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I wish to end up by saying I am a witness of care that was given me through medicaid. When I first moved into the neighborhood I was a cardiac patient. After moving into a housing development and being able to stop walking up stairs I slowly progressed. I am now able to be very active here at my second home.

Thank you very much.

Senator SMATHERS. We also have a statement from a caseworker at Hodson Center.

(The statement follows:)





Many health problems that were presented to the casework department stemmed not only from the individual member's personality and financial situation, but many problems arose because of the lag between the member's need and the lack of suitable resources in the community to provide service for this need. For all age groups, and most particularly for people over 60 years, a health problem has to be met not only with medical and drug therapy but must also be met with service therapy.

At this point, most of our members are familiar with the fact that they can secure extensive medical care through Medicaid and Medicare. Some people have deep seated resistance to applying for any service that is associated with public welfare. The complexity of the language used in the medicaid application and its explanatory booklet help to solidify the resistance such members feel. The forms should be written in simple words that an applicant can complete either by himself or at the most, with the help of family. The present application forms actually forbid rather than encourage use of Medicaid.

When a person receives his Medicaid card, he should be given personal individualized interpretation as to what he is entitled. This is particularly true for the person who is not using a city hospital but is using private resources. Many older adults who used clinics on a sporadic basis before Medicaid have no relationship to a family doctor and they need help with such information as which doctors take Medicaid and where they can obtain drugs. Many of our members who went on Medicaid did not know that they could apply to a Health Insurance Group. This is an important resource in the over 60 age group because such groups do provide 24 hour medical service including home visits during the night and free transportation to the physician's office when this is necessary. The casework department had many situations where a member suffered with severe anxiety because he had no assurance of medical care and where this anxiety abated after the member was referred to a Health Insurance Group.

Medicaid provides home health aides. However, it remains up to the individual to find such an aide. A person who is ill is not in a position to explore the community for such a resource. Many older adults do not have families or friends to do this for them. The physician who prescribes such a service should have agencies where he could immediately forward his prescription for attention. This procedure would ensure that there is a continuity of the medical treatment that the patient requires.

Many older adults find themselves growing dependent on assistance from housekeepers in order to remain in their own homes because of growing enfeeblement physically. It is common practice for the caseworker to offer guidance to a member who wants to establish his eligibility for household help. After the necessary medical verification is submitted to the Department of Social Services, it happens frequently that the member returns to us because the basis on which the Department of Social Services approved the number of hours a housekeeper was to work was too unreal. The average number of housekeeping hours for our members usually amounts to 4 hours weekly. The Department of Social Services suggests that people use the New York State Employment Service inasmuch as that agency only sends out homemakers in very special cases. The New York State Employment Service recently advised the Center's caseworker that it is impossible for them to find anyone who will work less than 6 hours. The Department of Social Services is willing to consider an increase in hours but the member must again go through the process of contacting his physician, securing a new medical report and seeing that it is forwarded to the Department of Social Services. Many doctors are not sympathetic to this duplication of effort and they express their negative feelings to the member. Procedures required by the public agency should be geared to facilitating the achievement of the services and not to result in antagonizing the relationship between the medical resource and the member.

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Another illustration of the lag between the need and dearth of local community resources is found with nursing homes. Some families of our members have come to the casework department with the problem that in applying for admission under Medicaid, they were informed by the nursing homes that there was a waiting period. I have known about situations where the families were able to meet the cost privately and admission was more rapid.

I would also like to point out that more older adults want admission to a Home for the Aged than there are facilities. Many homes, particularly those who are associated with the Jewish Federation, have a waiting period of several months to a year. In some instances, members who are on public assistance or who live on an income slightly above the minimum adequate level, have to wait for a crisis before they can gain the security of a protective environment. At the time of crisis, they enter the hospital and remain for an indefinite period. The Department of Social Services does offer a foster home program that aims to bridge the gap between application and admission but most of our members expressed discomfort at the idea of moving in with a family and preference was indicated for a nursing or aged home.


