MARYLAND STATE DEPARTMENT OF HEALTH 
REPORT 
OF A 
HEALTH OFFICER COMMITTEE ON THE COORDINATION 
OF PREVENTIVE AND CURATIVE SERVICES 
MAY 7, 1948 Maryland State Department of Health 
* ♦ 
REPORT 
OF A 
HEALTH OFFICER\COMMITTSE ON THE COORDINATION 
OF PREVENTIVE AND CURATIVE SERVICES 
May 7, 19^8 Maryland State Department of Health 
MEMBERSHIP OF COMMITTEE 
WILLIAM H. F, WAETHEN, M,D., Deputy State Health 
Officer of Baltimore County, Chairman 
P, F, PRATHER, M.D., Deputy State Health Officer 
of Washington County 
W. 3* JOHNSON, M.D., Deputy State Health Officer 
of Dorchester County 
WILLIAM A. HARRIS, M.D.., Deputy State Health 
Officer of Charles County 
DEAN ROBERTS, M.D,, Chief, Bureau of Medical Services, 
Maryland State Department of Health 
W. ROSS CAMERON, M.D., Chief, Division of Cancer 
Control, Maryland State Department of Health CONTENTS 
Page 
CHARGE TO THE COMMITTEE k 
ACKNOWLEDGEMENTS 6 
INTRODUCTION 7 
THE COUNTY ADVISORY COMMITTEE ON MEDICAL CARE 12 
THE COUNTY HEALTH DEPARTMENT aND THE PRIVATE PHYSICIANS Ik 
patient Master index file of preventive and curative services 15 
PERIODIC REVIEW OF MEDICAL CARE CASE SUMMARY RECORDS 17 
CONSULTATION SERVICES 20 
PUBLIC HEALTH NURSING VISITS TO MEDICAL CARE PATIENTS 22 
ROUTINE PHYSICAL EXAMINATIONS , 23 
CHILD HYGIENE SERVICES 2k 
DENTAL SERVICES,, 25 
LABORATORY SERVICES 27 
PLANS FOR MORE COMPLETE UTILIZATION OF REHABILITATION SERVICES 29 
CONCLUSIONS 30 
recommendations 31 
APPENDIX 37 CHARGE 
TO 
THE COMMITTEE ON THE COORDINATION OF 
PREVENTIVE AND CURATIVE SERVICES 
The committee is charged with the following responsibilities; 
1. Study existing records of services rendered under the medical services 
program in several representative counties, (Form MS-g), 
2, Take other steps to determine the extent to which preventive services are 
provided by the county health departments for beneficiaries of the program. 
3, Suggest possible arrangements between the county health departments and 
private practitioners that might be expected to promote closer coordination 
between preventive and curative services. 
k, Detail the preventive and curative services that might be provided 
routinely by: 
a. State end county health departments 
h. Private physicians 
c. Other agencies 
Under this topic, such questions as these should be discussed; 
a. Should a complete physical examination be provided for all 
persons being certified for medical care at public expense? 
b. If such an examination could be made routinely, what steps 
might be taken to secure correction of defects? 
c. Are the county health departments equipped to make 
periodic physical examinations? 
d. What expense would be involved in providing such facilities? 
e. Are funds for this purpose procurable? 
5. Study the current record system and decide whether it would be wise 
to develop in each county health department a central index file for 
coordinating records of preventive and curative services. 6, Consider other procedures that might he developed to promote closer 
coordination. 
7. Propose plans for more complete utilization of the vocational 
rehabilitation service and similar agencies. 
g. Confer with those who might he expected to contribute to the completion 
of the study. 
9. Submit recommendations to the Director of the State Department of 
Health, 
May 22, I9U7 
Medical Care Program ACKNOWLEDGEMENTS 
To Dr, Robert H, Eiley, Director of the Maryland State Depart- 
ment of Health, for giving to the Committee on the Coordination of Preventive 
and Curative Services the opportunity for the profitable educational experi- 
ence of exploring the intricacies of local preventive and curative services 
in the counties of Maryland; to all Deputy State Health Officers who have 
freely commented upon and given suggestions to the Committee in its work; 
to Bureau Chiefs and others in the Central Office of the Maryland State Depart- 
ment of Health who have advised the Committee and given generously of their 
time and effort in this report, the members of the Committee as a whole and 
individually are most appreciative and deeply grateful. 
The Committee wishes to thank sincerely Miss Elizabeth Mclntire 
Secretary to the Chief of the Bureau of Medical Services, for her fine con- 
tribution of meticulous note-taking during the all day conference of the 
Committee with Deputy State and County Health Officers on January 22, 
Miss Katherine Harris, Secretary to the Health Officer of 
Baltimore County has given hours of extra time to taking the minutes of the 
many Committee meetings held throughout the year and she has displayed extrar- 
ordinary patience in the painstaking task of preparing the many revisions in 
the several stages of the development of this report. This mimeographed 
volume is largely Miss Harris* handiwork. The Committee is grateful for her 
willing and generous efforts at all times. 
Miss Virginia Haphel of the Baltimore County Health Department 
very kindly drew the original stencil for tho illustration in the APPENDIX. Maryland State Department of Health 
REPORT 
OP A 
HEALTH OFFICER COMMITTEE OH THE COORDINATIOH 
OF PREVENTIVE AND CURATIVE SERVICES 
INTRODUCTION 
The salient features of the program for supplying medical 
care to those in Maryland who would not otherwise receive it were described 
by Dr, Robert H. Riley in an article in the August, 19*4-6, American Journal 
of Public Health,* The purposes and origins of the program as it concerns the 
counties of Maryland were reviewed and the techniques of administering the 
fee-for-service plan finally adopted were described. It was pointed out that 
late in 1939 following an open letter from the Medical and Chirurgical Faculty 
of Maryland to the State Planning Commission a standing Committee on Medical 
Care was appointed with instructions to make a field survey of the needs of 
the people of the counties cf Maryland for curative and preventive medical 
services and to make recommendations for the improvement of any deficiencies 
found. The Committee outlined five major objectives of this field survey. 
