imilillp$PPIIIII rani. s For Heart Disease, Cancer, Stroke, .And Related Diseases Regional Medical Programs Service Health Services and Meiital Health Administration Bethesda, Maryland 20014 34 )Pa' M(-dical 1'ro,-rap, t(-@ ileveiol, ol)@@r@@itioiia! 0 survex@s of needs @ti)d resource@ 0 feasil)ilitv studio, 0 craaiiiz@,ltlon aiid stiifiing 29 @043 REGIONS AND PROGRAM COORDINATORS OR DIRECTORS I ALABAMA J. L WH@ BLD. 9 CONNECTICUT B. B. Wells, M.D. Area III Coordinator H. T. Clark, Jr., INLD. 1917 Fifth Ave. S. CaliE Committee on RMPs 272 George SL Birmingham, Ala. 35233' Stanford University New Haven, Conn. 06510 703 Welch Rd., Suite G-1 2 ALBANY, N.Y. Palo Alto, CaliL 94304 10 FLORIDA F. M. Woolsey, Jr., M.D. D. Brayton, M.D. G. W. Larimore, M.D. Assoc. Dean and ProL Area IV Coordinator Director, Florida RMP Albany Med. ColL Calif. Committee on RMPs I Davis Blvd., Suite 309 of Union Univ. 15-39 UCLA Rehab. Ctr. Tampa, FI& 33606 47 New Scotland Ave. West Medical Campus G. C. Adie, M.D. Albany, N.Y. 12208 Los Angeles, Calif. 90024 South Fla. Area Coord. D. W. Petit, ALD. Florida RMP 3 ARIZONA Area V Coordinator Four Ambassadors D. W. Melick, M.D. CaliE Conunittee on RMPs 801 S. Bayshore Dr. ColL of Med. USC School of Medicine Miami, Fla. 33131 U. of Arizona I West Bay State Street 4402 E Broadway Alhambra, Calif. 91801 I- Crevasse, M.D. Suite 602 J. Peterson, M.D. Nooh FI& Area Coord. Tucson, Ariz. 85711 Florida RMP Area VI Coordinator Lakeshore Towers Calif. Committee on RMPs 2306 S.W. 13th St. 4 ARKANSAS Loma Linda U. Sch. of Med. -Gainesville, Fla. 32601 R. B. Bost, M.D. Loma Linda, CAHL 92354 500 Univ. Tower Bldg. J. Stokes III, M.D. I I GEORGIA 12th at Univ. Area VU Coordinator J. C. Barrow, M.D. Little Rock, Ark. 72204 Calif. Committee on RMPs Med. A@ of Ga. 7816 Ivanhoe Ave. 938 Peachtree SL N.K 5 BI-STATE La Jolla, CaliE 92307 Atlanta, Ga. 30309 W. Stoneman III, M.D. R. C. Com@ M.D. 12 GREATER 607 N. Grand Blvd. Area VIII Coordinator DELAWARE SL Louis, Mo. 63103 CaliL Committee on RMPs VALLEY U. of Calit-Irvine CaliE Co& of Medicine G. Clammer, M.D. 6 CALIFORNIA Irvine, CaliL 92664 551 W. Lancaster Ave. Paul D. Ward Haverford, Pa. 19041 Exec. Director Calit Committee on RMPs 7 CENTRAL 13 HAWAII 655 Sutter St., #600 NEW YORK M. Hasegawa, M.D San Francisco, CaliE 94102 R. H. Lyons, M.D. 1301 Punchbowl SL E. Rapaport, M.D. State U. of N.Y. Harkness Pavilion Area I Coordinator Upstate Medical Ctr. Honolulu, Ha. 96813 CaliL Committee on Rmps 750 F. Adams SL @ racuse, N.Y. 13210 14 ELLINOIS ay San Francisco General Hosp. 22nd and Potrero Ave. Wright Adanu, M.D. San Francisco, CaliC 94110 8 COLORADO- 122 S. Michigan Ave. Chicago, ][IL 60603 R. M. Nesbit, M.D. WYOMING Area 11 Coordinator H. W. Doan, M.D. Calif. Committee on RMPs Univ. of Colorado 15 INDIANA U. of CaliL-Davis Medical Center R. b. Stonehill, M.D. School of Medicine 4200 E 9th Ave. 1300 W. Michigan St. Davis,.Calif. 95616 Denver, CoL 80220 Indianapolis, Ind. 46202 4 16 INTERMOUNTAIN 25 MISSISSIPPI 30 NEW JERSEY C. IL Castle, M.D. G. D. Cam bell, M.D. A. A. Florin, M.D. Assoc. Dean U. of Mis& Ared. Ct,,. 88 Ross SL U. of Utah ColL of Med. 2500 N. State St. E Orange, N.J. 07018 50 North Medical Drive Jackson, Mis& 39216 Salt Lake City, Ut 84112 31 NEW MEXICO 26 MISSOURI R. H. Fitz. M.D. 17 IOWA A. E. RikU. M.D. U. of New Mexico W. A. Krehl, ALD., Ph.D. Medical School 107 Uwis Ifall 920 Stanford Dr, N.K 308 Melrose Ave. 406 Turner Ave. Albuquerque, N.M. 87106 Iowa City, Ia. 52240 Columbia, Mo. 65201 18 KANSAS/ 32 NEW YORK 27 MOUNTAIN STATES METROPOLITAN ]Ft. W. Brown. M D. 3909 Eaton Str' A. M. Popma, ALD. I. J. Brightman. M.D. eet 2 E 103rd St. Kansas City, Kan. 66103 525 West leffeison St. Boise, Idaho 83702 New York, N.Y. 10029 19 LOUISIANA S. C. Pratt, M.D. 33 NORTH CAROLINA J. A. Sabutier, M.D. Director, Mountain States M. J. Musser. M.D. 2714 Canal Street RMP-Montana 4019 N. Roxbo-ro Rd. P.O. Box 2829 Darhara, N.C. 27704 New Orleans, La. 70119 Great Falls, MonL 594ol 20 MAINE L. M. Phillips, M.D. 34 NORTH DAKOTA M. Chatteriee, M.D. Director, Mountain States W. A. Wright, M.D. 295 Water St. RMP-Nevada 1600 Univ. Ave. Augusta, Me. 04= 956 Willow Street Grand Forks, N.D. 58201 Reno, Nevada 89502 21 MARYLAND C. 0. Grizzle, M.D. 35 NORTHEAST Director, Mountain States OHIO S@Sp j M RMP-Wyoming B. Decker, M.D. r,,Yr 3100 Henderson br. 10205 Camegie Ave. W 5@ .Br@d BIt . Md. 21@ Cheyenne, Wyo. aml Cleveland, Ohio 44106 22 MEMPHIS 28 NASSAU-SUFTOL J. W. Culbertson, INLD. K 36 NORTHERN 62 South Dunlap G. E. Hastings, M.D. NEW ENGLAND J. E. Wennberg, M.D. Memphis, Tenn. 38io3 1919 Middle Country Rd. U. of Vt. ColL of Med. Cent@h, N.Y. ll!M 25 Colchester Ave. 23 METROPOLffAN ]3urlington, Vt. 05401 WASHINGTON. D-C- 29 NEBRASKA- A. E. Wentz. M.D. SOUTH DAKOTA 37 NOR NDS D.C- MedicalSociety H. Morgan, M.D. W. R. Miller, M.D. 2007 Eye St. N.W. 1408 Sharp gld-g. 375 Jackson