Dr. GLASS. In all admissions physicals Mr. ORIOL. I am talking about discharges. Dr. GLASS. Yes, well, in all admissions the physical phase of it is the most important because the individual usually comes in with a good deal of physical problems. Mr. ORIOL. Does the physician who signs the document actually examine the person? Dr. GLASS. Oh, yes. Mr. ORIOL. He does? Dr. GLASS. Oh, yes. We have physical examinations performed on these patients during the preadmission washup and then you have progress notes and laboratory work and so forth like in a regular hospital chart. Mr. ORIOL. Do you have anything else, Val? Mr. HALAMANDARIS. NO. Mr. ORIOL. As I see it, if there is any additional information on this point, I would be glad to have it for the record.* Dr. GLASS. We had something put out on this, didn't we, sometime ago? Mr. ORIOL. Dr. Hammerman, we haven't given you too much time to prepare your statement and now we have kept you waiting for a long time. Would you gentlemen care to stay up here while Dr. Hammerman testifies and perhaps we will have some discussion later. Dr. GLASS. All right. Dr. HAMMERMAN. Mr. Oriol, I tossed coins with Dr. Snoke and beauty won out over age. If you would like to ask Dr. Snoke for his testimony, I would be happy to defer to him. Mr. ORIOL. I am sorry, I didn't know Dr. Snoke was expected to testify. Dr. SNOKE. I just want to make a few comments if I might. STATEMENT OF DR. ALBERT SNOKE, COORDINATOR OF HEALTH SERVICES AND DIRECTOR OF COMPREHENSIVE STATE HEALTH PLANNING PROGRAM, STATE OF ILLINOIS Dr. SNOKE. I should identify myself. I am Dr. Albert Snoke. I am the Coordinator of Health Services of the State of Illinois and since last December I have also been the director of the Comprehensive State Health Planning Program for the State of Illinois. My only claim to fame, I think as far as you are concerned, is that I was executive director of the Yale-New Haven Hospital for some 22 years and during that time was professor of public health and hospital administration at Yale University. I haven't brought any prepared statements, sir. I have been sitting in on the last day and a half of these hearings listening because I frankly wanted to be educated and also to be able to react to what I have been hearing here. *See appendix 1, item 4, p. 1351. 62-264-71-pt. 13- -8 Part of my responsibility is to assist the Governor and his departmental directors associated with health to react constructively to this immediate situation, as well as to develop long-range solutions. The Governor and I are not concerned with attaching blame nor in trying to pass the buck to anyone. His questions to me have been: What are my responsibilities? What authority do I have or need? Do we have the necessary staff, budget or program to do our job properly? How do we go about doing what is necessary to assure proper care to patients in nursing homes? I propose to give him suggestions and recommendations on these points. THREE COMMENTS ON THE OVERALL PROBLEM There are three comments I would like to make on the overall problem. The first is that we have a broad responsibility. We have come here to talk about nursing homes but actually it is part of the whole matter of the proper care of the chronically ill and the aged. We must consider the whole situation. The second is that, after listening these 2 days, I must say that I am on the side of the individuals criticizing the nursing home that I heard speaking yesterday morning; in contrast to those that I have been hearing so much since then. It is true that there may be an emotional overlay, and statistically a 2-hour working job or a 2-day working job does not give you accurate or total information. However, my own information and my own experience supports their concern. Finally, I feel that the BGA and the Chicago Tribune have made a very substantial contribution. I would like to discuss some of the issues for the record. STANDARD GOODS... ENFORCEMENT NECESSARY Standards I think we have good standards. Our problem is that we are doing a poor job in inspecting institutions and in enforcing the standards, However, we should remember that it is relatively easy to develop and enforce standards for institutional care, but it is far more difficult to develop and have standards for 'people' care. This second aspect is intangible but important. As far as the inspection of the nursing homes and the enforcement of the standards is concerned, I think that the State Department of Health and the City Department of Health could have done a better job. We don't need to argue very much about this-the fact remains that, since the publicity came out and the spotlight was put on the problem, there has been a great flurry of inspections with the closing down of institutions. I think the criticism was deserved. We could have done a better job. I think we will be doing a better job in the future, and this is one reason why I think this exposé has been of help. I am disturbed over the problem of the Cook County Department of Health. It may be typical of other areas. We have a responsibil ity to see that we work more closely together with them in the fu ture. There are a number of other agencies that have not faced up to their responsibility. These have not been touched upon in this meeting. One is the responsibility of the general hospitals. I believe that they are too concerned with acute, episodic care. They have a responsibility regarding what happens to their patients after they are discharged. One of the things that I think we should be exploring, in our planning and programing, is emphasis upon developing a "continuum" of care. If hospitals are talking about being community health centers, they must be concerned with the community overall health care in the community-and not just the acute episode. Some kind of working relationship must exist between general hospitals and nursing homes, so that we can get feedback to the State licensing authorities. RESPONSIBILITY ALSO RESTS ON PHYSICIANS I put the same responsibility on physicians. Physicians are caring for aged people. Physicians are either going to the nursing homes and knowing what is happening or they aren't going in and they don't know what is happening. If they are going in, I think that they should be passing on information to the licensing authorities. Frankly, I would like to see physicians and others stop referring to "crocks." This is a derogatory and continual comment one hears in respect to these aged individuals. It is most inappropriate. Nursing homes obviously have a collective responsibility through their own organizations. They may have difficulty in disciplining their own members, but I believe they should assume more control and let the State help them with the muscle. There