I I @ 'III * o @ill a# 19435 68 3109 73 ON 42538 167 REGIONAL 6-9 8 10 3 2@9 73 2 0;4 1 MEDICAL 36 211 5 PROGRAMS 45 R:037531 7 4 %o 1 016152625, 182.4Q3lO74 9 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 Commications and Public Information, Regional Medical Programs Service. Coments and suggestions regarding this publication are welcomed and should be addressed to: Evaluation Brancik office of Planning and Evaluation Regional Medical Programs Service Health Services and l@lental Health Administration 5600 Fishers Lane Rockville, Maryland 20852 Additional copies may be obtained by writing: Office of Communications and Public Information Regional Medical Programs Service S600 Fishers Lane Rockville, Maryland 208S2 FACR BOOK ON REGIONAL NEDICAL PROGRAMS A Special Report to the National Advisory Council of the Regional Wdical Programs Service August 1971 DEPAR@MNT OF IILAL'nl EDUCATION AND WELF@@ Health Services aiid Mental Health Administratioii Regional Medical Programs Service PREFACE ."The American people have always shown 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 Z8, Z971 Regional Medical Program are a pluralistic approach to dealing with our health problems. 'Ihe Programs have developed a coalition of almost 1S,000 health providers and interested consumers to plan and implement activities tailored to local needs and resources. This 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. I-larold Margulies, M.D. Director Regional Medical Programs Service TABLE OF CONTENTS SECTION I: PURPOSE AND HISTORY OF REGIONAL MEDICAL PROGRAMS . . . I Purpose . . . . . . . . . . . . . . . . . . . . . . 2 Legislative and Administrative History . . . . . . 3 Appropriations and Budgetary History . . . . . . . 4 SECTION II: WHAT ARE THE OUMCFL@'RISTICS OF REGIONAL MEDICAL PROGRAMS? . . . . . . . . . . . . . . . . . . 5 Map of the RMPs . . . . . . . . . . . . . . . . . . 6 Demographic Facts . . . . . . . . . . . . . . . . .11 Population and Land-size Ranges . . . . . . . . .11 Geographic Characteristics . . . . . . . . . . .11 Funding Levels and Pwiges . . . . . . . . . . . . .12 When Regions Received Initial Planning and Operational Grants . . . . . . . . . . . . .12 SECTION III: HOW ARE THE P14Ps ORGANIZED? . . . . . . . . . . . . .13 Example of PM Organizational Structure . . . . . .14 Grantees and Coordinating Headquarters . . . . . .15 Regional Advisory Groups . . . . . . . . . . . . .16 Executive Committees . . . . . . . . . . . . . . .18 Task Forces and Co@ttees . . . . . . . . . . . .1-9 Local and Area Advisory Groups . . . . . . . . . .21 Core Staff . . . . . . . . . . . . . . . . . . . .22 Minority Representation . . . . . . . . . . . . . .24 SECTION IV: WHAT DO @s DO? -- PROGRAM ACRIVITIES . . . . . . .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, Treatment Rehabilitation . . .33 Disease Emphasis . . . . . . . . . . . . . . . .33 Areas of Special Emphasis . . . . . . . . . . . .36 Health Manpower . . . . . . . . . . . . . . . .36 Ambulatory and Other Out-of-i-lospital Care . . .37 Urban and IZural Health Care . . . . . . . . . .38 CONTENTS -- Continued Page Recent Developments . . . . . . . . . . . . . . .40 Health Nhinteiiance organizations . . . . . . .40 Experimntal Health Services Planning and Delivery Systems . . . . . . . . . . . .41 Area Health Education Centers . . . . . . . . .42 Who the RNTs Work With . . . . . . . . . . . . . .44 Relationships With Other Federally- Supported Programs . . . . . . . . . . .44 Model Cities . . . . . . . . . . . . . . . . .44 Comprehensive Health Planning . . . . . . . . .45 Appalachia Health . . . . . . . . . . . . . . .48 Veterans Administration Hospitals . . . . . . .49 Non-Federal Health Organizations . . . . . . . .50 Program Evaluation . . . . . . . . . . . . . . . .Sl SECTION V: WHAT PROGRESS FIAVE THE RMPS. MADE? . . . . . . . . . .S3 Improving %npower Resources through Education and Training . . . . . . . . . . . . . .S4 Number and Types of Professionals Trained . . . .S4 Improving Services through Regionalization . . . .57 Hospital Participation . . . . . . . . . . . . .57 Geographic Scope of Activities . . . . . . . . .sg Maps Depicting Regionalization . . . . . . . . .60 Turnover of Funds to Meet Changing Needs . . . . .62 GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6S vi SECTION I PURPOSE AND IIISTORY OF RFGIONAL W@DICAL PRO@ This section highlights the purpose, legislative, administrative, and budgetary history of Regional Medical Programs. PURPOSE OF REGIONAL MEDICAL PROGRAMS The Regional Medical Programs seek to strengthen and improve the NTation'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 Tegionalization of health facilities, manpower, and other resources. The RMPs develop their programs through a consortium of providers who come together to plan and implement activities to meet health needs which cannot be met by individual practitioners, health professionals, Hospitals, and other institutions acting alone. The RNIP 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 Proorams was to provide a vehicle by which scientific knowledge could be more readily transferred 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 care. I-Iven in its more specific mission and objectives, @T 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 areaiqide Comprehensive Ilealth Planning activities can the RMPs achieve their goals. -2- HIGtILIGtITS OF LEGISLATIVE AND ADMINISTRATIVE UTSTORV OF REGIONAL MEDICAL PROGRAMS 1964 DECEMBER The Report of the Prosident's Commission on fleart I)iseise, Cancer and Stroke presented 3S recommendations including development of regional complexes of medical facilities and resources. 1965 JANUARY Companion administration bills--S.596 and H.R. 3140--were introduced in the Senate by Senator Lister [fill (Ala.), and in the House by Representative Oren Ilarris (Ark.), giving concrete legislative form to presidential proposals. OCTOBER P.L. 89-239, the Heart Disease, Canc,3r and Stroke Amendments of 1965, 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 FEBRUARY Dr. Robert Q. Marston appointed first Director of the I)ivi- sion of Regional Medical Programs and Assoc. Director of NIII. APRIL First planning grants approved by National Advisory Council. 1967 FEBRUARY First operational grants approved by National Advisory Council. JUNE The Surgeon General submitted the Report on Regional Medical Programs to the President and the Congress, summarizing progress made and recommending its extension. 1968 MARCH Companion bills to extend Regional Medical Progrims were intro- duced in the House by flarley 0. Staggers (W.Va.) (I-I.R. 157S8) and in the Senate by Senator Lister llill (Ala.) (S. 3094). OCTOBER P.L. 90-574, extending the Regional Medical Programs for two years,was signed. Changes were: include territories outside of the SO States; permit funding of interregional activities; permit dentists to refer patients; and permit participation of Federal hospitals. 1970 JAN.-OCT. Bills extending MI introduced; hearings held. OCTOBER P.L. 91-SlS was signed into law. New provisions-. emphasis on primary care and regionalization of health care resources; added prevention and rehabilitation; added kidney disease; added authority for new construction; required review 'of P,14P appli- cations by Areawide Comprehensive Planning agencies; emphasized health services delivery and manpower utilization. APPROPRIATIONS AND BUDGETARY HISTORY (Dollars in Thousands) Fiscal Fiscal Fiscal Fiscal Fiscal Fiscal year year year year year year 1966 1967 1968 1969 1970 1971 Authorization ------------------------- $50,000 $90,000 $200,000 $651000 $120,000 $125,000 .Amount appropriated for grants -------- 241,000 43,000, 53,900 S6,200 73,500 89,SOO *Amount actually available for grants-- 24,000 43,934 48,900 72$36S 78,SOO 70.