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STATt uuuuivitnii



H:^ox.V||jg| Committee Finds Health IVeeds

To Be Low Priority ^m. s m



After more than three months
of work by six members of the
Study Committee, the first phase
of the study design for House Joint
Resolution 18, intended to examine
present public health services in
representative areas of the state,
is nearing completion.

Utilizing a Committee-designed
standard response format and col-
lecting both objective and subjec-
tive information, the team has been
conducting field interviews in three
separate counties representing a



wide spectrum of public health
services delivery.

The interviewing teams, consist-
ing of one health consumer and
one elected state legislator, con-
ducted their studies in one coun-
ty with minimal or no public health
services, in another with some
fragmented public health services,
and in a third offering many ser-
vices in a somewhat coordinated
system.

The committee asked that the
counties not be named.



With the completion of the field
interviews and the analysis of the
information, it is becoming in-
creasingly clear to the study com-
mittee what a can of worms the
public health service delivery sys-
tem represents.

The direct consequence to the
committee's work, a recommenda-
tion to the 1975 Legislative Ses-
sion, will have to address a system
that is marked by a lack of sup-
port by the people, local elected
— continued on page 4




MONTANA STATE oBRARY
930 East Lyndale Avenue

/IHOHTANA^^^^''°' ''^°"'°"° 59601



Second Class Postage Paid
at Helena, Montana 59601



COtllPRiH{MSt¥e
HiAiTH PLAHHIHe



liiws



570 Logan Ave. - Helena, Montana 59607 - Phone 449-3727



Volume 5, Number 4 — May - June, 1974



'b' Agencies to Be
Reimbursed



For the past 18 months, the area-
wide "b" agencies have been con-
ducting comment and review ac-
tivities on approximately 40 appli-
cations for new health facilities
and m.odifications on existing ones
in compliance with Section 1122,
Title XI of the Social Security Act
(PL 92-603).

The January-February issue of
the CHP NEWS contained an ar-
ticle on Section 1122 which des-
cribed its intent to assure that fed-
eral Medicare, Medicaid, and
Maternal and Child Health funds
are not used to support any un-
necessary capital expenditures
made by or on behalf of a health
facility or health maintenance
organization.

Among the elements of adminis-
tration of the 1122 review and
comment function is one concern-



ing the reimbursement to the
Designated Planning Agency
(DPA) which makes the final de-
cision regarding approval or dis-
approval of proposals under Sec-
tion 1122. In Montana, the DPA
is the Department of Health and
Environmental Sciences.

Up until now, the areawide CHP
agencies and the Department of
Health and Environmental Sciences
have had to pull resources from
other areas of their budgets to
finance their review and comment
procedures.

Nevertheless, the areawides will
soon be reimbursed for those ex-
penditures by the Social Security
Administration via the state DPA
with whom it has the contracts
for Section 1122 review and com-
ment activities.

The reimbursement funds will



be applied toward the staff time
spent in Section 1 122 review, the
travel expenses of committee mem-
bers attending review hearings,
and other miscellaneous costs in-
curred such as reproduction of
printed matter and newspaper
space.

The method of determining the
amount of reimbursement is some-

— See page 2




'^^'



Campbell — Formulas,
ratios, percentages.



B-Grant Submitted
$198,284 Aid Sought

At or around this time of year, grants have been accompanied by

CHP, Hke many other agencies is pages of technical information

required to make application for about the agencies which often

grants to cover operations for the reached voluminous proportions

upcoming fiscal year. On May 1, and ultimately slowed the process

a request for the Cooperative Area- of review.

wide Comprehensive Health Plan- Concerning the specific requests

ning Grant was submitted to the from the areawides, the federal

regional office in Denver. funds sought by the agencies are

The grant request petitions the as follows:

Health Services and Mental Health Northwestern $33,213

Administration (HSMHA) for a Northcentral 22,878

total $198,284 for fiscal 1975. Eastern 27,708

According to Warren Brass, Southwestern 54,362

Planning Coordinator for Areawide South Central 40,581

Affairs, these monies will be dis- State "a" 19,542

tributed among the areawide "b"

agencies. $198,284

Brass was assisted in his prepa- ""

ration of the request by Ms. Judith Reimbursement

Carlson, State-Regional Coordina- —Continued from page 1

tor. Ms. Carlson worked closely what different from other sources

with the regional office in Denver of income such as grants which

while writing and submitting the are requested on the basis of

grant proposal. budget predictions.

