health Care (Yale) 18,750 7/66 #19 Research Program Planning (Yale & U. Conn.) 36,831 1/69 #20 Regional Blood Bank (U. Conn.) 49,365 6/70 #2B Research Program Activities (Yale) 39,966 6/70 HEALTH SERVICE AREA PROGRAM ASSISTANCE #2A - Health Service Area Planning (Yale) 24,850 1/69 #3 - Continuing Care Demonstration (Yale) 93,000 1/69 #21 - Stroke Coordinator Demonstration (Gaylord Hospital) 32,000 6/70 UNIVERSITY-COMKUNITY HOSPITAL PARTNERSHIPS #5 - Community-based Regional Faculty 157,500 1/69 #6 - University-based Regional Faculty 2825707 1/69 (Yale & U. Conn.) #23 - Gastroenterology (Yale & Others) 42,073 6 70 #24 - South Central Diabetic Consultation (Yale) 25,194 6/70 CLINICAL SERVICES #7 - Regional Coronary Care (Hospital of St. 32,172 1/69 Raphael) HEALTH PROFESSION EDUCATION #11 - Nursing and Allied Health (Yale & U.Conn.) 32,000 1/69 #12 - Regional Library Service (Yale & U. Conn.) 62,092 1/69 CONNECTICUT RMP 6 RM 00008 2/71.1 (Funding History Continued) CENTRAL CRMP STAFF #18 - Core 381,000 7/66 Total $1,320,750 PROJECTS NOT FUNDED BY THE REGION Patient Care Workshops Study of Physician Office Practice Patient Status Study Organization and Delivery of Medical Care PROJECTS WITHDRAWN FROM CONSIDERATION High Energy Radiation Services DISAPPROVED PROJECTS Regional Clinical Reference Laboratory University of Connecticut School of Nursing, Regional Faculty Regional Reference Laboratory Regional Nuclear Medicine Program University of Connecticut Planning for School of Allied Health Professions APPROVED/UNFUNDED PROJECTS Planning Neighborhood Services in Hartford Southern Connecticut Kidney Disease Program RMPS/GRB 12/16/70 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE CONNECTICUT REGIONAL MEDICAL PROGRAM RM 00008 2/71.1 (CS) FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL RECOMMENDATION: Additional funds be provided for this.application. Recommended Year Request Funding 03 $86,766 $70,496 CRITIQUE: The reviewers noted that the Connecticut Regional Medical Program will submit its first Anniversary Review Application for Octobet/November 1971 Review Committee and Council. With the current submission, the CRMP is exercisitg its option to present an interim application. 'This proposal discusses the relationship of@the request to ongoing activities and the overbill Regional plat. The Review@Committee observed that Connecticut is one of the Regions which has had a "grand design" and specific Regional thrusts since the beginning of its operational experi6nce,.and although it occupies a somewhat pioneering position among the MQs on that count, it seems sometimes to fall short in its identification @of regional needs. Another issue which was discussed was the recent resolution of the Connecticut State Medical Society that the CRMP limit its activities to "disseminating scientific knowledge and improving patient care in the fields of heart disease, cancer, stroke and related diseases through the medium of education, research and demonstration and tha CRMP "is not authorized by statute to advocate policies and fund programs which promote restructuring of established patterns of providing a.nd financing health care se@vices.11 It was noted that Dr. Margulies reply to this condemnation was an eloquent one and stressed the@fact that the Medical Socleiy's criticisms w6r@ not on firm ground, not being based on the most recent legislation. @-However, the Review Committee did agree that since this is the second time CRMP has had a public dispute with the medical society (the first be'ng it 1968 during the first application for operational tatus), the RMP might have been derelict in not having exerted major efforts over the last 2-2 years toward healing the woutds. Connecticut @IP -2- RM 00008 Lack of communication between the two groups appeared to be a foremost tause. Although this issue had no particular bearing on the current application, the Review Committee suggested that it be investigated at the anniversary site Visit next fall. The.overall recommendation for the current application was for approval at a reduced level. The basis on which the Approved amount was calculated is discussed below. Pro ect liR Connecticut Utilization Patient Information and Statistica-L System.(CUPISS). The reviewers thought tha an additional year's support for CUPISS was a reasonable @@@request since the project is one which is closely related to @@.Re onal goals and one which is absolutely necessary to provide -9 a data base upon which CRMP can plan. The report of the CRMP Rev'@7 and Evaluation Committee, which was included in the application.% was'thought to point up problems and offer suggestion which the t6ject personnel should heed: i.e... the empliasis.upbn dialogue h pot nt' wi medical staffs. the need for better communication wit e ial us rs, an d convincing hos itals and physicians that the system is p suf ic3,-enti worthwhile to support it. Parenthetically the dit icu ties the Region has hadlin gaining the Active support of ho tals caused the reviewers to question the success of the ers t - Community hospital thrust of the C@ip. y Howe 6ti the need for this type of data by the Region and the pot ntiai offered by the project . insured a recommendation that the activity be funded for one additional year in the amount re4 ested. Project #jj Yalb-New Haven Regional Newborn Special Care Unit. e ew ommi ee cons of model ambulance service to be legitimate activity for two reasons: 1. Demonstrating whether adequate transportation actually "fa ts' lives. saves in n 2. Bui ding bridges between Yale-New Haven and the Deiibher y oweve seen to be the,responsibility of Yale. 'Therefore, the@reviewers th6 ght the CRMP should seriously consider limiting its support to approximately $10,,OOO necessary for the development of a model lance service. Mr. Thompson was not present during Committee discussion or action on e application. GRB/RMPS 1/15/70 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIDNAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) Florida Regional Medical Program RM 00024 2/71.1 (C&S) 1 Davis Boulevard) Suite 309 January 1971 Review CoTnmittee Tampa, Florida 33606 Program Coordinator: Granville W. Larimore, M.D. Request (Direct Costs) ReRional Year 03 04 05 For CommitteeLc-ouncil Action New Funding Four New Projects $ 735,651 $753,968 $801,838 For Staff Action Continuation 1,540,808 Core (692,645) 9 Ongoing Projects (848,163) TOTAL REQUEST $2,313,862 $753,968 $801,838 Funding Hi@r Planning Phase Period Award Comitted 11/l/67 - 10/31/68 $245,600 11/l/68 - 2/28/70 778,744 16 months 3/l/69 - 2/28/70 $ 706,688 3/l/70 - 2/28/71 1,721,648 3/l/71 - 2/28/72 $1,535,568 Florida RMP -2- RM 00024 2/71.1 (C&S) Background on Region: The Florida Regional Medical Program, covers the State of Florida with 67 counties. In the core section of the application, an excellent summary is given with charts showing the dif faculties that the State of Florida'has with the wide variations. Four counties report less than half the United States average income of $3,421 a year. Twenty-two counties are above the half mark but below the average income. Thirty-six counties are near the average and five are above-average. The unique characteristics of the population of Florida relate to the number of retired people and their location throughout the State, the large migrant work force, the larg6 agricultural work force which has somewhat the same kinds of health problem as the migrant work force, displaced Cubans, urban centers with big etto areas, rural poor, an uneven distribution of medical resources both physicians and hospitals, the descalation of space employment, and the large influx of vacationers. History of Grant: The Region received its initial planning funds on November 1, 1967, after submitting tliree.applications. Three areas were established, based at the University.of Florida.in Gainesville, Tampa, and the University of Miami in Miami. The North Florida area moved rapidly ahead in the development of projects, while the other two areas were experiencing staffing and organizational difficulties. Shortly after the Region received its planning funds, a hypertension screening project was initiated from earmarked funds. The present coordinator was appointed in the Fall of 196.8, and charged with coordinating the three area programs. Council approved operational status for the Region in February 1969 and funding for nine operational projects. A program site visit was made in January 1970 and the team reported a number of problems seriously hampering the program - the function of the RAG in relation to the Board of Trustees, representation of the RAG, the need for effective working committees, the.secessionist moves on the part of North Florida and program imbalance among three FP-4P areas. The March Council accepted the team's recommendations: to maintain Florida as a single program, to give priority funding for the central and southern areas of the state, and to advise the Region that the RAG should be strengthened and the review process improved. In the past year, a number of organizational changes have been effected. Ten district offices have been organized under the coordinator in Pensacola, Tallahassee, Jacksonville, Daytona Beach, Orlando, Tampa, West Palm Beach, Fort Myers, Miami-BrowArd and Miami-Monroe. The medical school staff have been relieved of area programing development responsibilities. Project monitoring has been strengthened. Florida RNP -3- RM 00024 2/71.1 (C&S) PRESENT APPLICATION Regional Advisory Group Report: The Regional Advisory Group report includes a fairly extensive descrip- tion of the Region's plans, priorities, organization and hopes. The RAG feels that this year has seen the opportunity to build the program on an established base of part-time physicians, medical schools, hospital educational programs, junior colleges, and voluntary health organizations. The by-laws call for an executive committee but it is felt that ad hoc committees requiring varied groups of RAG members will keep the executive committee from impeding the RAG in developing its role As an effective decision-making body. A major organizational change resulted from the report of a Conference Committee on the responsibilities and relationships between the Board 6f Directors of the Florida Regional Medical Program, Inc., and the Regional Advisory Group. The statement agreed to by all parties is delineated in the RAG report. The reorganization of the core, the RAG feels, was a critical develop- ment this year; ten district offices have been set up to be staffed by part-time physicians, superseding the three areas centered in the medical schools. This will not only enable the RMP Core Staff to service all areas but will provide for functional participation of the medical schools without having to be responsible for area development. The RAG report indicates that this change which has been supported within their committed funds has created funding problems. The district offices will share offices with the CHP (b) agencies where possible, a move which is expected to enhance Comprehensive Health Planning interrelationships. On the state level, the RMP and the (a) agency have had one joint project, a statewide health insurance study; one member of the Florida RAG is Chief of the Florida State Bureau of Comprehensive Health Planning and the Director of the Florida Regional Medical Program is a member of the Florida Health Planning Advisory Council. The Ad Hoc Committee on Directions and Priorities - seven people from the RAG, representatives from the Department of Health, labor, nurse association, dean of allied health school, Florida Hospital Association, the Bureau of Comprehensive Health Planning, and a practicing physician have outlined the following priorities: 1. Continuing education on a interdisciplinary basis. 2. Improvement in health care delivery. 3. Identification of health manpower needs. 4. Development of cooperative relationships with other planning groups. 5. Personal health education. Six categorical task forces and task forces on continuing health educa- tion have outlined Priorities in their respective areas as well as the planning that must go into meeting these priorities. Florida RMP -4- RM 00024 2/71.1 (C&S) The Regional Advisory Group report relates the new proj_cct8 contained in this application to the regional objectives and priorities. The .Iuntor College Model will strengthen inser-vice education and inter- cliange.of students among cooperating hospitals. The Post-graduate Intensive Service Education for Physicians wi,ll..allow the-physicians to return for study at the University of Miami. The..Statewide Cervical Cytology Program will@ build on a program,that'has been. supported by the State Health Department and.the Statewide.Renal Dialysis Program will build a transplant network. Core Progress Report: There are only six core staff members in the central office. The Task Forces have been.a major problem in developing a program approach because of their categorical project interests and clinical orientation. The categorical versus the disciplinary approach has been-a problem.for the Task Forces. It is felt that better staffing for tbe@Task Forces will help them develop a program outlook. Project Development and Review: The Committee on Directions and Priorities sets-the tone-through the priority framework for the Regional Medical Program. A Task Force reviews each proposal and calls on special. consultants as needed, either to make site visits or to review. The Regional,Advisory Croup Ad ltoc Project Review Committee then re'views the project; the.lioard of Directors of FRMP, Inc., looks at it from the standpoint of fiscal soundness and the affiliation agreements needed, and finally the RAG looks at it. The two CIIP (b) agencies in the state will be brought into the review process early in the project review process. Evaluation: The Core report on Evaluation cites several examples of how the Region is going about its evaluation. Site visits were set for early December on two projects, Multi-phasic and the Computerized EKG Processing Center, as a result-of staff evaluation (the Region has not submitted a request for continuing funding of these projects until the site visit reports are available to the RAG). Apparently a very hard look is being given to the ongoing projects to see whether they are accomplishing their purposes. In the Coronary Care Unit Training, they found the use of vignettes from students was a useful type of evaluation, more meaningful than some of the ore and post training that had been originally planned. The Evaluation Section indicates that the RAG is utilizing evaluation studies as guides for allocating the funds available to the Florida Regional Medical Program. Nl-"W PRO-Jf,'CTS Project #37 - Florida Communitv JLini.or College Extended C us I,'irst Yezir Concept. This project under the direction of Philip A. Frederickson from St. Petersburg Junior College, has $36,358 Florida RMP -5- RM 00024 2/71.1 (C&S) been conceived to assist community hospitals and nursing homes to improve the quality and availability of their inservice educational programs. It proposes an extended campus concept which develops cooperation between health care institutions and a community junior college through association with the project staff located at the college. The project has two segments, only one of which will be funded in part through funds from the RMP. The improvement of inservice education, it is felt, will favorably effect health care by: 1) improving skills and increasing the know- ledge of individual healthjworkers in the community health care institutions; and 2) making the employees' tasks more interesting and personally more satisfying thus leading to greater staff stability. The objectives are: 1) to develop a guide that will outline the steps and changes in administrative policy and structure in the Junior College and community health agencies that are needed to bring about a flexible relationship that utilizes community manpower, mindpower, hardware, software more efficiently. The guide will include suggested policy and procedure revisions relating to such areas as enrollment, attendance requirements, educational credits, tuition and fees, lending and borrowing of educational equipment and materials, etc.; 2) to develop a system whereby inservice directors, community health agencies, and the community junior college faculty can combine their talents and efforts to more effectively teach health workers basic "for the job" skills and continuing "on the job" skills. This will Include joint development of teaching materials and shared manpower, hardware and software; 3) to develop a pattern of continuing education whereby the directors of inservice education in the community health agencies are able to assist health workers to meet their continuing education needs. This mechanism will also provide the junior college with feed- back regarding community needs in continuing education and establishing other resource agencies and personnel outside the immediate area. The first year's activities will be directed toward the hospita s n Pinellas County, Florida, each of which has a functioning inservice education activity. At the beginning of the second year, nursing homes in Pinellas County will be encouraged to participate In the program. The third year will be devoted to consolidating experience gained and relationships developed in order to expatnd the concept throughout the region. The State Department of Education (Division of community Colleges and Division of Technical, Vocational and Adult Education) will be primarily responsible for the regionalization phase of the project. This project was approved by the Continuing Education Task Force, tll(@ Board of Directors, and the Regional Advisory Group. 02 Year - $53,803 03 Year - $56,710 Florida f@MP -6- RM 00024 2/71.1 (C&S) Project #38 - Florida Statewi e Svstem for the Care of the First Year Patient with End Stage Kidney Disease - The ert purpose of this project is to establish a kidney transplant $240, 260 network in Florida. This cooperative effort will: 1) provide a training curriculum of high quality for dialysis and trans- plant personnel to maintain and enlarge a recipient pool; 2) maintain an automated matching program with full information about each patient and the results of each matching effort in each transplant; 3) develop and implement a rapid and reliable transportation system for movement of donor organs among the participating centers; and 4) standardize and sustain the quality of tissue-typing throughout the system. Long-term hemodialysis is offered to chronic renal disease patients in Miami, Tampa, and Gainesville at the present time. In addition, Miami and Tampa provide home-dialysis teaching. Two smaller hemo- dialysis units are opening in the near future at Clearwater and Lakeland, both of which will relate to Tampa. At Jacksonville, a major population center in the State, efforts have been underway for a year to initiate dialysis service. In Pensacola there is some dialysis equipment which may be developed into a center. There are approximately 114 patients undergoing dialysis in Florida at the present time of which 75 or 65% are thought to be suitable transplant candidates. By combining these persons in one recipient pool, each time a donor is available, it is estimated that there is a 48% chance for a match with any available recipient as compared to respective chances of 37% at Miami, 22% in Tampa, 16% At Gainsville, if these centers operate separately. Under the auspices of this project, four transplant centers will operate in Tampa, Miami, Gainesville, and Jacksonville. Each will have a tissue-typing technician, trained in the same techniques who will test all recipients at regular intervals and all donors as they appear. I The existing computer-based system will monitor the potential recipients. When a donor organ is to be sent to another center, the transportation will be arranged by the transplant coordinators from the locations involved. Every active major dialysis group in Florida is involved in this project. The geography of the State is covered completely except in the Pensacola area which will be joined in the second year as the physician manpower becomes trained and available. Every surgical team that has done a transplant in the State is involved also. To supervise each center at representative network meetings, there will be a physician who possesses the full authority of his local colleagues to reach decisions and actions. A large recipient pool can be maintained only with an efficient dialysis facility, and it will be necessary to train the nursing Florida RNP -7- RM 00021',@ 2/71.1 (C&S) manpower. This project will. teach at least 36 nurses and technicians per year at a projected total cost of about $25,000 annually or less than $700 per trainee. Training will take place in Miami with 24 students and in Tampa with 12 students. The project budget includes a small amount of money to assist in the establishment of dialysis activities in Jacksonville. The equipment will be donated by a local hospital and space will be provided by another insititution. An essential partof an organ transplant program is public education activity to create a Positive atmosphere toward donation -immediately upon death. A study done by the Florida Regional Medical Program staff indicates that the majority of people questioned agreed that they would sign a legal document giving the physician permission to remove the kidney to be transplanted to another person in the event of sudden death. Different messages are planned for the older popula- tion, the younger population, hospital personnel, physicians, and funeral d-irpctors. The application states that a Board of National Consultants were asked to review this project who sent mail evaluations and conducted a site visit in Miami on October 9. The individuals involved in this review were not named. The Board of Directors of the Florida Regional Medical Program reviewed it from the standpoint of fiscal feasibility; an ad hoc RAG Review Committee looked at it from the standpoint of program priorities before the final RAG approval. 02 Year - $256,541 03 - $266,746 Project #39 - Florida Statewide Cervic - This First Year project to detect early cervical cancer among est the young, indigent, and medically indigent females over the $271,533 age of 20 has as its objectives: 1) the detection and necessary follow-up of treatment of cervical cancer; 2) the demonstration to hospitals and physicians of the feasibility and benefits of screening large numbers of women, utilizing residents, interns, and paramedical personnel; and 3) improvement of communications between the local health departments and hospitals and between the Pathology Department, the Out-Patient Clinic and the Tumor Clinics of these facilities. Salaries for nurses and clerks in the County Health Department and the respective county hospitals as well as three cytotechno- logists, for Dade County are requested. The patients will be from high, densely populated centers in Jacksonville. Miami, Pensacola, Tallahassee, Tampa, and West Palin Beach. 0 Florida RMP -8- RM 00024 2/71.1 (C&S) The project hopes to "plug" the gap between the present health department network and the hospitals. The health department program has been supported from cancer control and 314(e) funds since early 1960. 02 Year - $281, 06 1 03 Year - $290,794 Project #40 - Postgraduate Introductory Intensive Inservice First Year Education for Physicians in Miami - This project est is designed to establish, investigate and determine the value $42,810 of sliort-course continuing education for private physicians, using preceptors techniques and student curriculum selection. It will utilize the personnel facilities of a major medical complex In South Florida, including the major medical school teaching hospital (Jackson), a Veterans Ilospital. (Miami), and two prestigious private hospitals (Cedars of Lebanon-and Mt. Sinai). This diverse environment will offer a broad selection from which physicians may choose their ideal training circumstances, ranging from an academically oriented medical school to a private medical office. Subject matter will be equally comprehensive, extending from common practice problems to emerging complicated technology. Questions to be answered by the project are: 1. What type of physician is attracted to and takes advantage of this type of education? 2. What special features make itsusefulness popular (away from home, medical school center environment, preceptor teaching, personally selected curriculum, course length, etc.)? 3. Do persons seek this kind of training when they have, participated in noctlier types for several months or years? 4. What effect on medical practice habits and attitudes is mediated by the training program? A special information program will be used to announce the continuing education opportunity,to Florida physicians. There will be no emphasis on speciality or geography so that an evaluation of total impact can be conducted. The Journal of the Florida Medical Association will be used along with announcements and descriptions placed in bulletins of the 40 constituent counties or multi-county medical societies. Personal mailing to each practitioner will be made also. Enrollment will be accepted on a first come, first served basis, but this practice may be altered subsequent to accumulation of experience in the first 12 months. It is expected that 50 persons will be trained in the first year. The limit to the number of people to be trained is preceptor availability and trainee interest. Florida RMP -9- RM 00024 2/71.1 (C&S) There is no salary support or reimbursement for the preceptors, the faculty members, and physician teachers. The budget requests an amount of $250 for each trainee to be placed in a special fund for the use of the preceptors in furthering their training purposes. This money may be used to purchase audio-visual aides, special books and teaching material and similar materials which will strengthen the program and develop a foundation for sustaining the work in the future. The monies will be under the control of the coordinator at each of the cooperating institutions, No stipends or replacement reimbursement is requested for L@ic@ physicians: per them expenses of $25 a day are requested. 02 Year - $66,975 03 Year - $48,200 Project #41 - A Hospital Based Program for Cardio nar First Year Resuscitation - This project is a revision of Request. an earlier proposal which was reviewed by the July 1970 Advisory $144,690 Council. During earlie-.1- review, the one-day training period was questioned, the support after RMP support is terminated was questioned; information on the pilot study that led to this proposal was lacking, information regarding the coordination of personnel, utilization of consultants, teaching methods, selection of trainees, and follow-up was also lacking. Under the direction of the Chairman of the Florida Heart Association's CPR Committee, this program is designed to reduce premature mortality arising from cardiovascular and respiratory arrest. Educational training and modern cardiopulmonary resuscitation techniques are the means of attaini.n@, this objective. ')'he community hospital w serve as the base of the operation for development of liosl)iLa.1-o@rf.(.,rited programs. 'riic-- ob,j(-@ctl.ves are as follows: 1. To train and retrain key physicians and registered i.-iur::3es who will assume responsibility for training other hospital personnel. 2. To encourage and assist hospitals in establishing emergency resuscitation measures. 3. To establish uniform standards of training of hospital personnel according to the recommendations of the National Research Council. 4. To provide training for the future Instructors tn CPR at the community hospital level through a decentralized delivery system. Information is presented in this application relating to t,:Iie Specific concerns raised in previous Council review. The I)il.ot stuciv findings I are delineated, the personnel and the functions of the various personnel are itemized, the type of consultants and their functions are listed, Florida RNP -10- RM 00024 2/71.1 (C&S) and the evaluation protocol is outlined. The course has been changed The from a one-day course to three one-day visits to each hospital. trainees will,be hospital personnel with medical or nursing backgrounds since it is expected that only such individuals can establish and conduct CPR and re-training programs in the hospitals. These teacher trainees will receive the three visit CPR training, will be provided with guidelines for the development and content of CPR training programs, and will conduct CPR training under supervision. Each hospital will be requested to select trainees from the following personnel categories: 1. Nursing supervisors, head nurses, and assistant head nurses. 2. Inservice directors. 3. Representatives from Inhalation Therapy Department and Anesthesiology Department. 4. Chief Residents especially on medical and surgical services. Others to be invited include the Chief Physician in the Emergency Room, all members of the Hdspital's Cardiopulmonary Resuscitation Committee and members of Heart Association Cardiopulmonary Resuscitation Committees. No class should include more than 20 trainees. 02 Year $95,588 03 Year $98,288 RMPS/GRB 12/30/70 SULMMARY OF REVIEW AND CONCLUSION OF -January 1971 Review Committee FLORIDA REGIONAL MEDICAL PROGRAM @l 00024 2/71 (C & S) FOR CONSIDERATION BY FEBRUARY 197i ADVISORY COUNCIL I Committee recommended that this application which requ6sts support for five supplemental projects be@supported as foll@ows: AR REQUEST RECOMMENDATION 03 $735,651 200,000 753,968 160,000 801 838 145,000 OEA 2,291,457 505,000 When the site visitors reviewed the Florida @IP a year ago, they found a Region in serious trouble. An impasse was developing 00 qon the Regional Advisory Group and the grantee agency, which had us?arped ome of the W.G's authority and responsibilit The RAG's operation had y . e and --en hamp6r6d@by the lack of an Executive Committe, other subcommittees. Ther@-vias inad66uate representation on the RAG of consumers, minority mbets and professional individuals familiar with Floridal@ healtb, n Relationships were strained with the North Florida Area Coordinator n D6an,of the University of Florida at Gainesville who fostered the 0 of area cooperative arrangements rather than those to enhance the C, e nt of a statewide IU4P, and spearheaded moves for secession of the No t Florida area from FRK.IP. Some of the ongoina projects were running t6@s;erious: tec nical and organizational problems, and new projects were en quaiit . In addition because of the ambitious efforts of o@ unev i- y e rtb ii6iida area.dur)'n,,, the early part of the program, an imbalance n t e number of projects and amount of money invested among the three, a, ea6 had developed. n=i tee noted that the present application addresses most of the above c rns As a.re--ult of a Conference Committee, relationships and c esp nsibilities between the RAG and the grantee agency have been delineated reed to bv both parties. Goals and objectives, while general, ve en set. An Executive Committee and various other subcommittees have en ed. Membership on the RAG has been broadened Core has been 6or ized'to take the responsibility for area development out of the dontrol medical schools. At the same time, secessionist moves on the part t Unive sity personnel in North Florida have reced6di The RAG has arra ea site v sits to two of the ongoing projects and@is Presently n@ ering'phasin3z them out. The Region is also submitting more statewide, as w as 1-ild and South-Florida-sponsored projects, e ojeqts in the present application received a'mixed response frqm:the RMP FLORI'DA. -2 RM 00024 2/71 (C S) reviewers. Committee found interesting and unusual, the concept of ett g juniorcollege@and community hospital and nursing home representatives e inservice educational program's; however, oo* her to Plan th6v were unable to determine exactly how this should be carried out. It was,,recounended that the Region invest some funds for further planning in this promitin 9 n project #38., ri,da State @for the t ity. Adecision o The Flo wide Sy@-te;u @ Care f Patients wiih-tnd StaRe Kidney Disca',ge,@was deferred until,lit o=uld@ at@by a national Rrou although Cowmitt6e believed it ihoul ag'si aool a lower piciority,iii relation to other projects in this app li a :.on, a Of e r o d6quacie discussed se CDntrol Program. While the Statewide Cervical ly would reach migrant and other indigent women, t6vi6 rs txpresse t e that after ten years of funding by the PIIS other @geiicies would e its support. Project #40. Postf,,raduate-Introductor Intens e y ni ce.Ed tion for sicians in.lliarii. was ent u iastica@lly or.sed 7ell as involving physicians in the South Florida area, the t presents A unique way of budgeting the educational@expense@s. t p 0 fdir,&, sal@ary support for the preceptor, faculty me bars d rs, the budget requests $250 for each trainee be Placed in a @'Se nd for t'nd use of preceptors in furthering their training si i.e., b6ok6i a-tidio visual -.iids or other special tea in p ma With reg6rd to the os ital@as-d Pr@,liram for C s he reviewers questioned the 6xt invo all e @@C' - vi te note ver, a s Al le aer t field from Florida, Vab had not been involved in the earlier Al are how listed as participants. They tonclud-,d'that while the ,is iairiy-,@4611 organized, it could be supported at a lower le el quested, AM NW 0 0 9 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATIOIT (A Privileged Communication) Greater Delaware Valley RMP RM 00026 2/71.1 (CS) 551 West Lancaster Avenue January 1971 Review Committee liaverford, Pennsylvania Grantee Agency: University City Science Center Program Coordinator: George R. Clammer, M.D. Request (Direct Cost.-.), 03 year 04 year 05 year 4/l/71 - 4/l/72 - 4/l/73 Total Purpose 1/72 3/31/73 3/31/74 All Years Continuation Commitment* 21-109,357 2,109,357 Continuation Request 2,142,503 I/ 33@926 2$1761,429 Core (111603,620) (1,603,620) 6 Projects (5-@18 31 883) (33,926- (572,809) one project) Additional Components 565$946 1740416 164,259 904,621 4 new Projects (270,591) (174,416) (164$259) (609,226) 5 previously approved activities (295,355) (295,355) Totals 231 708,449 208,342 1645259 3$081,050 *Staff Action on Commitment 2,109,357 33,926 ----- 2,143,283 o@mmittee Action Required 5651,946 174$416 164,259 904,639 1/ Continuation Request $33,146 over Commitment. Funding History Planning Stage Giant Year Period Funded (d.c.o.) 01 4/l/67 11/30/68 $10358 31 270 02 12/l/68 3/31/69 (4 mo.) 256,152 Greater Delaware Valley RMP -2- RM 00026 2/71..] (CS) Operational Program Council Future Grant Year Period Approved Funded (d.c.o.) Commitment 01 $2,215,967 Core 1,628,336 1/ ------- Proj. 596,201 02 4/l/70 - 3/31/71 2,248,070 Core 1,628 336 ------- Proj. 815:150 2/ 03 4/l/71 - 3/31/72 2,289,691 ---- $2,109,357 04 4/l/72 - 3/31/73 33,926 (#13 only) ---- 33,926 I/ Includes $155,478 carryover funds from 02,planning grant year. 2/ Includes $317,387 carryovee funds from 01 year. Geography: This Region covers eastern Pennsylvania, all of Delaware, and southern New Jersey. Discussions to explore issues of mutual concern are held with the six adjoining RMP'S: New York Metropolitan, Albany, Susquehanna Valley, Maryland, Central New York and New Jersey. Demography: A. Population: 8.5 million (1965) 1. White 92% 2. Non-white 8% B. Facilities 5 Medical Schools (Philadelphia) 1 School of Osteopathy C. Physicians 12 31 214 (medical) D. Osteopaths 1,090 Program Priorities: 1. Improvement of health care delivery systems with special emphasis on the poor. 2. The continuing education, primarily of physicians but with attention to nurses and other allied health personnel. 3. The development of program activities, primarily for heart disease, cancer, stroke, kidney and respiratory diseases. Greater Delaware Valley RMP - 3 RM 00026- 2/71.1 (CS) Review Procedure: A revised review procedure has been developed and recommended by the Grants Review Committee of the RAC. If the recommendations are adopted, the Grants Review Committee of the RAG will be replaced by the Regional Review Committee which includes members of the RAG. The RAG itself will remain the final reviewing committee. Review will be initiated by three paralled review committees: 1) Administrative Review Committee. Staff members to include the Executive and the Deputy Executive Director, the Associate Director for projects and members of his staff will review proposals individually and subsequently will meet to prepare a report of recommendations. 2) Technical Review Committee. A fifteen-member technical review committee 'll be appointed. A member of the staff will be appointed Executive wi Secretary without vote. Recommendations for nomination will be made by the Executive Director and appointments (for one year) by the Board of Directors. The chairman will also be appointed for a one-year term by the Board of Directors. Meetings will be held at least once a year, more often according to the number of proposals to be considered. 3) Area-Wide Committee. Each area-wide committee will review proposals originating from its respective area whenever the activities of the project directly involve the area. A Regional Review Committee will be appointed to recommend approval or dis- approval to the RAG. The Committee will consist of a representative from the Board of Directors, who will act as Chairman, a representative from the Coordinating Committee, the Chairman of the Technical Review Committee, the Chairman or representative of the area-wide committees and a represen- tative from the RAG, and a member of the Executive Director's staff. In reviewing proposals the Committee will receive reports from the Administra- tive, Technical and Area-Wide Committees. The RAG will take final action on all proposals approved by the Regional Review Committee and may act on any disapprovals at its own discretion or upon appeal for reconsideration by the sponsor. Regional Advisory Gr@u . The RAG has been expanded to 53 members with representation from 17 counties of the Region and is representative of the broad spectrum of health interests, resources, and socioeconomic groups within the Region. The RAG meets four times a year. Four committees appointed by the Chairman (Evaluation, Membership, Nomlna- ting and Grants Review) holdindividual meetings throughout the year. Board of Directors. The new 1970 Board of Directors has been expanded from 6 to 17 members (all members of the RAG) and includes: 6 representatives of medical schools, 5 representatives of health agencies and 6 representatives of subareas. The Board is designed to function as Greater Delaware Valley P4P - 4 - RM 00026 2/71.1 (CS) the policymaking body of the GDVRMP. Standing Committees and Local Action Gto"-S. 1. Health Care of the Poor 2. Continuing Education 3. Categorical Disease (Heart Disease, Cancer, Stroke, Respiratory Disease and.Kidney Disease) 4. Coordinating Committee 5. Project Review includes the Technical Review and Regional Review Committees. 6. Committee on Planning Methods (staff). General Concerns of DRMP Staff regarding Greater Delaware Valley RMP During March 1970, staff reviewed the Region's second year operational continuation application for the year April 1, 1970 - March 31, 1971. The continuation of the operational projects evoked little concern and,, in general, were recommended for approval at their committed level4 However,, staff had very serious concerns regarding the basic organization of the Region and the functions and activities of the large core staffs both in the Executive Director's office and in the medical schools. Staff recom- mended that a program site visit be made to the Region to explore the inter- relationships of the Core staff with the projects, as well as the degree of coordination among the various staffs of the Core components. The site visit was conducted on June 18, 1970, and was composed of the acting director of RMPS and senior staff members. The major concern of the site visitors regarding the GDVRMP was that the Region lacked a coordinated planning effort between the Medical Schools, subareas and the Central Core staff. How funds were budgeted and administered was viewed as a major problem. A reflection of the inadequacy of fiscal procedures was the large amount of unexpended funds accrued during the 01 year. The site visitors were in agreement that a ltliough the various activities reported on by the medical schools were perhaps well conceived and implemented, they were neither coordinated nor related to any long-term planning effort by the Region. The site visitors believed that each school had developed its own plan and activities based upon the interest of the staff at each school. The Coordinating Committee, made up of the Chiefs of RMP units based at the Medical Schools, reportedly functioned as a central planning, coordinating, and advisory committee to the Region and specifically to the Executive Director. However, it was concluded that it was more of a liaison group than anything else. The site visitors questioned the role and the primary focus of the grantee, the University City Science Center. It was pointed out to the site visitors that the UCSC was a non-profit stock corporation (established in 1965) and consisted of 23 owners (institutions). Membership is made up of the medi- cal schools, colleges, and teaching hospitals in the Philadelphia area. Greater Delaware Valley RMP - 5 Rm 00026 2/71.1 (CS) It was indicated that the primary emphasis was in research and development but that they are beginning to get more involved in community service pro- grams. The overall impression of the site visit team regarding the GDVRMP was that it did not truly represent a regional program - a program that had assessed its resources and problems in a systematic fashion, developed a plan, established priorities,, etc. The Medical Schools and especially the staffs of the RMP units have initiated many excellent activities, but most do not fit into a total plan for the GDVRMP. The Central Core staff ' especially the area coordinators, are primarily concerned with servicing the various sub-regions. Expansion in the membership of both the Board of Directors and the Regional Advisory Group was viewed positively by the site visitors. It was felt that with the leadership of these two groups, the GDVRMP has the potential to build a regional program that will be visable and responsive to the problems of the Region. Currently, the Region has the following appr6ved/unfunded projects: Com- munity Health Coordinator, Wilmington Medical Center; Regional Radiation Therapy Network; Develop-.nent of Tumor Control Centers in Delaware Medical Society; Thera-Flicks Delaware Curative Workshops; and Coronary Care Train- ing Program, Underwood Memorial Hospital; Coronary Care Training for Nurses, Crozer-Chester Medical Center and Fitzgerald-Mercy Hospital. Listing of Current Funding Status of Core and Operational Projects in GDVRMP. Amount supported Project Number Title through 3/31/71 00 Core 1) Executive Director $753,890 2) Bahnemann 153,814 3) Jefferson 142,332 4) Philadelphia Osteopathic 106,860 5) University of Pennsylvania 164,363 6) Temple 113,297 7) Women's Medical 119,404 Subtotal (Core) $1,553,960 *1 Coronary Care Training Wilkes-Barre General Hospital $ 91,338 *2 Coronary Care Training Reading Hospital 81,804 3 Ceneral Intensive Care Courses 94,278 *4 Philadelphia Regional Chronic Pediatric Pulmonary Disease Program 242,447 ('.reater Delaware Valley RMP - 6 - RM 00026 2/71.1 (CS) Amount supported Project Number Title through 3/31/71 5 Retraining Program for Women Physicians, Women's College of Pennsylvania 759884 6 Coronary Care Training Units Wilmington Medical Center 729600 8 Centers for Respiratory Care Hahnemann, Allentown, Wilkes-Barre 719179 10 School of Radiotherapeutic Technology at Six Cooperating Philadelphia Hospitals 379 150 13 Renal Disease Patient Support Program 489470 14 Improving Patient Care in Hospitals Through Self-Evaluation 59,963 15 Development of Three-Dimensional Models for Cancer Detection 14,413 Total $2,4439486 (d.c.) Carryov er included above: #1 $173,391 #2 209964 #4 98,103 $136$458 The Region plans to submit its Triennial Application during fiscal 'ear 1972. y Present Application This application contains requests for: 1) One year continuation for support of Core activities and the following on-going operational projects: Coronary Care Training - Wilkes-Barre; Coronary Care Training - Reading; Intensive Care Training; Chronic Pediatric Pulmonary Disease Program; Retraining Women Physicians; and Renal Disease Patient Support. Staff will act on the continuation request for Core and the above projects. 2) A request for funds for five previously approved activities funded from Coro and carryover, 3) Four new operational projects. Greater Delaware Valley RMP - 7 - RM 00026 2/71.1 (CS) On-c@oing Projects Project #6 - Coronary Care Training - Wilmington, Delaware 03 Requesting 4/l/71 - 8/31/72 Direct Costs $69,600 The purpose of this project is to train graduate nurses in all respects of coronary care so that they will be able to assume responsibilities in caring for coronary patients in intensive care units, coronary care units, or related medical facilities. To date four four-week courses have been con- ducted and a total of 32 nurses from the first two courses were trained. At the time this request was submitted, information relative to the numbers of trainees completing the last two courses was not available. Project #8 - Respiration Care Centers, Wilkes-Barre General Hospital, Wilkes-Barre, Pennsylvania 03 Requesting 4/l/71 - 3/31/72 Direct Costs $71,179 The purposes of this project are: (1) to provide excellent acute respira- tory intensive care at the three participating institutions .(Wilkes-Barre General, Hahnemann and Allentown Hospitals); and (2) to train physicians, nurses and inhalation therapists capable of providing good respiratory care by giving training programs in different areas of the Region four times A year. During the year from April 1, 1971 through March 31, 1972, four formal workshops in respiratory intensive care will be held. One will be given in both Allentown and Wilkos"Barre and two in Philadelphia. Each course will train a minimum of 15 physicians, nurses and inhalation therapists. The course will offer both formal lectures and bedside participation in the care of critically ill patients and each course will last two weeks. In addition, each hospital will use their respiratory care facilities as part of their in-service training programs. In May 1970, a 12-bed intermediate respiratory care unit was opened in Wilkes-Barre General Hospital. The unit is intended to provide skilled medical and nursing care to patients with severe respiratory disease who are recovering from an episode of respiratory failure ' Also, in May 1970, a five-bed respiratory intensive care unit was opened at Hahnemann Hospital to treat patients who are acutely ill with pulmonary insufficiency. Tile unit has served as a training facility for medical students, interns, nurses and residents and to date, 39 medical students have completed a training program in respiratory care. In an attempt to increase the Greater Delaware Valley RMP 8 - RM 00026 2/71.1 (CS) number of medical personnel who are trained in respiratory care, a two-week workshop has been developed. The first workshop was given at Allentown Hospital during March 1970. Five physicians, three nurses and one inhala- tion therapist were trained. The second workshop held at Hahnemann Hospital during July 1970 trained 17 students. Included were 8 physicians, four nurses and five inhalation therapists. Three additional workshops have been scheduled and to date 15 students have already been accepted. Project #10 - School of Radiotherapeutic Technology at Six Cooperating Hospitals 03 Requesting 4/l/71 - 3/31/72 Direct Costs $373,150 The objective of this project is to develop, through quality instruction, a technologist who will be fully capable of assisting the therapeutic radiologist in the examination, treatment and follow-up of the cancer patient. The training program involves the University of Pennsylvania Hospital, Hahnemann Medical College and Hospital, Jefferson Medical College and Hospital, Temple University Hospital, Mesericordia Hospital and the American Oncologic Hospital. It has been the intent of the program to train no less than 12 technolo- gists each year, however, due to recruiting problems, only about 50% of this quota has been reached. In June 1970, five students completed the prescribed twelve months training course and have passed the National Registry Examination. All are currently employed in Cancer Treatment Centers. Six students are currently in training. The applicant states that, at the present time, they are unable to identify any agency from which future funding might be secured. Project #14 - Improving Patient Care in Hospitals Through Self-Evaluation - Chestnut Hill Hospital, Philadelphia, Pennsylvania 03 Requesting 4/l/71 - 3/31/72 Direct Costs $845,846 The overall purpose of this project is to develop a self-evaluation approach for continuing education in six of nine hospitals to improve patient care based on a process of quality of medical care review. The project is proposed in three phases. Phase I would involve a two-day seminar to be held for the representatives from community hospitals -- 11 member of the board of trustees, at least two of the medical staff leaders, a member of the administrative staff, and a physician designated by the Greater Delaware Valley RMP - 9 - RM 00026 2/71.1 (CS) hospital as the person responsible for the educational programs of its attending staff. The purpose of the meeting would be to get a commitment from the hospitals that measurement of patient care in their hospitals is essential. Each hospital wanting to continue in this program has to agree to give to two of its physicians a mandate to evaluate patient care in the hospital. In return for the commitment, the GDVRMP will share equally with each hospital costs for the personnel needed for patient care evalua- tion and for the educational programs designed to meet the verified patient care needs. Phase II will determine needs. Through a series of meetings, each hospital will select a system of data retrieval, probably PAS-MAP, since most of the hospitals now have this service. Once this decision has been made, six months will be allotted for the self-selection of criteria and the collection of data and at least three high priorities of patient care needs. Phase III will be the educational program an eva uation. The educational coordinators at the hospital (the two physicians who have the mandate to establish the evaluation of medical care in that hospital) will construct the medical education programs designed to meet at least two of the three needs. Joint meetings among the hospitals will be held, and consultation will be available for this phase. Evaluation will be dependent upon the data or lack thereof supplied by each participating hospital. If improvement of patient care is documented., the activity would be considered a success in that hospital. If it is not documented, the proposal is considered to have failed in that hospital. The final evalua- tion of the success of the program would be the decision of the hospital board of trustees to assume full cost of the program after two years. Project #15 - Development of Three Dimensional Models for Cancer Detection Trainingi Temple University Health Sciences Center 03 Requesting 4/l/71 - 3/31/72 Direct Costs $32,580 The overall purposes of this proposal are: (1) to develop three-dimensional models which closely simulate the normal human rectum, female pelvis and female breast,, in respect to sight and touch; (2) to develop methods by which simulated pathologic "lesions" can be incorporated into the models (breast lumps, rectal and pelvic masses, and so forth); (3) to develop models which could be produced commercially and sold at low cost; (4) to field@test each model to determine its reliability and validity as an evaluation tool of physical examination skills important in cancer detec- tion programs; (5) to test the effectiveness of the models as learning -devices for the development of physical examination skills; (6) to deter- mine the feasibility of acting as the clearinghouse for the GDVRMP in disseminating information about three-dimensional models useful in training phys icians in allied health personnel. RM 00026 2/71.1. (CS)' Greater Delaware Valley RMP - 10 New Projects Project #25 Greater Delaware Valley Regional Dialysis Training, Project Crozer-Chester Medical Center 03 04 05 Requesting, 4/l/71-3/31/72 4/l/72-3/31/73 4/1]73-3/31/74 All Years Direct Costs $661,487 $49,612 $53,568 $169,667 The thrust of this proposal is to provide effective training in home dialysis to physicians, registered nurses, licensed practical nurses, technicians and social workers in the Region. The physician course will be limited to a maximum of four physicians and will be scheduled in a flexible but structured manner each requiring a period of three consecutive days. The courses are designed for physicians having had little or no first hand experience with a hemodialysis program. The Nurse course will be six weeks in duration and will be repeated four times yearly. Each course will be restricted to a maximum of eight students. Candidates will be referred from interested and cooperating hospitals. Candidates for the Dialysis Technician Training course must be referred from interested and cooperating hospitals and will be restricted to a maxi- mum of four students. The classes will be simultaneously with the classes for nurses. A one-week course given to provide overall orientation to hemodialysis will be held for community nurses. Each course will be restricted to a maximum of four students. The five-day orientation period will include three days in the training center and two days of field trips visiting dialysis patients in their home. The long range plan for this training program would be that it becomes self- supporting, relying upon tuition and contributed services. Project #26 - Demonstration and Evaluation of a Dialysis Training Program, Thomas Jefferson Universi@ 03 04 05 Requesting 4/l/71-3/31/72 4/l/72-3/31j@3 4/l/73-3/31/74 All Years Direct Costs $75p725 $63,271 $650657 $2043, 653 The goals of this proposal are three-fold in that training programs are to be directed toward additional nurses and dialysis technicians for staffing intermediate care facilities, training patients and families of patients in hemodialysis care, and continuing education of nurses and physicians specializing in care and treatment of kidney diseases. Greater Delaware Valley RMP - 11 - RM 00026 2/71.1 (CS) One of the objectives is to provide training of personnel to staff inter- mediate care centers to provide dialysis care for patients who do not have facilities or capabilities for home care and who do not need hospital care. It is proposed to train about 27 nurses, technicians and assistants each year. Evaluation of the project is expected to be developed on the basis of production of qualified technicians and assistants, as well as a better understanding of the needs of kidney disease patients by nurses and physi- cians. The proposed plan carries the endorsement of highly qualified specialists in several hospitals in the Region who have indicated a desire to partici- pate in the training program. Project #27 - Director of Medical Education for Downstate Delaware Hospital Belford Memorial Hospital, Inc., Milford, Delaware 03 04 05 Requesting 4/l/71-3/31/72 4/l/72-3/31/73 4/l/73-3/31/74 All Years Direct Costs $561,175 $37,693 $20JI058 $113,926 This is a proposal to provide coordinated continuing medical education for physicians, nurses, technicians and other paramedics personne n two lower counties of Delaware ' The plan calls for employing a Director of Medical Education to coordinate the medical education efforts between three hospitals (Milford, Beehe, and Kent General) in the area serving a population of about 175,000 people. The three hospitals have a combined bed capacity of 446 and a total of 90 medical physicians and osteopaths. The primary responsibility of the Director of Medical Education will be for continuing education of staff physicians. He will be responsible for the following Activities: 1) Evaluation of educational needs 2) Organization of educational activities 3) Organization of inter-hospital educational activities 4) Organization and implementation of continuing medical education activities for health professionals other than M.D.'s 5) Evaluation of educational programs and activities. The Director of Medical Education will also utilize part of his time to become familiar with educational programs and concepts being developed or utilized within the GDV Region and in other parts of the country. Evalua- tion of the program will be along several lines: (1) the number of educa- tional activities implemented in comparison to preceding activities, (2) the willingness of the hospitals to continue to support the coordinator or director of medical education on their own and the extent to which educational needs are defined and programs to fulfill these needs are implemented. Greater Delaware Valley 12 RM 00026 2/71.1 (CS) It is proposed that, the cooperating hospitals will assume full financing after three years, if the position proves to be of value to the hospitals. Project #28 First Care Cardiopulmonary Resuscitation Training Program Delaware Fire School, Dover, Delaware 03 04 05 Request@n 4/l/71-3/31172 4/l/72-3/31/73 4/l/73-3/31174 All Years Direct Costs $72$204 $23,840 $2410976 $121,020 The goal of this proposed project is to provide training on a statewide basis for persons who are likely to be confronted with such situations in methods of emergency care for victims of heart attacks and/or stroke. Training in cardiopulmonary resuscitation techniques would be provided for specially trained lay personnel, paramedical personnel and medical per- sonnel. The training programs will be specially designed to fit the needs of the various groups and the capabilities of the individuals taking the training. The program evaluation is to be developed on the basis of written examina- tions at the close of each training session. A substantial part of the first-year request is for equipment, particularly a Mobile Coronary Care Training unit to be used in the training program covering all trainees in all areas of the state. $49,500 of the total $72,204 request is for equipment. GRB/RMPS' 12/17/70 (A Privileged Co,-,,@iiiiic.@tioct) SLU4MARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW CO@ZIITTEE GREATER DEI,A@4A'IZE VALLEY REGIONAL MEDICAL PROGRA@! R,@4 00026 (S) 2/71.1 FOR CONSIDERATION BY FEBRUARY 1.971 ADVISORY COUNCII, Recommendation: The Committee recommends that this application which requests three-year support.for four new projects b@- partially supported as follo,:qs: YEAR REQUE,;T RECO@@TENDED FUNDIF(@ Ist Year $270,591 @$50,000 I/ 2/ 2hd'Year 174,416 -O- 3rd Year 164,259 -0- TCFFAL $609,266 $50.,Ooo I/ Support of Project #28 - First Care Cardiopulmonerv Resuscitation Tr@-,Inin@ Program, Delai@lare Fire ScTool, Dover, Delaware may be precluded hv ITT policy which limits support to training activities which Pre directed principally to medical -and allied health personnel who are epiplo-,7(,et in hospitals and in other inpatient facilities, or in out-1)@t-lr,,nt emergency facilitie@.operated by or directly related to innti.ti-itio-,-@s in which folloT,?-Up care is immediately available. Projects llr25 - Greater Va],LN,@R @i q L@!. Ii Tr.)inifi@r. Pro'ie'c-t and Project lr'26 - Deni,)rtstrqtf.on and EViF.Itlltioll Of q p Tr,@i.ning Erogr @i, Thomas Jefferson Uri'varsity are to be further consirFeTe- @y special Renal Com.,Tti-ttee which is to be COTIVelle6 before February 3971 Council m(,Pti.ii(y. LIEI-C"L@round.: The Committee ,,as @.-T,7are that staff on January 4, 1971 had revicT,,eO the continuation component of this Tii e request was for $2,142,503 for t@e (03) year continuation of Core ?ct-ivities .and six projects and a supplemental request@for support of five approvf2d but unfunded projects ($295,355 d.c.) @)liich have been supported out of carryover funds or throuah rebudgetin- of core.funcls. Staff recommended to C, C, the Actin- Director, RITPS approval. of continued funding at the (03) year committed level of $2,109,357 rather then the requested $2,437,858. It was agreed that the five projects which have been previously supported out of carryover funds or through rebud-etin- could be supported within the committed level of support. ('he Acting Director has not tal@en action on this recommendation.) Therefore, the R(-vie-r,) CoTzi,-,iittee interested in how the four new proposals were to interdigitate with the Region's total program. area ter Del.aware Vall.ey RMP -2- RM 00026 (S) 2/71.1 Critique- This Region has many built-in strength s and much, as yet, untapped potential. Their objectives .are extremely broad s.o th-at "almost 7@ anything will fit into them." On this basis, the RAG obviously has difficulty in project scl.ection and approval in relation to the Region's goals and 0 'he 6bi6ctivos. The Region has large core components supported in b th t, Execi-itive Ditec-tor's office and five of the six medical schools (approximately 1.6 million per year). In spite of this, the regional input for most of the projects is not clear. This was made evident in this application for the stoport of tl@?o, almost identical dialysis training projects. Project lr@25 Regional Di6lysis Traini Proect - Crozr-,r-Chest-.r Medical Center and #26 - D6m.6@ist@ation and Evelunti6n of a.@DI-81.ysis omas@ Jefferson U-Lliveksity were reviewed simultaneously. ile both a proposals w re referred and are sch doled to be rOviciiod b, y@a special nal@Committee, the Review Committee recommended that they be returned to he Ogton so that they may consolidate the prooosels and more 'important, escribe hoiqthis type of activity wil.1 fit into the Reglbn's plans for nal diseas@e. vi@7 Committee did@ riot di!gcLi.,-@ Project li@28 - Fire@t C re Co@ diOT4ulm@)tlar esupoi.tatibh TK6iniiig Program in any depth In addition to a possible nf fct@with @l'@'S policy, this -,p7as considered an equipment proposal $50,@ 00 of Ist year budget of $72,000 is for Van,). The needs were not ocumeoted and the proposal failed to'describe how this type of program ould fit the Repi6nis priorities. Once-again the Committee questioned ,w is type of@pronosal gets through the local review process. The nimitt66 bellev6d that this program, #27 - D.M.F,. Fnl;, Do@,7n,,5t.,ite D la@. re Hospitals: 1) related to the broad goals.-and objectives of the i@iould@initiate an important continuation education activ ;y-" on an i n a rni-rural area far removed from the medical, sthool. The Cc.)mmi tee Plieved that the R@IP should consider providing the "seed" money to initiate-:@ it has good potential.. for con e e program, since i tinu d support from local. ourcos. RNPS/GRB 1/18/71 - 0 @ 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) HAWAII REGIONAL MEDICAL PROGRAM RM 01-03 (AR-1-SD) 2171 Harkness Pavilion January 1971 Review Committee 1301 Punchbowl Street Honolulu, Hawaii 96813 PROGRAM COORDINATOR: Masato Hasegawa, M.D. REQUEST (Direct Cost Only) REGIONS OPERATIONAL YEAR 03 04 05 Total (Anniversary Review Package Due on May 1971) I. Developmental Component 92,314 92,314 II. @4=New Proiects 412,647 381,675 @385,220 1,179,542. Total 504,961 381,675 385,220 1,271,856 RMPS Staff Review of Non-Competing 03 Year Operational Continuation Grant Application on 8170 Awarded Commitment Commitment REGIONS OPERATIONAL YEAR 03 Year 04 Year .05 Year I. Core 382,781 -0- -0- 11. Eight Ongoing Projects 563,158 149,909 96,647 Total 946,539 149,909 96,647 FUNDING HISTORY (Direct Cost Only) GRANT YEAR PLANNING STAGE Period Funded 01 7/l/66-6/30/67 108,006 02 7/l/67-6/30/68 122,297 OPERATIONAL STAGE 01 9/l/68-8/31/69 Care- 362@872 Projects- 475,031 Total- 837,903 OPGRATIONAL STAGE (continued) Period Funded 01 5/l/69 - 8/31/69 Pacific Basin Planning 30,000 02 10/l/69 9/30/70 Core 336,101 Projects- 471,503. Pacific Basin- 17 .,082 Total 824,686 02 6/l/70 9/30/70 Projects 90,000 03 10/i/70 9/30/71 Core 365,511 Projects 563,758 Pacific Basin- 17,270 Total 946,539 Georgraphy and Demographp. The Regional Medical Program of Hawaii (RMPH) is responsible not only for the Hawaiian Islands, but also for the Pacific Basin--Trust Territories (Micronisia), Guam, American Samoa. The State of Hawaii includes a long chain of islands almost exactly in the middle of the Pacific. It stretches from the Island of Hawaii to tiny Kure Island, approximately 1,500 miles to the northwest. The populated part of the state includes the seven major islands: Hawaii, Maui, Molokai, Lanai, Oahu, Kauai, and Niihau. These seven major islands are relatively close to each other. Hilo, Hawaii, is about 200 miles from Honolulu. Both Kahului, Maui and Sihue, Kauai ar6 approximately 100 miles from Honolulu airport. The .Molokai Airport is about 54 miles from Honolulu. Lanai and Molokai are only eight miles apart at their closest point. Honolulu, the state capitol and largest city of Hawaii, is located on Oahu, as is Waikiki, the major tourist destination area. The resident population of Hawaii, according to the preliminary 1970 census count, is 748,182 persons, including 41,362 military personnel. The population has increased 18 percent since 1960 and is expected to reach more than one milli on by 1980. In addition to the resident population, Hawaii has approximately 1.4 million visitors each year. This number Is expected to double by 1975. Medical needs of these visitors have a distinct bearing on medical planning for the state. Ethnically, the population of the Hawaiian Islands is 67 percent oriental and/or Polynesian, 32 percent Caucasian and 5 percent Negro. The median age is 24.3. The economy of Hawaii has expanded tremendously in the past two decades and is based on four major industries: sugar, pineapple, military expenditures ard tourism. Hawaii RMP -3- Rm 01-03 (AR-1-SD) 2/71 In addition to the University of Hawaii which has approximately 20,000 students in undergraduate and graduate programs, there are five small private colleges and five two-year public community colleges within the state. There are thirty-three hospitals in the State of Hawaii. Nineteen of these are accredited by the American Hospital Association and eight have approved training programs for interns and residents.' The University of Hawaii's College of Health Sciences includes a two-year School of Medicine, a School of Nursing, School of Public Health, and School of Social Work. The community college system provides training for licensed practical nurses and other allied health workers. The Trust Territories include 2,100 islands (700 square miles of land) spread over 3,000,000 square miles of Pacific Ocean-an expanse greater than the territory of the continental United States. Guam is a single island (209 square miles) 3,300 miles southwest of Honolulu. American Samoa includes seven islands (76 square miles), 2,300 miles south-south- west of Honolulu. There are 92,000 Micronesians in the Trust Territory, 76,500 mixed Chamorro in Guam and 26,000 Polynesians in American Samoa. History of Regional Development: The Region submitted its initial planning application in September 1966 (the first application received from any region) for establishment of a RMP consisting of Hawaii, Trust Territories, Guam, and American Samoa. In June 1966,, the Region received its 01 year planning award at a funding level of $90,005 d.c. Very little progress was made in the first year. the Coordinator, Dean Cutting, has been unable to spend much time on RMP and the Deputy Coordinator, Dr. Graham, has apparently not stimulated either planning efforts or community involvement. Only $20,000 of the $90,000 award was spent. Concern was expressed that RMP was conceived mainly as a means of supporting the new medical school. In June 1967, Hawaii was awarded its 02 year planning award at a level of $91'978 d.c. In July 1967, a staff visit was made to Hawaii (Dr. Sloan, Dr. O'Bryan, Mr. Anderson). Staff was impressed with the enthusiastic And strong leadership of the RAG. The medical school did not appear to dominate the RMP; as a result, the physician community appeared to be warming up to the program. It was decided that the RMP offices would be moved out of the Leahi Hospital (next to the Dean's office) and into a "neutrAl" building at the Queens Medical Center. It became clear that a new program coordinator would be chosen. In April 1968, Dr. Masato Hasegawa was appointed Program Coordinator, Dr. Hasegawa, a pediatrician, was a prominent member of the medical community, with great interest in community medicine." In October,1968, the Grantee changed from the University of Hawaii to the Research Corporation of the University of Hawaii. nilwilLiL The RMPH submitted its first operational application consisting of continuing core support and 10 project proposals in September 1, 1968. The major thrust of this application was in continuing education using Region Wide (Ilawaiiin Islands only) resources, in the absence of a fully-developed medical school. The application also stated that RMPH goals included development of "advanced health systems" which would improve the delivery of health care. A site visit was conducted to the Region in September 1968 (Drs. Millikan and Slater, Mr. Lewis and Mr. Jones). The site visitors were very impressed with the leadership of Dr. Hasegawa. In the few months he had been with RMPH, Dr. Hasegawa had clearly begun to involve diverse elements, over- come earlier hostility, and develop a separate identity for RMPH. Also, the visitors were profoundly impressed with Mr. Wilson Cannon, Chairman of the RAG, and with the vigor of the RAG as a whole. The visitors believed that the Core staff was developing well. In April 1969, this RMP received a $30,000 award for planning activities in the Pacific Basin-Trust Territories, Guam,, Samoa. In making this award, Council sharply reduced the $100,000 requested out of concern that RMPH might "spread itself too thin" and not concentrate its efforts sufficiently on building RMPH in Hawaii. During 1969, the Core staff expanded beyond the approved total level, and this posed A problem for the Region in terms of continuing support. The fiscal elements of the continuation application were particularly confusing, despite r6preated inquiries to the Region. Finally, the Division asked the Region's fiscal officer to meet with Division staff in Bethesda, where the difficulties were ironed out. In January 1970, a site visit was conducted to the Region (Dr. Millikan, Dr. Bessonl Dr. Zippen, Dr. Komaroff, Mr. Morales). The visitors were encouraged by the increasing involvement of the Medical Society, hospitals, and paramedical personnel; Core staff had grown stronger; the RAG had become more broadly representative; and planning activities in the Pacific Basin had been initiated. The visitors were disappointed at the diminishing involvement of the previously vigorous RAG chairman, Mr. Cannon. They also believed that the KFPH had progressed where Dr. Hasegawa required administrative assistance. Staff reviewed on September 28, 1970 the @IPH 03 year continuation application and believes that this RMP has made remarkable strides in the past year. The RAG's role and strength is still not clear, but an ad hoc evaluation committee and established policies and procedures provide hope that the RAG effectiveness will be improved. The Executive Committee of the RAG is the strong force; two of its members also serve on the RAG. Also strong forces are the categorical committees, which appear to have veto powers that vitiate the RAG's role. I Hawaii KIP -5- RM 01-03 (AR-1-SD) 2/71 Core staffing has been strengthened, both organizationally and with additional positions of an Associate Director, and the Chief of Con- tinuing Medical Education filled by Dr. Alexander Anderson (from George Mill-er's operation). The Region's responsibility for, and commitment to the ]'rust Territory has been expanding, and is a continuing source of concern to Dr. Hasegawa because of his limited resources of personnel, time and funds. The operational projects appeared to be well on schedule towards meeting their objectives. Organizational Structure and Processes: The Regional Advisory Group of the RMPH is composed of 45 members, 36 from Hawaii, 3 members each from Guam, American Samoa and the Trust Territory- The members from Hawaii are appointed by a Nominations Committee or three-year terms. The members from Guam, American Samoa, and the Trust Territory are designated by their respective chief executive. The membership of the RAG includes physicians (20), Registered T,',-,rses (2), Hospital Administrator (1), Social Behavioral Scientist (2), consumers (18), labor official (1) and a high chief from Samoa. The RAG activi- ties have centered around project review and approval. Other major activities of RAG during the past year included the following: Establishment of appointment procedures and functions of RMPH, RAG and other Committees as appended. Recommendation for a change in grantee institution to RMPS which was approved. The new grantee institution is the Research Corporation of University of Hawaii. Recommendation for the use of project summaries to facilitate the review process. Selection of the ad hoc Evaluation Committee of RAG of RMP-Hawaii. Discussion about regional priorities and input from specific health professions. An ad hoc Evaluation Committee of RAG is presently doing a study to determine how the RAG can function as a policy and decision-making body. The Core staff of the RMPH has twenty-one employees, twenty at 100'/. time or effort, The Core staff organization has been reviesed to include an Associate Director and a Chief of Continuing Medical Education. Exclusive of the secretaries, the Core staff consist of thirteen presently active members plus an Associate Director and a Chief of Continuing Medical Education. Hawaii RMP -6- RM 01-03 (AR-1-SD) 2/71 Following is a list of the core staff members and an organizational chart. NAME JOB TITL'G TIME OR EFFORT % HOURS Masato Hasegawa, M.D. Program Coordinator 50% TBA Associate Coordinator 100% Alexander Anderson, M.D. Chief of Continuing Medical Education 1000/. Satoru Izutsu Ph.D. Chief of Planning & Operations Pacific Areas 100% Omar A. Tunks Chief of operations 1007. Rosie K. Chang Chief of Allied Health Services 100 Ruth N. Denney Chief of Planning & Research Ser. 100% Norman S. Kuwahara Comptroller 100% Paul E. Cook Assoc. Chief of Operations 100% Nancy C. Fowler Assoc. Chief-Planning and Research Services 100% Clyde J. Winters Medical Librarian 100% Paul T. Okumota Audio-Visual Specialist 100% Nancy B. Crocco Asst. Chief-Cooperative Comm. Health Services 100% Patricia S. Coe Researcher 100% Thelma T. Fujisawa Bookkeeper 100% Vicki A. Johnson Executive Secretary 100% Ethel F. Kawano Secretary 100% Lynda Armstrong secretary 1001/. Elizabeth K. Medeiros Secretary 1 0 OP/@ Elizabeth M. Munoz Secretary I 0 (r/. Verna May S. Okano Secretary 1001/. 1-4 Hawaii RMP RM 01-03 W Eo F-- Ar(-I-SD) 2/71 >1 cn tn o@, 0 0 0 p 0 o rJ4 E--i 1-4 0 W -4 :t r4 U) :s 0P'4 $4 tu 0co 0 xr- E-40 En 1-4 (n -,4 u ..4 rn &4 co S-4 co 0 0 U) 4i Cd 14 0 P4 r4 U E-4 E4 r= rn 0 to :I 0 C> C: F4 -A < :; @ co x > M . . " 41 r= ;040 r4 lm C4 0 x 0 z r4 w C4 r4 co $4 0 P4 z 60 CZ C4 co E4 r4 i4 co C> M 4J tQ F4 F-40S4 0 -W co O' E/) fy4 0 0 1.3 H so >4 > H. C4 1-4 14 >1 U) U r4 uo PL4 @ 0 0 4J U) Cf) 0) cu wwV. P4 C-) F4 > C4 r4 E-,, L4 r4 En z rj) F-4 1-4 P4 i-4 En P4 14 co co F4 Hawaii RMP -7- RM 01-03 (AR-1-SD) Z//l I'lie Region indicated in the continuation application that previously the leverage in influencing the health care system was by "project grant mechanisms. They believe they are now ready for new dimensions in their strategy which will involve RMPH central staff. The central core staff will provide resources for consultation in medical core systems, in continuing medical education, in health services research and development, in health data acquisition and retrieval systems, and in health education of the public. They will not be considered merely as overhead to operating projects. Following are the names and functions of the Committees of RMPH: Executive Committee: Acts as the policy-making body for the overall operation of RMPH. It consist of ten voting members representing the University of Hawaii School of Medicine, the Hawaii Medical Association, the Hawaii Hospital Association and the consuming public. In addition, the chairman of the categorical disease advisory committees, the chair- man of the Advisory Courriittee on Continuing Medical EducaLlon, representa- tives of the grantee institution and the RMPH Direcotr serve as ex-officio members without vote. Finance Committee of Executive Committee: Studies and advises on the total fiscal maters of RMP-Hawaii. Personnel Committee of Executive Committee: Studies and advises on the functional organization of the Central Core staff. The Long-Range Planning Committee: Appointed by the Executive Committee its members develop long-range goals, objectives and priorities of RMPHO Technical Review Committee: The Director nominates for the consideration of the Executive Committee, the chairman and members of this committee. These members will technically review all operational proposals prepared by RMPH for funding4 Categorical Committees (Heart, Cancer, Stroke) Appointed by the Executive Committee the members encourage development of new projects and review all proposed projects in their subject areas. Other Committees: Advisory Committee for Allied Health Services Cooperative Community Health Program Advisory Committee Continuing Medical Education Advisory Committee Advisory Committee for Guam, Samoa & Trust Territory Hawaii County Advisory Committee Kauai County Advisory Committee Maui County Advisory Committee Project Review Process: Each project proposal begins the review process as a letter of intent submitted to the Director of RMPH. Ideas for project proposals are generated by individuals, agencies or organizations:@:@', in the health field. The Director and Core Staff assess the revelance Hawaii RMP -8- RM 01-03 (AR-1-SD) 2/71 of the idea, proposed in the letter of intent,,to the overall plan of RMPH. If it seems relevant, the Director assigns an appropriate staff member to assist in further development of the project with the advice of the committee set up for this. The development of the project often takes several months. The Core staff works closely with the applicant organization,throughout to construct a proposal which follows RMP Guidelines. After the final draft of a proposal has been completed, it is channeled through the appropriate Categorical and Technical Review Committees, then through the Executive Committee and the Regional Advisory Group. At any point, the proposal may be returned for revision, deferred, recommended for approval or disapproved. Upon final approval of the RAG, the proposal is sent to RMPS for national review. All proposals are reviewed in terms of: (1) Relevance to the overall plan of RMPH and the degree to which the proposal furthers regionalization and cooperative arrangements, to improve our present health care system in Hawaii. (2) Identification of needs and opportunities within the region. (3) Definition of objectives in clear, measurable termso (4) Assessment of resources, including the identification and use o existing resources, avoidance of duplication,, and the initiation of cooperative arrangements and closer linkages between the available resources. (5) Involvement of individuals, organizations and institutions within the region. (6) Indication of the priority level of the proposal in relation to the overall goals and objectives of RMPH. (7) Implementation, including strategy, methodology and techniques for accomplishing the stated objectives. (8) Evaluation protocol developed to measure achievement of the objectives and assess the overall effect of the proposal. Although there is no formal review relationship with CPH, projects are often discussed with CHP personnel during the preliminary stages of project development. A problem encountered with the present review mechanisms is the difficulty attendant upon the veto power of any one review committee. Clarification is required with respect to the effect of one review committees veto on the continued progress of a proposal through the local review mechanism. tiawaii mr @l VI-VI it&L%-L-Olij PROJECT REVIEW FLOW CHART GRANT APPLICATION (any agency, planning Staff RMPH) ADNINISTRATIVE OFFICE PROGRAM COORDINATOR (for.relevance to overall plan) PLANNING SECTION (when grant comes from a encies .9 other than RMPH for review by staff with expert advice as needed) CATEGORICAL ADVISORY CONMITTEE (for subject matter and excellence) TECHNICAL REVIEW COMKITTEE EXECUTIVE COMMITTEE REGIONAL ADVISORY GROUP DRNP Washington, D.C. RESEARCH CORPORATION OF U OF H (copy of project-- for information only) Hawaii RMP -10- PM 01-03 (AR-1-SD) 2/71 Annual Report of the Regional Advisory Group The Regional Advisory Group of the @IPH expressed in their report their satisfaction of progress made by the RMPH to meet goals and objectives set fo--th for the past year. In an item- by-item review, the Committee members felt that progress was satisfactory in continuing medical education, expansion of RMP into the Trust Territory, stimulating new projects, providing practitioners access to latest knowl- edge, expand electronic data processing and develop pools of health data information. Two areas they indicate need continued and greater attention relate to public education and staff assistance to hospitals and health care institutionsin evaluating their needs for facilities and service programs. The RAG was impressed but somewhat concerned with the broad but imaginative new perspective set forth for the 03 year. There was a question of staff capability and availability of funds to achieve the expanded goals. There was concern that a broad gauge approach could either duplicate or dilute the effectiveness of projects and activities which should be pointed toward meeting specific and big'fi priority health needs in R14PH. With this advice, the RAC members approved the new perspective goals and objectives of RMP]I which broadly set forth the major areas of activities. As indicated in this application the new perspective and strategy of the RMPH is to improve the health care system of Hawaii by instituting the following: 1. Continuing Medical Education 2. Demonstration projects for improving patient care 3. Health services research and development 0 4. Involvement in assessment of the quality of medical care 5. Health education of general public 6. Data acquisition and retrieval system Evaluation: The Region indicates that for the purpose of proper evaluation of operational projects, increased effort has been made to state project objectives clearly in every case so that per- formande can be effectively measured. The Evaluation Report by the RAG ad hoc committee is an important aspect of RMPH program evaluation. In order to further develop techniques for evaluation, the staff has con- ducted inservice workshops and sought the use of consultants. Developmental Component, The Developmental Component of the Regional Medical Program of Hawaii will follow the presently working review cycle and monitoring. The Region states that the Developmental Component provides the needed opportunity for RMP-Hawaii to establish innovative activities in continuing education as pilot studies; to test their feasibility, palatability and productivity on a limited experimental basis before extending their scope and insuring their longevity through the formal mechanism of project proposals. These educational programs will include-. A. Demonstration Projects of innovative patient care systems B. Feasibility and utilization study projects C. Staff development training programs The Region believes that the availability of the Developmental Component will provide an immediate opportunity for the Regional Medical Program of Hawaii to influence the need for organizational change of individual hospitals and in the overall hospital system of Hawaii. The Region believes that instituting organizational change in the present hospital system is the most economical and feasible way of insuring that compre- hensive care is accessible to every citizen that is in need of medical care. Activities which are being considered for improvement of the hospital system under the Developmental Component include: (a) Studies of hospital emergency care departments (b) Shared services with hospitals joining together for the operation of certain basic facilitative and supporting services, clinical and non-clinical in nature (c) Educational seminars for board members, hospital administrators and medical staff in understanding the role changes that are necessary in the organizational structure to provide compre- hensive medical care. (d) The operation of one or more sub-units of patient care by one central parent hospital corporation (e) Study of the feasibility of training doctor's assistants in hospitals, (f) Development of health manpower pools, (g) Investigation of the possibility of establishing an all-inclusive hospital rate (h) Promotion of an identification program related to designating routes and publicizing availability of hospital and emergency care services to the public. The Region is requesting a funding level of $92,314 for the developmental component which is an amount equal to 10% of the annual direct cost funding level (not including carryover) o f the Region at the present time. Supplemental Projects Requested Project #23 - Mobile Coronary Care. The primary purpose First Year of this project is to provide treatment $138,661 outside the hospital for acute, potentially lethal arrythmias by the utilization of a Mobile Coronary Care Unit. The Region explains that the two ongoing projects, the Cardiopulmonary Resuscitation Training Projects and the Coronary Care Training Project for Physicians and Nurses are preparing for expanded activities as approved their 03-year of operation. The Region believes that this project for Mobile Coronary Care will significantly extend the acute care capability in Hawaii and that these three projects inconcert should have an impact on death-rates from acute coronary attack in the State. The Region also indicates that this project will also provide training for allied health personnel, a high-priority component of most RMPII projects. Second Year Third Year $96,493 $100,101 Hawaii RMP -12- R4 01-03 (AR -1-SD) 2/71 Requested Project #24 - Hawaii Smoking Withdrawal Clinic Project. First Year The broad goal of this project is to $32,950 bring to the citizens of Hawaii an, opportunity to reduce or discontinue existing smoking habits as an important step toward the reduction of heart disease, cancer, stroke and related diseases. Withdrawal clinics will be established to assist cigarette smokers in their ddaire to break the habit of cigarette smoking and to combat recidivism among those who have discontinued the habit. Second Year Third Year $42,000 $52,000 Project #25 - Establishment of Health Appraisal Units in Requested Hawaii. The major objective of this First Year proposal is to define the health of the Individual in $139,510 the community through multiphasic screening and to link this appraisal closely to the medical care system. The Region indicates that this project is designed to maintain multiphasic screening as close as possible to the mainstream of medical care in Hawaii. The Region believes that this proposal for establishment of Health Appraisal Units in Hawaii incorporates several of the areas within RMP-Hawaii's strategy and focuses on health-care costs as well. The Straub Medical Research Institute of Hawaii, Inc.,is the applicant organization for this project. Second Year Third Year $172,866 $160,585 Requested Project #26 - Improvement of the Intensive Care Unit-American First Year Samoa. This proposal is requesting three years $37,857 support for the improvement of the Intensive Care Unit of the Lyndon B. Johnson Tropical Medical Center, the only hospital in American Samoa. Although an 8-bed Intensive Care Unit now exists at the Lyndon B. Johnson Tropical Medical Center, the medical staff recognize that it is not fully operable because of inadequate trained staff an an incomplete list of equipment. Second Year Third Year $6,280 $5,965 naWall I\L'IE Project #27 - Im@rovement of DietarV Management and Dietary Requested Counseling in Hawaii. The goal of this First Year project is to improve.care to patients with diabetes, $63,669 cardiovascular, renal-, and other diet-related diseases by increasing dietary knowledge of medical and allied health professionals through discipline oriented seminars and to increase community services by establishing a dietary counseling service. The Region explains that the relation of this project to RMPH strategy is that it renders continuing medical education of physi- cians and allied health personnel, education of the public in self- care and the use of demonstration projects. Second Year Third Year $64,036 $66,569 Present Year APPROV D AND FUNDED PROJECTS of Operation Project #2 Training in Rehabilitation in Catastrophic Disease 3rd Project #3 -Home Care Training Program 3rd Project #4 -Continuing Education of RMP support Nurses in Patient Settings Phased out Project #7 Cardiopulmonary Resuscitation Training 3rd Project #8 -Coronary Care Training (Queens Medical Center) 3rd Project #9 -Coronary Care Training RMP support (Hilo Hospital) Phased out Project #10 - Coronary Care Training RMP support (Wilcox Memorial Hospital) Phased out Project #11 - Region Pediatric Pulmonary Program 3rd Project #13 - Rehabilitation in Catastrophic Disease (Guam, and Trust Territory) 2nd Project #15 - Region Cooperative Chemotherapy Program 2nd Project #20 - Guam Memorial Hospital Constant Care Unit 2nd Hawaii RMP -14- RM 03-01 (AR-1-SD) 2//l APPROVED AND UNFUNDED PROJECTS Council Approval Project lfl2 - Program for Treatment of Cardiac Arrest (Saipan) December 1969 Project #17 - Hawaii. Mass I;creeni-ng of Children for Heart Disease March 1970 Project #18 - Anti-Smoking Education Project for Hawaii March 1970 Project #21 - Cervical Cancer Program for the Trust Territory July 1970 Project #22 - Training of Health Aides in the Trust Territory July 1970 PROJECTS DISAPPROVED Project #5 - Continuing Education Program in Pathology Project #6 - Hawaii Tumor Registry Expansion Program Project #14 - Cervical Cancer Program for Trust Territory Project #16 - Hawaii Tumor Registry Project #19 - Continuing Health Education Council of Hawaii RMPS/CRB/11/19/70 A PRIVILEGED COMMUNICATION SU@RY OF REVI.,M@l AND CONCLUS!Oii OF Jk'LIIUAI@Y 1971'REVIEW CO',%ii%i!TTEE HAWAII REGIONAL MEDICAL PROGRAM @l 01-03 (AR-1-SD) 2/71 FOR CONSTDERATION BY FEBRUARY 1971 A.DVISOP@Y CO'LJNCIL Recommendation: Additional funds be provided for this application. Region's Recommended @e a@t 2nal Year Request Fundin@ 03 Year $ 504,961. $366,300 (Developmental Component) ( 92,314) ( 92,314) (Five New Projects) (412,647) (273,986) O-/4 Year (Five New Projects) 381,675 285,182 .05 Year (Five New Projerts) 385,220 285,119 Total @71,856 $936,601 ritiqllt: Committee conct:rs with the site visit te@i-n that there has been considerable progress made by the H@)wai_i R@IP toward developin- the general principles of regionalization. The Re-,ion has developed a framework for planning the ach,,,-,vemen-t of goals and objectives I. %Ietliods for evaluation are bei-ng developed. The KIPH has developed a good worli@i-Lig relationship with the Hawaii Medical Associatioi, University o-@ Hawaii, St@@,te Health Depirtment, Comprehensive Health Planning, Ilo!E-,pital Association, e-Lc. These relationships are discussed in a report of a site visit to this Region conducted on December 3-4, 1970. The Program Coordinator, Dr. Masato Hasegawa, appears to have done a good job in pulli.og together the program since becoming Coordinator. Committee' however, believes that Dr. Hasegawa has built such a large organization so many complexities, that he now requires the assistance of a full-time deputy to help him administrate the day-to--day operations. This would free Dr. Hasegawa to spend more time in developing the philosophy and direction of the program. Hawaii- RMP -2- RM 01"03 (AR-1 SD) 2/71 This question was discussed in detail with both the Chairman of the RAG, Cbairmaft of the Executive Committee and with tb& Coordinator himself during the December 3-4, 1970 site visit. It was indicated to the visitors that steps are being taken to modify the existing situation by appointment of a deputy coordinator at this time. The Core staff has been strenthened by the addition of Dr. Alexander Anderson, who has assumed the position of Chief of Continuing Medical Education. The core staff appears to be generally competent and seem to work very well together. With the addition of the deputy coordinator the core staff should receive top level administrative direction for their activities The RAG has not assumed full responsibility in giving direttion to the RMPII and has played a minor role in stimulating project proposals. It is evident however, that the power group of the RMPH is the Executive Committee of the RAG, which has adeqtidte representa- tioii of the major provider institutions and significant insight into the health distribution problem and-the problem of the cost of health tare in Hawaii. This Committee is attuned to the general. thrust as well as the problems of the RMPH. In the.Pacific Basin the @IPH has been coordinating its efforts with @CHP bec ause they have been active for several years in health planning throughout the Trust Territory and has come up with a comprehensive "health plan for the area. They have also coordinated their efforts with the Hawaii School of Public Health and the East-W6st Center. It is apparent to the visitors that the R14PH needs to have visibility in these Areas, prior to establishing linkages with local health institutions. Just as the Cervical Cancer Project served to create visibility in Guam during the past year, the present proposal requesting the development of an intensive care unit training proaram at the L.B.J. Tropical Hospital in American Samoa will give visibility to Pd4PH with other existing institutions in Guam. DeV61Q]2mental Coiiiooiient While pro'r68s has been slow for this region, it has been in the direction of a.broadening and deepening involvement of RMPH with@ the provider of health services and the community* The long-range goals of the developmental component involves three major items: a) a focus on hospitals as a major mechanism for the delivery of co rehensive health care; b) the use of continuing MP education'programs; c) and the development of a data acquisition system that will'help to assess the quality of health care in Hawaii. The technical'ptbjetts proposed for implementation of long-range plans regarding the relationship between RMPH and the hospitals in the community appear to be well thou-tit out and implementation could 0 0 a REGIONAL MEDICAL PROGRAIMS SERVICE s Y OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) Illinois Regional Medical Program, Inc. RM 00061-02 (AR-1-SD) 2/71 122 South Michigan Avenue January 1971 Review Committee Room 939 Chicago, Illinois Grantee Agency: Same Program Coordinator: Executive Director - Morton C. Creditor, M.D. Request (Direct Costs) 02 Year 03 Year 04 Year 2/l/71 - I/l/72 - 1/l/73 - Purpose 12/31/71 12/31/72 12/31/73 All Years- Continuation Commitment 1,525,192 427,122 1,952,314 (Core and 2 studies) (947,460) (112,722) (1,060,182) (7 projects) (577,732) (3 proj. 314,400) 892,132) Renewal Components -0- 1,443,608** 1,851,190*** 3,294,798 (Core and 1 study) Additional Components 1,586,835 1,641,597 1,063,314 4,291,746 (Developmental) (158,564) -0- -0- (158,564) (2 new projects) (633,704) (772,882) (141,016) (1,547,602) (2 approved/unfunded projects) (275,155) (477,181) (518,821) (1,271,157) (2 approved/deferred Renal) (519,412) (391,534) (403,477) (1,314,423) 2 Supplements 407,258 407,258 Ongoing Activity (Core) (394,190) (394,190) (1 Project) ( 13,068) 13,068) Committee Action Required $3,519,285 $3,512,327 $2,914,504 $9$946,116 Includes $191,247 Renewal request for Educational Resource Study. Includes $201,000 request for Education Resource Study. 40 Illinois RMP Fundin tor Planning Stag@ Grant Year Period Funded -(d.c.o.) 01 7/l/67 - 6/30/68 $304,629. 