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The poor in America have had little share in the benefits of modern medicine; their medical care has characteristically been fragmented, episodic, and anachronistic. They are drawn into a pernicious poverty cycle. It starts with slum living, with inadequate diet and health maintenance; it leads to illness prolonged by inadequate care and environmental redeprivation; it results in loss of income and jobs, thereby forcing the poor ever more into blight.

The N.M.C.D. is trying to attack the health problems of the poor in a manner that is comprehensive and socially meaningful to them. This means providing the best available medical care-comprehensive, hospital-affiliated, family-centered team practice. It involves stimulating community concern to improve its own health care. It confronts the self-perpetuating problem of the unemployed by creating a training program to employ neighborhood residents in the provision of health services. It uses scientific techniques to determine the effect of the Demonstration on the community and the feasibility of applying projects elsewhere in the U.S.A.

THE NEIGHBORHOOD

The neighborhood chosen for the project is a 55-square block area in the east Bronx. It comprises Health Areas 24 and 26 located in the Morrisania Health District. Approximately 11,000 families, or 45,000 people live there. Of these 45,000, approximately 45% are Puerto Rican, 45% Negro and 10% white. The vast majority have received their medical care from the clinics and emergency rooms of nearby hospitals, from the five general practitioners in the area, and from pharmacists and faith healers. Continuity, follow-up and preventive medicine are almost unknown. There is a high infant mortality rate, and a high incidence of tuberculosis. Drug use and crime rates are also high. The area is blighted by run-down commercial buildings, empty tenements and littered vacant lots.

THE PROGRAM

The N.M.C.D. will be organized around a Health Center (located in the center of the neighborhood, at Third Avenue and East 170th Street), and smaller "satellite" centers. The Center will provide a focus for comprehensive therapeutic and preventive ambulatory medical and dental services, as well as social services and community activities. The program has four components:

1. Medical services

Medical services will be family-oriented: each family will have its own team of physician, public health nurse, and "family health worker." The family health worker is a neighborhood resident trained as a health assistant and a social "advocate." He or she will provide patient care and social case aide services, in the home, to all age groups. Local physicians will be employed wherever possible as the family doctors. Specialists in all the medical fields will provide services as required in the Health Center.

At least two satellite health centers will be established at convenient locations to provide referral service, well-baby care, the bulk of the pre-natal and postnatal care, immunizations, baby-sitting and transportation as required. These satellites will be run by public health nurses, aided by family health workers and health technicians. The effect of the satellites will be to extend the services of the health team further into the community. Major medical and surgical procedures will be provided at Montefiore and Morrisania Hospitals, which will also provide in-patient care.

2. Training program for health personnel

The N.M.C.D. training program fulfills two major needs. The first is to provide much-needed jobs, and jobs with a real future, in a community where there is a high level of unemployment. The second is to provide well-trained personnel for the N.M.C.D. health facilities, and other health agencies such as the local hospitals. The shortage of personnel in the health fields is very well known. The N.M.C.D. training program prepares local residents for both existing careers and for new health positions, such as family health workers and physician assistants. The program starts with an eight-week course ("core curriculum") in basic health skills, a survey of health careers, community resources, and remedial English and mathematics. Following this general orientation period students move on to the on-the-job training of their choice. The positions available include family health workers, laboratory technicians, medical record assistants,

obstetrical technicians and inhalation therapists. Trainees are recruited exclusively from the neighborhood; they may be from age 18 to 55 years; most were previously unemployed. They are paid by the N.M.C.D. during training. On satisfactory completion of their training, the length of which depends on the positions being trained for, there is a reasonable guarantee of a job.

3. Community development

The N.M.C.D. aims to become self-supporting, and to be a model that can be replicated elsewhere. One of its principal objectives is to involve neighborhood residents in the organization, policy planning, operation and provision of services. This is the mandate of the community development department. It is concerned with the two-way process of informing the community about N.M.C.D. and the N.M.C.D. about the community. To this end, the community development staff hold a constant series of meetings-with individuals, neighborhood groups and organizations, in people's homes, in churches, and in schools. They set up meetings of the Advisory Board to which all interested community residents are invited, and which has sub-committees to help plan and run the component parts of the N.M.C.D. program. The Board and the community development staff are also considering ways of establishing a community Board of Directors, which as soon as feasible-will have the responsibility for guiding the entire project.

4. Research and evaluations

The research department is responsible for providing analytic description and critical assessment of each stage of the N.M.C.D. program, and also of the project's impact on the community. A total census of the neighborhood has been completed, which has provided much valuable information about the community served by the project. By means of on-going evaluation and assessment, the research staff point out the program's strengths and weaknesses and through this "action" orientation help the program meet its goals.

