5. Hospitals

We recommend that some hospitals, with careful community and administrative planning, employ their own staffs of home health aides and provide for the necessary bedside nursing and public health nursing supervision of the aides. Thirty-three hospitals have some type of Home Care program and are already certified as Home Health agencies.

6. Community Health Centers

We recommend that Community Health Centers which are hospital based, with careful community and administrative planning, expand existing staffs of public health nurses and develop new programs for homemaker-home health aides and other therapeutic services. Since the Office of Economic Opportunity and the Department of Health, Education and Welfare, now on a federal level, have contractual arrangements for comprehensive care, there are likely to be more funds available for training, demonstration and ongoing services. Qualifications and training of staff should have the long-range goals of reimbursement under Medicare and Medicaid.

7. Community Progress Centers and Community Corporations

We propose that the Community Progress centers and Community Corporations (now almost totally youth oriented) use their staffs imaginatively on behalf of their communities' elderly. This Project will encourage the Community Progress Center leadership to use their block workers and other staff, for case-finding, information and referral, escorting, friendly visiting, "meals-on-wheels", and employment of the aging in the Community Progress Center structure, in the community and at home.

ADDITIONAL RECOMMENDATIONS

In New York State, unlike the rest of the country, home health aides must be supervised wherever possible by public health nurses. We suggest that crash programs be organized for recruitment and training of such personnel.

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 Hill-Staggers legislation-Public Law 89-749.

CONCLUSION

In conclusion, Medicare and Medicaid have answered some of the most acute medical problems of the elderly. We wish to call attention to some of the legislation's shortcomings and the gaps in services that still must be filled in. 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.

Senator SMATHERS. Thank you very much.

(The chairman addressed the following questions to Mrs. Kinoy in a letter written after the hearings:)

1. Your comment, "Too often nursing home care has been planned only because nothing else was available," is of considerable significance. Have you any information on the extent of such assignments to nursing homes? Have you additional information on individuals who must remain in hospitals because homemakers, home health aides, or housekeepers are not available?

2. What is the basis of your estimate that a minimum of 4,000 homemakerhome health aides are needed in New York City for the elderly alone?

3. How, as suggested on page 7 of your written statement, could the resources of the Office of Economic Opportunity be used to promote home health services. 4. May we have additional details on your proposals for

a. "Crash programs" for recruitment and training of public health nurses to supervise home health aides;

b. "An additional number of reimbursible home visits under the Medicare legislation;

c. "Experimentation in order to provide greater expansion of home care be encouraged under Hill-Staggers legislation-Public Law 89-749."

5. Dr. Wise of the OEO Neighborhood Health Service Demonstration in the Hodson Center area has discussed the often critical role that housing can play

in accelerating the discharge of elderly individuals from hospitals or other institutions. You pay considerable attention to housing needs in your overall project, and I would appreciate some discussion from you on work relationships needed among municipal agencies to provide housing in such cases.

6. The description of your project puts great emphasis on the need for city-wide action. Do you envision the ultimate establishment of a municipal agency to implement coordinated programs for health and social services?

7. Can you give us any details at this time on your plans for the two pilot projects now contemplated?

(The following reply was received :)

My comment "Too often nursing home care has been planned only because nothing else was available" is part of a letter to Community Council from a New York City voluntary hospital. The complete quotation begins on page 5 through the middle of page 6 of my mimeographed testimony. I believe that several of the statements within this total quotation support the statement to which you refer. The following is a typical situation which clearly illustrates need:

A municipal hospital recently reported to the Council the case of an 84-yearold woman initially hospitalized for a three-week period but requiring an additional month's hospitalization, at taxpayers' expense, due to the unavailability of a homemaker-home health aide. The patient, hospitalized because of a stroke, had been cared for by a daughter in her fifties. The daughter, an arthritic with edema, along with a sprained ankle, was now also partially bedridden. The Department of Social Services was able only to provide a homemaker 12 hours per week. This was not enough care for the patient. A nursing home was suggested by the Department of Social Services, but this was rejected by the family. During the patient's additional stay at the hospital, the daughter recovered sufficiently and was thereafter able, with the help of the 12-hour per week homemaker-home health aide, to care for her mother as well as herself.

At present, most institutions do not keep a statistical report of individuals who must remain in hospitals because homemaker-home health aides or housekeepers are not available. One of our undertakings, in the course of this threeyear project, is to attempt to document this need. Any data we collect will, of course, be made available to you.

I was interested to note in the New York Times' report of the hearing, that Dr. Israel Zwerling, Director of the Bronx State Hospital, stated “*** 25% of the hospital's 448 elderly patients could be discharged if there were homes to receive them." Not having read his testimony, I make the assumption that Dr. Zwerling was not only referring to nursing homes but private residences as well. Obviously, a person going back to his own home would, no doubt, need some assistance from a homemaker-home health aide.

