(1) I am gratified to have been asked to testify before this subcommittee since I feel that the provision of health services especially for the aged and disadvantaged is of primary importance in the forwarding of the Unfinished American Revolution's guarantee of life, liberty, and the pursuit of happiness;

(2) The central cities' overburden must be recognized and compensated; (3) The federal government's accent upon "creative" or "balanced" federalism is appreciated.

STATEMENT OF ELMER M. JOHNSON, ASSOCIATE DIRECTOR OF THE METROPOLITAN ST. LOUIS HOSPITAL PLANNING COMMISSION,

INC.

I wish to provide information about the status of home health services in the St. Louis Metropolitan area, and to cite obstacies to the further development of this service.

The present total annual expenditure for organized home health services for the sick in the metropolitan area is $1,100,000. We have about 2,300,000 persons in the area, so this represents a rate of less than 50 cents per capita.

Eight home health service agencies serve the area, employing 57 registered professional nurses and 102 home health aides. The number of nurses employed today is about 20 greater than one year ago before the beginning of medicare. There were no home health aides a year ago, although a few homemakers performed similar functions. Training programs financed by the Office of Economic Opportunity trained 88 of the presently employed home health aides. Another 20 were trained but there were no immediate job openings in this specific type of service at the time of completion of their training.

The great majority of home health service here is provided by non-hospital, community based voluntary agencies. Only one nurse from a tax-supported agency provides home health services for the sick in the metropolitan area.

Charges for visits by registered professional nurses range from $4.50 to $10.65. The lower rate is charged by a small-town visiting nurse association-the higher by a city hospital-based program. The average charge is about $9 per one hour visit-up 25 percent over a year ago. Home health aides customarily work in each home about 4 hours per visit. Charges for aides services range from $1.60 per hour to $2.50 per hour.

The ratio of aides to professional personnel is 5 to 1 in one agency, while another has no aides. The biggest agency has about 2 aides for each 3 professionals. Generally, the visiting nurse associations have lower ratios of aides to professionals than other types of home health agencies.

The total active caseload of all home health agencies in the area at any one time is approximately 1,000. This compares to average daily occupancy of 8.800 in short-term general hospitals and 8,600 in log-term care facilities, excluding mental and T.B.

At the present level of care home health services cost about $3 per active case per day in the metropolitan area.

The rate of use of this service here is only about the rate in communities where home care is highly developed. I believe the reasons for under-use of home care locally are:

Inadequate interpretation of home health service to doctors and the public. Lack of relationships between home health agencies and many hospitals. No home health service benefit payments for public assistance recipients under age 65 in Missouri.

Limited number of hospitals (6 of 42) qualifying to admit Blue Cross patients to home care.

Some parts of the metropolitan area with only nominal home health service coverage.

In addition to problems of insufficient use of the service, existing home health service programs need to be examined to determine if there is:

Too little medical surveillance of patient care.

Inappropriate "mix" of professional, technical, and aide services.

Inefficiencies caused by duplication and overlap of service areas of home health agencies in metropolitan area.

Increased use and more appropriate use of home health services could be encouraged at the federal level by :

Requiring that each medicare certified hospital and extended care facility has a transfer agreement with a home health service agency, or itself provide home health services.

83-481 0-67-pt. 1-9

Adding home health services to the present list of five services that are mandatory under Title XIX of the Social Security Act.

Developing educational materials and resources for local use in interpreting home health services to doctors and to the public.

Stimulating the establishment of national accreditation for home health service agencies which involves review of patient records by a team of competent specialists in mediicne, nursing, physical therapy, etc.

STATEMENT OF BERNARD FRIEDMAN, MEDICAL DIRECTOR AND SUPERINTENDENT, ROBERT KOCH HOSPITAL, KOCH, MISSOURI

On June 3, 1967, I attended a meeting, with others, at the request of Mr. William E. Oriol, Staff Director of the United States Senate Special Committee on the Aging. At the time we discussed the question of federal programs and health services to elderly Americans. Subsequently, we were asked to write a statement on the particular facet of health services in which each of us was most interested. This present statement repeats in general the oral statement that I made at that meeting.