APPENDIX 2

COMMUNITY LIVING PROJECT FOR THE AGED

(A joint project proposal submitted to the NYC Housing Authority by Bronx State Hospital, Hodson Center for the Aged, neighborhood medical care demonstration (Montefiore-Morrisania Hospital), the PIBLY Fund, Inc.)

BACKGROUND

We have a deep concern regarding the problems which increasing numbers of aging people in our population must face. The problems of providing them with adequate income, maintenance housing, leisure time activities, and attending to their medical and psychiatric needs is a major concern in our society.

For a substantial number of our elderly patients with moments of intellectual impairment-without a family to care for them or adequate funds for a nursing home the mental hospital has become the final "dumping ground". Once a patient has been accepted into a mental institution, though he may have made a recovery, he seems no longer acceptable to existing facilities, e.g., Homes for the Aged, Nursing Homes, etc. The mental hospitals (especially the state hospitals), as a result are becoming the unwilling repository for the aged. Many of these patients can manage in the community with a little support from creative and reaching-out community resources.

OBJECTIVES OF PROJECT

1. Provide community facilities for elderly patients released from mental hospitals.

2. Provide a 24 hour “on call" professional person in close proximity to the living situation of the persons in the project to give social and personal services. 3. Provide the necessary housekeeping and appropriate cooking services.

4. Provide educational and recreational services to those in the project through a recognized social agency providing such services.

5. Provide comprehensive medical care through a medical service in the community.

METHODOLOGY

A. The participants for this demonstration project to be selected by the psychiatric staff of Bronx State Hospital. Criterion for selection to include the following:

1. Demonstrated ability to re-assume community living (through test living in Bronx State's special "Hotel" living arrangement).

2. Must be ambulatory.

3. Previous residence experience (former residence in a low-income housing project would be helpful).

4. Residents of the project area (Health Districts 24 and 26) would be given priority.

B. Selection of 8 apartments in the Claremont Village Housing Authority complex (includes Butler, Webster, Morrisania and Murphy Houses) to house up to sixteen individuals. The apartments to be leased to the Pibly Fund, Inc., (a non-profit philanthropic organization dedicated to the welfare and social needs of the people especially through providing housing for special projects such as this one). The Pibly Fund, Inc., has already entered into a contractual agreement with the New York City Housing for a similar project involving the Bronx State Hospital in the Edenwald Houses. The leasehold would be in perpetuity to the Pibly Fund, Inc., so that turnover of clientele will not affect the continuation of the demonstration project. Selection of individuals for public housing, of course, will be in the hands of the New York City Housing Authority.

C. Recreational and educational services to be provided by Hodson Center, a recognized agency serving elderly members of the Claremont Village area.

D. Comprehensive medical services to be given by Montefiore Hospital's N.M.C.D., through its main Health Center, which will be situated in close proximity to the Claremont Houses.

E. Psychiatric Aides (selected from the Claremont area and trained by the N.M.C.D. Training Program) employed by Bronx State Hospital and living in the Claremont Village Housing area to give daily and round the clock "on call” personal and social services to the project members.

F. Evaluation methods to be worked out.

(The chairman addressed the following questions to Dr. Wise in a letter written subsequent to the hearings:)

1. You have already submitted material giving additional information about your program, but I would like to have some discussion from you on the importance of your family health workers. How many such workers, would you say, will be needed in your overall project? Can other Federal programs be of assistance to you in providing additional training facilities or other services? (You ask in your statement for training funds to demonstrate employment opportunities for the elderly in health and social services, but I am curious as to what agency would conduct such a program).

In areas without OEO Health Centers, can such family health workers be provided through other programs, or would new legislation be needed?

2. May we also have statistics and descriptive material about other individuals trained in conjunction with your Demonstration, or does your September 1, 1967 report give us the latest information?

3. You have given us a proposal for a Geriatric Group Living Project in Claremont Village. What is the status of that proposal?

4. Can you give me additional commentary on your proposal that funds now available for hospital construction be made available for Health Center and Home Care Facility construction? It seems to me that you emphatically believe that such centers should be associated with major hospital centers. Can such centers function well unless supported by an effective hospital center?

(The following reply was received:)

1. THE FAMILY HEALTH WORKERS

The family Health Workers are the multi purpose workers with medical and social service skills. She has incorporated into her role some of the sub-professional functions of the Public Health Nurse, the Lawyer and the Social Worker. Most of their time is involved in making home visits in the community. I am enclosing a paper describing the Family Health Workers, which you may use as you

wish. The Family Health Worker has allowed us to use fewer scarce health professionals and to use them more efficiently without compromising the high quality of medical care provided by Montefiore Hospital.

There appears to be great potential for upward mobility for the Family Health Worker. We are at present negotiating with the City University of New York so that Family Health Workers can be put on a career ladder which would give them at the end of additional training, a Registered Nurse degree and would provide much needed nursing manpower to serve in the out-patient and home care field.

