1. Present and future funding mechanisms, governmental and nongovernmental, 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.

BASIC NATIONAL STANDARDS FOR HOMEMAKER-HOME HEALTH AIDE SERVICES I. The agency shall have legal authorization to operate.

II. There shall be an appropriate duly constituted authority in which ultimate responsibility and accountability are lodged.

III. There shall be no discriminatory practices based on race, color or national origin; and the agency either must have or be working toward an integrated board, advisory committee, homemaker-home health aide services staff, and clientele.

IV. There shall be designated responsibility for the planning and provision of financial support to at least maintain the current level of service on a continuing basis.

V. The service shall have written personnel policies; a wage scale shall be established for each job category.

VI. There shall be a written job description for each job category for all staff and volunteer positions which are part of the service.

VII. Every individual and/or family served shall be provided with these two essential components of the service:

A. Service of a homemaker-home health aide and supervisor.

B. Service of a professional person responsible for assessment and implementation of a plan of care.

VIII. There shall be an appropriate process utilized in the selection of homemaker-home health aides.

IX. There shall be: A) initial generic training for homemaker-home health aides such as outlined in the National Council for Homemaker Services' training manual; B) an on-going in-service training program for homemaker-home health aides.

X. There shall be a written statement of eligibility criteria for the service.

XI. The service, as an integral part of the community's health and welfare delivery system, shall work toward assuming an active role in an on-going assessment of community needs and in planning to meet these needs including making appropriate adaptations in the service.

XII. There shall be an on-going agency program of interpreting the service to the public, both lay and professional.

XIII. The governing authority shall evaluate through regular systematic review all aspects of its organization and activities in relation to the service's purpose(s) and to the community needs.

XIV. Reports shall be made to the community, and to the National Council for Homemaker-Home Health Aide Services, as requested.

ITEM 6. STATEMENT AND ENCLOSURES FROM JANET E. STARR, EXECUTIVE DIRECTOR, COALITION FOR HOME HEALTH SERVICES IN NEW YORK STATE

The following statement on the home health provisions of S. 3286 and H.R. 13870 is submitted for the record in response to a request from the committee for technical advice and for information gathered by the Coalition. The Coalition is a statewide collective effort on the part of 88 organizations and 148 individuals to strengthen the development of comprehensive programs of home health services in New York State.

Title II of the legislation in question contains a shift in emphasis of great import to elderly citizens. It proposes adding to Medicare a long-term care program which would require that care at home or in a day care or foster home program be considered and used, if possible, before a patient is placed in an institution. This provision is designed to make better use of health care dollars, since care at home or as an outpatient is usually less expensive than care in an institution.

A recent report by Regina Reibstein for the office of program analysis, planning and budgeting of the New York City Health Services Administration, states, "If 1,000 persons are treated at home instead of placed in nursing homes, the (annual) savings to the city could amount to as much as $1.5 million." The saving to the Federal Government would be even greater because it pays one-half the cost of institutional care, while the city pays one-quarter.

Even more important than dollar savings are the human values involved, Under the proposed programs the dignity and independence of an elderly person would be nurtured. Most people not acutely ill prefer to be at home, and they do better at home if their health needs can be met there. Physical and mental deterioration can be slowed or halted.

In concept the proposed long-term care program is a major step in the right direction. Whether it can achieve its aims is open to question, in my estimation, because of the limited range of services to be made available.

IMPORTANT ADDITIONS

The proposed program does add homemaker and nutrition services to those covered by Medicare. These are urgently needed additions. The important role of the homemaker on the home health care team has been pointed out previously in testimony from the National Council for Homemaker-Home Health Aide Services and in publications prepared for the Special Committee on Aging by Brahna Trager. The Coalition's experience supports this testimony.

The addition of home-delivered meals and services given by a nutritionist in a patient's home remedies a major defect in the Medicare program. This is pointed out in a position paper on implementation and delivery of nutritional care services in the health care system which was prepared for the U.S. Senate Select Committee on Nutrition and Human Needs. Miss Ruth Kocher, regional director of public health nutrition for the New York State Department of Health and a Coalition director, is one of the authors of the paper. The position paper states that the net effect of being unable to recover direct costs of nutrition services has been that few home health agencies provide them. In New York State, for example, only six of the 129 home health agencies employ a nutritionist on a full- or part-time basis. Yet nutritional deficiencies are at the root of many of the health problems of older Americans. Nutrition counseling in the home may be needed to explain therapeutic diets. The effect of drugs and other therapy on the nutrition of a patient may need monitoring, especially when the physician does not see the patient frequently. Home-delivered meals may be a lifeline to those who cannot shop, prepare meals or have social contacts with others.

