II i i E I , !1 f I I i 1 i ? ' :I !! I I : I I I I 1 I I!III @. Ili41 !I I ii ii II i !! I!!I 1 ,Iiiiiii !Ili III! *EOO 1 82* REGIONAL MEDICAL PROCRAYS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEIENTAL APPLICATION (A Privileged Communication) ARIZONA REGIONAL MEDICAL PROGRAM RM 00055 5/71 University of Arizona Coll,ege of Medicine April. 1971 Review C6mmitt6e Tucson, Arizona 85721 Program Co2rdinator: Dermont W. Melick, M.D. Requested- Direct Costs 02 (6 mo.1 0.3 05 (6,mo.) TOTAL - Core $1@56,650 @0- -0- -0- $ 156,650 5EiServ. Areas) 37,475 $157,932 $209,191 $108,684 511,282 CE(Phys.) #14 72,798 l@47,010 176,946 92,744 489,498 Ariz. ECHO #15 1911762 324,044 204,064 69,081 791.,001 Cont. Ed. Nur,,qinp, #16 31,034 .52,115_ 5),'171 25,789 l@64,?33 TOTAL $491,719 $681,171. $645,514 $296,298 $2,114t762 Current Funding: A funding history gummary,is appended. The.current 2nd year is funded at $81.1.,191.e,.co. for core and five projects. The commitment for the third'year is for $304,081 d.c.o. for the continuation for five projects only. The Region is to submit a triennium application August 1971 and the core budget is estimated d.c.o.: 01 - $994,586; 04 - $1,067,242; and 05 - $I,.I'23,561 (total - $3,185,389). Geography7pemokraphy: The ARMP serves the entire state of Arizona, 6 !Ian area of 114,000 §quare miles and a population of 1,741,000. The state is bordered by California and Nevada to the west, Utah to the north,.Nev Mexico to the east and Mexico to the south. Medical facilities: 1) University of Arizona Medical School will graduate its first class in 1971.; 2) seven schools of nursing, two of which are baccalaureate degree programs; 3) five schools of medical technology; and 4) six x@ray technology facilities. Medical manpover includes 2,120 physicians (132 per 100,,OOO population); 241 osteopaths, and 5,000 nurses @@348/100,000). Arizona T4P -2- RM 00055 5/71 the Governor a ppointed a Backp,round: The ARMP began in Spring 1966 when steering committee headed by the Dean of the Medical School. The initial grant application was submitted December 1966 and support for pl,anning was authorized for two years and three months beginning April I 1967. The Dean of the Medical School served as part-time program coordinator until September 1567 when the current coordinator was employed on a full- time basis. Due to delays in the review and funding of the Region's operational program, the planning period was extended by nine months to a total of three years. Planning awards d.c.o.: 01 - $119,045; 02 - $409,108; 03 - $375,209; Total - $901@,362. In June 1968, the Region submitted an operational. grant application for support of a pulmonary disease project. Based on the' findings of the August 1968 site visit, the November 1968 Council recommended that the application be returned for revision. In May T969 Council considered the initial operational application. As recommended by Council, a site visit was made that same month to assess the Region's operational capability. The application requested support for core staff activities and six projects. The site visit team was greatly concerned about the dominating needs of RMP in Phoenix and periphera I areas, and the contrast in the Region's plans to concentrate its headquarters near the Medical School in Tucson. Regional problems noted included: 1) need for better health care for the minority croups (I,?6,000 Indiana - 87. of the population and 187,000 Mexican-Arnericans 11% pop.);. 2) the State Medical Association's apparent disinterest in RMP; 3) the medical school had only recently begun and could no t assure immediate strong support; and 4) 75% of medical service activities were in Maricopa County (Phoenix). Of 1,650 physicians in the State, 55% are in the Phoenix area and 3M. in Tucson. Osteopaths are the primary health care providers in a number of counties. Sixty nercent of the hospitals in Arizona have @ess than fifty beds. There was some concern about@.@ the bylaws that provided the Dean of the Medical a.chool with the authority to appoint the Regional Advisory Group. Tne site visitors nointed out that the bylaws were not explicit regarding the Regional. Advisory Group responsibility in appointment of its members and approving. applications. It was also"believed that the evaluation capability of the, Region should be strengthened by acquiring the services of a specialist. Impressions of staff leadership were favorable. Although there were some majo r problems, the team believed there was adequate evidence that the ARMP was ready to assume operational status. The visitors were convinced that further planning would not add to their capacity for implementing an operational program. Followi-rg_ approval by the August 1969 Council, $821,521 (d.c.o.) was awarded the first year for Core and five projects. During the first year Council recommended non-approval action II for four proposals; Nutrition Care, Education in Coronary Care, Community Education for Nurses, and Long-term @cT(i c a t ib-n fo In I i gl, tIof Councti"s dis7a"rovat o@-e Tatter three and their suggestions, the Region redeveloped a program for coronary care training ohich will ultimately involve five projects. Two of these, #11 - Continuing Education for Nursps and #12 - Postgraduate Courses anO Seminars for Pny4,;icians. Hospital Personnel and Trustees @,ere approved by the July I Council. 'rut not yet funde@. Arizona RMP The second year continuation application for $842,125 d.c.o. for core 'and five projects was reviewed by RMPS staff in December 1.970 and upon their recommendation, $811,191 d.c.o. was awarded, The broad goals were essentially the same as originally stated, but the 102 (1971.) objectives were diffuse. Staff expressed hope that the objectives (long and short-term, data-based, nd priority-oriented) will be better presented in AR triennium application Submission to RMPS August 1971. Staff also expressed concern that the half million dollar core is directing most of its energies into development of projects for which there will be insufficient RMS support. It was believed that there would be wisdom in the Region's reassessment of its operations in relation to priority needs and current available resources. In light of federal funding restraints some core activities miIght be appropriately redirected. A copy of staff comments and recommendations to the Acting Director, RMPS is appended. Goals Otiectives and Priorities as described in the recent second /e@r continuation application: The goals and objectives are essentially the same as previously stated, but have been restructured with more detail and time frames for management monitoring. Goals in terms of core staff and projects are as follows- 1. Develop Adequate Health Manpower Res ources. A) Update the knowledge of Health Professional,s B) Increase the number of Health Professionals C) Innovative use of manpower D) Increase tt, e opportunity for upward mobility of Health Personnel l@i. improve Community Health Programs. 111. Develop Cooperative Relationships Among Health-Related Organizations in Arizona. IV. Have the Necessary Financial Organization Support to Accomplish the ARNP Objectives. The 102 objectives are related to the following critical health issuer,,: 1. Gap between new biomedical knowledge and its application to patients; 2. Availability and accessibility of health service; 1. Health needs of tne poor, children, migrant workers and Indiana; 4. Inner-city health problems; 5. Shortage of health manpower. RM 00055 5/71 Arizona PMP -4- ject #4 - Con uin Priority ranking for the second year: Core first, Pro Education for Nurses second, Project #3 - Chronic Pulmonary Disease third, Proj'ect #6 - Cardiopulmonary Resuscitation fourth.$ and Project #5 - Recruitme Service last. Approved unfunded e present application are not ranked. A five-year long-range plan is to be fully described in the triennium application due August 1971. organization Structure and Processes: The organization of the ARMP remains essentially the same. The 17 RAG members are appointed by the Dean. The RAG elects its Chairman, Vice- Chairman and five man Executive Committee. The Chairman and Vice-Chairman serve the same offices on the Executive Committee. Changes in the bylaws as amended March 1970 expanded the RAG term from two to three years (may be reappointed for two additional terms) and include a provision allowing the RAG to delegate to the Executive Committee responsibility and final authority for final approval of applications. The Executive Committee also serves as the Review Committee. Thirteen committees (7 categorical and 6 area or ad hoc) with 189 members are utilized by the Region. Relation- ships of the RAG with other health groups includes the CHP 314-A Agency, Arizona.Heart Association, Arizona Division of the American Cancer Society, and Indian Health Service. The RAG Chairman is President of the Arizona Medical Association. Arizona law requires that all Regional Advisory Group members serve on the',Advisory Council of the Arizona Health Planning Authority 314-A. To permit CHP flexibility in appointing the required 51% consumer representation to the Council, the RAG size and number of consumer members have been kept to a minimum. CHP has not been included in the ARMP review process. There seems to be evidence of tie-,in with professional resources including 314-B Agencies. Subregion activities will be undertaken as necessary, i.e., pLoject #16 -nursing education, Indian 'reservations, model cities, continuing education service areas, etc. The overall strategy, however, will Ie -region--Nvile Core: According to the 02 continuation application, much of the projected core.activities revolve around the submission, approval and funding of several- new Drojects. Projects being developed include home dialysis, multiphasic screening and rheumatic fever, cate orical disease workshops, 9 dial access, pediatric conferences, physician assistants and registeries. Planned core activities include educational programs for physicians and allied he alth professionals; efforts to train indigenous workers for model cities and neighborhood health centers; efforts for enactment of state legislation to legalize physician assistants; plan for state rubella vaccination program; assistance for further development of Area CHP in Arizona Ry? 'PM 00055 5/71 the northern area, Phoenix and Tucson; continued studies for planning, including a survey of health manpower and continuation of "checklist" 20th century books. A notable objective is the cooperative arrangement with Maricopa 'ounty CHP Council to develop a proposals) for multiple funding of health programs for low income consumers comprised of many Mexican-Americans and Indians. An 01 year objective no longer alluded to: "explore the feasibility of having all health continuing education -programs brought within the organized system of education in Arizona." Project Program'.Status: When reviewing the continuation application, staff was favorably impressed by project 4k4 - Continuing Education in Nursing Care of Patients an outstanding program with a record of success. This activity existed in a limited fas ion prior to RMP support. The other projects, all education oriented, had been operational for only a few months and many were late tool.ing up. It was believed that a better assessment cat be made at the time of the initial triennium review in the November 1971 cycle whet more . meaningful progress data should be Available. Present A@olitation: This it a,request for supplemental support for core staff for six months and support for four new projects for three years. Core-Activitieg - The sum of $148,982 is requested for Requested additional core staff support to work Onl,y 6 Months in the areas: 1) development of comprehensive health $1.56,650 services primary focus on prevention and early detection; 2) accelerated health manpower and facilities; 3) further integration of ARNP program activities with those of the CEP A and B agencies, Model Cities program, OEO and other public and private heal.th-related program; and, 4) additional support and coordination of operational project activities, and increased responsibility delegated to the Region by RMPS. The supple- ment proposes adding 11 professional and 7 clerical positions, for a total staff of 58 (41 professionals and semi-professionals, And 17 clerical personnel). The request includes $7,668 for continuation of the pilot work on the dial access program which began in the previous year. A project proposal for this activity is planned as part of the triennium application submission to RMPS August 1.971. The proposed core supplement increases the current annual level to $816,600 d.c.o. Project #1.3 - A Broad Continuing Education Pro Requested Ist Period For-Physicians in Arizona - Development 6 Months of Continuing Education Service Areas. This is a $37,475 companion to Project #14 - C6nt inuing_Educatioh for Physicians. Proposed by the University of Arizon.a College of Medicine, this is a project to organize 15 sub-regional continuing education areas to insure formal education opportunities to all Arizona physicians. The areas wil:l be organized through the coordination and assistance of the Arizona -6- RM 00055 5/71, A project CESA Program Coordinating Committee for Medical Education. directo' and the Committee are to be appointed by the Dean of the Medical r School. The focal point for each CESA will preferably be a hospital and each area will have a local functioning committee. Each CESA focal point is to have teaching facilities and.equipment. The local committees will be responsible for working with fellow physicians in the development of workshops and conferences to meet their needs. The Committee and four CESAs are to be functionable within six months, ten CESAO within eighteen ,.months and all fifteen within the third project period. The educational activities will be provided through the resources of Arizona heal.th organizations, i.e., the University Colleges of Medicine and Continuing Education; ARMP; and Arizona Medical. Association. ,The project will be monitored and evaluated by project personnel with assistance from ARMP core staff, the CESA Committee and participating physicians. Evaluation procedures will include physician self-evaluation questionnaires, comparative patient management problem scores and comparative chart audits. The applicant assumes that the project will be supported by the Medical and Osteopath Associations, and fees after cessation of the grant. Second Period, Third Period Fourth Period (6 mos.) $1.57,932 .$209,191 $108,684 Project #14 A'Broad Continuing Education Program Requested First Period for Physicians in Arizona Workshops, 6 months Conferences and Other Pos@raduate Medical Educa.tion. $72,798 Fro-posed by the University of Arizona Medical School, this is a companion project to #13 CESA. The purpose of this project is to deliver the continuing,education to physicians through the fifteen CESAs on a structured and regular basis'. The proposed program is based on responses to a survey of physicians, Medical Association resolutions, and 18 workshops conducted in 1970 by ARMP. The project director will serve on the CESA Coordinating Committee and will work closely with that project as well as the each chairman of the 1.5 local committees. Designated disease categorical coordinators, all of the College of Medicine, will have responsibility of development of specific curricula in response to wishes of the local committees. The workshop conferences will be physician oriented, but allied health personnel will be welcome, and when appropriate they will be util.ized as faculty, Topics of snecial value to practicing physician will be reproduced into slide cassette tapes and copies distributed to al.1 of the CESAS. Selected cassettes produced by other health organizations will also be distributed. Workshop projections: 17 during the first six months, 40 in 1972, 53 in 1973 and 30 in first six months of 1974. Arizona RMP -7- RM 00055 5/71 Effettiveness of the workshops willbe determined by project staff, ARMP staff, the CESA Coordinating Committee, local medical education committees and participating physicians. Information upon which evaluation will be based includes number of workshops, attendance, post workshop suggestions by attending physicians, periodic questionnaires to physicians attending and those not attending, and the extent CESAs develop programs bevond the workshops. An attempt will also be made to evaluate behavorial changes. With regard to continuation after three years of ARMP support, the applicant anticipates that some financing can be assumed by the College of Medicine through appropriate legislation. Other means of future funding might include assessment of the recipients and their organizations. Second Period Third Period Fourth Period (6.mos.) $1.47,010 $176,946 $92,744 Project #15 - Arizona Evidence for Community Heal.th Organization Conjoint funding proposed 01 (6 mos,@ 02 03 0 (6 mos.) TOTAL RM.P $193,762 $324,094 $204,064 $ 69,081 $ 791,001 State & Local Health Depts. -0- 81,024 249,41.2 161,190 491,626 Total Direct Costs $193,762 $405,118 $453,476 $230,271 $1,282,627 Proposed by the Arizona Department of Health, the purpose of the project is to provide for a unified system for acquiring Arizona population health data. Similar to a system used in Michigan, a pilot test was accomplished in Tucson (Pima County) and Phoenix (Maricopa County). The project provides for a statewide expansion and incluees: 1) collecting data about environ- mental and personal health conditions; 2) anal.ysing the data and converting it into readily usable information for both technical and non-technical "ersons: 3) providing a mechanism for distribution of data at all levels; and 4) provision for education to ensure use of data. This system including 14 county health department subsystem, wil-I afford information necessary to planning development and evaluation to the State Health Department agencies including 314 (A), two CHP 31,4 (B) agencies, 14 county health departments, RMP and other health organizations. The Commissioner of the Arizona Department of Health will appoint a project director and advisory committee.consisting of representatives of the Arizona RM 00055 5/71 participating organizations. Personnel already trained in the two pilot counties will be used to train personnel in the remaining twelve counties. The work projections are based on the Governor's designated six planning areas. Projections for implementations: @egin complete Area I & II 711/71 1/1!73 Area III 6/i/72 1111 74 Area IV & V 7/l/7) 1/l/74 Area VI 6/1173 *.11/1/75 Dates beyond the RMP funding relate to continuation of implementation through local support. Effectiveness of the project will be determined chiefly be frequency data is drawn upon. Some random samples of the "p6rson to person" acquired survey information will be rd-evaluated for accuracy. The Arizona State, Department of Health will request funding from the State legislature to begin mid 1973. Continuation of the project after cessation of RMP funding seems to rest with the legislative process. Most of the budget'is for personnel. Of $122,002 for personnel the first six months, $73,011 is for positions (most already filled) for the Pima County and Maticopa Health Departments. $40,618 is budgeted for personnel in the State Health Department and $15,142 in the three county health departments of Gila, Yuma and Pinal. Second Period Third Period Fourth Period (6mos.) $324,094 $204,064 $69,081 Requested First Period Project #16 Continuation Education for Associate Six Months Degree and Diploma Nurses. Proposed by $31,034 the Northern Arizona University, the project aims to make available 30-40 hours of continued education to each registered nurse in Arizona by 1976. The project aims include the involvement of junior colleges in providing nursing continuing education opportunities in five non-metropolitan county areas with a focus on Indian Health Service nurses. Work projections: 1) annual 10-day workshops at the Northern Arizona 'University for about 15 faculty members of associate and diploma nursing nrog-ams- 2) four annual workshops in non-metropol.itan areas, utilizing resource faculty selected at the workshops for faculty; and 3) a 3-5 env course at the close of each project year for 25 of local. workshop narticipents to specifically hel.,p them develop additional. staff and leader- ship cann'@-ilities. Consultat ion services will. also be offered to nurses in the tarzet areas. RM 00055 5/71 Arizona RMP The section of the narrative dealing, with the evolution of the nroject allu(ies-to two other nursing continuing education projects approved by ARMP, one of which is ongoing. However, specific relationships are not spelled out. Evaluation, will be based on the numbers of: 1) nurse participants; 2) nurses assigned positions of more responsibility as a result of the project education activities; and 3) participating agencies and individual requests for consultation. Evaluation of effectiveness will include pre- an4 liost-testing, assessment by faculty during consultation, course evaluations by participants, self-evaltiations, post follow-up evaluations 1-Y employer and supervisors and nursing audits. The University of Arizona Dopartmpnt of Systems Engineering will be utilized in evaluation on a sub-contract arrangement. The applicant anticipates cost-sharing by cooperative arrangements, and even state legislative support, after cessation of the grant. Second Period Third Period Fourtn Period (6 Mos.) $52,135 $55,373 $25,789 GRB/?/5171 RM 00055 5171 Ari7one RMP DEPARTMENT OF HEALTH. EDUCAT',ON. AND WELFARE PUBLIC HEALTH SERVICE -S AND rV.ENTAL HEALTH ADMINISTRATION HEALTH SERVICR December 17, 1970 Relit)? to Attiz of., of Arizona Regional Medical Prograin's Staff Review December il, 1970@ S@i,jecl: second year continuation applications 5 G03 RM 00055-02 TO: Acting Director Regional @edical Programs Service Thru: Chairman of the Month Acting Chie @epional Development Branch Actino Chi& ee@@6w Branch est: This is A request for $842,125 d.c.o. which includes the com-. riitited level $811,191 and $30,934 carryover. Uiiexpended funds at the close of the current period are estimated at $30,957. Recommendation: Approval in the amount of the commitment $811-191 d.c.o. The recommendation includes advice to the Region about the concerns of the reviewers. Staff also believes that consultation a d/or assistance at an early date Rtay be helpful to AMIP prior to sul)- mission of their initial anniversary review application. The use of carryover or new funds does not seem justified at this time. In some instances, i.e., legislative backup assistance, utilization of g o e s 'aff and/or rebud,,eting w existi'n c r t ould seem appropriate. Basis,for the Level Recommended Reqfieste( Recommended Commitment La over Total Core $503,300 1/ $30,184 $533,484 $503,300 #2 Med.. Lib. 36 31 211 -0- 36,211 36,211 #3.Pulm. Di.s. -112,000 -0- 112,000 112,000 #4 Con t. Ed. Ntir'sing Care 65,807 -0- 65,807 65,807 95 Recruit. & Cont.'d Educ. Social Ser.. 57,5'00 750 58,250 57,500 3 3 6_@l 3 #1 CPR 36.373 *811,191 $30,934 $842,125 @811,193 Ari7nnm RMP RM 00655 5171 Harold Margulies, M.D. December ',-7, 1970 1/ $10,794 project evaluation 1011590 support of "dial-a-tape" T)il.ot T)ro@,,ram untiL submission of the project to RMIS 2/l/71. (start 7/l/71) 8,800 health planner and writer (6 (cooperative effort with State Ilealtli Department, C'flll A & 13, and County Hc!altll Departments) backup for legislative approval of the Arizona Health Data Service $30$184 General Comments: The broad goals are essentially the same as previously stated. The 102 (1971) objectives enumerated and soared to completion dates are diffuse. Hopefully the objectives .(long and short- tem,, data based and priority oriented) will be better presented in the AR triennium application submission to RIMPS August 1971. The organization is about the same. Arizona law requires' that all ARMP RAG members serve on the Advisory Council of the Arizona Health Planning Authority (CHP 314-A). To permit CHP flexibility in appointing the required 51t consumer representation to the Council, the RAG s-Lze and number.of consumers has been minimized. The RAG members are appointed by the Dean - a matter of concern to previous reviewers. The bylaws were recently amended to increase RAG terms from two to three years (may also be reappointed for two additional years). The Executive Committee may act for the RAG in the interim between meetings. Thirteen committees (seven categorical and six area or ad hoc) with 189 members serve the Region. The review process includes the utilization of categorical committees, and review by the Executive Committee prior to final action of the RAG. CHP is not currently involved in the review process. A major concern of. future RMPS visitors wil.l. be organizational effectiveness including thne RAG's actual role in regional affairs. Adequate technical review as part of the review process will be essential. Mutual reviews and critiques o@'- goals, objectives, plans and specific proposed activities by A@IP and C14P might be beneficial. The core staff includes 21 professionals (7 part-time) and 8 administrative/ clerical positions. Five of the professionals (1 part-time) and one office supervisor are budgeted-for the Phoenix Office. One professional (20% @MP and 80% Coconino County Health Department) is budgeted for Flagstaff, Subsequent to submission of the application, ARMP advised that all four unfilled positions are committed. Curriculum vitae for newly employed were provided. Job descriptions for newly acquired employees and positions to be filled would have been helpful to the reviewers. Staff express@d concern that the half million dollar core staff is direct- ing most of its energies into development of Drojects for which there will be insufficient RMPS support. It would seem that there would @e wisdom in the Region's reassessment of its op.erations in relat-l.on to RM 00055 5171 Ari7ona RMP Harold Margulies, M D. December 17, 1970 priority.ndeds and current limited available resources. In light of federal funding restraints, activities., including core, might be aR2ro- priately redirected. With one exception, the current funded projects have been operational for only a few months. Many were late tooling up. A better assessment can be made at the time of the next anniversary review when more meaningful data should be available. Staff was favorably impressed by project #4, "Continuing Education in Nursing Care of Patients an outstanding regional program with a record of success. Liit er 'J. Says Public Health Advisor Grants Review Branch Action by Director Initials -7e Date Attachments: 1) Mr. Says', GRB, review comments RMPS staff who attended this review meeting: L. J. Says, GRB Jim Smith,, RDB R. D. Merck6r, GMB Teresa Schoen, OPPE Mary Asdell, CETB Arizona RMP R,4 00055 5/71 REVIEW AND FUNDING HISTORY SUMMARY PLANNING lit Year 4/l/67-3/31/68 $119,045 (Site Visited August 1-968) Cduncil: 1967 - February 1.968 - May, November 2nd Year 4/l/68-3/31/69 346,125 02 Supplement 1/l/69-3/31/69 62,083 TOTAL 02 $409,108 Chronic Pulmonary Disease Program Application for "Earmarked Funds" Disapproval with advice to resubmit 03 Year 4/l/69-6/50/69 Extended with Funds 4/l./69-9/30/69 117,208 Extended with Funds 4/l/69-i,2/31/69 106,630 Extended with Funds 4/l/69-3/l/70 13,276 TOTAL 03 $375,209 OPERATIONAL I/l/70-1.2/31/73 (Site Visited May l@969) Countil: 1969 - May, August 1970 - March, July Direct Costs Approved oved Period Funded Future Level Core 2 years (01) $503,300 (03) -0- (02) 503,300 #1 Checklist 20th Century Books 3 years I/ Approved in principle with no additional funds #2 - Medical Library Network 3 years (01) 39,233 (03) $ 35,211 (02) 36,211 #3 - Chronic Pulmonary Disease 3 years (01.) 139,988 (03) 120',OOO (02) 112,000 Arizona RY.P 14- RM 00055 5/71 #4 Continuing Education in 3 years (01) 51,895 (03) $ 84,118 Nursing Care (02) 65,807 #5 Recruitment & Continuing 3 years (01) 32,621 (03) 28,379 Education Social. Service (02) 57,500 #6 CPR (01) 26,106 (03) 36,373 (02) 36,373 #7 Continuing Education Coronary Care Disapproval with advice to resubmit #8 - Continuing Education for Nurses Disapproval with advice to resubmit #9 -.Long-Term Continuing Education for Nurses Disapproval with advice to'resubmit #10 Nutritional Care Disapproval with advice to resubmit #11 Coronary Care Continuing Education for Nurses Approval I (unfunded) 412.- Coronary Care Post-gred@ Courses & Seminars for Pby§icians, Hosp. Adm. Personnel & Trustees, Approval I (unfunded) TOTALS (01) $793,133 (03) $304,081 (02) $811 191. I/ Supported through Core-- 01 year APPROVED & UNFUNDED PROJECTS (D.C.0) 01 02 03 #11 $ 7C,583 $ 77,405 79,988 ..74,812 68,648 #12 70,640 TOTAL $151 395 $146,053 $150,628 Ari7ons RMP -11 Ali"' ZOINA -12/70 c,rrc-nz '/-/o Program Funding: --------- $ 311,19',L First Schedui@d AR ipplicatic'-',Auyuat t971 Approved for Ctrrent Year ----- Operating level i@ Current Year Regior,'$ Optional plans: iy $ 3 1 1, 19 I Recommended Commitment for next year --- s 304,081 r COMPONENTS BY DISEASE CATEGORY COMPONENTS COMPCKEN-L; BY TYPE OF ACTIVI':Y ON-GOlt-" TRAlt@l@iG AND EDIICATI(-,N HEART ore--@',zO3,300 on-going 5 on-goinit . 0 Projects _ # Projects 0 #2 Lib. Network Total-ss 307 891 Total SS 0 % 38% 0 $36, 21 1 Approved/unfunded 2 #3 Chr@ Pul. Dis. __Ris@pr ved 4@ as r $ 112,000 #4 Cont'd Ed. CANCER Nursing Care on-going Projects 4 $65,807 DEMCCST@TION OF PATIENT CARE Total SS #5 Recruitment- On-R.Oing & cont. Ed. Projette % SS Approved/unfunded Socia! Service Total SS Disappi $57,500 SS 1 Approved/tinfunded #6 CPR Disapproved $36,3 1 RESEARCH & DEVELOPITNR Nurses i oil-going $76,583 Projects KIDNEY I Total SS #12 C.C- Poat-Grad i % SS On-going 0 Ed. Phys. HOSP- p proved /un funded # projects A Total SS 0 Adm. & Trustees Disaoproved % SS 0 @4 ql2 - Total Appr oved/unfunded 151,39 i$8 roved RELATED DISEASES QUEST I A-DMI-Nr---- *n-going SUPPL. RE STRATION & PLANNING # Projects Core On- P'Oin9 Total $s 14 T7, @k Projects 1 ((,.ore. % Ss Total SS 503,300 Approvedlunfunded % SS 6@% as pro@d #13 Coqt. Appro@ed/unfunded I.-Ser. Arei Disapproved MULTICATI(.ORICAL $37,4j # Projects 3 15 code. Ed.- Total SS % SS Physicians i Approved/unfunded 3 @72,798 ,@L.approvel ECliO 1 GENERAL on-P.Olne $193i762 # Projects 1 (Core) Total SS 503 00 62e % SS d. Approved/unfunded 0 Nurses of Assoc* Disa Degree & Diploma Programs - .$31,034 - * #1 Check list 20th Cent. Books Approved & unfunded is funded through Core le .(A Privileged CominLti-ii.catioli) SU@,4'MAY@Y OF RE\,IEIL j@NI) COI@;CLUSION OF tiPRIL 1.97i. REVIE@. COIIL@iTl@T-i,-,!," AP,IZOI-Il@@ REGIC),@,AL IIFI)ICAL PPOGRA.@L P@l 00055 5/71 FOR CC-IIISI'DERATIO'Li BY IIAY 1971. ADVISORY COUNCIL RE('$'),%Z'END,kTION: Disappkoval of additional Core support and approval bk projects with no additional funds. YE.-t-lil R E 9LJ EL,@' FIJI\'Dli\'C- 02 (6 r@ios.) $491,71.9 -0- 03 681,171 04 645,5-."4 01- $2,114,726 -0- LP@ U@E: Tiie CoiTni:ttee noted that the current level of of Arizona's is (d.c.o.)@ of which $503,300 (62%) is for Co@-(, activities. Tlie.present: request would the annual cost of core to r@iore than $F300,0,,',O, nid slickil-d not be a-,,)proved. Current support should be 3deqLiate for ecirc, activities some L)il@.-)t work on the di,-)I access pro-,rari,@. The Comin.;.ttc-e also recognized the concerns tl@ct staff had when renewing the second-vear continuation nppl.icat4@oTI: that the objectives were not clear and that core activities were preclot-ri-@n,),t:ely @)roject or-i-ent(!d. C6ri-iiittee concurred. vii!-ii staff that there woul.d be i,7isdo,,ii in the llegioii's reassessment of its operations rel ti.vc- to priority needs and resources, i@@ of 7-'dNi"-3s funding co.,.,.St)@.@iit,,ts -ILi7i fiscal year 7 and 724 Also, as reported l@y staff, the-Rc!,o,4,on has planned a retreat in late p i@i. r,@el?s staff are to attend and may be helpful in guiding the Regi.on. Arizoi-,I'S,Prirnary p-coject tlirust continues to be training ind education. The five currently funded pro3ects include a library network, chronic pulmonary disease, nursing care, sr@ciil service, and CPR. Two coronary care training projects were approved, but unfunded. Tll@ present ap-P.13.- cation does not include i ra-n'L" list of all projector. The projects presented represent noii-categoric-@ll ouireecl-i,l)rogra-,Is qnd do relate to the Reoioiis broad goals. Correlztioii with ol)er.',tiTIc- objectives -I,Yttl T.)riorities is not clear. The two ContinLiinc, Ilclu,--ati.on for Pl,,Isiciahs (Projects' 13 and 14) are coritp,,@iiion pr(-j,,@,cts irti@L41-it be co@!@t)].ned and accomplished for less costs. The "Arizona Evidence for Cor@,@iii.inity Iliealth Orgaiiizctiori" project ip'15 may etil,-iance ARIZONA DIP -2- RM 00055 5/71 and evaluation efforts @,?i-th health departments CHP a@,Lnc,.es end others. The "Continuation Education for Associate Degree and Diploma Nurses" project #16 has a much needed focus on Indian Health. Comr.qittee noted that the May 1.969 site visitors recognized that one of the Regionts problems @,7as need for better health care for the minority groups (136,000 Indians - 8% of the population and 187,000 llexican- Americans - 11% pop.). The question arose as to the Re-ion's current involvement and plans in this direction. In conclusion the Corirtil.ttee did not believe expansion of core is justified. Projects' may have merit but additional funds at this time are not vyarrqnted. The Region's trienium application is due August 1, 1971 and will include a site visit to examine their total proEritti, progress ?nd capability. Pkl'-PS /CRB 4/21,/71. REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF OPERATIONAL SUPPLEMEMTAL GRANT APPLICATION (A Privileged Communication) BI-STATE REGIONAL MEDICAL PROGRAM RM 00056 5/71 (Washington University) April 1971 Review Committee 607 North Grand Boulevard St. Louis, Missouri 63103 Program Coordinator: William Stoneman III, M.D. This application requests supplemental funds to support two new operational projects. This Region is currently funded at $945,233 (direct costs) for its second operational year (which is an 11-month period) ending September 30,,1971. Due to RMP fiscal 1971 (and 72) apportionment this total in to be reduced by $60,314. For this year the Region received indirect costs of $305,046 on its $945,233 which represents an average indirect toot rate of 32%. The Region will submit its Anniversary Review Application in time for review during the July/August 1971 review cycle. REQUESTED (Direct Costs On v) Project Title lot year 2nd year 3rd year Total #15 - Public Education $@5,390 $20,988 $15,000 $71,378 Program on Harmful Effect of Cigarette Smoking #16 - Develop a Model 16,750 15,850 15,850 48,450 for Testing Physician dontinuitm Education TOTALS $52,140 $36,838 $30,850 $119,828 Staff hat conducted its review of the Regions application for second-year .operational funding. While there were several programmatic and budgetary Issues identified by staff, (see Addendum page) because of the nature of this application (operational supplement) the Region did not relate to these concerns. It can be assumed that information relative to the issues.will be included as a part of the total program review at the time the Anniversary application is considered. BI-STATE REGIONAL MEDICAL,PROGRAM 2,- RN 00056 5/71 FMINI; HISTORY' Planning Stage Grant Year Period -Funded (Direct Costsi 01 4/l/67 - 10/31/68 (19 mO $495,395 02 11/l/68 - 10/31/69 443,625 Operational Stage 01 .7/t/69 - 10/31/70 (16 Mo. ) $1,094,077 02 11/l/70 - 9/31/71 (Ij Mo. ) 945,233 (of which $64,293 is carryover) 02 Year Listinit of Funding Status of-Core and operational Prolects in Bi-State RMP Project Title Amount Supported (d.c.) Through 9/31/71 $489,296 0 core 2 Cooperative Regional Radiation Therapy Program .118,564 4 A Comprehensive Diagnostic Demonstration Unit for Stroke 46,037 5 A Nursing Demonstration Unit in Early Intensive Care of Acute Stroke 55,690 8 Cooperative Regional Information System for Health Professi I ons 39,748 9 Health Surveillance Education and Care Accessibility for Idw-rent projects 1312605 12 C.C. Training Program for Nurses 64,293 a/ a/ carryover funds TOTAL $945,233 This amount is to be reduced by $60,314. The breakdown of the reduction is not available at this time. BI-STATE REGIONAL MEDICAL PROGRAMS 3 - RM 00056 5/71 The Region has a fairly well-balanced overall program between Heart Disease,, Cancer, Stroke and Multi-Categorical activities. B*ckground Information 1. Population: 4,9000,000 (estimated) (a)-Urban 80% (b) Non-White 9% (c) Median age 31.6% 2. Medical Schools (a) Washington University (b) St. Louis University (c) Southern Illinois (To open in 1972) 3. Physicians - 5021 4. General Hospitals - 178 22,000 beds 5. Geography (A) 66 Counties in Southern Illinois (b) 42 Counties in Southeastern Missouri SUMMARIES OF NEW OPERATIONAL PROPOSALS Requested let year . (d.c.)_ $35,390 Proposal #15 - To Provide Coordination for Public Education Programs in the Bi-State Metropolitan Area on the Harmful Effects of Cigarette Smoking. The Bi-State Inter-Agency Council on Smoking and Health for the Greater St. Louis area (includes 30 health or health interested agencies) requests through the Bi-State Regional Medical Program a total of $71,378(only direct costs are requested)to plan and implement this proposal for a three-yeat period. The program is to be physically based in the offices of the St. Lou a Medical Society (without charge to the grant). The program was reviewed by the Region's Cancer Committee, the Scientific and Educational Review Committee and the Regional Advisory Group. In the latter group it received a priority rating of 250 on a 100 to 500 scale. The program has a tingle objective which is to improve coordination of the Bi-State Metropolitan area (six Missouri and Illinois Counties) efforts in public education on the harmful effects of smoking. According to the application this proposal will advance the Region's strategy in that the program has strong categorical disease application,as well as professional acceptability and BI-STATE REGIONAL MEDICAL PROGRAMS 4 RM 00056 5/71 consumer appeal. Bringing education to the public, especially the younger public, on the harmful effects of cigarette smoking, the proposal will also bring visibility to Bi-State RMP and heio.define the program as a unifying factor in the Region's health care planning. Essentially support is requested to provide for a full-time program coordi- nator and secretar' plus the usual expenses (excluding rent) who will survey y existing activities and resources and then develop and implement a coordinated anti-smoking public education plan for the area. A means of evaluating pro- gress is outlined. Basically its success will be measured in terms of local support which the program receives. While the primary program target area is Greater St. Louis, the program will be made available to interested groups in other parts of the region. 'The proposal i presented with a descending scale budget. The second year request is :olely for the support of the coordi- nator and secretary, while the third year requests a single salary for the program coordinator. The Region has been given reasonable assurance that as the program matures, its costs will be borne by other agencies. Second Year $20,988 Third Year $15,000 Proposal #16 To DeveloR a Model for Testing Effectiveness Requested of Physician Continuing Education Programs in lst year- Terms of Patient Management. $16,750 The Bi-State Region requests a total of $48,450 (only direct costs are requested) to conduct this activity for a three-year period. The proposal was first re- viewed by the Region's Continuing Education Committee which recommended some changes. These changes were incorporated and a second review was conducted by the Scientific and Educational Review Committee. The proposal was then presented to the Regional Advisory Group. During its initial review, the RAG recommended that action be with@eldi pending approval of the plan by the Illinois and Missouri State Medical Association (Society). The Missouri State Medical Association approved and commended the innovative idea. The Illinois State Medical Society recommended that the proposal be approved. Following this, and upon re-review, the RAG unanimously approved the program with a priority rating of 150, on a 100-500 scale. This is the highest priority given to any Bi-State proposal to date. The program has two objectives which are to: (1) Determine the feasibility and acceptability to practicing physicians of an experimental system for ascertaining patterns of patient management from hospital record analysis. (2) Test the.usefulness of such patient management analysis to faculty and local physicians in planning continuing education programs. Three hospitals and their medical staffs, two in Illinois, one in Missouri, have presented formal evidence of their willingness to have hospital charts 1. "I&I-STATE REGIONAL MEDICAL PROGRAMS 5 - RM 00056 5/71 analyzed to determine baseline physician performance data on selected diseases and in selected clinical hospital procedures. Using this information, problem- oriented Continuing Education Programs, with each community identifying the fields of clinical practice in which it is most interested, will be developed. The proposal incorporates not only local physician design of an education pro- gram but also a mechanism for measuring the effectiveness of the program in terms of level of patient care delivered. According to the application, this proposal will relate to and enhance each of the-Region's strategy components as determined by the Regional Advisory Group. Additionally,the region reports that the innovative character of this program has engendered so much interest that the region has received requests from three additional hospitals and medical staffs to be included in the program. The continuing education activity is the product of three part-time physician coordinators who have been assigned by the region to the three areas for some time. Their mission has been to develop a program based on local need rather than on subjects a distant person believed local physician would want or need. The Regiongs full-time Planning Director will be available for overall project coordination. Evaluation will consist of pre and post-clinical performance using the analysis of hospital charts for base-line data. $34,200 of the total three-year budget request of $48,450 is for consultant services. These fund* are to be used to purchase the necessary expertise, either from the medical schools or the coa- munity, to conduct the continuing education activity in the given areas. If this experiment proves successful, continued local support is anticipated through medical societies, hospitals or voluntary health agencies. Second Year- Third Year $15,850 $150850 -6- RH 00056 5/71 BI-STATE REGIONAL MEDICAL PROGRAM ADDGNDUM Gereral Con@erris of Staff: 1. The "turf" problem between the Bi-State and the Illinois Regional Medical Programs. 2. At what level in the local review process vetoes may be im posed appc@aled? 3. Staff would be interested in kiio@, yitig the type of activities and the number of proposals which have been disapproved in the local- review process. 4. Evaluation methodology. 5. Staff was not convinced that the data collection system proposal would actually strengthen the planning efforts of the Region. 6. Assignment of a field Coordinator to the Springfield, Illin ois area in view of jurisdictional and geographic problems which are about to surface. 7. Contributions being made toward the goals and KIP objectives by the six categorically assigned Associate Directors'to the two medical schools. 8. Lack of impact operational projects have on the improvement of the Delivery of Health Care. 9. How some of the minimal requests for carryover ($200 - $350) were processed through the local review system. 10. The Region be given consultation concerning Coundil's July 1970 decision as relates to the s tipeiids, travel, etc., for short-term traineeships. GRB/3/11/71 (A Privileged Communicat4-on) S@- it!' OF @UIVTEt4 P-@'D CONCLUSION O@ APRIL J.971 PLPVIEW C(Yt@'IIITTEE BI-STATE !?.EGIONAL MEDICAT- PROGRAM P,M 00056 5/71 FOR ""ONSIDERATION BY MAY 1971- ADVISOIZY COUNCIL RECOMMENDATION: The Review Comni@i-ttee recommends that this supplemental. application which requests support for two- new projects be partially supported as follows: RECOINZIENDED YEAR P@r@2@EST FUNDING lst $52,1-40 $16,750 2nd 36,838 15,850 3rd 30,850 15,850 TOTAL $119,828 $48,450 CRITIQUE: The Committee noted that the Bi-State RMP will submit its anniversary review application in time for review during the July/August 1971 review cycle. Also, the reviewers were satisfied that tne Region will relate, in this future application, to til-@.e con- cerns of staff which were raised during staff's review of the Region's second year continuation request. Since this optional application included only two projects, the Committee did not have an opportunity to study the potential impact- on the entire program. It was concluded ,-hat the adding of Project #16- To Deve@o a Model. for Te-@ti-i@i,, I ,s4-c-'Lan Continu@,@ti(L tion would add strength and balance to '@-he Re@ion. @lenibers of the Committee believed that the proposed activities were innovative; that the pro- gram was presented in a proper cooperative setting; that the fiscal request was reasonable; and t[iat further plans forthe program include continued support from local sources. Conversely, the Committee viewed project #15 - A Public Edticatj@-on ProRram on Harmful Effect of @igare t@@ ni -,s a program which contained nothing new, I.acks innovation and riote@i that many similar antismoking programs have alread37 been supported across the country. It was concluded that this project would not be a priority for use of @,@rP funds. GRB/RMP S 4/21@ / -11 REGIONAL MEDICAL PROGRAMS SERVICE CALIFORNIA Regional Medical Program RM 00019 5/71 (Special Action) FOR CONSIDERATION BY APRIL 1971 REVIEW COMMITTEE STAFF INFORMATION This project was one submitted by the California Committee for Regional Medical Program for the November/December 1969 review cycle. The Lockheed Corporation, by means of a contract with Area 1, collaborated with personnel at Mt. Zion Hospital in the development of an electrocardiographic sur- veillance system which monitors silently a large number of patients simultaneously and continuously. The monitoring is silent until a deviation occurs, and there are no practical limitations to the number of patients or their locations. A site visit team,, which included an expert in biomedical applications of such techniques, visited the Mt. Zion Hospital in October 1969, to observe the system in action. The team found the project interesting from a number of standpoints, but had some concerns, largely technical, which were later relayed to the region. The proposal was also reviewed by the ad hoc Cardiovascular Panel and the following concerns reflect the opinion of all reviewers, including the National Advisory Council: 1. the educational aspects of the overall program were not clearly described; 2. evaluation methods were thought to be vague, with no record system to describe events monitored; 3. the validity of alarm signals was not clear; 4. the contribution of Lockheed Corporation to further development and de-bugging was not specified; and 5. the system had not received sufficient time for more extensive testing in a clinical setting. The team felt that approximately a year would be required to de-bug the system completely and allow the Mt. Zion personnel to test it before extending it to more remote hospitals in Area I. The Lockheed Corporation has offered to assume costs for instrumentation and engineering for three years at a total cost of $495,300.' CCRMP feels it is important for this program to continue to carry the label of RMP in order to assure that certain aspects concerned with patient care services, regiona- lization and professional education, etc., are retained in the program in a meaningful way. The amount to be allocated from CCRMP funds is $35,446 (d.c.) for personnel. A cost breakdown prepared by Lockheed is a part of the revised application, and provides a written understanding of terms of the arrangement. Specidl Action - page 2 The revised proposal was submitted to Doctor J. Franc is Dammann, Professor of Pediatrics and Biomedical Engineering, who served as consultant for this project on the site,team of October 1969.. -Dr.@ Dammann very graciously agreed to review the revised rotocol for the Mt. Zion program and his p report of March 2, 1971 is attached. RMPS/GRB 3/17/71 UNIVERSITY OF VIRGINIA SCHOOI OF rViEDlClr,4E UNIVERSITY OF VIRGINIA HO--PITAL CHARLOTI'ESVILLE. VIRGINIA. 22901 TMENT OF PEDIATRICS March 2, 1971 Division of Pediatric Cardiology Research - Box 218 Jessie F. Salazar Public Health Advisor Grants Review Branch Health Services and Mental Health Administration Rockville, Maryland 20852 Dear Mrs. Salazar: Per your request, I have reviewed the updated and revised project for patient monitoring at Mt. Zion Hospital in San Francisco. I believe that the applicants have satisfied all of the site visitors major objections to the program as it originally was set forth. Therefore, I think it very appropriate for the Regional Medical Program to support it as it now stands. Three major changes in the program have been made which answer most of the site visitors concerns. First, I deem it very appropriate indeed that Lockheed has agreed to pick up the expenses of building the system for trial at Mt. Zion Hospital. It seems to me to put the association of medicine, government and industry on a much more solid base, whereas government picking up the expense of the system did not appear to be justifiable. Secondly, the decision to restrict the systems trial in the field to Mt. Zion Hospital until after a total evaluation has been made also is wise. The system will get a solid evaluation before additional sums of money are spent to develop additional systems, This is a logical way to proceed. Finally, the applicants have recognized the need for a sound objective assessment of the value of the system in the patients at Mt. Zion Hospital. The results of that evaluation ought to be meaningful indeed, and ought to gi;e a firm basis for decisions concerning construction of additional units, modifications to be made in the units'and the benefits that might be expected from expansion to other hospitals. This plan for evaluation of the system as it was designed, takes care of objections that I voiced concerning the system. A complete study of all signals and alarms with emphasis on false alarms, failure to alarm and true alarms will establish whe ther the system can carry out what it was designed to do or whether changes in design approach are indicated. Since the system is unique and my concerns, were primarily theoretical, it certainly deserves a comprehensive trial, provided of course a complete evaluation is carried out. I think it very likely that such an evaluation will be carried out and therefore, I think it very appropriate that the program,continue as outlined- To recapitulate, I believe that the changes that have been made in this program since our site visit meet our objections and that therefore the program should be supported. as it now stands. Considering the manpower shortage and the potential value to community hospitals, if the trial at Mt. Zion proves strongly positive, I think this program should be supported at a high priority. I would very much appreciate personally if it is possible hearing ho%v this program evolves, whether it is supported and what the results of the evaluation are. Thanks for letting me review this application. If there are further remarks that you need from me, please let me know. Sincerely y J. @rancis Dammann, i'O. D Professor of Pediatrics and @omedical Engineering JF'D/vms (A Privileged Communication). SUMIA,RY OF REVIEtq AND CONOULUSION OF APRIL 1971 REVIE!@7 COMMITTEE CALIFORNIA REGIONAL MEDICAL PROGRAM RM 00019 5/71 SPECIAL ACTION #1 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL Project i@41 (Revision 2) - Area I - Patient Monitoring Recommendation:- Committee recommended approval of the proposal with no additional funds. Year steel Recommended $35,446 APT)rOvq i 02 36,178 Approval Total $71,624 (Dirc..,ct: Costs) k Bound: The Committee briefly reviewed the history of this proposal -- which began in 1969. It was reviewed on site in October 1969 and was recommended for return for revision because of several technical concerns Council concurred. The proposal was revised and resubmitted to the July 1970 review cycle at which time Council concurred with the recommendations at the ad hoc Cardiovascular Study Panel that the pro- posal required further revision. At that time the application was still believed to be unappr6vabl.e on technical grounds. ,iti ue: The revised proposal appeared to satisfy the specific concerns which had been relayed to the Region, Some,.discussion revolved on the point of the value of the evaluation effort RMPS is asked to -support. The original proposal included a budget approximating $260,000. The revised version requests only $35,4.46 mainly for personnel since Lockheed has agreed to assume the costs for instrumentation. The' reviewers felt that this joint industry - medical effort provides a solid,.practical basis for development 'and@@.thcit CCE-74P's proposal to evaluate the clinical usefulness of the system is an important aspect of the undertaking. Further, the reviewers &greed that the region's endorsement (RLIP label) for this system,is also important. Drs. Mitchell Spellman, Gerald Besson,, John Mitchell and Donald. Brayton were not present during the discussion of this Li- L) ,)plication. RMPS/GltB/4/26/71 REGIOINAL IEDICAL PRO"7P-AMS SERVICE CA',r,IFORNIA Regional Medica' Pro-ram RM 0001.01 5/71 (Special. auction #2) FOR CONSIDERATION BY APRIL 1971 REVIEW CO,@LIITTEE California RM 00019 "Cooperative Planning Effort of Regional Medical Programs and Model Cities for Training in the Allied Health Professions" This is a new program to be based in Core Staff activities in Area 1, San Francisco. It is an outgrowth of Regional Medical Program participation in health planning for the Richmond Model Cities Program. There are six Model Cities in Area I, and this request is made for support to explore solutions to the health service problems, particularly in the field of training of allied beal.th professionals. This is an 18-month proposal requesting $73,349 d-'@rect costs for the first year,and $39,333 direct costs for the remaining six months. GRB/4/19/71 SUMMARY OF REVIEW Xiilj '@'OiNCLUSION <)F- APRIL 1971 REVIEW COMMITTEE CALIFORNIA RECIONAI, MEDICAL PROGRAM RM 00019 5/71 SPECIAL ACTION #2 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL "Cooperative Planning Effort of Regional Medical Programs and Model Cities for Training in the Allied Health Professions" - Area I Recommendation: Committee recommended that the request be returned for revision with advice as enumerated below. Year Request Recommended 01 $ 73,349 -0- 02 39,333 -0- Total $112,682 Direct Costs -0- Critioue: The reviewers agreed that the proposal was a well written planning document, but that therein lay an overriding negative factor. The proposal represents a ni-Li effort while ,-he Model Cities endorsement fosters a@ action plan. There is no action target t0 be r6acbed in the 18-month plan. Committee believes the proposed program area of involvement is of high priority, and if the real "product" is the training of allied health professionals, then the methodology should be redirected--not to employ "Planners" but to develop steps of action to reach the people in the target districts. The Committee suggests that the Region arrange its own "site visit" method, drawing on regional consultative resourc6s such as Dr. Stanley S. Skillikorn in Area III (for his planning for health delivery improve- ments in th6.Cardner district of San.Jose), and Dr4 Mitchell Spellman in Area IX (for functional experience gained by the Drew Postgraduate Medical School planning). Hopefully, the-bext step can be a more affirmative action plan. There was consensus that the proposal would benefit by a "phased" approach. During phase one, staff would be hired, utilizing consultants, and initial cooperative arrangements should be firmed up. Phase two would involve careful review of the Task Force (site visit) recommenda- tions by CCRMP sta ff and RAG. Phase three would present the recommendations of the Task Force to the Model Cities Health Council and other appropriate agencies for action and implementation. Staff.Note: February 1971. Council approved the use of Developmental Component funds by the California RMP. The Region will submit a triennial application May 1, which will be reviewed by the July Committee and August Council.-- Drs. Mitchell Spellman, Gerald Besson, Joll-@i end Donald Brayton were not present during the discussion of -@lt@'s a-t-)pl@Lcation. REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENTAL GRANT APPLICATION (A Privileged Communication) IOWA REGIONAL MEDICAL PROGRAM @l 27-03 5/71 University of Iowa April 1971 Review Committee 308 Melrose Avenue Iowa City, Iowa PROGRAM COORDINATOR: Harry M. Weinberg, M.D. This application requests supplemental funds to support five new operational projects. The Region's Triennial application is due in August and will be reviewed by the October Committee and November Council. Requested (Direct Costs Only) Project # and Title 01 Year 02 Year 03 Year Total #17 -Laboratory Improve- $45,182 $ 35,337 $ 25,141 $105,660 ment Program #18-Minowa Continuing 45,200 45,192 46,275 136,667 Education 4kl9-Renal Failure Manage- 80,317 83,508 87,839 251,664 ment Training #20-Organ Procurement 48,920 35,272 36,719 120,911 a Preservation #21-Multimedia Nursing 108,737 35,500 22,500 166,737 Education Totals $328,356 $234,809 $218,474 $781,639 The last staff review in January 1971 noted that the region has made considerable progress in the following areas: The Core staff, for the first time since the inception of this Region is now fully staffed; the Regional Advisory Group which has been increased from 46 primary and alternate members to 76 primary and alternate members appears to be a truly regional cohesive group which shows great strength and ability in the Region's decision-making process and in providing guidance to the Region: and in the development of cooperative arrangements with Community hospitals, and the involvement of the various disciplines of the allied health professions, practicing physicians and the University of Iowa Clinical faculty in the planning and decisioh-making process of the IRMP. The operational activities are primarily in the heart and stroke areas. Staff recommended approval of the request for continued funding for the 03 year at the commited level of $651,417. However, due to 1 71 fisca contraints, the region will be funded in a reduced amount of $596,047 (d.c.o.) Iowa Regional Medical Program - 2 RM 27-03 FUNDING HISTORY PLANNING STAGE Grant Year Period Funded (d.c.o.1 01 12/l/66 - 1/31/68 (14 months) $214,000 02 11/30/68 (10 months) 213,000 OPERATIONAL STAGE 01 7/t/68 1/31/70 $455,000 02 2/l/70- 1/31/71 736,67.3 03 (Current Year) 2/l/71 -i2/31/72 (11 months) 596,047 Following is a listing of the 03 year funding status of Core and the Operational Projects in Iowa RMP: Project No. Title Amount Supported Thru 12/31/71 (d.6.o.) #1 Core $290,070 #2 & #3 Ventral Stroke Educa- tion and Stroke Management 134,930 #4 Training Program in Cardio- 3,985 Pulmonary Resuscitation #5 Coronary Care - Supervision Training for Physician & Nurses 65,712 #11 Pediatric Cardiology Training :51,400 Program #12 Cancer Educational Program 2,355 #13 Mobile Intensive Care Unit 37,460 #14 Cardiac Auscultation Training for Physicians 10,135 Total $596,047 Members of staff have learned that the amounts shown reflect the revised budgets for these components. The reduced amounts were approved by the Iowa Regional Advisory Group on February 28, 1971. It was also learned that project #4 and #12 will terminate as of April 1, 1971. It was further indicated that the Iowa Heart Association would assume full funding of project #4 at that time. Iowa Regional Medical Program - 3 - RM 27-03 5/71 SUMMARY OF NEW OPERATIONAL PROPOSALS Project #17 - Laboratory Improvement Program 01 02 03 Requesting 7/l/71-6/30/72 7/l/72-6/30/73 7/l/73-6/30/74 All Years Direct Costs $45,182 $35,337 $25,141 $105,660 The State Hygienic Laboratory through the Iowa RMP requests three-year funds for a program which has been funded through the Office of Compre- honsive Health Planning since February 1969. The program is designed to increase the general level of competency of clinical laboratories in the Iowa Region. The ultimate goal is to improve health care delivery at a local level by a comprehensive continuing education program for clinical laboratory personnel within the districts and sub-districts of the Iowa Region and to have available to all Iowans, adequate, accurate and totally capable clinical laboratory practices regardless of the size on geographic location of their local facility. The specific aims of the proposal are: (1) To determine the quality of performance of laboratories in the Iowa Region by ,tilization of national and local proficiency testing programs. (2) To improve the quality of laboratory services through a comprehensive continuing education program with the cooperation of the Iowa Association of Pathologists. (3) To assist participating facilities to provide standardized equivalent laboratory services to all disciplines. (4) To provide consultation services to laboratories in the Iowa Region. In addition to the State Hygienic Laboratory, the Iowa Association of Pathologists, the University College of Medicine, the Iowa State Health Department and participating Community hospitalsare involved in this activity. Project #18 - Areawide Continuing Education for Health Care Personnel in the Minowa Health Planning Area 01 02 03 Requesting 7/l/71-6/30/72 7/l/72-6/30/73 7/l/73-6/30/74 All Years Direct Costs $45,200 $45,192 $46,275 $136,667 Iowa Regional Medical Program 4 This proposal is an outgrowth of interest among six Northeast Iowa counties to coordinate efforts to supply a continuing medical and health science educational program for health care personnel of their combined areas. The project is designed to demonstrate the feasibility of such an undertaking in a rural environment, where the accessibility and adequacy of continuing medical education currently fall far short. of satisfying the needs of health care personnel. The project proposes to: (1) identify and improve continuing edtica- tion programs for physicians and allied health care personnel; (2)- identify unmet and fill needs for continuing education; and (3)' com- bine or link together hospital and other related'agency or community programs. The continuing education programs planned under this pro- posal will be primarily for the counties of Howard, Winneshiek, Allamakee, Chickasaw,Clayton and Fayette; however, perso=el from contiguous counties in Iowa, Wisconsin or Minnesota will, :Lf interested, be permitted to participate in any of the activities. The project will be based at the Area.l.,Vocational-Technical School at Calmr in Winneshiek County. Other agencies involved in the devel- clude the-Mi'owa Area Health opment and implementation of the program in , n Planning Council, The University of Iowa College of Madigtne, the Mayo Clinic, the Adolf Gundersen Medical Foundatim ila Wiscoiii-in and four hospitals in the six-county area. The Minowa AreaHealth,3?lan'ning Council will provide overall direction of the project through a 12-member steering committee who will act in an advisory capacity in surveying the medical community to determine the educational needs, setting priorities and developing curricula. The University of Iowa College of Medicine, the Mayo-Cltftic, the Adolf Gundersen Medical Foundation will provide teaching personnel and consultative s.ervices, the latter being utilized in establishing priorities and developing curricula. The four hospitals have agreed to place the coordination of their in-service programs under the project. A Project Director will be employed. Local funding of this project will be accomplis hed by progression (over a three-year period) in the tuition charged to participants involved in the program and through charges imposed on the hospitals for coordination and provision of in-service training. It is expected that many of the on-going programs can be incorporated with the Community College structure and financed by tuition charges and school tax funds. #19 - Renal Failure ManaRement Training 01 0 2 0 3 stin _,,--771/ 1-6/30/72 7/ /72-6/30/73 7/l/73-6/30/74 All years Direct Costs IltoO,317 $83,508 $87,839 $251,664 Iowa Regional Medical Program - 5 - RM 27-03 5/71 This proposal represents part of a cooperative effort of a number of ncies in Iowa to organize an effective plan for the care of the tient with utemia. Involved in this development are the University ical Center-including the University of Iowa, University Hospitals, and the VA Hospital and the Regional Medical Program; a number of communities of the State; insurance underwriters; voluntary health agencies; the Legisldture; the State Department of Health; and many private citizens. The specific aims of the project are: 1) To provide practicing physicians a course of intensive study in clinical nephrology. The course will vary from one week to six months. A total of twenty (20) physicians are expected annually in the one- week course and two physicians for one month or longer. Participants will be capable of improving the general level of care of patients with renal disease and hypertension. With adequate support they would be able to manage small dialysis centers, stations for home dialysis supervision and instruction, and units where cadaveric kidneys might be retrieved. 