02 7/l/68 - 10/31/69 (16 mos) 976,341 03 il/l/69 1/31/70 (3 mos) 357,840 Generational Program Council Funded Future Grant Commitment Year Period Approved D.C.O. 01 2/l/70 1/31/71 1,585,643 855,097* Core ------- 730,546** Projects 02 2/l/71 12/31/11 1,532,333 -------- 1,532,333 03 1/l/72 12/31/72 427,122 -------- 427- l@2 * Includes Educational Support Resource Study $174,500 ** Includes,Hypertension St. Lukes $145 600 Illinois RMP -3- RM 00061-02 (AR-1-SD) 2/71 Geogr@h : The borders of the Illinois region are, like those of other regions, not defined. in the initial planning grant application the Illinois region was defined as encompassing the State. All of Illinois' five schools of medicine and the School of Osteopathy were located in Chicago. It was .felt that these institutions, working together could cover the requirements of the state better than could be done by apportioning parts of the state to each school. However, the Bi-State Regional Medical Program, based in St. Louis, Missouri, also designated approximately the southern half of Illinois as, in their view, being in that region. As time has passed and both regions have matured this "turf" problem, which remains unsolved, is taking on greater dimensions. On the west, Moline, Rock Island, and other coumaiities of that area are a part of a metropolitan area which includes Davenport, Iowa. In health services, some relationship with Iowa City exist. Along the northern state line of Illinois there are no areas with 'very strong ties to Wisconsin. The state line appears to be an appropriate boundary. Based on present health service patterns, there are sharp differences of opinion in northwestern Indiana (Gary, etc.) as to their most appropriate region. The area is a part of the Chicago Metropolitan Area, but has substantial loyalties to Indiana. Demorraphy A. Population: Approximately 11 million 1. Roughly 81% Urban 2. Roughly 89% White 3. Median Age: 31.2 years B. Medical Schools: at present seven, (including one College of Osteopathy) soon to be expanded to eleven. C. Hospitals: Approximately 300-350 D. Physicians: 14,000 medical and 363 Doctors of Osteopathy History of Regional Development On March 9, 1965, a committee of the five Medical School Deans in Illinois, members of the Illinois Division of American Cancer Society and the Chicago Health Department, was appointed by Dr. Morris Fishbein, President of the Chicago Heart Association, to discuss the possibilities of a RMP in Illinois. During July 1965, Mayor John Daley and Governor Otto Kerner appointed separate Advisory Committees for RMP which subsequently (January 1, 1966) were fused to form an original Regional Advisory Committee. Appointment, responsibility and authority of the membership to the RAG was vested in the Governor until changed on November 25, 1968. on that date the RAG appointment authority became vested in the RAG. From July 1, 1965 until July 1, 1969, the Coordinating Committee of Medical Schools and Teaching Hospitals of Illinois Illinois RMP -4- RM 00061-02.,(AR-1-SD) served the function of Trustee, with the University of Chicagp,@i@g the grantee agency and fiscal agent. The Coordinating Committee was7 comprised of the six deans of the schools and the administrators of some 1.6 major medical school hospitals. It had, and exercised,,the responsibility for the policy decisions relating to core staffing and administration, and to both planning and operational components of IRMP. The August 1966 National Advisory Council considered the initial planning application submitted by the Coordinating Committee of Medical Schools and Teaching Hospitals of Illinois for implementation of RMP in Illino,;Ls. Council rejected it, feeling the proposal was "superficial and inadequate." It'contained no description of the local Advisory Group or its method of procedure and there was no appearance of involvement of community medical faciliti es. A revised planning application was submitted and approved by May 1967 Council at areduced level for a two-year period 7/67 through 6/69. Several concerns were still present'. These were: Administrative structure appeared cumbersome. Heavily medical-school oriented with minimal involvement of other health-care areas. Advisory Group is physician-oriented; the only Negro member is elderly and out of touch with the regional planning. Lack of information about involvement of the central.part of the state. During September 1968, the Illinois Regional Medical Program submitted its original operational application. Subsequently, this was withdrawn by the Regional Advisory Group following a November 1968, DRMP staff assistance visit. The visitors concluded that the Region contained the following weaknesses and strengths. Weaknesses 1. Little evidence of real commitment of leadership by the medical schools. 2. inadequate representation from outside of Chicago on the various committees d the advisory group task forces an 3. Core staff is much too smal 1 for such a large and complex region. 4. Need for aggressive leadership by the power structure. 5. IRMP is too passive;should be more active. 6. The foundation of IRMP, its core staff and its planning leadership capa is not ready for the superstructure of an operational program. I I ".-.j II @ i I i I 11 Illinois RMP -5- RM 00061-02 (AR-1-SD) 2/71 StrenRths 1. The obvious interest and talent of many task force committee chairmen and members. 2. The beginnings of hospital networks related or Potentially related to medical schools. The revised operational application was submitted for consideration during the July/Aiigust 1969 review cycle. The application contained a two-year request for support of planning and Core activities beginning November 1, 1969 (the grant period had been extended from July 1. 1969 to November 1, 1969) and support of three to five years for 8 new operational projects. A pre- operational site visit was conducted during June 1969. The members of the site visit team were impressed with the amount of planning and maturation that had taken place since the original operational application and the November 1968 staff assistance visit. Members of the site visit team recommended that on the basis of the evidence presented of cooperation between Medical schools, hospitals, councils, voluntary and public agencies, the region was now ready to mount an operational program. Seven of the eight operational proposals were recommended for approval. The team further recommended that the request for additional funds for core not be approved, until a new program coordinator could be appointed. The site visit team further recommended that if the IRMP was approved as an operational program, the Region should be made aware of the program recommendations of the team@ These were: 1. That the Regional Advisory Group, Boards, Task Forces, and Committees contain minority group representation, both professional and lay consumers; 2. That there be broader distribution of allied health and health manpower involvement; 3. That there be a more realistic relationship established between the Board of Trustees and the RAG pertaining to application review; 4. That concrete efforts be effected to solve the upstate versus the Down- state cast of the Region; 5. That a more organized, realistic approach to the collection and collation .of data be obtained; 6. That the aims and objectives of contract arrangements be continually reviewed in relationship to their history, ready availability of any particu- tar information sought, and the real, proposed effect on the future of the Region's Program; 7. That a 'lan be developed and a policy established and agreed upon between agencies and institutions to provide for an auditable accounting procedure for any fees or funds earned in or as a result of any project - supported activity And; Illinois RHP, -6- RM 00061-02 (AR-I-SD) 2 8. That the Region appoint and establish a Region-wide representative Stroke Committee. Both the July Committee and August 1969 Council concurred in the re@ ommendation ..of the site visit team. During February 1970, the Region was awarded opera- tional funds to support Core and the seven new projects. A breakdown is provided. Project Amount Supported (D.C.) Number Title through 1/31/71 00 Core (Basic) 680,597 Hypertension Study-St. Luke's Hospital 145,600 Education Support Resource Study 174,500 CORE TOTAL $1,000,697 Organization of a Coordinated Home Health Services Project in North Cook County 35,525 2 Multiphasic Screening iii Chicago Area Industrial Plants to Detect Coronary- Prone Persons and Individuals with Sub- clinical Heart Disease 199,826 4 Regional Coordinated Cancer Program 108,950 5 Radiation Therapy Treatment Planning Center 24,300 6 Macon County Stroke Coordination Program 33,790 7 Comprehensive Stroke Rehabilitation Program 111,225 8 Comparative Endnoscopic Study and training program in the Early Diagnosis of Gastric Cancer 71,330 TOTAL $1,585,643 Following the recommendations of a June 1970 technical site visit team, the August 1970 Council recommended approval of four new operational projects; two in renal disease, one in cancer and one Utnified Health Information and Counseling Service. Currently these are approved but unfunded projects. Review Process Review is carried out in two stages. The first is a technical review done by either a standing committee or task force, or an Ad Hoc committee. The reviewers may recommend approval, disapproval or may recommend revision of the application. The second review is conducted by the RAG. Illinois -7- RM 00061-02 (AR-1-SD) 2/71 Regional Advis rou The Regional Advisory Group is a 40-member body with representation from a broad spectrum of people involved throughout the Region in health care and health planning. Members are nominated by a committee composed of representatives from the Board of Directors, the RAG, the Heart Association, Cancer Society and State Medical Society. Members are elected by the Board of Directors with ratification by the RAG. The members are elected for five-year terms with one-fifth of the membership rotating each year. The group meets on a bi-montly basis and a five-member Executive Committee of the RAG meets on alternate months. The Executive Committee of the RAG prepares the agenda and considers matters requiring immediate attention, subject to approval'by the group. The B@-Laws of the Board of Directors and the RAG were revised on May 25, 1970 which provide for two major changes: 1. The membership of the RAG was expanded from 30 to 40 members in order to provide for broader representation of consumer and allied health interest from other areas outside of Chicago. Eleven new members were added most of whom represent minorities, consumer and Allied health groups. Since the last election of members to the RAG, some of the original members have resigned, leaving a present membership of 36 individuals. Potential members are presently being sought from among minority and consumer groups, especially from the downstate area. 2. The RAG is now officially designated as the body responsible for overall policy and guidance for the IRMP in planning and operational programs. They conduct final project and grant application review. The revised BY-Laws have relieved the Board of Directors of both project and application review responsibilities. Board of Directors This is a 22-member body which meets monthly (3 members also serve on the RAG) and has corporate responsibility for the financial and other affairs of the not-for-profit organization. Executive Committee of @oard of Directors This is a 9-member group composed basically of the Deans of the Medical Schools which may act for the Board should it become necessary. This group met in the last year. The IRMP has recently reorganized its Committee and Task Force structure, and now contains the following: 1. Task Force - Health Information 2. Task'Force -,Manpower and Education 3. Task Force - Continuing Education 4. Task Force - Evaluation and Research 1. Heart Committee a. Sub-committee Myocardial Infarction Illinois RMP -8- RM 00061-02 (AR-1-SD) 2/7 2. Cancer Committee a. Sub-committee,,Chemotherapy b. Sub-committee on Radiation Therapy 3. Stroke Committee 4. Screening Committee 5. Nursing Committee 6. Public Relations - Public Information Committee 7. Medical School Coordinators 8. Kidney Disease Committee (just forming) All committees and Task Forces are engaged in making policy recommen at ons and have advisory responsibilities. Major Changes in IRNP July 1, 1969 - applicant organization - fiscal agent changed from University of Chicago, College of Medicine to a separate not-for-profit organization, the' Illinois Regional Medical Program Inc., June 1, 1970 - Morton Creditor, M.D. assumed full-time duties as Executive Director of IRMP. Dr. Creditor Replaces the now retired Dr. Wright Adams who was IRMP's original full-time coordinator. Dr. Creditor has been responsible for creating a "new look" and emphasis for the Illinois Region. The RAg. committees, task forces and staff are now engaged in the setting of new program priorities. A site visit is to t;-- conducted on December 3-4, 1970. The report will be available during the January/ February 1971 Review cycle. Present Application This is a pentagonally structured 3-year renewal request. It contains requests for: A. Renewal of Core and continuation of seven on-going operational projects. B. A rather large supplement to the basic core component plus a supplement to one of the on-going projects (Home Health Services). C. A Developmental Component, D. Funds to implement four previously approved operational activities and E. Two new operational proposals While the Region has one additional 12-month period (2/l/71-1/31/72) of committed support for core and its seven projects, they have opted to request a total program renewal for three years. Illinois RMP -9- RM 00061-02 (AR-1-SD) 2/71 A. Core and Operational Projects The Region presently has a commitment of $947,460 for the core component which includes terminal year support for a Hypertension Study. This application includes a request for first year $394,190 supplementation to this amount. If approved, the previous $887,137 (excluding Hypertension Study) would be increased to $i,281,327 for basic core support. (Core only) (2/l/71-1/31/72) Committed- First Year Requested_ Basic 712,637 1,106,827 Educational Resource Study 174,500 174,500 Hypertension Study 60,323 60,323: $947,460 $1,341,650 The second year request of $1,556,330 includes $112,,723 committed funds plus $191,247 for the continuing Educational Resource Study at the University of Illinois. The third year request of $1,851,190 includes $201,000 for continued support of the Educational Resource Study. The three-year total request for core component is $4,749,170. The increases requested in the core component are to provide for continuation of efforts to obtain the Region's previously presented broad objectives (at this point, it should be noted that the present Executive Director, Dr. Morton C. Creditor assumed his position full-time, on June 1. 1970, and has inherited a vrop"ram which was developed under a previous administration. Doctor C@editor has caused a shifting of emphasis, particularly in terms of strategies to be employed and recognizes that limited financial resources will require application of efficient managerial practices to maximize the impact of each demonstration. The Region's new strategy is designed to facilitate the generalization of innovation and will capitalize upon the mutual interests and resources of other agencies. The additional core funds requested Are to be used primarily to fill gaps in the present core staff by;l) employing a physician who will serve as primary assistant to the Executive Director' and 2) upgrading coordinators assigned to medical schools from part-time ;o full-time status. The application requests continued support at the committed level for the seven operational projects listed on page 6. in addition, $13,068 is requested as a supplement to project #1, Home Health S@rv This project was funded for $35,525 (dc.) on February 1, 1970 for the first year of an approved two-year project period. If approved, the supplement would raise the second year funding from the currently approved $35,577 to $48,645. The additional funds are to be used to support a full-time services organizer whose duties would be to handle the detailed arrangements with a great number of potential provider agencies. Details of duties as well as how this project fits into the Region's plan are listed under Illinois RMP, -10- RM 00061-02 (AR-1-SD) 2/ Tab OGI-S in Volumbe II-. B. Developmental Component The Region requests $158,564 for one year only to support a Developmental Component. The major purpose for use of developmental funds will be the exploitation of opportunities for acceleration of the rate of fulfillment of the established objectives of the IRMP and as a corollary, rei nforce- ment and enhancement of the techniques and methodologies employed in fulfillment of those objectives. The application lists under Tab IV, Developmental Component in Volume I, many examples of the intended utilization of these types of funds. Some of these are: 1) Appearance of new areawide planning Council requiring Developmental support for survival. 2) Unexpected opportunity for new medical school'to appoint associate Dean for RMIP. 3) Opportunity to establish liaison relationships with allied or associated resources. The application also lists specific restrictions for which these types of funds will not be used. Example-funding of proposals which had been disapproved by any IRMP or RMPS Review process. C. Request for Funds to Initiate Previou d Operational Activities Following the recommendation of a June 1970 technical site visit team, the August 1970 National Advisory Cguncil recommended approval (with conditions) of four new operational projects. Currently, these are being held in the region as approved but unfunded activities. The Region now requests funds to initiate these approved/unfunded projects: Project Amount Council Number Titl!i Re ted oved #10 Continuing Education in 01 Yr. 134,982 162,257 Nephrology 02 Yr. 146,550 181,948 03 Yr. 156,300 191 883 #10 Total $ 437,832 $ 536,088 #11 Regional Transplantation 01 Yr 384,430 1503,000 Program 02 Yr 244,984 150,000 03 Yr. 247 177 150 000 #11 Total $ 876,591 $ 450,000 Illinois RMP RM 00061-02 'kAR-1-SD) 2/71 Project Amount Council Number Title Requested Approved #12 Cancer Education 01 Yr. 37,096 49,155 02 Yr. 24,348 12,289 #12 Total 61,444 61,444 #13 Unified Health Info. 01 Yr. 238,059 226,000 and Referral 02 Yr. 452,833 317,000 03 Yr. 518,821 -0- #13 Total $1,,209,713 $543,000 All Ye'!ars Total Requests and Council Recommended Amounts for Projects #10, #11, #12 and #13 Current Request Council Previously Recommended ist Year $?,94,567 587,412 2nd Year 868,715 661,237 3rd Year 922,298 341,,883 T(YTAL $ 2,585,580 $ 1,590,532 Requested D. Summary of New Operational Proposals First Year Project #14 - Valley Prolect - A Community Health Center $482,612 The Board of Trustees, University of Illinois requests through the Illinois Regional Medical Program $482,612 (d.c.) for the first year of a two-year project request to support a community health center for residents of the "Valley" Community, a health-ppverty area of 10,1000 people. This proposal is the result of a $71,400 IRMP supported planning study. The primary objective is to design a system which will deliver family- oriented, comprehensive health care and to initiate those activities required to insure full-scale program implementation on or before the beginning of fiscal year 1972. The achievement of the primary objective is dependent upon the attainment of a series of interrelated goals as envisioned by the Valley Community representatives in defining perceived community needs and developed in concert with the Medical Center Campus representatives. A. To provide a wide range of health services for the residents of the Valley Community include: 1. Diagnosis and treatment of acute and chronic illness 2. Development of programs concerned with disability limitation and rehabilitation 3. Design and implementation of programs for the detection and management of asymptomatic disease 4. Development of programs for the promotion and maintenance of health and prevention of disease Illinois RMP -12- RM 00061-02 (AR-!-SD) 2/1 5. Emphasis on health care for infants, children, and pregnant women. 6. Coordination of the program with other agencies involved in health services affecting the community B. To provide health-related jobs for community residents C. To identify, develop, and encourage health training programs and health career opportunities for community residents D. To increase the application of existing knowledge and techniques of health care at the community level E. To develop new approaches to health care delivery and health education that are appropriate and acceptable to the community and the University and which may serve as models for other communities and institutions F. To explore new dimensions for professionals and non-professionals within the health care team G. To explore ways with the community to afford opportunities for staff, undergraduate and graduate health professionals from the University of Illinois Medical Center to participate in the activities of the Community Health Program in order to create sound educational experiences, better understanding of community health matters, and additional resources for present and future community health needs H. To utilize existing methods and develop new techniques of evaluation as an ongoing part of the total program The achievement of a Comprehensive Health Care System is to be pursued in 3 phases. The first phase is to be the provision of clinic services for diagnosis and treatmen t of episodic illness and accidental injury. Phase II and III are projected for less acute patient services, coordination and planning. A specifically designed evaluation mechanism will be developed to measure the degree-of improvement in delivery of family-oriented, comprehensive health care. The application describes plans for RNIP phaseout. $385,652 of the first year total budget is for I)ersonnel services. Second Year - $654,039 Supplement to Pr ect I#Pl4 This is an unusual Requested request. The Region asks First Year in addition to the basic application for Project #1.4, $64,736 that the reviewers consider a two-year request (#149) at a reduced ldvel. This two-year request should be considered as both supplementary to and separate from the basic project. An amount of $64,736 (d.c.) is requested for the first year to support a history-taking technique for the community health center. They propose to at first, use a Medequip TM Automated Testing System adapted especially for residents of the Valley Community. Illinois RMP -13- RM 00061-02 (AR-1-SD) 2/71 Personnel of the Educational Resource Study, funded as a part of IRMP core activity, would be utilized in evaluation of the history-taking techniques. The applicant states that the successful introduction of the history-taking component alone would make an important contribution to the developing health system at the Valley Clinic. A total of $26,336 for personnel in this supplemental (#14s) is also included in the batic project. If both basic project (14) and the supplement (#14s) are approved, the combined total request of $547,350 could be reduced by $26,336 for a net requirement of $521,014. Project #1@ - A Proposal to Establish a Program for the Requested Development of Nursing Resources in Illinois First Year The Illinois Nurses Association requests $112,690 (d.c.) $112,690 through the Illinois Regional Medical Program, for the first year of a three-ytar project period to initiate this program. The funds will be used to finance a program whose purpose would be to initiate, promote, facilitate and coordinate activities designed to meet the nurse. manpower needs in Illinois in accordance with the report of the Illinois Study Commission on Nursing and subsequent studies and reports. The specific objectives of the proposal are: 1. Initiate a plan of action for a crash program designed to accelerate the movement of experienced registered nurses into and through baccalaureate and masters programs in order to meet present and future needs for nursing leadership, particularly teachers, administrators and specialists. 2. Establish a statewide network for selective recruitment, counseling and guidance in order to increase the present proportion of high school graduate (male and female) who choose careers in nursing; direct prospective students into appropriate educational programs; encourage and enable mature individuals and those from minority groups to enter nursing in greater numbers; assure full utilization of all available class spaces. 3. Promote the development of the career ladder for mobility so that competent practitioners will be available on a continuing basis at each level and in each area of practice. 4. Seek increased financial support and assistance for nursing education through both public and private sources at federal, state and local levels. 5. Initiate and take leadership for statewide and community planning to assure orderly transition, expansion and development of nursing schools as recommended by ISCON and is to meet the changing health care needs of society. Illinois RMP -14- RH 00061-02 (AR-1-SD) 2/71 The Illinois Counittee-on Nursing Careers (jointly sponsored by the Illinois Nurses' Association and the Illinois League for Nursing) will serve as the steering committee for the proposed program. In addition, a broad based advisory committee will be formed to provide representation for the various health related organizations, consumer groups and other concerned agencies and individuals. The present staff of the Illinois Committee on Nursing Careers will form a nucleus around which the proposed program can be built. The staff will, in some instances be activators and initiators. At other times, they will serve as advisors, consultants, conveners, resource persons, and as liaison for other groups. The committee and staff will plan and implement those programs that fall within their purview, and will work with and through local, regional and statewide groups, lending impetus and assistance to programs developed by others, encouraging or persuading others to develop needed programs, and coordinating the various activities to assure optimum results. The total program will be developed and implemented over a three-year period, with certain ongoing activities extending beyond that time. An integral part of the program will be continued research and data collection which will provide a basis for evaluation of progress toward meeting the goals. At the conclusion of the third year, a detailed anaylsis will be made of the supply of nursing manpower in Illinois. ISCON recommendations will be reviewed and updated on the basis of changing needs and trends Goals and objectives will be reviewed and a new plan of action formulated as need and circumstances dictate. The applicant believes that this proposal is related to one of the basic IRMP goals--to assist in making health resources available to patients. Data will be compiled for evaluation purposes., among others, which will focus on measuring progress toward the overall goals to assure that the needs for nursing leadership and manpower in Illinois are met. $70,000 of the first years' total budget of $112,690 is for personnel. During the second and third years personnel requests increase to $95,000 and $99,000 respectively. The second and third year personnel increases will provide support for a counselor and a secretary in the downstate area. Second Year - $137,204 Third Year - $141,016 DRMP/GRB 12/15/70 SUMMARY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW CO@IMITTEE ILLINOIS REGIO'iiAL MEDICAL PROGRAM RM 61-02 (AR-l-tSb) 2/71' FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL B KGROUND. This is an unusual request. It contains a request for continuation. supplemental funding for an ongoing project an Co e,.and a request for renewal support with a developmental component. @T n:'scu'rrent budget period has been extended for two months @(2 3/31/71) without additional funds. The Region has one additional 1 eriod (4/1 71-3/31/72) of committed support ($1,525il92) for p the r c e activities and 7 operational projects. Staff considered the @6 tinuation Portion of the application but due to a number of difficulties, @vo@ d defer@any fur er ac on un e si e v s 0 mine-w ch avenue, (continuation and supplement, three-yeat renewal, etc.) t @@Region wis ed@to take. During the December 3-4 1970 site visit, the Pr gr @Coordinator, the Chairman of the RAG and the ChAikman@of- the B ar of Trustees advised the@team that, after due consideration. it was de ide @that the application be considered a three-year renewal request. The Committee recommended that this application, which 7@- 8: 1) three-year renewal support at an inc eased request r e ctiviiies including an Educational Resource Stud y o e@ e@ ati6n for@7 projects and second year continuation for 3 hese projects; 2) 4 developmental component program; 3) support for pp d/ A supplemental request to an ongoing project; partially. SU ed for 2,000,000 for a one-year period. Included as - part of the ree tio is that. 1) The amount requested for a developmental 66m- $i58,564) for the first year not be approved. 2 2,000,666 is.predicated that any carryover funds will not be a 1 e to the Region as an additional amount. REQUEST RECOMVNDED FUNDING ;I e $3,519,285 $2,000,000 @2nd Ye @3 512,327 none :@3rd Year 2 194i5O4 none ALS $9,946,11 6 $2iOOOlOOO In e n IQ its d libetati6 , the Committee considered the Site Vis@it,@ Report, Illinois Regi6nal-Medidal Program, December 3-4 e he 5tte isitots recoimdended'triennial s-up :rt'b provided for dire t Po e c runai6g in the Amount of $2,000 ch of three years, momberq@of .000 for ea t elwhile concuring W3,.t'h the amount, recommended that support be Illinois:Regi6nal Medical Program RM 61-02 (AR-1-CSD)2/71 A ember of the Review Committee, who was also a member of the-Decembet 3-4,, 1970 s te visit-team, related the findings of the team to'the Committee. He reported the overriding positive factor in -this RMP is-@@the- new program coordi ator who assumed full-time leadership on June 1, 1970. In his short tenure, he has caused the IRMP to assume a new personality,, has st@arted@@the process of turning the program around and is definitely ch ngin the program eippha@is. He went on to state that Illinois already- 9 @ha -th necess.ary@@streagths-and-potenti6l to enable i@t to become one of iti leading Regions in the country. Bo h t e Composition, to include more minority members and consumer erests, and'the role of the Regional Advisory Group has:bee-n changed. e as little doubt that-this @becom'ng de ply involved group is@now e as t-he@@primary determiner of goals, objectives, priorities And Policy @f th Resion@. Core activities,have,been reo g@anized@into a four- ho ed tru6t&rd which now includes regionali.-ation, core functional 4c4@i ities,, administration and management, and re gional program development. The Com ittde was encouraged to learn that since the last total program e ev June 1969). in addition to an attempt to improve the otkAniiAtion and ca ab 1 ties of both the RAG anct C6re@Staff, there are-now much @st ng r ties and@relationshipt with the medical centers and other a ci s,and institutions within the Region. @@s re ionaliza ion has always been a major-problem in this Region,@as it s I similar Regions, with a historical upstate versus a@downst:ate;. Ca ently., the Region has been working closely @,7ith-several sub@ e ealth viannink a enci6s (exam le - S ringfield) in an effort to b to solve this perennial drawback to an effective program. T C ittee was on that a rather larg r stea. A large portion of this was to increase support of the time ffo t of the resent 5 pArt-timO coordinators assigned to medica@. p s s@from vakttime to fulltime. Additionally, support for full-time coorctil t-ors li requested for the two other alre6dv established s schools n t e@Region-P Us 4 new medical schools which are in the process of being es (S Kingfield, Peoria, Rockford, and hampaign). Both the P. at r's'@4nd members of-the Cbmmittee,qu'estioned the value oftthese s without some medical school-M4P Oritten plans; expectati;onsL@@ in.es. ion spec a ist. In line with this, members f Commi e conun the evaluation expertise that is already available in this there is no excuse for evaluation of poor qualit.y.@ In the future- h 9 r rem6 is for the activit are to be expected. y @@As' cted'in the site visit-repprt, the Committee.,was@in a@reement wi@th, RM 61-02 (AR-1-CSD) 2/71 Illinois Regional Medical Program -3- the team regarding the priority to which new projects should be supported,. In arriving at a recommendation, the Committee .generally agreed with the observations and conclusions of the site visitors that the Illinois RMP is obviously in the process of turning around and should be encouraged. While they also agreed with the yearly level of funding recommended by the site visit6rsl they believed that $2,000,000 should be awarded for one year instead of the three years requested.. The sitr-.visit6rs considered this to be a "new" Region in spite of its being in operational status for almost one year (since February 1970). Therefore, the Committee reasoned that the Warding of funds for a one-year period would provide the opportunity for the Region to prove-its maturity and also allow time for the Regibnls planned total program renovation. In conclusion,, the Committee recommended that the total program as presented in@this application be partially supported at $2,000,000 for aone-year per' d, rather than for the three-year period request6d, This recommendation .ill cause the R 5zion to reapply for triennial support in time for the w january/r-etruary 1972 Review Cycle. as a part of the reconLmendAtion is that: The amount k6qu6sted for a developmental component not be approved. 2) The $2,00031000 is predicated that any carryover funds not be made av iiabie to the Region as an additional amount. Fu eri the Review Committee strongly recommend that staff convey to h @Region its concerns regarding the necessary planning which should t pl 66 before full-time IU4P medical school coordinators are assigned and@its concerns regardin the quality of evaluation which will be ex cted@from-fhis Region. @Drs@. Schm dt and Ellis were not in the room during the deliberation on application. DRMP/GRB 1/15/71 NW 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) INDIANA REGIONAL MEDICAL PROGRAM RM 43-03 (AR-1-CSD) 2 71 1300 W. Michigan Street January 1971 Review Committee Indianapolis, Indiana 46202 PROGRAM COORDINATOR: Robert B. Stonehill, M.D. REQUEST (Direct Costs Only) 03 04 05 All Purpos 1973 Years Continuation 1,256,308 -0- -0- 1,256,308 Core & 3 Feasi- bility studies 422,573) -0- -0- ( 422,573) (5 projects) (833,735) ( 833,735) Renewal Components 671,122 517,891 559,673 1,748p686) (4 projects) Additional Components 136,005 -0- -0- 136,005 (Development) (127,000) -0- -0- (127,000 (1 new project) 91005) -0- -0- 9,005) Sub-Total 2,063,435 517,891 559,673 3,1 0,999 Supplemental Appi. Deferred 11/70 Council 2 projects 120,576 68,188 69,389 258,153 Total 2,184,011 586,079 629,062 3,399,152 Staff Action on Continuation 1,256,308 -0- -0- 1,256,308 Committee & Council Action 927,703 586,079 629,062 2,142,844 Note: 1) The continuation request includes the commitment $1,121,411 and carryover $134,897 to support core and seven projects. Three of t!ie projects have been ongoing for two years; three were funded one year from carryover; and one approved for three years is to begin. 2) In addition, carryover was requested for continuation of #5 and #6. Subsequent to submission of the application, Grants Review Staff informe the IRNP that these two projects were approved and funded for one year only and must now be considered as renewals by February 1971 Council. Meanwhile, staff will consider extending their current support for three months with additional funds until the renewals are acted upon. INDIANA RMP -2- RM 43-03 (AR-1-CSD) 2/71 FUNDING HISTORY (Direct Costs) Planning 01 1967 $384,750 02 1968 592,106 03 1969 217,473 OPERATIONAL Grants Year Period Council Approved Funded Commitments 01 1/ 1969 $1,363,571 $1,363,571 02 1970 1,271)411 2/ 1,513,690 03 1971 1,121,411 I/ Merged with 03 planning 2/ Includes $242,279 carryover Demography A. Population: Approximately 5,000,000 in 1969 1. 65% urban 2. 93% white 3. median age 28.9 years (U.S. average 29.5) B. Land: 36,185 square miles C. Mortality per 100,000 1. Heart 373 2. Cancer 156 3. CNS vascular lesions 126 D. Facilities 1. Indiana University School of Medicine 2. 38 Schools of Nursing (12 of which are affiliated with colleges and Universities and 5 grant B.S. degrees 3. Allied Health Programs: 17 schools of Medical Technology 2 cytotechnology facilities 18 X-ray technology facilities IUMC has a Division of Allied Health Sciences with programs in 10 professions, i.e., health education, P.T., O.T. and inhalation therapy 139 hospitals with 36,335 beds INDIANA RMP -3- RM 43-03 (AR-1-CSD) 2/71 Manpower (1966) 1. 5,111 M.D.s and D.O.s - 100/100,000 2. 13,769 active nurses - 275/100,000 History of Regional Development: During September 1965, the Dean of the Indiana University Medical Center appointed a Study Committee which included representatives from the State Medical Association, State Health Department and Medical Center. After extensive preparation, the first meeting of the Regional Advisory Group was held in July 1966 followed by submission of a planning application to RMPS in September 1966. The Region received a three-year planning grant beginning Januaryl, 1967. The current coordinator joined the staff in July 1967 and was named successor in his present position in January 1968. A site visit was made September 1968 to determine IRMP readiness for operational status. Impressed by the Region's leadership, community involvement and good working relationship with the university, the site visitors strongly recommended approval of the operational application. The November 1968 Council recommended approval for three years. The third planning year merged with the first operational year during which time $1,363,571 (d.c.o.) was awarded (03 planning - $152,295 - and 01 operational - $1,211,276) for core staff and five projects. On reviewing the second year continuation application, staff believed the IRMP was progressing satisfactorily. The amount of $1,513,630 (d.c.o.) was awarded for core and ten projects (3 continuing and 7 new projects approved by Council). The award included $242,279 use of carryover funds, most of which was for support of three approved and unfunded projects for one year with no continuing commitment. The current Application for third continuation support was reviewed by staff November 24, 1970 and a summary of their comments is appended. Goals and Objectives: The overall goal remains to make available improved patient care through cooperative arrangements including continuing education and demonstrations in the areas of heart disease, cancer, stroke, kidney and related diseases. Original emphasis was in the area of expanding Continuing Professional Education, increasing manpower and stimulating appropriate research. Increased emphasis will now be placed on stimulating the delivery of needed patient care. Within the broad objectives, the RAG assigned priority ranking to all projects; 1 to 13. Ranking order: REGIONAL ADVISORY GROUP PROJECT PRIORITY DETERMINATION Priority # Project (1) 2.89 4 Coronary Care ................... (Funded until December 31., 1.971) (2) 2.79 3 Stroke .......................... (Funded Until December 31, 1971) RM 43-03 (AR-1-CSD) 2/71 INDIANA RN? -4- Priority Project (3) 2.67 13 Nursing in Coronary Care Units ... (Funded until December 31, 1970) (4) 2.58 2 Multiphasic Screening .......... (Funded until December 31, 1971) (5) 2.55 16 Chronic Pulmonary Disease ...... (Funded until December 31, 1970) (6) 2.50 18 N.W. Indiana Community Coronary Care..(Approved-Unfunded) (7) 2.27 11 Nursing Continuing Education.... (Funded until December 31, 1970) (8) 2.19 21 Radiation Therapy ..... (Deferred for site visit by 11/70 Council) (9) 2.10 22 Respiratory Care Technician ( " it 11 it 11 to of 11 (10) 2.06 14 Library ..................... (Funded until December 31, 1970) (11) 2.00 5 Health Manpower ............. (Funded until December 31, 1970) (12) 1.95 9R Neighborhood Health Centers (Funded until December 31, 1970) (13) 1.72 6 Health Hazard ............... (Funded until December 31, 1970) ? ? 23 Smoking Program ............. (To be considered by 2/71 Council)i.!..-,..t During the latter part of the year, the Regional Advisory Group turned its attention to the development of a long-range plan. Accordingly, a special committee the Long-Range Goals and Objectives Committee, was formed to consider this matter. With assistance from Core Staff, the following set of goals and objectives was approved and recommended to RAG. These objectives are not intended to outline a set of programs that would be supported from Core Staff funds, but are intended rather to reflect patient care needs in the Indiana region and to suggest the kinds of activities and projects which the Regional Advisory Group would be likely to view favorably if they were submitted for approval. The document is perceived to be dynamic rather than static, and will likely be modified to reflect changing needs within the region; however, it should serve as a guide to those who will be submitting proposals for funding through IRMP. The goals and objectives below fall into five categories: prevention, detection, treatment, rehabilitation, and a general category for objectives that overlap two or more of the first four categories. 1. PREVENTION A. Goal It is the goal of IRMP to lower mortality and morbidity by means of strategies to prevent the occurrence of illness. B. Long-Range Objectives 1. To make it possible for every Indiana citizen to live in an ____z - - - - - - t-n ce-.nri hpql t-h - INDIANA RMP -5- RM 43-03 (AR-1-CSD) 2/71 2. To enable every Indiana citizen to avail himself of every feasible prophylactic strategy, from personal health habits to immunization, to avoid disease and disability. C. Short-Range Objectives 1. To enlist the citizens of Indiana in attempts to deal with the the problems of pollution and environmental controls. 2. To increase the availability of proven immunization techniques, particularly for low-income citizens. 3. To increase the dissemination of preventive medicine information. 11. DETECTION A.Goal It is the goals of IRMP to lower mortality and lessen disability by means of early detection (and subsequent treatment) of treatable disease B. Long-Range Objectives 1. To provide opportunity for periodic health screening for every Indiana citizen. 2. To educate every Indiana citizen concerning those danger signals of disease which he can himself detect. C. Short-Range Objectives 1. To increase the number of Indiana communities having free or low-cost health-screening facilities. 2. To increase the number of Indiana residents who receive periodic health-screening. 3. To increase the incidence of disease-detection at a treatable stage. III. TREATMENT A. Goal It is the goal of IRMP to reduce mortality and morbidity by making quality medical care available to every sick Indiana citizen. B. Long-Range Objectives 1. TIo provide opportunity for treatment of illness and disability for every Indiana citizen. 2. To provide means for bringing the latest developments in medical knowledge and practice to the attention of physicians and medical Dara-Drofessions and technicians. INDIANA RMP -6- RM 43-03 (AR-I.-CSD) 2/71 C. Short-Range objectives 1. To increase the availability of medical care, particularly for residents of low-income areas. 2. To encourage and support programs intended to increase the efficiency of health care delivery systems. 3. To encourage and support the continuing education of physicians and allied health personnel. IV. REHABILITATION A. Goal It is the goal of IRMP that rehabilitation services be available to every Indiana citizen, so that the handicaps and limitations resulting from disease and disability be mitigated as much as possible. B. Long-Range Objectives 1. To make it possible for every Indiana citizen to receive professional help to offset and compensate for the debilitating sequelae of disease and disability, in order to allow each citizen to pursue as productive a life as possible. 2. To prolong the longevity and productivity of the elderly as much as possible. 3. To enable those born with physical defects to function normally and effectively in society. C. Short- tives 1. To increase the number of rehabilitation therapists (S.T., P.T., O.T.) practicing in Indiana. 2. To increis(! the number of students In r(!Iiabillt.,ition tr,-ilrilri,@ programs In Indi;ina. 3. To increase the availability of reliai)ili.tition -i(.-rvic(!s Lf) Ltic rural and urban poor. V. GENERAL/RESIDUAL A. Coal It is the goal of IRMP to enhance the health program in Indiana by all ancillary services consistent with RMP guidelines. B. Long-Range Obiectives 1. To bring Indiiiia to or above the national median in per c;il)iti etintiiv nf and allied health persotii)(@l . INDIANA RMP -7- RM 43-03 (AR-1-CSD) 2/71 2. To provide Indiana medical personnel with competence to utilize newly developed equipment and apparatus necessary in medical practice. 3. To stimulate systems for the delivery of health care most effective in utilizing resources and manpower to meet health needs. 4. To enhance a high degree of cooperation among the various groups concerned with health: practitioners, consumers, voluntary agencies, educators, governmental units, health insurance agencies,etc. 5. To encourage redefinition of medical practice patterns of physicians, nurses, and allied health professionals in order to permit more efficient and effective utilization of skills and manpower (i.e. broaden responsibilities of allied health professionals; develop new health disciplines). 6. To reduce the relative cost of quality medical care. C. Short-Range Obi6ctives 14 To maintain a state-wide health data bank, including data regarding health facilities and manpower, morbidity, and mortality. 2. To support efforts to recruit medical manpower, 3. To extend to remote parts of the state, rural and urban, health care systems which have been demonstrated to be effective in local pilot projects. 4. To inaugurate and support community action groups concerned with health. 5. To develop continuing-education centers at the proposed regional campuses of I.U. School of Medicine. 6. To support the introduction of proven medical practice innovations to Indiana medicine. 7. To encourage changes in the Indiana legal code so as to re ect changing medical practice. 8. To study ways of utilizing available health manpower more effectively. 9. To study ways of developing new manpower in the light of emerging needs. 10. To enlarge the representation on, and increase the activities and effectiveness of, the Regional Characteristics Committee. 11. To develop cooperative relationships for data collection and utilization with CHP, the Indiana State Board of Health and other agencies. INDIANA RMP -8- RM 43-03 (AR-1-CSD) 2/71 12. To develop methods for determining the cost-effectivenesn of medical programs. 13. To increase the efficiency of health care systems. 14. To increase utilization of facilities and reduce per-unit cost. 15. To train technicians to perform tasks now performed by physicians and nurses. 16. To extend the availability of medical care among minority groups and the poor. Organization: The RAG consists of 49 members (22 physicians) provides overall advice and guidance to IRMP and considers all projects as well as the core staff budget. It elects its own officers, Chairman, Vice-Chairman and secretary. It also elects a 12-man Executive Committee to function in the name of the RAG in the interim between meetings. Minority representation includes 2 blacks. Consumers number nine and allied health is represented by 6. Sixteen Regional Committees have a membership of 150 and four area committees account for 118. The RAG meets 3 times each year. The Executive Committee meets two weeks prior to RAG meetings and at other times when necessary. According to the narrative, the committees and local groups are actively involved in planning program development, and project review. The fabrication reflects interweaving of cooperative efforts. The state is divided into 14 sub-regions for purposes and are the same as those for CHP. Because travel time from the central office is minimal, no sub-regional offices are planned. Plans include the use of field represen- tatives. Sub-regional programs are being created through CHPB,agencies (4 now in existence, 6 campuses of Indiana and Purdue University, hospitals participating in the graduate and continuing medical education system of the Indiana University Program for state-wide Medical Education and 7 Indiana University Centers for Medical Education). The project planning development and review process begins with the originator forwarding a summary to the Coordinator. If the idea is within the scope of IRMP, a team (1 central staff, I member of an appropriate IRMP committee and I representative of an appropriate health agency) are appointed to assist the applicant in the development of a proposal. If there is an active CHPB agency in the area, a representative is invited to participate in the development and review of the proposal. The completed proposal is reviewed by the Scientific Advisory Committee, after which a formal site visit is made. With the benefit of the reports from the Scientific Committee and site visit team, the Executive Committee reviews the proposal and makes recommendations to the RAG. The RAG makes the final decision based on their review including comments and recommendations of the three prior review including comments and recommendations of the three prior review groups. The project proposer appears before both the Executive Committee and RAC. DIVISION OF REGIONAL MEDICAL PROGRAMS INDIANA REGIONAL ADVISORY GROUP EXECUTIVE COMMITTEE p NG-RANGE GOAIS PLANNING and EI)UCATIOI- ;r RULES and MEMBERSIII TAFF and OBJECTIVES COMMITTEE COMMITTEE COMMITTEE SCIENTIFIC ADVISORY ET 0 COMMITTEE STANDING COMMITTEES CORONARY CARE MA@ 10-1-70 INDIANA RMP -10- RM 43-03 (AR-1-CSD) 2/71 Core staff is divided into four distinct budgets: the Coordinator's Office (central core), and three feasibility study core groups (Cancer Committee, Regional Characteristics Committee (data) and Continuing Education and Technical Support) The Central staff consists of 10 professionals and 4 secretaries. Pro- fessional personnel includes 3 new positions;2 field representatives and a staff assistant. The staff assistant's role is geared to pro.ject control and evaluation (progress reporting, financial status and evaluation including determining costs effectiveness). Initiation of developmental component activities will add to existing staff responsibilities. Three positions are currently unfilled: the epidemiologist, one field repres ntat.ve an one secretary. The Cancer Committee Core consists of a full-time physician and two secretai-te8. Tie Regional Cancer Committee and staff have established 13 sub-regional committees. The Regional Characteristics core (3 professionals and 3 clerks) is a data gathering group, including continuing studies of hospital discharge and related morbidity and mortality data. The Continuing Education and Technical Support staff's (3 professionals @ 25% time and 2 secretaries @ 50%) most significant contribution is apparently the, planning And implementation of 10 postgraduate courses annually co-sponsored by IRMP and the Indiana University School of Medicine. Following is a list of core staff budgeted for the 03 operational year (1971) and the organizational chart. COORDINATOR'S OFFICE (Core Staff) Institution % Time Title Affiliation Effort Professional R. B. Stonehill, M.D. Coordinator Ind. University 100% - 12 mo. R. A. Hagstrom Dir. Program Management H. C. Smith Dir. Nurs. & All Hlth. Sc. C. F. Leamnson Dir. Community Relations J. Svaan, Ph.D. Dir. Educational Services C. R. Hudson Dir. Admin. Services To be Appointed Epidemiologist J. B. White Field Representative E. Ferguson Staff Assistant To be Appointed Field Rep. INDIANA RMP -11- RM 43-03 (AR-1-CSD) 2/71 CONTINUING EDUCATION AND TECHNICAL SUPPORT (A Portion of Central Staff) Personnel Institution Name & Title Affiliation Time J. Royer, M.D. Assist. Dir. of Postgrad. Ed. iusm 25% To be appointed Conference Coordinator iusm 25% To be appointed Education Evaluator iusm 25% Sharon Bowers Secretary iusm 50% To be appointed Secretary iusm 50% CANCER COMITTEE (A Portion of Central Staff) William M. Loehr, M.D. Project Director Cancer Committee Indiana Activities University 100% Mary Chitwood Secretary Indiana University 100% Carolyn Henry Secretary Indiana (South Bend) University Part-Time (Hourly) REGIONAL CHARACTERISTICS SECTION (Core Staff) RMP Job Title Institution Affiliation Time or Name & Discipline or Function (Includ. Subunits, i.e., Effort Depts., Schools, etc.) % / Hours D. Parrott Research Associate Indiana University IOO'A Reg. Char. F. Brown Analyst - Reg. Char. Indiana University 100'7. M. Hensley Clerk - Reg. Char. Indiana University 100% R. Valentine Clerk - Reg. Char. Indiana University 100% C. Hensley Clerk - Data Bank Indiana University 100% S. Graves Analyst - Data Bank Indiana University 100% INDIANA REGIONAL MEDICAL PROGRAM CENTRAL STAFF ORGANIZATION u OF CANCER DIR E ASST. I EDUC POSTC SER s E COORDINATOF SEE AND C, EDL C. Hudson Dr. Loehr Di Dr. ri 13 IUNIC RESEARCH FIELD REPRESENTA- CONIPI-'TATIO-N TIVES CENTER STANDING COMMITTEES 10-1-70 INDIANA RMP -13- RM 43-03 (AR-1-CSD) 2/71 Annual Report of the Indiana Regional Advisory Group: The IRMP RAG addressed goals and objectives as outlined in that part of this summary. "This report covers year 02 of the Operational activities of the Regional Medical Program and sufficient data do not exist relative to cost effective- ness of such programs. Such information will emerge as more data are accumulated and more detailed program evaluation are made." Relationship to other programs concerned with planning and improvement of the organization and delivery of health services. "Direct participating relationship exists between the State and area- wide Comprehensive Health Planning Programs (P.L. 89-749), for the Director of the State Comprehensive Health Planning Program is a member of the Regional Advisory Group and is Chairman of the Committee on Regional Characteristics of the Regional Medical Program. Equally there is direct participating of the Regional Medical Program and Model Cities Planning through the activities of the standing Committee on Neighborhood Health Centers. Metropolitan Health Council of Indianapolis has submitted a project request to Model Cities for funding of Neighborhood Clinics. Until recently, Indiana has not had a state OEO office. Plans will now be de- veloped to integrate appropriate OEO programs into Regional Medical Program's goal and objectives. Cooperative relationships exist with Medicare, Medicaid, welfare, Hill-Burton, atmospheric pollution, radiation health, manpower development, and various HEW programs involved with professional education, stipends, and continued education." Impact of the Program "It was suggested that the Regional Advisory Group evaluate the impact of the program in: (a) quality of individual care provided; (b) more efficient utilization and organization of resources; and (c) improved distribution of services so as to be more readily available and assessable to all within the Region. At the moment it would be more difficult for the Regional Advisory Group to evaluate, items (a), (b), and (c) listed above. The program has not been operational to the point in time that would permit such qualitative evaluation by the Regional Advisory Group. Evaluation will require a related and mean- ingful system of data collection and analysis. The Regional Characteristics Committee is currently in the process of developing techniques whereby such data can be accumulated.' Without the obvious advantage of quantitative and qualitative data it is the impression of the Regional Advisory Group that the impact of Regional Medical Program on the quality of individual care provided has been most positive. This is based on the activities of the following operational programs: Coronary Care, Stroke, Nursing in Coronary Care Units and Chronic Pulmonary Disease. INDIANA RMP -14- RM 43-03 (AR-1-CSD) 2/71 it is further felt that there-is sufficient utilization and organization of resources as demonstrated in the Flanner House Multiphasic Screening Program, and Health Hazard Appraisal Program. Improved distribution of services can be reflected in the activities of the Neighborhood Clinics of the M6tropolitan Health Council, Stroke and Coronary Care Units." The RAG further reported that the IRMP is an excellent program under strong, efficient administration and with a staff which exhibits an unusual sense of pride in its organization. The grantee institution is the Indiana University Foundation, a non-profit organization chartered in 1936. The Foundation is a separate and distinct entity and does not come under the supervision of Indiana University. However, key officials of the University serve on the Board of Trustees of the Foundation. The relationship of the Foundation to IRMP is essentially that of a fiscal nature. The IRMP staff reports directly to the RAG which has administrative authority over the program and is responsible for the development of overall IRMP policies. The RAG Acts in a stewardship role as well as advisory. The IRMP staff are employees of Indiana University and are, therefore, subject to all rules and regulations of the University. Salaries of staff are based on a survey of wage structures in and out of the Region. Evaluation: As indicated in the application, an effort is being made to strengthen this aspect. A staff assistant has been employed and will concentrate on this area. The "Regional Characteristics" section of core also plans to aid evaluation. Developmental onent: The IRMP has requested $127,000 which is an amount equal to 10% of the current level of funding, excluding authorized use of carryover funds. The Region believes that it has the capability of administering these funds that will permit them to move rapidly and effectively into new programs and activities. Mucti of this activity will be based on current and continued studies by Long-Range Goals and Objectives Committee. Potential areas: Rural Health Care, extension of health centers, disease prevention, studies of health care delivery systems, feasibility studies, coronary care programs, health manpower studies, leadership development, community information and referral programs, home health care, and program planning and development. The process of review and management is adequately described. Requests for more than $10,000 must be acted upon by the RAG. Applications for less than $10,000 may be approved by the Executive Committee without review by the RAG. Requests for less than $5,000 may be acted upon by the Program Coordinator (chief executive officer of the RAG). Supplemental Projects: Requested Project #23 Cigarette Smoking Deterrent Program First Year This is a pilot program that will try to $9,005 develop a unique anti-smoking program at the high school level. The program will be carried out by a group of students in one high school. INDIANA RMP -15- RM 43-03 (AR-1-CSD) 2/71 A similar school will serve as a control. The project effectiveness will be evaluated by assessing behavior and attitudes of random samples of students in the two schools before and after the program. The special student group (council) will be selected by the project director in consultation with the school administration and faculty. No restrictions will be placed on the student council in the development of program. However, the project director and an Advisory Board will be available to consult and assist the students. Second Year Third Year -0- -0- Renewal Projects: Requested Project #5R - Health Manpower Recruitment This is a First Year request for renewal of a project submitted $25,000 with the initial operational application for three years support at an approximate annual level of $316,000. The September 1968 site visitors recognized the project director's enthusiasm about the proposal but did not believe the protocol was sufficient. The program was already ongoing supported by an annual budget of $60,000 provided from numerous community organizations, and there was no evidence of effectiveness. As recommended by the site visitors, the Review Committee and Council, the project was approved and funded in the amount of $25,000 for one year only. The current application indicates that the project is presently budgeted at $60,000, $25,000 from (5/12) IRNP, and $35,000 7/12 from CHP and the Indiana State Health Department with 314-D money. The purpose remains to be the motivation recruitment and admission of students And adults to education/training for health professions. The objectives and methods are unchanged. Much of the activity is devoted to dissemination of literature and responding to requests for information. Wor is a so carried out in the core city program through schools, i.e., consultation, in school programs, and workshops for guidance counselors. Second Year Third Year -0- -0- Requested Project #6R - Prospective Medicine This is also .a request First Year for renewal of a project which was submitted $20,734 'th the initial operational application for three years' support wi at an approximate annual level of $370,000. The September 1968 site visit team noted the enthusiam among practitioners for the program and the concept of the health hazard approach seemed educationally stimulating. However, several deficiencies in the proposal were note . The small number (40.1 of physicians receiving the continuing education reflected its high costs. The health hazard concept was innovative but the teaching techniques were traditional. No plans were outlined for evaluating the effect of the program in improving health care. As INDIANA RMP -16- RM 43-03 (AR-1-CSD) 2,/71 recommended by the site Visitors, the Review Committee and Council, the ,project was funded for one year only in the amount of $20,734. The pro- ject also has received a grant of $73,830 for the period July 1, 1970- July 31, 1971 from the Indiana State Board of Health (314-D funds). The objectives of this project are concerned with the performance of health hazard appraisal in three different medical care situations; a small community hospital, the family physician's office and two neighbor- hood health centers. Accomplishments include a manual for the practice of medicine and exhibits at State and National medical meetings resulting in appraisals on 1000 physicians. Second Year Third Year -0- -0- Requested Project #9R - Neighborhood Health Centers This is a request First Year for renewal of a project which first began $584,827 as a feasibility study during the planning and received one year's support in the amount of $169,550 for one year during the 01 operational period. The site visitors (September 1968) found this to be an impressive endeavor directed by capable people. It was noted that RMPS support was only about one third of the anticipated costs and funds from other sources, i.e., local groups, Flanner House an O.E.O., would be sought. The visitors had no hesitation.in recommending its support, but believed it to be the type of activity that could be supported in the future by Model Cities CHP, O.E.O. etc. Renewal for one year was requested, approved and funded in the amount of $169,550 for one additional year. The reviewers were somewhat uncertain as to the relationship of the project to the goals of RMP legislation. It was believed that an additional year would allow the centers to become firmly established and provide the necessary time to be brought under funding agencies for these purposes, i.e., Model Cities. Two companion activities serve the Indianapolis Model City; #2 "Multi- phasic Screening" and #9R "Neighborhood Health Centers". According to information received from the RMPS representative, HEW Region V Office, the projects qualify for Model Cities certification. The three health centers, each operated by a hospital , are sponsored by the Metropolitan Health Council. The aim of the project is to provide high quality continuing medical care to the disadvantaged. 130 patients were screened at the Southeast and Central Avenue Centers. The Martindale Center has seen 376 of 453 patients referred there from the multiphasic project. One or more diseases were diagnosed in 291 of their patients. Second Year Third Year $477,280 $524,058 RM 43-03 (AR-1- INDIANA RMP -17- CSD) 2/71 Project #16R -,Chronic Pulmonary Disease This is a Requested request for renewed support of a project First Year originally proposed, approved and funded for one year. $40,561 The support was to provide a five-day conference for individuals trained Ipreviously and newly identified physicians. The RMPS Con- tinuing Education and Training Panel recommended disapproval on technical grounds stating that past progress had not been well docu- mented. Since the Region had already been authorized to use unexp6nded funds to begin the activity, the Committee believed it should be allowed one year to complete the program; the basis for it's approval and funding. The major aim of the current proposal is to improve education in Pul- monary Disease through the development of sub-regional centers by: 1) Training and continuing to train increasingly larger "target groups" of physicians from hospitals geographically representative of the various communities within the state; and 2) Maintaining continuous contact with these "trainees',',', (a) providing them with guidance and supervision, and with the teaching techniques, material and aids necessary to promote and encourage in their own institutions teaching activities intended to divulge information in this field to a larger group of community practicing physicians, and (b) Assisting them in making available in their respective communities diagnostic and therapeutic facilities and services, such as pulmonary function laboratories, rehabilitation stations and respiratory care units. The applicability of this educational model was evaluated and tested in the past two years, during which time the program was considered as a pilot and feasibility study. From all the information available it can I$e inferred that this educational system has been very successful Beginning with 9 participating hospitals from large geographic areas within the state and with 12 "trainees," the various activities were gradually expanded to include at present 16 hospitals and 29 "trainees". At least 10 of the sub-regional "centers" so developed are now participating very actively within the functions of the IRMP. At this time it is felt that the scope and the operational scale of this program are ready to be expanded and it seems most desirable to have it supported over the ensuing three years. Second Year $40,311 Third Year $35,615 INDIANA RHP -18- RH 43-03.(AR-1-CSD) 2/71@ Prolects Approv d-Unfunded'of Partially Funded With no Commitment for e Whic ort ested. Project Years 01 02 03 Approved Funded @pproved Commit@ AP12roved Commit '2/'$51 450 #11 $ 82,036 $88,850 -0- -0- #12 31109,003 -0- 69,702 -0- $72'375 -0- #13 40,428 40,428. 36,947 &.0- 38,720 -0- #14 27,497 2/ 26,197 29,064 -0- 30,026' -0- #18 41,966 -0- 309050 -0- 32,390 -0- Total $191,927 $118,075 $254,613 -0- $173,511 -0- Footnotes: 2/ supported from carryover funds in the 2nA operational year approved with no additional fundd4 GRB/RMPS 11/25/70 DEPAIRTI/IENT 0'7 IIEALTH, EDUI::.@"ITIOr-4, Ai,4D 1,VELFARE ['U't'tLIC I-IEAL.Ti-i C,@@?VICF- HEAI-'T'Vi SERVICE.3 AND MLr4-rAL ti@-,',LTii ADMit-41CTF@ATION December 15, 1970 Rep@ to Alln of. Staff review November 23, 1970, of In(li@i-,ia REgioiiil Medical PI.-o,,,ramf,,3 Continuation Application r@l 00043-03 (Af.@-l-CDS) 2/71. To: Actini, I)jrcctoi- regional Medical. Programs Service Tlii-ii: Cliii.riiiin of the Itontli Cli.iL@f, Gritit,; liiii.,igenic-nt Br;.iii(@lt Act@ili@, The continuation rc!(Iuest is part of the ti@oi-i for $2,184,0-Ll (d.c.o.) for their 03 c)l)(!i-atioTiil- This amount includes their supplemental. ippl.ic,-,tioli (1-1-Yo I)roj(-(@t:,;) co-,n- sidered by the November 1970 Council and deferred for the 1, 1.970, site visit. The continuation request is for $1,302,042 ($I.,]-2.]-,411 commitment jrt(l $180,631 carryover) for core and seven approved pro-. ects. Three of the projects il)l)roved with three year commj-.t,.i-@entc@ have be(@n onpoir)g t-i-7o years,. Three of the approved projects (two for three years tnd one for t@.7o yc@;irs) wc@re begun durint@, the current y(.@,ir from c@irryovc@r funds with if() coirii-iit- in(--nt. One approved for three years is to commence during the O')' vc-,-Ir with support froii both the lev(-@l and (--zirryr)v(--r. C(-)ijtiiiiiiL-or of 1)roj(.!ctc. #5 and 6 from cirryover was ;also blit@ advised the l,',c-.i,!.on that were ,j.l)pi-ov(@(i ;jj-i(I fiiii(.1c@(I for on(@ oiily and w@i.11 now lizivc@ to be a@: I)y tlj(.@ l,(,I)rLi,.iry '11)/l. (.'ounce.'[. an for inont@ii..,; wi.tl:j i(Jcii.t-ioti:jl fail(].,; Should be considered until renewal ctatus is acted itj)on. Reconim(@n(lat Lon: Approval in the amount of $1,175,,591 cl.c.o. i.jicl.u@irip,, the use of (,arryover or new funds in the amount of $54,180.. Basis for level recommended: Committed Carr l,ev(!l New Pounds Total. Core $422%573 $422,573 #4 CCU 157,250 157,250 #3 Stroke 271,000 271,000 Harold Margulies, M.D. 2 December 15, 1970 Committed r 0 -"r Total Level New Funds #2 Multi Screening 225pOOO 22@,000 #11 Nursing Allie i 42p747 88,335 Health Cont, Ed. 45.,588 #5 Health Manpower (3 mos.) 60250 6 5- 250 5,183 5,183 #6 Prospective Med. MOS.) $lpl2l,411 $54,180 $1,175,591 The attached summary of 01 and 02 iwards and 03 request ind rc!co7cnendati-ons may be helpful. I This recommendation is based on staff review and site v' Lsi-t information attained duri,iig the Deceribc,-r 1, 1970, site vi.sit. #1.1., and Allied Itealtli Continuing Education , is I statewide progra7ii of vast cd a groat deal of time importance to the Region. Core staff has invest in its development and necessary cooperative arrangements. Continued support would allow completion of the two year activity. The site visitors agreed to recommend approval of renewal of projects #5 and 6. This then is the reason for staff's recommendation for their extension for three months until renewals are acted upon. Support is not recommended for project #18 (N.W. Indiana CC) because it is a three year project and there is no assurance of continuation. Also, like most projects, there would be some time required for tooling up. Projects #1-3 (Nursing in CC) and #14 (Library Program) were funded from carryover funds with the understanding that no further B14P support would be required. A group recommendation iiis not i@.-,rc@ed upon by ,taff dtirii),,, ti)(@ir 2 November review. The above recommendation is based on the review all(] subsequent site visit - December 1, 1970. Messrs Says, Cl@B, and Robertson, ltDB, were members of the team. Staff reviewers' comments prepared prior to the site visit are attached, including Mr. Teets', GMBL who recommended approval at the commitment level. Note: A site visit was made December 1, 1970, and a report will- be pre- sented to the January 1971 Review Committee. Tile site visitors believe that in the absence of a meaningful- specific data based statcwide plan, the I%"IP is not ready for a developmental component. Ilowever, the team expressed confidence in the coordinator and staff leadership, as Harold Margulies, M.D. 3 - December 15, J970 wc,l.l is general speculation of pre,@ent projc@c-t activities. The visitors will support @i recommendation for approval. of three nc@w and four renewals ($927,703 d.c.o.). The site visit confirmed staff's concerns about the need fo r better evaluation. Some effort has been made to strengthen this aspect, iT)Cj-ud- ing the employment of a staff assistant. The regioiiil characteristics section of core (health data unit located at the Indiana State Board of Health) seems to be a fragmentc-d.effort from planning, development and evaluation. Outside consultation might be beneficial. Also, IRMP should explore cost sharing of data service. The IRMP letter December 9, 1970, to you is an accurate accounting of the site visitors' feedback and recommendations. Hopefully, the Im4P consider the scope of work required prior to their next submission of August 1, 1971, and necessary rebudgeting. Saran J. Acting Chief Grants Review Branch Ac t ion by D ir ec t or v td Initials Date c,, 0 Attachments: 1. Summary of 01 02 awards and 03 request and recommendation by GRB and RDB 2. Recommendation by CMB 3. Review comments by GRB a-nd'OPPE staff 4. Copy of IRMI)'s letter December 9, 1.970. @IPS staff who Attended this continuation re-view meeting: L. J. Says, GRB Lee Teets, GMB Dale Robertson, RDB Leah Resnick, OPPE Mary Asdell, CETB A PRIVILEGED CO@MNICATIOI SU@RY OF REVIEW Al\'D CONCI",USION OF JANUARY 1971 REVItl@ COLN@ TI'EE I-T\TDIANA REGIONAL MEDICAL PROGRAINI PIA 43-03 (AP,-l CSD) 2/71.1 & 2/71.2 FOP, CONSIDERATIO@N BY FEBRUARY 1971 ADVISOI-',Y COITNCIL 6@cormend&tibn- The Committee considered the supplemental portion of the application for support of four renewal projects one ew pt6jett and the d6velopmental.component. The supplemental application r sup-p6rt of two new projects deferred for a site visit by the vember 1970 Council was also considered. In View of the site visit indi gs, the Committee recommended disapproval of the developmental. owever. contrary to the site visitor's recommendation the Committee I It co nds.additional funding in the amount of only $150,000 for et Tonal activities. Note, The Continuation portion of the application was reviewed and acted upon bv stakt., An.award in the amount of-the committed level 1, 1,411) for core activities and six projects was being processed i co 6nsurate with !RMP's grant period beginning January,l, 1971. A d aft report-of the December 1, 1970 site visit r was presented findings of which were highlighted by a...Comft@ittee member of @t te broad@generai objectives and lack of a data base by which goals could r u66d to Dribri.ty-oriented specific work to meet defined deficits in t e ReRibn. This problem coupled with the array of projects precluded pro t4m Pr spectiveo Evaluation was cited as another weakness. qp 6 thes @PrA!ems, the visitors believe that the IR'i'4P has strength t6fttial capability. The organizational structure is basically @n There was evidence of competent staff leadorshiv, as well as G involvement. The review process including technological input eems@ adectiai6. AlthouRh ttiereare no formal geographic subregions, it ess ry to viable 6p6rations were apparent. The site visitors, co c . ed that in the absence of a meaningful and specific data-based At id& plan,,tho !PIIP is not ready for a developmental component nd id not tecomme6d its approval. The te4m, however, did express p act'v ties. The team recommended approval of t e@pr6posed t ew projects and four renewals ($800,103). T e i plicati6n and the site visit findings prompted a r6at deal of 9 d set sion and debate about appropriate action t6,be taken. The d tomy between the written descripti-ons,and what has actua IY ' -2- RM 43-03 (@R-1 CSD) 2/71.1 & 2 Indiana RMP been done was recognized and one of the values of site visits is finding out reality. Concernwas expressed about disa proving the developmental p c@dinrkon6ftt approximately 10'/. increased funding), and on the other 'hand pptoving all new and renewal projects (60'/. increase). There was agreement that the site visitors found sortie good projects in the Region that just did not happen. They were nurtured by !R@IP. The problem is that the activities are like stepping stones that lead no place. There as 6,olidar'lty in the opinion that the word must g6t to IRMP that their next Anniversary Review Grant Application reflect the suggestions made to them bv the-site visitors. There was disparity in reaching a decision r 6omrfl6lAdati on e 01-1 of the funding level6 The Coiiinittee questioned whether e Region had taken any positive action since the site visit. In response,, taff@advised that the IRMP got the site visitors message and that they eem@ o understand the scope of work to be undertaken prior to their ext@submission in August 1971. A retreat for Core staff and RAG was nticipated in January 1971. Befo e reaching, agreement on a recommendation two moti.obs did hot carry. The first r(ioton for "disapproval of the developmental and additional 466,000 for one year for projects with a clear message" was defeated. he second motion "a proval in the amount requested for one-year with p a cl6 r mbssAge4', was not seconded. n conclusi6ft- the Committee recommended additional funds in the amount f $ 50,000 d#C.O with s.trong advice to the R6gioni 1) that funds be used n t e,necessary planning to move the program forward as recommended by the, ite visitors; 2) future proposed activities be based on scientific iud of needs And Priorities; and 3) evaluation include patient care GRB/RMP8 1/19/71 0 0 0 REGIONAL 'MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Comunication) INTERMOUNTAIN REGIONAL MEDICAL PROGRAM RM 15-05 (AR-1 CDS) 2/71 50 North Medical Drive January 1971 Review Committee Salt Lake City, Utah 84112 PROGRAM COORDINATOR: Hilmon Castle, M.D. FOR CO @ TTEE/COUNCIL REVIEW 05 Year 06 Year 07 Year Total Developmental $ 75 000 $ 75,000 Two Renewal Projects 321:022 $328,336 $351,673 1,001,031 Three New Projects 367,014 368,508 389,194 1,124,716 TOTAL $763,036 $696,844 $740,867 $2,200,747 FOR RNPS STAFF REVIEW 05 Request Core $ 973,090 11 Projects 1,489,034 $2,462,124 Committed 2,446,230 See attached Summary of Staff Review. FUNDING 05 Year 06 Year 07 Year New $763,036 $696t844 $740,867 Ongoing 15,894 Now Committed $2,446,230 $2,417,167 -0- TOTAL DIRECT COSTS $3,225,160 $3,114,011 $740,867 FUNDING HISTORY Planning Year Awarded 01 $ 456,415 02 350,294 Operational Year 01 1,832,760 02 2,267,074 03 2,445,193 04 2,986,791 Commitment 05 2,446,230 Intermountain PM -2- RM 15"05 (AR-1 CDS) 2/71 GEOGRAPHY AND DEMOGRAPHY: The region encompasses an area of 564,000 square miles, including the State of Utah and parts of Nevada, Montana, Idaho, Wyoming and Colorado. The greater portion of the land area is arid or mountainous and is sparsely populated. Approximately one-third of all the people reside in a small irregular rectangle some 80 miles -long by 1 to 25 miles wide, centered in Salt Lake City. Most of those remaining, live in 13 'cities of 20,000 to 50,000 population and 25 smaller towns of 5,000 to 20,000 persons. Some uncertainties relative to boundaries probably attend all areas except the State of Utah. Salt Lake City is the approximate geo- graphical center of the region, and it also represents the trade, educa- tional, religious, cultural, social, as well as medical center for all of Utah, southern and eastern portions of Idaho, western Wyoming, northern Nevada, southwestern Montana, and the area in Colorado which lies on the western slopes of the Rocky Mountains. Salt Lake City is the well- established center for all methods of transportion. The population numbers roughly 2.25 million for the region, with about 50% urban. In addition to the University of Utah School of Medicine, there are seven institutions of higher learning, each with a pre-medical program and training for allied health personnel. Four have nursing degree programs and two provide advanced studies in nursing. The University of Utah has a Bureau of Community Development experienced in conducting surveys of health needs. The region contains a total of 87 hospitals, with 10,230 beds. There are 2,100 physicians (94/100,000), and 7,000 registered nurses, 5,200 who are active (231/100,000). HISTORY OF REGIONAL DEVELOPNENT: The University of Utah School of Medicine began planning for a Regional Medical Program in mid-1965. In October 1965 a fulltime Coordinator was appointed. Numerous meetings throughout the region were conducted during this pre-@lanning period. The region based its planning on five areas: community and p ann ng resources; manpower; inservice training programs; continuing health education; and hospital facilities and equipment. The Intermountain Regional Medical Program was one of the first programs to submit an application for operational grant funds. A site visit was made to the Region in November 1966, and the site visitors reported the program was ready for operational status, the RAG was prepared to assume responsibility for priority setting, and that the proposed activities Intermountain RNP -3- RM 15-05 (AR-1 CDS) 2/71 would extend existing expertise from the University of Utah Medical Center to hospitals throughout the five-state area. The proposed operational program was weighted toward continuing education and cardio- vascular disease activities. The inclusion of a physiological monitoring research and development project, under the direction of Dr. Homer Warner, was also proposed, and a special technical site visit was recommended, and later carried on to appraise this aspect of the proposed program. The first operational grant was awarded in April 1967 for a three-year period. During the next three years,, new activities were added in stroke and related diseases areas; the initial thrust in the cardiovascular field was continued and heavy emphasis was placed on continuing education and training. In 1969 the region requested renewal support for Core and all ongoing projects, and a site visit was again made to the region in October 1969 to study the results of the three-year funding and the region's plans for the future. The 1969 site visitors were much impressed with the accomplishments that had ensued in the past three years. Patient care services and trained personnel existing throughout the region were direct results of the Regional Medical Program. The region had developed a capable core staff, apparent good working relations with physicians and nurses in hospitals and was beginning to think in non-categorical programming terms. The site visitors commended the core staff and the RAG for the accomplishments of the past three years, but urged them to consider turning the program in other directions away from the concentra- ti6n in categorical diseases diagnosis treatment, and toward prevention as well as un-met health delivery problems existing throughout the region. The site visitors also urged the region to concentrate more on developing @le relationships and less on technology as the primary vehicle for peop regionalization. In the Spring of 1970, the region submitted a request for funding to develop multi-phasic screening activities for a 314(e) Neighborhood Health Center in downtown Salt Lake City for the urban poor. This was approved and funded. The application for the fifth operational year at the commited level was reviewed by RMPS Staff in November 1970. A copy of that review is attached. REGIONAL ADVISORY GROUP,, Three new consumer representatives have been added during the past year. An effort to involve members in identification of high priority problems and in feedback is being attempted. Three new Task Forces on Health Manpower Problems, Health Services for Medically Impoverished, and Program Impact Evaluation have been organized. Membership on all such groups always reflects personnel from outside the Salt Lake City area. Some members of the RAG are also members of the Health Planning Council (314b). Intermountain RNP -4- RM 15-05 (AR-1 CDS) 2/71 The region is reported to have developed a very comprehensive review process which was time-consuming but apparently responsible and mature. The RAG was involved in several stages of 27 steps in project development. PRESENT APPLICATION FOR ADDITIONAL FUNDING DEVELOPMENTAL COMPONENT:. The amount requested is $75,000. These funds will be invested in pro- Jects that can become self-supporting quickly. Not less than ten such activities will be ready for implementation by April 1, 1971. Priorities will be aimed at health services to both urban and rural poor, and studies to improve productivity of physicians and health personnel for more efficient use of health resources. The RAG will allocate such funds and will analyze the proposals in light of needs, resources and program priorities. RENEWAL AND NEW PROJECTS: The application requests renewal support for two.on-going projects, #16R Endocrine Program and #18R - Model Stroke Program, and funding for three new projects, #30 - Chronic Respiratory Disease Project, #31 - Diabetes Education, #32 - Head, Neck, and Oral Cancer Detection Training. A comparison of the types of activities supported now in this fourth operational year with the request in regard to the portions allocated to various areas follows; Components by Disease Category Present Proposed Heart 19.5% 17% Cancer 6% 8% Stroke 4% 5% Related Diseases 9% 17% Multi-Categorical 32% 22% General 29.5% 31% Components by Type of Activity Training and Education 21.1% 25% Demonstration of Patient Care 33'8% 30% Research and Development 15.5% 15% Administration and Planning 29.5% 31% Thus, it can be seen that the Region is making aslight change in direction. The above figures do not include the proposed developmental component of $75,000, which will be utilized for venturing into new areas of programming. RMPS/GRB 12/l/70 DEPA[ITMENT OF FIEAL_-ri-1, EDUCATION, AND WELFARE PUI.IL.1r: @t@izvicF- iiFAt-I'll t.;f.I?VICLS Af,4f) @,11.'N,rA[- til-ALTH AV)MINI'-]'f?A'['IOF4 Noveiiil)cr 27, 1970 Reply to Atin of. Subject: Staff Review of Continuation Portion of Application - Intermountain Regional Medical Program RM -15 To: Acting Director Regional Medical Programs Service Through: Cliiirm.4n of the Month Acting Chief, Regioni@Development Branch S SOUI'fl ,,AI!J --Tt@F:L'F' 25, 19-i'O c)n July 11, 1-970 University of @lla s 11-1 i ig'L. o n SeEi'Lae, Was'iairlgEon Doe-ir Sirs: I am a Genorc@l Practicionei-, doing 10cimily Practice in the small, rache@- iso- latcd co,-i-iniurii-'cy of Milford, Utah. My practice is active and busy, and deriizinding. If I don'!L- need some help now, I certainly will'. in the very near fUL-Ll,--e, , as my v.,o.-k load has increased year',\,,, 'or the last 15 years. I have read of your i@or Physici-a-,q's Assist@ii-i'cs Lf -@il-@@n-@ Care, April 30, 1970') . I believe my community would be 'u.-'Iizinc ',Ohysician AssistEin-L- . accep'L,@" n g a ri j- Lia In nay practice I have a young man who is an Ex-Corps,-nan, wife has completed his 4 years oil college, has a small 'La,-riily and is marf-'te(ft -L-o a young oi' 'this community. This young man thoroughly en,oyed his wor.< as a "riiedi--" and has expressed very real interest in the Prograr1q. I also have an o-L@ 'Lice, assistant, who has wo,-'-Iec,' for roe as my C)i@'Lice -.\--ui-se for the past IS years. She is vigorous and healthy and co,-rlDeLent and intelligent. She -is E, Registered LFb -in(ft X-,i@ay Techricia,-@. She has al.so exp--resseci sincere interest in pursuing the "iVL-,.7!DEX" Progcam, if it would be available to hc@ r I:i'cher oj' th s c-, p,-- o p I ewould he we'll qual.i.Fied, dedicated, sensi.k@i.v-@ iridivid.uE@.Is in the capacity of a P,-iysician's Assisl@-@inc, and I would be delighted to carry on 'the 9 months on-the-job training, in nay office for e i'L-1-ier o-F I would appreciate any information you can send ri@e, thaLwoLild help me in my goal c)i'.Obtciining effective, corflp,-Lc-,nt help. Plecise coiiirf,,ent specifically (f, 4 as -to th s liability of the above Can lclc@tes 'or the MEDEX e vi T"nanks very much for your help. Yours sincerely, I* I- D. A. Sy-,iio.,-id, Nrl.lD. INTEPiNIOUN'fAIN REGIONAL @DICAL PROGRAM STAFF OBSERVATION: Mr. Daniel Webster, Pegional Office Representative, RMPS, Denver, Colorado, called to report the.following about the.Intermouritain Regional Medical Program: 1. Robert Satovick, M.D., has been appointed coordinator.of the Intermountain Ple to replace Dr. C. Hilmon Castle. Dr. Satovich has served on the IFIM core staff, with special responsibility for developing the teteb-,t6V6@cula-r- program. 2. Mrs. Irene Sweeney has retired. Her responsibilities for sub-- regional development will be assigned to Artnur Anderson, a member of the IRMP core staff i-Those'former duties were in'the renal program area. A PRIVILEGED COMMNICATION SUMRY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW CONMITTEE INTERMOUNTAIN REGIONAL MEDICAL PROGRAM RM 15-05 (AR-1 CDS) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: Award of $75,000 for a Developmental Component and $150,000 for operational activities. Recommended Year Request Funding 05 (Developmental $ 75,000 -75,000 Comppftent) 2 Renewal Projects 321,022 @3 N w Projects 367,014 150,000 Total $763,036 $225 000 6riti4ue: The Chairman of the site visit team repcrrt6d on the visit made on December.3-4. 1970. The findings and recommendations th team confirmed the previous visit of November 1969 which was 0 ganized for an extensive program review and renewal. IRMP,has a ell-tra.-ned and'competent Core staff, o d cooperative relationships th soital6 and a well-developed review process. e 6view Committee discussed the implications of the search for a' c nator, with Dr. Castle now Chairman of the Department of @C itv Medicine For instance, the University resources or ost aauate education and-family medicine have been placed in the-. a 0 amun posti doate 6cati6n4, This@may create problems for the new cooro at6i. particularly when it is realized that:the IRMP has a larger dg, than the Department of Community Medicine. The hew Coordinator 11 designated as Associate.Dean of. the M6dical Sdhool-,'ahd it w e rec ns t ide the sphere.of the Department of Community Medicine w i@ a te 1 challenge. (Note: since the meeting of the Review C i@ ee. R has been formally advised b hairman of the !RMP y the c h p IRMP Coordinator.) t e ointment of Dr. Robert M. Satovitk as he C mittee was in agreement that-the IRMP has: exhibited the nec@es .ry@mat ritv and decision-making ability, both on the part of the I and Core staff., to justify.an award of Developmental funds. _,@--Intermountain RMP -2- IM 15-05 (AR-1 CI)S) 2/71 As further demonstration of good judgment on the part,of the RAG, a very modest D.C. was deliberately requested to allow the region to first gain experience in this direction. The reviewers noted the important step in sub-regionalization efforts through the appointment-of ten Medical Education Coordinators in ten 'hospitals throughout the re ion but also noted an apparent lack 9 of understanding of the community organization nedessaty for such ub-regionalization. There is no cleat strategy for Accommodating e M,E.Cs with the:University of Utah in order to expand education, training and health manpower. The Core staff,needs to be encouraged to utilize and seek the assistance of the resources of local organi- tdtibns rather than d6pendin entirely on Core staff. 9 The plan for M.E.C.s is a laudable first step away fr6m@technically- oriented pr6'ects that !RMP has consistently emphasized, but the i reviewers noted that this region will probably always use a technological approach in view of its geographical and weather characteristics. The reviewers loatned that the Physiciant s Assistant Project, which had been looked upon negatively by the Review Committee in October as a very important element of high priority for IRMP.. The degree f physician involvement in the planning And development of the togt m is i tepsive. The RAG, as well as Core staff, has indicated ev eel it is critical for IRMP to contribute to this program, even if@funding for the educational portion emanates from the National Center for HP41tb Services Research and Development. he RevieW Committee discussed the question of the IRMP RAG representa- Ion. it was noted that the Pr6sident of the University of Utah poi ts members of the RAG, and while the very intricate relationships. at XiSt between IRMP and the RAGs of Colorado/wyomiftg and other pighb6ri@g tegions are excellent, minority and consumer participation s mi@ imal@. The reviewers feel that regional r6soutces are well utilized, although ha necessarily depended on a variety of "multiple represettation". ere many, of the same people appear on all committees. be COmmit,'.tee questioned the tegion's failure to come to grips with e@p obl@m 6f@seeking other sources of support and phasing out projects ere was $0 feeling that such a monolithic structure motivates of in t a@fle luility of such-action. Further, the review pr cess arentl does not@allow evaluation that would provide for such P app y rnov6r Or phasing out. Committee would be interested in demonstrated id6 te of accomplishments of its various programs with an aftalvsis fexpetienc6 tdgultihg from funds invested. Ithe opinion of the reviewers, the IRMP needs to develop criteria or ntinuing ongoing programs, with scientific documentation which Intermountain RMP -3- RM 15-05 (AR-1 CDS) 2/71 will measu re output of programs, their ability to "sel,f-renew" or obtain dollar support elsewhere. Also, they should try to develop .a local process designed to eliminate projects that fiave (or have not) accomplished their regional goals. In a discussion dealing with an appropriate dollar recommendation for .IRMP, the reviewers addressed a per capita approach. The site team had recommended aft additional $150,000 to support .new projects, and noted a lack of enthusiasm about the Endocrifte Laboratory an stro e programs. The matter was discussed by the site team with the region, and there was agreement that the program has not fulfilled its expectations. The Committtee's deliberations on the Developmental Component award elicited the opinion on the part of some of the reviewers that such an award should be provisional upon the receipt by RMPS of adequate data-on the progress of ongoing programs, particularly those that have had large investments of funds. This, in turn, led to an- examination of the current level of funding and the site team's recommendation of $150,000 to be awar e or projects. Th ere was consensus that the region'is adequately funded for its site., population, etc. The maturity of the region, the.capa6ity of RAG for responsible decision-making, and indications of ,objectives and priorities justify such an Award. Also, these ..,funds should enable the region to move more rapidly away from project orientation. There was also agreement that the management of grant funds is well-designed and efficient. Core staff has ability to develop a more imaginative thrust, but will require new funds since the'present grant fundsare tied up in ongoing activities. Sist6r Ann'Josepbine was absent from the room during the discussion. RMPS/GRB/l/22/71 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Couiiiiunication) LOUISIANA REGIONAL MEDICAL PROGRAM RM 33-02 (AR-1-CSD) 2/71 Suite 401 Januarv 1971 Review Committee 2714 Canal Street New Orleans, Louisiana 70119 PROGRAM COORDINATOR: Joseph A. Sabatier, Jr., M.D. Request (Direct Costs Only) 03 04 05 All Puri)ose 3/l/71-2/29/72 3/l/72-2/28/73 3/l/73-2/28/74 Years Continuation Com@ttment $628,369 $ 628,369 Core ($346,777) (346,777) 4 Projects 281,592) (281,592) Adeitional Components $1,678,644 $1,214,216 $1,193,121 $4,085,981 Developmental ( 62,837) ( 62,837) 6 Projects (1,400,096) ($1,080,577) ($1,065,597) ($3,546,270) 4 Approved but 215,711) 133,639) 127,524) (476,874) Unfunded Projects Total $2,307,013 $1,214,216 $1,193,121 $4,714,350 Scaff Action 628,369 628,369 Commitment Committee $1,678,644 $1,214,216 $1,193,121 $4,085,981 Action Required Funding Ilistory PLANNING STAGE Grant Year Period Funded (d.c.o.) 01 I/l/67-2/28/68 $490,448 02 3/l/68-2/28/69 454,445 03 3/l/69-2/28/70 425,300 OPERATIONAL PROGRAM Council Funded F'i-iture Grant Year Period Approved (d.c.o.) Connitment 01 3/l/70-2/28/71 $821,628 $673,887 02 3/l/71-2/29/72 705,611 $628,369 03 3/l/72-2/28/73 211$043 1-31,701 LOUISIANA RNP KM JJ-UZ @AK-1-Ubi)) L//i Geography and Demography The Louisiana RMP serves the entire state of Louisiana, which has a population of approximately 3.7 mill,-'on. It has interfaces with the Texas, Arkansas and Mississippi RMP'S. B,r national standards, Louisiana is an economically poor state. In 1966, 29 of the 64 parishes were poorer than 90% of the counties in the U.S., and 15 other parishes were poorer than 75% of the U.S. counties. Thus 69% of the parishes are at a high poverty level. Much of this poverty is concentrated in rural areas of the state and is reflected in poor health status. There are three medical schools in Louisiana - Tulane University Medical School and the Louisiana State University Schools in New Orleans and Shreveport. The major teaching hospitals in the state, serving the three medical schools are charity hospitals, which treat the indigent patients. Louisiana has a legislatively fragmented health care delivery system, divided among the state charity hospital system, the private care system, and the State Department of Health. There are 156 hospitals in the state with approximately 26,637 beds. This number includes eight federal hospitals and ten state-operated charity hospitals with 4,898 beds. A total of 4,194 non-federal physicians practice in Louisiana and 8,370 nurses are actively employed. Regional Development The original planning application, submitted by the Louisiana State Department of Hospitals as the grantee agency in Jurie 1966, was returned for revision because reviewers thought it represented more of a pre-planning than a planning effort. The revised submission was approved in late 1966 with the condition that the Region: 1) clarify how the program would cover areas outside-, metro- politan centers; 2) identify the person or organization adminstratively responsible for the program; 3) reduce the budget; and 4) clarify how the systems portion would fit into the overall aims of the program. After a National Advisory Council site visit by Drs. Peeples and Hurst, funds. were awarded in December 1966. About the same time, Dr. Joseph Sabatier was appointed Coordinator. During the first planning year, the Region requested and received permission to use planning funds to implement a coronary care unit program in Lafayette, Louisiana, with the purpose of testing the concept of RNP as a catalyst for development of an adequate community-wide structure for long term community health planning. This experiment turned out later not to have been very successful. After second year planning funds were awarded, the LRMP began work on its operational application, which contained a request for core funds and two projects - Health Careers Recruitment and Delineation of Medical Service Regions. In reviewing this application, Council stated that, while the LRNP had made progress in planning, they did not believe the application reflected readiness for an operations I program. The Region's second operational submission was approved-by the August 1969 Council, following a site visit in June, which indicated that the Region had been particularly successful in bringing together the important health institu- tions and organizations in the state. At the time the Region was beginning to LOUISIANA RMP -3- RM 33-02 (AR-1-CSD) -'@/71 examine its organizational structure and to take steps to change the grantee gency to a nonprofit corporation. The Regional Advisory Group appeared to &be dominated by physicians and lacked adequate consumer representation. The site visitors expressed the hope that the Region would begin looking at Droject activities in terms of the total Louisiana area, not just the New Orleanc Medical Center Complex. The operational application included funds for -@@ur projects: i@l - A Training Program for Tumor $116,956 Registry Secretaries #2 -A Proposal for Teaching Conferences 25,000 for Diabetic Patients Y@3 - Proposal to Establish an Office of 106,954 Research and Development in Educational Renewal (ORDER) '#4 - Audiovisual Lecture Demonstratiorts in 24,791 Radiology and Radiologic Techniques $273,701 Funding of the first operational year was delayed until March 1970 due to federal fiscal constraints. Consequently, the Region is still in its first operational year. During this year the Region has submitted two supplemental Applications. The first requested $535,747 for project #5, Development of a @egional Medical Center Coronary Care Training Unit. This proposal, which would have established a 19-bed coronary care unit at Charity Hospital, New Orleans, was withdrawn by the Region after the November 1969 Review Committee meeting and has been resubmitted in the present application as Project Y@18. The second supplemental application included these projects with the following action: @A8 Cardiopulmonary Resuscitation Revision Required #9 - Metropolitan Organ Bank Funding deferred pending development of Guidelines #10 - Study of Health Care Delivery Patterns of the Medically Indigent Approved #11 - Lymphomatous Tumors in Louisiana Approved without funds #12 - Telemetry of EKG's Returned for Revision #13 - Continuing Education Program for Physicians of Ruston, La. Approved without funds Since none of the approved projects have been funded, all but project #12 have been included in the present application to be reconsidered for funding. Louisiana PMP -4- RM 33-02 (AR-1-CDS) 2/71 Regional Objectives The Region has identified three critical health issues, which gave rise to the Region's objectives. These critical health issues are 1) health care needs of the disadvantaged, 2) methods of improving the productivity of the health care-deliv6ry system, and 3) health care costs. The following are the objectives: 1. To improve and expand the "data base" and systems of data management for health planning in the region. 