WIDE RANGE OF SERVICES NEEDED

The other home health services included in the proposed legislation are those covered under the present Medicare program. The inadequacy of programs restricted to these services to meet the home health needs of older Americans are amply documented by the hearings on barriers to health care held by this subcommittee during the past 2 years. The testimony of the Coalition last July emphasized this.

Supportive as well as professional services may be needed if care at home is to be possible. Some patients may need one or two services. Others may need several. The availability of a range of services makes it possible to meet the needs of the individual.

1

The effectiveness of programs offering a comprehensive range of services is illustrated by cost figures from the Home Care Association of Rochester and Monroe County, N.Y., where Blue Cross covers a full spectrum of services. A study of 16 terminal cancer patients who died at home shows that the average cost of home care per patient day was $24.39, compared to $116, the average daily cost of hospital care in the community. The estimated saving in hospital costs was $54,233 for the 16 patients. Eight of the patients were over age 65, with an average age of 76 years. For these patients, Blue Cross 65 insurance supplemented Medicare coverage to make the full range of needed services available. The services used were nursing, laboratory, homemaker-home health aide, patient transportation, equipment rental, equipment delivery, medical supplies, drugs, oxygen and medical social work.

1 See table, p. 1522.

A similar cost analysis of 14 uncomplicated myrocardial infarct patients (8 of them 65 or over), with the same range of services available, plus electrocardiogram, shows that the average cost per patient day for home care was $13.98. Again, Medicare A and B were supplemented in most cases by Blue Cross 65 coverage. Unfortunately, most older Americans do not have supplementary insurance which will cover such a range of services. Home health care programs are discouraged from offering a truly comprehensive range of services by the restrictive coverage available for home care in most health insurance policies, including Medicare.

The Eastman Kodak Co. in Rochester has found that coverage of home care pays dividends. A company spokesman stated in the fall of 1973 that Kodak covers up to 90 days of home care per year under the basic health plan, with unrestricted additional coverage under the major medical plan. This results in an average reduction in hospital stays for Kodak employees of 21 days per patient and a net savings in health costs to Kodak of $160,000 per year.

SAFEGUARDS FOR USE OF SUPPORTING SERVICES

Funding sources are concerned about whether supportive services are a legitimate part of patient care mainly, I feel, because they fear use will be uncontrolled in a noninstitutional setting. It is evident, as shown above, that one or more such services may be needed to make care at home feasible. Criteria could be developed to determine legitimate use of supportive services when professional services are not needed regularly. The following stipulations might be made:

1. The service is needed for a health or health-releated reason and would prevent, postpone or shorten institutional care.

2. Evaluation of the patient's situation shows that care at home is the appropriate choice.

3. The initial evaluation of the patient's needs, periodic reassessment and either supervision, where required, or periodic monitoring of the supportive service is done by a professional person connected with a comprehensive home health services program.

4. The agency coordinating the supportive services provides access to a continuity of care, and is held accountable for the services provided or coordinated under its auspices.

OPPORTUNITY FOR CREATIVE COMBINATIONS

The proposed inclusion of day care and broader home care benefits under Medicare presents an opportunity for creative combinations which will enrich the lives of those having long-term illnesses, as well as provide support and reinforcement to families trying to care for such members at home.

St. Camillus Nursing Home in Syracuse, N.Y., has such an experimental program underway. Chronically ill patients come to a day care program 1 to 5 days a week. Services available to them are physical therapy, occupational therapy, speech therapy, recreation therapy, lunch and group social activities. The charge for this is $15/day for private patients and $12.60/day for Medicaid patients. The private fee is reduced to the level of the Medicaid fee in cases of need. Transportation costs are extra. Most patients come by wheelchair cab (cost: $12/round trip). Others come by private car or regular taxi. The program now serves 45 patients.

Mrs. Eleanor Fiumano, social services director at St. Camillus and a Coalition member, says that many of the patients in the day care program receive home health care services on the days they remain at home. Others may need an aide to come in for an hour or so on the days they attend the day care program to help them dress and get ready. She feels that the patients in the program need the services offered to maintain their present level of functioning; otherwise their condition deteriorates.

