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PROCESS AND BASIS FOR FUNDING PILOT ARTHRITIS PROGRAMS
Summary Statement

been
Pilot arthritis grant programs have/ authorized to be carried

out in 31 Regional Medical Programs during 1975. While program
activities up to a level of $4,737,360 have been approved, the
actual cost of the programs which will be conducted will not

be known until all of the awardees have effirmed that they wiil

undertake the program approved in their Regions.

The new program was made possible by a special Congressional
earmark in the 1974 RMP appropriation of $4,500,000. Under
special guidelines, the RMP's were permitted to apply for pilot
arthritis program grants in addition to their regular RMP pro-
gram applications. Arthritis grant applications were received
from 43 RMP's, in the amount of nearly $15,900,000. In the
review and approval process, the Arthritis Ad Hoc Committee,
and the National Advisory Council on Regional Medical Programs
developed guides on program priorities to govern the review and
appioval cf the arthritis grant applications. The guides advo-~
cated outreach activities from centers, and cont rained approval
of activities which, while otherwise meritorious, appeared to
reviewers to be high cost or collateral activities unlikely

to achieve fruition in the grant year, or not contributory to

patient care delivery improvements.
The arthritis grant review process, conducted in May and

June, 1974, resulted in recommendations for approvel and
funding of the 31 RMP applications at approximately $4,800,000.
In recognition of country-wide needs on arthritis, and that
their recommended approvals exceeded available earmarked funds,
both the Ad Hoc Committee, and the National Advisory Council
requested that the Division of Regional Medical Programs seek
identification of other funds so that all approved grant pro~

grams could be supported.

The review bodies ranked all of the approved programs on
quality and achievability factors to provide specificity with
regard to programs approved for funding with earmarked funds,
and those for which additional funds should be sought. Of the
31 approved programs, the 27 higher ranked programs can be
funded with the earmarked fund. The remaining 4 have been
authorized to allocate other RMP funds in their possession to
pilot arthritis activities if they identify arthritis as a
high priority, but only up to the amounts approved, and only

for the approved activities.

Modification downward of requested amounts of most arthritis
grant applications was imposed by the review bodies in order
to achieve outreach characteristics and development of patient
services, obtain a more cohesive National pilot effort, and
achieve optimal outcome with limited, one-year pilot arthritis

funds. The modification of some of the grant requests was
extensive, and in some instances may result in regional
decisions to abandon the pilot arthritis activity as a
priority activity. For this reason, all letters of award
advised recipients that they cannot spend the grant funds
until they accept in writing to the DRMP the modified pre-
grams approved. The DRMP is waiting for these acceptance

letters.
PUBLIC HEALTH SERVICE
HEALTH RESOURCES ADMINISTRATION
BUREAU OF HEALTH RESOURCES DEVELOPMENT

 

 

 

      

 

Arthritis Ad Hoc Review Committee
. Summary of Committee Recommendations
(By Rank Score)
Rank Total ’ Recommended

Region Score L/ Requested Total
Kansas 85 390,013 242,400 A
Texas 85 356,559 . 244,200
Arizona 80 241,638 215,000
California 80 726,343 397,250
Georgia 80 595,000 200,000
Hawaii 80 461,820 216,000
Mississippi 80 862,409 58,000
Tri-State 80 844,775 213,370
Wisconsin 80 267,857 62,000 \
West Pa. ‘ 78 281,051 140,400 kK
Inter-Mntn. 75 385,463 169,500 ht
Michigan 75 823,413 194,700 | Eo" \9
N. Dakota 75 340, 800 111,000 <r
Arkansas 73 260,011 100,000 |
New Mexico 73 ; 272,765 163,600
Alabama 70 272,360 228, 400
Grtr Del Val 70 385,001 247,500
Ohio Valley 70 711,166 46,500
Towa 65 87,554 87,550
N. Carolina 65 433,962 211,500
Oklahoma 65 . 157,526 66,050
Central N.Y. 60 92,492 70, 200
Metro D.C. 60 845,301 176,900
Virginia 60 188,857 80,000
Colo-Wyo. 52 362,621 174,240
Albany 40 175,975 130,940 V
Puerto Rico . 40 122,541 2,16
Susquehanna 33 254,901 139, 500 yt” ‘\\
Lakes Area 30 602,500 45,000 We fun
Wash /Alaska 21 361,167 75,000 gun’
Tenn Mid<So. 20 420,401 ___ 138,500

($12,584,242) $4,73 737,360 360
Disapproved
Bi-State 164,442
Connecticut 328,183
Florida 115, 700 1/ NOTE: Rank Scores
Illinois 449 ,000 relate. to the’
Louisiana 335,528 modified program, and
Maine 74, 346 not to the original
Maryland 351,759 request.
Missouri . 693,362
Nassau-Suf folk 332,190
New Jersey 200, 000
N.Y. Metro 227,829
No. New Eng. 10,000

$15.866.581
Il,

DIVISION OF REGIONAL MEDICAL PROGRAMS

Review of Pilot Arthritis Program Grants

Review bodies were confronted with 43 applications which requested a
total of $15.9 million against available earmarked funds of $4,275.000.
Reviewers deliberated on ways to extend support for work which would be
most creative and productive within the one-year funding period, and
which would also provide cohesiveness of effort across the country.

The result was a number of Resolutions and Guides to govern program
recommendations. Reviewers recognized that in the context of wide-
spread arthritis program needs, the necessity to prioritize within
available funds required the disapproval of otherwise meritorious
programs and activities. ‘the review Resolutions and Guides are:

OUTREACH

Resolution: The major thrust of approved pilot arthritis programs
shall be outreach.

 

Background: Examples of requests for personnel, equipment, and other
support for centers were noted which appeared to represent an "over-
whelming emphasis on the further development of an on-going center."

This was characterized as “inreach.” It was recognized that some

support of centers is in order to conduct an outreach program. The
center is often the source of reaching out, and upgrading of center
resources to the degree necessary to initiate and conduct outreach is
appropriate. The main thrust, however, should be the improvement of

12 health system, and the respective levels of care
which it can provide. Facilitation of patient access and entry into

the system should be emphasized. The intended thrust of the pilot artn~
vitis program cannot be fulfilled if centers only keep bringing patients
into the centers. While much should be expected of the larger, estab-
lished programs, equal or greater needs and lessons are present in lesser

developed areas.

 

DATA COLLECTION, AND AUTOMATED REGISTRIES AND DATA BANKS
Resolution: Separate arthritis data banks and registries should not be
funded. Program statistics should conform to American Rheumatism
Association (ABA) standards as these are developed.

Backeround: While it is recognized that specific data is required to
plan, conduct, and evaluate pilot arthritis programs, the expenditure of
relatively large sums for a variety of data gathering and analysis activi-
ties, especially those proposed to be automated at many sites, and in
different ways was opposed. it was noted that the ARA is conducting a
study to develop standardized nomenclature and reporting, and these will
be puolished.
II.

IV.

The support of automated data programs with the limited pilot arthritis
funds appears to be premature, and unduly costly in view of the uniform
approach to these needs which is being developed. State Health Agencies
were considered more appropriately responsible for morbidity and pre-
valence data. There is pending Federal legislation which, if enacted,
would more adequately address arthritis data needs.

web

AND OTHER INFORMATION PURPOSES

FILM/TAPE DEVELOPMENT, AND PRODUCTION FOR PUBLIC AND PATIENT EDUCATION.

 

Resolution: Those portions of arthritis program applications which request

support for the purchase of hardware for film and tape production should
not be funded. Consent might be given to the support of software costs

if the program is otherwise approvable. The widespread development of such
materials is not considered wise when superior products can be obtained
through qualified sources. It was suggested that DRIP and the concerned
RMP's cooperate to provide coordinated identification and procuremeat from
central, qualified sources of widely needed film and video tape materials.

