about the lack of medical manpower. We have a lack of housing so that if we have a patient, for example, that gets better in the hospital often we don't have the kind of housing in the community especially for an older person who needs an elevator, who needs special kind of cooking facilities. We don't have the housing in the community to look after that patient. We have the problem of the patient's income. Patients who have to subsist on social security, most of them as you saw this morning are without any other kind of pension where the income really and the kind of food you have and the kind of home you live in is very important for the health that exists. Another area that I would like to talk about a little is loneliness. The Beatles talk about all the lonely people. I think that of the lonely people I meet the most lonely are the elderly. Really the Eskimos are much more forthright in dealing with the problem; you are put on a piece of ice if you are old and you are sent away. We have another way of dealing with it here in that families don't seem to want to look after their parents and they isolate them in different ways. We don't really have the kinds of recreation services and we don't have work programs that really can tap the great experience that the elderly have. We have a training program right across the road, you can see it over there. Our best counselors from life's experience have been those people over 50, and yet no one that I know of has looked to train and employ and utilize people over the age of 65 as social counselors or use them in a part-time way in the health and social service fields and in all the recreation programs. I think you are sitting in a unique institution. Now recreation programs treat the elderly as if they were children with rah-rah kinds of activities where people as a result deteriorate and begin to stare at television sets. The elderly are really not challenged. As a part of mental health and well-being I think that recreation and housing and income are equally important with the medical care services we offer. Let me just jump over to some of the approaches to the solution that we have been involved in. One is that we have tried to offerand I am embarrassed to use the word because it is not really "comprehensive❞—it is comprehensive in the old sense in that it looks after the "hard" medical problems but it is not comprehensive in the real sense in that the social problems are often beyond our reach. ONE-STEP HEALTH SERVICE We have organized a health system where the services are simple for patients so that you don't have to go to a left heart doctor and a right heart doctor and a kidney doctor, you go to your doctor and if he needs a specialist and he is called in for a consultation then your doctor carries out the treatment. It sounds old fashioned but I am talking about a family doctor. To the family doctor we have added a nurse and a family health worker and we have organized the way we practice so that we can do it with fewer doctors than most institutions do it. So if most institutions need one doctor per thousand, we think we can give equally good or better medical services by using fewer doctors and giving the work that doctors don't have to do to public health nurses and family health workers. The family health worker has extended our care so that she goes into the home and looks after many of the nursing and social service activities and really works together with the doctor as a team to extend his hands. That is how we have organized it and we have recruited in our training program people from the area and trained them for the positions. We think that there are many people now working with us as family health workers or health technicians who under different circumstances would be doctors had they been given the opportunity, and we are going to approach various agencies to see if they can be given this opportunity. There is no reason why somebody in a community who has displayed his competence as a medical technician cannot go on and become a doctor or a family health worker and go on and become a nurse. This is Mrs. Lopez. That is really the most traditional part of the medical care that we are involved in. We try to coordinate our services. We have coordinated our services with the home care program at Montefiore so that as soon as our main health center is open we will be able to bring medical care services into the home. You can keep people at home in a much better situation if they can provide meals on wheels, for example. If that is the only reason people are in the hospital and they want to be at home and they cannot cook their meals, there are mechanisms where we can deliver meals right to their bed three times a day, two hot meals. In recreation and in employment of the elderly I must admit that the oldest person that we have trained is 55 but by next year we plan to pilot a program using people over 65 really as social counselors and to see how they function in this respect. We are talking about other answers to the medical care shortage here and I think one of the ways that we have to do that is to attract doctors, we have to have attractive facilities for them to work in, we have to pay them good salaries so that they would not lose money by practicing in areas that are not as well endowed as other areas. We might even by paying their way through medical school get from them a contract, a kind of commitment to work in an area that is underdoctored for a period of 3 to 4 years. This is not new, it has been done in other countries. One of the ways that we cooperate with the Bronx State Hospital would be to take patients who have recovered from their problem and really provide medical and social services for them in the home, and then if it was necessary we always have the backup of the current hospital to fall back on. I think that the problems of income and the problems of housing are problems that you are much more knowledgeable about, and there are better