2) To train nurses to staff areawide nephrology units (satellite centers). Two types of educational programs will be offered. The first, which will be four weeks in length, will be a basic indepth educational pro- gram to prepare nurses to care for patients receiving hemodialysis to supervise other nursing personnel. ,rty (30) nurses will be trained in the preparatory hemodialysis pro- gram in the first year; twenty-four (24) in the second year and eighteen (18) in the third. Ten (10) nurses will receive training in the devel- opment and administration of a hemodialysis training program during the first year and twenty (20) will be trained in the program to deal with home dialysis and the care of the patient with renal hotwtransplant. A second educational program -consisting of workshops will provide con- tinued development of nurses in the community involved in caring for patients on dialysis or those who have been transplanted. 3) To establish workshops for technicians, social workers, dietitians and public health nurses to orient them to special problems presented by patients with renal disease. Annual workshops will be held at the University of Iowa Medical Center for this group and at least one visit will be made annually to each of the satellite centers by members of this group to observe problems associated with the sate te cen ers, suggest solutions and promote communications within the system. Some of the programs will be interrelated with those of physicians and nurses, but special problems in each group will be dealt with separately. The applicant is requesting a total of $13,389 for stipends to be paid to those physicians attending the program for intermediate periods of from one to six months. The stipends will be paid on a monthly basis. .1-owa Regional Medical Yrogram #20 - A Program of Human Organ Procurement and Preservation for use in Clinical Transplantation 01 02 03 Requesting 7/l/71-6/30/72 7/l/72-6/30/73 7/l/71-6/30/74 All years $48,920 $35,272 $36,719 $120,911 The overall goal of this proposal is to better utilize existing sources ,of organ donors in order to make renal dialysis and transplantation available to more uremic patients in the Iowa Region. Sponsored by the University of Iowa-Veterans Administration Hospital Renal Program, the major objectives of this proposal are: 1) to train organ preservation technician by two months on-the-job training; 2) to develop for clinical use an improved system of organ preservation by continuous cold perfusion; 3) to organize within community hospitals (five initially) cadaver organ recovery teams of physicians and nurses, thereby maximizing organ recovery potential, this will be coordinated with Project #19; 4) to,extend cooperation to other regions, continentwide, in order to exchange and evaluate a greater number of well-matched, viable organs.. The IRMP will also assist the Kidney Foundation in launching a campaign to stimulate public understanding of the need for organ donors. The evaluation activities will be in collaboration with those described in the preceding proposal "A Program to Train Physicians and Nurses if - in Renal Failure Management. The inte relationship of these two pro- 'Posals and their co ined impact on renal disease in the Iowa Region is tied to an increased capacity to perform transplants in Iowa. The applicant has requested operational funds for a total of three years. However, as the program develops in clinical service, income will be generated and will be applied to the costs of continued opera- tion of the program. The extent to which the proposal will be able to support itself will depend on the number of organs recovered and transplanted each year. The applicant states that a bill has been introduced in the Iowa General Assembly that proposed a fund to assist Iowa residents in the payment of medical bills arising from human organ transplants and if approved, will enable this activity to become self- supporting. Iowa Regional Medical Program 7 - #21 - Multi-media Nursing Education oi 02 03 RettgestLI 711/71-6/30/72 7/l/72-6/30/73 7/l/73-6/30/74 All Years Direct Costs $108,737 $35,500 $22,500 $166,737 The Iowa Hospital, in cooperation with the Department of Nursing, Marycreat College, Davenport, the Department of Nursing, the Mercy Hospital, Iowa City and the Audiovisual Center of the University of Iowa proposes to upgrade nursing care in the Iowa Region by utilizing a self-instructional multi-media program of continuing nursing education. The proposal addresses itself to health care facilities providing nursing care for patients with cancer, heart disease, and stroke during all phases of their illness. These include general hospitals, extended care and convalescent care facilities, nursing homes and outpatient clinic. The program has as its target population, the Registered Nurse. The specific aims of the project Are to: 1) develop a programed course manual and multi@dia materials to be used in a self- instructional continuing nursing education program; 2) demonstration in five community hospitals thp- feasibility c the programmed, self-instructional multl-mdia par-kage'for continuing nursing education;, 3) evaluate the program continually in order that the,program format and-coutent may be adopted to changing needs And demands; 4) make available to health care institutions and and 4@ies itt the Iowa Region a self-instructiorlal multi-media prograt% of Vtttltxuing nursipg -.education and; 5) evaluate the im- pact of the liroject vitirei-ng attitude and behavior in the Iowa Region. #omo of ttle expected advantages of this approach are that it willoprmit each hospital or health facility, regardless of size or location to update the knowledge of its nurse prac- titioters 4i@4out sending them away and losing their services for va;:ying@@eriods of time. It reduces the cost of carrying on an effective continuing education program, because it elim- inates the use of live teachers to keep repeating a program. Additionally, it will allow an inservice educator to use her time more productively and it will encourage recruitment of inactive nurses back into nursing by offering them an opportunity to up- date their skills at their own pace. The applicant states that the proposal will become self-supporting after RMP funding has been terminated. RMPS/GRB/3/16/71 (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW COMMITTEE IOWA REGIONAL MEDICAL PROGRAM RM 00027-03 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL 'RECOW@ENDATION:. The Review Committee recommends that no additional funds be provided for this,application. The Ad Hoc Renal Panel, on the other band, believed one of the two Renal proposals, which were a part of the application, was funda le at a reduced level. DIRECT COSTS ONLY YEAR REQUEST RECOMMENDED lst year $328,356 - 0 2-nd year 234,809 - 0 3rd year 218,474 TOTAL $781,639 0 I UE: The reviewers noted that the Iowa Regional Medical Program will submit its Triennial application for October/November 1971 Review Corri-,i--.ttee and Council. The Review Committee was in agree- ment that the Iowa P@IP has a dynamic program and the five proposed activities, although lacking innovation, are essentially excellent projects. However, both the primary and secondary reviewers were con- cerned that the proposals are not congruent w@th the emerging goals and 6b .ectives of Regional Medical Program Services, as described i in the Ptesident's Health and Budget Messages, and that providing funds to support these activities would not be a priority use of RMP uil s. Some of the Committee felt that disapproval of the projects was anti- thetic to the concept of decentralization and 1(.cal goal.-setti.ng. In teaching a recommendation, eleven (li-) of the reviewers were in agreement, -while three (3) members opposed and one (1) member abstained. Iowa RMP 2 RM 27@03 5/71' Renal Projects During its review of this application the Committee did not have the benefit of the recommendations of the Ad.Hoc Panel on Renal Disease which met concurrently with the National Review Committee-. 'fhe Ad,Hoc Panel on Renal Disease believed that Project #20 A Program of Human Organ Procurement and Preservation for use in Clinical Ttdns- plantation wastechnically sound and worthy of support at a reduced total -jamount of $43,500 for the lst year. Specifically, the Panel believed reductions were warranted in the categories of personnel, consultant services, supplies and equipment. Regarding the 2nd and 3rd years of support, the Panel believed that actual funding would have to be determined by the progress made during the lst year of the project. #19,- A Proposal to Train Physicians and Nurses in Renal Failure @na e ment. The Panel did not believe that this project should be supported. The proposal appears to be a poorly conceived effort to provide support for the training of renal fellows which is not appropriate under RMPS policy. Further, thd Pan-el suggested that the Region may wish to direct its efforts in the area of the development of home dialysis training programs* Miss Kerr was not present during the Committee discussion or action on@thig application. R@IPS/GRB 4/23/71 KANSAS SUMMARY Table of Contents P. Fiscal Information Geography and Demography p. 5 p. 5 Regional Development p. 8 Organizational Structure and Processes P. 8 Regional Objectives P. 9 Developmental Component P. 10 Application Core P. 10 Continuation Projects p. 12 Renewal Projects p. 12 p. 14 Approved but Unfunded Projects Supplemental Projects p. 16 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) KANSAS REGIONAL MEDICAL PROGRAM Rm 00002-05, 5/71 3909 Eaton Street April 1971 Review Committee Kansas City, Kansas 66103 Program Coordinator: Robert W. Brown, M.D. This region is currently funded at $1,633,600.,(direct costs) for its third operational year (which is an,ll-month period) ending June 30, 1971. It gubmiti a triennium application that proposes: I -A Developmental Component 11 -The continuation of Core and 2 ongoing activities III -The activation of 4 Council approved but unfunded ctivities IV -@e renewal of 6 activities V -The implementation of 1 new activity vi -The termination of 2 activities The Region requests $2,244,073 for its fifth year of operation, $2,158,176 for the sixth year, and $2,503,999 for its seventh year. A breakout chart identifying the components for each of the three years follows. A site visit it planned for this region, and staff's preliminary review of the application has identified several issues for the site visit teamis. consideration. These are also covered briefly in this summary. FUNDING.HISTORY Planning Grant Year Period Funded d. c. 0. 01 7/l/66 - 6/30/67 $1.80,520 02 7/l/67 - 5/31/68 205,891 Operation o ram Grant Year Period Funded (d.c.o.) 01 6/l/67 - 5/31 /68- $ 592,248 02 6/l/68 - 5131/69 1.1644,819 03 6/l/69 - 7/31/70 2,096,926 (14 mos.) 04 8/l/70 - 6130/71 1,633,600 (11 mos.) 05 Future Commitment 1,353,159 06 Future Commitment liO25,702 I 000@2 5 /71 CYCLZ (Tr4@enniu- 6'; .1 DEVFLOP@TAL 'T o@ COLMPONE'@\ 410 1 171 !C Eilucational Proqra-ls 1 @6.11 !$I @9,574 #IR- Great Benci - 47 175,n 136,441 @#4 Cardiovascular N O' 50,056 I(?,526 lq,526 CE for Car,lioc Cnre 1 74 9,864 41,938 32,074 OR Nurse RetrAining r 0. 3 50,288 3?,345 11,94 Nurse Training 345 683 68,961 1,683 7,278 #23R medical Library Svst., 6 6 3 12,000 1,599 13,599 12,000 I institute for Dietitians ---- i 6,415 -0- 6,415 Med, Record Clerks CZ 6,415 $133,673 133,678 23,933 157.611 -740 Comprehen. Neplro 82,803 82,803 19.671 102.474 is4l Cancer Info. Center 64.262 8,692 2,954 64,262- :#42 cE Cancer Care 98 125.212 12,786 137,9 125,212 -- --- @,44 Nurse Clinician -0- 37.290@ $3.7,290 37,290 #45 Model Cities $1,314,266 $323,202 .$405,955 $200,650 $2,244,073 $506,504 $2,750,577 Ri;Gic@@ KAN'SAS R,-i ('LIUUZ @171 (:6 PZ'P@ICD T ieni..) c -AG $201.134 2 $ 201.134 -0- 21 134 @@L 0 ool- 1.744,28 i 10,44-6 35,514: 145.960 $110,446 #4 #-8R @9R #21R 68,846 5.,481 74,327 68.846 #23R #32R #38 108,081 .26,078 134,159 #40 $108,081 88,358 88,158 1 21,435 109,793 #41 70,957 70,957 13,238 84,195 -142 - - 136.116 122,183 13,933 122,183 A44 37,290 37,290 37,290 -f 45 @$2,667,255 $1,350,881 $179i292 $389,579 $238,424 $2,158,176 $50@,,079 2q fA 07 5171 RM 00002 599 .122 DE@IEL. $234,628 -0- i ii4.142.374 5.336,860 1,620,083 $ 475, CORE 1$1,6200083 47 17@ 37..338 154 3@ 367 35 1171,015, i'IR 1015 136,441 175.088 #4 ii 39.526 50,056 i-8R i 3 2 4 41,938 #9R LO74 50,288 '38 145 -42IR 87.226@ 211.125 80,596 80 30 230,514 #23R 13,599 12.000 #32R ---- --- 6,@5 6,415 #38 4,7461 43,161@ 35 @34IL3@' #40 114,746 28,415: !L 5@ 35 101,314 1 101 3141 23,354 124.668@ 272,475 6-935 441 #@2 2,1721 13,695 85,867@ 2-07,,391 243,01 6,155i 15,180 14i,335@ 373,550 415@449 -v444 -.0- 37,290@ 111,870 111,870 #45 '$S,,522.2.98 $271 918 '$2,503,999, $600,467 -.43,104pa@ 906,248 $6 O',-" A-, 3 $197,-611 $414,357 $1,620;08 -5- Rm 00002 5/71 Kansas RMP Geography and Demograph -y The Kansas RMP boundary is the Statels. A population of 2,200,000 is contained in the 82,000 square-mile area. The Region is primarily rural; its two largest cities are Kansas City and Wichita. The Kansas @ shares boundaries. with the Nebraska, Colorado-Wyoming, Oklahoma and Missouri RMP'S. The relationship with the Missouri RMP's activities in Kansas City, Missouri, as well as the medical care flow patterns between the two political units, have been difficult to determine and appear to fluctuate from year to year. A liaison committee to coordinate the operations of the two RMP's in Kansas City was established several years ago, but neither M4P mentions it in their present applications. The state of Kansas has one medical school - the University of Kansas and 34 schools of nursing, including diploma, associate degree and L.P.N. schools. There are also 61 schools of allied health. Kansas is served by 2,218 pr acticing physicians (there are 2,442 M.D.'s in the state), 184 doctors of osteopathy, and 8,323 active nurses (there are 11,001 R.N.'s). There are 173 hospitals in the state; of these, 15 are state, military or V.A. Regional Development RNP planning in Kansas began with a Governor-appointed Commission who selected a Regional Advisory Group and named Dr. Mills as Coordinator. The planning grant was awarded in July 1966. During the first operational year Dr. Charles Lewis was appointed permanent Coordinator and a site visit was held. Both reviewers of the early planning application and site visitors commented on the close ties of the RMP with the medical school. The medical school served as both the grantee agency and fiscal agent, representatives of the medical school served as RAG Chair- man and in charge of important core functions, and early efforts in continuing education activities appeared to be a continuation of already existing activities of the medical school. Conversely, representation on the RAG and involvement in the program of community interests, minority groups and other agencies needed-to be expanded and strengthened This Region was one of the first to submit an operational program. The Region received funds for projects in April 1967. One of the first approved projects was the Great Bend Educational Program, which was to serve as a model for developing continuing education programs to attract and keep health care personnel in the rural and small town areas, developing linkages to provide better care to peripheral elements and increasing the overall capacity of providing care. The projecti supported since June 1967, requests an additional three years of support in this application. Other projects approved during the first operation year included: #2 - Reactivating Nurses (Great Bend) #3 - Circuit Course for Active Nurses ff i fr@04"4n& RM 00002 5/71 Kansas RMP -6- #5 - Cancer Detection #61- Physical and occupational Workshops #7 - Cardiovascular Work Evaluation All but Project #4 have been terminated. During the second and third years a large number of continuing.,education courses for physicians, nurses and allied health personnel were submitted and approved. The,following is a listing of the activities and their present status: #8 - Continuing Education for Cardiac Care Renewing #9 - Metropolitan Kansas City Nurse Retraining Program Renewing #10 - Healtb'Dats Bank Terminated #11 - Self-Instruction Centers Termin ated #12 - Training Program for Cancer of the Gastrointestinal Tract Withdrawn #14 - Perceptual Motor Dysfunction Assesment and Treatment Terminated #15 - Physical Therapy Workshop Terminated #16-- Therapeutic Nutrition Terminated #17 - Cancer Chemotherapy Seminar Terminated #20 - Continuing Education Program for Occupational Therapists Terminated #21 Cerebrovascular and Neurological Nurse Training Renewing #23 Kansas Medical Library System Renewing #24 Food Service Personnel Using the Dietary Consultant Approach Terminated #25 Coordinated System for the Continuing Education of Medical and Paramedical Transferred Personnel to Core #26 - Cancer-Care Continuing Education Program Terminated #28 - Seminar on Basic Medical Librarianship Terminated #29 - Kansas City Council on Health Careers Manpower Recruitment Program Approved but Unfunded #32 Institute for Dieticians Renewing While these projects seemed to have developed to solve rather specific problems in the allied health and continuing education areas, the reviewers believed there appeared to be an increasing need at the regional level for Committees or Task Forces in continuing education and allied health. During the second and third operational year,'the KRMP began the build-up of the tubregional offices. Kansas has nine subregions which correspond geographically to CHP regions. Great Bend and Wichita were the-first two to be staffed. Topeka, Colby and Emporia followed in 1969. Full subregional staffing was completed in 1970 with the addition of Garden City, Salina, Kansas City and Chanute (see attached map). Kansas RMP -7- RM 00002 5/71 A site visit was held January 1969 to learn more about the regionalization process, the relationship of projects to the regional plan and to gain more information about the decision-making and priority-setting process. The team reported that: 1) significant progress had been made in subregionaliz- ation, although there was not general agreement in the Region as to what the concept would be; 2) as far as the team could determine, the projects fitted into a regional plan; 3) objectives were very general and not measur- able and it was difficult to determine that priorities had been established. In February 1969, Dr. Robert Brown, Director of the.Great Bend project, succeeded Dr. Lewis as Coordinator. With Dr. Lewis' resignation, the hypertension earmark project, #19, which he directed, was discontinued. Projects submitted and reviewed since May 1969 include the following: #33 - Nursing in Long Term Illness Disapproved #34 - Basic C6ntinuing Education Program in Community Health Nursing Returned for Revision #35 - Basic Education Program for Medical Clerks in Kansas Hospitals Returned for Revision #36 - Short Course in Instrumentation for Medical Technologists Returned for Revision #37 - Care of Patients with Fluid Electroiyte and Renal Problems Funded #38 - Revision of Project it35 Funded #39 - Demonstration Project to Improve Community Chronic Ilinets Care Return for Revision #40 - Comprehensive Nephrology Training Program Deferred #41 Cancer Information Service Approved but Unfunded #42 Cancer Care Continuing E ucat on Program Approved but Unfunded #43 Model Rehabilitation Project Funded by Rebudgeting #44 Nurse Clinician Program Approved but Unfunded The approved but unfunded projects are included in the Triennial Application for further funding consideration. In these later applications the Region's program emphasis continued to be continuing education and its program implementation to reflect a one-by-ont approach to education and training. In addition, nursing input in t e development of curriculum or in project evaluation in nurse training project$ was lacking, as was evid6nce of coordination between various professions involved in a single project. At the review of the last continuation. application in July 1970, staff raised the following issues: 1. The difficulty in determining the RAG's contribution in policy- making and goal setting; 2. The need for measuring the impact the projects make in the institution and health care patterns, as,well as for more overall program evaluation; I RM 00002 5/71 Kansas RMP 3. The need for a-regional strategy in allied health and continuing education; and 4. The need for greater core staff assistance from the central and subregional levels to the projects in such areas as formulating education design. Organizational Structure and Processes The Kansas RMP has a 20-member Regional Advisory Group, which includes five- consumer representatives. The RAG sets priorities, reviews ongoing operations, core staff activities and the activities of the Committees, Boards and subregional councils. The RAG is served by the following committees: Executive Committee Continuing Education Unit Policy Board Lead Committee on Cardiovascular Disease and Rehabilitation Lead Committee on Cancer Renal Dialysis Medical Advisory Committee Renal Dialysis Advisory Council RAG Committee on the Annual Report The specialized committees listed above exist to study problems and offer technical advice on policy in tbeir respective area of ex ertise. They do p not participate in the review process. In addition to these groups, there are nine Local Advisory Groups, whose membership is representative of consumers and most of the health interests in each of the subregions. They serve in an advisory capacity to the Coordinator on matters concerning the health needs, problems and priorities and review project applications submitted from their subregion. The present review process provides for an assessment by core, the sub- regional advisory groups and the RAG. Although review by ad hoc technical groups is shown in the review process proposed in November 1970, the Coordinator has stated that these are not yet operational. A schematic of the proposed review process is attached to the summary. REGIONAL OBJECTIVES The Kansas RNP has developed the following overall goals for 1971.- 1. To strengthen existing cooperative arrangements to improve health care and to establish new ones. 2. To improve health professional performance and thereby patient care through effective continuing education. 3. To study and modify favorably the factors which influence distribution of health professionals and service. Rm 00002 5/71 Kansas RMP 4. To provide special training opportunities for new or relatively underdeveloped health professionals. 5. To evaluate components of the health care system and to support elements which rationally might increase quality, capacity or accessibility. 6. To improve communications, facilities, equipment and techniques related to the use of these. 7. To improve effects of the program in the Region. The Kansas RMP states that it exists to improve the quality and availability of health services to people within the Region. Functioning within the framework of regional cooperative arrangements, the program has designed planning and operational components which "create an environment favorable for recruitment of critical health professions and assure these professionals career satisfaction aad prominence in their locations" in each subregion. DEVELOPMENTAL COMPONENT First Year Second Year Third Year $163,360 $201,134 $234,628 Developmental activities,described in the application are largely extensions of ongoing Core activities and are generally related to the Regi6n's seven I objectives. More specifically, the Region plans for use of the developmental component funds include the following: Data Requirements - For the past three years, KRMP hat been co- sponsoring and jointly funding with CHP a study.t6 provide a broad data base for planning purposes, and the Health Manpower Information. Further development is plann6d for cooperative studies relating to health manpower, personal health services, and facilities. Manpower Training and Continuing Education - the Region has established working arrangements with both UKMS and the Wichita State University College of Health Related Professions (CHRP). a. Regarding the first, emphasis has been placed on the development of affiliated health education and resource centers as part of regionalization efforts. Developmental activities, involving a potentially large number of medical communities seeking affiliation, will consist of extensive planning, initiation of education programs, communications support systems, and related activities. Kansas -10- RM 00002 5/71 b. The working relationship with WSU will concentrate on development of an expanded role for the CHRP in planning and implementing education programs which are coordinated, multi-institutional, formal and continuing education programs for@health-related professions, and in analysis of present projected curricula. c, Closely associated with the WSU effort, the Kansas Hospital Association and KRMP are cooperating in the development of a Personnel Development Program involving,"inservice" programmed education in Kansas Hospitals for related health professionals, pre-professionals and other hospital personnel. Community Programs - Two community-oriented activities of the KUMC Department of Human Ecology are of particular developmental interest to the Region: a. A KRMP proposal to assist in defining a health care plan for the immediate area to improve accessibility. b. A medical student preceptorship program to facilitate movement of students between institutions. Four-level System of Medical Care - In June 1970, the Kansas Medical Society passed a-resolution proposing a special study and recommending approval'in principle of a four-level system of medical care suggested by the editor of the Salina Journal, Salina, Kansas, at the 1969 State Medical Meeting. The system would consist of: 1) routine, immediate care in smal I towns by "superior nurses, o erating@under the direction of a p physician; 2) physicians practicing in larger towns in cooperation with nurses.in small.,towns, and skilled nursing homes; 3) physicians (including specialists) in regional centers with fully equipped hospitals, laboratories and nursing homes;. and 4) a broad range of facilities and specialists as at Wichita and KUMC, interlocked with with State institutions and the Research center. The Region views the study of such a four-level system as providing many Areas for mutually usefull activities by KMS and KRMP which could be funded through a developmental- componet. ,Administrative Procedures for Allocating Developmental Component Funds Contracts will be executed on approval of the entire RAG, and expenditures approved by the Director or his designee. PRES@- APPLICATION Requested Fifth Year Core $I,,171,410 DL.ring the Dast year, the core function has been reorganized to consolidate - . --- ---I -- corn nf t-'hp Atibrpgional offices from projects Kansas RMP RM 00002 5/71 to core. It now has six central sections and nine subregional offices. The central core offices, coordinated by the Office of the Director, include to following: 1. Office for Institutions and Administration - provides liaison between the central staff and nine subregions and develops working relationships with the Kansas Hospital Association and health-related institutions. 2. Office of Continuing Education - provides assistance in planning continuing education policies and strategy, in cooperation with the Continuing Education Planning Committee and Continuing Education Policy Board. 3. Office of Nursing - stimulates educational programs for nurses, both at the local and university level. 4. Office for Related Health Professions - develops at the regional lev( pilot activities, feasibility.studies and educationsi@@iog-rams and at the subregional le in-dev'eloping pr-ojects anJ vel assists locally planned educational activities in the related health professions. 5. Office of Research And Evaluation -.develops models of evaluation for project directors and a planning and evaluation strategy to permit program assessment. The Office of Health Manpower Information Program, with responsibility for data collection and analyses, is also included in this Evaluation sect on. 6. Office of Special Services - provide data processing and communications services for the Region. There are subtegional offices located in these nine locations - Kanias City, Emporia, Wichita, Great Bend, Topeka, Chanute, Colby, Garden City and Salina. Geographically KRMPle subregions relate closely to CHP subregions. Several of these core functions were formerly funded as projects and have been brought into Core auspices during the post year. The personnel in the subregional offices work with both the Planning and operational activities And serve as executive secretaries to the Local Advisory Groups. Core staff has sponsored a number of feasibility studies and joint planning efforts with other agencies. Examples@ of these cooperat ve efforts include studii conducted withthe Wichita State University College of Health Related,Professions, with the Kansas Hospital Association, and with CHP. A complete listing occurs between pages 98-127. There are 66 (61 full-time equivalents) positions budgeted for 1971-72; all but one are filled. This number includes 18 professionals and 28 secretarial positions. Sev nth Year Sl.yth Year $1,350,881 $1,620,083 -12- RM 00002 5/71 Kansas Continuation ects Continu equested for the following two pr jects: ation support is r 0 ues e@d Project #4 - cIardiovascular Nurse Training $136,441 Support is requested to continue a unified in-service training program for'nurses in providing care to acute cardiac patients in coronary and intensive care units. The program has trained over 100 nurses to date in six-week courses on electrocardiography, cardiopulmonary resuscitation and pharmacology of cardiac drugs. A physicians' course will be offered in the spring of 1971, both to update physician knowledge and to overcome the problem of lack of confidence in KRNP-trainied coronary care nurses. The Region ranks this project tenth. it is directed towards goal 2 (improving professional performance). sted Pro ect #38 - Basic Continuing Education for Medical Record $6,415 Clerks. Funding would support a 3-month continuation ,period to allow extension of consultative visits beyond the present funding period for this project. Purpose of the project is to present -a basic training program in medical record science to personnel in statewide hospitals who lack, or are unable to have, more formal training. Consultative visits are designed to evaluate on-the-job performance of librarians after training. Forty-two trainees participated in the first session, with post-test score$ indicating a 42% knowledge increase. Second and third sessions were scheduled for January and April 1971, with similar objectives and format. The Region ranks this project #12. It is directed toward goal 2 (improvement of performance). Ren cts The Region requests additional years of support for'these six projects: Requested Project #lR - Great Bend Educational Program Site visit, Committee and Council action are required to extend support of this project for two additional years. The project which has been operational since 1.967 requests support to continue development of this comprehensive, subregional, model education center affiliated with the University of Kansas Medical Center. The Center provides physician education, nurse retraining and allied health continuing education. Proposed activities will continue with some change in emphasis, including a shift toward incorporation of linkages within the subregion and evaluation tion with the resources of the central Core of the overall program in coopera staff'. This project is ranked first by KRMP since it addresses all seven of the Region's revised goals. It has resultbd in a contract between Kansas University and central Kansas medical centers and working arrangements among Kansas RMP -13- RM 00002 5/71 a variety of subregional institutions to carry out cooperative arrangements; improved technological and related health professional support for physicians; reduced previous restraints to shared practice; improved recruitment of physicians to the central Kansas area; and reactivated many nurses through the reorientation course. The project has, through reassessment of delivery methods, increased both capacity --- with the development of home health care services --- and quality of care through initiation of improved programs of care. There has also been installation of communications, teaching and computer aids. Finally, the project allows for experimentation and evaluation of its activities. Sixth Year Seventh Year $110,446 $1,17,015 Requested Project #8R - Continuing Education for Cardiac Care - Wichita $39,526- Funds will continue the support of a unified training course for nurses providing care of acute cardiac patients in coronary and intensive care units, and to provide continuing education for physicians. To date, 265 nurses have completed the two-week's training, and more than 100 physicians have participated in the two continuing education courses. The Re gion ranks this project #ii. It is directed towards goals 2 and I (improving professional performance and strengthening cooperative arrangements). Requested Project #9R - Metr( nsas City turse Retraining $320074 (Reorientation to Clinical Nursing Project) Support is requested to continue an interregional program of retraining or updating nurses for reactivation in the Metropolitan Kansas City area. To date, 133 have been trained. Of the first 84 participants, 747. were working 12 months after course attendance. The 17 participating hospitals have indicated interest in continuing the program and capability for assuming responsibility after July 1, 1971. The Region ranks this project #9. It has provided spin-off in the form of instruction to teachers in outlying communities. The project is directed towards goals 2, 3 and I (improving performance modification of factors influencing distribution of professionals, and strengthening of cooperative arrangements). Requested Project #21R - Cerebrovascular and Neurological Nurse Training @:36,.j45 Funds will continue support of a program providing intensive training to prepare clinical@ nurse specialists in the area of cerebrovagcular and neurological disease and trauma, and provide other short-term training for upgrading nursing competencies. Six enrollees have been trained to date to expand response and enrollment. The proponents wish to shorten the clinician course from 4 to 3 months, provide a variety of related courses varying in length and objectives, target the project towards other health professionals, and publicize the program to reach a larger audience. The spring and summer of 1971. would be used to plan retargeting of the program to reach nurses in all of the mid-continent states. Irv,@ vocinn ranks this project #14. Kansas RMP -14- RM 00002 5/71 Requested Third Year Project #23R-Kansas Medical Library System $61,1-681 Similar action is required for this three-year request. Future support is asked to continue development of this system - of medical library service designed to provide ready accessibility to health professionals. Additional activities proposed include: education of library personnel with limited experience initiation of quality control of library services, completion of @he revision of KUMC film catalog, publication and distribution of 1,000 medical bibliographies to medical librarians statewide, and the securing of future financial and administrative support for the library system in view of eventual KRMP funding termination. This project is ranked third by the region, relating to goals 1,2, and 6 (strengthening coop- erative arrangements, improving performance, and improving communications). Fourth Year: $68,846 Fifth Year: $80,596 Eeguested Project #32R-Institute for Dieticians. $12,000 Support is requested to continue this two-part training program, sponsored by the Kansas State University, which is designed to update knowledge of therapeutic dieticians currently employed and reorient inactive dieticians; The program offers a 'one-week institute in therapeutic nutrition and a second one-week institute in Dietary Department Management. The summer 1970 session trained 21 in the first course and 17 in the second. Both will be offered again in 19-71 with no basic changes in format or methodology. The Region ranks this project #13. It is directed towards goal 2 (improvement of performance). Approved but Unfunded Projects Projects.#40 - 44 were previously reviewed by Council in November 1970. No action was taken on Project #40 until the Council had an opportunity to review the Kansas RMP Anniversary Review application and site visit findings. Projects #41, 42, and 4 4 were approved, but due to national funding constraints could not be funded. Committee and Council action on these three is needed in determining a funding level for the next year and not for approval of the activities. Project #40 - Development of a Comprehensive Nephrology Program Requested First Year $133,678 Action on this project was deferred to a later Council so that the site visitors could review the proposal in light of the total KRMP -15 RM 00002 5/71 Kansas RMP program and statewide efforts in kidney disease. The Region has just terminated a renal disease training program, Project #37, Care of Patients4 with Fluid, Electrolyte and Renal Problems. The Region is presently negotiating with the Missouri and Bi-State RMP,'s to develop a multi- regional renal program appropriate for 910 funding (p.166) for sub- mission March 1, 1971. This project, IP40, would be implemented in three phases. In the first phase,, a six-week training course in center-based (or back- up unit) dialysis for communit- hospital nurses and technicians will . y be developed and implemented, and a series of courses for physicians will be developed to update knowledge of renal care and improve inter- action of physicians and nurse nephrologists. Existing KUMC facilities will be expanded for all training. In the second phase, physician . I training will be implemented and training of Nurse Nephrologists begun. Hospital administrators will also begin training in both funding of treatment and accounting procedures. In the third phase,'With planning already completed for coordinated renal prevention, detection and treatment, Nurse Nephrologists will be introduced into the care system. Future sponsorship for the project will also be arranged at this time. This project is ranked seventh by the region,.and is directed toward goals 4, 3 and 2 (training of new and underdeveloped health professionals, modification of factors influencing distribution of health professionals, and improvement of professional performance). Second Year: $108,081 Third Year: $li4,746 Requested Project #41 - Cancer Information Service $82,803 This project would establish a uniform and complete computerized central cancer registry to replace costly manual systems now supported by only a few hospitals in the State. Support of par- ticipating hospital registries will requirp education of medical records personnel and periodic auditing of abstracts in the hospitals by a traveling medical record librarian or expert cancer registry secretary. Other activities will include: provision of cancer con- sultation service, study of the value of a newsletter in disseminating information on available registry data, education and computer-aided instruction, study of the value of a central registry and a tissue section repository, and A p ilot study on means of extending cancer education in Kansas. The Region ranks this project fourth. It is directed towards goals 1, 2,.and 6 (strengthening cooperative arrangements, improvement of professional performance, and im rovement of communications facilities, I p equipment and related techniques). Second Year: $88,358 Third Year: $101,314 RMP rwi vvv%j4. @t Requested Project #42 - Cancer Care Continuing Education Program $64,262 The purpose of this project is to train RN's. LPN's operating room technicians, and families of cancer victims in the etiology, diagnosis, and treatment of cancer; and to develop a coot- dinated hospital and home care program to serve the subregion. Evalua- tion procedures will be designed to record both knowledge and attitude changes in trainees and development of the hospital home care program. This project is ranked eighth by the Region, and is directed towards goals 2 and 1 (improving professional performance and strengthening cooperative arrangements). Second Year: $70,957 Third Year: $72,172 sted Project #44 - Nurs6 Clinician Program $125,212 The purpose of this proj'ect is to train nur.sea to act in a primary therapist's role in the medical management of patients, as a remedy to physician shortage and maldistribution, and lack of accessible, comprehensive services. The two-part program would consist of an eight-week core program and a six to ten month preceptorship program. The core program is designed to train a maximum of 120 clinicians after three years, with four classes per year. Each trainee must have physician or agency sponsorship with a guarantee of employ- ment after training. Upon completion of the core program trainees will begin a preceptor- ship to develop in-depth knowledge and expertise in management of care under a physician's tutelage, and in a variety of possible prac- tice settings. It is viewed as potentially providing a comparison study with programs elsewhere in the nation geared to developing physician assistants. The project is directed towards goals 4, 3, and I (training new or underdeveloped health professionals, modification of factors influencing distribution of professionals, and strengthening cooperative arrangements). Se ond Ye@r: $122,183 Third Year; $126,155 Supplemental Project.: sted Project #45 - Model City Health Manpower Education and $37,290 Recruitment Program. The purpose of this project is to raise the level of knowledge and understanding among Kansas City, Kansas model neighborhood residents about good health practices and to provide a means of their entry into health professions as health aides, while at the same time easing the health manpower shortage and Access problems prevalent in the area. Under supervision of a health coordinator, six health aides will be involved in class- room instruction on community health, practicum activities, and supervised activities involving communication with and teaching of residents in Kansas RMP - 17 - RM 00002 5/71 need of education or services. A Model Cities supplemental grant will provide the trainees' salaries. Another Model Cities project is being funded by Missouri RMP in the Wayne-Miiier area of Kansas City, Missouri. The Region ranks this project sixth. It is directed towards goals 3 and 4 (modification of factors influencing distribution of profes- sionals and training of new professionals). Second Year: $37,290 Third Year.: $37,290 Terminated Projects (6/71) Project #24- Food Service Personnel Using Dietary Consultant Approach Project #37-.Care of Patients with Fluid, Electrolyte and Renal Problems GRB/2-17-71 KAXSAS RC.GIOXAL MEDIC,IL PROGRAM SUBREGIONS (AND DATES ACTIVITIES IJERE. I.NITTAZED) 17 C H I'@, OLC@ PH@LIPS LL nIL GR@@.HAIt roogs I OS-o.--.c AS SHEAIDA.-Z TCIEGO SFL.L 11 porl q\ !CiiAl Alio E R0 !A74VI-:y Doj.30@ IVU@16,11 AL, E ;EO@f.;:DS DGWIC FOl 0 ELK -j CLA,-,K STCVZTJS C-C:-, co CD VII No,rth@iest I Northeast :V Flin,@. Hills VT V Cen-tral II iNorthcen@6ral IT Southeast T IX Capitol Sou'6hcentra'i VI South%iest KR L@ PRO REVIEW PROC@SS JECT Es t', tnated Days C@;P Technical Adv@sor to @KRMP 'Vied 1 DR-1- Con.;>Iete Exec. Cor.1m. Lead A 8 0 T ua- Grants Staqe Proponents Staff RAGI, L RI Agency Hea n Review On o@j 0 .60 0 0 03 65 :CT) 90, .oo 100 0 00 o@- t.0 130 0 0 00 KEY Document flcrei Review of project need I.nforrlation /S? Decision to su -bmit project to DRVP Decision to continue Docu-..,--n@ f icv Review of Prcec, ion to fund J w;icn required @T technical as;act@ review process PI Or Coil se c t IFI -20-- DEPAr@-i't/41:j'll' 017' AN[) WLLFAr@f--' 1-iF'ALTFI St-F4VI(';F.'S AIJI-) MENI'AT- FIEALTH AO?AINIST,@tTION Date: February 16, 1971 Repty to Attn of. .':'t@iff 1'evievi of tire Triennial A-,)plication fzo.-@i tiie Y@,@n-r,,as ilcr@iorial Subject: I-ledic.-.1 Pro-rc-t-.i 2-05 TO: i@.ctinc, Director regional 'eledical Pro-rppln Ser u Cliairtiall of the Chief, Grants Revie ii t s 14,? n z 'ri Chief, Gr L ri cl-i Actina Chief, Rsfional Staff riot to revive,,? the triennial cii.)plicat@-on I-,y the l@lansar, Medical Pro-ram. A primary o'L ties reviei; v;@is to identify arid r-liscuss issues for the site visit on ll,,arcli 4-5. Sitici,, only t@.;o projects have co,.-I-. and this i@ a triennial look, clel:'Lb--ration of the cotititki-iatioi-, of Llic application sce-@iod superf tious. The application requested the following total costs for the 05 year-. Core ConLiliuntion Projects 181,5 f4 and fr'3u' 1',eno.,Lil -Projf,-cts 400,746 Cs 1, 8, 9, 21, 23, 32 Previoi.,,@,ly AT,)I,-co,.?@ei/Uofuneed 471,037 40, 41@, 42, 44 Projects 37,290 Developiacntil Cc:7iportont TO""P.L $2,750,577 Sir.c(@ %ir3L, or,,e of tlie fil-rt to Ilse tire staff b,,-,--@n the L and problc,;--@s the- for!,is and nbo,@.it 1,1@),,-? LISC!D t"@,@-Tn. 1. .';taff a-rec@d tlilt the foi:.-,r, pi.-esentccJ, p,@-iod cc)P.Aci@rc of Core 0 fe,is@@.bility rtt@idier. atici projects Llia@L f.-Acilitz-ltc-cl tiz;c of tt-t@a de,@ci.-ipto).- fori.-to f,)r the ti-ir, otii,,?.r ;.,nl on projr-c,..-.r, it e-.@4ffi.culL to ar@ plitili@rl, of Io t@, the J.ffcrcflct-- it of- tic-altl @-rd the uc,@-cl to C.;,, -,,y 2. I the local r(--vici? p@cccf, 111'.@, n L:.@; to tt i qt@@- L I,,,) ri n r)c, i i@Ae (@l -(it -.-I Cy o to of 21- the Re-ion ivuld disc,-z@-@- ovc.-,Ill s@ri@c-@y n ..a or prograL-1 areas, sucli, 0- A. as continuing education. In the l@linons progr@@.i by far the largest nu@mber of projects and nirount of money are invented I..q continuing education. In the past, fraomeritation of these activities hns given cause for conccrn about a coordinated plan in this nrea. in this application, the sense of fra,,-.iont,,ition is ff-trt:licreet 'by the pic-cciac,.il -ipproic'ti to the pro-rnm throu@,h the discti-f,.ion.q in terr:ts of with or,,.inizf'.tiolis, I)rojccts and core fe,ir;ibility rather Lilin as a wiole. As ,t consc.@cl,,iciicc-, stiff t;@-14 the ne.@d for info::i:,.ition of tt-iis rcrt bcin- either requested in the application or in an interini position popzr v.,Iiicit cotild b@- r@,ade available for the site visitors and other rovi.ci.-zrb,. 4. 'i@icro is no ovcriill- bidet picture givin,-, L) totals for the 02 aLid 03 yeirti and riibtot,-ils for core niid projects for all years. Becf-,iase the progrzi-.i had to be writtc!n to provide this info m. ation the IIIS could not have the. infoiritio.,-i availil)lL, Li.,it3.1 the ti-@-12 of the meetinc,. Staff, therefore, did not have it available for individual study and thus li@id to cILiplicite the systc-,.i's effort.- i.,- order to l'oo!,, at the fiscal side of. the Recioit's request. etiny Indirect Cost figures are prior to tLic not available for the 02 and 03 years for b@id-et projection purposes. 5. Since no geographic or dc-.o@ral),%Sc data provided, staff needed to call the Region to get the information. Thus, x,,hile KansaG has made fairly good tiGe of the forLis, it involvesa special Charlene to staff in providli.n- additional material for the site visitors which N-iill highlight the issues and present a clearer picture of the KanGas program. I'he f-olloi-iiii&! is-,ties and questions for tiie site vinitors and national, revi-c-,2.:!rs h,-ive been grotit,)cd z,..ccordiiig to the cate,,orie@- of the Rev-.'Lc-ii Criteria. 1. Coal 0 @c 3 V C, -q Kansas has outlined seven objectives ind given each project a priority rahl-,ing purportedly based on its relition to the objectives. lniit Is the c)ztcnt of the acceptance of these objectives and the priority ran'@in,, on the part of those associated x-7ith Staff, Locl] Advisoi--y PAG. The Great 11@-nd procr@-m is rz-,nircci @."l and Dr. Bro-,,.,-'l x,,as the director of this progr-@,@-i before lie becivz-,o, Coordinator. 2. 52--ati Pal Ef-f-l-c a. Coordinator - Dr. Broi7a, %-;,to is well-!,no,,:n thro,,iclilo-Lit the @rt,-ite, is generally re-arded as a strono coordi.n"ltoi.. '.Llici:c. are so-;--- indic,-tti.oi,- froni core qtaff nc;jibcrs threat Dr. 1,rot;a's of control in the riny be too restrictive. As in r,,"XS Stiff life. le@ti-ned confidentially that his staff are not peri-qitted to attend 1,;%G meetings. b. Core Stif'L - I-I,iit is the rel,-.ition,-'4i5.p bet@?cL,.-i the central core staff in Kan,-,as City ana the sub,,:c-,iotial staff? kind of a--r-.i,-,tincc tlic, cciltr@-I core provide the -3,,ibrogi.onil coor(iinILO):S? re,,zir(I Lo core 22- -3- c.-i,bil,,i Iit v qttid@- c-,@ : 11 I-", y is YT-@ st directly ic-tivit-ie.!3 desi@n@Dd for ro,--dicil students and residents? 2) is tti-@ need for three automated rp,edical record systeras (p. 110, 111, 117) -nd i.;I,@at is the relationship zLionr,, the three? I,,'-hat use is rial-,in3 of the lar-c @imoi-int of ongoing fork in 0 this area? c. ornittcd - section in outline not applicable to discussion. I d. Pccional A..dvi.,;ory Group - To extc,-.),t is this a cr(:!,ature of the Coordinatoi-'s or an indep(@nclcnt c@,c-,it? 'ii-icre is one ni.irse, '.)to is affiliated %7ith tl)c U@iivc-r,,@,ity and no allied health representative on t@-e RAG. In viet@7 of the lir,-e proportion of activities involving tl-te--e gro,,tps, should corciderat-.;,on be given to increzisir.- this representation Is there sufficient Minority -ro,,ii) (bl,-,ckc., Incli.@ir)s, migranti;) representation? Irnat provision is being aide for Iti@, rci)rcse,,IL:ition? is there lii:ovision for local Advisory Groups' inp-Li@'t into the Pi'@G's decision risking,? el O-,tbre@,i.on@liznt;i.on I?'jll his nine sL@brc3j'-onal offices, ti@o of %7hicli Hill be visited by tll(-@ site visit thin (Greif- B(,n(i and ll'ic.Aita). Conce@tis i,,Iiicti staff brotl@l E: up for considerate n sre: 1) provi.(.'@cr and ,I 0 cons,@,,,ier acceptance of the cubre-ional pro-rartis; 2) iny chan,,cs in direction and future plans; 3) functioning of the local advisory rotips; 4) the relationship betve,,-n s-Libro-.iot-ial core staff and projects either on3oit-ia or proposed) in the stibre-i.ons; and 5) li.n!ta-er. %.;ith the 4pmedical schooloand other health i.notiLutio@ns; 6) spirtoff effects in terias of serving as the i-petiir, for the c-.tibl.J.ch,nent of activities in the s-lirrot@iidin- arc-Li; 7) ho-t-) do the othc2r vic-i, the C--,c.Lit E@--,id and pro,@rz@,.-kis; and 8) is the for decidin- ii'nbther a project fill be (lesiFned for @-i subregion or the entire Region? 9) in a subrecional project, %.into a-recs that a particular hospital serves as a focal point for the project? llith regard to the pro-r,@-.1 it Grc@-it Peid in particular, staff ,L, 1) Is there any educator iiip,.tt in the des3.,@,,n of the educational pror,rc.--4s; 2) I'tis ttic procr---i icttiilly rerultc(.l in the recruitment of 0 health personnel to the area; 3) 1,T@iat is the participation of the LAGIS in goal setting? In reviewing the I-',Iichita pro-rz;,i, staff queric(l: 1) I-,"iizit is LI)c,, of the subrc-ional office to project -C'3, C,)ntiniti.ri@ J.'clticitioii f(-)]. Care at and I.,",IiL .1.@;cistziztce, if any, Leon offerec' to the 2) ir, the rel,-iti.ono',iij) the C!'IP(b) in l,licliit,-t and tile Vi'ic',.Iita ct,iLe university Coll.cgc@ of Pelated Prcifes:-.ior.Ls; 3) 1',')'@7 had the Y,-"r, efforts t,iore do.,@lt N7ith the enrl.y secessionist I-,iovl-@ on tile part of physician and ho-p'Atils? 3. chool cor)i-d-iniLor liic; t,@!,e;i 0 cl-@.IT'-c tli-ir,, DtlcLl I:-@ r,-,.@sL of tile vac,-Incie.---- occurred on rscove staff .14'tcr tile l@,SL Coo'.retil-i;itnr left x.;!.tli fic,,tl.ty 23- -4- ion', .11 as ,pcct of the procyr, POw effecti pc3:connel and increasin- t:he subrcr,@ have these efforts been, staff iondered. llitl-i the ' P-L3o 4 n trien tor a new CIIP (A) r, %@;iat is the relationship with this aoency. Aoency Directo Ilany references are 4. oi- Prob made in the ap- '-t-o-t-hc--c,;i7lZct;j.on of t , including a Ilealth 1-1-inpo@@r Information Pro"r,--,i based in 'fope'r@la and the Health Information Syste-@n funded by core. @!hat have these studies and surveyr, rlio@,m ibolLiL health care needs in K@insis and ho,.,7 has tl@is infor6intion been used to determine objectives and go..3).s, as %.YL-11 as project activities. Staff noted an apparent duplication of- effort oL-t, core staff in collecting and analyzin- data -;i-tich rhould be inveoLir,@tcd (refer to appendices). 5. Procr@i.,-i IMT)I.C!,Ient;atj.on Treat 1-inds of proposals are coiiing up tli@ Lill@ @f@revic-@7 procct;s have been disapproved durino the past year? I-;hat kinds of activities i;ould the develop-i--ntal cc,-I-L)onent fund? V@iy has the region elected to renexq so many projects? vrnat efforts is the Reaion riiaking to fi@d other sources of support for these activities? As noted before, the Kansas program has a heavy continuing education c,-.iphasis. VTiiat role does the Continuing Edtication Co-@-nittee vis a vis the Director of Continuing Education and core staff, Dr. Risin,-,, play in determining this aspect of the program? In the past, there'lins been a unilateral, rather thp-.n a r.@ulti--disciplinary or te@.zi i,2proacli to colitil-i,lip.- CaLiciti.on and trai-nino. Has the Pegionts approach to this I-,'iiit is the role of v k2 Lead Cor.,%-!iittees in determining objectives and priorities in their respective areas of concern? 6. EvaliLintioii - Staff generally pleased x.,ith the Pc,.,ion's project ,L@rabl.c terms, prorress is evaluated evaluation. Objectives are set in meet accordingly and projects appear to be monitored by core staff. I-ladels of 0 evaluation for project directors are also provided by the evaluation section on core staff. Staff believed, however, that prograui evaluation needed to be strengthened. The followin,- staff inenibers attended the tiecting: Dona Iloti@-cal, Grintf-, rcvic-,.,, Branch Teresa Schoen, Planniti- & Evaluation ky, Revionnl Develoi)7@icnt Branch Frant@ Zizlnvs Gerald Gnrd--Il, Grants Charlie Bariies, Grants I',,inagc,,-,,,ent rranc-li Lai-irc!,,ir,c Ptilicn, Grants innocent Branch Juli@l Cot-itinu-Lno, Education Branch Bob Chn 9 - -il Lii'Lsoti --ibliss, Or aniz.-itioii, -24- -5- Kidncy Disease Control Pro-ril;ra Ted tooreil Joe Ott, Systei-,,,s Ilani@c,;:@cnt Joanne Oll@Ialley, Syste@-,-Is l,lanapc-@aent Harold O'Flaherty, Plankiing & I,'valuati.on Spiro I.Ioutsatsous, Pl@inriing & Evaluation Dona E. Ilouseal Public liciltli Advisor Gi:anto revieii Branch (A Privileged Communication) SUMMARY OF.REVIE@,l Al@'D CONCI,USIOL,@ OF APRIL 1971 R-EVIEII CO@@III'Tl,',E KANSAS REGIONAL MEDICAL PRO@-IM RM 00002 5/71 FOR CONSIDERATION BY MAY 1971 l@DVI;O'ORY COUNCIL RECOI,E-IEI@IDATION: The Committee recommended that this application which requests.: 1) the activation of four Council approved but unfunded activities, 2) renewed support'for six activities, 3) the implementation of one new activity and 4) a developiiic-iital component, be partially supported as follows: R E, Q 1,@T COI@IMIT- DEVELO@ll@IN'Ei@L SUPPLE@,[E',-qTAI, Y.C 2,@ r, MENT CU@IPONENT PROJECTS TOTAL 05 $1,314,266 1/ 163,360 766,li47 2/ 2,244,073 06 1,350,881 I/ 201,134 60r,,161. 2/ 2il53,l76 07 1.620,083 I/ 234.628 61@@9.288 2/ 2,503,999 TOTAL $4,285,230 599,122 2,021@,8106 6,906,248 SITE VISIT AND k',O@li,,!ITTEE RECO,',',@,f@'si\'DATIONS DEVELOPI@IENTAI@ TOTAL YEAR STAFF COMPONENT COilIPOLiENTS 05 Deferred to -0- 1,800,000 1&2/ 06 Site Visit -0- 1,800,000 07 Teir,,i -0- l@800,000 I,&-2! TOTAL .5, 00,00 l./ Includes core and projects #4 and 38. .Z/ Includes p--ojects IR, 8R, 9R, 21R, 23R, 32R, 4.0, l@l, 42, 44, 45 Critioue: In its deliberation, tlic!' CoLT@iitittee accepted the report o t e site visit to the Kinsas Region on March 4-5, 1971. Under the dynamic leadership of the Coordinator, Dr. Brown, this Region has co.-ae far sin.ce its early operational. years when University representatives dominated the RAG, its faculty occupied tfie major Core positions, an the projects were generated at the University, if not actually locat-ed there. The Uni.versity's predominant influence li,@s been di.senQ--ced y 0 @ frritit -the prograta. In line with its growing coTnriitinetit to the recl,,'-,)nqlization of health services and education, @he University nc%@7 looks to PIIP as a KANSAS PdvIP -2- RYi.-OO002 5/71 vehicle for subregionalization of medical education and new mod(-Is of health care delivery. Kansas has severe medical manpower problems throughout most of the state. Most of the KR'i'IP's programs have been directed to some aspect of the - manpower problem, usually continuing education for heal th professionals. C> While many projects continue to be continuing education - oriented, their emphasis has changed from that of an end in itself to ameans of fostering better health care. The subregional part of the Kansas program, which includesia local Advisory Group and a Core staff member in each of the nine subregions has been developed in order for people in these medical service areas to determine their own needs in improving health care. Part of the site visit team went to Great Bend and Wichita to meet with Core sta ff members, project staff, and providers and consumers involved with KP,@IP i.n these communities. While early slibreai.onal. efforts were developed to desian models for the entire Region, the visitors i.