NATIONAL ASSOCIATION OF REGIONAL MEDICAL PROGRAMS, INC. Sol In MEETING HIGHLIGHTS September 1975 INTRODUCTION The Primary Purpose of the National Association of Regional Medical Programs is to pro- vide information and educational opportunities in areas of pertinence to the members. The format of the assembly in San Diego was, therefore, designed to provide a spectrum of informational interchanges related to the theme of the development of a health system for the community. The program began with current perspectives regarding the National Health Planning and Resources Development Act of 1974 (P. L. 93-641) as viewed from state government, the federal administration, health care and institutional professionals. It proceeded to the presentations and discussions of successful programs in high priority areas such as access, manpower, regionalization, quality assurance, and implementation and regulation concern- ing current legislation, There were special programs on health cultural awareness, RMPs in transition, hypertension, and technical assistance centers. The conference culminated with provocative presentations and discussion of implementations for the future. Many individuals, both NARMP members and non-members, prepared materials and made important presentations to the assembly and we are most grateful for their very significant contributions. However, the real measure of success of any such program relates to the worth placed upon it by all participants. The members of the Program Committee endeav- ored to design the conference so that there would be much of value, both in information exchanged and in thought provoking stimuli. We sincerely hope that there was reasonable attainment of this objective. J. S. REINSCHMIDT, M.D. Chairman, NARMP Program Committee rv I I RI I The atmosphere of high resolve to overcome problems posed by Public Law 93-641, present at the opening of the second annual meeting of the National Association of Regional Medical Programs, persisted to the very end of the three-day session --- with one change. At the end, resolve was coupled with a clear picture of what must be done to make the law work, the result of con- centrated attention to an explanation of the law's anticipated impact on the health care delivery system. FIRST PLENARY SESSION The meeting, particularly in the two plenary sessions, provided a forum for expression of opinions and concerns. To the first session came representatives of government, practicing physicians, hospital administrators, medical schools and other health interests. Few faulted the law's basic concept-access to quality health care for all at reasonable cost. The concern was with the way the law proposed to achieve this, the Health Systems Agency 2 organization mechanism, its operation, impact on various segments of the health care de- livery system, accountability and responsibility both as to location and geographic scope. STATE GOVERNMENT Robert D. Ray, Governor of Iowa and Chairman of the National Conference of Governors, reminded the assembly that the mid-western governors at their recent conference voted to have P.L. 93-641 repealed in its entirety. The conference's main objection was to removing health planning from "public officials affected by, accountable and responsible to the people that elect them." Among suggestions for improving the law were provisions for complete care capability in each health service area, relaxation of population limits, permitting gov- ernors of rural states with few HSAs to name a reasonable percentage of HSA board mem- bers in place of appointing a state coordinating body, and more emphasis on quality of HSA board membership and less on categorical representation. FEDERAL GOVERNMENT Kenneth Endicott, M.D., Director of the Health Resources Administration, voicing need for rapid communication during transition, announced formation of an RMP multi-regional coordinators group to act as a special liaison committee between RMPs and the Depart- ment of Health, Education and Welfare. Relating to Dr. Endicott through Dr. Margulies, the committee is to function in an advisory capacity, identifying, collating and classifying problems and issues. Harold Margulies, M.D., former Director of the Division of Regional Medical Programs, now Deputy Director of the Health Resources Administration, said more attention should be paid to what will work than to the precise wording of the law. Cautioning against erosion of expectations such as has occured in the past, he pleaded for their reduction so that the law has a fair chance to work. He predicted HSA funding will be low and urged preserva- tion of successful RMP projects through outside funding rather than hope forlornly for continuation through HSAS. Eugene Rubel, Acting Director, Bureau of Health Planning and Resources Development, stated that the primary concern of HEW with regard to the new HSAs is the "caliber of governing board members and the staff." He granted that technical changes in the law were needed but added that changes could not be expected until after the law is imple- mented and a number of HSAs established. 3 PHYSICIAN IN PRIVATE PRACTICE Joseph F. Boyle, M.D., in private practice in Los Angeles, American Medical Association trustee and speaker of the California Medical Association house of delegates, attributed lack of success in past community health planning partially to provider non-participation, and made a strong plea for providers to avoid repetition of this past mistake. "it is ra- tional that those who have the experience and educational background participate as fully as possible. It is also equally sensible that the people for whom this care is being planned ... participate so that they receive what they perceive as an answer to their needs and not an answer to the needs as perceived by someone who may never have been there themselves." Referring to the greater federal expectations from the new law to be achieved seemingly with lower funding, Boyle warned of an apparent "impossible task" for the community to undertake. He urged best efforts to make the law work because "if you fail in an im- possible task, we may have to write some other kind of legislation to take care of it again in the future." HOSPITAL ADMINISTRATION Stephen M. Morris, past president of the American Hospital Association and President of Samaritan Health Service, Phoenix, Arizona, reiterated the almost universal concern over the discretionary power vested in HEW and the shift in health care planning from the local to the state and federal arena. He added that "federal leadership and direction are neces- sary to solve the health service problems that we face, and the regulation that follows is inevitable. We in the profession have a duty to make sure that this regulation is a good regulation and that it does what it is designed to do." He foresaw, as a rational development, the possibility of dividing the HSA planning and regulatory functions with regard to hospitals, with a consortium of hospitals doing coop- erative planning. MEDICAL SCHOOLS Donald Brayton, M.D., medical director, Kern Medical Center, Bakersfield, California, spelled out an extensive list of recommendations from the Association of American Medi- cal Colleges for inclusion in the federal guidelines. These recommendations dealt with the certificate of need process and federal use of funds, which he described as areas of primary concern to medical schools. The guidelines include requirements for consideration of edu- cational goals of teaching institutions in the conduct of HSA review, criteria development, timeliness of review, project renewal and continuation. "There could be no doubt but that P.L. 93-641 is possibly the most intricate piece of leg- 4 islation ever developed. It's guidelines and recommendations must of necessity be intri- cate. Our exchanges here will perhaps lead to more workable regulations and thereby may ultimately enhance the law's effectiveness." SECOND PLENARY SESSION- The second of the plenary sessions dealt mainly with in-house matters, with emphasis on the future of successful