Mrs. Fiumano sees day care and home care as natural partners for many patients. A combined day care-home care program frees home health aides in cases where day-long aide service is necessary. It keeps patients out of a nursing home and in their normal environment. It keeps the family unit intact. Inclusion of day care benefits in Medicare will make it available to patients who do not qualify for Medicaid but cannot afford even the reduced day care fee.

1 See table, p. 1522.

3

The program at St. Camillus and the after care program at Montefiore Hospital in New York City, described to the subcommittee in the testimony of Isadore Rossman, M.D., demonstrate what can be done when there is an opportunity for innovation. The inclusion of a broader range of home health services under Medicare, emphasis on care at home or in the community when possible and an opportunity to use home health services in new arrangements with other health services offer new hope to the many older Americans who are victims of longterm and chronic illnesses.

Services, Costs, Sources of Payment for 16 Terminal Cancer Pat, onts who expired at bone while on the Home Care Progra
Services Provided

JAN.

1974

ITEM 7. STATEMENT FROM ARLENE M. WILSON, R.D., PRESIDENT, AMERICAN DIETETIC ASSOCIATION

Dietitians who have worked closely with agencies providing diet counseling services to persons requiring nutritional care at home know that whenever appropriate and possible utilizing home health services is preferable to institutional care. Most persons who are chronically ill prefer to be at home and home care is much less costly. For many persons utilizing the spectrum of home health services achieving and maintaining optimum nutritional status may be the key to benefiting from related care services, particularly the rehabilitative services such as physical therapy, speech therapy or occupational therapy. Patients debilitated by poor nutritional status have been known to respond dramatically to rehabilitative therapies only after dietary improvements that helped to correct a nutritional anemia, provided the nutrients for healing decubitus ulcers, or fractured bone, or generally improved the patient's stamina and well being. For many patients inactivity and/or excessive calorie intake contribute to undesirable weight gain which may interfere with mobility and impede rehabilitation efforts.

The concern of the members of the American Dietetic Association is that the full range of nutrition services is available to the Medicare patient as long as he is hospitalized. Upon discharge to a home health agency his eligibility for the services of a dietitian through home health visits is denied under existing law. Under the present conditions of the hospital insurance program of Medicare the utilization of home health services has declined while the cost of inpatient hospital care has risen sharply.

In 1971, 45 percent of the health bills in this country were paid by those 65 and over while this group represented only 10 percent of the population. The average daily rate for hospital care now exceeds $110 according to figures quoted by the Secretary of the Department of Health, Education, and Welfare. Services that would assist in keeping patients from hospitalization or rehospitalization certainly are worthy of serious consideration.

The position of the American Dietetic Association is that the inclusion of nutrition as a component of health care will significantly reduce the number of people requiring sick care service.

A number of dietitians working with certified home health agencies have been providing some nutrition services for many years so we do have knowledge of the scope of needed services and their value to the recipients. The services include: assessment of dietary intake, consultation with physicans prescribing diets, patient and family counseling and followup conferences with nurses and therapists, and the recording, reporting and monitoring of progress and results of the nutritional care.

Nutrition services, however, are not reimbursable so the costs must be absorbed by other resources available to the agency. This has limited the number of agencies that could offer service so it is not universally available. Home health services account for less than 1 percent of the Medicare dollar. It is estimated that the extension of home health benefits to include nutritional care would cost less than $5 million.

While dietary evaluation or assessment is desirable for all patients receiving home health services so that they can be assured optimum nutritional health and benefit from the variety of home health services offered not all beneficiaries of home health services need nutritional care. Those who do need it are not having it under the present terms of Medicare simply because they cannot afford it. Although some nutrition counseling can and should be offered by the public health nurse the knowledge and experience of the registered dietitian should be coordinated with the nursing services.

Many patients need more in-depth guidance on dietary needs as well as dietary adaptations than the nurse can provide. Some patients receiving care at home require a physician prescribed therapeutic diet. Few patients receive full adequate dietary instructions in the hospital or doctor's office. For some families the requirements of a therapeutic diet and the relative problems of food buying and preparation are both baffling and frustrating as well as costly. Careful, considerate counseling adapting the therapeutic meal pattern to the patient and the family eating pattern. life style and food budget is required so that the diet can function effectively in therapy.