2. To develop planning aids (models and tools) to increase the effectiveness of the region's health planning related to achieving LRMP objectives. 3. To implement regional programs through "subregionalization" of the health services and delivery systems of the region: a. Contribute to the upgrading of medical care for those people in the region who have been found to be disadvantaged in terms of health care received. b. Promote efforts to make quality health care more.accessible. c. Encourage the provision and utilization of comprehensive health care (e.g., prophylaxis, adequate patient follow-up and,continuous care). d. To promote efforts to contain or reduce the cost of quality health care. e. To promote efforts which are directed at improving the capacity of the health service and delivery systems (e.g., improving the number and utilization of health manpower and other resources). These regional objectives will be achieved within the framework of a regional conceptual strategy. This conceptual strategy includes the following five principles: 1) region-wide perspective 2) catalytic role 3) collaborative involvement 4) utilization of existing resources 5) involvement of a limited duration Organizational Structure and Processes At the time the grantee agency was changed to a nonprofit corporation, the Regional Advisory Group was reorganized by incorporating more groups with a central interest in RMP and by increasing consumer input. The 36-member RAG now consists of 9 ex-officio members, 21 elected representatives of organizations and institutions, and 6 public representatives. In addition to Its project approval function, the RAG also considers program statements OUISIANA -5- RM 33-02 (AR-1-CDS) 2/71 from and offers guidance to the planning committees and receives progress reports on core. The LRMP employs the following committees in its overall process: a) Program Planning Committees (Heart Disease, Cancer, Stroke, Epidemiology and Statistics, and Continuing Education and Health Manpower) are responsible for determining needs and developing programs within their assigned specialty. b) Ad Hoc Program Development Committees are temporary committees formed to aid in the development of specific projects and at the request of the project proposer. c) Ad Hoc Project Review Committees are established to evaluate the technical, scientific and operational excellence of each project. Consisting of experts in appropriate fields, these committees are usually from outside the region. d) Areawide Planning Staff Liaison Committee, composed of representa- tives of CHP b agencies and the a agency, provides liaison between CHP and RMP; it does not make official recommendations on projects. e) The Executive Committee of the RAG composed of the RAG Chairman, Vice-Chairman and four other members, represents the RAC, between its regular meetings and reviews continuation requests. The LRMP review process comprises three steps: 1) administrative review by Core staff, 2') technical review by the Ad Hoc Review Committee (copies of which are included with each project), and 3) final evaluation by the RAG. For a discussion of Core structure and function, please refer to the continuation section of application component of the summary. PRESENT APPLICATION Developmental Component $62,837 The Devel.opmental Component funds will play an important role in the three major activities of LRMP activity: 1) development and improvement of health planning and decisiori-inaking systems (including evaluation); 2) development of programs designed to meet specific needs; and 3) imple- mentation of programs. Examples of these activities could include: a) data gathering processing, interpretation and utilization; b) acquisition of authoritative information and advice; C) limited experimental studies in health care delivery systems or applied clinical research; d) dissemination of information; and LOUISIANA RMP -6- RK 33-02 (AR-1-CDS) 2/71 e) development of certain -unusual operational projects key to the implementation of high priority programs. The Coordinator will submit a detailed explanation of the proposed activity to the RAG, who will then approve or disapprove ilt. Upon completion of the activity, the Coordinator will report its results to the RAG. Continuation Component: These components have been reviewed by staff. Their program and funding recommendations are in a supplementary memo. Core $346.,-77.@-, Medical School Coordinator Advisors Dr. Joseph Sabatier I i Deputy Director I I 1. Planning 2. Evaluator 4. Assistant Director for Section Administration r- I i 1 3. Project Development Staff Secretarial Business Section Writer Staff Manager 1. The Planning Staff will coordinate and implement activities in data gathering, resource planning and delivery systems planning. Examples of these are a feasibility study of developing a hospital discharge abstract system, an assessment of the region's radiation therapy facilities, and an evaluation of models to improve the quantity and quality of health care delivery to rural and urban poor. 2. The newly employed Evaluator will develop methods of program evaluation and refine the program's priority setting mechanisms. 3. The Project Development- staff will stimulate and develop those projects specifically related to specific regional purposes. 4. The proposed activities of the Administrative staff include revising the regional guidelines and improving the regional communications systems. The LRMP has assisted health groups in other then project development. For instance, the RMP provided a panel of experts to investigate the current status of the Louisiana Hospital Television Network, a study recommended by the pre-operational site visit team. LRIM also provided assistance to the Cancer Commission of the State.Medical Society in assessing problems of establishing a statewide cancer registry, as well as to several other organizations. Core staff also uses subcontract funds to conduct planning and feasibility studies. The LRMP has no subregional office staff of its own. It has, instead, -7- RM 33-02 (AR-1-CDS) 2/71 LOUISIANA RHP fostered the developmnt of local CHP agencies. Financial and planning assistance has been offered to the six areavide health planning councils by LRNP. These agencies, in turn have been asked to comment on R14P projects in their areas- All of Core staff's 17 positions (15.5 F.T.E.) are filled. Continuation support in the amount of $281,592 is also requested for four projects: #1 - Training Program for Tumor Registry Secretaries #3,- office of.Research and Development in Educational Renewal 'n --Of iki&ical Service keiions in Louisiana #6 - Delineatio ofr'-li6c ui nt@ -#to@'gr'am ,#7.--,-,@Health Care r Approved but Unfunded Pro ects These projects fall into two categories: 1) Those which had funds approved by Council, but which RNPS, due to funding constraints, was unable to fund; and, 2) Those which received a recommendation of approval without additional funds from Council. @committee and Cou.ncil consideration of these projects is needed in determining a funding level for the next year and not for approval of the activities. 1. The Region has assigned both of these projects a high,priority. lot Year Project #9 - Metropolitan Org n Bank $102,035 Sponsored by Tulane University School of Medicine, this proposal would conduct a feasibility study on the development of An organ bank for the methodical procurement, preservation and supply of vital organs for purposes of renal transplantation in New Orleans. Second Year Thi d Year $77,242 $79,342 Proiect #10 - A Pilot Project to Establis a Method of Evaluating Health Care Delivery Patterns of' ndigent witn Hea se, Cancer, Strok ad Diseases The Louisiana Capital Area Health Planning Council, a 314b agency, will initiate a pilot study to determine health care pattern characteristics of low income residents in Baton Rouge, Hammond, and New Roads and form an Ad Hoc Committee on Comprehensive Health Services for low income citizens which might help evolve a plan for comprehensive health delivery system in an urban target area. LOUISIANA RMP -8- RM 33-02 (AR-1-CDS) 2/71 II. Both of these projects were assigned a relatively low priority rating by the Rbgion. lst year Project #11 - Lymphomatous Tumors in Louisiana $56,921 The major purpose of this proposal is to establish a statewide surveillance system for identification and histologic classification of all newly- diagnosed cases of Hodgkin's disease occuring within a two-year period and to coordinate resources for treatment. The Tulane University School of Public Health and Tropical Medicine will sponsor the project. Second year Third year $46,994 $48,192 Project #13 - A Proposal to Establish a Continuing Education Program for the Physicians of the Lincoln General Hospital Ist year $7,258 The physicians of Ruston, Louisiana, in conjunction with the development of a plan to supply health care services to the medically indigent, seek to develop a structured program to upgrade skills in their respective specialties. Physicians from Lincoln General will spend two weeks in appropriate specialty departments at Baylor College of Medicine in Houston following individually designed programs in their specialty. Conditions regarding the description of the courses, the parish-wide plan for comprehensive health care, and the ORDER's (project #3) involvement in evaluation, have been discussed by the project director. 2nd yr. Supplemental Projects $9,46-3 Committee and Coundil action are required on the following six projects, which the Region has grouped into roughly three priority groups: 1) High Project #18 - CCU Training at Charity Hospital Project #17 - Regional Pediatric Pulmonary Center Project #15 - Health Data Information Center 2) Middle Project #16 - CCU Nursing in the Capitol Area 3) Low Project #14 - Nurses Continuing Education Project #19 - CPR LOUISIANA RMF -9- RM 33-02 (AR-1-CDS) 2/71 @Project #14 - Coordinated Continuing Education Program for Nurses in Louisiana lst Year $156,487 Proposed by the Louisiana State Nurses' Association, this project would develop a statewide coordinated continuing education program for professional nurses and other nursing personnel. The program would be incorporated into the L.S.U. Adult Education Division. Because the intent of the project is to show relevance to the particular needs of the nurses in the subregions while upgrading the nursing manpower of the region, the project would serve the Region's third objective of implementing regional programs through subregionalization. Second Year Third Year $252,005 $249,331 i-@t Year Prolect #15,- Louisiana Health Data Information Center $63,348 The objectives of this proposal are @hree-fold: 1) Establish and operate an information resource for users of health and related data. 2) Stimulate studies in data acquisition and identify needs for data not currently available. 3) Develop an inventory which can be monitored over a long period and at a minimal expense. The proposal, sponsored by the Louisiana State Department of Health fulfills the primary project objective of establishing a data base for health planning. Second Year Third Year $53,580 $54,383 Project #16 - Ongoing Training for Cardiac Care Nursing Personnel in the Louisiana Capital Area Ist Year ,5 The Louisiana Capital Area Health Planning Council proposes to adopt the ROCOM system to construct a teaching program of 120 hours for participants in the CCU nurse training. Courses will be held in three hospitals in the Baton Rouge area. The project addresses the objective of improving the capacity of health services and delivery systems by increasing available manpower resources. Second Year Third Year $30,738 $31,646 LOUISIANA RMP -10- RM 33-02 (AR-1-CDS) 2/71 Project #17 - Regional Pediatric Pulmonary Center' $460,331 The Tulane School of Medicine Department of Pediatrics seeks funds to establish a multidisciplinary pediatric respiratory care unit in the children's ward, Charity Hospital, to deliver modern quality respiratory care to indigent children by establishing a four-bed special care unit, an inpatient ambulatory treatment unit and a teaching demonstration unit. Since the project is directed toward those who are disadvantaged in terms of having and paying for health care, it supports one of the Region's high priority objectives. I Second Year Third Year $548,765 $565,247 Project #18 - Development of a Regional CoronaEX Care Training Unit at Charity Hospital of Louisiana at New Orleans $509,381 This project, sponsored by the Charity Hospital in New Orleans which serves the medically indigent, would attack the regional priority of providing medical care to the disadvantaged. Although the application states that LRNP recognizes RMPS' reluctance to approve funding of CCU hardware and architectural renovations, this two-year project requests funds from RMP primarily for alterations and renovations and equipment because state tax funds cannot be stretched to provide the same. The proposal intends to establish a model CCU with a 19-bed capacity. The LSU School of Nursing and LSU and Tulane Medical School would then provide three-week courses for nurses and one-week courses for physicians. This proposal was previously submitted to RMPS in 1968 and withdrawn by the Region after the Review Committee Meeting to strengthen the proposal. Second Year - $36,536 Project #19 - Cardiopulmonary Resuscitation Program $177,016 The Louisiana Heart Association as the sponsoring organization seeks funds to determine the extent of CPR training and the current level of competence of individuals' involved in CPR programs in the state and then to establish a statewide program to train and retrain at periodic intervals such groups as physicians, registered nurses, licensed practical nurses, dentists and general hospital personnel. This proposal was returned for revision by the July 1970 Council because the proposal had not adequately delineated certain aspects of the training program, the previous experience with this activity in the state or certain items in the budget. This proposal would promote subregionalization of health care services (objective #3). Second Year $158,953 Third Year $164,990 DRMP/GRB 12/9/70 DEPARTMENT OF HEALTI-I, EDUCATION. AND WELFARE PU13L[C HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Date: December 14, 1970 Rel)ly to Atitiof.- Staff Review of Non-Competing Continuation Application from the Subject: Louisiana Regional Medical Program, 5 G03 RM 00033 To: Acting Director Regional Medical Programs Service THROUGH: Chairman of the Month Acting Chief, Regional Development, Branph nch Chief, Grants Management Bra Ac'ti'@Cl@ief, Grants Review Branch The Louisiana Regional Medical Program is requesting continuation support for its 02 operational year for core and four projects. Since Louisiana's budget year does not start until March 1, 1971, and the 45-day estimate of expenditures is not due until mid-January, requests for use of carryover funds have not been included in the present application. Therefore., the discussion was limited to general program issues and the following continuation request. Continuation Requested Amount Core 346,777 Project #1 - Training Program for Tumor Registry Secretaries 731447 Project #3 - Office of Research and Develop- ment in Educational Renewal 140,867 Project #6 - Delineation of Medical Service Regions in Louisiana 3,303 Project #7 - Health Career Recruitment Program 63,975 Sub Total Projects $281,592 Total Request $628,369 Besides the continuation request, the Region has included in its AR application, a request for a one-year developmental component, funding of four approved but unfunded projects and six new projects. The Region Acting Director, PkiPS - Page 2 was supported by a funding level of @673,887 during the 01 year. Recommendation: Approval of the committed amount of $628,369 for core and four projects. Staff also strongly urges, that in light of the Region's present constricted funding level and the quality of core staff, that serious consideration be given to increasing this Region's commitment for next year. The following staff members attended the December 4 meeting: Miss Dona Ilouseal, Grants Review Branch Mr. Michael Posta, Regional Development Branch Mr. Lawrence Pullen., Grants Management Branch Dr. Alan Kaplan, Continuing Education Branch Miss Mary Asdell, Continuing Education Branch Miss Joan Ensor., Planning and Evaluation Branch Miss Loretta Brown, Planning and Evaluation Branch General Comments Staff was impressed with the present application and surprised that for a Region which has been operational for less than one year, it had begun to address a program concept so well. The regional goals and objectives are described, as is the regional conceptual strategy and critical health issues. Staff noted that the Region is attempting to address soine of the health care problems of the disadvantaged through its projects based at Charity Hospital. The LRMP has reorganized its RAG during the last year and has added consumer and black representation. The Region provides orientation to each new RAG member. Staff believes that with the new grantee agency, a nonprofit corporation, and the new guidel'ines and bylaws, which states that each RAG member votes on each project, a more democratic and active RAG should develop. Because of the recent reorganization, however, it is too early to tell just how strong it will be. At this point in time, it shows more promise than progress. The regional review process up to the RAG level is strong. Core staff provides administrative review and Ad Hoc Keview groups composed of expert consultants generally from outside the Region provide a technical assessment of the proposals. The Region has included these assessments with the projects, as well as the reasons why the proposals, which the RAG disapproved, were turned down. One suggestion RMPS staff would make Acting Director, RMPS - Page 3 is to advise the Region to describe how the approved projects were changed as a result of the review. Core staff appears hig]-il-y qtiilificd. Although program evaluation efforts are still in the "to plin" tlic, c@v@iltiitor has only just recently been empl.oyed and a methodology has been formal.tz(@(l. As far as data collection is concerned, core in conjunction with the Ref;ion's Epidemiology Committee, has been ver@, idroit in using outside resources and in avoiding duplication of effort. The proi,ram has excellent fiscal guidelines and monitors its expenditures closely. RMPS staff is concerned in the case of Projects #17-,'The Regional Pediatric Pulmonary Center, and #18, A Regional Coronary Care Training Unit at Charity Hospital, which contains large 'equipment and A and R requests, that LRMP staff is either weak in allowing the project applicants to include these items or else is flaunting national policy. In its introduction to one of these projects, however, LRMP states that it is aware of the national trend away from funding such items, but that local need for such units to serve primarily the disadvantaged is so urgent, that the Region wishes it to be considered. In fact, the RAG has assigned the coronary care training project the highest priority. i. The progress on the ongoing projects appeared satisfactory. As for the tumor registry secretary training, project #1, staff was concerned. that the project may be emphasizing tra.l.ning tumor registry secretaries without considering the need for producing better output data for tumor registries. The Office of Research and Development in Educational Renewal, project #3, seems to be operating as a genuine resource for project proposers, as well as for institutions and agencies throughout the Region. Staff was curious about the relationship, if any, between the project's Advisory Council and the Region's Continuing Education Committee. Conclusion: The committed amount of $628,369 is recommended for the Region's second operational year. Dona E. Houseal Public Health Advisor Grants Review Branch Action by Director Initial Date (A Privil.eged Communication) Sli,@,,MARY OF PEVIET@ t,,@@;D CO@ICI,USIOj4 OF January 1971 Review Co,-,iTittee LOUISIANA REGIOINAL LNE@DICAL PROGRAM RM 33 (AR-1-CSD) 2/71. FOR CONSIDERATION BY FEBRUARY 1971. ADVISORY COUNCIL RECO,@NDATION: Committee recommended approval of $400,000 i.b new funding for one year only. ui--Si YEAR CO,@TIFENT NEW FUNDS TOTAL lst Year $628,369 $1.,678,644 $@,307,013 2nd Year --- 1,21-4,216 1,214,2,16 3rd Year 1,193,121. 1,1-93,121. TOTAL $628,369 $4,085,981. $4,714,350 RECOI@^,IENDATION YEAR STAFF COMMITTEE TOTAL ist Year $628,369 $400,000 $1,028,369 2nd Year Contingent on results of 3rd Year site visit CRITIQUE:@, Committee thought that the LR@IP he(l@accompl.ished much during.its first operational year. It has established liaison with a wide variety of groups in the Region involved with planning for or delivering health cake. It has added black and consumer representation to the RAG and is in thi-@@process of reorganizing ongoing Committees which serve the RAG. The revip:v7 process, which utilizes exoerts from outside t he Region to technically review the projects, operates effectively. Goals and objectives, while somewhat vague, are well stated and in consonance with the general, dire ction of R@. Reviewers found,several areas of weakness Lo which they believed the ReRion should devote their attention and efforts during their second operational year. Louisiana RMP -2- RM 33 (AR-l.-CSD) 2/71 Regional goals and objectives need to be further delineated as to how they would improve patient care, and the planning strategy should be developed on the basis of hard data which will show how regional activities will improve patient care. At the present it appeared that the generality of the goals and lack Of Systems analysis in establishing goals would make it difficult for the Region to select or reject as.wel.1 as evaluate program and nrojcct activities. The efforts of the Region's Epidemiology Committee in dealing with the collection of data and the proposed project 15, Louisiana Health Date Information Center, which would C*oordinate date already collected by various agencies in the Region, will help overcome this A cloF.@ y related issue is the need to strengthen the planning and evalu- 6tion capabilities of Core staff. While planners and an evaluator have recently been added to Core stAff, Committee noted that their specific bacl,,groun(,IF are not in tli(-, health care delivery or health planning and administration areas. Reviewers suggested that their exnerience be suo- ,Dler,irnted by outside consultants. Pro ect as well- as pro-rem evaluation buttressed. In conclusion, Committee recommended that $40r),OOO be a(3d,c.,@rl to the Region's funding level for the next year, and tcey stated that these funds could be used to supplement Core, includin- pl.anning and feasibility activities, or fund projects. Whil.e no funds were recommended for future years, the Committee stated that funds iioul.d be approved contingent on a satisfactory showing of progress at a site visit when the Region's triennial application is submitted. Projects were not individually. Committee recommends that Council@ look at Project lk9, the Metropolitan Organ Ban!< which has been previously approved by Council but not yet futi(lorl, with the kidney projects submitted by other Re-I.ons, RMPS/GkB 1/1,5/71 's 9 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) Maryland Regional RM 00044-03 (AR-1 CSD) 2/71 Medical Program January 1971 Review Committee Suite 201, 550 North Broadway Baltimore, Maryland Grantee Agency: Johns Hopkins University Program Coordinator: Edward Davens, M.D. 03 year 04 year 05 year 3/l/71 - 3/l/72 3/l/73 Total Purpose 2/28/72 2/28/73 2/28/74 All Years Continuation* $2iO77,883 ----- ---- $2,077,883 Commitment (Core including Epidemiology & Statistical Unit) (808,161) ----- ---- (808,161) 16 Projects (1,269,722) ----- ---- (1,269,722) Additional Components 10363,149 $1,045,401 $1,062,775 3,471,325 (Developmental) (1009000) (100,000) (100,000) (300,000) (4 New Projects) (1,263,149) (945,401) (9629775) (3,171,325) Totals 3,441,032 1,045,401 1,0629775 5,549,208 * Staff Action Commitment2,077,883 Committee Action Required 1,363,149 1,045,401 1,0629775 3,4719325 Funding History Planning Stage Grant Year Period Funded (d.c.o.) 01 I/l/67 - 12/31/67 $438,106 02 1/l/68 - 2/28/69 678,182 Maryland RHP -2- RM 00044-03 (AR-1 CSD) 2/71 Operational Program Council Future Grant Year Period Approved Funded (d.c.o.) Commitment 01 3/l/69 - 2/28/70 $2,294,177 724,360 Core ------- $1,208,523 Projects 02 3/l/70 - 2/28/71 2,314,535 784,556 Core ------ 1,420,101 Projects) 03 3/l/71 - 2/28/72 2,350,115 ------ $2,077,883 04 3/l/72 - 2/28/73 145,000 ------ 145,000 (#19 only) Includes $251,417 Carryover funds Gpograpby: The Maryland Region includes the State of Maryland without Mont- gomery County (where the patient flow is traditionally into the District of Columbia) and York County, Pennsylvania. Demography: Ponulation @.4 million a. Uri@an 71% @. White 91% Facilities: a. Johns Hopkins University School of Medicine Enrollment 150 b. University of Maryland School of Medicine - Enrollment.367 Physicians: a. Medical Doctors 5,450 (1965) b. Doctors of Osteopathy - 20 (1965) Program Priorities 1. Continuous determination of needs through a well established RMP Enidemiology and Statistics Center. a. Consumer needs - extent and characteristics of di.seases and health nrolilems. b. Providers of service - adequacy and distrittition of facilities and health manpower to deal with consumer needs. Maryland RMP -3- RM 44-03 (AR-1- CSD) 2/71 2. Review and encouragement of innovative. models for health care delivery, including primary heal.th care. 9, To identify promising experimental efforts and disseminate knowledge about collaboration among the directors of the new orogrems. b. To identify geographic gaps in health care service and encourage development of organized services to fil.1 the gaps. Strengthening of Central RMP Core Unit, as well. as support of innovative projects in the del-ivery of health care will be necessary to accomplish the priorities above. 4. Continuing Education 5. Expansion of inter-agency and inter-institutional cooperation. 6. Review and evaluation of ongoing operational and new projects. Review Process The review process includes: review by staff; examination by the Epidemiology and Statistics Committee to assure that objectives are clearly defined, methods of achieving these objectives identified, the data collection process is appropriate and the methodology for directly evaluating each project in terms of its achieving its own objectives and in terms of its relationship to the overall Program is established. Following this, the review of the Epidemiology and Statistics Committee is passed on to the scientific Advisory and Review body. When finally approved, the project will pass on with both the evaluative and the scientific Advisory and Review Committee's review to the Regional Advisorv Group for final approval. Regional Advisory Group The ?.@-v6ting member Regional Advisory Group has been broadened by adding six new membprq to fill. vacancies. Three of these are llack one from the field of ntil-lic hpalth, an obstetrician and one is involved in the field of social services for the disadvantaged. Three vacancies were filled during the October 16, 1970 meeting. These include the Director of Baltimore Model Cities Agency, a consumer representative from the Eastern Shore of Maryland, and the Executive Director of the Maryland Compr(@hensive Health Planning Agency. Two medical students (one from each School of Medicine) have been added at non-voting members. The RAG meets ten times a year. Administrative Committee - This Committee is composed of the following ex-officio members: Deans of the two medical schools; Dean, Johns Hopkins School of Hygiene; Commissioner of Health; Coordinator of RMP; and Chairman of the RAG (without vote). The functions of the Committee are to: 1) appoint the Coordinator; 2) make final decision on all administrative matters; 3) appoint members of the RAG; and 4) establish policy for administrative operation. Rm 4*.,Ol (AR-1 CSD) 2/71 Maryland RMP -4- Other Committees -The RegioTf has seven categorical committees: Heart, Stroke, Cancer, Epidemiology and Statistics, Continiiin,@, Education, Kidney and Pulmonary. History of Regional Development Based on a series of preliminary planning conferences during 1966, Dr. William Peeples, State Commissioner of Heal.th, Dr. Thomas B. Turner, Dean of Johns Hopkins lAndical School, and Dr. William Stone, Dean, University of Maryland School of Medicine, a Regional Medical Proaram Steering Committee was fo rmed composed of three representatives from the Johns Hopkins Medical Institutions, the University of Maryland Medical School and the Maryland State Department of Health. This Committee served as the overall Coordinating Committee for the Maryland RMP. The representatives on the Steering committee of each cooperating institution were selOcted I,-v and served at the nleasure of the Gox,ernin?, 'Boards of their respective institutions This Committee appointed a 6 man Fill--committee on Planning, oho was given the responsibility for developing the application for a planning grant. An advisorv Group, composed of representatives of the official and voluntary health agencies, the public at large, medical society, etc., was formed. Dtiring 8eptemlier 1966, the Maryland Regional Medical Program submitted its first planning grant which was approved with the following conditions: 1. Clarification of fiscal. responsibility for the grant; 2. Assurance from applicant of legality of the responsibility of administering the program; 3. Clarification of the responsibilities of the hospital administrators and staff, as well as the listed eleven professional people; and 4. Statements as to how the integration of the components of the three participating organizations will be effected and managed. The first year planning award was for the period of January 1, 1967 - December 31, 1967. During the initial planning stages of the Maryland RMP, Dr. William J. Peeples, Chai-tman of the Steering Committee was the Program Coordinator. In March 1967, Dr. Thomas Turner, retiring Dean of the Johns Hopkins University School of Medicine was appointed as Program Coordinator. In March 1967, staff considered a request from the Region for the second year to continue Core planning activities. Staff felt that although overall progress in this program during its first year had been modest, definite accomplishements had been Achieved in the areas of (a) recruitment and organization of Core staff, (b) the development of a functional decision- making process which involves the RAG and appropriate planning Committee, (c) the stimulation of Coonerative relationships with Community hospitals, and (d) the delineation of regional boundaries. Staff recommended approval for a second-year planning grant for the period January 1, 1968 - December 31, 196P. Also, during the second year of planning the Region received approval to initiate six feasibility activities in the following areas: Epidemiology Maryland RMP -5- RM 44-03 (AR-1 CSD) 2/71 and Statistics, Evaluation of Continuing Education or Medical Care, Heart, Stroke, Cancer and Continuing Education. Dr. William S. Spicer Jr., was appointed Acting Coordinator during January 1?6?. In August 196P. the Region submitted a planning renewal request for the sunno-t of A Central Core Administration and seven other planning units. Also s,i-- mitted was the first year operational grant application which inclueer; 1, operational projects. A site visit was made to the Region in December 1968, to review the planning to date as well as the request for operational funding. The site visit team was impressed with the "vigorous" leadership which the program coordinator had provided, and had r?cruited and organized what appeared to be a very competent staff. It was the recommendation of the team that the Core planning renewal be maintained at approximately the current level funding. The teams impressions of the operational application were generally favorable although there appeared to be a significant service orientation. In addition, some of the activities sponsored by the medical schools did not clearly refl.ect active or intended outreach to the broader community. The team concluded that this was a viable region prepared to mount an operational program. The team recommended approval of $1,511,81.2 for 14 of the proposals. The January 1969 Review Committee recommended a level of funding at approximately half the amount recommended by the site visitors. Because of the disparity between the recommendations of committee and the site visit team, Council appointed a special Council referee committee to restudy the entire back- ground and application materials and recommend a level of funding. Following negotiatio@with the Region in March 1969, the Region received an award which included $742,360 (d.c.o.) Core activities and $1,208,52? (d.c.o.) for 11 of the operational proposals, a total of $1,932,8P3 (d.c.o.). In November 1, 1069, Dr. William S. Spicer resigned and Dr. Wm. Peeples former commissioner of the Maryland State Department of Health was appointed Pro,-,ram Coordinator. During February 1970, staff considered a request from the Region for the second operational year for the continued support of Core Staff activities and 1.@ ongoing projects. The request was composed of a total of $1,93/-,FS2 from Committed funds for support of Core staff activities ($7?P,521) and $1,20/4,@5q for the 11 onvoing projects, and a portion of funding ($?I,"iti2) to initiate approve but unfunded project #19 - Tisstic Typing Laboratory. Alro included in the request T,7as a total of $]P,7,656 from unrxnen(led ftintlg foi- the extension of two projects and additional funds for Project #19 (al-.Ove). Staff was Disappointed with the Region's nrofress and expressed the following concerns: 1. The anplication itself was uncoordinated and did not reflect any degree of organization. 2. The progress reports were prepared at an early date by the Region and as a resul.t, reflect meager resul.ts. Maryland RMP -6- RM 44WD3 (AR-1 CSD) @/71 3. it appears that little coordination exists between the various institutions with dore staff, and less coordination exists among the projects and their staff. As a result,. it was difficult to arrive at a firm judgement about how much progress had been accomplished during the Region's first seven months of support. However, no information was presented within the application which would justify disapproval of any of the components. Staff recommended approval as requested and further recommended that a program site visit be scheduled in early June 1970 with a member of Committee and Council and DRMP staff to explore the intrarelationships of the core staffs with projects, as well as the degree of coordination among the various core components. Listing of Current Funding Status of Core and Operational Projects in Maryland RMP. Project Amount supported Number Title through 2/28/71 no Core and Administrative Staff Central- Unit $218,960 Johns Hopkins University 98,271 University of Maryland 123,751 State Health Department 34,011 Epidemiol.ogy and Statistical, Unit 239,092 Clinical Cancer Program 3,220 Continuin- Education Feasibility Study York 17)946 Cancer Feasibility Study 1-2,000 Oral Cancer Detection 12,392 Symposium on Pulmonary Disease I, 013 Pulmonary Function Study 16,400 Conference on Delivery Medical Care 1,500 Maryland Hospital Education and Res. Education 6,000 CORE SUB TOTAL $784,556 1 Continuinp, Educational Program for Peninsula General Hospital 17,550 2 Development and Eveluat+on of a Comprehensive Technical Screening Program for School-age Children of Low-income Families - University of Maryland 76,816 Early Detection of Cardiac and Malignant Disease in Pre-school Children - Mercy-Hospital 24,173 4 A Program for Mass Detection of Heart Disease in School Children - Baltimore City Hospital 22,54" 1) Early Detection of Heart Disease in the Newborn - Johns Hopkins 20,000 Maryland RMP -7- RM 44-(.)3 (AR-1 CSD) 2/71 Project Amount supported Number Title through 2/28/71 7 Coronary Care Program A) University of Maryland 79,700 B) Baltimore City Hospital 21,846 P'. Closed Chest Cardiopulmonary Resuscitation Maryland Heart Association 38,000 0 A) Acute Stroke Unit - Johns Hopkins 118,618 B) Chronic Stroke Unit - Baltimore City Hospital 179,821 10 Acute, Intermediate and Long-term Stroke Care - York Hospital 145,596 11 A) Proposal on Stroke - University of Maryland 138,8lq B) Pronosal on Strol@e - Nursing Education University of Maryland 42,555 C) Proposal. on Stroke - Rehab. Nursing Montebello Hispital 61,714 12 Proposed Coordinated Discharge Pl.anning Program for Wicomico and Somerset Counties - Wicomico County Health Department 15,083, 13 Regional Medical Program for Outpatient Strokes Deer's Head Hospital - Salisbury 1,8,51)tt 14 Demonstration and Training Program in 163,653 Rehabilitation of Stroke Patients - Sinai Hospital 16 An Ambulatory Program for Comprehensi-v(, Pulmonary Services - Maryland General Hospital 90,0')O A) Tissue Typing - Baltimore City - Johns Hopkins 83,1/@7 B) Tissue Typing - University of Maryland l')],r)53 TOTALS $2,204,65@ Incltj,'e8 $251,417 Carryover March 1970 Committpe/Council recommended that action on a November 196P Supplemental Operational Application be deferred pending the site visit. This November Application contained the. following proposals: #2'i - Position of Director of Continuing Education - Anne Arundel General flogri ta I . it?5 - Comnrphpnsive Sti-ol.,r, Prol,,.ran - Prince Geor-ge's General. Hospital ,Maryland RMP RM 44-ni (AR-1 CSD) 2/71 els #26 - Stroke Rehabilitation Program in the Home and in the Prince Georg County Health Departmetit Rehabilitation Clinic #27 - Management of Intestinal. Stomas - Baltimore City Hospital.s (The site visit was conducted on May 11-12, 1970) The site visitors found that the RMP had bumped along, grown and evolved schools. largely through the strengths that pre-existed in the two medical It was apparent to the team that there are too few ful.1-time neople on the Central. Core Staff and that they have found it difficult to guide, or in fact, counteract the strengths of the schools. Recommendations both to add funds and rebudget funds from institutional cores were made by the site visitors, and accepted by the July 1970 Council, which should strengthen the central core, not in an attempt to subjugate the Medical Schools per se, or to destroy their roles in the creation of more programs, but to help give the schools directions which may be something other than the traditional ones the schools Osually take. Also, whil.e large core staffs are partially supported in both Hopkins and Maryland, these appeared to the visitors to be little concern for developing interrelationships between the various program components. One of the overriding probl.ems in this region is the rapid turn- over of program coordinators. The present coordinator, Dr. Edward Davens who'bep,an on July 1970, is the fifth Coordinator since this Region @egan its plannina phase during January 1967. The Region has received approval (unfunded) for the following nrojects: Projects #25 and #26 Combined - Comprehensive Stroke Program, Strol,-p Rehabilitation; #27 - Management of Intestinal Stomas; and, #."I - RheijrTintic Fever Prevention. Present application: This is a reqtipst for four new proposals qn(i a developmental component. Nct@l Proposals #12 Contindine Education Program for Hartford Memorial Hospital 03 R(,qti tin I/l/71 - 2/28/72 Direct Costs $33,909 The Hartford Memorial Hospital, Harve de-Grace, Maryland is requesting a ,;t,lpnlemental salary to employ a full-time Director of Continuing Education in addition to a secretary to assist him in his duties. The Director of Continuinc, Education will. participate in the Maryland RMP seminars and forLinis for Directors of Continuing Education in order to lead the hospital more effectively to an expanding standard of excellence, become acqt.tqintpd Keith expert consultants in various fields, and establish channels for rapid Maryland RMP -9- RM 44-03 (AR-1 CSD) 2/71 acquisition of materials and advice. He will have an active role in the many functions related to quality of care review, and will. assume responsibility for coordinating various programs within the hospital in consultation with the chiefs of Service, relating these programs to the individual physicians and servina as liaison officer with the teaching Medical centers and surrounding health care facilities. He will arrange and moderate conferences, lectures, scientific sections of staff meetings, and assist with departmental meetings. In addition, the DOCE will assist the staff with specific Problems regarding diagnostic and therapeutic procedures an(] will orvanize seminars for nursing and other paramedical personnel with emphasis on updating their education. He will have the resnonsibility for developing appropriate tpachin"- loarning materials where none exist and in cooperation wi.tti the librarian, u,ill supervise the needs of the Library. By employing a Director of Education, the applicant states that the Hospital will have a more direct method of assuring itself that good health care is being rendered to its patients. The DOCE will be responsible professionally to the medical staff and its Executive Committee, and Administratively to the Board of Directors and the Administrator. The Objectives of the project will be to: 1) assist the Staff, Administration and Board through the development of structured Continuation and Reparative Education activities as part of the physician and hospital daily activity; 2) continue to arrange for cooperative educational health care activities with surrounding smaller community hospitals, clinics and extended care centers; and 3) provide for inservice training for the Directors of Continuing Education as well as continuing education for the Staff. #33 - Comprehensive Regional Approach to Education and Therapy for Chronic Renal Failure 01 04 05 Requpsting I/l/71 - 2/2,8/72 I/l/72 - 2/2?,/73 '1/1/71 - 2/2P/714 All years Direct Costs $1,101,662 $850,178 $P68,002 $?,Iz,20,042 The Primary purpose of this program is to expand existing facilities to provi(!e an effective form of therapy for Patients with irreversible renal failure. Currently, some 10 patients are being maintained on dhronic (Ii.alysis through four hospitals, and only 12 renal transplants have been Performed in three of these institutions. The objectives of the project will be: 1) increased dialysis and transplantation capabilities within the cooperating institutions as a demonstration of patient care. Wi.th current staff and space, maximum Iialv,;is facilities are: Baltimore City (10),Jolin,,q Hopkins and University of Maryland (4), the total number of Patients on dialysis at one time t-eini@ 22. Thi.s project calls for expansion of facilities in some hospitals and initiation of program in others. Home training programs will be (levfloperl at Baltimore City, Maryland Ceneral, and Sinai Hospitals. Maryland RMP -In- RM 44-03 (AR-] CSD) 1 2/71 Anticipated facilities are: Baltimore City (10), Good Samaritan (16), Johns Hopkins (8), Maryland -General (6), Montebello State (4), Sinai (4), and Maryland University (8). The total number of patients on dialysis (in- patient) at any one time would be 56. It is also estimated that 25 natients could be moved to home dialysis during the first year. The Programs at Baltimore City, Univ6raity of Maryland, and John Hopkins will accept patients from other institutions for Renal transplantations. Montebello will provide a service for patients from inaccessible areas of the Region awaiting Cadaveric transplantation. 2) Development of adequate referral systems for patients in need of treat- ment. Referring @hysicians may contact any of the cooperating institutions for evaluation of their patients. Based on the availablity of an opening the patients will be accepted for evaluation directly or referred elsewhere. 1) Training of physicians, nurses, and technicians in the referred specialized technique for care of individual patients locally and throughout the Region. Training opportunities will be provided for full-time physician trainees in the Departments of Medicine, Surgery, Urology or Pediatrics of the various hospitals, and for part-time community physician trainee who can acquire srecial skills in patient management which will be applicable in their own "ractice. Fellows will be assigned to the program from one to three years end will be given major clinical responsibilities as their skills an(] knowled?,e arlv@ince. Experience will be provided in the management of patients on chroni.c fien)o(lialvsis, and during all phases of renal transplantation. They will also be trained in renal Tihysiology and transplantation immunology. Ilurses will receive training in the basic principle of disordered renal physiology and the management of chronic renal disease along with the management of clinical nroblems specifically related to dialysis and renal transplantation. This will be eone through lectures and practical clinical experience. Technicign traininginvolved through familiarization with the central dial.ysete dispensing Equipment individual delivery systems and maintenance of all dialysis equip- mpnt. A) Encouragement of the development of additional facilities in other insti- tLItions throughout the Region by means of an Educational Program. ';) Evaluation of the economics and efficacy of the various treatment forms used and the feasibility of the entire program. @lethotis of evaluation inclutle mont'nly Pt-etinps of (iiqlysis directors and transplantation team members to evaluate the status of each p@itient in track nroc,rem and to discuss educational progress. An the home program momentum and as physicians, nurses and technicians enter the cent(.,rs for trainin?, periods, their liro,(,,ress will l,e evaluated. Economic factors and therapeutic results will be periodically evaluated and comparison made amoni.,, type of treatment. The Region states that this program in Renal disease is FL111V congruent with thp Maryland RMP's objectives an(] will be the framework for the Region-wide system of continuing education. Maryland RMP -II- Rm 44-01 (AR-1 CSD) 2/71 #14 - Regional Oncology Affiliation 03 Requesting 3/l/71 - 2/28/72 Direct Costs $6F,905 The nurnose of this proposal is to establish a continuing association between the Johns Hopkins Oncology Center and an increasing number of Community Physicians and hospitals to provide a clear demonstration of modern multi- disciplinary care of cancer patients and continuing post-graduate training in clinical oncology oriented about existing patient management problems. A basic goal of this Proposal is the creation of an organization throuch i4hich Physicians can work together in a cooperative way to improve their capabilities in caring for patients with cancer. Full-time telephone coverage ioill be provided so that patient problems can be handled as they arise and questions can be considered while they are fresh in mind and clinically pertinent. Rapid access will be provided to ambulatory patients for compre- hensive diagnositic evaluation and multidisciplinary consultation. A specific Panel of specialists will serve this purpose. If treatment is require(] and cannot be administered by the referring physician, this will be provided by the Center staff. Where required, prompt admission will be provide() for patients needing @'najor diagnostic and treatment procedures. Continuing Education is also a basic goal of this proposal. The Johns Hopkins Oncology Center will provide the organization and supervision necessary to create a Productive program. The major emphasis will be directed toward clinical application. The initial thrust of the professional education proq 'll be directed along the channels of Patient referral. Inquiries ,,ram vii about specific problems will be answered promptly, but later will be repeatedly followed up by brief newsletters or references to new developments in the specific area of inquiry. Regtjlarl!v scheduled visits to affiliated community hospitals will be marle for the purpose of clini.cal consultation of Tiost@raciiiate education. The Stan(-Iar(i methods of bedside teaching, presentations at staf f ro(inrlr an(] @pecia seminars will be employed. An annual two or three-day oncolopy course will be provided bv th,- Center. A fully automated comTiijter-I)aserl rpco-rel and communications will be Ieveloned at the center for the purposes of: 8) cli-niral-(,(Iitcatioiial communication; b) evaluation of current management I%ractices7 c) Program evaluation; and d) program planning. The applicant states that it is expected that the annual Course Will IleCOM(' largelyself-sut,porting after the first 3 years and some future support of the educational acznect@ of the program can be expected from the participating hospitals. Wnenever possible professional fees will be collected by the University from patients in the program and will be applied to the costs of the Troject. Maryland Rig -12- RM 44-03 (AR-1. CSD) 2/71 #35 - Home Care Program communi@Health Center - Bon Secours Health Center 03 V.+ UD T'@eqtlested 3/l/71 - 2/28/72 3/l/72 - 2/28/73 3/l/73 - 2/28/74 Direct Costs $66,673 $66,673 $66,673 This proposal for a Home Care Program,an activity of the Bon Secours Community Health Center,will be under the auspices of the Bon Secours Hospital Inc. The principal objective of the Community Health Center is to provirle the basis for a more efficient way of delivering health care - botn quantitatively and qualitatively to a Population of over 20,000 persons in West Baltimore. Initially, the Community Health Center will tal,.t- care of 5,000 persons. It is proposed that the Community Health Center will. try to develop a stron;,, and @,r@r,i broad aml,ulatory an(] home care program to aim at: a) avoiding unnecessary hospitalization b) implementing early hospital discharges-, and c) practicing Preventive medicine to improve the community health standards. Thd Community health center will provide comprehensive heal.th services based on family iinits and will try to coordinate all the heal.th facilities fbi-the area for the t-enefit of the community. It is estimated that about 33% of the nopulation of the Bon Secours Hospital area is under age 15, and approximately 11% is over age 65. Based on these figures and on the experience of other home care nro-rams. it is estimated that for a population of 5,000 the Health Center will make annroximately 80 nursing visits per month for reasons of chronic sicl-,,iiidri.,i (city) 91 ArljitE,,to,-i Co., Va. 163 Fall,, (;Iilircli City, Va. 10 Fairfax Co., Va. 275 Percent U):I-)an: I.,Tnf,,Iiingtoii, ]).C. Alexandria, Va. Falls C,,iurch, Va. iooz, Fairfax Co., Va. 7 8/, Ifoiitgoitir--ry CC). , Md. 8 6/@ Prince CLoroe's Co., Md. 83-/, Ap,e o o tiLitioi-i: (1960) Maryland Virginirt Median U.S. D.C. Mont. Co. Pri-ncc- Al c!x. Arl. ],-aii- f ax. Age 29.5 32.2 28.1 25.2 28.0 30.8 2zi. 5 I\Iumber PC-,],Ccllt (in thousands) Total 12 6.2 65 yrs. of age and over D.C. 7 9.1 Mont. Co. & Pr. Gco. Co. 3 4.4 *Vii-,,),i.nia 2 4.1 *Represents Alex., Arl., Co. & I.,airfa@: Co. METRO DC 7 RM 31-04 (AR-1 CDS) 2/71 January 1971 Review Committee Tot,al 498 25.2 C. 419 ')4.8 l,'@ont, C(". 13 3.9 Co. 32 9.1. 9 5.6 5.4 @l(,,7, (,7'/ of poj)ii L (-)-ii ()j'- 1). oi'- 1 1-1 I tj I i -i 271.,(@)0,0 111-@)(I 01 el i c: 1, S cl C) o I Eii o I I i ii, t ii i li (I cl I . II 1. I @l! if@! i-j 'i@ 0 G o r,, e tjlliv. 8 7 3 Y led. - I w 11) i c o c@ @,i i'. @'L c@ (@l Tot-zil. Are 'I II. 4 3 1).C. @i of 2 Otli(:r of Cy o c@(@iiiio I op,.@, J) C. I ,)Ii i (@l i i s tlnj.v(t 17@; -1.1-y af.fi. I i tiA I @, : II o n - I @'e (I (, r @ i I 'i,ot, I 1. S h C) -r J,O)-I"" S I I o r l,o3i'@-, No ii - 1) C. @l@l 2 1 3 8 3 1 1 V"A @4 - 4 5 11, C) Li 23 5 28 January 1971 Review Columittee PROGRAM HISTORY AND DE-VELO @,\T The Regionts first year of planning was a 14 month period 1/l/67-2/28/68 and was supported at $188,000 (d.c.). In February 1968 a pre-operational site visit was conducted to the Region. The site visit tean consisted of George Miller, M.D.; Leonidas Berry, M.D.; Mieczyslaw Preszcynski, M.D.; Martha Phillips, RMPS Staff; Patricia McDonald, RNPS Staff and Dr. Thomas Bodenheimer '@S Staff. The site visitors were impressed with the wide range of individuals, groups and practicing physicians that appeared to be actively interested in the program and who attended and participated in the opening session ot the visit. The D.C. Medical Society appeared to be coffimitted- to regional systems. Representation of Allied Health groups and nursing groups on the RAG was lacking and it was noted the Region had difficulty getting individuals who are not in medically-related fields to participate in the program. The site visitors commended the active involvement of the RAG and the extensive guidance and review it has given to the development of the program. It was felt the Region was aware of the.need to cooperate with adjacent Maryland and Virginia R@Ts. Concern was expressed @hat'plan'ning was being done for individual projects without interaction among them. It was noted, ho@,:ever, that this was probably due to insufficient staff to provide the necessary coordination. Although organized planning for the Region, local priority setting, and identification of regional strengths an---' needs had not been yet approached,the site visitors concluded tle D.C. program was moving in the direction of truly regional coordination and that it would continue to be strengthened by the time t-e program was reviewed at the close of The site visitor the first grant period. s endorsed the readiness of the Region to move into the operational phase of the program. Committee and Council co.-c-,:rred with the site visitors recommendation and the Region was awarded $241,642 (d.c.) for planning and $350,506 (d.c.) for support of three operational projects, both for the period 3/l/68-2/28/69. On September 1, 1968 A@-t'iiur 14entz, @NI.D. replaced Thomas Mattingly 7 L- -year as Program Coordinator i February 1969 Staff reviewed 02 continuation application. It was noted that some stage in the local management process caused an unexplained delay in notifying project directors that they cou'Ld start their projects. In addition other severe administrative difficulties were evident from some questionable handling of other fiscal- aspects of the program. It was also recommended, in addition to staff's --@-co-,mendation to continue support, that appropriate staff visit -.-e Region to review its procedures for program administration. On March 6, 1969,Grants Management Personnel of It'@S visited the Region and succeeded in resolving many of the fiscal. and policy problems which were noted in the February Staff Review. Metro D.C. 9 RM 31-04 (AR-1 CDS) 2/71 January 1971 Reviev Committee During the 02 year of operational status, 3/l/69-2/28/70 the Region was awarded a total of $1,400,416 (d.c.), of this, $554,908 (d.c.) supported Core and $845,508 (d.c.) supported nine operational projects. As a result of concerns expressed by Committee and Council, regarding supplemental applications, during the August 1969 review cycle, a site visit was conducted to the Region in October 1969. The site visit team consisted of John Thompson, Chairman; Russell Roth, M.D.; Victor Vertes, M.D.; William DeMaria, M.D.; Walter Hangen, RNPS staff, and Michael Posta, RMPS staff. The visitors observed that the Washingtoq program had not as yet achieved any real statement of goals and 'objectives, and consequently was unable to set priorities in any ki'nd of rational fashion. They found it difficult to judge the projects in light of the overall problems of the Region or the projected program of the Region. The only way tt@le goals (which were really"areas of concern) were used, was to classify the individual projects as they were submitted into one grouping or another. Concern was expressed with regard to the separate organization of a post- graduate medical "faculty" within Core and outside the formal university setting. This activity was actually being carried on under the Hospital Council and there was no indication of how the educational effort of the projects would relate to the organization or center. The team concluded the D.C. RMP was moving slowly and continued to have ver real problems in establishing its own identity. y It was felt,however, the reorganization and formalization of the RAG will assist them to do better planning. In February 1970 Staff reviewed the Region's continuation for the 03 operational year (3/l/70-2/28/71). Staff agreed the application was the best yet submitted by the Region and that it seemed to reflect the leadership provided by the coordinator and his struggle to accept advice from RMPS and outside sources. The following issues were raised and the Region was asked to respond to them. 1. A plan of action for coordinative RMP planning and operations with health programs for inner-city populations, including model city, comprehensive health planning, health department and OEO programs. 2. A plan of action for increased involvement of inner-city representation in RMP planning. 3. An outline of procedures and time schedule of RMP priority committee. 4. A substantive description of activities of Continuing Education Staff working with the Hospital. Council, including a list of hospitals for whom DME support is provided and the basis for support. 5. A plan of action for approach to overall health manpower planning. L%r& -)L-Vl+ kAn-.L %,UO) ZI/L Metro D.C. January 1971 Review Committe4 In May 1970 the Region responded to the questions posed to them. In its review Staff observed that this Region has not made a significant contribution to planning for inner-city. With the exception of a number of funded RMP projects, few examples of specific achievements or plans could be cited. Although the Associate Coordin- ators at the universities were apparently charged 'with the responsibility of cooperative planning, they saw their role as being more " involved in the structuring of projects which reflect the institution's concept of their appropriate role in RMP activities"; a philosophy which is more consistent with the type of program that has evolved from this Region. T.he Region also cited as evidence of inner-city involvement and cooperative planning, the fact that twelve agencies which theoretically represented the inner-city were represented on the RAG. Staff questioned the degree to which these representatives were active participants, noti-.ig none served on RAG sub-committees. This review re-emphasized a second concern which various numbers of staff had harbored for quite sometime, namely the almost complete separation of the Center for Continuing Education with the Hospital Council from Core staff activities and management. It was noted- the Center's activities closely coincided with those of the Council in that they were hospital-oriented and for the most part catered to short-term needs, with little thought of cooperative planning on a long"ter-m basis with various kinds of education institutions at all levels. This observation was borne out by many activities and in particular the manpower surveys reported by the Region which focused just on employment needs of hospitals. Another concern of Staff was the fact that there was evidence the Center was instituting educational programs which were not only of questionable value, but also served to undermine established programs. In view of the concerns expressed regarding both the planning for the inner-city and the course pursued by the continuing education center, it was agreed some kind of strategy to help the Region change these aspects must be employed by Staff before the Region submits an application for Anniversary Review. The Regionlas a result of RMPS Staff's efforts to assist, has'taken steps to re-organize Core so as to strengthen the continuing education aspect of the progra,-,i. Attempts to improve the staff concerns about the inne-r-city have resulted in the formulation of the Health Care Delivery Planning Committee which serves as a horizontal group composed primarily of Blacks who have specifically dealt with the immediate health needs of the disadvantaged in the center-city. Further, attempts to improve the organizational structure have resulted in the proposed Office of Program Planning, Office of Community Health and Program Activities and the Office of Program Appraisal. Metro. D.C. r@,T@t 31,-04 (AR-1-CSD) 2/71 ION CORE STAI'F total amount requ sted for fir@t year of the triennium The c I beginning March 1, 1971 for of Cc)r@., activities is $766,269. This total represents a continuation req,,ie@@t for $571,201 committed support and a supplemental request for $195,068 of additional funds which would provide su-port for 10 new professional. positions to Core staff. In addition to this first 7)7e r the Region is also requesting renewal of Core for the f,"?'@1)20,000) and third ($870,000) years of the Triennium. The 10 new positions being requested would raise from thirty t@ forty the total number of Cor@--@ Stzq.,!'f positions, Of the present 30 positions allocated to Core, 24 arc-,, STRATEGY AND GOTI,S The Region's overall pro,@E,Iram objective ]@s "'co on increasing the Region's capability f@,@r @jc,ovi(iing outpatient, and preventive health and medical care services in liecirt- cancer, stroke, kidney disease and related disease to all. the citizens of the ReE,,ion." Each categorical planning ti-@,tmiiittee hills certain identified areas of emphasis: 1. Heart Disease Plinaing Committee: a. Program emphasis should be directed toi,,ai-d keeping private physicians of developments in the cardiopulmonary area. b. Out-of-hospit,,! progrE@.i,,i,,, for the patient aimed at primary and second,,iri;, prevention through early recognition and I improved diagnosis should be supported. 2. Cancer Planning Cr,@,@,itL:ee: a. Start activities in fields of public information, patient ediicati.or-@ Hand prc)fcss,(.c)n 1, I:ral.ning. b. Promote early screenir.@g and detection procrams r@ for those tumor sites which lend themselves to this approach. 3. Stroke Planning C,o-r,,uittee: a. Institute a placement center to assist patients and physicians in locating e@cterded. care, ambulatory and rehabilitative services. RM 31-04 (AR-CDS) Zfll METRO DC January 1971 Review Comittee SOCIETY OF THE MEDICAL DISTRICT- OF-COLUMBIA POLICY AND STEERIFIG ..-CotlniTTFF PLROGRAM COORDINATOR MEDICAL DAT intelligence oi egion's xpressions of Need.. Health Car ANNING COM Assessi ds PR[ ORITIES COMMITTEE Areas of Emphasis PROGRA@ GOALS f Criteria or Activities EGIONAL DVISORY R(IIIP Evaluation of Goals erms of Region's Needs als Do Not Meet Needs Goals, Meet Needs Goals Partially Meet Needs REGIONAL MEDICAL PROGRAMS SERVICE Federal Review METRO DC 12 RM 31-04 (AR-1-CDS) 2/71 January 1971 Review Comittee b. Establish consultative services based on cooperative relationships among local institutions to upgrade the quality of stroke care in hospitals and extended care facilities of the region. 4. Renal Disease Planning Committee: a. Coordinate dialysis facilities within the Region to evaluate the capacity of the coordinated facility in delivering this therapeutic modality. b. Develop financial coordination to provide permanent funding for services through third party carriers and publJ.c assistance. 5. Other Major Diseases Planning Committee: A. Improve diagnostic and screening centers which would provide broad support for comm6nity health act v t es. b, Develop a lead poisoning control prog-.c,,3m. 6. Education and Training Planning Comm).tte@,,, a. Coordinate existing educational pyopr,-ms. b. Improve efficiency and effectiveness of in-service education and training. 7. Health Care Delivery Planning Committee: a. Make effective use of existing and acquired facilities, funds and personnel., b. Design programs to improve quality of tteal.tq cL@re delivery in the Region. 0. HE14, Ptl-,, li@',-P.SA 0 Regional Medical Programs Service 0 C9 > N Medical SOC4ety o' the L T)istrict of Columbia Regional Advisory Group Policy and Steerin Committee Plann Pr4-oritv Com-mi@tee ing, and S ,%ft.@'14P Program Coordinator Admini-s@ra t4 ve Deputy Program Coordinator Coordinators @'or an Categorical Disease -Irozra7,s F4,scal Assoc. Coord'Lnators for Co=un-'@cat4ons I.'Jtl-L. Depts. and LiosT)ital Co@-'!C"@ and Piibl4.c information 'Ith Olfce of Hea Development: Continuing Educ. foi@ P'.ivsic-'-ans Office c. Office of Conti uin- Educ. for Program e ot Of -ILic n conmullitv Program Planning Allied Hlth. Educ. & Tri@' Healtl,i ane Appraisal !'o;7ereiice Resotii-ce Progri-q Act' 4 es Policv 0 KETRU Du - L-V - %---- ---, -, @ - .REVIEW OF ACTIVITIES jasuary 1971 Review Committe STATED PROGRAM G0ALS HEALTH COMMUNITY STATED CRITERIA )Iicited Unsolicited FOR ACTIVITIES roposals Proposals PROGRAM COORDINAT CORE NNING STAFF IAMITTEES GUIDELINES A I I EVALUATION, OF PROJECT, Rejection Meets Goals as not meeting the Fulfills Criteria RAG Program TECHNICAL ASSISTANCE COMMIITEE Te hnical Review li Technically Adequate Needs Technical Revision PRIORITIES COMMITTEE Ordering ctivities in Terms c Goals, Criteria & Funding TOTAL PROGRAM 00 IREGIONAL ADVISORY GROUP REVIEW 0 TOTAL PROGRAM Difference of Not Financially Program Opinion with Feasible Does Not Committee on Meet Goals Program goals met, Recoiiimc.nded Priorities Approved, Priorities Pro am Financially Feasible REGIONAL MEDICAL PROGRAMS SERVICE - 15 - Metropolitan D.C. Rm 31-04 (AR-1-CSD) 2/71 1971 Review Comittee RF,NF,WAT, PROJECTS Core: As c't@-@-d under the previous section on Core '@@,-@q@-sted the Region is requesting $571,20i committed. stip-,)ort First Year and $195,068 supplemental support for the first triennium $820,000 year. It is also requesting renewal support in the f6rm of a commitment, for the se,:@ond and third triennium years. The purpose is to have Core and project suppo@-t in phase, at least for the most part. Second Year - $870,000 @ro@ct il,2R Disease Follow-tip aiicl Si.irveillan e@yAtem This renewal request has previously submitted Requested to the Noiember 1970 rev4LLw cycle. Comraittee ard Council First Year returned it for the upcoiLing site vi.,-iL. "el4O,727 Request is made for 36 months additional support for this project sponsored by Georgetown University. The project was initiated in 1968 to acquire information on stroke occurrences in the Washington Region which can be used to pro-vide better care for the stroke patient, planning for needed facilities (bads, rehabilitation centers) and eiientiially control and prevention o'Ll stroke. The goals of the project are: 1. To maint.@,in a continuing renort@L@.-ig system for evaluating medical@ care for str,olr6 patients in the Region ane,, to provide a means for measuring the effectiveness of the Regional Metiical Program. The reporting system will provide co@@unity-wide ii-iformation on stroke incidence,, surviia)., rehabilitation, geographic distribution, hospital stay, demogranhy and epidemiology. 2. To provide a source of information for carrying out epidemiologic or demographic studies by providing a basic patient population upon which special studies could be, based. These studies will. provide the information necessary for control and prevention. Information on strok(@ patients is to be hospital records, private physicians and offer pertinent sources. hT',,uring the initial two years of operation, the Stroke Surveillance System has established the basis for a Regional reporting system by concluding cooperative arrange- ments with 29 hospitals in tile Region. The Sys@'.-em will attempt to expand to all hospitals through the local Medicz,,l Societies. Other information sources are also Laing @.,xplorod. Successful implementation of this program on a continuing basis will provide information an the extent of the stroke problem in the area as well ag a mechanism for evaluating the Regional Medical Program stroke program. A counkrehen,sive progress report is provided on the project's activities and success to date. Second Year - $144,609 Third Year - $148,635 January 1971 Reviev Co@i Metropolitan D.C. RM 31-04 (AR-1-CSD) 2/71 Proiect #12R - Mobile Coronary Care Unit Renewed support Requested for one year is being requested for the First Year Mobile Coronary Care Unit in Montgomery County. The $100,000 purpose of the unit is to demonstrate that mortality from heart attacks can be reduced if the patient received care during the crucial period immediately following the attack. The mobile van, or heartmobile, provides the same services an equipment that can be obtained in a hospital coronary care unit. An important feature of the project is that it is staffed by paramedical personnel. A volunteer physician communicates with the team via a telemetry system. Preliminary evaluation as of July 14, 1970, shows that 59 percent of the total number of patients transported by the van were admitted to coronary or intensive care units More extensive evaluation is being conducted in conjunction with the Department of Health, Education, and Welfare, Fed6ral Heart Disease Control Program. METRO DC 17 RM 31-04 (AR-1 CDS) 2/71 January 1971 Review Comittee PREVIOUSLY REVIEWED PROJECTS FOR WHICH SUPPORT IS,,BEING RE2UESTED Project #17 - Health Careers Council Approved with no funds recommended. 01- $35,200 02 - $53,825 03 - $55,368 Project #19 - Cancer Registry Approved and funded, has committed support of $40,000 for upcoming year. Request supplemental support of $28,445 Project #20 - Peripheral Vascular ,cilit Approved and funded, has committed support of $50,000 for upcoming year. Request supplemental support of $43,608 Project #23 - School of Inhalation Therapy Approved and funded first and second years with carryover funds Request - Third year support at $86,490 Project #26 - Community Hospital Stroke Program Approved and unfunded Request 01 - $80,611 02 - $91,600 03 - $86,000 Project #28 - Coronary Care Nurse Training Approved and funded first year with carryover Request 02 - $54,471 03 - $55,860 Project #31 - Area Hemodialysis Trainin& Program Deferred pending further study of supporting such renal projects Request 01 - $328,295 02 - $233,247 03 - $134,150 Project #37 - Early Detection of Chronic Obstructive Pulmonary Disease Approved and unfunded. Request 01 - $38,477 02 - $45,118 03 - $49,428 (Second and third year request exceeds approved level of $40,618 and $44,928) January 1971 Review Comittee NEW OPERATIONAL PROJECTS Requested First Year Project #39 - Regional Exercise Stress Testing $77,724 Referral Services. This project sponsored by George Washington University proposes the establishment of exercise stress units in three hospitals or clinics. The objectives are to evaluate coronary disease status and support multifactoral approaches to coronary risk reduction and post-myocardial infarction rehabilitation. The units will be located so as to provide equitable availability to all citizens. After one year the equipment will be moved to other sites to start similar activities. Referrals will be made by physicians and patients will be returned to the referring physician for followup. The stress test will be a multi-stage, progressive submaximal test to the "Target Heart Rates" recommended by the Scandinavian Committee on Exercise Electrocardiography. Tests will be conducted by highly competent personnel who will educate others to assume the continuing operation of the programs at each site. Evaluation will cover the attitudes of both physicians and subject patients at or just after the testing, and what influence the results had on living habits and coronary risk factors in follow-up studies. The project relates to the program goals in that it emphasizes disease prevention. Second Year: $72,120 Third Year: $74,827 Requested Project #40 - Metropolitan Washington Pediatric Pulmonary First Year Program. This project sponsored by Georgetown $200,205 University Hospital has as its major goal, improved standards of care for children suffering with chronic asthma, cystic fibrosis and other severe respiratory illnesses. Under this plan, the outreach work benefit 92% of all children in the Washington Area. This proposal would: 1) Maintain the organizational framework of the Pediatric Centers now operating so that the evaluation of this initial effort can be completed. 2) Maintain the current computer based pulmonary registry for in-house patients. Modify the current automated system to include pulmonary outpatient data from the three university Pediatrics Hospitals Programs (Georgetown, George Washington and Howard). 3) In the second year, establish a specialized outpatient clinic for children with pulmonary disease at Providence Hospital which would serve as a model for the implementa- tion of similar facilities on a regional basis. )MO DC 19 RM 31-04 (AR-1 CDS) 2/71 January 1971 Review Comittee 4) Extend the based pediatrics p@@.-og.,rams to other affiliaLE--.,-! tioi,i-jl@.tals such as D.C. Genei-, @,,@)spital and Fairfax Hospital in the third year. 5) Continue training programs at the undergraduate, graduate and fellowship levels in order to meet the critical shortage of trained physician in the area of Pulmonary diseases. 6) Numerous ol@@portuni.ties for paramedical and allied medical training of personnel could be provided. Second Year: $230,845 Third Year: $285,310 Project #41 - Tra am: Cardiovascular 'technicians and Requested Physicians Assistants. This project sponsored First Year by the Washington Hospital Center is a revised version of the $172,717 ongoing project ik3 - TraininR for Cardiovascular Technicians, which will terminate at the end of the current year. It proposes the: 1) Continuation of the Cardiovascu!-ar Technicians Training Program in its present form to teach two 18-weel.@ classes a year. 2) Introduction of an extension of the above one-yea-r- program in order to produce a more highly trai.@ied individual capable of increased responsibility in the cardiovascular field. On graduation he receives a certificate representing one year of college work, approximately 28 credits. This "advanced program" is planned in conjunction with i,ic)ntgc)m(-,ry College. 3) Introduction of an associate degrce @)rogra-in in conjunction with Montgomery College to train iTioro. bro@-.-Adly based pliysi.cian's assistants. This program will be ericei--@ed Directly by a candi- date who elects to do so. Candidates who have completed the basic and/or advanced Cardiovascular Technicians Training Program will be able to apply credits obtained in those programs to their associate degree. Second Year: $240,959 Third Year: $246,105 Requested Project #42 - Establ ishm -,i : of Seic-c.Le(i -@l, -Ie,:te-,".ISlon Clinics First Year in Fcotioipica ssc@d Areas, This project $185,181 sponsored by the Hospital and Medical Care Administration of the Department of Humane Resources is designed to improve health care of patients with hypertension within the Region by establishing a reference and control center tying together five clinics. The District of Columbia General Hospital, WastiingiLon Hospital Center, The Anacostia Neighborhood Clinic, Freednians Hospital and Columbia Hospital for Women. MTRO DC - 20 - RM 31-04 (AR-1 CDS) 2/71 January 1971 Review Committee The referral center would be staffed to provide a community education program; (Addendum I'll a referral system based on patient needs and staffed 24 hours a day; a central research element to bring together data generated by the separate clinics with the objective of improving preventive measures and providing continuing data for better patient management. It would coordinate the use of paramedical personnel furnished by the D.C. Department of Health. The clinics at all five locations would be coordinated to meet the needs of all patients within their respective areas. Special procedures would be developed at the Washington Hospital Center to provide home and clinic care on a reasonable cost basis for the economically marginal group residing in the areas served by these hospitals. The concept developed here is to reduce clinic visits by patients by providing scheduled home health visits in conjunction with scheduled clinic visits. The care of patients will be based on the physician's Health Management Plan. The major concerns of many inner city patients with transportation, travel time, waiting time, and frequency of attendance will be reduced by at least one-half the demand of the present system. Second Year: $174,151@ Third Year: $178,982 Requested Project #43 - Cervical Cancer Detection. By means of First Year this project, the District of Columbia @150,000 General Hospital and Howard University Collefe of Medicine is requesting support to continue ongoing programs of cervical cancer detection currently funded through section 314 (e). The primary objective of this proposal is to increase the number of women who are protected from cancer of the cervix by supporting and extending the services of the Cervical Cancer Protection Center at D.C. General Hospi-@al,.with particular emphasis on serving women who are not already under supervision by a private physician. A secondary objective is to increase physician skills in the early detection of cancer of the cervix. Joint gynecologist- pathologist conferences sponsored by the Project Staff provide a learning opportunity for medical students of Howard, Georgetown and George Washington Universities; the Project prepares an annual Metropolitan Symposium with the Cancer Society and Medical Societies. Special health education staff are requested to increast patient understanding. This project receives support from the American Cancer Society. Patients screened by the project staff include those who are not dependent upon D.C. General Hospital and who are referred for follow-up at other community hospitals. Referrals will be January 1971 Review Committee METRO DC - 22 - RM 31-04 (AR-1 CDS) 2/71 lieinodia@Lysis unit to provic@c- i-,Leans for managing patients with kidney failure @@iiio do riot-. have adequate facilities for home dialysis. It represents one part of the developing program in the Metropolitan Washington Region for the care of kidney disease and is a part of the present dialysis program at The George Washington University Medical Center. Stich a mobile unit will be established in a truch or trailer and will be moved from patient to patient. It will be available to any deserving patient in the Metropolitan Washington Region previously trained in the use of the artificial kidney and can serve to support existing dialysis training centers at Georgetown University Hospital and Veterans Administration Hospital, as well as the one at The George Washington University Medical Center. The unit will initially be supported by tl-ie present request, but subsequently will derive support through fees and donations. Second Year:- $18,668 'Third Year: $19,443 Requested Project #47 " A Regional Neplir ogy Prop-ram. First Year This proposal sponsored by the Georgetown $718,876 University Medical Center would be the first systematic approach to integrating an extension of present facilities and cominglina, patient care, training, and research. It would take advantage of the existing facilities of the Georgetown University Nephrology Division which are outlined in a detailed organizational chart. These resources consist principally of the D.C. General Neplirology Section(§ix trained personnel including one physician and two nurses), the Metropolitan Washington Dialysis Center (10 trained personnel including two additional physicians and three -nurses), the Georgetown University Nephrology section (14 trained personnel including four physicians and two nurses), the Nephrology Fellowship program (7 physicians), and an administrative staff (four trained personnel including one nurse) and an editorial office (2 trained personnel). The proposal would integrate these facilities in a systematic way to provide an organized approach to the treatment of renal failure in a major segment of this region. It will do this by providing additional individuals required by the plan, by supplying some new facilities such as the one at the D.C. General Hospital, provide the basis for planning an out of the hospital home care facility, and provide an administrative-social worker unit as a resource for screening patients for dialysis and transplantation which in turn could bernade available on a fee for case-service basis to any hospital in the region having a dialysis facility. This could interdigitate with the existing 12 university contract program for tissue typing and exchange or donor kidneys on a "best match" basis. Second Year: $586,9z@5 Third Year: $617,107 .-. - @ -- %-- x %.,Vol 41 r L January 1971 Review Comittee encouraged from D.C. agencies and the community. A community Advisory Committee wil-L be established. Second Year: $125, Third Year-: $125,000 Requested First Year Project #44 $174,400 ge proposed the development of a-La Inter-Regional Program of Inter- stitial Cancer T'ileriiDN,. S,@)ecifically, a program would be set up to manufacture Iridium 192 seeds and package them in such form as to make implantation a more safe and convenient procedure. Special instruments and improved after-loading techniques will also be developed and made available to all hospitals, tumor surgeons, and radiotherapists in the Washington Metropolitan area and the other 13 regions in the Southeastern Regional medical Program consortium who are qualified to use the same. Consultation to user groups will be available on a request basis. Iraining in interstitial radiotherapy will be provided for visiting i--vldi.ologists, radiation physicists radiologic residents and technicians. Second Year: $78,449 Third Year: $58,691 Requested First Year 1-Iroject #45 -- Home -Base Care of Crronic Obstructive Lung $42,720 i@sea-se. The Pulmonary Disease Division of Gec--aletown University S--hool of '4edicine proposes the development of a three-year program oriented to improve the delivery of care in the home and in outpatient fac4-l4-t-ies for patients with chronic obstructive lung disease (COLD) in Mell-r,Dpo'Lita@n Washington. To accomplish this goal requires the development of adequate facilities and personnel in the community geared to -orovide expert care bv: training Vis@; ling 'lur.ces and ublic Health Nurses in basic aspects of COLD including therapy applicable in the home; (2) training physicians in comminitv clinics in the performance and interpretation of pulmonary function testing; (3) education of patients with COLD and their fa7,,ilies on those aspects of COLD which they can control and manage; (4) team visits from Phil applicant 2Lnstitut-Lon of pulmonary nurses, physician therapists L inhalation therapists.. Second Year: $53,650 Third Year: $58,880 Requested First Year Project #46 - Mobile Dialysis Cen@(-,r. This proposal $39,527 cir)or,,;t,)red bv the George Washington University Itedical Center seeks co demonstrate the feasibility of a niobile - 23 - RM 31-04 (AR-1 CDS) 2/71 MMO DC January 1971 Review Comitte, Requested First Year Project #48 - Nurse-Midwife Maternitv Nurse Clinician $411,333 program. In order to meet the acute health manpowere needs of the metropolitan area this "doctor- multiplier" program sponsored by District of Columbia Department of Human Resources will produce two new careers for registered nurses: The maternity nu se practitioner who expands the nurse role to provide total medical supervision to well maternity patients and certain gynecological patients in an out-patient setting as delegated to her by a physician. The classic nurse-midwife who in addition to the above functions also manages labor and performs delivery, wor'fing on a team with a board certified obstetrician. The proposal has a number of components. These include a service program which provides a setting to train and return midwives to active practice, an educational component in conjunction with Federal City Collegeblhpartment of Continuing Education,and a preceptorship placement service to provide on-the-job experience in private, voluntary and public institutions. Second Year: $678,840 Third Year: $614,167 METRO DC 24 - RM 31-04 (AR-1 CDS) 2171 January 1971 Review Comittee DEVELOPMENTAL COMPONEN'T The Region is requesting three years of developmental support: first year - $97,067, second year - $110,000,, third year - $140,000. The Region proposes to use the developmental funds to support the following studies: 1. The creation and staffing of a committee composed of Medical School Departments of Community Medicine, members of the Department of Publit Health of the District of Columbia, staff of the Office of Eco- nomic Opportunity, neighborhood health centers and consumers to explore means of stimulating the development of neighborhood health centers. 2. The use of formal instruction to improve the effectiveness of plan- ning committees. 3. The feasibility of establishing a clearing house to identify educa- tional employment opportunities for medical students iwishing to become involved in innovative health care activities designed to improve delivery of health care to inner city populations. 4. The feasibility of developing a computer-based clearing house to locate patient care resources for stroke patients needing "after the acute phase" care at home, in extended care facilities, or in outpatient rehabilitation resources. 5. The development of a pilot study in patient education to improve the after-care portion of medical treatment by getting the patient to understand the nature of his particular disease and what the patient needs to do to improve the management of his continuing treatment after dis- charge under a physician. 6. Exploring the most suitable ways of expanding, up-dating, and coor- dinating multiphasic screening activities in the Region with initial emphasis on early detection of major diseases i-.i people of limited economic resources. The developmental funds will be expended under the following set of rules: 1. Studies must be completed and result in a proposal for an activity consistent with the program goal for the triennium. 2. Funds for any single study proposed may not exceed twenty percent of the total sum made available in the year for development of activities. 3. Core staff will be assigned to each study and will be responsible for completing the study within the approved budget and within the time framework established. MLMMO DC 25 RH 31-04 (AR-1 CDS) 2/71 Jamary 1971 Review Cmmittee RM 31-04 (AR-I.-CSD) 2/71 -------------- 3 /1 -'O-.- 2 $551:1031i st.-@c),.@c: St,,:tlo,,i 139 296 121,812 4.@3 49,600 11-5 of Ov,-4rl,:i@ C, C. r il C. IL 37,500 @,-'l 2 Cc)r(,)ci,,;-@-y Ccir--@ Urtit 8 5 .. -IC r P, i t: -Cy Fa c t y "' i 1 ri C) i-I i -C -r I V C, LI I I ii 2 t I'C) Schc-,,,)! or 22,600 ,I, cl; 2 #28 Coronary Care Nurse Training 49,438 2 9 'j'r c:, i t i. n @i i-i (i -c z, e,c ri, #35 S - --I t Li 0 f P r 2j -!@r FLI C, (I Project TiLle and ',iuriber Status 1/4 - liome Telecasts of Medic.@l Suryical Conferences Disapproved #6 - Coriisrc-ii(@nsive ilospitil and tioae Cire of Strol-,c llatic-.iiL.,; DI..iz!l)rrovc-(] #7 - Puerperal Hemi.pl.egia Disapproved - 1,od(,] ';crc)k(, for: L@ictro. D.C Di--approvc(,' -cry D4.se.-!.,4c: The r,,ole of Ey, - Ari C. r c its -',,I()bille Coroiiiry Care Unit for l,@cti.-o. T). C. Di.sap;)rov(.c', #13 -Mobile Coroi-iiry Care Unit -' Georgetown Uni%;c.-i.-,,;ity Disapproved f@14 -Home Telecast of Yiedic.,.41-Surpic@l Cardiovascular Funde@ & Conferences T6rininated #16 -. Paramedical lletrzining by Video Tipes (No fun o -cconmc-nF@e(.) #17 -Health Careers Council Approved (No funds recor;7.11-,reicd' #18 -Application of Technological Advances to Education in Cnncer Dis&pprov(-('@ Ir i@21 -Applying Conir.-,uiiity Health Research Findings in tne Region D i #22 Pediiit'ric Coii-,,,-ii.inity '\idney Dis@ase PrevQntion Center App::c;v(--,i #24 ALteript to Ir@i,,-xrove Cire an(] Patient Cooperation Rettir,-t for in Hypertension Revisioli i@2 7Contiiiu-Iri-, Eeii.,c.F.,tion inei Socin] Services for Pediatric Or-Lcolo.yy Di.,;Pnprc)ved C> 11!30 -Cori.,.iunity Re.-al Diar,-,iosis Service Us'inc.' floure.scence Dispppi-oved 3 1 -Ilemodi@-lysis Triirii,-ig Progrrri Approved - Unfunded #34 -Filr@i':on "Care of the Colostociiy Patient" for DefL-ri-c-(i for Pat'@'ent Instruction Additic),7t,-! Inilormaticin 3 6 -Diob(,t(@s and Obesity EvLiluitioyi and Prevention Nl o 1)@, L@'t i n r] i n Re c cl e r@ ..3 7- Detcctic,,-i ox' C,iroi)ic O'@)structivc- tppi-OV,2d U-,IfLlndC'6 3C. r (I o vs c i,i 1, @, r D j. i- @ 0 1 1 C)-. LI (I C; I I- V I-, C Uri T C c 0 C,,C t oi,,,i #26 Comprehensive Hospital Stroke Program Approved Unfunded 27 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC FIEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Dal.,: November 27, 1970 ,Reply to A.tin of. Subject: Staff Review, November 23, 1970, Metropolitan Washington, D. C. RMP Triennium Application To: Acting Director Regional Medical Programs Service THRU: Sarah J. Silsbee, Acting Chief, Grants Review Branch Backgrodnd: The Metro Washington RMP, currently in their 03 operational year, hIas submitted a Triennium application requesting $4,410,861 (DC) for its initial year scheduled to begin March 1, 1971. The total budget request for the next three years is $12,175,325 (DC). The current projected commitment to this Region for its 04 year is $1,008,728 which consists of $571,201 (Core) and $437,527 for four program (project) activities. The subject application requests approximately $195.,OOO additional. funds for Core Staff with the balance earmarked for two renewals, ten new activities, a developmental component and approximately six supple:,iental activities either not yet funded or initiated with carryover funds with drastically reduced expenditures, (or budgets). Purpose of Staff Review.@ Participants were advised that a site visit has been scheduled for Dec- ember 7-8, 1970. Dr. Ellis (National Advisory Committee) and Dr. Hunt (National Advisory Council) will be the principal leaders. Therefore, the two purposes for the Staff Review were to: A. Make recommendations to the Acting Director, RMPS, regarding the commitment for the 04 year. B. Identify issues for the site visitors. I General Observations about Nr@4/Bl4P: Up until this date, the Region had place d most of its emphasis in stitnu- lating individual project activities utilizing the Associate Coordinators placed at Georgetown, George Washington and Howard Medical Schools, and at the D. C. Department of Public Health and the Washington Hospital- Council. The Regional. Advisory Group had been quite busy at each of its quarterly iiiectin,-s with "project" review. Until. recently priority rankina was accomplished only on those activities being revi-c@t.7(! at trick particular RAG session.. Very little evidctncl- of planning or evaluation including surveillance had been demonstrated by the Core Staff. Acting Director Most of these short comings were adequately spelled out to the Region by the site visit team this past year (October 1969). The Coordinator and staff have been quite active in attempting to alleviate many of these apparent problems' and have responded to them in the subject application. Key RME% staff who were willing to rank this Region in the lowest quartile based on past progress and RAG involvement, are now suggesting that it could be given a higher grade based on future potential. Assets include: 1. The establishment of seven planning committees of eiaht members each. Thus, all 57 members of the RAG (including its Chairman) will be more actively involved. 2. The establishment of a priorities committee composed-of chairmen of the seven planning committees. 3.' The proposed additional offices for Planning, Community Health and Program Activities, and Program Appraisal to the Core Staff. 4. A better delineation of program objectives. 