people than me to deal with this but I am saying that income and housing are as important as the traditional provision of health care in the health of the elderly as well as the health of everyone. Immediately our concern is, and we are operating on a year to year grant, if they are interested in demonstration I think that they ought to fund programs for a period of time where they can really be tested out and not have to depend on going back. The mood of Congress each year I think puts these programs in great jeopardy. I don't think that if Congress cuts back on the neighborhood health centers or on any other program without a period of testing, we won't have learned anything from this experience. I think that I have made really the major presentation I wanted to make. I wonder if Mrs. Lopez or Mrs. Davis want to add to that? It is hard for me really to describe problems of the elderly except as I see them as a physician. [Applause.] (Dr. Wise's complete prepared statement follows:) PREPARED STATEMENT BY HAROLD B. WISE, M.D., MONTEFIORE HOSPITAL A PORTRAIT OF AN OLDER LADY Mrs. J. O.1 is a 72-year-old widow living alone on the fourth floor of a walk-up apartment building in the Southeast Bronx. She was born in South Carolina. In 1950 her family moved to Harlem. Her husband was the superintendent of an apartment house. They had three children. In 1961 her husband died. She and her youngest unmarried daughter moved to the Southeast Bronx. Soon afterward her daughter married, and Mrs. O. remained in the Bronx, living alone. Mrs. O. was in good health until about ten years ago. Then she began to have problems. She had become overweight and complained about numbness in her legs, and was discovered to be diabetic. Five years ago she began to develop pain in her chest and was diagnosed as having angina pectoris-a heart condition. Three years ago the numbness in her legs became increasingly worse; she stumbled in her apartment and fractured her hip. She underwent surgery and had a long convalescence in a general hospital. While her husband was alive, Mrs. O. received her medical care from a union health plan of which her husband was a member. After his death she had to get her medical care from a variety of charity services. She went to the diabetic and cardiac clinic of a city hospital, and to the clinic of a medical school where she was part of a special research project. When she had acute minor problems she would visit the emergency room of the city hospital. There was a private physician who practiced a few blocks away whom she used to consult for minor problems, but in 1963 he retired from practice. For the past six months she had increasing difficulty getting around. A neighbor's son did her shopping. She has become somewhat fearful of leaving her apartment, and although she was generally known as a happy person, she has recently become depressed. Her apartment, once known for its cleanliness, has become untidy. She spends much of her time watching television and sleeping. Her daughter, although very troubled about the situation, is unable to take her into her home in Brooklyn because of the small size of her apartment and the demands it would make on her own family. To summarize her problem, Mrs. O. has rather common chronic disease problems-heart disease, diabetes, neurological problems-requiring her to spend a great deal of time traveling from clinic to clinic, with many hours of waiting in the clinic for treatment. The small amount of money she receives from Welfare and Social Security provides her with a mere subsistence. At the present time, if left alone, one of three things might happen to Mrs. O.: 1. Her condition would greatly deteriorate. Perhaps she would sustain another fractured hip or develop an acute illness and be taken to a city hospital, there to wait for many months for a bed in a nursing home. 2. If her forgetfulness became manifest, neighbors might call the police and she might then spend the rest of her days in a state mental institution. 3. Perhaps worst of all, her condition would greatly deteriorate and she might be discovered one day dead in bed. 1 The case history has been slightly altered to protect the identity of the patient. What is lacking Medical manpower Thirty years ago the area we serve was populated by 25,000 people and had a minimum of 25 doctors' offices, many dentists and pharmacists practicing right in the area. At the present time the population has nearly doubled, to 45,000, and there are only 5 doctors practicing in the area, one on a part-time basis. There are 6 dentists, 2 of them on a part-time basis, and 9 pharmacists. The need for medical manpower is critical. Comprehensive services At the present time the poor must make their way through a variety of emergency rooms, sub-specialty clinics, and welfare services. For many the emergency room has become the chief source of medical care. Home care services Many of the elderly are able to walk and do not require home care services. A large number, however, are somewhat disabled and require some home care services. Others are bed-bound and require the full range of a hospital-based program. Unfortunately, few hospitals have home care programs. For the great majority of the poor home care health services do not exist. Income The major concern of the poor is the income and what that income commands. Others have spoken of this problem with much more expertise, but I must reiterate it in its relationship to the health of the elderly. Housing Next to income, housing which is individualized to the needs of the person is the second priority of the elderly. There is need to deal with the Twentieth Century phenomenon of children denying responsibility for their parents. Unfortunately, adequate housing for the elderly is in great short supply. Many of the elderly sick poor now find their housing on the wards of general hospitals and the state mental hospitals. This kind of care leads to despair on the part of the elderly and to rapid deterioration. The