@i in *E LJNI,I'ED SRAI'ES ('.OVI,.1@NNIENT DEPAR'I'ML@N'I' OF Ei)IJ(:A-1-ION, ANI) 'VVAr:I.FA',,tE IIUBLIC III-.AL,rif Ivi'em o,@,(@ du m DA'rF., March 1, 1968 Philip R. Lee, @I.D., Assistant Secretary for Iloalth and Scientific Affairs Rlbm Associate Director@ NIH, and Director .Division of Regional Medical Programs UBJECT: Regional I-ledical Programs--An Investment in Improved I-lealth Care,--Fiscal Years 1969-1973 This memorandum aucmcnts the memorandum sent to you on February 16, 1963, i-i'lich analyzed the projected need for Regional Medical Pro-ram @r@inL funds through fiscal year 1973 on the basis of estimated net aggregate demand. In this ,ncmorandum we would like to set forth the objectives of Regional Medical Programs, t he rationale for those objectives, and the outputs which are relevant to evaluating the progress toward the objectives. We have structured this document to a large extent in terms of the concept of the Planning, Programming, and Budgeting Systems. It is our view that this discussion of objectives justifies the investment of Federal funds pro- -jected in the February 16 memorandum. IjItin,,,itc 0I)joctiv(@s The Surgeon Generalls Report to the President and the Congress on@Ret2-onal L@i'cdical Programs states the goal of the Regional Medical Pro-rarii:; is . . . clear and unequivocal. The focus is on the patient. The o'L)jcct is Lo influence the present arran-emcnts for health services in a manncr that will permit the best modern medical care for heart disease, cancer stroke, and related diseases to be available to all.' The ultimate achievement of Regional Medical Pro-rams, therefore, has to be measured in terms of end-product outputs, such as changes in morbidity and mor- tality in these disease fields, and the impact on the quality of life. I-lowever, measuring such ultimate outputs is considered by most leading experts to be very difficult and, in most cases, impossible in terms of relating s ecific end results to specific i p nputs. For example, the death rate for diseases of the heart declined three per cent for the period of January-November 1967 accordin- to the National Center for Health Statistics Deaths from strokes dropped 2'- per cent '2 during the same period while deaths from cancer rose three per cent. Yet it would be very misleadin- to attribute any part of these changes Lo the initial activities of Regional Medical Programs. The Division of Regional Medical Programs is supporting studies to improve the capability of the Regional Medical Programs to evaluate activities in terms of effects on the health status of people. Several papers presented at the recent STE ST REDUCTION PROGRA,%I 2 Regional Medical Programs Confercicc-14orkshop described such t;tu(Iies. But such cnd-product analysis is not yet dcvclol)cd to the point @ii)cr(, it is useful either for projections for the next: five years or for' analysis of the effects of those initial investments during the five- year period. Furthermore, progress in reducing mortality from one chronic disease may have the'overall effect of increasing the inci- dence of another ailment. Interim Objettives Because end-product analysis is not useful for our immediate purpose @of reasonable projections of investment in Regional Medical Pro3rams, we must adopt working hypotheses or assumptions. These assumptions serve as interim objectives for action and are valid bases for cval- uating the progress of the pro-,ram on an interim basis. We fully realize that these working hypotheses need to be tested as the program develops and modified as improved techniques and tools are developed for defining more precisely the effects of program activities. Most of the major assumptions and constraints, which serve as the current basis for the development of Re-ional Medical Programs, are found in the authorizing legislation and the legislative history which led to the establishment of this program. These assumptions and constraints are relevant to this discussion of why a sizable invcstnbnt of Federal funds for these purposes is justifiable at this time and why we can posit that the significant return on the marginal Federal dollar invested in this program at this time justifies increased investment during the next five years. PL 89-239 assumes that a gap exists between the type of health services this society is capable of making available in these disease areas and the actual availability of such services to large senments of the popu- lation. The gap may be in terms of ac@ess to services or in terms of the quality of the services bein- provided. This gap may be widened L) in the coming years due to the continued advance of medical science Unless specific action is taken to close the gap. Many different cle- ments are relevant to closing the gaps and the mix of these elements is different for different areas of-the Nation and for the various problems that comprise the gap. Therefore, these programs are to be developed on a regional basis with the flexibility in the national guidelines to permit each region to develop programs based on their particular needs and resources. Many different types of activity are relevant to closing the gap between our current health system and the availability of high quality 3 care to all. Major elements are stated in the law-. 