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culosis, a hiatus hernia, a cataract of the left eye, chronic bronchitis, varicose veins, arterio-sclerotic heart disease with a healed anterior wall cardiac infarct, and, finally, diabetes mellitus. Now, if you ask this man what is his chief complaint, he will tell you quickly enough that it is his wife.

His wife is 75 years of age; she had a thyroidectomy but, unfortunately, the recurrent laryngeal nerve was cut. She cannot shout at him, but she nevertheless can scold him rather effectively in a whisper. She has a tracheotomy with a lot of excoriation around the neck, and she is rather miserable, but they are miserably happy together as elderly people often are.


Now, if this man would come to a major teaching hospital, this is perhaps what would happen to him. For his cancer of the larynx and related conditions, he would visit the ear-nose-throat clinic and the cancer clinic; the hiatus hernia would be seen in the surgical clinic; the cataract in the eye clinic; bronchitis, chest clinic; hypertrophy of prostate, GU clinic; vericose veins, vascular clinic; the heart condition, heart clinic; the diverticulosis and hiatus hernia, medical clinic; diabetes mellitus, metabolism or diabetes clinic-10 clinics in all. This man is much too sick to go to 10 clinics. How long would he last as an ambulatory patient waiting in the waiting rooms of one clinic after the other, of 10 specialty clinics in a teaching hospital?

Actually, he is a noncooperative patient, and that was an advantage because he didn't go to the clinics.

I can tell you what happened to him: he went to none of the clinics because the traditional pattern of medical care which was available to this medically indigent old man, living with his wife in a public housing project, was not one which could help him. It would have incapacitated him. Suppose he had tried to go to the 10 clinics. One can readily predict what would have happened. He would have become exhausted and sooner or later would no doubt have become so weak in one of the clinics that he would have required an emergency admission. and then, how long would the average hospital allow him to occupy a hospital bed? It would not be very long before he would be referred to a nursing home. Once he entered a nursing home it seems fairly obvious that he would never leave, and his wife, too, would have to be admitted fairly soon to a nursing home. Because of the way we do things in our culture, they would probably be put in separate nursing homes at a cost of about $10 each per day.

This episode I have just related occurred 4 years ago. This man is still living with his wife, and they are still miserably happy together. He now attends a hospital clinic about once every 2 weeks. The bulk of his medical care-and it is quite a bulk-is received in a small clinic, a branch of the general hospital outpatient department which was opened within the housing project where he lives. This man is receiving fourth-stage medicine, the kind of medical care so many patients like him need and which so few hospitals have become equipped to render close to the patient's home.


Let us consider the mental problems of these old people. If you take a man in the prime of life, deprive him of his wife, his hearing and vision, his job, his contemporaries and confine him to his home month after month and year after year, you would not be surprised if he developed some strange personality traits. Yet this is frequently what happens to our senior citizens with hearing and sight diminished, his friends departed and his arthritis severely limiting his mobility. It is not unusual that he avoids medical care because it is too taxing to his physical resources and that he withdraws from society into an unrealistic shell of his own drab world.

Senator MONDALE. Would you yield at this point? We had testimony from Dr. Ostfeld, University of Chicago, indicating that many senior citizens do not present themselves for an examination of symptoms but may disclose serious health conditions because, fearing the worst, they pretend the symptoms do not exist. If they have a bad cold, they might present themselves but if they have something that sounds like a bad heart or something serious that they are disinclined to do it. Do you think this is a phenomenon that is rather widely found among our senior citizens?

Dr. JAMES. Yes. The studies which have been done in which populations of older people have been offered free disease detection examination services generally show that only about a half of the population will come, and even the best of them are able to recruit only twothirds. The small clinic we opened for this man I have just described, even though it is right within the housing project, has only recruited half of the elderly people in that institution as clients, even though every effort is made to recruit them.

Senator MONDALE. In other words, the others living in the same public housing project as the person about whom you are testifying who have available to them this new type of chronic patient clinic won't show up?

