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NOVEMBER 14, 1968. DEAR SENATOR WILLIAMS: I am glad to reply to your request for comments on some questions relating to the costs and delivery of health services to older Americans. Probably few countries have begun to face the full implications of the aging population for health and welfare services. Our experience with Medicare and Medicaid have only suggested the variety and magnitude of the prob. lems presented by a program directed at providing even minimal health services to an increasingly larger group of elderly persons in our population. The inci. dence and prevalence of mental disorders in this group is high, and comprehensive health services should include continuity of care from prevention through screening, outpatient and hospital treatment, and aftercare, and should cover medical, psychiatric, and social and supportive services. Although in most cases specific methods for the prevention of mental illness and for the treatment of many mental disorders of the elderly are not yet possible, at least the severity of disorder may be ameliorated by symptomatic treatment, its personal and social consequences can be mitigated, and humane treatment and care can be made available.
I am not well acquainted with the details of costs related to the delivery of health services in general. but I should like to emphasize the need for close liaison and coordination among all agencies, health care personnel, and services working in this field. The problems associated with prevention, treatment, and rehabilitation of the geriatric mentally ill not only are enormous and complicated by lack of knowledge, but also are inextricably tangled. Coordination of efforts is necessary from screening and the identification of persons with problems through treatment and aftercare and the provision of supportive services. Screening, for example, is useless if services for referral are not available or are located where they are not easy to reach or if transportation and assistance to get there are not available.
Screening programs that see patients at times of psychosocial crisis hare shown the wide variety of resources needed : general hospitals, psychiatric units in general hospitals, public and private mental hospitals, medical and psychiatric office care and home visits, psychiatric outpatient clinics, nursing and boarding homes, family care homes, old age homes, and homemaker services, visiting nurses, "Meals on Wheels," and other services to make it possible for some elderly patients to remain at home. But someone must assume responsibility for continuity of care and for the necessary flow of information from one facility or caretaker to another. The elderly person needs a "representative” to look out for his interests and to assist him in obtaining needed care. Especially pressing are the need for outpatient psychiatric services and the need to remove various restrictions on psychiatric care in contrast to general medical care.
NUMBER OF ELDERLY MENTALLY ILL Government at all levels, as well as the commuity as a whole, is vitally concerned with the availability, quality, and delivery of services to the elderly. Community studies have found moderate or severe psychiatric impairment in approximately 20 per cent of elderly persons living in the community.' Well over three hundred thousand persons aged sixty-five and over with mental disorders were resident in long-stay facilities in the United States in 1963, about half of them in state and county mental hospitals and the other half in nursing homes, geriatric hospitals, homes for the aged, and related facilities. The figure for the number of mentally ill in nursing homes and related facilities undoubtedly is a minimum one and has increased considerably since the implementation of Medicare.
The present trend to make use of alternative placements for those elderly mentally ill who traditionally have been committed to state mental hospitals has brought to attention some serious problems. Nursing and boarding homes are in increasing use both for the initial placement of patients and for the transfer of already hospitalized aged patients. But standards of care provided in these facilities must be raised, and this means increased costs. Adequate licensing and review procedures for each type of facility, relating to personnel requirements as well as to physical plant facilities, are imperative. There must be coordination
* Lowenthal. M. F., Berkman, N., and Associates. Aging and Vental Disorder in San Francisco (San Francisco : Jossey-Bass, 1967. p. 37.
? Kramer, M., Taube. C., and Starr. S. Patterns of use of psychiatrie facilities by the ased. In A. Simon and L. J. Enstein (Eds.), Aging in Modern Society, Psrchiatric Research Report No. 23 (Washington, D.C.: American Psychiatric Association, 1968). pp. 89-150. 3 Kramer, et al.,
of licensing agencies; in California, for example, some homes now are licensed by the Department of Social Welfare, some by the Department of Mental Hygiene, and some by the Department of Public Health. I'nification and clarification of licensing procedures are required. The most pressing need is for social workers to deal with families and for rehabilitation workers to inaugurate and carry out activity programs in the various types of home.
As to the need for psychiatric outpatient services for the aged, the National Institute for Mental Health has been collecting and publishing data on the numbers and characteristics of patients receiving services in outpatient psychiatric clinics since 1954. The clinic population has been weighted heavily with children under eighteen and adults in the 18-44 year age groups, with relatively small proportions in the age groups 4.–64 and 65+. Persons aged sixty-five and over constituted only 2 per cent of the total admissions to outpatient clinics in 1M. In contrast, persons in this age group constituted 29 per cent of all first admissions to public mental hospitals for the same year.'
