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than non-Medicare patients. The ancillary service billings are $97.00 more than the average non-Medicare patient. Thus, with rising costs, some borderline patients face serious financial problems.

In addition, the traditional charity given by large private hospitals is not as
effective as formerly for two reasons. First, the same dollar amount will not buy
as much medical care and, second, the government policies will not permit these
costs to be included as part of legitimate overhead charges. It seems to me that
this particular reimbursement policy might be re-examined.
Yours sincerely,

Vice Chancellor for Medical Affairs.


As Chairman of the Planning Committee on Aging of the Health and Welfare Council of Metropolitan St. Louis, I was asked by the Honorable Alfonzo J. Cervantes, Mayor of St. Louis, to prepare some brief comments regarding problems, as I see them, of the cost and delivery of health services to older Americans.

I have had contact with a number of individuals in the past few months regarding generally the problems of the elderly. The Health and Welfare Council is conducting a program sponsored by a Title III grant from the Older Americans Act. This program, called Aging Information and Direction Service (AIDS), is one of providing information and referral services to older adults. I could cite you case histories regarding some of these problems, but in the interest of time, I will merely describe the problems as I see them.

With the advent of Medicare, older individuals qualifying under the program, who previously used the out-patient clinic services provided at City Hospitals, are now billed the full fee for a clinic visit, whereas prior to Medicare, they were billed approximately one-eighth of this amount. This is very frustrating to many of them who are living on reduced or fixed incomes and cannot afford to pay this fee. Once the hospital has billed the patient in the amount of the $50 deductible, they are no longer billed for services. They are, however, charged the 20% of the full clinic fee at each clinic visit. If the patient could not pay the $50 deductible fee, or the following 20%, this is collectable under Medicare as a bad debt. It would seem that some different way of handling this situation could be arranged to alleviate the personal suffering and worry on the part of the older patient.

Another problem that still faces us is in the area of nursing home care. The quality of much of the nursing home care available today still leaves much to be desired. A nursing home can be licensed by the State of Missouri as a professional or practical nursing facility. At the time the inspection of the home for licensure takes place, the home may meet staffing standards. However, one month after licensure, staffing may change, which means an inadequate staff arailable to provide needed and requested services. This is an unfortunate situation and I recognize the many problems involved in staffing nursing homes today, but I do feel that something should be done to more adequately insure that a home which is to receive payment for a certain quality and quantity of care, is qualified to provide that care. This might be in the form of inspection teams, which would periodically inspect these nursing homes on an unannounced basis.

There are nursing homes in operation in Missouri and St. Louis which have repeated and numerous violations at the time of their "regular" inspections by authorities. It seem that it is very difficult to revoke the license of a nursing home operator. When the inspectors do find a situation which warrants and allows them to bring action against a nursing home operator, only the violations found at the last inspection are permissable as evidence. The past history of the operation of the home, no matter how deplorable, is not used. It is possible, also, for operators to obtain continuances for lengthy periods of time, meanwhile continuing to operate their home in a manner which does not meet standards. Something needs to be done about this where there is federal money involved.

It is also brought to my attention that in many cases medical records kept in the nursing home may not be adequate to insure the patient a continuity of quality care necessary to promote their living in as optimum a situation as their illness or disability will permit.


Some provision should be made to insure that each patient ir an extended care or other nursing facility have a medical and social re-evaluation and diagnosis at least each year. This is required for those patients receiving Medicare payments but for those on public assistance, this may not be the case. It would seem that far too often an individual patient is diagnosed and evaluated upon admission to a home and cared for on the basis of this diagnosis for too extended a period of time, even though their medical situation might have changed during this time.

We have tried in this country for some time to promote the idea that when an older person goes into an institution, he be made to feel that this institution is in fact his home while he is there. Nursing home, homes for the aged, and domiciliary care facility operators have come a long way in recognizing the need for this kind of philosophy of care. Now we have a situation in which an extended care facility may provide both a residential and domiciliary care facility and a nursing home facility. Suppose a person living in the domiciliary facility could benefit from some home health services. Could not these home services be provided to them in the domiciliary facility from the nursing home facility. This, I believe, needs some clarification and redefinition.

We have many elderly living in public housing projects. Getting services to people in public housing would seem, at first glance, to be an easy matter due to the fact that you have such a large number of clients living in close proximity. This does not always prove to be the case. The problems of people in public housing are of such a magnitude as to be overwhelming. One is struck by the amount of difference which exists between public housing designed specifically for the elderly and public housing designed generally for the total community. For example, in public housing for the elderly, the elevators stop on every floor, and there is more community space available. I ask you, is this disparity desirable? Suppose an older person lives in public housing where the elevators may not stop on every floor. If this person becomes ill, they may be requested to climb many steps in order to get to and from their apartment and the services in the community which they may require. Of course, for some medical reasons these elderly can have their apartment changed and be placed on a floor where they have access of an elevator, but I submit to you, gentlemen, that this reshuffling of human beings in degrading and frustrating.

