Senator CLARK. I want to congratulate you for providing this bus and making it available to the whole county. I know it is going to be an enormous help. Transportation continues to emerge as a major problem for older Americans and, in fact, I understand some of you came in on this bus today.

Those who did, raise your hand. [Show of hands]

Senator CLARK. Good. Excellent.

Well, it has already been put to use.

I want to thank this panel very much.

We have one more panel with three people and we hope you can stay for that. This panel did an excellent job and gave very helpful information. We thank you very, very much.

Mayor MURPHY. Thank you, Senator.

Senator CLARK. The next panel is on health services and it is made up of Anne Snell, R.N., regional supervisory nurse, Iowa State Department of Health, Ida Grove, Iowa; Dennis Tobin, director, Department of Social Services, Ida County, Iowa; and James Krick, Ida Grove, Iowa.

Please come up to the table. We will hear from each witness and then have a question period.

We will hear first from Anne Snell. Anne has worked for years. here in Ida County and she knows the health service needs of the residents here. As I understand it, she is going to relate what health services are severely lacking for the elderly now, and the consequences of what must be activated to compensate for the lack of health services in such rural dwellings.

PANEL ON HEALTH SERVICES

STATEMENT OF ANNE SNELL, R.N., REGIONAL SUPERVISORY NURSE, IOWA STATE DEPARTMENT OF HEALTH, IDA GROVE, IOWA

Mrs. SNELL. Thank you, Senator Clark.

The goal of most elderly persons is to retain their independence and live in their own homes as long as possible. This goal can be reached only through expansion of existing home health services. Are public health nurses who assume responsibility for most of the home health services provided in our rural counties serving the elderly population? Let us look at some 1974 statistics of two counties in the area, Ida County, which we are now in, has a population of 9,100, with 1,900 persons or 21.3 percent-being age 60 or over and 1,400 or 15.9 percent-being age 65 or older. During the fiscal year July 1, 1975 to June 30, 1976, the one public health nurse in the county made a total of 1.397 visits; 1,202-or 86 percent-of the visits were to persons, age 65 and older; 112-or 8 percent-of the services were to persons between the ages of 45 and 64; and 83-or 6 percent-to persons under age 45. About 19.5 percent of the 16,000 residents in neighboring Cherokee County are age 60 or older. Of the 2,210 home visits made by two public health nurses during the past fiscal year, 1,862-or 84 percent of the visits were to persons 65 years of age or older. So when we think about the number of visits for 65 and older, we see

that nurses are spending over 80 percent of their time in this area and still are not beginning to meet the needs of the people.

Last fall the public health nursing services and departments of social services in Calhoun and Pocahontas Counties established there was a need to provide health screening for persons age 60 and older as many of these persons do not see a physician regularly due to physician shortage, transportation problems, lack of finances, or they do not recognize the need. Around 22.7 percent of the 14,300 residents in Calhoun County are over 60 years of age, and Pocahontas County, with a population of 12,700, has 20.5 percent age 60 and older.

SCREENING CLINICS ESTABLISHED

Grant funds were obtained from the Iowa State Department of Health to establish well-elderly screening clinics. These clinics are held in each of the towns in the 2 counties on a rotating basis. There are 21 towns in the 2 counties with 7 physicians located in 1 town, 3 physicians in 1, 2 in another, and 1 physician in each of 2 townsleaving 16 communities with no physician. A hospital is located in 2 towns, and nursing homes in 8-leaving 13 communities with no health care facilities.

The well-elderly screening clinics have been in operation only 5 months. During that time, 180 persons who had not seen a physician within a year were screened. The screening program includes obtaining a social and medical history, vision screening, including glaucoma testing, blood and urine testing, a complete physical assessment, counseling regarding the findings, and referral.

To show that these clinics are needed, 107-or 57 percent-of the persons screened were referred; 71-or 66.4 percent of the referrals were to physicians; 22-or 20.6 percent-to public health nurses, and 14 or 13 percent to others, such as dentists, ophthamologists or optometrists, department of social services, and mental health centers. Many other counties recognize the same need but are unable to provide a similar program due to lack of funds.

