request, to review the original draft of the home health regulations for the title XIX, a year before they ever went into the Register.

Mr. WEINER. Earlier today, HEW testified they had received 1,000 comments on the regulations.

Mr. WILSMANN. I think that is an understatement. I would guess they are something well in excess of 2,000.

Mr. WEINER. The implication was that these are comments that came in from the field.

I wonder if you can tell us what Upjohn has done in terms of developing grassroots support by encouraging letters to HEW?

Mr. WILSMANN. In every location we have offices, we went to the people involved in the control of title XIX programs, in position there, and asked them to please comment on the new regulationsstudy the regulations, and comment on them.

We did not provide them with material saying that we would like them to comment this way or that way.

We simply asked them to look at them so they would get a representative feeling from the field, where the rubber meets the road, and we did that through all of our 200 offices throughout the country.

Mr. HALAMANDARIS. Thank you, gentlemen. We appreciate the testimony.

As some of you know, we are doing a study of the comparative quality and costs of for-profit home health care. If any of you would care to contribute further data, we would welcome your help.

Mr. HALAMANDARIS. We will now hear from another panel made up of Dr. Ellen Winston of the National Council for HomemakerHome Health Aide Services; Miss Nancy Tigar, assistant director, Council for Home Health Services, National League of Nursing, New York, N.Y.; Eva Reese, director, Visiting Nursing Service of New York, N.Y.; Ms. Helen Rawlinson, director of home care, Blue Cross Association of Greater Philadelphia; Ms. Janet E. Starr, executive director, Coalition of Home Health Services, Syracuse, N.Y.; and Mary Ann Pfau, coordinator of ambulatory and home care nursing services of the American Nurses Association, Kansas City, Mo.

Welcome to the subcommittees, ladies. We will hear first from Ms. Ellen Winston.

STATEMENT OF DR. ELLEN WINSTON, NATIONAL COUNCIL FOR HOMEMAKER-HOME HEALTH AIDE SERVICES, NEW YORK, N.Y.

Dr. WINSTON. My name is Ellen Winston. I present this testimony in my capacity as chairman of the Social Policy and Legislation Committee of the National Council for Homemaker-Home Health Aide Services, a national, nonprofit 501(C) (3) membership organization with offices in New York, N.Y. I am accompanied by Mrs. Florence Moore, executive director of the national council.

The national council was incorporated in 1962 and has worked steadily toward its goal which is availability of quality homemakerhome health aide service in all sections of the Nation, for individuals and families in all economic brackets, when there are disruptions

due to illness, disability, social and other problems, or where there is need of help to achieve or retain independent functioning and selfsufficiency.

The national council is a membership organization composed of 608 members of which 256 are agencies providing homemaker-home health aide service; 55 are organizations, and 297 are individuals1974 year-end figures-all of whom are committed to promoting quality inhome care.

Homemaker-home health aide service helps families remain together or olderly persons to remain in their own homes, when a health and/or social problem occurs, or to return to their own homes after specialized care. The trained homemaker-home health aide, who works for a community agency carries out assigned tasks in the family's or individual's place of residence, working under the supervision of a professional person who also assesses the need for the service and implements the plan of care.

The need for a variety of inhome services for the ill, aged, and disabled individuals has been documented many times before congressional committees. Homemaker-home health aide service, an essential home health service, is one of the most urgently needed of these inhome care programs.

A homemaker-home health aide service should be of good quality to be safe, effective, and efficient for the recipient, and it should be administered responsibly to protect the workers involved.

There are already trends developing, especially under title XIX and also under title XX of the Social Security Act, which threaten the quality of this service. For the August 21, 1975, medicaid regulations to be implemented now and in their present form would add further concern about the quality of homemaker-home health aide services.

These regulations need to be held in abeyance until careful study of their impact, not only on the quantity, but also on the quality of homemaker-home health aide service has been made.

We suggest that such a study will reveal a need to tighten up and to clarify existing medicaid regulations involving home health aide and related personal care services before new ones are implemented, and especially before regulations with the potential impact such as those of August 21, 1975, are put into effect.

Some needed changes in the proposed August 21, 1975 regulations are detailed in this testimony.

STRIVES FOR INCREASE IN SERVICES

Since its inception in 1962, the National Council for HomemakerHome Health Aid Services has worked toward an increase in the number of homemaker-home health aide services across the country for the thousands of families and individuals who need this inhome. service to help them remain independent and in their own homes. It is most reassuring to know that this need is being recognized too by congressional committees such as the two subcommittees holding these hearings.

Removing any doubt about medicaid not being bound to skilled nursing and prior institutionalization is a very useful contribution

in the August 21 proposed regulations. This will remove a major barrier to the receipt of inhome services by many very needy individuals.

However, on other points in these regulations further change is needed. Experience of agencies across the country has demonstrated time after time that both the personal care tasks and the home management tasks are needed by individuals with a health problem who wish to remain at home rather than to have to go into an institution. Therefore, we are glad to see the following phrase in 249.150i (1) listed among the duties of the aide: "household services essential to health care at home." We strongly recommend that in this section and others which refer to home health aide services, the terminology be changed to homemaker-home health aide services. This will assist in the integrated delivery of needed service to the recipient with a health problem and make this intent clear to provider agencies. There are still a number of programs which have two paraprofessionals going into the home, one to provide personal care and another to attend to tasks essential to the operation of a home, such as shopping, cooking, and cleaning. It becomes much more costly from every standpoint to send two people into the home when one trained, supervised paraprofessional can undertake all the practical services required.

