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health care; making critical independent judgements about patients and their care; and increasing and disseminating the body of nursing knowledge which enhances health care."
The present requirement that the home health reimbursement must follow a hospital stay of at least three days under "Part A" makes admission to home health care dependent on institutionalization. This is self-defeating in a system which hopes to encourage alternatives to institutional care.
The least expensive part of the Medicare Program which affects Home Health Agencies (Part B) has been the first to be restricted. Present regulations allow reimbursement for acute phases of illness, yet the major health problem of our aging population is not related primarily to acute illness, but rather to chronic illness. Current regulations do not provide payment for home health services needed to prevent regression of the chronically ill patient who has limited potential for rehabilitation, thus making the patient a potential candidate for hospitalization. In the second annual report from the Secretary of Health, Education and Welfare on operation of the Medicare Program, the utilization data is of interest. In-patient admissions to long and short-term hospitals amount to an annual average of 291 admissions for every 1,000 persons covered under the Program. Twenty percent represented second or subsequent admissions. Admissions to home health services averaged 13 per 1,000 persons covered with payments averaging $69.00 per recorded claim under hospital insurance and $42.00 under medical insurance. Besides reasons of simple decency for assuring nursing care and comfort to those in need, valid practical economics support our mission. Unfortunately, insufficient attention is paid to the savings to the public that could accrue from expansion of Home Health Agency services.
Home Health Agencies have demonstrated their ability to move forward, initiate new home health practices and to cooperate with and assist satellite health care units, social action agencies and group practices. In order to substantiate savings to the public we are including a portion of a study on utilization of Home Health Services in Rhode Island. This Study was conducted by Dr. Helen Cleary of the New England Tri-State Regional Medical Program and submitted for publication in May 1971.
"Reference was made to information on costs for those patients who, in the agency's judgment, could not be maintained in their homes without nursing service. The obvious questions related to this point are: What does it cost to maintain these patients in their homes and what would it cost if they were patients in a nursing home, boarding home or extended care facility. In order to answer these questions, information on the patient's expenses in addition to medical care, as well as their financial resources, would have to be available. A different kind of study than this would be needed to gather these data.
"The data we do have include: the cost to the agency to maintain these patients in their homes for the first nine months of 1970, and the per diem rates allowed by Medicare and the Welfare Department for nursing-boarding homes and extended care facilities. If we apply the percentage of patients in our study sample eligible for these two sources of payment to the 2313 patients, and do some arithmetic, interesting figures result. This process assumes that all Medicare and Welfare patients could not be maintained in their homes without nursing services. This is not a vaid assumption. It is, however, valid to assume that few people required to live in a nursing home or similar facility can afford to pay their own way over time. At some point, public monies must be available to support them, whereas many may be able to support themselves at home.
"We suggest, therefore, that the following calculations are useful as a very rough comparison of the cost of nursing service in the home as against maintaining a patient in a facility outside his home. These figures do not include medical care costs in addition to nursing service in the home, or board, room and nursing care outside the home.
"1. The total cost to the nursing agencies to serve the 2313 patients for the first nine months of 1970 was $660,464.47, or, assuming all patients received equal care, $285.54 per patient.
"2. The primary source of payment for 42 per cent of the patients in the study sample was Medicare. If this percentage is applied to the 2313, 971 were Medicare patients. Carrying this assumption one step further: 971×$285.54=$277,259.34, or the cost to agencies for Medicare patients for nine months.
"3. The range of per diem rates allowed by Medicare for nursing homes or an extended care facility is $11-37; median cost, $22. Therefore, the cost to maintain 971 patients in these facilities for one month would range from $320,430 to $1,077,810; the median, $640,860.
"4. The primary source of payment for 22 per cent of the patients in the study sample was Welfare (19 per cent) or Medicaid (3 per cent). If this perecntage is applied to the 2313 patients 509 were the responsibility of Welfare or Medicaid. The cost to the agencies for these patients would be: 509×$285.54 or $145,339.96 for nine months.
“5. Than range of per diem rates allowed for boarding and nursing homes by the Welfare Department is $7.50-$13.75; median, $10.21, Therefore, the cost to maintain these 509 patients in a nursing home or similar facility for one month would range from $114,525 to $209,962.50; median $155,906.70.