St. Washington, D.C. 20006 Lincoln, Neb. 68508 St. PauL Minn. 55101 24 MICHIGAN R. H. @yes, M.D. Asso. Coordinator-S. Dak. 38 NORTHWESTERN A. E. Heustis. M.D. Nebraska-South Dakota RMP OHIO 1111 Michigan'Ave. Suite 200 U. of S. DaL Med. School C. IL Titde. Jr., M.D. 216 East Clark 2313 Madison Avenue East Lansing, Mich. 48= Vermillion, S. Dak. 57069 Toledo, Ohio 43624 REGIONS AND'PROGRAM COORDINATORS OR DIRECTORS (Continued) 39 OMO STATE 47 TENNESSEE 51 WASHINGTON- N. C. Andrews, M.D. MID-SOUTH ALASKA 1480 West Lane Ave P. E. Tewhan, M.D. Columbus, Ohio 43221 1100 Baker Bldg. D. R. Sparkman, M.D. 110 21st Ave. S 500 "U" District Bldg. 40 OHIO VALLEY Nashville, Tenn. 37203 1107 N.L 45th St. W. H. McBeath, M.D. Seattle, Wash. 98105 P.O. Box 4025 1. Belmont 1718 Alexandria Dr. 48 TEXAS Area Coord.-Entem Wash. lxxington, Ky. 40504 C. B. McCall, M.D. Washington/Alaska RMP P.O. Box Q 1130 Old National Bank Bldg. 41 OKLAHPMA 2608 Whitis West 422 Riverside Ave. D. Groom, M.D. Austin, Tex. 78712 Spokane, Wash. 99201 800 N.K 13th St. Oklahoma City, Ok 73104 J. K. Lesh, M.D. 49 TRI-STATE Area Coord.-Southeastem Al& 42 OREGON @ Baumgartner, M.D. Washington/Alaska RMP E. L. Goldblatt, ALD. Exec. Director Gusta@us, Alaska 99826 Med. Care and Education J. Aase, M.D. 3181 S.W. Sam Jackson Foundation Portland, Ore. 97201 Two Center Plaza Area Coord.-Central Boston, Mas& 02108 South Central Alaska 43 PUERTO RICO Washington/Alaska RMP 519 Eighth Ave., Room 200 A. Nigagfioni, M.D. IL Lium, M.D. Anchorage, Alaska 99501 Chancellor Mas& State Coordinator Medical Sciences Campus Tri-State RMP 52 WEST VIRGINIA U. of Puerto Rico Med. Care and Education C. D. Holland* P.O. Box XR. Foundation W. Va. Univ. Med. Ctr. Caparra Heights Station Two Center Plaza, Room 400 Morgantown, W. Va. 26506 Puerto Rico 00922 Boston, Mass. 02108 53 WESTERN 44 ROCEIESTER, N.Y. C. B. Walker, M.D. NEW YORK R. C- Parker, Jr., M.D. New Hampshire Coordinator J. R. F. Ingall, M.D. Tri-State RMP Sch. of Med. U. of Rochester Med. Ctr. 15 Pleasant SL State U. of N.Y. at Buffalo 260 Crittenden Blvd. Concord, N.IL 03301 2929 Main SL Rochester, N.Y. 14620 Buffalo, N.Y. 14214 H. S. M. Uhl, M.D. 45 SOUTH CAROLINA Rhode Island Coordinator 54 WESTERN V. Moseley, M.D. Tri-State RMP PENNSYLVANIA Med. Coll. of S.C. Brown U. Program of R. B. Carpenter, M-D- 80 Barre St. Medical Science 508 @ery Bldg. Charleston, S.C- 29401 Providence, R.L 02912 3530 Forbes Am Pittsburgh, Pa. 15213 46 SUSOUEHANNA VALILEY 50 VIRGINIA 55 WISCONSIN R. B. McKenzie E. R. Perez, M.D. J. S. Hirsehboeck, M.D. 3806 Market SL Suite 1025, 700 Bldg. Wisconsin RMP, Inc. P.O. Box 541 700 E. Main SL ilo E Wisconsin Ave. Camp HilL Pa. 17011 Richmond, Va. 23219 Milwaukee, Wise. 53202 Acting NATIONAL- ADVISORY COUNCIEL M. J. BRENNAN, RD. J. T. ENGLISH, M.D. A. NL POPMA, M.D. President (Chairman) Regional Director Mich. Cancer Foundation Administrator Mountain States Regional and Prot of Medicine Health Services and Medical Program Wayne State University Mental Health Admin. 525 West Jefferson St. 4811 John R Street 9000 Rockville Pike Boise, Idaho Detroit, Mich. Bethesda, Md. B.W.CANNON, B. W. EVERIST, JR., RD. R. B. RO TH, M.D. RD. Div. of Neurosurgery Chief of Pediatrics Vice Speaker of House. U. of Tennessee Green Clinic of Delegates of Amencan ColL of Medicine 709 South Vienna SL Medical Association Memphis, Tenn. Ruston, La. 240 West 41st Street Erie, Pa. J. R. HOGNESS, M.D. E. L CROSBY, M.D. Exec. Vice President Director U. of Washington M. 1. SHANHOLTZ, M.D. American Hosp. Assoc. 301 Admin. Bldg. State Health ComnL Chicago, M Seattle, Wash. State DEPL of Health Richmond, Va. A. R. CURRERI, M.D. F. S. MAHONEY Prot and Head 3600 Prospect Ave., N.W. C- TREEN De'pL of Surgery Washington, D.C. Director, Pension and U. of Wisconsin C- H. MILLIKAN, RD. Insurance Dept. Madison, Wisc. Consultant in Neurology United Rubber, Cork Mayo Clinic Linoleum and Plastic M. R DEBAKEY, M.D. Workers of America Prot and Chairman Rochester, Minn. Akron, Ohio DepL of Surgery R D. PELLEGRINO, M.D. Pres. and Chief Exec- Off. Director of the Med. Ctr. F. WYCKOFF Baylor ColL of Med. State U. of New York 243 Corralitos Road Houston, Texas Stony Brook, N.Y. Watsonville, CaliE REVIEW COMM=E G. E. BESSON, RD. G. R MILLER, M.D. R. J. SLATER, M.D. 877 West Fremont Ave. Director, off. of Research President Sunnyvale, CaliE in Med. Educ. The A@ for the Aid COIL of Med., U. of IIL of Crippled Children L CHRISTMAN, Ph.D. Chicago, JIL New York, N.Y. Dean, School of Nursing J. S. MURTAUGH Vanderbilt University Exec. Secretary hL W. SPELLMAN, RD. Nashville, Tenn. Board of Medicine Department of Surgery Nat. Academy of Sciences UCLA School of Med. H. W. KENNEY, M.D. Washington, D.C. Center for Hlth. Sciences Medical Director L- Angeles, Calif. A. PASCASIO, Ph.D. John A. Andrew Memorial Hosp. De-, School of Health Tuskegee Institute Related Professions