Background: While reviewers were personally aware of the capabilities of

films and cassettes for patient and other educational activities, it was
not considered wise to support the volume and diversity of requests made
for these purposes. The needs for such materials is Nation-wide, and
considerable expertise is required to efficiently produce high quality pro-
ducts. The high cost reflected in the applications does not appear to be

a productive way to employ the limited RiP funds. Previous RNP experience
in this area has demonstrated that extraordinary administrative problems
are encountered in obtaining first-rate products, even in facilities with
sophisticated equipment and expertise. There are a number df institutions
which operate high quality audio-visual facilities where equipment presently
exists (iichigan was noted). It was proposed that the DRMP might cooperate
through concerned REP 's to produce selected video tapes, on sudject matter
widely sought, through one or two experienced centers.

PUBLIC EDUCATION (Cand fund raising

Resolution: Activities geared solely to public education will not be sup-

ported.

Background: A number of the arthritis grant applications requested support
for audio-visual equipment, vehicles, printing, publications, and items re-
lated to mailing, etc, for purposes of public education. Distinctions were
drawn between patient and family education, and professional and para~profess~
jonal training, viewed as meritorious and appropriate in the pilot program,
and public education. Reviewers determined that public education was net

an appropriate use of the limited RMP funds. Such activities appear to pe
more appropriate for support by Chapters oi the Arthritis Foundation, local
departments of heaith, and medical societies. Reviewers drew a distinction
between undesirable public education, and other desirable types of education
by noting the use of vans and other equipment used in British Columbia to

provide services to patients, and their families, and local medical and

tay

health personnel about arthritis disease treatment. Another exanole is the
VI.

‘
dissemination of information about diagnosis and treatment of gout, an
eminently treatable disease for which appropriate diagnosis and treatment
is not always rade available outside of centers. Such activities are
appropriate elements of the pilot arthritis grant program,

Specific note was taken of requests for support of overt, or implied fund-
raising activities. Use of Federal funds for this purpose is prohibited.

EQUIPMENT (including vehicles)

Guide: In view of the one~year availability of the RMP arthritis funds,

lease or rental of expensive items of equipment should be seriously con-

sidered before commitments are made to purchase.

Background: Activities without firm continuation support may unnecessar~
ily commit limited funds to equipment which cannot be effectively utilized

when program support ends.
RESIDENCIES AND FELLOWSHIPS

Cuide: Reviewers emphasized compliance with RMP policies with respect to
professional training and education.

Background: Various applications included requests for support of
residencies, fellowships, and other education activities which cannot

be supported under RiP policies.
\ DRAFT (7/12/74)

A NATIONAL PILOT ARTHRITIS PROGRAM TO BE CARRIED OUT IN THE
REGICNAL MEDICAL PROGRAMS

A National pilot arthritis program has been initiated through
one-year grants provided to 31 Regional Medical Programs by
the Division of Regional Medical Programs, Bureau of Health
Resources Development, Health Resources Administration, PHS.
These grants were made possible by a Congressional earmark of
pilot arthritis funds in the 1974 RMP appropriation. It is
anticipated that approximately $4,500,000 will be expended

this year for the special arthritis program.

Indicative of the widespread needs which exist in the arthri-
tis field is the fact that RMP grant applications for pilot
arthritis program support totalled nearly $15,960,000, or
approximately 4 times the available earmarked funds. These
applications were reviewed and analyzed by a technical peer
review body, the Arthritis Ad Hoc Review Committee, and the
RMP policy advisory body, the National Advisory Council on

Regional Medical Programs. These review bodies formulated an

 

arthritis grant review perspective to provide a uniform ana-
lysis of the grant applications so as to detgrmine activity
approvals within available fund limits. In addition to weigh-
ing general application merits, the review perspective, or
guides, provided definition of high priority activities which

appeared to be innovative, practical, achievable, or a combi-
2
nation of these qualities, and which would result in a
Nationally cohesive pilot arthritis thrust. The review
guides advocated outreach services from established medical
facilities, and disparaged support for high-cost, collateral
activities less likely to achieve fruition in the grant year,
or not clearly contributing to patient care delivery improve-
ments. Activities proposed which route +ecoumended for dis-
approval included production of educational films and video
tapes, diversified approaches to automated registries and data
banks, development of publications, expenditures for high-
cost equipment, and requests related to development of medical

center capabilities beyond the level required to support

outreach activities.

The emphasis of the approved pilot program is the extension
of present knowledge in arthritis diagnosis, treatment, and
care through coordinated services which demonstrate improved
patient access to care, and extension of professional services
through expanded utilization of allied health personnel, and
existing communityeresources. Arthritis clinics will be
established in medical centers, community hospitals, and fam-
ily health facilities. Educational programs will increase
the arthritis handling capabilities of hospital and private
physicians, and will equip larger numbers of allied health
personnel to support services in hespitals, clinics, and home
care settings. Increased patient self-care will be demon-

strated through the development of patient/family training
activities. Seminars and workshops will be conducted at

many sites for improved utilization of community medical and
health personnel in arthritis services. Existing health
department personnel and facilities, and health groups such
as the Visiting Nurse Association, local councils on aging,
and operating community health worker training programs, are
cooperating in demonstrations of improved arthritis health care
delivery. Several modest studies to develop criteria for
quality care through provider performance standards are veing
conducted. An industry survey is planned in one Region, and
an@ employee/employer education program will be developed in
concert with better organized occupational therapy services.
Another Region will investigate the utilization of sheltered
workshops in support of patient restoration to productive
activiesi A number of programs are focusing on the problems
of low income rural groups, and others are developing demon-
strations of care delivery to economically disadvantaged inner
city residents. Localities which presently have little, or
no rheumatological resources are being supported in the ini-
tiation of medical school arthritis departments. Across tne
country, Chapters of the Arthritis Foundation are providing
program coordination, dissemination of publications, and
increased numbers of volunteer workers in support of services

and increased patient referrals to local clinics, and physi~

cians.

The constraints imposed by one~year limited funds were keenly

appreciated by the review bodies. It was recognized that
while nuchWvaluable work could be accomplished with the ear-

marked funds, many otherwise meritorious concepts and acti-

vities could not be approved. In this respect, the Arthritis
Ad Hoc Review Committee noted, "... we consider this a very

 

meager effort toward a tremendous problem, and it in no way

reaches a point of beginning to provide a solution of any

definitive kind wee
ALABAMA:

ALBANY:

ARIZONA:

ARKANSAS:

SUMMARY OF ARTHRITIS PROGRAM

Reguest ~ $273,360 Outreach from U.A. Birmingham, to 3 areas

with no rh. services: @ UA Huntsville; UA Tuscaloosa,¢#Coll. of Med.
Methods: patient consultation with teams; trng. PH Nurses to identify

& refer patients; mo'ly conferences to train PH Nurses, psychotherepists,

and phy's asst's: and molig pat. care conf's for practicing physicians.

Reduction - $43,960 In'tout/ pat. study of Spain Rehab. Center.
Reduced equipment/supplies, so as to do more outreach. ,

Approved - $228,400

Request - $175,975 Strengthen Alban Med. Coll. via lab and more
people, and provide educational programs. Develop 3 sat. clinics,
staffed part-time with local phys's. Develop computerized record
systen.

Reduction - $45,035 Computer system and related personnel; 1 satellite
out. Possibly cut personnel and lab in order to do more outreach.

Approved - $130,940

Request ~- $241,638 Develop diagnostic treatment & rehab in 6 counties
around Tucson, building 3 selected communities. Develop a Tucson
Interagency Committee, and a local Committee in each of 3. Develop
consulting teams, with PT backup in each area. Public ed. In-service
ed ~ 6 didactic conferences. Improve pat. transportation.

Reduction - $26,638 Public ed, and patient transport.

Approved - $215,000

Request - $260,011 Establish 12 clinics in larger communities staffed
by local physicians. Employ and train 5 part-time District Health Ed.
Coordinators to work with local committees; 6th PH Educator in

Little Rock. Employ and train 2 new Pt's, and provide 73 working PT's
a 2-day workshop. Public ed. via a PR firm, and develop an automated
registry, 24-hr "What's Your Arthritis Problem" answering service.

Réduction — $96,411 Excessive central RMP administrative funds,
public education, patient registry, and related costs. Reduce clinics
to 6, and commensurate reduction in District Coordinators, and PT
training. Social services should be given larger role.