It is the fourth of these which is of prime importance and interest to those 
who study the development of the integration of preventive medical and curative 
services as applied in the county as a unit. The fourth objective of the 
survey is stated as follows: 
"To study the state health needs and give suggestions 
for securing more effective use of existing agencies, 
either by improving or extending their activities or 
by the organization of other services," 
*Riley, Robert H., Medical Care in Maryland, American Journal of Public 
Health. August, 19*4-6, Vol, jS, No, 8, pp. SOS~Sllm Coordination Committee Roport-p.S 
It is well known by those who worked closely with the Medical 
Care Committee that much thought was given during its many meetings to the 
correctness of this original thesis: that the State Health Department and 
its local agents, the county health departments, should organize and operate 
a medical care program. As data in the survey were collected and analyses 
were made it became increasingly clear that the service to he rendered hy a 
medical care program, must he closely integrated with those already in existence 
and should logically, therefore, he included in the health department organi- 
zation rather than in another agency of the State government. The Committee 
was fully aware also that the adoption hy the Maryland Medical and Chirurgical 
Faculty of its report of April and the suhseouent incorporation of its 
recommendations in the Acts of could not and would not guarantee at once 
the hirth of a full grown, robust medical care program in the counties of 
Maryland, The situation existing at the inauguration of the service and still 
existing today is that described hy Dr, Hiley in the concluding paragraph of 
\ 
his article Medical Care in Maryland: 
”The program is a new venture in public 
health and one that may he accompanied hy errors. 
It is believed, however, that vigilance to detect 
these mistakes and willingness to correct them 
will help to insure its success. Above all, needs 
of groups intended to benefit from the medical 
services must be kept in the foreground, for the 
entire medical care program has been established 
for the sole purpose of serving these sections of 
our population.” Coordination Committee Heport-p.9 
It is pertinent at this juncture to point out that the 
delegation of administrative responsibility for the medical care program 
to local health units was made possible by the pattern of organization of 
county health departments which has been developed during the last two decades. 
Each of the twenty-three counties has a health department with at least a 
minimum staff consisting of a physician who is the health officer, two or 
more public health nurses and clerical personnel, all serving on a full time 
basis. In the larger counties the minimum staff is supplemented by assistant 
health officers, dentists, additional nurses and nursing supervisors, medical 
social workers, sanitarians, and other auxiliary personnel. The administrative 
head acts both as County Health Officer and Deputy State Health Officer. He 
is appointed by the County Board of Health but his appointment must be approved 
by the State Board of Health. As County Health Officer, he is responsible 
to the Director of the State Department of Health. The county health department 
is financed jointly by State and local funds. The local administration of the 
medical care program is one of the responsibilities of the health officer in 
his capacity as Deputy State Health Officer. 
Health officers in charge of their administrative units have 
the responsibility of developing an efficient medical care program and at the 
same time improving, by strengthening and enlargement, their already existing 
preventive program. Both programs are dynamic and, with increasing medical 
knowledge, must grow in order to be vigorous. It should be made clear that 
what is ordinarily termed the preventive program has by no means reached a 
state of perfection. The health officers fully realize this situation. They 
know that their major task is to make the preventive program better and to 
reach more people as speedily as the public opinion they influence permits. 
They know, too, that the medical care program must receive the same treatment. Coordination Committee Report-p,10 
The medical care program should stimulate the preventive program to develop 
more rapidly and in a healthier way and the preventive program should he of 
great assistance to the curative. But the fact remains that both preventive 
and curative techniques and practices must he improved and new areas must at 
the same time he developed if there is to he full integration of preventive 
and curative services and an enlarged and more efficient public health service 
by the health department. This improvement of total service and all of its 
dependent categories continues to he the constant preoccupation of every health 
officer. 
The absorption of new functions within the department is not 
new to the health officers in Maryland, As an excellent example the child 
hygiene program was assimilated not many years ago. In a short time child 
hygiene became an integral part of the program of every local health depart- 
ment. Medical care will follow the seme course, becoming more and more part 
and parcel of the whole program, and for the same significant reasons, chief 
among which are the productive efforts of enthusiastic health officers and 
their well directed and properly staffed health departments. 
The medical care program in the counties of Maryland is unique. 
Since its inauguration in it has made remarkable strides and within 
this relatively short period of time has achieved many of the objectives 
visualized before it was actually begun. The task of organizing this new 
and all-inclusive service under the several county health departments has 
been one of first magnitude. Its accomplishments have been due almost wholly 
to the unusual and sustained interest of the county health officers under 
the guidance of the Bureau of Medical Services. However, it becomes evident, 
as the program emerges from its period of organization, that many of the 
county health departments look upon the medical care program a„s an activity Coordinrtion Committee Heport-p.ll 
quite separate and apart from the preventive services. This is not always the 
result of lack of interest or enthusiasm. Daring the period of organization 
it has been necessary to place first emphasis on the development of the 
administrative machinery required for the operation of this new health depart- 
ment responsibility. As a consequence, the importance of coordinating the 
medical care program with preventive services has sometimes been neglected. 
It is a timely and pertinent observation of those who have recently studied 
the medical care program in the counties of Maryland that unless the health 
departments can make all of the proven preventive services available to 
clients of the medical care program, there can be little Justification of 
health department administration of medical care. 
■ On May 22, I9I7, a little more than two years after Governor Her- 
bert R, O’Conor signed the bill which had been passed by the State Legislature, 
and thus made legal the provision of medical care in the counties of Maryland, 
Dr, Robert H, Riley, Director of the Maryland State Department of Health, 
appointed a committee of four health officers and two representatives of the 
central office to study, discuss and make recomraendations concerning the ways 
and means for establishing policies to promote closer coordination between 
the- preventive and curative services. The charge, in terms of the responsibili- 
ties of the committee, is given as an insert in the first pages of this report 
(pages h and 5)* 
As a result of detailed study on the part of individual 
committee members, of conferences covering several months and of a meeting 
of health officers end bureau chiefs held on January 22, 19*+&, the following 
statement of suggested policies was prepared. Its purpose is to create as 
soon as possible a maximum of interest on the part of every health officer 
and health department staff member in integrating every preventive service Coordination Committee Report-pc12 
nov/ available with the curative services to be conducted in the county. 