RMP projects and future leadership in health matters. Nathaniel Polster, NARMP Washington representative, expressed belief that if RMPs would focus on programs of Congressional priority and demonstrate effectiveness they would not only be likely to find funds for continuation of successful RMP projects but also would es- tablish the kind of impressive record that results in leadership in re-writing P.L. 93-641 when the time comes. Paul D. Ward, Executive Director of the California Regional Medical Program stated his be- lief that we may be at the low end of the Congressional funding curve for health now and must be ready to provide leadership when the upturn occurs. He urged RMPS, as the only group which understands the needs of consumers and providers and which demonstrates a comprehensive approach to health care, to continue the information flow to the legislative and administrative branches of federal government, to see that health dollars get appropri- ate priority, to use the multi-regional liaison committee to look for opportunities to provide information for appropriations committee hearings, to develop public accountability re- ports so that they are useful at the congressional and HEW levels and to work together to develop a stance regarding extension legislation. PLENARY AND LUNCHEON SPEAKERS P. L. 93-641 As Viewed by a Governor The Honorable Robert D. Ray, Governor of Iowa and Chairman, National Conference of Governors, State Capitol, Des Moines, Iowa 50319 P.L. 93-641 - Expectations of the Federal Administration Kenneth Endicott, M.D., Director, Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852 P. L. 93-641 - As Seen by a Practicing Physician Joseph F. Boyle, M.D., California Medical Association, 731 Market Street, San Fran- cisco, California 94103 P.L. 93-641 - From the View of a Hospital Administrator Stephen M. Morris, Past President, American Hospital Association; President Samari- tan Health Service, 1410 North Third Street, Phoenix, Arizona 85002 P. L. 93-641 - Impact on Medical Schools Donald 0. Brayton, M.D., Medical Director, Kern Medical Center, 1830 Flower Street, Bakersfield, California 93305 Eugene J. Rubel, Acting Director, Bureau of Health Planning and Resources Development, Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852. Harold Margulies, M.D., Deputy Director, Health Resources Administration, 5600 Fishers 6 Lane, Rockville, Maryland 20852. Nathaniel Poister, NARMP Washington Representative, 2128 Wyoming Avenue, N.W., Washington, D.C. 20008, Paul D. Ward, Executive Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621. The following workshop summaries present a distillation of 90 formal papers and panel discussions on health resource development activity nurtured by Regional Medical Programs. Detailed information may be obtained by writ- ing directly to the participants, whose addresses immediately follow these reports. Bold type introductions to each workshop summary are based on information developed by the national RMP Public Accountability Reporting Group. 7 ACKNOWLEDGMENT Preparation of this San Diego meeting report was made possible with the generous help of the following individuals: Roger L. Beck, Virginia Regional Medical Program; June Estes, Mississippi Regional Medical Program; Patricia Estes, Tennessee Mid-South Regional Medi- cal Program; J. R. Gallagher, Iowa Regional Medical Program; Katherine Herzog, Arkansas Regional Medical Program; Robert C. Hunt, South Dakota Regional Medical Program; Linda R. Johnston, Texas Regional Medical Program; Steve F. McCourtie, Michigan Re- gional Medical Program; Kay Page, North Carolina Regional Medical Program; Virginia Rodgers, Memphis Regional Medical Program; J. P. Smith, Colorado-Wyoming Regional Medical Program; Ellen Soo Hoo, Illinois Regional Medical Program; Jerold G. Sorensen, Intermountain Regional Medical Program; Carol Sympson, Ohio Valley Regional Medical Program; and Linda Wenze, Nassau-Suffolk Regional Medical Program. ACCESS TO PRIMARY CARE The provision of primary care services for medically underserved populations is first among ten priorities mandated for action under the provisions of Public Law 93-641. During the year which ended June 30, 1975, Regional Medical Programs wholly or partially funded some 550 new health service activities in the development of primary care services in rural and medically underserved areas. Rural Programs Workshop participantsdiscussed problems concerned with ac- Use of technical and financial support to establish 12 rural cess to primary care in urban and rural areas, with the effec- community health centers was cited as an example of RMP tiveness of nurse clinicians and community health workers, efforts to improve primary care access in rural areas. Fea- with the role of the university in primary care manpower pro- tures of the program included: development of fixed sites duction and education, and with the problems facing the for services; commitment of local funds or services; provi- newly emerging Health Systems Agencies in dealing with ease sion of varied types of health services; and establishment of of access and availability of health services. minimums for times and types of services offered. A state- wide committee on primary care has guided implementation 8 Some of the findings: of the project, and will aid in evaluation. Urban Programs An example of an RMP function in an urban area was pre- sented. One RMP effectively worked with Model Cities pro- Manpower grams, using hospital-based resources, to establish and expand community ambulatory care centers. In this example, a dol- An example of the evaluation of one type of physician ex- lar-for-dollar local match was required. These centers were tender has produced preliminary evidence that use of a nurse rapidly accepted and continue their operations without R.MP clinician in a rural solo practice can increase productivity by funds. The use of hospital-based resources provided several 20-30 percent. It would appear that increased use of such advantages: personnel might have a signif icant effect on the overall avail- ability of primary care. Hospitals were already located in each of the underserved areas. Use of these existing facili- In another example, an RMP has a task force studying 44 ties avoided the necessity for costly develop- projects utilizing the Community Health Worker to: describe ment of new facilities or services; utilization patterns; standardize methods of training; develop credentialling procedures; and develop third party pay or Physicians preferred delivering outpatient ser- funding for community health worker services. vices in the hospital setting, which offered ap- propriate facilities and services, including estab- lished administrative systems. Role of the In another example, an RMP incorporated a hypertension screening program sponsored by an inner city neighborhood Panelists agreed that universities had not taken the lead in health center as a means of stressing The importance of a improving access to primary care, citing their preoccupation specific disease process in an ambulant, black population. with other activities, and the lack of appropriate encourage- The intent was to develop or modify patterns of utilization ment from federal funding sources. However, medical of available resources. Through a successful program of schools are now perceiving primary health care as a desirable detection, treatment, and improved compliance, the hyper- avenue for teaching and research. A number of state legisla- tension orientation augmented the comprehensive health tures, who provide a large portion of medical school budgets, care services offered by the center. Indigenous personnel have been urging production of more primary care providers were trained and used as outreach workers in the project. and decentralization of the education process. Problems for Health Systems Agencies Conclusions There is a necessity for HSAs to build on the RMP experience Participants in the @,vorkshop expressed the ollowing strong with respect to access to primary care. The following sugges- concerns: tions were offered, 1. It is vital that the accomplishments of 1. Involve public officials in the planning pro- RMPs in ir-nidlementing programs to im- cess to facilitate implementation and con- prove access and availability of health tinuation of health programs. services be recognized as a basis for con- tinued expansion. 