of licensing agencies; in California, for example, some homes now are licensed by the Department of Social Welfare, some by the Department of Mental Hygiene. and some by the Department of Public Health. Unification and clarification of licensing procedures are required. The most pressing need is for social workers to deal with families and for rehabilitation workers to inaugurate and carry out activity programs in the various types of home.

As to the need for psychiatric outpatient services for the aged, the National Institute for Mental Health has been collecting and publishing data on the numbers and characteristics of patients receiving services in outpatient psychiatric clinics since 1954. The clinic population has been weighted heavily with children under eighteen and adults in the 18-44 year age groups, with relatively small proportions in the age groups 45-64 and 65+. Persons aged sixty-five and over constituted only 2 per cent of the total admissions to outpatient clinics in 1965. In contrast, persons in this age group constituted 29 per cent of all first admissions to public mental hospitals for the same year.3

Although psychiatric clinics claim not to discriminate against particular groups, there does seem to be a de facto discrimination against geriatric patients. A survey of admissions to the Outpatient Department of the Langley Porter Neuropsychiatric Institute for the year July, 1963, through June, 1964, showed that slightly less than 2 percent of these admissions were of persons over the age of sixty. Subsequent conversations with professionals involved in the private and public sectors of social services, with psychiatrists in private practice, and with non-psychiatric physicians in private practice suggested, however, that there was a large need for outpatient services for people in the older age groups. Our feeling was that if the public could be informed of a special clinic that had a particular interest in the psychologic disorders of the aged, there would be substantial utilization of the clinic's services. Such a program might also provide social agencies with consultative services regarding difficult client problems and a psychiatrist who could make house calls on clients who, for physical or psychologic reasons, could not go outside their homes for help.

TRAINING FOR CARE OF ELDERLY MENTALLY ILL

The need for training programs and the upgrading of salaries and experience is especially obvious in relation to nursing personnel-nurses and nursing aideswho care for the elderly. There is a rapid turnover of nursing personnel, largely because of poor pay, and a continuing scarcity of adequately trained and experienced aides. Training courses might well be made part of licensing requirements. Operators of boarding and family care homes greatly need training courses, and psychiatric consultative services should be made available to them and their use encouraged. The psychiatric profession must become increasingly involved; at present, psychiatrists are not adequately trained and experienced in working with the elderly mentally ill, and they are not called upon often enough by those who operate and staff these facilities.

Not only are the geriatric mentally ill being placed initially in other facilities than state mental hospitals, but patients already in these hospitals-some for many years are being transferred out in increasing numbers. Most of these are placed in nursing home or family care settings, although some are able to return to the community. Careful evaluation and screening for appropriate placement are essential, as are continuing social work and medical and psychiatric supervision, if such transfer programs are to be successful.

GERIATRIC OUTPATIENT PROGRAM

In the summer of 1967, with support from a grant by the State Administration on Aging, The Langley Porter Neuropsychiatric Institute Outpatient De partment began a Geriatric Outpatient Program. A press release was sent to the San Francisco daily newspapers, and one of the papers printed an extensive interview with the coordinator of the program. In addition, there was a radio interview on a popular noontime program. Representatives of many agencies dealing with the elderly population were invited to meet with the staff of the project to discuss its work and the kinds of involvement the agencies would like to encourage. As a result of these conferences, a psychiatrist was added to the staff to work as a consultant with the social agencies and to see patients for them, either individually or in groups, and also to conduct evaluations and treatment of homebound patients referred by the agencies.

3 Kramer, et al., ibid.

Within four days after the initial publicity in the newspapers, the project received 60 telephone calls. These were taken by the project social worker, who evaluated the urgency of the need and tried to have the most pressing cases seen first. Other requests were placed on a waiting list, and these applicants received letters from the Project Coordinator saying they would be called as soon as time became available. Patients who were accepted were evaluated by a trainee (who might be a psychiatric resident, social work student, medical student, or post-master nursing student) and then were discussed at an interdisciplinary staff meeting. The patient then was assigned for appropriate psychothrapy and received medication and other somatic therapy when indicated. The Inpatient Services of the Institute were available for those patients needing hospitalization. During the first ten months of operation, the admissions of persons aged sixty and over to the Outpatient Department rose from slightly less than 2 per cent to 13.5 per cent of all patients admitted. Sixty-six geriatric patients were admitted for outpatient psychotherapy following evaluation of 162 requests. Half of the patients seen came for five or more visits. Seven required hospitalization at the time of the first interview. Most of the patients seen were diagnosed as having depressive reactions.