Approved — $163,600
BI-STATE:

CALIFORNIA:

Request - $164,442 (Eastern Missouri - Southern L1l., centering
on St. Louis) Washington University, St. Louis University, and the
AF Chapter. Send roving consultant team to 12 sites twice a year.
Expand capabilities of Wash 4. lab., & provide St. Louis U. with

a complete lab. equal to Wu's. Provide patient, physician, and
public ed. Develop a long range plaa.

Reduction: - 0 Question direct benefits to patients of WU lab.
expansion which appears research-oriented. Cooperative services
would obviate need for St. LU lab. Question about commitment and
coordination of roving teams.

Approved - $164,442

Request - $726,343 2 major thrusts involve 12 projects: (a) State-
wide data base; and (b) develop quality care, and criteria.
Components (projects):

154A Central Admin. - compile demograph data with facilities of
resources; 1-2 demonstration sites to develop quality of
care criteria, and test.

154B Cal. Med Assn, San Fran. - Statewide patient ed. program,
exhibit for State Med meeting, and provide translation of
leaflets.

154C UC, Davis-extend limited rheumatologist resources to JRA
population in N.E. Cal on a referral basis; extend info and
training to local practitioners.

154D UC, San Fran - add RA services to existing hospital resources
in 11 central Cal. hospitals via roving consultation teams.
Develop teaching program.

154E St Mary's Hosp., San Fran - demonstrate comprehensive care to
RA at single institution level using allied health personnel;
encourage pat. referral, and physician consultations.

154F Stanford U. ~- work with 3 hosp's in Palo Alto area to develop
a data base, and demonstrate automated clinical diagnosis.
Info & computer to be made available to interested hospitals.

154G O'Connor Hosp. San Jose - out-patient demonstration project.
Develop a library. Provide consultation and referral services
for mid-coast area where there are no rheumatoligists.

154H Cedars-Sinai Hosp., LA ~- evaluation of needs in their catchment
area, develop program, & then fit it in new hospital now building.

1541 USC, LA - develop an automated patient registry so as to have
data for epidemiological studies & planning for a system of
clinics in L.A. County. Also identify existing resources.

154] Orange Co. Med. Center - Employ a PT, OT, and Nurse practitioner,
and extend services in County. A second clinic will be established
and patient and physician education developed. Provide physician
and allied health conferences.

154K Loma Linda U. - extend.services in San Bernadine/Riverside
communities, and coordinate with 2 new RA clinics.
CENTRAL N.,

COLO.~-WYO.:

154L Scripps Clinic/Res. Fudn, Ed Center - U.C. San Diego, & Scripps
will cooperate to initiate and operate 2 RA clinics in the
Imperial Valley, demonstrating a comprehensive team approach.

154M UC, San Diego - Cooperate with Scripps, above. Particularly
armed at low income population. Make home, and follow-up
visits.

Reduction - $329,093 154F, G, and H. disapproved. Cut 154B to $5,000
excluding RMP support of public education. 1541 approved in view of
ARA study support. General reductions of equipment and personnel to
foster cost~sharing.

Approved ~ $397,250

Y.: Request - $92,492 Employ a PT, OT, Voc. Counsellor, & 2 Nurse
clinicians, increase clinic sessions from 2, to 3/wk, train 2 Nurses,
to upgrade quality of care, improve operation of the Clinic at
Upstate Medical Center, and provide consultation & referral for
primary physicians. Adopt POMR in hospitals. Add bi-monthly clinics
at Binghampton, and Johnson City.

Reduction - $22,292 Delete lL sec'y, and 1 nurse, cut voc. counsellor
to 50%, and inject social services. Arrange more frequent clinic
visits, such as by visiting each monthly for 1/2 day.

Approved - $70,200

Request - $362,621 The Arthritis Chapter will establish a small,
separate office to provide coordination and administration. UC Med.
Center will bring in local physicians from the 2-State area for
instruction, and work in the UC clinic. Additional personnel will
permit UC to increase cousultative visits into 8 small community
hospitals. Install latest tecting capabilities in the UC Lab.
Expand the present 1/Mo juvenile clinic to 2/mo. General Rose
Memorial Hospital would add staff to expand capabilities, and share
teaching and consultative work with U.C. Ewuipment needed in
Gottsche Rehab. Hospital. Data collecting program proposed to
standardize medical records, and to support care cost analysis

Reduction - $188,381 Relatively high "inreach" should be converted
to increased outreach. Data and registry activities deleted, and
some teaching audio-visual costs. Personnel $ reduced to induce

cost sharing.

Approved - $174,240
GEORGIA:

Request - $595,000 Proposal described GRMP's "Umbrella" system: a
central coordinating point, 2 Regiona, 4 Areas, and identified
community programs. Future contracts will provide teaching,
consultation, and quality of care improvements in all Areas.

Reduction - $395,000 Program should be developed in 2 Areas in
accordance with review guidelines, and reported to DRMP.

Approved - $200,000

GREATER DEL. VALLEY: Request - $385,001 Six institutions are invoived:

HAWAII:

Temple U. will attempt to upgrade 17 community centers. U.P. will
do the teaching including production of 12 films. Hahneman Med. Sch.
will provide pat/fam. workshops, and Children Seashore House will
upgrade juvenile clinics. Thomas Jefferson U. will develop educa-
tional capabilities (physician self-assessment). Albert Einstein
will train allied health personnel. Established evaluation criteria
will be applied, and statistical retrieval from uniform records will
be pursued.

Reduction - $137,501 Automated data, general visual aids production,
and public education activities disallowed. Temple upgrading activi-
ties reduced 50%. U.P. visual aids and self-teaching aids deleted.
Cautioned not to let visiting teams supercede development of local

practitioners.

Approved -— $247, 500

Request - $461,820 Develop a center at H.U., develop a pat. education
program, develope a rhuematological assistant program (Nurses), and
evaluate changes in quality of care. Audio-visual materials will be
developed, and some translated. A good deal of tape and film equip~
ment, and office equipment is requested. Multidisciplinary teams

will visit the islands - 45 trips, plus 6 trips to the Trust Territory.
Clinical services are based at Queens Hospital.

Reduction - $245,820 Support the base structure of an arthritis
program. Delete $150,000 in audio visual production salaries and
equipment; cost-share personnel, and cost~share approved equipment.
Reduce outside Consultant costs. Delete $20,000 subsidy to patient
care costs.

Approved - $216,000
- Oo -

INTERMOUNTAIN RMP: Request — $385,463 Univ. Utah will develop 6 primary and

IOWA:

KANSAS:

5 secondary facilities in the Region, Consultation services will be
bolstered by a relatively large amount of extra-regional people on
services contracts. A "Home and Midway Care Program" involves
multidisciplinary personnel in both patient, and services evaluation
at $20,000 for each of 3 States. Professional education will be
provided at U.U., especially to upgrade primary and secondary
providers, to reduce the existing patient backlog, and to extend
better care. Duplicate patient testing will be reduced by employment
diagnostic and treatment standards distributed to all providers with
reference to RA, osteo., gout, and SLE.

Reduction ~ $215,963 Personnel costs to be cost-shared, and data
processing costs deleted. Reduce equipment costs 40% (cost share),
and reduce travel, and outside consultant costs.

Approved -— $169,500

Request ~ $87,554 Outreach clinics will be established by UI at

Des Moines, and Muscatine. Des Moines is basically a service clinic,
while the Muscatine facility is a patient care demonstration program.
A multidisciplinary team will be developed at each site, and a single
professional education conference will be held using one or two
outside experts.

Reduction — None

Approved — All

Request - $390,013 KU-VA in KC will develop professional/pat. info.
and ed. units in KC, Topeaka, Salina, and Wichita under thocal
sponsorship to provide diagnosis, assessments, and referrals of
patients. Laboratory equipment is requested for the center, and
automated data operations are proposed in connecton with center review
and counselling on local diagnosis and treatment. Professional train-
ing will be conducted.

