19,35268 3109 7 3 ON 42538:16 6' 7 REGIONAL '9 8 10 3 2.- 1 1,9 MEDICAL 73 2 0;4 PR .OGRAMS 3 1 5 2 @l 8!03'7 5 3 1 40-' ,6i,52625'918 4; 2 g 310 7@4 August 1971 A SPECIAL REPORT TO THE NATIONAL ADVISORY COUNCIL REGIONAL MEDICAL PROGRAMS SERVICE The Fact Book was prepared by the Office of Planning and Evaluation with graphic assistance from the Office Of Co ications and Public Information, Regional Medical Programs Service. Comments and suggestions regarding this publication are welcomed and should be addressed to: Evaluation Branch Office of Planning and Evaluation Re ional Medical Programs Service 9 Health Services and @iental Health Administration 5600 Fishers Lane Rockville, Maryland 20852 Additional copies may be obtained by writing: Office of Comunications and Public Information Regional Medical Programs Service 5600 Fishers Lane Rockville, Maryland 20852 FACR BOOK ON REGIONAL ICDICAL PROGRAMS A Special Report to the National Advisory Council of the Regional Medical Programs Service August 1971 DEPAR@IENT OF L[EAIMI EDUCATION AND WELFARE Health Services and Mental Health Administration Regional Medical Programs Service PREFACE ."The American peopZe have always sham a unique capacity to move toward common goals in varied ways... our efforts to reform health care in America will be effective if they build on this strength. President's Health Message February 18, 1971 Regional Medical Programs are a pluralistic approach to dealing with our health problems. The Programs have developed a coalition of almost 15,000 health providers and interested consumers to plan and implement activities tailored to local needs and resources. 'Ihis Fact Book presents, in abbreviated fashion, how RMPS have organized this effort and the progress they have made. It is hoped that this publication will serve as a ready reference source for those interested in Regional Medical Program activities. 1-farold Margulies, M.D. Director Regional Medical Programs Service TABLE OF CONTENTS Pap,re SECTION 1: PURPOSE AND HISTORY OF REGIONAL NE-DICAL PROGRAMS . . .1 Purpose . . . . . . . . . . . . . . . . . . . . . .2 Legislative and Administrative History . . . . . .3 Appropriations and Budgetary History . . . . . . .4 SECTION II: WHAT ARE THE CI"CIL-RISTICS OF REGIONAL NEDI CAL PROGMIS? . . . . . . . . . . . 6 . . . . . .s Map of the R\lPs . . . . . . . . . . . . . . . . . .6 Demographic Facts . . . . . . . . . . . . . . . . .11 Population and Land-size Ranges . . . . . . . . .11 Geographic Characteristics . . . . . . . . . . .11 Pmding Levels and Ranges . . . . . . . . . . . . .12 When Regions Received Initial Planning and Operational Grants . . . . . . . . . . . . .12 SECTION III: HOW ARE THE MAPs ORGANIZED? . . . . . . . . . . . . .13 Example of @IP Organizational Structure . . . . . .14 Grantees and Coordinating Headquarters . . . . . .is Regional Advisory Groups . . . . . . . . . . . . .16 Executive Comittoes . . . . . . . . . . . . . . .18 Task Forces and Co @ ttees . . . . . . . . .. . .19 Local and Area Advisory Groups . . . . . . .. . .21 Core Staff . . . . . . . . . . . . . . . . . . . .22 Minority Representation . . . . . . . . . ... . . .24 SECTION IV: WHAT DO RWs DO? -- PROGPM ACFIVITIES . . . . . . .27 Program Planning . . . . . . . . . . . . . . . . .28 Assessments of Needs and Resources . . . . . .. .28 Setting Program Priorities . . ... . . . . . . .28 Program Implementation . . . . . . . . . . . . . .31 Functional Emphasis, i.e., Education, Training Health Delivery, Research . . . . . . . . .31 Health Care Emphasis, i.e., Prevention/ Screening, atment, Rehabilitation 33 Disease E-mphasis . . . . . . . . . . . . . . . .33 Areas of Special Emphasis . . . . . . . . . . . .36 Health Manpower . . . . . . . . . . . . . . . .36 Ambulatory and Other Out-of-liospital Care - -.37 Urban and Rural Health Care . . . . . . . . . .38 v CONTENTS -- Continued Page . . . . .40 Recent Developments . . . . . . . . . . Health Maintenance Organizations . . . . . . .40 Experimental Health Services Planning and 41 Delivery SYstcms . . . . . . . . . . . .42 Area Health Education Centers . . . . . . . . .44 Who the Rmps Work With 4 . . . . . . . . . . . . . Relationships With Other Federally- Supported Programs . . . . . . . . . . .44 Model Cities . . . . . . . . . . . . . . . . .44 Compreliensive Health planning . . . . . . . . .45 Appalachia Health . . . . . . . . . . . . . . .48 veterans Administration Hospitals . . . . . . .49 Non-Federal Health Organizations . . . . . . . .so PrograTn Evaluation . . . . . . . . . . . . . . . .Si SECRION V: WHAT PROGRESS FLKVE- THE RWs. MADE? . . . . . . . . . .S3 Inproving @-power Resources through Education and7Training . . . . . . . . . . . . . .54 Number and Types of Professionals Trained - - - .S4 Services through Regionalization . . . .57 improving . . . . . .S7 Hospital Participation s. . . . Geographic Scope of Activitie . . . . . . . . .59 maps Depicting Regionalization . . . . . . . . .60 Turnover of Funds to @et Changing Needs . . . . .62 GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 vi SECFION PURPOSE AND HISTORY OF REGIONAL WDICAL PRO@ This section highlights the purpose, legislative, administrative, and budgetary history of Regional Medical Programs. PURPOSE OF REGIONAL MEDICAL PROGPAMS The Regional Medical Programs seek to strengthen and improve the Nation's personal health care system in order to bring about more accessible, efficient, and high quality health care to the American public. To accomplish these ends, the RMPs promote and demonstrate among providers new techniques and innovative delivery patterns; support training which results in more effective utilization of health manpower-, and encourage the regionalization of health facilities, manpower, and other resources. The RMPs develop their programs through a consortium of providers who come together to plan and ' lement activities to meet health needs imp which cannot be met by individual practitioners, health professionals, hospitals, and other institutions acting alone. The RMP provides a framework deliberately designed to take into account local resources, patterns of practice and referrals, and needs. As such it is a poten- tially important force for bringing about and assisting with changes in the provision of personal health services and care. The initial concept of Regional Medical Prourams was to provide a C> vehicle by which scientific knowledge could be more readily transfer to the providers of health services, and by so doing, improve the quality of care provided with a strong emphasis on heart disease, cancer, stroke, and related diseases. The implementation and experience of RMP over the past five years, coupled with the broadening of the initial concept especially as reflected in the most recent legislation extension, has clarified the nature and character of Regional Medical Programs. Though RMP continues to have a categorical emphasis, to be effective that emphasis frequently must be subsumed within or made sub- servient to broader and more comprehensive approaches. RMP must relate primary care to specialized care, affect manpower distribution and utilization, and generally improve the system for delivering compre- honsive car . Even in its more specific mission and objectives, RMP cannot function in isolation. Only by working with and contributing to related Federal and other efforts at the local, state, and regional levels, particularly state and areawide Comprehensive Ilealth Planning activities can the RMPs achieve their goals. -2- HIGtIL7G[iTS OF LEGISLATIVE AND ADMINISTRATIVE HISTORV OF REGIONAL MEDICAL PROGRAMS 1964 DECEMBER The Report of the President's Cormnission on llcart Disease, Cancer and Stroke presented 3S recommendations including development of regional complexes of medical facilities and resources. 1965 JANUARV Companion administration bills--S.S96 and H.R. 3140--were introduced in the Senate by Senator Lister liill (Ala.), and in the House by Representative Oren Harris (Ark.), giving concrete legislative form to presidential proposals. OCTOBER P.L. 89-239, the Heart Disease, Cancor and Stroke Amendments of 196S. was signed. The Commission concepts of "regional medical complexes" and "coordinated arrangements" were replaced by "regional medical programs'! and "cooperative arrangements," thus emphasizing voluntary linkages. DECEMBER National Advisory Council on Regional Medical Programs met for the first time to advise on initial plans and policies. 1966 FEBRUARV Dr. Robert Q. Marston appointed first Director of the Divi- sion of Regional Medical Programs and Assoc. Director of NIII. APRIL First planning grants approved by National Advisory Council. 1967 FEBRUARV First operational grants approved by National Advisory Council. JUNE The Surgeon General submitted the ical Proarams to the President and the pr gress e an re( 1968 MARCH Companion bills to extend Reg ional Medical Programs were intro- duced in the House by Harley 0: Staggers (W.Va.) (H.R. 157S8) and in the Senate by Senator Lister Ilill (Ala.) (S. 3094). OCTOBER P.L. 90-S74, extending the Regional Medical Programs for two years,was signed. Changes were: include territories outside I of the SO States; pennit.funding of interregional activiti6--,; emit dentists to refer patients; and permit participation of p Federal hospitals. 1970 JAN.