division of
regional
medical
programs

A communication device
designed to speed

the exchange of news,
information and data on
Regional Medical Programs

MAGAZINE FEATURE - Regional Medical Programs Today
And In Historical Perspective

September 29, 1969 - Vol.3, No. 27

 

As a public service the System Development Corporation
of Santa Monica, California, has devoted its entire
September, 1969 issue to Regional Medical Programs, and
a copy is attached for your review.

The lead article tells the story of the development
of Regional Medical Programs in historical perspective, and
also brings their current activities and problems clearly
into focus.

The remaining two articles detail the development and
some of the on-going activities of the Tennessee Mid-South

and Mountain States Regional Medical Programs.

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service © Health Services and Mental Health Administration © Bethesda, Maryland 20014
 

SOC MAGAZINE

 

 

 

 

 

 
September 1969
Volume 12 Number 8

SDC MAGAZINE

SYSTEM DEVELOPMENT CORPORATION
2500 Colorado Avenue
Santa Monica, California 90406

 

Editor: Virginia Carabillo
Managing Editor: Russell Paquette
Production Manager: Mary Lou Dossett
Editorial Staff: Harry Bain
Peggy Dobrusky
Karen Profet
Art Direction: Allan Walker
Photography: Allan Walker

 

 

CONTENTS
RMP: & for Home Rule in Health Care

Page Three
Tennessee/Mid-South—Contrast,
Cooperation and Quality

Page Thirteen
Mountain States—A Case Study in
Grass-Roots Planning

Page Twenty-three
OF NOTE

Page Thirty-two

 

System Development Corporation, 1969.
Permission to reprint articles in this
publication may be obtained by writing
to the editor.

 

Published by
Corporate Communications
Manager: Donald Ramsay
Assistant Manager: Virginia Carabillo
Head of Corporate Publications:
Russell Paquette

 
 

A 12-year-old 4-H Club member begins a pattern of
life in rural America much like his father before
him, while across the country in a large urban area
a Negro boy and his brother play on a run-down city
street. They share little in common except that they
are growing up with a better chance of beating the
odds on heart disease, cancer and stroke than their
parents. Part of the story is a new federal program
that asks us grown-ups to plan and then carry out
our own campaigns against these killer diseases. This
edition of SDC Magazine describes that program.

  

SDC MAGAZINE ® 1

 
LE

oe oe tl
MCD A

i
>
LJ
Ww
°
a

 
Hal Johnson lives in Roseville, Cali-
fornia. To get there you drive north
from Sacramento along U.S. Interstate
Highway 80. Usually the trip takes
about 20 minutes. There’s a lot more
traffic now than there used to be, and
the once vacant grasslands along the
way are sprouting tract houses as
Sacramento reaches out for more bed-
room space. Roseville, an historic Old
West railhead, is being sucked into
the metropolis.

Since Hal Johnson began practicing
medicine for a living nine years ago,

 

AMP

for Home Rule in
Health Care

by HARRY BAIN

he has come to know quite a few of
Roseville’s 20,000 citizens. He sees pa-
tients every day in his office on Oak
Ridge Drive or at the Roseville Com-
munity Hospital where he’s a member
of the staff. Johnson and his five part-
ners in group practice are members of
a fast disappearing physician minority
—the general practitioners.

This doesn’t seem to bother John-
son. He takes pride in what he’s doing.
There’s no trace of the defensiveness
you sometimes sense among GPs in
this age of increasing medical special-

 

 

ization. But if you’re getting some
mellow notion that he’s a storybook
country doctor, you’re in the wrong
town. The word for Hal Johnson is
Mod.

He swings in a medical and scien-
tific sense because he works at it. He
reads the right journals regularly—
and learns from them. He makes the
time to get to two or three continuing
education seminars every year to keep
up-to-date. You'll usually find him
draped across a chair at classes offered
by the local hospital.

SDC MAGAZINE © 3

 
 

As a member of the Roseville City
Council and the local schoo! board, he
also swings in the community involve-
ment sense. He’s the councilman with
the crewcut gray hair who makes it to
all the meetings and has a reputation
for being well up on issues that con-
cern the community. Watching him
hold up his end during a clash of
views on local taxes, you’d have to
concede that for a stripling (39} he’s
politically hip. This applies in medical
politics, too, where Johnson has been

 

a president of his county medical
society.

In medicine, as in city government,
Johnson likes to describe himself as a
progressive conservative. He says he
welcomes change so long as it carries
along the positive achievements of
the past and is based on politically
workable and economically sound
assumptions.

Like many of his colleagues in or-
ganized medicine, Hal Johnson has
harbored deep suspicions about gov-

 

ernment medical programs, especially
those that have emanated from the
federal level. He has been apprehen-
sive that they might eventually destroy
the personal doctor-patient relation-
ship or undermine the private practice
of medicine. Private medicine, he is
convinced, is both a wellspring of
medical excellence and a powerful
witness to individual freedom.
Knowing how Hal Johnson feels on
this score makes what he has been
doing the past 15 months all the more

 

 

=

 

 

Rae Be MBE a a

 

 

 

z

ae Bt FE NE

Ra A cat ais

;

4 8 SDC MAGAZINE

 

 
remarkable. Since July 1968, he has
been helping set up a federally spon-
sored health program in Roseville. He
believes it will benefit his own pa-
tients and those of other Roseville
physicians. He fought to get it. It is
being paid for under Public Law 8g-
239, passed in 1965 and amended last
year by P.L. 90-574. Johnson, and thou-
sands of other physicians who have
had their thinking changed by this law,
call it Regional Medical Programs, or
simply, RMP.

 

 

 

 

 

To capture the support of doctors
like Hal Johnson, RMP has to be a
special program, It is. It is the first
federal health program to insist on
grass-roots leadership in the decision-
making process. Regional advisory
councils call the shots, and the law is
explicit that the councils be represent-
ative of all elements of the health com-
munity, including consumers. There’s
a great deal more about RMP that is
different from past government efforts,
but first let’s talk about how the law
came into being.

 

CONGRESSIONAL
RESPONSE

Looked at historically, RMP is dollars-
and-cents Congressional recognition
that there is much more than short-
ages of physicians, other health spe-
cialists and hospital beds to what
Presidents Johnson and Nixon have
called the health crisis. Shortages may
grab the most space in our news media,
but leaders in the health sciences are
beginning to talk more and more
about a breakdown in our system for
delivering health care.

This was essentially the message of
the President's Commission on Heart
Disease, Cancer and Stroke when it
submitted its report in December 1964.
Chaired by famed Houston heart sur-
geon, Dr. Michael E. De Bakey, the
Commission pointed with pride to the
great strides made in medical research
and then viewed with alarm the slow-
ness with which the results of this
research were being made available
to patients throughout the nation,

The following summer, Congress
acted to improve the delivery of medi-
cal knowledge by passing the Heart,
Cancer and Stroke Amendments to
the Public Health Service Act. This
created Regional Medical Programs
‘to afford the medical profession and
the medical institutions of the nation,
through...cooperative arrangements,

 

 

the opportunity of making available to
their patients the latest advances in
the diagnosis of heart disease, cancer,
stroke, and related illnesses.” The
diseases selected were appropriate
targets. As a group, they are our most
lethal killers, accounting for 71 of
every 100 deaths in America.

The Commission study, now known
as the De Bakey Report, had called for
the establishment of “centers of ex-
cellence’ for the dissemination and
demonstration of new knowledge.
This concept smacked of too much
centralism for the medical profession
to swallow and was finally scrapped
by Congress in favor of “cooperative
arrangements” among medical schools,
hospitals, medical associations and re-
lated elements of the health care sys-
tem. Such cooperative arrangements
are one of the most unusual RMP
features.

Congress went even further toward
allaying the fears of many physicians
when it declared that RMP was to
accomplish its ends “without interfer-
ing with the patterns, or the methods
of financing, of patient care or profes-
sional practice, or with the adminis-
tration of hospitals....”’ This guarantee,
along with the local autonomy dele-
gated to individual regional advisory
councils, in large measure explains
why practicing physicians like Hal
Johnson have greeted RMP so warmly.

 

DOWN TO THE
GRASS ROOTS

 

Physicians have been joined in their
enthusiasm by nurses, hospital admin-
istrators, medical educators and repre-
sentatives of voluntary health organi-
zations, to name the most prominent
professionals whose membership is
required, along with that of physicians,
on the advisory councils. Congress
also made it clear that it expected to
see some average citizens among the
council members.

SDC MAGAZINE ® 5

 
 

In drafting P.L. 89-239, the legisla-
tors recognized two distinct but re-
lated phases in getting RMP into busi-
ness—planning and operation. In the
first, the regional advisory council
draws on all the resources in its area
to identify what is needed to deal
with the problems related to heart
disease, cancer and stroke as they
exist in its own region.

Once needs are known, the council
must get down to the task of setting
priorities among competing needs and
hammering out the cooperative arrange-
ments required to develop remedial
measures. This effort is supported by
planning funds granted under the Law
after approval of the National Advi-
sory Council of the Division of Re-
gional Medical Programs. DRMP is the
capping agency that administers the
RMP program for the Department of
Health, Education and Welfare. Plan-
ning grant approval hinges on accept-
ance of the region’s organizational
plan and method for proceeding.