Although psychiatric clinics claim not to discriminate against particular groups, there does seem to be a de facto discrimination against geriatric patients. A survey of admissions to the Outpatient Department of the Langley Porter Neuropsychiatric Institute for the year July, 1963, through June, 1964, showed that slightly less than 2 percent of these admissions were of persons over the age of sixty. Subsequent conversations with professionals involved in the private and public sectors of social services, with psychiatrists in private practice, and with non-psychiatric physicians in private practice suggested, however, that there was a large need for outpatient services for people in the older age groups. Our feeling was that if the public could be informed of a special clinic that had a particular interest in the psychologic disorders of the aged, there would be substantial utilization of the clinic's services. Such a pirogram might also provide social agencies with consultative services regarding diflicult client problems and a psychiatrist who could make house calls on clients who, for physical or psrchologic reasons, could not go outside their homes for help.
TRAINING FOR CARE OF ELDERLY MENTALLY ILL
The need for training programs and the upgrading of salaries and experience is especially obvious in relation to nursing personnel-nurses and nursing aides who care for the elderly. There is a rapid turnover of nursing personnel, largely because of poor pay, and a continuing scarcity of adequately trained and experienced aides. Training courses might well be made part of licensing requirements. Operators of boarding and family care homes greatly need training courses, and psychiatric consultative services should be made available to them and their use encouraged. The psychiatric profession must become increasingly involved: at present, psychiatrists are not adequately trained and experienced in working with the elderly mentally ill, and they are not called upon often enough by those who operate and staff these facilities.
Not only are the geriatric mentally ill being placed initially in other facilities than state mental hospitals, but patients already in these hospitals some for many years are being transferred out in increasing numbers. Most of these are placed in nursing home or family care settings, although some are able to return to the community. Careful evaluation and screening for appropriate placement are essential, as are continuing social work and medical and psychiatric supervision, if such transfer programs are to be successful.
GERIATRIC OUTPATIENT PROGRAM
In the summer of 1967, with support from a grant by the State Administration on Aging, The Langley Porter Neuropsychiatric Institute Outpatient Department began a Geriatric Outpatient Program. A press release was sent to the San Francisco daily newspapers, and one of the papers printed an extensive interview with the coordinator of the program. In addition, there was a radio interview on a popular noontime program. Representatives of many agencies dealing with the elderly population were invited to meet with the staff of the project to discuss its work and the kinds of involvement the agencies would like to encourage. As a result of these conferences, a psychiatrist was added to the staff to work as a consultant with the social agencies and to see patients for them, either individually or in groups, and also to conduct evaluations and treatment of homebound patients referred by the agencies.
Within four days after the initial publicity in the newspapers, the project received 60 telephone calls. These were taken by the project social worker, who evaluated the urgency of the need and tried to have the most pressing cases seen first. Other requests were placed on a waiting list, and these applicants received letters from the Project Coordinator saying they would be called as soon as time became available. Patients who were accepted were evaluated by a trainee (who might be a psychiatric resident, social work student, medical student, or post-master nursing student) and then were discussed at an interdisciplinary staff meeting. The patient then was assigned for appropriate psychothrapy and received medication and other somatic therapy when indicated. The Inpatient Services of the Institute were available for those patients needing hospitalization.
During the first ten months of operation, the admissions of persons aged sixty and over to the Outpatient Department rose from slightly less than 2 per cent to 13.5 per cent of all patients admitted. Sixty-six geriatric patients were admitted for outpatient psychotherapy following evaluation of 162 requests. Half of the patients seen came for five or more visits. Seven required hospitalization at the time of the first interview. Most of the patients seen were diagnosed as having depressive reactions.
Our experience shows that when a psychiatric clinic expresses interest in their problems, older people will avail themselves of outpatient services to a degree more closely approximating their representation in the general population than is generally the case. Age does not preclude a meaningful psychotherapeutic intervention.
A valuable side-result was obtained with respect to the attitude of trainees involved in the program. Although most trainees came onto the Geriatric Outpatient Program team with the usual negative bias against the treatment of older patients, during the course of their experience they generally changed their attitude and became, if not positively oriented toward the treatment of these patients, at least less professionally nihilistic.