J. D. THOMPSON Tuskegee, Al& U. of Pittsburgh Prof. of Public Health Pittsburgh, Pa. Yale U. School of Med. New Haven, Conn. H. M. LEMON, M.D. S. H. PROGER, RD. Prof. of Internal Med. PhYsician-in-Chief P. T. WHITE, M.D. ColL of Med., U. of Neb. Tufts N.F- Med. Ctr. Prof. and Chairman Omaha, Neb. Boston, Mass. DepL of Neurology C. H. W. RUHE, RD. Marquette U. Sch. of med. W. D. MAYER, RD. Assistant Secretary *ilwaukee, Wi, Dean and Director Council on Med. Ed. U. of Mo. Med. Center American Med. Assoc. Columbia, Mo. Chi-go, m 7 HISTORY AND PURPOSES OF REGIONAL MEDICAL PROGRAMS On October 6, 1965, the President sgned Public Law 89-239. It authorizes the establishment and maintenance of Regional Medical Programs to assist the Nation's health resources inTnairing available the best possibfe patient care for heart disease, cancer, stroke and related diseases. This legislation, which will be referred to in this publication as 'Me Act, was shaped by the interaction of at least four antecedents: the historical thrust toward regionalization of health resources; the development of a national biomedical research community of unprecedented size and productivity; the changing needs of society; and finally, the particular legislative process leading to The Act itself. The concept of regionalization as a means to meet health needs effectively and economically is not new. During the 19ws, Assistant Surgeon General Joseph W. Mountin was one of the earliest pioneers urging this approach for the delivery of health services. 'Me na. tional Committee on the Costs of Medical Care also focused attention in 1932 on the potential benefits of regionalization. In that same year, the Bingham Associates Fund initiated the first comprehensive regional effort to improve patient care in the United States. This linked the hospitals and programs for continuing education program of physicians in the State of Maine with the university centers of Boston. Advocates of regionalization next gained national attention more than a decade later in the report of the Commission on Hospital Care and in the Hospital Survey and Construction (Hill-Burton) Act of 1946. Other proposals and attempts to introduce regionaliza- tion of health resources can be chronicled, but a strong national movement toward regionalization had to await the convergence of other factors which occurred in 1964 and 1965. One of these factors was the creation of a national biomedical research effort unprecedented in history and unequalled anywhere else in the world. The effect of this activity was and continues to he intensified by the swiftness of its creation and expansion: at the beginning of World War II the national expenditure for medical re- search totaled $45 million; by 1947 it was $87 million; and in 1967 the total was $2.257 billion-a 5,000 percent increase in 27 years. The most significant characteristic of this research effort is the tre- mendous rate at which it is producing new knowledge in the medical sciences, an outpouring which only recently began and which shows no signs of decline. As a result, changes in health care have been dramatic. Today, there are cures where none existed before, a number of diseases have all but disappeared with the application of new vaccines, and patient care generally is far more effective than even a decade ago. It has become apparent in the last few years, however, (despite substantial achievements), that new and better means must also be found to convey the ever-increasing volume of research results to the practicing physician and to meet growing complexities in medical and hospital care, including specialization, 8 PT increasingly intricate 'and expensive ty pes men,, and the distribution of sca of diagnosis and treat- resources. Ile degree rce nanpower, facilities, and other these ' of urgency attached to the need to cope with Issues is heightened by an increasing Public demand that the latest and best health care be made available to everyone. Ilis public demand,, in turn, is largely an expressi On Of e@tations aroused by awareness of the results and research. Promise of biomedical In a sense, the national commitment to biomedical investigation is one manifestation of the third factor which contributed to the n creation of Regional Medical Pro--rains: the changing eeds of society-in this case, health needs. Ile decisions by various private and public institutions to support biomedical research were responses to this societal need perceived and interpreted by these institutions. In addition to the support Of research, the same interpretive process led the Federal GO'v4;r@Inent to develop a broad range of other pro. grams to ixnprove the quality and availability of health care in the Nation. Ile Hill-Burton Program which began with the passage of the previously mentioned Hospital Survey and Construction Act of 1946, together with the National Mental