At this point, the region is ready to
enter the operational phase, which is
another way of saying it is ready to
send in an initial grant proposal to
the Division of Regional Medical Pro-
grams. As required by the Law, DRMP
won't give out money for patient treat-
ment except where such funds are to
be used for “demonstration” purposes
only, and not to set up permanent care
and treatment programs. There is also
no provision in the Law for money for
construction.

Neither Congress nor the division
has laid down any hard-and-fast time-
table for moving from planning to
operation. It hasn’t been unusual for
the two to proceed concurrently. A
few RMP grantees—North Carolina,
Kansas and Missouri, for example—
had a long history of regional coopera-
tion and planning and were able to
move quickly to full operational status.
Others have found it necessary to
move more slowly.

6 * SDC MAGAZINE

 

 

 

DR. ALFRED M. POPMA

 

 

 

The real decision on the timeliness
and acceptability of operational activi-
ties lies with the division as expressed
by the recommendations of the Re-
view Committee and the National Ad-
visory Council on RMP. The latter is
a body of distinguished medical prac-
titioners and administrators who re-
view and make recommendations on
all regional proposals, again as re-
quired by law.

Dr. Alfred M. Popma, a Boise, Idaho,
radiologist for more than a quarter-
century before turning his full time
attention to RMP, knows all the angles
in the review process. He is one of the
16 members of the National Advisory
Council, has served on the Review
Committee and keeps his local per-
spective sharpened as program direc-
tor of the Mountain States RMP.

“At council review sessions, we are
insisting more than ever on excel-
lence,” Popma says. “The successful
operational grant must reflect the kind
of solid region-wide planning that will
enhance and improve patient care in

 

heart disease, cancer and stroke. The
council makes its recommendations
to the Surgeon General who author-
izes DRMP to fund approved propos-
als. So far, none of our findings has
been reversed, but recently some have
been deferred because of a lack of
funds.”

Perhaps the most important factor
in council deliberations is the quality
and durability of the voluntary cooper-
ative arrangements. Says Paul Ward,
coordinator of the California RMP,
“All operational proposals are based
on voluntary cooperative arrange-
ments. It’s the term we’re stuck with.
What does it mean? Simply plain old
verbal agreements between given
people to do given things, provided
they can get the resources from one
place or another.” Once plugged into
a grant proposal and approved, how-
ever, these verbal agreements take on
all the legal force of a formal contract.

In form, then, RMP goes well be-
yond encouraging local participation.
It demands it. Moreover, the tactic of
local control has been strengthened
through the philosophies of Drs.
Robert Q. Marston and Stanley W.
Olson, the two physicians who have
served as directors of DRMP. (Mar-
ston moved up in 1968 to become
the first administrator of the newly
created Health Services and Mental
Health Administration and subse-
quently became director of the Na-
tional Institutes of Health.) Both have
employed the division more along the
lines of a flexible staff resource than
as a heavy-handed federal director
and enforcer. In keeping with this atti-
tude, the Guidelines put out by DRMP
run but 32 pages.

Refuting the notion held by some
that RMP is the beginning of a na-
tional blueprint for dictating stand-
ards of medical care, Dr. Olson has
said, “Even if we knew enough to
draw such blueprints—which we do
not—this method of procedure is so

 
 

 

PAUL WARD

 

DR. MARC J. MUSSER

 

 

foreign to the American tradition that
it would fail if for no other reason
than lack of acceptance.

“What in fact is intended is that
planning shall be accomplished com-
munity by community, neighborhood
by neighborhood, hospital by hospital,
and doctor by doctor, not for the con-
sumer but with him.... Regional
Medical Programs, though federally
supported, are intended to strengthen
voluntary institutions and organiza-
tions of our country in their effort to
develop local resources to meet local
needs.” Olson learned this lesson on
the firing line. Before coming to Wash-
ington, he was coordinator of the
Tennessee/Mid-South RMP.

 

A LEARNING PROCESS

The idea that local communities
should guide their own destinies has
caught hold in a number of recently
enacted federal programs. Says Irving
Lewis, deputy director of the Health
Services and Mental Health Adminis-

 

 

tration, within which DRMP now oper-
ates, “We have tried to move more
and more decision making out into the
field, recognizing that coordination of
federal action cannot be accomplished
in Washington alone....Moving the
point of decision to the community,
we find there is no one best way of
doing things.”

Lewis must have been listening in
at some of the meetings in the 55 RMP
regions funded since passage of P.L.
89-239. Observers have been struck
by the innovation and differentiation
of approach that have distinguished
the groups as they moved to solve
their own health problems. Original-
ity in this case is no accident. It is as
integral a part of the RMP fabric as
local initiative.

Listen once more to Dr. Olson: “A
Regional Medical Program requires a
wholeness that cannot be achieved by
an aggregation of loosely related proj-
ects. It fosters innovation and change.
Change is constantly taking place, and
we can no longer accept at any stage

 

in our development the belief that we
have arrived.”

Physicians, hospitals, nurses, lay-
men and the rest have found it any-
thing but simple to live up to this kind
of demand. To begin with, they aren't
used to sitting down together to re-
solve their differences and plan a med-
ical future for an entire geographic
region.

In this vein, RMP signals a new de-
parture in the way decisions are made
in medicine and the health sciences.
Dr. Marc J. Musser, executive coordi-
nator of the North Carolina RMP, says,
“For the first time in the history of our
country, the health professionals and
health interests are joining together
to make our health care system more
cohesive and effective, not by legisla-
tion or with large sums of money, but
by involvement of the right people,
communications, good judgment and
a challenge to local initiative,”

California’s Paul Ward goes even
further: “This is a new role for the
majority of our institutions and one
that is not fully understood or ac-
cepted. Involving outside community
forces in planning is difficult enough
let alone entering into operational
projects that give responsibility to
those outside the institution.”

Adjusting prerogatives, adjudicating
local differences and coming up with
projects that embody: both medical
excellence and regional benefit have
caused the planning process to move
deliberately in most of the regions.
Consequently, there has been some
impatience both within the programs
and in Congress. The latter, always
strongly in support of RMP, has had
difficulty understanding why the re-
gions as a whole haven’t spent all the
money that has been appropriated.

RMP has had carry-overs of $22 mil-
lion from Fiscal Year 1966, $38 million
from FY 1967, $36 million from FY
1968 and $20 million from FY 1969.
From 1966 to 1968, the fact was that

SDC MAGAZINE ® 7

re IR TNL
there was an insistence on quality
and compliance with the Law, an in-
sistence that left some funds unobli-
gated as indicated by the carry-overs.
However, the most recent carry-over
of $20 million from 1969 to 1970 was
an administrative decision of HEW
and not the result of a shortage of
worthwhile projects. The fact remains
that at the end of FY 1969 (June 30)
there were some $25 million worth of
‘approved but unfunded projects.

In a March 1968 appearance before
the House Subcommittee on Public
Health and Welfare, Dr. Michael De
Bakey anticipated, this development.
“There have been times when I have
been guilty of impatience,” he ad-
mitted, “but the fact is that this pro-
gram has developed, I think, at a nor-
mal pace and in a very sound way.”

He pointed out that the planning
phase of RMP had stressed the design,
not the implementation, of health pro-
grams. This resulted in smaller ex-
penditures than were projected in the
beginning, but De Bakey emphasized
that regional planning efforts were
about to pay off in more expensive
operational programs that would re
quire close to $300 million by 1971.
He further suggested that Congress
“contemplate authorization levels of
some $500 million” by 1973 to main-
tain standards and momentum in the
program.

 

AN EMERGING PATTERN

Through Fiscal Year 1969, the 55 re-
gions had received some $145 million
in beth planning and operational
grants. In part, this paid the freight
for the nearly 2500 paid staff mem-
bers (47 percent physicians) in the
programs. It did not reflect the enor-
mous volunteer efforts of the nearly
10,000 private individuals, professional
and lay, who man the regional and
national advisory councils and serve
on various subcommittees, task forces
and local action groups.

 

8 = SDC MAGAZINE

 

Active RMPs now blanket the Con-
tinental United States and reach be-
yond to take in Alaska, Puerto Rico
and Hawaii, the latter grant including
Guam, American Samoa and Micro-
nesia. In land area, the regions range
from Washington-Alaska to Washing-
ton, D.C. California leads in popula-
tion with nearly 20 million; Northern
New England, headquartered in Ver-
mont, has but 425,000. All Americans
now live within at least one RMP area.
Because of regional overlapping, some
live in as many as three.

Some states, like New York with
five and Ohio with four, have set up
multiple regions within their bounda-
ties. The opposite has happened in
the wide open spaces of the West
where the Western Interstate Commis-
sion for Higher Education administers
a program that takes in four states
and overlaps portions of four others
that have their own RMP activities.
California, in turn, is a single region
but has organized itself into “areas”
defined by the medical service areas
of the state’s eight medical schools.

Of the 55 organizations that have
fiscal responsibility for the programs,
25 are medical colleges or university
medical centers. Seven others are uni-
versities, while the remaining grants
are split among 17 specially chartered
foundations, commissions and associ-
ations, four state medical societies,
one advisory council and one state
agency.

