xt77pv6b3w4m https://exploreuk.uky.edu/dips/xt77pv6b3w4m/data/mets.xml The Frontier Nursing Service, Inc. 1973 1974 bulletins  English The Frontier Nursing Service, Inc. Contact the Special Collections Research Center for information regarding rights and use of this collection. Frontier Nursing Service Quarterly Bulletins Frontier Nursing Service Quarterly Bulletin, Vol. 49, No. 2 and 3, Autumn 1973 and Winter 1974 text Frontier Nursing Service Quarterly Bulletin, Vol. 49, No. 2 and 3, Autumn 1973 and Winter 1974 1973 2014 true xt77pv6b3w4m section xt77pv6b3w4m Jfr ntizr 33 z' g $ h'
Qwxartzrlp igullztin
Volume 49 Qutumn, I97 3 2Humi1zr 2
  winter, 1974 £umhzr 3
' fp.
" l
   V   ·’·’ ’   .-     -V-*4 f*'V-gz       A"? .. l¢$*··¤.,J "’·; S"
   .2 ._,,,_   V--    ,“v’-v-,       ,;,_ , , A,9_ -e. *'·¤ y.; Z3.,-,  
  . '   ;!§Q$,;,_§$".{Z'*#~# X2}? "'Q, 57*7 J" `"• ` . • VY " · - p "·V ‘
      /»~r i»;>;i;»-·”:.  ¤V ~‘»y‘,¢; · ;.' qfv }• '*~ (
my V   * ;;h _ 1;. .  ‘ ,,  V ,  . f f   ;;···.;-·2··"*¥··¤. .r~ .*1;,     ,V:_; .V _;, · ' » · ,
" _  ‘  /   ay,  xv  L V !)  H      ,4:,, ji I E _ ·  5*, {   _,:>_
T f¤_v‘T*% 2/U W (tie, ii- ~- V• kiwi;.     »     Wi O I ;· \ ·  
;,'¢¤y• ,_;".. ,.* {*33* _f‘Y€;:" " '.  g '_,y-·   ·  _;  "~ " ° A Y A' ,  "· ; ..""v·f-‘- 3** . V ‘ ° “,_ I .
##:3- `¥*€~;,’7*"I’?"‘€-’  *'  »  `5’"`“'*‘·?*’·~ ~*:-?*( ",. #:—.- ·   9    A" F · 9
j ,__' u-   ;‘f··»&2P"_ _ •   [_ ,.2; ·¢·{;,*   ‘{(·"""j4; ;•g'   . `7!·7‘ ‘
éifrl   I wg",.   ,- I V { -'~.;{: .·/&_’l,_ `,,,  ,.v€‘_ ·;,,;•%’·;· :(.·
PU" /'r?5‘°` ’ """‘*'*>*‘ `•¢` ~ ""`·‘."’ " '~’     ;.» §’·"’1""’ ·• 5 ’   -T
’, if =¥/=, ¤·»;~J·*"'tt;4 V¢¢;. J;   x  -9 ~ * , -V 1- · *’ * ” ¢'»   ·»*· ‘ ’
' ,· r ·”’ ··- ~¤ai» :.·'· **4: **5* '  . "`»·¤.~€·* {OM. *’ »’° " ··°"  
.·   5...,--’___:‘_,!•,.*;¤:*~ $,;,4* V;¢f__;—;-Q ,  ,7,;.;;/,g§ * * ,,. wav,    , ii  r . .¤r@1:
,_._· /··.,L_   { J’—_·__/1:_‘~`ilA__' ~· ._ , ‘l,__   ‘ ` ·~·¤ `;$» -4f 9    . t , ,  
·/__»;,, · V·;= _;-V--,5, " ig ··= /  » ,    -   -"‘T•" *‘·‘¤·,—  - ·  ' *' `»—'
-» · ·-x · ,—· ·,. »·~.  · .. ·~V¢*{;*;..}•   J-- . - » 
r     A   A '{   Va} ;  f f_ _   
