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in large boarding homes as well as individual interviews have been made to help alleviate the heavy caseload. According to the caseworker, however, many services are still needed but are impossible to be taken care of because of lack of staff. Services provided are many and of diverse types. They range anywhere from writing a letter to a daughter or son for a boarding home resident, to protecting a mentally retarded man from an intimidating boarding home operator.

Below is a list of the most frequented types of services provided.

1. Periodic visits with boarding homes depending on type of home, attitude of operator, care of resident and individual problems of residents that may arise from time to time.

2. Transportation is provided for medical reasons, recreational activities, to the Social Security Office, pre-placement visits to other boarding homes and to visit with friends and relatives, etc.

3. Protection from exploitation and intimidation by the boarding home operator. These protective services for adults include seeing that the resident is being properly fed, the home is adequately clean, and in some instances, removing a client who has been physically abused by the operator.

Since the separation of agencies in January of 1973, it has been the procedure of the New Mexico State Hospital to call our agency in reference to placing patients as residents in the boarding homes. This is how the majority of our residents are placed. Other referrals have come from families who are seeking a boarding home for a family member, from the Health Department and also from the Public Assistance Agency.

Prior to January 1, 1974, an average of 30 referrals a month were given to our agency by the Public Assistance Agency.

Since the conversion to BSSI, only an average of 3 referrals a month are given to our agency by the New Mexico State Hospital because the patients cannot apply for BSSI while in the institution.

ITEM 3. LETTER FROM MRS. CONNIE SANCHEZ, BOARDINGHOME OPERATOR, LAS VEGAS, N. MEX.; TO SENATOR PETE V. DOMENICI, DATED JUNE 27, 1974

DEAR SENATOR DOMENICI: As of today 13 Boarding Home Operators have joined the R.A.S.H. Organization, and this 13 have always been interested and dedicated. Our facilities were inspected this past week and aside of some deficiencies the majority of the homes were given an annual license, while other were given 90 days to up-grade or less; but in order for the operators to meet such stringent standards we need You the government to up-grade the rate that is being paid for the services that these homes offer.

The majority of the people that we care for have no one else to care for them or else their families are incapable of caring for them. Thanking you for your concern.

Sincerely Yours,

CONNIE SANCHEZ.

ITEM 4. LETTER FROM ADELINA ORTIZ DE HILL, ASSISTANT PROFESSOR, DEPARTMENT OF BEHAVIORAL SCIENCES, NEW MEXICO HIGHLANDS UNIVERSITY, LAS VEGAS, N. MEX.; TO MR. WILLIAM E. ORIOL, STAFF DIRECTOR, COMMITTEE ON AGING, DATED JUNE 5, 1974

DEAR MR. ORIOL: I am enclosing excerpts from the 1. AARP testimony that I referred to in my comments. 2. Also I would like to place in the order of sequence the testimony I submitted Saturday, May 25, 1974, the afternoon of the hearing. 3. Finally I would like to comment on health needs the focus of the Committee hearing. I realize that my concerns seemed narrowly confined to the boarding home problem and that while there are health implications involved it is more a concern of mental health.

1. The AARP: State Legislative testimony: I think it is significant to note that Boarding Homes were ranked first in a series of recommendations relating to problems for aging persons in New Mexico, also that it is referred to as prime

importance. I have placed a star alongside the material I submitted for a supplemental comment. I will leave it up to your staff to determine its relevance.

2. In addition to the testimony I submitted Saturday:

a. I provided a demographic profile of New Mexico listing several variables including rural-income-age over sixty-five, etc.

b. Also a copy of the regs in relation to Adult Services which removes from the register money mandated services, always a good excuse for offering none. This hurts rural areas where the Welfare Department and Social Services are the only resource for services. Also Social Services could assist even those not eligible, on sliding scale payments in particular Home Health Aides.

c. The packet of Adult Services which I developed to accompany information on the Medical Evaluation form for Boarding Home residents.

