0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) Al.@]iANY Rl-"GIONAI@ MEDICAL PROGRAM RM 00004 7/70.1 Albany @,tedical College of Union June 1970 University Review Committee 47 New Scotland Avenue Albany, New York 12208 ram Coordinator: Frank M. Woolsey, Jr., M. D. Requested Program Period Ist Year 2nd Year 3rd Year TOTAL Direct Costs $61,700 $61,730 -0- $123,430 Indirect Costs 17,831 18,243 .-O- 36,074 TOTAL $79,531 $79,973 -0- $159,504 I-IISTORY: The Albany Regional Medical Program received a planning award in June 1966, and its first operational award in April 1967. The current annual level of support is $1,534,208 total costs: $993,951 for core and $540,257 for eight projects. See History Supplement at the end of this Summary Sheet. After two years operating experience, a renewal request for the entire program (at that time, Projects #1, 2, 4, 5, 6, 7, 12, 13, and Core) was reviewed by May 1969 Council. The reviewers were concerned about the progress of the Region: it appeared not to have developed much beyond the initial continuing education efforts with concentration of activity at the Albany Medical Center; the Coordinator and the Department of Post-graduate Education seemed to dominate the planning, review and implementation process: and the Region lacked plans for phasing out support of present activities. A subsequent site visit in May, 1969, conveyed the reviewers misgivings to the Region. Recommendations of the August 1969 Council on the renewal package and one supplemental operational project were designed Lo communicate the reviewers' concerns to the Region and provide time for program realignment e.g.,curtailed one year support was recommended for some projects about which there were concerns, but five vears! full funding was recommended for the supplemental operational project for a community leadership AI,BANY -2- RM 00004 7/70.1 Regional Medical Program program. The Council felt that any future application for funds must indicate that the ARMP has come to grips with its problems. Subsequently, March 1970 Council recommended that Project #17, comprehensive Communitv Stroke Program, be returned for further planning and revision. It was noted, however, that the stroke program proposal represented a welcome break from the Albany-based continuing education pattern which had been established. PIZESENT API'LICATION: This application contains a proposal for renewal support for Project #7- Community hospital Coronary Care Training and Demonstration Program, which was initiated ir April 1967. The project is presented in two parts, #7A and #7B, which are discussed separately below. The application also includes a request for Litil)-Dlemental funding of a new activity: Proiect #18 - Albany Regional Libra Service rovement of Library Services and Resources in Co iitv Hospitals. Direct costs only Ere noted in the project descriptions below. Project #s 7A (R) and 7B (R) and Demonstration Programs. August 1969 Council and the site visitors noted that the original intent of these two satellite centers to provide CCU training for nurses from nearby hospitals had been somewhat altered in practice, and the project appeared Lo be concentrating on training their own personnel. Consequently, onl.v One vear's additional funding was recommended with any future support dependent on the number of trainees from other area hospitals. The funding history of these two activities is as follows: 3OM5 7/lt§@-9/30/69 1-0/i/69-9/30/70 llroject #7A $27,705 $23,435 $17,940 Project #7B 27,705 24,485 18,990 Ilroject #7A (R) - Community Hospital Coronary Care Training and ue,,Lted Demonstration Program, Berkshire Medical First Year Center, Pittsfield, Massachusetts. This is a $17,9140 request for continued partial support to professional personnel i.ii proportion to their involvement in the educational component of coronary care activities at the Berkshire Medical Center. l@'ar.l.v in Albaiiy's history, as it became clear that the primary C()ronarv care training program at the Albany Medical Center (Ilroject #6) could not meet the staffing needs of all hospitals in the Region, a decision was made to establish secondary centers on a subrei,ional Al, BANY -3- RM 00004 7/70.1 Regional Medical Program '-)asis. The function of these facilities would be to share with the primary center the responsibility of training health personnel in intensive coronary care, to serve as a subregional demonstration unit. and to relate in appropriate fashion with the Albany Medical Center on one hand and the smaller community hospitals on the other. -It was in this atmosphere that the Berkshire Medical. Center developed a subregional coronary care program early in 1968. In order to effectively implement the program, it was decided that a minimum of three physicians contribute at least ten percent of their time to training, educational, and consultative activities. Similarly, three nurses were to devote one third of their efforts to these activities. The services of one half-time secretary were also deemed necessary. To date, 82 nurses have been trained at the Center, 73 from the Center itself, 8 from other community hospitals, and one from an extended care facility. Of these nurses, 33 received training in the three 25-hour courses conducted during 1969, and five were from outside Bc-!rkshire Medical Center. Future plans include involving more nurses from smaller liospitals,(at the time this application was prepared, eight nurses from other hospitals were enroll-ed for the next scheduled course) arranging a number of advance seminars at the Albany Medical Center, adding the ROCOM Ifultimedia Instructional System to the existing coronary care programi and cooperating with the Tri-State Regional. Medical Program in several joint ventures. These latter include a proposed Fellowship in Cardiology at the Berkshire Center and a system of telephonic ECG monitoring between the Center and a hospital and several institutions. Second Year: $17,940 Third Year: None Project #7B (R) - Community Hospital Coronary Care Training and Requested Demonstration Program, Vassar Brothers First Year Hospital, Poughkeepsie, New York. This $18,990 request is nearly identical to that made for Project #7A above, the single difference being that there are only two nursing positions in this proposal. The Vassar Brothers hospital was another of the sites selected to be one of the secondary, subregional coronary care centers described above. AI)proximately 90 nurses have participated in the program so far, and again, the vast majority were on staff at Vassar Brothers hospital. -4- RM 00004 7/70.1 Al,liANY Regional Medical Program (In 1968, six from other hospitals in the Poughkeepsie area partici-' pated.) Of these 90 nurses, 19 received training during 1969, and the application states that although an effort was made to involve partici- pants from other area hospitals, no candidates were made available. In the future, courses will be extended to other ancillary.personnel such as LPN'S, efforts will be made to,encourage more participation ,by smaller coummunity hospitals, and along these lines, it has been suggested that the ROCOM system be used in these smaller hospitals. There will also be a series of advance seminars at the Albany Medical Center for nurses chosen for their leadership potential at boththe educational and service level. Second Year: $18,990 Third Year: None Project #18 - rv Service Proiect - Improvement Requested d Resources in unit First Year a result of repeated requests $24,770 by hospital ad stance in training library personnel and partly due to the findings of a somewhat limited survey of library facilities and personnel, AMV has concluded that there is an urgent need for improvement in these areas. To meet this need, the Region has developed a program that is to be implemented in two phases. The first phase will concentrate on training existing community hospital personnel in the basic essentials of medical librarianship, and it is for this phase that support is being requested in the present applica- tion. The second phase, which is to be initiated two years after the start of Phase 1, will attempt to establish a cooperative medical library network within the Region for exchange of materials and reference service and to provide a professional librarian to coordinate and supervise the library network in the Region. During Phase I, hospital administrators and executive committees of medical staffs will be informed of the nature of the project and will be given the opportunity of sending one individual to the nearest training center. They will be encouraged to seek candidates with bachelor degrees to fill vacancies that occur in hospital libraries. The hospital administrator sending a candidate into the program will also be encouraged to declare his institution's willingness to purchase a minimum core collection of library materials and provide a budget to insure its upkeep and servicing. The Phase I proposal is for two training centers to be established within the geographical bounds of the Albany region, Ellis Hospital located at ALBANY -5- RM 00004 7/70.1 Regional Medical Progtam Schenectady, New York and Will Rogers Memorial Hospital, Saranac Lake, New York. Each training course will,be given over a period of 40 hours. It .may be given in a one-week. program or it may take place over a -.Longer time, interval depending on circumstances. There will be between four and six students in each course. As for evaluation, trainees will be examined before and after the course to determine the amount of knowledge acquired and again six months later to measure the degree of retention. The hospitals that have had personnel trained through this project will be surveyed by the project coordinator to determine the type of book and journal collections and to evaluate the amount and quality of services rendered to the staffs of these hospitals. Finally, and in anticipa- tion of Phase II, all community hospital libraries, regardless of whether they have sent people throughthe program, will be requested to maintain certain minimal statistics including the number of books and journals in the library, the number and types of items circulated in six months and one year, the number of reference questions received and interlibrary loans made in the same time period. This data collec- tion would begin with the start of Phase I. ARNP is aware of a number of other similar efforts in varying stages of development within the Region. These include New York State Inter- library Loans (NYSILL), Capital District Library Council, State University of New York Biomedical Network, New York and New Jersey Regional Medical Library, and several others. The Region states that the present proposal does not duplicate any of these other programs. More detailed information on Phase II will be submitted at a later date,, but at present, it can be said that it intends to make available virtually all learning modalities: books, journals, tapes, films, records, etc. Services that are to be provided include reference, interlibrary loans, bibliographic and technical assistance, and rap:kd communications. Second Year: $24,800 Third Year: one RM 00004 7/70.1 -6- ALBANY Regional Medical Program HISTORY SUPPLEMENT Current Yearl@ Support or Initiation PROJECT Project Title Status (DCO) Date 1 Two-Way Radio Communication System $143,975 4-1-67 2 Community Information Coordinator Now included 4-1-67 in Core 3 Communication and Information Disapproved Activities 4 Postgraduate Instruction Development Panel $80,745 4-1-67 5 Community Hospital Learning Centers $111,082 4-1-67 6 Albany'Medical Center Coronary Care Training and Demonstration Programs $71,746 4-1-67 7 Community Hospital Coronary Care $36,930 4-1-67 Training,and Demonstration Program 8 Regional Rehabilitation Team Disapproved 9 Training Program for Physical Therapy Aides Not Funded by Region 10 Expansion of Albany County Tumor Registry Not Funded by Region Development of Computer Utilization Disapproved Intensive Cardiac Care Unit - Herkimer $7,207 4-1-67 1-3 Schenectady Cancer Coordinator $5,000 1-1-68 114 Core $712,094* *IL should be noted that the core bud2et included $60.020 in personnel costs for partial support of the planning and development stage of the Albany North End Community Health Center. The Health Center project is OCHP - approved but not funded. As soon as OCHP money is available, support will end. ALBANY -7- RM 00004 7/70.1 Regional Medical Program 15 Establishment of Regional Cancer Disapproved Program 16 Development of Community Leadership Program $9,030 10-1-69 17 Comprehensive Community Returned for revision Stroke Program GRB-5/19/70 SUi4MARY OF 0, JUiiE 1.970 ALBANY MEDICAL PROCIIA.14 @l 00004 7/70.1 FOR CONSIDERATION BY JUT:,Y 1970 ADVISORY CO@ICIL General: The Committee recalled its lengthy discussions of a year ago which were occasioned by the Albany Regional Medical. Prograni's continued concentration of efforts in continuing education throtlch the Albany Medical Center. It was noted that the Community Hospital Coronary Care Training and Demonstration Program, which is presented as Project l@-s 7A(R) and 7B(R) in the present application, represented an effort toward r(@gionalization of R@IP activities, and approval of renewal support was -ii @c@i-ni-nei-ided on those grounds. The Albany Regional Library Service Project f@ @,7hich supplemental funding is being requested, was not considered v@ enough developed to warrant approval at time; the Committee @,,3tecl revision. Project Yi's 7A(R) and 7B(R) - o@Tmn n@ity I il2s2_tal g2r narv Care Trai.ni-,IP, 2 and Demonstration Pro@rraitis. Ln@a ( i@: These two satellite coronary care training programs in community hospitals, Project 7A (Pittsfield., Massachusetts) and Project'7B (Poughkeepsie, Now York), were discussed together because of their marked similarities. It was noted that there appears to be some increase of trainees from the area surrounding the Berkshire Medical Center (although still rather minimal) since Committee reviewed t j@,9 project a year ago, but very little involvement of those hospitals ill the Poughkeepsie area (but with expectations for future involvement licaLioii). This prompted a discussion as to whether expressed in the app such a slight increase in the number of trainees from other hospitals was sufficient justification for further funding of the two projects. It was pointed out that one of the primary problems of the Albany P,@I.P has been its abysmal lack of involvement outside of the city of Aibaiiy itself and that these projects represent definite regiortil-izatioii efforts; that these. activities evidence an interest the care world (albeit education); that efforts are being made to rc@d,-@ @@lie apparent resistance 1, on the part of other hospit@.Is i,ii the ar,,@a to I ;@o each of these two coil.imilriity cc-nt-c,.rs for training of their personi-!,'@ .,iiid that these programs are working to break down the seeming iriLc-,rprof@- .formal ai)i.iiiosity toward this outward expansion. Many Committee the modest of money requested :co2- these two projects got the Re@,ioi:k over hu.,,,i P. It was also iiote(.t that the costs of the programs will be absorb(-et at the local- level- at the end Of tl,7o additional. years of support. R e c -@i eri cl t i, c)-,i In light Of the ,ti)o-,;e the Cc)i,,siiit:tce r,@,coiii,.@ic,.nclcd Appro\tal I i@) the finite and aiiiouT-it: two ALIM-INY Vegloiiai kleclicai Program -Z. - IWI VVUV'E /tiv.-L that a mechanism be developed to provide encouragement for the involvement of personnel of community hospitals in the two training centers, and 2. that the Region clearly specify that the training program will, be continued beyond the project period without additional support from PL%IP. DIRECT COSTS ONLY: Project Ist Year 2nd Year 3rd Year 7A(R) $17,9/4-0 $17,94o 0 7B(R) 18,990 1.8,990 0 There were two dissenting votes. Project Y[18 - Llb @n Ser-vi.ce Prolect - IInDrovemeiit of LibraL.y.13-.r@v-Lcc,,@l d Resources in Coinmu.nitv I-Tosi-)i.tals. The Co,@nmi-ttee was hampered in its evaluation of t-hi.s project by the lack of basic information as to the number of courses planned and any supporting data documenting the availability of students. It was noted that there appeared to be little transition from data glc@an,ed through a survey of library needs and the proposed solutions to pro e.-i.-ns which are contained in this project proposal. Specifically, altl-iou.@.@ll trained personnel does not surface from the survey as a primary need, the approach i-s to train personnel as a first step,, There was also concern about the relationship between the budget iiid the Phase I proposal. Almost half of the request is for a project coordinator at the Albiny College while the training is to be carried out at the Ellis and Rogers Hospitals. A National Library of Medicine technical review indicated concern as to the apparent overemphasis which the project places On training without the important aspects of consultation. a)-id assistance to the librarians trained which might be necessary to make the system work. The NIM reviewer also noted that the ippli.catior@ appears to propose the beginnings of training projects in the absence of any plan for the long-range measurement of li.])rary and information needs within the Region. pi-i-)iiary ict:i-vitic-@s would be the Since one of the project cooi--A planning of future projects, the "revie@@ic@@ics bc-lie-vcd that pertiips the main function that would be sorvc.,@,(1 by the project would be the development Of a greatly expanded request for library activities in the Albany Region. In short, although the Regi.oii has collected data relative to the hospital. library situation, it was felt that the 3-c-,@tiltii@ig project: is not adequately developed to warrant fun.0i,ng at tiAis time. It was suggested that the project ]Dt-- returned for revision, pointing out the eie.@Eici-ciici.(@s ilient i@011,E@Cl above,,, advising thit the Region develop either a rc!qLi(@st for pla-i@).f).in,,, for library activities or a request for training If the rc,,vi.si..@@,,i is to be a training request, the prc)roF,,il-, in idclitioii f-@ out the should clearly defi.).-),c,@ on a of potential. trainees and the nuTpl)(.,r of the col-@rses be Non--Apl)rov@-I ",-I Y@.c@v@l.,sion adv:Lcc@. ALBANY Regional Medical Prograin -3- P\M 00004 7/70.1 Concl.usions: .01 Year 02 Year 03 Year Project #7A(R) $17,94.0 $17,9@@o 0 Project Y@7B(R) 18,990 18,990 0 Project Y@18 Non-Approval II Return for Revision TOTAL $36,930 $36,930 0 DRI\IP /GRB 7/10/70 a 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) ARIZONA REGIONAL MEDICAL PROGRAM RM00055 7/70.1 University of Arizona College of Medicine June 1970 Tucson, Arizona 85721 Review Committee Program Coordinator: Dermont W. Melick, M.D. Re -,3tcd Program f-eriod Ist Year 2nd Year 3rd Year Total Direct Costs $151,395 $146,053 $150,628 $448,076 Indirect Costs 33,189 34,786 36,560 104,535 TOTAL $184,584 $180,839 $187,188 $552,611 IIISTORY: Support for initial planning in this Region was authorized or two years and three months (April 1, 1967 - June 30, 1969), $119,045 the first year, $409,108 the second year and $138,095 the third period of three months. During the second year, an application for earmarked funds for a Chronic Pulmonary Disease Program was disapproved by Council (November 1968) with advice to revise and resubmit. Due to delays in the review and funding of the Region's operational program, the planning period was extended by nine months, April I - December 31, 1969 (two separate extensions) with additional funds totaling $500,028. In May 1969, Council considered the initial operational application. As recommended, a site visit was made that same month to study the Region's operational capability. The application requested support for renewal of core staff activities and six projects. Two of the projects were in the medical library field, one for continuing education of nurses, one for recruitment and utilization of social service manpower one cardiopul- monary resuscitation training and one revision of the previously submitted chronic pulmonary disease program. The site visit team was greatly concerned about the dominating needs of RMP in Phoenix and peripheral areas, and the contrast in the Region's plans to concentrate its head- quarters near the Medical School intucson. It was also believed that the evaluation capability of the Region should be strengthened by acquiring the services of a specialist. Impressions with staff leadership were favorable. The team believed that there was adequate evidence that the Region was ready to assume operational status. Although some major problems had hindered development of the Region's program, the I- itors were convinced that further planning would not have increased the capacity to implement an operational program. *v s ARIZONA Regional Medical -2- RM00055 7/70.1 Program As recommended by Council during the August 1969 meeting, $795,406 (d.c.o.) was awarded for support of the operational program. This action excluded the cardiopulmonary resuscitation training project which was deferred pending further study and policy decision. The Council recorded its interest in observing this Region's progress in dealing with the problems of delivery of health care to the people of this state, particularly the widely dispersed rural population of American Indians, Mexican-Americans, and migrant workers, and others not being served. During the August 1969 meeting, Council also considered the Region's first supplemental operational application for support of three continuing education projects: Education In Coronary Care; Community Education for Nurses; and Long-Term Education for Nurses. Council recommended disapproval with advice to resubmit. Reasons for this action included: 1) absence of coordination between the three projects; 2) lack of medical school involvement; 3) inadequate physician partici- pation; and 4) weakness in ob ectives, curricula, and evaluation. With regard to the long term education project, the reviewers also believed there might be some overlap with the regular Master's Program in- Medical Surgical Nursing offered in Tucson. Following the evolvement of a policy by Council during the December 1969 meeting, the Region appropriately revised the "Cardiopulmonary Resuscitation Training" project, including strengthening the evaluation component. Although approved, funding status has not been determined. Council alto considered a new supplemental request for support of a "Nutrition Care Program for Heart, Cancer, Stroke, Diabetes and Related Diseases" project. Recommendation: Return for revision (with the suggestions of the Review Committee). PRESENT APPLICATION: In light of the August 1969 disapproval of three Continuing Education Training projects, and Council's suggestions, the Region redeveloped a program for coronary care training which will ultimately involve five projects. Two of these are submitted for funding consideration. The remaining three, still in development to be submitted later, deal with 1) outreach continuing education for nurses and physicians; 2) public information and education; and 3) continued education for nursing personnel in the Tucson area. The Region believes that the projects now meet all the suggestions by the Council and will provide basically needed education and consultation services. First Year Project #11 - Continuing Education Program for Nurses $76,583 Submitted by St. Joseph's H ospital, this is a project to be centered in the Phoenix metropolitan area. In planning the program, the ARIZONA Regional Medical -3- RM00055 7/70.1 Program applicant was assisted by an Advisory Committee, membership which included representatives of appropriate agencies including the Region and the University of Arizona College of Medicine. The project proposes a series of courses for Arizona registered nurses. Training involves four levels of instruction; basic, advanced, refresher, and leadership. The four courses, ranging from three days to four weeks, will entail 11 sessions (23 weeks) for 420 enrollees. For purposes of sharing coronary care facilities for instruction and clinical experience, four other Phoenix hospitals will participate. Cooperating hospitals are: St. Joseph's Hospital and Medical Center, John C. Lincoln Hospital, Southside Hospital, Baptist Hospital and St. Luke's Hospital. In conjunction with the companion project #12, eight seminars are to be conducted in different localities. Jointly, the projects will also provide consultation to Arizona Hospitals. A Liaison and Coordinating Committee for the overall Coronary Care Program in Arizona is to provide guidance in scheduling and evaluation. A project Advisory Committee will also be utilized in the evaluation process as well as the professional assistance of the University Department of Systems Engineering, a subcontract arrangement. Approximately 50% of the budget is for personnel, three full-time positions (Nurse Director, R.N. Instructor and Secretary) and ten part- time (Project Director, Medical Director, M.D. Instructor, lecturers, four hospital nurse preceptors, Leadership Instructor and Physical Therapist). Support is also requested for an electronics engineer, equipment, supplies, travel, subcontracted evaluation-service, publications and per them stipends for course enrol-lees. Second Year: $77,405 Third Year: $ 79,988 Project #12 - @oronary Care Trainin@ Pro4ram of Arizona, Post-graduate Courses and Seminars for Physicians, First Year Hospital Administrative Personnel and Trustees. $74,812 Submitted by the Department of Cardiology, College of Medicine, University of Arizona, this is a companion to project #11, "Continuing Education Program for Nurses." This is a three-year proposal to provide three annual five-day courses for physicians from hospitals where nurses have attended or are scheduled to attend recognized training programs. Alternating between Tucson and Phoenix, the training will be conducted in the coronary care units of five participating hospitals: Veterans Administration, Tucson; University of Arizona Medical Center, Tucson; St. Joseph's, Phoenix; St. Luke's, Phoenix; and Tucson Medical Center. It is anticipated that 108 physicians will be trained during the tliree-year project period. Courses will be conducted simultaneously with the "basic" nurse course offered by companion project #11. @ ARIZONA Regional Medical -4- RM00055 7/70.1 Program In addition, eight annual one-day seminars will be conducted in eight localities and consultation services will be offered. Coordination with other projects of the "Coronary Care Training Program of Arizona", is to be accomplished through a Liaison and Coordinating Committee. This Committee and the Regional Core Staff, assisted by The Arizona Department of Systems Engineering, will be responsible for assessing program effectiveness. Approximately 40% of the budget is for personnel, 2 full-time positions (secretary and assistant to the project director) and four part-time positions (the project director, two physician instructors, and a practicing cardiologist instructor). Support is requested in all budget categories; the most significant amounts are for special consultant services to hospitals, three consultants for each of the eight seminars, evaluation subcontract and travel. Second Year: $68,648 Third Year: $70,640 ARIZONA Regional Medical -5- RM00055 7/70.1 Program REVIEW AND FUNDING HISTORY Ist Year Planning Award 4/l/67 - 3/31/68 $119,045 (February 1967 Council) 2nd Year Planning Award 4/l/68 - 3/31/69 346,125 02 Supplement I/l/69 - 3/31/69 62,983 (May 1968 Council) Chronic Pulmonary Disease Program - Application for "Earmarked Funds" (May 1968 Council) Deferred (Site Visit August 1968) (November 1968 Council) Disapproval with Advice to Resubmit 03 Year Planning Award 4/l/69 - 6/30/69 138,015 03 Year Extended with Funds 4/l/69 - 9/30/69 255,303 03 Year Extended with Funds 4/l/69 - 12/31/69 361,933 INITIAL OPERATIONAL APPLICATION (May 1969 Council) (Site Visit May 1969) (August 1969 Council) Fun0e@ A-pproved Future Level rojects (1/l/70 - 12/31/73) 01 Year 02 Year 03 Year 'W@00 -Core Staff Activities $503,300 $@03,300 0 I - Checklist - 20th Century Books (Approval in Principle) 0 0 0 2 - Medical Library Network 35,211 35,211 35,211 3 - Chronic Pulmonary Disease 150,000 112,000 120,000 4 - Continuing Education in Nursing Care of Patients 56,895 74,307 84,118 5 - Recruitment and Cont. Ed. Social Service 50,000 50,000 0 6 - CPR (revised March 1970) Approved not funded as of 4/9/70 $795,406 $774,818 $239,329 FIRST OPERATT'@ONAL SUPPLEMENT APPLICATION (August 1969 Council) 7 - Continuing Education, Coronary Care Disapproval with advice to resubmit i@ 8 - Continuing Education Program for Nurses Disapproval with advice to resubmit 9 - Long-Term Continuing Ed. for Nurses Disapproval with advice to resubmit RM00055 7/70.1 ARIZONA Regional Medical -6- Program SECOND OPERATIONAL $UPPLENENT APPLICATIONAL (March i970 Council) #10 - Nutritional Care Program Disapproval wit@ advice to resubmit *August 1969 Council - Deferred for further study December 1969 Adopted CPR policy March 24, 1969 Region submitted a revision in keeping with policy 5/5/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW CO@IITTEE ARIZONA REGIONAL @IEDICAL PROGRAM RM 00055@- 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Review Committee concluded that this application for $448,076 (d.c.o.) for three years should be funded in the re duced amount of $426,326 with conditions and an expression of concerns as indicated below under specific projects. It was noted that this application is the outcome of the disapproval of three continuing education training projects reviewed in August 1969 and Council's suggestions. The Region is redeveloping a program for coronary care training which will involve five projects, two of which are in this application. The remaining three are still in the development 9tage and will be submitted later. Reasons for disapproval of the previous proj- ects were taken into account in the preparation of this application. Interlocking relationships between the two projects is noted as well as cooperative arrangements in the Tucson and Phoenix areas. Funding will allow the ARMP to begin a regionalized coronary care program. Project #11 Coronary Care Training Pro,-,ram of Arizona, Continuing Education for Nurses Critiaue: The Committee noted the favorable review comments prepared by the Continuing Education and Training Branch staff. However, the Committee believed the project leadership may not be as strong as is implied in the application. Also, there was concern that the curriculum is too didactic and should be more clinically oriented. Committee questioned why "training in nursing administration" is a prerequisite for the associate project director position. It was also believed that send- ing hospitals should share half the costs for stipends. Recommendation: Approval I with the condition that only half the costs of stipends be supported with RMP funds, the remainder being the responsibility of the participating hospitals. It is also recommended that the ARMP be informed and requested to respond about the concerns, as well as the question about the administrative requirement for the associate project director. Project #12 - Coroiaarv Care Training Program of Arizona, Post-graduate Courses and Seminars for Physicians, Hospital Administrative Personnel and Trustees Arizona 2 Critique: Committee concurs with the review comments by the Continuing Education and Training Panel. 'In general, the plan seems well designed and the need is adequately founded. The operational objectives are clear, but the goals relative to change of behavior are not and are less measurable. In terms of time frame, staffing and utilization of resources, the project is feasible. The foci of the evaluation are upon the acquisition of knowledge and the degree to which the project will stimulate the development of additional care facilities. There should be a greater focus on the outcome of training as it will effect patient care. Of major concern is the method of selecting physicians for train- ing. It is hoped that physicians accepted for the course would come from hospitals with specialized facilities and equipment, and that they would be utilized with greater precision after training. Recommendation: Approval I in the amount requested. It is a so recom- mended that the ARNP be informed of the concern about the selection of physicians. S Y OF RECOMHENDATIONS Direct Costs Projects 01 -02 03 Total #11 Cont'g $ 69,333 $ 70,155 $ 72,738 $212,226 Ed. for Nurses #12 Post-grad. 74,812 68,648 70,640 214,100 Courses & Sem. for Phys. Hosp. Adm. Personnel & Trustees TOTAL $144,145 $138,803 $143,378 $426,326 DRMP 7/2/70 0 0 REGIONAL NEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLENENT GRANT APPLICATION (A Privileged Communication) ARKANSAS REGIONAL MEDICAL PROGRAM RM 00052 7/70.1 University of Arkansas Medical Center June 1970 Review Committee 500 University Tower Building 12th at University Little Rbck, Arkansas 72204 PROGRAM COORDINATOR: Charles W. Silverblatt, M. D. Requested Program Period lst Year 2nd Year 3rd Year Total Direct Costs $88,149 $82,769 $83,896 $254,814 Indirect Costs 13,771 14,459 15,905 44,135 TOTALS $101,920 $97,228 $99,801 $298,949 HISTORY: Arkansas received its first planning grant ($341,846 d.c.6.) on April 1, 1967 and its second, for the same amount, on April 1, 1 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's progress in developing its program and evaluating ten supplemental project proposals. The site team concluded that considerable progress had been made since the earlier visit, especially when consideration was given to the limited resources the Region had to work with. The only area of concern was the Regional Advisory Group's project rather than planning orientation. 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 13 projects. See the History Supplement following this summary sheet for a listing of projects. ARKANSAS REGIONAL 'MEDICAL PROGRAM -2- RM 00052 7/70.1 As a result of the recent release to RMPS of funds that had been placed in administrative reserve by the Bureau of the Budget, negotiations are now under way to fund five of the Region's back- log of approved-.unfunded projects in the amount of approximately $200,000. Also of note is the appointment in January 1970 of Charles W. Silverblatt, M.D., as Program Coordinator. Dr. Silverblatt succeeds Dr. Roger Bost. PRESENT APPLICATION: This application requests supplemental support for one new project, #35 - for Dieticians and Health Facility Food Service Supervisors n Arkansas. Direct costs only are noted below. Project #35 - Continuing Education for Dieticians and Health Requested Facility Food Service Supervisors in Arkansas. First Year The goals of this proposal are to improve the skills of the $88,149 personnel (dieticians, dietary consultants, and food service supervisors) in charge of nutritional services in hospitals, nursing homes, and related facilities and to encourage pre- sently inactive dietetic personnel to return to work. Of the 331 hospitals and nursing homes in Arkansas, only 71 have any supervision of food service by qualified dieticians (of which there are 59 working full and part-time). Because of the lack of qualified dieticians, greater responsibility for dietary services has fallen to the food service supervisors and to relatively untrained persons acting in this capacity. A survey of the 331 institutions showed that the @ could expect 520 participants per year at dietetic courses. There are 32 inactive dieticians in the State, 18 of whom indicated through a survey their interest in returning to active employment if training opportunities and jobs were available. Since the types of training will differ with the sophistication of the audience, several presentations are planned. These programs and public forums will be held in four different areas of the State as follows: 1. Seminars for dieticians and food service supervisors of two and one-half days length in Little Rock, Fayetteville, Jonesboro, and Arkadelphia are expected to accomodate 400 participants. 2. A two-week diet therapy short course for dieticians will be presented at the University of Arkansas Medical Center in Little Rock for 25 people. ARKANSAS REGTONAL MEDICAL PROGRAM -3- RM 00052 '7/70.1 3. Institutes for diet consultants in Little Rock and Fayetteville will be presented for an expected 70 participants. Each course will be two and one-half days in length. 4. One-day workshops for food service supervisors in each of the four locations mentioned above will train a total of 200 people. 5. Hour-long public forums will be presented in each of the four areas. Thirteen organizations and institutions in Arkansas have pledged to participate in and to support this program and plans have been made to coordinate this project with other @ on-going activities. An evaluation protocol is presented which includes measuring the upgrading of skills of those participating through pre and post tests and determining the number of inactive personnel who return to the field as a result of this program. After the three-year period of the program has been completed, educational institutions within the State will be encouraged to offer continuing education programs for dieticians and food service personnel. The first year request for $B8,149 includes $31,866 for personnel and consultants and $24,900 per them for course participants. Second Year: $82,769 Third Year: $83,896 ARKANSAS REGIONAL MEDICAL PROGRAM -4- RM 00052 7/70.1 HISTORY SUPPLEMENT Annual Initiation Project Title Support d.c.o. Date 1 Core Support $304,425 4-67 2 Coronary Care and Supporting Diagnostic unit for Postgraduate Training of Physicians and Nurses 82,295 2-69 3 Nurses Coronary Care Training 51,526 2-69 4 Pilot Study - Computerized Assistance to Cardiac Patient Care Unfunded 5 Cardiopulmonary Resuscitation Program 29,533 2-69 6 Computerized Tumor Registry 57,428 2-69 7 N.W. Arkansas Regional Cancer Program 23,020 2-69 8 Health Careers Recruitment 26,065 2-69 9 Regional Hospital Medical Library System 31,037 2-69 10 Nuclear Medicine Technology Training Program 18,902 2-69 11 Dietetic Internship and CE Program Disapproved 12 Western Arkansas Cancer Study 24,705 2-69 13 CE for Nursing Personnel and Citizens 38,570 2-69 14-19 Revised as Project #'a 28-33 20 North Central Arkansas Region Cancer Center Approved/Unfunded 21 Twin Lakes Rehabilitation Center Approved/Unfunded 22 North Central Arkansas Stroke Rehabilitation Center Approved/Unfunded 23 Revised as Project #34 24 Remote Computerkssistance to Arkansas Pbysicians 25 CE for Physicians 26 CE for Pharmacists Approved/Unfunded 27 Refresher Training for Medical Technologists and Technicians Approved/Unfunded 28 CE in Cardiology for Physicians Approved/Unfunded 29 Model Cardiac Care Unit - Stuttgart Memorial Hospital 30 Area-Wide Intensive Care Unit and CF in Coronary Care for Physicians and Nurses A@%'@SAS REGIONKL @U-@DICAI, PROGWI -5- IZ@l 00052 7/70.1 31 Instruction in Neurologic Aspects of Stroke, Brain Tumor and Cancer Approved/Unfundc@d 32 Demonstrqtion and Training in Care and Handling of Stroke Patients 33 CE in X-ray Technology and Relited Fields Approved/Uiifutided 34 Regional Laboratorv Quality Control Approved/Uiifunded *An award of $200,000 is expected to be made before July 1, 1970 for partial support of these five projects, DRMP/GRB 5/28/70 !eRed Communication A Privi, SMILRY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE ARKANSAS REGIONAL MEDICAL PROGRAM RM 00052 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL ogram has General: It was noted that the Arkansas .Regional Medical Pr s of the limited resources but an expansive program in term number and types of activities being supported. the reviewers were impressed with the breadth of the program. ,Project #35 - Con ucation iails and Healt Facility Foo Service SuDervisor in Arkansas. The Committee agreed with the Continuing Education and Critique: Training Branch that the project proposal presents a well- documented needt a technically--,@ound methodology, and a good phaseout plan for the continuing education of dieticians and food service super- visors. Since food service supervisors, by definition, are concerned partly with management functions, some time was devoted to a discussion ibil4ty for continuing of the personnel level at which MT respons I education ends. Although the reviewers agreed that their reactions 5,_I-it be different if this were another geographic area where nursing mi@ at the homes might have dietition staff, a consensus was reached th quality of food service supervisors has a direct bearing on the quality h- ursing homes in Arkansas, and t is is a of health care rendered by n legitimate area for RllP support. Even though the general impression of this project was most favorable the Committee had certain specific concerns it wanted to build into its recommendation of approval- 1. The project advisory committee is composed of dieticians only. The reviewers believed the addition to the committee of one or two food service supervisors would be most helpful in assuring that the continuing education program is designed to -meet the needs of this group. 2. The proposal does not address the beneficial effect this project could have as a stimulus for encouraging the involvement of Arkansas community colleges, high schools, and other educational resources. For instance, community colleges might be induced to develop associate degree programs in dietetics. 