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percent coverage-or part A benefits—this person has to be hospitalized for 3 days. Otherwise, if the patient is ill at home and requires our services, this patient falls under the category of part B; which Medicare only pays 80 percent and the patient himself has to pay 20 percent reimbursement.

Now, many times the patient cannot pay this 20 percent; and, if we feel that the patient requires this care, then the agency has to pay for 20 percent. Now, Mrs. McDermott spoke about skilled nursing care--and I think this is an important point, in that the definition of skilled nursing care-as Medicare sees it may be different from the way we interpret it. Not only that; but, more importantly, the way that the intermediary, or Blue Cross interprets the definition of skilled nursing. I think that this is an important point because there are, as you know, so many different cases and ways of interpreting things. I included a definition of this but I won't read it here.

Senator PELL. A definition of what?
Miss HUGGINS. Skilled nursing care.
Senator PELL. I would like to hear it.

Miss HUGGINS. All right. This definition comes from the Rhode Island Nurses Association and this is their official definition:

Professional nursing is a health service to individuals and groups which is based on principals derived from the biological, physical and social sciences. It utilizes the skills, observation, communication, and interpersonal relationships. It contributes to the maintenance and promotion of health into the pro vision of physical and emotional care, comfort and support to the people with a variety of health needs by teaching and supervising of patients and families. Teaching, supervising, directing, and participating with all members of the nursing team in identifying patients nursing needs, developing and implementing appropriate nursing and collaborating with the other health professions in comprehensive health care and making critical and independent judgments about patients and their care and increasing the body of nursing knowledge which enhances health care.

The least expensive part of the Medicare affects the Home Health Agency which is part B, and this was the first to be restricted. Now, the present regulations allow reimbursement for the acute phase of illness; but, as we know, among our elderly it is a chronic illness that is most prevalent. We feel that this almost forces a patient to hospitalization in order for them to get the coverage that they should have. There are many patients, whom we see, who don't have to have hospitalization; but, not all the patients have medical coverage or doctor's care.

Senator PELL. I think the general public is probably not aware of the fact that when citizens are over 65 I think the statistics showand you know much better than I do; but, if my recollection is correct/one-third of the people over 65 have some kind of chronic sickness or illness, two-thirds of the people over 65 have a form of chronic sickness and one-third have two kinds of chronic sickness.

Miss HUGGINS. This is where Medicare is so restrictive, in that if a patient is ill at home and doesn't receive hospitalization then he is not reimbursed fully, but only 80 percent.

ELDERLY CAN'T AFFORD ILLNESS

Senator PELL. The ridiculous thing is when people need the money the most for hospital care and sickness, their income has usually declined the most and when you are young you don't have the chronic sickness when you can best afford it. That is the irrational controversy that we face today.

Miss HUGGINS. I think, too, that it is unfortunate that enough attention is not paid to the savings to the public that could accrue from expansion of the home health service. We feel that health teaching, health guidance, prevention, screening clinics and this type of thing would not only find out about a patient, who needs our care, but also it will prevent that person from being hospitalized—I think that is important to us. We feel that the patient should have every right to stay at home, and receive care at home, and be with the family in surroundings that he enjoys, instead of being hospitalized or being put into a nursing home, or an extended care facility. Of course, we realize there are many times when this has to be done. However, if a patient can stay at home we feel that everything should be done to permit this. And it is going to be a lesser expense to the taxpayer in the long run, actually, because nursing homes and hospitals are more expensive than home health care.

Senator PELL. I so agree with you. I think one of the cruel things about our society—and we are rather unique in this—is that when our parents get older-instead of taking them in, as did the countries from which most of us came, and making them part of the home—we tend very often to push them out. If they are still lucky to be well, you have these wonderful housing for the elderly projects—and here in Woonsocket you have a particularly good number. We should throw a compliment to Congressman St Germaine in this regard because he is the Congressman, of all the Congressmen, who has more housing for the elderly in his district. He is on that HUD Subcommittee of Housing for the Elderly and it started under him. When you come to Woonsocket you see that you have an extra large share here, and it should really be called St Germaine Memorial Housing for the Elderly, I think. But nevertheless the need is for more of this even more than he has been able to fill. We come back to one of the things that is wrong with our society, which is that the young don't take in the families but but tend to push out their older parents. I would hope that one result of the publicity and hearings would be to make middle-age citizens realize that the place—if at all possible—for older people is with the family. They have more of a sense of purpose and love and utility there.

