Mr. GIAIMO. Thank you.

Mr. O'HARA. Mrs. Russell, thank you again on behalf of the committee. I am aware of the recommendations made by the California conference to the White Mouse Conference on Aging. I think the effective action of the California delegation played an important part in leading the Conference to the conclusion that improvement was

needed in this field.

We are very grateful for the information you have given, Mrs. Russell. Thank you very much.

The next scheduled witness is Dr. Daniel Blain, director of the department of mental hygiene. Dr. Blain, please identify yourself to the reporter and proceed in whatever manner you wish.

STATEMENT BY CHARLES DEVEREAUX, ASSISTANT TO THE CHIEF OF SOCIAL SERVICE IN THE DEPARTMENT OF MENTAL HYGIENE, STATE OF CALIFORNIA

Mr. DEVEREAUX. First of all, I am not Doctor Blain. I am Charles Devereaux, assistant to the chief of social service in the department of mental hygience. Doctor Blain expresses his regrets. He had pressing business elsewhere and could not meet with you today, and I am here to make a statement on his behalf.

And I would like further to preface my comments by saying that in view of the short notice that we received to prepare a statement such as we would wish to present to you, I do not have a finished draft for you, but will make copies available to you before the hearing is over today.

Mr. O'HARA. Thank you. If you have additional material, you may submit it later. These hearings will continue for several weeks, and we would be happy to include additional material in the record of the hearing.

Mr. DEVEREAUX. Thank you.

Mr. O'HARA. If you are ready to proceed, we are looking forward to hearing your testimony.

Mr. DEVEREAUX. In view of the limited time for this discussion, we wish to speak to the one point which from our point of view we consider most urgent, the provision of Federal contributions to financial assistance to mental care and mental after care of elderly patients.

California, like other States, faces the difficulties born of prolongation of human life. Our most immediate concern is the impact of the aging population on our State hospital program.

In California, patients aged 65 and over have increased from 18 percent of the total hospital population in 1940 to more than 31 percent in 1961, although only 8 percent of the State's population is 65 or over. Approximately 1 in every 105 California residents in this aged group is in a State mental hospital; 3 out of every 5 patients aged 65 and over in our mental hospitals will remain hospitalized until death; even though these older patients comprise 31 percent of the hospital population, only 7 percent of the patients being discharged alive are in this aged group. The group of which we speak comprises in excess of 12,000 human beings in our State hospitals for general psychiatry.

The rising tide of elderly State hospital patients has two sources, the increasing admissions of persons aged 65 and over, and the mentally ill persons admitted prior to their advanced years, who represent treatment and rehabilitation failures, and who remain in our hospitals throughout their later years.

We will consider first the elderly persons admitted to State hospitals. In his advanced years the individual increasingly is subject to the hazards of life, while income diminishes, costs of needed service tend to rise. The oldster faces isolation, loneliness, physical decline, and economic depression. Often, for lack of appropriate health and welfare services, or early recognition of his needs, the elderly person suffers what appears to be a psychiatric disorder leading to displacement from home by admission to a distant State hospital.

Thirty-five to forty percent of the elderly persons admitted to State hospitals could be better served in their own communities with substantially less disruption of their personal and social lives. Another 20 percent of these geriatrics patients need only the diagnostic services of a State hospital, after which they can best be served in other than a State psychiatric hospital.

A study in the northern part of California has shown that in 52 percent of the cases of elderly persons admitted to the State hospitals, the doctors did not find the kind or degree of symptoms or behavior described by the county as the basis for State hospitalization, and in 17 percent of the cases there was basis for doubt.

In another study recently reported from southern California, a group found that for person aged 60 years and older applying for admission to a State hospital, over a 6 months' period of screening, review, and psychiatric social work help, more than 37 percent of the applicants found more suitable alternatives in the community. The screening services provided assistance in evaluation of the patient's symptoms, evaluation of possible resources designed to care for patients, evaluation of financial capacity and assistance in securing financial assistance where unused eligibility existed, working out conflicting feelings regarding the patient and placement alternatives and tangible selection of and referable to appropriate facilities. The problem is not the overt psychotic patients who are the danger, or potential danger to himself or others. These are accepted by State hospitals with symptoms identified by our department as indicating State hospitalization. Rather, the problem is one of early identification and provision for the needs of persons who are gravitating toward psychotic disorder for causes which can be interrupted by provision of necessary and sufficient health and welfare services on the client's home ground, and, too, prompt meeting of acute and chronic medical and social disabilities, which have resulted in psychotic symptoms, but which yield rapidly to skillful treatment supported by needed community services.