Many older adults who live alone find that their physical symptoms become more acute during the night. One of the most urgent problems presented to us is how to cope with this situation. Any individual, whether or not he is on Medicaid, can telephone the emergency number of the Police for an ambulance that takes them to the City Hospital in their district. After the symptoms are treated in the Emergency Clinic the result most often is that the patient is found suffering more from fright than actual severe illness necessitating hospitalization. The patient is then dismissed by the hospital with no provision for transportation home. The members have had to sit in the Emergency Clinic for hours either until daybreak or until someone on the hospital staff realized the situation and assisted the member with finding a taxi. People on public assistance have little or no money to put out for such an exigency as taxi fare. While the Department of Social Services reimburses the members for the cost, he must show proof of the expenditure and there is again a wait for the cash. Members who have had this experience have indicated their belief that it would help their emotional as well as their physical well-being, if they could be guaranteed medical service in the home at night; or if they must use the Emergency Clinic, provisions should be made for transportation back home. Perhaps, the same ambulance that took them should see that they get safely back in their apartment.

Another serious problem that we have seen in our casework practice is concerned with older people who become senile. There is no day center in our community to provide such a case with supervision as well as with medical and psychiatric treatments. There is medical substantiation that in some cases of senility, the rate of deterioration can be slowed if the person receives proper attention. Older adults who are senile and come to the Center, feel that they are not accepted by the healthy members and this aggravates their condition. The presence of a senile person also has an adverse affect on the well members of the Center. Furthermore, the Center is not staffed to offer any constructive service to such a member. Again, there are not enough Homes for the Aged who service this group. Much suffering ensues for the spouse who is well and who must cope not only with the emotional aspect of seeing one's mate grow unrelated to reality, but must also cope with the hard work that results if the senility takes the form of incontinency and inability to handle dressing and eating.

Some members of Hodson Center show symptoms of emotional disturbance although they can function in the community. Because of the paucity of mental health facilities in our community such situations are usually not referred for a psychiatric evaluation or treatment. Referrals are usually made of the occasional member, whose symptoms indicate interference with his continued functioning in the community. While we have Morrisania and Bronx Lebanon Hospitals which offer mental hygiene clinics, it takes a long time for a referral to be processed by them because of their waiting lists. This community needs more mental health resources where referrals can be made simply and where they will be processed quickly. We also need resources that would be adequately staffed so that they could forward the psychiatric evaluation of a member's condition to the agencies like this Center. Such a procedure would be of considerable help in enabling staff to work more effectively with these members. It is also conceivable that with proper mental health care, the extent of emotional disturbance can be checked and the individual can remain in the community until his death.

Senator SMATHERS. All right. Our next witness is Mr. Leon Fraiter.


Mr. FRAITER. Ladies and gentlemen, thank you very much for inviting me here. I am a man of 75. I have a cardiac condition. Some years ago I joined the Redshieid Day Center and became very active among the senior citizens. I teach, I take an active part in the dining room. I do almost anything around the center. I am still a patient at the hospital getting treatment for my heart and high blood pressure. I have no trouble with medicine. I get a low number, I go and get my medicine and when that is exhausted I get another refill. I find myself getting along nicely and I am very grateful that I am strong enough to help others who are less fortunate than I am at the center.

Thank you. [Applause.] Senator SMATHERS. Thank you. From the Citizens Committee on Aging of the Community Council of Greater New York we are now going to have Mrs. Susan Kinoy, project director, Promoting Home Health and Social Services to New York's Aging.

Mrs. Kinoy.


Mrs. Kinoy. Thank you very much, Senator Smathers. It gives me great pleasure to be here today to testify, especially because this project that I am privileged to direct is funded under the Older Americans Act which you and your committee had a great deal to do with. We commend your committee for the work that was done in funding so many of these projects. I think there are over 20 in New York State right now. I hope they are continued and expanded.

There are now about 1 million people 65 and over in New York City. Ninety-six percent of this group live in their own homes and outside of institutions. Most elderly people wish to remain living independently in their own communities.

The vast majority of the aging live alone or with a spouse. The average base of their incomes is under $110 a month social security. This is supported by private benefits, savings, contributions by children, and welfare benefits.

For the most part, the elderly are scattered throughout the five boroughs of New York City, often living in walkup apartments, remaining in deteriorating or changing communities because they cannot afford to live in rent-controlled apartments. Although the majority of the elderly live below the "poverty line” they frequently do not cluster in “poverty areas" in which community progress centers and the community corporations have been established and in which plans for neighborhood health centers are underway. So when we plan health services for the elderly we have to think in terms of citywide services, not merely services in special areas.

