noone yi NATIONAL ASSOCIATION OF REGIONAL MEDICAL PROGRAMS, INC. MEETING HIGHLIGHTS September 1975 f INTRODUCTION The primary purpose of the National Association of Regional Medical Programs is to pro- vide information and educational opportunities in areas of pertinence to the members. The format of the assembly in San Diego was, therefore, designed to provide a spectrum of informational interchanges related to the theme of the development of a health system for the community. The program began with current perspectives regarding the National Health Planning and Resources Development Act of 1974 (P. L. 93-641) as viewed from state government, the federal administration, health care and institutional professionals. It proceeded to the presentations and discussions of successful programs in high priority areas such as access, manpower, regionalization, quality assurance, and implementation and regulation concern- ing current legislation. There were special programs on health cultural awareness, RMPs in transition, hypertension, and technica! assistance centers. The conference culminated with provocative presentations and discussion of implementations for the future. Many individuals, both NARMP members and non-members, prepared materials and made important presentations to the assembly and we are most grateful for their very significant contributions. However, the real measure of success of any such program relates to the worth placed upon it by all participants. The members of the Program Committee endeav- ored to design the conference so that there would be much of value, both in information exchanged and in thought provoking stimuli, We sincerely hope that there was reasonable attainment of this objective. J.S. REINSCHMIDT, M.D. Chairman, NARMP Program Committee The atmosphere of high resolve to overcome problems posed by Public Law 93-641, present at the opening of the second annual meeting of the National Association of Regional Medical Programs, persisted to the very end of the three-day session---with one change. At the end, resolve was coupled with a clear picture of what must be done to make the law work, the result of con- centrated attention to an explanation of the law’s anticipated impact on the health care delivery system. FIRST PLENARY SESSION The meeting, particularly in the two plenary sessions, provided a forum for expression of opinions and concerns. To the first session came representatives of government, practicing physicians, hospital administrators, medical schools and other health interests. Few faulted the law’s basic concept-access to quality health care for all at reasonable cost. The concern was with the way the law proposed to achieve this, the Health Systems Agency 2 organization mechanism, its operation, impact on various segments of the health care de- livery system, accountability and responsibility both as to location and geographic scope. STATE GOVERNMENT Robert D. Ray, Governor of lowa and Chairman of the Nationa! Conference of Governors, reminded the assembly that the mid-western governors at their recent conference voted to have P.L. 93-641 repealed in its entirety. The conference’s main objection was to removing health planning from “public officials affected by, accountable and responsible to the people that elect them.’’ Among suggestions for improving the law were provisions for complete care capability in each health service area, relaxation of population limits, permitting gov- ernors of rural states with few HSAs to name a reasonable percentage of HSA board mem- bers in place of appointing a state coordinating body, and more emphasis on quality of HSA board membership and less on categorical representation. FEDERAL GOVERNMENT Kenneth Endicott, M.D., Director of the Health Resources Administration, voicing need for rapid communication during transition, announced formation of an RMP multi-regional coordinators group to act as a special liaison committee between RMPs and the Depart- ment of Health, Education and Welfare. Relating to Dr. Endicott through Dr. Margulies, the committee is to function in an advisory capacity, identifying, collating and classifying problems and issues, Harold Margulies, M.D., former Director of the Division of Regional Medical Programs, now Deputy Director of the Health Resources Administration, said more attention should be paid to what will work than to the precise wording of the law. Cautioning against erosion of expectations such as has occured in the past, he pleaded for their reduction so that the law has a fair chance to work. He predicted HSA funding will be low and urged preserva- tion of successful RMP projects through outside funding rather than hope forlornly for continuation through HSAs. me oe Eugene Rubel, Acting Director, Bureau of Health Planning and Resources Development, stated that the primary concern of HEW with regard to the new HSAs is the ‘‘caliber of governing board members and the staff.” He granted that technical changes in the law were needed but added that changes could not be expected until after the law is imple- mented and a number of HSAs established. PHYSICIAN IN PRIVATE PRACTICE Joseph F. Boyle, M.D., in private practice in Los Angeles, American Medical Association trustee and speaker of the California Medical Association house of delegates, attributed lack of success in past community health planning partially to provider non-participation, and made a strong plea for providers to avoid repetition of this past mistake, ‘It is ra- tional that those who have the experience and educational background participate as fully as possible. It is also equally sensible that the people for whom this care is being planned .. participate so that they receive what they perceive as an answer to their needs and not an answer to the needs as perceived by someone who may never have been there themselves.” Referring to the greater federal expectations from the new law to be achieved seemingly with lower funding, Boyle warned of an apparent “impossible task’’ for the community to undertake. He urged best efforts to make the law work because “if you fail in an im- possible task, we may have to write some other kind of legislation to take care of it again in the future.” HOSPITAL ADMINISTRATION Stephen M. Morris, past president of the American Hospital Association and President of Samaritan Health Service, Phoenix, Arizona, reiterated the almost universal concern over the discretionary power vested in HEW and the shift in health care planning from the local to the state and federal arena. He added that “‘federal leadership and direction are neces- sary to solve the health service problems that we face, and the regulation that follows is inevitable. We in the profession have a duty to make sure that this regulation is a good regulation and that it does what it is designed to do.” He foresaw, as a rational development, the possibility of dividing the HSA planning and regulatory functions with regard to hospitals, with a consortium of hospitals doing coop- erative planning. MEDICAL SCHOOLS Donald Brayton, M.D., medical director, Kern Medical Center, Bakersfield, California, spelled out an extensive list of recommendations from the Association of American Medi- cal Colleges for inclusion in the federal guidelines. These recommendations dealt with the certificate of need process and federal use of funds, which he described as areas of primary concern to medical schools. The guidelines include requirements for consideration of edu- cational goals of teaching institutions in the conduct of HSA review, criteria development, timeliness of review, project renewal and continuation. “There could be no doubt but that P,L. 93-641 is possibly the most intricate piece of leg- islation ever developed. It’s guidelines and recommendations must of necessity be intri- cate. Our exchanges here will perhaps lead to more workable regulations and thereby may ultimately enhance the law's effectiveness.” SECOND PLENARY SESSION The second of the plenary sessions dealt mainly with in-house matters, with emphasis on the future of successful RMP projects