@ @vv I i s California regional medical program FM 0 m @ I .winter 1974 A SYSTEM THAT SAVES LIVES . . . . . . . . . . . . 3 A story about the evolution of a mobile emergency medical system and the Long Beach community that made it happen. COMMUNITY CENTER CUTS RED TAPE . . . . . . . . . 7 A provider-consumer alliance that pays off in less red tape and better health care in Santa Paula. GOOD CARE FOR PATIENTS . . . . . . . . . . . . 9 Doctors, nurses and hospital specialists are joining together to improve patient health and well-being. THE HEALTH MANPOWER NETWORK . . . . . . . . . 13 Helping to insure the best health care possible through Statewide manpower and consumer education activities. The California Regional Medical Program (CRMP) invests capital and technical assistance in the development of improved health care services in California. It helps to unite doctors, nurses, pharmacists, hospital administrators, medical teachers, public and private health agency officials, patients and anyone else committed to better health in a crusade to solve health problems. CRMP Profile is published by the California Regional Medical Program, 7@00 Edgewater Drive, Oakland, California 94621, Telephone (415) 635-0290. Support has been provided by a grant from Regional Medical Programs Service of the Health Resources Administration, U.S. Depart- ment of Health, Education and Welfare, but these agencies are in no way responsible for the contents. CRMP Editorial Board Jackie K. Reinhardt Karen Johnston Harriet Baumgarten William Boquist, Editor 40 ONCE THE PATIENT HAS BEEN STABILIZED, he is transported by private ambulance to the hospital. The ambulance attendants and the paramedics place an accident victim on a stretcher as onlookers v@,atch at the scene of a busy Long Beach intersection. A System That Saves Lives The shrieking, blaring sirens of the Fire Department system of delivering emergency care to its residents. used to bother Jim Cox whose north Long Beach The Long Beach mobile emergency medical pro- home is only blocks away from the neighborhood gram links together the Fire Department, a private fire station. But that was before last June 25, the day ambulance company and four hospitals. St. Mary's the 46-year-old oil driller's heart almost stopped Hospital is the base station with which the para- beating. medics establish initial communications in an "They can make all the noise they want to as far emergency and Pacific, Memorial and Community as I'm concerned," says Cox today of the engine Hospitals serve as satellites. All are capable of company and paramedic rescue team who are receiving and transmitting on-the-scene information, credited with saving his life. "They are my friends." including EKGs via telemetry. Cox suffered a ventricular tachycardia, an exces- sively rapid heart beat which, according to his THREE MINUTE RESPONSE cardiologist, Alan J. Hermer, M.D., would have These linkages make it possible to respond to any resulted in immediate death had life-saving drugs medical emergency within the city in three minutes. not been promptly administered by the paramedics. Take Joseph Duhem, who was sitting in a Pacific Fortunately for Cox, he lives in one of a growing Coast Highway restaurant last February when he was number of communities whose firemen are not only struck in the head with a blast from a 20-gauge trained to the level of Emergency Medical Techni- shotgun. cian (EMT) 11, but which has developed an organized The proprietor placed a call to the Fire Depart- 3 ment. The closest engine company, an ambulance developing the system. An estimated $50,000 will be and one of the city's four paramedic units were required annually to maintain the system. dispatched to the scene, Within two minutes the unconscious Duhem was receiving mouth-to-mouth CONCERN ABOUT ECONOMICS resuscitation from the firemen. Less than a minute "I don't think any city can afford not to be later the paramedics arrived, took his vital signs and concerned about economics," noted recently retired on the orders of an emergency physician inserted an Fire Chief Tullio J. Rizzo, "and the main thing we esophageal airway and began giving him intra- found out from our field research was that it was the venous fluids. cost of additional salaries that killed other pro- Once stabilized, Duhem-accompanied by a para- granis." medic-was transported by ambulance to Com- But the decision to use existing personnel also munity Hospital. The emergency room staff not only posed some additional hardships on the Fire Depart- anticipated his arrival, but they knew in advance the ,,ent. It meant that most of the paramedics would care he had already received. Although the incident have a dual responsibility to respond to fires as well resulted in the loss of his right eye, Joseph Duhem as medical emergencies. could have lost his life. As an alternative, some cities are considering In a very real sense the "system" saved him. It separate paramedic units in their Fire Departments, enabled the medical community to respond with which Long Beach does not rule out. the appropriate skills at the time they were most needed. SYSTEM DIDN'T JUST HAPPEN This capability didn't just happen. The communit y working with the former Long Beach Regional Medi- cal Program Committee made it happen@ More than a year was spent bringing together medical and related interests, designing