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                                 T, -----                 ---------------
                                 From

                                 F-HONE



                                 FORM HF-W-30 REv. If/%    UTE SLIP,@,,:




   MEMORANDUM                              DEPARTMENT OF IIEALTI-T, EDUCATION, AND WELFARE
                                                           PUBLIC liEAI,'l'fl SERNIICE

                                                        IIEALTIL RESOURCES ADMINISI'RATION

                                                     BUREAU OF HEALTII RESOURCES DEVELOP?.IENT
   TO       Acting Director                                      DATE: January 23, 1975
            Division of Regional Medical Programs





   FROM
                                r

   ,SUBJECT: Trip report; Arthritis Conference, Kansas City, Missouri, Jan.  19-20,1975



            This an interim report on the conference. There is to be  a  Conference
            Report, but that will not be available earlier than late February.  The
            conference expressed its desire that the traveller undertake to draft  the
            arthritis report. I acceded to this request by indicating that  I  had
            made preliminary arrangements with Mr. David Shobe for the writer staff of
            the Arthritis Foundation to assume this task if circumstances prohibited
            my ability to effectively carry out this responsibility.

            The Arthritis Conference was Chaired by Dr. Roger D. Mason, Senior Vice
            President for Health Affairs, Blue Cross/Blue Shield, Omaha,  Nebraska.
            More than 100 persons participated in the conference, representing
            arthritis program and project directors, and some of their staff,  RMP
            Coordinators and arthritis program administrators, and some of  their
            staff, the writer (DRMP), and Dr. Lawrence M. Petrocelli, Director  of
            Arthritis Activities, NIAMDD. The above participating  groups  included
            representatives from the conference sponsoring, and host organizations.
            Dr. Gordon R. Engebretson, Director Florida @'IP, participated in the
            conference proceedings as the representative of the Program  Account-
            ability and Reporting (PAR) group of the NARMPC.

            The conference was organized to devote attention on the first day
            primarily to substantive aspects of the pilot arthritis program to
            identify its characteristics, and associated needs and  opportunities.
            The output from these discussions was presented to the conference  orally,
            and in written form at the end of the first day as background for   the
            second day is deliberations.
            The first day's material was developed through short talks on five  (5)
            selected program areas, a luncheon talk by Dr. Engebretson, a  dinner
            talk by Mr. David Shobe, on the new arthritis law (PL93-640), and six  (6)
            workshops. These workshops addressed pilot program aspects  of  physician,
            allied health, and patient education, demographic factors, and arthritis
            services, and service deployment.






                                               2




            The focus of the second conference day is most succinctly  characterized
            by the question, "Where do we go from here?"  A panel discussion wa s
            presented first to explicate overall arthritis program documentation
            and assessment, vs. project evaluation. Four (4) workshops  followed  to
            discuss, and bring back to plenary session recommended conference  perspec-
            tives, positions, and proposals regarding Program Documentation, Care
            Delivery Initiatives, Special Report Opportunities, and Program Continuity.
            The afternoon was devoted to hearing the workshop reports, and  conference
            action on workshop recommendations.

            All of the materials needed to prepare an accurate and comprehensive
            conference report are not yet at hand. However, there are  enclosed  mater-
            ialsabout and from the conference which elaborates on this brief  report.
            These are:


               Exhibit  1.  Conference Program
               Exhibit  2.  Roster of workshop Co-Moderators
              1/Exhibit 3.  Responses to Program Interrogatory
               Exhibit  4.  Summary of "A Workshop" reports (first day, A-1  through
                               A-6).
               Exhibit  5.  Instructions to Evaluation Panel
               Exhibit  6.  Summary of "B Workshop"reports (2nd day, B-1, through
                               B-4), including recommendations.

            All of the second day workshop recommendations were supported by a majority
            vote of the conference.  However, there were a number of modifications which
            cannot be accurately reflected until the writer receives a transcript  of
            the Monday, January 20, plenary session.

         1/The Program Interrogatory was a  simplified application of a  brainstorming
            technique.  The objectives were to obtain overall conference  participant
            input to the respective A workshops, and to quickly involve the participants
            in (a) thinking about mutual concerns, and (b) stimulating thought  proces-
            ses about matters which would be addressed in the workshops.  The  extent
            to which these objectives were met is moot; minimally, the conferees obtain-
            ed insight about the spectrum of viewpoints shared by their colleagues  and
            associates on the question subjects.

            The Interrogatory process required a question to be asked orally, and  res-
            pondents were given one (1) minute to record their responses on 3" X  5"
            slips of paper.  These slips were immediately collected, and later reviewed
            for categorization in written pages referred back to the respective  work-
            shops. Questions 13, 14, and 15 (not here available), were posed  later  as
            a reflection of conference enthusiasm; No. 13 from the floor during  the
            Interrogatory, and Nos. 14, and 15, by Dr. Engebretson in connection  with
            the panel discussion on Program Evaluation, January 20.
            The 13 questions were posed in between the five opening session  speakers
            on January 19.  The questions were:






                                               3



           Affected    Question
           Workshop    Sequence          Question

              A-1         1        How can arthritis physicians achieve optimal util-
                                   ization of their skills?


              A-6         2        How can arthritis services deployment be defined,
                                   or characterized?


              A-2         3        How can the allied health role as  service  extenders
                                   be improved, or expanded?

              A-5         4        How can the arthritis capabilities of several provi-
                                   der institutions be coordinated for better care deliv-
                                   very? (The responses to this question  were  lost  in
                                   the mass of generated paper slips, and could  not  be
                                   reported.)

              A-3         5        How can patient vulnerability to non-prescribed
                                   medications and devices be reduced?


              A-4         6        How can existing, or proposed, arthritis services
                                   be made more responsive to demographic characteristics
                                   of the locality?

              A-1         7        How can family physician resistance to  education  in
                                   arthritis be reduced?


              A-6         8        How can the deployment of arthritis services improve
                                   the integration of local resources?

              A-2                  How can continuing education in arthritis be main-
                                   tained for practicing allied health personnel?

              A-5       10         How can an arthritis center best support, or back up
                                   community services?

              A-3       11         How can patients be motivated to follow prescribed
                                   regimens?

              A-4       12         How can demographic information be accumulated through
                                   current program activities?

           Gen&ral      13         How can special needs of children be addressed by
                                   arthritis resources?


           Panel        14         How can the approach used to evaluate drugs  be  used
                                   to evaluate education, training, and services?





                                                4



           As suggested above, a speaker was scheduled for each  meal  period.  At
           the Sunday luncheon, Dr, Gordon R. Engebretson, Coordinator, Florida @IP,
           discussed the adaptability of a PAR-developed cancer program evaluation
           procedure to the arthritis program. Ile also offered PAR  assistance  in
           reporting, and assessing this program. At the  Sunday  buffet  dinner,
           Mr. David Shobe, Director of Government and Community Affairs, Arthritis
           Foundation, described and discussed the "National Arthritis Act of 191'4",
           P.L. 93-640. At the Monday luncheon, Dr. Evelyn V.. Hess,  University  o
           Cincinnati Medical Center, discussed the standard nomenclature and data
           base for arthritis developed by her staff under the  auspices  of  the
           American Rheumatism Association.
           Administrative arrangements for the conference were  superbly  organized
           and directed by Mr. Charles Hine, Kansas RNP, and Mr.  Gordon  Waller,
           Executive Director, Kansas City Division,  Arthritis  Foundation.  For
           instance, plenary sessions and workshop reports were performed by a
           team of Court Reporter students made available at no cost by  a  Kansas
           City business school; workshop Co-Moderators were able to dictate  all:
           reports.

           All sections of the conference proceeded on schedule,  and  participants
           generally  satisfaction with the meeting.  A number of noteworthy
           results may result, all of which cannot be reported at  this  time.  For
           instance, it appears that PAR will organize and execute overall program
           documentation; PIMA Health Systems, Tucson, Arizona, has funds and
           resources to support evaluation of many, if not all projects;  and  the
           allied health participants proposed to organize a special arthritis
           program session at their annual meeting this year at New Orleans in  June.