THE COUNTY ADVISORY COMMITTEE ON MEDICAL CARE 
A far-seeing decision was reached in the early days of the 
organization of the State-wide Council on Medical Care whose establishment 
was provided for in one of the sections of the Medical Care Law, The 
Council recommended the creation in each county of a County Advisory Committee 
on Medical Care* 
The membership of this Advisory Committee as originally 
suggested included three physicians nominated by the County Medical Society; 
one representative of the County or District dental society and one pharmacist 
chosen by the Maryland Pharmaceutical Association, The Executive Secretary 
of the County Welfare Board, the Chairman of the Board of County Commissioners 
or his delegate and the county health officer were to serve ex officio. The 
health officer was to serve as Chairman, The Council further recommended 
that additional members named by the health officer should be chosen from 
minority racial groups, the Department of Education, the local hospitals 
and existing special lay health organizations. 
The health officers of the several counties at once organized 
Committees on Medical Care in accordance with recommendations of the Council, 
hut later observation has shown that many of the county committees are now 
meeting with only a fair degree of regularity. It should be pointed out here 
that the Council laid particular emphasis upon the importance of this local 
advisory group and requested that every county committee should, when it was 
completed, submit to the Bureau of Medical Services a program of its proposed 
method of operation. Only after review and approval of this program by the 
bureau could the supply of services be begun in any county. 
It was soon evident from the experience of many counties that Coordination Committee Report-p,13 
the health officer could enhance the close working relationship between the 
practitioners of medicine and the health department by the establishment and 
continuation of an active committee on medical care. Such a committee 
demonstrates its value by advising the health officer in regard to local 
situations in the county so that he may more intelligently and effectively 
plan and carry out a program which is adjusted to the needs of his particular 
county. 
The effective functioning of an advisory committee on medical 
care or other similar counselling group as a useful administrative instrument 
depends largely upon the ingenuity of the individual health officer in 
bringing together the key people in the official agencies and in the important 
professional and lay groups. Leadership is a quality which can he acquired 
and developed, hut it can he exercised only by care and continuous effort. 
The health officers of the counties of Maryland have so far shown good leader- 
ship in their counties, hut constant effort needs to he made by each health 
officer to continue and develop it. A well organized advisory committee is 
important evidence of successful leadership on the part of a health officer. 
It is the concensus of the Committee on Coordination that the 
importance of the County Committee on Medical Care can hardly he overestimated* 
The frequency of meetings may vary with the needs and conditions in individual 
counties* hut there should never he less than four meetings each year, A 
regular monthly meeting is desirable, hut where the committee is large, sub- 
committee meetings may he held monthly or at even shorter intervals and the 
meetings of the whole committee may he held less frequently. Some health 
officers may wish to enlarge the membership of the committees, as has 
recently been recommended by the State Council, and to expand the program of 
the committee to a consideration of any of the functions of the health depart- Coordination Committee Report-p,lU 
raent, whether preventive or curative. 
THE COUNTY HEALTH DEPARTMENT AND THE PRIVATE PHYSICIANS 
At the beginning of the medical care program each health 
officer presented the proposed plan to his county medical society for its 
endorsement* It is thus both wise and .just for the health officer to make 
periodic reports to the society of the progress of the various phases of the 
complete program of the health department, preventive or curative. The 
frequency of these reports must, of course, depend upon the judgment of the 
health officer. 
New Physicians, A personal interview between the health 
officer and every new physician who establishes a practice in the county is 
a valuable way of promoting a close working relationship between these 
practitioners and the health department. This conference may well include a 
thorough review of all health department activities which have a bearing on 
the practice of medicine. It should cover such matters as the reporting of 
cases of communicable disease and the various clinic services provided by the 
department, as we 11 as the services available through public health nurses 
and the department laboratory. The medical care program can be fully ex- 
plained and the physician supplied with all the forms needed for participa- 
tion in the program at this interview. Such a conference will do much to 
strengthen the working relationships between the medical profession and the 
health department. 
Established Practitioners, In some counties the health officer 
may be able periodically to visit all the private physicians practicing in 
his county. Where this is possible, the health officer is able to keep the 
practitioner fully informed regarding his working connection with the services 
of the health department. Coordination Committee Report-p,15 
Visits of Public Health Iflurses to Private Physicians. Another 
valuable aid in securing the fullest cooperation between the health depart- 
ment and the private practitioners of medicine is a regular visit by the 
public health nurse to the private physicians in her district. The purpose 
of the visit should be to explain to the physician the ways in which she may 
be helpful in his work with his own patients. Such visits by the public 
health nurse are of value only when the health officer has already established 
a friendly cooperative relationship with the particular physician to be 
visited. 
Public Health Education. The Committee on the Coordination of 
Preventive and Curative Services recognizes the need for a more effective 
program of public health education and of better public relations particularly 
with the professional groups primarily concerned, A striking example of poor 
practice in such matters is the large number of mimeographed sheets now sent 
in unsealed envelopes to physicians. Any public relations expert will testify 
to the complete ineffectiveness of this and of certain other methods now in 
use. These should at once be changed if public health information is to be 
gotten to the private physician in such a way as to produce effective action. 
This is a subject beyond the charge to this committee and it 
is suggested that a separate group be appointed to study the problem. 
patient master index pile of preventive and curative services 
At the present time each county health department maintains 
a separate file for each specialized program, A single patient or family 
may have records in as many as four or five of these files, but the files 
are not crossed-indexed or coordinated. For example, when a patient comes 
to a maternity hygiene clinic there is no simple way of determining whether Coordination Committee Rcport-p.l6 
or not this patient has also received service from the tuberculosis program 
or the medical care or any other department program. In order to provide 
a simple means for assembling all the pertinent data concerning a particular 
patient, it is recommended by this committee that a master index file be 
maintained in each health department. This file vrould contain a separate 
card for each individual served by any program, preventive or curative, of 
the health department. 