2. Provide educational programs for people in- volved in the planning process. 2. There is no central agency in Washington responsible for improving access to pri- 3. Coordinate the effective use of local resources. mary care, a high priority component of P.L. 93-641. This situation contributes to the slow realization of the solution of this complex problem in health care del ivery. 9 WORKSHOP PARTICIPANTS ACCESS TO PRIMARY CARE Moderators: Robert W. Brown, M.D., Director, Kansas Regional Medical Program, 4125 Rainbow Boulevard, Kansas City, Kansas 66103 Marlene Checel, M.P.H., Director, Access to Primary Care Program, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 John A. Mitchell, M.D., F.A.C.S., Associate Professor, Community and Family Medi- cine, University of Arizona, 1501 North Camel Avenue, Tucson, Arizona 85724 Panelists: Improving Access to Primary Care Through Hospital-Based Ambulatory Services in New Jersey Alvin A. Florin, M.P.H., Coordinator, New Jersey Regional Medical Program, 7 Glenwood Avenue, East Orange, New Jersey 07017 Health Center Development in Arizona Phyllis Reifurth, Health Systems Specialist, Arizona Regional Medical Program, 5725 East 5th Street, Tucson, Arizona 8571 1 Problems for the Health Systems Agencies in Access and Availability of Primary Care John A. Mitchell, M.D. 10 Role of University in Improving Access to Primary Health Care John A. Packard, M.D., Associate Dean, University of Alabama, College of Community Health Services, P. 0. Box 6291, University,Alabama 35468 Categorical Entry to Primary Care - Projec t High Blood: Screening and its Aftermath Samuel U. Rodgers, M.D., M.P.H., Project Director, Wayne Miner Neighborhood Health Center, 825 Euclid, Kansas City, Missouri 64124 The Community Health Worker Gloria Ellis, Community Health Worker Component, Access to Primary Care, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 A Physician-Extender Study Geraldine C. Holmes, Ph.D., Planning and Evaluation, Kansas Regional Medical Program, 4125 Rainbow Boulevard, Kansas City, Kansas 66103 Development of Primary Health Care Services in Los Angeles County Loren G. McKinney, M.D., Assistant to Medical Director, Department of Health Services, 313 North Figueroa Street, Room 805, Los Angeles, California 90012 The Challenge Teresita Moreno, Program Officer, New Mexico Health Cultural Awareness Program, 2701 Frontier Place, N.E., Albuquerque, New Mexico 87131 MANPOVVER The number of health professionals trained in new roles by RMP's for an 18-month period extending through June, 1975 has been estimated at 32,456. Categories include nurse practitioners, physicians' assistants, emergency medical technicians, and others. For the corresponding period, it is estimated that 5,120,000 people were served by these RMP- trained new health manpower providers. The Health Manpower Workshop intended to step outside When these tools are designed in cooperation with their the day-by-day living and working experiences of health users, local planners and decision makers; when these tools manpower planners, educators, and employees. One half are powered by accurate, timely, appropriate data; and of the program was devoted to identification of key issues when these models are respected as abbreviated representa- and changing priorities with regard to h@alth care delivery/ tion of reality; then they may be effective methods for education systems. The second segment examined recent determining future manpower supply and demand. work in the application of social science technology to health manpower planning. Several "micro" health manpower models were described. The thrust of these econometric efforts is the development One effective method for assuring balanced health manpower of specific information for local level use in reaching health planning from small communities to statewide or regional manpower planning decisions. areas - is through the comprehension and amplification of existing linkage systems. An individual linkage is the con- The sessions also received a detailed technical presentation nection or relationship between two functions or between on a new "micro" health manpower model. Such instru- two people; a linkage system is the sum of all the individual ments are designed for use on regional, interregional or linkages. even national scales and may provide unique and useful insights into the over-all manpower arena. Many different agencies and organizations conduct health manpower planning activities. Seldom does any one group The conference shifted from reviewing planning and model- direct its planning at the broad range of health manpower ling, to considering finds and conclusions from a number as it is related to the total health care delivery system, A of specific strategies. These projects are aimed at health statewide linkage system concept is most useful when com- manpower solutions in the nurse practitioners, physician bined with a step-by-step planning process. Suggested assistant, and physician extender realms. process steps include: (1 ) assemble staff, (2) develop a work plan, (3) determine current process, (4) develop link- The group studied some of the problems of developing, plac- age mechanism, (5) develop planning process, (6) identify ing and evaluating innovative efforts for health manpower future conditions, (7) determine manpower supply and de- and related health programming strategies. mand, (8) alternate strategies developed, (9) draft, test and publish a health manpower plan, and (10) develop a data It was noted that most innovations come as a result of the collection system. efforts of a single charismatic person. When he leaves, the innovations vanish. The decisions and priorities generated by the health man- power planning process are augmented by health manpower Innovations in health manpower education were studied. econometric models. It is important that these models It was stressed that these approaches (AH EC, HS/EA, VA be considered as tools for employment in the health man- and others) are but one resource in the development of power planning process. a community health education system. Community health education efforts continue to be a prime consideration, The health manpower workshop ranged through process since, historically, health education programs have done for (1) developing small community data, to (2) statewide much in shaping the delivery of health care. planning and to (3) the federal dilemma in applying national programs to regional requirements. The importance of decision makers (gate keepers) in social action programs was stressed. Highlight of the workshop The challenge may be summed up in the idea that health was a description of 40 years of technical work which re- planners, especially health manpower planners, should be sulted in the use of such models as the BHSDS, EMCRO, aware of social, political and economic factors; but they UHDD, and PSRO. should be keenly aware of the differences between what they, as planners, think is needed and what is really needed. WORKSHOP PARTICIPANTS MANPOWER Moderators: Donald G. Brekke, Director, South Dakota Regional Medical Program, 216 East Clark Street, Vermillion, South Dakota 57069 C. Kenneth Proefrock, Executive Director, Mahoning Shenango Area Health Education Network, 5211 Mahoning Avenue, Youngstown, Ohio 44515 Charles W. White, Ph.D., Program Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Panelists: Summary Analysis of Health Manpower Models Timothy C. Doyle, Ph.D., Program Director, Vector Research, Inc., P. 0. Box 1506, Ann Arbor, Michigan 48106 12 Manpower Planning Models and Quality Assurance Paul Sanazaro, M.D., Director, Private Initiative & Professional Standards Review Or- ganization, 703 Market Street, Suite 535, San