-OCT. Bills extending MI introduced; hearings held. OCTOBER P.L. 91-515 was signed into law. New provisions. emphasis on primary care and tegionalization of health care resources; added prevention and rehabilitation; added kidney disease; added au ruc f RMP appli-, thority for new const tion; required :review o cations by Areawide Comprehensive Planning agencies; emphasized 1,@-nl f'h 4ze-ruic--Ps delivery and manpower utilization. APPROPRIATIONS AND BUDGETARY HISTORY (Dollars in Thousands) .Fiscal Fiscal Fiscal Fiscal Fiscal Fiscal vear year year year year year 1 1966 1967 1968 1969 1970 1971 00 $12S,000 ------- $50,000 $90,000 $200,000 $6S,000 $120,0 39 Authorization ------------------ 43,000 S3,900 S6,200 73,SOO .1500 Driated for grants -------- 24,000 Amount appro, 78'soo 70.$298 *Amount actually available for grants-- 24,000 43,934 48,900 72,365 Amount actually a7,,iarded for grants---- 2,066 27,052 43,63S 72,365 78,202 70,298 Includes unspent funds carried fo-nvard from previous year minus amounts held in reserve by the Office of N@gement and Budget. SECRION 11 WHAT ARF, TIE G"CTFRISTICS OF RFGIONAL MEDICAL PROGRNC? IriAis section provides a brief overview of the 56 Regional Medical Programs, including their geographic boundaries, population ranges, land size, operational.status, and ranges of Current funding levels. 56 REGIONAL MEDICAL PROGRAMS 4 so za i IT THE 56 REGIONAL MEDICAL PROGRAMS BY GEOGRAPHIC AREA COVERED REGION Covering the entire State of Alabama. 2. ALBANY REGION Including 21 Northeastern New York counties centered around Albany and contiguous portions of Soutjie-ni Vermont and Berkshire County in Western Massachusetts. 3. ARIZONA REGION Covering the entire State of Arizona. 4. AI"SAS REGION Covering the entire State of Ar sas. S. BL-STATE REGION Including Southern Illinois counties and Eastern Missouri centered around St. Louis metropolitan area. 6. CALIFORNIA REGION - Covering the entire State of California and interface with Reno-Sparks and Clark County (Las Vegas),, Nevada. 7. CENTRAL NEW YORK REGION - Including 15 Central New York counties centered round Syracuse, New York and Bradford and Susquehanna counties in Pennsylvania. 8. COLORADO-WYOMING REGION - Covering the entire States of Colorado and Wyoming. 9. CONNECTICUT REGION - Covering the entire State of Connecticut. 10. FLORIDA REGION - Covering the entire State of Florida. II. GEORGIA REGION - Covering the entire State of Georgia. 12. GREATER DELAWARE VALLEY REGION - Including Southeastern .Pemsylvania, (Ph- en), Northeastern'Pemsylvania (Wi lkes Barre-Scranton) and the southern part of New Jersey, and the entire State of Delaware. 13. HAWAII REGION - Including the entire State of Hawaii, plus American S @oa, Guam, and the Trust Territory of the Pacific Islands (Micronesia). 14. ILLINOIS REGION Covering the entire State of Illinois. 15. INDIANA REGION Covering the entire State of Indiana. 16. INTERMOUNTAIN REGION -.Including the entire State of Utah, and portions of Wyo-m'ng, Nevada, Montana, Idaho and Colorado. -7- 17. IOWA REGION - Covering the entire State of Iowa. 18. KANSAS REGION - Covering the entire State of Kansas. 19. LOUISIANA REGION - Covering the entire State of Louisiana. 20. MAINE- REGION - Covering the entire State of Maine. 21. MARYLAND l@-GION - Including most of the State of Maryland, (except Montgomery anL[ llriiice Georges Counties) and York County in Pennsylvania. 22. MMIIIS REGION - Including Western Tennessee centered around Memphis, Northern Mississippi, Eastern Arkansas and portions of Southwestern Kentucky, and three counties in Southwestern Missouri. 23. MEIROPOLITAN WASI-IINGTOlq, D.C. REGION - Including the District of ColumBia and contiguous counties in Maryland and Virginia. 24. MICHIGfiN REGION - Covering the entire State of Michigan. 2S. MISSISSIPPI REGION - Covering the entire State of.Mississippi. 26. MISSOURI REGION - Including the State of Missouri, exclusive f@the Metropolitan St. Louis area. 27. MOLIP4TAIN STATES REGION - Including the States of Ica Montana, Nevada and Ilyoming. 28. NASSAU-SUFFOLK REGION " Including the counties of Nassau and Suffolk (Long Is!-aiid) of the State of New York. 29. NEBRASKA REGION - Covering the entire State of Nebras a. 30. NEW JERSEY REGION - Covering the entire State of New Jersey. 31. NEW MEXICO REGION - Covering the entire State of New Mexico. 32. NEW YORK METROPOLITAN REGION - Including New York City and Westchester Rockland, U@ge and Putnam Count.ies, New York. 33. NORTII CAROLINA REGION - Covering the entirc,State of North Carolina. 34. NORTII DAKOTA REGION Covering the entire State of North Dakota. 35. NOI@i'll]Ali'l' 01110 Id:(;IOiN - fjicludiiig 12 counties in Northeast Ohio, ccritered around 36. NOIZ'Ilil:l@,N 141:W @GLAND 14:(;JOiN - Including the entire State of Vemont and three contiguous counties in Northeastern New York. 37. NORTIFLANDS REGION - Covering the entire, State of Miruiesota. 38. NORTFIWESTERN O]IIO RL-GIOIN - Including 20 counties in Northwestern Ohio, centered around Toledo. 39. OHIO STATL-' REGION - Including 61 counties in central and soutHern two-thirds of the State of Ohio, excluding Metropolitan Cincinnati areas and Dayton. , 40. OIIIO VALLEY REGION - Including the greater part of Kentu cky (101 of 120 counties), Southwest Ohio, (Cincinnati-Dayton and adjacent areas), contiguous parts Of Indiana (21 counties) and West Virginia (2 counties). 41. OKLAHOMA REGION - Covering tJie entire State of Oklahoma. 42. OREGON REGION - Covering the entire State of Oregon. 43. PLJERTO RICO RLGION - Covering Comonwealth of Puerto Rico, and the Virgin Islands. 44. ROCIFESTER REGION - Including 10 counties'centered around Rochester, New York and interface with 3 Northeast Pennsylvania border counties. 45. SOURH CAROLINA REGION - Covering the entire State of South Carolina. 46. SOURH DAKOTA REGION - Covering the entire State of South Dakota. 47. SUSQUEII"A VALLEY REGION Includin 27 counties in Central 9 Pennsylvania, centered around the fiarrisburg-liershey areas. 48. -SSEE MID-SOURH REGION - Including 84-of 94 counties covering the central an eastern sections of Tennessee, Southwestern Kentucky and 3 contiguous Alabama counties. 49. TEXAS REGION - Covering the entire State of Texas. 50. TRI-STATE REGION - Covering the entire Statm of Massachusetts, New Hampshire and Rhode Island. -9- SI. VIRGINIA RL,GION - Covering the State of Virginia, except for counties and cities of Alexandria, Arlington and Falls ChurcJi. S2. WASHINGFON/ALASKA REGION - Covering the entire States of Washington and Alaska. S3. WEST VIRGINIA REGIOIN- Covering the State of West Virginia. S4. WESTERN NEW YORK REGION - Including 7 Western New York ounties centered around Buffalo, and the counties of Erie and McKean, Pennsylvania. SS. WESTERN PINNSYLVANIA REGION - Including 28 counties in Western Pennsylvania, centered around Pittsburgli. ' S6. WISCONSIN REGIOIN Covering the entire State of Wisconsin. -10- OVdt&Cll-"RI,STIC,S Ol-' IU-,GIONAL MI:I)ICAL IIROGRAMS DEMOGRAPHIC FACTS There are 56 RMPs which cover the entire United States and its trust territories. The Progrm6 include the entire population of the United States (204 million) and vary considerably in their size and characteristics. LARGEST REGION In population: California (20 million) In size: Washington/Alaska (638,000 square miles) SMALLEST REGION In population: Northern New England (445,000) In size: Metropolitan Washington, D.C. (1,500 square miles) GE-OGRAPIIIC BOLJNDARIES: Nmber of Regions which Encompass single states . . . . . 33 Encompass two or more states . . . . . . . . 4 Are parts of single states . . . . . . . . .11 Are parts Of two or more states . . . . . . 8 POPUIATION: Number of Regions which have Less than 1 million persons . . . . . . . . 5 1 million to 2 million . . . . . . . . . . .11 2 million to 3 million. ; . . . . . . . . .14 3 million to 4 million . . . . . . . . . . .8 4 million to 5 million . . . . . . . . . . .7 Over 5 million . . . . . . . . . . . . . .11 G"CFE-RISTICS * FUNDING UVELS: Regions vary from Highest: California ($8.3 million) Loivest: North Dakota ($309, 000) * FUNDING LEVEL RANGES: Regions with Less than $SOO,000 . . . . . . . . S $Soo,ooo to $999,000 . . . . . . . 16 $1 million to $1.4 . . . . . . . . 15 $1.5 million to $1.9 . . . . . . . 10 $2 million to $2.4 . . . . . . . . 6 More than $2.5 million . . . . . . 