The size and shape of cards used in such a master index file 
should he uniform for all counties, and the card should contain all the data 
necessary to identify any individual known to ho a recipient of service from 
the health department. This should include t1he name, color, sex, date of 
hirth, and, to prevent confusion of patients with the same name, the name 
of the head of the family. There would he entered on each cand the type of 
clinical record already on file in the health department and the place in 
which it is to he found. The type and location of records may he indicated 
hy abbreviations or coded numbers, depending upon the wishes of the individual 
health officer. Information may also he recorded as to whether the record 
is active or inactive. It is most important that the individual cards he 
filed in alphabetical order hy surname and he readily available, completely 
summarized and easy to use. An illustration of an index card of the type the 
Committee on Coordination has in mind will he found in the Appendix, Page i. 
The maintenance of a master index file in each county health 
department should he made the duty of one clerk who will give to it as much 
time as may he necessary. This clerk is charged with the responsibility for 
making all entries and keeping the file ctirrent and in satisfactory order. 
Provision must necessarily he made that all information on new and on closed 
cases he reported at once to the clerk in charge of the file hy field and Coordination Committee Report-p.lJ 
clinic workers. The specific method of carrying this out in the several 
counties will, of course, vary somewhat according to local conditions. 
PERIODIC REVIEW OF MEDICAL CARE CASE SUMMARY RECORDS 
The MEDICAL CARS CASE SUMMARY RECORD (MS-8) contains information 
which, if carefully reviewed hy the health officer, gives valuable aid in 
determining the amount, kind and quality of care that is being given, A 
periodic review of these records is perhaps the best means of becoming 
familiar with the over-all operation of the program in a county and of the 
individuals receiving care as well. 
These summary sheets are made up from the MEDICAL REPORTS 
OE SERVICES RENDERED (MSJ+) and DENTAL REPORTS OP SERVICES RENDERED (MS-5), 
which are the monthly statements of the services rendered hy individual 
physicians or dentists. This service record was designed to give the maximum 
possible amount of useful information without being unduly burdensome to 
physicians. It may he necessary at some time in the future to revise both 
these forms so that they will furnish more complete information regarding 
the examinations made as well as the diagnosis and treatment, hut for the 
time being they appear to he as adequate as the situation demands. 
The medical care clerk should ho instructed to select from the 
files for review hy the health officer any MEDICAL CARE CASE SUMMARY RECORDS 
(MS-8) that present unusual features or problems. The tealth officer should 
also he acquainted with all those cases that have incurred unusual expense 
to the program, as well as those who have sought the service of many physicians, 
or those who have had multiple diagnoses. He should also know of cases that 
present unusual diagnoses or whose diagnosis does not appear to he consistent 
with the service rendered, for example, a case of severe disease with 
few visits, or conversely, a disease of moderate severity with many Coordination Committee Report-p.lS 
visits. He may wish to review the records of certain patients diagnosed as 
having a reportable disease, in order to discover any case that may not 
have been reported to the health department, He may want to review the 
records of cases diagnosed as cancer, heart disease, diabetes and similar 
conditions, particularly if he plans to establish a special program or clinic 
for the special service of patients with these diseases. 
With these things in mind, the medical care clerk should in 
the course of her daily work, select from the files, for review hy the health 
officer or his representative, groups of MEDICAL CARE CASE SUMMARY RECORDS 
(MS~g) on the basis of the following criteria: (l) cases costing more than 
$50*00 in a period of six months, excepting obstetrics and surgery, or cases 
costing more than $25.00 in a period of one month, with the same exceptions; 
(2) all cases showing use by a client of two or more physicians in any one 
month, unless one of the two is a specialist; (3) all cases having multiple 
diagnoses; (U) all canes needing special study such as reportable diseases 
and special conditions such as cancer, heart disease or diabetes. 
The health officer may set aside a regular time for reviewing 
the information on the summary records which have been withdrawn by the 
medical care clerk on the basis of the criteria cited above. In some counties 
where preliminary studies have been made, experience has shown that the 
health officer or his representative can obtain valuable information regarding 
the operation of the program by such a systematic review of these records. 
Evidence of inadequacy of medical care or of abuse of the program by vendees 
or vendors may bo noted. Any apparent discrepancy between the diagnosis as 
recorded by the physician and the amount and character of service reported as 
given may be recognized. The health officer may Judge if the preventive 
measures offered by the health department have been utilized, or if hospital- Coordination Committee Hcport-p.,19 
izatlon for acute or chronic disease is desirable. If hospitalization would 
afford better medical care to the patient than frequent home visits by an 
attending physician, that fact may be apparent from the record. It may be 
possible to judge if rehabilitation service vrould bo beneficial to a particular 
case or to estimate the extent of any deficiency in the notification of 
reportable disease in a large segment of the population. Where the information 
concerning a case indicates that the health officer and attending physician 
should confer regarding the future management of a case, such a conference 
may be arranged. 
The county advisory committee on medical care can and should 
play an active part in assisting the health officer in reviewing any of the 
summary records that present special difficulties or that cannot he handled 
in a routine manner. The committee can he of invaluable assistance to the 
health officer in difficult and puzzling cases, particularly when the health 
officer feels need of the advice of medical men hotter acquainted than himself 
with methods of diagnosis and treatment. 