1) r%c.,.carcii and development into better means for ri4ll"in,, the advances of medical science more readily available to the population In need of these benefits; 2) Training, including continuing education, which can hc'L:., close acute gaps in manpower, create new types of manpower for evolving health functions, retrain existing manpower for the changes of function brought about by advances in knowledge, and can upgrade the quality of existing manpower as it is currently utilized in the health system; 3) Demonstrations of patient care, which serve to integrate into the total system improved techniques and mechanisms for prevention, diagnosis, treatment and rehabilitation, whi.ch provide the means for extensive involvement of our health manpower and institutions in the Oroccss of improving health care capability. Most importantly, the law makes clear that these activities are to be considered part of, and contributors to, the evolution of a system which -establishes and strengthens, on a regional basis, functional relationships aiiong the elements of the health system. The law assumes that cooperation of all essential elements of the health resources in a region is an c,@sen- tial means of topinc, with the complexities of specialization, high cost., -nanpower neddsi and educational training needs which are the by-products of the dynamic advances of medical science. In overcoming the fra@nta- tion and insularity of health resources, it is desirable to establish a continuing relationship with the research and teaching environment of the medical center, the patient care activities involving the co.-=unity hospital and practicin- physician, and other health organizations and agencies. The law assumes that only through such regional arranccr"cnts can the health status of the patient benefit fully from the accomplish- ments of medical science. The assumptions include major constraints. First, the development of the programs is constrained by limitations of manpower resources and by the availability of strong and imaginative leadership. Overall manpower limitations and, in some cases, shortages of physical space for new activities, demand the development of solutions to the target problems within these resource constraints. Another vital constraint is the necessity of modcratin- the rise in medical care costs. The sharp rise in costs requires that means be found,to accomplish improvements in health care capability with extcn- sive attention to moderating the increased cost of the improvements, including the 'utilization.of the advances of medical science and tech- nology to provide superior care at equal or reduced cost. Another significant constraint provided in the law is tfic (Icvcl.opni(.@nL of l@c,,,,ioiial licdical Pro-rams throu(,fh a voluntary cooperative approach. The .,cgioi-Lal Medical Pro-rams may stimulate and foster improvements ill the health care system and establish terms and conditions for participation in activities of Regional Medical Pro,,--.---rrLs, but the programs miy not coerce existing institutions and activities into conformance with the Regional Medical Programs. A final major constraint is the lack of a basis of experience and know- ledge which can guide the developments of Regional Medical Programs. The scarcity of existing relevant models calls for the application of the experimental approach to the development of Regional Medical Programs.. The Ilroccss of-Rcgionalization Dr. Lester Breslow, in a talk at the recent Conference-Workshop, said, "To those concerned with the improvement of health care in this country, re-io-,ialization has become the order of the day." In the revised Guidelines for Regional Medical Programs we 'i".,,ve chosen to describe the overall mechanism for achieving the goal of Regional Medical Programs as a process of regionalization. This process encompasses the development of the activities described above on a regional basis and reviews those activities in a framework where they contribute to an improved organiza- tioii and delivery system on a regional basis. Excerpts from the revised Guideli.nes describing the major elements of this process are attached to this memorandum (see Attachment I). The Primary Output Measure Improving the Organization and Quality of Health Care The progress of Regional Medical Programs during the next five years can properly be measured on the basis of the assumptions which arc explicit and implicit in the authorizing legislation. The primary output measure becomes therefore t, 'le extent to which the Regional Medical Program is achieving the functional process of regionalization that can be expected to improve the organization and quality of health car(,. There are some difficulties in developing precise uniform measures of organizational Chan-es or modifications in the attitudes and behavior of health insti- tutions, organizations, and practitioners; yet progress in modifying the icipantz in the hcaltl-L endeavor should have a very attitudes of the part great impact on the improved efficiency and affectivencSG of the total health care system. The emergence of now patterns of attitudes and relationships in the health field assumes very major importance when it is realized that significant improvements in L'.,,e organization and delivery of health services within the constraint of minimum coercive power are to a Iiirl,c dtilrec dependent upon iiioLlificztLion of prc!,,;(.,nt 1)@iLLorns i-)f r(-,l;lLionsl-iij).;. SolilLioilr, LO 111,Llly Of particular ,3r,,blci-,is of closing the gap bcLw(!cyi potCliLl.a'i and practice depend Upon a rc!,',iI ipprozicti that effectively utilizes many elements of tilc.