3. The Committee would like to see a careful evaluation of the PrOL,,ram's progress and effectiveness after two years of operation. ARKAliSAS Regional Medical Program RM 00052 4. The Committee recommended, as it did with other continuing education projects reviewed during this cycle, that a 50% cost-sharing principle be applied to the amounts budgeted for per them and travel,_,,for course participants. Recommendation: Approval I in a reduced amount for two years with the . specific conditions noted above: expansion of the advisory committee to include food service supervisor representation; involvement of educational resources in Arkansas; comprehensive progress report and evaluation of two years' experience; and reduction of the budget to provide for 50% cost-sliaring of participants' per them and travel expenses. 01 $71,330 02 $65,950 DRMP/CRB 7/10/70 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) BI-STATE REGIONAL MEDICAL PROGRAM RM 00056 7/70.1 (Washington University) June 1970 Review Committee 607 North Grand Boulevard St. Louis, Missouri 63103 Program Coordinator: William Stoneman III, M.D. Requested Ist Year 2nd Year 3rd Yea-, L Direct Costs $146@815 $123,165 $128,790 $398,770 Indirect Costs 52,325 55)184 58,200 i65,709 TOTAL $199,140 $178,349 $186,990 $564,479 History: The Region was awarded an initial planning grant for the year April 1, 1967 through March 31, 1968. The original award was extended for a seven-month period through October 1968. Staff review of the continuation application for Core planning resulted in a second-year award (November 1, 1968 through October 51, 1969) of $644,922 (total costs) which included basic funding of $331,622 and a carryover of $313,300 from the first-year planning grant. The Region submitted its first operational application during December 1968. This application requested support for additional Core staff to initiate the operational program, plus funds (2% overhead) to be used for 'developing satisfactory financial arrangements with affiliated institutions and for insuring the accurate accountability of funds. The overhead requested was subsequently denied because of a lack of justification. The original operational application requested support for six projects. A preoperational site visit was conducted during April 1969. The team's report favored having the Region become operational. Following this, May 1969 Council recommended approval of three of the six projects (see last page for History Supplement - Projects #2, #4, and #5) plus the additional Core support requested. It was recommended that the three remain- ing projects be returned for revision. Effective July 1, 1969, an award of $433,395 (total costs) was made to the Region - to support the Core Supplement plus the three approved projects. During the July/August 1969 review cycle, the Region submitted a supplemental operational application which contained a renewal request for Core support, plus support for three operational projects. Council recommended approval for the Core renewal and the three projects. Due to fund limitations, the three projects are classified as "approved - unfunded" projects (see History Supple- ment - Projects #7, #8, and #9). The Core renewal has been awarded. The Regional Advisory Group is composed of 56 members, representing a mix of physicians, allied health personnel, personnel from health organizations, and public members. Reorganization of the RAG has been planned for some time. The DI-STAT,,E RECIONAL MEDICAL PROGRAM -2 RM 00056 7/70.1 present--@xperienced group has been retained because of substantial tinr-erLa'Lnties regarding major strategy decisions at this level. Of ma or concern are the uncertain prospects for funding and the possible necessity for organizational changes involving priorities. Also, in .the near future, the Regional Advisory Committee and the Administrative Liaison-Co=ittee plan to recommend a reorganization of the Core staff so the Southern Illinois University (one of the three participants in the ini tial consortium agreement) will be included in Core activities. A Dean has recently been appointed to the new Southern Illinois University School of Medicine. There will now be three medical schools in t e Region. The advent of Regional Medical Programs has acted as a catalyst and provided the means by which St. Louis University and Washington University have lea'rned to cooperate in solving the multitude of health problems existing in the Bi-State area. It can be assumed that this feeling will be communicated to the new medical school. Present Application: This is a request for two individual projects which represent the Region's initial attack on heart disease. (Note: During the April/May 1969 review cycle, a proposal - Project i@l - for the of a program of rehabilitation and a secondary pre- vention Eo-- -;ati--r-ts who have had myocardial infarction, was considered. In -rec;.,r,-!,-'nending "non-approval - revision requested," Committee viewed the program described as a clinical research activity which might be more acceptable if oriented toward the development of a service.) Direct costs only are noted in the following project descriptions. 7 Requested Project #12 - A Proposal to Establish a Coronary Care Trainin?, First Year Program for Nurses - St. Louis University School $73,015 of Nursing and Allied Health Professions. This is a three-year request for coronary care training for nurses, to meet the Region's need for nurses trained in care of the acutely ill coronary patient. A survey recently conducted by the Bi-State RMP Heart Committee revealed that the rate of establishment of coronary care units outpaces the supply of trained personnel needed to man the units. The surv6 was the outgrowth of the activities of the RMP Heart y Committee. The Heart Committee's deliberations led to formation of a subcommittee on coronary care training; the findings of the subcommittee motivated this proposal. Question naires were sent to 154 geographically well-distributed hospitals, and 78 interested hospitals responded. The hospitals care for a substantial portion of the Region's myocardial infarc- tions. The program will consist of eight five-week courses per calendar year. A minimum of 210 nurses will be trained during the three- year period. The courses will include both didactic and clinical instruction and are designed to meet the needs of nurses who are, BI-STATE REGIONAL MEDICAL PROGRAM -3- RM 00056 7/70.1 or will be, working in a coronary care unit. The courses will be open to registered nurses nominated by a hospital with a coronary care unit currently in operation, or by a hospital planning to install such a unit. On return to their own hospitals, the nurses are expected to pass on their newly acquired knowledge and experience. Cooperating in the instruction portion of the program will be: St. Louis and Washington University Schools of Medicine, Barnes Hospital, St. Mary's Hospital, John Cochran Veterans' Administration Hospital, and the St. Louis Heart Association. Second Year: $59,025 Third Year: $61,623 Requested Project #13 - A Proposal to Establish a Program of Rehabilitation First Year for Patients Who Have Had a Myocardial Infarction - $73,800 Washington University School of Medicine. The purpose of this proposal is: 1) to provide patients (in the St. Louis area) who have had a myocardial infarction, with rehabilitation services which will help them return to an active, productive life; 2) to educate members of medical and lay communities regarding the benefits patients can derive from coronary rehabilitation procedures. This project is an outgrowth of a recent survey conducted by the Bi-State RMP Heart Committee. The survey showed that 84% of the responding physicians had indicated that they would be interested in such a program, and stated that about 580 patients would be referred by them to a coronary rehabilitation program over a twelve- month period. Headquarters of the program will be in the Department of Preventive Medicine, Washington University School of Medicine and will have two operational bases, the Irene Walter Johnson Rehabilitation Institute, and the St. Louis Heart Association. The program will also use the facilities of the Jewish Association of Community Centers and the downtown YMCA. The program will consist of the following four phases: 1) initial patient evaluation; 2) diet therapy; 3) exercise therapy; and 4) follow- up therapy. The program will be available to any patient in the St. Louis area who has had myocardial infarction and who has written referral from his physician for inclusion in the program. Education of the medical profession and the lay community will be accomplished through lectures and demonstrations and will be arranged and presented under the auspices of the St. Louis Heart Association. Evaluation in terms of the stated objectives will be as follows: To determine whether the rehabilitation service has helped the patient return to an active productive life, patients will be interviewed by BI-STATE REGIONAL MEDICAL PROGRAM -4- PM 00056 7/70.1 the program's social workers at six-month intervals. The success in educating the medical Community will be evaluated by: 1) keeping a, record of the rate of patient referrals by physicians to the program; 2) keeping a record of the number of physicians referring patients to the program; and 3) at twelve-month intervals physician opinion will be sampled on the value of coronary rehabilitation. Second Year: $64,140 Third Year: $67,167 DRMP/GRB 5/21/70 BI-SI'ATE Regional Medical. Program RM 00056 7/70.1 HISTORY SUPPLEMENT LISTING OF CURRENT STATUS OF CORE AND OPERATIONAL PROJECTS IN BI-STATE A - FUNDED PROJECTS Project Amount Supported (D.C.) Number Title Through 10/31/70 00 Planning - Core support $559,487 (Includes $11,950 carryover funds) 2 Cooperative Regional Radiation Therapy Development & Support Program 152,071 4 A Comprehensive Diagnostic Demonstration Unit for Stroke 92$243 5 A Nursing Demonstration Unit in Early Intensive Care of Acute Stroke 80$077 8 To Establish a Cooperative Regiona In ormat on System for Health Professionals 38,500 (Note: This project was approved for a three-year period by August 1969 Council. The Division is currently in the process of awarding $38,500 for the first year.) TOTAL $922,378 B APPROVED UNFUNDED PROJECTS 7 To Establish a Major Radiation Therapy Facility (Regional implementation is planned for 10/l/71.) 9 To Inaugurate a Program for Health Surveillance, Health Education, and Health Care Accessibility for Residents of a Low-rent, Urban Housing Project (Scheduled for funding effective 7/l/70.) C PROJECTS NOT APPROVED I A Program of Rehabilitation and Secondary Prevention with Myocardial Infarction 3 Regional Consultative & Educ;itional Programs in Cancer Chemotherapy 6 Center for Continuing Education in Long-term Care 10 A Proposal to Inaugurate an Operating Room Technician Training Program II A Proposal to Establish a Center for Continuing Education in Long-term Cate (Note: This was the revised version of llroject #6.) DRMII (A Privileged Communication) SUMMRY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE BI-STATE REGIONAL MEDICAL PROGRAM RM 00056 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Review Committee recommended that this Supplemental Operational Application, containing two individual projects and requesting $398,770 d.c.o. for a three-year program period, be partially funded at $178,677 d.c.o., to support Project #12 for the time requested (thr6e years), for a reduced amount. Committee believed that action on Project #13 should be "nonapproval" - no RMPS funding recommended. Project #12 - A Proposal to Establish a Coronary Ca-re Train@@@ro for Nurses - St. Louis University School of Nursing and Allied Health Professions. The reviewers believed.that the preplanning of this program had been accomplished through a survey generated as an outgrowth of the activities of the Region's Heart Committee. The Heart Committee has established a subcommittee on coronary care training; the findings of this subcommittee motivated this proposal. Committee members were influenced somewhat by the excellent review of this proposal conducted by the Ad Hoc Cardiovascular Study Panel. The resources and procedures described appear to be adequate to meet the primary objectives. A question was raised regarding the practicality of the number of courses proposed (eiobt five-week courses). It was noted that the applicant requested neither stipends nor per them support but the request for'travbl appeared excessive. It was believed that a better method is needed for the selection of candidates for the training courses. The need and justification of a two-bed, fully-equipped mockup unit was questioned. The Panel members felt strongly that all clinical equipment must be capable of actual patient monitoring and the Committee agreed. In recommending approval in time and for a reduced amount, the Committee further recommended that conditions of approval should'be: 1) that the applicant establish a method to better determine the needs of the individual candidates and examine closely their educational qualifications; 2) reduce the amount requested for equipment by deleting one mo6kup unit and reducing by 5(f/. the remainder of the equipment request; 3) reduce travel expense by 5Crk; 4) improve the method of evaluation; and 5) the Applicant should be encouraged to restrict.both the number- of courses offered and the number of nurses enrolled per course. Recommendation: Approval in time and reduced amount subject to the conditions outlined above. Direct Co Onl ist Yr. 2nd Yr. 3rd Yr. $59,229 $58,425 $61,023 BI-STATE Regional Medical Program RM 00056 Proj,ect #13 - A Proposal to Establish a Program of Rehabilitation for Patients Who Have Had a Myocardial Infarction - Washington University School of Medicine. Critique: Members of the.Review Committee noted that during.-the April/May 1969 review cycle, a similar proposal (for the Establishment of a Program of Rehabilitation and Secondary Prevention for Patients Who Had rdial Infarction) was considered, In recommending "nonapproval - revision requested for the former proposal, the reviewers considered the program as a clinical research activity which mig,ht be more acceptable if oriented toward the development of a service. In considering this revision the reviewers noted that the applicant had apparently developed a sufficient need through a survey of physicians., The objectives are clearly stated as to numbers, examinations, and programs to be undertaken. There was some concern expressed in this review (as in the review by the Ad Hoc Cardiovascular Study Panel) as to whether the project can be accomplished in the three-year program period proposed. The Committee believed, however, that this is a tenuous proposal for the following reasons: 1) Although a survey of physicians has been accomplished, the pr ogram lacks the endorsement of the Medical Society. 2) Lack of involvement of rehabilitation personnel in the planning of this proposal. 3) Method of early evaluation is unrealistic. 4) No concrete plans were presented for phasing out this activity. 5) The overriding concern was that the rehabilitation of the heart patient is the direct responsibility of the patient's physician and, as such, it was doubted that referrals for this type of service would actually take place in the numbers anticipated. In view of these overriding concerns, the Committee did not believe support is warranted. Recommendation: Nonapproval no RMPS funds recommended. 7/i/70 BI-STNRE Regional @tedical Program -3- RM 00056 SUM@TARY OF RECOT@,NDATIONS @O @C t- Number Title Ist Year 2nd Year 3rd Year 12 A Proposal- to Establish A Coronary Care Training $59,229 $58,425 $61,023 13 o o.,3 -to Escablisl, A rani of Rehabilitation for Patients Who Piave Had Non--approval - o@a dial Infarctiol No @IPS funds recommended TOTALS $59,229 $58,425 $61,023 Year TOTAL DIRECT COST 01) $59,229 02) 58,1-.25 03) 61,023 TOTALS @179,677 DP,21P GRB 7/6/70 m 0 0 REGIONAL MEDICAL PROGRAMS SERVICE St@R'@ OF AN Ol.'PRATIONAI, SUPPLEMENT GRANq' APPLICATION (A Privileged Conununicati.on) (,'Al,,] l@'C)R,141A MEDICAL EDUCATION AND RM 00019 7/70.1 RESFARCII FOUNDATION June 1970 Review Committee 69'3 Skitter Street San Francisco, California 94102 I)rop.ram Coordinator: Mr. Paul D. Ward R,.e@ested @IT-ogram Peri(-.,d: lst Year 2nd Year 3rd Year Total I)i.rect Costs $535,250 $505,893 $549,323 $1,590,466 Indirect Costs 68,880 87,502 93,683 250,0 5 ,j,o,rAi, $604,130 $593,395 $643,006 $1,840,531 .1,11STORY: The initial planning grant was awarded to the California Region in November 1966. A second-year planning grant provided @3upport for the eight Area components of the Region, the California Medical Education and Research Foundation (fiscal agent), and central Core staff activities. The request for the second-year planning grant proposed the establishment of a new Area IX to be based at the Charles R. Drew Post-Gradtiate Medical School in Watts-Willowbrook. The recommendation of approval provided for designation of Area IX when the CRMP feels it is indicated. The Region'.- first operational award, totaling $2,232,864 was effective July 1, 1968. An operational supplement, in the amount of @140,124, was awarded September 1, 1968, to support the six communities project of the Northeast San Fernando Valley area. Two extensions were made of the planning grant to permit merger of the planning grant into the operational grant and for Committee and Council to assess a request for an increase in the Core support. 2'@ spc!cially-structured site visit team visited each of the Area offices in the Region from April 14-18, 1969 to: (1) relate individual Core requests to ongoing operational projects, 2) analyze the organizational and functional structure of each area and its relationship to the central. office and (3) recommend future action. As a result of the site team's recommendation, an expanded Core was approved by May 1969 Council. The current annual level of support (in the second year) is $6,390,227 which provides support for the eight (nine including Watts-Willowbrook) Area (,t-)iiiponeTiLs, the California Medical Educati.on and Research Foundation (CMER.F--fiscal- agent), and central Core staff activities. The California i is presently funded under a single operational grant, effective ,J@,ily 1, 1969 in the direct cost amount of $7,806,671 for a 14-month period. This amount supports 17 ongoing operational projects,, Nineteen Council- approved projects are as yet not implemented. CALIFORNIA Medical Education -2- RM 0001.9 7/70@l and Research Foundation A site visit of July 7-9-, 1969 in Los Angeles, recommended approval of eleven new projects in the approximate amount of $1.5 million (D.C.), and this action was concurred in by both Committee (July 1969) and Council (August 1969). To complete the "backlog" of projects awaiting review, a 10-project supplement was the subject of a site visit in October 1969. Five projects received affirmative action by Council in December 1969, amounting to $569,776 (D.C.) Presented to.March 1970 Council were six new supplemental projects and 'one renewal (Medical TV - #7R). The renewal was approved in the requested amount for one additional year only. Three of the six new projects were approved. A supplemental award is currently under negotiation which will enable the region Lo activate seven new pro@ects from its backlog of Council-approved but unfunded projects. The regidn is preparing a third year continuation request for submission on July 15, at which time re-budgeting to accommodate the remaining backlog of Council-approved but unfunded activities is expected. PRESENT APPLICATION: This application is composed of two new operational .projects and a revision of one previously submitted but returned with suggestions for specific revisions. Both of the new projects were studied by a technical review panel in the region as part of the new review procedure adapted by CCRMP last year. As a result of this technical review, both new programs were revised before submission to D@IP First Year "roject #41 - Area I - Patient Monitoring $263,186 BACKGROUND: The site visit team which reviewed the supplemental application from this region in October 1969 visited @lt. Zion Hospital in San Francisco where this project is based. The team saw a demonstration of t!ie equipment which was developed by the Lockheed Laboratories, and had the opportunity to discuss it in depth with the technical people from Lockheed and also the Project Director and his staff. The monitoring equipment was described by the proposers as an "early warning system" with application to patients with a variety of diseases and not necessarily restricted to lieart disease. Questions were raised by the site visitors concerning various technical I)roblems, i.e., false alarms, the decision-makinc., process when a warning signal occurs, required training for nurses and other hospital personnel, ctc., iii orc;er to utilize the system, etc. 'rile evc@luiti(iri i(ietliodology appeared to be in need of more planning and tlic, recording system for the data was vi-ewed as deficient. The si.tc,. visitors felt generally that this is an exciting prospect, but i- iieed (@f more research and (leveloprii(,nt, particularly in @l clinical S(,tti.n,@,, -:it the i@it. 7,ion Hospital. It was not belicved to be read), for field tri.@'.ilv @jitlit)zit further clarification of the validity of signals, development of in (Evaluation methodology, clarification of how decision-niaking would I)c, -3 Pll 00019 7 7 0 I cl Corporation E@t@frinii-iaL.i-oii of what Lo(,kfie(! I -I- @)t-t CVE'L. @)pmen t and "d e - bugg ing I I- C iicl n ii s i@ L (@@ t eaiTi, wli i- c @i wa s c oi-ic urr ed i.n by was a ret--irn for revision. bc@l.ic,.@ve tliall- they have amply provided for the ]act-< -in original proposal by establishing an nurses, scientists, and outside .id and analyze all pertinent data for evaluation in a clinical setting I "f a Ise" S L Li 17 11. @3l.gnal.s and alarms, specifically 1) -.iTid '.3) true alarms. evaluation will be controlled by trained 'tariL electrocardiograms, and by long- n ,', C)I'i 1 i- A al@@o of: 1) alarms indicating a life threatening il-,@ri,ns I.eading to improved patient management. In e@i(-,It t:Jic, decisions mad(,, by doctor or nurse will be tabijlar(,(,, At 4t--Iie same time, evaluation of the impact 1 (,T@ L population will be examined, not for mortality d i l@ or-i c,- 1-@i-i t alsc) for psychological effects. The impact on a@@ @-o acceptance, assessment of the usefulness c, r! [ect on the care of the acutely ill. patient 1) i I I direct resp(-)nsibility for all evalu- C"": a N@irse Director, Cultural Statistician and Data Analyst. cjL-@L@c@r tliree years federal funds will not be to provide monitoring for: 1) coronary af ter tlir,i),- frorit an existing CC[f, 2) patients who cii- s from acute myocardial injury, 3) paLi.ents -i@ 1) @l I i @2, ja 1,@ y @ v F) and /@) patients in the hospital who )Tr,,, any i,i or surgical disorder which carries l@,, iiia(lecluate coronary circulation. T)ropo@;al is an educational and training ri 1)(,,i - @@ I 1, @ I T@@ r ()Y@ I)I@y:@ r,urse,; ancl other personnel. The course will @i. II i-i ri of acute care for patients, whether t t@,r c@ii the @@eneral- floors, Special- training in t:ti, ii,,c, @)f@ w@i.11. occupy approximately one half of the @iiici dirin@, LIIE@S(@2 peri.ods there will be practical experience patients. The educational and training 1,711-t@ the existing Area I coronary care -4 - Rm 00019 7 /70. 1 (,ALIFOR-NIA Medical Education and Research Foundation The training courses will be tailored to the needs of the learners Courses will be of whom there will be 16 for each one-week period. given four times yearly. The project will not be extended to participating hospitals until about the 22nd to 28th month of the program when an installation of the second 20-bed unit will be made i-n the Vallejo General Hospital. The third will be the General Hospital of Eureka,California, 280 miles from San Francisco. This facility has 103 beds, no acute care unit, and no house staff. This unit will be installed and implemented by the 30th month of the grant. The budget requests funds for providing for the construction and installation of the first 20-bed unit, and the educational training components at Mt. Zion Hospital and Medical Center. The budget alslo includes items for anticipated costs in further development and de-bugging of the system, llreliminary testing was carried out at Mt. Zion Hospital and Medical Center by means of a model financed by research grants from Mt. Zion Hospital and Medical Center, with contributions from Lockheed Missiles and Space Company (approximately $56,000). The surveillance unit may be available for purchase, installation and maintenance at a cost which will not be prohibitive. The units will be capable of monitoring any desired number of patients for about $1,000 a bed, and maintenance costs will be approximately $48 a bed per year. The statement included in the Appendix entitled "Why Lockheed" documents the reasons for the selection of Lockheed Missiles and Space Company to develop this project. These were based upon the many years of research and development programs and in space-related efforts for the military and NASA in which the Lockheed Company has designed, developed and utilized medical monitoring equipment of all types ranging from sensors to complex signal processing equipment. Also Lockheed has long experience in producing modular data processors with the aid of integrated circuits, without'which the system could not have been developed. Second Year: $227,156 Third Year: $260,309 Requested Project #60 - Medic lL ILnifoiramiicatit-ion Services - Area VI.'This program is irst Year based on a pilot program initiated in cooperation with $39,388 the Area VI office and committees to develop Regional Medical Libraries Information Systems, linking the major medical libraries with each other and with hospitals within CCRMP so that information is readily accessible to all health personnel. CALIF.'C)RI41A -.5 RM 00019 7 /70. 1 and In information resources and services ')ouLlt-"Yest Region (States of Arizona, C@i Iifornia, H a) was conducted by the Directc@r of Lil)rat@i-ec,, The survey revealed that Area V,'@ of is one of the most backward areas i.ii the Southwest s re i,,)Ie -Lc@il library resources and services. @,!(,)st me('I-'.(,a-i are extremely inadequate in Area VI. The @r-egioy@, @-o i-i,,-,-@-hen. the most important single @oui.-ce of -Ls personal medical range of general journal literature through a I'@i-Ls will bring information directly to the four counties of Area VI. A major resource and tl)is is also a MEDIARS Stati-on. A telel--y@-)c- I-).@ D.@@,ii Installed to provide a direct little I,)etw '@C;j'-,A Biomedical Library to give @i reasonable speecJ, arid (@f loan service. The UCIA Bi.orn(-,cl:i-(-al- Lil.)rar, Library for the Pacific Southwest Region) is @lo. Z@8. It was also developed as a result of a pilot @r.@our district libraries. The proposal was for when the original operational was first 'DuL- was revised, resubmitted and subsequently approved. ecl-udes Los Angeles County which is covered by a by @l-lie Los Angeles County Medical ssoci-eitio@@l will not duplicate any services r@r@)-,,7idecl IDy .1 i brary , but it is be I i eve d that RM1.1 services stren,,@,L@iene(I through new library service will cooperation between t@ ii,@, be @t vital back-i-ip ..,c)iiia Linda University Library can refer @r.-eque,@,,ts i.rc)-cii its own resources. Area 'VI wi.l..t C, s -OIL@@ for lic)spital library per oiiriel-,, rlt @f- has prepared a manual of library r@roc@clires @l' 7@ it is @Dr(-)P(:@@3ed @..o @@@l ,.-,,uccessful Current Aware- ness Servi,..,-@, togeti@,@,.@ @@@i@o@o(,c)py service, while commencing a e ,.@.i@-L(,ations Service. "F h e @.@i rc!,-, 1. t h p i: C) f E@ I @L-o Linda University Library by niai.J- or )f a specific journal article. i.'; @--nd rae@ilc@cl as quickly as POF@s@.bi;,, If f.,onika Linda, an inter- library loan l@, c) The UCLA Biomedical Library. A s @lil.sc) offered as another of t.rLi:i.c@ed librarian will s i, t@ o s p i -L@ a s @@7 i.@,, three times a year CALIFORNIA Medical Education -6- RM 00019 7/70.1 and Research Foundation to encourage and assist in establishing medical information services in hospitals where none exists. A bimonthly or quarterly newsletter will convey information and exchange ideas among all hospital adminis- trators and library personnel within Area VI. Continuing education courses and training programs for professional medical libraries throughout the Pacific Southwest is planned as a part of the ongoing project (#48 - RMP Library), and all medical librarians located within Area VI will be encouraged to participate in these programs. The region has identified three potential areas of future support from non-federal sources: 1) subscription basis on the part of the health professional; 2) support from individual hospitals; and 3) support from voluntary health agencies, county government, private philanthropic organization, industry (especially pharmaceutical), local service clubs, etc. Evaluation will utilize data from a number of sources, such as statistical records at the Loma Linda University Library to show clearly the extent to which each service is utilized. At the end of the first year a questionnaire will be niailed to all that have used the services offe-ed. A Field Consultant will be constantly in contact with hospital library staff and to some extent individual practitioners. Hospital personnel also will be invited to evaluate the services available to them, with emphasis on the consultation service. Second Year: $46,797 Third Year: @49,975 Requested Project #61 Integgraded Assis-La-its Program - Area III. This is a First Year three-phase program developed by the Stanford University @232,676 Hospital in cooperation with the Foothi 1 1 7unior College and community physicians. The program has been discussed over a two-year period and reviewed and approved by the Sa-@ita Clara @IP District Committee, the Stanford Faculty RMP Advisory Committee, the Area III RYIP Committee and the California Committee on @ . The project represents a commit- rqent on the part of Stanfo@University Hospital to broaden significantly its effort in the training of allied health manpower. Phase I has already been implemented with support from the Stanford University Hospital and the Carnegie Foundation. Stanford has provided approximately $20,000 annually for personnel and the Carne-ie Corporation $65,000for the pilot study. An add-@'-L-Lcnal request of $56,000 for imple- menting Phase 3 of the prooram has been made. Phase I deals with a coi-nr)utc-,riz--d educ,-.t@--,)iial program des-'-,-Ined by the Stanford School of Education and made available to hospital employees (chiefly from minority groups) wish to complete high school requirements. It also provides on-@Lhe-job ouidance in learning facilities, including a compute,.- dedicated to self-instructional programs. Upward mobility into Phases 2 and 3 from the bottom of the health career ladder is made possible 'D3, Phase 1. 1,@,.:@I RM 000 19 7 70. 1 P life s e @ip[ 0 c@@)tirs e f or t L:@)y,y ani::i 14 months s (,,ve@ry three 40 @l @-'()tirse i,n ftiiida- 1), pr@icticaL k, ot-[(, of a vri I' i c, I- k)f 11 I I) ilot pro,,,raiii oi. ti) i L,,l p c, I i a r- the support of t@if LJrl)af:i i 7 Liti@i,s course are tor,[s @ Phase 2 may loyc@@cl c, t i 1 1-@l@ t)(@! a sLeppii@g-.Stc)@-i 11 programs lead in@, '3 L II) ,I y k@/ i L I I 'I in i 11 WL11 be lieaLtli p (! I:, 0 i-i I li@(Ici 1 i (@i @,!i,tli nort-rfiedical backgr-@.@@iiids I 1) r i i--ca ii g c.@ o f p ra c t ic a I c @-i p,,i t) @i I- i t i c, i r@ cl i:@@ I' i I) ly arranged in (@l l-,@ I @-o,,2ram for qualification t I @. r o ti (i t i -f-@ a I i is a physicians @'i s s is @IrLt 1)(@,@c i.i-.ij--ensive coronary ma terna I and -type residency Ti@c, 1)@.ii Ld,, i i-9@)@i by a program i. ecl ])ea L tti pos i t ion s r I", s r i t [I f@ I I c@ 11 t@@ 1 T) o -f Sc,@iool and @@A curriculum was c'rafti",@] ari(-i @i l@,@ i-- '19()8 Keith seven iii i. ii or j. t@N, F, t, jd eii t@ -I l@ I @l service staff @it tl).(-@ i@,le@iical Cc-,ckL(-,r, t @,iii 1 i) ei.r,L classroom and laboratory l@>I.aced in the I" i'@ To Altc) Neighborhood (,,enter fc).r@ 4 ii -in g. At VI-ie end of C I i s c@ r @l. o cl a @'I @L I L .@l r E@Inp I-c)@ ee,@ at the training. ()f hospital and ,(inin@ir tyroups to @minori.ty group L l')c@@c@@irtmerit was formed hospital jobs; RM 00019 7/70.1 CALIFORNIA Mc@dical Education and Research Foundation 2) develop training programs for minority persons in the Medical School and the University Hospital; 3) promote harmonious intergroup relationships within the hospital staff. By April 1969, the Intergraded Assistants Program described in this application was develo@)ed as a result of suggestions requested from the various departments. It is not directed exclusively at disadvantaged or minority groups, although the program will provide unique opportunities for them. The program does envisage the creation of new careers in the allied health field and the provision of training programs designed to facilitate upward mobility into these careers. Phase 2 will concentrate on the training of health technology assistants. A high school education or its equivalent will be required for the approximate 40 persons to be trained. Two hundred interested recruits out of a possible 240 minority group employees of the Medical Center have expressed interest in participating in the program. One hundred and forty of these have an educational attainment of tenth grade or below and are appropriate for Phase I education. Thirty of the others are now holding semi-skilled jobs are interested and appear to be candidates for training in Phase 2. The initial eight weeks of training will be spent in laboratory instruction at the hospital. Instruction will be by means of lecture and reading assignments in several standard textbooks. Tutorial-type sessions with individual students or pairs will be arranged. Various experiments with discussion and interpretation of material, as well as individualized instruction is planned so the trainees can prepare for their specific assignment when they move to on-the-job training. Trainees can participate in parts of Phase 1 while enrolled in Phase 2. lqhen students complete laboratory instruction they will be assigned to various appropriate specific locations in the Medical Center for four months of on-the-job training. They will work under the direction of medical and health professionals and skilled technicians, who will instruct in a one-to-one manner for improvement of specific skills and tec niques. Following training students will be assigned as follows: fadiologic technologist, radiology nurse, X-ray service technician, inhalation therapist and technician, etc. During this portion of training these students will act as aides or assistants to the professional/ Lechnical personnel. Students will be paid by the project during the two-month training period a rate of $400 per month. A further alternative for trainees is the opportunity to participate in an occupational training program in health sciences at DeAnza and Foothill Colleges in technical specialties. The Phase 3 portion of the application deals with the training and placement of Physicians Assistants. This involves 20 months of intensive training- Candidates will be trained largely by physicians to be a highly competen@ extension of the physician's technical arm in certain designated areas of RM 000 19 7 /70. 1 a i-i. (I I'@ c@ f@@,q i- r-t 'i'@ I)Iiy@@ i,@iiis . (,la,-,ses will consist on Admissions and (;r@i (ii i @ri i-@-ic(ii.i@y pl@ysi(-@i.ans, ,,I physicians t I r-I i ri S L r I].( t@ 'I L@ a t@@ i @7 (@ F, () f tlic, a I tied liea I tli pe(@ i,'@ I t i, @@@ic@ (,c)ii.c@tirners of health services. and recommended bv supervisors or OLIICI@@ r 0 ii. s I- i-) ii school diploma or its 1 @@p(,.ri(iice of at I-east two years, 2. i1 c@ri tli(,,:! Sc@liolastic, Aptitude Test ']'est of the College Entrance character references and i)@ evaltiati.(>il by the Committee receive a stipend of $400 per 1-@-I tl)e need for continuous S f.@.,L i r@ @.tisti-uctc)r.,s as well as the 1) () s E@ c@ I- L 1-1, Ti p(@rsc)iin(:,]- department and other li e i@,t r- i- i. c@ i-i.II pai- Ls consisting of one @/ear (i@ @fie,,i @i-ca I theory with emphas is p (.) l@ t@ I I r",l c t@ i a a @)s t.-rac t . TI@iis will be followed practice through assignment r..@ent-er. The final segment will (,.c)nj:;i,@,t c@f i-r) a specialized area, working ti nd 0 1 a hospital. situation, doctor's f7 f i ro@)rit. A. detailed outline of @).I- @@@t@iL-id@ir(lizatiori will occur v c- @@i t @'LY, i-) t F) @i(it@l@iors feel tiiat it is I tA I I i@@ @,i @r., oa c i @ o r d (@r t o a cl a p t t li e of program on tire basis of 11,C)t@ licensed i.ii California t@ i, i@ I f -1 i for Lo be employed as assistants to @@Ls 1.@1.1@el.y that legislation to permit L i t@ i@ t i C-@ r, 0 f I i.11@,@@ 'L (2 I' @A be passed in the California 'L@l'ici before the graduation of the (.:.laws Fr,-)iii LI 1),@, @,71ic,,ther it is achieving health manpower and o,,@@iLy @iroup persons and others occup@it@[c)tis . Evaluation of @L@i c@ cor@t:iiiiic)iis basis in order that I:)@- desi.aii(-,d and implemented i-)@.iiiiber and background of trainees @-itei.i- @iccept@@ince in new positions CAI,IFORNIA Medical Education -10- RM 000 19 7 /70.1 and Research Foundation after graduation. Other evaluation measures will involve student progress (in all phases),-job performance, continual feedback and a final summary of evaluative analysis. Program direction and coordination will be the responsibility of the program director to be assisted in various administrative functions by the Minority Relations Department. Evaluation will be directed by Robert Heath, Ph.D. Associate. All instructors responsible for Phase 1, 2, & 3 have been identified. A number of methods for public and professional information will include a lecture circuit for physicians in CRMP Area III to reach physicians via county me dical society meetings, specialty group meetings, etc. Second Year: $231,940 Third Year: $239,039 CALIFORNIA Medical Education RM 00019 7/70.1 and Research Foundation 02 Operational Budget Period Support (14 month period) Core* CMERF 54,931 Regional Office 373,635 Area1 634,640 (Includes $6,500 02Sl) II 244,854 III 354,244 IV 802,288 v 646,993 VI 198,664 vii 224,649 viii 225,104 (Includes $10,000 02S2) Project #35 (Area IX) 185,464 TOTAL $3,945,466 Area I l@ I-Coronary Care Training Area 1 312,792* @kl5-A Regional Cancer Program 330,610*** #18-Training of Physicians in Intensive Care for Small Hospitals (Pilot Program - Pacific Medical Center) ii,ooo** #20-Hypertension - Area I - Northwest Calif. 362,070* @i25-A Proposal for Rehabilitation and Continuity of Care Services 187,061*** #26-Intensive Training Course in Cardiopulmonary Resuscitation for Emergency Rescue Personnel 10,634-* ,@27-University Medical Center - Rural Community Hospital Demonstration Cooperative Program in Primary Physician Training & Continuing Education 92,981-** #55-Solano Supplement to Program for Rehabilita- tion & Continuity of Care Services Approved 3/70 LinfLinded Area 11 @k 2 -Roseville Pilot Program 92,145* Area IV 4 -A Training Program for Physicians in Coronary Care Cedars-Sinai Medical Center (UCIA) 236,192* #7R -RMP Medical TV Netweork - A Center for the Continuing Education of Health Care Profes- sionals Using Television and other Audio- visual Materials 392,000-* #24 -San Fernando Valley and Pacoima Health Planning Project 160,890- #58-Training Program in Coronary Care Approved 3/70 Unfunded Area V #11-Program for Training Physicians and Nurses in Coronary Care Techniques 483,281* #23-Chronic Respiratory Disease 113,913*-,@* Area VIII Y@21 -Pediatric Pulmonary (U.C. -Irvine) 206,520* #28 -A Comprehensive Stroke Program 370,802-- (Transfer of $29,259 from indirect @ing) #54 -Rapid Hospitalization for Acute Myocardial Infarction Approved Area IX #6 - Watts-Willowbrook Post-Graduate Education 498,314* TOTAL $7,806,671 * commitment for one future year ** no future commitment *** commitment for two future years DRMP/GRB/5/14/70 . 