US (o2S
PROFESSIONAL PROVIDER PARTICIPATION
EPSDT - MEDICHEK
LOCAL DEMONSTRATION PROJECT
WILL-GRUNDY COUNTY MEDICAL SOCIETY
FINAL REPORT
REPORTS
RJ 102 .5 13
B76 1976
RONALD R. EXECUTIVE
BRYANT SECRETARY
Since 1974 the Will-Grundy County Medical Society, ini-ially under subcontract to the Committee cn Health Care of the Poor of the American Medical Association and later in direct contract with the Social and Rehabilitation Service of the Department of Health, Education and Welfare, has sought to demonstrate professional provider participation in planning for the successful integration of the Sarlv Periodic Screening Diagnosis and Treatment Program into the public and private sectors of the health, welfare and social systems in Will County, Illinois. While this report will detail the activities of the 1975-76 contract period, it is in a larger sense, a final statement of the role of private physicians in a public-private partnership and the limited success in devel- oping alternatives to traditional modes of delivery.
In understanding the 1975-76 project, it is important to remember that the present contract is an extension and expansion of the initial sub-contract. The 1974-75 project was devoted to exploring alternative methods of delivery of EPSDT services in private office settings while simultaneously attempting to fac- ilitate entry of EPSDT-eligible children into the health care delivery system through an active outreach program through communication and coordination with various community agencies offering direct or indirect services to the Medicaid-el igible population. At the same time, efforts were initiated to address bureaucratic roadblocks which impeded the delivery of EPSDT services.
In order to satisfy the goal of delivery of EPSDT services in private office settings during the sub-contract period, the Society expanded a rotation system of assignment of patients to physicians. Under the program, Medicaid-eligible patients con- tacted project staff and were assigned to a volunteer pool of physicians. To increase public awareness of the program, outreach was directed through the local Department of Public Aid and through local schools. Project staff developed record-keeping mechanisms to handle the assignment of patients to physicians and to record the results of those contacts. Since the system was maintained through the second contract period, a description of the patient enrollment and family history files appears latar in this report. In an attempt to minimize bureaucratic roadblocks, physician volunteers submitted claim forms to the project office rather than directly to the Illinois Department of Public Aid. A system of prior claim review was developed to eliminate clerical and billing errors which delayed payment to physicians by the State of Illinois. As an additional service, project staff provided training to pri- vate office personnel in the preparation of complicated forms.
A second major activity of the 1974-/5 subcontract was the participation of the Society in a mass screening program of elemen- tary school children who had failed to complete physical examina- tions as required by state law. The mass screening program, co- ordinated with the Will County Health Department and Joliet Grade School District 36, provided an opportunity to identify 2PSDT- eligible children and bring them into the program. Although over six hundred children were examined in the program, problems of confidentiality hampered identification of SPSDT-eligibles . The orogram did result in development of an outline to address these problems and to improve the educational opportunities of the program. This outline was included as an integral portion of the 1975-75 contract.
The physician rotation program was discontinued prior to the completion of the 1974-75 subcontract. The termination was the joint result of a successful outreach program which increased the number of patients at greater numbers than they could be assimilated into the system combined with a steady decrease in voluntary physician participation in the program. The decrease in physician participation was generally attributed to three factors:
A. Patient overload infringed on the delivery of medical care to established patients.
B. The Medicaid payment system of the Illinois Department of Public Aid was unresponsive to the increasing cost of deliv- ering medical care and, therefore, the program was not economically sound,
C. Patients did not conform to office routine, i.e., a high rate of missed appointments, demanding attitudes, and over- utilization of services.
Thus, although local project staff was able to develop a record-keeping mechanism, and although EPSDT services were deliv- ered, the experience of the 1974-75 contract posed major problems for the Society in meeting the terms of the contract:
A. The failure of attempts to establish meaningful ccmmunication with the Illinois Department of Public Health and the Illinois Department of Public Aid which jointly share administration of the EPSDT program, designated as Medichek in Illinois. The program carried a low priority in both departments and attempts to resolve bureaucratic problems which increased the level of physician frustration were not seriously con- sidered by either department.
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3. Failure to resolve the problem of confidentiality. Although
t.-.e Society was willing to explore means of providing services to EPSDT-eligible children, we were consistently unable :c locate eligibles due to the nature of federal and state statutes which protect the identity of public aid recipients. The solution to this problem was beyond the authority and capability of the Society at a local level and a solution was not forthcoming at a state or national level.
C. The growing frustration of physicians to the apparent unres- ponsiveness of the Illinois Department of Public Health, the Illinois Department of Public Aid and the Social and Rehabil- itation Service of the Department of Health, Education and Welfare to long-identified problems combined with the diffi- culties of dealing with public aid patients in private settings. Many problems were initially identified in "A Report on Pro- fessional Health Provider Participation - EPS DT - Medicaid - 1974", and in fourteen specific problem areas discussed in
the final report of the 1974-75 subcontract project.
D. A growing shortage of primary care physicians in the area resulting in growing patient loads as population of the area increased.
The role of the American Medical Association during the sub- contract period was to serve as a fiscal intermediary, to assist in creation of an administrative mechanism and to provide tech- nical staff support in operation of the local demonstration project. The vehicle was the AMA ' s Committee on Health Care of the Poor. Because the Committee could not see progress in solving problems previously identified in "A Report on Professional Health Provider Participation - EP S DT - Medicaid - 1974", near the end of the subcontract period, the Committee decided that little could be accomplished by continuing. While the American Medical Association recommended discontinuation in direct participation with the Department of Health, Education and Welfare, AMA did offer to assist the Will-Grundy County Medical Society if the local society decided to continue the project. Despite the continuation of long identified program problems, the Social and Rehabilitation Service, Medical Services Administration, Department of Health, Education and Welfare urged the Society to accept a direct contract to con- tinue the project with the proviso that the American Medical Assoc- iation accept a subcontract for second-year activities. Pressure was applied to the Society through project staff by Medical Services Administration staff members at an evaluation meeting which followed the mass school screening program in April, 1975. This view pre- vailed over the reluctance of many physicians involved in the
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The major elements and timetable of the 1975-7-5 ~ontrac_ were jointly developed by staff of the Social and Rehabilitation Service of the Department of Health, Education and Welfare and local project staff in a period of less than thirty days. Many physicians were unaware of the scope of these developments. The intent of the new contract was to continue to seek means to develop and improve communication between the public and private sectors and to explore new means of delivering EPSDT services. This intent was expressed in the statement of purpose in the scope of work of the new contract:
"The purpose of this project is to explore alternative solutions to providing the assistance needed by professional health care providers attempting to meet EPSDT needs in solo practice settings and to develop a model whereby individual professional health care providers will be involved in a Com- munity Health Services Program which draws upon existing resources and those that can be developed through a coordinated effort of all related community agencies and services including the schools, under the sponsorship of the local Medical Society".
Implicit in this statement of purpose is commitment of con- tinuation of project activities developed during the subcontract period and a major expansion of the project with development of the Community Health Services Program. The hurried development of the new contract would later prove to be a major weakness which would require considerable time and effort to repair.
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THE AREA
It is important to provide a description of the area against which the project has been projected daring both contract years. Will County, one of the most rapidly growing areas in the State of Illinois, covers 845 square miles in the northeastern section of the state. The county is within fifty miles of Chicago and is adjacent to the counties of Cook, DuPage, Kane, Kendall, Grundy and Kankakee in Illinois and Lake County, Indiana. The population of Will County in 1970 was 249,498, an increase of 30.2% since 1960. Will is the seventh largest of 102 counties in Illinois and the county's growth rate from 1960 to 1970 was exceeded by only two other counties in the state. The population pattern for the county shows an 11% growth rate from 1970 to 1973 with a 1973 census of 278,060. The majority of Will County is rural with two heavily urbanized areas located in the northeastern and northwestern por- tions of the county. The city of Joliet, with a population in excess of 78,000, located in the northwestern quadrant of the county, is the governmental, educational and cultural center. Joliet, with its adjoining metropolitan area, has been the center of activity during both contract periods. The 1970 population of the metropolitan Joliet area, encompassing four townships was 160,960, representing 64% of the population of the entire county. Two of the townships in the metropolitan area registered a more than 30% growth rate between 1960 and 1970.
The Will-Grundy County Medical Society has 176 member phy- sicians in solo and group practices in Will County, 150 located in the metropolitan Joliet area. The area is served by two general hospitals with a total of 983 beds offering physical therapy, in- tensive care and cardiac care, psychiatric care, and accredited schools of nursing, medical technology and radiologic technology. Other health resources include twelve long term care institutions with 794 beds and 91 dentists. In addition, the Will County Health Department, headquartered in Joliet, has divisions dealing with mental, dental and environmental health, health education and nursing services. A variety of related social and welfare services is provided by 149 public and private community agencies in Will County .
The continued pattern of rapid growth in Will County, and particularly in the metopolitan Joliet area, have taxed the capa- city of existing resources to meet the ever-increasing demand for health services. This problem is intensified by a steady decline in the availability of primary care medical services since 1964.
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Approximately 53 physicians left private practice in Will County between 1964 and 1975, 4 6 in the categories of family practice, pediatrics, internal medicine and obstetrics. During the same period, 67 physicians entered practice but only 26 in the primary care, some part-time. The result was a net loss of 22h primary care physicians during a period when the population of the county increased over 30%. The ratio of primary care physicians to patients in the metropolitan Joliet area is 1/3,499, however, physicians do not restrict their practices to residents of that araa. Most residents of rural areas of Will County are dependent on health care facilities in the metropolitan area, thus the ratio of primary care physicians to the population of the county is 1/6,045. This overload has caused many physicians to restrict the size of their practices. These restrictions of practices resulted in an increase of crisis oriented delivery in local hospital emergency rooms particularly for the low income segment of the population .
These problems, coupled with the lack of education of the general public in health matters, a serious transportation in- adequacy in the metropolitan Joliet area, the clustering of a majority of the public aid recipients of Will County in the Joliet metropolitan area and growing physician resentment of the non- responsive bureaucracy of the Illinois Department of Public Aid, have erected significant barriers to health care. These barriers have served to perpetuate cycles of illness, limited health aware- ness, education and poverty, particularly frustrating the poor and alienating them in their relationship to society. It is estimated one or more of these barriers to health care affects up to 39% of the population of the Joliet metropolitan area.
The involvement of the Society in the EPSDT Program was an attempt to isolate and resolve some of these barriers to health care delivery, however, that involvement was increasingly tempered by the attitude of the medical community. That attitude, hopeful in the beginning, became increasingly discouraged over the two years of the project, particularly during the 1975-76 contract period. The discouragement was fueled by the shortage of primary care physicians, the already existing patient overload, the pre- viously described difficulties in treating public aid patients, and frustration with the public aid system and the unresponsiveness of the State of Illinois in responding to physician problems and concerns. Another problem contributed to the steady erosion of physician interest and participation in the EPSDT Program, a generally shared belief that the majority of malpractice litigation, particularly non-meritorious suits were initiated by public aid patients. This belief was only a part of a much larger concern with the entire malpractice problem as experienced by physicians but it added a significant piece co the growing mosaic of physician
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It is not unusual that the Will-Grundy County Medical Society should choose initially to become involved in the SPSDT Program. The recan- history of the Society has been one of involvement in the creation of community agencies related to federal health pro- grams and community problems. Since 1969, the Society has initiated or assisted in the development of a community drug abuse program and a comprehensive health planning agency. The Society founded the Quad River Foundation for Medical Care, the only operative Professional Standards Review Organization in Illinois in 1975. In each instance, the Society committed considerable volunteer- physician time and resources as well as financial and staff support. In each instance, the Society provided office space to the fledgling organizations. It was with this history that the Society accepted involvement in the Early Periodic Screening Diagnosis and Treatment Program. Having been successful in previous endeavors, the Society entered the 1974-75 sub-contract with high expectations. Despite the lack of progress evident at the end of that period, the Society retained enough confidence in it's ability to overcome obstacles to accept a second contract despite advice to the contrary from the AMA . Even when severe administrative problems had surfaced after signing of the 1975-76 contract, the confidence of physicians was such that, followinga site visit, Elsie Tytla, M.D., medical advisor to the Medical Services Administration of the Department of Health, Education and Welfare, was prompted to comment:
"My general impression is that this is an unusual, highly motivated, activist county medical society. It has the only designated and operational PSRO in the entire State of Illinois. It has intense desire to be creative, constructive and successful but is unable to overcome a series of unfortunate events over which they had little control." 2
Elsie Tytla, M.D., Report on visit with Will-Grundy County Society-September 23, 1975, iatsd September 30, 1975.
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PHASING INTO SRS 500-75-0030
The "series of unfortunate events" described by Doctor Tytla actually began develop prior to initation of the 1975- 76 contract. As reported earlier, the staff level negotiations of the scope of work of the contract were completed in a brief period of time and the substance of these negotiations were not presented to physicians of the Society. Thus the contract was encered without a clear understanding of its terms. Indeed the committee with primary responsibility for the EPSDT Program, the Public Health and Medical Services Committee, had voted not to recommend a second contract to the Society's Board of Directors. The Board of Directors did not receive that recommendation, in fact, did not officially consider the second contract. The docu- ment was approved later on recommendation of the Executive Com- mittee. An ad-hoc physician committee was created, by staff, to work with other community organizations to resolve problems en- countered following the collapse of the physician rotation program during the 1974-75 contract. This ad-hoc committee, aware of only one area of program development, represents limited physician contact in development of the new contract. In effect, the 1975- 76 contract was primarily a staff document, concieved, written, finalized and signed at that level. The respective roles of the Society and the Department of Health, Education and Welfare were not defined at a decision-making level in the Society. Although the new proposal mandated development of a sub-contract with the American Medical Association, no guidelines were provided or developed to specify the role of the AMA in the project. The roles and responsibilities of the major parties to the contract would not become clear in the Society until several months had passed. This was acknowledged by the Department of Health, Education and Welfare when Doctor Tytla reported:
"This project scope of work is way beyond the capabilities
of this Medical Society and its staff at this time who
wrote up the proposal is no longer there is a good project
director but needs help in the health care delivery field. The active physicians are all practicing specialists who honestly want
to produce something useful but need help Mot only has there
been no cooperation from Welfare but no response to any suggestions in Medichek procedures from the State Health Department either. IN ADDITION, WE AT THE CENTRAL OFFICE HAVE NOT RESPONDED TO ANY OF THEIR PLEAS . " 3
Tytla, M.D., Report cn visit with Will-Grundy County Medical y, September 23, 1975; dated 3 apt amber 30, 1975.
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By September 1975, it was claar that the Department of Health, Education and Welfare had negotiated the contract in lass than good faith in rarms of the technical support and assistance to the Society in meeting the scope of work in the contract.
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MAJOR PROJECT ACTIVITIES
The departure of key staff personnel from the Society and confusion over assignment of project personnel at the Department of Health, Education and Welfare put the Society in a position of not having a project officer at a crucial time. The confusion in staff identity at Department of Health, Education and Welfare persisted from July to November 1975. With new personnel at both ends of the project, unacquainted with each other or with the nature and background of the project, the Society was faced with the responsibility of defining specific areas of activity to meet the scope of work of the contract. These activities were broadly defined into three general areas :
A. Discussions with state and national leadership relating to specific EPSDT program barriers.
B . Development of a Community Health Services Program to explore alternate methods of delivery of health care to the Medicaid- eiigible population including but not restricted to EPSDT- eligible children.