           Enclosures




              EXHIBIT 1                                                       EXHIBIT 1


                                       ARTili@ITIS CONFEI@l,"NCE


                                      Kansas City,  Missouri

                                      January 19     20, 1975

                 @O 13@O                                             Hosts
           Amcr. Acad. Orthol)aedic  Surgeons                 KC Div., Arthritis Foundation
           Arthritis Foundation                               Kansas RNP
           Participating R@ 's

                               CHAIRMAN        Roger D. Mason, M.D.


                                            PROGRAM


           Sunday, January 3.9

             8:00 a.m.  Registration.        Mezzanine Floor, Ballroom Assembly Room

             8:45  A.m.  Conference  Convention                Colonial Ballroom


                            Welcome
                            Conference  Charge
                            Introduction of Chairman


             9:30  a4m.  Program  Interrogatory                Mr.  Matt Spear

            10:20 a.m.  Coffee Break,

            10:30  a.m.  Program  Presentations

                            Cost Evaluation of Patient Care System     E. R. Convery, M.D
                            Developing Rural Services                  Elam Toone Jr., M.;.
                            Enlarging-Allied Health Roles              Paul Young, M.D.
                            Developing Pediatric.Services              Balu Athreya, II.D.
                            Nursing Outcome Criteria                   Janice Pigg, R.N.

            12:00 Noon  LUNCH                                  Grand Ballroom


                            SPEAKER


             1:30 p.m.  Workshops

                            Physician  Education               Music Room
                            Allied Health Education            Tower  22
                            Patient  Education                 Private Diiii:-rig Room 4
                            Demographic  Factors               Private Lining Room 3
                            Arthritis  Services                Junior Ballroom
                            Service Dep  oyment                Private Dining Room I

             3:45 p.m.  Coffee Break





                                                  hf





                                                         2   Proi,lram



                      4:00 p.m.  Plenary Session                            Roger D. Mason, M.D.
                                   Colonial Ballroom


                                      Workshops Reports

                                      Adjourn

                      6:00 p.m.   Coc](t,                                   Cash Bar

                      7:00 p.m,   Buffett Dinner                            Grand Ballroom



                   Monday. January 20

                      84.00 a,m.  Colonial Ballroom
                                  Call to Order                             Roger D. Mason, M.D.

                                  Panel Discussion     Program     Evaluation

                                      Gordon R. Engebretson, Ph.D., Moderator
                                      0, Lynn Deniston, M.P.H.
                                      Fvelyn V. Hess, M.D.
                                      Carl W. 6cnwartz, rima healtn systems

                      9:45 a.m.  Coffee Break


                      10:00 a.m.  Workshops

                                      Care Delivery Initiatives             Private Dining Room
                                      Program Documentation                 Music Room
                                      Special Report Opportunities
                                      Program Continuity                    Tower 22

                     12:00 Noon  LUNCH                                      Grand Ballroom


                                      Speaker

                      1:30 p,m,  Plenary Session, Colonial Ballroom         Roger D, Mason, M.D.

                                      Workshops Reports
                                      Recommendations
                                      Plenary Deliberations

                                  Adjourn





               EXHIBIT   2                                                    EXHIBIT 2





                                                14culil.eb@icb Ilotel
                                               Kansas City, Kansas
                                              January 1.9   20, 1975



                                             Workshop  Co-moderators

                                                Sunday, Jan, 19
                                                                 C@.4y le,
                    A    1  Physician   Education
                                                                 Russell T. Schultz, M.D.

                    A -  2  Allied Health Education              Marjorie C. Becker, Ph.D.
                                                                 Robert Godfrey, M.D.

                    A -  3  Patient Education                    Frank E. Emery, M.D.
                                                                 William G. Sale, M.D.

                    A -  4  Demographic   Factors                0. Lynn Deniston
                                                                 E. L. Angie Hebbeler

                    A--  5  Arthritis Services                   Gene V. Ball. M6D.
                                                                 John L. Magness, M.D.

                    A    6  Service Deployment                   Raymond I',. H. Partridge, 14.D.
                                                                 Donald L. Riggin


                                                Monday, Jan. 20

                    B    I  Program Documentation                F. Richard Convbry, M.D.
                                                                 Carl 11. Eisenbeis, M.D.

                    B    2  Special Report Opportunities         Ivan F. Duff, M.D.
                                                                 John L. Kline


                    B -  3  Care Delivery Initiatives            Roy L. Cleere, M.D.
                                                                 C. 11. Wilson, Jr., M.D.

                    B -  4  Program Continuity                   Ephraim P. Engleman, M.D.




              EXHIBIT   3                                                   EXHIBIT 3


                                       A-] PHYSICIAN EDUCATION

               @-io@.; can family physician resistance to education in arthritis be reduced?

               A.   Services
                        @la ke ba c k u;D r,,lo r e a va i I a b I e.
                    2.  Er@iphasize team approach; include practioi-ier.
                    3.  Don't take at@iav his patient.
                    4.  Access to peer review to assess care effectiveness.
                    5.  Assure  re'Dorts back to physician of what center did, found, recommends.
                    6.  O@-,e-to-one contact.
                    7.  Help locate allied health Dersonnel in their offices.
                    S.  Help establish 2-way refferal.
                    9.  See patients together.
                    10. increase assistance opportunities from centers.


               B.   Education
                    1.  Through orofessional societies.
                    2.  Use simpler educational tools; eg; cassettes.
                    3.  Distribute bulletins and journals.
                    4.  Devise more appropriate motivational methods.
                        Teach on their home ground
                    6.  Center-office interaction improvement.
                    /.  Make continuing education available to TV at convenient times.
                    8.  Strong programs such as state symposiums.
                    9.  Educate patients to seek care wisely.
                    10. Identify the prospective ratio of arthritis patients.

               C.   General
                    1.  AF %,.4ork @,ii th AMA
                    2.  Financial insentives, other incentives.
                    3.  Don't talk down to local physician.
                    4.  Patient feedback.
                    5.  Solicit private physiciam participation.
                    6.  Differential fees (higher) for arthritis Rx/
                    7.  Establish need in community for practitioners services in arthritis.
                    8.  PSRO controls for  a'uality care.
                    9.  Direct patient (consumer) demands.
                    10. Public pressure.
                        Start low key development of trust, and cive local physician credit for
                        delivery role played.






                                        A-] Physician Education

                How can arthritis physicians achieve optimal utilization of their skills?

                L. Through education of Primary Care Physicians.

                2. Conducting workshops in Rheumatology.

                3. Give clinics to instruct other medical and paramedical personnel.

                4. Learn about knowledgeable needs of local practicing physicians.

                5. Prepare a broad base of consultation systems to Primary Care Physicians
                6. Delegation of responsibility to others within their field of accomplishments.
                7. By consulting with non-professional personnel especially trained in arthritis.

                8. Restrict practice to Rheumatology only.

                9. Computerize patient records.

                IO.. ..'@PAtient Compliance

                II. Well planned patient presentations.

                12. Desimmation of known activities.





                                         A-2  ALLIED HEALTH EDUCATION



            How can the allied health role as service extenders be improved or expanded?

                                                      By delegating total responsibility for
                                                      screening reserve fellowship programs.

                                                      Have Allied Health personnel do more
                                                      rhuematism reports.

                                                      The Allied Health personnel need to
                                                      know more  about  arthritis  care  prob'lems.

                                                      By designing and providing the organization's
                                                      framework.


                                                      By using  Allied  Health  personnel  to  help
                                                      screen patients.

                                                      Use Allied  Health  5ersonnel  as  members  of
                                                      the team.


                                                      Improve  Allied  Health  personnel   training
                                                      and use of quantitative measurement devices.

                                                      Education of physcian as to role that
                                                      All@',@t'd Health and how they can assist  the
                                                      physcian.

                                                      Physcians  should  accept  their  quality  and
                                                      not fe6i that M.D.'s are the only real
                                                      professionals.

                                                      Get third  party  for  all  health  personnel
                                                      skills by using all health personnel to
                                                       help screen patients to determine when
                                                      arthritis treatment is needed.


                                                      Increased  instruction  in  home   programming
                                                      heAj@th development of home followers.

                                                      Include patients as part of the health team.

                                                      Circuit writing "  screen  nurses  "  to  find
                                                      rhuematic arthritis in the physcians offices.