A research study of elderly persons admitted for psychiatric care in local facilities shows that a large proportion of these persons who appear to be psychotic clear up rapidly with a brief period of intensive medical, psychiatric, and social service which can be provided near at home. They are promptly restored to their more normal mode of life.

The second part of the problem is that of our growing proportion of oldsters currently resident and occupying beds in expensive State

hospitals for general psychiatry. Study shows clearly that in excess of 50 percent of the old persons could live in nonpsychiatric facilities closer to their home communities. Of the remainder, although they need psychiatric setting, 372 percent of them could be in a boarding or nursing home with knowledge of how to deal with chronic psychiatric patients. Only 9 percent need the confines of a psychiatric hospital per se. Almost 40 percent of those elderly patients would be able to live in the supportive protective setting of a family care home or family oriented type of small facilities. The same study reveals that none of the patients when first released could live in the community without some means of supervision and care.

We know that there are unnecessary admissions of old people to our large, distant State hospitals, and unnecessary retention of elderly persons in expensive hospitals for general psychiatry. What then is needed?

The major problems-the major obstacle found to release elderly patients from the State hospital is lack of money-money for medical care, money for protective out-of-home support and care. A similar need is evident for elderly persons applying for State hospital admission. The State of California is working to meet its obligation in providing these moneys for this purpose. We are of the conviction that the Federal Government is discriminating against a significant group of ill and handicapped citizens consistently, the Social Security Act and the pending legislation discriminates against a substantial proportion of the group of persons we have been considering.

The language is identical. These programs do not, and I quote— include any such payments to or in behalf of any individual who is an inmate of a public institution or any individual (a) who is a patient in an institution for tuberculosis or mental disorder, (b) who has been diagnosed as having tuberculosis or psychosis and is a patient in a medical institution as a result thereof.

This has included noninstitutional care such as foster homes. We are aware that it has been reported in the papers that Secretary Ribicoff has issued a directive to make possible Federal participation in public assistance grants for out-of-home care for the mentally handicapped. However, as yet there has been no evidence of operating changes which would free additional moneys for this purpose.

Additional assistance from the Federal Government to the States can mean a significant reduction of State hospital admissions and substantial increase in therapeutic releases from hospitals for geriatric patients.

Mr. O'HARA. Mr. Devereaux, I know you cannot speak with the same degree of authority for other States, but it is my impression that the problem you described with regard to elderly persons in mental institutions is one that is certainly not peculiar to California. It is a problem in all parts of the country, is it not?

Mr. DEVEREAUX. That is certainly true.

Mr. O'HARA. In the State of Michigan, we are experiencing difficulties in our State mental hospital system. The State has tried to accelerate the treatment of persons admitted to mental hospitals in hopes of giving more intensive treatment and quicker discharge. But we are faced with an increasing number of elderly persons who, for one reason or another and I think you distinctly outlined them-are not sus

ceptible to this kind of a program. In many cases, there appears to be no adequate program for their care.

Your recommendation for the care of elderly persons who do not need to be in State hospitals but who can be cared for in foster homes or nursing homes, involves, I suppose, the establishment and maintenance of a larger number of such homes and greater financial support for them, is that correct?

Mr. DEVEREAUX. That is correct.

Mr. O'HARA. You believe major progress could be made if the language in the Social Security Act and pending legislation were changed, is that right?

Mr. DEVEREAUX. Yes.

Mr. O'HARA. In other words, let us consider as an example a person who is entitled $125 a month under the old age survivors insurance program. If he were to receive the $125, even under ordinary terms of commitment to a State institution of one sort or another, you believe it would help in solving this financial problem. Did I understand you correctly?

