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II. GRANTS Access To Care Some 30 million Americans are without health insurance. The demographics of these people are dim-se -some are working, some are temporarily unemployed, some are destitute--and their ranks continue to grow as the service industry burgeons and as competition in health care increases. Foundation funding in this area ranges from economic analyses of the reasons for the problem to the direct provision of care. National

Programs:

Program. This program supports state and local initiatives that improve accessto a broad range of health care and community services for the chronically mentally ill. Recent grants will address their diverse needs, such as appropriate medical and mental health care, suitable housing, and employment.

Mental Health Services Development

$10 million for four years. Funded by The Robert Wood Johnson Foundation.

Selected grants: Los Angeles Men’s Place. $600,000 for forty-eight months to provide around-the-clock mental health services for as many as 500 chronically mentally ill persons. Vermont

Department

of Mental Health, Waterbury,

VT. $600,000

for twenty-four months to provide support for the completion of a statewide system of integrated community services and housing for the chronically mentally ill. Funds will also assistin the development of new short-term inpatient and emergency servicesin community hospitals. Communitywide Health

Programs:

Care in Cook County

Grant Program.

This initiative

assists

organizations concerned with providing health care to the underserved populations of Cook County, Illinois. $10 million for five years. Funded by The Chicago Community Trust.

Selected grants: Mercy Hospital and Medical Center, Chicago, IL. $896,167 for three

years on behalf of Project Alivio, to plan and implement an integrated, comprehensive health care system serving the needs of Hispanic residents in Pilsen, Little Village, and Back of the Yards. University

of Illinois at Chicago. $265,000 for three years for a School

of Public Health study on maternal and child health in the Austin, Near East Side, and West Garfield Park areas.

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Grant Awards:

The Boston Committee on Access to Health Care. This grant will support the prenatal accessgroup, which is focusing on removing financial barriers to early, comprehensive prenatal and delivery care for Boston’s uninsured and underinsured pregnant women, and Healthline, a multilingual health information and advocacy service. The committee is a thirty-five-member task force representing providers, payers, business,government, and consumers. $155,000 for one year. Funded by The Boston Foundation. Denver

Department

of Social Services. Funds will support the city’s

efforts to prevent homeless persons from being continuously recycled through the temporary shelter system and to help ensure their transition to a stable living environment. $230,890 Northwest

forthree years. Funded by The Colorado Center, Philadelphia,

Trust.

PA. This grant will support the re-

search and evaluation component-of the center’s project to provide community-based services to the city’s deinstitutionalized mentally ill and retarded persons. $148,000 for eighteenmonths. Funded

The Pew Charitable Trusts.

of California, San Francisco. This grant will help the university identify local underserved populations, pinpoint the causesof their lack of access,and determine how they can be linked to the health delivery systems. Assessingprograms. for infants and pregnant women will be emphasized.

University

$867,539 for three years. Funded by the W. K. Kellogg Foundation. Health Care For The Elderly By the year 2000, 20 percent of the American population will be over sixty-five. Planning for the financing and humane provision 0f medical and social servicesfor this group is becoming an urgent task for both the public and private sectors. Foundations are devoting resourcesto all aspects of the challenge-from medical research of patient functioning to the creation of innwative home health care organizations and other subacute facilities. National

Programs:

Dementia Care and Respite Services Program. This program, cofunded by the Alzheimer’s Disease and Related Disorders Association

(ADRDA) and the federal Administration on Aging (AoA), will support as many as twenty-five adult day care programs. The goal is to demonstrate that financially viable, comprehensive day care servicescan

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be provided for people with dementia resulting from Alzheimer’s, Parkinson’s, Pick’s, and Huntington’s diseases.Individual projects will be funded on a declining basis to encourage self-sufficiency over time. $7.5 million. $6.25 million funded by The Robert Wood Johnson Foundation with $625,000 each from ADRDA and AoA. Individual

Grant Awards:

United Hospital Fund, New York, NY. This grant will be used to study the patterns of health care sought and received by New York City’s Medicare recipients and to determine how changes in the health care system have influenced quality of, accessto, and cost of care. $255,000 for three years. Funded by the Josiah Macy, Jr. Foundation. Health Professions Education How health professionals are trained is one of the most important building blocks in effective health care delivery. Traditional medical school curricula are under examination as research shows that more attention should be devoted to areas such as the humanities, peventive medicine, and general practice. In addition, increasing the number of minorities in the health professions has received renewed attention. Foundations are encouraging thesechanges. National

Programs:

The Commonwealth

Fund Executive

Nursing

Fellowship

Program.