"It should be noted that calculations for supporting a patient outside of his home are for one month, and the nursing agency figures are for nine months. Despite the inequities in these figures which we have noted above, it is clearly obvious that patients cannot be supported less expensively outside the home than in their homes."
The Home Health Agencies of Rhode Island wish to make the following recommendations:
-That the Congress state clearly in the law the intent to include coverage of home health services necessary to prevent hospitalization.
-Place all home health benefits under Part A with a maximum eligibility of 200 visits per year.
-Remove the three day hospital stay requirement for home health benefits and the requirement that services rendered be related to the condition for which patient was hospitalized.
-Provide for co-insurance for the second 100 visits per year.
-Remove the $50 deductible restriction.
-Provide direct reimbursement for medical supplies to the provider or 100% reimbursement to the Home Health Agency.
-Provide for reimbursement on an actual cost basis to the providers of services rendered to patients receiving custodial care who are not entitled to services under the Medicare Program.
-Adoption of the Rhode Island State Nurses' Association's official definition of Professional Nursing as the Medicare Program's definition of skilled nursing care.
It is our sincere belief that our elderly citizens who are able to be maintained at home are entitled to quality care in their own homes, with the dignity and family comfort they deserve, and to postpone hospital or nursing home placement as long as possible.
We wish to thank this Committee for the opportunity to share our views and concerns for the elderly patients under our care.
VISITING NURSE SERVICE OF GREATER WOONSOCKET
1971** (4 mths)
No. of visits made to patients age 65 years and over.
No. of such visits made to people age 65 years and over---
7, 666 69.3% 6, 602 59.7%
3, 233 2,474 76.5%
2, 328 72.0%
Visits NOT covered by Medicare (13.9%)
Approximately 275 Medicare patients served during 1970.
As of May 31, 1971:
Active patients on caseload__
Patients on Part A, Medicare (4.54%)
Patients on Part B, Medicare (4.83%).
**January 1, thru April 31, 1971.
ITEM 2. REPORT OF SOME OF THE ELDERLY PROBLEMS AND SOME OF THE SOLUTIONS TO THE PROBLEMS THAT HAS BEEN BROUGHT TO BEAR BY SOCIAL PROGRESS ACTION CORPORATION AND SERVICES PROGRAM
Prepared by: A. M. Duarte Jr., Executive Director
JUNE 12, 1971.
The city of Woonsocket has a large elderly population, in 1965 our senior citizens age 65 and over accounted for 11.86% of Woonsocket's population and in 1970 the figure jumped to 13.01%. The Department of Health, Education and Welfare Division of Social Security administration has indicated, that Woonsocket has the highest percentage of Elderly in the state.
According to the 1970 census figures, the state's elderly population accounts for 11% of the total population.
The Woonsocket Housing Authority has attempted to meet the large demand for Public Housing for Senior Citizens; by having two high rise for the elderly housing 453 residents and two units presently under construction with a total of 300 units. The present waiting list consist of some 900 names.
Outside of the Woonsocket Housing Authority, there is no other agency in the community, that deals specifically with the elderly other than Social Progress Action Corporation, the Community Action Agency of the City of Woonsocket, SPAC through it's Senior Opportunity and Services programs, which was designed solely to deal with the elderly and their multitude of problems, has attempted to focus in on the problems of nutrition.
Utilizing the problem of nutrition as a focal point or base of operation, the Senior Opportunity and Services Program with it's federal funding of $19,000.00, from the Office of Economic Opportunity, started what is termed locally, as "The Gay 90's Diners Club."
Within the program, we employ five senior citizens age 55 and over on a part time basis. The office of the Senior Opportunity and Services Program is located in the Kennedy Manor Building, a high-rise for the elderly. The Woonsocket Housing Authority allows the agency the use of the building at no cost.
Once weekly, a complete nutritional meal is served to approximately 200 to 225 senior citizens at no cost. Eligibility requires that the individual be age 55 years and over, meet the requirements of the O.E.O. poverty guidelines and is a resident of the City of Woonsocket. Needless to say, at this point, there is a great demand from many senior citizens residing outside of the City of Woonsocket, for participation in the program. Because of limited funds, this is an impossibility at this time.
