STATEMENT OF CLOACE MCGILL, R.N., M.P.H., AMERICAN NURSES' ASSOCIATION, ACCOMPANIED BY ALICE DAVIS SEALE, R.N., M.S., AND CONSTANCE HOLLERAN, DIRECTOR OF GOVERNMENT RELATIONS, AMERICAN NURSES' ASSOCIATION

Ms. MCGILL. Thank you, Mr. Chairman.

My name is Cloace McGill. I am director of continuing education at the University of Texas School of Nursing at San Antonio. I am a past member of the executive committee of the American Nurses' Association. Continuing Education Council, and presently a member of the ANA Technical Advisory Committee to the PSRO project. This is a project which the ANA is conducting under a contract with the Bureau of Quality Assurance, Health Services Administration, Department of Health, Education and Welfare.

With me this morning is Alice Davis Seale, who is past chairman of the ANA division on Community Health Nursing Practice and formerly assistant director of nursing, Division of Medical Care of the Massachusetts Department of Public Health; and Constance Holleran, director, Gove nment Relations for ANA.

The American Nurses' Association appreciates the opportunity to appear and testify before the Subcommittee on Health, concerning medicare problems and issues. We wish particularly to speak to professional standards review organizations provisions of Public Law 92-603. Mrs. Seale will speak to our concerns about home health care. The ANA throughout its 78-year history has fostered and supported the basic principle of accountability of all health care practitioners to provide care which is of a high standard and which is available and accessible to all at a reasonable cost. Effecting improvement in quantity and quality of nursing care available has been a constant challenge of the nursing profession and its professional association.

The American Nurses' Association was an early leader in promoting the establishment of professional licensure to assure safe practice and thus provide a protective mechanism for the public. The association continues to facilitate and share in this form of accountability through the Council of State Boards of Nursing which monitors the licensing examinations.

The association promotes active participation in continued learning for all members of the profession and recently initiated a program of certification to identify and recognize those who give evidence of superior performance in the practice of nursing. The association has issued a code of ethics, standards for organized nursing services, standards for nursing education, and standards for nursing practice.

A major aspect of its current program relates to devising ways to facilitate the implementation of these standards to the end that the profession achieves efficient and effective self-regulation and the public can be assured of high-quality nursing care.

The nursing profession has long supported the concept that there is a shared responsibility between the government, on behalf of the people, and health professions in providing and maintaining health care which is of an acceptable quality. The profession acknowledges that the ever-enlarging presence of the Federal Government in health care matters will bring with it an increasing governmental concern about standards of practice and their implementation by professionals.

We support the concept that government and health professionals should work together to develop mechanisms that increase the effectiveness of their self-regulatory activities. We view PSRO as having the potentail of being such a mechanism.

The nursing profession believes that the public would be better served if it were recognized that "health care" and "medical care" are not synonymous terms. Health care services encompass a wide range of activities designed to maintain the physical, mental, and social wellbeing of people. Several disciplines must be involved in planning, providing, and evaluating health care.

Each discipline must be accountable for the quality of its own practice, whether the client is served in the home, the school, the place of work, or in a health care facility or institution.

Physicians are intimately involved in all levels of PSRO activities. and also have been given authoirty for all decision-making relative to medical care. The same type of self-regulating mechanism for other health professions is not clearly stated within the current provisions of Public Law 92–603. Attempts to rectify this lack of clarity within the law through regulations and policy manuals is not a satisfactory solution.

Public Law 92-603 which provides for the structure and authority for PSRO has failed to clearly provide for an appropriate involvement and decision-making on the part of health professionals other than physicians. We support the efforts of these health professionals to gain appropriate identification and involvement in PSRO and the regulations that govern its implementation.

As the largest professional group within the health field, with about 857,000 nurses engaged in active practice, nursing must be acknowledged as a vital component of the health care team and be accorded the appropriate rights and responsibilities as professional practitioners within this law.

