Rural programs are particularly involved in questions which explore the recruitment, retention, and redistribution of providers of services; the provision of emergency services to remote areas, and communication linkages between widely scattered primary and secondary provider services. Environmental health measures and their influence on health outcomes also have high priority in rural areas.

The use of the health dollar for economic development and economic impact in poor communities is also being explored in a variety of programs.

Primary health care providers other than physicians, are being utilized in many urban and rural programs. Methods of selection and training are being evaluated. Questions which relate to the quality of services provided, patient acceptability, costs, and systems development are being explored and documented.

The OEO neighborhood health center programs differ in concept from the HEW programs in several fundamental areas. As the HEW programs generally explore questions relative to the minimal benefit package of medical care necessary in given communities, the OEO programs search for the optimum blend of health services necessary to satisfactorily solve questions about the relationship of health to poverty and vice versa. Consequently, aspects of manpower development aimed toward the utilization of the unskilled labor pool in low income areas are significant focuses of attention in the OEO programs. Another question which the OEO NHC programs uniquely address is that of the effect consumer praticipation, in varying degrees, upon costs, efficiency, accountability, and quality of health care. Other key differences include the HEW strong and almost exclusive emphasis on personal entitlements and elimination of financial barriers to health care as opposed to the OEO examinations of questions relating to organization of delivery services, alternative financing mechanisms and their relationship to cost and quality of care, identification of unmet needs, and alternative methods of responding to such needs. The exploration issues of public policy as it relates to the health care problems of the poor and broader investigation of the economics of health care to the poor.

Because of the role of OEO as a social research and development agency, varying approaches to solutions of old problems are necessary and necessitate broad involvement in systems of health care. This of necessity will occasionally lead to what are perceived as duplications of effort but are in reality complementary efforts in meeting the unmet needs of the poor in different locations.

MIGRANT HEALTH

Mr. CONTE. What is the nature of the new migrant health project that is being planned in collaboration with HEW?

Does your work in this area include the utilization of paramedical personnel? Do you find this to be a promising development in the medical field?

Dr. COOPER. The purpose of this research and demonstration project is to develop an integrated system of health care for migrant and seasonal farmworkers whose home base is in the vicinity of Belle Glade and Ft. Pierce, Fla.

Special features of this project are:

(A) The home-base program will incorporate a special capitation based finance system.

(B) A major portion of the project's efforts will be spent on the design and implementation of a system to provide for continuous upstream care to enrolled families.

(C) The instream system proposes to develop linked contractual relationships with a variety of providers-hospitals, health centers, health departments, private and group practitioners, et cetera-utilizing a common medical records systems, information system, and billing system as well as common standards of quality review. The program will develop a mechanism for communication with the entry point home-based operation.

The HEW/HSMHA Migrant Health Branch is participating in the development of this effort as is the local health department, RMP, medical society, and farmworkers' cooperative.

During its initial funding period, the project will develop a decentralized group practice model at the home base to deliver comprehensive family oriented health services to approximately 15,000 to 20,000 migrants and seasonal farmworkers. The two major primary care units will be located in Belle Glade and Ft. Pierce. The project will develop the needed referral and information systems which will be the basic systems to arrange for continuity of health services while the farmworkers are away from the home base.

The work program also anticipates the need to establish satellite units to the home base primary care units because of the dispersed service population even in the home base area. These satellite units, as they are phased into the program, will be staffed by nurse practitioners.

For the first 6 to 12 months, Florida Atlantic University, Palm Beach Fla., will act as the grantee for this project. The major responsibility within that period will be the organization and probable expansion of the Board of the Rural Improvement Council, Inc.-RIC. Specifically the board will develop board based support from the farmworker and health provider communities. It is anticipated that the Rural Improvement Council, Inc. will move to grantee status within 6 to 12 months following the award of the grant.

The project as noted will have two major responsibilities: organization of the home base system and developing the support systems which will provide for out of area coverage.