%298 Amo il 27,OS2 433,63S 72.%36S 78 202 70,298 unt actually a7,,iarded for grants---- 2 066 % Includes unspent funds carried fo-nvard from previous year minus amounts held in reserve by the Office of N@gement and Budget. C-% SECFION II WHAT ARE IliE@ G"CRERISTICS OF REGIONAL @DICAL PROG@? This 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. -s- 56 REGIONAL MEDICAL PROGRAMS a so 28 I IC THE 56 REGIONAL MEDICAL PROGRAMS BY GEOGRAPI-IIC AREA COVERED 1. ALABAMA REGION Covering the entire State of Alabama. 2. ALBANY REGION Including 21 Northeastern New York counties centered r@ound Albany and contiguous portions of SoutJiern Vemont and Berkshire County in Western Massachusetts. 3. ARIZONA REGION Covering the entire State of Arizona. 4. AIU@SAS REGION Covering the entire State of Arkansas. S. BI-STATE REGION Including Southern Illinois counties and Eastern issouri 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 around Syracuse, New York and Bradford and Susqueharma counties in Pennsylvania. 8. COLORADO-WYOMING REGION - Covering the entire States of Colora 9. CONNECTICUT REGION Covering the entire State of Connecticut. 10. FLORIDA REGION - Covering the entire State of Florida. 11. GEORGIA REGION - Covering the entire State of Georgia. 12. GREATER DELAWARE VALLEY REGION - Including Southeastern Pemsylvan- Northeastern'Pennsylvania (Wilkes Barre-Scranton) and the southern part of New Jersey, and the entire State of Delaware. 13. HAWAII REGION - Including the entire State of flawaii, plus @ric Samoa,, Guam, and the Trust Territory of the Pacific Islands (Micronesia). 14. ILLINOIS REGION Covering the entire Stat6 of Illinois. 15. INDIANA REGION Covering the entire State of Indiana. 16. INTERMOUNTAIN REGION - Including the entire State of Utah, and portions@o Wyming, Nevada, Montana., ldaho 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 REGION - Including most of tlio State of Maryland, (except Montgomery and llriiice Georges Counties) and York County in Pennsylvania. 22. MEMP]IIS REGION - Including Western Tennessee centered around Memphi.s, Northern Mississippi, Eastern Arkansas and pqrtioiis of Southwestern l@'entucky, and three counties in Southwestern Missouri. 23. METROPOLITAN WASI-IINGTOlq, D.C. REGION - Including the District of Columbi guous counties in Maryland and Virginia. 24. MICTIIGfiN REGION - Covering the entire State of Michigan. 25. MISSISSIPPI REGION - Covering the entire State of Mississippi. 26. MISSOURI REGION - Including the State of Missouri, exclusive of the Metropolitan @t. Louis area. 27. MOU?4TAIN STATES l@GION Including the States of Idaho, Mont ing. 28. NASSAU-SUFFOLK l@-GIOiN Including the cowities of Nassau and id) of the State of New York. 29. NEBRASKA REGION - Covering the entire State of Nebraska. 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 NETROPOLIRAN REGION - Including New York City and Westchester, I and Putnam Counties, New York. 33. NORTII CAROLINA REGION - Covering the entire State of North Carolina. 34. NOI;Cfli DAKOTA IU:GIO,'NT - Covering the entire State of North Dakota. fjic.lijd'i)g 12 counties in Northeast 35. NORI'il]A@'l' 01110 ld(',ION I I Ohio, centered around (:Icvclwi(l. 36. NOI@IIH@16 @41,:W ENGLAND IZL,'(,ION - Iiicludiiii@, the entire State of Vermont and three contiguous counties in Northeastern Now York. 37. NORTliLANDS REGION - Covering the entire State of Minnesota. 38. NORTIMESTERN OHIO REGION - Including 20 counties in Northwestern Ohio, centered around Toledo. 39. OHIO STATE REGION - Including 61 counties in central and southern two-thii7ds of the State of Ohio, excluding Metropolitan Cincinnati areas and Dayton. 40. 01110 VALLEY REGION - Including the greater part of Kentucky TIO-1 of 120 counties), Southwest Ohio, (Cincinnati-Dayton and adjacent areas), contiguous parts of Indiana (21 counties) and West Virginia (2 counties). 41. O@IOMA REGION-- Covering the entire State of Oklahoma. 42. OREGON REGION - Covering the entire State of Oregon. 43. PL)L-RTO RICO REGION - Covering Commonwealth of Puerto Rico, and the Virgin Islands. 44. ROCHESTER 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 D ota. 47. SUSQUEHANNA VALLEY REGION Including 27 counties in Central Pennsylvania, centered around the fiarrisburg-liersliey areas. 48. TENNESSEE MID-SOURH REGION - Including 84 of 94 counties covering the central and eastern sections of Tennessee, Southwestern Kentucky and 3 contiguous Alabama counties. 49. TEXAS REGION - Covering the entire State of Texas. SO. TRI-STATE REGION - Covering the entire Sta@ of Massachusetts, New Hampshire and Rhode Island. -9- Si. VIRGINIA RL,'GIO\l - Covering the State of Virginia, except for the Northern counties and cities of Alexandria, Arlington and Falls Church. 52. WASI]INGTON/ALASKA REGION - Covering the entire States of WasHin-gton an Alaska. S3. WEST VIRGINIA REGION- Covering the State of West Virginia. S4. WESTERN NEW YORK REGION - Including 7 Western New York counties centered around Buffalo, and the counties of Erie and @IcKean, Pennsylvania. 55. WESTERN PE\'NSYLVANIA REGION - Including 28 counties in Western Pennsylvania, centered around Pittsburgh. 56. WISCONSIN PEGION Covering the entire State of Wisconsin. -10- CIAI@(,IT:R@ISI'ICS 01@' fd-',GIONAL ML:I)I('Al, IIROGIMS DEMOGRAPHIC FACTS There are 56 RMPs which cover the entire tJnited States and its trust territories. The Programs include the entire population of the United States (204 million) and vary considerably in their size and characteristics. IARGEST 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, 1).C. (1,500 square miles) GE-OGRAPI]IC BOUNDAI@IES: Number of lZcgioris 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 POPULATION: 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 S million . . . . . . . . . . . . . .11 CHARACI'E-RISTIC.S * FUNDING LEVELS: Regions vary from Highest: California ($8.3 million) Lowest: North Dakota ($309,000) * FUNDING LEVEL RANGES: Regions with Less than $500,000 . . . . . . . . 5 $Soo,ooo to $999,Ooo . . . . . . . 16 $1 million to $1.4 . . . . . . . . is $1.5 million to $1.9 . . . . . . . 10 $2 million to $2.4 . . . . . . . . 6 More than $2.5 million . . . . . . 4 * MEDIAN LEVEL: $1.2 million -------------------------------------------------------------------- I%IEN REGIONS RECEIVED INITIAL PLANNING AND OPERATIONAL GRANTS 60 - 50 - 48.e - I Plann ng 40 - - Number of Regions 30 - erational 20 - 10 - 7 0 1966 '67 '68 169 '70 171 Fiscal Year Highlights: To date,only one RMP has not yet received its first operational This is because it received its first grant South Dakota. 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 hwi(l, it was not iijitil the end of FY '69 that (41) lzcgioi I I l,nost is rcce vc(i tlic'r first operational grants. -12- SEffION III HOW ARE REGIONAL NEDICAL PROGRAMS ORGANIZED? This section highlights the organizational structure of the RMPS, including the composition and function of Regional Advisory Groups, task forces, committees and staffs. Summrized also are overall changes which have occurred in these groups over the past five years, and minority representation. 