STATEMENT OF HAROLD B. PARKER, EXECUTIVE DIRECTOR, GEORGIA STATE COMMISSION ON AGING

Mr. PARKER. Thank you, Mr. Oriol.

The thing that disturbed us very greatly is the same thing that you have been discussing here this morning. There is a drying up of extended care facilities in Georgia. We felt for a long time that ECF was being underutilized and now we find that the ECF operators are just cutting down the number of beds that they are willing to devote to this area of endeavor. There is no rhyme or reason for the retroactive denials and the doctors seem to be reluctant to use the extended care facilities and the operators are looking to move into other areas of service.

We have got a very unique situation in Georgia where we have built nursing homes in the communities where people live so that the community life can be continued by the patient. The neighbors and family and old friends can be contacted, community life can be maintained, and we are real proud of this type of operation.

Last week my staff and I visited 46 nursing homes in southwest Georgia and we found that these nursing homes by and large had fully embraced the idea that old people can get well. And it is a sort of thrilling and exciting thing to say, as these two great doctors who preceded me said, that old people are worth treating and saving and that they can function and their functions need to be preserved. This is something that has not always been thus, as you know.

We want the full right to this service through the extended care philosophy that a person goes into a nursing home with the 100 days and there is a day they are going to leave, maybe it is not a hundred days. It used to be they abandoned hope. Today we have hope and we have hope in nursing homes.

It was very thrilling for me to observe the therapy in action in south Georgia last week. One nursing home has an outpatient therapy clinic for the community which was just great. I saw a physical therapist work with a newly blind lady. I saw one very impaired gentleman about 70 years old being taught to walk, and the therapist told me that it was just as much fun to teach an old man to walk as it was to teach a baby how to walk. We found much of this attitude that we do want to preserve this particular attitude that old people can get well. Thank you.

Mr. ORIOL. Mr. Parker, I do not believe we have your correct title for the record.

Mr. PARKER. I am Harold B. Parker, executive director of the Georgia State Commission on Aging.

Mr. ORIOL. Can you tell me approximately how many nursing homes or extended care facilities in Georgia have stopped using the Medicare or stopped providing the Medicare extended care benefit? Mr. PARKER. I am not aware of the number that have quit. Mr. ORIOL. The percentage.

Mr. PARKER. The Wesley Homes, which is a very fine nonprofit church sponsored agency in Atlanta, had 166 beds devoted to ECF with a wonderfully fine staff all geared up for rehabilitation and all these great services that are available to the people under this approach. They put out an announcement the other day that they were no longer to be an extended care facility, that they were going into long-term care because they don't have any ECF patients.

Mr. ORIOL. I got the impression that perhaps dozens of extended care facilities in the State had dropped out of the program.

Mr. PARKER. That is my impression.

Mr. ORIOL. Do you have any reason to believe that the enforcement of the civil rights provisions of the Medicare has anything to do with that?

Mr. PARKER. No, sir; none whatsoever.

Mr. ORIOL. What is the most common reason given?

Mr. PARKER. We have a committee on health and related care. I am out of the Commission on Aging and we have had the intermediaries representatives from Social Security, the medical profession, nursing home operators, health, welfare, and the like to sit and talk about extended care, and it seems that the intermediaries did not exactly make this announcement but that they had been instructed to tighten up.

Mr. ORIOL. Where were they instructed from?

Mr. PARKER. From Social Security.

Mr. ORIOL. Have you seen anything in writing on this?

Mr. PARKER. No, and a member of the Commission called Social Security to follow up on this piece of information they had gotten from an intermediary and they denied it, said they are doing the same thing they had always done.

He said, "What happened to the patients?"

Mr. ORIOL. The intermediary was saying this?

Mr. PARKER. No; the Commission member.

Mr. ORIOL. Mr. Miller.

Mr. MILLER. No questions.

Mr. ORIOL. Mrs. Lowry, identify yourself and one of your positions

or several.

STATEMENT OF JOYCE LOWRY, SPECIALIST IN REHABILITATION SERVICES AND THERAPEUTIC RECREATION

Mrs. LowRY. I am Mrs. Joyce Lowry, specialist in rehabilitation services and therapeutic recreation.