and future leadership in health matters. Nathaniel Polster, NARMP Washington representative, expressed belief that if RMPs would focus on programs of Congressional priority and demonstrate effectiveness they would not only be likely to find funds for continuation of successful RMP projects but also would es- tablish the kind of impressive record that results in leadership in re-writing P.L. 93-641 when the time comes. Paul D, Ward, Executive Director of the California Regional Medical Program stated his be- lief that we may be at the low end of the Congressional funding curve for health now and must be ready to provide leadership when the upturn occurs, He urged RMPs, as the only group which understands the needs of consumers and providers and which demonstrates a comprehensive approach to health care, to continue the information flow to the legislative and administrative branches of federal government, to see that health dollars get appropri- ate priority,.to use the multi-regional liaison committee to look for opportunities to provide information for appropriations. committee hearings, to develop public accountability re- ports so that they are useful at the congressional and HEW levels and to work together to develop a stance regarding extension legislation. PLENARY AND LUNCHEON SPEAKERS P.L. 93-641 - As Viewed by a Governor The Honorable Robert D. Ray, Governor of fowa and Chairman, National Conference of Governors, State Capitol, Des Moines, lowa 50319 P.L. 93-641 - Expectations of the Federal Administration Kenneth Endicott, M.D., Director, Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852 P.L. 93-641 - As Seen by a Practicing Physician Joseph F. Boyle, M.D., California Medical Association, 731 Market Street, San Fran- cisco, California 94103 P.L. 93-641 - From the View of a Hospital Administrator Stephen M. Morris, Past President, American Hospita! Association; President Samari- tan Health Service, 1410 North Third Street, Phoenix, Arizona 85002 P.L. 93-641 - Impact on Medical Schools Donald O. Brayton, M.D., Medical Director, Kern Medical Center, 1830 Flower Street, Bakersfield, California 93305 Eugene J. Rubel, Acting Director, Bureau of Health Planning and Resources Development, Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852. Harold Margulies, M.D., Deputy Director, Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852, Nathaniel Polster, NARMP Washington Representative, 2128 Wyoming Avenue, N.W., Washington, D.C. 20008. Paul D. Ward, Executive Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621. The following workshop summaries present a distillation of 90 formal papers and panel discussions on health resource development activity nurtured by Regional Medical Programs. Detailed information may be obtained by writ- ing directly to the participants, whose addresses immediately follow these reports. Bold type introductions to each workshop summary are based on information developed by the national RMP Public Accountability Reporting Group. ACKNOWLEDGMENT Preparation of this San Diego meeting report was made possible with the generous help of the following individuals: Roger L. Beck, Virginia Regional Medical Program; June Estes, Mississippi Regional Medical Program; Patricia Estes, Tennessee Mid-South Regional Medi- cal Program; J. R. Gallagher, lowa Regional Medical Program; Katherine Herzog, Arkansas Regional Medical Program; Robert C. Hunt, South Dakota Regional Medical Program; Linda R. Johnston, Texas Regional Medical Program; Steve F. McCourtie, Michigan Re- gional Medical Program; Kay Page, North Carolina Regional Medical Program; Virginia Rodgers, Memphis Regional Medical Program; J. P. Smith, Colorado-Wyoming Regional Medical Program; Ellen Soo Hoo, Hlinois Regional Medical Program; Jerold G. Sorensen, Intermountain Regional Medical Program; Carol Sympson, Ohio Valley Regional Medical Program; and Linda Wenze, Nassau-Suffolk Regional Medical Program. ACCESS TO PRIMARY CARE The provision of primary care services for medically underserved populations is first among ten priorities mandated for action under the provisions of Public Law 93-641. During the year which ended June 30, 1975, Regional Medical Programs wholly or partially funded some 550 new health service activities in the development of primary care services in rural and medically underserved areas. Workshop participants discussed problems concerned with ac- cess to primary care in urban and rural areas, with the effec- tiveness of nurse clinicians and community health workers, with the role of the university in primary care manpower pro- duction and education, and with the problems facing the newly emerging Health Systems Agencies in dealing with ease of access and availability of health services. Some of the findings: Urban Programs An example of an RMP function in an urban area was pre- sented. One RMP effectively worked with Model Cities pro- grams, using hospital-based resources, to establish and expand community ambulatory care centers. In this example, a dol- jar-for-dollar local match was required. These centers were rapidly accepted and continue their operations without RMP funds. The use of hospital-based resources provided several advantages: Hospitals were already located in each of the underserved areas. Use of these existing facili- ties avoided the necessity for costly develop- ment of new facilities or services; Physicians preferred delivering outpatient ser- vices in the hospital setting, which offered ap- propriate facilities and services, including estab- lished administrative systems. In another example, an RMP incorporated a hypertension screening program sponsored by an inner city neighborhood health center as a means of stressing the importance ofa specific disease process in an ambulant, black population. The intent was to develop or modify patterns of utilization of available resources. Through a successful program of detection, treatment, and improved compliance, the hyper- tension orientation augmented the comprehensive health care services offered by the center. Indigenous personnel were trained and used as outreach workers in the project. Rural Programs Use of technical and financial support to establish 12 rural community health centers was cited as an example of RMP efforts to improve primary Care access in rural areas. Fea- tures of the program included: development of fixed sites for services; commitment of loca! funds or services; provi- sion of varied types of health services; and establishment of minimums for times and types of services offered. A state- wide committee on primary care has guided implementation of the project, and will aid in evaluation. Manpower An example of the evaluation of one type of physician ex- tender has produced preliminary evidence that use of a nurse clinician in a rural solo practice can increase productivity by 20-30 percent. It would appear that increased use of such personnel might have a significant effect on the overall avail- ability of primary care. In another example, an RMP has a task force studying 44 projects utilizing the Community Health Worker to: describe utilization patterns; standardize methods of training; develop credentialling procedures; and develop third party pay or funding for community health worker services. Role of the University Panelists agreed that universities had not taken the lead in improving access to primary care, citing their preoccupation with other activities, and the lack of appropriate encourage- ment from federal funding sources. However, medical schools are now perceiving primary health care as a desirable avenue for teaching and research. A number of state legista- tures, who provide a large portion of medical schoo! budgets, have been urging production of more primary care providers and decentralization of the education process. Problems for Health Systems Agencies Conclusions There is a necessity for HSAs to build on the RMP experience Participants in the workshop expressed the rollowing strong with respect to access to primary care. The following sugges- concerns: tions were offered: 1. It is vital that the accomplishments of 1. Involve public officials in the planning pro- RMPs in implementing programs to im- cess to facilitate implementation and con- prove access and availability of health tinuation of health programs. services be recognized as a basis for con- tinued expansion. 