-enort@(@d to Committee that the Region seems to have learned from @Iii-s experience that each subregion must determine its own model.. The leadership for this program lies clearly with the Coordinator, who is A forceful administrator is respected tht-.oLirl-ioLit the state and has apparently a firm grasp on the Region's problems and the methods needed to solve them. He has been successful in buil.din(, 11@IP committees brotirid existing groups established by other a(,cncies, rather than creating sbpatate falP groups. He has established a very capable Core, staff whose members are involved with the new Wichita State University Colle-e of Health Related Professions, with migrant and inner city health problems, and in manv 8ubre ions providin- staffing for CHP are,)wide plaiitiiiic, g c@ 0 groups. As 6 consequence, RMP is becominc,,.an integral part of health services planning in Kansas. Dec,ision-making, priority-setting and review processes are areas of weakness and should be strengthened. The review process could not e t> evaluated since it is still on paper. The policy-setting Lead Committees in various categorical areas ate still just being organized. The RAG relies heavily on the Coordinator for direction of the Program and for setting goals, objectives and priorities. Because Dr. Brown serves as the principal conveyor of information between the RAG and Core staff, Local Advisory Groups, the lead Committees and project proposers, the RAG is isolated and generally reacts to, rather than initiates program ideas. The communications problem attendant to Dr. Brown's key position of filterer of information has afso prevented better LAC input into establishment of regional goals and objectives. Committee concurred with the team's recommendation tLiat the Coordinator develop broader communications linkages among the various regional groups and place high priority on fostering a more independent role for the RAG. At the same time, however the Region shows potential for securing provider support and establishing an organizational pattern for the regionalizatibn of improved health care delivery and health manpower education which Committee believes is valuable and should be encouraged. Y,ANSAS RMP R@l 00002 5/71 Committee had concerns about the Region Is priority-setting and decision- making process, whic h ranked a computerized cancer registry proposal (Project lt4l) higher then a Model Cities health aide training program (#45). The site visit team members' present at Committee indicated that the hard decisions required in coping with a reduced budget might produce a different alignment of priorities and that with regard to the tumor reoistry proposal, the Coordinator would probably be able to take Advantage of any funds available in the state for further developmental efforts. Committee, thought however, that their reservations about the wisdom of allocating @',IP funds for the proposal should be communicated to the Region, since the evaluation of existing funded computerized ke istries as related by.PMPS staff showed Generally inadequate results. 9 0 pom itt6e suggested that the Region be reminded of Council policy on tOw,dr registries, which states that RMP support may be provided when: they make important contributions to regionalized improvement of patient care, they plan to disengage @IP funds promptly, and RMP support is confined to organization, planning of output and development 6'L new methods and not major equipment purchases or operation. Committee agreed with the rationale for the site visitors' funding recommendation which would give the Region some funds to continue the more successful ongoing activities and at the same time apply pressure to the Region to develop new and more innovative activities. Because of the RAG's relative inactivity in the decisiot-making and priority-se.tti.i-ig process and the latitude for developmental activities provide or in the Core budget, there was no dissent with the site visitors negative recommendation on the developmental component request. Project #40 - Development of a Comprehensive Nephrology Tra@n Program, was reviewed by the Ad Hoc Panel on Renal Disease. Comm ttee did not have access to the Panel's recommendations during its review. The proposal had been reviewed in November 1970 and deferred until it could be looked at by a site visit team in terms of its relation to the overall program. While the site visitors did not assess the technical merit of the proposal, they questioned the proposets.abbut the proposals relationship with other programs in the state, the efforts of the RMP Lead Committee in-Renal Disease and the proposed 910 application to be submitted by the Kansas, Missouri and Bi-State RMP'S. The team was satisfied that the Region would coordinate regional resources) seek to prevent duplication of effort and combine efforts @for 1.31annin@ of a complete regional program. The site visitors included funds for the proposal at a reduced level in their overall recommendation for support. Committee accepted the recommendation. The Panel deferred their decision because of lack of information. Panel Technical Critique: Because the Panel had been provided only a short summary of the proposal and not the complete description originally submitted in August 1970, they deferred their recommendation. in Addition, they stated that the proposed short-term training (severAl @days) for physicians has been proved inadequate for proper trai-.iing. The I home dialysis training is not discussed fully enough in terms of existing needs. present status of therapy and resources in details of design and method. 'RMP /rRR --ION, AND VVR-LFARE DEPAR't'MENT Oi7 I-IE-:ALTi-1, EDUCA PUBLIC HEALTH SERVICE HEALTH SERVICES A,4r.) MENTAL HEALTH ADMINISTRATION, Date: March 26, 1971 biect' Kansas Regional Medical Program Quick Site Visit Report, March 4-5, 1971. 7-0 -Director Regional Medical Programs Service THROUGH: Acting Deputy Director Regional Medical Programs Service I. STRUCTURE The site visit was divided into two parts for the March 4 session because of the importance of the 8ubregioiial program and the need to speak to the Great Bend and Wichita representatives in their home-communiti-es. A list of the site visitors is attached. The site visit was structured so that: 1. The Kansas City team (Dr. Schm 4dt, Dr. Weinbe g and Miss Hous6a!, r Miss Schoen and Mr. Maddox from .staff) met with the Coordinator, the RAG various-Committoe members and representatives of the University, CHP and others interested in RMP from around the state, and 2. The Great Bend-Wichita team (Mrs. Wyckoff and Dr. Nic.hol.as, and Mrt Z-Izlavsky and Miss Kula from staff) met with Core staff members, project staff and providers and consumers involved with the in these locations. After spending the morning in Great Bend and the afternoon in Wichita, this team joined the. first group in Kansas City. The eni-@,@re team met with.Core staff on the second day. IT. MAJOR QUESTIONS Brief , the major concerns of thi.s site visit were: 1) the amount of control over the program-exercised by-the Coordinator; 2) the represeiita-- tion and decis,-on-making of the RAG; 3) KRMP's relationship with the Univ6isitv* 4) the adequacy of the technical. aspect of the review process; 5) t apparent programmatic emphasis on continuing education; 6) the in ol omen6 at the su@bregional level and the relationship of subre-gional progr ms and groups with the regional gr-oups and the statewide program; and 7i the relationship of KRNP with statewide grou,,)s such as ClIp. Page 2 Director, RMPS III. FINDINGS AND PECO@NDATIONS Dr. Brown, the Coordinator, is clearly the pivotal point in the Kansas program at present. He dominates the Core staff, and,the Regional Advisory Group is his creature. He serves as a filter for communications between the RAG and Core staff, Local Advisory Groups categorical Lead Committees and project proposers. As a consequence, the RAG is isolated and fairly weak and generally reacts to, rather than initiates, program ideas. This amount of &ontrol can be rationalized somewhat by Dr. Brown's need both to shore up the program after the last Coordinator resigned and to disengage the program from the medical school's domination. While Dr. B.rbwnis control of the program may be justly criticized, he has, however, several major accomplishments to his credit.. He has assembled A very capable Core staff. He has the cooperation-of the appropriate state- wide groups and has been even more effective in working with individual Physicians and hospital administrators in getting things done. As in, many Reg3'.ons., RMP has been on the scene longer than CHP and has consequently been more. successful in garnering support at the local level.. Dr. Brown has also been very adept in building MT technical committees arou d existing groups established by other agencies, rather than creating ,separate RMP groups. Examples of such efforts are the Pulmonary, Renal and Cancer Lead Committees. The Coordinator also seems to be directing increasing attention.to health services delivery, and there is evidence that he is in contact with those in the ReRion who may be developing health maintenance organizations. The site visitors commended Dr. Brown for taking advantage of these kinds Of opportunities but they also recommended that he involve the PkG and other regional groups in more of the decision-mak'lng so that the program would be less of a one-man show. The technical aspect of the review process is still on paper, but is expected to go operational this year. Provisions have been made for CHP comment. In Great Bend, the multi faceted education program for health care persoi@ nel is making Progress. Particularly impressive is the R.N. retraining p ogram,@whicb returned 55 nurses to active employment out of a total enrollment of 65 in the course. While the Great Bend project has not been le to recruit more physicians to the area, it has helped those practicing in the Great Bond area by arranging for individual consultation on difficult cases by K.U. medical center personnel. Leadership in the Great tend area is distributed among the director of the Great Bend project, the s regional Core staff and the Local Action Group,,coTrprised of multi-agency d professional repr6sentatives@@-as,well as consumers. The LAG has been Page 3 - Director, RNPS p rticularly active in helping to identify and involve local people in the RNP sponsored educational activities. The subregiotal Coordinator in Wichita has developed excellent working relationships with local project directors and with health professionals in surrounding counties. He has brought about stronger ties with the State Medical Society and has been instrumental in achieving better relationships between-physicians and hospital groups* I He has also been a prime instigator in the.establishment of the new College oIf Health Related Professions at Wichita State.University. A weakness of the Wichita Core operation was the data collection efforts, which so far have not provided information which is applicable or helpful to RNP planning. The Wichita subregion also has a mature and functioning LAG, which relates well with the CHP (b) Council. .LAG representatives from both subregions indicated that while they have informal communications with the RAG through Core staff and, in one instance from a RAG member who also is on the LAG, some better method of@ formal reporting of RAG meetings,such as written reports bf'RAG meetings, and of getting,LAG input into establishment of regional goals to be instituted. After discussing their experiences in Great Bend, Wichita and Kansas City, the site visitors realized that the continuing education and subiegional activities, rather than being ends in themselves, had been developed to regionalize health services for improved health care on the local scene. Core staff and Local Advisory Groups were developed in order for people in t@'nese medical service subregions to determine themselves what they neectp-@. One of the biggest let3,sons the Region seems to have learned from the eat Bend and Wichita experiences was that the model for each sub- region should be "what each subregion wants to do. 11 In@line with the subregionIa.1 concept the Univeksity is now looking to as@the vehicle for subregionalization of medical education and new models of health care delivery rather than, as in the early days of the program, using-@RNP as a funding source for continuing education programs out of the medical center. in allied health, the R-MP will support and utilize the resources of the newly developing College of Health@Related Professions at Wichita.State College. The team concluded that the Rc-gionhas made significant progress since the last site visit. They are developing a subregioaal program using tonti uing education as a vehicle designed to improve health care. The most;significant need is for the Coordinator to develop broader communica- t@ions linka-aes among various regional groups ('@%4C, LAG, Lead Committees, etc.) apd to foster a more independent role for the RAG. Page 4 - Director, RMPS The funding level recommended for the Region"S fi.ftl-i, sixth and seventh years is approximately $1.8 million (direct costs). Because @lthe RAG is not an active enough participant in the decision-making process the developmental component request was disap roved. p t-,4 Dona E. Houseal Public Health Advisor Grants Review Branch REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION (A Privileged Communication) MAINE'S REGIONAL MEDICAL PROGRAM RM 00054 5/71 Medical Care Development, Inc. April 1971 Review Committee 295 Water Street Augusta, Maine 04330 Program Coordinator: Manu Chatterjee, M.D. This Region was awarded $904,473* for its ni operational year ending September 1971. The Ol year award included indirect costs of $1,976, which rprresents an average indirect cost rate that does not even ap"roach one percent. The current application requests one-year supplemental funding of $27,896 from the Model Cities earmark to conduct a program in Family Nurse Associate Training which will have an impact in the Model Cities areas of Portland and Lewiston. FUNDINC HISTORY Planning Stage Grant Year Period Funded (Direct Costs) 01 5/67 - 4/68 $193,909 02 5/68 - 4/69 358,170 Operational Program Funded Future Commitment Grant Year Period (Direct Costs) (Direct Costs) 01 7/68 - 6/69 $ 428,106 --- 02 7/69 - 9/70 (15 mos.) 1,229,634 03 10/70 - 9/71 904,473* --- 04 10/71 - 9/72 $637,642 n5 10/72 - 9/73 57,133 Reduced to $868,592 (see footnote on page 2) -2- RM 00054 5/71 Maine RMP maine's Regional Medical Program received one of the first anniversary program site visits in October 1970, and was enthusiastically recommended for developmental component funding by the site team, Committee, and Council. Supplemental funding for two new projects was recommended as well, for a total 03 funding level of $1,304,969 for this Region. Financial stringencies, however, have prohibited the awarding of new funds, and this Program is operating at its previously committed level of funding, as follows: Core $440,496 Guest Resident Program 30,940 Kennebec Valley Regional Health Agency 171,144 Smoking Control Program 37@538 Coronary Care Program 146,812 Physicians' Continuing Education 56,228 Regional Library 21,315 $904,473* Regional Objectives Maine's Regional Medical Program and its Regional Advisory Group have isolated six program objectives. In priority order these are: 1) experiment vantaged areas; with new methods for delivering health care to disad 2) develop new health manpower; 3) improve and update the level of medical knowledge; 4)'develop subregional capabilities for area-wide health planning and the delivery of health services; 5) maximize the capability for delivery of quality medical care through community hospitals; and 6) maximize the capability for providing diagnosis, treatment, and medical educational leadership in referral hospitals. October 1970 Site Visit The prologue to the site visit report gives a good summation of the sentiments of the Committee, the site team, and the Council. about this Region. The site visitors saw the evolution of Maine's Regional Medical. Program as being remarkably consistent with that of the program at the national level - starting with a categorical- emphasis but expanding to include a clear commitment to the development of an integrated system of medical care which provides access to medically depressed populations as well as improvement of availability of care to the c*mmunity at large. The six program objectives identified by the Region, and ranked in priority order by the RAG, reflect this emphasis, but also are geared to the Because of RMPS fiscal stringencies, the amount of money available to Maine during its 03 year has been reduced to $868,592 (including $50,693 carryover). Rebudgeting among program components, however, has not yet been c ompleted. Maine RMP -3- RM 00054 5/71 unique needs of Maine itself. The progress MRMP has made to date appears goo,], with some peaks.of excellence and few valleys. Essentially, the Region has been carrying out the public health functions of the a-tate. The visitors were impressed with the sincerity and effectiveness of the Coordinator and his core staff. With the few exceptions described in the body of this report, the role of the Regional Advisory Group indicates the readiness of the Region to receive and administer developmental component monies. The Regional Advisory Group is established as the final review authority and comfortably occupies a policy and decision- making position. MRMP has developed good and productive rela'tion- ships with other organizations in the state. In general, the site team thought this Region possessed the regional maturity, the capabilities, and the appropriate management abilities to make good use of developmental component monies. The site team did suggest, however, that the Region take steps to: 3.) change the character of consumer representation on the RAG to include n6n-medically oriented consumers and those of modest means; 2) develop a subcommittee or task force structure for the Regional. Advisory Group; and 3 clearly separate the functions of.the Board of Directors from those of the Regional Advisory Group. 01 Year Request Project #20 - Family Nurse Associate Training Proposal. $27,896 This proposal is related to the first two program priority areas of the Region: 1) experimenting with new methods far delivering health care to disadvantaged areas; and 2) developing new health manpower. The goals of the proposal are: 1. To increase the depth of skills, knowledge, and understanding of specially selected family-oriented nurses. 2. To provide more effective and comprehensive management of family patient care with physician direction in the home, the clinic, and other community settings. 3. To relieve the stress and pressure on existent systems and facilities delivering health care. The application states that this wil.] complement an existing RMP-supported Pediatric Nurse Associate program and should be followed by an OB-NA program to complete the trilogy. Six Registered Nurses (four of whom will come from Model Cities areas) will participate in the first course. The year-long schedule includes four months of intensive training and eight months of field supervision. Six hospitals and agencies (including the Model Cities Neighborhood Health Station) have offered their facilities for use in the clinical portion of the program. Irogram evaluation will be the responsibility of MRMP's Division of Evalu- ition, and will involve a pre/post/foll.ow-up assessment. RM 00054 5/71 ,Maine PMP The budget submitted to RMPS provides m8lhlY for personnel and consultant services. Other sources of support, to include student stipends, are being explored. If the first course is successful, two additional years of support will be sought from RMPS. Efforts, will be made to build this training program as an on-going course of the University of Maine's Continuing Education Divis on.. RMPS/GRB/3/12/71 (A Privileged ConununitatIion) SUMMARY OF REVIEW AND CONCLUSION 04 APRIL 1971 REVIEW COMMITTEE MAINE'S REGIONAL MEDICAL PROGRAM RM 00054 5/71 FOR,CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMENDATION-,.Additional funds be,provided for thi,s application.. Year R6quest Committee Rec6mmetdation 03 $27,896 $27,896 CRITIQ E. The favorable reports of the October 1970 site team and the January/February 1971 Review Committee and Council regarding @ e.ac ompiishment§ and future potential of Maine's Regional Medical P ogram were recalled by the reviewers of Project #20 Family Nurse As 66i4te Training Proposal. It was agreed that this supplemental ai)i)li 4ti6n for Model Cities earmarked funds was re 6 e 1 ted to th @s first two@priority areas: (1) experimenting with tow moth ds to,r delivering he ith care to disadvantaged areas, and (2) developing @n health manpower. The training of Family Nurse Associates was AM s en as@the second step in Mainef8 nurse associate triad: complementary t'6@ex@ ing RMP supported-pediatric NA and future obstetrical NA Pr gr liu Chatteree was not present during the discussion of this aPlitati6n. GRB/MPS 4/19/71 (A Privileged Communication) REGIONAL MEDICAL PROGRAMS SERVICE SU i OF AN ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION MISSISSIPPI REGIONAL MEDICAL PROGRAM RM 00057 5/71 University of Mississippi Medical Center April 1971 Review Committee 2500 North State Street Jackson, Mississippi 39216 Program Coordinator: Theodore D. Lampton, M.D. This Region is currently funded at $1,095,428 (d.c.) for its second operational year ending June 30, 1971. $320,241 of this amount represents unspent first-year funds reauthorized as carryover into the second year. The Region currently receives indirect costs of $375,958 which is 32% of the direct costs award. It submits an application that proposes: (1) Developmental component for one year. (2) The continuation of core and seven projects for one year. (3) Three years additional funding for one project, CPR Training. (4) Three-year funding for two new projects, in hypertension control and in renal diseases. The latter activity has been supported for an interim period throug carryover funds. (5) One-year funding for Phase I of a new project in Stroke Rehabilitation. The Region requests $1,430,979 (direct costs) for its third operational year, $301,023 for continued funding of two new projects and one renewa project for the fourth year, and $301,189 for the fifth year. The breakdtt chart identifying the components for each of the,.,three years follows'. The Region's triennial application is expected next year at this time, when a site visit is planned. The Region elected to request developmental funding and new project funds to take advantage of the planning ahead that has developed this year. The former coordinator has resigned to work full-time for the VA Hospital, but remains on the RAG. Dr. T.D. Lampton, who had been his associate, has been appointed as coordinator of the RNP. The former Dean of the University Medical Center, Dr. Robert Carter, a so left the area in the past year, and has been replaced by Robert E. Blount, M.D., Acting Director and Acting Dean of the University of Mississippi Medical Center. During staff review of the application, specifically the continuation portion, the following points were made that may be of special interest to Committee and Council in reviewing this application: MISSISSIPPI RMP -2- RM 00057 5/71 (1) The Regional Advisory Group seems to be more active in developing the direction and priorities for the Regional Medical Program. A roster of 14 new members, special orientation.for new members, and a workshop retreat were factors contributing to the RAG's functioning. (2) The Core Staff has been serving in a broader capacity than before. Project review and surveillance have taken a lesser portion of time than before. Staff has been involved in a variety of joint efforts to develop activities for funding from other agencies. The trend toward full-time positions and greater emphasis on sub-area development were considered strengths for the future of this program. (3) Health manpower remains the Region's first priority, but the focus is widening from' concentration on numbers and upgrading of skills to include consideration of distribution and more effective use of minority populations as health care providers. (4) The funding request for new projects'includes medical care costs, as well as training and. consultation costs. This has been a recurring feature in this Region. (5) The RAG has not taken a clear stand on phasing out RMP support. The request for three years of additional funding for the CPR project is a case in point. When this Region was originally site visited for operational status, the site visitors recommended two-year finon-renewable support" for the CPR Training project. (6) Staff's general impression of the total activities of this Regional Medical Program is that the program has been instrumental in providing consultation, training and service from the University Medical Center to all parts of the State. The training has involved other educational institutions besides the University. Projects include integrated training, patient care and consultation. Fb'NDING HISTORY Planning Grant Year Period Amount Funded 01 /l/67 - 6/30/68 $ 454,206 02 7/l/68 - 6/30/69 648,607 Operational 03 7/l/69 - 6/30/70 1,229,567 04 7/l/70 - 6/30/71 1,095,428 The Region has been advised that its funding level for the upcoming year must be held to $884,037 due to overall budgetary constraints. P.ECION MISSISSIPPI CYCLE RM 00057 5171 "I@'(')UEST 03 PERICD 0 IT@@-V OUS L'@ I NEI%F -ACTIVTT7.-S @@AL A P R @T F U N :ACTIVII'TES DIPECT 'T@,'; D T,',l E C T- OT,, CORE $ 162 , 95 7 $ .5 7 156.490 S 7 #1 R Stroke Care T)emon. 131,094 1-31 094 56 92@, 188.022 mon. & Training in ry Disease t5, 178,000 72.210 250.21.0 r2R Pulmona liuo 43 - Postgraduate Institute 57,187 57.1-87 15,370 72.557 #5 - Cardiovascular Clinic 33,175 33,175 4,535 37,710 0 46 - Coronary Care Unit 89,285 28,135 117,42 89,285 #10 Ra?ietion Therapy 45,422 1 45,422 16,565 61,987 ,ill Co'r,,.p. Neurology Clinic 69,040 69,040 16,278 85,318 #16 -'Stroke Rel,.abilitation 05 1 2@5 05 -0- 42,505 $ 42.5 200,739 206,739 69,309 270,048 @17 - Renal Disease Program 70,790 70,790 1,0,@27 81,017 #18 H)rpertension Control 53,267 4.0- 53,267 -ISR -.CPR Pr m $53,267 97,518 97,518 -0- 97,518 DEIJELOP@LNTAL CO.MPONENT 7 Ln Ln $966,160 $53,267 $411,552 $1,430,979 $446,979 877,026 REGIGI\ MIS CYCT,F, B'RE,'-KOUT OF R---QUES-1 04 PE-RIOD I?REVICUSLY 1 TO'.AL CO\TL I DIRE T !ACTII 5 #6 #16 184,14' #17 #18 $42,470 #8R DEVELOP'MENTAL I 383,519 $301$023 $82,496 '@;$258,553 $42,470 05 rERIOD cn cn 'I' ALL YEARS 1 ALL YEARS DTR'CR .1 TC-I@L or AC-,-!@FITIES '.R Z I,' A T, APPR. /LTiNFLrN' CTI@'ITIES DI,@F I' LIIRECT I TOTAL i 362, 57 On 519,447_ #!R 131,094 188 Q22 --- 178,000 25@@i-0- ,2 R 57,187 57,187 33,175 37,710 89,285 117,420 #6 45,422 61,987 #10 I' 69,040 85,318 42,505 42,505 1 6 #17 $190,354 $190,354 $75,476 $265,830:@ 575,236 791,067 77@515 193 89,708@t 222,715 256,585 #s,, $33,320 33,320 -0- 33,320! 129,057 129,057 97,518 97,518 DEVEL. $33,320 $267,869 '$301,,'89 $87,669 $388,858'; $2,033,191 :$2,399,093 JL MISSISSIPPI RNP -6 RM 00057 5/71 GEOGRAPHY AND DEMOGRAPHY Mississippi Regional Medical Program encompasses the State of Mississippi. Mississippi is rural in nature and rather sparsely populated with its capitol, Jackson, as the axis. Responsibility for the northern-tier of counties is shared with the Memphis Regional Medical Program; according to the RAG report, that part of the State attaches itself either to Tennessee or Mississippi, whichever appears to its advantage; the two RMPs and staffs work together well. The Regional Medical Program relates program development to the Comprehensive Health Planning and Economic Development districts where possible, but RMP activities are not bound by these areas if others seem more appropriate. Mississippi's health, education, and economic plight is a matter of public record. It is down at the bottom of the list in the ratio of physicians to population. According to the 1968 analysis of all health indicaters, only one Mississippi county is on equal footing with the top half of the nation; 62 of the 82 counties fall into the lowest one-sixth of all counties in the United States in health status. Few resources are at hand to correct this deficit. The State is 62% rural. The average per capita income is less than $1,800 per year; almost half the families have annual incomes under $3,000. Of the families in the bare subsistence category, about 53% are nonwhite and 43% are white. The illiteracy rate is about 5% double the national average with an average of less than nine years of schooling reported by Mississippi adults. REGIONAL DEVELOPMENT In November 1965 the Mississippi Heart Association invited representatives of health and civic organizations collectively to consider the potential for Mississippi of the newly enacted legislation setting up the Regional Medical Programs. Dr. Robert Q. Marston, then the Vice-Chancellor of the University of Mississippi, Congressman G.V. Montgomery, then President of the Mississippi Heart Association, and Dr. Warren N. Bell, then President of the Mississippi Division of the American Cancer Society, were asked to serve as an ad hoc committee to develop a planning group. The Mississippi Heart Association, the Mississippi Division of the American Cancer Society, the University Medical Center, and the State Board of Health each contributed $2,000 toward the cost of planning activities. Concurrently, Dr. Marston Appointed an ad hoc committee categorical study groups to pool their know- ledge in heart disease, cancer and stroke as a resource for the overall planning group. In September 1966, Dr. Guy Campbell, Chief of the Pulmonary Disease Section at the VA Hospital, was employed as a half-time coordinator for the proposed Mississippi Regional Medical Program. From November through December 1966, the ad hoc study groups furnished the planners a,broad assessment of the level amount, site of pertinent MISSISSIPPI RNP -7-- RM 00057 5/71 and competencies. An 18 member Pc-,.gional Advisory Group was designated, including 8 from Jackson, and 10 from the rest of the State. In December 1966, the RAG considered an initial draft of the Regional planning grant application which was later submitted to DMQ. After a site visit was made and consultation was provided from the Division of Regional Medical Programs, the application was revised and resubmitted in April- 1967. Funding began for the Mississippi Regional Medical Pro- gram on July 1, 1967, with the University of Mississippi Medical Center as the fiscal agent. During the planning period, the Region also received funds for two feasibility studies from earmarked funds: to set up a demonstration stroke unit and a training program in chronic pul- lwnary diseases. Another project for hypertension control. in the rural Delta County was also submitted, but not approved. The operational program application was submitted in March 1969. The Region was site visited in May 1969 and the Region was awarded operational funds on July 1, 1969. ORGANIZATION STRUCTURE AND PROCESSES The RAG now consists of 36 members, 17 of whom are new members. The geographic representation in the RAG is statewide. Eight of the members can be identified as minority representatives. The RAG consists of representatives of a variety of state organizations including Compre'rien- sive Health Planning, Medicaid, the presidents of the Mississippi College, Jackson State College, and Alcorn College, a faculty member from Alcorn, the Dean of the School of Nursing from the University of Southern Mississippi, the Acting Dean of the Medical Center and the Director of the University Hospital. The RAG has concentrated this past year in developing a plan o action for the future. Formerly, consumer members on the RAG were not involved in the program and the core staff has made a deliberate attempt to increase their commitment through better orientation. In addition, a retreat was held with the RAG staff and the Planning Committee to deveio@ clear objectives and prior ties. The Planning Committee is, and has bee@ a key group in the organization of this Regional Medical Program. Consisting of 15 elected members from the Heart, Cancer, Stroke, Continuing Education and Hospital Liaison Committees, it represents the peer review structure in the Region. Eleven of the 15 members are from Jackson, 9 are from the University itself. Since the initial categorical committees were appointed by Dr. Marston, these committees have played an important role in the Regional development. The review process is under study in an attempt to streamline it. Briefly, the steps now involved are: the idea is developed by a proposer, the coordinator considers it, the categorical coordinators provide consulta- tion and help, staff reviews it, a categorical committee reviews it with help from paid consultants, if necessary. Then, it goes to the Planning Committee which looks at its relevance to the program and assigns a MISSISSIPPI RNP RM 00057 5/71 priority. Finally, it goes to the RAG which studies it from the stand- point of relevance to overall goals and priorities of the program. The evaluation of the ongoing activities and the program as a whole is also under study, with the Planning Committee taking a major role. The progress reports from the project directors are studied by staff with help from a new consultant in evaluation. Any.problem areas are worked out by the staff and the categorical committees. The RAG does not appear to have a major role in evaluation at the present time. OBJECTIVES AND PRIORITIES The objectives most recently defined by the RAG at its workshop retreat in December are as follows: (1) To alleviate the health manpower shortage. (This has always been the number one priority for this RMP.) (2) To encourage improved designs for systems for health care delivery in Mississippi. (3) To provide continuing education for the health team. (4) To stimulate public education regarding concepts and resources. The priorities to be exercised in meeting these objectives include: a) incorporating minority groups in the health manpower pool, as possible b) to make the health care delivery system receptive to the Region's necessitous citizens; c) to shift the focus of emphasis to responsible action on the local community while still maintaining regional trainir,,, and consultation services as resources for local health care providers; d) to reach the functionally illiterate and stimulate an informed interest in health matters; and e) to encourage emphasis on quality, equity, efficiency, and economy in the delivery of health care. PRESENT APPLICATION_ Developmental Component First Year - $97,518 The Region requests $97,518 for one year for the Developmental Component. The plans are to use developmental funds for the following purposes: 1) initiate support for relevant activity when delay would be detrimental to optimal impact; 2) to deal with unforeseen problems in program implementation; 3) to enhance the effectiveness of ongoing projects by filling the gap between them; 4) to take advantage of special skills, personnel or opportunities if they become available; 5) to participate in appropriate federally-supported and other programs as they become available; 6) to test the feasibility of new program activity or concepts .by the use of the small-scale pilot projects. Devel-opmental'component funds are conceived as a tool to grasp unique opportunities not subject to nor bound by technical restrictions applicable to formal. operational MISSISSIPPI RMP -9- RM 00057 5/71 projects. They will not be used to e-f-.Iarge OY extend the core staff. Any proposed activity must be consistent with the objectives and priorities and there must be a substantial- probability that the activity will produce information applicable to future programmatic decisions. The application further states that the proposed developmental activity should be capable of activation with minimal delay, it @;hould have an action component, and it should be capable of generating much more volu, involvement and participation than could be purchased iteer interest, on a total cost basis. The administrative procedures for allocation of developmental component funds will be initiated by the Plannin@ Coni- mittee and approved by the RAG. The core staff will play an important role in perceiving opportunities and receiving requests for the most appropriate use of such funds and will provide the Planning Coumiittee and the RAG with information, research and developmental services for their study. The RAG will have a developmental component study group for preliminary review of the developmental component proposals to enable the RAG prior study of the potential by their own group. Core Activities Third Year - $362,957 Dr. T. D. Lampton, who came to the Mississippi Regional P4edi-cal PrograTr as Heart, Stroke Coordinator in July 19(@8, became the Coordinator in January. The Staff has also been strengthened by the addition of Ili individual experienced and trained in personnel practices, Pat L. Gilliland, named Assistant Director for Program Coordination in January. At the beginning of this current year, the core staff numbered 11 full- time and six part-time personnel in all categories. Two medical stu ents were also employed during the summer. Six budgeted professional and technical positions were unfilled. In January, the staff totaled 22 at all levels, 15 full-time and seven part-time. Only two budgeted pro- fessional and technical slots are now open. Of the six professional and technical staff who are less than full-time, one is shared with the stroke unit, one is a Jackson physician, one is self-emp.'Loyed and thr(-@,@ are shared with the University Medical Center. The RAG indicates they like the trend toward full-time staff. Analysis of the total core staff activities in the application indicates that most effort is directed toward: (a) project development and manage-- me-nt and (b) professional consultation and community re'Lations,each accounting for some 25% of the total. About 15% each goes to: (c) program administration and direction and (d) planning studies and inven- tories. While (e) feasibility studies and (f) miscellaneous activities are estimated to absorb 10% each of the total effort. Work with com- munity, sub-regional and regional groups in development of cooperative arrangements will command grea'@er porportions of staff effort In the coming year. By RAG direction, the fiel.d services will be expanded with the two field workers designated, for this act@l.vity. The application indicates that the core staff has rel.ated to a number of different agencies within the state. For examples the core staff -iO- RM 00057 5/71 MISSISSIPPI RMP helped a local medical society centralize its health and welfare information service. It helped a group called "Operation Shoe String,' a local non-profit organization which provides a variety of services in a transitional poor neighborhood seek new sources of funds. The State Medical Association is exploring with the core staff the possibility of developing a utilization and review manual for primary use with peer review committee functions through the medical association. The Mississippi Dietetic Association is requesting help with the develop- ment of a dietetic manual training program for food service supervisors in continuing education workshops for dieticians. A number of planning and feasibility studies are described in the application. The core staff has served as consultants for several joint efforts, including the health law compilation with Comprehensive Health Planning, a hospital management study with the Mississippi Hospital Association and the Mississippi State University, and a survey of Lafayette County health needs with the Memphis Regional Medical Program. The University of Mississippi, the Mississippi State University, the University of Southern Mississippi, the Mississippi Research and Development Center, and core are cooperating in conducting studies in manpower development. Hines Junior College helped to structure clinical training aspects of three RMP established training programs for allied health professions. A general impression from the core progress report is that the limited resources in Mississippi contribute to cooperation among the various professional staffs. Vocational Rehabilitation, Comprehensive Health Planning, the State Board of Health, universities and other educational institutions are involved in PM . The core staff has also been instrumental in developing a grant application to the Appalachian Regional Commission for a 20 county area. In addition, the staff has been involved in developing a maternal and child health program aimed at reducing maternal and infant deaths in a rural five-county area, funded from five different sources. ONGOING OPERATIONAL ACTIVITIES Third Year - $603,203 A study bf elected funding characteristics of the operational activities supported by the Mississippi Regional Medical Program contrasted with funding characteristics of all Regional Medical Program projects points out a revealing profile for Mississippi. mi All ons Sponsoring Agency Medical School 77% 41% Public health agencies 16% 5% Training for Health Professions Separate programs for MD's, RN's or MP's and RN's 23% 47% Other combination, including Allied Health, LPN'S, etc. 77% 35% MISSISSIPPI RMP Rm 00057 5/71 lissil All Region S Activities Toward Target Populations Poor 43% 15% Not applicable 57% 85% Categorical Impact Heart 28% 24% Cancer 7% 12% Stroke 29% 13% Pulmonary 27% 7% Multicategorical 9% 38% Health Care Impact Diagnosis & Therapeutic 73% 34% The tie-in of the leading institutions and the combination of training and consultation service to target populations indicate that this Region is reaching an impressive number of communities and patients not previously served. For example, the stroke unit not only provides care to patients that was simply unavailable before, the @ staff provides consultation to physicians and patients through a neurology project and cardio- vascular clinics planned by the State Board of Health. The Coronary Cate Training project involves the University Medical Center, the VA Hospital as clinical training centers; in the first course, eight nurses from five communities, in the second - 15 nurses from 6 communities, and in the third - 11 from 7 communities have been trained. The radiation therapy project serves 51 new patients a month, compared with about 36 before the RMP support began. Family physicians have been trained, radiologists have been provided regular dosir,,ietry service at the VA Hospital, Mississippi Baptist Hospital, and the Howard Memorial Hospital at Biloxi. The radiation therapist has provided consultation to physicians in eight different communities. The radiation physicist has provided-help to nine hospitals in seven communities. New treatment centers at Oxford, Tupelo and Meridian, Mississippi are being established. Forty-two neurology clinics in 14 different locations have provided consultation and patient service.Through the social worker at the Univer- sity, patients have received referralservice to welfare, Crippled Childrenis Society, Vocational Rehabilitation, Mental Health and special education courses,. The CPR project sponsored by the Heart Association has held 220 courses; 66 hospitals are participating. Faculty instructors have been increased from about 20 to 139. Seventy-eight hospitals now have CPR committees and 37 have code-blue procedures. NEW OPERATIONAL PROPOSALS First ear C'St #16 - Statewide Community Stroke Rehabilitation Program $42,505 This is a pr posal sponsored by the Mississippi Heart Association to plan the development of model stroke centers MISSISSIPPI RMP -12- RM 00057 5/71 in each of the health care sheds of Mississippi, to serve the diagnostic, treatment and rehabilitation needs of patients in the surrounding areas. Funds are now requested only for Phase I of the project to concentrate on developing a prcitocol for optimum care of stroke patients, to recruit volunteer physicians, nurses and physical therapists f or team training at the @ Stroke Unit as a.prelude to the organization of the community stroke centers. During Phase I, community interest and involvement will be enlisted to aid in the development of the stroke units. The CPR training plan will be used as the model for the project with its "each-one-teach-one" approach and community involvement as focal points. The proposal speaks of the neurology clinics now operating with funding, but its relation and comparative priority for the Regional Medical Program is not clearly stated. Three additional years of funding are anticipated for Phase.II of the project, but the funding needs are not projected at this time. The Region anticipates putting in a request for the next three years at the time of its triennium application. #17 - Renal Disease Progr@ A version of this proposal was First Year included in the initial operational application from Request the NRNP. The site visit team learned that a chronic Hemo- $200,739 dialysis Demonstration Program had been supported since 1966 and would receive partial support through 1970 through other Federal funds. (Kidney Disease Control Program, now part of RMPS has been instrumental in this support.) The site visitors recommendations, supported subsequently by Committee and Council, were to provide partial RMP support for further planning and development of the training aspects of the program. The July 1970 Advisory Council reviewed a revision of the original proposal and returned it for revision. The recommendation stated that the '@eturned for revisio-d'was not to be construed as encouragement to submit a revision, that the concerns were related to the relation and expense of this activity as compared to other health priorities 'the RMP. This particular proposal has been developed with in assistance from the Kidney Disease Program Staff. To keep the unit viable during the time that the revised program was being developed, the Director, under the delegated authority, allowed the Region to utilize $47,347 in direct costs funds from carryover. This proposal thus represents a third attempt by the RMP to achieve stable support for its renal program during a period when Federal guidelines and priorities have been shifting. The proposal will be reviewed for its technical merits in relation to national guidelines by an ad hoc renal panel. The proposal is divided into three parts: 1. Comprehensive Renal Training Program II. Decentralized Home Dialysis Centers III. Urinary Catheter Care MISSISSIPPI RNP RM 00057 5/71 Earlier reviews pointed to the necessity for the Mississippi Regional Medical Program'to plan its program focus in relation to resources available in nearby states, as well as within its own state. A unique feature of the earlier proposals cited by the reviewers, was related to the trailer dialysis training in communities. The present proposal includes several trainee features which may be contrary to Council policy. 02 Year - $184,143 03 $190,354 #18 - Hypertension Control Demonstration This Region submitted First Year a hypertension screening application for earmarked funds Request during its planning period. The proposal. was located in $70,790 Bolivar County and was disapproved, primarily because of its isolated development and apparent lack of commitment by the practicing physicians serving in the area. The present project proposes to screen the population of Sharkey and Issaquena counties, two of the most rural, sparsely populated, low income counties in Mississippi in "an effort to determine the incidence of hypertension." Diagnosis, treatment and fol.low-up of hypertensive patients will be provided by the health department, the sponsoring agency, with assistance from the local medical personnel and the University Medical Center. A letter of agreement to serve as co-sponsor is included from one of the local physicians. Aside from the objective of determining the feasibility of screening, the project's objectives include: 1) Demonstrating the ability of nursing and allied health personnel to conduct a screening program with minimum physician supervision; 2) Demonstrating that education about hypertension will increase knowledge of the public so they will seek care. Initial screening will focus on "target" groups such as public recipients, especially the disabledand old age recipients. Bi-monthly diagnostic and evaluation clinics will be held utilizing staff and residents from the University Medical Center. A screenee may elect to receive care from a private physician or the clinics mentioned above. Social service technicians will follow-up the private patients. For those utilizing clinic services, laboratory and drugs will be provided as needed. Mississippi's minimum medicaid benefits presage a large number of patients requiring drug therapy support through this project. There are no plans for phasing out this aspect of the program. 02 - $74,410 03 - $77,515 NISSISSIPPI RNP -14- RM@@00057 5/71 #8R - Cardiopulmonary Resuscitation Training - This is a Th-ird Year request for three additional years for the Cardio- Request pulmonary Resuscitation Training. When the site visit team $53,267 visited the Region in its pre-operational phase, they found that this project was very important but recommended that the project be supported for two years only and be non-renewable. Since the project began, a number of training courses have been held and 66 hospitals are participating. The next three years of the project indicate that they will extend to all of the hospitals instruction for the hospital teams and in addition, the application states "there is a great need for training in ECPR to be made available to all ambulance personnel, rescue squads, civil defense, fire and police departments, Highway Patrol, National Guard, utility companies and employees of their high risk industries, life guards, school officials, Boy Scouts and community groups or organizations." This aspect of the training program is contrary to Council guidelines, which-indicate that RNP support for CPR training activity should be confined to hospital-related personnel, including ambulance drivers. The proposal for the next three years does not speak to any specifics. 04 $42,470 05 $33,320 RMPS/GRB 3/24/71 ST.WIARY OF REVIEW AND COI@CLUSION OF APRIL 1971 REVIE@,L CO@ELMITTEE llvLSSISS'@LPPI REG@LONAL 'r D ATCAL PROGRAM RM 00057 5/71@ FOR COt4S!DERAtIO@N BY MAY 1971 ADVISORY COUI@ICIL RECO@lf,@,T,'Nl,i'kTION.- Approval at the current level with advice not to fund renewal of the CPR project. The recommendation does not include consideration of the renal disease project #1.7 which was reviewed simultaneously by a special R@IPS Ad Hoc Study Panel. The panel recommended its approval with a site visit to negotiate a reduced budget. Support requested by the Region and recommended by the Reviet,7 Committee: --.Direct Costs f)@r@tionzil Y acquire Re tee, Recommended 03 $1,430,979 $1.,095,428 04 301.,023 141,623--- 05 301 l@9 -O--- TOTAL $2,033,191 $1,237,051 P,14PS commitment for support of the stroke project in its third year. CRITIOUF,- The Review Committee noted that the IfRt@IP is currently in its 2nd operational year funded at $1, 095,428. The Region's first triennial, application under the new anniversary review system, is expected at this same time next year, when a site visit will be conducted. MeenTYhile the Region optioiied-,.to request a developmental component and support for new projects as part of planning that has dc@vel.6ped this yeer. The former associate coordinator i-I no,,7 full-time Coordinator. His predecessor resigned to worli: -'Ll.111 time for the VA., bit remains on the RAG. A change in the Dcan of the Univorbity is al,ro noted. Of special interest to Corr,.iiittf',c-, x.@@n:,re points raised by staff cm review of, the conti.,noa,L- iorL api)l-j-CaLicti-t. Al.thoLigb the l@iG has taken on a new mevAber, and seems more active iii develol.,irig I)rogriTa direction and priorities; they have not tal,,en positive ,steps to phase out some current activities and move It-,i new directions. of th-k.s is their request for r nr--i,7al of the CIII', project has rece-)@.vcd support for t@7o years, recorl'i,,iicnded by the l@4ay 1969 -,Ite Althotioh manage- t'r e I i!n ii- t c@ mf,-,nt techniques hL-ve not been fully dz,--v,@@iop,,,2(i, a fairly effective core staff b@-@s CVO'J.17C-(J' and is developing with Appropriate statewide in the state MISSISSIPPI Rll@@ -2- RM 00057 5/71 and there is or, eciii@hasiE,, on @,uo-area development. iTealth m,,inpo-v7er continues to be ti-@c, top priority and success has been atliieved in generating tJni.vcri@l.t.@r @i,-clical Center assistance to all. parts of the state, as well as involving ot'Ller institutions of higher learning. In light of the findings citir:Litg. pnst: site visitF,, the Committee is well aware of the dearth of hcaJ.tl,-i care needs of Mississippi and the fact that it has only one medical @-cliool,center located at Jacl,,son, For this reason, as has been the case in previous reviews, t e Committee was concerned about the type of activities-presented for support with the limited available funds. In general, it is bel.ieved that the activities proposed are not ne,17 nor do they relate i-7el.1 with the stated objectives and priorities. Projects i@;ith continuation com@ll-itments probably merit continued suvdl?ort but the region slioLil.,] bcairt no-,,? to pl-6n for appropriate phasing out RI@FP support. Al.though the Rcaioii needs some funds for sorr..l-@ nex-Y and approval of a dcvelopr@icnt,31 component at this time-, is premature. The proposed new project on strole rehabilitation rel@iter; to the ongoing stroke -care project 1"'I,R which is sl.ated for one more year of RIIP support, The hypertension project does not relate to the coronary care project and it is believed that it -v7ill@ not provide epidemological data expected. The Committee also expressed concern about continuation of the latter after cessation of M,,T support. The Committee believed the renal disease project has merit but is concerned about the Rcgion's hesitation to invest its funds in more basic problem areas affecting more people. Some though that unless the Region has the capacity -.nd/or resources, despite the renal. program's excellence, it might impede t@te-function of the Region in general. In general., the Committee believed Mississippi is making some progress, but has awesome problems and limited resources. RAG and Core have not yet developed sufficient management and evaluation capabilities to warrant full support. The Committee bel.icved that merely taking this action and sending back the i.,igrd is not enough, Direct RLMPS assistance is needed in llississippi prior'-to their-sttbmissi.on of the next application. This might be accomplished best by a "thitilr, session" with Rii@S participation and/or a pre-site visit. I RI@IPS AD ll.OC KIDNEY DISEASE C Ll'f P,- The panel thought this to be an, excellent proposal, well documented, and describing on area of the country in Deed of assistance. It was, however, believed that the budget should be reduccd'frotti $270,048 to a range of $75,000-$100,000. The Panel. recommended approval with a site visit to negotiate a reduced budget. CPB/Rl@iPS/4/26/71. MISSOURI S Y TABLE OF CONTENTS Page No. General 1 Fiscal Information 2 Geography and Demography 6 Orgatizational Structure and Processes 6 Regional Development 7 Planning 7 Operational Program 7 Early Background 7 computer and Bioengineering Program 8 community-Based Programs, including 9 Kansas City Continuing Education Program 11 Regional Objectives 11 Application 13 Developmental Component 13 Core 14 Computer/Bioengineering Proposals 16 Comunity-Based Proposals 18 Continuing Education Proposals 22 (A Privileged Communication) REGIONAL MEDICAL PROGRAMS SERVICE S Y OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION Missouri Regional Medical Program RM 00009-05 5/71 406 Turner Avenue - Lewis Hall April 1971 Review Committee Columbia, Missouri, 65201 Program Coordinator: Arthur E. Rikli, M.D., M.P.H. This Region is currently funded at $3,800,000 (direct costs) for its fourth operational year (ending June 30, 1971. It submits a triennium application that requests: 1. A Developmental Component II. An expanded core III. The continuation of 11 ongoing activities IV. The renewal of two activities V. The activation of two Council approved but unfunded activities VI. The implementation of 16 new activities VII. The termination of 15 activities The Region requests $5,061,962 for its fifth year of operation, $4,310,940 for its sixth year and $3,511,564 for its seventh year. A breakout chart identifying the components for each of the three years follows. Several of the proposed new activities have previous review histories, which will be elaborated on later in the body of this summary. A site visit is planned for this Region, and staff's preliminary review of the application has identified several issues for the site visit team's consideration. Because of the complex nature of the Missouri program, the site visit has been divided into four parts dealing with: 1) the review, decision-making and administrative processes of the overall program (to be reviewed in Columbia, Missouri); 2) the continuing education program (Columbia); 3) the computer and bioengineering activities (Salem and Columbia); and 4) the development of the subregional program in Kansas City. The issues related to each of these components are discussed in detail in the sum- mary and in a separate memo to the site visitors. MISSOURI RMP -2- RM 00009'05 FUNDING HISTORY Planning Stage Grant Year Period Funded 01 - 6/30/67 $ 332,130 02 7/l/67 -3/31/68 255,93 Operation Program 01 4/l/67 - 3/31/68 2,619,000 02 4/l/68 - 3/31/69 4,681,609 1 03 4/l/69 - 6/30/70 5,678,568 f/ & 2/ 04 7/l/70 - 6/30/71 3,800,000 05 Future Commitment for Core and 6 Projects 1,851,610 06 Future Commitment for Core and 5 Projects 1,707,075 1/ Includes A restriction of $240,343, which was placed in the 02 year, carried over to the 03 and never released to the Region. 2/ For a 15-month period. L RER,!DN t4lSSOURI CYCLE RM 000()q 5 /71 BREAKOUT OV REQT.TEST 05 PERIOD Trienniut,) NEV -9 !ACT!',IIT:LES i DIIZECT IINDIRECT TOTAL AG-EIVITI.ES iltE,@L@4AL iAPPR/UN '@DEVrLOPMF.NTAL COMPONENT :$ 400,0()O I$ 400,000 -n- 400,0(10 156-! 'CorlE $1 474,165 ._I,474.165 _U-_! 1,819,953 ri --- I 1 163.419 53.115 @;' 216,654 i 161,419 @#5n - Strokt, Prpv. & Rehnb, -7@6. 107,796 107.796 2Er.. 65 136.0( #52 Health Caree-s Program!, 100,777 I 00. 7 77_' 2@6 ! f) 126,997@ 114,572 114,572 15,,iSO 130.452 -C-A- -@'-E -O-, #58 CV Eetic. & E%@al. 116,570 116,579 11,167' 149@332 82,566 13,180 95,946 82,566 #37 Radioisotope Program 102,444 102.444 6,768@ 109.212 ii e a 1 t !I A i @. e P o@i 1 1,683 141,683 45,794 187,1,77 el!9 Phoncerdioscan 37,21.8 17,218 1 7, -)OO _45, 11 8 75 8@74---- 83 .F4)-=b-FaF t@pi-Tn-cTi'l I dren 759874 3@,709 111,5 @,162 - Drug Infor. Center $32,589 32,589 11,870 44,459 4 46,R!4 11,794 59,628 46,83 1;25R - StrOL-e ICU 6,964 9@."72 298,936 i 6,322 37,4nl in Can. HosO. 11,079 @1,079 148 i 67 148 'A7 L87 @,168 - Prev. of CV Pultn. Prob. !-_@7 - 104.615 290.710 i 29n,710 51 , n6-7 ?41.777 Tia,- Airiq i 58,40.5 14,161 /Z, -) 72 1726.R- Nurse Trng7Arrhy. & Reg i 58 405 75,07n 75,070 1 2, @161,1 Q7.4'1,4 #71 - APHAS Firld Tp-tt 417 - ALTD, Ph,,-t. 5 1 7 171 q"g in #71 - Sub-Retz. E-,nprg. Serv, ',9,883 18.888 @168 40, r)56 7@A77 1, pni --Z@e_i_-z 142,6?P i42,428 74,114 417,142 ,#75 - Bio,-.erlical Tnfo. Sfrv. j - lxnl,,ilp Rpbar- Re-vice --O_l 27(, 91@776 'I') 7 I I PI (In '4 14,651 184,651 16. 1,Fll 221,112 4T 7 7 - Ca-,;iar Care I 91 44n ii-sn? @7q - l@-ovement of 11.9ni 11,901 56,9 12.670 #PI CaTpron Health Care 145,@78 CE - Coordination 114.062 114,062 @1,116 G-repn lits-I @h @@r 9 'i - 6 61 070 Unassigned @@,146,117 $79,423 @$2,tl2p $7,6n4,737 $,7@)5,369 433 $5,O6lt962 $6, 2()8, 079 REGIO CYCL7 Triennium@ BRE,@KOUT OF REQUEST 06 -PERIOD T c T i 0 CO',@TI"Ul',\G I ;PRIZVICTJSL'! !iEW T,\IDIRE@@T TOTAL IT.;ACTIVITIES DIRECT AC',- 'Pt!, . IVITES ;RENEWAL JAPPr,/UN I ; . on,ono I$ 400,000 i$ 4 DE'v'ELOP@INTAL r)27. COPE i-,687,83 179,458 179,458 r 7 63 .,157 P,5,214 14 45 119,11@5 126,111 i 120,5]i 120,511 .K, r 3 7 81,986 i 81,98 6 i 36,984 $36.984 i -- -4T 708 52,272 $52 2 72 @25R IS3, 83 6 I 7,095 67,095 6 6 3 -2:1 822 17e,82 52,364 !72 6R 52.364 #73 i 37,595 1 37, @;74 288,/4/4n 2SR.440 6 94,f,25 94,625 15().554 159,554 7 7 i 47,480 47. 7 480 71,610 73,610 i In,146? 10.461 460 28,460 2 ,R. 142 94n 142,940 95.077 95.077 0 - Unassigned 1$10,'@,636 $84,692 -'$4, 31 0, 940 T 0 Ttt'- $2,463,615 $I,657,997 Rm oooog 5171 BR:-:AKOL'T OF REQUEST 07 PERIOD ALL Y-LARS ALT- Y-ZARS A N:-: w :T ACT!' CTTV'4'T_'- DIRECT 114T APPR. /U'@FTq. )I@EC TOTAL DiRzLCT f$ 40r), Onr) 400 is i,?nn.or)o "OP. nnr) 6, 61 7 F- 8() 6. 1 7 lt2.1'771 2 --- 322! 5 240,681! I 247,081 -82.56@ 7 _102.41-4 iL 141,68-. 17,218 157,860 @62 $39,165 1 19 1 6 -5 i 108,738 i VI #;;4 50,259 1 50,259 144,801 1 @,2 5R 259,236 45.085 45,085 110,000 1-34,24-3 "9 12Z,716 22,71(, 592,24,R #26R $52,287 52,2871 63,056 --- 75,070 7 2 @,74 85@222 75 259,440 2 ',9 rn 44f,) 890, @r,,s ii r 153 82@@ f53,82 1;77 L 498,027 -7 47,778 - 47.778 i 148.6QS 8 7c) 7'4 @ 61 f,) 71,r,10 221,21n 1 463 10 4@,' I 0-1 32. @,7 7 g, o.