todial. Perhaps modest expectations provide some hedge against immodest expenditures. To a large extent our reluctance to expect more reflects a moral confusion over the feasibility of establishing worthwhile goals for individuals no longer deemed capable of adding to the productive wealth of our nation and our economy. I would like to suggest some objectives for a program of long-term care. These are not meant to be exhaustive and they surely warrant an extended public dialogue, careful testing and an ordering that would establish working priorities: 1. Access to a coordinated system of comprehensive social-health care of high quality as a right, with safeguards for the financial stability of family groups; 2. A maximum range of services that are uniformly available and acceptable and that do not make unusual demands on the part of the people to be served-mobile services rather than mobile people; 3. A rational and national funding arrangement related to explicit program goals and patient care plans. All too often the source of funding determines the quality and type of care a person will receive; 4. A unified system that covers all citizens. When all social and economic groups are included in a program, consumer demand tends to be more visible and effective; 5. A centralized responsibility for planning, mobilizing, delivering, and monitoring resources, with and in behalf of the users of such care; 6. Minimization of fiscal or physical barriers that cause delay in early diagnosis and treatment. Such hurdles are self-defeating, since more intensive care, at greater cost, will be required over longer periods of time. The financing scheme must support, not hinder, the potential use of services, if quality of care and cost controls are to be maximized; 7. Safeguards for the quality of life or "life style" of the elderly through cooperative decision-making and personal involvement in a plan of care the blending of need, a professional determination, and demand, the older persons definition for desired care; 8. The development of specific goals and procedures that operationally define who is to be served? under what conditions? in what locations? with what resources? and ultimately to what end? That is, to bring into being a system with respect to long term care that moves from broad social values to operational objectives, to criteria and standards for judging movement or change. To move from pronouncements to tested applications of controlled services and appropriate short range objectives; 9. A continuum of health services with effective linkages between prevention, acute care, rehabilitation and maintenance services; between institutional programs, hospital, home health, specialized housing, and social services; and finally, 10. The utilization of manpower and facilities in behalf of human need and the return of tested knowledge to this resource pool through programs of education, training and research. We have in the past expected all this to happen automatically. The fate of 20,000,000 older Americans can no longer be left to chance, the vagaries of benevolence and private charity, or the mysterious hand of the market place. Some experimentation with designing a comprehensive system of long-term care, centrally coordinated, administered and financed, is already underway. Here, in Chicago, the Jewish Federation has announced its intention, through the establishment of a Gerontological Council, for just such a program. It projects a comprehensive and flexible program of care for the elderly that will employ existing facilities and agencies, as well as developing new components of service wherever needed. Eight broad program elements are being considered: Diagnostic and Evaluation services; multi-functional out-patient programs; in-patient short term care; long-term custodial care; a community health task force; area transport services; a variety of different housing arrangements; and provisions for research, education and training. I understand that a copy of the proposed plan has been made available to the Committee. Important values about human beings are being expressed through such a proposal and certain assumptions are being made about the relevancy of specific services to effect an improvement in the quality of life for chronically ill older adults. Such efforts offer a magnificent opportunity for government and the public to support such demonstrations and research efforts. What is the impact of various program mixes on different client populations? What type of incentives can be developed for both users and providers to maximize projected patterns of utilization? What type of outcomes are being proposed and how fully can they be achieved? At what cost? The questions that need to be posed and answered are directly related to the development of social policies that will guide legislation in this important area of human services. It is imperative that we move from our current position of dealing with the problems of the aged on a crisis by crisis basis to a position of leadership in developing long range programs oriented to providing the best possible care