- health care system, and requires patterns of organization of health care resources that make efficient utilization of expensive cal):Lal facilities, scarce,manpower, or realize the full potential of the new technology. recause a regional medical program provides the fririework for ,tieli @.i process of regionali.zalion, it is tpprol)ri.,ttc that LI)L, primary output be measured in terms of improved organization and delivery of health services. 'Durin- this period of time overall progress is bein- :acasured in terms L> of irit,)roved.organization and delivery of health services, thc,. individual regional medical pro.-rams and the Divi.,;ion are dL-voL!.nir coiisidcra'olc effort to the development of better tool:; for the measurement of the efa'ccts of program activities in end-product terms, such as channels in morbidity, mortality, or other measures of health status, and the application of these tools to the activities of rogioia,@l medical programs.. (See Ati@achment II for some cxaniplef; of thc.,;c cffort,@.) While improved measuring techniques are bein- developed and their application to-SLee-1, the evaluation processes are already underlay in regional medical programs. These procram evaluations in terms of improvciii(@rits in the quality of health care will continue to rest, to a large degree, on criteria established through the consensus of best professional jud','Mcnt. Such criteria will of course, be applicable to individual activities within the regional medical program, and will not constitute a common index of effect by which the total progress of the regional medical program can be measured. Additional Outputs The stimulation of improvements in the organization of health services does not, however, totally encompass the valid output measures of the effects of re-ional medical programs.. These outputs result from the planning and implementation of the individual re-ional medical programs, and the specific activities undertaken by any re,,ional medical program will vary in composition and amount from re-ion to region. Therefore, as the programs emerge into the operational phase, it will be possible 3. to describe these additional outputs with increasing specificity. Examples in the following categories can be identified at this time (see Attachrient II for a fuller description of examples actually occurring in regional medical program5).4 1) Some of the activities of the regional medical programs may be defined as research and development in health services. These research and development activities may be in different methods of organizing 6 health resource.,;, in the development ,Liid LOSLilIL!, in actual Cofilmulli.L ,y use iiciv diiieiio.@;Lic and treatment techniques previously confined to the laboratory research Lii-L(.1 eicv(,lopni(.,nt; in the Lccliniquc of evaluir-ion of medical care, researc'l into improved techniques for . education and training in the health pro'Lcssions, cost-benefit analyses, and the development of now technologies that can moderate increased medical costs, 2) The trainiiia activities of regional medical programs will result in outputs which can be measured in terms of additional numbers and improved effectiveness of health manpower. These outputs can include the development of new types of health manpower, the filling OA. .)articular manpower gaps and the improved effectiveness of existin@ hca!Lh manpower through pro-rans of continuiii- education. These activities justify a considerable level of investment because the improved effcctiveicss of health manpower should logically increase the efficiency of the health care system as given inputs of manpower resources result in greater outputs measured in end-product terms. 3) Demonstrations of patient care in regional medical pro-rams t> generate outputs in terms of the delivery of health services and the. prevention and control of disease. All of these additional outputs are occurrin- and will occur within Regional Medical Programs, but these additional outputs will take place within an action framework that influence::; tl-ic improved organization and delivery of health services. Therefore, the multiple outputs will have a synergistic effect in terms of improved health care. Factors Affectinf,, the Level of Investment In order to make a decision concerning an appropriate level o investment in these programs a number of factors should be examined: 1) All elements of the health system are relevant to the purposes of the Regional Medical Programs. In order to achieve the purposes, the impact of =I activities has to be felt at numerous points in the System with extensive involvements in the activities of the pro-rams. The r.,.ag- niludc of this task can be seen in the numbers of elements that should be affected by the programs, including the 5700 general hospitals, 100 medical schools, 285,000 practicing physicians, 640,000 nurses and many other health organizations and institutions. Since the total slrcam of activity is so great, any activity intended to brin- about modifications and improvements in the total system requires sufficient extra funds to accomplish these modifications. In order for any effects to be seen or measured this basic investment level must be considerable, and an invest- @ment below this minimum level might be substantially wasted since the opportunity to demonstrate the validity of the assumptions on which these 7 pro-rains are based would be lost. It is not lilcoly that there is a eiroect proportional relationship b(.,twer-@n invcstnic@rit and return ii-c, I- i I this critical mass of initial fuiidin(-, i,@ cxclcclcd. in launciiiii,, nci,7 programs the initial iiivestuiLnLs must bc.