TRANSFERS TO HEW

Mr. CONTE. What programs under this heading do you plan to spin off to HEW this year?

Dr. COOPER. The Office of Health Affairs considered the transfer of programs which have limited flexibility for research and demonstration work and programs which were in an operational rather than developmental phase.

Projects which were seeing patients and which were primarily focused on the delivery of services and preoperational projects which seemed to be predominantly service oriented seemed appropriate for transfer.

Included by these criteria were the following projects: (1) East Palo Alto; (2) Houston; (3) San Antonio; (4) Charles Drew, New York; (5) Provident, New York; (6) Charleston, South Carolina; (7) Mile Square, Chicago; (8) Roxbury; (9) Boston City; (10) Luzerne County; (11) Pittsburgh; (12) Salt Lake City; and (13) Renton. The transfer of these projects is reflected in the fiscal year 1973 budget requests of OEO and HEW.

DRUG REHABILITATION

Mr. CONTE. Would you explain in greater detail your work in integrating drug rehabilitation with manpower training?

Dr. COOPER. One of the greatest obstacles in rehabilitating a drug dependent person lies in getting him a job after he has overcome his drug dependence. Recidivism is nearly 100 percent unless the ex-addict can embrace alternatives to his previous behavior. Other kinds of civil disabilities, for example inability to be bonded, inability to obtain driver's licenses, and so forth, compound the problem of helping the exaddict to find work. In addition, most addicts have some sort of previous history with a correctional institution.

At the present time, virtually the only avenue of employment readily available to the ex-addict is working in drug rehabilitation programs. While there is a recognized need for utilizing ex-addicts in rehabilitation programs, these programs obviously cannot employ all rehabilitated drug dependent persons. Further, all ex-addicts are not necessarily qualified nor are they interested in working in drug programs. Therefore, we have become involved in programs of manpower training and job development. Two major nationwide projects in Maryland and Louisiana are dealing with manpower efforts to break barriers in both public and private job sectors. Individual rehabilitation programs include job development and vocational counseling as programmatic elements to help meet this need of the rehabilitated addict.

FAMILY PLANNING EXPERIMENTS

Mr. CONTE. What are some of the new mechanisms for the delivery of family planning services that you are testing?

Dr. COOPER. The OEO Office of Health Affairs is currently funding the following special R. & D. delivery mechanisms:

1. Hospital based postpartum program.

2. Private physicians on a fee for service basis in rural areas.

3. Expansion of existing clinics to provide other related services such as nutrition and pediatrics.

4. New distribution channels for nonprescription contraceptives. 5. Referral and service centers for migrants while they are in stream. 6. Family planning nutrition sites for Indians.

7. Special information and education modules for teenage projects. 8. Statewide and metropolitan area coordinating councils.

9. Services for women and men in penal and mental institutions with followup when they are released.

10. Delivery of services through utilization of paramedical personnel.

FOOD STAMP PROGRAM

Mr. CONTE. What accounts for the continued requests for conversion from commodities to food stamps by the States and counties?

Dr. COOPER. Most counties perceive food stamps as a more advantageous program than food distribution for families for the following

reasons:

(a) Benefits to local government: Food stamps has a more favorable cost-sharing ratio the administrative costs to the local jurisdictions are lower. Food stamps generate revenue in the form of sales tax on the increased quantity of food sales.

(b) Benefits to local economy: Food stamps increase sales in grocery stores, increasing profits, allowing some additional employment. Food stamps provides some local administrative jobs, by virtue of the more favorable Federal cost share. Food stamps helps in the local economies by injecting money which "turns over" numerous times.

(c) Benefits for the poor: Though it is difficult to compare benefit levels, food stamps provides a higher benefit package. Food stamps gives participants the opportunity to choose what food to buy.

Mr. CONTE. Do you expect the commodities program will eventually be phased out in favor of the food stamp program?