and service to the older citizens of our country. The provision of a more rational and coherent system of long-term care can best be achieved through the application of appropriate incentives, new patterns of organization, and powerful political and emotional appeals. A shift in our sense of national purpose can produce important shifts in our readiness to allocate resources and upgrade priorities. The strategy of tying long-term care objectives to cost-benefit measures is one which merits consideration. The large expenditures necessary to provide health care in the long-term care field may be compared for purposes of measurement, to a reduction in dependency, or social stabilization, and these may provide savings of public expenditures in other forms of public outlay. It may be possible to devise, therefore, a formula that transfers savings in one area to providers of medical care. Self-contained comprehensive social-health organizations can, perhaps by a capitation system, derive sufficient return by maximizing services that stress self-care and independent living objectives and reduce utilization of high cost, special institutional, services. Outcome, specified in advance and related to a reasonable functional prognosis and tied to financial incentives, may help break the cycle we are currently in, whereby sickness and disability are rewarded and client improvement is punished. Nationally we appear to be moving toward a significant revision of our health care system in order to better control the quantity, quality and cost of these services. Group practice arrangements with some form of pre-paid capitation mechanism as a method of financing care, delivery through a corporate or community sponsored health maintenance organization offering access to comprehensive services over which control can be maintained, and expanded opportunities for consumer participation on both matters of quality and cost-all indicate the general direction this planning effort must take. There is much hope generated by these events. To date, however, the unique problems of the chronically ill have been conspicuously absent from these plans. Every proposal for National Health Insurance now pending before Congress assumes that problems of chronic illness and disability have been adequately taken care of by Medicare. These proposals offer an unpromising medium for achieving the type of social health policy suggested here. The tragedy of limiting our view with respect to long-term care is that we can indeed do much better than current practice would indicate. We know enough now to begin to design and support a rational social-health care system for the aged. Our failure to do so will only force unnecessary strains on acute care services by eliciting a redefinition of illness that accommodates itself to funding for covered services. It would be helpful, rather, to explore the possibility of applying the HMO concept to the long-term care field. Can new methods for organizing and delivering care be structured in such a way as to reward providers for keeping people healthy by fixing financial incentives in favor of prevention and early detection of disease as against costlier forms of episodic care and hospitalization? Ideally, a social health policy should be predicated on what we are trying to achieve and not on how to achieve it. In other words, our concern must be with outcomes, performance or output, and how the system of care can be shaped to produce these results. 'How' to achieve these goals, then, can be subjected to an ongoing review and analysis that measures the differential impact of different mixes of services. If we assume that our primary objective is to maintain or support the individual's capacity for continued self-care and to reduce the rate of physical, mental and social deterioration, within an optimum independent living ar rangement, then it would be necessary to establish individual baselines for judging human potential for change. A cost-effectiveness policy in long-term care will need to put these gains in the context of savings or changes in utilization of a wide variety of social-health services, housing, etc. As adequate as individual institutions may be, and many can be singled out for commendation, the very nature of their form of service and their inability to control, mobilize and administer a wide range of community based as well as in-patient services, severely limits their capacity to independently establish a comprehensive program in behalf of the chronically ill aged. It would be naive to think that the health system needs of the chronically ill will provide the motivating 'wag' for changes in our present health system. The traditional acute care model is still the main arena of public debate where the dominant actors are located. Long-term care must, however, become part of the picture of any serious effort to develop a comprehensive health service, and therein lies its hope and claim for inclusion. Moreover, social health planners should remain custodians of the whole view, the utopian tradition-a restless concern for the intangible attributes of the 