4 MEDIAN LEVEL: $1.2 million -------------------------------------------------------------------- 11[iEN REGIONS RECEIVED INITIAL PLANNING AND OPERATIONAL GRANTS 60 - 55 55 54 50 - ning 40 - Number of 30 - Regions @rational 20 - 10 - 0 1966 167 '68 '69 '70 '71 Fiscal Year To date, only one RMP has not yet received its first operational grant South Dakota. This is because it received its first planning grant in FY 171. By the end of FY 167, 48 of the current 56 RMPs had received their initial planning grant. On the -other hajid, it was not Luitil the end of FY 169 that most (41) lzc-gioiis received tlici.r first operational grants. -12- SECRION III HOW ARE REGIONAL PCDICAL PROG@ ORGANIZED? This section highlights the organizational structure of the RMPS, including the c osition and function OMP of Regional Advisory Groups, task forces, committees and staffs. Summarized also are overall changes which have occurred in these groups over the past five years and minority representation. '13- B"LE. OF THE ORGANIZATIONAL STRUCTURE OF A REGIONAL @DICAL PRO@ Gre Coordinator Regional Advisory GrouD FOpei inistration Executive FALCIM Committeel Task Forces and Manpoiver Research Subregiona Services Committees and and Off and Education Evaluation Resources Local -Advisory Groups ORGANIZ,KFION S AND COORDINATING F@UARTERS PLIRPOSE: Each Regional Medical Program is fiscally administered by a grantee which may be a public or private non- profit institution, agency or corporation. The grantee is responsible for fiscal control and fund accounting procedures to assure proper disbursement of and accounting for such RMP funds. A coordinating headquarters my be described as being responsible for t implementation, administration and coordination of a Regional Medical Program. As such, itlis.involved in the development of regional objectives as well as review, guidance and evaluation of the ongoing planning and operating functions. Grantee and Coordinating ileadquarters,Fiscal Year 1971 Coo Grantee S6 Headquarters 56 Universities 34 31 Public (27) (TS-) Private 7) 6) Other 22 25 New Agency/ Corporations (15) (18) Existing Corporations 3) 3) Medical Societies 4) 4) Comwnt: In sow RNPS, the grantee differs from,the coordinating headquarters. For example in the North Carolina RNP, the grantee is Duke University, but the coordinating headquarters is the non-incorporatcd agency--the North Carolina Association for Regional Medical Programs. ORGANIZATION REGIONAL ADVISORY GROUPS PURPOSE: Regional Advisory Groups reflect a broad spectrum of healtJi interests and institutions, including private practitioners, community hospitals, allied health personnel, and consumer representation. They have as their primary function overall program guidance - that is, deteminatioii of the overall scope, nature and direction of the program. Each Regional Advisory Group must dete@e policies, establish criteria and priorities, allocate RMP grant funds accordingly and review operational projects. SIZE: 1967 1,600 total iwmbership 30 average group size 1969 2,500 total membership 45 average group size 1970 2,700 total membership 48 average group size 1971 2,743 total membership 49 average group size ------------------------------------------------------------- Ranges in Size of RAGs--1971 10- 19 members: 3 RAGs 20- 29 members: 11 RAGs 30- 59 members: 34 RAGs 60- 99 members: 5 RAGs .100-199 members: 2 RAGs over 200 members: I RAG -16- Of@(IANIZAI'TON Fiscal Years 1967, 19 9, 1971 Voluntary Other Agencies Health lVo-rke-rs medical Public Practicing Hospital Center I-le al th Meubers of Physicians Admin. Officials Agencies Public Other 1967 ... ... ........ 1969 .......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1971 .............. .................. .............. ----------- 0 20 40 60 80 100 Ilexcont Hi Practicing physician representation has increased considerably from 23% to 28%. @ledical center officials have decreased markedly, from 16% to 8%. Voluntary agencies and public health representation has decreased. Increase in members of the public from 15% to 21% reflects more consumer involvement in R4Ps. ORGANIZATION EUCUTIVE COMMITTEES e comittees are appointed by the Regional PURPOSE. Executiv Advisory Group to provide advice and counsel to the RAG and serve as the day-to-day aclvisor to the RMP coordinator and core staff. They also act in the stead of the RAGs except on final project or policy decisions. COWOSITION: C upa-rison of@Membershili for 1969 and 1971 Professional Categog Number Percent (19 1971) (19 1) Physicians 284 266 670-o 58% Nurses 18 16 4% 4% Allied Health S6 so 13% 11% Other 67 127 16% 27% TOTAL 42S 459 100% 100% Highli@: The decline in the actual number and percentage of physician membership has been countereId by an increase in "Other," from 67 to 127, or 16% to 27%. The increase in "Other" -reflects more hospital and nursing home administrators members of the public and others. Nursing representation has remained stable. ORGANIZATION TASK FORCES AND COMMITFEES PURPOSE: Task Forces and Comittees have ma3or responsi- bilities for project development and/or review of projects. Nearly all of them assist in the establishment of objectives and priorities for program activities. They perform a great deal of the coordination and liaison in fostering cooperative arrangements among institutions, organization and various interest groups. NLMER AND SIZE: 1969: 492 Comittees in 54 Regions: 5320 Total membership 1971: '410 Comittees in SS Regions: 6379 Total membership CDMPOSITION: Comparison of 1969 and 1971 By,Profession Nmber Percent (19 9) (1971) (1 69) (1971) Physicians 3273 3523 61% SS% Nurses 486 580 9% 9% Allied Health 672 802 13% 13% Other 889 1456 17% 23% TOTAL 5320 6379 100% 100010 Total membership has increased 20% lans show a 6% decline while "other" category Physic' which includes members of the public, hospital administrators and others, has increased 6%. ORC,ANIZATION Comparison of Task Forces and Comn4ttees 1969 and 1971 By Type of Task Force/ No. of Committees Percent Comittee (1969) (1971) (1969) (1971) Heart, 65 41 13% 11% Cancer 60 42 12% 10% Stroke S4 36 11% 9% Other Disease (including 39 30 8% 7% Kidney) Planning & Evaluation 30 27 6% 8% Continuing Education & 45 47 9% 12% Training Health Manpower 11 27 2% 4% Other 188 160 3 90-o 39% TOTAL 492 410 100% 100% Number of Task Forces and Committees has declined. from 492 to 410 or about 20%. categorical Disease Committees have decreased while planning/evaluation, continuing education and manpower committees have increased. The significant increase.of manpower committees clearly e departing from traditional indicates that RMPs ar approaches and'are now concerned with the development of approaches to overcome the existing health manpower crisis. . The significant number of 0-th6i comi-ttees include health maintenance organizations, experimental health delivery systems, finance, legislation committees, etc. . 39 Regions have Heart committees; 36 Regions have Cancer committees; 55 Regions have Stroke committees. -20- ORGA,NIZATION LOCAL ARFA ADVISORY GRO@S Assist in project development and implementation PURPOSE: ty needs and to strengthen to meet cOmun' local institutions) organiza- relationships among They are th the medical center- tions and wl the basis of population generally Organized on - . d trade areas. Some are organize or medical hospital areas and to local medical according to groups do Some local area and advisory schools. d coordination with planning an cles. cooperative Health Planninp 314 'lb" agen rehensive COMP the site for coordination of efforts They are often . s where they intersect locally. between RW region ITION: Comparison of 1969 and 1971 Percent B@ profession 19 1 0 ans ................ 4 42% Physici 11% Nurses .................... . 15% Allied Health ............ . 31% other ................... TOTAL PEOPLE 4,843 6,047 HI lights Total membership has increased from 4,843 to 6,047 or about 25%: slightly which entation has increased Nursing rep@es in alli@ health e- t by a slight decrease has b en offse representation- includes hospital admi'ftistrationt nursing "other" which iic has home administrators, and @ers of the pub remained unchanged. -21- ORGANIZATION MINORITY REPPESFAN'TAT'ON Of minority groups at all levels of RW Appropriate participation equisite to planning, decision-making and implementation is -r , flects responsive relevant program development. Data beloii re minority representation on core and Project staffs, RAGS, and co@ttees. Nff NORT- T I E- S' 'call Indians, Orientals, Defined as Blacks, spaii.sh surname, AmcT' with the I,-, aiis, ctc.)) Indiai , POJYIlcsi and others iLal es. According to being in the first four categori preponderance lation is classified the-1970 Census, 12% of the total U.S. POPU . lude as Black or other. However, the oti-ic-r category does not inc ame. Therefore) by extrapolating from the 1969 Census Spanish surn one arrives at an estimated 16% data on persons of Spanish origin, ties as clefined above. of the population being 'niinO'ri Project Staffs I Time Equiiale-n 1971 2 20% minority 16% Population 1 ------------------------- --- of U.S. -rcent is 16% Pe 12% Minori ty 6% ssion Secre ari professions Secr6taria PROJF,CT STAFFS CORE STAFFS highlights' Titles; 17% core :3taf f are M:LNO Only 9% of the total 1,640 FTF .. rities. of the 2,440 FrE project staff are nuno -e-, full and part-time personnel) In terms of actual Deople (i ories, ranging ities is less In all categ the percentage of @0r project professionals. from lo6 fewer core professionals to 3% fewer . - 1-time In other words, minorities are more liRely to be ful personnel. -24- ORGANIZATION Minori s and Other 20- --------------------- Minority 16 --------------------- Population of U.S. - is 16% 12 Percent 10% Wnority - 8 8% 1 6% 4 1969 1971 1969 1971 RFGIONAL ADVISORY ALL O'niER GROUPS CDWTTEES Highl 'Ihe minority representation on RAGs has increased by 3% to lo% of the 2,700 mmbership, but is still 6% shy of being representative of the nation. ndttees has on the other hand, priority 1)c-rcentago on other Co decreased by 2%, to a low of 6% of the total 12,000 membcrslill). -2s- ORGANIZATION ative Distribution of Estimat d National (includes Americ her Indian Amer indi 26% panish pa urname 68% Black ur 69% Black D ii s Tt- r il 'bull It- iL'OJ 'n" Es imted National Distribution ibution is relatively consistent The comparative distr Blacks) with one (surprisingly so in the case of ed. exception -- the Spanish surnames are uiider-'re resent .p - ----------------------------------- ----------- ---------------------- F le Partic Re2ional medical Programme ;HIGHLIGgS-: 00 females involved in Regional Medical There are over 6yO I>rograMS. ity (54%) of the professional Project personnel are A Mai Or women. emales. only 14% of Regional AdvisorY Group embers are f 1 a-re women- professional core staff persome 31% of of core and Project secretarial,staffs are fe@les. -26- SECTION IV WHAT DO REGIOM4L I&DICAL PRO@ Do? PROGRAM ACUT-ITVVJIIT-'TrEISJ This section outlines the kinds Of activities carried out by the Programs) including how and what they PLAN.9 describes _TleLEW,'VT, md EVALUATE. It areas of special emphasis and new program developments as .well as the relationship of the RWs to health and healtl"-,related agencies and Programs, particularly to other federally-supportecl progr@. -27- PROGRAM ACTIVITIES R@ PLANNIIIG in planning AND RFSO CES: The initial step -regional OF NEDS cation Of the icle'ntif i two-prongecl most this is a omittees a-ncl task of health c r, what the id ing,in a consensus @e ion of .St. The other is the collect where thev exi ent of the p'rOblevs anci the need a-re, the ext llg 1970 and pertinent data to determne Duri resources available for use in their solutions- election 1971 the @s carried out nearly 400 such data co es in the following areas: of Studies acti-viti er I Area of Data collection 50 Manpower distribution and availability 98 facilities. 