()o 76,L25 2 250.2115 256@2!15 9 P@ 4 7 tl77-' 9 5, 77 2t'15 81 5 ssigned 1 $1,896,617 $52,287 1,24 $1,473,236 'GRB 3/l/71 Missouri Regional Medical Program -6- RM 00009 5/71 GEOGRAPHY AND DEMOGRAPHY The Missouri RMP boundary is roughly that of the Statels, except for forty-two counties in the St. Louis area. The population of 2,849,594 occupies a land area of 69,138 square miles. The Region is 58% urban and roughly 93% white. The Missouri RNP has established some relationships with the neighboring RMP's of Kansas, Bi@State, Iowa, Oklahoma, Arkansas and Memphis. Coordination of MRMP and KRMP activities in Kansas City is effected through A,CHP b Council in Kansas City. A working relationship has also been established with the Memphis RMP in southeast Missouri. The MW includes two medical schools and two colleges of osteopathy: the University of Missouri Medical School in Columbia with an enrollment of 412, the University of Missouri Medical School in Kansas City with a projected enrollment for its first class (Fall 1971) of 36, the Kirksville College of Osteopathy and the Kansas City College of Osteopathy. The Region has 18 schools of nursing--four baccalaureate, six associate degree and eight diploma schools. There are also 13 medical technical schools including .11 baccalaureate and two diploma programs. General hospitals (including osteopathic institutions) total 130 with 15,012 beds. There are also two Veterans Administration Hospitals with 728 beds. (The figures for all hospitals exclude extended-care facility beds). Missouri is served by 2,414 practicing physicians (there are a total of 2,571 in the Region); 90i active doctors of osteopathy (total 959); 5,678 active RN's (total 8,518); 4,082 active LPN's (total 5,233); and a total of 31,864 other allied health personnel. ORGANIZATIONAL STRUCTURE AND PROCESSES The Missouri RMP "Regional Advisory Group" is a three-part organization composed of a Regional Advisory Council, a Project Review Committee, and a Liaison Committee. The RAG as a whole is designed to establish overall policy and to review project proposals. The RAC has 12 members appointed by the Governor from candiate.9 recommended by the Project Review Committee. Rob'ert E. Frank, Director of Barnes Hospital in St. Louis, has moved from membership on the RAG to the chair- manship, replacing retiring chairman, Nathan Stark. Other members include: 5 practicing physicians, I osteopath, I sociologist (Black), 1 State Senator, I State Representative, I attorney and 1 businessman. The RAC provides overall guidance on policy, program planning, development and operation of MRMP. Based on recommendations and priorities of the other two RAG components and the local District Liaison Committees, the RAG sets its own priorities on projects and makes recommendations to the National Advisory Council. Missouri Regional Medical Program -7- RM 00009 5/71 The Project Review Committee has nine members who represent the four medical and osteopathic schools, and the directors of the Missouri divisions of Health, Mental Health and Welfare. This Committee assesses project proposals and other,policy matters on merit, establishes priority ratings and forwards these with its recommendations to the RATC. It also recommends candidates to the Governor for RAC membership. The Liaison Committee consists of representatives from 23 voluntary and professional health agencies. This Committee provides recommendations to the RAIC on project value and their relevance to the represented agencies, besides serving as a two-way communi cations link between agencies and the MRMP. In addition to the three RAG components, there are District Liaison Committees presently in three of the six areas - Kansas City, South- west and Southeast, and similar committees are being planned for the ot er areas. Each committee is responsible for providing recommendations regarding lodal need for projects proposed from its own district and impact on other areas, as well as for developing its own district policy. The Greater@, Kansas City Liaison Committee has been replaced by a group nominated by the local CHP "B" agency--an arrangement also being considered by other districts. REGIONAL DEVELOPMENT I. Planning - Planning began in Missouri in April 1966 with the submission of a planning grant application by the Program Coordinator, Dr. Vernon Wilson, The reviewers of the application commented that: 1) planning for and representation of the St. Louis area on the RAG seemed weak (the Bi-State RMP later encompassed this area); 2) the program was vaguely defined; and 3) the apparent emphasis on community service was most impressive, although not wel-l-budgeted for. The award was made in June 1966. II. Operation o ram A. Early Background - In October 1966, the Region submitted an application for three operational pilot projects, which was deferred for a site visit. At the same time DRMP suggested to the Region that a more comprehensive operational grant application be prepared, with the possibility of the becoming one of a few timodel programs." The Region explained at a site visit in 1969 that Dr. Wilson gathered together several members of the University faculty interested in RMP and spent "forty days in a DC-3" with them traveling around the United States looking at possible types of innovative projects to develop. The Region then submitted an application containing 20 additional projects, three of which were community programs, three population and data studies and the rest computer and bioengineering activities. Submitted at a time when the RMP budget for 1970-71 was projected for $200 million, the intention of these latter proposals was to use the computer and bioengineering resources at the University to develop and deliver diagnostic and therapeutic assistance to practicing physicians isolated from the medical center. The Region was site visited in November 1966 with a favorable report, and the Region became one of the Missouri Regional Medical Program -8- RM 00009 5/71 first RMP's to become operational when the award was made in April 1067, at a level considerably below that requested. Three conditions were placed qn the award: 1) the RAG add minority group representatives; 2) more attention be given to the urban ghetto areas; and 3) more emphasis be placed on cancer programs. During this same year two- supplemental applications for project support were submitted: Project #19 - Automated EKG in a Rural Area, was approved and a proposed stroke center at Kansas City General Hospital was disapproved. At the beginning of the second planning year (July 1967).,another site visit was held to look at several supplemental project requests. The visitors were impressed with the concept of regionalization and the Region's intention to phase-out RMP support after three years of funding. In October 1968 Dr. Arthur Rikli replaced Dr. Vernon Wilson as Coordinator. At this point in its history, the program seemed to reviewers to separate into decided program areas. A. Computer and Bioengineering Activities Eight projects were funded in this area: multiphasic screening, mass screening - radiology, automated patient history acquisition system, data evaluation and computer simulation, computer fact bank, operations research and systems design, bioengineering and automated EKG for rural areas. Both DRMP and MRMP r6alized that these were developmental activities, but both hoped that after three years, they would be able to make definite contributions to the delivery of health care. At that time of the second year's continuation review of the original projects, the Region submitted a request for $860,000 more than the committed level, foi-expand computer and bioengineering activities as originally planned. A restriction of $240,483 primarily for A and R, which involved computer facilities,,was placed on the award, and a technical site visit was recommended. Although the Fall 1968 visit was only for one dgy, reports of progress on the individual activities were discouraging. Within the next few months, the Region proposed support in their third operational year for a ilinical core resource which involved approximately $800,000 for staff in the computer/bioengineering projects in addition to the ongoing projects in this area. As a result of the critical site visit comments and the uncertainty about the concept of clinical core, Council recommended that these activities be reviewed in depth during a site visit that year. In October 1969, a major site visit was held which included three peer reviewers with expertise in computers who spent two days assessing the activities. As a result of the site visitors' conclusion that none of the activities had yet demonstrated success in improving the delivery of health care or in enhancing regional, cooperative arrangements, Council in MArch 1970 recommended that the Region reduce its expenditures for these activities and then phase-out RMP support completely by June 30, 1971. The project was awarded approximately $1. million for its fourth and final year of operation in 6rder to combine the former eight parts.to make the Missouri Regional Medical Program -9- RM 00009 5/71 system compatible, and to field-test the module in one physician's office in Salem, Missouri. At the time of staff review of the last application from Missouri in July 1970, RMP staff requested additional information about the Advanced Technology Proposal. The Region's replies raised concerns which rtlated to: 1) the liklihood that the components would be completed, made compatible and fully operational in the private physician's office in Salem in sufficient time to test enough patients to obtain meaningful results within the project time period; 2) the coordination necessary to cohese so many different elements; 3) the detail and comprehensiveness in workscope timetables and planning needed to bring the divergent subprojects together in an orderly and coordinated manner. The Director, RMPS, recommended that the Region call in outside experts in systems design and computers, epidemiology and clinical medicine to review, monitor and make suggestions for appropriate changes in order that the project would be completed by June 30, 1971. A site visit including Dr. John Hirschboeck, Wisconsin RM.P Coor inator and a member of the October 1969 site visit team; Dr. Morris F. Collins, Director Medical Methods Research, Perman6nte Medical Group and Dr. Martin D. Keller,, Department of Preventive Medicine, Oiio State University, was held by the Region to the Salem operation in January 1971. The report, a copy of which has been forwarded to RMPS, is enthusiastic about the results. The Region's proposal for continuing these activities is discussed on pages 16-18 in the summary. B. Camunity-Based Programs MRMP's early efforts in developing community-based programs were in Smithville and Springfield. Smithville in northwest Missouri evolved and was praised by national reviewers as a model for small communities in developing total care facilities, including continuing education opportunities, which have become self-supporting and cost-efficient. The Smithville project began in April 1967 and terminated after three years of support. The Springfield Cardiovascular Program in southwest Missouri was an early effort in building linkages to rural practitioners. The project, which was expanded and reviewed as Project #58 in 1970, appeared to site visitors to be an effective instrument for subregionalization of health services and education. There were other early subregional efforts such as a Comprehensive Cardio- vascular Care project at Kansas City General (#27), a stroke pilot project at the Kirksville Clinic of Osteopathy and Surgery (#28), a regional program in rheumatic fever prevention using a detail man (#32), and a radioisotope cancer program in Cape Girardeau (#37). In the Region's third operational year (1969-70) the subregional projects began to experience some difficulty during their review at the national RM 00009 5/71 Missouri Regional Medical Program -lo- level, which had profound repercussions in the Re9ion. At a time when 9 the computer and bioengineering activities were being funded at a $2,4 million level, the disapproval in two review cycles of an intensive care program in Sikeston, a stroke program in Joplin, a coronary care unit in Osceola, and a comprehensive rehabilitation program in Le' banon, inadvertently conveyed a false--impre-asioTi to the Region of the -- national reviewers' wishes concerning the future emphasis of the Program. While each project was viewed individually and returned for substantive technical reasons, the cumulative effect on the Program of these individual actions was finfdrtanate. The site visitors in October 1969 heard repeatedly about the Sikeston community. After a study of the site visit findings concerning the discouraging results of the computer bioengineering investment and the lack of emphasis on community-based programs, Council in December 1969 recommended that the Region f4i;vise and resubmit these community- based projects during the next review cycles. In the February-March 1970 review cycle, Council did approve the resubmissions from Joplin (#50) and Sikeston'(#51) and a renewal of the Springfield effort (#58). The Region's community-based requests since then have not fared so well. The Region submitted a comprehensive health care system proposal for the Cameron Community in northwest Missouri (#60),, an intensive care and rehabilitation project in Branson in southwest Missouri (#61), and a comprehensive health care system proposal for eleven hospitals in the Green Hills area (#65). While Council recognized the earlier advice to the Region to encourage community development, it was concer ned with the types of support requested by the Region in each project. Items such as equipment, staffing for provision of services and a communications system for centralized cost accounting, reviewers felt should be under- written by the hospitals and not by RMP. In addition weaknesses in documenting need, describing what would be done and h;w it would be evaluated indicated the need for more assistance from the MRMP Core staff. The Region's revised submissions of these proposals are summarized in pages 20-21 of this summary. Descriptions of new activities in this area are on pages 1.8-20 of this.summary. Until the last year there was little evidence of RMP activity in Kansas City, other than the cardiovascular project at Kansas City General (#27). The October 1969 site visitors found that the Core office was not staffed, and the Kansas City Liaison C- ittee had become inactive. However, with the development of a new medical school in Kansas City and the proposed involvement in the Wayne Miner Neighborhood Health Center through the Hi-Blood project (#46), prospects looked favorable. During the past eighteen months, the Kansas City Core office has been staffed and the CHP b Council now serves as the liaison committee for MM and KRMP in Kansas City. A Core supplement was disapproved by the November 1970 National Advisory Council because the proposed activities were too diffuse and did not appear to be correlated with the rest of the MRNP. This application again proposes supplemental core funds for Kanszw'Ctry aA& two projects, #78 and #70'described on page- 23' ' of this summary. Missouri Regional Medical Program RM 00009 5/71 D. Continuing Education and Training The third major aspect of the Missouri program has been continuing education. While not designated as such, many projects had continuing education or training as a major feature. There seemed to reviewers and site visitors to the Missouri program to be two concurrent and separate trends in this area developing in the Region. One was the excellent efforts fostered by individual project directors independently of the University 14 projects such as Smithville, Springfield, and Cape Girardeau. The other was the University-connected activities, such as the stroke ICU and cardiac ICU training proposals at the medical schbol (#25 and #26) and the telecture series, which linked community hospitals throughout the Region with the medical school by two-way radio (#33). This side of @'s continuing education program seemed to be supporting continuing education competence within the medical school without building any visibility for RMP. A Core-Continuing Education resource based at the medical school was submitted by MRMP in mid 1969. Its lengthy review history is described on page 23 of the summary, but its difficulties in gaining approval aty be Attributed partly to its emphasis on developing an institutional organization to provide continuing education rather@than developing programs which would focus on improving patient care. Other factors, including the size of the request, are discussed as background to the revision in this application. Other proposals denoted by the Region as primarily continuing education are included in this section. In conclusion, this Region is at a critical point in its history. Over a year has elapsed since the major program site visit and the Review Cr ittee and Council review which made substantive recommendations about the direction of the program. The Region is now preposing a three-year plan which is an outgrowth of its total experience since 1967. The regional objectives and the three-year plan to address these,objectives follow. Regional Goals The Missouri RMP has developed the following program goals: 1. Through cooperative arrangements to accelerate health and medical innovations and demonstrations. 2. To develop a balanced program of problem-and-patient-care oriented continuing education for health professionals. 3. To develop a relevant data base and the data haidling capability to permit effective project and program evaluation. 4. To stimulate the prevention and early detection of heart disease, stroke, cancer and related diseases. Missouri Regional Medical Program -12- RM 00009 5/71 5. To stimulate lay health education - information programs, emphasizing prevention and early detection of diseases. 6. To strengthen the diagnostic and treatment capabilities of the region with respect to RSC & RD.. 7. to expand and'strengtnen long-term-care, rehabilitation-and home care for HSC & RD. 8. To develop a comprehensive health services project in each of the six subregions. 9. To facilitate health manpower recruitment,, thus helping the physician make optimum use of his knowledge and skills. 10. To achieve close coordination with other health and health-related programs. 11. To co-sponsor'activities and programs with neighboring Regional Medical Programs. -13- PM 00009 5 /71 Missouri RMP PRESENT APPLICATION Developmental Component First Year Second Year Third Year $400,000 $400,000 $400,000 The Missouri RMP states that its developmental component activity is expected to have two benefits: greater responsiveness of-the IARMP'@s objIectives to changing regional needs, and increased effectiveness of the MRMP Pi-opram.l.n achieving these objectives. Proposed developmental activities Incl.ude: 1. Providing opportunities for a wi(ler variety of professional and lay input into the Region's decision-making bodies in reg8rd to reshaping objectives. The Region might provide part-time support and secretarial. service for one member each from the I.aw school, an allied health profession, or a minority group, who would.study RMP legislation and the Health care system from their vantage point, recommending fresh approaches. This might lead either to revamping of objectives or to proposal develop- ment, 2. Selectively supporting the development of proposals which 0 specificAll,y address regional objectives. Developmental component funds might be used to encourage development of the most relevant projects proposed to the Region by letter of intent each year. Support would include vart-time support of the project director, support for a research associate, secretarial help, evaluation consultation, and for activity required to obtain co-operation and coordination in the project area. Funding surveys and feasibility studies to ensure development of proposals which would be more effective in reaching program objectives. Develonmental funds might support both the studies which would val.idate the assumptions usually made about expected benefits of proposed activ- ities. as well as the dita-gethering activities necessary for developing and evaluating a proposal being written or considered. 4. Funding activities which would themselves I.ead to achieve- ment of Regional objectives. This would allow greater flexibility in the Region program. The develop- mental component could provide total support for short-term projects of I imi ted scope, a Rwell as partial or complete support of projects awaiting RMPS approval should the RAC consider earlier funding necessary. RM 00009 5/71 Missouri RMP -14- dminiptrativp procedures for Allocating Devel.opment a] Component Funds The T)evploinmental component will be managed primarily by core staff. Requests will be submitted for approval to the RAC, and funds awardecl an(] managed by the regular administrative support system. CORE Fifth Year: $1,474,165 The Core of the MRMP.has been organized into three offices: 1. The Office of the Coordinator, which provides administrative support and professional consultation in electronic data processing, fiscal affairs, information and management. An Associate Director for Continuing Education, who will be responsible for all continuing education activities in projects and in the district offices, will be added to the Office of the Coordinator. Fifth Year Request $647,795 2. The Office of Operations, which is primarily responsible for program implementation and evaluation. When projects have been funded, the Office coordinates and monitors the progress of ongoing projects through in-house site visits in the next-to-th@e-last year of the projects, district project directors meetings, and project directors meetings via the telelecture network (not yet initiated). This Office also requires quarterly progress reports. In order to help regionalize some of the results of the bioengineering projects, the "detail man" of the MRMP- funded rheumatic heart disease project has been added to the operations staff. Consultants are made available to project directors in the areas of communications, continuing education, medical and scientific affairs, hospital and allied health affairs, computer science and evaluation. Fifth Year Request $181,981 Ihe Office of Plannin_gwhich develops an overall MRMP plan an@ major disease catep6ry plans to be implemented through projects. This Of'ice works with neople developing proposals and staffs the meetings of the MRMP A,Ivisory Council, Project Review Committee, Liaison Committee and Subregions! T,ieison Committee. The Program Metho(lolop,,y Unit, formerly funded as a project and with expertise in epidemiology, statistics and Flats processing, is incorporated into the Planning Office. It provides various data for project purposes and for the RMP's planning purposes by utilizing existing sources of date and occasionally collecting its own. Evaluation is also the responsibility of the Planning Office. Although presently placed within the Planning Office, it appears from the organizational chart on page 51 that the district offices will be made Missouri RMP -15- RM 00009 5/71 directly responsible to the Coordinator. District consultants have been chosen for each of the districts (Kansas City, Northwest, North- Past, Southeast, Southwest and Central). District offices in addition to the Kansas City office will be developed over the next three years. Fifth Year Request $458,11'4 The Kansas City Area Planning Office provi(les.planning activities for the five-county areas of Jackson, Clay, Platte, Ray and Cass Counties in support of MRMP activities. Its staff includes a Planning Director, Assistant Directors in communications, community services, allied health and professional relations. Activities of the Kansas City Area Office (described in pages 1.64-175 of the application) include efforts in planning phy6ician's assistants program, restructuring nursing curriculum at the junior college level, developing career-ladders for L.P.N.'s and studying the feasibility of a two-way medical TV network. Fifth Year Request $186,276 Coordination and some overlap of membership is planned between the MRMP area committees and CHP (b) councils4 The experience of the University Extension Division, which has offices throughout the state, will also be tined in developing public education programs at the subregional level. The MRMP Core has also been administering the state's $200,000 appropriation for hemo(lislysis and is presently involved in developing a multi-regional renal disease program with the Kansas and Bi-State RMPS. The total number of positions requested is 80 (71.5 F.T.E.): of these 80 positions, 58 are presently fil.led. Sixth Year Seventh Year $1,687,81-1 $1,896,617 Descriptions of these terminating Program Guidance Projects can be found in the application following the core section. Communications Research Unit #11 - Population Sturly Group Surveys #14 - Automated Hospital Patient Survey Projects The Region has orgeniz ed the discussion of their projects into various subject areas in their application. In describing the proposed activities in the summary, Staff.has changed the Region's arrangement somewhat, in order to better align the project discussion with the background -16- RM 00009 5171 Missouri, RMP material, The three major sections fe Computer and Bioengineerin@., Projects, Community Service Projects and Continuing Education Projects. Computer and Bioengineering Projects While the Advanced Technology Project and its eight components (Multi- rhasic Testing, Mass Screening Radiology, Automated Patient History Acquisition System, Date Eval.ustion and Computer Simulation. System, Computer Fact Bank, Operations Research and Systems Design, Biomedical Engineering and Automated EKG in a Rural Area) are terminating as such, the work begun (luring the past four years will be continued in the following five projects: Requested First Year Project #64 - Bioing rumentati n $46-.834 This project was previously approved by Council but has not yet been funded. It was developed as a result of one of the recommendations of the October 1969 site visit report which urged that the medical instrument- ation servites of the biomedical engineer in t e Biomedical Engineering Project be made more widely available to hospitals throughout the Region. The project would help regional hospitals optimize their utilization of patient monitoring instrumentation by: 1)'Giving engineering counsel in ICU-CCU design and in the selection of biomedical patient care instrumentation, thereby assuring patient protection against accidental electrocution; 2) Providing specialized instruction for engineers and technicians in routine maintenance procedures, recognition of substandard operation and safety practices; and 1) conAucting seminsi- a on request within regional institutions to instruct medical and paramedical members in techniques for ontimum utilization of their patient care instrumentation. Second Year Third Year $47,708 $50,259 Requested First Year Project #69 - Computer Processed Diagnostic Aids $290,710 in a Rural Area This proposal is an extension and field testing of the automated electrocardiogram with the addition of new diagnostic aids, including artificial pacemaker analysis,-cardiac arrhythmia analysis, exercise ECG analysis of lung function by spirogram and screening analysis of the phoncardiogram. The project plans for 38 stations and 50,000 ECG's per year. A special sim would be to provide aid to the smallest medical Missouri RMP -17- RM 00009 5/71 facilities - community hospitals under 100 beds, group practicies and solo practitioners - at a reasonable cost. The proposal also offers training for medical and electronic service personnel. Second Year Third Year $178,882 $122,716 Requested First Year Project #71 - Automated Patient Iiistory Acquisition $75,070 System Field Test The Durpoiqe of this proposal is to field test this approach to acquiring a meiical history in the offices of a three-man internal medicine group practice in Cape Girardeau. The APHAS program has designed the question- noire in laymen's language with anatomical sketches and cartoon characters an,! a computer program to present these questions on the computer terminal. When the patient finishes the questionnaire (usually in 45 minutes), the computer prints out a summary of the patient's responses to the questionnaire as well as the positive responses to symptoms of diseases for the anatomical area troubling them. Some preliminary evaluation has been done of the patient's responses. Requested First Year Project lt72 - Automated Physician's Assistant $153,537 The project woul.d attempt to determine the effectiveness of a computer- related system of medical tests designed to function as a "physicign's assistant." The total package would consist of the APHAS questionnaire, an EKG, 12 blood chemistries, blood pressure, height, weight, eye test, hearing test, chest X-ray, spirometry, tonometry4 Achilles tendon reflex and a phonocardioscan. A prototype of this system which is presently installed in a physician's office in Salem, Missouri, is funded until June 10, 1971. Further support is requested to test the effectiveness of each of the components and permit further evaluation of the system by the physician and his patients, Requested First Year Project #75 - Biomedical Information Service $142,428 Formerly known as the Computer Fact Bank, the Biomedical Information Service proposes to tie together library activities and systems for information coordination and transmission. While the present system has developed a system of storage and retrieval of biomedical information with ten operating outlets in the Region, the BMIS would utilize the 102 tplectivp units, 15 teletypewriter units of the ECG project and 27 Patollitp Extension Heal.th Information Centers to be developed. The proposal hopes to increase smaller medical library utilization by: 1) holding workshops, in-service training and continuing education sessions for library staff personnel, hospital administrators and physicians; 2) arranging for interlibrary loanso information exchange and bibliographies and specific literature; and 3) provision of con- oultation services. Second Year Third Year $288,40-' $259,440 RM 00009 5/71 Missouri RNP -18- The MRMP Advisory Council has recommended that this proposal incorporate the services of the Health Sciences Libraries System and the Drug information Central (#62). Community Service Projects The terminating project is: #29 -N.E. Missouri Cooperative Stroke Pilot Project Continuing Projects with Committed Support art: #46 Hi-Blood #50 Joplin Stroke Prevention #51 Sikeston Intensive Care Unit #52 Health Careers Continuing Projects with no committed support (these proposals were originally approved but unfunded; however, the Regton has elected to initiate them with carryover or by rebudgeting): #36 - Missouri Cervical Cytol.ogy #37 - S.E. Missouri Radioisotope #38 - Homemaker Health Aide #39 - Phonocardioscan #43 - Diabetes in Children #62 - Drug Information Central New Projects In these projects, the Region provides services either to several locations or for the entire region on a community basis as part of a plan to extend regional activities to the patient's bedside. Projects #76 (Mobile R6habilitation Service) and #77 (Cardiac Care Missouri) both relate to objectives: 1) cooperative arrangements; 2) continuing education; and 6) diagnostic and treatment capabilities. Project #76 also relates to objective 7 - rehabilitation and home care. Project #68 (Cooperative Prevention for Cardiovascular Pulmonary Problems) includes not only objectives 1,2,6, and 7 but also objectives: 4) prevention and early detection; and 5) lay education. Project #80 (Cameron Health Care) is rel.ated to 10 of the 11 Regional. objectives and #81 (Branson Intensive Care) includes all 11 of the Region's objectives. Project #25R- (Stroke Intensive Care) relates to Regional objectives: 2) continuing education; 6) diagnostic and 'treatment capabilities; an 8) development of community health services. Mi@ssouri RMP -19- RM 00009 5/71 Pro t ft68 - Cooperative Prevention jec for Cardiovascular Pulmonary kP'rOblems This project would involve hospitals in the Kirksville area serving seven counties in Northeast Missouri. It is based on the Northeast Missouri Cooperative Stroke Project (#29) now terminated, Objectives of the new project are: 1) initiation of innovative continuing education programs for physicians and allied health personnel. (coordinated with Columbia and Springfield graduate nursing courses) and a community education program emphasizing prevention; 2) development of a preventive and therapeutic activity center in collaboration with the Division of Health and Physical Education of the Northeast Missouri State College; and 3) establishment of progressive care and rehabilitative programs for cardiovascular-pulmonary patients as a part of the new expansion at the Kirksville Osteopathic Hospital. First Year Second Year $67,148 -T67,095 Project #73 - Regional Emergency Service Quantitative Up@a(linp, (RESQU) This it a planning effort, involving an eight-county rural area of Southwest Missouri, which would establish an organized ambulance service ,capable of getting patients to medical facilities in optimum condition. Upon successful implementation in these counties, the program would be expanded to the remaining 25 Southwest counties. First Year Second Year $38,888 -0- Project #74 - Platelet Plasmapheresis Program This Project will establish an efficient, full-time and ultimately self-sustaining plasmapheresis program in the southwest Missouri subregion. When implemented at St. John's Hospital in Springfield, the program could accommodate patients in any southwest hospital where platelet transfusions are (lone. Primary purpose of the project will be provision of compatible platelet infusion. Tissue type and liisto-compatibility techniques would also be initiated along with this project. First Yes Second year $47,627 $37,595 Project #76 - llobile Rehabilitation Service This project would provide rehabilitation services, now unavailable to rural areas of southwest Missouri, by establishing a mobile service under the supervision of an orthopedic surgeon and in consultation with a Missouri RMP -20- RM 00009 5/71 phyiistrist. Two teams, each comp osed of a physical therapist and a I nurse a side (with part-time access to an occupational therapist), would provide 20 days O'f service each month to outlying hospitals and nursing homes. First Year Second Year $93,276 @94,625 Project #77 - Cardiac Care Missouri This project is designed to provide improved care to patients with acute cardiovascular illness through: assessment of present care and consultation on corrective measures; coordination of ongoing programs; education of providers, patients and their families; establishment and' improvement of communication (such as tel.e-transmission of EKG's); and assistance in arranging continuing clinical consultation. The project structure will include a Missouri Heart Association "task force", providing assistance to any community or subregion in Missouri, and cardiovascular care committees in each participating hospital relating both to volunteer staff in each subregion and to an MHA Cardiovascular Care Committee of 12 local physicians. Initially, project activity would concentrate in southeast Missouri. First Year Second Year $184,651 $159,554 Third Year $153,822 Project #80 - Cameron Health Care This is a revision of a previous submission which was disapproved because of weaknesses in evaluation and educational design and because it requested support for services which,sbould be financed by the community. Based at the Cameron Community Hospital, this project is designed to upgrade, through physician education programs, the diagnostic and treatment , capabilities in categorical diseases of 13 area private practitioners and to organize and train supportive medical personnel. The use of consultants from neighboring institutions should help reduce the isolation of the private practitioners. The project will also provide: appropriate patient care equipment from hospital funds, effective emergency care in ambulances, rehabilitation services, an(] trained personnel for follow-up care through a home health agency. First Year Second Year $11,901 $10,463 Third Year $10,463 Project #81 - Branson Intensive Care and Rehabilitation Project This revised proposal was turned down originally primarily because it-appeared to represent the interests of a single institution, rather than a truly regional effort. Mi.asouri RMP -21- RM 00009 5/71 This project is designed to provide immediate access to hi.gh quality, low-cost health care at the Skaggs Community Hospit8l, establishing cooperative arrangements with referral centers, with special emphasis on improving service to the large number of elderly disadvantaged and rural poor in the area. To do this, the project provides for both training and continuing education of nursing personnel technicians and Doctors of the hospital medical staff. Consultants will be drawn from St. John's Hospital, Sprin gfield (intensive care) and the U.M. Department of Physical Medicine (rehabilitation). The proj'ect will incl.ude evaluation of post-treatment results compared to past results and results at other hospitals. First Year Second Year $38,965 $28,460 Third Year $9,000 Project #83 - Green Hills Cooperative Health Care Project Disapproved by the November 1970 National Advisory Council because it also requested support for services and equipment which would ordinarily be underwritten by the hospitals, the project has been revised and resubmitted by the Region. This project is designed to combine the resources of 11 cooperating hospitals in the 12-county Green Hills medical service area to ensure improved quality and quantity of health care, with efficient, economical use of resources and comprehensive care for the entire area. This effort wil-I require establishment of a communications network serving all 11 hospitals, and development of: techniques for continuing education of all medical personnel, adequate ambulance service, adequate coronary and stroke emergency care in all hospitals, an areawide inhal- ation therapy program, an areawide comprehensive rehabilitation service, and a home health agency for the area. First Year Second Year $95,661 $95,077 Third Year $950077 Renewal Projects Project #25 R - Stroke Intensive Care Unit This project, located in a temporary unit at the UMMC, will continue to examine the effects of stroke intensive care nursing on mortality and morbidity of stroke patients. Presently, personnel in the temporary Missouri RMP -22- RM 00009 5/71 unit have become efficient with the electronic equipment and are preparing for the opening of,a new ICU. Nurses have already demonstrated ability to detect new or progressive neurological changes in the stroke patient. Of the 15 patients admitted to the ICU, twelve survivied; while of the 16 admitted as a control group to the regular care group, nine survived. Continued random admissions to the ICU and increased patient referrals will.provide an opportunity to conclusively document these results. Fourth Year Fifth Year $206,964 $52,272 continuing Education Projects The terminating projects are: #27 - Programmed Comprehensive Cardiovascular Care #33 - Continuing Education for the Health Professions (telelecture) continuing Projects with, Committed Support are:, #55 - Cameo #58 - Cardiovascular Education and Evaluation New Projects The new continuing education projects in this application include a variety of proposals which-address themselves to in-service training, improvement of health care problems related to laboratory services and two regional approaches to the organization of continuing education. Projects #79 (Improvement of Pharmaceutical Services) and #78 (COMPACT) are related to objectives: -1) cooperative arrangements and 2) continuing education. Project #70 (Training in Arrhythmia and Resuscitation) also relates to objective 2. Project #67 (Health Education in Cancer Hospital) relates not only to objective 2 but includes aspects of: 9) health manpower; 6) diagnostic and treatment capabilities, and 7) rehabilitation and home care. Project #67 - Health Education-in A Cancer Hospital Setting This project is a trial of comprehensive health education in a hospital setting, Ellis Fischel State Cancer Hospital. in Columbia. This effort will include development, implementation and evaluation of education programs for patients and their families, all hospital employees, and the public. Within two years, concepts developed in,this project will be shared with other facilities in the State through workshops and consultations. First Year Second Year $31,079 $33,836 Third Year Missouri Me -23- RM 00009 5/71 Project #78 - Cooperative Ongoing Medical Health Participation and Continuing Teacbing This project will establish regular inter-hospital departmental meetings to upgrade educational programs in metropolitan Kansas City hospitals which will be utilized by the new medical school for clinical teaching. COMPACT uDuld coordinate meetings of each specialty in conjunction with joint hospital departments so that multiple hospitals would be represented. A review, or coordinating, committee for each specialty or department would coordinate clinical review with a scientific session. Each department, then, would share in eight joint meetings annually, as well as in four administrative meetings at their respective hospitals. First Year, Second Year $51,440 $47,480 Third Year $47,778 Project #79 - Improvement of Pharmaceutical Services - Rural Health Care Institutions Sponsored by the University of Missouri (Kansas City) School of Pharmacy and Division of Continuing Education, this project will evaluate pharmaceutical services in hospitals and nursing homes - particularly in rural areas - to determine for each: current status of services, facilities available for such services, and local pharmacists available to provide proper services. This information will be used to plan and implement needed improvements in each institution through a cooperative effort of project staff and institution personnel. First Year Second Year $73,990 @73,610 Third Year $73,610 First Year Project #82 - Continuing Education - Coordination Project $114,062 This proposal has had a lengthy review his tory. Originally submitted in mid-1969, it was deferred by Council for further consideration by the October 1969 site visitors, reviewed at the site visit, returned for revision by the December 1969 Council, resubmitted by the Region in mid-1970, and again disapproved by Council. The substance of the cumulative criticism of this proposal related to: 1) the emphases on developing an organization rather than on designing programs geared to improving patient care; 2) lack of date used to identify needs; 3) lack of agreement among university, RMP and project representatives about the role of the extension agent; 4) the absence Missouri RMP -24- RM 00009 5/71 of plant for coordination of the educational benefits from other MRNP activities, particularly community-based ones, with the proposed activities of this project; 5) lack of'systemmatic evaluation; 6.) the size of the request ($2,000,000 over A five year period) and 7) the need for more full-time direction o f such a comprehensive activity. Briefly, this proposal would attempt to develop the framework of voluntary participation, interaction and cooperation of continuing education agencies and institutions which are necessary before a region-wide system of continuing education can be established. Cooperative arrangements would result from three related activities: 1. A Continuing education inventory would he initiated, with continuous updating, of all continuing education activities provided by institutions in the Missouri subregions. This would identify duplications, overlaps and gaps in overall educational programming in the Region. 2. Teacher-consultant linkages would be developed consisting of a specially assembled cadre ot representative health professionals working with Regional counterparts in specific locations, to ation needs common to each profession. The' identify educ consultants will also provide links to the Advisory Committee on Continuing Education 3. A local educational coordinator in each of five subregions would give individualized assistance to health care institutions in developing continuing education programs tailored to their own needs. (A sixth subregion will receive this,help from central project staff.) These coordinators would be part of Core staff. Second Year Third Year $142,940 $256,245 Fourth Year Fifth Year $225,172 $212,172 Renewal Projects Renewals Project #26R - Training in Arrhythmia and Resuscitation (Community Hospital Nursing Staff) This project would provide two weeks of training at UMMC in monitoring and resuscitation techniques for acute cardiac conditions to community hospital nursing staffs. The course will consist of one wee,k's initial training and a week's advanced training 3-4 months later, utilii,ing the Rocom Multi-Meals Instruction System and observation t the Coronary Care Unit, UMMC. Approximately 100 nurses would be t:ained per year at the UMMC plus another 50 in community courses. First Year Second Year Third Year @@- -1, - tri IR7 25- O'. i@'rat - -1-ii, EDUCA'I-ION, Al@D WELI:-ARE HEALTii sE--.r@vICt!5 At'.D t,4LtJTAL IIF--AL-Iti ALti,iNl';T,tATION ate: March 8, 1971 .Y to Alin Of.- Subject: Staff Revie@.., of the Missouri @@iP's Tri-ennial- Application, R@109. To: Acting I)irecLor Regional Medical Programs Sc@rv:' THROUGH: Chairman of the Month Chief, Grants Review Branch,@ ,Chief, Grants Management Branch Acting Chief, l@opioiial Dc,,vel.opi-tic.-iit Brai-L Staff met to rc,V!.C-v7 the triennial. application stil.)niitL(-@d by ti)(@ M-R-1-1-P. A pr.-Lti-,ary purpose of this review ,i@is to icl(,i-itify an-,I discuss issues for the si-te visi,t on March 30-31. Si-nce only six projects have cori,.-,I!Lment and since any reduction i.n the level of funding for 1-971--72 would coiicc@ival)ly ilLer the Regi,oii's plans for use of committed funds, deliberation of the conti.n'Ll- ation portion of the application seemed of lesser importance. Staff recommended approval of the following continuation request: #46 Hi-Blood $163,41-9 #50 Joplin Stroke Prevention 87,653 #51 Sikeston Intensive Care 107,796 #52 Health Careers 100,777 #55 Cameo (tumor registry) 114,572 #58 Cardioviscular Education and Eval-uation 11-6,570 $690,787 Staff was gc@riC:17al,ly siLisfi(@d with the first ycar's I)rc)greFs of these projects. Rc!pi7eselitiLivc@s from the Coi-iti,ntil.ng Education Branch iic)tc@(I LliiL S-LTICC' the C@-Lr(--Crs ploposa-l- no longer fall-s within fit' policy and since some of the activities have been undertaken by contact wi.Lli the AiV.4C Division of Studcnt Affairs (with funds), the Region rflight@ wish to consider reducing Or evc@n T)II,!Sil-l@l-ollt up T) Cj 1, t of this pro@ect. Staff @.,,oncl(ij--cd tric- CA"i,'-O project .i i receiving any technical. assistance in computer -26- Page 2 Acting Director, RMPS f would also like from the Advanced Technology Proposal (#49). Staf clarification of the statement that the objectives of project #51, Sikeston Intensive Care, are beina incorporated into the new proposal,' 0 iat Care Missouri. Staff also recommends approval of the #77, Card core continuation request of $1,100,000, while recognzing that with the proposed expansion of core by $374,165 for district offices, continuin- education staff and activities in Kansas City, the total core request will be a major issue at the site visit. In addition to the continuation request, the Region's fifth year budget includes the following Cbre $. 374,165 Approved but Unfunded Activities 519,208 Supplemental and Revised Projects 1,703,690 Renewal Projects 274,112 Developmental Component 400,OOQ $5,061,962 The issues for the site visit are in an attached memo directed to the members of the site visi.t team. One issue which staff raised requires your specific consideration and guidance. This issue conce@,8 the structure of the Regional Advisory Group and whether the ultimate decision-making responsibility rests with the entire three-committee group (Liaison Committee, Project Review Committee and Advisory Council) or with the Advisory Council only. A description of the Regional Advisory structure is on page 2 of the attached memo. Our questions are twofold: 1) Can the entire three-body group constitute the RAG; 2) If not, what would be an acceptable arrangement? With the impending appointment of both VA and CHP representatives (to the Project Review Committee), this question assumes greater urgency. The following staff members attended the meeting on February 95th: Ted C Moore, Kidney Disease Branch Abraham Ringel, Operations Research and Systems Analysis Branch Cleveland R. Chambl-i.ss, Office of Organizational Liaison Cecilia Conrath, Continuing Education and Training Branch Spero Moutsatsos, Planning and Evaluation Teresa Schoen, Grants Review Branch Dan Spain-, Regional Development Branch Lee Teets, Grants Manag(,,iaei-it Branch Charles Barnes, Regional Development Branch Dona liotiseal, Grants Review Branch 27- Pac,e 3 - Act@Liig Director, RMPS Rc-.coir.iiiendati.oii: Approval of the contittuaton request of $1,790,787 for core and projects #46, 50, 51, 52, !i5 and 58. Don@i E. Houscal PLibli(-, fact Advit-,or CranLs Revl.c%.j Brancli Action-by Director Initials Date cc: Dr. Pahl (A Privileged Communication) SUMMARY OF REVIEW AND CONCLUSION OF APRIL 1971,REVIEW COMMITTEE MISSOURI REGIONAL MEDICAL PROGRAM RM 00009 5/71 D FOR CONSIDERATION BY MAY 1971 A VISORY COUNCIL RECO,MMENDATIO .N: The Committee recommended that this application which i quests: 1) an expanded Core, 2) the renewal of two re activities, 3) the suppo.rt of seven Council approved but unfunded activities, 4) the implementation of 16 new projects and 5) a developmental component be partially supported as follows: $2,.450,000 for the 05 year, $2,012.,OOO for the 06i and $1,825,000 for the 07 year. A comparison of the request and the site visit team and Committoe's recommendation for the 05 year is outlined below. Request site visit Committee 1. Core $1,474,000 $850,000 $850,000 II4 Computer and Bioengineeking 861,000 600,000 250,000 Activities (ir69, 71072,75) III. Community based Activities (#25R,, 36 37 38,39,43,46 50, 51 64,68@73,74,76,77, p 80,81,83) 1,664,000 .120009000 1.,000,000 IV. Continuing Educa- tion Activities (#52,55 58,67,78 p 31 79,82,26R) 663,000 400,000 350,000 V. Developmental Component 400,000 -0- TOTAL $5,062,ooo..!/ $2,860,000 $2,450,000 $1.8 million is committed support. Missouri RMP RM 00009 5/71 in its deliberation the Committee accepted the report of the site visit to the Missouri Region on March 30-31, 1971. The site visit was a 'comprehensive one, with members of the t .eam reviewing eparatelv the activities in Kansas City, the continuing education pr ogram, computer and bioengineering proposals, as well as the central decision- maki.ng., review and administration processes in Columbia. Two members of the site visit team participated in the Committee discussion. The visitors reported that the Region had made progress in certain aspd'cts of program development since the last site visit, but that..or@anizational weaknesses were hampering growth in many areas. The Regionts goals are broadi with poorly defined intermediate objectives. Program has been primarily determined by a collection of projects, which have been submitted by interested-individual-s and aligned with Regional goals after the-fact, rather than stimulated on the basis of Regional needs. Program evaluation is geared to assessing the achievement of project objectives. While the Coordinator is well-liked, he is not as forceful or efficient an administrator as he could be. Organized at a time when PIIP's budget was projected for a $200 million level, the Core staff is oriented almost exclusively to projects (processing applications and monitoring approved projects) and has attained a size out of proportion to the program it handles. In addition, Core staff has continued to maintain its adament position that proposals from sponsors in communities outside the University setting be,developed with little staff assistance in order to preserve local flavor and feelings of pride. The team recommended that the size of Core staff be reduced and that better service be offered to local proposers. At the same time, the team encouraged the Pegion to disengage itself from the project approach reprogram development by seeking other sources of support, using smaller amounts of Core funds to initiate activities on a short term basis, and phasing out projects which are no longer appropriate or are not performing ad64uat6ly, The Missouri RMP Regional Ad vi8ory Group has a unique tripartite structure. While it appeared to the site visitors-to work effectivelythe decision on the legality of the arrangement, particularly in relation to the placement of VA or CHP representation, seemed more appropriate for General Counsel. Reviewers felt that the very nature of the RAG may have contributed to the broad @nd irrelevant goals. ThIe Regional Advisory Group also appears heavily oriented to project review, rather than to broader regional planning. The review process, which includes technical consultants and a ranking system, appears adequate. Relationship with regional resources, particularly providers and voluntary healtbagencies, is a strong point in the Missouri program. The visitors were distressed that the Region seems to feel that consumers aIre adequately involved in program development through CHP representation in the advisory groups. Medical school leadership is still active in the program, although the proportion of Aft Missouri RMP -3-; Pm oo69 5/71 University sponsored projects is declining. As the grantee agency, it also provides fiscal and administrative support. The 'continuing education part of the program seemed in need of a strong director of continuing education on Core staff with an Advisory Committee to serve him. The Coordinator should coordinate efforts of, and offer assistance to, project proposers by locating resources, opening lines of communication with the medical school and developing models of evaluation. After discussion with project personnel, the team felt such a staff person would prove more effective to the Region than initiation of the Continuing Education Coordination project. The visitors felt that some of the functions of inventory and teacher- consultant activities outlined in this proposal could then be carried out by contract with the UM Extension Division. With little assistance from Core staff the subregional part of the program has continued to be one of the stronger features of M@IP. The Kang@ City Area Planning Office has hired staff, engaged resources and worked as a cobrdinator-facilitator between the new medical school and the rest of the community's health system. The COMPACT proposal, which would coordinate interbospital departmental meetings and upgrade medical education, resulted from these efforts. The site visitors found the concept'of such a proposal sound and believed it should be funded by RMP for one year until the participating hospitals assumed its support. Because of the difference in approach to program development and the unique problems of the urban setting, the Kansas City Office's relationship with the central MRMP Core in Columbia shows 'signs of @strain. At the present, MRMP's relations with Kansas City ate primarily that of fiscal agent and source of final project review. The site visitors recommended that priority be placed on staffing proposed gubregional districts and strengthening those already in operation. Both site visitors and Committee members had difficulty determining what course to follow with the computer and bioeftgineering proposals. Much has been invested in these activities during the past four years with reports of mixed results from previous site visitors. The present team was pleased with the Region's progress@, and recommended reduced support for one last year, but with the realization that actual marketing and full implementation of the-systems could still be two to three years away. They felt that the operation in Dr. Bass' office in Salem (#72) could prove valuable in determining the practicability of such a module in a solo practitioner's office, although they had reservations about its cost effectiveness. Initiation of the automated patient history system field test in Cape Girardeau' was considered ap imprudent investment at this time. The site visitors presented their funding recommendations for Comniittee's consideration. Committee accepted the teamts recommendation for a reduction o.f the Core budget to $850,000 and a reorganization of Co@e functions. Implicit in the recommendations is the advice to, 1) preserve and strenatben the district offices, including the Kansas City Office, and the Program Methodology Unit, 2) add a Director of continuing Missouri RMP -4- RM00009 5/71 education to Core staff, and 3) reduce the Planning and Ope-tat'ions staff and consolidate its functions within the Coordinator's Office. Committee was disturbed that the Region had not learned to make better use of the Program Methodology Unit, which could serve as a great resource by supplying data bases for determination of Regional o "' 11 needs. That the unit had t se . the Region on using its service's highlighted Committee's continuing concern with MRMP's overall program development and management. Committee deducted $50,000 from the site visitors' proposed $400,000 level for continuing education activities because they did not believe that new money for continued support of project #55, CAMEO, should be provided. The development of a computerized treatment logic system for patients with breast cancer and colon cancer raised fears about diffusion and acceptance of the treatment modalities being generate by the system. The $1,000,000 level for comniunity-based projects was accepted by Committee. Although they were pleased that provider support had been successfully brought into l@IRIIP,,high priority should now be placed on involvin& consumers in program development. Needs should also be better defined so that such proposals really meet the more pressing health proBlems of the community. Committee was opposed to the site visitors' recommendation of $615 000 for ComputerLand bioengineering activities. T4hile a further year's investment in Dr. Bassi operation ($150,000) was accepted, Committee recommended that support for the other three proposals be phased out this year. $100,000 was provided to phase out these Activitieso Complete termination reports of the five years activities should be submitted to RMPS. One reviewer raised the question of appropriateness of continued RMP support for computerized EKG development when commercial funds are now available. In addition, be stated, most systems have not progressed to where review by a cardiologist can be totally supplanted by the computer analysis. Reviewers also thought that Missouri s efforts should have been directed to hospitals with larger volumes of EKG's than to individual physicians. There was agreement with the site vislitor's that the developmental component be denied since neither group believed that tbb Region had demonstrated it was ready for or would utilize such funding in imaginative ways. In conclusion, Committee stated that they thought a site visit in a year's time for assistance, as well as evaluation pupposes would prove b6loful to the Region. Dr, Mayer was not present during the deliberations of this Region. RNP S / GIZB 4/22/71 DEPAriTMPNT OF tiEALTH, EDUCATION, AND'WELFARE PUBLIC HEALTH SERVICE IQEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION April 12, 1971 Short Summary of Missouri RMP Site Visit Findings, March 30-31, 1971. To: Director gional Medical Programs Service Thro Rh. Acting Deputy Director Regional Medical Pr6gtAms Service The@site visit team consisted of: 0. V4 Brindley, Jr., M.D., Chairman Department of General and Thoracic S gery, Scott and White Clinics, Temple, Texas, and Chairman Of th 8'te Visit. e i le 6d&r M. M6Phedran, M.D., Emory University Clinic and Council M et. ilit4m'L. Black, Ph.D., Staff of M.I.T. Lincoln Laboratory D.n F.@Brayton, M.D., California rea oor na or Oncis DAmmann, M.D., Professor of Biomedical Engineering, u ve-rsitv of VirRi6ia School of Medicine job Son, M.]?., Practicing Physician, Rockford, Illinois r ny K6maioff, M.D., B6th Israel Hospital, Boston, Massachusetts. ill rd L. Thompson, Ph.D. Dean of General Studies Sessions and et Sessions, University.Of Minnesota. .P,D6na H66seal, Grants Review Branch, RMPS r n E. Leach, Ph.D., Continuing Education and Training Branch Mr. Ray Maddox, DHEW, Region VII. s Teresa Schoen, Planning and Evaluation Branch bAn Spain. Regional Development Branch e@@ urpose of scheduling a site visit for Missouri at this stage in e Regibn'8 development was to examine the new MRMP thre6-year plan-- .a duct@of its operational ex eri@nce since 1967 which requ6sts expanded p p n at a time of reduced overall PIIP grant moftles. This level Of t n g would support further program development in t e Kansas City D s i6t@ n8,in smaller regional centers, renewal of several computer/ oo @9-inee ihg R & D attivities,@,and A substantial developmental nt.@ Projects presented in this plan can be grouped in four i uing education, mai plagses- Orogram guidahce,-conmunity service, cont n d 0 t6r/bloengineerihg activities. an Om u@ of the complex character of the Region, the sitevisit WAS Cl@Iv d i to four parts. On Match 29th, the entire team met in a as City for an evening btiefing and strategy session. On March i6t the@team divided into groups. Page 2 - Director, eMPS Team I (,D7-. Brindley, Dr. Brayton, Miss Houseal and Mr. Maddox) traveled to Columbia to review the region's central decision-making processes core operations, and relationships with other statewide agencies and institutions. Team II (Drs. Thompson and Leach) accompanied the fiIrst team to Columbia and met that afternoon and the following morning with various regional representatives involved with the Region's continuing education activities. Team III (Drs. Dammann, Black and Komaroff) flew to.Salem, Missouri, to review the computer/bioengineering components which had been assembled and field tested in a local physician s office. They also met with the pto4ect proposers in Columbia on the following morning. i Team IV (Dr. McPhedran, Dr. Johnson, Mr. Spainand Miss Schoen) remained in that area to discuss RMP developments there - particularly relationships with the new medical school and linkages with providers And other health-telated a 6ncies. 