Medical school involvement in RMP
is written into the Act, since the medi-
cal colleges are at once a prime locus
of new knowledge through research
and because of their tradition as a
vehicle for disseminating such knowl-
edge through established extension
teaching activities in their own medi-
cal service areas. From the outset
Congress intended that RMP have
heavy educational emphasis, and it is
something of an understatement to
say that the most popular and well
supported thrust of RMP among doc-

 

tors and allied health personnel has
been in the direction of continuing
education courses.

In fact, Dr. Dwight Wilbur, immedi-
ate past president of the American
Medical Association and a staunch
RMP supporter, has said: “These [RMP]
programs should be primarily educa-
tional, for the better educated physi-
cians are, the higher the quality of
medical care they can render....Facili-
ties and financing are important, but
of prime importance is the widespread
availability of high quality medical
care. The key to this is more and
better education of practicing physi-
cians.” Small wonder the regions
maintain close relations with medical
colleges in their jurisdictions, or that
operational grants to date have been
notable for their innovative ap-
proaches to providing educational pro-
grams across a wide range of medical
and health specialties.

Few, if any, would disagree alto-
gether with Dr. Wilbur’s support of
continuing education, but there are
many who question that such pro-
grams should be the dominant theme
in RMP. Dr. H. Jack Geiger speaks for
many of these when he argues that
RMP should devote much greater at-
tention to the total health problems
of the urban and rural poor.

Now acting chairman of the depart-
ment of preventive medicine at Tufts
University School of Medicine, Dr.
Geiger holds that the categorical RMP
emphasis on heart disease, cancer and
stroke is too narrow and should be
broadened to include not only all
disease problems that confront the
poor, but also such pressing extra-
medical issues as poverty, discrimina-
tion, lack of education and unsanitary
inner city and rural housing.

Differences of opinion like these
don't intimidate Dr. Olson and his
staff at DRMP. They call theirs a liv-
ing program in the sense that they
expect to see it change and grow as
conditions change and new health pri-

 
orities emerge. They’ve already seen
the categorical emphasis expanded
somewhat through greater attention
to kidney, respiratory, diabetic and
other diseases that fall under the “re-
lated illnesses” portion of P.L. 90-574,
and they fought successfully to have
dentistry included within the RMP
rubric. .

Moreover, they have established
close liaison with social action agen-
cies both in HEW (Office of Economic
Opportunity) and HUD (Model Cities)
and have encouraged individual re-
gions to forge cooperative arrange-
ments with these and other programs
wherever possible. (A subsequent sec-
tion in this issue touches on such
interagency cooperation in Nashville,
Tennessee.)

For all this, the program has experi-
enced some disappointments. One of
the most persistent has been the slow-
ness with which RMP has moved in
some of our largest and most problem
ridden urban areas. This has been ac-
centuated by the speed and success
realized in rural and alpine regions.
Much of the problem traces to hang-
ups in getting RMP organized in the
core cities where, among other prob-
lems, there is a plethora of health
institutions, people and activities, all
of which are essentially autonomous.

The division has made no effort to
soft-pedal these difficulties in its testi-
mony before Congress or in its public
statements. Olson has said: “The com-
plex problems of our cities pose a
national crisis of the gravest order....
We recognize that the complexities
involved in developing regionalization
in urban areas have delayed the de-
velopment of regions in the very areas
where their services may be most
needed. This is a matter to which I
have already given a great deal of my
time and to which I am prepared to
devote more of my personal efforts.”

Dr. Olson’s “complexities” are the
same bugaboos that plague most pub-
lic programs in the cities—inadequate

 

 

 

DR. STANLEY W. OLSON

 

 

 

funds, social fragmentation, the diffi-
culty of bringing together all the cul-
turally diverse groups that must be
included in the planning process, im-
movable bureaucracies, indifference.
By and large, the rural regions have
had to deal with a far less numerous
but more homogeneous population, a
circumstance that goes far toward ac-
counting for their rapid progress in
getting into operational status. Com-
parative operational grant histories
tell the story about as well as any-
thing else.

Let’s consider the Kansas RMP and
the Intermountain Program based at
Salt Lake City, Utah. These regions,
both largely rural, have received grant
funds totaling some $3 million and
$7.3 million, respectively. Another
fast-starting group, the Albany RMP
in upstate New York, has received
almost $2.8 million. Together, these
regions represent about eight million
people.

On the other side of the coin, the
latest DRMP directory of operational
grants lists none for Chicago, Cleve-
land, New York City or Pittsburgh.
The New York Metropolitan RMP

 

alone has more people than Albany,
Kansas and Intermountain combined.
While awards have been made for
projects in Los Angeles, Philadelphia,
St. Louis and Baltimore, they have
been on a far less ambitious scale
than those for some of the more thinly
populated regions.

Not that there aren't some encour-
aging urban programs. Watts-Willow-
brook, a project to develop a post-
graduate medical center to serve the
people of Central Los Angeles, is
widely regarded as a possible proto-
type of future community health cen-
ters in ghetto areas. The Tennessee/
Mid-South RMP, combining the activi-
ties of predominantly black Meharry
Medical School with those of tradi-
tionally white Vanderbilt University
Medical School, is embarked on a pre-
ventive medicine program that links
multiphasic screening and an OEO-
sponsored Neighborhood Health Cen-
ter in a deteriorating section of North
Nashville. Similar programs are on
the drawing boards in such regions as
Illinois, New Jersey, Detroit, Washing-
ton and New York City.

 

A GLIMPSE AT
WHAT’S GOING ON

The working draft of a directory pre-
pared by DRMP at the end of Fiscal
Year 1969 required nearly 240 pages
to furnish biographical data on the 55
regions and capsule descriptions of
the projects in the 41 regions that had
achieved operational status. Most of
the space was devoted to the latter

task.
Predictably, the individual projects

differ as markedly in design as the re-
gions themselves differ in topography,
demography, and health manpower
and facilities. Just as predictably, there
are pronounced similarities, for gaps
in the armamentarium for attacking
heart disease, cancer and stroke have
some characteristics that transcend re-
gional boundaries.

 

SDC MAGAZINE ® 9

a eememeeenneemmesenmmmepenemmn rarer
For example, the best equipped and
trained personnel are found in the
major hospitals and university medi-
cal centers, whether these are in rural
or urban regions. Logically, then, these
institutions find themselves involved
in some way in nearly all educational,
training or demonstration projects
that have won approval for opera-
tional funding.

Commonly, RMP strategy has been

. two-fold—to build on existing
strengths wherever there is a strong
local program and to extend knowl-
edge outward from the medical centers
to the smaller community hospitals
where specialists and sophisticated
equipment are often nonexistent. No-
where is this strategy better illustrated
than in the emphasis on coronary care
programs, an emphasis that threads
its way through RMP activities from
Hawaii to Florida, from sparsely
peopled Idaho to crowded New Jersey.

In the Memphis region, the Univer-
sity of Tennessee Medical Center
plans to install a 12-bed “showcase”
coronary care unit (CCU) that the
medical staff will use to give training
and demonstrations to health profes-
sionals from throughout the area. The
Metropolitan Washington, D.C., RMP
is literally putting its coronary care
program on wheels by designing a
mobile CCU that will rotate among
three hospitals in the area. The hos-
pitals will provide their own nurses,
who will be specially trained, and phy-
sicians will be drawn from the Heart
Disease Control Program of HEW.

Joint action by the Central Ohio
Heart Association and the Ohio State
University College of Medicine char-
acterizes coronary care training in the
Ohio State RMP, a 61-county region
in the central and southern portions
of the state. Nurses from hospitals in
10 core cities come to Columbus for
two weeks’ intensive training that
prepares them to return to their own
institutions as “nurse educators.” Phy-

10 =" SDC MAGAZINE

 

sicians, in turn, are eligible for coro-
nary care seminars right in their own
local hospitals.

These projects give some idea of
the style, if not the scope, of RMP
coronary care activities. There are still
other innovations. Some of the regions
have installed 24-hour telephone hook-
ups that allow small hospitals to dial
regional medical centers directly for
electrocardiogram analysis and profes-
sional consultation. Another twist has
been the development of coronary
care training programs in hospitals
other than teaching hospitals, an ap-
proach that is especially relevant to
those medical personnel who live
great distances from the large training
institutions. Whatever the approach,
the separate regional efforts share a
common bond of helping the practic-
ing physician, the nurse and others to
improve their skills in behalf of cor-
onary patients.

To Marc Musser, it is this recogni-
tion of the needs of patients, as much
as the recognition of the educational
needs of health professionals, that
accounts for the RMP emphasis on
coronary care units. He says, “Coro-
nary care units represent increased
awareness of the acute problems of
patients. RMP picked up the CCU
program at the right time, since it
combined our initial emphasis on con-
tinuing education and the means to
effectively meet needs in patient care.”

What holds for coronary care is no
less true of programs in cancer and
stroke. Most of the regions have
moved solidly into these areas with
tumor registries, tumor boards, stroke
management programs, and cancer
and stroke screening projects. With-
out exception, the regional plans dem-
onstrate conscious attempts to mount
a balanced attack against all the
diseases identified in the legislation.
(The final segment of this issue in-
cludes discussion of a cancer program
being developed in Boise, Idaho.)