Number of workers necessary

We estimate that we need one Family Health Worker for every five hundred people in the community with an active case-load of about one hundred people. Financing of training

Although there is some money available through the Office of Economic Opportunity and through manpower training for training of Family Health Workers, it is not really sufficient. There is no money now available allowing the nonprofessional to continue his training to the professional level.

Use of the elderly

Training of the elderly could be of great use in home care services. Social Service roles in recreation roles, those who are fit in Family Health Worker roles. The home care services are sufficiently flexible to accommodate the part-time person as Home Help Aides. Hospitals with organized home care programs or with Health Centers would be, in my mind the best training focus. Funds could be made available for training through HEW or through the Social Services Administration.

Family Health Workers can be readily adapted to other health service institutional roles. For example, Dr. Zwerling of Bronx State Hospital plans to use them in psychiatric service. There is no legislation, however, to provide for the training or support of Family Health Workers as they are presently constituted. 2. ENCLOSED YOU WILL FIND OUR MOST RECENT STATISTICS, DESCRIBING OUR TRAINING PROGRAM

3. GERIATRIC GROUP LIVING PROJECT IN CLAREMONT VILLAGE

Except for the possible legal difficulties, the Housing Authority has accepted the principle of providing housing for the elderly especially those discharged from State and General Hospitals. We have only begun negotiations with the Housing Authority for the Geriatric Group Living Project.

4. FUNDS FOR HEALTH CENTERS

At the present time, the Federal Government puts up one-third matching funds through Hill-Burton for hospitals. Although HUD provides money for multi purpose facilities, no money from HUD has yet been obtained and with the present budget cut that Congress has enacted, it does not look like money is available for new construction of Health Centers. Montefiore undertook the purchase of a building, which the OEO helped renovate. I am sending you a copy of an article from yesterday's New York Times, describing the City's attempt to get the Health Centers financed through use of municipal funds.

STATEMENT BY MRS. DAVIS

Mrs. DAVIS. Senator Smathers, we have a great feeling for old people here in New York and especially in the Bronx. There are many feasibilities that can be reached to lengthen their lives. If something is done when a person is in a hospital and has been cured as far as medical aid is concerned, that person needs to be dismissed from the hospital, put back into society with an active life. I think it is very unfortunate and very unfair to have a person in a hospital when they can be out in society doing a creative job in their own little way and releasing places that they are holding for someone who is ill and really needs it.

Now here in the Bronx in the 24th and 26th Districts with the NMCD we have worked and we have a little idea as to how these things can or may be done which to us will be experimental. We know that you know more about it than we do. However, I would like to say that if we would take about six or eight units and set those units up, make homes for these people who are unable to care for themselves, train homemakers or health workers to look after them, to go in and see that they are kept clean and comfortable, give them their mealshere at Hodson Center this is a center for rehabilitation. I am quite sure they can get recreation and exercise here. Now to do that you would have to ask the better informed to help us, and I think that these people who have given so much are entitled to a little help.

There is a lot more that I could say but the time is short and I think Mrs. Lopez has something to say and I would like her to, but please think it over. [Applause.]

STATEMENT BY MRS. LOPEZ

Mrs. LOPEZ. Well, after listening to Mrs. Davis I don't think that there is more that I can say, but I really agree with her that we really need some help for them because I think they deserve it. [Applause.]

Senator SMATHERS. Thank you very much, Dr. Wise, and thank you, Mrs. Davis, and thank you, Mrs. Lopez, for your very informative and very helpful testimony. You can be certain that we are impressed with what you say.

We do hope the Congress would be of such a mind. Certainly if we could control it, there would be no problem but we have 435 Members of the House of Representatives and 100 Members of the Senate. You can be certain, however, that Senator Kennedy, Senator Javits, and I will do everything we can to keep this kind of a project going. Thank you very much for your testimony.

Is Miss Gertrude Landau, the director, here?

We want to thank you, Miss Landau, for the many, many courtesies which you have extended to us while we have been here.

Miss LANDAU. You are certainly welcome.

Senator SMATHERS. Our next witness is the ranking minority member of the New York State Joint Legislative Committee on Public Health and Medicare, former chairman of the committee when the Democrats were in power, Seymour Thaler, who is New York State senator from the 10th District.

Senator, we are delighted to have you.

STATEMENT OF THE HON. SEYMOUR THALER, NEW YORK STATE SENATOR, 10TH DISTRICT, QUEENS

Senator THALER. First I want to thank you, Senator Smathers, for this opportunity to appear before your committee and present my views on the care of the elderly. Sometimes disappointing is the performance of the National Health Act of 1965 which we commonly refer to as medicare and medicaid. My prepared statement is limited to part B of title 18. However, in view of the somewhat misleading statements about the great performance of part A, I will try and summarize what I have prepared so that I can have some time to talk about the fact that part A in its application is not as rosy as Dr.

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