9 The entire site visit team convened in Columbia on the evening of the 30th for a review of the first day and to discuss changes in strategy. Toward's the end of the second day, time was provided for an executive session to discuss overall findings and recommendations and then to pr6vid feedback to the Region before adjournment. il6 the structure of this site visit was more complex than most, the Sir a d- diversity of the Missouri program necessitated a review similar to that conducted at the last visit in Ottober 1969. The site visit team was generally pleased with the Region'sprogress since that visit but stated that serious organizational weaknesses were hampering growth in many areas. The Region's. goals and objectives are vague and broad. They do not seem to have changed much since the beginning of the program. There was not much evidence that the Region had attempted to incorporate HEW or HSMHA 6bi6ctives or priorities within their own. Program has been primarily determined by a collection of projects,. which have been submitted by interested individuals and aligned with Regional goals after the fact, atber than stimiated on the basis of regional needs. Evaluation, then, as beoomea matter of looking at the achievement of project objectives. he orgah@iiational effectiveness of Core. was seriously questioned by the site visitors. While Dr. Rikli, the Coordinator is well liked around the Region, he is not as forceful An administrator as he could be. With SI man project activities, a large core staff, his involvement with the tension Division and other 'University matters, be is spread so thin t at his control of the program suffers. ore staff .,itself has several strengths and weaknesses. The strengths are the Kan@sas City operation (to @e discussed below), the other subregioaal Page 3 - Director, MPS offices whichIare engendering provider support at the community level, and the Program Methodology Unit, which could serve as a great resource in building program definition by supplying a database. The chief weakness is that Core is presently organized around projects first processing project applications and then monitoring the approve proposals. The site visitors further determined that the number of staff hired to perform these tasks was out of proportion with the total size of the program and should be reduced. A further criticism was that the planning section had hot offered enough assistance to project proposers, particularly to those outside the university setting, in project development. Core staff has not vered from last year's adament position that proposals be written withoutcore staff assistance in order to preserve local flavor and feelings. of pride. The team., however, thought that better service could be offered to these local proposers without injuring their integrity. In fact, the overall program could benefit from a more aggressive approach to proposer assistance - from recommending tb6 deletion of aspects of projects which are not appropriate for RMP support to helping to find other sources of funding. In a time of lessening availability of funds from the national level, Core's persistence in turning out a large number of projects seemed anachronistic. The site Visitors believed that the central Core could profit the Kansas City operation's example of using smaller amounts of Core funds imaginatively to@initiate activities on a short term basis until others could support them. Core also seemed to become so committed to funded projects that they rarely modified weak proposals and had difficulty in phasing out those which were not performing adequately. The site visitors felt that it should not take three years to phase out those projects. The Regional Advisory Group also appeared heavily oriented to project review. While data for planning on a Region-wid6 basis has been collected by Core staff, there was little evidence that the RAG has used this information to assess need and recommend the initiation of appropriate program activities Little thought had been given to the use of the developmental component, other than to stimulate or start up project activity. The Missouri Regional Advisory Group has a uniqud structure among RMP'so It includes,three bodies-- the Liaison Committee, the Project Review Committee, and the Advisory Council. The membership and the structure are described in the staff summary of the application. Arranged this way in order to allay fears of University domination of the program, the Regional Advisory Croup as a whole performs effectively. The problem of which group the CHP and VA representative should belong to and the legality of such a structure, particularly when projects disapproved by the Liaison and Project Review Committees are then approved by the Advisory Council, the site visitors believed, should be settled at the General Counsel's level. The review process, which is the responsibility of the RAG, is adequate, It provides for an assessment of the proposal's relation to activities supported by other agencies in the Region, technical review (with occasional site visits) and a determination of its place in the overall Page 4 Director, APS RMP nrogram. 'Two of the three Igroups use a numerical rating, although the criteria on which the rating is based has not-been formalized on paper. CHP comment has been instituted. Relationships with the regional resources is a strong point in the Missouri program. The program seems to have the support of the Medical Society and many practicing physicians, the doctors of osteopathy, nurses, allied health professionals, and hospital administrators., Voluntary agen6ies' representatives spoke well of MRMP, as did those from CHP. Although the Region seems to feel that consumers were adequately involved through CHP, they are not generally well involved in program development. Medical school leadership is still active in the program, although the proportion of University-sponsored projects is declining. As the grantee agency, it Also provides fiscal and administrative support. Program as stated earlier, is a composite of projects. Two parts of the site visit team reviewed particular parts of the program-continuing education and computer,fbioebgineering - in great depth. Continuing Education Drs. Thompson and Leach spent a great part of their time discussing the Continuing Education - Coordination Project and the proposed Appointment of a Core director of continuing education with the Regional tepresenta- tivbs. The visitors agreed that the inventory and teacher"consultant activities described in the twice disapproved and revised Continuing Education Coordination Project would possibly serve useful functions in identifying continuing education needs of various health professions around the Region. Discussion with directors of ongoing and proposed projects brought the visitors to the realization, however, that what is most needed is a strong director of continuing education on.Core staff, who could coordinate efforts of, and offer assistance to, project pro osors by locating resources, opening lines of communication with p the medical school and developing models of evaluation. There was significant concern among University-affiliated staff that such a person ould not involve MRMP Coro in, or sponsor through Core,operational activities. This would, in the opinion of the site visitors, weaken the ability of such a person in assuming a strong role with the Continuing Education Coordination project or with--6ther projects. The site visit team recommended strongly that the Coro Director position be funded and that the functions of the Continuing Education Coordination Project be given to the Core Director of,Continuing Education. An Advisory Committee named in the proposal should also be selected and serve the Core Director. Core might then contract with the Extension Division for some of the functions outlined in the inventory and teacher-consultaftt activities. Projects designated by the Region as primarily continuing education- oriented were,also reviewed. By and large., they serve the.purposes of an individual institution or community, rather than the Rbgion's needs in continuing education or manpower development as expressed in an overall plan. Page 5 - Director, tIMPS Computer/Bioengineering The visitors who reviewed this part of the program were pleased with the progress since the last visit. The site visitors traveled to Salem to visit the proposal which had assembled and field tested the computer and bioengineering components in a solo practi.ti.oner's office in Salem, Missouri. While Dr. Bass' exceptional interest and enthusiasm were obvious assets, the visitors had reservations about the cost benefit of establishing this comprehensive system in a solo practition&r's office located in such a small community. T-lith the commitment of Dr. Bass, the practicing physician in Salem, the cooperation of the University-based project personnel, the system is operational and being tested in his office on two to three patients a day- The system includes the automated patient history acquisition system, automated EKC-., biochemical screening, fact bank and an on-line radiology reporting system. There is still,mucb work to be done with consolidating design, software, and.hardware changes, and marketing of ti-ie total system may be two or three years away. With a change in project direction, the automated EKG proposal has overcame many of the obstacles, including reducing the cost per EKG, facing it in the-fall of 1969. Several major weaknesses still neeg to be corrected before full implementation. Since developments are occbtiftg 80 rapidly, however, the site visitors recommended looking at these components in another year to determine future funding. The site visit team believed that the Fact Bank should be supported by outside sources after this year and that the Cape Girardeau experiment not be started at this time. O@mmu-nitv--based ProgrAmsi including Kansas I After hearing from some physicians-in smaller Communities around the state and vi8itina the Kansas City subregional program, the site visitors concluded that the activities in these areas continue to be some of the more dynamic aspects of the program. The Kansas City Area Planning Office has made great progress since the last-site visit---staff has been hire resources found and program activities initiated. Located in the only major metropolitan area in MRMP, the Kansas City Area Planning Office has seen its tole and problems as distinctly different from those of the Region as a whole. In the "Hospital Hill" section particularly, kansas City has a considerable concentration of health resources and ongoing activities, including: a developing, communitv-oriented Medical School, a large number'of community and ljniversity-affiliated hospitals, developing Model Cities and OEO clinics and health centers, a burgeoning CHP "b" agency, supportive civic leadership and professional societies a variety of allied health training resources and continuing education programs and a new, nonprofit technical assistance organization the Health Resources Institute. Page 6 - Directu- RMPS With such resources available, the KC Area Planning Office has Concentrated on a cobrdinator-facilitator role, particularly focusing on activities related to Medical School development as part of the total community health sy'steml(i.e., assisting in establishment of a Community Wide Residency to provide programmed clinical experience for medical students and residents in community hospital, health centers and the KC Ceneral Hospital docent units.) Four projects have been developed in the area -- the terminating Programmed Comprehensive Cardiovascular Care Pro'oct, the ongoing project Hi. Bloodi the proposed Improvement of Pharmaceutical Services and COMPACT. The Site Visit team considered these to be basically sound concepts and well developed. But despite encouragement from MP-IIP to channel its efforts into further projects, the Kansas City Office prefers to maintain its current role, which site visitors agreed was an appropriate one. This independence, a probable source of tension within MRMP, nevertheless seems to have been accepted by the Region in view of the areals peculiarly urban problems. Besides general concurrence of Kansas City goals with very broad Regional oals, Y@RMP's relations with Kansas City are now 9 primarily that of fiscal agent And source of final project review. Conclusions and Funding Recommendations The site visit team concluded that the Missouri RMP is making progress, particularly in subregional development, which should continue to be fostered. Serious organizational problems, 4n overwhelming project. orientation to the Accom lish@ent of program, a nd lack of full assistance for those developing proposals at the community level disturbed the site visit team and influenced their determination of funding recommendations. For their next three years, the Region has req@ested: 05 06 07 $5,061,962 $45310,940 $3,511.,564 The fftli includes: 1 'year request $1,500,000 for Core 600,000 for continuing education activi 900,000 for computer and bioengirioeting proposals 1,700,000 forIcomniuftity-bas@d activities 400,000 for a developmental component $1,800.,OOO of the $5,100,000 request is committed support. The site visitor,s.recommended a $2,865,000 level for the 05 year which includes: @850,000 for Core with the strong suggestion that the subregional or district offices, including the Kansas City Office, and the Program Metbodology'Unit be nerserved and strengthened. 'llie Core Director of Page 7 - Director, -,MPS Continuiftk tducation should be added to staff. However, it was recommended that the Planning and Operations staff be reduced and consolidated with the Coordin'ator's Office. $400, 1000 for continuing and new continuing education activities. This amount includes reduced funding for projects l@26R. one-year funding for #78, full funding for #79, no funds for #82 and #67 and suggestions for inyproving and phasing out ongoing activities for which outside support now exists or RMP support is no longer appropriate. $615,000 for one year only for computer and bioengineering proposals. $1,000,000 for community-based projects with advice to the Region to continue to emphasize this vital part of the program. No funds for the developmental component, since the site visitors did not believe the Region has demonstrated that it was ready for or would utilize such funding in imaginative ways. 'A summary of the three years funding recommendation foll-o@@ys: 05 06 07 $29865,000 $2;067,000 $1,825,000 Dona Houseal Public -Health Advisor Crants Review Branch REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF ANNIVERSARY REVIEW AND AWARD GRANT APPLICATION (A Privileged Communication) MOUNTAIN STATES (WICHE) REGIONAL MEDICAL PROGRAM RM 00032 5/71 525 West Jefferson April 1971 Review Committee Boise, Idaho 83702 PROCRAM COORDINATOR: Kevin P. Bunnell, Ed.D. This region is currently funded at $1,873,974 direct costs ($365,146 ind.) for its third operational year, ending February 28, 1971. The Anniversary date has been changed to June I at the request of the region, with additional funds ($64,776 ) being required for the 3-month extension, based on the present rate of expenditure. It should be noted that varying indirect costs for the region represent an average indirect rate of 19.5 %, of the total direct cost award. The Triennium application under review is composed of: I. - A Developmental Component II. - The Continuation of Core and 11 ongoing activities III. - Proposals for 6 new projects IV. - The renewal of 1 activity The region requests $2,449,940 for its fourth year of operation, @,2,617,542 for the fifth, and $2,486,328 for the sixth. A chatt identi.- fying the components for each of the three years is included in this summary. A site visit is scheduled for March 8-9, 1971, and a preliminary staff review of the application has identified several issues for the visiting team Is consideration and assessment. These are also a part of this summary. In the general reduction of funding levels for all regions,MS/RMP (WICHE) received a committed direct cost level for FY 1971 of $1,474,765 (from $1,611,764). FUNDINC HISTORY (direct cost only) PIANNING STAGE Grant Year Period Funded 01 II/l/66 - 10/31/67 $698,845 02 II/l/67 - 12/31/68 884,034 OPERA'I'f.ONAI, f'ROGRAM 01 3/l/68 - 2/28/69 (overlaps with planning stage)and 01(increase) supports I operational activity and 2 months Core 346,159 MOUNTAIN STATES RMP 2 RM 00032 5/71 OPERATIONAL PROGRAMS (cont.) 02 3/l/69 - 2/28/70 $1,562,967 03A2 3/l/70 - 2/28/71 1,873,974 [ITSTORY OF REGIONAL DEVELOPMENT Development of the Mountain States Regional Medical Program was based on an extensive analysis of the area's health needs, and methods to meet those needs were carried out during its planning phase. @@.IICHE (@.le§tern Interstate Commission for Iiigher Education), a compacting organization of 13 western states, had been interested and active in developing medical education programs in the western states that did not have medical schools. The TDICHE Advisory Council on Medical Education recommended that the four states be designated as a Region for a Regional Medical Program under P.L. 89-239, and that WICHE apply for a planning grant with objectives of upgrading and improving the existing facilities at community levels to provide optimum patient care in heart disease, cancer and stroke. INIICHE received a planning grant from the Division of Regional Medical Program for a two-year program, beginning November 1, 1966. T4ithin a relatively short time, four full-time and six part-time physicians formed the nucleus of a professional staff. A regional office was opened in Boise, Idaho, to coordinate activities in the four-state area. State field offices were opened in Great Falls and Missoula, Montana; Boise , Idaho; Cheyenne, Wyoming; and Las Vegas and Reno, Nevada. @,.IICHE headquarters office in Boulder, Colorado handles the fiscal Management. Preliminary analysis of the surveys made under the auspices of the planning grant indicated a,critical need for coronary care training and cancer diagnostic and treatment centers. The establishment of the Missoula Intensive Coronary Care Training Program for physicians and nurses, and the Tumor Institute in Boise, served as first steps in meeting the goal to develop new clinical resources and educational programs. The survey findings also indicated the health professional's desire to increase his capabilities to care for patients and provided the impetus to develop programs focused to meet local needs. ';he regionts first operational si.te visit took place in February 1968 and its second in October 1968. It was clear that the regional council of State.Directors was becoming more effective as an integrating and planning activity. As state programs evolved, a network of stibregional offices developed in Las Vegas, Reno, Boise, Pocatello, Cheyenne, Buffalo, ('@reat Falls and Missoula. '['I)e site teams believed that this Represented the minimum organization mandatory for continued health planning and the development Of further operational programs for the region. MOUNTAIN STATES RMP - 3 - RM 00032 5/71 G1710GRAPHY AND DEMOGRAPHY The Mountain States (WICHE) Regional Medical Programs includes the four-state area of 435,643 square miles of Wyoming, Nevada, Montana and Idaho with a total population (enumerated in 1970 Census) of 2,230,000 persons. The population in the four states increased about 14'/,, compared with the 1960 Census (and notably Nevada). Keith the exception of the few larger cities, the rural population represents nearly 50'/. of the total. FACILITIES AND RESOURCES In the last few years there has been a shift in resources and facilities with an increase in training facilities and hospital capacity. Nevada has a developing 2-year medical school, with opening scheduled for 1972. The number of active practicing physicians and osteopaths totals 2,100: 647 in Idaho, 696 in Montana, 451 in Nevada and 306 in Wyoming. The ratio of physicians and D.O.'s averages about 94 per 100,000 population ranging,from: 89 in Idabolto 102 in Nevada; a ratio of 98 for Montana and 94 in Wyoming. The latest data regarding graduate nurses indicates a total of about 9,600 registered nurses. Of these 6,700 (,almost 70'/.) are reportg5d to be actively employed in nursing. They are located as follows: Idaho 1,954, Montana 2,483, Nevada 1,060, Wyoming 1,209. @'The increase since 1962 is about 250. The number of schools Al-ch are training, allied health staff has increased some. There are a total of 14 schools of medical technology (all hospital affiliated) in the region Vftb 6 in Idaho, 4 in Montana, 3 in Nevada And I in Wyoming. There are 22 schools which provide training for radiologic technicians: 7 in Idaho, 6 in Montana, 7 in Nevada and 2 in Wyoming. Two in Nevada are University based. The regionis 15 professional nursing schools, 13 of them college or university affiliated are: 4 in Idaho, each college affiliated; 6 in Montana, 4 of them college affiliated; 2 University based in Nevada and 3 college affiliated in Wyoming. 30 licensed practical nurse training schools are also operated. Many are school district or college affiliated as follows: 15 in Idaho, 5 in Montana, 2 in Wyoming and 8 in Neva a. Community general hospitals have increased in number and in bed capacity, compared with 5 years ago. There are 148 short term non-Federal hospitals with a capacity of 10,496 beds: Idaho has 48 and 2,879 beds; Montana has 56 and 3,841 beds; Nevada has 17 and 1,951 beds and Wyoming 27 with 1,825 beds. There are also 4 long-term special general hospitals with 963 beds and 5 V.A. general hospitals with a total capacity of 826 beds. 14OUNiAIN STATES RMP - 4 RM 00032@5/71 l@f,-,(;TONAJ, ADVT@,ORY (;ROUP The necessity for streamlining the operational structure of MS/RMP promted a regoranization of the RAG, retaining the geographic represents-, tion while reducing the total number of members. Geographic coverage, has been broadened and Task Forces and committee s have been increased. The Core staff and the RAG working together developed specific feasible and long-range objectives for the MS/RMP Triennium. Utilizing ' questionnaires to each member, critiques and comments were obtained to assist in shaping the final draft, which was presented to the entire Group for consideration and approval. The broad regional objectives established by RAG represents expansion of ongoing activities which are focused on four specific targets: 1) Sub-regional centers for Continuing Education; 2) Health Centers for Residents; 3) Stimulating Health Manpower development; and 4) Specilized Centers Development. A system for setting priorities for activities within these objectives is currently under development. The Mountain States RMP is providing expertise and resource personnel for health planning in each of the four Model ,Cities within the region. Core as well as RAG representatives have leading roles in each state and areai The present RAG includes two CHP representatives as well as one appointee from the Veterans Administration. REGIO,NAL GOALS AND OBJECTIVES The re gion has identified four goals which are expected to be areas of major program emphasis for the next Triennium. These may change in the event of unexpected circumstances, but long-range planning (3 year) reflects the following overall objectives: Sub-regional Centers for Con@tinuing Education - These will be associated with a community hospital and, when possible, an educational institution, have a local Advisory Council consisting of consumers from a variety of health occupations. Continuing health education opportunities, through a sub-regional faculty of skilled practitioners who are also skilled teachers, will develop a mechanism for continual evaluation of continuing health education needs. These efforts will be coordinated with Public nealth Departments, voluntary health groups, hospitals, and other organizations in developing programs. Health Services for Rural Residents - The region hopes to improve the quality of, and accessibility to, basic health care for citizens of the region, with emphasis on those living in rural areas. This will be accomplished through the use of new types of manpower, new organizational patterns, service-oriented systems, and new equipment. Plans are underway for development of basic health care teams having MOUNTAIN STATES RMP - 5 - RM 00032 5/71 an appropriate combination of health occupations, with new kinds of manpower to serve rural areas,e.g.,Medex, medical referral specialists, nurse clinicians, etc. The region is also planning and developing s(ib-regional health centers, transportation mechanisms for rural patients, demonstrations of use of remote TV for diagnosis and prescription. Educational opportunities for indigenous "health educators" such as health aides, and Indian health advisors, are also being explored. Stimulate Health Manpower Development - MS/RMP hopes to stimulate educational institutions, state systems of higher education, hospitals, and professional associations to plan and develop new programs and improve programs for in-service education. This will be done through the strengthening and expanding existing programs, and encouraging planning and development of programs for new health careers. Also, attention will be gi.ven to the development of basic sciences education and other clinical training for medical education and students of health occupations. Ir-service education opportunities that will improve careers and facilitate transfer into new careers will be developed. S2ecialized Centers Development - Through educational programs MS/RMP will assist in development of specialized centers located in selected urban centers within reasonable access of urban and rural residents as model or demonstrations for diagnosis, consultation and education related to major diseases and disorders. The 14AMI Program (Washington, Alaska, Montana, Idaho) is under-way to provide medical education extending beyond the campus of the University of Washington at Seattle to communities of this region in Idaho and Montana. Sub-regional centers with the four states have been identified in twenty strategic areas having a critical mass of population, patients and practitioners. These new centers, now in various stages of implementation, will provide an organizational base for the coordinated activities throughout the region. Ic"laho has established seven SLib-regional centers with part-time Coordinators, each located in communities served by a university or community college. Montana has designated five RMP Districts, with Medical- Education Coordinators thus far for Districts one (Western Montana) and three (Eastern Montana). A Coordinator for each of the years 1972, '73, '74, is a long-range projection for the remaining three Districts. Nevada has appointed community Coordinators in Elko and Ely, and a third is proposed for Carson City. MS/RMP is working with the Nevada IUniversity System in its development of a two-year medical- school in Reno. Wyoming is developing Educational Processors (medical educators for Ik @ospitals) through special seminars. MOUNTAIN STATES RMP - 6 RM, 00032 5/71 (,ORE @J'AFF ACTIVITIES Core gtaff consists of 34.92 full-time equivalents located in the regional and four state sub-regional offices. t4o significant changes in organization or structure have been made during the past grant period. Sub-tegional community education coordinators on both a voluntary and a part-time basis were recruited. A full-time person with training in the applied behavioral sciences was employed at the regional office level to coordinate planning ' and evaluation efforts. The position of Coordinator of Operations Programs was abolished and expanded and these duties were assumed by the Deputy Regional Director. l,lith the emergence of a medical school in Nevada, discussions are expected during the upcoming Triennium to explore an orderly transition leading to an independent Nevada Regional Medical Program. It will probably be affiliated with the University of Nevada. With the upcoming Triennium, Core staff will assume responsibilities for administering Project #5 - The Montana Continuing Education for Health Professionals. This will be a step in systematizing the development of sub-regional centers for continuing education. The facilitation for planning, development, and inter-relatedness of all operational projects will continue to be a Core staff activity, which will provide leadership for activities proposed,for the triennium. Other activities will include the development of an explicit priorities system, a refined reporting system.which is valid and of immediate use in making decisions,to provide continuous recording and monitoring of program impact. Also, the region is thinking of conjoint Core staff and efforts directed toward the development of more refined program objectives in terms of specific individual staff assignments. Core staff will also be responsible for planning for the use of developmental funds in order to assist in the transition, a heavy emphasis on continuing education to other forms of "systems intervention." @IS/RMP will not abandon continuing education efforts, but the strategy o,@ continuing education will aim toward community-based systems changes a@ lid improved inter-professional, and inter-organizational effectiveness. There are four active Model Cities in the region and members of the Core staff in the Idaho' sub-region have participated in the Planning a,-id Advisory Committees in the development of the Model Cities program in Boise. An educational specialist on Wyoming Core staff is Chairman of the Health Section Advisory Group for a Model Cities program in that state. A staff member of the Montana Division serves on a state-wide coordinating committee for the two Model Cities in that state. MOUNTAIN STATES RMP - 7 - RM 00032-5/71 TtiE REVIEW PROCESS The review process of the MS/RMP is closely coordinated with project development. Survey data and inventories of resources within the region are utilized in generating and developing ideas, which are responsive to regional objectives, as well as regional and national priorities. New by-laws,.have been adapted for an ad hoc Technical Review Panel. These provide critical review by three experts outside the region which are appointed by the Regional Director in consultation with the RAG Chairman. 'ti@.ile there is no formal mechanism for project review with the CIIP agencies, mi-tual memberships of executive and advisory boards with..RMP Core staff provide for an interchange of information. EVALUATION With the employment of a full-time person with training and experience in applied behavioral science on the Core staff, a systematic program evaluation method has been developed, computerized and implemented in December 1970. It includes correlated information from: (1) a common registration form; (2) a multi-dimensional, objective and open-ended "analysis and satisfaction" form for participants; (3) s,ta'"- dardized faculty and observer information; (4) an attitudinal ' 'f assessment of participants; and (5) administrative and other descriptive information. A major criterion in the evaluation system is that it must res'kLi t in usable, useful and used information for planning and organizational growth. Simultaneously, a more extensive system of program evaluation takes place through staff conferences, consultations with RAG members and involvement of grassroots health providers. In addition, each operational project contains a provision for consul- tation on the technical aspect of systematic project evaluation, based on the principle that evaluation, particularly at the regional level, should be an integral part of the initial development of proposals. Work is also underway on the development of standardized methods for evaluation of application of learning in the existing Continuing Education Projects. Two training sessions have been held by MS/RMP Core and operational staff to stress technical aspects of evaluation and other working conferences for staff are scheduled. Another p@ n of the evaluation activity has been the initiation of several sh6 I t into questions of concern to program functioning. -4,,, - 8 RM 00032 5/71 MC)UNTAIN STATES RMP DEVELOFMENTAL COMPONENT The stated purpose of the request of $71,000 is for "developmental activities to pursue practical goals oriented approaches to.meet emerging needs and opportunities identified by mission-oriented task forces and MS/@P staff." The provision of developmental funds will increase the region's' capability to improve communication and planning and to study and redefine emerging health needs at the local level. MS/RMP hopes to explore pilot activities in response to community needs, moving with flexibility and coordination into appropriate programs to strengthen existing capabilities to find effective and efficient ways to improve health service. This will also expedite exploratory- activities while local resources are mobilized for self-support. in recognition of.a change in national direction, the MS/RMP is making an effort to meet the newly established priorities. The policy of i4S/RMP Regional Advisory Group establishing priorities, and allocating and authorizing funds will continue with the award of developmental funds. .The review procelss for developmental proposals will be the same as for operational.projects with' proposals submitted quarterly to RAG members to permit critical review of documents prior to regular meetings. Technical review panels will evaluate proposals as to feasibility and potential for implementation. The region is in the process of developing criteria such as those used by the Michigan RMP and the Washington/Alaska RMP for reviewing proposals to determine priorities. Areas of concern will include appropriateness, probability of success, workable relationship, evaluation mechanism, contractional arrangements, potential for development, commitment for continuation after RMP funds have expired, and cost-sharing possibilities. The region submits a list of activities which they consider having a potential for developmental funds; (1) a pilot program for . intensive infant care unit in selected hospitals; (2) development of Health Maintenance Organizations; (3) stimulation of cooperative arrangements between federal, state and local authorities to improve emergency transportation services; (4) introduction of new patterns of health services; (5) interregional cooperation and programs for development of kidney disease control and dialysis centers; (6) development of radiology and laboratory proficiency; (7) study of the feasibility of a three phase program for diabetics. Fourth Year OPERATIOINIAL PROJECTS St $148,582 Project #2R - Intensive Coronarv Care Training - A slight increase in funds is requested for the next (01) period of the Triennium, MOUNTAIN STATE RMP - 9 - RM 00032 5/71 after which time it is anticipated that the project will be transferred to the University of Montana and Montana State University for continuation. The training center was established at St. Patrick's Hospital in Missoula, Montana and has served as a prototype for the development of similar units and programs in other areas of the region. The Pro-jecti-,; considered successful, quite popular and has received excellent support of all participating institutions. Accomplishments of the program have made significant impact on this region with i-mproved coronary care becoming available to an increased number of citizens. Management methods have been improved and interest continues high in participating hospitals. This has resulted in excellent cooperation with the University of Washington, the University of Montana, Montana State University School of Nursing and the five regional hospitals providing supervised bed-side experience. In addition to the existing program for training of physicians and nurses, two new programs are planned - one in ECG monitoring for anesthiologists and the other affording short preceptorships to provide tutorial experience for practicing physicians. Requested Fourth Year t'roject # 3R- Mountain States Tumor Institute The region is requesting 0 three additional years support or support for the project's third, fourth and fifth periods. The region feels that continuation for another full three years is imperative to ftillyimplement all aspects of the program and to establish its efficacy through appropriately evaluated mechanism of a regional cancer diagnostic and educational center. The Institute, which is a total cancer therapy center, constructed by St. Luke's Hospital in Boise uses a multi-disciplinary approach to patient treatment with an added component of education. It is the first of its kind in the region if not in the entire West. The MSTI, including land, building and equipment, is provided by St. Luke's Hospital, and is a fully incorporated subsidiary of St. Luke's Hospital and Ntirse's Training School. The same Board of Directors governs both institutions. In addition, a policy and planning council with delegated responsibilities fi)r MSTI has been established. A Nurse Coordinator was employed on a part-time basis during the 02 grant year, and a full-time Nurse Educator, a dosimetrist and an additional full-time radiotherapist are also requested. Fifth Year: $207,172 Sixth Year: $207,172 MOUNTAIN STATE RMP 10 Rm 00032 5/71 Requested Fourth Year $76.177 Education for ll(,@aitli Ilrofeqslonals Project l@5 - Montana Continuin@, ],, - One additional year is requested(fourth period) although three, ed over th additional Medical Education Coordinators are to be add, e next three year period. Program activities will be expanded by responding to unfilled requests. Twenty-three programs for 18 disciplines are already scheduled through.September of 1971, and at least 10 additional programs are in-the planning stage two of which will be for two additional categories of health professionals. Groundwork is being laid to insure the orderly transition of this project to a self-supporting status. Some supporting contributions already are being made by health professional organizations in the region. Project. #6 - Rocky Mountain States Cooperative Tumor str - One additional year of support is requested with a slight increase in funds largely for personnel for the four state area. This cooperative registry, which is patient-physician oriented, is designed to be of value to the practicing physician in insuring him patient data and systematic follow-up. The registry involves all of the four states,and in addition, the Intermountain and Colorado/Wyoming RNIPS. While progress has varied from state to state, three of the four now have functioning Cancer Coordinating Committees. Some hospitals are not participating as yet, but it is expected that the majority will join during the next year. All registries have participated in advisory committee meetings of the Rocky Mountain States Cooperat ve Tumor Registry and registry secretaries have attended training sessions in Salt Lake City. The means to continue these activities after June 1, 1972 is under active investigation. The Montana State Department of Health is seeking legislative authorization and funds to continue their portion O@ the program when it terminates. The State Medical Societv of ,@lloming is actively encouraging its state to continue participation. Project #7 - Continuing Education For Nursing - Nevada Requested This project became fully operational July 1, 1970 with Fourth Year the employment of a project director. It will serve as a $91,271 model for the first of a four phase regional approach to develop a cooperative continuing nursing education program for the four states. The four components of the program have common goals. However, the methodology has been modified in each to meet the specific needs of each state and to maximize use of their educational resources. The deans of the four baccalaureate schools of nursing conceived, planned and guided the emergence of this approach to continuing nursing education. They meet annually to assure continuance of its broad concept. Fifth Year: $97,500 Sixth Year: $48,250 (6 mos. only) MOUNTAIN STATES RMP RM 00032 5/71 Requested Project #8 - Inhalation Therapy Continuing Education - Fourth Year This project is moving into its second year with a $76,068 slightly reduced request in funds. The program which is devised for the states of Idaho and Nevada has offered courses attended by personnel throughout the region and other parts of tne nation. It provides information, training and skills in the most recent advances in pulmonary care through a two-fold program on a regional basis. Faculty and supporting staff are employed on a part-time basis, primarily from local participants. Consulting services are obtained from the Mayo Clinic, the University of Colorado and the University of California at San Francisco for the nurse technician and the physician courses offered. Workshops and seminars have been conducted as well as other traini ng courses for nurses and physicians and inhalation therapists. Pre and Post-tests have been administered to participants in the nurse and technician courses, and in addition, verbal and written critiques from the seminars are obtained from the students, with their recommendations. LF'fth Year: $82,402 Requested Project #9 - Cardiac Care Training - Las Vegas, Nevada Fourth Year The program,initiated in November 1970, is based at the $70,737 @i,-nrise Hospital, Las Vegas, with laboratory sessions offered a@. the University of Nevada in Las-Vegas. An additional two years support is requested. In addition to the project director, who is a cardiologist, four physicians from the Las Vegas area and one from the University of California in San Diego, serve as faculty. A qualified nurse educator is the primary nurse faculty. In addition, faculty and project staff from other regional coronary care programs 'have served as consultants to this pro'ect as well as sharing of curriculum and teaching informational materials. Three courses for nurses are planned during the upcoming year with 15 to 18 students per course. An accelerated program is anticipated for the 02 year and will include three physician courses. Fifth Year: $63,700 Requested Fourth Year Project #10 - ConsLiltin@ Teams in Rural Areas - Nevada $33,343 This project is requesting limited funds for an additional two years after an experimental period begun early in 1969. Its major purpose is to stimulate interest and increase skills in 'health professionals in isolated areas. A nucleus of interested, knowledgeable and pro@@lt-if-nt physicians, nurses and other health professionals in the Reno .4 -,@,-h#ve been mobilized to serve as a resource panel from which a con@6'1-'ting team TS drawn to visit regularly community hospitals. Local participation MOUNTAIN STATES RMP - 12 - Rm 00032 5/71 been almost 100'/., with the exception by all health professionals lia, of Carson City and Elko, which have the largest number of health. professionals, with about 50'/. participation. Reaction and suggestion forms completed by participants early in the program indicate interest and a high level of satisfaction. These forms were designed primarily to provide feedback.to consultants. Bi-monthly consultant visitswill continue to be scheduled In all nine communities, and in addition, evening sessions will be scheduled. The continuing nursing education program (Project #7) will provide nursing follow-up between visits. Fifth Year: $18,500 Requested Fourth Year Project #11 - Continuin@ Education for Nursing - Idaho $89,255 This project became operational July 1, 1970, and is based at the Idaho State University in Pocatello. It is the second phase of a regional approach to develop a cooperative continuing nursing education program for the region. Its development follows the pattern of the Nevada project (Project #7) and the four components have common goals. The project director, based at Idaho State University Department of Nursing also serves as faculty for educational activities in Southeastern Idaho. A second faculty member is serving Northern Idaho based in the Department of Nursing, Lewis and Clark Normal School at Lewiston. A third faculty member will be based at Boise State College and will serve Southwest Idaho. Fifth Year: $96,887 Sixth Year: $108,459 Requested Fourth Year Project #12 - ContinuinR Education for Intensive (are Personnel- @88,827 Southwest Idaho - The request for fund.s for the next Triennium for this project which was reviewed by the November 1970 National Advisory Council, plus continued contributions from the are hospitals and the Idaho Heart Association will permit expansion of the effort to include more physicians and nurses. ]'lie program is inter-regional and inter-agency i-n character and is an adjunct to the oversubscribed MS/RMP coronary care training program originating in the Missoula, Montana area (Project #2). This program will harmonize with the regional objectives and will be consistent with the training centers, as well as with the plan to develop stibregiotial centers of continuing education. A consortium of our area hospitals (St. i,tike's and St. Alpl)onstis,Boise; Mercy, Nampa and Caldwell Memorial) was formed and their contribution plus @i substantial amount from the Idaho lleart Association, permitted early implementation of the program. It has made a significant impact on Southwest Idaho and Eastern Oregon. Fifth Year: $92,614 Sixth Year: $85,860 MOUNTAIN STATES RMP - 13 - RM 00032 5/71 Requested f@roject #13 - Continuing Education for Nur,,;i.ng offtin Fourth Year ']his project was approved by the National Advisory Council $77,308 on November of 1970 and became operational January 1, 1971, with the employment of a project director. It is the third phase of a regional program to develop a cooperative continuing nursing education for the region. 'I'lie University of ',,,Iyoming has agreed to continue the project, subject to availability of funds and other resources at the end of the third year as in the previous application. The development follows the pattern of the Nevada proposal (Project #7). Fifth Year: $82,275 Sixth Year: $85,860 Requested Project #15 - Continuing Education for Nursing - Montana fourth Year This is the fourth and final phase of the continuing $94,820 education for the four states. The development follows as the preceding projects, the pattern of the Nevada program (Project #7). The project will be based at the MontanaState University School of @@ursing of Bozeman, with community health facilities sharing responsibilities. A network of seven learning centers will be established with each center serving one or two secondary centers near or at the nurse's place of employment. Montana State University has agreed to assume responsibility for the project after the first three years of operation, subject to the availability of funds and other resources. Fifth Year: $94,521 Sixth Year: $98,407 .,EW PROJECTS ( Proposed for periods two and three of the Triennium) During the next Triennium the MS/RMII will be involved In a transitional period during w'nich several project-, will phase out, others will be phasing down and/or developing new emphases. The following programs have been designed to achieve a systems change in manner which is viable and feasible at the grassroots level. Project i@16 - A Program for Stibregional Development of Health Maintenance Organizations. The goal of this proposal is the stimulation of the development of a locally feasible and acceptable organization of portions of the health delivery system in selected communities. The organization will offer: Comprehensive health care for consumer, including preventive programs; ambulatory care services; strengthened linkages into a referral system; development of a specialized center; and a pre- payment mechanism. MOUNTAIN STATES RMP 14 - Rm o6O32 5/71 The proposal is correlated with the accompanying one dealing with manpower utilization, which will stimulate readiness for HMOs which will be feasible at the local level and commensurate with national and regional goals. The "systems transformation" called for by this program consists of successive community adoptions and refinements of revised organizational patterns for improved delivery in specific communities. Fifth Year: $49,400 Sixth Year: $110,285 Project #17 Improved Utilization through Expanded Roles of Existing Manpower. The proposal will support extensive development of more effective patterns of manpower utilization in rural communities. Tt will concurrently support the training of a "middle-level practitioner" category and facilitates their introduction through community based manpower reorganization efforts. Specific activities will include health personnel training and collaborative learning of new styles of working arrangements. Specific designs will be based on individual characteristics of communities and based on involvement of the key health services and health resource personnel. A coordinated planning and administrative mechanism will be maintained at the regional level. Fifth Year: $58,900 Sixth Year:.$70,800 Project lkl8 - Centers for Care of Childhood Disorders - This proposal will attempt to reduce infant mortality and morbidity in the neonatal period and prevent long-term sequelae of birth-associated events for infants in the Mountain States area. This is only one aspect of a comprehensive program of maternal and child health. The prbgr@.ii7i will designate regional centers through evaluation of vital statistical data, geography and transportation factors and medical specialists available. Secondly, centers will be designated to train personnel. Faculty (physicians and nurses) will be recruited and equipment will be obtained for demonstration teaching. Evaluation will include data,measuring the centers' ability to correct life threatening conditions through the use of trained personnel and special equipment and facilities and overall improvement in neonatal death rates. Fifth Year: $78,000 Sixth Year: $100,000 Project #19 - Extension of Cancer Centers - The purposes of this project are identical to Project #3, which established in Boise a regional cancer diagnostic and treamtment resource, (MSTI) which in addition provides intensive and continuous cancer education program for medical, dental and allied health personnel. @IOUNTAIN STATES RMP - 15 - RM 00032 5/71 Funds are requested for establishing in a centrally located community -in Montana, a similar resource. There are three hospitals and about 40 physicians w@io provide major medi.cal specialty referral services for eastern Montana. Both cobalt and chemotherapy are available to a limited degree but services are fragmented. The center planned for this will follow the concept of MSTI in Boise. A Linifi.ed center similar also to MSTI is also planned for Las Vegas, Nevada. There has been much interest and enthusiasm by health interests in the area for such a center. It will serve a community of 300,000 residents, utilizing the MSTI as a prototype. Core staff will assist in planning and development. Fourth Year: $50,000 Fifth Year: $70,000 ?roject 4@20 - Preparation of Physicians as T,?achers - The proposal calls for the development of new and relevant educational skills for key health practitioners in the new subregional system for continuing education. This will provide key health practitioners--particularly selected physicians with advanced skills in emerging and existing medical and health education opportunities. Preparation of physicians and other 'health personnel as key teachers in stibregional centers will be accomplished through ail educational design which: (1) provides for reducing the "knowledge-practice gap"; (2) provides a "renewal" experience to give participants a competence to effect significantcommunity changes in medical care practice: and (3) provide competence to create and sustain an optimal learning environment allowing for increased discipline competence and more productive interdependent behavior directly related to the community's overall health system effectiveness. Fourth Year: $62,441 Fifth Year: $92,800 Project #21 - Laboratory and Radiography Improvement Program - This program will be designed to improve and make more readily available, reliable clinical laboratory and radiography services. This will be very significant in the overall improvement of medical care in rural areas. Subregion committees will be utilized and consist of consumer representatives, as well as all health professionals (including hospital administrators) having an interest in linica laboratory and radiography performance. The program will utilize local resources to the maximum; and the system will be largely self-supporting. All aspects of the program will be identified with the subregional committee and not with any official agency or professional group. Cooperation of state and local health departments, community hospitals and professional groups, through appropriate official representation 'IOUNTAIN'STATES RMP - 16 RM 00032 5/71 on the subregional committees, will be emphasized., Cod6 numbers will guard the anonymity of laboratories and radiology departments. A well-trained experienced technologist wit some teathi ng methodology will be employed'as project director. He will coordinate all continuing education and quality control programs and serve as executive secretary of the overall committee. Each subregion will employ a part-time person (25%) to work with local committees and assist the project director carry out program ictivities in his own area. Fourth Year: $40,000 Fifth Year: $50,000 RMPS /GRB /3 /I/71 REGIC' iviO'-iN'TAIN STATES CYCT i-: RM 00032 5/71 B--EAY,OUT OF REQ'JEST 04 PE.DIOD (Triennium) O." CONTIN',j!N"G i 'zpi'@VTC,"S:,Y Nr-@! I A;@'T7VTT-@ES @REZE,AAL fAPPR/UNF@'N.IACTTVTTIES DIRECT !!.%'DIRECT TO-.AL $71,001) 71,000 @$21.927 $1,159,109 il,159,109 @1233.L25 1,292.5@4 C(--oni7-v C,-rc, Tr@inin@: 582 i $148 ',-48.582 25 174,197 2 1 79 C 1: Prof. 76,177 7 6 :1 7 7 -0- 75.,77 166,271 I(,.5j,2' 7).- 2 71 91.271 91,271 21i,752 -n-P 7 0 ') (1) 76,0t')S i 0, @, I @1) 7@- 7n.7'17 33, 31@3 33 , 343 T,--3 5 9 35. 7 C,@ (if!@ho) S@) 2 5 5 89.25 5 2 0. 61 3 1 0 fr-12 C@re Trc-'-ning C. @- 7 83,827 8,882 7 @ 1)@4 3,,(339 c-- r r - -nin 77.31,)@ "5 C7- 'c- 94, 82 0 ,4,820 20, F,33. I- .3 cole oi: Ixis,,ne @,lanpower --- --- @'18 Cc-,i',crs for Care of @;r;19 E@-tenrion of C:?ncer -r,20 - Pre"zrction of P',I)I!Z. Lz!@orntorv & Ra(7iogrcT"@y a-,X-C ,$2, 023,l@06 355, 7 54 $71,000 $2,1@49,940 @507,136 $2,95/-,C,-6 First year of Trienniu-ii (3rd year t@ be considered as part of: renewkil. STATES- "EGIO CYCL@- ov 0 ERIOD .@p,@EVIUI@SLY l@EW -@ECT TO TR IND !ACTIVI-,IES-- D ::C" APP4 /i@'NFUN - A C T @@4 117 $ 71,00(l 471 265 176,155 =7 647 26.5 12t;.7614 97.5@'@) 2-,@2@,4 7.50 :zq . 1; (,2 7. O 8148 7 02 1 co 5 F @,900 1 50 0,00@ 10 ol@o . $1, Oc), 71@l $2,617.5,'@'-' BR--AKOUT OF REQUEST 0 PERIOD RY, 00011,2 5/71 7 C,"@ I C)' C @--,VICUSLY ALL YZ-ARS ALL YZARS T,%D!R@CT A ACT7VT TCJ.AL DI@7ECT TOTAL ',,A L -3:'R. S 7Cr Ti DIR 7r,. 1 29 7 2@8,229 172 2r'7.172! C, 1: 1, 7(,.177 76,11-,7 r@,',. ? 7 7 4@.25@i ','.@,2 6 I . F"@ 2. 217,n2i f, n 7 .2),7@@, I-,2,lr 2,),, , r) I i 1)2 i --99.9 c) 7 1 r 1 n @i , 2,,- 2 7,q. 01)7 5 , p r) 1) 121 , I?zi(4 2,' 5@ 3 S 7 7 I. (,', : I @ 2 . P, 2 P 7 . 7 110,285 1 1 1 2 q.@ 1 5 5 ')OO 7 0. 7@. S('o 1 2 0 , 7(,@-) 1 2. 7nn 7 0. i 0, 01,,P 1 O,). O()(', I 01) (,@n 1 7- , O@O 1 7 o@o 000 7 C) . fl) 70, or,) 120.000 i 1 2 O,. or.(I 92. 1,@00 1)2 , -,Of@ 92 . 301) 15 5 , 2 41, 5 5 50.000 50,000 90,000 90,0(@o $'@,714,271 '@207,172 $5r)4,885 $2,486,-@2 $470,748 @2,957,071, $7,553,810 $9,047,3111 .(A Privileged Comniu.nication) SU@MRY OF REVIEW A.ND CONCLLTSIOI\L OF A@DRIL 1971 REVIF,,UL COMMITTEE MOUNTAIN STATES REGIONAL MEDICAL PROGRAM RM 00032 5/71 FOR CONSIDERATION BY MAY 1971 ADVISORY COUNCIL RECOMMEI\TDATION: The Committee recommends approval of triennial funding to include the developmental component at the following direct cost 16vels: Year e@st Recommended 04 $2,44.9,940 $1,741,000 05 2@617,542 1,511,000 06 -2,486,328 1 5 36 .2 0 Total $7,553,810 $4,618,000 No renal activities were proposed. -TI UE: Two members of the site visit team presented findings from the Yierch 8-9 site visit which'was held in Boise, Idaho and Reno, Nevada. The Boise portion of the visit was devoted to study of the organization, progress, and future plans for the Mountain States RMP as a whole, while the Reno portion of the visit was concentrate on plans for a proposed Neva(-la RIIP, separate from the Mountain States Program. The team learned that the RMP has developed an effective network for health planning in the four-state area. Several of the operational projects have been outstanding in promoting better patient care services. The Regional Director has successfully recruited and retained excellent Core staffs. Subregionalization has been effected through the establishment of the fout-state office, while the regional headquarters at Boise has been instrumental in seeding effective program activities throughout the Region. The RAG has been reorganized from an original group of 160, to a more manageable And effective number of 26. How6ver, the present membership is too heavily we'ialited toward physicians; the RAG needs to be broadened with Allied Health and consumer representatives. Both the RAG and the State groupings of practicing physicians and nurses, community hospitals, voluntary and official health agencies appear to be well versed on the needs for priority seti-linc, and decision makin Core staff has been instrumental in initiating a number of community activities in priority areas. The team felt the Reg!-on is able to accept responsibility for developmental fuj-.iding- The team also reported that the iiove toward separate RMP status by Nevada a peared to be very amicable. Both WICIIE, the grantee p MOUNTAIN STATES RMP -2- RM 00032 5/71 organization, and the Mountain States staff appear ready to assist Nevada in its next steps; the @IP has been a positive resource in the development of the new medical school in Nevada. The separation issue will be fully explored in the next year. The reviewers agreed with the site team's recommendation that a dialogue begin with all interested parties--representatives from Boise, Boulder, Reno and, the RAG--to explore means of accomplishing mutually acceptable solutions to all issues involved with autonomy for Nevada as.a separate RMP. The Committee concurred with the site visitors' recommendations regarding the approval of developmental component funding and three- year support for the Region. The Committee noted that the continuing education programs in the four states need better coordination and that EMP support for the Mountain States Tumor Institute should be limited to two more years. The Region should also be advised to broaden its RAG membership. RMPS/GRB/4/26/71 DEPK., flAEN-rOF HEALTI-1, EDIJCATIOI@,l, ANr, IELFARE PUIBLIC HI@'ALTH SERVICE HEALTFI SERVICES AND WIF:NTAL HEAI-TH ADN41NISTRATION Mar6b 16, 1971 Mountain States (WICHE) Site Visit ,o: Harold Margulies, M.D. Acting Director .Regiorfal Medical Programs Service Through, Sarah J. Silsbee Chief Grants Review Branch This i s a "mini" site visit report to give you a very general and condensed impression of the regionts present status. The team was composed of the following members.