Another problem which I would present to you today is the one of the older person's ability to travel distances to get to services they need. We have facilities in a metropolitan area designed to provide services to many of our elderly, but whether the individual can get to that service is another matter. I am sure we have heard time and again about the need of localizing services. Providing services where people live is of great importance.

There is still much confusion on the part of the elderly about Medicare benefits. A need still exists to acquaint them with their rights under the legislation. Many elderly still fear to utilize services available under the new law.

A common complaint of older persons is that the cost of various services has gone up since Medicare became operational. Until they reach the $50 deductable limit, this causes a hardship in many cases.

I do not envy the task of this Subcommittee but believe me when I say that you have my sincerest support and best wishes for finding solutions to some of our country's most pressing problems.


St. Louis, Mo., June 16, 1967. Mayor ALFONSO J. CERVANTES, . City Hall, St. Louis, Mo.

DEAR MAYOR CERVANTES : I hope that this letter is received in time, by you, for submission of your testimony to Senator Smathers' Committee.

The thinking expressed in this letter is part of the problem which I reviewed in my letter to you of June 9, 1967.

The legislative definition of “a spell of illness" is very detrimental to the benefits of many elderly people of advanced age who cannot move from a nursing institution or an Extended Care Facility.

A resident of such an institution who becomes acutely ill at the beginning of the year and is hospitalized, say for the maximum of ninety days and then returned to the Extended Care Facility, say for a maximum of the one hundred days benefits, cannot become eligible again during the year for any hospital benefits unless transferred out of the Extended Care Facility or nursing home to a domiciliary center for sixty days.

As I mentioned, such transfer would be detrimental, and in many instances, dangerous to the health of the advanced chronically ill aged. As a result they are not able to end "a spell of illness" and lose the benefits mentioned in the Medicare Law.

This inequity has become quite obvious and serious, and many efforts have been made to secure legislative change; but to no avail.

I hope your testimony can emphasize this point and help secure remedial legislation. Sincerely yours,

SAMUEL ZIBIT, Executive Director.


St. Louis, Mo., June 8, 1967. Hon. ALFONSO J. CERVANTES, Mayor of St. Louis, City Hall, St. Louis, Mo.

DEAR MAYOR CERVANTES : A giant step has been taken to enactment of Medicare legislation in bringing to the older people within society the quality and quantity of medical and health care which is their right.

The exposure and services provided by the Medicare Program have enabled us in our activities to experience and appreciate the enormous benefits being made available to society. However, in addition hereto it is focusing our attention on numerous additional aspects of health care needs which must still be considered.

One example might be elimination of all deductible and co-insurance features of the Medicare Program, removal of waiting period and deadlines for enrollment. Deductibles form barriers to needed care for those least able to pay.

Secondly, extension of coverage for drugs regardless of their association to hospital confinement. I hope these comments will be of some help. Sincerely,


Director. Mr. ORIOL. Now, I call the last witness, Mrs. Mary Guiney, who is project director for Project Well-Being in Detroit, Mich., and planning consultant on aging to the United Community Services of Metropolitan Detroit and who has so many honors and a history of work on the project relating to the elderly and others in need of health that we will insert this description we have in the record.


The welfare of Senior Citizens has commanded the devoted energies of Mrs. Mary (Molly) Guiney for more than a quarter of a century. Regarded as one of the nation's foremost authorities on the aging, she has been Planning Consultant for Services to the Aging, United Community Services of Metropolitan Detroit (CCS), since 1953.

Mrs. Guiney's major responsibility currently at UCS is as administrator of Detroit's "Well-Being Project for the Aging". Regarded as a "first” in the nation, this Project was launched in June, 1964, as a three year demonstration program to help older people maintain their health and precious personal independence in their own homes. It receives its major financial support from a C.S. Public Health Service grant and is being carried out in three geographic areas of Detroit which was high concentrations of older residents.

A native of Rochester, New York, graduated from the Rochester Institute of Technology and later completed studies at the New York School of Social Work at Columbia University.

Her broad experience and knowledge of the needs of older people was gained in both public and private agencies in Detroit. When the Bureau of Social Aid was established in 1940 in Detriot, she was named its supervisor and given the job of organizing it. During the years she remained with the agency, Mrs. Guiney administered old age assistance to many thousands and was responsible for licensing convalescent and other homes for the aged.