Francisco, California 94103 Overview of the AHEC, VA, HS/EA Consortia Models Lawrence H. Miike, M.D., J.D., Research Director, UC San Francisco Health Policy Program, Washington Study Group, 1828 L. Street, N.W., Suite 700, Washington, D.C. 20036 Some Economic Aspects of Health Manpower Planning Donald E. Yett, Ph.D., Director, Human Resources Center, University of Southern California, Los Angeles, California 90007 Congressional Viewpoint on Health Manpower Carl A. Taylor, Health Manpower Manager, Office of Technology Assessment, Congress of the United States, Washington, D.C. 2ooo6 Problems of National and Areawide Plarining for Appropriate Distribution of Health Personnel William Shonick, Ph.D., Associate Professor of Public Health, University of California, Los Angeles, California 90024 Health Manpower Linkage Systems B. Jerald McClendon, Project Coordinator, Health Manpower Planning and Linkage System, State Department of Health, Pierre, South Dakota 57501 Innovations in Health Manpower Training and Utilization Charles E. Lewis, M.D., Chief of Division of Internal Medicine and Health Research, University of California, Los Angeles, California 90024 WORKSHOP III - REGIONALIZATION ACTIVITIES Regionalization of services has been a major RMP goal from the beginning. During calendar years 1970 through 1974 it has been estimated that 10,962,000 patients received direct health services in demonstration projects having strong regionalization of secondary and tertiary care components. In 1974 alone, 2,276,000 persons received direct health services for heart dis- ease, cancer, stroke, kidney, hypertension, pulmonary disease, arthritis and other disorders. Regionalization system development --- statewide kidney transplant and dialysis networks, regional referral and transportation systems for neonatal intensive care, arthritis centers and support networks and other services --- received more than $25 million, 22 percent of all RMP 1974-75 awards. 13 Perinatal - Neonatal Hypertension Although the value of perinatal centers has been extensively The RMP commitment to community-level management documented---one center recorded a drop in high risk infant of high blood pressure often linked with the early involve- mortality, from 200 per 1,000 to 150 per 1,000 --- panelists ment of the American Heart Association, has spawned a agreed with the sentiment that "if medical care is offered variety of approaches. In one instance, a cardiovascular on a per pound basis, then newborns certainly need some- disease network, established after task forces recommended one to fight for them." secondary and tertiary care programs, is now serving more than half the health districts of one state and the remainder Outreach education is for many RMP projects the first step are expected to become involved in the coming year. toward regionalization of neonatal intensive care. "Mini- fellowships", in which physicians spend up to 10 days at a Other projects dealing with screening and treatment within tertiary center as full members of the NIC unit staff and the existing health care system coupled with effective follow- performing hitherto unfamiliar techniques, have encouraged up were supported in high impact urban settings, emphasizing participants in one project to train their own nurses in NICU peer group pressure "on the job." In one, control rate of 82 techniques back home, starting the nucleus of a perinatal percent was achieved largely because of easily accessible care. team for comprehensive infant care in the community. This Detection and readily available treatment are an effective "ripple" method of continuing education has helped to team. overcome many problems encountered in neontal/perinatal health care delivery; for example, infrequent deliveries in Another approach used a statewide council to provide coor- large, but sparsely populated geographic areas, the failure dination and technical assistance, establish priority activities, to transport patients appropriately among facilities, and the target efforts and assure evaluation, As a result, nine service tendency of a physician to overextend himself by perform- areas around medical centers were established. ing delicate techniques in which he is not proficient. Efforts at hypertension control in isolated, small rural com- NICU ideal conditions will have been reached when high munities, hampered by physician shortages and inadequate risk mothers are routinely detected beforehand, and their transportation, has often led to the organization of commun- pregnancies completed in effectively managed centers. ity groups whose purpose is to deal with high blood pressure services and to seek widespread public utilization. A recently However, such centers require expensive equipment and instituted mobile unit seems in one project, to be more suc- personnel not likely to be replaced as the RMP structure cessful in attracting large numbers of the public than a disappears as the result of Public Law 93-641. stationary clinic. in-service education for hospital and nursing education, home staffs and a comprehensive clinic program staffed by physician assistants in three rural communities. Still a different type of regionalization project by an RMP, concerned itself with adverse drug reactions suffered by pat- ients in 10 participating hospitals. Patients were monitored, reactions recorded and controlled. The additional pharmacy and drug information and poison control data have been shared, and the project provides continuous, easy access to the latest pertinent information through a network serving 450,000 patients per year. Kidney Disease Control Necessary components for a successful kidney disease con- trol program are a transplant center, facilities for tissue Emergency Medical Services typing, organ preservation and organ procurement center, limited care services, home and satellite dialysis, and ancil- The amalgamation of diverse political jurisdictions to build lary laboratory facilities. Most of the projects described for a truly regional EMS system can involve major obstacles to panelists were begun five years ago and included statewide success. Included among them are a lack of contact and kidney disease information systems, nephrology manpower communication with top executives of the various jurisdic- studies, formation of a society of transplant surgeons, train- tions, Federal Communications Commission rules changes ing of surgeons in renal transplantation and professional and and radiobroadcast problems. The planning and implemen- public education designed to lead to organ procurement. tation of improved emergency health care must, however Traditional physician cooperation to improve care of end- difficult, include at the earliest stages a realistic plan for evaluation of the developing system. Rural EMS systems, stage renal disease patients has recently been augmented by panelists were told, suffer from a number of special prob- joint efforts in organ sharing, cooperation in immunology, lems, among them, the absence of even one conforming organization of common transplant recipient pools, more 14 ambulance, lack of appreciation for the elements desired formal referral and organ harvesting networks, and passage and the importance of quality EMS, and a geographic terri- of pertinent legislation. tory and population mix that are not in compliance with funding agency requirements. Professional education efforts have been highly successful, with high attendance at training workshops, and dramatically Other Regionalization Activities improved viability of harvested organs and organ retrieval rates. Inadequacies in rural health care delivery were reduced in one region by a project designed to have a large well established One project concerned with public education funded through group practice clinic coordinate services throughout more the Kidney Foundation found that three out of four persons than 100 hospitals and clinics. Outreach activities included surveyed expressed positive feelings about medical transplan- physician consultation, computer assisted electrocardiography. tation, and