stay on top of all the title programs that are being developed and to develop proposals to tap into these programs. As a result of the lack of continuity we have had during this past year, we are very concerned about whether we are even going to have a senior citizens program during fiscal year 1977.

We are in agreement with the need identified at the Phoenix National Indian Conference on Aging that funding for all programs to serve native American elders through the Administration on Aging be granted for a minimum period of not less than 5 years. Those programs which have then demonstrated their effectiveness in serving native American elders should be continued to be funded on an ongoing basis.

A fourth major need of our Dakota elderly is adequate transportation. Our elderly people are geographically dispersed throughout the seven rural tribal districts on the Lake Traverse Reservation. There is a need for a transportation system to be developed that would facilitate senior citizens being able to shop, visit the doctor, go to church, and participate in senior citizen and recreational programs. We have written a proposal for an additional senior citizens van; but unless we have money to operate the vehicle, we will not even receive the grant to purchase it with.

Another obstacle that we have encountered in our efforts to tap into State Older Americans Act funds (and others) is our lack of matching capital. Our lack of capital is a real handicap when dealing with State programs.

INDIAN LIFE EXPECTANCY SHORT

Another problem that we have identified is with the regulation in title 7 and some of the other programs under the Older Americans Act which defines a "senior citizen" as a person who is 60 years of age or older. It is well known that the life expectancy of Indian people is shorter than that of the average American population. The National Indian Conference on Aging held in Phoenix in June 1976, went on record to lower the age requirement for Indian participants to 45 years of age. On the Lake Traverse Reservation we are envisioning a program that would include persons who are 50 years and older.

We have two HUD units in our community that are designed specifically for elderly people. We identify the need for other such units in our community-perhaps in some of the other tribal districts. Such units make it possible for tribal senior citizens to remain in their communities and near their families while at the same time providing for their comfort and special needs.

We have identified a need for a congregate meals program on the Lake Traverse Reservation. We think the Indian participants will benefit socially as well as nutritionally from such a program. We hope that we can receive funding for such a program.

We identify a need for an in-service orientation to be provided for staff persons working with tribal senior citizens to inform them about all the benefits that are available for senior citizens and to explain to them how to tap into these programs. These staff persons should be given an opportunity to develop and practice organizing skills (through role-playing sessions and group discussions) so that they will have a better idea of how to go about getting the senior citizens organized and operating efficiently.

There is a need to mobilize existing community resources to benefit tribal senior citizens. We need to make resource people aware of the needs of our tribal elderly and to make our tribal elderly aware of the existence of these services so they will make use of them. We further identify a need for expansion of existing homemaker aide services, nursing services, legal services, and other outreach services.

Please note that all of our testimony relates back to our need to have a tribal senior citizen program. At the National Indian Conference on Aging, held in Phoenix in June 1976, it was recommended that the Congress of the United States be petitioned to amend the Older Americans Act to provide for direct funding of programs to Indian tribes. We think that there is a definite need for such a legislative change. But in the meantime, we want to see our tribal senior citizens benefitting from existing programs.

The welfare of our tribal senior citizens has been a primary concern to the tribal human services board and to the Sisseton-Wahpeton Sioux Tribe in general. We have appreciated the opportunity to have the Sisseton-Wahpeton Sioux Tribe give testimony at this hearing about the needs of our Dakota elderly.

The Sisseton-Wahpeton Sioux Department of Vital Statistics has furnished the following data concerning Sisseton-Wahpeton Sioux Tribal members who are 60 years old or older:

Senator CLARK. The next panel is on senior organizations and it is made up of Pete Gregor, president of the South Dakota Congress of Senior Organizations and South Dakota Association of Senior Citizen Centers, Winner, S. Dak.; Eunice Anderson, vice president of Mountain Plains Congress of Senior Organizations, Sioux Falls, S. Dak.; and Don Daughetee, State coordinator, South Dakota Congress of Senior Organizations, Pierre, S. Dak. It seems to me that there was to be one other person as well. Dr. Robert Hayes is also accompanying the panel.

Now this panel is going to speak, as I said, on senior organizations. Each of them have a prepared statement-some of them may not. Please try to limit your statements to about 4 or 5 minutes and then we will have some questions.

Let's start with Pete Gregor.

STATEMENT OF PETER GREGOR, PRESIDENT, SOUTH DAKOTA CONGRESS OF SENIOR ORGANIZATIONS AND SOUTH DÁKÓTÁ ASSOCIATION OF SENIOR CITIZEN CENTERS, WINNER, S. DAK.

Mr. GREGOR. Senator Clark, ladies and gentlemen, my name is Pete Gregor. I am the president of the South Dakota Congress of Senior Organizations. I am honored to have the privilege of offering testimony to your distinguished committee.

