Asia "4 SDC AGAZ@NE 7-) w Published by System Development Corporation Volume 12 Number 8 04 for Home Rule in Health Care by HARRY BAIN Hal Johnson lives in Roseville, Cali- he has come to know quite a few of ization. But if you're getting some fornia. To get there you drive north Roseville's 20,000 citizens. He sees pa- mellow notion that he's a storybook from Sacramento along U.S, Interstate tients every day in his office on Oak country doctor, you're in the wrong Highway 80. Usually the trip takes Ridge I)rive or at the Roseville Com- town. The word for Hal Johnson is about 20 minutes. There's a lot more munity Hospital where he's a member Mod. traffic now than there used to be, and of the staff. Johnson and his five part- He swings in a medical and scien- the once vacant grasslands along the ners in group practice are members of tific sense because he works at it. He way are sprouting tract houses as a fast disappearing physician minority reads the right journals regularly- Sacramento reaches out for more bed- -the general practitioners. and learns from them. He makes the room space. Roseville, an historic Old This doesn't seem to bother John- time to get to two or three continuing West railhead, is being sucked into son. He takes pride in what he's doing. education seminars every year to keep the metropolis. There's no trace of the defensiveness up-to-date. You'll usually find him Since Hal Johnson began practicing you sometimes sense among GPs in draped across a chair at classes offered medicine for a living nine years ago, this age of increasing medical special- by the local hospital. SDC MAGAZINE 3 remarkable. Since July 1968, he has To capture the support of doctors the opportunity of making available to been helping set up a federally spon- like Hal Johnson, RMP has to be a their patients the latest advances in sored health program in Roseville. He special program. It is. It is the first the diagnosis of heart disease, cancer, believes it will benefit his own pa- federal health program to insist on stroke, and related illnesses." The tients and those of other Roseville grass-roots leadership in the decision- diseases selected were appropriate physicians. He fought to get it. It is making process. Regional advisory targets. As a group, they are our most being paid for under Public Law 89- councils call the shots, and the law is lethal killers, accounting for 71 of 239, passed in 1965 and amended last explicit that the councils be represent- every loo deaths in America. year by P.L. 90-574. Johnson, and thou- ative of all elements of the health com- The Commission study, now known sands of other physicians who have munity, including consumers. There's as the De Bakey Report, had called for had their thinking changed by this law, a great deal more about RMP that is the establishment of "centers of ex- call it Regional Medical Programs, or different from past government efforts, cellence" for the dissemination and simply, RMP. but first let's talk about how the law demonstration of new knowledge. came into being. This concept smacked of too much centralism for the medical profession CONGRESSIONAL to swallow and was finally scrapped RESPONSE by Congress in favor of "cooperative arrangements" among medical schools, Looked at historically, RMP is dollars- hospitals, medical associations and re- and-cents Congressional recognition lated elements of the health care sys- tem. Such cooperative arrangements that there is much more than short- ages of physicians, other health spe- are one of the most unusual RMP cialists and hospital beds to what features. Presidents Johnson and Nixon have Congress went even further toward called the health crisis. Shortages may allaying the fears of many physicians grab the most space in our news media, when it declared that RMP was to but leaders in the health sciences are accomplish its ends "without interfer- beginning to talk more and more ing with the patterns, or the methods about a breakdown in our system for of financing, of patient care or profes- delivering health care. sional practice, or with the adminis- This was essentially the message of tration of hospitals...." This guarantee, the President's Commission on Heart along with the local autonomy dele- Disease, Cancer and Stroke when it gated to individual regional advisory submitted its report in December 1964. councils, in large measure explains Chaired by famed Houston heart sur- why practicing physicians like Hal geon, Dr. Michael E. De Bakey, the Johnson have greeted RMP so warmly. Commission pointed with pride to the great strides made in medical research DOWN TO THE and then viewed with alarm the slow- GRASS ROOTS ness with which the results of this research were being made available Physicians have been joined in their to patients throughout the nation. enthusiasm by nurses, hospital admin- The following summer, Congress istrators, medical educators and repre- acted to improve the delivery of medi- sentatives of voluntary health organi- cal knowledge by passing the Heart, zations, to name the most prominent Cancer and Stroke Amendments to professionals whose membership is the Public Health Service Act. This required, along with that of physicians, created Regional Medical Programs on the advisory councils. Congress "to afford the medical profession and also made it clear that it expected to the medical institutions of the nation, see some average citizens among the through ... cooperative arrangements, council members. SDC MAGAZINE - 5 In drafting P.L. 89-239, the legisla- heart disease, cancer and stroke. The tors recognized two distinct but re- council makes its recommendations lated phases in getting RMP into busi- to the Surgeon General who author- ness-planning and operation. In, the izes DRMP to fund approved propos- first, the regional advisory council als. So far, none of our findings has draws on all the resources in its area been reversed, but recently some have to identify what is needed to deal been deferred because of a lack of with the problems related to heart funds." disease, cancer and stroke as they Perhaps the most important factor exist in its own region. in council deliberations is the quality Once needs are known, the council and durability of the voluntary cooper- must get down to the task of setting ative arrangements. Says Paul Ward, priorities among competing needs and coordinator of the California RMP, hammering out the cooperative arrange- "All operational proposals are based ments required to develop remedial on voluntary cooperative arrange- measures. This effort is supported by ments. It's the term we're stuck with. planning funds granted under the Law What does it mean? Simply plain old after approval of the National Advi- verbal agreements between given sory Council of the Division of Re- people to do given things, provided gional Medical Programs. DRMP is the they can get the resources from one capping agency that administers the place or another." Once plugged into RMP program for the Department of a grant proposal and approved, how- Health, Education and Welfare. Plan- DR. ALFRED M. POPMA ever, these verbal agreements take on ning grant approval hinges on accept- all the legal force of a formal contract. ance of the region's organizational The real decision on the timeliness In form, then, RMP goes well be- plan and method for proceeding. and acceptability of operational activi- yond encouraging local participation. At this point, the region is ready to ties lies with the division as expressed It demands it. Moreover, the tactic of enter the operational phase, which is by the recommendations of the Re- local control has been strengthened another way of saying it is ready to view Committee and the National Ad- through the philosophies of Drs. send in an initial grant proposal to visory Council on RMP. The latter is Robert Q. Marston and Stanley W. the Division of Regional Medical Pro- a body of distinguished medical prac- Olson, the two physicians who have grams. As required by the Law, DRMP titioners and administrators who