2. Provide educational programs for people in- volved in the planning process. 2. There is no central agency in Washington responsible for improving access to pri- mary care, a high priority component of P.L. 93-641. This situation contributes to the slow realization of the solution of this complex problem in health care delivery. 3. Coordinate the effective use of local resources. Moderators: Panelists: WORKSHOP PARTICIPANTS ACCESS TO PRIMARY CARE Robert W. Brown, M.D., Director, Kansas Regional Medical Program, 4125 Rainbow Boulevard, Kansas City, Kansas 66103 Marlene Checel, M.P.H., Director, Access to Primary Care Program, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 John A. Mitchell, M.D., F.A.C.S., Associate Professor, Community and Family Medi- cine, University of Arizona, 1501 North Camel Avenue, Tucson, Arizona 85724 Improving Access to Primary Care Through Hospital-Based Ambulatory Services in New Jersey Alvin A. Florin, M.P.H., Coordinator, New Jersey Regional Medical Program, 7 Glenwood Avenue, East Orange, New Jersey 07017 Health Center Development in Arizona Phyllis Reifurth, Health Systems Specialist, Arizona Regional Medical Program, 5725 East 5th Street, Tucson, Arizona 85711 Problems for the Health Systems Agencies in Access and Availability of Primary Care John A. Mitchell, M.D. 10 Role of University in Improving Access to Primary Health Care John A. Packard, M.D., Associate Dean, University of Alabama, College of Community Health Services, P. O. Box 6291, University, Alabama 35468 Categorical Entry to Primary Care - Project High Blood: Screening and its Aftermath Samuel U. Rodgers, M.D., M.P.H., Project Director, Wayne Miner Neighborhood Health Center, 825 Euclid, Kansas City, Missouri 64124 The Community Health Worker Gloria Ellis, Community Health Worker Component, Access to Primary Care, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 A Physician-Extender Study Geraldine C. Holmes, Ph.D., Planning and Evaluation, Kansas Regional Medical Program, 4125 Rainbow Boulevard, Kansas City, Kansas 66103 Development of Primary Health Care Services in Los Angeles County Loren G. McKinney, M.D., Assistant to Medical Director, Department of Health Services, 313 North Figueroa Street, Room 805, Los Angeles, California 90012 The Challenge Teresita Moreno, Program Officer, New Mexico Health Cultural Awareness Program, 2701 Frontier Place, N.E., Albuquerque, New Mexico 87131 11 MANPOWER The number of health professionals trained in new roles by RMP’s for an 18-month period extending through June, 1975 has been estimated at 32,456. Categories include nurse practitioners, physicians’ assistants, emergency medical technicians, and others. For the corresponding period, it is estimated that 5,120,000 people were served by these RMP- trained new health manpower providers. The Health Manpower Workshop intended to step outside the day-by-day living and working experiences of health manpower planners, educators, and employees. One half of the program was devoted to identification of key issues and changing priorities with regard to health care delivery/ education systems. The second segment examined recent work in the application of social science technology to health manpower planning. One effective method for assuring balanced health manpower planning from small communities to statewide or regional areas - is through the comprehension and amplification of existing linkage systems. An individual linkage is the con- nection or relationship between two functions or between two people; a linkage system is the sum of al! the individual linkages. Many different agencies and organizations conduct health manpower planning activities. Seldom does any one group direct its planning at the broad range of health manpower as it is related to the total health care delivery system. A statewide linkage system concept is most useful when com- bined with a step-by-step planning process. Suggested process steps include: (1) assemble staff, (2) develop a work plan, (3) determine current process, (4) develop link- age mechanism, (5) develop planning process, (6) identify future conditions, (7) determine manpower supply and de- mand, (8) alternate strategies developed, (9) draft, test and publish a health manpower plan, and (10) develop a data collection system. The decisions and priorities generated by the health man- power planning process are augmented by health manpower econometric models. {t is important that these models be considered as tools for employment in the health man- power planning process. When these tools are designed in cooperation with their users, local planners and decision makers; when these tools are powered by accurate, timely, appropriate data; and when these models are respected as abbreviated representa- tion of reality; then they may be effective methods for determining future manpower supply and demand. Several ‘micro’ health manpower models were described. The thrust of these econometric efforts is the development of specific information for local level use in reaching health manpower planning decisions. The sessions also received a detailed technical presentation on anew “micro” health manpower model. Such instru- ments are designed for use on regional, interregional or even national scales and may provide unique and useful insights into the over-all manpower arena. The conference shifted from reviewing planning and model- jing, to considering finds and conclusions from a number of specific strategies. These projects are aimed at health manpower solutions in the nurse practitioners, physician assistant, and physician extender realms. The group studied some of the problems of developing, plac- ing and evaluating innovative efforts for health manpower and related health programming strategies. It was noted that most innovations come as a result of the efforts of a single charismatic person. When he leaves, the innovations vanish. Innovations in health manpower education were studied. - It was stressed that these approaches (AHEC, HS/EA, VA and others) are but one resource in the development of a community health education system. Community health education efforts continue to be a prime consideration, The health manpower workshop ranged through process since, historically, health education programs have done for (1) developing small community data, to (2) statewide much in shaping the delivery of health care. planning and to (3) the federal dilemma in applying national programs to regional requirements. The importance of decision makers (gate keepers) in social action programs was stressed. Highlight of the workshop The challenge may be summed up in the idea that health was a description of 40 years of technical work which re- planners, especially health manpower planners, should be sulted in the use of such models as the BHSDS, EMCRO, aware of social, political and economic factors; but they UHDD, and PSRO. Moderators: Panelists: should be keenly aware of the differences between what they, as planners, think is needed and what is really needed. WORKSHOP PARTICIPANTS MANPOWER Donald G. Brekke, Director, South Dakota Regional Medical Program, 216 East Clark Street, Vermillion, South Dakota 57069 C. Kenneth Proefrock, Executive Director, Mahoning Shenango Area Health Education Network, 5211 Mahoning Avenue, Youngstown, Ohio 44515 Charles W. White, Ph.D., Program Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Summary Analysis of Health Manpower Models Timothy C. Doyle, Ph.D., Program Director, Vector Research, Inc., P. O. Box 1506, Ann Arbor, Michigan 48106 12 Manpower Planning Models and Quality Assurance Paul Sanazaro, M.D., Director, Private Initiative & Professional Standards Review Or- ganization, 703 Market Street, Suite 535, San Francisco, California 94103 Overview of the AHEC, VA, HS/EA Consortia