9,.;*5- ··V ‘i` Fai E ¢·>*:'k‘ g ·+i/ ~2··  ;·?"*$·¤>·-sa»*··;_,*’*!~»-»L°‘.éa>¤2....¢C‘{ ,-·;.;=:*- -- -9+
_ A;_.,_`,j.;- »· ‘/ -;·_,·-_-, ;g,_· .=~_*/'_,   -_" " ‘·¤ _  5. F'? 1* :5,* ' qQi?, a' / —   
.r- · eng ·*¢¤-,4wr·».·.: I L. ·   “ · .·   e=···· . ··-* ,'
 .4,; 7‘;»•¢r°'iQ;r&‘- ', iff.;  ’‘4 `    . E!    ~'g ,i '  ' 4
.,* 3* ° V` <, ~ *..3, ` , .. T ‘- _•* >""*‘;. ,' V»*
I » _-> »_··,'-Ag!   "{· — " _ _ ;_")   _ V "‘f»~.:.'·:C: ""»;• *2 ’  ·:
.j,.-A   }.»- _; :.»,.;~·-)_ _g\.·/ , — ;g- \ ‘] -  » *  ,   ».~'   ‘ 1*
V} __". _‘v·`,_74_'.r,_ ,_: Li} f .   ) ,   im   •.,_ Qrv ;4~ x
,  - x 4*1,4, V} ,} V ,. we /_/     ._  _. '  }_`}&•__,_ _   •_ __ ,7
J "", 9; ~• ..   ‘ _ , _V ~_ . _ **9. 6%... _ 
E"· __   “ V- J  MM /E-S E   T7}  “· ,.  1 **** .»‘ ";?é$":?·;g**%?¢·'*     ’ "`* 
·   3 . -: 9/ wt ‘ ,_ ‘ -; /: -@9*  *-—v          ’      · 4.·9-·· 2
@#5 J;. _ ‘ J — A V ‘ S V  ,,._   ~ V ' V. Je:   · Q, my- ·   ;"
  ‘i“7'?(” ·,:.,-·:i`-- -¥·»=·-"`Y"`,     R: .3 U        “ r > ~ I; V ··  -.~’·‘  
    ·9~*   * `·v**  -    I * ·   -»==—~··-·-""1   *‘    
fig: -     ‘ ·m i n " ~ `\ ..V.   »·_%g;r ; _    
"‘-     A ; LIZ;  V/__ _ , ‘.•,,; _ . ___> ·;_ . -  ·- V ,_ _,§_ , ,_,,       * * _ * >`—-‘ 3 >·_;l _‘V;v; ‘f*= r . - V
· .__, .,~~·' — .-L _ ·   MM  =; ·· _ ; l=»Vl‘Q;V-¢--96%**  ·<~Vi:¢ ‘g‘° .· ‘ - }-*%*‘“ `T" ~ _
"‘{"»· » >- —- I _,, · Y T _   ¢
#?'j_   A' . “ ‘   . - _. ,i’·'»$£i=Sé r-   ‘ ·
**9 e /<   V — -   ...· · ,..v`£t¤a"».    
I V ·V -   _- J`*€;,, I :;_   M \,,. W V:   V ,` .. »··. ._ . ,_. . -1
. -11- *‘· ,· -- , - ·- "‘  `·—; :.¢·*‘~-Ik-     ` A-- , - —-
,, » V -- : / ·   -..»—· ; - —· . ·~ · z·—V  A
V »` . ·- _ ,' .»#·J" · ·' 4 . ' `Y”"?` ‘»•‘  4--* . -V " -,t" sag; YR ¢.·:'J¤. f? ESF? .7
?  ";“;’°" T 7*9 ` ~_ ~ >- A-V_ —- ·~          
lj kw   V ,. /.              
.. ,_; ' $»   1 . _ V   ·_» _. %* ""‘;;i "f·'·` gg; pj   , ‘· "gy-·- ~   ., _ — ,,‘-- ;:p—¢ (  V :- *¤§»» .,;V,
L;r`°i,., f` · · · 7‘ ~; --   *,2 »-Z-  _,,·~’        "~¥ \;,z ~ Qi   ·
- » _..-... ~ ..   A .  _. , ,~g;.-   -.: y,-V-·L .· · _., .·.-·:.V  -_   N ,.—..—··y g,   _,  
*’ ~ e V.» ·#·». ~   - .   r¢"—<·fyV #V~¢ .. ·€*=?  _,.»·£;i»;;  ¤.¢.‘=   i·    `•·· »iB—?~>F.¤;;. . . T
Photograph by Nano-y l)ummn1m