C. Continuation of administrative assistance in the delivery of EPSDT services in private office settings combined with develop- ment of community outreach programs and patient-oriented health education materials.
The implementation of each of these program areas has been charac- terized by a nearly total breakdown in communication between the Society and the Department of Health, Education and Welfare leaving the project in a vacuum.
The single exception to the communications breakdown was in the relationship of the Society to the American Medical Association. Staff members from the Department of Rural and Community Health assisted local project staff in development of a formal sub-contract and maintained their involvement in, and concern for the project. American Medical Association staff provided virtually the only link in continuity between contract periods. Throughout the 197 5- 75 contract period, the American Medical Association proved to be the only reliable source of technical assistance and materials for local project staff. As late as April, 1976, project staff was verbally informed by the Department of Health, Education and Welfare that materials were available to assist in planning and decision making but the information was never forwarded.
In a visit to the Department of Health, Education and Welfare shortly after initiation of the 1975-76 contract, project staff
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expenses resulted in such a severe cash flow shortage that the project was nearly forced into suspension in three months when local staff could no longer meet expenses.
To resolve this difficulty and assist in implementing the three general areas of activity previously mentioned, physicians and project staff designed a mechanism of quarterly activities with specific goals in each contract quarter. A verbal agreement was obtained with the Department of Health, Education and Welfare al- lowing the release of withheld funds at the end of each quarterly period. The Society was not assisted by the Department of Health, Education and Welfare in this re-evaluation. As was the case through- out the contract, the Department relied on sporadic verbal contact with local staff.
In November, 1975, a growing frustration on the part of the Society was expressed in a letter to Mrs. Beatrice D. Moore, Acting Director, EPSDT Division, Department of Health, Education and Welfare from the president of the Society:
"We would make only four (4) requests as we submit these reports :
A. That someone read them in their entirety since they were re- quested in precisely this form.
B. That those who read them will understand that they were written slowly, carefully and sincerely.
G. That the authors, approximately fifteen (15) people, really believe that Medichek is a good idea and with changes can live and grow, but without changes will surely die a horrible death .
D. That someone initiate some changes seen before the frustration level of Will County primary care physicians exceeds their patience with those who keep encouraging them to try again."
There was no response from the Department of Health, Education and Welfare .
With this general background and an understanding of the dif- ficulties which attended initiation of the 1975-76 contract, we can examine the operation of the project.
Albert w. Ray, Jr., M.D. letter to Mrs. 3eatrice Moore, dated
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DISCUSSIONS WITH STATS AND NATIONAL LEADERSHIP RELATING TO SPECIFIC EPSDT PROGRAM BARRIERS
One of the major barriers to delivery of EPSDT services identified in the 1974-75 contract was the participation of the Illinois Department of Public Health and the Illinois Department of Public Aid in the program. In the 1975-75 project, the Society viewed its role as that of advocate for the Department of Educ- ation and Welfare in addressing problems of inadequate provider re-imbursement , lengthy delays in provider r e - imbur s ement , in- creasing the generally low priority of EPSDT at the state level and the simplification or removal of bureaucratic paperwork which hampered delivery of EPSDT services in the private medical com- munity. Several specific activites were initiated to address these problems.
A. Discussions with the Illinois Department of Public Health and the Illinois State Medical Society to re-design the EPSDT reporting form.
B. Testimony before the Legislative Advisory Committee on
Public Aid, a joint committee of the Illinois General Assembly.
C. Development of an internal system of prior claim review
and training of office personnel for patricipating physician members of the Society.
Discussions with IDPH and ISMS
It was assumed that revision of the EPSDT claim form would be relatively simple. In September, 1975, project staff met with representatives of the Illinois Department of Public Health, Illinois Department of Public Aid and the Committee on Govern- mental Health Program Reimbursement of the Illinois State Medical Society. The meeting was the first between the Society, the two state code departments and the State Medical Society to discuss specific revisions since the involvement of the Society in April 1974. A series of eleven (11) specific program recommendations were submitted by project staff and physicians and the Illinois State Medical Society to representatives of the two state depart- ments. The recommendations were:
A. M-M-R- Vaccine to be included within Program extending to age 10 with provisions made to update children who have not been immunized against mumps.
3. Incortor ation of newborn examination into the Medichek 3 2 3? fi a 1 3 ncr ^rccr^ram.
C. Closer coordination of Medichek with IDPA diagnosis and treat- ment components.
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D. Make provisions within program to allow private provider to be aware of vision and hearing results on patients.
S. Need for greater coordination of outreach and education throughout the state.
F. Consideration of including a learning disability screening test within the Program allowing payment to providers . Ident- ification of referral sources for foiiow-up must be identified and the adequacy of those referral sources to absorb children identified through screening.
G. If newborn examination included in screening package and budget requires the exclusion of other examinations, the following changes were recommended; drop eighteen month visit, combine three and four year, combine five and six, coordinate ten and fourteen with required fifth and ninth grade exams and combine seventeen- twenty .
H. Developmental appraisal reporting should be changed to allow for the report by the physician and also should allow the physician to administer a specific test of his choice and report the results of his test.
I. Urinalysis-allow physician to run a routine urinalysis and pro- vide payment for the procedure, and have the dipstick urine test be made part of the routine exam without payment provided.
J. There is concern as to the over-immunization problem on
children and there is a need to provide local feedback to physicians on immunization status of children .
K. Claim form revision-consider possiblity of devising a billing form suitable to IDPA and Medichek reporting requirements and set the form up in a similar format such as the AMA Health Insurance Claim Form which all physician offices are familiar with. 5
Representative of the Illinois Department of Public Health and Illinois Department of Public Aid were not authorized to make com- mitments to basic program changes and indicated that ediroriai re- vision of the claim form, as requested in point 11, would take approximately six months.
Will-Grundy County Medical Society SRS Project-Monthly Project Report, September, 1975.
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Although consideration of. and further discussion on, either points was promised, there were no further meetings on those topics. In February, 1976, the revised claim form was reviewed by project staff and the Committee on Governmental Health Program Reimburse- ment of the Illinois State Medical Society and a representative of the Illinois Department of Public Health. Although several ad- ditional specific editorial changes in the claim form were suggested, the overall reaction was later summarized by the Illinois State Medical Society:
"Overall, the physicians felt that the changes in the form would have little effect upon the major problems in the Medichek (EPSBT) Program. The form is long, difficult to use and understand though it is considered better than the previous one." °
There were no further discussions or communications with the Illinois Department of Public Health on this relatively simple matter.
Separate discussions were initiated with staff members of the Illinois Department of Public Aid in an attempt to further clarify private provider concerns with state administration of the EPSDT Program and to discuss those concerns through the local project. It is important to remember that the Society had been attempting to begin discussions of this nature since the beginning of its in- volvement in the EPSDT Program in 1974. It was felt the discus- sions were necessary in order to relate the local project to the state program. The Society also believed it was fulfilling its role as advocate for the Department of Health, Education and Welfare by opening detailed discussions with the Illinois Department of Public Aid .
What follows is a summary of major provider concerns and staff responses from the Illinois Department of Public Aid from a meet- ing in October 1975:
A. We questioned the nature of the responsibilites of a new Pro- vider Relations Unit in the Illinois Department of Public Aid and asked about coordination between the new Unit and the EPSDT- Medichek Program of the Illinois Department of Public Health.
State staff responded that the new Provider Relations Unit would assume responsibility for provider enrollment in the Medicaid pro- gram and would provide provider education for state vendors. Under the educational component, we were told that state staff would be made available to private offices, on request, to assist in proper claim form preparation and systems operation.
°Larry 3. Bcress, Illinois State Medical Society, letter to
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In addition, the Unit was assigned the development of a monthly newsletter to providers detailing Medicaid program changes and providing status reports on development of the Medical Management Information System. Mo direct relationship between the Provider Relations Unit and the EPSDT/Medichek Program was detailed. Al- though sporadic copies of the monthly newsletter were received during the balance of the contract period, no other evidence of the operation of the Unit was provided to local project staff.
3. We inquired about EPSDT activities in other areas of the state and requested information to contact the operators of other local projects with the goal of exchanging information on successful project activities.
State staff verbally provided information on the operation of EPSDT projects by several county health departments in other areas of Illinois and promised follow-up information which was never received.
C. We asked about long range plans to identify Medichek-eligible children not presently receiving services and about plans to intensify outreach efforts to draw them into the program.
IDPA staff indicated that the Medical Management Information System might develop the capability to identify EPSDT-eligibles not re- ceiving services but said the Department would not solicit medical visits. State staff expressed the belief that outreach would not be intensified because of the fiscal crisis faced by the State of Illiinois in the Medicaid program. This statement served to con- firm the Society's impression that the EPSDT program suffered a low priority at a state level and would continue to do so. Since a basic tenent of EPSDT is to locate eligible children and enroll them in a continuing program of screening, and since an active outreach component is necessary to locate eligibles and to keep them enrol- led, the reluctance by the Illinois Department of Public Aid to conduct active outreach for economic reasons casts a negative re- flection on the probability of program success.
D. Since the Society was concerned about the use of EPSDT educational materials and wished to explore the possibility of coordinating the development of patient-oriented educational materials through the local project with state activities, we inquired about materials currently available to public aid staff at the county level .
We were informed that the development of educational materials on EPSDT had been limited to a handout pamphlet and a packet designed for use by professionals and related service workers outlining the
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provisions and administrative structure of the EPSDT/Medichek program. An annual mass mailing of the handout pamphlet is the chief means of distribution of information to public aid recipients. State staff also outlined plans for development of educational programs for county level staff and development of a pamphlet for the mothers of newborns. We did not learn if this activity was completed. The development of educational materials for the mothers of newborns is of questionable value since the State of Illinois does not include newborns in the EPSDT/Medichek program.
E. With patient transportation remaining as a major barrier to the delivery of SPSDT services, we inquired about the policy of the Illinois Department of Public Aid regarding transportation al- lowances for medical care.
State staff responded that medical care transportation was generally provided to recipients as follows:
1. Vendor payment to a company, private taxi or public mass transit, for example, is available but requires prior ap- proval and a company agreement before delivery of the transportation service.
2. Mileage r e- imbursement at a pre-arranged rate with a volunteer. This method requires a considerable amount of time, state staff indicated sometimes in excess of two months.
It was indicated that medical care transportation allowances were restricted when the State of Illinois implemented a flat grant pay- ment system replacing a need item payment system. It is apparent, from the information provided, that medical care transportation is difficult for recipients to obtain, again causing a negative im- pact on the delivery of EPSDT services with its mandated schedule of medical visits.
F. In an attempt to further explore the administrative commitment to EPSDT at a state level, a series of general questions were posed relating to the amount of informational exchanges among county level EPSDT/Medichek coordinators, the future of un- filled staff positions in the EPSDT/Medichek program and the duties of county level coordinators.
State staff responded that there was not a regular program of meetings for county level staff to discuss program problems and successes and that no state-wide meetings for county level staff had been conducted to discuss program changes since early in 1975.
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It was felt that due to fiscal limitations, several vacant adminis- trative positions in the Medichek program in the Illinois Depart- ment of Public Health would not be filled. It was acknowledged that Medichek coordinators at a county level were salaried through the 75/25 federal matching formula provided through federal EPSDT regulations although activities of these workers were considered part of service activity and most were assigned other duties as well. This was particularly important to local project staff since a major local problem was the lack of a Medichek coordinator in the county public aid office.
G. We asked about the involvement of other governmental or private agencies in the EPSDT/Medichek program other than the Legis- lative Advisory Committee on Public Aid of the Illinois General Assembly .
State staff indicated that no other governmental agencies or commit- tees and no other private agencies or organiztions were actively involved in the EPSDT program. There was an indication that a welfare rights group had filed suit against the State of Illinois for failure to implement EPSDT early in the development of the pro- gram, but state staff was unable to report on the outcome of the suit .
H. General inquiries were posed relative to the state of the
relationship between the State of Illinois and the Department of Health, Education and Welfare concerning development of the EPSDT program. We specifically inquired about the state re- sponse to the publication of proposed penalty regulations.
State staff declined to discuss these questions with local project staff without written authorizations from the Director of the De- partment. We were informed that the Director has responded to the publication of proposed penalty regulations but since the response was over his personal signature, state staff declined to discuss the nature of the response without the Director's personal author- ization.
As the summary illustrates, many areas of discussion were opened however there was no follow-up to these initial discussions by the Illinois Department c: Public Aid. It should also be noted that IDPA staff reviewed and approved a draft of the report of the discussion prior to its inclusion in the October 1975 monthly progress report of the local project to the Department of Health, Education and Welfare. Local staff reaction to the exploratory discussion was also reported:
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"As a result of the IDPA meeting, project staff became more aware of the reality of the financial limitations currently being on the Department of Public Aid in the State of Illinois. The Governor has ordered 6% cuts in all State Departments and in ad- dition, fifty million dollars was withheld from the Public Aid appropriation for fiscal 1976. These cuts, in addition to the imposition of a statewide freeze in hiring new employees signif- icantly affects and limits Illinois' ability to implement a mean- ingfull and effective EPSDT Program. In addition, I question the Departments' ability to provide the services required by law to categorically eligible persons in the State. Vacant desks were evident in Springfield offices and Will County in particular is understaffed with approximately 3-6 uncovered caseloads of approx- imately 180 cases each affecting approximately 540 to 1080 people. This means locally, eligible families are not being afforded the services and attention required by law, and at the administrative level in Springfield position vacancies prevent efficient manage- ment of Department functions.
It is within these limitations that the Department of Public Aid is implementing EPSDT in Illinois. Budget cuts have been in most every medical assistance program including the drug program, physician services, long term care programs, hospital payment pro- grams, etc. Only two medical programs sponsored through the De- partment of Public Aid were left unscathed. Family Planning and Medichek. This action, as token as it may be, appears to be the singly, most significant step the Department has made in implement- ing EPSDT. The fact that they did not lump Medichek with the rest of the medical programs is a hopeful sign that someone recognizes the importance of the Program and its apparent effect on AFSC federal matching funds.
Project staff attempted to point out the apparent weakness of the program as perceived locally in the questions asked, but more im- portantly attempted to show the willingness of project staff to work for a more effective, meaningful and successful program of EPSDT in Illinois. Earlier in the contract at the IDPH, IDPA and ISMS meeting, staff gladly volunteered project time to serve on any com- mittee or task force appointed to work in the area of EPSDT. This offer was made again to IDPA staff including the Public In- formation Office, Medichek Supervisor and the Acting Chief Bureau of Medical Services. It appears however, that the enthusiasm for program improvement by project staff is not shared by the responsible authorities in Springfield. Unfortunately, it appears that Illinois will continue to slide by with the EPSDT Program until such time the Department of Health, Education and Welfare exercises its
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authority by imposing the 1% penalty for failure to implement the program . " '
In a future attempt to broaden communication at a state level and as a result of information gathered in staff level discussion with the Illinois Department of Public Aid, local project staff prepared a report on the involvement of the Society in EPSDT for presentation to the Legislative Advisory Committee on Public Aid in November 1975. The Committee is a bi-partisan joint Senate House watchdog committee of the Illinois General Assembly which has been successful in introducting some reforms in the public aid system in Illinois. The report, delivered by Albert W. Ray, Jr., M.D., president of the Society, summarized a number of problem areas in the EPSDT/Medichek program:
A. Medichek program given low priority by state and local depart- ments of public aid and public health.
B. Difficulty in reaching the Medichek-eligible child-the prob- lem of confidentiality.
C. Strong identity with Illinois Department of Public Aid hinders program acceptance by physicians.
D. Medichek is adminis tratively-not service delivery-oriented.
E. Failure to develop patient-oriented educational materials.
F. Failure to provide for diagnosis and treatment of develop- mental disabilities.
G. Inadequate staffing at Will County Department of Public Aid.
H. Inadequate knowledge of abnormal r eports-direc tly related to the problem of confidentiality. 8
The testimony also summarized special local problems and pointed out the Society's difficulty in dealing with the Illinois Depart- ment of Public Aid and Illinois Department of Public Health since 1974. A list of eight specific recommendations was also presented
A. Newborns must be covered under the Medichek program.
B. Medichek reporting forms must be reviewed.
7
Will-Grundy County Medical Socety, SRS Project, Monthly Progress
> c t o b e r 1375.