Reduction - $147,613 Laboratory, IEU, office rental, and office
equipment costs deleted as more appropriate for coverage through local
sponsors’ earning services. Automated data costs deleted

Approved - $242,400
LAKES AREA:

Request - $602,500 - 2 year support to establish 3 clinics,
two in Buffalo (7 Hospitals involved), and one in Erie, Pa. (4 Hospi-
tals involved). provide monthly consultation in each of 8 outer
Counties. 3 Clinics will institute continuing education in the
9 Counties. A Central registry of patients and resources will be
established. The 3 clinics would be directed primarily by a Fellow.

Reduction - $557,500 - delete second year request, plus 2/3rds of
clinics, plus Fellows. Program not deemed viable on a 1-year basis,
and Fellows, depended on for full time manning of clinics, inappropri-
ate for RMP support and for effective teaching relationships with
experienced local physicians.

Approved — $45,000 to establish one clinic with part-time rheumatologi-
cal direction, and/or trained nurse direction.

METROPOLITAN D.C. Request - $845,301 - The D.C. Dept. of Human Resources (DHR)

will provide public education, with some muiti-disciplinary team
surveying and consultation regarding treatment, and home care (VNA).
Incidence will be studied. Freedmen's Hospital (FH) will signific-
antly beef up its services by training callied health people , and
organized inpatient, and outpatient care for the inner city population.
Patients not attending clinics will be identified and brought in.
Home visits and care will expand, as will pat./fam. education. In
additionto multidisciplinary care and home visits, the team will hold
monthly team conferences. Washington Hospital Center (WHC) will
cooperate with Shaw Community Health Center: to improve care through
increased multi-disciplinary diagnosis and treatment. An RN will be
fully trained for continuity operation of the Shaw Clinic, and an

SW will be trained to improve intake and screening for referral to
WHC. The National Orthopaedic and Rehab. Hospital (NORH) will
stimulate local patient referral, perform outpatient diagnosis and
treatment, and seek to improve care quality and continuity. Several
short-term professional and public educational conferences and
seminars are planned. A "Regional Arthritis Directory’ of services
and facilities will be compiled. Georgetown Univ. Hosp. (GU) will
develop 21 slide and video tape teaching/self-teaching programs of

20 min. each on 15 selected subjects aimed at both physicain, and
allied health users. Programs will be provided free to local hospitals,
and libraries. The Arthritis Rehab. Center (ARC) a privately-owned
facility, will establish 2 new community clinics in addition to 3 now
operated.

Reduction - $668,401 Projects from DHR, NORH, GU, and ARC are disapprove

as duphicatory, and/or low priority. FH reduced by pat. transport costs
and 1/2 Admin. Asst. WHC reduced by pat. trans. costs, and.$27,000

in personnel (cost-sharing).

Approved - $176,900 community outreach clinics and services at
FH, and WHC
MICHIGAN:

Request — $823,413 UM will establish a geriatric arthritis
center with both inpatient, and outpatient services for persons
over 55 in Weshentaw County, and coordinated with an on going
gerantology program. Also evaluate present status, and post-care
status to assess comprehensive care results. Professional and
patient education will be performed. Wayne Univ. will develop

and improve mechanisms for health care for RA, and degenerative
joint disease, The care will rest primarily on the nurse clinician,
and is essentially a care evaluation project. Expanded Lab.
facilities are requested. Medical College of Toledo will support
the Northwest Ohio AF proposal with establishment of a clinic at
MCT to provide professional training, support the establishment

of a Div. of Rheumatology, and to stimulate patient referral.

Reduction — $628,713 Wayne State and Toledo components deleted

as inreach. UM proposal reduced in personnel costs through both
position reductions, and cost-sharing, and deletion of automated
data and visual aid production costs.

Approved - $194,700 - for core staff support and development of

the demonstration and educational components which are coordinated
with the Council on Aging, and various local public and voluntary
agencies all of whom will refer patients. Primarily, treating and
care personnel in existing nursing homes and day~care centers will »«
identified, and provided training. Most of the patients involved

is the project are recent releasees from hospital care.

MISSISSIPPI: Request $862,409 A new hospital Mississippi Methodist Hospital

and Rehab. Center, adjacent to MU will allocate 15 beds to arthritis.
There will be a clinic at each, MU, and MHRC, 4 community clinics
around the State. Patients will be classified by ARA standards and
progress analyzed; patient-oriented records will be employed, and

a cost effectiveness study will be conducted. A large education
program includes professional, patient, and public emphases, and
there is a telephone consultation service. Community clinics will
be headed by local internists who will be trained.Audio-visuali aids
will be produced.

Reduction - $804,409 covers items of cost related to the 15 beds,
and other hospital costs, general supplies, a van, audio-visual
production.

Approved — $58,000 covers satellite clinics! budget, and professional
education activities.
NEW MEXICO: Requested - $272,765 The UM and NMAF will cooperate in the
establishment of clinics at Las Cruces, Roswell, and Taos to provide
care, and serve as prof./pat./pub education centers. State and
voluntary agencies, and community hospitals are cooperating. UM will
send multidisciplinary teams to the clinics monthly, and increased
local support/assumption of work will be fostered. Three existing
clinics in Albuquerque are under murse practioner supervision, and
will be upgraned by professional consultations on patients, and
training of personnal at UM and other hospitals. These clinics will
expand patient and public education activities. A Juvenile RA clinic
will be developed in the UM Dept. of Pediatrics. A multidisciplinary
medical team drawn from the Arthritis Foundation Medical Council will
visit all clinic sites, and will organize and help support greater
involvement of local physician, and allied health people, and volunteer
individuals, Pat./Fam. seminars will be conducted. Special pamphlets
and audio-visual materials will be produced, and/or translated for
Indian and Spanish-speaking people.

Reduction - $109,165 Audio-visual production is deleted, one of the
3 clinics, and the juvenile clinic as a separate clinic (apart from
adult services). Automated data activities are excluded.

Approved - $163,600 To establish 2 clinics, one of which may incorporate
juvenile RA Capabilities, the multidisciplinary teams, and professional
and pat./fam. education, as well as the development of greater

experstise in local communities.

NORTH CAROLINA: Requested - $433,962 The AF will provide coordination, organize
professional education programs and provide volunteers' assistance,
and conduct a detection program at Burlington Industries plants. At
Asheville Orthopedic Hospital and Rehab. Center train RN's, and other
allied health personnel to monitor drug toxicity, perform patient
screening, serve (RN's) as physician assistants for follewup, and to
train patients. A station outside OHRC will be established to conduct
retinal function evaluation, and retinal toxicity monitoring of
anti-malarial drugs. UNC €chool of Medicine, Chapel Hill, will expand
its clinic operations (100%), provide a multidisciplinary team to visit
and assist AHEC hospitals to develop model clinics, and develop video
tape educational programs. The Central Piedmont Community Hospital at
Charlotte will establish a paramedical patient teaching program.
Local physician "centers" will be set up with one or more paramedical
personnel working under the local physician. Duke University School of
Medicine will establish outreach clinics, and a series of seminars for
physicians and allied health personnel. Local physicians will be
invited to attend referral clinics with their patients. A State-wide
symposium will be conducted. Training materials will be produced.
Bowman Gray School of Medicine will send multidisciplinary teams
regularly to 3 existing Clinics to improve and expand their capabilities
(N.C. Baptist Hospital, and East Bend Community Family Physician
Assistant Clinic, and the Farmington Nurse Practitioner Clinic).
Reduction - $222,462 - a reduction of positions, and cost-sharing
of the remainder. The AF request is reduced, reflecting excessive
"coordination" proposed. OHRC, Asheville, is reduced to exclude
audio-visual, and support a more achievable coordination effort.
UNC, Chapel Hill reduced to exclude video tape production, and
tighten program. CPCH, Charlotte, disapproved as the scope of
utilization was undetermined, and sintability of some paramedical
activities questioned. Duke U. seminars were halved in cost.
Bowman Gray reduced 50% as the effectiveness of the proposed
activities were questioned.