In San Francisco prior to 1963, approximately two-thirds of the patients over age sixty who were admitted to the San Francisco General Hospital psychiatric observation wards each year subsequently were committed to state mental hospitals. A geriatric screening unit established by the California Department of Mental Hygiene in association with the hospital in 1963 has made a remarkably successful effort to locate and utilize alternate placement facilities in the cominunity for these elderly patients for whom commitment would otherwise be sought. A summary of the activities of this program, written by Miss Mary Lou Clark, Director of the Geriatric Screening Unit, is attached.*
In summary, the need for health services for the elderly is great, and the problems of this group are such that only a truly comprehensive health program can meet its needs. All levels of psychiatric care certainly need upgrading, from the long-term care of patients who grow old in the hospital to brief outpatient services. Coordination of the efforts of all resources and personnel is essential if adequate services are to be made easily accessible to the large group of elderly persons who are in many cases in really desperate need of help. Sincerely,
ALEXANDER SINOx, M.D.
ITEM 11: LETTER FROM DONALD L. SPENCE, PH. D., STAFF SOCIOLOGIST, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO MEDICAL CENTER
November 27, 1968. DEAR SENATOR SMATHERS: I am extremely sorry for the delay in responding to your inquiry of September 27. Dr. Feigenbaum and I have discussed your letter at some length, however, and feel that we do have some recommendations concerning the problem of medical student attitudes toward the geriatric patient.
Dr. Freigenbaum directs an outpatient program in geriatric psychiatry. His experience indicates that when students or trainees are exposed to this program their original negative attitudes are generally changed to a more positive stance with regard to the treatability of older people. This suggests two factors in the shaping of attitudes toward older patients. First, that some exposure to older patients is essential in any training program where the intent is to influence attitudes. But, probably more important in terms of the nature of the attitudes formed is the type of exposure. For a student to see an older patient properly diagnosed and placed in a treatment program designed for his care is a far cry from what most of them see when in their training they are exposed to the "old peoples ward” in some public general hospital or to a hospital for chronic illness.
*Retained in committee files.
What this means is that early in their medical education, students should be instructed in the problems of gerontology in all its medical aspects. Later in their training when they are exposed to a variety of elderly patient situations, they will have the conceptual framework to understand how these situations fit into a broader picture. To accomplish this will require the training of persons to carry out this instruction. It will also be necessary to convince medical schools that this type of instruction is worthy of a significant place in an already overburdened curriculum. Ideally, this instruction should be taught in conjunction with existing courses in appropriate medical specialties. This, would require the re-orientation of the same individuals and professionals who are currently perpetuating the negative stereotypes. The problem, therefore, becomes one of the best strategy to produce the desired change in an ongoing, self-perpetuating situation.
Some change is already occurring. For example, there is a subcommittee of the Gerontological Society on training of medical students with respect to geriatrics. This subcommittee is currently headed, I believe, by Dr. Alfred H. Lawton of St. Petersburg, Florida. Also, the Western Interstate Commission for Higher Education had geriatric psychiatry as the content for one of its recent training sessions for psychiatrist teachers of practicing physicians. Another such program is now in the formative stages and is due to start in May or June of this year. The Committee on Aging and the American Psychiatric Association has made recommendations concerning the teaching of geriatric psychiatry for both medical students and residents in training. And, the very fact that your subcommittee exists and is concerned with the problem suggests the direction of change. Maintaining the impetus for change should be a primary objective.
Publicity, money, and programs are what is needed. Publicity in the right places is difficult to develop. For example, our article as published was rejected as inappropriate for the Journal of Medical Education. As for funding, you are undoubtedly aware that appropriations for training and research were cut this past year. And, in terms of operational programs, it is important to implement those which are the most appropriate to meet current needs. Your committee, is in a position to influence all three of these strategies.
Enclosed you will find a copy of our article as well as a background paper on the problem.? If we can be of service in any way please let us know. Respectfully,
D. L. SPENCE, Ph. D..
ITEM 12: LETTER FROM DR. HAROLD RICHTER STARK,
NOVEMBER 22, 1968. DEAR SENATOR WILLIAMS: I was happy to see an article by you in the November Geriatric Times regarding your work and interest in geriatrics. As you may note from my letterhead (F.A.G.S.) I am a specialist in geriatrics. Over a period of 20 years, I have attended many people in the old age bracket both in private practice and in various convalescent hospitals in southern California.
