Applying heating pads or hot water bottles as directed by the physician, nurse, or therapist.

Helping client regain his speech or to relearn household skills, under the direction of a physician, nurse, or therapist.

Assist or give client prescribed medication as directed by the attending physician or nurse.

Personal care services will vary from client to client, depending upon the nature of the illness, its severity, and on the availability of other family members to render personal care to the sick or disabled member.

(3) Individual counseling: Casework service is available to clients on the basis of individual need through experienced and professionally trained Homemaker supervisors. It is extended to clients directly on a person-to-person relationship, indirectly through the homemaker who has been carefully selected to assist the client, or usually through a combination of both techniques. When prolonged and intensive casework service is indicated in an independent referral. HMS will attempt to secure it for the client through a family counseling agency in the community. In agency-referred cases it is expected that the referring agency will provide the necessary casework service, and where it is in the best interest of the client, the supervision of the homemaker is transferred to the caseworker of the referring agency. Individual counseling services usually include assisting clients in such matters as:

The wise expenditure of time, energy, and money, including the develop ment of realistic family budgets and the expenditure of funds within these budgetary limitations.

The rearrangement of work areas and equipment so that a client with a disability can better perform her usual activities of daily living.

Assuming greater responsibility for themselves and for some of the household tasks.

By a combination of personal example, repeated demonstrations, work-sharing experiences and frequent discussions, clients learn how to better carry out the normal functions of home management. Deepening the client's understanding of his role in his family and community strengthens his ego mechanism, lessens his anxieties and gains more self-confidence. Ultimately client earns a more respectable and acceptable position in his community.

(4) Friendly visiting: Homemaker_visitation service is provided to senior citizens by vounteer members of the Junior League of Los Angeles, who have been carefully selected, specially trained and are professionally supervised. The purposes of this friendly visiting service are to help alleviate loneliness, to establish new contacts leading to lasting friendships, to help insure that benefits provided by public and private agencies for the comfort and well-being of senior citizens are provided and to stimulate interest and widen the contacts of senior citizens as a means to maintain and/or reestablish their sense of belonging to the community.

Friendly visiting service usually includes the following helpful activities: (1) Assistance in contacting relatives or friends, either by telephone, letter or personal visit.

(2) Encouragement through participation in new or familiar hobbies. (3) Providing information about community resources particularly as they relate to health, welfare, and recreation services.

(4) Recognizing and reporting to the supervisor, problems or situations that require practical help, such as provision of meals from outside sources; transportation to church or social meetings; assistance with shopping, gardening or exchanging library books, etc.

(5) Be alert for likely causes of home accidents and report same to supervisor; i.e., loose linoleum, ill-fitting or wornout footwear; ragged carpets; dim lights on stairways or paths; electric cords in areas of locomotion; etc.

All clients will not require or be interested in friendly visiting services, and therefore the number of hours will vary from client to client, depending on the personality, need, and opportunity to assist the client. Because senior citizens often are unable to leave their homes because of chronic disease, impairment of senses or disabilities, and therefore feel cut off from community life, it is our intent to bring a measure of life's stream to them.

VI. PERSONNEL FACTORS

(a) Recruitment and selection of homemakers. Certain minimum desirable qualifications have been established for homemakers employed by HMS/LA. These include the following objective criteria:

Age and sex: Women preferably between the ages of 40 and 55 years. Education: Priority will be given to persons with more than a high school education.

Experience: Five years' demonstrated experience as a successful homemaker, either in their own home or with a reliable agency providing similar service.

Health: Successful completion of preemployment and periodic health examinations covering not only homemaker's physical ability to handle the job but also the absence of a communicable disease.

Transportation: Current valid driver's license and the use of an insured

automobile.

Fiscal: Some additional outside income from investments, pension, insurance, etc.

Other essential qualifying factors include evidence of emotional maturity, a demonstrated capacity to provide other persons under difficult conditions an inexhaustible supply of "tender loving care,” and experience in providing home care to chronic disease patients. Before applicants are accepted as staff members they are personally interviewed both in the central office and in their own home and all references are carefully screened and investigated by our staff supervisor. Homemakers are recruited from all social and economic levels, faiths and beliefs, geographical location and sources of referral, including the California State Department of Employment, whose vocational counseling services and screening processes are most helpful. HMS/LA bonds and covers all homemakers by several types of insurance.

(b) The supervision of homemakers is provided by staff members with master's degrees in an appropriate graduate curriculum (social work, special education, psychology, etc.) and with many years of experience in a related setting. The social worker gives continuing supervision to all homemakers and this supervision is adapted to each individual problem situation. All of our supervisors are successful homemakers in their own right and normally provide supervision to 12 to 14 homemakers.

(c) Homemaker training: Under the supervision of a professional educator from the staff of the adult education branch of the Los Angeles city schools, a basic training course has been established. This course consists of 30 hours of instruction, demonstration and practicum. The curriculum covers:

Home management, such as menu planning, food buying, preparation and serving, optimum use of time, money, and energy, preventive home maintenance.