5. A good Fiscal Policy and competent staff. Staff Recommendations: A. For the Actini Director, RMPS: 1. Regarding the commitment for the 04 year, staff recommends the decision concerning the Core continuation be deferred until after the site visitors' findings, especially since $195.,OOO additional funds are requested to supplement the $571,20). currently earmarked for this function for the 04 year. Specific reasons for this recommendation are found below under the heading "Issues for Site Visitors." 2. Regarding four projects to be continued: a. #IR - (;troke, Freedrens Hospital) - Staf f reconuncnds approval at the requested amount - $203,677 (DC) b. #19 - (Cancer Registry - D. C. Dept. of Publ.i.c Health) Staff recommends approval at the committed amount of $40,000. The site visitors might wish to fiirtll(.'.r investigate the request for additional funding for this 29 Acting Director, RMPS activity. Progress denotes minimum "output" to date. Most of the operation has been directed in gat ering material for computer tabulations. C. #20 (Peripheral Vascular - George Washington) Staff recommends approval of the committed amount of $50,000. A recent change in Project Directors might lead the way for the establishment of satellite clinics which were originally proposed but not yet implemented. Again the site visitors might wish to inquire about the need for supplemental funding requested for this activity. d. #25 (Radiotherapy Program - Howard University) Staff recommends approval at the committed and requested amount of $143,850. This activity was just recently funded under the earmarked funds for modelcities. Because of the time factor, a progress report was.not expected. 6. In addition to the recommendation for the $437,528 (DC) included in items eta" thru "d" above, it is suggested that additional committed funds be considered for activities previously funded with Carryover Funds. Specific reference is made to'Projects #12, #23 and #28 which are included in this application. It should be noted that eight project activities were funded this past year from carryover. T e Region might be commended for such action; yet many problems have arisen in spite of getting more institutions on boar ended that the next three-year program exclude It is recomm carryover financing for activities scheduled for more than,, one year's duration. Since Projects #12 (Mobile Coronary Care Unit)"an-d t2 (Inhalation Therapy Training) have one more year remaining, carryover could be considered for partial funding of these activities. Staff recommends $55,000 additional commitment for Project #28 (Coronary Care Nurse Training - Howard University) for a two year period. B. Suggested issues to be raised by the site visitors: 1. There is some question as to the need for ten additional profes- sional positions on Core Staff. The application indicates that some of the presently employed Associate Coordinators will assume new roles (or @ual rol.es),in manning three of the new proposed 30 Acting Direc tor, RMPS offices (Planning, Program Appraisal and Community Health and Program Activities). The Organizational Chart (Volume 1, page 63) should include the necessary positions under the respective Sections so that the budget sheets can also be compared with the "new look". 2. The Office of Manpower Development should also be examined so ,that Continuing Education activities can be more clearly .'defined. 3. With reference to items 1 and 2, the reviewers wish to know if the Region wants to get Iaway from the institutional approach (phasing-out of some of the Associate Coordinators). The Region's report on Core's Stewardship seems to be an extended apology. They recognize the need to restructure the organiza- tion and suggest sweeping changes in over-all philosophy and more involvement of its RAG. Yet, through its apology, they seem to be suggesting necessary changes in -the Program irrespec- tive of whether they may be receivi ng additional funds. In short, the Region may have stated its case better by submitting two plans for reorganization instead of the one which poses so many questions. After reading the position descriptions to be included in the new organizational structure, it becomes even more difficult to see who is oing to be at what helm. 9 4. Monitoring, surveillance and evaluation have been rather weak in this Region. The new look suggests that the Office of Appraisal should alleviate these problems. What about RAG members? Can they become more involved in these kinds of activities? 5 . Staff notes that a large portion of the RAG is from Virginia and Maryland. Site visitors may wish to pursue the composition of this body even though funded activities in Virginia and Maryland have been quite limited. 6. Expenses of RAG and Task Force members should be further ex- plored. Perhaps a budget figure would reveal these costs are not, in fact, too extravagant (Page 134). 7. A pictorial chart depicting the review process would further clarify the narrative presentation. It is suggested that evaluation be included in the chart. 8. Some staff members were concerned about the first two mentioned firules" under which the developmental component is slated to operate. The first rule appears unvorkable'and the second seems unwise. Acting Director, RMPS - 31 9. Questions concerning two renewal requests should be pursue a. Mobile Coronary Care Unit - This activity was approved for a two year period and actually got underway in Match 1970 with carryover funds although limited funds were used for to6ling-up prior to that time. In view of recent Council action regarding Mobile Units, should another $100,000 be allowed for the further evaluation of this activity as proposed for one additional year? b. Stroke Registry - This renewal (#2R) was deferred by the National Advisory Council which met in November 1970, pending further investigation by a site visit team. Principal questions centered on future use of the material being gathered. 10. Of the ten new proposals to be considered, two points should be clatified: a. of the three kidney proposals, can the Region identify one of them which can be considered priority? b. Can the Cervical Cancer Detection Program be considered in view of the recent Council's 'recommendation? This proposal combines two previously funded 314 (e) grants. What is the amount of expected carryover for the current 03 operational year! SUMMARY OF REQUEST AND RECOMMENDATION Recommendation Conimitt@d ort (Deferred for Site Core $571,201 Visit Consideration Projects IR,19,20, & 25 3 IL7 @43@ 2@7 $1,008,728 $437,527 In addition to the recommendation on committed support, Staff also recommends project #28,which is funded in its first $55,000 year from carryover,be awarded $55,000 additional commitment for its second and third years of operation. TOTAL $492,527 Michael J. Posta Operations Officer Regional- Development Branch HAROLD MARGULIES@ iki.D. Action Z. c 'O v Date Signatur( Listed below are RMPS members who attended this Type V meeting: Dr. Marian'Leach - Continuing Education Branch Margaret Mullins - Planning and Evaluation Branch Rod Mercker - Grants Management Branch Lorraine KyttlO- - Grants Review Branch William Reist - Grants Review Branch Michael Posta - Regional Development Branch GRB 12/24 70 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF JAIQUARY 1971 REVIEW CO@IITTEE METROPOLITAN WASHINGTON D.C. REGIONAL MEDICAL PROGRAM RM 31-04 (AR-1-CDS) 2/71 ]FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Lt NDATIO@iS:. (1) Continuation support be ptov ded in the amount committed for the 04 year. l@ (2) Additional support in a reduced amount be provided for the core renewal and new projects in this application. (3) Developmental funding be denied at this time. Committed Committed Additional Additional Support Support Support Support Total Year Requested Recommended Requested Recommended Rec rmuended Ist @1,008,728 $1,008)128 $3,402,133 $ 574,623 @1,533@351 2nd 189,08.2 189,082 3,813)289 1,095,824 11284,9Cr6 3rd -0- -0- 3 762,093 1,041,353 1 041,353 Tot 1 $1,191,810 $1,107,810 $ _.10,971,515 $2,711,800 $3,909,610 Staff reviewed the continuation com onents (core and four projects) of p The Acting Director deferred these this application in November 1970. components to the visitors of the upcoming site visit for consideration. The site visitors in turn recommended approval of the contuation components in the amount committed. Commi ttee after consideration of the application and'the site visitors'report concurred with this recommendation. CRITI the site visitors I observation that this Regioli. -QUE: Committee accepted I hap made substantial progress in the form of reorganization duritio the n@ist year and that while progress program-wise is not as evident, organizational weaknesses have been strengthened to the ext6nt the Region now shows greater potential. This new potential can also be attributed to what was considered the high caliber of key members of Core StAff. The restructured RAG committees were considered a significant change which should bring about greater involvement in program development; hbwever, it was recognized it will take time for them to demonstrate progress towards a total program. While the reviewers had reservations regarding the minority representation on the RAG, it was noted most of the funded activities appear to be centered in the lower socioeconomic areas of the District. The review process was considered satisfactory-, however, there is a need for mote emphasis on program review and use of outside e-4zperts on the planning and priorities committees.' Although there appears to be considerable cooperative effort ith other community organiza e Region might w tions, the reviewers agreed th land and Virainia Vant to delineate further priority pocket areas in.@lary a and consider future programs for theri.- It was also suggested closer ties be developed with the Health Departments in these states. MF4TROPOLITAN WASHINGTON D.C. PMP -2- RM 31 04 (AR-1-CDS) 2/71 While the site visitors believed the Reg:Cbn needs to develop a system. of utilizing the data being collected and to establish sharper criteria in identifying specific needs some Committee members were more highly critical of the entire programming process, from assessing needs to evaluating achievements. They cited the expensive Cam rehensive Kidney p Program as an example of how the Region has given priority to a program upon which the need appears relatively insignificant when compared with ot .6r needs of the community. Along the same lines it was believed the new projects represent a "shotgun approa@ch" and lack a common thread dra ing them together into a total program. Concern was.also expressed over what appears to be the strong dominance of the medical schools as 'ht be ief! cted by the fact that a majority of the projects are sponsored mig e by these institutions. It was also noted that none of the.projects are co-sponsored or represent a cooperative endeavor or effort by the Medical Schools. After considerable discussion and debate Committee concurred with the site visitors that while program progress does not ustify additio al n support, potential based on the reorganization does and the Region should be given@additional project support.for each of three years and renewed support of Core for the second and third years. With respect to the D6velopmental Component, however, Committee did not concur with the site visitors recommendation of $75,,O.00 additional funds, but rather took the 'tion that support of this component should not be granted on the posi basis of potential but should be withheld until such time as the Region ,'has demonstrated its potential in the form of program progress. In addition to these recommendations Committee concurred with the visitors observation that the three projects, which compris,e.the Comprehensive Kidney Disease Program, lack planning, contain too much overlap and fail to utilize all available@resources. It also agreed with the recommendation that no additional funds be provided for these proposals, but that @15,000 Core supp?rt be provided to develop a comprehensive plan for kidney dis'ease control. RMPS/GRB 1/20/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF SUPPLEMENT@AL GRANT APPLICATION (A Privileged Communication) Michigan Association RM 00053 2,171.1 (S) Regional Medical Program January 1971 Review Committee Suite 200, 1111 Michigan Avenue East tansing, Michigan Grantee Agency: Same Program Coordinator: Albert E. Heustis, M.D., M.,":.I.@ Request (Direct Costs) Ist yr. 2nd yr. .3rd yr. All years_ Direct Costs $428,073 $426,098 $448,274 $1,302,445 Indirect Costs 38,505, 41,971 45,748 126,224 Totals $466,578 $468,069 $494,022 $1,428,669 Funding History Planning Stage Grant Year Period Funded (d.c.1 01 6/67 - 7/68 $1,040,639 Operations Program Council Future Grant Year Period Approved Funded (d.c.) Commitment 01 7/l/68 - 6/30/69 1,495,330 721,763 Core -------- 773,567 Projects 02 7/i/69 - 8/31/70 2,054,020 8491814 Core -------- 10134,863 Projects 03 9/l/70 - 8/31/71 2,031,533 822,136 Core -------- 1,164,961 Projects 04 9/l/71 - 8/31/72 501,255 ------- 385,730 05 9/1,/72 - 4/30/73 360,940 ------- 281,727 (8 months) Michigan RMP -2- RM 00053 2/71.1 (S) Geography: The boundaries of the Michigan Regional Medical Program are the same as the state Borders. Physically the Region is composed of two peninsulas - an upper peninsula which is separated from the more densly populated lower peninsula by the straits of Mackinac. The total land area is.57,019 square miles. The vast land area coupled with centers of medical excellence and decen- tralizod health resources, its relatively self-sufficient pattern of obtaining care, and its array of health manpower argue well for the one state - one region concept in Michigan. Demography ,Populatio@i (1968) 8,800,,OOO (Estimate) a. Urban 73% b. White 91% Facilities a. University of Michigan Medical School 4 year enrollment 780 b. Wayne State University School of Medicine enrollment 516 C. Michigan State University College of Human Medicine Physicians a. Medical Doctors - 9,625 (1962) b. Doctors of Osteopathy - 1,691 (1962) Program Priorities - (Listed in Order of Importance) (Approved by RAG March 13, 1970) 1. Immediate health service needs of the poor. 2. Concerns for younger age groups 3. Increasing the delivery of health services 4. Prevention of disease and its complications 5. Improving the quality of medical services Review Process Staff - Prepares a summary to generally highlight the project's objectives and technical approach. Additionally, any staff "concerns" are surfaced to the technical review committee for their consideration. Technical ]@eview Committee - (Generally an Ad Hoc Committee of outside consultants) Meets with the applicants, and makes a comprehensive review to determine the project's merit, its benefit to the community, the significance of the disease pressure, the fulfillment Michigan RMP -3- Rm 00053 2/71.1 (S) of an actual need, the mechanism of effect, the competence of the technical approach, evidences of cooperative arrangements, and its concern toward fulfilling a MARMP priority concern. Board of Directors - (7 members - all members of RAG) Reviews the complete project, the staff summary, and the report of the technical review committee from the standpoint of the intent of RMP legislation, devel- opment of cooperative arrangements, and applicability of the program plan. Regional Advisory Group - (34 members) Receives the Board of Director's recommendations as well as the other material which has been considered by the board. At this time, the RAG either approves the proposal for submission to RMPS or returns th,2 proposal to the sponsor. The right of appeal is available. Program Coordinator - Albert Heustis, M.D. was chairman of the Governor's Advisory Council on Heart Disease, Cancer and Stroke when it first met during November 1965 to discuss.the implications of RMP to Michigan. During June of 1966 the Region was incorporated. During September 1967, Dr. Heustis was appointed fulltime program coordinator. Regional Advisory Group - (Membership on RAG is synonymous to membership in the Association - Members of RAG are automatically members of the association and vice-versa) On October 9, 1970, during the annual-meeting of the members of the MARMP Association, new members of the Regional Advisory Group were elected. The RAG currently has 34 members. New Organizational memberships include representatives from the Michigan Academy of General Practice, the Michigan Association of General Practitioners of Osteopathic Medicine and Surgery, a member of the Comprehensive Health Planning Advisory Council, the Kidney Foundation and the Health Planning Council of Michigan. A group of six representative Public-at-large Members was also elected. Michigan's triennial application is due for submission in May 1971 for consideration in the July/August 1971 Review Cycle. Listing of Current Funding Status of core and operational projects in MARMP. Amount Supported Project Number Title Through 8/31/71 CORE #1 Central Planning $ 326,381 #5 M.S.U. Planning 189,975 #7 U. of Micbigan Planning 63,480 #14 Wayne State Planning 177,460 #15 Ziegler - Botsford Hospitals 64,840 CORE subtotal 822,136 Michigan RMP -4- RM 00053 2/71.1 (s) Amount Supported Project Number Title Through 8/31/71 Generational Projects #3 Coordinated Data Collection (Dept. Public Health)- 231,656 #4 Model CCU Michigan Heart Association 109,856 #8 Postgraduate Nurse Education 102,707 #9 Drug Information and Therapy.Analysis University of Michigan 79,489 #12 School of Dentistry - U. of Michigan 31,636 #16R Surveillance of Electronic Equipment 45,701 #17 Stroke Base Center - Wayne State 10,196 #18 Comprehensive Attack on Problems of Stroke 115,314 19 Stroke Demonstration Unit -.Detroit Osteopathic Hosoital 91,633 #20 Central Michigan Comp. Stroke Program 82,857 #21 Stroke Education Program 62$216 #22 Develop CVR Center Benton Harbor Mercy Hospital 35,720 #25 Western Michigan Medical Education Program (Blodgett,Memorial Hospital) 801250 #26 Inner-city Cont. Education Program 85,730 Total Core & Projects $1,987,097 Summary of Existing Michigan Regional Medical Program Components The Core component of the Michigan Region hag four agencies in addition to the central staff for which it provides funds for promoting, planning, facilitating, and/or coordinating activities of concern to the Regional Medical Program. These ire Michigan State University, University of Michigan (which includes a Dental Section), Wayne State University and Ziegler/Botsford Osteopathic Hospitals. Clarification of relationships between these have been the concern of a Regional Advisory Group (RAG) committee which has been studying the Situation since the first of the year. Michigan RMP RM 00053 2/71.1 (S) Operational Proiects A. Heart Disease 1. Western Michigan Continuing Education Program, Blodgett Hospital, Grand Rapids; #25 - Physician Training in Satellite Hospitals. The larger general hospitals in Grand Rapids are cooperating with each other and with ten smaller surrounding hospitals in developing and implementing a physician education program in Cardiovascular Diseases. The staffs of smaller hospitals are helped to identify their own needs, make their needs known to visiting specialists, and receive appropriately tail.ored individual help in their own hospitals. The project also provides for the services of a replacement physician to enable local practicing physicians to attend educational programs. 2. Physician Training in Cardiovascular Care; #22, Mercy Hospital, Benton Harbor. This program is developing a cardiovascular center with facilities for cardiac catherization And, angiograpoy. It is also developing and carrying out an educational program in C/V Diseases for the physicians in the surround- ing three-county areas through visiting consultants, inter-Hogpital Conferences, and monthly clinics. 3. Cuoronary Care Unit Training Program; #4, Michigan Heart Association. This program offers two-week courses for nurses and one to three-day seminars for physicians throughout the region who function in coronary and intensive care units. Programmed learning texts to be used with teaching machines for hospitals with (or planning CCU'S) are being developed. 4. Survey of Electronic Equipment in Special Care Units- l@16R, Wayne State University. This program surveys hospitals in the Metropolitan Detroit area to assess personnel practices with respect to the electronic equipment used in their coronary and intensive care units and in emergency rooms. The program is also determining the potential hazard in the use of such equipment and providing pertinent safety data about specific equipment. B. Stroke 1. Regional Stroke Base Center; #17, Wayne State University. This Program will provide professional consultation to the cooperating stroke centers and the stroke information program, assist in the design of professional educational opportunities to meet their needs, and be responsible for the overall evaluation of the region's stroke program. 2. Cooperating Stroke Centers; #18, and #19, and #20. This is a three-horned program involving Detroit General Hospital, (Wayne State), Detroit Osteopathic Hospital and Sparrow Hospital (Michigan State University). Acute stroke units established in these institutions are to serve as demonstration an(] training centers for physicians and alli.(!(l health p(!rsonnel.. New(@r methods of diagnosis, treatrti(@@nt ano rehabilitation of patients with acute stroke will be demonstrated. Cooperative arrangement ire to be developed with surrounding hospitals, and f@s of experts from the centers will visit cooperating facilities for the purpose of conducting consultation, teaching rounds and seminars. Michigan RMP -6- RM 00053 2/71.1 (S) 3. Stroke Education Program; #21, Michigan Heart Association. This program is designed to impress people regarding the predisposing factors and symptoms of early stroke and to motiva.te them to take advantage of what they and physicians can do about them. C. Multi-Ca@orical - Heart, Cancer, Stroke 1. Continuing Education for Nutses; #8, University of Michigan. This program is to develop and implement continuing education programs in heart, cancer and stroke for nurses throughout the region. 2. Drug Information; #9, University of Michigan. This program provides drug information on a 21rhour basis to physicians and allied health professionals throughout the region. Drug therapy patterns are analysed. 3. Continuing Education Program for Small Inner-city Hospitals; #26, Wayne State. This program is for a continuing education program for physicians and allied health personnel in three, small inner-city hospitals. Technical assistance is offered through Wayne State. It involves self-study programs, 'identification and assessment of factors contributing to any health care gap and the development of programs to overcome the gaps. D. Evaluation and Data Collection; #3, Michigan Department of Public Health. This program is concerned with the development of methods to assist in the definition of target populations needing care and to measure the performance of the health care delivery system. Of a total of 29 new individual project requests, Michigan RMP has had one ne,,i operational proposal not approved at the at the Federal level due to programmatic considerations. A revised version of that request is included in this application. Currently the region has two operational projects which are approved - unfunded. These are: 1. Comprehensive Health Care for the Urban Poor - Wayne County General Hospital. This program, designed to serve an urban poor population, will establish a modern and comprehensive screening, diagnostic, and treatment center using the facilities of the out-patient and in-patient departments of the Wayne County General Hospital. 2. Demonstration and Teaching of Specialized Care of Stroke in a Generalized Hospital. This proposal will add another unit to the Michigan Regional Stroke Program. It is to serve as a demonstration an(] training center for physicians and all.ied Health personnel Initially from five Detroit hospitals, Alexander Blain, Jejiniiig Memorial, Evangelical Dea(-oniiess, Detroit Memorial (Center), and the South Macomb Hospitals. Present Application: This is a request for two individual projects. One proposal is in the field of cancer, the second is to provide community health service coordinators for model neighborhood compre- hensive health programs. Direct costs only are shown in the following descriptions. Michigan RMP -7- RM 00053. 2/71.1 (S) Requested First Year Project #30 - The South Eastern Michigan Regional Cancer Program. $220,720 This is a revised request of the original proposal which was reviewed during the June/July 1970 review cycle. The critique and recommendation of the June Review Committee which was supported by July 1970 Council was: "Critique: This is the Region's first cancer proposal and is to improve the care of cancer patients in a tri-county area by providing a clearly identified and publicized network of cancer consultants in nursing, medicine and social service. A survey indicated that the level of practice regarding cancer management is outmoded by about ten years. Members of the Review Committee believed that the concept of training cancer consultants is naive (if a physician is an oncologist, he is a cancer consultant). It was difficult for the reviewers to understand why he should be paid a per them to do what he should or probably would do any way. Additionally, it was believed the requirement that all hospital admissions have "pap" smears appeared to be an expensive duplication. A question was also raised regarding the value of establishing cancer guidelines for this small geographic area. There was concern about the experience the proposed project director has had as an educator. In recommending non-approval, the reviewers believed that the proposal should be recast to include much more planning of the educational aspects as well as concrete phase-out plans, with a greatly reduced budget. Phasing of the program was also suggested. It was suggested that the Region utilize medical education evaluation consultation at Wayne State University and that the RMPS Continuing Education and Training Branch staff provide assistance in this effort. Recommendation: Non-approval II - revision required." Summary of proposed program: Wayne State University requests $220,720 through the Michigan Regional Medical Program for the first year of a three-year proposal which is to improve the care of cancer patients in a tri-county area, by providing a clearly identified and publicized network of cancer consultants in nursing, medicine and social service. This is the Region's first cancer project. The project proposes to establish cancer consultants throughout the tri-county area (Wayne, Oakland, and Macomb Counties) to increase the availability expertise in cancer management to practicing physicians. A Central Teaching Group of Cancer Experts from Wayne State University will serve as faculty for training the cancer consultants and for developing for management of patient wi.t@@li malignant The cancer constjlt;irit:,,4 will 1)(@ i.(Ientifi(,(l tin(] r(,nppoirit@t,(] I)y Lli(, ilro)(,(,t@ Director annually iii(i will have the responsibility of: I.. I.mpl(,mc,r)tin,,,, i monthly tumor board in their hospitals; 2. implementing an(] attending clinical teaching conferences in their own hospitals; 3. attending the monthly conferences Michigan RMP -8- RM 00052 2/71.1 (S) of the Central Teaching Group; and 4. providing consultation (on a fee-for- service basis) to physicians and furnish information on current management and evaluation standards and therapy recommendations. ,An area-wide cooperative program among radiation therapists will be developed to provide needed services and to improve the scope and quality of the therapy offered. @All pathologists in the tri-county area will be given an :opportunity. to become active participants in pathology slide seminars to be held at two hospitals (St. John and Wayne State). A two-week cancer educational program will be provided (maximum of two per year) which will enable key nursing personnel throughout the tri-county area to gain the necessary knowledge and skills to effectively provide cancer nursing care and to teach other nursing personnel. The establishment of hospital nursing units primarily devoted to the care of cancer patients requiting aggressive nursing care, will be encouraged. Each tri-county area hospital will be encouraged to work toward the establish- ment of a mandatory Papanicolaou cervical smear requirement for women admitted to the hospitals. The project proposes to demonstrate the feasibility of cooperative utilization of social workers in hospitals with less than 250 beds. A referral center telephone service will be made available to answer such questions as where to go for financial assistance in purchasing costly drugs or where to obtain a bed for home care. On page 32, the region outlines the changes in the proposal and budget which are in reply to concerns raised during the initial committee/council review. The region states that the cancer program is fully congruent with the MARMP's regional cooperative cancer management plan which "seeks to promote maximum utilization of existing resources and to expand general cancer facilities and services only as needed." Additionally, it meets the qualifications to be ranked highest and second highest priorities of the recently passed program priorities. The revised budget shows an approximate 1/3 reduction per year: Year Original Budget Revised Budget 01 $346,852 $220,720 02 357,530 229,433 03 3211,, 01) / 251,000 TOTAI,S f,; I , O',@ 3,0 /9 $701,702 Second Year Third Year $229,433 $251,609 Michigan RMP -9- RM 00053 2/ 71.1, (S) Requested First year Project #31 - Program for Community Health Services Coordinators $207,353 The Detroit Model Neighbor@ood Comprehensive Health Program, Inc., a non-profit organization developed by the Detroit Model Neighborhood Agency, requests $207,353 for the first year of a three-year program which is to help provide comprehensive health services for model neighborhood residents. The proposal was developed by the MARMP financed Wayne State University Planning Staff and with the help of the MAR@ financed Planning Office at Wayne State University. This proposal specifically addressed itself to the implementation of specific items i,,-!.-;.thi.n tht-- regions two highest priority areas. If approved, and funded, this program would interdigitate with the regions approved/unfunded project Comprehensive Health Care for the Urbin Poor, providing, of course, that program is funded. Funds ate requested for the development, testing and evaluation of a new system of providing comprehensive health care services to the residents of the Detroit Model neighborhood. The project is to be integrated into the ongoing operations of the applicant organization which is presently providing comprehensive care to a prepaid population of approximately 10,000 model neighborhood residents under contractual arrangements with the health Council of the model neighborhood. At present, general and speciality medical- surgital-health services, for enrolled model neighborhood residents, are provided directly by or through the comprehensive health care group. The goal is to increase physician, nurse, and other health professional utilization and to increase patients acceptance and utilization of health services by the development of a manpower program generating community health workers. A new type of trained health worker, the health services coordinator, is to be trained. He will, in fact, become the family broker for health services. Program activities will be designed to focus on three systemic points w ich are planned to: 1. Increase effective utilization of health care providing personnel. 2. Increase utilization of available health care services. 3. Increase impact of comprehensive health care services. The Health Service Coordinator will assume the roles of interpreter, negotiator, advocate, advisor, instructor, counselor and helper to the disadvantaged population. Evaluation is to be performed on the basis of specific criteria which include before and after comparisons and various assessments. The Program is so structured that if it proves successful, it will not only become self-supporting (funded by corporation) but it would have a good potential of being copied elsewhere. $162,000 of the first years total budget is for personnel.. Purchase of four vehicles are requested during the first year. This is a one-time expense. Michigan RMP Rm 00053i 2/71.1 (S) Second year Third year $196,665 $196,665 2nd and 3rd year funding is projected at continuing levels since sufficient takeover by the applicants is projected to compensate for increased costs. RMPS/GRB/12/2/70 SUNL4ARY OF REVIEW AND CONCLUSION OF J@nuary 1.971 Review Committee MICHIGAN ASSOCIATION REGIONAL MEDICAL PROGRAM RM 00053 2/71.1 (Supolement) FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: The Committee recommended that this application, which requests support for two new operational projects be p6rtially supported as follows: YEAR REQUEST RECO@-2,TENDED FUNDING l,st Year $ 428,073 $ 368,073 2nd Year 426,098 366 098 3rd Year 448,274 388, 2 74 TOTAL (d.c.) $1@,302,445 $1,122,445 @it@ut,: The Committee noted that the Michip,,an R?, IP will submit its triennial application for consideration in the July@/@ug,,ist 1971 Review,Cvcle as noted in previous reviews of this Region. The committee reviewers commented on the qu-zl-i.ty of local review, Since this optional application included only two projects, the Committee did not have an opportunity to study their potential impact on the entire programs lioi-2ever, as noted on the pink component sheet, only 2% of the Regioh's current funding floTi into cancer activities, and the Cominittee believed the Southeastern Mi h@icln Cincer Pr(l,,r@erLi (Proect #30) would add needed balance to the total programs In addition, the Committee fel.t that Project #31 - Program for Community Health Service Coordinators would help alleviate identified needs of the urban poor, ,2ill develop @) nucleus of traine.d health service coordinators, has outreach, involves many health resources and represents good coordination between two federally-funded programs, the RMP and Model. Cities. The-Committee understands earmarked funds are available. The Southeastern Michigan Regional Cancer Pro-ram (Pro4ect IA30) has been revised; in line with Councils suggestion regarding the earlier -version, the budget has been reduced, educational aspects strengthened and phate- but plans are included. Dr. Hess e7as not present durina Committee discussion or action on the application. GRB/RMPS RE(@lO@4A], PROCitAMS SUI,@IA]tY 01@' ANi4l-Vi-I'l,@,A]tY A@@ll) Al@@All,l) APPL'FCAJ.'IO@4@ (A Privil.c,g(!d Coqii@iunicaLiori) NLI%' JERSEY REGIONAL MEDICAL PROGRAM RM 42-0 2 (AR-1-CSD) 2/71 7 Glenwood Avenue January 1971 Review Cornniittee East- Orange, New Jersey PROGI@@L COORDINATOR: Alvin A. Florin, @I.D. REQUEST (Direct Costs Only) 03 04 05 Al], I'Ljrl)ose 4/l/71-3/31./72 4/l/72-3/31/72 4/l/73-3/31/73 Years C011ti.IlLiaLioji Coniiititiii(,.iiV. $1,236,1@76 $1,236,176 Core 656,931-) 656,931.) 6 Projects 579,245) 579,245) Rc,nc,i,i,il Coi-npc)ri(,.rits $ 54,216 $ 54,216 1 Project (54,216) (54,216) Additional Contponents $3,490,515 $11,770,391-@',- Dev(,Iop7,,c,ntal 123,500) (123,500) 15 T,)tojects ($3,367,015) $3,300,621@ $3,299,625 (@ll.,646,891)* Total $4,780,907 $3,300,624 $3,299,625 $13,060,783 taff Action Com- 1,236,176 1,236,176 mitmc,-it Os Conirnittc!e Action Requ@Lred $3,544,731 $3,300,624 $3,299,625 $11)824,607 -(Prc @, ect @r'18 has requested support for a fourth ($832,21@2Ta cl fi h ($847,'85 years.) Fuildi,]L,@l L-,La@y_ PI-ANNI!,T(; SJ'A-(;I-',. Grant Yc!@,ir Per 1 c)d 01. 7/l/6Y-6/30/68 $271@,/il7 02 7/l/68-6/30/69 $614,1@62 OPERATIONAT, PIIO(,Ib@Yt Grant Council l'undc,d Year Period @Lr o@@ cl d (L-@ 4/l/69-3/31@/70 $1,306,273 $ 979,705 02 4/l/70-3/31/71 1,415,891, $1.,306,906 2-1 03 4/l/71-3/31/72 1,623,?97 @1,236,2'j5 01@.@ 4/l/72-3/31/73 197,833 97,000 I./(9 for nii(i I? ;iL ,,t ](,v@-i $68,22-'j of 01 yc,,,ir.) Nhl4 JERSEY RMP -2- RM 42-02 (AR-1-CSD) (;(@oi?raphy and D ri h The New Jersey Region is coterminous with the state. IL has interfaces with the Metropolitan Nciw ;ft)rk an(] tile Creater Delaware Valley RMPS. There is over lapping _@ltiris(licLion, however, in the southern seven counties of New Jersey with Llic (;reaL(!r Delaware Valley RMP. A special liaison committee has been organized to help deal with this problem. New Jersey is a very densely populated state, with approximately 7,100,000 people, as of the 1960 census, in its 7,521 square mile area. The New Jersey Region is served by 8,531 M.D.s, 523 D.O.s and 23,758 active nurses as o 1962) and has 54,960 hospital beds. New Jersey has two medical schools: the New Jersey College of Medicine and Dentistry in Newark and the Rutgers Medical School in New Brunswick. As of July 1, 1970, legislation was signed by the Governor, establishing a single Board of Trustees for the two medical schools. A steering committee has been formed and will serve as the Department of Continuing Physician Education of the medical school of the state as the new administrative arrangements are determined (p. 178). Regional D evelopment: The New Jersey Joint Committee for Implementation of P.L. 89-239 was incorporated in early 19.66 to draw together the appropriate groups to begin planning for all RMP. The first planning application, received in September 1966, was returned for revision because of the 1) lack of a strong medical school (one was under development and the other was undergoing extensive reorganization), 2) the vagueness of the proposed plans and 3) the lack of definition about existing resources. The revised submission was approved in July 1967 with the following comments: 1) indication that the role of the two medical schools has been diminished in favor of a separate group of professional people who will spear-head the planning was viewed as an improvement; 2) the program methodology and evaluation were not clearly stated; and 3) the region will have to consider disposition of staff and equipment if future planning dictates dividing the area into new regions for the operational phase. During the planning phase, Dr. Florin, on loan from the State Health Department's fIeart Di.sease Control Program, was appointed Coordinator and 18 other Core staff personnel were also employed. Urban health planning was becoming a strong feature of the program: the Urban Health Task Force was organized and three staff were employed t.o work with the three Model Cities Programs in tile state. 'File operational application was reviewed and approved, following a site visit in September 1968. The site visitors pointed out that: 1) the medical schools problems of reorganization and early growth has forced the @IP to draw on the skills and abilities of the more highly developed hospitals and other facilities; full information about the portion of medical needs of New Jersey being met in New York and Philadelphia is not available; 3) individual New Jersey hospitals NEW JERSEY RMP -3- RM 42-CP (AR-1-CSD) have developed independently and may have less experience in cooperative efforL than in areas where medical school affiliations have been in effect; ,,iti(I li) the historical separation between the northern and southern parts of state @,,i.ves way slowly. Approval was given to three coronary nurse training proposals, an external cardiopulmonary resuscitation program, a training program in coronary cineangrography, an evaluation of the status of implanted pacemakers, tumor conference boards in hospitals, a medical tape and fall library, and a hemodialysis training program. f)uring the first operational year, a supplemental project request to detect high risk atherosclerosis in an industrial setting was submitted and dis- approved, and Core was renewed for three years. Problems arose during this time between the Camden County Medical Society and the proposers of the West Jersey Hospital ambulatory care project, which would have attempted to evaluate a new,pattern of health care for an indigent population in an urban ghetto area. Since there were feelings among certain forces that the proposal would disturb the existing patterns of delivery of service, the proposal was withdrawn from RAG consideration. The second operational year saw the approval and funding of six Urban Health Coordinators for Model Cities areas, the approval and funding (from carryover) of A cancer care course for nurses and continuation of Core and six of the original nine projects. The Region's present level of funding is $1,306,906, $69,125 of which is carryover ' The Region has allocated $872,956 to Core (including the Urban Health Component) and $433,950 to projects. Regional Objectives Determination of the NJRMP's objectives came as a result of the reorganization of the RAG. While some members apparently felt"that the law should be inter- preted literally," others looked upon the legislation as a general guideline. The Regional Advisory Group reports that its many new members (including several consumer and minority group representation) urged that the program be concerned with improving the accessibility, quality and quantity of health care for the disadvantaged. As these consumer interests emerged, they received support from some of the provider representatives. Three general. goals have evolved: 1) improving accessibility, quality and quantity of hc-al.tfi servi.ces for the urban disadvantaged; 2) increasing the effectiveness and efficiency of existing health facilities and services; and 3) increasing the skills and knowledge of health practitioners. The Region has discussed each of its program components as they relate to these objectives and has also assigned a priority rating to each new project. Organizational Structure and Processes Ttiiti,ill.y the NJRMP RAG had 57 members with a 15-member Executive Committee composed of representatives of the medical profession, medical schools and ;tat:e and voluntary health agencies. Following a major reorganization, the N EW J ERS CY @T -4- RM 42-@ (AR-1-CSD) 25-member RAG now includes 13 members at large and 12 permanent members who continue to represent the major health interests of the Regioq. With the 13 general members, consumer representation was added. The RAG is the major priority setter and decision-making body. They review ongoing (,I)erations, Core staff activities and the activities of the councils and task forces. Rather than reviewing individual proposals on their own merits, the RAG now considers each in the context of the three regional objectives. 'I'lic following councils and committees have been established by the RAG: Executive Committee Nominating Committee Council on Ifeart and Related Diseases Council on Cancer Council on Cerebrovascular Disease and Stroke Council on Continuing Education for Physicians Council on Continuing Education for Allied Health Personnel Urban Health Task Force Council on Communications Committee on Information and Library Services Each council develops areas of priority and suggests project activities to be deve loped by staff. Following approval of a specific project concept, it is then discussed by the RAG and approved for project development. After staff development, when the project is written, it is reviewed by the appro- priate council and referred to the RAG with the council's recommendations. The councils' technical review criteria have not be discussed in the applica- tion. Fc)r a discussion of Core structure and function. please refer to the continuation section of the application components. Developmental Component $123,500 Developmental funds will be used to explore new areas and test new concepts related to the three regional goals. 1. Improving Urban Health. The Region will explore group practice in the ghetto area, new health career opportunities and career ladder opportunities for the utilization of community health consultants, and the concept of the liospital-based family health care center. 2. Increasin- Existing Health S(--rvices. Ideas the Region would like to investigate under this objective are a method for collecting health information on facilities, service and manpower, the need and acceptability for a comprehensive treatment service for patients with chronic obstructive lung disease, and a plan for the procurement, storage and utilization of human organs for transplantation. 3. Improving the Skills and Knowledge of Health Practitioners. A(@-ti@- vi.ties planned under this objective are programs to encourage Physicians Lo increase their diagnostic skills in early recognition NE4 JERSEY -PMP -5- RM 42-02 (AR-1-CSD) and treatment of coronary heart disease, the establishment of community centers designed and equipped to identify high risk heart disease patients, and programs in stroke education and management. allocation of funds will be determined jointly by staff, councils and RA(;, with t[ic- RAG giving final'approval of each activity. Present Application Continuation - These components have been reviewed by staff. Their program and funding recommendations are in a supplementary memo. Core $656,931 Coordinator Dr. Alvin Florin I Fiscal Office ---------------- Deputy Coordinator ------------- Communications Dr. James Harkness Statistical Services Administrative Assistant Dirlector of I Continuing Program Director Director of* Education of Heart Disease Urban Health Physicians Associate Program Coord. Planning I Coordinator Cancer and Project Coordinator* Program Coord.* Urban Health Field Coord.7- & Asst. Coord. Coordinators* NJCM&D -,Stroke Program 2 Field Coord'@. Coordinator South Jersey -- 2 Nursing & Allied Health Coordinators *Funded by operational projects. Each funded and proposed project is assi.gn(@d ,i Core staff I.iaisoii officer who assists the affiliated institution in achieving i.Ls goals, relating the activities of one project to others and monitoring the project's progress. During project development, fie assists with wording purposes and objectives, suggests funds required to achieve stated objectives and develops evaluation methods. In addition, a large number of the new projects in this application resulted from feasibility studies, in whicfi staff participated. These activi- ties form the documentation upon which evaluation of program achievement is made. Staff also are expected to be familiar with developments in the region and the nation in his substantive area. Each senior Core staff member has major responsibility for staffing a council or task force. NI;14 JERSEY DIP -6- Rm 42-0,' (AR-1-CSD) Salaries of several of the Core staff members are funded by projects. The Urban Health Coordinators-are one example. This project was written to provide each of the nine Model Cities with a senior health planner to help p 1,'iii, develop and implement the health component of the DIIUD Model Cities @)ro,,,ram. They have also operated,in many instances, to obtain technical @issistance and categorical funding for the health plan and related projects. Tn addition to the.Urban Health Coordinators (Project #12), the cancer program coordinators are assigned to the tumor conference board program and a physician will be detailed to assist with the first year's development of Project #14, Regional Program for Continuing Physician Education. Other staff members are assigned to the New Jersey College of Medicine and Dentistry, the SLate Health Department and the Southern District Health Office of the SLate Health Department for development of an application to establish a CHP (b) Agency. As far as relations with CIIP are concerned, there were some suggestions that @IP and CHP staffs be combined. A joint committee studied a plan for possible merger, but after a new Director of CHP was appointed, plans were dropped. Subregionalization activities in the NJRMP have been coordinated with the development of b agencies. Core staff members have been involved in numerous other activities which facilitate planning in the region. They have been responsible for such activities as arranging for systems analysis consultation for a statewide mobile screening service, assistance to a local hospital in developing a pro- posal for psychiatric aspects of patients with coronary artery disease organizing subregional cancer conferences and facilitating project dev;lopment@@',@, . in funded Model Cities related to other federal and state agencies. There are 28..5 full-time positions budgeted; all but one are filled. Continuation support is also requested for six ongoing projects: Project #4 -External Cardiopulmonary Resuscitation Project #6 -Evaluation of the Status of Implanted Pacemakers Project #7 -The Establishment of Tumor Conference Boards in New Jersey Hospitals Project #,9 -II(-modialysis Training Program Project lkil- Cancer Care Course for Nurses llrt-ii cc ti'r' IUrban ][earth Component @'(,iiewat ilroject 7-,@'-3R - Ro,,,,ioAal 'rraiiiin@; for Cardiac Nursing. $66,252 @ile visit, Committee and Council action are required for this one-year rc,ii(-,w,il request. The project requests a third year of support to continue to meet the needs of the Region's community hospitals for registered nurses trained in intensive coronary care until the transition to NJRMP is goal of decentralized nurse training is achieved. The Newark Beth Israel Medical Cc,nter will train an additional 80 nurses in the four-week course. NE14 JERSEY RMP -7- RM 42-0? (AR-1-CSD) Supplemental Projects. Site visit, Committee and Council actionarerequired in the following 1.5 projects. Project /r'1.3 - Hospital Based Family ft(,alth Care Service, Middlesex $235,066 General Hospital, New Brunswick. This project establishes a three-year demonstration program to evaluate the effectiveness, acceptability, quality and cost of a family-oriented comprehensive ambulatory health care service provided by a comunity general hospital representative of the majority of community hospitals in the region. The service is designed to strengthen existing community re- sources for the disadvantaged with a formal mechanism for direct community participation in the planning and operation of the service (objective #I).. This experience will provide the New Jersey Regional Medical Program with guidelines for the establishment and operation of hospital-based ambulatory services to meet the health care needs of the disadvantaged. These NJR4P guidelines will be available to community hospitals throughout the region. As the Regional Advisory Croup reviews the availability of health care services for the disadvantaged throughout the region, they will recognize gaps in services, establish priority communities and promote the adoption of community hospital-based ambulatory services, and be able to recommend a tested mechanism for the organization and delivery of service. The Regional Advisory Group will promote the establishment of a statewide committee to make recommendations for securing new financial resources in order to insure the continuation of this service and its adoption in other community hospitals. Second Year: $223,670 Third Year: $237,647 Project l@14 - Regional Program for Continuing Physician Education. $70,758 This project proposes to provide all practicing physicians in the region with an opportunity to become aware of all phases of medical knowledge and development through a medical school organized program of continuing physician education in order that the hi.ghest quality of medical care can be delivered through a coordinated and supervised system. The Medical College of Now Jersey at Newark will organize a region-wide educational program for practicing physicians involving community hospitals and specialty societies. 'this project addresses the goal of increasing the skills and knowledge of health practitioners (#3) by coordinating educational programs for physicians sponsored by hospitals, medical schools, the Academy of Medicine and specialty societies. Second Year: $108,062 Third Year: $151,649 NEW JERSEY RNP RM 42-02 (AR-1-CSD) e' 3,973 Comprehensiv Stroke Car and Educational Program. Project #15 e $15 'File purpose of this project is to encourage the staffs of six local hospitals serving a population of 616,640 in a two-county area to parti- cipate in a cooperative educational and clinical program designed to increase their knowledge'@and effectiveness in the care of patients with'transient Lscliemic attacks and completed strokes. 'file Council on Cerebrovascular Disease and Stroke established a regional plan for the development of comprehensive stroke care services. After ayear and a.lialf of detailed planning and building cooperative working relation- ships, an application for a two-county program was designed. Project #15 provides new services and facilities (objective #2) for stroke care. It wi also encourage physicians to refer patients to these services. This project will coordinate the resources of six hospitals to insure that all stroke patients in a subregion receive the full range of services required. Second Year: $132,971 Third Year: $138,911 Project,#16 - Professional and Patient Stroke Educational Program. $73,873 The a.im of this project is to encourage and stimulate the staffs of ten community hospitals in Bergen County (population one million) to strengthen the management and prevention of cerebrovascular disease by participating in cooperative demonstration education programs designed to increase the knowledge and effectiveness of physicians, 'nurses, allied health personnel, and families of patients. Developed on the basis of recommendations'-",..-,.' of a feasibility study, this project attacks objective #3 by improving patient care through the education of physicians, nurses and other allied health personnel. It also helps to achieve a balanced categorical program for the region, promotes subregionalization and involves the practicing physician in planning. Second Year: $77,091 Third Year: $76,174 Project #17 - Regional Blood Freezing Program. $63,720 This project hopes to increase the opportunities for all patients in New Jersey to have access to a frozen blood program so that they will receive the advantages of newer and safer methods of blood replacement. It will accomplish this aim by expanding the Essex County Blood Bank to a region- wide system, educating health professions about the use of frozen blood, and increasing the emergency supply of blood in the region. '-riiis. project serves the region's second objective by decreasing the risk invofved in multiple transfusions and increasing the effectiveness of organ transplants. It also provides an additional source of blood for emergencies and rare blood type needs. Second Year: $54,021 Third Year: $18,185 NEW JERSEY RMP -9- RM 42-OL> (AR-1-CSD) Project #18 - Model Cities Community Health Improvement Program. $824,929 ']'lie. Model Cities Community Health Improvement Program has been formulated to provide health planners with the requisite information for designing ii(ic,ded improvements i.n the health care delivery system for ghetto residents. Program wil.l. Identify and describe the scope of major health problems, the utilization of existing health services and the spectrum of obstacles to utilization - information, motivation, availability, accessibility, facilities, and financing. Through a large-scale mobile screening service, employing Model Cities residents, the proposed program will include inter- views, health examinations, referral and follow-up services, and provide a limited funding mechanism for the medically indigent. It will permit entry into the health care system, and give impetus to the improvement of local health care delivery through specific recommendations to Model Cities agencies resulting from the analysis of.program operations. This project is designed to offer screening and referral services until the comprehensive health centers are more widely established. Second Year: $954,084 Third Year: $967,820 Fourth Year: $832,242 Fifth Year: $847,385 Project #19 - Comprehensive Family Health Service, Newark Beth Israel @51,21r),59f, Medical Center. This project would establish a tiiree-year demonstration program to evaluate the effectiveness, acceptability, quality and cost of a family-oriented, group practice,comprehensive health service in an urban community hospital setting. The service is designed to fill the physician deficit in a central city area serving disadvantaged and medically indigent families, and to provide for direct consumer decision-making in the planning and operation of the service. This experience will provide the New Jersey Regional Medical Program with the ,necessary information on personnel and facility and funding needs for deliver- ing acceptable and adequate medical care to this population through community hospitals. The information will be used to develop guidelines for the establishment and operation of a hospital-based ambulatory care service with recommendations for the funding required to provide this type of care for the entire region. High priority has been accorded by the.Region to this project and Project #13 as ways to test the concept of providing compreheiisiv(-! heal.th services to the disadvantaged (objective #I) through the existing hospital facilities of the region, rather than tliroupli the establishment of new, co,@ti.y free-standing centers. Second Year: $1,150,513 Third Year: $1,193,249 Project #20 - Decentralized R.N., L.P.NI Cardi,ac Nurse Training. $84,405 Tile aim of this proposal is to improve the care of patients with cardiac conditions by increasing the capability of local hospitals in a four-couhty NEW JERSEY RMP, -10- RM 42-02 (AR-i-C@D) subregion to conduct their own training programs for nurses, and by establishing a new'role and training progrqm for Licensed Practical Nurses in intensive cardiac care. The project resulted from a feasibility study of multimedia instructional systems which determined that, when utilized under the supervision of skilled faculty, this teaching method can be effectively and economically employed in local hospitals to train'their own staff. The proposal furthers the aim of objective #3 by improving the knowledge and skills of R.N.s and L.P,N.s6 Second Year: $70,496 Project @k2l - Nursing Education for Leadership and Clinical Teaching. $41,579 Proposed by Rutgers University, Extension Division, this project would attempt to meet the region's continuing need for leadership and teaching of hospital nursing'staff in specialized clinical areas by inaugurating an educational resource within Rutgers, to develop the leadership skills of iiurses and prepare them as clinical instructors in cardiovascular-cardiopul- monary patient care in the first year, and additional clinical areas in the second and third years. Second Year: $48,598 Third Year: $50,168 Project #22 - A Regional Radiation Automated Dosimety Project. $184)082 Project #22 is grouped under the objective of increasing the effectiveness and efficiency of existing health facilities and services. It will link the resources of major medical centers of the area to the community hospitals by establishing a mechanism to program radiation doses. Radiotherapists and physicists will be freed to extend their services to hospitals treating patients with megavoltage equipment, but without qualified personnel. Directed by the New Jersey College of Medicine and Dentistry, the project will make available and accessible optimal radiation therapy for cancer patients through- out the region by providing radiation therapy consultation and automated dosimetry for patient radiation therapy departments having megavoltage radia- tic)n therapy equipment. The project developed as a result of a regional radiation therapy survey undertaken by the NJF14P Cancer Council. Second Year: $96,116 Third Year: $100,955 Project #23 - A Cervical Cancer Screening and Education Program. $162,825 Originally funded as a 314e grant, this project provides a means of delivering the benefits of a cervical cytology program (referral, screening and follow-up) to increase the early detection of cervical cancer among females at high risk in low socioeconomic groups in a sub-region of New Jersey (Middlesex County: population 560,000 people); and also provides a demonstration program for other sub-regions of the state. The proposal is also expected to increase the region's knowledge about the extent of disease among the disadvantaged (objective #1). Second Yoar: $174,469 Third Year: $197,686 Ni@'w JPRSI-l'y l@P RM 42-02 (AR-]--CSD) Project IP24 - A Training Course for N.J. Tumor Registry Secretaries $19,140 Sponsored by the NJRMP, this proposal will organize courses and workshops to train tumor registry secretaries. It was generated from the activities of the ongoing Tumor Conference Board project, which saw the need for comprehensive and up-to-date records of cancer patients to insure follow- up and suggest the location of specialized facilities for cancer treatment. As such, it addresses the goal of improving the knowledge and skills of health practitioners (objective l@3). Second Year: $19,142 Third Year: $19,778 Project #25 - Primary Rheumatic Heart Disease. $66,517 This project's purpose is to reduce the incidence of rheumatic heart disease through the early identification of streptoccoccal infection by providing free throat cultures to all school children with symptoms of sore throat in a subregion, utilizing school nurses; by outlining and conducting an educational program on the importance of this procedure; and by providing a home follow-up mechanism for children failing to maintain penicillin treat- ment. IL will increase the effectiveness and efficiency of existing health services (objective #2) by utilizing the services of the school nurse, Second Year: $59,035 Third Year: $56,792 Project #26 - Regional Medical Library and Information Network. $122,608 Sponsored by the New Jersey College of Medicine and Dentistry, this project is designed to strengthen the capability of the region's community hospital libraries to provide readily accessible, comprehensive medical information for patient care by creating a regionallibrary network, training personnel and expanding information services. The capability of community hospital libraries and their staffs will be increased and made more effective through this network, which will link all hospitals to the existing regional li-brary resources at the medical schools. Second Year: $92,790 Third Year: $63,842 Project #27 - New Jersey Consumer Health Radio Program Series. $52,950 This project will call. upon the resources of all 49 local radio stations within the region for disseminating specially prepared programs for the disadvantaged and the general public. The project @7ill be organized and directed by the Communications Division of the New Jersey College of Medicine and Dentistry working with the scientific faculty. Thus, the project utilizes existing radio facilities and various departments and resources within the college, as well as informing the disadvantaged about good health practice,-,, answering questions about special health problems, and providing information about access to available services (objective #].). The College conducted a pilot experiment in the use of radi-o to answer consumer questions concerning health and medical care with a grant from the flunt Wesson Corporation, which produced exceptional results: an increase in registration iL tl@ic Pre-Natal C'li-nic, Drug Abuse Clinic and Family Health Care (,enter and, some decline in the use of the Emergency Room for optional services. Second Year: $39,256 Third Year: $26,769 DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE PUBLIC HEALTH SERVICR@ HEALTH SEFTVICES AND MENTAL T-IEALTH ADMINISTRATION Date: December 1, 1970 to ,in Of. Subject. Staff Review of Non-Competing Continuation Applicati on from New Jersey . Regional Medical Program, 5 C03 RM 00042 Acting Director 'Regional Medical Programs Service THROUCII: Chairman of the Month a]. Development Bra Acting Chief, Region nch The New Jersey Regional Medical Program i.s requesting continuation support for its 03 operational year for core and six projects. Since New Jersey's budget year does not start until April 1, 1971, and the 45-day estimate of expenditures is not due until mid-February, requests for use of carryover funds have not been included in the present application. It should be noted that the Region has no approved and unfunded projects. Therefore, the discussion was limited to the following continuation request. Continuation Requested Amount Core $656,931 #4 -.External Cardiopulmonary Resuscitation 50,545 #6 - Evaluation of :the Status of Implanted 68,104 Pacemakers #7 -Establishment of Tumor Gonference Boards 150,02 in New Jersey Ilospitals #9 -Hemodial.ysis Traini.no Program 40,144 C) #II- Cancer Care Course for Nurses 61)414 #12- Urban Hoilth Component of Core 209@01.6 Total Request $1 236,176 Besides the continuation request, the R(@gi.on has included i,ii its AR application, a request for a one-year devclopiiletital component, one renewal and 15 new projects. The Region was supported by a funding level of $1,306,906 during the 02 year; this amount included $69,1.25 in carryover. Acting Director, RMPS Page 2 Recommendation: In view of the progress evidenced by the projects (some have exceeded their objectives) and the apparent competence of core staff, approval of the committed level for the 03 year is recommended. The following staff members attended the November 23 meeting: Miss Dona Houseal, Grants Review Branch Mr. Lee Teets, Grants Management Branch 'tte, Planning and Evaluation Mr. Larry Wi Branch Dr. Veronica Conley, Continuing Education and Training Branch Gene al Comments and Site Visit Issues: Staff found the application well-presented. Three regional objectives are outlined, and throughout the application, past, present and future activities are related to these goals. The regional objectives are: 1) improving the accessibility, quality,and quantity-of health services for the urban disadvantaged; 2) increasing-the effectiveness and efficiency of existing health facilities and services; and 3) increasing the skills and knowledge of health practitioners. The application informs us that the Regional Advisory Group's responsi- bility is to establish priorities and review proposals based on these objectives, while the Task Forces and Councils provide technical review of the projects and recommend policy in their special. areas. Core staff involvement includes assisting with development of projects, conducting feasibility studies and staffing the Councils and Task Forces. Based on this information, staff raised the following concerns for the site visitors' attention: - Review C i-teri-a. The Region has not included its review criteria used by its Task Forces and Councils for technical review of projects. Since this type. of review has now been transferred to the Regions, it becomes very important for national reviewers to have some judgment of this process. Therefore, the Region should be asked to discuss this during the site visit. Staff was also interested in knowing how ideas for feasibility studies for proposed projects are selected. Reorg:aiiizati.on of RAG. Following a major reorganization , the RAG now includes 13 general and consumer members, five of whom are blicks. As a result of this change, certain objectives have been set for the Region.. Staff wonders what problems have occurred and how the PI@IP --- Corr-, review groups and involved organizations -.-- have coped with them. The -question f Medical @ociety involvement is crucial here- 0 Acting Director, RMPS Page 3 Evaluation. Who on Core staff is responsible for coordinating evaluation efforts, both project and program evaluation? medical School Involvement. Medical school development is in a state of flux in New Jersey. Staff is concerned about the degree of medical school involvement in RMP as a result of this change. Status of Board for Grantee Agency_. In November 1968, the RAG was reduced from a 57-member to a 25-member policy-making body which was to serve as a Board of Directors for the governing body of the grantee institution, the New Jersey Committee for Implementation of P.L. 89-239o Staff is concerned about this overlapping membership and that the RAG, by serving as the board for the grantee agency, may be advising itself. Staff would like the site visitors to explore this situation and determine whether such a conflict of interest exists in guidance of the program. Support of Proposed Projects Without RMP Funds. The Region is requesting approximately $11,500,000 in supplemental project activities. Given the'apparently bleak prospects for a significant increase in the national vailability of funds for such activities in the next year, staff wondered if the Region had any plans for alternate sources of funding. Conclusion:: The committed amount of @1,236,176 is recommended for thta Region's third operational year. Sarah J. Silsbee Acting Chief Grants ReTiew Branch Action by,Director Initials Date @l, 11 C.! c@ 4,@ ST- T @,v7 A. @@t) Co 42-02 1- CS!)) 2 /7 1 cp-17J 13'Z 1971. t 2) t C, for 15 projects, arLl 3) zi 1):! partially sttp,@,@.rtr@et z,!; f c, 1 107 7@@, y $ I , 2 3 1 3,300,624 3 , 3 "D 2 l@ 3,299,@625 3,,299,625 $123,5f.')O 70 1, I,-,7 $ 1 3 0 7 3 Yi l@R A 1) a, v -a Ir,@ "Ii c t s 03 $1,236,176 -1 2 @Do 2 5 $2,9S9,50'L 1 31,17 75,@', 1,357 05 1,276,466 Tb,.r.,@ L 1 2 3 5 0 0 @4,264,041. $5,623,7.17 tioiis Ba,,ie es site visit recon@i@@Lid@. Iii its del5.bei7,iti@c)ii, tl.,c@ Cr)nii@.ii.ttee vccc-,-)ted ttie report of thc- site visit to the P..t@-,-I,on on 10-11, 19700 Ti-ie visitors on of this -@)@ic2 tl@ie 1,i 5 t NEII J@",SEY RZ-IP -2- -Ml 42-02 (AP,-I-CSD) 2/71 site visit. Pic reo::-a.,iized Regional Advl,,,--oy-y Ipp@@,ir's to be functioning very effectively as a poli6y-makiii@ body, The PAC, has established tlire@@.a goals for Lllc-- o-r),-r-,tionil projects ;,;hicli have been developed by a proceeds of r!ecrotiatioiis knIrnoLIrr the PA-r, merib rt;. Althou-b not very sy,,3teTY.,.@tic, title process because the L,%-ro' is quite active and involved. and lotir, o jectives should be developed, however, to insure a plan of action that is consistent and measurable. Vie Itt@i-P has not @t data bise, although they I,-.tve li (I available d,-it,- collected other a@e@icies and has collected to SLIDPOrt ne@-,J3 fo-r call the pr,-),ject:s. T c Region sh,),,lld devote, rp-.3re attention to ejt,4blis'tlinr, a (lita base, which t..7ould mainly involve the synthesis of data from otber,a,.,encies* e proj@ct re-viel,7 procedures are i,7ell devcloi)@e, appear to effectively etteen projects,, set priorities aiid r,,onitor the -success of already f nded projects. The team reccri-inended and Co,-,,ni.ttee concurred that the r visa,) process@should@inclticip- an idversnry r@vie-@q step conducted by: l@ di-%Ii@Cluals OtIfic-@r those. if;,ib b@ave @-2ork,@O on tla-- dev6').o o@: -Ci@ j ic)@i Mechanics Iiia or,,,: -i- ti.n-n is 1,7elj. Vri(i 1,@@-o Oct eV @t bly i@l; iiiisle.-@.red. tii@c cl@@@.oi@iat c)f n@7,i tlie O,, ic@ receivers, core stafl I,."@lly be ve@'d@d to Al--IE)r.11le t I c-@ a 11-Orkloc7d (Since on@- of the present Core staff Positions I,,,Ill be funded out of a project budget in the future, this position could be de ic tei to t efforts). Al far as iiiiple,,l,,erLt@,tion ot the program is concerned, this Region, has ria -- r,@ i-,ie important achievemc@xits. In ttie o,.f stroriz" radical schools affiliate('. m6dical centers, tinny coril,@iunity hospital,-, ire the "I i,,-i sporso its continuing education ind patient care detionstration c @ a tiv-"-tieb. A education is bel,n3 dc!Nelnntd i,@,-.-ich v the co @ unity as the education and training locus for p sicignsi nurses and otlier health personnel. IP has also been a f rc-e n getting groups of hospitals together to pl.LiK-i region,--illy, such at @i6i &6tbk6 care progrcl,@s and radiation ficilit.1.6s. RevieTiers v; re iticularly intri-yited by the proposed to be ri,@-in-tecl by lu ity hospital.-, (in tl,-i-7ark and BrunswicIF) i.;Iiich 7,70uld test the c t, acceptance an overall feasibility of the co@,,ritinity hospital based comprehensive care center in a large and hospital setti@n"7 0 i pressiv6 wore the ReRion's efforts in'the urban hEllalth.6ector. RO'liog has s6.v6t6l vocal black consu erscn the-. G n active urban It 'Taslt Force and'r4i Urban -lif,.alth component of 'coie -..10hich places s aff in the n ne tioddl Citi6s to assist with the development of the h it part of the l@-,del Cities npplicationo These urban health planners h e:als6 provdd viluAble in seeking other sources of fun ng for various progta,-,i6, increasing the awareness of residents about health Ine d6.@@ind influcncit-trr the overall level of for 6tiier aspects of th'e;@ladel Cities prorram. Re;ion has been effective in involving other state@1.1--@@Cl-- croLi-,DS such ci s thin I-IP-dicr@.1 Socic-,t,,,, the tissociatioii and th,.- ly@iiriDes A6s6ciation. IIE@L JER@SLY PdAll -3- RI-,I 4,?-@iO2 (A-R-1-CSD) 2/71 c 0 )!T..di I-Scliool nnl involvc@,t,--,nt -.t the prec,,-rt is c nditionvj@, by tite@Lr probl :,is or and @,,c iile ti:ie colitelill tl,.e Gre ter Pc-lw,@iare Va Iley- a-nd t-li@. I,,L-w- -.Ters,@.y F-,4p 'over tille te@ri sout'@,i,@rn in Jer is co-@,itrol, agreed w2lt,@ the site visitors it slio'tiliA c-oi:.ttirtuc! to be -r,@.,7nitoreLI(I.7 attcntioii til@ possibility @Ono mo@@,bee of Co@@il!-Iittee brou-tit to the groLp of conflict Of- iritelt:est in the orgaiii@z@,itio@@i iii iF@-i3ch the-, 'iloard mciitbers- of- t,- tr, t c-, ri @.ttic@y, 't'-I-C Ci@.L--r@-,-it--Lo,@-: for t :e Ir@i)l PL. 8o-g39, @l:'c all@ litic, I:, '01c, tlic, site visitors liL-Vad t t t'@i i p sitttntibli cio-c,.@n't@iccessarily clictnte ci conflict of interest, c tee ttiet.in order to obvi.,,@tte ariy cloubt in. the futt@re, it should be rec-c 'L@eiided that the I-Ieaion ad he Boar(,Ils mefrb-@ sh@il in just t p -o t w@,y, p ssi@bIN,@by @dlinjz v@n-R.AG me,@bei8 to tliip- Board In-@co r-Iiisiort, t@ie reviewers I,erc pro tc.)@ date ,-aid is to tl,i,@ incr@-i c.,cl .j:,L I i i it tl.,,-@ Anni@,@-rse..zy Rr@vici@7 rs 1) :,Le, bo 'this c,7)tiitl b,-.@ at i@ lo .2.L' f i.@ i ri level t l@y til Cr@i itt; c re ,iltecl fr -I Llie of c@mllr3 atinsz fro -ij4ot 6L",6,anl.zritional cottin-s sucl"@ as hoipitals an(i ni§ 1-C I school . Piif-Is for a devol.or,@,A-Ac-.,4ital co.-.@,poncnt vi@re included, in @t ic i 4irig 16-vel. tec@,,use tili@,@ has ,t good rc-@co',.d of tAsiElz Ef.'Iall a hunts,, of T"66 v Spiac,in@-ttively, as t,7ell ar: tisii%cl furi(Is to initiate activ.@ ies e other -,otircc-s of sopp,ort, @,&Trec@d that this gion r,,6ritecl the privilege of h@.vin@,, fle:,,ib3.e Money.. REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAT GRANT APPLICATION (A Privileged Communication) New Mexico Regional Medical Program RM 00034 2/71.1 (S) University of New Mexico Medical School January 1971 Review Committee 920 Stanford Drive,, Northeast Building 3-A Albuquerque, New Mexico 87106 Program Coordinatot6 Reginald H. Fitz, M.D. Request (Direct Costs) Committee/Council Review: 03 04 05 Total Project #16 $45,188 $55,558 $575,069 $157,815 (formerly #12) Note: This project was presented to Committee and Council review at the February-March 1970 cycle. The Committeels recommendation for a "Return for revision and resubmission to include clarification of certain' concerns was endorsed by the National Advisory Council. This present application represents these efforts. In order to keep the program active and in phase with the New Mexico school year, $16,000 was granted from unspent balances from the 02 year with the 03 year award, for six months only (September 1-February 28, 1971). RMPS Staff Review: Continuation Support for Core Staff and 11 ongoing $1$1036 ,719 (commitment) activities Carryover 133,452 Total (d.c.) $1,170,171 Funding History (direct costs only) Planning Sta&e Grant year Period Funded 01 10/l/66-9/30/67 (grant extended from $384*317 10/l/67-11/30/67) 02 12/l/67-6/30/68 $252,379 (7 months) New Mexico RMP 2 RM 00034 2/71.1 (S) operational Program Grant year Period Funded oi 7/l/68-6/30/69 $965,305 02 7/l/69-8/31/70 (14 mos.) 1 252,911 03 9/l/70-8/31/71 191703,171 HISTORY OF PRESENT APPLICATION: This project was originally submitted for the February/March 1970 cycle and returned for revision in view of certain deficiencies. The reviewers felt that New Mexico is an almost ideal area to carry out a PhonoCardioScan screening program, and moreover noted that it was an indication that New Mexico had established an appropriate set of priorities. The primary concern about the application was that a program of this scope could not rely completely on volunteer technicians as was planned. Also it was unclear how the computerized registry would be used for follow-up, and there were no other indications of such measures to be utilized. There were no plans presented for phasing out RMP support, nor a statement of how the state, county health departments or school boards, would eventually be called upon to provide support for the program. There were other technical and budgetary concerns which were communicated to the region, as well as the suggestion that NM/RMP should seek assistance from other similar programs that are functioning well, such as Baltimore and Metropolitan District of Columbia. At the time of the submission of the request for continuation for the 03 year, RMPS staff gave special attention to a request for carryover funds (for one year only) to continue the salaries of physicians who had piloted certain demonstration activities. Staff agreed to this proposal, in order to keep the project operational, and the continuation award of September 1, 1970 granted the amount of $16,000 to continue the program, but with the last six months funds restricted pending the receipt of an Anniversary Review package on November 1, 1970, to include a revision of the project in line with Committee/Council suggestions. NM/RMP decided to delay submission of the A/R application until February 1, 1971, which made it necessary to revise and update this New Mexico RMP - 3 - RM 00034 2/71.1 (S) project request for three years, for submission to the JAnuary/February 1971 cycle. PRESENT APPLICATION: First Year The revised application has followed very closely the suggestions Recluested and concerns of the Review Committee and National Advisory Council. $45,188 The objectives are: 1. To detect previously undiagnosed organic heart disease in school children. 2. To provide initial evaluation and, if needed, long term follow-up for children who are found to have unrecognized organic heart disease. 3. To establish the prevalence of previously known and unknown congenital and rheumatic heart disease in New Mexico school children. 4. To "delabel" children who have been previously diagnosed as having heart disease, and are found to be free from cardiac disease by the screening physician. 5. To utilize these and other epidemiologic data to establish a registry for congenital and rheumatic heart disease. 6. To acquaint health professionals in New Mexico with this program, and to conduct education programs (e.g., in association with screening clinics) for practicing physicians and nurses. 7. To develop educational programs for children and parents related to the nature, prophylaxis, and treatment of heart disease. This proposal has been approved by the State Medical Society and has received favorable review by the Comprehensive Health Planning "A" Agency Council. Community acceptance has been excellent and many localities have requested the program on their own initiative. There have been no problems in recruiting volunteer technicians. In Los Alamos, an educational program for practicing physicians has been conducted in association with the local cardiac clinic. All communities requesting heart sound screening must obtain local medical society approval for one of the following two alternatives: (1) local medical society appoints one physician to conduct secondary screening in the school setting, or (2) requests the services of the Project Director or Assistant Director, or other physicians designated by them. The PhonoCardioScan Registry was established in order to facilitate accurate data collection and storage and to provide a means of continuing, regular follow-up of patients. An elaborate computerized system will not be necessary since the anticipated number of new cases will probably not be greater than 150 - 250 per year. It is possible that ultimately that the PhonoCarioScan data will be incorporated into the region's Health Information System which is New Mexico RMP - 4 - RM 00034 2/71.1 (S) planned. Data collection and storage will be manual but will be designed for adaptation to computer systems if needed later on. The Project will be staffed by a Director, Dr. Robert F. Castle, assisted by Dr. Jonathan Abrams, (20'/. and 15%), a full-time Nurse Coordinator and full-time Assistant PCS Program Coordinator, plus ti4o part-time clerical staff. Three PhonoCardioScan computers have already been purchased, one by the N.M. Heart Association and two by the NM/RMP. The Heart Association has also allocated $1,350 for travel expenses and provides office space and part-time additional secretarial assistance. The Heart Association has thus far absorbed telephone costs as well as office supplies, and has pledged from $10,00-$15,000 in 1974-75 with modestincrements thereafter. Cost of individual case detection will be computed periodically. Direct costs vary inversely with numbers screened, since the major outlay has been for the PhonCardioScan computers. Costs will be computed with respect to grade and socioeconomic levels, although data collec- tion to date has not been so analyzed, but will begin with the appointment of the full-time Coordinator. The registry, when established, will provide efficient cost analysis, as well as preva- lence rates from different socioeconomic and geographic areas. It is hopedthat the screening will become routine in most New Mexico school districts and some locally autonomous programs may be functioning by the end of the third year. In most school systems the program will include pre-school (Head Start) children, as well as 4th and 10th grade students. Direct costs for the program from February 1969 through August 1970 totalled approximately $19,780. Cost per child screened was $1.20 (through June 1970). The cost of detecting each child with previously undiagnosed heart disease was $1,312. The latter figure reflects the large initial cost of the screening devices. These costs will decrease with more screenings per machine. During the academic year of 1971-72 an expansion of the program is projected. By this time, a group of physicians and trained volunteers should be established throughout the state conducting the program in many communi'ties. Some long term support will be requested from CHP as well as state and local health budgets. 03 Year: $55,558 04 Year: $57,069 RMPS/GRB/12/22/71 A PRIVILEGED COMMUNICATION S@RY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIE7@ CO@a',IITTEE NEW MEXICO REGIONAL MEDICAL PROGRAM I00034 2/71.1 (S) FOR CONSIDERATION BY FEBRUARY 1971. ADVISORY COUNCIL RecoLn,iiendation: Additional FunJs as requested to be provided with emphasis on the importance of follo@,7-up data to be provided to the registry. Y@ar' Request Recommended Vund'n 03 $45,188 $45,188 04 55,558 55,558 05 57,069 57,069 Total $157,815 $157,815 r@i@@e: Project #16 (formerly#12). The Review Committee was impressed with the improvement in this revision, but still had reser- vations about part"time.physician personnel. It was felt that the region'should be encouraged to enlist additional assistance from volunteers in order to maximize progress made thus far to maintain its momentum. The project is believed to be realistically planned for the needs of New Mexico children. The involvement of the Heart ssociation is noteworthy as is the interest of the Department of Public Health which will eventually take over the program. The reviewers questions d the Consultant costs ($10 000) in lieu of full-time staff, which will provide a fee of $50.00 per half-day for the secondary screening. It was noted, however, that such physicians would be local, qualified, specially trained individuals, or fu -time faculty of the University of New Mexico Med,ical School. In the latter case, the $5OoOO honorarium will be paid to the Faculty of Medicine Fund and not to the individual physicians. The other concern expressed was in reference to the documentation of cases detected. Committee wondered if the registry will provide the means for continui@ follo-v7-up of these children, how they will be identified, etc. The emphasis here was on the importance of the registry being kept in an "active" status and not allowing the data to lie dormant without appropriate follow-up. The region should be cautioned about developing an excellent system, which without careful monitoring along the way, could fail the children for whom it was designed. Pi,TT).q Ir-pp,II 8 /71 REGIONAL MEDICAL PROGRAMS SERVICE SUMKARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) New York Metropolitan RM 58-02 (AR-1-CDS) 2/71 Regional Medical Program Janaury 1971 Review Committee 2 East 103rd Street New York, New York 10029 Program Coordinator: I. Jay Brightman, M.D. Request (Direct Costs) Committee/Council Review 02 03 04 Developmental Funds 329,000) Four New Projects 811,686) $647,943 $760,512 Total New Funds $1,140,686 $647,943 $760,512 RMPS Staff Review Core ($1,146,791) 10 Projects 1,538,061) Total Continuation Funds $2,684,852 TOTAL REQUEST $3,825,538 $647,943 $760,512 Staff Recommendation: Continuation Funding at Committed Level $2,539,887 ( 1,146,791) Core ( 1,393iO86) Projects Funding Histor_y Planning Stage Grant Year Period Award 01 6/l/67 - 5/31/68 $ 967,000 02 6/l/68 - 9/30/69 1,688,875 03 10/l/69 - 1/31/70 516,000 New York Metropolitan RNP -2- RM 58-02 (AR-1-CDS) 2/71 Operational Stage Grant Year Period Award Commitment 01 2/l/70 - 1/31/71 $2,163,744 02 2/l/71 -12/31/71 $2$539,887 03 1/l/72 -12/31/73 1,932,320 Background: The New York Metropolitan Regional Medical Program covers the five counties of New York and the contiguous counties of Westchester, Rockland, Orange and Putnam. It serves nine million people, including 35,000 physicians, 223 hospitals, 43,000 nurses and a multitude of other professionals. Seven medical schools are located in the Region: New York University, Columbia University, Albert,Einstein, SUNY Downstate Medical Center, Mount Sinai, New York Medical College and Cornell University. The Associated Medical Schools of Greater New York is the grantee agency. This organization was set up for the Regional Medical Program and includes the seven medical schools and the New York Academy of Medicine. The Trustees are the seven deans and the director of the Academy. Nominees for the Regional Advisory Group are recommended by a Regional Advisory Group (RAG) Committee and appointed by the Trustees. The New York Metropolitan RMP was first awarded planning funds on June 1' 1967. Two projects were funded during the planning phase from earmarked funds for a mobile coronary care unit and a pediatric pulmonary diseases program. Dr. I. Jay Brightman was appointed coordinator in January 1969. The Region applied for operational funds in May 1969, and a site visit was made in July 1969 at which time the team was impressed with the organizational changes that had been made under Dr. Brightman's direction: broader representation of the RAG, the emergence of a Planning, Priorities, and Evaluation Committee, closer supervision of the medical school core staff and project operations by the Directors, and broader functions for the Technical Consulting Panels. Council approved operational status and funding for five of the eight proposed projects in August, but due to funding restrictions, the first operational grant was not made until February 1, 1970. Still, in its first year the Region has 10 on-going operational projects. Technical site visits were made to the Region in February 1970 and July 1970. A site visit to study the Region's readiness for developmental funding was made in December 1970. New York Metropolitan RNP -3- RM 58-02 (AR-1-CDS) 2/71 PRESENT APPLICATION Regional Advisory Group Report: The report describes the changes that h'ave been made in the organization of the Regional Advisory Group. The rules were'revised in 1969 by an Ad Hoc Committee on rules which has since been appointed a standing co@ mittee. The Steering Committee was increased to a 35-member Committee on Planning, Priorities and Evaluation. A Screening Subcommittee was organized as well as a Subcommittee on the Developmental Grant and Priorities, a Subcommittee on Renewal Applications (which not only looks at renewal requests but continuation requests) and a Subcommittee on Evaluation. Considering the geographic impact of the Regional Medical Program to date, the RAG report indicates that the Northern counties, especially Orange and Rockland Counties, are still behind in their organization. Queens County will now have a County Committee. There is cross representation with the New York City Health Services Administration, the Health Department, the Westchester Health Department, the Health and Hospital Corporation and the Hospital Council of Southern New York. The Comprehensive Health Planning (b) Agencies have not yet been established although there is cross representation with the statewide CHP. The categorical disease planning groups completed regionalized plans in heart disease and cancer. Stroke, diabetes, and renal disease regionalized plans are well along the way in draft form. The RAG report indicates that the contribution and involvement of the medical schools faculties is still a problem. They found that the Associate Director positions had not worked out as well as expected and a Medical Allocations Committee has been set up, composed of two trustees, two members of the RAG, and the director, to look over the 12-month plans of medical school for budget and program. Manpower is considered an important problem in the region and there is an interdisciplinary committee on allied health education as well as an ad hoc committee on personal health services. The RAG report states that a project in Bedford-Stuyvesant was turned down in the technical review process; an appeal was made to the RAG indicating that the needs in that area were so great that this project was greatly needed; the RAG approved the activity and decided a different set of criteria was needed to look at these projects. The RAG report also states that the developmental component is considered an important element that would enable the region to go ahead with activities and not have to await national review or a turn down by the national review processes for things that they know are important locally. /71 New York Metropolitan RMP -4- RM 58-02 (AR-1-CDS) 2 Following is the number of people from various categories that are on the RAG and on the Committee on Planning, Priorities, and Evaluation: Membership RAG CPPE County Medical Society 9 6 Dental District 5 0 Nursing District 5 0 Other Societies 7 2 Voluntary Health Agencies 12 6 Hospital Administrator 8 2 Planning Groups 5 2 RMP County Committees 5 2 Public Health Agencies 8 0 Educational Agencies 15 8 Public Members 16 3 Core Staff: The progress report on core staff activity indicates t at the organization and central office has proceeded along lines recommended by the Management Assessment Team that visited the region last summer. A new position has been established for Assistant Director for Field Services and the planning and evaluation activities have been separated and will be an Assistant Director for Planning and an Evaluation Specialist. An office in White Plains will be set up through the New York Medical College and an office in Harlem is staffed by the Columbia University Associate Director. Queens County will have a staff representative as well as a County Committee. The application states that plans to have the Comprehensive Health Agency review the applications have been delayed because the Mayor's Task Force on CHP is not in a position to review applications now. The core staff is helping the Mayor's Task Force on CHP. A data book has been published and is available to groups throughout the region. A number of studies have been made through the core staff operation which enable the region to involve new geographic areas and program areas. Following is a list of the studies: 1. Intensive CCU Training with the Orange County Community College. 2. Epidemiology Survey of Cerebrovascular Diseases by the King County Medical Center. 3. Study of Facilities Services for Respiratory Diseases and Disorders. 4. Coronary Care Training Surveys. The medical school staffing for which about half of the budget has been allocated in the past, is now being studied and evaluated by a Medical Allocations Committee. While still a problem area, the application states that the medical school faculty is becoming more involved in the program. New York Metropolitan RMP -5- RM 58-02 (AR-1-CDS) 2/71 Developmental Component.- The subcommittee for developmental grant and priorities has fairly well'-rounded representation; three medical doctors, one doctor of Osteotrophy, and three consumers, including the RAG chairman. The application for the developmental component speaks to the need to build on the categorical disease planning that has taken place. The region-wide plans on the categorical diseases will serve as guidelines for priorities for program development. The region anticipates using developmental component funds primarily for pilot project-type activities which will determine feasibility, identify the problems, determine methods of overcoming the barriers and develop evaluation indices so that a major project can be developed. Each pilot pro- ject will be looked at from these criteria: will it serve more people, will it provide better service and will it help increase the manpower pool. A number of suggested ideas that might be considered for developmental funding are identified in the application. New Projects Project #25 - After Care Center for Chronically Ill Patients at First Year Montefi,)re Hospital - The project proposes to Request demonstrate the impact of a new modality of medical care through $164,310 the development of a Montefiore After Care Center for nursing home and home patients throughout the Bronx. Comprehensive diagnostic, theraputic, and rehabilitative services will be provided to the patients who are transported from their nursing homes or homes to the hospital. An estimated 300 patients would be served each year by the center. It is anticipated the project will provide better, more comprehensive care for more patients and that it will result in better utilization of scarce professional personnel by eliminating the travel time and single patient service now necessary for the home care service. It is also expected that the patients will benefit from the socialization and interaction with patients and hospital personnel. The project has the backing of all the major medical care institutions in the Bronx, the Visiting Nurse Association, Medicaid and the Bronx Medical Society. Based on current patient loads, it is expected that about 70 percent of the patients will be on Medicaid and/or Medicare and the services can be reimbursed. The project is expected to be self-supporting in two years. Cost effectiveness of the After Care Center Service and comparison of the program effects with additional home care programs, nursing homes, and extended care facilities will be studied. The project builds on a pilot study made by the Montefiore Home Care Service and the Department of Physical Medicine which indicated that six patients per hour could be served by a pbysicial therapist with the help of a physical therapy aides in the hospital setting, compared with six patients a day served by the home care service. New York Metropolitan RNP -6- RM 58-02 (AR-1-CDS) 2/71 Medical Director The project will be directed by Dr. Isadore Rossman, of the Montefiore H6me Care and Extended Services. Experienced personnel from Home Care Service and other Montefiore Hospital de- partments will be utilized in the project. The review history indicates that the Home Care Technical Consulting Panel reviewed and approved this project with certain modifications regarding possible methods of self-support. The estimated third party reimbursements have now been deducted from the full cost of the project and RMP is expected to provide only those funds that are not reimbursable. The project was reviewed and approved by the Committee on Planning, Priorities, and Evaluation and the Regional Advisory Group. 