Models Lawrence H. Miike, M.D., J.D., Research Director, UC San Francisco Health Policy Program, Washington Study Group, 1828 L. Street, N.W., Suite 700, Washington, D.C. 20036 Some Economic Aspects of Health Manpower Planning Donald E. Yett, Ph.D., Director, Human Resources Center, University of Southern California, Los Angeles, California 90007 Congressional Viewpoint on Health Manpower Carl A. Taylor, Health Manpower Manager, Office of Technology Assessment, Congress of the United States, Washington, D.C. 20000 Problems of National and Areawide Planning for Appropriate Distribution of Health Personnel William Shonick, Ph.D., Associate Professor of Public Health, University of California, Los Angeles, California 90024 Health Manpower Linkage Systems B. Jerald McClendon, Project Coordinator, Health Manpower Planning and Linkage System, State Department of Health, Pierre, South Dakota 57501 Innovations in Health Manpower Training and Utilization Charles E. Lewis, M.D., Chief of Division of Internal Medicine and Health Research, University of California, Los Angeles, California 90024 WORKSHOP III - REGIONALIZATION ACTIVITIES Regionalization of services has been a major RMP goal from the beginning. During calendar years 1970 through 1974 it has been estimated that 10,962,000 patients received direct health services in demonstration projects having strong regionalization of secondary and tertiary care components. In 1974 alone, 2,276,000 persons received direct health services for heart dis- ease, cancer, stroke, kidney, hypertension, pulmonary disease, arthritis and other disorders. Regionalization system development---statewide kidney transplant and dialysis networks, regional referral and transportation systems for neonatal intensive care, arthritis centers and support networks and other services---received more than $25 million, 22 percent of all RMP 1974-75 awards. Perinatal - Neonatal Although the value of perinatal centers has been extensively documented---one center recorded a drop in high risk infant mortality, from 200 per 1,000 to 150 per !,000---panelists agreed with the sentiment that “‘if medical care is offered on a per pound basis, then newborns certainly need some- one to fight for them.” Outreach education is for many RMP projects the first step toward regionalization of neonatal intensive care. ‘’Mini- fellowships”, in which physicians spend up to 10 days at a tertiary center as full members of the NIC unit staff and performing hitherto unfamiliar techniques, have encouraged participants in one project to train their own nurses in NICU techniques back home, starting the nucleus of a perinatal team for comprehensive infant care in the community. This “ripple’’ method of continuing education has helped to overcome many problems encountered in neontal/perinata! health care delivery; for example, infrequent deliveries in large, but sparsely populated geographic areas, the failure to transport patients appropriately among facilities, and the tendency of a physician to overextend himself by perform- ing delicate techniques in which he is not proficient. NICU ideal conditions will have been reached when high risk mothers are routinely detected beforehand, and their pregnancies completed in effectively managed centers. However, such centers require expensive equipment and personnel not likely to be replaced as the RMP structure disappears as the result of Public Law 93-641. Hypertension The RMP commitment to community-level management of high blood pressure often linked with the early involve- ment of the American Heart Association, has spawned a variety of approaches. In one instance, a cardiovascular disease network, established after task forces recommended secondary and tertiary care programs, is now serving more than half the health districts of one state and the remainder are expected to become involved in the coming year. Other projects dealing with screening and treatment within the existing health care system coupled with effective follow- up were supported in high impact urban settings, emphasizing peer group pressure ‘‘on the job.” In one, control rate of 82 percent was achieved largely because of easily accessible care. Detection‘and readily available treatment are an effective team. Another approach used a statewide council to provide coor- dination and technical assistance, establish priority activities, target efforts and assure evaluation, As a result, nine service areas around medical centers were established. Efforts at hypertension control in isolated, small rural com- munities, hampered by physician shortages and inadequate transportation, has often led to the organization of commun- ity groups whose purpose is to deal with high blood pressure services and to seek widespread public utilization. A recently instituted mobile unit seems in one project, to be more suc- cessful in attracting large numbers of the public than a stationary clinic. Emergency Medical Services The amalgamation of diverse political jurisdictions to build a truly regional EMS system can involve major obstacles to success. Included among them are a lack of contact and communication with top executives of the various jurisdic- tions, Federal Communications Commission rules changes and radiobroadcast problems. The planning and implemen- tation of improved emergency health care must, however difficult, include at the earliest stages a realistic plan for evaluation of the developing system. Rural EMS systems, panelists were told, suffer from a number of special prob- lems, among them, the absence of even one conforming ambulance, lack of appreciation for the elements desired and the importance of quality EMS, and a geographic terri- tory and population mix that are not in compliance with funding agency requirements. Other Regionalization Activities Inadequacies in rural health care delivery were reduced in one region by a project designed to have a large well established group practice clinic coordinate services throughout more than 100 hospitals and clinics, Outreach activities included physician consultation, computer assisted electrocardiography; reference laboratory, blood banking, equipment repair and maintenance, psychiatry, psychology and psychiatric social services, electroencephalographic interpretation, neonatal emergency care, pulmonary function testing and remote con- tinuous cardiac monitoring. Solutions in one large state with complex geographical and cul- tural barriers were found by opening many new clinics and generating local support. Supplementary services were devel- oped by recruiting and training interested community mem- bers to coordinate and monitor local planning efforts and health programs. Panelists heard of a 10-year old program that began in a large state as a home health agency. Since RMP involvement, it has added early and periodic screening, diagnosis and treat- ment, lead poisoning and senior citizen screening, family planning, alcoholic rehabilitation and detoxification, dental education, in-service education for hospital and nursing home staffs and a comprehensive clinic program staffed by physician assistants in three rural communities. Still a different type of regionalization project by an RMP, concerned itself with adverse drug reactions suffered by pat- ients in 10 participating hospitals. Patients were monitored, reactions recorded and controlled. The additional pharmacy and drug information and poison control data have been shared, and the project provides continuous, easy access to the latest pertinent information through a network serving 450,000 patients per year. Kidney Disease Control Necessary components for a successful kidney disease con- trol program are a transplant center, facilities for tissue typing, organ preservation and organ procurement center, limited care services, home and satellite dialysis, and ancil- lary laboratory facilities. Most of the projects described for panelists were begun five years ago and included statewide kidney disease information systems, nephrology manpower studies, formation of a society of transplant surgeons, train- ing of