- considered as risl@ capital with a considerable potential payoff. The extent to which tlic invest- moiit acliieves its expectations can only be given a full evaluation if Lila initial capital is sufficient. 2) The return on the funds invested to date seems to be-consider- able 2;..i terms of the preliminary informed judf,,Lients that the Regional Medical Programs have prospects for,making significant progrc3& toward their goals. This was the conclusion of the @')tirercon rc!ncral':; P.,c-,po-rt to the President iiid the Conf@ress and the conclusion is strcngllhcred 'by the recent Confercnce-WorkGhop on Regional 14edical Prograras@ Thc initial return justifies additional investment especially since reach of the initial progress has taken place in anticipation of that further investment. There is evidence that the return of marginal dollars invested in these purposes continues to be high when measured by the achievement of interim objectives. 3) The costs of the various types of activities that are being undertaken in Regional Medical Pro-ranis provides some indication of the magnitude of expenditures that are required for ,@ucli activities as: the organizational infrastructure of the Regional @ledical-Pro-ram including the planning and evaluation capability as well as sy.,,tcirs for the gathering and analysis of;,data on the health care systciii; educational activities which must reach nearly all of the currc,.,i'u-'pool -a of health manpower; demonstrations of patient care that are sufficic tly distributed geographically and are supported at a level that can catalyze improvements in the total health care systems; and the development and o@,ioloration of new means for organizing health care and for utilizing C2 new technologies. It should be stressed that tiicse types of activities are unlikely to be supported at a sufficient level to accomplish these purposes within the existing orgz,,nizational,institutional, and finan- ciii- frameworks of the health care system. Therefore, these purposes can only be achieved by some additional investment external to.the current sources of financing of health care. Conclusion Thera are two approaches that can reasonably be -idopted to determine, the actual amount of initial investment that will generate significant progress towards the goals of Regional Medical rrograms within'the next five years. The estimated not aggregate demand of Lila Rc-ion al Medical Programs, ci as outlined in the memorandum on February 16, is an appropriate basis for iiivostnioiit decisions in the initial rLagcs of this arc -ciicratcd tlirou,-I-i a process that is rc,-@ioii,il -oils and prio@itics and wliicL-i ti,.'il-le into consideration the various resource constraints within the regions. Until @:pcricnce is c,a4Lned and evaluated this estimated dcrcLaiid, after careful rcview-and C> evaluation by the review process at the national level, might constitute the most reasonable estimate of the investment needed Lo provide a basis for determining whether a program based on these assumptions can-achieve its goals. Since this pro,-rarti has many ccpcrimontal aspects and s;-ncc previous models do not provide much information on which to base iiivcst,-acnt decisions, it is also reasonable to view the projected investment for the nc:,,L five years as a level of effort based on a proportion of the fundii-t- for the total health care system which this ii-tvcstmciil in- tended to influence. Ti-iis.initial level of effort could be vicijld as the iiivestilio-itt necessary to make productive change, C.,;[)ccially for accomplisliiii,, improved quality and distribution of care. If the total national investment in hcalLli by 1973 is running at a level in czctss f 60 billion dollars per year, the effects of investment -rhrouc,ii 0 Regio-,ial Nicdical Programs should be measured in terms of i.mprovcr,@,ents in the system, not just in terms of units of activity purchased with the funds. As an initial level-of-effort investment dccision,.tlie proposed authorizations through fiscal yc;.z 1973 constitute lcss-than 1 per cent of the total annual national expenditures on health. Therefore, we believe that the estimates provided in the memorandum of February 16 are a reasonable basis ior projecting the investment in Regional Medical Programs at this time. D. Attachments C; I I A 1Ti I 'rilL i\A"'U!'],' AND OF CO,\T, I 1)1,ICCS tllL' Goal Of Cc! @!-C;ll 1) - lisloric@ll co,,iCc%L and iliVo-S I ful-l-c-C 900 lie keL 1), 'Wliic'&l 1 L fori',I, L',',e Coal is described! ir, I:',,u focL@ i:; on t,Llc p;,i:: i ence the prn@Cllt larll:liiio s to ill u llc!al":,Li sccvacc,,; that: will permit the best in niod'cri% mcdic-il care for heart diGLz,@c cancer, stroke, and related di:;Lla:;es to be available to all.." S Ti'T? PRO"7SS 01' I l-(,'T.O'i\'AT,TZAT"O'i\ riA i\ I,. k., i \'o t c 'R c -Loiiali2ation car, connote T",Orc tlia-a d regional cool)c.Lat:iv@ but for the purpose of tire two terms will be i;@cul L Uses "rClioi7.@al Coo:)Crz-ktiVo The Ac aruangcmciit but has beconic a more convenient synonyiA. A regional cooperatives. full arr.,i,, of health rc:;ourccs is a necessary ill dv@i-.ic@s in medicine to people wherever tilc live, ill tl,,,c:y a y !love (Icfille(l. It ciizlblcz; Lo bc-@r,@f.'Lt fro.-,I Llic.- ind divi.,;-Lo o' I.,,iboi.- wind-, inCV-;.Labic specialization 11 Of m@dical l@iiowl.ceigc 'bccii.i.@;c it providoL; ral@cL'.OiIS'Llil,)S anion,- liciltli personnel -ii-Lci the atic)ns in WiliCli they work "'his rCcluil7e(,; a of -'Lv @'L z L L .lead i-.I!;'.'iLuLional spirit and resources,; w'iiiCli IIIUSL I)c xqor',@ed oiiL 'L)y cac Pro-rai-a. It is facilitated by voluntary "'o serve, sy6te,-IaL4-cally, Liie needs of the li)Uli)liC ZS rC,,ar(iG the CaL@-TO.