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has had national distribution, 450 pages, done primarily by professors at the University of Southern California on special grant.

Then there have been training programs. There were two endeavors last year, one at Cedars of Lebanon and one at Rancho Los Amigos in Los Angeles, one of them conducted for nursing home operators and the other one for owners and nursing in nursing homes. These are inservice training endeavors, short-term intensive instruction and conference-type institute, to stimulate their thinking and to improve methods in response to new endeavors and newer information that is available.

Then a third is a physician study of adequacy and appropriateness of care given to elderly patients in California.

Another item that I would like to mention is this department's efforts beyond the regulations that are required of nursing homes and hospitals to require improved services for the benefit of patients in rehabilitation facilities and medical-assistance-to-the-aged patients in hospitals and nursing homes-two categories.

About a year ago standards were set by our department in cooperation with the State department of social welfare, for that rehabilitation center, and we are now engaged in perfecting the standards that would apply to nursing homes and hospitals for the benefit of many medical-assistance-to-the-aged patients. These standards will more or less guarantee quality of service, adequancy of records, and a manner of substantiating the cost for reimbursement purposes to guarantee a satisfactory arrangement for public-financed medical care for this group of people.

The State licenses 540 hospitals with over 66,000 beds and 726 nursing homes with over 20,000 beds. California's Hill-Burton program is an outstanding example of Federal-State-local relationship in a grant-in-aid program. Since 1946 about a quarter of a billion dollars worth of hospital expansion in communities throughout the State has been assisted, financially. California is the only State which matches Federal funds. Local communities on the average provide about 50 percent of the cost of each project. The remaining 50 percent is equally financed by Federal and State money. It figures out onethird Federal, one-third State, and one-third local, but when the project is completed more local money has gone into it usually than the one-third. Federal and State appropriations now exceed $10 million per year in support of the California program. Hospital planning by the State department of public health has assumed statewide and national leadership, it has also stimulated regional and local planning to achieve more effective development in the use of hospital and related health facilities.

California now has 10 hospital beds of all types per thousand population. The planning goal for 1975 is 7.5 beds per thousand population, down from 10. Based on more effective planning on use. We believe the attainment of this goal will save hundreds of millions of dollars in capital investment and result in more effective and economic care of the patient.

Now there is one other point that I would like to cover. In the 1961 Federal appropriation for States, something like $300,000 was awarded to California for chronically ill and aged programs. Most of that money was distributed throughout local health departments,

and to make sure that it would be used for the purposes for which it was intended, local departments were asked to submit a plan for us of the allocated amount indicated that would accrue to them on a population basis, in advance of the allocation.

Now

Now although the year was short, because the money didn't become available until late in 1961, and could not be allocated to us until January 1962, we feel that the counties did an excellent job in planning to utilize these funds for the benefit of older people. there was a variety of plans reflected, local interests, local deeds, and local ingenuity. Twenty-seven of the departments provided home nursing care for chronically ill and aged people, either by expansion of an existing service or creating a new one. Nine of the counties provided disease-screening facilities in which chronic diseases such as diabetes and glaucoma could be detected. Six of the departments expanded in educational endeavors to advise older people on health measures, nutrition and preventive procedures. There were four departments that instituted some survey method to select chronically ill from among populations. By these methods, applied to other population groups, it would be possible to detect groups that were in need of special kinds of services.

Three of the departments instituted care of the chronically ill patients in the home. Two of them were interested in rehabilitation, two of them were for case finding and treatment of neurologically handicapped and one of them was an expansion of labor facilities.

This reflects a variety of expansions that were financed by this $300,000 of Federal money in California. There was another more important effect that it had. It stimulated a great deal of interest locally and I think throughout the whole of California it has done more than any other thing to emphasize the needs of special attention to the health of older people. There is need for more money. I am sure that local agents would be responsive again to making an effort to find and fill the needs if resources became available.

Mr. O'HARA. Doctor, I am very impressed to learn of the fine effect this grant program has had upon the thinking and direction of efforts by the various local health agencies. I assume from your description that you are inclined to agree with some of our other witnesses who have said that the Federal grant program sometimes has the effect of stimulating local activity.