re- served as directors of DRMP. (Mar- won't give out money for patient treat- view and make recommendations on ston moved up in 1968 to become ment except where such funds are to all regional proposals, again as re- the first administrator of the newly be used for "demonstration" purposes quired by law. created Health Services and Mental only, and not to set up permanent care Dr. Alfred M. Popma, a Boise, Idaho, Health Administration and subse- and treatment programs. There is also radiologist for more than a quarter- quently became director of the Na- no provision in the Law for money for century before turning his full time tional Institutes of Health.) Both have construction. attention to RMP, knows all the angles employed the division more along the Neither Congress nor the division in the review process. He is one of the lines of a flexible staff resource than has laid down any hard-and-fast time- 16 members of the National Advisory as a heavy-handed federal director table for moving from planning to Council, has served on the Review and enforcer. In keeping with this atti- operation. It hasn't been unusual for Committee and keeps his local per- tude, the Guidelines put out by DRMP the two to proceed concurrently. A spective sharpened as program direc- run but 32 pages. few RMP grantees-North Carolina, tor of the Mountain States RMP. Refuting the notion held by some Kansas and Missouri, for example- "At council review sessions, we are that RMP is the beginning of a na- had a long history of regional coopera- insisting more than ever on excel- tional blueprint for dictating stand- tion and planning and were able to lence," Popma says. "The successful ards of medical care, Dr. Olson has move quickly to full operational status. operational grant must reflect the kind said, "Even if we knew enough to Others have found it necessary to of solid region-wide planning that will draw such blueprints-which we do move more slowly. enhance and improve patient care in not-this method of procedure is so 6 SDC MAGAZINE there was an insistence on quality Active RMPs now blanket the Con- tors and allied health personnel has and compliance with the Law, an in- tinental United States and reach be- been in the direction of continuing sistence that left some funds unobli- yond to take in Alaska, Puerto Rico education courses. gated as indicated by the carry-overs. and Hawaii, the latter grant including In fact, Dr. Dwight Wilbur, immedi- However, the most recent carry-over Guam, American Samoa and Micro- ate past president 'of the American of $20 million from 1969 to 1970 was nesia. In land area, the regions range Medical Association and a staunch an administrative decision of HEW from Washington-Alaska to Washing- RMPsupporter,hassaid:"These [RMP] and not the result of a shortage of ton, D.C. California leads in popula- programs should be primarily educa- worthwhile projects, The fact remains tion with nearly 20 million; Northern tional, for the better educated physi- that at the end of FY 1969 (June 30) New England, headquartered in Ver- cians are, the higher the quality of there were some $25 million worth of mont, has but 425,000. All Americans medical care they can render.... Facili- approved but unfunded projects. now live within at least one RMP area. ties and financing are important, but In a March 1968 appearance before Because of regional overlapping, some of prime importance is the widespread the House Subcommittee on Public live in as many as three. availability of high quality medical Health and Welfare, Dr. Michael De Some states, like New York with care. The key to this is more and Bakey anticipated,this development. five and Ohio with four, have set up better education of practicing physi- "There have been times when I have multiple regions within their bounda- cians." Small wonder the regions been guilty of impatience," he ad- ries. The opposite has happened in maintain close relations with medical mitted, "but the fact is that this pro- the wide open spaces of the West colleges in their jurisdictions, or that gram has developed, I think, at a nor- where the Western Interstate Commis- operational grants to date have been mal pace and in a very sound way." sion for Higher Education administers notable for their innovative ap- He pointed out that the planning a program that takes in four states proaches to providing educational pro- phase of RMP had stressed the design, and overlaps portions of four others grams across a wide range of medical not the implementation, of health pro- that have their own RMP activities. and health specialties. grams. This resulted in smaller ex- California, in turn, is a single region Few, if any, would disagree alto- penditures than were projected in the but has organized itself into "areas" gether with Dr. Wilbur's support of beginning, but De Bakey emphasized defined by the medical service areas continuing education, but there are that regional planning efforts were of the state's eight medical schools. many who question that such pro- about to pay off in more expensive Of the 55 organizations that have grams should be the dominant theme operational programs that would re- fiscal responsibility for the programs, in RMP. Dr. H. Jack Geiger speaks for quire close to $300 million by 1971. 25 are medical colleges or university many of these when he argues that He further suggested that Congress medical centers. Seven others are uni- RMP should devote much greater at- "contemplate authorization levels of versities, while the remaining grants tention to the total health problems some $500 million" by 1973 to main- are split among 17 specially chartered of the urban and rural poor. tain standards and momentum in the foundations, commissions and associ- Now acting chairman of the depart- program. ations, four state medical societies, ment of preventive medicine at Tufts one advisory council and one state University School of Medicine, Dr. AN EMERGING PATTERN agency. Geiger holds that the categorical RMP Medical school involvement in RMP emphasis on heart disease, cancer and Through Fiscal Year 1969, the 55 re- is written into the Act, since the medi- stroke is too narrow and should be gions had received some $145 million cal colleges are at once a prime locus broadened to include not only all in both planning and operational of new knowledge through research disease problems that confront the grants. In part, this paid the freight and because of their tradition as a poor, but also such pressing extra- for the nearly 2500 paid staff mem- vehicle for disseminating such knowl- medical issues as poverty, discrimina- bers (47 percent physicians) in the edge through established extension tion, lack of education and unsanitary programs. It did not reflect the enor- teaching activities in their own medi- inner city and rural housing. mous volunteer efforts of the nearly cal service areas. From the outset Differences of opinion like these 10,000privateindividuals,professional Congress intended that RMP have don't intimidate Dr. Olson and his and lay, who man the regional and heavy educational emphasis, and it is staff at DRMP. They call theirs a liv- national advisory councils and serve something of an understatement to ing program in the sense that they on various subcommittees, task forces say that the most popular and well expect to see it change and grow as and local action groups. supported thrust of RMP among doc- conditions change and new health pri- SDC MAGAZINE orities emerge. They've already seen alone has more people than Albany, the categorical emphasis expanded Kansas and Intermountain combined. somewhat through greater attention While awards have been made for to kidney, respiratory, diabetic and projects in Los Angeles, Philadelphia, other diseases that fall under the "re- St. Louis and Baltimore, they have lated illnesses" portion of P.L. 90-574, been on a far less ambitious scale and they fought successfully to have than those for some of the more thinly dentistry included within the RMP opulated regions. p rubric. Not that there