When found necessary, or advisable, the health officer should 
confer personally with the physician treating the patient whose records 
have been reviewed, and should discuss with him the findings about which question 
has arisen. Any action of a health officer in disposing of difficult or contro- 
versial cases should take into account the diagnostic, consultation, hospital, 
clinic and rehabilitation services available in his community. Each health 
officer should work out a method of his own for the disposition of especially 
difficult cases. He may, for example, after consultation with his county 
advisory committee, decide to form a subcommittee consisting of physician 
members who would sit with him individually or collectively when he confers 
in his own office with a particular physician who appears, from the data on Coordination Commit tee Report-p,20 
the MEDICAL &J&E CASE SUMk'ARY RECORD (MSLg) of cases treated by him, to he 
Incompletely Informed regarding the provisions of the program or to have mis- 
interpreted them or who seems to he abusing the service. 
An attending physician should be asked to make a special re- 
view and report on cases which the health officer has found to have required 
continuous care over too long a period, A carefully phrased letter based on 
the facts of the individual case in question will usually be found better 
than a printed form for this purpose. 
The health officer should always keep in mind that these 
situations are most liable of all his relations with physicians to give rise 
to misunderstanding and resentment. Each case should be handled with 
extreme care and with the utmost tact and consideration. To suggest even 
indirectly that the physician is neglecting the pa/tient on the one hand, or 
making unnecessary visits on the other, will almost always arouse antagonism 
and may permanently destroy the possibility of maintaining good relations 
between the doctor and the health department. 
CONSULTATION SERVICES 
Over a period of years the specialized programs of the health 
department have developed a nucleus of important consultation clinics in the 
fields of obstetrics, pediatrics, orthopedics, otolaryngology and cardiology. 
This program has recently been strengthened by the establishment of cancer 
detection clinics and will in the near future be further enlarged by addition- 
al psychiatric clinics developed under the mental hygiene program. 
Utilization of Existing Consultation Clinics. The medical 
care program should not establish consultation services which in any way 
duplicate those already in operation. Every effort should be made, however, 
to encourage full utilization of existing clinics by patients who are eligible Coordination Committee Report-p,21 
under the medical care program, as well as by patients who arc eligible under 
other health programs. The Director of Services for Crippled Children has 
indicated that the consultation clinics sponsored by that program are open to 
patients of the medical care program. Physicians should be encouraged to 
refer such patients as are in need of consultation services, to the ortho- 
pedic, cardiac end hearing clinics sponsored by the crippled children’s pro- 
gram, The availability of this service should be given full publicity. 
The services of the chest clinics are also fully available to 
clients of the medical care program. This makes possible referral of all 
persons having serious chest conditions and is not limited to cases having or 
suspected of having tuberculosis. 
The medical care program discovers many patients with com- 
plicated gynecological problems who are greatly in need of consultation 
service. It is to be hoped that consultation clinics in gynecology may soon 
be developed under the supervision of and utilizing the staff of the Bureau 
of Child Hygiene, 
Establishment of Few Consultation Clinics. The Bureau of 
Medical Services should endeavor to supplement existing consultation services 
by the establishment, as soon as is practicable, of new consultation clinics 
in such fields as ophthalmology, internal medicine, surgery and in any other 
fields in which consultation services are needed and arc not now available. 
The medical staffs of these consultation clinics should possess the highest 
possible professional qualifications. They should preferably be licentiates 
of the appropriate specialty board or have equivalent training and experience* 
Wherever practicable use should be made of members of the faculties of the 
medical schools. Such consultation services might well be developed under 
the guidance of a committee representing the University of Maryland School 
of Medicine and The Johns Eopkins School of Medicine, Coordination Committee Report-p,22 
PUBLIC HEALTH NURSING VISITS TO MEDICAL CARE PATIENTS 
The health department should make every effort to have a 
public health nurse visit each case or family as soon as possible after 
admission to any of its services. The visit should be designed both to 
determine the health needs of the patient and his family and to give any 
necessary nursing care. The nurse should always attempt to teach some one 
in the home to render as much of the necessary nursing care as possible 
so that too frequent nursing visits will not be required. 
Before inaugurating such a nursing system, the health officer 
should discuss with his advisory committee the method of arranging with the 
attending physicians for such nursing visits. In most cases it would seem 
advisable for the health officer to present the matter to every eligible 
physician at the beginning of the program, cither individually or at a county 
medical society meeting. This should do much to avoid misunderstanding on 
the part of the physicians and prevent the development of any feeling that 
the nurses were in any manner checking up on the attending physicians. 
All cases enrolled in the medical careprogram should as far 
as is practicable bo visited periodically by the public health nurse. Such 
visits will frequently bring to the attention of the nurse other persons in 
the family who need either preventive or curative service which might be 
provided by the health department. 
The patient master index file can very well he used as a basis 
for the scheduling of nursing visits to individual cases. Those cases should 
he visited which have not been seen by the nurse within the period specified 
in the nursing policy of the department. This period will vary according 
to the need of individual, cases and will of course be dependent upon the 
nursing personnel available. The actual planning of the frequency of visits will Coordination Committee Roport-p.23 
therefore he based on the judgment of the health officer. In all visits of 
this nature and in all plans for the care of patients end facilities visited, 
the public health nurse should be guided by the Nursing Manual of the Maryland 
State Department of Health. 
ROUTINE PHYSICAL EXAMINATIONS 
It is evident to everyone familiar with the medical problems 
in the social and economic classes from which come most of the patients re- 
ceiving medical care under the State program, that there exists in this group 
a great reservoir of unrecognized and therefore untreated disease and defect. 
Ideally, it would perhaps bo advisable to provide a system whereby all 
recipients of the service would receive a complete physical examination at 
the time of their enrollment and at stated periods thereafter. 
The economic and technical difficulties in the way of estab- 
lishing such a system arc however so grea.t that it is obviously impracticable 
to attempt to put it into effect at this time. It is, therefore, all the more 
important that the facilities for diagnosis that are now available should be 
used to the fullest possible extent. 