^Raccr- of the Will-Grundy County Medical Society on EPSDT/Medichek Program for the Legislative Advisory Committee on Public Aid, November 17, 1975.
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C. A mechanism must be devised whereby Medichek-eligible patients can be identified and included in the program without violating confidentiality.
D. Staffing of public aid offices at both local and state levels must be augmented to cope with the project. This might include an EPSDT coordinator.
S. Active outreach programs must be instituted by lecal public aid departments .
?. Must develop and effectively distribute consumer-oriented health education materials to emphasise the importance of preventive care .
G. Utilize centralized facilities, schools if necessary, for screening purposes.
H. Provide for automatic replacement of vaccine administered to Medichek patients. '
It was the intent of this presentation to enlist the support of the Legislative Advisory Committee on Public Aid in opening communi- cation with the two state departments at a decision-making level. We were advised to anticipate further contact from the Committee in January, 1976, after Committee staff had reviewed our presentation but there was no follow-up and no further contact with the Committee.
The Society also had little success in communicating with the Will County Department of Public Aid. The local office suffered a severe shortage of personnel from August 1975 through February 1976 as a result of a statewide moratorium on hiring instituted by the Governor. In addition, the local supervisor was transferred in November 1975 and was not replaced until January 1976. Attempts to reopen communication following the appointment of a new super- visor also failed. In January 1976, project staff, Doctor Ray and a state representative met with the new supervisor to introduce the Society's project, to discuss the possibility of the transfer of project records to the local office following termination of the contract and the development of a mechanism to allow the local office to continue the services of prior claim review and foilcw- up being provided the medical community through the project office. Although an offer to use project staff to provide EPSDT training for new public aid employees was accepted, there was no response to our other overtures.
The Society's growing sense of futility in gaining input at a state or local level was compounded by what was percieved locally as a lack of supportive involvement by the Department of Health, Education and Welfare. From July, 1975, until January, 1976, it was our impression that the Department would initiate a review of the Illinois EPSDT program to determine if the State of Illinois was out of compliance with basic program regulations. It was further our belief that some of the documented lack of responsive- ness on the part of the State to this project would be considered in that review. Accordingly, the Society commented on the proposed penalty regulations as published in the Federal Register, Volume 40, N . , 162, dated August 20, 1975:
"The delivery of EPSDT services is not, and should not, be a yes or no, accept or refuse proposition. Rather, these services should be an educational process of helping people understand that regular medical and dental care, in combination with healthful eating habits and moderate physical activity provide ingredients necessary to insure good health.
"Public aid recipients are already innundated with reams of papers requiring signatures for such things as medical information, insurance information, verification of school attendance and agre- ements to cooperate in support enforcement activites to name a few. It is our considered opinion that requiring an additonal signature for the purpose of accepting or refusing EPSDT services is not the most effective means by which to inform recipients of these services.
"We believe a federally-supported program, with funds specified for employment of individuals to provide outreach and follow-up services and supportive health education is a more beneficial and effective means of informing Medicaid-eligible families of EPSDT services. It is further our opinion that additional complication of a physician's office routine by requiring another form docum- enting diagnosis and treatment will antagonize the medical com- munity and will result in decreased participation by the very people needed to insure finding' and treating all problems ident- ified in screening." 10
Our interest in and anticipation of a review of the Illinois program was also confirmed a: a staff level:
Albert W. Ray, Jr., M.D. letter to Administrator, Social and Re-
habilition Service, Department of Health, Education and Welfare, da~sd September 18, 1375.
"As we understand the situatxon . . . . the state must submit a program improvement plan by October 30, 1975 and a penalty decision will rest on that plan.
"The central office position in this matter is important to this Medical Society since we have begun to develop documentation on the problems of the Medichek program for possible presentation to a legislative sub-committee which oversees the operation of IDPA. We were concerned that this presentation would be pointless if the Department of Health, Education and Welfare felt the state was not out of compliance." "
At the local level, the belief persists that only direct inter- vention by the Department of Health, Education and Welfare can increase the priority given EPSDT by the State of Illinois. This belief was first expressed in correspondence to project staff at the Department of Health, Education and Welfare in October 1975:
"Pursuant to our telephone conversation of October 7, 1975, we agree with your assessment that the State of Illinois will be of small assistance in the local level implementation of the EPSDT program... The State of Illinois has provided very little assist- ance to this project and we have little reason to expect a change in the position. We will not be a factor in any decisions de- claring Ilinois to be out of compliance but we are concerned that some of our communication difficulties with your office has been caused by a preoccupation with implementing a penalty on the State. This preoccupation has existed in both the Central and Regional office . "
"The failure of the State of Illinois to provide meaningful assistance in the implementation of EPSDT can be directly traced to the very low priority placed on the program in the Department of Public Aid and the Department of Public Health. You will note in our September progress report that we participated in a staff level meeting with representatives of both departments and that it was the first meeting of this type since our involvement in April of 1974. We feel some progress was made in that meeting but it failed to address the greatest weakness in the system, i.e., that EPSDT in Illinois is not service delivery oriented."
Ronald R. Bryant, letter to Phillip Otto, Department of Health, Education and Welfare, dated Octer 23, 1975.
"We are confirming by -his letter that our contact with the Region 7 office has been very sporadic, and again we will offer to be'a resource in further dealings with the Stace of Illinois." 12
Although local project staff was unaware, these views were receiving independent and official confirmation:
"Due to the reorganization of the state agency and turnover in State staff (three Sta-e agency Medichek Coordinators
since March, 1974) the Stare has encountered considerable diff- iculty in establishing a high priority program and developing procedures to assure effective reportable county implementation. The State's Medichek program is not effectively operationalized at the county level for this reason."
"The major weakness in the State's Program relate to its difficulty in obtaining and submitting reports on the number of children who receive complete screening examinations; the lack of a State computerized tracking system; the failure of local offices to document requests for screening or the assistance provided clients in obtaining this or diagnosis and treatment within a specified time frame as required by regulation; and, the States' inability to mandate program participation and uniform reporting for private practitioners and the voluntary clinics per visit rates." 13
Local project opinion was then directly considered:
"We have reviewed the letter submitted by Mr. 3ryant and regret the delay in replying. We agree with Mr. Bryant's opinion the Department of Public Aid has not evidenced sufficient interest in this project or established the working relationship necessary for its finding to have impact on the State's program operation. This has been discussed with the State EPSDT Coordinator who re- ported that the major problems stemmed from two factors; 1. limitation of staff at state level and, 2. problems with the administration of the public assistance program in Will County. Because of the latter problem the previous county superintendent has been removed."
"We likewise concur with the observation that the Medichek program in Illinois has not been handled as a priority program. Until this is changed, we share Mr. Bryant's pessimism about the possible accomplishments of the project in assisting the State to develop effective implementation of a meaningful EPS DT program in Illinois. We believe that our Quarterly EPSDT Penalty Reports and recent Program Analysis Report substantiate this fact."
"Mr. Bryant is also correct in his statements regarding the sporadic contacts between project staff and the Regional Office and the fact that HEW emphasis has been on monitoring penalty compliance. We have tried, however, to maintain open lines of communication with the Will-Grundy project. However, due to other work pressures and changes in assignments within Medical Services, we have been unable to work as closely with the project and the State agency as desired, necessary and originally planned. Hope- fully,this can be accomplished in the near future." I4
It should be noted that these communications reached the local project indirectly and several months after transmittal The direct contact between the Region V office and the local project never material i z ed .
The locally perceived apathy to the development of EPSDT on the local level on the part of the State of Illinois and the Department of Health, Education and Welfare was again summarized at the conclusion of meetings regarding revision of the Medichek claim form, as described earlier:
"As we near the completion of two years of attempting to im- plement the delivery of Medichek services in private office settings we are forced to the obvious conclusion that neither the Illinois Department of Public Health nor the Department of Public Aid have any real interest in Medichek or in working cooperatively with the medical community. Major problems in the Medichek program, ident- ified initially in 1974, remain unchanged. It is our opinion that these problems will remain unchanged until a more powerful entity than organized medicine forces a change." 15
Clyde V. Downing, Memorandum to Dr. Keith Weikel , Commissioner, Medical Services Administration, dated December 16, 1975.
Ronald Bryant, letter to Larry Boress, Illinois State Medical Society, dated Atril 21, 1976.
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The lack of response to this project by the Illinois Depart- ment of Public Aid and Illinois Department of Public Health is not surprising when viewed against the climate surrounding the public aid system during the contract year. The entire public aid program has been embroiled in controversy since the onset of the local project in July, 1975. The Medicaid program in particular has been repeatedly wracked by scandal centering on program abuses by various categories of providers. The United States Attorney in Chicago has publicly referred to Medicaid abuses as one of the most serious law enforcement problems faced by his office. Concurrent state and federal investigations of the Medicaid program are continuing .
An attitude of def ensiveness and mistrust on the parts of state officials and providers, engendered by the continuing investigations and public reaction to them, has been further aggravated by a de- teriorating relationship between the Illinois Department of Public Aid and the Illinois State Medical Society. The decline in this relationship was heightened following testimony by the president of the Illinois State Medical Society to the Legislative Advisory Committee on Public Aid in October 1975:
"In the past, the Illinois State Medical Society strongly encouraged its members to participate in this program. As a result more than 3,000 physicians are now treating Medicaid patients in Illinois. However .... in view of IDPA's recent irresponsible ad- ministrative directives and proposed cuts in reimbursement levels ....we cannot in good conscience continue to urge participation.
"Perhaps the only solution is to remove administration of Medicaid from the Illinois Department of Public Aid and place it in an area where it can be administered responsibly .... and with emphasis on the quality of care."
"The Illinois State Medical Society acknowledges that re- sponsibility for assuring quality care under Medicaid is shared by government and the medical pro f e s s ion . . . . al 1 we ask is that we be given the opportunity to share in that responsibility."
°J. M. Ingalls, M.D., President, Illinois State Medical Society, testimony to the Legislative Advisory Committee on Public Aid, October 16, 1975.
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These statements were followed, in November, 1975, by approval of a resolution by the House of Delegates of the Illinois State Medical Society, reading in part;
"RESOLVED, that the Illinois State Medical Society affirm the policy that withdrawal of individual ISMS members from the Medicaid and Medichek programs will not be considered unethical, unprofessional or dis- ho nest." 1 '
It was against this background that the local project was attempt- ing to establish a working relationship with the Illinois Depart- ment of Public Aid and Illinois Department of Public Health to assist with local implementation of the Medichek program.
At the local level, project staff has been faced with con- tinual withdrawal of physician participation in the Medichek pro- ject as a result of the general climate already noted and the specific failure of the project to resolve long identified problems. The growing frustration, particularly among primary care phy- sicians, was best summarized in the annual report to the Board of Directors by George E. Hord, M.D., Chairman, Public Health and Medical Services Committee:
"I doubt that any undertaking of this Society has so tested the frustration tolerance of those involved. Details of most of the problems encountered have been elucidated by Doctor Albert Ray in his November appearance before the Illinois Legislative Advisory Committee on Public Aid....
"However, more important than any of these enumerated prob- lems are the attitudes toward Medichek. The Illinois Department of Public Aid views it as a bastard child dumped on its doorstep and gives it minimal attention. Legislators are poorly informed and perplexed by the commotion. Most physicians see it as another bureaucratic infliction upon them. The public remains apathetic.
"Our official involvement in the Medichek Project ends July 1, 1976. Despite the difficulties, we are continuing to do what we can ... .
"In the past eighteen months, we have seen only token and superficial changes made in Medichek. Unless dramatic revisions are soon forthcoming, Medichek is doomed to an agonal demise. May it rest in peace and may we choose our windmills more care- fully in the future." *-8
i -j
Resolution 7 5 N - 2 5 , HO use of Delegates, Illinois State Medical Society, Adopted November 12, 1975.
EPSDT/Medichek , 1975 Year End Report, George E. Hord, M.D., presented to the 3oard of Directors of the Will-Grundy County Medical Society, January 11, 1976.
This summation was supported by a report to the Will-Grundy County Medical Society Board of Directors, documenting the investment of over 330 physician hours in the project operation between July 1, 1975 and December 31, 1975. Local physician frustration with the Medicaid system was sharply illustrated again in April, 1976, with the decision of a large mu 1 1 i - spec ial ty group in Joiiet providing medical care to approximately one-half the Medicaid-eligible fam- ilies in Will County, to terminate services. That decision was withdrawn but the group remains opposed to continued long range participation in the Medicaid program.
What, then, have we learned through discussions with state and national leaders concerning implementation of SPSDT at a local level? Our findings can be briefly summarized:
A. The problems initially identified in 1974 in "A Report on Professional Health Provider Participation, EPSDT/Medichek , and restated in Professional Health Provider Participation, EPSDT/Medicaid , our 1974-75 final report, remain virtually unchanged. The slowly and carefully developed recommendations for solutions of these problems remain unconsidered and un- implemented. Local project attempts to open channels of communication for cooperative discussion of these problems for a period of two years were greeted with apathy and dis- regard .
3. A county medical society alone is unable to overcome the dynamics of larger events which contribute to a deterior- ating relationship between organized medicine and state government to accomplish the goals of a local project. These events, and the general climate in which this project was conducted, effectively prevented the Will-Grundy County Medical Society from having a significant impact on implement- ation of delivery of the EPSDT program.
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COMMUNITY HEALTH SERVICES PROGRAM
The Community Health Services Program was originated from the findings of the 1974-75 sub-contract period. The impetus for the inclusion of the program into the present contract was the cancellation of the Society's physician rotation program. As a result of that cancellation, the Executive Committee of the Society authorized the immediate investigation into developing an altern- ative delivery system. That directive was refined in the proposal to develop the 1975-76 contract:
"....it was recognized that the private practitioner could not handle EPSDT needs alone and that the professional community must take a leadership role in developing accessibility to the health care systems even to the point of encouraging non- traditional methods of delivery of health care services. The con- tractor intends to find or develop the needed alternatives." 19
A further refinement of the concept is mandated in the contract:
"3. Development of a plan to provide a Community Health
Services Program. This plan would address the following issues :
A. Ability to utilize related health professionals in the delivery of primary care services.
B. Methodology for the delivery of coordinated community health welfare and social services by taking those services, where practical, to the target population.