'good' life (too easily sidetracked by having to achieve short-term, partial solutions). Visions of betterment can become epidemic in communities, raising civic aspiration and forcing solutions in long-term frameworks that they help establish. Mr. ORIOL. Do you have anything else? Mr. HALAMANDARIS. One quick question, for you, Dr. Hammer man. Are you familiar with the point system as it functions in Connecticut? Dr. HAMMERMAN. No, I am not. Mr. ORIOL. That is a point system that works very differently from the system here and it makes it interesting. Dr. SNOKE. It is an evaluation of the nursing home and so on. Dr. SNOKE. I am from Connecticut and I sent my staff out at times to get them to do this, to evaluate this. May I suggest that you not just talk to the State Department of Health people who think it is wonderful, but talk with some of the individuals who go into the homes and you will find that it ain't quite as beautiful or as perfect as the advocates say, because like ours isn't as perfect as some of our advocates say. Mr. ORIOL. Anything further? Mr. HALAMANDARIS. Would you want to amplify that for me just a little bit? Dr. SNOKE. I can-well, I can refer you to Mr. Herbert Parrish who is the director of ambulatory services, Yale-New Haven Hospital. He was the fellow that I used to evaluate nursing homes when I was director of Yale-New Haven and I am not sure if he is the assistant director up there but also contact at Waterbury, James Malloy. They were the two that reviewed this and their point was that you could build up quite a high point system with all kinds of things like teaching arithmetic, dancing, and things of that sort. Mr. ORIOL. Once again, I would like to thank the witnesses and let the record show that we have about 20 long-term listeners in the audience today who lasted this long and, thank you very much. (Whereupon, at 3:30 p.m., the subcommittee recessed, to reconvene at the call of the Chair.) APPENDIXES Appendix 1 ADDITIONAL MATERIAL FROM WITNESS ITEM 1. IMPACT ON THE COMMUNITY OF THE ACCELERATED DISCHARGE PROGRAM OF ELDERLY PATIENTS FROM ILLINOIS STATE MENTAL HOSPITALS; REPORT-DIVISION FOR SENIOR CITIZENS, ROBERT J. AHRENS, DIRECTOR, DEPARTMENT OF HUMAN RESOURCES, CHICAGO, ILL. I. INTRODUCTION For the past two or three years, a number of Chicago neighborhoods, particularly the Uptown community area, have voiced growing concern about the large number of elderly mental patients being discharged to the community from state mental health institutions. For neighborhoods called upon to absorb and plan for massive concentrations of such older persons, this concern relates to a complexity of problems, i.e. 1. Lack of sufficient and/or appropriate institutions to meet both chronic health and mental health needs, 2. Lack of comprehensive supportive and follow-up services, 3. Lack of trained personnel experienced in serving such persons in general community agencies, 4. Lack of sufficient resources to pay for the proper care of retired, dependent or mentally disturbed persons, 5. Lack of adequate comprehensive planning to meet the multiple needs of such persons and, above all, 6. Lack of delineation of responsibility for resolution of various aspects of the problem among the multiple community components involved. In the face of such built-in problems, new state legislation, (House Bills) 992-9951) supported by the Illinois Association for Mental Health, Inc. and signed into law by Governor Ogilvie on September 12, 1969, authorizes the discharge of all elderly patients now in state mental hospitals who have been receiving custodial care exclusively. Estimates by the Illinois Department of Mental Health indicate that 7,000 to 10,000 elderly patients would be returned to the community by mid-1971 under the new legislation. Granting the humanity and logic of a state policy which prohibits the use of its mental institutions as "dumping grounds" for older persons for lack of appropriate alternative resources, the fact remains that: 1. The continued lack of such community resources and the complex problems it has created have not been legislated out of existence, 1 Synopses of House Bills 992–995. 992. (Ch. 911⁄2 par. 1-11) Amends Mental Health Code. Revises definition of person in need of mental treatment to exclude a person of advanced years who does not show characteristics of mental illness." 993. "(Ch. 91. new par. 10-2.01) Adds to Mental Health Code. Requires review of condition of mental patients age 60 or older committed before July 1, 1964, as to his legal competence and a. to the possibility of adequate care outside the hospital." 994. (Ch. 91%, new 3-7) Adds to Mental Health Code. Requires persons age 60 or older to be examined before being admitted to mental hospitals to determine whether they may be given adequate treatment in their home community." 995. (Ch. 91%. par. 100-15) Amends Act codifying powers and duties of Department of Mental Health. Requires persons placed by Department in outside facilities be visited at least quarterly and that consideration be given social, recreational and other aspects of the person's environment." |