My own special interest in the problems of the elderly came about through my work at Robert Koch Hospital. Our hospital was originally the municipal tuberculosis hospital of the City of St. Louis. As empty beds were made available, as a result of the impact of the modern treatment of tuberculosis, these beds were used to develop our Intermediate Care Divisions. Our Intermediate Care patients are patients that come to us usually from a general hospital, municipal or private, who no longer need the intensive care of a general hospital, but who requires services greater than that obtained in a nursing home or in their home.

Experiences with these divisions have been most revealing. For one thing, these divisions have become essentially divisions for the rehabilitation of the elderly. For another, it has become evident that very often the main obstacle preventing the patient from returning home is not the medical problem for which the patient entered the hospital. Very frequently the patient overcomes his stroke sufficiently so that he may again be up and about, his hip fracture heals well enough so that he becomes essentially self-care. The problems that occur over and over again are social conditions that prevent the transfer of the patient back to the home or apartment from which he came. A third floor level apartment of a patient who is short of breath because of emphysema, a toilet in the basement of a patient who has already fallen once and broken her hip going down stairs, a patient whose neighbor has in the past done her shopping and looked in daily. but is now moving to another location-these are the kind of problems that may actually make the difference between sending a patient home or to a nursing home. There is no question in my mind but that there are thousands of patients in nursing homes who have been transferred there not because they need to be in a nursing home but because of the social problems involved in the patient living on the outside. Two patients can reach the same levels of self-care with the same diagnosis. One can be discharged to a family eager and waiting to have him back, another can not be discharged because the home circumstances are unfavorable. The extension of home health services, home care, and such services as meals on wheels would help tremendously in keeping the elderly, chronically ill patients in their home. In working with these elderly people we find that an adequate social service staff both in the hospital and for out of hospital care is indispensable. At our Intermediate Care Divisions all efforts are made to prevent permanent institutionalization. The following is a table recording the disposition of our discharged patients in the last 3 fiscal years.

These results are, in my opinion, not particularly extraordinary. A few years ago, however, a significant number of the people we now send home would have been sent to nursing homes. On the other hand, a significant number of patients that we still send to domiciliary care institutions or nursing homes could be discharged home if some of the social problems of home care could be solved.

STATEMENT OF MORRIS ALEX, M.D., MEDICAL DIRECTOR, HOME CARE PROGRAM, ST. LOUIS, MISSOURI

At our meeting in Mayor Alfonso J. Cervantes' Office on June 3, 1967, with Mr. William E. Oriol, Staff Director of the United States Senate Special Committee on the Aging, it was suggested that I write up and submit to your subcommittee on Health of the Elderly the following portion of our discussion. I am happy to do

SO.

As a result of advances in the health sciences, there has been a profound change in the type of care required for many people. In the past acute diseases were predominant but now exacerbations of chronic diseases are more prevalent. With increasing numbers of older people in our population there has been a shift toward larger numbers of chronic diseases and as a result of this, need for longterm care and rehabilitative care. During the last 10-15 years, many voluntary and state organizations have arisen to help meet certain needs from either a social or medical point of view. Now it has become necessary to coordinate existing resources in order to make maximum use of the available resources and to develop new methods of coordinated care.

It is estimated that at any one time about one per cent of a communities population are not found in the world of the well. They have been withdrawn into the hospital world as patients. Of this number, some are there because they need treatment or diagnosis, and some are there simply because they cannot be contained within the world of the well but yet, do not require acute hospitalization. The latter group are the ones we are discussing at this time for if the occupant of the bed is not in a condition to use or respond to the expensive services of the acute hospital then doctors and laymen alike say that the bed is used for social rather than medical purposes. For most efficient use, in-patient medical care is to procure patients sent to them from the world of the well and to return them to the world of the well as quickly as possible. Home Care has a far wider use, it is responsible for managing the sick and all illnesses whether curable or not that do not require the acute hospital. In this management there is more than just therapy because this home care includes aid in living with the disabilities of the illness whether transient or permanent, limitations of disturbances in all the social systems which an illness disturbs-notably the household in which it is contained and establishing a partnership with those charged with the care of the sick individual in the community.