Personal care of clients, such as bathing, feeding, dressing and personal hygiene, normal growth and development patterns, preparation of special diets, bedside care, escort service, etc.

Counseling techniques, such as demonstrations, work sharing experiences, use of good example, frequent discussions and explanations, simple laws of learning and motivation.

In cooperation with specialized professional agencies and institutions in Los Angeles County an advanced training course is being developed which also will include 30 hours of instruction, demonstration and practice for a selected group of homemakers who will specialize in the care of senior citizens. This course will concentrate on providing interpretive material concerning this specialized area of service. The curriculum is designed to provide a greater degree of insight and understanding concerning the psychological and emotional factors, the health and welfare conditions, and the social and economic situations of senior citizens.

In addition, a continuing and intensified inservice training program is conducted by the Homemaker Service professional staff. This training includes approximately 20 hours of instruction and deals primarily with the organization and administration of Homemaker Service. It concentrates on such major areas of interest as: public relations, cost and expense factors, reporting functions community organization and resources, board functions and responsibilities, organizational structure, etc.

VII. ADMINISTRATIVE FACTORS

(a) Basic general policy: Experience over the years has proven the soundness of certain principles accepted by the health and welfare professions and other helping agencies concerned with the development of Homemaker Service. These principles which form the basis of policies adopted by Homemaker Service of Los Angeles region are as follows:

(1) Homemaker Service will provide service in the home to all persons in need of such visiting home care, regardless of race, creed, color, religion, country of origin, or economic status.

(2) Homemaker Service is available on a fee-for-service basis adjusted to income with a minimum basic charge.

(3) Homemaker Service is provided only under the direct supervision of a professionally trained and experienced person, and is adapted to the individual needs of the client.

(4) In emergency cases referred by health and welfare agencies, Homemaker Service is available within 3 hours of request. Normal processing of referrals requires 3 days.

(5) Referrals are accepted primarily from public and private health and welfare agencies serving the Los Angeles trade area and from individual residents.

(b) Referral and closing process: All applications for Homemaker Service under this project will be made to HMS/LA's central office for investigation of the referral and a determination as to the nature and extent of the problem. Referrals will be accepted from any health or welfare service where a recommendation has been made for Homemaker Service or from interested individuals. In determining the priority of selection in referred cases, HMS/LA will be guided by the recommendations of the West Los Angeles Homemaker Advisory Committee.

The functions of this advisory committee are outlined under section VIII of this project description. A written report on Homemaker Service provided each client will be given to the referring agency within 5 days of case closing. All client records will be handled on a confidential basis and will be available only to professionally eligible persons.

(c)_Organization: To implement this project HMS/LA will establish in the west Los Angeles area a small office to house supervising social worker and a steno/clerk. Referrals coming within the criteria of acceptance for Homemaker Service will be sent to the district office for verification of the nature and extent of the problem and the selection and assignment of the best qualified homemaker available to service the referral. Homemakers employed on this demonstration project will be recruited principally from and utilized in the west Los Angeles

area.

(d) Cost factors: Based on the limited experience of Homemaker Service of Los Angeles region during the first 2 years of operation, as well as independent cost studies reported in the 1959 Conference on Homemaker Service and other information subsequently secured from current Homemaker Service agencies, it is estimated that the establishment of Homemaker Service in one district of the Los Angeles region for the assistance of senior citizens will cost approximately $2.86 per hour, based on a minimum of 1,500 hours of Homemaker Service per month for a period of 1 year. This would involve the employment of 10 to 15 homemakers, some on a part-time basis.

The first year costs are estimated as follows:

(A detailed analysis of this budget will be found in enclosure E.) The first year budget has been established on the following assumptions: (1) Fourteen homemakers will be employed on a part-time basis (approximately 110 hours per month).

(2) During the first year a total of 18,480 hours of service will be available; 17,580 for clients and 900 hours for professional training.

(3) Personnel costs include hourly wages ($1.25-$1.65) for homemakers, salaries for professional HMS staff, social security payments, and insurance. (4) Cost of office equipment has been amortized over a 5-year period.

(5) Local travel and transportation expenses for both district supervisor and homemakers is based on the opening of approximately 200 new cases during the first year.

(6) Other expenses include space rental, utilities, postage, telephone, training, research and evaluation and administrative supervision, which is budgeted at less than 15 percent of the total estimated cost.

(7) The cost of service will decrease with an increase in the number of hours of service provided, as an example: 1,000 hours of service would cost approximately $3.25 per hour, 10,000 hours of service would cost approximately $2.24 per hour. (See enclosure F for details.)

(e) Duration of the project: It is recommended that this homemaker demonstration project for senior citizen clients be continued for a period of 3 years and that financial support be made available in the following amounts:

Calendar year 1962-
Calendar year 1963_

Calendar year 1964_.

(See enclosure G for details of financing during this period.)