4 - 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE,' SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) CALIFORNIA MEDICAL EDUCATION AND RM 00019 7/70.2 RESEARCH FOUNDATION June 1970 Review Committee 693 Sutter Street San Francisco, California 94102 PROGRAM COORDINATOR: Mr. Paul D. Ward Requested ram Period lst Year 2nd Year 3rd Year Total Direct Costs $77,307 $77,248 $81,393 $235,948 Indirect Costs 1,467 1,542 1,571 4,580 TOTAL $78,744 $78,790 $82,964 $240,528 HISTORY: This proposal was reviewed 'by February 1970 Review Committee and March 1970 Council and deferred for additional information concerning its relation to CHAIRS, a project in Los Angeles County approved by the Council, but subsequently funded by the National Center for Research and Development. Notes concerning an expert review of the two projects are attached. Project #56 - Community Resources and Information Services St Year. (CRIS) - Area VIII. This project proposes to $77,307 create an organization which will make available, through one telephone call, knowledge of all the community services avail-able to the caller in Orange County. It will establish a ric,ri-profit Community Referral and Information Center to be professionally staffed and managed to assure continuing and improving service to all the people. The Community Referral and Information Service (CRIS) will identify resources for total patient care in the broadest sense to meet the physical, social and emotional problems of the patient and his family. Its services will be available to all members, professional and lay, of the community. This program is similar to one which was reviewed bv a si.te visit team in ,July 1969, (CHAIRS Pro ect #30) and subsequently received approval- and recommendation for funding by both the Review Committee and the National- Advisory Council. Such a service of information and referral will. contribute to regionalization by (1) identifying needs and opportunities for thei.r solution; (2) coord- ination of the RMP with other activities in the Region; and (3) providing the Region with a continuously updated inventory of existing resources and capabilities. This project will provide a coordinating body for the numerous community service organizations and services providers. There are large gaps in services and under-utilizat@i,c)ri -;f many of the existing ones, and there . . -- -.r. --- - 1 -1 ,@ll -n-rr)@7irlp information CALIFORNIA medical Education -2- Rm 00019 7/70.2 and Research Foundation and referral services to make known all available community resources in Orange County and coordinate with a network of referral programs in Los Angeles County. The service will be available on a 24-hour day, 7-day week basis. It is hoped that the program will act as a catalyst to existing agencies in the action required to fill in identified gaps. Periodically, a directory will be published to guide the delivery of health, education, welfare, vocational and recreational services in Orange County. The program emerged from planning of an ad hoc committee, which includes representatives of the Regional Medical Fr g@rams, Area VIII, the University of California at Irvine, Orange County Health Department, the Medical Association, Chapters of the National Foundation, Tuberculosis Association, Heart Association, Cancer Society, the Medical Center, Mental Health Association, private industry and others. In May 1969, an ad hoc committee on incorporation was elected and a charter of incorporatio@iq;s-drawn up. Articles of Incorporation and approved Bylaws were formally adopted September 16, 1969 and are included in the application. The Co unity Referral and Information Service will operate under a mm Board of Directors. A technical advisory committee, made up of representatives of various professional disciplines will advise the CRIS board and the executive director on programs and policies. An executive director will be hired by the Board of Directors. Funding through the Orange County United Way will be requested as well as other funding sources explored. Evaluation measures will be readily available from the beginning of the program and will be reflected in an increase in the number of referrals and the increase in the willingness of local agencies to assume financial support. The statistical reporting system presently in use at the Los Angeles Welfare Information Service will be utilized in the early part of the program. This is a tabulation of the media for the initial inquiry, its source, types of problems, kind of service provided, the community in which the person with the problem resides and the referral agency. The records per se of CRIS will be another form of evaluation of the project as well as a follow-up of calls. As volume increases, evaluation of a random sample of calls planned and controlled for accuracy will be utilizp,d by the usual and accepted statistical techniques. 2nd Year: $77,248 3rd Year: $81,393 CALIFORNIA Medical Education -3- RM 00019 7/70.2 and Research Foundation Review Committee, February 1970: CRITIQUE: The Committee found the project to be well planned for an obvious need, and noted that the project will become self- supporting in three years. The question was raised as to the degree to which the source o t e information can answer questions, and does the process in fact bypass the physicians? This in turn raised the question of the legality of such bypassing. It was also noted that California has the highest number of malpractice suits in the Nation. The similarity of this project to one previously reviewed from this Region (CHA-IRS - Project #39) was recalled and it was noted that the National Center for Health Services Research and Development has funded this project for a five-year period in the total amount of approximately $700,000. This program is based in Area V (USC). In view of the decision to fund this program by the Sanazaro group, the committee agreed that perhaps a deferment of the decision to approve would be in order until we are able to evaluate the success of the CHAIRS program. RECOMENDATION: Deferral for further information subject to expert and indepth review in relation to the CHAIRS project in order to ascertain if it is (1) worthwhile; and (2) justified for funding under PM. National Advisory Council, March 1970: Council reviewed additional information from CMT, but requested infor- mation from an expert in thefield of information and referral services on the comparison of CHAIRS and CRIS. Action was deferred pending this information. DRNP/GRB June 4, 1970 OF HE/,I-:f@1--I, EDU@-A-f-101@, SEI-@VICE FIEAL'f-ll @El-@'VIC,E@-@ A@41:1 1970 Tel-ophoi-io Conversation with Miss Eileen Lester, Comprehensive Hc--al-tli Szi,@ject: Services, Concerning Her Review of the CRIS Proposal- #56 from Area VII.I, California P,@IP To: For the Record Miss ],ester was the project officer from one of the initial infornia- tion and referral services (in Rhode Island) and has provided consultation to the majority of 1.5 programs funded under a Community Health Service contracts since then. She had re@Viewed both the CHAIRS project in Los ATigel-es County and the CRIS proposal in Orange, County. I called her to request specific information about the questions raised by Committee .ii-id Council regarding relationships, similarities and differences between the two activities. Following are her telephonic comparison of these two projects, her comments about strengths and weaknesses of the CRIS proposal and information about experience, with other information and referi-@il- services: (1) The basis objective of both CHAIRS and CRIS is the same: to establish a Central- Information and Referral Service. (2) -The methodologies employed are different the CHAIRS project is CODCC@rned with the application of computer technology to the process of referral and will utilize a i-7ell-establisbed Information and Referral Service. The CRIS proposal- wo@cl employ stai-iclircl accepted and Provo-II. techniques in developing a new service. (3) l,.ach project is unique iii its own way. CHAIRS is a research and development activity which is experimenting with computer technology. The CRIS project is a seed activity for an essential component of a comprehensive health program in one of the fastest growing counties in the United States. The County has, iiid will continue to have limited resources which must be utilized to full-est effe'ctivei-iess. The County Health Departii-,C-,nt has a very competent heal.tli officer who is unusually cooperative toward the medical- school- and the )-.\Iegiol-ial. I.',c-,dical. Program. Project planning- has resulted in commitment from an array of community agencies, i,i)dLi . The number and viri-e-t@yof agencies involved @CILI t@ry- at the planning stage is unique in Miss i,ester's experience. (6) The fact tliac CHAIRS is locate cl in Los Angeles County and CRIS in contiguoi-i Orange County is an advantage since the CRIS For the Record Page 2 persoi-inel i-7ill. have ttic@ benefit of coi:istiltat@l..oii, from CI-11@lP@S, iiid will be able to utilize basic information on Los l@iigc@-I.es County fac@i-l-itics which serve Orange Cou,-)ty rc-@sicleiits i-i-icl ii--iforiiiatioii oi.-i any Oraii-e County facilities that Los An-cles residents may use. Miss Lester indicated tli@-tt a provision of thc@ li@tiiig aloiic@ save six ll,,ontlis tiTtie for CRIS qnd enables them to pursue new agency inforiiiat@ioii. Even more important, she said, was that the Los Aii-eles prograni. has evaluated the age-,icy information, a process vTli-i-ch usually takes Ibout two years to complete. (5) Miss Lester did not see any advantage in withholding a start on CRIS until- the CHAIRS project is coiTTleted because CHAIRS is a three--year research and developirient activity in computer technology which i-,)ay or ipay not be applicable fo3- County with only a 1.4 million population. (6) The strength of the CRIS proposal, Miss Lester fc,@elo, is the creation of a basic service under Regional Medical Pro-rain auspices i@ihic@li can assure the provision of pi.-ofessio-i-iil and medical talents. The i-Le@,7ncss of the TJi-iivcrsity Medical Center and the, I-,nowii- con-amitiiie-nt of coi,@Lunity agencies augtir for its future. (7) The Tiiajor weakness of CRIS, she felt, was ii-i the staf:fiiis proposed. She felt that more tim@ of the project director should be devoted to building fi.rrii working relationship-- with the-- c@oiti:munity agencies and in,-"clical profession. She felt tlso that the second posi.tion should be filled by someone with experience in con,,iiiii-ii-ty organization rather than in ciF,(@ i.@oi-l-,. The eTnl)l-ia.sis of staff should be on developing the service; the cooperating agencies should provide any individual case work. (8) Miss Lester says that i)o other source of funds are available for developing central information and referral services. Experiel-ice- with 15 contract projects has been that all have- bee-i-i iyt-aintained througl-i community resources after three years of i-iiitial su.piDorL. Tjnited Community Funds have been the principal source for and the Funds will- not support the initiation of a service -until it has been tested and pro)7ed effective; furthermore, the initial expenses in developing and evaluatiiag referral inforniiti..oi@. are barriers. (9) Miss l,estc@)- indicated PIic, would be gl..-,cl to provide- consultation to Cl@@@J.-S. , @'C' I/Sir,,i.11 11'. Silsbee Acting Chief Gi@@aiit-, Rc@vic.@,7 Brincli 0 (A Privileged Communication) S Y OF REVI'EW AND CONCLUSION OF JUNE 1970 VI:EW CO@RIIITTEE CALIFORNIA REGIONAL MEDICAL PROGRAM RM 00019 7/70.1 & .2 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The California "package" presented at this review cycle consisted of two new operational projects and a revision of one (#41) previously submitted but returned with suggestions for specific revisions (7/70.11 plus another proposal (#56) which was reviewed by February 1970 Review Committee and March 1970 Council and deferred for Additional information concerning its relation to another similar program in Los Angeles County, approved by Council, but subsequently funded by the National Center for Research and Development. (7/70.2). The combined direct cost budgets request $613,200. Project #41 - Area I - Patient Monitoring The Review Committee noted the technical concerns raised by the Ad Hoc Cardiovascular Study Panel, particularly the support of a 20-60 bed arrythmia detection system before documenting such a system in a one or two bed "live" system. The reviewers believed the objectives of the project-to be clearly sta ted, although their attainment within the time proposed was thought to be problematical. The failure of the region to submit bard data to support their conviction that arrhythmia detection unit is feasible, valid and reliable detracted from a strong case:br the application. The personnel budget seemed reaso nable. The question was raised about the unusually high indirect costs for the Lockheed Corporation, as well'as the 15% profit. The application was unclear as to whether funds are being requested for equipment already installed in Mt. Zion Hospital. The Committee believed that evaluation pl-an based upon clinical experience at Mt. Zion would not necessarily be an appropriate analysis for small. hospitals. There were no comparison groups included in the proposed analysis and the reviewers felt the extrapolation of experience at Mt. Zion for application to small hospitals would require peer review. The application was believed to be unapl)rovabl.e on technical grounds since the state of the art (24 hour'on-line monitoring) to date has not proven feasible and is -,til.1 in the re-search and development stage. California RNP 2 RM 00019 7/70.1. & .2 Recommendation: Non-approval II Revision to be referred to a panel of experts for technical review. Project #60 - Medical Information Services - Area VI Critique: The Review Committee recalled that.a request for this project was submitted with the first operational proposal from this region, and its subsequent disapproval, The area has persisted in its desire to strengthen its medical information resources by bringing information directly to individual practitioners in the four-county Area VI, based at Loma Linda. The reviewers noted its obvious importance to the Area and the excellent cooperative efforts of the Area VI office and committees to link all the major medical libraries with each other and with hospitals throughout the region. It will afford the Loma Linda facility with easy access to the larger library at UCLA. The representative of the National Library of Medicine, who also served as a consultant for this project, was present at the Review Committee meeting and was able to clarify this project's relationship to other similar programs in this Area. He did not feel that a reduction,in funds would damage the project. Recommendation: Approval I - In a reduced amount. 01 Year: $30,000 02 Year: $40,000 03 Year: $40,000 Project #61 Intergraded Assistants Program - Area III Critique: The reviewers concurred with the comments of the Continuing Education and Training Panel that proposed training course -appears to be overly ambitious. The curriculum content was thought to be unfeasible in that it includes too much for the length o training proposed. They cited page 232, item I, "Techniques of centrifugation including the use'of refrigerated ultracentrifuge", as an apparent inconsistency with nationally established one year post high school programs for Certified Laboratory Assistants. Also,'there is no indication from radiologists or the State Medical Society that they endorse this program or would employ this level of trainee. It was a point of question as to whether trainees could be employed outside of Stanford,in view of the rigid California licensing laws for laboratory personnel. The request for such training was believed to be relatively expensive-- approximately $8,200 per full-time student. The proposal will probably add some personnel to the manpower pool at Stanford, but its overall contribution to patient care in the region was questioned. California RMP 3 RM 00019 7/70.1 & .2 Phase III of the program was difficult to assess in view of the unaccept- ability of the Phase II portion above. The reviewers felt that the curriculum emphasizes the laboratory too much and not enough on general internal medicine. Alg-d@--@ttLe responsibilities of the physicians Iassistants are not spelled out. The relationships to existing health personnel are not stated. The applicant makes no reference to other similar programs under development in the country. Generally, this project was believed to be very poorly thought out. The training aspects ate quite unclear, the licensure problem is not dealt with, and it-would appear that the region has not investigated existing programs (such as Duke 'University) for preparation of this program. Recommendation: Non-Approval I Project #56 - Community Resources and Information Services (CRIS) - Area VIII The Review Committee acknowledged the review of this project by a staff member of Comprehensive Health Services, who has provided consultation to a majority of fifteen existing programs throughout the U.S., funded under Community Health Service contracts. One of the original concerns of the Review Committee was the -relationship of this project to one previously reviewed and funded by the NCRD (CHAIRS). The basic objective of both projects is the same: to establish a Central Info rmation and Referral Service. The methodologies are different. The CHAIRS project is concerned with the application of computer technology to the process of referral, whereas the CRIS proposal will employ standard accepted and proven techniques in developing a new service. CHAIRS is a research and development activity, and the CRIS project is a seed activity for an essential component of a comprehensive health program in one of the fastest growing counties in the U.S. The county has, and will continue to have, limited resources which must be utilized to fullest e'ffectiveness. The number and variety of agencies involved in the planning for this program is not only com'iuendable but unique. The pro5z and peripheral hospitals. In fact, it was noted that cooperative arrangements with other hospitals in Mciiiphis were not feasible at this time. The Cc)rirAittee felt thaL this type of cooperative arrangement - outside of Menipliis, but without other niajor @icinpl-iis hospital component-.,,; - r,,,,otild jeopardize and hinder needed regioiialj-za.tion in thisi.mportai.it area. Other aspects noted in review were the absence of objectives for the technologists' training, the lack of justification for the equipment and the question of fellowship training. Reco3Timen-dat-i,on:- Non-Approval I, No R@ff)S funding recommended l@VIET,@l CO',.,EITTTI.,-E FATDI.NG 11,ECOI,@,)-,,NDI\TTOI@S Project Year @@q@i c@ -@, t e cl 01 Year 02 Year 03 Year Total- 27 01 $47,761 02 57,056 --O- 03 _@2,_g 9_L SUB TOTAL $167,808 28 01 $31-2,922 02 1,98,09/@ 03 215,367 -0- -0- -O-.- --O-- 04 234,225 05 254,816 SUB TOTAL $1,21.5,424 TOTAL $1@,383,232 0 -.0- -O-- -.O-- 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) METROPOLITAN WASHINGTON D.C. RM 00031 7/70.1 Regi.onal Medical Program June 1970 Review Committee 2007 Eye Street, N.W. Washington, D. C. 20006 PROGRAM COORDINATOR: Arthur M. Wentz, M.D. Requested: Ist Year 2nd Year 3rd Year TOTAL Direct Costs $114,731 $106,515 $ll3j495 $334,741 Indirect Costs 40,148 43,134 46,098 129,380 TOTAL $154,879 $149,649 $159,593 $464,121 HistorV: The Regi.on's first year of planning was a 14-month period, I/l/67- 2/28/68, and was supported at $188,000. Following a site visit in Februar)@ 1968 the Region was awarded $241,642 for planning and $350,506 for support of three operational projects, both for the period 3/l/68-2/28/69. During the 02 year of operational status, 3/l/69-2/28/70, the Region was awarded $1,400,416, of this, $554,908 supported Core and $845,508 supported nine operational projects. As a result of the February 1969 Review of the Region's continuation application, it was awarded $980,514 for the 03 operational year 3/l/70-2/28/71; Core is supported at $554,034 and twelve projects at $426,480. During the first two years of operational status the Region has submitted approximately 35 projects for DRMP review. The Region currently has four approved but unfunded projects. The projects currently being supported are outlined on an attachment to this summary, as are those projects which for one reason or another have not been funded. In its review of the continuation application for the third operational year, RMP staff noted that some progress had been made in core staff planning and coordination, that the RAG has been reorganized with broader representation and that a Priority Committee of the RAG composed of representatives from the categorical review committee was actively engaged in overall priority determinations. Furthermore, this Region has actively sought involvement of the suburban Virginia and Maryland communities. However, involvement of the community representative of the City of Washington was not apparent; in fact, involvement of Blacks and consumer groups generally is minimal, particularly at the decision-making level. Furthermore, there seemed to be a dearth of core staff time and interest committed to cooperative planning for better health care of the inner-city residents. The Region has been asked to respond to these concerns of staff before July 1, 1970. Present Application Requested Project i@36 - Diabetes and Obesity Evaluation and Prevention Program. First Year The long-range goal is the establishment of methodology $71,754 ,,and standards for the early identification of those children likely to develop diabetes mellitus with its attending degenerative compli- cations and the institution of prophylactic measures to prevent further METROPOLITAN WASHINGTON D.C. -2- RM 00031 7/70.1 Regional Medical Program progression of the disease complex. Th e process for achieving this is based on the hypothesis, suggested by preliminary results of prior testing, that adult symptomatic diabetes is preceded by asymptomatic biochemical abnormalities in childhood which can be detected and identified; and that children of diabetic parents, siblings of diabetic children, and obese children and their siblings represent a predisposed group. A Pediatric Regional Community Diabetes Evaluation and Prevention Center established at Georgetown University Medical Center is proposed to provide a service for early diabetes detection in the pediatric age group and hopefully, for prevention. The Center would encourage referral from private practitioners, health departments and school agencies, of children in the predisposed group. Secondary screening centers will be established in five collaborating hospitals: Arlington Community, Fairfax, Children's, Providence, and the Hospital for Sick Children. Blood samples of children examined at the secondary centers will be referred to the primary center. Although it is estimated 50-100 siblings of diabetic children will be examined, no estimate is made for the number of children of diabetic parents, or obese children and their siblings, to be screened. Other goals are to: establish comprehensive diagnostic guidelines for,the recognition of the prediabetic stage in the pediatric age group, and to establish monthly conferences and progress reviews as a form of continuing education in the private physicians and other interested groups. Evaluation as outlined is limited to blood testing procedures and analyses. The personnel budget request is based on experience gained during the past two years of preliminary research cond Iucted on obese children and siblings of diabetic children, which was supported by a grant from the National Institute of Arthritis and Metabolic Diseases. The applicant states the proposed application of this experience cannot be continued without financial support. The budget request for personnel is $50,854. The major item in the equipment category is Gamma Counting Equipment, $12,000. Second Year: $61,397 Third Year: $64,067 Requested Project #37 hronic Obstructive P nar First Year Disease (C This project, presented by the $42,977 Pulmonary Division of the Howard University College of Medicine and Freedmen's Hospital, is directed at improving the effectiveness of unaffiliated practicing physicians in detecting and treating Chronic Obstructive Pulmonary Disease. A short course in the clinical, pathophysiologic and therapeutic features of COPD will be taught to 60 physicians and their assistants over a three-year period through lectures, demonstrations and the inquiry method. Four courses presented each year will accommodate five physicians and their office assistants. The curriculum is designed to be presented in two sessions for a total of six hours instruction. Attending METROPOLITAN WASHINGTON D.C. -3- RM 00031 7/70.1 Regional Medical Program hysicians and assistants, where appropriate, will be offered additional courses in pulmonary diseases at, and supported by Iloward University. Upon completion of the course each partici- pating physician will be provided'with a "relatively inexpensive" ($225) vitalor, and respiratory history forms so that he may undertake private office screening of all patients over the age of 40 an(] all patients with histories or physical findings suggestive of COPD. Patients presenting positive findings will be directed to the function laboratory at Freedmen's Hospital for more detailed study. Initially ten patients weekly will be fully tested. This will be raised to 15-20,by the end of the first year. Those confirmed to have COPD will 'De referred back to the private physician for treat- ment and follow-up. Although the applicant states the project will compliment the Georgetown University Adult Breathing Improvement Course and the Inhalation Therapy School at Washington Hospital Center, already approved by the Metro-Washington RAG, no specific plans for coordination are included. No specifics are provided as co how the Breathing Equipment Loan Service will serve as an assisting agency. A general plan for evaluation is presented. econd Year: $45,118 Third Year: $49,428 METROPOLITAN WASHINUI'UN 1).U. Regional Medical Prograrn Summary of projects currently being supported by MRtro. D.C. RMP Pro ect Title and Number Approved Project Funded 3rd Year Period (direct costs) 3/l/70-2/28/71 #1 Freedmen's Hospital Stroke Station 3 Years $ 16,100 li2 Cardiovascular Disease Follow-up 3 Years 97,812 and Surveillance - GeorgetowA #3 Training for Cardiovascular Technicians 3 Years 19,600 Funded 2nd Year costs) (direct 3/l/70-2/28/71 Core 3 Years 554,034 #5 -Audiovisual Library of Ovarian Neoplasms 3 Years 2,500 for Continuing Education #10 -Comprehensive Care of Patients with 3 Years 7,500 Pultionary Disease - Georgetown #12 -Mobile Coronary Care Unit 2 Years 50,000 #19 -Metropolitan Washington Regional 3 Years 40,000 Cancer Registry #20 -Metro Washington ileripheralvascular 3 Years 50,000 Funded Ist Year (direct costs) 3/l/70-2 /28 /71 #23 - School of Inhalati era 3 Years 12,600 l@26 -Comprehensive Community Hospital 3 Years 49,438 Stroke Program - Arlington #28 -Coronary Care Nurse Training 3 Years 14,790 Freedmen's School of Nursing #29 -Mass Screening, Tre and I Year 16,206 Eradicating As)rmptomatic Bacteriuria TOTAL $980,514 @IETROPOLTTAN WASHINGTON D.C. -5- @l 00031 7/70.1 Regional @ledical Program Status of Projects not funded Project Title and Number Status #4 - Home Telecasts of Medical-Surgical Conferences Disapproved #6-Comprehensive Hospital and Home Care of Stroke Patients Disapproved .7-Puerperal Hemiplegia Disapproved '@8-@iodel Stroke for @letro. D.C. Disapproved "@9-Coronary Artery Disease: The Role of Exercise Disapproved in its Management '@ll -@lobile Coronary Care Unit for @letro. D.C. Disapproved #13 -i@lobile Coronary Care Unit - Georgetown University Disapproved 16-Paramedical Retraining by Video Tapes Approved (No funds recommended) "'17 -Health Careers Council Approved (No funds recommended) 18-Application of Technological Advances to Disapproved Education in Cancer '@@21 -A@ lying Community Health Research Findings in the Region Disapproved Approved ,@22 -Pediatric Community Kidney Disease Prevention Center (No funds recommended) "24 -Attempt to Imp)rove Care and Patient Cooperation Returned for in Hypertension Revision -Cancer Radiotherapy Unit - Education Consultation Service Approved but Unfunde( @"27 -Continuing Education and Social Services for Pediatric Oncology Disapproved #28 -Coronary Care Training - Freedmen's, Approved but Unfundec #30 -Community Renal Diagnosis Service Using Immunoflourescence Disapproved @'@31 -Hemodialysis Training Program Approved but Unfundec "34 -Film on "Care of the Colostomy Patient" for Patient Instruction Deferred for Additional Informatic -National Medical Association Foundation Nursing Approved but Unfunde@ Home Development DRMP/GRB 5/27/70 SUmmARY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE icAL PROGRAM METROPOLITAN WASHINGTON D4C. REGIONAL MED RM 00031 7/70.1 FOR CON.SIDERATION tY JULY 1970 ADVISORY COUNCIL General: The Committee approved this application with specific conditions; one project was not approved and one was approved at a reduced level. Committee's,observations on these projects closely paralleled those of the outside reviewers. Proieci #36 Diabet s and obe itv Evalua This project which was considered to be an applied research project of activities previously supported by NIR was received bnth siasticolly by Committee which cited numerous program concerns and ifie n iar d points in the narrative. It was questioned whether the hyDoth sig on which the program is based is sound enough for translation @into an action program and if so, whether it could be effectively evaluated. It was noted the total number of children to be examined is not specified a it is unclear as,to what happens to the obese children in terms of ecific corrective measures and follox,7-up. Also measures to be used in nonob6se children who show prediabetic changes are not described. The program is not structured for the low income group which ne dsa screening and referral service.. The letters of endorsement are non-comittal and some Committee members were not assured of the cooperation of the private sector upon whom referral and follow-up would depend. The same members !so doubted The value of the educational component which is designed to i is6 the index-of-suspicion of physicians, arguing practitioners are ware of t e problem And it is questionable how many will make use of the facility. in ietAtion to the budget i.t was noted,no mention is made of the division of responsibility and duties of personnel. In the absence of the number of children to be studiedi it is im osIsible to estimate the cost per child p examined. Since there was no information given to estimate the number of tests the Gama Counting equipment could do, the reviewers were not convinced of the need for the equipment. The role of the M.D.-ttainee is not clear is he 0 post resident or will he be in residency training. Although the pt6je t will probably generate income from charges for services, no inf6r ation is provided on this aspect. Also no plan is presented to phase out RMP support. @Committee noted and concurred with the Continuing Education and Training anch comments that; specific information is lackin2 for the program of cntinuinr education for professionals, as well asfor the children and fniiiies; no information is provided to evaluate feasibility, no mention I i made of existing resources and the budget reflects the lack of staff - Ifo -the continuing education component. P tnmmp-ndation: Non Approval I - No DRMP Funding Recommended. ROPOLITAN WASHINGTON D.,C. -2- RM 00031 7/70.1 egional Medical Program ect #37 - Early Detection of Chronic Obstructive Pulmonary Disease. itique: Committee and the Ad Hoc Cardiovascular Panel were in basic agreement regarding this project. Both noted there is un- .estioned need to improve the effectiveness of the unaffiliated practicing .ysician in the detection and treatment of chronic obstructive pulmonary sease. It was also recognized that this project is designed to improve rvices to the serious needs of ghetto patients. would seem, however, that the staff might train mote physicians per ar and could provide some follow-up in the offices of physicians as eded. It is not clear how baseline data will be obtained for later aluation of success and although clinical research is suggested as a ans of evaluation, no plans are included. The need for evaluation of ysicians' response and benefits to the community are recognized but e forms are extensive and vague, and the procedures need clarification. e six-hour course is not spelled out, making it impossible to evaluate e educational design. The request to purchase Vitalors to be given to ysicians as an incentive to participate was considered inappropriate in at it would set a precedent that would initiate a flood of similar quests. Some doubt was expressed that a full-time laboratory technician d a full-time equipment maintenance specialist is justified, particularly e latter, since Vitalors are subject to little breakdown. Plans for asing out RNP support is not in evidence. !commendation: Approval I - at the reduced level of 01 - $38,477, 02 - $40,618, 03 - $44,928 with the following conditions: 1) No support for Vitalors 2) Justification of maintenance technicians 3) Clarification of evaluation techniques IMARY OF RECOMMENDATIONS ,.oiect Title and Recommendation 01 02 03 Total 16 -Diabetes and Obesity Non-Approval I -0- -0- -0- -0- Evaluation and Pre- vention Program @7 Early Detection of Approval I at $38,477 $40,618 $44,928 $124,023 Chronic Obstructive reduced level Pulmonary Disease with conditions Total Application Approval with $38,477 $40,618 $44,928 $124,023 Specific Condi- tions John Johnson was not present during the deliberation of this application DRMP/GRB 7/14/70 0 0 0 Ml,-,I)LCAL Pl-',OG[@AMS SEI),V@f(;F Of,' A @,tJPPI,FT4ENIIAL OPERAI'IONAI, (,FAN.[' APPI,ICAI'TON' (A Privileged Communication) Ri@"(;IONAL --,,IEDICAI, PROGRAM E,,l 00053 I'/i-,O.l -LlitC@ 200 June 1.970 Revi.ew Committee 111.1 Michigan Avenue East l,arioinF!,, Michigan 1'ro@,rani Coordinator: Albert E. HeListis, M.D. Requested lst Yr. 2nd Yr. 3rd Yr. TOTAL I)irect Costs 897,822 $ 812,104 $ 806,156 $2,516,082 Indirect Costs 134,053 192,340 204,49?- 530,885 I O 31., 8 7 5 $1@,004,4li4 $1,010,61,8 $3,046,967 I] i.s t-ory: The @li.ciiig,.in Associat@iori for Pegional Medical Programs was awarded i.t@s initi-al planning grant of $1,040,639 during June of 1967. The grant supported a central planning staff qnd separate subsidiary planning groups. These were: 1) Michigan State Department of Public Health (continued support for this agency not requested after the first year). 2) Michigan. State Universitv Medical. School. 3) Iklayne Stite University Medical School. 14) L@niversity of Michigin Medical School. A consolidated planning operational application was submitted near the end of the first planning year. Following a preoperational site visit during ,Iune 1968, the Region became operational as of July 1, 1.968. TTi addition to (,oi.-e, ten operational projects were supported, at $773,567. The budget period was changed from July 1 to September 1, 1969, at the end of the first year. The second operational year (14 months - 7/i/69 to 8/31/70) is funded qt q total of $2,304,595 (d.c.) - $1,945,901 basic and $358,694 carryover funds. This amount supports the Core central planning and administrative staff, plus subsidiary Core components in the three medical schools. In addition, nineteen operational projects are, or will be, supported during this year (see History Supplement for details). ilistorical.lv, the reviewers have noted the obviously excellent local., technical. and RAC reviews that projects receive in this Pegion. In fact, since the Region became operational- (July 1968) only one of a total of twentv-six projects has been recommended for nonapproval, and this action was based on DRi4l' policy involving the type of training acti-vity proposed. T)Irect costs only ire noted in the following project descriptions. PM 00053 7/70.1 @1TC]II.GAN R(@gional .Iedi.cal Program - 2 Requested First Year 1-1 res en t Lal 1 c a t i on: 'I 'his ipl)lic,,itior) requests ,upport for one renewal and two new three- ye.ir ol-)erllional projects. @Project #16 (R) - Surveillance of Electronic Equipment- $45,701 n Special Care Units - Wavne State Universi Detro This is a one-year renewal request to support eviously approved by C,3uncil for one year in the amount of $49,135. While the total program request shown is $86,381, the Region anticipates in grant-related income which will be credited to the project. Thus, the Region requests $45,701 RMP funds for the @twelve-month period. The specific objectives were: 1) to assess the practices with respect to electronic equipment in coronary and intensive care units and emergency rooms in Metropolitan Detroit hospitals; 2) Lo determine the degree to which use of such equipment fulfills tile desired medical objectives; 3) to determine the potential hazards in the use of such equipment; 4) to determine the need and frequency of monitoring of such equipment; 5) to provide pertinent safety data about specific equipment to personnel in units surveyed; and 6) to determine if incompatibilities in equipment represent a significant safety hazard. By the end of the first year of operation 25 hospitals will have been"' initially surveyed, and numerous equipment discrepancies have been identified within each hospital. Some of the problems found were: 1) defibrillator output not meeting specifications; 2) defibrillator carts were not reasonably ready for use; 3) equipment's internal components were not meeting reasonable standards; 4) pacemakers were not receiving adeGuate care; and 5) poor design by manufacturer. Because of the seriousness of the malfunctions associated with the electronic equipment, new objectives have been developed to broaden the scope of the new project. The new objectives are: 1) to establish a plan to continue the present project as an ongoing program Without the financial support of RMP; 2) to continue and expand the scope of tile present project; and 3) to inform the hospitals and medical community on the hazards involved in the mi.suse of electronic equipment. 'I'lie renewal request includes two electronic technicians to be employed to better facilitate continued evaluation of the hospital's electronic equipment. it is anticipated that with this additional help they will be ,ible to screen 60 new hospitals (urban and rural). The Region states that the response to this offer of service has been much higher than anticipated. Also, the team plans to revisit 75% of the hospitals that were visited during the first year. Electronic equipment in operating and emergency rooms, special care and cardiac care units will be included in the expanded investigation. inspection standards and frequencies will 'IIC!I-IGAiN f@c-gioiial Nledical Prograii,. - 3 00053 -,/70.1 f@e4uestEd F'Ii@st Year i@)e O@t@IbliSlIC-(i for equipment common to most (:Cll Ind (3rit(,rgency t-oonis .Coi@tilt@ition will be provided to hospitals purchasing (,,i@iii)mei@t, bL]il.ding or remodeling special care units. A,, -i iiii-@@ins of informing the medical community on the lilzcirds faulty electronic equipment, it is planned to: (.,on(@lt)ct@ A three-d@iy seminar for physicians; 2) publish four @@rticl(!s for inclusion in hot]) regional and national health and 3) produce a fifteen-miriute color f@i.1m. The publicity @iiid distribution of the film will be made through the of the Michigan Ileart Association will will also provide assistance in the development of the three-day seminar for physicians. Two hospitals, Providence and Sinai, have already offered to cosponsor the seminar and will provide free facilities and staff support. f-oiig-ratige plans include the development of a course on the safe and effective use of medical and electronic equipment which will be included in the medical or osteopathic school curriculum. Ii-i- I)oi.isc@ educational programs to be presented to community hospitals will also be considered. These programs wi-11 acquaint the hospital ,@t,iffs with the correct techniques of keeping and using safe medical electronic equipment. Several agencies will be approached in an effort to obtain sponsorship to guarantee continuity of support after termination of RMP funding. Ilroject l@27 - T)emoiistration of a Comprehensive Health Care $505,269 Program for the Urban Poor. Wayne County General hospital requests $505,269 through the Michigan R@IP, For the first year of a ttiree-year program to initiate a demonstration program of comprehensive health care for the urban poor. This is a revised application. The original. project was reviewed by the Ativ,tisL 1969 Advisory Council, and approval of planning funds in an amount not to exceed $40,000 for each of two years, was recommended. The Council I-)elieved the project should be recast with specific, clear objectives and methods of procedure; and should include information pertaining to the following points: 1) (oiicrete diagnostic, treatment and fol'lowup procedures should be set forth and documented; 2') (:tlrreiit demographic inforrTiati-OTi as it relates to the target group; i) An oijtline showing a more sophisticated screening program; @'4) A realistic, cooperative, d,-tt@.i-gatl)ering program; ')') A cL(,,irl.y written commitment from relating,agencies; 6) A concrete commitment From Wayne County regarding support after termination of RMP funds; 7') A method of handling fee,-, gener@it@ed throti@h project activities, 9) A complete, clear training program for "aides" and statements on the intended use of personnel after the training period; and A clear statement of the value of tfiis activity over the existing programs for the target Population. ,,,IICIII(;AN Regional Medical Program - 4 00053 7/70.1 Requested First Year '['lie revised proposal is for the development of a comprehensive health care clinic (including detection, diagnosis, treatment and followtip procedures) with the outpatient department of Wayne County (;eneral Hospital. The major impact will be directed to the care of the medically indigent population in Wayne County. IF lie project is designed to compare two systems of health care, both to operate concurrently in the outpatient department during the ttiree-year project period. The first system refers to the episodic care system (processing of patients in the same maiiner used for years, except that every alternate patient will be referred to the second system). The second system is aimed at establishing a comprehensive care system involving an automated, computerized, mttltipliasic screening program and followup procedures. The project plans to utilize, as much as possible, nonprofessional personnel who will be expected to obtain employment in the operation of the Comprehensive Health Care Clinic after completion of their training. currently there are 43 separate clinics operating in the outpatient department of Wayne County General Hospital. The outpatient visits have increased from 10,000 visits in 1950 to about 76,000 visits in 1969. The applicant describes three p,overty-type target areas to'be served by this project: 1) Cit of Inkster - located a block from the hospital y has a population of 37,000, of which 42.3% are nonwhite; 2) Ecorse located a few miles from the.hospital - has a population of 17,238; (,the community's nonwhite populatioi-i is estimated at 33.3% (99% black); and 3) Ronit-ilus Township (located a few miles from the hospital) has a population of 17,000, of which 16% are nonwhite. Lt is planned to process four groups of patients through the Comprehensive Care Clinic. The four groups are: 1) every alternate new indigent patient admitted to the clinic (sixty-five are expected weekly); 2) everv alternate clinic patient who has not had a comprehensive health evaluation for over a year (two hundred and fifty expected X,7eekLy); 3) apparently "healthy" individuals referred from Wayne County OEO, Senior Citizen's and other similar community groups (one hundred and fifty expected weekly); and 4) every alternate patient admitted to the hospital who is not acutely ill. Sc,-eeii@@tig tests, examinations and procedures will consi.st of: anthropotiieti-y; a twelve-lead electrocardiogram; chest x-ray; mammography; pelvic examination (including a pap smear); oral and clent@il inspection; visual acuity and tonometry; photographs of full and side face; spirometry; audiometry; blood and urine specimens. The Region states that during the local review of this proposal, the R,-,giollii m(-@dicil, Ilrogram - 5 00053 7/70.1 l@ (-@ (I I I ('!