The elderly receive fragmented medical care. They may attend a union health center for an annual medical checkup; they may travel to an arthritis clinic, a cardiac clinic, or a diabetes clinic on different days in one or more hospitals, and may, in addition, visit one or more neighborhood doctors when they feel too ill to travel to clinics or feel they cannot wait long periods in the emergency rooms. Different medications and courses of treatment are prescribed by individual doctors.

Medicare has provided welcome changes in patterns of payment for medical care. It has provided much-needed emergency care and medical insurance for catastrophic illnesses and serious operationscare that previously might have bankrupted an elderly person or his family. But serious problems exist in the workings of medicare. Some problems are to be expected as new legislation begins. But it is now apparent that there are weaknesses and gaps in the legislation and in the way it is being utilized that must be remedied.

Many of these have been mentioned today and I am not going to go through them in detail. I would like to summarize along with the many people who testified today, who feel as we do.

The deductibles must be removed; they impose an extreme hardship on aging persons with fixed incomes.

We recommend the standardization of rates acceptable to physicians that will be made available to elderly patients prior to the provision of services. We just get too many complaints from a person being charged $500 for an operation thinking this is the fair and equitable fee and thinking that he will get back 80 percent of this and he finds that he is going to get back 80 percent of $300 and has to pay the remainder.

A patient should have the option to request the assignment of fees by private physicians.

There must be additional coverage under medicare for hearing aids, prostheses, eyeglasses, dental needs and drugs.

We are alarmed by the probable increase in monthly medical premiums for persons with fixed incomes. Increases, if ordered should be accompanied by corresponding increases in program benefits.

We think that larger amounts of savings should be permitted under medicaid.

The gap between a person who cannot manage the payments under medicare and yet has too large a lump sum of savings to benefit under medicaid is too large. The financial gaps must be closed between these programs.


In the few minutes allotted to me, however, I would like to emphasize the great need for services in New York City that can improve and prolong the independent living of older persons in their own homes, services that can prevent, shorten or postpone institutionalization. With properly organized and adequate home health services some elderly can, at a lower cost to the community, avoid extensive prolonged hospital stays or premature extensive and traumatic institutionalization in nursing homes or homes for the aged.

I quote from a letter from a hospital which is quite typical of many we receive. “Over 1,000 extra days of hospital care were necessary during the period of 8 months because of lack of facilities in the community to provide nursing homes, chronic care and home health for patients 65 or over in this institution. It was possible in some instances to send patients home with homemakers and various types of home help.

In one instance, which is typical of many, a patient was sent home having waited 26 days for admission into a nursing home. There was a problem in obtaining the needed services and special funds had to be used to meet the cost until a voluntary homemaker agency could meet the need. If home help had been more readily available, the patient could have been sent home earlier. It is of interest to note that many patients do so well at home when there is help, often to an unanticipated degree that applications for nursing home care have often been canceled.

One of the services in shortest supply to the elderly in their own homes is that of homemakers, home health aides and housekeepers, all subprofessionals, who, under the supervision of doctors, nurses, and social workers can provide personal care and homemaking assistance to the elderly. These services, mainly part time, are in great demand by the aging. They are less expensive to provide than institutional


Today in New York City there are about 900 homemakers or home health aides, less than half of whom are used to meet the needs of the aging in the five boroughs of New York City. Only 4 to 6 percent of the elderly in New York receive assistance from the department of social services and one-half of these homemakers are employed by that department. Therefore, there are even fewer of these subprofessionals available to the majority of the elderly. It is our estimate that a minimum of 4,000 homemakers or home health aides are needed to begin to meet the needs of the elderly in New York City today.

We appreciate that provision has been made for home health services under both titles 18 and 19. These services have been expanded in New York since the inception of medicare and medicaid legislation but the services have not as yet begun to meet the need of the 1 million elderly in New York City today.

About 35 hospitals and four visiting nurse services are certified as home health agencies under titles 18 and 19. Only four of these agencies, however, the three voluntary nursing agencies and the Dominican Sisters of the Sick Poor, now provide home health aides under this program. These four agencies have done an excellent job of recruiting, training, and supervising these aides, but the approximately 150 that are now in this program can't begin to meet the need that we see, and you heard this need explained by the people you visited at lunch today.

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