 US ISSN 0016-2116 [
· i
. $.1
Ex l
The cover photograph of three small boys §
on the river bank was taken at last year’s I
Easter Egg Hunt at Wendover.  
Published at the cnd of each Quarter by the Frontier Nursing Sewice, Inc. ‘:
Lexington, Ky. °
Subscription Price $1.00 a Year l .
Editn1·’s Ollice. \Vcnd0ver, Kentucky 41775 `_
  _ 4
WINTER. 1974 NUMBER 3 gg
Second class postage paid ut Lexington. Ky. 40507 qi
Send Form 3579 to Frontier Nursing Service, Wendover, Ky. 41775 ·
Copyright, 1974. Frontier Nursing Service, Inc. V,

Q Beyond the Mountains 45
  Come Here to Learn Sally Rinehart 17
  Field Notes 49
' $3* Frontier Nursing Service:
V Continuing Development 1974 Gertrude Isaacs 3
j Hyden Hospital and Health Center
and The Mary Breckinridge Hospital 21
  In Memoriam 48
  Old Courier News 25
E Old Staff News 35
    Tammy and A Friend A Photograph Inside Back
i E Cover
    The Use of Drugs at the Frontier
{ Z Nursing Service by Registered
1 1 Nurses With Specialist Training
i in Family Nursing and Nurse-
{ Midwifery 31
V True Lent (Verse) Robert Herrick 2
· A Young Housewife . . . Modern Maturity 27
· An Old Norfolk Joiner . . . The Comitrymazi 30
  Cousin Wilf The Countryman 16
  Cultivated Entertainment The C'om1tryman 30
ll Devon Patient . . . The Countryman 55
E Earning Her Keep The Coimtrymcm 34
g; FNS News FNS Sta]? 28
  Old Chinese Proverb 29
  g ` Optimist Modern Maturity 15
i ty . Shropshire The Coimtrymzm 47
    Strange Encounter The Coimtrymcm 20
    Trying to Teach . . . Modern Maturity 34
?  T White Elephant 48

Is +his a +as+?—T0 keep  
The Iarder Teen  
And clean  
Fr0m +a+ 0+ veeles and sheep?  
ls E+ +0 +as+ an h0ure?  
Or ragged g0?  
Or shew  
A c+0wncas+ +00k and s0ure? E:
Is +his +rue Len+?  
N0—`+is +0 +as+ +r0m s+rI+e,  
Fr0m 0+d deba+e T
And ha+e:  
T0 circumcise +hy |i+e, T
T0 sh0w e hear+ qrie+—ren+,  
T0 s+arve +hy sin,  
N0+ bin;
And +ha+`s +0 keep +rue Len+. M
-ROb€r+ Herrick  

