Glasse, President of the Older Women's League, a national membership organization devoted exclusively to the concerns of midlife and older women. The Older Women's League was formed following the White House Mini-Conference on Older Women in 1980, and now has over 20,000 members and 100 chapters. Through education, research and advocacy we work for changes in public policy to eliminate the inequities older women face.

I would like to introduce to you Laurie Shields, co-founder of the Older Women's League and coauthor of our recently published book Women Take Care: The Consequences of Family Caregiving in Today's Society. In researching the book, Laurie, her co-author Tish Summers, and the OWL Task Force on Caregiving, interviewed over 400 caregivers.

National surveys have shown that caregivers are in desperate need of support services. Services like adult day care, respite care and in-home services are critical. Furthermore, our own research has shown that these services can substantially lift the emotional and economic burdens of caregiving.

Family caregivers are the unpaid workers in this nation's system of health care for frail, dependent persons. Without the attendance, assistance and nursing that caregivers devote to the elderly, our hospitals and skilled nursing facilities would be flooded.

As health care costs have risen over the last twenty years and as government has engaged in intensive cost containment policies, more and more responsibility for care of the sick and the aged has been shifted to families. Studies show that, for every person in a nursing home, there are four living in the community who receive unpaid care from families and friends. And because people are living longer, increasingly aging adults are caring for very aged parents.

This shift toward greater family responsibility has occured at a time when out of economic necessity more women are entering the paid labor force. These two events are causing personal and family disruption as well as economic hardship for millions of families and, particularly, millions of women.

Women traditionally have been the caregivers to both young and old. Roughly three out of four (72%) caregivers of the elderly are women, totaling 1.6 million. The most common relationship of caregiver to elderly care recipient is that of daughter or wife. Studies indicate that the average woman today can expect to spend as many years caring for a dependent parent or spouse as she does in caring for a dependent child.

We expect them to adjust their work schedules, their social and marital relationships their leisure time, indeed their lives, to provided succor to aged relatives. And more caregivers are doing just that--lovingly, willingly, regardless of the cost to themselves.

For many, this time of taking care of a loved one is a treasured time of sharing, a time to express love through tenderness, patience and understanding. But it can also be the backbreaking work of lifting, bending, turning, and of cleaning soiled bed linens. For many, this strenghtens and deepens the commitment of the caregiver and the cared for to each other, and it provides lasting memories. For some it is a time of pain, struggle and exhaustion that may stretch to a breaking point their capacity to care.

Sometimes too much is asked of caregivers. Frequently they carry the burden alone, housebound and isolated, often depressed and financially depleted, they may abuse the person dependent on them or may become ill themselves. A University of Bridgeport study found that 20% of caregivers it surveyed had been under a doctor's care and 22% of them suffered from frequent anxiety or depression. Most of us have known someone who has risked her own health in order to care for another. Among the 1.6 million women who are caregivers, almost half (44%) report they are in fair or poor condition.

The economic effects of caregiving can be devastating for women. Job interruptions for family responsibilities are a major factor in poverty among midlife and older women. Between the ages of 21 and 64, full-time women workers average 11.5 years out of the paid labor force, while men average 1.3 years. These differences are most extreme among midlife workers. For this group, full time women workers between the ages of 45 and 64 have spent almost two decades out of the paid labor force caring for family members, while men in this age category have spent less than one year away from work. This loss of job tenure has both a direct effect on present income, as well as on future retirement benefits. Job interruptions have also meant that vesting in a pension plan is often unlikely, even when retirement benefits are available.

The corporate community is increasingly turning its attention to the balancing act of working and caregiving. Employers have good reason to be concerned. A study conducted by the Family Survival Project looking at the joint demands of caregiving and employment found that 22% of those surveyed had quit their jobs because of a relative's caregiving needs. Of those who remained employed, 55% had to reduce the number of hours that they worked. More than half of those still employed reported decreased productivity. The study found that employed caregivers spent an average of 34 hours each week working and another 35 hours each week caring for their disabled relatives. These working caregivers spent as much time taking care of an ill or disabled adult as they spent at work. Those who left their work in order to care for a relative estimated lost income to be $20,400 a year. In addition, they spent an average of 18 hours a day giving care.