3. In regard to Barriers to Health Care in the State of New Mexico there are several issues I would like to develop. Some will require legislation, others may be administrative.

a. First, I would like to say I concur with Mr. Lopez's testimony about the building of a health care system on a house of cards. There are many areas in the state where doctors will not treat welfare clients, in particular the Eastside and Dona Ana County because of paperwork and red tape.

b. I have always been a proponent of preventive screening. However, I understand that after screening and referral that doctors often do not effectively follow up on referrals. This may be attributed to two things, the shortage of doctors particularly in Northern New Mexico and what Kasterbaum refers to as the "reluctant therapist" less interest in the problems of ill aging people. Despite the fact that this may be the case I still believe that periodic screening for health problems and the possible prompt diagnosis of diabetes, for example, is worthwhile.

c. The language of medicare information, indeed much information, coming from the Social Security Administration is not easily understood. Payments disregard, etc., often the printing is too fine for many elderly whose visual acuity has diminished. A case was reported to me of a woman with a drawer full of uncashed social security checks, because she simply did not understand the instructions about the change of her status. BSSI has now taken on a client with an average of a third grade education. I feel it will have to make a special effort to be intelligible.

d. That while much is said about folk medicine in the Spanish-speaking culture, good medical care can be provided if the care giver understands and can communicate confidence and understanding of some practices. The stoism and fatalism attributed to the Spanish speaking may be the case in minor ailments or illness that to be due to "susto" or a psychosomatic cause. Which may be the case in the greater population as well, certainly the pre-ponderance of drug commercials implies it. Education in the preventive area is quite important and needed. e. Home health care is also preferred to institutionalization and should be reimbursed by medicare payments.

f. The rural elderly in some communities do not have access to telephones and ancillary health care givers are needed in smaller communities to supplement medical care.

g. Too often nursing homes become terminal placement because families are reluctant to care for the infirm elderly person due to ignorance and lack of training for the minimal up-keep in home. The medical mystique is frightening and the family feels it is unable to give adequate care in the home.

h. In some cases nursing homes could function a day care center for some infirm elderly who require some monitoring such as cardiac problems, etc., so that working family or a housewife can get some relief from the constant care required. This may also be reimbursed by medicare and would minimize use of nursing care homes fulltime or on a cost benefit bases be worthwhile exploring.

i. For the most part I can concur with most of the witnesses who have recommended that prescription drugs, insulin and therapeutic vitamins formulas be covered by medicare.

Thank you again for giving us a forum in which to focus our concerns for our aging population.

Sincerely,

ADELINA ORTIZ DE HILL,

Assistant Professor of Social Work,

Department of Behavioral Sciences.

ITEM 5. LEGISLATIVE PROPOSALS FOR CONSIDERATION BY NEW MEXICO JOINT LEGISLATIVE COMMITTEE ON HEALTH AND AGING, RECOMMENDED BY NATIONAL RETIRED TEACHERS ASSOCIATION/ AMERICAN ASSOCIATION OF RETIRED PERSONS STATE LEGISLATIVE COMMITTEE

SUPPLEMENTARY COMMENTS

1. Establish and enforce sound standards of safety, hygiene and operation nursing homes, retirement homes and boarding homes housing elderly persons. A. Increasing, if necessary, payments for indigents who are housed in these facilities so that adequate care is given.

B. Establish as a "minimum standard of need" for indigents the amounts developed in a study by Dr. Gerald J. Boyle and reported to the 1972 Interim Committee on Aging. In brief these are:

1 adult in boarding house.
1 adult living alone---
2 adults living together.

COMMENT

Allowance per month

$86.50

147.00

195.00

The State of New Mexico now has an agency (Health and Social Services Department) which should be qualified to set up appropriate standards of safety, hygiene and operation of places housing older people, whether these are privately owned or publicly owned establishments. Assuming that this is already accomplished the agency should be responsible for enforcing these standards. We hear that the HSS does not have sufficient manpower to adequately supervise and enforce its present standards let alone any higher level of standards. If the agency is not manned to do this job then it should contract or otherwise have the job done.

We also hear that these establishments housing older people claim State payments for welfare recipients are insufficient to maintain adequate standards. We cannot offer judgment in these instances, we only see upon visitations, dire need. Our investigations have revealed that some older recipients are living in deplorable circumstances. This should not be tolerated.