   QUARTERLY Runnmuu s
I Education Director
  This is a sta.tement designed to clarify the directions in
  which the Frontier Nursing Service is planning to move to
* strengthen the rural primary care service and training center
r it operates as part of a larger system.
  The Frontier Nursing Service is currently moving in several
  directions, all part of its l0ng—range program planning, which
  are all inter-related and designed to provide a better coordinated
El approach to the provision of health care in rural areas. The
g aim is to work in close collaboration with the federal, regional
  and state Departments of Human Resources in their new devel-
  opments; and to avoid undue disruption of services currently
i being provided, that are responsive to the needs of the people
E being served.
  The following comprises a list of projects that are currently
i under-way and others that are under consideration:
Q 1. The Frontier Nursing Service has under construction a new
? $2,500,000 research and training health care center with in-
E patient services (40 beds) supported by a matching grant
Q from the Appalachian Regional Commission, scheduled for
‘ completion in the summer of 1974. It consists of three
,` stories, one for outpatient care and supportive services, one
{ for inpatient care, and one for education and research. Den-
i tal and mental health services are included. It is designed
to provide primary care services to a population group of
, 15-20,000. The Frontier Nursing Service considers this an
M appropriate model for the development of local health cen-
  ters for the provision of primary care. The new building
  will take the place of the old 26-bed Hospital and Health'
QQ Center built in 1928.
  2. The Frontier Nursing Service has a three-year Primex Grant
  (March 1972-February 28, 1975 for $300,000) from the Na-
  tional Center for Health Services Research and Development,

for training and research of the primary care nurse in rural 1
areas. One hundred and six registered nurses have been  
admitted to the program since June 1970, eighty have gradu- t
ated from the program, and twenty—two are currently en- ·
rolled. The program is four to sixteen months in length, »
depending on whether the students wish to include mid-  
Wifery in their training. Valuable data is being collected V
regarding costs, tasks performed, man-power involved, and ».p
types of care provided according to diagnostic categories, M
age, sex, family, place of care and disposition. Training _
content is being compared with six other university pro- i
grams. The system established for data collection has wide- g
spread uses, since it involves all outpatient services being ’
provided. Less comprehensive statistical data is available  
for all previous operations since the Service was inaugurated  
in 1925. The aim is to evaluate and document the feasibility  
of developing a rural primary service and training care cen-  
ter at costs that are reasonable and that is acceptable to the  
people and operative from an organizational point of view.  
3. The Frontier Nursing Service has collected PAS MAP data  
since 1971 for services provided through the hospital for ;
comparison with other community hospitals., and for stand- `
ardizing its own care as part of its utilization review sys-  
tem. This data, in conjunction with outpatient data, provides €
more comprehensive data regarding the efhcacy of the total i
system. 4
4. The Frontier Nursing Service submitted a grant for Univer- I
sity of Kentucky affiliation for its training program to the l
Division of Nursing which was approved, but not funded
due to withdrawal of federal funds last year. The grant has o
been transferred to the Regional Oiiice and is still viable. The tj
education director has a professional appointment on the  
College of Nursing faculty. Such an affiliation should help g*?’
in program expansion. The ability to meet the demand for  
training and graduates in primary care both within and out- Q  ,
side the state is well beyond the scope of the Frontier Nurs- ‘  
ing Service. This is also an attempt to obtain university  
credit for primary care training for nurses, and to broaden . 
training and service opportunities.  

1 5. A grant has been submitted to National Institute of Mental
  Health to implement and study further integration of mental
; health into the primary care system. Currently, the mental
— health system is operating as a separate system. The Fron-
. tier Nursing Service has from the beginning of its primary
  care training program sought to develop an approach for
if closer coordination between physical, mental and social
mp health care in the provision of primary care. Mental health
i at the local level should, preferably, from the Frontier Nurs-
$° ing Service point of view, be an integral part of primary care.
, 6. The University of Kentucky College of Medicine is proposing
  to negotiate with the Frontier Nursing Service for the train-
ii ing of primary care nurses for the primary centers being
Q developed in the state through the University, and to provide
  training for medical students and other allied health care
  professionals, as part of the primary care team. Sixty per-
  cent of the primary care nurses trained by the Frontier
  Nursing Service are still in the state. Only five were resi-
P, dents of the state prior to entering training. Support from
il within the state should increase the numbers remaining in
  the state and this mechanism should serve to strengthen the
, development of primary care in rural Kentucky. This is the
  only program for primary care training in the state at this
4 7. The Frontier Nursing Service views its primary care center
Z as the nucleus for a rural Health Maintenance Organization
. (HMO) which, if coordinated with both regional and state
service and training centers for specialty services, can pro-
vide a workable system for providing comprehensive care in
3 rural areas at reasonable costs.
T The Frontier Nursing Service has all the essential com-
,¢?’ ponents of an HMO except the marketing system. The man-
  ner in which this can best be developed needs to be explored.
T  , The current notion is that this can best be accomplished by
i   developing a network of primary care centers for marketing
, purposes and to establish a coordinated system for referral
i  and reimbursement of specialty services at both regional and
  state levels. This potential is being discussed with extra-