 

 

TOWARD THE FUTURE

Of the many issues that will face RMP
in the 1970s, none is likely to remain
more visible than the health needs of
the urban poor. Dr. Olson believes,
“Regional Medical Programs can
assist in the improvement of health
service activities through projects that
supplement elements of both old and
new systems aimed specifically at the
urban poor.

“True, we suffer from several con-
straints as we attempt to deal with
these problems. Facilities are needed,
but we have no authority to use funds
for construction of facilities. Neither
may grant funds be used to pay for
the cost of medical services or hos-
pitalization, Nevertheless, there are
major contributions which Regional
Medical Programs can make....

“Regional Medical Programs are
functioning organizations specifically
designed to link the providers of care
together for the purpose of collectively
improving services to patients....To
do this, RMP must enter into coopera-
tive arrangements with the many local
and federal programs already address-
ing themselves to health problems of
the urban poor.

 

“The [RMP] programs can and
should contribute significantly in plan-
ning general health services for these
populations, because it is only in this
fashion that we can come to grips
specifically with the problems of heart
disease, cancer and stroke.” Clearly,
the DRMP staff doesn’t intend to
dodge its responsibilities in the cities.

Nor, if Dr. Olson is to be believed,
will RMP diminish its emphasis on
continuing education. He is on record
as being convinced that continuing
education is one of the most signifi-
cant single components of RMP activ-
ity. In years to come, however, the
division expects to promote more com-
prehensive and innovative approaches

 
designed to make health professionals
active participants rather than passive
receptacles in the educational process.

In Olson’s view there is no conflict
between the requirement for continu-
ing education and the need to do some-
thing in the cities. In fact, he believes
that RMP is flexible enough to accom-
modate the problems of the rural poor
as well. Education and social action
can coexist comfortably in Olson’s
philosophy, because he regards them
as essential to each other.

He sees continuing education in
urban areas as one sure way to achieve
better care and treatment for disad-
vantaged patients. In the same vein,
he believes that cooperative health
arrangements worked out by agencies
in the cities can be copied elsewhere
to benefit the rural poor. This outlook
again reflects the importance DRMP
attaches to balanced programs.

This emphasis is certain to grow
even stronger throughout the 55 re-
gions in coming years. The division—
through its own staff, the National
Advisory Council, outside consultants
and the Review Committee—has tra-
ditionally insisted on excellence in
the operational proposals that come
before it for review.

In recent months, Dr. Olson has
strengthened this policy and called on
the regions to work harder than ever
to improve the quality and regional
significance of their requests. Perhaps
the most effective means toward this
end will be the encouragement of
more rigorous standards of review
and criticism among the regional ad-
visory councils when they evaluate
their own operational proposals.

The quest for excellence doesn’t
stop there. Today there is also more
attention than ever to the problem of
project evaluation. All proposals must
include formal mechanisms for peri-
odic evaluation, and the division has
invested a great deal of effort in de-
veloping sensitive tools for this task.

 

 

      

EDWARD M. FRIEDLANDER

 

 

 

The object is to help the regions iden-
tify weaknesses and eliminate unpro-
ductive programs. It turns out to be a
continuing responsibility.

 

GETTING TO KNOW THE
PUBLIC AND EACH OTHER

Programs like RMP recognize that
their success is almost totally depend-
ent on timely and accurate communi-
cations to a wide and heterogeneous
set of audiences, There’s Congress,
the mass media, the general public,
the medical schools, the professional
organizations, local governments,
state health agencies, voluntary asso-
ciations, and on and on and on.

At another but equally important
level, there is the requirement for
open communications between the
division and the regions and among
the regions themselves. Under DRMP
Assistant Director, Edward M. Fried-
lander, the division has worked out a
program to produce maximum recip-

 

 

rocal feedback. Within the separate
regions, most core staffs now include
a professional public information
officer.

It’s important that he.do a good job,
for as Marc Musser has said: “Most
of the problems in RMP result from
failure to communicate at the right
time. Leave someone out and things
can get sticky. You might think that
busy doctors could care less, but that
has been far from the rule so far in
RMP. Overlook them and they let you
know about it in a hurry.

“Frankly, getting the commitment
of local people is only the beginning.
Communications exchange must be
reciprocal. It must be continuous. A
lesson all of us around the country
have learned is that good communica-
tions in a region don’t just happen.
You must do a lot of work to make
them happen. A good core staff is
essential.”

This basic lesson hasn’t been lost
on Ed Friedlander and his group at
the division. Early in the game they
set in motion a systematic program of
interregional meetings designed to
draw together RMP staffs from the
same geographical parts of the coun-
try. Such gatherings serve several pur-
poses. They allow for briefings on
what is going on at the federal level in
regard to budget and legislative policy.
They also serve as a platform for inter-
preting divisional guidelines and giv-
ing the regions a chance to air their
gripes about what the division is doing.
That way everybody has a chance to
learn some of the basic facts together.

If the meetings accomplished no
more than this, chances are both Dr.
Olson and Friedlander would consider
them worthwhile. There’s another
angle, however, that may prove even
more useful to the regions in the long
run. Friedlander and his people are
using their get-togethers with the re-
gions to encourage permanent chan-
nels by which the regions can com-

SDC MAGAZINE * {1

TTT TT a aS eT a SS
 

t

municate regularly with each other,
separately and as groups.

DRMP is convinced—-as are many
of the regions—that there is a many-
fold pay-off in this kind of activity.
For one thing, a frank exchange of
data on operational program successes
and failures can help the respective
regions avoid expensive false starts.
For another, it can provide late-start-
ing regions with helpful tips on how
to secure the enthusiasm of their own
people and how to initiate the plan-
ning process. Of increasing importance,
it can also help iron out jurisdictional
problems or stimulate cooperative ar-
rangements among regions whose pro-
grams overlap each other.

At a February 1969 meeting in
Tampa, Florida, the coordinators and
other staff of the 15 regions that make
up the Southeastern Region furnished
proof that interregional cooperation
and exchange are gaining in apprecia-
tion. Spurred by Marc Musser and Dr.
J. Gordon Barrow who directs the
Georgia RMP, the Southeastern group
voted to share the cost of an inter-
regional coordinator whose task
would be to “ride circuit’? among the
regions and keep everyone apprised
of what his neighbors are doing. The
new man has already been on the job
for several months.

 

BUDGET OUTLOOK

 

The fact that the regions are now
ready to look beyond their own imme-
diate interests is an indication that
the four-year-old RMP is coming of
age. Further proof—if any is really
needed—lies in the rate at which pro-
grams are moving out of planning into
operational status. It is at this point
that RMP requires much higher levels
of financial support. The program is
already feeling a pinch.

Says Dr. Olson: “Clearly, we are

12 = SDC MAGAZINE

 

moving from a circumstance where
there has been a surplus of funds—at
times an embarrassing surplus—to
one in which the reverse will be the
case. Looking at applications already
in hand, we can predict that the aggre-
gate demand for grant funds will ex-
ceed our appropriations in the Fiscal
Year 1970. Beyond that, the amounts
that the Review Committee and the
National Advisory Council will likely
recommend for approval from yet-to-
be-received applications will also ex-
ceed available funds.”

Because RMP didn’t spend all the
money Congress made available to it
in the first four years, some of the
lawmakers have been dubious about
whether program requests do in fact
represent a reasonable estimate of
need. Although final Congressional
appropriations for RMP grants are yet
to be voted, this dubiousness, com-
bined with Administrative and Con-
gressional belt-tightening, resulted in
a House Appropriations Committee
recommendation of $50 million in
grants for FY 1970. This is $24 million
less than the Administration asked
for and $70 million below what was
authorized by legislation.

Many in RMP regard this as a body
blow to the future health of the pro-
gram. Both Marc Musser and Paul
Ward serve on the Coordinators’ Steer-
ing Committee, a group of 10 coordi-
nators elected by their fellows to ad-
vise DRMP on national policy and
programs. Ward and Musser think
present funding projections are far
from adequate.

Musser calls the budget outlook
unpromising. He warns that some
programs may have to cut back and
that the fiscal situation will almost
certainly discourage new starts. “On
the whole,” he says, “this is occurring
with the worst possible timing, since
so many new localities and communi-

 

ties are clamoring to get into RMP.”

Speaking to the same point, Califor-
nia’s Ward said, “I suppose that at the
present time you can say that the pro-
gram is at its most critical stage. Years
of planning are coming to a head, and
the projects are rolling in. Now if you
don’t get the money in a reasonable
time, the people who made the co-
operative arrangements move away
or change their minds, and you have
to try to put it all together again. Well,
that’s very wasteful.

‘Understand me, it’s not hard to
sell Congress on RMP. They were
always willing to authorize just about
as much as the program could use, be-
cause their opinion of us was always
high. The only thing Congress has had
against us is that in the beginning we
asked for too much—more than we
could realistically use. That is the
problem.”