better than half felt positive about donating I reference laboratory, blood banking, equipment repair and specific parts of their own bodies. maintenance, psychiatry, psychology and psychiatric social services, electroencephalographic interpretation, neonatal Many states have recently passed legislation authorizing organ emergency care, pulmonary function testing and remote con- donor pledges on driver licenses, millions of dollars for hemo- tinuous cardiac monitoring. dialysis, new definitions of death and the easing of restric- tions on home dialysis patients. Solutions in one large state with complex geographical and cul@ tural barriers were found by opening many new clinics and generating local support. Supplementary services were devel- Arthritis Control oped by recruiting and training interested community mem- bers to coordinate and monitor local planning efforts and A shortage of physicians specializing in rheumatology, a sev- health programs. vere maldistribution of those who practice, and a clear need for continuing education of doctors, nurses, physical thera- Panelists heard of a 10-year old program that began in a large pists, social workers, and allied health care team members state as a home health agency. Since RMP involvement, it hamper this emerging medical specialty. Panelists were told has added early and periodic screening; diagnosis and treat- that fewer than 500 physicians are board certified in the na- ment, lead poisoning and senior citizen screening, family tion; most are in California, and those are concentrated in planning, alcoholic rehabilitation and detoxification, dental Los Angeles - San Francisco. This occurs in spite of the fact that patients appear to be evenly distributed throughout problems such as in-service training needs, shortage and turnover of personnel, communication and practical "do it the Country. yourself" answers can lead to many benefits and, eventually, Against this background, innovative solutions are sought. In to self-sufficiency through cost savings. Sharing of lessons one project, a rural care model @-vas developed. Local physi- learned in fiscal management and administration, and in cians identified as community coordinators were combined developing acceptable peer review systems are other out- with other health personnel to compose a local arthritis care comes that lead to additional benefits. team. Consultative clinics and patient family education were held in local communities with visiting consultants examining, evaluating and prescribing comprehensive treatment that was Cancer Control to be carried out by the referring physicians. Regionalization of RMP-funded cancer control projects has re- Arthritis centers may focus on development of sub-regional sulted in a higher quality of care for cancer patients, more ef- clinics, special problems of children with arthritis, professional ficient utilization of medical personnel and the ability to cen- and lay education, assistance and regular physician visits to tralize certain key services previously handled by disparate or- widely dispersed communities, evaluation, follow-up and ganizations. monitoring of patient progress, and linking all state physicians into a medical information service system by telephone. Panelists were told that successful cancer regionalization ac- Another goal is to establish rheumatology as a high-need tivities have several characteristics in common. Usually the specialty among physicians, nurses and other health care pro- project relates to health problems that no single agency can viders, with special emphasis on those physicians in training handle alone. Usually the project affects a large geographic for family practice. Not forgotten are the all important pol- area and involves some highly specialized activity or some icy-making medical institution administrators. technology that is new, scarce and expensive. Participating institutions in the regionalization activity include those or- Cost Sharing ganizations that were recognized centers of excellence before the project was initiated. Results can build closely-knit Objectives of shared services include the provision of other- networks of major therapy resources, statewide tumor reg- wise unavailable services, prevention of loss of autonomy to istries, radiation therapy and visiting consultant programs, otherwise stronger forces,- i.e., government or competing or- annual statewide cancer workshops, facility planning and ganizations, through cost reduction, bet!'-,r patient care, re- development for new centers, clinical traineeships, shared 15 duced inventory, and attempting to satisfy competing de- allied health personnel projects and vastly improved patient mands and consumer criticisms. Cooperation on common ca re. VVORKSHOP PARTICIPANTS REGIONALIZATION ACTIVITIES Perinatal-Neonatal Moderator: Sheldon Korones, M.D., Newborn Center, John Gaston Hospital, 860 Madison Avenue, Memphis, Tennessee 38103 Panelists: A Multi-State Rural System Development Effort in Neonatal Care Sidney C. Pratt, M.D., Project Director, P. 0. Box 2829, Great Falls, Montana 59401 Regionalization of Neonatal and Perinatal Activities Sheldon Korones, M.D. The Regionalization of Perinatal Care in VVisconsin Craig Anderson, M.D., 5721 Odana Road, Madison, Wisconsin 53719 Florida's Perinatal Program Richard Boothby, M.D., Project Director, Hope Haven Children's Hospital, 5720 Atlantic Boulevard, Jacksonville, Florida 32207 Regionalization of Perinatal Care in the State of Kansas 16 Howard Fox, M.D., Department of Pediatrics, University of Kansas Medical Center, Rainbow Boulevard at 39th, Kansas City, Kansas 66103 Hypertension Moderator: Elliot Rapaport, M.D., President, American Heart Association, 1370 Mission Street, San Francisco, California 94103 Panelists: Regionalization of Hypertension Services Morris M. Bradley, 938 Peachtree Street, N.E., Atlanta, Georgia 30309 The Future of Community Hypertension Control Funding Under Recent Federal Legislation Howard J. Bochnek, M. E., Coordinator of Hypertension Control Program, Metro- politan New York Regional Medical Program, 2 East 103rd Street, New York, New York 10029 Regionalizing High Blood Pressure Control in California Adelbert L. Campbell, Director, Program Coordination and Development, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Development of a Statewide Hypertension Registry Program Robert S. John, Assistant Director of Program Development, Illinois Regional Medical Program, 122 South Michigan, Room 939, Chicago, Illinois 60603 Planning for a Hypertension Control Program in a Rural Area John L. lsbister, Chief, Bureau of Community Health, Michigan Department of Public Health, 3500 North Logan, Lansing, Michigan 48914 Emergency Medical Services Moderator: James 0. Page, Project Director, Lakes Area Regional Medical Program, 2929 Main Street, Buffalo, New York 14214 Panelists: Regionalization of Emergency Medical Services Activities Vaughan E. Choate, 2007 1 Street, N.W., Washington, D.C. 20006 Regional EMS Program: An Example of Cooperative Planning and Funding Alan Dimick, M.D., Department of Surgery, University of Alabama, University Station, Birmingham, Alabama 35294 Emergency Medical Service in Northeast and North Central Missouri Jacqueline C. Hall, R.N., Kirksville College of Osteopathic Medicine, Kirksville, Missouri 63501 17 Review of Developing Rural EMS Systems Richard Walsh, M.D.; Joan Baker, R.N., 2701 Frontier Place, N.E., Albuquerque, New Mexico 87131 Other Regionalization Activities Moderator: Gordon R. Engebretson, Ph.D., Director, Florida Regional Medical Program, 1 Davis Boulevard, Suite 307, Tampa, Florida 33606 Panelists: North Central Outreach Program David L. Draves, Director, Regional Medical Services, Marshfield Clinic, Marshfield, Wisconsin 54449 Regional Health Resources Development in New Mexico Frank A. Otero, Project Director, Community Health Resource Development Project, New Mexico Regional Medical Program, 2701 Frontier Place, N.E., Albuquerque, New Mexico 87131 Regionalization of Health Services in Central Maine John LaCasse, Deputy