Dr. COOPER. It can be expected that most counties will choose the food stamp program over the food distribution for families. However it can also be expected that food distribution for institutions will be a growing program.

LEGAL SERVICES PROGRAM

Mr. CONTE. In this month's issue of the American Bar Association Journal, Vice President Agnew asserts that the legal services program has had "little or no central direction and no firmly established policies and procedures." He also indicates that too often the program sacrifices the needs of individual clients to the personal ambitions of attorneys to perform "social engineering on a grand scale." How would you respond to these allegations?

Mr. TETZLAFF. With respect to central direction, policies and procedures, the Office of Legal Services has, over the past year, established methods of attaining effective and responsible program administration. This has been accomplished primarily through improved reporting systems for program activity and statistical data, thorough evaluations of funded programs utilizing independent management consulting firms, extensive monitoring of these programs by our firms, extensive monitoring of these programs by our regional offices on a year-round basis, and enforcement of the many OEO instructions which regulate program and personal activity of funded agencies.

It must be understood that central direction is severely limited by two important factors: First, local boards of directors are responsible for administering the programs, and the priorities which must be set for each program are set by these communities and must be based on their different needs. Second, as President Nixon has stated unequivocally, there can be no restrictions placed on the types of cases handled by the local programs which are not imposed by Congress.

The second assertion, relating to social engineering, refers to the possibility of attorneys pursuing their own personal agendas rather

than truly representing their client's legal interests in a highly professional manner. The policy of the Office of Legal Services is clearly that the wishes and interests of the client are paramount and that poverty lawyers must represent these interests in an ethical and professional manner. Most of the cases handled are settled, often at the expense of a precedent-setting case. In one recent case against a utility company for shutting off heat in a client's home in the dead of winter without notice, this charge was made against the young attorney handling the case, that is, that he was seeking to make a big case out of one that may not have been what the client wished. The attorney's response was that it was a big case that would in fact set an important precedent, but that he had previously settled over 80 similar cases because he was able to do so and believed it was in the best interests of his clients. The only reason he did not settle this one was that the utility company flatly refused to negotiate any settlement.

Mr. CONTE. Mr. Agnew also charges that most programs now turn away individual poor clients with routine legal problems. Have you any statistics indicating the number of cases handled and clients served during the past year?

Mr. TETZLAFF. During fiscal year 1972 we estimate that OLS programs handled nearly 1.2 million legal problems. A random sampling of 15 programs showed the following cases handled by them during the past year: Consumer and employment 9,215; administrative 6,467; housing 7,605; family problems 20,903; miscellaneous 15,512. These and other statistics indicate that the typical or general breakdown of legal services caseloads is as follows: Consumer and employment, 18 percent; administrative, 9 percent; housing, 11 percent; family problems, 42 percent and miscellaneous 20 percent.

Programs that do not immediately service individual poor clients with routine legal problems must do so because of the inadequacy of their resources to meet the demand for legal services. However, only a relatively few programs have instituted systems of caseload control, recognizing their professional obligation to perform at an adequate level and provide the maximum service that can be provided in a given day. Systems of caseload limitation do not "turn away" clients, they instead handle the most acute problems first, and persons with nonemergency types of cases are put on waiting lists. An example of the former is an eviction, which is handled immediately; the latter would include a change of name or a divorce if there are no plans for remarriage, fear of bodily harm or requirement for welfare purposes. Mr. CONTE. What steps are you taking to involve the private bar in the delivery of legal services to the poor? How cooperative has the private bar been in this effort?

Mr. TETZLAFF. Virtually all programs have a certain number of seats on their governing boards allocated to appointees of the local bar association. Local programs are expected to make the greatest possible use of members of the private bar in serving the poor. OEO programs are required to raise 20 percent of the program costs from the local community. Most of this "non-Federal share" for legal services programs is provided in volunteered services donated by private attorneys. In general, the private bar has been extremely helpful and the Office of Legal Services plans to experiment with new ways of