the system and testing its feasibility. But the time was well spent in the view of Irvin Ungar, M.D., who directs the base station operations at St. Mary's Hospital. "We were able to develop a system that included all the necessary components and to assure they all functioned together," Dr. Ungar said. "We also tried to focus on some of the needs that were peculiar. to the Long Beach community." To the Long Beach planners, however, the system is not static. Rather, it is evolving. As an example, they expected a greater number of coronary emergencies because more than 13 percent of the city's population is over 65 years old. When that didn't occur, the paramedic curriculum was modified. Also unpredictable were the traffic control prob- lems at the scene of an emergency which has led to an informal working agreement with the Long Beach Police Department. As with any major effort, costs were an important consideration in the design of the program. RMP's announced phase-out (retracted in September, 1973) had severely curtailed funds available for the Long Beach system. One of the first questions theytackledwaswhether to use existing firemen as paramedics or to train new personnel. Even though it was felt that former medical corpsmen and many ambulance personnel SENIOR PARAMEDIC GARY ROBERTSON uses biocom equip- could qualif they chose the firemen because of the ment at the scene to communicate with emergency physicians Y, at St. Mary's Hospital, the base station for Long Beach's city's willingness to underwrite the training and emergency medical system. Here he awaits orders after reading equipment costs-the bulk of the $370,000 spent in the patient's vital signs. (Photo by Reinhardt) 4 That possibility appeals strongly to most of the He estimated that DOA (dead on arrival) patients paramedics whose only avenue for promotion is have dropped from 10 to 15 a month to two to four through regular Fire Department channels. One of since the program was initiated. the original 28 trainees already has dropped out to Although pleased with the technical performance accept a promotion to Captain-a salary differential and judgment demonstrated by most paramedics, of $400 a month. Jerry Hughes, M.D., director of both St. Mary's The paramedics receive an additional $35 more a and Community Hospital's emergency departments, month, yet most acknowledge that it was other would like to see greater emphasis placed on team things that brought them into the paramedic ranks. training in emergency care. "it was so frustrating before to respond to an "We need to develop closer working relationships emergency and not be able to save someone's life among the emergency room staff, the ambulance because your skills are limited," explained officer dants and the Gary Robertson, one of the senior members of atten paramedics because they are the Rescue Unit 1. emergency system," he said. "To think of the private But neither he nor his counterparts in the othpr physician or other specialist being available during three rescue units functions with that handicap today. tnose critical first hours is a dream." Their training encompasses almost six months, CALLS EXCEED 900 A MONTH including didactic and clinical instruction at County- It is increasingly obvious over the past 18 months USC and Harbor General Hospitals and an internship that Long Beach residents are relying more and more in the various departments of local hospitals. The heavily on their emergency system and the para trainees spend a month riding with a rescue unit medics in their critical role. before their assignment as paramedics. The Fire Department used to get an average of 125 just like many other professionals, the paramedics calls a month but since the system's initiation that also must meet continuing education requirements number has increased more than 900 a month. The to be recertified. They receive a 40-hour refresher nature of the calls also has changed-from first aid course every year to reinforce their basic skills and to life-threatening emergencies. extend their knowledge in the management of car- diac conditions, shock, burns, orthopedic and other In a recent month 55 percent of the paramedic emergencies. This instruction is offered by local responses involved trauma victims and central nerv- emergency physicians and other medical specialists ous disorders, ranging from seizures to overdoses; who volunteer their time. It is hoped, however, to another 25 percent were cardio-respiratory. More integrate these courses into the junior college than 75 percent of the patients were transported to a system so that the paramedics can receive college hospital. credits. Although the public's-acceptance of the program is welcomed, the program's administrators express DOCTORS NO LONGER SKEPTICAL concern about the potential for over-utilization of Despite the paramedics' extensive preparation, the system for non-emergencies. . many physicians viewed them with a "jaundiced Gene Haufler, alarm superintendent in charge of eye" at first, recalls Frank Hurtebise, M.D., a general dispatch operations, observed that too many people surgeon and emergency room director at Memorial expect the paramedics to come out and see them like Hospital. a doctor. "A vocal minority was skeptical that something "We suggest they call their family physician," he could be done to save lives in the