95 s rvices and tions 29 H diseases 23 c 42 ation - 38 Ci ECIUC 3'rS Data Bank TOTAL ---------- ----------------- -------------------- ----------------- -ola-rming Is F ,s S@ING OF PROGRAM PRIORITI Another steP.ln - ified health those locally ident. .. to be of sett3: me cal Progr@ have deterfninecL -- ttillg of priorities (usually needs locallY. The se the reatest url ideally enables the RW to with 9- Advisory G-rouP, done by the Reg@ I allocate funds in accordance gions proposals and the 56 Re review activitY needs. To date 45,of gionts most pressing of the 45 RWs@ about 5 name the Re et priorities. ily be mistaken for goals; have :Cormlly sroad theY I -le theY included some ities so b whi prior e of another 30 presented list e most part a vast ey-Pans of of need,'w ani7ation and delivery spe ific areas ssues 'r 1. 10 con i cancer, a troke"; only about., ca,x t disease speci priority areas. Regi Teportecl definitive 28- pROGRAM ACTIVITIE,,,;... PLANNING pR.TOR.TTIES The riorities which have been set by the 41 RITs relate gen- p as: health care organization and erally to three broad are systems., health professionals, and patient sepvices and target groups. Virtually all of the 45 IZegions named education Or man- power as a major regional need. One-third identified disease prevention and early detection- 2o identified health care for the poor. 7 specified urban health, while 10 @ecl rLral heart'.. Sumary of: Prioriitie, Health Care organization and Systems Raiiization and delivery of cAre; S Of 16 PMs named or_ these specified new and innovative models for organi- zation and delivery.* and quality s naTwd availability) accessibility, 12 RW of care. 10 Ws nawd health needs and resources assessment. 6PMs named coordination of existing resources and distribution of services.* SRWs named ambulatory care.* SWs named efficiency of health care organization and systems' 4 of these specified health care costs and financin - 9ecialized and long-term care. 3PMs named sp Health Professionals education and training.* 33 Ws named continuing 29 Ws named manpower development, utilization, mid distribution.* 4Ws named increasing I)rovider efficiency.* These have also been named as IlSgLl\ priorities for IN). 29- S ... pLANN-TNG PRIORITIES pROGRAM ACTIVITIE coordination among 2 RWs named commication and provider grOuPs- eer mobility for allied 2RWs named education and car health personnel Patient Se2vices and Target populations Ms named health care delivery for disadvantaged 20p if iecl urban populations; OLI.ps*; 7 of these spec a particular gr ions; 2 name 10 specified rural populat @oritY grOuPs. ntion and early detection.* 14 RWS named disease pTeve tion and education. 11 RNPs named public informa sRws named -rehabilitation. ill health la'nni'ng' umer participation p 3 pie snamed cons 3RNTs named infant and child health-* snaTwd health care for migrant workers - 2RMP s d emergency services. 2RW name These have also been named as Priorities for RW. -30- PROGRAM ACFIVITIES PROGRAM IMPLEMENTATIOIN Program implementation follows planning efforts. Once the needs have been identified and the goals and priorities have been set, activities to meet these needs are designed and conducted. These activities may be described in a number of ways, including (1) functional emphasis or primary purpose, e.g., education, patient care, etc., (2) health care emphasis, e.g., prevention, rehabilitation, and (3) disease emphasis. The following sections highlight what the RMPs are doing in terms of these three areas including areas of high priority and special emphasis, such as special manpower programs, programs for urban and rural poor, and others. FLNCTIONAL EMPI-IASIS: What the RNTs do to implement their progrzm is in five major functional areas: General continuing education--tliose activities concerned with maintaining or improving the level of practice of health personnel through improved skills or increased knowledge. This includes such activities as seminars and conferences for physicians, nurse training in patient management, dial-accoss@ consultation, etc. @ower utilization and traininr--activities aimed at improving the distribution, development ana,utilization of health personnel. This function includes training in new skills, training new categories of personnel, curriculum development, and other areas. Organization and delivery for patient sorvicos--these activities relate directly to patient care delivery through demonstrations of new techniques, development and demonstration of organizational models for delivery, and improving coordination of patient services. Research and develo-pmcnt--activities which emphasi ze the testing or investigation orpr-ototn)es for new systems, processes, techniques, etc. Program coordination and administration--overall RMP direction a-nUcoordaa-tion, including r opment, evaluation activities, program coordination, co ity liaison, and interrelationships of health institutions providing multiple levels of care. f'ROGIW,l ACTIVITI]@@S. FLB,,ct-i,onal L-jTi[)Iiasis, 1969-71 100 ....... .......... ........... ........... ...... ... ................. ....... .................. ........... ................. .......... ................. ........... ... ....... ...... ........... General Contin- .......... ........... ..... .......... ........... ........... uing Education ........... ........... .......... .......... ........... ... ........... .......... ........... .......... 80 ........... .......... Manpower Utilization 60 it Organization 40 and delivery for patient services 20 Research and Development Program Admin- istration 1969 1970 1971 ($72,365,000) ($78,202,000) ($70,298,000) Research and development activities have taken on less significance due in part to the fact that the new emphasis is oil methods for the actual delivery of patient care. RW5 are still devoting a large portion of their resources atient care but the em'phasiswithin this category has to p shifted to the newer concepts of organization and systems for the delivery of patient services particularly for primary care, Since 1969, manpower activities and studies have shown a steady increase, with a proportionate decrease in general continuing education activities. The trend in Regional Medical Programs today is toward activities concerned with better utilization of personnel and improving manpower distribution rather than only education to increase medical knowledge and expertise. -7 ') PROGRAM ACTIVITIES ... IMPLEMENTATION l@'n-I CARE- BT[IASIS: RMPs arc supporting training, delivery, and coordi t@ion of: Screening and early detection programs such as cervical cancer, new stroke detection techniques; Demonstration treatment and diagnostic services programs such as in kidney dialysis and laboratory services; Stroke and other more comprehensive rehab- ilitation programs, often using the ealt team approach; and Demonstration comprehensive care programs, such as complete ypertension management. All such activities are coordinated with other support services to promote continuous, comprehensive care. -------------------------------------------------------------------- DISEASE EMPHASIS: The disease focus of program activities has shifted since the first few years of RMP implementation. Most Programs are moving in favor of a broader approach to health problems and are supporting ess heart disease and more cancer and kidney disease: ison Percent Disease Category of Funds 1968 1971 lieart disease . . . . . . . . . 35% 26% Cancer . . . . . . . . . . . . 9% 13% Stroke . . . . . . . . . . . . 12% 12% 0- Kidney disease Related diseases . . . . . . . 8% 6% Multicategorical and non-specific . . . . . . . . 