Dr. JAMES. That is right. Every effort is made to recruit them. They are advised at all the affairs which this housing project holds for its older people. The clinic is well described. There are many satisfied patients living in the same development, but still they do not come. I think the answer is fairly obvious. As you pointed out, the threat of illness is such an overwhelming threat to what little security they have, particularly if they live alone, they find it difficult to act on their symptoms.

The sociologists have done some interesting studies in which they showed the steps one goes through in deciding to visit a physician. You wake up in the morning and your stomach bothers you. You tell your wife, and she says, "See a doctor." Later she asks you, "How do you feel?" "Well, I don't feel so well." This acting out and discussion with another person plays a major role in getting an individual to seek medical attention. A person who lives alone and is denied this opportunity is much less apt to act on this symptom. This is the reason in addition to the tremendous threat to a person's whole life that a serious illness should be looked into.

Senator MONDALE. What about in this case, you have what you might call a chronic clinic, a one-stop chronic clinic conveniently lo

cated for the occupants of this public housing development and you say only about half of them show up despite every effort to persuade them. Have there been any efforts to go to their unit?

Dr. JAMES. Yes. A great deal of work is being done to try to bring 'hese people in, and I think that it will eventually be handled in one of two ways. One, to get the patient used to coming for medical care as a routine instead of waiting until he feels sick. Let this be a health maintenance program to keep them well, rather than only an emergency service after illness strikes. This presents much less of a threat and can be presented in a warm, friendly, supporting way.

Second, you have to develop the kind of services that will backstop them if their security is threatened. Very intensive home care services, homemaker services, make him feel that he has a family that will look after his social needs as well as his stomach or gallbladder if that is what is afflicting him.

In New York City we have a million and a half people that live alone; many of these are young but many of them are old. We have couples that moved into public housing projects at the age of 60 and now 20 years later only one is left. Often the husband who does not even know how to boil an egg and lives alone with a neighbor supplying him with food. If that neighbor gets sick and goes to the hospital, suddenly people discover this poor old man is living without anything.


There are many social problems which are closely related to disease and are part of the care of these people. As a matter of fact, the physician is often the least important person in the total medical care of what I call four-stage medicine or chronic care of the aged. Very few of these conditions are cureable, but there are problems of adjustment. of a man and his environment which require quite a team of people. What I am going to tell now is highly pertinent. Recently an exciting program to combat this vicious cycle has been developed by the Henry Street Settlement in New York. Here about 100 senior citizens banded together to help their colleagues. Showing unusual patience and empathy, they started a friendly visitors program in which they periodically visited old people in their homes. Often their first efforts were rebuffed. Only after making dozens of visits were doors opened, conversations and friendships begun, and new recruits enlisted into the ranks of the friendly visitors. The rehabilitation thus became double, with both the patient and the visitor finding a new meaning to life.

Old people do not generally want to sing in glee clubs or do basket weaving. They can recognize such busy work for what it is, and they do not usually do it well. But here they have a mission which they have the time and ability to perform in a way which is vastly superior to that of our so-called professional manpower. The potential of this untapped resource is enormous.


A report recently prepared by the Public Health Service indicates that there are only 70 medically directed home care programs now in operation in the United States, and these serve only 5,500 persons. I

might add that one-third of them are in New York City. Truly this is fantastic considering the enormous numbers of persons who are either homebound or understandably lacking in the ability or motivation to seek high-quality medical care, no matter how much we offer to pay for it. One patient of ours consistently refused to attend the cardiac clinic for a severe heart ailment. Careful study of his total problem revealed that his feet hurt. After receiving corrective attention to his painful corns, he was so grateful he walked, despite his diseased heart, 3 miles to the cardiac clinic as a favor to the nurse who spent so much time trying to gain his cooperation.

