The provisions of title VIII, part B, open up the possibilities for a concerted effort in this direction. I would hope the Administration on Aging would be charged to conduct appropriate studies to produce estimates of the demand for these services so that the provisions of part B may be implemented at an early date.

As was noted in the earlier portion of this statement, Iowa has problems involving health care delivery, especially in rural areas. I would call the committee's attention to two recent developments in Iowa which may show the way to other States which need to improve their situations in this regard.

The college of medicine has taken the leadership, with the active support and cooperation of local practitioners and other segments of local communities, in developing two model health care delivery programs. One is in Muscatine, which is a medium-sized city in area 9. The other is in Red Oak, which is a much smaller city in a rural area in area 13. In Red Oak the program involves the grouping of solo practitioners, the recruiting of additional doctors, and the development of satellite clinics. The major objective of these programs is to experiment in innovative ways of organizing a medical practice. We believe they have real implications for the care of the elderly-both at home and in longterm care facilities.

A health related topic which is often everlooked concerns the hearing problems of the elderly. It was of some interest, therefore, to read in the House committee's description of H.R. 3922 the committee's belief that the Administration on Aging should support, under section 308(a), the development of (a) model projects designed to inform hearing-impaired elderly citizens of the need for and availability of appropriate professional evaluation, diagnosis, and aural rehabilitation, and (b) model projects designed to expand or improve the delievery of aural rehabilitation services to the hearing-impaired elderly.

I called this to the attention of Dr. Charles V. Anderson, associate professor of audiology in the University of Iowa Hospitals who I knew was interested and concerned about the hearing problems of older adults, and I asked him to give me a brief statement of his findings. Dr. Anderson's statement follows:

"Through the years, audiologists (the professionals most appropriate to provide evaluation and aural rehabilitation for hearing loss) have attempted, without much support or success, to develop service programs for any citizen who is over 65 years of age. In eastern Iowa some of these attempts have been made by audiologists and students on a volunteer basis. Service, teaching, and research commitments of these volunteers in their regular employment has precluded having sufficient time, space, and equipment to accomplish the goals.

"The major aspect which has been accomplished is to 'scratch the surface' in identification of problems. Referrals for service from these identification programs have been followed sparingly due to a lack of followup and funding. The two most common responses which we receive from the older citizens who have a hearing problem are:

"1. I don't have a problem which can be treated; I'm just old,' and "2. "If that costs money I'll have to wait.'

"The answers to these two sources of rejection of referral obviously lie in the matter of availability of personnel for followup and in funding to underwrite services. The purpose of the followup is to inform (maybe convince) these citizens that there are rehabilitative services which will improve their communication ability and thus improve their socialization. The funding is needed to insure that services are available at a cost which the recipient can afford. The services which are needed include:

"1. Hearing evaluations which will define and describe the hearing loss and provide a basis for decisions about aural rehabilitation.

"2. Hearing aids which with proper instruction can be used to improve communication.

"3. Hearing aid orientation which will help the user take maximum advantage of the assistance provided by a hearing aid.

"4. General aural rehabilitation which will teach the person with a hearing loss to make maximum use of his/her hearing and vision to become an efficient communicator.

"5. Counseling and training for those who communicate with the person who has the hearing loss. This included counseling with family and friends as well as inservice training for the personnel in retirement homes, extended care facilities, and nursing homes.

"During the last 12 months, several of my students and I have attempted to respond to the pleas for help in the immediate area of Iowa City. This area in

cludes primarily a rural population. These services have been provided totally on a volunteer basis. Two types of programs have been offered and each was welcomed. The one program is strictly identification and referral of individuals with hearing losses. In this program the team of audiologists travels to sites such as congregate meal programs and retirement homes. A short program discussing hearing loss, hearing aids, and aural rehabilitation is presented. This is followed by hearing testing (basically screening) and referral for further services. Under this program, discussions have now been held with over 350 older citizens of which 168 received hearing tests. Of these 168 people, 130 (77 percent) had hearing losses sufficiently great to interfere seriously with communication. Not one single individual had yet received what was considered to be adequate services for the hearing loss prior to the program.

"In the second program the volunteers have traveled to retirement homes and presented five 40-minute discussion sessions about hearing loss, good communication habits, and aural rehabilitation to residents who volunteered to participate. Although only two such programs have been presented to date, the response has been rewarding. However, again, providing adequate followup has been difficult. "Although we have requests to serve more than 300 additional citizens, we are presently considering abandoning the program for that reason. It seems unwise and maybe even harmful to the elderly to identify hearing problems which 'could' be treated but which won't be because of lack of resources.