Approved- $211,500 - The AF will provide coordination especially

with respect to patient referrals, and will provide patients and
physicians with educational literature. Im An industrial complex

will be surveyed and employee/cmployer education developed. Professional
personnel will be trained, multidisciplinary teams will work with
existing and new clinics, and increased utilization of allied health
and local physicians should occur.

NORTH Dakota; Request - $340,800 No. Dakota Medical Research Foundation will
assist and coordinate the establishment of arthritis treatment programs
in Bismark, Grand Forks, Fargo, and Minot which are also AHEC centers.
Participating personnel, and program planzing will be selected, assisted
and coordinated by special committee of public and private persons.
Expansion of patient care services will be accompanied by standardized
patient assessment, treatment, and evaluation reporting. A POMR systen
will be incorporated into and automated data to be processed in the
Dakota Hospital at Fargo. At Grand Forks, Fargo, and Minot, a
multidisciplinary team will conduct twice-monthly clinics; itinerant
services will be extended to homes, and physicians offices, and clinics.
Ambulatory patients will be brought out of centers by extended services.
Public and professional education will be provided.

Reduction: - $229,800 - Reduced program from State-wide, 4 centers, to
pilot 2 centers. Costs reduced accordingly, plus publication and
computer costs. Travel, and consultant costs reduced, as are
personnel, to foster cost-sharing.

Approved - $111,000 to develop 2 centers, with accompanying services
and trials indicated above.

OHIO VALLEY: Requested - $711,166 Request includes 1 from OV/RMP, and 3 from
State of Ohio. U. Louisville will establish a comprehensive treatment
program for low income residents, based at Louisville Gen. Hosp.
Centralized specialist services will be nade available here and
through community and VA referrals. Paramedical and lab. backup
services will be increased, as well as hone care services through VNA.
At Cincinnatti, the AF Clinical Research Center, UC, VA, Drake Hospital,
Good Sam. and Christ Hospitals and local physicians have large back-
logs of untreated cases, mostly minor conditions. "Arthritis Assistants"
(mostly nurses) will be trained patient evaluation and followup, and
OKLAHOMA:

~ 10 -

will comprise part of multidisciplinary teams to provide weekly
visits to 4 existing clinics in Hamilton County. Capability for
specialized lab. tests will be added to the AFCRC, and "assistants"
will be trained to do urinalysis and blood tests for outpatients
under fold salts treatment. A standard patient info system will be
developed per ARA system. The Central Ohio AF will improve
capabilities ar 7 hospitals in and around Columbus through prof-
essional education, doubling clinic frequencies, establishing 3 new
clinics outside Columbus, improving lab. backup services, ann developing
a uniform clinic referral and reporting system. Case Western Reserve
at Cleveland will expand juvenile RA and Lupus services at Abington
House Locomotor Unit. Referral and education will be increased, and
a study conducted on the effectiveness of patient education.

Reduction - $664,666 Louisville, all lab and related costs,
consumable supplies, and patient transportation costs ($67,560),
Cincinnatti, Columbus, and Cleveland programs.

Approved - $46,500 - all Louisville coordination, planning and
operating staff involved in service development training, and

outreach.

Requested - $157,526 ~ UO has no rheumatology division. A new
orthopaedist in coming. Clinics staffed by 1 internist/rheumatologist
recently started at each OU Hlth. Sc. Center, VA hospital. Want

2 full-time rheumatologists in the clinics and expand referral,
treatment, and Physician and Physician Associate training. Referral
services will be developed RA clinics at OUHSC will increase from

2 to 3 times weekly, and clinics will be initiated at OCVAH.
Activities will be related to 10 south-central counties where an
Health Development Area Program is operational.

Reduction - $91,476 - supporting staff, supplies and equipment which
should be borne by sponsoring facilities.

Approved ~- $66,050 to support rheumotologic salaries.

PUERTO RICO: Requested - $122,541 to develop a model clinic at PR Med. Center,

and local clinic at Cagues, or Bayamon. Public and professional
education will be initiated, clinic services will be pianned and
initiated, and data collected.

Reduction - $30,381 - to delete duplicatory planning activities,
publications, lab. equipment, and rental costs.

Approved - $92,160 - to organize and operate clinics, and training
cativities.
SUSQUEHANNA VALLEY Requested - $254,901 Central Pa. AF will coordinate

activities to develop patient and family education, physician and
allied health education, and clinical services. Education at

2 Northern clinics, and 4 southern towns. Visual-aid materials
will be produced. Patient education will also be developed in the
centers. The AF will establish clinical services at Williamsport
Hospital, with satellites at Lock Haven Hospital, and Blossburg
Family Health Center. Services will be expanded at Geisinger Med.
Center, Danville.

Keduction - $115,401 - High proportion of salaries raised concern
re. continuity. $21,000 deleted, and cost-sharing of remainder
advocated. Audio-visual costs deleted, and other cost categories
reduced.

Approved - $139,500 to proceed with clinics, training and outreach
activities. Inreach to be reduced.

TENNESSEE MID-SOUTH Requested — $420,401 - Vanderbilt'U. will be site of new,

TEXAS;

and first, arthritis center and clinic in the region in cooperation
with the VA, and Nashville-Metropolitan GH. Outreach clinics will be
developed, and public, patient and professional education. Both a
juvenile, and adult clinic will be established at East Tennessee
Childrens Hospital, Knoxville. A uniform patient record will be
euployed. Audio visual, vehicles, and large equipment costs are
indicated.

Reduction — $281,901 - vehicles, lab. equipment, hospitalization
costs, and automated costs deleted. Personnel costs to be cost~shared.

Approved - $138,500 - to undertake a more modest, achievable program
in an area which has few arthritis capabilities at present. Clinics,
training and outreach to be pursued. »

Requested _ - $356,559 - Feve Med. Schools and the AF are cooperating
in a State-wide program. A Governor's Conference is pianned. Public
and professional education will be conducted in 48 communities,
including regular clinics. Public forums will be conducted in 402

of all towns of under 10,000 pop. and will involve local physicians
and hospitals in arrangements, and production. A demonstration van
will be developed &employed in south central Texas. Lab capabilities
will be upgraded, & a technician employed at each of the 5 schools,
and practitioner and allied health refresher sessions held at Texas
Tech U. (El Paso, Amarillo). Regional arthritis workshops will be
held at 3 schools for all allied health people. Outreach clinics will
be augmented by physician conferences (1 at each of 3 schools), and
bi-weekly seminars at T. Med Sch., 5an Antonio. A minimal-care
facility will be developed and operated at Galveston to treat and
train seriously handicapped patients.

Reduction - $112,359 - deleted support for the Governor's Conference,
TRI-STATE:

VIRGINIA

public education, lab. upgrading, demonstration vehicle, and
automated data, and required cost-sharing of patient-treating
personnel at Galveston.

Approved - $244,200 - provide professional education, expanded
services, and outreach. The Galveston minimal-care unit strongly
advocated for support.

Request ~ $844,775 - the Robert Bent Brigham Hospital will develop
public and professional educational materials, and seek acceptance
of POMR by practicing physicians and local hospitals. Bostcn City
Hospital will develop a multidisciplinary team to improve care, and
provide outreach to inner city patients. Emphasis is development
of allied health personnel, and services, including physician
assistants. A standardized data reporting system will be developed.
At Tufts New England Medical Center, 8 new community clinics will be
initiated, and 4 existing ones expanded. 12 Nurse clinicians will
be trained; Tufts pediatric services will be improved. Mass. General
Hospital will initiate in Essex County Pilot Program emphasizing
physician education, case comsultations, coordinated community
services, and demorgraphic studies. RBBH, and Boston U. Med. Center
will participate. The New England Rehab. Hospital (for profit) in
cooperation with UM Sch. Med., and Worcester City Hospital, will
develop the clinics at 6 community hospitals, increase professional,
and pat./fam. training, and stimulate exchange of research and
therapeutic information

Reduction - $631,405 - Robert B. Brigham Center, Mass. G.H., and
New England Rehab. Hospital programs disapproved. Others reduced to
delete library and visual aid costs, and reduce personnel and equip-
ment costs.