has been considerable criticism of the Department of Mental Health, and the 7,000 mental patients that were supposed to have flooded the nursing homes. Doctor Murray Brown referred to the fact that, in 1962, there was a scandal about nursing homes-and that thing then got better up to 1968. He stated that then the situation became worse and that this was because of the outpouring of mental health geriatric patients. I have been in Illinois since October 1969. One of my first acts was to sit in on the first planning meeting for the pilot program of the geriatric placement program at the psychiatric hospital. This programing was the result of the enactment of the Chicago State Copeland bill, which was signed in September 1969. They didn't start doing much until November 1969, and didn't really get going until the 1st of January 1970. This is the start of the time when "tremendous numbers" were supposed to have been discharged. ... WHAT WE ARE TALKING ABOUT I suggest that it is important to pin down just what we are talking about when Dr. Brown and Dr. Weinberg refer to 7,000 patients, and Dr. Glass tells of 2,600 or 2,800. What figures are we talking about, over what period, and where did they go? There should be no conjecture here. The facts are available and the committee staff can very easily get from the departments of Mental Health and Public Health the facts that will indicate that the 7,000 patients "dumped" in the nursing homes are pure fantasy. There were questions raised about the profit versus the nonprofit nursing homes by Senator Percy. I have a bias, because my whole career has been in the voluntary hospital system. I haven't thought too much of proprietary hospitals as contrasted to the voluntary institutions. I don't have the same bias as far as the proprietary nursing homes go. This may be because I ran a voluntary hospital and I was fearful of assuming responsibility for chronic care patients because I thought I would go broke. I don't know whether I was right or not, but I do know that the problem of financing is serious. I suggest that we cannot, baldly or blandly, say that nursing homes should be nonprofit; nor that we should be against the profitmaking institutions. This is a very complicated situation, for there are even some nonprofit institutions that go into it for a tax dodge. I don't know the answers. I should also point out that the Federal Government isn't so pure in all of this, either. There is the whole problem of financing. You and your Federal colleagues certainly have mixed us up, gentlemen. Mr. ORIOL. We are mixed up, too. MEDICARE/MEDICAID RETROACTIVE DECISIONS HINDER Dr. SNOKE. Yes. We are mixed up on what are the policies for payment as far as Medicaid, Medicare are concerned. I also have a very uncomfortable feeling that long-term care facilities are unwilling to care for Medicare or Medicaid patients, because of delayed or retroactive decisions on acceptance or inadequacy of payment. I recognize your concern about the practice of "gang visiting," where the doctor comes in for 30 visits in a half hour. On the other hand, I am told that the doctor will get paid each day, when he sees the patient in an acute general hospital; but, that, when he sends his patient out to the long-term care facility, he can be paid only for visits once a week, or once a month, or something like that. I don't know the facts. I am just raising this question for we should not be putting a premium upon keeping a patient in an expensive general hospital unnecessarily. Finally, I would like to submit to you a copy of the special message on health that Governor Ogilvie submitted to the legislature April 1, 1971.* In the message are six specific items relative to a program for nursing homes. This is just a beginning, as far as we are concerned, toward the problems of nursing homes and chronic care. There is one short paragraph in the message that reads: While taking immediate action on the problems of surveillance and enforcement as necessary [and here the Governor is referring to nursing homes] We recognize broader issues in caring for the aged and that comprehensive analysis is needed and will be done. Actually Dr. Hammerman has already started doing this and I have received his preliminary report on this subject. It so happens *Retained in committee files. that this is parallel to my concern for comprehensive health planning on the problems of the aged and on rehabilitation of the chronically ill. We expect to put high priority on this subject during the coming year. I appreciate very much your coming. I hope that you will let Dr. Hammerman say something to you. If you want to throw any questions at me, use your own judgement. Mr. ORIOL. Dr. Snoke, I will ask one quick question. One thing we will be interested in getting is the text of the Governor's program that was described in the press, the Chicago Tribune, yesterday. Reference was made to nursing homes but no details were given. Dr. SNOKE. Yes? Mr. ORIOL. Do you have Dr. SNOKE. I will send you a copy of the total message.* Mr. ORIOL. Do you have any, at this point, any priority, any one item that you are focusing on as far as nursing homes are concerned; in addition to increasing the number of inspectors? WILL ACT ON INSPECTORS' REPORTS Dr. SNOKE. Inspectors, in themselves, don't mean very much. We plan to see that when the inspectors submit reports, judgments, and recommendations, that we will not ignore them, but will act on them. I think that is, probably, one of the main things that we are going to be doing. Second, we will be working more closely with various communities such as the city of Chicago. We have worked out-and you have a memorandum on that-arrangements by which we will be working together. Dr. Murray Brown and Dr. Yoder know that we will be trusting each other-up to a point. However, we are also going to check on each other. So that we will be following through to see that Murray does a good job; and Murray will be needling us to do our part. Now, beyond that, I have a task force that is going to be working with me to develop a long-term program. A representative of the Better Government Association has been invited to review unofficially what we are trying to do. Mr. ORIOL. Has that task force been named yet? Dr. SNOKE. It consists of the brain trust of the department heads related to health. Mr. ORIOL. Oh? Dr. SNOKE. It is comprised of individuals in the departments. Mr. ORIOL. It is a standing committee? Dr. SNOKE. Well, no, it is not a standing committee. It happens to be myself, Mr. Lanier, Mr. Wessel, Dr. Flushner, Mr. Elbow, and others. Mr. ORIOL. You are not going to have private citizens? Dr. SNOKE. At this stage of the game, it is an in-house task force. Retained in committee files. |