@ t@ e (I first Year i-(@viewei-s I)c-l,ieved that all of the points rai.sed by the RMP," I)ad been satisfactorily covered in this proposal with the exception of the commitment of Wayne County to carry on the activi-ty after termination of RMPS funds. The major portion of the requested budget is in the categories of personnel ($173,094), equipment ($163,175), alterations and renovations ($91,000) and "other." "Other" includes rental cost for a computer ($60,000). Second Year: $454,574 Third Year: $477,459 I)roject 4@28 - Proposal for the Southeastern Michigan ReRio-nal $346,852 Cancer Program. Wayne State University requests $346,852 through the Michigan Regional Medical Program for the first year of a three-y6ar proposal which is to improve the care of cancer pati-ents in a tri-county area, by providing a clearly identified and publitized 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 fri.-county area (Wayne, Oakland, and Macomb Counties) to increase the availability of 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 "guidelines for management of patients is 11 with malignant disease. The cancer consultants will be identified and reappointed by the Project Director annually and will have the responsibility of: 1) implementing a monthly tumor board in their hospitals; 2) implementing and attending clinical teaching conferences in their own hospitals; 3) attending the monthly conferences 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 requiring aggressive nursing care, will be encouraged. R-,,i 00053 7/70.1 @IICIIIC;A'i Regional @tedical Program 6 uraged to work toward the Each tri-count@y area hospital will be enco establishment of a mandatory Papanicolaou cervical smear requirement for women admitted to the hospitals. I'he 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. Diagnostic/therapeutic baselines (to be used as aids) for selected malignant diseases will be developed and will be disseminated to practicing physicians in the tri-county area. The Project Director will have overall responsibility for evaluating ongoing and terminal program accomplishments. Terminal evaluation of the extent to which program activities have improved patient care will consist of physician evaluators who will review all available records, x-rays, and tissue slides of two patient samples selected so as to permit generalizations. A systematic quantitative and qualitative analysis of all preceding project evaluation data will also be included in the terminal evaluation. $219,422 of the total request of $346,852, for the first year, is for personnel. $74,770 of the request includes stipends for the cancer consultant mass program mailings to area physicians, Advisory Council luncheon conference costs and maintenance of off-campus office. Seco,id Year: $357,530 Third Year: $328,697 MICIIT.(',AI4 BEC.LONAL MEDICAL PPOGRAM - 7 - RM 00053 7/70.1 HISTORY SUPPLEMENT IIISTTNC OF CIIRRENT ST E & OPERATIONAL PROJECFS IN MARMP A - F-,NDED PROJECTS PROJECI@ qlq'LE AMOUNT SUPPORTED THROI:GH 8/31/70 BAS IC CARRYOVER I* Central Planning & Administrative Staff (East Lansing & Subregions) $253,080 $22,000 3 Coordinated Data Collection and Analysis: Planning for Automation of Multiple Screening, MPH 286,487 -- 4 Heart Association, lbdel CCU 103,590 50,250 5* MSU, Planning Office 228,568 -- 6 MSU, Hypertension Clinic 52,534 7,', U. of Mich., Administrative Secretariat 70,444 8 Postgraduate Nursing Educ. - U. of Michigan 96,315 9 U. of Mich. - Drug Information and Therapy Analysis 78,783 2i$200 II U. of Mich. - Medical Care Evaluation 100,292 22,288 12 School of Dentistry Program - U. of Mich. 31,636 -- 13 Survey of Physicians' Attitudes - U. of Mich. -- 57,521 14* Wayne State Univ. - Planning Office 139,879 4,290 15 Zieger-Botsford Hospitals - Survey and Continuing Physician Education 64,840 10,100 16 Wayne State Univ. - Surveillance of Electronic Equipment in Special Care Units 13,211 39,855 21 Michigan Heart Assoc atioii Public -- 65,038 Information Project. 22 Development of a Cardiovascular Center, 34,440 Mercy Hospital, Benton Harbor *Cote Planning MICHIGAN REGIONAL MEDICAL PROGRAM 8 RM 00053 7/70.,l A FUNDED PROJJTECTS (continued) '@ORTED AMOUNT SUP PROJECT TITLE THROUGH 8/31/70 NLIMBER BASIC CARRYOVER onstration of Compr' ensive Hea 23 Dem eh Ith Care for .the Urban Poor - Wayne County General Hospital $ 319712 25 Innovative Approach to a Continuing Medical Education System Based on Existing Satellite Hospital Concept 40,512 SUBTOTAL $1,560,171 $358,694 B APPROVE6 - UNFUNDED PROJECTS $ a85,730 (Note: DRMP is in the process of awarding $385,730 - annual base - to partially fund the following approved,, unfunded projects) 17 Stroke Base Center - Wayne State 18 Development of a Comprehensive Attack on the Problems of Stroke - Wayne State i9 Stroke Demonstration Unit at Detroit Osteopathic Hospital 20 Central Michigan Comprehensive Stroke Project 26 An Experimental Continuing Education Program for Small Inner-city Hospitals TOTALS $1,945,901 $358,694 C DISAPPROVED PROJECT PROJECT TITLE 24 Nuclear Medicine Technician Training - Hackley Hospital D DISCONTINUED PROJECTS 2 Michigan Department of Public Health - Planning 10 Nonprofessional Staff Utilization Wayne State University DRMP 4/30/70' A Privileged Communication SUKZMY OF REVIEW AND CONCLUSION OF JUNE 1970 RE-VIEW COMMITTEE MICHIGAN REGIONAL MEDICAL PROGRAM RM 00053 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee recommended that this supplemental operational application which requests $2,516,082 (d.c.o.) @or a three- year program period by partially funded at $1,483,003 (d.c.o.) to support Project #16 for one year (renewal) and Project #27 in the time and amount requested (three years). Committee further recommended "non-approval - revision required"- for Project #28 for the reasons as set forth below. Once Again as in past reviews, the Committee commented on the excellent local review of individual project proposals which are submitted from this Region. Project #16R -.Surveillance of Electronic Equipment in Special Care Units Wayne State University Critique: Members of the Committee were very pleased with the progress made thus far in this project. The Review Committee concurred with the Ad Hoc Cardiovascular Study Panel that the need for this type of service has certainly been demonstrated by the results obtained; that the objectives are clear and well defined; that the procedures utilized are apparently adequate; and the budget is modest. A.ccordi ng to the appl.i- cant, a plan has been devised to continue and develop the present project as an on-going program without financial support from RMP after this year. It was noted that the project is beginning to acquire national recognition. The reviewers agreed with the study panel's unanimous recommendation that the project is technically sound, capably directed and recommends that it be continued in time and for the amount requested. Recommendation: Approval'in time and for the amount requested. Direct Costs Only: Ist Year -2nd Year -3rd Year $45,701 Not requested Not requested Project #27 - Demonstration of A Comprehc,,nsiv,c-- Health Care Prc)@rii@t for the Urbaii Poor r@iti@uc: This is a revision of an application which was originally reviewed during the April--Ilay 1969 Revic-i,, Cycle, i.ii which this proposal was one of four proposals to be included in a. technical s-,-"-e visit. Foll-o@@7ing a July 15, 1969; site visit, the August 10,69 Coi-irici-I.. Michigan RMP 2 RM 00053 7/70.1 recommended $40,000 for each of two years to continue planning of the proposal. In addition, nine specific points were raised which Council believed needed clarification. The reviewers believed this proposal satisfactorily relates to all issues raised, with the exception of the current demographic information on the .target population and a commitment from Wayne County regarding support after termination of MM funds. Members of Committee believed that more detailed demographic information would have been helpful in the review. Also, they reAli,zed that it is politically unrealistic to expect the present Board of Supervisors to commit funds three years hence, although the Board's interest in the services to be provided were noted. During the review,, the Committee raised some questions and issues which they believed the Region should try to resolve. These were: (1) It was difficult to determine from the written application to what extent the people that are affected by the proposal were actually involved in the planning of the program; (2) The obligation to RMP to purcl-iase, install and maintain costly and fixed equipment; and (3) Evaluation procedures were considered inadequate, although a cost- effectiveness factor may be determined at the end of three years. it was noted that the Michigan School of Public Health plans to mal@ use of the data obtained. In recommending approval, the Review Conmiittee recommends that a condition of approval be that the applicant seek more participation from the target population and suggested that this be accomplished through the establishment of a subcommittee on Health Care of the Poor. it was further recommended that the subcommittee be well represented by consumers of health. services from the target groups. (An Ad Hoc Committee member, a Program Coordinator, abstained in the vote on this proposal. He commented that'he failed to understand how this project can be called comprehensive care rather than multiphasic screening since the patients in the study will receive treatment from the same sys- tem as the control patients will. Ile further suggested that the follow- up period is insufficient for study and voiced his concern of the lack of community input into the project.) Recommendation: Approval'i.n time and amount requested subject to the condition outlined above. Direct Costs @l-_: lst Year 2nd Year 3rd Year $505,269 $454,574 $477,459 Michigan KT 3 RM 00053 7/70.1 Project #28 - Proposal for the Southeastern Michigan ReRional Cancer Program Critique: This is the Region's fir4st 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 outiiioded 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, lie is a cancer consultant). It was difficult for the reviewers to understand why be should be paid-a per them to do what he should or probably would do anyway. Additionally, it was believed the requirement that all hos- pital admissions have "pap" smears appeared.to be an expensive duplica- tion. 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 greatlv -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 Contin uing Education and Training Branch staff provide assistance in this effort. Rdcommendation: Non-approval II - revision required. SUMMARY OF RECOL@ENDATIONS Number Title lst Year 2nd Year 3rd Year #16R Surveillance of Electronic $45,701 Not requested 'got requested Equipment in Special,,Care Units #27 Demonstration of a Compre- 505$269 $454,574 $477,459 hensive Health Care Program for th e Urban Poor #28 Proposal for the Southeastern Non--approval II - revision required Michigan Regional Cancer Program TOTAL $550,970 $454,574 $477,459 Michigan RMP 4 RM 00053 7/70.1 Year Total Direct Costs 01 $ 550,970 02 454,574 03 477,459 TOTAL $1,483,003 DP,MP/C@RB 7/13/70 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) MISSISSIPPI REGIONAL MEDICAL PROGRAM RM00057 7/70.1 2500 North State SLreet June 1970 Jackson, Mississippi 39216 Review Committee Program Coordinator: Guy D. Campbell, M.D. Requested Program Period Ist Year 2nd Year 3rd Year Total Direct Costs $520,713 $401,609 $420,679 $1,343,001 Indirect Costs 194,962 160,472 169,082 524,516 TOTAL $715,675 $562,081 $589,761 $1,867,517 HISTORY: This Region received a two-year planning grant beginning Julyl, 1967; $322,845 the first year and $505,932 the second. The first year award was supplemented in April 1968 by $131,361 to begin an earmarked two-year Comprehensive Stroke and Detection Center (Project #I). The second year planning award included $122,610 for the second year continuation of Project #1. A Supplement of $142,675 (earmarked) was awarded the second year for a Training Program in Diagnosis and Treatment of Chronic Pulmonary Disease (Project #2). Following the review of the initial operational application by the Review Committee in April, a site visit was made the following month to assess the Region's ability to assume operational status. The shocking lack of resources contrasted with the tremendous me ica care needs impressed the site team. The shortage of health education resources outside of the University Medical Center is a serious problem which cannot be solved overnight and will influence the degree of quality medical care possible in this Region for years to come. But the site v@sitors were impressed with the commitment of the staff, participating organizations, and RAG in the Regional Medical Program. The site visitors felt that Mississippi had to have operational funds in order to begin this important task of effecting the facility of care. The May 1969 Council approved operational status. The first operational award included Core and nine projects. One other CPR training project was approved, but funding was deferred until Council policy was clarified. During the December 1969 meeting, Council reviewed and approved a supplemental renewal application of Project #1 for three years and three months. Subsequent to this action, the third period of the current award was extended from July 1, 1969 - March 31, 1970 (9 months) to July 1, 1969 MISSISSIPPI Regional Medical -2- RM00057 7/70.1 Program June 30, 1970 (12 months) to be sustained by anticipated unexpended current funds. Future support for three years is subject to fiscal restraints in FY 1971. For ease of reconciliation, please refer to the attached "Review and Funding History." PRESENT APPLICATION: This is a supplemental ap lication for support p of two new projects and one renewal, each for three years. They will be based at the University Medical Center, but are action-oriented at the peripheral community level. Requested Pro'ect #2R - in Diagnosis and Treatment First Year of Chronic PulmonarV Disease $323,730 This is a request for renewal of a two-year program which began as a feasibility project during the second planning year. The Council, during its review of the initial application in May 1968, believed that the proposal was well presented and in a Region needing better medical care. There was some question as to tenure of commitments and justi- fied level of support. Deferral for a site visit was recommended. The site visitors, September 1968, observed that the Region's capability was not then adequate enough to undertake all aspects of the proposed program. The visitors were also concerned about the weakness in the evaluation process, particularly the absence of baseline data, against which progress could be measured. During the November 1968 meeting, Council recommended approval for two years in a reduced amount of approximately half that requested. Following a favorable report of a site visit in May, 1969, Council recommended approval for continuation of the project in the second period, including $72,000 for needed remodeling of facilities. A continuation application for the third period of the current grant (July 1 - December 31, 1970 - 6 months), is expected in the near future. The level of support requested for three additional years'renewal beginning January 1, 1971, is considerably less than the amount requested for the same period of time in the original five year proposal. Current education and training programs include: 1) long and short term training activities for physicians, nurses and allied health personnel; 2) mobile demonstration seminars for outlying hospitals; 3) cooperative programs for pulmonary therapy aides; and 4) implementation of a formal four-month training program for pulmonary therapy aides. Other activities include: 1) demonstration of improved health care of children and adults with pulmonary disorders, particularly home care programs; 2) development of reproducible bacteriological surveillance techniques for therapy equipment; and 3) development of screening procedures for early detection of chronic airway obstruction. MISSISSIPPI Regional Medical -3- RM00057 7/70.1 Program As reflected in the increased budget, five new programs are planned. In the development and demonstration of improved health care to I patients with chronic pulmonary diseases, a special pediatric cliric will be conducted once each month. This is in addition to the current cystic fibrosis clinic which meets two half days per month. This clinic and laboratory will also be part o@-' the facilities used for the project's continued education and training activities. Bacteriological studies will be undertaken to evaluate different practices for cleaning inhalation therapy equipment. An internship program (6 to 12 months) including evening seminars will be offered to graduates of approved schools of inhalation therapy.. The efficacy of the ambulatory home program is to be evaluated. By use of a mobile unit van, included in the equipment budget, demonstration seminars to peripheral hospitals are to be offered each week, an anticipated annual increase from 150 to 500 participants. Second Year $21E),006 Third Year $219,179 Requested First Year Project #13 - Emergency Nursing in Critical Illness $35,420 The purpose of this project is to upgrade the quality of nursing the critically ill, emergency and day-to-day care. In tune with this objective, a five-day course will be offered to 60 nurses annually. The budget indicates that twelve courses will be held each year, approximately five trainees per session. Mindful of the need for additional training of nurses in small hospitals, the courses will initially be limited to nurses who have close contact with extreme emergency and critically ill patients. Enrollees will be required to return annually for a one-day conference for updated information and to review individual problems. Program assessment includes pre- and post-testing, on-the-job logs by trainees, on-the-job observation by a project facility member and evaluation of trainees by their hospital administration. Second Year $36,946 Third Year $39,455 Requested First Year- Project #14 - Comprehensive Renal Training Program $161,563 This is a recast of Project #12, same title, which was funded in a greatly reduced amount for a one-year trial period for further planning and development of the program. This action by Council, May 1969, followed a site visit that same month. The site visitors recognized the need for the activity. However, it was believed that the proposal was overly ambitious and lacked sufficient planning. MISSISSIPPI Regional Medical -4- RM00057 7/70.1. Program The purpose' of this project is to reduce the gap between knowledge, and its application. Utilizing present facilities, training programs will be offered to physicians nurses, te hnicians, dietitians, social .1 c workers, and administrators. Present facilities include the Artifi cial Kidney Unitlthe Renal Laboratory and the Home Dialysis Training Ce nter. Other project aspects include testing screening procedures, teletype tie-in with a kidney donor data program, tissue typing training and statewide telephone consultation for physicians. Approximately 70% of the budget is for personnel. Support is requested in most other budget categories, most significant amounts of which are for equipment and travel. Second Year $154,657 Third Year $162,045 MISSISSIPPI Regional Medical -5- RM00057 7/70.1 Program REVIEW AND FUNDING HISTORY lst Year Planning Award 7/l/67 - 6/30/68 $322,845 February 1967 Council (return for revision) March 1967 Site Visit May 1967 Council Project #1 (feasibility study - earmarked funds) Stroke Detection and Treatment 4/l/68 - 3/31/70 (01-3 mos.) $131,361 Approved Future Level - Direct Costs 02 03 (9 mos.) $80,293 $61,927 2nd Year Pianning Award 7/l/68 - 6/30/69 $505,932 (includes $122,610 for Project #1 - 02-12 mos.) September 1968 Site Visit Project #2 (feasibility study - earmarked funds) Training Chronic Pulmonary Disease - I/l/69 - 12/31/70 (01-6 mos.) $142,675 Approved Future Level - Direct Costs 02 03 (6 mos.) $167,467 $89,000 Initial Operational Application Projects 7/l/69 - 6/30/72 May 1969 Site Visit May 1969 Council August 1969 Council MISSISSIPPI Regional Medical -6- RM00057 7/70.1 Program Direct Costs Funded Commitments 01 02 03 00 Core Staff $306,879 $329,678 $353,488 *#I Stroke Detection and Treatment(9 Ws.) 62,619 0 0 #2 Training Chronic Pulmonary Disease 2 00, 2 92 (6 ms) 89, 000 0 #3 Post Graduate Institute in Medical Sciences 38,509 47,187 45,396 #4 Recruitment of Health Manpower 70,000 0 0 #5 Cardiovascular Clinics 29,018 29,968 30,966 #6 System of Coronary Units1 1641,586 79,489 81,409 #7 Lowndes General Hospital Disapproved - No RNP Funds to be Used #8 CPR Training (9 mos.) 38,988 46,247 0 l@9 Central Tumor Register Disapproved - No RMP Funds to be Used #10 Radiation Therapy 204,861 78,629 762898 #11 Regional Neurology Clinics 67,494 66,186 68,909 #12 Renal Disease Training 46,321 0 0 Totals $1,229,567 $766,384 $657,066 Staff action on 2nd year continuation application. First Supplemental Operational Application December 1969 Council #lR Stroke Care Demonstration and Teaching 4/l/70 - 6/30/73 (3 years - 3 months). Subsequent to Council approval, the current 02 period was extended from July 1 - March 31, 1969 to July 1, 1969 - June 30, 1970 with no additional funds (to be sustained with current unexpended funds). Approved Future Level- Direct Costs 01 02 03 $119,803 $131,094 $141,623 DRMP 6/3/70 A Privileged Communication SUMMARY OF REVIEW AND CONCLUSIONS OF jUNE 1970 REVIEW COMMITTEE MISSISSIPPI REGIONAL MEDICAL PROGRAM RM 00057 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Review Committee recommended that this Supplemental opera- tional Application requesting $1,343,001 (d.c.o.) for three years, be partially supported at $378,821 (d.c.o.); $213,420 the first year, $125,946 the second and $39,455 the third. Throughout the review of this application, the Committee was mindful of the dearth of medical care in Mississippi and the lack of adequate medi- cAl facilities and manpower. Although the recent second year continuation application indicated the Region has made some progress 'in tackling its problems the staff reported, the Committee expressed concern that the MRMP does not seem to be addressing "real world" priorities And the cate- gorical emphasis may have attributed to this problem. It was believed that there is great need for RMPS staff assistance in helping the Region study its representation on the RAG so that basic health needs of the people are considered in setting priorities. Project #2R - training Program in Diagnosis and Treatment of Chronic Pulmonary Disease Critique: The Committee reviewed the history of this two-year project for which renewed support ($752,915 d.c.o.) is requested for three Years. Previous site visit and Council actions outlined in the history summary were noted. It was believed that though needs are well documented, evaluation procedures are limited and reported accomplishments are meager. While the bacteriological surveillance of aspects would prob- ably go well, there is some question about the capability of carrying out meaningful education. The shortage of physician and allied health resour- ces in Mississippi is well known6 M@ programs are moving in categorical areas and perhaps the immediate needs are for more comprehensive Activities. The question arose as to whether pulmonary training is a major unmet health need in Mississippi. Regardless of the prbject's priority status in the MRMP, the Committee felt that not enough documentation was pre- sented to justify approval of the Amount nor the period of time requested. Recommendation: Approval at the current annual level ($178,000) for 18 months. The Region should be given assistance by the Continuing Education Branch staff of RMPS to assure that the next continue, ation application includes progress defined in specific terms. Mississippi RMP 2 RM 00057 7/70.1 Project #13 - Emergency Nursing in Critical Illness Critique: The Committee agreed with the comments provided by the Continu- ing Education and Training Panel. The design in general is well written and developed and the direction is a helpful one for this Region. However, there is no indication of preassessment of learner's knowledge (especially in physiology and chemistry) necessary to compre- hend the course co-,itent. There is some question of the appropriateness of course content for rural nurses. There is not enough indication of nursing participation in the development of the program, of nurse teach- ing in the course, or of the nature of follow-up support. Objectives are stated well in program terms, but learner behavior reference is not. There is a need for more evidence of interest in utilizing co-trainees' new skills from hospitals and their medical staffs. Evaluation, for which there is probably too little staff time allocated, is all in terms of learner s knowledge and attitudes rather than in behavior. A more mean- ingful evaluation might be in terms of the impact of training on patient care. The budget may be too modest for staff time for the secretary and nurse coordinator. There are no specifics presented about phasing out or continuing the activity beyond cessation of the grant. Although answers to questions'and concerns are desired, the project was considered worthy of support. Recommendation: Approval I in the amount requested. It is also recom- mended that the MRMP be informed about the reviewers conc(!rns and questions. Specific suggestions: (1) nursing faculty be utilized in teaching nursing content; (2) curriculum vitae for nursing personnel be provided to @S;(3) assurance of adequate staff time to carry out secretarial work, circuit riding and evaluation; and (4) docu- mentation of commitment of sending hospital's administration and medical staff to utilize training of students on their return to work. Project #14 - Critique: The Review Committee noted that this project grew out of experience with Project #12, same title, which was funded in a greatly reduced amount ($46,321 d.c.o.) for one year for further plati- ning and development. Review comments indicating that the program was feasible under certain conditions by the Continuing Education and Training Panel were considered. Conditions included concerns that the physician courses are too minimal, the nurse course 201 seemed impossible for the time allotted, and the tissue typing course should be eliminated. The Panel believed that the curriculum should be better defined to indicate where all the different categories of personnel will fit in. Other concerns included equipment budget justification; specific information needed about the number and location of satellite dialysis programs; need for better description of Mississippi RMP - 3 - RM 00057 7/70.1 the trailer dialysis unit, and other types of dialysis aci ities, c ari- fication of fellowship program (e.g., is this for board certification; patient selection criteria needs should be better identified (e.g., will patients over 65, for whom medicare will reimburse, be selected over younger patients who cannot pay). This proposal stimulated a great deal of discussion in terms of (1) tech- nical soundness and-feasibility of the application; (2) the priority of renal disease program@ in MRMP; and (3) RMPS' role and limitations in this area. The Committee had the benefit of comments from one of its members with expertise in nephrology and knowledge about the status of renal disease management in Mississippi. He stated that Mississippi seems to have most of the five basics needed for an end stage kidney program: (1) a dialysis center; (2) multiple satellite dialysis units; (3) tissue typing; (4) or- gan retrieval and (5) transplant facilities. He also believed t e proj- ect director to be capable of conducting a successful program. It was noted that the trailer dialysis unit is a new innovative aspect that may prove to be very worthwhile in Mississippi. Some believed that RNP funds for renal disease should be limited to training, which is the purpose of this proposal. The question then arose that unless more dialysis facilities are needed and established, why train additional personnel? This question was not satisfactorily resolved. Others believed RMP funds should not be used for programs in end stage kidney disease, that there are other greater needs for available dollars. The Committee, however, recognized that RMPS had to become involved in renal diseases but on a carefully considered basis. They request Council to spell out a clear policy for RMP funding to guide them. The high cost of the proposed program for 240 patients was considered in relation to other unmet health needs of more people, and the Committee felt that a RAG more representative of all the people in Mississippi might come up with a different order of priorities. Two motions for recommendations were defeated by a narrow margin. They were: (1) Approval I with conditions cited by the Continuing Education Panel and (2) Non-Approval I. Recommendation: Non-Approval II Revision Required. This action is not to be construed as encouragement to submit a revision' It :Ls strongly recommended that @S staff assistance be provided, parti- cularly regarding the relation of this activity to other health needs. ig RM 00057 7/70.1 Mississippi RMP 4 SUMMARY OF RECOMMENDATIONS DIRECT COSTS 01 02 03 Total #2R Chr. Pul. Disease $178,000 $ 89,000 -0- $267,000 #13 Emerg. Nursing Critically Ill 35,420 36,946 39,455 111,821 #14 Compr. Renal Trg. -0- -0- -0- -0- TOTAL $213,420 $125,946 $ 39,455 $378,821 DRNP 7/8/70 0 0 1 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privile,',ed Communication) MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 7/70.1 Lewis Hall June 1970 Review Committee 406 Turner Avenue Co lumbia, Missouri 65201 PROGRAM COORDINATOR: Arthur E. Rikli, M.D., M.P.H. Requested lst Year 2nd Year 3rd Year Total Direct Costs $343,253 $223,540 $161,938 $728,731 Indirect Costs 105,856 81,075 61,554 248,485 TOTAL $449,109 $304,615 $223,492 $977,216 BACKGROUND: The Missouri Regional Medical Program is beginning its fifth year of planning and its fourth year of operations. The level of funding which the Region has requested for the year beginning July 1, 1970, is approximately $3.8 million (d.c.o.) of which $.74 million is carryover of une@nded funds from the 1969-1970 year. The $3.8 million includes $2.7 million for projects and $1.1 million for core (these amounts are currently under negotiation with staff). A complete list of Missouri's projects are included in an attached staff observation. The Region has no approved but unfunded projects. The Missouri Regional Medical Program has as its applicant organi-, zation, the University of Missouri, located in Columbia. Dr. Arthur Rikli, who had served as Director of Operations since early 1968, was appointed Coordinator in October 1968. The core staff, which has 27 positions, includes the Office of the Coordinator, the Office for Operations, which administers the projects, and the Office of Planning, which includes health care studies and six subregional offices. The 12-member Advisory Council,composed of practicing physicians, hospital administrators, a lawyer, state legislators, a sociologist and businessman, approves the applications and assists in determining program priorities. An eight-member Project Review Committee, chaired by the Dean of the School of Medicine at the University of Missouri, a Central Liaison Committee representative of 23 organizations and three area liaison committees assist the Advisory Council in its review function. The area liaison committees representing the Greater Kansas City, the Southeast Missouri, and the Southwest Missouri areas also serve to answer boundary or jurisdictional questions of project proposals. Although the majority of the Missouri RNP's earlier MISSOUP,L REGIONAL MEDICAL PROGRAM' -.2- RM 00009 7/70@.1 projects are based at the University Medical Center, the Region's more recent submissions. have been based in areas peripheral to the Medical Center - Kansas City, Sikeston and.Joplin. The Missouri WV had been encouraged'by DRMP' in 1966 to develop an operational program and it.became one of.the first Regions to become operational. It developed a program emphasizing a computer and bioengineering approach to improving the delivery of-health care. However, in the meantime, changes in the federal health effort and RMP's role in that effort in the last three years and the lack of demonstrable success of these activities seemed to dictate a change in emphasis. A ma or-pro-ram site visit was held in October i969; the site visitors also believed that these pro- jects had not lived up to their expectations and noted growing enthusiasm among various Missouri @ groups for subregional pro- grams-. They recommended that the computer -bioengineering projects at the University be phased out by June 1971 and that the Region emphasize commtmity-based activities. Review Committee and Council akreed to the need for the change, and made their recommendations for the Region's future funding levels accordingly. the Regio n s funding picture in direct costs for 1969-70 may be presented as follows: Computer and Bioengineering,Activities $2.0 million Subregional Projects .6 million Core 1.1 million $3.7 million Carryover Funds 1.1 million $4.8 million Council's recommendation for 1970-71 was: For phase out of Computer and Bioengineering Activities $1.0 million Subregional Projects #25, 26, 27, 29, 33 and 46 .96 million Core 1.1 million $3.06 million Council also suggested the Region use $ .94 million up to approximately $940,000 in carryover funds for additional subregional activities $4.0 million Y.ISSOURI REGIONAL NEDICAL PROGRAM -3- RM 00009 7/70.1 Inherent in-the phase-out of the computer and bioengineering activities, for which support was not recommended beyond June 30, 1971, was an expansion of subregional activities. In the grant year beginning in July 1971 and 1972, Council recommended that approximately $2.2 million and $1.8 million, respectively, in new funding be available for the approved core, new supplemental and continuation projects. Council stated that these recommended levels in no way represented ceilings and that the Region could compete for Additional funding with subsequent applications. Other recommendations which national reviewers made include: 1) expand the membership of the Regional Advisory Council to include a more representative group, analogous to the composition of the Liaison Committee; 2) differentiate more clearly between the pro- gram of the medical school and the program of the Missouri RNP; 3) concentrate more efforts in the Kansas City urban povertv area and delegate more responsibility to the new medical school in Kansas City for RNP activities there. Correspondingly, the core office should also make greater attempts to involve local people in communities outside Columbia in decisions affecting them; and 4) take cognizance of continuing education efforts throughout the Region rather than concentrating on improving the program of the medical school. Project #60 - Cameron Health Care System Project. This Requested proposal is geared toward improving both the First Year quality and quantity of health services in an established $108,335 medical service area. The Cameron Community Hospital ia a 58-bed facility located in the center of a four-county service area in the Northwest Corner of Missouri. The disappearance of M. D. physicians from rural areas has left Cameron with a staff composed entirely of osteopathic physicians. The proposers believe that the rural and attendant professional isolation has contributed to the loss of physicians from the area and hope to reverse this trend by instituting a better health care system with the following sub- systems: 1) Continuing Education of Physicians and Allied Health Personnel involves sending two physicians for a one-month course; sending five registered nurses to UMMC for training in intensive coronary care; subscribing to weekly videotape lecture series of wet clinics with faculty from both medical schools; obtaining special training for the home health agency discharge nurse at the UMMC; and sending four nurses to the UMMC for training in rehabilitation techniques. 2) Intensive Coronary Care Unit. The hospital would need RNP funds for training physicians and nurses, as the hospital would supply all the necessary monitoring MISSOURI REGIONAL MEDICAL-.PROGRAM -4- RM 00009 7/70.1: equipment and a crash cart. Eventually the hospital will build an addition to house an enlarged rehabilitation unit.and an enlarged physical therapy unit and will increase the twb-bed unit to four beds. The hospital will also add a third telephonic ECG link-up with cardiologists in Kansas City. 3) An Ambulance Service is needed because the advent of Wage and Hour Law is precipitating funeral directors' phase-out of such service. As the hospital is purchasing the two ambulances, PM support is needed to supply an ECG and heart-lung resuscitation equipment and supplies. -Nine attendants will be sent to UMKC for 60 hours of training. When not devoted to ambulance-service, the attendants will be used elsewhere in the hospital. 