field," he noted, said. "but now they admit it can and is being done." To better inform the public, the four hospitals and Jeff McDonald, M.D., an emergency physician at the Fire Department are embarking on a city-wide St. Mary's Hospital, is quick to reinforce that view. education program, although they acknowledge that "Hemorrhaging stops at the scene rather than in such an effort represents a long-term commitment. the hospital," he stressed. "People who would have The program not only focuses on when to call ' the died earlier are walking out of the hospital today." paramedics but on what to expect when they arrive. (Continued) 5 STABILIZATION-THE PARAMEDIC FUNCTION Writes Mrs. James 1. Eighmy after her husband's "Many people still think the paramedics are there heart attack: "The doctor told me that night-if it to transport the patient," Captain George Morgan, was@', t for the immediate and excellent care he - received from you he wouldn't be here now. I can't paramedic coordinator for the Fire Department sing your praises loud enough." pointed out."But their job is to stabilize the pati'ent's E@hoing her sentiments is T. C. Donovan who was condition so he can be transported by ambulance . to the hospital." t)ack on the job as Pacific Southwest Regional Sales Manager for the Kaiser Gypsum Company the ay R. B. (Bob) Shue, one of 28 paramedics trained to after suffering a reaction to an allergy shot. "Little date, concurs, recalling a patient with a congestive did I believe before the day ended I would be heart failure and pulmonary edema. indebted to men I didn't even know for saving my "A neighbor really gave us a bad time, insisting we life," he wrote. take the patient directly to the hospital," he said. Perhaps, the greatest tribute of all to the life- "Six months later when we responded to another saving capabilities of the Long Beach system was call in her building, she couldn't say enough good paid by Ai Caplan, Jr., a coronary victim. The first things." thing he did after his release from Community Neither can most other Long Beach citizens if the Hospital was to walk to his neighborhood Fire mail coming into the Fire Department and City Hall Station with a word of thanks. is an example. Jackie K. Reinhardt THE JIM COX'S THANK the Long Beach paramedics for the opportunity to enjoy a morning coffee break on the porch of the couple's north Long Beach home. The prompt administration of drugs after Mr. Cox suffered a heart attack is credited with saving his life. 6 Community Center Cuts Red Tape teers or block leaders to help people solve their own health problems. Defining health problems broadly as "anything which impairs or impedes good health," the Center strives toward problem solving and sometimes its methods are unorthodox. "if our block leaders find a family assigned to sub-standard housing, they go to work with the local housing authority to see that the derelict is upgraded or that more sanitary conditions are provided else- where," says Hazel McHenry, R.N., staffer at the Center. She notes that prevention of illness or injury costs much less than hospitalization or surgery. "By educating the community, especially those receiving subsidies, about preventive health care, the costs to them and to the public will decline." "CLIENTS" NOT ALWAYS PATIENTS Sometimes the Center's "clients" aren't patients, but physicians or hospitals with a problem. The Center works closely with the area's physi- cians, dentists, optometrists, pharmacists and other health providers to cut short some of the red tape often associated with subsidized patients. When a local dentist reported difficulty in meeting a billing submission deadline because his patient, who had received considerable services, had lost the eligibility sticker that must accompany all billing to Medi-Cal, the Center took immediate action. Proof-of-eligi@ility Nestled between the foothills of Ventura County was established and the proper documents hand is a unique community-Santa Paula. It's a quiet carried from patient to doctor, who then submitted friendly little town where sun ripened citrus orchards the forms to the appropriate agency before the blanket the surrounding hillsides. People say Santa deadline expired. With this assistance the dentist Paula hasn't changed much in the last 20 years and collected his $700 fee. for the most part residents like it that way, with one "Very often Medi-Cal patients who are only notable exception-health care. allotted two medi-labels and four proof-of-eligibility It wasn't that health services in Santa Paula and stickers a month, don't understand they must bring nearby Fillmore and Piru were out-of-date, but that these stickers in when they come for treatment,"- a full spectrum of services was not available to a said the office manager for Santa Paula's only ortho- broad cross-section of the area's population. This pedic surgeon. was especially true of the rural dweller, the migrant, "We've had instances where the Center has saved the federally subsidized patient and the private us considerable time by contacting patients who patient who had not found his own physician. Today don't have telephones or who don't speak English. that is no longer the case, thanks to local physicians, Block leaders remind them of their appointments, county health officers, residents and the California see that they bring their stickers