Now, going back to some questions with each one of you, who are very professional and very skilled. First, to Mrs. McDermott; as I understand it, part of the problem is confusion regarding interpretation of the guidelines issued by the Social Security Administration. What is your own recommendation, what do you think can be done to reduce the confusion? Do you have any thoughts in this regard?

Mrs. McDERMOTT. Sir, it seems to me—the guidelines and interpretation—that before a patient was admitted that I would be told. I would know that this patient would be covered for, say, 30 days, because of the diagnosis, because of the type of care that is usually required in this case, and with an extension if necessary. The interpretation and the guidelines, or anything to do with Medicare, depend on who is making this interpretation. But I will tell you, if the home has interpreted it wrong the home loses—no matter whose interpretation it is.

Senator PELL. Now, what would happen if one of your patients—as you mentioned, it was determined he was not eligible for Medicare and then must be terminated. What happens to a patient who is terminated and for one reason or another there is no family; his children cannot take him, and are not living in the neighborhood, and he has no place to go. Now, is that problem handled in fact?

Mrs. McDERMOTT. This patient can stay as a paying patient.

CANNOT AFFORD TO PAY—THEN WHAT?

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Senator PELL. I am talking about a patient who cannot afford to pay as a paying patient and Medicare cannot pick it up.

Mrs. McDERMOTT. On many occasions, before the patients are admitted, an application is submitted to Zambrarino and is placed on their waiting list. If their name is on the waiting list and they haven't been called for admission, then they are transferred out-into Stateapproved nursing homes, or homes that do accept Medicaid.

Senator PELL. Now, in this neighborhood, how many homes are there that accept Medicaid patients?

Mrs. McDERMOTT. I would say the majority of the nursing homes. Senator PELL. Which would be roughly 10,15 ? Miss Gray. There are two in Woonsocket, licensed by the State in Woonsocket only.

Senator PELL. I was confused. If you have to transfer a patient to a nursing home that accepts Medicaid patients, where would they be transferred to?

Mrs. McDERMOTT. Hopefully, surrounding the neighborhood; and I would guess there are 10 nursing homes around Grandview that are approved by Medicaid.

Senator PELL. I thought there were two nursing homes?
Mrs. McDERMOTT. I am talking-
Senator Pell. Northern Rhode Island basically?
Mrs. McDERMOTT. Yes, but two E.C.F.'s.

Senator PELL. Of your patients who have been terminated roughly how many go back home or go to another nursing home or Zambrarino? A third? What would be the ratio? This is very roughly.

Mrs. MCDERMOTT. A very small percentage of Zambrarino because of the waiting list. I would say over 50 percent are transferred home or to State-approved nursing homes.

Senator Pell. The reason you can't accept the Medicaid patient, basically, is that you provide a level of service that is expensive and gives more than the Medicaid patient can afford to pay you?

1 Mrs. McDERMOTT. That is correct. Senator Pell. Right. Is yours a proprietary home? Mrs. McDERMOTT. Yes. Senator PELL. The other is proprietary, too? Mrs. McDERMOTT. Yes. Senator PELL. What can be done in your view to increase the number of nursing homes within this area, you have any recommendations for us?

Mrs. McDERMOTT. Norto increase the number?
Senator PELL. Yes.
Mrs. McDERMOTT. No.

Senator PELL. Would it not be a correct statement to say that the guidelines that revolve around whether or not a patient can be rehabilitated are a question of whether he can be rehabilitated. That is the guideline; and, if the patient cannot be rehabilitated then you cannot accept him or keep him isn't that the case ?

— Mrs. McDERMOTT. That is correct. This patient will not stay—under Medicare, at least.

Senator PELL. Under Medicare?

Mrs. McDERMOTT. Because under Medicare, in order for the patient to be approved, he has to be rehabilitable.