"Maybe we should accept the response of the elderly that they are simply 'growing old' and nothing can be done rather than point out their problems to them without providing followup service.

"Obviously, personnel with special training in communication problems of our older citizens will be needed. We are attempting to integrate more of this into our own program. This institution (University of Iowa) is a natural to be in the forefront in this; our concern is well known."

NURSING HOMES

We have long been aware of abuses and neglect of patients in some long-term care facilities. The report of the Senate Special Committee on Aging entitled "Nursing Home Care in the United States: Failure in Public Policy," confirmed the existence of serious and disgraceful mistreatment of aging persons in some of these facilities.

We in Iowa were made painfully aware of similar distressing conditions in our own State by a recent report to Iowa legislators by the Iowa Student Public Interest Research Group (ISPIRG). This report has been read also by the officials of the Iowa State Department of Health which now has a bill under consideration in the general assembly which should help correct some of the abuses by reducing the number of levels of care from seven to three, by writing carefully considered sets of rules and regulations governing these facilities, and by enforcing inspection findings with a system of citations and fines when standards of care are not met.

We would concur with the statement made to the Brademas committee last January by Harry Walker who was then President of the National Association of State Units on Aging who testified as follows:

"In our opinion, it would be appropriate and desirable for the Older Americans Act to provide incentives to State units on aging to establish within their agencies effective and responsible nursing home ombudsmen. Such incentive should be at least in the form of specific language calling on State agencies to perform this function, thus strengthening the agencies' ability to do this successfully. Ideally, the ombudsman not only would investigate alleged abuses, but would let it be known to patients and their families that there is a place to turn when they have a legitimate complaint."

Senator Clark, this concludes my prepared testimony. I appreciate having the opportunity to present this information and my views to the committee.

[Whereupon, at 11:25 a.m., the hearing recessed to reconvene at 1 o'clock the same day.]

AFTERNOON SESSION

Senator CLARK. The hearing will come to order.

This is going to be a discussion this afternoon, although we are going to have people testify at the outset.

I thought what we might do is to just go around the room and have each person identify themselves so we can get to know one another. Then we are going to hear from Harry Bryan, Mary Ellen Lloyd, and Patrick Madden. I believe Elizabeth Myers is not here yet. She may come at any moment.

Let's start over here with Mr. Scott.

Mr. SCOTT. Raymond Scott; I am the director on aging in the State of Arkansas.

Dr. MADDEN. I am Patrick Madden from the department of agricultural economics and sociology, Pennsylvania University.

Dr. MORRIS. Woodrow Morris, associate dean, college of medicine, University of Iowa, and chairman on the commission on the aging. Senator CLARK. Scott Ginsburg of my staff.

MS. KILMER. I am Debby Kilmer, committee staff.

Mr. MILLER. I am John Guy Miller, of the committee on aging. Mr. BROTMAN. I am Herman Brotman. I am retired now. I was formerly an assistant on the commission on aging. I am a consultant to the Special Committee on Aging.

Mr. BRYAN. I am Harry Bryan, executive director, South Carolina Commission on Aging.

Ms. LLOYD. Mary Ellen Lloyd, director of the nutrition program for the elderly in southwest Virginia.

Senator CLARK. Let's go ahead and hear the three witnesses first. You can proceed in any way you like, Mr. Bryan, then we can have a discussion.

IMPROVEMENT FOR RURAL ELDERLY

I hope the discussion is centered around ways of improving the Older Americans Act with regard to the rural elderly. That is what we want to try to emphasize.

We will start off with Senator Domenici and then we will turn to Mr. Bryan.

Senator Domenici of New Mexico.

Senator DOMENICI. Thank you very much, Dick. I know you have a short period of time on a broad subject. I have my prepared statement. I would ask that it be put in the record.

Senator CLARK. It will be.

Senator DOMENICI. Basically, I am concerned as you are about the fact that there are many areas where there seems to be a disproportionate thrust in terms of resources going to the elderly and the need of the elderly in rural areas versus the heavily concentrated urban areas. I know it is difficult to prepare programs for rural America. Transportation witnesses all contribute to this.

But it seems to me, stressing as you are these problems, that does not mean there is not a great need and that does not mean that we ought to let that condition exist and force our elderly to move to big cities as a solution.

Rather than take up time I would rather listen to experts and have my statement placed in the record.

Senator CLARK. I appreciate that very much. That is coming from a former mayor of Albuquerque, too. It is even more meaningful. He is aware of the problems of rural areas. His firsthand experience in New Mexico is helpful to all of us here in the Senate, and we appreciate the Senator's interest in rural Americans.