Helen Gossett, Consultant, Nursing Homes, United Hospital Fund, having analyzed the Nursing Home literature, states that ten to twenty percent of people admitted to nursing homes are sufficiently alert and mobile to remain in their own homes with homemaker services, but are not able to take full and independent responsibility for themselves.

It is our estimate that a minimum of 4,000 homemaker-home health aides are needed to begin to meet the reeds of the one million persons 65 and over in New York City. Dr. Ellen Winston estimates that for families with children, as well as aging chronically ill families, provisions should be made for one homemaker-home health aide per 1,000 population. This is based both on the British and the American experience. In its Fourth Annual Report, the National Council for Homemaker Services states that 200,000 homemaker-home health aides are needed in the United States today.

The resources of the Office of Economic Opportunity could be used to promote home health services in several ways. Training funds could be utilized in increasing amounts for programs to train sub-professionals as homemaker-home health aides. Block workers and other community workers now employed by local Community Progress Centers or Community Corporations could be sensitized to the needs of the elderly. They could be trained to seek out the elderly, provide information about community resources to the aging, and could be taught to provide escort, friendly visiting and shopping services to them.

We call for an additional number of reimbursable home visits under the Medicare legislation. The one hundred visits permitted under Part A plus the 100

visits permitted under Part B of Title XVIII must be divided between all home health disciplines, i.e., doctor, nurse, physical therapist, occupational therapist, speech therapist, medical social worker and homemaker-home health aide. For some patients this is an adequate number, but for others it is not sufficient. If, for example, a nurse were to visit a patient in his home twice a week, and a homemaker-home health aide were to go in for three 3-hour sessions weekly, this would consume the first 100 visits in 20 weeks, or five months. If a medical social worker or a physical therapist were needed as well, the 100 visits might be totally utilized at the end of two or three months. We suggest, therefore, that the legislation be amended to allow as many medical, nursing, and other home health personnel visits as the doctor and nurse prescribe as an adequate medical plan for the patient. Then, following a stated period of time, a review committee would re-evaluate the case and would recommend a continued plan.

Because some limited experimental funds are available under the Hill-Staggers legislation-Public Law 89-749-we suggest that some voluntary and municipal hospitals consider experimentation whereby they can build homemaker-home health aide services into their own programs to supplement those presently in existence.

The elderly population of New York City is scattered throughout the five boroughs. There are few areas where the elderly are concentrated. Only 15 percent live in public housing. The majority remain in rent-controlled housing. Twenty-one percent of housing rented by the elderly, and nine percent of the housing owned by the elderly in New York City is deemed unsatisfactory.

Patients frequently cannot be discharged from hospitals nor can they be properly cared for in their homes because they live in walk-up or basement apartments that are unfit in terms of heat, light, sanitary facilities, privacy and safety. Sometimes medical authorities state that housing conditions of patients are too poor for the utilization of medical personnel in patients' homes.

Various kinds of housing are required to meet the needs of different aging people with medical problems. Community health centers should be available in all neighborhoods where hospital services are distant, so that persons in all types of housing can have access to medical care. Some elderly merely need good, inexpensive housing. Some need good housing with home health services built in. Others need the protection of a resident-hotel type of living arrangement, with a strip kitchen and central dining and/or recreational facilities. Still another group needs foster care and on up the continuum to homes for aging or nursing homes.

"MODEL CITY" POSSIBILITIES

It is necessary for the Departments of Health, Hospitals, Housing and Social Services (Welfare) to work cooperatively to provide satisfactory living arrangements for the elderly. In New York City, planning among all city agencies is beginning under the Model Cities Program. Perhaps methodology of joint planning between governmental agencies will be established in these three experimental areas which can be utilized in the city as a whole.

New York City is so complex, and the unmet needs are so great, that at the present time it is impossible to visualize the ultimate establishment of a municipal agency to implement coordinated programs for health and social services. The Community Council of Greater New York feels that responsibility for health planning and coordination between public and voluntary agencies should be given to a publicly accountable body responsible to the Mayor. (See attached statement "Organization of Comprehensive Health Planning for the City of New York.")

In order to most effectively implement coordinated programs for health and social services, a two-pronged approach must be utilized. The first is the utilization of Mayor Lindsay's plan for the coordination of all city services under the four categories, Human Resources Administration, Housing and Redevelopment, Health Services Administration, and Environmental Protection. Second, on the neighborhood level community multi-function centers should be established in which personnel from both voluntary and city agencies provide "one-stop" services to any local resident.