and sometimes even Regional Medical Program, which provided financial provide transportation. For us, that's a real time support. saver." Working together they generated an unusual The Center helps in other ways too. Recently the solution to a common problem; tying existing business office of a local hospital called the Center resources to existing needs. This was done not only for help. One of the Center's clients, who received by expanding some of the county's health services nearly $300 worth of medical services and had not in the area, but more importantly, by capitalizing on paid anything to the hospital, was about to move. close neighborhood commitments and a spirit 0 The Center ironed out the difficulty by contacting community involvement. A Health Care Referral the patient and arranging for installment payments to Center was created which uses neighborhood volun- be forwarded from Los Angeles. 7 BLOCK LEADERS GAIN ACCESS TO SYSTEM "Our goal is to bring good health services to every- one in the community," says Nurse McHenry. "That means teaching them how to gain access to the system." Volunteer block leader Gloria Rico, a bus driver for a local education program, tells how she first gained access to the system. "At one of our training sessions we were given Referral Center identification pins to wear when doing block leader work. Naturally, the first time I took a bus load of clients to the General Hospital in Ventura, I forgot to wear my pin. "Even though the Center reached an agreement with the hospital staff to treat my people first so we could get them back to Santa Paula, Fillmore and Piru, the nurses didn't know who I was and couldn't take time to listen to what I was telling them. "It took me all day to get my clients through there. The next time I wore my pin, we zipped in and out of that hospital in no time at all. I've learned my lesson, you can believe, I never forget my pin now!" laughs Gloria. Gloria Rico is one of forty-three women from neighborhoods in Santa Paula, Fillmore and P' u who were trained with California Regional Medical Program help in special sessions to spot and solve potential health problems or problems which eventually may affect good health. For the most part their work includes helping to solve client's health problems by providing elementary health education, transportation and translation by using the Center's resources to plug into existing community or county services. Although Santa Paula and its neighboring com- munities may not have changed much in the past decade or two, the Health Care Referral Staff and its contingency of voluntary block leaders insures that a full spectrum of up-to-date health services is widely available to their friends and neighbors. Karen Johnston 8 Good Care For Patients Doctors in California are beginning to develop a "We did an audit on hospitalized patients with contagious enthusiasm for patient care appraisal adult-onset diabetes," a spokesman explained, "and procedures once regarded in some quarters of the we found that although our controls were okay a medical profession as just this side of heresy. substantial number of patients each month were The reasons for their enthusiasm are solidly trapped in a revolving door syndrome. They were in grounded: the system is voluntary, fits in with health and out of the hospital fairly regularly." care providers' needs to continually improve their The PMC staff very carefully examined its criteria skills and, best of all, gives patients better car@- for acceptable management of diabetes "and we Is Dr. Smith confident enough to sit down with found that although there was a systematic discharge Nurse Jones and other allied health professionals on and home treatment program no one was following a hospital medical audit team to see how well thev work together? Well, it turns out that yes, Dr. Smitk up on it. As a result we devised a new patient care is, more and more, likely to accept -such a review. education program and the revolving door syndrome Medical audit teams are developing rapidly in stopped abruptly." California, spurred by early and exciting results in PATIENT CARE EVALUATION projects supported by the California Regional Medical Program. Pacific Medical Center-PMC-was one of the first At Pacific Medical Center in San Francisco, for institutions in California to adopt new patient care example, the impact on patient care has been appraisal techniques. The system has several terms dramatic. -medical audit, quality care evaluation, patient care 9 appraisal-each with its subtly different shade of meaning. Although related to peer review medical audit is not the same. Peer review has traditionally involved the review of one individual physician's credentials, ethics, training and experience by another individual of similar training and experience. Medical audit involves interdisciplinary deliberations, interdisci- plinary setting of appropriate patient-care standards, interdisciplinary review of the health care given the patient and interdisciplinary action to search for and remove deficiencies. Once established as a regular procedure in the hospital medical audit also permits documentation of trends or cycles in patient care. A medical audit workshop was co-sponsored in the Fall of 1971 by the California Medical Associa- tion, and the California Regional Medical Program. This