ce i NRE IIt. ACTIVITIES AND ACCOMPLISHMENTS — NARRATIVE Page General ...ccccernccccceenccccccvcceesscsceves L Availability and Accessibility of Care........ 8 Improved Utilization of Manpower .....+-+-eeee12 Regionalization and Kidney Disease Programs...16 Quality of Care ...... ce eeee Paes eee ee eae ew ae «+20 Program Activities ....... ccc eee c cere eee e000 25 © IIL. ACTIVITIES AND ACCOMPLISHMENTS - NARRATIVE A. General There was a marked expansion in the level of RMP activities over the 3-year period of 1970 to 1972. This was a direct result of the signifi- cant increase in the availability of grant funds in 1972 as compared to the previous years and thus in the awards to the 56 Regions. In fiscal year 1970, awards to the 56 RMPs totaled $78.2 million, while in fiscal year 1971 they totaled $70.3 million. Funding totaled $111 million in fiscal year 1972, an increase of $40 million or over 50 - percent. The expansion in operational activities was even more dramatic. At the end of fiscal year 1971 (June 30, 1971) roughly 600 operational projects were receiving support through the 56 Regions. One year later (June 30, 1972), just over 1,000 operational projects were in progress. In addition to this expansion in the level of RMP-initiated activities, there has been increased attention given to the relationship between activities relating to particular categorical diseases, and those relating to more comprehensive problems in the health delivery system. Fiscal year 1972 saw an acceleration of the longer-term trend of broadening the categorical emphasis of Regional Medical Programs, so that the program might promote the integration of such categorical activities into the broader health care framework, rather than allowing such efforts to fragment the delivery system. Not only is it possible to improve compre~ hensive care through the input of such categorical efforts, but frequencly the effectiveness of particular disease efforts is improved by increasing public access to those efforts. This often requires collaborative work which ties the primary and ambulatory care networks through which people - enter the health care system, to the more specialized care related to heart disease, cancer, and other specific diseases. Thus RMP support in FY 72 included a range of efforts to improve care in terms of not only single disease entities, but also in terms of a variety of multicategorical programs and others truly comprehensive in nature. Among operational activities addressed to individual disease problems, there have been some significant shifts over the past few years. The major result of these shifts is that there is now a far greater balance among the several categorical diseases specified in title IX (i.e., heart disease, cancer, stroke, kidney disease, and other related diseases). The shifts in funding from FY71 to FY72 are shown in the summary table below: FY 71 FY 72 No, of No. of Net Projects Amount Projects Amount Change Heart and Hypertension 156 $11.7™ 124 $7.4M -$4.3M Cancer 89 6.2M 98 6.5M + 3M ‘Stroke 65 5.5M 57 4.2M - 1.3M Kidney " "22 1.5M 74 6.2M . +4.™ Other (e.g. Diabetes, Pulmonary Disease) 41 3.5M 77 5. 2M + 1.7M The fourfold increase in the funding of operational projects concerned with kidney disease largely reflects the response of the RMPs to the Congres- sional priority on end-stage renal disease programs. The significant decrease, nearly 40 percent in the funding of operational projects focused exclusively on heart disease is directly related to the gradual disengage- ment of RMPs from coronary care demonstration and training activities. This had, until recently, constituted the single largest discrete area of RMP activity. That task, the making of high quality coronary care far more readily accessible to the entire population, is not finished. Considerable progress has been made, however, and Regional Medical Programs have contributed to that progress. Two points highlight that contribution. In the 3 year period, 1966-69, over 7,000 nurses had received coronary care training as a result of the efforts of the 56 RMPs; and by the end of fiscal year 1972 that figure well may have risen to 10-12,000. That such specialized facilities and services are more widely available in illustrated by the fact that the Maine RMP's five-year Coronary Care Project has assisted 48 of that State's 59 community hospitals in their development of coronary care capabilities. Prior to the initiation of this project there were only four hospitals in Maine with CCUs. Similarly, 250 of Arkansas’ 1,700 physicians, most of them from rural areas where there are few cardiologists, have been trained in the care and treatment of acute heart disease in CCU settings as a result of Arkansas RMP funding. 