I recently had a heart attack and am recuperating at the present time in one such hospital, so I have had an opportunity now to observe as a practicing physician and as a patient some of the great problems of geriatric care in such hospitals.
Inasmuch as the Government is paying for much of this care in such institutions, I wonder if you would mind if I made a few comments which I hope may help you in the governmental phase of this work.
When a patient is placed in such an institution, it appears he is placed there for one of two reasons, or possibly both : that he has a health problem which may be minor or major and such placement is for the convenience of the doctor. Or it may be because the family feels unable to care for the patient and wishes to be unloaded of the burden.
It is obvious to me, and to you as well I am sure, that most of these convales. cent hospitals are run by private individuals with the idea of profit in mind. Con. sequently, there are certain prerequisites for the management and for the patient.
* Retained in committee files.
It appears to me that the patient being placed in such an institution, if he is ill, should have the best of medical care, nursing care, food and general supervision.
I am convinced that in the present status of medicare that this is not always the case. Most doctors, in the first place, are allowed only one monthly visit per patient and are not particularly interested in geriatrics professionally. Such institutions become a dumping ground for those who are terminally ill, or a place where they can be cared for outside of the family.
The medical care, from the standpoint of the physician, is only partially sucressful. Communication with the doctor is difficult. Illnesses or medical emergencies are left to the discretion of the nursing staff or telephone conversations. I have personally noted that most of these difficulties may occur at night and the doctors are not available for consultation.
This places a responsibility on the judgment of the nursing staff. Most of this staff consists of licensed vocational nurses and medical aides—with the emphasis on the medical aides whose pay schedule is the minimum. Thus, only certain types of individuals can be procured to do this work and the nursing staff in general has no special preparation in the field of geriatrics. They know very little about the psychology and actual care of the older person, who is becoming greater in numbers each year.
It is my belief that these nurses and aides should be specially trained in courses in geriatrics and geriatric medicine. It is my personal belief, after observing the medical emergencies in such an institution which can occur in great numbers in one evening, that every convalescent hospital or nursing home of any size whatsoever should have a resident physician whose duties are to make medical rounds every morning and evening and to take care of any emergencies that arise during the night. It is my belief that such patients referred to a convalescent hospital by individual doctors should be placed under the care of such a resident physician so that the referring doctor no longer has any responsibility.
I feel that, if this is done, a higher quality of medical care can be established by each institution and that the Government of the United States will receive more for its money than at the present time under the present circumstances. Also, a program for our older people could be developed to which America could point with pride.
This resident physician could train the geriatric staff, supervise the diet, make judgment regarding the further disposition of the case at hand, possibly provide for Occupational therapy and the necessary psychological counseling for these older people.
The problem that presents itself, however, is that most of these nursing homes are built by private organizations with profit in mind and it would probably be impossible for them to afford the services of such a resident physician.
It may be that there should be a Government subsidy and some sort of financial arrangement made with the Government of the l'nited States to finance this.
You will note in the enclosed article* a survey made of the University of California Medical Center at San Francisco showing what the attitude of the young physician is in the field of geriatrics. I feel that very few physicians are interested sufficiently in the older patient, or that they do not have the proper time to devote to them, which constitutes an extremely grave problem, in my mind.
Thank you for your interest in the geriatric patient and in geriatrics. I hope that you will continue this great interest and perhaps solve this problem somehow; possibly, with a Government subsidy of hospitals or whatever is necessary to guarantee these older people the best of everything in the remaining years of their life. Very sincerely,
H. R. STARK, M.D.
ITEM 13: STATEMENT OF BOYD THOMPSON, EXECUTIVE DIRECTOR,
SAN JOAQUIN COUNTY MEDICAL SOCIETY, STOCKTON, CALIF. The San Joaquin Foundation for Medical Care is an incorporated body under sponsorship of the San Joaquin County Medical Society. The specific and primary purposes for which this corporation is formed are to promote, develop, and encourage the distribution of medical services by its members to the people of San Joaquin and adjacent counties at a cost reasonable to both patient and physician; to preserve unto its members, the medical profession at large, and public, free
*Retained in committee files.