Program to consider the total array of resources within its Region in relationship to a comprehensive program for the care of the myocardial infarction patient. Thus, what was a concern of individual hospitals about how to introduce coronary care units has been transformed into a project or group of related projects with much greater potential for effective and efficient utilization of the Region's resources to improve patient care.

Assessment of Resources-As part of the process of regionalization, a Region continuously updates its inventory of existing resources and capabilities in terms of function, size, number and quality. Every effort is made to identify and use existing inventories, filling in the gaps as needed, rather than setting out on a long, expensive process of creating an entirely new inventory. Information sources include state Hill-Burton agencies, hospital and medical associations, and voluntary agencies. The inventory provides a basis for informed judgments and priority setting on activities proposed for development under the Regional Program. It can also be used to identify missing resources-voids requiring new investment—and to develop new configurations of resources to meet needs.

Definition of Objectives-A Regional Program is continuously involved in the process of setting operational objectives to meet identified needs and opportunities. Objectives are interim steps toward the Goal defined at the beginning of this section, and achievement of these objectives should have an effect in the Region felt far beyond the focal points of the individual activities. This can be one of the greatest contributions of Regional Medical Programs. The completion of a new project to train nurses to care for cancer patients undergoing new combinations of drug and radiation therapy, for example, should benefit cancer patients and should provide additional trained manpower for many hospitals in the Region. But the project also should have challenged the Region's nursing and hospital communities to improve generally the continuing and inservice education opportunities for nurses within the Region.

Setting of Priorities-Because of limited manpower, facilities, financing and other resources, a Region assigns some order of priority to its objectives and to the steps to achieve them. Besides the limitations on resources, factors include: 1) balance between what should be done first to meet the Region's needs, in absolute terms, and what can be done using existing resources and competence; 2) the potentials for rapid and/or substantial progress toward the Goal of Regional Medical Programs and progress toward regionalization of health resources and services; and 3) Program balance in terms of disease categories and in terms of emphasis on patient care, education and research.

Implementation-The purpose of the preceding steps is to provide a base and imperative for action. In the creation of an initial operational program, no Region can attempt to determine all of the program objectives possible, design appropriate projects to meet all the objectives and then assign priorities before seeking a grant to

implement an operational program which encompasses all or even most of the projects. Implementation can occur with an initial operational program encompassing even a small number of welldesigned projects which will move the Region toward the attainment of valid program objectives. Because regionalization is a continuous process, a Region is expected to continue to submit supplemental and additional operational proposals as they are developed.

Evaluation Each planning and operational activity of a Region, as well as the overall Regional Program, receives continuous, quantitative and qualitative evaluation wherever possible. Evaluation is in terms of attainment of interim objectives, the process of regionalization, and the Goal of Regional Medical Programs.

Objective evaluation is simply a reasonable basis upon which to determine whether an activity should be continued or altered, and, ultimately, whether it achieved its purposes. Also, the evaluation of one activity may suggest modifications of another activity which would increase its effectiveness.

Any attempt at evaluation implies doing whatever is feasible within the state of the art and appropriate for the activity being evaluated. Thus, evaluation can range in complexity from simply counting numbers of people at meetings to the most involved determination of behavioral changes in patient management.

As a first step, however, evaluation entails a realistic attempt to design activities so that, as they are implemented and finally concluded, some data will result which will be useful in determining the degree of success attained by the activity.

K. P. BUNNELL, Ed.D.
Assoc. Director
Western Interstate Comm.
for Higher Ed.
Boulder, Colo.

G. JAMES, M.D.
(Chairman)
Dean, Mount Sinai
School of Med.
New York, N.Y.

H. W. KENNEY, M.D.
Medical Director

John A. Andrew Memorial
Hosp.
Tuskegee Institute
Tuskegee, Ala.

E. J. KOWALEWSKI, M.D.
Chairman,

Committee of Environ. Med.
Acad. of Gen. Practice
Akron, Pa.

