In order to expand needed services in the home it is necessary to plan very boldly and creatively and to use all existing resources. I would like to report on some of our recommendations very briefly. We hope that the three visiting nurse services will continue to expand their very excellent services. We hope in addition they will subcontract with the existing homemaker services of the voluntary homemaker agencies so that more persons can be trained by the homemaker agencies and thereafter be part of the personnel available through the visiting nurse services.

We propose that the nonmedical voluntary agencies in addition to subcontracting creatively expand their services.

Third, we propose that the Bureau of Public Health Nursing of the Department of Health become a certified home health agency providing bedside nursing service when necessary and public health nursing responsibility for the supervision of home health aides. This would make possible contracting with the Department of Social Services, division of homemaker services or the voluntary homemaker agencies, of employing their own subprofessionals, thus providing additional homemaker/home health aides.

Fourth, we recommend that the Department of Social Services work, as we said, with the Department of Health and that, in addition we recommend the expansion of their entire program of homemaker services. They are now in the process of almost doubling their homemaker staff.

Fifth, we recommend that some hospitals with careful community and administrative planning, employ their own staff of home health aides and provide for the necessary bedside nursing and public health nursing supervision of these aides.

Sixth, we recommend that community health centers which are hospital based, with careful community planning, expand their existing staffs of public health nurses and employ home health aides.

Finally, in New York State, unlike the rest of the country, home health aides must be supervised wherever possible by public health nurses. Because there is such a tremendous shortage of public health nurses we suggest that crash programs be organized for the recruitment and training of such personnel. We hope that you will take leadership in planning for such an expansion of training of nurses.

We call for an additional number of reimbursable home visits under the medicare legislation.

Finally, we suggest that experimentation in order to provide greater expansion of home care be encouraged under the Hill-Staggers legislation.

In conclusion, I would like to repeat that medicare and medicaid have answered some of the most acute medical problems of the elderly. We wish to call attention to some of the legislative shortcomings and gans in services that still must be filled.

Finally, we would like to emphasize the need for the rapid expansion of home health services so that more of this Nation's elderly can remain in their homes, thus freeing needed hospital and institution beds.

Thank you.

(The prepared statement by Susan Kinoy follows:)

STATEMENT OF THE COMMUNITY COUNCIL OF GREATER NEW YORK, PRESENTED BY MRS. SUSAN K. KINOY, PROJECT DIRECTOR, PROMOTING HOME HEALTH AND SOCIAL SERVICES TO NEW YORK CITY'S AGING

My name is Mrs. Susan K. Kinoy, Project Director of a program at the Community Council of Greater New York entitled, "Promoting Home Health and Social Services to New York City's Aging."

This is a three-year Project, funded under Title III of the Older Americans' Act through the New York State Office for the Aging. Its goal is to promote increased home-health services and housing for the elderly in New York City. (A Summary of our Project is attached).1

There are now one million people age 65 and over in New York City today. 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 along 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.

"Last year, in the United States, there were close to 7 million families with heads aged 65+. About 41% or 2 out of every 5 of these older families had incomes of less than $3,000; half of them with less than $2,000.

More than a quarter of a million older families had incomes of less than $20 a week or $1,000 for the year; a half million families had incomes between $1,000 and $1,500; and three-quarter million families had between $1,500 and $2,000. At the other end of the scale, 10% or about 700,000 older families had incomes of at least $10,000 and some 75,000 of them had $25,000 or more.

A quarter of the almost 5 million older people living alone or with nonrelatives had incomes of less than $20 a week ($1,000 a year) and well over another quarter had between $20 and $25 per week ($1,000 to $1,500 a year)".*

For the most part, the elderly are scattered throughout the five boroughs of New York City, often living in walk-up 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 under way.

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 to wait in 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 operations care 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.

MEDICAL COSTS

Many older people with ongoing chronic illnesses are paying more for medical care now than they did prior to Title XVIII. Some of the people are receiving less medical care for money spent. They are paying the $40 deductible under Part A, the $50 deductible under Part B, and the $36 per year premiums totalling $126 plus the 20% coinsurance. Medical fees have increased steadily since the start of the program. The elderly complain that they are often not told in advance the doctor's "fair and reasonable" rate for a medical service. They may be billed $400 for an operation expecting to pay only 20% of this fee and find instead that the "fair and reasonable" fee was $300 and that they were responsible for paying

1 See app. p. 531.

A Profile of the Older American, by Herman B. Brotman. Paper presented October 16, 1967.