6 Faonrma Nunsmc snavicn =
mural program personnel at the University of Kentucky and -
the Department of Human Resources. .
8. Through new legislation, Social Security Administration is , ],
proposing to reimburse primary care nurses for clinical care i
on an experimental basis. The Frontier Nursing Service has
been asked to serve as an experimental center for such reim- (Z
bursement. This will eliminate the current problems of the
vast amount of unreimbursable Medicare-Medicaid services Q
being provided through nursing. This type of reimbursement uy
is essential to help make the provision of primary care a i
viable operation in rural areas. Long experience and recent  
research indicates that this is a highly satisfactory approach gj
to good health care. s
9. Through a combination of the above developments, the Fron-
tier Nursing Service proposes to serve as a model primary A ‘
care service and training center for the training of primary l
care teams and to serve as a base for a consultant team to  
newly developing primary care centers in rural areas. Hope-   2
fully, this will provide a baseline for developing rural HMO’s   ·
in eastern Kentucky and perhaps form the nucleus for more g.
regional planning. The Frontier Nursing Service has been §
contacted by the State of Tennessee personnel for assistance  
in such planning. é A
Description of Service and Rationale for this {
Type of Development  
The Frontier Nursing Service has for over 46 years provided _
coordinated home health clinic (nursing and hospital) and in-
patient care services in rural Appalachia, through a primary  
care service and training center. It was started in 1925 by li
building six nursing stations. Currently it operates eight such  
stations and a centrally located hospital and community health  
center which provides primary health care to a 1,000 square j*§`
mile rural area; primary care training; and serves as a link  
with regional and state specialty services and training. In addi- k  
tion, the Frontier Nursing Service provides supportive services  
to two nursing clinics operated by other agencies.    
This system facilitates the provision of well coordinated " 
health services at a range of levels, to make modern health  

  care readily accessible to the people at reasonable costs and in
ll an acceptable manner. It helps bring health care back into the
g mainstream of daily living without excessive costs or undue
i 1 u inconveniences.
  The nurses at the outposts currently manage 55% of the
ambulatory care encounters of the Frontier Nursing Service;
ii and the family nurses at the hospital manage 50% of the am-
` bulatory care encounters at the hospital. It is anticipated on
the basis of accumulating evidence that the ratio of care pro-
"l vided by the primary care nurse in the nursing stations will
  increase as more well—prepared nurses are placed in these
E stations.
  The nursing clinics save the patient the time and cost of
  travel to the central station for the lesser problems. The care
is more personalized, and the cost less. The nursing clinics
;» also serve as a source of employment for people who do not
’ E wish to commute to the bigger centers.
  There is ample and established evidence that the nurse,
  given additional training and with medical consultation and a
  referral system, can adequately manage the greater portion of
g ” conditions managed through an ambulatory care clinic without
jeopardizing the health of the patient. Also we are getting in-
Ei creasing evidence that the nurse can give better primary care
j, in a coordinated home health-clinic service than the traditional
ii health team can provide from a clinic setting. This, of course,
ty requires that the home health clinic is well coordinated with
jr a medical and hospital care system. This is essential for the
ii provision of back-up services, the management of conditions
_· that cannot be adequately handled by the nurse in her clinic,
_ ; and the entrée to specialty care.
  The nursing clinics can be built, equipped and maintained
  at relatively low costs to provide preventive and maintenance
§ care, and to manage the greater portion of common illness. Both
  manpower training and utilization costs are lower. Practical
  epidemiological problems are more readily managed by the
Q   nurse who is familiar with the family and its environment. The
  nurse can be more practical and realistic in her planning because
i  of her proximity to, and knowledge of, the problems involved.
 3 She is in a better position to help the family cope with its own
  problems or help them carry out prescribed regimens of care;