Ward feels much the same as Dr.
De Bakey did when he testified last
year before the House—that the pro-
gram must continue to grow and ex-
pand. Characterizing RMP as a means
for distributing medical knowledge,
Ward draws an analogy from the
business world: ‘You know, General
Motors would never think of develop-
ing a new automobile and then not
spend some of their resources on cam-
paigns to get it in the hands of cus-
tomers. The same is true today in
medicine. You might just as well for-
get the research unless you are willing
to devote some money to distribution.

“That’s what RMP is all about, and
if we are talking $100 million as a
plateau for all time, we are engaged in
the wrong kind of planning. You've
got to preserve your momentum and
the faith that people have manifested
in the future of the program. Other-
wise the voluntary contributions and
local participation will largely be lost.
That is what would really hurt.”

 
TENNESSEE/MID-SOUTH

Contrast, Cooperation
and Quality

 

 

About 120 miles east of Memphis the Tennessee River wheels north and rolls past Wayne, Perry, Humphrey,
Houston and Stewart Counties. The Tennessee/ Mid-South RMP begins along the river’s east bank and
stretches some 400 miles farther east to the Virginia line. It takes in 74 counties in Tennessee and a cluster
of 14 more in southwestern Kentucky.

That’s room enough for a lot of contrast. The 3600 residents of rural Van Buren County follow a life-
style that has its roots in the cotton and tobacco culture of the antebellum South. Over in urban Davidson
County, some 400,000 Tennesseeans are setting a pace that’s about as hectic as you'll find in any other
metropolitan section of the nation. Altogether, RMP is planning or providing services for some 2.75
miilion citizens in the region.

Tennessee/ Mid-South activities hub around Nashville, probably less famous now as the educational
and cultural “Athens of the South” than as the home of the Grand Ole Opry and a burgeoning country
and western recording industry. Nashville’s importance to RMP, however, stems from the presence of
seven large hospitals and Vanderbilt and Meharry medical schools.

Both schools are committed to the success of RMP. Vanderbilt administers the RMP grant, and faculty
from both institutions have been generous in volunteering assistance to the program. The same goes for
most of the hospita's throughout the region and for such seats of higher learning as Fisk, George Peabody,
Tennessee State and the University of Tennessee.

Tennessee/ Mid-South went into business on November 1, 1966, and began operational activities 15
months later. There are now 28 active operational projects, with another four approved but not yet funded.
The annual budget comes to about one dollar for every resident of the region. Much of the emphasis is
on training programs that give physicians and hospital personnel a chance to improve and expand their
skills in the detection, diagnosis and treatment of heart disease, cancer and stroke. The programs have
generally started with existing strengths and built from there—more often than not with imagination and
a willingness to dare something new.

 

SDC MAGAZINE ® 13

a a A A SSSR
Estebished from the Office sf Emam i

MEHARRY NEIGHBORHOOD HEALTH CENTER
TEMPORAHY WOCATION —————————
[ae

te Ma raga ts Ann Coslrion of Nevin Reda Cont

They call it North Nashville. Like other inner city neigh-
borhoods in other American cities, it traces a jagged
poverty scar through broken streets where half the
dwellings are either deteriorating or dilapidated. Thirty
thousand people live here. Of the adults over 25 years
of age, only one in three has made it past the eighth
grade. Three of every five families have annual incomes
of less than $3000, and women head half the house-
holds. Negroes make up 80 percent of the population.

Across the country, RMP has had trouble getting started
in places like North Nashville. But health officials here
think they have come up with an approach to assure
delivery of quality health services to Nashville’s urban
poor, The plan revolves around interagency cooperation
between RMP and a new OEO-sponsored neighborhood
health center that is one of the first to be constructed
in the South.

The center, which began in a run-down store on Jefferson
Street, will soon move into brand new quarters, Super-
vised by faculty and staff from Meharry Medical College,
it will offer comprehensive care and treatment with
emphasis on the dignity of the patient. It will also be
closely tied to another Meharry project, sponsored
through RMP and aimed at bettering the health fot of the
disadvantaged, not only in North Nashville, but in the
rest of the city as well.

Called the multiphasic screening laboratory, and cen-
tered in Lyttle Hall across from Hubbard Hospital on the
Meharry campus, this operational RMP project will offer
the latest advances in the detection of heart disease,
cancer and stroke and other disorders that may lead to
those illnesses.

14 = SDC MAGAZINE

 

Testing for visual acuity
and visual field.

 

      

A major aim of the project is to learn how screening
services, combined with treatment services at the
neighborhood health center, affect levels of health in
the area. This will be tested over a 10-year period by
clinicians on the project and by social scientists from
the Center for Community Studies at George Peabody
College.

The clinical program will utilize 21 screening stations
to provide such services as electrocardiography, visual
acuity testing, spirometry, blood pressure, cervical
cytology and a battery of 27 blood tests. Hours will be
from 1 p.m. till 9 p.m. to make it easier for those who
have to work every day, and the patient will spend from
one to three hours on his visit to the lab.

The screening sequence will be automated in an effort
to conserve time for the attending physicians and make
test results available as soon as possible. Much of the
work will be carried on by nurses and technicians, with
many of the latter trained and qualified as part of an
educational emphasis in the program. To be eligible for
screening, patients must be referred by a private phy
sician, a public agency or the neighborhood health
center. The goal is about 25,000 examinations annually
Surgeon Frank A. Perry
of Meharry is project di-
rector of the multiphasic
screening program. His
view: “We will be able to
apply preventive meas-
ures on a continuing
basis as opposed to the
episodic care that is now
the rule in this area. We
have good people. We're
excited about our future.”

At the blood pressure sta-
tion, determinations are
made on both arms.

SDC MAGAZINE ® 15

 
     
  
 

“Blood chemistry screening utilizes two machines and takes one patient sample per

minute. It measures electrolytes in the blood. This procedure will also be on-line.”

16 = SDC MAGAZINE

 

SEA ME 39807

40 —*O

 

 

> tala
a

eee

 

Leonard B. Victor is a clinical pathologist on the Me
faculty. He also is director of screening operations. |
is the Coulter Counter for hematology analysis. It w
on-line and can handle a patient every 20 seconds.’
 
     

 

 

gens ner
Spee \

 

 

179397198084

 

 

bk

t
}

This autoanalyzer gives
us a blood chemistry pro-
file based on 12 determi-
nations. It is an economi-
cal and swift way to let
the physician know which
patients have abnormal
value such as low blood
Sugar content which is
an indication of diabetic
tendency.”

| |

 

Cooperative arrangements keynote the multiphasic screening program. Fisk University,
adjacent to Meharry, is Providing accommodations for the computer. Specialists from
Vanderbilt's computer center and schoo! of engineering have assisted in planning
hardware/ software requirements and specifications. Clinicians from both Meharry and

Vanderbilt have volunteered their expert judgments on what and how many tests should
be included in the screening battery.

 

 

“Our computer is an inte-

gral part of the screening
process. We have a defi-
nite plan for bringing the
various screening sery-
ices on-line. Our object
is to provide results to
the referring physician
Or agency as fast as
possible.”

  

SDC MAGAZINE ® 17
 

Williamson County Hospital is just outside Franklin, a
rural community of 10,000 on the L&N railroad 17 miles
south of Nashville. Last year the 100-bed hospital ad-
mitted 4128 patients from its medical service area of
30,000 people. About one of every 15 admissions was a
cardiac patient, 22 of whom died. Physicians and nurses
at Williamson are working to lower that figure through a
cooperative RMP arrangement with Vanderbilt Medical
School's coronary care center.

The project, under the direction of Dr. Noel Hunt of
Vanderbilt and Dr. Robert Hollister of Franklin, is an
effort to find out if a small community hospital can and
should maintain a coronary care unit. Williamson has
set up a 2-bed unit and designed a 33-hour course to
prepare its staff for handling the coronary patient. It also
sent nurse Martha Miller through the rigorous coronary
nursing program at Baptist Hospital in Nashville.

 

Through a dual monitoring system, patients at Williamson can also be monitored by
the nursing and professional staff at Vanderbilt. Moreover, there is a 24-hour data
phone hookup to pass vital patient data between attending staff at the two institutions
This arrangement allows any of the nurses or 10 physicians on the Williamson staff
to have immediate access to faculty cardiologists and highly trained cardiac nurses
at the medical school. Patients, the people for whom all this is being done, have
already benefitted. Williamson administrator Cliff Gardner credits the program with
saving seven cardiac patients in its first seven months of operation.

 

18 = SDC MAGAZINE

a
 

   

 

 

 

ee. ge abet.

  
= SDC MAGAZINE

The dual monitori

tem allows Vande
physicians and n

to follow the identic
tient signs display
the nurse’s station i
liamson County Ho

 
 

Maen ney

 

 

cardiac
ller of

has nurses

In an emergency,
nurse Martha M

Williamson

ine

Bonnie Land and Jean

re-

Jolly and the full

sources of Vanderbilt’s
coronary care center

right at her fingertips.