--Cal diseases On a rdgional rather than sonic r@,ore narrow basis. ilc,;ionalizat-@'on, or a regional Cooperative several other 4,-.,7)ortant --accts: con%-eyt of Rcaional Medical Progra,,iis has A. it is both functional and character. Functionally, regioaalization Di@T i@,; the iiioci).iiii.,;ni l@k)i- i@Ild C.,clz;cz-iL-I.c,,n Lo r)'j-oV@.dc'. '.ICt:iViLiLt,-; WCII a@j Liie total L of a ,,cl:vc Lo for \@'iiicli c;icli riicd and coiicc and rcspoilsibi-'Lit:y il-,olild I)C '07 responsiveness, wli-icli i.,@ cEA'ccLC(I 'i)y providing the pol)ul.z,16-ioi-i wiL'ti ct ciii-, voice in the rc-iona'L pro-ravi's u dccision-making process. It I)roviCics a i-,ic A- limited LO l,,llill)owvl7 ailtl f. I-al.VC LIIC (1,ULliLy Vll(l Li;'ti',L:iLy 'C)i' and service available Lo Llic population, and to do ti-tis as ccoilo,-@--ica".LY as possible. 'In soric in!3tarCC@;, Vay require iilLcr-rcg.-Loi-l-@..,Il COOI)Cratioi-, bc;tl,?Cell LWO or ariong several Finally, it a'L-so constitute.,; a ior c ordinating it6 caLcg 0 in the rc,,io,,i @,ritli otilor licalLI1 so that their coml)il'lc-,d effect 'TINY 'bc: iicrciscd and so t'il,-i'L L410-y C011tribuLc to the creation ind niai.nccilanca O': a ,;ysL@n, of conlprclldnsiva licalt'ii care wit'llil entire regional 0 PrOgra",', Zra-,-,t to it is not the intent f a Regional @L cithor Federal or non-Vedcral sources of supnort or varlo'us zcL.: re'L,-,Lcd to achieving its Purpose. 0 provides an opportunity Lo illtro(It,cc activities %vllicll d,:,,Iw upon a,.I@ C'4..6ccLively link zicLivitics already supported, or throu@,h oLliCr sources. ClirrCilt of other ";.,Cclcral Pro- resources- o@ that provide essential inputs iiito tire,. i@egion are: otlier activities of t.) particularly the 'iNatioilil licarL Iii:;LiLuL(.,, urolot -and Nitioiiil Institute of Nc I)iso. @;cs o' coii:-ItitiicnLs of the Department of lic.-illtli, I-L,UClLiOll, illlcl I)arLiCUlarly tilo'Comprellcllsivc in tire Office of the Suri-,coi-i Geiicrzil, tlio liureau of Dise@iso- aiiu' !Lavironmental Control, the Bxireau of llicilLI1 L\'*all-,)OwCr, LIIC II I I nRArT !)roco.,-;s of rcf,:Loiiiilizauioii, cr of ZIL 10@',,;L tilC fOllOWillg ClCnICI-IL@i- -l'iLiL Ol)jOCLiVC,-;, ,ieLLiilg O' I)riO l@ll-,ilc t'll,,c,,;c seven cjclacllt:s ill the proccG.I; will I)C dc."jcrir)c..d a-,IC', L@7 cu@;sod separately, ill PrZICtiCC tilLy are interrelated, COL'IL';-Z-,UOUL; arc; often occur simultaneously. Tiia involvement and Of )iis iiid institutions Which Will onga,b,c i-,l a itedical Progrilni, is well. t:]-LOGO @iliicli wi!,L i)c by tli4.s activity, Dill.-,L tindor'Lic -a l@ci.,,ioiial !)ro3raiii. ily irivolv .L the stcj)s of study and decision all those in I rc.,@11011 W@io "I,:L to iniplei,,,,antation and ultimate :3uccc!;4;, L)ct:tc.@r ,;ol.utions.Tiiay 'ou Zile opportunity for wider accc,,)tiincc o@' dccisioi-,G is iri,)'Leiiic,.itLtion of decisions i s a c'ii -7-cvc(l iror(2 r@ipiOI.y. to health resources; Oil 5 Lli@'fiell' Ly Qr liive been (livcrt-od fl:Oll-k LliCiV Ob'UCLiVL.i Was IIOL this Voluntary inVOlVCI','iCIIL -Ill(! CIO-.1',Illit',IICIIL )y LT-IC individual.,;-, institutions and organizational. The tct is Lc i,-@cc:Lz:Lc to a!;surc this necessary involvc,,.icrt in l@c-io-nal Mcd-@.cal L) dcai-ics, for example, the minimum conil,)oSitiOn Of RL-ional Advi@ory Orou?s. Ltl,-) ,%CC SLZITCS these Rcgion@il AdviL;o-:y C;roul)s inc'Lud@ physicians, nicdical c,2iiter officials, I: c - sontatives from appropriate medical 1IL:.-Iltll and representatives 01 Other OrganiZ41tiOnS, co;iccrncd - activities 4itli of the Irin(I to [)c ci-l:rice, or, under and members ol@- the public faiTiiliar wiLil Li-.C I-,LC!d f-O-L- the under the progrlka. To ensure a opl)or,:Ui-,@'-Ly @or Z;ic cor,@,I)o@-ition of the Regional Advisory Group also 1-tould 1L)ct @cf,CCL-.,Vc, of the tOtll SpZCLYUI-a. of health in,@o-ccsts and resources O.' ":"I@ rc it should be broadly representative i,-on. of the gco,,rapil4lc ;areas and all of the socioeconomic groups which will be served b tac Regiona y Pro -rari. 2 of Health Service.$, the.Social Security Acii,lini,,@',:rition, the Of-.7ice 0 -A, Education, and the' Social and Rehabilitation Service; and ot%icr Go-,,orn Tient agencies, particularly the Off:cc of Lcoilo-.-.iic L..- ',,'o(lel Citici;,I"rol,,rain of the Dol);II'LlllCllt Of -it, @iiid tli(-, Ve terms Now ok@ for aCt"'-ViLio.; rclntc.-d Lo a durin,, both the planning and oi)crat:ioii.,il 2 National Advisory Groul) should !)rovide Over@%I'L iiclvici in the planning and operational Prograiii, I'rOlll the i.riLiii SL:C,)s ill LC):I.1t; Which OffLI: of i',ICkliC.-il C@,irL- fol: LIie Lll:,,,CL it riu,@t 10 beyond a pcii@r@ilizcd to iliLo OI)L!r;itioiial ictivit@. Ilart cul@a,: de.@inea by: ideas and approaches generated Li-,C,. t C.,zC) 0 -4z -LiviLics already rcscnt WiL!i-@@il the cLild developed elsewhere which lili"llt be ai),nlicd with :(c;@ oil. activities jkrion,@, various identified liae(IL'. there also -,re Ofl:cll %,Ylicn perceived, offer even i,,rcaucr opportunities for 50IUZ.Lc),it:;. of 11 if The diii-,,,cr project vision, which ii3 alciii to tunnel be guarded against. O' O-\amining the prol)lCTil Of COI'O",":Y Care UnitS tilroUlllioUL -@@L:; I, for example, a PcgiOnal ?rO'raiii iiiay rcco,-,nizc that tli,2 Gore c@r approicli %,7ould be to coi-isider the total prol)lcni of tIlC C,;: irlrocardial infarctioi patients Within tLic,. l@cgioi-1. Ti-,:LL; @PI)ro,-tcil on a regional basis enables the Lo the total array of resources within its l@cgioii in to coriprciicii-6ive progrl,@,-,. for the cire of the niyoczl,..d:L@.11 @rfai:c',:ion' wi@,,i@ was a concern of individual 1-io,..;pitals al-iou'L- 'A@lo%.j to introduce corollary care uni ts has been transformed into a projcc;z or group ot L@al for c@"Lectivc and 0:4.ic.