and to recognize early problems of complications. If the
patient has more complex problems or does not respond satis-
factorily to the nurses’ levels of expertise, medical consul-
tation and referral is readily available. ,
Generalized services are provided by hospital clinic and in- Q
patient services which are centrally located. This includes medi- ‘
cal, pharmacy, laboratory, x-ray, EKG, social service, nutri- li
tional consultation and other back-up, consultant and referral
services. A high percentage of ambulatory care and hospitaliza- _
tion can be adequately managed at the local level at much lower  
costs and greater convenience, again without jeopardizing the  
health of the patient, and often to his advantage healthwise.  
The costs of constructing, equipping, and operating a primary  
care center is much lower than the cost of a specialty care cen-  
ter. The proximity to the community assures greater conveni-  
ence, permits a more personalized type of care that is more V
responsive to community needs; and, provided there is an ade-
quate specialty consultation and referral system, the patient
in outlying areas is usually assured of a more speedy and
appropriate entrée into the specialty care system and more
appropriate follow-up when the patient is returned home.
Specialty services in such a system can similarly operate at
a more efficient level and perform those functions for which
they were originally intended. The primary component of care
has unfortunately been sadly neglected in our present day cul- .
ture and creates much dissatisfaction, yet the concept seems
so simple and practical. Fewer health problems are neglected
until they become major problems which are much more costly
to manage.
The important thing is that it works. Through this system
the Frontier Nursing Service has consistently maintained peri-
natal and maternal mortality rates which are below state and
national rates. Average hospital stay is cut in half; The average ,
stay per patient is 4 days and for 65 and over it is 7% days, {P
compared with 8 and 15 days, respectively, for other community  
hospitals in this country. This county has approximately 10 V ,
patients in nursing and personal care homes compared to an ~¤· 
expected 50-60 nationally for a county population of 12,000. The S
percentage of people 65 and over is comparable with national ”
figures. The percentage of referrals of mental patients to re- r

gional and state hospitals is also below the expected for this
area. The degree to which overall admission rates are modiiied
through this type of care needs further study. Indications are
. that the institutionalization of the aged and disabled is mark-
Q edly reduced.
QW The difference in hospitalization patterns is largely attributed
U to the home health maintenance and preventive services pro-
vided in conjunction with the nursing clinics in the community-
gi a factor that is largely ignored by the majority of health service
;_ agencies in the country.
il, This is largely possible because of family cohesiveness in
  the area, which has been strengthened according to a preliminary
,$ report of a recent study by a nationally-known cultural anthro-
A pologist, Dr. Marion Pearsall, who returned to this area to do
1 a ten year follow-up of an earlier study, to do a community pro-
file, to study the social impact of the family nurse, and to assess
the knowledge, attitude, and health practice patterns of this
area. The observed increase in family cohesiveness and com-
munity organization would appear to be the reverse of what is
happening in other parts of the country. Could it be that the
family health services provided by the nurse had co-ntributed
to this change, and that primary care provided within the com-
munity can help re-establish family and community ties?
. The University of Kentucky Medical Center, which serves as
both a training and specialty service resource, has reported that
the patients referred by the Frontier Nursing Service tend to
be more carefully selected according to medical care needs and
more carefully worked up, resulting in better specialty care. The
University reciprocates by sending better follow-up reports. Also
an increasing number of regional and state specialists visit the
Frontier Nursing Service on a regular basis to provide specialty
. services on a selected basis; e.g., it has monthly clinics conducted
KT by orthopedic, ophthamology and pediatric specialists, and two
  annual clinics conducted by ear, nose, and throat specialists.
Q , Medical internists conduct classes and case conferences on a
‘¤ ‘  regularly scheduled basis. These are reciprocal arrangements
l which strengthen local, regional and state services, keeping each
if abreast of state wide development. Further evaluation of the
t cost and use of specialty services in relation to· well established