Miss FAIT. That was definitely true in our experience.

Mr. O'HARA. So the effect of the program is far beyond

Miss FAIT. The money that comes

Mr. O'HARA. The money that actually is expended.

Miss FAIT. That's the way we feel about it.

Mr. O'HARA. I assume that on the whole you are satisfied with your relationships with the Federal agencies that deal with health problems.

Dr. PULLEY. Yes, we have had satisfaction.

Mr. O'HARA. I would assume further that you do not favor any change in the Federal programs to assist the aging that would amalgamate the programs and channel them through a central Federal agency to central State agencies.

Dr. PULLEY. I didn't have in mind making any specific recommendation along either line.

Mr. O'HARA. Thank you for bringing this to our attention. I have closely followed the work of the Committee on the Problems of the Aged and the Aging under the chairmanship of my colleague from the State of Michigan, Senator Pat McNamara. He has been very impressed with the importance of health questions in the problems of the aged.

Dr. PULLEY. There is one thing, Mr. O'Hara, that I might mention again, and that is that we feel that administration of Federal funds in California can best be accomplished by the State and local agencies dealing with Federal agencies, because we do have a plan of working with health officers where they can, where they convene twice a year regularly and in committees more frequently, and the use of Federal funds has always been discussed thoroughly with them and we have a statewide plan that we think works quite well.

Mr. O'HARA. Any questions?

Mr. GIAIMO. No questions.

Mr. O'HARA. Thank you very much, Doctor, for your testimony. Mr. Simmons, if you will identify yourself to the reporter and proceed, we would like to hear your testimony.

STATEMENT OF HAROLD E. SIMMONS, DEPUTY DIRECTOR, STATE DEPARTMENT OF SOCIAL WELFARE, STATE OF CALIFORNIA

Mr. SIMMONS. I have in the audience other members of the staff who will not be making a presentation, but who will serve as a resource for information in case questions arise which are of particular interest to you.

The staff members are Mr. Vern Gleason, who is the director of our special projects program; Miss Helen Clauson, who is the chief of our Bureau of Boarding Homes and Institutions, and Agnes Gregory, who is a consultant on aging in our Bureau on Old Age Security.

Before discussing public welfare programs and problems in regard to the aging, I would like to present two concepts which are basic to any consideration of programs for the aging population as follows: 1. Regardless of age and disability, man must continue to be engaged in purposeful activity which has meaning to him and which is appropriate to our culture. The power that man has to act, to move, to work, creates out of its very existence a need to use this power. Moreover, the culture in which we live establishes work and other kinds of productive actions as essential. Consequently, failure to use such powers productively results in unhappiness and in physical and emotional deterioration. Man has no other way to be at peace with the world and with himself, to be related to others, and to retain his individuality except by making productive use of his own powers. If he fails in this, even though his own culture accepts uselessness in retirement, he cannot attain inner harmony; he is torn and split and out of his feelings of uselessness, boredom, impotence, he regresses to a state of physical illness or emotional apathy and dependence.

2. The physical and psychological diseases of the aged are largely stress-associated ailments in the sense that social-psychological stress results from the trauma of adaptation to retirement, loss of loved ones, financial stress, etc. These stress conditions set off a physiological process which can be physiologically traced and which results in

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emotional and physical disease. We must recognize that disease and mental deterioration are not inevitable concomitants of aging, but that vulnerability to these conditions has been increased by the aforementioned stress situations. Heart and artery diseases, metabolic disorders, skin disorders, thyroid ailments, diabetes, obesity and other kinds of ailments associated with malfunctioning of the endocrine glands are clearly associated with stress.

3. If the logic of these above-stated concepts are persuasive, then the methods of dealing with problems associated with the aging become clearer.

(a) That Government and industry will establish a plan which will accommodate the interests of the aging in persuing purposeful activity, whether in work for hire, voluntary services, or cultural and vocational pursuits. The objective will be that of enabling the individual to engage in full-time or part-time work at a factory, at a work center, or even at home when disablement prevents outside activity. Concurrent with these developments we should continue to concern ourselves with the development of social, recreational, and hobby services and facilities which will fulfill the needs of the individual in this respect. Thus the enablement of the individual to achieve a rhythm of activity which includes work and play will surely be preventive of accelerated physical and emotional deterioration. Man's capacity for long, useful life will be determined by the success of these achievements.