02 Year - $73,891 Project #26 - A Commur,-ity Model for Early Care of Heart Attack First Year Suspects - This demonstration project is designed Request to make changes both in the usual behavior, at the onset of a $150,650 heart attack, of patients and their families in a large defined population in Queens and in the responses of the medical care system serving this population. It represents the combined effort of the Health insurance Plan and two of its Queens' medical groups serving a population of 100,000 (50,000 age 35 to 74 years) and LaGuardia Hospital. The goal is to effect more rapid requests for medical care after the onset of a heart attack, And to institute a system capable at all times of a rapid and appropriate response which fully utilizes medical knowledge. The end goal is the reduction in the present high rate of sudden deaths from coronary heart disease. The project will be built around the HIP medical record which indicates those patients at high risk, those with prior coronary heart disease, hypertension, hyperglosterima; patients will be urged to visit their doctors once a year at which time the physicians will explain the program to them and the importance of calling into the system early. In addition, quarterly mailings of material will be sent to all the HIP clients in Queens. There will also be mailings of special project materials after they have been field tested. The project was originally conceived as having four main elements: 1) patient education; 2) centralized telephone screening at LaGuardia Hospital by physicians of calls from all possible coronary suspects will take place 24-hours a day, seven days a week, to reduce communication delay in bringing the patients!symptoms to medical attention; 3) a mobile team of para- medical personnel trained in necessary techniques for emergency care of patients experiencing mild myocardial -infarction complications with telephone and radio communication with the project's physician based at LaGuardia Hospital; 4) the operation of a special pre-coronary care area at LaGuardia Hospital for the observation of patients in two defined categories: (1) persons who do not meet the usual current criteria for hospitalization but who may be in the early stage of an acute myocardial-infarction not yet recognizable; and (2) patients New York Metropolitan RMP -7- RM 58-02 (AR-1-CDS) 2/71 who might be experiencing an ischemic episode not destined to lead them to a mild myocardial-infarction but capable of inducing a fatal arrhythmia. After the original proposal was reviewed by technical review process, the mobile team aspect was eliminated from the project. The project director felt while this would be a positive contribution, he agreed with the site visitors assessment of the less relative importance of this particular component. The project director intends to make arrangements with existing community transportation facilities to assure rapid response to calls from the centralized coronary screening physician. The KT site visitors also recommended that a separate, distinct, and well-staffed coronary care unit be established at LaGuardia Hospital; the project director gave definite assurance to the RMP that modifications would be made in the present coronary cake unit to restrict it to coronary patients but it was not possible at this time to have the CCU located in close proximity to the pre- coronary area. Long-range effects of this demonstration program are anticipated once the results have been evaluated. The project advisory committee is seen as the mechanism for disseminating results throughout the region. The American Heart Association has indicated an interest in supporting the field testing of materials. Information on the RMP review indicates that the project received careful review which resulted in changes in scope and costs. 02 - $178,840 03 - $189,575 04 - $190,140 05 $168,550 Project #27 - Ambulatory Care Nurse Training Program This project is proposed by the Bronx Medical Center Hospital - Jacobi, Albert Einstein School of Medicine and will also involve Morrisania, Lincoln, and Fordham Hospitals in the Bronx. The project is based on four years home care experience which indicated a need for the home care,patients to have one person in the hospital to whom they could relate for needed medical care. The project is designed to expand nursing practice in the ambulatory care clinic. It will make maximum use of the registered nurse in the setting of the ambulatory care nurse clinic; each patient will be assigned to a nurse after he has been seen In a diagnostic clinic or the emergency room. The nurse will follow her patients in subsequent clinic visits to see if therapeutic regimen prescribed by the physician is being carried out, to look for any changes in the patients' clinical status and in general, to provide a mechanism whereby the patient can avail himself of any hospital service he needs at any time. DS) 2/71 New York Metropolitan RNP -8- RM 58-02 (AR-1-C expand its nursing The Albert Einstein College of Medicine will training program to develop this type of ambulatory care nurse. A didactic program of 302 hours has been planned which will focus on nursing and medical care, and specific diseases, with strong emphasis on detecting changes in a patient's condition that will require the I ill also spend a total of physician s intervention. The trainee w 52111 hours in supervised clinical practice. The entire program will be six-months in duration. Eight ambulatory care nurses will be trained in the first year; 40 will have been trained by the third year. Each nurse, when fully trained, is expected to be able to handle a panel of 300 patients per year (or some 2,000 clinic visits per year); one physician will be available to work with a group of four or five such nurses. Trained nurses will also serve as perceptors for new trainees. The,project will be evaluated by an independent group of evaluators who will compare patients of the project nurses with the control group of patients with respect to each of the objectives of the program. The tooling up period is expected to take one year. The first eight nurses trained will be expected to go to four municipal hospitals to set up ambulatory care nurse clinics. A review history of this project, indicates that funding was found for the trainees' salaries through the New York Health and Hospital Corpora- tion. The RMP staff apparently did considerable work to emphasize the importance of the close collaboration between the nurses and physicians, and the applicant has accepted the New York Metropolitan RMP adopted principles relating to the expanded role of the nurse. 02 - $90,078 03 - $109,700 Project #28 - Earl of Breast Cancer - This project calls irst Year for establishing two breast canc r screening programs est in conjunction with cervical cancer screening programs at the $413,701 Metropolitan Hospital and Maimonides Medical Center in New York. The project will be directed by the Guttman Breast Diagnostic Institute, which has been established through support by the Guttman Foundation and the American Cancer Society to study, develop, and promote mass breast cancer screening on a practical basis. An estimated 20,000 women will be examined each year. At the present time, the Guttman Institute is performing 60 to 70 examinations a day to women over the age of 35, at fee of $15. A new type of mammography equipment (Senograph machine) is used for the mammography. The use of this machine has enabled the Guttman Clinic to speed up the process and reduce costs. Thermography is also used for selected patients. A mammography project has been conducted since 1963 with the Health Insurance Plan of Greater New York through the National Cancer Institute funding. It involved 60,000 women divided into two equal New York Metropolitan RNP -9- RM 58-02 (AR-1-CDS) 2/71 groups, one of which was periodically screened and the other, control group, not screened to test the effectiveness of mammography as a screening @thod. The result showed a significant difference in mortality from breast cancer among the women screened (31 deaths) as compared to those in the control group (52 deaths). During the latter part of this period, the Guttman Breast Diagnostic Institute was established to experiment with more efficient methods of breast screening including mammography, thermography, clinical examination and history taking. This project will attempt to incorporate the methods utilized by the Guttman Institute into ongoing hospital procedures. Both Metropolitan Hospital and Maimonides Medical Center have had projects (no longer funded through 314(e) funds) to examine women for cervical cancer and have carefully established follow-up procedures. By adding breast cancer to the screening procedure, the follow-up procedures already functioning can be utilized. The cervical cancer screening will:continue to be done by the gynecology department. The mammography will '7)e done by the radiology department but the mammograms will be read by the Guttman project director and his associate. The Guttman Institute will set up the project, will provide the equipment, train technicians and clerks, arrange for processing and interpretation of the films, supervise the follow-up and keep the records. The East Harlem Screening Clinic is also mentioned in the application; apparently the project director will be providing consultation to the center which has its own equipment. The budget request funds for a radiology clinician and techn c an at each of the hospitals as well as two health aides and a half-time program coordinator. Senograph mammography machines are requested for each of the two hospitals as well as thermograph machines. It is expected that this project will become self-supporting in two years. Not as much information is presented concerning the review of this particular project. It was reviewed by the Committee on Planning, Priorities, and Evaluation and the Regional Advisory Group. There do not seem to have been any changes as a result of the review. It is stated in the application that screening for breast cancer is considered a high priority activity developed by the cancer region-wide planning group. 02 - $205,134 03 - $102,567 Ongoing Pr cts, (See attached November 30, 1970 memorandum on staff review of continuation application.) Ten operational projects are now funded by the New York Metropolitan Regional Medical Program. Four of these projects have been functioning New York Metropolitan RMP -10- RM 58-02 (AR-1-CDS) 2/71 f Practicing only since July 1970. Project #11 - Continuing Education o Physicians at Brooklyn-Cumberland Med-ical Center and Project #12 - Development of an Area-wide Program of Continuing Medical Education for Physicians in Upper Manhattan Area at St. Luke's Hospital are both aimed at the physician unaffiliated with any hospital or without membership in education-oriented professional societies, of which there are about 3,000 in Manhattan, Brooklyn, and the Bronx. The Technical Consulting Panel on Continuing Medical Education and the RMP Associate Director for Continuing Education are studying these projects. Project #13 - Regional Program for Treatment and Investigation of End- Stage Renal Disease :- provides home dialysis training for professional personnel and for patients and families in the upper Manhattan and Bronx areas. Project #14 - Coronary Care Nurse Training Center - fits well into the region-wide plan for heart disease. Project #17 - Harlem Region Stroke Program - has not yet begun, but is designed to serve as a prototype of the entire region with its inadequate stroke service. Five of the older projects are being monitored by the following pro- cedures: bi-mnthly observation by RNP staff, review by its respective Technical Consulting Panel during the ast part of the fiscal year, fiscal control, evaluation procedures t core staff o be developed with and special presentations before the RAG or its Committee on Planning, Priorities and Evaluation. Project #1 - Mobile C ronary Care Unit - St. Vincent's Hospital - The Technical Consulting Panel - Heart Disease - would like to see mobile unit coverage extended to all of lower Manhattan, but no action is being taken in this direction until an RMPS National study is completed. Project #9 - Educational Program in Rehabilitation of Allied Health Personnel at Barbe Fo-in ation Rehabilitation Center - Providing continuing education opportunities for rehabilitation personnel and developing career ladders for less skilled employes are high priority areas for the RMP. Cost-benefit analyses will be instituted in the second year. Project #2 - Pediatric Pulmonarv Disease Center at Babies' Hospital - has developed a more regional-type of program this year as contrasted with its early institutional bias. Self-support possibilites are to be fully explored during thp third year as well as cost-benefit studies. Project #6 - am - Memor ospital - While the region has no ity of this continuing education activity, the need to broaden its focus to the whole field of rehabili- tation is being studies. In addition, core staff reports difficulties in getting a clear cost picture of this project since it is closely intertwined with other hospital activities. GRB/@S 12/29/70 [)I PAI','@ f@,l ()I, I I f7,' 1. 'r I I At V -L --A" pt,liit-l(, I11 AI .-III f, IIE/@i 'I 1-1 f';I- I?VIC /,,J I) r@A L.( I IA() tl 30, '1970 At@@; c 1: of iNoi-i--C;o[iil)cti.iig Cont@i-iiu,-.iti.oi-i Appl-.i.citi.oii frc)lrl ',NC@.%,7 York Pro(,r@ini Act iLi,, 1) t Pi-o,@rain S(@rvi.cc@ Ae t@: 1 ng Cli-i-(@f Acting Ciii.cif (:r,,ints llc@%, i Pr,@incli Ch-i.c,f Grz-@tits M,.iiiac,,eiii(.,iit Brari(-Ii I'Iijs i!)plicat--L.on is a part of the fi.rE,,I- A@-in-lvctr@,ary Revi(!@,! ;-aid a@@!z-i-r(I ipplic@it.i.on xilk@i,ch requests -til-)y)orL for tlj(-- of tc.---l prc)jects atid co-r,@ ($2,684,852 d.c.), i dcvelopri).,?iit@tl. co,-jipon@@,it d.c.) an(! for a gr@iit consi@tj-n,, of four I)rojc@rt,@ ($811.,686 e,.c.,). Staf,"s review of tlic, cont@!rLtiiL!,o[i ai)i)l.ica@.-loti coticcy-iLr@itc@.d OLI OVOL'al.1 p r o r@ @-i isF@ues rather than on individual T.)roj(,cLs. '@,',ajor issues discLts@l;c@d by the staff Were: (1) Al.tiiou,@li LI)E@ Rec,!.ori staLe@, tl-),qt dLirli-t,l the pasL ycar his been on toLal Drograiii ttiCl, reflc@.cts nioi:c of a project or-LcLLLed tyl)c, of op,-@r@i@iori by sLiff Ets well as c(:)ill(lli.t- tc,-es. Concurrently, it appears Lti,,iL@ projecLs are, develo[)C,(.1 wit'ti RMPS as the T)ri-nci.pal so@ircc- of @LLpliot-t. Staff concluded tliir. Llic! RegioLi should [)lace additional ci,@pliisi@,, on Llie catalytic ai)proac.ii and that joint funding of qcLivities should be eiicoura-ed., Planning activities dL@scribed are tt)p- rc@sults of the iari@,oi.,,; Technical 'niisulting Panels. Stalf fel-t that the slioul.d be niore@ revolved in there pl-iL-ini-iic, activities,;. 1 (3) C@iitral Core St-aff cap,,il)il..-ity in Cc)nt..ii-itil.rig, I.,Idkic,-ttioti needs to bi, strerictfic,@tic@,fl. (It t w @ i @; ;@t @', ri:, (I L h,7 L II y@- . 1, I- 1 i-, I I tI I Ii d iii,-i (I t- c t) I I:; (I i- i 1) I. ill @fO@t-, fol- them prc),,,rt-,r,f@ at: tlij.@, T,)niiit i-,21 s o iii !I !,'I t la II ill til(@ Page 2 - Dr. Margulies (5) An accountant has been added to the central office staff as was recommended by the Management Assessment site visit team in July, 1970. Staff questioned whether the contract for fiscal services had been revised as a result of this and of equal importance, has the contract been reduced. Possible .payment for duplicative services prompted this discussion. In summary, staff believed that this Region, now applying for its second year of operational support, has made significant progress but that much iniproveiiic!iit is needed in the development of the total program especially in regards to additional- output from the medical. schools. Recomnic@iidatioii: Approval- of continued funding at the committed level of $2,539,887 d.c. rather than the requested $2,684,852 d.c. The difference in the requested and committed level- of support iF, due to the fact that the Regi.on elected to request the National Advisory Council approved level for Project #17, Harlem Re-ioiial Stroke Program, rather Q .than the committed level.. Since the region will be given a twelve month budget for an eleven month year due to a change in anniversary dates, staff was of the opini.on that funds would be available for this project if the Rdaion believes additional support is necessary. Dan M. Spain Operations Officer Regional Development Branch Approved: Da Le ector, RL!IPS The followiii- staff members participated in the reviei.; of this Conti.nuation Application: Mr. Morales Mr. Teets Yir. Spain Miss Morrill Mr.- Witte Mr. Baum (Observer) cc: Mr. Gil.v-ior Mi.ss liorril-1. Mrs. Silsb(-@e Mr. Witte Mr. Spain @Ir. Morziles Nlr. Teets (A Privileged Coiiii)it-inicatic)i-t) SUNFiAs.RY OF l@EVIEVT Al@D CONCLUSIO!I OF JANUAP,Y 1.971 REVII@'@4 C01@,11'1!TEE NFI,! YOPV@ @IETROPOI,ITAQ RT'@GTO,,Ti@L @!Ei)IC@Al, Pi'lloGtl"4@l@ll RM 58-02 (AR-1,CDS) 2/71 FOR CONSIDL,'!,'-@TIO@%T t@Y F'EBRIJAPY 1.971 ,',!)VISORY COUJN(,TL PECO@tl,!EDIDATION: Additional funds be provided for this application fo@- for the 02 year only. R E,@' 2) 17. YFAR FUNDING 02 @1,140,6@)6 @200,000 03 647,943 -0- 04 760,512 -0- Total $2,5@9,i:!,]- $2003000 The T-I,O'@l'-on will be subf@,iitti-fi@, its Aiir,'i-,,,@rsary r@ Apl' 0 c@ )lic. @ic)TI@ 1, 1971., tire P(Icliti-o@!al, fLiii.cliiig be c(,,iis Tli@ Rc-g-i-oii has a. l@,vcil- of "-@,2F,@-,320 fc,-,: 03 o crat-.:Onal- year (core and 1.0 proj,@,c-:ts). rn _UjLl: The Co@n ittec believes thnt the NYP,-o,@IP is becci-o,-,ii,,,, a mpt-Lire P,c-gion. Several changes have occurrcei ii@ tlic-@ c)rg,.irki.zatiop,,il structure a r, dnieTbershi.p of the central- core stuff, all. of which are vi@2@,/C',Cl favorably. A,dditions to the staff include an Assistant Direc or or Planning, Evaluation Specialist, an accou.-it,,.iiL. I,!itli the iii,, of core staff plans qrc, for their grc-@t't-.e)- 1),iri:i.cipiti.o.@ in @.r)g with cofTLTunities in the devclopine-@it of projects and oLl-te-,c '.Ulie Associate Directors of the Medical- School.,-,@ are to thc-ins--lves morc- with stirroui-Ldi-ci@ conL-GiLir@-L.ties an.,J rre- wt:)rkinQ @,ii.11-h Icc.,).I. planning coniTnittc-es designated by The. Cbiiii-n-i-ttee believes that the Cc)oi-dictlit@c-.i@, )r. 1. j@,y his been doing a good administrative job. lie is ,, off the pos i!L)ili-i--y of the NYI;d-@LP becoming a medical sc,!'.IOOI program by establishing objectives, guidelines, and categorical plans for Region. Ili.s strategy appear's to be to work around the @robleir, of the @ic@dicil SC 1C)o and keep thcia involved in areas where there is little ciiiiice for cc)llli,)Iic.@l-@ tions. Dr. Brightipctri is planning, hu,,.,Tovcir, to obtain greater in-17.ol.vei,len',,.- and output fi-oLi the iftedical schools tl).rough the Associate located at the various schools. In 'ILine 19C-9 a no@,,7 procedure was itiit'i,-tecl by which each Associate Director would propose. a 12-rriolith proc,3:a-c:, de@vc-.,-,op-. rqent activity in his area to fit NYk@TPi@i'll plans. These proposals were reviewed by a nc:r,.7ly established @Ic!di.c..il. Al.1t:-)cpti-ons of,two representatives of the Bo,7,rd of Trustees and two of the R@-G, ,,7ith@tne Director. Allocations of funds to cover t'l-i costs of acceptable, NEW YORK METROPOLITAN @,IP -2- .-RM 00058 protocols are to be made to the medical schools. A quarterly review of the progress of the proposals will be conducted by the Mcdic@il. Allocations Committee and reports will be made to the P@. The acceptance of these medical school programs is very recent and.tlie value of the new approach has yet to be proved. Ilowever, the RAG members are hopeful that dc-.noiistr@,iti.o-iis and studies f-rom this approach will increase the visibility of N@ll@ and offer a return commensurate with the dollars expended. The Committee is E,,ncoLtr@iged' by ti-ic@ maturity which @.1-ie RAG of this Rec,@i-oii has developed. It appears that they are a rubL)z,,a.- stamp type operation but rather have assumed their responsibility in giving,t is Region leadership and direction. Mr. Robert L. Popper is the Chairman of the RAG and appears to be very active in the Program. He was highly to-@,?arcl the core staff and especially, the D-i-rectot, Dr. Brightman. Cat@egori,cal program i-ticludiiicy priorities are generated by Technical consulting Panels and a-ce beiii- used by the Reg@lonil Advisory .Groups and Sub-1--c--ioTIL-,l cof@@Llnittees as guiec!l..in,-2s for the generalization and review of projects. of those. Panels reflect the new goals and objectives of the Region particularly in the area of paramedical education. The question of setting priorities from within the various categorical and functional committees to arrive at overall P,L4P priorities has not been completely resolved. The. Committee believes that the true test of the priority setting procedures out iiio would take place with the awarding of developmental funds. D',PVELOP,,IEtl@TAL CO@IPOi'.,TT7NT: The Committee believes that the developriiental- component is necessary for the continuing progress of the N'DI,I"@"!P and recommends a reduced amount of $200,000, 'based on the present level of maturity of this Recion. The application for the developmental component speaks to the need to build on the categorical disease plan-,iiii- that has taken place. The Region-widb plans on the categorical. diseases wil.l. serve as guidelines for priorities for pr ograi-,i development. Tlie.regioit anticipates using developmental component funds primarily for pilot project-type acti",Ii:ti6s which will detbrmine.fe,,Isibility- ideiitify.the problems determine methods -of overcoming 'the'barriers and deve-lop Evaluation ind-ic'es so that a major project cart be developed.- Each pilot project wili. be looked at from these criteria: will it serve more people, will'it provide better services and will it help increase the manpower pool.. A number of suggestecl'idca's that might be considered for devel6pmental funding are identified in the application. SUPPLIMENTAL FUNDING: The Committee recommends that no additional funds be provided for the following activities because they do not clearly relate to the present objectives and goals of the NYRT,,IP and they have little relation- ship to the developmental component. They appear to be activities which NEt4 YORK METROPOLITAN @-IP -3- RM 00058 iri, the systE-in prior to the Region's dcvelop@,iient of present were priorities, goals aiid objectives. Project-. @,@25 - After Care Center for Ch-(-oi-iical.ly 11.1 Patiorits it Moiitefiore--,Ilos-pi-Lal Project 141-@26 -A @lodel- for Eirly Ci-t@c, of Ile,,a3-L Attack Project IF'27 - Apibi-ilatorv Care Niirse Traii-i Project l@28 - EarL@,,_@6t.c-ction of Ilr@ii,,t Cai:tccr RMPS/GRL, REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) NORT H DAKOTA REGIONAL MEDICAL PROGRAM RM 60-02 (AR-1 CD) 2/71 University of North Dakota January 1971 Review Committee 1600 University Avene Grand Forks, North Dakota 5 01 PROGRAM COORDINATOR: Theodore H. Harwood, M.D. REQUEST (Direct Costs) COMMITTEE/COUNCIL REVIEW: 02 03 04 Total Developmental $31,482 $31,482 Component RMPS STAFF REVIEW: Core $295,640 4 Ongoing Activities 90,444 Carryover 23,038 Total $409,122 FUNDING HISTORY Planning Period Funded 01. Year 7/l/67 - 6/30/68 $188,010 02 Year 7/l/68 - 12/31/69 257,100 Operational 01 Year 1/l/70 - 12/31/70 325,946 Future Commitment 02 I/l/70 - 12/31/71 310,683 03 I/l/72 - 12/31/72 255,942 (Core only) North Dakota RMP -2- RM 60-02 (AR-1 CD).2/71 GENERAL: The present application is composed of a request for continuation for the second operational year, a Progress Report, details about Core Staff activities, a request for a.Developmental Component, and budgetary information. With the exception cof the Developmen tal Component, all these elements Are dealt with in the Staff Summary of December 15, which is attached. DEMOGRAPHY AND GEOGRAPHY OF THE REGION: The geographic boundaries of @he region are conterminous with the state boundaries. In planning for the region, other possibilities were considered, including portions of Minnesota, South Dakota and Montana. These arrangements were not acceptable to the North Dakota State Medical Association, and the decision was made to remain autonomous within the state boundaries. The region's headquarters is at Grand Forks. The population is estimated at 632,,446 for a land area of 70,665 square miles. There is a two-year basic medical science School of Medicine at the University of North Dakota located in Grant Forks with an enrollment of 83. There are nine schools of nursing, three which are university affiliated and one which is degree granting. There are seven schools of medical technology, all of which are college affiliated. There are seven schools of x-ray technology, four of which are affiliated with the University of Minnesota. There are noschools of cytotechnology, physical therapy, or medical record librarians. There are 68 non-federal hospitals, two are long-term and 66 short-term. Beds total 3,811 in the short-term and 1,907 in the long-term. There are within the state five.short-term federal hospitals with a total of 476 beds. 'There are 594 physicians, 13 Doctors of Osteopathy, 2,138 active nurses, 33 physical therapists, 33 occupational therapists, 284 dentists and 3 medical social workers. HISTORY OF REGIONAL DEVELOPMENT: North Dakota Regional Medical Program re-states its objectives in its request for a Developmental Component. These have not varied appreciably since the inception of the program: (1) "To develop medical care facilities with a reasonably wide range of services in recognized service areas. (The main factor of importance is not the actual distance in miles to be traveled, but whether or not having traveled these miles, the individual receives prompt and efficient care.), and (2) To make the most efficient use of each professional individual's training and capability, utilizing his time and talents at his highest possible achievement level." North Dakota RMP -3- RM 60-02 (AR-1 CD) 2/71 NDRMP represents the providers of health care in the state of North Dakota, since the North Dakota State Medical Association assumed the responsibility for bringing RMP to the state and for its continued direction. Accordingly,Core staff development and function revolves around this concept--that in order to develop a sound basis for a continuing overall program,extensive participation by physicians is an essential element. The region states this premise as the backdrop for the development thus far of: (1) a capable and dedicated staff; (2) a physician Board of Directors; (3) a Regional Advisory Group with predominantly physician representation; and (4) a committee structure with a high degree of physician representation. The region has attempted to develop a "total program concept" rather than individual and unrelated projects. As a consequence, a strong staff and technical committee function has emerged. Generally, program activities develop as a result of a combination of committee and staff action, with representatives of organizations where a potential to pursue the program is evident. The Core staff of ND/RMP has made a wide range of contacts with people, and institutions, and has a good knowledge and understanding of existing capabilities. Early in the development of a program, the appropriate committee of the RAG is involved, together with representatives of the sponsoring institution, and final development and planning of all aspects involves all three groups. When the completed proposal is presented to the Regional Advisory Group and the Board of Directors for their review and approval, they are usually familiar with it. The major responsibility for continuing evaluation of details of the program rest with the technical Committees. This has strengthened the interaction of the committees, staff and the RAG. Committees keep the full membership of the RAG informed of activities through a formal report at each meeting, plus frequent communication in the interim periods. In the development of new programs for North Dakota, this method of active staff participation in all stages of development has proven to be the most effective. North Dakota has tapped the resources of a plan developed by the Extension Division of N.D. State University in Fargo to identify representative consumer groups in and around recognized medical service areas of the state. It was found that in some areas there was an existing organization which conducted studies and was planning for needed services. The general trend in such communities has been to develop a method of cooperation between existing institutions and individuals, leading toward the development of a single hospital system. In some instances this means a move toward total coordination of all health care and social services. Two examples of such planning are underway in Grand Forks and Rugby. The former city has under development the concept of a total medical center. Administratively, the two existing hospitals have united already, and are planning for a completely new medical center which will involve all elements of the medical community, including the University of North Dakota Schools of Medicine, Nursing, Allied Health North Dakota RMP -4- RM 60-02 (AR-1 CD) 2/71 Sciences and the Rehabilitation Hospital. other cities in the state are planning similar moves and the ND/RmP has stimulated and assisted in these efforts. ' The Rugby community proposes to connect the existing clinic group, which consists of seven physicians and a single hospital of about 100 beds, with an additional structure to provide new and much needed facilities. These will include extended care, rehabilitation, etc. In addition, the new building will include all the various social and community services such as welfare, mental health, social services and related activities. The intent is to Icoordinate and facilitate the use of all medical and social services by locating them under one roof. A Federal planning grant has been awarded to Rugby for development of the scheme and other related research studies are evaluating its progress and ultimate implementation and operation. The Core staff of ND/RMP has assisted in a variety of ways, and will be an active component of the research project presently being developed by Dr. James Cummins of Brandeis University. The data obtained by the collaborative efforts of the N.D. State Extension Division and the ND/RMP staff, will be furnished to Compre- hensive Health Planning and other interested groups as an accurate base for health planning. There is a strong trend toward group practice by physicians in the state, and 353 physicians are presently practicing in groups of three or more. In the larger urban centers there are well-developed functioning multi-specialist groups with a wide range of services. There is little, if any, organized out-patient service provided at hosptial centers, and for all practical purposes, no free clinics for indigents. Approximately 65,000 people are eligible for Medicare, and approximately 46% of the population are enrolled in Blue Cross- Blue Shield, with another 25% under other forms of commercial health insurance. Further details concerning the region's development and progress are contained in the attached RMPS Staff Summary of the Continuation Request of 12/15/70. REGIONAL ADVISORY GROUP: The Board of Directors of the North Dakota Medical Research Foundation (Grantee) which is identical in membership with the Council of the North Dakota State Medical Association, serves as the Board of Directors of the Regional Medical Program. The Regional Advisory Group has been expanded to include consumer representation, and while not actively involved in committee deliberations, the interest of various consumer groups and organizations appears to be developing and promises to expand. (See attached staff review(memo 12/15/70) for further details concerning the RAG.) North Dakota RMP -5- RM 60-02 (AR-1 CD) 2/71 DEVELO M NTAL COMPONENT: The proposed Developmental Component Activities are broadly based and proposed to serve as an instrument whose major role is to assist in the development of any and all methods for making it possible for the populace to receive the highest possible quality health care. At the same time, the region points to the difficult factors concerning supply, distribution and financing. Specific developmental activities proposed include: 1. Improved undergraduate educational opportunities. In particular, the School of Medicine at the University of North Dakota is studying the feasibility of expanding to a four year school, and the ND/RMP is making significant contributions in planning. 2. Development of a scheme for bringing the rural populace in contact with health services, patterned somewhat along the lines of neighborhood health centers and similar to previous efforts of the Indian Service. This would utilize the efforts of the Medex program, with variations) such as other types of physicians assistants.. 3. Development of an academic continuing education activity, not only for the School of Medicine, but for other educational institutions in the region. 4. Collaboration with planning groups for closer coordination of efforts with a view of the centralization and elimination of duplication of health planning activities. 5. Development of the Team Teaching and Care Concept, beginning with the organization of teams for Stroke. The RAG Stroke Committee has been active in this development. 6. Concentration of efforts to elevate the health standards of Indians living on reservations, to include training and general education programs for health aides on a variety of subjects such as nutrition, obesity, diabetes, etc., in a collaborative effort with the USPHS hospitals. The ND/RMP will act as the coordinating agency and clearing house for such services, developing the communication device and opportunities for better utilization of existing facili- ties and services4 This will build on the experience of feasibility studies already initiated by the Core staff in Tuttle Mountain Reservation. SITE VISIT - DECEMBER 7-8, 1970: This is a separa te document which will be supplied later. GRB 12/18/70 DEPARTMENT OF HEALTVI. EDUCATION, AND WELFARE 4. PUBLIC HEALTH SERVICE HEALTH SERVICES AND'MENTAL HEALTH ADMINISTRATION Date: December 15, 1970 Rcp@ to Att;i of.' Slibject: Nortli Dakota Conti.nuati.on AI)pli.catioi-i Staff Review, December 1, 1970, 5 C03 l@l -60 7'o: Acting Di.i.-ect.or Reg,i.onal Medical. IlroL!,Yiiiis Serv@ice Thrdugh: Chairiii@in of the Month Chief, Grants Management Brai)c Acting Chief, Regional Development II)ranch Acting Chief, Grants RcZ)e 7@Brancli General: Staff consideration was directed to the request for continua- tion for the secordand final (committed) year, the unexpended balance and evaluation of progress of the region, and in broad terms, the request for a Developmental Component. The region was supported for its first operational year in the direct cost amount of $325,946, wi.tli an amount of $3iO,683 r(--coiiii-iien,](!(l for the second (final) yeir. In both the planning and operational. applications, the region requested two year support only. The present application is composed of a Progress Report, details about Core staff activities, a request for a Devel.opniontal Coitiponent, a request for continuing support for four operational projects, and expenditure and budget information. rv and Fiscal Status: The region estimates an unexpended net balance of $23,038, and requests the use of such funds to implement two Council -Ipproved but unfunded projects, and expansion of Core staff support ii-id other ongoing operational activities. Extensive staff discussion resulted in a consensus to hold in abeyance a final recoiiliflciiclition for the carryc)vcr request pending the findings and recommendations of the sit(, visi.t scheduled for Deceiiil)cr 7-8, 1970. This act-ion did not. i.nc]Lldc a re-bud@,oti.ng request which wi@; pI-cs(!Ilte(I a few days following the Noveiiil)cr 1, deadline. The regi.oti his budgeted its funds wel.1 and efficiently, and is 11 cost-coiisciou-;" to the extreme. They have never requested indirect costs until the pist.year when they were permitted to use indirect costs amounti.n,, to $12,590 to finance the salary of a nurse. This was the result of a recommendation of the site visit team of June 1969, .7 Acting Di.rcctor, ]@MI'S that a nurse at a Masters Degree level be recruited for the Rehabilitation Nursing Program. The region had been unsuccessful in its search for a qualified candidate until this past year and autliori- zation was given by RMPS to rebudget indirect costs funds for her salary for the balance of the 01 year. This action did not, of course, carry a commitment for the project's second year. Continued support of this postion from carryover funds i-s part of staff recommend- ations. The Grants Management representative expressed concern about the fact that the.region had subm-'@tted its request for continuation based on the application of two years ago, rather than the level funded (recommended) amount of $310,683 for its second year support. This was apparently a misunderstanding on the part of the region, and a visit to RMPS by the Arsociate Director last week has clarified this issue. New budgets will be submitted at once which will reflect allocations in agreement with Council committed amounts for the 02 year, Regional. Advisory Group-. The RA.C@ is concerned and interested in the program, although they seem to rely on Core staff for ideas and project develo mei-it. A sy steni of project review has been developed which involves the entire Group, rather than a Task Force or Commi.ttee approach. North Dakota feels this works best for their Group. The site visit report to follow should shed light on the present organi- zation which has always appeared somewhat duplicative and over-structured. The report does not specify the criteria used by the Croup for program and project review or decision-making. Twelve new members have been added during the past year, including five physicians, six representa- tives from the general public and one Indian, who is a Hospital Administrator. The Group also includes the lieutenant Governor. Rep;ional Progress a@id o i e@n t :The operational activities of the,N.D. @IP, which are almost exclusively continuing education, appeat"to have been shaped and directed to a large extent to gain the confidence and cooperation of the physicians of the region. There appears to be no .overall plan to identify and meet the continuing education needs of physicians, nurses and allied health throughout the region'. Rather, continuing education activities seem to be conducted primar@ly in response to an interest by health professionals to cooperate with the N.D. @IP, thus establishing lines of communication where one existed before. A further characteristic of the region's continuing education activities is that they have been provided for nursesipredoniinantly, yet there is little or no involvement of the nursing profession in the regi.on's planning or decision-niaking. For example, the @IP Continuing ECILtcati.on Committee is composed of physicians exclusively! Although there appears to be interest by N.D. RMP in establishing, improved relationships with the nursing profession, there continLICS to be an Unfortunate schism between N.D. RMP and tlic,. nurse, education Acting Director, PKIPS leadership. Both groups are sensitive to'this situation but there' appears to be an impasse at present, which precludes significant improvement. Efforts to involve the nutrition profession is reflected in the Diabetes project which is apparently functioning effectively. However,.there appears to be little involvement of the dietetic profession in the N.D. RMP structure. As yet, outreach to ot:ljei- allied health personnel is al.most non-existent. Al,tlioLigii there are small numbers of alli.c!d health practitioners in the region, there are programs in the state to educate physical tlicril)ists, occupational therapists, medi.cil technologists, and radiologic technologists. There are Indications that the continuing education activities may reflect greater innovation in the future. The region Is experimenting with multiprofessional education in the project "Diabetes and Nutrition". On the basis that those who learn together are more likely to function more effectively as a team, physicians, nurses and dietitians are instructed together in some classes. Also, the important role of the region in making possible the development of a Medex program in conjunction with the Department of Co@nmunity Education at the University of North Dakota is significant. North Dakota is one of the four centers in the country which is funded by the; National Center for Health Services Research and Development in its ef forts to develop a uniform evaluation protocol for physician assistant type programs. N.D. Pd4P, and its Director in particular, have largely been the stimulus to encourage the medical profession to extend beyond its boundaries to become involved in this study of national scope, funded by a federal agency, and in a controversial beaitb'nianpo@qcr area. Invicw of the deficiencies of N.D. RR.IP i.n its evaluation activities, perhaps the close relationship between N.D. @IP and NCIISRD in this Medix study will be reflected in an increased interest and emphasis on evaluation in the program itself. The representative of the Program Eval.uation Bxanch expressed concerns which were, for the most part, generic. These elicited much discussion about ;the "unusual" characteristics of this region. ,then measured agains't regions that have developed sophisticated evaluation systems and strategies for planning and decision maki.ng, N.D. RMP undoubtedly falls ;short. if N.D. @IP is judged in terms of wliit existed before RMP as : compared with wliit his been accomplished to date with a very modest,investment, N.D. @IP represents a new and accelerated effort to mee,t the health needs of the peopl.c of North Dakota. The re;gion should be encouraged to develop a Core staff focus for both planning and evaluation. This need is supported by the fact that the application does not delineate the nature of the regioil's plannf.ng process; what role planning pl.@iy in decisi.oli-mal,,iiig; who is responsible for implementing pliiinii)g activities; and how evaluation is built i.nto projects. If there is agreement that North Dakota should not be excluded from national programs simply because they have not achieved optimum results, in three yeirs, in heil-tli planning in a traditional sense, then there must r)c@c@@,,3sarily follow an acceptance of the way that North Dakota P\@IP is going about developing lines of communication upon which to build a program. It is probably the only way, at the present time. Recommendation: Continuation for the second year in the committed amount of $310,683 direct costs, plus $12,590 from carryover funds for a Council approved (currently appointed) position in Project #2. The balance of c@-irryovcr funds ($20,000 approximately) to be granted based on the rc@coriiincnclati.ons and advice of the si.te visit te,@im. Jessie F!. Sal.a/,ar Public Ilcaltli Advisor Grants Review Branch Action by Director Ini.tials Date A PRIVILEGED CO@IMUNICATION Ol:' COi':4CLUSIO14 OF ].g-ll 1,@EVT JANUARY -Li,-14 CO@ZIITTEE NORTH DAKOEA REGIONAI, IIEDI@CAL PROGRki%l RM 60-02 (AR-1 CD) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: Additional funds to be provided. Year 02 Request Recommended Funding Developmental $31,482 -O- *SupplementAl Funds -0- $30,000 Total $31,482 $30 000 Not requested by region but recommended by site i!isit team. LzILt u : The present application is a reqliest,for continuation for the second operational year, a Proaress Report, details C, about Core staff activities, a request for a Developmental Component and budgetary and fiscal information. The critique is addressed to the results of site visit team findings (Dia6ember 7-8, 1970) and recommendations concernin the proarai@l as a 9 0 whole, and in particular, the request for a Developmental Component. The Chairman of the site v4-s@;t team reported on the findings and recori- mendatioiis of his group. Its purpose was to determine the readiness of the North Dakota @IP to embark on a course of independent decision-. making, as well as to assess ,the region's ability to utilize developmental f tilids. Core Staff The Program Director is. in ef f-ect, the Pro-ram. Ile exerts strong and forceful leadership and speaks effectively for ND @IP. He has been the moving force-in initiating and stimulat@i-ig necessary liaison for the successful operation of the program thus far. He enjoys effective personal relationship with the medical community who hold him in e.steem, and has been the primary reason for a general acceptance of the ND/@IP. This has been aided by the Core staff which has continued to be committed, hard working and loyal to the program. It is notable that since the inception of the program, Dr. Wright has attracted competent people who exhibit high motivation and enthusiasm. Tbe'staff has been very active in project development, reinforcing, relationships and strong in initiating public and provider education. Staff has also provided leadership to fill the void caused by the lack of involvement of the North Dakota University Medi.c-.L@l @c'fiool, Nursing North Dakota RMP -2- RM 60-02 (AR-1 CD) 2/71. School or the voluntary and public health agencies. Despite this lack of support, the Core staff has adroitly implemented projects to deal with the community as sole functionary and without the active support of those agencies. Even though the ND/@IP staff has exemplified regional cooperative ventures in initiating their activities, and have done so with remarkable economy, the region does not consider one of its major functions as a supportive influence in planning, integrating aid coordinating such developments. The concept of program planning with coordinated project parts, complementing and maki-.ng up the whole seems to be unfamiliar to the staff. The staff apparently does not view these movements, concepts, activities, etc., as its role and this is a major deficiency in the growth of the program. @@@@tional Program Activities A wide variety of activities have been undertaken, and include appi-oxi- niately 120 se,-,iinars and workshops. There as een @i movement to improve patient care, especially in stroke and diabetes. The region is providing support and encouragement for the new North Dil,,ota Medc,.% Program. While this will not be funded frciii R@ill@S funds, the implelyl(-2rita- tion has been dependent on the background of the Core staff, especially in regard to providers and opportunities for preceotorsliips and training possibilities. Another interesting proposal under development will provide expertise and assistance in a grant proposal for the Ileart of American Hupian Services Center. This is an innovative project to provide comprehensive and integrated delivery of health and social services to a rural Cacbement Area of Rugby, Nortl Da ota. Progress was noted in the region's building of bridges to the University, particularly in the Department of Continuing Education, the newly created Department of Community Medicine, the Computer Center, and for arrange- ments with students in the School of Medicine for a Summer preceptor program. e@velopniental Component The North Dakota Regional Medical Program has not yet clearly and concisely described its regional objectives. There is a lack of movement toward an overall long-range plann-ing process or a program conc6pt" with project components utilized as building blocks in the program. There is very little evidence of a transfer to a programmatic approach from a project approach, and this has tended to fragment their efforts. The region needs to plan for projects that are congruent with national as well as regional priorities. This latter observation was pointed up by the lack of evidence of a systematic approach to identifying "VLLil LJt@UL41 XWlr Ni@l ov-vz tV) Lill program for the nutritional management of persons with diabetes arid other chronic diseases, which was approved at $33,506 direct costs. All revi,(,--,,iers noted the enthusiasm this project generated throughout the region. It is well designed, under very capable.leadership and ,shows potential for further development of a team approach for patient care. This is a much needed concept that is becoming increasingly acceptable to the medical community of Nortli Dakota and will benefit by further de iaor-Lstrat-!,ori immediately. The region needs to give some thought to project planning which is con- gruent with current national priorities. Alsb, a more systematic approach to identifying local needs is called for, with broader input from areas other than Grand @-ori-s and Fargo. The RAG piemberslil-p would benefit by a more diverse representation to include representatives of labor, health insurance and allied health professions. Core staff should be increased, at minimum, to the level of an Associate Coordinator. There is also a need for Core staff to develop skills in proc-r@11[i Planning and development, in delineating program objectives and definition of priorit@l-c@s, as N,7cl.l as establishing evaluation procedures. Some thought should be given to development of a review process to.all.@,, for a technical review with advice and collaboration on evaluation of program components. Careful measures should be taken to insure that the ,needs of all local areas are considered. The design of a method of evaluation should include review of progress to provide information to determine modifications, etc. The reviewers urged that the region initiate a long-range "regional" program with appropriate iritecyrated components. This should begin C, immediately so that it can be included with the Triennial application. RMPS/GRB/l/18/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) NORTHLANDS REGIONAL MEDICAL PROGRAM RM 21-03 (AR-1 CSD) 2/71 375 Jackson Street January 1971 Review Committee St. Paul, Minnesota 55101 PROGRAM COORDINATOR: Winston R. Miller, M.D. REQUEST FOR NEW FUNDS (Direct Cost Only) REGIONS OPERATIONAL YEAR 03 04 05 Total 1. Core $ 99,082 $ 990,400 $1,045,685 $2,135,167 II. Ongoing Projects 6) 236,366 -0- -0- 236,366 III* Approved Unfunded Projects (3) 144,602, 58,690 60,418 263,710 IV. Renewal Request (1) 34,330 34,495 35,950 104,775 V. Developmental Component 131,500 131,500 131,500 394,500 VI. New Projects (4) 270,238 361,194 362,726 994,158 Total $916,118 $1,576,279 $1,636,279 $4,128,676 RMPS Staff Review of Non-Competing 03 Year Operational Continuation Grant Application (December 10, 1970). Recommended Award Commitment Commitment REGIONS OPERATIONAL YEAR 03 Year 04 Year 05 Year I. Core 839,053 -0- -0- II. Ongoing Projects (7) 476,315 $49,441 .0- Total $1,315,368 $49,441 .0- FUNDING HISTORY (Direct Cost Only) GRANT YEAR PERIOD FUNDED Planniny, Staize 01 1/1167 - 12/31/67 $344,998 02 1/l/68 - 12/31/68 549,643 02S 7/l/68 - 12/31/68 27,849 02S 1/l/68 - 6/30/69 6,838 Northiands RMP -3- RM 21-03 (AR-1 CSD) 2/71 The Region had established good relationships with the practicing physicians and the State Medical Association. The allied health professionals were minimally involved, as was the School of Public Health at the University of Minnesota and the State Division of Rehabilitation. Representatives of community hospitals were very reticent about their involvement and needed a lot of encouragement and work to bring them into the program. Better liaison was developed with the Comprehensive Health Planning (A-Agency) with whom the NRMP coordinated data gathering efforts, than with the voluntary area-wide planning agencies. The reviewers discovered that the ad hoc committees have not generated projects in needed areas, but rather screened proposals which were developed prior to the formation of the committees. The National Advisory Council for RMP's approved in March 1969 the operational grant application at a funding level of $1,189,964 (d.c.o.). The Northlands RMP Inc., became the official grantee and fiscal agent for the program with the award of the operational grant succeeding the Minnesota State Medical Foundation and the Mayo Foundation. During the year of 1970 the Regional Advisory Group was reorganized (three more consumer representatives and osteopaths were added) and the new members were oriented by the NRMP core staff. All of this regions twelve operational projects are in the area of continuing education and manpower development. Following is a list of the planning and feasibility studies which core staff has activated: 1. Core Curriculum for Continuing Medical L. D. Stauffer, M.P.H. Education University of Minnesota 2. Standards of Medical Practice W.H. Trow, M.D.; MSMA 3. Video-tape on New Physician-Patient B.F. Fuller, M.D. Interviewing T6chniques University of Minnesota 4. Regional Laboratory Facility: GiG. Stillwell, M.D. Feasibility Study Mayo Clinic 5. Rural Health Care: Feasibility E.T. Carter, M.D. Study Mayo Clinic 6. Regional Consultation Service of J. Minott Stickney, M.D. Mayo Clinic Mayo Clinic 7. Albert Lea-Austin Health Services B. Dornblaser, MIH.A. Regionalization Study University of Minnesota 86 On-going Inventory of Practicing R.N. Hill, Ph.D.; NRMP Physicians ; Northlands RMP -4- RM 21-03 (AR-1 CSD) 2/71 9. Changing Dimensions of Physicians R. N. Hill, Ph.D.; NP.IIP Manpower 10. An Analysis of Group Practice in R. N. Hill, Ph.D.; NRMP Minnesota 11. Patient Orgin Study R. N. Hill, Ph.D.; NRMP 12. Cancer Mortality Study R. N. Hill, Ph.D.; NRMP 13. Physician Migration Study L. F. Cole, M.A.; NRMP 14. Metropolitan Physician Mobility T. J. Litman, Ph.D.; Study University of Minnesota 15. A Collage: Selected Allied Health M. J. Deschler, R.P.T., Manpower Statistics M.P.H.; NRMP Present Application: In this application NRMP is initiating the Triennial Review System and requesting a Developmental Component Award. Also, support is requested for the Core Component, twelve continuation project components, one renewal project component and four new project components. The complete system of NRMP is described in this applica- tion to facilitate a "zero-based" review. NRMP is organized with subdivisions into three functional areas of concern(l) Continuing Education, (2) Manpower and (3) Health Services Development. The three Planning,Review and Management Committees charged with coordinating responsibility in these areas, oversee all program components. The core component of the program is structured in detail under three broad goals, (1) Administration, (2) Facilitation, and (3) Problem Definition and Solution. All activities of NRMP have been reorganized into a composite-whole consisting of the three functional areas of concern and the three broad goals of the core staff. The specific administration and facilitation responsibilities of the core staff overlap the functional area sub- divisions, but problem definition and solution activities are completely subdivided. Facilitation activities include research studies, and planning coordinating activities in each of the three areas. In the revised system of NRMP all project component staff will be integrated with core staff into the broad staff of NRMP. Activities of both groups will be coordinated through accountability to the three Planning, Review and Management Committees and through them to the entire RAG and Board. In the initial development of NRMP, like most RMP's ' heavy emphasis was placed on Continuing Education components. Recently more emphasis has been placed on Health Manpower and Health Services development, especially in core activities, in order to produce A better balance Northlands RMP -5- RM 21-03 (AR-1 CSD) 2/71 in the whole endeavor. In addition, the expanded Continuing Education Program has permitted a more complete program in this area.. The Developmental Component will be utilized by the NRMP to initiate appropriate and timely feasibility studies, short-term pilot programs, statewide conferences and special research studies, under direction of the RAG. The three Planning, Review and Management Committees have suggested many areas of activity which will be the basis for soliciting specific developmental activities. ORGANIZATIONAL STRUCTURE AND PROCESSES The Board of Trustees: The group consistsof representatives from what is called the nine sponsoring organizations of the incorporation. They are as follows: Minnesota State Medical Association Minnesota State Board of Health Minnesota State Medical Association Foundation American Rehabilitation Foundation Regions of the University of Minnesota Minnesota Heart Association Minnesota Hospital Association American Cancer Society, Minnesota Division Inc. Mayo Foundation The Board has corporate responsibility for the operation, administration and fiscal control of all the activities of the program. All members of the core staff are accountable to the Board through the Program Director (Coordinator). The Board appoints four to eight members at large of the RAG, and all members of Planning and Review, and Advisory Committees. The Regional Advisory Group (RAG): The constituency of the RAG was formed by Asking 34 organizations in Minnesota to select a representative. In addition, four to eight public members are selected by the Board. The Regional Advisory Group presently is composed of 36 members, (9 sponsoring organization representatives, 9 Minnesota State Medical Association Councilor Districts representatives, 7 consumer representatives and 9 members from other organizations). The RAG has authority and responsibility for program development and management. Three members of RAG are on each of the Planning and Review Committees, which review all applications in detail. The RAG members on those committees present committee recommendations to the entire RAG. The RAG also receives progress reports on all core and demonstration project component activities. The RAG exerts it program authority and responsibility by voting on all program components in every application for funding. Under the new Anniversary Review System, the RAG has elected to act as a committee-of-the-whole to authorize use of Developmental Funds. The group has agreed to meet as often as necessary for this purpose. Northlands RMP -6- RM 21-03 (AR-1 CSD) 2/71 Planning and Review Committees (P and R Committees): There are three P & R Committees with the responsibility for development of program goals and objectives, and for detailed review of all program component applications. The three P & R Committees are: Continuing Education, Health Services Development, and Health Manpower. These three committees made their recommendations to the RAG. Each P & R Committee includes a chairman and ten other voting members (one or two.from each Medical Center,, three non-medical-center members from the RAG, and two to four members at lar,,e). Advigory Committees: NRMP has appointed advisory committees in various areas of expertise to advise the three P and R Committees, as well as the Board and the RAG concerning program development. The following committees are currently active: (1)Heart Disease and Stroke (7)Communications (2)Cancer (8)Intensive Coronary Care (3)Nursing (9)Dial-Access Library (4)Dentistry (IO)Diabetes (5)Radiation Therapy (11)Mayo Postgraduate Education (6)Rehabilitation Staff Organization: The Core Staff of the NRMP has forty-six employees, twenty-nine at 100'/. time and effort. The core staff organization and functions have been changed to reflect staff responsibilities toward three program goals: (1) Administration, (2) facilitation and (3) problem definition and solution. Overall direction is provided by the Program Director, and three Associate Directors, (The Deputy Director; the Associate Director, University of Minnesota; and the Associate Director, Mayo Institutions. The Director and three Associate Directors constitute the Executive Staff. The following is a list of the core staff membersand an organizational chart: Time or Effort Name Job Title % Hours W. R. Miller, M.D. Program Director 100*/@ R. J. Wilkins, M.H.A. Assoc. (Deputy) Director 1001/. J. M. Stickney, M.D. Assoc. Director 70% W. R. Fifer, M.D. Assoc. Director 80'/. L. B. Stadler Program Management Director 100*/. L. G. Berglund Project Management Coord. 1001/. E. D. Leyasmeyer Cont. Educ. Coord. 1001/. D. A. Lee Fiscal Director 1001/. K. A. Kiley Communications Coord. 1001/. R. N. Hill Evaluation Officer 1001/. J. @l. Schowalter Nursing Coordinator 100% @t. J. Deschler Rehabilitation Coord. 1001/, R. D. Place, D.D.S. Dental Coordinator 5 O'/, T B A Health Care Economist 100% Northlands RMP -7- RM 21-03 (AR-1 CSD) 2/71 Time or Effort Name Job Title % Hours M. J. Ryan Liaison Librarian 1001/. G. Foreman Ext. Librarian 41.5% J. Lorrig Ext. Librarian 41.5% L.@ F. Cole Research Sociologist 10(r/. L. A. Sonderegger Research Assistant 100% R. P. Buckley, M.D. 0. M. Heiberg, M.D. R. Schnabel, M.D. J. Ballantine, M.D. Comm. Coordinators (25% each) 1001/@ R. Axness Bookkeeper 1001/. 11 personnel Secretary/Assistant 1001/, T B A (2 half-time) Secretary (Mayo) 100% T B A (3 half-time) Secretary (U. of M.) 150'/, M. B. O'Sullivan, M.D. Reg. Lab. Dir. (Mayo) 50% G. C. Wollner Reg. Lab. Admin. (Mayo) 50'/, G. M. Needham Reg. Lab. Coord. (Mayo) 30'/, T B A Lab. Tec. Coord. (Mayo) 50% E. T. Carter, M.D. Rural Health Dir. (Mayo) 40% T B A Phys. Asst. (Mayo) 50'/. T B A C.M.E. (U. of M.) 50% M4 K. Cragun C.M.E. Coord. (U. of M.) 50'/. T B A (5) DCME's (20'/. each) 1001/. Northlands RMP -8- RM 21-03 (AR-1 CSD) 2/71. T A B L E 0 F S T A F F 0 R G A N I Z A T I 0 N F 0 R N-R M P P R 0 G R A M A D M I N I S T R A T I 0 N 6 R A i'@ T E NRMP, Inc. ARD FF -TRUSTEESI REGIONAL ADVIS(RY GR@P I PROGRAM DIRECTOR *W. R. Miller, M.D. R. J. Wilkins, M.H.A. ii,ector INTERNAL SERVICES EXTERNAL SERVICES Communications - K. A. Kiiey '@ursing - J. M. Schoaiter,T\ti,M@'d Evaluation - R. N. Hill, Library - iv. J. R,:2n, Fiscal Management - D. A. Lee, Rehabilitation - M. J. :;schler, RPT,I/.!'!! Sociology & Data - L. F. Cole, I-IA Eentistry - R. D. Place, DDS Economist - Community Cooi,d. - (5 CONTINUING EDUCATION HEALTH tiANPOWER HEALTH SERVICES SECTION SECTION DEVELOPT;ENT SECTION *W. R. Fifer, I.iD *k. J. llilkitis, ti@IA *J. t,l. Stickney, IID Associate Director Associate Director Associate Director CCI@'TT@ HEiLT.-, COI.;14!TT.@ COMMITTEE Lee D. @taur@fer, Chairman Chairman E.D. Leyasmeyer - Coord. L.G.Berglund - Coordinator*'-, L.B.Stadl,2r@ ,.J. Frey, flD - Bd. Rep. J.W.Rivall, MHA - Bd. PTOJECTS EIE.140"iSTRATIOI@ P@@OJECTS 3j7CTS Diabetes - Etzwiler Nurse Refreshp-r led. Card. - Lucas Stryker 'LC,:U - Lee (Ophth. Tech.'."':':* (Cone-. I:Q --i'-seise***- Stroke - Er,-ith Hi Z Z) Access - BelgZzird Clin. !,utr. - Ve2,strate !.!ed. Tech. - I-lerritt (M,aY,o;P.G.E@*** - PROBLEY3 DEFINITIOIN' PROBLEY, 'iO' Osmi@idson) AND SOLUTION AND SCL,'@ (Univ. Ped. Educ.'@ Manpower R. HIZZ Itudies Cole Educ.:'.'** P@g. L Mayo Rural Health Carter Vital StatisticE, F.@OBLEM '@EFlj'IITIOli AI;D SOLUTION (2) Leyasineyez, Library - .,.,@an 'I'l@e D@-rec4@,i,, together w-l@:@ the I-le@c!icai Audit - Fi,,"cr .!),.",(jtors, co-pr@lse the !,,,,"t7iout i)ote ui2funded. Northlands RMP -9- RM 21-03 (AR-1 CSD) 2/71 The total core budget of $938,135 in direct costs for Fiscal Year 1971 requested by the NRMP exceeds both the level of commitment for core and the level approved by the National Advisory Council for the 03 year operation. 03 N.A.C. Recommendation $923,830 03 Commitment $839,053 03 iZequest $938,135 The Region explains that since this is a triannual application with inclusion of a developmental request, no attempt was made to tailor the budget to the 03 year NAC authorized level. They indicate that the core budget in this application was developed to support the com- pletely revised program of Nortblands Regional Medical Program. The increased budget request over the 03 year lies in the personnel and travel categories. The increase in the personnel buget is due to a slight shift in the types of personnel and a projected average salary increase of 6/. for NRMP employees. The increase in the travel category reflects principly the increase in RAG and Committee meetings planned for the next year. The Region explains that in response to the stimulation provided by the new Anniversary Review System, the NRMP has undergone extensive self-renewal of its.entire program. In this application the NRMP system is described in full. It has documented its integrated development, its readiness for greater autonomy and its capacity for administrating a developmental award. The fundamental philosophy has been retained for emphasis on the three general functional areas - Continuing Education, Health Manpower, and Health Services Development. The three com parably designated Planning, Review and Management committees have developed more specific policy, statements which provide guidance not only for project component review but also for design of work programs for Core activities. Project Review Process: The new and preferred procedure for development and inclusion of new project components is as follows: 1 A proposer interested in submitting a proposal for inclusion in the program will first contact the Program Director. 2. The Program Director will assign a member of his staff to prepare A two page abstract or outline of the roposal to be developed p 3. The Core staff member will present the abstract or outline,to the appropriate Planning and Review Committee for its tecom- mendations. 4. Upon approval of the P & R Committee, the staff member and the proposer of the new component will proceed with project development. 5. The costs required for development of the project may be paid out of Core funds. This may include reimbursement to the sponsoring organization for time and effort and other costs. (Board approval required) Northlands RMP -10- RM 21-03 (AR-1 CSD) 2/71 6. As. soon as the proposal is completed in final form it will be processed through the local review mechanism. Expert budget and program consultants may be employed to provide unbiased technical assistance. The P & R Committee will then conduct its review. Proposers desiring to have their application included in the next Anniversary Application will be well advised to complete applications for a first time review several months before the July lst deadline for final review. This will allow time for revisions which are frequently required by P & R Committees before final approval. 7. After approval by the P & R Committee, proposal applications will be reviewed by the Regional Advisory Group and the Board of Trustees. 8. Approved project components will be included in the supplemental portion of the next annual composite application. 9. Deadline for'inclusion will be July 1, each year. Although not preferred, an alternate procedure will be accepted if circumstances warrant. Project proposers may submit component applica- tiong in completed form to the Program Director. If applications meet NRMP standards they will be submitted to a P & R Committee for review. Proceedings of review committees meetings are regarded as privilege communications, prepared only for use by Consultants, Centra Sta and Board of Trustees. A summary of the Review Committee s report on an individual project will be submitted to members of the Regional Advisory Group when this is appropriate. The Committee members, individually, do not advise applicants of Committee recommendations. To avoid situations of possible conflicts of interest, members of Review Committees absent themselves from the meeting room when applications submitted by their own institutions are being discussed. Individual Committee members recognizing other conflicts of interest are expected to voluntarily request the same action. In such cases, the individual Committee members do not prepare a personal report of his recommendation. The Committee recommendation is made by majority vote of the members. The chairman of the review committee prepares a summary report of the Committeels appraisal and recommendation of each project proposal considered. This report follows the same outline as the individual reports from Committee members. The average numerical rating scale of all Committee members is included. The Committee approves, disapproves, or defers each project proposa considered. When a project is disapproved or deferred, the Committee specifically lists the deficiencies which were the basis for the action, particularly important when projects are deferred. The Review Committee provides the staff with a very clear and detailed statement of what it wants changed. The report includes concrete, constructive cr tic sm. Northlands RMP -II- RM 21-03 (AR-1 CSD) 2/71 Each member of the Review Committee includes in his report a numerical rating as indicated on the attached format page. The five point scale rating is applied to each project with regard to: A. Intrinsic Merit B. Relevance to NRMP Goals C. Priority for Inclusion in NRMP. Each rating is independent of the other two. Averages of the individual Committee meember ratings have a semblance of objectivity to the total Committee recommendation. Each member comes to the Committee meeting with a complete typewritten report emphasizing the following points: Description: Give a concise description of the proposal, including aims and procedures as each is appropriate to a clear understanding to the project proposed. Are the objectives concise and specific enough for results to be evaluated: Discuss the strength and weakness of various aspects of the proposal. Are the aims logical? Is the approach valid and adequate? Are the procedures feasible? What is the significance and pertinence of the proposed study with regard to the state of the field and importance of the objectives? Personnel and Resources: Discuss the competence and background of the investigators and the adequacy of other personnel and facilities to be employed, Is continuity assured for the duration of the project? Evaluation: Comment on the adequacy of proposed self-evaluation methods4 Is the project planned in phases, so it can be effectively reviewed at periodic intervals? Is there an evaluation method covering each stated objective: Regionalization: Is there adequate proof that cooperative arrangements are firmly established? Does this project have the potential for statewide improvement in the delivery of health services? Budget: Is it realistic in terms, and aims, and methodology? Are all items justified on the basis of the approach, procedures, and analysis of the data proposed? Itemize and provide specific reasons for reductions in time or amount of funds which you recommend. Annual Report of the Regional AdvisM Group (RAG): The RAG has a deep sense of responsibility for t s program, and at the same time feels almost overwhelmed with the magnitude and scope of the activities. It expresses a genuine desire to become more involved in planning of program components, and specific direction of activities and in facilitating a more extensive outreach to peripheral areas of the state. The date the RAG has approved what it considers to be mertiorious projects. They recognize that these projects serve particular problems, and while relatively narrow in their scope contribute to the whole. In reviewing the projects and programs funded to date and in considering protential future activities the RAG has become Northlands RMP -12- RM 21-03 (AR-1 CSD) 2/71 increasingly aware of the totality of the health care problem. Together with trustees, the staff and the committees of the NRMP, the RAG is planning to define problems that exist in greater depth and attempt to establish more detailed methods and priorities in solving identified problems. Program goals, policies, and guidance developed by three Planning and Review and Management committees have been unanimously adopted by the RAG. Individual members expressed some concern over the magnitude and rapid growth of the program,, fearing the growing pains might impede successful progress. In approving the continuation components in this application, the RAG felt that all of them had a significant achievement and should be continued. In order to maintain program momentum, the continuation components should have priority for funds if they are insufficient funds to cover the whole program. The RAG believed that special consideration in priority for funding needs to be given to one renewal and one new project component in the application. The dial access information system (Project #10 R) is a continuation and expansion, with specific orientation to Minnesota, of the previously funded dial access project component conducted in conjunction with Wisconsin. The RAG believes that the Diabetes Edutation Center Component (Project #20) will provide the basis for continuation of projects #5 and #15 and represents a renewal of the emergency funding provided this year for project #18. The second and third years of this project component will amalgamate components #5, #15 and #20 into one unit. The Regional Advisory Group believes that this NRMP should do everything possible to develop strong relationships with other Regional Medical Programs adjoining Minnesota. The members were impressed with the five or six specific examples of interregional activities between Minnesota, North Dakota, Wisconsin and Iowa. The RAG has frequently emphasised the need for strengthening the health system in sub-regional areas of the state. It has endorsed the activities of community Coordinators and staff in project component activities which seek to develop strong outreach to peripheral areas. It was impressed with the Core staff presentation of 16 core activities and 7 project component activities which are designed to stimulate improved cooperative arrangements in sub-regional areas to strengthen the health care system in the periphery of the state. Some of the members were distressed with the feeling that they have not moved fast enough in this direction and that no great accomplishments have yet been achieved. The RAG of NRMP feels a deep sense of responsibility for the program but at the same time feels a frustration with the organization. In the minds of many of the members, this frustration increased when they became aware of the magnitude of their responsibilities, the Northiands RMP -13- RM 21-03 (AR-1 CSD) 2/71 difficulties in understanding the multiple components of the program, and the time and effort necessary for them to execute their responsi- bilities. The RAG has never the less expressed its confidence in the competence and diligence of the program leaders and wishes sincerely to see the program succeed. Program Evaluation: The Northlands RMP's approach to evaluation has been multi-dimensional, employing a variety of techniques and methods to appraise progress toward the three broad goals of the program as well as accomplishments of the objectives of individual projects. Thus far, considerable stress has been placed on the use of evaluations as the intitial step towards self-improvement with emphasis given to self-appraisal and self-assessment of activities and achievements. As Northlands RMP reaches maturity, greater emphasis will be placed upon an evaluation process which calls for hypotheses testing proceeded by some exploratory study and descriptive and diagnostic investigation. The major dimension of the evaluation process thus far has included self-evaluation with internally developed criteria, scientific evaluation of program and project accomplishments and external appraisal more at processes than at ov.tcomes. The Region seems to be taking an overall look at their program as well as individual projects in developing a plan for evaluation. Developmental Component: The Northlands Regional Medical Program is applying for a developmental component award of 10'/. of the total 02 year operational budget an amount of $131,500. The Board of Trusteesi Regional Advisory Group, and RMP Staff indicate their confidence that the NorthlAnds RMP has developed specificity of program goals, strength of core staff organization, and strength of program fiscal management sufficient to demonstrate its readiness to receive the developmental award. The NRMP explains that they have had fairly extensive experience with program activities and analogous to those which will be conducted with the developmental award. During the planning phase, nine such component activities were conducted, four by specific re-allocation authority of RMPS, and five by the employed core staff. Three of these studies resulted in demonstration project component applications. During the operational phase, NRMP has conducted twelve more such short term studies. The Developmental award however, will make it pos- sible for NRMP to fund activities under the local authority of the RAG without waiting for special RMPS approval as was necessary n t e seven activities carried out previously by this method. The NRMP will utilize developmental funds to conduct special feasibility studies, short term projects, or special research activities, appropriate to NRMP goals which are not already a part of Core or project component activities. They indicate that developmental funds will not be used to provide support for operational projects, either those previously submitted or those pending review. Neither will they be used for initiating long term activities or for purchase of equipment. Northlands RMP -14- RM 21-03 (AR-1 CSD) 2/71 The submission and review of request for developmental funds will follow the presently working review cycle and monitoring system estab- lished'by the Region. Broad Goals of the NRMP 1. To develop and maintain a flexible organization capab le of administering an ongoin@ cooperative program involving 9 the multiple health care organizations and personnel in Minnesota. 2. To stimulate existing health care personnel,institutions and programs to commit their talents and their resources to cooperative efforts to develop more optimal health care services for all the people of Minnesota. 3. To characterize and attack specific problems in a coordinated program to improve health care services to the people of Minnesota. SUPPLEMENTAL PROJECTS Requested Project #20 - Diabetes Education Center This project will irst Year provide the basis for continuation of Project $135,210 #5 and #15 and represents a renewal of the emergency funding of $81,62i provided this year for Project #8 - Diabetes Detection and Education Center. The RAG gave top priority for funding this program. The objectives of this program are to (a) improve health care by stimulating patient interest in and knowledge of their disease; (b) provide continuing education for physicians and allied health professionals; (c) serve as a res@ource center for practicing physicians; (d) develop and make available to other programs,educational materials, techniques, and systems; and (e) stimulate and coordinate development of health education programs, The NRMP believes that this'program interrelates with Core, other project activities, planning and review committee policies. Second Year Third Year $247,113 $254,473 Project #21 - Minneso a Congenital Heart Dise Requested This proposal is to establish a congenital First Year heart disease registry in Minnesota to facilitate a multi- $20,448 disciplinary approach to this disease entity. Data obtained from an optically read registry form will be used to coordinate and improve the currently available health care system for afflicted children. The Minnesota Heart Association allocated $5,000 for research and development of the optically-read form. The participating agencies have contributed staff and clerical time for planning and development. Northlands RMP -15- RM 21-03 (AR-1 CSD) 2/71 The objectives of this program support the Northlands goals of improving patient care, professional education, and disease prevention. There will be a close and cooperative relationship with such other NRMP component projects as Pilot Study in Postgraduate Education in Pediatric Cardiology, Pilot Program of Regional Postgraduate Medical Education - Mayo Institutions, and Postgraduate Education In Diseases of Cardiovascular and Nervous Systems and Neoplastic Diseases in Childhood - U. of M. This program has encouraged, during its planning phase, harmonious cooperation between independent and diverse health institutions and promises to continue doing so if it becomes operational. Second Year Third Year $26,088 $28,688 Project #22 - Continuing Education in the Radiological Sciences Requested at the University of Minnesota Medical Center: First Year The dissemination of information on new techniques used in the $63,886 practice of radiology is the fundamental objective of this proposal. This program relates directly to the goals of Regional Medical Programs as well as to the goals established by Northlands. The education focus of this program will provide the means for conveying the latest advances in radiology and nuclear medicine so as to bridge the gap between the existing knowledge and skills and their implementation. The project will link the expertise of the medical centers to the radiology practitioner. The upgrading of radiological services throughout Minnesota will permit the best in modern care to the patient. Second Year Third Year $45,715 $46,715 Project #23 - A Continuation Course for Nurses Care of th.e Requested Patient with Neurological Disease. First Year The primary purpose of this program is to train nurses in $50,694 neurologic and cerebrovascular disease nursing. The program will be presented by three nurse educators and one physician, augmented by recording and filming portions of the course presented by experts unavailable for travel to peripheral institutions. The Continuing Education Committee of NRMP has established policies into which the goals of this project fit unquestionably. These goals stress the need to better the level of practice of health professionals, develop programs which advance cooperative relationships, provide educational opportunities at the site of the health professional's practice, and utilize the interdisciplinary team approach. This project will not conflict with the presently funded project entitled "Improving Stroke Rehabilitation Through a Regional Program of Continuing Education" which deals exclusively with the rehabilitation of long-term patients. Personnel from both courses have agreed that the courses differ. Second Year Third Year $42,278 $32,850 Northlands RMP -16- RM 21-03 (AR-1 CSD) 2/71 APPROVED AND UNFUNDED PROJECTS The Region has requested in-this application new funds to activate the following approved and unfunded projects: Requested Project #13 (Previously Known as Project #9) - Pediatric Educa- First Year tion: This program is aimed at,hose physicians $38,693 whose practice is devoted, in a large part, to the care of children. It will provide an educational experience to the participants in (1) pediatric cardiology, (2) pediatric neurology, (3) infectious disease and immunology and (4) metabolic disorders and neoplastic disease in childhood. An entire day each week will be designated as a postgraduate effort by ten to fifteen members of the faculty of the Department of Pediatrics. This project relates to the Regional Program Plan in that it will enable utilization of limited manpower. The Region has requested one-year support at the' NAC a proved level for 01 year of $38,693. p Project #14 - Course for Medical Technicians in Opthalmology: Requested This program proposes to train selected First Year individuals to perform those technical and mechanical $5@1,850 determinations required in the treatment and diagnosis of eye disease and thus extend the time availability of the Opthalmologist. This project complies with the goals and objectives of the Region because it provides for the development of new health manpower. The Region believes it has documented very well the health manpower shortage in Minnesota. The Region has requested three years support at the NAC approved le,;el. Second Year Third Year $27,855 $30,083 Project #19 - Mobile Health Unit: The objective of this Requested proposal is "to extend the arm of the First Year physician" into a rural section of Northwestern Minnesota $54,059 utilizing a mobile van and the services of registered nurses. The program relates to Regional goals and objectives in that it increases equity of access to a system of quality health care and increases the system productivity while constraining costs. The Region has requested three years support at the NAC approved level. Second Year Third Year $30,835 $30,335 Northlands RMP -17- RM 21/03 (AR-1 CSD) 2/71 RENEWAL REQUEST Project #10 R - A Minnesota Dial Access Information System. Requested The Dial Access Medical Library has been First Year an operational project since March 1969, in cooperation $34,330 with Wisconsin RMP Dial Access Program in Madison. This application for a Renewal grant is for the purpose of establishing, expanding and coordinating a Dial Access Information System specifically oriented to the practicing physicians in the State of Minnesota. The Education Committee of NRMP believes that this program could become an essential component of an extensive information network which eventually could link the various health facilities with the medical centers throughout the State. The RAG of the NRMP has designated this program as a high priority activity for this Region. The Region indicates that this program relates directly to the goals of of Northiands because it helps to make the latest medical knowledge constantly available to all practicing physicians within the Region. It will further help to develop integration of information available from other project activities supported by RMP as well as information available through existing region-wide resources. Second Year Third YeaL $34,495 $35,950 SUPPLEMENTAL FUNDING OF ON-GOING PROJECTS Project #2 S - Multidisciplinary Improvement in Medical Care Requested of Myocardial Infarction in Minnesota: First Year This was an approved and unfunded project which was initiated $82,792 with carryover funds awarded by the RMPS on July 1, 1970. The Region has requested new money at the 02 year NAC approve level for continuation of the program. The primary objective of this program is to provide practical courses for nurses who are directly involved in the care of coronary patients. Project #1.2 - (Previously known as Project #8) - Pilot Program Requested of Regional Postgraduate Medical Education (Mayo First Year Foundation). This was an approvedand unfunded project which $31,002 was initiated with carryover funds awarded by the RMP. The Region has requested new money for continued support of this program in its 02 year. The NAC approved level for this project in its 02 year is $69,960. In addition the Region has requested supplemental funding of the following ongoing projects: Diff. in Req. Project Commitment NAC Approved level Request vs. Commit. #2 $187 500 $259,841 $259,841 $72,341 #3 24:917 45,161 32,018 7,101i #5 481,000 66,130 66,130 18,130 #7 75,000 100,000 100,000 25,000 Northlands RMP -18- RM 21-03 (AR-1 CSD) 2/71 Present Year APPROVED AND FUNDED PROJECTS of Operation Project #2 -Mutidisciplinary 2nd Improvement in Medical Care of Mycardial Infarction Project #2S - Supplement to Project #2 (above) lst Pro ject #3 - Postgraduate Education in Pediatric Cardiology 2nd Project #5 - Diabetes Regional Center 2nd Project #7 - Improv ing Stroke Rehabilitation through a Regional 2nd Program of Continuing Education Project #12 - (Revision of Project #8) Ist Pilot Program of Regional Postgraduate (carryover Medical Education, Mayo Foundation funds) Project #10 - Telephone Dial Access- Medical Library 2nd Project #15 - An Education Program in Clinical Nutrition lst Project #16 - Upgrading the Quality of Clinic Laboratory Tests by Improving lst Performance of Laboratory Personnel in Non-Urban Hosptials through Continuing Edcuation. Project #17 - Refresher Courses for Nurses lst Project #18 - Diabetes Detection Center lst APPROVED AND UNFUNDED PROJECTS Council Approval Project #13 - (Revision of Project #9) Postgraduate Education in Disease of December 1969 Cardiovascular and Nervous Systems and Neoplastic Disease in Childhood, llniv. of Minn. Project #14 - Course for Medical Technicians in Ophthalmology December 1969 Project #19 - A Proposal for a Mobile Health unit November 1970 Northlands RMP -19- RM 21-03 (AR-1 CSD) 2/71 PROJECTS DISAPPROVED Project #4 - Information Network for Education and-Clinical Evaluation Applied to Coronary Artery Disease Project #6 - Service-Oriented Cancer Registry Project #11 - Development of a Stroke Rehabilitation Management Simulater RMPS/GRB/12/10/70 A PRIVILEGED CONMNICATION S@RY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIEW COMMITTEE NORTHLANDS REGIONAL MEDICAL 'PROGRAM RM 21-03 (AR-! C8D) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: The Committee recommended that additional funds be provided for this application as follows: 639, 32 - 03 @'/ear; $1,462,159 04 year4, and $1,378,700 - 05 year. TOTAL REQUEST AND RECOMMENDATION RMP Request Year Developmental Other Total 03 1313,500 2,099,986 2)231,486 04 131,500 1,494,220 1$625,720 05 131,500 1,504,799 1,636,279 Total $394,500 $5iO98,985 $52493,485 Committee Recommendation Year Developmental Other Total 03 131$500 1,822,900 1/ 119954,400 1/ 04 131,500 1,380,100 2/ 1,511,600 2/ 05 13ls5OO 1,247,200 1,378,700 Total $394,500 $4,450,200 $4,844,700 (Includes $1,315,368 of t6nnitted funds approved by staff.) (Includes $49,441 of committed funds for one project.) critique; A site visit was conducted to this Region on December 15-16, 1970 and the visitors reported that they were favora y impressed with this Region's development to date. Concentrated efforts are being made to stabilize the planning and decision-making process and respond to new program direction as well. The Regional Advisory Group has assumed the leadership role and now has full responsibility Northlands RMP -2- RM 21-03 (AR-1 CSD) 2/71 for program direction. While valid, the goals and objectives of the region were found to be general in nature. The Region is, however, aware of this problem and is presently formalizing its regional objectives. The Region is in the process of shifting its program emphasis from continuing education to health care delivery. As yet, the l@C has not dealt with the issue of setting priorities on indi.vidi.iil components of applications. The RAG, however, plans to face this issue once it knows what level of funding will be awarded to the Region. Dr. Winston R. Miller, the Program Director, is a very capable administrator and.he has a competent supportive Core staff. The Associate Director for RMP at the University of Minnesota appears to be a positive force of the NRMP. The RMP Coordinator at Mayo, however, has had difficulty getting his institution's active participation. Dr. Miller has developed a good rapport with project representatives, the RAG, and the Board of Trustees and he skillfully manages to keep the latter two groups well informed of Core staff activities. In view of the broad goals, Committee was concerned with the relevance of projects to the goals, especially in the area of continuing education. There appears to be fragmentation in specialized training activities. It was reported, however, by the site visit team that Core staff is making some attempt to correct this problem by working with hospitals, colleges and allied health associations. Committee's overall impression is that further program development will be accelerated with the increased RAG interest and involvement, especially when coupled with the continued support of a strong Core staff led by an extremely capable Coordinator. Developmental Component Committee recommends a developmental component award for the NRMP because it believes it will encourage continued interest and involvement of the RAG, and enhance program development which appears to be in progress. The Developmental Component has been a primary stimulus for strengthening the RAG's position and the RMP appears to be capable of administering the Developmental Component. Principle use of the developmental funds will be in the areas of manpower and health delivery services. The Region should be advised that continued support of the Developmental Component after its first year will be based on an extremely critical review of the effectiveness of the RAG in its new leadership position. Northlands RMP -3- RM 21-03 (AR-1 CSD) 2/71 Supplemental Projects (New Activities) Project #20 - Diabetes Education Center - In considering this project, Committee had to consider the Region's total Diabetes Education Center Program. It is proposed that in the 02 year of this project that projects #5 and #15 will be incorporated. The Project Director for all three projects is the same and has been recognized nationally for his competence. He is developing a model for a center which has national as well as regional benefits. The Committee believed, however, that the RMP should consider phasing out, at the end of the Region's 04 operational year, those activities formerly supported under projects #5 and #15. Project #21 - Congenital Heart Disease Registry - The Committee noted that the input into the registry would be from pediatric cardiologists only, and feedback would o to only the 9 pediatric cardiologists, and the Pediatric Committee of the Heart Association. It also appears that the cost per case is high. The Committee believed that prior to supporting this project, the RMP should reevaluate it in light of the concerns expressed about registries by the National Advisory Council in November 1970. Project #22 - Continuing Education in the Radiological Sciences at the University of Minnesota Medical Center - The Committee found little evidence that this project is based on an analysis of regional needs. Project #23 - Continuation Course for Nurses Care of Patient with Neurological Disease - There is no indication that this project is based on an analysis of regional needs. Further, this was another reflection of the fragmented continuing education program of the region. Committee also wondered why this type of activity was not a part of the general education program for nurses. Approved and Unfunded Projects (The region has requested in this application new funds to activate the following approved and unfunded projects.) Project #13 - (Previously Known as Project #9) - Pediatric Education- The Committee noted that this project is limited in its sphere and is not truely a regional effort. Further, the project is not in keeping with change in emphasis of the Northlands @IP. The project represents a unilateral approach and reflects the fragmentation of the Region's Continuing Education Program. Project Y@14 - Course for Medical Technicians In Ophthalmology - This program is currently being supported to a limited degree from local funds. Committee believes that it should not take an additional three years to establish a training program. The Committee believes that the RMP should consider providing funds for two years only at the level previously recommended by Council Northlands RMP -4- RM 21-03 (AR-1 CSD) 2/71 Project #19 - Mobile Stealth Unit - The Committee found tliit this pro;,r,)rii clearly relates to regional goals and objectives. It increases equity of access to a system of quality health care and increases the systems projectivity while containing costs. RKenewal Requests Project #10 (R) - A Minnesota Dial Access Information System: The Committee noted that this program represents a high priority item for this Region and was impressed that it is not only providing educational. linkages, but has the potential for a much broader educational program. Supplemental Funding.of On-going Projects Project #2 - Multidisciplinary Improvement in Medical Care of Myocardial Infraction in Minnesota - Committee noted that this basic program has been progressing adequately with the amount of funds provided up to date, and believed that it would probably continue without additional RMP funds. Project #2 (S) - Committee believes this supplemental activity of Project #2, initially implemented with carryover funds, would allow the continued expansion of the current project. Expansion of the basic program appeared warranted. Project #3 - Pilot Study in Postgraduate Education in Pediatric Cardiology- The Committee believes that this project should be permitted to expand out of the cardiology field into the neonatology area. Committee noted that this project is involving a five-state area and is a good regionalization component which is involving 11 or 12 cardiologist. Project # 7 - Improving Stroke Rehabilitation through Regional Program of Continuing Education - The committee noted that the American Rehabilitation Foundation has a long record in education, specifically in allied health. There is a great deal of enthusiastic local commitment to this project which has now reached over 8,300 people. Its multi-pronged attack is involving nurses, families and clergy. Pro ect #12 -(Previously known as Project J@8)- Pilot Program of Regional Postgraduate Medical Education (Mayo Foundation): This was an approved and unfunded project which was initiated with carryover funds. The region has requested new money for continued support of this program in its 02 year. The Committee wondered why the RMP wished to continue this project. Progress has been slow, and apparently something is wrong. The Committee believes that perhaps the RAG may not have had adequate opportunity to review the contintintion request. Further, it appears that if Mayo was committed to the project they should be putting some of the institutions' funds into the program. RMfl@ /CRB / I / 18 / 71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) OREGON REGIONAL MEDICAL PROGRAM RM 00012 2/71.1 CS 3181 S. W. Sam Jackson Park Road January 1971 Review CoT=ittee Portland, Oregon 97201 Program Coordinator: J. S. Reinschmidtl M.D. REQUEST (Direct Costs Only) 04 05 06 Purpose 4/l/71-6/31/72 7/l/72-6/30/73 7/l/73-6/30/74 All Years Continuation Commitment $311,064 $311,064 Core (2291,765) (229,765) 3 Projects (81,299) 1/ (81,299) Renewal Components 329,210 $267,966 $229,612 $826,788 4 Projects (329,210) (267,966) (229,612) (826,788) Additional Components 317,872 196,625 191,144 $705,641 2 Previously Approved Prj. (85PO75) 59,147) 61,169) (205,391) New Projects (175,356) (137,478) @129,975) (440@,809) i Supplement to Core (5710441) 2/ (57,441) Total $9581146 $464,591 $'420,756 $1,843,493 Staff Action Commitment $311,064 $31.1,064 Committee Action Required $647,082 $ 464 -591 $ 420@756 $.I,532,429 I/ (Three months of committed support for three of the four Renewal Projects below) 2/ (Three months of support for core requested to change Region's budget year to July 1) 2 - RM 00012 2/71.1 CS OREGON RMP FUNDING HISTORY PLANNING STAGE Grant Year Period Funded (d.c.o.) 4/l/67 - 3/31/68 $166,494 01 203,793 02 4/l/68 - 3/31/69 $ OPERATIONAL PROGRAM Future Grant Year Period Council Approved Funded (d.c.o.) Commitment 01 4/l/68-3/31/69 $955,097 $522,287 885 994 854,146 02 4/l/69-3/31/70 03 4/l/70-3/31/71 921,948 837,328 1/ 04 4/l/70-6/30/72 3191)854 $319,854 28,920 05 7/l/72-6/30/73 28,920 I/ Includes $107,795 in carryover. Geography and Demographz The Oregon RMP is bounded by the Washington, California and Mountain States RMPS. The state has approximately 2.05 million people in its 96,248 square miles. The major portion of the population is concentrated in an area between the Pacific Coast and the Cascade Mountain Range. The remain- der of the population resi Oa in widely separated cities, small communities and rural areas throughout the state. Oregon has a university medical school in Portland and seven schools of nursing. There are 87 general hospitals with a total of 7,608 beds. The population is served by 2,770 M.D.'s and D.O.'s and 7,851 nurses. Regional Development The second planning application was approved in February 1970 after the initial one had been returned for insufficient detail. Conditions were placed on the first award asking the Region to clarify the role of the medical school, community hospitals, practicing physicians and the Kaiser Foundation Health System. The first of four Coordinators to serve the program was Dr. Myron Grover, Director of Continuing Education of the Medical School, which serves as the grantee agency. Dr. Grover was succeeded by Dr. Goldblatt during the OREGON RMP - 3 - AM 00012 2/71.1 CS second planning year. When Dr. Goldblatt became Coordinator, the Region requested and received a modest planning supplement for planning an administration costs. The operational application was submitted in December 1967 and following an enthusiastic endorsement from a site visit team in February 1968, Council approved the submissions. Shortly afterwards, the Region sub- mitted two supplemental applications with eleven projects, which were all approved. #2 - Early Diagnosis and Therapy,of Cerebrovascular Disease #3 - Surgical Treatment of Vascular Lesions and Cerebral Complications of CVA Disease #4 - Diagnosis and Treatment of CVA Disease and Influence of a Stroke Clinic on Stroke Care #5 - Stroke Continuing Education Program #6 - Mid-Willamette Valley CCU Training Program #7 - Training Nurses for Coronary Care #8 - Educational opportunities for Physicians in Diagnosis and Therapy of Cancer #9 - Central Oregon Heart, Cancer and Stroke Pilot Project #10- Coronary Care Teaching Aids #11- Guiding Patients with Aphasia #12- Southern Oregon Diabetic Instruction and Evaluation The first six projects, which were awarded funds, are in their third year of support. Of the remaining five, the Region funded four out of unexpended funds. (The Region is requesting renewal support for Projects #1, 4, 6 and 7, and committed funds for a year of support for Project #8 in the present application. Site visitors to the Region in April 1969 came away greatly impressed with all aspects of the program, including core staff, Regional Advisory Group, and evaluation efforts. Although the program appeared heavily producer and continuing education-oriented, there were indications that staff was Developing activities involving other groups and in other areas. As a result of the site visit findings, continuation of core and approval of two supplemental projects #13 - Mobile Emergency Cardiac Project, and #14 - Training Programs to Promote Better Care of the Diabetic Patient, were approved and funded out of carryover. The Region's request for continuation of core and ten projects for the third year was well-received by staff. It appeared that the Region had come a long way in establishing itself as a broadly-based, ongoing program as opposed to a series of isolated projects. The key to this trend seemed to be the RAG's increasing awareness of the meaning of local autonomy. The RAG, complemented by a capable core staff, had developed a mechanism for evaluating both incoming proposals and ongoing projects. As a result of this evaluation, the Region had prematurely terminated one project - #3. 