psychiatric evaluation or treatment. Referrals are usually made of the occasional member, whose symptoms indicate interference with his continued functioning in the community. While we have Morrisania and Bronx Lebanon Hospitals which offer mental hygiene clinics, it takes a long time for a referral to be processed by them because of their waiting lists. This community needs more mental health resources where referrals can be made simply and where they will be processed quickly. We also need resources that would be adequately staffed so that they could forward the psychiatric evaluation of a member's condition to the agencies like this Center. Such a procedure would be of considerable help in enabling staff to work more effectively with these members. It is also conceivable that with proper mental health care, the extent of emotional disturbance can be checked and the individual can remain in the community until his death. Senator SMATHERS. All right. Our next witness is Mr. Leon Fraiter.

STATEMENT OF MR. FRAITER

Mr. FRAITER. Ladies and gentlemen, thank you very much for inviting me here. I am a man of 75. I have a cardiac condition. Some years ago I joined the Redshield Day Center and became very active among the senior citizens. I teach, I take an active part in the dining room. I do almost anything around the center. I am still a patient at the hospital getting treatment for my heart and high blood pressure. I have no trouble with medicine. I get a low number, I go and get my medicine and when that is exhausted I get another refill. I find myself getting along nicely and I am very grateful that I am strong enough to help others who are less fortunate than I am at the center.

Thank you. [Applause.]

Senator SMATHERS. Thank you.

From the Citizens Committee on Aging of the Community Council of Greater New York we are now going to have Mrs. Susan Kinoy, project director, Promoting Home Health and Social Services to New York's Aging.

Mrs. Kinoy.

STATEMENT OF MRS. KINOY

Mrs. KINOY. Thank you very much, Senator Smathers. It gives me great pleasure to be here today to testify, especially because this project that I am privileged to direct is funded under the Older Americans Act which you and your committee had a great deal to do with. We commend your committee for the work that was done in funding so many of these projects. I think there are over 20 in New York State right now. I hope they are continued and expanded.

There are now about 1 million people 65 and over in New York City. Ninety-six percent of this group live in their own homes and outside of institutions. Most elderly people wish to remain living independently in their own communities.

The vast majority of the aging live alone or with a spouse. The average base of their incomes is under $110 a month social security. This is supported by private benefits, savings, contributions by children, and welfare benefits.

For the most part, the elderly are scattered throughout the five boroughs of New York City, often living in walkup apartments, remaining in deteriorating or changing communities because they cannot afford to live in rent-controlled apartments. Although the ma

jority of the elderly live below the "poverty line" they frequently do not cluster in "poverty areas" in which community progress centers and the community corporations have been established and in which plans for neighborhood health centers are underway. So when we plan health services for the elderly we have to think in terms of citywide services, not merely services in special areas.

The elderly receive fragmented medical care. They may attend a union health center for an annual medical checkup; they may travel to an arthritis clinic, a cardiac clinic, or a diabetes clinic on different days in one or more hospitals, and may, in addition, visit one or more neighborhood doctors when they feel too ill to travel to clinics or feel they cannot wait long periods in the emergency rooms. Different medications and courses of treatment are prescribed by individual doctors.

Medicare has provided welcome changes in patterns of payment for medical care. It has provided much-needed emergency care and medical insurance for catastrophic illnesses and serious operationscare that previously might have bankrupted an elderly person or his family. But serious problems exist in the workings of medicare. Some problems are to be expected as new legislation begins. But it is now apparent that there are weaknesses and gaps in the legislation and in way it is being utilized that must be remedied.

the

Many of these have been mentioned today and I am not going to go through them in detail. I would like to summarize along with the many people who testified today, who feel as we do.

The deductibles must be removed; they impose an extreme hardship on aging persons with fixed incomes."

We recommend the standardization of rates acceptable to physicians that will be made available to elderly patients prior to the provision of services. We just get too many complaints from a person being charged $500 for an operation thinking this is the fair and equitable fee and thinking that he will get back 80 percent of this and he finds that he is going to get back 80 percent of $300 and has to pay the remainder.

A patient should have the option to request the assignment of fees by private physicians.

There must be additional coverage under medicare for hearing aids, prostheses, eyeglasses, dental needs and drugs.

