a hospital setting. For example, hospitalization would be necessary when difficult diagnostic procedures are indicated, when the severity of illness requires constant medical observation, when highly skilled nursing techniques must be applied. But when the diagnosis has been made, when the course of treatment has been determined and assured, when there is no immediate danger of relapse, and when the plateau of illness has been reached, it may be psychologically desirable and economically prudent to transfer the patient to nursing home care if his condition warrants his being seen only periodically by a physician and being cared for by nurse-attendants under professional nurse supervision. In brief, chronic hospital care should be used only for those patients truly needing the battery of hospital skills and equipment. Any other course would be wasteful of facilities, skills, time, and money. Yet, what is really needed is hospital care for such chronically ill persons and this can be provided in an adequate general hospital as well as in a chronic hospital. In fact, many highly competent physicians and hospital administrators are convinced that the general hospital is the better locale where the patient has constant access to the medical specialists. Also, the integration of general and chronic hospital care in one facility should insure more flexible and more economical use of the capital structure. In this connection, New York State in 1947 formulated recommendations for a comprehensive, statewide program for the care of the chronically ill but, unfortunately, little progress has been made in bringing these proposals to fruition. In that connection, I have submitted a summary of that program. However, I think it may be a little unjust to ask that it be made a part of the record. Senator PURTELL. That is this document entitled "Summary of a Program for the Care of the Chronically Ill in New York State"? Dr. BOURKE. That is right. Senator PURTELL. All right. Dr. BOURKE. With regard to funds for planning and research, the Congress has shown true wisdom by including in Senate bill 2758 provision for grants to the States toward planning, study, and research addressed to diagnostic and treatment centers, rehabilitation centers, chronic hospitals, and nursing homes. Knowledge is limited in these fields and the need for experimentation essential. The sums proposed for actual construction are conservative in relation to need but should serve as an incentive to States and localities to initiate pilot-type projects. Much will be learned from these new facilities and the concurrent study and research so that, should greater capital sums become available in the future, a new body of knowledge will be available, based on facts and experience. It is recognized that problems of geography, economics, and the wishes of the people differ among States and, within States, among communities. Although the following suggestions are based upon situations and experience in New York State, they are respectfully submitted for your consideration. SUMMARY OF A PROGRAM FOR THE CARE OF THE CHRONICALLY ILL 1. Where possible, diagnostic and rehabilitation centers, chronic disease facilities, and nursing homes constructed under the program set forth in Senate bill 2758 should be contiguous to or an integral part of community general hospitals meeting national accreditation standards. 2. In ascertaining the potential location of such facilities, careful consideration should be given to the sponsoring community's actual need, its ability to use fully the contemplated units, the quality of service which it is prepared to render, and the flexibility of usage which it is willing to insure. For example, the construction of a chronic-disease hospital requiring certain diagnostic and treatment facilities and equipment might be envisaged for an isolated location, while an accessible, existing general hospital is fully equipped and staffed. In such an instance, economies in capital construction and operation might be effected by planning the chronic disease hospital as a unit of the existing general hospital. This arrangement might also be desirable from the standpoint of changing patient demands, i. e., should the general care load decrease and the chronic load increase, the combined plant would still operate at a desirable occupancy rate. 3. Since the public assistance programs of many States now provide for the purchase of medical and hospital care for many dependents, the traditional concept of providing hospital care for the needy only in public facilities has become outmoded. Therefore, any facilities constructed in these four categories should be available, in my opinion, to all economic groups, just as so many hospitals constructed under the current Hill-Burton program are now operating. 