4 RM 00012 2/71.1 CS OREGON RMP Although generation of project activity slowed down somewhat, the Region submitted and had approved the following projects: #15 - Physician In-residence Course in Cardiology (received new funds from RMPS) #12R- Southern Oregon Diabetic Instruction and Evaluation Project #16 - Training Program for Personnel of Oregon Health Care Institutions (funded from carryover) The third operational year has also seen two changes in coordinator. Dr. Goldblatt was replaced by Dr. David Johnson, who served as Associafe Professor of Public Health and Preventive Medicine at the University of Oregon. Dr. Johnson resigned in November to become Regional Health Director for Region X, and has just recently been replaced by Dr. J. S. Reinschmidt, who has been with the Student Health Service for the past seven years (curriculum vitae attached). The Oregon RMP, then is in a state of transition. The new coordinator has just assumed his position. The core staff's time for the past six months has been consumed with preparing the AR application and therefore not devoted to developing the program. As the application aptly states, "daily routine drives out planning." The Regional Advisory Group has been struggling with RMP's changing role; it "has recently broadened its program beyond its conservative interpretation of public law 89-239." The Region is also requesting a change in its anniversary date from April I to July 1, because the November 1 national review deadline would require the Region to do most of the application preparation during t e summer months which imposes a hardship on the Region. Oregon apparently has only two months of sunshine in which everyone takes their vacation. Thus, the Region is unable to get quorums for RAG and other review group meetings and project directors are not available for consultation. For this reason and because the Region needed more time with a new coordinator to develop their triennial look, RMPS gave the Region permission to change the anniversary date. Regional 0-jectives Within the goal of improving the care given to patients with the categori- cdl diseases and the ultimate objective of reducing morbidity, disability and premature death by: (A) stimulating more widespread and effective use of the latest advances in the prevention, diagnosis, treatment and rehabilitation of these diseases and (B) by encouraging experimentation with and adoption of more efficient mechanisms in the dispensation and administration of health care services, the Oregon RMP has the following more immediate objectives: A - 1. To encourage the development of cooperative arrangements among the Region's medical school, research centers, health organizations, medical institutions, and individuals engaged in the delivery of health OREGON RMP - 5 -, RM 00012 2/71.1 CS services or In the provision of health-related professional educational programs. 2. To assist persons involved in the delivery of health services on continuing educational programs to transform ideas for improving care into well-developed and expertly presented operational projects, and to consult with and advise such individuals in regard to potential sources of funds for these projects. 3. To assist directors of operational projects and affiliated insti- tutions in the efficient administration, responsible fiscal monitoring, and meaningful evaluation of their projects. 4. To provide for the continuing education of the ORMP staff and of appropriate members of th@ RAG and its committee system so that the latest and most effective administrative and instructional methods are employed and so that the volunteer policy-making component of ORMP can be assured that it will determine any new directions for the program in an informed and meaningful fashion. I B - 1. To determine, in concercwith the RAG, a consensual set of specific operational objectives for the ORMP; taking full cognizance of emerging RMP legislation and guidelines; to be completed by February 1, 1972; and to include explicit reference to the particular manner and extent to which ORMP can or should in the absence of increased fiscal resources address itself to the issues of distribution of health care, innovative use of medical personnel, relationships with CHP. C - 1. To prepare by February 1, 1972, a consolidated AR application for program triennium review. Organizational Structure and Processes Oregon has a forty-member Regional Advisory Group, representative of most of the important health provider and consumer groups in the state. Its operation is facilitated by the following committees: a) a three-man Executive Committee responsible for administration of the program between RAG meetings. b) a Grants Application Review Committee, which reviews the applications. c) a Regional Cooperation Committee, which studies the coordination and activities of the various grantees in the state, through the use of subcommittees and consultants. d) an Evaluation Committee is available to evaluate funded grants, as well as the activities of the terminated projects. It will also accumulate and present factual evidence of the accomplishments of the entire RMP. It may draw on the resources of consultants. e) the Heart, Cancer and Stroke and Continuing Education Subcommittees are composed of experts in these respective areas. Their function is to (1) evaluate project ideas for feasibility, scientific soundness and OREGON RMP 6 RM 00012 2/71.1 CS applicability to RMP, (2) make recommendations to the Grants Application Review Committee regarding project requests, (3) determine needs to improve care of patients with the categorical diseases (4) provide solutions for needs, and (5) act as regional consultants. The grant application review schedule is attached. If the ORMP is not awarded monies to support all ORMP approved grant requests, a priority rating will be assigned by the RAG in order to determine which shall be funded. The rating will be made using the following criteria: i. the amount of regionalization (the creation of cooperative arrange- ments, avoidance of duplication of existing effective efforts, written support from all appropriate agencies, and anticipated benefits to institutions other than just the applicant organization); ii. its concern with the prevention and/or early detection of categorical diseases, and to those directed toward commonly occurring illnesses, especially those tending to'affect children or adults in the most pro- ductive years of life; iii. the inclusion of some element of continuing education either as a pre- dominant or as an important component part; iv. its orientation around the problem analysis approach, as outlined in the ORMP instructions for writing applications; and V. the cost per unit of accomplishment when compared to (1) other programs of a similar type, or (2),alternative solutions to the same problem. For a discussion of Core structure and function, please refer to the con- tinuation section of the application componen s. Present A@lication Continuation - These components have been reviewed by staff. Their program and tunding recommendations are in a supplementary memo. 4th Year Core $287,206 The Oregon RMP has a small core staff, which until this point in time, has been more organized to deal with the preparation of well-developed and well-written project applications, than with the stimulation of program. The Region admits that the broader RMP programs now envisioned may require a staff reorganization and the addition of more members. There are seven full-time professional personnel and four secretaries. The professional positions include the Program Coordinator, Coordinators for Community Organization, Program Administration, Information and Communication, Nursing and Allied Health, Project Development and an administrative assis- tant. Evaluation services are provided through contract with the Northwest OREGON M@@.P - 7 - RM 00012 2/'71.1 CS Regional. Educationi,'- La@-)r,,r@,tory. Contract funds will al,so be utilized to continue a patient origir, study. Core funds arc,. al@--,o being used to dr@,ielop a physicia;-i,-, assistance program in conjunction with the Medical School Division of Family Practice. In addition to their application preparation function, staff provides assistance on request to vari-ous regional organizations. Examples of this type of help include: (1) providing data, special charts and reports to hospitals and conferring with architects and hospital consultants in four areas of the state; (2) serving on the Ombudsman Committee of the Oregon Medical Association and (3) involving many different organizations in the Portland area in an ii.formal planning effort to explore means of improving the organization and delivery of health services, particularly for the low-incotrie families. Continuation support is also requested for: 15 months for project #15, Physician Inresidence Course in Cardiology 3 months for projects #4, Comprehensive Stroke Care in. the Regional Education; #6, Mid-Willamette Valley Coronary Care Training Pro- gram; and #7, Coronary Care for Professional Nurses and Physicians (These projects are also requesting renewal support for three additional years). The Region also hopes to fund the following Council approved projects from carryover: Project #9, Ifeart, Canc(--r and Stroke Pi,-ot Project Project #10, Coronary Care Teaching Aids Project #11, Adult Patients @qith Aphasia Pro ect #14,, Diabetic Patient Care. Approved but Unfunded Projects These projects liave been previously approved by Coui@icil, but due to national funding constraints, have not been funded. Committee and Council consider- ation of these projects is needed in determining a funding level for the next year and not for approval of the activities. Project #8 - Educational Opportunities for the Oregon Regional Physician in the Diagnosis and Thera.pv of Cancer. Ist Year $42,369 This project will provide an intensive one-month in-resideiice course at the Medical Center for eight physicians per year. The curricu- lum will be tailored to the physicians' needs and those of his community. Second Year Third Year $59,147 $61,169 OREGON RMP 8 - RM 00012 2/71.1 CS Project #16 A Training Program for Personnel of Oregon Health Care Institutions let Year $42,706* The purpose of this project is to provide informational courses to a multidisciplinary spectrum of sub-professional health care u7orkers. The courses will be designed so that students may comprehend and carry out their own specific responsibilities under formal institutional standards concerned with the control of significant health care problems. This project has received some support from carryover funds since October 1970. *for a 15-month period Supplemental Projects: Committee and Council action are required on the following nine projects: Renewal Projects Project #lR Heart, Cancer, Stroke Circuit Postgraduate Course for the Oregon Region. 4th Year $1805,747* The purpose of the circuit course program is to provide continuing educa- tion for physicians, nurses and allied health personnel at 19 locations in the Region. Sponsored by the University of Oregon Medical School, faculty from this institution and selected private practitioners, through the use of video tapes and other teaching techniques, will bring medical care advances of the research laboratory and medical center to health personnel in the small community. During the past three years of operation, the courses have reached approx- imatelv 1600 physicians inoverlOO presentations, 900 nurses in 23 courses and 70 medical technologists in five sessions. Since evaluation appeared weak,, the proposers have taken steps to evaluate through a questionnaire changes in patient care practices as a result of the courses. Fifth Year Sixth Year $1362,409 $1332 363 *Note: for a 15-month period. Project #4R - Com2rehonsive Stroke Cate with Regional Education 4th Year $52,375* The Cood Samaritan Hospital and Medical Center in Portland wishes funds to renew RMP support for a strole program, which includes the following three elements: OREGON RMP 9 - RM 00012 2/71.1 CS a) a stroke evaluation and education team at the sponsoring hospital, b) satellite clinics at Bend and Astoria, and c) a series of 12-day courses in care of the stroke patient for nurses. As far as progress is concerned, the project has continued the activities of the Outpatient Clinic and assisted in the establishment of an inpatient Stroke Care Unit at Good Samaritan Hospital and Medical Center. Panel discussions and exhibits have been presented by the staff, directed toward both physicians and nurses. A formal 12-day course for nurses has been established, and a one-day Circuit Course was given in four communities during the last three months of this fiscal year. The Satellite Clinic in Bend has been established and clinical research is underway. A cost effectiveness study has shown that the savings from patients going home has resulted in a savings of almost three times the budget for the project for a year in hospital and nursing home costs, assuming a patient with a major stroke is cared for only one year in a nursing home. Fifth Year Sixth Year $54,444 $561-617 *Note: This project has three months of committed support ($14,215) from April 1 to June 30, 1971. If approved, the Project's level of funding for the 15-month period (April 1, 1971 to June 30, 1972) would be $66,590. Project #6R - Mid-Willamette Valley Coronary Care Training Program 4th Year $44,113* A program of coronary care nurse training (four three-week courses for 32 nurses a year), advanced training and workshops for nurses, and a physician post-graduate education program would require three additional years of RMP support. A total of 110 nurses have been trained and over 500 physicians have attended the courses thus far. A spinoff of the project has been that all but one hospital in the state have policies governing coronary care as opposed to three at the initiation of the project. The training is con- ducted by the staff of the Salem Memorial Hospital in Salem, who will have trained 110 nurses and 512 physicians in these courses during the past three-year period. Fifth Year Sixth Year $37,438 $19,294 *Note: This project has three months of committed support ($13,039) for the period April 1, 1971 to June 30, 1971. If approved, the project's level of funding for the 15-month period (April 1, 1971 to June 30, 1972) would be $57,352. OREGON RMP 10 RM 00012 2/71.1 CS Project #7R C6tondt_v Care for'Pt6fOs8ionAl'Nurs0s and Physicians lst Year $51,775 Nurse trainees will come from approximately 16 Oregon hospitals with coronary care facilities to Sacred Heart Hospital in Eugene, for one or all of the following courses in coronary care nursing: (1) a three-week basic course held three times a year; (2) a 40-hour advanced course held five times a year, and (3) an advanced workshop for nurses once a year. Over 100 nurses have been trained to date. In addition, project staff will visit participating hospitals to conduct a six-hour training session for physicians. Second Year Third Year $39,675 $2Ot338 *Note: This project has three months of committed support ($18,460) for the period April 1, 1971 to June 30, 1971. If approved, the project's level of funding for the 15-month period (April 1, 1971 to June 30, 1972) would be $70,235. New Projects Project #17 -The Mid-Willamette Valley Diabetic Patient Project lst Year $17,516 The purpose of this proposal is to train out-patient diabetics and their families in personal care of diabetes. The Salem Hospital in Salem will provide 40 courses of 30 hours duration (ten patients per course) with special attention to those patients from smaller community hospitals and outlying doctors' offices. Additional efforts will be directed to adoles- cents and deprived groups. The project would also provide additional information for physicians, training for paramedical personnel and increased public awareness of the need for patient education. The concept of this course is directed toward better patient care in a sub-regional area. The courses will make available facilities to diabetics otherwise not available to them, and by improving their care also reduce the economic loss to themselves, the community and public agencies. Second Year None Project #18 - An Operational Service for Remote Coronary Care Monitoring lst Year $7931 501 Emanuel Hospital, Portland would provide an operational coronary care remote monitoring system to community hospitals on a volun- OREGON RMP RM 00012 2/71.1 CS tary basis by transmitting the EKG signal via telephone lines from the outlying hospitals to the Emanuel Hospital CCU. Project nursing personnel would continuously monitor the signal on oscilloscopes. The service would also offer special education for the CCU nurse emphasizing common electrocardiographic patterns, techniques of defibrillation, and equipment procedures. Continuing education for physicians may also be arranged. This project stresses an operational mode for the improved care to patients with myocardial infarction residing in less populated areas of Oregon. The project also builds on the successful pilot programs demon- strating the feasibility of the larger central hospital's monitoring the coronary patient in a rural hospital. Second Year Third Year $67,758 $70,142 Project #19 - Pendleton Region Stroke Rehabilitation Project lst Year $23,592 The Pendleton Stroke Education Group (PSEG), an unofficial group repre- sentative of the agencies and institutions involved in stroke care in Pendleton, was formed as part of one of the initial stroke projects. St. Anthony's Hospital in Pendleton, in conjunction with the PSEG, intends to improve the level of stroke care in the area by: I 1. Identify4ng local problems in providing stroke care,, 2. Improvin,, the continuity and coordination of stroke care C, 3. Providing continuing education in stroke rehabilitation for members of the health care team in the subregion, 4. Developing a home health program, and 5. Educating the public about the effectiveness of rehabili- tation for the stroke patient. The project contributes to ORMP goals by building cooperative arrangements among health personnel and institutions, improving patient care and utilization of resources and skills, as well as providing continuing education and developing innovative approaches to treatment. Second Year Third Year $18@874 $14pl56 Project #20 - CommunitV Coordinators of Continuing Medical Education Ist YeaL $22,344 ORMP support is requested by the Oregon Medical Association to subsidize an integrated system of 17 volunteer coordinators of continuing 12 - RM 00012 2/71.1 CS OREGON RMP medical education for Oregon physicians. Practicing physicians would be trained to determine needs in their communities and in educational tech- niques in order to enable them to act as part-time Directors of Medical Education for their communities. Coordinated by a central administrative information and resource jnit, the physicians would also coordinate state educational resources and short preceptorship experience for physicians. The project relates to ORMP goals of utilizing existing resources more effectively, and of innovatively using mainly volunteer personnel to deal with the provision of adequate continuing education opportunities to physicians. Second Year Third Year $22,494 $15,650 Project #21 - A Drug Information Service for the Health Professions Ist Year $329403 A drug information center will be established at the School . of Pharmacy, Oregon State University, which will serve as a central reference source collection with the capability for aiding all health practitioners in exercising a rational approach to drug therapy. A drug information specialist will answer specific requests for information and publish a bulletin containing drug information of general and current interest. The Drug Information Specialist will also encourage utiliza- tion of the Drug Information Service by seeking contact with health pro- fessionals through participation in local and regional continuing educa- tion activities of the various professional groups. The proposal contributes to improvement of patient care and represents a. cooperative effort of health professions to identify and meet local needs. It also increases the economy of health care delivery by sharing available resources. Second Year Third Year $2810352 $30,027 GRB/RMPS 12/17/70 CURRICULUP! VZTAE FOR J. S. R-PIk,SCffl,!IFff bl. D. -throuSh hi Born in Pensacola, Florida, 1925, and received education gh school. there.' Military Service World War II, U.S. Army Pla@ed, 2 children Education:, A.B. Vanderbilt University 1950 M.D.-Vanderbilt University 1953 Ilost-radtiate Tt-airii.nL,: Internship (i.-o'Llatin-) Colorado General Hospital, Denver, Colorado L> Cone@,l Surc@ery Residency University of Colorado ?,Iedical. Center 1954-1956 and 1959-1962 included one year in research. Teachin- -of interns, residents and nurses part of responsibilities. Experience: General Prac'Llice Tekoa, Washin-.ton, 1956-1959 Surgery and General Practice Pullman, Washin-ton, Igo'2-1963 (Student Health Se--vice Washin-ton State University) Student Health Service University of Orevon Eugene, Ore,-on, 1963 to -present. Directok since 1966-1967. Plem'oer and current chairman of i@ledical Education Committee and member of Library and Publications Cor..,jiittee Sacred Heart Hospital Yiedical Center, Eu-ene, Ore-oni Served as P- moderator in clinical seminars of the annual scientific session of American Academy of General Practice 1968 and invited to t-erve in like capacity for 1970. 'Organ'-zationst Araerican Academy of General Practico Lane County i@',edical Society (Secretary 1970) Ore-on L'-Iedical Association (Dele,ate to House of Dele-ates and member of Venereal Disease CorrLmittee and. Ad hoc Subcommittee) American Mrjdical Association American Colle-e Health Association (L',Iember of Council 1068 to present) -Pacific Cop-St Collec-e Health Association (President 19'9 C> o -1970) Staff Sacred 'rfcart Hospital Eu-ene Eugene Sur-ical Society Lane County Corbiunity Health Council Publications: D. "Traumatic Pancreatitis, An Incre@.sin- Problem", Henry C. Cleveland,, Julian S. Rcinsch@,iidt, @t. D.; William R. Waddell, 14. D.: @r Ical Clinics of Iforth APerica Vol, 43, No. 2, April, 1963 14 oll S. Reinschraidts go'Do Publications: (continued) l'Infectious Mononucleosis in American Negroid Students". R. J. Carson, II. D'. ; J. S. Reinschmidt, @l. D. ;H. C. Lemon, 1-1. D. -n College Health Association Vol. 16, Journal of the Americ@ No, 2, December, 1967 "History and Physical Foria for Student Health Services", J. S. Reinschmidt, @I.D. ; R. A. MacHaff ic, M.D.; S. Carlson, PhD.; James Tomb.OLI-hs Northwest Medicine Vo 1, 67, 110. 11, NoveDibcr, 1968 ATTAC@ -, IT G OREGON REGIONAI @Ac:,:)ICAL PROGRAM L GRANT APPI-I@CATION REVIEW SCHEDULE Fc@:ASIB!ILITY REVIEW IDEA Pi@-Crr-iV=-D STAFF REVIEW-Mq-ET',NIG WITH APPLICAINT- GRANT DEVCLOPMENT-TO REVIEW CYCLE i i I Reccr'a'ed I I i Filed Acknowledged reasib,@l,"I-Y SLcc:es@ to Co-nplete or Deadline Set Xeroxed Sugg--st,ons Low Pricril-y to Appliccrit REVIEW CYCLE EXECUTIV .E DIVISION OF REGIONA] A PAB MEDICAL PROGRAMS SEI SL,)IBCOMMITTEE C- A,-@ C u w view i; Xe rox e ev,@) KeVie @c,.Cll d c. and Si i. @/@eeting Ccncer ec. cnd Rec. an SI- r' S+roKe @c.,cT' Recor" Staif Report Stcff Repo,-t Ic-@ 7 ,led 'i-o Sj'o. Dec on Mc' is! cnd Appliccnt L-volucl,-Ion Com;-niltee Applicant and Applicant cnd f Report to Applicant r, Work Working Working Subcc,-nrnittees imposition of Grant (A Privileged Cor,@@nunic,-ti-on) SU'-%r@LkRY OF 01? JA',,FJArLtY 1971 RI,,VIEW CO",@',@'ITTi7E O,",EGO"'l REGIO"Z'IL IMDICA'@- PiloGlvq%l RI--I 00012 (CS) 2/7L CO@"iSIDERATYO'@'i BY FEBRUARY 1971 ADVISC,RY COUki@lt Co,, ittee ,ipro- Li o thi ),,Jlicnti.on icl, ircllldes reqcests for,' 1) rezi@,,i@7il for three,- for four-I)rojzcts azicl, 2) Y,@ars for fiv,, projects; 3) fu@nd,, for ti7o previously ap-proved but u@iifurkded projects; and 4) a supplenierit to Core, at'tlie following reduced vr.,iouittso. g;T REGIO'41 RE -JEST SUPPL-c,.',,Til,@i@l'@ ro TO@'RAL ol $311,061., $614 7 08 2 $ 953,146 02 464,591 464,591 03 42Ot7@6_ 420.756 T(Yf Al. $311,064 $1,532 Z@29 $1,843,493 STAI,'P RE TOI'AL 01 $391,128 $613,986 $1,005,114 02 54,444 54,444 03 56.617 56.617 TOTAI, $391,128 $725,047 $1,116,175 Inclt@tac@s 3 t-Ilot'ittis extens-,oti for Core and Project @rl5. -r t i (i Cotyr,)ittee reviei-,,@d the probic--e3s bcsp-ttin- this R.?c,io-n in tile, dev,@lop.,eLit of tiie present application: 1. 'rne Oregon lVvIP has find three Coordinators duriti@ the pnst year, Dr. Reinsc'nnidt ba,4,in@. L-maii appointed De6criber 1, 1970. Revie@iers recog- ni@zed that t@,,ith tiis unasual tu.-novar, program develoi;-,Pent has been in abeyance. 2. K*cause of difficulties iii getting @ipproi)rinte groups and pro- ject directors tog@attic@r during the the Region requested a change iii their P.@.iiiivarsary dates frot,,i A-,r)ril I to July 1. This chance will -@iot only -Ilow the Regicti to submit in Fel)rLit4ry OREGOII PtF[l 2 PYi 00012 CS 1/71 frorn no;,7 on, but durin,- the prp-:5@tit ye@2,," it give the net Coordinator additional tinia in @!liich to plan its A? application. 3. The lp, attei-Illptincy to reei3fin,,@ its priorities in terin3 of the net? perception of R@lli@. T"ne p@-es.-@nt application reflects this ri-I th@-- la"-',, of Set of goals; objective with I)-Coj(,-Cts developed -..ccordiri,,Iy. As a recult of ttincr--rtaint'Les, to ippro@,,r-, funls fc)-- ciore than t'@ic current year uLitil rcvJ.(,T,;@,rs could see evidence of Tt-i:! e-xc@@pt-!Lo-,) P-L'OJcct St Care with acgioti@ll Elucntion, @-;nicli has s'iowii that the savings from patients going has reat.,Itcd in 6 savings of alr@lost tfirce tiT,',@-s the budget for the project for a year in hospital and niirsiric, ho-.-,c costs, as5;ir,,iin- a patient with a Trajor stto!,-]. CSD) SUSQUEIIA@@,;"L,'A VAT-,LEY PT,,-I.' 6 $469,700 Core The SVP,'@IP Core staff is completely ]-ay. Its Coordinator was the former Executive Director of the Pennsylvania Medi-cal- Society, which serves as the grantee agency. An organizational chart for Core staff is attached to the stiTiin, iry. The f unctio-,is can be brief ly cli-f ined is f ollox,Ts: 1. Techi-i--!-cal- Services - plans, establishes and directs the technical ser-- vices for: appl-icaLioii@; grants TPai-ia@c-,,@neiit, research and evaluation services, development and operation of library activities and general office management. 2. Cop)Ttluni.cations - directs the production of communications material and provides liaison with the news media. 3. provides staff services to coauliittep-@,, councils and pl-anp-in@, groups, coordinates ecL,-lcati.oiial activities and programs, assists with the establishment of regional goals, objectives and priorities, and provides personnel recruitment services for staffing. In addi-t-io-L-i., Field Services are included in this.braiicli. A field represeiitati ve is assigned to each of the four Areas to provide regional coordination and staff services to all volunteer committees and groups in the Region. With the assistance of the field representatives, various Area Committees or subcommittees have developed standards for coronary care, sponsored a cancer detection clinic survey and conducted a cancer incidence and mor- tality survey. The SVR@MP Core budget last year included funds for "progr@-Lm related acti- vities." These are funds in the magnitude of $50,000, which t e Reulon used for various purposes, such as to conduct pilot studies of various proposed project activities, hold conferences, and supply educational mater- ials to health professionals. Types of activities for which these funds will be used next year include a conference for re,.-ional directors of coronary care units, an audio-tape cassette scientific program service, data collection and a consultation program for tumor clinics and tumor registries. The budc@e@t for 1971-72 includes funds for 25 full-time positions, 22 of, 0 which have been filled. The new positions .would be a Systems Coordinator, Nursing eciali-st and receptionist. @p Continuation support in the amount of $76,215 is also requested for three projects:, if'9 SVMIP Information Service #16 Radi-ological- Health Training Program #17 Coluinbia-llontour Home Health Services Reneiial_Lr@ -@ts 3rd Year Project #611 C narv Care N,,jrse@,' Pro@r@i-m, Gpj-sint-E!t $29,425 The Geis-i-il,-,er @lledical Center will. conduct SUSQUYIlb@TIU,, VAI,I,li'y JUJII RM 00059 2/71.1 (Al'\.-,I CSD) 7 four four-@qeel& coronary care courses per year. Each class wil-I admit .4 ten traii)ees., who are principally recent diploma graduate nurses. The curriculum includes lectures, laboratory work, and cli-ni@al- experience in special nursing techniques for the cardiac patient. Community hospitals tlirou@,lio-Lit the Susquehanna Val-ley Region, as well as border areas, may use this traininc, pro,rrim to staff their coronary care units with qualified nurses. This project was submitted with the Region's initial operational applica- tion and applied for and received one-year renewal support last year. Since its inception, it has trained 42 nurses. Fourth Year $31.,551@ Ap p,LbVE@d but Un'i-inded Projects These projects have be-en p5@ovibus]-y'approved by CriL@iicil, but due to i-i.ation-- al funding constraints, have not been funded. Committee and Council con- siderations of these projects is,needed in determining an overall funding level for the Region for the next year and not for approval of the activities. I.st Year Project ill-8 - P@heiili-,,@@itic Fever Control This project $75,217 will impress upor.. physicians and the public the necessity for throat cultures in diagnosing streptococcal infections. Hospitals and physicians in 16 of the Region's 27 counties iiill- receive free throat culture kits. The kits will be used on people bet@,7ceii the a.-es of two and forty-fivb who have upper respiratory infection or a sore throat. The participating hospitals will. interpret the cultures and send reports to the attending physicians. The physicians will fc)llo@,T--up with appropri-- ate treatment. .Although this project involves the demonstration of patient care, the aspects of continuing education are also present. In addition, the promotional efforts of the Heart Association, who will participate in the program, will increase the publi.c's awareness of the value of the procedure. Second Year $64il4l7 let Year Project #19 @'Cardiopolm6i!atV Re-susCi.!:atiOn Ttdini-@,. $16$693 Sponsored by the Heart Association, the purpose of this project is to establish an emergency cardiopulmonary resuscitation team in every hospital in the Susquehanna Valley Region. SUSQUEfLk@T@q'A Vi@LLI@"Y P@IP 8 RM 00059 2/71.1 (AR--I CSD) First, the InstrLictor's Traiiij-n,-, Center at the Harrisburg Hospital @qil-l be expanded to include a special training course in emergency clirdio- pulmonary resuscitation.' Each year, teams from 18 hospitals wil.1 complete this course. Then, u8iiia the organizational- framework of the PeiinE;yl-vania. Heart Associati-on and its chapters, these i-ie@@ly trained teams will traip- other hospital- teams. The wide geographical distribution of emergency teams will be ideal for 0 training local- ambulance crews, rescue squads, and other health personnel throughout the Region. Second Year Third Year $).5,481 @16,066 I-st Year Project #21- El-iterostOTal Ther,@p-V Trainin,@ The Harrisburg $9,934 Hospital will conduct twelve, four-iicsek courses in onlerostor,,al therapy per year. One student will be trained in each course. Training will included bedside instruction and practice, medical lectures, technical lectures and conferences. The graduate therapists will be able to provide patients with stomal care and management, therebyfreeinc, nurses and physicians for other work. In addition, the therapists will instruct patients in self--care and teach allied health personnel the principles of stoeial management. Second Year Third Year $10@439 $10,920 lst Year Project #26 - Cardiopulriionarv and CVA Transport Vehicle, $82,200 York Hosp t@al. This pilot project will determine the effect of a specially equipped and staffed transport vehicle in reducinc, the conipli-- cations and deaths associated with heart attack and stro@e. The custoic,-designed van which will contain a resuscitation unit, a respir- ator, a two-way radio, drug --tora-e facilities, and other emergency eqtiip- 0 ment, will be on call 24 hours a day, staffed by a physician or coronary ,care nurse, orderly, and driver. Second Year Third Year $68@050 $71,548 New Prolects ist Year Project #27 - Nurse DiAl- Access. Robert Packer Ilbspi.t@il, $29,969 re,@eniL-- .y Dial- Access for Nurses wil.1 cover Central New York State and the entire state of Pennsylvania. It is a special telephone information system for R@l's, LPN'S, student nurses, and others particularly those practicing in an isolated setting --'@.7ho do not have the resources-available for their continuing education Availe.bl.e on an around- SUSQUEI:IAI,,R@A VAT,LEY 9 RM 00059 2/71.1 (AR-1 CSD) the--clocl-I basis from any telephone, it provides the caller with free, five-to-six minute taped messages on a variety of subjects, such a-, (1) nursing care for specific conditions, 2) new procedures an Equipment, (3) availability of community resources, (4) nursing care in emergency situations, and (5) legal aspects of nursing situations. The Central New York @4P is presently funding a Physician Dial Access pro- gram out of the Sayre Hospital. S V l,'.'L'IP Core funds are being used to extend coverage of the physician program to their Reaion. Second Year Third Year $29,453 $3-J,224 Ist Year Project #28 - Autor@,.,ated Coiii)uter--Assisted Analysis of the $294,470 @PG, Pennsylvania State University. Four participatiiic, hospitals, located in three areas of the Region, will send computerized EEG signals to Penn State's Hybrid Computer Laboratory. The information will be interpreted by computer at Penn State and the dialonosi-s returned -to the' sendinc, hospitals. Each computer diagnosis will be coi,,if),,ired to the phy- siciants final diagnosis. The purpose of this project is to install and further develop this computerized EEG system, and at the same time, deter- ,mine the feasibility of providing all hospitals throughout the Region with rapid and valid electroencephalogram interpretation service. Since January 1968 the Geisi-tiger Medical Center and the Pennsylvania State University have been conducting research on automatic computer analy- sis of EEGS. Second Year $82@062 lst Year Project #29 - @m Literized EKG Pil-ot PrSn, @i@. This project $300,186 would establish a computerized EKG transmission and analysis system which woul-d link 13 hospitals in a 27-county area to a computer center at@l@larrisbur Hospital. EKG's would be transmitted to the center, 9 ..processed and the interpretation transmitted to the originating hospital.. A formal training program, conducted by a cardiologist from the Hershey. Medical C'P-nter is planned for physicians and technicians involved in the project. ithe'project resulted from a pilot program at the Harrisburg Hospital.!; Second Year Third Year $300 186 $300 186 'l,@t'Year Project #30 Coordinated Home Care Ptpgtain of Lancaster $1.06,128 L@@t Lancaster County y. The Coordinated Home Care Agency of T will arrange quality medical, nursing, social, and related services for patients in their homes. The central administrative Coordinated Home Care 0 Agency wi'Ll: -i Cs])) SUSQUETIANNA VALLEY I-,TIP 10 R@.-I 00059 2/71...[. 1. Coordinate community resources in the delivery of optimum home health care services. 2. Act as the one sourcc-.of referral for the physicians. 3. Serve as a center for coiTi,)rchc-,-nsivc- planning, evaluation, and fol-l-owup of home care services. 4. Act as an. information service for physicians, patients,, participating agencies, and the public. 5. Hold periodic joint conferences with physicians, other professional- or allied persons, and consumers of service to determine how effectively the program is functioning. Second Year Third Yei.r $106,367 $11-5,400 Ist Year Project #31 - Fa,7@iilv and CoTnii-ilii-tv Ileal.tli Service I?ro-2:@,@l, $145,630 Lancaster General Hospit ' The main objective of the Family Health Service Program is to deliver comprehensive faraily-oriented, pri- mary health care as part of a community hospital-. The new system also "seeks to create a structure @7hicii casts a physician as a health a vocate- for his patient. Home health aides will be used to provide health e uca- tio-@i and develop cornnunication with the clients. Residents of the low income areas will serve on a board to review and analyze the effectiveness of the delivery system, which includes Family Practice Residents and T@urse Practitioners. Second--Year Third Year $145.$724 $159 086 lst Year Project #32 - Central P@ n@q Iva@a @.in@. -@if Eclucati.on and $296,1.78 Treatment,Ceriter, Al-toona Ilos-pital. This project w 11 provide physical facilities equipment, and personnel. to conduct a cancer education and treatment center. It wil-1 utilize cobalt therapy, deep therapy, and isotopes for diagnosis and therapy and provide a firm basis for continuin- educationlfor physicians in cancer detection and treatment. It will a]-so provide a':super-voltage facility in an area geographically and economically separated;'from the nearest similar facility by more than 50 miles, as well as allow tor continuity of treatment, detection of recurrences, and new primary tumors, while maintaining identity with the patients personal- physician. The Pegion's Ad Hoc Coatriiittee, on Radi.i.t-.Lon Therapy, which is studying the Regionis radiation therapy resources, has re-viewed the project and endorses the need for a facility in Altoona. Second Year Third Year -$2021,075 $210@050 StTSQ'tiFITAI"ITl@ Vlil,LEY r,'-IP P,Lq 00059 2/71..].. (AR-1. CSD) lst Year Project It'33 - ilaf--!.I.ton Health Cenucr. The 11,@iiai.ltol-L Health $147,1@75 Center, Inc., a nonprofit organization directed by a group of coiisL,,,@ie,rs and representatives of providers of health care, requc@st support to establish a cc)mi3rc@hc--nsi.vc- health care system in a disadvantaged area of Harrisburg. The neighborhood health center will be served by a f,q,ial..Iy heal-th @,@nicl- inc-l-udes corpiiitinit-ly health rec-i.-Lil.ted froi-c. the, nei@cbl)orliood. Second Year Third Year $Z,,57,811 $678,897 @Asst D4-rec,'.or f 0- 'Dro, echn-i F r,@ n S on-1 yslers CoT-,,,iun- Ac-'U-4-vit-'@es -rv-'Lc-- cn@ ic no, 0- o c r 4- n o r Cc)ord-'Ln@-'Vor, C oo--,-d4- u I coor(fL@4.nt-'-Ior l.o or n u o r' .,es cEt,-,ch 7-; A n lic Lield a @2 C 'S e c eo,,esen 'C@ - ---S c o,,', i @L list@ i Pc,,oresen C:. s S@ L A.,3 s t 11-@'.br Sen, i e.L Secre@va--y, "",Secr ua--y i @Secre'uary@ i@ S c c,-- elu rlry Secreta@,, Mach-'@n' Z. - ":,7 C.@@ e @Recept op er o-- 13- -i-10@,4; A,',!D @-I JENI' O'@ L) EP'A, EDUCI@ PUI',L.IC FIEAI-Tti S:7%F@VICLT, A,'AD 1)(;t,-: 23, 3@970 .AI?71 of. Staff Pevici,7 of Continuation Appl.:Lc.,iLic)!-t front tlll@ u s uelianna valley regional. i@ledical Pro-raiii, 5 C03 IZI@T 00059 To: AcLi.r,,- I)i.roctor ,odic.il Pro-ra@ms Service Ttii--i-i: Chii.riti-in of- the itor,.th Acting Chief, Re"ional Developnt'ent Branc@, Chief, Crants @lanag,-@-iient Branch Acti-n- Cliicj', Grants Pevic-.k.7 Branch The Valley Re-.ional ',Ieclical Pro-,rE,iii is requ,,e,-;tijic, coiitinlia- tion support for its 03 operational year for core and tliiee.projetts. Since Susquehanna Vallev's bud-et year does not start until April I., and tile 45-day estimate oL' expavditures is not clue. until. itij.d-Fe-bi-uary, requests for use of carryover funds have not been incl.uded.in the present a 1) 0 1 -'t ci t i. on. Therefore, the discussion was I.iriit:ccl to ceneral pro-,rant issues and the foll-o@7i-tia continuation request. C, Conti-Tittatio-.i RecLtested Amount Core $469,700 Project #9, SVR-'-LI? Inforniati-on Service 45,614 Project 1'f'1-6, Radi.ol6@ical Health Trai-niii- Pro-raiLi 17,501 Project #17, Colu[qbia-i!'ontour Home Health Services 10Q T'Otal $545,91.5 Besides the continuation request the. Pe-,ibn has included in its rkR application a request for a developmental component, fundi.n,@, of 'our 5 1 C, 1. ,approved but unfunded projects, a renewal- and seven ne,,,! projects. The I'@egion was supported by a fundiii-. level of @Y671.,997 during the 02 year. R6coFtniendation: Approval- of the coii-,Tqittc@d @-ii7iouit of $545,91.5 for core and three projects. -14- Harold Dc@cc!iiil)ci: 23. 1-970 The following staff ric-,ii,)ers attended the Doce-ri,il)cr 17 iiiecL.iii,-: Miss Dona Ilouseal,, CRB Mr. Dale Robertson, RDB Mr. Georce Ilinl-lo, GMB Miss Mary Ascle-1-1, CEB Mrs. Patricia @ii-il-I.ins, P'j" f'3 Miss Loretta Broi,"In, PEB Gener@il' Comments C,40nlS C, the past year. TMile Staff was pleased with this Rel@ progress dtirin., this Region is only bo('Iinning to deal with the settil-l" of more specific goals and objectives and is just st.-Lrtirl- to co]-I.c-cll- needed data, its efforts in co@)in-- ri7ith sr-,-e of the problems identified by the site visitors a-,id reviewers last year were encoura-:i.na: .I-. The evaluation reports by a physician of the-five termj,.na tirLj coronary care Drojects, which have been sorely needed, have been included in the application. The evaluation reports included with the terminate on reports appeared tliorou,,h and the criteria developed should prove valuable to the other non-TV-@IP funded units developed around the -Region. 2. The SVP@,'P core staff including the Coordinator is completely lay. While tnis type of core can function with imagination and work very capa'ol-y, in the past this has not al.@,,,ays been the case, Several. kinds of capabilities were missi-iia from the staff and this weakened the program. For example, the conti-TiuinQ education se -i@ent has been marked by frag- C) mentation and a lack of awareness of what has been done elsewhere. Some of this may be solved by getting outside consultation (to be discussed belo@@i), but Core staff is also adding needed expertise in continuipc, education:and allied health. A proc7ram development director, syst.ems coordinator and a research and evaluation specialist are also beinc, em- pi.oyed. Problems with the Recional Advisory Group caused by poor coiii- MUD-ications have prompted the staff to spp-n-@-more time. personally advisin,@ C> .the PAC members of SV@1.0 activities and changing the presentation of written material ooinc, before the PAG. 3. As a result of site visit recommendations in February 1970, the-Region has s6u,, t consultation in plannin-. A group including @larshall- Raffel, PE'!nn State Universit - Dr. Joel Nobel, Emergency Care Research i y@ Insti.tute@ as well as state health department and Buck-nell University personnel was called to-ether toaavise on the structure and composition LI of a proposed Pl@abning Co,-,unittee, There is a]-so evidence that the Region has @oticht outside expertise in various technical areas. 4. The review process is bEiii@ streLi@t@he-,ic@d. Formal review procedu res including a set of criteria and a numerical syste.,ci @,Th-i.cn -ives 15- Harold Marcul.j-es II.D. Deceiitl)cr .23, 1970 all- ric@i@ projects a priority number, have. been devised for Lli e rAG. Plaiis are underlay to develop a sii,@il l@ir -systei,,i for the CoLiticii-s and Area Con,-riiittees. 5. The relationship bcti7con the INIP Barrel the cr@Liitee'aceiicy, the PoliLlsyl- vania Medical Society, has improved slightly. 'Thc, Medical Society still considers the PL@IP as a branch of their orcat-Li-/,ati.oti ivcl ma:Lnt@l.,-L.ns c-, a degree of control consistent with this concepts Discussions have been held with the and @r@i.ntee acency concerit-@.ii- the of a C, 0 nonprofit corporation, but at the present its estEiblj-sl-tilient seems a lonc, way o.L'f, Conclusion: Approval of the committed amount of $545 91.5 is reconmiended for the Pegion's third operational year. Dona E. lIoLiseal Public Health @dv:i.sor 6ranLs Revic@q Braiich Action by Director Initials Date REVISED REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD APPLICATION (A Privileged Communication) SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM RM 00059 2/71.1 (AR-1 CSD) 3806 Market Street, P.O. Box 541 January 1971 Review Committee Camp Hill, Pennsylvania 17011 Program Coordinator: Richard B. McKenzie REQUEST (Direct Costs Only) 04 05 06 Purpose 4/l/71-3/30/72 4/l/72-3/30/73 4/l/73-3/30/74 All Years Continuation Commitment $545,915 $545,915 Core (469,700) (469,700) 3 Projects (76,215) (76,215) Renewal Components $29,425 $31,551 $60,976 1 Project (29,425) (31,551) (60,976) Additional Pro_iects $1,503,780 $1,482,065 $11,592,377 $4,578,222 4 Previously Approved Projs. (184,044) (158,387) (98,534) (440,965) 7 New Projects(1,319,736) (lp323,678) (1,493p843) (4,137,257) Developmental Component $54,596 $54,596 $54,596 $163,788 Total $2pl33,716 $lp568,212 $lp646,973 $5p348,901 Staff Action Commitment $545,915 COL=I t tee Action Required $1,587,801 $lp568,212 $1,646$0973 $4,802,986 #26 Deleted - 82,200 - 68,050 - 71,548 - 221,798 REVISED TOTAL 1,505,601 1,500,162 1,575,425 4,581,,188 FUNDING HISTORY Planning Stage Grant Year Period Funded (ti.c.o.) 01 6/l/67 - 5/31/68 $251,530 n2 6/1,/68 - 1/31/69 $250,056 - 2 RM 00059 2/71.1 (AR-1 CSD SUSQUEHANNA VALLEY RMP Operatiotal Pro& a@m Future Grant Year Period Cou@cii',,'approved Funded d.c.o. Commitment 01 4/l/69-3/31/70 $698,052 $532,444 02 666,495 671,997 03 4/l/71-3/31/72 695,333 $545,915 04 4/l/72-3/31/73 650,075 497 644 05 4/l/73-3/31/74 483,294 1/ Represents 75% funding of projects 2/ Includes $124,390 in carryover Geography and Demography This Region consists of 38 counties in the central corridor of Pennsylvania bordering on Maryland in the south and New York in the north and separated from the Western Pennsylvania and Greater Delaware Valley RMPs by moun-. tainous terrain. The total population of the Region is projected to be 2,323,751 (1970 Census). Much of this population is centered around the ains large rural and forest throe urban areas, but the Region also cont areas with low population concentrations and underdeveloped facilities. The Milton S. Hershey Medical Center of the Pennsylvania State University was established in 1963. The first class of 40 medical students was enrolled in 1967. The Region also has 55 hospitals. It is served by 1,776 M.D.'s and 218 D.O.'s. There are 8,909 active nurses. Regional Development in 1966 the Susquehanna Valley Committee on Heart Disease, Cancer and Stroke,presided over by the President of the Pennsylvania Medical Society (PMS), met to plan an RMP for the central Pennsylvania Region. The first planning grant, submitted by the PMS, was approved in June 1967 pending clarification of the role of the new medical school, the state health department and administrative and staffing patterns, and assurance of allied health involvement. The Executive Director of the PMS, Mr. McKenzie, was appointed Coordinator in August 1967. During the second planning year, the Region encountered a number of problems with the completely lay Core staff and the grantee agency, which considered ,the RMP Core staff as another branch of the PMS. There was strong senti- ment among Core staff regarding the degree of control the PMS maintained over routine office matters and the relatively low salary scale. Several staff members resigned as a result. There was also some confusion about the relationship between the RAG and the PMS Board. A management consulting firm was retained to study the entire program and recommended certain staffing changes, some of which, have gone into effect. SUSQUEHANNA VALLEY RMP - 3 - RM 00059 2/71.1 (AR-1 CSD) The Region began work on its initial operational application which would contain five coronary care unit proposals and a request to train coronary care unit nurses. A site visit was held in December 1968. The visitors recommended operational status to convince the local physicians that RMP would actually help them improve patient care, While leadership from the RAG was slow in developing, the Region had an impressive amount of physi- cian involvement at the grass roots level through the Area Committee structure. In fact, the bywords for the SVRMP in these early days became ligrass roots involvement" and "coronary care." Council approved the Region's request with the understanding that the CCU projects were pilot projects for the Region with evaluation of the results before additional projects are funded and with the stipulation that 50 percent of the equip- ment funds be made available for physician training. Shortly afterwards three more proposals were submitted, approved and funded. They were a stroke care unit,, a home health care project and a regional medical infor- mation service. New projects submitted during the second year, however, continued to emphasize coronary care. Reviewers found them, on the whole, to be a disparate group of projects, attacking the problems of coronary care in an isolated fashion. They disapproved the projects and recommended that the Region establish an overa p an invo ing greater coordination, coop- eration and consolidation. Core and the coronary care training proposal at the Geisinger Medical Center were renewed. A site visit held in February 1970 reviewed the overall progress of the Region and four new projects. They concluded that the Region should: 1) consider broadening the base of its grantee agency to insure that all appropriate groups feel represented. A change to a nonprofit corpora- tion was seen as a possible solution4, 2) utilize consultants from both inside and outside the Region to improve efforts in data gathering and epidemiology; 3) appoint a liaison member of the Hershey Medical School fatuity part-time to the RMP staff to both improve relations with the new medical school and involve physicians on Core staff; 4) while continuing to encourage grass roots involvement, devote more attention to developing a regional decision-making process which selects projects on the basis of a regional plan, rather than just on a community's needs. Projects funded during this past year include: 1) an extension of the original five CCU's with carryover funds for an additional year, 2) the CCU nurse training project, 3) the second year of the SVPIQ library information service, SUSQUEHANNA VALLEY RMP 4 RM 00059 2/71.1 (AR-1 CSD) 4) project #7, the Stroke Care Unit and #8, the Home Health Service, out of carryover, and 5) projects #16, the Radiological Health Training Program and #17, Columbia- Montour Home Health Services. Projects #18, a Rheumatic Fever Control Program, and #19, a CPR project were approved but unfunded. The Region submitted one further application during its second operational year. Only the Znterostomal Training Program and the CPR and CVA Transport Vehicle, York, were approved. Council requested additional information on the CCU Nurse Training Program at the Altoona Hospital before it could be approved (this information has been received and will be forwarded to the February 1971 Council). The remaining four projects, including an emphysema program, a stroke rehabilitation and training program, a cart- ridge viewing system pilot project and a supervisory CCU nurse training program, were turned down. The Region's present level of funding for its second operational year is $671,997. Note: A site visit was not planned for this Region; one had been held during the past year; and the Region informed RMPS only a week before the review deadline of its decision to include a request for a developmental component in its AR application. t7 The SVRMP frankly admits that its centralized program planning to date represents a disconcerted effort and that the Region does not have a specific plan which details specific objectives that result in specific applications. Interest in the past has happened to center on heart dis- ease and coronary units. At its fall 1970 meeting, the RAG established formal goals which set the stage for development of primary goals and specific objectives. The primary goal is to "improve the quality of patient care working with and through the providers of health care as they function in the existing health care system; and by influencing the present arrangements for health services and by concentrating maximum effort on those activities which have the highest local, regional and national priorities." The primary goal is approached through specific goals in three basic areas organization, strategy and program. nal Structure and Processes The SVRMP has organized a 30-member RAG, with representatives from each.of the four Areas and from various health organizations and institutions of the Region. The RAG has Executive, By-Laws and Nominating Committees and SUSQUEHANNA VALL17Y RMP RM 00059 2/71.1 (AR- Cc,D) is in the process of selecting Planning'and Evaluation Committees. The RMP has divided the Region into four Areas, each of which is served by a Committee ranging from 60 to 135 members. Each Committee has Appointed subcommittees to serve as study groups and an Executive Committee. To provide review and planning at the regional level in specific functions, Councils (formerly Task Forces) have been established in the categorical areas, as well as in Facilities and Services and Continuing Education. Each Council also sets goals and objectives in its respective interest. The review procedure consists of the following steps: 1. Consideration by the volunteer Area Committees through their Executive Committee and specialized subcommittees. 2. Consideration by the members of categorical councils who supply spec- ialized professional technical review on a regional scale. 3. Consideration of the relevance of the proposal to regional goals and objectives by the RAG. At each step, staff members provide administrative assistance. Formal review procedures, including a set of criteria and a numerical ranking- system,, which assigns all new projects a priority number, have been devised for the RAG. Plans are underway to develop a similar system for the Councils and Area Committees. PRESENT APPLICATION: Developmental Component $54,596 Activities initiated t',qrough developmental component funding "will seek to improve the quality of patient care by working with and through the providers of health care as they function in the existing health care sys- tem, by influencing the present arrangements for health care services, And by concentrating maximum effort on these activities which have the highest local, regional and national priorities." An example might be an explora- tion of appropriate methods and means for developing improved patient care techniques and systems in kidney disease prevention and control. The review mechanism described under organizational structure and processes above will apply to the developmental component as well. $54*596 $54,596 Continuation Component These components have been reviewed by staff. Their program and funding recommendations are in a supplementary memo. SUSQUEHANNA VALLEY RMP 6 RM 00059 2/71.1 (AR-1 CSD) Core $469,700 The SVRMP Core staff is completely lay. Its Coordinator was the former Executive Director of the Pennsylvania Medical Society, which serves as the grantee agency. An organizational chart for Core staff is attached to the summary. The functions can be briefly defined as follows: l.- Technica Services - plans, establishes and directs the technical ser- vices for: applications development, grants management, research and evaluation services, development and operation of library activities and general office management. 2. Communications - directs the production of communications material and provides liaison with the news media. 3. Program D provides staff services to committee.$, councils and planning groups, coordinates educational activities and programs, assists with the establishment of regional goals, objectives and priorities, and provides personnel recruitment services for staffing. In addition, Field Services are included in this branch. A field representative is assigned to each of the four Areas to provide regional coordination and staff services to all volunteer committees and groups in the Region. With the Assistance of the field representatives, various Area Committees or subcommittees have developed standards for coronary care, sponsored a cancer detection clinic survey and conducted a cancer incidence and mor- tality survey. The SVRMP Core budget last year included funds for "progra7m related acti- vities." These are funds in the magnitude of $50,000, which the Region used for various purposes, such as to conduct pilot studies of various proposed project activities, hold conferences, and supply educational mater- ials to health professionals. Types of activities for which these funds ..will be used next year include a conference for regional directors of coronary care units, an audio-tape cassette scientific program service, data collection and a consultation program for tumor clinics and tumor registries. The budget for 1971-72 includes funds for 25 full-time positions, 22 of which have been filled. The new positions would be a Systems Coordinator, Nursing Specialist and receptionist. Continuation support in the amount of $76,215 is also requested for three projects: #9 SVRMP Information Service #16 Radiological Health Training Program #17 Columbia-Montour Home Health Services Renewal Projects 3rd Year Project #6R - Coronary Care Nurses' Training Program, Geising@r $29,425 Medical Cpnter, The Geisinger Medical Center will conduct SUSQUEHANNA VALLEY RMP - 7 - RM 00059 2/71.1 (AR-1 CSD) four, four-week coronary care courses per year. Each class will admit ten trainees, who are principally recent diploma graduate nurses. The curriculum includes lectures, laboratory work, and clinical experience in special nursing techniques for the cardiac patient. Community hospitals throughout the Susquehanna Valley Region,, as well as border areas, may use this training program to staff their coronary care units with qualified nurses. This project was submitted with the Region's initial operational applica- tion and applied for and received one-year renewal support last year. Since its inception, it has trained 42 nurses. Fourth Year $31,551 Approved but Unfunded Projects These projects have been previously approved by Council, but due to nation- al funding constraints, have not been funded. Committee and Council con- siderdtions of these projects is needed in determining an overall funding level for the Region for the next year and not for approval of the activities. lst Year Project #18 - Rheumatic Fever Control Program. This project $75,217 will impress upon physicians and the public the necessity for throat cultures in diagnosing streptococcal infections. Hospitals and physicians in 16 of the Region's 27 counties will receive free throat culture kits. The kits will be used on people between the ages of two and forty-five who have upper respiratory infection or a sore throat. The participating hospitals will interpret the cultures and send reports to the attending physicians. The physicians will follow-up with appropri- ate treatment. Although this project involves the demonstration of patient care, the aspects of continuing education are also present. In addition, the promotional efforts of the Heart Association, who will participate in the program, will increase the public's awareness of the value of the procedure. Second Year $641,417 18t Year Project #19 - Cardiopulmonary Resuscitation Training. $16,693 Sponsored by the Heart Association, the purpose of this project is to establish an emergency cardiopulmonary resuscitation team in every hospital in the Susquehanna Valley Region. SUSQUEHANNA VALLEY RMP - 8 - RM 00059 2/71.1 (.kR-1 CSD) First, the Instructor's Training Center at the Harrisburg Hospital @@ill be expanded to include a special training course in emergency cardic- pulmonary resuscitation. Each year, teams from 18 hospitals will ;@-ompi-ete this course. Then, using the organizational framework of the Pennsvlvania Heart Association and its chapters, these newly trained teams will train other hospital teams. The wide geographical distribution of emergency teams will be ideal for training local ambulance crews, rescue squads, and other health personnel throughout the Region. Second Year Third Year $15,481 $16,066 lst Year Project #21 - Enterostomal Therapy Trainin&. The Harrisburg $9,934 Hospital will conduct twelve, four-week courses in enterostomal therapy per year. One student will be trained in each course. Training will include bedside instruction and practice, medical lectures, technical lectures, and conferences. The graduate therapists will be able to provide patients with stomal care and management, therebyfreeing nurses and physicians for other work. In addition, the therapists will instruct patients in self-care and teach allied health personnel the principles of stomal management. Second Year Third Year $100439 $10,920 lst Year Project'#26 - Cardiopulmonary and CVA Transport Vehicle, $82,200, York Hospital. This pilot project will determine the effect of a specially equipped and staffed transport vehicle in reducing the compli- cations and deaths associated with heart attack and stroke. The custom-designed van which will contain a resuscitation unit, a respir- atori a two-way radio, drug storage facilities, and other emergency e(iuip- ment, will be on call 24 hours a day, @taffed by a physician or coronary care nurse, orderly, and driver. Second Year Third Year $6810050 $71,548 DELETED PER REQUEST FROM REGION, SEE LETTER OF JANUARY 4, 197]f ATTACHED. New Proiects lst Year Project #27 Nurse Dial Access, Robert Packer Hospital, $29,969 Sayre, Pe nsylvania. Dial Access for Nurses will cover Central New York State and the entire state of Pennsylvania. It is a special telephone information system for RN's,, LPN'S, student nurses, and others particularly those practicing in an isolated setting -- who do not have the resources available for their continuing education. Available on an around- SUSQUEHANNA VALLEY RMP - 9 - RM 00059 2/71.1 (AR-1 CSD) the-clock basis from any telephone, it provides the caller with free$ five-to-six minute taped messages on a variety of subjects, such as (1) nursing care for specific conditions, (2) new procedures and equipment, (3) availability of community resources, (4) nursing care in emergency situations, and (5) legal aspects of nursing situations. The Central New York RMP is presently funding a Physician Dial Access pro- gram out of the Sayre Hospital. SVRMP Core funds are being used to extend coverage of the physician program to their Region. Second Year Third Year $290453 $30,224 lst Year Project #28 - Automated Computer-Assisted Analysis of the $294,470 EEG, Pennsylvania State University. Four participating hospitals, located in three areas of the Region, will send computerized EEG signals to Penn State's Hybrid Computer Laboratory. The information will be interpreted by computer at Penn State and the diagnosis returned to the sending hospitals. Each computer diagnosis will be compared to the phy- sician's final diagnosis. The purpose of this project is to install and further develop this computerized EEG system, and at the same time, deter- mine the feasibility of providing all hospitals throughout the Region with rapid and valid electroencephalogram interpretation service. Since January 1968, the Geisinger Medical Center and the Pennsylvania State University have been conducting research on automatic computer analy- sis of EEGS. Second Year $821)062 lst Year Project #29 - Computerized EKG Pilot Program. This project $300,186 would establish a computerized EKG transmission and analysis system which would link 13 hospitals in a 27-county area to a computer center at Harrisburg Hospital. EKG's would be transmitted to the center, processed and the interpretation transmitted to the originating hospital. A formal training program, conducted by a cardiologist from the Hershey Medical Center is planned for physicians and technicians involved in the project. The project resulted from a pilot program at the Harrisburg Hospital. Second Year Third Year $30010186 $300,186 lst Year Project #30 - Coordinated Home Care Pto&ram of Lancaster $106,12T' County. The Coordinated Home Care Agency of Lancaster County will Arrange quality medical, nursing, social, and related services for patients in their homes. The central administrative Coordinated Home Care Agency will: SUSQUEHANNA VALLEY RMP; 10 - RM 00059 2/71.1 CAR-1 CSD) 1. Coordinate community resources in the delivery of optimum home health care services. 2. Act as the one source.of referral for the physicians. 3. Serve as a center for comprehensive planning, evaluation, and followup of home care services. 4. Act as an information service for physicians, patients, participating agencies, and the public. 5. Hold periodic joint conferences with physicians, other professional or allied persons, and consumers of service to determine how effectively the program is functioning. Second Year Third Year $106$367 $115,400 lst Year Project #31 - Family and Community Health Service Program, $145,630. Lancaster General Hospital. The main objective of the Family Health Service Program is to deliver comprehensive family-oriented, pri- mmunity hospital. The new system also mary health care as part of a co cture which casts a physician as a health advocate seeks to create a stru for his patient. Home health aides will be used to provide health educa- tion and develop communication with the clients. Residents of the low income areas will serve on a board to review and.analyze the effectiveness of the delivery system, which includes Family Practice Residents and Nurse Practitioners. Second Year Thir ear $145,724 $159,086 lst Year Project #32 - Centra Pennsylvania Cancer Education and $296,178 enter. Altoona Hospital. This project will provide personnel to conduct a cancer education and treatment center. t will ut ize cobalt therapy, deep therapy, and isotopes for diagnosis and therapy and provide a firm basis for continuing education for physicians in cancer detection and treatment. It will also provide a super-voltage facility in an area geographically and economically separated from the neatest similar facility by more than 50 miles, as well as allow for continuity of treatment, detection of recurrences, and new primary tumors, while maintaining identity with the patient's personal physician. The Region's Ad Hoc Committee on Radiation Therapy, which is studying the Region's radiation therapy resources, has reviewed the project and endorses the need for a facility in A toona. Second Year Third Year $202 075 $210,050 SUSQUEHANNA VALLEY RMP RM 00059 2/71.1 (AR-1 CSD) lst Year Project #33 - Hamilton Health Center. The Hamilton Health $147,175 Center, Inc., a nonprofit organization directed by a group of consumers and representatives of providers of health care, request support to establish a comprehensive health care system in a disadvantaged area of Harrisburg. The neighborhood health center will be served by a family health team, which includes community health aides recruited from the neighborhood. Second Year Third Year $457,811 $678,897 GRB/RMPS 12/28/70 I IRECTOR rector Asst Director for r -@oFrem De-Vel@ Technical Serv Education,,il Graits Service @a-na -1 ,s Corn--nunic Activities !Syster ordinq-tor --rdinator Coordinator ico Coo Coordinator ]Research I-ol-'@c ---IC, i o,@ I & ',--Val Admin CoirLnunic lYurs--',n Field ifiele- 9 -@sL, IS-oecialist ISpecialist Spec4alist, ec-,al-s Represpn 2e-g e Sf ,ec- a' LP- S4-afl k, s t Libr Serv secretary Secretary Secretary Secretary etp-ry S-,AFF' C,,-,GAPII7-A:rION Machine @ec @erator S'@l S t)!j q &N!,N tA VA@- REGICNAL 3- (.)F F,U t IfAI .'I I I @;[-r 23, 1.970 Ailit oj. St@@ff pev@tek4 of @Nori-Coripc-,tin(, Cc,ntintiation Application from the LI S!I;jtci: 1 Pro,-ram, 5 G03 R@l 00059 Valley Regional @ledica Act-in@ Director I.,OF,ioll@ll @l(,(Iicll. Pro(,rims Service Iiii-ti: C@ti;iir;iliii of the iloiltli A(-t iiii, C,il i f, A c, t. l@tic, Va'l.]-ey Rc!@.-i.onal 1,1(-clical, Program j,,; re(ILte@sti.ii,,y co,-iL!iiLi.-,- tioii sui)l)ort for its 03 onc-ratio[-ial year for CO,-E' --Ind three projects. SITICC' SI-ISC[Lieliann.a Valley's bud-et year does not start until Apri-I. 2, 1-971, and tti@- 4')-day estimate of exponditur(--s is not clue until Tlii.d-l-'C-'.bru@iry, reqttt-,,3ts for use of carryover funds have not been included in the present application. Therefore, the discussion was limited to general program issues and tlte followinc, continuation request. Continitatiion Requested- Amount Cor@. $469,700 Project #9, SVRILIIII Information Service 45,61,4 Project #16, Rridi.ol-ogi.cal Tr@Lin@iii,, LI Pro@;rarii 3.7,501 Project #17, Col.iiifil-)ia-Mont@ir Itome fic@,.iltli Services 010- Total $545,91.5 Besides the continuation requ,?st, the Region his incIL.ICIC@(I in it AR application, a request for a developmental component, fi-in(Iiii@! of four approved but unfunded projects, a renewal. and seven ne.,.,i projects. I'h e Region @..,as supported by a fundiii- le-zel of $673.,997 during tlLc-, 02 year. L i on: Approval, of the committed amount of $545,915 for core and three projects. -14- 11@irc)ld @tirgLiliCS, December 23, 1.970 I'lic, following staff nic@nil)crs attended the Dc,.cc-iiil)(tr 1.7 Miss I)on,,i My. Dtle Pol)(-!rL.,;oii, RI)I@ Mr. (;c-,orgc- lliiiklc!, Ct4ill Mi-ss Mary Asdoll, Cf,:13 Mrs. Patrici-a '@lul.l.in@;, PI',']'j Miss Loretta Brown, PEB General Comments Staff was pleased with this Region's progress ditrina the past year. I.,Ih i 1 e this Region is only beginning to deal with the setti.n- of more specific goals and objectives and is just starting to collect needed data, its efforts in copin,- with some of the problems identified by the site visitors and reviewers last year were encouraging C> 1. The evaluation reports by a physician consultant of the five termi.na- ting coronary care projects, which have been sorely nc,,c@dcd, liavc- been included in the application. The evaluation reports included wi.tli tiir2 termination reports appeared tliorou-Ii and the criteria developed should prove valuable to the other noTi-IOIP funded units developed around the .Region. 2. The SVI@@IP core staff including the Coordi-nitor is completely lay. UThile this type of core can function with imagination and work very capably, in the past this has not all-' ays been the case. Severil. kinds of capabilities were nissi@ng from the staff and this weakened the program. For e-. developed a nuE,,er-7cal r,-tin,, system i rtir.-@erical priority C@ 0 to each project. Plans are under consideration for ttie adoption of a similar system for t,ie Councils and Are.@- Committee noted that only sl.i-lit -i.mprc)vcitlL@rit had been made in the 0 relationships with the Hershey Medical School and the. grantee agency, rho Pennsylvania Medical Society. Since there seems to have been much change and redirection of the pr ogram reviewers had difficult in assessing a reasonable fLindina recoa,,riien- .% y C) dation. Individual projects were not reviewed. Several options were considered by Committee before decidina on their reco,g@-nenda tion: 1) that the Reaion be @unded at the present level with a consultation visit before next ye-@r's submission. 2) that the Region be advised to review and Strengthen the staff capability particularly in the proo-rai7,1 pl@,.nnino and evaluation area and that 6 site visit be scheduled later to review the Re-.ion's pro-ress and determine whether further fundina should be added to the program. 3) that the Region be given approximately $200,000, an amount comparable to the Region's request for previously approved but unfunded projects, for the next year, but that no funds for new projects be approved until a site visit is made to review the status of the program. 4) that the Region be site visited before any funds be approved for the Re@ion with the exception of the ongoin,, renewal project @F'6R. Thi last option was decided upon, partly in order to give the Region any additional funds at the becinnina of, rather tnan later in the year. C, in li.clht of the present funding stritir,,(,,-idies, 'the need for such urgency 0 u does not apply. RMPS/GRB 1/19/71 SUSQUEHANNA VALLEY RM 00059 2/71 STAFF OBSERVATION -PROJ&CT #25, ALTOONA HOSPITAL TRAINING PROGRAM FOR CORORNARY CARE NURSES The SVRMP first submitted this project, the Altoona Hospital Trainin- Program for Coronar Care Nurses, for review in late 1969. 0 y 'When it was returned (because Council could not as.ce@tain this project's part in the Region's overall plan for coronary cars units), the Region revised the proposal and resubmitted it for the June-July 1970 review cycles Review Committee had additional technical concerns and recommended disapproval. The technical concerns were: I)-the objectives are not stated in terms of education of the learner; 2) other than a 'eneral 9 reference to follow-up,, the proposal does not speak to any evaluation of the studen't's retention of knowledge or employment status after training; and 3) evidence of nursina input into the curriculum is a missing. Council, however, recognized the need for and importance of the Project in the Recion since this project would be the only ccu nurses trainina center in I-lestern Pennsylvania, and indicated that if the project director submitted additional material speakina to Committeels a concerns for their review,, they would reconsider it, The Recion has, forwarded the additional information for Council review and wislieg the project to be considered in recommending a fundina level for this application. 1/12/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Comunication) TEXAS REGIONAL MEDICAL PROGRAM RM 00007 (S) 2/71.1 P. 0. Box "Qll January 1971 Review Committee University Station 2608 Whitis Street Austin, Texas 78712 Program Coordinator: Charles B. McCall, M.D. MUEST (DireLt Cost REGIONS OPERATIONAL YEAR 03 04 05 Total Four Supplemental Projects 212,736 219,499 177,568 609,803 FUNDING HISTORY (Direct Cost Only) Planning Stage Grant Year Period Funded (d.c.o.) 01 7/66 - 6/67 969,541 02 7/67 - 6/68 1,039,295 Operational Stage Council Future Grant Year Period Approved Funded (d.c.o.) Commitment 01 7/68 - 9/69 1,700,000 1,615,000 02 10/69 - 9/70 20,580,043 2,220,891 1/ 03 10/70 - 8/71 2/ 2,097,076 1,866,044 51 -- 04 9/71 - 8/72 1,547,870 1,029,105 05 9/72 - 8/73 240,386 214,050 1/ Included $444,178 carryover 2/ Change in budget period at request of RMPS to facilitate transfer to anniversary review. Toward is for 11 months. 3/ Included $549,34.4 carryover Texas Regional Medical Program -2- RM 00007 (S) 2/71.1 History: Texas received an 01 planning award ($969,541) on July 1, 1966 and its 02 award ($1,039,295) on July 1, 1967. A site visit was conducted in June 1968 to determine the Region's readiness for operational status and to review the proposed continuation of planning activities into the operational phase of TRMP's development. Of major concern to the reviewers was the apparent lack of central direction and coordination of the program. This was illustrated by the uneven progress made in the development of the nine subregional planning units and by the fact that operational proposals appeared to be "based on institutional interests and strengths with very little regard for community needs and goals - either regionwide or local - and only a few show evidence of true cooperative arrangements or even unilateral peripheral involvement." The site team also observed that the Regional Advisory Group, through under stron- leadership,, had not been active in the identification of program goals and the development of program plans. The RAG was also weak in its representation of minority groups, consumers, allied health professions, and the practicing community. With these considerations in mind, the Council recommended a one-year approval of the Texas operational application, including the continued planning support, with future funding contingent upon demonstrated improvement in the areas mentioned by the reviewers. Accordingly, a one-year operational award was issued on Jiily 1, 1968 in the amount of $1,615 000 (d.c.6.), these funds to be divided evenly between operational and planning activities. This combined package included fourteen operational projects and a number of planning efforts which included core support and support for the nine institutional planning units. A subsequent visit was held in April 1969 to judge the progress made in fulfilling the conditions laid down the year before as necessary for further funding, that is, strengthening central administration and expanding the RAG. The reviewers were well satisfied that these requirements were being met; a new coordinator had been appointed and had presented his plans for tightening up the organization, and the RAG included nine new interested groups that had not been represented earlier. on thatbasis, an 02 year operational award was made, but since the Division considered the Region still in probationary status as far as managerial direction was concerned, support for the 12 new approved projects was not included in the calculation of supplemental funds or of the commitment for the next (03) year. Instead, the Region was awarded and committed funds at the 01 year level. Consequently, ten of the new projects were funded from carryover to keep the Region from stagnating. When the Region applied for 03 year continuation, the financial bind in which it found itself was apparent. From an 02 year operating budget of $2,220,891, TRMP dropped to an 03 level of around $1,400,000. This substantial decrease resulted from a combination of the Core commitment's Texas Regional Medical Program -3- RM 00007 (S) 2/71.1 reduction because of the phasing out of planning bases and the Region's use of carryover to initiate a number of activities during the 02 year. In reviewing the application, staff emphasized th;,,'- this fisczl disarray was not the fault of TRMP; rather it was the fault of circumstances and past Division policies. Staff review further emphasized that Dr. McCall's plan appeared to be working. The planning bases were phased out by ' January 1970 (except for development of a subregional office in Houston) and for the first time the Region has a multidisciplinary core staff in Austin. Functional differentiations between the RAG and the core staff have been made. The RAG has adopted a set of by-laws and seems to view itself in a new light as being involved in program development. The five task forces, with their primary review responsibilities, have been made agents of the RAG rather than of the Coordinator. Financial management procedures have been altered with help from RMPS. Planning and evaluation functions ha*e been consolidated in the Coordinator's office. There are obvious close relationships between TRMP and the Texas Hospital Association and a formal working arrangement with CHP. Subregionalization is being pursued actively. There is the subregional office in Houston, and there are plans for establishing four additional subregional offices during the year and creating in Austin a Division of Community Health Organization. Because of the progress the Region had made during the past year, and because of the promise it showed for the future, the 03 year award was for $1,866,044. This figure included $549,344 in carryover funding to permit the Region to retain the momentum it had built up. The funding history at the end of this summary lists the projects currently supported. Re&ional G a s In the RAG report submitted with the August 1970 continuation application, the following regional goals and program objectives were outlined: 1. To assist in the advancement of the practice,, knowledge teaching, and education of medicine and allied health sciences. 2. To promote demonstrations and research in the delivery of health care services. 3. To promote and encourage cooperative arrangements among all segments of the health care community--both provider and consumer, official and voluntary. 4. Through planning and evaluation, to analyze existing health care programs, and through cooperative and collaborative efforts promote the effective, efficient and economic utilization of health care services. 5. To promote innovative approaches to the delivery of health care services on a regional basis. Texas Regional Medical Program -4- RM 00007(S) 2/71.1 Present Application The present application contains requests for supple@,.-.ital funding for four projects. The projects are presented below in the priority order in which the Region has ranked them. Two of the projects (#a 51 & 52) with slight modification, have been supported in the past by RMP, and two (#a 50 & 53) have been supported in the past by other agencies. Project #50 - Control of Hypertension and Chronic Renal Disease Requested The first three years of this activity were First Year supported by the Chronic Disease Program of the U.S. Public $1401000 Health Service, and the current year by the Moody Foundation of Galveston, Texas. Its stated purpose is the improvement of delivery of health services by developing the means for providing ready access to early diagnosis of high blood pressure and chronic kidney disease for the majority of the population. This is to be accomplished through a serial annual investigation of a cohort of 10,000 schoolchildren in Galveston county and assistance to the county schools to extend similar health care to all school children. Although the immediate effects of this project-will be limited to health care consumers in the county, the information and experience gained can have applicability throughout the Region. Even through the project is envisioned as requiring a total period of twelve years (it is now in its fourth), RMP support is requested for only three years, during which time the investigations of the delivery system will be completed. After that, since the longitudinal studies to be carried out are research oriented, support will be requested of other sources. Among the four proposals in the present application, this activity has received the highest priority from the Texas RNP because of: the involve- ment of the Medical School, the County Medical Society, and the community; the preventive medicine orientation of the project; and its Regional program potential. Second Year - $144,659 Third Year - $149,551 Project #51 - Helping Hospitals Organize and Strengthen First Year Inhalation Thera2y Patient Care Programs. This project $26,900 is the same, except for geographic coverage, as Project 04 of the same title which was operational between July 1968 and September 1970. When 03 year continuation was requested in August of this year, continuation of this activity was not included. During its previous operating phase the project was under the aegis of the Methodist Hospital, but when support resumes the Texas Hospital Association will assume responsibility. The objective of this project is to assist hospitals throughout the state in organizing and strengthening their inhalation therapy patient care Texas Regional Medical Program -5- RM 00007 (S) 2/71.1 programs. This will be accomplished by: (1) Four two-day institutes to acquaint administrators, nursing directors, potential inhalation therapy employees and others with ttle principles, organization and clinical application of an organized inhalation therapy program. (2) Four two-week periods of clinical experience for employees selected by their hospitals so that Lhe employees may return to help their in- stitutions organize and strengthen inhalation therapy patient care program. (3) Follow-up training education. The previous two years of experience was confined to approximately half of the state, and the application states that as a direct result of project activities 20 hospitals have established inhalation therapy departments, 19 have strengthened their programs, and 11 are actively developing plans and soon.will have organized units in operation. The two-day institutes were attended by 641 people from 103 hospitals, and 98 employees from 50 hospitals completed the clinical experience. The present application seeks to extend these activities to the other half of the state. Second Year - $26,500 0 Project #52 - Education Media Instrfictional Program for Requested Allied Health Educators This project is in much the First Year same situation as the one above, in that $20,860 it had one previous year of support by RMP as Project l@43, and ittoo, is being transferred from the Methodist Hospital to the Texas Hospital Association. It is designed to assist allied health educators to improve instruction through the use of educational media by: (1) Six one-day educational media institutes at selected sites throughout the state for personnel involved in allied health education programs in hospitals and other health care facilities as well as junior and senior colleges. (2) Six five-day in-depth workshops for allied health educators who will then be equipped to improve their instruction through better utilization of audiovisual media and the selection, design, and production of such media. (3) Supplemental follow-up education and training. An Evaluation method is described. During the year in which this program previously operated, three institutes were presented for a total of 108 participants from 43 institutions. Evaluation questionnaires indicated to the Region that the three institutes were successful. Second Year - $22,250 Texas Regional Medical Program -6- RM 00007(S) 2/71.1 Project #53 - Choricardi_,ioma and Related Trophoblastic Diseases The Trophoblastic Disease Center was established Requested in October 1967 under USPHS grant support which now has First Year terminated prematurely. Funding is being requested of $24,976 RMP so the Center may continue to provide HCGG determinations for all physicians who ALeed the service, to'compile and evaluate patient data,, and to stimulate interest and provide consultation to all physicians who want it. The Center has progressed from an average of 30 sample assays per month during its first year of operation to the current level of 90 samples monthly. To date, 439 patients have been assayed, of whom 246 were diagnosed and reported as having some kind of trophoblastic disease. Although this proposal received the lowest priority ranking by the Region of the four projects in the present application, RMPT sees its function here as that of sustaining a needed service through its period of transition to self support. Second Year $26,090 Third Year $28,017 Texas Regional Medical Program -7- RM 00007(S) 2/71.1 History Supplement Project Title Current Support Initiation (d.c.o.) Date I Medical Genetics (MDA) 14,000 7/68 2 Child Welfare Workdrs Training (MDA) Approved/Unfunded 3 East Texas Teaching Chain (Grad. Div.) RMP Support Terminated 4 Inhalation Therapy Patient Care Prog. (Methodist) RMP@Support Terminated 5 Regional Consulation in Radiotherapy (MDA) 30,000 7/68 6 Consultation Service in Medical Physics (MDA) 45,000 7/68 7 Cancer Survey (MDA) RMP Support Terminated 8 Statewide Cancer Registry (Houston) 105,300 7/68 9 Educational Television (Grad. Div.) Disapproved 10 Microwave System Development (MDA) Disapproved 11 Consultation Services - Radiotherapy via Television (MDA) Disapproved 12 Dissemination of Cancer Literature (MDA) Disapproved 13 Communication Study (MDA) Disapproved 14 Stroke Demonstration (Dallas) 151,000 7/68 15 Area-Wide Total Respiratory Care (12 counties) 80,000 7 68 16 Rehabilitation Program A (Baylor) 72,068 7/68 17 Rehabilitation Program B (San Antonio) 48,000 7/68 18 Rehabilitation Program C (Dallas) 47,000 7/68 19 Cardiac Work Evaluation (Baylor) RMP Support Terminated Texas Regional Medical Program M8@ RM 00007 (S) 2/71.1 History Supplement - cont-4.nued Project Title Current Support Initiation (d.c.o.) Date 20 Eradication of Cervical Cancer (San Antonio) 90,000 7/68 21 Core 696,222 7/68 22-30 Planning Bases - Phased out 31 Long Distance Telephone Consultation (Dallas) 20,000 10/69 32 Cardiovascular Nursing Institutes (Texas Wo-a,---.i's U. ) Unfunded 33 Coronary Care Nurse Training in Community Hospitals (St. Joseph's and Riverside Hospitals) 64,915 10/69 '@24 Regional Coronary Care & Training By Computer (Galveston) Disapproved 35 Reduce Complications Following Radio- 'therapy (Den tal Branch - Houston) 40,986 10/69 36 Inter-Regional Cooperetive Serial Control Systems in South Central Library Region (Statewide) 28,610 10/69 37 Health Careers Personnel Program (Statewide) 66,862 10/69 ':'.8 Dial Access (MDA) 19,963 10/69 39 Anniial Clinical Conference (MDA) 11,520 10/69 40 CB in CVD, Coronary Care and Intensive Care (Galveston) Unfunded l@l Social Workers' Training in Neoplasia (MDA) Approved/Unfunded 42 CE for Occupational Therapists (Dallas) 24,311 10/69 43 Educational Media Instructional Program for Allied Health Educators (Baylor & Methodist) RMP Support Terminated 44 Health Occupations Improvement (Multiple locations) Deferred (A Ilrivi.Ici@(:,(i Corn-,il-@_IE14Cat,_ril SPECIAL ACTION TEXAS REGT.ONA'L I-IEI)ICAL PROGPO@-r@l Pl,l 00007 January 1971 Revie@,7 ColfliltiLtc-c- The June/July 1-970 Revie@.7 Committee and Council rL.@viewed a request for a three-year renewal of Project i'@14R - Stroke Demonstration Pro-.ram e@. i@-e Patient Care, which previously had received funds as a one-yLar earmarked supplement to the planning grant. Subsequent to the original ai@7ard the project period was extended without additional funds to provide time for the completion of the construction of the stroke unit. e f '71 In reviewing this reouest, the Cmiimi-ttee and Council- agre d ti, t most of the staff for this project is now on hand ii-id seems to be well qualified and that the project should be continued. Ho,,,Teizer, @the application itself was deficient in that- L. -- , it Coll'-a4llc-d no indication of the num,Ders of physicians and nurses to be trained during the three years or the amount of time to be devoted to education and consultation activities for community hospitals.- Further, the proposal did not contain a -discussion of the intents during the second and third years of-the grant renewal request. There was also needed a more full discussion of g-rari@--and-hospit,.il--gei-ierated income. Consequently, the recommendation was for approval in the time and a,..iou:it requested, on the condition that Information be provided to contain answers to the aloove questions as well a s an assurance that at the completion of three years, no additional grant support for the project will be requested frot.T,, P-'4-@DS. The Committee and Council also restricted the expenditure of funds over the current level of expenditures the requested information had received approval. The amounts recommended (and awarded subject to approval of this material) were: 01 Year: $1.96,244 02 Year: $164,344 03 Year: $11@2,844 CIZB /P@,TS 12/29/70 (A Privileged Communication) S@i@Y OF REVIEW AND CONCLUSION OF JANBAPY 1971 REVIEW CO@UIITTEE TEXAS REGIONAL MEDICAL PROGRAM RM 00007 (S) 2171-.l FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: Additional funds be provided for this application. Year Request Committee Recommendation 03 $212,736 $265900 04 219,499 $26,500 05 177,568 - Total $609)803 $53,400 @r The Revie-@,7 Committee thought the Texas Regional Medical Program had come a long way in the last year and a half, as is discussed in the yellow summary sheet. The Regional goals appear reasonable - the mission is broad - and priority setting among regional components is good. The reviewers admitted, however, that in order to get a complete picture of the ov-erall TRNP activity .we will have to wait for this Regionis first anniversary review, application, which will be seen during the JLily/August 1971 tevie.