We are alarmed by the probable increase in monthly medical premiums for persons with fixed incomes. Increases, if ordered should be accompanied by corresponding increases in program benefits. We think that larger amounts of savings should be permitted under medicaid.

The gap between a person who cannot manage the payments under medicare and yet has too large a lump sum of savings to benefit under medicaid is too large. The financial gaps must be closed between these programs.

TO PROLONG INDEPENDENT LIVING

In the few minutes allotted to me, however, I would like to emphasize the great need for services in New York City that can improve and prolong the independent living of older persons in their

own homes, services that can prevent, shorten or postpone institutionalization. With properly organized and adequate home health services some elderly can, at a lower cost to the community, avoid extensive prolonged hospital stays or premature extensive and traumatic institutionalization in nursing homes or homes for the aged.

I quote from a letter from a hospital which is quite typical of many we receive. "Over 1,000 extra days of hospital care were necessary during the period of 8 months because of lack of facilities in the community to provide nursing homes, chronic care and home health for patients 65 or over in this institution. It was possible in some instances to send patients home with homemakers and various types of home help.

In one instance, which is typical of many, a patient was sent home having waited 26 days for admission into a nursing home. There was a problem in obtaining the needed services and special funds had to be used to meet the cost until a voluntary homemaker agency could meet the need. If home help had been more readily available, the patient could have been sent home earlier. It is of interest to note that many patients do so well at home when there is help, often to an unanticipated degree that applications for nursing home care have often been canceled.

One of the services in shortest supply to the elderly in their own homes is that of homemakers, home health aides and housekeepers, all subprofessionals, who, under the supervision of doctors, nurses, and social workers can provide personal care and homemaking assistance to the elderly. These services, mainly part time, are in great demand by the aging. They are less expensive to provide than institutional

care.

Today in New York City there are about 900 homemakers or home health aides, less than half of whom are used to meet the needs of the aging in the five boroughs of New York City. Only 4 to 6 percent of the elderly in New York receive assistance from the department of social services and one-half of these homemakers are employed by that department. Therefore, there are even fewer of these subprofessionals available to the majority of the elderly. It is our estimate that a minimum of 4,000 homemakers or home health aides are needed to begin to meet the needs of the elderly in New York City today.

We appreciate that provision has been made for home health services under both titles 18 and 19. These services have been expanded in New York since the inception of medicare and medicaid legislation but the services have not as yet begun to meet the need of the 1 million elderly in New York City today.

About 35 hospitals and four visiting nurse services are certified as home health agencies under titles 18 and 19. Only four of these agencies, however, the three voluntary nursing agencies and the Dominican Sisters of the Sick Poor, now provide home health aides under this program. These four agencies have done an excellent job of recruiting, training, and supervising these aides, but the approximately 150 that are now in this program can't begin to meet the need that we see, and you heard this need explained by the people you visited at lunch today.

In order to expand needed services in the home it is necessary to plan very boldly and creatively and to use all existing resources. I would like to report on some of our recommendations very briefly. We hope that the three visiting nurse services will continue to expand their very excellent services. We hope in addition they will subcontract with the existing homemaker services of the voluntary homemaker agencies so that more persons can be trained by the homemaker agencies and thereafter be part of the personnel available through the visiting nurse services.

We propose that the nonmedical voluntary agencies in addition to subcontracting creatively expand their services.

Third, we propose that the Bureau of Public Health Nursing of the Department of Health become a certified home health agency provid ing bedside nursing service when necessary and public health nursing responsibility for the supervision of home health aides. This would make possible contracting with the Department of Social Services, division of homemaker services or the voluntary homemaker agencies, of employing their own subprofessionals, thus providing additional homemaker/home health aides.

Fourth, we recommend that the Department of Social Services work, as we said, with the Department of Health and that, in addition we recommend the expansion of their entire program of homemaker services. They are now in the process of almost doubling their homemaker staff. Fifth, we recommend that some hospitals with careful community and administrative planning, employ their own staff of home health aides and provide for the necessary bedside nursing and public health nursing supervision of these aides.

Sixth, we recommend that community health centers which are hospital based, with careful community planning, expand their existing staffs of public health nurses and employ home health aides.