Other studies have confirmed these findings. Research by the Philadelphia Geriatric Center in 1987 and the National Center for Health Services Research and Health Care Technology in 1986 found that 12 percent of their samples of caregiving daughters had quit their jobs. A sampling of caregivers done by Elaine Brody in 1984 found that 40% of women who left their jobs for caregiving responsibilities had incomes under $15,000.

Many companies have begun to conduct their own studies. In December 1985 the Travelers Companies found that twenty percent of all its home office employees, aged 30 and older, provided some form of care for an older person. This survey found that these employees provided an average of 10.2 hours per week of care for an older person, with 8 percent of them spending 35 hours or more per week at the task. Forty percent managed the elderly person's finances, and 30 percent provided direct financial support. Other company surveys are finding the same results, creating concern about personal productivity. Many companies have instituted policies to help employed caregivers, such as corporate sponsored adult day care, caregiving fairs, flexible work hours and expanded leave policies.

Too often, caregivers are reluctant to seek services, even when they are available and affordable. A recent study found that three out of four of the disabled elderly, who reside at home, do not receive any formal service. Only 5% receive all their care from paid services. Many caregivers do not know that services exist. Some feel that they should be able to solve their problems on their own, without turning to outside help. Some feel guilty for wanting to get away from caregiving. Some are uncomfortable with a stranger coming into their home. Some feel that no one can care for their relatives as well as they can.

But waiting until a crisis erupts before looking for services means that the choices will probably be more limited and the stress on both patient and caregiver will be greater. Unfortunately, not all of the needed services available. Though some are available, they are too costly.

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Among the services noted in Women Take Care are adult day care, respite care and home health care. Paying for these services however, presents a serious problem for families. Medicare, the largest government payer of health care for older Americans is focused exclusively on "acute care", which in practice means hospital care.

Ironically, the health care containment policy adopted by the government with such fanfare occurred at the same time that the Administration's practice of Medicare reimbursement for home health aid service was quietly downgraded. The number of days covered was reduced and reimbursement became more restrictive. The patient is now required to be sick enough to be homebound and at the same time well enough to need only intermittent care. In other words, if the person is so sick that he/she requires skilled nursing services, services may be available in the home a few hours for a few weeks. Some health planners call this a NO-CARE ZONE.

Medicaid, on the other hand, allocates 40% of its nationwide budget to nursing home care, but a couple must impoverish themselves to qualify the disabled spouse for Medicaid coverage.

As you know, Medicaid may pay some home health care but eligibility criteria vary from state to state. In a few states Medicaid will pay for adult day care for a person is eligible.

Private insurance plans offer little assistance to the disabled spouse and caregiver once he leaves the hospital. There is a growing interest among some insurance carriers in offering long term care insurance but we have a long way to go before adult day care, respite care and adequate in-home services are available and affordable to families in need.

In conlusion, we need national health policies that support families as they care for their incapacitated members. We need policies that are concerned with the well-being of the caregiver as well as the person cared for. We need a federal system of services for long term care that will strengthen families who give care, not weaken them; that will nurture the caregiver, not exploit her.

More adult day care programs need to be established that will provide relief from constant caring and at the same time enable the caregiver to remain in the paid labor force. We need to encourage the development of more affordable respite care programs. The Older Women's League urges the

expansion of Medicare and Medicaid to cover respite, adult day care and home health care.

Day care can also help some elderly persons over the "rough spots" which might otherwise result in nursing home placement. We had an example of that in our own center not long ago. An 86-year old woman from another area of the state was widowed in early 1987. Shortly after that, she was admitted to the hospital-depressed, confused, and over-medicated. She was in psychotherapy for four months, during which time her family sold her home and moved her to Billings where the family lived.