workshop, perhaps a @vatershed for improved continuing medical education and patient care eval- uation, was conducted by Dr. Clement Brown, Jr., of Philadelphia. His medical audit procedures were impressive. They offered a way to learn more accurately what a patient may need to recover from illness, and they place the center for that learning in the local community hospital. SEMINARS AND WORKSHOPS Several other California seminars were conducted following the highly successful joint CMA-RMP effort in San Francisco. Meanwhile the CMA committee on accreditation formally adopted medical audit as the basis for accrediting hospital continuing education programs. More workshops were needed than Dr. Brown and his colleagues from Philadelphia's Chestnut Hill Hos- pital could conduct. Plans were made to develop skillpd California-based faculty leaders and consult- ants'to help make medical audit a widely used process in California's community hospitals. The CMA planned and conducted more work- shops, and with RMP cosponsorship, carried out a one-year project that involved 24 hospitals in Northern California in the workshop experience, under the direction of Drs. Rodger M. Shepherd and Samuel R. Sherman. Meanwhile Dr. Richard Opfell and Dr. Martin D. Shickman were reaching several hospitals in South- ern California. The medical audit workshops are essentially an intensive training session with hospital teams (ideally consisting of at least three physicians, one nurse, one administrator, one board member and the medical records administrator) going through all the steps involved in the medical audit of two diseases. This process, taking three days in the workshop, might normally take months in a hospital. The learning process can't stop with the workshop, but continues with a follow-up in each hospital- 10 and the realities of medical audit begin to be appre- gives us a method of improving; it will give us a ciated, or resisted, by staff members-followed, still handle to demonstrate that we are competent, later, by evaluation of what has been accomplished. continuing our competency and acting in the best Medical audit teams are interests of people." taught to pick diagnostic Dr. Elmendorf places the practice of medicine categories and to develop among the societal changes that lead to increasing criteria showing what serv- requirements for public accountability, and he thinks ices, procedures or out- medical audit programs will help. comes of care should be Arthur Jost, executive director of the Kings View entered in patient charts corporation in Reedley and president of the Cali- to document whether ac- fornia Hospital Association, agrees. ceptable care was admin- "Medical audit is terribly important," he says. "It's istered in the hospital. going to take a long long time to educate the public, Persuading some memt)ers of the audit team to agree to help them to feel confident, as we would wish them to feLbl, that they're getting their money's on the criteria often takes Arthur lost %vorth." a lot of energy. As one physician put it: "Getting it together back home is Adds Gordon Cumming, director of research for really something else." the CHA: "Government and the consuming public are interested in good quality and good values in TAILORED REMEDIES health services. Doctors and hospitals have a com- if deficiencies in care appear-and they do, as in munity of interests in encouraging the development the PMC case of adult-onset diabetes-then remedies of solid factual information on hospital services and are proposed. A medical education program is their costs, to satisfy this demand." frequently called for, with the results evaluated, MEDICAL SCHOOL RELEVANCE critically, months later. Dr. Opfell, a Tustin internist/hematologist, asso- There are legal and developing professional standards calling for medical care appraisal. Such ciate clinical professor of medicine at the University programs, according to Attorney Ross E. Stromberg, of California at Irvine, and chairman of the California of Hanson, Bridgett, Marcus & Jenkins, "are here to Medical Association's committee on accreditation of stay and must be carried out effectively." While continuing medical education, was one of the first ver possible or t some physicians may express fear o he CMA leaders to delve into medical audit. adverse legal consequences for taking part in medical Traditional continuing medical education pro- audit programs "the law has recognized these fears grams, he felt, were often laced with a feeling on and has provided adequate protection for members the part of the medical schools "that they were of the hospital's medical staff, administration and adversaries to the practitioners in the medical pro- governing body," he says. fession, and that 'only 10 percent of practicing But medical audit is becoming more and more physicians really participate in continuing medical attractive to both doctors and hospitals as a means education.' of helping to assure that quality care has been given "it became apparent to the patient and as a particularly excellent means of me that something ought improving health care skills and institutional pro- to be done to bring the cedures, all tied intimately to the real needs of the two together. My own patient. impression was that MDs "BEST FOR PATIENTS" were doing a hell of a lot more, but that they were Says Dr. Thomas