4) Rehabilitation Services would be made possible by hiring a physical Thera-pis-t and training four rehabilitation nurs6s who would in turn train aides assigned to the unit. Because dental care is an important part of this service, PM funds are requ@sted to purchase dental equipment for the unit. 5) Home Health A ervices would be provided by a nurse who would receive training at the UMMC and then function as a discharge-nurse in the hospital. A Project Coordinating Committee composed of three lay board members and three professional staff members will determine policy for the project director. Each subsystem will have a staff member as chair- man. Each of the subsystems will be evaluated both objectively, by test scores, cost comparison, mortality figures, etc., and subjectively by physicians, nurses, administrators and the community. The bulk of the three-year $198,744 request is for personnel ($152,375). Second Year: $54,967 Third Year: $35,442 Project #61 - Branson Intensive Care and Rehabilitation Project. sted This proposal would create within the Skaggs IFirst Year Community Hospital in Branson, Missouri, a comprehensive - $135,168 intensive care unit and a rehabilitation unit. The hospital has 59 beds and is located in the Southwest corner of Missouri, 40 miles from any other hospital. The project would "provide a model for demonstrating effectiveness of regionalization in establishing new services in a small community hospital." Space will be remodeled to house the four-bed intensive care and the rehabilitation units. Physicians and nurses would receive training in cardiovascular care techniques and in physical t--dicine in the Springfield Cardiovascular Education and Evaluation Project (Project #22). A physical therapist and a part-time MISSOURI REGIONAL MEDICAL PROGRAM -5- RM 00009 7/70.1 occupational therapist would be hired. Continuing education would be conducted in regular seminar sessions and through the use of the ROCOM Program (a multimedia instructional system produced by John Sutherland). The staff of the Springfield project and the University of Missouri Medical Center will be available for consultation on establishing the program and for evaluation. While $23,084 is requested for the first year for equipment and $10.000 for alterations and renovations, funds are primarily budgeted for personnel and their training ($91,424). The third year's budget is for evaluation efforts. Second Year: $57,620 Third Year: $9,000 Project #62 - Drug Information Central. The UMMC Department of Requested Community Health and Medical Practice will First Year sponsor this proposal to develop a centralized comprehensive $99,730 drug information service that would be available to ail health professionals throughout the Region. This system will serve to rapidly furnish drug information on request, supplement continuing education programs , save time for health professionals, and provide composite information on drug interaction and incom- patibilities. Operating in conjunction with the Computer FACT (Fast Access to Current Text) Bank, various types of drug information would be accessible by telephone or mail inquiry, as well as by personal visit. Additional access would be possible through the existing four-station Telex network (Springfield, Kansas City, Kirksville, Sikeston). It would make.available information of practical importance in the managment of patients, information not currently available in any single book, set of journals or review articles, and information being continually updated and expanded at a rapid rate. During the first six months of operation, D.I.C. Terminals will be established in six community hospitals. In the second year they will be placed in atleast twelve more hospitals and probably in several group practices, clinics, and physicians's offices. During the third year, it is expected additional hospitals, clinics, etc., will request terminals and be prepared to cover their entire cost and that institutions and physicians in neighboring regions will arrange for D.I.C. Terminals via negotiations with the Missouri RNP. MISSOURI REGIONAL NEDICAL-PROGRAM -6- RM 00009 7/70.'l Together with computer-developed records, evaluation will be based on a questionnaire circulated at si@month intervals aimed at determining the number of inquiries received, the number answered and the mean time required, and the number of repeat inquiries from other sources in the same category. As for continuation of the'Drug Information Central beyond the period of RNP involvement, the Region reports some promising preliminary talks with FDA, NIMH, and several other interested organizations. It also hoped that local institutions and individ- ual- physicians would lend financial support in order to continue to enjoy the benefits of the system. Second Year: $110$953 Third Year: $117,496 DREP/GRB 5/25/70 MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 7/70-1 A Privileged Communication STAFF OBSERVATIONS Actions STATUS AND PROJECT CURRENT SUPPORT #1 - Smithville Community Health Service Program Terminated #2 - Communications Research Unit (04) $25,349 #4 - Multiphasic Testing (now in Project #49) (04) (67,673) #5 -Mass Screening Radiology (now in Project #49) (04) (37,693) #6 -Automated Patient History (now in Project #49) (04) (72,880) #7 -Data Evaluation and Computer Simulation (now in (94,538) Project #49) (04) #8 -Computer Fact Bank (now in Project #49) (04) (107,348) #12 -Operations Research and Systems Design (now in (32,839) Project #49) (04) #13 -Populations Study Group Survey (04) 20,585 #f4 -Automated Hospital Patient Survey (04) 36,955 #16 -Program Evaluation Center Terminated #17 -Bioengineering (now in Project #49) (04) (52,883) #18 and #30 Core 1,100,000 #19 -Automated EKG (now in Project #49) (04) (223,257) #22 -Comprehensive CV Care Units, Springfield Terminat(@d #23 -Manual of Services Terminated #25 -Stroke Int ensive Care Unit (03) 150,'062 #26 -Training Unit for the Intensive Care of the 156,735 Cardiac Patient (03) #27 -Programmed Comprehensive Cardiovascular Care (03) 12-),417 #28 -Tumor Registry - Terminated #29 -Northeast Missouri Cooperative Stroke Pilot 67,31-4 Project (03) MISSOURI @IP STAFF OBSERVATIOiqS - 2 RM 00009 7/70.1 #32 - Effectiveness of the Detail Man Approach Terminated #33 - Continuing Education for the"Healtb Professions 228,098 (02) #34 - Community Services for Heart Disease, Cancer Terminated and Stroke #35 - Education of. Greene County Residents About Disapproved Heart Attacks #36 - Missouri Cervical Cytology Project (02) 71,725 #37 - Southeast Missouri Radioisotope Program (02) 77,462 #38 - Homemaker liome-Health Aide Project (02) 108,198 #39 - Phor@ocardioscan Project (02) 34,055 #40 - ICU and Pulmonary Function Laboratory, Returned for Sikeston Revision #41 - Stroke Prevention and Rehabilitation Program, Returned for Joplin Revision #42 - Early Detection of Cervical Cancer Disapproved #43 - Early Diagnosis and Treatment of Children 61,831 with Diabetes Mellitus (02) Returned for #44 - Cardiac Care and Risk Evaluation Revision #45 - Lebanon Model Project Returned for Revision #46 - Hi-Blood (02) 129,985 #47 - Core-Continuing Education Returned for Revision #49 - Advanced Technology Project 917,111 #50 - Stroke Prevention and Rehabilitation, 91,819 Joplin (01) #51 - Intensive Care Unit and Pulmonary Function 95,983 Laboratory, Sikeston (01) #52 - Health Careers Program (01) 62,240 #53 Early Detection of Cervical Cancer Disapproved 'STAFF.OBSERVATIONS - 3 RM 00009 7/70.1 MISSOURI @IP #54 - On-Line Diagnostic and Reporting System Disapproved #55 - Cancer Management and Education 112,973 Optimization (01) #56 - Supportive Communication for Satellite Units Disapproved #57 - Automated Patient History Acquisition Returned for Revision #58 - Cardiovascular Education and Evaluation, Springfield (01) 127,503 .#59 - Regional Blood Inventory System Disap ved Total $3,800,000 1/ 1/ Award includes $3,074,230 new funds and $725,770 in carryover. GRB/6/19/70 A Privileged Cc)iiiinui-iication SUI,R-IAITY OF RF,,VIEI,l Al\'D COI\TCLUSIO'@i ON JUNE 1970 I;IEVIET-1 CO@@IITTEE MISSOURI IEGIONAL MEDICAL PROGI@L P,M 00009 7/70.1 FOR CONSIDEI@TION BY JULY 1970 ADVISORY COUNCIT, Cenc,ral: The @lissouri RMP submitted a supplemental application for three projects requesting $1,185,059 for a th.ree-year program period. The Coiyiinittee concluded that the application be supported as follows: $33,243 the first year, $36,981@ the second year, and $39,--t.65 the third year to support Project #62, Dru- Inforiiiati.oii Cei-itral-. Projects #60 and #61 were disapproved. The Coni.@lnittee was rei-ai-ndc-d that previous re-,@ic@@qers have encouraged the Region to submit conirtunity-based activities and d(@emphapize University-- based projects in computer and bioengiiieeriiig areas. WI).ile the Region has fol-lo-v7ed this advice in the present application (two projects are based i - !i.-)spitals in small communities anO. one at the University of Missour@@ -1.)artment of Coir@mu.iiity Health and 1.4.cdica.1 Practice), the re- vie-v7ey@c.1 generally disappointed with the projects. The projects in Brailsoi@i Caineroi,.i appeared to be gapfilling measures for the liospita. s wli e r e support was being substituted for what the community shoul-d be supporting. Specific criticisms concerning each project fol.low. Project #60 - Cameron I-leal-th@ar@Sy@ -,.i Pro2ject r@i.tj,g,ue: This request is a potpourri of individual projects within one, directed at improving care within a 58-bed hospital in the northwest corner of @,lissouri. Because the hospital. is served entirely by osteopathic physicians who have not related wel' to the medical. doctors in the area, an additional @iii,,i is the i-Y)iprO -\7ei-ao-,nt of cooperation between these two groups. In reviewing the educational- portion of the project--,, the Continu-1y).g Ed@icati@on and Training Panel concluded that the objectives were not stated in measurable terms and no mention was riia e of resources for educational methods. No provision is made for staff or funds and no description of methods is given for evaluation. For these reasons and because the project would buy services with EL@IP funds which the Cc)nri:r@-'LtLec,, fc-l.t the cor,.-,@niuni.ty should be supporting, (I:ls- approval- was recor,,@.iTiei@).cled. Rec@c)iT).mei-.id-atioi-).: Non-appi-c)v@il. I (no R"@-P funding recommended. Missouri- l@LT 2 RM 00009 7/70.1 Project #61 - Brqpsoi-.i Intensive Care and Relial.)il.itation Lr_)e@-ct IJE@: This project also serves" a. small con-Luunity in rural Itissoui-i, but reviewers thought it was representative of the ambitions of a single institution, rather than a truly regional cooperative effort. The Continuing Education and Training Panel believed that the need for a four-I)ed unit based on 90 patients a year was overstated. Souie descrip- tion. of in-hospital days, nature of diagnosis, ages of patients and use by ambulatory patients would have been useful- i,i-i substantiating the need for more beds. The Panel also felt evaluation could be improved: while the project would measure effectiveness in terms of morbidity, reviewers believed improvement in the functional capacity of patients should also be measured. A more adequate description was needed of how all health professionals, particularly nurses and allied health personnel, would be involved in further planning and operation of the project. In ligrit of these technical criticisms and the lack of conviction that this project would truly further regional-j-zatiori efforts, the Committee recommended disapproval. Peconimc@n.dati.on: 1,Ton-approval I (no n@IP funding recommended). Project #62 - Dru Information Central. @i- i@-u @: The Committee was satisfied that the project would serve a need for pliysic-,i-an-- by providing adeclu@i.tc- updated drug ini'o-L'- iiiatioii@ from reliable sources. I%Thile the reviewers thought that the dial access system for drug -J-nforniation night be a useful tool in providing the information, the amount of funds requested seemed high. Furthermore, tbb hospital pha_-i-.qaci.sts do not seem to be an integral part of the System and the Committee felt that their involvement was essential. Accordingly, approval was recommended at one-third of the requested amount wl.t t e condition that the format be revised to involve existing hospital pliar--- macy mqnl)ower. RecoF,-@Tendation: Approval I at the following level with the condition that the format be revised to include existin@, hospital 1)ha-i.-- macy inanpo%7er. 01. 02 03 $33,243 $36,984 $39,165 Conclusion: A, total. of $109,392 was i-@ecoli,,j-nc--,riclcd for Project l@62. 1.)octor Wi-Iliai,,i I.,IaYE'!'I.- not present dzir-t-ii.2, the deliberation of Missouri Pl,[P 3 RM 00009 7/70.1 01 02 03 Project #60 -- Cameron Hea.1-th Care System Project Non-approval I - no Rlfi@ funds recommended Project #61 - Branson Intensive Care and Rehabilitation Project Non-approval I - no RMP funds recommended Project #62 Drug Information $33,2zi3 $36,984 $39,165 Central TOTAI, $33,243 $36,984 $39,3.65 DP@IP 7/10/70 I 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 7/70.2 Lewis Hall June 1970 Review Committee 406 Turner Avenue Columbia, Missouri 65201 PROGRAM COORDINATOR: Arthur E. Rikli, M.D., M.P.H. Requested: Ist Year 2nd Year 3rd Year 4th Year 5th Year TOTAL Direct Costs $109,596 $179,345 $234,260 $485,531 $526,187 $1,534,919 Indirect Costs 34,860 55$183 75,133 151,849 167,034 484,059 TOTAL $144,456 $234,528 $309,393 $637,380 $693,221 $2,018,978 HISTORY: A general history for the Missouri RMP may be found in the summary (RM 00009 7/70.1). The project in the application (RM 00009 7/70.2), entitled Continuing Education - Coordination Project, was originally submitted on May 1, 1969. The original application requested $1,384,647 for five years, most of which was in personnel. The 5roposal was divided into three parts: 1) the core cooperative activity, 2 the teacher-consultant activity, and 35 the local educational coordinator. A history of the review of.this project is outlined in a Staff Observation. PRESENT APPLICATION Requested Project #63 - Continuing Education - Coordination Proiect. The First Year primary goal of this project is "the improvement of $109,596 patient care through the development of a meaningful system of con- tinuing education that is built into the day-to-day, week-t@week practice of health professionals of the Missouri Region." This propo- sal would develop the framework and linkage mechanisms of a meaningful continuing education system which would provide the bridge between the agencies and institutions in Missouri concerned with continuing education. Its objectives and methodology would serve to help under- stand: 1) the current efforts to avoid overlap and duplication; 2) the degree of effort the organizations are willing to exert in the future; 3) the degree to which these same organizations will use this project to enhance their own activities, as well as support others' activities; 4) the needs of individual professionalsand of each health profession and the means to communicate'these to the system; and 5) a method whereby hospitals can receive assistance in developing programs for staff based in patient care needs. These understandings of the current system and the subsequent develop- ment of a more meaningful system will result from the following three related activities: MISSOURI Regional Medir_lal Program' -2- RM 00009 7/70.2 ctivit 1. A Continuing Education Cooperative A y proposes the establishment of an inventory of continuing education activities in the six subregions of Missouri. An outgrowth of this activity would be a clearing-house function to make available information on continuing education programs to all health professionals of the Region. An Advisory Committee whose tiembers will be drawn from the producers and consumers of continuing education activities in Missouri will review the inventory and appraisal data and recomend educational programs which should be initiated. Staffing for this part will consist of two half-time co- directors (salaries paid by the University of Missouri) and a secretary. II. The Teacher-Consultant Activity is a cadre of various health professionals who will establish linkages with the various health professionals of the Region and between the health professionals and the Advisory Committee on Continuing Education. They will also serve as liaison with the organi- zations and institutions on the Advisory Committee and provide advice to those hospitals, clinics and organizations who wish to initiate and develop continuing education activities. Through these linkages the needs of the indivi- dual members of given health professions at specific locations will be coordinated. The proposers envision several full-time physicians, educa- tionalists, nurses, allied health professionals and secretarial personnel in this component. III. The Local Educational Coordinato would place a physician-coordinator in each of five subregions to assist health care institutions and health professions in the institutions to develop and initiate a program of continuing education. The sixth subregion will be served by the central office. A coordinator will be placed in one of the subregions the first year with additional ones to be added to the other subregions during the subsequent years. All components will have available to them the facilities of the Medical Center and University and the benefit of contacts the non-campus staff of the University has made. Hopefully, other participating agencies will volunteer additional resources. The control of the project is shared with the Missouri RMP, the Advisory Committee on Continuing Education and the Dean of the School of Medicine. MISSOURI Regional Medical Program -3- RM 00009 7/70.2 Evaluation efforts will consider documentation of the time involvement of individual professionals, anecdotal reports of project personnel, surveys, information transfer and effect on patient care. The five-year $1,534,919 request consists primarily of personnel costs ($1,282,438). Second Year: $179,345 Third Year: $234,260 Fourth Year: $485,531 Fifth Year: $526,187 DRMP/GRB/5/19/70 A PRIVILEGED COMMUNIC&TION Missouri RMP 00009 7/70.2 STAFF OBSERVATIONS The following is a summary of the past review actions and comments of t!le Continuing Education - Coordination Project. July 30-31, 1969 Review Committee Core - Continuing Education Critique: The Review Committee and Continuing Education and Training Panel both agreed that this core activity speaks well to coordination of continuing education activities but beyond the philosophical tenets, the proposal gives little indication of the activities which are going to take place. Personnel costs, which constitute the largest budget item, are not justified by job descriptions or functions. Other than one general paragraph thereis little or no indication of the relation of this project to existing projects in continuing education, particularly Project #33, Continuing Education for the Health Professions. No evidence exists, in the form of letters, surveys or otherwise to indicate that the practicing physician, community hospitals or voluntary health agencies have been involved in planning this project, or would support or utilize its services. In view of the vagueness and the unanswered questions, the Review Committee defers a recommendation until after the site visit findings are available. Recommendation: To include the application with the material to be reviewed by the site visit team and defer a recom- mendation until the November 1969 Committee meeting when the site visit report is available. August 26-27, 1969 - Council recommended: Deferral for further consideration during the upcoming site visit. Site Visitors Comments, October 7-10, 1969. Core Continuing Education Spokesmen: Dr. William Mayer, Mr. Gail Bank, Mr. John Mowrer, Mr. Carl Marienfield, Dr. Vernon Wilson Dr. William Mayer was able to briefly describe his proposal, and the visitors discussed the proposal at greater length with Dr. Vernon Wilson, Mt. Carl Marienfield, and the proposed project staff. Unfortunately, Dr. Mayer was not present during the "feedback session" on the final day of the site visit to hear the site visitors' perceptions and recommendations. STAFF OBSERVATIONS -2- This is an extensive three-level operation designed to bring about coordination of continuing education activities within the region. The first level of activity, and the first priority, is the estab- lishment of a state-wide advisory council to involve institutions and agencies concerned with continuing education. This framework would provide a headquarters for the University of Missouri Medical Center continuing education programs. The second level of activity is the provision of teacher-consultant teams to identify the personal-professional needs of individual pro- fessionals and professional groups. The manner in which these teams would accomplish this objective was not clearly defined. The third level of activity is the local education coordinator who serves as 'extension agent" in the communities. Considerable difference of opinion was noted among the Missouri RMP, the Extension Division, the Medical Center representatives, and Dr. Vernon Wilson as to what the role and qualifications of this key person would be. There was considerabledifferenceof opinion among the groups concerned as to whether this individual should be a physician or should be more ofa sociologist or educator, whether he should live in the local community or be there on a part-time basis, whether he should work as a DME in a local hospital or be based in other community resources. Impressions: The visitors,likt the Continuing Education Panel, had major reservations about this proposal. It seemed, primarily, to be organiza- tionally oriented to furthering the continuing education effort of the University of Missouri Medical Center. There appeared to be no clear mechanism for feeding the educational benefits of RMP activities into this RMP "Core" proposal. The proposal tended to be isolated from the other activities of the Missouri RMP, rather than central to and in a position to coordinate these activities as a "Core" effort should. The team had the highestregard for the leadership of Dr. Mayer, but was much less certain about the capabilities of the project staff on whom success of the project depended. In view of the differences of opinion among the people concerned about the qualifications for the staff, the lack of philosophical agreement, the vagueness about the methods of identifying educational needs, the lack of systematic evaluation, and in view of the isolation of this project from the very activities which it should,be coordinating, the site visit team recommended that the proposal be returned for revision. The site visitors noted that this recommendation coincided with the unanimous opinion of the Continuing Education Panel. November 5-6, 1969 Review Committee Project #47 - Core - Continuing Education. Critique: The site visitors were directed by the August 1969 Council to review this project during the October site visit. The STAFF OBSERVATIONS -3- site visitors found that although this continuing education activity would be funded as a part of the Missouri RMP core, it appeared organizationally oriented to furthering the continuing education effort of the University of Missouri Medical Center. Interviews with several other project directors indicated that the proposal seemed to be iso- lated from other Missouri RMP activities and that a mechanism for feed- ing the educational benefits from community-based activities into the central core resource was lacking. These findings confirmed the under- standing the Continuing Education and Training Panel had about the project. Although the Dean of the Medical School was able to respond only briefly to the site visitors about this proposal, the visitors did hear from thoseconcerned with the direct operations of the core component. The visitors were unable to obtain samples of kinds of data which would be used to identify educational needs. There were varying opinions among the Missouri RNP, the Extension Division of the University, the Medical Center representatives and the Vice President for Academic Affairs, Dr. Vernon Wilson, as to whether the extension agent described in the third level of activity should be a physician, a sociologist or an educator; whether he should live in the local community or commute; whether he should be a DME in a local hospital or be based in other community resources, The major criticism of this proposal, however, was that its focus is on the development of an organization rather than on the improvement of patient care. The site visitors recommended that the Region revise the proposal and develop a vigorous continuing education program as part of RMP and directed to RMP needs. The Review Committee, however, believed that such a continuing educa- tion resource was needed in the Missouri RN:P program and should be en- couraged, despite the substantial university influence. The site visitors' recommendation was modifipd.to approval with no RMP funds to be included in the award for this component (the Region may rebudget its previously awarded funds) and with significant feedback to the Region detailing the site visitors' concerns. The reviewers hoped that the Region would consider these concerns when requesting funds for this activity again. Recommendation: Approval, no new RMP funds recommended. December 16-17, 1969 - Council recommended: Nonapproval with revision required. DRMP/GRB-5/19/70 A Privileged Communication S@RY OF REVIEW AND CONCLUSION OF JUNE 1970 REVIEW COMMITTEE MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 7/70.2 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL Project #63 - Continuing Education - Coordination ect Critique: Committee reviewed the background of this project which had been reviewed by Committee, deferred for a site visit and returned for revision by Council. Previous criticisms related to the following points: (1) the focus was on development of an organization rather that on the improvement of patient care; (2) reviewers, including site visitors, were unable to determine what kinds of data would be used to identify educational needs-, (3) there were varying opinions among university, RMP And project representatives about the role of the exten- gion agent; (4). a mechanism f or f eeding the educational benef its f rom other Missouri RMP activities, especially cominunity-based ones, into the continuing education core seemed lacking and (5) there was a lack of systematic evaluation. Committee reviewed the revised proposal in light of these criticisms and were not satisfied that the previous deficiencies had'been corrected. The project does not speak, except in passing, to the linkages which need to be built between the education function and other agencies, schools of allied health, and RMP projects which have already successful education activities. Evaluation efforts still seem vague and a more detailed method of identifying needs than'appeared in the original application is @missing. Reviewers were not satisfied that the elaborate three-step organ- zation, unchanged since the original application, would improve continu- ing education efforts in the Missouri RMP. While the reviewers were impressed with the quality of leadership the Dean of the Medical School, as co-director5 would bring to the project, they were uncertain that he would be able to devote enough of his time to the project to assure the quality of direction requisite for a project of this magnitude. There was agreement that the Missouri RMP needs to identify educational needs and coordinate their continuing education pro- grams, but it was pointed out that this type of activity is ordinarily a function of core and performed at much less expense to the Region than an average cost of $400 000 per 'eat. While some reviewers believed that y the vroi6ct should be approved (at a much lower level.) in order to permit the Region to initiate the clearinghouse and catalyst function, the majority were of the opinion that the project did not merit any support and should be disapproved. Missouri RMP 2 RM 00009 7/70.2 R6cpm6ndation: Non-Approval I (no MT funding recommended. Th&re was one dissenting vote. Note: The comments requested from an outside reviewer were not received until after the Review Committee meeting. His review essentially corroborated that of Committee. He, too, believed that the ap lication p had not responded to the criticisms of the site visitors, Committee and Council, and that the implicit principles upon which the proposal was based were educationally unacceptable. While he could find some value in the local Educational Coordinator function, he too believed that the overall project should be disapproved. RMPS/GRB 7/14/70 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL CRANT APPLICATION (A Privileged Communication) MOUNTAIN STATES REGIONAL MEDICAL PROGRAM RM 00032 7/70.1 Western Interstate Commission June 1970 Review Committee for Higher Education University East Campus, 30th Street Boulder, Colorado 80302 PROGRAM COORDINATOR: Kevin P. Bunnell, Ed. D. Requested Program Period Ist Year 2nd Year 3rd Year Total Direct Costs $184,976 $191,117 $197,804 $573,897 Indirect Costs 21,950* 27,268* 28,348* 77,566* TOTALS $206,926 $218,385 $226,152 $651,463 HISTORY: The initial planning grant for this Region became effective in November 1966 and provided for the organization and staffing of the core program, a four-state study of resources necessary for an operational program, and the establishment of four state offices, the Regional Director's Office in Boise, and the Coordinator's Office in Boulder. The operational phase began in March 1968, and the current annual level of support is $1,541,557, which supports Core Administration, four State Offices, the Regional Director's Office and the Program Coordinator's (Executive Director) Office at the WICHE Headquarters) and seven on-going operational projects, as follows: PROJECT TITLE FUNDING LEVEL (d.c.o.) 1 Core Administration $943,587 2 Coronary Care Training Missoula 134,349 3 Diagnostic, Treatment, and Educational Program for Cancer 207,172 5 Continuing Education - Montana 104,956 Does not include Idaho Heart Association Indirect Costs. -2- RM 00032 7/70.1 140@TAIN STATES REGIO?\'A-L IEDICAL PROGRAM Tumor Registry $134,472 @6 -7 Continuing Education Nevada 78,243 Inhalation Therapy 79,659 9 Intensive Cardiac Care Nevada 62,195 10 Consulting Team - Continuing Education - Rural Nevada 40,000 11 Continuing Education - Idaho 38 196 TOTAL $1,822,829 PRESENT APPLICATION: This application requests funding for two projects to extend on-going successful activities into new geographic areas. ICU Trainine in South This sted Pro'ect #12 west Idaho. program is designed to provide nurse and Filrst Yyear physician training for acute coronary and general intensive $107,469 care in Southwest Idaho and Eastern Oregon. This is a rela- tively dense population area of the Mountain States Region. The,.program represents the combined efforts of three communities (Boise, Caldwell and Nampa), the Idaho Heart Association and the-WICHE Rie. The program is patterned along similar lines of the Intensive Coronary Care Training Program in Missoula, Montana which serves communities of Montana, Northern Idaho and Wyoming. This was the-.basis of the original operational grant to the Mountain States RW . It has demonstrated the feasibility of a regional approach to training personnel to staff coronary care facilities in-small hospitals, and has trained 107 physicians and 148 nurses since May 1968, This-proposal is also in line with the plan to develop subregional centers of continuing educat@on through cooperative efforts of local health professionals, facilities and colleges. A nucleus of this plan is already present in seven locations in Idaho under the MSIRW program. The training center for which support is requested is comprised of four core hospitals which have agreed to provide classroom space MOUNTAIN STATES REGIONAL MEDICAL PROGRAM -3- RM 00032 7/70.1 and clinical facilities. All four hospitals have established coronary care facilities and have experience in coronary care inservice training. They are: St. Alphonsus and St. Lukes Hospitals, Boise, Mercy Hospital, Nampa and Carwell Memorial Hospital in Carwell. Contributions by the four core hospitals and the Idaho Heart Association to conduct the initial courses for nurses have totaled $12,972; clerical assistance, office space and teaching time by nursing preceptors and physicians was donated. The staff of any hospital in the Region and eastern Oregon is eligible to participate in this training program providing certain conditions are met. They must provide usable space and a workable plan for installing an intensive care facility that is well integrated with other hospital services. They must agree to use the standardized data collection methods provided by the program and make these data available for study. A specific registered nurse to work with the RNP consultants must be designated, and cooperating hospitals must participate in the postgraduate train ng activities of the program. Approximately 96 to 100 nurses can be trained in the first year; priority will be given to nurses from Southwest Idaho and Eastern Oregon, who will be working in a CCU general intensive care unit or a combined unit. Initially, courses will be limited to 24 trainees. Physicians have requested training programs designed especially for the small town practitioner. Three-day symposia for up to 24 physicians will be conducted three times a year with faculty of physicians and nurses staffing the training center, a physiologist, pathologist and a consultant cardiologist. One two-day session will be held each year offering information beyond the basic coronary care that physicians need to keep up to date. The WICHE organization will enter into an agreement of affiliation with the Idaho Heart Association, which will serve as the coordinating and fiscal agent for the project. The Executive Director of the Idaho Heart Association will serve as Project Director, without salary. The physician faculty will be employed part-time. The basic course curriculum will be evaluated in terms of the course objectives. The individual trainee entering and completing the RM 00032 7/70.1 MOUNTAIN STATES REGIONAL MEDICAL PROGRAM course will evaluate her own progress through these objectives. After the.student has r eturned to her/his own clinical environment and ha@.-,had opportunity to implement training, further evaluation of th@,@basic curriculum can be made through feedback. A physician and 'nurse consultant from other coronary care training programs will be invited to assist with an objective evaluation, i.e., Mis.soula, Montana, and Seattle, Washington. The general level of coronary care will be assessed through changes in mortality rates utilizi ng data collected throughout the four stat es. Several indices will reflect the degree of interest and cooperation in the Regional Medical Community, such as the number of -applications for training, number of facilities that have bec ome available to patients, evidence of sharing educational talents, skills and tools, and opinion data from participants, e-,np.,@ipyers and associated staff. Sec@o,rid Year: $105,894 Third Year: $110,377 Project #13 - A Program for Continuing Nursing Education sted min . This is a supplemental proposal for First Year continuing education of the Mountain States RNP, and is a $77,507 third phase of a course of action to develop a cooperative continuing education program for nursing for the four-state regi.on. It will provide a program of continuing education for.,--n-ursing personnel in Wyoming in cooperation with similar programs in Idaho', Montana and Nevada. The.Iprogram will: 1) develop a sustaining "system" of continuing education; 2) develop a sound educational approach which involves the learners and provides continuity and coordination in pro- -gra mming; 3) train key people in the process of adult education; 4) develop part of the program at "the home base of the learner"; andi@) develop a continuing education program for nurses in anticipation that continuing education requirements may become a,,necessary prerequisite for annual li.censure. The-,,School of Nursing in the College of Health Sciences at the University of Wyoming will provide the administrative focus for the ect, and will work closely with the Division of Adult -proj Education and Community Services. A Project Coordinator, one nursing teacher and an administrative secretary will be employed when-the project is funded. Six months later a second nursing MOUNTAIN STATES REGIONAL MEDICAL PROGRAM -5- RM 00032 7/70.1 teacher and a clerk-typist will be added. The project staff will be an integral part of the University of Wyoming School of Nursing. The Region has developed a plan which will divide Wyoming into four zones. These are based upon geographic factors and representative of established patterns of relationships and cooperation between health facilities. The educational activities will involve workshops, clinical con- ferences, and consultative services. The project is ready to become operational immediately upon approval and funding. A feasibility study was initiated during the planning phase which organized four study groups of nursing personnel throughout the State to study the continuing education data from survey quest onna res. As an outcome, a statewide Continuing Education Advisory Committee for Nursing was appointed to serve for the duration of the project and will continue in a permanent capacity to the University of Wyoming School of Nursing. A Task Force selected from this Advisory Committee has been responsible for the development of this applica- tion. An independent study laboratory grant application has been approved under another program -but not yet funded for the University of Wyoming School of Nursing. All of the seven community colleges in Wyoming support the project and offer full cooperation, making available faculty, and audiovisual materials and physical facilities. Other agencies such as the Nurses Association, the Wyoming League for Nursing, the Wyoming Heart Association, etc., have also documents their cooperation and commitment. The evaluation of the project will determine the effectiveness and efficiency of curriculum content, instruction and planned educational experiences and will involve mechanisms such as: descriptive progress, reports@, questionnaires and conferences with participants in health care facility administrators. Reports will be prepared semi-annually, including appropriate project and curriculum changes. Second Year: $85,223 Third Year: 87,427 DRNP/GRB 5/22/70 A Priviieged uomaitin3.caLion. SU@,R,iARY OF REVIEW AIID CONCLUSION OF JUNE 1970 REVIEW COIDLITTEE 'DICAL PROGRA!4 (I)ICIi,) MOIJI.qTAII,l SFATES REGIOI@AL Idy,@ MA 00032 7/70.1 FOR COiNSIDERA'rION BY JULY 1970 ADVISOIIY COUNCIL General.: The committee approved the present application requesting $184,976 for two new operational projects to extend ongoing activities into .new geographical areas. Project i@12 - CCU-ICU Traini.@IZ_in Southwest Idaho Lrit:L@ie: The reviewers endorsed the findings and recommendation of the Ad Hoc Cardiovascular.Study Panel which found its objectives clear and obtainable ,iithin the proposer] time limit. The reviewers believed that it would be helpful if "student objectives" for educational training program could be included. The procedures are adequately described and the approach is realistic and workable. The project should enhance inter and i.ntr@--comriiunity cooperation, knowledge and respect. The Committee noted. hear provision is made for consultation with outside sources. ilie budget requested was believed to be reasonable, but i,t,w@is unclear as to whether $3.00 tuition fee is realistic. Other areas ai-e:charg-'Xi-tg between $300 and $350 for a 7-week program. Although details about the mechanism for evaluation are not included in the' application, evaluation seems to have been considered in all areas pertaining to the impact of the program upon the individual riu@-ses ind physicians, is well is the impact upon the community and region. Other resources of support are being utilized from 8 prior pilot project and the local Heart Association. Tuition fees ai:c,. also expected to assist in defraying costs. Phasin out would seem to evolve naturally but the reviewers raised the 9 question of cost-sharing. The project overall shows excellent coordination within the region, is tecl-ini- cally sound and capably dir'ected. Recoi-ii@-r@endation: ApprovalI First Year Second Year Third Year $107,469 $105,894 $13.0,377 MOUNFAIN S'EATES IU/IP kV@'IULiL) -4- &WI vvv@@ I i I Project i'@13 II -rdtic6ti.oli t@i q i@e :There wa-@ consensus tliit this program is well organized and comprehensively planned. It is obviously supported by all professionals in th@- area which speaks highly of the involvement of the three baccalaureate school,,; of nursing, as well as the seven community colleges that have been involved. The program will emphasize "training the trainer" and using the "home base" of the learfier as the teaching laboratory. The educational activitie s are described but the behavioral objectives, content and length of courses will apparently be developed after the personnel are hired. The reviewers noted that the applica tion shows a weakness in that with all of the coordinated planning and preparation for this program, they have not spelled-out in any detail the curriculum that is proposed. For instance, will there be clinical experience to enrich the training? This is not to imply that there is doubt that the trainers will be well prepared but the Review Committee felt it would be advisable to have the region submit more details about the planned curriculum for staff review. The Review Committee. noted that the university has agreed to assimilate this project, subject to the availability of funds and other resources at the end of the third year. Recoin@@iendation: Approval I - Conditional upon submission of curricula as they are developed for review by Continuing Education Branch. First Year Second Year Third Year $77,507 $85,223 $87,427 SUIIil@IARY OF l@COij@,ENDATIONS r@j,@C 01-Year 02-Year 03..Yeir TOTAL #19 $107,469 $105,894 $110,377 $323,-iliO #13 $ 77,507 $ 85,223 $ 87,li.27 @250,157 Total $1.84,976 $1@91.,117 $197,804 $573,897 RMI'S/GRB/7/13/70 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE s Y OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) NEW MEXICO Regional Medical Program RM 00034 7/70.1 The University of New Mexico June 1970 Review Albuquerque, New Mexico 87106 Committee ,Program Coordinator: Reginald R. Fitz Rttauested Prmram Period: lst Year 2nd Year 3rd Year Total Direct Costs $180,895 $174,324 $112,834 $468,053 Indirect Costs 38,614 42,630 26,633 107,877 TOTAL $219,509 $216,954 $139,467 $575,930 HISTORY-. The initial planning grant in the amount of $449,736 was awarded for the period of October 1, 1966 to November 30, 1967. Seven- month planning funds in the amount of $108,048 were made for the second- year planning continuation (December 1,1967 to June 30, 1968). This phasing was due to the Region*s submission of its first operational request, which was disapproved by the National Advisory Council in May 1967. The application comprised of 7 projects was revised and resubmitted for consideration by the May 1968 Council with a resultant affirmative action. The Region's first operational award in the direct cost amount of $965,305 was made, effective July 1, 1968, to support seven operational projects, Core staff, and one project (#8) from earmarked funds, and for the last two months of the grant year, (from anticipated unexpended funds) implemented a Cardiopulmonary Laboratory in Seats Fe (#10). Another supplement requested funds for Project #11, to establish a model rural clinic. This project was later funded by NCHSR&D-by contract. A project to screen New Mexico School Children for Heart Sounds and Murmurs (#12) was reviewed at the February/March cycle. The reviewers were in agreement that the proposal was a significant one for the region, but identified several areas in need of clarification and re-structuring. The recommendation was unanimous for a return for revision and resubmissioa. This will probably be forthcoming for the next cycle. NEW MEXICO Regional Medical Program -2- RM 00034 7/70.1 Continuing support for the second operational year was made in the direct cost amount of $1,252,911 for a 14-month period. The Region is presently funded at an annual level of $1,053,768. PRESENT APPLICATION: This is a three-part application requesting funds to support three new programs. One of these (Project#14) was presented to the staff in March as a request for rebudgeting of funds to support a pilot phase of a monitoring program for decentralized coronary care units. Because the proposal involved many technical and clinical com- plexities, and indeed presented a new dimension to the New M&xico Program, it was the consensus of the staff that approval of any rebudgeting to imple- ment this pilot study before submission to the Review Committee and Council, was inappropriate. The other two operational projects making up this three-part supplement are (#13) Leukemia-Lymphoma Program and (#15) Streptococcal Throat Culture Pro- gram. These programs represent new operational efforts. Prolect #13 - Leukemia-Lymphoma Pr_p_gram. This proposal will initiate First Year a LeuKemia-Lymphoma Center which will be organized to Requested provide-education, drugs and consultation to the referring physician $73,275 for patients with hematologic malignancies. The project will be located at the Bernalillo Medical Center, a fully accredited general hospital and one of two major teaching hospitals of the University of New Mezico School of Medicine. A $6 million addition now under construction will be completed in 1970 to provide expanded laboratory and radiology facilities, a new emergency suite, new out-patient facilities consisting of 102 rooms, a new operating room suite and intensive care facilities. This hospital also contracts with the USPHS for care of Indian patients from the Navajo, Apache and Pueblo Reservations. The majority of patients come from the more than 300,000 residents of the county. The Project Director is already identified. In collaboration with a health educator, who will probably need to be bilingual, he will develop an educational program to communicate to thelbysicians throughout the State the availability of such collaborative care and investigation of patients with leukemia or lymphoma. This program will be designed for medical students, house staff and physicians. An in-patient therapy unit) including a patient isolation system will be established, in collaboration with the departments of Pathology, Radiology,, Pediatrics, Microbiology, Epidemiology and Community Medicine, and the services of the Infectious Disease Laboratory and Blood Bank. Clinical records on all patients w@th leukemia and lymphoma will be main- tained for follow-up and epidemiologic studies in collaboration with the existing NM/RMP Tumor Registry. The M.D. Anderson Hospital and Tumor Institute in Houston and the South- west Cancer Chemotherapy Study Group will participate through other sources of funds to develop immunotherapeutic approaches to acute leukemia, first in animals and later in humans, in collaboration with the Immunology Program, NEW MEXICO Regional Medical Program -3- RM 00034 7/70.1 A full-time technician, a nurse social worker secretary, a full-time health educator will be required and a Co-Director will be employed at 15% of the time. Second Year: $67,355 First Year Project.