Once approved, the grant would Explained Cathy Campbell, CHP

provide 75% of the agencies' basic Health Planner, "The amount of

funding the remaining 25% to be reimbursement is determined by a

composed of matching state <ind formula. First the CHP expendi-

local resources. tures for the entire state are mul-

Although the grant would pro- tiplied by the percentage of effort

vide a considerable sum for the CHP agencies spend in cost con-

areawides, Brass emphasized the tainment, that figure not allowed

importance of continued local to exceed 50%.

matching. "That product is then multiplied

"Areawides are encouraged to by the ratio of federal expenditures

provide local matching funds to under Medicaid, Medicare, and

further enhance the possibility of Maternal and Child Health Pro-

their receiving additional federal grams for nursing home and hos-

funds," he said adding, "This also pital care to the total expenditures

indicates local support and com- from all sources for hospital and

mittment for the program." nursing home care within the state.

For the first time, this year's "Montana," Ms. Campbell con-
grant application incorporates a tinued "has a much higher per-
concept of "new federalism" ac- centage of its hospital and nursing
cording to Brass. home care paid for out of those

With a spirit of "new federal- federal funds. So we get more

ism" in mind, the federal govern- money to conduct Section 1122

ment is supposed to trust the state reviews than most states. In fact,

in keeping record of day-to-day we get more money than any state

materials such as by-laws, boards in the region," she said.

of directors, etc. According to the formula, that

"These no longer have to be in- total amounts to $64,496 for fis-

cluded with the grant application cal year 1974.

but must be kept on file in the As outlined in the Section 1122

state office," Brass stated. regulations, the DPA may retain

In the past, the applications for no more than 30% of the funds

PAGE TWO



ON THE MOVE



SOUTHWESTERN AHONIMIA

•MOmrn DRUQ PROGHAHi











The Southwestern Areawide
Health Planning Council Offices,
formerly located at 510 Logan,
Helena, have moved to new facili-
ties.

The Executive Director's new
offices are now located at 324
Fuller Avenue, Helena. SWAHPC
can now be reached at 449-2825.

except as agreed by the U.S. De-
partment of Health, Education and
Welfare. The remainder of the
money must go to the areawide
CHP agencies.

The areawides will actually be
getting more than 70%, but this
is only the reimbursement for fis-
cal 1974. Beginning this coming
July 1, there will be another reim-
bursement for fiscal 1975.

Concerning the method of distri-
bution, Campbell said, "This first
year (fiscal 1974) the areawides
will get about equal amounts if
they can justify it, which I believe
they can. For future years, they
will project how much they plan
to spend, and it may show that
some areawides will spend more
than others. Right now, there is
no more fair way to do it than to
divide it up evenly."

Fortunately, neither the area-
wide CHP agencits nor the De-
partment of Health and Environ-
mental Sciences will have to dip
into the till to conduct future re-
views this coming fiscal year as
the anticipated $64,000 will come
beforehand.



HHA-Bringing It All Back Home



Begun last October, an experi-
mental home-care nursing pro-
gram was devised through the ef-
forts of the Southwestern Area-
wide Health Planning Council en-
abling many Helena residents to
obtain needed health services in
the home rather than in the hos-
pital.

With a staff of two nurses, Sr.
Elizabeth and Noreen Baretch and
an aide, Pam Templin, the Lewis
and Clark Home Health Agency
helps in alleviating some of the
overload at St. Peter's Hospital
as well as saving many people the
expense of rapidly rising hospital
costs.

Concomitant with the ensuing
demand for health services, it was




Luck: Independence and dignity.

discovered that many of those
heretofore provided by the hospi-
tals could be made available to the
public through other means, ac-
cording to Jim Foley, Director of
the SWAHPC.

"Through the program we dis-
covered that 25-30 people a day
could have been treated at home
rather than in the hospital," Foley
said.

When an alternative to hospitali-
zation is mentioned, one element in
particular comes to mind: money.
At this time, a private room at St.
Peter's costs $55 per day. A semi-
private one goes for $50 per day
and a bed in a ward for $45.