13- EXAMPLE. OF THE ORGANIZATIONAL STRUMM OF.A REGIONAL MEDICAL PROGRAM Grantee tor Regional Advisory Gr OEp e:i Task Forces and Research Subregional Services comittees ancl Offices and Evaluation Resources Local Advisory Groups ORGANIZATION ES AND COORDINATING F@UARTE@RS PURPOSE: 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 RV funds. A coordinating headquarters may be described as being responsible for the implementation, administration and coordination of a Regional Medical Program. As such, it is 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 Coordinating Grantee. 56 Headquarters S6 Universities 34 31 Public (27) (25) Private 7) 6) Other 22 25 New Agency/ Corporations (IS) (18) Existing Corporations 3) 3) Medical Societies 4) 4) Comwnt: In some RMPS, the grantee differs from the coordinating headquarters. For exaffq)le in the North Carolina RMP, the grantee is Duke University, but the coordinating headquarters is the non-incorporatcd agoncy--the North Carolina Association for Regional Medical Programs. -is- ORGANIZATION REGIONAL ADVISORY GROUPS PURPOSE: Reaional Advisory Groups reflect a broad spectrum of 0 health 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,determinatioii of the overall scope, nature and direction of the program. Each Regional Advisory Group must determine policies, establish criteria and priorities, allocate RMP grant funds accordingly and revieiq operational projects. SIZE: 1967 1,600 total membership 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 mmbers: S RAGs 100-199 menfbers: 2 RAGs over 200 mmbers: 1 RAG -16- ORC)ANIZATION Composition of Regional Advisory G-roups Fiscal Years 1967, 1969, 1971 Voluntary Other Agencies Health Workers @dical Public Practicing Hospital Center Health MeTrbers of Physicians Admin. Officials Agencies Pub.1 i c 0they 1967 ... ............... 1969 .......... ........................ ................. ............... 1971 ......................... 0 20 40 60 so 100 Percent Highlights: Practicing physician representation has increased considerably from 23% to 28%. Medical center officials have decreased markedly, from 16% to 8%. Voluntary agencies and public health representation has decreased. increase in members of the public from IS% to 21% reflects more consumer involvement in INPS. -17- ORGANIZATION EY,ECURIVE COMMITFEES PURPOSE: Executive Comittees are appointed by the Regional Advisory Group to provide advice and counsel to the RAG and serve as the day-to-day advisot to the RMP coordinator and core staff. They also act in the stead of the RAGs except on final project or policy decisions . CONTOSITION: Comparison of-Membe-r8hip for 1969 and 1971 Professional Category Number Percent (19 1971) (19-69) (1971) Physicians 284 266 67% 58% Nurses 18 16 4% 4% Allied Health S6 so 13% 11% Other 67 12" 16% 27% - l@- I - - TOTAL 425 459 100% 100% HighliLhts: The decline in the actual number and percentage of physician Membership has been countered by an increase in "Other," from 67 to 127, or 16% to 27%. The increase in "Other" reflects more hospital and nursing home administrators, m@ers of the public and others. Nursing representation has remained stable. ORGANIZATION TASK FORCES AND COMMITFEES * PURPOSE: Task Forces and Committees have major 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 Committees in S4 Regions: S320 Total membership 1971: 410 Committees in SS Rpgions: 6379 Total membership * COMPOSITION! Comparison of 1969 and 1971 By Profession Number Percent (1969) (1971) (1969) (1971) Physicians 3273 3S23 61% SS% Nurses 486 S80 9% 9% Allied Health 672 802 13% 13% Other 889 14S6 17% 23% 1 TOTAL S320 6379 100% 100% Highlights: Total membership has increased 20% Physicians show a 6% decline while itother" category, which includes members of the public, hospital administrators and others, has increased 6%. ORGANIZATION Com ison of Task Forces and Conpittees 1969 d 1971 .par By lUe of Task Force/ No. of Committees Percent Committee (1969) (1971) (1969) (1971) Heart 6S 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 & 4S 47 9% 12% Training Health Manpower 11 27 2% 4% Other 188 160 3 Y-6 39% TOTAL 492 410 100% 100% Highlights#. Nuwber of Task Forces and Comittees 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 indicates that RMPs are departing from traditional approaches and'are now concerned with the development of approaches to overcome the existing health manpower crisis. . The significant number of -o'ther' committees include health maintenance organizations, experimental health delivery systems, finance, legislation committees, etc. . 39 Regions have Heart committees; 36 Regions have Cancer committees; 3S Regions have Stroke committees. -20- ORCANIZATION LOCAL AND AREA ADVISORY GROUPS PURPOSE: Assist in project development and implementation to meet community needs and to strengthen relationships among local institutions, organiza- tions and with the medical center. They are generally organized on the basis of population or medical trade areas. Some are organized according to hospital areas and to local medical schools. Some local area and advisory groups do cooperative planning and coordination with Comprehensive Health Planning 314 "b" agencies. They are often the site for coordination of efforts between RMP regions where they intersect locally. COMPOSITION: Comparison of 1969 and 1971 By Profession Percent 19 9 1971_ Physicians ................ 41% 42% Nurses .................... 9% 11% Allied Health ............ 19% 15% Other .................... 31% 31% TOTAL PEOPLE 4,843 6,047 Highlights Total membership has increased from 4,843 to 6,047 or about 25%. Nursing representation has increased slightly which has been offset by a slight decrease in allied health representation. "Other" which includes hospital administration, nursing home administrators, and members of the public has remained unchanged. -21- ORGANIZATION CORE SFAFF FLJNCTIONS: The people who serve on the core staffs provide services in the following areas ... Project Develo@ent, Review and Management - Staff members @s.ist organizational sponsors in developing and conducting educational and patient service activities, process grant requests, support technical review groups, and monitor discrete projects. * Professional Consultation. Co ity Relations and Liaison Staff prove es consultation (unrelate@ to specific projects) to hospitals, Model Cities agencies, community colleges and other agencies; facilitates the development of cooperative relationships among medical schools, professional societies and other groups; develops or works with community or sub- regional groups to identify health needs and plan programs. * Program Direction and Administration - Provide overall direction cc gram, policy develop- ment, evaluation, financial management, communication and information activities, routine statistical reporting, and project coordination. * Planning Studies and Inventories - Conducts ad hoc or periodic studies designed to help determine objectives, needs, and priorities. These include manpower distribu- tion studies, incidence of disease studies, etc. * Feasibility Studies - Conduct activities being tested for a specific trial period to determine if larger scale, long term or permanent operations are desirable. Central IZe2ional Services - Provides a centralized service su@c as seleCtE ervices, data banks, dial access, system , etc. Other - This section includes any other core staff activities not previously mentioned, such as helping to develop heal maintenance organizations, conducting conferences and seminars, etc. -22- ORGANIZATION CORE STAFF DISTRIBLJTION OF CORE STAFF EFFORT BY FLJNCFION Project Development . . . . . . . . .20% Professional Consultation . . . . . .29% Program Direction . . . . . . . . . .22% Planning Studies . . . . . . . . . .14% Feasibility Studies . . . . . . . . . 