REVIEW COMMITTEE

G. E. MILLER, M.D.
Director, Off. of Research

in Med. Educ.
Coll. of Med., U. of Ill.
Chicago, Ill.

P. M. MORSE, Ph.D.
Director, Operations
Research Ctr.
Mass. Inst. of Tech.
Cambridge, Mass.

A. PASCASIO, Ph.D.
Assoc. Research Prof.
Nursing School, U. of
Pittsburgh
Pittsburgh, Pa.

S. H. PROGER, M.D.
Prof. and Chairman
Dept. of Med. and
Physician-in-Chief
Tufts N.E. Med. Ctr.

Pres., Bingham Assoc. Fund
Boston, Mass.

D. E. ROGERS, M.D.
Prof. and Chairman
Dept. of Med.
School of Med.
Vanderbilt U.
Nashville, Tenn.

C. H. W. RUHE, M.D.
Assistant Secretary
Council on Med. Ed.
American Med. Assoc.
Chicago, Ill.

R. J. SLATER, M.D.
Executive Director
The Assoc. for the Aid of
Crippled Children
New York, N.Y.

J. D. THOMPSON
Prof. of Public Hlth.
School of Public Hlth.
Yale U.

New Haven, Conn.

PUBLIC LAW 89-239

Through grants, to afford to the medical profession and the medical institutions of the Nation the opportunity of planning and implementing programs to make available to the American people the latest advances in the diagnosis and treatment of heart disease, cancer, stroke, and related diseases by establishing voluntary regional cooperative arrangements among...

The activities of Regional Medical Programs are directed by fulltime Coordinators working together with Regional Advisory Groups which are broadly representative of the medical and health resources of the Regions. Membership on these groups nationally is:

Dr. LEE. The leadership you and members of the subcommittee and full committee have provided in the field of migrant health has brought medical care to great numbers of Americans who might not otherwise have known any of the benefits of modern medicine.

Until passage of the Migrant Health Act in 1962, health care for migrants was virtually nonexistent. Today, thanks to extension of the act in 1965 and your continued support, major gains have been made in bringing health services to this group, who, in spite of their vital role in the agricultural industry, remain the last to receive health benefits most Americans take for granted.

The core provision of the act is the family health service clinic. At present, family health service clinics are operating seasonally or year round at more than 200 locations. The typical project places major emphasis on general medical care offered by private medical practitioners in family health service clinics, in out-patient departments of hospitals, or in their own offices.

Some projects provide dental services. All provide nurses who welcome incoming migrants, informing them of the services available to them. All provide sanitation workers and health education programs, Hospitalization was added to the scope of service under the provisions of the 1965 extension of the Migrant Health Act. Funds became available for the first time for this purpose during 1967.

In the latest 12-month period for which summarized project data are available, migrants made 215,000 visits to physicians and 24,000 visits to dentists. In addition, nurses made 125,000 visits to migrant. households and sanitarians made almost the same number of visits to living or work sites. Many communities and individuals have invested their own time, facilities, equipment, funds, and other items essential to the provision of project services.

The improvements which have been made in migrant health care since the passage of the act are quite dramatic, but there is still much to be done. Grant-assisted projects are reaching only about one-third of the Nation's migrants, and these for only part of the year.

Nearly 40 percent of the counties with seasonal migratory workers still have no grant-assisted project services. Medical visits and dental visits made by migrants are only about one-fifth and one twenty-fifth of the national per capita average. Deaths from influenza and pneumonia, tuberculosis and other infectious diseases, diseases of early infancy, and accidents are from 150 to 300 percent of the rates for the Nation as a whole.

Without continued and expanded financial and technical assistance, much of the current effort would be lost. The President's National Advisory Commission on Rural Poverty has recommended extension of the Migrant Health Act with sufficient funds to expand the program in terms of geographic coverage and services offered.

The advantages of a separate health program to migrant families have been great. But the time will come and very shortly-when migrant families will be far better served by a recognition on the part of the States and communities that for all their unique problems and needs, migrant families are much like the rest of the population. They must have access to medical services at a price they can afford to

pay.