#14 - Monitoring of Decentralized Coronary Care Unit. The sted proposal here is similar to a project underway in t e Oklahoma REP $85,520 since May 1969. It will build on experience of the Coronary Care Nursing Training project of the NMIRMP and will initiate pilot pro- jects involving satellite hospitals in Grants, Gallup, Espanola and Albuqqerque. The program will initiate training for physicians and nurses for monitoring and supervising personnel in the central monitoring unit. The training for nursing personnel at the remote unit will include training in cardio- pulmonary resuscitation, intravenous medication (where applicable), pro- cedures for defibrillation, clinical recognition of emergencies, etc. The course, approximately 40 hours, will include on-the-job training in the central monitoring unit as well as the remote unit. These activities have already begun at the Osteopathic Hospital in Albuquerque, i4 anticipation of being tied into the Bernalillo Medical Center, Albuquerque, in the near future. The training of physicians in the remote units will conform to the outline of the course designed to acquaint physicians with the management of patients with acute myocardial infarction, particularly in the areas of prophylaxis and treatment of cardiac arrythmias. Although written documentation is not a part of this application the Espanola Hospital has indicated its willingness to participate. The@@patient will be monitored on a continuous basis at a Central Monitoring Unit Corporation. However, the project still ]-ins ).r@eas of weakness such as no guaranteed adequat-e patient intake -in(J specifics oil how the computer time r(-,quested x,)ill@ be ut:il.i.7,ed. An influencing factor on Co@nt,.iittee's decision to approve this project,. is the progrqdi's projection for,- revei'lue iqlij.cl-i will allow it to assume the major portion of support for the program !.is second Fired third year and henceforth. Committee would lil,-,e tlir-- Region to I)rovid a mechanism through which e patient intake and revenue can be-9 Llarai:itced, -is ones been projected in the second 6tid third )rear of the project. Although the patient follow-up plan 1-in@- been improveci@ Cc,,-iiii)ittee believes it can be furti-ier strengthened. Recominc.,nd,itio).-t: Approval I - provided the ]@@(@pion submit additional iiiform@3- note showings (a) That the Region can provide a mechanism which wi I-1, guarantee the patient intense iLid revenue which it has projected. (b) 'fix,)t the Regioi.-i c;Ftri cldc@(.Iuately justify the amount of cot@iputkr name it has r6quested. If not, the amount reqi.iesl--c(l for this iterii should be,, deleted vt:ien the year's award is cranted. F i. I- @,,- t - y ea I- Second Y(@at- Third Year $968,552 $480,479 @533,50141- VIRGINIA M4P RM 0004@9 7/10.1 RE@VIEW COi@itll'ffEE FUNDING RECOIt4ENDATIONS ect Year @m U-e -@ @ Recoftimended #10 01 $268,552 $268,552 02 480,479 480,479 03 533.501@-- 533@ 01 TOTAL $1,282,535 $1,282,535 @,'PS/GRB/7/10/70 0 0 0 A Privil-eged'CormDunication SPECIAL ACTION VIRCINIA REGIONAL @fl,'@DICAL PROGRAM PdA 000@9 'I]-, Rural Cominun - Medical ect- Project #4 - Stroke in A Sma ollege of Virginia Request:- The Virginia Regional Medical Program has requested that the restriction from the NAC on Project #4 be lifted so that the program can be activated. The approved level of funding is as fol.lo,,7s: 01 year - $73,375; 02 year - $64,050; 03 year.- $71,050; a total of $208,475 for three-years support. Background: The Virginia Regional Medical Program submitted to the December 1969 Council as one of its initial operational proposals Project #4 - Stroke in A Rural Coinniu@. . Council action on this project was Approval I, as recommended by the site visit team, contingent upon the necessary certification of the Maple La@,Tn Nursing Home by Medicare as an extended care facility. This program will study the incidence of stroke and the management of patients with stroke by general practitioners in a rural community. It will attempt to discover what changes are, needed and what changes can be made in the pattern of care of patients with stroke by general practitioners in a rural community. This will be done by close and regular consultation with specialists from the medical- center coming to the rural community and by providing for further training of the local- personnel, both in their home community and the Medical Center. The small community in which this study is to be done is Blackstone, Virginia with a population of 5,000 and is located approximately 70 miles from the Medical College of Virginia. In the community there are three general practitioners who have a group practice, a physical therapist and two Public Health Nurses. In addition to the three physicians in Blackstone, there are general practitioners in four small.. adjacent towns and all. have agrees,, to cooperate in the program. A site visit' to this Region @7as condi.ictccl. in October 1969 and the visitors noted that the problems with Project #4 were basically the same as those reflected by a previous site teaiu; specific-,ally, that the @lapl-e La@,7n Nursin- I'@ofiie is functioning as an intermediate! care facility but is not accredited to receive Medicare services. The site visit team, however, was impressed that the proposal has been expanded to incl-ude the participation of seven community physicians from the sur-- rounding areas. The proposal has a]-so been expanded to involve the- community physicians in the training of other practicing physicians through the Region. These additional- activities and the, fact that one of the general practitioners in.vol.ved in the program is the President of Virginia Academy of General Practice, were considered addc@d stuci)gtl-i. SPECIAL ACTION - Virginia Ri@iL-1 -2- @l 00049 The site visit team felt the program had the pot. ial outreach to strengthen much-needed regional.j.zation for thi.,,@ 4,,j.on, since it involves the Medical Center, community Iiospitals, community physi- ciaris, nurses, etc. The Virginia Regional- Medical Program has indicated that the lack of certification for the Maple Ila@,7n Nursing Iloine steiiis froiTi: (a) the Ilome not providing 24-hour nursing service and (b) certain architectural deficiencies. Recent information received from the. Region informs us that the nursing home has been purchased by a large nursing home corporation, Progressive Care, Incorporated. The new owners have indicated that all deficiencies that have prevented accreditation by Medicare will be corrected. Dr. Mack I. Shanholtz, State Ilealtli Commissioner, contends that tiie facility complies with Medicaid requirements but it still lacks Medicare certification. The Virginia Regional Medical Program also contends that the project and the nursing home are not inter-related except for an occasional patient that may become part of the statistical report of the study. The Virginia Regional Medical Program has expressed concern that t e contingency of certification by Medicare will delay the implementation of this project indefinitely. They have indicated to staff that the project has a high priority a-,id have requested that the restriction be lifted. Staff recommends that Council consider a temporary waiver of the restriction so that the project can be implemented iiyi-i-ciediatc-ly, subject to the condition that all deficiencies are corrected by December 31, 1970. This date is six -months subsequent to new ownership and coincides with the end of the current grant period. This should allow the facility sufficient time for alterations and renovations to be implemented I.iid the initiation of 24-liour nursing services that Medicare certification requires. D PIIP C 1-1@B 7/10/70 a 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) REGIONAL MEDICAL PROGRAM Pdl 00013 7/70.1 (formerly 3/70.1) for WESTERN NEW YORK February 1970 Review Committee. 2929 Main Street March 1970 Council Buffalo, New York 14214 June 1970 Review Committee Program Coordinator: John R. F. Ingall, 'ill-D. R sted Program I-eriod lst Year 2nd@@Year 3rd Year Total Direct Costs $ 988,174 $ 872,987 $ 895,1-99 $2,756,360 Indirect Costs 183,680 152,864 202,507 579,051 Total $1,171,854 $1,065,851 $1,097,706 $3,335,411 History: The initial planning period for the Western New York Regional Medical Program began in December 1966, and the first award for operational support was made in March 1968. This Region's annual level of support is.$1,428,915 (total costs): $390,377 for core activities and $1,038,538 for six operational projects. Two additional projects (#'s 13 & 14) have been initiated from carryover funds. December 1969 Council recommended disapproval of a proposed Medical Genetics Clinic, but recommended approval of three projects in a total amount of $276,522 direct costs for the first year: Topical Chemotherapy Treatment for Precancerous Lesions and Cancer of the Skin (#13), Infor- mation Dissemination Service (#14), and a Respiratory Intensive Care Unit (#3S), which is a supplement to the ongoing Project #3 - Chronic Respiratory Disease Program. A request for continuation of the present operational program will be submitted in mid-January 1970. Present Application: Support is requested for the initiation of three projects: A Total Regional Program in Dialysis (#15), a Regional Coagulation Reference Laboratory (#16), and A Regional Program for the Prevention of Atherosclerotic Disease (#17). A fourth project was originally submitted with this application--Radiotherapy Technician Training Program--but subsequently was withdrawn because of the DRMP policy not to support basic education and training in established health professions. REGIONAL MEDICAL PROGRAM for WESTERN NEW YORK -2- RM 00013 7/70.1 Re ted First Year Project #15 - A Total Regional Program in Dialysis. $623,970 h@is project is designed to expand dialysis- transplant services in the Region through the development of a training program for all levels of personnel to be centered in five hospitals, (Buffalo General, Deaconess, E. J. Meyer Memorial, Roswell Park Memorial Institute in Buffalo and Hamot Hospital in Erie, Pennsylvania). It is hoped that the program will increase the number of patients for which treatment is available, develop a communications system among hospitals to insure referral of patients to hospitals which can provide care, make it possible to locate dialysis facilities throughout the Region, establish criteria for evaluating resources, and maintain a continuing education program and consultation service. The planned training program will permit each hospital to teach the techniques it uses with its equipment, form an integrated faculty with participants from each of the five hospitals, offer appropriate training aimed toward physicians, nurses, technicians, and patients' families (courses for other allied health personnel will be instituted at a later date), and train personnel to develop and expand the resources of the Kidney Bank and Research Society of Buffalo and Western New York. The training courses which have been planned are approximately six weeks in duration, and outlines of the content of each are provided as appendices. 1. . This program will consist of three parts: didactic, clinical observation and instruction in each of the five centers, and four weeks at the hospital of the participant's choice. The trainee could also accept a several-month fellowship, either at one of the participating hospitals or rotating among them. Funds for six such fellowships are requested. 2. Nurses. During the first two weeks the theory and factual basis for dialy 1 transplant treatment will be presented. ;The last four weeks will be devoted to clinical experience, during which time the nurse will learn to operate the equipment and provide optimal care to the patient. Conferences will be scheduled occasionally during the six weeks. 3. Technicians. In the course for nurse technicians, mechanical technicians and laboratory technicians, the initial two weeks will be spent on the theory and background of dialysis, and the remainder of the time on clinical experience appropriate to each type of technicians There will also be conferences. 4. Families of Patients on Home Dialvsis. The training will start with two weeks of theory and background information (during which time the trainee will also observe dialysis in the hospital), followed by REGIONAI, MEDICAL PROGRAM for WESTERN NEW YOPI@ 3- RM 00013 7/70.1 several weeks of actual dialysis performance in the hospital under supervision, and terminating with a period of the trainees performing home dialysis with hospital personnel available for consultation. The length of this final period of training will vary according to individual need. Thereafter, the families will be encouraged to participate in periodic group discussions. It is estimated that 20 physicians and 100 nurses and technicians will receive training, with their hospitals paying their full salaries dur 4 ng the six-week training period and the grants providing $12 per day allowance. Ultimately, it is hoped that the employing hospitals will assume the latter expense. Evaluation techniques will include pre- and post-training tests, faculty evaluation of trainees, and six-n@onth follow-up assessments by employing institutions. When the program has had more experience, an evaluation of its impact on the community will be undertaken. The major portion of the requested budget is concentrated in the categories of personnel and "other." "Other" includes funds for fellowships, labor- atory tests, costs of blood, reimbursement to participating hospitals, maintenance.and repair of equipment and per diem for trainees. Second Year: $615,856 Third Year: $625,722 Requested -Fl r,-3 Y@e a r Project #16 - $256,041 blood coagulation reference laboratory which would have training, service, and research components. Although Roswell Park Memorial Institute has been providing some free services in this field, increasing community needs and decreasing funds for Roswell Park have prompted the submission of this proposal. An education program will be developed which will include: 1. Medical Laboratory Technician Training. Students at the SUNY Buffalo Department of Medical Technology will receive instruction within the framework of the school's course in hematology and practical experi- ence in the laboratory itself (approximately 50 lectures and demonstrations per year), laboratory training will be provided technicians from community hospitals, and graduate laboratory technicians will participate in quarterly, week-long seminars and workshops. 2. Medical Students. Approximately 25 hours annually will be devoted to lectures and demonstrations in hemostasis and blood coagulation problems (will be incorporated into the Medical School's curriculum), ,,EGIONAL MEDICAL PROGRAM for WESTERN NEW YORK -4- RM 00013 7/70.1 third and fourth year students on clinical services will have access to consultations with the staff, and summer fellowships in coagulation will be available through the School of Medicine. 3. Post-Graduate Training. Periodic lectures, laboratory demon- strations, films and videos will be offered in cooperation with the Department of Post-Graduate Medical Education. The laboratory will also offer an intensive two-week course each year, and participate in two separate hematology fellowship programs. It is hoped that this educational program will produce an increase in experienced coagulation medical personnel and provide well-trained technicians for community hospitals. The proposal calls for the provision of clinical consultation ser,lices to physicians. Laboratory consultation service will also be offered because, although the laboratory will not perform any routine coagulation studies for area hospitals, in order to have clinical material avai a e for the various training and testing programs, it is considered necessary for the laboratory to engage in limited clinical service. One hundred twenty cases per month is the estimated load of hematologic workups for more complex problems of blood coagulation and hematosis. Special diagnostic reagents and sera will be prepared and made available, work will be done on standardizing tests, and a voluntary program of quality control will be conducted. Research will not be emphasized, but will be conducted as necessary. The requested costs are primarily for personnel and equipment. Second Year: $183,282 Third Year: $192,186 Re ted First Year Project #17 - $108,163 Atherosclerotic Disease. In an effort to identify people in the Region with a high risk for heart disease and stroke, a reference lipid laboratory will be established to measure serum cholesterol, serum triglyceride, and lipoprotein electrophoresis on the following high-risk groups: 1. Patients with coronary artery disease 2. Patients with peripheral vascular disease 3. Patients with xanthomata 4. First-degree relatives of hyperlipemics. Although cholesterol determinations are being performed now in many hospital laboratories in the Region, neither triglyceride nor lipoprotein electrophoresis measurements are available on a service basis. The proposal states that in order to diagnose the exact lipid abnormality and prescribe the proper therapy, all these measurements must be performed. RLGIONAL MEDICAL PROGRAM for WESTERN NEW YORK -5- RM 00013 7/70.1 According to the proposed protocol, all chemical determinations on the blood sera will be done locally and the sera will then be shipped to the central laboratory where lipid analyses will be performed at no charge to the high-risk patients. The laboratory test results will be furnished the referring physician as well as the clinical director and nutritionist consultant of this study who will recommend to the physician appropriate diet and drug therapy. All therapeutic decisions are ultimately, however, those of the patients' private physicians. On request of the physician, the proposed program will also offer direct dietary counseling service to the patient (either by telephone or in person if the patient can travel to Buffalo) and provide specific dietary recommendations and appropriate teaching materials to the physician. The nutritionist will also work on developing new approaches to patient teaching. Therapy evaluation is planned. -It is hoped that the program will be self-supporting within three years. The requested budget is primarily for personnel and equipment costs. Second Year: $73,849 Third Year: $77,291 : February 1970 Review Committee General: The Review Committee recommended that all three projects i.-n this application receive a technical site visit and be returned to Committee. It was observed that the Western New York Region is one of the better RMP'S: it is well organized) well managed, and has a reasonable spread of regional activities. The Committee noted that two of the projects in the current appli- cation (#'s 16 & 17) signify a trend of moving toward a series of isolated specialized laboratories instead of general diagnostic laboratories, and was curious as to the economics of such a tren Project #15 - A Total Regional Program in Dialysis Committee agreed with the Kidney Disease Program, Regional Medical Programs, that the proposed dialysis project is truly comprehensive with a well-organized plan of operation. The educational programs were considered excellent. The proposal speaks not only to the technological aspects of dialysis, but the social problems brought about by the impact of technology upon the patient ate also considered. The Kidney Disease Program questioned the wisdom of establishing dialysis centers in five hospitals, and it suggested that the project be limited to two or three hospitals. This would reduce redundant expenditures. There was also some concern on the part of the Committee about the appropriateness of the five-hospital plan, especially since one of the hospitals is a cancer research institute. However, most Committee members approved of starting the program in the five hospitals, particularly in view of the fact that inte- gration of activities is planned. The Kidney Disease Program further had questions about some items of equipment, equipment main- tenance costs, and the lack of information regarding the intention REGIONAL MEDICAL PROGRAM f,Dr WESTERN NEW YORK - 6 - RM00013 7/70.1 Other questions of the Committee included: 1. Is the New York Kidney Institute at Albany involved in this project and is this application to set up an alternate Kidney Institute in the Western part of the State? 2. Why is $62,500 requested for hospital costs? Will the New York Blue Cross/Blue Shield not pay for this? It seemed to the reviewers that the dialysis program should be able to support the beds (if Blue Shield does not) and the laboratory tests. 3. How long does the Region envision the training program's continuing? How many people need to be trained eventually? Will the educational program train only people from the Western New York Region or will it seek to provide trained personnel for other Regions? 4. How does the proposed program tie in or compare with the home dialysis training pr@mof Central New York (approved but as yet unfunded)? Although the Committee seriously considered recommending Approval II (no additional funds recommended), with the amount allocated to the project not to exceed $500,000, it was decided that in view of the questions raised a technical site visit would be worthwhile.. Recommendation: No action taken - need technical site visit. Project #16 - Regional Coagulation Reference Laboratory Although the Committee could see the need for improvement of laboratory facilities, it was unimpressed with the teaching aspects of this proposal. The project appeared to the reviewers to be primarily basic service with an educational component tacked on as an afterthought. It was observed that Roswell Park already has an ongoing program in blood coagulation but that this institution is runningintofinancial difficulties and needs new sources of support. Eventual phasing out of RMP support is not discussed in the application. The proposal received a technical evaluation by the Coagulation Section, Laboratory of Blood and Blood Products, Division of Biologics Standards, NIE. Their reviewer had (1) concerns regarding the need of individual hospi- .tals'for specially trained staff since the referral laboratory will perform the more specialized tests, (2) specific questions as to reagent preparation and procedures, and (3) doubts about certain items in the supplies and equipment categories. The project was considered to be very expensive. In sum, although the Committee recognized the need for more specialized laboratories, the educational component of this proposal is unimpressive REGIONAL MEDICAL PROGRAM RM 00013 7/70.1 for WESTERN NEW YORK - 7 - and the budget is extremely large. Consideration was given to a recommendation of Approval II (no additional funds recommended) to permit support of the project until funding from other sources could be obtained or until the activity became self-supporting, but it was decided finally that a technical site visit would be a more appropriate recommendation. Recommendation: No action taken - need technical site visit. Project #17 - A Regional Program for the Prevention of Atherosclerotic Disease The Review Committee observed that this proposed project seems to be hanging free in space and appears not to be coordinated with any other activities. The only backup letter is from the local Heart Association. The reviewers were concerned that it is not tied in with already existing programs of such groups as the Diabetes Association, VNA, Public Health Nurses or activities of the State Health Department. The Ad Hoc Cardiovascular Study Panel suggested that: (1) expert consultation be sought relating to the feasibility of the project, (2) consideration be given to deleting electrophoresis on all initial examinations, and (3) a site visit be made. The Panel also questioned the documentation of need for the project, whether a single dietician can perform all the duties outlined, and whether a greater precentage of the budget might not be assumed by the local or State Health Department. The Committee initially recommended that the application be returned for revision but on reconsideration decided to recommend a technical site visit. Recommendation: No action taken - need technical site visit. March 1970 Council Action: Council concurred with the recommendation of the Review Committee that the three projects receive a technical site visit Site Visit - May 18, 1970 A report will be available at the Committee meeting. RMPS/GRB 5/25/70 REGIONAL MEDICAL PROGRAM for WESTERN NEW YORK 8 - RM 00013 74/70.1 HISTORY SUPPLEMENT Current Year's Support or Initiation Project Project Title Status -(DCOF Date 1 A Two-Way Communication Network $180,253 3-1-68 2 Coronary Care Training 168,152 3-1-68 3&3S Chronic Respiratory Disease Program 655,379 3-1-69 and Respiratory Intensive Care Unit 4 Immunofluorescence Service and Training 34,590 6-1-69 5 Computer-tased Regional Poison Control Program Disapproved 6 Pilot Study in Nuclear Medicine Terminated 3-1-69 7 A Test of Two Continuing Medical Education Techniques 17,920 6-1-69 8 Planning and Education Program in Renal Disease Terminated 6-1-69 9 Core 346,206 12-66 10 Tumor Registry 46,294** 6-1-69 11 Medical Genetics Clinic Disapproved- Inappropriate for RMP Funding 12 Provide via the Mass Media Information to the Impoverished Residents of the Region Disapproved 13 Topical Chemotherapy Treatment for Precancerous Lesions & Cancer of the Skin 47,454 4-1-70 14 Information Dissemination Service 31,960 4-1-70 Total of $1,528,208 includes $347,046 carryover monies $23,147 restricted pending Council Action on this project (see Special Action) RMPS/GRB 5/25/70 (A Privileged Coiiiiiiunic.,itioii' 'SU@@IAIIY OF @ili COINCLUSION OF JUNE 1970 COi)2,11'.UTEE WESTE Pi@( NEI,@T YORK REGI'Oj\,TA.I, l@IEDICAf, PP\O('@RA@l P\m 00013 7/70.1 FOR CO'@'iSIDERATION BY Jtjf,'Y' --970 AT)Vl,',OP,:.f (,'C)UN(@,I.L General.: February 1970 Committee recommended that the three projects in this application (along with the Tuino-.r@ Registry proposal which is presented as a Special Action) receive a technical. site visit. The visit was made on May 18 and the report of tic site team was available to the Committee reviewers. It was observed that the Western New York R14P is very well organized and has good regioiialization. The Committee concluded that this application. which reques@ $2,756,360 for a tliree-year rograni period should be partially supported at the reduced amount of @890)000. Project I[I.5 - A Tot@il. Regional Pro@,rarfi in Dialysis. L@t Lqn@: The Committee reviewers were -'mpresse(I with the regionalization evidenced by the project design and noted that the Region has the five components n.(@,cessary to the success of such a program, i.e., dialysis capability, satellite centers, an organ retrieval system, a tissue typing facility, and transplant competence, Committee agreed with the technical site visitors that the educational component for nurses, techni- ciaiis and other allied health personnel bad considerable merit but that the plan for physician training was unrealistically ambitious. Further, the physician.fellowship program falls outside the purview of MIP in that it is designc primarily for those who would use this time as part of their training for board certification. The equipment needs of the project@ were considered to be far less than indicated in the application. The Committee experienced the same difficulty as the site visitor s i.ii. determining the rationale for creating five dialysis centers, Alth(@)-,Igli the site team thought that a more efficient way to h.-ii-.)dlc, the training program would be to establish only three centers, the Committee reviewers pre,'fcrreci a reduction to two. There was some sentiment among Committee i-a@,iil:>c,.rs that perhaps Western New York had,i-aorc- important prol)le,-ns,@ than end-stage rc?7-iil disease. Ai.'I(l there I was concern, as well, as to the wisdom of establishing dialysis centers in the absence of any llltiOD,al blueprint. Parenthetically, the review of this project emphasized the problems caused by the lack of guidelines to be used in evaluating the plc@t@ior,). of dialysis projects bein- presented for C@c)i-Eii-nittee consideration. The following minority report we-,; by one- iii-ei-n,ber. cannot support a dialysis proc,i.-,,@i-i of this scope which: is not integrated into for teririii-ial- renal, disease care, Ilegi.or).al Medical Program is not educationally directed at anything but terminal reri@-ii disease and lacks pediatric reiial. diagnostic and preventive training, is solely community hospital based and does not have the direction of a major medical center, has no provision for subsequent funding at end of year 3. I suggest the Regioi-i has lost track of its real health priorities for doctors' p27iorities." R e c ortp)i (3-ri cl a t i on :Despite the concerns voiced in the minority report, the reported enthusiasm of the project personnel, the regionali- zati-c)n aspect of the program, and the quality of the project itself prompted the CoriT.Tiittee (with one dissenting vote) to recoiiijiiencl Approval I in a reduced amount of $250,000 for each of threc,.,years to provide for the establishment of dialysis centers at two hospital.,@;. Specifical.13r: th(-- training courses for nurses, technicians, and other allied health personnel should be instituted is planned (but in two hospitals rather than five),, the training program for physicians shoi.il.d be less ambitious and limit itself to familiarizing participants with aspects of dialysis necessary for local physicians; tli-e personnel for training should be reduced to that necessary for only two centers; and the costs for all equipment, fellowships, laboratory tests and reimbursements to hospitals should be deleted from the operating budget. 01 - $250,000 02 - $250,000 03 $250,000 Project -li@16 -ReRi-onal Coa2u].ation Referenc@e Labor o @r (1: It was not-led that even though very few regions would be able to have such a central laboratory with personnel of such bxpertise, the project goals appear overly broad in that, in, iclditi.oii to the training of technicians from outlying hospitals, the project design calls for the performing of complete coagulation studies on patients from throughout the Regioi-i in order to have clinical material to tcacli medical students, techni- cians and other interested personnel. Physician education would result only as a consequence of discussion and handling of referred cases The Com-@nittee reva-c@,?ers igreed with the technical- site toiy[i. that although the goal of having a reference and stin,(Iardizin,@,, laboratory was an excellent one, the rest of the teaching and service, aspects should be (]!-riiiiislied considerably. A more reasonable and adequate objective was seen to be Llic,. training of tecllillicial-i,@-, -froyri outlying hospitals to perform coagulatioii, tc,,st,,,,. It was thought that a greatly reduced budget-. would be sufficient for such an ej-.iclc@,ivo@-. l@l E@,f YORK El@l uu@il.5 ///U. J@ Reg-ioi-itI. Medical Program tiori: Appi-c@-%7,-@l -1 for three years in a reduced amount with the following conditions: 1. Revision of f)rojec@t: goals as indicated above. 2. Provision with the third-year continuation request of a report on the. progress and impact of the project in the first two years of operation including a discussion of the appropriateness of the testing costs. 01 - @60,000 02 - $40,000 03 - $40,000 Project #17 A Regional. Propram for Atherosclerotic Di@sease. Critique: The Conimittec,. revi.c-,@@,7ei--s agreed with the technical site visit teii-n that any study of the type proposed should be directed more toward primary than secondary prevention, that the -Viltie of performing electropho-r.-e@-is on all patients was questionable, that the follow,-up methodology was deficient, and that the budget was excessive. It was noted that the project bid not received a review by a cardiovascular group at the Regional level. In genera the feasibility of the proposal was doubtful and the value of the dietary management and pl.aiiE-,, for physician education left iiiuct to be desired. Reco,,-rii'lic,nr a t i on :Noii--Appro-@,7al Ino Dr-a4.]:) funding recommended. Sal@'@lA@-ly OF RECO',,, IEI\TD.A,'110',,S: PROJECT 01 Year 02 Year 03 Year TOTAL W-1@5 Regional Proy-t.-oty[i in Dialysis N,25C),OOO $250,000, $250,000 $750@000 lp'16 Co@igijlation 60,000 iO,000; 40,000 1-40,000 Laboratory Yr'17 Prevention of At:!-icroscl.erotic ..O- -0 -- -0 -O- Discast-- TOTAL $31C))OOO $290,000 $290,000 $890,000 DR@IP GP\.B 7/13/70 @o@ 0 0 Privileged CbEiiiit-iiiicati@ol@1) SPECIA], ACI'ION REGIONAL @'@EDICA.], PI"OGRAIL FOI', @@fl,"STI,',I"N Nill@w YOID@ RY, 00013 February 1970 Review Coiiiiii@i-tte-c-, March 1970 Council- @une 1970 Review Committee Project #10 Western New York Tumor 11, _Le -,@a When this project for a Tumor Registry was revie@ve'd in April-May 1969, it was considered by Committee and Council to be of good design with well-docuniented procedures. Approva for a five-y@eai- period was I recommended in the ay.,@ount reqtiested@-laiid the project was funded in June 1969. During staff review of the progress report and continuation application for the Tumor Registry in mid-Feby-uary 1.970, it was discovered that the three key people who submitted the proposal- had left Roswell Park and that a new project director had been found who, with the help of the Hospital Management Enoi.neering Program of tli(-,, Western New York Hospital Association, evaluated the project design and concluded that the supporting services to be provided by such an automated system must be revised. Althou,,h the original proposers had envisioned the r6gistryis usefulness in epidemiological research, clinical-pathological- mortality correlations, and diagnostic/treatiiieiit method evaluation," and described a highly innovative and unique, technol-ogically-oriented registry, an abstract form designed to include all the proposed items is now deemed by the Region to be far too lengthy and complex, especially in light of the costs involved and the volume- of paperwork which would be required. Consequently, the primary objective of the project has been revised to become i@proved patient care through improved followup. A shortened abstract form of 41--items has been adopted. In short, the registry which is now being implemented is significantly different from that originally proposed and approved by Review Committee and Council. In view, of this change in design, the 02-year award for this project carried a restriction on use of half the funds until Review Committee and Council recommend acceptance of the rev:@sed plan. The Region has been asked to submit information as to the degree and kind of difference between the original and the revised project, the acceptability of the revised design to the Regional Advisory Group, and the relative priority of this project in the Regi.ori's overall plan. February 1970 Review Committee. Review Ccff@inittee. recommended that a technical site visit teiii,, evaluate the revised project as compared to that originally approved by Con,-@iittee and Council. Committee noted that the revised tumor registry is of standard design and provides information for follov7tlp and teaching purposes. The revi.e@,7crs thought t@iat since the project plan now includes fewer facets than did the original proposal, the budget might be reduced. A technical site visit ,!as considered necessary to evaluate the differences between I - - @ t- p the original -.iO revised. It wls ','Ll,@.0estc(.1 that th site team a-Isc) of Institute to the Western York Medical P,c@comn,endati-on: Dc-f(,.r for tc@ctini-cal- site visit and return to Committee. Western Ne-v; Yorl@ PDIP 2- l@1,4 00013 7 /7 0 Special Action Mar(,h 1-c@170 Coi-incil- Action Council agreed with the Revie@,2 Cor-irf@ii.ttee that action should be deferred pending the report of a technical site visit. Staff was authorized to arrange for funding to maintain the prograDi until final action is taken. Site Visit - T.@ay 18, 1970 A report will be avail-able at the Cow-,.iiittee meeting. I/ 01 $72@137; 02 $46,294; 03 $50,438; 04 $54,464; 05 $58,726 RMPS/GRB 5/27/70 (A Privileged Communication) SPECIB@ AG'!'-,'--ON WESTEIUZ NEI-J YORK RECIONAI, MEDICAL --@)ROGr@l RM 00013 General: A technical site visit team evaluated the revised tumor registry proposal in comparison with the original design which was approved by April-May 1969 Committee and Council. Project #10 - Western New York Tumor str The Committee agreed with the technical site team that although the revised tumor registry does not embody the innovative aspects of the original proposal, it does represent a more realistic registry program for this region At this time. The early growth of the project was retarded by the revisions in personnel and design, but the reviewers saw the possibilities of the registry as a good vehicle for regionaliza.tion. The active involvement of the Western New York Hospital Association and the plan for assumption of support by participating hospitals at the end of RMP funding were considered to be especially propitious. Recommendation: Approval I - was recommended for continuation of the cancer registry in the amount originally recommended by the National Advisory Council for the remainder of the period for which support has been committed. 