We maintain that it is the responsibility of the Legislature to insist that its agencies (HSS) establish adequate standards and enforce them. It is the responsibility of the HSS to inform the Legislature of the costs of an adequate realistic program. The Legislature should then arrange for funds so the program can be implemented.

One of the serious problems occur when old persons are elevated out of the State income area restrictions or guide lines by Social Security of other income benefit increases.

We understand that after Jan. 1, 1974 under HR-1, the Federal Government will underwrite some of the expense of the indigent to the extent of

1 adult in boarding house---

1 adult living alone_--

2 adults living together.

Allowance per month

$86.50

130.00

195. 00

Whether this will result in a net relief to present State funding we are not sure but it seems to support the minimum need study of Dr. Boyle to which we subscribe.

The 1973 Legislature approved several major legislative items dealing with the Health and Social Services Department and a departmental appropriation of $30.7 million for the fiscal year beginning July 1.

The HSSD Board subsequently approved a total operating budget including Federal funds of $104.4 million for the next fiscal year.

Although the legislators did not okay all programs and expenditure levels sought by the department, relations with the legislative branch were generally "smooth sailing" in contrast to some sessions of the past.

One important bill enacted by the 1973 session extends the Medicaid portion of the Aid to the Aged, Blind and Disabled (AABD) program to those persons who were presently just over the AABD income line but who are facing severe medical difficulties which might lead to death without such assistance.

Passage of the bill, Chapter 311, was given impetus by a State Court of Appeals ruling that the department must provide such aid-even though the Legislature had never specifically mandated such a program nor appropriated funds to operate it. Caught between conflicting pressures, the department sought-and received the legislative solution represented by Chapter 311.

The bill carried an appropriation of $250,000, which HSSD officials hope to match with Federal funds, but department spokesmen say there is no way of knowing at this point whether the appropriation will be sufficient.

We urge each member of the Health and Aging Committee to secure, read and study a publication entitled "A Guide for Social Services in Nursing Homes and Related Facilities" which is available from the Superintendent of Documents, Government Printing Office, Washington, D.C. 20402, at 50 cents per copy. This Guide was prepared by experts in the field. Its 25 pages of comments and conclusions have a wealth of information for the ordinary layman.

Citing just a few items of interest that has come to our attention through this Guide.

I. Characteristics

WHAT IS A NURSING HOME

A nursing home may be "free-standing," a special section of a hospital, of an infirmary in a home for the aged. Increasingly, homes for the aged are adding facilities for medical care for their ill who may have been relatively well on admission but often develop illnesses with advancing years. Older related resources include: "personal care," "rest" or "residential care" homes, "country homes," foster and boarding homes, and chronic disease hospitals or geriatric wards in general hospitals.

Current estimates (1965) indicate that there are approximately 19,000 licensed nursing homes with over 760,000 beds in the United States, 87 percent of which were occupied in any one day. Not represented in these counts is a substantial number of unlicensed facilities (e.g., 3,595 in California representing 34,065 beds, which are considered personal care homes rather than nursing homes).

With about 60 percent of all nursing home residents throughout the country now receiving some form of public assistance, payments by welfare departments have been a major factor in determining adequacy of care. Because of the great range in the amount of payments, often considered inadequate by administrators, some homes have not been willing to accept public assistance recipients. II. Standards

In the past, attempts have been made by health or welfare departments to classify nursing homes according to services available, and the residents by the needs they present. The basic purpose of this procedure is to match the patient to the home and to compensate the administration for the type of care residents receive, adapting the scale to changes that occur in the resident's condition.

Other standard-setting methods have also been employed. Licensure is the principal method of regulation and standard-setting in nursing homes and related facilities. The agency carrying this responsibility in nearly all States is the State Health Department. In all States and Territories except Guam and the Virgin Islands, nursing homes are licensed. Homes for the aged are also licensed in all but two States and three Territories. There is no established pattern for licensure for other types of group facilities, some of which are blanketed into the nursing home regulations and in other instances are licensed separately or not at all.