4 As trained personnel have become available, the hospitals in that state have added intensive care units. In 1966 there were three such units; by 1971, 40 were operational with another 50 hospitals planning them. ‘ RMP efforts in support of multi~-categorical and comprehensive programs increased markedly in FY72 over previous years. Funding for such projects rose from $16.8 million in FY71 to $46.7 million in FY 72. Multi-cate- gorical efforts are aimed at improving the utilization of resources which might potentially be used for a single disease focus, but which can serve to include a variety of diseases with some redirection of effort. Particularly in areas of training and some patient care demonstrations, resources can be used most efficiently by broadening the focus to include more than-a single disease focus. The following types of activity point out how these types of activities can serve to cover a variety of disease entities: ‘North Carolina is involved in developing a model system which rapidly screens adults to detect signs of diseases of the circulatory system, involves a minimum of medical manpower, and incorporates referral to physicians and follow-up procedures which can considerably reduce the incidence of disabling and fatal events. Funded under a grant from the North Carolina RMP, the North Carolina and Forsyth County Heart Association are conducting a pilot screening project with three population types: low-income urban residents, rural residents, and employees in industry. Tests are designed to detect possible hyper- tension, heart disease, impending stroke, diabetes, and anemia. The program is utilizing about 150 volunteers and two nurse coordinators, as well as a small administrative staff. Volunteer groups of physicians and allied health personnel are securing the cooperation of the medical community in accepting referrals and providing for follow-up of the medically indigent. - The need for additional training for personnel serving the 12,000 nursing home beds (93 percent occupancy) in Arkansas is indicated by the fact that the patients are cared for by 4,000 aides, 265 LPNs and only 125 full-time registered nurses. The nurses have been active in a series of workshops held in central locations by the Arkansas League for Nursing. The workshops, however, did not reach aides and LPNs. A training program sponsored by the Arkansas League for Nursing and the RMP is attempting to change this by on-site workshops designed for the LPNs and aides. The ultimate goal is to improve the care and facilitate the rehabilitation of heart, cancer, and stroke patients in the State's nursing homes through one and two-day annual workshops in each of the sub-regional communities throughout the State, . RMP is also making increasing efforts to develop projects of a comprehensive nature which deal with major pieces of the health care system. Many of these attempt to improve accessibility and availability to various components of the health care system, both at the level of ambulatory care and more specialized care. Others deal with efforts aimed at quality assurance and assessment. The expanding range of activities which RMPs have become engaged with in responding to local needs and problems include the following: * Emergency Medical Services was highlighted as a national health priority in the President's Health Message in January 1972.. By the end of fiscal year 1972, less than 6 months later, 36 RMPs had responded to the priority with over 50 EMS proposals. ‘As a result, additional funds of $8.4 million were awarded to 28 Regions for new EMS operational projects in fiscal year 1972. * Regional Blood Banks - The country's first statewide Regional Blood Freezing Program was among the projects initiated with support from the New Jersey RMP last year. That program will double the supply 6 of frozen blood in New Jersey in one year, blood needed as replace- ment for cancer and surgical patients, individuals on hemodialysis, and rare-blood types. It also seeks to organize a system for rapid. delivery of blood.and improvement of donor programs throughout the State. One other general development has been clearly discerned in the last few years, although it is still of modest proportions. That relates to growing inter-regional cooperation and activities. A few examples in the way of illustration: * Cooperative development and funding of operational projects by adjoining Regions as reflected by a recently initiated rural health clinic effort jointly funded by the Tennessee Mid-South and Ohio Valley RMPs. As a result, residents of three Appalachian communities in eastern Tennessee and Kentucky will have full-time health care available. The RMP funds will allow daily operation of several clinics, each staffed by a nurse practitioner, a health aide, driver, and an outreach worker. The area served has no resident physicians and over 57 percent of people living there have annual incomes of $3,000 or less. * The development by the 14 Southeastern RMPs just about one year ago of a Committee on Quality of Care Assessment. That Committee and its supporting staff resources are drawn from the Regions. It has as one of its principal purposes, the constitution of an inter- regional resource to provide technical assistance, consultation and guidance relative to the development and implementation of mechanisms for quality of care assurance and monitoring to any group or organization (e.g., local medical society, HMO, community hospital) requesting