- Clark H. Millikan, M.D., Chairman Henry Lernon, M.D. Willard A. Wright, M.D. Miss Dorothy E. Anderson, RiN. Herbert B. Pahl, Ph.D. Jessie F. Salazar Miss ElsA J. Nelson Rodney Mercker Richard F. Clanton, JR. Daniel. P. Webster The first day, March 8, was spent in.Boise, with all four state offices and the regional Core staff and '@,7ICHE represented by Dr. Kevin Bunnell, from IQICHE, who is the Coordinator, ind Mr. John Staley, the Fiscal Management Officer. Dr. Popma serves as Regional Director- Dr. Bunnell discussed the relationshi 'of p the MS/RMP to WICHE, which is the grantee organization. WICIIE has provided the cohesiveness and sound fiscal. management to the region, And in addition filled the role of "cente-r- of excellence" which did not exist in any of the four states Prior to RMP. While the WICHE Commission (39 members) has overall power to criticize, and even reject, program suggestions, there is no evidence that tb6te has been any conflict produced by this authority. The RAG has b,@-@cn reorganized., f-rt)m an group numbering about 160, to a uiorf., manageable and effective size. The Group needs strengthening @--c include a representative of alabor union, minority group or someone who would be considered an "average" consumer, The new Chairman is Exe,-uti.ve Director of Wyoming Blue Cross-Blue Shi@@ld. PAge 2 - Dr. M--.gulies Sub-r6gional development is progressing. An example of this is the Mo tana and Educational Foundation which was funded by@Proect #5, July 1,@1969. The Foundation has a Board of 13'me-,nbers which has produced 81 separate educational programs, attended by 3,600 individuals. Currently the Board is reviewing priorities of this organization; looking at problems related to the need for health manpower development and how this might be expedited. They may explore prospects of becoming more active in the development of ID10s. Dr. Grizzle (Wyoming) reported that through IIS/RMP's efforts in sub-regionalization, a new record system was developed. at the Big Horn Hospital wbich,is now being extended to other hospitals in the area. Also, the University of Wyoming has now taken over the responsibility for the communication network originally developed by RMP. The Mountain States Tumor Institute in Boise treated 770 patients last year, and the estimate is for about 1500 patients for Idaho Alone in the current year. The team made some suggestions to be re- layed to St. Luke's Hospital Board of Trustees for diversifying its funding sources. The site team visited the new facility which will soon be ready for occupancy. MS/Pl4P has wisely concentrated on objectives via their projects which were capable of accomplishment and have led to formation of "contact points" throughout the four States. They.sbould probably now direct their attention to the design of other programs which may be introduced into the already established system. The site visit team addressed the question of administrative methods for priority setting and decision making in terms of program content, budgetary considerations, etc. The team learned that An Executive Committee, working with the RAG will work out recom- mendations for budget cuts, And each State subregion will also develop its recommendations. The two sets of recommendations will be negotiated into one list which will be reviewed by the Executive Committee, If necessary, it will be considered by each 8ub-region again, and thence to the RAG.for final action. The team was assured that MS/RMP fully understands that the RAG carries'the responsibility for the important concept of-priority setting and decl'sion-making. Also, pr,-,cticingwphysicians and organized medicine community hospitals, voluntary and. official. health agencies are playing a significant role in the fo-Ur--state program. Participatio@-I and involvement of nursing professionals is expensive. There is amp;16 evidence that Core activities have resulted in actiou-oriented planning, particularly in local level co@T,,ffiuriity organization and planning i.ei, CHP and Model Citi es. Page 3 - Dr. Ma@gulies The second,day (March 9)'was spent in Reno, at the University of Nevada., To quote.Dr. Millikan, if there bad been a big bonfire going (for separation), it had been dampened considerably before the confrontation with the visiting team. Dr. Georg6 Smith, Dean of the School of Medical Sciences, was Chairman. A,lthough@- Dr. Smith delineated about eight reasons for Nevada's wish to become an autonomous RMP, there was no real description on his part,, or others who spoke for the Nevada group, of what would be done differently -if they were independently organized. The Nevada group appears.to be quite far away from the development of a concept of the necessary organizational structure, objectives, etc., in terms of local capability In other words, there was-conclusive evidence that planning has not proceeded very far, The presentation in Reno was a most interesting description of educational opportunities in Nevada, both at an undergraduate level and the new two-year medical school. BUT, there was no definition of the roles to be played by the "N6vada Regional Medical Program." Doctor Fred M. Anderson, Member of the Board of Regents, University of Nevada and Commissioner from Nevada to WICHE., as well as Member of the Nevada Section of MS/RMP RAO, reported that statewide elements favor autonomy as soon as feasible for Nevada. He suggested as one possiblity, an affiliation agreement with WICHE on an interim basis to benefit from WICHE's expertise in planning, while Nevada continues to plan for full autonomy with the University as the grantee. Doctor Pahl discussed briefly the "transition scheduling", in terms of a target date for separation and referred to timing factors in line with-preparation of new applications, review cycles, etc. The suggestion wag made that perhaps a small group which would be representative of WI.CHE MS/RMP and Nevada could meet to work out-a plan of procedure, which, in turn could be presented for National Advisory Council consideration and advice. Dr. Millikan pointed out that the split in South Dakota and Nebraska was not viewed.by RMPS and the N.A.C. as a precedent upon which Nevada (or any other region) could build its case for secession. Each is.a distinct phenomena and with many differences.readily apparent. He was complimentary to the Nevada and to the MS/RMP t6p e8ontatives in its desire for orderly procedures in steps to establish Autonomy. He emphasized the need for an organizational matrix to stimulate staff int6r-relationsbips and provide the environment for a series of dialogues. This should include, of course, identification of the requirements of WICHE and give due 'deratibn to needs of all four states. consi 'Bunnell, in stating WICHE's position in the Nevada separa- Doctor tion expressed the opinion that all of the points raised by Nevada are resolvable, but, mutually beneficial resolutions will have to be negotiated with representatives of Reno, Boise and Boulder , 0 Results must be beneficial to all concerned. Page 4 - Dr. MarL, Les The team discussed very briefly the effect of the cut in funds to the overall program, but did not specifically pin down items for such cutsi Doctors Popma and Cerdes listed anumber of areas where reductions would not result in appreciable amage to t e program. The region has exhibited expert know how in 'developing an effective network for health planning in this large four state area. The Regional Director has been successful in recruiting and retaining an excellent Cote staff. The site visitors noted that sub-regionaliza- tion through the establishment of four state offices, plus the regional headquarters office in Boise entails considerable expense. There was agreement, however, that this cost is justified when one considers the significant impact of this means of distributing RMP activities to many communities of varying size throughout the four Stat6s* The consultants recommended approval of the Developmental Component in an amount to be commensurate with pending overall budget negotiations. sie F. Salazar Public Health Advisor Grants Review Branc A Privileged Communication RM 00032 SITE VISIT REPORT MOUNTAIN STATES REGIONAL MEDICAL PROGRAMS March 8-9, 1971 SITE VISITORS Clark H. Millikan, M:D., Chairman, Consultant in Neurology, Mayo Clinic, Rochester, Minnesota, Member, National Advisory Council Henry M. Lemon, M.D., Professor of Medicine, Nebraska Medical School, University of Nebraska, Omaha, Nebraska, Member, Review Committee CONSULTANTS Willard A. Wright, M.D., Director, North Dakota RMP, Crand Forks,, North Dakota Dorothy E. Anderson, R.N., M.P.H., A,ssistant Coordinator, Community Programs, California RMP Area V, Alhambra, California REGIONAL MEDICAL PROGRAMS SERVICE STAFF Herbert 8. Pahl, Ph.D., Acting Deputy Director, RMPS Jessie F. Salazar, Public Health Advisory, Grants Review Branch Elsa J. Nelson, Specialist for Program Development, Continuing Education and Training Branch Rodney Mercker, Crants Management Officer, Grant4 Management Branch Richard F. Clanton, Jr., Operations Officer, Regional Development Branch Daniel P. Webster, Regional Office Representative, Region VIII MOUNTAIN STATES REGIONAL MEDICAL PROGRAM STAFF Alfred M. Popma, M.D., Regional Director, Boise, Idaho John W. Gerdes, Ph.D., Deputy Director, Boise, Idaho Kevin P. Bunnell, td.D., Coordinator, Boulder, Colorado Laura C. Larson, R.N., M.A., Coordinator of Nursing and Allied Health, Boise Charles E. Smith, Ph.D., Coordinator Planning and Development, Boise Mrs. Helen Thomson, Coorinator of Information, Boise, Idaho Fred 0' Graeber, M.D., Director, Idaho Subregion, Boigei Idaho Sidney C. Pratt, M.D., Director, Montana Subregion, (.;rest Falls, Montana Joseph B. Deisher, M.D., Director, Nevada Subregion 'Reno, Nevada Claude 0. Grizzle, M.D., Director, Wyoming, Subregion, Cheyenne, I-lyoming Donald Erickson, M.A., Educational Specialist, Wyoming Subregiono Cheyenne Mrs. Helen Alexander, Assistant Director for Administration, Montana Subregioft' Great Falls, Montana Louise Alcott, R.N., Assistant Director for Administration, Nevada Subregion$ Reno, Nejada Wilma Frederickson, Staff Associate, Nevada Subregion, Reno, Nevada Bette Jean Tranum, Administrative Secretary, Boise, Idaho John Staley, Administrative Services Officer, Boulder, Colorado MOUNTAIN STATES RMP 2 - RM 00032 REGIONAL ADVISORY GROUP Arthur R. Abbey, Chairman, RAG; Executive Director, Wyoming Blue Cross/ Blue Shield; Cheyenne, Wyoming l,aura 0. Walker, Ph.D., Vice-Chairmn, RAG, Head, School of Nursing, Montana StateIUniversity; Bozeman, Montana Charles A. Terhune, M.D., Immediate Past Chairman & current member, RAG; Practicing Physician, Burley, Idaho WICHE COMMISSIONERS Dermont Melick, M.D., Chiirman, WICHE Commission Regional Programs; Coordinator, Arizonza RMP- Professor of Surgery, Arizona College of Medicine; Tucson, Arizona Thomas Tucker, Ed.D., WICHE Commissioner: Chairman, Department of School Administration & Supervision, University of Nevada; Reno, Nevada Juanita White, Ph.D., WICHT Commissioner; Nevada State Representative; Boulder City, Nevada Fred M. Anderson, M.D., WICHE Commissioner; Practicing Surgeon; Board Regents, University of Nevada; Reno, Nevada OTHERS Loryp A. Kopan, Administrator, Veterans Administration Center; Ex officio Member, Regional Advisory Group; Boise, Idaho E. E. Gilbertson, Administrator, St. Lukes's Hospital; Boise, Idaho Maurice M. Burkholder, M.D., Practicing Physician; Boise, Idaho Ronald Koons, M.D., Head, Radiation Therapy,. Mountain States Tumor Institute, St. Luke's Hospital; Boise, Idaho Ra@ Cottner, Assistant Administrator, St. Luke's Hospital; Boise, Idaho Shirlee Koons, R.N., Nurse,Coordinator, Mountain States Tumor Institute St. Luke's Hospital; Boise, Idaho Marie Crisp, R.N., Chief-;Technologist, Mountain States Tumor Institute Boise, Idaho Member, Core Committee for Mountain States Tumor George Baker, M.D., Institute, Practicing Physician; Boise, Idaho Cl.enn Talboy, M.D., Member, Core Committee for Mountain States Tumor Institute; Practicing Surgeon; Boise, Idaho Verne Reynolds, M.D., Member, Core Committee for Mountain States Tumor Institute: Practicing Gynecologist; Boise, Idaho Alfred Stone, M.D., Member, Core Committee for Mountain States Tumor Institute. Chief, De artment of Radiology, St. Luke's Hospital; Boise 0 p John Edwards, M.D., Practicing Physician; Idaho State Representative; Council, Idaho Kay Ortman, R.N., Recent Graduate, Stanford University Nurse Clinician Training Program; Cambridge, Idaho Ethelda Thel6n, R.N., Program,Coordinator, Continuing Education for Nursing Nevada; Reno, Nevada George Smith, M.D., Practicing Physician; Dean, Medical School, University of Nevada; Reno, Nevada MOUNTAIN STATES RMP - 3 - RM 00032 4D Oli,tiERS (cont.) I Thomas S. White, IA.D., Practicing Physician; Member Regional Advisory Group; Boulder City, Nevada Richard Licata, Ph.D., Professor of Anatomy, University of Nevada; Member Regional Advisory Group; Reno, Nevada Marjorie J. Elmore, Ed.D., Head, Or@is School of Nursing, University of Nevada; Member Regional Advisory Group; Reno, Nevada Dean Fletcher, Ph.D., Professor of Cancer Research, University of Nevada; Reno, Nevada David Brandsness, Administrator, Sunrise Hospital; Member Regional Advisory Group; Las Vegas, Nevada Hugh Collett, M.D., Practicing Physician; Elko Nevada N'. Edd Miller, Ph.D., President, University of Nevada; RenoNevada Veriyn Elliott, MiD. President, Nevada Medical Society; Fallon, Nevada Mountain States Site Visit Report -4- RM 00032 INTRODUCTION: The first day of the site visit was spent in Boise, with all four-state offices and the Regional Core Staff 4nd WICHE represented. Dr. Kevin Bunnell discussed the relationship of the Mountain States Regional Medical Program to WICHE, the grantee organization. WICHE has obviously provided the cohesiveness and sound fiscal management to the region, and in addition, filled the role of "center of excellence" which did not exist in any of the four states prior to RMP. REGIONAL ADVISORY GROUP: The RAG has been reorganized, from an original group of about 160, to a more manageable and effecti'e number of 26. The v site team felt that this is a much more realistic and workable group, and in accord with the previous site visit recommendations. However, the team found the Group to be largely weighted with..medical people and generally inadequate in alliedhealth and consumer interests. There was almost unanimous agreement that the Group will be strengthened and enriched by including representatives of labor, minorities or other "average" consumers. The new RAG Chairman is Executive Director of Wyoming.Bltie Cross-Blue Shield. The recently inaugurated review procedures developed for the RAG seem to be quite comprehensive and workable. -These should benefit also by greater input from the broadening of membership referred to above. GOALS, OBJECTIVES AND PRIORITIES: There was neatly uniform agreement from the site visitors that the goal, of improving the health care of the largely rural residents of the four-state Area was the most over-riding of the four that are stated. The goals of manpower development and health center development appear subordinate to these. The region seems to have very adequately assessed its needs, problems and resources; objectives and goals are congruent with national priorities. To some extent, funding of operational programs to date appear to have beendevelbped with political considerations in mind to give each one of the states some share in activity, This seemed to the team an entirely reasonable and necessary consideration. ORGANIZATIONAL EFFECTIVENESS: Dr. Popma, the Regional Director, has served in an outstanding manner as a result of his broad experience and involvement with Regional Medical Programs on a national level, and his keen sense of the qualifications required by his organization. The team agreed that the Core staff, which reflects a broad range of professional and management competence in all areas is highly effective. Noted particularly was the management and fiscal responsibility which falls under the purview of WICHE. One of the strongest features of the MS/RMP organization,is the sub-regional activity, which seems to be proceeding well, especially in Wyoming, Montana and Idaho. Nevada was considered-to be somewhat less well developed in this regard,.possibly due to its greater distance and isolation. While sub-regionalization appears expensive, it has proved important in maintaining liaison throughout the four-state area, and as a framework for future development in improved patterns of medical care. The grantee organization (WICHE) traditionally embodies an even larger number of western states for educational purposes, which has strengthened this aspect Mountain States Site Visit Re'port -5- RM 00032 of MS/RMP, The site team was unable to determine the real extent of relationships with Comprehensive Health Planning on either the A or B levels. Indeed, the team did not glean any positive impressions of CHP activities in any of the four states. Regional resources are well utilized in all four states. There was feeling, however, that lacking is an involvement in non-government and private industrial interests, i.e., the copper companies in Montana and the Boise-Cascade Corporation in Boise. These might prove to be an excellent source of lay individuals, who can serve an effective role in hea.Lth planning. Practicing physicians and organized medicine are significantly supporting and participating in the program. Many community hospitals, including their boards and staffs are firmly committed and involved. The involvement of nursing professionals is extensive. It general, there seems to be satisfactory political and economic interaction in the MS/RMP. One infet- esting development is WAMI, a program emanating from the University of Washington School of Medicine, aimed at increasing the output of physicians by getting peripheral educational and community health facilities personnel involved in the training of doctors. Idaho and Montana are actively involved in this plan. ASSESSMENT OF NEEDS, PROBLEMS,AND RESOURCES: The site team felt that these havetbeen adequate in most respects, but planning appears to have been limited to the immediate future. For instance, in the Mountain States Tumor Institute program, (based in St. Luke's Hospital), it was clear that planning has thus far been rather limited in scope, that the full scientific potential of the enterprise has not been planned for, and as yet no formal linkage to a state college unit has been developed. This would provide the avenue for educational funding, which will be needed to make the Institute a real community asset. It was suggested that an exploration of an affiliation with the Boise State College might lead to development of a School of Allied Health based at St. Luke's and St. A!Ohonso Hospitals. The team also recommended that the Board of St. Luke's consider the development of a Scientific Advisory Cormnittee, with thought given to planning for other medical disciplines. It was noted that there is a very excellent surgeon engaged in a large volume of angtography in Boise, and Also that 75% of the 150 practicing physicians in Boise are spec a sts. In time, the Mountain States Tumor Institute could become a multicategorical health resource. The team also suggested that cancer center planning grant, or other federal support, should be explored with the National Cancer Institute. PROGRAM ACCOMPLISHMENTS: Outstanding is the impressive coronary care training program in the Montana area, and the nucleus of an excellent cancer care activity in the Mountain States Tumor Institute in Boise. Further, RMP outreach to selected communities in developing the nurse practitioner program through a realistic method of obtaining individuals who can contribute to local health care is representative. Also, there is evidence of adequate surveillance of ongoing activities via the sub-regionalization network. This shows great promise for future Mountain States Site Visit Report -6- RM 00032 development, particularly in rural health care if the Core staff sub- regionalization organization is preserved. The nurse practitioner program will need to develop its own training program-in view of the discontinuance of Stanford's. The visitors believed that operational programs developed in this region have faithfully reflected the region's initiallobjectives of improving - y postgraduate educational availability for practitioners by bringing the program to medical and nursing practitioners. Missing, as far as could be determined by the team, is dental or allied health training on a continuing basis. These efforts have been intermittent. The postgraduate educational activities appear to be quite diverse and fragmented throughout the states, and rather loosely coordinated by the regional office. These programs have been expensive in terms of travel funds and consultant fees. However, evaluation of the impact of some of these activities, particularly the coronary care program, has indicated positive results. This has been particularly notable in small community hospitals in influencing physicians'and nurses'coronary care procedures. The MS/RMP realizes that it is now moving beyond the phase of postgraduate training and is beginning to think about the generation of new manpower. The region is faced by the necessity for major cuts in the approx imately $800,000 of the continuing education request. While such programs have strengthened the image of Regional Medical Programs throughout the four states they have also been an excellent proving ground.to many health professionals in the.four states for what can be accomplished through future cooperative efforts. There was concern on the part of the site visitors that in planning for present and future operational activities, Stroke has almost been tom- pletely by-passed. The team expressed the hope that in due course this omission can be alleviated. The expanded Mountain States Tumor Institute facility, already referred to above, will be in operation later this year. The planning for this facility has been excellent and includes prospects for ten stories to be constructed stop the present basement level unit. The MSTI is seeking the services of a radiotherapist, a chemoth6rapist, a physicist, a social worker and technicians. The Institute is beginning to break even in terms of fees and grant funds. In 1970 there were 300 new radiotherapy cases, 400 chemotherapy patients and 70 old cases, all of whom paid fees. The new patient load that is anticipated with the opening of the new facility is 700. The hospital board's failure to think in somewhat broader terms of a future, multicategorical facility has already been referred to under Assessment of Needs, Problems and Resources. The site team emphasized that the hospital board should think about developing a Scientific Advisory Committee which could, in turn, broaden the horizon for the Institute and develop into a major health resource, not only in cancer, but in cardiovascular and neurological diseases as well. Mountain States Site Visit Report @7- RM 00032 The influence of Regional Medical Program activities is quite evident in the Nevada area, largely due to the interest of the Reno physicians and the development of the new medical school. This is most apparent in planning for the training activities of the school. The team was interested to hear from the Deputy-Direct6r that he viewed the lack of a medical school in the region as one thing that has influenced the emergence of interaction of local talent in a manner that might not have evolved if medical school leadership had been available. The Montana Medical and Educational Foundation (Project #5) was funde July 1, 1969. It is directed by a Board of thirteen members which has produced 81 separate educational programs, attended by 3,600 individuals. The concept provides a multidisciplinary approach to continuing education for all health professionals. With funds expiring in March 1972, the RAG is now studying ways and means of attracting other resources, perhaps by providing some service as well as educational functions. Long-range plans for the program, which now crosses state lines into Idaho, Montana, Wyoming and North Dakota . Eventually it will move into existing or future university systems. Also under consideration is the prospect of becoming more active in the development of HMOs. , The site visitors were interested to learn that the University of Wyoming has now taken over the responsibility for the communication network originally developed by RMP. Also, through RMP impetus, a new record system was adopted in the Big Borh Hospital which is being extended to other hospitals in the area. The site team was interested to learn about the development of the Nurse Physician Assistant Program. The first registered nurse to be trained will practice in the Cambridge, Idaho community which is presently served by two physicians and cover a radius of 200 miles. The Nurses Association was active in developing the legal instrument--the Nurses Practice Act-- which was spearheaded by Doctor John Edwards, a member of the Idaho State Legislature. Out of 66 physicians contacted personally, and 132 physicians (from a total of 198) who returned the questionnaire, 10 expressed the desire to have a Registered Nurse Assistant. Although this would appear to be a low figure, the team felt that acceptance of the concept in this area is more significant. Nurses are really doing patient work with only somewhat dis- tant supervision. Also, it was noted that liability insurance covering practice activities for participating physicians is continuing without an apparent increase or mark-up in premiums. Planning discussions are underway with the 'University of Wa;tiingt'on leading to participation by Idaho and Montana in WAMT(I,Tishington- Alaska-M6ntana-Tdaho). This experimental program proposes regionalization through training by the University of Washington School of Medicine of medical students, interns and residents in the Mountain States Site Visit Report - 8 - RM 00032 states of Alaska, Montana and Idaho. Communities will be chosen by the University of Washington, based on existing local resources and manpower. In the state of Idaho a series of seminars involving the Medical Association, CHP, the Advisory Committee to the State Board of Education, RMP and others, is seeking the means for establishing an administrative base to relate to WAMI. EVALUATION While the application did not give specific details about Evaluation methods, the team was unanimous in the impression that, under very capable direction, evaluation for the program is of very high quality. The results thus far have been.project, rather than program oriented. Also, the team recommended that the assessment of the overall program would be strengthened by in- creased participation of consumer groups and allied health representatives. Since the evaluation mechanism is quite new, there was not, as yet, evi- detce of a strong feedback method to relate program and project evaluation to the Regional Aclvisory.Group. It was agreed, however, that this will doubtless be a very real part of the upcoming reappraisal of use of reduced funds in the forthcoming Triennium. The data presented to the site team is comprehensive And indicates practical applications and Accomplishments in a short period of time. The feedback for improvement in programming is receiving attention. There is in operation now a computer print-out, a common registration form, a quick response scheme, a satisfactory questionnaire, etc. WICHE AS THE GRANTEE In addressing the question, "WICHE--What is it?", Doctor Bunnell explained the functions oIf the three programming divisions of WICH9: (1) planning and management. systems, (2) mental health, and (3),general "regional" programs such as Regional Medical Programs, student exchange, etc. WICHE as the "backdrop" for the Mountain States RMP seems to be a reasonable and functional organizations mainly because WICHE was already regional in concept. It was organiz&d to serve an educational function, and through thefaulkner Report, had identified the need for a 'regional' medical school. Finally, it provides strong management expertise. WICHE is committed to the spons.orship of a strong Regional Medical Program and provides the MS/RMP with an amicable, historical and mutually beneficial background for program goals. Doctor Bunnell responded to the question of the future role of IIICHE in Regional Medical Programs with a statement concerning new thrusts for RMP away from Continuing Education to new roles, such as development of Health Maintenance Organizations. Mountain States Site Visit Report 9 - RM 00032 NEVADA AS A SEPARATE REGIONAL MEDICAL PROGRAM: This portion of the site visit took place in Reno, the location of the new School of Medical Sciences, University of Nevada. The site team had previously identified several concerns about the request from Nevada for separation. These were discussed in a friendly and responsive manner. Doctor George Smith, Dean, outlined about eight reasons for Nevada's wish to become an autonomous RMP: Nevada feels it is capable of assuming its own leadership role; they need the authority to assume better local control; an independent Nevada RMP would decrease intermediate levels of bureaucracy (Washington-Boulder-Boise-Reno); better utilization of their own facilities and personnel would be,possible; more effective coordination of overlapping Regional Medical Programs activities (Intermountain, Mountain States, Davis,, Loma Linda) would be possible; development of local priorities would be enhanced; as would the development of new relationships with WICHE. The last point was considered somewhat irrelevant to the issue of a separate Regional Medical Program for Nevada. Indeed, there was no real description on the part of spokesmen for the Nevada group of what would be done differently if they were independently organized. The Nevada group appears to be a long way from the development of A concept of the necessary organizational structure, objectives, etc., in terms of local capability. The presentation was a most interesting description of edu- cational opportunities in Nevada, both at an undergraduate level and the new two-year medical school. However, there was conclusive evidence that planning for a new Regional Medical Program has not proceeded very far. Neither was there a definition of its role in the new School of Medical Sciences. Doctor Fred M. Anderson, member of the Board of Regents, University of Nevada and Commissioner from Nevada to WICHE, as well as Member.of the Nevada SectLon of MS/RMP RAG, reported that statewide elements favor :autonomy as soon as feasible. He suggested as one possibility, an affiliation agreement with WICHE, on an interim basis, to benefit from WICHE's expertise in planning, while Nevada continues to plan for full autonomy with the University of Nevada as the grantee. Dr. Elliott, who represented the State Medical Society, spoke about inter- relationships at the state level which could be strengthened through an autonomous RMP--the Department cEHealth, State Medical Society and the School of Medical Sciences. An attempt was made to get an understanding of the "administrative stumbling block" which now prevents smooth and workable relationships with IJICHE through the existing RMP structure. it was learned that no definite'time has been set for NevAda's separation; the local group appears unanimous in its desire to withdraw from the four-state area. At the same time, the retirement of Dr. Popma later this year and tied recent appointment of Dr. Joseph Deischer as State Director for Nevada, may influence the timing of autonomy for Nevada. i4ountAin States Site Visit Report -10- Rm 00032 The Chairman of the site team expressed appreciation for the posture of Nevada in its flexibility of timing for autonomy and its constructive attit ude about a separate Regional Medical Program. He referred to a planning application which would represent the organizational structure for such autonomy and outlined the objectives, which ideally, such an application should incude. First, there should be a definitive design for the RMP in terms of.local capabilities and commitments. Also, a full description of a Nevada Regional Medical Program will be required by all reviewers and the National Advisory Council. Consideration must be directed toward 611 health interests - professional and voluntary organi- zations, hospital interests, desires of practitioners, etc. All will need to be weighed, and hopefully, a "blueprint" for a new.Regional Medical Program will emerge. This will require many months of study and preparation. The site visitors discussed the "transition scheduling" in'terms of a target date for.separation, and the timing factors in line with preparation of new applications, review cycles, etc. The @eam suggested that perhaps a small group, which would be representative of WICHE, MS/RMP and Nevada, could meet to develop a plan of procedure, which in turn, could be presented for consideration of the Review Committee and the National Advisory Council. The Chairman also pointed out that the split in South Dakota and Nebraska was not viewed by RMPS and the NAC as a precedent upon which Nevada (or-any other region) could build its case for secession. Each case is a distinct phenomena and with many readily apparent differences. Nevada was complimented on its obvious desire for orderly procedure in the steps to establish autonomy. However, the need for an organizational matrix to stimulate staff inter-relationships was emphasized in order to provide an environment for a series of dialogues. This should include, of course, identification of the requirements of-IIICHE as well as give due consideration to the needs of all four states. Doctor Kevin Bunnell in stati-ng the position of WICHE, expressed the opinion that all of the points raised by Nevada:for becoming independent, are capable of solution. He also pointed to the necessity of.achie'vin:g mutually beneficial resolutions which will have to be negotiated with representatives of Reno, Boise and Boulder. REDUCTION IN PROGRAM FUNDS The site team was naturally concerned about the administrative format for setting priorities and decision-making within the present budgetary restrictions. Regional representatives pointed out that the Executive Committee, working with the MS/RMP RAG, will develop recom- mendations for cuts. In turn, the four-state Core staffs will develop their recommendations, and a combination of the two sets will be formed. These will again be reviewedty the Executive Committee, and if necessary, by each State Advisory Group. After full agreement, the list will be presented to the RAG which has authority for final decisions. Mountain States Site Visit Report -11- RM 00032 The regional priority system will be utilized in developing plans for phasing out, termination, cut-backs, etc. of existing programs. An attempt will be made to maintain program viability in all four states. A number of ec?5nomies can be effected in travel, meetings, elimination of RMP funds for the Cancer Registry after December 1, 1971, consolida- tion of fragmented training programs below the eight current ones, exploration of a variety of ways to assure that the Mountain States Cancer Institute would not need to receive significant funding beyond two years from now, etc. The MS/RMP hopes to effect such reductions in line with recommendations of the site team, particularly as regards the design for a transition from coronary care-intensive care activities to other broader concepts for RMP, utilizing such facilities and personnel to a maximum extent. -SUMMARY OF FINDINGS AND RECOMMENDATIONS 1. The region exhibited expert know how in developing an effective network for health planning in this large four-state area. The Regional Director has been successful in recruiting and retaining excellent Core staffs. Sub-regionalization through the establish- ment of four state offices, plus the regional headquarters office in Boise 'although expensive, is justified when one considers the significant impact of this means of distributing Regional Medical Program activities to many communities of varying size throughout the four states4 The Core staff should be encouraged to continue to plan, develop and implement new patterns of health services. 2. A real achievement for RMP is the emergence of the School of Medical Sciences in Reno, undoubtedly due to RMP influences in that area. the next few years will be critical in its development and the region was cautioned that RMP has never been viewed as the mechanism for support for medical schools or undergraduate training. 3. The MS/RMP needs to direct its attention to better coordination of Continuing Education Programs. One means of accomplishing the reduction of such fragmentation would be by the development of a multi-disciplinary (involving all health professionals) approach. This should focus on comprehensive patient care instead.of the professional disciplines involved, and develop into a team approach for continuity of patient care as well. This should afford a more economical and effective continuing education program, with improved utilization of manpower. 4. RAG membership needs broader representat on. 5. The Mountain States Tumor Institute should attack its needs in grantsmanship without further delay, in line with previous details. It was agreed that RMP support for this activity should be limited Mountain States RNP Site Visit -12- RM 00032 to two more years. In developing the Scientific Advisory Committee: at St. Luke's, consideration should be given to the inclusion (per- haps by means of consultants or sub-committees) of other health dis- ciplines, such as nurses, educators, physical therapists, social workers, etc. This will assure.tbat planning will be more relevant and comprehensive. 6. MS/RMP and l@IICHE should attempt to coordinate the current influx of health professionals into all four states. 7. There was consensus on the part of the site visitor t at t e mechanisms for decision-making are sound, well organized and managed. Further, the region was advised to apply the same principles a.nd tools,that have demonstrated success in order to economize on diminishing RMP support. 8. The Region has been most innovative in appr oaches to solving health problems. Lacking thus far are realistic thrusts in the areas of hypertension and kidney'disease'. These needs should be addressed in due course. 9. The separation of@Nevada issue was thoroughly explored with all interests. There was agreement among the visitors that init ation of a series of dialogues should now begih-with all parties represented with a view to the establishment of meaningful and mutually benefi- cial RMP organizations. 10. Developmental Component Approval in amount re4ue'sted $71,000. The region is fiscally soundi mature in management, and has demonstrated responsibility in program development and decision- making to warrant the flexibility of'judgement and ability to direct its own Regional Medical Programs affairs. 11. Continuation of Core staff support and all operational activities, as follows: MOUNI'A,IN STATES RMP 13 RM 00032 Recommendation Project No. and Title Reluebt 04 Year 05 Year 06 Year Developmental Component 71,000 71,000 $ 71,000 71,000 CORE 1,159,109 800,000 850,000 875,000 #2R-Coronary Care Training 148,582 100,000 -0- -0- *#3R-l'umor Institute 207-,172 200,000 150,000 **50,000 #5-CE for Health Prof. 76,177 70,000 70,000 ***50,000 #6-Tumor Registry 166,271 100,000 -O- -0- lk7-CE for Nursing (Nevada) 91,271i 70,000 50,000 -0- #8-Inhalation Therapy CE 76,068 50,000 50,000 50,000 #9-Cardiac Care Training (Nevada) 70,737 70,000 70,000 ***709000 #10-Consulting Teams (Nevada) 33,343 #11-CE for Nursing (Idaho) 89,255 50,000 50,000 ***50,000 IP12-Coronary Care Training (Idaho) 88$827 60,000 50,000 ***50,000 #13-CE for Nursing (Wyoming) 77,308 50,000 50,000 ***50,000 #15-CE for Nursing (Montana) 94,820 50,000 50,000 ***50,000 TOTAL $2,449,940 $1,741,000 $1,511,000 $1,366,000 *200,000 @l 711,000 Region currently supported $10873,974 *For New Projects implementation - $200,000. **Tumor,Institute to phase out in 05-06 years. ***Recommend phasing out by 06 year to mak6 these funds available for new programs. RMPS/GRB/5/5/71 REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPMTIONAL APPLICATION (A Privileged Communication) NASSAU-SUFFOLY, REGIONAL MEDICAL PRBGRAM RM 00066 5/71 19lq Middle County Road April 1971 Review Committee Centereach, New York 11720 PROGRAM COORDINATOR, Glen E. Hastings, M,D. This application requests operational status and,funding for the Nassau- Suffolk RMP. Prior to South Dakota's independence starting in planning, Nastau-Suffolk was the only one of 55 RMPs still in planning status. 01 02 03 04 t"a Core $ 451,755 490,408 530,043 0 $1,472,206 #1 Home Care 95,182 95,260 97,603 $72,448 360,493 #2 Stroke 72,111 94,196 118,426 0 284,733 #3 Pap Smear 95,956 105,468 106,557 a 307,981 #4 Rtg. Med. Libtar 46,860 46,750 48 994 0 142,604 y #5 Radiation Rx 27,830 19,085 19,085 0 66,000 #6 Smoking 27,910 7,050 0 0 34,960 #7 Computer Assisted Electr6eardiology 302,632 92,576 58,788 0 453,996 & Spir6metty #8 Training Community Health Aest's 109,382 67,225 46,860 0 223,467 Advocates #9 Drug Info. Center 146,316 149,511 i54,019 0 449,846 #10 Clinical Nurse Specialist 53,762 55,550 0 @o 109,312 #11 Dial Access 37,525 38,416 39,306 0 1154247 .TOTAL $1,467,221 $1,261,495 $1 219,681 $72,448 $4 020,845 NOTE: Indirect costs allowance is not requested. Instead, 1M. of direct costs ate budgeted for subcontracting with Stony grook Foundation as fiscal agent. Fiscal fees budgeted the first year total $130,433, (Coro - $40,747 and 10 proj6cto - $89,686). Nassau-Suffolk RMP -2- RM 00066 5/71 SUMMARY OF PLANNING PHASE FUNDING: 01 (8 months) 02 Total 1169-6/70 7/70-6/71 $263,01.1 $350,269 $613,280 BACKGROUND: This Region encompasses Nassau and Suffolk Counties comprising 100 miles of Long Island east of Queens, The area was originally included in the Metropolitan New York Regional Medical Program. The efforts to begin a separate region began with the formation of a Advisory Medical Group in 1967. In June 1968, the Group incorporated as the Nassau-Suffolk Regional Medical Program, Inc. operating within $1.0,000 contributed by eight interested agencies. More than eighty organizations supported the new region in its planning. The Metropolitan New York Regional Medical Program agreed with the two counties that it was reasonable that Nassau- Suffolk Counties form a'separate region having geographic capability with other major relative organizations, e.g., the Long Island Hospital and Health Planning Council; the State Health Department for CHP; the Nassau- Suffolk Regional Planning Board, financed by HUD for planning in housing, economics and educational development; and the New York State Department of.Mental Hygiene. Distance and transportation posed difficulties in, developing vital relationships between the counties'health professions and t- an N.Y. medical centers. The new Health Sciences t e - ero@oli Center be n h me developed at the Stony Brook Campus of SUNY had brought-medical center competence directly to the N-SRMP. The developing Stony Brook Health Sciences Center is to include Colleges of Medicine, Dentistry, Nursing and Allied Health; a School of Social Work, a Health Sciences Library; a University HosDital; and a VA Hospital. Other resources in the region include 41 hospitals, county health departments, several specialized research facilities, and the Brookhaven National Laboratory. The planning application was reviewed by the Review Committee and Council in the December 1968 cycle. Planning objectives: improvement in the delivery of medical services to all people in the community; extension of professional education; increased public education and the development of more extensive research, particularly in epidemiology and etiology. The Committee believed that the regional assets compensated for the lack of specificity in the application In response to questions raised by the Committee, the Region named previously unspecified members of the Execqtive committee and added 20 non-corporate members to the RAG. Additional information about staffing patterns was also provided. Although Council bad the additional information it shared the Committeets concern about the ROgion's heavy emphasis on computer and epidemiological personnel. Support was approved for two years of planning beginning January 1, 1969 (01 - $223,256 and 02 - $320,024). B of difficulties in personnel recruitment there was little activity ecause until the appointment-of the current Program Coordinator on June 1, 1969, For this reason, the first grant period was extended from 12 to 18 months z@-.. Nassau-Suffolk 'RMP RM 00066 5/71 with no additional funds. In lieu of indirect costs, the award was amended authorizing an increase of $29,755 the first period and $30,245 the second period for fiscal agent fees. The fiscal Agent is Stony Brook Foundation, Inc. The second year planning continuation application was reviewed by RMPS staff. Needed refinement of objectives and activities as outlined by the Program Coordinator's letter of October 7, 1969 were noted. Region- alized cooperative arrangements and program development had quickened with the appointment of a Program Coordinator and subsequent employment of sthff. Staff agreed that satisfactory accomplishments coupled with projected activities reflected continuity and movement toward effective operational status in 1971. Of particular interest, was the link witb. CHP and the Long Island Health and Hospital Planning Council. The Program Coordinator heads both IW and CHP and office space is shared. The Health and Hospital Planning Council is also.considering joining the sharing of quarters. DEMOGRAPHY AND GEOGRAPHY: Long.,'Isl.and Sound SUFFOLK Atlantic Ocean @New York A) Population: Nassau County - 1,428,000 Suffolk County - 1,011,000 2,438,000@ Urban: Nassau - 99.7% Suffolk - 77.3% Racial: Nassau - 97/. white Suffolk - 95% white 8) Land Area: Nassau - 300 sq. miles Suffolk -'.922 sq. miles 1,222 Nassau-SuffOlk RMP -4- RM 00066 5/71 C) Facilities: The State University of NY. at Stony. Brook is in the process of developing a Health Sciences Center to include Colleges of Medicine Dentistry, Nursing and Allied Health Professions; a School of Social Work; Health Sciences Library; a University Hospital (60.0 beds); and 6 VA hos ital (750 beds). p There are 41 hospitals in the region with 35,840 beds. D) Health Manpower: 3,121 physicians (Nassau - 2106 and Suffolk - 1,015) 124/100,000 6,981 nurses (Nassau - 4,143 and Suffolk - 2,838) 280/100,000 GOALS: The long range goals are: 1) To improve the distribution, accessibility, volume capacity, cost effectiveness, and quality of personal health services available to all residents of Nassau and Suffolk Counties; and 2) To develop mechanisms intrinsic to the health care system which.will permit systematic ongoing identification and documentation of unmet health needs and the evolution of alternative solutions to meet those needs. Immediate goals, as detailed on page 13 of the application, deal with innovations in continuing education for allied health manpower, public education and cooperative health planning. Ob'ectives for the first 12 months are described beginning on page 13. PRIORITIES: Priorities have been developed and because of their relevance to the projects discussed later in the summary.are worth repeating and are appended. Protocal for ranking projects by priority is enumerated in section II of the appendices. Each project has the potential scoring of 10 to 100 against two criteria: 1) where it falls in the Priority List; and 2) its intrinsic merit. STRATEGY: A multiple-leveled program strategy has evolved from the planning process. It is based upon NSRMP's general conclusion that many, if not most, of the major problems of delivering health services to victims of heart disease,, cancer, stroke, renal disease, and related diseases, are not unique to victims of these afflictions, but are problems afflicting the entire health care system. Therefore, NSRN? proposes that improving services for victims of the categorical disease can beat be done by addressing major flaws in the M-itself. health care syste Naagau-Suffolk R@ -5- RM 00066 5/71 "The basic program strategy of N-SRMP is to develop mechanisms within and outside of the health care system to establish and legitimatize consensus planning as a mechanism for building commitment to change parallel with the implementation of needed changes in the health care delivery system." ORGANIZATION: organizational structure and project review charts are appended. The bylaws provide for two classes of RAG memberhsip, 25-100 corporate and 20-50 non-corporate. There are three minority ethnic members and twelve consumer representatives. The prescribed membership ratio is 3 corporate to 1 non-corporate. According to the rosters, the current RAG consists of 82 members (63 corporate and 19 non-corporate). The RAG meets every three monthso It has responsibility for approving all contracts and , applications and receiving quarterly reports from officers of all expend- itures and actions undertaken by the corporation, Non-corporate members may not hold office as an officer or member of any Committee' of the Corporation or the RAG.' The Board of Directors consists of 30 members representing appropriate disciplines and/or organizations described in the bylaws. At each annual meeting of the members, ten directors whose terms expire are elected for three years by the corporate members. The Board meets during at least ten months of the year and their duties include managing the business in the months intervening between RAG meetings. The Board shall also submit at each quarterly meeting of the RAG a detailed report of the Corporation'*' progress during the previous quarter. The Executive Committee consists of the four officers of the Corporation and the Chairmen of the three standing committees of the Board. The Executive Committee shall conduct the affairs of the Corporation between meetings of the Board of Directors. The,officers of the Corporation (President, Vice President, Secretary and Treasurer) are elected by the RAG at the annual meeting. Candidates must be directors. There are three standing committees of the Board of Directors. They are Administrative, Program and Evaluation, and Membership. Standing committees of the RAG: nominating and aims. Other committees (ad hoc): Health Information and Communication Systems; Cancer; Editorial and Public Relations,, EdutAtion: Finance; Heart; Personnel Practices; Project Ranking; Stroke; Renal D196A#e: and 'Respiratory. CHP and RKP staff functions have been integrated. There is a formal line organization for contacts outside of the organization; developing new staff activities and relating them to the RAG or its subsidiary group; an emp oyee accountability and evaluation. Alternate organizational forms which allow for maximum employee participation are used for problem-solving and technical teak performance. Core,tooks are divided into throe caiegoriet.4 1) organit- ition maintenance (41.7% time); 2) planning tAske (38.9%); and 3) project- related talks (19.4%). Nassau-Suffolk RMP -6- RM 00066 5/71 Formal geographic sub-regionalizati(Yn is not planned. The rationale is that the region is small. and there are rapid changes in population concentrations. RELATIONSHIPS TO OTHER HEALTH PLANNING PROGRAMS, The major relationship is with CHP. Eighteen members of the RAG serve on the N-SCHP Council and five are represented in executive groups of both organizations. Three CHP volunteer members serve on the RN? Aims Committee. There has been a merger of staffs, as well as Committees on Health Information and Research. Negotiatioha are currently under way for a total merger. There are cross reviews of projects by CHP and RMP. N-SRM? and N-SCHP continue to explore merging with the Long Island Health and Hospital Planning Council, including office sharing. Meanwhile N-SRMP And N-SCHP review all construction applications to LIHHPC. Likewise LIHHPC staff assist in the review of RMP and CHP proposals involving constructi-op and renovations RAG representatives also serve on the Suffolk Task Force on Hospitals and Health Related Activities. The Task Forc e. four years old, is to devise a long-term master plan for allocating public funds for health. The Region is participating by a contractual arrangement with Harvard University Center for Medical Care and Health Services Research in A multi-regional roject designed to identify useful evaluation criteria p and techniques. Relationships also exist with the New York State Health Planning-Comission, H.E.W. Region II, and the Nassau-Suffolk Planning Commission. The application includes a core staff consultative activities list of approximately 150 Agencies indicating that cooperative arrangements exist, with practically all resources. EVALUATION: Some steps relevant to both program and project evaluation have already been taken. Several steps will provide baseline data for mea.suring future progress: some steps are to increase the.regionts Acceptance and use of evaluation as part of planfting; and some steps have lead directly to project proposals and future planning efforts. The N-GRMP has studied the evaluation experiences of other regions, as well as soliciting other regionslcomments on its own approach. Outside consultation is being sought as evidenced by the Regiofib participation in the multi-regional program evaluation through the Harvard Center, NAssau-Suffolk Regional Medical Program -7- RM 00066 5/71 PRESENT APPLICATION: Core support is for three years. One project is for four years, eight for three years and two for two years. A developmental component is not requested. Each of the projects received preliminary review and comment by staff and the appropriate categorical disease, or other ad hoc committee. These reviews were made in the light of: a) assessment of the technical merits of each proposal; b) the prospects of merger with similar pro- posals; c) the prospect of extending the proposals organizational base so as to develop the widest possible number of "cooperative arrangementsll between different organizational groups; d) suitability of the project for funding under the guidelines of PL 89-239; e) exploration of alternative funding sources; and f) potential of-@,the project for supporting future planning activities. Of the original 41 project outlines submitted for the development for RMP funding, 16 were withdrawn by the project authors. The remaining 25 wore reviewed by the Program and Evaluation Committee, Aims Committee and RAG. RAG final recommendations include considerations by 22 of its sub-ieview bodies. only 12 projects were approved, one of which was subsequently withdrawn by the applicant. Project numbers represent their priority rank order as approved by the RAG November 12, 1970. CORE: The request reflects an increase of about 25%. Requested Personnel ($302,587) includes nineteen First Year positions all of which are filled except two. Pro- $451,755 fesdionals include the executive director, two assistant directors, two planning associates, one coordinator for planning and evaluation, one administrative associate, one health educator, one systems specialist, three planning assistants, and one (M.D.) coordinator for continuing education. The director and one planning assistant are paid 50% from RNP funds and 50% from CHP. Six secretaries art-budgeted (4 full time and 2 part time - 1107,). The amount of $40,147 (10%) is budgeted for the fiscal agent. Core activities in the planning years have included 9 feasibility studies. Data collected include available health facilities and services n @ng Island, health training programs, and geographic distribution and sociological characteristics of health professionals in the region. Un- met needs have been inventoried and objectives and priorities set. objectives for the first operational year: develop and secure funding for health projects which incorporate new regional cooperative arrangements And address problems of major regional importance; enhance visibility, utility and credibility of N SRW among both providers and consumers of health care; establish mechanisms for regional and subregional consensus planning and resource sharing both inside and outside of RMP; enhance the informational data base useful in health planning decisions; devi*6 methods of evaluating N-SM4P's impact upon the health care systeeg Naaaau-Suffolk -8- RM 00066 5/7, Regional Medical Program address directly some of the regions gaps in health care delivery And ed- ucation through funding of projects in this application; enhance the level of expertise for developing innovative and effective continuing education; and further cooperative integration of N-SRMP with the activities of other planning and program development agencies. The work plan also includes a description of proposed activities. Second year: $490,408 Third year: $530,043 Project #1 Comprehensive Home Care- The project aims Requested at improving First Year services to ratients with heart disease, cancer, stroke $95,182 and related diseases by seeking solutions to problems inherent within the health care delivery sytem. The project is related to the Project #2, Stroke Referral and Evaluation, in that both provide mechanisms for'coordinating the services available to the chronically ill and the handicapped. The Rome Care project seeks direct resolution to 'Substantial organizational marketing problems in the delivery of home health services, while the Stroke Referral and Evaluation project serves principally as a patient protection device coordinating care of chronically disabled persons across all levels of care (hospital, ECF, home care, ambulatory care, nursing home). The Stroke Referral and Evaluation Program thus will provide a data base from which both formative and silmmative evaluation of the Home Care Ptogram's effectiveness in improving patient care may be assessed. The proposed activities of Phase I of the Comprehensive Home Care Project are to identify and seek feasible resolutions to the existing market constraints and organizational constraints limiting the delivery of comprehensive home health services. PhasevII and III will establish financially self-sufficient administrative mechanisms through which home health services in Nassau and Suffolk Counties may be coordinated and int egrated; through which administrative, cost accounting, and patient records keeping procedures may be standardized; and through which inefficiencies, duplication of effort, and disproportionately high administrative overhead costs may be reduced. Phase II involves pilot testing individual administrative mechanisms in selected areas and/or agencies and Phase III involves extension of successfully piloted mechanisms to all participating agencies. The project will provide an organizational planning mechanism and a systematically obtained data bast from which the level of need for ancillary home health services may be documented and those services added in a preplanned, integrated fashion. The program represents the next step in the integrated planning and development of Home Health Services in the Nassau-Suffolk area which has grown from the Nassau-Suffolk Task Force on Home Health Services. The project addresses the problem of delivering home health services in a more cost 11 -effective manner, and of improving the availability, accessibility and volume capacity of home health services available to the residents of this region. These are priority I concerns of the Region. Nassau-Suffolk Regional Medical Program -9- RM 00066 5/71 The project includes an evaluation component. Also included are letters of endorsement from 23 agencies. If the project succeeds in establishing administrative means to permit greater cost effectiveness in delivering home care, it is anticipated that those administrative structureswill continue indefinitely as a legitimate overhead expense for participating agencies, with the cost of the expense defrayed through conventional third party payments. Second Year: $95,260 Third Year: $91',603 You-rth Uw: $72$448 Project #2 Stroke Evaluation and Referral- This project Requested is designed First.Year to improve access to coordination of the community $72,111 resources available to stroke victims residing in Nassau-Suffolk Counties and their families. It will further document areas in which needed services are not available or accessible and the reasons behind lack of Accessibility to existing resources. The project will provide: 1) a service function' by coordinating available resources to the benefit of stroke victims; 2) an ongoing planning function through identification of existing "gaps" in services; 3) an evaluative function through sequential reassessment of the functions abilities of stroke victims; 4) an educational function through identi- fying areas in which informational deficiencies of health professionals may,hinder the appropriate use of community resources in dealing with the problem of stroke victims and their families and through Assisting in the development of "stroke census" in community hospitals; and 5) a research function through the identification of social, therapeutic and biological determinants of successful rehabilitation. The project will pursue these objectives by augmenting an existing centralized stroke registry by instituting A system for more rapid identification of stroke victiz&s. by providing periodic assessment of the functional capabilities and health service needs of stroke victims and providing a referral mechanism to insure that contact is initiated between each stroke victim and the agency or practitioner with skills relevant to each victim's needs. The project staff will also provide a direct educational service by assisting co ity hospitals in the organization and operation of "stroke teams."' Measures of the effects of therapeutic intervention, social factors, and biological determinants upon the rehabilitation potential of stroke victims will be measured in terms of death, disease, progression disability, social disruption and professional and family satisfaction with both the services provided and the rate of reha i tat on. At the end of the third year of RMP funding, if successful, the program,, will be continued through a combination of local and state funding sources. If the project proves to be unsuccessful, it wtil be discontinued. Nassau-Suffolk Regional Medical Program -10- RM 00066 5/71 Its high priority lies in that it addresses the problem of improving the coordination and integration of existing services to a particular category of patients with important therapeutic service needs (a- Pkiority I problem). It is aimed at improving access to available services (also a Priority I problem). It aims at improving the coordination of home health services (a Priority II problem). The present project builds upon a strong base of acceptance among the laity, among the physicians, among voluntary agencies and among health facilities, previously established through the.existing stroke registry. The project contains the potential for expansion into a regionwide patient referral and evaluation network for victims of all chronic diseases. e Care, in that The program is related to project #1, Comprehensive Hom many of its patients will at one time or another be referred to one or Mort home health agencies. The project is also related to the proposed educational resource designed as a core staff activity, in that it will provide data regarding educational needs of health professionals. It will also provide information regarding needed additions to the Dial Access Lecture Program. Second Year: $94,196 Third Year: $118,426 Project #3 Development of Pap Smear and Breast Examination eques ed Para-Ptofessional Personnel- The purpose$of this First Year project are twofold: a) to recruit, train, introduce and $95,956 demonstrate the usefulness of.a new type of paraprofessional health worker in the Long Island community; b) to provide mechanisms for earlier treatment of uterine and breast cancer among high risk, low income populations through improvements in case findings, public education and Accessibility to diagnostic services. For each of three years, seven residents from a low income, predominantly black community will be recruited and trained in the techniques of: 1) procuring specimens for Papanicolaou examination by the direct cervical scope ttchnique; 2) obtaining Papanicolaou specimens by the vaginal irrigation technique and 3) instructing other residents in the techniques of self,breast examination. The newly trained health worker will elicit public participation in the program by: 1) direct door-to-door personal contact; and 2) public appearances at community meetings. Five of the newly trained health workers will remain in employment at the Martin Luther King Neighborhood Health Center in Wyandanch, the training and diagnostic center. Those workers trained during the second and third years will be employed at either Public Health D6paitments and/or voluntary health facilities in the region. Nassau-Suffolk RMP RM 00066 5/71 Followup care and definitive treatment of patients found to have examination abnormalities will be provided through the Martin Luther King Neighborhood Health Center and Good Samaritan Hospital. Its high priority ranking is based upon the following considerations- 1) it is aimed at improving accessibility of a highly needed service to a low income, high@risk target population lacking access to the service (Priority I); 2) it aims at improving the cost-effectiveness of health care delivery by delegating a technical skill normally performed by a physician to a non-professional worker (Priority I); 3) it provides entree into the health careers for disadvantaged recruits (Priority I). It is also reported that the project's site is important as the expanding population of Suffolk County will probably promote rap id assimilation of newly trained health workers. The project blends with the Suffolk Health Department'6 plans to extend the number of its ambulatory care facilities to five low income target areas over the next five years. The project relates to the health manpower development program presently being developed by RMP-CHP staff and Labor Department officials,' local educators and health industry employers. Although reducing mortality from uterine and breast cancer is the nAjor Ain of th e project, this goal will not be meagureable due totthe lack of unreliable data and the short project tenure. The project will be evaluated in terms of achieving @ projected number to be trained and screened. Two thousand women will be screened each year for uterine cancer and will have learned self-breast examination. Fifteen paraprofessional health workers will be trained and it is anticipated that v rem& n emp oye n te health field after termination of the project. Second Year- $105,468 Third Year: $106,557 Project.