Two of the most valuable aids to diagnosis, an x-ray of the 
chest and a chemical and microscopic examination of the urine, can now he 
provided without difficulty through the existing facilities of local depart- 
ments of health. It would therefore seem the part of wisdom to explore the 
possibility of furnishing these two diagnostic services to every new case 
enrolled for medical care. The results of this exploratory procedure may 
well point the road to a practicable plan for more comprehensive examinations 
in the future. Coordination Committee Report-p,2^ 
CHILD HYGIENE SERVICES 
Maternity3 Present prenatal clinics and obstetrical con- 
sultation clinics can be enlarged and expanded and new clinics organized in 
areas where there is need to furnish increased care to medical care patients. 
As a part of this expansion the present policy of calling the attention of 
private physicians to the availability of these servhes should be continued. 
As soon as possible after an application for maternity care 
in the medical care program is received the patient lould be visited at home 
by a public health nurse who will determine the needs of the patient for 
maternity services and explain to her those available through the health 
department. 
Infant and Preschool. Child health conferences should 
similarly be enlarged and new services inaugurated in areas as need arises. 
This need can freouently bo determined on the basis of the distribution 
within the county of medical care patients less than six years of age. Here 
again, as in maternity hygiene, it is important to continue the present 
policy of calling the attention of the private physicians to the availability 
of child health conferences. 
An application for pediatric service under the medical care 
program should wherever possible be ma.de the occasion fo r an immediate home 
visit by a public health nurse. The purpose of the visit should be to determine 
the need of the patient for existing health department pedia.tric services, to 
explain to the parent the availability of these services and wherever possible 
to arrange for enrollment of the infant or child in a child health conference 
if only for immunization purposes. 
School Health Services. School health services in Maryland are 
rendered as a joint activity of the departments of education and health and Coordination Committee Report-p,25 
the coordination of preventive and curative medical services for this age 
group is an extremely complicated matter. It is to he hoped that the Joint 
State School Health Council will he of assistance in this matter, and it is 
recommended that in each county there he formed a county school health council 
with the health officer and the superintendent of schools serving as cochair- 
rnen. In this group the local parent-teacher association, medical society and 
dental society should also he represented. These councils should have 
regular monthly meetings if they are to provide the necessary service of 
coordination. 
The medical care program can he of value in finding pediatric 
patients of school age. Automatic follow-up of all such cases should he 
provided through school health services to determine whether or not any school, 
environmental changes, special rehabilitative measures, or other action may he 
indicated. Each county health department should adopt the policy of calling 
to the attention of private physicians and of educators and parents as 
well, the availability of certain public health services for school-aged 
children. This may well he done through the medium of the county school health 
council. The State School Health Council stands ready at all times to assist 
the preventive and curative programs of the county health departments in 
matters relating to all phases of pediatric care for school-aged children. 
DENTAL SERVICES 
Factors in Dental Services. The complexities involved in 
rendering either preventive or curative dental services by public agencies 
tend to make it a major problem in public health. Among the difficulties arei 
(l) the almost universal prevalence of dented, caries, the results of the 
neglect of dental caries and the recurrent character of dental diseases; (2) 
the inadequacies of present facilities for dental service as indicated by Coordination Committee Report-p,26 
dentist-population ratios; and (3)- the grea,t lack of appreciation on the part 
of the public of the importance of oral health, of the value of preventive 
dental practices and of care for the young age group* 
These factors with many others indicate the necessity of 
approaching the solution of the problem of dental health, through cither 
preventive or curative methods, by a concentration of effort within a limited 
age group which offers, by its size* a reasonable chance of complete coverage 
and, by its age, an opportunity for truly preventive activity. 
Preventive Dental Services, By preventive dented services is 
meant; 
1, Dental health education. Such a program should 
be directed toward informing the public on the 
importance of; (a) the dento-nutritional relation- 
ship; (b) proper mouth hygiene (cleanliness); and 
(c) regular examination by dentists. 
2. Services based on new dental procedures. At least 
two new procedures may at present be accepted as 
proper services for health department administra- 
tion, These are: (a) bacteriological diagnosis 
for determining individual susceptibility to dental 
caries; and (b) the topical application of fluoride 
to the teeth. 
Preventive-Curative Services, Preventive-curative services 
are those operative procedures carried out, usually in younger children, as a 
means of preventing incipient and small defects from becoming gross. This 
activity is the one that promises the best results so far as future dental 
health is concerned. It is essential to the success of such a service that Coordination Committee Report-p,27 
it "be concentrated on the completion of all the dental needs of a,s many 
individuals as possible rather than the partial completion of the needs of 
larger groups. Removal of sources of infection by extraction of non-savable 
teeth is, of course, a necessary service. However, the eventual 
evaluation of a dental health program may well be based on a ratio of a large 
number of teeth conserved by filling as against a small number extracted. 
Restorative Services. This service includes those procedures 
necessitated by previous failure to employ the foregoing 
practices. In older age groups restorative service is based principally on 
the necessity for: (a) masticatory function; (b) appearance, as influencing 
employability; and (c) health as it is influenced by lack of functions and by 
appearance. 
Heed for Coordination. Consideration of dental health services 
tends to emphasize the need for a closer correlation between health depart- 
ments and the dental profession. The limitations ordinarily associated with 
dentistry have served, unfortunately, to minimize the utilization of the pro- 
fession a.s a bulwark of general public health activities. It seems obvious 
that a clearer understanding of health department activities by members of the 
dental profession would well serve both groups. The desirability of a closer 
relationship is also based on the fact that in the hands of the general 
practitioner of dentistry lies the ultimate solution to the problem of dental 
health. 
LABORATORY SERVICES 
Present and Future Growth of Laboratory Services. It is 
recognized that an active and efficient program which seeks to correlate 
preventive and curative services in county health departments will of . 
necessity require progressively extending laboratory services for patients of the Coordination Committee Report-p,28 
medical care program who are to receive increased preventive and curative 
services at the hands of the local health department and the private physician. 
The need for laboratory service is obvious if physical examinations are to be 
conducted under the auspices of the county health department on patients 
enrolled under the medical care program. 