The health care agency is a
blessing in that category. A visit
from the nurse is $10. One from
the nurses' aide who can provide
personal hygiene and related ser-
vices is only $6.



According to Holly Luck, Presi-
dent of L&CHHCA's Advisory
Board, "This is a considerable sav-
ings when you consider what it
costs to simply walk into a doc-
tor's office. It's far cheaper than
going to the doctor frequently or
even to the hospital as an out-
patient.

"Some insurance companies,"
Ms. Luck continued, "have home
health care plans, but most do not.
So this is a considerable savings
for the Medicaid and Medicare pro-
grams as well."

In addition to providing an al-
ternative to the hospital, the home
health care concept supplements
the services of existing visiting
nurse programs.

"Visiting nurse programs are
preventive in nature and services.
As opposed to the public health
care, the home health care nurse
can come into the home and ex-
amine the patient afterward pass-
ing that information along to the
doctor," Ms. Luck pointed out.

With that information in hand,
the doctor can then make further
prognoses without the expense and
effort of an appointment. However,
the benefits of such a program
are not bounded by financial and
expedient considerations alone.

"For the elderly, this type of
health care is particularly advan-
tageous, because it provides them
with the services in the privacy
of their own home. This permits
them a certain amount of independ-
ence and dignity in their treat-
ment," Luck added.

Prospects for continuation and
expansion of the program which
now includes some 30 patients are
bright according to Foley.

"We were able to begin the pro-
gram with a $10,000 grant from
the Intermountain Regional Medi-
cal Program in Salt Lake City, for
six months. It is our intention to
have the program become self-
supporting by the end of July."

The approach to financial auto-
nomy being taken by the program's
framers is to confront the com-
panies writing health insurance
policies with the concept.

Fortunately, the program has



been enthusiastically received
among those of the medical pro-
fession here. Said Ms. Luck, "We
have fantastic support from the
doctors in Helena, but we still need
more community involvement. Af-
ter all, it is a program designed for
Helena which has only one hospi-
tal.

"With that and the support we
have so far, we should be able to
make it," she noted confidently.

Among some of the principles
involved with the program's im-
plementation are its board of direc-
tor's members;

David Berg, M.D.

L. H. Blattspieler, M.D.

Leon Claassen, M.D.

Harrison Hanson, M.D.

Lois DeFord, R.N.

Joyce Jacobson, R.N.

Sister Mary Carol, R.N.

Maudie McCauley, R.N.

Ruth Meyers, R.N.

Daisy Prentice, R.N.

Marlene Stellmon, R.N.

Joan Duncan

Rena Sullivan

Cornelia Robinson

Jeannette Folsom

Rex Whitaker

Judy Harkins

Phyllis Miller
The Lewis and Clark Home
Health Care Agency is located at
530 N. Ewing. It can be reached at
443-4140.



MONTANA COMPREHEN-
SIVE HEALTH PLANNING
NEWS is published bi-month-
ly in January, March, May,
July, September, and Novem-
ber by: Comprehensive Health
Planning Division of the De-
parment of Health and En-
vironmental Sciences, 510
Logan, Helena, Montana
59601.

Editor Jim Jasper

Editorial Assistant —

Laura Shellenberg
Photography Jim Jasper

Views and comments on
CHP NEWS are welcomed.
Address letters to the Editor,
CHP NEWS, Cogswell Build-
ing, Helena, Montana 59601.



PAGE THREE



HJR 18

— continued from page 1
officials, and state government.

That system has continually
come out on the short end of the
stick in competition with other
community needs.

Also, it is one whose value is
recognized neither by the consum-
ers nor the people responsible for
its provision.

Finally, the system has been
characterized by fragmentation, in-
accessibility, political boundary-
guarding, and personnel that are
under-paid and over-worked.

The most striking and recurrent
reality uncovered by the interview
teams is the low priority given
public health needs when they are
in competition with other commu-
nity needs. As one interviewer re-
marked, "County health officers of
all counties seem to be at the bot-
tom of the totem pole when the
help and concern of county com-
missioners is needed."

Another significant problem
identified is the low, and in sev-
eral cases almost non-existant.
level of awareness of the value of
public health services on the parts
of the average Montana citizen
and those elected or appointed of-
ficials charged with making health
decisions on the local level.