This program was established to help strengthen the management skills of nurses so that they may participate more effectively in the broader strategic decisions affecting hospitals. This present grant provides up to fifteen fellowships of $25,000 each for full-time study leading to a master’s or doctoral degree from a graduate school of business of the recipient’s choice. $492,000

forone year. Funded by The Commonwealth

Pew National

Veterinary

Education

Program,

Fund. Phase II. This program

is designed to promote excellence in veterinary education. Veterinary medicine contributes directly to human health by controlling diseases passedfrom animals to humans, by assuring the wholesomeness of foods of animal origin, and by improving our knowledge about medical science through research of human diseases on animal models. Phase II will support a leadership training seminar that includes strategic planning. $5.5 million for four years. Funded by The Pew Charitable Trusts. Individual

Grant Awards:

American

College of Physicians,

Philadelphia,

PA. Funds will support

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the development of a Society for General Internal Medicine (SGIM) substance abuse training program to provide the skills necessaryto care for substance abusers, and to teach residents and students about the diagnosis and management of such cases. $70,000 forthree years. Fundedby The PewCharitable Trusts. Development Center, Inc., Newton, MA. This grant will support Project EPIC (Educating Professionals in Injury Control), which will work closely with administrators and faculty in nursing, medical, and public health schools to find the most effective way of incorporating the science of injury control into existing courses.

Education

$400,000 for fouryears.Funded by The Pew Charitable Trusts. University, Baltimore, MD. This grant will support the pilot phase of a Johns Hopkins University/Dunbar High School health professions partnership to improve the quality of the prehealth applicant pool among Baltimore’s disadvantaged minority students. The Johns Hopkins

$125,000 for one year. Funded by The Henry J. Kaiser Family Foundation. Academy of Medicine, New York, NY. This grant will support the development of the National Seminar on Medical Education to assesscurrent developments in the structure and financing of medical education, examine the relationship between diverse health care settings and physicians’ education, and explore new options.

New York

$271,400 for sixteenmonths. Funded by thefosiah Macy, Jr. Foundation. Foundation, Inc., New York, NY. Funding will support a program of six Anglo-American-Canadian conferences on comparative issuesin medical education and health care policy.

Royal Society of Medicine

$210,000 for three years. Funded by the Josiah Macy, Jr. Foundation. University

of Rochester School of Medicine

and Dentistry,

Rochester,

NY. Funding will assist the university in developing a program of electives that introduces first- and second-year nursing students to the medical needs of the elderly and to issues in maternal and child health. $48,000 for three years. Funded by the Josiah Macy, Jr. Foundation. Health Promotion

And Disease Prevention

Research continues to document the effect that diet, exercise, and lifestyle have on health status. Preventable illness and injury claim wer a million American lives each year, costing society more than $455 billion in 1980. As these huge costs become apparent, promoting healthy behavior has become a primary concern of many foundations.

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HEALTH AFFAIRS I Fall 1987

Multifoundation

Efforts:

Program. The goal of this program is to ameliorate, through community projects, five serious health problems facing the United States: heart disease, cancer, drug and alcohol abuse, teenage pregnancy, and injuries.

Health Promotion

$20 million over ten years. $15 million from The Henry J. Kaiser Family Foundation and $5 million fromThe Colorado Trust, The J. M. Foundation, The Robert Wood JohnsonFoundation,The Ruth Mott Fund, The PewCharitable Trusts, The San Francisco Foundation, and The Stuart Foundation.

Recent grant: Stanford University, Palo Alto, CA. $3,302,650 for three years for activities of the Health Promotion Research Center, which provides expert services for communities that received funding from the Health Promotion Program. The center also provides consultation, technical assistance, training, program manuals, and mass-media materials for health promotion activities in other western communities. Individual

Grant Awards:

Funds will support the development of a permanent exhibit on health promotion for children. The exhibit is aimed at motivating youth to adopt healthy lifestyles by focusing on social, emotional, and behavioral growth and development. $900,000forthree years. Funded by the W.K. Kellogg Foundation. Denver Museum of Natural History. This grant will support the Hall of Life, a new project that will include exhibits and educational programs that teach how the body functions, motivate positive health choices, and emphasize the role of personal responsibility in health and physical fitness. The Chicago Museum of Science and Industry.

