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D. Total, All Clinic Services.—

Number of clinic sessions..

Number of individuals served_

Number of clinic visits___

Average attendance per clinic session....

381 2,693

7, 129

18.7

Medical services at the Harney Lane and Matthews Road clinics were terminated on November 10 and November 17, respectively, when the camps were closed for the season. Mobile clinic services were terminated at Acampo, Terminous, and Vernalis on November 17, by which time most migrant families had departed from these areas. The mobile medical clinic continues to visit Linden and Thornton once weekly.

E. In-Office Medical Services.-In-office services were initiated during July, 1967, after funding of all components of the project was assured. As of November 30, 533 referrals had been made, 310 (58.2%) of which were successfully completed:

Harney.
Matthews.

Mobile..

Total...

Physician
office

Private laboratory

X-ray

Dental

Total

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Reports on referrals continue to be received. Some patients deliberately delayed acceptance of referral until they were no longer working. The final proportion of successful referrals (on which reports will be received) will undoubtedly be higher than the 58% presently recorded.

F. In-Hospital Care.-The hospitalization component of the original comprehensive plan was not funded. All patients in need of hospital care were therefore referred to San Joaquin General Hospital. During the period April 1-November 30, 89 patients were referred for in-patient care:

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Recorded referrals and admissions for hospital care do not adequately reflect the need of migrant families for such care, for the following reasons:

(1) The Harney Lane camp operated at capacity for less than seven months; Matthews Road camp was occupied for six months, but operated at full capacity for less than four months. The mobile clinic service was provided for less than five months; no service was provided in outlying areas during the months of April, May, June, during which months San Joaquin County experiences the largest influx of migrants (cherry season).

(2) San Joaquin General Hospital staff may not admit all referrals, particularly some for whom, in the opinion of clinic physicians, elective procedures are indicated. The number of such patients has not yet been documented.

(3) Inpatient care was provided at San Joaquin General Hospital for some migrant individuals who received no clinic services at the camps, but went directly to the Hospital. Efforts are under way to identify these individuals.

III. Conditions For Which Medical Services Were Provided.-A statistical record was prepared for each service provided in the program. Analysis of these records is now in progress, and detailed tabulations of conditions diagnosed and treated

and of services rendered, are not yet available. Preliminary review of clinic records indicates that comprehensive services have been provided for a wide range of

conditions:

Adults served at the clinics were found to have a wide range of chronic conditions: anemia, arthritis, diabetes, other endocrine problems, hypertension, chronic respiratory disease, obesity, minor and major surgical problems.

Approximately 17% of all clinic visits were for diagnosis and treatment of respiratory infections.

Obs.-gyn. services included prenatal care, family planning, diagnosis and treatment of g.u. infections and other gynecologic problems. Obs.-gyn. services were provided regularly by qualified gynecologists at each clinic location; these sessions were conducted in addition to the general medical clinic sessions. Special efforts were made by Health Aides to promote client acceptance of prenatal and family planning services:

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Approximately one-half of all clinic visits were made by children. Services included not only care for acute illnesses, but also examination and counselling of well infants, preschool, and school age children. Qualified pediatricians staffed each clinic at least once weekly. Although children having acute problems were seen daily, effort was made to refer children to the pediatrician whenever possible. Immunizations were provided at all clinic sessions. Some 3304 immunizations were administered (DPT, DT, Polio, Measles, Smallpox). The numbers of completed series of the several immunizations have not yet been tabulated. Particular effort was made to immunize adults as well as children.

Tuberculin skin tests were done routinely for children and for as many adults as possible. The Health District and Bret Harte clinic provided chest x-rays and other indicated examination for tuberculin reactors. To date, followup has been completed for 72 of 106 such referrals. One case of active tuberculosis was diagnosed. One adult male "converter" and seven tuberculin positive children were placed on INH prophylaxis after receiving complete evaluation. Local, intrastate, and interstate followup on other tuberculosis suspects continues. Although tuberculosis case-finding efforts have not yet been evaluated adequately, the prevalence of tuberculosis among migrant families does not appear to be as high as that observed among single male transients in this County. (In a continuing case-finding program which has been conducted since 1953, the active tuberculosis case rate among these men has ranged from a high of 20.2 cases per 1,000 men examined in 1955 to a low of 3.4 per 1,000 in 1966.)

IV. Public Health Nursing, Health Aide, and Related Services.-Detailed reports on Public Health Nursing and Health Aide services are not yet available. Public Health Nurses and Health Aides served at each clinic location five nights per week, as provided in the project plan. In addition, Public Health Nurses and Health Aides paid from regular Health District budget provided services daily to all camps and the two day care centers, during regular working hours.

Amblyopia screening and audiometric screening were provided for children attending the two day care centers during the summer months. Public Health Nurses provided followup for children found in need of further examination.