Health Act of 1946, was the first in a series of post-World War 11 legislative actions having major impact on health affairs. When the 89th Congress adjourned in 1966, 25 health-related bills had been enacted into law. Axnong these were Medicare and Medicaid to pa for hospital and physician services for the Nation's aged and poor;ythe Com rehensive Health Planning Act to provide funds to ea@h rical health Planning and to support services ren, state and other health activities; an@ Public Law 89-2 Regional Medi. cal Programs. The report of the President's Commission on Heart Disease, Cancer, and Stroke, issued in December 1964, focused attention on societal needs and led directly to introduction, of the legislation an- thorizing Regional Medical Programs. Many of the Coinmission's recommendations were significantly altered by the Congress in the legislative process but 7le Act was cleariv d to meet needs . passe and problezns identified and given national recognition in the Corn. raission's report and in the Congressional hearings preceding pas- sage in The Act., Sozne of these needs and problems -were expressed as follows: 10 A program is needed to focus the Nation's health resources for research, teaching and patient care on heart disease, cancer, stroke and related diseases, because together they cause 70 per. cent of the deaths in the United States. 0A significant number of Americans with these diseases die or are disabled because the benefits of present knowledge in the medical sciences are not uniformly available throughout the country. 07lere is not enough trained manpower to meet the health needs of the American people within the present system for the delivery of I health services. 9 40 Pressures threatening the Nation's health resources are building because demands for health services are rapidly increasing at a time when increasing costs are posing obstacles for many who require these preventive, diagnostic, therapeutic and rehabilitative services. 0 A -creative partnership must be forged among the Nation's medi- cal scientists, practicing physicians, and all of the Nation's other health resources so that new knowledge can be translated more rapidly into better patient care. This partnership should make it possible for every community's practicing physicians to share in the diagnostic, therapeutic and consultative resources of major medical institutions. They should similarly be provided the op- portu'nit'y to participate in the academic environment of research, teaching and patient care which stimulates and supports medical practice of the highest quality. 0 Institutions with high quality research programs in heart disease, cancer, stroke, and related diseases are too few, given the magni- tude of the problems, and are not uniformly distributed through- out the country. 0 There is a need to educate the public regarding health affairs. Education in many cases will permit people to extend their own lives by changing personal habits to prevent heart disease, cancer, stroke and related diseases. Such education will enable indi- viduals to recognize the need for diagnostic, therapeutic or re- habilitative services, and to know where to find these services, and it will motivate them to seek such services when needed. During the Congressional hearings on this bill, representatives of major groups and institutions with an interest in the American health system were heard, particularly spokesmen for practicing physicians and connnunity hospitals of the Nation. The Act which emerged turned away from the idea of a detailed Federal blueprint for action. Specifically, the network of "regional centers" recommended earlier by the President's Commission was replaced by a concept of "regional cooperative arrangements" among existing health resources. The Act establishes a system of grants to enable representatives of health resources to exercise initiative to identify and meet local needs within the area of the categorical diseases through a broadly defined process. Recognition of geographical and societal diversities within the United States was the main reason for this approach, and spokes- men for the Nation's health resources who testified during the hearings strengthened the case for local initiative. Thus the degree to which the various Regional Medical Programs meet the objectives of The Act will provide a measure of how well local health resources can take the initiative and work together to improve patient care for heart disease, cancer, stroke and related diseases at the local level. The Act is intended to provide the means for conveying to the medical institutions and professions of the Nation the latest advances in medical science for diagnosis, treatment, and rehabilitation of 10 patients afflicted with heart disease, cancer, stroke, or related' di- seases-and to prevent these diseases. The grants authorized by