Elmendorf, Willows general disappointed in the medi- practitioner a'nd president of the California Medical cal schools' offerings and Association: "I really think patient care appraisal is relevance and found it probably the most important thing we can do for the difficult to weave what patients we serve. It will give us a more objective they were being taught way of self-determination as to quality of care. It wi I Thomas Elmendorf, M.D. into their everyday prac- identify problems not only in perfecting Medici I tice." practice but the educational needs in the whole As a practitioner who teaches, Dr. Opfell often sphere of interrelationships between patient and asks himself what a physician needs, and the answer physician. It is a truly helpful way for physicians to "soon comes down to patient-care needs. That was determine the milieu of the medium in which they how I learned and the information I gathered stuck. practice. We're never going to be perfect but this I can remember Mrs. W. who had a pheochro- mocytoma, for example. So it became my policy as rather than being some exotic case of pathology a way to make medical'education programs more brought in by the resident,will nowrelate themselves meaningful to relate them to patient care needs." to patient care needs in the hospital. Conceptually Too often medical schools, he feels, do "a lousy job I think they've got all the nails hit on the head." of evaluating whether what they are offering is Dr. Shepherd, a pediatric cardiologist who is now useful, and they have had no evaluation in terms of associate director of continuing education at Pacific patient care. The whole concept-of how new knowl- Medical Center, was the director for an RMP-funded edge fits in to the practice of medicine is often out project that exceeded most of its objectives. of context with real needs of patient care. The usual At the end of a year 5 medical audit workshops course lecture is probably the least effective but had been conducted, involving 24 hospitals, 14 audit probably the most utilized. But physicians learn by teams were active (meeting at least each month and doing and by problem-solving." working on a problem), 11 hospitals.had completed COMMUNITY HOSPITAL TEACHING SITES one audit cycle, 20 health professionals had been trained to be consultants to new audit teams. Several In 1967 the California Medical Association and the hospitals intend to expand their medical audit California Regional Medical Program co-sponsored procedures. a planning and goals conference at which it was recommended that the primary teaching site for CALIFORNIA REGIONAL PROGRAM continuing medical education e in community By early January, with the CMA's pioneering efforts hospitals. There were several reasons, Dr. Op I and the success of the RMP-funded projects as said. "We could determine what the educator I inspiration, a regional quality of care program, needs are, we could evaluate what we were doin funded by the California RMP, was under way, and we could more closely weave continuing involving CMA, Pacific Medical Center,the California medical education into the day-to-day practice 0 Hospital Association, the California Nurses' Associa- medicine. With community hospitals we could us tion, the California Medical Records Administrators, modern teaching in small groups and we could have and the State's medical schools and schools of public more participation of practitioners." health. This massive effort will be directed by Dr. As this concept matured the CMA recommended Samuel R. Sherman,' retired surgeon and former that a continuing medical education accreditation president of the California Medical Association, with program be established, and the CMA and the the medical and public health school component American Medical Association established reciprocity coordinated by Dr. Donald W. Petit, director of for accreditation principles. Dr. Brown's medical on-campus programs in the department of post- evaluation techniques, modified for local needs, graduate medicine at the USC School of Medicine. followed. Both are among the State's most highly respected Dr. Opfell directed a small project to introduce physicians. The program is expected to introduce the medical audit process in four Orange County medical audit to all of California's 580 acute general Hospitals-they are now evaluating their work-and hospitals in five years. One hundred have, thus far, has undertaken an experimental medical audit of been exposed to the process. office practice of family practitioners. There a e To Dr. Opfell "this is beautiful. The RMP proposal r has l@ percent in it for evaluation. This whole con- about a dozen local practitioners actively involved' some are quite enthusiastic and they all feel it is cept has caught on in the United States," he said, "worthy of further exploration." pointing to a recent AMA statement that the California formula of accreditation and medical ENTHUSIASTIC RESPONSE audit workshops is, with some modification being Dr. Shickman, a cardiologist and associate director adopted in 38 states, the District of Columbia and for continuing education in health sciences at UCLA, Puerto Rico. also had a small grant from the California RMP, to "What's turning doctors on in California," says the introduce medical audit to a local community hospi- CMA's Dr. Elmendorf, "is that you can't overempha- tal and to a large medical center. size the educational aspects of patient care appraisal. The process has been started at the community Nobody is forcing anybody. Doctors act like it was hospital, and really caught on-to a "total hospital their idea to begin with. They really like it. The level"-at the medical center. "What was meant to principle of self-determination in education applies be a little pilot," he said, "has become a massive here, too. They don't have to have anybody dictating highly enthusiastic program. The continuin ed@ca- to tkem. With this technique they can carve their . 