surgeons in renal transplantation and professional and public education designed to lead to organ procurement. Traditional physician cooperation to improve care of end- stage renal disease patients has recently been augmented by joint efforts in organ sharing, cooperation in immunology, organization of common transplant recipient pools, more 14 formal referral and organ harvesting networks, and passage of pertinent legislation. Professional education efforts have been highly successful, with high attendance at training workshops, and dramatically improved viability of harvested organs and organ retrieval rates. One project concerned with public education funded through the Kidney Foundation found that three out of four persons surveyed expressed positive feelings about medical transplan- tation, and better than half felt positive about donating specific parts of their own bodies. Many states have recently passed legislation authorizing organ donor pledges on driver licenses, millions of dollars for hemo- dialysis, new definitions of death and the easing of restric- tions on home dialysis patients. Arthritis Control A shortage of physicians specializing in rheumatology, a sev- vere maldistribution of those who practice, and a clear need for continuing education of doctors, nurses, physical thera- pists, social workers, and allied health care team members hamper this emerging medical specialty. Panelists were told that fewer than 500 physicians are board certified in the na- tion; most are in California, and those are concentrated in Los Angeles - San Francisco. This occurs in spite of the 15 fact that patients appear to be evenly distributed throughout the country. Against this background, innovative solutions are sought. In one project, a rural care model was developed. Local physi- cians identified as community coordinators were combined with other health personnel to compose a local arthritis care team. Consultative clinics and patient family education were held in local communities with visiting consultants examining, evaluating and prescribing comprehensive treatment that was to be carried out by the referring physicians. Arthritis centers may focus on development of sub-regional clinics, special problems of children with arthritis, professional and lay education, assistance and regular physician visits to widely dispersed communities, evaluation, follow-up and monitoring of patient progress, and linking all state physicians into a medical information service system by telephone. Another goal is to establish rheumatology as a high-need specialty among physicians, nurses and other health care pro- viders, with special emphasis on those physicians in training for family practice. Not forgotten are the all important pol- icy-making medical institution administrators. Cost Sharing Objectives of shared services include the provision of other- wise unavailable services, prevention of loss of autonomy to otherwise stronger forces; i.e., government or competing or- ganizations, through cost reduction, betier patient care, re- duced inventory, and attempting to satisfy competing de- mands and consumer criticisms. Cooperation on common problems such as in-service training needs, shortage and turnover of personnel, communication and practical “do it yourself’ answers can lead to many benefits and, eventually, to self-sufficiency through cost savings. Sharing of lessons learned in fiscal management and administration, and in developing acceptable peer review systems are other out- comes that lead to additional benefits. Cancer Control Regionalization of RMP-funded cancer control projects has re- sulted in a higher quality of care for cancer patients, more ef- ficient utilization of medical personnel and the ability to cen- tralize certain key services previously handled by disparate or- ganizations. Panelists were told that successful cancer regionalization ac- tivities have several characteristics in common. Usually the project relates to health problems that no single agency can handle alone. Usually the project affects a large geographic area and involves some highly specialized activity or some technology that is new, scarce and expensive. Participating institutions in the regionalization activity include those or- ganizations that were recognized centers of excellence before the project was initiated. Results can build closely-knit networks of major therapy resources, statewide tumor reg- istries, radiation therapy and visiting consultant programs, annual statewide cancer workshops, facility planning and development for new centers, clinical traineeships, shared allied health personnel projects and vastly improved patient care. Moderator: Panelists: Moderator: Panelists: WORKSHOP PARTICIPANTS REGIONALIZATION ACTIVITIES Perinatal-Neonatal Sheldon Korones, M.D., Newborn Center, John Gaston Hospital, 860 Madison Avenue, Memphis, Tennessee 38103 A Multi-State Rural System Development Effort in Neonatal Care Sidney C. Pratt, M.D., Project Director, P. 0. Box 2829, Great Falls, Montana 59401 Regionalization of Neonatal and Perinatal Activities Sheldon Korones, M.D. The Regionalization of Perinatal Care in Wisconsin Craig Anderson, M.D., 5721 Odana Road, Madison, Wisconsin 53719 Florida’s Perinatal Program Richard Boothby, M.D., Project Director, Hope Haven Children’s Hospital, 5720 Atlantic Boulevard, Jacksonville, Florida 32207 Regionalization of Perinatal Care in the State of Kansas Howard Fox, M.D., Department of Pediatrics, University of Kansas Medical Center, 16 Rainbow Boulevard at 39th, Kansas City, Kansas 66103 Hypertension Elliot Rapaport, M.D., President, American Heart Association, 1370 Mission Street, San Francisco, California 94103 Regionalization of Hypertension Services Morris M. Bradley, 938 Peachtree Street, N.E., Atlanta, Georgia 30309 The Future of Community Hypertension Control Funding Under Recent Federal Legislation Howard J. Bochnek, M.E., Coordinator of Hypertension Contro! Program, Metro- politan New York Regional Medical Program, 2 East 103rd Street, New York, New York 10029 Regionalizing High Blood Pressure Control in California Adelbert L. Campbell, Director, Program Coordination and Development, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Development of a Statewide Hypertension Registry Program Robert S. John, Assistant Director of Program Development, Illinois Regional Medical Program, 122 South Michigan, Room 939, Chicago, Illinois 60603 Planning for a Hypertension Control Program in a Rural Area John L. Isbister, Chief, Bureau of Community Health, Michigan Department of Public Health, 3500 North Logan, Lansing, Michigan 48914 Emergency Medical Services Moderator: James O. Page, Project Director, Lakes Area Regional Medical Program, 2929 Main Street, Buffalo, New York 14214 Panelists: Regionalization of Emergency Medical Services Activities Vaughan E, Choate, 2007 | Street, N.W., Washington, D.C. 20006 Regional EMS Program: An Example of Cooperative Planning and Funding Alan Dimick, M.D., Department of Surgery, University of Alabama, University Station, Birmingham, Alabama 35294 Emergency Medical Service in Northeast and North Central Missouri Jacqueline C, Hall, R.N., Kirksville College of Osteopathic Medicine, Kirksville, Missouri 63501 Review of Developing Rural EMS Systems Richard Walsh, M.D.; Joan Baker, R.N., 2701 Frontier Place, N.E., Albuquerque, New Mexico 87131 Other Regionalization Activities Moderator: Gordon R. Engebretson, Ph.D., Director, Florida Regional Medical Program, 1 Davis Boulevard, Suite 307, Tampa, Florida 33606 Panelists: North Central Outreach Program David L. Draves, Director, Regional Medical Services, Marshfield Clinic, Marshfield, Wisconsin 54449 Regional Health Resources Development in New Mexico Frank A. Otero, Project Director, Community Health Resource Development Project, New Mexico Regional Medical Program, 2701 Frontier Place, N.E., Albuquerque, New Mexico 87131 Regionalization of Health Services in Central Maine John LaCasse, Deputy Coordinator, Maine Regional Medical Program, 295 Water Street, Augusta, Maine 04330 Moderator: Panelists: Moderator: Panelists: Regional Drug Information Network Carol McCarthy, Associate Director, Nassau-Suffo!k Regional Medical Program, 1919 Middle Country Road, Centereach, New York 11720 Kidney Disease Control Frederick C, Whittier, M.D., Chief, Nephrology Section, Veterans Administration Hospital, 4801 Linwood Boulevard, Kansas City, Missouri 64128 Impact of RMP on End Stage Renal Disease in Arkansas Tom E. Brewer, M.D., Assistant Professor, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, Arkansas 72201 Experience with Criteria Setting in Two Dialysis Units Arlene Sukolsky, Kidney Project Director, California Regional Medica! Program, 7700 Edgewater Drive, Oakland, California 94621 A Survey of Public Opinion on Transplants Jackie K. Reinhardt, Coordinator, Transplantation Council of Southern California, 1281 Westwood Boulevard, Suite 207, Los Angeles, California 90024 Chronic Kidney Disease Patient Care Systems H. Earl Ginn, M.D., Chief, Nephrology Division, B2218 Medical Center, Vanderbilt University, Nashville, Tennessee 32232 The Renal Program for Texas Robert Humble, Deputy Director, Community Programs, Texas Regional Medical Pro- 138 gram, 4200 North Lamar Boulevard, Room 200, Austin, Texas 78756 Arthritis Control David D. Shobe, The Arthritis Foundation, 1629 ““K” Street, N.W., Washington, D.C. 20006 Intermountain RMP Discrete Arthritis Activity Steven J. Anderson, M.D., 325 Seventh Avenue, Salt Lake City, Utah 84103 Arthritis Activities of the Tennessee-Mid South RMP Richard O. Cannon JI, M.D., Director, Tennessee-Mid South Regional Medical Program, 110-2ist Avenue South, Suite 1100, Nashville, Tennessee 37203 California RMP Pitot Arthritis Program: Initial Steps Toward the Regionaliza- tion of Care for Patients with the Rheumatic Diseases Charlene Brax, M.P.H., Arthritis Project Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 A Madel Center-To-Clinic Project Gene V. Ball, M.D., Professor of Medicine, Division of Immunology and Rheumatology, University of Alabama in Birmingham, University Station, Birmingham, Alabama 35294 Cost-Sharing Moderator: Albert M. Donnell, Coordinator, Oklahoma Regional Medical Program, P. O. Box 26901, Oklahoma City, Oklahoma 73190 Panelists: Oklahoma Regional Health Development Area Program (RHDAP) Albert M. Donnell Green Hills Area Cooperative Health Care Project Herbert Henry, Noll Memoria! Hospital, Box 428, Bethany, Missouri 64424 Regionalizing Management John Richey, Assistant Director, Grants Management, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Regional Medical Audit Review System Jack Rorex, Director, Health Planning, White River Planning and Development District, P. O. Box 2396, Batesville, Arizona 72501 Cancer Contro! Moderator: Alfred M. Popma, M.D., 1903S. Roosevelt, Boise, Idaho 83704 Panelists: The Illinois Cancer Council: An Experiment in Regionalization Lorraine C. Hannah, Program Administrator, INinois Cancer Council, 122 S. Michigan, Room 939, Chicago, IHinois 60603 Automated Treatment Planning for Radiation Therapy in Arkansas Alex P. Turner, Ph.D., Assistant Professor, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72201 Regionalization of Cancer Services Francis Morrison, M.D., University of Mississippi Medical Center, Jackson, Mississippi 39216 The Regionalization of Cancer Services in Georgia Don J. Trantow, 938 Peachtree Street, N.E., Atlanta, Georgia 30309 QUALITY ASSURANCE PROGRAMS Quality Assurance of health care has been a priority area for RMP resources since 1970. From that time through June, 1975 it is estimated that 143,820 health professionals have been trained in techniques to systematize standards for and determine deficiencies in medi- cal care, develop corrective action and implement activities which result in demonstrably improved quality of care. The Quality Assurance Workshop provided a forum in which twenty-eight speakers presented information on a variety of RMP-funded efforts to improve patient care through quality assurance projects. Papers dealt with pro- grams in hospitals, nursing homes, and home health care in both urban and rural settings, the development of innova- tive collaborative arrangements between disciplines to pro- vide quality care, attempts to establish and evaluate quality care standards, management criteria and performance feed- back for specific diseases such as hypertensiun, coronary and pulmonary disease, and for laboratories. Discussion of Pro- fessional Standards Review Organization (PSRO) and Joint Commission on Accreditation of Hospitals (JCAH) involve- ment concentrated on current functions, relationships between professional organizations and RMPs, and the future of health care quality assurance from the federal per- spective. Hospital Quality Assurance Programs Quality assurance efforts should maintain and improve medi- cal care of patients, and outputs should be professional edu- cation, development of new programs of patient care and patient education, and changes in the administration and structure of the system itself. A key element in initiating quality assurance efforts in hos- pitals is the establishment of close, positive working relation- ships with medical and administrative staffs to insure that a quality assurance system, whether urban or rural, will be accepted and operational. A few highly motivated physi- cians and hospital administrators might form the nucleus - of the group designated to establish the system. The process of establishing criteria has been improved by in- 20 cluding patients as participants on hospital medical audit committees. The multidisciplinary approach, which includes physicians, nurses, medical records administrators, hospital administrators and trustees, pharmacists and dentists, has proved highly effective in meeting JCAH and PSRO require- ments. Peer review of emergency room medical records has proven as effective as physician interview and examination of patients after discharge. Non-Hospital Quality Assurance Programs Although efforts to evaluate patient care in ambulatory settings are not yet mandatory, nor as developed as hospital programs, studies are being conducted to test various current methods of evaluating ambulatory care. An attempt is being made to validate the “‘tracer’’ method utilizing discrete, identifiable health problems in relation to one another. The relationship between process and outcome approaches in outpatient care has shown that these two methods when applied to hypertensives do not yield similar conclusions, and that cases must be categorized by severity of disease. Nurses in skilled nursing facilities in an expanded role pro- vided through training document patients’ treatment plans, disease status and daily activities more completely, are better able to assess the total patient's needs and provide more appropriate and better quality care. 21 Quality Assurance Projects Among Professional Disciplines and Organizations The presentation included programs to train nurses in the development of patient health outcome criteria through sem- inars Using the nominal group technique, and to validate cri- teria through seminars where outcomes were critiqued by researchers; to computerize a reporting system using social workers in health care to conduct research to study their effectiveness and establish norms for social work service delivery; to develop standards and guidelines for reviewing individual certificate of need applications utilizing a mathe- matical model and a panel of experts; to train medical records associates in audit procedures, and to use medical self-audit to point out needs for continuing education among an organization of private medical practitioners. Quality Assurance Programs Related to Specific Diseases Discharge summaries were evaluated in order to determine changes in blood pressure levels of hypertensive patients resulting from educational programs; it was found that pre- sent techniques for educating such patients have proved successful only temporarily and that better methods must be sought. Through the conduct of medical audit for a hypertension registry, established criteria provided to