C. Recruitment, and potential employment of physicians to work in the Program.
D. Removal of historical barriers to accessibility to care caused by inadequate numbers of primary health care providers. 20
Request for Non-Competitive Procurement, Helen S. Martz, Ph.D, dated May 7, 197 5.
20.
Scope of Work, Contract SR3 300-75-0030, date;
un
30,
1 9 7 5
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The planning structure to implement the contract mandate was in place, in the form of the Community Steering Committee, prior to the beginning of the contract. The Committee included:
Executive Director - Will County Health Department
Executive Director - Joliet-Will County Community Action Agency
Executive Director - Will, Grundy, Kankakee Comprehensive
Health Planning Council
Supervisor - Will County Department of Public Aid
Administrator - Silver Cross Hospital
Administrator - Saint Joseph Hospital
President - Will-Grundy County Medical Society
The Community Steering Committee was an ad hoc group initially formed to deal with the effect of the cancellation of the Society's patient-physician rotation assignment program and the problems caused by the resulting increase in patient load in hospital emergency facilities. The group conducted several informal discus- sions prior to initiation of the 1975-76 contract period without formalizing its structure, defining its role or establishing definite goals. Since the group contained all of the community elements which would have been gathered to address this phase of the contract, it was continued as a committee. Input from the Society was arranged through creation of an ad hoc committee of eight physicians under the direction of the chairman of the Public Health and Medical Services Committee. Five of the physicians were mem- bers of that standing committee, three were drawn from the general membership of the Society.
The organization of the Community Steering Committee and the ad hoc committees was informal and there was no specific under- standing of the role of each in relation to the other in develop- ment of the program. The only link was the presence of project staff. Members of the Community Steering Committee were initially unaware of the commitment of the Society to the contract. Although members of the ad hoc committee were aware of the responsibilities of the contract, they defined their role as limited to providing medical advice to plans developed by the Steering Committee and viewed their function as self -liquidating by January 1, 1976. It was the general understanding of the Ad Hoc Committee that develop- ment of the program requiring their input would be completed by that date.
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Again the discontinuity between contract periods at a local staff level caused confusion in the direction of the program. Although the Community Steering Committee had been meeting for nearly three months prior to implementation of the contract there were no records of the activities of the group. The Committee had no formal leadership until immediately prior to implementation of the contract when the Executive Director of the Will County Health Department assumed that function. Through a series of individual interviews with members of the Committee, project staff was made aware of a series of very general decisions made prior to the beginning of the contract period concerning the creation and op- eration of a community health center. The Community Steering Com- mittee had accepted the concept of a health access station to be centrally located in the city of Joliet to provide services to a target population roughly defined as the poor, elderly, public aid recipients and those in need of service who were not on public aid but unable to pay for services. There was no clear definition of what those services would be. Members of the Community Steering Committee favored creation of a separate legal entity to assume responsibility for operation of the health access station but had not determined the nature of that entity or who would be involved in it. Some committee members were concerned about the possibility of conflicts of interest, duplication of services or competition developing between the health access station and other community organizations providing social and welfare services to the same broadly defined target population.
In order to formalize the planning process, project staff developed and presented to the Community Steering and Ad Hoc Committees a timetable of activities based on the schedule of anticipated activities included in the contract. This timetable reflected the original commitment of the contract to complete planning of the Community Health Services program by January 1, 1976. Areas of responsibility between the Community Steering Committee and the Ad Hoc Committee of the Society were defined as follows :
Steering Committee Discussions.
1. Identification of basic community resources.
2. Development of methodology for gaining access to resources
3. Development of specific materials reflecting methods of gaining access to community services.
4. Development of svstem to coordinate health welfare and
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3. Ad Hoc Committee - Will-Grundy County Medical Society.
1. Development of plan to evaluate the quality of services related to the Community Health Services Program.
2. Consultation with the American Medical Association relating to the technical aspects of the EPSDT programs and the Community Health Services Project.
Other features of the planning timetable related to contact with community agencies outside the Steering Committee, the type of service agreements necessary, a determination of the possible patient load, the type of legal entity to assume responsibility, scope of services to be offered, identification of potential local, federal and private funding sources and development of a draft model.
Recognizing that a major problem area is the growing shortage of primary care physicians in Will County, the two committees in- dependently authorized development of an application to the National Health Service Corps seeking designation of Will County as a critical medical shortage area and requesting assignment of a physician. A preliminary application was developed and submitted to the Bureau of Health Manpower on July 18, 1975 and was refined and resubmitted on July 30, 1975. The application was denied in September, 1975. The denial was viewed by the two committees as a setback to the project since the application had been regarded as one tool for physician recruitment for the health access station.
Basic weaknesses in the involvement cf two independent com- mittees appeared rapidly. An obvious weakness was in the exist- ance of the committees as separate entities with neither assuming overall responsibility of project planning, but with both assuming equal authority. This placed project staff in the position of attempting to obtain dual authorization for any action and comp- licated coordination of overlapping areas. For example, both committtees requested cost estimates on the operation of the health access station but neither could arrive at specific des- criptions of the station on which to base the estimates. It was impossible to develop this information accurately without first defining the scope of services to be offered. Development of that information with the separate assistance of each committee required more than a month. During that time, project staff re- mained the only link between the committees. An attempt was made to correct the weakness by installing the chairman of the ad hoc committee as a member of the Community Steering Committee. This, however, served to confuse the members of the ad hoc committee on their role in the project and their responsibilities.
Proposed Timetabla Community Health Services Project, Will-Grundy County Medical Society 5R3 Project, Monthly and Progress Report July, 1975.
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The confusion was compounded by a reluctance on the part of individual members of the Community Steering Committee to make any firm commitments in behalf of their respective agencies and their reluctance to design or serve as part of the legal entity which would assume control of the project on a long term basis.
Following a series of meetings with staff of the Department of Rural and Community Health of the American Medical Association in August, 1375, local staff developed recommendations to clarify the planning structure. Although it was felt the agencies re- presented in the Community Steering Committee should remain in- volved in the project, local project staff recommended increasing membership on the committee to include persons at a decision-making level from each agency. It was further recommended that represent- ation on the Community Steering Committee be broadened to include other segments of the community, specifically the business, indus- trial and educational communities. With the committee thus re- organized and expanded, project staff recommended dividing the responsibility in a specific area. Finally, local staff suggested a re-examination of the concept of the health access station as previously accepted by the Community Steering Committee in light of the time remaining to complete the project. American Medical Association consultants also expressed concern at the decision of the Society's Ad Hoc Committee to phase out as of January 1, 1976 since it was becoming apparent that because of the slowness in planning, the project would not be completed by that time.
It should be noted that the slow pace of the project during July, August and September, 1975, was due in part to the increasing diversion of local staff time to resolving cash flow problems developing as a result of the payment mechanism described earlier in this report. The amount of staff time absorbed in attempting to resolve the payment mechanism with the Department of Health, Education and Welfare increased with the degree of severity of the problem. By the end of September, 1975, the cash flow sit- uation had deteriorated to the point where the continued operation of the contract and employment of the staff was in danger.
A re-evaluation of the project during September, 1975 ident- ified and isolated four planning weaknesses which inhibited de- velopment of the health access station as concieved by the Ste- ering Committee:
1. "Lack of specific documented need.
This became apparent when attempts were begun to reasonably estimate the number of persons who would use the services
cf the health access station. The experiences of the Medi:al Society in the FFSDT demons traticn project, the Physician ".oiation program and the School Screening project,
while these experiences indicated a need in the community for development of' an alternative system, they did not specifically define that need. The concept of a large, centrally located facility is untenable on this basis.
2. Lack of broad-based community involvement in planning.
Many segments of the community, most notably consumers, remain absent from this planning effort. The lack of in- volvement of the business, non-medical professional and educational sectors demonstrates the restricted nature of this planning effort to date. While tentative attempts to involve some of these components were not successful, it is obvious that the involvement and commitment of these segments of the community are essential to the success of the project.
3. Duplication of services in the low income population.
This relates directly to the development of a clinic serving low income persons in Joliet and will be discussed later in this report.
4. Failure to specifically define area to be served.
Although planning in this project was being done on the basis of serving the entire population of Will County Illinois, it became obvious that the service area under consideration in- volved only a small portion of the county. We found the Community Steering Committee had not admitted that a small area was involved but they really had not defined even that area. The service area was being vaguely described as the greater Joliet metropolitan area". 22
To address these weaknesses, the Steering Committee adopted a program planning outline and approved the development of a physician survey in cooperation with the Will, Grundy, Kankakee Comprehensive Health Planning Council to provide an indicator of physician perceptions of delivery problems. In addition, the Will, Grundy, Kankakee Comprehensive Health Planning Council, a designated 314 (b) agency under the Public Health Service Act, was asked to serve as a resource for the demographic data needed to reasonably project community need for the services of the project.
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In adopting the following program planning outline, the Steering Committee agreed that the outline would serve as the outline for development of a project model:
"PROGRAM PLANNING OUTLINE
I. PROGRAM OBJECTIVES
A. Provision of high quality comprehensive medical and related health servces which are economically available and acces- sible to residents of Will and Grundy Counties.
B. Provision of high quality comprehensive medical and related health services which are economically available and acces- sible to residents of Will County.
II. ALTERNATIVES
A. Permanent community facility with full time staff
B. Temporary facilities located throughout community with a rotating health care team
C. Mobile health unit or units with full time staff
D. Permanent community facility with full time staff using mobile unit or units with rotating health teams
III. ALTERNATIVE CRITERIA
A. Are sufficient resources available or obtainable?
B. What will be the cost for services?
C. Will the alternative improve the overall health of the community?
D. Time estimated to complete the alternative?
E. What organizational structure is required?
F. Can the alternative be coordinated with on-going fun- ctions and programs?
G. Will the alternative be acceptable to the professional and to the consumer?
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IV. SELECTION OF ALTERNATIVE
A. 3ased on which alternative meets the majority of criteria while meeting needs of community.
V. COMMUNITY NEED
A. Physician Survey
3. Consumer Health Survey
VI. ORGANIZATIONAL APPROACH
A. Community Health Services Council
1. Health Services Providers and Educational Institutions
2. Community Groups and Individuals a. Industry
b . Bus ine s s
c. Non-health Professionals
d. Civic Groups
e. Educational Leaders
f . Local Government Officials
3. Consumers of Health Services
a. Educational level
b. Family Income
c . Ethnic
d. Age group
f. Vocational representation
4. Size of Council
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5. Function
a . Sat general policy
b. Develop constitution and by-laws
c. Decision making
d. Selecting consultants or enlisting aid of specified sub- committees
e. Serve as requesting agency for outside financial aid
f. Coordination with overall community planning efforts
. . . 2 3
g. Inform the community or activities
During the period of September and October, 1975, the focus of both the Community Steering Committee and the ad hoc committee of the Society was diverted from planning by the implantation of a new medical clinic in Joliet. Since the new clinic was located in the same general area under consideration for the health access station and was attempting to provide medical care to the same target population, both committees questioned the need to continue with the project. Instead, contact was initiated with the admin- istrators of the new clinic to explore the possibility of developing a contractual arrangement with the clinic for primary services with the two project committees assuming responsibility for development of the related social and welfare services. This approach was dis- continued when information developed by the Community Steering Com- mittee under the program planning outline indicated the new clinic alone could not satisfy projected need and the ad hoc committee of the Society was unable to resolve questions concerning the organi- zation and operation of the clinic and the quality of care delivered
The decision to discontinue negotiations with the clinic was based in part on the findings of a special data sub-committee of the Steering Committee which was charged with the task of addressing the lack of specific documented need. With staff assistance frcm the Will, Grundy, Kankakee Comprehensive Health Planning Council, the sub-committee was able to assist the Steering Committee in determining the primary service area for the project as four urbanized townships in the northwest quadrant of Will County
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Ac the same time, the Steering Committee adopted an outline for pro i ect model :
"COMMUNITY HEALTH SERVICES MODEL PLANNING OUTLINE
I. PROBLEM DEFINITION III. GOAL STATEMENT III. COMMUNITY NEEDS IV. ALTERNATIVES A. Cost 3 . Location C. Manpower V. DEVELOPMENT OF COMMUNITY HEALTH COUNCIL VI. DEVELOPMENT OF COMMUNITY HEALTH PROGRAM A. Implementation 3 . Operation VII. PROGRAM EVALUATION 24
The Steering Committee also approved a staff timetable for de- velopment of the actual model specifying presentation and re- view of all outline steps except Step IV by mid -No vember , 1975, presentation and review of Step IV in early December, 1975 and completion and submission of the project model at the end of December , 197 5.
The Project model, excluding Step IV was completed and accepted by the Steering Committee. A copy of the model was sub- mitted as Attachment A to our November, 1975, Progress Report and is included as Exhibit I to this report. The development and adoption of the project model served to resolve the earlier identified planning weaknesses in the Community Health Services program and also provided a frame work of specified activities to allow the Community Steering Committee to proceed with the project. Throughout the period of identification of weakness,
"^Will-Grundy County Medical Society 3RS P r o j ac r -Mc n thly Progress Report, October, 1975.
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re-evaluation and development of the project model, the support and assistance of staff of the Department of Rural and Community Health of the American Medical Association was invaluable. The American Medical Association provided technical reference materials and advice to local project staff through each stage of development of the model.
Several factors contributed to the extremely slow pace of development and completion of the project model. Throughout the period of July to December, 1975, the organization of the Com- munity Steering Committee remained loose and informal. It was difficult to assemble the Committee more than once or twice per month and attendance at Committee meetings was sporadic. The Committee also demonstrated a reluctance to make formal decisions on various staff recommendations often creating an atmosphere of confusion about the status of the project at various times. This general lack of direction was further complicated by the continued existance of the dual committee structure. Despite attempts to draw the Community Steering Committee and the Ad Hoc Committee of the Society together, the groups remained independent. The necessary re-evaluation of the project which led to development of the project model removed emphasis from the role of the Ad Hoc Committee which had responsibility for medical input to the pro- ject. Although it became apparent that the project would not be completed in the original six month time frame, the Ad Hoc Com- mittee did not change its resolution to dissolve as of January 1, 1976. Active participation by physicians on the Ad Hoc Committee through the period of July to December 1975, was sporadic limited basically to the specialist members of the committee. These specialists also served on the Community Steering Committee but there was little interaction between the groups. Some of these difficulties were summarized in a report to the Board of Directors of the Society in January, 1976:
"The concept of a Community Health Services project grew out of the failure of our rotation system to fulfill the medical needs of those in this community without a physician. A Community Steering Committee was formed and expected to develop the project model with the necessary medical input being supplied by this Ad Hoc Committee of the Medical Society. Unfortunately, the Steering Committee was reluctant in making firm commitments and slow in formulating any sort of plan. Consequently, with a looming con- tract deadline, the responsibility of model development fell on (project staff) and the Ad Hoc Committee. This monumental task was made even more difficult because anticipated technical assist- ance from CHP and DHEW has been lacking. Even the Ad Hoc Commit- tee itself has been difficult to assemble and certain committee members vet to be seen."