                                                      Increase credibility of all health professionals.









                                      A-2  ALLIED HEALTH EDUCATION



           How can continuing education in arthritis be maintained for practicing
           allied health personnel?

           1.  By working programs in conjunction with continuing education programs
               which will involve allied health professional schools.

           2.  Through hospital in-service programs.

           3.  Keep continuing education in arthritis to licensing requirements--pay
               people to come for courses and hold courses in attractive places.

           4.  One to one with physicians.

           5.  Development of allied health experts to conduct continuing education programs.

           6.  Active participants in allied health professional chapters of national
               allied health professional sections of arthritis foundations.

           7.  Appropriate and sufficient funds for continuing education programs--
               not merely leftovers from physician's programs.

           8.  Utilize team approach which include patients as part of the team.

           9.  Avoid duplication, that is, coordinate existing educational efforts.

           10. Contact and coordinate with state boards of nursing, OT, PT, home health
               agencies and other allied health professional organizations.

           11. Inclusion of arthritis in allied health licensure examinations.

           12. ChanSe in state licensing laws may be needed with medical schools offering
               the necessary leadership.







                                          A-3  PATIENT EDUCATION



            How can patients be motivated to follow prescribed regimens?


            1.  Through patient education which assures the patient that results will
                be beneficial with less pain and suffering if regimes are  followed.

            2.  Through family and peer pressure--general public education that  can
                be understood.


            3.  Education of the disease, treatment and resources for each step carefully
                explained.

            4.  Better education from physician's and orthopedic organizations--effect-ive
                use of A.H.P.'s.


            5.  Motivation through group therapy coordinated by arthritis  treatment
                centers.


            6.  Give patient adequate time to learn about disease, treatment and results
                that may be obtained.

            7.  Frequent monitoring of all patients in the beginning of regime.

            8.  By  demonstrations "seeing success of (-)thers."

            9.  Let the patient know with documented details that dosages taken  now
                and then and not regular will not help and will possibly cause harm.

            10. Free medication with "easy to understand" education material.

            11. Follow up by telephone to patient, "Are you taking your pills,"  "How
                do you feel?"  Develop the "we care"  attitude, (team approach.)

            12. Make the patient a part of the team.







                                                       A-3 PATIENT EDUCATION

                     Hovi  can patient vulnerability to non-prescribed medications and devices be reduced?



                     A.    General
                           1.    Monitoring by consumer advocate groups.
                           2.    Peer review on recommendations for commonly accepted Rx.
                           3.    Central  audit of  reimbursements.
                           4.    Tax the non-prescribed medications and devices higher.
                           5.    Reduce cost of prescribed medication.
                           6.    FDA Regulations
                           7.    Prove their "worth"
                           8.    Advertising regulations.
                           9.    Greater publicity on "quackery".
                           10.   Concerted pressures on the media;  expose  imposters.
                           11.   Expand certification requirements.
                           12.    Officially  investigate effectiveness of available medications and devices.

                     B.    Education
                           1.    More,  better,  faster,  more  intensive,  better planned/developed patient
                                 education.
                           2.    Physicians give patients more attention as an educational  measure;  educate
                                 from physician's office.
                           3.    Specific  instruction by allied health personnel  of the patient's treatment
                                 requirements.
                           4.    Media seminars.
                           5.    Public fourms;  clearinghouse  information.
                           6.    Consumer education  in schools, media,  and physician's offices.
                           7.    Intensive mass media education.
                           8.    Educate the children.
                           9.    Educate the adults.
                           10.   Patient group session education.
                           11.   Use patients to help educate other patients.

                     C.    Providers
                           1.    Professional  observing ethical  approaches.
                           2.    Prefessional  iko;qsm   counseling,  be sure  it occurs.
                           3.    Good care will  reduce patient  interest  in quackery.
                           4.    make care more available.
                           5.    Physicians advise patients.
                           6.    Get feed back on patient functional  assessments.
                           7.    Abstain from criticism to gain patient's  trust.
                           3.    Better patient followup.
                           9.    PSRO activities.
                           10.   Maintain central  inquiring point for patients to check reliability of claims.
                           11.   Research.








                                         A-4  DEMOGRAPHIC FACTORS



            How can demographic information be accumulated through current program
            activities?



            1.  Set up national or regional standards of demography information and
                seek universal consent for data use.


            2.  Establish special projects using expertise already existant outside
                your areas if not within your area.

            3.  Using uniform case sheets and reporting systems through the established
                RMP Centers.


            4.  Collection of specified data, which are centerally analyzed by a computer
                system.

            5.  Use data base for standardization of evaluation and treatment regimes.

            6.  Initiate national criteria for data collection, computer analysis, and
                standardization of pui)l ication.

            7.  Set up arthritis registry in uniform system on national basis.

            8.  Use RMP Centers for collecting uniform data with central computer to
                analyze and publish.





                                        A-4  DE,'IQGRAPHIC FACTORS


           How can existing or proposed arthritis services be made more responsive to
           demographic characteristics of the locality2


           1.  Consumer participation on Advisory Committee

           2.   Inclusion of consumer on planning committee.

           3.   Inclusion of consumers on implementation review.

           4.   ,4oving away from hospital based programs to outside screening.

           5.   By moving personnel to patients.

           6.   Involvement of mobile teams.

           7.   Refine existing demographic data.

           8.   Frequent review of data.
           9.   A@,qareness of specefic areas to be served, i.e., culture, language,
                financial needs and services available.

           10.  Organize committee as a feed dash in mecahnism.

           11.  Aggressive public relation program.












                                       A-5 ARTHRITIS SERVICES



                HOW CAN AN ARTHRITIS CENTER BEST SUPPORT OR BACK UP COMMUNITY SERVICES?



                ORGANIZATION



                1.  leaving coordinator who is available to everyone.
                2.  0 rgan i ze seconda ry- p r i ma ry I i nkages
                3.  Medical Society support to education
                4.  Center-outreach programs which provide "credit" to participants
                5.  Establish coordinated  referral  system
                6.  Coordinate arthritis services
                7.  Support development Of Mi5Sing services
                8.  Joint community planning
                9.  Cooperate in coordinating services

                COMMUNICATION


                1.  Improving all  community  relationships
                2.  Communicate with local health professionals; personal links
                3.  Cooperate in educational activities between centers and center-clinics
                4.  Jointly sharing ideas on needs
                5.  Make information listings available
                6.  Disseminating useful information; exchange information locally
                7.  AssistirTg/facilitating conferences, workshops, consultations
                8.  Develop innovative educational programs
                9.  Visit community hospitals  and  clinics
                10. Involve local practitioners in treatment of local patients
                11. Serve as an info-educational clearinghouse
                12. Have community agencies attend conferences/seminars
                lfi-)-. "Inreach"  training for outside groups


                SERVICES


                1.  Continuing education programs
                2.  By best of all  being  service-oriented
                3.  Finding out what is needed and help   coordinate development
                4.  Provide excellence at professional levels
                5.  Assure consultation services
                6.  Assure non-duplication of services
                7.  Laboratonatory support
                8.  Provide outreach services
                g.  include community services and resources as an element of professional training
                10. Use them!  Take referrals to and from them
                11. Provide a community liaison coordination person








                                   A-6  ARTHRITIS SERVICE DEPLOYMENT



           How can arthritis services deployment be defined or characterized?

           1.  General
               a.  By regional or local needs.
               b.  By available facilities.
               c.  New outreach to communities.
               d.  Laison between provider and teaching institutions.
               e.  Use of many personnel backgrounds, and  skills.
               f.  By relationships of physician, allied health, and patient education
                   activities and patient services (functions.)
               g.  Groups of specialists taking care of  patients.
               h.  Structured use of allied health and physician skills.
               i.  Reaching people not reached before.
               j.  Defining service goals, and expected  outcomes.
               k.  Objectifying sets of variables and  components.
               1.  By cost benefit.

          11.  Education
               a.  Improved professional education.
               b.  Increased public education.
               c.  Organizing medical schools in alliance with local professional personnel.
               d.  Consumer education.
               e.  By teaching value.
               f.  New disciplines to meet new needs.
               9.  Must obtain a multi-disciplinary approach.
               h.  Consultant services to outlying areas.