Coordinator, Maine Regional Medical Program, 295 Water Street, Augusta, Maine 04330 Regional Drug Information Network Carol McCarthy, Associate Director, Nassau-Suffolk Regional Medical Program, 1919 Middle Country Road, Centereach, Nevv York 1 1 720 Kidney Disease Control Moderator: Frederiel< C. Whittier, M.D., Chief, Nephrology Section, Veterans Administration Hospital, 4801 Linwood Boulevard, Kansas City, Missouri 64128 Panelists: Impact of RMP on End Stage Renal Disease in Arkansas Tom E. Brewer, M.D., Assistant Professor, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, Arkansas 72201 Experience with Criteria Setting in Two Dialysis Units Arlene Sukolsky, Kidney Project Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 A Survey of Public Opinion on Transplants Jackie K. Reinhardt, Coordinator, Transplantation Council of Southern California, 1281 Westwood Boulevard, Suite 207, Los Angeles, California 90024 Chronic Kidney Disease Patient Care Systems H. Earl Ginn, M.D., Chief, Nephrology Division, B2218 Medical Center, Vanderbilt University, Nashville, Tennessee 32232 The Renal Program for Texas Robert Humble, Deputy Director, Community Programs, Texas Regional Medical Pro- 18 gram, 4200 North Lamar Boulevard, Room 200, Austin, Texas 78756 Arthritis Control Moderator: David D. Shobe, The Arthritis Foundation, 1629 "K" Street, N.W., Washington, D.C. 20006 Panelists: Intermountain RMP Discrete Arthritis Activity Steven J. Anderson, M.D., 325 Seventh Avenue, Salt Lake City, Utah 84103 Arthritis Activities of the Tennessee-Mid South RMP Richard 0. Cannon II, M.D., Director, Tennessee-Mid South Regional Medical Program, 1 10-21st Avenue South, Suite 1 100, Nashville, Tennessee 37203 California RMP Pilot Arthritis Program: Initial Steps Toward the Regionaliza- tion of Care for Patients with the Rheumatic Diseases Charlene Brax, M.P.H., Arthritis Project Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 A Model Center-To-Clinic Project Gene V. Ball, M.D., Professor of Medicine, Division of Immunology and Rheumatology, University of Alabama in Birmingham, University Station, Birmingham, Alabama 35294 Cost-Sharing Moderator: Albert M. Donnell, Coordinator, Oklahoma Regional Medical Program, P. 0. Box 26901, Oklahoma City, Oklahoma 73190 Panelists: Oklahoma Regional Health Development Area Program (RHDAP) Albert M. Donnell Green Hills Area Cooperative Health Care Project Herbert Henry, Noll Memorial Hospital, Box 428, Bethany, Missouri 64424 Regionalizing Management John Richey, Assistant Director, Grants Management, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Regional Medical Audit Review System Jack Rorex, Director, Health Planning, White River Planning and Development District, P. 0. Box 2396, Batesville, Arizona 72501 Cancer Control Moderator: Alfred M. Popma, M.D., 1903 S. Roosevelt, Boise, Idaho 83704 19 Panelists: The Illinois Cancer Council: An Experiment in Regionalization Lorraine C. Hannah, Program Administrator, Illinois Cancer Council, 122 S. Michigan, Room 939, Chicago, Illinois 60603 Automated Treatment Planning for Radiation Therapy in Arkansas Alex P. Turner, Ph.D., Assistant Professor, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72201 Regionalization of Cancer Services Francis Morrison, M.D., University of Mississippi Medical Center, Jackson, Mississippi 39216 The Regionalization of Cancer Services in Georgia Don J. Trantow, 938 Peachtree Street, N.E., Atlanta, Georgia 30309 QUALITY ASSURANCE PROGRAMS Quality Assurance of health care has been a priority area for RMP resources since 1970. From that time through June, 1975 it is estimated that 143,820 health professionals have been trained in techniques to systematize standards for and determine deficiencies in medi- cal care, develop corrective action and implement activities which result in demonstrably improved quality of care. The Quality Assurance Workshop provided a forum in The process of establishing criteria has been improved by in- 20 which twenty-eight speakers presented information on a cluding patients as participants on hospital medical audit variety of RMP-funded efforts to improve patient care committees. The multidisciplinary approach, which includes through quality assurance projects. Papers dealt with pro- physicians, nurses, medical records administrators, hospital grams in hospitals, nursing homes, and home health care in administrators and trustees, pharmacists and dentists, has both urban and rural settings, the development of innova- proved highly effective in meeting JCAH and PSRO require- tive collaborative arrangements between disciplines to pro- ments. Peer review of emergency room medical records has vide quality care, attempts to establish and evaluate quality proven as effective as physician interview and examination care standards, management criteria and performance feed- of patients after discharge. back for specific diseases such as hypertension, coronary and pulmonary disease, and for laboratories. Discussion of Pro- fessional Standards Review Organization (PSRO) and Joint Non-Hospital Quality Assurance Programs Commission on Accreditation of Hospitals (JCAH) involve- ment concentrated on current functions, relationships Although efforts to evaluate patient care in ambulatory between professional organizations and RMPS, and the settings are not yet mandatory, nor as developed as hospital future of health care quality assurance from the federal per- programs, studies are being conducted to test various current spective. methods of evaluating ambulatory care. Hospital Quality Assurance Programs An attempt is being made to validate the "tracer" method utilizing discrete, identifiable health problems in relation to Quality assurance efforts should maintain and improve medi- one another. cal care of patients, and outputs should be professional edu- cation, development of new programs of patient care and The relationship between process and outcome approaches patient education, and changes in the administration and in outpatient care has shown that these two methods when structure of the system itself. applied to hypertensives do not yield similar conclusions, and that cases must be categorized by severity of disease. A key element in initiating quality assurance efforts in hos- pitals is the establishment of close, positive working relation- Nurses in skilled nursing facilities in an expanded role pro- ships with medical and administrative staffs to insure that a vided through training document patients' treatment plans, quality assurance system, whether urban or rural, will be disease status and daily activities more completely, are accepted and operational. A few highly motivated physi- better able to assess the total patient's needs and provide cians and hospital administrators might form the nucleus more appropriate and better quality care. of the group designated to establish the system. Quality Assurance Projects Among Professional JCAH and Federal Perspective Disciplines and Organizations Quality assurance activity as a continuing trend in health The presentation included programs to train nurses in the care has shifted from voluntary to required. Assessment development of patient health outcome criteria through sem- of the actual process of health care delivery and the out- inars using the nominal group technique, and to validate cri- come of health care services has taken precedence over as- teria through seminars where outcomes were critiqued by sessment of structure. Organized quality assurance activity researchers; to computerize a reporting system using social has expanded from the acute hospital setting to the long workers in health care to conduct research to study their term care and ambulatory sector and has become more the effectiveness and establish norms for social work service ongoing responsibility of organized external groups than delivery; to develop standards and guidelines for reviewing the function of internal staff committees on an episodic individual certificate of need applications utilizing a mathe- basis. matical model and a panel of experts; to train