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"Soon we must present this finalized package to -he Medical Society for approval or revision. It can then be presented to the Community Steering Committee (or Board of Directors) to put into action. We will meet our contract deadline. However, based on the early inertia of the Community Steering Committee, I remain somewhat skeptical about the implementation of this model. It will necessitate full cooperation of many agencies, and based on earlier reluctance, it may not be forthcoming. As a Society, we cannot, and should not even attempt to, implement this project alone." 2 5
The development of the project model and its implementation by the Community Steering Committee was also seriously hampered by the loss of members from the Committee. Since each member of the Committee represented a segment of the community vitally im- portant to the project, the departure of any member diminished the capability of the Committee. Between July and December, 1975, the Committee lost the participation of the Will County Department of Public Aid and the Will, Grundy, Kankakee Comprehensive Health Planning Council.
Representation of the Will County Department of Public Aid was lost with the transfer of the local supervisor to another post. The position was left unfilled by the Illinois Department of Public Aid for several months. When a new supervisor was appointed, he did not respond to invitations to j o in . the . Communi ty Steering Committee. The loss of the only link between the project and the public aid system deprived the Community Steering Committe of needed input relating to problems of the majority of the target population .
The loss also terminated the development of a mechanism to include EPSDT services in the project model or to explore means of removing administrative roadblocks, identified earlier in this report in the implementation of the project model.
Community Health Services Project, Year End Report, George E. Hord, M.D., presented to 3oard of Directors, Will-Grundy County Medical Society, January 11, 1976.
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The active involvement of the Will, Grundy, Kankakee Comprehensive Health Planning Council on the Community Steering Committee ended abruptly in December, 1975, with the dismissal of the Executive Director of that agency. This action left the Commmunity Steering Committee without a source of localized technical information necessary to the development of the project model. The loss of this agency on the Committee deprived the Committee of its research arm. The involvement and support of the Will, Grundy, Kankakee Comprehensive Health Planning Council had been one of the primary reasons for inclusion of the Community Health Services Program as part of the Society's contract. With- out access to the resources of the agency, completion of the project model, primarily a staff document, was very difficult.
The Community Steering Committee encountered another, un- anticipated obstruction through Public Law 93-641, the National Health Resources and Development Act of 1974. The Will, Grundy, Kankakee Comprehensive Health Planning Council became an applicant for conditional designation as a Health Systems Agency under the new planning law. Although the Community Steering Committee was not aware, staff participation of the agency in the Community Health Services project was increasingly limited during the period of September to December, 1975, as the HSA application was developed, The decreasing availability of assistance from the agency accelerated following the dismissal of the Executive Director of the agency in December, 1975. This increasing internal preoccupation with com- pletion of the HSA application prevented completion of items im- portant to the Community Health Services project. For example, in writing the project model, project staff was left with the task of sorting out a mass of demographic information supplied by the Will, Grundy, Kankakee Comprehensive Health Planning Council after much of the data proved to be outdated, unreliable and unrelated. This task was completed with the assistance of staff members of the Department of Rural and Community Health of the American Medical Association. The physician survey, initiated during the re-eval- uation of the project in September, 1975, although scheduled for completion within six weeks, was never finished. The reason did not become apparent for several months:
"Unfortunately, the final report of the Physician Survey, undertaken by the Comprehensive Health Planning Council will not be available until March 15, 1976. The reasons for the delay are twofold: 1) at the onset of the Physician Survey, I was unaware that I would be assigned, full time, from November 15th to January 19, 1976, to work on the Health Systems Agency Application, and
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2) than our Project Review Officer would resign, causing my assignment to Project Review."*
As internal problems over staffing and management of the agency increased during January and February, 1976, work on the physician survey was not resumed and was dropped following the resignation of the staff liaison.
Development of the HSA application placed other pressures on members of the Community Steering Committee which brought im- plementation of the project model to a virtual halt for several months. Because of the inter-relationship of the community, all non-physician members of the Community Steering Committee were also members of the Board of Directors of the Will, Grundy, Kankakee Comprehensive Health Planning Council. The time of these Committee members was increasingly absorbed by problems surrounding completion of the HSA application and by growing pro- blems regarding the continuation of the CHP agency itself. During the period of January to March, 1976, the agency faced serious internal problems relative to financial management and staffing. While implementation of the Community Health Services project lay nearly dormant, Community Steering Committee members devoted their energies to addressing other problems. These problems were finally resolved in April, 1976, by the withdrawal of designation of the Will, Grundy, Kankakee Comprehensive Health Planning Council as a 314 (b) agency by Region V, Department of Health, Education and Welfare and the closing of the agency.
The structure of the Community Steering Committee was also threatened by the opposition of the Society to the HSA application, spearheaded by physician members of the Committee. This opposition developed after the Society was asked for a routine endorsement of the application in December 1975. Project staff was assigned to review the application which resulted in the opposition of the Society to several technical components of the application. This opposition resulted in physician and staff participation in a series of meetings during December, 1975 and January, 1976, directed at correcting what the society viewed as gross defic- iencies in the application. When these meetings failed to resolve differences over the application, the relationship between the
Ken Marshall, Health Planner, Will, Grundy, Kankakee Compre- hensive Health Planning Council, Memorandum to R. 3ryant , Will- Grundy County Medical Society, January 21, 1976.
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Society and the Will, Grundy, Kankakee Comprehensive Health Plan- ning Council solidified into adversary positions. Under the pressure of these positions, staff level communication became strained, then ceased completely. These events, coupled with the eventual denial of the HSA application and the closing of the Will, Grundy, Kankakee Comprehensive Health Planning Council, combined to deprive the Community Health Services project of one of its most important local sources of support and assistance. The small momentum of the Community Steering Committee, generated by completion of the project model in December, 1975, was at first, disrupted, then halted by the pressure of larger, outside events.
During the period of mid-January, 1976 to late April, 1976, physician members of the Community Steering Committee attempted to restart movement in the project by attempting to develop a firm concept of a feasible alternate delivery system:
"The Ad Hoc Committee of the Will-Grundy County Medical Society has been considering alternative methods for delivery of primary care services in the Community Health Services project. The com- mittee has arrived at what would appear to be a viable means of providing services but wishes to communicate the options to the Community Steering Committee prior to inclusion in the project mode 1 .
Research by the Ad Hoc Committee indicates that the develop- ment of an independent free-standing clinic may be an unnecessary duplication of services already available in the four townships considered the primary service area of the project and assured continuous funding from any source in the current political climate seems unlikely. It would seem a more valid approach for the Com- munity Steering Committee to consider developing appropriate con- tractual arrangements with several already existing entities to deliver primary care services. The Ad Hoc Committee has only recently become aware of the development of facilities within the community which would allow this approach.
If a contractual approach is acceptable, it would leave the Community Steering Committee with the responsibility to develop only a small, reasonably inexpensive administrative facility. It would be the responsibility of this administrative structure to negotiate contracts, to register patients and guide them to appropriate facilities and to provide negotiating services be- tween the Illinois Department of Public Aid and the participating facilities. These negotiating services would include prior review of Medicaid and Medichek bills and the resolution of disputes
between IDPA and participating facilities. Ail payments, however, would be made directly to the participants. Once this system is established and operating, efforts can be initiated to develop ancillary services and transportation services through the ad- ministrative core.
It is also the opinion of the Ad Hoc Committee that the Com- munity Steering Committee should carefully consider the potential impact upon this project of the impending development of a Health Systems Agency. The Will, Grundy, Kankakee Comprehensive Health Planning Council has already organized an ambulatory care committee which has set ambulatory care planning and resources development as its primary goal. It is reasonable to assume that if the Will, Grundy, Kankakee Comprehensive Health Planning Council receives conditional designation as a Health Systems Agency under Public Law 93-641, the function of the ambulatory care committee will be transferred to the new agency. The nature of PL 93-641 is such that the Health Systems Agency will have significant authority over the development of projects such as ours.
Public Law 93-641 specifically provides that each Health Systems Agency will be generally responsible for preparing and implementing plans to improve the health of residents of its health service area; to increase the accessibility, acceptability, con- tinuity and quality of health services in the area; to restrain increases in the cost of providing health services; and to prevent unnecessary duplication of health resources. The law also pro- vides that Health Systems Agencies will review and approve/disap- prove applications for federal funds for health programs within the health service area. It is the opinion of the Ad Hoc Committee that these are valid issues for the Community Steering Committee to consider at this time.
It is the suggestion of the Ad Hoc Committee that the Com- munity Services Committee meet at the earliest possible date to review these issues relative to Health Systems Agencies and to consider the alternative for delivery of services broadly outlined in this letter." ^7
George Hord, M.D., letter to James Barringer, Chairman, Community Steering Committee, January 14, 1976.
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The impetus for this suggestion was the development of an informal outpatient clinic by a private group of physicians under contract to provide emergency room services at Silver Cross Hospital in Joliet. The suggestion was also a restatement of the Society's concern to utilize existing facilities in the community rather than impose new duplicative facilities. This concern had first been expressed in October, 1975, in attempts to develop a contractual arrangement with the clinic described earlier in this report
Although the Community Steering Committee met to consider the suggestion and authorized project staff to develop a model contract, the effort was forestalled by the controversy surround- ing the Health Systems Agency application and other internal problems of the Will, Grundy, Kankakee Comprehensive Health Planning Council to which the Community Steering Committee was tied.
Two events in April, 1976, caused the rebirth of the Community Health Services project. The first was the release of $30,000 in federal revenue sharing funds by the City of Joliet to the Joliet- Will County Community Action Agency for use in the project. The funds had been placed in escrow in December, 1975, following a preliminary review of the project model. The second event was a reaction to mounting physician frustration with the Illinois De- partment of Public Aid with the tentative decision of a large multi-specialty group to discontinue participation in the Medicaid program. That tentative decision raised the possiblity that ap- proximately 45% of the Medicaid patients in Will County could be without direct access to medical care except through hospital emergency rooms. Meeting to consider these developments, the Community Steering Committee arrived at a number of important decisions, some long overdue.
Members of the Committee are formalizing their commitment to the expansion of primary care services through incorporation of a non-profit legal entity tentatively named Will County Health Care Incorporated. Members of the initial Board of Directors are:
Albert W. Ray, Jr., M.D., Will-Grundy County Medical Society Guy A. Pandola, M.D., Will-Grundy County Medical Society George Z. Hord, M.D., Will-Grundy County Medical Society James 3arringer, Will County Health Department Keyton Nixon, Administrator, Silver Cross Hospital Robert Schinderle, Administrator, Saint Joseph Hospital Doris Dalton, Executive Director, Joliet-Will County Community Action Agency.
The legal mechanics of incorporation under the Illinois General Not For Profit Corporation Act are underway at the writing of this report. The new Board has decided to implement the broader involvement of the community as described in the project model upon completion of formal organization of the corporation. The project model itself has been adopted as a general guide for the organization .
The new 3oard has also voted to pursue development of alternative delivery mechanisms beyond the expiration of the subject contract with a target date of becoming operational as of January 1, 1977. Staff support in these efforts will continue from the Society.
The new Board has begun investigation of private funding sources for development of new ambulatory care mechanisms. Pre- liminary applications for funding have been prepared for the Mobil Foundation of Mobil Oil Company and for the Hospital Research and Educational Trust of the W. K. Kellogg Foundation. Copies of these preliminary documents are included as Appendix II to this report. A response to these applications has not been recsived at the writing of this report.
In summary, the Community Health Services project must be viewed as a qualified success. The project was initiated in con- fusion over the roles of its various components, its goals, its direction and the relationship and responsibilities of its par- ticipants to this contract. Much of this confusion can be at- tributed to the discontinuity between contract periods and changes in local project staff as discussed earlier in this report. The project survived a searching re-evaluation of its structure and necessity and succeeded in development of a model with the po- tential of expansion into an alternative delivery system. It will be possible within that structure to design a mechanism for con- tinued delivery of EPSDT services and to explore the development of an ambulatory care review system as a method of evaluation of the projects' services to its target population.
The decision of members of the health care community to the project was demonstrated by their withstanding of unforeseeable events and by continuance of the project despite the loss of several important components. The loss of these components, par- ticularly of the Will, Grundy, Kankakee Comprehensive Health Planning Council, contributed to the slow progress which character- ized the project. Despite the setbacks, there was progress through- out the project and majority, if not all, of the objectives of the project were accomplished orior to the end of the contract.
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SCHOOL SCREENING PROGRAM
The 1976 School Screening Program was a major component of contract SRS 500-75-0030 as mandated in Exhibit A of the scope of work of the contract. The exhibit consists of an outline prepared following evaluation of the school screening program under the 1975 sub-contract as an attempt to develop a more adequate mechanism for mass screenings. The outline provided specific guidelines to elevate the qualtity of physical asses- sments performed in a mass setting:
MECHANICS
To facilitate handling large numbers of students the scre- ening could be broken down into three phases; pre-screening , screening and evaluation.
1. Pre-screening; this phase of the program would include medical history taken by qualified volunteers, immunization history, developmental history, psychologic evaluation, T.B. testing, urine and hemoglobin testing and statistical data collection.
2. Screening
a. General Physical
b. Special Neurologic
c. T.B. Test Reading
d. Dental examination-at the discretion of the Dental Society
3. Evaluation: This phase could take place shortly after the screening with staffing by teachers, psychologists, social workers and physicians reviewing the information gathered and the following dispositions made:
a. Medical problems referred for diagnosis and treatment.
b. Dental referral for corrective work.
c. High risk educational problems directed toward immediate placement in individualized remedial programs after more extensive testing.
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d. Low risk problems directed toward regular classroom activity but under close observation." *°
In addition, the pr e-scr eening portion of the outline contained seven specific recommendations to implement the generalized con- cepts included in the introductory statement. The approach was designed to provide the physician with the most complete infor- mation available on aach child participating in a mass screening examination. The task of the project staff was to define and develop the specific activities to implement the outline through available resources in the community.
The organization vehicle chosen to implement the 1976 School Screening Program was the School Health Advisory Council. Composed of representatives of the Will County Health Department, the Joliet-Will County Community Action Agency, school nurses from Joliet Grade School District 86, the office of the Will County Educational Service Region and the Medical Society, the Council was formally organized from the committee which planned and directed the 1975 school screening program. Although a new organization in its formal state, the Council was experienced in the program and incorporated the elements necessary to implement the mandated outline of the 1976 program.
The point of departure for the program was identical to the 1975 program; a requirement by the State of Illinois that children entering kindergarten, 5th grade and 9th grade complete a physical examination prior to the beginning of the school year. Each year the schools are faced with the problem of indigent families who do not complete the required examinations, because of financial difficulties, the family does not have a regular physician, or through parental apathy. While state law requires that children who do not complete the examinations be excluded from classes, the schools are reluctant to take that step. Thus, the school screening program provided an opportunity for the schools to re- solve a continuing problem while providing the Society with an opportunity to identify Medichek-eligibles and enroll them in the program .
Exhibit A-Contract SRS , 5 0 0-7 5 -0 0 3 0 -Depar tmen t of Health, Education and Welfare-June 30, 1975.
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In December, 1975, the model outline was presented to and adopted in principle by the School Health Advisory Council. A target date of early April, 1975, was approved for the mass screening clinic to allow rime to develop and complete the neces- sary pre- screening activities. The Will County Educational Service Region was requested to provide a list of children who had not completed physicial examinations from each school district in the county. It should be noted that this list did not identify Medichek-eligible children due no the restrictive problem of confidentiality. The single eligibility criteria was the absence of a completed physical examination at the required grade level and financial inability of the family to obtain the examination privately. As indicated from previous experience, the majority of eligible children were students of Joliet Grade School District 86. 3y the end of January, 1976, a total of 613 eligible children were identified by Joliet Grade School District 86 was an estimated 200 eligible children were located in other school districts of Will County.