Our experience shows that when a psychiatric clinic expresses interest in their problems, older people will avail themselves of outpatient services to a degree more closely approximating their representation in the general population than is generally the case. Age does not preclude a meaningful psychotherapeutic intervention.

A valuable side-result was obtained with respect to the attitude of trainees involved in the program. Although most trainees came onto the Geriatric Outpatient Program team with the usual negative bias against the treatment of older patients, during the course of their experience they generally changed their attitude and became, if not positively oriented toward the treatment of these patients, at least less professionally nihilistic.

In San Francisco prior to 1963, approximately two-thirds of the patients over age sixty who were admitted to the San Francisco General Hospital psychiatric observation wards each year subsequently were committed to state mental hospitals. A geriatric screening unit established by the California Department of Mental Hygiene in association with the hospital in 1963 has made a remarkably successful effort to locate and utilize alternate placement facilities in the community for these elderly patients for whom commitment would otherwise be sought. A summary of the activities of this program, written by Miss Mary Lou Clark, Director of the Geriatric Screening Unit, is attached.*

In summary, the need for health services for the elderly is great, and the problems of this group are such that only a truly comprehensive health program can meet its needs. All levels of psychiatric care certainly need upgrading, from the long-term care of patients who grow old in the hospital to brief outpatient services. Coordination of the efforts of all resources and personnel is essential if adequate services are to be made easily accessible to the large group of elderly persons who are in many cases in really desperate need of help. Sincerely,

ALEXANDER SIMON, M.D.

ITEM 11: LETTER FROM DONALD L. SPENCE, PH. D., STAFF SOCIOLOGIST, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO MEDICAL CENTER

November 27, 1968.

DEAR SENATOR SMATHERS: I am extremely sorry for the delay in responding to your inquiry of September 27. Dr. Feigenbaum and I have discussed your letter at some length, however, and feel that we do have some recommendations concerning the problem of medical student attitudes toward the geriatric patient. Dr. Freigenbaum directs an outpatient program in geriatric psychiatry. His experience indicates that when students or trainees are exposed to this program their original negative attitudes are generally changed to a more positive stance with regard to the treatability of older people. This suggests two factors in the shaping of attitudes toward older patients. First, that some exposure to older patients is essential in any training program where the intent is to influence attitudes. But, probably more important in terms of the nature of the attitudes formed is the type of exposure. For a student to see an older patient properly *Retained in committee files.

diagnosed and placed in a treatment program designed for his care is a far cry from what most of them see when in their training they are exposed to the “old peoples ward" in some public general hospital or to a hospital for chronic illness. What this means is that early in their medical education, students should be instructed in the problems of gerontology in all its medical aspects. Later in their training when they are exposed to a variety of elderly patient situations, they will have the conceptual framework to understand how these situations fit into a broader picture. To accomplish this will require the training of persons to carry out this instruction. It will also be necessary to convince medical schools that this type of instruction is worthy of a significant place in an already overburdened curriculum. Ideally, this instruction should be taught in conjunction with existing courses in appropriate medical specialties. This, would require the re-orientation of the same individuals and professionals who are currently perpetuating the negative stereotypes. The problem, therefore, becomes one of the best strategy to produce the desired change in an ongoing, self-perpetuating situation.

Some change is already occurring. For example, there is a subcommittee of the Gerontological Society on training of medical students with respect to geriatrics. This subcommittee is currently headed, I believe, by Dr. Alfred H. Lawton of St. Petersburg, Florida. Also, the Western Interstate Commission for Higher Education had geriatric psychiatry as the content for one of its recent training sessions for psychiatrist teachers of practicing physicians. Another such program is now in the formative stages and is due to start in May or June of this year. The Committee on Aging and the American Psychiatric Association has made recommendations concerning the teaching of geriatric psychiatry for both medical students and residents in training. And, the very fact that your subcommittee exists and is concerned with the problem suggests the direction of change. Maintaining the impetus for change should be a primary objective.

