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Possible income.-1st 6 mo. similar to last 6 mo. of project year. Possible budget: $75,063 - 8,640 = $66,423.

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Possible income. It is suggested that consideration be given to the possible realization of one of the objectives of the project, i.e. supplemental support to boarding home operators by the health and social services department or the department of hospitals and institutions. As such, reimbursement for operator training may be obtained during the 4th project year.

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INTRODUCTION

During the preparation of the final draft of this proposal, the following story appeared in the APA Monitor (The American Psychological Association, March, 1974):

NEW YORK TOWN BANS MENTAL PATIENTS

Long Beach, New York . . . passed an ordinance . . . that bans anybody requiring "continuous" psychiatric, medical or nursing care, or medication from being registered in any of the city's facilities... Carried to its logical conclusion, the... law would treat former mental patients (and present mildly or moderately disabled individuals, ed.) as permanent lepers and would cripple the progressive movement toward community-based outpatient care. (The rate of admissions to New Mexico State Hospital from Bernalillo County has decreased from 27% prior to the development of a community based program to 4%, while the number of applicants for service has tripled, ed.)

The article points out that the city's intention is not to ban mental patients but to regulate and supervise the city's 30 odd hotels and rooming houses which were never intended to be health care facilities and many of which are substandard. Apparently, however, the city is regulating people and not substandard facilities as no positive support or closing of substandard facilities is indicated. Proponents of the law reportedly also represent some senior citizen groups who shouldn't be forced to live with mental patients. The point is elaborated on in the article with the consideration, would any one put his mother in the same room with a mental patient. Obviously not; but, perhaps as equally important and in reference to this proposal, would anyone put their mother in a substandard rooming house or "hotel" or situation which does not consider the more intangible aspects of quality living-social stimulation, opportunities for a sense of self worth and competence. (The complete text of the article is an addendum to the proposal.) At another level, consideration should be given to reference in the 1970 U.S. Government Census Report regarding persons in group living situations. One reference, listed along with prisons, is to inmates of homes for the aged—lacking further definition, it is assumed reference is to nursing homes as rooming houses are also listed. Nonetheless, it is felt that the use of the term inmate carries a popular negative connotation although the denotative reference is also not necessarily complimentary: one of a group occupying a single residence; especially a person confined in an asylum, prison or poorhouse. (Today's nursing homes are indeed costly and the poorhouse can be where you "end up" after being in one; "confined" implies, as against one's will which is not necessarily true of a person who voluntarily uses a nursing home facility.)

More specifically in regard to the project, it is assumed that any agency providing human services develop their intervention plan with due regard for both the figure and background aspects of the client. As an example, it would be foolhardy for a client to be prescribed a medication and have no financial means of obtaining it, i.e. the agency would refer or assist the client to or with resources, eg. an HSSD application. Similarly, agencies such as mental health, various medical programs and rehabilitation programs develop intervention plans, but unintentionally may overlook a possible variable which can seriously jeopardize the plan (or even limit potential clients from seeking services). This variable is the client's psychological and physical residence which, for many, is a boarding home. With due respect to the fine boarding home operators, general public opinion appears to be pessimistic about the quality of living provided and negativistic about the intentions of operators. No known local project has existed which attempts to offer positive consideration of operators' "side of the story." The proposed project is such an attempt: Project staff will be trained; work in boarding homes or operate one for a specified period; provide psycho/social services; gather management and other data; analyze data and develop a Boarding Home Operations Training Package for statewide use that focuses on fiscal/physical management and Physical/Psychological Care Development. If, as indicated by the data, further positive support is necessary, the data will be presented to possible resources, e.g., the Health & Social Services Department and/or the Department of Hospitals and Institutions.

Many boarding homes contain a mixture of older and younger residents. The Project will: 1) Focus on this typical boarding home resident pattern as best as possible and 2) Be considered as part of the development of a comprehensive (mental health) program on aging.

As a final introductory comment, it may be argued that the proposal focus, boarding homes and their operation, fall beyond the realm of sponsorship by a mental health facility. However, it is suggested that this is a service gap area and that the Mental Health Care/Department of Psychiatry play only a leadership and stimulation role that will eventually bring forth a, perhaps, more appropriate sponsoring agency or the development of a private organization of boarding (and perhaps nursing) home operators. In addition, the two alternative methods for obtaining the objectives of the Project are time limited.

BOARDING HOMES

Boarding homes are not to be confused with skilled or intermediate care nursing homes. The latter provides a residential situation with trained nursing personnel. The former is not required to provide in-house nursing care. A boarding home is a group residence which provides sleeping facilities and meals. In those instances where some physical assistance is provided, e.g. dressing, bathing, feeding and where certain physical plant requirements are met, e.g. crash bars on the doors, the home may be designated a sheltered home. Few homes are so designated because of the financial expense of meeting the physical plant requirements. (Often a room and board operator may assist with feeding, bathing, etc. because of his own personality style.) An individual who seeks to board more than two individuals in his home, must meet license requirements (primarily related to the physical plant) of the New Mexico Health & Social Services Department.