Me Act are to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institu- tions, hospitals, and other medical institutions and agencies to achieve these endsby research, education, and demonstrations of patient care. 71rough these means, the programs authorize The Act are also intended to improve generally the health manpower and facilities of the Nation. In the two years since the President signed 'Me Act, broadly representative groups have organized themselves to conduct Regional Medical Programs in more than 50 Regions which they themselves have defined. These Regions encompass the Nation's population. They have been formed by the, organizing groups using functional as well as geographic criteria. These Regions include combinations of entire states (e.g. the Washington-Alaska Region), portions of sev- eral states (e.g. the Intermountain Region includes Utah and sec- tions of Colorado, Idaho, Montana, Nevada and Wyoming), single states (e.g. Georgia), and portions of states around a metropolitan center (e.g. the Rochester Region which includes the city and 11 surrounding counties). Within these Regional Programs, a wide variety of organization structures have been developed, including executive and planning committees, categorical disease task forces, and community and other types of sub-regional advisory committees. Regions first may receive planning grants from the Division of Regional Medical Programs, and then may be awarded operational grants to fund activities planned with initial and subsequent planning grants. These operational programs are the direct means for Re- gionai Medical Programs to accomplish their objectives. Planning moves a Region toward operational activity and is a continuing means for assuring the relevancy and appropriateness of operational activity. It is the effects of the operational activities, however, which will produce results by which Regional Medical Programs will be judged. On November 9, 1967, the President sent the Congress the Report on Regional Medical Progrwns prepared by the Surgeon General of the Public Health Service, and submitted to the President through the Secretary of Health, Education, and Welfare, in compliance with 'Me Act. The Report'details the progress of Regional Medical Programs and recommends continuation of the Programs beyond the June 30, 1968, limit set forth in The Act. The President's letter transmitting the Report to the Congress was at once encouraging and exhortative when it said, in part: "Because the law and the idea behind it are new, and the problem is so vast, the program is just emerging from the planning state. But this report gives encouraging evidence of progre@and it promises great advances in speeding research knowledge to the patient's bedside." Thus in the final seven words of the President's message, the objective of Regioral Medical Pro- grams is clearly emphasized. THE NATURE AND POTENTIAL OF REGIONAL MEDICAL PROGRAMS GOAL-IMPROVED PATIENT CARE The Goal is described in the Surgeon General's Report as . . clear and unequivocal. The focus is on the patient. The object is to influence the present arrangements for health services in a manner that will permit the best in modern medical care for heart disease, cancer, stroke, and related diseases to be available to all." MEANS-THE PROCESS OF REGIONALIZATION Note: Regign@tion can connote more than a regional cooperative arrange- ment, but for the purpose of this publication, the two terms will be used interchangeably. Ile Act uses "regional cooperative arrangement," but "regionalization' has become a more convenient synonym. A regional cooperative arrangement among the full array of available health resources is a necessary step in bringing the benefits of scientific advances in medicine to people wherever they live in a Region they themselves have defined. It enables patients to benefit from the inevitable specialization and division of labor which ac- company the expansion of medical knowledge because it provides a system of working relationships among health personnel and the institutions and organizations in which they work. This requires a commitment of individual and institutional spirit and resources which must be worked out by each Regional Medical Program. It is facilitated by voluntary agreements to serve, systematically, the needs of the public as regards the categorical diseases on a regional rather than some more narrow basis. Regionalization, or a regional cooperative arrangement, within the context of Regional Medical Programs has several other impor- tant facets: 0 It is both functional and geographic in character. Functionally, regionalization is the mechanism for linking patient care with health research and education within the entire region to provide a mutually beneficial interaction. This interaction should occur within the operational activities as well as in the total program. The geographic boundaries of a region serve to define the popula- tion for which each Regional Program will be concerned and responsible. This concern and responsibility should he matched by responsiveness, which is effected by providing the population with a significant voice in the Regional Progra&s decision- making process. 