BACKGRO'@@1) FOR SPECIAI. MEETING OF REPRESENTATIVES OF IIEAT.Til SERVICES AND MENTAL HEAL'171 iV@D REGIO@N7AL LNIEI)ICAL PROGRA@IS Ai.-lie House Warrenton, V-Lrc,,in@-a August 23--29@, 1.969 The attached statement of DRAFT PRINCIPLES FOR PROGR@*IS SUPPORTED BY THE HEALTH SERVICES A@ND MENTAL HE@i'H ADMINISTRATION was prepared within the Health Services and Yiental Health Adininistrat4loii for discussion purposes o'nly by a s7iall group consisting of program directors and other senior staff. 'Its purpose was to perTii.t consideration of what guiding and coordinating strategy might be followed bv the Health Services and Mental Health Adiii-nistration and its procra.T. constituents, includl-f,,- Coriiprel,@onsi-ve Ilct@q.lth Planning, Hill.-Burton, National Institute of Mental Health, ard Servi,.cc-. desi@ned only to provide a ba:;is on which to test The paper was d ideas and engender discussi-o-i, does not- refl-ect the conclusions 01- tha It should also be noted that this parer was not intended It roup. for general distribution and, as such, is classified as AD@"INISTRA@IVF, In reviewing this statement there are two specific points that should be kept in mird The inference that mi,-,Iit be drawn fror,,. the section on pqge 7 ("'i@,e activities of region,--!- medical- I)ro@raTns at the corfLn@tin@Ltv 'Level should be carried out under the auspices of the area-wi-de @-o-Lnt)rehE@iisive health planning age-@icv") was not Tneant to suggest that Regional liedical Prografrs would Le ac-1;@-.4-n--'strati-vei-y under or subordinate to such an agency, but rather that a Rcaional @tedical Prograri would be a professional. arn to the area health planning ac,-ency and that its activities -@ould need to be closely coordinated with those groups at the co-@MT@unity level. The eiQDI@ia.si.s on the specialized -ature ol-7 Regioiia'L Medical Proara:,,,s in the statement does not adequately @ake into acceun,, the- T,,ti-ich broader role that it al.-ready -ind 4--icrea @ 41 ;-n future, particularly i-t rp-la-Les 1:@) as well as s-o@,c;.a!4zcd care NISTRATIVE CONFID@ DRAFT PRINCIF FOR HEALTH PROGRAMS SUPPORTED BY THE. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION I. Purpose The purpose of these guidelines is to assist communities in making the most effective use of sources of Federal support for improving the organization and delivery of health services'within the community. These Federal programs. have come into being as a response to perceived inadequacies in the organization and delivery of health services inadequacies which are reflected in problems of distribution,.cost, and quality of'health services. While the Federal Government has responded to these needs by making available support, the extent to which programs will achieve their objectives is largely dependent on the effectiveness of implementation at the community level. The essential role of the Federal Government, with the assistance of the States, is to help community resources to develop more effective systems of health-services. The Federal programs discussed below represent a variety of flexible mechanisms which can be utilized to meet community needs. 'These guidelines are intended to assist in that process. II. Scope These guidelines specifically deal with the coordination of health programs supported by the Health Services and Mental Health Administrationi 2 although the coordinating approach is relevant to other Federal programs supporting health services. The primary HSMHA programs which will assist communities in improving the organization and delivery of health services are Comprehensive Health Planning at the statewide and areawide level. Regional Medical Programs, Community Mental Health Centers and related activities in alcoholism and narcotic and drug abuse, project grants for the establishment of primary ambulatory care programs, project grants for maternal and child health services, and Hill-Burton construction grants for health facilities. Detailed guidelines for each of these programs are attached. The summary guidelines are intended to assist communities in putting together a package of Federal support which has maximum impact on the health services problems of the community. To the community, these programs represent programmatic tools, each designed to fit an important part of the community's machinery for developing improved health and mental health services, each with sufficient flexibility to enable the community.to build a coherent strategy for making maximum use of each program's contribution. III. Definition of Community f community for purposes of There can be no fixed definition o effective organization of health services. The community of solut-ion" for putting together the many facets of effective systems of health care ser- vices should encompass a wide enough area so that only rare cases would need to be refer red outside of the community for specialized services. The community should encompass those elements of the health system that interact on a regular basis. In most situations this concept of community will match the coverage of the areawide comprehensive health planning agency. This broad community may have subunits for specific purposes, such as a neighborhood health.program, the catchment area of a community mental health center, or the natural service area of a community hospitals But the community must be broad enough to encourage and permit effective coordination of services rather than'contribute to further fragmentation. With the great variety of local circumstances, there can be no fixed model of geographic or population coverage which would serve the purposes of effective program coordination. We will work with each community, however, to encourage a coherent pattern of geographic coverage for the various programs s port through the HSMHA funds. The ge ographic coverage UP of an areawide planning agency .should consider the mental health catchment areas, any subregions of the regional medical program, hospital service patterns, and other economic and local planning considerations. Attention to the geographic scope of the community health plans can facilitate effective program packaging and coordination. IV. The Role of the State It is an objective of HSNM policy to encourage an effective state tole in health programs. The state carries out many important functions in the health arena; and for many health activities at the community level, the state is an integral part of the "community of solution." For the state as for the Federal Government, the focal point for the organization of services is at the community level, and HSMHA's support to the state strengthens the state's capability to assist communities in achieving the objective of more effective organization of services. This support is provided through formula grants to state.health de- pattments for.the support of public health services and through the support of state comp rehensive health planning. The primary purpose of health planning at the state level is to assist the governor and the various state agencies with roles in health activities to carry out their'responsibilities more effectively through studies, analysis, advice, and assistance in the area of health-affairs. In addition to providing assistance on specific responsibilities of state government in health, the state health planning agency can provide oversight from the governor's perspective on the activities of community health planning agencies and other