Without objection, the statement of Senator Domenici will be inserted into the record at this point.

STATEMENT BY SENATOR PETE V. DOMENICI

Mr. Chairman, I am most pleased for this opportunity to discuss the effects of the Older Americans Act on persons living in rural areas. Although the rural and urban elderly face similar problems such as low incomes, inadequate transportation services, unsuitable housing, and an inadequate health care delivery system, these problems take on different aspects for the rural elderly than for the urban elderly because of differing geographical and economic conditions.

There are nearly 9 million persons age 65 and older living outside our major cities representing 41 percent of the senior population. The rural elderly are essentially a low-income group with one-third living on incomes below the poverty level. This compares to 25 percent of the elderly in the central cities and 17 percent of the elderly in suburban areas who have incomes below the poverty level.

Transportation is one of the most serious problems for older persons living in low-density areas. According to the 1971 White House Conference on Aging, rural transportation problems must be solved before there can be effective solutions to rural health, income, employment, or housing problems. The rural elderly also must cope with an inadequate health care delivery system. Although rural people have about the same access to general practitioners and hospitals as do individuals living in metropolitan areas, they have to drive long distances to these services and they are not accessible to medical specialists. They also are in need of more home health care services which may often mean the difference between remaining in their home and living in an institution.

As a result of activities under the Older Americans Act, an increasing number of services are reaching the rural elderly. Escort services, home repair services, telephone reassurance, home-health services, meals on wheels, and information and referral services are examples of the kinds of services now available to many elderly. Existing services in rural America, however, fall gravely short of the actual need.

EQUALIZE RURAL ELDERLY SHARE

I am concerned that a disproportionate share of Federal dollars allocated under the Older Americans Act, as well as other Federal programs, are being spent in rural areas. Under the title III State and area program, for example, State agencies on aging divide the State into planning and service areas and establish area agencies on aging which then serve as planners and brokers in developing comprehensive and coordinated service systems for the elderly. These agencies, primarily, introduce older people to existing services and spend relatively little money in establishing new services in areas where they are unavailable. We must realize that rural areas have too few existing services.

The title VII nutrition program, however, does provide proportionate service to rural elderly. Under the title VII nutrition program for the elderly, 25 percent of the meals are served in rural sites. In

my own State of New Mexico, I am happy to report that 68 percent of the title VII participants live in rural areas. Nationally, 40 percent of the participants live in rural areas.

It is my hope that this trend will be followed in all programs serving rural Americans. The Older Americans Act should generate community interest in meeting the needs of older people and help provide the stimulus needed to direct additional Federal dollars to those older individuals living in less populated areas.

Senator CLARK. Mr. Bryan.

STATEMENT OF HARRY R. BRYAN, EXECUTIVE DIRECTOR, SOUTH CAROLINA COMMISSION ON AGING, COLUMBIA, S.C.

Mr. BRYAN. Slightly over half of our senior South Carolinians, 52 percent, live in rural areas, and I appreciate the opportunity to represent them and speak on their behalf here today.

I am delighted to be able to emphatically state that the Older Americans Act is now helping many of the rural elderly. Reports from our field staff, from our area agencies on aging, and from our title III projects operating in rural areas where there is no area agency, all indicate that the information and referral, the outreach, and the transportation services being provided with the help of the Older Americans Act are definitely reaching-and in many cases sustaining-some of the most needy, rural elderly.

I have personally observed this encouraging development since we initiated one of the first areawide model projects on aging several years ago.

The rural elderly are also being served in the title VII program in South Carolina. Seventeen of our 55 meal sites are in rural areas; many others are in very small towns.

IMPROVEMENTS FOR RURAL ELDERLY

But these services to the rural elderly can and should be expanded. I discussed this matter with some of my colleagues last week, some from South Carolina, some from other States. Having the benefit of their thoughts, I respectfully present the following suggestions for improving and expanding services to the rural elderly through the Older Americans Act:

1. The rural elderly need homemaker, home health, and chore services, but we feel these should be provided through title XX of the Social Security Act or other federally funded programs. To make this possibility a probability, I recommend that the Older Americans Act be amended to provide that Older Americans Act funds can be used as matching funds to draw in title XX and other Federal dollars to help provide these essential services to the needy elderly. This is not a new concept. It has been done to help the inner city poor in the model cities program and the poor in the Appalachian area with funds allocated through the Appalachian Regional Commission. Why not help another group of disadvantaged Americans-the elderly-in this same way?

2. Help the rural areas, most of which have less resources to draw on than do the urban areas, by mandating that the matching ratio for Older Americans Act funds be the same in areas not having an