7% Central Regional Services . . . . . . 6% other . . . . . . . . . . . . . . . . 2% ------------------------------------------------------------------ COMPOSITION: Professional Breakdown (1969 and 1971) (Full-time Equivalent, FrE) June 1969 June 1971 No. Percent No. FTE Percent Physicians . . . . . . . . 226 15% 230 14% Registered Nurses . . . . 53 3% 66 4% Allied Health . . . . . . 45 3% 33 2% Social Scientists -- Planners & Evaluators. . 120 8% 164 10% Business & Public Administration . . . . . 60 4% 82 5% Other Professional/ Technical . . . . . . . . 528 34% S40 33% Secretarial & Clerical . . . . . . . . S14 33% 525 32% TOTAL 1,S46 100% 1,640 100% Highlights The number of full-time equivalent core staff members has increased by 6% over the past two years. The professional make-up of core staff has remained fairly constant with the most significant change being in the social scientists category (8% - 10% in 1971). -23- ORGANIZATION MINORITY REPRESENTATION Appropriate participation of minority groups at all levels of RMP planning, decision-making and implementation is requisite to responsive relevant program development. Data below reflects minority representation on core and project staffs, RAGS, and committees. WNORITIES: Defined as Blacks, Spanish surname, American Indians, Orientals, and Others (Asiwi Indians, Polynesians, ctc.), with the preponderance being in the first four categories. According to the 1970 Census, 12% of the total U.S. population is classified as Black or Other. Ifowevcr, the Other category does not include Spanish surname. Therefore, by extrapolating from the 1969 Census data on persons of Spanish origin, one arrives at an estimated 16% of the population being minorities as defined above. Minority Representation on Core and Project Staffs (Full-Tim Equivalents), 1971 2 20% 16% Minority 16 ------------------------- ---- ------ - Population Percent of U.S. Minority - 12% is 16% 8 6% O' Secretarial Professional Secretarial ofessi n@al CORF STAFFS PROJECT STAFFS ighlights- Only 9% of the total 1,640 FTE core @.3taff are minorities; 17% of the 2,440 FFE project staff are minorities. In terms of actual people (i.e., full and part-time personnel) the percentage of minorities is less in all categories, ranging from 1% fewer core professionals to 3% fewer project professionals. In other words, minorities are more likely to be full-time personnel. -24- ORGANIZATION Minority Representation on Regional Advisory Groups and Other Co @ ttees o Tonal Medical Programs 1969 and 1971 20- 16 ------------------------------------------ Minority Population of U. S. is 16% 12 Percent 10% Minority - 8 8% 6% 4 0 1969 1971 1969 1971 RF,GIONAL ADVISORY ALL O'nlER GROUPS (DMMIMEES Highlights: The minority representation on RAGs has increased by 3% to 10% of the 2,700 membership, but is still 6% slay of being representative of the nation. On the other hand, ndiiority percentage on Other Comdttoes has decreased by 2%, to a low of 6% of the total 12,000 membership. -2S- ORGANIZATION Comparative Distribution of Estimated National Minorities and RMP @iinorities, 197-1 American (includes 11% Ind Orient American Indi 26% Spanish 5 Surname n 68% Black 69% Black Estimated National Distribution RMP Distribution The comparative distribution is relatively consistent (surprisingly so in the case of Blacks) with one exception -- the Spanish surnames are und(-,r-represented. --------------------------------------------------------------------- Female Partici-pation in Regional Medical Programs Full-Time Equi-,,al&n-l -HIGHLIGfffS: There are over 6,000 females involved in Regional Medical Programs. A majority (54%) of the professional project personnel are women. Only 14% of Regional Advisory Group members are females. 31% of professional core staff personnel are women. 98% of core and project secretarial staffs are females. -26- SECTION IV @T DO REGIONAL @DICAL PROG@ DO? -- PROG@ ACTIVITIES This section outlines the kinds of activities carried out by the Programs, including how and what they PLAN, IATLEAEIVT, and EVALUATE. It describes areas of special emphasis and new program developments as well as the relationship of the IMs to health and healtj-i-related agencies and progrwns, particularly to other federally-supported programs. -27- C, PROGRAM ACRIVITIES PROGRAM PLANNING ASSES@ OF NEEDS AND RBSOURCES: The initial step in planning or Regional Medical Pr( e identification of regional health needs and -resources. For most RNPS, this is a two-pronoge-d approach: one , the development of health committees and task forces to assist in identifying,in a consensus er, what the needs are, and where they exist. The other is the collection of pertinent data to determine the extent of the problems and the resources available for use in their solutions. During 1970 and 1971 the RWs carried out nearly 400 such data collection activities in the following areas: Area of Data Collection Number of Studies Manpower distribution and availability . . . . . 50 Services and facilities .. . . . . . . . . . . . 98 Health conditions . . . . . . .. . . . . . . . . 95 Categorical diseases . . . . . . . . . . . . . 29 Screening . . . . . . . . . . . . . . . . . . . 23 Continuing Bducation . . . . . . . . . . . . . . 42 Data Bank . . . . . . . . . . . . . . . . . . . 38 TOTAL 375- ----------------------------------------------------------------- SETTING OF PROGRAM PRIORITIES: Another step in planning is sett s -- those locally identified health needs which Regional Medical Programs have determined to be of the greatest urgency locally. The setting of priorities (usually done by the Regional Advisory Group) ideally enables the RNP to review activity proposals and allocate funds in accordance with the Region's most pressing needs. To date 45 of the 56 Regions have formally set priorities. Of the 45 RNPS, about S named priorities so broad they might easily be mistaken for goals; another 30 presented listings which, while they included some specific areas of need, were for the most part a vast expanse of comprehensive issues ranging from "organization and delivery of carell to "heart disease, cancer, and stroke"; only about 10 Regions reported definitive, specific priority areas. -28- PROGRAM ACFIVITIEC; PLAIVN-TNG PRIORITIES The priorities which have been set by the 4S RMPs relate gen- erally to three broad areas: health care organization and systems, health professionals, and patient services and target groups. Highlights: Virtually all of the 45 lZegions named education or man- power as a major regional need. One-third identified disease prevention and early detection. 20 identified health care for the poor. 7 specified urban health, while 10 named rural health. Surmnary of Priorities Health Care Organization and Systems 16 PMs named organization and delivery of care; 5 of these specified new and innovative models for organi- zation and delivery.* 12 RVs najwd availability, accessibility, and quality of care. 10 RMPs named health needs and resources assessment. 6 RMPs named coordination of existing resources and distribution of services.* 5 PMs named ambulatory care.* 5 RMPs named efficiency of health care organization and systems; 4 of these specified health care costs and financing. 