02 Year: $46,294 03 Year: $50,438 GrJl 7/9/70 A PRIVILEGED COMMUNICATION RM 00013 TECHNICAL SITE VISIT REPORT WESTERN NEW YORK May 18, 1970 Site Visitors & DRMP Staff Victor Vertes, M.D. (Chairman) Director, Division of Medicine Mount Sinai Hospital of Cleveland University Circle Cleveland, Ohio 44106 Cyrus C. Erickson, M.D. University of Tennessee College of Medicine 62 South Dunlap Memphis, Tennessee 38103 Leonard Scherlis, M.D. Professor of Medicine Chief, Department of Cardiology University of Maryland Hospital Baltimore, Maryland 20201 Abraham Ringel Public Health Analyst Operations Research and Systems Analysis Branch Regional Medical Programs Service 5600 Fishers Lane Rockville, Maryland 20852 Eileen Faatz Public Health Advisot Grants Review Branch Regional Medical Programs Service 5600 Fishers Lane Rockville, Maryland 20852 Individual representatives of the WNYRMP are listed in the text of the report. Western tew York - 2 RM 00013 PROJECT #10 - Western New York Tumor Registry Pat Shine Regional Medical Program L. Donald Meyers Regional Medical Program Leonard Kaye Regional Medical Program Elsa Kellberg Regional Medical Program Marion Sumner Regional Medical Program John R.F. Ingall, MiD. Regional Medical Program Jc,hn C. Patterson, M.D. Regional Medical Program Dolores Celest Tumor Registry Ray Caputo W.N.Y. Hospital Association Bob Keefe W.N.Y. Hospital Association The original tumor registry proposal was approved by May 1969 Council and was funded in June 1969. The objectives and methodology of this project, however, were changed in midstream because of changing personnel, the three key people who developed the registry having left Roswell Park. Dr. Patterson, the 'new project director, with the assistance of the Hospital Management Engineering Program of the Western New York Hospital Association, evaluated the original design and concluded that it should be revised. In reviewing the request for continuation of the tumor registry into the 02 year, staff decided that the Review Committee and Council should approve the revised plan. February/March 1970 Committee and Council recommended that a technical site visit team evaluate the difference between the original and revised projects. The revised program is less innovative and sophisticated than the original but more feasible and acceptable to the participating hospitals. In fact, one of the reasons for revising the project was that hospital administrators and staff physicians looked askance at the expenditures which participating hospitals would incur under the original design. Revisions it, personnel and design retarded the early growth of the registry, and the system did not really get under operation until January 1970. Fourteen hospitals now are par'ticipating in the tumor registry, and six additional hospitals are expected to join the project soon.'To date, only onehospital has refused to cooperate. It was the feeling of the site visitors that the revised project has more strength than the original in that it is more realistic for this Region at this time. Although there is nothing particularly novel about the present program, it does have a cancer hospital as its fulcrum (with which the WNYRMP has apparent good relationships), and it holds the possibility of gaining the cooperation of a number of outlying hospitals. Dr. Patterson explained to the site team that project personnel consulted with the New York registry which they found will provide them with only death information. Even though the project is off to a slow start and programming may have been premature, the visitors saw in the registry the potential for cooperative efforts among several hospitals in developing a standard service and educationally- oriented tumor registry. The development of this cooperative system was viewed as increasing the opportunities for physician education in cancer and the development of referral patterns in specialized facilities. Of extreme importance is the fact that the engineering group of the Western New York Hospital Association is participating in the implementation of the registry. At the end of RNP support it is planned that the partici- pating hospitals themselves ultimately will assume the costs of operation. The revised budget total is identical to that requested and awarded for Western New York Site Visit - 3 RM 00013 the original proposal, and the visitors considered the budget well within reasonable bounds. Recommendation In summary, the revised cancer registry does not have the unique character of the original proposal, but the site team viewed the changes as for the better. The recommendation is for continuation of the project in the amount originally recommended by the National Advisory Council for the remainder of the period for which support has been committed: i.e., the rest of the 02 year and the 03 year ($46,294 and $50,438). Although some members of the site team suggested that further programming be halted until the project has accumulated much more data and tested the existing programs, others felt that such a limitation was unduly prohibitive. PROJECT #15 - A Total Regional Program in Dialysis Dr. Albert D. Menno Meyer Hospital, Deaconess Hospital Dr. John M. Hodson Deaconess Hospital Dr. Roland Anthone Buffalo General Hospital Dr. Sidney Anthone Buffalo General Hospital Marion Sumner Western New York RMP Dr. John R.F. Ingall Western New York RMP, Director Dr. J.D. Lasher Hamot Hospital Mr. V. Sirak, Jr. Hamot Hospital Dr. G.P. Murphy Roswell Park Memorial Institute This proposal received generally favorable reviews from the Kidney Disease Program, the Review Committee, and the National Advisory Council. There were concerns, primarily revolving around the wisdom of establishing dialysis centers in five hospitals, that prompted Committee and Council to recommend a technical site visit for this project. The site team was most impressed with the regionalization evidenced in the project design and with the fact that there are in this region tissue typing facilities and the beginnings of a kidney bank which encompasses Western New York and parts of Canada. The physicians and nurses involved in the proposed project are well trained and well motivated. The project representatives explained that the New York Kidney Institute at Albany is not involved in this program and the goal of this project is not to establish an alternate institute in the Western part of the State. The Albany program is mainly extramural and developed primarily in New York Ci'ty. The group was not aware of the approved but unfunded dialysis training program in Central New York. A detailed analysis of the teaching program convinced the team that there is considerable merit to the educational component for nurses, technicians, and other allied health personnel. Plans call for training Western New York Site Visit - 4 - RM 00013 t@iese people at the rate of approximately 100 per year in six-week courses. There was, however, considerable concern about the physician training component. The goals appear overly ambitious 'in that at the end of a six-week education period it is expected thatthe 20 physicians trained each year will be capable of establishing dialysis units in their hospitals and handling the patients from conservative therapy through dialysis, transplantation, and possible rejection. A physician would have to leave his practice for six weeks in order to participate in the program. The project staff anticipates that 20 such physicians would be available each year. The intent of the program for nurses and physicians is to concentrate on training people from the Region, although the courses will be open to participants from other areas and Canada. The costs for Canadian trainees will not be charged to the RNP grant. The number of people who will need to be trained ultimately is a question the Region has not yet addressed, although it is expected that a number of the nurses will drop out because of marriage, pregnancy, etc ' There are, in addition, plans for providing six fellowships for those physicians who whish to remain for a several-month period. These fellowships would be primarily for those who would use this time as part of their training for board certification, and the site team thought this training did not fall within the purview of RMP. The visitors questioned the need for equipment and wondered why RMP would pur-chase apparatus that the hospitals should have already. Project staff explained that the intent was that each hospital would have one kidney machine to be used solely for teaching purposes. Further, since patients being trained for the home would have to buy their own equipment, the site team saw no reason why training could not be achieved on the machines to be used for a given patient in the home. In addition, it was agreed that the costs for laboratory tests, blood, and reimbursement to hospitals for beds could be eliminated from the budget if the teaching program would concentrate on those patients with Blue Cross, Medicaid, or other tliird-party coverage. Project staff failed to convince the site team of the desirability of having five dialysis centers, expecially since the didactic training would occur in only one institution (using personnel from all participating hospitals) and the experiential phases would rotate among the institutions. The visitors thought that a more efficient way of handling the training program would be to establish only three centers. This number would still provide the trainees with a varied background in dealing with different equipment and techniques. Recommendation The site visitors recommended approval of the program in a reduced amount of $250,000 for each of three years to provide for the establishment of dialysis centers at three hospitals. Specifically, they believed the training courses for nurses, technicians, and other allied health personnel are well-designed and should be instituted as planned (but in three hospitals rather than five). It was felt that the training program for physicians should be less ambitious and limit itself to familiarizing participants with aspects of dialysis necessary for local physicians. It was considered that the personnel for training is essential, but should be reduced to that necessary for three centers. Western New York Site Visit RM 00013 Further, the costs for all equipment, fellowships, laboratory tests and reimbursements to hospitals should be deleted from the budget. PROJECT #16 - e ional Coa ulation Reference Laborator Lvis L. Mosovich, M.D. Department Pediatrics - Children's Hospital Norman B. Courey, M.D. Gynecology & Obstetrics Deaconess Hospital Marion St Lmner Regional Medical Program Western New York Julian Aribrus, M.D. Roswell Park Memorial Institute Clara Ambrus, M.D. Roswell Park Memorial Institute Irwin B. Mink, M.D. Roswell Park Memorial Insititute Herbert E. Joyce, M.D. Regional Advisory Group The February/March review bodies recommended that this project receive a technical site visit, primarily because of the unimpressive educational component and the extremely large budget. Ti'ie site visitors found that the expertise of the individuals involved with this project was exceptional and that their knowledge of coagulation and the existing laboratory facilities were most impressive. The tests described in the proposal are ongoing activities. The site team felt, however, that the goals of the project are too broad. Besides training technicians from outlying hospitals, the project personnel intend to perform complete coagulation studies on patients from throughout the Region in order to have clinical material to teach medical students, technicians, and other interested personnel. To accomplish this, the Director is applying for the complete furnishing of a new laboratory as well as funding for 13 technicians, a senior biochemist, and a senior physician. The site team thought 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 considerably. It was the visitors' opinion that training technicians from outlying hospitals to be able to return to their own institutions and perform some of the coagulation tests was a more reasonable and adequate objective. It was thought that perhaps one-fifth of the budget would be necessary for this type of endeavor. Recommendation Approval of $60,000 forthe first year and $40,000 for the second and third years, with revision of project goals as suggested above. PROJECT #17 - A ReRional Program for Atherosclerotic Disease W.E. Mosher, M.D. Erie County Health Department, Commissioner Millicent Toppin Erie County Laboratory Thomas Tiffany Erie County Laboratory Wallace T. Williams Dietetics & Nutrition, State University College George Johnson Erie County Laboratory Western New York Site Visit - 6 - RM 00013 Christine Falkowski Erie County Laboratory Leonard Kaye Western New York RMP Erie County Laboratory - E.J. Meyers Leila Edwards Memorial Hospital Division Michel A. Ibrahim Erie County Department of Health and Department of Preventive Medicine Ruth Kocher NYS Health Department, Buffalo Max E. Chilcote Erie County Laboratory, Department of Chemistry, SUNYAB Marion Sumner Western New York RNP John R.F. Ingall, M.D. Western New York RNP, Director Robert Kohn, M.D. SUNYAB When this proposal went through the February/March 1970 Review Cycle there were many general questions as to the feasibility of the project, the coordination of this activity with others in the Area, as well as more specific procedural concerns. A technical site visit was recommended. The visitors found that the positive aspects of this program included: (1) the interest and ability of project personnel to establish the laboratory and perform the analysis with quality control, and (2) more involvement of other agencies, such as the State Health Department, than had been expected. In addition, there is presently no aci ity in Western New York which handles such analyses on a routine basis. The project representatives described the goal of the program as being the provision of prompt prophylactic measures for atherosclerosis, yet the group which they will be treating has already had evidence of atherosclerotic disease. The value of this program was questioned seriously since the visitors felt that this type of study should not be directed toward the secondary group but should be looking more to primary prevention. There is an exclusion of patients who would benefit by primary prevention and, therefore, by the dietary control. No attempt will be made to deter- mine other high-risk factors in patients, such as documentation of the presence of hypertension,obesity, etc. The visitors further questioned the desirability of performing electrophoresis on patients with normal cholesterols and normal total triglyercides, but the project representatives offered no justifiable explanation. Another concern of the visitors revolved around the follow-up and evaluation scheme - the methods used to define the success of the project. The project will attempt to answer such questions as whether the patients follow the prescribed therapy and whether the prescriptions do, in fact, reduce lipids. But the problem of whether the therapy prevents atherosclerotic disease will not be addressed. The team considered this a major deficiency in the project design. The budget was considered excessive to the goal of establishing a referral laboratory. Furthermore, patients who are referred to the laboratory by their physicians but who do not fit into the defined high-risk group will be charged $20.00 per determination. This fee will not be applied to the Western New York Site Visit - 7 - RM 00013 cost of the project but, rather, will go into a special research fund of the laboratory. Recommendation The suspicion of the visitors that this project had received no local review by a group knowledgeable in cardiovascular disease was confirmed. Although the team felt there was a definite need for a reference laboratory, the feasibility of the current proposal was in doubt, and the value of the dietary management and plans for physician education left much to be desired. It was the visitors' consensus that this project should be disapproved and returned to the Region for referral to a local heartcr research group for funding or for revision and reorientation of the program to emphasize multiple risk factors and concentration on primary prevention, Conclusions of Site Team Recommendation .Project # and Title 01 Year 02 Year 03 Year #10 Western New York* $46,294 $50,438 - Tumor Registry #15 A Total Regional $250,000 $250,000 $250,000 Program in Dialysis #16 Regional Coagulation Reference Laboratory $60,000 $40,000 $40,000 #17 Regional Program for the Prevention of Atherosclerotic Disease Disapproval - - Total $356,294 $340,438 $290,000 *Continuation of 02 and 03 years recommended. GR-B-6/23/70 @10 0 0 ,REGIONAL-MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) WESTERN PENNSYLVANIA RM 00041 7/70.1 REGIONAL MEDICAL PROGRAM June 1970 Review M-240 Scaife Hall Committee 3550 Terrace Street Pittsburgh, Pennsylvania 15213 Program Coordinator: Francis S. Cheever, M.D. Requested Program Period lst Year 2nd Year 3rd Year 4th Year 5th Year Total Direct Costs $43,911 $44,820 $46,995 $4,800 3,900 $144,426 Indirect Costs 11,062 11,474 12,030 1,229 998 36,793 TOTAL $54,973 $56,294 $59,025 $6,029 $4,898 $181,219 History: The planning grant was funded January 1, 1967 in the amount of $271,736 (D.C.). During the firstyear some organizational difficulties were experienced. This resulted in an extension of the grant, without additional funds, for 90 days, to March 31, 1968. A Program Director was named during this period and assumed full-time responsibility June 1, 1968. The Regional Advisory Group was expanded and reorganized to include representatives of hospitals as well as county medical societies. The second year planning continuation grant was awarded effective April 1, 1968 in the direct cost amount of $260,484. With a car.ryover balance of $212,823, the new funding amounted to $113,942. A supplemental planning grant award in the amount of $93,750 (D.C.) was authorized by Council in January 1969 for Core activities in order to provide continuity to the program while the region awaited approval of its operational status. A site visit was made on February 24-25, 1969 to evaluate the region's request for operational status. The site team examined how the program had evolved, the extent of involvement of all health interests, how the region determines priorities, relationship between the grantee institution and the Rt4P, roles of the RAG and committees and future plans. Council concurred with the site visit team and Com mittee's recommendation of approval of five projects and Core. One project was returned for revision with advice to re-submit a request for the RMP-relevant portion only. The WP/RMP received its first operational grant award in the total amount of $1,157,896 ($934,041 D.C.) effective July 1, 1969. Project #4 to provide -2- RM 00041 7/70.1 i4estern Pennsylvania RMP training for hospital Emergency Resuscitation Teams, was supplementally awarded ($88,000 D.C.) for an eighteen-month period after issuante,of the N.A.C. policy for projects of this kind. Project #8 - Laurel Mountain Home Health Aide Training and Demonstration Project - was recommended for disapproval by the November/ December 1969 reviewing bodies. After evaluating comments of the N.A.C., the local Advisory Committee for the three-county Area involved and the R.A.C. of WP/RMP reaffirmed their belief that the project is significant to the outreach of the WP/RMP, and asked for reconsideration for approval for implementation from unexpended funds. The N.A.C. recommended approval, with no additional funds, of support for such training costs. The present level of support for the region for Core and seven projects is $1,022,041 (direct costs). The operational activities are as follows: Project Funding Level (D.Cj Core $475,041 #1 -Postgraduate Faculty of Medicine 34,000 #2 -Hypertension Management 90,000 #3 -Regional Program for Nurses in Heart, Cancer, Stroke 160,ooo #4 -Emergency Resuscitation Team Project 88,000 (18 mos.) #6 -Training of Nursing Home Personnel 125,000 #7 -RHP Library System 50,000 #8 -Laurel Mountain Home Health Aide Project No Additional Funds TOTAL $1,022,041 Present Application: GENERAL: After more than half-way through the first year of operational activities, the region feels that planning efforts are showing satisfactory results. A first Annual Planning Conference was held in the fall of 1969. This application reflects the priority expressed then. The Comminity Involvement Committee has completed the organization of nine Area Advisory Groups. This Committee has stimulated interest in development of health care programs for the poor and there is agreement that the RMP should focus on methods of improving the system of primary medical care for this segment of the population. Western Pennsylvania RMP -3- RM 00041 7/70.1 The Grants Review Cowmi.ttee membership has been broadened for a wider community representation in the Grant Review process, and in addition, the Committee is working with WP/RMP staff on project evaluation. Ist Year $43,911 Project #9 - TraininR of Cancer Chemotherapists for the Community Hospital This project proposes to develop a cadre of physicians who are interested and competent in the advancing field of chemotherapy. The appli- cation requests support for a preceptorship training program in cancer chemotherapy for practicing physicians in Western Pennsylvania. These physicians will serve as important members of cancer committees in hospitals throughout the region in line with the region's four highest priority interests. These Chemotherapiate, in cooperation with other members of their medical staffs, will provide cancer p&tientB with a balanced treatment program including cancer chemotherapy, radiation therapy, surgery, radioisotope therapy, etc. in addition to beginning the organization of a cancer treatment system for the region, the project is designed to make available the benefits of modern cancer chemotherapy to patients throuer,@out Western Pennsylvania. The program emerged as a result of planning of the Cancer Committee of the Western Pennsylvania Regional Medical Program and its Task Forces on 1) tumor clinics and tumor registries; 2) angiography; 3) chemotherapy; 4) radiation therapy; 5) community education and motivation in oncology; 6) continuing postgraduate education in oncology; 7) nursing and paramedical manpower; and 8) screening and casefinding, The priorities for a Regional Cancer Program were developed by these Task Forces, discussed and modified by the Cancer Committee, and approved by the Regional Medical Program Advisory Committee (R.A.G.). Their objectives include 1) support of multi-disciplinary efforts in cancer management by hospital staffs throughout the Region; 2) establishment of a network to link these multi-disciplinary groups to each other and to teaching hospitals in Western Pennsylvania; 3) cancer registries as needed; 4) postgraduate education efforts for health professionals and 5) an educational. program to motivate the public to seek earlier care for symptoms suggesting cancer. The region's Cancer Program will be augmented by a feasibility study for which approval has been requested from the Division Staff. This study will be initiated by a nurse specialist in oncology in cooperation with the Pennsylvania Cancer Society. Initial programs will be carried out in cooperation with local units of the Cancer Society, but will also provide professional liaison with various lay groups simulated by the Society, such as the Lost Chord Club, the Reach for Recovery Group, etc. The WPIRMP has developed a close relationship with the Hospital Utilization Project (HIJP), which provides participating hospitals with a ready-made registry of all cancer patients admitted. The registry in its present form provides only minimal information about therapy (surgical procedures primarily). western Pennsylvania -4- RM 00041 7/70.1 The project will also rela-te to the State Health Department which provides partial support of cancer registries in 31 hospitals and includes 68% of the hospital beds in Western Pennsylvania. By correlating the efforts of all three agencies (WP/RMP, HUP, and the State Health Department), it is hoped that the needs for data about cancer programs by local medical staffs can be met. ' The Cancer Committees in the various hospitals will consist of at least the hospital radiologist, pathologist and the community chemotherapist trained in the present program. In addition, a surgeon with special interest in cancer and other appropriate members will be chosen by the hospital's medical staff to join this committee. One physician member of the Chemotherapy Committee (Dr. John B. Hill) will give ten hours per week (1/4 time) as Project Director supervising the program attending to the administrative details, etc. He will be assisted by a secretary (1/3 time). The Project Director will work from his office at the Vestern Pennsylvania Hospital which will act as the fiscal agent for the program. An oncologist will be added to the WP/RMP Core staff to work closely with Dr. Hill and the University Health Center oncology group. He will assist in the full development of the Community Hospital Cancer Committees as a part of his major role, and will assist Dr. Hill in implementing program evaluation. Four to six students will be accepted in each six-month period over three years, Selections will be based on potential for service, taking into consideration training, age, health, hospital staff appointments, etc. All will be physicians in practice, including both general and specialty practices. The faculty for the program will consist of 11 Pittsburgh physicians who are fully trained members of the Pittsburgh Chemotherapy Committee. Curricula Vitae are attached to the application. It is the intent of the training program to develop in the 36 participating physicians the knowledge and skills adequate to permit them to initiate certain kinds of commonly needed chemotherapy. They will take responsibility for the continuation of more complex or unusual treatments which are initiated in a referral center. Participating physicians will be encouraged to refer appro- priate patients to treatment centers for new or highly complex forms of chemo- therapy requiring special skills or facilities. They will also be encouraged to work with other members of their hospital staffs to provide a balanced cancer care program. During the final two months of the course, students will be encouraged to undertake the treatment of selected patients in their home areas, and will discuss these patients' problems with their preceptors. Refresher courses will be offered each six months in the form of another day and a half course. For one and a half years following the initial six months training period each community chemotherapist will report regularly on his chemotherapy practice. In addition he will make quarterly reports describing the progress of all patients. The staff oncologist and/or Dr. Hill will visit the chemotherapist in his coamnity to provide on site consultation and guidance. Second Year: $44,820 Third Year: $46,995 Fourth Year: $ 4,800 Fifth Year: $ 3,900 western Pennsylvania kul vuuz-@i ///V.i FF OBSERVATIO'@N Attention is drawn to the internal r6-View,process of WP/RMP and specifically page 31, Section 6, which indicates that in 6Valuating the project, the R.A.G. made certain reductions in the budget. This accounts for the difference in the amounts on pages 8 and 9, which reflect reduction in the equipment and space rental requests. GRB 5/6/70 K I LiV L It: I-, U 1.1 UIJLLIIELK@LIL J- -11 SUMMARY OF'REVIEI%T AND CONCLUSION OF JUNE ]@970 P,1!7VIEl@@ CO@il@ITI@'l",L", WEST)3RN PENNSYLVANIA REGIONAL MEDICAL PROGRAM RM 00041 7/70.1 FOR CONSIDERATION BY JULY 1970 ADVISORY COUNCIL General: The Committee approved this application, requesting funds for one new project. This is the region's first effort at establishing a region-wide cancer program. It is a cooperative endeavor with local Units of the Cancer Society, various lay groups, such as the Lost Chord Club, The Reach for Recovery Group, etc. It will ilso,relat@e to the State Ile@iltl-i Depart- merit, as v7c-11 as the Ilospital. Utili?.ation Project, which provides particil)atin- hospitals,uith a ready-made registry of all cancer patients admitted. Project lr'9 - Traini.n5z of Cancer ChE@iiiathera ists for the Community Hospital. @ri@). The proposal was found to be quite impressive and one of the best written of 4-t8 kind. It indicates a great deal of sophistication in its development and is thoughtful and thorough in spelling out its details. The outreach aspects are excellent. The goals of the project are capable of mc@asuremc@jit and i,n accordance ivit P,MP goals. 1rie reviewers noted excellent documentation as to numbers of patients who will, be iffected by this training activity. V.Tiil6 the evaluation plan i.s appropriate, project staff identified for this purpose was not considered to be very strong. It was noted, however, that there is apparently a good evaluation backup on the WP/PI-IP staff. The suggestion was made that the applicant should be quc-rri.ed to make cortairr the evaluation they propose can be carried out within the requested financial allotment. The overall plan seems sound except for a possible problem with trainees whose practices mi.ght i.nL(@rfei.-e wi.tli their training scb(,idiil.es. It would appear that a busy practitioners ability to spend one day a weel@ would be difficult to accomplish. The reviewers also raised the question of the oncoloE,,i,st'. who is being recruite for the WP/PdIP Core Staff. They wondered if his salary would be partially financed otherwise. Recommendation: Approval I First Y ar Second Year Third Year @43)93.1 @44,820 @46,995 WE,i'J'Ef@1'4 PLI.,,TNSYLVAN'!A Rli-@D iui ooo/@i 7/70.1 SIRI-%L4PY OF 01-Year 2 @,Y r 03-Y6ar To ta 1. L@O e@C t #9 $43,911 $44,820 $46,995 $135,726 Total $43,911 $44,820 $46,995 $135,726 R).4PS/ORB/7/13/70 a a a REGIONAL MEDICAL PROGRAMS SERVICE "I!I!N,Al@Y OF A St)PPLEM.FNTAI, OPT-,'RAI'TONAT, GRANT APPI,TCA'! 10@l (A Privileged (,omniiinicatioii) t@l,,(;I,ONAL, MEDFCAL PROCRAL 0003,-, i-/-i'O.-i I I 0 I:;-) S i@ t-f i @('OTISi n Avenue Jt)ne 1970 Review Committee @lilw,,tiil@ce, 5"1202 (coordinator: John S. Hirscliboeck, M.D. l@c@qtiested Ist Yr. 2nd Yr. 3rd Yr. TOTAI, I)i.rect (,osti $132,915 $125,215 $125,215 *383,345 Indirect Costs. 20,330 20,330 20,330 60,990 ']'O'I'AI,S $153,245 $145,545 $1145,51@5 $444,335 History: See 7/70.2 for regional history of this application.) This application was originally submitted during July 1969 as a major manpower development project with eleven subcomponents. The original program Would establisl) a multidisciplinary and interinstitutional. approach Lo the tr,)i.ning of health science personnel through the, development of q Department of Health M@inpower and Contii)uing Education at the Marquette School Me(licin(, - with ten separate training components. However, during October 1969, t[it- Region requested that the application be withdrawn from the review process. This request was made because of anticipated fiscal developments -)t @lar(Itiette. I'lie school, which was in serious financial trouLle when the @ipptication was originally submitted, is now receiving essential financial Support for its operation from the State of Wisconsin. It was believed that ,an endeavor of this magnitude could not have been undertaken until the fi-nin(-,i;)l structure of the school became more solid. 'I'lierefore, ttie Region is now requesting that the original application be restoi-e(i to the review system in a modified form and with redt.iced budgets. 11, lie modifications are defined in a letter from the Program Coordinator, dated February 12, 1970, which states that seven of the twelve original components were deleted (C,D,E,F,G,H, and J), and components A,B,I,and K were retained @ts integral parts of the application. The revised application now consists of the February 12, 1970 letter and the four components mentioned above. (,Subcomponents A,B,I,and K are separated by pink papers in tlii.s application.) Direct costs only are noted. Requested F'i.rst Year I)roject #I(SA - Department of Health Manpower and Continuing $50,765 Education at Marguette'School of Medicine. 'I'he original request for Component A, for the first year, was $130,400. This has now been reduced to $50,765. Project ComponentA of the Health Manpower@Development Project calls for the establish- ment of a Department of Health Manpower and Continuing Education at the Marquette School of Medicine. This department will be the kev to the Regional @ledical 11'rogr@im - 2 - Rl,l 00037 7/7(J.1 Requested development of continuing education in the Medical Center which First Year is being planned to be, among other things, the 'locus for inter- professional and interinstitutional continuing education coordination in the southeastern Wisconsin area. The project provides a base til)oti which the entire continuing education program can be developed. Since it relates to the Medical Center and the associated institutions, it should provide the basis for the coordination of teaching efforts not only for medicine but of the various members of the team effort in medical and health practice in the major teaching hospitals in this ni-e.i. Its objectives should be therefore: 1. To develop and coordinate interdisciplinary continuing education for medical and health professionals in the Medical Center facilities. 2. To provide the meeting place and communication for the coordination and develoliment of continuing education of institutions and pro- fessional organizations outside the Medical Center. 3. To develop and maintain interprofessional and interinstitutional evaluation of continuing education both within and outside the Medical Center. 4. To act as a resource and consultation staff to professional and institutional organizations desiring to establish interdisciplinary and interinstitutional continuing education programs. ,@itice the medical, center is not expected to be fully developed for several vears, and the coordination of continuing education will be an ongoing task, it is proposed that staffing of the Department of Continuing Education begin on a liqlf-ri.ii:e including an associate dean in medicine, an Associate director !-,ji: ni-irsir,-, and an associate director for allied health, pILis a f@ill-tinie secretary. 80'4 of the budget request is for personnel. Second Year: @e46,965 Third Year: $46,965 Llro.ject ',@ISB - Nephrology. The original request for Component B $21*100 was for $26,959 for the first year. This has now been reduced to $21,100. Other than a total of $1,300 for supplies and travel, the remaining support requested is for personnel. A !)iock of clinical experience will be provided internists, surgeons, gynecologists, urologists, and general practitioners, geared to@)ard: 1) improving their ability to interpret electrolyte and acid- base measurements, and translate this information into appropriate plans of therapy; and 2) improving skills in early detection of kidney disease, rising simple routines available at all hospitals. Physicians who complete training will be invited to return and attend weekly teaching conferences of the Renal Service and other pertinent meetings. They may also elect to return at intervals, in order to add to their technical skills or gain more information ibout specific problems they encounter. It is hoped that 12 i)ltysicians will receive this training. i@@giotiil ',Iedical Prograii) - 3 R@l 00 7/-O.l 'Re ci, Liested First Yeir ,!ill be offered one aiontli of sLi,-.)ci-\@i,,@ed c t ill i cc, I t@ r@l i IIiig i ii the c@i re of patients wit l-I d iSt Lirbaiice,,, i ii f't@iict c,lecL.,-ol@,te and acid-base metabolism. A detailed curriculum is development. illins call for 12 nurses to be trained. @'eam LL,,iciiitig will- be utilized and coordinated physiciiii-niirse care is intended. !2@ecoii(i Year: $21,100 Third Year: $21,1,00 l@t-t)ject 4@18t - Iltilmonary Di.sease. '-f'lie origi.nal request for $26,400 Component I was for $185,800 for the 1-irst year. 'I'liis II, @).@ [low been reduced to $26,400. $22,000 of this total is I-or P(,rsonyiel . Disease Component will be conducted as a small pilot portion of the total proposal. It @,7ill, consist of a one-month-long program for physicians and nurses desiring to learn the treatment of I)ati-c@nts in respiratory failure. "This would inciLide instruction i.n (.establishing a respiratory care unit in their hospital, experience in t@1)(@- tisc, of all equipment utilized in the care of these patients qs %,tell. ti-.Ieir actLlll management duri.ng the acute episode and through the recovery period. Instruction i-n the technique-, of blood gas analyzers and the utilization of these determinations in patient management Would be provi-ded. Didactic sessions on 1)@isic pulmonary I)iiy.@iol.ogy qrid acid-base balance would be i.nclildecl." LI 1. To enabl(- pl)ysiciins to treat and manage pati.enLs in respiratory I-ailt,tre, utilizing latest methods and equipment. 2. 'I'o enable nurses to cire for pati.ents in respiratory f@,)ilure., including proper handling of tracheostomies, prolonged endot-i-,ichc@,@il it-)Lttbntion, utilizing latest techniques and equipment. -3. @'o enable physicians and nurses to work cooperatively in the care of patiei)ts in respiratory failure towards maximizing patient benefits from latest tecl-iniqt.ies ind equipment. :'.@e-con(I Year: $22,500 Third Year: $22,500 llrojec,t Closed (Circuit 'I'elevi-sion Prop-r@ini. The original]. $34,650 request for Component K was for $61,675 for the t i.rs[ vc-!zii . 'I'Iiis has now been reduced to $34,650. A I I of he i.s ,intoiiii t @@ii I 1, be uril i-zod to -support personnel. According to the Region, Tile Milwitikec@ Medical 'I'elevi,;i.ori Net@,,.-ork i,-@ I fine exiiiil)lc of interinstitutional cooperation with tile goal of enhancing 4 - RI@l 00037 7/70.1. kqf,@(,ONSTN Regional Medical Program Requested First Year and .coordinating continuing education in the medical care and health fields. It provides a focus around which the various institutions and professions can meet to consider their respective and joint goals in continuing education. Because of its ability to reach substantial segments of the professional audience any given time, it is a means for communication with the health and medical paralleled by any other means. It personnel of the area which is un can provide the basis for evaluation of the effectiveness of various teaching techniques with large segments of the medical health pro- fessional groups in different settings, in different places, but with Common Source material. The development of local programming and filining of local material should provide the opportunity for inter- disciplinary and interprofessional groups to cooperate and formulate concerted.approaches to continuing education on an interdisciplinary basis. Television ProRram roiect K - Obiectives. 1. Coordinated production of T.V. programming for cooperating health and medical care institutions. 2. Provision of uniform educational content to health and medical care personnel in cooperating institutions. 3. Provide intensive T.V. media programming to fill gaps in knowledge and abilities of personnel in cooperating institutions. Second Yeir-. $34,650 Third Year: $34,650 Evaltiat-loi-) -I.s planned at four levels. These are: 1. "])e extent to which the program has been established as approved and funded, i.c,., staff recruited, readiness of facilities and cclt.iiT),,nent, etc. 2. otiantity of output as compared to proposal. 3. Qi-)a,'.itv or effectiveness of teaching. f new, enlarged or revised interinstitutional programs developed by stimulus of this program. 5/18/70 A Privil(,3(!cl AlqD .z or 1970 REV@l@i@7 CC)il"2@@@i'.@',Iklili'."@., RY, 00037 7/70.1 FOP, CI);'@SIDF@P-t@TI:O-.@,T L@Y JULY 1970 CO'@LTI@CIL General: The Review Committee application 70.1 wi-ii,cli reqte,-,,ts $383,31@5 (d.c.0.) b@,! partially fLtii(@le,d a'(-- (d.c.o.) to support 18A for a prograrli pc@riocl. Cc@ic,,@"flittee furtlic4r racc@,-;,-fte-rided tlk@'t ac,@,tion, on C(i puilel-@.t6l ISB, 181 and lsl'\, bc-- 1-@ort-al)provcl, 110 rliTS reco,,fL,,i-iei.-ided. This T,?ns ori-i),iall,y dui-i.,,)-_ July 3,969 I,,3 a mciiipoi,@er x.@ith eleven sttb- c 0 Fiji Ti t s . The progi:,ii@i would establish @i multidiscii)ll.,i-i,-ry and interii.i.,,,(:itutiorial. approach to thc@ of li,-,@,-ilth -cicTice ti@irou, ti. the of a of llealt,.Ii and Eduic,@tl@ori at tile Sc@lool of cpl)ll"lte trtiil-i@iz;g coi in OctoLer 1969 the cat'i,on be fi-or@l thawed. rcvi(.@w proor- Thir, request cause of c'Pticipat.(-,d fiscfil rit.-s ,it Du-i,ing 1970, ttt(@ Regi(,,n tl-iit tii(-, bL@ to Lli(,@ syrt(@iii in a form qnci N.,iti-L rcr3uced Therc-,@forc,, ttit, Revic!@7 corn iclei--ed o@,ily coT-,.-tponenti, 11, 1, K. Project Cor@ipoi-ic,,,it t @t . 0 f (i (i u. 1Lj@ c,, I t for tlii,r, for tT.k(,@ f,,'.;cf3t yc!,!T@,r alleges f,,I,30,4-00. This redt,@ced to .$50,765. It I 7,-; "41 (;'@ir UL o a t I', c 0 0 -@', e r I tI)ro@i)o@.. e@@ ",2t t a 1) of Y,, for card by the ii b y t@o ciL@.,,L.,bl.0 th,- to pro-@)c ic-., i er,l)'i@,@c@@c). ,,.5 0 7,,',,.' e;46,965 il.TISCCIII'- Sit.'f 2 I'@@l 00037 7/70.1 Prc@ject Col) oat a n rl 1 p Pro Critiqu,e: ',Clio Njas in re(,.criimetiding noia-approval of all three of these cort-ipoiients. Altliougli the total originally roqur--rted tic-ive b,lllc,@ri j@edu@ec-@d in the tylodificte, qp- p I i c @-., t i o-@l. ,the that: these Prci rc!qucsts for fui-ids to support persoiiiiel into are ev.-@efcntl,y @ilrcady ernlil.oyed by the institution. In addition, the eTil:i.rc- ecluctitio@,iil design of the xrarioi.%,@ components, ,-IS written, v,@ex,e conci(le7.-c@l k. Recou@atirz,,ndc@tioii: IZoia-approvel. - no RMPS fliitdiii- r(@coiirtiendcd. Doctcsr Philip Whit6 was not present during on this applicati.o-,.i. AI,7).) OF 1970 2ncl Ye.,ir 3rd Y(..iar 18 A 1, fol- Cor,ipotl,Clli: 1)@r) rtf-@l I,-),t C)I' $50,765 $46,965. $46,965 ISA IBB 0 Ilozi@@approval no RI'PS funds rc-cciriL,@,.c..,Yided 181 P117.rT" 18K Clor,"%(" TO'.PA L $50,765 $46,965 $46 965 yc"?, r To@,,zl 01) $50,765 02) 6, 9 ()5 03) 40,9r)5 695 7/10/70 @ r- m 0 0 0 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF A SUPPLEMENTAL OPERATIONAL GRANT APPLICATION (A Privileged Communication) WISCONSIN REGIONAL MEDICAL PROGRAM INC. RM 00037 7/70.2 110 East Wisconsin Avenue June 1970 Review Committee Milwaukee, Wisconsin 53202 Program Coordinator: John S. Hirschboeck, M.D. Requested Ist Yr. 2nd Yr. 3rd Yr. TOTAL Direct Costs $620,248 430,126 437,580 1,487,954 Indirect Costs 104,893 41,792 42,095 188,780 TOTALS $725,141 $471,918 $479,675 $1,676,734 History: The Wisconsin Regional Medical Program Inc. has been operating under grant support from the Division of Regional Medical Programs since September 1, 1966. The first year of a two-year planning period began on that date with an award of $319,458 (d.c.). During its second planning year the Region became operational, following a preoperational site visit in July 1967. Therefore, the second year (9/l/67-8/31/68) award of $548,1866 (d.c.) 