One team member observed, "On
the basis of the interviews with
the providers, county commission-
ers, etc., one could conclude that
public health services are being
provided satisfactorily."

"In fact," he went on, "they
know nothing about the program,
and with rare exceptions, it does-
n't seem to bother them. They
seem to believe this should be
someone's responsibility; but it
does not really concern them," he
concluded.

Another team member expressed
the opinion that the ordinary citi-
zen who is not involved with local
government or public health ser-
vice provision is not aware of
these services and has very little
idea what services he would like
to see provided in the future.

As a reflection of this problem,
several recommendations were re-
ceived by the teams to encourage
city and county health boards to
initiate "better public relations in

PAGE FOUR



order to inform the community of
the services they provide."

Due in part to the low level of
state and local support, public
health personnel, where they do
exist, were found to be normally
over-worked and under-paid. It
was noted by one interviewer that
most public health workers,
especially in those counties with
minimal or seriously fragmented
services, "only have so much time
and they have to cover a lot of
area, so they are not always avail-
able."

This inaccessibility to public
health services compounded by
serious transportation problems
was seen as a major stumbling
block to proper delivery of ser-
vices.

As the HJR Study Committee
had expected, the field investiga-
tions revealed that there exists in
Montana no standard level of pub-
lic health services. In many areas
of the state, public health services
to protect sanitaion or render
oher basic public health or medic-
ally-related services either do not
exist or are inaccessible to a sig-
nificant portion of the population.

The study has revealed that only
three counties in the state, Cas-
cade, Lewis & Clark, and Missoula
offer a full range of traditional
public health services in any or-
ganized or coordinated manner.

Between these three isolated
islands lies a vast expanse of un-
coordinated and for the most part
unorganized public health service
delivery. Depending upon the per-
sonalities of local elected and ap-
pointed officials, members of the
local boards of health, and the
monetary constraints they must
contend with, every county in the
state addresses the public health
services problem with an individ-
ual, fragmented, and often unique
approach.

Perhaps most significantly, the
study teams reported that despite
moves by the past two governors
to encourage the creation of dis-
trict or multi-county organizations
for planning purposes and for the
delivery of comprehensive services,
the issue of political boundaries
in public health organization was
seen as the major stumbling block
to improving public health services
for Montanans.



Despite the fact that most coun-
ties are financially unable to pro-
vide comprehensive traditional
health services, most are reluctant
to develop a regional approach.
There continues to be heavy oppo-
sition to any new concept that
appears to threaten existing politi-
cal jurisdiction or erode local
power.

Instead, there seems to be either
a general dissatisfaction with exist-
ing services, however minimal, or
the desire to have the state play
a greater role in financing local
operations.

While local officials identified
the present low level of state sup-
port for public health services as
a problem, they expressed a gen-
eral unwillingness to accept more
state support unless it coincides
with the existing local political
jurisdictions.

Although a final report has yet
to be issued on Step No. 1 of the
Study Design for HJR 18, it ap-
pears that not all the news about
public health services is bad.

There seems to be a general feel-
ing of optimism among most peo-
ple who were aware of these ser-
vices. Manv reported the opinion
that a gradual building of an inte-
grated public health program "That
would provide comprehensive ser-
vices of optimum quality, equally
available and accessible to all
Montanans is necessary."

Many feel that the state should
assure every community of cover-
age by an official health agency
and access to the complete range
of Dublic health services.

The consensus seems to be that
the state should stimulate and sup-
Dort the development of local
health units that would provide
the necessary public health ser-
vices to local communities.

This attitude was tempered by
the feeling that though the state
and federal support should be in-
creased, the functions and controls
which would normally accompany
such assistance should be delegat-
ed to local health units as much as
possible.

Some interviewers reported
recommendations for the provision
of financial incentives with state
aid for any necessary reform in
the structure and organization of
(continued on next page



THE READERS' RIGHT

Gentlemen — Friends:

Perhaps it is because I am a
native of Montana (born near Bil-
lings) transplanted to Oregon that
your newsletter seems particularly
interesting and good. I do appre-
ciate being on your mailing list
even though we are not recipro-
cating. The Oregon "a" agency
does not publish a newsletter and
being a lowly "b" agency, ours is
a mimeo in-house affair.