         Ill.  Services
               a.  Services and needs of given areas.
               b.  Documenting number and type of services delivered.
               c.  Efficient delivery.
               d.  Patient services on all levels.
               e.  Patient self-care teaching.
               f.  By the scope of treatment services.
               g.  Documenting services.
               h.  Age and function demands of environment.
               i.  Developing good algorythms for documentation.
               j.  Comprehensive care plan.
               k.  Referral pattern networks.
               1.  Institutional vs. private practice orientation.
               M.  Inadequate.






                                         A-6  SERVICE DEPLOYMENT


            How can the deployment of arthritis services improve the integration of local
            resources?


            1.  Educational programs of all persons involved, using the team  approach.

            2.  Create a local officer as Committee as a structure on which to build,
                with periodic review of results.
            3.  Consider the need and involve the Community in the development of
                service capabilities through a referral agency, (local arthritis chapter.)
            4.  By giving the lay organizations a medical unit that is recognized as
                their resource center.

            5.  Improving communications between providers of care and educating
                the consumer of existing services.

            6.  Establish referral programs through physician education.

            7.  By personal contacts in the communities.

            8.  By drawing together systems of services with like objectives.
            9.  Utilization of all existing local services plus manpower in setting  up
                local linkeages.
            10. By carefully developing arthritis services around existing services
                as a catylist to improve services in general.
            11. Make sure area of deployment is large enough to encompass a  population
                sufficient to utilize and be able to access resources which are to be
                integrated.

            12. Let local arthritis centers coordinate multiple  in-patient/out-patient
                services through a referral system.





                  3



                How can special needs of children be addressed by arthritic resources?


                No difference between needs of children and adults.

                Identify special needs and then provide services to meet them.
                 Use screening questionaire.

                Include pediatrician in all levels of planning and care.

                Training AHP in meeting identified special needs.

                Training physicians in diagnostic (awareness) and treatment capabilities in
                Med School and continuing education programs.

                Increase communication between primary physician and specializing physician
                or clinic.


                Educate public to be aware of the disease

                Use existing resources to refer ie: Public Health and school nurses.

                Regional facilities to serve wide geographical area.

                Include patients own environmental influences in planning care.
                 Physician, Orthopedist, School, Parent, Family

                Educate and involve patient and family in planning and care.

                Increase number of MD & AHP specialists.

                Establish more Pediatric Arthritis Clinics.




               EXHIBIT 4
                                           PHYSICIAN EDUCATION                  A-]



           TECHNIQUES_
           The workshop identified the following main techniques being employed by  the
           Arthritis Program funded through R.M.P.:
             1.  PRECEPTORSHIP-  Such efforts involve medical students participating in
                 local health care deliveries as well as physicians returning to medical
                 schools for specialized rheumatoid training.
             2.  CLINIC PARTICIPATION- Through these'techniques difficult patients  are
                 presented to consultate physicians and others in the local  community.
                 The medical problem is discussed in some detail and treatment recommend-
                 ations made.
             3.  CONSULTATION-  Conventional consultation contacts have evolved from out-
                 reach efforts.
             4.  WEEKLY LECTIVE SERIES-  Some programs have employed regular lecture series
                 on specific problems of the treatment or diagnosis of rheumatic diseases.
                 REGIONAL DAY LONG SEMINARS- These seminars are usually conducted at a local
                 site by a panel of rheumatologists of the areas medical centers.
             6.  MEDICAL CENTER SYMPOSIUMS- These are more formalized presentations using
                 out of the area experts of some renown and are usually one or two days
                 in duration.
             7.  SELF OR PROGRAMMED INSTRUCTION- A few programs have developed self-assesment
                 and programed instruction instruments.  This technique is available to
                 individual physicians to apply at their own time and pace.
             8.  MEDICAL STUDENTS AND HOUSE STAFF PROGRAMS- There is a conscious attempt in
                 many projects to involve medical students and house staff in the rheumatic
                 disease educational programs.


           PROBLEMS
           The following list of problems related to physicians education was enunciated by
           the  workshop group:
           1.   Local physicians are over-worked and claim no time to participate in programs
                conducted in medical centers.
           2.   Treatment of the arthritic patient is a team effort, therefore, training
                should realistically be conducted on a team basis ( several team teaching
                programs are being conducted with reasonable success).
           3.   Programs should be planned to meet the individual need of the particular
                community.  Without some degree of tailoring rapport between medical center
                and community can be lost.
           4.   There seem to be a insufficient number of trained rheumatologists in the
                medical teaching institutions to meet the demands of an extensive  out-
                reach program.
           5.   Evaluation of the effectiveness of out-reach teaching is at best difficult,
                no suggestions were offered.
           6.   If out-reach programs are too serviced  orientated and patients begin to
                circumvent the local health care system, rapport will be lost.





           A-]                              PHYSICIAN EDUCATION                      page  2


                The attempt should be to emphasize education rather  than  patient  service.

           7.   In areas where distances between population centers  are  great,  experience
                shows a lethargy amoung local physicians for  continuing  education  effort.
                Distance also creates a teaching resourse problem.,

           8.   Medical school faculty are not all enthusiastic about participating in
                out-reach clinics. Many feel their  responsibilities  lie  elsewhere,  such
                as research and institutional instruction.



           EVALUATION


           The workshop discussed evaluation in broad  terms.  No  concensus  was  achieved
           on the best ways to evaluate the programs discussed.  In  fact,  it  was  generally
           agreed that such short term efforts could not be evaluated  in  terms  of  their
           effect on patient treatment and physician behavior.

           It was suggested that where possible all programs maintain  and  compile  cost  and
           "students reached" data. From this information it  may  be  possible  at  the  end
           of the R.M.P. program to make judgement concerning the  cost  effectness  of  var-
           ious teaching techniques.  This data could be of great value to those responsible
           for continued funding. It might also be pertiant  to  an  evaluation  of  the  cost
           of basic medical education in rheumatoid as apposed  to  continuing  education  in
           rheumatoid.


           The workshop participants heard a report of an assessment of pro essiona  e uca-
           tion conducted by the A.R.A. and national Arthritis Foundation.  Dr. Evelyn Hess
           presented some preliminary information which indicates  a  potential  shortage  of
           physicians trained in rheumatology. Their survey  indicated  few  house  staff  and
           medical students involved in arthritis centers.  It also pointed to the relatively
           number of post-doctoral fellowships available in rheumatology.  Numerically
           the data would indicate the exsistance of less than  2.5  rheumatoligists  per  in-
           stitution surveyed. ( The survey covered 120 teaching and private treatment
           institutions.)

           Final results from this survey are expected to be available at the national
           meeting in June 1975.

           RECOMMENDATIONS

           Many suggestions were offered for improvement of  physician  education  by  program
           basis, but several recommendations were offered which relate  to  the  over  all
           task of educating physicians in the area of rheumatic diseases.

             1.  Educational programs should be aimed at the need of the patient and
                 address the physicians problem related to patient need.

             2.  The guide lines for funding of the R.M.P.  Arthritis  Initiative  were  quite
                 restrictive. It is recommended that  future  Funding  allow  more  latitude
                 for program emphasis between out-reach education and  education  of  -medical
                 students and house staff.








            A-]                             PHYSICIAN EDUCATION                 page 3


              3.  A coord inate attempt to gather assess and evaluate data on the various
                  education techniques employed, R.M.P. Arthritis program should be im-
                  plimented.  Perhaps the P.A.R. group in coordination in D.R.M.P. could
                  assimilate the appropriate information for such an analysis.
              4.  The workshop supports continued funding of the Arthritis Center approach
                  and other programs designed for the continuing education of the practicing
                  physician.









                                            ALLIED HEALTH EDUCATION




               Summary                                         Workshop:  A-2
                                                               Room:  Tower 22
                                                               Sunday, Jan. 19, 1975


                                                   Edited By:


                    Marjorie C. Becker, R.P.T., Ph.D.          Robert Godfrey, M.D.
                    University Hospital                        Univ. of Kansas School
                    Ann Arbor, Michigan                              of Medicine
                                                               Kansas City, Kansas


                    Each project summarized their activities, including educational A.H.P.
               activities.