To accomplish the pre-screening phase of the model outline, the School Health Advisory Council approved a two step program in January, 1976:
Outr each-Thi s phase involved visits to the homes of eligible children by volunteer outreach teams. Each team was composed of a professional outreach worker from the Joliet-Will County Community Action Agency and student nurses from the St. Joseph School of Nursing, the School of Nursing of Lewis University and the School of Nursing of Joliet Junior College. It was the responsibility of each outreach team to obtain written parental consent for participation in the program and to complete a medical history on each eligible child. Consent forms were developed with staff assistance from the American Medical Association. Each consent form contained space to allow parents to identify children as Medichek- eligible and to authorize completion of a Medichek examination through the school screening program. Completion of this section of the form required the outreach teams to present an explanation of the Medichek program to parents and to explain their rights of freedom of choice in participating in the Medichek program. Local project staff assumed the responsibility to design the appropriate consent form and to gather and collate other educational materials presented to parents during the home visits. In addition to patient- oriented Medichek pamphlets, these materials included infor- mation from the Will County Health Department on immunization clinics and Well-Baby Clinics and program materials from the Joliet-Will County Community Action Actencv.
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Project staff arranged and conducted three training sessions for the volunteer outreach workers and student nurses involved in this phase of the program. In addition to informational packets, these training sessions included detailed discussions of the legislative and program background in EPSDT, the involvement of the Will-Grundy County Medical Society in the local demonstration project and the overall purpose of the school screening program. Each program was presented with the assistance of a physician and public health n u r s 6 s of tri e Will County Health Department. The sessions were conducted at the St. Joseph School of Nursing, for students of that school and from the School of Nursing at Joliet Junior College, at the School of Nursing at Lewis University and at the offices of the Joliet-Will County Community Action Agency.
To facilitate the actual home visits, project staff developed visiting schedules, grouped appointments by geographical area for each outreach team, and as much as possible, arranged appointments in advance with families by telephone. The master list of eligible children supplied by the schools was used in coordinating this activity. In addition, project staff met with the outreach teams each day to review assignments, discuss problems encountered in day to day activites and to inspect informational packets distrib- uted to the teams to insure the packets were complete. The medical histories collected by the outreach teams were reviewed by a physician to avoid important omissions, whenever possible. Infor- mation recorded on daily assignment sheets was also recorded on the master school list for later use in followup visits. All volunteers were asked to work at least three hours per day and since various groups of volunteers were available at different times, local pro- ject staff assumed responsibility to coordinate outreach workers and student nurses. At the end of each day, the records of Medichek- eligible children were separated from the overall pool and project staff completed the necessary reporting forms for the State of Illinois .
Using this mechanism, visits were completed to the homes of 621 eligible children in six days, from February 9 to 11 and February 16 to 18. At the end of the second week, outreach teams made multiple efforts to complete previously unsuccessful home visits. The public was made aware of the program through infor- mational releases to local news media prior to the beginning of the home visits. As an additional service of the program, individual schools were notified at the end of the first week of the names of children dropped from the program. This information was also made available to the office of the Will County Educational Service Region. As mentioned earlier, all volunteers were asked to work
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at least three hours per day in the outreach phase but in fact, many worked far beyond that. The actual number of volunteers was relatively small:
Joliet-Will County Community Action Agency - 21
School of Nursing-Lewis University - 19
St. Joseph School of Nursing - 17
Miscellaneous -10
Pershing School PTA
Will-Grundy County Medical Society Auxiliary Pediatric nurse practitioner Friends and family of project staff
In addition, four local business firms and a community agency donated materials and suppies used in the outreach phase.
In the six days of the outreach phase, medical histories and parental consent forms were completed on a total of 299 children eligible to participate in the program. Project staff made random home visits with the outreach teams. The reception of families visited was positive and the teams reported no problems. It should be noted that the outreach phase of the program was charac- terized by a spirit of cooperation.
b. Pre-screening : The Will County Health Department assumed responsibility for completion of Phase II, or the pre- screening portion of the school screening program. Pre- screening services included TBN testing, urine testing, blood testing and immunizations. During the month of March, 1976, teams of Joliet school nurses and public health nurses from the Will County Health Department, accompanied by pro- ject staff, visited individual schools in Joliet Grade School District 86. Specimens were analized by the laboratory at the Will County Health Department, at no cost, and the re- sults were distributed to schools for attachment to each child's individual health record. Three days following administration of the T3Ns , school nurses read the casts and reported the results on the health records which would accompany each child to the mass clinic in April. In a separate, but related program, the Will County Health De- partment completed dental examinations in the schools and these results were added to the child's individual health record. Standing medical orders were prepared by the Will-
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Grundy County Medical Society and distriburad to the necessary personnel of the Will County Health Department and school nurses of Joliet Grade School District 86 in advance of the pre-scraening activities. In this manner, testing and immunizations were pro- vided to approximately 300 children scheduled to attend the mass clinic in April.
Since the School Screening Program was offered to all school districts in Will County, project staff attempted to aileviata transportation problems for districts in outlying areas by ar- ranging for examinations in private physicians offices. Since small numbers of children were involved in each of these districts, it was not practical to apply the first two phases of the program in outlying areas. After securing the agreement of physicians in outlying areas, letters were sent to eligible families advising them of the arrangements made for their children. Informational materials from the Will County Health Department, as previously described, were included with these letters. A total of 35 children were screened in this manner although, since there were no home visits, there was no way to determine how many were Medi- chek-eligible .
The program format was altered from the model outline by the School Health Advisory Council with the deletion of develop- mental assessments as a component of the screening program. This decision followed consultation with officials of Joliet Grade School District 86 who indicated that developmental assessments were being made through other school programs. In providing this information to the School Health Advisory Council, the school district presented a brief explanation of its ongoing programs:
"The Educational Regional Association (S.R.A.) provides
disgnostic and supportive educational services for children ages
0-21. Title VI federal funds are applied for and administered it
"Among the goals of the Title VI grant, "Child Find" is emphasized. Two major areas of concern are the 0-3 age group and the high school dropout. Assessment techniques used to determine the functional level of the child in the 0-3 age group are the "Learning Accomplishment File" by Chapel Hill Project and Educ- ational Profile" by the Peoria Association for Retarded Citizens 0-3 Project. These were compiled from selected materials by authorities recognized in the field of child development. Por- tions of the Denver Developmental test are incorporated in the above tests. After this assessmnet is made, many children ara
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then referred for educational evaluation, speech and language evaluation and audiology. If further evaluation is indicated, the child is referred to the nurse to review current physical appraisal and to obtain a complete medical and developmental history and to the psychologist for psychological evaluation."
"Preschool screening is available for every child in District 86 between the ages of 3 and 5. The DIAL screening device is used as it quickly assesses four areas of developement : Fine Motor, Gross Meter, Concepts and Speech and Language. Norms were established on the DIAL Screening device on a large cross cultured sample .... Children failing the screening are referred for further diagnostic evaluation for individualized help or program . "
"Children entering kindergarten or in school who function below expected achievement, who exhibit lack of perception in learning concepts, who are withdrawn, or display lack of self- control are referred to the case action team (psychologist, nurse, speech therapist and social worker) for appropriate evaluation."
"No children are placed in learning disability, education- ally handicapped or emotionally disturbed programs without psychological s . " 29
In mid-March, 1976, the School Health Advisory Council met to review the results of the Outreach phase of the program and to finalize plans for the mass screening clinic. Final plans for clinic routing, transportation schedules, needed voluntary personnel and equiment as developed by project staff were reviewed and approved at this meeting. Plans for a final training session for volunteers were finalized and informational packets prepared. Instructional materials were developed by the office of the Will County Educational Service Region and the Director of Nursing at the Will County Health Department outlining final plans and responsibilities of participating individual schools. A letter requesting volunteer support was sent to each member of the Will- Grundy County Medical Society and a physician schedule was de- veloped from the responses. Supplies and equipment for the pro- gram were donated or loaned by St. Joseph Hospital, Silver Cross
Vivian Johnson, R.N., M.S., Teacher-Nurse Consultant, Joliet Grade School District 86, letter to Guy A. Pandola, M.D., dated January 14, 1976.
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Hospital/ St. Joseph School of Nursiig, Professional Medical Surgical Supply Company and other local businesses. More than 150 volunteers were enlisted for the clinic representing:
School of Nursing - Lewis University
School of Nursing - Joliet Junior College
Will County Dental Society
Will County Dental Society Auxiliary
Will-Grundy County Medical Society
Will-Grundy County Medical Society Auxiliary
Non-project staff -Will-Grundy County Medical Society
Joliet-Will County Community Action Agency
Will County Health Department
Staff members - Quad River Foundation for Medical Care
School Nurses - Joliet Grade School District 86
As can be expected in a mass program of this nature, the actual operation of the clinic was hampered by unexpected events. For example, to avoid lengthy delays and congestion at the clinic site, one of the most serious problems of the 1975 program, the arrival of buses from Joliet Grade School District 86 was carefully coordinated to provide a steady flow of children through the clinic. The arrival schedule was designed to cover most of the children attending the clinic and was communicated to individual schools through the District administration which was responsible for trans- portation. The schedule was interrupted at the beginning when the first bus was involved in a minor traffic accident enroute to the clinic site. The problem was compounded when the second arrival was late. Both buses arrived at the clinic site near midday with a total of 128 children. With other buses arriving on schedule, a backlog soon developed in the clinic.
Since the transportation schedule had been carefully arranged, volunteer time was arranged on the same basis. It was anticipated that the majority of physical examinations would be completed during the morning session of the clinic, so the majority of volunteers were at the clinic site during that time. As a result
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of the breakdown in the arrival schedule, many volunteers had little to do during the early hours of the clinic. When the majority of children arrived, many volunteers had departed. This was particularly critical with physician volunteers since they were enlisted for specific time periods and many had other commitments. Most of the physician volunteers had departed when the majority of children arrived and in addition, several physicians scheduled in the afternoon hours, failed to appear. Despite the problems which overloaded the program mechanism, a total amount of 370 screenings were completed. Approximately 80 children were returned to their school without examinations. These examinations were completed in a follow-up clinic at a local grade school during May.
In all, a total of 485 examinations were completed at the major and follow-up clinics, and through physicians private offices encompassing all schoool districts in Will County in- cluding parochial schools. Of these, 174 were identified as Medichek-eligible , a significant increase over the 1975 program. Medichek records were completed and forwarded to the Illinois Department of Public Health for inclusion in the program. Arrange ments were made for school nurses and public health nurses to contact the families of children with identified conditions re- quiring follow-up diagnosis or treatment with individual referrals to be arranged through the Will-Grundy County Medical Society. At the close of the demonstration project, no referrals had been received .
The 1976 School Screening Program was the most valuable, effective and instructive component of the demonstration project. The adoption of the model outline, authored from the experiences of the 1975 program, and the addition of the outreach and ore- screening phases of the program developed from that outline made the second program far superior to the original. With the com- pletion of medical histories and the results of pre-screening tests available, the physical assessments were more complete and comprehensive than in the 1975 program. It is our opinion that the basic mechanism of the program as developed this year is sound and provides opportunities for further refinement and develop- ment. The only program element deleted this year was develop- mental assessment which was disappointing since we regarded it as an important component of a comprehensive assessment.
The 1976 program again successfully demonstrated the cooperation and support of many segments of the business and professional communites and through the outreach phase, provided an educational opportunity for nursing students not otherwise available to them. Both St. Joseph School of Nursing and The School of Nursing at Lewis University have indicated their interest in continuing the participation of their students in a future program.
A major key to the success of the program is the supportive involvement and cooperation of local schools which provided a means to partially overcome the problems of confidentiality in idenuifing Medichek-eligible children. While this is not the best answer to the confidentiality problem, it is the best one discovered in this project. Although a significantly higher number of Medichek- eligibles were identified in the 1976 program, it is reasonable to assume that an unknown number of Medichek-eligible children were not identified if parents chose not to identify them during the outreach phase of the program. In considering that statement, it must be remembered that all children who participated in the program had been previously identified as financially unable to obtain them privately and it is reasonable to conclude that a higher number of them were members of recipient families of the Illinois Department of Public Aid than were identified. This is a situation which will continue to exist until the overall problem of confidentiality is resolved at a higher level than this project.
We have learned from the 1976 program that a single mass screening is not the most efficient means to deliver the services of the program. The problems of transportation, delays at the clinic site through overcrowding or delays in clerical work can be expected to repeat themselves and we must state again the position of the Society that mass examinations are an undesirable and inefficient method of preventive health care delivery.
We believe the mechanism can be altered however to eliminate many of the problems associated with mass screenings. Since a program of this type would not be possible without the involvement of the schools, we would suggest developing the program on a con- tinuing basis throughout the school year. Using the same outreach and pre-screening technique on a month to month basis, smaller number of children would be examined at each encounter. This would eliminate the need for a single mass program and increase the possibility of completing the examinations in a private physician's office. We believe this approach would be more accept- able to individual physicians. Since the schools would be so
closely involved in a continuing program, the adminsistrative organization of the program should become a responsibility of the schools at a county level. The role of a medical society should be advisory since a majority of county medical societies do not have the staff resources available to effectively organize and implement a program of this nature. The Will-Grundy County Medical Society would not have been able to make the 1975 screening pro- grams available without the resources provided by the Department of Health, Education and Welfare through the local demonstration pro j ec t .
Another possibility would be to organize and administer a continuing screening program through a local community action agency. As is the case with the schools, adequate staff resources would be available and both entities can readily identify the target pop- ulation. A community action agency has the added advantage of employing professional outreach staff to carry out the first phase of the program. In either instance, the role of a local medical society should be limited to providing medical expertise and man- power and to arranging for physician volunteers to participate in the program and to utilize existing referral patterns for additional diagnosis and treatment of identified abnormal findings.
In terms of the overall EPSDT program, the use of school screenings in any form has two major weaknesses. The program pro- vides no mechanism for continuing care for the children involved since the physician performing the screening may not see the child until the next school-required examination several years later. This would affect the majority of EPSDT-eligibles in whom no abnormal conditions are identified. The program also provides no mechanism to identify and enroll infants and pre-school children in EPSDT. As operated in the demonstration program, a physician would not see an EPSDT-eligible child until five years of age losing the most formative period of the child's life. The obvious conclusion is that such a weakness does not provide optimum pre- ventive health care delivery. We can conclude then by saying that the school screening program did enable us to identify one method of addressing the problem of confidentiality and to make EPSDT services available to a larger number of children. While we believe the program does not provide solutions to many issues, it is reproducible in other areas. The program does have possibilities for further refinement and development and if administered by the agency, the schools or a community action agency with the support of a local medical society, can make EPSDT services available to a greater number of children. At the close of the current project, we can make no statement on the local future of the program.
( 57 }
The school screening program has been conducted for two years locally using the resources provided under this contract and no agency has stepped forward to continue the program. We have advised the School Health Advisory Council that while the Will- Grundy County Medical Society will not have the resources to administer another program, we will participate again under the sponsorship of another agency.
(53)
EPSDT - ONGOING ACTIVITIES
In order to assimilate data from Medichek and Medicaid claim forms, a record keeping system developed by project staff during the 1974-75 subcontract period was maintained throughout the 1975- 75 contract period. This system enabled project staff to monitor the level of delivery of services in private office settings and provided the additional benefit of a claim review system for physicians of the Will-Grundy County Medical Society.