A model law was developed in 1966 by the Council of State Governments which incorporates many of the recommended standards in the Conditions for Participation. This document was developed by a multidisciplinary committee collaboratively with members of the Council, including representations from the National Association of Social Workers.

III. Current trends

Funds for modernization and construction of new facilities are available through Hill-Burton, Federal Housing and Small Business Administration sources, each of which provides financial means for improving the physical standards of these facilities. Policies continue to be liberalized with regard to loans, making it easier for nursing home administrators to use these resources. One of the emerging trends is the use of nursing homes as day centers and for temporary care of persons who can live at home or with relatives but who need supervision at certain periods. Some of the senior centers, which are primarily geared to recreation and socialization, have been extending their services to

residents of nursing homes. This increased involvement contributes to closing one of the principal gaps in services, that of stimulating experiences which assist the residents to remain alert and interested in other people.

Undoubtedly the most important development in relation to nursing homes is the impact of the Medicare legislation. One significant sequel of its passage will probably be in conversion of some nursing homes from their former role of largely custodial institutions to post-hospital convalescent care facilities with high quality medical and nursing (including restorative) services.

There is documented evidence that deterioration often accompanies congregate living and long-term institutionalization even with the best of care. Movement of patients in and out of nursing homes and the use of the facilities for short stays has only in recent years become a growing pattern. The current trend is to provide an attractive and safe environment, medical supervision and high quality nursing care, restorative service and such supports as social services, pastoral counselling and recreation, to enable patients more frequently to return to their normal environmental rather than remain in an institution for the rest of their lives.

People in general are becoming more knowledgeable and are insisting on better care. Somewhat more slowly, the public image of the nursing home is changing. The community is also coming to realize that in these nursing home beds are people with social and emotional as well as physical problems-similar kinds of problems to those of older people who are not in nursing homes, plus others created or aggravated by illness and enforced absence from their normal environment.

PEOPLE WHO RECEIVE CARE IN NURSING HOMES

According to a study made by the National Center for Health Statistics, residents in nursing and personal care homes (from April-June 1963) had the following characteristics:

Age.-Residents of these institutions were primarily an elderly population. The average age of all residents was 77.6 years; 70 per cent of the residents were 75 years and older while only 12 per cent were under 65 and only 2 per cent were under 45.

Sex. 66 per cent of the residents were women, a proportion which varies with age; with increasing age, the proportion of women increases. Men predominate (54%) only among those residents under 65. Among all residents 85 and over, women represent 75 per cent of the nursing home population. The average age for women was 79 years, for men 70 years.

Health Status.-About 57 per cent of the residents in all homes were able to be out of bed except for sleeping; about three-fourths were continent; half were generally mentally alert and four-fifths did not have serious hearings or visual problems. There was an increase in physical disability with advancing age. Summary and Comments.-Despite variations for age categories, the overall picturization of residents of nursing and personal care homes is predominately one of the aged, with women substantially outnumbering men.

From the cited source and other references, information was provided that, on an average, people stayed in nursing homes approximately one year; some left earlier or later to return to community living or were transferred to other kinds of facilities; however, many lived there the remainder of their lives. For the total nursing home population, hospitals referred between one-fourth and one-third of the residents, other long-term facilities about one-fifth, and the largest and remaining proportions were self-referrals or were referred by others while the patients were living in private dwellings. Available information on the sources of support for care indicates that family members, alone or together with public welfare, carry considerable responsibility for payment to nursing homes.

Some studies have also indicated that between one-third and one-half of the people residing in nursing homes do not need skilled nursing care, but have been referred primarily for social reasons or because other resources are lacking. With the realization that a shortage of nursing homes with acceptable standards still exists, there is growing appreciation that such facilities should be reserved for persons requiring nursing care or supervision.

As other supportive services become increasingly available, nursing homes will be more selectively used in the future than they have been in the past. Community programs for special housing for the aged, visiting nurse services, organized home care, homemakers and home-delivered meals will enable aged persons to remain independent within the community for longer periods of time.

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