9 tion authorities have taken the position that meaicai own niche; they can do their own thing." conferences, staff conferences and grand rounds, William Boquist 12 The Health Manpower Network Dale Spencer is 52, has always been in good health, The CommonHealth Club involves people person- and like most people, only visited the doctor when ally in health education through a medical testing there was something specifically wrong with him. program. -Each member goes through a battery of Last year, although he felt fine except for some tests administered by volunteer local health pro- sluggishness, he joined the CommonHealth Club. He fessionals. Medical personnel later explain the learned that he had high blood sugar and was a purpose and results of each test and give short talks borderline diabetic. He was overweight and had on health problems. No diagnosis is made-if a test high blood pressure. Spencer is now something of indicates some abnormality, the member is urged to a health fanatic- he's lost weight, his blood pressure see a physician for treatment. The members are is down, and his blood sugar level has dropped. He given guidance in how to control certain health talks to friends about "Preventive" health care. problems and what they mean to the individual's What brought about this radical change? The Corn- total health picture. For example, if someone has a monhealth Club in Santa Rosa, a part of the Sonoma high cholesterol level, he or she is taught just what Health Services/Education Activities (HS/EA) funded this means and ways it can be corrected. If enough by a grant from the California Regional Medical members indicate an interest in say, back problems, a Program (CRMP), class with an expert lecturer is arranged. Thus con- CommonHealth Club originated last year in Santa sumers, by knowing more about their own personal Rosa under the aegis of its present coordinator state of health, are motivated to learn more about Kenneth Bubb with the guidance of local health various problems. it is this personal involvement professionals and the enthusiastic support of the that keeps them coming back and 90% of the club's Sonoma HS/EA's director John C. Wong. Bubb's task 1150 members (age range 18-94) indicate that they was to get the people of Sonoma County interested will return for a second screening in a year to see in learning more about their health, something that whether their health has improved. Well over 50% too few people care about before a crisis situation show a definite health behavorial change-stopped arises. He soon realized that traditional health smoking, lost weight, sought medical attention-due lectures did not interest many people and started to their participation in the CommonHealth Club. toying with the time-tested educational formula of Coordinator Bubb readily admits that the Club's "learning by doing." testing procedure is not the ideal complete annual 13 check-up, but realistically it serves the purpose of making people aware of potential health difficulties and causes more consumers to seek medical atten- tion. Dale Spencer, thinner and with less chance of becoming diabetic, would concur. FAMILY HEALTH WORKERS Language and ethnic barriers, rather than a lack of motivation, can also prevent people from taking advantage of the health care available to them. You are Spanish and don't speak or read English. You've just given birth, and the hospital has instructed you to continue feeding your baby the same pre-mixed formula that they've been using. You go home from the hospital, buy the same formula, pour it into a bottle and try to feed your child. He won't accept it. You contact a Spanish-speaking family health worker in your community and learn that because you couldn't read the English directions on the formula that say "dilute with water" you were feed- ing your baby a concentrate. Your doctor, who doesn't speak Spanish, decides you need surgery. He can't explain exactly what the procedure will be, or more important why it's neces- sary. A family health worker talks with you, answers any questions you may have and serves as an inter- pretor between the doctor and yourself. Your suspicions and hostility are mollified and you agree to go through with the needed surgical procedure. These are just some of the vital services performed by the family health workers of the Northeast Valley Health Corporation, whose training was coordinated by the San Fernando Valley Health Consortium, under a grant from the CRMP. Twenty-six people who had no previous experience in the health field were recruited from the communities to be served. They underwent a six-month training period con- sisting of a twelve-week nursing assistant course that can be credited toward a twelve-month licensed vocational nursing program, and took fifteen college credits in speech, health science, psychology, soci- ology and emergency medical procedure. Because they are already members of the predom- inately Spanish and Black community, the family health workers help overcome much of the suspicion and hostility that exists toward the bulk of local white health professionals. They serve as one-to-one health educators and have helped to concern the local populace with preventive medicine. They interpret feelings as well as language for the patient, and help the doctor explain medical treatment ranging from diet to how to take prescribed medica- tion to surgery. Thus, a group of people who frequently did not seek medical care, and didn't understand it once they found it, are now better able to take care of themselves. 