(b) That services of varying kinds will be developed to remove obstacles which preclude the achievement of the above-described objectives for man. These services must include a full range and variety, the social worker, the physician, psychiatrist, the occupational adviser; facilities which include outpatient services such as nursing homes, boarding homes and institutions, must be provided. If we are to prevent physical and mental deterioration of the aged we cannot settle for the issuance of financial aid alone. In the interests of the individual's well-being, the interests of the taxpayer and the society as a whole, it is important that services will be provided that will prevent and correct physical and emotional deterioration. Thus it becomes imperative that governmental agencies, in conjunction with private agencies, will develop social, medical, psychiatric, vocational and avocational services and facilities.

The aged who come to our agencies have varying degrees of economic need, of social, emotional and physical health, and of physical and mental deterioration. It is imperative that we develop systems and methods of administration which will insure that care and services appropriate to the needs of the individual are available to him.

In the State of California we have established, or are establishing, systems in public welfare which do this. We will describe them under the headings of "Social Services," "Nonmedical," and of "Medical Care Services."

1. Income maintenance, through an assistance grant is the first and primary social service which public welfare renders to aged persons. Public policy, Federal and State, seeks to assure to aged persons an income adequate to meet essential need.

California, by action of the legislature, asserts that the minimum need of an aged person requires an income of $101 to meet it. Every

person eligible to receive old-age assistance (known as old-age security in California law) must, therefore, receive assistance in this amount or in an amount sufficient to bring his income up to this minimum level. But many persons have need above this minimum. The State's standard of need appropriate to a public assistance program includes a provision for the cost of shelter (rent or costs of ownership) and utilities, as paid, up to $63 for the person living alone and up to $45 for the person sharing costs.

Other needs above the minimum are recognized also. Notable is the cost of care in nonmedical out-of-home care as provided by a boardand-personal-care home or institution. The standard recognizes the charge for such care up to $150, and there is a provision by which the county public welfare agencies shall, as necessary, modify this maximum upward to fit local conditions. The cost of care in private psychiatric facilities is recognized up to $175, with the same provision for local modification.

Prior to January 1, 1962, the largest grant that could be paid, however high the need, was $115. It is now possible to pay a grant up to $166 if that much is needed, or to supplement the recipient's income to bring his total up to the amount of his need or to $166 if his need reaches that figure. This provision by the legislature makes it possible to meet need much more adequately than before, especially for those persons who have little or no other income. This standard of assistance compares very favorably with the so-called elderly retired couple budget, not related to assistance.

While all income of the recipient must apply to his need within the maximum grant figure of $166, there is a provision by which need found in excess of that limit can be met by voluntary contributions. Friends, organizations, and relatives not legally liable for support can thus help to meet such high-cost needs as that for out-of-home care. Supplementation by county government from county funds also is usable in this way.

A single example of the operation of a grant of assistance will serve to show how public welfare in California helps aged persons to obtain the care and services often so badly needed. Mrs. M. is a widow, 75 years old. She has been living alone and managing quite well on a small private pension of $50 and a grant of OAS to make up a total need of $125. Now she has become frail and forgetful to the point where it isn't possible for her to remain alone. She asks the county worker to help her make another plan. Together they arrange for her to move into a small board-and-care home where the charge will be $150 per month. The standard allows for personal needs not provided by the home, in the amount of $25. The worker then provides for an increase in the OAS grant to bring Mrs. M.'s total income up to $166, including her $50 pension. This is still short of her total need of $175, by $9, but she has no relatives able to assist her and she will need to manage with $16 for personal items. Even so, her big need has been met and she is in congenial, protected surroundings, with good care. If the charge for care should be much higher, the county might elect to make up the deficit from county funds in order to assure this needed care of a lonely, helpless old person.

There are, currently, approximately 250,000 recipients of old-age security. This represents 172 per 1,000 of persons in the State 65

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