cost in social and personal terms is enormous. With the spiralling costs of health services, it seems irresponsible that we are providing, at great cost to the taxpayer, "public housing" in institutions wholly unsuited for that function. Work and recreation Some societies have been much less hypocritical than ours in dealing with the problems of the elderly. Among the Eskimos, when their time had come, the elderly were placed on floating pieces of ice and set adrift. Loneliness is a characteristic of the elderly poor. The inability to find meaningful work and recreation, and the isolation from the rest of society, lead many elderly people to despair. With a few notable exceptions, recreation programs for the elderly are much like those arts and crafts programs designed for children. The life experience of the elderly has not been systematically examined and utilized in social counselling. The results are that many elderly persons talk of "killing time". This is perhaps misstating the case. Rather the reverse is true-time is killing. Some solutions The Neighborhood Health Center program of the OEO provides some answers to the organization of medical services in a way that is human and rational and meaningful to all the consumers, including the elderly. (See Appendix 1, NMCD short summary.) Medical manpower a. Group practice. b. A Physicians' and nurses' corps. It will clearly fall into the government's lot to provide professional manpower for low-income areas. In return for payment for tuition in colleges and universities, physicians and nurses might be required to serve two or three years in a low-income area to fulfill "service obligations". It seems that financial inducements would be a major method of attracting physicians to low-income areas. Comprehensive services The greatest need a patient has is for someone to assist him in co-ordinating the complex medical and social services now available. A family doctor, or a team of a family doctor, a nurse and a Family Health Worker, must assume responsibility for the co-ordination of the health and social services of their patients. The complexity of modern health services required administrative answers. These should not be left to the patient. The neighborhood health service potential offers the full range of comprehensive services-preventive, treatment and rehabilitative services. Home care services All Neighborhood Health Centers should be affiliated with hospitals that have a full range of home care services. Home care programs in Neighborhood Health Centers must be flexible enough to provide the various needs of people with varying degrees of disability. Housing In every urban renewal project, in every lower income housing project, and in the greater community the elderly should be provided with individual apartments, or with group living situations, or in foster care environments, or halfway houses, each method individualized to the patient's needs. I would urge the government to prepare model zoning resolutions that reflect the latest research and findings on living arrangements for the aging and will permit flexibility and a response to changing needs. Methods of providing housekeeping services and meals-on-wheels programs have been worked out and are easily administered, and could be adapted to the maintenance of many of the elderly in the home. Institutionalization in nursing homes should be regarded as a last resort. (See Appendix 2, Bronx State Hospital Geriatric Program.) Recreation and employment Employment programs must be adapted to accommodate the part-time employee and to utilize the experience of a lifetime that many of the elderly have to offer. Few training programs, if any, have attempted to modify the experience they had during their working days. Neighborhood Health Centers with manpower training programs have the opportunity to train elderly persons and to utilize them as providers of social services in the health center operation. In the same way recreation must be meaningful and challenging to the elderly. The television set, surrounded by a group of elderly patients in varying degrees of consciousness, or teen-age rah rah programs, are, I think, an insult to the elderly and account for the pattern of withdrawal that is so characteristic. Federal actions to encourage more widespread utilization of the Montefiore Hospital Health Center: 1. Provide training funds to demonstrate the various kinds of employment for the elderly in the health and social service fields. 2. Make certain that every urban renewal or federal housing project has consulted a hospital with a home care program and has provided for flexible housing, housekeeping maintenance and provision of meals for a large percentage of the elderly. Provide for a recreation facility to be part of every new project, with required consultation with the elderly for these projects. 3. That funds now available for hospital construction be made available for Health Center and Home Care facility construction, and that financial incentives for home care services be strengthened. 4. 5-year grants The most time-consuming and wasteful procedure of the Health Center program is the necessity for annual grant submission. Because of this regulation, it is very difficult to recruit professional staff where they cannot be assured of longterm contracts. In addition, key staff spends considerable time preparing for new fund requisitions. I would suggest that the Health Center grants be made on a 5-year basis. I suggest that the present fiscal and auditing controls the federal government has on the program would be equally applicable to a project funded over a 5-year period. APPENDIX 1 NEIGHBORHOOD MEDICAL CARE DEMONSTRATION The Neighborhood Medical Care Demonstration is designed to demonstrate a new approach to comprehensive medical care. It was developed in the Division of Social Medicine of Montefiore Hospital in the Bronx, New York, and was funded in July 1966 by the federal Office of Economic Opportunity. |