Two Health Educators on Health District staff assisted physicians, other members of clinic staff, Public Health Nurses, and Health Aides, in providing health education services. Educational materials were provided in Spanish as well as English. Although project staff participated in some group activities, person-toperson contact was emphasized.

Medical, nursing, and related services were coordinated with the activities of a Federally funded migrant education project conducted in the two fixed camps. Particular effort was made to ensure that preschool and school age children received medical evaluation and other preventive medical services.

V. Population Served.-Accurate figures regarding the population served are not available at this time. However, estimates derived from several sources

indicate that at least 6000 persons had immediate access to medical and related services provided by the project.

Occupancy at the two fixed camps varied during the seven month period:
Harney Lane-low of 75 families, high of 126 (June).

Matthews Road-low of 42 families, high of 140 (September).

Data regarding family size and length of stay in the fixed camps are available, and will be analyzed. Public health nurses have identified several groups of migrant families who did not live in the fixed camps, but who utilized the camp medical clinic services.

Estimates only are available for the migrant population in the areas served by the mobile medical clinic:

Acampo, 400-500 (includes 40 families in one private camp).

Linden, 1000-1200 (several private camps).

Terminous, 50-75.

Thornton, 150-200.

Vernalis, 500-550 (80 families in private camps).

Continued effort will be made to obtain more reliable estimates of the migrant population during various times of the year.

In previous years, the migrant population in San Joaquin County has been estimated as 12,000–13,000. A large proportion of total migrants comes to this County during cherry harvest (May-June). Although medical services were initiated at the Harney Lane Camp in April, the mobile clinic service did not start until July. Operation of the mobile clinic during the period April-June next year will allow provision of care for a greater number of migrants than received service this year.

VI. Costs. All claims for payment for services and supplies have not yet been received, and project records have not yet been audited. However, current review of records indicates that all components of the project have remained well within the amounts budgeted. All services provided will be subjected to cost analysis when the projects are completed.

VII. Problems Encountered.

A. The hospitalization component of the comprehensive project could not be implemented, because funds for this purpose were not available. Individuals in need of inpatient care were referred to San Joaquin General Hospital, resulting in loss of continuity of care.

B. Initiation of in-office care and utilization of laboratory resources were necessarily delayed until adequate financial support was assured in July. C. Facilities at Harney Lane and Matthews Road Camps were less than ideal for clinic activities. A portion of available space was necessarily used for other camp activities (educational and social). Opening of the second unit at the Matthews Road Camp improved the space situation for the clinic at that location.

D. Attendance at the first few sessions of the mobile clinic was low, even though efforts to stimulate attendance were made prior to the clinic dates. Public Health Nurses and Health Aides devoted additional time to locating migrant families and providing information about available services, with the result that mobile clinic attendance increased during succeeding weeks. E. Dental care was provided for a relatively small number of individuals. The project budgets included only token amounts for dental care, and referrals initially were limited to patients having dental emergencies. Late in the summer, permission was granted to use otherwise uncommitted funds for purchase of additional dental services. However, time did not permit development of a more comprehensive service before the fixed camps were closed.

VIII. Plans for 1968.-Physicians in San Joaquin County believe that the feasibility and desirability of providing comprehensive medical services for migrant families have been demonstrated. If adequate financial support can be obtained, services for 1968 will include:

1. Outpatient medical services at the fixed migrant camps, beginning in April, 1968. As the existing State OEO contracts terminate March 31, 1968, medical services can be provided at Harney Lane and Matthews Road camps only if funding is assured prior to that date.

2. Mobile medical clinic services to outlying areas in which migrant families will reside. Experience gained during the first five months of the current project will be utilized in determing the locations to be served. Consideration will be given to providing medical services for single male agricultural workers, if facilities are provided for housing these men next

year. As the existing contracts for support of the mobile medical clinic terminates on June 30, 1968, provision of services during the summer and fall will be contingent upon receipt of assurance that this program will be funded during 1968-1969.

3. In-office medical, dental, laboratory, and radiological services. During a five month period, this project has demonstrated that migrant individuals have a need for medical services more comprehensive than can be provided in a camp clinic. The project has also demonstrated that, contrary to the beliefs of some, migrants will accept referral to private resources, if assisted in doing so.

4. Hospitalization in community hospitals in the areas in which migrants reside. Continuity of care can be achieved only if in-hospital care can be provided by the physicians who are providing outpatient care. Migrants are entitled to the same quality of care as are residents of the area, and such care must include hospitalization.

The present program is supported by three State and Federal contracts in the amount of $162,223. Experience gained during the past eight months indicates that this amount, plus approximately $10,000 additional for dental care (primarily for children), would allow provision of an adequate level of outpatient services during the period April 1, 1968-June 30, 1969. The addition of $50,000 for hospitalization would allow provision of truly comprehensive services.