Information to Physicians. Current information as to the 
services available is of inestimable value if the laboratory is to make its 
full contribution to the program of the health department. Recently a 
nultilithed booklet giving concise information about specimen mailing con- 
tainers available, types of specimens to be sent to the laboratory, and accurate 
designation of outfit in ordering has been sent by the Bureau of Bacteriology 
to all the registered physicians in Maryland, This is a commendable step in 
the direction of informing the practitioners, the chief users of the 
laboratory service. 
Leaflets issued to private physicians by the Bureau of 
Bacteriology regularly at short intervals cah be highly effective in raising 
the quality of laboratory service for the individual patient by inculcating 
in the minds of physicians, through information, a greater discrimination of 
use of particular services. These leaflets can be prepared so as to include 
essential information on the clinical characteristics of a particular 
disease, types of tests which can be ma.de and their character, value and 
limitations of the various tests, Bequests for such information are constantly 
received. It would be of great value to Maryland physicians and health 
officers to have such carefully prepared leaflets, one for each commonly met 
disease, issued to them as frequent, regular bulletins by the Bureau of 
Bacteriology. Coordination Committee Report-p,29 
PLAITS FOR MORE COMPLETE UTILIZATION OF REHABILITATION SERVICES 
The curative services provided by the health department can 
ho substantially strengthened hy coordination with the Vocational Rehabili- 
tation Program of the State Department of Education, The Rehabilitation 
Program offers a very complete range of services to persons who have a 
physical disability which constitutes a vocational handicap. For stich persons 
the Rehabilitation Program provides the following services; 
1, General medical examination by the family physician, 
2, Consultation and diagnostic services as indicated, 
3* Physical restoration which may include surgery, 
U, Certain types of medical, dental and psychiatric treats 
ment, 
5, Prosthetic appliances including artificial limbs, 
6, Hearing aids, 
7, Vocational training, counselling, guidance and Job 
placement. 
The services indicated above are available only to persons who 
offer a reasonable prospect of placement in remunerative employment. In the 
review of MEDICAL REPORTS OF SERVICES RENDERED (MS-U) and MEDICAL CARE CASE 
SOT-HIaHY RECORDS (MS-g) , the health department should keep constantly in mind 
the possibility of referral of suitable cases to the Rehabilitation Program, 
In order to make full use of the Vocational Rehabilitation 
Program the following suggestions are made to county health departments: 
1, Obtain a supply of descriptive literature of services 
available from the Vocational Rehabilitation Program, 
State Department of Education, Lexington Building, 
Baltimore 1, Maryland, This descriptive material should Coordination Committee Report-p.30 
be brought to the attention of the entire staff of the 
health department, particularly the public health 
nurses and the medical care clerk, who should be 
intimately acquainted with the services available. 
2, Invite representatives of the Rehabilitation Service 
to discuss their program with the staff of the dounty 
health department. 
3. Invite the local representative of the Vocational 
Rehabilitation Program to review periodically with 
the health officer MEDICAL CARE CASE SUMMARY RECORDS 
(MS-g) in order to find patients suitable for 
rehabilitation services. 
CONCLUSIONS 
Three years after its inauguration in its constituent counties 
the Maryland Medical Care Program shows satisfactory progress toward the ab~ 
sorption of functions peculiar to a medical care program into the older functions, 
now often referred to as the regular functions, of the county health departments. 
Much needs to he done to bring these preventive services into more perfect 
alignment with curative services as exemplified by the medical care program* 
The Health Officer Committee on the Coordination of Preventive and Curative 
Services has carefully explored all the factors which in its judgment may so 
far have had a bearing upon the success of this absorption. The Committee has 
considered as well those factors which in the future may influence the 
smooth and speedy establishment of a closer working relationship between the 
preventive and curative services in the interests of a broadened and more 
efficient public health service to the people of the State by the several 
county health departments. The general conclusion has been reached that Coordination Connittec Heport-p,31 
mcdical care as it has been established and applied in Maryland, is rightfully 
a function of the State Health Department and its component local health 
units. This opinion is concurred in by the deputy health officers who have 
participated in the thoughts and discussions of the committee and by those 
vitally and immediately concerned in the central office who have been 
consulted or have supplied material to the committee. 
The major assignment of the Committee on Coordination has 
been the task of bringing into existence a list of ways and means for improv- 
ing immediately and at long range, whenever possible, the preventive and 
curative services of the county health departments and for effecting as 
rapidly as is reasonable a complete integration of these two services. The 
assignment has been accepted and the task assumed by the committee and the 
results of its work are shown in summary form in a series of recommendations. 
It is with every guarded hope for the soundness and lasting practicability 
of these recommendations that the committee submits them. 
HEC0M1 lEHDiiT I CHS 
1, The county advisory committee on medical care is, when wisely directed by 
the health officer, a useful instrument in enhancing close working 
relationships between the health department, the private physician and 
other key individuals in official and non-official agencies. Such a 
committee should meet regularly. Serious and immediate consideration 
should be given to enlarging the membership to include those individuals 
familiar with school health and general health activities. 
2, Periodic reports of the progress of various phases of the complete health 
department program should bo made by the health officer to the county 
medical society. The frequency and character of these reports must rest 
entirely with the judgment of the health officer. Coordination Committee Rcport-p*32 
3- The health officer should include in his duties a personal interview and 
conference with each new physician who establishes a practice in the 
county. This conference should include a thorough review of all health 
depaxtnent activities. 
h, An effort should he made hy the health officer to establish a regular 
procedure for visits by the public health nurse to the private physicians 
in her district. This is possible only when the health officer has been 
able to achieve a friendly, cooperative relationship with those physicians 
who are designated for such visits by nurses. 
5, There is evident need in the county health departments for a more 
effective program of public health education and of public relations 
particularly those directed toward professional groups. The Committee on 
the Coordination of Preventive and Curative Services recommends that a 
special committee be appointed to study this problem. 
6. Each county health department should establish as soon as practicable a 
master index file, alphabetically arranged, of individuals receiving 
services, both preventive and curative, from the health department. 