0 It provides a means for sharing limited health manpower and facilities to maximize the quality and quantity of care and service avail able to the Region's population, and to do this as eco- nomically as possible. In some instances, this may require inter- regional cooperation between two or among several Regional Programs. 12 0 Finally, it also constitutes a mechanism for coordinating its categorical program with other health programs in the Region so that their combined effect may be increased and so that they contribute to the creation and maintenance of a system of comprehensive health care within the entire Region. Because the advtince of knowledge c@es the nature ol medical care, regio@ization can best be vieued as a continuous process rather than a plan which it taay deve@d and then implemented. This process of regionalization, or cooperative arrangements, con- sists of at least the following elements: involvement, identification of needs and opportunities, assessment of resources, definition of ob- jectives, setting of priorities, implementation, and evaluation. While these seven,elements in the process will be described and discussed separately, in practice they are interrelated, continuous and often occur simultaneously. Involvement-Ile involvement and commitment of individuals, organizations and institutions which will engage in the activity of a Regional Medical Program, as well as those which will be affected by this activity, underlie a Regional Program. By involving in the steps of- study and decision all those in a region who are essential to implementation and ultimate success, better solutions may be found, the opportunity for wider acceptance of decisions is improved, and implementation of decisions is achieved more rapidly. Other attempts to organize health resources on a regional basis have ex- perienced difficulty or have been diverted from their objectives because there was not this voluntary involvement and commitment by the necessary individuals, institutions and organizations. 'Me Act is quite specific to assure this necessary involvement in Regional Medical Programs: it defines, for example, the minimum composi- tion of Regional Advisory Groups. The Act states these Regional Advisory Groups must include "practicing physicians, medical center officials, hospital administra- tors, representatives from appropriate medical societies, voluntary health agencies, and 'representatives of other organizations, institu- tions and agencies concerned with activities of the kind to be carried on under the program and members of the public familiar with the need for the services provided under the program." To ensure a maximum opportunity for success, the composition of the Regional Advisory Group also should be reflective of the total spectrum of health interests and resources of the entire Region. And it should be broadly representative of the geographic areas and all of the socioeconomic groups which will be served by the Regional Program. The Regional Advisory Group does not.have direct administrative responsibility for the Regional Program, but the clear intent 'of the Congress was that the Advisory Group would ensure that the Regional Medical Program is planned and developed with the continuing advice and assistance of a group which is broadly representative of the health interests of the Region. 'Me Advisory Group must approve all proposals for operational activities within the Regional Program, and it prepares an annual statement giving its evaluation of the effectiveness of the regional cooperative arrangements established under the Regional Medical Program. Identification of Needs and Opportunities-A Regional Medical Program identifies the needs as regards heart disease, cancer, stroke and related di within 'the entire Region. These needs are stated in terms which offer opportunities for solution. This process of identification of needs and opportunities for solu- tion requires a continuing analysis of the problems in delivering the best medical care for the target diseases on a regional basis, and it goes beyond a generalized statement to definitions which can be translated into operational activity. Particular opportunities may be defined by,: ideas and approaches generated within the Region, ex- tension of activities already present within the Region, and ap- proaches and activities developed elsewhere which might be applied within the Region. Among various identified needs there also are often relationships which, when perceived, offer even greater opportunities for solutions. In examining the problem of coronary care units throughout its Region., for example, a Regional Program may recognize that the more effective approach would be to consider the total problem of the treatment of myocardial infarction patients within the Region. This broadened approach on a regional basis enables the Regional Program to consider the total array of resources within its Region in relationship to a comprehensive program for the care of the myo- cardial infarction patient. 