A recent survey showing the length of time persons had not been seen by a physician was done at the well-elderly clinics in Powesheik County by the public health nurses. Of 245 elderly persons seen at the clinics, 43 were seen by a physician 1 year ago, 67 between 1 and 2 years, 78 between 2 and 5 years, and 57 had not seen a physician for 5 years. There were many reasons given for not seeing a physician, but the most common were, "My doctor doesn't have time to talk with me." "I can't stand to sit in the waiting room 2 or 3 hours and then see the doctor for only 5 or 10 minutes," and then, of course, the common one, "I can't afford to go."

I feel that the primary problem in providing adequate home health care services to the elderly population in our rural communities is lack of funding. Local health fund moneys are appropriated from the county's general fund, which creates problems. Many counties in Iowa receive shared salary appropriations from the State department of health for one nurse, but there are several counties in northwest Iowa who receive none as there is no money available. These counties were able to establish home health agencies through use of Federal Grant 314d funds which were available for 3 years, after which they went

on county funding. The 9 percent limit placed on increasing expenditures from the general funds has created problems in several counties. Studies show that to provide adequate public health nursing service there should be one public health nurse for each 3,000 population, whereas there usually is one nurse for 8,000 to 12,000 population. This nursing shortage is not due to lack of available personnel-there are plenty of trained personnel. It is due to lack of funding.

LIMITED FUNDS HAMPER SERVICES

Less than half of the home health agencies in northwest Iowa are certified for medicare, thus depriving many persons of the benefits they should be receiving. These people should be entitled to services provided by nurses, home health aides, physical therapists, speech therapists, occupational therapists, and medical social workers. Personnel are not available to provide these services due to lack of funds. Studies are being done throughout the State to compare costs of home care and nursing home care. One study recently submitted to the home health agency surveyor showed the following expenses in the care of an 84-year-old lady with cardiovascular disease who was admitted to a home health agency in June 1972.

There were 100 visits by public health nurses from June 1972 through April 1976 at a cost of $1,160, and 396 visits by home health aides at a cost of $2,962-for a total of $4,122. Nursing home cost in the community from June 1972 through April 1976-1,418 days at $17.59 per day-would have amounted to $24,814.

So think of the savings in being able to keep them in their own homes.

We have found to be true what Senator Clark said in his support for the Church-Kennedy home health care amendments. People are better off when they can take care of themselves in their own homes with some assistance. Our public health services can provide that help at less public expense than institutional care. There is no other provider for this service that can meet the needs as well.

Thank you.

Senator CLARK. Thank you for a very comprehensive statement—a very complete one. We thank you for it.

We are going to hear now from Dennis Tobin, who is the director of the Department of Social Services for Ida County. He has worked chiefly with the homemaker-home health programs and will relate what his aides find to be the most requested services, those which are lacking, and those which are attempting to suffice the need in predominantly rural areas.

Dennis.

STATEMENT OF DENNIS TOBIN, DIRECTOR, DEPARTMENT OF SOCIAL SERVICES, IDA COUNTY, IOWA

Mr. TOBIN. Thank you.

I have been asked to speak to this committee regarding the health needs of the elderly and, more specifically, the homemaker-health aide program. In order to discuss the homemaker-health aide program, it is first necessary to explain the context in which the program functions.

80-462-77-4

The department of social services has two very basic goals: to maintain people as independently as possible, and to protect those persons unable to protect themselves.

The homemaker-health aide program and the chore service program work toward these goals while combating some of the other basic problems of the elderly, such as loneliness, boredom, special dietary needs, and lack of knowledge of existing programs.

We find few persons who are really physically unable to leave their homes. The program finds itself in a continuum of services ranging from simple financial assistance, so the elderly can avail themselves of existing services, to complete institutionalization, hopefully of a temporary nature.

PROGRAMS LISTED

These programs include, but are not limited to:

(1) Financial assistance, social security, SSI, and SSA.