primary care services is. needed for the development of rural
HMO’s. ‘
That overall cost of care will be reduced by the development  
of a primary care system is questionable. Most likely, costs will  
be increased as better care is made available to more citizens  
through this system. The likelihood of reducing the need for, or F
the cost of, specialty care is minimal. Marked increase in health _;
manpower training at the basic level would not be anticipated, F*`
if we had better utilization of current manpower (one third of _
the registered nurses in this country are not employed, which ‘
can largely be attributed to poor patterns of utilization and em- I
ployment practices). The Frontier Nursing Service, in spite of 5
its rural location, has no shortage of nurses.  .
Some redistribution in facilities and health manpower utili— i
zation and training would be indicated. Change could, however, V 
be introduced without major disruptions by gradual modification  _
of the present system. The major change would involve the f
strengthening of existing primary care services and training cen- “
ters and the development of new centers, where none exist.  
Below is a simple pattern of the type of health care system  
University National .
Nursing Local Regional Medical Research
Station Center Center Center Center .
500 popula- 15,000-25,000 200,000 popu- 2,000,000 4 or 5 national p
tion group population lation group. population centers as are .
per nurse in group. One Health man- group. Health currently  
rural areas; physician per power ratio manpower operated by
1,000 in 3,000 popula- probably un- ratio probably Mayo Clinic A
urban areas. tion group, 1 changed unchanged. and NIH l
nurse per (average size (Average size (average size z
500; average 400-bed hos- 1,000-bed hos- 10,000-bed  Q
size 40-bed pital with pital with hospital with "
hospital with outpatient outpatient outpatient {
outpatient facilities) . facilities.) facilities) . ,?`
facilities. i Q,
This distribution would not change current numbers of hos-   _
pital beds. It is anticipated that the specialty centers would  
continue to operate in very similar roles, though more eiiiciently Y
with a more elaborate communication system with primary care
personnel and development of proposed primary care centers,  

which would take time. Current demands and interest indicate
‘ that change would not be sluggish, provided that undue resist-
 _ ance from the medical and nursing organizations were not forth-
  coming. Resistances are sporadic and vary vastly from state to
it state. There is, however, considerable evidence of fear of pro-
  fessional disruption on both sides, mostly from those with
E* minimal exposure, and those who are comfortably situated within
?_ a protected environment where they can restrict services and
  training with minimal awareness of the problems; e.g., where a
* secretary can say by telephone, "I am sorry we have no openings
, on our schedule for two weeks, two months, or whatever."
S Should demands for specialty care decrease it would be
j gradual, and by that time some of the bigger medical centers
’ would be outdated, so that change in type of demands, closure,
 · or discontinuation of services would have only limited impact
 K on society. They should be permitted to die a natural death if
.  their services no longer have relevance to society. This is highly
 . doubtful, as newer and more costly methods of providing spe-
  cialty care are constantly being identiiied.
, Size and population groups served by the specialty care cen-
j  ters could vary substantially depending on demography. Exist-
2 ing facilities and manpower distribution, to operate efficiently,
  need to be closely coordinated with primary care.
t Local health centers would likewise vary; most could be
- established using existing resources with the addition of primary
, care nurses or the physician’s assistants as appropriate. Flexi-
f bility would need to be retained to meet the needs of the area
Z, served. The point to remember is the need for keeping primary
5 care centers small and personal and in close proximity to the
  people served if care is to remain important and meaningful to
  the family, and responsive to the needs of the community.
  Two recent studies in this area by the University of Ken-
  tucky and the University of Wisconsin research staff (part of
  _ the Primex Project) indicate that this method of care is highly
  satisfactory in terms of the patient receiving the care, and pro-
Y fessionally in terms of type of care provided. Preliminary reports
are glowing. Both indicate that the Frontier Nursing Service is
l achieving what it set out to do as defined by its philosophy and