At present, there are thirty-nine licensed facilities in Bernalillo County and fifty-five in the remainder of the state with many in Las Vegas where the State Psychiatric Hospital is located. Four facilities in Bernalillo County will be excluded from statistical presentation; (three related to drug rehabilitation programs and one sponsored by the Albuquerque Association for Retarded Children). Thus, the licensed capacity of the remaining thirty-five homes is approximately 350. For the rest of the state, it is 485. In addition to licensed facilities, it is estimated by HSSD personnel that there are 700 unlicensed facilities locally creating a potential capacity of 1,400. Little supervision or knowledge of these homes is available. Expanding further on the spectrum of "living" facilities are the many less expensive motels and hotels in the core city where elder or the younger disabled may reside.

Who live in boarding homes? No concrete "diagnostic" or descriptive material is available. However, as community based mental health staff have occasion to consult or work with residents over the past five years, one might characterize a majority of the residents as the infirmed elderly, the young and older adult retarded and the young and older adult marginal functioning individual, oftentimes ex-state hospital patient.

Why a concern for boarding homes as they are a private, profit making business? As, it is believed, Mark Twain once said about the weather, everybody talks about it, but nobody ever does anything about it. Refer to any agency personnel that has contact with boarding homes-Visiting Nursing Service, Office of Economic Opportunity, Family Health Center, Mental Health Center, Coordinated Action for Senior Adults, Albuquerque Community Council, Mid-Rio Grande Health Planning Council, Community Services Office of New Mexico State Hospital, Health & Social Services Department, Environmental Health-and question the quality of living aspects of many boarding homes. Over a year ago, community concern, that periodically waxes and wanes resulted in the closing of a few facilities for fire-safety violations, e.g. insulation of heating equipment, too many residents, including one blind person living in a basement bedroom, etc. The concern, however, that stifles many more closings is where are the residents to be "shifted." Indeed, it should be up to the individual to move if he is not satisfied, however, because of lack of cognitive/emotional capacity or the limited financial resources of many, the number of choice alternatives is limited. Further, speaking recently to a senior resident who was exploring her plight of being physically mishandled, she at the time was reluctant to be placed elsewhere as she had established friends in the home and was also fearful she would no longer be able to visit with relatives in the general neighborhood.

For at least the last five years, the general attitude regarding boarding homes has been a negativism mixed with outrageous indignation and a sense of punitiveness. The general solutions offered are for tougher regulations, enforcement and closing. Several other "input" variables need to be considered: (1) Several states

are moving to close state institutions. California is a leader in this regard, but as one recent visitor to California stated, "They have created new 'ghettos'—the mentally ill district." In other words, adequate community placement plans or facilities appear to be lacking; (2) Las Lunas Training School seeks to place residents in the community as does the Acute Geriatric Unit of New Mexico State Hospital; (3) Future planning for New Mexico seeks to attract retirees including some folks who may eventually run out of retirement "nest eggs" and who will be in need of some type of less expensive form of residence; and (4) The National Cancer Center at the University of New Mexico has the potential for drawing in future residents who may eventually be in need of a boarding home type of residence.

What kind of care are residents of boarding homes receiving? Excluding the condition of the physical plant of some homes, residents contract for care as one would in a motel-none (with due respect to the motel industry). Boarding homes are not treatment/care facilities-boarders are boarders and not patients. Some operators are concerned about their image-many do attempt to provide some care, Mr. and Mrs. X who would transport a resident to the emergency room in the middle of the night and stay two-three hours, or to the doctor during the day, or oversee, as best as possible, a resident's medication, or allow a church group into the house to visit, or take a resident to a Day Treatment Program, etc., etc. Several operators have banded together in the past to attempt to foster the image of a Residential Aide and Service Homes Organization. Perhaps a positive action approach could develop a potential resource into a strong supplement to any rehabilitative attempts with all categories of social service agency clients. Put another way, are out patient attempts at treatment of a medical or mental health facility or on a specific DVR client enhanced or detracted from when the client lives in a boarding home as many currently exist.

TOWARD A POSITIVE APPROACH

Writing in Mental Health: Principles and Training Techniques in Nursing Home Care (DHEW Publication No. (HSM) 73–9046) W. Beattie, Director of the Gerontology Center of Syracuse University points out that "most of the administrators of these facilities are not educated beyond the high school level and the personnel have scant education and receive minimal wages." Reference here is to nursing homes-one may speculate on the "qualifying" background of boarding home operators (again, many of whom have the best of intentions).