'Mus, what was a concern of individual hospitals about how to introduce coronary care units has been trans- formed into a project or group of related projects with much greater potential for effective and efficient utilization of the Region's re- sources to improve patient care. Assessment ol Resources-As part of the process of regionalization, a Region continuously updates its inventory of existing resources and capabilities in terms of function, size, number and quality. Every effort is made'to identify and use existing inventories, filling in the gaps as needed, rather than setting out on a long, expensive process of creating an entirely new inventory. Information sources include state Hill-Burton agencies, hospital and medical associations, and voluntary agencies. The inventory provides a basis for informed judgments and priority setting on activities proposed for develop- ment under the Regional Program. It can also be used to identify missing resources-voids requiring new investment-and to develop new configurations of resources to meet needs. Definition ol Objectives-A Regional Program is continuously involved in the process of setting operational objectives to meet identified needs and opportunities. Objectives are interim steps toward the Goal defined at the beginning of this section, and achieve- ment of these objectives should have an effect in the Region felt far beyond the focal points of the individual activities. This can be one of the greatest contributions of Regional Medical Programs. 14 'The completion of a new project to train nurses to care for cancer patients undergoing new combinations of drug and radiation therapy, for example, should benefit cancer patients and should provide additional trained manpower for many hospitals in the Region. But the project also should have challenged t]6e Region's nursing and hospital communities to improve generally the continuing and in- service education opportunities for nurses within the Region. Setting of Prio,,ities-Because of limited manpower, facilities, financing and other resources, a Region assigns some order of priority to its objectives and to the steps to achieve them. Besides the limitations on resources, factors.include: 1) balance between what should be done first to meet the Region's needs, in absolute terms, and what can be done using existing resources and compe- tence; 2) the potentials for rapid and/or substantial progress toward the Goal of Regional Medical Programs and progress toward re- gionalization of health resources and services; and 3) Program balance in terms of disease categories and in terms of emphasis on patient care, education and research. Impleme@on-The purpose of the preceding steps is to provide a base and imperative for action. In the creation of an initial op- erational program, no Region can attempt to determine all of the program objectives possible, design appropriate projects to meet all the objectives and then assign priorities before seeking a grant to implement an operational program which encompasses all or even most of the projects. Implementation can occur with an initial operational program encompassing even a small number of well- designed projects which will move the Region toward the attainment of valid program objectives. Because regionalization is a continuous process, a Region is expected to continue to submit supplemental and additional operational proposals as they are developed. Evakwion-Each planning and operational activity of a Region, as well as the overall Regional Program, receives continuous, quan- titative and qualitative evaluation wherever possible. Evaluation is in terms of attainment'of interim objectives, the process of regionali- zation, and the Goal of Regional Medical Programs. Objective evaluation is simply a reasonable basis upon which to determine whether an activity should be continued or altered, and, ultimately, whether it achieved its purposes. Also, the evaluation of one activity may suggest modifications of another activity which would increase its effectiveness. Any attempt at evaluation implies doing whatever is feasible within the state of the art and appropriate for the activity being evaluated. Thus, evaluation can range in complexity from simply counting num- bers of people at meetings to the most involved determination of behavioral changes in patient management. As a first step, however, evaluation entails a realistic attempt to design activities so that, as they are implemented and finally con- cluded, some data will result which will be useful in determining the degree of success attained by the activity. 