                    The potential under the grant initiative, and in any other way, is
               essentially untapped.  The primary method and technique for strengthening
               the effect of A.H.P. education can most rapidly and efficiently be obtained
               by a massive A.H.P. training program.

                    We do not want to let rigid certification or licensure to take place
               so thatit precludes using manpower and talent at a level that is presently
               available.  We want to encourage the earliest possible educational inter-
               action between all health occupations.  We need to correlate or to include
               the A.H.P. contribution within the A.R.A. central health data basis.


                    Recommendations for future A.H.P. educational activities are:


                    1.  To support Allied Health Professional Section of the Arthritis
                        Foundation


                    2.  Set up a national meeting of Allied Health professionals to
                        share their R.M.P. project outcomes and methodologies, and
                        it was suggested that this might be held in New Orleans,
                        preceding the June meetings, in conjunction with the National
                        Arthritis Foundation meetings.

                    3.  Have each of the twenty-nine project directors assign an A.H.P.
                        coordinator to report specifically on the Allied Health
                        involvement in their projects.  This information could be
                        forwarded to the Allied Health Education Workshop participants
                        for some sort of generalization or compilation and distribution.

                    Anticipated outcomes of greater Allied Health Professional Education:

                    1.  We could better assure greater numbers of rheumatic patients
                        receiving services from appropriate levels of health professionals.







               Page 2
               ALLIEC HEALTH EDUCATION



                    2.  Therefore, we can increase the total volume of patients
                        serviced.

                    3.  We would enhance better the level of sophistication of the
                        patient so that the patient utilizes the physicians' time  and
                        vice versa, which also overcomes physicians' resistance to
                        his professional education.

                    Unresolved issues that might provide agenda items for future meetings:

                    1.  Who should be doing Allied Health Professional  Education?
                        Should discipline train discipline?

                    2.  Who should define criteria for competency, training, and
                        performance?

                    3.  How should we approach third-party payers for coverage  of
                        Allied Health Professional services; and identify other sources
                        of funding for continuing current and proposed projects?

                    4.  How should we utilize non-physician-Allied Health resources,
                        such as the Arthritis Foundation and other national and  local
                        community health resources,for provision of  complementary
                        public education, patient education, or simple secretarial
                        services?

                    The Allied Health Education group strongly recommends that  Allied
               Health training, recruitment, and research should be an extremely  high
               priority item when the National Arthritis Act is being  considered.














                                               PATIENT EDUCATION


                     The participants in this  workshop consiste,' of orthopedics, R.N.s,
               Arthritis Foundation personnel and R.M.P. administrators.  The expenses
               and needs for q,--!ucation of all varied considerably and it was enlightening
               to some to know that they were ahead of others.     The problems viewed
               were:

                     1.  dissemination of educational information and who is responsible
                         or should be for local arthritis centers.
                     2.  The geographical, social, and economical needs of various groups
                         as far as education and how they would feed it to the programs,".
                     3.  Is there a method to evaluate effect of patient education?
                     4.  Participants need list to answer patient needs and discuss patient
                         problems.

                     5.  Arthritis Foundation would like to find if anything is available
                         in the way of education for the problems.








                                           DEMOGRAPHIC FACTORS

            Summary                                                Workshop:   A-4
                                                                   Room:        3
                                                                   Sunday, Jan. 19, 1975

                 General discussion pursued definition of Demographic data.   Basic
            distinction was made between what should be termed classical Demographic data,
            e.g., age, race, income, etc., and a broader definition which  should  include
            any statistics collected which further programmatic goals, e.g., physical
            profile, 3rd party payers, community resources, etc.  Conclusion  was  reached
            that should be termed "lassical Demographic Data, which should be used  as  an
            adjuncted to the broader definition of data.  By this is meant that the initial
            data is used to augment and facilitate the planning process in general.

                 The group as a whole developed a set of classifications and  generated  a
            laundry list under each one.  The list will appear below with clearifications
            being given  subsequently.

            1.  Population Data
                          What is normally available through the use of census data and
                 any related national or local resources.

            II. Patient Data
                 Age
                 Sex
                 Income
                 Occupation
                 Health Insurance
                 Weight
                 Family History
                  -family rheumatoid
                  -personal history
                 Smoking Patterrs
                 Level of Education
                 Race
                 Urban-Rural
                 Language Spoken
                 Living Arrangement
                 Functional Capacity
                  -diagnosis rheumatoid
                  -diagnosis other
                 Other Health Care
                  -traditional
                  -nontraditional
                 Mobility
                 Transportation

            III.Provider Data:  both physician and AHP"s
                 Practice Arrangements
                 Professional  Profile

                  -age
                  -training-speciality
                  -place of  education
                  -place of  residency
                  -involvement of allied health professionals
                 Physicians Referal Patterns








                                            DEMOGRAPHIC FACTORS

            Summary                                                Workshop:   A-4
                                                                   Room:        3
                                                                   Sunday, Jan. 19, 1975

                 General discussion pursued def inition of Demographic data.  Basic
            distinction was made between what should be termed classical Demographic data,
            e.g., age, race, income, etc., and a broader definition which  should  include
            any statistics collected which further programmatic goals, e.g., physical
            profile, 3rd party payers, community resources, (,tc. Concitision was  reached
            that should be termed '.Iassical Demographic Data, which should be used as  an
            adjuncted to the broader definition of data.  By this is meant that the initial
            data is used to augment and facilitate the planning process in general.

                 The group as a whole developed a set of classif ications and generated  a
            laundry list under each one.  The list will appear below with clearifications
            being given  subsequently.

            1.  Population Data
                          What is normally available through the use of census data and
                 any related national or local resources.

            11. Patient Data
                 Age
                 Sex
                 Income
                 Occupation
                 Health Insurance
                 Weight
                 Family History
                  -family rheumatoid
                  -personal history
                 Smoking Patterns
                 Level of Education
                 Race
                 Urban-Rural
                 Language Spoken
                 Living Arrangement
                 Functional Capacity
                  -diagnosis rheumatoid
                  -diagnosis other
                 Other Health Care
                  -traditional
                  -nontraditional
                 Mobility
                 Transportation

            III.Provider Data:  both physician and AHP"s
                 Practice Arrangements
                 Professional  Profile

                  -age
                  -training-speciality
                  -place of  education
                         nf  rac!AAnrxj






           Demographic Factors                                              Page  3

           III.Provider Data
                American Hospital Guide Issue
                AMA Directory
                State and Local Directories
                State Licenser Boards
                PSRO's
                          If the above prove unsatisfactory or inadequate it may be
                desirable to interview the providers themselves.  It is recommended
                that this be done in only selective situations and as a last recourse.

           IV. Institutions,Data
                Medical Care Standards, State Agencies
                State Institutional Licenser Regulatory Authorities

           V.  Community Data
                Center for National Health Statistics
                          It is suggested that local volunteer resources be explored.

           Long Term Program Goals
                In light of the scope of the current projects and recently enacted and
           hoped for legislation, it is suggested that collective action be taken in order
           to answer the following three areas.
                          1. What appropriate mechanism be devised in order to  facilitate
                uniform data collection.
                          2.  The present arthritis programs, coupled with new  legislation
                which mandates arthritis  initiative suggest collective evaluatio46 of all
                the funded arthritis projects through a central mechanism.
                          3.  The present public accounting system (PAR) of the regional
                medical programs provides a resource for centrally collecting and dispersing
                project data.  Further, this activity for PAR is appropriate and consistent
                with the responsibilities delegated regional medical programs to  evaluate
                operational projects.  Consistant with new legislation fod help planning
                and resources developement. This data will be incorporated  into  national
                and regional HEW and NIAMMD when appropriate.  This will serve as the
                basis for an ongoing long term evaluation of the arthritis initiative.






                                                   A-5


                                            ARTHRITIC SERVICES



                     The arthritic services worksl-.op began by a review of the activities
                     of the participants in the workshop in their particular units.    The@e
                     seemed to be general concensus that an important part  of  the  arthritis
                     service program was decentralization of present services from medical
                     centers and medical clinics out into  the  respective  communities.
                     This was perhaps brought out by 30 per cent of the workshop participants.
                     The exact type of arthritis service was divided  into  three  areas:

                         a.  An area of physical treatment.
                         b.  An area of social and emotional treatment.
                         c.  An area of economic, vocational and educational treatment.