3 FMs named specialized and long-term care. Health Professio?,iaZs 33 RMPs named continuing education and training.* 29 RNTs named manpower development, utilization, and distribution.* 4 RWs named increis ijig provider of f i.cicncy. These have also been named as li')MIA priorities for IN). -29- PROGRAM ACFIVITIES ... PLANNING PRIORITIES 2 RWs named commication and coordination among provider groups. 2 PNfPs nmed education and career mobility for allied health personnel. Patient c)ervices and Target Populations 20 RNIPs named health care delivery for disadvantage grou,.ps*; 7 of these specified urban populations; 10 specified rural populations; 2 named particular minority groups. 14 @-lPs nwned disease prevention and early detection.* 11 RNTs named public information and education. 5 RNIPs namd rehabilitation. 3 @lPs named consumer participation in health planning. 3 @lPs named infant and child health.* 2 Ri\lPs named health care for migrant workers. 2 @iPs named emergency services. These have also been named as HSMHA priorities for RMP. -30- PROGRAM ACFIVITIES PROGRAM INIP TATION Program implemntation 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, program for urban and rural poor, and others. FLINCTIONAL EMPIIASIS: What the RMPs do to implement their progrms is in five major functional areas: General continu@ 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-access, consultation, etc. @ower utilization and traininq--activities aimed at improving the distribution, development and utilization of health personnel. This function includes training in new skills, training new categories of personnel, curriculum development, and oticr areas. Organization and delivery for patient serviccs--these activities relate directly to patient care delivery tirough demonstrations of new techniques, development and demonstration of organizational models for delivery, and improving coordination of patient services. Research and development--activities which emphasize the testing or investigation of prototypes or new systems, processes, techniques, etc. Program coordination and administration--overall RMP direction and coordination, including policy development, evaluation activities, program coordination, community liaison, and interrelationships of health institutions providing multiple levels of care. -31- PROGRAM ACTIVITIES...IAff?LgAg@NTAY'ION Functional Emphasis, 1969-71 100 .......... ............... General Contin- ............ uing Education ..................... ................ ................. ................... ................... ................ 80 ................. .................... .............. ................. Manpower 60 Utilization or Organization 40 and delivery for patient - services 20 Research and lopment gram Admin- tration 1969 1970 1971 ($72,36S,000) ($78-202,000) ($70,298,000) 51 Research and development activities have taken on less sj-gnifi-cwicc due, in part, to the fact that the new emphasis is on methods for the actual delivery of patient care. RWs are still devoting a.@arge portion of their resources to patient care, but the emphasis i@ithin this category has to the newer conce shifted 4 pts of organization and system 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. -32- PROGRAM ACTIVITTEIQ ... I,&IPLEMENTATION f@TH CARE, @IASIS: RMPs are supporting training, delivery, and coordination of-. screening and early detection rograms such p as cervical cancer, new stroke detection techniques; Demonstration treatment and diagnostic services programs suc as in kidney dialysis and laboratory services; Stroke and other more comprehensive rehab- ilitation programs, often using the ealt 'Eeam approach; and Demonstration comprehensive care programs, such as complete hypertension 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 less heart disease and more cancer and kidney disease: Comp:arison Percent Disease Category of Funds 1968 1971 Ileart disease . . . . . . . . . 3.5% 26% Cancer . . . . . . . . . . . . 9% 13% Stroke . . . . . . . . . . . . 12% 12% Kidney disease . . . . . . . . .. 4% Related diseases . . . . . . . 8% 6% Multicategorical and non-specific . . . . . . . . 36% 38% -33- 11(2dlUi t-clie iAiiPli@@ OPERALTIOINM FUNDS (Millions) PERCENT 20 10 0 0 20 40 60 ---- Prevention and ----- Screeiiina cn ---- Diac,,iiosis mid---- Treatinent ---- Rehabilitation ----- ---- ComT)rehensive ------ Care 1969 1971 Highlights 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 ... 17YPLEMENTATION EXAMPLES OF HEALTH CARE ACTIVITIES To @rove @n ower utilization and capability and to coordinate the delivery of health services: Confederation of Coronary 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 @rove the organization for delivering services and upgradi@ quality: "Acute Stroke Management Demonstration Project in a Com- amity Hospital" -- South Carolina: This project involves a coordinated team approach to@t oke management, 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 healt nurse, coordinated by the two physicians who direct the project. To expand manpower availability and utilization in ghetto areas: Model Citz Health Manpower Education and Recruitment Program -- Kansas: 'I'his activity raises the level of knowledge and un erstanding among Kansas City, Kansas model neighborhood 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 co ity health, practicum activities, and participate in supervised activities involving communication with and teaching of other residents in need of education or services. -35- PROGRAM ACFIVITIES ... @LEAENTATION AREAS OF SPECIAL EMPHASIS The problems of accessible, available, high quality health services, particularly in deprived urban and rural areas, are of increasing concern to the RNPs and they are addressing these problem through a variety of avenues, including-. (a) Programs to improve manpower distribution, utilization and development (b) More emphasis on ambulatory care programs, including activities linked to neighborhood health centers, out- patient clinics, home health programs and the like; and (c) Training and other programs to increase the availability and utilization of health services by ghetto and rural residents and to heighten their involvement in the delivery of services. HEALTH MANPOWER Approximately one-third of RMP ftmds support activities to improve health manpower utilization and development. These include training programs (1) to expand the duties of existing health personnel; (2) to develop new health manpower personnel; (3) to study distribution and utilization; and program to retrain and',improve manpower availability. I In particular, regions have: Number of Regions Established Health Manpower as Priority . . . . . . . . . . . . . . 29 Established Health Manpower Committees . . . . . . . . . . . . . . 27 Designated Core Staff @ipber for Manpower . . . . . . . . . . . . . 