Approved _- $213,370 -training, clinics and outreach activities
proposed at Boston City Hospital, and Tufts New England Medical
Center (Maine and Mass. satellite clinics).

Request — $188,857 - satellite clinics will be conducted in Richmond,
Norgolk, and the Appalachian area of southwest Va. Each will be
visited every 4-6 weeks by a team of: a physician, a PT, anda

nurse. Assistance will be given on record keeping, as well as

with patients. Plan to hold these at 8 family practice training
centers, and offices of 15 physicians. There will also be 5 regional
workshops. Allied health personnel will be invited to serve in-service
training periods in the program. It is also planned to test the
benefits of early intensive care. A full-time PT, and nurse practi-
tioner will carry out activities -- home visits, clinical therapy,
patient education. Controls will be developed from existing patient
records, A controlled study on Acupuncture is proposed. Vocational

rehab. services will be incorporated into the pilot program.

Reduction - $100,857 - The studies are deleted and clinics are
reduced.

Approved - $88,000 to develop 1/2 the proposed clinics
WASHINGTON-ALASKA: Request - $361,167 - 13 components are presented covering:

administration and coordination; public education; production of a
resource book; a patient transportation system; a telephone consultation
system; PT/OT home services to patients released from hospitalization;
traveling multidisciplinary consultant teams; expand the training
capabilities of Mason House Residential Facility; short-term, in-service
PT/OT training at Virginia Mason Medical Center, and at the Western
Washington AF Chapter; a pediatric clinic; establish an RA reference
laboratory at UW Med. Sch.; development of a physicians assistant
training program; and continuing education for physicians.

Reduction ~ $285,167 - deletes all but the 2 OT/PT components, and
the vans for traveling PL/Ot's.

Approved - $75,000 to conduct PT/OT outreach and PT/OT training.

WESTERN PENNSYLVANIA: Request - $281,051 - 2 yr's support requested. A

WISCONSIN:

coordinated network of 6 centers will be developed, with monthly
consultation visits, and employing a demonstration van. Short-term
professional training courses will be conducted. A regional directory
of services will be produced. Referrals to sheltered workshops will

be developed. Public education, and a uniform reporting system will

be developed. A van will be employed for patient and physician training.

Reduction - $140,651 - to delete public education, and automated
data activities.

Approved - $140,400 - to establish centers, conduct training, develop
consultative and referral activities, and develop the directory. The
van should be leased.

Requested - $267,857 - the Wisconsin AF will administer and coordinate
the program. It will collect State-wide data and compile a directory
of services. This will be done by a SW/Nurse team. A Health Educator
will assist and coordinate patient education at treatment units.
Nursing standards will be developed after a study of nursing care on
2 well-defined groups of patients. A committee of physicians, with
other professional participation, will develop standards on Medical,
Surgical, and physical care of 2 or 3 common diseases. A multidiscip-
linary teaching team will be formed to provide 1-2 day training
sessions at local hospitals. Public education will be developed.

A study on patient education will be conducted to develop a model
program to (a) establish education quidelines, (b) identfy outcome
criteria, and (c) disseminate the model.

Reduction - $205,857 - activities which appear to be more traditional,
or suitable for AF support.

Approved ~ $62,000 - to carry out the Quality Assurance of Nursing
Care study, the patient education study and to support the multidiscip-

linary teaching team.
DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE
PUBLIC HEALTH SERVICE
HEALTH RESOURCES ADMINISTRATION
ROCKVILLE, MARYLAND 20852

 

February 21, 1974 BUREAU OF HEALTH
RESOURCES DEVELOPMENT

TO ALL RMP COORDINATORS, NATIONAL ADVISORY COUNCIL MEMBERS, AND
REGIONAL HEALTH ADMINISTRATORS, PHS

SUBJECT: RMP Arthritis Initiative Under the 1974 Appropriation
Earmark of $4,500,000

Guidelines relating to applications for arthritis funds "earmarked"
in the RMP 1974 appropriations, and a brief background statement on
arthritis, are enclosed. Included in the guidelines are application
instructions and review criteria. These materials were developed
with two audiences in mind --- the RMP's which must apply for the
funds, and individuals or groups who may be interested in developing
project proposals.

Our distribution of these materials is to the 53 RMP's, the Arthritis
Foundation Headquarters, and other interested agencies. These agencies
will send an announcement about the availability of the application
materials and a list of RMP Coordinators and addresses from which
interested parties should obtain specific information.

Since the arthritis "earmark" is from FY 1974 funds, the review of
applications and the award of grant funds must be completed by

June 30, 1974. Thus, we are all under severe time constraints.
Applications are due in DRMP, Room 114-18 by close of business on

May 6. No applications received after that date will be considered.
Please note that the room number for the receipt of arthritis appli-
cations is different from the room number to which regular RMP program
applications are to be sent.

Several points from the attached materials need immediate highlighting:

1. Regional Medical Programs will submit the application for
arthritis "earmark" funds, incorporating those project proposals
which have undergone CHP review and comment and have received
Regional Advisory Group approval, as is normal for other
activities proposed for RMP funding, i.e., the normal review
process applies.

2. The applications for "arthritis" funds, however, should be
submitted as a separate application to the Division of Regional
Medical Programs. The arthritis applications will compete for
the earmarked arthritis funds, only.
-2-

3. Applications will receive technical review at the national
level by consultants assembled in May by the Division of
Regional Medical Programs for this specific purpose.

4. The National Advisory Council on Regional Medical Programs
will review the applications during its June, 1974 meeting;
the Council will approve or disapprove the applications and
recommend funding levels to the Director, DRMP.

5. The Director, DRMP, will inform, in writing, each RMP of
Council recommendations concerning its application and the
amount of supplemental funds that will be awarded from the
"earmark",

6. The “earmark” supplemental awards will be effective
July 1, 1974.

Should you have questions, please call the Operations Officer assigned
to your Regional Medical Program.

 
 
 

cerely yours,

dudoaul g

Cleveland R. Chambli

Acting Director

Division of Regional Medical
Programs
ANNOUNCEMENT REGARDING APPLICATIONS FOR ARTHRITIS FUNDING
The Division of Regional Medical Programs has announced that $4.5 mil-
lion will be awarded in FY 1974 to Regional Medical Programs for one

year program development in the arthritis field.

Applications for the special arthritis funds are due in the Division of

Regional Medical Programs by close of business May 6, 1974. All appli-

cations will receive technical review by an ad hoc panel of consultants

in mid-May, 1974, and by the National Advisory Council on Regional Medi-~
cal Programs during its June 1974 meeting. Awards will be made prior

to June 30, 1974 for the period July 1, 1974 - June 30, 1975.

All applications must be submitted to CHP (a) and/or (b) agencies for
review and comment. Anyone interested in applying for these funds should
contact the Regional Medical Program serving the geographic area for
information regarding guidelines, and the RMP's schedule for submission

of project proposals for review and Regional Advisory Group consideration.

Further information may be obtained from Mr. Matthew Spear, Division of

Regional Medical Programs, Parklawn Building, Rockville, Maryland 20852,

telephone 301/443-4385.
A.

GUIDELINES AND REVIEW PROCEDURES FOR ARTHRITIS
PROGRAMS

BACKGROUND

Under P.L. 93-192, Congress appropriated up to $4,500,000 for planning
and development of pilot arthritis centers in 1974. This document sets
forth the governing RMP arthritis program guidelines and related infor-
mation for activities to be carried out with these funds. In develop-
ing the guidelines, the Division of Regional Medical Programs has had

the benefit of consultation and advice from RMP coordinators, the
National Institute of Arthritis, Metabolic, and Digestive Diseases,
members of the American Rheumatism Association, and the National Advisory
Council for Regional Medical Programs.

PROGRAM EMPHASIS AND DEFINITION

The term "pilot arthritis centers" is defined for purposes of this RMP
initiative as organized pilot programs to develop optimal delivery of
care to arthritis patients in a defined population. The goal of the
arthritis program is to develop, strengthen, and improve arthritis care
delivery in order to obtain more accessible, efficient, and high quality
care for victims of the arthritis diseases. In this perspective, the
traditional view of a center is broadened to include the medical service
area. Improved extension of advanced treatment and care methods, and
improved patient referral practices, should be facilitated by coordina-
tion of the collective health and medical care provider system of the
area. Linkages of these elements of the system should bridge the gap
between research and clinical investigations, and the care which is

made accessible to arthritis patients.