15 CRITERIA-EVALUATION OF REGIONAL MEDICAL PROGRAMS The criterion for judging the success of a Region in implementing the process of regionalization is the degree to which it can be demonstrated that the Regional Program has implemented the seven essential elements discussed in this Chapter: involvement, identifica- tion of needs and opportunities, assessment of resources, definition of objectives, setting of priorities, implementation, and evaluation. Ultimately, the overall success of any Regional Medical Program must be judged by the extent to which it can be demonstrated that the Regional Program has assisted the providers of health services in developing a system which makes available to everyone in the Region improved care for heart disease, cancer, stroke, and related diseases. PUBLIC LAW 89-239 Through grants, to afford to the medical profession and the medical institu- tions of the Nation the opportunity of planning and implementing programs to make available to the American people the latest advances in the diag- nosis and treatment of heart disease, cancer, stroke, and related diseases by establishing voluntary regional cooperative arrangements among ... 0 Physicians 0 Voluntary Health Agencies * Hospitals 0 Federal, State, and Local Health Agencies 0 Medical Schools 0 Research Institutions 0 Civic Organizations IL6 REGIONAL ADVISORY GROUPS The activities of Regi6nal Medical Programs are directed by fulltime Co- ordinators working together with Regional Advisory Groups which are broadly representative of the medical and health resources of the Regions. Membership on these groups nationally is: Hospital. Adminis't Public Healt Officials Other Health Workers 1% Voluntary Health Agen dical Center- School Officials Total: 2315 Members of the Public 17 EVENTS ACTION 1964 DECEMBER Report of the Prcsident's Commission on Heart Disease, Cancer, and Stroke .1965 FEBRUARY TO JULY Congressional hearings OCTOBER Enactment of P.L 89-239 DECEMBER National Advisory Council meeting Initial policies and Guidelines reviewed 1966 FEBRUARY Establishment of Division Publication of preliminary Guidelines National Advisory Council meeting Policy for review p@ Review Committee meeting and Division activities set APRIL National Advisory Council meeting 7 planning grants awarded JUNE Review Committee meeting National Advisory Council meeting 3 planning grants awarded JULY Publication of Guidelines Review Committee meeting AUGUST National Advisory Council meeting 8 planning grants awarded BER Review Committee meeting NOVEr4BER National Advisory Council meeting 16 planning grants awarded 1967 JANUARY Review Committee meeting National Conference National views & information for Report provided F'EBRUARY National Advisory Council meeting 10 planning and 4 operational grants awarded APRIL Review Committee meeting MAY National Advisory Council meeting 5 planning and 1 operational grant awarded JUNE Report to the President & Congress JULY Review Committee meeting AUGUST National Advisory Council meeting 2 planning grants awarded OCTOBER Review Comntittee meeting NOVEMBER National Advisory Council meeting 2 planning and 3 operational grants awarded 1968 JANUARY Conference Workshop Regional activities and ideas presented Review Committee meeting FEBRUARY National Advisory Council meeting 5 operational grants awarded APRIL Review Committee meeting MAY National Advisory Council meeting 1 planning and 10 operational grants awarded JULY Review Committee meeting AUGUST National Advisory Council meeting I operational grant awarded OCTOBER Review Committee meeting NOVEMBER National Advisory Council meeting 1 planning and 7 operational grants awarded 1969 JANUARY Review Committee meeting F'EBRUARY National Advisory Council meeting 9 operational grants awarded APRIL Review Committee meeting MAY National Advisory Council meeting .5 operational grants awarded JULY Review Committee meeting 18 Additional publications on Regional Medical Programs which are available on request are: 0 DIRECTORY OF REGIONAL MEDICAL PROGRAMS Revised as of June 4, 1969 to Include All Approved Operational Projects and Program Data 0 GUIDELINES-Regional Medical Programs Revised May 1968 * SELECTED BIBLIOGRAPHY of Regional Medical Programs First Revision February 1969 0 qUMULATIVE INDEX (Ma 1967-May 1969) y For News, Information and Data Publications These publications and other material on Regional Medical Programs may be obtained from: Publications Service Office of Communications and Public Information Regional Medical Programs Service Wiscon Building, Room 308 9000 Rockville Pike Bethesda, Maryland 20014 U. S. GOVERNMENT PRMMG OFF7CE: 1969 695-669(loo4) 19