good the institution, certain demands for conformity or standardization will be made upon the individual. To some extent, he must alter his pace and accustomed patterns to fit in with the group or the institutional regimen. Often, the process of institutionalization itself aggravates the problem and reduces ability to function. MANY COULD REMAIN IN HOME At least 10-25 percent of the population now in institutional homes of varying kinds could be cared for and remain in their own homes if organized services beyond episodic nursing and medical care were available. Some people are there because they require assistance with their activities of daily living-ranging from complete hygiene and feeding to minimal assistance in getting out of and into bed. Some are there because they do not have the physical reserves to maintain a clean and uncluttered environment. Some are there because they do not have family members to assist them, or because those family members can assist them for only a portion of any given day. Some are there because they require medications or treatments, the response and progress of which must be evaluated on a daily basis. Some are there because they require treatments and medications which must be administered by someone else on a daily or twice-daily basis. Some are there because they need special types of equipment in order to function or to survive. While individuals may be presumed innocent until proven guilty, home health services are presumed unnecessary until proven essential. In certain instances, third-party payers imply that agencies delivering services are either inept in their ability to valuate need for service or dishonest in their claims. On occasion, the position is taken that, while this service may be necessary, it is not reimbursable or covered under the terms of contract or eligibility criteria. Claims by insurance programs imply to the consumer that, in the event of a health crisis or health need, he will receive full service to the extent of his need; policies and contracts are so worded that they may be interpreted in any manner by the insurance companies. While many of us jokingly refer to contracts or policies as having all benefits in large print and all restrictions in microscopic print, it becomes far from laughable when individuals are faced with the economic crisis which often follows the health or illness crisis. There are some insurance policies which offer "X" number of dollars per week or month to people when they are hospitalized. People subscribe to this insurance, expecting to insure income during a nonearning period. However, should this same individual be confined at home receiving services there, this policy would not apply. In fact, many of these companies will not even cover the period an individual is in an extended care facility for continuing treatment of the illness for which he was hospitalized. Thus, a person might well discover that if he remains in the "acute hospital," he would be covered by his hospital insurance and receive an income, while if he remains at home or leaves the hospital sooner with supportive services in his home, he may have to pay all of his own medical bills and nursing bills with no income to fall back on. Insurance carriers should be required to write policies with such clarity that consumers can readily understand the coverage. Interestingly enough, those in the middle income group are the most affected by the varying restrictions. Their usual income levels do not qualify them for municipal, state, or federal aid, nor do they afford them sufficient money to pay for the services. The poor are also affected, because the degree of proof that services provided are indeed essential is almost prohibitive. The concept of individuals going into the home to assist or minister during times of crisis or illness has always been present. Many of these services were delivered free of charge to the needy. They were whimsical, dependent upon the extent to which the recipients were considered deserving and were visible. Today our criteria for the "deserving" would, on the surface, appear less whimsical, but, in fact, they are still capricious. Individuals or families are deprived of necessary services because of rigid restrictions by Medicare or because of the inability of the providers to correctly interpret and understand the implications of the conditions. One must, in effect, prove that home health services are necessary and a substitute for institutionalization and consequently less costly. For want of a walker, an individual may be chairbound. For want of a skilled therapist, an individual may lose the use of a hand or a leg. For want of an hydraulic lift, or individuals skilled in lifting, a person may be bedbound. For want of delivery of an oxygen tank and instructions in the use of a mask or inhalator, an individual may remain within the confines of an institution, fearful of leaving. Our production line technological approach has extended to the care of the sick, the elderly, the infirm, and the isolated and lonely. We put them where the services are, rather than bringing the services to them. Most major hospitals today have a home health or home care coordinator. This person, most frequently becomes involved after admission of an individual to the hospital setting and usually when discharge is being considered. It is rare that one sees a home care coordinator involved in the evaluation of admissions to the hospital or in the outpatient units. Again, this reflects a concept of home health services to the ill as an aftermath of continuation of institutional care, so that our present continuum of care is most likely to be hospital, then home, rather than choice of hospital when care in the home is impossible because of the need for specific services which are not transportable and to which the individual cannot be transported for a brief treatment. In 1972, the Special Committee on Aging of the United States Senate, in the previously cited report on home health services in the United States, made the following major recommendations: Medicare and Medicaid regulations must be interpreted and applied so as to provide, rather than restrict, home health services; Home health planning must be based primarily on the professional judgments of those familiar with consumer needs rather than remote decisionmakers far removed from the problems; Institutionalization as a condition for home health care must be