Programs will be developed and processed through the local RMP's in

order that Regional expertise and assistance will be available to
applicants. Arthritis programs should benefit from and contribute to

the health care delivery experience and resources existing in the Regions.

TYPES OF ARTHRITIS PROGRAM ACTIVITIES

Activities developed should contribute to organized programs of arthri-

tis patient services. Existing and expanded skills and resources at all
community levels should be united in the provision of care to arthritis
patients in the population served. Programs approved for support should
display coordinated courses of actions which can result in exemplary
demonstrations of community health resource mobilization to meet the treat-

ment needs of the community's arthritis patients.

Both care providers (physicians, nurses, and allied health professionals),
and consumers should be involved in planning and developing proposed
pilot programs. Characteristic activities contemplated within pilot
arthritis programs include, but are in no way limited to the following

examples:
Improvement of community arthritis clinics to broaden the care
delivery base (especially outpatient care), as well as to aug-
ment multidisciplinary diagnosis and treatment of adult and
pediatric arthritis patients.

Home, and "mid-way" care programs to improve care access, and re-
duce long term or chronic treatment workloads on hospitals and
clinics.

Center-to-center, and center-to-clinic linkages of services which
expand the specialty base of patient services, and accelerates the
dissemination of advanced care, especially restorative and rehabi-
litative methods and techniques. Particular note should be taken
of opportunities to relate to Veterans Administration facilities,
vocational rehabilitation programs and other private and public
operating health services. Maximum utilization of existing care
delivery resources should be obtained.

Community advisory bodies representing provider and consumer inter-
ests to maintain surveillance and evaluation of activities, and
facilitate the development and coordination of community services
for arthritis. Such groups might also establish liaison with other
arthritis and chronic disease programs, as well as undertake studies
of arthritis care delivery problems.

Alternative sources of service funding to sustain program viability
when RMP funding ends. In this respect, it would also be useful

to determine the magnitude of the arthritis problem, and the costs
of different modes of care delivery.

Program-wide reporting system to aid patient referral, prevent
patient loss from the system, improve continuity of care, reflect
program progress and indicate program deficiencies to program
authorities, and provide the base for program evaluation.

Standards of quality care for different categories of arthritis,
and for effective utilization of different levels of care pro-
vider personnel and facilities.

Public education programs to motivate patients to seek qualified
provider services, and to formulate more positive public atti-
tudes toward arthritis and its crippling effects.

Professional education to refresh or expand the responsibilities
of physicians, nurses, and allied health personnel in arthritis’
therapy, and to motivate united action against arthritis disease.
Existing seminars, and health service/education consortiums should
be utilized to determine manpower needs, develop curricula, and
improve education and training.
D. OBJECTIVES OF PILOT ARTHRITIS ACTIVITIES

1. Patient Care

a. Improve patient access to high quality care, including multti-
disciplinary treatment planning, and including conservative
management to prevent, delay, or reduce pain and loss of
function.

b. Expedite referral of patients to appropriate care in the least
care-intensive setting.

c. Improve diagnosis and treatment.
d. Reduce loss of work caused by arthritis.
e. Reduce pain and disability due to arthritis.

2. Facilities and Services

a. Integrate arthritis services with existing health care services.
b. Provide optimal utilization of available health personnel.

c. Develop new care delivery methods responsive to special commu-
nity or patient needs.

d. Accelerate exchange of advanced technical and semi-technical
information.-

e. Develop an effective program evaluation system.

E. FINANCING

Awards for approved pilot arthritis programs will be in addition to the
regular RMP grant award. The amount allocated for arthritis will be
indicated under "Remarks" of the Notice of Grant Award (Form HSM-457).
Arthritis funds may not be rebudgeted to other activities without prior
written approval by the Division of Regional Medical Programs.

To avoid misunderstanding, applicants should be clearly advised that the
arthritis funds provided in PL 93-192 are available in FY 1974, only, and
these will be one-time grants. They shoudd also be made aware that the
earmarked arthritis funds must cover both direct and indirect costs of
their arthritis program requests. The funded programs should include
development of third-party payment mechanisms, and rigorously seek recov-
ery of costs for services to maintain program viability. Existing restric-
tions on the use of RMP funds apply to these grants; e.g., direct patient
care costs, basic education and training, research, construction, etc.

RMP staff counsel to applicants should go beyond discrete fund restrictions
to include advice about known Advisory Council preferences, and previous
activity approaches which have proved impractical.

3
F. APPLICATION REQUIREMENTS

Applications for support of pilot arthritis programs should be submitted
separately (not included as a section) from applications for regular RMP
program support. However, discrete or different arthritis programs with-
in the same RMP may be presented in a single application.

For each application (Form RMP-34-1), only one Face Page (Page 1), and

one set of Assurances and Certification (Page 2) are required. The Face
Page should show the entire amount, both direct and indirect costs, if

the application includes several discrete program proposals. Each dis-
crete pilot arthritis program proposal involving different local sponsors
(or applicants) must have a separate Page 3 and Page 16 for each separately
sponsored program component, or activity.

The Form 15 should be employed as the first, or face page of a complete
Program Description as noted below. After the appropriate boxes are
completed, the Program Description should be started in Item 11, entitled
"Proposal", continuing on additional pages to describe the essential
points or elements noted below. Descriptions of each component, or ele-
ment of the overall arthritis application should normally be less than

20 pages.

PROGRAM DESCRIPTION

In presenting the arthritis Program Description, applicants should be
responsive to the four pre-printed questions in Item 11, on the Form 15.
As a categorical, earmarked program, arthritis proposals must provide a
comprehensive program description, as distinct from the summary of on-
going program for which the Form 15 is normally used.

A description of the substantive nature and activities of each component
of a pilot arthritis program is required (component examples: establish-
ment of clinics; patient services standards; home care delivery, etc).
The description should include the following specific information:

1. Activity: What is planned to be done.

2. Plan: What is the sequence, or schedule of salient events, and how
do they relate.

3. Location: Where the activity will be conducted geographically, or
organizationally (hospitals, clinics, rural areas, named suburbs, etc).

4, Responsibility: Name, title, and location of person responsible to
conduct or monitor the work, if different from the Director named in
Item 7, Form 15. This person's authority, and the manner in which
directive action can be taken to maintain momentum should be indicated.

5. Objective: The end result to be achieved should be stated in quanti-
tative measures, insofar as possible; e.g., increased # of patients
to be brought into treatment, increased # of categorical professional

4
personnel to be activated in the referral/treatment system, increased
population to be served by a clinic or coordinated services operation,
new methods to deliver care, etc. It may be useful to differentiate
immediate impact under the grant supported program from post-grant
momentum.

6. Benefit: (May be identical to No. 5, Objective) What quality or
quantity of the service area's arthritis problem will be ameliorated,
or controlled?

7. Resources: Identify both new and existing personnel, equipment,
supplies and facilities required to carry out the program. Item 2,
Plan, and Item 10, Budget, may be related to this discussion. It is
useful to show how the capabilities of existing services and facili-
ties are being improved, or expanded. New services should be clearly
identified.

8. Continuity: Foreseen needs and prospects to maintain program viability
after the grant period should be identified so that their further
attention during the grant period will be an integral part of the pro-
gram development activity.

9. Evaluation: A formal plan should be developed with appropriate cri-
teria and schedulled "pulse-taking" to measure progress, identify
problems, and permit eatly action on any program deficiencies.

10. Budget: In addition to the budget summary (Page 16, or Form 34-1),
a detailed budget should be prepared which itemizes personnel posi-
tions and costs, and identifies specific equipment and supply pur-
chases proposed. Full-time, and part-time personnel effort should be
indicated. Care should be exercised to exclude furniture and supply
items which are normally covered by indirect cost allowances. Non-RMP
program support should be indicated in all cost categories. RMP grant
funds cannot be used to supplant existing arthritis support.