-,LL'nt rcl,-ttccl projects with inuch greater poten utilization of the Region's resources to iraprovo patient care. the I)ROCCI; As part of of Resoiii. a Of rCiOrialiZ a l@cL-,ioii iiust have contilLuOusly Updated iiivliit:ory of rL'@0',;rC@S I I I and capabilities in ternis of fu',ICLiOll, size, and CUal4.iLy. v Q y cfforc should be riade to identify and use existing inventories, in LI-,a ga s as needed, ratiiar than Setting OUL on a long, expensive p ly involved in 'the review AnCC C@nG@ II It should be active Cooi'dinILCU' c;,,raluaLion of the ongoinL-, planning and ol)c@ati@ig c t I-, s@,ou'Ld be constituted to encourage cooperation Occ"l health organizations, health personnel, and :state Illd I lied under tlit sucn as thd health planning bodies 'acing hbnsive health Planning Pro&rniii, Public l,aw 90-174. it should be concerned with continuing review of the ddgrcc of rblcvancc 0" itics to the objections:; c-f 'Care planning and operational activ A. I'& C.; 0 'eledical Program and particularly with the effectiveness O' t' activities in attainill& the Coal of improved patient care. The 4 i.@, o r y DILKFT OL ;Oll t:.i L t! Tiic inVC'.IILOI:y Zill(I I)riority ,;ottin- Oil IL Vo iiircc,@--voids 6C'VL'10,@) IILW resL new colifleurilZioilL; of re@oUrCC,5 Lo IIICUL, ii 0 1) v A Rci;ioili). ill tile I)roCes@; of SeLtill-I OpL'r@lLi.C)ll,'Il LO -I(--CL 7T identified Fees and opportunities. O'Dj CCt iV @tc to\@,ird tl,,c, Goal defincd -t t tlip- of- 4i acliicvciiicllL Of tIlOSO Objectives SIIOU'L(I li@ivc@ cffc.@C" -@r, @lu P,.C."-' felt beyond the focal points of tile individual . 'Z 'I, 'I.' I @! I L CZIAI De One of the greatest contributions o@' l@cgioiial Tlio c,)i;li)lction of a n(,.@-i project to train iiijrses to c@irL, z-or canccr oing new c ),itionts under,-, oribiiiations of- 6rug and r.-IdiaL-on should benefit cancer -)@iLiClitL; iiid Should I)ro@idc! additional trained manpower for -,iaiiy liot;l)itals in l@-ioll. u 1: lie Rc,,ipri's nuri@ing the project also should have C'Ilallollge.:l L hot;i)-A.tiils Co-,Il;llUlliLie.'; to iMprOVe the continuing and in-servicc., education OpporLunities-for iiurscs within the hc,-io-,i. 1,3_c,. 0 -41 P I, i. 1'. t :i (- P) - )3c..,caucc OIL hundred financing -,,iid other resources- a llc!,-,ion r.,,u@t as.,;ign serve Ord(-'-,C ol-' prior4.ty Lo its objectives and to tile Steps to aC]l the I-;.iiiitatiors oil resources, factors to consider include: 1)" batch bctx,,cc,,i Viia t should be done first to the l@ci,,I.on' i-,LCd., bsoluto terris, and what can be done rCSOUrCC'S a,-, c C,.-. a tcnco; . 2) the potentials for rapid and/or su'L)staiit-Lal the Goal- of Regional @tedical Prograi,,is an(! progress toward of 'ncaltli rcgources.and services; and 3) Prograii baliiice inc of 'disease categories and in tc;::: D.@ emphasis on patient card, cduc"Lio.-, and research. T.-,,.i)].(!nicn-Lition The purpose of the preceding stc,,)s lics boc!n to A. 'Prov'do a base and imperative formation. lfi the creation of all initial Group does not have direct admiiii4;traL4LVQ responsibility 0 -Z. tile P::o- but the clear intent of the war; that LIIO G-zoi;r. would insure tliit the Regional i@'tcdical !?rocrain is With the continuing advice and assistance of a group wli-,A.ch 1 i; - 1) ol y representative of the health interest.7. of- 'the I'@orioi-i4 The IL4viL;ory Group is expected to prepare an annuil St,'ILCInCnt tivill- it,@ of effectiveness of Clio roaionil Cooperative under the Regional Medical Pkogr6m.. DRAFT iI @ I I I I ; . I I I L . . , i I I i ,I I l@rol,,i:.ini, iio l@(,;;iuil C;ll'i Lo L 1.0 1.0 II @ill 01)(,riit:iol)i.-tl Ci-C of tile I)-,:Ojcct,4. 'ilill).I@IIICIILILI.Oil C@iii Occur wi'L'il @,n i.li@.L i,-i'A.' even a iiuiiil)ci- of- I)roju@L@ wllicll will iliove tliL, Ilefion towird tile @iLtaill-,FiCil": OA-- v@'@i(I Obj CC L i',Ic liecau:3c rcgionalizitioii i:; a CoilLiriUO'Ut; is expected LO Continue to stiL)iiiit su,,)pl@nieLital and additional ol-@cr--tional proposals as tlicy are developed. @f tcr tile ill tation of an ol)craLional pro- tlirc,?,L,, Lo be avoided. One is ti)i!L I)rojCCi'.S will @egioial idciiLiLiCS by becoming institutional ,)17ojL-cL,,, and CanCcl tile opportunity for the operational Lo 1)@i,,/c-. sco,)c Miller effect. The other LlirL,,-Lt is tIlZIL I)rOjc-'C'U'.'; Wil'i 10.,;(- L"'.(- reizitionsliil)!; one to another which niainLiii-L the interaction L n;: care, calicaLion and rcgoarch. Proveiitin- tl)c:;c brealtl,,(:o@is rc..quirc,- projccc I',Id program adiiiinistratio,,-L of a Iiirli order:; it also rcc,.Q:Lrcs sustained communications involvcricnt, and the application of CValUaL-.on procedures. I,-iiinini, iiicl @ac@iviLy ol wall .1.,; Llic,. overall -receive iiid qu@iliLilLiVe e_lv-lllllLiO@,l W110-rt.VOr -'Ilotll,d I)(.- ill LCI:MS Of attlilllll@IIIL Of ilILCI-ilil OI)JCCtiVL,;, tile I)rOCC:z;6 01: -iti6ii aiid b,ic Coal of I'Ncgioiial l@iL-dical rc ObjoctivL, evaluation is ,;i-,iipl.y a determine WI-IC.'Lllcr an activity should be continued or alLCCC-6, ultimately wlictlicr it icliievc.,d its !Arco, Llio- C.,v.11 u.1 o@@ One aCtiViLy IIIZly Sugf,,C.I;t modifications of@ alloLlIer activity wii-.-'Lcll would increase -its CffeeLiVelleSS. 