I think this is wrong. I wish to thank you for asking me to come here today. I wish to say that I am very happy that you were reelected. As we knew you would, you have given us some very good information and some food for thought on this problem of better providing for our elderly. Your last discussion of public housing and the lack of other attention to those who do utilize public housing has a great deal to be said for it and I think your proposal makes good sense. Of course, I am strongly in favor of this campus idea. As you know, I have talked about that in some of my speeches, suggesting that this might be a very desirable thing. You have spelled it out even better today. I am glad of it. I am especially glad to have that discussion and analysis of the way your center is set up and the way it is working now in Connecticut. Do you have a smaller size chart like that that we can reproduce for the record? Mr. DE PREAUX. If I had had one, sir, I would not have had to carry these on the plane. Senator Moss. Maybe we had better take a picture of it because I would like to have that in the record.1 I think it is diagrammatically presented there and it is helpful in that respect. I do thank you. As I have said before, you run an excellent home and we commend you for it. We will excuse you, with those thanks. We did have Mr. Labe B. Mell, Administrator of Moody Nursing Home, Decatur, Ga., and Mrs. Jeannette R. Kramer of Plum Grove Nursing Home, Palatine, Ill., who were invited but were unable to attend. I said in the beginning I expected this to be a very interesting and helpful hearing and it was going to emphasize the positive, which I think has been borne out very well by the witnesses we have had. Our hearing is sort of like everything in the news media. If it is bad or there is something wrong with it, it gets a lot bigger play than it does if things are going well and going along as we would like to have them go. I think for that reason over a period of years as we have had inquiries and hearings about nursing homes and care for the elderly that we tended to get publicity for all the bad situations. That is fine; they ought to be aired and they ought to be corrected. I don't think any of it should be excused. But it has perhaps blurred the picture, obscured the picture in part that we are making some very fine progress in this field. There are some very excellent facilities in operation and there are a lot of devoted and dedicated people that are giving their energies and intellect and, in fact, their love to trying to better serve those who are elderly and infirm. These potential needs are not only physical but social and psychological as well and we have heard a good deal about how to cope with them this morning. 1 See app. 1, p. 1863. However, we should not be complacent. We still have much to do in all of our States. I commend particularly those of you who came here this morning and told us of the things that you are doing and that you have visualized for the future improvement of this field. We hope, as we try to round out a rather long period of study of this long-term care problem, to be able to come forward with some recommendations and possibly some legislation or amendments to help us along toward the goal that we all seek. Thank you very much for being here. We are now adjourned. (Whereupon, at 12:35 p.m., the hearing was adjourned, subject to call of the Chair.) APPENDIXES Appendix 1 ADDITIONAL MATERIAL SUBMITTED BY WITNESSES ITEM 1. PREPARED STATEMENT OF JEANNETTE R. KRAMER, AD- HOW THE ADMINISTRATOR ORGANIZES A THERAPEUTIC PROGRAM FOR The most difficult problems that staff members of long term care institutions face are in the psychological and behavioral areas. In the physical diseases -stroke, cancer, heart disease, fractures, Parkinson's disease, multiple sclerosis-doctors and nurses generally know the accepted methods of treatment. There are few guidelines, however, when these chronic conditions are combined with depression, regression, frustration, loss and confusion in patients who also have deficits in seeing, hearing, memory, motivation and mobility. The long term care administrator needs a road map for establishing a milieu which can incorporate medical and nursing therapy into a broader concept which includes treating the illness while concentrating on helping the patient regain his maximum level of both physical and psychological functioning. This has been the concern of the Kramer Foundation over the last ten years. We believe that the answer lies in combining traditional medical and nursing care with the therapeutic community concept developed in psychiatric hospitals since the fifties, and the understanding of institutional and family systems. Then patients who reside temporarily or permanently in long term care institutions can be as free as possible to live their own lives while receiving individual programs of care. We have coordinated and put into practice principles in organizations and communication which we believe are necessary if a long term care institution is to be fully therapeutic. We have used Plum Grove Nursing Home in Palatine, Illinois, a 69 bed proprietary facility in order to test our theories. Enthusiasm for and belief in the therapeutic program must extend from the very top of the administrative hierarchy to every member of the treatment team, including all shifts and all disciplines. The patient himself is part of the plan, as well as his family and other important people in his life. Thus everyone concerned is working together with the same commonly known information. When a patient is admitted to the home, he is at a critical point of transition. He can be admitted in such a way that there is the best chance for his therapy to be successful. Relevant social, psychological and medical data contribute to the staff's understanding of the family's