eliminated, as well as requirements for coinsurance payments; Costly and confusing red tape must be eliminated in providing home health services, including in particular the practices of prior authorization and retroactive denials; Proposals for national health care legislation must include provision for comprehensive home health services; A national approach to the provision of adequate coverage of the population by home health services is essential. In 1973, individuals are still being institutionalized and being maintained in institutions because of lack of adequate home care servces or, where the services do exist, because of inability to pay for them or to have them covered through some form of health insurance. II. Implications for Action A. Types of Services Necessary The quantity, range, and pattern of organization of home health services will depend upon the socioeconomic, cultural, and age characteristics of the population to be served and the types of health and social problems most prevalent in the area. Differing geographic areas (urban, suburban, rural) will also influence the range and patterns of services required. Basic service components which must be available for effective and highquality care to individuals in their homes include medical, dental, and nursing care; homemaker-home health aide services; physical, occupational, and speech therapies; social work, nutritional, health education, laboratory, and pharmaceutical services; transportation and medical equipment and supplies. Regardless of the specific components required in individual situations for safe and effective care, all of the above components-with the possible exception of physical, occupational, and speech therapies should be available on a sevenday-a-week basis. Social problems have a direct relationship to the health and well-being of individuals within a society. A complete health service program must foster means and methods to improve the social setting as well as provide direct medical and nursing intervention to deal with the resultant health problems. The following factors must also fall within the purview of organized home health services: patient and family education to enhance compliance with prescribed regimens ; provision for adequate and safe housing; assistance with maintaining a clean and nonhazardous environment; nutritional services including home-delivered meals, or shopping, as well as preparation of food; arrangements for individuals to move beyond the immediate confines of their homes to socialize and interact with others, whether it be the sick individual or members of the family who may not be free unless someone can relieve them; and planning for socialization within the home for the completely homebound, through periodic visits of others. Central to the organization of high quality patient care services at home must be mechanisms for coordination of the various services and components of care required by individual patient and family situations. B. Present Effect on Economy 1. Loss of Work.-Empirically, it is known that there are a number of individuals who could work either at home or in an outside work setting if provisions could be made to get work to them, or to get them to work. In addition, concentrated supportive rehabilitative services in the home could assist them to develop sufficient capacity to function productively within the home, and, in many instances, to be able to independently travel to and from a work setting. Money spent in such a program would be returned indirectly through the earning capacity of these people. Family members who might be capable of earning or working are confined to home because of the prolonged or permanent invalidism of a sick member. In addition, this type of input creates emotional as well as energy drains upon well family members, which often precipitates both physiological and psychological illness increasing the health problem. 2. Use of Institutions at Higher Cost.-There are people who are institutionalized beyond a necessary time due to lack of organized services to meet their particular needs. The following figures represent the difference in cost for home health agencies and institutions of any kind. MEDICARE REIMBURSEMENT FOR HOME HEALTH SERVICES AND INPATIENT HOSPITALIZATION, 1969-72 [In millions of dollars] 1 Estimated on the basis of claims received through Dec. 7, 1972 (1st 6 months multiplied by 2). 1 Includes some reimbursables for which type of service is unknown. 5,026, 025 40, 771 167, 834 5, 234, 630 1,748, 270 15, 824 104, 778 12, 398 75, 062 1 1, 956, 423 7, 191, 053 NOTE. Home health (parts A and B) reimbursements for 1971, total $56,595 (in thousands) or 0.787 percent of the total Medicare reimbursement for services in 1971. Source: Prepared by Department of Home Health Agencies and Community Health Services, NLN 2-20-73. III. Recommended Policy We must approach the problems of the chronically ill, aging, and infirm with the same vigorous leadership that we have demonstrated in the past in dealing with communicable diseases and maternal and child health, for these illnesses are also a part of family health and the public's health. Therefore, it is recommended that APHA : 1. Endorse the "Home Health Services Definition and Statement" (Appendix B), developed by a task force composed of representatives of outpatient and home care institutions, American Hospital Association; the Council of Home Health agencies and Community Health Services, National League for Nursing; the National Association of Home Health Agencies; and the National Council for Homemaker-Home Health Aide Services. 2. Develop a multi-disciplinary task force to develop guidelines and criteria to further the implementation of Home Health Services. 3. Support liaison with other national organizations involved in delineating and supporting Home Health Services with the goal of strengthening delivery and coordination of services. Advise the federal government of the importance of allocating funds in support of these services based upon the guidelines established by the organizations. 4. Encourage local communities through the Comprehensive Health Planning Agency to study and determine the extent and type of needs peculiar to their area and develop programs to meet these needs. 