Inasmuch as providers educated and practicing in professions other than nursing do not have the experience or educational background to effectively evaluate the necessity, appropriateness, and quality of nursing care, it follows that members of the nursing profession should be involved in decisions as to the quality of professional care-service rendered by nurses.

This testimony will now focus on a summary of what the profession of nursing believes are the minimal changes necessary in P.L. 92-603 to effect the appropriate role for nurses in PSRO. The full text of the legislative language being proposed is presented in the appendix. The American Nurses' Association proposes that the appropriate sections of Public Law 92-603 be amended to provide for the designation of registered professional nurses and other licensed health care practitioners as members of Professional Standards Review Organizations. Thus, it is suggested that in all instances where doctors of medicine and doctors of osteopathy be enumerated, the law be amended to include licensed professional nurses.

The interface of care given to patients-clients by many disciplines in health care make it unwise and difficult for any one profession to review its practice wholly independent of others. Therefore, an interdisciplinary review system that prevents fragmentation of health care review and serves to improve all components of health care is con

sidered the optimal structure for maximum efficiency and clientpatient benefits. The adoption of such amendments would permit nurses to participate in that review system.

In all instances within the law where reference is made to "medical care," this be changed to "health care." The law must be consistent in recognizing that medical care, which is care given by medical doctors and doctors of osteopathy, is not synonymous with health care. This is a critical concept to support the inclusion of other health care practitioners in PSRO legislation and indeed in all health legislation.

The association proposes that the concept of review in hospitals be broadened to review in all health care facilities. The nursing profession belives that although it was appropriate to initiate review under PSRO in acute care settings, it is now timely to effect one system of review in all health care facilities, including acute care settings, chronic long-term settings, HMO's, and so forth.

Such a system would promote comparable standards, provide compatible data, insure the equitable assumption of accountability by practitioners regardless of location, and in the long run, minimize competition and confusion among the multiple review systems now in effect.

Consistent with the association's position regarding the appropriate involvement of nurses and other professional practitioners in the critical points of decisionmaking, we believe that the concept of "medical necessity for institutionalization" be changed to reflect participation of other health care providers in such decisionmaking.

We believe the participation of professionals, other than doctors of medicine and doctors of osteopathy, particularly in long-term care settings, is vital to achieving the goal of efficient utilization of institutional facilities.

People are admitted to health care facilities because they have a need for continuous professional health management which cannot or is not provided by family or community resources. The need may be related to medical and/or nursing management of a health problem. In some instances, such as the need for long-term care, the most valid criteria may be related to nursing care, rather than medical care.

Therefore, it follows, that the need for nursing services is one valid criterion for admission, for assigning length of stay, and for continued stay review. Professional nurses should develop nursing criteria relative to admission and continued stay or where interdisciplinary review is possible, they should participate in the development of such criteria.

Examples of nursing rationale for admission or determination of continued stay to a health care facility are (1) inability to maintain therapeutic regime, (2) inability to meet basic physiological needs, and (3) lack of knowledge, ability, or resources for health management. The Loeb Nursing Center in the Bronx, New York, and the Iowa Soldiers Home in Marshalltown, Iowa, are specific examples of how nurses are participating effectively at the decisionmaking level in admission certification and continued stay review.

Consistent with our recommendations for the inclusion of nurses at all levels of the PSRO mechanism, we propose the following changes in the membership of Statewide Professional Standards Review Council: One representative selected from two nominees rep

resenting different disciplines designated by each PSRO; three physicians designated by the State medical society; three nurses, two of whom are designated by the State nurses' association; and three persons knowledgeable in health.

We further recommend that advisory groups to statewide professional standards review organizations be composed of not less than five and not more than nine members who shall be representatives of hospitals and other health care facilities and two consumers. No member or family member of the advisory group should have financial interest in a health facility within a State.

The association proposes that National Professional Standards Review Council consist of 15 members: five physicians, five registered professional nurses, and five other licensed health care practitioners.