#4 Reitional Medical Library Service and Training Requested This project addresses the need to improve the First Year availability, quality and techniques for use of medical library $46,860 services in the region. It involves four major objectives and areas of activity: 1) the establishment of both in-service and collegiate training programs in the region for a new category of health mnpower, to be called Medical Library Technician; 2) the establishment and upgrading of library resources, and services available in (and to) all community hospitals In the Nassau-Suffolk region; 3) the development or expansion of hospital committees charged with continuing responsibility for hospital library and educational resources and services; 4) the establishment of a functional regional educational library and information network among all health institutions for the purpose of securing optimal availability and use of regional resources. -12- 066 5/71 Nassau-Suffolk RMP RM 00 This project will involve all of the hospital medical libraries in Nassau and Suffolk Counties, as well as the libraries of the two county Medical Academies, and the library of the Health Sciences Ce ter, S.U.N.Y. at Stony B-i6ok ' (whe-ke project staff will be locate(i).'- 31 The project addresses the Priority I area of concern; the more efficient use of organization and personnel resources through improving the level of resource sharing. The project includes an evaluation component. The Department of Library Sciences of the Health Sciences Center of SUNY at Stony Brook,, the grantee,, will assume responsibility for continuing the activity after cessation of, the grant. Second Year: $46@750 Third Year: $48,994 Project #5 Computerized Radiation Therapy Treatment Planning Requested Service- This project proposes to develop First Year a technical service providing Computerized Radiation $270830 Therapy Treatment Planning which can be utilized by hospitals of all sizes and by private medical offices concerned with radiation therapy planning in addition to the major institutions where it is now available. Nassau Hosp ital, Department of Radiation Therapy, will function as the central station for the project, receiving proposed treatment plans from participating hospitals or private offices by telephone or telecopier. The information will be reviewed by a physicist for the purpose of program development by a computer. Simple programn will be imediately run by the Nassau Hospital computer; complex programs will be sent by messenger to Grilmnan Data Systems. The completed program is to be returned to the sender within 24 hours if by telecopier, or three days if by mail. Experience with the development of the technical phase of this program and the functional relationships which are developed among the partici- pating institutions will determine the future of the program. It may remain limited to technical service or it may become a stepping stone towards a clinical oncology program. The priority given to this project was based on'it meeting the following needs: (1)' Priority I - Increase efficiency, coordination, cooperation, resource sharing and better referral between existing health services, professionals and agencies; (2) Priority II - develop a shared accessible, exhaustive, and continuously current regionwide health information system composed of manpower data, availability of health service, financing data and patient- related information; and (3) Priority III - improve the level of technical sophistication of available services. Nagsau-Suffolk R14P -13- RM 00066 5/71 The project is related to the development of a regidnwide comprdhensive cancer program as is the Pap Smear and Self Breast Examination projecti it aims toward the evolution of a regionwide health information system as do the Home Care, Stroke Referral and Evaluation, Regional Library, Computerized EKG and Spirometry, and Drug Information Projects. It is also designed so as to reveal professional educational deficits in the area of Radiation therapy and thereby is 'related to the cord con- tinuation education development activity- Parameters to be evaluated include the extent of utilization of the project sdrvides and the projects direct result on patient care. It is anticipated that the project will become self-supporting by the- participating institutions' purchasing its services. Second Year: $19,085 Third Year: $19,085 Project #6 Smoker's Withdrawal Workshop -'The@purpose Requested of this demonstration program is to decrease First Year the prevalence of cigarette smoking in Nassau and Suffolk 27,91 Counties. It aims at preventing the occurrence of syWtonatic heart disease, carcinoma of the lung, chronic obstructive pitimonary disease, arteriosclerosis obliterans$ carcinoma of the urinary bladder and other pathological conditions Associated with cigarette smoking. The project proposes the institution of a series of "Smoking Withdrawal Clinics7. The clinics would incorporate the previous experience of a wide variety of similar efforts nationwide. In addition, a number of principles drawn from the literature on behavior modification would be utilized which have not been incorporated into previous anti-smoking programs. The format was pilot tested for logistical feasi ity n June and September 19.70. observation and curriculum development personnel will participate in all sessions. Their function will be to observe, in detail, what happens during the course of each session, and to make correlations and evaluations in relation to specific techniques applied and the observable results. The observation and curriculum development personnel will meet with those conducting the course along with the participants to determine which techniques are most productive and which are not. Succeeding workshops will thbn be altered as new experience is gained through the results of the ongoing *valuation conferences. Participants will come from two basic sources: (1) self referrals; and (2) referrals from health professionals, institutions, and strvicesag W ies. Self referral is to be promoted by the Tuberculosis and Restiratory D sease Associations, the Cancer Societies, the Heart Associations, both County Health Departments, and,the participant hospitals. Public relations Activities will include placing of posters in public places, radio spot Nassau-Suffolk RHP -14- RH 00066 5/71 ts, newpaper releases and flyers distributed in participant announcemen hospitals. Physician referral is to be encouraged by circulating flyers to all physicians in both Nassau and Suffolk Counties 30 days prior to each clinic. Special notices will also be sent to Department of Inhalation Therapy and Chest Service in hospitals, physicians working in Chest Clinics of Health Departments, Directors of Medical Education and Nursing In-Service Directors in all hospitals. The reason for the project ranking is that it relates to disease prevention and improving the availability and accessibility of a service, both Priority I concerns of the N-SRM. RNP funding is to cease after eighteen months. If the program proves effective, the individual hospitals with modest support f rom the TB and RD Association, will continue similar programs. Second Year (6 months)' $7,050 Third Year: -0- Project #7 A Regional Approach to Computer Assisted Blectro- Requested cardiography and Spi@o@e - This First Year project proposes developing the cap 0f the $302,632 region's hospitals to administer computerized EKG's and spirogramn. only hospitals with both in-patient and out-patient facilities will be selected. The project anticipates that 40,000 patients of all races, incomes and levels of treatment will be tested. The goal of the project's first year is to prove that this technique is reliable and feasible as a screening tool and as a routine hospital test. The hospital environment provides the built-in referral mechanism necessary for proper patient treatment and validation of the computer programs results. Simultaneously, the project will bollect, store and analyze the demographic data. -u 'i g' '- 'i-iEaticTiifd "form, The data gathered by s n a -An lie' -i-h-aioid' by the participants, as well as 'used f r further planning. ,c 0 Once the techniques have been proven, the long-range goals of the project are to add additional computerized diagnostic tests and to expand the collection of shared data outside the province of the specific tests.' Consequently, this project forms the basis for a hospital-based multi- phasic screening center and a regional data bank. The proposal addresses six health priority items established by the N-SRNP. Three of these are: (1) improving the availability of services by providing techniques for the consumer which do not exist at present; (2) improving the accessibility of services both in terms of geography and affordable costs; and (3) insure continuity and coordination of services by continuing the Task Force Committee for future program operation. Evaluation areas include: Physicians ancrhospitals use of and satisfaction with the system; cost benefits; use of screening data for planning; and-further development to include additional tests. Nassau-Suffolk RKP -15- RM 00066 5/71 It is anticipated that after three years, the hospitals will ass,--- financial responsibility for the EKGS, spirograms and data processing. Second Year: $92,576 Third Year: $58,788 Project #8 Curriculum Development for the Training of CommunjU Requests Health Assistant and Community Health Advocates First Year This project addresses the problem of designing a structured $109,382 educational curriculum for commity health aides and commuity health advocates, based upon a preliminary task analysis of the functions Actually performed by such persons employed in Suffolk County. The training program introduces a two-stage "career ladder"-in that those personnel demonstrating the highest level of proficiency as community health aides will be selected for training as commmity health advocates. Further career advancement beyond the second stage is the subject of on- going planning between the Suffolk County C ommunity College, Suffolk E.O.C., Suffolk Department of Public Health and the Health Sciences Center, S.U.N.Y.. at Stony Brook. The aim of the program is to formalize the training of underemployed low- income cow=ity health workers, so as to provide a more stable and better defined pathway into the health professions for such workers. The purpose of defining the training program and the skill level of such employees is to demonstrate the relevance of their experience and training to the functions performed by health personnel working at higher levels. The Health and Family Planning unit of the Economic Opportunity Council of Suffolk and the Suffolk County Department of Health have budgeted for positions in this new category of health manpower. In ad dition, the 12 Readstart centers and the several Day Care centers in Suffolk County are also planning to utilize this category of health manpower if the proposed training program is successful. The Comunity Health Assistant program graduate will also find job opportunities with upward mobility in the hospitals of Suffolk County. The project relates a Priority I problem identified by N-SRNP, to improve the effective utilization of the skills of health workers. Its major thrust, however, is to build an improved access pathway into the health services professions for unskilled and underemployed residents of the aria. If successful, the curriculum design might serve as a Model for Similar training programs. Demonstration of specific skills by graduates of this program might enable existing educational programs and institutions to modify the length of formal instruction required for Licenses Practical Nurse certification or certification in other health occupational categories. A team consisting of representatives of Suffolk County Community College, Suffolk County Department of Health, Economic Opportunity Council of -16- RM 00066 5/71 Nassau-Suffolk RMP a of the enrollees and the consumers, a Suffolk, R.]K.P., representative representative of the Division of Allied Health Professions at the S.U.N.Y. at Stony Brook, and outside consultants as necessary, will have the responsibility of ;ngoing, periodic and concluding evaluation of the project. The main objective of the evaluation team the first year is to test the effectiveness of the core curriculum in relation to performance of the Community Health Assistants. Modification of the curriculum during the training period will be made when the need is indicated by the evaluation team. Evaluation tools are described in the narrative. RMP support is requested for three years, after which the training programs are to be funded through M.D.T.A. and local resources. Second Year: $67,225 Third Year: $46,860 Requested Project #9 - Regional Drug Information - The objective First Year of this project is to establish a regional $146,316 drug information system which will. allow participating hospitals to collect, correlate and learn from adverse drug reactions. On the basis of the collected data and its analysis, the project would then attempt to perform an ongoing educational activity for participating hospitals, for hospitals generally in the region, for nursing homes, community pharmacists and physicians. c A network of communications services will be developed to include eiectroni communicating devices, sub-regional meetings, newsletters; monthly work- shops for participating hospitals'and a publicity program to incl de radio and/or television. Mercy Hospital, having developed a diversified drug program over four years, will serve as the focal point. It is anticipated that the initial seven participating hospitals will be expanded to a regional network. The project addresses priority III relative to continuity and coordination of service, in addition to development of communication linkages and cooperative arrangements. The project will al.so be relative to improving the quality of care. The project also addresses priority VI - research and information deficienc es. The project director and his staff are to evaluate the program semi-annually and submit annual, reports to participants, interested individuals an RMP evaluation criteria are described. It is anticipated that the participating hospitals will -assume financial support of the project after three years. Second Year Third Year $149,511 $154,019 Nassau-Suffolk RMP -17- RM 00066 5/71 Requested Project #10 - Clinical Nurse Specialist in a Small General First Year Hospital. The purpose of this project is to $539,762 explore the impact of the role of a clinical nurse specialist in a small general, non-profit community hospital with an affiliated free- standing health center. The concept of the "Clinical Nurse Specialist" as a practitioner, role model, supervisor of patient care, counselor- resource person, teacher, coordinator, change agent and researcher, will be implemented to demonstrate that this practice will enhance the quality of nursing care. One unique contribution of the study could stem from the continuum of care for the socially and economically deprived patients who could be followed through the health center. The clinic I,n roe. sD-ec-@@ Sued function in both the hospital and health center as the needs of her specific patients arose. She would be a role model to the nurses in the hospital, health center, and community for coordination of services, This study could determine if the clinical nurse specialist's role should become an integral part of the hospital structure in the near future. @it would also determine if, through involvement of other nursing adminis- tratort in the surrounding community hospitals through workshops, con- ferences, newsletters and publicity, interest in the clinical nurse specialist's role can be stimulated and positions opened up. The project addresses five of the six problem areas identified by the ly: Program and Evaluation Committee of the Regional Advisory Group, name accessibility (Priority 11); continuity and coordination (Priority III); quality of service (Priotity IV); efficiency in provision of service (priority V); and research and information (Priority VI). Evaluation will be accomplished by the project investigators and a committee of consultants. Methods focus on change in hospital staff response to the clinical nurse specialiet's role and patient care. Good Samaritan Hospital, the applicant organization, will provide future funding if the project proves ef ective. Second Year Third Year $55,550 $ - 0 - Requested Project #11 - Nassau-Suffolk Dial Access Lecture - First Year The Dial Acess Lecture Project is designed $37,525 to taip into and share an existing Dial Access Lecture program already in operation in Central New York RMP region and Susquehanna Valleq RMP region. The activity will serve the goal of increasing the continuing educational opportunities for the health professionals of the Nassau- Suffolk RMP region, thereby improving the quality of health care in the region. The project's major costs are for telephone services. The project will supply lecture services for both physicians and nursing personnel in the region by utilizing a WATS line. Nassau-Suffolk RMP -18- Rm 00066 5/71 The project proposes to extend the scope of existing services by upplying current and frequent updated library references upon request. The existing program will be modified slightly to improve its.function as a source for. identifying practitioner's perceived educational needs. The project aims at improving the quality of health care (Priority III) and attempts to do so by providing access to a previously established Dial'A:ctess TA,cture Program. A second attraction of the dial lecture project is its apparent enthusiastic popularity among the region's practicing physicians. Data obtained through the Dial Access program about physician perceived educational needs might provide useful input into the Core Staff Educational Development service. Information gathered through the Stroke Program, Radiation Therapy Planning Program, Computerized EKG and Spirometry Program, Drug Information System Program, and the Regional 14-brary Service Program would all be useful in defining possible subject material for additional tapes. Evaluation includes determination of the utilization of the a yotem, users satisfaction and querying the Regions health leaders. There is no provision for continued support-of this project after three years. Second Year Third Year $38,416 $39,306 NA89AU-SUFFOLK REGIONAL MEDICAL PROGRAM I.anninR Phatie Funded I A Reauest 19.- p at'on" "'C"t'o" 1 467.221 @01 111/69-6/30/70 $263,011 01 7 1 71-6 30 72 '02 7/l/70-6/30/71 3@O@769 02 7/l/72-6/30/73 1,261,495 Total $613,280 03 7/l/73-6/30/74 1,219,681 04 7/l/74-6/30/75 72,448 Total $4.0020,845 PROPOSED 01 OPERATIONAL CO@tP@.FNTS BY TYPE OF ACTIVITY CiX4POI.E,%TS.BY DISEASE CATEGOIZY COMPONENTS -co e $451,7 TRAINING AND EDUCATIO4 EART r 55 6 0 Projects 1 Projects 42le55. Total $S Total $S 302 632 29 @l Home Care % $S % $s 21% Approved/unfunded $95,182 Disapproved CANCER 2SCroke- 0 projects 2 $721,IIL TIENT CARE Total $s 123,786 DE!40';STFATIC,4 OF PA % $S 8% Projects 5 Approved/unfunded @3 Pap Smear Total $S 593,711 Disip rd@ved- $95,956@ % $S 40% STitOKE Approved/unfunded Dis@pproved Projects #4 Regional Med. Total $s 72,111 Library % SS 5% $46,860 RESEARCH DEVELOPMENT #5 Radiation 4 Projects 0 KIDNEY $-279830 TotAl $S 0 4 Projects 0 % $S 0 Approved/unfunded. Total $S 0 sapproved % $s #6 Smoking Di 0 $27,910 RET.ATED DISEASES -#7 Computer ElectrocardiologY ADMINISTRATION @NNING -1 Projects 0 Total SS 0 $302,632 # Projects core SS 0 Total SS -@51 755 % $S 31% #8 Train'g Approvc,t/unfunded @unity Health Asate Dlsappr'oved ISUI,'fiCATEGORICAL .,$109,382 if Projects' 7 Tot3l $S 516,937 % Ss 35% Drug l@fo.- Ctr. $146,316 CFI;e'RAL 10 clinical Nurse 9 Pro c -Sp6cialist j@;ti 'Ore Total 451 ,755 1 . $53.76 % ss, 31% - . I I I I #fl Dial Ae.ces's I' §37 5@2 _ -1 RMPS/GRB-311171 I I* -20- NASSAU-SUFFOLK REGIONAL MEDICAL PROGRAM PRIORITY LIST Priority I' (Urgent) 1. Act ivities aimed at increasing accessibility of health care services, especially in relation to specific population subgroups currently lacking access (e.g., the poor, the near poor, the elderly, the disabled, migrant laborers). 2. Activities aimed at increasing health manpower availability or improving efficiency of manpower utilization. 3. Activities aimed at increasing efficiency, coordination, cooperation, resource sharing and better referral between existing health services, professionals and agencies. Priority II (important) 1. Activities aimed at innovative improvements in professional continuing education. 2. Activities aimed at developing a shared accessible, exhaustive, and continuously current region-wide health information system composed of manpower data, availability of health service, financing data and patient-related information. 3. Activities aimed at instituting health measures presently unavailable in Nassau and Suffolk Counties. Priority III (Necessary) Activities aimed at improving specifically those health planning mechanisms which are presently weak. 2. Activities aimed at development of new rehabilitative and home health services. 3. Activities aimed at improving existing third-party financing mechanisms for direct services. 4. Activities aimed at innovative improvements in lay health education. Priority IV (Useful) 1. Activities aimed at improving the bed-to-patient ratio of general care And ECF beds, or promoting their more efficient utilization. 2. Activities aimed at improving the level of technical sophistication -21- 3. Activities aimed at reinvolving all physicians lacking hospital affiliation @ack into the mainstream medical milieu. Priorit_y V (Relevant) All other activities falling within the framework of PL-89-239, -22- ORGANIZAI'10.'@AL STRUCTURE .4 'r NASSAU -SUFFOLK FIL-GIO! AL N, -DICAL PPIOGRAM, INC. Regionil Advisory Group (Corporate & Non-corpol'ate' t%4emb,.,rsiiip) Nassau - Suffolk RiviP Stony Brook Incorpoiale(i (Corporlie IVicinbcrsliip)' I-'otiricf3ticin (Fiscal Agent) Aims,!nd Noiiiinnting Prograin Board of objectives Conirnittee and Directors Conifnittee Ev3luation Coinr-rtittee Heart Committee Cancer in;)nce Coii)niitic-c 'ninittee - Stroke Personnel Committee Coniinittc,., - Renal Dise@c By Laws Conimitt,@e Comiiiittee Education Mer nbersliir) - Conimittce Coi-nmittee Respir@itory Editorial -.Ilcl - Disease Fulilic fl,(!I:iti'ons Coinmittee Coo-,)il)ittee llealili Infoi-n-,-ition - ;and Co.,iinitj;-!ications Coinlili',tcc F. IA, P + CHP TABLE OF ORGP-.@IIZATION R@'tP/Cl-'.P Executive Di,-e@-tor + Administrative Associatf Coordinator for I p i n Gi ,,id 'EvalLatior,- - - - - - - - - - - - - -ve Assistanl ACni n i s.LraL I Surey + .Beckman iecret6rial/Clerical Assistant Dir6ctor 'MIssistant -Director Assistant Dire@r Europe + Kress ----------- ----------- Planning Assistant Planning Assistants 'I) e I + Students +. ?1.3rinir.g Associate ilealtii E-@'uc-itor Education Specialist Planning Associate Fari i I ton Miller (unfilled) Page S- - T@s Tp7eci-alist yst -Fl@nin-g-As-si-s-t-an-t- PI Tn n-i T@s s I-S -Fa7n t Roth Fistiel + Alson Planning Assistant Librarian Marcus We,ize + (A Privileged Communication) SUM.,NP,Y OF REVIEW AND CONCLUSION OF APRIL 1971 REVIEW CO,@;iIITTEE NASSAU-.SUFFOLK RLGI07iiAL MEDICAL PROGRAM RM 00066 5/71 FOR CONSIDERATION BY 14AY 1971. ADVISORY COUNCIL RECOri,n4ENDATIO@l: Approval for operational status for three years with the following conditions: 1) that the Region obtain the services of an outside consultants to assess the current otganiza- tional structure including CHP-R@T relationships; 2) that the concerns of the reviewers be communicated to the Region; 3 that the second year continuation application be reviewed by Committee and Council. and include a site visit; and 4) that the level. of funding be increased if significant progress has been nchieved during the first ycar. The Committee al.so recommends Council policy statement on us@e of PS funds for computerized EKG and spirotictry (Project i,!-7). The Committee recommends approval of the amount requested for core activities: 01. - $451,755; 02 - $490,408; 03 - $530,043. For projects; $1,01-5,466 is requested the first year, $171,087 the second year, $689,638 the third year and $72,448 the fourth. The reduced amount of $378,000 is recommended each year for three year.-,. The total requested and recommended is as follows: Direct Costs Year sted Recbmmei)ded 01 $1,467,221 $ 829,755 02 19261,495 868,408 03 1,219,681 908,043 04 72 448 TOTAL $4,020,845 $2i6O6,206 These ranges for the 02 and 03 year may be modified by action taken under conditions 3 and 4 above. @l@!LT The findings of the site visit 14arcli 25-26, lq7l were presented by the Chairman of the team. Major concerns: 1) organizational structure is cumbersome and the corporate Hong corporate delineation of RAG does not seem functional; 2) the roles of the Aims and Program Committees have overlapping responsibilities; 1) CHP and RMP merging relationships seem awkward and may inhibit relationships with beal.th care providers; 4) core staff hidden objectives are not clear; 5) need for more clearl.y defined operating objectives and necessary data base; 6) although working reasonably well, the review process seems unwieldy: and 7) the Coordinator is NASSAU-SUFFOLK RMP -2- RM 00066 5/71 well qualified but because of his dual rol.e as director for both CTIP and RMP, lie does need a full.-time strong administrative assistant to provide continuous central direction to core staff. Some of the projects were apparently developed early in the Region's planning phase. Projects were modified by staff assistance, rather than initiated by core. Additional proposals are noi-i being,d@evelotied, and some of these may have a higher priority than those -for which support is oregently requested. As reported by the visitors, the Region's accomplishments to date include assembling a staff and a fiscal basis4, conducting a number of studios as enumerated in the application; and the forniinL,, of cooperative arrangements. Some notable progress wag evident in that tile Region has been successful in: l@ getting the blocl,, ohysiciens and dentists together to embark on medical. practice and pr lem areas in the ghettos, 2) assisting the dentists in establishing a continuing education program; 3) assisting schools in establishing community 'hool health programs; 4) assisting industry and labor in exam' ac ining health insurance programs; 5) assistance in the design of I)re-pay group plan foundation; and 6) providing technical systems assistance to induce cooperative sharing of comouter hardware and software. Some of Committee expressed disappointment i.n the proposed projects and their relationship to the stated priorities. The Committee questioned the wisdom of RMPS funding research type activities such as computerized electrocardiography and spironetry (Project #7) and believed a Council policy statement might be appropriate. There was general agreement by Committee with the site visit findings an retommendati6ns. The Committee believed the Region needed the challenge of operational status and recommended approval o core as requested and projects at a reduced median level ($378,000) as recommended by the site visit team. The Committee also recommended discouraging the Region from funding project nos. 7, 9 and 10. DEFi.@TNIEtIT OF HEALTI-I to PUBLIC HEAUI-H S-C--RVIC-E HEAL'i'l-I SEFIVICR-S AND liENTAL i-IEAL@TH ADNRAINISTRATION Date.- 'i@lirch 30, 1971 I,v fo Alin of. @Tubject. eport o the Ncissau-Suffolk Site Visit @)uick 1, n March 25-26 1971 (Stony Brook, New York) TO. Director Regional @l@@cal Programs Service Through: Actino Deputy Director Regional Medical Pro-rams Service 1. SITE VISIT TEAM: @IPS Staff John E. Kralewski, Ph.D.(r,,,.'leirman) Alan S. Kaplan, M.D. Pli,IPS Review Committee Continuing Education Branch Edward D. Coppola, M.D. Spencer Colburri Consultant (Practicing Surgeon) Regional Developmental Branch Paul E. Teschan, I,,I.Do Robert Shaw Director HEW Region I Tennessee Mid-South Pdqp FIIPS Rep. Chairman Lawrence Witte Program Planning & Evaluat-ion Roger Miller Grants Management Branch Luther Says Grants Review Branch 11. STRUCTURE: The entire visit took place at-the Regionts headquarters ,71tli approximately 60 area representatives. Ilowever, the tTLeetiii- was structured along the lines previously augc,,,ested by the site visit team and the mission was ch three major sessions and seven sub-grou discussions accomplished three. p attended by appropriate persons. First Session (3 liou Parti@alts 1. Organi@zat-l.op. and 1)(-cision-@ Site visit Team (9) Makin6 Structure - Legal Structure -Offit6rs (4) - Governin@_ Bodies -Attorney -2- IUG Corporate members (4) - Regiooial Advisory Group (3 consumers & 1 provider) RAC non-corporate members (4) - Chief@Operating Officers (3 providers & 1 consumer) - Goals, operating objectives Chairmen (2) Aims & Program Committees and Priorities - Activities Underl,7ay Coordinator &,Key Staff- (3)@ - CHP & PDIP relationships - Manaoement Inforn,6tion System - Accom li8hraeftts p Second Session (4 hours) 2. Operational Programs - Site Visit Team Development - Officers (4)- - R6view procedure - Chairmen (2) Aims & Program Committees - Key core staff - Role of RAG -@Staff assignments - Project authors (10) - Priority assignment - Medital Societies representatives (4) - Evaluation - Hospital rbspresentative..3 (4) - Dental Society (2) - Plans for phasing but RMPS support - Health Department (2) - Regionalizat on - Cooperative Arrangements - University (2) CHP representatives 3. Community involvement Discussion Groups (4) 1. Project Authors -3- 2. Health Institution Representative 3. Planning Agency Representation 4. Community Representation Third Session ours 4. Staff Or-anization - Site-Team and Activities - Line and staff organization - All professional core staff (9) - Task allocation - Personnel & turnover - Internal operation activities & accomplish ments - Ilaftagement controls including data base, monitoring and evaluation Budget review Discussion Groups 1 Budget revie-vi 2. Staff organization & management 3. Continuing I'ducation 4. Acconiplisliv,-ientr, Fe6d Back Session Observationp & Recommendations - Site Team of Team (no mention of recommended funds) - Chairman of RAG - Key Core (9) Ill. SU@IMARY OF FINDINGS-. The multi-faceted organization Near inherited. The RAG membership remains relatively unchanged since 1969 and a rather load level of attendance of meetings w6s noted. The corporate and non"corporate membership appears to have created a cumbersome situation. The question arose as to .1. AG (corporate and non-corporate the functional differences betx.7een the It -4- members), t@e Board of Directors (corporate members) and the Executive Committee. 'Th6 roles and interchanging relationships of the Aims and Program Committees are not clear and there is some question about their sense of direction. The project review process was considered cumbersome bu is -working odetate'Lv @?elli t Of major concern to the visitors, was the i-,ir@rging.functions of CHP and MP i.e. integration of the two staffs one staff dirc@cto-t-@for both agencies and the mergina of the two Aims Committees. A more C, -formal merger is under consideration which is to include the Lotic, Island Health and Hospital Planning Council. The visitors believe that this meld has contributed to the Rbgion's waning influence with the medical community. Two separate and distinct agencies with interfacing relationships might be more effective. The Region's priorities are reasonable and relevant but there is ,a need for more clearly defined operational objectives and necessary data base. Core staff aversion to acquisition and use 6'L data was apparent. @Operational Planning see,-,is to be more by the "human" approach rather t an the "quantitativ6" approach. "Hidden objectives exist but are values .16t6rnal affairs are on-a sound footing, particularly since the., "Managor6ent Assessment Visit" conducted in July 1970 by PD,IPS. The Region is doing a good job in personnel management. Fiscal services, including purchasing and prdtiipt reporting, are adequate and the costs are very reasonable (10%). There was st@@.,Iqe concern, However about the many responsibilities of the oordinator and the need for providing central direction to the staff. full-ti@vie strong administrative assistant (deputy) is needed. Some of the projects were apparently developed early in the ReQion's C, planning phase, Projects were modified-by staff assistance rather than . I initiated:by core. Additional proposals are now being developed., and some of these may have a higher priority than those for which support is presently'requested. The ReRion's accomplishments to date, include a. staff and a fiscal basis; conducting a number of studies as enumerated in the C> application; and the forming of cooperative arrangements. Some notable pro2res %,.,as evident in that -lie Region has been successful in: 1) ettina 11 9 the black physicians and dentists together to euibark on medical. practice and,problem areas in the ghettos; 2) assisting the dentists in bstablishit-i(" a continuing education program; 3) assisting schools in establishing comnu6it y school health programs; 4) assisting industry and labor in examining health insurance programs; 5) assistance in the design of pte-pay group @ien ioundatloft, and 6) providing technical sy8tecits is,,3istance to induce cooperative sliarin@ of computer hardware and software. -5- IVi RECO@Pi,@'ENDATIOliS: @ApproVel for operational status for three years with the following conditions: 1) that the Region obtain the services of an outside consultants to assess the current organizational structure including CHP-@IP relationships; 9) that the concerns of the site visitors be communicated to the Region; 3) that the second year continuation appli- cation be reviewed by Committee and Council in addition to staff and 4) that the level of funding be increased if significant pi-ogress has been achieved during the previous year. The site visitors recommended approval of th e amount requested for core activitiesias follows: 01 02 $451,755 $490,1,,OS $530,043 The first-year request for eleven operational projects is $1,01.5,466. u rt is recociii F, ppo a nded at a reduced level in three ranges as follows. Maximum $423,000 liedium 378,000 Minimum 326,000 The tot8l. amount recommended for tne 01 year at the maximum, medium and minimum amounts are: MAXIM@I 111'@DILT@4 IIINIMIIN Core $451,755 $451,755 $451,755 Projects 423 000 378.000 326 OQO Total $874,755 $899,755 $777,755 These ranges for the 02 & 03 year may be modified 'oy action taken under conditions 3 and 4 above. Lu Says , Public Health Advisor Giants Revi-ew Branch' 11 11 11 @ @ I,.,J. Says Sl'f'v- VISIT REPORT NASSAU-SCFFOI,K REGIO'@INIAL MEDICAL PROGRAM March 25-26, 1-971 SITE TEAM 1,@l- IBERS John E. Kr,-il@@isl@i, Ph.D., Cl-iairriin, Review Committee Member, Chairman Health Administration, University of Colorado, School of Medicine, Denver, Colorado Consultants Edward D. Coppola, I.I.D., (Practicing Surgeon) Associate Professor in Surgery, Ilahne-,nann Medical College, Philadelphia, Pennsylvania Paul E. Tesclian, M.D., Coordinator Tennessee @lid-South Regional Medical Program, Nashville, Tenn. P,@,IPS Staff Alan S. Kaplan, M.D., Continuing Education Branch Spencer Co]-burn, Regional Development Branch Lawrence @,.7itte, Office of Planning and Evaluation Robert Shbw, HE14, Region II, New York City Roger Miller, Grants Management Branch Luther J. Says, Grants Review Branch REGIONAL REPRESENTATIVES Officers of @@ISPDNIP Edmund D. Pellegrino, M.Di, President Reverend Richard P. Hendel, Vice-President Frank Gibson, Secretary Henry Bang, Treasurer Members of the Regional Advisory Group Costas Lambrew, M.D., Chairman Al.,ms Committee Edwin Clare, Attorney for IOIP Leonard An-dors, D.D.S. Ms. Priscilla Roe Leon Rushmore Lawrence Scherr, M.D. William Warner 2 Nassati-Suffoll@ ILTIP Project Authors Martha Browning, Comprehensive Home Care I.indoLi Davis, iI.D., Stroke Peferral'& Evaluation I,lm. Messinger, '@I.D., Regional Approicli to Co-,nptiterized EKG Paul Diamond, l'i.D., Regional Approach to Computerized EKG Walter O'Connor, @I.D., Development of PAP Smear & Self Breast Exam Ms. Stacey Sal.ev,-Regional Medical Library Ms. Elsie 1,@Tilensky, Regional Medical Library Perry Mandel, ',I.D., Computerized Ridiation TI@)erapy Harold Aqtorita, Computerized Radiation Therapy Sister Marie Buckley, Si-noker's Withdrawal Ms. David Arella, Smoker's Withdra\qal Daniel DePonte, Curriculum Development Sisiter Jane Marie Durgin, Regional Drug Inform3tioft Clenna McLean, R.N., Clinical Nurse Specialist Emil- Frey, Pli.D., Dial Access Lecture Health Institution Representatives John Dowling, l@.D,, Nassau County Health Dept. Micheal Bustemi, M.D., Suffolk County Health Dept. Leo Fishel, I.I.D., Nassau County Medical Society Maurice Tulin, M.D., Nassau County Medical Society Milton Rosenberg, @',.D., Suffolk Couity Medical Socioty Walter O'Connor, M.D., Suffolk Countyi%ledical Society Jack Dillman, Executive Director, NassAu-Suffolk Hospital Council Martin Nester, Administrator, Long Beach Memorial Hospital Francis Fosmire, Administrator, Brookhaven Memorial Hospital Richard Schoen, D.D.S., 10th Distri.c Dental Society Robert Brunner, State University Health Sciences Center Planning Agency Re2resentatives Henry Bang, Exec. Vice-President, Long Island Health & Hospital Planning Council Reverend Richard Hendel, Long Island I-Lealth & Hospital Planning Council William Warner, Chairman, Comprehensive Health Planning Council Ms. Louise Pan, R.N., Comprehensive Health Planning Council Ms. Joyce Turner, Comprehensive Health Planning Council Sanford Lenz, Comprehensive Health Planning Council Community Agency Representatives Arthur Risbrook, M.D., Clinical Society Sister Marcella Ann Hannon, Home Care Task Force Joyce Turner, Brentwood Schools* Mark Kenyon, Medical Foundation Eugene McNamara, Business/Industry Sanford Kravitz, Health I,,Ianpower John F. O'Donnell, BioMetric Systems ,Wm. Larregui, Suffolk County Task Force James Culhane-, Suffolk County Task Force Louise Pan, R.Ni, Task Force on Nursing Education ic@is. Pan and Ms. Turner represented their interests at both groups. I,I,ac,sau-Suf folk 3 Core Staff' Glen E. Hnstings, II.D. , J-,xecutivc, Director, P !I' & CliP John Kress, Assistant Director for Technical- Support Steven Roth, S37St&,-@I.S Specialist Sharon lianiil.ton, R.N., Planning ',,s,-,oci.atc-, Project Grants/@lanagement & Development James R. Europe, Assistant Director, CIIP Harrison OweLi, Assistant Director for Organi.zational Liaison and Special Projects Robert Beckman, Coordinator for Evaluation and Planning Annette Gilpin, Administrative Associate T4illie Paye, Planning Associate liassau-Suffoll@ I-'_,,Ip - 4 PUR'4DOSE: In li-lit of the present initial triennial application for operational status, the site. visit conducted to study and assess the Region's pToor@tm structure, achievements and capability. SIT'@, VISIT ST,@t,'CT IT Prior to the visit, I'-',TS documents Revie@.7 Process Requirements and Standards" and "I-'roram Revieiq Criter5.,@, were provided to the Rc@gion and the site visitors. 'ITe lallter was used as i clicc',-, list in structuring the agenda and in the conduct of the visit. T'ne entire meeting too]-, place at the I,,caclquarters @,.,,i.th approximate C, y 60 area representatives. Illo-vl;ever, the -triicture,,l along the lines prc-v,o-,iE'!,, I)v the --tc vif"it tcel -,Lid the i@-tis,.@ion was three major sessions at-id smaller subgroup discussions, each attended by appropriate persons. Tiie first session-(3 hours) with their otficc-,,rs, -onie f@,G members, the attorney and Key sta@@-f, f--cused on structure; -oal@-- objectives, ,-riori-ties, achievements, information, and Cl-',P-I7@@.P relationships. The second session (4 hours) also included project authors, providers, consumers and other health interests groupsand centered on operational programs (development, reiiew, evaluation and phase out plans), and regiorializatioll and cooperative arrangements. Tiie discussions were further amplified through L'our small groups;.l) project authors, 2) health institutions (Health Departments, Medical Scoieties, Dental Society, Hospitals and University),'3) planning ai,cncies, and 4) local or gani?.ations. Nassati-Suffolk The third session (3 hours) on the second day was with the principal, staff and dealt with staff organization, task allocation, personnel, internal operations, management controls and budgets. Small discussion groups included 1.) budget review, 2) staff organization and management, 3) continuing education, and 4) acco,-iiplisli,.rerits. The meeting concluded i..7ith.a one hour feed back of observations and recommendations (no mention of 'Lunds') to the Chairman of RAG and principal staff. S[Il@ri.,,!Ar,Y OF FIi\TDI@'CS: Until South Dekota's recent separation from Nebraska Nassau-Suffolk was tli,L- last of the 55 Regiotis still in planning. After two and one half years in planning, the NSI:VLIP is now requesting operational status and initial support for core activities and eleven projects. Core funds ate requested for three years, one'project for four years, eight.for three years and two for two years. I. Historical DevelopRient The Region encompasses Nassau and Suffolk Counties comprising 100 miles of Long Island east of Queens. The area was originally included in the C, Metropolitan New York Regional Medical Program. The efforts to be-,in a separate region began with the formation of a Advisory Medical Group in 1967. In June 1968, the Group incorporated as the Nassau-Suffolk Regional Medical Program, Inc. operating within $10,000 contributed by eight interested agencies. More than eighty organizations supported the new region in its planning. The Metropolitan New York, Regional Medical Program agreed with the two counties that it was reasonable that Nassau- Suffolk Counties form a separate re(,ion cc)gr@iplii.c@ capability with other riiajor relat:L-,@c@ orf,anizztio,.-Is, c@.@,. ti@(@ Lon- lsliricl Tlospital and Health Planning CoLipcil; the State I)c@.,p@irLi@ient for CIIP; the l@,assati.- Suffolk Regiocial.Planning Board, financed by PUD for planning in housing, economics and educational development; iiid the New York State Department 'of Mental Ilygiene. Distance and tran Spott&t4. on posed difficulties in developing vital relationships bet@veen the counties' health professions and ttie ,@,ietropolitan I-I.Y. medical centers. The rie@,..7 Ilealtl). Sciences Center being, develop' d at the Stony Broo,@ Campus of SUIZY is bririF4-Ln@ [tracheal center e competence directly to the 14-Sl@,,P. !'he developing Stony Brook 1--iealti-i Sciences Center is to include Colleges of Medicine, Dentistry, Nursing and Allied health; @i School of Social Work,, a Health Sciences Library; a University Hospital; @i@qd a VA hospital. Other resources in the region include 41 hospitals, county health departments, several specialized research facilities, and the Brookhaven National Laboratory. Support was approved L@or two years of planning beginning January 1, 1969 (bl-$223,256 and 02-$320,024.). There Xmas little activity until the appointment of the Program Coordinator June 1, 1969 and subsequent staffing. For this reason the planning period was extended for six months until June 30, 1971 with no additional funds. In lieu of indirect costs, awards for ,direct costs including fiscal.agent fees, $29,755 for the first grant period and $30,245 the second period. The fiscal agent is Stony Brook Foundation. LN'assau-Suffol,',( TRIP - 7 Of particular interest has been the Lesions li@@k-itP i.,,i.th CIIP "b" and the Lon- Island 11(@,alth ii-Icl Hospital Pl@ni-,i-ng Council.. The Program Coordinator heads both @IP and CIT.P, and offices are share(] by L)otli groups. A more formal merger of the two agencies is under consideration. The Health and Ilospit.@l PI-arin4pg Council is also considering joining t e s aring, ol.- quarters. @l. Goals, O'i)jectives & Prior-',-,U-ies Operational planning seems to be more by the "human" rather than the quantitative approach. '-ihe goals, objectives, and priorities have evolved from a "laundry list" of perceived problems. l@iiile the priorities set by the organization seem to be consistent @@ith the needs of the country/in general there has been little effort devoted towards the collection of data to determine specific needs and priorities for the Nassau-Suffollc region. As a result the @6neral priority list has not been developed into operational objectives other than for the staff to go forth and do good under the general direction of "hidden objectives". The staff believes they can not promulgate these hidden objectives in writing because they would create too much an:'47. per year on employee health and the c,-,,ployees @@.-,ere igL@in at least that much. It was pointed out that pre-paid care could probably do the job cheaper and better. Various public utilities and private corporations are involved in tl@cse discussions. An informal, @,roup has been organized which has 'oeen meeting for a year and in tli(,@ pas,t year the membership of the aroup has doubled. These companies are currently spending @40 million per year an health. Insurance companies have been approached and representatives from them have joined the group. PAIP Core Staff is ,assisting this group in plannin-. The response from the medical coiimun 4ty has been either "rion-plu-@-"ed" or very interested. The Fassau Yedical Society has-r.-)ade iticuiries about being a potential bidder for such a health plan. 4) There are five other potential groups starting to look in this direction and they have come to r@iP Core Staff for advice and assistance. N2@ s s,. program for pro,.@idin,, health c@,,re to the poor-liacl been planned with the Riveric-,,ad Tiie D@@,-,@rtiieit of I:)a(l coz:,,tfiittcd @,'300,000 to proi(,Ct owns was to c--iiit-,iit $100,000. Vi e hospital had a,,-rccd to -fc)rir4 a Depa.@teitnt of l@lerJici.ne and ha.f-i approval of the hospital adrcii@rii@-tr@t:or and board of trustees. the pro-rani x,,as defeated by one vote in i medical staff iu(-,eting, preventing its initiation. 6) P. similar type ol' pro<,ram is bein- developed at the Brookhaven hospital although some details of '-the are not quite the same as the P,,!.vcrhead Ilospital project. 7) Core staff are workinc, Keith the evaluation coiyil,)onent of the C3 Southwest Suffolk health Proc-ram which is a joint CEO-IIIP program from 2500 i.@elfare recipients. 8) Assistance is being given to the O"uffoll< County Ilealtli Departnent in preparin- seminars for county legislators. 9) Staff is also assisting the dentists i[i establishing a continuing education program. 10) Technical systems assistance is provided to induce cooperative sharing computer hardware and software. VI. EVALU@iTIO@@': The Region has developed a critical pathways form for project monitoring. T,'ne concept v)as developed by the C, construction industry several years ego (also called PERT) and allows for monthl, -Li - "-u f s m ay Lc@ co,;,parLd to l@IC)St ol tllr 1)@TL the lic@ioii's overall is va,-Lc, of data l@ase. The 11-IC-s studi(@d the evall,,@tioli O.' other rc.,@,,iois, as well as o',--her reunion,,; coq,,-icnts on its approach. Outside consultation is bei-,.i- sou-iit as evidenced by the participation in t@e multi-r6gional program c-,7a lua t@LoLi throur,h tiip lizirvnrd Cc@,nter. Phase I of the H@irv,2rd study includes ,ti ,3tue;.y of 17 staff by -ion (10 paid by 'U@-!P and 7 paic CIIP), 27 P14."@(,l (1.0 i -corporate and 17 corporate), and 25 non-P,@,.G merni)(@rs. T'LIL, 1,@,tLcr 52 represented some of the most"influential people" those in health care. Preliminary results indicate the Region's first order of priorities are congruent with major health problems identified by the respondents. The second order of priorities should be reevaluated. -L'ne projects for which funds are requested address a large number of the major health problems. All respondents agreed that the major pur@,,Ds,-s of @qSI@'IP should be to plan and improve health care in general. The greatest current visibility of NSR@IP seems to have been generated by activities unrelated to llbip projects per se. This phenomenon is to be after the Region is funded and operational. All respondents predict a merger between @IP and CHP at local and national levels and are otherwise uncertain of the future of 1-1@IP, 11 c I c@ 0, i-I c p -'le Ic)o y @',)'!,y had to -iie riiaii)y in --s structured durin- tl)c- format@j-,,7e ye,-,rs ',@O OCCOPI!,,Or@"LIL@-I tei. t c@ of 1; c f@e@ roLip s t i-,,r:) V 4 the for IC)!),- t - -i,bnal s c@ c -,'k. a I 1 y not -vc- a to r;rc@%, role believed that the -.tiality oi the top i,); the corpoi,--,tion: w--)c@ oF nature that ..4-OUld iris-tire success of tiie program. Therefore, the team shared many reservations organizational, structure @r,,df state of the corporation E,,iil pro-r@j@L C,,C--'--,7C-lop.Tnent , tLie N,T,- s --Ltots @,eli@-ve that the has o- deal of potential and fill benefit from and congequen-LI.y do justice to the challenge of an operational proc-raf@i. L4ajor Crincerns: 1) Tiie corporate structure is cumbersor@-,e and the corporate non-corporate delineation among the Re-ional P@dvisory Group iDe-c@iberstaip is artificial and disfunctional, therefore this area should be re-exar@ii-ned and possibly restructured. '2) The role ot the Aii-,s and Objectives Committee. versus that of the Pro-ram Committee is not well defined and as a result it appears that these L@,C,70 groups have overlapping responsibilities for the development ot l.onc.--range plans. A more worl-,able arrangement should be developed for tiie determination of lori-- and short-range goals and the structuring of 0 programs to meet those goals. I 3) Toe internal or@,,a;-.-zation oi: L@,@c o;-, -ind dirc-cti-o@l, Its 2 it appco,@-S that -Lit,c@ on @i reactive rather then free-float-"-nE,, basis @,,,-'@th no cic,,,3r cut 4) -ilic. rysi--c:ii V,,,-'@thin the oleratin,-, level of the orgeni;.,,ati-c)i-i @pl)Ie,,,-rs to be relat4,lvelv I,"iost@ of the employees report their progress to the director or, an informal basis few opci-atiii,, I.ittlc, :rLc@asureiieit to they are qctuilly achieving results. The methods by wliich t,ie director reports to ti-t-- bo@ird seems to be more structured alt',-iou--h ,,,,.uch of it is 1) sod on communications. 5) The salary structure and allocation of resources in the or,@eni,--,,,,tion appears to have been accomplished on a rather liapli,3z,-3rd basis. Some salaries seem hi,,h for tne l@inds of talent being hired. It also ippear-, thit the various talents have not been !)rou'@,,',..t tc),-IeL'Lier to 'JI-or@@ll @l composite group who would accommodate and build on each otiiar's e:@pertise. Same other Core 'D-adc,et items see,@ equally itap--rudeiiL, costs (plan to relocate in th6 near future) and consLiltiiA- services for writing ,@tant applications. The internal administration of the pro,@l-r@@m should be thoroughly reviewed and strengthened. Consideration should be given to employ an administrator to provide continuous day to day direction. This is especially important since the coordinator heads both CIIP and PIIP activities. 6) T'iie project review procedure is extremely cumbersome with the &@G being I-,rought into the picture much too late in the process. l,,cviei,2 procedures need to be streamlined. It was noted that the review procedure appears to have incorporated proper scientific and managerial reviews to insure integrity oj' each project a]-though it is.di.L'ficult to see how the projects a S -Uff(- )@7 L@ LI - S, fit into a total,. proZram. 7) Too little ef,7ort: his been rc.1 -i."ojocts more -i realistically meet i?,Oals of As a result t:li4-- program C' is riade up of project- developed on ,i rr@ore or basis with little- pro-r@@..!)l consistency. 8) There is concern ibout the close relationship the Pl@,P and CllilP and the evident- corifijsion't,@@is (,_@-usc@,d i,i,-i Lljie viii.iicj's of the health care practitioners. Some of the site-vi,,it tc@@-,r@i T,.,,ere concerned that the region has lost at i-easL same of the supi)o,-t oj' the medical Un4ty4 They believed that in part this is c 0 nllrriI due to t'ie close relationship with CIIJ'-. 9) There has been little efi@ort t-j,,,@,a-cds irid use of data to determine specific needs and priorities. As a result the -,zcncral priority list has not been developed into ol)r@retiorial objectives Also there are too many hidden object:L@70S. 10) Levels of attendance is relatively low at tlif-- Air,,is )iid Program Comriiittee meetings when the priorities were being established. Those present, however, did represent a -ood cross section ot consumer ai-td provider groups. RII,CO,Nr,!Ft-,ITDATIOI,.T: The site visitors recommend t@Liat the Region be allowed to go operational ind believe that by doing so under Specific guidance and advice frofa fl@iPS, the pro(,ram will be greatly strejagthencd. Therefore, approval is recot@iricnde(i for three years,-with the following considerations: 1) the P@@i.bn obtain the services of an outside consultants to e@-at-@iiiie and assess the organization structure N"gssiu-Stiffoll, c,iicl vl-litl,, tmq,-,rd the 2) fc.@,ion ddrcs,@:11 the concerns of the visitors; 3) the second year ap-.)Ii-c@ition I)C-, reviewed by Comi-nittr--c, and Cotinc-.'Ll and c.@ site ariej 4) that the level of funding be increased if sifrificilit pro@ress is achieved dilrilic, the first operational year. ror core activities, trie site vif-,itors reco7,iiL,,Pl @-pproval of the amounts requested as 01 02 03 $451,755 @490,403 $530,01@,3 For eleven projects, @1,015,466 is requested first year, $771,087 the second year, $6,@)9,6-JOU the th-@@rd year anci @72,4,!i8 the fourth.A reduced amount is recorrinended each year for three years tit one of three levels as folloiqs: $423,000 $378@000 $326,000 Therefore., the total for core and projects is recommended at one of three levels as follows: 01 02 03 $913,403 litzi $374,755 $0@53,04.3 l@IEDIU,'-! 829,755 868,403 043 MINIMb@il 777,755 816,408 856,043 (A Priv'leged Communication) I REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL GRANT APPLICATION NEBRASKA REGIONAL MEDICAL PROGRAM RM 00068 5/71 Nebraska State Medical Association April 1971 Review Committee 1902 First National Bank Building Lincoln, Nebraska 68508 Program Coordinator: Harold S. Morgan, M.D. REQUEST: This is an application for status as a new Regional Medical Program, to serve Nebraska. Requested (3 years beginning July 1. 1971): Projects ist Year 2nd Year 3rd Year TOTAL Core $394,670 $432,247 $440, 5@3 $1,267,570 #1-C6ronary Care 195,174 189,562 -0- 384,736 Training #2-Communications Facility 130,983 133,981 -0- 264,964 #3-Mobile Cancer Detection Unit 129,2§3 133,801 -0- 263,094 Direct Costs 850,120 889,591 $440,653 2,180,364 Indirect Costs 179,104 187,925 98,042 465,071 TOTAL $1,029,224 $1 077,516 $538,695 $2,645,435 FISCAL INFORMATION: This region is currently part of the Nebraska/So uth Dakota Regional Medical Program which was funded in the total amount $1,583,391 for core and three projects A period of 18 monthsi ending June 30,1970. Based on recent budgets for the last six months, the current annual level of support is as follows: ects Direct Costs Indirect Costs Total Nebraska $790,070 $165.,424 $955,494 Core & 3 Projects South Dakota $210,430 $51,916 $262,346 Core & part of Coronary Care Project Total $1,000,500 $211,340 $1,217,840 Nebraska Regional Medical Program -2- RM 00068 5/71 Attachments include "Fundirig Summary" and "Current Annual Level of Su port",. both.for the Nebraska-South Dakota REgional Medical Program. South Dakota's planning Application for a separate RMP was reviewed by the February 1971 Council. Council recommended approval in the amount $@799500 d.c.o. for the first year ($259,500 for core and $120,000 for South Dakota's part of the Coronary Care project for one year only) with a level of cote support $313,000 the second.year and $376,000 the third year. C,F,OGRAPHY AND DEMOGRAPHY: Chadron a Crawford Norfolk @scottsbluff North Platte Si( er and Is. Lincoln gs Mc Cook Red Cloud Beatrice Nebraska, encompassing 76,712 square miles, is bordered on the north by South Dakota, to the west by Montana, Wyoming and Colorado, to the south by Kansas and to the east by Iowa and Missouri. Some characteristics of-the.1.5 million inhabitants are. 54% urban, 98% white and 30.2 years median age. Mortality rates per 160,000 are 385 for heart diseases, 161 for cancer, 128 for CNS vascular lesions and 24.4 for kidney diseases. Health facilities include Creighton University School of Medicine, t e .University of Nebraska College of Medicine, 9 schools of medical technology, 8 schools of X-ray technology,,l school of cytotechnology, 14 schools of nursing (R.N.) and 4 schools of practical and vocational nursing. According to the Journal of the American Hospital Association, Nebraska has approximately 116 registered hospitals with 12.,700 beds. Of these only about 48 have more than 50 beds, 24 have more than 100 .beds and 19 more than 200. Of the 14 teaching hospitals, all in Lincoln and Omaha, 9 are major teachin affiliates of the two medical schools. 