However, it is amazing how
similar are our problems and our
programs. Because of this and be-
cause CHP is without many guide-
lines to follow, it is especially help-
ful to learn about what others are
doing.

Congratulations! You seem to
have a very active and worthwhile
program. Items in your last publi-
cation which I found especially
helpful were the ones about devel-
opment of your state health plan,
the one about the home-health
care project and the overview of
pending Congressional legislation.
Of course, this latter may change
us all. Our Board of Directors is
violently opposing the 500,000
population requirement since in an
area such as Oregon (and presum-
ably Montana) it would all but
destroy local voluntary participa-
tion.

Janet C. Guches

Director

Jackson-Josephine CHP

Medford, Oregon



HJR 18

— continued from page 4
local public health organizations
to attempt to overcome the resist-
ance of "territory-guarding."

Initial indications are that reor-
ganization and development of new
and improved patterns of state
districting that would consolidate
old local political boundaries will
be necessary before rationally-
based local health jurisdictions
that are financially capable of do-
ing the job can be established.

However, the problem at this
point is that the probability of in-
creased state support appears
doubtful and an increase in local
support seems even more remote
until the public is made more



EDITORIAL

BY DAVE TURNER

Nothing makes us more aware of our age and how old we're getting
than to experience change. We seem to float along for a while in our own
private bubble of reality until . . . POP! Somebody or something pricks it
with a pin. For example, take what happened to me recently.

1 dropped into my local hardware store last week to pick up some
basic fishing supplies — hootes, sinkers, that sort of stuff — and as I
was drooling over the vast array of equipment a little gizmo caught my
eye. For the life of me I couldn't figure out what it might be used for.
It looked simple enough, being nothing more than a foot-tall heavy piece
of Y-shaped wire coated with plastic.

I was still standing there turning the thing over and over in my hands
when a sales clerk happened by. Knowing full well I hadn't bothered to
call ahead for an appointment with the young man, I nonetheless grabbed
his sleeve and brashly inquired, "What the hell is this"

Somewhat miffed at being interrupted in his journey from the shot-
guns to the nail bins, he disdainfully informed me that it was nothing less
than their best "Hold-Zem" model, a teflon-coated fishing rod holder.

I couldn't believe it! A teflon-coated steel pole holder!?! At $3.59 a-
piece, no less! Whatever happened to the "good old days" when you
simply whipped out your pocket knife and cut a pole holder from the
closest bush?

I found out later that same evening when I trucked on out to the
river to fish. An old timer with whom I'm acquainted told me about a
secret fishing hole of his and made me promise on his death bed that I'd
never reveal its whereabouts to another living soul . . . even under torture.

Well, it must have been a while since he'd fished that hole because
when I got there I discovered his "secret" fishing place was not so secret
after all. Since he'd been there last, the parking area had been graded and
covered with an inch of gravel (keeps your feet dry) and was complete
with picnic table, fireplace and a dozen other fishermen.

And wouldn't you know it, there wasn't a bush to cut a pole holder
from for miles — they'd disappeared long ago. So there 1 was with my
pole lying in the gravel getting scratched and dusty while up and down
the bank everyone else looked over from their aluminum folding chairs
and smiled benevolently from behind their Foster Grants, their fish-
ing rods setting high and erect off the ground on those teflon-coated, steel
rod holders.

I tell you, the sight of the evening's slowly sinking sun reflecting
off the plastic of a dozen rod holders like that was enough to jog over
the meter of your electronic, solid-state Fish Detecto device.

Ah, changes. Bobby Dylan forwarned a few years back, "the times,
they are a changin'," and I find myself changin' as I leave CHP to begin
new adventures in new realms. Seems like not so long ago when I first
joined the agency that I was pretty pessimistic about the prospects of
health planning, but with time I've come to recognize its worth. Now
with new legislation on the federal horizon, I find myself feeling quite
optimistic about CHP's potential for really making a positive impact on
the health of the people of Montana. And while it may not be teflon-
coated, I think in the end it'll get the job done.

One year ago I'd never have thought it possible. Changes. That's
what it's all about isn't it?



aware of the merits of public


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