medical records associates in audit procedures, and to use medical Major quality assurance issues will be review of additional self-audit to point out needs for continuing education among nonfederally funded care by PSROS, the need to prepare for an organization of private medical practitioners. National Health Insurance, the need for a national strategy to define problems, address them and establish priorities, Quality Assurance Programs Related to Specific and the need to reduce over-reliance on PSROs as mechan- Diseases isms to lower costs. Discharge summaries were evaluated in order to determine PSROs should function as coordinating nuclei for community- changes in blood pressure levels of hypertensive patients wide quality assurance systems which include representatives resulting from educational programs; it was found that pre- from all health care disciplines and reflect needs and practices sent techniques for educating such patients have proved of the locality. successful only temporarily and that better methods must be sought, Through the conduct of medical audit for a hypertension registry, established criteria provided to hypertension clinics 21 are used to reallocate resources according to the needs of patients. Setting standards for data collection and providing perform- ance feedback have led to improved patient care and a 50 percent drop in in-hospital mortality from acute coronary disease. In an area of high incidence of respiratory problems and con siderable patient movement between hospitals, pulmonary care standards and a computerized inter-link system have led physicians to use findings of tests completed at other hos- pitals and to avoid repetition. Small rural hospitals with few trained laboratory personnel formed a preceptorship system stressing feedback to health care professionals on how their performance met standards. WORKSHOP PARTICIPANTS QUALITY ASSURANCE PROGRAMS Current PSRO Activities Moderator: Samuel R. Sherman, M.D., Director, Quality of Care Program, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Speaker: Edward Zivot, Executive Director, California PSRO Support Center, 215 Market Street, Suite 1301, San Francisco, California 94105 Hospital Quality Assurance Programs Moderator: Leslie Sandlow, M.D., Vice President for Professional Affairs, Michael Reese Hospital and Medical Center.. 29th Street and Ellis Avenue, Chicago, Illinois 60616 Panelists: Quality Assurance in Community Hospital 22 William P. Nelson 111, M.D., Associate Professor of Medicine, Veterans Administration Hospital, Albany, New York 12208 Rural Hospital Quality Assurance Consortia John T. Rorex, Director, Health Planning, White River Planning & Development District, P. 0. Box 2396, Batesville, Arizona 72501 Health Care Review in Rural Hospitals Robert H. Barnes, M.D., Director, Health Care Review Center, 909 University Street, Seattle, Washington 98101 Quality Assurance Workshop and Follow-up System Samuel R. Sherman, M.D. Evaluation of Nurse Practitioner in a Hospital Emergency Room Department Glen E. Hastings, M.D., Associate Professor of Medicine, University of Florida, Center House Inn, 1400 N.W. ldth Avenue, Suite 15F, Miami, Florida 33136 Non-Hospital Quality Assurance Programs Moderator: Robert G. Rowland, Coordinator, Quality of Care Program, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Efficacy of Tracers in Ambulatory Care Ira Gabrielson, M.D., Chairman, Department of Community and Preventive Medicine, Medical College of Pennsylvania, 3300 Henry Avenue, Philadelphis, Pennsylvania 19129 Quality Assessment Through Outcome Analysis Fred Nobrega, M.D., Director, Health Care Research Unit, Mayo Clinic, Rochester, Maine 55901 Improvement of Quality of Care in Skilled Nursing Homes Patricia Wihtol, R.N., Nursing Instructor, 16 Crescent Ave., Scituate, Massachusetts 02066 Patient Care Audit in Skilled Nursing Facilities Lila Maples, R.N., President, California Nurses Association, 2172 DuPont Drive, Suite 215, Irvine, California 92664 Quality Assurance in Home Care Rita Berkoben, Project Director, Quality Assurance Project, Pennsylvania Assembly of Home Health Agencies, 200 Meyran Avenue, Pittsburgh, Pennsylvania 15213 Professional Disciplines and Organizations Moderator: Kay Horswill, R.N., M.S., Nursing Coordinator, Wisconsin Regional Medical Program, 5721 Odana Road, Madison, Wisconsin 53719 Panelists: Patient Outcome Criteria by Peer Review Connie Keyes, R.N., M.S., Project Associate and Clinical Nurse Specialist, 6622 May- wood Avenue, Middleton, Wisconsin 53562 Computerized Social Work for Patient Care Project Miriam Birdwhistell, A.C.S.W., Ed.D., Chairman, University of Virginia Medical Center, Division of Social Work, Box 275, Charlottsville, Virginia 22903 23 Developing Standards for Specialty Care Skip Habich, Associate Coordinator, New Jersey Regional Medical Program, 7 Glenwood Avenue, East Orange, New Jersey 07017 California Medical Records Quality of Care Project Cynthia A. Boudreau, R.R.A., Member, CMRA Committee on Patient Care Audit, 250 Masonic Avenue, San Francisco, California 94118 Medical Association's Voluntary Self-Audit Daniel Hamaty, M.D.,Director, Connecticut Medical Institute, 90 Sargent Drive, New Haven, Connecticut 06551 Specific Diseases and Procedures Moderator: Edward W. Francisco, Ph.D., Coordinator, Northern New England Regional Medical Program, Executive Square, 346 Shelburne Road, Burlington, Vermont 05401 Panelists: Assessment of Quality of Care for Hypertensives Gerald Wolf, M.D., Associate Professor of Radiology and Pharmacology, University of Nebraska, 42nd Street and Dewey Avenue, Omaha, Nebraska 68105 Use of a Hypertension Registry in Medical Audit Fredric L. Coe, M.D., Director Renal Division, Michael Reese Hospital, 29th Street and Ellis Avenue, Chicago, Illinois 60616 Coronary Care Management Criteria Richard E. Bouchard, M.D., Associate Professor of Medicine, University of Vermont, Burlington, Vermont 05401 Laboratory Standards Clay Elting, Allied Health Specialist, Washington/Alaska Regional Medical Program, 1107 N.E. 45th Street, Suite 500, Seattle, Washington 98105 Pulmonary Care Standards Tom Pace, Coordinator, Quality of Care Programs, Intermountain Regional Medical Program, 540 Arapeen Drive, Suite 201, Salt Lake City, Utah 84108 Future of Quality Assurance Programs Moderator: Samuel R. Sherman, M.D. Speakers: John D. Porterfield, M.D., Director, Joint Commission on Accreditation of Hospitals, 875 North Michigan Avenue, Chicago, Illinois 6061 1 Leslie Ford, M.D., Division of Peer Review, Bureau of Quality Assurance, 5600 Fishers Lane, Rockville, Maryland 20852 24 IMPLEMENTATION OF PUBLIC LAW 93-641 With inflation in the health industry rising 50 percent faster than the federal economy panel- ists saw governmental intervention in the market place as inevitably growing, and the Health Planning and Resources Development Act of 1974 as perhaps a fresh attempt to solve a stubborn problem. Intending to combine health planning as a tool of regulation to achieve effective cost controls and more optimal distribution of health services, the law poses diffi- cult and complex choices. Health Systems Agencies are being developed as both advo- Control over much of the health care system in the United cates of areawide health needs and enforcers of Department States is passing through this legislation into the hands of the 25 of Health Education and Welfare policy. In its administration Secretary of DHEW, allowing him to exert whatever measures of the legislation DHEW will try to satisfy Congress, on whom he finds necessary to achieve the purposes of the law. His it depends for funding; similarly the HSAs will implement the power over state agencies and how they operate, through the law as satisfactorily to the department as possible. But in this withholding of Public Health Service funds from states deemed process it was felt there is likely to be a blunting or a disregard to be implementing the law too slowly, or inappropriately, is of the legitimate needs for health services arising from local immense; it usurps traditional prerogatives of state