aren't some encour- Moreover, they have established aging urban programs. Watts-Willow- close liaison with social action agen- brook, a project to develop a post- cies both in HEW (Office of Economic graduate medical center to serve the Opportunity) and HUD (Model Cities) people of Central Los Angeles, is and have encouraged individual re- widely regarded as a possible proto- gions to forge cooperative arrange- type of future community health cen- ments with these and other programs ters in ghetto areas. The Tennessee/ wherever possible. (A subsequent sec- Mid-South RMP, combining the activi- tion in this issue touches on such ties of predominantly black Meharry interagency cooperation in Nashville, Medical School with those of tradi- Tennessee.) tionally white Vanderbilt University For all this, the program has experi- DR. STANLEY W. OLSON Medical School, is embarked on a pre- enced some disappointments. One of ventive medicine program that links the most persistent has been the slow- funds, social fragmentation, the diffi- multiphasic screening and an OEO- ness with which RMP has moved in culty of bringing together all the cul- sponsored Neighborhood Health Cen- some of our largest and most problem turally diverse groups that must be ter in a deteriorating section of North ridden urban areas. This has been ac- included in the planning process, im- Nashville. Similar programs are on centuated by the speed and success movable bureaucracies, indifference. the drawing boards in such regions as realized in rural and alpine regions. By and large, the rural regions have Illinois, New Jersey, Detroit, Washing- Much of the problem traces to hang- had to deal with a far less numerous ton and New York City. ups in getting RMP organized in the but more homogeneous population, a core cities where, among other prob- circumstance that goes far toward ac- A GLIMPSE AT lems, there is a plethora of health counting for their rapid progress in VVHAT'S GOING ON institutions, people and activities, all getting into operational status. Com- of which are essentially autonomous. parative operational grant histories The working draft of a directory pre- The division has made no effort to tell the story about as well as any- pared by DRMP at the end of Fiscal soft-pedal these difficulties in its testi- thing else. Year 1969 required nearly 240 pages mony before Congress or in its public Let's consider the Kansas RMP and to furnish biographical data on the 55 statements. Olson has said: "The com- the Intermountain Program based at regions and capsule descriptions of plex problems of our cities pose a Salt Lake City, Utah. These regions, the projects in the 41 regions that had national crisis of the gravest order.... both largely rural, have received grant achieved operational status. Most of We recognize that the complexities funds totaling some $3 million and the space was devoted to the latter involved in developing regionalization $7.3 million, respectively. Another task. in urban areas have delayed the de- fast-starting group, the Albany RMP Predictably, the individual projects velopment of regions in the very areas in upstate New York, has received differ as markedly in design as the re- where their services may be most almost $2.8 million. Together, these gions themselves differ in topography, needed. This is a matter to which I regions represent about eight million demography, and health manpower have already given a great deal of my people. and facilities. just as predictably, there time and to which I am prepared to On the other side of the coin, the are pronounced similarities, for gaps devote more of my personal efforts." latest DRMP directory of operational in the armamentarium for attacking Dr. Olson's "complexities" are the grants lists none for Chicago, Cleve- heart disease, cancer and stroke have same bugaboos that plague most pub- land, New York City or Pittsburgh. some characteristics that transcend re- lic programs in the cities-inadequate The New York Metropolitan RMP gional boundaries. SDC MAGAzrNE 9 For example, the best equipped and sicians, in turn, are eligible for coro- trained personnel are found in the nary care seminars right in their own TOWARD THE FUTURE major hospitals and university medi- local hospitals. cal centers, whether these are in rural These projects give some idea of Of the many issues that will face RMP or urban regions. Logically, then, these the style, if not the scope, of RMP in the 1970s, none is likely to remain institutions find themselves involved coronary care activities. There are still more visible than tfie health needs of in some way in nearly all educational, other innovations. Some of the regions the urban poor. Dr. Olson believes, training or demonstration projects have installed 24-hour telephone hook- "Regional Medical Programs can that have won approval for opera- ups that allow small hospitals to dial assist in the improvement of health tional funding. regional medical centers directly for service activities through projects that Commonly, RMP strategy has been electrocardiogram analysis and profes- supplement elements of both old and two-fold-to build on existing sional consultation. Another twist has new systems aimed specifically at the strengths wherever there is a strong been the development of coronary urban poor. local program and to extend knowl- care training programs in hospitals "True, we suffer from several con- edge outward from the medical centers other than teaching hospitals, an ap- straints as we attempt to deal with to the smaller community hospitals proach that is especially relevant to these problems. Facilities are needed, where specialists and sophisticated those medical personnel who live but we have no authority to use funds equipment are often nonexistent. No- great distances from the large training for construction of facilities. Neither where is this strategy better illustrated institutions. Whatever the approach, may grant funds be used to pay for than in the emphasis on coronary care the separate regional efforts share a the cost of medical services or hos- programs, an emphasis that threads common bond of helping the practic- pitalization. Nevertheless, there are its way through RMP activities from ing physician, the nurse and others to major contributions which Regional Hawaii to Florida, from sparsely improve their skills in behalf of cor- Medical Programs can make.... peopled Idaho to crowded New Jersey. onary patients. "Regional Medical Programs are In the Memphis region, the Univer- To Marc Musser, it is this recogni- functioning organizations specifically sity of Tennessee Medical Center tion of the needs of patients, as much designed to link the providers of care plans to install a 12-bed "showcase" as the recognition of the educational together for the purpose of collectively coronary care unit (CCU) that the needs of health professionals, that improving services to patients .... To medical staff will use to give training accounts for the RMP emphasis on do this, RMP must enter into coopera- and demonstrations to health profes- coronary care units. He says, "Coro- tive arrangements with the many local sionals from throughout the area. The nary care units represent increased and federal programs already address- Metropolitan Washington, D.C., RMP awareness of the acute problems of ing themselves to health problems of is literally putting its coronary care patients. RMP picked up the CCU the urban poor. program on wheels by designing a program at the right time, since it "The [RMPI programs can and mobile CCU that will rotate among combined our initial emphasis on con- should contribute significantly in plan- three hospitals in the area. The hos- tinuing education and the means to ning general health services for these pitals will provide their own nurses, effectively meet needs in patient care." populations, because it is only in this who will be specially trained, and phy- What holds for coronary care is no fashion that we can come to grips sicians will be drawn from the Heart less true of programs in cancer and specifically with the problems of heart Disease Control Program of HEW. stroke. Most of the regions have disease, cancer and stroke." Clearly, joint action by the Central Ohio moved solidly into these areas with the DRMP staff doesn't intend to Heart Association and the Ohio State tumor registries, tumor boards, stroke dodge its responsibilities in the cities. University College of Medicine char- management programs, and cancer Nor, if Dr. Olson is to be believed, acterizes coronary care training in the and stroke screening projects. With- will RMP diminish its emphasis on Ohio State RMP, a 61-county region out exception, the regional plans dem- continuing education. He is on record in the central and southern portions onstrate conscious attempts to mount as being convinced that continuing of the state. Nurses from hospitals in a balanced attack against all the education is one of the most signifi- 10 core cities come to Columbus for diseases identified in the legislation. cant single components of RMP activ- two weeks' intensive training that (The final segment of this issue in- ity. In years to come, however, the prepares them to return to their own cludes discussion of a cancer program division expects to promote more com- institutions as "nurse educators." Phy- being developed in Boise, Idaho.) prehensive and innovative approaches 10 SDC MAGAZINE designed to make health professionals rocal feedback. Within the separate active participants rather than -passive regions, most core staffs now include receptacles in the educational process. a professional public information In Olson's view there is no conflict officer. between the requirement for continu- It's important that he.do a good job, ing education and the need to do some- for as Marc Musser has said: "Most thing in the cities. In fact, he believes of the problems in RMP result from that RMP is flexible enough to accom- failure to communicate at the right modate the problems of the rural poor time, Leave someone out and things as well. Education and social action can get sticky. You might think that can coexist comfortably in Olson's busy doctors could care less, but that philosophy, because he regards them has been far from the rule so far in as essential to each other. RMP. Overlook them and they let you He sees continuing education in know about it in a hurry. urban areas as one sure way to achieve "Frankly, getting the commitment better care and treatment for disad- of local people is only the beginning. vantaged patients. In the same vein, Communications exchange must be he believes that cooperative health reciprocal. It must be continuous. A arrangements worked out by agencies lesson all of us around the country in the cities can be copied elsewhere have learned is that good communica- to benefit the rural poor. This outlook tions in a region don't just happen. again reflects the importance DRMP You must do a lot of work to make attaches to balanced programs. them happen. A good core staff is This emphasis is certain to grow EDWARD M. FRIEDLANDER essential." even stronger throughout the 55 re- This basic lesson hasn't been lost gions in coming years. The division- The object is to help the regions iden- on Ed Friedlander and his group at through its own staff, the National tify weaknesses and eliminate unpro- the division. Early in the game they Advisory Council, outside consultants ductive programs. It turns out to be a set in motion a systematic program of and the Review Committee-has tra- continuing responsibility. interregional meetings designed to ditionally insisted on excellence in draw together RMP staffs from the the operational proposals that come GETTING TO KNOW THE same geographical parts of the coun- before it for review. PUBLIC AND EACH OTHER try. Such gatherings serve several pur- In recent months, Dr. Olson has poses. They allow for briefings on strengthened this policy and called on Programs like RMP recognize that what is going on at the federal level in the regions to work harder than ever their success is almost totally depend- regard to budget and legislative policy. to improve the quality and regional ent on timely and accurate communi- They also serve as a platform for inter- significance of their requests. Perhaps cations to a wide and heterogeneous preting divisional guidelines and giv- the most effective means toward this set of audiences. There's Congress, ing the regions a chance to air their end will be the encouragement of the mass media, the general public, gripes about what the division is doing. more rigorous standards of review the medical schools, the professional That way everybody has a chance to and criticism among the regional ad- organizations, local governments, learn some of the basic facts together. visory councils when they evaluate state health agencies, voluntary asso- If the meetings accomplished no their own operational proposals. ciations, and on and on and on. more than this, chances are both Dr. The quest for excellence doesn't At another but equally important Olson and Friedlander would consider stop there. Today there is also more level, there is the requirement for them worthwhile. There's another attention than ever to the problem of open communications between the angle, however, that may prove even project evaluation. All proposals must division and the regions and among more useful to the regions in the long include formal mechanisms for peri- the regions themselves. Under DRMP run. Friedlander and his people are odic evaluation, and the division has Assistant Director, Edward M. Fried- using their get-togethers with the re- invested a great deal of eff ort in de- lander, the division has worked out a gions to encourage permanent chan- veloping sensitive tools for this task. program to produce maximum recip- nels by which the regions can corn- SDC MAGAZINE municate regularly with each other, moving from a circumstance where ties are clamoring to get into RMP." separately and as groups. there has been a surplus of funds-at Speaking to the same point, Califor- DRMP is convinced-as are many times an embarrassing surplus-to nia's Ward said, "I suppose that at the of the regions-that there is a many- one in which the reverse will be the present time you can say that the pro- fold pay-off in this kind of activity. case. Looking at applications already gram is at its most critical stage. Years For one thing, a frank exchange of in hand, we can predict that the aggre- of planning are coming to a head, and data on operational program successes gate demand for grant funds will ex- the projects are rolling in. Now if you and failures can help the respective ceed our appropriations in the Fiscal don't get the money in a reasonable regions avoid expensive false starts. Year 1970. Beyond that, the amounts time, the people who made the co- For another, it can provide late-start- that the Review Committee and the operative arrangements move away ing regions with helpful tips on how National Advisory Council will likely or change their minds, and you have to secure the enthusiasm of their own recommend for approval from yet-to- to try to put it all together again. Well, people and how to initiate the plan- be-received applications will also ex- that's very wasteful. ning process. Of increasing importance, ceed available funds." "Understand me, it's not hard to it can also help iron out jurisdictional Because RMP didn't spend all the sell Congress on RMP. They were problems or stimulate cooperative ar- money Congress made available to it always willing to authorize just about rangements among regions whose pro- in the first four years, some of the as much as the program could use, be- grams overlap each other. lawmakers have been dubious about cause their opinion of us was always At a February 1969 meeting in whether program requests do in fact high. The only thing Congress has had Tampa, Florida, the coordinators and represent a reasonable estimate of against us is that in the beginning we other staff of the 15 regions that make need. Although final Congressional asked for too much-more than we up the Southeastern Region furnished appropriations for RMP grants are yet could realistically use. That is the proof that interregional cooperation to be voted, this dubiousness, com- problem." and exchange are gaining in apprecia- bined with Administrative and Con- Ward feels much the same as Dr. tion. Spurred by Marc Musser and Dr. gressional belt-tightening, resulted in De Bakey did when he testified last J. Gordon Barrow who directs the a House Appropriations Committee year before the House-that the pro- Georgia RMP, the Southeastern group recommendation of $50 million in gram must continue to grow and ex- voted to share the cost of an inter- grants for FY 1970. This is $24 million pand. Characterizing RMP as a means regional coordinator whose task less than the Administration asked for distributing medical knowledge, would be to "ride circuit" among the for and $70 million below what was Ward draws an analogy from the regions and keep everyone apprised authorized by legislation. business world: "You know, General of what his neighbors are doing. The Many in RMP regard this as a body Motors would never think of develop- new man has already been on the job blow to the future health of the pro- ing a new automobile and then not for several months. gram. Both Marc Musser and Paul spend some of their resources on cam- Ward serve on the Coordinators'Steer- paigns to get it in the hands of cus- BUDGET OUTLOOK ing Committee, a group of 10 coordi- tomers. The same is true today in nators elected by their fellows to ad- medicine. You might just as well for- The fact that the regions are now vise DRMP on national policy and get the research unless you are willing ready to look beyond their own imme- programs. Ward and Musser think to devote some money to distribution. diate interests is an indication that present funding projections are far "That's what RMP is all about, and the four-year-old RMP is coming of from adequate. if we are talking $100 million as a age. Further proof-if any is really Musser calls the budget outlook plateau for all time, we are engaged in needed-lies in the rate at which pro- unpromising. He warns that some the wrong kind of planning. You've grams are moving out of planning into programs may have to cut back and got to preserve your momentum and operational status. It is at this point that the fiscal situation will almost the faith that people have manifested that RMP requires much higher levels certainly discourage new starts. "On in the future of the program. Other- of financial support. The program is the whole," he says, "this is occurring wise the voluntary contributions and already feelinc, a pinch. with the worst possible timing, since local participation will largely be lost. Says Dr. Olson: "Clearly, we are so many new localities and communi- That is what would really hurt." 12 - SDC MAGAZINE Contrast, Cooperation and Quality About 120 miles east of Memphis the Tennessee River wheels north and rolls past Wayne, Perry, Humphrey, Houston and Stewart Counties. The Tennessee/ Mid-South RMP begins along the river's east bank and stretches some 400 miles farther east to the Virginia line. It takes in 74 counties in Tennessee and a cluster of 14 more in southwestern Kentucky. That's room enough for a lot of contrast. The 3600 residents of rural Van Buren County follow a life- style that has its roots in the cotton and tobacco culture of the antebellum South. Over in urban Davidson County, some 400,000 Tennesseeans are setting a pace that's about as hectic as you'll find in any other metropolitan section of the nation. Altogether, RMP is planning or providing services for some 2.75 million citizens in the region. Tennessee/ Mid-South activities hub around Nashville, probably less famous now as the educational and cultural "Athens of the South" than as the home of the Grand Ole 0pry and a burgeoning country and western recording industry. Nashville's importance to RMP, however, stems from the presence of seven large hospitals and Vanderbilt and Meharry medical schools. Both schools are committed to the success of RMP. Vanderbilt administers the RMP grant, and faculty from both institutions have been generous in volunteering assistance to the program. The same goes for most of the hospita';s throughout the region and f6r such seats of higher learning as Fisk, George Peabody, Tennessee State and the University of Tennessee. Tennessee/ Mid-South went into business on November 1, 1966, and began operational activities 15 months later. There are now 28 active operational projects, with another four approved but not yet funded. The annual budget comes to about one dollar for every resident of the region. Much of the emphasis is on training programs that give physicians and hospital personnel a chance to improve and expand their skills in the detection, diagnosis and treatment of heart disease, cancer and stroke. The programs have generally started with existing strengths and built from there-more often than not with imagination and a willingness to dare something new. SDC MAGAZINE - 13 NEIGHBORHOOD HEALTH CENTER They call it North Nashville. Like other inner city neigh- borhoods in other American cities, it traces a jagged poverty scar through broken streets where half the dwellings are either deteriorating or dilapidated. Thirty thousand people live here. Of the adults over 25 years of age, only one in three has made it past the eighth grade. Three of every five families have annual incomes of less than $3000, and women head half the house- holds. Negroes make up 80 percent of the population. Across the country, RMP has had trouble getting started A major aim of the project is to learn how screening in places like North Nashville. But health officials here services, combined with treatment services at the think they have come up with an approach to assure neighborhood health center, affect levels of health in delivery of quality health services to Nashville's urban the area. This will be tested over a 10-year period by poor. The plan revolves around interagency cooperation Testing for visual acuity clinicians on the project and by social scientists from between RMP and a new OEO-sponsored neighborhood and visual field, the Center for Community Studies at George Peabody health center that is one of the first to be constructed College. in the South. The clinical program will utilize 21 screening stations The center, which began in a run-down store on Jefferson to provide such services as electrocardiography, visual Street, will soon move into brand new quarters. Super- acuity testing, spirometry, blood pressure, cervical vised by faculty and staff from Meharry Medical College, cytology and a battery of 27 blood tests. Hours will b it will offer comprehensive care and treatment with from 1 p.m. till 9 p.m. to make it easier for those wh emphasis on the dignity of the patient. It will also be have to work every day, and the patient will spend from closely tied to another Meharry project, sponsored one to three hours on his visit to the lab. through RMP and aimed at bettering the health lot of the disadvantaged, not only in North Nashville, but in the The screening sequence will be automated in an effor rest of the city as well. to conserve time for the attending physicians and mak test results available as soon as possible. Much of th Called the multiphasic screening laboratory, and cen- work will be carried on by nurses and technicians, with tered in Lyttle Hall across from Hubbard Hospital on the many of the latter trained and qualified as part of a Meharry campus, this operational RMP project will offer educational emphasis in the program. To be eligible fo the latest advances in the detection of heart disease, screening, patients must be referred by a private ph cancer and stroke and other disorders that may lead to sician, a public agency or the neighborhood healt those illnesses. center. The goal is about 25,000 examinations annuall 14 - SI)C MAGAZINE Surgeon Frank A. Perry of