involvement and their goals as well as the goals of the patient. A social history questionnaire is a good way to obtain this information. Staff is chosen, trained and supervised to help, not hinder, the team goals. Besides being technically competent, each staff member must also believe it is worthwhile to work with disabled and dysfunctional elderly and gain satisfaction in seeing the patient do things for himself. This means giving up, as much as possible, the typical nursing role of doing for him. She is willing to take time to listen to the patient and use his ideas since he is also part of the team. She is open to a continuous personal learning and growing experience. This in turn requires a training program which involves all levels of staff. Although responsibility is centered in the nursing supervisor, the nursing assistant is the one who spends the greatest amount of time with the patient. Supervisors share responsibility with nursing assistants as they develop to their fullest capacity. Methods of communication evolve which cut across professional lines and allow staff members to respond to the patient and to each other. At Plum Grove we have community meetings of patients and nursing staff members on each floor who meet together weekly to talk about both positive and negative aspects of the group living situation. Reality reo-rientation is both a 24-hour practice and a specific daily half-hour group meeting led by nursing assistants. Nursing assistants take turns as activity aides and all are trained as rehabilitation aides. Our mental health consultants have trained a group of interested staff members-including nursing assistants, supervisors and consultantsin family interviewing and we have an on-going program of meeting with all families of patients in the home. General staff meetings are held weekly of all employees in the home-all shifts in nursing, housekeeping and dietary-so that all may learn consistent, practical and effective ways of integrating their efforts to care for the patient. Supervisors of all shifts discuss supervisory problems and patient care plans in supervisory staff meetings. The core group is composed of those with primary responsibility for patient care in the institution-administrator, assistant administrator, director and associate director of nursing, activity director, physical therapist and mental health consultant. This group has actively worked on its communication in a bi-weekly process group. We feel that the core group is the prototype for effective communication in the institution. Basic to fee communication is a method of conflict resolution-whether among patients, among staff members, between patients and staff or in areas involving the patient with his family or with members of the outside community. Negotiation skills are taught to supervisors so they can get people together to resolve issues and find more funcional solutions. Airing opposing opinions is encouraged. Mistakes are corrected without establishing blame. The administrator organizes a setting which allows freedom in communication up the hierarchy as well as down, while clearly establishing medical and administrative accountability. Every aspect of the institutional situation must be evaluated in terms of its contribution to the total therapeutic care. This includes the physical setting, the organization of staff, the educational program, and group and individual patient care programs. Mental health consultation allows for professional help and objective feedback. We find that we are dealing with two systems-1) the professionals and their assistants working primarily within the institution as an organized team and 2) the patient and his emotionally significant family members who have requested service from the institutional system. We are using "system" as social scientists do who have in recent years applied general system theory to human interaction. Like all systems, the long term care system and patient-family system function according to basic principles or laws. Any happening which affects one part of the system affects the rest of that system and, in turn, the other system, which then sets up circular feedback patterns. We believe it is not only possible but necessary to put into operation these psychosocial principles in combination with traditional medical and nursing treatment. As one looks at the total picture, disturbed behavior often becomes understandable and new ways of relating and changing become evident. Physical rehabilitation becomes part of the total program, concentrating on areas where there is still room for change and growth and relevant human experience. Let me explain the interdisciplinary team more clearly. In order to provide the patient with an integrated program, we make nursing the central focus of all care. When consultants work with patients, they have to work through nursing. When the physical therapy consultant sets up an exercise and gait training program, she must train and supervise the nursing assistant caring for that patient. We do not have a separate physical therapy room-our rehabilitation equipment is on the floor for nurses to use throughout the day and evening. This is by design because the patients we are caring for need a little exercise many times a day aimed towards taking over as much of their self care as possible themselves. The physical therapist is then also able to supervise the approach to the patient as well as the way the physical aspects are handled. In the same way, the activity director (or adjunctive therapist or occupational therapist) works through the nursing department. She also works with volunteers we have 45 at the present time but it is essential that nurses also be involved; they have great leverage in encouraging or discouraging participation in activity programs. Nursing assistants take turns as activity aides for several |