 

 

SDC MAGAZINE © 21
  

Many of the RNs in the
coronary care unit at
Nashville’s Baptist Hospi-
tal have completed that
institution’s widely re-
spected 8-week training
program in coronary nurs-
ing and have received
their treasured Cardiac
Nurse Specialist pins.
Most of them now teach
alongside the 25 hospital
staff members responsi-
ble for the curriculum in
the program. Given three
times a year, the course
is restricted to 30 stu-
dents drawn mainly from
the region, but also from
as far away as the West
Coast. As RMP develops,
Baptist will be the pri-
mary resource for coro-
nary nurse training.

22 © SDC MAGAZINE

 

 

 

Baptist Hospital is a 625-bed general facility with teaching programs for interns and residents and a professional s
that is more than 90 percent specialist. Its coronary care unit, established in 1964, was the first in Tennessee and
several surrounding states. Today, it plays a central role in cardiac nurse training and patient consultation progr
carried out through cooperative arrangements with RMP and several small community hospitals in distant toi

The intensive care pavilion at Baptist accommodates eight patients, while an adjoining 14-bed progressive care p
ion is reserved for those who, in their physicians’ judgment, require less intensive supervision.

The coronary care unit will also perform a major advisory and consultative role in the Tennessee/ Mid-South coron
care network, a hookup that will tie 11 small hospitals to coronary care centers at Vanderbilt and Baptist. Baptis
already linked to 2-bed units at Crossville and Tullahoma, with Manchester slated to join the net soon.

 

 

 

 
 

 

 

 

 

MOUNTAIN STATES

A Case Study in
Grass-Roots
Planning

Al Popma and his wife, Dorothy, were born in Orange City, a
little farming town at the northwestern tip of Iowa. Both are
from Dutch stock as are most of the people who live around
Orange City. They came to Boise, Idaho, in 1938 when Al was
a young doctor about to begin the practice of radiology. He
kept at it until 1966 when he “retired” to take a full-time post
as program director of the Mountain States RMP.

By that time Al had become one of the best known and most
respected radiologists in his part of the country and a familiar
figure in medical circles at the state and national levels. He is
a past president of the Idaho Medical Association, and when
the American Cancer Society was reorganized in 1945, he was
one of the original board members. He later served as national
president of the society.

From 1953 until 1966 he was a commissioner of the Western
Interstate Commission for Higher Education (WICHE), the
organization that administers the Mountain States RMP and
is involved in the total spectrum of educational planning

throughout most of the western states. As a WICHE commis-
sioner, Al helped draft the planning grant application that
established the RMP program he now directs.

He has strong convictions about RMP. “I came into this pro-
gram,” he says, “because it is perhaps the first program with
federal dollars in it that has some local autonomy. For the first
time we feel that we have an opportunity to produce projects
without regard to state boundaries. This is truly a first in fed-
eral health programs. We are also discovering that through
RMP, and again for the first time, we can develop autonomous
projects...that people at the grassroots can make determina-
tions about their own future in health care.”

These advantages share prominence with what Popma sees
as RMP’s greatest long-range contribution—the encourage-
ment of permanent continuing education programs that benefit
the patient by helping physicians, nurses and other health pro-
fessionals improve their skills. He discusses this and other
RMP issues in the following pages.

SDC MAGAZINE ® 23

SSDS
Al Popma has long been concerned about the lack of formal
continuing education programs for doctors, nurses and other
health professionals who practice in Idaho, Montana, Nevada
and Wyoming, the four states that together compose the
Mountain States RMP. In his 13 years as a WICHE commis-
sioner, he became convinced that one of the region’s greatest
needs was for some permanent mechanism to create and sus-
tain such education and training efforts.

“WICHE undertook a number of studies to assess health
training requirements in the four state region,” he recalls. “A
number of years ago, for example, we made a study of health
manpower needs and came out with very accurate predictions
of the demand for health personnel, particularly physicians,
over the next couple of decades.

‘And following the lead of the Faulkner Study on the need
for medical schools in this region, WICHE set up an advisory
council on medical education facilities. 1 became chairman of
the council, and it was largely through its work that WICHE
grew interested in the legislative hearings that led up to the
establishment of RMP. In fact, the council went to Washington
to testify before the House committee that eventually wrote
the RMP law.”

Popma and other council members felt at the time that a
grass-roots program such as RMP would provide the spark for
permanent educational activities in the four state area. ‘We
were in agreement,” Popma says, “that although we had a
myriad of continuing education courses most were on a hit-
and-run basis.

“Nothing was formally organized, and the professions de-
pended almost entirely on volunteer agencies—the Heart As-
sociation, the Cancer Society, the medical associations, the
nursing societies and so on. To put it another way, the profes-
sional groups themselves were entirely responsible for sustain-
ing continuing education in the four states. There was little

24 * SDC MAGAZINE

coordination among them and quite often there was duplica-
tion of course content and expenditures.”

This was the situation as Popma remembers it in 1965 when
Congress passed P.L. 89-239 and launched RMP. From the
outset, he and other WICHE members were determined to
include Idaho, Montana, Nevada and Wyoming in the new
program. The first order of business was to sit down and put
together an application for an RMP planning grant.

“This was drafted by the advisory council, working with
Dr. Kevin Bunnell, associate director of WICHE,’” Popma
recollects. ‘To assist in the effort, the council recruited three
distinguished practicing physicians from the region—Dr.
Frank McPhail from Montana, Dr. Francis Barrett of Wyoming
and Dr. Fred Anderson from Nevada. All were WICHE
commissioners.”

The group got the job done, producing an application that
was approved by the Division of Regional Medical Programs.
Mountain States RMP, with Al Popma as program director,
began its life in November 1966. It was—and still is—the only
RMP region without at least one medical school, a circum-
stance that some had thought would make the area ineligible
for RMP funding.

In Popma’s view, the absence of medical schools is the
major reason there has been a lack of coordination and con-
tinuity in continuing education activities in the four states.
Not having medical schools also created a set of organizational
problems for the fledgling Mountain States program.

“One of the first things we had to do to meet the require-
ments of the Law,” Popma says, “was to organize a regional
advisory group. To satisfy the requirement for medical school
representation we had to go outside our boundaries. Logically,
we went to medical colleges in surrounding areas to take ad-
vantage of traditional relationships to practicing physicians
in our region.

 

a | =a
 
26 = SDC MAGAZINE

“We invited representatives from the schools in Washington
and Oregon and chose Paul Ward to represent the several
California institutions. For representation on our southern
border, we turned to the new schools in Arizona and New
Mexico. Since our physicians have always had strong ties to
the Universities of Utah and Colorado, we added members
from both medical schools. Then we went a little farther away
and took in representatives from the medical college at the
University of Minnesota, the medical schools in North and
South Dakota, and from Creighton University in Omaha.”

Once medical school representation was settled, Mountain
States asked for recommendations from each of its four states
to round out advisory council membership. Seventeen addi-
tional people were added, including three Indian members
who speak for the major minority group in the region. With its
advisory group selected, the program was ready to turn to
other matters.

Looking back, Popma recalls that no one in the sprawling
region had accurate information on what medical facilities
were available or what the training and educational needs of
health professionals were. ‘‘We recognized that we had to
assess these needs,” he says, “and we decided to ask the
people at the grass-roots level to tell us what they had to have.
With this information, we could then attempt to design ade-
quate programs.”

After examining several alternatives, RMP and WICHE staff
members decided that the best approach was a field survey
using direct mail questionnaires. ‘There was one problem,
though,” Popma remembers. “Never having devised such ques-
tionnaires or formulated computer programs for this kind of
data analysis, we came to the conclusion very quickly that we
required some rather sophisticated assistance. And so we
made an arrangement with System Development Corporation
to provide us the necessary know-how.”

Even while the agreement was in negotiation, the program
was having to face up to the task of creating a regional organ-
ization that could carry out the survey work and become the
permanent staff resource for long-range planning and oper-
ational activities.

“We decided to set up an office in each state and were
fortunate enough to secure four outstanding practicing phy-
sicians to serve as state directors,” Popma notes. “Although
there have been changes, we retain excellent state leadership
in Drs. Sidney Pratt of Great Falls, Montana, Dr. Claude
Grizzle of Cheyenne, Wyoming, David Barton of Boise, Idaho,
and Lorne Phillips of Reno and Las Vegas, Nevada. The open-
ing of our regional office in Boise was the final touch to give
a true regional flavor to the whole program.”

Of course, it wasn’t quite as simple as it reads today, some
three years later. Says Popma, “Compared to other programs,
we had kind of a rough time getting going. Most of the others
emanated from medical schools where there were trained
people to write applications and get the program rolling.

“We had to start from scratch. We had absolutely nothing.
We had to rent office space here in Boise and in each of the
states, and we had to recruit qualified people. To be frank,
there’s a critical shortage of manpower to do this kind of job.

 

 

 

John Gerdes is one of those qualified
people who are in such short supply in
health programs across the country.
He was on the faculty of the School
of Public Health at the University of
Pittsburgh but came West because he
preferred the clean air and outdoor
life.

Al Popma says Gerdes is ‘‘one of the
top-notch young men anywhere in the
country when it comes to developing
the kind of community supported
health programs required in RMP.”
Among other projects, Gerdes has
been prominent in planning an inhala-
tion therapy training program for the
region.