such. Its activities, which are now supplemented by a small contract from RMPS, included a two-day Conference on Quality of Care Assessment held in Atlanta this June aimed at providing an opportunity to the state medical society members and staffs of the 14 RMPs in the Southeast to improve their knowledge and skills in assessing the quality of medical care. Elements of the end-stage kidney disease programs of the New Jersey, Nassau-Suffolk, and Metropolitan New York RMPs would be integrated by a pending proposal. The Community Blood Center of Greater New York, acting on behalf of these three Regions, is the applicant. © B, Availability and Accessibility of Care Regional Medical Programs are supporting a wide variety of activities aimed at increasing the availability and accessibility of health care, particularly in the target disease areas. They address such problems as the acute lack of health manpower in rural and inner-city areas; the poor utilization of physicians and allied health manpower in most medical trade areas; andthe uneven availability and accessibility of health services, again most scarce in rural and inner-city areas. Special efforts to improve availability and accessibility are beng made in terms of minority and inner-city populations and in rural areas. Minority and Inner-City Populations: In fiscal year 1972 activities , directed at special taraet populations such as Blacks, Spanish- ©} Americans, and Indians more than doubled, from 46 projects and $5.4 million to 147 projects with $17 million in RMP funding. Some examples are as follows: * More than 5,000 black children in 20 Grand Rapids, Michigan schools have been screened in a massive, free program of testing for the crippling, fatal disease, sickle-cell anemia, a hereditary condition which primarily attacks black people. The tests uncovered 309 carriers of the trait. Begun 16 months ago, the tests are part of demonstration programs, funded by a grant from the Michigan RMP. The project also i provides follow-up screening for relatives of carriers, as well © as genetic counseling for affected families. The total program 9 is designed to build a prototype model whereby the new low-cost test and follow-up procedures can be made available to all black people within a community. * The people of some three communities in Northern New Mexico have set up clinics designed to bring medical care directly to the poor of remote mountain villages as well as in the cities. Special courses in emergency medical care provided by the New Mexico RMP train community members to be self-reliant in treating illnesses and accidents. The New Mexico RMP's "Operation Home Run" in Santa Fe has provided surplus medical equipment to La Clinica de la Gente, the first full-time outpatient clinic of its kind in that city. * A Hospital-Based Family Health Care Service at Middlesex General Hospital in New Brunswick, New Jersey is providing health care to 4,000 of the city's poor. The project was initiated last year with a $143,000 grant from the New Jersey RMP. Rural Health Care: The problems of developing rural health delivery systems is another area in which Regional Medical Programs involvement is growing. This is reflected in the change in resources directed to this area; the number of “RMP-funded projects rose from 57 projects and $3.1 million in fiscal year 1971 to 171 projects and $10.9 million by the end of fiscal year 1972. In terms of total RMP opera- tional funds, this represents a doubling of effort, from 7 to 14 i percent of total project activity designed to improve health care in rural areas. Among the types of activities being carried on: 10 * Continual electronic heart monitoring services comparable to those available in large urban hospitals have been introduced to Oklahoma's small community and rural hospitals as a result of a statewide Coronary Care Monitoring Network for Rural Areas initiated by the Oklahoma RMP. To date, 43 monitor-equipped beds in 29 small community hospitals have been linked by special tele- phone lines to 10 central monitoring hospitals. Specially trained nurses in the central monitoring units help monitor remote patients, and when an abnormality is detected, confer with local ' The importance of immediate staffs by telephone “hotlines.' coronary care stems from the fact that most heart attack victims who die, do so within the first few hours. Under the sponsorship of the Lakes Area RMP in Western New York, the Rural Externship Program has become an effective means of directing health manpower toward delivery of primary care in underserved rural areas. The program places teams of health science students from a variety of disciplines in a number of rural health care settings for a period of eight weeks during the summer. By so doing, the project provides rural communities and community hospitals with access to health science students, while at the same time providing a means for attracting such students to medical careers in rural communities. The program also pro- vides health science students with a first-hand exposure to primary care, and to health care settings not currently