14 VARIED PROGRAMS Both the CommonHealth Club and the family health workers training program are part of a state- wide network of eleven consortia engaged in health services and educational activities, with coordination coming from the CRMP Oakland office of Charles White, Ph.D. Each of the eleven HS/EA's is involved in a variety of programs funded by grants from CRMP -the following are some highlights. In San Diego County there is an ongoing health career education and recruitment program in which minority students are paired with black physicians in a "big brother" program to create an awareness of various health careers. Also in San Diego, health educator Marcia Kerwit has assisted in the establish- ment of a well-women's clinic. The Santa Clara County consortium, in conjunction with other groups, is helping to educate diabetics to be more responsible for managing their own illness and is supporting a rural health manpower development project. The Los Angeles East Health Manpower Consortium is seeking a strong alliance between providers and consumers to recognize and meet the needs of the largely Chicano community, and has @'ll be working for more effective interaction conducted a successful Health Awareness Program between health providers and educators in the to orient Indian and Chicano students about health establishment of initial and continuing education careers. The San Joaquin Valley HS/EA is assembling programs to meet the area's manpower needs. The a health education directory to assist high school San Bernardino consortium is at work devising an guidance personnel in counseling students about informational system to promote consumer aware- health-related fields. Superior California (the twelve ness of existing health resources. northeastern counties) is working on in-service By attracting much-needed manpower into health training coordination for nurses with local hospitals. careers, coordinating continuing education curricula The new South Central Health Manpower consort- for those already in the health field, and conducting ium of Los Angeles will rely heavily on a community various consumer education activities, the HS/EA ombudsman whose expertise in the area will create network has become an integral part of the health an effective liaison between the community's needs spectrum. For without the trained manpower to and the consortium's activities. In Kern County they implement medical care and without consumer are in the process of meeting consumer needs in awareness, the greatest advances in medicine, as largely rural and isolated areas through education well as everyday medical care, will be provided for a and more effective manpower. distribution. The minority rather than a majority of this country's Pomona East San Gabriel HS/EA has conducted a citizens. survey of community health beliefs and attitudes and Harriet Baumgarten 1 5 California Committee on Regional Medical Programs James Adair Charles Guttas, M.D. Clayton Rich, M.D. Fresno San Mateo Stanford Frank F. Aguilera David B. Hinshaw, M.D. David Robertson Los Angeles Loma Linda Newport Beach Franz K. Bauer, M.D. H. Corwin Hinshaw, M.D. Robert J. Schroeder, D.V.M. Los Angeles San Francisco Downey Herbert Bauer, M.D. The Very Rev. Msgr. Davis Timothy O'Brien Oren T. Skouge, M.D. San Francisco San Francisco Miss Lyndall Birkbeck J. E. Smits Sacramento Julius R. Krevans, M.D. San Francisco Glendale Lester Breslow, M.D. Los Angeles James C. MacLaggan, M.D. Miss Faustina Solis Mrs. Helene Brown San Diego La Jolla Woodland Hills Richard H. Mailman, M.D. Mitchell W. Spellman, M.D. Vincent Carroll, M.D. Northridge Los Angeles Laguna Beach Sherman M. Mellinkoff, M.D. William Mayer, M.D. Albert G. Clark, M.D. Los Angeles Sacramento San Francisco John Moxley, M.D. C. John Tupper, M.D. Henry Dishroom La Jolla Davis Richmond J. V. Naish Russell Williams William G. Donald, Jr., M.D. La Jolla Los Angeles Berkeley Stanley van den Noort, M.D. Warren Winkelstein, Jr., M.D. Mrs. Juanita Dudley Irvine Berkeley Los Angeles lifton 0. Dummett, D.D.S. David E. Oisson Mrs. Mildred Younger c Los Angeles Los Angeles San Jose Eldon E. Ellis, M.D. Mrs. Gertrude Pechey Paul D. Ward Redwood City Ventura Executive Director Leslie H. Gaelen, M.D. Clyde A. Pitchford, M.D. John A. Mitchell, M.D. San Diego Riverside Deputy Director A Bulk Rate CALIFORNIA COMMITTEE ON NON-PROFIT ORG. REGIONAL MEDICAL PROGRAMS U.S. POSTAGE 7700 Edgewater Drive PAI D Oakland, California 94621 OAKLAND, CALIF. PERMIT NO. 3268 too Donald W. Petit, M. D. Keith Bldg. - Room 312 2025 Zonal Ave. Los Angeles, CA 90033