Along with serving a nutritional meal in a pleasant social atmosphere, at the same time a program is designed to meet some of the other areas of concern of the senior citizens. For example, the area supervisor of the Division of Social Security Administration has at four consecutive weekly meals to answer questions and give information concerning Social Security Benefits. Speakers concerning food stamp information, health aspects, old age assistance, housing and many more have appeared to give help, guidance and assistance to the Senior citizens of the "Gay 90's Diners Club."
Because of this program, many Senior citizens have been helped to receive benefits, that they would otherwise not receive, due to their ignorance of benefits, shyness, lack of mobility, pride and isolation.
There are many of our Senior citizens that are living alone and in isolation, they have developed poor eating and nutritional habits. The more commonly referred to phrase, "the tea and toast diet," is a reality to many Senior citizens in the City of Woonsocket.
Through the efforts of the "Food Lift and Information Program”, in a five month period, some 300 Senior citizens have been certified and are currently receiving food stamps. The "Food Lift and Information Program", is a food stamp out-reach program operated by Social Progress Action Corporation.
In establishing this program in the community, one of the most difficult barriers to remove, was one of mistrust. All to often in the past, promises were made, but the actual delivery of services never came about. Presently in the program, there are over 850 Senior citizens actively participating in the program. The justification for expansion exists, but again limited funds presents an acute problem to expansion.
The problems of Senior citizens are unique and many. Surveys of Senior citizens have been conducted, many of them, the results are the same. No survey can produce the types of information or indicate the true needs of the Senior citizen, as can be produced through the bringing together of some 200 plus people in a pleasant informal social atmosphere.
Senior citizens want to be needed, they need to be wanted. This is evident by the vast amount of energy and exuberance they display in association with the program. An average of 22 Senior citizens volunteer weekly to do the serving for the weekly meal. Many of our Senior citizens have a fine talent for sewing, as a result, a program is underway whereby Senior citizens are making clothes for teenagers who are receiving welfare assistance. Many more are offering their services to volunteer in a variety of ways.
The demonstrative needs of the Senior citizen, have now become a part of the program. Consumer buying, consumer education, nutritional education, which consists of preparing a meal for a single elderly, first aid courses designed specifically for the elderly are some of the program activities, based on the demonstrative needs of the Senior citizen.
As indicated earlier in this report, many of our Senior citizens live alone. It has been discovered in the past, that some Senior citizens who have passed away have gone undetected for four or five days, and in some isolated cases, even longer.
As a result of this discovery a "Phone Buddy System" has been established, where Senior citizens call each other daily, to check on their well-being. In conjunction with this, Senior citizens have fallen and injured themselves, and lay on the floor for hours at a time. People have become ill, and have had no way of communicating with the outside world.
The staff of the Senior Opportunity and Services Program have established a tremendous amount of rapport with the Senior citizens of the City of Woonsocket, as a result of this, the S.O.S. Program has become the focal point for them, and has also become the referal agency for a majority of their problems.
In a previous part of this report, it was mentioned that one of the most difficult obstacles to overcome was one of mis-trust. The comments were: "Nobody is going to provide these services at no cost, somewhere along the line we'll have to pay," or "this program will never last, as soon as it's doing good the federal government will take the money away." The last comment is of great interest. With $19,000.00 we have hired a program director and five Senior citizens, we have been able to provide approximately 1,000 meals monthly, a portion of those meals are provided to shut-in citizens who are physically unable to attend the meals, we have involved over a thousand low-income Senior citizens in our program, and have purchased some necessary equipment to operate the program. For the first time in the City of Woonsocket, Senior citizens are saying, "this program is for us."
Two weeks ago, it became the sad and difficult responsibility of this executive director to inform the smiling faces of over 200 Senior citizens, that O.E.O. had indicated, there were no federal funds to continue the program. It is needless to say at this point, how the smiles disappeared, and heads bowed in sorrow. Some of their earlier fears had come true.
Due to the fact, that the 1970 census figures are incomplete we refer to the 1965 Rhode Island Census, which indicated, that 8.5% of the people age 65 and over were receiving Old Age Assistance, and approximately 8,420 people were receiving retirement benefits from social security.