The figures recorded in II-F above regarding hospitalization represent a minimum estimate of the need for inpatient care. As indicated in the comprehensive plan originally submitted in February, 1967 (QV), available information indicates that the migrant population in San Joaquin County will represent a group at risk of approximately 3000 person-years, would require approximately 2100 days of inpatient care, if such care were readily available, and would cost approximately $100,000. Previous estimates of the cost of in-hospital medical care and the source of the local share of the cost of hospitalization are still valid.

Dr. GIANELLI. Now, just so you won't think that this is a one-man project, I would like to submit exhibits B and C. These are speeches delivered by the president of our county seat, Dr. John Morzumi, one delivered in Chandler, Ariz., and another in northern California.

Senator WILLIAMS. That is not in the material that you presented? Dr. GIANELLI. I will submit them. I didn't want to confuse you with all of the papers. I thought perhaps you would think we were trying to run competition to the Government, but in both reports a prominent position is given to our agricultural program and I will leave these with the secretary.

(The material referred to previously follows:)

WESTERN CONFERENCE ON FUTURE DIRECTIONS AND DECISIONS IN MEDICAL

CARE

(Comments from the San Joaquin County Medical Society, John Morzumi, M.D., President)

Public Law 89-749 has been the cause of a deep sense of urgency in the minds of the members of the San Joaquin County Medical Society. This feeling is as much borne out of what we don't know as what we do know and what our experience has been. I would like to take a few moments to outline what our experience has been in the few areas that are appropriate to the discussions of this conference.

REGIONAL HEALTH FACILITIES PLANNING

Our Medical Society became interested in the concept of regional health facilities planning in 1953. A local attempt had been made by our Hospital Council to organize a regional health facilities planning council and their grant application had been denied. It was during this period that the Medical Society recognized the need for regional planning and passed a resolution supporting the concept.

Upon a request from community leaders, the Medical Society loaned its staff and resources in an attempt to organize a regional health facilities planning council that would meet with the approval of the State Department of Public Health

and the U.S. Public Health Services. A six-county region was established and an application was drawn up and submitted. This application was ultimately approved, resulting in the establishment of the North San Joaquin Valley Regional Health Council. Our county society's executive secretary served as the initial executive director during this organizational period and until an adequate staff was secured.

Our involvement at the present time is as follows:

1. General support as a matter of policy.

2. Financial support.

3. Representation through individual physician members appointed to the local county committees and to the governing board.

We are strongly committed to the principle of voluntary planning and would be interested in seeing this type of program become more vital and virile under any new structure set up to qualify for Public Law 89-749.

Last month our county medical society joined with our County Board of Supervisors and with the North San Joaquin Valley Regional Health Council in adopting a joint resolution which issued a general call to the community for interest and involvement in the establishment of a regional program that would qualify under Public Law 89-749.

HEALTH PROFESSIONS TRAINING COUNCIL

The Medical Society, in cooperation with several other agencies, has long recognized the serious implications involved when there is an inadequate supply of para-medical personnel coupled with a rising demand for such services.

Because of this concern, the Medical Society organized, in April, 1966, the Health Professions Training Council in an attempt to evaluate and to promulgate ways to recruit and develop medical manpower to meet these needs. The Council is composed of representatives from education, hospitals, medicine, nursing, and employment. Membership in the Council is held by representatives of:

San Joaquin County Board of Supervisors.

San Joaquin County Hospital Council.

San Joaquin General Hospital.

Director of Nursing, San Joaquin General Hospital.

San Joaquin Delta College.

Division of Nursing, San Joaquin Delta College.

California State Department of Employment.

Stockton Unified School District.

District Nurses Association.

Visiting Nurses Association.

San Joaquin Local Health District.

Longterm Care Facilities Association.

San Joaquin Valley Regional Health Planning Council.
University of the Pacific.

San Joaquin Dental Society.

The purpose of the Council is to:

1. Obtain and synthesize data on the volume of jobs, their location, wage rates, personal and educational standards and relationships to job advancement and career opportunities.

2. Determine the need and supply of para-medical personnel and project this into the future.

3. Analyze the cost factors involved in school courses and facility clinical training under varying patterns of operation.

4. Explore the methods of teaching, length of training period and the effectiveness of various teaching aids.

5. Analyze the possibilities of career advancement training and design a system to implement such a program.

The first meeting of the Council was held in October of 1966. Since that time the Council has had several study projects before it and has made some recommendations that have led to meaningful programs. The medical profession has been surveyed to ascertain whether or not there was a need for a training course for medical assistants. A refresher course for R.N.'s was stimulated at our local junior college. A recommendation has been made that hopefully will help lead to the establishment of a bacalaureate program for nurses at the University of the Pacific. Upon the Council's recommendation, a nurses aid training program using M.D.T.A. funds was established in cooperation with the State Department of Employment. A survey of the local dental profession resulted in the presentation of a course at

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