health institutions and organizations, public and piivaie, whose activities have an impact on state responsi- bilities in health. V. Scope of the Areawide Comprehensive Health Planning Agency HSNHA will encourage the development of the areawide comprehensive health planning agency as the fundamental instrument for integrating the impact of health programs on the needs of the community. The areatqide agency should carry out this responsibility as a part of its evolving role as the focus for community responsibility in health affairs. With the community mandate deriving from its broadly representative advisory group, this agelicy's concern should include the distribution of serviIces within the community, the efficient use of health resources, including a concern for the costs of medical care, and a purview over the effec- tiveness and quality of services. The agency is also in a position to highlight the health impact of environment factors and to advise an assist those agencies with operational responsibilities in the environ- mental area on the health implications of their responsibilities. g respo sibilities, The areawide agency should have the followin n identifying and analyzing community health care problems, providing information and analysis on health needs and resources analyzing the costs and effects of alternative courses of action in meeting health needs serving as the convener agency for bringing together representatives of various elements of the health care system to work on specific problems or programmatic developments -- serving as a mechanism for the expression of consumer concerns about health care problems, such as accessibility and cost of services Iand for the expression of community priorities and hea t monitoring the efficiency and effectiveness of the health care systems within the community serving as the stimulator and developer of appropriate joint management responsibilities for elements of the health care system, including the possible development of nonprofit management corporations for health activities -- assisting community health resources in the.effective packaging of Federal support to meet community needs. The areawide planning agency can serve as the umbrella for committees concerned with specific aspects of community health, such as mental health, environmental health, utilization review, and implementation of advanced technology and knowledge in improving the health care system. VI. Capital Financing The areawide comprehensive health planning agency should review and comment on all proposed construction of health facilities which would utilize Federal funds@ including those provided through Medicare, Medicaid, and the Maternal and Child Health Programs. HSMHA will encourage agencies responsible for funding decisions on capital ton- struction to weigh heavily the comments of the areawide agency in making those decisions. In reviewing state plans for Hill-Burton 31 HSMHA will give important consideration to the role assigned to areaivide planning,, the extent to which plans for construction of facilities are matched with careful analyses of health services needs within the community, and the impact of that construction on encouraging the use of less expensive services and efficient utilization of highly specialized services. In reviewing plans for the construction of community mental health centers, review and comment by the areawide planning agency will be required. VII. Comprehensive Primary Care HSMRA policy encourages the development of comprehensive family-centered primary care At the neighborhood level. Community health plans should specifically include an approach to providing comprehensive primary care with priority for lower economic groups. Since all available evidence indicates that comprehensive primary care, including effective preventive and community outreach services will reduce the utilization o more expensive health services as well as increase the effectiveness of health, services for the population group served, the community s plans for developing systems of health services that meet the needs of the entire population should lay out an approach to more effective organization of primary services and the development of specific relationships between primary services and higher levels of care. The use of HSMHA sources of support for developing primary services through project grants for health services and maternal and child health project grants should be @-linked with community plans for the development of other aspects of health services through other HSMRA programs. HSMHA will provide technical Assistance to communities in the development of plans for these relationships. VIII. Regional Medical Programs The regional medical programs are intended to insure that advances in medical knowledge are made more widely available and are introduced into the health care systems in an effective and efficient manner. The activ- ities of the regional medical program at the community level should be tarried out under the auspices of the areawide comprehensive health planning agency. The areawide agency could turn to the regional medical program for the following assistance and support: the provision of technical assistance and consultation on the application of advanced technology to medical care, as well as support for selected projects that involve cooperative arrangements among a number of elements of the health care system. -- the provision of assistance, consultation, and support concerning improvements in the substance of health care, including the organization and support of programs of continuing education. -- organization and support for specialized training activities meeting the needs of the community or region, RNP serving as a broker between the institutions utilizing health care personnel and institutions providing training. development under the @IP of highly specialized health care capabilities and the establishment of regular referral patterns with the community for the efficient use of these capabilities; development of the specialized capabilities should be coordinated with the general health care planning undertaken by the areawide planning agency. In carrying out these functions, the @IP can utilize the capabilities of major teaching institutions of the region and can serve as the bridge between this expert capability and the needs of the community. The specialized assistance provided through the RMP can be applicable to all levels of health resources within the community- IX. Community Mental Health Centers The community mental health centers provide an important element of the health care system of the community. The areai-i-'Lde health planning agency should play a role in establishing relationships and referral patterns between the community mental health centers and other health care resources. These organized patterns of relationships should make possible an effective division-of function between the development of comprehensive primary care, including some aspects of mental health services and more specialized mental health capabilities provided by the community mental health centers. These relationships, however, would not exclude direct or self-referral to community mental health centers for those in need of mental health services. X. Technical Assistance to Communities Assistance in the interpretation and implementation of these guidelines will be provided to communities through the regional offices