My credentials are: I have a masters degree in rehabilitative recreation services plus specialized training in gerontology as an AOA trainee at the Institute of Gerontology, University of Michigan, Ann Arbor, Mich.

I would like to say one thing. There has been no mention of recreational services as a therapy. One of the times I was looking for a new position I went to a not-for-profit rehabilitation hospital, and although my credentials were good very little consideration was given to hiring me simply because, as the administration said, we can't find any way for payment for your type of services. In other words, their payment plans of different titles, et cetrra, did not include recreational therapy as a recognized service.

At the present time I am employed by an organization called Nursing Centers, Inc., which is a proprietary for profit organization. I would like to present excerpts from a paper that I gave last week in Milwaukee. By the way, Wauwatosa is across the street from Milwaukee, we have the same post office.

*

Retained in committee files.

This paper was presented at the Great Lakes Regional Conference of the National Recreation and Parks Association and its branch organization, the National Therapeutic Recreation Society.

We feel there must be recognition of a continuum of care and the team approach for development of a totally therapeutic setting for the care of our elderly sick, ill, and disabled. The role of the therapeutic recreator then may need greater definition to all those concerned with the care of the geriatric patient.

Of the populations served by therapeutic recreators, I would surmise that the older adult is the least understood and probably the least constructively worked with of all persons suffering from any disability.

Another reason for the older adult not receiving the kind of recreational program that has therapeutic value is fairly traditional. For a long time it has been the practice of nursing homes, long-term care facilities and rehabilitation units to use some form

Mr. HALAMANDARIS. Excuse me.

Mr. Birch, Norman, I just want to ask the gentlemen if they have any remarks for the record. If you do, just stay another moment and we will be glad to hear you.

Mr. BIRCH. No.

Mr. HALAMANDARIS. That was Norman Birch, the executive director of the American Nursing Home Association.

I am sorry for the interruption.

Mrs. LowRY. That is all right.

A lot of nursing homes have used some form of recreation activity for the elderly as a filler to the concepts of useful leisure. After all, what do older people in such settings have except a lot of time on their hands: leisure that is meaningless and nonrewarding to the individual.

Most chronically ill older adults are not expected to leave institutions and return to community life, and there is a reason for this. There is a lack of supportive services and community understanding as major factors that cause retention of certain persons in institutions when they should be living in the community.

For that portion of the elderly who will be returning to the community to live, the responsibility of any therapeutic recreator is the same as for any age group with emphasis on the resocialization processes. We work to keep the older person from becoming an isolate, a recluse in any community.

When working with the older adult, we work to expand group experiences and to give them opportunities for new and satisfying experiences in the institution or in the community and, primarily, to help them identify their position in life and the world and thus enable them to accept and utilize their potential for a life that does not disengage prematurely or to that extent that mental illness is imminent. The goal is to prevent rejection from peer groups and thus prevent debilitation of social relationships which often leads to more intense disengagement processes which we know lead to definite mental illness. This, of course, is in relation to organic brain changes and organic brain damage. Since most older people have not had a lot of leisure time they do not really know what to do with it. I would like to say that there is one thing that the recreational therapist has to fight and that is that other therapies are thoroughly accepted and fairly well understood, but not recreation therapy.

The physical therapist teaches them to rewalk and reuse injured muscles or artificial limbs. The occupational therapist teaches the geriatric to dress, perform personal hygiene tasks, and to feed himself. But what for? If the geriatric as a person has no social identity, nor outlets for creative, stimulating or socially satisfying experiences and does not know how to obtain these, of what use are the physical or emotional therapies that have been used to put the person back together again? It is like putting all the pieces of a model together and forgetting the cement or glue which will enable the model to withstand stress and the destructive forces that can break it once again into unrelated parts.

I would like to say that I would applaud Dr. Miller and many of the things that he said. The hospital oriented physiatrist is not familiar with recreational therapy, he does not know how to write a prescription for recreational therapy. We are part of a continuum of care and we are an integral part and a necessary part because what you are asking is that people receive physical therapies, the emotional and mental therapies of psychiatric social workers, but the elderly have forgotten how to live as other people. If therapy is not accepted, then you are just putting together nothing.