$1,676,000

fortwo years. Funded by The Colorado

Trust.

Food and Nutrition Board, National Academy of Sciences, Washing ton, DC. This grant will support an expert committee’s efforts to develop

detailed strategies for the implementation of national dietary guidelines. $688,441 fin- two years. Funded by The Henry J. Kaiser Family Foundation. Harvard School of Public Health, Cambridge, MA. Funds will help the school’s Center for Health Communications review current literature on adolescent substance abuse risk-taking behavior and to study the use of mass media in influencing adolescent behavior. $250,000for two years. Funded by The Pew Charitable Trusts. Preventive Medicine Research Institute, San Francisco, CA. Funds will support the Coronary Artery Atherosclerosis Reversibility Project, which is attempting to demonstrate the effectiveness of a lowfat diet on

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the reversibility of coronary atherosclerosis. $314,405 for eighteenmonths. Funded by The Henry J. Kaiser Family Foundation. School of Medicine, Detroit, MI, Funding will aid in the development of a model nutrition and health promotion program for the middle-aged and elderly populations of Detroit.

The Wayne State University

$968,666 for three years. Funded by the WK. Kellogg Foundation. Yale University,

New Haven, CT. University

investigators will analyze

the controversy between public health professionals and traditional biomedical researchers over the results of community-based health promotion programs. The aim is to create a new methodology for assessingthe accomplishments in health promotion and diseaseprevention. $173,739 for three years. Funded by The Henry J. Kaiser Family Foundation. Information

Dissemination

One of the most common themesrunning through health policy discussionstoday is change. Tracking and understanding the dynamics of the health sphere has become an imposing challenge to anyone involved in the policy process. Data are frag mented,federalpolicies are confusing and continually revised,and innovation in the businesscommunity is occurring ata hectic pace. Foundations have funded several organizationsthat are attempting to gather and disseminateinformation in a useful, efficient, and timely manner. Fund for the City of New York. This grant will support the establish-

ment of an independent, private-sector commission on acquired immunodeficiency syndrome (AIDS) to increase public understanding of the steps necessaryto respond to the growing epidemic. $100,046 for 1.5 years. Funded by The Robert Wood Johnson Foundation. Conference of State Legislatures (NCSL), Denver, CO. Funding will support the efforts of the NCSL to inform state legislators and their staffs about adolescent pregnancy and parenting. Efforts will include a program at the annual conference and the maintenance of a clearinghouse. $198,000for two years. Funded by the Ford Foundation. National

International

Health

The health problems facing less developedcountries are overwhelming. High birth rates, poor maternal and child nutrition, vector- and waterborne diseases,and now acquired immunodeficiency sydrome (AIDS) have taken a large toll, especially on

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HEALTH AFFAIRS I Fall 1987

infants and children.The child survival strategiesof oral rehydrationtherapy and immunization havebecome major priorities in federal funding. Foundationshave funded severalorganizations promoting continuing medical education, tropical diseaseresearchand control,family planning, and nutrition. Individual

Grant Awards:

University, Ithaca, NY. This grant will assist in the development of a study of interleukin 1 and other regulators of the immune response in the pathogenesis of trachoma, a leading cause of blindness, in lessdeveloped countries. $200,000 for three years. Fundedby The Edna McConnell Clark Foundation. International Rescue Committee, Inc., New York, NY. This grant will support a health education training program for Ethiopian refugees in eastern Sudan. The project will strengthen skills in maternal and child health, sanitation, and health care. Cornell

$200,000 for two years. Funded by The Pew Charitable Trusts. University, Baltimore, MD. The university will use these funds to organize a task force to coordinate and assessresearch activities in trachoma.

The Johns Hopkins

$98,000 for two years. Funded by The Edna McConnell Clark Foundation. National Postgraduate Medical College, Nigeria. The grant provides supplemental support for the major physician training program in primary health care and community-oriented medicine. $150,000 for two years. Funded by the Ford Foundation.