As briefly reported in Hospital and Community Psychiatry, (1974, 25, 125), a program was recently begun in California to provide operators of residential homes for the developmentally disabled an intensive eighteen week training program to increase their awareness of the resident's capacity for growth and full participation in normal community life and to increase their own skills to promote such growth. The training is followed by nine months of personalized training in the caretakers' homes. (The "news brief" does not present specifics in regard to the residential homes, but it should be remembered that the level of welfare aid is higher in California than New Mexico.)

At present, it appears that there are some facts known and feelings that exist about boarding homes. However, it is proposed that a living laboratory situation be established in regard to boarding homes. Two alternative models for such a living laboratory will be presented with the following objectives:

1. To obtain objective data on boarding home management, e.g. financial, dietary, medical, behavioral, stress factors and as yet unknown variables that affect, positively or negatively the operator and resident.

2. To develop and teach operators problem solving skills in areas as related to Objective 1.

3. To provide data to and coordinate with. for example, the Department of Health & Social Services or Department of Hospitals and Institutions in the development of, if indicated by analysis of project material: (a) Possible supplementary financial support to homes for staffing, physical plant, etc; (b) Standards regarding qualification and screening of new operator application for licensure: (c) Further standards for operation as consistent with 3a; (d) Methods of stimulating initiation of additional homes through the private sector or other local sources; (e) Alternative forms of semi-independent living situations. 4. To provide a focal point and more positive attitude of community/agency support to encourage attempts at self-help organizing among operators such as RASH.

5. To provide, on a limited basis, direct mental health care of various degrees and formats and referral for ancillary services-medical, physical/social re habilitation, financial, legal services.

6. To explore exit difficulties and possibilities.

7. To develop a training/counseling program whereby relatives who place a resident can resume responsibility and care of the relative in their own home as previously.

8. To develop a system of analysis of current boarding homes whereby potential residents could be matched with a home by more formal/objective means to both the satisfaction of the resident and operator.

9. To study and make recommendations or stimulate a more formal system for interactions regarding two way placements between New Mexico State Hospital, Nursing Homes, Boarding Homes, Mental Health Center, HSSD, Los Lunas Training Hospital and the like.

10. To provide a focal point for coordination of allied services which can be involved in boarding homes, e.g. Family Health Center, Visiting Nursing Service, Public Health Service, HSSD, and the like. Within the past month and a half, a mini team, LOS VECINOS, of the outpatient program of the Bernalillo County Mental Health Center is focusing, on a part time basis, on three boarding homes with the intent of providing mental health services or social/activities program in addition to eliciting other supportive services, i.e. Family Health Center to do general medical screening, e.g. blood pressure checks.

11. To explore use of the project as an on-the-job training experience for other programs to develop skills for advanced placement in homes or other care facilities.

12. To provide practicum situations for psychiatric residents, medical, nursing, graduate psychology, counseling and guidance students and related disciplines to provide them with a minimal awareness of geriatrics and other younger developmental disabilities or encourage specialization in these areas.

13. To develop a Boarding Home Operation Training Package that could expand on materials as presented in the California project of above.

14. To train project staff in skills of teaching/training that at the end of the project, project staff could consult and train boarding home operators within the county and throughout the state. To again quote Beattie in reviewing the National Conference, "It was pointed out that there is a need to train not only administrators and staff (of nursing homes) but, as a first step, train the trainers, all of whom must be knowledgeable in areas of aging and mental health, as well as aware of the multifaceted problems faced by homes in caring for their residents" [emphasis added].

CONSIDERATIONS COMMON TO PROJECTS A & B

The target area of either project would be within the Primary Service Area (PSA) of the Bernalillo County Mental Health/Mental Retardation Center (MHC). Carlisle NE & SE roughly divides the two service areas, with the western portion of the County being the PSA. For MHC/federal funding purposes, this area is also designated as a poverty area. In addition, approximately 16,000 of the 30,000 plus individuals over the age 60 reside in this portion of the county. Close to 9,000 individuals over the age of 60 are Spanish speaking or Spanish surnamed; this area of the county, i.e. the Valley is traditionally known as the preferred residence area of the Spanish American and therefore it is presumed to contain the major portion of elderly. Similar information on other ethnic groups is not available through 1970 census statistics. The South Broadway and Kirtland areas of the PSA are however recognized as the prime residence areas of the Black community. The majority (approximately 90%) of the licensed boarding homes are located within the PSA.

The Metropolitan Areawide Aging Agency is charged with the task of coordinating and planning programs on aging. It has drawn together personnel of various agencies and senior citizens to develop a Comprehensive Areawide Plan for the Elderly. The Project would draw upon Metro 3A for community support and participation. In addition, the residents of the homes themselves could be developed into a formal task group or would be a primary informal data source in addition to the home operator.

The Senior Aide Program (Department of Labor) could be involved in either project at two levels: (1) Assistance with work placement of residents over the age of 55; and (2) Placing individuals in the project providing additional

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