17 Designated Core Staff Representative on CHP or State Manpower Council 12 -36- PROGRAM ACFIVITIES ... IAPLEWNTATION 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 @s 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 co ity 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. MCULATORY' AND OUR-OF-HOSPITAL CARE Approximately one-fifth of RMP 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 ACR!VITIES ... IMPLEMI,7NTATION 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 50 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 HEALIH CARE About 17 percent of RW funds now support special programs 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 SO activities totaling about $3.2 million. Over half of the inner-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 programs include training activities to experiment with expanding the amount and level of services which allied health personnel can deliver, they also include programs which coordinate existing sIervices for broadened outreach. -39- PROGRAM ACTIVITIES ... I14PLEMENTATION RECENT DEVELOPM34TS 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 sys ems. @TH MINTENANCE ORCANIZATIONS: The Regional Nbclical Programs are invo. 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 group of persons in a geographic area and ... is reimbursed through a pre-negotiated and fixed periodic payment made by or on behalf of each person or family unit enrolled in the plan. Fifty-two of the S6 Regional Medical Programs (one RV 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 :Lq possibly establishing HMO'S. In addition approximately 7S% of the RAP'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 committee, for @ core staff, practicing physicians and others. The institutions, individuals and groups contacted have been rather diverse as the table below reflects: RMP Contacts Regarding IM's Kind of Institution No. Contacted Nt ical S ools . . . . . . . . . . . 20 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 programs . . . 12 Private insurance carriers . . . . . 4 Labor unions . . . . . . . . . . . . 2 Other . . . . . . . . . . . . . . . . 10 177 EXPERINENTAL HEAL71i SERVICES PLANNING AND DELIVERY SYS@: The Experimental Health Services Planning and Delivery Systems Program is a new effort of the Health Services and Ntntal 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 communities which have come together and voluntarily agreed to participate. Sixteen comunities or sites have been selected for partici- pation. The degree of RV 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 Mountain States. The sites selected represent a range of @)crimental situations, including throe States, four rural areas, three large cities, three modoratc-sized cities, one sub, city, and two counties. -41- PROGRAM ACRIVITIES ... I@LEAENTATION AREA HEALTH EDIJCATION CENTERS: 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 co ity and neighborhood facilities, including the private practitioner, Hospital and other health service 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 co ity colleges along with increased emphasis on interdisciplinary learning to enhance the team concept on the delivery of comprehensive health services. RMP Involvement Despite the fact that there are no fully develope 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 co ities to be included in Center. -42- PROGM ACTIVITIES ... IATLE, @NTAI'ION Analyzing provider needs and attitudes toward Area Health Education Centers. Assisting in develophient of expanded roles for existing health professionals. Examples of selected Regional Medical Programs' activities are as follows: The Kansas Regional Medical Program has developed a prototype area health education center hi the rural Great Bend area. The program has established link- ages between the existing educational system witji the smaller peripheral and regional community hospitals in an attempt to meet the needs of the areals health service workers. The Maine Regional Medical Program has directed considerable effort toward the development of a health/science education center with a medical school component, using a remote teaching faculty from nearby universities, community hospitals and medical schools in Massachusetts, Vermont and New Hampshire. The Western New York Regional Medical Program has effected the institutional arrangements that have permitted residents and interns from the Upstate New York Wdical Center at Buffalo to train at co ity hospitals across the state line in Pennsylvania. These community hospitals are seen as prototype area centers. -43- I)IZOUZAM ACTIVITIES ... IMPL,-,MENTA7'ION IVIIO ITIE- RMPs IVORK WITH ]Zegional Medical Programs have close-workiiia relationships with the broad spectrum 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 l@%Ws to influence and contribute to high quality, comprehensive health care. Of particular interest are the other federally-siipported programs with which the @II)s work. RELATIONSHIPS lllni OTHER FE-DERALLY-SUPPO@FED PROGPA,\IS: Include ategory arc such programs as: @lodei Cities, Comprehensive Health Planning, (both "a" and ' agencies)and Appalachia Health, to name a few. Specific examples of how RMPs interrelate with these programs are: Model Cities @s provide: 1) technical expertise to the ,Nlodel Cities proarams; 2) support specialized 0 service programs; and 3) participate in joint planning activities. Approximately 26 of the 147 @lodel Cities programs in the United States have active relationships with the P,%IPs. One-fourth of the IM-)s (IS) support a total of 20 operational activities in @iodel Cities areas. Very few RMPs have Model Cities agencies represented on their Regional Advisory Groups or other planning committees. Exam7ple: The New Jersey PNIP (1) has tailod staff to serve as health planners for the @lodel Cities agencies; (2) established an urban health task force; (3) supported a heart screening survey in Newark; (4) is assisting @i jici@ liosl)ital-based family Health care service in Now ]Brunswick; ajicl (S) helped support a citizens health survey in Hoboken. -14- PROGRAM AC'l'IVITIIiS -IMPLEMENTAT-TON C@prehensive li@altfi Planning Cooperation between RMP and C2-IP is be ing fostered through emphasis on their comple- mentary roles. CHP agencies provide an expression of the consumer's viewpoint, while RMPs eypress the provider's view'of needs. Current RMP legislation requires that the Regional Advisory Groups include representation from health planning agencies. Similarly, CHP legislation requires RMP represenation on both "a" and "b" agency Councils. RELATIONSHIPS WITH CHP "a" AGliNCIES: All S6 RMPs fall within t e boundaries of at least one of the S6 C]iP statewide agencies. Relationships between RMP and 0111 "a'.' agencies include: A. InterlockinR Board and Committee Memberships RMP's relate to SI of the CIIP 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 CIIP ".a" Agencies have Board or staff on RAGS. A total of 23 RMPs reported RAG or Core staff on CliP "a" committees; 14 CHP "a" agencies have Board or staff personnel on RMP committees. B. Data Collection, Processing or Analysis 43 GIP "a" a(,encies cooperate with PM's on joint studies or surveys- data banks, systems, or centers; health information committees; and exchange of services in data collec- tion, compilation or analysis. -45- PROGRAM ACFIVITIES - 1WLEMENTATION C. Cooperative Mechanisms for Review of Grant Applications . In 46 RAPs the CHP "all agency has an opportunity to reviet-i all or part of W proposals and applications. . In another 4 cases, RMPs' proposals are either sent directly to CHP 'lb" agencies or channeled through "a" agencies for "b" 'review. D. Other Joint or Cooperative Activities . Additional cooperation includes the development o@, support or other assistance to lb'' agencies. . Joint sponsorship or planning of con- ferences and workshops, consultation, shared staff, and joint projects development. REIATIONSHIPS WITH CHP 'lb" AGENCIES: Forty-eight of the S6 RMPs have at least one ot tne funded areawide CHP "bl' agencies within their Regions. A. Interlockim Board Relationship@ * Forty-four @ are represented on the CHP A-reawide Advisory Groups. * Thirty-three RMP RAGs include CHP "b" representation. B. ts Relati Data Collection, * Of the 48 @ having a recognized lb agency within their region, 46 have some data sharing with at least one areawide agency. -46- PROGRAM ACFIVITIES ... 