Publicity, money, and programs are what is needed. Publicity in the right places is difficult to develop. For example, our article as published was rejected as inappropriate for the Journal of Medical Education. As for funding, you are undoubtedly aware that appropriations for training and research were cut this past year. And, in terms of operational programs, it is important to implement those which are the most appropriate to meet current needs. Your committee, is in a position to influence all three of these strategies.

Enclosed you will find a copy of our article as well as a background paper on the problem.' If we can be of service in any way please let us know. Respectfully,

D. L. SPENCE, Ph. D..

Staff Sociologist.

ITEM 12: LETTER FROM DR. HAROLD RICHTER STARK,

LITTLEROCK, CALIFORNIA

NOVEMBER 22, 1968.

DEAR SENATOR WILLIAMS: I was happy to see an article by you in the November Geriatric Times regarding your work and interest in geriatrics. As you may note from my letterhead (F.A.G.S.) I am a specialist in geriatrics. Over a period of 20 years, I have attended many people in the old age bracket both in private practice and in various convalescent hospitals in southern California.

I recently had a heart attack and am recuperating at the present time in one such hospital, so I have had an opportunity now to observe as a practicing physician and as a patient some of the great problems of geriatric care in such hospitals. Inasmuch as the Government is paying for much of this care in such institutions, I wonder if you would mind if I made a few comments which I hope may help you in the governmental phase of this work.

When a patient is placed in such an institution, it appears he is placed there for one of two reasons, or possibly both: that he has a health problem which may be minor or major and such placement is for the convenience of the doctor. Or it may be because the family feels unable to care for the patient and wishes to be unloaded of the burden.

It is obvious to me, and to you as well I am sure, that most of these convalescent hospitals are run by private individuals with the idea of profit in mind. Consequently, there are certain prerequisites for the management and for the patient.

1 Retained in committee files.

It appears to me that the patient being placed in such an institution, if he is ill, should have the best of medical care, nursing care, food and general supervision. I am convinced that in the present status of medicare that this is not always the case. Most doctors, in the first place, are allowed only one monthly visit per patient and are not particularly interested in geriatrics professionally. Such institutions become a dumping ground for those who are terminally ill, or a place where they can be cared for outside of the family.

The medical care, from the standpoint of the physician, is only partially successful. Communication with the doctor is difficult. Illnesses or medical emergencies are left to the discretion of the nursing staff or telephone conversations. I have personally noted that most of these difficulties may occur at night and the doctors are not available for consultation.

This places a responsibility on the judgment of the nursing staff. Most of this staff consists of licensed vocational nurses and medical aides-with the emphasis on the medical aides whose pay schedule is the minimum. Thus, only certain types of individuals can be procured to do this work and the nursing staff in general has no special preparation in the field of geriatrics. They know very little about the psychology and actual care of the older person, who is becoming greater in numbers each year.

It is my belief that these nurses and aides should be specially trained in courses in geriatrics and geriatric medicine. It is my personal belief, after observing the medical emergencies in such an institution which can occur in great numbers in one evening, that every convalescent hospital or nursing home of any size whatsoever should have a resident physician whose duties are to make medical rounds every morning and evening and to take care of any emergencies that arise during the night. It is my belief that such patients referred to a convalescent hospital by individual doctors should be placed under the care of such a resident physician so that the referring doctor no longer has any responsibility.

I feel that, if this is done, a higher quality of medical care can be established by each institution and that the Government of the United States will receive more for its money than at the present time under the present circumstances. Also, a program for our older people could be developed to which America could point with pride.

This resident physician could train the geriatric staff, supervise the diet, make judgment regarding the further disposition of the case at hand, possibly provide for occupational therapy and the necessary psychological counseling for these older people.

The problem that presents itself, however, is that most of these nursing homes are built by private organizations with profit in mind and it would probably be impossible for them to afford the services of such a resident physician.

It may be that there should be a Government subsidy and some sort of financial arrangement made with the Government of the United States to finance this. You will note in the enclosed article* a survey made of the University of California Medical Center at San Francisco showing what the attitude of the young physician is in the field of geriatrics. I feel that very few physicians are interested sufficiently in the older patient, or that they do not have the proper time to devote to them, which constitutes an extremely grave problem, in my mind. Thank you for your interest in the geriatric patient and in geriatrics. I hope that you will continue this great interest and perhaps solve this problem somehow; possibly, with a Government subsidy of hospitals or whatever is necessary to guarantee these older people the best of everything in the remaining years of their life.