She entered our day care program shortly after the move. We had a special arrangement to offer her because our day care program is physically located in our nursing home. During her time in day care she received the support services of both the day care and nursing home staff on her health and social needs. Within six weeks she was able to move into a retirement home, where she continues to function well.

This was a case in which a nursing home staff worked with a day care staff to successfully avoid nursing home placement. We believe that this teamwork has helped most of our participants avoid, or at least delay, institutionalization. Of course, if the widow I mentioned had not been

able to recover as she did, and had been admitted to the facility, she would have had an opportunity to work with the staff before admission. believe that would have eased her transition somewhat.

Efficient Use of Limited Resources.

We

We are all concerned about health care costs, and nursing home costs have especially captured public attention. The program at St. John's not only reduces the state and national burden of nursing home costs, because nursing home placement is avoided, but it additionally uses nursing home resources to reduce the costs of adult day care! The frequently-quoted average cost of adult day care is $30-$35 per day. At St. John's our arrangement with the nursing home permits us to offer a broad range of health and social services, utilizing the expertise of specialists in nursing, dietetics, social work, and activities for $16 per day, including lunch. A participant who comes to our center five days a week for a full day, pays $80 a week for those services. That totals a little more than $4,000 per year, compared to $18,000-22,000 for nursing home care. Conclusion

Allowing the elderly to maintain their independent life styles, reducing stress on the family members who care for them, and doing so in an economic manner is a challenge we hope others will accept. We appreciate this opportunity to share these ideas with you Mr. Chairman, and thank you again for the support you have provided on this very important issue.

The CHAIRMAN. Thank you, Don.

Ms. Larmer.

STATEMENT OF KAY LARMER, CHAIRPERSON, NATIONAL INSTITUTE ON ADULT DAYCARE, NATIONAL COUNCIL ON THE AGING

Ms. LARMER. Senator Melcher and committee members, I am Kay Larmer, coordinator of Adult Day Health Care Programs for Fairfax County and also Chairperson of the National Institute on Adult Daycare, a membership unit of the National Council on Aging.

The National Council on Aging, founded in 1950, is a national, non-profit organization. Its membership includes individuals, voluntary agencies, and associations, business organizations, and labor unions united by commitment to the principle that the nation's older people are entitled to lives of dignity, security, physical, mental, and social well being, and to full participation in society. The National Institute on Adult Day Care is the only organization composed of professionals in the field working to develop and expand the adult day care field, to advocate for those who rely on adult day care services for daily and continuing support, and for those working to ensure that adult day care is of the highest quality, based on solid standards of excellence and available throughout the nation.

I am very pleased to be here today and have the opportunity to testify on behalf of this service and its benefits to older people and their families.

You have all received copies of my testimony. In fact, most of what I have said in my testimony has been eloquently said by the Senators and people that came before me.

During the past 10 years, adult day health care has developed to meet the needs of the ever-increasing frail and impaired population in our country. It provides a variety of services and activities that enable impaired adults to remain in their homes and communities.

As the term implies, adult day health care is a program of care during the day in a protective group setting. It is an innovative and effective way to organize and blend traditional health and social services for impaired adults.

Although adult day care is not a new concept, it is still not an integral part of the long-term care system in many areas. It was first introduced in the 1960's, but it has been very slow to develop, largely due to the lack of stable funding sources.

In 1973, there were only 15 programs. Today, however, there are 1,400 serving approximately 66,234 persons daily. This growth has been largely a grass roots effort, developing without any national initiative or coordinated funding source. In fact, it has occurred in spite of a public policy that long has favored institutional care.

Programs have sprung up throughout the country under the auspices of a variety of sponsoring organizations, both public and private. The majority are non-profit. They are located in churches, hospitals, multi-purpose senior centers, elderly housing projects, nursing homes, and homes for the aged.

The average per diem cost for adult day care is $27. Earlier, it was mentioned that it is $31, and that is if you include the in-kind