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 fiealtli Services Planning and Delivery Systems and IM applications. RWs have assistod now areawide agencies in collecting, I)rocossi.ng and analyzing data, especially for their organizational application. C. Staff Sharing wid-Staff Contacts All 48 RMPs having an Areawide agency within their region have regular meetings with CHP representatives. Thirteen RNTs reported sharing staff on a full-time basis. In many R4Ps 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 application-, and activity proposals; the remaining 11 RMPs either have no areawide agency or are now establishing review mechanisms. E. Other Joint or Cooperative Activities and Relationships Some RMPs and CHPs have merged Program Committees. RMP local advisory groups coincide with the areaia.,ide (TIP agency boundaries in many areas. -17- PROGRAM ACFIVITIES... IP.IPLE14EjllTATION I- 1 a@H @a The Appalachian Conniii-ssi-o-q was es Lablished to improve the hea.ltl-,, econoiri-.1-C aid social conditions of -those residing in @Ll-ie AP-palachian region of the co-Lincr-,,r, The area --overed is from Virginia -to -A-Ial)ama. 'fliis area. of the country has ra-@-her --,ico@-iouriced heal.@h probler@,s; therefore, a logical. as we!", as rjeeded set or' cooperative arrangements hatre been developed between Regional 14edical Progrgi@- uid the Ap- palachian P-r,ograins. Expp P- of co arati.-@rcL - a:f-.ca:igemeDts: The Tennessee M-',cl-Scra-'t-,h @@,IP has helped plan for a con!13-reheii5j:tre ',-iealti'l care procFram in an isolated colmlilL.-ti-,@-v-ir. ea-,;tern m,iessee and '[(C- 'ic;7 i cariperat4 Te rtuc n Lon with the 01-iio Va-'Lley' Peg4Ln-a-ial Medical Program and the Appalachi-o-ri Regional Comission. Through R@iP si-.--pport it ha--, been possible tc -,i. L. k- three isolated rural cl-in'-cs ina valley of @ast Tennessee for the first time by telephone so that the cli.i-iic nurses can CoilMD.iCa-te with c)pe and witJi the -.3!iysicians oil the-), depend for cl CO-@'Liltati-or, an ?c) rt. The Al-abim. a PIAP hci@, i@,oi-ked with the Appalac-h:,', an program i,i-, ;i @)roject involving Alabamals 17 jwiior co!'Le ges and the Regional Technical Institute, University of A-labama@, in an attemi-t to me6t the needs of heal@, service l@ol7kers for the State's community hos-Inital.s and health- related facilities. -4S- PPOGRAM ACFIVITIES ... IMPLEMEIVTATION Veterans Administration Hospitals A total of 83 (out of 131) Veterans Administration hospitals are presently involved in activities in 42 fWs. The breakdown by planning and operational activities is as follows: Number of VA flospi-tals 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 reality 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 UCIA 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 ACFIVITIES ... IMPLE74EIVTATION NON-FEDERAL HEALTH ORGANIZATIONS -- PARTICIPATION IN RMP @ING AND DECISION-MAKING Representatives of about 6,800 health and other institutions and organizations have been or are actively involved in the planning and decision-making processes of the regions. 'Fypes and numbers of institutions represented are presented in the following table: Kind of Participant Number Institution or Organization Represented Educational Institutions, including Medical Schools 638 Medical Societies, State and Local 761 @ sing, Dental and Other Health Professions Groups 546 Voluntary Health Agencies 721 Health Planning and Related kgencies 790 Hospitals, Nkirsing Homes and Other Caro Institutions 43,110 Others, (largely non-health) 642 TOTAL 8JI208 -so- PROGPAM ACTIVITIES PROGRAM EVALUATION Along with planning and implementation, evaluation is a key activity used by the Regional Medical Programs both as a means for measuring 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 MI, 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 Program 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 Evaluatioft Directors - fifty Regions now employ 53 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 programs for use in decision-inaking. 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 RACs now site visit ongoing projects. Program evaluation, though actually being implemented in only a few RMPS, is in the developmental stages in many Regions. '51 SECFION V WHAT PROGRESS HAVE THE Ms MADE? This section describes MT progress toward uTroving manpower resources through education and training. It also describes the extent of hospita participation as an index of the regionalization of health services. Lastly, the section describes the extent and character of the phasing- out of RMP support for specific projects and the reinvestment of these funds by the Ms into other worthy activities. S3 PROGRAM PROGRE-SS l@IPROVING NiMMIVF:iR Rr-,,@URCES UiRCiUCJI EDUCATION AND TRAI,"IINC, l@,IP-supported training, education, and manl)oi@cr 1)rogriffis Irc (](.,sign(,(] 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 RW to date. PercentaRe 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) 0 Physicians 29% 3 'O 23% 21% Registered Nurses 64% 45% 2S% 25% Allied Health 6% 12% 29 % is% imulti-professional -- 13% 2 3 11-0 39.% TOTAL I:IFOPLE 2,948 51,726 10S,613 97,706 1 highlights: There has been a considerable increase in the number and pro- portion of allied health personnel trained. 'Hie sharp rise i-ii the miilti.-I)rolessioiial Proup reflects the trend tox.;,,ir(i developing tr@iiiiiiig I)rogr,-mis which (1) train for tii(, health toiin il)proich, iii(i (2) train physicians, nurses, -iii(i ollict-s iiii(for one I)i-otzr.,ini. ii)it.iii training I)j-ogriiii.,; tvct-c. (ii.,;ci-etcly For physician,:,. Now, a I)i-oi(lor ,irr,,iy of' ire I)ciiii@, trained. -54- PROGRAM PROGRESS ... TRAINING Percentage and Number of Health Professionals Trained By Disease Category FY 1968 FY 1969 FY 1970 FY' 1971 Percent Percent Percent ercent (as of 4/71) Heart 51% 46% 48% 49% Cancer 7% 4% 7% 7% Stroke 8% 8% 13% 10% Related Disease 7% 8% is% 10% Multi-categorical 37% 34% 17% 24% TOTAL PEOPLE 29948 51.1726 105$613 97,706 Highlights: More people are still being trained in heart disease than any other area. This includes over 10,000 physicians, nurses, and others trained 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. ------------------------------------------------------------------ Percentage of Total Professionals Trained By Length of Training (FY 1969-1971) FY 1969 FY 1970 F)( 1971 Percent Percent Percent (as of T771) One day or less 33% 68% 60% 2 - 5 days 44% 23% 27% 2 - 5 weeks 22% 7% 11% @re than 5 weeks 1% 2@, 2% TOTAL PEOPLE 51,726 105,613 97 706 Highlights: Most of the training continues to be one-day or less with only a few program including extensive, continuous training, such as coronary care. -ss- PROGRA\L PROGRE'SS ... TRAINIfiG PercentaRe of Professionals Trained B-v Training, FY 1971 Registered Allied multi- Physicians Nurses licalth Professional Percent Percent Percent Percent one day or less 60% 44% 75% 64% 2-'D days 31% 24% 16% 31% 2--@ weeks 7% 27% 3% S% MO 2% 5% 6% re than S weeks TOTAL PEOPLE 20,944 24,366 14@319 38,077 Hi ,Qhl @its. RNs are the group receiving the lengthier training, and this has been primarily in coronan,@ care. Many of the one-day or less sessions are seminars and conferences. 