government. communities. If the state fails to meet the requirements of the law and of The Congressional charge to the HSAs is much more sharply the Secretary within a specified time, then the Secretary may focused than it was for Comprehensive Health Planning Agen- withhold all federal health funds appropriated under the Public cies; statutory authority will be much greater. Selection of Health SeIrvice and related acts from use within that state. HSA board members with mandated representation quotas, This could involve a significant sum of funds since this group should include "the yeast of at-large, maverick consumers of federal acts includes all federal funds for research grants, and nonestablishment consumers" to forestall provider or medical education, nurse training, allied health, mental establishment domination of board direction. The very ex- health, mental retardation, alcoholism programs, facility plicitness of the law and its inherently contradictory elements construction, support funds for Departments of Public may overwhelm the health planning process and cripple its Health, and other related programs. These funds may not operation. only provide support for state activities, but also go to Public Law 93-641 evokes a particularly skittish reaction from universities, local government and some private non-profit hospitals, since they receive such a large share of the health corporations. care dollar and thus feel most vulnerable to new regulatory State powers are further eroded through Public Law 93-641 procedures, The law pumps planning in at "too late a stage" by the mandate that acceptable certificate of need legisla- and gives the impression that regulation pre-empts planning tion must be passed before a state government can enter rather than being an accompaniment to it. While hospitals into an agreement with the DHEW Secretary. Providers may not have a cohesive stand, the new law nevertheless en- believe that such legislation must be linked with rate-setting; genders widespread dissatisfaction. It does not regulate in a the rate-setter ought not be an important major purchaser simple, easy to understand manner; some of its regulations of health care, as both state and federal governments are. cannot be equitably administered; others cannot be adminis- Thus, there is a glaring conflict of interest in the new law tered at all. Perhaps sixty per cent of the federal cost control effort is likely to be directed at hospitals, yet they may have permitting the Secretary of DHEW to be both a regulator no more than one or two representatives on an HSA govern- and a purchaser of health care services, leading to captured ing board. regulation in the hands of vested interests. Finally, although it appears that a majority of the HSAs June 30, 1976, there is no clear commitment to fund the now being developed to fulfill the first purposes of the program at levels sufficient to begin realistically to achieve legislation will have received conditional designation by the ends of the new law. 26 IL'i WORKSHOP PARTICIPANTS IMPLEMENTATION OF P.L. 93-641 Planning Moderator: Gary Fink, Associate Coordinator, Iowa Regional Medical Program, Oakdale Hospital, Oakdale, Iowa 52319 Panelists: Progress Report on Health Systems Agencies Collin Rorrie, Ph.D., Assistant to the Associate Director, Health Resources Planning, Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852 Functions, Staffing and Board of Health Systems Agencies Steve Sieverts, Special Consultant, American Hospital Association, One Farragut Square South, Washington, D.C. 20006 Health Systems Agencies: Advocates of Community Needs or Enforcers for DHEW Darwin Palmiere, Ph.D., Dean, Human Resources, State University College, Brockport, New York 14420 Regulation Moderator: Paul D. Ward, Executive Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 27 Panelists: Theory and History of Regulation Henry Zaretsky, Ph.D., Director of Research, California Hospital Association, 925 "L" Street, Suite 1250, Sacramento, California 95814 Regulatory Aspects of P. L. 93-641 Paul D. Ward Health Facility's Reaction to P.L. 93-641 Regulation Robert Derzon, Director, Hospitals and Clinics, University of California Medical Center, San Francisco, California 94143 Health Resource Development Moderator: Charles D. Holland, Director, West Virginia Regional Medical Program, 258 Stewart Street, Morgantown, West@Virginia 26506 Panelists: Title XVI Replaces Hill-Burton Agencies Edward N. Duncan, Director, Facilities Development, Bureau of Health Planning and Resources Development, 5600 Fishers Lane, Room 12-1 1, Rockville, Maryland 20852 Resource Development by the State and by the Health Systems Agency Charles D. Holland Resource Development and the Federal Government Richard L. Russell, Chairman, Developmental Fund Work Group, Bureau of Health Planning and Resources Development, 5600 Fishers Lane, Room 1 1A-46, Rockville, Maryland 20852 HEALTH CULTURAL AWARENESS Health Cultural Awareness Failure of health planners to take into consideration varying 07017), the session included presentations by a multi-cultural cultural backgrounds often leads to health legislation and pro- panel of experts, representatives of a variety of health pro- grams that neglect the very people they were designed to grams and agencies, both public and private. serve. Usually such people are of ethnic minority groups whose approach to health problems differs widely from Panelists related their personal experiences and cultural dif- that of the majority, ferences and similarities in terms of ethnically traditional as well as current and projected health needs. Viewpoints The Health Cultural Awareness discussion was conducted in specifically represented included Island Blacks, Chinese, response to a request from Regional Medical Program coor- Mexican-Chicano, American Indian and Puerto Rican. Pan- dinators to consider the needs of these minority groups. elists called for a plan of action that would incorporate Sponsored by the Center for Human Resources Planning and ethnic and cultural considerations appropriately into 28 Development (7 Glenwood Avenue, East Orange, New Jersey national health legislation. NATIONAL ASSOCIATION OF REGIONAL MEDICAL PROGRAMS Board of Directors John R. F. lngall, M.D., Chairman, James W. Culbertson, M.D. Buffalo, New York Memphis, Tennessee J. Gordon Barrow, M.D. Robert W. Lawton Atlanta, Georgia Cranston, Rhode Island Robert W. Brown, M.D. Benjamin Morgan Kansas City, Kansas Buffalo, New York Charles W. Caldwell Donal R. Sparkman, M.D. Oakdale, Iowa Seattle, Washington Paul D. Ward Oakdale, California 29 Program Committee J. S. Reinschmidt, M.D., J. R. Gallagher Oregon Regional Medical Program Iowa Regional Medical Program Harry Auerback Charles D. Holland Illinois Regional Medical Program West Virginia Regional Medical Program J. Gordon Bar 'row, M.D. John R. F. lngall, M.D. Georgia Regional Medical Program Lakes Area Regional Medical Program William Boquist Robert Miller California Regional Medical Program Lakes Area Regional Medical Program Donald G. Brekke Benjamin Morgan South Dakota Regional Medical Program Lakes Area Regional Medical Program Robert W. Brown, M.D. C. E. Smith, Ph.D. Kansas Regional Medical Program Mountain States Regional Medical Program Charles W. Caldwell Paul D. Ward Iowa Regional Medical Program California Regional Medical Program James W. Culbertson, M.D. Roger J. Warner Memphis Regional Medical Program Arkansas Regional Medical Program Gary Fink Charles White, Ph.D. Iowa Regional Medical Program California Regional Medical Program 30 Public Information Committee William Boquist, Chairman California Regional Medical Program Edna Carroll Bi-State Regional Medical Program Frederick E. Frazier Missouri Regional Medical Program Gerald N. Gold New Jersey Regional Medical Program Jim Robe Florida Regional Medical Program Sylvia Sterne Louisiana Regional Medical Program 1975 National Association of Regional Medical Programs, Inc. Non-Profit U. S. Postage One Davis Boulevard, Suite 307 PAID Tampa, Florida 33.606 Permit No. 495 BUFFALO, N.Y. I I