‘It began in the fall of 1968 at a
meeting in Las Vegas where we were
trying to compile a list of physicians
who might be interested in undertak-
ing such a program,” Gerdes says. ‘Dr.
Richard Browning, a Las Vegas intern-
ist, had already gotten one under way
for the state of Nevada, and our state
directors were anxious to find a way

 

 

 
 

to extend it to other parts of the region.

“We already knew of another inha-.

lation therapy training program just
25 miles from our regional office at
Caldwell Memorial Hospital, Idaho.
It was being run by Charles Reed, a
31-year-old internist, as part ofa two-
year program at nearby Treasure Val-
ley Junior College.”

Gerdes asked Reed and Browning
if they would be willing to expand
their programs to include shorter-term
training for personnel of hospitals in
the region. Both were receptive, and
they sat down together’ to design a
curriculum and draft a grant proposal
to set up complementary inhalation
therapy training institutes at Caldwell
and at the Southern Nevada Memorial
Hospital, Las Vegas. The request is
pending before DRMP.

“The exciting thing about this pro-
gram,” says Gerdes, ‘is that two com-
munity physicians, in communities
1000 miles apart, are working in con-
cert on a common project with a real
regional emphasis and outlook. Even-
tually, if we can interest other phy-
sicians like Drs, Reed and Browning
in becoming instructors, we hope to
make this curriculum available to hos-
pitals throughout the four states.

Gerdes points out that up to now
Dr. Reed’s program has been aimed at
students going for a junior college AA
degree or expecting to transfer to a
four-year school. The Mountain States
emphasis, predictably, will be on mak-
ing the training available to hospital
personnel or others who have the apti-
tude to become inhalation technicians.

Says Gerdes: “Typical enrollees will
come from small community hospitals.
They may be RNs, but we hope also to
attract students who, while they have
no special medical training, do have
the aptitude to learn the material. Our
theory is that we can upgrade the
skills not only of RNs, but also of
licensed practical nurses, nurse’s
aides and others with the ability and
desire to acquire this training. This is
consistent with the Mountain States
philosophy of training its own.”

 

For patients with heart and respiratory diseases, inhalation therapy can afford
short-term relief and be a significant factor toward recovery. The inhalation
therapist also comes into play in such emergency situations as cardiac arrest or
serious chest injury. The latter is simulated here by students and faculty of the
Caldwell Memorial Hospital Inhalation Therapy Training Program.

 

 

LL See eT aS

SDC MAGAZINE © 27
 

And since we were highly geared toward field research and
obtaining information, we had to find people who thought
along these lines.”

Eventually the offices did get set up and staffed, at which
point Mountain States was ready to sit down with SDC’s
Health and Environmental Systems Department to develop
the series of questionnaires that eventually would go to nearly
all health personnel in the four states.

“Our survey universe included physicians, dentists, regis-
tered nurses, licensed practical nurses, hospital administrators,
X-ray and lab technologists, physical therapists....1 think
there were eight categories we wanted to reach,” Popma says.
Deciding just how to reach these groups required that the
Boise staff meet regularly with state offices and representa-
tives from SDC to work out questionnaire logic and wording.

“Tt took a lot of time and a lot of wheel spinning to come up
with the proper questions,” Popma recalls. “Some of our
people had never done this, and you can imagine that there
were problems. Often there was quibbling or quarreling over
the correctness of a single word.”

When the rough spots were ironed out to the point that
everyone could live with the results, the questionnaires were
printed and mailed to 100 percent of all health personnel
except RNs and licensed practical nurses. These populations
were large enough to require use of a random sampling
procedure.

“Across the region we had better than a 50 percent return,”
Popma says with satisfaction. “The data were keypunched
and put on the SDC computer in Santa Monica. So far, we
have run two analyses on this file, and the results have helped
us in devising certain operational activities. After all, provid-
ing data for operational programs was the purpose and func-
tion of the questionnaires.”

At the same time the health professional survey was in
progress, Popma’s staff was also busy collecting information
on health facilities in the region. To get an accurate line on
such things as the number of hospital beds, the number and
location of nursing homes, and the adequacy of transportation
services, the staff designed what it now calls its Health Profiles.

“These focus down to county levels,” Popma explains, “and
enable us to tell what the health facilities needs are in indi-
vidual communities. I should mention that SDC didn’t assist
on this effort. We devised it almost completely on our own.
Naturally there were times when SDC looked at what we were
doing and made suggestions, but the work was almost all ours.”

However, SDC did have a lot to do with a third data gather-
ing effort aimed at consumers of health services. This survey

28 = SDC MAGAZINE

 

 

 

 

 
 

 

is perhaps unique to date in RMP. “‘As far as I know,” Popma
says, “ours is the only RMP‘ that has made a systematic broad-
scale effort to find out what kind of health services the ordi-
nary citizen wants to have available for patients with heart
disease, cancer, stroke and the related diseases.

“This questionnaire, which we call the Survey of Consumers,
went out to 10,000 people in the four states,” Popma recaps.
“We drew our random sample from telephone directories and
from a list maintained by the Department of Agriculture that
shows families without telephone service. Again, our rate of
return was over 50 percent.”

All told, the Mountain States RMP now has three large files
of information—health professionals, health facilities and con-
sumers. “This planning data base took almost two years to
assemble,” Popma sighs, “but when it is all put together it
gives us a sound basis for developing operational projects.
Both the professional and consumer files are stored on the
computer in Santa Monica.”

Part of the agreement between Mountain States and SDC
was that there would be someone from the Health Systems
Department full time in Boise. Speaking of the arrangement,
Popma says, ‘‘we had Bob Mendenhall who did a very excel-
lent job for us. He is one of the finest people we ever worked
with. No job was too great, and there was never any question
of hours. If it took till midnight, Bob would be there to do it.

“I was very interested in Bob. Our kind of program was
something new for him since it was the first time he had been
with a program that fundamentally and physically was at-
tached to the practice of medicine, Naturally, there was a lot
he didn’t know, but he learned very well and quickly and
blended in with no difficulty. Bob gave us a tremendous
amount of help, and I was sorry when the contract was up
and he had to leave for a job elsewhere.”

(Mendenhall is now project leader for SDC on a study to
assess health care requirements for residents of the rural
Upper Kennebec Valley in the state of Maine, The corporation
retains its ties with Mountain States RMP, however, through
a formal consulting agreement.)

Popma is quick to point out that not all the effort in Moun-
tain States has been taken up with the surveys, The program
has five operational programs under way, another approved
by DRMP and four more pending DRMP review and approval.

“We did a small study in Montana to assess the needs in
coronary care,” Popma says, “and we learned that 85 percent
of people having heart attacks die at home. Now Montana is a
rural area with many small hospitals of from 15 to 50 beds,
meaning that the coronary patient can’t be transported to a

nearby large medical center with facilities to care for him. So
these people die at home.

“We recognized that if we were going to be able to take care
of such patients we had to help establish facilities and train
people in small hospitals,” Popma explains. “Our philosophy
is that if a coronary care unit is good for patients in the Los
Angeles metropolitan area, it is also good for those in Shelby,
Montana. If we accepted the tenet that a hospital has to have
300 beds before a coronary care unit is financially feasible, we
wouldn't have any coronary care programs.”

Believing this, Popma and his associates sat down and de-
vised a prototype program to prepare both physicians and
nurses to provide coronary care in the small hospital. On
March 1, 1968, thanks in large measure to the leadership of
Montana physician, Frank McPhail, Mountain States opened
its first coronary training center at St. Patrick’s Hospital,
Missoula, Montana. The project draws on cooperative arrange-
ments among the hospital, RMP, the University of Montana
and the University of Washington Medical School which
furnishes consultants. About 120 people went through the
course in its first 16 months.

“A second interesting operational program we have going
aims at providing the latest training in cancer diagnosis and
treatment,” Popma notes. “There is something for physicians
and for both the practicing and student nurse. Practicing
nurses will have a chance to come to the Mountain States
Tumor Institute that we are developing in association with
St. Luke’s Hospital in Boise. Here they can study and learn
the latest techniques in cancer nursing.

“Undergraduate nurses who matriculate at the four bacca-
laureate nursing schools in the region will have a chance to
enter the same program on an elective basis. Since none of the
schools has facilities for this kind of training, the opportunity
to attend the institute should provide a new dimension in
baccalaureate nursing programs.”

Like RMP administrators in other regions, Al Popma has
given a lot of thought to what it takes not only to get a pro-
gram started, but also to keep it moving over the long haul.
“In my judgment,” he says, “the first thing that has to be done
is to sell the practicing physicians and the medical societies.
You need more than their interest; you have got to have their
participation. This also holds true for nurses, hospital admin-
istrators and other professionals.”

Reactions to RMP have varied among physicians in the four
state area. At the outset, there was a lot of fear and suspicion
in some communities. “We tried to convince everyone that
RMP was their program and was under their control,” Popma

SDC MAGAZINE ® 2

CE  —————
7. wee 'ae

 

recalls. “We said—and we meant it—that they could take part
or not take part or even drop out if they got disillusioned.”