$51, 500

34, 334

17, 166

(f) Fee policy: It is the policy of HMS/LA to charge a service fee related to actual costs and the ability of the client to pay. Many agencies, individuals, and organizations capable of paying full costs of service are expected to do so. Because all clients cannot pay the full cost of service, the agency depends upon the community for funds to subsidize the program through contributions and donations. Independent referrals are charged in accordance with a fixed-fee schedule that is related to net monthly family income and number of dependents. (See enclosure H for details.) Fees for agencies who are members of the L.A. Welfare Federation or are independent voluntary health agencies have been established at $2.50 per hour, with 24-hour service provided at a maximum cost of $25 per day.

(g) Billings and payments: HMS/LA has established a cost accounting system under the direction of a certified public accounting firm. Service fees will be adjusted quarterly to provide the referrant with every possible dollar saving consistent with high quality service.

Billings will be made monthly to all clients and referring agencies on an individual case summary basis, detailing number of service hours provided, payments received from clients, and net unpaid balance due. Payments to HMS/LA are expected within 15 days of billings.

VIII. PROJECT ADVISORY COMMITTEE

To assist the supervising social worker in the implementation and coordination of this demonstration project in the west Los Angeles area a small but active advisory committee will be established consisting of eight or nine members. They will be both lay and professional persons and will be chosen because of their active interest in the development of this generic community health and welfare service. It is planned that this committee will serve as a nucleus for a continuing organization in the West Los Angeles area. Within the general policies established by the HMS/LA board of directors, the project advisory committee should interpret the needs of the community to the agency and the policies and practices of the agency to the community. However, its major function would be to coordinate Homemaker Service with all other community health activities. The chairman of this project advisory committee will be a member of the board of directors of HMS/LA. It would be a self-perpetuating organization, recruited initially from among those persons who have had an active interest in the development of Homemaker Service in the West Los Angeles area. (See enclosure F for list of initial agency representatives.)

Each of the cooperating agencies represented in the advisory committee will have a significant role to play in the development of Homemaker Service and will be expected to provide HMS/LA in accordance with their ability and resources, one or more of the following services:

(a) Technical advice in the form of professional consultation concerning client care and treatment, personnel practices, staff training, community organization and administration, etc. As an example, from the public health nurse, HMS/LA

expects to secure cooperation in the training of homemakers, referral cases, instructions to the homemaker in individual cases with respect to administering medication, helping patient with prescribed exercises, etc.

(b) Case referral: It is anticipated that the health and welfare agencies, both public and private will be the principal sources of referral during the early development of this project. They will need to clearly understand the role that the homemaker can play in a supporting service to senior citizens and where necessary call this to the attention of the proper health or welfare agency in order that a proper referral can be made. They will need to take the initiative in many of these situations to insure prompt action.

(c) Public education and information: All agencies utilizing Homemaker Service should play an expanding and supporting role in interpreting the functions and services of Homemaker Service to the community. A full understanding and acceptance of the agency's function in the total pattern of community health and welfare services is essential to this interpretative responsibility. The sharing of mailing lists for educational purposes, identifying community resources, both of personnel, material, supplies and services are two ways in which a cooperating agency can help HMS/LA meet its responsibility in the area of public information and education. Invitations to speak at public meetings, exhibit at annual meetings, and show educational films at staff or professional group gatherings are more illustrations of how the community agencies can cooperate with HMS/LA.

IX. PLAN FOR EVALUATION OF EFFECTIVENESS OF PROJECT

Periodically throughout this demonstration project a written report evaluating the results achieved to date, as related to the stated individual case objectives will be provided by an independent social research analyst from the research division of the Welfare Planning Council of Los Angeles Region.

Dr. Genevieve Carter, a social research specialist, will direct this independent objective evaluation. Her technique will include personal interview of an adequate sample of clients receiving Homemaker Service, using a standardized evalaution schedule. This schedule will contain the major case work objectives outlined in each case record and the interviewer will seek opinions from client, homemaker and supervisor concerning the extent to which service met these objectives, i.e., the objective in the Mr. R case was to prevent nursing-home care for a hip fracture. This was accomplished by using 105 hours of Homemaker Service although wife didn't like Homemaker during the first week.

The collection and processing of accurate factual material relative to the program services and the cost factors related thereto is also a major objective of this project. To accomplish this, a basic data card containing over 60 items has been designed by Remington Rand and adapted for use in the Kardex system. Basic data is recorded on this case record card which will then be stratified and encoded for machine data processing and analysis. This action will supplement the interview evaluation process broadly outlined above.

X. SUMMARY

Because of the special conditions associated with providing Homemaker Service to senior citizens, careful attention will be paid to such factors as:

The conservation of energy through a modified tempo of living extra sleep and rest.

Providing personal care with a minimum modification of the familiar physical surroundings.

Fostering the development of inner resources so as to create a more purposeful pattern of living.

Constantly stressing self-help and self-care activities.

Encouraging continuing contact with old friends through the use of the telephone, writing of personal letters, short visits.

The physical support and protection which elderly people need because of the impairment of their senses.

All items of expense so as not to threaten their sense of financial security. Very flexible policies geared to the frequency and period of time that Homemaker Service assists senior citizens will prevail. Because of the nature of this demonstration project, it will be important that close working, day-by-day contacts are available between the social work supervisor and the Junior League