Meharry is project di- rector of the multiphasic screening program. His view: "We will be able to apply preventive meas- ures on a continuing basis as opposed to the episodic care that is now the rule in this area. We have good people. We're excited about our future." At the blood pressure sta- tion, determinations are made on both arms. SDC MAGAZINE 15 Williamson County Hospital is just outside Franklin, a rural community of 10,000 on the L&N railroad 17 miles south of Nashville. Last year the 100-bed hospital ad- mitted 4128 patients from its medical service area of 30,000 people. About one of every 15 admissions was a cardiac patient, 22 of whom died. Physicians and nurses at Williamson are working to lower that figure through a cooperative RMP arrangement with Vanderbilt Medical School's coronary care center. The project, under the direction of Dr. Noel Hunt of Vanderbilt and Dr. Robert Hollister of Franklin, is an effort to find out if a small community hospital can and should maintain a coronary care unit. Williamson has set up a 2-bed unit and designed a 33-hour course to prepare its staff for handling the coronary patient. It also sent nurse Martha Miller through the rigorous coronary nursing program at Baptist Hospital in Nashville. Through a dual monitoring system, patients at Williamson can also be monitored b the nursing and professional staff at Vanderbilt. Moreover, there is a 24-hour oat phone hookup to pass vital patient data between attending staff at the two institution This arrangement allows any of the nurses or 10 physicians on the Williamson sta to have immediate access to faculty cardiologists and highly trained cardiac nurse at the medical school. Patients, the people for whom all this is being done, have already benefitted. Williamson administrator Cliff Gardner credits the program with saving seven cardiac patients in its first seven months of operation. 18 - SDC MAGAZINE r, I I m SDC MAGAZINE - 19 The dual monitorin tem allows Vand physicians and n to follow the identic tient signs display the nurse's station i liamson County Ho 20 SDC MAGAZINE In an emergency, cardiac nurse Martha Miller of Williamson has nurses Bonnie Land and Jeanine Jolly and the full re- sources of Vanderbilt's coronary care center right at her fingertips. SDC MAGAZINE - 21 Many of the RNs in the coronary care unit' at Nashville's Baptist Hospi- tal have completed that institution's widely re- spected 8-week training program in coronary nurs- ing and have received their treasured Cardiac Nurse Specialist pins. Most of them now teach alongside the 25 hospital staff members responsi- ble for the curriculum in the program. Given three times a year, the course is restricted to 30 stu- dents drawn mainly from the region, but also from as far away as the West Baptist Hospital is a 625-bed general facility with teaching programs for interns and residents and a professional Coast. As RMP develops, that is more than 90 percent specialist. Its coronary care unit, established in 1964, was the first in Tennessee and Baptist will be the pri- several surrounding states. Today, it plays a central role in cardiac nurse training and patient consultation progr mary resource for coro- carried out through cooperative arrangements with RMP and several small community hospitals in distant to nary nurse training. The intensive care pavilion at Baptist accommodates eight patients, while an adjoining 14-bed progressive care ion is reserved for those who, in their physicians' judgment, require less intensive supervision. The coronary care unit will also perform a major advisory and consultative role in the Tennessee/ Mid-South coro care network, a hookup that will tie 11 small hospitals to coronary care centers at Vanderbilt and Baptist. Baptis already linked to 2-bed units at Crossville and Tullahoma, with Manchester slated to join the net soon. 22 SDC MAGAZINE A Case Study in Grass-Roots Planning Al Popma and his wife, Dorothy, were born in Orange City, a throughout most of the western states. As a WICHE commis- little farming town at the northwestern tip of Iowa. Both are sioner, Al helped draft the planning grant application that from Dutch stock as are most of the people who live around established the RMP program he now directs. Orange City. They came to Boise, Idaho, in 1938 when Al was He has strong convictions about RMP. "I came into this pro- a young doctor about to begin the practice of radiology. He gram," he says, "because it is perhaps the first program with kept at it until 1966 when he "retired" to take a full-time post federal dollars in it that has some local autonomy. For the first as program director of the Mountain States RMP. time we feel that we have an opportunity to produce projects By that time Al had become one of the best known and most without regard to state boundaries. This is truly a first in fed- respected radiologists in his part of the country and a familiar eral health programs. We are also discovering that through figure in medical circles at the state and national levels. He is RMP, and again for the first time, we can develop autonomous a past president of the Idaho Medical Association, and when projects ... that people at the grassroots can make determina- the American Cancer Society was reorganized in 1945, he was tions about their own future in health care." one of the original board members. He later served as national These advantages share prominence with what Popma sees president of the society. as RMP's greatest long-range contribution-the encourage- From 1953 until 1966 he was a commissioner of the Western ment of permanent continuing education programs that benefit Interstate Commission for Higher Education (WICHE), the the patient by helping physicians, nurses and other health pro- organization that administers the Mountain States RMP and fessionals improve their skills. He discusses this and other is involved in the total spectrum of educational planning RMP issues in the following pages. SDC MAGAZINE - 23 Al Popma has long been concerned about the lack of formal coordination among them and quite often there was duplica- continuing education programs for doctors, nurses and other tion of course content and expenditures." health professionals who practice in Idaho, Montana, Nevada This was the situation as Popma remembers it in 1965 when and Wyoming, the four states that together compose the Congress passed P.L. 89-239 and launched RMP. From the Mountain States RMP. In his 13 years as a WICHE commis- outset, he and other WICHE members were determined to sioner, he became convinced that one of the region's greatest include Idaho, Montana, Nevada and Wyo'ming in the new needs was for some permanent mechanism to create and sus- program. The first order of business was to sit down and put tain such education and training eff orts. together an application for an RMP planning grant. "WICHE undertook a @mber of studies to assess health "This was drafted by the advisory council, working with training requirements in the four state region," he recalls. "A Dr. Kevin Bunnell, associate director of WICHE," Popma number of years ago, for example, we made a study of health recollects. "To assist in the effort, the council recruited three manpower needs and came out with very accurate predictions distinguished practicing physicians from the region-Dr. of the demand for health personnel, particularly physicians, Frank McPhail from Montana, Dr. Francis Barrett of Wyoming over the next couple of decades. and Dr. Fred Anderson from Nevada. All were WICHE "And following the lead of the Faulkner Study on the need commissioners." for medical schools,in this region, WICHE set up an advisory The group got the job done, producing an application that council on medical education facilities. I became chairman of was approved by the Division of Regional Medical Programs. the council, and it was largely through its work that WICHE Mountain States RMP, with Al Popma as program director, grew interested in the legislative hearings that led up to the began its life in