Physicians were requested to submit Medichek claim forms to the project office rather than directly to the Illinois Department of Public Health for payment. Due to the complicated nature of the form, a clerical review was completed to correct any errors or omissions. When errors were located, they were corrected with the assistance of the submitting office. Two copies were then made of the form and the original was submitted to the Illinois Depart- ment of Public Health in Springfield for payment directly to the provider .
The copies of each form were used to initiate records and referrals as follows:
a. An abnormal follow-up report was initiated from all claim forms which identified an abnormal condition requiring follow-up treatment or referral. The report included the case name, child's name, case number, child's birthdate, date of the examination, examining physician and the nature of the abnormality identified. This information was trans- mitted to the agency responsible for follow-up, in the pro- ject area, the Will County Department of Public Aid. The report contains space for Public Aid personnel to record case findings during follow-up contacts. A copy of the report documenting follow-up contact was kept by the Will County Department of Public Aid and the other was returned to the project office.
b. In addition, an internal control form was used to document and control the: a.) age and date of a child's enrollment in the Medichek program, b.) for use in setting controls to maintain the program's schedule of visits, and c.) a family history file copy for use in recording all Medichek screenings and contacts made by the project with the family. The enrollment file was checked upon receipt of the claim form. If the claim form represented an initial screening, the internal control form was initiated. The enrollment file was undated icon the completion of each scheduled visit.
This review system was designed to increase the effective- ness of the local project in several areas. The system attempted to assist physicians with billing problems and to avoid delays in payment through errors in claim form completion. Throughout the duration of this project, delays in payment to physicians was, and remains a serious and unresolved problem. The prior claim review system used in the project had no impact on this continuing source of physician frustration. The use of an abnormal report form did enable the project office to speed up the referral process and to prevent children from becoming lost in the bureaucratic process however the system was adversely effected by the internal personnel difficulties of the Will County Department of Public Aid as discussed earlier in this report.
A weakness in the data gathering and control process developed during the 1975-76 contract period because of the voluntary nature of the program. When the system was designed, it was based upon physician participation in the rotation system. Since project staff coordinated the assignment of patients to physicians under the rotation program, the system was better able to monitor the number of visits and track follow-up.
With the cancellation of the physician rotation program late in the 1975 subcontract period, project staff was removed from direct participation with physicians and patients. Since project staff was no longer able to assist patients with scheduling of appointments, the level of direct contact with patients declined throughout the 1975-76 period. Without the rotation program, physician participation in the Medichek project was completely voluntary and while physicians were encouraged to submit Medichek claim forms through the project office, and it appears that the majority did so, there was no established control on which to base evaluation of data. It cannot then be said that all physicians participating in the Medichek program utilized the services of the local project.
The Tables which follow in this report represent the accum- ulation of data from the system described for the duration of the project from March, 1974 until June, 1976. It should be noted that significant trends cannot be identified from the tables. The figures involved are too small and the time period is not of suf- ficient length to draw conclusions.
Table I represents the total number of Medichek screenings by month for the period of March, 1974 to April, 1976, reported to the project office by submission of claim forms. The Scheduled
Visits column represents the number of screenings performed in accordance with the mandated schedule of the Illinois Department of Public Health. The Scheduled Visits are permitted at 5 weeks, 4 months, 6 months, 9 months, 12 months, 18 months, 2 years, 3 years, 4 years, 5 years, 6 years, 10 years, 14 years, and 17 years of age. The column labeled Unscheduled Visits represents those screenings reported to the project officer performed at other times than allowed in the Medichek Program. Table II is a break- down by month and age over the duration of the project.
(61)
TOTAL VISITS 3Y MONTH
TABLE I
SCHEDULED VISITS
UNSCHEDULED VISITS
MARCH 197 4
APRIL 1974
MAY 1974
JUNE 1974
25 33 39 54
0 5 5 6
TOTAL'
156
TOTAL VISITS
172
|
JULY |
1974 |
68 |
17 |
|
|
AUGUST |
1974 |
129 |
15 |
|
|
SEPTEMBER |
1974 |
82 |
7 |
|
|
OCTOBER |
1974 |
112 |
12 |
|
|
NOVEMBER |
1974 |
85 |
25 |
|
|
DECEMBER |
1974 |
49 |
AVERAGE VISITS |
12 |
|
JANUARY |
1975 |
81 |
PER MONTH 96 . 5 |
8 |
|
FEBRUARY |
1975 |
66 |
3 |
|
|
MARCH |
1975 |
73 |
9 |
|
|
APRIL |
1975 |
108 |
3 |
|
|
MAY |
1975 |
36 |
17 |
|
|
JUNE |
1975 |
114 |
13 |
|
|
TOTAL - |
1058 |
151 |
AVERAGE VISITS PER MONTH 12 . 6
TOTAL VISITS
1209
JULY 1975 38 5
AUGUST 1975 97 10
SEPTEMBER 1975 111 AVERAGE VISITS 16 AVERAGE VISITS
OCTOBER 1975 23 PER MONTH 73.6 50 PER MONTH 10.7
NOVEMBER 197 5 4 5 9
DECEMBER 19" 5 54 5
(62)
TOTAL VISITS BY MONTH
|
SCHEDULED |
VISITS |
UNSCHEDULED |
|
|
JANUARY |
1976 |
41 |
6 |
|
FEBRUARY |
1976 |
19 |
2 |
|
MARCH |
1976 |
9 |
4 |
|
APRIL |
1976 |
174 |
|
|
TOTAL** |
736 |
107 |
TOTAL VISITS
*If extended for 12 month period the total scheduled visits would be 468 with 60 unscheduled visits. Since the Will-Grundy County Medical Society had just begun formal participation in the Medichek Program, and the Program had received minimal emphasis among member physicians, the extended figures are reasonable assumptions of the level of screening for 12 months without the impact of the local demonstration project.
** Figures for May and June, 1976 not available. Using an average of 73 scheduled visits per month, the projected total for the 1975-76 contract period would be S82. Using an average of 10 unscheduled visits per month the projected total for the 1975-76 contract period would be 137. The projected total visits would be 1019 for the final contract period.
Some explanatory notes from Table I:
--The total of Scheduled Visits for the months of April, 1975 and April, 1976 are artificially high because of the number of Medichek screenings performed in the school screening program in both years. The majority of screenings in these months fell into the 5, 5, and 10 year age groups.
--The peak screening months for both contract periods were June, August, September and October. The higher total screenings of these months probably reflects the number of school physicals being performed in private office settings and reported through the Medichek project office.
--The decline in the average of scheduled visits per month between the first and second contract periods is the result of a combin- ation of factors. The return of participation in the Medichek project to voluntary status following cancellation of the ro- tation program, the growing frustration of physicians with bureaucratic difficulties with the Illinois Department of Public Aid and Illinois Department of Public Health are reflected in this decline. The sharp decline in screenings, exclusive of the school screening program in 1976, reflects physician aware- ness of the impending termination of the local demonstration pro j ec t .
--Outside the peak months, the variance in monthly totals may be attributed to periods when the Medichek program received publicity either publicly or internally in the Will-Grundy County Medical Society.
--The relatively consistent numbers of screenings throughout the contract period indicate the local demonstration project did have an impact on the delivery of EPSDT services in the private sector. However, the fact that the number of screenings did not increase through the two year period, in fact declined slightly suggests the program was maintained more through the good will toward the Society on the part of individual physicians than through acceptance of the Medichek program.
(64;
TABLE II
MARCH 1974- JULY 1974- JULY 1975 TOTALS
JUNE 1974 JUNE 1975 JUNE 1976*
|
6 |
'Jasks |
"1 Q |
7 0 |
4 6 |
13 5 |
|
4 |
Months |
1 8 |
39 |
54 |
161 |
|
O |
Months |
1 4 |
"7 n i 9 |
8 6 |
17 9 |
|
9 |
Months |
1 3 |
5 a |
43 |
119 |
|
12 |
Months |
21 |
63 |
42 |
131 |
|
18 |
Months |
3 |
68 |
32 |
103 |
|
2 |
Year |
6 |
61 |
19 |
86 |
|
3 |
Year |
6 |
39 |
28 |
73 |
|
4 |
Year |
9 |
55 |
19 |
83 |
|
5 |
Year |
6 |
65 |
49 |
120 |
|
6 |
Year |
2 |
65 |
12 |
79 |
|
10 |
Year |
10 |
103 |
42 |
155 |
|
14 |
Year |
12 |
34 |
18 |
114 |
|
17 |
Year |
1 |
8 |
5 |
14 |
Unscheduled
Visits 16 161 107 284
*Figures from School Screening Program, April, 1975, not availab for inclusion.
(55)
SOME EXPLANATORY NOTES FROM TA3LE II
The impact of the Society's physician-patient rotation pro- gram is most clearly illustrated in Table II. The figures in all age groups are higher during the 1974-75 subcontract period when the rotation system was in full operation. The figures for the 1375-76 contract period indicate the effect of the cancellation of the rotation program on the demonstration project.
Table II also would seem to indicate that the EPSDT program does not reach the top age groups although the project period was too brief to draw a firm conclusion.
The high number of unscheduled visits (screenings reported which do not fall within the mandated schedule by the Illinois Department of Public Health) would seem to indicate a lack of knowledge of the program on the part of the parents. It should also be remembered that the figures for the 5, 6, and 10 year age groups, particularly in the 1974-75 subcontract period are artificially high due to the school screening program. Figures from the 1976 school screening program were not available as records were not returned to the project from the schools in time for inclusion in this report.
(56)
CONCLUSION
As we reach the conclusion of the EPSDT/Medichek-Community Health Services project, we do not find ourselves in a position to make recommendations for development of the EPSDT program. Our recommendations have been repeatedly made; in Professional Health Provider Participation, EPSDT-Medicaid 1974-75, in testimony to the Legislative Advisory Committee on Public Aid of the Illinois General Assembly and in our monthly reports in the present con- tract year. We have repeatedly pointed out that there has been no substantial change in either the problems or the recommend- ations in the EPSDT-Medichek program since our initial involve- ment and since our involvement in the 1975-76 demonstration project was a further attempt to address these issues, we believe it would serve little purpose to repeat the litany here. We can, however, make some observations on our experiences.
It has been frustrating and annoying to attempt to meet the goals of this project while working in good faith against a background of governmental mistrust and apathy. It is obvious from our previous documentation that we have been unable to engage the interest of the Illinois Department of Public Aid or the Illinois Department of Public Health in addressing matters of concern to physicians. It is equally obvious that internal staff problems, at both the regional and central offices of the Depart- ment of Health, Education and Welfare, severely restricted the availability of technical assistance to the local project. These problems, of which we were only indirectly aware, sufficiently interrupted the free exchange of information to a point where our project operated in a near vacuum for most of the contract period .
It is unfortunate that we were forced to lose nearly a quarter of the contract period resolving administrative difficult- ies with the payment mechanism which required rearranging the scope of work of the contract. We accomplished that task while simultaneously attempting to operate the project however we believe the difficulties could have been resolved to a much shorter time had assistance been available.
We would point out that a considerable number of volunteer physician manpower were provided to this project in administrative and policy areas. It was our feeling that the project was impor- tant enough to justify the donation of this time in the beginning.
(57)
A3 our frustration at the lack of program progress and develop- ment increased, physician involvement was maintained only in a commitment to discharge an obligation. We are appreciative of the support of the Will-Grundy County Medical Society in completing this project under adverse conditions.
We find the outcome of this project both disappointing and ironic. Having directly initiated development of a Professional Standards Review Organization and a Health Systems Agency in our area, and having been successful in both endeavors, we are not inexperienced in government funded health programs. We did not find the same level of support and cooperation in the ZPSDT project as characterised the other projects. The problems en- countered in the EPSDT project are more puzzling when examined against the viewpoint of M. Keith Weikel, Ph.D., Commissioner, Medical Services Administration, in discussion implementation of EPSDT .
"Together, we have the power to master, rather than be mastered by, the so-called revolution in health care. The rising expectations of our people can be met through an exertion of reason and control. But to do this, we must believe in our powers, agree among ourselves, and then work together as we have never done before." 30
M . Keith Weikel, Ph.D., Address to the Annual Meeting of the
American Academy of Pediatrics, Washington D.C., October 22,
ATTACHMENT A
COMMUNITY HEALTH 3EE7TCSS PROGRAM
NOVEMBER, 1975
Prepared by the Will-Grundy County Medical Society and the Will- Grundy-Kankakee Comprehensive Health Planning Council in cooperation with:
St. Joseph Hospital Silver Cross Hospital
Joliet-Will County Conmrunity Action Agency Will County Department of Public Health Will County Department of Public Aid Quad River Poundation for Medical Care
C GMMUNT^Y" STEERING COMMITTEE MEMBERS
1. JAMES BARRTNGER, CHAIRMAN
WILL COUNTY PUBLIC HEALTH DEPARTMENT
2. BORIS B ALTON, EXECUTIVE DIRECTOR
JOLIET-WILL COUNTY COMMUNITY ACTION AGENCY
3. KEYTON NIXON, ADMINISTRATOR
SILVER CROSS HOSPITAL
k. PRANK 0. RANGER, PHD. , EXECUTIVE DIRECTOR WILL-GRUNDY-KANKAEEE CHP COUNCIL
5. DR. ALBERT RAY, PRESIDENT
WILL-GRTO1DY COUNTY MEDICAL SOCIETY
6. ROBERT SCHINDERLE, ADMINISTRATOR
ST. JOSEPH HOSPITAL
STAFF: RONALD BRYANT, PROJECT DIRECTOR
WILL-GRUNDY COUNTY MEDICAL SOCIETY
KEN MARSHALL, HEALTH PLANNER WILL-GRUNDY-KANKAKEE CHP COUNCIL
PAGE NUMBERS
INTRODUCTION , 1-3
GOAL STATEMENT h
PROBLEM DEFINITION 5-3
COMMUNITY HEALTH PROGRAM 9-11
ALTERNATIVES
PROGRAM EVALUATION
INTRODUCTION
'â– /ill County, one of the most rapidly growing areas in the State of Illinois, covers SkS square miles in the northeastern section of the state. The county is within 50 miles of Chicago and is adjacent to the counties of Cook, DuPage, Kane, Kendall, Grundy and Kankakee in Illinois and Lake County, Indiana. The population of Will County in 1970 was 21+9, i+98, an increase of 30.2% since 1960. Will is the 7th largest county of the 102 counties in Illinois and the county's growth rate from 1 960 to 1970 was exceeded by only two other counties in the state. The population pattern for the entire county shews an 11% growth rate from 1970 to 1973, with a 1973 census of 278,060. Much of Will County is rural with two heavily urbanised areas, located in the northeastern and northwestern portions of the county.
•The primary service area of the Community Health Services program consists of four urbanized townships, Joliet, Lockport, Troy and DuPage, located in the northwestern quadrant of Will County. The location of these townships is illustrated in EXHIBIT A. The 1970 population of the primary services area was 160,960, representing 6h°/o of the entire Will County population. Two town- ships of the primary service area, DuPage and Troy, were areas of significant growth from i960 to 1970, each registering a more than 30% growth rate. The Village of Bolingbrook, in DuPage Township, has experienced the sharpest rate of growth, from 7»275 in 1970 to 25,519 in 1 97U- The primary service area also encompasses the City of Joliet, county seat and the largest single munici- pality in the county with a 1970 population of 80,378. Joliet is the govern- mental, educational and cultural center of the primary service area.