Senator Clark, you are to be commended for your concern for our elderly. The topic I would like to discuss is difficulties in the delivery of health services in rural South Dakota as it affects both Indian and non-Indian people. The foremost hardship for the elderly is the serious shortage of physicians and professional health personnel in rural areas. It is especially difficult or impossible for the Indian and non-Indian elderly who are no longer able to drive or cannot afford a vehicle because they live on fixed social security incomes. In many instances, living in a rural area means driving 50 to 70 miles one way to get medical attention.

We have proposed some solutions. About 2 years ago Dr. Robert Hayes, who was then secretary of the South Dakota Department of Health, recognized the serious shortage of physicians. He organized a physicians extender program and was successful in getting the State legislature to appropriate funds for a pilot program. To date, Dr. Hayes has placed and oversees four physician extenders in four of South Dakota's more isolated communities. The program is work

ing very well, but it falls far short of covering the many more rural areas in need. We desperately need Federal assistance to expand this type of program and to provide more widespread health care coverage.

In my area near Winner, Mission, and White River, 12 to 13 percent of the population are Indians. Under Dr. Hayes' program, both Indian and non-Indians get health care indiscriminately. Mr. Oriol has asked me to invite Dr. Hayes to this meeting to tell us more about this program and now I yield to Dr. Hayes.

Thank you, Senator Clark.

Senator CLARK. Thank you.

We are particularly pleased to have Dr. Hayes here. You may proceed in any way you think appropriate.

STATEMENT OF ROBERT H. HAYES, M.D., UNIVERSITY OF SOUTH DAKOTA MEDICAL SCHOOL, WALL, S. DAK.

Dr. HAYES. Thank you, Senator Clark, and staff.

I came from Iowa and was educated there and migrated to South Dakota back in the fifties and have been here ever since.

I am sure our problems in South Dakota and Iowa are somewhat similar. Iowa certainly has made great strides in terms of what it is doing in terms of health care for its populations. Most of you folks here know the University of South Dakota School of Medicine has just gotten started. We now have our first class of senior medical students in a 4-year program and we are certain that that will at least ease this burden. Certainly in Iowa you have done a great deal about serving the needs of the people in rural areas.

The lack of health services is acute, as Mr. Gregor has mentioned. I am pleased to say that we didn't really have much trouble with our legislature in asking for funds and getting them. I have a great many friends there who are very interested in the program. Our administration, our Governor and his staff, and our legislature provided the means, and we are now doing that. I won't go into that in great detail. I might say that what it amounts to is that we did pass the physicians' extender law. I should explain that term because most people don't know what that means. We have young people in the health field now who are nurse-practitioners and physician assistants. These folks help the doctors, they do certain amounts of work the doctors once did and they do it quite well. They have been trained very thoroughly to do it. It requires a physician like myself to work with those folks, to visit them each week, and to work with them each week. For example, I have a little circuit and I guess I am called a circuit-rider now because I go from the little town in which I now live, Wall, S. Dak., to Murdo, S. Dak., to White River, and over to Martin, and back up. It makes kind of a circle. Most of you know it covers about four different counties. We do take care of a lot of people. I will have a detailed report for our State legislature as we meet with them later on in the year.

I quickly tried to get some figures to show you, however, of what can be done and how it can work, for example, in the little town of Wall which is less than 1,000 people. This is just one of our sites in our project.

Senator CLARK. I believe we have all been to Wall..

Dr. HAYES. I am now from Wall. So far, for exampple, this yearand we have been in operation there in our clinic since November-we have had 3,010 patient visits. We have done pretty well. In other words, those visits run somewhere in the neighborhood of 10 to 20 a day. A person can get into our office and get the basic things done. If, for example, we cannot do what that patient needs, we refer him to a physician in the nearest town and that is 52 miles one way, 45 miles another, and 36 another, so the distances that other people have alluded to are about the same everywhere. It is a "fur piece."

Really, I think we have something to offer. We don't have the final outcome of it yet; we don't know which, exactly, will be the best way to use these folks. The model we have is one of the models. Certainly our medical school took on a big task when it did try to do this because it had enough troubles getting a medical school started without this. Our dean, Dr. Karl Wegner, I think made a very lonesome decision and a very important one-he decided to do it. I am certainly pleased to work for the school and for him and to try to do this for our folks in South Dakota.

I don't have anything else to say at this time.
[The prepared statement of Dr. Hayes follows:]

PHYSICIAN EXTENDER PROGRAM

The State of South Dakota has the lowest physician-to-population ratio in the United States. Medical care and health facilities are located, for the most part, in the larger cities of the State with little emphasis on the rural areas.