Mr. ORIOL. Thank you, Mrs. Lowry.

As I understand it, there is no Federal program which in any way provides payment for the type of service you provide.

Mrs. LowRY. No, sir.

Mr. ORIOL. Could you give us just a few examples of what a recreational specialist provides in an institution?

Mrs. LowRY. Well, the recreational therapist has the job of coordinating with all the other therapies. For example, I coordinate with physical therapy in terms that they tell me which patients need more exercise. I set up a social group and in a social setting developing inner-personal relationships I can get these people to do physical movements that the therapist herself has been unable to attain, and I have had physical therapists tell me this.

I have had OTR's, occupational therapist, registered, tell me that unless we had a continuum of care that whatever the OTR does is lost. I know, for example, in Chicago in a rehabilitation hospital they have a director of therapeutic recreation. He takes amputees of all kinds-wheelchair, on crutches, and so forth, out into the community to help these people adjust to going out into public view. Now you can give a person all the psychiatric help he can use but until he is subjected to and withstands the stress of the public eye staring at him with a hook for a hand or no legs, you have not completed your job. Does that answer your question?

Mr. ORIOL. That certainly gives insights into it.

What would you say is the rough daily charge for a service of this type?

Mrs. LowRY. For example, there is no specific charge for recreational therapy. I happen to be doing at this moment some special work for my corporation as the rehabilitation recreation person in a transitional living arrangement. I have 143 men who come to us on referral from mental health institutions, both Veterans' Administration and the mental health institutions of the county. They come from correctional institutions, they come from social agencies. My job there is to get

these people to relate to each other. We don't have any title XIX or any other kind of payment because we are not a skilled nursing facility. We give no nursing service.

Mr. ORIOL. But you would say that quite often you cut down the period of time for which Federal funds are provided.

Mrs. LowRY. Yes.

Mr. ORIOL. Under extended care.

Mrs. LowRY. Yes.

Mr. ORIOL. Or even under Medicaid.

Mrs. LowRY. Yes.

Mr. ORIOL. SO you are saving the Government money.

Mrs. LowRY. Right; not only that but helping the older adult to learn a function in the community. When he goes out, he does not deliberate. We are talking about giving people the know-how to live. What good is it if he lives in public housing and he does not participate in anything? He has no experiences, he sits there and disengages. He becomes mentally ill, he becomes disoriented. He does not eat properly because there is nobody to eat with, nobody to share it with. He does not know how to get together with somebody and he is going to land in a mental institution. He is going to, he can't stay out of one.

Mr. ORIOL. Mr. Parker, this is a similar type of experience that you witnessed, isn't it?

Mr. PARKER. Yes, this is true. We do have some recreators in Georgia in the State hospitals. There are some attempts at times of recreation programs but not this therapeutic type of program.

Mrs. LowRY. The National Recreation Therapeutic Society is very interested in trying to develop accreditation programs for universities and colleges and establish a certification program.

I have been in contact with the Gerontology Society just yesterday and Ed Kaskowitz and I are going to develop some regional training for therapeutic recreation working with the geriatric.

Mr. ORIOL. Do you have any questions?

Mr HALAMANDARIS. Yes.

I would just like to give my greetings to Mr. Parker. I have not seen him since I was down in Atlanta and he conferred his many courtesies on my behalf, introduced me to a very charming young lady, a southern belle.

Mr. ORIOL. Do you want that in the record?

Mr. HALAMANDRIS. Yes, that is in the record.

I had hoped that we could come down to Atlanta sometime in the spring when the peach trees were in blossom Mr. Parker, but it did not work out that way, for which I extend my sincere appropriate apologies.

We did receive a letter from you not too long ago commenting on the mass transit bill, and I believe you had a request asking if it was not possible to include in the mass transit bill a provision which would provide reduced fares for seniors on mass transit.

Mr. PARKER. Yes.

Mr. HALAMANDARIS. I think this is certainly a laudable goal. With Washington, D.C., some 4 or 5 days ago instituting this program there are now 35 major cities that have adopted this program. This was reported, incidentally, in Aging magazine; I think it was the recent edition.