The answer to the problem of medical care for our aged is to reorganize our services around the patient and his needs, rather than to insist that he spend what few energies and motivations he has in a futile round robin of visits to various specialty services. Ideally, all people should go for medical care not because they fall ill and feel sick, but because as people they should receive a routine checkup for all stages of many different diseases. At Senator Neuberger's hearings last year, I deplored the fact that Americans take far better care of their automobiles than of themselves. Automobiles are usually sent for a spring and fall checkup. Perhaps some day we may see the wisdom of doing as much for ourselves.


Happily today we are seeing the development of a significant number of demonstration programs aimed at giving medical care to people and their families on such a comprehensive basis. One of the first of these to be done on a major scale was the Cornell-New York Hospital comprehensive care program. One thousand welfare families were invited in for medical care as whole families as soon as they were added to the public assistance lists. Incidentally, inviting them in as families is a means of breaking down their resistance to coming. Of course, these are the more fortunate older people who have a family.

The same team of physicians attempted to follow the family as outpatients, inpatients, in the nursing home, and in their own homes. Certainly the specialist was used, but the specialist always referred his findings to the general medical team. Data on the program are being collected, cost information is being studied, and very interesting results are being discovered. For example, they are finding that only rarely will an individual ask for home visits, even though the treatment team is willing to go to the home. Part of this is because the patient is not quite sure he will see the doctor whom he knows, and he is sure that he will see him if he comes to the clinic.

The other reason is that there is not as much need to have home calls, because the patient has had his diseases detected and under treatment before the symptoms have appeared. It is also of interest that an enormous amount of very significant disease has been discovered from this population. One sidelight which reveals something of this program is that for the first time New York Hospital has had to print signs in Spanish for its waiting room. They have a group of patients they never had before.

In New York City we also have the Gouverneur program where the staff's of several city departments are starting a program with Beth

Israel Hospital. As you know, a new hospital building is being erected and all agencies will try to cover the total health needs of the area's total population. There is also St. Vincent's Hospital with a program for its welfare patients which is now expanding to include the rest of the family. What we are dealing with here in the efforts of these and other hospitals is the adaptation phenomenon. They are trying out various methods in order to learn how to approach total family care and how to treat all stages in the natural history of disease.


The first step in one of these programs could be anything which will bring an institution or a service into closer contact with a group of patients which has not been seen before. These patients may actually be the hospital's own patients, but that particular institution may never have looked at them before in relation to many of their total health needs. Ideally, a hospital should pick a population group, as Beth Israel is now doing in the Lower East Side. This will be "their" population for the total practice of medical care. The hospital plans to try to meet all the medical care problems in that area to the best of its ability, utilizing all the modalities of private practice, clinics, chronic care, health center services, and home care.

Senator MONDALE. How is Beth Israel financed?

Dr. JAMES. This program has been going on now for several years. It was begun with their own funds. They received a significant grant from the Office of Economic Opportunity, and now, of course, with medicaid in New York State it can be amply supported that way. Senator MONDALE. Are they using medicaid for this now?

Dr. JAMES. Yes; but they still have a large OEO grant.

Senator MONDALE. Medicaid and OEO?

Dr. JAMES. They have a large OEO program which will last for a few more years.

Senator MONDALE. What about the earlier program to which you made reference?

Dr. JAMES. The Cornell-New York Hospital?

Senator MONDALE. Yes.

Dr. JAMES. New York City is unique in having its own little "NIH," for health programs, called the health research council. Mayor Lindsay has continued the program whereby a dollar per capita is appropriated. It is 50 percent reimbursable by the State health department. It is dedicated to the support of worthwhile research in biology and medicine in New York City, and one of the priorities has been medical care. So this Cornell project was supported by a 5-year grant. Actually, several million dollars was invested in this program and it has been the prototype for many others which are developing in New York


Senator MONDALE. Would this program we are now discussing be fundable under medicaid?

Dr. JAMES. It is fundable under medicaid not as a program, but it is fundable in the sense that the doctors could be paid for giving the treatments. Therefore, by putting together all the doctors' fees, we could obtain support from the program. It would be highly desirable. for there to be better support than there is for such demonstrations,

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