4. The proposed bill specifically apportions the amount of money to be expended by the States in each of the four categories of facilities. It is possible that some States may have difficulty in developing suitable projects in one or more of these categories. Therefore, to encourage sound planning and full utilization of the authorized amounts, the interchange of funds among categories should be permitted. Although potential sponsors might be interested in developing certain types of projects, they may hesitate to do so because of inability to envision sources of support for their operation. This may prove particularly true of chronic hospital and nursing-home facilities caring for long-term, expensive illnesses. This uneasiness about maintenance funds for hospitals, related facilities, and supporting services probably will not be resolved until the relationship of the various sources of support to the hospital become more clearly defined. These sources include the patient and his family, Blue Cross and Blue Shield plans, workmen's compensation programs, philanthropy, commercial insurance carriers, and government at all levels. Thank you, sir. Senator PURTELL. Thank you, Doctor. Senator HILL. Doctor, it seems to me your thought is, insofar as possible, chronic disease hospitals and nursing homes should be contiguous to or an integral part of what we call a general hospital? Dr. BOURKE. Yes. There may be geographic factors in other parts of the country which preclude that. Senator HILL. But as far as New York is concerned Dr. BOURKE. We have, Senator Hill, from the very start of the program in our State plan had a minimum size for general hospitals because of our geography transportation, of 50 beds, and have specified the basic specialties that should be found in that community hospitala qualified surgeon, radiologist, pathologist, and internists-and we have deviated in only 2 instances from that. Senator HILL. In other words, your general rule has been to tie them in there? Dr. BOURKE. Rather than to have a multiplicity of units, we have set up 50-bed units, and we encourage their working with the larger medical teaching centers. Senator HILL. I want to refer to the letter I referred to earlier from our hospital planning division head. I stated at the time I had not had an opportunity to read this letter, and I will have to be frank and say I haven't yet read the letter because I wanted to hear the testimony of the witnesses, but I do note one thing-another thing here, too-and that is this: It says: H. R. 8149— that was the companion bill, of course, in the House— does not require the facilities constructed thereunder to be operated in accordance with the State-adopted standards except in those States which have a licensure act covering such facilities. We feel operation in accordance with the State standards is most essential in the proper operation of the facility and in the protection of such standards afforded. This is particularly true in the case of nursing homes and chronic disease hospitals. Do you agree on that? Dr. BOURKE. Some of the States, I know, are working with the nursing-home problem. We had it under study in New York State through the welfare department the past several years. It is something more than facilities. It is an analysis of what the quality of care is and how much attitude toward rehabilitating these people occurs in that type of setting. Senator HILL. Of course, without being critical, and I certainly. don't want to draw any indictment here, and particularly I do not want to draw any indictment against the home people, I know many of these chronic hospitals and nursing homes are doing a wonderful job for the finances they have. You have to always bear that in mind-what you can do with what you have. Isn't that right? Dr. BOURKE. That is right. Senator HILL. But the truth is one reason we need more chronic hospitals and nursing homes is that the standards in some, to say the least, are pretty low, and I say they are low because, and I am sure this is true in large measure, of the lack of finances. Isn't that true? Dr. BOURKE, Yes; I think so. Senator HILL. But surely your State standards ought to apply. You agree on that, don't you? Dr. BOURKE. I think anything should be done that will prevent the isolation of these institutions from the focal point of medical service. Senator HILL. I was interested, too, Doctor, in your testimony that you agreed with Mr. Bugbee of the American Hospital Association in stating that these funds ought to be interchangeable because, as you suggested, one State might have a pressing or compelling need for one type of facility or might be able to go forward with the construction of that type and some other State might have another type of facility it was able to go forward with or had the compelling need for. Dr. BOURKE. We have constructed diagnostic centers as part of our medical teaching centers under the basic program. Senator HILL. Under the basic program? Dr. BOURKE. Yes, sir. Senator HILL. And you would have these funds interchangeable? Dr. BOURKE. Yes, sir. Senator HILL. You would hold fast, would you not, in any amendments of this act, I think this is important, to the basic conceptand there wasn't anyone who hammered this more than our good friend, Senator Taft-the basic concept of the administration and the authority in this act being at the State level rather than at the Washington level; is that right? Dr. BOURKE. I think that has been one of the basic facts of the success of the program, Senator Hill. Senator HILL. Thank you, Doctor. Senator PURTELL. Thank you, Doctor. If there are no more questions, our next witness will be Mr. Richard C. Parmelee, attorney for the Connecticut Private Hospital Association. I welcome you here, Mr. Parmelee. I know that you have got some testimony that is going to be very