@q cycle.. There was con5ensus, though, that RMPS is getting its money's worth in Texas. It was noted that two of the four projects in this supplemental application previously have been funded by other agencies but support has terminated and financing is being sought of RiNiT. The Review Committee thought the TRMP should be discouraged from sending in proposals of this nature unless their relation to regional goals and importance to the Region s clearly delineated Project #50 - Control of Hypertension and Chronic Renal Disease This project proposal provoked considerab e iscussion Among the reviewers. It was agreed that in'the four years it has been in operation, this study has don@ an excellent job of developing cooperative relationships between the school system and the county medical society. It was alsd realized that this. project has suffered through PHS reorganizations and in@lool@ing .for other sources of funding has encountered the problem of research institutions saying the activity is service-oriented and service agencies claiming it is research-oriented. The Committee .was concerned that such attitudes--Dtay spell the demise of a significant study - everyone's thinking someone else should support it. As a way out of this dilemma, Committee would suggest to Council that this is a potentially valuable project, but.one which requires nuinerou@ years of support before results can be realized. It was (t, Privilege(.1 Corrritunic,-,tion) SIL,',@lMliR@@ R VI@,'Tl A@'@D OF January 1-971 Revi-ei,2 Coriintitt-!e Texis Reg@Lon@l. Medicgl PrograiTi 2/71 (SPICIAI, A-TIC-,') Rt,l Orl'007 FOR CONSIDERATF.'ON BY I'EBRUARY 1971 ADVI@')OT@Y COUNCIL The Rpvi@ew CoGimitt@-t-, 'illc,@,ionil tilcl ,n(IC'qLl.-ItOl@y C,'.ISt,2C@re.'J tne o@f.' t'ite pievi.ot-is revic-%,) g-roii,@)s corlcernitic@ the Stroke D@lmonstratiori Procrem for Pro@,ressive Patient Care. It agr(-@ed ehat the restriction on the expeti(.1il-ure of funds for this project' should b6 lifted. RMPS/GRB 1/20/71 REGIONAL MEDICAL PROGRAMS SERVICE S@RY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) VIRGINIA REGIONAL MEDICAL PROGRAM RM 49-02 (AR-1 CDS) 2/71 700 E. Main Street January 1971 Review Committee Richmond, Virginia 23219 Program Coordinator: Eugene R. Perez, M.D. REQUEST FOR NEW FUNDS (Direct Cost Only) REGIONAL OPERATIONAL YEAR 02 03 04 1. Approved, unfunded projects (1) $211,728 $263,685 $299,875 II. New Projects (2) 288,468 242,109 249,784 III. Developmental Component 40,000 100,000 125,000 Total $540,196 $605,794 $674,659 RMPS Staff Review of Non-Competing 03 Year Operational Continuation_ Grant Application on 11/30. Awarded Commitment Commitment Regions Operational Year 02 Year 03 Year 0.5 Year 1. Core $475,255 -0- -0- II. Ongoing Projects (6) 442,536 $449,235 -0- Total $917,791 $449,235 -0- In addition to the above, the Region requested $193,189 of carryover funds to supplement Core ($39,184) and ongoing projects #1,#2,#3,#4,#7, and 9 ($59,203); to initiate the approved unfunded projects #8 - Tumor Registry ($83,928); and utilize $10,871 in Project #10 - Multiphasic Screening Program. These request for utilization of carryover funds were disapproved by the Director of RMPS. FUNDING HISTORY (Direct Costs Only) Grant Year Period Funded Planning Stage 01 I/l/67 - 12/31/67 $226,800 02 3/l/68 - 2/28/69 254,000 03 3/l/69 - 2/27/70 475,255 Operational Stage 01 1/l/70 - 12/31/70 Core 375,413 Pro ects 410.718 40tal -786,,131 Virginia RMP -2- RM 49-02 (AR-1 CDS) 2/.71 Geography and Demog@h The Virginia Regional Meaical Program which is headquartered in the State Capitol of Virginia services the entire State of Virginia with a land area of 39,838 square miles. The population of the state is 4,692,675 covering 96 counties (and 37 independent cities) with an average density of 100 people per square mile. The Virginia RMP is divided into five district areas which correspond to the same five regions of the Virginia Hospital Association. Fifty- seven percent of the Virginia population is urban and roughly 81% is white. The population has a median age of 24.1 years. There are ten major colleges in the state of Virginia. The state has two major medical facilities, the Medical College of Virginia and the University of Virginia Medical School. Within the state are 43 nursing schools which offer L.P.N. programs and 33 which offer R.N. programs (including 21 diploma degrees, six associate degrees, and six baccalaurate degrees.) There are eleven schools of medical technology, two of which are affiliated with medical schools (the others are affiliated with hospitals.) There are four cytotechnology facilties within the state, two being affiliated with medical schools and the other two being affiliated with hospitals. There are 20 x-ray technology facilities in Virginia of which two are affiliated with medical schools. The total number of hospitals in Virginia is 156 (of which 107 offer general medical services) with 40,116 beds. There are 150 nursing homes within the state, (55 having extended care facilities) with 7,879 beds. There are in Virginia 5,018 physicians (123/100,000) and 38 osteopaths (1/100,000) within the Region. There are 15,883 nurses (R.N.s) and 5,743 (L.P.N.) nurses. History of Regional Development: Shortly after the approval of Public Law 89-239 the Governor of Virginia appointed a fourteen (14)member Covernor's Regional Advisory Group representative of community a,-id state interests. This group, under the Chairmanship of the State Health Commissioner, coordinated the development of an application for planning funds, which resulted in An initial planning grant award in January 1967 of $226,800 first-year support. The applicant organization was the University of Virginii School of Medicine in Charlottesville, Virginia with the Commonwealth of Virginia as the designated region, with some overlapping in the north with the District of Columbia. A continuing cooperative relation- ship was established with the Metropolitan Washington Regional Medical Program. On July 1, 1967 Doctor Eugene R. Perez, was appointed as the full-time Program Coordinator. The Regional Advisory Group consisted of twelve physicians. In their review of the planning application, Council expressed concerns about the absence of representation of Virginia RMP -3- Ril 49-02 (AR-1 CDS)2/71 of paramedical personnel and minority groups on the Regional Advisory Group, the planning as submitted was quite non-specific and the evaluation plans and procedures were not emphasized. Early in December 1967, at the request of the Region, the planning grant was extended without additional funds through February 29, 11)68, to permit additional time for organization and planning. When the continua- tion application was submitted in late January 1968, the responsible fiscal agent was changed from the University of Virginia to the Medical College of Virginia in Richmond, now known asthe Virginia Commonwealth University. The Core staff at this time consisted only of a program director and an administrative officer. The Regional Advisory Group consisted of nine physicians and five laymen. There was an Executive Committee consisting of six members drawn from the Regional Advisory Group to exercise authority in the interim between meetings of the RAG. It appeared that the previous recommendations from Council to expand the RAG to include representation from Allied Health Professions and minority groups had not been met. Evidence of a cooperative medical school commitment to the program from the two medical schools was not present. Planning efforts continued to remain at a minimum level and evidence of sub-regionalization was at an elementary stage. Early in July 1968, the Virginia RMP submitted its initial operational grant application requesting support of 16 projects for a three-year period The projects submitted included four in heart disease, six in cancer, one in stroke, four in continuing education, and one for expansion of core. A site visit was made to the region in September 1968, and the site visitors reported that the continuous problems with cooperative arrangements, regional planning and RAG membership still beset the Region. Council did not approve operational status for the region, but did approve the continuation support of planning activities. Council urged that the region be advised that core activities be strengthened, that a regional approach be used in project development and that the new operational plan tie in with the previous planning phase. Another recommendation which was again stipulated by Council was that the Advisory Group be increased in number and that it include representation from paramedical professions and minority groups. The region resubmitted their initial operational grant application to the December 1969 Council and a site visit was made to the region on October 1-2, 1969. The December 1969 Council concurred with the recommendations of the site visitors and the Review Committee that this region be awarded operational status. Of the seven projects in the application, Council approved five projects and disapproved two projects. The Medical College of Virginia continued to be the responsible fiscal agent for the Virginia RMP. Nine additional members had been appointed to the Governor's Regional Advisory Virginia RMP . -4- RM 49-02 (AR-1 CDs).2/71 Group, which brought the total present Regional Advisory Group member- ship to twenty (20) members. Four standing committees on heart disease, cancer, stroke and related-diseases were created to replace Task Force. members and were broadened to include dentists, nurses, hospital administrators and minority representation. Regional representation was also taken into consideration in the formation of these committees. An Executive Committee,vihich consisted of six members and exercised all of the authority of the Advisory Group relevant to its functions and interim between meetings of the Advisory Group was activated. Each medical school has an RMP Committee for heart disease, cancer, stroke and related diseases. The chairman of each medical school RMP Committee acts in liaison capacity between the schools and the RMP Central Office and also as official members of the Coordinating Planning and Evaluation Committee. Other representatives on the Coordiniting Planning and Evaluation Committee are two representatives from the Medical Society of Virginia, Comnittee on Heart, Cancer and Stroke, one representative from the Virginia Hospital Association, one representative chairman from a Standing Committee on Categorical Diseases. This Committee provides advice to the Regional Advisory Group and to the Virginia RMP Director regarding needs and resources 6@ the Commonwealth of Virginia Region. It is also to determine proper relationships between program elements including the identification of needs, determination of priorities and analyze program performances and results. In carrying out these functions the Coordinating Planning and Evaluation Committee would designate and direct sub-committees, review proposals and submit recommendations to the RAG. In February 1970, the RMPS Staff reviewed this r.egion's continuation application, requesting support of the Core component. Chan@es in staffing patterns were noted, which had the effect of diminisbigg the number and total effort of physicians involved in the Core operation. Furthermore, the region expended only 55.1% of its funds. To permit time for the region to clarify the rationale for the new staffing patterns and to project its rate of expenditures, an award was made at the committed amount of $475,255 (d.c.o.) with a restriction on the use of $100,000. Staff believed that this action served two purposes: (1) assured the RMPS that funds will be available for program development, either for a better documented Core plan or new operational projects that may be approved; (2) permit RMPS to maintain a degree of stewardship over this rather shakey, but hopeful Regional Medical Program. The paramount issue currently involving the time and efforts of the Virginia Regional Medical Program are their plans for breaking away from the present grantee, the Medical College of Virginia, and becoming a corporate body. They are presently developing guidelines for personnel policies which they hope will be the basis for forming a corporate structure. The motivating reason for the proposed change from the present grantee stems from what the staff of the RMPS believes to be inadequate fringe benefits. It seems since the Medical College is a state supported institution, its employees are regulated by the State Merit System and given State retirement benefits. Since the VR14P employees are paid by a Federal grant and are not considered to Virginia RMP -5- RM 49-02 (AR-1 CDB)2/71 be state employees, they are not eligible for these fringe benefits and consider this to be an injustice. Ccnsequently, they feel their only alternative is to incorporate and provide their own fringe benefits. The Director of Regional Medical Programs Service believes these reasons are not only logical but of prime importance in the development of a productive program for the state of Virginia. Witt) respect, however, to the By-Laws and Articles of Incorporation for tile proposed corporation, the Director of RMPS has recommended that these documents be revised in order that the membership of the corpora- tion will be separate from that of the Regional Advisory Group. Indications from the VRMP at present are that if they have to separate the membership of these to groups, they may decide not to incorporate. In this anniversary review application the VRMP has requested support for the following: (1) Continuation support for core and operational projects #I, #2, #3, #4, #7, and #9; (2) a developmental component; (3) supplemental support for two new projects; (4) and new funds to activate Projects #10 - Virginia Model Multiphasic Health Screening System, and #8 - Tumor Registry. Staff review of the Continuation Application concerned itself with total program and not individual projects. Generally, everyone was in agreement that the region has made some progress during the past year. This was particularly reflected in the composition of the applica- tion which was a considerable improvement over previous submissions. The region has shown improvement during the past year in that they have reacted to staff suggestions regarding Core staff personnel by taking steps to strengthen the program evaluation and administrative sections. They have accepted the suggestions of staff that additional physician input on Core staff is needed and are actively recruiting for a physician to fill the deputy coor inator posit on. Organizationdl Structure and Processes: The Regional Advisory Group of the VRMP is composed of 20 members, 10 physicians, 1 registered nurse, 2 hospital administrators, I allied health representative, 4 non-health professionals, I labor official and 1 businessman. These-members are appointed by a nominating committee made up of no less than 3, nor more than 5 members of the Regional Advisory Group and then recommended by the RAG for appoint- ment by the Governor. Appointments shall be for a term of four years with the term of office of each member beginning with the March Meeting. The membership of the Regional Advisory Group shall not be less than 20 persons and they shall be selected in accordance with the provisions of P.L. 89-239. Regular meetings of the RAG are held on the third Thursday of the months of March, July and November of each year at a location designated by the Chairman. The RAG shall be the final authority for approval of all activities proposed during the planning and operational phases of the program and of all matters of policies related to the program. It is indicated in the application that RAG activities during the past year have included the following: (a) Regional Advisory Group review of goals and priorities submitted by the standing committees, and made final decisions on the Regions objectives; (b) the RAG has been involved in the proposed incorporation Virginia RMP -6- RM 49-02 (AR-1 CLIS) 2/71 of the VRMP and has been studying and encouraging its implementation; (c) the RAG has worked toward the establishment of overall policy and a framework for the functioning of Core staff; (d) the Regional Advisory Group has given careful study and review to projects submitted for their action; (6) the RAG has formed three committees of the RAG which are the Personnel Committee, the G-oals Committee and the Incorparation Committee. These committees were charged with investigating and recommending means to athieve a more effective organizational structure for the developing progr . Following are the names and functions of the committees of the RMP: Ad Hoc Committees: These committees contain expertise from various cate- gorical health service areas and are appointed by the chairman of the Coordinating Planning and Evaluation Committee. There are ad hoc committees in the following areas: Continuing Education for Nursing Personnel; Man- power Survey; Tumor Registry; Plan Multidisciplinary Stroke Programs; and Radiation Therapy. Coordinating, Planning and Evaluation Committee: This committee functions as its title indicates. It is an essential mechanisim for program development, coordination, planning and evaluation. This committee has consultants available and has the right to form Ad Hot Committees as necessary for special purposes. In addition, it can call on the Standing Committee for advice. The Coordinating, Planning and Evaluation Committee also screens and evaluates all operational grant proposals and makes recommendations to the Governor's Regional Advisory Group. Standing Committees: The standing committees' functions are directed by the coordinating, planning and evaluation committee. Their principle function is the generation of ideas that can be used on a state-wide basis in accordance with the RMP concept of regional cooperative arrangements. They also serve in an advisory capacity to the coordinating planning and evaluation committee. There is a standing committee for heart disease, cancer, stroke and one on related diseases. Taken into consideration when forming committees has been geographic distribution and representation from the variety of health professions. Each medical school has an RMP committee for heart disease, cancer, stroke and related diseases. The chairman. of the Medical School RMP Committees servein a liaison capacity between the schools and the RMP Central Office and are official members of the Coordinating Planning and Evaluation Committee. The Medical Society of Virginia, fleart, Cancer, and Stroke Committee consists of ten members of the Medical Society of Virginia drawn from the ten congressional districts which affords broad geographical representation. The Chairman is an official member of the Coordinating Planning and Evaluation Committee, thereby having direct representation and participation in a committee concerned with all aspects of the program; he is also an ex officio member of the Regional Advisory Group. Following is an organizational chart utilized for planning and operation of the Virginia Regional Medical Program. 0 Itll',GINIA REGIONAL Vi'@'DI'Al-@ PtIOGRAiM ORGANIZATION CHART FOR PLANNING AND OPERATION GOVER.NOR'S Rr-_GIO'\AL ADVISORY GROUP P, Executive Committee Coordinator/ Director HosD4Ltal and Relate \,,.e,4-cal School Core Sta,.f Health Organizat4Aons Re-oresentatives Ad Hoc Committees Fiscal Aor nr- ii7 t4 Coo.-dina n-r, Planning, and Medical Society o'l' Viroinia Consultants > r-valuatioi,, Coirnii .ttee Heart, Cancer, Stroke Committee f'@i li Re,@,,zed Disc@ises Fearr LIJ41sease Cancer S r o'@- e ol Cor,,,-..' 10,2 Con-.mittee C ITIMI-Ltee Coi-,-ini;.ttee Virginia RMP -8- RM 49-02 (AR-1 CD.S)2/71 The Core staff of the Virginia RMP has 29 positions, 24 at 100'/. time or effort. The Core staff organization has been expanded to include an accountant, editorial and allied health officer positions and the time and effort for the unfilled positions of education research and evaluation officer have been increased to 100'/.,ratner then 50%. The three positions of heart, stroke, and cancer consultants have been deleted and an internist has been proposed instead. The internist presumably will cover heart disease, stroke and Dr. Perez, the cancer field. The time and effort for the two Medical School representatives and the epidemiologist position have been reduced from 50% to 25%. The net effect of these changes diminished the number and total proposed time and effort of physicians involved in core staff operations. During the review of the continuation application the questions troubling staff were how Dr. Perez could direct the continuing planning effort and new operational activities, supervise a staff of 28 people, only four of whom are physicians (1.75) and five of whom are located in sub-regional offices, maintain the institutional and community relations necessary for a strong Regiona Me ical Program, an provi e ea ersh p or the. G. Following is a list of the Core staff members and an organizational chart. TIME OR EFFORT NAME JOB TITLE % HOURS Eugene R. Perez, M.D. Director 100 A. S. Cann Communications & Public Information Officer 100 T. Y. Tully Editorial Assistant 100 C. 0. Martin Administrative Officer 100 A. Burton Project Fiscal Officer 100 No L. Doeppe Administrative Assistant 100 J. D. Bobbitt Secretary (Clerk-Steno) 100 D. K. Brooks Secretary (Clerk-Steno) 100 M. L. Cosby Secretary (Clerk-Steno) 100 K. F. Meyer Secretary (Clerk-Steno) 100 TBA Personnel & Payroll Clerk 100 TBA Purchase & Supplies Clerk 100 M. @4. Proctor Survey Officer 100 TBA Heatlh Planning Officer 100 TBA (Epidemiologist) 25 J. L. Mason Educational Sciences (and Evaluation) Officer 100 TBA, M.D. Medical Officer 100 F. L. Peters, R.N. Nurse Officer 100 TBA Allied Health Officer 100 B. L. Peace, R.R.L. Medical Record Officer 100 l@T.B. Hunt, Jr. M.D. (Medical School Liaison) 25 TBA Secretary 50 M.P. Neal, Jr., M.D. Medical School Liaison 25 TBA Secretary 50 TBA Chief, Community Liaison 100 P.L. Beamer Community Liaison Officer 100 H. D. Kauffelt Community Liaison Officer 100 14. W. Schmidt Community Liaison Officer 100 M.P. Gray Community Liaison Officer 100 Virginia *W -9- RM 49-02 (AR-1 CD8) 2/.71 V).IIGINIA III.-4'GIONAI, Ml,-',]'.)ICA], l']IOG]tAM (coltL.l Staff) Organization Cliart as of 30 Soptcml)cr 1970 DIRECTOR Medical Scliool L-'pidci'jiiologist Liaison Officers (2) 'PLI'J'Y DIRECTOR (Vacant) Comii-itiiiicatlojis ,tiicl Adniiiiist-i,,itive Officor@l: I'Liblic Information (.rcnil)orary) I'll.'Oject Fiscal sistant Offi cer Adiiiinistritive Secretary Secretaries Survey OffiIccr Medical Officer (Vi ci iit) Nurse and Allied Educational Sciences f-lealtli Officer -icaltli Vacant) Officer (Allied I Projects D&vclopinoiit and" medical l@cr-ords Man,igciiient Officer* Off i cer lic-,iltli Planner COMMLIflity I-,iaison Officers (4) (Vacant) (I vaciiicy) -10- RM 49-02 (AR-1 CDS), 2/71 Virginia RMP qMA slnl@a'il'v (aC[D I-,q,A) 20-e4% MA e- Following is a folow chart of the project review process of the Virginia Regional Medical Program. NfA A1010it(V Submission of Proposal Summary to VRMP, Staff Review :yo @, Q it *Review y @')qW'I')o@rq&in'aotip-nrk,"'HK-h)nfiRA19-Nwgi%lpion Committee (If Approved *Review by the aXC)-PgTlln and/o.- Ad Hoc Committees 'L- 4e Th dica Committee Developmant of application with -asses ance fro iu Y,rtj,.,.,ici *+Review by th !very -@l:)r Ad Hoc Committees and the Medical Society Coiimittee -1.0,)illo ovijr;-i )roved) p (X-tr.-IO(ifflOrfy-+-Review'@ trg't' 977Y-anning @nd ENdilog (If-approved) RevLew by the RAG ill o a '10 irir3i iaaa. fr@i iibH (If approved) o RMPS oviir;-ilainirriba ed back to the -rigina 0 ,c)g@may @e -eferr tor for (1) not conforming to goals and strategies of VRMP and/or (2) revision. e referred back to the appropriate review committee for further review, development and/or revisions.. as Lon when in the review; process. ro formal review relationship with CHP,-.statfs of e tat tA)f activities ayid mttual interest. i Regional Advisor) Group --'-@e IWC-":rii TT t' a s a r e s u 1 t o fa t i o n a I A d v I T6@6-uW, i, oi r n@l Advisory Group las become mo-r the Vi e J,, Ld-@ d-pi ibility. AiLte-r,,.@euiaw- t4dy of the RMPS re( onunefidations,!,.t-@.@l.@ng,.c were implemented: (a) the RAG was enl@ rged@with representation an diversified both professional and geographically; (b) the standing committees 'Ch 5'@or; -s sT'd -nf@- 7fi- .Ioflfl , ,@y6@,@fRW)ye Task Force) were iversified b( pji Virginia RMP -11- RM 49-02 (AR-1 CDS) 2/71 geograhically; (c) a stronger and more organized review procedure Tqas initiated; (d) the core staff was enlarged; (e) the RAG adopted by laws. The Regional Advisory Group went on to identify its general goals and specific goals in the categorical areas of heart disease, cancer, stroke and related diseases. The RAG indicates that the enlargement of standing committees in the RAG provided for program representation of key health interest and agencies. In addition the staff of VRMP has worked.closely with many public and private health agencies, institutions, and groups throughout the region in development of program goals activities. They explain that as a result of activities generated by the VRMP many people from different disciplines and areas of interest, as well as members of the public have talked together about health care problems in the region for the first time. They identify some of these as the medical schools, practicing physicians, dentists,nurses, allied health groups and other health manpower in the region. The RAG indicated that it became apparent to them in early 1968 that there was a need for sub-regionalization in order that the program might be more effectively administered. After extensive study by the Core staff of various possibilities it was decided to adopt the Virginia Hospital Association Division of five sub-regions. The RAG explains that in order to relate the VRMP to the critical issues of the poor and the inter-city health problems,the Virginia RMP,staff has been in contact with two model cities programs in the state. In addition the Model Cities Program was represented and participated in the VRMP Continuing Education Workshop for Nursing Personnel which was held in the Tidewater area of Virgnia in November 1969. Rapport has been excellent with both the Model Neighborhood Programs in Richmond and the Norfolk Model Cities Program. The RAG also indicates that it must be remembered that Virginia in contrast to many other regions, has rural health problems, which perhaps, supercede the urban health problems of this state. Many of the health problems in the states rural population are found in the Appalachian Region which covers 21 counties in the Southwestern portion of the state. Seven of these counties lie in the heart of the poor areas of Appalachia. The VRMP staff has concentrated considerable planning efforts into the problems of Appalachia and other rural areas of the region. The RAG indicates that the VRMP staff is also working very closely with the Virginia Council on health and medical care. The Virginia Council's main thrust is a health careers program, and the recruiting of physicians and allied health personnel for rural areas in the state. The RAr, indicates that there is a good working relationship between the RMPS and other health related organizations such as the Comprehensive Health Planning, Blue Cross-Blue Shield, Virginia Health Insurance Council, Virginia Department of Vocational Rehabilitation, Virginia Heart Association, American Cancer Society Virginia Division, and the Virginia Appalachian Health Services Regional Health Demonstration Program. It also states that there is a close working relationship with the two medicalschools in the region as well as the Medical Society and the State Health Department of Virginia. Virginia RMP -12- RM 49-02 (AR-1 CDS) 2/71 Evaluation The Region explains that the core staff activity in the area of evaluation has been largely concerned with providing technical assistance in the writing, monitoring and reporting on theprogress of operational projects. The reasons given by the Region for these Activities is the requirement that the RMPS sponsored activities conform to the seven criteria stated in the guidelines for RMPS. These criteria are essential elements; involvement identification of needs and opportunity, assessment of resources, definition of objectives, setting of priorities, implementation and evaluation. It appears that evaluation which is involved will be concerned with the individual component activities operational in the region. Virginia Regional Medical Program Coals 1. The overall goal of the Virginia Regional Medical Program is improved patient care through continuous upgrading of the know- ledge and skills of physicians, dentists, nurses, and allied health professionals so that the latest and best in modern medical care for heart disease, cancer, stroke, and related diseases.is available to all the people of Virginia. 2. The objective of improved patient care is to be achieved by establishing voluntary cooperative arrangements among the medical schools and/or medical centers, with the practicing physicians, dentis@s, nurses, and allied health professionals, primarily through programs of continuing education. 3. The mechanism of cooperative arrangements and the essence of the Regional Medical Program concept is the linkage of patient care with health research and education involving the full array of available health resources and personnel on a statewide basis to provide a mutually beneficial interaction. 4. The realization of the above goals with be achieved by project activities and other efforts which, when taken together, constitute coordinated programs to reduce morbidity and mortality in each of the categorical disease areas. These coordinated programs n turn represent the overall purpose of the Virginia Regional Medical Program. Developmental Componen The Region is requesting a three-year developmental component award, as follows: 01-Year $40,00; 02-Year $100,000; 03-Year $125,00; a total of $265,000 for 3 years support. The Region indicates that this award would provide the Virginia RMP with the capability of initiating activities not possible without the developmental component; and that these funds may be restricted to the conduct of conferences at which concepts can be thoroughly discussed prior to the preparation of a complete proposal. Funds may also be used to employ personnel on a short term basis to support a contractural service for the conduct of studies from which facts Virginia RMP -13- RM 49-02 (AR-1 CDS) 2/71 can be obtained and recommendations generated , Tt is anticipated th@.';- I each activity requesting developmental- funds will- be reviewed and administered in a m t-ler similar to that of fully funded operational projects. Supplemental Projects First Year Project #11 - Emergency Coronary Care: The purpose Requested of this project is to prepare Volunteer $92,916 Rescue Squads to provide optimum emergency care to acute coronary care victims in the city of Virginia Beach, from the time of their arrival on the scene until the transfer of the patient to the hosoital emergency room. To accomplish this goal the project will provide emergency coronary care training and equipment for the ten volunteer rescue squads in the Virginia Beach Area. Data for analyses will be collected in all phases of the project to provide information for evaluating its effectiveness. After adequate review of the data by persons knowledgeable in the field, the design will be available for other communities to utilize in organizing similar activities. The region indicates that this project relates to the overall regional plan and goals established by theregional Advisory Group. Under the strategy for heart disease, and immediate goal was approved for the initiation of a pilot study of pre-hospital neighborh6o coronary care. It is the intention of this proposal on emergency coronary care to accomplish this goal and the proposal has been enthusiastically and unanimously approved by the VRMP standing committee on heart disease. Second Year: $57,521 Third Year: $56,207 First Year Project l@12 - Procurement of-Cadaver Kidneys for Transplantation: Requested The purpose of this project is the development $195,552 of a mechanism by which Cadaver Kidneys may be procured to save the lives of patients dying of end-stage renal disease. The project will establish a program of professional, administrative and public education which the region believes is necessary to carry through the primary purpose of the program. The goals are consistent with the RMP goals as they require regional cooperation between medical schools and community hospitals not only within Virginia, but also In adjacent states. Second Year: $184,588 Third Year: $193,577 Approved and Unfunded Projects First Year Requested Pro'ect #10 - The Virginia Model Multiphasic I-lealth Screening System. $222,602 i The region is requesting new money to activate this approved unfunded project which was approved by Council in July 1970. This project proposes to establish a multiphasic health screening system with facilities for gathering data on patients physiological state and Virginia RMP -14- RM 49-02 (AR-1 CDS) 2/71 the follow-up necessary for the early detection of disease. Primarily,' the project will look for non-manifest symptoms or risk factors associated with heart disease, cancer, and stroke. In the process, medical and health data will be generated which will be generally valuable to the referring physicians in the management of his patients. The total funds requested by the Virginia Regiona I Medical Program for support 6f this activity in 01-Year is $222,602. It has requested utilization of carryover @ollars in the amount of $10,877 and $211,728 of new money. In its 02 and 03 projected revenue will be utilized to reduce the amount of new funds required for support of the program. Commonwealth University has stated that it will assume full financial responsibility for any deficit between the funds requested and granted and revenue anticipated in the second and third year of the program and subsequent years. The Council approved level for this project were as foll(xqs: 01 year $268,552; 02 year $480,479; 03 year $433,704. These levels of funding were approved with the condition that the VRM could guarantee sources of revenue for the program. The region has responded to this condition to the satisfaction of RMPS staff. Approved and Funded ects Present Year of Operation Project #2 -Coronary Care Evaluation First Year Project #3 -Cardiopulmonary Resuscitation Training Program First Year Project #4 -Stroke in a Small Rural Community First Year Project #7 -Virginia Medical Information System First Year Project #9 -Continuing Education for Nursing Personnel First Year Approved and Unfunded Projects Project #8 State-wide Tumor Registry 01 $113,584 02 $ 98,600 03 $110,100 Project #10 Virginia Model Multiphasic 01 $268,552 Health Screening System 02 $480,479 03 $533,504 Disapproved and Unfunded Projects Project #5 - Stroke Program and Training Unit RMPS/GRB/12/21/70 A PRIVILEGED COMMUNICATION SUMMARY OF REVIEW AND CONCLUSION OF JANIJARY 1971 REVIEW COI@II'ETEE VIRGINIA REGIONAL MEDICAL PROGRAM RM 00049-02 (AR-1 CDS) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL c@o @eridation: AdditionA]. funds be provided for this application. CoLincil's special attention is called to the Multiphasic Screening Program. Region@s Recommended Operational Year Request Additional Funding 02 $ 540,196 $211,,728 03 605,794 263,685 04 674,659 299,875 Total $1,820,649 $775,288 In addition to the above, the Region requested $193,189 of carryover to supplement Core ($39,184) and ocigoing projects #I, #9, #3, #42 '#7, And #9 ($59,203); to initiate the approved unfunded project #8 - rumor Registry ($83,928); and utilize $10,871 in Pro ect #].O - Mtjl.tiphasic il j Scree-nin'g Procram. These requests for utilization of carfvover funds were I disapproved by the Director of MIPS. The Region was awarded only the committed level of $917,791 for their 02 year of operation which begins JAnuary 1, 1971. Lri@L@e: Generally, Committee believes that this Region continues to have problems with cooperative arrangements and regional planning.' The VMIP has not fully defined its goals and priorities; categotical program plans are general-and non-specific; and develop-- ment of a. definable regional plan of action and mechanisms for .establishing priorities are very vague. Conmiittee'expressed concerns over the reduction in medical representation on the Cote staff. Three positions of heart, stroke and cancer consul- tants have been deleted and.int6rnist has been proposed instead. The internist is expected to cover heart disease and stroke; and Dr. Perez, the cancer field. Commit tee was encouraged that the core staff organization has been expanded to include an accountant, editorial and allied healt 6 ficer positions and the time and effort for the unfilled positions of education research and evaluation officer have been increased to 100'/. rather than 5 O'/@ Virginia RMP -2- RM 49-02 (AR-'I CDS) 2/71 Committee recognized that the VRMP has established a satisfactory relation- ,ship with the Virginia Medical Society; however, they have not been able to successfully acquire the support and active participation of the two Medical Schools in the Region. 'Additional Fundi The Dev@-lop-,n n@t@@ Component request was not recommended for funding. The Region has not reached an adequate level of maturity. The Coninittee believes that the Region should receive an in,depth site visit in relation to its Anniversary Review Application in the November 1971 Review Cycle. The Committee found little relationship between the two new proposals, Emergency Coronary Care and Procurement of Cadaver Kidneys, and the stated goals and priorities of the VRMP. The Committee noted, however,- that the implementation of tne approved,but unfunded Project #10 - Multiphasi.c Scrc@,-riinc Program, could stimulate cooperative arrangements and give the VRI,.TP needed visibility. Aware of the Council's concerns about @lultiphasic Screening Proc,rarn, the Corimi.ttee did not know what effect the May 1971 report to Council on the state-of-the act would have on already approved niultiphasic screening projects.. There ore, the Committee calls special attention to the Council on this recomelida- .tion for additional funding. @IPS/GRB/l/19/71 RECTONAI, LNiEDI(,,AL SERVICi,-' SIT@lA@-@Y OF A'@@i@IVT7RSA@'Y REVIP@,L A'o!D AILKF,D GRANT AP-PI,ICATION (A Privileged Coiiniiuiiicati.on) 1-@@N-SHIN.,GTO@\'/AT,ASKA REGrLO@@Al, Z@lEi)ICAL PROG-L@IM @l 38-0@-", (AP,-,I-CD) 2/71.1 500 U,@tiver,(3itv District Building January 1971 Review Se@i'L-tl.e, @,,Iasliin-to.-i. 98105 P-P,'Dr"P,AL@l COO"DTL@@'@TOR: Donal R. Spar,@tian, IT.D. 1', DLT @L@_CL) i r @ t- C@c),c; t s On I y 04 05 P @t e 2 /l/71-.12 /31/71 I/l/72-12/31/72 All@ Yt,@ Continuation Commitment $1.,503,450 $1,596,935 $3,100,.)85 (Core) (638,906) (1-4 Projects') (664,935), - - Two Approved Projects - Unfunded 79,765 3'0,800 I/ 11.6,565 9/ Ne@,i D@-velop-.nental CoTiponent 120,000 156.000--- 276.0k)o Total Funds Related to this Request $1,7 3@')I,5 @1,789,735 ,3,492,95@) Less; Co-,@tinuqtioii Request (Sta4-' -1,503,45t) -I-,596,935 -3,100,38-@-I Cominittt-e./Couricil Acti-o-, Required $ 'L99,765 $ 19'),SOD $ '-z92,5,c-@5 I/ Not Reflected in Application Budget - release of new money requested . ( L 2./ (Not Reflected in Application Budget) Funding Historv. PIA-Lvl'-N-ILN'G ST,'@CE Grant Year Period Fu-,ided-(t.,c-.@- 01. 9/l/66-8/131/67 $-@66,Z-48 02 9/l/67-8/31/E,8 655,1.48 03 (17 mos) 9/l/68-1/31/70 840,518 OPEP\ATIO-@@AL PROI@'P@iM Grant Year Period Council. Appro-\7ed Funded (d.c.o) Future C'oiriirit,.uc@t ol 2/l/6S-],/31,/691-/ $1,021,06- $]-,021,067 02 2/l/69-1/31/-/O.'--/ 1,490,000:--; 1,312,740 ---- 03 2/l/70-1/31-/71 2,441,202 1,820,8643/ 04 2/i/71-12/31/71. 1,945,812 ---- $1,596,935 05 1/1,/7'-)-12/31/7^ 1,690,618 1,596,935 1,/ (Cc)re funded undei.- Pi-inn4l-ng Gr,@nt@). 2/ (Approxinia@Le) 3/ (1ccl.udes $215,000 02 carr-vo,,7er funds) Washington/Al.a:7,1,@6 'Rl;,T -2- RM 38-04 (AR--l-CD) 2/71 li,7 - T,iis incltij s tti r-' states of incl @loo 000 square miles. The 3.2 million rec, Alaska which f-ncoiaip@,@'@'s $ idents of Washitic,ton state are served by about 3,100 practicing physicians. More than half of the physicians live in two population centers, Seattle qrid Spokane, which are opposite sides of the state. Alisl,.a's 279,000 residents ire serv@,d by soilz-- 200 pr@icti,clltio, physicians, of wioia, about 90 live in Anchorage. Only two other Alasl-nn communities have i@iorc than 15 practicing physicians. .Washington has about 10,234 active nurses -ind Alasl@,i about 628. Ancliora@e serves the r@i;ajol- g,,@o-rc,@phic population area-, of Al;isl@,i. The state of Washington, somewhat like is ,eogreplil.rall.y divided by 11).rurttzl-.ns into at least t-,@,,o ri,,n-joi-- acograp'@iic The lar-cst ce,@itpr cist of the mountains and the largest population area is Spokane, located in the northeastern corner of the stite. Tne Spoirine medical facilities draw patients, not only from the northeastern part of llisliingtori, but also from areas of Western Montane and the panhandle of Idaho, which are in the Mountain States Rl,fP. LCTl,)l Devel.ol-)riE,,nt - 'The University of Wishinc-,tort, School. of 1,@'@-dicine was designated as grantee a-,ency in 1965. Ecirly in 1906, Dr. Donal R. Spnrl-Ir-oaii i.,,as appointed ti'@e Ri'@P Coordit@,qtor. In Se-ptei@;I',)er 1966, the Regional Medical Pro-,ratn was officially establisher with tl@i@ of a three-year plennin,, grant. During tli,@ of tlie second year and folio-T-71'.119 a site visit, the Reg@Loii beC@lTrle operational with a pro-rz;ni which fell int@; three categories: 1) f_u@ption end Trei.i-ijnc, - Continuing education for physicians was ei@i@)I-iarized using different methods of -.udio@,islial instruction, consultation, and preceptorship technique. PtogriFis' @@ere ilco designed for paramedical personnel. An expanded library resource ;7as developed for Alasl-a; 2) Stiidics -tid Services - Activities in this category were concerned i@ith and consultation and pl@@terns of care for cancer patients; and 3) 14)L@e Lo@,@@ i@@lLi@onstration were implemented in the field of computer aided instruction, and cy-O'Lic fibrosis. Reviewers of the operational ippl.ic@-tion noted that the proposal clearly fit together in terms of the broad getieT-,-jl concept of the Regional Medical Program. Many of the projects emerged front local. coi,,-P.Unities far distant from the University Center. A ntir@.-iL-cr of imaginative individuals froi.1 c@ut- side the Univer,.-I.ty's framework l@ind been involved. The coordinator had collected a good administrative staff. The educational projects which generally er,-ierged free nreas outside the university, appeared stronger than the developmental. or more narrowly oriented service projects which stemro@d free university sources. Ti@7o,probleri areas were noted: 1) The, staff appeared lacking in fiscal expertis6, and 2) the area of evaluation was i7eak for ill projects. Early in 1969, the region was evain site visited to: 1) revietq the pro@ress 0 1z, of,the Region',,, total pro,,rem; and 2) further study a supplemental operational grant application. Tl,ic team was extremely impressed with the ongoing planning and evaluation, operating procedures the accomplishments of the Re-ion. Much of the success was attributed to the leadership provided by the Progr@-tm Coordinator, Dr. who sconce] uniquely suited for the position. During its first operational year, efforts Iiid beef-, made to strengthen the PM 3.8.-04 (t@R-1-CD) 2/71 /Alasl i' -3- role of ttic Regional. Adv-sory Grotjp P-tic', its r("Presentziti.oi. A sound and wholesc)r@,i,-@ relationship between the 1111;!P and the University of Vlasnin-ton had been established. A small but competent stiff li@ici been developed. Som@e tio-,7c!vc@r, stil,l noted in the- are,] of evaluation. At this stage of the Rcaic)n's devclopt,--c-iit, its repres@oiit@itives were Ittemptin-. to shift frorii E,,eii@ral objective-, cet-itrcil.ly developed, to specific ones based on need, as expressed tlirouc@hout the l@cgion. The tr@irisi.tion fror@i one .perspective to another was proving difficult. The lic-,gion's original concept was to develop overall objectives i,o,,.ild t(-IE' Plitl-lill- Of appropriate projects. The fail.u-@e of t@ti-'Ls strategy was attributed to the R,i ions perio,@', wr@en the objectives were still very general.. In an attempt to m@,il@ the chift, staff was to dQveiop a five-year plan x@,,tiich was to be presented to the RAC for its consideration. Al.8o during the first year, the R"'r- had involved other q-ertcl.e:-, and had developed stron- relations'Liips a,--,ong thcta. This pirtieLil.-II.-ly true 'fo.- sucl-i agencies as OEO, the Rcgio-iil Pl,,,n,-iiri,-, Council and the State I-Iceltli D.@--pprLr@icrit. The of cc)fii-itiztity hosi) viis riot clearly evident, efforts v.-,ere bni.n- to this 7,rea. Society involv@-,,@.,.@-,nL slo,.@ not uiiifoi-ri, bait At this sta@e of it- riot4if-I threat tire Core sLo,'Lf the initiative ir. pro,,ra.-it end -a, ei Ministration of inclividti@il projects. There was evidence ho-,7cver, that project development was being stii'@,,iloted at the griss roots level. DLii,in@ its -(-fcoii(i year of opLr,,ition, the Pcgion expin(.', d its pro@rir@is in coronary care, share, and cancer, t'iirouc.,Ii various continuing education and demonstration projects. in October 1.969, @-iiioti-icr site visit to the P,T?IP i7,is nece@,F@ctry to rc@vie@7 the Region's application for rene@,7ed support of Core staff pl.@nring activ- iti@eq -iid 10 projects, and the request to it-cpl.cipent 4 reeve projects. Since the Regi6rt ,7as about to enter its fourth year of planning, n-@iej third year of operational st-itts@-, the over@,I.l of the site visit t,,zis piiced Oil prq@l l@rev-!,c.-,.@7 rather their project r(l-vic,,,;. As a result of this review it was ].earned that a nu.,,,iber of ir@@ipres!iivc Vi-i.-Lificnnt tied occurred i,7iti@iiii the M@l,? durin,, it,, socc)-iirl operational The most significant chariE,;es were those related to the roles of the Regional Advisory ComF@.iittee and staff, and the influence of th,e consuricr. There had been a r@.ajor tr8nsitio-i fro,-,i staff leader,,iliip to RAC and coiiruricr leadership in program planninc, and direction. The chen-c arms most notable wiieii the PAC rejected a thtee-ye@,r operational pla-L-i which was the primary effort of the W/AP,l@fP planninc, staff. The was not only undergoing a si@,iiific,-I-Lit transiti on in philosophy, pro-rar,,i direction ciilO, I,eider,,,,Iiiip, but was il.fo beginning to iriipl(,i7ierit a pro-r@ir,.i to-,,7ard a set of ne@7 goals. Individual L> projects reflected en attempt to build on the philosophy of the Region's flo'utreac'ii" pro-i-gni. The philosophy .@.,@)d direction ut-idertnl,-,Oil indicated that- not only was the proararii accepted -throuclio,,3.t tt'i,2 but its direction was being t,@tro-igly infltic@iiced by tlic,. tl-,rouc--ti the Ri,@C. The involvement of the consut-.,,cr .;.-is particularly in tl@ie develop- n7le",,it of the Central l@lasli-,ngt(>n for the Spokane area uii-'@qu(@. o@i tl-i other none!, t]-tc. Prc-,@ pro raiti Washington/Alast@a Rf@',P -4- RM 38-O!@ 2/11 was considered to be predo,,,Iiii@ntly oriented. The gonls for that area were not clear z:.,sid the activities were Cicci-iocl innovative. Tile RtVt, however, ,7as i@i@211 of lack of resources, and the problems involved in pro-raiii The cc)licer-n,-,c] reviewers in txio t@7,3@7s. First, the sub-regio-.-i@.il or "o,,Itre,-ich" philosophy vTas not clearly evident in the indivi-OiLi@il projects is presented in the written cippl-)2.c a L ion. This to be due to the uiifii.@iil.iirity with grantsii,,@-i-iship of those individuals who prepared the proposals. The second and riost important concern v7.is over the impression of the projects were attenLptitiy to c,-@rry out the "outreach" phil,o,@-ol-)Iiy on an individual basis. This particularly i-ioLi.c(@,@l)le in the are@i of coritiniii!@- It appeared tiiz@@t the core staff could help coordinate the "outreach" impacts of the individual. projects. Further, RI-IPS revic@,7ers believed that the blendiii,-,'of these different npproaclies should be a primary concern of the R14P, since the conflicts of philosophies and a lack of cboriinati6 ii ariona C, projects were most lil,-e y to occur at the corp.,P.,,inity level. The reviewers were irtlprer,@,ed r.,,ost with the cardiac pro-rar.-i. the sub- ii.i field appeared to a close x7orl@in@ relE,.tioi-t,-hip i,7it'ii the Core staff planning officer, and also to be very familiar with the operational projects. The -tro'zce prot-,ra@ii i@)os considered to 'h-lvc- bid re,-3so@i,obl-c and it,@%- pl@irniiir, efforts e-,,pc.,ctee,@ to be ,Iccelnrated and strengthened by the i(lditio;,i of -i stro'i@e planning officer. It ilai-I noted that the cancer program had been pr@Ltii@,,rily centered around the automated tumor registry. The continuing education pro,,rL,,m found to be provider, rather then 0 probl-er,,i-orieTitee,. Pro-,ra,-,is for physicians, nurses .iiicl allied lic@,,ilti-i all seemed to have adequate thrust. It appeared, ho-7ever, that these pro,-'rat.,is bad different Directions. R6vic@iers believed that spccial attention should be given to coordin,@)tiri- these various approaches. Further, the itteiiipt to 0 coordinate these education programs by Core staff should have been r,.-Iucli greater that it appeared. Evaluation off educational activities seemed very good, but very SpOLLy. 1, recent reorgn-,iization of Core staff respoisi.- bility indicated that the Core staff role tied been redesigned to carry out the R@IP plans es developed by the PAC. Also, it appeared t't'i@it a good Core staff had been developed and i.;oul.d be further strengthened by the addition of.a iie@.7 director for evaluation. Dr. Sparl,,tr@an, the coordinator, still remained as chairman of the RAC, however, there were strong implications that a clian-c would be forthcoming. The RAC was found to be .,in exLrc.,@@aely active group ind @,7os committed to the revised goal., "Provide optinturti health care to persons in I-lesliington-,@laslta at rislt of heart diseases cancer, stroke and related dis6ase.1' The methods by which the Region planned to work toward this goal was: 1) support the development-of cooperative, integrated reuional health care systems of- malting comprehensive personnel h,,-al.th services available to al.1 people in the-Region; 2) support and organize continuing education pro,-ram for all health providers to tipcl.-te.thcir skills and services; and 3) sponsor activity to increase the "capacities" of providers of hciltli -ervSces. Wastiirigton/Alasl-,a Pi,iP -5- Rl,t. 38--Ol@ (Al,-I@-CD) 2/71@, Tov7ard the end of its third operational year, the llce,,ioii submitted a supplemental application i,;Llici-i reqt:,.csted support for the. Alis'-,', @lerlical Library and tile 1,c-d-ical Co@,iputcr . Services Projects. 'Cilcsc t@,,,o components %?ere favorable revie-,7@d by term 1)@c-ember 1.970 Ccuncil., but are not funded. In addition, tiir-@ -UI)Tilitt@Cl @i-,l ey,clusively -,Ii.tli dircise Tot-fi,,-d the Diseise Control Progrpni, the proposal. contained el.cverL interrelated parts in four major areas: Al.t@ioti-h the noted tli,@:t the St:,@-tc, of has a rc-,,Iil c in S--@ttl@2 tIli2 coalition of proposals fro,-,.i re-,ial disea@es expe-,ri",frc)@'ll both Seattle and Spoknrle,.the only tiqo densely populated areas to be served by the pro@@ret-,i,- it appeared to the that the plan in tirIC application li,-)d been developed by the rerial experts with little input frozen the RI-!P Core st:,i'Lf. 14o additional r@,2,iT'o funds Here, for tl@,,@ I'licivicy Tli c@ Region h@i,, is by and x,.!ill. be the subject of a separate surt:nary. and role in hc-@ilt'@i c@@re records, tile of tile in some detail the plan for 1969-73. In light of pi--ogreri experience ducal the past year and of of reSicn,-il health needs .fill(] resources, the plan 1969-1973 i,,,as Modified and Simplified to b(@tter_Cxflress re@,,ional objectives -,P, noT7' preceivod. Priorities hive been set for the expenditure of tiT@ic a,,-id effort. Goils have been far relel.-ion to their importance and ur-oncy for the Region, inei to the li/Al,@",'@p capacity to meet thei@i keel)in,, in mird the p-zbbl-c-,nr@ peculiar to the and the unique streii<,tbs of The reni@iiig o@ pro(,ri,-n priorities is follo;.,s: 1. W/t.,I'.,!P Priorities (ProOtict) 1. Support develon@,i-,,iit of cooperative, integrated re-ioiill care netiorks ,o that eicli p--itic.@nt r,-i,@,y ree,--@'-eve qu,nlitiy service appropriate for his o7,7n pcobl.c@@liz-, and as - close to his home as is consistent i@itli optittiurn quility at reasonable costs. 2. Support activities to better defiiiE,. health rii,-inpoi@7r2r and health services deficiencies and to @,;oi-k to-,@,@ird their resolution. 3. Support activities to it.@,prove care for the medically disadvantaged. 4. Support modification of the e@.istiiic, health cire systet-,i airiied at. ir@-iproving tne efficiency of providers in the organization and del.ivery of (ju,,!@i.ty 'ic@-ilth care. Washinoton/Alask@i P,' RI-I 38-04 (AR-1-CD) 2/7). Prioriti,oz; (Proc@ @"s' tctiOlls by @@,"ii-ch the Db@v four objectives are to be 1. Ex,,),@ii)d 's ro'@r2 as n catalyst incl coordinator with he@jltl-i-rel,ited agencies develop closer coor(.Iiii,nti.on v7i(:ti state lieili:li igencieL,. 2. Support an Continuing Eriucat-.i.@,n l,rcorrat,.i for in C)rde-@- to level of pro'L iithiii the health care oil liu-cl-,4-L, and allied health personnel. 3. Increase cr@.ipha@,is O',i screening, pre%,ciitioll, early care, rehabilitation, ambulatory care end eiTerociicy care. C, 4. Assist public health I)ro,,,r to better utilization aj@' care I,,Thile the to a,@c) tl) re fail be a C).L' f o c I,, F@0 c n c P, t. r C) a-,id related diLea@ ,'4 e 1: C I'@l I t . cc)- .0 @i c't:. i o t-i ti i@ f atio-,i of continues to be an 1)zirt of tt-ii@ goal of improving health care. Examples of cooperative are offered as follc)@,,7s: 1) A co[n,-,itinity coordinator group foi-rfic!d two years ac-,c) by 11)1)ol.ntrci@ilt from the State 1.1,2!dical Association, the University of 1-7@istiiiiSIL:ol School of I,'Lc,dicine and tf,.,- has proven to be @ii link these three orgnniz@@ti-onq; 2) Ilo,@pit-.@ll t,-osociatioils meaningful of hospitals x7itli Ri,it) h,-..r; b-.(,n to iiiiteri,-Iize than was this relationship with but Progress has been r@iode; 3) Relation to other I)roZr@rio co@,,ccrcice, ..7ith planning end ii4,lprcvr@,i-@-.c-iit of health both tlir2 Seattle lic)del, Citi.tes and the State and I,,,,,oiicies are represented on the PAC. Further, crof3s of staff and Advisory con."@iiittee iiid C;@-P L)'L title, St,,tr-@, Arc,,i-@2i.cle iiicl County levels continues ,id been incre@lL@ed. is @'i 2,00@i Cli,fl"@,,tc of cooperation bt!tuc-p-n and CIIP i.,z t@,,o are, c., ob,,t@lclcs to @,ccovxpl.isltin,, @c@,)Cl joint t.-iorkiiig in i p-co@,i:,iri oil 4) I,.Iashingto,-i State D@p-irtr@i,2rit of I'@e.,ilth - Close ind productive relations exist with the Washir@-ton State Dapartir@citt of Health i,71,lich is now a pnrt of the State Social and Health Services 5) 'University of Washington School of i.,il.@dicirie - joint point ilLs between the RI,,? and the Uhiveroity School of l@l.,--dici,ne continue. A total. of 93 physicians from the School of IL!edicine his participated in Continuing E:ducatiol'i Protl,iprps and the close ties bet@7ce.n the ContinLljn(,-,, Ec]Ltcition and University of Waship.gton ContiiiLtin.@ 1,1,,dice.1 Education ire ini-itunlly b-@n6ficial. in many ways; 6) Voluntary 17'ealth t,-cncic--c - There irc- i@itiltiple croos representations beti,7-2c--n of the F,,'LIP and the two St@,tc,, Ilieai:t Associations and five jointly sponsored @,ct-@vitier,. The director served as consultant to 7- 38-04 (AP-1-CD) 2/71 the Rel-iibi.li.t,-@tion Section of the li,-iter-Soci'.et:y C@)@@ziiirsicii on Car(liovasci-iiir 'Dise,nse and on a at the in ti7ovembc@r 1.970 wl-iic'p. diicu@-rcd x-7ays in RI-i-i"E, and Ileirt affiliates call work together to the ISCCV A F ,c@ocl repre@-ent,3tioi-i --t @- 1 ito I continues to t I I,lz I rk c,I and Alaska divisions of the P.E,.aricnii Cancer Societ-v. Evidence of cooperative d relations is deiion-,,t-i:tited by t-.i-ic, cclitribtitioi,i of both the I-Iisliingtoi-i and A I a c, cl i v i E i O,.,) o f IC 17, -'Lear, to the Ri,-llll Boune@prif.-!3: Both the states of l@Ial-hin-ton and continue to agree that of the t@,io stated, clearly fits into the regional cciicept and is beneficial. The southern and borclc!i.@s of ttic, IIishingtoii portion of the ll,eQio-.,i have been the subject of s(-,iTie discussion. For most purposes of tit,,2 the prer@cnL boundaries of the Stp@te of l@,lsliiilgt@-,i and satisfactory dcliiicLitio@,i of their ictivitie,.;. Piiysici-.ons Arco in cIC2,-'!.-Ce for active tL-,.@ Bond to eirite, hive! no desire to cl,i,@in-c southern bc,,iTl@'zj-!.-y. ns tried center /Al@ @"O for EasterLi z,,rid T,!,'cstc.,r@i Inc] @@7 Pr spill iiit-t7; th,@@@.@ z@re-L7,,, 11 there has been no re(4u,-,It to incorporate any portion of Idaho or l@'onttit-,a into I,,'/ARI@.P and such a step does not seen i,,eccssi@-y for pu-A:po@,@,es of continuing education or to it-.il)rov,- health care services, In t@,7o areas of Epstctrp. Washib-ton on the border of Idaho ni!riLly, Le-@,7iston- Cl@irt-cston, turn professionals froi-..i bot:li -t,-tc-s hiv-@. joined i@-i @p ate. activities in French and the 'fountain Stal R" jointly pnrticip, 'o@-L: The Co@@:@lunity Sei:-%,!.co,,-, D'@vQ]-C)p, art,:-' Procretis have been gi-vc!i@i prir,,sry responsibility fo@ t@-licing ccci:essive steps tot,,-ard subrerlion@il- clcvelopi,,-@nt. 11 ,tlth Care,of Tiie F,.AC li,-is decided that: - 1) the Region shouted itself to the hceltit faced, of all the citivens in Washington and Alesl@; and 2) slid! @7orl@ to the efforts of other groups seen ns CFO and li'lod,@l Cities @.@tiosc pri,-Iiary riission is issistii-ice to the needy. Cotqt of Ecol.tli Care: It is hoped that appropriate Modification of the l@t- s-y,s--t-e-r-i-of @,.,hich the P,'rl'fl r-,ny properly be involved such qs the ,Yider use df ill,-erl Health personnel of and health service,- should lea4 to availability of quality care at lesser cost IL IL31 iLt y@. Ci r-c@ : l@lc--sureable iml)rovc-,-rc-iit in the quil.ity of care is an objective c!@': @-@l the coritini-iii-tc., education projects. 13ettet lJtiliz8ti.aii need 'Pistri.l)-Litio-Li of C,.ir(-, The Region ti<.IS contributed in the planning, in the teleran,' of I-li@DEX personnel at the University of This p-corrari cc)-,i@ributes to a better distribution of healt'n -service-.-, ot-d n greit an,,-,ilabil4.ty of the sair@,e. The hospital autopsy rrrdj(@ct led !-o better of the F,,,@neril. practitioner and i-icl@Arby Washinotozi/Alasl,,a RIJ? P,@l 38-04 (AR-1--CD) 2/71 "he 1, p rtictil@it-ly through its El@cLitivc@ Co@,.@imittc-.e has i@orke(T--'c-'I---o-.-cly' @@;,-t-h Core stiff in irnproveriicnts in prorii:,?,@'i duriii,@, the past year. These have produced clearer definitions of staff responsibility better r@icasures of perforni,,.nce, ir,,,pro,,,cd co.-,.,!-.,,iiinicition st@iff, and bet,,,icen staff and RAC. The Cc-re ctaff the d(?,,,,ire to serve in the "honest brol,,er" capacity to coordinate efforts to,.I,,.ir,(,' improving the effective- ness and Satisfaction of health provi(,'or,-, in their i@7c)rl-, nrcl they are maki,n,.- qt3ality henlt'o. care te) the izi the Region. In this 17,ly, of the tl-@ Prcgz7,3,.n his ttic rerl)ect of thL, StriActLI-)-e Up@n the impl.e.-ti--ntation of the '@klaii for the I)evel.op@-ient of W/APIIP 1969-1973" an vn,, ii-iitint-ceA to determine -vil'ic.,ther or not the of 1,7,ns suci'l stiff cc,,-ilei, by itfi Iicti.vitic@-,, accoui,@ll.sh the Fcials an,-l o'Dlecll-i.va., set forth. 1,@s a reL-,,,ilt, tli,2 was re,.ti:Llcttjrr:,@d c).-i a pi.-o-ret7i bases a rel.itcc.1 groui,),, of activities hav4@rL-1, The office of the Di.rector was rezil..'Li;ne4 for pi. Icluei.ii@ cc)or(l@i-@,,ni--ion, @,,ervices adri-tiyii.,>tr,itiozi pLi.!)Iic Specific prc,@,,rirns fare set Lp in C@ic -tion, d--velopiiic-ntFil folloi-ting al7C,,-,aS: heart, cancer, stro.@e, continuing oe@itc@ proc-,ram and cot,,,@-e,,-.trLity health services. An Aclvl-sory jCor@,@@nittre, under the of the RAC was assigned to each procriri ire,-t. Tlic@ of Associate Dirc,(-tor created for c,@cli proc-,r@@@i. As the pro-i-or@,l n@atinger, he assLivies the usual executive fii-icticn,, associated Nitli the aclr.,i@.iiirt@r@itic)n of his prbgra@-i@, fiscal and Ilis program responsibilities @re defined as ad,,-Pinisteri.ng, pILiiiiin- and coordinating progrrtt-.q activities and projects. A detailed organization c,iart is sho-.@7ii on page 112 of the -,ppli.cntion. ,E@c,-ional Executive, Pla-iinii@@,, i-Lid other Cc),,.-,iii.ttc-.'C?s The RAC has eeiftotis tr,-ter-I its willing ,ic--ept,.ince of the policy and decision-- making role ttint the defl.nitior,, of this body Is responsibilities in laxq and That Liricc@rt,@,icity as to the direction of the procrii,,i lirigered is sho@.,-ri by the continuation of the di.rectoz of the progr@i-cli Is .Cliairi@-aii of the RAC until IIov,@-riber 1969. Oi-i@thit date, lir. Robert Ogden, -i business Haiti fro,-,a qr)c'@ene and an npl)ointe"e to the RAO at its inception vias elected ch@iiriii@.n. The RAC to ti,-@et every t@7o or three mo,.iths and the Executive Conipiittee, composed of members of the PAC, m(@cts once a month. Advisory Co-@,@-Lii-ttees for heart disease, cancer, stroke and continuing education lia@,7e existed -ince the beginning of the Corr,-,Iittees or the developmental programs and cor@i@,,Liriity health rei:-vices hive riore recently been formed. These coi-ii[iitteo.,g, broadly repi.-t-.,-,entative of @ippro,@;:!..,tc di seaplanes and with adequate, di,@,;trib,,jtic)n, have met re@Uinrly and have functioned effectively in I)I.c@iiniric,. staff, revic-,@iiil-. applications for graiit@- or other @ul)port developing guidelines for care in.the area of their responsibility arid particular corrpeifctice. In the 9- Rtl 38,@04 (Al,,-1--CDN 2/71 --cl hc)c- Ul,) C)L@ T)',@j) P I,- I: of the RAC nict repeatedly to develop tiif,, IIIAL@LL _III fC) 1969-1973. Prc)visio.,-k by special- -of the Pll.'l to it fo,,: 1971-@1974 acco@ tire P\-i@C i@)js and by the E-,ecutive Co,,jii@,ii-ttec, in for pre@,ei,itiLioLi of the revised I)Iciii to the PAC for their The PAC is co,.iposed of 42 r@ic@,,7ibers qs follo-,-,s: 19 physicians of wilcim t@,7o represent Public I'l@nit'q f,t!r @,,ind- staff rc-is-i:erco' nurses both of i;ltoiii represent schools of nursinr.,; three hospital admiiii t)-,qtors; one Allied 1--,,,ealth rel)rc,,,,ientative; t@,7o Social arid ]:')Behavioral Scientists. one of rep-,:Csc-Lits a @.adic-nl school., the o,-Iie-c a Til@ii-in@Iric, for Urban disndvi.,,nta-ed; three non-healt'li professionals; teii business or r.,@ann,,cri.nl of reprec-,cnLr, ties Ui-tiv@-r.7,i.ty, three rely - c)rg,-.nizciLic;,@-i for t:ti,, Urbili and 'L' @ i f our Ilt-,, 1) 1, 1 c o- Con c3 .i t..i@r re 1: C., s C!,-t L,-,, t i vC,-., 2 or 0 f f i c il I and one slot'ttc@r" Pr 7 vLry cii p5i,,eF, 72 - 79 of tli@,.! ' 11 The proceon is broker, tt-.rec: i.@ajor areic, initial aic!i preliminary reveal, application preparation, ni-id forr@.i--il t 1. The T)ro,,,rari i@- r@.,,netc- up of a total. syct(-@i@ ethical coi-itr,)l -nd, for Of spocifi.c prograri@:@',.cd activities. Each specific pro,,rii,- @-,,ithin the n-nster pro,,raai is made up of related groups ol' acti.vit5,e@- haiiing goals and objectives. the basis for this type of I)rogrir,,i appro-,-ic,i i.-, Detailed pli-,inin, pr6,,ii(-],js for the step by step develo@pr@T!i7i'c of t:@ii operz?4tiT.-i5.-, pl.an 17i!iC't'@ the results d--,Sired over a period of Usii-ig this apprc,-.cli, a plan for iiij approved arid pro%,ie@ s t'-te )'or tt-ic pl@in and an operating p@;ii for each fL!,-)ctioiairt,, project. These plans @,7ill be used as 4piiei basis for @ictic.,ns for the prc)-rir4.i for 1971-74. This concept PI.,-,II for the total prc,@,r,,ir@i, and ol)er,)tin,,! plan for each function and each project, i7iiicti describes in clet,@il the overall goals and objectives,, the detailed activities anl schedule for each facet ind the monetary -,iiiOLI'tlt to Portion qnd part of the procr,)ril. a@iiiiin,? Peasi@bil-ity Studies: To date Core staff funds were used to carry out or participate in eight planning studies durin- the 1970 fiscal yeari These (lot,), collection aid analysis efforts were in addition to tvio inforr.,iatiot-i '-oriented operational projects and jelected data collection and analysi,4 activities in supp,,)-@-t of edtic,;ti..clial The eight studies end their as of October 1, 1970 ore: 1. Spc)7f.,@ne I-loi-fie Cn@--(2 Aid to asses,-, interest in resources of Marc! service concerning nc, d for 1-i@Eltl) to for in Co[-,-ipletecl 1970. W ingto,.-@ IA P -10- (A7,-I-Ci)) 2/71 2 . Wlii-tui,7in Survey to select i r,.-,p or t,-@ i-,iI tl t pr co I c I'll ri -Nice iu r-, I I-) ol@ i Ch t@i e I,"ii i ttq,,i n County COP could bcgin pl@-@niiiiit- for hciltli care, Co.,Tip I.c-, ted August 1970. 3. 1,@hatco@,i, Si-,a@.,it, Island Szin Ju,,iti Coi.ii@l@i Health S-.-ia.-vev - to survey of fieil.tli care for pr-',r@-nry )n(i ct@,,,2rf--eicy c@,re. cr,7plClt-e, 1-1,@ly 1970 4. BLirc,,iti. o CoL.;---ii Develo,-)ti,-?-qt Survey - to assess patterns of health care of fqr;ii.lies .predomiiintly rural region concerning the possibility of being able to supper--t both neiditio--,-i@il rti-@di,cnl oiicl the dcveloptn2lit of a COT-rl)ined exte-,ided care facility and rural area clinic. to identify the health status of the of tl,,e of I't,,irbor, resources Iricl facilities available. to rti-,et tl-,@-- needs id@iiti.fi-td in re]-,..,tion,-,hip to status,;, and to irt-vo'j.va @-i of the co.-Ice-r-..is for problci-.s of 1970. 6. Wnsni.n@to-@i State liLirsc-,,@@ A,,@t;oci,-@tion Cc;-t-itinLiin(-r, Survf! to de-terii-@n(@ pr,@ceived continuing educ,-,tio,,i need of 1-1@611,-nE,@ton State v@ui-sc!s. In process. 7. lye,-,,rt Stiz@,,c2ry - to ol)t@iin rc,-nrdi.nL-, ex,-,,-riencL- @,7itli tic-art surgery in the r@c.,.gion. On-oin,-,, subsumed under Core staff support, the of this projoct is: (1) to obtain baseline inforr,.atic).-i ,s to Morbidity and mortality of coroi.,ary, artery disease in a selected slib- region of IFI@tsliiyitc)i-i (2) the test the feasibility of P@ of obtaining such inforr,intion about all- categories of disease of concern to ttic@ throughout the Re early tare, hospital and chronic care, and rehabilitation for persons with- in each community of the Reaion, with special attention to matters of distribution, cost effectiveness and quality of care. Project 'I'@'6R - Coronary Care Unit Coordination Project This project is in the third year of its -Five-year program period ind its goal is to coordinate the actions of persons involved in the care of coronary patients through the development and improvement of cooperative networks 16 - involving cor.-iiuniti,-s in health care provides for the benefit of coronary care practice. Its objective are: 1) to i.-@Tprov(@, coitit@iuyii(,ations iii,ong persons involved in the care of coroni-r-,, patients; 2) develop and i.i,,iprove r-,",U educational programs in continuing nursina education; 3) provide support to continuing education pro-,rar@is for nurses, physicians and other related to cardiac care; and 4) evaluate data, needs and technology relatinQ to coroiary care in TI@7ashington and Alasl@a. Pro@@rcss indicators are: 1) judgment of the Cardiac Sub-Co-,T,-i,.ittc-e leased on quarterly reports and interviews -@.tith the pro4ect staff of evidence of effective and appro- priate use of project funds and personnel tirte directed to-,.7ard the ob- iectives listed in (--he operation plan; 2) 300 nurses trained; 3) 20 courses receiving, coisultati.on and I,,%f support; l@) 2'0' clinical preceptor- ships; and 5) 60 studeits' advanced course. r,@ipay-v indices': 1) loi,er Mortality rate of patients in Cl,U's; 2) decrea,,@e in percentage of units found hazardous; and 3) 'UO,O'UO units of training using CO_u workshop. Project #28 - Subre,,@i.onal Coron,73:@, Care Educational Pro@raiii. (This project has been combined T@,@ith Prolect 130 natio,,-i, for fiscal year 1971). ','his pro ect is in the middle of its second -,Tear of it s ti-2o-year proZra,,-.ct period and its -oal is to provide a beginning frarile- x.,ork For e,,.evelopL,,icnt @nd ir.--.p,@ov(-,i.-,evit of cooperative net@@,,orks x,,,itli@Ln and betijeen subreaional. coTn7-rlinit-I.es, tilei-r health care professionals, and institutions in the development of self-supportin- coi@.tinuin- nursing education, through the support iii(i coordination of subrecioiial coronary dare nurse education programs. Its are,- 1) develop and i.iTi-,orove programs and processes useful in continuing nursir,.- education: 2) implement meaningful evaluation of the pro@(,ct's impact on the nurses involved and their patient car--; 3) provide support to conti.iiuin- education programs for nurses; and A) encourage cooperation among the education centers in order to reduce the amount of direct -1@'undin,, required to continue project activities. Primary evaluation indices are: 1) 300 nurses trained; 2) 20 courses receiving support; and 'j) 175 proceptee training days. Project l'i'20 - Pe-iial and Adren@-il Ilyperteiision. This project is i-,-. the T--!iddle of the secol-id year of its tl,!O-year program period and its ob@,ective is to improve the early detection and dia(,laosis of renal and adrenal hypertension so it can be treated -,hile still curable a-id to' lo,@)e-,-- the- ass-@-.7 cost throu-ii --he use o.@ i.-Adio-iiiin!uno ass@.ys and other assays. Its oo-'.ectives are: 1) the 'for plasir.,a renin activiL-.r as -, ccr@.7i--C; 2) develop establish t,ie cli ical correlation of raclio-iT,lr,'@UnO assay of regain; 3) develop alrlosteroiie assay; establish and maintain a hypertension re-isti.-y; ar,,d 5) educate medical personnel about the advances ir- di-i-rosis And treatment of curable hypertension. Pro2ress indicators are: 1) "O additional case pickups; 2" 1500 tests aiven; and 3) 10 C> te-,tf3 110-IC f2l,-exjhere. Pripiar@ evaluation indices are: 1) 30 additional case pici-,ups; and 2) 600 bi-o-,-is--,iy tests civeii.. 0 Project #27 - A Col'Eniinity ,%Dproach to the Therapy of i,ife-Thr--@atenin@ Arr'iijthr@,,ias and Acul@p- I,,',7ocardial infarc,lion outside the This project is in the middle of the second year of its three-year program period and its @,oal is to stud,,,, the Feasibility and efficacy of Operating r;iobil.e staffed and equipped Lo h--ndle icute, potei,.L@izilly lethal. ai-rliyl--hr,-,,ias anrl to fuiietio,.-i as corc,,ii,-,ry care ut-ii.ts outside the hospital. Its objectives are: 1) operate the s,,stel-n inci assess the effect of the I,"o.)ile In- tensive,"Coron,.),r@, Care Ufnit sNrsteri in sudden death in acute Toyocar- dial infarctioii, and in other life tLlreaf@eririg. situati-o-,is for %@hich it has been utilizecl- 2) determine the feasibility a-,id efficacy of ol3eratincr a @II'CCU @;ithout i.,,r.-.,ediate attendance of a physician, utilizin- trained., experienced firer,-.en ,,ho have access to medical direction 'ijN7 radio transtiissjoti of voice and electrocardiogram; 3) study the of the local sudden death pop- ulation a,-,d Utilize triese data in -in effort to improve the @"II/CCU operation, -- of I;,Cl lu and to better define the potential val.ii this 1.1 tTJ system iTi the coning nity; 4) continue to e::pand efforts air education, both at the professional level and to the -eiieral community; and 5) secure additional funding for continued operation of the systei@i beyond Auc.,ust 1, 1970, Pro,c,,,-i-ess indicators ",re.- 1) systc-,,. capable of operatin- paramedical staff only- 2) lives saved; public response i.iiiicacea' b-,7 increased num.)er of calls; -,nd 4) establishment of quantifiable data.Pri,.-.iir-)7 Eialuatio-.i. in(.Iir-e@,: 1) system capable of operating iqith paramedical staff only; 2) number of lives saved; 3) public response indicated by increased number of calls; and 4) establishment of quantifiable data. r STP.OTIE COE@@L: Promote end en a-e in ictivities directed toi,,,ard the a--hieve-,,-,eitt of cpti-P.@al health care for all persons in the P,,egion v7ho have had or are at significant risk of suff--riii@ 'Lroin stroke and related diseases. Project i@21 - St3-ol-e Edtication-Personnel. This project is 3.n the middle of the second year of its ti,,,o-year program period and its coal is to proinote and Drov-i.de modern knowledge all,-,I skills to medical, paramedical and appropriate lay persons in order to achieve optimal health care for all- persons in 1,;'ash-@n-tori and llaska Nqlio suffer from or are at high risk of stroke and""or related disorders. Its objectives are! 1) in- crease interest. and I-,noi,,-I-edge, @nd -,ilso improve and maintain abilities of appropriate persons regarding stro.@@e and related ('tireases, 2) increace consul- tant availability in areas of need; 3) evaluate needs @ind methods of ineetinc, these needs in the region-, and 4) promote cooperation and cooperate @,7ith other P,l@iP and nor--T,.',@T projects. Proaress indicators; 1) stroke ;pecialist nurses developed and practicing in 1,c,,ion; 2) iieitrop-itholo-y technician developed c> 0 and practicirc- in P@e-ion; 3) 450 nurses trained; Z@) 50 physicians trained; 5) 200 lay people (educational proQraws) trained; and 6) 15 consultation trips completed. PriT,@:e,-@v evaluation. monetary: 1) 300 nurses, 100 physicians, and 50 lay people trained; 2) 3 consultation trips completed; 3) 1 stroke special- is@ nurse trained; and 4) 1 neutopathology technician trained. Project @,@24 - Stroke Pehabilitation rursirig Proarai-@i. This project is in t,)-- middle of the second year of its tllr-@e-year program period and its -oal is to improve strol@e patieLit care in 10,,Tashington and !ilasKa through increasi-pa knowledge and skills of IU',Ils in the area of rehabilitation. Its objectives are: 1) provide instruction in rehabilitative nursina for RN's at Good Sartiaritan Rehabilitation Center; 2) support community action in stroke rehabilitation; 3) evaluate ir.-.,pact of course on nurses and patients; and 4) determine project self-support potential, -ogress indicators: 1) 116 nurses trained; 2) 5 two-i,7eek nursin<- courses held; 3) 1 @r-ollo@i-Lip course held-, 4) four family stroke classes held; held; and 5) dcntonstrat:ed chan@e in patienl- care. evilt itior, indices are:' 1) 81,,. nurses trained; 2) 5,040 tr.-iirinc, days; and 3) demonstrated change in patient care. I Project i',@31 (,ountv Unic State Heart Assori.atio-Li Strol-,e This project is in the i,,iiddle of the seco nd year of its two-year proaram period and its coal. is to introduce -,.@-id develop the concept of restorative and rehabilitative nursing into' the. hospitals, Pitrsir,,- holes and homes of and Thurston Coui-@l:ies. Tts 07) iecL!.ves are: 1) develop s'i,:ills, attitudes and techniques in restorative and rebabi litat4ve nursing for rITls, LT.'@T I S t@ end 17@urses Aides; 2) proriot,-- the acceptance of Litilizina. the concept of restorative and rehabilitative ilursiii<,; 3) ii-,iplei-fieii'c hor,,,.e health ai.de pro,,rar,.--,s t@,7ith rehabilitation ind restorative nursin,@, emphasis; 4','F develop course for families so they may better understand and case for tiie strol.@e patient:; and 5) evaluate ii,,pecL of courses in knowledge and attitudes of students and on restorative a-..id rehabilitative nursin,, i.-Li the consulate,. Pro7-rc-rs indicators: 1) 10 I-,or,-te health aides trained; 2) 54 nursiii.,- persoi@riel trnined, 3) 72 ph@,,,;!.cia-Lis oriented-, li.) 150 participants in ii.-i-service trai,,iin-; -@,.id 5) 500 hours iii-service trairin- completed. rr4lr@.,!I-r@7 indices: _A - .- 1) 11,4 Illou-@-s didactic instruction; 2) 192 hours !,,,i)orcli:ory; 3) 60 nur S 4 -fl. p_ personnel trained 4) 500 hours itistructioti of in-service trainin-; and 5) 1.50 in-service traininy participants C!,I,TCZR PPOC-2,IJI- COAL: Promote and en-a-@e in regionally coordinated C', - activities directed tox-7ards a balanced proiyriiii for the prevention, cure and optimal palliative care of cancer, @.7liere cure air not possible, for persoiis N,jitliln the area. Project -@r'12!L', - '2,ae-@iolo-ical Physics Program. This project is in the third year of i@s four-year program period and its coal is to provide a radiological physics service to radiotherapists through the provision of accurate physical data, modern tools and corpiiuni- cation of improved techniques which fill result in better care of the cancer patient. Its objectives are. 1) create an effective or-anizat on to provide a radiological ph,?,sics service; 2) provide physical data essential for tire practice of radiotherapy; 3) provide services of benefit to patients; 4) provide radiological safety service to tire radiotherapy departments; and 5) provide devices and instruments of general use air radiotherapy. Pro,7,ress indicators.: 1) 80% of radiation therapy patients encompassed by the project; and 2) 50% enhancement of the quality of patient care by the use of the physics service indexed by the yearly increase in these services. Prirnarx evaluation indices: 1) 75% of radiation therapy patients encompassed by the project; and 2) 20% e@nancement of the quality of patient care by the use of the physics service indexed by trie yearly increase in these services. Project 21@@32 - l,ashin@-tonIt@la3 1-a Auton-ate(i Tui.)or -e i<-tr This project is in ,-lie riddle of the seco-,-id year of its t@.7o-year program period and its aoal is to provide hospitals wife Auto@,-@iated Tumor Pegistry 0 services i.,,hic,i N%iill collect, coribine, co-,Tpare a,,-,d evaluate uniformly defined RM 38 2/71.1 information on cancer patients dp-si,@neet to i!,.iprove patient care and insure proper Its ob@e-tiveo ira: 1) provide a qu@,lity s,,Isi:er-i of data collection a,.,.d file T:la2ln'ce,,lance co thit i,,Ieanin@,ful reports ire continuously producec-'!, interpreted a rid used! 2) provide effective qu@lity control of data and evaluate iiiforiii.at4-or, ]:)@j continuous trairLin,; 3) provide a fol.lo-,,l-up service for all part5.cipai@-i-ng hospitals can pror!, 'o@e and e-,tpedi.te pati.e-c@.t 'Lollo@,,-tip; I:.) provide comparative data lists for all hospitals N,,,hich n:easLire -In(.1 coi7@p@ire the quality of diagnocis aril effectiveness of vir4,ous tre,-iti,-Ienf@ @@@od,?,IiLies; 5) conduct training seuii-aars -for all tuT.,@or re@ist,-r-@r secretaries special training for Autorated T-ti.@-or !:'c-,istry pro@@.74.d(-- consultation to l-,.o@,p@,-tal i@:ith respec.': to --oiitiiiuous 1-ul.d Oi-illt assistance slio,,il(I jz av@iil,-;!)le to aDslz-.---act ciser,; 7) p,,7ov,'--@le da@@-e@ e s , @',) - -i lu 1, , t C.,. -TIOI-ir for special stuiie s-.L c 1. e .I i tj Llllet LT of cancer 4Lve of -.late in ipte-,,-I,)ret;-ve reports stration tre-ti,.eit; 'a-fiet f 0 ry! - atio-., of a Ttir.@,,or o q a '@-bruar-, actu , 1, 1971 cases 35,000 par,-icipatir- hospitals 19; 2) p--oiected Dr--ceT.,,iDer 'il, l.'@71 cases 4'),OOO p,7,rticiprttiii,- I-lo,-7tpi-tals 21. 1) actual Febri-,ai.-y 1, 1970 - cases 1.9,CjOO, ilO,';PiLal@'3 IC); projected Jzi,.i-,.-,ry 30, 1971 - cases 27,/@00, pai-ti-cipatin- hospitals 17. Pr,:GTOI,'AL MEDT(tT., PRO'7,ItM@LS SFITVICE' r)UMYil,@t@'I OT@ All OPEPATIONAL rUPP@1,EITTAL CRATIT APPI,ICATION ,(A Privileged Commnication) 17ASIIINGTON-AIASKA REGIOtaL MEDICAL PROGRAM Mvi 00038 2/71.2 500 "Ull District Building 1107 N.E. 45th Street Seattle,Washington 9810 Donal R. Sparkman, M.D. Program Coordinator: Requested Program Period lst year 2nd year 3rd year Total Direct Costs $281,803 $279.1347 $199,016 $760,166 Indirect Costs 489047 511,189 292494 1280730: Total $3299850 $330,536 $228*510 $888,896 Historv: (See History of (AR-1-CD) 2/71.1 also under consideration) Backaround: In November 1970 Council considered a proposal from the W/A/R MP termed the Kidney Disease Control Program which contained eleven interrelated ivni - onA education parts in four msior areas: administration; transplantation: kav it The Council noted that the State of Washington has a well-known renal diseases center in Seattle and that the application reflected a coalition of proposals from renal diseases experts from both Seattle and Spokane, the only two densely populated areas to be served by the program. It appeared to the Council that the plan in this application had been developed by the renal experts with little input from the RMP core staff. In a sense, the full-blown plan seem to be imposed on the r44P. The application included considerable detail about the eleven individual proposals, but it failed to provide any analysis of the options available in planning kidney service programs in this type of geographic area; i.e., the cost of relocating and rehabilitating patients in center population area as compared to diffusing services transplant to areas; or information on the distribution of potential receipients. The program proposed to serve the Mountain States RMP as well as Washington and Alaska and coordinators are requested for both Seattle and Spokane. The Council questioned the need for the two full-time positions. The necessity of a medical advisor was questioned when consultants and advisory groups are available. Many of the activities have merit, some seem questionable for PMP support, some seem questionable from a scientific viewpoint , and several seem unnecessary, The clinical training activities appeared to have merit. In the absence of regional alternative priorities for the renal program in the area, the inclusion of several debatable activities and the expectation that this RKP with its strong RAG, capable core staff and a well-known pool Page 2 - R", Summary of,an Operational Supplemental Grant Application of renal diseases expertise should present a more realistic funding request,, the Council concluded that no additional funds should be provided at this time The Council, however, expressed interest in reviewing a less diffuse renal diseases program that focused on clearly-delinaated high priority areas of need for the Region. Present Application: This is an updated revision of theor@ginal. proposal. In modifying the original request, two principles have been followed. (a) re- sources have been allocated only to those areas of highest priority and (b) maxi- mum possible use has been extracted from existingresources. Accordingly, some of the originally proposed activities have been deleted and others re-oriented. ;The budget has been reduced for each year as follows: el- from $858,501 to $281,803; 02- from $824,253 to $279,347; and 03- from $627,016 to $199,1016. The areas of hig eat priorities have been identified as: (1) the institution of capability for coordination and planning at the regional level, (2) the expansion of transplant resources and (3) the evaluation of dialysis techniques and equipment. A synopsis of each of the 11 parts originally proposed and major modifications follow. The figures in parentheses are the originally requested amounts. Project #41 - Regional Administration - This aspect of r@ovoial would-a-ii an associate director for-Kidney First Y@@, disease to the 14AR.MP core staff and a kidney coordinator for the Request-@-...,., Mountain States RIP, as well as other staff, to assure continued ($112,170 coordinated planning and implementation of the kidney disease program. 57,200 Second Year -($119,232) Third Year - ($126,550) 712145 76)590 .,@P41 Changes - Budget reduction. The administrative structure envisaged as originally proposed with moderate reduction in personnel and operating budget. Project IP42 - Regional Tr ansplant Program - The four activities included in this area of the program are all interrelated. The Tissue-Typing, Host- Graft and Professional Transplant activities are designed to increase professional and technical capability and distribute it among the major medical centers in the Region, as well as provide direct service to all ireas. The Donor- Organ Retrieval System will involve ten or more Regional centers in supplying cadaveric organs. #42 Changes - The Host-Graft Project (42D) will be deleted as it is still in the early developmental stage and will not have assured impact on cost of care. Pro_iect f@42A - Regional Tissue-Typing Laboratory - This project will First Year be directed by Dr. E. Donnal Thomas at the Public Health Service ITos- Request .,. pital in Seattle. The facility that the Public Health Service lios- (464,20;.@', pital has now, is primarily intended for research and cannot provide Page 3 - RMP, Summary of an Operational Supplemental Grant Application tiss,je-typing service for an augmented transplant program. It is necessary that tissue-typing capability be developed outside to provide services for Seattle to extend the time coverage and to reduce the costs. The funds requested would permit this facility to expand its operation to provide these services. In addition, they will determine the feasibility, economics . and efficiency of expanding the tissue-typing capability using one of two possible approaches, a central typing facility or blood banks. Four technicians will be trained in the course of this project each year; two from the facility at the Public Health Service Hospital and two from the Regional Blood Bank. Second Year ($68,380) Third Year - ($10,000) 7,537 -o- #42A n es Budget reduction. Funds requested only to maintain activity at its present level. Project #42B - Regional Organ-Donor Retri - This aspect First Year of the program will be directed by Dr. He, ff in the Depart- Request ment of Medicine at the University of Washington. This program will ($32,588) @develop a plan for Regional network for the harvesting and transportation 41,938 of cadaveric kidneys, train one or more surgeons in cadaveric kidney removal And preservation techniques in each of ten major medical centers within the Region, operate a r6gional donor-organ retrieval system,, and coor- dinate development of the donor-organ retrieval system with the development of the tissue-typing laboratory And expansion of the transplant program. A start has been made on setting up this system in Spokane. In addition, nine other medical centers will be involved in the program - Tacoma, Bellingham, Bremerton, Yakima, Wenatchee, Boisei Billings, Anchorage and Olympia. Second Year ($29,695) Third Year ($1,000) 37,932 631 500 @4@42B- Changes - Budget increase. Change in personnel. Project #42C - Professional Trans@arnt Capabili@ - The director First Year of this activity is Dr. Thomas Marchioro from t e Department of Request Surgery at the University of Washington. Specific objectives of this ($589700) activity to increase the professional transplant capability are to 20,950 recruit an additional full-time surgeon to work with the surgical transplant team, to provide one year training in transplantation surgery and to provide one year training program in immunology to two physicians. This project in interdigitated with the Professional Education Project - #44. Second Year (#58,995) Third Year - ($44,606) 7,860 -0- #42C - c@ e - Budget reduction. Original @proposal scaled down. Page 4 RKP, Summary of an Operational Supplemental Grant Application Project #42D - Determination of Host-Graft I.n.t.--rrelationship@ - First Year This project will be directed by Dr. Gary Striker, Department request of Pathology at the University of Washington. As a means of ($4.9,000) increasing the life of Renal transplant patients, this activity -0- will focus on increasing the knowledge of physicians on the use and interpreta- tion of the technique for detecting the blocking serum substance. Three months' training will be provided for four physician trainees. The trainee physicians will be the surgical transplant trainee, the immunology trainees and the nephrology trainees who are enrolled in the Professional Transplant and Professional Education projects. In addition, technicians being trained under the Regional Tissue-Typing Laboratory Project will also receive special instruction. .Second Year ($29,663) Third Year ($24,637) -0- -0- ,@42D CompletL-lY deleted. Project #43 Regional Dialysis Program - Five distinct activities are proposed to improve the quality of dialysis care and the system of delivering care to the patient. @r43 @hanges - Assessment of needs for following cases (43C) has been deleted, eritorial dialysis evaluation (43E) combined with Equipment Evaluation Project (43D) Project #43A - Kidney Failure.RegistIZ - This project will be directed First Yr. by Dr. F. Kingsbury Curtis, Chief, Dialysis Unit,, Veterans Administra- Request tion Hospital, Seattle, Washington. ($62,450) 311700 This will eventually collect data from all three - post - transplant and dialysis patients in the Region, thus involving physicians in local communities as well as those in treatment centers. It will develop a c6m- puter system to be used as a control data collection system for both transplant and dialysis aspects of the program. Second Year - ($108,695) Third Year - ($103,2 5 37,870 419257 43A - Changes Budget reduction in personnel time, consultation, and sub- contracts. . Project #43B Evaluation of Home Dialysis Patient Training_- First Year This activity will be directed by Dr. Tom Sawyer of the North- Request west Kidney Center in Seattle. The Eastern-14ashington/Montana/ ($110,140) Idaho Artificial Kidney Center in Spokane will also be involved. 432075 Page RMP, Summary of an Operational Supplemental Grant Application This activity will focus on evaluation of the present procedures for training home-dialysis patients, a revision of the curricula and testing of new approaches based on the evaluation and development of a final training package. This is noted as a great need for the country as a whole. Second Year - ($84,155) Third Year - (-O-) 40,108 -0- @1,43B - Changes - Budget reduction in personnel costs, supplies and equipment. Project lP43C - Assessment of Needs for Follow-Up Care in the Local First Year Commni@- The project-director will Be Dr. -Jerry fendras, 7)irector, Request Northwest Kidney Center, Seattle. The Eastern Washington/Idaho/Montana ($70,663) Artificial Kidney Center in Spokane will also participate, -0- This activity is desig-.ied to quantify the needs for follow-up on a systematic and defensible basis,, to identify personnel who should deliver care and to design and implement a pilot project to deliver the follow-up care needed by dialysis And transplant patients in their local communities. Second Year - ($859503) Third Year - ($93,933) -0- -0- #43C - Changes - Deleted Completely. Project -@43D - Evaluation of New Dialysis Equipment and Techniques First Year Dr. James J. Cole, a Nephrologist in the Department of Medicine at Request University Hospital will direct this project. The Eastern Washington/ ($89,950) Idaho/MontAna Artifical Kidney Center in Spokane, the Veterans 32,400 Administration Hospital and the Northwest Kidney Center in Seattle will also participate. This activity will evaluate dialysis equipment in laboratory, clinical, and home settings, will develop performance criteria for consideration at regional standards, will develop pre-test for personnel to be administered before they use the equipment and to assist the manufacturers in improving their equipment design and standards of quality control. Second Year ($94,845) Third Year - ($100,230) 35 780 -0- I Project Y@43E Demonstration of New Eqx4iEment and Techriques for Home First.Year- Peritoneal Dialysis anA-Te6ting Its Ro e in the Mnnagement of Request Chronic Renal Failure. This activity wiLl-be directed by Dr. Henry ($94,850) -Tenckhoff, Department'of Medicine at the University of Washington, who -0- also directs the Regional Organ-Donor Retrieval System under the Transplant Program. This activity will investigate the feasibility of long-term peritoneal Page 6 - lU4P, Summary of an Operational Supplemental Grant Application dialysis based on a newly developed home fluid supply system in a variety of situations on a variety of patients. Training in the new techniques is also planned for physicians and,other medical personnel. Second Year ($290550) Third Year - ($35,470) -0- -0- 43D and 43E ChanjXes - Budget reduction. It is proposed to maintain evalua- tion activities in the Peritorial Dialysis project (43E) and combine this administratively with the Equipment Evaluation Project (43D) Project iP44 - Regional Education ram - Dr. Christopher Blagg, First Year Nephrologist from the University of Washington Hospital, will Request direct the program. It is related to the other aspects of the ($113,790) program, Regional Transplant and Regional Dialysis. It consists 47,415 of the following parts: (1) Clinical Traineeships - one-year training in transplantation surgery for one surge on each year; one-vear training in transplantation immunology for two physicians each year; one-year training in clinical nephrology for one physician each year; rotating training of two to six physicians each year to take a two to six month training in clinical nephrology; and four three-month training program in medical nephrology for "appropriate" urologic trainees each year. (2) Coordinated Continuing Education Program for physicians, nurses and dialysis technicians and it will include development of ten film strips, three TV shows, a traveling circuit course for eight communities in Washington, Alaska, Idaho and Montana, distribution of quarterly bulletin, and the support of trcvel expenses for consultations and continuing education for all types of personnel involved. Second Year-($115,540) Third Year - ($87,325) 41$1115 37,050 #44 Changes Budget reduction. Clinical traineeships have been eliminated. @lso, budget for continuing medical education activities has been reduced. Project will draw more heavily on the Education and Support Unit of Tel/A@@IP. GRB/12/29/70 T120 i- k 14 Al 7Z All 'Rpivc@4 0 1 co@ 9 9,/,4 6 7AL 5-0 (90,;ZY'3) @6 73@) (@3 4) - TITAiLl S PKAAJ 6 0 Oa 7, I- -317 7 -2,P,9 3 1.2S 7 3.3 79. @/, zs 7 @7@@Ill 116,i?-27 4'3 A - 7 4,/f 33 w-u 7L. V,9 41 -?,r- - t4r, I /.Z YFIO I'/,/ ',9 ( @7 @/@ / // y @',/ ",) -,) IF @; @ ( 3 7, O_X61 -@'- @'@ @) @V41 - @ .3 ;"/ f ) ,OOCA 7-1 t) tv ?@ 0-6 ) @ - (A Privileged Communication) SUMMARY OF REVIF-VNT AND CONCLUSION OF TANUARY 1971 REVIf,,Iq COI%IITTEE WASHINGTON/AT,ASKA REGIONAL MEDICAL PROGRAM @l 38-0/4 (AR-].--CD), -2/71 1 FOR CONSIDERATION BY FEBRUARY 1971 ADVISOII@Y COUNCIL RECOBDIENDATION: Committee recommended that this application be approved and additional funding provided as requested. F@IDING RECO@S,',IENDATION DEVELOPMEN'EAL YEAR COMPONENT OTHER TOTAL --7 Ist @120,000 $1@5921144 $1,712,14@.@'2 2nd 156.%OOO 1,633,735 1,789,735 3/ I/ (Difference between this fi-ure and total shown on summary for 04.year Q represents an additional 8,929 recommended by staff as part of continuation application.) 2/ (includes $1,512,379 continuation bud,-et recommended for I prov al p by staff.) 