Prior to joining the Bureau of Social Aid, Mrs. Guiney served in a supervisory capacity with the Emergency Relief Administration and was general case supervisor for the Public Welfare Department of Detroit. Her first position was as a home economist with the Visiting Housekeepers Association in 1919.

She serves on both the Michigan Commission on Aging and the Mayor's Departmental Committee on the Aging. She is a past president of the Detroit Chapter, National Association of Social Workers, and holds memberships in several state and national organizations, including the American Public Welfare Association, the National Committee on Aging, the Michigan Society of Gerontology, and the National Society of Gerontology, Inc. She was a delegate to the first White House Conference on Aging, called by President Dwight D. Eisenhower in January, 1961.

Honors: Community-wide recognition of her efforts on behalf of the aging was accorded Mrs. Guiney in 1958 when she was named “Woman of the Year" by the Detroit Soroptomist Club, and again in 1965 when she received the “Award of Merit" from the Detroit Chapter, National Association of Social Workers.

Mr. Oriol. We are very happy to have you here today.




Mrs. GUINEY. Thank you, Mr. Oriol.

I am honored to be here and I thank you for the opportunity of allowing me to come. I apologize for the public relations department in sending that stuff out without letting me see it. A lot of the material really is, I think, just for windowdressing.

I have prepared a very short narrative report of this project and I will try in the time allotted to offer some clarifying comments and some examples about the Well-Being project.

We will in the next few weeks be preparing a full 3-year report of the project.

I would like to refer to how this project came about. It was a combination of circumstances. The determination on the part of the metropolitan Detroit committee, to undertake the project was a culmination of 10 years of concerted effort to achieve its objectives, of finding and helping older people where they are and when their need arises, through other means.

It is unusual, of course, for a voluntary community planning body to provide direct service. In spite of the significant list of programs which were promoted, encouraged, and given financial support by the United Community Services, we found that the missing link in all of them was a way to reach and know older people before they became the statistics which we are all so familiar with, the newspaper stories of them being found dead, of fires started by the frail, of the exploitation of their resources by promoters of schemes of all kinds, and so on.

The project is a direct individualized service to the aging people who live in three geographic areas of Det roit, where the Detroit Housing Commission in its Department of Urban Renewal and Housing is carrying out neighborhood improvement activities. The core of the


service, which is called a sociomedical service, is a team of social workers and public health nurses on loan from the Visiting Nurses Association, who work directly with older people in their own homes.

They give nursing care and social services which are aimed at helping them to remain independent and avoiding or delaying unnecessary placement in institutions. They work with them on an intensive basis, covering a wide variety of problems.

Some of the older people are alone and have no family ties. Others are alienated from their families because of what the families call their ways"

The staff people work with the families as well as with the older individuals. Some of them are financially independent, but do not know how to go about getting needed services. The problems which we deal with include financial, transportation, senility, social isolation, ill health, protective care, and guardianship.

Many have difficulty in finding proper housing, as they face eviction from their homes in the central cities because of condemnations brought about by the urban renewal, homes which they often occupied since they went into them as brides and grooms. Also, they have difficulties in taking care of their homes because of the infirmities of old age.

They are, in the main, those people whose health and social needs are not met by existing agencies in the community. They include, of course, the very elderly, the crippled, the recluse, the nonjoiner and they are people who have remained for the most part unknown and unseen.

The services of the Well-Being project includes such things as finding doctors. Doctors really are an essential part of the team. They find doctors in the community who will make home calls. They secure housekeepers, themselves turning in on occasion to do some cleaning, some cooking. They give nursing care, from simple things like clipping toenails to intensive care. They ride in the ambulances, take them to the old age assistance office, help them to fill out forms for medicare, deal with emergencies, go to court, taking guardianships, find volunteers, et cetera.

The teams, as I have said in the statement, employ the oldest techniques of the trade. These techniques were employed long ago by the Curés in old France who went up and down the streets doing good, and by the workers in the early settlement houses in this country, who also went up and down the streets. But these practices have now fallen into disuse as professionals of all kinds have become officebound.

They wait for people to come to them and to be able to tell what their problems are and then to respond to a request for service.

The lessons which we have learned in the project we believe can be applied in rural as well as in other urban communities. in fact, they can be employed wherever older people are.

The other witnesses here this morning have referred to the need for providing services for the ambulatory in their own homes, whether it be in group medical practice or other forms of cooperative services established in the community.


We have confirmed what those who work with the aged already know, that regardless of advanced age or of economic or social status,

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