This file should be maintained in readily usable and current condition 
and should form the basis for planning for the individual and the family 
every available service of the health department. 
7* The Committee on Coordination of Preventive and Curabive Services is 
strongly of opinion that it is a highly important and almost necessary 
procedure to institute and systematize a review of the data currently 
entered on the MEDICAL CARE CASE SUliHARY RECORD (MS-S) in each health 
department in order to maintain a satisfactory current knowledge of the 
way in which the medical care program is being carried out in the county. 
Review of the information on the MEDICAL CARE CASE SUMMARY RECORD (MS-g) Coordination Committee Report—p,33 
should he a critical one carried out routinely hy the health officer or 
his representative. 
The county advisory committee on medical care should play an 
active part in assisting the health officer in reviewing those MEDICAL 
CASE Gn5E SUMMARY EEC0EDS(MS-8) which present special difficulties and 
cannot he handled in a routine manner* 
Hie attending physician should he asked to make a. special 
review and report on ca,ses which the health officer has found to he 
requiring continuous care over a period of several months. The special 
precautions necessary in this procedure are suggested. 
8, The Bureau of Medical Services should endeavor to supplement existing 
consultation services hy the establishment of new consultation clinics 
in such fields as ophthalmology, internal medicine and surgery, and in 
any other field in which consultation services axe needed and cannot he 
ma.de available through other existing services. 
Physicians staffing consultation clinics should carry the 
highest possible professional qualifications and he licentiates of the 
appropriate specialty hoard or have equivalent training and experience. 
If possible, they should he members of the faculty of an approved medical 
school. 
The consultation services might well he developed under the 
guidance of a committee representing the University of Maryland School of 
Medicine and The Johns Hopkins School of Medicine* 
9, A continuing approach should he ma.de hy county health departments toward 
the ideal procedure of having the public health nurse visit each case or 
family as early as possible after admission to health department services 
to determine the health needs of the patient and family and to give the Coordination Committee Eeport-p,3h 
necessary nursing case, but before inaugurating this service the health 
officer should discuss with his advisory committee on medical care the 
method of clearance of such visits with the patient’s physician. 
The public health nurse should be guided by the Mirsing 
Manual of the Maryland State Department of Health in making visits and 
planning the care of the patient and family, 
10, Consideration should be given to the need for providing routine physical 
examinations for recipients of medical care, but before attempting to 
develop any such program, it is believed by the committee to be essential 
that a careful ’’pilot” study be conducted in a selected area. 
11, Present prenatal clinics and obstetrical consultation clinics should be 
enlarged, expanded and organized in new geographical areas as indicated 
by the demand to furnish increased care to medical care patients as well 
as to suitable individuals not included in the medical care program. 
Wherever possible, application for maternity care in the 
medical care program should result in an immediate home visit by a public 
health nurse to determine the need of the patient for existing services 
and to explain to the patient the availability of these services. 
Child health conferences should be enlarged and new ones in- 
augurated in geographical areas where the need is demonstrated. The 
standards of need for these conferences should be restudied in terras of 
distribution within the county of medical care patients less than six 
years of age. 
Wherever possible, application for pediatric care should be 
ma.de the occasion for an immediate visit by a public health nurse. The 
purpose of the visit should be to determine the need of the patient for 
existing health department pediatric services, to explain to the patient Coordination Committee Report-p,35 
the availability of these services and whever possible to arrange for 
enrollment of the infant or child in a child health conference if only 
for immunization purposes. 
Each county health department should a.dopt the policy of call- 
ing to the attention not only of private physicians the availability of 
certain public services for school-aged children, but also of educators 
and parents through the medium of a county-wide school health council, 
12. Vigorous efforts should be made by the health officer to bring about as 
soon as possible a closer coordination of the program of the health 
department with the individual practitioners of dentistry. Specific 
recommendations as to ways of improving distribution of dental health 
information to private dentists may be forthcoming, when and if a 
committee is found to study public health education and public relations 
among professional groups as given in Recommendation 5* above, 
13, It is recommended that laboratory services be enlarged as is necessary to 
meet the growing demands to be placed upon it by patients actually treated 
clinically in the medical care program. 
Steps should be taken to inform continuingly all the private 
physicians of the county concerning the exact nature of laboratory ser- 
vices which are currently available. 
Leaflets should be prepared and issued by the Bureau of 
Bacteriology to private physicians and health departments relating the 
clinical features of the more common diseases with tha types of tests 
which can be made and the character, value, interpretations and limita- 
tions of the various tests, 
Ik, The curative services provided by the health department can be substantially 
strengthened by coordination with the Vocational Rehabilitation Program Coordination Committee Report-p,36 
of the Maryland State Department of Education, In order to make full use 
of the rehabilitation program, it is recommended that each county health 
department: 
1, Obtain and bring to the attention of the entire staff of 
the health department, particularly the public health 
nurses and the medical care clerk, descriptive literature 
of services available from the vocational rehabilitation 
program. 
2, Invite representatives of the rehabilitation service to 
discuss their program with the staff of the health de- 
partment, 
3, Invite the local representatives of the Vocational 
Rehabilitation Program to review periodically with the 
health officer MEDICAL CAPE CASE SUHiaRI HECOEDS (MSLg) 
in order to find patients suitable for rehabilitation 
services. Maryland State Department of Health 
APPENDIX Appendix-p,i 
Name Ppe. * 
LAST FIRST 
Tear of Birth 195Q Sex....F Color. ,.W 
Father «7W95. Mother,,.. J£§n§ 
Address... 
Type of Record 
....4.? 
....Sye 
.Hed.C$r§.... 
(over) 
Where Piled 
,PHN,..L? 
.A.O...LP. 
.A.Q...LP 
Opened 
,..7-rkV7.... 
Date Closed 
>n.. 
OBVERSE 
Name, 
LAST FIRST 
Type of Record 
Where Piled 
Date Opened 
Date Closed 
...CROSS INDEX CARD 
S.D.21 : 1-J+7“10M 
REVERSE