               2.    A discussion of what constitutes comprehensive arthritis service was
                     held. There seemed to be a wide spectrum as in physicians use of
                     community resources. A discussion was held  concerning  the  use  of
                     volunteer organizations, charitable  organizations,  including  the
                     Arthritis Foundation, available community resources such as the
                     Public Health nurse, in order to provide service for the arthritic,
                     ,.7ixed or mobile evaluation and follow-up teams.  Considerable  variabilty
                     @exsisted among the members of the workshops    among the constituents
                     of such a team.  These varied from 1)  The use of specialized physicians,
                     orthopedists, rheumotologists, physiatrics, and  pediatricians  with  the
                     Allied -@ersonnel fulfilling a constructive role; 2)  teams comprised
                     primarily of Allied Health personnel utilizing a  nurse,  arthritist
                     specialist, physical therapist, occupational  therapist,  social  service
                     worker and psychologist and nutrition specialists.  The teams varied
                     in thrust from teams that were designed primarily to act as
                     demonstration or teaching teams, to.!,. teams designed primarily to engage
                     in diagnosis and treatment, community resources, fixed or mol)ile.
              3.        Medical center or cl inic programs.   It was emphasized that there
                     was a need f or a cent ra I i zed res ou rce cen te r , w i t h s oph i s t I ca ted
                     seralogic laboratory support in order to provide the  resource  and
                     research r;ata necessary to handle complicated patients and often with
                     specialized clinics for juvenile rheumatoid arthritics, geriatric(, lupus.
                     4) Educational programs. It  was  felt  that  patient  paramedical
                     and post grant education @.were all the important parts of the arthritis
                     service program, but -re being discussed under other specific sessions.
                     5)  Vocational need.  !t was felt that vocational assistants, ranging
                     f rom home-bound or sheltered workshops to special ized employment
                     opportunities would be necessary in order tosupport the arthritic in
                     job placements.
               .4.   A discussion was held on the role of Allied Health personnel in the
                     arthritis treatment and service programs.   Consideralbe philosophical
                     differences existed as to what the responsibilities of  the  nurses
                     practioners and Allied Health personnel  should  be.  Some-general
                     concensus was reached that there is need for a nurse arthritis specialist
                     to be involved in an evaluation,data collection and treatment situation
                     under the supervision of the physician in charge of the care of the







                      Considerable discussion hinged on obtaining funds for a continuation
                      of arthritis services that are begun under the R.M.P. @rant Program.
                      It was felt that some help would be obtained from charitable, federal
                      and state sources but a majority of the support of the individual
                      programs would very likely come from fee-for-service charges from
                      both physicians and Allied Health personnel.








             A-6  QP.TIICE DEPLOYI,!P,"TT


                   As regards the general proaran n-F ex@-stiiit7 arthritis
             the  first  question  that  was   raise@   was   how   the                     o4
                                                                            @ -1     -14-
             arthritis patients is provided, and it i@iis q,iite c-1. r  h,.          " this w s
                                                                      4@   lr
             with the private physician, par ic,,ijl.a.rlv with  he                rierl,.ir-al.
             practitioners.  The  cT,.iestion   was   raised   as   to   whether   physicians
             have any idea as what ir,7 a@,-@itilabi..e  to  -trthritis  pt@ier.+:s  in  the
             area,    r@lany  services  nay  be  a,rail,abl.e  that  the  nhysi@an   is
             of.   It was also apparent            rqptny services +--hat are         able
             compete  rather  than  cooperate  wi  th  one  a-0  4-'ier.  The  nef--rl  he-P.  appears
             to be directory of resources           -@.e ,@-uestion was r-iiserl as @r)  @,7hos-
             responsibility it is to oversee this (iirectorv o-O                         and,
             of  course,  the  question  was  also  ;-raise.('  as   -o              w h o or      e s
             @ie deployment of the arthritis services that are available.

                   Circ,,L-nstanres that ef-Fectivel@,- inhibit ser@,i-n@s:       eo I OyTn. e n -t- an -1
             use @.7ere  O,.iscussed.  Some  of  these  are:  one,  t--Px.e  phvsicil.ns  Rrp.
             conservative by natiirel two, a fear tha+- -e@errin" T.)atients tc,
             other clinics or  facilities,  that  these  T,)all--.i-en@.s  will.  be  lost  to
             there;  three,  poor   educational   physicians   as   to   what   in   arthritis
             service can offer; and four, suspicion n-9 rTn7Ternment                     services.
                   Other inhibiting factors of deplov,-,ent.-. anr@ ,itil-,i,,,ation of services
             are  financial  ones,  particularly,  on  the   part   of   the   patient   and   the
             abilitv of the patient -to Pay.         Tt T-ias -Fe!-t that  riore  lisp  should  be
             made of insurance carriers to pa,?,                      fees,   ancl   sin@   @his
             is  undeveloped,  this  could  be  a  further  factor  thai-  shoiii..,-'   be

                   It was noted that with  the  @7ational  Health  Act  j')(z-incy  Iisr--iisserl.  in
             Cong--ess,  greater  propaganda  emphasis  in  the  next   si;-.   riont@s   shoiilcl
             I)E-- put on  the  financing  anrl.  -methods  of  financing'r  in   the   arthritis
             field.    All areas of concern for arthritis patients                    be
             The role of tie  present  reaion  or  r,.eOj.ca-1.  pro"r,@  in  acl,7inc-  to  or
             changing                           physicians  and  pa--ents  or   -@l,-rrals   cTi,,,en,
                        attitudes o-F local   -
             it was -!-o-'Lt, particularly 1),kr physicians in rural @rr-,.as,           there
             was  a  marked  impact  and  that  these  physicians  were   bernrine?   T,-licli

                    L
             ,more familiar with arthritis problems n,nr7 han(I.IinfT the-r, with oireater
             ease.    There was also a better iiti7.i7a@,io-i of                    -',-ie tise ol-
             para-meo.ical  personnel  @,7as  discussed,  who  (7ire(-ts   the.-,   what   is
             their role linking the  local.  physic-an  an('  p;g@ie.@it,  ar,71  4-1,i@
             gist and patient.
                   The neeO for  early  diagnosis  and  the  (7s--i-elopT-,ent  n-F  Iiarinnstic,,
             centers was emphasized, utilizing oerir)hf--ril. fac@i'L.i.ties -For con@i-ni-,,,.,-.inn
             of the nrograrq.     It was clear that- -there i,.,,-As m. rromat Tiper7 -Oor phvsi-
             cians and patient education as to what car. be provide-.   Sore Discussion
             was  achieved  of  the  priorities,   whether   one   sho-kilrl   concentrate   on
             qualitv versus cruantit@7 oO care,  an@,+  i@  lips  7enp,-a!7.v  -Pel-t  t!L@'it  h
             first prioritv was to increase the av,--il.a-bl.(-- Lq.,-@r-,ss f-.o            care
             by arthritis P-i4@,ients.





              EXHIBIT 5                                                   EXHIBIT 5




                                                PP,OC)Vk3-1 EVAI,UATION



                                                 Panel  Discussion


                                                 Monday 8:00  a.m.
                                                 January 20,  1975



                    Moderator:


                         Gordon R. Engebretson, Ph.D.
                         Deputy Director, Florida IOIP
                         Telephone:   813/253-0931
                         Member: Program Accountability Reporting
                              A cooperative group from  the  RMP's
                              formed to develop national descriptive and
                              evaluative information about RMP programs.


                    Participants:

                         0. Lynn Deniston, M.P.H.
                         Program in Health Behavior, SPH 2
                         University of Michigan
                         Telephone:  313/764-9494
                              Evaluation of Michigan program, and others

                         Evelyn V. Hess, M.D., F.A.C.P.
                         Professor of Medicine
                         University of Cincinnati  Medical  Center
                         Telephone:   513/872-4701
                              Developer ARA standard data program


                         Carl W. Schwartz
                         PIMA Health Systems
                         Telephone:  602/881-4770
                              Evaluation of Arizona program and others

                    This will confirm our telephone conversations regarding the need for a
                    panel discussion on program evaluation at the arthritis conference in
                    Kansas City, January 19 - 20.  The panel is scheduled on the enclosed
                    program for 8:00 a.m. Monday morning, January 20.  This timing is poor
                    with respect to the assistance with program evaluation factors which may
                    be needed in the Sunday workshops.  It is suitable, however, with respect
                    to the crucial conference workshops schedulled immediately after the
                    panel discussion.  The experiences you individually encounter on Sunday
                    may permit specific commentary during the panel discussion with regard
                    to substantive project evaluation, as distinct from overall arthritis
                    program evaluation, or assessment limits.