Once physicians began to get a personal stake in the pro-

gram, however, attitudes warmed considerably. “Working on
the state advisory councils, the committees, the task forces

and the surveys produced a 180-degree turnabout in many of

our physicians,” Popma says. ‘Feeling grew so favorable that
the Montana State Medical Association, for example, went on

record supporting continuing education for all health person-

nel, if funded through RMP. It even set up a foundation to
help work out cooperative arrangements and assist in health
planning.”

Striving to maintain rapport with health professionals is a
task that Mountain States shares with every other region in
the country. Another common bond is worry over where to

find enough trained people to man the respective regional
health care systems. Says Popma, “In my experience, the short-
age of qualified people is universal. But in our area, the hos-
pitals and other institutions don’t have the means to compete
salary-wise with the major medical centers. That’s why our
strategy of training our own is obvious...and reasonable.”

Looking ahead, Popma doesn’t expect RMP to fade out of

the picture any time soon. In his view there will simply be too

 

much community involvement at stake to let this happen. E
tells a story about the Mountain States Tumor Institute |
Boise to make his point.

“To finance the Fumor Institute,” he explains, “we ai
drawing on all the resources we can bring to bear. St. Luke
Hospital is providing the facilities—about $800,000 wor
Over the first three years, RMP has approval to provic
$621,000. We'll derive additional income from patient fe:
and we expect to realize part of our operating expenses fro.
philanthropic gifts.

“Take what just happened at our annual Fundsy Drive i
Boise, for example. The Fundsy Drive is a community projec
in which local companies and individuals donate gifts that ay
auctioned off, with the proceeds going to designated charitab]
institutions. This year the Tumor Institute received $70,00
for capital outlays.

“Taking all this together, I think it makes a good case stud
in how RMP can spark local enthusiasm and involvemer
Because of this we fully expect the institute to become pe
manent and self-supporting when and if RMP money must b
used elsewhere for other activities. But local support and cor
mitment will remain. This is what we need. This is the geniu
of the RMP approach and its most durable feature.”

 

 

 

 

30 © SDC MAGAZINE
 

 

 

Cancer training for nurses is but one

facet of the medical services Mountain

States Tumor Institute is providing in

the region. Under Dr. Maurice Burk-
holder, Dr. C. Ronald Koons and other

clinical specialists in the community,
the institute is polishing an ambitious

program to help the practicing phy-
sician acquire the latest diagnostic

and treatment assistance for his can-
cer patients.

Koons, a young internist who was

on the faculty at Johns Hopkins and
' studied radiation therapy there and
at the M.D. Anderson Hospital and
Tumor Institute at Houston, came to
Boise because he liked the challenge
of developing a “first-rate” cancer pro-
gram in the region.

“The purpose of the Tumor Insti-
tute,” he says, “is to give this region a
fully staffed and equipped cancer treat-
ment and education center so that
patients and their physicians won’t
have to travel the vast distances they
have been traveling to benefit from
such facilities.” It isn’t uncommon for

 

physicians in the four states to refer
cancer patients as far away as Seattle,
San Francisco and Denver.

“At this institute,” Koons continues,
“we'll concentrate on outpatient treat-
ment, using radiation therapy, chemo-
therapy, conventional X-ray, radium
and a special unit for skin cancer [a
common medical problem in the area].
We are also about to add a physicist
with experience in radiation physics
and radioisotopes. When the institute
is fully operational we expect to offer
about as much as any medium-sized
center in the country.”

Physicians who staff the institute
are emphasizing an interdisciplinary
approach, “There are no ‘stars,’”’
Koons says, “but there are a number
of qualified clinicians with sound train-
ing in the various modes for treating
cancer. We will offer recommenda-
tions only. The community physician
will select the course of treatment and
continue to care for his patient. We
will simply provide specialized diag-
nostic and treatment data.”

DR. C. RONALD KOONS

 

At the heart of the program are the
Cancer Planning Conferences, held
every Monday, Tuesday, Thursday
and Friday, at which community phy-
sicians present cases to the institute
staff. Every effort is made to schedule
live patients, some of whom are
brought in from as far away as Pendle-
ton, Oregon (200 miles), and Twin
Falls, Idaho (120 miles).

Initiative for the conferences re-
mains with the community physician
who decides he would like consulta-
tion, a review of treatment or other
assistance from the institute staff. The
physician contacts the institute, asks
to present his patient and takes respon-
sibility for sending along relevant
X-rays, pathological slides, patient his-
tories and records of any special
medical treatment. If necessary, a con-
ference can be arranged within three
or four days.

Says Koons: “Our aim is to encour-
age the community physician to bring
in any and all cancer problems, be-
cause the staff is seeking the widest
possible opportunity to discuss and
demonstrate newer techniques. In
keeping with our interdisciplinary ap-
proach, we want to stress how differ-
ent modes of treatment—surgery,
chemotherapy, radiation therapy, for
example—can complement each other
to the ultimate benefit of the patient.

“The attending physician presents
his own patient, including pre- and
post-treatment data, and we empha-
size bringing the patient in as early as
possible. The interdisciplinary ap-
proach makes the institute staff both
teachers and learners. We learn from
the community physicians and other
members of the staff.

“Our interdisciplinary philosophy
even carries over to the design of the
institute outpatient facilities here at
St. Luke’s Hospital. Examination and
treatment areas will be close to each
other in an attempt to maximize inter-
action among the attending staff.”

 

 

SDC MAGAZINE §

 

 
 

 

 

 

Cancer training for nurses is but one

facet of the medical services Mountain

States Tumor Institute is providing in

the region. Under Dr. Maurice Burk-
holder, Dr. C. Ronald Koons and other

clinical specialists in the community,
the institute is polishing an ambitious

program to help the practicing phy-
sician acquire the latest diagnostic

and treatment assistance for his can-
cer patients.

Koons, a young internist who was

on the faculty at Johns Hopkins and
- studied radiation therapy there and
at the M.D. Anderson Hospital and
Tumor Institute at Houston, came to
Boise because he liked the challenge
of developing a “‘first-rate”’ cancer pro-
gram in the region.

“The purpose of the Tumor Insti-
tute,” he says, “is to give this region a
fully staffed and equipped cancer treat-
ment and education center so that
patients and their physicians won’t
have to travel the vast distances they
have been traveling to benefit from
such facilities.” It isn’t uncommon for

physicians in the four states to refer
cancer patients as far away as Seattle,
San Francisco and Denver.

“At this institute,” Koons continues,
“we'll concentrate on outpatient treat-
ment, using radiation therapy, chemo-
therapy, conventional X-ray, radium
and a special unit for skin cancer [a
common medical problem in the area].
We are also about to add a physicist
with experience in radiation physics
and radioisotopes. When the institute
is fully operational we expect to offer
about as much as any medium-sized
center in the country.”

Physicians who staff the institute
are emphasizing an interdisciplinary
approach. ‘‘There are no ‘stars,’”’
Koons says, “but there are a number
of qualified clinicians with sound train-
ing in the various modes for treating
cancer. We will offer recommenda-
tions only. The community physician
will select the course of treatment and
continue to care for his patient. We
will simply provide specialized diag-
nostic and treatment data.”

 

DR. C. RONALD KOONS

At the heart of the program are the
Cancer Planning Conferences, held
every Monday, Tuesday, Thursday
and Friday, at which community phy-
sicians present cases to the institute
staff. Every effort is made to schedule
live patients, some of whom are
brought in from as far away as Pendle-
ton, Oregon (200 miles), and Twin
Falls, Idaho (120 miles).

Initiative for the conferences re-
mains with the community physician
who decides he would like consulta-
tion, a review of treatment or other
assistance from the institute staff. The
physician contacts the institute, asks
to present his patient and takes respon-
sibility for sending along relevant
X-rays, pathological slides, patient his-
tories and records of any special
medical treatment. If necessary, a con-
ference can be arranged within three
or four days.

Says Koons: “Our aim is to encour-
age the community physician to bring
in any and all cancer problems, be-
cause the staff is seeking the widest
possible opportunity to discuss and
demonstrate newer techniques. In
keeping with our interdisciplinary ap-
proach, we want to stress how differ-
ent modes of treatment—surgery,
chemotherapy, radiation therapy, for
example—-can complement each other
to the ultimate benefit of the patient.

“The attending physician presents
his own patient, including pre- and
post-treatment data, and we empha-
size bringing the patient in as early as
possible. The interdisciplinary ap-
proach makes the institute staff both
teachers and learners. We learn from
the community physicians and other
members of the staff.

“Our interdisciplinary philosophy
even carries over to the design of the
institute outpatient facilities here at
St. Luke’s Hospital. Examination and
treatment areas will be close to each
other in an attempt to maximize inter-
action among the attending staff.”

 

 

SDC MAGAZINE #®

 

 
i. ~S Bela re Relay (il ae
~ a true revolution from the middle class
unless we develop a health delivery system
MOTE RC a Uae che nce Cyice
_ The middle class, not just the poor, is telling us unmistakably
that there cannot be a continuation of the same situation in health
services. RMP provides a means toward solving this problem by

moving into new and original patterns of health care delivery.’

ROBERT M. METCALFE, MD
ASSOCIATE DIRECTOR
TENNESSEE/MID-SOUTH
REGIONAL MEDICAL PROGRAM

bf