hypertension clinics are used to reallocate resources according to the needs of patients. Setting standards for data collection and providing perform- ance feedback have led to improved patient care and a 50 percent drop in in-hospital mortality from acute coronary disease. In an area of high incidence of respiratory problems and con: siderable patient movement between hospitals, pulmonary care standards and a computerized inter-link system have led physicians to use findings of tests completed at other hos- pitals and to avoid repetition. Smail rural hospitals with few trained laboratory personnel formed a preceptorship system stressing feedback to health care professionals on how their performance met standards. JCAH and Federal Perspective Quality assurance activity as a continuing trend in health care has shifted from voluntary to required. Assessment of the actual process of health care delivery and the out- come of health care services has taken precedence over as- sessment of structure. Organized quality assurance activity has expanded from the acute hospital setting to the long term care and ambulatory sector and has become more the ongoing responsibility of organized external groups than the function of internal staff committees on an episodic basis. Major quality assurance issues will be review of additional nonfederally funded care by PSROs, the need to prepare for National Health Insurance, the need for a national strategy to define problems, address them and establish priorities, and the need to reduce over-reliance on PSROs as mechan- isms to lower costs. PSROs should function as coordinating nuclei for community- wide quality assurance systems which include representatives from all health care disciplines and reflect needs and practices of the locality. Moderator: Speaker: Moderator: Panelists: Moderator: WORKSHOP PARTICIPANTS QUALITY ASSURANCE PROGRAMS Current PSRO Activities Samuel R. Sherman, M.D., Director, Quality of Care Program, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Edward Zivot, Executive Director, California PSRO Support Center, 215 Market Street, Suite 1301, San Francisco, California 94105 Hospital Quality Assurance Programs Leslie Sandlow, M.D., Vice President for Professional Affairs, Michael Reese Hospital and Medical Center, 29th Street and Ellis Avenue, Chicago, Illinois 60616 Quality Assurance in Community Hospital 22 William P. Nelson IH, M.D., Associate Professor of Medicine, Veterans Administration Hospital, Albany, New York 12208 Rural Hospital Quality Assurance Consortia John T. Rorex, Director, Health Planning, White River Planning & Development District, P. O. Box 2396, Batesville, Arizona 72501 Health Care Review in Rural Hospitals Robert H. Barnes, M.D., Director, Health Care Review Center, 909 University Street, Seattle, Washington 98101 Quality Assurance Workshop and Follow-up System Samuel R. Sherman, M.D. Evaluation of Nurse Practitioner in a Hospital Emergency Room Department Glen E. Hastings, M.D., Associate Professor of Medicine, University of Florida, Center House Inn, 1400 N.W, 10th Avenue, Suite 15F, Miami, Florida 33136 Non-Hospital Quality Assurance Programs Robert G. Rowland, Coordinator, Quality of Care Program, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Efficacy of Tracers in Ambulatory Care lra Gabrielson, M.D., Chairman, Department of Community and Preventive Medicine, Medical College of Pennsylvania, 3300 Henry Avenue, Philadelphis, Pennsylvania 19129 23 Moderator: Panelists: Moderator: Panelists: Quality Assessment Through Outcome Analysis Fred Nobrega, M.D., Director, Health Care Research Unit, Mayo Clinic, Rochester, Maine 55901 Improvement of Quality of Care in Skilled Nursing Homes Patricia Wihtol, R.N., Nursing Instructor, 16 Crescent Ave., Scituate, Massachusetts 02066 Patient Care Audit in Skilled Nursing Facilities Lila Maples, R.N., President, California Nurses Association, 2172 DuPont Drive, Suite 215, Irvine, California 92664 Quality Assurance in Home Care Rita Berkoben, Project Director, Quality Assurance Project, Pennsylvania Assembly of Home Health Agencies, 200 Meyran Avenue, Pittsburgh, Pennsylvania 15213 Professional Disciplines and Organizations Kay Horswill, R.N., M.S., Nursing Coordinator, Wisconsin Regional Medical Program, 5721 Odana Road, Madison, Wisconsin 53719 Patient Outcome Criteria by Peer Review Connie Keyes, R.N., M.S., Project Associate and Clinical Nurse Specialist, 6622 May- wood Avenue, Middleton, Wisconsin 53562 Computerized Social Work for Patient Care Project Miriam Birdwhistell, A.C.S.W., Ed.D., Chairman, University of Virginia Medical Center, Division of Social Work, Box 275, Charlottsville, Virginia 22903 Developing Standards for Specialty Care Skip Habich, Associate Coordinator, New Jersey Regional Medical Program, 7 Glenwood Avenue, East Orange, New Jersey 07017 California Medical Records Quality of Care Project Cynthia A. Boudreau, R.R.A., Member, CMRA Committee on Patient Care Audit, 250 Masonic Avenue, San Francisco, California 94118 Medical Association’s Voluntary Self-Audit Daniel Hamaty, M.D., Director, Connecticut Medical Institute, 90 Sargent Drive, New Haven, Connecticut 06551 Specific Diseases and Procedures Edward W. Francisco, Ph.D., Coordinator, Northern New England Regional Medical Program, Executive Square, 346 Shelburne Road, Burlington, Vermont 05401 Assessment of Quality of Care for Hypertensives Gerald Wolf, M.D., Associate Professor of Radiology and Pharmacology, University of Nebraska, 42nd Street and Dewey Avenue, Omaha, Nebraska 68105 Use of a Hypertension Registry in Medical Audit Fredric L. Coe, M.D., Director Renal Division, Michael Reese Hospital, 29th Street and Ellis Avenue, Chicago, Hiinois 60616 Coronary Care Management Criteria Richard E. Bouchard, M.D., Associate Professor of Medicine, University of Vermont, Burlington, Vermont 05401 Moderator: Speakers: Laboratory Standards Clay Elting, Allied Health Specialist, Washington/Alaska Regional Medical Program, 1107 N.E. 45th Street, Suite 500, Seattle, Washington 98105 Pulmonary Care Standards Tom Pace, Coordinator, Quality of Care Programs, Intermountain Regional Medical Program, 540 Arapeen Drive, Suite 201, Salt Lake City, Utah 84108 Future of Quality Assurance Programs Samuel R. Sherman, M.D. John D. Porterfield, M.D., Director, Joint Commission on Accreditation of Hospitals, 875 North Michigan Avenue, Chicago, Illinois 60611 Leslie Ford, M.D., Division of Peer Review, Bureau of Quality Assurance, 5600 Fishers Lane, Rockville, Maryland 20852 24 25 le L IMPLEMENTATION OF PUBLIC LAW 93-641 With inflation in the health industry rising 50 percent faster than the federal economy panel- ists saw governmental intervention in the market place as inevitably growing, and the Health Planning and Resources Development Act of 1974 as perhaps a fresh attempt to solve a stubborn problem. Intending to combine health planning as a too! of regulation to achieve effective cost controls and more optimal distribution of health services, the law poses diffi- cult and complex choices. Health Systems Agencies are being developed as both advo- cates of areawide health needs and enforcers of Department of Health Education and Welfare policy. In its administration of the legislation DHEW will try to satisfy Congress, on whom it depends for funding; similarly the HSAs will implement the law as satisfactorily to the department as possible. But in this process it was felt there is likely to be a blunting or a disregard of the legitimate needs for health services arising from local communities. The Congressional charge to the HSAs is much more sharply focused than it was for Comprehensive Health Planning Agen- cies; statutory authority will be much greater. Selection of HSA board members with mandated representation quotas, should include ‘the yeast of at-large, maverick consumers and nonestablishment consumers” to forestall provider or establishment domination of board direction. The very ex- plicitness of the law and its inherently contradictory elements may overwhelm the health planning process and cripple its operation, Public