Vanderbilt University, Nashville, TN. Funds will help Vanderbilt set up a task force to oversee and coordinate research efforts of vaccine development for the waterborne diseaseschistosomiasis. $300,000 for threeyears. Funded by The Edna McConnell Clark Foundation. Maternal+ Child, And Adolescent Health In the past thirty years, the United States’ infant mortality ranking among the twenty most industrialized nations has dropped from sixth to nineteenth. Morbidity, especially complications from low birthweight, is also a problem. Teen pregnancy, poor nutrition, and reduced access to health care among the poor have been suggestedas causesfor thesestatistics. Addressing the specific needsof mothers and children, and the health needsof adolescentsin general, has becomea top priority for several foundations. National

Programs:

Healthy Futures Program. This program aims to help southern states in

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the reduction of infant mortality by improving care to infants and pregnant women. It will encourage states to coordinate their systems of perinatal care to ensure adequate care, and to strengthen the capacity of key front-line health care services to provide outreach, risk assessment, casemanagement, and other social and medical services.As many as five four-year grants of up to $1.2 million will be awarded. $6 million for four years. Funded by The Robert Wood Johnson Foundation. School-Based Adolescent Health Care Program. This program provides

start-up and implementation grants to public secondary schools for the establishment of comprehensive school-based clinics. Each clinic will provide services for substance abuse, pregnancy, sports injury, depression, and illnesses.Some programs may provide infant day care services. Ten recent grants have been made to high schools in Alabama, California, Louisiana,‘Michigan, and Minnesota. $16.8 million for two- and four-year grants. Funded by The Robert Wood Johnson

Foundation. Individual

Grant Awards:

of Junior Leagues, Inc., New York, NY. Funding will support the, dissemination of-results of the Teen Outreach Program (TOP), which was initiated by The Junior League of St. Louis in 1978. This school-based program is designed to prevent teen pregnancy and encourage students to stay in school. Association

$195,000 for three years. Funded by the Charles Stewart Mott Foundation. of Health and Hospitals. This grant will support an effectiveness evaluation of a community-based violence prevention project for high-risk youth. The goal is to change community attitudes toward violence and to reduce the incidence of violent behavior and associated injuries. The evalution will measure program effectiveness in South Boston and Roxbury. $359,720 overthreeyears. Funded by The Henry J. Kaiser Family Foundation.

Boston Department

Healthy Child Program, Boston, MA. This program’s goal is to prevent and treat major health and psychosocial problems of children raised in poverty. $150,000 for one year. Funded by The BostonFoundation. University; Baltimore, MD. This grant will supplement previous grants to allow for additional analysis of data from clients of a family planning clinic located near a Baltimore junior and senior high school.

The Johns Hopkins

$120,000 for fourteen months. Funded by the Ford Foundation.

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HEALTH AFFAIRS I Fall 1987

Project LIFE (Lowering

Infant

Fatality through

Education),

Boston,

MA. This grant will be used for a peer support project in Mission Hill, an area with a high infant mortality rate. Local women will be trained to locate pregnant women in the neighborhood, refer them to existing medical and counseling services, and provide support during birth and the postnatal period. $170,000for oneyear. Fundedby The Boston Foundation. Medical Practice (Quality,

Outcome, And Variation)

The high cost of care and society’s changing health care needs have stimulated a great deal of innovation. However, along with this experimentation has come uncertainty about the effects of the changes on the quality and outcome of medical services. Foundations are funding extensive research projects to determine what constitutes good care and how it can be achieved and sustained. Individual

Grant Awards:

This grant to the university’s Florence Heller Graduate School for Advanced Studies in Social Welfare will assist in strengthening the management of the prototype social health maintenance organization (SHMO). The SHMO incorporates long-term care for the elderly into a prepaid health care system. Brandeis

University,

Waltham,

MA.