Mr. DEVEREAUX. Yes, sir. That is right. Really, that divides. itself, as I see it, into two pieces; one is those elderly persons who essentially could live in a home type of setting with minimum but necessary supervision and guidance, in what we think of for example as our family care homes; then there is the other group, and this is perhaps even a larger group, of elderly persons whose major disability-disabilities-are enfeeblement, and with some medical and nursing needs, who could live in the smaller, more personal type of nursing homes, and although these persons may still have evidence of chronic psychosis, this is not the primary disability. The primary disability is the social inadequacy of enfeeblement, their needs for nursing and medical care, so that they are occupying really an inappropriate facility, but a necessary facility of the State hospital till provision can be made for them in alternate ways.

Mr. O'HARA. You indicated more money is needed to carry out the recommendations you propose. Would you comment on the adequacy of research and development of programs to deal with the problem of the aged in mental institutions?

Mr. DEVEREAUX. Yes. Had we had more time, I probably would have developed more information on some of the things that we have been learning through our research. Now, in my prepared statement, I referred to some evidence, the evidence that I gave was based on two kinds of studies, three kinds of studies. Those studies that have been furnished by national institutes of mental health in cooperation with the department of mental hygiene, funds that have been furnished by our own department, research studies, and then quite a large number of cities that are coming out, that is, people are doing them because they are concerned and interested. These researches have been of basically three types. One has been in relation to an understanding, a better understanding of the aging process and it is both-it is physiological, psychological and sociological. These are being carried on within our local communities and within our State hospitals.

It was such a study that a part of which revealed that a number of these substantial portion of persons-seemed to be inappropriately admitted to the State hospitals, that they could have been helped elsewhere.

Another part of research that is going on, that I referred to, is that which deals with the admitting process and the needs of people who are applying for admission, such as the Lindley support study, this was finished by MIMH, as carried on by our department, while we are studying the reasons why people apply for admission and to studies as to their medical, their social needs, from what kinds of environment have they come, what can they be released to, what are their needs. This is a similar study of what could very limited parttime kind of effort accomplish in the way of forestalling State hospital admission, the study I referred to in the southern part of the State.

And the third part of the research is this other thing I referred to, where we have been taking a closer look at what is our elderly hospital population comprised of in our State hospitals.

Up until quite recently, no one really knew what were the major medical disabilities, what were the major social disabilities, what proportion were actually psychotic to the point where they actually need a State hospital, or a psychiatric hospital, whether State or private or public of any sort, what proportion really might be released to less expensive and more appropriate types of care, so this has been a kind of a three-pronged attack that has been going on continually, but it isn't enough.

We really don't know, for instance, who knows at this point what kinds of facilities really would be most adequate, how should they be established, in what ratios, in what communities. Who knows? We need to find that out yet.

Mr. O'HARA. That is what I was wondering about. While there has been some recognition of the fact that the system of handling the needs of the aged who have been committed could be improved, it seems to me that we really know very little about just how we could carry out the alternative.

Mr. DEVEREAUX. That's right.

Mr. O'HARA. I would like to make one further observation and ask you if it is correct. This program would provide better means for taking care of the needs of the aged now in mental institutions through other appropriate procedures. It would result in the release of a great deal of energy and resources to a more effective treatment of persons who do need mental institutional care. Is that correct? Mr. DEVEREAUX. Yes. Yes, because if you have to give this nursing and maintenance care, you are using your staff, you are using skilled psychiatric staff who are in very short supply, for a service really that could be provided in another way and let them use their special skills and special equipment for the treatment of the acutely ill. Mr. O'HARA. Thank you, Mr. Devereaux.

Mr. Giaimo?

Mr. GIAIMO. I have no questions.

Mr. O'HARA. Mr. McCord?

Mr. McCORD. No.

Mr. O'HARA. Mr. Ellsworth?

Mr. ELLSWORTH. I just have one question; that is, you indicated that there is a shortage of trained personnel. There is also a shortage, as I understand it, of the secondary personnel, nursing care and so forth. Has your department given any thought, or do you feel that