Finally, in New York State, unlike the rest of the country, home health aides must be supervised wherever possible by public health nurses. Because there is such a tremendous shortage of public health nurses we suggest that crash programs be organized for the recruitment and training of such personnel. We hope that you will take leadership in planning for such an expansion of training of nurses.

We call for an additional number of reimbursable home visits under the medicare legislation.

Finally, we suggest that experimentation in order to provide greater expansion of home care be encouraged under the Hill-Staggers legislation.

In conclusion, I would like to repeat that medicare and medicaid have answered some of the most acute medical problems of the elderly. We wish to call attention to some of the legislative shortcomings and gans in services that still must be filled.

Finally, we would like to emphasize the need for the rapid expansion of home health services so that more of this Nation's elderly can remain in their homes, thus freeing needed hospital and institution beds.

Thank you.

(The prepared statement by Susan Kinoy follows:)

STATEMENT OF THE COMMUNITY COUNCIL OF GREATER NEW YORK, PRESENTED BY MRS. SUSAN K. KINOY, PROJECT DIRECTOR, PROMOTING HOME HEALTH AND SOCIAL SERVICES TO NEW YORK CITY'S AGING

My name is Mrs. Susan K. Kinoy, Project Director of a program at the Community Council of Greater New York entitled, "Promoting Home Health and Social Services to New York City's Aging."

This is a three-year Project, funded under Title III of the Older Americans' Act through the New York State Office for the Aging. Its goal is to promote increased home-health services and housing for the elderly in New York City. (A Summary of our Project is attached).1

There are now one million people age 65 and over in New York City today. Ninety-six percent of this group live in their own homes and outside of institutions. Most elderly people wish to remain living independently in their own communities.

The vast majority of the aging live along or with a spouse.

The average base of their incomes is under $110 a month social security. This is supported by private benefits, savings, contributions by children and welfare benefits.

"Last year, in the United States, there were close to 7 million families with heads aged 65+. About 41% or 2 out of every 5 of these older families had incomes of less than $3,000; half of them with less than $2,000.

More than a quarter of a million older families had incomes of less than $20 a week or $1,000 for the year; a half million families had incomes between $1,000 and $1,500; and three-quarter million families had between $1,500 and $2,000. At the other end of the scale, 10% or about 700,000 older families had incomes of at least $10,000 and some 75,000 of them had $25,000 or more.

A quarter of the almost 5 million older people living alone or with nonrelatives had incomes of less than $20 a week ($1,000 a year) and well over another quarter had between $20 and $25 per week ($1,000 to $1,500 a year)".3

For the most part, the elderly are scattered throughout the five boroughs of New York City, often living in walk-up apartments, remaining in deteriorating or changing communities because they cannot afford to live in rent controlled apartments. Although the majority of the elderly live below the "poverty line" they frequently do not cluster in "poverty areas" in which community progress centers and the community corporations have been established and in which plans for neighborhood health centers are under way.

The elderly receive fragmented medical care. They may attend a union health center for an annual medical checkup; they may travel to an arthritis clinic, a cardiac clinic or a diabetes clinic on different days in one or more hospitals, and may, in addition, visit one or more neighborhood doctors when they feel too ill to travel to clinics or to wait in emergency rooms. Different medications and courses of treatment are prescribed by individual doctors.

Medicare has provided welcome changes in patterns of payment for medical care. It has provided much needed emergency care and medical insurance for catastrophic illnesses and serious operations care that previously might have bankrupted an elderly person or his family. But serious problems exist in the workings of Medicare. Some problems are to be expected as new legislation begins. But it is now apparent that there are weaknesses and gaps in the legislation and in the way it is being utilized that must be remedied.

MEDICAL COSTS

Many older people with ongoing chronic illnesses are paying more for medical care now than they did prior to Title XVIII. Some of the people are receiving less medical care for money spent. They are paying the $40 deductible under Part A, the $50 deductible under Part B, and the $36 per year premiums totalling $126 plus the 20% coinsurance. Medical fees have increased steadily since the start of the program. The elderly complain that they are often not told in advance the doctor's "fair and reasonable" rate for a medical service. They may be billed $400 for an operation expecting to pay only 20% of this fee and find instead that the "fair and reasonable" fee was $300 and that they were responsible for paying

1 See app. p. 531.

A Profile of the Older American, by Herman B. Brotman. Paper presented October 16, 1967.