3j (Includes $1,596,935 commitment for Core and 6projects.) The Committee noted that this application had not been site visited since the Region had been subjected to two major site visits in 1969. The last site visit in October 1969 placed primary emphasis on program rather than project review. In the case of each site visit, significant progress toward the development of a mature Regional Medical Program was noted. The reviewers, inclu-ding an individual who had served as chairman of the last visit and as a member of two previous visits believed that this application substantiated the extremely positive report of the October 1969 site visit. There was no doubt thit this Region has reached a very mature stage of development. Some reviewers believed that the Committee would no longer have a function if all Regional Medical Programs were as strong as the W/ARMP. RMPS/Gl@ 1/19/71 (A Privileged Communication) STJi%ZIAP,,Y OF REVIF,$L AND CON@CLUSION OF JI@NUARY 1971 REVIL@L@ COyi,@IITTEE IqAS[Il@,IGTON/AIASI@ REGIO@\TAL @TEDICAL IIPOG@kL%l @'4 38--04 (S) 2/71.2 FOR CONSIDEfj@TION BY FEBPU,@RY 197i ADVISOE@Y COUNCII, RECOI@'@@IENTDATTOY@: The Corimittee recommended additional funds for this application pending a favorable revi.e-,,7 by the ad hoc Advisory Coiimittee on Kidney Disease Grant Applications YEAR y-') dco. RECOiqMENDED o Ist @281,803 $281,803 2nd 279,347 279,3 7 3rd 199,016 199,016 Total $760,166 $760,166 CRITI The Committee believed that this u dated revision of the, p original proposal adequately responded to the major concerns raised in Corniaittee's previous review. It was noted that the budget has been greatly reduced and the revised proposal clearly delineates 'high priority areas of need for the Region. RMPS/GRB 1 19 71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) WESTERN NEW YORK REGIONAL MEDICAL RM 13-04 (AR -ICDS) 2/71 PROGRAM January 1971 Review Committee 2929 Main Street Buffalo, New York 14214 PROGRAM COORDINATOR: John R.F. Ingall, M.D. Request (Direct Cost Only) 04 Year 05 Year 06 Year Purpose 3/71-2/72 3/72-2/73 3/73-2/74 All Years Continuation No No Component $1,029,472* Commitment Commitment $1,029,472 (Core) (379,234) (4 Projects) (650,238) Renewal Project 171,516 174,304 177,236 523,056 Additional Components 1,078,517 869,740 646,777 2,595,034 (Developmental) (118,116) - - (118,116) (4 Nei%, Projects Anniv. Appl.) (495,608) (434,990) (291,555) (1,222,153) (2 New Projects Deferred Appl.) (276,885) (234,227) (241,957) (753,069) (3 Approved/ Unfund- ed Projects) (187,908) (200,523) (1139265) (501,696) TOTAL $2,279,505 $1,044,044 $824,013 $4,147,562 -Staff Action on Commitment $1,029,459* Committee Action Required $1,250,033 $1,044,044 $824,013 $3,118,090 *The 04 Year Commitment for these activities is $1,029,459. Funding History (Planning Stage) Grant Year Period Funded (d.c.o.) 01 12/66-11/67 $117,026 02 12/67-11/68 $271,185 Western New York - 2 - RM 13-04 (AR-lCDS)'2/71 (operational Program) - Council Funded Future Grant Year Period Approved (d.c.o.) Commitment 01 12/67-2/69 $615,015 $615,015 ------ 02 3/69-2/70 1,445,545,1 1,340,76 ------ 92/ 03 3/70-2/71 1,663,777@/ 4 ,, 1,667,67 04 3/71-2/72 1,383,29@' $1,029,459 05 3/72-2/73 124,78 1/Does not include $250,000 for approved/unfunded regional dialysis program. 2/Includes carryover funding of $486,512 GEOGRAPHY AND DEMOGRAPHY The Western New York Regional Medical Program until recently was composed of eight counties (seven in western New York and one in northern Pennsylvania), but during the last year a second Pennsylvania county has been incorporated into the WNY program, bringing the total number of counties to nine. The largest town in McKean County, ia (the recent addition to the Region) Pennsylvan , is on the New York border, and has a referral pattern dominantly to Buffalo. The Region is bounded by Lake Erie to the west and Lake Ontario to the north. The counties to the east of this Region traditionally have looked to Rochester for medical care. The approximate'population of this 8,200 square mile Region is 3,002,000, and it is primarily urban and white. The two metropolitan centers of Buffalo, New York and Erie, Pennsylvania account for around 750,000 of the total population. The area is served by 57 short-term hospitals with 8,800 beds, four VA hospitals with 3,100 beds, and two state tiospitals.with nearly 6,000 long-term beds. There are 2,661 physicians, 8,525 active and 4,550 inactive nurses. Major facilities include SUNYAB School of Medicine and Roswell Park Memorial Institute, as well as 15 schools of nursing (four degree-granting), six schools of medical technology, one school of cytotechnology,.eight schools of X@ray technology, and one school of pharmacy. HISTORY OF REGIONAL DEVELOPMENT Regional planning was instituted late in 1965, and in the Spring of 1966 a formal planning application was submitted with Dr. Douglas Surgenor, Dean of the School of Medicine at SUNYAB, as interim program coordinator. Generally, the application was received enthusiastically by the reviewing bodies, although there were some questions revolving around the lack of program evaluation and the lack of relationships among the six planning projects which were proposed. After problems regarding the legality of the Health Organization of Western New York (HOWNY) were resolved, a planning award was made in December 1966. Western New York - 3 - RM 13-04 (AR-lCDS) 2/71 In the Spring of 1967 Dr. Ingall became the program coordinator. A planning supplement application later in the year requested funding for new activities and instigated a February 1968 site visit to make a determination as to whether the Region was entering, or should enter, its operational phase. The site visit team reported that the concept of regionalization was recognized and accepted by representatives of all of the counties, that RAG representation was well-balanced, that cooperative arrangements appeared to be substantial, and that administrative procedures were being developed. There was, however, little evidence of a unified approach to priority setting or identification of regional resources and needs. There was agreement that the Region should achieve operational status and An operational award was granted in March 1968. During the nearly three years since its first operational award, the Western New York Regional Medical Program has submitted project applications with regularity. Although there have been two technical site visits, program considerations were not involved, and the Review Committee and the Council have kept in touch with this Region primarily through its applications. Nearly every review body evaluating one of these proposals has commented on the diversity of interests and the wide spread of ongoing Regional activities. Of the four projects for which the national review bodies have recommended disapproval (in the areas of poison control, medical genetics, mass media in ormat on to ghetto residents, and atherosclerotic disease) in three instances the negative recommendation was prompted by the questionable,categorical relevance of the proposed activity. The 03 year award of $1,667,674 (which includes $486,512 in carryover funding) is supporting the following activities: Core Planning and Administration $435,902 Telephone Lecture Network 181,053 Coronary Care 168,152 Chronic Respiratory Disease 638,879 Immunofluorescen(:e Service & Training 34,590 Test of Continuing Education Techniques 38,190 Tumor Registry ' 63,794 Topical Chemotherapy for Pre-Cancerous 47,4 -) Lesions and Cancer of the Skin 54 Funded entirely information Dissemination Service 31,960 @ through carry- Regional Coagulation Laboratory 27,701/ over & rebudget ing There is, in addition, on the books an approved but unfunded regional dialysis program. Western New York - 4 RM 13-04 (AR-l,CDS) 2/71 ORGANIZATION AND REVIEW PROCESS LIT.-'GIO,@Al, ADVISOfl@Y GIZOUP -rS COUNIY CO't@',I'rri.. .County Coi-.ulittec- !BOA'.ZD 01@ "iooil Ol.? :Liaison OF H.O. D.Y. S.U.N.Y.A.B. ,Telel,ho,.Ie L4,.cLtire rsonnql a:id a iarf !-,ic-Tit ,Bi-isiness l-'@e [,As s-o- -c- i ae -.'.-)Lrector G:I.@@i'r D-- 'T :VI, _Jnr". A ir) Also "V'),Cll; IC.IT.P The above diagram, prepared by the Region, indicates the functional and organizational interrelationships that exist within WNYRMP. Solid lines indicate lines of authority. Dotted lines indicate specific channels of communication. The Anniversary Application states that this chart is intended to show: the effort within WNYRNII that is given to maintaining lines of communication between the RAG and the Director; the increased regional responsibility for program planning and translating evaluations and research into grant development, manpower development, and management; and the specific RMP staff linkage that has been established with CHP Western New York - 5 - RM 13-04 (AR-lCDS) 2/71 The Regional Advisory Group (Health Organization of Western New York -- HOWNY) is composed of nine county committees, ranging in size from nine to 78 members each. The total membership currently is in the neigh- borhood of 300. The executive body of the RAG is known as the Board of Directors of HOWNY. The Board has 29 members: nine representing the county committees, nine the county medical societies, with the remaining membership representing CHP, the health departments, Hospital Association, the University and Roswell Park. There are, in addition, three members chosen to represent the interests of urban minorities. The Board of Directors is the final arbitrating body of the RAG. The standing committee structure has been expanded during the last year to include groups on rural health manpower, telephone lecture network, evaluation, and health happenings. These are in addition to the previously existing committees on proposals, by-laws and constitution, coronary care, cancer, stroke, dialysis, and pulmonary planning. The WNYRMP sees one of theprimary benefits of the review process as its value as a continuing education experience for all involved. New project proposals receive preliminary review by the county committees before being received by the Proposals Committee. The Proposals Committee (often with outside technical assistance and reviews by the State Health Departmenti county health officers, University Department of Social and Preventive Medicine and others) provides a technical review and forwards the project and its report to the Board of Directors. The Board is vested with final decision-making authority. The Board recently has been looking at ways in which it might alter its review process in light of the annual review concept, and is considering the institution of site visits. It is thought that in addition to allowing a continuing reassessment of ongoing activities and priorities, site visits could involve consultants from throughout the Region and strengthen the regionalization process. Other changes contemplated include the establishment of a chronological priority rating system And the introduction of quarterly review of the grand design. The core staff includes 13 professionals, all but one full-time. The Region has been unable to fill a long-vacant slot for Associate Director for Epidemiology, so this position is no longer budgeted. The organization chart outlines current staffing patterns. The core staff pictured in the anniversary application is reflective of the emphasis the Region places on its role as broker/facilitator/enablihg agency. REGIONAL OBJECTIVES The Region has developed a grand design, outlined in the Regional Advisory Group report. It is described as a fluid plan which permits easy revision in response to changing needs. Three overall program objectives have been identified: 1. Accessibility to medical care. 2. Quality of care. 3. Economy in the delivery of health services. Western New York - 6 RM 13-04 (AR-lCDS) 2/71 In addition, thirteen policies are described. A policy is defined by the Region as a strategy for achieving program objectives. In brief form, the policies deal with: the development of specific relationships; increasing manpower resources and their effectiveness; correcting the maldistribution of health resources; upgrading abilities of health personnel; improving access to specialized diagnostic and treatment centers; developing ambulatory care facilities; developing comprehensive rehabilitation services; improving continuity of care within-the Region; assisting physicians with information and services; encouraging projects of patient education; promoting areawide planning and coordination of health services; and improving the management of health problems of the aged. As the Region moves away from project planning and toward total program planning, it will need constant baseline data for the definition and re-definition of Regional problems. The increased planning capabilities on core staff, the hopefully strengthened abilities of CHP (it is now apparently in a slump from which WNYRMP is helping it rise) and the information gained from the Information Support System (supported by an RM?S contract to the Harvard Center for Community Health and Medical Care) are expected to be of help in this regard. The Board of Directors apparently has not yet developed a system for the priority ranking of objectives. Neither have priorities been assigned the new projects in the Anniversary Application for which supplemental support is being requested, although on- going activities are ranked according to their importance to the Program as viewed by the Board of Directors. PRESENT APPLICATION Continuation Components: The Region is requesting its final year of commitment for the continuation of five components, in the following amounts: Core $379,234 #2-Coronary Care 121,237 #3-Respiratory Disease 439,962 #4-Immunofluorescence Service 35,359 #10- Tumor Registry 53 680 TOTAL CONTINUATINN REQUEST $1,029,472 The continuation request will be reviewed by staff, and its recommenda- tions will be the subject of a separate supplemental memorandum. Terminal Reports: Final progress reports for Project #6 - Nuclear Medicine, and Project #7 - Test of Continuing Education Tec n ques, are presented for information purposes only. No further RMP funding is requested. Western New York - 7 RM 13-04 (AR-lCDS) 2/71 Renewal Component Requested Fourth Year Project #1 - Telephone Lecture Network. Renewal $171,516 support is being requested for the fourth, fifth, and sixth years of operation of the Telephone Lecture Network. Although the primary objective of the network is stated to be the provision of continuing education programs to all persons involved in the delivery of health care, it has found wide use by the core staff and Coordinator as an easy access to the health community of the Region, especially for surveys, meetings, regional conferences, etc. It also is used for meetings of the Board of Directors and various committees. In addition to the regular lecture series, the network is helpful to other ongoing activities: it is used occasionally by the Respiratory Care and Immunoflourescence projects,and it is a necessity to the operations of the Coronary Care Program and the Information Dissemination Service. It has been used for presentation of courses in Spoken English for foreign medical personnel and is used regularly by a community group, Parents of Diabetic Children. This project is considered to be the number-one funding priority by both the Coordinator and the RAG. It is seen As a most successful vehicle for regionalization. The Telephone Lecture Network connection has expanded from 36 to 60 separate locations throughout the Region and two counties outside the geographic boundaries of the RMP. Fifty-three of the receiving units are located in hospitals. Since its inception, over 300 specially-designed educational programs have been presented over the network. A survey is currently under way through which the staff can more thoroughly evaluate the effectiveness of the program and determine the extent of financial support that can be expected from participating institutions (the monthly contribution now is $20). Other avenues of support for the network are being investigated as well. It is stated that the development of a self-support mechanism for the network is of foremost concern to the Region. Fifth Year: $174,304 Sixth Year: $177,236 Requested Additional Components First Year $118,116 Developmental Component: The Anniversary Application explains that the developmental component is fundamentally problem-oriented and ultimately will be shaped by the definition of crucial problems in the receipt of adequate health care. This will involve an examination of new settings for the delivery of health care, new organizational and inter-professional relationships, and new roles for allied health personnel. Although the developmental concept is of an innovative and comprehensive nature, the Region already has identified certain specific areas in which such monies might be put to use: Western New York - 8 - RM 13-04 (AR-lCDS) 2/71 1. Definition of reasons for spiraling health care costs and measures to curtail them. 2. Inquiry into medical care patterns and self-administration of medicine in the area of diabetes. 3. In association with other concerned agencies, definition of the problems of the underprivileged. 4. Work toward better communications among, and increased social consciousness of, health care planners. The Region intends to apply its developmental monies evenly throughout the first three quarters of the budget year. A priority system will be established, and judgments on distribution of funds will be made by the Board of Directors at intervals during the year. This request is for a developmental award for one year only, to coincide with the remaining year of core commitment. New Projects - Anniversary Application: This Anniversary Application requests support for the initiation of four new projects. The application states that the RAG sees these proposals as consistent with current priorities viewed in relation to the grand design. Project #20 Regional Bone Pathology Laboratorv. The Requested First Year major objective of this proposal is to improve the care of patients with bone diseases by $64,453 establishing a Regional Bone Pathology Laboratory at SUNYAB which will facilitate the diagnosis of musculoskeletal disease by evaluation of the bone biopsy or resected specimen. The consulting service will be aimed at the diagnosis of a wide Spectrum of bone diseases, and there will be no charge to the patient, physician, or hospital. In addition, training programs are planned for private physicians and the house staffs of hospitals for the purpose of instruction in the management of bone conditions in their patients. The Telephone Lecture Network will be used for conferences and seminars. Final y, a regional bone tumor registry will be established in order to assess and improve current treatment. The proposal states that in three years, if the project has demonstrated its effectiveness, support will be sought from county and state health departments. Second Year: $48,398 Third Year: $49,567 Requested Project #21 - Choriocarcinoma and Related Trophoblastic First Year Disease. This request essentially is for $50,856 RMP assumption of support for a Trophoblastic Neoplasia Center established in 1967 by SUNYAB and Roswell Park under a USPHS grant. Grant support was scheduled to continue until 1973 but was discontinued prematurely in September 1970. Although no charges Western New York - 9 - RM 13-04 (AR-lCDS) 2/71 will be made, the project directors hope the diagnostic services of the laboratory will become self-supporting within the next three years by instituting a schedule of reasonable charges. The purpose of the Center is to provide area physicians the means for diagnosis and follow-up of patients with trophoblastic neoplasia, provide consultative services on treatment, educate young physicians in the management of the disease, and conduct research to improve diagnostic methods and treatment. In addition the high-risk population (which is calculated to be 3,000 in the WNY Region) will be screened annually. Second Year: $52,795 Third Year: $54,830 Requested Project #22 - Comprehensive Continuing Care for Chronic First Year Illness. This project will be located at $175,625 the E.J. Meyer Memorial Hospital in Buffalo, where a preliminary and small-scale program has been in operation since 1968 to develop a more coordinated approach to the care of patients with chronic diseases. Building on that base, this project will develop a model demonstration program ( using multidisciplinary teams) which will afford comprehensive, continuous care for chronically ill patients, whether in or out of the hospital, and will incorporate into the program the unique resources of a major university teaching hospital. Particular emphasis will be placed on patients who are economically deprived. Educational opportunities for physicians, nurses, social workers, and allied health personnel will be provided. The program will be evaluated to determine its efficiency in improving t e quality of care, reducing hospitalizations, improving compliance with treatment regimens, reducing disability, and changing patient and health worker attitudes, as well as to ascertain the costs of such a program compared to the costs of traditional treatment. Second Year: $183,587 Third Year: $187,158 Project #23 - Planning of a Computer-Based Health Data Requested System. This two-year request is for the First.Year development of a detailed master plan for a health data $204,674 network for the Western New York Region. Educational programs will be designed to acquaint health professionals with the capabilities and restrictions of the data system. Also, a systems analysis will be conducted to determine current data handling practices, standardization of these practices will be sought, and the data needs of each user will be defined. Finally, small-scale field trials will involve placing experimental terminals in two hospitals, one large nursing home, one health department, and the offices of five practitioners. During these trials, experience will be gained as to the volume and nature of input-output requirements, acceptance by users, problems of confidentiality, Western New York - 10 RM 13-04 (AR-lCDS) 2/71 acceptable turn-around time, cost/information assessment, and other issues which wourd affect the design of the general plan. Once the full-scale operation is attained, every effort will be made to switch from external fund support to a self-supporting operation. Second Year: $150,210 New Projects - Deferred Application: Two projects received recommendations of deferral from the November 1970 Advisory Council, although the Review Committee previously had suggested a recommendation of @ipproval with no additional funding, and with the condition that no RMP monies be tunnelled into Project #19 because of its inappropriateness for FM support. In reviewing these two proposals, both Committee and Council had difficulty determining the relationship of project goals to Regional priorities and objectives, primarily due to an absence of a description of the Region's overall plan as well as the amorphous nature of project goals. Requested Project #18 - A Model Program for Comprehensive Family Health First Year The major objective of this project is to $170,977 demonstrate the efficacy of a multidisciplinary team approach to the provision of excellent primary medical care to a representative cross section of society. The Deaconess Hospital of Buffalo, the sponsor of the proposal, has established a Family Practice Center with a director, staff, including seven residents, and a waiting list of patients. FM support is requested for those portions of the program related to community health nursing, medical social work and nutrition, and to study the application, utilization and correlation of these disciplines as applied to ambulatory patients. Funding is not requested for the service component or the residency training aspects. The development of the family practice model at the Deaconess Hospital will emphasize the four parameter of demonstration, education, research, evaluation and assessment, and service. Second Year: $138,310 Third Year: $142,406 Requested Project #19 - Prevention and Treatment of Respiratory Distress First Year Syndrome Due to Hyaline Membrane Disease in $105,908 Infants. The proposed project will be located at both Children's Hospital of Buffalo and the Roswell Park Memorial Institute. A study has been conducted in the use of urokinase activated human plasmin in infants with respiratory distress syndrome. Results of the study indicated that in the plasmin treated group there was a doubling of survival time, while in the sub-group consisting of those whose birth weight was two kg or less, plasmin therapy tripled survival rate. The purpose of this project is to extend the benefits of this study to all infants in the region. Two independent studies are planned: Western New York RM 13-04 (AR-lCDS) 2/71 1. Prevention of respiratory distress syndrome with plasminogen. 2. Treatment of respiratory distress syndrome with streptokinase activated plasmin. If studies are successful, plans call for the introduction of these methods to all hospitals of the region which would be handling such I.nfants. Second Year: $95,917 Third Year: $99,551 Approved/Unfunded Projects: These three activities received approval from previous Councils but have not been funded by RMPS. This year, however, project #'s 13 and 14 were initiated by the Region with carryover funds and project #16 through rebudgeting of basic grant funds. Consequently, these activities have no future commitment. Requested Project #13 - Topical Chemotherapy for Precancerous Lesions Second Year and Cancer of the Skin. This is a proposal $49,631 for a program to provide community physicians a recently- developed technique of topical chemotherapy for the prevention and treatment of precancerous growths (solar keratoses) and cancers of the skin. The program was planned for three phases: I. Developing an operational system for implementing, co- ordinating, and evaluating the program. II. Professional e ucat on. III. The actual operational phase during which topical chemo- therapy will be performed as a treatment method. Phase I was aided greatly by the Buffalo-Rochester Dermatologic Society which supported the project and formed a liaison committee for this activity. Phase II has been initiated and is progressing smoothly. Although PhaseIII will be deferred until Phases I and II have been completed, a number of physicians who have specialized training and experience will start this operational phase on an exploratory basis. This will provide information to guide the general implementation of Phase III. The two further years of support requested are consistent with the second and third years of support recommended by the December 1969 Advisory Council. Third Year: $52,180 Requested Project #14 - Information Dissemination Service. The Second Year objective of this program is to es- $38,275 tablish an information dissemination service to prov e the physician and other health professionals with printed information from a broad spectrum of medical and scientific journals and books and to alert them to new developments in Western New York - 12 - RM 13-04 (AR-lCDS) 2/71 their field of interest through a current awareness service. The Telephone Lecture Network is the communication link used in this activity. The Health Sciences Library at SUNYAB is designated as the resource medical library. To date, 34 of the 53 hospitals in the telephone lecture network system have received orientations as to the services offered through this project; meetings have been arranged with the remaining 19 hospitals. Personnel at each participating in- stitution are designated to channel requests to the resource library. As of July 1970, 72 requests for services had been received and filled. It is hoped that ulitmately the information dissemination services can be supported by hospitals and the local medical societies. The requests for second and third year of support for this project are approximately $6,000 in excess of the amounts approved by the November 1969 Review Committee. Third Year: $39,515 Requested Project #16 - Reeional Coagulation Reference First Year This proposal originally was submitted to $100,000 the February/March 1970 review cycle as a request for the establishment of a blood coagulation reference laboratory- which would have training, service, and research,components. Roswell Park Memorial Institute had been providing some free services in this field, but increasing community needs and decreasing funds for Roswell Park prompted the submission of this proposal. After a technical site visit, the June 1970 Review Committee recommended that although the goal of having a reference and standardizing laboratory was an excellent one, the rest of the teaching and service aspects should be diminished to concentrate only on the training of technicians from outlying hospitals to perform coagulation tests. It was thought that a first year budget of $60,000 and second and third year budgets of $40,000 each would be sufficient for such an endeavor. The subsequent Council agreed, but expressed its willingness to allow the Region to increase the funding of this project to a maximum of $100,000, providing such a level of funding would be required to maintain this valuable regional resource. In September 1970, after assurances that the laboratory was developing in the direction of training technicians rom outlying hospitals, the Region received permission to rebudget $27,700 into this laboratory to retain trained staff personnel until the end of the current budget period. At the time the progress report was prepared, three technicians were receiving training, schedules were being established for two physicians, blood coagulation studies were being carried out, and physicians associated with the center had participated in 40 consultations. Three years additonal support is requested. Second Year: $108,828 Third Year: $113,265 GRB/RMPS 12/9/70 (A Priv4leged Communication) SLTI@RY OF REVIEW AND CONCLUSIO@i' OF JANUARY 1971 REVIEW COMITTEE WESTERN NEW YORK REGIONAL iqEDICAL PROGRAM RM 13-04 (AR ICDS) 2/71 FOR CONSIDERATION BY FEBRUARY 1-971 ADVISORY COUINCIL. RECOMMENDATION, Additional funds be provided for this a pl' .p icatioii. Committee Year Recommendation 04 $1,250,033 $359,424 05 $1,044,044 $374,827 06 $824,013 $113,265 TOTAL $3,118,000 $1,024,752 I UE,. The Review Committee agreed with the site visit team that this Regicn has not yet completed the transition from project to program emphasis; althouah it does appear to be trying.. The Committee-did not ac,Iree withthe site teani's recommendation to provide developmental funding. In committee's view this Reg-Lon is not yet ready for this type of flexibility. The Rea4-orial- goals are global in nature and the strategies for achievin- them (termed policies" by the Region) even though more specific, appear not to'be based on a rational assessment of Regional needs. It was thougb--that the collection of projects for which furid@-Lnc, is requested did not rev&Al. a sound review process so far as blen -ing proposed activities with overall goals of the Region. Although the RAG is composed of nine county committees and has a total membership in the neighborhood of 300, the final arbi.ting body is the 29member Board of Directors. 'The,Board is heavily physician@riented, and the Region is considering the possibility of expanding the membership with the addition of nine additional. non-phy8ician representatives. The Review Committee agreed with the site team that the Region should be encouraged to accomplish this expansion. It was also thought that the decision-making and priority-settinr role of the RAG should be strengthened. The .county committees were seen as having outstanding potential as forces for 8ubtegionalization, and the Review Committee, and the site team were in agreement that the Region should be urged to diversify the functions of these groups to include activities -beyond the mere review of projects. The county committees could serve as vehicles for genuine grass rools participation in progriiii devel-OI)Tli-'Ilt. Western New York RMP -2- RM 00013 The extent to which the resources of the Region have been involved in the TAINYMV was seen as one of the most exceptional features of this program. This has been accomplished by dint of constant concentration on this goal by the Coordinator and the Core Staff. The Region is beginning to make inroads in assessing the needs of the area and developing a planning base to use as a guide for the development of a total program and the setting of priorities. Likewise, efforts are being made in the direction of program-evaluation. Since she WNYRMP will be requesting core renewal in another year, and RMPS will then have another opportunity to take a close look at this Region, the reviewers thought it would be well if the Region devoted the coming year to completing its transition from project to program orientation, with emphasis on- 1. Developing a sound program plan and priorities, based on identified Regional needs. 2. Increasing the decision-making role of the RAG and diversifying its membership through the proposed expansion. 3. Developiiig th.e county committees into something other t),an mere project review bodies, and working toward realizing their potential as forces for sbbregional.ization. Consequently, the recom@mended monies for the Region's 04 year, .although@increasing the absolute award, represent a decrease from the 03 year operating level, which had been increased through the use of large amounts of carryover. The 03 year basic award of $li!81,162 was expanded to $1,667,674 by carryover. The 04 year suggested award of $1,388,883 represents a combination of continuation funding of $1,029,459 and renewal and supplemental funding of $359,424 recommended by this Review Committee. Since no projects in the c urrent application will be specifically disapproved, the feeling was. that the recommended award is one which will maintain the Region during its 04 year but also force it to make decisions about. exactly where the money will be applied. The discussion below outlines the basis on which the recommended new and renewal funding of $359,424 was calculated. It should be noted that this is somewhat different from the funding level arrived at by the site@team, although it was prompted by the same considerations and is merely a slightly different means to the same end. DEVELOPMENTAL CO@FPONENT: Although the site team had suggested one year@ developmental funding on the basis of this Region's potential for imaginative use of these monies'. the Review Committee was not persuaded that this Region was quite ready for a developmental component. The recommendation of the disapproval of developmental- funding was based on all the deficiencies noted above as well as the RAG's not yet having developed precise . . @ I - - RM 00013 Western New York -3- .RMP RENEWAL REQUEST: The Review Committee agreed with the site team that the Telephone Lecture Network, for which renewal funding is requested, is one of the most exciting activities It has been used in very imaginative wa s. It in this Region. y is an integral- part of many ongoing and proposed projects, and for regionalization. There was unanimous is a definite force Agreement that renewal funds for this component should be included in the award, although it was suggested that if the Region were to increase the presently nominal financial contributions by participating institutions, award monies would become available for rebudgeting into other regional activities. APPROVED UNFUNDED: There are three projects which have received approval from previous Councils but have not been funded by RKTS. During the 03 year, however, these three projects were initiated with carryovet funds and through t e robudgdting of basic grant funds. cal Chemotherapy for PrecanceroLis Lesions and Cancer of the.Ski-a Information Dissemination Service Re '.onail C-Lozaigulation Reference Laborator The Region is requesting that supplemental funds be awarded for the continued conduct of these activities. Although the site team had recommended supplemental fundin- calculated on the request for only one of these projects ( Information Dissemination S6tvice) because of the good job it does in promoting regionalization, the'Review Committee thought that since the projects already had been initiated, the entire request for their continuation should be recommended. The decsions to include these funds in the calculation of support really was an attempt to bring the Regibn's funding for the 04 year to a workable level, And it was recognized that the Region would have the option to rebudget these monies among Rozi-onal components as it saw fit. El PROPOSALS-. The four new projects in the anniversary package and the two projects which were deferred by November Council for the site visit, brought the total number of new proje cts for which supplemental funding was requested to six. ional Bon el ted Tro hobllaassttli-c Disease iag Cuare for Chronic Illness 'Planni @ o A omputer-Based Health Data System A Model Prog am for CulomDrehensivp Family Health Prevention and Treatment of Respiratory Dis Due'to Hyaline Plembrane Disease in Infants Western New York -4- RM 00013 RMP Since the Region did not demonstrate, and the site team could not discover, the relationship of these individual Components to the overall program, and since there were no sound Regional priorities, the Review Committee agreed that there was no basis on which to.judge these proposals. Their technical sufficiency was presumed to be adequate, but the review process which approved these activities without any mesh with the overall Regional plan was questioned. In the absence of any basis on which to assess these activities the Review Committee agreed with the site team that although none should be specifically disapproved, they should not be included in the recommended funding calculation. This would not prohibit the WNY@IP from rebudgeting into any of these -ix activities. FUNDING CALCULATION First Year Committee @ie@st Recommendation Developmental Component $118 116 -0- Renewal $171,516 $171,516 Three Approved/Unfunded $187,908 $187,908 Six New Projects $772,493 -0- Total Supplemental Funding $359,424 Dr. Perry was not present at the deliberation of this application. 1/20/70 GRB/RMPS REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REV'IijW AND AWARD GRANT APPLICATION (A Privileged Co , nication) WEST VIRGINIA REGIONAL MEDICAL PROGRAM RM00045 2/71 (C&S) West Virginia University Medical Center January 1971 Review Comittee Morgantown, West Virginia 26506 Pron,,ram Coordinator: Charles D. Hollaud Requested (Direct Costs Only) 02 03 04 All Pur]2ose 1971 1972 1973 Years Continuation.l...L/ $535,467 $515,965 - 0 - $1,051,432 Core j6/ 485,713 490,740 - 0 - 976,453 2 projects I/ 49,754 25,225 - 0 - 74,979 ,1/ Includes $18,900 Carryover ($18,000 -core ss-.aff for renovating new quarters and $"O for project #6 (Helicopter Study) Supplemental $173,829 $186,094 $167,561 $ 527,484 Developwatal - 0 - - 0 - - 0 - - 0 Renewals - 0 - - 0 - - 0 - - 0 New $173,829 $186,094 $167,561 $ 527,484 3 projects Total Requ*qt $7n9,296 $7n2,059 $167,561 $1,5780916 *Staff Action 53,5.467 515,965 - 0 - 1,051,1@32 Comittee *nd Council RejuireA Action $173,829 $186,094 $167,561 $527,484 *RMPS staff reviewed the non-competing 02 year continuation portion of the application and rec uded approval in the amount of $534,567 including the use of $18,000 carryover funds for renovating new headquarters. FUNDING HISTORY d.c.@ Planning: 01 1967 $ 150,798 02 1968 350,717 03 1969 3789045 WEST VIRR.INIA RMP 2 RM45 2/71 (C&S) OPERATIONAL Grant. Year Period Council Approved Funded Commitments 01 1970 $395,048 $395,048 02 1971 $516,567 03 1972 515,965 APPROVED UNFUNDED PROJECTS (d.c.o.) lat yr, .2nd yr. 3rd yr. Total #8 Self Audit $138,901 $184,556 $147,292 $470,759 #9 Roop. Assistance 33,583 32,626 - 0 - 66,209 #10 multi-unit 50,561 42,304 42VO83 134,950 Comunications Total $223,047 $259,496 $189,375 $671,918 GEOGRAPHY & DEMOGRAPHY: Land Area: 24,079 square miles Population: 1,811,000 Urban 38% White 95% Median Age 28.5 Mortality per 100,000 Heart Disease 422 Cancer 168 CNS Vascular Lesions 115 Facilities: 1) West Virginia University School of Medicine 4 yr. school (enrollment approx. 250) 2) Eleven schools of nursing 3) Seven schools of medical technology 4) Ninety-one hospitals (5 federal) with 15,963 beds (1,396 federal) Seventy-six are short-term facilities. Personnel: Physicians (1968) 1550 (85.6/100,000) Osteopaths (1968) ill ( 6.1/100,000) Registered Nurses (1966) 5011 (276.6/100,000) HISTORICAL DEVELOPHENT: In December 1965, Dr. Clark K. Steeth, then Dean of the West Virginia University School of Nedicine, convened a meeting to discuss the Statate participation in RMP. The meeting was,attended by representatives of the State Departments of Health and Welfare, the West Virginia Heart Association, the West Virginia Division of the American Cancer Society, the West Virginia WEST VIRGINIA RMP - 3 - RW@5 2/71 (C&S) Hospital Association, the West Virginia University Medical Center and the general public. Upon unanimous agreement to participate, the Medical Center 4pwas selected to initiate and coordinate planning to establish the WVRNP. A 28-member RAG was appointed and Dr. Steeth was elected chairman. The RAG appointed a 12-member staff committee to prepare the planning grant application. This Region received a planning grant for three years beginning January 1, 1967. The amount awarded the second year included a supplement of $141,807 for four feasibility studies; (1) Survey of a Rural Area (Blackoville); (2) Nechanical Morbidity Reporting by Physicians; (3) Coronary Care 'Unit; and (4) Physicians Self-Audit. The latter three were also supported in the third year. The third year was extended seven months to August 31, 1970, and the Self-Audit to September 30, 1970, with no additional funds. A site visit was made in July 1969 to assess the Region's capability to become operational. It was noted that when the WVRHP began, it had many obstacles to overcome. The State suffered from critical economical crises, leaving most areas without adequate health care. Small towns, rural and mountain areas, so predominant in West Virginia, lacked health personnel. The medical school was only 11 years old and there was little evidence of effective continuing education into the hospitals and medical profession. Adding to these oroblems, Dr. Wilbur the Regional Coordinator, recruited in June 1967, died in January 1969. Mr. James G. Holland, Associate Coordinator, was serving as Acting Program Coor- dinator. Despite the dearth of resources and the unfilled coordinator position, the site visitors believed the Region was ready for operational status. The West Virginia University Nedical School had taken an active role in the WVRMP and good physician and nurse participation was evident. The Region had also reestablished appropriate cooperative arrangements. As pointed out to the Region, there was a need for much better minority representation on the RAG. The , 35-member RAG had only recently organized its committee structure, (Executive Committee, Project Review Committee, four planning Committees, and nine Sub-Area Advisory Groups) and it wastIoo.early to determine how well it was working. t Sub-area offices based on joint planning with Comprehensive Health Planning were projected for the near future. The August 1968 Council recommended approval for operational status for three years for core and four projects. Pk. Charles D. Holland was appointed Regional Coordinator. To provide appropriate super- vision of the medical aspects, a special Medical Advisory Committee was con- stituted to assist the Coordinator. 'GOALS AND OBJECTIVES: As originally stated, the overall goal of WVRMP is to assist the nation's health resources in making the best possible care for patients with heart disease, cancer, stroke and related diseases. Kidney disease has been added. The objectives have been refined and set to a time frame for management-monitoring. (Section III - Appendix). Objectives: 1) Stimulate effective responses to community and area health needs by developing and maintaining a system of area offices. 2) To provide for description and evaluation of health care systems for the purpose of pro- gram planning and development by securing, maintaining and analyzing basic data concerning health related variables - focusing particularly on facilities, personnel and their utilization. 3) To enhance patient care by assisting to 0 WEST VIRGINIA RMP - 4 - RM45 2/71 (C&S) the establishment of improied methods of continuing education for physicians, nurses and allied health personnel. To assist in the establishment of new types of health manpower programs, to expand the capabilities of,the tradi- tional health care providers and gain their acceptance throueh continuing education. 4) To analyze current problems and patterns of emergency medical care and'to promote improvement. 5) Within the constraints of limited health resources, develop innovative programs to support rural family health maintenance 6) Promote the development of necessary cooperative arrangements among health providers and related groups to improve health care. PR16RITY RANKING: lot level I - Core 2nd level (Continuation on-going funded ac tivitiea) I - #4 Nursing Care of Stroke Patients 2 - #6 @licopter Study 3rd level 1 - #11 Rural School Health 2 - #12 Cancer Education and Service 3 - #10 Multi-Unit Communications 4.- #13 Hospital Service 5 - #8 Self Audit 6 - #9 Hospital Assistance ORGANIZATION: The present application includes the annual report of the RAG, much of which is alluded to in this summary. The organizational structure includes a RAG of 35 members which meets quarterly. During interim meeting of the RAG, a seven-man Executive Committee is authorized to transact business. The WVU Medical Center Staff Committee is a special Com- mittee to guide the Coordinator and his staff. Other committees (40 members) include Planning, Review and Evaluation, Education, DemonatrationF;, and Research. Project applications are reviewed by the Review and Evaluation Committee, CHP "A" and "B" Agencies. The final review and recommendation is by RAG. The RAG is definitely not a rubber stamp group as evidenced by their change in the priority ranking of projects (Section III, pages 76-77). As indicated in the narrative some of the reviewers tend to ignore the criteria. Core staff is aware of the problem and believe promised guidelines from RNPS may be helpful* The number of professional core staff has increased from 16 to 20; an addition of two field staff, a physician consultant and a pediatric nurse consultant. Because of the required travel, efforts failed to recruit an assistant Director and this position has been changed to Coordinator of Field Services. The Associate Director is now for Planning and Development. Other changes includes the addition of a.Physician Consultant and Research Assistant. Clerical and secretarial positions have been increased from 9 to 11. Core progress includes staffing four of nine sub-regional offices. Two additional offices will be staffed during the second year. Core studies-have included-. hospital patient WEST VIRGINIA RMP - 5 - RM45 2/71 (C&S) flow; medical students' choice of practice and location; rural health patterns nd resources; characteristics of users and the operation of emergency system On a complex medical facility. Activities have also included working with the RAG, Committees and project applicants in program development. Three core staff (a physician, nurse and secretary) will be committed for about one year in the development of a Pediatric Nurse Practitioner project. Plans also include study and necessary planning for innovations in health manpower and renal disease. Efforts will include more involvement of the allied health professions, particularly physical therapists. Cooperative arrangements with appropriate agencies continue. @ t notable are those with the State Medical Society and CHP, A and B Agencies. There are no model cities programs in W. Va.i but there are numerous O.E.O. sponsored Com- munity Active programs of which VVRNP has had contact with.four-significant mutual activities are anticipated. The great distance between the central WVM in the northern part of the state and the Southern West Virginia Regional Health Council has been a deterrent to a coordinated effort in the Appalachian 202 multi-county demonstration@in the southern part of the State. Rowever, the two agencies continue to work toward the development of a "Guest-Residency Prograii" in the Appalachian area. Of the four approved and funded projects during the first year, three were implemented and PMS staff believe that progress is satisfactory. One (#l-@- cation for CCU Staffs) was funded for one year, but will continue after cessa- tion of RMP support. Continued support is requested for continuation of (#4- Nurit-ag Care of Stroke Patients) for its second year. Continuation is requested r two additional years for (#6-Helicopter Feasibility Study). Project #5- oke and its Treatment) approved and funded for one year by RMPS ($31,400 was t implemented because of the problems in personnel recruitment. An unexpended balance of approximately $145,000 is anticipated in the current year and is re- flected mostly in the core budget and by not funding project #5. EVALVATION: The Review Committee has responsibility for evaluating project I @ proposals and recommending a priority ranking to the RAG. Core Staff is responsible for monitoring projects. However, detailed information about evaluation is locking. NEW PRWECTS: Requested I First Year Project #11 - Progressive School Health Programs for @89,366 Rural Commuitiol Sponsored by the Upshur County Board of Education at Budkhannon, the objective of thin project is to develop a model school health program that can be repli- cated within the constraints of limited financial and human resources in rural areas of West Virginia. The project will have two elements: 1) education and 2) services. The school education aspect will be undertaken by training elem mentary grade teachers in curriculum content for health education. This ap proach will be carried Into higher grade levels later as curriculum develops and is available. The health services aspect will be directed by a registered nurse assisted by a school Health Assistant. The Realth Assistants, a new type manpower, will be trained (six the first year) to perform many tasks now WEST VIRGINIA RIIP 6 RM45 2/71 (C&S) done by the school nurse. S-upplementat services of a dental hygienist, pedi- atric nurse practitioner and physician consultant are planned. The difference from other similar school programs is the planned follow-up with family and community resources through the use of the school Health Assistant. Evaluation is planned in terms of measuring progress in implementation and ultimate impact of the project. Plans include efforts to secure other sources of funding after cessation of WVRNP grant support. Second lear Third year_ $89,791 $98,154 Requested Project #12 - Cancer Education and Service First Year $52,956 Sponsored by the West Virginia University School of Medicine, this is a Cancer registry focused education program for 63 hospitals. Each of the hospital's registries will be the educational outlet for upgrading cancer information resulting in improved care of cancer patients. The project will provide avail- able text books, periodicals, audio visuals and hardware to registry directors. Efforts will be made to utilize the existing West Virginia University nurses Service's tele-lecture unit hook-up to 45 hospitals (34 have tumor registries). An-9 istance will be given to registry directors to develop more meaningful information and follow-up programs. In cooperation with the Liaison Fellows of the American College of Surgeons, the American College of Radiology Coumtittee on Cancer Management and the Cancer Control Division of the Wes-41. Virginia State Department of Health, problem-oriented workshops are planned through the West Virginia Chapter of Tumor Registrars. The current limited distribution of the annual report by the Central Registry is to be increased to inclade all the physicians in the State. Evaluation will be based on the end result reports - hopefully improved survival. Continuation of the project supported by other sources is planned after termi;- nation of RMPS grant support. Second Year Tkird Year $53,392 $55,252 Project #13 - ge@tati*oi,of Hospital Service Areas Requested First Year $31,507 The purpose of this project is to provide hospitals in the State more infor- me,tion upon which to base individual and regional planning decisions. Objectives:ll) learn more about patient characteristics; 2) learn more about hospital information needs; 3) develop some comparative measures of hospital care delivery; 4) gain better understanding of type and size of the community hospital planning unit most appropriate to better delivery of hospital care; 5) sustain the impetus for regional planning by input - to effect better hospital care; and 6) foster additional researdh on problems of health care delivery. The definition and analysis of "marketing" areas will be used to assist in planning for expansion of services and facilities; determining areas and potential-, WEST VIRGINIA RNP - 7 - RM45 2/71 (C&S) patients that are not now adequately served, physician referral relationships, etc. The project will be completed in two phases during the 29-mouth period. The first phase (January - December 1971) test demonstration in a four-county, area which includes 5 hospitals and approximately 120 physicians. The second phase beginning in January 1972 will be implementation of the project on,;a state-wide basis to include 75 in-state hospitals,lt9 out-of-state hospitals and about 300 physicians. The program is one of investigation and RMP continued support after the project period is not indicated. Second Year Third Year $42,911 $14,155 WEST VIRGINIA UNIVERSITY REGIONAL ADVISORY ---------------------------------- GROUP VE EE TO INFORMAI OFFICER ING TEES COORDINATOR- ASSOCIATE DIRECTOR FIELD OPERATIONS PLANNING AND DEVELOPMENT ELKINS AREA PARKERSBURG HUNTINGTON BEHAVIORAL- STATISTIC OFFICE AREA OFFICE AREA OFFICE SCIENTIST MORG,LNTOWII BECKLEY AREA CHARLESTON AREA OFFICE OFFICE AREA OFFICE PHYSICIAN NURSE CONSULTANTS CONSULTANTS WEST VIRGINIA UNIVERSITY STRATEGY FOR VOLUNTARY COOPERATIVE ARRANGEMENTS ------------------------------------------------------------------------------- PROGRAM ----------------- ---------- A D V I S 0 R Y G R 0 U P DIRECTOR R E X E C U T I V E C 0 M M I T T E E m p PLANNING COMMITTEE RESOURCE SUB- c COMMITTEES FOR ELIGIBLE ACTIV- 0 ITIES cn z R 0 F4 REGIONAL E SUPPORT TO RAG PROC@@T OFFICE cn OBJECTIVES AND COMMITTEES z En P4 s T AREA A OFFICES W 01 x 9 F COMMUNITY SYSTEKATIC PROGRAM TRUSTEESHIPS EA DEVELOPMM4T PRIORITIES L------------------------------------------------------------------------------- REGIONAL MEDICAL PR SERVICE SUMMARY OF ANNIVERSARY REVTi'@W AND AWARD GRANT APPLICATION (A Privileged Coumunication) WEST VIRGINIA REGIONAL MEDICAL PROGRAM RMD0045 2/71 (C&S) West Virginia University Medical Center January 1971 Review Comittee Morgantown, West Virginia 26506 Pro.-rau Coordinator: Charles D. Holland Requested (Direct Costa Only) 02 03 04 All Purpose 1971 1972 1973 Years Continuation,;,.L/ $535,467 $515,965 - 0 - $1,051,432 Core i/ 485,713 490,740 - 0 - 976,453 2 projects 1/ 49,754 25,225 - 0 - 74,979 .I/ Includes $18,900 Carryover ($18,000 -core staff for renovating new quarters and $900 for project #6 (Helicopter Study) Supplemental $173,829 $186,094 $167,561 $ 527,484 Developwntal - 0 - - 0 - - 0 - - 0 - Renewals - 0 - - 0 - - 0 - - 0 - New $173,829 $186,094 $167,561 $ 527,484 3 projects Total Requomt $709,296 $7n2,059 $167,561 $1,578,916 *Staff Action 535,467 515,965 - 0 - 1,051,432 Comitte* mud Council RejuireO Action $173,829 $1869094 $167,561 $527,484 *RMPS staff reviewed the non-competing 02 year continuation portion of the application and recommended approval In the amount of $534,567 including the use of $18,000 carryover funds for renovating now headquarters. IMING RISTORY d.c.*._l Planninit: 01 1967 $ 150,798 02 1968 350,717 03 1969 378,045 P4 w WEST VIRR.INIA RMP 2 RM45 2/71 (C&S) OPERATIONAL Grant. Yeer Pel-iod Council Aperoved Funded Comitments 01 1970. $395,048 $395,048 02 1971 $516,567 03 1972 515A 965 APPRCUED UNFUNDED PROJECTS (d.c.o.) is 2nd 7r. 3rd Yr. Total #8 Self Audit $138,901 $184,556 $147,292 $470,759 #9 Hosp. Assistance 33,583 32,626 - 0 - 66,209 #10 Multi-Unit 50,563 42,304 42,083 134,950 Communications Total $223,047 $259,496 $189,375 $671,918 GEOGRAPF,Y & DEMGRAPHY: Land Area-. 24,079 square miles Population: 1,811,000 Urban 38% White 95% @dian Age 28.5 Mortality per 100,000 Heart Disease 422 Cancer 168 CNS Vascular Lesioras 115 Facilities,. 1) 14eat Virginia University School of Medicine 4 yr. school (enrollment approx. 250) 2) Eleven schools of nursing 3) Sever, schools of medical technology 4) Ninetlv-one hospitals (5 federal) with 15,963 beds (1,396 federal) Seventy-six are short-term facilities. Personnel: Pliysitions 1550 (85.6/100,000) Osteopaths (1.968) Ill. ( 6.1/100,000) Registered Nurses (1966) 50ii (276.6/100,000) HISTORICAL DEVELOP'rOiiTi In December 1965, Dr. Clark K. Sleeth, then Dean of the West Virgi-,iia University School of Nedicine, con,,reued a meeting to discuzs the otate's participation in RMP. The meeting was attended by representatives of the State Departments of Health and Welfare, the West Virginia Heart Association, the West Virginia Division of the American Cancer Society, the Weat Virginia WEST VIRGIUIA 3 (C&S) Ho a p i t a I A Ei 4"@ i t Wc.,o'@- the u Center gener ci-paf:e, t,@. was sel("@,cced to and the WV#'@-4L,4. A 28- me-ofaer RAG was a l@,r. Sl@c-eth was elecLi@,l chairman,, The RAG appo@@@,yt@t I a 12- eob i:, aL@ f@ counitte--@a to rel@n@re pl. grant application. This Region received a ?lanning grant for t'rtree years begit@iiing January 1, 1967. The amount awarded the tiecoad year included a supplement of $141,807 for four feasibility studies; (1) Survey of a Ru@ral Area (Blackvville); (2) Mechanical Morbidity Reporting by Phyef.cians- (3) Co:cnary Care Unit; arid (4) Peiysicians Self-Audit. The latter three were also supported 'Lri t e t-lhird year. The third year wag extended seven @oonCli8 to August 31, 1970, and the Self-Audit to September 30, 1970, With no additional fui@ads,, A site visit ,,ias i..i July 1961; to a seas the Regiu@ ' capability to become operational. It u-as a@otf@,cl that wi@ien the WVAMP began, it 'than many obstacles to overcome. The State suffered from critical economical crises, leaving most areas without adequate health care. Small towns, rural aud mountain areas, so predominant in West Virginia, lacked health Personnel. 'Zhe medical school was only 11 years old and there was little evidence of effective continuing education into the hospitals and medical profession. Addivi.,, 'zo these i@XoL@lems, Dr. Wilbur the Regional Coordinator, recruited in June i,967, diec"I ii 3@.@iiuary 1969. Mr. James G. Holland, .49sodiate Coordinator, was serving as Acting Program Coor- dinator. Despite the dearth of resources ayid the unfil'LeO. coordinator position, the site visitors believed the Region was ready for operational status. The West Virginia 'Jnivers-."Lt@@@7 l@dica'.'i Sc@iao'Z'. had takeL@i an acti@,,re role in the ;IVRMP and good physician and nurse participation was evident. '.,"eie r(egion had also established appropriate cooperative arranga@@its. As pointed out to the Region, there was a need for better mirior.t@, representation on the RAG. The 35-member RAG had only recently organized its ca=ittee structure, (Executive Committee, Project Coya-ii ttee, four planni,:ig Co=it sets, and nine Sub-tLrea Advisory Groups) and 'r@,e was@t'oo early to dete,@rt,@ine how well it was working. t Sub-area offices based on joiii@@- p@@anning with Car,,-kpretteLsive 'Tlealth Planning were projected for the near future. The August 1968 Council recommended approval for operational status for tiiree years for core avoid four projects. W. Charles D. Holland was appointed Regional Coordinator. To provide appropriate super- vision of the medical aspects, a special @dical Advisory CouQittee was con- stituted to assist the Coordinator. GOALS "D OBJECTI'rJ2S: iiv originally stated, the overall goal of WVIUIT is to assist the nation's health -cetiq:)urces in uking the beat possible care for pat:@.ents with heart disc@ase,l cancer, strol@cA@ and related diseases. Kidney disease has been added. Ti-i;e objectives have been refined and set to a time- fraim for managempnt-momi.toring. (Secti@Dit III - Appendix). Objectives: 1) effective response to community and area health needs by developing and w;a@Lntiiinirg a aystet,,a of arec offices. 21 To provide for description and evaluation. of healt'@. care sys,@--em,@L for the purpose of pro- gram planning and development oliy securing, ma,'-Tntain'Lig end analyzing basic data concerning health related variables - focut;in,?, @articularly o@'i facilities, personnel and their utilization. 3) To enhance patient care by assisting in WEST VIRGMA RMP - 4 RM5 2/71 (C&S) the est ablishwnt of improved-methods of continuing education for physicians, nurses and aliied health personnel. To assist in the establishment of nev.- types of health manpower programs, to expand the capabilities of the tradi- tional health care providers and gain their acceptance throueh continuing education. 4) To analyze current problems and patterns of ewrgency medi.--al care and'to promote improvement. 5) Within the constraints of limited health resources, develop innovative programs to.support rural family health maintenance. 6) Promote the development of necessary cooperative arrangements among health providers and related groups to improve health care. PRIORITY RANKING-,. lot level' I - Core 2nd level (Continuation of on-going funded activities) I - #4 Nursing Care of Stroke Patients 2 - #6 Uelicopter Study 3rd level 1 - #11 Rural School Health 2 - #12 Cancer Education and Service 3 - #10 @ ti-Unit Communications 4-- #13 Hospital Service 5 - #8 Self Audit 6 - #9 Hospital Assistance ORGANIZATION: The present application includes the annual report of the RAG, much of which is alluded to in this summary. The organizational structure includes a RAG of 35 members which meets quarterly. During interim meeting of the RAG, a seven-man Executive Committee is authorized to transact business. The WVU Viedical Center Staf f Committee is a special Com- mittee to guide the Coordinator and his staff. Other committees (40 members) include Planning, Review and Evaluation, Education, Demonstrations, and Research. Project applications are reviewed by the Review and Evaluation Committee, CEP "A" and "B" Agencies. The final review and recommendation is by RAG. The RAG is definitely not a rubber stamp group as evidenced by their change in the priority ranking of projects (Section 111, pages 76-77). As indicated in the narrative some of the reviewers tend to ignore the criteria. Core staff is aware of the problem and believe promised guidelines from RMPS may be helpful. The number of professional core staff has increased from 16 to 20; an ad it on of two field staff, a physician consultant and a pediatric nurse consultant. Because of the required travel, efforts failed to recruit an assistant Director And this position has been changed to Coordinator of Field Services. The Associate Director is noii for Planning and Development. Other changes.includes the addition of a Physician Consultant and Research Assistant. Clerical and secretarial positions have been increased from 9 to 11. Core progress includes staffing four of nine sub-regional offices. Two additional offices will be staffed during the second year. Core studier, -have included: hospital patient WEST VIRGINIA RW - 5 - RM45 2/71 (C&S) low; medical students' choice of practice and Ic)cation; rural health patterns end'resources,, characteristics of users and ti-Ae operation of emergency system In a co@)lex medical. @@acility. Activities leave als@o included working with the RAG, Committees and project applicants in torogram develop at. Three core staff (a physician, nurse and secretary will be committed for about one year in the development of a Pediatric Nurse Practitioner project. Plans also include study and necessary planning for innovations in health manpower and renal disease. Efforts will Include more involvement of the allied health professions, particularly physical therapists. RESOURCES' Cooperative nrrangements with appropriate agencies continue. Most notable are those with the State Medical Society and CHP, A and B Agencies. There are no model cities programs in W. Va., but there are numerous O.E.O. sponsored Community Active programs of which WVRMP has had contact with four-significant mutual activities are anticipated. The great distance between the central WVRMP in the northern part of the state and the Southern West Virginia Regional Health Council has been a deterrent to a coordinated effort in the Appalachian 202 multi-county demonstration in the ,southern part of the State. However, the two agencies continue to work toward the development o a "Guest-Residency Program" in the Appalachian area. CURRENT PROI-ECTS: Of the four approved and funded projects during the first year, three were implemented and RMPS staff believe that progress is satisfactory. One (#l-Education for CCU Staffs) was funded for one year, but will continue after cessation of RMP support. Continued support a requested for continuation of #4 - "Nursing Care of Stroke Patients" for ts second year. Continuation is requested for two additional years for #6 - Helicopter Feasibility Study." Project #5 - "Stroke and its Treatment" approved and funded for one year by RMPS ($31,400) was not implemented because of the problems in personnel recruitment. An unexpended balance of approximately $145,000 is anticipated in the current year and is reflected mostly in the core budget and by not funding project #5. E The Review Committee has responsibility for evaluating project VAITJATION. I proposals and recomending a priority ranking to the RAG. Core 'Staff is responsible for monitoring projects. However, detailed information about evaluation is lacking. NEW PRIVECTS: Requested First Year iroject #11 - Progressive School Health Programs for $89,366 Rural Communities Sponsored by the Upshur County Board of Education at Buckhannon, the objective of this project is to develop a model school health program that can be repli- cated within the constraints of limited financial and human resources in rural areas of West Virginia. The project will have two elements: 1) education and 2) services. The school education aspect will be undertaken by training ele- mentary grade teachers in curriculum content for health education. This ap- "roach will be carried into higher grade levels later as curriculum develop$ Rpi,rd is available. The health services aspect will be directed by a registered nu se assisted by a school Health Assistant ' The Health Assistants, a new type of man@r, will be trained (six the first year) to perform many tasks now WEST VIRGINIA TO'P - 6 BLv,,45 2/71 (C&S) done by the school nurse. Su-p-)Iemental services of a dental hygienist, redi- stric nurse prk;.ctitioner L-,.d physician consultant are plavineA. Ybe difference from other cimilzr uchool programs is the plonred follm,,-cp with family and ccmlnunity resources through the use of the school Health Assistant. Evaluation f:@ plann,e4 @n tcr=. of wasuring progress in implementation @ ultimate iiVact L the project. Plans include efforts to secure other sources of funding after cessation of ViViO.? grant support. @CS'l@ r-ar Third veer $89,791 $98,154 Requested Project #12 - Cance4- Educa@--ion cn Service First Year $52,956 Sponeored by the West Virgin-La 'Ci-,iiversity School of @dicine, this is a Cancer regiF.try focused education program for 63 Hospitals. Each of the hospitals registries will be t.ie educational outlet for upgrading cancer information resulting in improved carn of cancer patients. The project will provide avail- able text books, periodicals, audio visuals ard hardware to registry directors. Efforts will be made to utilize the existing West Virginia University Nurses Servicets tele-lectu-@e-unit hook-up to 45 @os?italc (34 have tumor registries). Asr-s totance will 'De given to registry directors to develop more M'nningful information and fol-I.ow-up programs. in coo erat'Lor, with the Liaioon Fellows p of -,he American Collece. of Su-@g--,ot!s, the Auericart C--Ilege of Radiology Committee viuion of the West Virginia State on C&Lcer Management and the Cancer Control Di Department of Health, problem-oriented workshops are planned through the West Virginia Chapter of Tumor Registrars. L".ie current limited distribution of the annual report by the Central P%egiatry is to be incresse4 to include all the physicians in the State. Evaluation will be based on -Ilae end result reports - lio?e@Lully improved survival. ,-'orit@Lnuati(-,t of t.-.e @u--,,@orted by o-,"4&er gcurces is planned after termi- nation of IL4PS grant si;pport, Secaud 4c-ar $53,392 $55,252 -,,o L"eas Requeste ? I 1.1ervic First Year $31,507 T'ki(-- --urpose of tl-.1@ i:o provld@- 'Lloc,@)-'Ltals 'Ar. t'Lle St&te ttore i,.ifor- r upon Wnicb @L-o b8se individual and @-egio%ial @laitrin'Y 6'ecisions. c O'ojiactive5: I') lea@-.- ma@- abouf-- rLtier.@t cL-iar@cZeri-r;tic--; 2) learn more about hospital in;'armation 3) develop .2cta!,n,-Ltive mr-e.Lires of I-.ospital care d3livery; 4) -@i2ia better cf t-,-rld of the community hospital planning unit @st @,"2repriste 11--o bettei- of hospital care; 5) sustain the im?etus for re.@onal pl&nning by input - to effect better hospital care; and 6) foster additioiiL'S. researdh on problaimi of health care delivery. The definition and analycis of- "trarketing" arer-s will be uGei to a.3sist in planning for ex?Lr-sion of Service Lid fc;cil4-tieG@; deterr-in.Lng areas and potential WEST VIRGINIA Me - 7 RM45 2/71 (C&S) patients that are not now adequately served, physician referral relationships, etc. The project will be completed in two phases during the 29-mmth period. The first phase (January - December 1971) test demonstration In a four-county, area which includes 5 hospitals and approximately 120 physicians. The second phase beginning in January 1972'will be implementation of the project on a state-wide basis to include 75 in-sttte hospitals,'19 out-of-state hospitals and about 300 physicians. The program is one of investigation and RMP continued support after the project period is not indicated. Second Year Third Year $42,911 $14,155 CRB 11 7, /1 71@ 70 Rc,visrti 1115/71 WEST VIRGINIA UNIVERSITY REGIONAL ADVISORY ---------------------------------- GROUP VE EE ASSISTANT TO INFORMAT[ON OFFICER STANDING THE DIRECTOR COMt4ITTEES ATE DIRECTOR COORDIN PLANNING AND FIELD OPE DEVELOPMENT E-KINS AREA PARKERSBURG HUNTINGTON BEHAVIORAL ATISTICI OFFICE AREA OFFICE AREA OFFICE SCIENTIST ORG&NT014iN BECKLEY AREA CHARLESTON REA OFFICE OFFICE AREA OFFICE PHYSICIAN CONSULTANTS ,qEST VIRGINIA UNIVERSITY STRATEGY FOR VOLUNTARY COOPERATIVE ARRANGEMENTS ------------------------------------------------------------------------------- PROGRA,ll --------------------------- A D V I S 0 R Y G R 0 U P DIRECTOR E X E C 1,J T I V E C 0 M @i I T T E E PLANNING COMMITTEE RESOURCE SUB- CO@NITTEES FOR ELIGIBLE ACTIV- ITIES 0 REGIONAL SUPPORT TO RAG PROGRAM OFFICE AND CO@ZIITTEES OBJECTIVES AREA OFFICES s OP x 9 COMMUNITY SYSTAIATIC PROC,@L TRUSTEESHIPS AREA PRIORITIES DEVELO@ilENT L ------------------------------------------------------------------------ 10 DEPARTT,,LENT OF' HEALTFI, EDUCATio@l, AND WELFARE PUF3LIC HEALTH SERVICE HEALTH SERVIC@CAND MENTAL HEAI-Ti-l ADMINISTRATION Deceiiiber 17, 1970 Staff Revievi of Noti-Coiiipeting Continuation Application froi-ii West Virginia Regional Medical Prograin R[4 00045 - 2171 .1 (C&S) 7 o: Acting Director Regloii,il I-.ILdical Pt-ograiiis Service Th)-OLlgil: Chciiriiian of th,,-, Montil@, Acting Chief, Regio.ii5-l Developiflcnt BranC West Virginia Pegional Medical Prog@'aiii requests continuation suppoi-'L- for the 02 operational year for Core and t@@io projects, plus use of $0/00.00 cart-yover. Staff concurred on the following recoii,,riienda@Lions: 1. Support in the coinniitted aipount for Core and Projects L'4 and #6. -n Li ci I)atc 2 . Disapproval of the $900.00 request or use of a d carryover. (Staff concurred that the activity planned for the use of carryover tias needed and justified . liovj(-,ver, lag-tiiiie in recruiting staff for Core in the 02 year should provide the funds necessary for SLInport of this request.) Sui-iii-ii;,iry Of action recorilinended: 02 Year Staff Coniniitted Ai,,ioutit @e ues-Lcd R e c o r,,i;,, 1 r-. r; (-I c. @l Core $467,713 $467,713 $467,713 Project r4 15,054 15,054 15,054 Short Teri,.l Training Tyson Ca-r@of-- t@r k@e FFaii-ent Project -:6 33,800 34,700* 33,800 lLelLtc2pl r@@ s@ibil_Lty Total $516,567 $517,467 $516,567 Includes recit,ic-,st for use of $900 anticipated cii-ryover. Page 2 Acting Director, RMP'J @lest Virginia R,!P @,,,as apl)i@oved-for operational status effective January 1, 1970, with funds provided to support Core and three Projects: Education !@or CCU Staffs (I yr.), #4 - Nursinq Caro of Stroke Pati yrs . and 41-15 - Stroke and I ts I yr . In May, 1970, Project -Ir'6 - Helicopter Feasibilit Stud was approved y- Y. and funded. The present application was submitted in the AR forniat presented at Airlie [louse and contains a request for supplemental funds to support three now projects as well as continuation support for Core and t@ie two projects with commitments for the 02 operational year. No develop- mental component was requested at this time; however, a request %,.,as included to utilize $900.00 anticipated carryover. Staff review did not include consideration of the supplemental request as this will be considered by conii-nittce and Council in the January-February, 1971, Review Cycle. Staff discussion of the application included the organ- ization, structure and functions of Core, the RAG, Executive and other Committees, Regional priorities, acconiplishi-iients, etc. Staff rioted Project ',-T'5 - Stroke and Its Treatment - approved for one e@d d7u-- of year only, was never activ-a- e -U6--lF@, '- - v@i6 key project staff @,ii th no hope for replaced.i,:@nt within the one year period. Revieviers concurred progress reported for Core ancl Projects #I, I''4 and @16 was satisfactory. Project llr'l was well received and provided training for a greater riur,,,@er of applicants than had been anticipated. As previously noi,,P-(!, t@iis project was approved for one year only. The activity will coriti(iU(il on a reduced scale with non-RtIP support. Staff also discussed a potential problem developed in the after Submission of this application. The University of VIC@st Virginia. Medical Center can no longer assure contiguous space for new Ri"iP staff added to Core and is negotiating viith a hotel in downtown t@iorganto%,,,ri for a SLlite.Of offices for Core staff headquarters. It is anticipated approximately $18,000 will be needed to refurbish this space. At this time funds are available in the Region to.support thi@. [lo,,,iever, it is uncertain whether ary,,-tngeinents can be completed prior to termination of the Current grant year. In t@ie event arrangements cannot be completed within the current grant year, staff agreed a request -icroi;i the Region for use of carryover (o)- for near funds if policy precludes use of carryover) viould br-, needed, and justified particularly for this one- time only expenditures 12 page 3 Acting Director, R14PS Staff also highly recommended that all due consideration be given to funding the three projects recommended for approval by the National Advisory Council in the November 1970 meeting. It is the consensus of Staff that these activities are sorely.needed to give the Region visibility and to assure continued support of affiliated and coop- erating groups and individuals in the Region. The following staff members participated in the December 7, 1970, meeting: Mr. Frank Nash, RDB Mr. Larry Pullen, GMB Dr. Margaret Sloan Mr. Luther Says, GRB Miss Carol Larson, CT&E Additional comments submitted by reviewers are appended. Frank S. Nash Operations Officer Regional Development Branch, Attachments Approved Date Disapproved D. Acting Dir s A PRIVILEGED CO,@IIJNICATION SUI,n,L,@RY OF REVIEW AND CONCLUSION OF JANUARY 1971 REVIE@@T CO@l@-TIIEE WEST VIRGINIA REGIONAL @TEDICAL PROG@'4 Rl,l 000ii5 2/71.1 (C & S) FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY.COITNCIL Rdcorruiie.ndatio,-i: The Co-tTi-@i@@tLE,,o considered opl)l-l'-catioii which includes requests: 1) continuation support for core activities and two.projects and 2) supplemental support for three new projects. In reaching a recommendation for- the level of funding, the Committee also considered three projects previously approved by Council but unfunded, and their program relevance including ranl@ order by the WV/@IP. Funds requested by WV/@IP and reco,iiiiiE,.nded by CoriiHii.ttee are as fol@ Io-"7s Direct Cost Year Requested Recoi-@@Liieiided Ftir)din@ O? I/ $ 932,343 2/ $ 776,567 03 961,555 2/ 775,965 04 356,936 2/ 260,000 Total $2.12501834 $)-,812,532 The Co:iii,.tittee also recommends that its conceri-@.s be co@l-uli!lnica.Lt--d to the WV/Rt,',Il. Direct Cost 0 Re fight 2 Year 03 Year 04 Year Continuation Core & 2 projects $535,467 $515,965 -0- 3 New Projects 173@82L 186,094 561 Sub Total $709 296 $702,059 $167,561 Approved & Unfunded 223,04/' 2591496 189,375 Total $932,343 $961,555 $356,936 2/ The second year continuation re.ciuL-st was reviewed by staff and $516,567 d.c.o. was recommended. Committee reco,,@ended additional funds in the amount of $260,000 each year for three years for new projects. W6st Virginia RMP -2- RM 00045 2 71.1 (C & S) Critique: The Committee noted that although t.he Region has been operational for only one year, the program seems to be moving forward under -effective leadership. The requested level of support is modest, particu-. larly in view of the dearth of needs in the State. The Committee noted the new core staff positions budgeted and wondered if they could actuall be recruited. As reported by staff, the Coordinator y on a recent visit to RMPS indicated he expected no great prob ems n filling the positions. The Rural Scl-iool- Health proposal, ranl,,ed first of the six new projects by the RAG, is an interesting concept and worthy of support. 'The Committee, however, was concerned about the assurance of adequate follmq-up. The question arose as to the number of pediatricians available in the target area and a clearer statement of follow-up care is needed. Also, the amount budgeted for consultant services is high. By the nature of the goals of the "Cancer Education and Service" project, the current registry program appears to be only aquisition of data... The project is designed to u,@ rade and stimulate utilization of information gathered. Like Council, the Committee has little enthusiasm for the program. The Committee believes that if WV/@IP considers funding this project, ...they should be aware of the November 1970 Council's discussion and 'Action about registeries. The Committee believed that the "segmental ion of hospital service areas" 'Proj6ct is a study concept that might be more Appropriate as a Core plannina activity and/or CHP. It would seem that some of these data would have been acquired during the WV/RMP planning phase. The concept of niedical-self audit as represented by project #8 is recognized as a very innovative activity in WV/RMP and of great interest., RMPS/GRB/l/19/71 REGIONAL MEDICAL PROGRAMS SERVICE SUM14ARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) Wisconsin Regional Medical Program, Inc. RM 00037-04 (AR-1-D) 2/71 110 East Wisconsin Avenue January 1971 Review Committee Milwaukee, Wisconsin 53202 Grantee Agency: Same Program Coordinator: John S. Hirschboeck, M.D. Request ct Costs) Purpose 04 year (9/l/70 - 8/31/71) Additional Component (Developmental) $200,000 Funding History Planning Stage Grant Year Period Funded (d.c.6.) 01 9/l/66 - 8/31/67 $319,458 .Operational Program Council Future Grant Year Period Approved Funded (d.c.o.) Commitment 01 9/l/67 - 8/31/68 539,366 Core 415,093 ------ Proj. 133,773 02 9/l/68 - 8/31/69 1,365,463 Core 438,974 ------ Proj. 723,707 03 9/l/69 - 8/31/70 1,338,194 Core 438,974 ------ Proj. 800,536 I/ 04 9/l/70 - 8/31/71 1,794,257 Core 438,974 ------ Proj. 1,153,299 2/ 05 9/l/71 - 8/31/72 499,425 $484,120 06 9/l/72 - 8/31/73 442,805 442,805 I/ Includes $141,080 Carryover 2/ Includes $60,704 Carryover Wisconsin RIIP RM 37-04 (AR-1-D)2/71 G h : The boundaries of the Wisconsin Region are coincident with those of the State. The University of Wisconsin Medical School sphere of medical care influence includes parts of Minnesota, Iowa and Illinois; similarly, the Marquette University School of Medicine has medical care influence in the Michigan peninsula and part of Illinois. Diamogr.aphy A. Population: approximately 4.5 million 1. Roughly 64% urban 2. Roughly.98% white Median age 29.4 years 3. B. Medical Schools: 2 C. Hospitals: Approximately 200 D. Physicians: 4,803 (medical) Region's Objectives: The objectives fall into three categories; those related to direct patient care, those related to requirements for effective support of direct patient care; and those related to basic research. The objectives are as follows: Develop a plan to improve preventive medicine capabilities throughout the region in the fields of heart disease, cancer, stroke, and related diseases. Plan to improve diagnostic capabilities with the region as related to heart disease, cancer, stroke and related diseases. Plan for improvement of the capability within the region to provide long-term medical care and rehabilitation for patients with heart disease, cancerstroke, and related diseases. Improve patient care through a plan to increase nursing support within the region. Plan to improve the support capability of allied health personnel within the region. Plan to increase the number of physicians in the region and to improve utilization of physicians within the region. Improve patient care through a plan for expansion of physical facilities, and the more efficient use of existing facilities within the region. Develop plans for expanding the effort in clinical research for heart disease, cancer, stroke, and related diseases. - - . ' - J--- And Wisconsin RKP -3- RM 37-04 (AR-1-D) 2/71 information flow program for the region. Formulate a plan for the development of an optimum program for con- tinuing postgraduate education in fields of heart disease, cancer, stroke, and related diseases. Develop a plan which provides for the most extensive participation and utilization of the capabilities of such established organizations as the American Cancer Society, Public Health Services, Heart Associations, etc. Expand and diversify already strong basic research programs in cancer, heart disease, stroke and related diseases and initiate new research relative to rehabilitation. Priority Determination: The Region indicates that the priorities are tied to points of decision related to the overall planning process. At each decision point, priorities are required to allocate resources in the best possible way. Six steps are outlined which are required to produce results for WRMP proposals. Three of these steps concern decision making that concern priorities. In the first step, WRMP establishes what it wishes to do during a particular planning cycle and attempts to establish priorities among potential proposals. A number of methods may be used to establish priorities to begin a planning cycle: a) progressively defining and redefining the organizations, goals & objectives. Ultimately, such a process could identify a set of manageable activities; b) various data sources, such as profiles of emergency room activities, hospital discharge data and national health survey can be used to isolate frequency of ailments and identify needs; c) a judgemental process could be used, presenting a decision maker with a set of possible programs and descriptive information expecting that he would add to this list. The results would be a raking of the possible proposals identified. The second step of the planning process is to examine the feasibility of high priority potential,proposals identified in the first step. For example, the staff would be concerned with the overlap of these potential proposals, their feasibility for development during the planning period, the approximate amount of resources they might require and the availability of these resources. The third step requires staff and volunteer development of feasible proposals. The fourth step of the planning process is the local review. The decision makers of WRNP, (the RAG) are responsible for this decision. There are two basic results from this review: establishing basic merit for each proposal and ranking acceptable proposals in order of local preference. Step five is DRMP review and rebudgeting constitutes the last step in a planning cycle. Priorities during rebudgeting represent the specific allocation of the available resources to approved projects. -4- RM 37-04 (AR-1-D) 2/71 Wisconsin R14P R gional Advisory GroU'D The group meets on a quart( .!rly basis and is composed of 40 members representing the following areas: Medical, from Clinic to individual practice: Insurance; Labor Unions; Minority Nursing; Dental, Medical Education; ic group interests; ;legal; Industry; Finance area-wide planning agencies; Pubi Health and Comprehensive Planning; Voluntary Agencies; Public Relations and Industry and Mercantile interests. The RAG was recently reorganized for the purpose of becoming more actively involved in all aspects of the work of WRMP. The group provides overall advice and guidance in the planning and operational program of WRMP; is responsible for the development of the goals and objectives and is involved in the review and evaluation of ongoing planning and operational functions. All Committees and study groups are subcommittees of the RAG with the chair- man of each subcommittee a member of the RAG. The duties of the RAG have been combined with those of the subcommittee in ways that have effectively involved people of diverse skills in many areas of the health, health- related and allied fields in cooperative efforts toward developing a strong and viable RMP. The by-laws of the RAG have been amended to roved for a 5-member Executive Committee who shall act for the RAG p between the regular quarterly meetings on matters specifically assigned by the RAG for interim action. .Review Process The Project Review Committee is composed of six members ox the Regional Advisory Group, representing hospital administration, nursing, and medicine. The committee meets before each Advisory Group meeting to study the applications and provides the Regional Advisory Group with a detailed review of the advance or completed application for project support and recommends action regarding the applications for final decision to the Advisory Group and endorsement by the Board of Directors. History of..Regional Development In April 1965, both the University of Wisconsin and Marquette University submitted separate applications which were considered by the National Advisory Council on Regional Medical Programs, and were deferred with the suggestion that a revised application be submitted. It was further suggested that cooperative arrangements would be enhanced through closer collaborative efforts between the two Medical Schools. During the interim between April 1965 and July 1966, the Wisconsin Regional Medical Pro ram Inc., was formed as a collaborative venture by the Marquette 9 School of Medicine and the University of Wisconsin. The Corporation is controlled by the Presidents of Marquette University and the University of Wisconsin. Management of the Corporation is vested in a 9-member Board of Directors with a broader representation which includes the State Medical Society of Wisconsin, The Wisconsin Hospital Association and Consumer interests. Dr. John S. Hirschboeck was elected secretary and appointed Regional Program Coordinator who is appointed by the Board of Directors. The Program Coordinator is directly responsible to the President of the corporation. The Board of Directors also appoints the Regional Advisory Committee and its chairman. Wisconsin RMP -5- RM 37-04 (AR-1-D) 2/71 In July 1966, the Wisconsin Regional Medical Program Inc., submitted a revised 2-year planning grant application which was'reviewed and approved by Council for the period September 1, 1966 - August 31,, 1968. After one year of planning activities 9/i/66 - 8/31/67, ttie second year planning grant was merged with the first year operational grant. The Region became operational following a preoperational site visit in July 1967. The second year (9/l/6,7 - 8/31/68) award provided continued. support for Core planning and administration, plus support for three feasibility studies (two in dial access tape libraries, And one for single concept films). In addition, funds were provided to support three operational projects. These were in Uterine Cancer Therapy, Pulmonary Thromboembolism and Cancer Chemotherapy for adults. During its third year, 9/l/68 - 8/31/69 (second operational) the region received approval for the renewal support of Core planning And Administration. Also during this period the region requested support for nine new operational projects contained in two separate applications. Seven of these were recommended for approval. During its fourth year, 9/l/69 - 8/31/70 (third operational) the Region received approval for the following projects; A Comprehensive Program in Renal Disease; Cardiopulmonary Resuscitation Project; Medical Library Service; Nurse Utilization Demonstration Unit; and renewal support for Dial Access Library Service for Physicians; Dial Access Library Service for Nurses and Single Concept Films project. In August 1970, staff considered a request from the Region for the fourth (operational) year (9/l/70-8/31/71) which contained requests for continued support for Core ($438,,974) and twelve ongoing projects (see listed below). The request was comprised of the total committed support of $965,444 and carryover in the amount of $60,704 as partial support for two approved projects; #16-Medital Library Service and #17-Nurse Utilization Demonstration Unit. Approval of continued support in the amount requested for the fourth year was recommended. Currently, the Region has the following approved/unfunded projects: Department of Health Manpower and Continuing Education; An Education Program for Cardiac and Intensive Care Nursing; and renewal support, with no additional funds for Inactive Nurse Education. Listin& of Current Funding Status of Core and Operational Projects Project Amount Supported (D.C.) Number Title Throukh 8/31/71 1 Core $ 438,974 4 Cancer Chemotherapy for Adults 38,500 5A Library Service for Physicians 16,900 -6- Rt4 37-04 (AR-1-D)2/71 Wisconsin R14P Table Continued Amount Supported .(D.C.) Project Thrnilah B'@l Number Title $ 19,020 5B Library Service for Nurses 5C Single Concept Films 20,500 6 Radiology and Nuclear Medicine 126,906 7B Coronary Angiography 5,800 57,256 7C Pediatric C;'ardiology 8 Cancer Chemotherapy Program (Milwauk6e) 64,384 11 Tissue Typing Program 50,950 12 Uterine Cancer Screening Proje'ct 50,820 Comprehensive Program in Renal Diseases 450,000 15* 16,525 16 Medical Library Service n Unit 119,613 17 Nurse Utilization Demonstratio 20* Detection and Management of Gynecologic Malignancy 116.125 TOTAL $ 1,592,273 Carryover included above: #16 $16,525 #17 44,179 $60,704 Not considered during staff review of continuation application. present Application This application contains a request for a developmental component in the amount of $200,000 for a one-year period beginning 9/l/70 - 8/31/71. Use of Developmental Funds The Regional Advisory Group identified areas of high priority program interest and recommended that developmental funds be made available for feasibility studies and program development. The following program areas were approved for use of developmental funds: Wisconsin RIIP -7- RM 37-04 (AR-1-D) 2/71 a. the planning and promotion of an improved coronary artery disease care system for the Region. b. the planni ng and development of innovations in health care delivery and manpower utilization. c. the planning and development of improved hospital emergency care and improved transportation of the sick and injured. d. the planning and development of innovations to improve long-term patient care, including home care and Nursing home care. e. the planning and development of means by which education can be brought to those health professionals who are not presently served. f. the planning and development of continuing education which is designed to develop proficiency in using new knowledge or new technology. the planning and development of improved health care for isolated rural residents. h. the planning and development of improved health care services for the poor and those who find it difficult to enter the health care system. i. the promotion of further involvement of health profession schools and their faculties in RKP activities. DRMP/GRB 12/8/70 (A Privileged Comniunication) SUMMARY OF REVIEW AND CONCLUSION OF January 1971 Review Committee WISCONSIN REGIONAL MEDICAL PROGRAM @M 00037--04 (AP,-l-D) 2/71 FOR CONSIDERATION BY FEBRUARY 1971 ADVISORY COUNCIL Recommendation: The Committee recommended that this application, which requests $200,000 for a developmental component be deferred and incorporated into their.triennial application. YEAR REQUEST RECOMMENDED FUNDING lst Year $200,000 TOTAL $200,000 Critiqi-ie: In its deliberation, the Committee considered the Site Visit Report, Wisconsin Re '.onal Medic ember 8-9, 1970. While &I al Proaraiii, Dec the site visitors recommended a proval for approximately $160,000 for p one year for the developmental component, rather than the $200,000 requested, members of the Review Committee believed that action should l&,b6 deferred with advice to the Region to incorporate their proposal for developmental funds into their triennial application, due May 1971. A member of the Review Committee, who was also a member of the December 8-9, 1970 site visit team, reported the findings of the team to the Committee. He reported that the Wisconsin PIIP has many strengths and much potential. One of the positive factors is the Program Coordinator who has fully devoted himself to the goals and objectives of RMP and who has done an excelient.job through the years of maintaining control over the management and direction of the I%TRMP. However, the team agreed and suggested to the Coordinator that he could probably use another M.D. on his staff as back-up to himself and to coordinate monitoring of WPMP planning and operational activities. He went on to state that while@the core staff appeared to be a cohesive group which has stayed together over.the years, they believed that i@ lacked sufficient depth and 8frength as to its ability to evaluate total program as related to objectives. Physically, the Core Staff is split'between Milwaukee and Madison. While the essential strengths are presently in the Milwaukee Core-offices, the Region is considering a plan to move and combine the two offices into one Central Core office which will be located in Madisoni I'he'Regional Advisory Group was viei,7ed-by the site visitors as being a well-balanced group, having broadened the range of professional and -health interests. Geographical representation has also been improved. It was noted that there is currently only one Black member.on the RAG, ut"this may be improved through appointment to a vacancy. The Committee RM 00037 (AR-1-D) 2/71. Fage 2 learned that the RAG has a strong role in policy direction and guidance of the program and has a strong input into the review pro@ess. The extent of the subregionalization efforts in Wisconsin was one of the concerns of the site visitors, although the Region is progressing in this effort, the team believed that further efforts should be made especially in the rural areas of the State. One of the major concerns of the site -visit team was the. lack of objective methods of evaluation. While the Region has the expertise available through the'Universities, evidental.ly this talent is not being fully exploited. Members of the Committee learned of the team's concerns regarding the large Renal Disease Project i-71iicLi is currently being funded in the Region. While the Reviewers were aware of the receri@ funding of this activity it agt6ed with the site visitors that some earl.y technical assistance would be necessary if the project is expectc@(-l to achieve its objectives. While the site visitors agreed that the MIP.is a we]-l-adjusted Region which has demonstrated that it has the machinery, expertise and loca 7utonomy to successfully and prudently administer and use a developmental omponent as a part of their tbtal- program, members of the Committee believed that the developmental component was too broad and all encompassing. it was believed that the Region should more adequately describe and speci y how developmental funds would relate to the priority needs of the Region. In conclusion, in spite of the site visitors.posit@Ll@@erecommendation on the request for developmental funds, the Review Committee a ter a some- what lengthy discussion, believed that the awarding of a developmental component at this time was not indicated. Rather, the Committee recommended that action on the developmental component be deferred with the thought, that the Region may wish to incorporate its proposal for developmental funds in the triennial application, which will. be considered during the July/Atigust 1971 Review Cycle. In arriving at the recommendation to defer action on this application, the Committee believed that the delay wou provide the Region with the opportunity to replan its anticipated use of developmental fundsi Also, the Committee further recommended that a technical site visit to include members of MMPS Kidney Disease Program, be made to review and assist the Region with the Renal Disease Project.. Dr. White was not present at the deliberation of this application. GRB/RMP 1/19/71