                                                     Page 2



                    Backf,y otind: The pressures under  which  the  arthritis  grant  applications
                    were developed contributed to a  generally  poor  response  to  program  eval-
                    uation requirements.    Lack of staff at I)IOtl' prevents development of  this
                    program element.  The rapid phase-out of I)I@T, and the transitory position
                    of the l@P's makes followup of arthritis program evaluation impossible.
                    A meeting last November with representatives of the organizations which
                    are sponsoring the conference resulted  in  consensus  and  agreement  to
                    convene the conference, seek to assure  that  the  experiences  of  the  grant
                    program are documented,  and  reinforce  the  evaltiation/assessment  forces
                    which exist.

                    Panel- Problems:  What scale or intensity of evaluation is appropriate
                    with regard to the various  kinds  of  projects  being  undertaken?  What
                    scale, or intensity of assessment is appropriate  with  respect  to  t  e
                    total program, or identifiable  segments  of  it?  How  should  these  tasks
                    be accomplished?  What resources are available to undertake them?
                    How reasonable are the costs involved?

                    Commentary: I am enclosing  for  background  two  of  the  better  suggestions
                    for evaluation which were received in  response  to  our  call  for  sugges-
                    tions last Fall (No. Carolina,  and  Colorado-Wyoming).  If  any  of  you
                    have material which might be helpful  to  project  and  program  heads,  you
                    may wisli to bring handouts (150 copies).  We will have reproduction
                    facilities at the conference, and the  Kansas  RMP  will  make  its  facili-
                    ties available if you cannot bring copies.





                                                                     EXHIBIT 6
              EXHIBIT 6
                                        PROGRAM DOCUMENTATION


                BASIC AGREEMENTS
                1.  Documentation according to objectives.

                2. Can document-@ effort
                                                   other than by numbers.
                3. Do not expect to measure outcome
                4. Documentation at end of one year is of value primarily with
                   reference to future planning.


                The processer identified as being measurable by numbers and amenable
                to cost analysis wore:

                1. Training persons

                2. Personnel trained

                3. Centers estabi ished

                4. Patients treated

                It was emphazied that most programs were designed to expand services
                by education and outreach.  Therefore, documentation will  be numerative,
                and not intended to provide conclusion regarding training effectiveness and
                quality of care.
                Documentation should be prepared so the following elements can be identified:

                1.  Effort

                2.  Performance


                3.  Adequacy

                4.  Efficiency

                5.  Process








                                                                      B-1

















                                      Workshop Recommendations
              1.  RMP should provide common data collecting system for uniform docu-
                  mentation.

                                                                         units of:
              2.  Documentation should be reviewed and evaluated by sub-
                  RMP ,AF, and AAOS.
              3.  summaries should be made available to all interested parties.






                                     SPECIAL REPORT OPPORTUNITIES            B-2


                In addressing ourselves to the charges given to  us,  we  would  philosophize
             the stree on reporting the achievements of the arthritis RMP initiatives were to
             place emphasis on primary patient care--- NOW. That  majority  of  the  projects
             are now doing this is reflected in their activity reports.  This concept of
             responding to the needs of patients == of doing something for them now-- should be
             protected for fostered in the realization of the National Arthritis Act
             which in its language places stress upon research.
                  In all of the 29 projects, education is other a major or a m-inor outcome.
             Education should really not be aimed at any one group; it should, rather, enchance
             the activities of all concerned, i.e. physicians, allied health professionals,
             patients, their families and the public. Because of the multiplicity of
             efforts to design good educational materials, it I s'suggested that a national
             clearing be established.  This, it is emphatically suggested, should be the
             Arthritis Foundation-- this is reflective of the decisions make in the
             AHP and Physicians Educational Workshops.   It is suggested that educational materials
             be designed in response to documented patient,  physician  and  alliebd  haealth
             professional wants, needs and demands.  Ths educational clearing house
             should actively seek out and maintain relationships with other pertinent
             organization dealing in the divilopment of.educational materials.
                  In this workshop eight out of the  12  projects'Represented  were  actively
             seek out and maintain relationships with other pertinent organizations dealing.

             in the development of educational materials.
                  In this workshop eight out of the 12  projects  represented  were  actively
             collecting "data".  We encourage these activities in.the  light  of  the  estab-
             lishment of a national arthritis data base.   We demand that the responsibility
             for data generated In the arthritis initatives be  in  a  repository  accessible
             and responsive to meet the needs of Xhe field.  It is recommended, because of
             lack of uniformity in reporting, that each  project  immediately  remipt  copies









                                                       William Campbell associated with the
              of their data collecting instrument to D
              Tennessee Regional Medical Program arthritis project.  He will only assemble and
              disseminate the instruments as information to the project people.  It is also rec-
              @mmended that central collection and dispersion of data be undertaken by the
              public accounting system (PAR) or some other appropriate entity but under the
              specifications of arthritis as delineated, for instance, by Dr. Hess and her

              committee.
                  In the future it is recommended that high prio@ity be assigned to evaluation
              of:  (1) long term efficacy of comprehensive (optimal) arthritis management
              versus episodic care, i.e. the usual type of clinical care; (2) the effectivenss
              of the nurse practicioner versus the physician.  A cooperative report based
              upon the contributions of everyone involved in the training of nurse practicioners

              in arthritis is desirable.
                  Third party reimbursement of alliedhealth professionals should be explored
              in a cooperative report with the hope including allied health professional care

              serveces as a reimbursable item.
                  It is recommended that likages be established between the various levels
              of care providers: this will optimize their utilization.
                  Among special studies that should be reported we list: (1) Arthritis in
              Industry; (2) Alabamals Medical Information Service by Telephone, i.e. the MIST
              program modified to the needs of practicioners with arthritis patient problems;
              (2) the Western Pennsylvanaia Regional Medical Program which defines the lack
              of knowledge, gearing of their educational efforts thereby, and providing
              follow-up evaluation of their efforts.
                  Through out this conference very little has been said about the methods
              and problems of outreach into the community.  We wish to inform that this
              is what the RMP is all about.  A cooperative report based upon our individual






            experiences is certainly in order so that methologies used, the solution the
            problems which we have encountered are not to be lost.
                 In conclusion, we are all agreed that experiences from this imitative should
            form a basis for activities to be sponsored by the National Arthritis Act.






                                           RECOMMENDATIONS

              ,I. Establishment of a national clearing house for educational  materials,
                  efforts and methodologies.  This office is to actively seek out and
                  maintain contact with other pertinent organizations dealing in the

                  development of educational material.
              2.  Because of lack of uniformity in data collection, each project  should

                  immediately remit copies of their data collecting instruments to
                  Dr. William Campbell, Bioengineering Medical Program, Department of
                     ineering, Science and Mechanics, University of Tennessee, Knoxville.
              3. The central collection and dispersion of data is to be  undertaken  by
                  the public accounting system (PAR) or some oth@r appropriate  entity,
                  but under the specifications and guidance of Dr. Evelyn Hess.
              4.  Eventrually, high priority must be assigned to (1) definement of  the
                  long term effectiveness of different modes of health service  delivery
                  employed in the important types of arthritis and (2) the effectiveness
                  of the nurse practicioner versus the physician. A  cooperative  report
                  'based upon the contributions of everyone involved in the training of

                  nurse practiciobers is desirable.
              5.  Third party reimbursement should be explored in a cooperative  effort.
              6.  The final recommendation is to establish a cooperative report,

                  reflecting outreach experiences in the arthritis project.
              In conclusion, we are all agreed that experience from this initiative
              should form a basis for activities to be sponsored, in the future, by

              The National Arthritis Act.