The problem of chronic illness in the Greater St. Louis area has been primarily a problem of the core city of St. Louis because of the unusually large number of persons 65 and over residing within the City of St. Louis. In the City of St. Louis in 1960, 12.3 per cent of the total population was 65 and over. By 1970 it is estimated that it will reach 15.3 per cent. By the same token in 1970 it is estimated that in St. Louis County the percentage will be 6.4 per cent. To make this problem more apparent, almost 55 per cent of metropolitan aged population resides in the City of St. Louis; whereas about 20 per cent lives in St. Louis County. A public assistance picture adds another dimension to the extent of the problem of chronic illness. In the year 1963, of the 102,409 old age assistance cases in the State of Missouri, 13.1 per cent were located in the City of St. Louis as compared to 2.7 per cent in St. Louis County. Of the total of the permanent and total disability group 29.1 per cent were in the City of St. Louis and 4.3 per cent in St. Louis County.

It is estimated that there are some 24,000 cases of heart disease in the City of St. Louis, 22,000 cases of hypertension, 7,725 cases of diabetes, 12,225 cases of visual difficulties, 29,250 cases of hearing defects and almost 10,000 cases of paralysis of one or more limbs due to either cerebral vascular disease or to other neurological deficits.

The City of St. Louis has been and is now doing something about the problem of chronic illness and coordinating care. However, because of the extent of the problem and the late start, the solutions are not easy. In 1955, the City submitted

for vote a $100,000,000 Bond issue in which the primary health item was $4,000,000 for a new Chronic Hospital. Prior to the inclusion of this item, the Mayor requested the Health and Welfare Council of Greater St. Louis (then known as the Social Planning Council) to appoint a committee of citizens, professional and lay, to evaluate the need for this Bond Issue item. This group of citizens found that the Greater St. Louis Community provided very little (private or public) for the chronically ill person other than acute in-patient medical services and long-term institutional care (primarily custodial). This committee, therefore, advised that the Chronic Hospital Bond Issue item should be included, but with a provision that the actual building be contingent upon the findings of a study of the "health needs" of the City of St. Louis. The Chronic Hospital Bond Issue item was approved by the voters and in 1956 the City contracted with the American Public Health Association to make the survey. Additional monies enabled the survey to be extended to the Greater St. Louis area. It was completed in 1957. Among its findings pertinent to the problem of the chronically ill were these:

1. The financing of the medical care for the indigent and medically indigent is a serious problem in the St. Louis area. In Missouri, the County (the City of St. Louis is not in a county and, therefore, must assume all of the usual county functions) has been deemed responsible for medical care, other than mental illness and tuberculosis.

2. Voluntary hospitals in the St. Louis area are primarily concerned with the short term acute case; where they are adding beds for chronic disease, the purpose is to provide rehabilitation for relatively short periods of time.

3. The City of St. Louis needs a separate department of Public Health and hospitals to discharge the City's responsibility for health of the public by planning and operating a single unified program of service that range from prevention through treatment and rehabilitation.

4. A new chronic hospital is not necessary, if the City of St. Louis develops a comprehensive integrated program of medical care for the aged. Emphasis should be placed on improving patient care through an increase in prepared personnel and in services and programs to make health services more readily available-other than in-patient hospital care. This should include home care, rehabilitation and improved services in the out-patient departments.

5. Home Care programs are relatively new in the City of St. Louis. There is one comprehensive program which is operated by the Jewish Hospital of St. Louis. A home care program should be established by the municipal hospitals; the voluntary hospitals, particularly the larger ones closely associated with medical schools, should explore the feasibility of developing home care programs.

Since the survey these actions have been taken by the City of St. Louis

1958: The voters approved the creation of a single department of health and hospitals to be directed by a physician well qualified in public health and hospital administration and to be responsible to the Mayor. The director was appointed in January, 1959.