utilized in their formal clinical curricula. “dl * The Memphis RMP is experimenting with a mobile multiphasic screening wmit in Northeastern Mississippi. A minimum of 11,000 persons annually receive up to fifteen different multiphasic screening tests and general health education. IVA is providing technical assistance and ‘computer interpretation of ECG's and the Mississippi State Board of Health laboratory also provides assist- ance to the projects. In addition, many Regions have assisted rural communities in which | no physician is present to substitute other types of health care service. An empty doctor's clinic in Rochell, Georgia, for example, has been staffed by nurses with the help of the Georgia RMP in an experiment to provide health care. The clinic is being developed into a new Health Access Station. The Maine RMP is directing a program which will link the Stonington Island Medical Center, where there is no doctor, to Blue Hill Hospital via two-way television. And in Darrington, Washington, two registered nurses will staff a long-empty clinic, built to attract a doctor. When no doctor was found, the citizens appealed to the Washington/Alaska RMP, which has now helped finance and staff the facility to provide emergency care, health screening and counseling. 12 C. Improved Utilization of Health Manpower As a minimum an estimated $17 million, or over 20 percent of opera- tional funds awarded in fiscal year 1972 were being directed toward manpower development and utilization activities. (This does not include any continuing education, for which an additional $12 million was awarded.) An increasing emphasis of these activities is the improved utilization and increased productivity of existing health manpower, especially nursing and allied health personnel. The central focus of RMP activities in the health manpower area is on developing programs that more closely relate education to the health service delivery needs of an area. The definition of such health service needs must involve participation of a wide range of health service and education institutions, such as community colleges and hospitals as well as health professionals and consumers, A community-based identification of health services needs must, more- over, precede any determination of the numbers and types of health personnel needed and how they should be trained. In RMP's approach to resolving manpower problems, the emphasis is on assisting communities to identify their needs and to link and relate total health resources in such a way as to ensure a better balance between the quality and quantity of manpower available and locally determined needs for service. e RMP support for manpower development and utilization is generally 13 divided into three categories: 1. Training existing health personnel in new skills aimed at enabl- ing the person trained to assume new responsibilities in his already chosen career field. The emphasis is on increasing the productivity of personnel and includes expanding the functions of registered nurses and career mobility for licensed practical nurses; Activities directed toward the training and development of new categories of personnel, the establishment of training programs for new categories of personnel such as physicians' assistants, nurse practitioners, and community health workers. The primary objective here is to expand the manpower health pool through the . development of these new categories of health and allied health professionals who can become part of an expanded health services delivery team; Continuing education activities aimed at maintaining or improving the levels of practice of health professionals. An effort is being made toward relating career (or continuing) education more closely to deficiencies identified as a result of quality of care monitoring. Activity in the second area, the development of new kinds of health manpower, has increased markedly in the past year as RMPs have 14 sought to promote the concept of the health delivery team approach. Projects dealing with new categories of personnel increased from 16 and slightly less than $1 million in fiscal year 1971 to some 55 projects and $3.5 million in fiscal year 1972. The Family Nurse Practitioner, for example, will play an increasingly vital role in helping solve the health manpower shortage in North Carolina, especially in communities beset by physician shortages. In a health center or clinic, a physician's office, or patient's home, this new breed of nurse may be the first person the patient sees. She takes a health history, does the physical exam, uses her own judgment to start preventive screening or diagnostic procedures. She coordinates health care needs, makes proper referrals, provides health instruction, counseling, and guidance. A pilot project was held last year for seven carefully selected nurses. Six are now the core of a two-county Comprehensive Health Service Program with a central clinic at North Carolina Memorial Hospital and two rural satellite clinics. In these rural areas, the Family Nurse Practitioner is part of a health team which also includes physicians and community health workers. This year, through support from the National Center for Health Services Research and Development, the University of North Carolina, and a $70,000 grant from the North Carolina RM, twelve more Family Nurse Practitioners are being trained. 