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. The award for the period 9/l/68-8/31/69, was for $1,162,581 (d.c.). This provided continued support for Core activities, including the three feasibility studies mentioned above, plus nine operational projects. The Region is currently in its fourth year (third operational year, 9/l/69-8/31/70). The total award of $1,689,510 (d.c.) is composed of $1,548,430 basic and $141,080 carryover funds. (See History Supplement on last page for a breakout of this total.) Present Application: This application requests support for six (five new and one renewal) operational programs. The renewal proposal requests one additional year's support for a project designed to prepare inactive nurses for return to the practice of nursing. The remaining five proposals are in the fields: heart (3), cancer (1), and a proposal related to high-risk fetus and newborn infant. Direct costs only are shown in the following program descriptions. WISCONSIN Regional Medical Program - 2 - RM 00037 7/70.2 Requested First Year Project #13A (R) - Inactive Nurse Education - University of $60,800 Wisconsin Extension. This is a one-year renewal request for a project that, was approved for a two-year period, during the November 1968 Council, for $60,000. The project initially was to start -March 1, 1969. However, because of funding restrictions during 1969, the project was not funded and did not become functional until September 1969. The Region states that an additional year's support is necessary to fully meet the objectives as originally stated. The overall objective of this renewal request is, to facilitate the immediate and eventual return of the inactive nu rse to the practice of nursing. The project plans to offer: 1) non-credit refresher courses for inactive nurses in selected areas of the State; 2) a series of telephone/radio conferences on a Statewide basis; and 3) individual study guides on selected nursing topics. The refresher courses will be patient-oriented and the enrollees will be assigned to care for patients with commonly- seen conditions that will be discussed in formal classes. The courses will provide the nurse with the opportunity to update her nursing knowledge and practice as well as to learn about resources for keeping this knowledge current. The nurse will also learn about changing nursing skills and knowledge, organization, patterns of care, and current trends and concepts in nursing service and education. It is planned to include in this course the projected plans for the care of the patient after he goes home, and information about available community resources. Three of these courses (four weeks each) were offered in the areas of Rhinelander, Neillsville, and Marinette during the fall of 1969, and a total of 17 nurses attended. Seven of these nurses have returned to practice and an additional six plan to go back to work in the near future. Another course started in Sturgeon Bay in March and plans are under way to offer a course in Monroe, and another in Portage or West Bend later during the year. The television/radio programs are offered on an hourly basis, twice a month, and have 575 inactive nurses currently enrolled. The sessions are designed to assist the inactive nurse in locating and using resource materials available to her. The sessions also include discussions on recent developments in nursing, changes in medication, clinical aspects and community health. The programs are taped and made available for loan to participants who are unable to attend the study sessions, and for those who are interested in forming study groups. The individual study gui-des will be implemented during the next budget year, and 80% of the nurses who are enrolled in the telephone conferences WISCONSIN Regional Medical Program RM 00037 7/70.2 Requested First Year indicated an interest in the service. Some of the suggested topics to be developed include: 1) emergency care as it relates to shock, hemorrhage and childbirth; 2) nursing management of the patient with myocardial infarction (already developed); 3) the burned patient; 4) the unconscious patient; 5) congestive heart failure; 6) acute care; 7) disaster nursing; 8) psychiatric nursing, etc. At the conclusion of this project, the individual study units and the telephone conferences will be phased into the ongoing programs of the Department of Nursing, at the University of Wisconsin Extension. An overall evaluation of the enrollees will be conducted at the conclusion of the project, to determine the extent of the return to practice of the enrollees. The evaluation forms include: 1) a refresher course questionnaire (mailed six months after course terminates); 2) listener's response sheet and interim survey sheets for telephone conferences; and 3) evaluation form for individual study unit. Approximately $44,000 of the total request of $60,800 is for personnel and consultant services. Project l@19 - An Educational Program to Improve the Care of the $136,040 High-risk Fetus and Newborn Infant - University of Wisconsin. This project proposes to organize and coordinate a limited number of specialized facilities which would be used as referral centers for the care of special problems related to the high-risk fetus and newborn infant. I Plans are to develop at least f4-ve regional centers in La Crosse, Madison, Marshfield, Milwaukee And, tentatively, in Green Bay. These centers would provide intensive care for the high-risk newborns and specialized care for high-risk pregnancies during the antepartum and intrapartum periods. In order to provide the necessary trained personnel to staff the centers, several educational programs have been developed. One program would be aimed at preparing nurses who are currently employed in intensive care units for the newborn which do not have instructional personnel to meet the need of orientation and ongoing inservice training. This program would be offered concurrently in Madison and Milwaukee over a two-week period. A second program would be aimed at preparing nurses who would be caring for infants following their hospitalization in an intensive care unit. The infants may be transfer patients still requiring hospitalization, or may be ready for discharge. The nurse would be prepared to give continuity of care and subsequent followup into the community. A third program would involve consultation services made available to hospitals and communities for the purpose of training nursing personnel to recognize the high-risk mother and infant. WISCONSIN Regional Medical Program - 4 - RM 00037 7/70.2 Requested First Year The Madison Regional Center Program is designed to serve hospitals in the State of Wisconsin (except'the Milwaukee Region) and could also be available to hospitals in Duluth, Minneapolis, St. Paul and Southeastern Minnesota. At present, there is an active intensive care center. An enlarged intensive care nursery is under construction and will have space to accommodate up to 28 high-risk infants. It is planned to operate 4-5 classes yearly, with a limit of four nurses per class in the first year - later expanding to five or six nurses per class. The instruction will take place primarily in the intensive care unit at St. Mary's Hospital in Madison. The nursery accommodates 2,000 newborns per year. The Milwaukee Regional Center has a 25 to 30-bed intensive care unit at Milwaukee County Hospital and serves Milwaukee County and South- eastern Wisconsin. The program will be conducted in the Milwaukee County General Hospital obstetric and nursery areas and will operate four to five classes per year, with four nurses per class initially, later expanding to five-six. The hospital has a total of 1,500 births yearly and more than 30% of these fall into high-risk groups. From the previous capacity of 15, the intensive care facilities are being expanded to accommodate 20 babies. The La Crosse Regional Center serves the Western area of Wisconsin and.adjacent areas of Southeastern Minnesota. The target group would be the nurses in the La Crosse Regional Newborn Center at St. Francis Hospital, the nurses from referring hospitals within the Region, and physicians involved in neonatal care within the Region. The educational program would be conducted on a weekly or bi-weekly basis, utilizing resource people from the Madison Center program to participate with the La Crosse Regional Center nurses in the development and presentation of the program. The program for the nurses from the surrounding area would be held at the Regional Center, on a one-day seminar basis - two or three times yearly, and would involve lectures, demonstrations, and in-the-unit participation. Bi-monthly or monthly perinatal mortality conferences and perinatal care seminars will be conducted for the physicians. The Marshfield Regional Center is designed to serve the North Central Region of Wisconsin. The target group will be the nurses within the regional newborn center, the nurses from referring hospitals within the Region, and physicians involved in neonatal care within the Region. The organization of the'course follows the same design as the program described for the La Crosse Regional Center Project. The development of a center in is currently under way. This center will provide service to the Northeastern Region of Wisconsin. For the next two years the developmental and educational IJISCONSIN Regional Medical Program - 5 - RM 00037 7/70.2 Requested First Year aspects of the program will be carried on from the Madison Center. The educational program will be evaluated by: 1) written pre and postcourse tests based upon behavioral objectives-, comments from the participants; and 3) followup visits to the participants by the teaching staff. $114,240 of the total request of $136,040, for the first year, is for personnel. Second Year: $132,840 Third Year: $132,840 Project #20 - An Action Program for Detection and Management $116,125 of Gynecologic Malignancy - University of Wisconsin Medical Center. This project is an outgrowth of the Study Program for Uterine Cancer Therapy and Evaluation which has been funded through 8/31/70. This is a request for a one-year program to develop a network of regional centers designed to make available the techniques of colposcopy and directed biopsy to the physicians of the State and their patients. The present centers involved are: The University of Wisconsin Medical Center, Madison, Marquette Medical School-County Hospital Center, Milwaukee, St. Mary's Hospital,Milwaukee, and the Marshfield Clinic, Marshfield. New centers will most likely be developed at La Crosse and Green Bay, Wisconsin and Duluth-Superior (Wisconsin and Minnesota). It is hoped that by substituting these techniques for the evaluation And management of patients with abnormal cytology, the use of the surgical cone will be reduced, thereby reducing hospital costs and surgical hazards. An informational program will be implemented to inform physicians of the advantages and availability of colposcopy and directed biopsy.- The information will be disseminated through: 1) RMP newsletters and releases; 2) State Laboratory of Hygiene newsletter; 3) State Board of Health publications; 4) Wisconsin State Medical Journal briefs; 5) dial access tapes; 6) circuit seminars among the County Society, Councilor District meetings, etc.; 7) direct individual contact with physicians; and 8) "detailing" by county agents on the latest advance in medical developments. When it is judged that a reasonable physician understanding has been achieved, the State Laboratory will begin to include with each physician's report of abnormal cytology information on where and when this service can be obtained. The names of both physicians and patients will be distributed (at regular intervals) to the centers that are located in close proximity to both the patient and the physician. An attempt will be made to explain this service to the physician and to elicit his understanding and participation. When this is achieved, the physician @4ISCONSIN Regional Medical Program - 6 - RM 00037 7/70.2 Requested First Year will send or bring his patient to a prearranged colposcopy clinic at one of the centers where a repeat cytology and directed biopsy will be obtained as colposcopy is performed. A report will be sent to the patient's physician within 48-72 hours, with suggestions regarding further diagnosis or therapy where appropriate. Followup on all contacts will be maintained by the cooperating centers, the State Laboratory of Hygiene and other participating agencies. Every effort will be made to maintain uniformity between centers in the collection of data concerning tissue interpretation and demographic information. Patient fees will be maintained at a re. inimum and will be initially limited to institutional charges. Professional charges for the diagnostic colposcopy and biopsy will not be made to referred patients, unless these patients are referred for definitive treatment. Indigent patients will be cared for at no cost. The applicant states that an interregional relationship (Section 9-10) is being developed with neighboring Regions such as the University of Minnesota and,the University of Iowa which will allow: 1) their use of dosimetry programs currently available in this center; 2) their participation in clinical data collection and tabulation in gynecologic malignancy; and 3) the joint utilization of ideas, expertise and facilities of any one of the institutions by all participating centers. The budgets in the application for Iowa and Minnesota are samples rather than requests for funds. As a means of evaluating the success of the program, the number of patients being coned each year in the projected Regions or in the State as a whole, will be determined for a specific period of time. If the program is successful, it is expected there will be a decrease in the number of surgical cones and an increase in the number of colposcopic studies with biopsy. A second approach to evaluation will be possible, utilizing physician understanding of the place of colposcopy and directed biopsy as an indication of success. The preparation of a uniform reporting and evaluation system for gynecologic malignancy in the multiple Regions served should also be an indication of success. Staff was advised by the Program Coordinator that the Wisconsin RAG approved this proposal for one year to afford them an opportunity for a complete evaluation o progress. Second Year: None Third Year: None WISCONSIN Regional Medical Program - 7 - RM 00037 7/70.2 Requested First Year Project #21 - A Computerized Electrocardiogram Project for $124,581 Wisconsin - Marshfield Clinic Foundation. This is a three-year request for a proposal which would provide a centralized electrocardiographic interpretation service for the ',Iisconsin Region. The system would offer four distinct advantages: 1) direct service to the patient and physician; 2) decreased cost; 3) increased speed of interpretation and application of the results to the patient; and 4) better and more efficient utilization of the cardiologist's time by assisting in the interpretation of more tracings in less time. The initial target population will be those patients served by the following hospitals: 1) Park Falls Hospital, Sacred Heart Hospital, Ashland Community Hospital, Oconto Falls Hospital, Adams-Friendship Community Hospital, Medford Hospital, St. Joseph's Hospital, Marshfield Clinic, Neisville Memorial, and Black River Falls Hospital. These hospitals have a total bed capacity of 1,004 and run 25,111 electro- cardiograms per year. Most of the hospitals are rural and only one (St. Joseph's) has a full-time cardiologist. The eventual target population would include over 9,000 hospital patients in the State. The project will be administered by the Marshfield Clinic Foundation for Medical Research and Education. The cardiology, electrocardiographic, and the computer services of the Marshfield Clinic will be utilized to provide the personnel, equipment, and technical services. The educational programs will be provided by personnel from the Foundation, the Clinic and the 3M Company. The first three months of the project will be spent setting up the central operation (to be located within the Marshfield Clinic), training personnel and checking computer programs. A training program for technicians will be established and will involve an intensive program in EKG analysis, interpretation, and the use of the equipment for taking EKG'S. The Marshfield Center technicians will be trained on site and the technicians from the cooperating hospitals will spend an initial week at the Clinic. Formal and informal seminars will be held in each of the cooperating institutions for physicians in an effort to familiarize them with the computerized EKG program and how it can be used as a service to both the physician and the patient. The second phase of the program will begin at the end of three months. At this time EKG's from the Clinic will be run to verify the programs and to establish the procedures to be used. In addition, during this phase of the project, the trainees from the cooperating hospitals, along with local hospital personnel, will receive further instructions. WISCONSIN Regional Medical Program 8 - RM 00037 7/70.2 Requested First Year The third phase of the project will begin approximately six months after initiation of the service to the regional hospitals. During the second year of the project, 10 to 15 additional hospitals will be incorporated into the network and 10 to 15 more in the third year. This program will be evaluated in five stages. The initial stage will be verification of the computer program and interpretation of the electrocardiogram by the center's staff cardiologists. This will be done for all electrocardiograms for the first six months, on a random basis. The second portion of the evaluation will deal with the user increase of the program. The third evaluation stage will attempt to determine whether or not the computerized electrocardiogram actually supplied the physician with the data which is useful in his diagnostic determinations. This will be tested in all cooperating hospitals. The fourth phase of the evaluation plan deals with computation of the cost of the electrocardiograms. Finally, continuing evaluation of the geographic area to be served will be made, to insure that the service will be made available to all areas which have a need. At the end of three years the project will be taken over by the Marshfield Clinic as a service function. $45,408 of the first year's total request of $124,581 is for personnel; $70,773 is for equipment; and $8,400 is requested for supplies and travel. c-econd Year: $125,667 Third Year: $128,533 Project #22 -Community-Oriented Continuing Education in $54,341 Rehabil tation Medicine for Physicians and Allied Health Personnel - Division of Health, Wisconsin Department of Health and Social Services. This is a three-year request for aproject to provide physicians and allied health professionals with an opportunity to develop skills, increase their knowledge, and to improve the coordination of rehabilitation activities. The target area is a three-county nonurban area located in central Wisconsin. All three counties have a significantly higher percentage WISCONSIN Regional Medical Program - 9 - RM 00037 7/70.2 Requested First Year of people in the 65 and over age group than the State as a whole. The project's objectives are: 1) To improve the ability of physicians in the target community to respond to patients' r@.eeds for treatment and rehabilitation through participation in interdisciplinary educational programs. As a result of these educational programs, it is anticipated that the physicians will be able to identify potential or actual disability, and determine the degree to which the condition diminishes the patient's ability to cope with his environment. In addition, the physician will be able to select and prescribe the appropriate therapy to minimize or prevent disability; and will also be able to contact and identify the appropriate allied health personnel to provide specialized therapy services when needed; 2) To improve the ability of allied health professionals to assist in the process of providing complete and coordinated care to patients in need of rehabilitation, by participating in educational programs. As a result of this objective, the allied health personnel will be able to determine the extent of the patient's disability and relate it to current techniques of their specialty. They will be able to recognize the needs of the patient for services which go beyond their own area of competence and training, and make proper referrals. In addition, the allied health personnel will be able to adequately perform their functions and provide their services in locations that lack the facilities ordinarily available in a hospital setting; and will be able to adequately perform consultative, teaching, and supervisory services. 3) To provide health professionals, persons in need of rehabilitation services, and their families with a source of information on the full range of rehabilitation services available in, or to, the target communities. The educational activities to be conducted include individual patient consultations, rehabilitation evaluation clinics, and formal teaching sessions. Consultation (provided by therapy consultants from the State Division of Health) to individual agency administrators, allied health professionals, and key agency personnel will be made available upon request. A referral and information service will be developed. Information on local, area and State resources will be compiled by the local coordinator with the assistance of the @IRMP staff. The rehabilitation evaluation and teaching clinics will be held for a full day once a month in each community, for a period of ten months; and will be carried out by the project physicians and the therapy consultants and, occasionally, other medical or technical specialists. WISCONSIN Regional Medical Program - 10 - RM 00037 7/70.2 Requested First Year Evaluation methods of Objectives I and II include: a) Pre-tests and post-tests to determine the health professional's knowledge of such factors as the identification of disability, appropriate therapy, current techniques, etc. b) Pre and post-use of a structured study to determine their understanding and concern with the patient's needs in rehabilitation. c) Observation of course participants in a clinical setting. d) Examination of hospitals' and physicians' records on disabled patients who receive care during the project period. e) Examination of nursing and other allied health personnel care plans and records, for information on sources of referrals, their types of functions, patients' treatments, and consultations. Method-s of evaluating Objective III (which relates to the establish- ment of a referral and information source) include a survey of patients and/or their physicians with rehabilitative needs, to determine the number of persons aware of the service and number who have utilized the service. Those using the service could also be surveyed to determine.whether or not they actually received the services they needed. Approximately 16% of the first year's total request of $54,341 is in the personnel category. Second Year: $57,428 Third Year: $62,016 Project #23 - An Educational Proaram for Cardiac and Intensive $128,361 Care Nursing - University of Wisconsin, Milwaukee. This is a request for three-year support for a proposal to establish a comprehensive intensive and coronary education program for registered nurses in the Wisconsin Region, in an effort to improve the availability, effectiveness and efficiency of registered nurse manpower to hospitals with ICU-CCU. Plans are to provide training for 72 registered nurses each year of the three years. During the third year it is also planned to conduct workshops with School of Nursing faculties to identity that ICU-CCU content which should be included in basic and graduate nursing curricula. The core training program will be developed at the University of @qisconsin-Milwaukee School of Nursing in collaboration with Marquette University Craduate Department of Nursing, and Marquette School of Medicine. WISCONSIN Regional Medical Program 11 - RM 00037 7/70.2 Requested First Year The teaching program is planned for five days per week for a six-week period. Four hours of each day will be devoted to theoretical instruction and four hours to clinical experience. Of this, two hours are allotted to planned formal classes, one hour is allotted for self-study, and one hour for seminar and group discussion work and films. The seminar and group discussions will include various resource people such as dieticians, social workers, clergymen, Public Health nurses, and a former patient. The trainees will be selected according to the following criteria: 1) The trainee will have at least one year of postgraduate nursing experience; will have been employed within the past year; and will be a licensed registered nurse. 2) Preference will be given to trainees with experience in ICU/CCU and emergency room. 3) The trainee will have an employment contract to work in nursing during the ensuing year. 4) The sponsoring hospital will be asked for a written commitment to support the trainee in what he has learned. 5) !,Then the trainee is from a hospital, the physician responsible for the CCU-ICU will agree to participate in two seminars conducted during the course of the training program. 6) The hospital will agree to participate in a followup evaluation and consultation visit involving the hospital administrator, director of nursing, and responsible physician. The applicant states that the objectives are described in terms of behaviors to be achieved at the end of the course. Evaluation then becomes a measurement of the attainment of these behaviors. Approximately $47,000 of the first year's total request of $128,361 is for personnel and $43,344 is for stipend allowance for 72 trainees. Second Year: $114,191 Third Year: $114,191 WISCONSIN REGIONAL MEDICAL PROGRAM - 12 - RM 00037 7/70.2 HISTORY SUPPLEMENT LISTING OF CURRENT STATUS OF CORE SOPRRATTONAL PROJF.CTS TN WRMP PROJECT TITLE AMOUNT SUPPORTED (D.C.) NUMBER THROUGH 8/31/70 BASIC CARRYOVER I Core $438,974 2 Study Program for Uterine Cancer Therapy and Evaluation 105,032 3 A Pilot Demonstration Program for Pulmonary Thromboembolism 55,404 4 Cancer Chemotherapy for Adults 38,492 5 Postgraduate Education for Health Professions 58,520 -- 6 Interrelated Programs in Radiology and Nuclear Medicine 112,059 11,141 7 The Prevention, Diagnosis and Treatment of Cardiovascular Disease Part B - Coronary Angiography 5,800 Part C - Pediatric Cardiology 57,374 8 Cancer Chemotherapy Program for the Metropolitan Milwaukee Area 66,725 9 Community-oriented Continuing Education in Approved no funds Stroke Rehabilitation for Physicians and recommended Allied Health Personnel 10 Coonerative Project in the Diagnosis and Approved - no funds Treatment of Secondary Hypertension recommended 11 Tissue Typing Program 51,350 12 Uterine Cancer Screening Project 48,700 13 An Operational Program for Nurse Training (Two parts) A - Inactive Nurse 60,000 -- B - Nurse Shock -- 12,400 TAIISCONSIN REGIONAL MEDICAL PROGRAM - 13 - RM 00037 7/70.2 LISTING OF CURRENT STATUS OF CORE & OPERATIONAL PROJECTS IN WRNP (continued) PROJECT TITLE AMOUNT SUPPORTED (D.C.) NUMBER THROUGH 8/31/70 BASIC CARRYOVER 14 Cardiopulmonary Resuscitation Project Nonapproval 15 A Comprehensive Program in Renal Disease $ 450,000 (Note: This project was approved for a three-year period. The Division is currently negotiating a $450,000 annual level of support) 16 Medical Library Service 16,950 17 Nurse Utilization Demonstration Unit 100,589 SUBTOTAL $1,548,430 $141,080 GRAND TOTAL (BASIC AND CARRYOVER) $1,689,510 DRMP 4/30/70 17 i V e C-.,d c, II II -i.r 0 oi@ Stil'T@ilill,@@7 CJ7 1.9'/() CO-" I I'J'T i@ 1. WISCONSII'4' l@EGIC)@\IAII 0OCi@117 7/70.2 FOk BY J',@j!:Z 191'0 COT.TNCIE. C or c.,, r,-i 1. '."he Rev,--ew Cori,,iiiittee supplemental- operational ,-pplicatio-i-i -- 7/70.2 - which rc-tl,--,c-rts $1,487,951+ for a tlll.-ee-year I)criofl, be partially funded tt $551,60,', d.c.o. This is to support Pi-o@@cts Y@-20 and Y@22 i-ri the enC'). tmou-t-it i,e-quected and Project YF23 in the time recluc-..@,,ted, in a reduced aa,lota,,it. Cor-iiiittee further recommended )pl)i@t)val of Project #13A (R) for them. time requested but did not recommend addit,,-c)i-ial f uncl P c) c (-@ t il-19 wj,.-@ for deferral periling technical revie,,y by tl,.@, and Cl-iild He,).Ith Staff. Coniriittec,@ recommended t@li@it Project #21. not: be ap-p@rovc@e, - no funding I'c was further recorrr,-n,@,ii e that Council. conlje-.Ie a committee to exp!6r(-! ,.re@2s of computer assistance 9,iid monitoring 'Dy re-Laote cor@trol devices. Project Yi':I.3A (R) - inact@i.vo@ NLirse ECI(ic,@it:ioii. (,'r 1. vi., e @ Committee noted tliit this @,7a-. a one-year rene;4al -.oi- a project that T@7as approved for a tt.)o-yeir T.)rogrz,,iii 13e!,---,.od during thc@ 1968 CoiL).ncil. Ilo@@7ever, t-eceu,,;e of fundiiAg restrictions during l@969, the project N,7js not funded and did not becoEfia functional. tint-Il.'L 1,969. Wli@Lle the '-'oDT@-nittee agreed that the need for tlii.s type of program is cleai-I results fro,-P. programs of this type -eiie)-al'Ly are 'Poor. Apparently, this -,Ls rD true with this program since only seven out of 17 nurses who have are icttiall.y'back on duty. Mt--rr@,bc.@rs of the Committee noted the review and favore,i)]-e i-ecorf@riiel-i q-tioi-i of tlte Continuing Education and Training Branch Staff pertaining t:o tlii..@; pro Po In recoii@t@Tc@ndin@ approvpl, the Co@nmittc-e believed that the c)-Lie-year additiona time period reouested may serve to assisti the project in meeting its Ilo@,7evc-.r-, it recommended that. no additional RI-,IPS funds I,C, i allec,,@@ted to this activity. in triple, with i-i,) IZM,':'S funds reco-!i,,inendc-,cl. Pro'ic-,ct. @,,@1.9 - l@n Educational to Ci37(@ Of the Fe.t,,ir. and Ne@171)'orp, C r,;', t@ i (4, (i c,. :The %?!.tl) the revi4--@,7 of the AO, Iloc Carcliovasctilai.- St:tl@ly Pai-,c.@l. that the proposo-I is wcll r@ I- c: f) the -faced tIlCi C)i) C-Cl@i@)E'-,@, )--e clear end of tc, E-tc--corllpl-isl? the 1)@) t orl,, iT-,-i.jor iic>t(.,d I.f7, of life this in WISC.ONQIN Regional Medical Program RM 00037 7/70.9 It was noted that the re was no clear evidence that nurses are available to participate in this specialized training and function. The Committee debated whether to recommend approval of this proposal for two years, with specific conditions, until a Program Coordinator (who was serving 69 an ad hoc committeeman) suggested that the proposal be reviewed by the Maternal and Child Health Staff-. From prior knowledge, he believed that similar types of programs were being supported out of Maternal and Child Health funds. The Committee accepted his recommendation that no action be taken pending a technical review by staff of Maternal and Child Health Services. This has been requested and should be available in time for Council meeting. Recommendation: D&ferral pending review by staff of Maternal and Child Health Sorvices4 Prbj'ect #20 - An A6tion ProRram for Dot6ction and ManaRement of CynecolbRic Critique: The Review Committee noted that this is a worthwhile cancer project in spite of believing that there is little interest in colposcopy in the United States. The Committee was interested in the statement that this will be a part of an interregional relationship (Section 910) which is being developed with Wisc6nsin's neighboring Regions - Minnesota and Iotqa4 When this re 16tionghip is developed, it will provide for: 1) use of @@d6simotry programs currently available in Wisconsin by the participating out- lof-S@tate Universities; 2) participation in clinical data collection and tabulation in gynecologic malignancy; and 3) the joint utilization of ideas, expertise and facilities of any one of the institutions by all participating centers. The budgets shown in the application for Iowa and Minnesota are samples rather than requests for funds. In addition, the reviewers noted that the Wisconsin RAG had approved this proposal for one year only to afford an opportunity for a complete evaluation of progress, Recommendation: Approval in time And amount requested. Direct Costs Only: Ist Year 2nd Year 3rd Year $116,125 Tiohe requested , None requested Project #21 A computerized El@ectrocard@aT @r@ect for Wisconsin Critique- The Committee concurred with the opinion of the Ad Hoc Cardiovascular Study Panel that although a limited need for this type of service by small hospitals in rural Wisconsin is described, the total forecast of need by all small Wisconsin hospitals is not adequately documented. It was agreed 7 that while the objectives are quite clearly stated, the "state of the art" I f computerized ECG interpr etation is not as advanced as indicated in this WISCONSIN Regional Medical Program - 3 - RM 00037 7/70.2 The reviewers questioned whether it was realistic-to assume that a physician can be trained to understand and use ECC interpretation in a four-hour session. Tb6 method of evaluation proposed is unrealistic in that the Medical Systems Development Laboratory of the Public Heal th Service is no longer available for consultant service. In recommending nonapproval, the Review Committee accepted the Panel's conclusion that the application is unapprovable on technical grounds. Committee urged R14P Council to take action to convene an expert consultant committee to explore the entire area of computer assistance and monitoring by remote control devices. Recommendation: Ndnapptoval - no RMPS funds recommended. The Comnittee recommended that the RMP Council take action to convene a consultant committee to explore the entire area of computer assistance and monitoring by remote control devices. Pr6j4ect #22 - Community-oriented Con'tinui Education in Rehabilitatio LI L E-C, I - a Medicine for Physicians and Allied Health Personnel. r@lt@ue: The Review Committee relied on the comments made regarding this proposal during the review conducted by the Continuing Education and Training Panel. The educational design of the program is considered adequate. In establishing a need for the projects the applicant has done the necessary pr6plAnning which includes: 1) the use of statistics on the extent of the problem; 2) the experience from other States; 3) review of the literature; 4) a survey of existing resources; and 5) lack of manpower in the rehabilitation field. members of the Committee agreed with the Panel that the objectives are stated in measurable terms.. The Committee observed that the pr6gram,will: 1) Utilize many staff members from other agencies. 2) Establish an Advisory Committee which will involve many resources and which will provide general guidanc&, interpretation, and liaison for their organizations. This will be the primary group with the responsibility for planning the continuation of the activities at the-end of the three-year Or6joect period. The applicant states that the State Health Department will. continue the activity if it proves successful. 3) Develop cooperative arrangements throughout the Region. The Review Committee agreed with the Panel's recommeiAdAtion-of approval since this appears to be a technically sound and ea ably directed program. p Approval In time and amount requested. ist Year 7ild Year 3rd Year $54,341 $57,428 $62,016 WISCONSIN Regional lledical Program 4 RM 00037 7/10.2 Project Y@23 - An Educational PIO@ram--fo-i---C-a-i-diac and Intensive Care Critique, The Review Committee considered the review of the Ad Hoc Cardio- vascular Study Panel. Committee agreed with the Panel that the objectives are clearly stated and should be attainable,providing appropriate applicants are available for training. A question was raised as to the appropriateness of a six-week course for CCU nurses as compared to the usual four-@jeek courses but it was recognized that six-week courses may be appropriate for intensive care training for nurses. Although the resources appear to be adequate, a-question was raised as to physician involvement in the training program. This point is not covered in the application. The amounts requested for equipment, stipends, and publications were considered excessive. The necessity to develop and produce one dozen thirty-.minute video- tAp6s ('In view of the request of R.OCOM) was questioned. The estimated $2,000 per capita cost is high when compared to a per capita cost of approximately $1;000 for similar courses funded by the Heart Disease and Stroke Control Program. The Committee believed that the Region should attempt to persuade the University of 141.sconsin to @,7aive the $115 tuition expense requested. 'the reviewers concurred with the Study Panel's conclusion that tb6 application is technically sound and capably presented but the budget is excessive. Therefore, as a condition of approval, the Review CoiTmiitt6eArequested that Staff suggest budget reductions which would bring the cost of tbi§ program in line with the cost of similar programs. Staff suggested the following first-year bu(het: Direct Costs From To Personnel (reduce. Project Director's time and salary by 10'/.). $ 46,997 45,064 Consultant Service 6 000 6,000 (same) Mont (deletes $6,000 for Multimedia Instructional System). 14,170 8,170 §up Ites 2,300 2,100 ,p Travel (by reducing amount for trained travel) 6,500 5,750 Publications 3,750 3,750 (same) 2the'r (Development of videotapes) 5 300 0- Stipend Allowance @@3 344 2 l@ '@4 TOTAL $129,361 92,678 $84.;508 per year, for e@tcb of- two years, is the amount ,,uggested for the second and third year, The reductions are principally in trainee stipends and travel. Recommendation. Approval Iin time with tiie amounts and conditions as st@a-ted above. t Costs 0-nly4 lst Year 2nd Year 3rd Year $92 678 @84.,508 $81@,508 i 'n- 'Di, II,,- T@Tl, -I4--. .,, - --i- AI,@; ,@ elnl --If-4 nr, nf thi o- -inn l 4 ri i-i c),,-i - ,/@IOCO' SII,7@. P,(- _@,,ional I,,Iedical Prograiii RM 00037 7/70.2 -O' SL'14,,,IAIZY OF iqS Project Number Title Year 2nd Year 3rd Year 13A (R) Inactive l@urse Education Approval no additional funds recommended 19 An Educatiol;ll_l@o@,'LIM to Deferral for special review (MCII) Care of the 1-1 Rh- risk Fetus and Nc@@,il-)oryi Infant 20 An Action Prof,,--ram for Detection $116,125 None None and ManaReti@@nt of CynecoloRic requested requested mali@na2-c2 21 A Corny)t-lt'erized Electroca.i.-di-o@,rarti Nol-iapproval - no RMPS funding Project recommended 22 Coi-ft-@iiiinity-ori.ented Co $ 54,3141 57,4?8 62,016 Education ii-i Reliabilitati-oii Medicine for Physici6ns and Allied Health Personnel 23 An Educ,).tio,-ial ProRram for $ 92,678 84.,508 84,508 Cardiac and Intensive Fire Nursing TOTALS $263,144 141,936 146,524 YEA,RS TOTAL DIRECT COSTS 01) $263,144 02) 141,936 03) 146 524 $551,604 7/15/70 Wisconsin RMP RM 00037 7/70.2 DEPARTMiEl4T OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADIVINISTRATION Date: Jill 17 1.01 l@)70 to ProT.@)osal -- "An Educational Program to Improve 'the Care of the Subiect: F-i(Il)-risl,< !,'etus and Ne@,;born Inr'Fjnt" Project #19 7'o: Acti g Director Reoioii6l Medical Programs Service I appreciate the opportunity to review this Eiropo@al. @-7e are @.,-.ur..)poi,.,ting a number of similar training programs as well as four neonatal intensive care unit projects, the latter with funds ava,,I@a'blE- for the first time in fiscal 1.97,). I have no c3.o@6t about the im ortance of increasing the P @ui@,dei--stanclin,--f of tl-le neWoorn among physicians and nurses. III reviewing such an a-L3r)licz,,tibn as -LI-,is, it i.s cyuite possible that :Ecaftil-@ of reference may ].De different from yours since r(, f3-o@i@it the bacl-,jrouricl. of the prograi-,is in I function rather than the l@icd-ical Prc)@ education in itself is a-clesirac)l.e objec I v7ould. t 61.5o !-)r@ interested in,l,-i-iowincj what br@nefitF, :C I.- C) m@ such El 'O @l rot I -v@buld not ,,@-.Tivc@ @-,'@i.@,consin high p:t-i.orit@@7 i@t @-ap, a -f-a-,,,bra'olc- in:Fant rc,.ort-c-ility rate -Irf,,org the 15.4 i.iifant deaths per 1,000 in 1967. I-lo\,@@ this pro@-,ram ii@,."P:rove the situation ')e@on@ J-u@l-ie utioiis w Iz) d e. been rt', ci y the StDte -red: years is not cl@ ar. It i',s questionable -that i,,iuch pro,:frc@-ss can .:)c made in and neonatal mortality uiilc-.1@s there is a I)rog to i, @:)rc)ve.tliic- maternity cc-ire of the Iii. Costc-tric patient 9 and Nl,-iic@i %-Tell increase t'@)e avai@lz@bili.-Ly of- fn,,,iily planning The ptog)@a-@n,r-@ay,be hFirnr--)er'ed if lo maternity patients Oo not have resources to meet the costs of the care they need. pzi,.,fe on program evaluation is we a In cohclLlsi@orl, if gains in fetal and mortality Fi-id in rbviii@-@ such ..III-it rates are among for ID.P a p r -p,,) s,-, 1 i@ n P, e.,@ i@ o n a I i@l@- d, i c a 1. 1) i- o@- I r Fl i-Li !-J. r@ a I,:) p Ia. t 1. c@ n d r) t e, ri to to a favor@@bl.(@ A J. t c,i