November 1966. It was-and still is-the only establishment of RMP. In fact, the council went to Washington RMP region without at least one medical school, a circum- to testify before the House committee that eventually wrote stance that some had thought would make the area ineligible the RMP law." for RMP funding. Popma and other council members felt at the time that a In Popma's view, the absence of medical schools is the grass-roots program such as RMP would provide the spark for major reason there has been a lack of coordination and con- permanent educational activities in the four state area. "We tinuity in continuing education activities in the four states. were in agreement," Popma says, "that although we had a Not having medical schools also created a set of organizational myriad of continuing education courses most were on a hit- problems for the fledgling Mountain States program. and-run basis. "One of the first things we had to do to meet the require- "Nothing was formally organized, and the professions de- ments of the Law," Popma says, "was to organize a regional pended almost entirely on volunteer agencies-the Heart As- advisory group. To satisfy the requirement for medical school sociation, the Cancer Society, the medical associations, the representation we had to go outside our boundaries. Logically, nursing societies and so on. To put it another way, the profes- we went to medical colleges in surrounding areas to take ad- sional groups themselves were entirely responsible for sustain- vantage of traditional relationships to practicing physicians ing continuing education in the four states. There was little in our region. 24 SDC MAGAZINE "We invited representatives from the schools in Washington and Oregon and chose Paul Ward to represent the several California institutions. For representation on our southern border, we turned to the new schools in Arizona and New Mexico. Since our physicians have always had strong ties to the Universities of Utah and Colorado, we added members from both medical schools. Then we went a little farther away and took in representatives from the medical college at the University of Minnesota, the medical schools in North and South Dakota, and from Creighton University in Omaha." Once medical school representation was settled, Mountain States asked for recommendations from each of its four states to round out advisory council membership. Seventeen addi- tional people were added, including three Indian members who speak for the major minority group in the region. With its ,advisory group selected, the program was ready to turn to other matters. Looking back, Popma recalls that no one in the sprawling region had accurate information on what medical facilities were available or what the training and educational needs of health professionals were. "We recognized that we had to assess these needs," he says, "and we decided to ask the people at the grass-roots level to tell us what they had to have. With this information, we could then attempt to design ade- quate programs." After examining several alternatives, RMP and WICHE staff members decided that the best approach was a field survey using direct mail questionnaires. "There was one problem, though," Popma remembers. "Never having devised such ques- tionnaires or formulated computer programs for this kind of John Gerdes is one of those qualified data analysis, we came to the conclusion very quickly that we people who are in such short supply in required some rather sophisticated assistance. And so we health programs across the country. made an arrangement with System Development Corporation He was on the faculty of the School to provide us the necessary know-how." of Public Health at the University of Even while the agreement was in negotiation, the program Pittsburgh but came West because he was having to face up to the task of creating a regional organ- preferred the clean air and outdoor ization that could carry out the survey work and become the life. permanent staff resource for long-range planning and oper- Al Popma says Gerdes is "one of the ational activities. top-notch young men anywhere in the "We decided to set up an office in each state and were country when it comes to developing fortunate enough to secure four outstanding practicing phy- the kind of community supported sicians to serve as state directors," Popma notes. "Although health programs required in RMP." there have been changes, we retain excellent state leadership Among other projects, Gerdes has in Drs. Sidney Pratt of Great Falls, Montana, Dr. Claude been prominent in planning an inhala- Grizzle of Cheyenne, Wyoming, David Barton of Boise, Idaho, tion therapy training program for the and Lorne Phillips of Reno and Las Vegas, Nevada. The open- region. ing of our regional office in Boise was the final touch to give "It began in the fall of 1968 at a a true regional flavor to the whole program." meeting in Las Vegas where we were Of course, it wasn't quite as simple as it reads today, some trying to compile a list of physicians three years later. Says Popma, "Compared to other programs, who might be interested in undertak- we had kind of a rough time getting going. Most of the others ing such a program," Gerdes says. "Dr. emanated from medical schools where there were trained Richard Browning, a Las Vegas intern- people to write applications and get the program rolling. ist, had already gotten one under way "We had to start from scratch. We had absolutely nothing. for the state of Nevada, and our state We had to rent office space here in Boise and in each of the directors were anxious to find a way states, and we had to recruit qualified people. To be frank, there's a critical shortage of manpower to do this kind of job. 26 - SDC MAGAZINE to extend it to other parts of the region. "We already knew of another inha- lation therapy training program just 25 miles from our regional office at Caldwell Memorial Hospital, Idaho. It was being run by Charles Reed, a 31-year-old internist, as part of.a two- year program at nearby Treasure Val- ley junior College." Gerdes asked Reed and Browning if they would be willing to expand their programs to include shorter-term training for personnel of hospitals in the region. Both were receptive, and they sat down together' to design a curriculum and draft a grant proposal to set up complementary inhalation therapy training institutes at Caldwell and at the Southern Nevada Memorial Hospital, Las Vegas. The request is pending before DRMP. "The exciting thing about this pro- gram," says Gerdes, "is that two com- munity physicians, in communities 1000 miles apart, are working in con- cert on a common project with a real regional emphasis and outlook. Even- tually, if we can interest other phy- sicians like Drs. Reed and Browning in becoming instructors, we hope to make this curriculum available to hos- pitals throughout the four states. Gerdes points out that up to now Dr. Reed's program has been aimed at students going for a junior college AA degree or expecting to transfer to a four-year school. The Mountain States emphasis, predictably, will be on mak- ing the training available to hospital personnel or others who have the apti- tude to become inhalation technicians. Says Gerdes: "Typical enrollees will come from small community hospitals. They may be RNs, but we hope also to attract students who, while they have no special medical training, do have the aptitude to learn the material. Our theory is that we can upgrade the skills not only of RNs, but also of licensed practical nurses, nurse's For patients with heart and respiratory diseases, inhalation therapy can afford aides and others with the ability and short-term relief and be a significant factor toward recovery. The inhalation desire to acquire this training. This is therapist also comes into play in such emergency situations as cardiac arrest or consistent with the Mountain States serious chest injury. The latter is simulated here by students and faculty of the philosophy of training its own." Caldwell Memorial