20% of the $300 plus the additional $100. For years Blue Cross and Blue Shield have been able to establish reasonable fees for medical services. Could not this practice be adopted under Part B of Medicare?

ASSIGNMENT OF FEES

The problem of rising costs is compounded by the fact that the elderly often are expected to pay private physicians (sometimes borrowing from families or from loan companies to do so) and then must await reimbursement by the carriers. Although private doctors may assign fees, many do not do so.

UNREIMBURSED SERVICES

There are important services not covered by Medicare. These include surgical and orthopedic services, prostheses, hearing aids, eye glasses, dental needs, and drugs. Many elderly must pay $10 to $20 per month for medicines, and frequently report not buying or refilling prescriptions because their budgets will not permit this expense.

DIFFICULTY WITH FORMS

Finally, many older persons with poor education find difficulty filling out the medical claim forms.

PROPOSED INCREASE IN PREMIUMS

If the monthly premium is increased next year because of the escalation of medical costs, this will mean excessive financial hardship for the aged without any corresponding increase in program benefits. We suspect that this will mean that large numbers of the elderly will be unable to continue their participation in the Part B program.

MEDICAID

We see a serious gap between those people who cannot now afford Medicare but who are not eligible for Medicaid in New York State. A senior citizen may qualify for Medicaid in terms of his monthly income, but because he has savings of $1,000 or $2,000 more than the approximately $1,000 or $2,000 permitted, he is ineligible. The line between the totally indigent and medically indigent is too thin. One senior citizen said the other day, "The person who has tried to be thrifty during his working years is penalized under Medicaid”.

In New York City, as has been frequently reported, private physicians are not participating in the Title XIX program in large enough numbers. This forces a particular hardship on the home-bound elderly, unable to attend clinics, who previously had been aided by panel physicians who visited them in their own homes, assigned by the Department of Welfare (now called the Department of Social Services). These patients must now seek their own private doctors and frequently have difficulty locating adequate medical help.

Because Medicare and Medicaid rates differ in nursing homes, it is reported that frequently patients following their 100 days institutionalization under Medicare are asked to leave proprietary institutions because the Medicaid fees are lower.

We recommend therefore

1. The removal of the Medicare deductibles as imposing an extreme hardship on aging persons with fixed incomes.

2. The standardization of rates acceptable to physicians that will be made available to elderly patients prior to the provision of services.

3. The assignment of fees whenever possible by private physicians.

4. Additional coverage under Medicare for hearing aids and other prostheses, dental needs and primarily drugs and medication.

5. 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.

6. A larger amount of savings should be permitted under Medicaid.

7. Finally, the financial gaps and services gaps between Medicare and Medicaid should be closed so that a continuum of health planning is possible.

In the few minutes allotted to me, I should like to emphasize the great need for services in New York City that can improve and prolong the independent liv

ing 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 expensive and traumatic institutionalization in nursing homes or homes for the aging. I quote from a letter sent by a hospital in New York City which is typical.

"Over one thousand extra days of hospital care were necessary during a period of eight months because of lack of facilities in the community to provide nursing home, chronic care and home help for patients 65 or over, in this institution. "It was possible in some instances to send patients home with homemakers and various type of home help. In one instance which is typical of many, patient was sent home after waiting 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 cost until a voluntary homemaker agency could meet the need. If Home Help had been more readily available, patient could have been sent home earlier. "It is also 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 cancelled.

"There are also many instances in which type of care is needed is debatable and with rejections for nursing home care and from chronic care institutions, adequate planning seems to reach a deadlock and thus making it necessary for patients to remain in the hospital for long periods of time. In the case of one patient, a plan for patient's care at home was evolved with help through Medicaid. A hospital bed, wheelchair and home attendants were provided and family members also took turns in caring for patient. Despite the cost involved, this was less expensive than hospital or institutional care. It did take two weeks of concentrated activity to work this plan out to obtain needed services.