Senator PELL. So many of us when we become older become sick, and can't be rehabilitated. We have to be cared for as we are. What can we do to help these people?

Mrs. McDERMOTT. Well, sir, this is the type of patient that I discussed earlier. I don't know the answer to this. This is the hardest type of care to give. If this patient goes home, it isn't a tour of duty for 8 hours as in the nursing home—it is for 24 hours. I don't know what you do with a patient that you can't rehabilitate.

Senator PELL. This is really, I think the question that we are faced with today is the question of definition. Because the majority of the people with chronic sickness and chronic illness can't be rehabilitated, it is a question of caring for them as best you can-making them feel part of the community as they are. This is why I come back to this point. I think the visiting nurse service probably would be the most important single thing to help this. It keeps the older people in the homes with the families where they are loved, and gives them the care that they should have. Now, I am just curious here. I would like to ask and satisfy myself—because part of the purpose of this hearing is selfeducation for me, as a relatively new member of this committee.

How many of you here—and I would request you to put your hands up and give me a feeling, here—how many of you would agree with my theory, that our society is a fairly cruel one, in that older people have a sense of rejection by their children, of being middle aged and being pushed out? And, how many would disagree; and think I am wrong, and prefer to be out on their own and not with the families ? All those who think that it is a cruel society raise their hands. Well, nobody is raising their hands. The mayor of Woonsocket tells me that I didn't make my question clear. My question, and it is one that has bothered me for some years, all of you who think that society in America—the United States, with its emphasis on material possessions and improvement of status—very often results in the older citizen being pushed out by their families, where they belong, and where they live? Now, in Europe—where I lived a good deal of my life—the older citizen was part of the family and the grandfather and grandmother stay until they die. I think this is perhaps a healthier situation and one that shows more love and kindness in many ways. The question I am asking is to show your hands either way, I hope I made it clear.

How many of you feel that the families in America should go back to staying with the family as a unit as opposed to being outside the family in a nursing home? First, how many think there should be more with the family as a unit? How many on, the other hand, think they are better off in a home for the elderly away from the family? Well, that is very interesting because six or seven times more people put up their hands about remaining with the families. I would hope the press noticed the percentages in this case; because it was interesting and bears out this theory.

Now, returning to the panel—and forgive me for the interruptionto Miss Gray. Do you know of many instances where you have had to keep people in the hospital because there wasn't an opening for them or opportunity for them outside?

Miss GRAY. Yes, a good many.

Senator PELL. Could you give any more—well, would you say the older people who come in would be say a quarter, a fifth, who stay, maybe, a little longer than they should?

Miss GRAY. Oh, a minimum of at least a quarter. The families don't want to take them.

WHAT IS CONFUSION IN MEDICARE PROGRAM! Senator PELL. Again from the viewpoint of the taxpayers, the more the older people can be given a lower level of care and in proportion to their need, the better off the taxpayer. Now, apparently from the response of the audience here, the better off the older person, himself, particularly if-as Miss Huggins has pointed out the visiting nurse can—the care can be given at home. What in your view, Miss Grey, is it about the Medicare program that causes confusion in the minds of the patients? Why do so many patients come to you about what Medicare does?

Miss Gray. Because they all feel that the patient can stay in the hospital 90 days—regardless of whether they are in need of the care or not. And when you say that is only if needed, you might just as well tell them they are going to stay because they are not going to take them out.

Senator PELL. This is another purpose of the hearing—that the community can be educated to the fact that our older citizens do not have the right to 90 days in a hospital, unless it is needed for medical reasons and rehabilitation.

Miss GRAY. Right—then, of course, when the Utilization Review Team-which is a team of doctors that meet every week-when they review these cases and tell the attending physician that the patient does not belong in the hospital—he can be taken care of either in an extended care facility, or in a home licensed by the State—the families can't see it. If Woonsocket Hospital kept all these elderly patients—that want to stay there—we would have an old folks home and not a hospital.

Senator PELL. Thank you.

Now, going to Miss Huggins for a moment. I would just like to get the statistics of this. We were talking about this before the hearing. * How many visiting nurses are there in the State of Rhode Island ?

*See appendix 1, p. 191.

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