$355,368 for one year. Funded by The Robert Wood Johnson Foundation. Columbia

University,

New York, NY. This grant will enable research-

ers to monitor the impact of health care changes on New York, Chicago, Los Angeles, and Houston. The study will examine the surplus of acute care beds, the popularity of alternative forms of delivery, problems of uncompensated care, and physician surplus. $304,650for three years. Funded by The Robert Wood Johnson Foundation. Harvard Community Health Plan, Brookline Village, MA. This grant will support a national demonstration project on industrial quality control and health care quality. $218,071for eighteenmonths. Fundedby The John A. Hartford Foundation. Institute of Medicine, Washington, DC. The institute will plan and host an invitational conference on recent advances in health status and quality-of-life measurement and applications. $149,500 for twenty months. Funded by The Henry J. Kaiser Family Foundation. Rochester Area Hospitals Corporation, Rochester, NY. Funding will support the development and evaluation of severity-adjusted outcome measures in assessingthe quality of care. $628,881 for three years. Funded by The John A. Hartford Foundation.

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III. OUTCOMES Program Changes:

The Colorado Trust has recently announced a new funding area, the Rural Health Care Initiative. The general purpose of this initiative is to help clusters of rural communities to develop high-quality, locally accessible regional health systems. Models proposed for development and implementation under the initiative must address three specific aspects of health care in rural Colorado: regionalization, system development, and quality of care. Fund has recently approved funding of up to $600,000 forth e d eve1opment of the first composite intervention methodology designed to increase patients’ participation in their medical care. The program is based on the assumption that patients often accept passive, uninformed roles that may result in anxiety and can interfere with recovery. Phase one will consist of development of the intervention plan. Phase two will test aspects of the intervention on patients in different clinical conditions, and phase three will consist of the publication and dissemination of the results. This program was stimulated by consolidation of the JamesPicker Foundation with The Commonwealth Fund in 1986.

The Commonwealth

The Charles A. Dana Foundation

has reshaped its funding into the

following four areas: The neurosciences. Multidisciplinary programs at major academic medical centers will focus on linking basic research to clinical training, practice, and prevention. Funding centers on the training of clinician investigators. Aging. The goal of this program is to attract and train young clinicians to be geriatric investigators, with research focused on the aging syndromes that result in long-term disability and increased acute and long term hospitalization. Clinical epidemiology. Collaboration among Dana Foundation granteesand other research and training programs in clinical epidemiology in the United States and Canada is encouraged. Environmental health science. This program focuses on ways in which current and past grantees might collaborate to achieve common goals. Such goals include effective teaching of environmental issues in medical schools and the training of physicians in the disciplines needed to make headway against environmental health hazards. Grant Outcomes: Boston

at Risk. In response to the need for developing policies and

134. HEALTH AFFAIRS I Fall 1987 programs that increase primary care accessfor the poor, The Boston Foundation launched a two-year seminar focusing on public- and private-sector issuesrelated to access,quality, and cost of primary care. The seminar involved health policy analysts and a cross-disciplinary group of representatives from academic health centers, businesses,and government. At the same time, the foundation awarded a grant to a special task force to develop a comprehensive report on primary care problems in Boston. Bostonat Risk, published in September 1985, identified high-risk populations, reviewed the available data on accessand on insurance, and recommended policy initiatives. The key finding, that over half of the uninsured were employed, led to the establishment of a Governor’s Commission on the Uninsurance Problem in Massachusetts, as the report recommended. It also provided data for many groups developing responsesto the problem of the uninsured. Several of the report’s other recommendations were implemented as well. Efforts were made to strengthen Boston’s provider organizations, such as Boston City Hospital and neighborhood health centers, through the development of a capitated reimbursement plan that usesthe local providers in an HMO capacity. Developed in a collaborative effort between The Robert Wood Johnson Foundation and The Boston Foundation, giving $450,000 and $150,000, respectively, this system uses six to eight neighborhood health centers. This number is expected to increase to twenty-seven. In addition, a number of local health organizations established a data-monitoring system of high-risk populations. Boston Foundation contributions totaled $121,000 for two years, including $35,000 to implement the recommendations. Though Boston-related, this report has been used across the U.S. as a model for community response to health service delivery for the poor and continues to be cited in studies on accessand primary care. In the past year, local community groups, the Access Committee of the City of Boston, and state legislative committees have used the report in their planning and decision making. Contact The Boston Foundation, 60 State Street,Boston,MA 02 109. For A Cleaner Environment