In attempting to provide the rural areas of the State of South Dakota with primary health care, the 1974 South Dakota State Legislature, by legislative mandate, charged the University of South Dakota School of Medicine with the task of developing and implementing a 4-year degree granting medical school that would place emphasis on family practice.

The first third-year class began training May 12, 1975, and will be the program's first graduates in the spring of 1977.

Further concern for providing health care to the rural areas of the State of South Dakota prompted the 1975 legislators, upon recommendation of the joint committee on appropriations to appropriate $60,000 for the development and the implementation of a program for physician extenders.

The legislative mandate or charge was given to the University of South Dakota School of Medicine to develop such a program. The initial budget appropriation is to be used to initiate a service program using physician extenders in a health service shortage area and to attract additional physician extenders to locate in South Dakota. These additional physician extenders would be placed with cooperating physicians in service shortage areas throughout the State.

Since funding became available on July 1, 1975, the school of medicine was unable to pursue financial commitments prior to that date.

Dr. Robert Hayes, former Secretary of Health, was employed as the program director. Meetings and conferences followed with the faculty as well as with the president of the university. From these studies, meetings, and deliberations, the following program proposal has evolved for your consideration. Original proposals have been modified because of budget limits, problems concerning possible duplication of physician extender educational programs, malpractice insurance requirements and concerns regarding physician acceptance of these people.

A rural site near one of the potential modules of the medical school is suggested as the base of operation for the physician extender program. This has the potential of bringing the school of medicine into a community without a physician and also has the potential of being near the communities which are likely to have no doctors and would, therefore, be an appropriate site for physician extender use. The obvious support of the community is needed as well, but in most cases this would be anticipated.

ESTABLISH SCHOOL

It is proposed that Dr. Hayes, the program director, move to the selected doctorless community and establish the school of medicine physician extender office there. It is felt that the program should eventually consist of five or more physician extenders in rural communities in the western part of the State. This would require up to four communities/counties to employ physician extenders (either nurse practitioners or physician's assistants) who would then be assigned by written agreement to Dr. Hayes, and other physicians, if necessary, for direction and technical supervision, in compliance with existing State statutes which limit assignment of physician assistants to two per physician. Dr. Hayes would work with the physician extenders and assist them with their patients in a teaching-service model. The project could consider such communities as Wall, Murdo, White River, and Edgemont. This selection of communities for the project would be on the basis of established health service shortage area designation criteria. These criteria include the geographic area to be served, population, demonstration of need, relationship to other health services in the area, anticipated cost and benefit, attitudes of community, county, and area residents as well as nearest physician(s) availability and manner of financing, demonstrated commitment for immediate and continuing support by the community, and management and professional capability of the organization or governmental unit sponsoring the proposed service (physician extender.)

Dr. Hayes would be available to area solo physicians for locum tenens relief if desired. These physicians would be those who are alone in communities with hospitals and nursing homes. This would allow the medical school to accomplish the all important function of extending itself to help the local doctor "hold the line" until new doctors graduate from our medical school and complete the several additional years of training necessary before they can begin practicing medicine.

Dr. Hayes, living in the selected community, would be on call by telephone and/or radio to back-up physician extenders in the selected sites. He would visit and work with the extenders in these sites on a rotating basis of 2 to 3 weeks. If he is relieving one of the area physicians, he could carry out the same functions of telephonic and/or radio back-up from that community.

In addition to the above, the volunteer ambulance services of the selected local communities could be assisted by Dr. Hayes. This would provide support for the developing emergency medical services program and should be of benefit to those communities in the creation of a medical evacuation system.

Fees which are collected for patient services would be collected by the sponsoring governmental unit and would be turned over to a community health fund and its board or to the county health fund and the county commissioners. These moneys would help defray the cost to the local communities/counties for the physician extender and her/his office.

Several possibilities exist for the provision of physician back-up of the program director during vacations, sick leave, etc. These include support by a physician from the State department of health, participation by faculty from the school of medicine or assistance by area physicians in private practice. The best of these alternatives, and perhaps others, will be explored and implemented to the fullest extent of available resources.

An important function of the program director will be to provide a liaison function between the demand for and supply of physician extenders. The possibility of availability of physician extenders will be explored with existing educational programs. The responsibility of the project director will be to establish communication between those schools and possible user-communities and physicians. Time has been allocated for the project director to carry out this additional other major function of the physician extender office.

Malpractice insurance has been a problem as indicated in the July 18, 1975 report. However, it has been resolved, and Dr. Hayes will be covered by the St. Paul Insurance Co. The individual physician extenders are to be covered through their own employers (the counties or communities) by a company of the sponsoring communities' choice.

In summary, the medical school proposes a teaching service model for its physician extender program. The model will have a rural ambulatory care center (RACC) as well as physician extenders to deliver service to rural communities, to educate physician extenders, and to assist local volunteer ambu