A long-term illness medical service (known as intermediate care) was established at Koch Hospital for the group of municipal hospitals with 3600 bed complement (two general, Max Starkloff and Homer G. Phillips Hospitals; one psychiatric, Malcolm Bliss Mental Center; one tuberculosis, Robert Koch Hospital; and one long-term chronic institution, (mostly custodial) St. Louis Chronic Hospital. This intermediate care service started as a 40 bed service and is now a 200 bed service with a waiting list. Medical nursing, social work, physical and occupational therapy were coordinated to provide comprehensive medical care. It includes intensive rehabilitation. The service has attained a significant level of effectiveness; approximately 70% of all live discharges return to their own homes directly or via home care, since the latter was established in 1960. 1960 (May): An Information and Referral Center for the chronically ill was established by the Department of Health and Hospitals. It had existed earlier, from 1955-1958, as an activity of the St. Louis Chronic Hospital, which discontinued it in favor of a more traditional hospital admission procedure. Of the original Information and Referral Center the American Public Health Association Survey noted: "The experience of the Information and Referral Center not only justifies its continued operation, but its expansion into a Citywide adult counseling service for the chronically ill and aged." It was re

established on just this basis, a City-wide service. This action was necessitated because Chronic Hospital had filled almost all of its 1500 beds-despite the fact that a new domiciliary of 100 bed established at Koch Hospital a short time previously was completely filled. In the original operation there were less than 500 requests a year from chronically ill persons; in the first year of its reactivation there have been more than 800 requests. This increase is considered an index of the rise in incidence of illness requiring long term care.

Long term patients are "persons suffering from chronic disease or impairments who require a prolonged period of care, that is, who are likely to need or who have received care for a continuous period of at least 30 days in a general hospital, or care for a continuous period of more than 3 months in another institution or at home, such care to include medical supervision and/or assistance in achieving a higher level of self-care and independence."

1960 (September). A coordinated, medically directed, hospital-based Home Care Program was established by the Department of Health and Hospitals. By now there existed in the Department of Health and Hospitals these levels of care; acute in-patient, out-patient, intermediate care, long term institutional care, home care, and Information and Referral. Coordination was required to insure that the comprehensive needs of the long term patient were known and that he received the needed level of care; to this end, the Director of Health and Hospitals appointed a Long Term Illness Committee consisting of the Chiefs of Home Care, Intermediate Care, Physical Medicine and Rehabilitation, Psychiatric, Social Work and the Medical Director of the Chronic Hospital. This group, responsible to the Commissioner of Hospitals, delegated to its Chairman (Director of Home Care) the day-to-day decisions regarding the needs of long term patients and reserves for its weekly meetings those patient situations that are difficult and/or require administrative changes, and otherwise sets guidelines.

It should be noted that 63 per cent of all applications made to the Long Term Illness Committee came from either home, nursing homes, or from hospitals other than the public ones. From that group and the total group that was referred for long term illness care, approximately one-third have been feasible medically for Home Care. However, of the one-third that were thought medically suitable for Home Care, it should be noted approximately 20 per cent of those were accepted for Home Care and the remainder were not accepted. Of those not accepted a high percentage could have been accepted on a Home Care program providing they had a substitute home, a housekeeper, or meals on wheels.

As was stated previously, as a rule care in the acute hospital is merely the first stage in the program necessary for rehabilitation or for planning for long term care, either because of medical or social needs or both. Because of these long-range developments, the Director of Health and Hospitals, ordered the creation of the Long Term Illness Committee and the Home Care Department in 1960. The purpose of these two groups was to complement and coordinate the existing services of the two acute city hospitals, the intermediate, long term or rehabilitative divisions at Koch Hospital, Chronic Hospital and the Rehabilitative Division. The Information and Referral Center was created to provide accessibility to long term care planning for those citizens not under medical care within the municipal system.

Experience has demonstrated that planning for the future needs to be initiated as soon as the patient comes under care of a physician. Often this will be at the acute in-patient level; occasionally, it may be at the out-patient or emergency room levels. It should be realized that adequate planning cannot be started until the medical needs of the patient are known. The attending physician assumes the responsibility of identification of a patient's needs for long term planning and referral to the Long Term Illness Committee which provides direction and focuses on the planning needs. Over the seven years that this program has been in action, the sole purpose of the Long Term Illness Committee has been to coordinate planning, to determine the best level of care for the patient aimed at restoration to his community when possible. We have been able to significantly reduce the number of patients requiring long term institutional care and to increase the numbers of patients who can safely return to the community. A secondary result of this program has been the movement of patients from the hospital more rapidly and results in better teaching facilities for the hospitals and for the trainees in medicine.

While this program has worked in a public system, a few voluntary institutions have attempted to intiate similar systems. Increasingly the voluntary