36% 38% -33- PERCENT OPERATIONAL FUNDS (millions) 60 2) 10 0 0 20 1 40 P7) Pre,,,eiition and ----- Screeiiiiic, C, Diagnosis and ------ LTI, Treatment ---- Rehabilitation ----- Comi)rehensivo ------ Care 1969 1971 Highligh@s The funding emphasis on prevention and early detection activities has increased by 3% over the two-year period. This is in line with national and regional priorities. . Comprehensive programs have also gained significance; the proportion of dollars in this activity has increased by about 4%. . Activities concerned with diagnosis and treatment are still the largest portion of the health care picture, but have shown a steady decrease during this period. PROGRAM ACTIVITIES ... IMPLEAENTATION EXAMPLES OF HEALTH CARE AC71VITIES To improve manpower utilization and capability and to oordinate t e eliv, th services: .Confed6ration of Coro@r Care Units -- California: This activity covers 11 counties in northwestern California with a population of over 3 million. Sponsored by the Univer- sity of California, San Francisco Medical Center, the activity assists hospitals in designing coronary care units; provides the necessary training for their operation; and coordinates the delivery of coronary services. The pro- gram is multifaceted, including components of data collection systems, coronary care nurse training, advanced cardiac nurse training, coronary care teaching for nurse educators and practitioners, electronics consultation,, one- week physician preceptorships, physician consultation, and a library for unit directors. To improve the organization for delivering services and upgra@ing quality-: "Acute Stroke Management Demonstration Proiect in a Cm- mmity Os i Carolina: Th@ s a coor ina ke managem( and attempts to encourage additional stroke programs in the Region. The stroke team consists of stroke nurses, a speech therapist, a discharge planner, and a public health nurse, coordinated by the two physicians who direct the project. To expand manpower availability and utilization in ghetto areas: Model City Health Manpower Education and Recruitment Program Kansas: TRis activi@ and un erstanding among Kansas City, Kansas model neighl rhood residents about good health practices, and provides a means of their entry into health professions as health aides. At the same time, it helps to ease the health manpower shortage and access problems prevalent in the area. Under supervision of a health coordinator, health aides are involved in class- room instruction on comunity health, practicum activities, and participate in supervised activities involvi co ication @g with and teaching of other residents in need of education or services. -3S- PROGRAM AUIVITIFS - - - 114PLE'ENTATION s AREAS OF SPEC e, available, high quality health services, problems Of accessibl ar-of increasing - The deprived urban and rural areas' e through particularly in ese p-rob.le@ ern to the Rws and they are addressing th conc . luding: a variety of avenues, inc lization wer distribution) Uti (a) Programs to lffProve @Po and development on @ulatory care progrOs@ ncluding (b) More emphasis -ghborhood health centers, out- activities linked to nel and the like; and patient clinics, home health P'rOg'raTns ease the availability (c) Training and other progT@ to 'ncr and rural and utilization of health services by ghetto residents and to heighten their involvement in the delivery of services. @Tti MANPOIIER -third of BW funds support activities to Approximately one . These improve health manpower utilization and development expand the duties of include training Program (1 to oo new health manpower existing health personnel; (2) to devel-, utilization; and perso@el; (3) to study distribution and programs to retrain and improve manpower availability. Number of in particular, -r ons Established Health Manpower 29 as PrioritY . . . . . . . . . . . . . Established Health Manpower 27 Co@ttees . . . . . . . . . . . . Designated Core Staff Wmber for Manpower . . . . . . . . . 17 ignated Core staff Representative Des Council 12 on cHP or State.manpower -36- PROGRAM ACTIVITIES ..IAPLEAENTATION Regions have also coordinated: Nwnber.of -Regions Health Manpower Inventories or Feasibility Studies . . . . . . . 17 Health Manpower Legislation . . . . 10 Physician Assistant/Nurse Practitioner Development . . . . . . 29 Health Manpower Recruitment and Retraining . . . . . . . . . . . 23 Examples of Manpower Activities Several RMPs are helping to train nurse practitioners, particularly in pediatrics. One region sponsored a feasibility study to train 6,RNs in an 18-week pediatric nurse . course and all are now working with private physicians or home health agencies. Other RWs are helping to,train radiation/ nuclear medicine technicians in cooperation with local hospitals and community colleges. Curriculum development is another area -- one RMP helped develop the curriculum for a network of 17 -rural junior colleges all linked to a central training institute. AMULATORY AND OUF-OF-HOSPITAL CARE Approximately one-fifth of Iff funds are estimated to support activities related to ambulatory care and other out-of-hospital services. These include training, health delivery, and planning activities linked to neighborhood health centers; home health services; and.in a few instances extended and long-tem care services. -37- PROGRAM ACTIVITIES -TmPLEmp,,NTATION in particular: Five regions have singled out ambulatory care as a priority. Ambulatory care activities are estimated to have doubled over the past year. Currently over $8 Million is supporting more than SO activities. Almost half these activities contribute to providing comprehensive health services. For example, in one region a hypertension screening program has extensive referral services and is tied to major hospitals and home health services. About ten of the activities are linked to the services of a neighborhood health center, and include such activities as multiphasic screening and early screening for cancer and stroke. Home health activities have also doubled and now $1.5 million is supporting activities related to extended care and nursing home services. URBAN AND RURAL HEALTH CARE fibout 17 percent of RMP funds now support special program for the urban and rural poor, reflecting increased efforts in this area. In particular: Almost 10% of the funds are for inner city -residents and include over 30 activities totaling about $4.5 million. . Poor rural residents are the targets of over 50 .activities totaling about $3.2 million. . Over half of the imer-city activities relate to patient services, and include such activities as comprehensive stroke programs; improving the CO- ordination.of existing services involving multiple -38- PROGRAM ACFIVITIES ... IMPLEMENTATION levels of care, e.g., screening, acute hospital care, home health and rehabilitation services; and improved hospital-based primary care. The other half is for various types of training and planning efforts. . Several inner city programs involve training community residents to enter jobs with career mobility. . Many of the rural program include training activities to experimnt with expanding the amount and level of services which allied health personnel can deliver; they also include programs which coordinate existing services for broadened outreach. -39- PROGRAM ACTIVITIES ... 114PLEMENTATION RECENT DEVELOPWMS The success of Regional Medical Programs stem from their capability to be flexible and responsive to changing health needs and problems. It is this characteristic which has enabled RMPs to shift from a categorical approach, i.e., reducing the ill effects of heart disease, cancer, stroke, kidney and related diseases to the development of diversified systems of health delivery tailored to local needs. Regions are presently stimulating and fostering planning for such delivery systems. @'IH MUNTENANCE ORGANIZATIONS: The Regional I&clical Programs are invoivecL in the newly emerging Health Maintenance Organization program in a variety of ways. Foremost among these is providing assistance to help HMD's in the developmental stage and in improving and maintaining quality of care. A Health Maintenance organization is based on the following four provisions: It is an organized system of health care which accepts the responsibility to provide or other- wise assure the delivery of an agreed upon set of comprehensive health maintenance and treatment services for ... a voluntarily enrolled.g-roup of persons ina geographic area and ... is reimbursed through a pre-negotiated and fixed periodic payment made by or m behalf of each person or family unit enrolled in the plan. Fifty-two of the 56,Regional Medical,Programs (one RUP was non-reporting and three indicated that they had such contacts but desired not to be specific) reported a total .of 177 specific contacts with individuals and/or groups interested in possibly establishing HMO's In addition approximately 75% of the RMP's have sponsored or conducted seminars, panels or discussion sessions regarding HMO's for the Regional (or Area) Advisory Group, its executive -40- PROGRAM ACTIVITIES ... IMPLEMENTATION or steering comittee, for @IP core staff, practicing physicians and others. The institutions, individuals and groups contacted have been rather diverse as the table below reflects: PM Contacts MIS Kind of Institution No. Contacted Nbdical S ools . . . . . . . . . . . zo hospitals . . . . . . . . . . . . . . 29 Clinics . . . . . . . . . . . . . . . 22 Nbdical societies (state & local) . . 17 Individual physicians . . . . . . . . 18 Existing group practices . . . . . . 11 Planning groups (CHP & other) . . . . 32 Neighborhood health centers & other Federally-sponsored progr @ . . . 12 Private insurance carriers . . . . . 4 Labor unions . . . . . . . . . . . . 