Very sincerely,

H. R. STARK, M.D.

ITEM 13: STATEMENT OF BOYD THOMPSON, EXECUTIVE DIRECTOR, SAN JOAQUIN COUNTY MEDICAL SOCIETY, STOCKTON, CALIF. The San Joaquin Foundation for Medical Care is an incorporated body under sponsorship of the San Joaquin County Medical Society. The specific and primary purposes for which this corporation is formed are to promote, develop, and encourage the distribution of medical services by its members to the people of San Joaquin and adjacent counties at a cost reasonable to both patient and physician; to preserve unto its members, the medical profession at large, and public, free

*Retained in committee files.

dom of choice of both physician and patient; to guard and preserve the physicianpatient relationship and its innumerable benefits; to protect the public health; to work and study in cooperation with the insurance industry and service plans that provide for periodic and realistic budgeting for medical care and to work with all segments of the community to develop best possible ways of financing and providing medical care.

The San Joaquin Foundation was established in 1954 and is now responsible directly or through insurance companies for insurance for half the population of the 5 counties it serves. The Foundation concept has spread to include 31 counties in California and is established in some counties of 7 other states.

The majority of the physicians of the San Joaquin Foundation for Medical Care take pride in the fact that their Medical Society is sponsoring through its economic arm, programs that give to their patients comprehensive medical care with predictable costs at premiums that are under controlled devices. They are particularly pleased by the fact that, due to the administrative relationships between the Foundation for Medical Care and the insurance companies, governmental agencies and others that purchase Foundation programs, it has been possible to improve the coverage for medical services, and allow for comprehensive coverage of all needed medical care services. By this we mean the inclusion of such important items as care of infants from birth to assure protection against the catastrophe of birth anomalies; the coverage of patients who are critically ill and need physician attendance over many hours; consultive services for all types of problems; the ease in which new modalities, such as the intensive care unit and cardiac unit, can be covered under our programs.

A few of the physicians are unhappy about our program in that they chafe under the strict quality control and fee control mechanisms. These physicians, for the most part, are in the minority and probably will be with us for a long period of time.

This technique has spread to other areas and in the areas to which it has spread, the physicians have welcomed it because it gave them a device with which they could compete with other administrative modalities whose aim was the destruction of the traditional physician-patient relationship. In areas of less sophistication where the insurance mechanism has not been developed to any great amount, this technique would be completely impalpable. It is necessary for conflict for this technique to develop because it takes conflict to bring awareness as to the problems and possible solutions to the problems by the medical profession.

Preventive measures are encouraged under the Foundation programs, and early diagnosis is more easily arrived at because of the increased freedom of using x-ray and laboratory devices on an out-patient basis. The financial barrier of seeking care is removed in that the patient is aware of the cost factors involved prior to seeking his medical care and most, if not all, is covered by his prepaid program. Other ingredients in the improvement of preventive measures is seen in the fact that as physicians become involved in delivery systems of medical care they also become involved with areas of need and take steps to correct this need.

SAVINGS IN PUBLIC FUNDS

Does it result in savings of public funds? The answer to this question is an unqualified "yes". This can be proven through the work done in the San Joaquin Foundation as well as by the Foundation for Medical Care in Kern and Fresno counties in California. In the brief time that these three counties have been involved in experiments relating to Title XVIII and Title XIX of Public Law 89-97, considerable savings have been documented without a decrease in the quality of care and, as a matter of fact, with the increase in the quality.

The utilization control and medical audit features of the program are acceptable to most of the physicians who participate in the program for the simple reason that they know, in general, medical audit is being carried out which does not affect them personally. The 10% of physicians whose claims are chronically in medical audit, obviously, are unhappy about the program and their unhappiness perhaps attests to the thoroughness of the audit.

We have been asked if we have encountered any federal or state statutes, regulations, or administrative policies which unnecessarily impede or inconvenience our organization in rendering medical services. To some degree the answer would have to be yes. State statutes are restrictive in developing methods of payment that vary from participating and nonparticipating physicians. They also are restrictive in that any program that is carried out under our strict medical audit in San Joaquin County must also be payable in areas where the audit