8-Most of North Carolina; parts of eastern Tennessee, eastern 16-Most of Wisconsin; parts of Illinois and Michigan. 17 -The Chicago area; the northwestern part of Indiana. 18-Minnesota; most of North Dakota; the eastern half of South 20-Most of Oklahoma; most of the eastern half of Texas- 21-Most of Missouri; most of the southern half of Illinois; parts 22-Most of Kansas; part of western Missouri.. 24-Colorado and Utah; all of Montana except one county; most 26-The southern part of California; one county of Nevada.. 27-The Central and northern parts of California; the western part of Nevada; Hawaii and the Philippines.. 28-Washington, Oregon, and Alaska; most of Idaho; one county (V) REGIONALIZATION OF VA MEDICAL RESOURCES MISSION The Veterans' Administration Department of Medicine and Surgery functions to provide complete medical and hospital service for the care and treatment of veterans. Secondary and supporting missions include education and training of health care personnel to assist in providing an adequate supply of health manpower for the Nation, and medical research to advance the health care of veterans. VA MEDICAL CARE SYSTEM The magnitude and geographic dispersion of VA health care resources provides favorable conditions for organization on a regional basis. The VA system is the largest centrally directed health care system in the Nation, comprising 171 hospitals each of which also operate outpatient services, 42 additional outpatient clinics, 86 nursing homes and 18 domiciliaries. These facilities are staffed with over 173,300 employees. In fiscal year 1975, this system provided care for 1,220,107 inpatients. Outpatient medical services provided by VA staff at VA facilities during fiscal year 1976, is expected to exceed 14,200,000 visits. Veterans are also provided care in non-VA hospitals, community nursing homes, and from community physicians and dentists under VA auspices. In addition, VA provides financial assistance for construction of facilities and for the care of veterans to 31 States which operate a total of 8 hospitals, 31 nursing homes, and 36 domiciliaries. The geographic dispersion of VA health care facilities generally parallels the Nation's population distribution. There are one or more hospitals in each of the contiguous States and in the Commonwealth of Puerto Rico. In Hawaii and Alaska, the VA operates outpatient facilities and provides for hospitalization under contract with non-VA institutions. VA REGIONALIZATION CONCEPT The primary objective of regionalization in the VA health care system is to improve patient care through maximum effective, efficient and economical use of available resources. Paramount in the organization design is the consideration of providing ready access to the required multitudinous resources of a complete health care system. The patient may enter the system through any VA health care facility and is provided easy access to any resources required for his diagnosis and treatment. Specialized medical services of high quality cannot be provided by every facility; however, these are usually available within the medical district organization and can be provided through a simplified referral method. Referrals are also made when unique services are required that are not available within the medical district. The (1) regionalization concept also facilitates the flow of specialized consultative services among health care facilities and thereby obviating the need for referral of the patient. Other advantages of regionalization relating to improved patient care are that it facilitates accurate and rapid collection and transmission of timely information within a medical district for management of medical care resources. It also enhances programs for quality of care by being more responsive to findings and recommendations of systematic internal and external reviews which are part of quality assurance of the VA Health Services Review Organization (HŜRO). A secondary objective of regionalization is improved utilization of VA and community health resources and facilities. The wide variety of facilities available within a medical district can be effectively utilized to provide the appropriate type and level of care required by the individual patient. This makes possible a more timely delivery of health services, faster pace of care, decreased length of stay, better bed occupancy rates and appropriate placement to meet levels of care for patients' needs. It also avoids duplication of specialized equipment, facilities, and personnel. Regionalization permits expanded use of community resources and sharing of VA resources with community institutions since the broader needs and resources of the medical district tend to justify contractual agreements for sharing or mutual use of facilities which may not be justified otherwise. This is also true of arrangements for the exchange of medical information, health education, education and training programs, teaching aids, and research. The medical district structure has been developed using the "grassroots" approach. Each health care facility has been identified through veteran utilization data with a primary service area (PSA) which recognizes not only distance but other factors such as transportation services and normal commuting patterns distinctive of an area. PSA boundaries do not split counties. The facility serves as the normal point of entry into the VA health care system for veterans residing in the area. These facilities, with their assigned primary service area, are grouped into medical districts so that each such district has a variety of facilities and resources to accommodate all but the most highly specialized and unique medical needs. The needs for these services, such as, organ transplantation, stereotaxic surgery, blind rehabilitation and care of spinal cord injuries, may require referral beyond a medical district. A logical grouping of health care facilities and their primary service areas determine the medical district boundaries. Although the above defining criteria bear no direct relationship to State boundaries, the districts may be related to the many health services areas, State economic areas, or standard metropolitan statistical areas which they each encompass. Regionalization of medical resources in the VA has been designed to recognize and preserve the unique and innovative contributions which individual health care facilities, in conjunction with affiliated institutions, make to the strength of the VA health care program. Through joint planning and development, the interchange of skills and ideas, and mutual utilization of services, these strengths can be utilized in the best interest of our patients and promote maximum effectiveness of the system. Regionalization is to be a mechanism to improve the delivery of a broad scope and high quality of services to veteran beneficiaries; and to link health care facilities of a medical district into a functioning organization to achieve this objective. The identity and integrity of each health care facility is not intended to change as a result of regionalization, although the mission of some facilities may require modification to take advantage of particular strengths or location for the benefit of the medical district. Cooperation of individuals responsible for administrative and professional aspects of health care facilities in a geographic area is essential for firmness of commitment to add to the scope and integration of services. AUTHORIZING LEGISLATION Legislative measures have been enacted during the last decade which gave health care regionalization national recognition. A major impetus occurred with Public Law 89-239 passed in 1965 which, through grants, encouraged and assisted in the establishment of regional cooperative arrangements among medical schools, research institutions, and hospitals for research and training (including continued education). It also authorized grants for demonstrations of patient care in the fields of heart disease, cancer, stroke and related diseases. This Act made available to the medical community the latest advances in diagnosis and treatment of patients with these diseases through the establishment and operation of regional medical programs. In 1966, Public Law 89-749, was passed authorizing comprehensive health planning organizations, depending on an effective partnership, involving close intergovernmental collaboration and participation of individuals and organizations to assure comprehensive health services of high quality. Public Law 91-515 amended and extended the original regional medical programs and comprehensive health planning legislation. Under those amendments, the Chief Medical Director sat ex-officio on the National Advisory Council of the Regional Medical Programs Service. Each regional medical program was to include a representative for local VA hospitals on its Regional Advisory Group. Similarly, State comprehensive health planning agencies with VA hospitals located therein, were called upon to include VA representatives on their councils. The Veterans' Hospitalization and Medical Services Modernization Amendments of 1966, Public Law 89-785, assisted the Department of Medicine and Surgery in its mission of training and education of health service personnel acting in cooperation with other institutions and organizations. Called the "sharing law," it also provided that selected, specialized VA medical resources might be made available to community institutions as an alternative to the expense of duplicating them. This is to be accomplished with no diminution of services to veterans. Public Law 93-641, the National Health Planning and Resources Development Act of 1974, recognizes the role of the VA in health care nationally and regionally with involvement of the VA required at three of the five tiers of operation. The purposes of this law are threefold: First, facilitate the development of recommendations for national health planning; second, promote the development |