interesting to this committee. STATEMENT OF RICHARD C. PARMELEE, ATTORNEY FOR THE CONNECTICUT PRIVATE HOSPITAL ASSOCIATION Mr. PARMELEE. Thank you, Mr. Chairman. Gentlemen, I am here, as you know, on behalf of the Connecticut Private Hospital Association, and having been seated here this morning listening to the distinguished doctors who preceded me I am quite humble at this moment. However, on their behalf, and reading from a statement which was prepared at their request, and largely by them, I wish to state that the Connecticut Private Hospital Association is opposed to Senate bill number S. 2758 in principle, for the primary reason that it proposes to substitute nonprofit organizations to conduct nursing homes in place of private enterprise and placing such public institutions in competition with the estimated 20,000 nursing homes which for 20 years or more have cared for the indigent, the aged, and the chronically ill without aid or favor from either county, State, or Federal Governments. The next four paragraphs, gentlemen, in fairness to your committee, have been lifted from a statement made before the House committee at an earlier time, but I have been directed to call them to your attention because it so heartily represents the thinking of my Connecticut people. A nursing home is an institution unique to the American scene. Like many of the great prepayment health plans, these homes have grown and matured out of sheer necessity. They have served the communities of America with neighborly understanding. It came as a shock to virtually every privately owned nursing home when President Eisenhower in his address to the Nation suggested that the Federal Government through this bill, H. R. 7341, should survey the need for federally-sponsored nursing homes. For the past 20 years, 20,000 nursing-home operators have spent their time, their energies, and their fortunes in the development and promotion of nursing homes throughout the entire United States. These nursing homes are small, compact, friendly units caring for persons afflicted with some of the most dreaded diseases of our time with the sympathy and understanding that cannot be attained in larger, chronic institutions. The nursing-home operator locates the nursing home where it is needed. He employs local help, local nurses who would in many instances, because of family obligations, be unavailable to travel to more centralized chronic institutions. There is hardly a community in the United States without 2 or 3 nursing homes, thereby giving the families of the chronically ill and aged a variety and freedom of choice. The nursing home is two things: It is a profession and it is an industry. It is licensed under the laws of the various States; it must keep accurate records as to the medical treatment and nursing care of its patients. It must be prepared to solve an untold number of dietary problems; it must tend to the needs of patients who are completely bedridden; it must provide the facilities for comfort and care 24 hours a day, 7 days a week; it must conform to the rules and regulations of the various State departments of public safety, rules, and regulations that vary from time to time and are costly items in the maintenance of a nursing home. In Connecticut, the private nursing home or convalescent hospital is conducted by individuals and privately owned corporations on high standards and subject to regulation by the public welfare council, offices of the commissioner of health, and the fire marshal of the State. The homes are located in various parts of the State in suburban and rural areas and most of them are well managed and in keeping with high standards in all respects. The patients are cared for in a homelike atmosphere and the average population of the individual home is such that the patient who in many cases must spend all or a larger part of his life in such place feels more at home and at ease than in any large publicly operated hospital or institution. May I say at this point, gentlemen, and I think Senator Purtell is well aware of it, Dr. Stanley Osborne, our commissioner of health, has seen to it standards of health have been maintained, and more recently Dr. Margaret C. DuBoise has been employed there and is in charge of all hospitals in our State, and she has taken great and particular care to see to it in the nursing homes all State laws and regulations promulgated under the State laws are rigidly enforced and carried out. Also, with respect to the fire hazard, which I know gives concern. to your committee for certain other areas of this country, be it said now that under the able leadership of our former State police commissioner, who was lost to us, Mr. Hickey, who, in effect, was our fire marshal, some very rigid and very high standards of fire protection have been provided for in these nursing homes throughout our entire State, and they are still in force, and the effect of his able leadership on the fire protection in this sort of institution will be felt for all time. In our State the management of these nursing homes in most cases consists of a husband and wife, who add to the homelike atmosphere. In Connecticut at the present time there are 4,800 beds in licensed nursing homes, and there are 187 separately operated institutions. Not all of them are members of this association. |