Hospital Inhalation Therapy Training Program. SDC MAGAZINE 27 And since we were highly geared toward field research and obtaining information,. we had to find people who thought along these lines." Eventually the offices did -get set up and staffed, at which point Mountain States was ready to sit down with SDC's Health and Environmental Systems Department to develop the series of questionnaires that eventually would go to nearly all health personnel in the four states. "Our survey universe included physicians, dentists, regis- tered nurses, licensed practical nurses, hospital administrators, X-ray and lab technologists, physical therapists.... I think there were eight categories we wanted to reach," Popma says. Deciding just how to reach these groups required that the Boise staff meet regularly with state offices and representa- tives from SDC to work out questionnaire logic and wording. "It took a lot of time and a lot of wheel spinning to come up with the proper questions," Popma recalls. "Some of our people had never done this, and you can imagine that there were problems. Often there was quibbling or quarreling over the correctness of a single word." When the rough spots were ironed out to the point that everyone could live with the results, the questionnaires were printed and mailed to 100 percent of all health personnel except RNs and licensed practical nurses. These populations were large enough to require use of a random sampling procedure. "Across the region we had better than a 50 percent return," Popma says with satisfaction. "The data were keypunched and put on the SDC computer in Santa Monica. So far, we have run two analyses on this file, and the results have helped us in devising certain operational activities. After all, provid- ing data for operational programs was the purpose and func- tion of the questionnaires." At the same time the health professional survey was in progress, Popma's staff was also busy collecting information on health facilities in the region. To get an accurate line on such things as the number of hospital beds, the number and location of nursing homes, and the adequacy of transportation services, the staff designed what it now calls its Health Profiles. "These focus down to county levels," Popma explains, "and enable us to tell what the health facilities needs are in indi- vidual communities. I should mention that SDC didn't assist on this effort. We devised it almost completely on our own. Naturally there were times when SDC looked at what we were doing and made suggestions, but the work was almost all ours." However, SDC did have a lot to do with a third data gather- ing effort aimed at consumers of health services. This survey 28 - SDC MAGAZINE is perhaps unique to date in RMP. "As far as I know," Popma nearby large medical center with facilities to care for him. So says, "ours is the only RMP'that has made a systematic broad- these people die at home. scale effort to find out what kind 'of health services the ordi- "We recognized that if we were going to be able to take care nary citizen wants to have available for patients with heart of such patients we had to help establish facilities and train disease, cancer, stroke and the related diseases. people in small hospitals," Popma explains. 'Our philosophy "This questionnaire, which we call the Survey of Consumers, is that if a coronary care unit is good for patients in the Los went out to 10,000 people in the four states," Popma recaps. Angeles metropolitan area, it is also good for those in Shelby, "We drew our random sample from telephone directories and Montana. If we accepted the tenet that a hospital has to have from a list maintained by fhe Department of Agriculture that 300 beds before a coronary care unit is financially feasible, we shows families without telephone service. Again, our rate of wouldn't have any coronary care programs." return was over 50 percent." Believing this, Popma and his associates sat down and de- All told, the Mountain States RMP now has three large files vised a prototype program to prepare both physicians and of information-health professionals, health facilities and con- nurses to provide coronary care in the small hospital. On sumers, "This planning data base took almost two years to March 1, 1968, thanks in large measure to the leadership of assemble," Popma sighs, "but when it is all put together it Montana physician, Frank McPhail, Mountain States opened gives us a sound basis for developing operational projects. its first coronary training center at St. Patrick's Hospital, Both the professional and consumer files are stored on the Missoula, Montana. The project draws on cooperative arrange- computer in Santa Monica." ments among the hospital, RMP, the University of Mont-ana Part of the agreement between Mountain States and SDC and the University of Washington Medical School which was that there would be someone from the Health Systems furnishes consultants. About 120 people went through the Department full time in Boise. Speaking of the arrangement, course in its first 16 months. Popma says, "we had Bob Mendenhall who did a very excel- "A second interesting operational program we have going lent job for us. He is one of the finest people we ever worked aims at providing the latest training in cancer diagnosis and with. No job was too great, and there was never any question treatment," Popma notes. "There is something for physicians of hours. If it took till midnight, Bob would be there to do it. and for both the practicing and student nurse. Practicing "I was very interested in Bob. Our kind of program was nurses will have a chance to come to the Mountain States something new for him since it was the first time he had been Tumor Institute that we are developing in association with with a program that fundamentally and physically was at- St. Luke's Hospital in Boise. Here they can study and learn tached to the practice of medicine, Naturally, there was a lot the latest techniques in cancer nursing. he didn't know, but he learned very well and quickly and "Undergraduate nurses who matriculate at the four bacca- blended in with no difficulty. Bob gave us a tremendous laureate nursing schools in the region will have a chance to amount of help, and I was sorry when the contract was up enter the same program on an elective basis. Since none of the and he had to leave for a job elsewhere." schools has facilities for this kind of training, the opportunity (Mendenhall is now project leader for SDC on a study to to attend the institute should provide a new dimension in assess health care requirements for residents of the rural baccalaureate nursing programs." Upper Kennebec Valley in the state of Maine, The corporation Like RMP administrators in other regions, Al Popma has retains its ties with Mountain States RMP, however, through given a lot of thought to what it takes not only to get a pro- a formal consulting agreement.) gram started, but also to keep it moving over the long haul. Popma is quick to point out that not all the effort in Moun- "In my judgment," he says, "the first thing that has to be done tain States has been taken up with the surveys. The program is to sell the practicing physicians and the medical societies. has five operational programs under way, another approved You need more than their interest; you have got to have their. by DRMP and four more pending DRMP review and approval. participation. This also holds true for nurses, hospital admin- "We did a small study in Montana to assess the needs in istrators and other professionals." coronary care," Popma says, "and we learned that 85 percent Reactions to RMP have varied among physicians in the four of people having heart attacks die at home. Now Montana is a state area. At the outset, there was a lot of fear and suspicion rural area with many small hospitals of from 15 to 50 beds, in some communities. "We tried to convince everyone that meaning that the coronary patient can't be transported to a RMP was their program and was under their control," Popma SDC MAGAZINE 9