We also propose the creation of a seven-member advisory committee to advise the National Professional Standards Review Council, the Secretary of DHEW, and the Congress on the effectiveness of the PSRO mechanism in promoting effective, efficient and economical delivery of health care to meet standards established by the health professions.

The primary goal for the involvement of nurses in PSRO is tofurther engender the accountability of the profession to patientsclients for the quality of nursing care and the appropriate utilization of resources. The following objectives are directed to the accomplishment of this goal:

1. Establish criteria, standards, and norms by which nursing practice can be evaluated.

2. Establish a system whereby a review of nursing practice shall be conducted by peers who are engaged in similar practice.

3. Establish a review system whereby appropriate utilization of professional nursing services is assured.

4. Improve patterns in nursing practice through correction of deficiencies in nursing care identified by the review process and through continuing education and systematic study.

5. Establish mechanisms which will assure that issues related to the practice of nursing will be decided by registered nurses.

6. Promote mechanisms which will assure nursing participation in the development of policies and programs for collaborative review and problem solving for the total system of health care delivery.

Under a contract awarded to the American Nurses' Association in July of 1974, by the Bureau of Quality Assurance, the association has developed model sets of criteria for 15 patient populations.

These criteria will be widely disseminated and will undoubtedly stimulate increased interest and involvement of nurses in peer review systems. We also recently surveyed all PSRO's concerning the participation of nurses at the local level in these organizations. To date, there has been very limited involvement of nurses at the policymaking level in PSRO's.

It is the position of the American Nurses' Association that unless the minimal changes identified in this testimony are made in Public Law 92-603, the nursing profession would be severely handicapped in securing the authority and resources to accomplish the stated objectives for involvement of nurses in PSRO's.

60-447-75- 4

We, therefore, respectfully urge you and your colleagues to seriously consider and support these changes so nurses are duly recognized as providers of care, and recipients of that care can be assured of nursing care of the highest quality.

Thank you, very much.

MS. SEALE. During the period when health insurance for the aged under the Social Security System was being debated in the Congress, the ANA vigorously urged that home health services be included as a benefit in any program that was enacted. ANA contended that nursing care on a part-time basis in cases of acute illness was often more appropriate than hospitalization and that individuals with chronic illness could be maintained in their own homes. When medicare was enacted, the association was pleased that home care services were included in the program.

However, we have been concerned, since the initiation of medicare, about the limitations placed on home health services. For example, under title XVIII, part A, an individual was only eligible for care at home following a three-day hospital stay. This requirement was rigid and did not allow for an assessment, based on medical and nursing judgment as to the setting in which an individual's health care needs could best be met.

Health insurance in this country has tended to encourage the use of the most expensive facilities for the provision of care. The requirement of a three-day hospitalization prior to eligibility for home care services perpetuate this practice. Certainly, this has limited the utilization of home health care. The fact that less than one percent of the medicare dollar is spent on home health testifies to this.

The ANA has historically been supportive of the concept of home health care. ANA feels home health care should be available to whomever needs it, and further has called for the orderly expansion of the field. Too often, however, the piecemeal legislation that is proposed, and the subsequent interpretation by the executive branch, clearly demands that fragmentary issues, rather than the total system be addressed.

This call for "total" care plan was last made by ANA on June 23 of this year in a statement on home health services, before the Subcommittee on Health Maintenance and Long-Term Care, House Select Committee on Aging.

ANA's support of home health care, aside from the general concept, has stressed two major areas: The delivery of skilled nursing care to the homebound and the careful development and utilization of ancillary personnel in the field.

As further evidence of our support, the association in 1966 and 1967 issued "A Guide for the Utilization of Personnel Supportive of Public Health Nursing Services" and its respective addendum, "Guidelines for the Development and Utilization of Home Health Aide Services in the Community." In addition, testimony and positions have been offered to both the legislative and executive branches of Government over the last decade.

ANA is concerned about regulations pertaining to home health services. For example, proposed regulations for "Presumed Coverage of Post-Hospital Services" fail to recognize the nursing responsibility for planning nursing care though they deal primarily with nursing