                                        CARE DELIVERY INITIATIVE           B-@
               Summary                                              Room:     4
                                                                    Monday, Jan. 20, 1975


                           Dr. Roy Cleery            Dr. C. H. Wilson
                           Denver, Colorado          Atlanta, Georgia

                   The workshop explored the  prevailing  pattern  of  Arthritis  Care  Delivery
               in the past which has been a primary care physician,  I  on  I  delivery  system.
               A number of weaknesses of this system where pointed out:
                           1. A lack of property  utilization  of-allied  health  discipline  in
               the care of the patient with arthritis.
                           2. Since all care and patient education  in  this  system  is  derived
               primarily through the physician, this  requires  an  inordinate  amount  of  time
               and often is less effective than using experts in the allied health disciplines
                           3. This prevailing concept has  inhibited  full  functioning  of  some
               of the allied health disciplines because of  the  ambiguity  of  legal  systems
               based on this with regard to legal liability.
                           4. Frequently the physician  is  of  innated  in  delivering  primary
               care, that he is unable to  participate  in  continuing  education  activities.
               Only one strength of this system was pointed out and that was the very
               significant rapport developed between  patient  and  primary  care  physician.  It
               was felt that this could be transfered  and  shared  with  other  members-of  the
               health team without decreasing any effectiveness of    care.
                    In exploring the impact of the regional  medical  program  on  the  health
               system a number of project descriptions  were  explored  and  discussed,  varying
               from a traveling clinic concept over large areas to deliver care and for
               screening and diagnostic processes, to a more stable perminant clinic
               development program in community hospitals.  It  was  felt  that  all  of.these
               had had a significant impact as demonstration projects fitting the demographic
               situations for which they were designed.    The major effect  is  in  the  demon-
               stration of the team approach to the delivery of  services,  as  well  aq  educa-
               tional opportunities for those involved in the  care  of  the  arthritic  patient.
                           'It was felt that these projects are  significant  enough  that  they
               need to be continued for a longer period of  time  to  effect  proper  evaluation
               of  the'ir impact, as well as for continued  delivery  of  primary  health  services
               It was felt that if there was a gap period in which there  is  a  loss  of  funds
               before proper evaluation can occur much ob the potential impact of these
               systems will be lost, due to the collapse for lack of support.      Therefore,  it
               was felt that every effort should be made to  continue  interm  support  of  these
               projects.   It was the concensus of the workshop that a number of recommendations
               should be made:







                                          CARE DELIVERY INITIATIVE



               Resolutions of workshop:
                          1.  it is recommended that as many as possible of the Care Delivery
               Project of the Arthritis Program be continued beyond the present grant period
               by asking that immediate funding be made available, effective July 1, 1975 to
               keep these programs going during the time period from close of RMP to grant of
               the Arthritis Funds through the National Arthritis Act.

                          2.  The Arthritis Initiative Project shou.Id be extended, where
               there is a promise of learning from them, until such time as this learning can
               be demonstrated.  Potential sources are Unexpended Project Funds, other RMP
               resources, Industries, etc.
                          3.  Another source of continuing funds  would  be  through  extending
               contract benefits with health insurance organizations such  as  Blue  Cross  and
               Blue Shield.
                          4.  That this conference request the National Arthritis Act Task
               Force to consider extending funding care delivery into  areas  where  there  are
               not now centers.
                          5. That personel in the  Arthritis  Programs  contact  the  governors
               in their states for input into the composition  of  the  health  councils.  That
               contact with the council then be continued to seek funding through the National
               Health Services Planning and Delivery Act.







                                        PROGRAM CONTINUITY  B-4


               The discussion was opend by listing the variety of funds  being  utilized
          by the arthritis projects which includes arthritis chapter funds, some private
          sources, certain support from The National Institutes of Health, as  well  as
          fees for services.  In the 'latter category it was indicated that in most cases,,
          these are currently being paid by patients but that project  directors  have
          applied, or are applying, for reimbursement of these fees by Medicare, Medicade,
          or other third party payers.
               Dr. Mason said that the Federal government is now directing a variety of
          mechanisms that pay for nearly one-half of all medical care, but  third  party
          payers are responsible for another major part but the amount and type of
          payment is a negotiated factor.
               The question was asked as-to which A.H.P.'s are reimbursed  and  how  hir
          party payments are made.  Dr. Mason stated that if they are reimbursed, it is
          usually limited to in-patient services and that the rates are often  at  the
          game rate that those paid to physicians.  In some states, however, rates have
          been reduced by law to a lower fee schedule. Patient  education  services  are
          also reimbursed on an in-patient basis.
               No participants indicated that they were receiving any state f6ndi.ng
          for their projects.
               The question of future funding revolved around four centra  issues:
               1.  The possibility of additional RMP funds which may either be  in  the
                   balance of 29 regional programs or being held by  O.M.  Matt  Spear
                   stated that there is also the Continuing Resolution  which  provides up
                   to 78 million dollars during fiscal 1975, but whi@@h specifies  that
                   these funds should be used only for transition.
               2.  The second and third points concerned new authorizations.  The
                   new regional health planning, development and resources act was reviewed.
                   It was pointed out that project funds were unlikely to  be  available
                   until in late 1976.
               3.  The National Arthritis Act was also discussed particularly the section
                   dealing with screening and detection
               It was pointed out that if funds are made available to  implement  this
          section, that i-t is possible they could be applied to some of the current
          RMP Programs.
               4.  The fourth area of future funding discussed was  the possibility  of-
                   approaching governors and state legislators to authroize continuance of
                   specific programs in which local persons would not otherwise be
                   benefited.

               The discussion ended with the recommendation that all Arthritis Foundation
          Chapters in areas where RMP programs are currently in existence insure publicity
          for these programs, and, where possible, try to secure continuing funding for
          those projects for which public funding will no longer be available.









                            Draft of Arthritis Conference Resolutions


                            Kansas City, Missouri, January 20, 1975



          Workshop B-1:     Program Documentation

            Approved   1.   @ should provide a common data collection system for
                            uniform documentation of the present projects.

            Approved   2.   Documentation should be r@viewed and evaluated by sub-
                            units of RMP, AF, AAOS, and other concerned  professional
                            organizations, and they should develop a plan for  future
                            documentation of arthritis activities.

            Approved   3.   (Same)



          Workshop B-2:     Special Report Opportunities

            Approved   1.   A national clearinghouse should be established for educa-
                            tional materials, efforts, and methodologies through  the
                            Division of Long Term Care, or the Arthritis  Foundation,
                            and these agencies should seek out and maintain contact
                            with other organizations with educational materials.

            Approved   2.   (Same) Clarified: request for followup support is  to  be
                            issued, and procedure determined by responses.
            Approved   3.   Central collection and dispersion of data should be under-
                            taken by the PAR, or some other appropriate entity, under
                            the specifications and guidance of the AF Computer Committee.

            Approved   4.   (Same) Clarified to be a comparison of comprehensive
                            arthritis care to episodic care.

            Approved   5.   Third party reimbursement should be explored in a coopera-
                            tive effort by this (conference) group.

            Approved   6.   (Same)







          Workshop  B-3:    Care Delivery Initiatives

            Approved   1.   It is recommended that as many as possible of the care
                            delivery projects of the arthritis program be  continued
                            beyond the present grant period (June 30, 1975), by
                            availability of RNP funds, or requesting Congress for  a
                            supplementary appropriation, to keep these programs going
                            during the interim period between the close of RMP and
                            the time that funds become available under P.L.  93-640,
                            so as to be able to complete and evaluate present activ-
                            ities with regard to their effectiveness, and  potential
                            association with future arthritis programs.

            Approved   2.   (Same)

            Approved   3.   (Same)
            Approved   4.   That this conference request the Commission to be established
                            under P.L. 93-640 to investigate areas where there are not
                            now arthritis centers which might nevertheless be deter-
                            mined appropriate sites for allocation of P.L. 93-640
                            grant or contract funds.

                            (This resolution received strong vocal dissent with respect
                            to (a) possible duplication of existing P.L. 93-640 terms,
                            and (b) appropriateness with respect to the perceived main
                            thrust of P.L. 93-640.)

            Approved   5.   (Same)


          Workshop  B-4:    Program Continuity
            Approved   1.   (Notes do not elaborate on the written summary  report).