'v-'uation implies carrying UL WliatL-@VCr is feasible Witllin tic state L I.L 0 of tric art and i propriaLe for tile I.ICLiVity I)Llill@v LIV;IlUat:e@'.. '2'4 't L.,,; evaluation can range in ConipleXiLy frorl Silil,)3.y COUIIL@.llg PC6,,)lC a@- InOCtilips to LIIQ r.IOSt involved determination of bLIiavio-;:@il ciiangcs in aLicnt management. p :L -tic As a first stcl), however, evaluation onlaols a rcalie. to they are inil)lci,,iciitocl and filially 'Co,,ic',L'u-'cd, ideSior. activities Go thdt, as 11 be useful in dot i-miiiiii the dcgrQo OA. Some data will result which wi c 9 success attained by the activity. DRAFT o II r) ol),.l 'I xe.(, -;I ',I,, LIIC .1; VIC C (2.1,; S(i a' Lo Wli.i.Cli :!.t. I.)".. Clill)UCI.-: i)IVOIVC;,I(,'IIL, Ol)',)OrLUUiLiO.;, @l,-,SOSSnICIlt Of rC.';OU17CCS, d@!fillil:!.Ol-i O$' SetLill- of priorities, iniplliiientation, and evaluation Ulti-,Illte'y, Llic success of iiiy ReF,- onil ivicd-'cal Pi-o, judrcci 'oy the extent to wiiich it can be tllat Program I-,as assisted the providers of health services in c:cvL-lopi,-,3 a systc-.u which inal@es available to everyone -'Lii tllc lzc,,io-,i improved care Aor heart disease, cancer, stroke, and related diseases. Attachiacnt 11 EXA@IPLI'S l@,CTIV'[.T'(T,',") llu,,ic)nal Yiedical Programs, as cooperative endeavors for iniprovin3 the organization and quality of health services in tiic@ce disease field,,;' a variety of desirable and interrelated outputs -'Ln addition to this priT--,.ry output. Indeed, some of these additional outputs are attainable only tlirou-'n such cooperative ventures. Ilany of these additional outputs of program aCL4,vitieS can be oral catc(,ori included in three gcr iz- es; (a) Research and development in health services; (b) Manpower training; and (c) Actual'dolivery. services, includin- prevention, detection, and control of disease and its sequellae. E;@amplas of actual program activities illustrate the diversion--, of outputs: -1) 'Rt-:@., rcli a-,id Developm,--, i.n Health Servi.cer, in developing their plans the r, "onal medical programs hive-iiidicated @'that if- the goal of improved organization and delivery of health cz"@r@ is Lo be met, sonic entirely new means must be developed, and then accepLod by those rendering care. Many regions are using research Ealcnt in investigating new means for improving health care by testing them in the actual practice of medicine. 1. Temporary but lifc-threatenin- disorders of brcathin-, heart beat, blood pressure, etc. often accompany heart attack and stroke. The region containing one of the Nation's most sophisticated'ooiiioutcr centers for monitoring such disorders has linicc(; 'L:our community hospitals to the computer center at the Lattcr Day Saints Hospital in Salt Lakd City, and is studyino ways by which automated monitor- ing may be extended to all hospitals in the Region,, 2. The Intermountain Region and the University of Michigan Department of Industrial Engineering to-othcr are dcscribin- the functions of specialized units for the care of patients with heart.attacks Using systems and operations research techniques, both theoretic and actual model "coronary pare units" will be constructed, allo-,,,ing for.the most efficient and effective development of these units throughout the Nation. 3., To survive cancer, patients must be treated rapidly, vigorously, and optimally. Physicians must not lose sight either of their patients or of the latest advances in therapy. 'Four regions are now experimenting with computerized registries of cailcer.patients. Physicians@ treating cancer patients will regularly.receive reports listing their patients and the type of cancer, the progress of the and a comparison of his progress with optimal progress, and the best types of therapy then available for that particular type of patient and cancer, 2 4. Ver@@,i,.)nc is expo-rimcntin- with a systems -pproach t@@i tli, of medical care rencicred within the Re-ion. U@,(@ modern atiilytical techniques to study, f4:or exI-triplo, pupullLioll distribution, disease incidence, LrcxLTnent aict economic benefits of treatment will allow decisions to be.made which best fit the Rc,,ion's particular economic constraints and the 1;encral constraint imposed by the necc3sit' of moderating the increase y in the cost of health care. Concern with service of any type leads ii,.u@!,:2diatcly to a of nivnpowt2r needs incIL:.,iig the more efficient and effective ,.iLiliz--tion. R,-Icional ',L%Icd Ij 4j ical Programs has a direct charc,c to "improve 'generally health manpower of the nation. This has led to consideration of.l@ind, number, @nd quality of health manpower. Educational activities improving quality are important to Regional Medical Programs, but somewhat unc..cdccted were the needs demonstrated by Regions to seek new kinds and numbers of health manpower. Shortages of personnel have resulted in'two interesting experiments: 1. I.Ietropolitan New York City, having a shortage of trained manpower but a surfeit of disadvantages and potentially employable persons in its midst, is studying ways of developing health careers training programs, and finally, placement programs for'.those trained. th a similar manpower Shortage 2. The Colorado-Wyomina Region, wi but no untrained labor force upon which to draw, has developed a different solution. Colorado estimates that fewer than 15 percent of its residents having hioh blood pressure are either'identified or being treated adequately. Since t,-.@ required mass-screening.program would be too great an effort for the Region's physicians, nurses nurse-practitioners are being -;-r)ecially trained as fu'@Y competent to conduct a sophisticated screening program-. 