Homemaker-home health aide services should be of good quality and should include protection of the workers. A concern that there be good standards for this inhome service predates by many years the formation of the National Council for Homemaker-Home Health Aide Services. In fact, it was in part to help assure quality homemaker-home health aide service that 26 national health and social service organizations and eight Federal Government departments recommended that the council be established. Basic standards for the service were developed in 1965 and updated in 1969 and each of these efforts involved broad representation from the field nationally. Based on these standards and a national social policy statement adopted in 1971 the national council developed a national approval program and currently is taking steps to develop it into one of accreditation. This program is available to an agency under any auspice and set in motion in 1972 objectively reviews the practices that an agency actually follows. The review is undertaken by a national peer review committee which makes recommendations to the board. in regard to the approval status sought by the agency and recommends improvements to the agency to strengthen its service.

The two components essential to this process are, first, basic national standards and, second, an objective third party review. We submit that it is essential for each agency in the country regardless of auspice to participate on a regular basis in a recognized objective third-party review.

I might point out that many agencies are extending service to a 24-hour basis, and not an 8-to-5 basis as has been pointed out here today.

"MONITORING OF PERFORMANCE"

The August 21 proposed regulations do specify some standards and refer to "monitoring of performance." We would like to comment on the key standards and to share some of our experience in

monitoring standards in this field. We will use as our touchstone the 14 standards developed by the homemaker-home health aide field, which form the basis for the council's national approval program. A policy statement entitled "Safeguards for Delivery of HomemakerHome Health Aide Services," which includes these standards, is submitted for your information as a part of this testimony.

Since medicaid is a program involving health care, nurses, physicians, and therapists should be available to the home health agency. The national council believes homemaker-home health aide service is a team service which should involve the professionals appropriate to the nature of the recipient's problem.

In a medical situation, this will require, in addition to the physician, a nurse and a social worker and, at times, a therapist to assess the need and to establish the plan of care. And it may require more than one in some situations in the ongoing supervision of the paraprofessional. In addition to these professionals, the council urges agencies which serve large numbers of older people to utilize also home economists or nutritionists. In short, in a quality agency the paraprofessional members of the team carry out practical nonprofessional procedures under the plan of care established by and supervised by appropriate professional members of the health team.

There is increasing evidence to indicate that agencies with good standards, including the supervisory area, are less costly because they provide appropriate service for as long as needed but for no longer. They bring in less costly services such as meals-on-wheels or largely volunteer services such as telephone reassurance or friendly visitors when these can supplement the homemaker-home health aide service. At times the supplementary service is the only service that is needed. In other words, quality service will not only benefit the recipient but also be reflected in efficient service as measured by the cost of the case. Lack of quality service can be extremely costly in human and in fiscal terms as the following case example illustrates. An elderly woman discharged from the hospital obtained homemaker-home health aide service on the advice of her physician. Aides were provided around the clock on a continuing basis until the woman, distraught because all her funds were gone and she was in debt to the agency, called her minister for help. He went to the local social welfare department which took the case to court where the physician testified that his patient, with the help she actually needed, should have been on her feet and managing on her own a long time before. Instead the woman, physically, emotionally, and financially dependent, was admitted to a nursing home as a public charge. The commissioner of welfare has told the national council that he has had to handle a number of similar cases recently in which inappropriate and unnecessary care was provided.

We urge that the regulations under discussion require that the assessment of need and establishment of plan of care involve appropriate members of the health team and a professional social worker.

TRAINING OF HOMEMAKER-HOME HEALTH AIDES

Another key standard in the national council's approval program involves an initial generic training program as well as ongoing in

*See appendix 5, item 6, p. 254.

service training for the homemaker-home health aides. We are glad to note that the August 21 proposed regulations require not less than 40 hours of basic orientation and training for the aides. Many homemaker-home health aide agencies throughout the country provide considerably more than 40 hours.

Training is vitally important for homemaker-home health aides not only to protect the well being of the people they serve but also for the protection of the aides themselves. To take an extreme but true example, if an aide lifts someone without knowing how to do it, she may not only drop or otherwise injure the individual, but she could hurt her own back, resulting in permanent injury.

We urge that the content areas for training include, in addition to those listed in the regulations, the following: Mental illness, mental retardation, physical handicaps, disability through chronic and acute illness, and home accident prevention. We urge, too, that instruction in the training program be given by at least the following professional groups: Nurses-preferably public health nurses, social workers, and nutritionists, and home economists. Desirable, too, are doctors, both general practitioners, and psychiatrists, safety experts, and therapists-physical and occupational.

We recommend that the wording regarding inservice training be as follows:

There shall be, on a continuing basis, inservice training programs scheduled at least quarterly, in addition to on-the-job training which takes place during supervisory visits.

Homemaker-home health aide service is particularly vulnerable because the paraprofessionals do not usually come to their job trained for it as do professionals, such as nurses, doctors, and others. If the agency using their services does not train the aides or see that they are trained, this component of quality service will almost always be missing. Yet it is this member of the health team who lifts the patient, helps him walk again, prepares special diets, reminds the individual to take his or her medication, relates to ill, discouraged, and at times difficult individuals for hours on end.

SELECTION OF AIDES

Another key standard is the selection of homemaker-home health aides. In addition to selecting them for personal suitability, their own health conditions should be screened initially and again each year. Communicable diseases must be ruled out as with other vocational groups exposed to many people, including those involved in the preparation of food. We would recommend adding careful selection of aides to the regulations and require that a personal interview as well as information on any work performance elsewhere be taken into account.

We all know that some nursing home patients have been abused by some workers in those institutions. Obviously, in the privacy of one's own home abuse becomes much easier to perpetrate and more. difficult to detect especially if the persons being served are alone and vulnerable because they are aged, ill, or otherwise handicapped. Examples have been reported to the national council where the aides