(2) Chore service.-A program designed to arrange for persons to perform simple daily tasks that a client is unable to do himself such as lawnmowing, snow shoveling, and heavy cleaning.

This is a very efficient program, helping a lot of clients for very little expenditure. It should be expanded substantially as an alternative to higher levels of care.

(3) Homemaker-health aide program.-Performing many types of services for clients under the supervision of a PHN and/or a social worker to make it possible for a person to live in their own home rather than leaving their home for a higher level of care. We feel that a great majority of elderly can function at this level and would prefer it to higher levels of care.

(4) Family life homes, adult foster homes, and board and room homes. These programs allow the client a degree of freedom; however, they are no longer in their own home. We have a definite need for more of these facilities as an alternative to institutional care. They are currently bogged down with bureaucratic problems. (5) Custodial care. The least confining and most flexible level of institutional care. This level of facility can care for many elderly persons as well as younger persons who do not need a great deal of physical care. This type of facility is practically nonexistent in rural areas due to the strict requirements for physical plants and low payment level. Many current nursing care patients could function in a custodial home.

(6) Nursing homes.-These facilities have, in the past, been a catchall for all types of patients unable to function in their own home. With the availability of alternative types of care, it is hoped that clients will be allowed a number of choices other than the classic home or a nursing home.

(7) Extended care facilities.-These are special highly skilled nursing homes designed as an alternative to long-term hospitalization. In rural America they have simply been strangled by Government regulations and redtape. Since this is a program paid by medicare, many elderly are cheated out of part of their medicare benefits by the lack of these facilities.

(8) Hospital care and institutional care. We are blessed with a number of good facilities in this area. We need many lower levels of care to avoid unnecessary hospital or institutional care.

We have found the homemaker-home health aide program to be a viable alternative to these higher levels of care and ask that this committee attempt to see that State and local governments are allowed the resources and flexibility to develop these programs to their fullest. Thank you.

Senator CLARK. Thank you very much.

We will hear next from James Krick who is, as I understand, the former mayor of Ida Grove, and I believe someone who has experience in what Dennis Tobin was just talking about in terms of homemakers and the chore aide program, and so forth. You proceed in any way you think appropriate, Mr. Krick, and then I will have some questions.

STATEMENT OF JAMES R. KRICK, IDA GROVE, IOWA

Mr. KRICK. I think you sure picked a bum person to talk after all these good talks that have been given. I suppose I would have to say most everybody here has been in contact with me or my wife since I was in the transfer business for 46 years. My wife was 79 and I am going on 83, so if there are any mistakes made. just forget it.

Friends, Senator Clark, and Mr. Bedell, Mr. Tobin wanted me to tell my experience that I have had with the new social service of Ida Grove, Iowa.

Twelve years ago my wife, Rose M. Krick, had a stroke which left her a very much crippled person, and 10 years ago she had her second stroke. She stayed in Ida Grove Hospital for, I think. 46 days, and then went to St. Vincent's for a month to learn to walk again. She got along very well and I took care of her in our home.

Then 10 years later she had another bad stroke. She stayed in the hospital for a month or so. After a long stay, I was notified that her time of medicare was up and she could not stay any longer under medicare. I could not take her to a rest home or to another hospital, it had to be a private home so that she would get her privileges back from medicare.

I talked with her doctor, J. B. Dressler, and asked him if I could get a nurse to come once or twice a week to help. He said, "Yes," so I brought her home. Mrs. Anne Snell here-my wife was one of her first patients under this new program. At that time she was a county nurse. I took my wife home and we took care of her for about a month or so. Then she went to a new job in other counties.

SOCIAL SERVICE PROGRAM HELPED

So the county got Mrs. Betty McGuire as a nurse. She did a nice job and said the new social service was here in Ida Grove and that I could get a nurse's aide and chore women to help us out. I asked her to get someone to help out, which she did, and Mrs. Delores Peffer came five times a week to take care of Rose. Later, Joan Segebart came to help and then the chore women 3 hours a day per week. Nobody knows what that meant to me after 10 years of this trouble.