3. To increase the availability of tr,,ii.ii(!d ni;iiil)c)wLir, Rcgi.()ii,; are clesil,i-iiiiL.,, new attractions for split shifts for nurbes--broador career ol)i)orLuiiiLic.,, nice opportunities for career shifts by allii@@(I health workers-- and new types of on-the-job tcfrcshl@r courses arc bciii- offered. A-hi-c)ugh a cooperative effort of Los AnUcles County, LLC Charles E. Drew Medical Soz,i,cty (a component of the liatio.-,zil Medical Association), and the California Regional @ledicil Program a new community hospital and postgraduate medical education program is being planned for ".".Lts area of Los Anf,@,lcs, CaliforAia, 3 (c) Dclivcry of Servl.cc's While @ielt'ital care of pttients it; not a primary activity Of any Rc,,ion, rianv projects do result in the delivery of high quality services, including prevention, detection, and control of diseases: 1. The legislative authority for "donic)iit;tratiorLr, of paLicnt cai:l@I" results in L c esL of care einc, given to a number o@ to the establishment of the Mississippi Regional M,--dical Prograr.,i, no hospital bLd4; N,.,L!ro- available to 'llic large nu,-,,,!-)(-,r of indigent nogro or white patients with non-hcriorrhagic stroke, rolo-ic'spec,.alisto available to render c@xpf@.rt care. nor were neu el 'Ehe establishment, through the Ifissi ssippi Regional I-,Tcdical Program, of a four-bed unit at the University of Mississippi for the demonstration and teachili- of comprehensive care for the stroke patient, is res'ulti.-,: in an example of excellent'care being available for the first time which will favorably influence the quality of care provided to i large sc-nic!ii-@- of the population of the state. 2.. The Tcahcssee-MidSouth Region has responded to a specific need of @Icharry lledical College and a nearby Neighborhood Health Center, sponsored by the Office of Economic Opportunity, for efficient and rapid screening of patients E,@ a variety of disorders.. With the uxpert assistance of Vanderbilt University, a multipliasic screening laboratory is being planned. While the major question to be answered by this project is the best method to screen a rge population for specified disorders, answering the question will result in the much needed detection and subsequent treatment of disease in the population to be served.. 3. 'fvjo Regions, Washington-Alaska and 'Tennessee Mid-South 'have recognized that computation of the precise dose of radiation required by a patient with a certain type of cancer is a therap' can be difficult and complex process. While the actual y administered by technicians, the machine settings, the skin area to be included by the radiation, and other factors can be calcu- lated only by a few specially trained physicians, often-not be be found even where treatment facilities exist. Two Regions, on opposite sides of the nation, have developed computer programs for arror-free dose calculations, and'are extending this service by telephone links between hospitals and the computer. This has resulted in the optimal treatment of many more cancer patients. Variety Of projects have related to detection or contro.'L o@(' LIILIS, i@ii timing to their piLi.cTiL.0, the latest advances ii-L i in I-',cgions have rc!coi,,ni@;cd nc!@,, tc@cfiiiiquo. !IL)pulzition6 at risks and the population with carJ.y, and Ltierel'OrL, Tr,(.)rC treaLabl(4 disease. 1. Child Clinics, llc.@ad Start Programs, and 1)r@,.icticin& liysicians' offices are the resources for cardiolo,,@ic c--@iisult@,tion p anL case @'-.@Lnding in Georgia. Children with early and pi:(-v@.ously unsuspected heart disease are identified and brought into programs of prophylaxis, vocational and educational guidance. Thus, a program initially identifying children with car,liac dif'Licultics expands to fulfill the total physical and social needs of the child. 2. The Advisory Committee to the Sur@,,con General on Urban.llc-.iltli Affairs stated: "The time has passed when action to p-k-ovide (comprehensive personal health) services could be carried out by compartmentalized institutions and isolated units. -Now it is necessary for the various public and private components to assure eff ctive delivery of all health services needed by each c individuals liultiphasic screening program initiated in Tennessee '!id-South regional liedical Program and other 'A@ei;ions will identi y patients not only with heart disease, cancer, @trolre, iT,,,@InuLriLion.,' obesity, and diabetes, but also those With tendencies to diabetes with hypcrlipeniic states, gonital and cervical dysplasias, a-,id others. To so label patients will create a demand for a, second- generation" response, and compel an unpredictable expansion of the pro,,ram if patient needs are to be served and patients are to be afforded "the latest advances in the diagnosis and treatment of diseases." 3. In Iowa, a pro-ram is developing for the detection, marii,,cmcnt and rehabilitation of P.,@@.:,(-nts with a high risk of havii-,,-,,, a stroke or who have already had one. This prorrani@ carri.,-d out by a team of physicians,'nurses and physical therapists, cons4.sts primarily of consultation services and continuing education f@)i: health workers. The team will regularly visit various parts of the statei With broadened perception of the potential for earlier detection, for more,aggressive therapy, and for nicaiii-,igful rehabilitation, the@incidence of stroke and resulting iml),iir,.i,.ont is expected to decline. The imagination and innovative energies. of that Region art certain to multiply programs not yet implemented.