12 FRoNT11-an Nunsmo snrwrcm i
object; i.e., to provide broad ranges of services planned and car-
ried out in collaboration with other agencies, to make quality `
care accessible to the people at reasonable costs and in a manner i
that is meaningful to the people, and permits them to participate. l
Recent research in Canada confirms the above findings. (See [x
the New England Journal of Medicine, Vol. 290, No. 5, January `-
1974.) More practical research based on day to day needs, and Y
the practical resolutio-n of these needs, would be beneficial.
Problems A-
The Frontier Nursing Service 'has encountered several prob- ’
lems, all of which seem to be related to the difiiculty in explaining ·`
the primary care concept as an operational mechanism for pro- `
viding family-centered health services, as distinct from disease- `
centered care provided through the specialty care services. .
In family-centered primary care there is a greater emphasis i
on the interaction which helps the family assume greater respon- l
sibility for its own health, and in disease-centered specialty care -
there is greater emphasis on the diagnostic and treatment skills. .
Both are complementary and important as part of a total system.
Even the researchers, when they arrived at the Frontier ·
Nursing Service from the University of Wisconsin Health Re-  
sources Research Center, which had studied sixty more tradi- 2
tional health agencies, were no·t prepared for coding the type of
care provided through the coordinated 'home health nursing Y
clinic. Their coding system was not set up for identifying epi- V
demiological, family and community-centered approaches used .
by the nurses or the type of assistance provided by the nurse S
in helping the family cope with its health problems. They sent l
an SOS to the research center and, because no other coding `
mechanism could be developed, they classified it as socializing,  
even though it was done with a distinctive purpose in mind and l
related to the care provided. Further study is indicated to iden- Q
tify the essence of the service provided and its effectiveness. It  
is to this undefined quality that the Frontier Nursing Service ,3
attributes much of its success over the years.  
Problems may be broadly classified as follows:  
1. Because the Frontier Nursing Service was developed in a  V
relatively isolated area on a limited budget, it did not have  =

the manpower or mechanisms necessary to document its find-
` ings. On the other hand, it was also not handicapped by pre-
k mature application of sophisticated statistical and scientifi-
i cally developed methodology which often interferes with the
li more natural development of a practical methodology. This,
  however, makes it difficult to explain the service provided in
{ terms that are readily comprehended at the present time.
2. The Frontier Nursing Service system and pattern of care has
*" over the years never fitted into the federal or state require-
} ments for funding, without involving significant additional
f expenditures and disruption of the total system. The cate-
gories of support or the rules and regulations were not de-
` signed for the provision of primary care service. Further-
— more, new programs were generally in operation before fund-
j ing became available and therefore the Frontier Nursing
. Service never really met the "new and innovative" require-
V ments. For example, Family Planning was developed as an
· integral part of the health care program from its inception.
To separate it out as a distinct entity for funding purposes
· would have destroyed the very essence of the program that
ji the Frontier Nursing Service was struggling so hard to main-
‘ tain, and would have created unnecessary expense. Because
the Frontier Nursing Service did not wish to separate Family
F Planning from the total program, it did not meet the require-
‘ ment of being "new" when funding became available.
i 3. The Frontier Nursing Service has no formal affiliation with
· the University which is considered desirable by many. Such
— affiliation, until recently, mitigated against the local au-
  tonomy considered essential to remain responsive to com-
  munity needs. On the other hand, the Frontier Nursing Serv-
f ice has had very meaningful linkages with the University
gi Medical Center since its development. Further strengthening
E of these linkages is anticipated. New patterns for such link-
{   ages need to be developed which facilitate rather than hamper
 gf , or restrain local developments.
 ; 4. Funding of services provided has always been problematic.
, Eighty percent of the population is medically indigent. Cur-
 * rently the Frontier Nursing Service provides primary care

(home health, nursing and hospital clinics, and