(FACE), Woburn,

MA. Following years of

effort to determine possible links between toxic waste in the community and high incidence of leukemia and cancer, the citizens of Woburn formed FACE. Previous soil and water studies had uncovered high concentrations of arsenic, lead, and chromium in surface and subterranean lagoons but had failed to find any correlation between the toxic contamination and the residents’ diseases. The findings were alarming enough, however, for FACE to team up with the Harvard School of Public Health to perform what is believed to be the nation’s first comprehensive, citywide investigation of possible links between environmental contamination and community health. Using a $13,000 grant from the

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Charles Stewart Mott Foundation, 35,000 Woburn residents were surveyed by 300 FACE volunteers trained by Harvard staff. This early collaboration led to numerous other activities. Through its work with FACE, Harvard developed a ten-week seminar series covering such topics asecology, toxins, health and environmental laws, and community education and organizing. Recent funding from Mott has led to the development and dissemination of twenty videotapes based on that curriculum. Recognizing the importance of such community and university collaborations, the Mott Foundation has granted nearly $150,000 to Harvard in the last three years to provide New England communities with similar assistance. General support of $30,000 from the Mott Foundation over the last two years has allowed FACE to implement a citywide hazardous waste collection program, assist other communities facing environmental health problems, monitor the ongoing cleanup of two Superfund sites in Woburn, and continue to disseminate the findings of the Harvard health study. Following the success of the HarvardWoburn activities, the Mott Foundation--has made grants to a cluster of projects around the country that encourage university participation in community toxic problems. A network of nine regional assistancecenters has been funded. Contact the Charles Stewart Mott Foundation, 1200 Mott Foundation Building, Flint, MI 48502-1851. Publications: to the Community is a new report from The Commonwealth Fund Task Force on Academic Health Centers. The task force examined the economic impact of thirty medical schools in nine cities: Baltimore, Boston, Chicago, Denver, Houston, Los Angeles, New York, Philadelphia, and St. Louis. In 1984, expenditures of teaching hospitals in these cities accounted for close to half of all hospital expenditures$12.5 billion of the $25.5 billion total.. In addition to direct expenditures, the centers’ biomedical research activities channeled another $2.3 billion into these communities-fully a third of the $6.8 billion spent on research nationwide by the National Institutes of Health research and other noncorporate institutions. The task force also found that academic health centers are major ernployers in each of the nine cities. Another part of the report examines the diversity of relationships between academic health centers and community economic development organizations and service agencies. Eight case studies document the causes of community conflicts between the centers and neighborhood groups and describe the building blocks of the successful partnerships that have been formed. Contact The Commonwealth Fund, HarknessHouse,One East Contributing

75th Street, New York, NY 1002 l-2692. Risky Business: An Examination

of TEFRA

Risk HMOs and Their Con-

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HEALTH AFFAIRS I Fall 1987

tracting Experience presents information

from InterStudy’s survey regarding the Medicare health maintenance organization (HMO) riskcontracting experience. According to the Minnesota-based health policy research firm, many Medicare HMOs are dissatisfied with risk-contracting programs and indicate they may terminate their contracts if current policies are not changed. Based on a survey of forty-one large, experienced plans in the spring of 1987, Risky Businessidentifies two significant issues related to a plan’s reported financial experience: the perceived adequacy of reimbursement rates and hospital days per thousand. Additional findings show that 56 percent of the plans felt unfavorable financial experience was primarily due to inadequate capitation rates; 29 percent reported that adverse selection hindered their success;and 27 percent noted difficulties with the Health Care Financing Administration. The book discusses the implications of the findings and offers recommendations. Research was sponsored by The John A. Hartford Foundation and The Pew Charitable Trusts. Contact InterStudy, 5715 Christmas Lake Road, P.O. Box 458, Excelsior,MN 55331-0458. Key Personnel Changes:

Robert J. Blendon, senior vice-president of The Robert Wood Johnson Foundation, has left his position to become chairman of the Department of Health Policy and Management at the Harvard University School of Public Health. John R. Evans, president of Allelix, Inc., a Canadian pharmaceutical company, has been named chairman of the Board of Trustees of The Rockefeller Foundation. Evans, who was formerly an officer for the World Bank and president of the University of Toronto, replaces Clifton R. Wharton, Jr., who is retiring from the Rockefeller board after seventeen years of service. Thomas H. Meikle, Jr., dean of the Cornell University Medical College, has been named as president of the Josiah Macy, Jr. Foundation. Meikle succeedsJames G. Hirsch, who served from January 1981 to May 1987.