2 Other . . . . . . . . . . . . . . . . 10 17-7 EXPERINNTAL HEALTII SERVICES PLANNING AND DELI@RY SYSME: e Experimental Heal Servic ry Systems Program is a new effort of the H( ces and Nbntal Health Administration, with the National Center for Health Services Research and Development as the lead agency. It seeks to create a management capacity and function to rationalize and systematize health services in those co ities which have come together and voluntarily agreed to participate. Sixteen comunities or sites have been selected for pattici- pation. The degree of RMP involvement depends on the site, but in many of these, the Regional Nbdical Program was a moving force in putting together the application and is actively involved in setting up an Experimental Delivery System, such as in Vermont and the Nbuntain States. The sites selected represent a range of experimental situations, including three States, four rural areas, three large cities, three modoratc-sized cities, one sub, city, and two counties. -41- PROGPJ\M ACRIVITIES ... IAPLEAENTATION AREA HEALTH EDLJCATION The President's Health Message in February, 1971, and subsequent proposed legislation call for the development and support of Area Health Education Centers to meet identified health manpower needs in underserved areas. These Area Health Education Centers, in part, would be related to health science centers; their educational programs would be assisted by the health science faculty, and some patient care functions would rely on health science center personnel. The area centers would work with the com=ity and neighborhood facilities, including the private practitioner. Hospital and other health se rvice organization and educational institutional linkages will be established to provide both academic education.and clinical training. Allied health profession education will be strengthened through the development and expansion of curricula in comprehensive and commity colleges along with increased emphasis on interdisciplinary learning to enhance the team concept on the delivery of comprehensive health services. RMP Involvement @spite the fact that there are no fully developed Area Health Education Centers operating, many of the components of such a center can be found within some of the educational programs presently being supported by the Regional Medical Programs. Approximately one-third of the Regional Medical Programs are currently involved in activities related to Area Health Education Centers, such as: Assisting in conducting negotiating conferences of multiple interest for Area Health Education Centers. Providing demographic and health data for Center development. Providing "agency" linkages for curriculum development. Developing criteria for selection of communities to be included in Center. -42- pRoazAM ACTIVITIES ... IMPLL,:&tITATION Analyzing provider needs and attitudes toward Area Health Education Centers. Assisting in development of expanded roles for existing health professionals. Examples of selected Regional Wdical Programs' activities are as follows: The Kansas Regional Medical Program has developed a prototype area health education center in the rural Great Bend area.. The program has established link- ages between the existing educational system witli the smaller peripheral and regional commity hospitals in an attempt to meet the needs of the a-reals health service workers. The Maine Regional Medical Program has directed considerable ffo-rt toward the development of a health/science education center with a medical school component, using a remote teaching faculty from nearby universities, co ity hospitals and iwdical schools in Massachusetts, Vermont and New Hampshire. The Western New York Regional @dical Program has Fffe-ct ional arrangements that have permitted resider s and interns from the Upstate 'New York Nbdical Center at Buffalo to train at co ity hospitals across the state line in Pennsylvania. These co ity hospitals are seen as prototype area centers. -43- PROGRAM ACTIVITIES ... IMPLEMENTATION IIHO THE @[Ps IVORK WITH IZegional Medical Programs have close-working relationships with the broad spectno of public and private health and health-related planning, service, and education organizations, and with profes- sional societies and associations. These include hospitals, medical schools, state and local health departments, medical societies, and the like. These relationships are integral and requisite to the efforts of the IZMPs to influence and contribute to high quality, comprehensive health care. Of particular interest are the other federally-supported programs with which the RMPs work. RELATIONSHIPS WIlli OTHER FEDERALLY-SUPPORTED PROGRAMS- Included in this category are such programs as: Model Cities, Comprehensive Health Planning, (both flail and "b" agencies)and Appalachia Health, to name a few. Specific examples of how RMPs interrelate with these programs are: Model Cities RMPs provide: 1) technical expertise to the Model Cities programs; 2) support specialized service programs; and 3) participate in joint planning activities. Approximately 26 of the 147 Model Cities programs in the United States have active relationships with the RMPS. One-fourth of the RAPs (15) support a total of 20 operational activities in Model Cities areas. Very few RMPs have Model Cities agencies represented on their Regional Advisory Groups or other planning committees. Example: The New Jersey RNT (1) has et;iiled staff to serve as health planners for the Nlodel Cities agencies; (2) established an urban health task force; (3) supported a heart screening survey in Newark; (4) is assisting a now hospital-based family health care service in New Brunswick; and (5) helped support a citizens health survey in Hoboken. -44- PROGRAM ACI'IVITII:S ... IMPrEMEtITATION rehensive Health Plannin Cooperation between P,viP and CETP is being fostered through emphasis on their comple- mentary roles.. QfP agencies provide an expression of the consumers viewpoint, while RMPs express the provider's view of needs. Current RAP legislation requires that the Regional Advisory Groups include representation from health planning agencies. Similarly, CHP legislation requires RMP represenation on both I'a" and 'lb" agency Councils. REIATIONSHIPS WITH CHP a" AGENCIES: All 56 RMPs fall within t e boundaries Of at least one i 56 CIIP statewide agencies. RelationshiDs between RMP and UIP "a' agencies include: A. InterlockinR Board aiid Comittee Memberships RMP's relate to Sl of the CHP State Agencies through various types of interlocking memberships. A total of 48 RMPs have RAG and/or Core staff as members of CHP Agency Boards; 42 CHP ".a" Agencies have Board or staff on RAGS. A total of 23 RMPs reported RAG or Core staff on CHP "a" committees; 14 CHP "a" agencies have Board or staff personnel on W committees. B. Data Collection, ProcessinR or Analysis 43 CI[P 'la!' agencies cooperate with RMP's on joint studies or surveys; data banks, systems, or centers; health information committees; and exchange of services in data colloc- tion, compilation or analysis. -4S- pRDGRAm ACFIVITIES ... imPLEMENTATION C. Cooperative Mechanisms for Review of Grant In 46 RMPs the CliP "a" agency has an opportwAty to review all or part of RNP proposals and applications. In another 4 cases, Rmps, proposals are either sent directly to OT ffblt agencies flail agencies for "b" or channeled through review. D. Other Joint or Coo-perative Activities Additional cooperation includes the development of, support.or other assist7ance to 'lb" agencies. joint sponsorship or planning of con- ferences and workshops, cOlsultation, shared staff, and joint projects development - REIATIONSHIPS WITH CHP I-b" AGENCIES: Forty-eight Of the 56 RMPs ave at 14 ide CHP "b" agencies within their Regions. A. Interlockim Board Relationships . Forty-four @ are represented on the CHP Aremqide Advisory Groups. . Thirty-three RMP RAGs include (W 'lb'' representation. B. ive Efforts Relating to Data Collection, of the 48 IM having a recognized 'lb" agency within their regions 46 have some data sharing with at least one areawide agency. -46- PROGRAM ACTIVITIES ... IMPLEMENTATION Data activities include: joint preparation of directories of services and facilities; joint surveys of manpower needs; and assisting in the development of data for Experimental Health Services Planning and I)elivery Systems and IM applications. RWs have assisted new areawide agencies in collecting, processing and analyzing data, especially for their organizational application. C. Staff Sharin2 and-Staff Contacts- All 48 RMPs having an Areawide agency within their region have regular meetings with OP representatives. Thirteen R4Ps reported sharing staff on a full-time basis. In many RMPs a core staff member has been used as a special consultant by the Areawide Agency in such areas as manpower development and data collection. D. Cooperative Mechanism for Review Forty-three of the RMPS reported that they have established a cooperative mechanism for the review of grant applications and activity proposals; the remaining 11 RMPs either have no areawide agency or are now establishing review mechanisms. E. Other Joint or Coo ivities and Relations Some RMPs and CHPs have merged Program Committees. RMP local advisory groups coincide with the area,k,ide @ agency boundaries in many areas. -47- PROGRAM ACFIVITIES ... IMPLEMEIV.TATIOIV Appalachia Health The Appalachian