The primary service area is inter-sected by two federal Inter-State highways, and is served by five transcontinental highways and four state highways. In addition, the area is served by six railroads and four inter-city bus lines. Local mass transportation- is provided by a single bus line which operates six days per week in three of the four townships of the primary service area.
Health resources include 176 physicians in solo and group practices in Will County, 150 located in the primary service area. The area is served by two general hospitals with a total of 983 beds offering physical therapy, intensive and cardiac care, psychiatric care and accredited schools of nursing, medical technology and radiologic technology. Other available health services include twelve long term care institutions with 79U beds and 91 dentists. In addition, the Will County Health Department, headquartered in Joliet, has divisions deal- ing with Mental, Dental and Environmental Health, health education and nursing services. The department also provides heme and school health services, health counseling, vision and hearing screening services and health referrals.
The continued pattern of rapid growth in Will County, and particularly in the primary service area, have taxed the capacity of existing resources to meet the ever- increasing demand for health services.
One effort to meet this increasing need was the development of a physician rotation program by the Will-Grundy County Medical Society in 1971. Prom 1971 until 1 975 » 2,256 patients, a majority of them public aid recipients, were assigned to volunteer physicians. Of that number, 2,065 were assigned during one year as a result of increased publicity about the program. The Medical Society was forced to cancel the program in March, 1975 as the demand for services increased and voluntary physician participation decreased. In April, 1975? the Medical Society joined a number of other community agencies in a project with the local school district to provide state-required physical examinations for several hundred children, many of them Medicaid-eligible.
These activities, coupled with efforts to provide services in the Early Periodic Screening, Diagnosis and Treatment program in solo practice settings, led to a keener awareness of the needs of the patient relative to total health, welfare and social services and to recognition of the fact that private physicians could not handle those needs alone. The Medical Society recognized the fact that the entire professional community must assume leadership in developing accessi- bility to the health care system.
Prior to the cancellation of the physician rotation program, the Will-Grundy County Medical Society was in contact with various community agencies, both providers and consumers of health services, to discuss possible alternatives to expanding the existing health delivery system. The Community Steering Committee, as identified earlier, was formalized as a result of these dis- cussions.
The Community Steering Committee has met regularly for a period of six months in a cooperative effort to develop the elements to be included in this model Community Health Services program.
lanMMwaaMi wm meant*** rOTrirait^sa
scale •• I - 5 miles
.1 „ «» ikia t^nnrt was financed In part through Z rW«lnnment under .rovlslons of Sec. 701 ot the
Urban Development under proviso Houston Act of 1934 k» amended
J
GOALS AND OBJECTIVES
One of the primary objectives of most communities, 2nd especially of our community, is to assure all residents access to the health care delivery system. The development of a Community Health Services program, assuring this accessibility, requires the cooperative effort of many facets of the com- munity, which must include but not be limited to physicians, hospitals, allied health agencies and social agencies.
The primary goal of this program shall be to provide high quality, comprehen- sive medical and related health and social services which are economically available and accessible to the residents of Will County, Illinois. The initial focus of this program will be directed at providing additional primary care services to the residents of Joliet, Lockport, Troy and DuPage Townships who are now experiencing difficulty in obtaining these services. While the initial scope of the Community Health Services program is restricted to the four townships in the northwestern quadrant of the county because of the high concentration of population and the availability of existing health resources, the services of the program in the future will be available to all residents of Will County. It is anticipated the services of the program can be extended into outlying areas of Will County as the program develops.
To attain this goal, it will be necessary to meet the following objectives:
A.
To provide additional primary care services
B.
Improve the continuity and quality of health care services
0.
0.
Containment of cost through better utilization of limited and expensive facilities and manpower resources
Preserve and improve the physician 'patient relationship.
PROBLEM DEFINITION
The population of Will County, particularly in the primary service area, is confronted with a number of barriers to adequate health care services. These barriers are particularly acute in that segment of the population of low and moderate incomes and the aged. The locally identified barriers to health services are:
A. Unavailability of health services
The number of physicians in the areas of family practice, pediatrics, internal medicine and obstetrics has steadily declined since 1961+- Approximately, 53 physicians left private practice in Will County between 1964 and 1975* U6 in the above-mentioned areas. During the same period, 67 physicians established practices in the area but only 26 in primary care, some in part-time practice, with the result of a net loss of 22 1/2 primary care physicians. During the same period, the population of the county has increased over 30%. The re- sulting overload has caused many physicians to restrict the size of their practices. 'These restrictions of practices resulted in an increase of crisis- oriented delivery in the local hospital emergency rooms particularly for the low-income segment of the population.
B. Physician/patient ratio
The ratio of primary care physicians to patients in the primary service area is 1/3, 1+99 » however, physicians geographically located within the primary service area do not restrict their practices to residents of that area. Most residents of rural areas of Will County are dependent on health care facilities within the primary service area, thus the ratio of primary care physicians to the population of the county is 1/6,0U5« Ln addition, the medical service area for these same physicians includes an additional 100,000 people from ad- jacent surrounding counties, so the functional primary care physician/patient ratio is 1. 8,219.
C. Lack of education of the general public in health matters
This barrier is evident in the utilization of existing health resources, a lack of understanding of the value of preventive medicine, inability to understand and follow treatment regimens and communication gaps between providers and recipients.
D. Lack of transportation
There is no regularly scheduled, convenient public transportation available to all of the primary service area and few facilities exist for transportation of the aged or handicapped or others unable to use public transportation. Public transportation is available only in the immediate environs of the Cities
of Joliet, Lockport and Rockdale, during daylight hours, six days per week.
_nad.eau.ate dollar income
Many citizens of low and moderate incomes, not Public Aid clients, are finding the increasing costs of health care delivery difficult to meet. This problem is acute among the aged on fixed incomes.
3F. Inadequate provider re-imbursement
The use of a fee schedule, rather than the payment of usual and customary fees, by the Illinois Department of Public Aid and the lengthy delays in these payments and other administrative difficulties, combined with already heavy patient loads, have discouraged physician acceptance of IDPA patients.
These locally identified barriers to health services serve to perpetuate cycles of illness, limited health awareness and education, and poverty. These barriers particularly frustrate the poor and alienate them in their relation to society. It is the task of the professional health and health-related communities to involve the total community in developing a mechanism to remove these barriers.
With this in mind, the following demographic information on the primary service area was considered:
CHART I
How many people live in these four townships ?
WILL COUNTY
|
U.S. CENSUS ( |
1970 |
JULY 1, 1973 |
||||
|
1970) |
% 65 & |
ESTIMATED |
||||
|
TOWNSHIP |
TOTAL POPULATION |
OVER |
TOTAL POPULATION |
|||
|
JOLIET |
96,001 |
10.5 |
9U,527 |
|||
|
DUPAGE |
20,001 |
1.1* |
32,521 |
|||
|
LOCEPORT |
33,35V |
U.7 |
36,73U |
|||
|
TROY |
9,-95 |
2.0 |
12,151 |
|||
|
TOTAL OP |
||||||
|
k TWP. |
159,237 |
175,933 |
||||
|
Will County |
2U7, -25 |
7-2 |
27S, 060 |
|||
|
Illinois State 11 |
,113,976 |
9.3 |
11,176,356 |
|||
|
Source : |
U.S. |
Census |
||||
|
it has been determined for the |
purposes |
of the |
Community H |
ealth |
Services program |
|
|
that the greatest |
potential for |
•„se of |
alterna |
system exists in that |
||
|
ulation with |
j nconies |
of |10,i |
D00 ter year |
or 1 |
ess. 'This should |
|
|
not oe interpreted |
to mean that |
the _ar |
vices c |
tern would be denied to |
||
|
zzhes residents of |
'.va j — County |
*.v*no exce |
ed that |
as 5 ump o i on zi potential use 1.3 rs-mi crcsci oy the ic,ct that 3«2C5 P^^SliG a-.d recipients reside within the primary service area, representing a majority of public aid clients in Will County and whose incomes can be reasonably estimated to fall under 310,000 per year.
CHART II
TOWNSHIP 1969 % of Families' Earnings
Less than 37 » 000 - Col. 1
^7,000 o , 999 -j. 2
LuPage 6.0 11+.1+ 20.1+
Joliet 20.6 21.1 1+1-7
LockDort 13-7 '9.5 33-2
Troy 6.9 12.1+ 19-3
Source: Northeastern 111. Planning Commission Suburban Factbook, 1973, Table 17
Median Income 1970
DuPage Joliet Lockport Troy
312,630 311,086 311,658 313,503
Number of Number of families with Families children 13- under
2U,1S1+
7,150 2,730
3,711 13,U39 U,617 2,036
Source: CHP, INC. Metropolitan Chicago
Number of Families Below 310.000 in 1969
901 10,081+
2,373 £26
13,831+
Source: From tables above ( # of Families
from CHP, Inc. and Income from NIPC)
Number of "persons cer household:
Joliet Twp. 3*12
LuPage 1+.1+0
Lockport Twp. 3«51+
Troy Twp. 3.87
Will County 3«U3
State of Illinois 3«09
LuPage Joliet Lockport Troy
J. 3. Census Bureau - "970
For ice-mentation purposes, the figure of 3 persons per family was used to calculate the following information:
1 3 » - CLl families i 3-0 persons per family a 1+1 > 652 people
This represents 39% of the population of the primary service area and it is reasonable to assume that this segment of the population is most severely ef- fected by one or more of the previously identified barriers to adequate health care.
The demographic information presented here provides a reasonable framework for initial planning to remove these barriers to the delivery of health care services. The Community Steering Committee has determined its course of action to be:
A. To identify several alternatives for community consideration
3. To develop a methodology in which the community can evaluate and select from those alternatives.
T> (I'll i ' — - ->-£ vr n ,"*n > -i^-.t>,tt~ i — rr>->r Tr1 " THTT OO/VTJ ITT
Jhe first element of a Community Health Program is the development of a Community Health Council which should draw upon the common knowledge, experience and interest of the community ' s health care providers, civio leaders and residents. The com- munity Health Council should not include representatives of all community groups and organisations out should consist of a representative cross-section of the total community. A categorical breakdown of these groups could be:
A. Froviders of health services
1 . Health professionals Will-Grundy County Medical Society Will County Dental Society Public Health nurses
2. Health institutions St. Joseph Hospital Silver Cross Hospital
Will County Health Department Salem Home
Sunny Hill Nursing Home
3. Voluntary health and welfare agencies Will County Unit, American Cancer Society Easter Seal Rehabilitation Center of Will County American Red Cross, Western Will County Region Joliet-Will County Community Action Agency Will County Department of Public Aid
Illinois Department of Children and Family Services
B. Consumers of health services
1 . Industry
Will-Grundy Manufacturers Association Caterpillar Tractor Company United States Steel Corporation
2. Business
Joliet Region Chamber of Commerce
3. Non-health professionals Will County Bar Association
U. Farm organisations
Will County Farm Bureau
5. Organized labor
Will County 3uilding Trades Council
International Association of Machinists and Aerospace Workers Local 55 1
6. Religious leaders Diocese of Joliet
Joliet Ministerial Alliance
7. Educational leaders
q, Will County Educational Service Region Joliet Township Hi^i School District 201+ Valleyview School District 365-U
y. Local governmental leaders Will County City of Joliet Village of Romeoville City of lockport Village of Bolingbrook
9. Cooperative extension services
Will County Home Extension Association
University of Illinois Cooperative Extension Service
Representatives of each of these categories should "be formally invited to join in forming a Community Health Council. Each would be expected to function as a trustee of the community rather than representatives of individual or organization interest. A general meeting should he called to discuss the formalization of a Community Health Council and to reach agreement on the need for united community action. Since much work has been completed by the Community Steering Committee, the new Council should be able to complete its own organization and to begin review of alternatives. The new Council would then assume responsibility for planning and implementation of the Community Health Services program.
The Council may wish to function as a whole or appoint committees to perform certain functions. The use of Committees and possible functions to be performed are as follows :
1 . Committee to develop constitution and by-laws
2. Committees to select consultants to work with the Council and its Committees if needed in those areas where there is limited expertise:
- To identify community groups and organizations; also might assist in grant applications, data gathering and state and national con- tacts for information and assistance.
3. Committee to finance the Council and its programs:
- To collect and analyse data relative to funding mechanisms by identi- fying sources of payment for Council services, including other government and /or local funding, private individuals, foundations,
insurance companies, community fund drive, business, industry, etc.
_. lcmmi":~ee ~c inform "he ;cmmuni~y of the Council's ac~ivx~ies:
- To assist other Committees in their relationships within and cu-side the Community.
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Ii. Committee to inform the community of the Council's activities cont'd:
- Sevres as ccmmunication medium between the Council and community residents. Develop and implement publicity campaign regarding program description, progress, and success. To recommend action programs to the Council that may he approved by the community residents and meet their needs.
3. Community Coordinating Committee:
- To coordinate, gather information, and determine those community groups and organisations that can best assist the Council in its activities.
6. To be responsible for functions outlined in Program Evaluation Section.
It is estimated the Community Health Council can complete the following objectives by April, 1976:
1 . Begin review of alternatives
2. Select a Board of Directors and complete legal incorporation
3. Formalize committee structure
Ij.. Develop and adopt constitution and by-laws
It is estimated the Community Health Council can complete the following objectives by June 1, 1976:
1 . Select alternatives
2. To collect and analyze data relative to funding mechanisms by identifying sources of payment to include governmental and/or local funding.
The Council will have the services of a part-time staff person from January 1, 1976 until June 30, 1976 through the cooperation of the Will-Grundy County Medical Society. Other technical assistance to the Council can be provided by the Will-Grundy-Kankakee Comprehensive Health Planning Council and by the Department of Rural and Community Health of the American Medical Association. It is anticipated that within the six month period, the Council should be able to determine if continued staffing is needed and to determine a payment mechanism.
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(the alternatives section will be inserted here)
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PROGRAM EVALUATION
Evaluation is an essential part of effective management and should be performed on a continuous basis in order to strengthen the program. A method of evaluation should be incorporated into all aspects of the program during its development. Each program component should be reviewed periodically to determine accomplishments in relation to operational objectives. This review of actual services performed and resources expended to planned services and resources should include an assess- ment of the effectiveness and efficiency, as well as, the acceptability of the services provided.
As a method of evaluation, this program will attempt to develop a data base generated by the direct services it provides. All visits to the program will be recorded as will the direct services supplied. The number and types of referrals will be recorded as well as the number of vehicle trips. These factors will gene- rate a cost per patient for access to health care. Data will also be accumulated as to the number and type of home visits provided.
At the end of the first six months, and each six months thereafter, documents will be solicited from both physicians and patients. These will give some indication of patient attitude as well as physician attitude. Over a period of time, this will provide an indication of attitudinal change on the part of citizens, health care providers and health care institutions.
It shall be the responsibility of the Program Evaluation Committee to develop the proper documents to gather data, to review the data generated and to make appropri- ate recommendations.
To emphasise the importance of program evaluation, and to assure the quality of services rendered, it is anticipated the Council will request the assistance of the Quad River Foundation for Medical Care for the development of criteria for care services. It is anticipated this assistance will be sought at such time when the Quad River Foundation for Medical Care can develop a mechanism for ambulatory care review.
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