[Enclosure]

COMMUNITY COUNCIL OF GREATER NEW YORK, HEALTH DIVISION ORGANIZATION OF COMPREHENSIVE HEALTH PLANNING FOR THE CITY OF NEW YORK

The Health Division of the Community Council recommends that the Comprehensive Planning Agency for New York City be constituted in much the same way as the counterpart agency set up for the State of New York as a whole. The New York City organization should be an official agency of the City of New York. The advisory committee as in the State, should have a clear majority of representatives of consumer health services. The Health Division believes it is essential that the official planning body, following the pattern established by the State, have a full time planning staff and other necessary technical personnel. We recognize that if Comprehensive Planning is to operate effectively, the City of New York must arrange for adequate staff with adequate salaries. We are prepared to work with other community groups to achieve this goal. We believe that the planning agency must plan. It should not confine its activities to the collection of statistics. We also think that organizations such as the Hospital Review and Planning Council of Southern New York might be delegated specific technical functions under contractual arrangements with the local planning agency and thus avoid unnecessary staff duplication.

Senator SMATHERS. Our last witness on this panel is Mr. Walter Newburgher, president of the Congress of Senior Citizens, the witness of whom we have heard a great deal.

STATEMENT OF MR. NEWBURGHER

Mr. NEWBURGHER. Thank you. I want to express my appreciation for being granted the opportunity to appear before this fine committee. I also want to express my gratification to Senator Smathers for the fine statements that he made yesterday, which gives us the hope that the social security bill of 1967 might still be enacted before the Con

gress recesses.

If the amendment that you expressed opposition to had been tagged on as a rider to the social security bill, I daresay we would not have a social security bill for at least another year.

From as far back as I can recollect I have always cherished a great admiration for the medical profession, their oath of Hippocrates, and their dedication to what they term the ethics of their profession. It is only fair to say that many doctors conscientiously live by these precepts. However, a great many others, particularly since the advent of medicare, are resorting to practices which are not only deplorable but tend to destroy the image created by the millions of compassionate physicians serving humanity throughout the centuries.

Those ethical doctors whose devotion is almost a religion should be the first to cry out loudly condemning those men of their profession who have traded Aesculapius for Mercury, who have traded their professional status for that of the merchant. The escalation of medical fees are fragmented and the statistics do not really tell the whole story because they equate some modest increases with a fantastic doubling and tripling and you come up with an average that is completely unrealistic.

The great majority of the elderly are poor, and the reason is obvious. This is the generation that weathered the depression. Here in New York they actually constitute 28 percent of the poverty stricken. Were it not for medicare, they could never avail themselves of modern medical care, they would just die a little sooner.

Almost all doctors and surgeons will treat our junior citizens under the schedule of the fees established by Blue Shield. Why then must senior citizens make supplementary payments, particularly to surgeons? Is it not hardship enough that they must almost invariably borrow to meet the $40, $50, and the 20 percent? The deductibles and the coinsurance in most instances are a heavy burden.

As the leader of an organization of more than 150,000 organized senior citizens in the Greater New York area, improper action by doctors come to my attention almost daily. To get these people to be a witness publicly is practically impossible. They are scared. They are terribly afraid that the transgressor physician will wreak vengeance on them in some way or other. Life is precious to us all.

I want to relate to this committee a case which came to my attention only 3 weeks ago and I have promised faithfully that I would not reveal their names nor that of the doctor and the surgeon. These people had easily qualified for medicaid. They have no savings at all, no other income except very modest social security benefits. The husband became so violently ill that the wife had no recourse but to call the police who immediately summoned an ambulance and he was transported a a city hospital.

The wife signed him in and then phoned her family doctor who was well acquainted with their financial status and the fact that they had been enrolled under medicaid. The doctor appeared concerned that the wife had signed her husband into a city hospital and suggested that she sign him out again and remove him to a private hospital where he could take care of him.

Upon her arrival at the suggested hospital she was asked to pay $75. Luckily she had just cashed her social security check. Some days later she received a bill for $35 from an anesthetist and at this point she appealed to me. I contacted the hospital and explained that these people were on medicaid, only to be told that this particular hospital does not take medicaid patients and that as far as they were concerned this man was on medicare.

The original payment was $40 to part A and $35 for part B. I then spoke to the doctor and reminded him that these people were enrolled in medicaid. He merely shrugged his shoulders and reiterated that this hospital does not take medicaid but that this was all they would have to pay. When I reminded him there was still the matter of the 20 percent coinsurance, he stated as a rule the surgeon accepts the 80 percent as a total payment.

A week later the man underwent surgery which produced another bill from the anesthetist which the wife was able to borrow from friends.

After the operation the surgeon notified the wife that he wanted to see her in his office. She went there with trepidation fearing that a malignancy had been uncovered. However, the surgeon explained to her that his fee for such an operation was $750 but all he would derive under medicare was $400, which evidently was all that the operation was worth. He would, however, in view of the couple's financial condition be satisfied if she would send him a money order for $100.

The wife in her elation that no malignancy was involved borrowed the $100 and paid. Total cost $285, the equivalent of three social secu