Also, during this period of time, there were 745 Senior citizens residing in public housing, at the present time, there are over 90 people on the waiting list for Senior citizen housing.
Armed with this type of information, and the obvious success of the Senior Opportunity and Services Program, it is no wonder that the often misunderstood Community Action Program, has a difficult time in maintaining a standard of credibility, not only to the community at large, but more so to the people it is attempting to serve.
Through the efforts of the S.O.S. Program, we are only beginning to uncover the many problems of our Senior citizens, and this is only because they have learned to trust us. No one is naive enough to think that this program is a panacea to all the problems, but it is a good sound beginning.
All too often, we find when we are beginning to make stride, we have come to a complete halt. Senior citizens are a very cautious, and do not present their trust lightly.
The minor dent we have made in the nutritional problem of Senior citizens, is just that, “A Minor Dent". We have a long way to go and there is much more needed information to be sought out, demonstrative need to be brought to the forefront for solving problems, the removal of isolation and loneliness which constantly chips away at health, the delivery of health services and many more. The most prominent and important discovery on the part of Senior citizens, is the want to be needed and the need to be wanted by each other and by the community at large.
ITEM 3. REPORT OF THE SENIOR OPPORTUNITIES AND SERVICES PROGRAM OPERATED BY SOCIAL PROGRESS ACTION CORPORATION
Prepared by: Rebecca Doss, S.O.S. Program Director, June 11, 1971
THE GAY 90'S DINERS CLUB AS VIEWED THROUGH THE EYES OF THE PROGRAM DIRECTOR
The Office of Senior Opportunities and Services, under the auspices of Social Progress Action Corporation came into being in October 1970. By mid-October, we were settled into our office in the Kennedy Building, one of Woonsocket's Housing for the Elderly. On our first day there, news began to spread through the building that we had a brand new program for the city's elderly residents. Inquiries began to come into the office even before our phone was connected or my staff was hired. I remember one man in particular who stopped by my office out of curosity. He and his wife had moved into the manor several months before. His wife passed away 1 week after the move and he freely admitted he had become a hermit and that he was really curious why I would want to work for the "old people". He felt I should teach Kindergarten! Today, this gentleman is one of S.O.S.'s most active volunteers. He now appears years younger, no longer the drawn looking man who existed on beer and sandwiches. He has realized his problems are minor compared to some we see. He now has a new life to live.
The Gay 90's Diners Clubs we sponsor, four in all consisting of 200 members each, has given us one of the greatest opportunities of helping people possible. To be eligible for membership, 55 years of age is a minimum and a low income is a must-that is easily found in our community. We have stressed to our people that they are all individuals—yet, they are all equal when they walk into our dining hall. I've found this relieves a great deal of tension on the part of my people.
We had a difficult time convincing them that the U.S. Government was going to give them something terrific for free. The free part I didn't worry about, but, I had butterflies about it being terrific in their eyes. We began to ask questions about what they'd like to have. The first to speak up was a little lady without any teeth, who said turkey and hen! Our first meal was turkey and hen and she was there. She passed away two weeks later. I think of her often, but, I feel she really enjoyed herself at our first meal.
Every member of the Gay 90's has had something to contribute in their own way. I've spoken to over 900 prospective members individually and by asking a couple of questions, I find I can sit back and listen for a good 1⁄2 hour. As a group, some are shy or bashful about talking about their inner feelings, but, in their homes, my office or by phone, they are as open and honest as the day is long. My people are proud to be U.S. Citizens, but many would rather see Medicare add eyeglasses and false teeth to their list of services, than see a space ship go to the moon. They are thankful for Welfare supplements and Social Security checks, even if the money is promised to the landlord, the gas or electric company, but, most of all they are thankful for the freedom of choosing their own food products with their Food Stamps. These are really necessary items, food, clothing, shelter, but what happens to the mind when it sits idle? We've found that many of our people were not prepared for older age. Many were forced to retire due to illness, many due to age limit in factories, and suddenly they had a full 24 hour day in which to do nothing, other than what they wished to do, and what they wished to do they could not afford. These are not people who belonged to Social Clubs, Garden Clubs, the Y's, Bowling Leagues, or who held library cards, where do they go and what do they do? As of Nov. 25th, 800 of them have