Law 93-641 evokes a particularly skittish reaction from hospitals, since they receive such a large share of the health care dollar and thus feel most vulnerable to new regulatory procedures, The law pumps planning in at ‘too late a stage”’ and gives the impression that regulation pre-empts planning rather than being an accompaniment to it. While hospitals may not have a cohesive stand, the new law nevertheless en- genders widespread dissatisfaction. It does not regulate ina simple, easy to understand manner; some of its regulations cannot be equitably administered; others cannot be adminis- tered at all. Perhaps sixty per cent of the federal cost control effort is likely to be directed at hospitals, yet they may have no more than one or two representatives on an HSA govern- ing board. Control over much of the health care system in the United States is passing through this legislation into the hands of the Secretary of DHEW, allowing him to exert whatever measures he finds necessary to achieve the purposes of the law. His power over state agencies and how they operate, through the withholding of Public Health Service funds from states deemed to be implementing the law too slowly, or inappropriately, is immense; it usurps traditional prerogatives of state government. if the state fails to meet the requirements of the law and of the Secretary within a specified time, then the Secretary may withhold all federal health funds appropriated under the Public Health Service and related acts from use within that state. This could involve a significant sum of funds since this group of federal acts includes all federal funds for research grants, medical education, nurse training, allied health, mental health, mental retardation, alcoholism programs, facility construction, support funds for Departments of Public Health, and other related programs. These funds may not only provide support for state activities, but also go to universities, local government and some private non-profit corporations. State powers are further eroded through Public Law 93-641 by the mandate that acceptable certificate of need legisla- tion must be passed before a state government can enter into an agreement with the DHEW Secretary. Providers believe that such legislation must be linked with rate-setting; the rate-setter ought not be an important major purchaser of health care, as both state and federal governments are. Thus, there is a glaring conflict of interest in the new law permitting the Secretary of DHEW to be both a regulator and a purchaser of health care services, leading to captured regulation in the hands of vested interests. Finally, although it appears that a majority of the HSAs June 30, 1976, there is no clear commitment to fund the now being developed to fulfill the first purposes of the program at levels sufficient to begin realistically to achieve legislation will have received conditional designation by the ends of the new law. 27 Moderator: Panelists: Moderator: Panelists: Moderator: Panelists: WORKSHOP PARTICIPANTS IMPLEMENTATION OF P.L. 93-641 Planning Gary Fink, Associate Coordinator, lowa Regional Medical Program, Oakdale Hospital, Oakdale, lowa 52319 Progress Report on Health Systems Agencies Collin Rorrie, Ph.D., Assistant to the Associate Director, Health Resources Planning, Health Resources Administration, 5600 Fishers Lane, Rockville, Maryland 20852 Functions, Staffing and Board of Health Systems Agencies Steve Sieverts, Special Consultant, American Hospital Association, One Farragut Square South, Washington, D.C. 20006 Health Systems Agencies: Advocates of Community Needs or Enforcers for DHEW Darwin Palmiere, Ph.D., Dean, Human Resources, State University College, Brockport, New York 14420 Regulation Paul D. Ward, Executive Director, California Regional Medical Program, 7700 Edgewater Drive, Oakland, California 94621 Theory and History of Regulation Henry Zaretsky, Ph.D., Director of Research, California Hospital Association, 925 ‘‘L”” Street, Suite 1250, Sacramento, California 95814 Regulatory Aspects of P.L. 93-641 Paul D, Ward Health Facility’s Reaction to P.L. 93-641 Regulation Robert Derzon, Director, Hospitals and Clinics, University of California Medical Center, San Francisco, California 94143 Health Resource Development Charles D. Holland, Director, West Virginia Regional Medical Program, 258 Stewart Street, Morgantown, West:Virginia 26506 Title XVI Replaces Hill-Burton Agencies Edward N. Duncan, Director, Facilities Development, Bureau of Health Planning and Resources Development, 5600 Fishers Lane, Room 12-11, Rockville, Maryland 20852 Resource Development by the State and by the Health Systems Agency Charles D. Holland Resource Development and the Federal Government Richard L. Russell, Chairman, Developmental Fund Work Group, Bureau of Health Planning and Resources Development, 5600 Fishers Lane, Room 11A-46, Rockville, Maryland 20852 HEALTH CULTURAL AWARENESS Health Cultural Awareness Failure of health planners to take into consideration varying cultural backgrounds often leads to health legislation and pro- grams that neglect the very people they were designed to serve. Usually such people are of ethnic minority groups whose approach to health problems differs widely from that of the majority. The Health Cultural Awareness discussion was conducted in response to a request from Regional Medical Program coor- dinators to consider the needs of these minority groups. Sponsored by the Center for Human Resources Planning and Development (7 Glenwood Avenue, East Orange, New Jersey 07017), the session included presentations by a multi-cultural panel of experts, representatives of a variety of heatth pro- grams and agencies, both public and private. Panelists related their personal experiences and cultural dif- ferences and similarities in terms of ethnically traditional as well as current and projected health needs. Viewpoints specifically represented included Island Blacks, Chinese, Mexican-Chicano, American Indian and Puerto Rican, Pan- elists called for a plan of action that would incorporate ethnic and cultura! considerations appropriately into 28 national health legislation. NATIONAL ASSOCIATION OF REGIONAL MEDICAL PROGRAMS Board of Directors John R. F. Ingall, M.D., Chairman, Buffalo, New York J. Gordon Barrow, M.D. Atlanta, Georgia Robert W. Brown, M.D. Kansas City, Kansas Charles W. Caldwell Oakdale, lowa 29 James W. Culbertson, M.D. Memphis, Tennessee Robert W. Lawton Cranston, Rhode Island Benjamin Morgan Buffalo, New York Donal R. Sparkman, M.D. Seattle, Washington Paul D. Ward Oakdale, California tedont aagorst Pesan, ft the United Staves Domed Sparkes, Program Committee J. S. Reinschmidt, M.D., Oregon Regional Medical Program Harry Auerback [inois Regional Medical Program J. Gordon Barrow, M.D. Georgia Regional Medica! Program William Boquist California Regional Medical Program Donald G. Brekke South Dakota Regional Medical Program Robert W. Brown, M.D. Kansas Regional Medical Program Charles W. Caldwell! Jowa Regional Medical Program James W. Culbertson, M.D. Memphis Regional Medical Program Gary Fink lowa Regional Medical Program J. R. Gallagher lowa Regional Medica! Program Charles D. Holland West Virginia Regional Medical Program John R. F. Ingall, M.D. Lakes Area Regional Medical Program Robert Miller Lakes Area Regional Medical Program Benjamin Morgan Lakes Area Regional Medical Program Cc. E. Smith, Ph.D. Mountain States Regional Medical Program Paul D. Ward California Regional Medica! Program Roger J. Warner Arkansas Regional Medical Program Charles White, Ph.D. California Regional Medical Program 30 Public Information Committee William Boquist, Chairman California Regional Medical Program Edna Carroll Bi-State Regional Medical Program Frederick E. Frazier Missouri Regional Medical Program Gerald N. Gold New Jersey Regional Medical Program Jim Robe Florida Regional Medical Program Sylvia Sterne Louisiana Regional Medical Program SEL UIE ons National Association of Regional Medical Programs, Inc. of pent One Davis Boulevard, Suite 307 PAID Tampa, Florida 33606 Permit No. 495 BUFFALO, N.Y.