0 - PROG@L PROGRESS IMPROVING l@ni SERVICI",S TIIROUQ-I !IGIOi\',UI'@ATIOiN Hospital Participation REGIONALIZATION AND FIOSPI'RAL PARTICIPATION: Regionalization is one of the major themes of Regional. Medical Programs. Working relationships and linkages among community hospitals and between such hospitals and medical. centers are among the primary concerns of the program. 'f'lic li.tikiiig of less specialized health resources and facilities such as smal.l. co ity hospitals with more specialized ones is a critical. way to overcome the maldistribution of certain resources, and increase their availability and accessibility. I'horeforc, hospital participation is one key to the development of Regional Wdical Programs. Percent of Nation's Hospitals* Participating in RWs** National No. Percent Total Particip Participa FY 1968 5,850 851 15% FY 1969 S,820 1,638 26 FY 1970 5,8S3 2,084 36 FY 1971 (est.) S,880 2,693 46 Ifighlight: Almost half of the Nation's short-term non- Federal hospitals are now participating in IMs. ------------------------------------------------------------- Percent of Nation's W-dical Scliool-Affil.iated Ilospi-tals* Participating in Regional Medical- 1'r ams National No. Percent Total Participating Participating PY 1969 436 121 280, FY 1970 480 241 so FY 1971 (est.) 490 28S S8 Almost three-fifths of the Nati.on's medical scliooi-- affiliated hospitals now participate in PM's. short-term, non-Fedoral hospitals participation incl.udcs membership in advi-so-ry groups and committees and i.-i operational activities. r- -7 PROGRAM PROCl@SS...HOSPITAL PARI'ICIPATION Ilospitals* Participating in Operational Activities Only No. Actively @40. Generally Participating Participating Total and Percent and Percent FY 1968 301 60 20% 241 8000- FY 1969 l@246 247 20% 999 80% FY 1970 1 471 860 58% 611 42% FY 1971 (est.) 2YO79 1,221 S9,@,, 8s8 41% Cement Hospitals actively participate by sponsoring projects or serving as the location for an activity. For exan-ri)lc, 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 RMP Pa Total Participating Less Than 200-399 400 plus s 200 Beds Beds Beds ]TY 1968 8si 587 153 110 FY 19(-),) 1,638 1,081 327 229 @ 1970 2,084 1,344 467 273 1--Y 1971 (est.) 2,693 1,7SO S92 351 About 40% (1,7SO) of the @@ation's smallest hospitals are now participating. LI In contrast, about 8S% (3Sl) of the largest -o iiow participating. Hospitals a. short-term, jion-f-ecieral liosi)].tals - 1-1 IQ, - PROGRAM PROGRESS ... REGIONALIZATION REGIONALIZATION -- GEOGRAPI-IIC SCOPE OF ACTIVITIES: Geographical coverage of activities offers another insight iHt-o 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 regionwide activity might be a circuit course for nurse training 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 lmpliasis, 1971 Scope of ActivilL % Funds Regionwide . . . . . . . . . . . . . . . . . . . . . S8% Regionwide involving central and satellite units. .(13%) Subre@ional . . . . . . . . . . . . . . . . . . . . . 40% Inner city . . . . . . . . . . . . . . . . . . . . . (7%) Rural . . . . . . . . . . . . . . . . . . . . . . . (9%) Interregional 2% ------------------------------------------- I------------------------- LXAMPLES OF REGIONALIZING SERVICL@'S AND RL-SOURCL,3: 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- E,'WIPTX-, OF RE@GIONALIZATION OF KIDNI@@' DTSL-@ASI: ACTIVI'FIF@S IN @@-@SI-IINGI'ON/ALASKA Spokane 4k % Seattle Si Nlaj or Medical Centers Community fiospi tals % PROGRAM PROGRESS EXAWLE OF REGIONALIZATION OF CONTINUING EDUCATION ACTIVITTES IN GEORGIA Atlanta --- ----- thens Macon Columbus ------ Savannah Valdosta- --- Major Continuing Education Area Facilities Satellite Continuing Education Facilities ----- (Comunity Ilospitals) -61- PROGRAM PROGRESS TURNOVER OF FUNDS TO MEET CHANGING NEEDS PURPOSE: The M@s 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 RMP SUPPORT: During the oast six months,support for over 90 activities was withdrawn and reinvests in a comparable number of new activities. Activities for which PIAP erminate No. Amount By Disease Emphasis Activities (i--i thou) Percent Heart 34 $1,088 30% Cancer 13 4S4 12% Stroke 6 164 4% Related Diseases 8 294 8% Multicategorical 33 1,426 46% Total 94 $3,426 100 Hig hts: The extensive heart disease cutbacks primarily reflect a decrease of coronary care training activities. @lulticategorical terminations reflect reductions in audio-visual support services, and some multipurpose continuing education programs as well as other activities. -62- PROGWI PROGRESS ... TURNO'VER OF FUNDS No. Amount in By Pringry Purpose Activities (niousands) Percent 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 =d TV type activities. The 29% reduction in Training Health Professionals reflects primarily the reduction in coronary care training. REINVESTMFNF 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 funds have been reinvested in health care delivery activities, thereby markedly increasing efforts in these areas. -63- A GLOSSARY OF TERMS AREA HEALTH EDUCATION CENTER An Area Health Education Center, proposed under pending legisla- tion, would be a satellite of a university health science center for the purpose of increasing opportunities 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 rOI?CE,@") Groups of health care providers and other technical experts appointed 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 car and may e engaged in RMP activities. COOI?DINATING 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 whose prime responsibility is program development, coordination and admin- istration; providing 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 Comittee usually is appointed by the Re2ional 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. -65- EXPERIIVEIVTAL HEALTH CARE DELIVEFY SYSTEM An Experimental I-lealth 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 @-TPITENANCE CRG,4-ill-TZIAT-TO@l 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 Medical Program to advise it with respect to health care needs, priorities, and plans to be undertaken which should ameliorate many of the existina local health care needs and problems. OPER,4TIONAL GRANT Operational Grant is authorized upon a recommendation of both tJie Regional Advisory Group and the National Advisory Council on Regional l@ledical Programs to assist in the establishment and operation of a Regional Medical Program. PLANNING GRANT Planning Grant is authorized upon a recommendation of the National Advisory Council on Regional Medical Programs to assist in the planning and development of a Regional @-lodical Program. PL?OJISCT Project is a discrete activity which is undertaken by the Regional Medical Program as an integral facet of its overall operational program. These ma), include education, training, and patient service demonstration. PROVIDER Provider is an individual whose prime 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 spectrum of health professionals, institutions, and consumers whose prime function is determination of the overall scope, nature, and direction of Regional Ntdical Programs. REGIONALIZATION Regionalization is the linkage among health care institutions and 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- t . U.S. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE Health Services and Mental Health Administration