15 Similar activities are taking place in a number of other Regions: In Syracuse, New York, the Central New York RMP has provided a grant to a community hospital to conduct a seven-month course for ‘ registered nurses designed to increase the availability of health care services to areas with inadequate physician coverage by teaching nurses how to render primary patient care. Pediatric nurse practitioner and nurse clinician programs are being started with RMP financial and other assistance in a number of places such as California and Kansas where it was determined after a survey that most physicians preferred to hire nurses retrained for expanded assistant roles rather than ex-medical corpsmen or newly trained personnel. Part of the stroke program of the Puerto Rico RMP trains high school graduates to become "Assistentes de Salud Familiar." Their mission is to help the patient maintain good health, and bring together the patient and the community in cooperation with health professionals. 16 © D. Regionalization and Kidney Disease Programs Working relationships and linkages among community hospitals and between such hospitals and medical centers, with their more specialized resources is an important way of overcoming the maldistribution of certain resources and services. Kidney disease and heart disease are special categories in which the development of integrated regional systems can prevent the duplication which has so frequently wasted our. limited resources. In the field of kidney disease, for example, RMP is in the process of developing regional/ national networks of dialysis and transplant centers, so as to maximize access to life~saving services enhancing quality and efficiency. Between FY 71 and FY 72 there was a fourfold increase in the funding of © operational projects concerned with kidney disease. By the end of FY 72, 29 Regional Medical Programs were supporting end-stage renal activities at a funding level of approximately $6 million, in contrast to a level of $1.5 million in FY 71. (This does not include over $2 million on contract activities, primarily related to home dialysis training, also being supported directly by RMPS). The focus of the RMP effort is on the development and implementation of regionalized, end-stage kidney disease programs. This was reflected at the national level by the development of a long-range, "life plan" approach for dealing with the major problem represented by the 8-10,000 new patients eer afflicted with end-stage kidney disease every year. © The principal aim of the "life plan" approach is the efficient linkage, and orderly growth of scarce resources throughout the United States. The program 17 guidelines developed by RMPS and approved by the National Advisory Council seek to exploit the opportunities for regionalization of end-stage kidney disease’ programs without sacrificing quality and accountability. These guidelines require that in order to be eligible for grant support, RMP-proposed activities should include the following components: 1. Assurance of early identification of patients approaching renal failure 2. Rapid referral of such patients 3. Early classification of these patients regarding tissue-typing 4, Availability of the coordinated dialysis-transplantation facilities to assure treatment alternatives to both the patient and the physician 5. Effective cadaver kidney procurement and preservation operations, coupled with rapid kidney donor-recipient matching. ’The advantages of such an approach include the fact that patients would have access to conservative treatment before kidney function stops, an optimal organ in terms of tissue-typing would probably be found while the patient is still alive, and that almost all patients would be carrying out dialysis outside of the hospital. Kidney disease is one area in which the need to develop a strategy of sharing scarce and costly resources is clearly indicated. The cost of treatment has been the major obstacle to saving patients with end-stage kidney disease. Because of the technical complexity of treatment with an artificial kidney, this treatment usually had been provided in a medical center. While the cost of dialysis in the center was close to $20,000 a year, the advent of dialysis in the home, reduced this type of treatment to annrovimatat: $10,199 a -aar. Reranuse of these reduced casts, more patients were being saved ducing their most productive years, and being at 18 home, a larger percentage of them were able to carry out a large propor- tion of their normal activities. As the practicality of dialysis in the home and the feasibility of trans- plantation as the eventual treatment of choice became apparent, RMPs increasingly were in a position in fiscal year 1972 to launch regionalized programs optimally addressed to the particular needs and resources found in their areas. For example: *