5. APHA should go on record in support of the inclusion of home care coverage in whatever kind of national health insurance is to be enacted. Reference Material APPENDIX A Based on the data from the Health Interview Survey of the civilian, noninstitutional population, the U.S. Department of Health, Education, and Welfare has estimated that the number of individuals with some limitation on activity resulting from chronic conditions has increased from 22.2 million in 1961-631 to 24.8 million in 1971. In both periods these persons represented one out of every eight individuals in this country. It is obvious that the problems resulting from the development of chronic diseases are not easing, since the number of persons affected is increasing at the same rate as the general population. For three-quarters of those with activity limitation, such limitation pertains to their major activity (working, housekeeping, school attendance). Other types of activity affected are recreational, religious, and civic. The above figures apply to the non-institutional population. Surveys of resident places conducted by DHEW in cooperation with the Bureau of the Census show a very rapid rise in the number of occupants of such establishments as nursing homes, personal care homes, and homes for the aged. During 1969, an estimated 815,000 persons were residents of nursing and personal care homes compared to 554,000 in 1964 and 505,000 in 1963; 1969 thus represented an increase of 61.4 percent above the level in 1963. This, of course, is a much greater rate of increase than that of the general population. The great majority of the patients (75 percent) were in homes where the primary service was nursing care. An additional 18 percent were in personal care homes with nursing facilities. Less than 7 percent of all residents were in homes where the primary service was personal care only. Definition and Statement APPENDIX B Foreword. The following definition and position statement on Home Health Services was developed by a task force composed of representatives of the Assembly of Outpatient and Home Care Institutions, American Hospital Association; 1 "Chronic Conditions and Activity Limitations," National Center for Health Statistics, PHS Pub. No. 1000, Series 10, No. 17. "Current Estimates from the Health Interview Survey," NCHS, PHS Pub. No. 1000, Series 10, No. 79. 3 "Characteristics of Residents in Nursing and Personal Care Homes: June-August 1969," NCHS, PHS Pub. No. 1000, Series 12, No. 19. "Prevalency of Chronic Conditions and Impairments Among Residents of Nursing and Personal Care Homes: May-June 1964," NCHS, PHS Pub. No. 1000, Series 12, No. 8. 5 "Characteristics of Residents in Institutions for the Aged and Chronically Ill; AprilJune 1963," NCHS, PHS Pub. No. 1000, Series 12, No. 2. 6 "Inpatient Health Facilities," NCHS, PHS Pub. No. 1000, Series 14, No. 6. the Council of Home Health Agencies and Community Health Services, National League for Nursing; the National Association of Home Health Agencies; and the National Council for Homemaker-Home Health Aide Services, Inc. Definition. Home health service is that component of comprehensive health care whereby services are provided to individuals and families in their places of residence for the purpose of promoting, maintaining, or restoring health, or minimizing the effects of illness and disability. Services appropriate to the needs of the individual patient and family are planned, coordinated and made available by an agency/institution, or a unit of an agency/institution, organized for the delivery of health care through the use of employed staff, contractual arrangements, or a combination of administrative patterns. These services are provided under a plan of care which includes appropriate service components such as, but not limited to, medical care, dental care, nursing, physical therapy, speech therapy, occupational therapy, social work, nutrition, homemaker-home health aide, transportation, laboratory services, medical equipment and supplies. Statement on Health Services in the Home.-The home environment plays a significant role in promoting health and facilitating the healing process. Properly coordinated and administered home health care provides a meaningful health service for ill persons, speeds recovery and rehabilitation of individuals with acute or chronic health problems, and assists in the prevention of disease and disability. The provision of appropriate health care services to patients in their homes benefits the patient, the family, and the community. Therefore, it is imperative that quality health service in the home be a basic component of the health care system. Home health services can: 1. Contribute to the health and well-being of the patient and his family; 2. Restore the patient to health and/or maximum functioning; 3. Prevent costly and inappropriate admission to institutions; 4. Reduce readmission to institutions; and 5. Enable earlier discharge from hospitals, extended or intermediate care facilities, or nursing homes. Health services at home must be characterized by: 1. Provision of high quality care to patients; 2. Professional coordination of the various services delivered to the individual patient and family; 3. Evaluative techniques to insure the appropriateness and the quality of care provided; and 4. Appropriate administrative controls. Levels of care varying in intensity and service components responsive to the individual needs of patients must be available in the home. As patients' needs change, there must be adequate mechanisms for movement of patients within the varying levels of home care, as well as for transfer to other care settings. The economic realities of the cost of health services to individuals, families, and communities make it imperative that health services at home be included in all present and future health care delivery systems. It, therefore, becomes mandatory that: 1. Present and future funding mechanisms, governmental and non-governmental, adequately finance all levels and service components of home health care on a continuing basis; 2. Availability and accessibility of home health services for all populations be assured; 3. Developmental funds be an integral part of all financing for the expansion of existing services and initiation of new programs. Senator MUSKIE. Our next and last witness today is Dr. Isadore Rossman of the American Geriatrics Society. STATEMENT OF DR. ISADORE ROSSMAN, AMERICAN GERIATRICS SOCIETY Dr. ROSSMAN. Thank you, Mr. Chairman. Instead of referring to my testimony,' I will give you a few highlights from it, and some further thoughts. 1 See p. 1445. |