H. APPLICATION SUBMISSION REQUIREMENTS

Arthritis program applications must be received by the Division of
Regional Medical Programs (DRMP) by May 6, 1974. Applicants should be
provided a clear understanding of the submittal deadline required by the
servicing RMP in order to meet this schedule. The RMP must conduct a
review process which includes review and approval by the Regional Advisory
Group (RAG), and the (a) and/or (b) agencies of Comprehensive Health
Planning Service (CHP). The Regional Office of the Department of Health,
Education, and Welfare, (RO, DHEW) serving the applicant's area must be
advised of RAG-approved applications forwarded to DRMP.

The number of copies of approved arthritis programs required at DRMP is
26. This is the original, signature copy, and 25 additional copies of
the completed application. Complete applications include, in addition
to necessary forms, and Program Description noted above, a transmittal
letter, a report of RAG comments and approval, CHP comments, and program-

5
related letters and other written communications, such as cooperation
affirmations, or agreements.

The arthritis grant applications must be postpaid by the sending RMP.
They should be addressed to:

Mrs. Sarah J. Stlsbee

Division of Regional Medical Programs
Parklawn Building, Room 114-18,

5600 Fishers Lane,

Rockville, Maryland 20852

APPLICATION PROCESSING AT DRMP

Processing of arthritis program proposals at headquarters requires four
steps which must be completed by mid-June:

1. Staff review of each proposal to assure completeness, and com-
pliance with DRMP policies.

2. Technical review by selected arthritis and health administration
professionals.

3. Review and approval by the National Advisory Council for Regional
Medical Programs.

4. Notification to RMP'd of Council decisions.

DRMP REVIEW CRITERIA

The criteria by which arthritis programs will be evaluated at headquar-
ters are indicated above: i.e., B. Program Emphasis and Definition (see
"goal" statement); D. Objectives of Pilot Arthritis Activities; and

G. Program Description. To summarize the major points in these Sections:

1. Programs must comply with RMP, and CHP policies and requirements.

2. Programs must clearly contribute to improved patient access, and
quality of care.

3. Programs must build on existing health care services, thereby
improving health care delivery efficiency.

4. Programs must display efficient utilization of personnel and
facilities.

5. Program activities aimed at increasing numbers of patients, profes-
sionals, or services, must show why the numbers are necessary, or
desirable, and the basis of their computation, or estimation. 1/

1/Where firm evidence or documentation is not
immediately available, it is appropriate to
describe how it will be obtained. However,
planning, or negotiations should not normally
comprise the totality of the grant-supported
activity.
Programs purporting to benefit some professional, or patient group,
or locality, must reflect the beneficiary's approval or willingness
to participate in the proposed activity. 1/

Programs involving more than one group, institution, or community
must be accompanied by signed statements of the nature, extent, and
commitment to cooperative work. 1/

Programs must be professionally acceptable.

Program end-results must be feasible within the grant period, or
show liklihood of continued non-RMP support to their planned
compdetion.

There must be an effective program evaluation activity which will
be applied, and which is capable of providing meaningful informa-
tion (feedback) to responsible officials who are empowered to take
necessary action.

1/ Where firm evidence or documentation is not
immediately available, it is appropriate to
describe how it will be obtained. However,
planning, or negotiations should not normally
comprise the totality of the grant-supported
activity.

 
BACKGROUND ON ARTHRITIS

This is a summary statement about arthritis to provide staff with a basic
understanding of the disease, and salient problems. More complete infor-
mation can be obtained from local chapters of the Arthritis Foundation,
and local rheumatologists, orthopedists, and allied health professional
personnel engaged in arthritis therapy, and care.

The term "arthritis" literally means inflammation of a joint. It is
generally used, however, in reference to 80 - 100 different conditions
which cause aching and pain in body joints, and connective tissues.
The major forms of arthritis are chronic diseases.

Arthritis is the major cause of crippling, and among the chronic diseases,
is second only to heart conditions in limiting activity, and causing days
of hedtdisability. Systemic forms of arthritis damage organs, including
the eyes, heart, lungs, and kidneys. The causes of arthritis are unknown,
but medical capability exists to reduce pain, and prevent, delay, or
reduce crippling in up to 70% of the patients.

The most recent information on arthritis disease prevalence was obtained
in the 1969 National Health Interview Survey:

20,230,000 Americans suffer arthritis, rheumatism, gout, and
other arthritis-like conditions.

18,315,000 suffer arthritis (pyogenic and nonpyogenic acute arth-
ritis, adult and juvenile rheumatoid arthritis, spondy-
litis, osteoarthritis, and allied conditions).

992,000 suffer rheumatism (polymiositis, dermatomyositis, ftbro-
sitis, lumbago, torticollis, and other unspecified
rheumatisms).

753,000 suffer gout exclusively (data indicated 968,000, includ-
ing 215,000 persons counted with other complications).

170,000 suffer "arthritis-like" conditions (mostly psoriatic
arthritis).

--- (an estimated 100,000 - 400,000 patients, not included
in the data, suffer systemic lupus erythematosus, pro-
gressive systemic sclerosis, polyarteritis, and peri-
arteritis).

While in the aggregate, arthritis is mast common among the elderly
(everyone gets it as age progresses), ali age groups and both sexes

are respectively the principal risk groups for various arthritis diseases.
The prevalence of arthritis in women (44.9 %) approaches twice the rate
for men (28.7 %). Gout is twide as prevalent among men, as it is among
women. It appears that rheumatic disease is more prevalent among nonwhite
males than white males after age 65. The nonwhite prevalence is less in
the under-45 age group. In the U.S., there is no marked variation in the
prevalence of the three principal disease categories on the basis of
geographic region, or place of residence. However, while the highest
patient numbers appear in SMSA areas, arthritis prevalence rates are
higher outside metropolitan areas, peaking in the farm population. The
prevalence of arthritis and rheumatism is higher among individuals with
family income of less than $4,000 per year, than it is in other income
groups.

Osteoarthritis is the most common form of arthritis. It is associated
with aging, and degeneration of joint tissues, and is most frequently
observed in active men. Rheumatoid arthritis is the second largest cate-
gory of arthritis diseases, and occurs most frequently in women under
age 50. Gout occurs most frequently in men, increasing with age, and

is the only arthritic disease which can be medically controlled. Sys-
temic Lupus Erythematosus, a disease of the connective tissues producing
changes in the structure and function of the skin, joints, and internal
organs, is more prevalent in young women. A serious pediatric disease
is Juvenile Rheumatoid Arthritis, occurring in children under 16 (also
suffered by adults), which can stunt growth, blind, cripple, deform,
disable, and can kill in its systemic forms.

Although acceptable programs of comprehensive care for arthritis patients
are available, they are not generally offered to a large portion of the
arthritic population. Arthritis clinics are not numerous, and the
Arthritis Foundation reports less than 50 university~affiliated "centers
of excellence’. The primary interest in most centers is clinical investi-
gation; care is oriented to patients with acute crippling, or fatal
disease entities.

Citing the Arthritis Foundation, and Federally-supported reports:

1. Only about 20% of persons reported with some form of arthritis in
the 1969 National Health Interview Survey were under physician's
care for their disease.

2. Only 3.1% of the people who know they have arthritis were reported
to be under the care of rheumatologists.

3. Physicians are reluctant to refer their arthritic patients to
rheumatologists.

4, Rheumatologists, orthopedists, and physical therapists are not being
utilized to the fullest potential.

5. There is a general lack of knowledge among physicians and surgeons
treating the arthritides about the existence, functions, and capa-
cities of community health agencies and facilities.

6. There is a shortage of physical and occupational therapists, and
social workers in arthritis service.

7. Rehabilitation services are not adequately utilized in the care of
arthritis patients.

8. Third-party payers are not actively seeking to support arthritis
patient care.

9. There is widespread apathy and resignation about arthritis therapy
capabilities among both practicioners, and patients.

10. The annual economic cost of arthritis in the United States, accord-
ing to the Arthritis Foundation, is $9.2 billions.