Corm-Lission was established to =-rove the health, economic and social ditions of those residing in the Appalachian region of the country. The area covered is from Virginia to Alabama. This area of the country has rather pronounced health problems; therefore, a logical as well as needed set of cooperative arrangements have been developed between Regional Medica rograms and the Ap- palachian Program. The Tennessee Mid-South RW has helped plan for a comprehensive health care program in an isolated co@ty in eastern Tennessee and Kentucky in cooperation with the Ohio Valley Regional Medical Program and the Appalachian Regional Comission. Through R14P support it has been possible to link three isolated rural clinics in a mountain valley of East Tennessee for the first time by telephone so that the clinic nurses can co@cate with one another and with the physicians on whom they depend for consultation and support. The Alabama R4P has uorked with the Appalachian program in a project involving Alabamals 17 junior colleges and the Regional Technical Institute, University of Alabama, in an attempt to meet the' needs of health service workers for the State's commmity hospitals and health- related facilities. -48- PROGRAM ACFIVITIES ... IMPLEMENTATION Veterans Administration Hospitals A total of 83 (out of 131) Veterans Administration hospitals are presently involved in activities in 42 PWs. The breakdown by planning and operational activities is as follows: Number of VA Hospitals Represented: On Regional Advisory Groups 2S On Local Advisory Groups 13 On Task Forces and Committees 33 TOTAL (discounting overlaps) 55 Number Participating in Operational Activities 38 GRAND TOTAL (discounting overlaps) 83 Examples of Veterans Administration hospitals' involvement: The VA hospital in Tuscaloosa, Alabama, is sponsoring a training program in itreality orientation technique which is designed to improve the care and rehabilitation of older patients with cerebrovascular disease and stroke. The training is directed toward a broad spectrum of health service personnel with special attention to lower echelon personnel in nursing homes. The California Medical Television Network operating out of UCLA is funded in part by the RW and includes a package of 36 videotape programs distributed annually to 30 participating VA installations in the western United States. -49- PROGRAM ACrIVITIES...IMPLEMENTATION PARTICIPATION IN RMP ORGAI es of about 6,800 health and other institutions Representativ been or are activelY involved in the and organizations have sses of the regions. Types planning and decision-making proce and nwbers of institutions represented are presented in the following table: Kind of Participant @er Institut ization Represented Educational Institutions, including Medical Schools 638 Medical Societies, State and Local 761 Nursing, Dental and Other Health Professions Groups 546 Voluntary Health Agencies 721 Health Planning and 790 Related Agencies Hospitals, Nursing Homes and other Ca-re Institutions 4,110 others, (largely non-health) 642 TOTAL 8,208 -so- pROGR,*l ACFIVITIES PROGPA\L EVALUATION Along with planning and implementation, evaluation is a key activity s both as a means for measuring used by the Regional Medical Program impact and progress and as a management tool for decision-making and future planning. Evaluation within Regional Medical Programs has only recently taken on significance. In the first three years of PM', evaluation received little or no attention at the local level. For example, findings from a study conducted in the summer of 1969 illustrate that: 1) only 7% of the activity proposals reviewed nationally included an evaluation protocol within the project design; 2) only 30% of the funded Programs had an Evaluation Director on core staff; and 3) no Regions had even begun the development of a total program evaluation design. As of June 1971, however,, significant changes in evaluation have taken place: 20 additional RMPs have hired Evaluatioift Directors - fi ty Regions now employ S3 Directors or co-Directors: over one- -Cnird of these have backgrounds in the --social sciences; about 13% in education; 10% in business administration or economics; 10% in statistics; 10% in medicine; 8% in public health or epidemiology; and the remainder in fields such as operations research, basic science, and community planning. It is estimated that about 7-10% of the core budget is allocated for evaluation activities. Several RMPs are developing information systems for use in regional decision-making. About one-fourth of the RMPs have developed active evaluation program for use in decision-making. Some Regional Advisory Groups of these RMPs make extensive use of evaluation findings in their determination of the future direction of projects and Program. Many RAGs now site visit ongoing projects. Prov-ram evaluation, thou h actually being implemented in 9 onl@ a few RMPS, is in the developmental stages in many Regions. 'Si SBCRION v WHAT PROGRESS HAVE nE RPS MADE? This section describes RV progress toward improving manpower resources through education and training. It also describes the extent of hospital participation as an index of the regionalization of health services. Lastly, the section describes the exte:ftt and character of the phasing- out of RMP support for speci ic projects and the reinvestment of these finds by the IMs into other worthy activitie s. 53 PROGRAM PROGRESS I@1PROVING @i@l%'ER RFSOURCES THROUGH EIXJCATIOIN AND TRAININC, RMP-supported training, education, and manpower programs are designed to improve, update, and expand the knowledge and skills of health professionals so that more and better health care may be delivered in a more widely-distributed and efficient manner. Over 250,000 health professionals have been trained by FM to date. Percentage and Number of Health Professionals Trained Fiscal Years 1968-1971 FY 1968 FY 1969 FY 1970 FY 1971 Percent Percent Percent Percent (as of 4/71) Physicians 29% 30% 23% 210-o Registered Nurses 64% 45% 25% 2S% Allied Health 6% 12t 29 % is% Multi-professional -- 13% 23-% 39.% TOTAL PEOPLE 2,948 51.726 105,613 97p7O6 Highlights: There has been a considerable increase in the number and pro- portion of allied health personnel trained. The sharp rise in the multi-professional group.reflects the trend toward developing training programs which (1) train for tile health team approach, and (2) train physicians, nurses, and otliers tuider one I)rogrini. Initial training programs were discretely for physicians. Now, a broader array of professionals arc being trained. -54- PROGRAM PROGRESS ... TRAIN-TN.G Percentage and Numb of Health Pro@ "61 Fy 1969 FY' 1970 FY 19 "t ec,,,It e-rcent Pe,,e ,,en, (as of 4/71) 51% 46% 48% 49% Heart 7% 4% 7% 7% Cancer 8% 8% 13% 10% Stroke 7% 8% 15% 10% Related Disease 34% 17% 24% multi-catego-rical 37% 2,948 51,726 105A613 97,706 ii ts, ned in heart disease than More people are still being trai 000 physicians, nurses, any other area. This includes over 10, and othersItrained in coronary care techniques. The early increase in related diseases reflects, in part, an emphasis on pediatric pulmonary diseases due to an early Congressional earmarking of funds- -------------------- ---------------------------------------------- -rcentage of Total Professionals Trained FY 1969 FY 1970 FY 1971 Percent Percent Percent (as o 71) one day or less 33% 68% 60% 44% 23% 27% 2 - 5 days 2 - 5 weeks 22% 7% 11% Yjore than 5 weeks 1% 29. 2% TOTAL PEOPLE 51,726 105,613 97'706 Highli@ts: most of the training continues to be one-day or less with including extensive, continuous training, only a few program such as coronary care. -55- PROGRAM PROGRESS ... TRAINING Percentage of Professionals Trained By Training, FY 1971 Registered Allied Multi- Physicians Nurses @lealth Professional Percent Percent Percent Percent one day Or less 60% 44% 75% 64% 2-5 days 31% 24% 16% 31% 2-5 weeks 7% 27% 3% 5% more than 5 weeks 2% 5% 6% -- TOTAL PEOPLE 2Oi944 24,366 14.,319 38,077 RNs are the group receiving the lengthier training, and this has been primarily in coronary care. Many of the one-day or less sessions are seminars and conferences. -S6- PROGFA',L PROGRFSS IMPROVING l@'ftl SERVICI:S IIIROUCil REGIOINALI'ATION ital Particil)atioll REGIONALIZ-ATIOIN AND HOSPITAL PARFicipATioN: Rcgionalization cal Programs. lio-rking re- ationships and linkages among commity hospital-,; and between such hospitals and medical. centers are among -nis -ss the primary conce of the program The linking of Ic specialized health resources and facilities such as sfllall. commity hospitals with more specialized ones is a critical way to overcome the maldistribution of certain resources, and increase their availability and accessibility. Therefore, hospital participation is one key to the development of Regional Wdical Programs. Percen of Nation's flospi Is* Participating in National No. Per( Total articipating Partic FY 1968 5,8so 851 is% FY 1969 5,820 1,638 26 FY1 1970 5,8S3 2,084 36 1(est.) 5,88 2,693 46 rt-term non- cipating in IMs ------------------------------------------------------------- of Nation's Medi al Scliool-Affillated Hospitals National! No. Percent Total Participating Participati@ py 1969 436 121 28% FY 1970 480 241 so 490 28S S8 ion's medical school- cipate in Ws. short-term, non-Fedoral hospitals participation includes membership in advisory groups and comittees and in operational activities. r--'7 - PRDGRAM PROGMSS...HOSPITAL PARTICIPATION tivities Only No. Actively No. Generally Participating Participating Totall and Percent and Percent FY 1968 301 60 20% 241 80% FY 1969 1,246 247 20% 999 80% FY 1970 1,471 860 58% 611 42% FY 1971 (est.) 2,079 1,221 59% 858 41% Coment Hospitals actively participate by sponsoring projects or serving as the location for an activity. For example, many hospitals serve as coronary training sites or provide intensive stroke services. Other hospital participation may include such activities as sending personnel to be trained. -------------- ---------------------------------------------- Distribution by Bed Size of M Participating Hos-oitals* -Total Participating Less Than 200-399 400 plus Hospitals 200 Beds' Beds Beds I-'Y 1968 8si 587 lS3 110 FY 1969 1,638 1,081 327 229 FY 1970 2,084 1,344 467 273 FY 1971 (est.) 2,693 1,7SO S92 3Sl About 40% (1,750) of the Nation's smallest hospitals a-re now participating. In contrast, about 8S% (3Sl) of the largest hospitals are now participating. short-term, non-Federal hospitals PROGRAM PROG@USS REGIONALIZATION REGIONALIZATION GEOGRAPlilC SCOPE OF ACTIVITIES: Geographical coverage of activities offers another insight into the regional- ization process of RMPS. The trend during the last several years has been away from program activities concentrated in the medical center and towards those designed to improve and expand community resources and services. The following table shows program funds as distributed by geographical areas (regionwide, subregional, interregional) within the RMPS. An example of a reaionwide activity might be a circuit course for nurse training C, or a coronary care network; a subregional activity might be support of a multiphasic screening clinic in a ghetto area. Geographic Scope of RMP Activities by Funding @hasis, lg-/l Scope of Activity % Funds Regionwide . . . . . . . . . . . . . . . . . . . . .S8% Regionwide involving central and satellite units. .(13%) Subreaional . . . . . . . . . . . . . . . . . . . . .40% Inner city . . . . . . . . . . . . . . . . . . . . .. (7%) Rural . . . . . . . . . . . . . . . . . . . . . . .(9%) Interregional 2% -------------------------------------------------------------------- EXAMPLES OF REGIONALIZING SERVICES AND RESOURCES: Two maps follow which graphically describe: (1) a regionalized kidney program in the Washington/Alaska RMP, which includes a planned, coordinated program for kidney transplantation, dialysis, and education; SEE MAPS- and (2) an education program-in Georgia with major area education centers located in one or a cluster of large hospitals serving satellite hospitals. Each major center is linked to a medical school. -59- EXAWI-E OF REGIONALIZATION OF KIDNEY DISEASE ACFIVITIES IN IIA',gHINGTON/ALASKA Spokane % % % % Seattle % %% sis -----Major Medical Centers % % 0- - - - Commmity Hospitals % PROGRAM PROGRESS EX/MLE OF REGIONALIZATION OF CONTINUING EDUCATION ACTIVITIES IN GEORGIA Atlanta --- ----- Athens --- Macon Columbus ------ avannah Valdosta ----- Major Continuing Education Area Facilities @Satellite Continuing Education Facilities ----- (commity Hospitals) -61- PROGRAM PROGRESS NMVER OF FUNDS TO MEET CHANGING NEEDS PURPOSE: The RAPs hope to support demonstration activities or approximately three years, at which time local financing mechanisms should take over the support of the activities. This approach permits the RNP to reinvest its funds in other areas of urgent need and allows RMP to be a meaningful catalyst. TERMINATING RNP SUPPORT: During the Dast six monthssul)port for over 90 activities was withdrawn and reinvests in a comparable number of new activities. Activities for which RMP C" No. Amount By Disease Emphasis Activities (ii thou) Percent Heart 34 $1,088 30% Cancer 13 454 12% Stroke 6 164 4% Related Diseases 8 294 8% Malticat.egorical 33 1,426 46% Total 94 $3,426 100% Highl ts: The extensive heart disease cutbacks primaril reflect y a decrease of coronary care training activities. Nhlticategorical terminations reflect reductions.in audio-visual support services, and some multipurpose continuing education programs, as well as other activities. -62- PROGR41 PROGRESS ... TURNOTIER OF FUNDS No. knount in By Prima Activities (Thousands) Percent .a Purpose General continuing 24 $1,790 23% education Training Health Pro- 32 998 29% fessionals in new Skills 'Health Care Delivery 22 823 24% Health Planning & 5 348 10% Coordination Research & Develop- 11 467 14% ment Total 94 $3,426 100% Highlights: Many general continuing education for physicians programs have been terminated as well as videotape and TV type activities. The 29% reduction in Training Health Professionals reflects primarily the reduction in coronary care training. REINVE OF THE RMP FUNDS: The funds withdrawn from the above set of activities have,in part, been reinvested with a different emphasis: Highlights: * About one-fifth of the funds have been put into stroke activities, thereby markedly increasing stroke programs, particularly in ghetto areas. * Correspondingly, smaller reinvestments have been made in heart, but slightly more in cancer. * Over two-fifths of the fmds have been reinvested in health care delivery activities, thereby markedly increasing efforts in these areas. -63- A GLOSSARY OF-TERMS AREA HEALTH EDUCAT-TON CENTER tion Center, proposed under pending leaisla- An Area Health Educa tion, would be a satellite of a university health science center for the purpose of increasing oDDortunities for training, retraining, and continuing education of health professionals in an effort to enhance the delivery of health care in deprived areas. CATEGORICAL COMMITTEES AND TASK FORCES Gro s of health care providers and other technical experts appointed UP by either the Program Coordinator or Regional Advisory Group for the purpose of planning, evaluation, and review of projects which emphasize one or more of the following diseases -- heart disease, cancer, stroke, kidney disease, education, and other areas. CONSUMER A non-health professional who receives health care and may be engaged in RUP activities. COORDINATING HEADQUARTERS The agency responsible for the implementation, administration,, and coordination of a Regional Medical Program. It is involved in the development of regional objectives as well as review, guidance, and evaluation of ongoing planning,or operational RMP functions. CORE STAFF Comprised.of professionals and clerical persons whos6 prime responsibility is program development, coordination and admin- istration; providingg consultation or professional services to local institutions and serving as facilitators or conveners of multiple interest groups to solve local health-related problems. EXECUTIVE COMMITTEE Executive Committee usually is appointed by the Regional Advisory Group to provide advice and counsel to the RAG and serve as the day-to-day advisor to the RMP Coordinator and core staff. -6S- EXPERIPENTAL HEALTH CARE DELIVERY SYSTEM An Fxperimental Health Care Delivery System is a new grant program to create a management capacity to rationalize health services in a co ity. GRANTE,E Grantee is a public or non-profit institution, agency, or corporation which is responsible for fiscal control and'fund accounting procedures to assure proper,disbursement of and accounting for RMP grant funds. HEALTH MAINTENANCE ORGANIZATIOIV A prepaid, organized system of health care which includes a consortium of health care providers who come together for the purpose of making available comprehensive health maintenance and treatment services for a voluntarily enrolled group of persons in a specified geographic area. LOCAL ADVISORY GROUP A consortium of interested providers and consumers who reside in a geographic subsection of a region and are brought together by the Regional Ntdical Program to advise it with respect to health care needs, priorities, and plans to be unde-rt@en which should ameliorate many of the existing local health care needs and problem. OPER4TIONAL GRANT Operational Grant is authorized upon a recommendation of both the Regional Advisory Group and the National Advisory Council on Regional Medical Programs to assist in the establishment and operation of a Regional Medical Program. PLANNING GR,4NT Plarming Grant is authorized upon a recommendation of the National Advisory Council on Regional Nbdical Programs to assist in the planning and developmnt of a Regional Wdical Program. PROJECT Project is a discrete activity which is undertaken by the Regional Wdical Program as an integral facet of its overall operational program. These may include education, training, and patient service'demonstration. -66- PROVIDER Provider is an individual whose prim function is to make available health care services, e.g., physician, nurse, physical therapist, occupational therapist. .REGIONAL ADVISORY GROUP Regional Advisory Group is comprised of a broad spectrwn of health professionals, institutions, and consumers whose prim function is determination of the overall scope, nature, and direction of Regional Wdical Programs. REGIONALIZATION Regionalization is the linkage amon' health care institutions and 9 resources established for the purpose of improving both the quality of and accessibility to health care as well as gaps and duplications in the Region's health care system. -67- U.S. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE Health Services and Mental Health Administration