"How many patients, of those who were finally admitted to a nursing home or chronic care institution directly from the hospital, could have been cared for at home, even for a limited time is not definitely known. However, one can rule out patients who'require tube feeding. But experience has shown in many illustrations, that patients have been sent home when it was necessary and possible and that patients for the most part did well, and some to such a degree that nursing home care planning was dropped. If more home help was readily available, we would think in these terms.

"Too often nursing home care has been planned only because nothing else was available. This has seemingly resulted in a poor use of nursing home facilities.

"We are now noting that many patients and their families are resistive to nursing home care. One reason given is their concern about crowded conditions, lack of care, and often a depressing atmosphere. Another is their feeling that patient will be more comfortable and do better at home, and this is true. Experience through the years has demonstrated this".

The demand for home health services does not reflect the need because so many elderly as well as professionals do not know of the existence of such services. In addition, professionals are often discouraged from requesting these services because they have tried so often to obtain them, without success.

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 care.

Today there are about 900 homemaker-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. The rest are used to serve younger families, usually with children. These homemaker-home health aides are provided and supervised by voluntary and public social agencies and by nursing agencies. About 400 of these are employed by the Homemaking Department of the Department of Social Services (formerly the Department of Welfare). Since only 4% to 6% of the elderly in New York City receive public assistance, few of New York's elderly are served by these 400 homemakers.

It is our estimate that a minimum of 4,000 homemaker-home health aides are needed to begin to meet the needs of the elderly.

Provision is made for Home Health Services under Titles XVIII and XIX. These services have been expanded since the inception of Medicare and Medicaid legislation. But the services have not as yet begun to meet the need of the one million elderly in New York City today. (See attached: Homemaker-Home Health Aide and Related Services-Existing Patterns and Projected Plans).1 About 35 hospitals and 4 Visiting Nurse services are certified as home health agencies under Titles XVIII and XIX. Only four agencies, however, the three voluntary nurse 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 home health aides. But the approximately 150 home health aides that are now under this program could not begin to meet the need of patients referred by hospitals and by community agencies.

In order to expand needed services in the home it is necessary to plan boldly and creatively. It is important to utilize all financial resources provided by Medicare and Medicaid. Office for Economic Opportunity and other federal and state funds, as well as private philanthropy, and to coordinate the work of all existing agencies in the health and welfare field. It is imperative that high standards of training, care and supervision be maintained.

I would like to report on proposals that this Project has made for increasing the number of homemaker-home health aides in New York City.

1. Visiting Nurse Agencies

We hope that the three visiting nurse agencies will continue to expand their excellent services to the entire community. Cooperative contractual arrangements with the non-medical voluntary agencies such as the homemaker departments of Jewish Family Service, Catholic Charities, Self Help, etc., should be encouraged. In this way, trained homemakers can be utilized and reimbursed under Titles XVIII & XIX as home health aides by the visiting nurse agencies. In turn, the voluntary agencies will be able to recruit trained and supervised agency staff. 2. Non-Medical Voluntary Homemaker Agencies

We propose that the non-medical voluntary agencies, in addition to subcontracting with the visiting nurse services (see above) will creatively expand their services.

3. Department of Health

We propose that the Bureau of Public Health Nursing of the Department of Health become a certified Home Health agency, providing bedside nursing service when necessary and public health nursing responsibility for supervision of home health aides. This would make possible contracting with the Department of Social Services, Division of Homemaker Services or the voluntary homemaker agencies to provide homemaker-home health aides. It might also be possible for the Department of Health to employ, on an experimental basis, its own staff of home health aides. Such additional responsibility for the Department of Health, Bureau of Public Health Nursing would, of course, require re-evaluation of the total services for which the Bureau is responsible and the setting of priorities. This proposal is in keeping with new patterns of community cooperation to utilize the resources of Medicare and Medicaid which are developing all over the country and in many counties in New York State, thereby making possible the rapid expansion of services.

4. The Department of Social Services, Division of Homemaker Service

We recommend

(a) That the Department of Social Services work with the Department of Health as described above and thereby become eligible to provide homemakerhome health aides for Medicare and Medicaid patients;

(b) The expansion of homemaker services, even greater than that already planned, to meet the needs of the increasing number of aged in the community. We are especially concerned about the large number of the aging for whom medical problems may be secondary to feebleness and social problems due to age. (At this time, the Department is planning to double its staff).

1 See app. 1, p. 532.