9 Nebraska Regional Medical Program -3- RM 00068 5/71 Within Nebraska, there are 1,683 M.D.s (118/100,000), 61 D.o.s (41/100,000) and 4,653 active nurses (288/100,000). B-ACKGROUND: The development of the Neb.raska-South Dakota Regional Medical Program began in the Fall of 1965 and a request for planning was submitted in October 1966. The application represented individual planning programs by the Nebraska State Medical Society, University of Nebraska Colleges of Medicine and Dentistry, University of South Dakota Medical School and Creighton University School of Medicine. The November 1966 Council recommended approval with an expression of concerns about interrelationships of the five parties in planning and the apparent cumbersome administrative framework. The Nebraska-South Dakota Regional Medical Program was initally approve for two years of planning beginning January 1, 1967. A site visit was made in September 1968 to assess the Region's capability for operational status (core And four projects). The site visitors observed that the Region was in an early stage of regionalization. Two deterrent factors were the inability to complete major staffing until June 1967, and the need to create a new organizational structure to function as a whole. Planning also seemed to be by intuition rather than by design. There was a lack of adequate data needed to support project planning. Coopera- tive organization between the three medical schools (University of Nebraska College of Medicine, Creighton University School of Medicine and the University of South Dakota) was noted. There seemed to be good'partici- pation by Nebraska physicians, but much less involvement of South Dakota physicians. It was apparent that the Nebraska State Medical Association, the grantee institution, played a dominant role in Regional affairs. The site visitors believed that although the rate of progress in program planning and development was slow, there were beginning signs of regionali- zation. It was also agreed that continued development of the Region would depend upon the initiation of some operational projects to provide visi- bility and a focal point for the high degree of enthusiasm displayed. In view of the site visitor's report, the Review Committee and Council concluded that operational status was premature and recommended approval. for continuation in the planning phase. Accordingly, the three-year operational applica tion was funded as a renewal planning grant. The Region applied for support for four operational projects in May 1969. A site visit followed in June 1969 to assess progress and to review the projects. Changes in the bylaws seemed to have influenced progress toward regionalization. Major changes included: (1) designation of the Presidents of the two State Medical Associations to serve on a ternat ng years as Chairman of the RAG; (2),Presidents Elect of the two medical associations to chair the Executive Committee alternating annually; and (3) RAG representation was broadened to include minority group representation, volunteer health organizations and nurses (70 RAG members, 35 from each state). South Dakota, which previously was less enthusiastic about Jointiig with Nebraska as a Region., appeared to have adjusted and was Nebraska Regional Medical Program -4- RM 00068 5/71 participating on a more equal basis. The three medical schoolo.continued to maintain cooperative relationships. Planning also seemed to be on a more sound footing. Concurring with the site visitors, the August 1969 Council recommended approval for operational status. The Council, however, remained uncertain as to the real involvement of.South Dakota in this program which seemed to be a carefully balanced arrangement between the two Nebraska medical centers. Staff discussed this with the Region representatives in negotiating the award, emphasizing the need for real program outreach - not simply representation on various committees. The Region received an award for core and four projects in the current first operational year. The first concrete evidence of South Dakotals immense dissatisfaction and possible bteakway was in the spring of 1969 when Governor Farrer of South Dakota wrote.the Secretary, H.E.W., requesting p6@,saion to merge the South Dakota CHP and FM efforts. A year later, Dr. Robert Hayes, then RMPS Associate Coordinator for South Dakota, in a letter (February 20, 1970) to the Director, RMPS formally announced South DAkota's intention to withdraw from the current two-state RMP and establish its own Region. Subsequent dialogue between RMPS staff, Dr. Hayes, and the Region Program Coordinator I:e*-., to South Dakotals submission of a rreliminary.draft application in May 1970. A staff team visit was made July 15-16, 1970, for the purposes: (1) assess the possibility of keeping the two states together in a mutually acceptable functioning program and necessary mechanics; (2) if South Dakota still desired separation, obtain clarification and elaboration of their draft proposal, which was very general and inadequate; and (3) provide appropriate assistance. Part of the team visited key core staff and a past chairman of the RAG in Lincoln, Nebraska, and joined the rest of the team in Vermillion, South Dakota. South Dakota's intent to separate became crystal clear and Nebraska seemed ready to acquiesce. RMPS staff reactions to South Dakota's draft application were discussed in detail. The July 1970 Council preferred not to consider South Dakotals separation and the establishment of their own Region in advance of a formal application and the regular review process. For this reason, Council did not address a relevant question, whether or not South Dakota might Assume administration of parts of the existing three funded operational projects to Nebraska- South Dakota RMP. Upon receipt of South Dakota's formal application dated July 22, 1970, the applicant was advised that the issue of separation had to be taken up by the November 1970 National Advisory Council following a visit by two of its members. They were advised that the application would then be processed through the regular review process, Review Committee in January 1971, and final consideration by the February 1971 Council. Nebraska Regional Medical Program -5- RM 00068 5/71 Because of the proposed division of the two states, a supplemental application dated July 27, 1970 from Nebraska-South Dakota RMP for $4,616,825 support of 5 new projects for 3 years was returned. on the basis of the visit October 27, 1970 by two of its members, the November 1970 Council approved the separation. The report of the visit is appended. To provide interim support for Nebraska-South Dakota Regional Medical Program's core staff and three projects (beginning date January 1), the current first-yea r award was extended for six months until June 30., 1971 at the current level of support. The February 1971 Council recommended approval of South Dakotals planning application for three years including support of their part of the coronary care project for one year. An award will probably be effective July 1, 197.1 subject to funding restraints. PRESENT APPLICATION: Support is requested for core for three years and for the continuation of three projects for two years. GOALS: 1. To support programs at preventing the development of illness due to Heart, Cancer, Stroke, Kidney and Other Related Diseases. II. To support the design., of better programs for health care of the patient in his own community with reference to the diseases.11 OBJECTIVES: 11 I. To design better methods for the exchange of health care data. II. To develop research in training and demonstrations of patient care and to support more effective methods of the delivery of health care. III. To promote regionalization and cooperative arrangements as means of reducing health care costs. IV. To work with areawide health councils and other health planning agencies to develop programs necessary to meet, provide or ameliorate the determined health care needs of the community. V. To improve and update the knowledge and skills of existing community health practitioners through various techniques of continuing education; training courses, demonstration programs, seminars, traveling clinics and access to addio visual communication systems. Nebraska Regional,Medical Program RM-00068 5/71 VI. To encourage hospitals and nursing homes to. join in programs of continuing education for in-service personnel in order that these members of the health team be brought up-to-date on the latest techniques used in nursing care of patients with heart disease, cancer,,stroke, kidney disease and other related diseases." PRIORITIES 1971: I. Continuing education to be the primary activity. II. Development of education programs in community hospitals. III. Improve comnunications'and coordination with other health organizations. IV. Assist in all possible manner, efforts of organizations, in- stitutibns and medical centers to develop a comprehensive program for the prevention, early diagnosis and treatment of renal disease.'' ORGANIZATION: The application includes a list of current RAG composed of thirty-five members. However, Nebraska has revised the by-laws. A new roster of members (RAG, Officers, Executive Committee and Finance Committee) is to be provided prior to the April 1971 site visit. The President of the Nebraska State Medical Association presently serves as Chairman of the RAG-. The by-laws, Approved by the RAG January 27, 1971, provides for the election of officers by the RAG; chairman,.vice chairman and secretary by the RAG. There is also a provision for an Executive Committee and Budget and Finance Cormittee. EVAL@UATION: The brief description of methods for program and evaluation speaks only to rating proposals. CORE: The request for core budget for personnel in the Requested Central Office, Creighton University School of First Year Medicine, and the University of Nebraska has increased $3943,670 abo ffic' tion includes 12 ut 19%. The Central 0 e budget por professionals (10at 100%, 1 at 20% and I at @0%) and 6 full-time secretaries. Unfilled positions (5) include, a program planner, a nurse, a health educator, statistician and a secretary. Central office personnel includes project management personnel of the Coronary Care Communications projects, six positions at approximately $103,700. This transfer was made as a result of the RMPS management assessment visit February 1970. Core staff at the Nebraska College of Medicine ($44,783) and Creighton ($40,448) consists of two professionals and one secretary at each of the are supplies at $24 200 two medical schools. Other significant budget items and travel at $41,000. Nebraska Regional Medical Program -7- RM 00068 5/71 The foci of core activities has been the three operational projects. other activities have included a contract with the Continuing Education Department of the University of Nebraska to provide a series of telephone conferences in the two states and circuit courses. Nineteen telephone network conferences were conducted for physician@g@,.@ and nurses June 18 through December 15, 1970. Two additional conferences were planned, but were cancelled because of poor reception. Nine con- ferences reached a total audience of 471 physicians, an average of 52 per conference. Ten conferences reached a total audience of 1,144 nurses, an average 114 per conference. Post conference evaluation in terms of subject interest broadcast quality, usefulness of information, was done by written inquiry. Evaluation response ranged from 28% to 80% (average 59%). Six circuit courses were conducted in different communities in Nebraska and South Dakota with a total audience of 3 94 (average attendance 66). Evaluation of two courses dealing with care of terminal patients, indicated courses effectiveness in behavorial change. Televised continuing education for dentists is under study. one program sponsored by the Region and the South Dakota Dental Association was scheduled to be aired over the educational T.V. networks in both states. Some effort has been made to establish a closer relationship, with CHP A & B agencies, including a workshop initiated by the N-SRMP. A series of joint conferences are being considered. Sub-regions are to be developed where CHP agencies exist. Two "B" agencies are now in the planning stage and two are operational. The core staff at Creighton are assisting the planning for that ingtitution's involvement in the Inner City Health Delivery Services, including the development of health centers. This program includes involvement with the Omaha Department of Health, the CHP t agency, and the Greater Omaha Community Action Program. These personnel were also involved in the dental T.V. program; a survey of heart disease in children; and organizing a four-day seminar on health careers management. The core staff at the University of Nebraska are interested in developing a curriculum for allied health training at the University. These personnel also assist the University's component of the coronary care project. They are also responsible for the coordination of planning a kidney disease program. Second year: $432,247 Third Year: $440,653 Nebraska RX 00068 5/71 Regional Medical Program Project #1 - Coronary Care Trai@n -This application Requested is for continuing support of Nebraska's First,Year part of the project for two years. This project, $195,174 now in its first year, was approved for three years, $443,647 the first year, $313,138 the second, and $167,871 the third. As a result of study by the task force on heart disease, improved care for acute myocardial infarction patients was given the high priority. As a result, this project proposed coronary dare training for physicians, nurses and medical technicians in the Region, and to offer community hospitals technical assistance in maintaining equipment and establishing an information service. Its design was to offer the training programs in sevaLal locations and by several modes to provide maximum access.to hos itals remote from metropolitan medical centers. Thd@'project was p to have the potential to train 220 physicians, 330 nurses and 12 technicians annually. The present program represents the cooperative efforts of six institutions as follows: Bryan Memorial Hospital at Lincoln, Creighton University School of Medicine at Omaha, University of Nebraska College of Medicine at OmAha, University of South Dakota,, Vermillion, S.D., St. Johnis McNamara Hospital at Rapid City, S.D., and Sioux 'Valley Hospital at Sioux Falls, S.D. According to current revised budgets for the last six months of the current eight6en-month period, the current Annual level of support for the three institutions in South Dakota is $118,884 d.c.o. and $194,260 for the three in Nebraska. South Dakota Regional Medical Program has been approved for support of their part of this project at $120,000 for one.year. The award, subject to fiscal restraints, will probably be issued to begin June 1, 1971. Reasons for the slow start are cited as lateness in the award and tooling up. Fourteen 4-week coursesl,were conducted for 251 nurses in their place of residence. -Evening courses reached 73 nurses. The ROCOM system supplemented by physician lectures was rotated among 5 community hospitals for 61 nurses. Another program including a physiological and phar- maceutical workshop were conducted in 12 hospitals for 226 R.N.'s and 40 physicians. Five 2-day refresher courses were held for 174 coronary. care nurses. Five technician courses were attended by 23. Two equipment workshops were held in different locations for hospital personnel were attended by more than 70 engineers, nurses and technicians from 17 hospitals. 148 physicians participated in fourteen 2-day seminars. Project personnel visited 70 of (70%) Nebraska hospitals and 46 (70%) of those in South Dakota. ROCOM,teaching packages have been delivered to 18 locations, 9 in each state and 667 have been recipients of this training. Education by pre and post testing have proven to be of questionable value. Evaiuation of trainees performance six months after training .@--: I is now being done. , I Second year; $189,562 Third year: -0- Nebraska Regional Medical Program -9- RM 00068 5/71 Project #2 - Conmunications F it - This project, Requested now in its first year, was originally First Year approved for three years, $132,715 the first year, $130,983 $132,715 the second and $171,390 the third. South Dakota has indicated no interest in trying to divide the support of this project. The program is to develop a communications facility located in Omaha involving the facilities and resources of the local educational institutions: Creighton University, University of Nebraska Medical College@ University of Nebraska and several teaching hospitals. The facility, as proposed, is to consist of four components: 1. A telephone access information system accessible to medical personnel via a WATS line, a medical tape library service and drug information; 2. resource for referrals; 3. information resource for information and assistance for instructing materials; 4. audiovisual equipment supply and advice. The program, under the guidance of the project'administrator, is operated 24 hours per day, 7 days a week. The project line switch board connects Nebraska, South Dakota, Iowa and Kansas through a series of WATS lines. The drug information service received 390 calls. Study of drug Adverse reaction reports is a secondary objective. The media library staff have Accumulated some.library material and have visited 76% of the hospitals to assist in the development of in-service training programs. A tape library located at the Nebraska @College of Medicine, became operational in January 1971 and will provide the service to practitioners in Nebraska, South Dakota and Iowa. The project library now has 100 tapes owned by the University of Nebraska and 90 owned by the N-SDRMP. Iowa is to contribute 150 tapes. Second Year: $133,981 Third Year: -0- Project #3 - Mobile Cancer Detection Unit Now in its Requested first year, this project was approved for First Year three years,, $134,739 the first year, $128,739 the $129,293 second and third vears. The project proposed to provide an improved cancer detection program for the low socioeconomic families of Omaha served by the clinics of the two medical schools. The mobile unit is to augment the existing clinic services, and is also to be available to rural concentrations of American Indiana. Screening procedures include: oral, colon rectal, breast and uterine. A study is to be conducted to evaluate the effectiveness of the simple screening tests and the automated history Nebraska -10- RM 00068 5/71 R6gional Medical Program system.. The Communications Project is to provide backup on the question-, answer Iphase of the activity. A cancer detection education program &E the U.N. was also planned. The mobile unit is reported to be udder construction as of January 17, 1971 with delivery expected soon. Two nurses, a sociologist, a biostatician, and a secretary have been employed. equipment including a mammography unit* dental chair amd examining tables has been acquired. The socio- 16gist has done some work towards proposed service for lhdiansi One nurse requiring additional skills was given training under the direction of the Chairman of the Department of OB-Gyp, Kafisas University Medical Center. Project principals visited the Kaiser Permanent Multiphasic Screening Unit in Oakland, California. Projected scope of work including caseload is not specifically stated. Second year: $133,801 Third Year4 -0- Nebraska Regional. Medical Program RM 00068 5/71.1 NEBRASKA-SOUTH DAKOTA FUNDING SUMMARY RM 00047 PLANNING Council - November 1966 November 1968 Site Visit September 1968 lst Year I/l/67 - 12/31/67 Direct Costs $289,350 Indirect Costs 60,989 Total 350,339 2nd Year 1/l/68 - 12/31/68 Direct Costs $281,450 Indirect Costs 67.9.17 Total $349,367 3rd Year I/l/69 - 12/31/69 Direct Costs $440,375 Indirect Costs 70,831 Total I/ 2/ $511,206 Total 3 years 1/l/67 - 12/31/69 Direct Costs $1,Otl,175 ts 199,737 Indirect Cos $1,210,912 1/ The Region was initially approved and funded for two years of planning. U-non review of the three-year operational application, the Review Committee and Council concurred with the site visitors that operational status was rremature. Accordingly, the three-year operational application was funded as a renewal planning grant carrying 6ommitments (d.c.o.) $350,239 the second year and $738,832 the third year. The Region became operational beginning January 1, 1970, and continuation of core, reviewed by staff, was funded for one year with a commitment the second year; core support must be renewed for the third operational year prior to January 1, 1972. The renewal ewstd for the third year of planning included $107,880 ($102,520 direct costs and $5,360 indirect costs) for one year additional planning of two rrojects, #2 - Audio Visual Continuing Education Services and #3 - Coronary Care Program. Project #4 - Stroke Rehabilitation Technician Training - was disapproved. Nebraska Regional Medical Program -12- RM 00068 5/71 OPERATIONAL 1/l/70 12/31/72 Council - 1969 August and December Site Visit - 1969 June Direct Costs Approved Approved Period Funded Future Level 1/ 2 years (01) $443,647 (02) $425,903 core - 1/ (03) -0- #1 Coronary Care 3 years (01) 313,138 (02) 313,138. 03) 367,871 #2 Facility CommuInications 3 years (01) 132,715 (02) 132.,715 (03) 171,390 #3 Stroke Education Aproved Not Funded p #4 Neopiastic Disease 3 years (01) 134,739 (02) 128 739 (03) 128:739 TOTALS as of December 28, 1970 *(Ol)$1,024,239 (02)$liOOO,495 (03) $668,000 Note* 01 year award includes authorized use of,carryover $23,,744 ($17,744 Core and $6,000 mobile unit #4) Approved Not Funded #3 -.Stroke Education 01, 02 03 Total Direct Costs $187,350 $187,350 $187,350 $562,050 TOTALS as of December 29i 1970 (01) $1,312,992 (02) -0- (03) -0- The 01 award was amended December 29 1970 to extend the period for six months with additional funds. No future commitments were made because of the decision to dissolve the current bi -state structure and form two separate regions. 0 1 .1 NEBRASKA - SOUTH DAKOTA REGIONAL MEDICAL PROGRAM RH 00047 Current Annual - Level of Support Based on Budgets for the Period 1/l/71-6/30/71 Nebraska So. Dakota Total Direct Ind. Total Direct Ind. Total Direct Ind. Total Costs Costs Costs Coate Costs Costs Costs Costs Costs 'ore $334,358 $77,430 $411,788 $91,546 $24,006 $115,552 $425,904 $101 436 $527,340 'oronary :ore Iroject 194,260 34,896 229,156 118,884 27,910 146,794 313,144 62,806 375,950 :Ommuni- -ations )roject 132,714 13,834 146,548 132,714 13 834 146,548 cancer lobi le 128.738 39.264 168.002 128,738 39,264 168.002 $790:070 $165:424 $955,,494 $210,430 $51,916 $262,346 $-1,000,500 $217,340 $1,217,840 South Dakota RMP Site Visit -14- RNPS Vist.to South Dakota Vermillion, South Dakota Date: October,27, 1970 Place: School of Medicine, University of South Dakota (Vermillion) RMPS Visitors: Bruce Everist National Advisory Council, RMPS Clark Millikan National Advisory Council, RMPS Personnel from South Dakota: Dr. Henry Parrish, Acting Director (Program Coordinator) South Dakota Regional Medical Program Dr. Robert H. Hayes State Health Officer Dr. J. Patrick Steel, Radiologist, Yankton, South Dakota;' Member, National Advisory Council, National Institute of General Medical Sciences Earl B. Scott, Ph.D., Professor of Anatomy, University of South Dakota, School of Medicine Dr. Robert Quinn, Past President, North Dakota State Medical Association Mr. William Murphy, Executive Secretary, State Hospital Association Dr. Warren L. Jones Mr. Richard Erickson, Executive.Secretary, South Dakota State Medical Association Mrs. Bertha Damm, Executive Director, South Dakota State Nurses Association Mr. Peter Zwier, Executive Secretary, American Cancer Society, South Dakota Division Dr. Bruce Lushbough Mr. James R. Nordstrom, SDRMP Staff, 2() per cent South Dakota RMP Site Visit 15 Mr. C,.'Halt(,,r, SDRMP Staff,]OO per cent Mrs. Schwab, SDRMP Staff, 100 per cent Mr. Don Brekke, SDRMP Staff, 50 per cent (SDCHP Staff, 50 per cent) Miss Gloria Hansen, SDRMP Staff, 100 per cent Executive Assistant of President Richard L. Bowen, University of South Dakota Dr.,George W. Knabe, Jr., Dean, University of South Dakota, School of Medicine General: Tlif, N(@braska-Sotith Dakota Re@y,ional Medical Program apparently Login amiably in 1966 with what appeared to be a rational aT)proari) to rof,ionalization involving two adjac.ent states. Enthusiasm was apparently high in both states. Some of the difficulties described at the time of our visit were: 1. The meetings were apparently held in Nebraska, and the South Dakota representatives had to spend considerable time traveling to and from Omaha. Without adOquate airplane service, this meant a two-hour drive each way at a bare minimum. Ideas were germinated in South Dalota and come to fruition in Nebraska with little substitute change. 1. Ptincinal core personnel were placed in the two universities in Net,,rael I is In light of the present fund-i.ag stringenci.es, t.lie need for @ucli urgency does not apply. r@MPS/GRTi 1/1.9/71 c.-USQUEEIAI:,IiA VALIE@Y -3- b,AT)'O@,IAL ADVISO-@JY COIZTCIL !,i 'L?@1971@ "i7E-ETZ-'Fi c I dto Covii-icil. concurred w;th tl-ie Coviiriittee's re 't lia@ 1 V). fi de-tei.-inin@- -a FLin(linE@, level for the comin- year and to assess t'Lic Pegi.on's progress since tl-ie l,ast site visq -t. Council di(.] Disprove rene,@?,i] of Project @'6R, Coronary Care I\Iurse Training at tti(-, Geisii-igei7 Center, as requested and siipT)ort for Proj(?ct iA25, Coronsry Core Niirse Trbininc, at the Al.toone Hospital for one year. cP-,B/2/22/71, (A Privile@,e(I Communication)- STZIMNRY OF REVIEI@7 AND CONCLUSION OF APRII, 1971 REVIEIL CO@Ti',IITTEE SUSQUEMkNiNA, VliLLEY REGIONAL IIEI)ICAT, PROG.@L Rl,i 00059 5/71 FOR CONSIDERATION BY IFAY 1971 ADVISORY COUNCIL RECO@t@I.ENDATION: The Committee recommended that R@'4!'S provide $100,000 additional funding to Susquehanna Valley M4P with no specific advice as to its use. Hoi,@ever, the Region was not approved for developmental component funding as such. The application (submitted in November 1970 and deferred by February 1971 Council for a site visit) requests: 1) the activation of four Council approved but unfunded activities, 2) the renewal of one activity, 3) the implementation of seven new projects and a developmental component. r@i @u@: Committee recalled that a site visit had been held as a result of February Council's request, in order to determine a funding level for the coming year and to assess the Regionts progress since the last site visit. Review Committee and Council at their last meetin-s had difficulty in evaluating the application because the Region appeared to be undergoing several major changes and.neither group had a member with recent.on-site knowledge of the Region. Because the application showed evidence of continuing difficulties in leadership, regional planning and relationships with ttie-medical school, a site visit was considered necessary. The findings of the site visit to the Susquehanna Valley Region on M6rch 25, 1971, were reported to Comnittee. The visitors outlined the strengths and weaknesses of this Region and described the progress since the visit in February 1970. The excellent grass roots involvement of physicians in each of the four Areas continues to'be a major strength of the Region. The site visitors were impressed with the interest of providers in small communities in BIIP as a mechanism for improving patient care. The organizational plan, iiliich includes area committees, categorical. councils, an executive committee, as well as the @kG,, appeared workable. Young physician- chairmen of the Councils liave.given much assistance to the Core staff efforts. Core, whil.e completely la lins made some major contributions Ys in program planning. It -Ls also x,2orking with CIIP in some joint program efforts. The early emphasis on coronary care seems to have broadened as evidenced by proposals in areas such as home health care, comprehensive health care centers, and cancer education. Despite these stron- points, there are overriding weaknesses which C) discouraged both site visitors and Committee members. The most serious problem is the lack of stron- direction fresh any quarter. Neither the 0 Coordinator nor any one on Core staff provides dynamic leadership. The grantee agency, the Pennsylvania Medical@ Society, is not offering 0 strong support to the program. '@,lliile ti-ie ML I'P has tender-,] to function as la subordinate of the PL"IS,, the site visitors learned tilat the firant(,e C> SUSQUEIIANNA VALLEY W@IP -2- RM 00059 5/71 became so by default, not by any commitment to the program. The Dean of t'ne new medical school at Hershey has been unable to bolster the KIP, because of both his urgent and immediate concerns with starting the medical school and the lack of anyone on Cote staff with the professional background to require better commitment from him. The Regional Advisory Group has been weak and reactive to the grantee organization, to area demands and to national priorities and review decisions. At the same time, it has not provided much support to Core, possibly because of the lack of medical leadership on Core staff. In fast when informed by RIIPS that available funds were only $24,313 more then the current Core budget, the PAC had considered a severe cut-back in Core staff funding. Strengths in the leadership in categorical Councils have not been built in to the RAG. While some RAC members present at the site vi sit seemed to reassess their evaluation of Core worthiness, the site visitors also Pattern tc@(I to p alleviate the untenable fbndina situation imposed by IOIPS by recommending that the Region receive some additional support ($100,000) to preserve the very life of this RMP. The visitors hoped that such an'amount wou preclude expenditure of funds for such projetts as the Automated Computer- Assisted Analyses of the EEG, whicl@i seemed esoteric and out of line with the Region's more pressing health needs. The $100,000 should enable the Region to initiate some worthwhile project activities and give the RMP SOM6- visibility in the Region. Committee concurred with the site visitors reservations about the viability of the SVIL'AP as a Regional lledical Program. There was disagreement among its members about what course to pursue in light of the problems outlined above. Several members ques'tionned the desirability of investing further support when conditions necessary for improvement did not seem in the of f inc,, . Other members, hoige ver, believed that the Region had enough promise in its Core staff and community participation to warrant a chance to develop a program. In concert with the site visitors conclusions, Committee recommended that the Reoion should be informed that national reviewers had serious reservations about the future of the Program and given a year and some additional support ($100,000) to strengthen its leadership and produce a regional plan. The Region should also be informed that careful study will be made of the process by which the Region determines its allocation of funds and sets its proorain direction, and that medical leadership on Core staff is considered essential Committee con u e their discussion with the recommendation that both a strong message from the Director, Pl@iPS, regarding Commitlee's hopes and reservations about the Region and assistance from R@IPS staff accompany the feedback of their other concerns. The developmental component request as such was disapproved because of the weaknesses in the decision-malting structure. NOTE: There were five dissenting,-votes. ItMPS/CRB 4/211/71 DEPAR'I -.,ENT OF t-', LTH, EDLICA7rlO;'4, ;@@,!D WL-.1 FARE PUi3L)C H17ALT14 SERVICE HEALTI-I SERVICES A14D TAENTA'L- tiEAI-']'H ADMINiCI'RAT'.ON Dek., April 2, i971 Subjeci.. Short Summary of Susquehanna Valley PJIP Site VI-sit Findings, March 25, 1971 Directo Regional-led@tal Programs Service THROUGH. Acting Deputy Director Regional. Medical Programs Service The ,;-ite visit team consisted of: J. Warr&n Petry, Ph.D., Dean, School. of Health Related Professions State UniverF,,i-ty of New York at Buffalo Bland W. Cannon, M oD., Council member Manu Chatteriee, M.D., Coordinator, Maine Regional Medical Program Sarah J. Silsbee, Chief, Grants Review Branch, Pd@TS James Smith, Operations Officer, Regional Development Branch, RMPS Clyde Couch-aan, Regional Office Representative, DHEW Region III, RMPS Carol M. Lars6n, Allied Health Speci dlist, Continuing Education and Training, Branch, RMPS the ite visit was held on March 25 as A one-day meeting in Camp Hill, P&nnsvlvania. The visit resulted from Council.'s decision to defer action on the Regio@s request for additional funds including developmental funding. The Council felt that it could not make a determination of the Region s progress in decision-making, planning or priorities until an on-gite visit was made. Background This Region has had two site visit teams studying it. Both site visit reports indicate a concern about where the focus lies on d6cision-making, planning and priorities. Very early in its development, the Region developed A subarea organization with staff assigned to help area committees develop priorities in-- the categorical areas. All site visit teams have reported an unusual deareo of interest among the pro@ videts that Rrew out of this development. At the same time the site visitors noted a lack of overall regional- pl-anni.ng which.had the areas wor ing out of context of a regional plan. The 1970 site visit found at a council framework had been developed around the categorical areas And continuing education which was serving as a vehicle for regional planning in the categorical area. However, the overall. priorities of the Region and the goals for the program as a whole were still unclear. Both site visit teams reported a lack of understanding about the contri" b7.iti. of the grantee agency; the medical society, the Regional Advisory Group and the medical school to program development. Page 2 Director, RNPS Since this Region began, there has not been a physician or provider expertise on the core staff. The Council development resulted from recommendations of the first site visit team and last yeat's team recommended that a faculty member from the Hershey lqedical Center be added to the staff to provide a bridge to the provider community- The Region's proposed projects have seemed to be a series uP disparate activities unrelated to one another or to an overall.plan. The ap licati6n deferred by Council included two expensive co uter projects p MP dealing with EKG and EEG,techniques. The review process that forwards this type of activity at this point in time was of serious concern to the 1971 Site Visit Team. Findings of the 1971 Site Visit Tean,,: The site visitors came away wit ambivalent reactions to the Regional Medical Program in Susquehanna Valley. Qu6stio'ns remain regarding the effect of the grantee agency, the effect of the coinpletel lay core staff and the effect of the noia- y involvement of the medical school on the program.- In addition, the Regio al. Advisory Group itself does not seem to have a,clear program direction in mind. Despite this, the site visitors were impressed with the interest generated by providers in small communities that the Regional Medical Program could serve their needs in improving patient care. -These needs have been perceived in a categorical framework because the Region believes the original intention of Public Law 89-235 represented the parameters in which they could plan. The core staff has done a good job in promoting this interest. .The grantee agency, the medical society, 18 not providing leadership or domination to the program in a direct fashion. In fact, the representative of the board stated to the site visit team that the medical society had become the grantee by default. There had been some interest in having the Hershey Medical Center be the grantee but it was unable to take on the job. --The grantee organization takes its responsibilities for setting up the fiscal procedures and the staffing pattern very seriously, and has involved a management group to come in and lay out the organization staffing, the functions of the Regi6 al Advisory Group, the grantee and the core staff. This has @been carefully thought through and is quite clearly worked out. The core staff is completely lay and looks to Council members as their resource for provider expertise. The team was quite impressed with the amount of time and effort the Council members have given to.this a pect of the program. The Council chairmen as a group were young ysi6ians with very good qualifications in their individual fields but t ey worked as requested by the core staff. Page 3 Director, RNPS @'Furthermore, the council chairmen are involved primarily in vertical plannin in limited areas, not horizoiatAl latning in overall program. 9 p The team was impressed with what the core staff has accomplished while working under,the severe handicap of token support from the grantee and the RAG. The core staff simply does not have the composition - specifically, a physician - to demand commitment from the grantee, the medical tenter or the RAG. There was.some indication that the core staff does not feel the need for a@physician to serve in this capacity. Following on the 1970 site visit recommendations, representatives of UP the grantee organization (but not the coordinator) talked with Hershey Medical Center Dean about the assignment of-a faculty member half-time to the Regional Medical Program. The Dean was unable to provide the faculty time; however, core staff indicated that individual faculty members were participating in council activities, particularly in the Education and Manpoi@7er Council., During this site visit, the team requested from the Dean-a clear statement of commitment to the R@ from the Medical Center. The commitment was not forthcoming; instead the Dean aired his frustration about delays in faculty recruitment, lack of financial support from Pennsylvania State University, the parent institution, lack of clear authority to serve as the University agent for continuing education (at present Jefferson Medical College has the University contract for continuing education for physicians while'the University retains responsibility for continuing education for all Allied health personnel). n answer to direct questions, the Dean declared no concern about the medical society as grantee or about-the schools under representation on the RAG and lack of influence in the overall Program. Clearly, the Dean's immediate concerns preclude much thought about the Susquehanna Vall e P&[P. y The Regional Adviso,ty-Group has not been a positive sourc e of leadership or direction; kather, it has been reactive -@. to the grantee organization to area demands, to national review decisions.and to national.priorities as opposed to Public Law 89"239 priorities. Except for several members- at-large, the RAG membership is determined by area committees or org izatiorLs which make up the.coalition of interests in the PM . The council chairmen serve the RAG in a technical review capacity, but are not members. The team learned that the Regional Advisory Group was considering 9 severe cut-ba& in co-re funding, in order to fund several projects. The RAG apparently perceives tore expenditures as overhead and project expendi tures as "program.11 Thus, when informed by RNPS that the funds available would be only $499,513, or $24,313 more than the cu rr&nt coke budget, the RAG anted to cut the "overhead." The site visitors weke able to elicit s ff,iti6nt information About core activities which had resulted in program Page 4 Director, 'P@IPS -ts, that several P@ members were ,development, but not R@ proje.@ reassessing their evaluation of core worthiness. The,R.AC- i-7as.-to decide on new budget allocations on April 1. Recommendations of the Site Visit Team: 1. That RMPS@.Provide $100,000 additional funding to Susquehanna. Valley RMP with no stipulation as to how the funds should. be ut@i-lized. The RMPS.level does not take into consideration the fact that the Region's commitment included very little project funds. This Region is faced with an untenable funding situation imposed by the l@S decision. 2. That the Region be informed that national reviewers have serious reservations about its viability as a Regional Medital Prograt, the lack of cleat commitment to, or interest in,:an effective program by the grantee, the medical center and the FAG; the capacity of the Region to set priorities and to negotiate local area demands, as evidenced by the projects proposed.. 3. That the Region be informed that core staff is functioning well without much help from key groups. Its community participation and involvement are unique and impressive. These two strengths are responsibile for the additional funding recommended. 4. That the Region be informed that the national reviewers recommend ,additional funding at this time to give the Region a chance to chart its own@destiwy without dependence on national review actions, and that the national reviewers believe a physician on core staff would serve the Region:well. 5. That the Region be informed that careful study will be made of the Processes by which the Region determines its allocation@of funds and sets it program direction. J. Silsbee Chief ants Review Branch A Privileged Communication) SITE VISIT REPORT SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM March 25, 1971 SITE VISITORS -J. Warren Perry, Ph.D., Chairman, Dean, School of Health Related Professions, State University of New York at Buffalo, New York tiand W. Cannon, M.D., Council member, Memphis, Tennessee Manu Chatterjee, M.D., Program Coordinator, Maine Regional Medica Prbgrqm, Augusta, Maine REGIONAL MEDICAL PROGRAMS SERVICE STAFF Mrs. Sarah J. Silsbee, Chief, Grants Review Branch Mr. James Smith, Operations Officer, Regional Development Branch Mr. Clyde Couchman, Regional Office Repres&ntative I . Miss Carol M. Larson, Allied Health Specialist, Continuing Education Branch SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM Richard,B. McKenzie, Director James E. Smith, Assistant Director for Program Development John D. Hoffman, Assistant Director for Technical Services Richard E. Wright, Field Service'Coordinator Franklin E. Williams, Educational Activities Coordinator James Patterson, Grants Management Coordinator Robert M. Fisher, Communications Coordinator Ellsworth R. Browneller, M.D., Director of Governmental Affairs, Geisinger Medical Center, former Secretary of Health for the Commonwealth of Pennsylvania, Chairman of the RAG. George C. Williams, ESQ3- Wellsboro attorney, Vice-Chairman of RAG and Chairman of its Planning Committee, Community hospital board member John F. Rineman, Executive Director and-Treasurer of the Pennsylvania Medical Society, grantee for the-SVRMP,, RAG Treasurer John H. Harris, Sr., M.D., Harrisburg radiologist, RAG Executive Committee and Chairman of the Special Board Committe6.for SVRNP of the Pennsylvania Medical Society Aaron H. Claster, Lock Haven businessman, RAG Executive Committee, a community hospital board member, active in CHP activities J. Mostyn Davis, M.D., Shamokin family practitioner, RAG Executive Committee, the Northeastern Area Executive Committee James C. Kirk, Administrator of Pottsville-Hospital, RAG Executive Committee, Northeastern Area Executive Committee, Past President of the Hospital Association of Pennsylvania SUSQUEHANNA VALLEY RNP RM 00059 Charles A. 'Laubach, Jr., M.D., Chief of the Cardiovascular and Pulmonary Disease Section, Geisinger Medical Center, Chairman of the SVREP Council on Heart Disease, active in the Northeastern Area Committee, President of the Pennsylvania Heart Association Bernard F. Carr, Superintendent of Altoona Hospital, RAG Planning Committee and the Appalachian-Highland Area Committee, President- elect of the Hospital Association of Pennsylvania William.Sc@irmer, Assistant Administrator, Harrisburg Hospital, Treasurer of the Board of the Hamilton Health Center project, now funded from 314(e) funds George T. Harrell, Jr., M.D., Dean-and Director, The Milton S. Hershey Medical Center, The Pennsylvania State University, Member of the RAG, and of the Special Board Committee for SVRMP of the Pennsylvania Medical Society William H. Jeffreys, M.D., Director of the Department of Neurology and Psychiatry, Geisinger Medical Center, Chairman of the SVRNP Council on Stroke - Roland A. Loeb, M.D., Lancaster cytologist, Chairman of the SVRMP Council on Cancer David D. Pearson, Ph.D., Professor of Biology, Bucknell University, Chairman of the Northeastern Area Committee. Nikitas J. Zervanos, M.D., Director of Community Medicine, Lancaster General Hospital, Member of the SVREP Council on Facilities and Services, project director of the proposed Family and Community Medicine Program in present application. DRAFT (A Privileged Coumunication) SITE VISIT REPORT SUSQUEHANNA VALLEY REGIONAL MEDICAL PROGRAM March 25, 1971 Structure of Site Visit This was a one-day meeting, designed to assess the Region's progress in setting goals and priorities, in resolving differing expectations among the grantee organization, the RAG, the area committees and the core staff, and in enlisting involvement from the Hershey Medical Center. The site visit agenda, as originally developed by the coordinator, called for an early session with the core staff alone, followed by a long session with about seventeen representatives from the grantee organization, the RAG, area committees. the medical center and Councils. RNPS staff asked that the larger group be divided into functional lines for part of the day; instead, smaller groups of cross-8ectional representatives were scheduled for the morning and afternoon sessions. The PAG chairman and vice-chairman, as well'as individual members from Councils and area committees-were present during both sessions. The Hershey Medical Center dean was present for a short time during the afternoon, but was unable to stay for the feedback session at the end of the day. The feedback session was taped for later distribution. With only one day, the site visit team wasted no time in getting directly to the point of their visit; so with the cross-representative participation from the Region, the team's persistent probing reached all levels of planning and decision-making at the same time. Initially startled and defensive by the direct line of questioning, th@ participants then opened up w'lth frank, thoughtful responses. The Issues as Posed by the Site Visit Team "What has your Regional Medical Program accomplished and what does it hope to accomplish in the next few years? You seem to have amassed the necessary ingredients for a Regional Medical Program, but someth g is missing and we can't see the Program emerging. Your Region has several unique features. You have the State Medical Society as the grantee,-is this a problem in your development. Your Region has a core staff devoid of 'provider' expertise. What have you done to fill that gap? Your RAG seems-to be a coalition of representatives from organizations, is this a factor? Your medical center does not seem to be involved, except for the Dean's membership on the RAG; has this impeded your progress? We realize there are reasons for these unique features and we accept them. But show us what you have done, where you want thisprogram to go, and why you feel you need additional RNP dollars from the limited funds available." Later, to the Medical Center Dean: "Why isn't the.Medical Center more involved in the PM, for example, in continuing education? Is it the grantee, is lt'the lack of representation on the RAG ,is it the core staff?" SUSQUEHANNA VALLEY RM 00059 Immediate Responses to the Issues From the grantee representative s: The State Medical Society became the grantee by default; the Hershey Medical Center couldn't take on the job. ------ We have employed management consultants to help us map out the'organization, the core salary structure, the functions of the RAG, representation on the RAG, composition of the Councils and the Planning Committee. We have followed every suggestion made by national reviewers; last year we asked the Hershey Medical Center to appoint a faculty member half-time to serve on the core staff, as suggested by the site visit team, but the Dean was unable to assign any one. From RAG representatives: -When is Washington going to give us some clear signals on what it wants. Originally, we planned to make coronary care improvement our major priority, but the National Advisory Council said we had to limit our funding to a few pilot areas. We need project money. The Area Committees, cited previously as our strength, are showing waning interest because Washington's changing signals preclude funding of their project proposals. From the core staff: We have been succe'ssful in getting help from individual members of the Hershey Medical Center faculty, in planning the physicians assistant forum, and in the Manpower and Education Council. We get medical guidance from the Council chairmen. We have also worked in non-categorical program areas, were the resources used in developing the Hamilton Health Center proposals which has been recently funded by 314(e) funds. From the Council representatives: We have developed plans and priorities in the categorical disease areas. With a unique combination of specialists from the clinics and hospitals and area representatives, we have developed feasibility studies prior to project proposals. In the heart area, we have developed an evaluation,approach that involves not only the hospitals which received RNP funds but those that hoped to, but had to find their own financial resources. From the Area Representatives: Core staff have helped us develop project proposals. We need money for their implementation.. From the Medical Center Dean: The State Medical Society has always supported the medical center; we couldn't develop the center and serve as the grantee for the Regional Medical Program simultaneously, although later, we may be interested. We are using RNP funds for the library project which provides literature searches and reprints to physicians, the service seems well accepted. We may be able to develop some cassettes for educational purposes. We are glad to make auditorium.facilities available for RMP activities. My faculty is spread too thin now and could not serve on the RAG, perhaps later. I have no authority from Pennsylvania State University to develop a continuing education program.for physicians, Jefferson-Medical College has a contract for that, the University has responsibility in the allied health education field. Fatulty recruitment is behind schedule; financial support from the State -University has never materialized. SUSQUEHANNA VALLEY RM 00059 General Findings of the Site Visit Team 1. The Region is making some progress toward developing its goals, objectives and priorities, although it has a long way to go before they are clearly stated, specific, related to national goals and generally-understood and accepted throughout the Region. The RAG's new Planning Committee is tackling the problem with core staff assistance, and with subarea representation built into the RAG, the Planning Group's deliberations could be disseminated throughout the Region. The categorical Councils and the Councils on Manpower and Education and Facilities and Services are other possible.strengths, composed as they are of young specialists and area practitioners; however,, the Council representatives need to be utilized in broader program planning; at the present time, their skills are limited to vertical planning in a specific area. With this Region's strong community involvement of private practioners interested in patient care, the transition from categorical emphasis to a more comprehensive approach may not be as difficult a s in Regions which have not reached the physician at the community level. The subarea categorical committees may be a barrier to this transition. The team heard evidence regarding one areals cancer planning that left grave doubts about the present method of decision-making. One area, having decided to develop a mobil& cancer detection proposal for some unclear reasons, was now regionalizing the plan, after consultation with the staff and the Cancer Council. The use of data as an aid to planning objectives and priorities has not been recognized, although cote staff is seeking consultation from the medical center for'some data studies. 2. The organizational effectiveness is spotty. -The coordinator and the core staff have been performing herculean tasks with very little positive direction or support. The team was relatively effective in demonstrating that core staff activities had resulted in program development. The RAG and area committees were apparently measuring program progress by project funding and considering the core staff funds as "overhead." However, the coordinator does not have the background, experience or stature to command the commitment of the grantee organization, the RAG or the medical center. The cote staff needs tolave medical liaison to carry on these functions. The site visit team felt that several of the Council chairmen could serve in this capacity, if given the responsibility and authority. The tore staff also lacks representation from the allied health professions. In fact, nursing and other allied health influences are scarce throughout the various levels of decision-making. -T-he grantee organization has set up adequate procedures for managing the funds, providing staff services, etc. Throughthe help of a management SUSQUEHANNA VALLEY RMP -4- RM 00059 consultant fund, the functions of the grantee and the RAG have been carefully delineated. The grantee has not provided domination or direction of the program; nor, has it sought leadership from elsewhere. The RAG has not provided leadership or direction; rather, it has been reactive - to-the grantee organization, to area demands, to national review decisions and to national priorities as opposed to Public Law 89-239 priorities. Except for several members-at-large, the RAG membership is determined by area committees or organizations which make up the coalition of interests in the RNP.. The council chairmen serve the RAG in a technical review capacity, but are not members. The subregionalization efforts have been successful in enlisting local representatives in project planning. In the absence of regional goals, the subarea demands have been hard@to arbitrate. Also, the subregional representatives seemed relatively unaware of PM fiscal constraints on-the national level, the RAG reflects this same lack of communication. Nevertheless, the subregional development of this Program is a strength that can be utilized in program development. 3. The involvement of regional resources is spotty. The medical profession is involved, at all levels.; The nursing and allied health professions are involved in projects and subarea planning, not at the regional level. The community hospitals are involved to some extent, board members as well as physicians. The voluntary and official health agencies are involved on the RAG and in the subareas to a certain extent. The medical school is little involved. This is a real problem. The CHP development in this Region is just underway, and members of the RAG and Councils expressed-concern that their staffs would duplicate REP core staff. The team suggested that rather await signals from Washington, efforts be made locally to coordinate, complement or assimilate the staff efforts of the two organizations. The team did not get any feeling for involvement of consumers or political representatives. The RAG chairman was formerly State Commissioner of Health. 4. As noted before, the Region has not depended on a data base for planning or evaluation. 5. Core staff has done as well, or better than could be expected. They have developed a health center which is funded through 314(e) funds. They have developed feasibility studies with the help of Council members, and they have looked for other sources of funding for ongoing activities. Neither the operational projects funded nor the ones proposed are exciting.' The coronary training projects at Geisinger and Altoona would appear to be good investments and needed. An evaluation study in coronary care has evolved to encompass many hospitals throughout the Region. The computerized EKG and EEG project pro'osals are typical examples of this p -Region's lack of understanding about national funding priorities. SUSQUEHANNA VALLEY RNP 5- RM 00059 6. It is not surprising that evaluation has barely begun, but it has been started in the coronary care field. Recommendations of the Site Visit Team 1. That RNPS provide $100,000 additional funding to Susquehanna Valley RNP with no stipulation as to how the funds should be utilized. The RMPS level does not take into consideration the fact that the Region's commitment included very l'ittle project funds. This Region is faced with an untenable funding situation imposed by the PMS decision. 2. That the Region be informed-that national reviewers have serious reservations about its viability as a Regional Medical Program: the lack of clear commitment to, or interest in, an effective program by the grantee, the medical center and the RAG; the capacity of the Region to set priorities and to negotiate local Area demands, as evidenced by the projects proposed. 3. That the Region be informed of the necessity to have a physician serve a liaison leadership-role with the medical society, the medical center and RAG. 4. That the Region be informed that core staff is functioning well without much help from key groups. Its community participation and involvement are unique and impressive. These two strengths are responsible for the additional funding recommended. 5. That the Region be informed that the national reviewers recommend additional funding at this time to give the Region a chance to chart its own destiny without dependence on national review actions. 6. That the Region be informed that careful study will be made of the processes by which the Region determines its allocation of funds and sets it program direction. RMPS/GRB REGIONAL MEDICAL PROGRAMS SERVICE SUMMARY OF AN OPERATIONAL SUPPLEMENT GRANT APPLICATION ( A Privileged Co inication) TRI-STATE REGIONAL 14EDICAL PROGRAM RM 00062 5/71 Medical Care and Education Foundation Inc. April 1971 Review Co ttee Two Center Plaza, Room 400 Boston, Massachusetts 02108 Requested 01 02 03 Program Period 6/l/71-5/31/72 6/l/72-5/31/73 6/l/73-5/31/74 Total Direct Costs $463,292 $368,595 $381,513 $1,213,400 Indirect Costs -0- -0- -0- -0- Total $463,292 $368,595 $381,513 $1,213,400 History: In November 1970, Council reviewed the Region's total program and its Triennial application, and concurred with the favorable report of an October 1970 site visit. Council concluded that the Region had devel- oped the capacity for self-determination; had set realistic, timely and accep- table goals and objectives; and had adequate docision-making processes as well as management and evaluation capabilities. Although the Council approved level of funding for the Region's Triennial application during the next three years is $2,261,685, $2,015,591 and $2,043,035, RMPS fiscal restraints will only permit $1,722,474 funding and commitment for these periods. Present Avplication:. The application contains one kidney disease project, which is also to be reviewed by an RMPS Ad Hoc Panel on Renal Disease on April 14-15, 1970. Project #1- New England Regional Kidney Program Submitted by the Tri-State nO, this three-year project proposes to establish the New England Regional Kidney,Program (NERKPRO) to assure that no person will die of kidney failure because of a lack of funds, or lack of a plan to be treated on knowledge of what is available. The proposal is in three parts. Part I - A general introduction documenting need and resources. As a result of a recent series of meetings sponsored by the Tri-State RMP, a group of leading nephrologists and other interested persons joined to develop NERKPRO. (See Apendix X: Minutes of NERKPRO Meetings - Durham, New Hampshire; pp..,107-138). There is general agreement that NERKPRO must meet several basic TRI-STATE RIMP 2 - RM 00062 5/71 needs: 1) a present need for more cadaver organs; 2) the need for larger pools of prospective donors and prospective recipients; 3) professional training prog.rams are needed for physicians, nurses and technicians in the fields of hemodialysis, organ harvesting, organ transplantation, and tissue typing. Boston and New Raven are major transplant centers, and others are in the pro- cess of being developed in the region. Transplant centers are also centers for professional education and training in kidney disease. In addition, Boston is the location of the Interhospital Organ Bank (IOB), a clearinghouse for matching cadaver organs with potential recipients. NEW ENGIAND FACILITIES FOR END-STAGE KIDNEY DISEASE .Central Support: Interhospital Organ Bank Massachusetts General Hospital .Boston, Massachusetts Dialysis Units: Boston Maine Boston City Hospital Maine Medical Center, Portland Lemuel Shattuck Hospital Massachusetts General Hospital Connecticut Peter Bent Brigham Hospital University Hospital Yale-New Haven Hosp., New Haven Veterans Administration Hospital Hartford Hospital, Hartford St. Elizabeth's Hospital Veterans Administration Hosp., Other Massachusetts West Haven Bridgeport Hospital, Bridgeport St. vincent's Boap., Bridgeport Babcock Street Uniti Brookline Danbury Hospital, Danbury Lakeville Hospital, Lakeville Waterbury Hospital, Waterbury North Shore Regional Dialysis Unit., Beverly Hospital of St. Raphael, Springfield Hospital, Springfield New Raven St. Joseph's Hospital, Lowell Worcester Memorial Hospital, Worcester Transplant Centers: Operative Boston City Hospital Harvard and B.U. Services Massachusetts General Hospital Peter Bent Brigham Hospital University Hospital Vet6ran Administration Hospital Yale-New Haven Hospital TRI-STATE RMP - 3 - RM 00062 5/71 Part 2 - An application for funds to finance regionalization of the operations of the Inter-hospital Orpan Bank. Reoism-ni'zliti,o-u, -6f,--,-the IOB is a major component in the development of the, NERKMO program. The 'bank", a non-profit organization, is actually a center for information, expertise, the performance of technical functions (tissue t"ing), and administration,of organ allocation. Major functions of the IOB include: 1) Education and information efforts, primarily with physicians, to encourage the "harvesting" of cadaver organs suitable for transplantation; 2) Operation of a central office: (a) serving as a communication center through which information an organ availability, suitability, and demand can be ex- charged, (b) maintenance of a central registry of persons awaiting transplant and of potential donors, and (c) administration of a system forcT41td-fmiWin-g-the: allocation of cadaver organs available among the patients awaiting transplant, using information determined by central serotyping laboratory; and 3) operation of a central serotyping laboratory. The IOB is currently supported under a contract from the Kidney Disease Contro Program, RMPS, and funds from the Massachusetts Department of Health. The IOS has begun chargimgfees for serot"ing, and is negotiating with third party payers to make these and related costs reimbursable. The IOB is in the process of expanding the field of operation to serve the entire New England region. Financial assistance is needed to support the IOB during this transitional stage when: