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Program and financing

[In thousands of dollars)

Program by activities:
1. Construction and equipment, continued treatment building

(rehabilitation center)
2. Miscellaneous improvements of existing facilities:

(a) Air conditioning Nichols building
(b) Air conditioning geriatrics building -

(c) Other
3. Construction and equipment, treatment and cafeteria build-

ing
4. Extention and modernization of administration building --
5. Construction and equipment, security facility.

Total program costs.
Change in selected resources !
10 Total obligations.

Financing:
21 Unobligated balance available, start of year.
24 Unobligated balance available, end of year..
40 New obligational authority (appropriation).

Relation of obligations to expenditures:
71 Total obligations (affecting expenditures)
72 Obligated balance, start of year
74 Obligated balance, end of year
90 Expenditures-

! Selected resources as of June 30 are as follows: Unpaid undelivered orders, 1964, $532,000; 1966, $1,056,000; 1968, $988,000; 1967, $592,000,

Mr. FOGARTY. The committee will come to order. We have before us the request for St. Elizabeths Hospital. Dr. Cameron, are you ready with a statement ?

Dr. CAMERON. Yes, sir; I am.
Mr. FOGARTY. Go right ahead.

a

GENERAL STATEMENT

Dr. CAMERON. Mr. Chairman and members of the committee, I welcome this opportunity to meet with you to present the program objectives and appropriation requests of St. Elizabeths Hospital for fiscal year 1967.

St. Elizabeths Hospital, the largest federally operated hospital for the mentally ill, fulfills its statutory mission by means of three major programs: treatment, training and education, and research. The hospital seeks, with all means available, to provide therapeutic, protective, and rehabilitative programs utilizing professional, scientific, and other resources from many fields. A spirit of freedom in developing new and original approaches to the treatment and rehabilitation of patients is encouraged, while maintaining a respect for the values of accepted techniques. Independence of thought and an intelligent display of initiative are encouraged. Through training and research, advantageously pursued at the site of treatment, the hospital seeks to advance psychiatric knowledge and improve treatment methods.

Fiscal year 1965 marked the end of a decade which has seen dramatic changes in the treatment of the mentally ill at St. Elizabethis. There have been sharp reductions in average periods of hospitalization and decreases in the number of resident patients despite increasing numbers of patients admitted. The hospital employs several relatively new approaches in pursuit of its objective of providing the best in treatment and care. Although time does not permit the enumeration of all these approaches, I should like to cite a few of the more significant ones.

“SMALL HOSPITAL” CONCEPT First, there has been the gradual reorganization of St. Elizabeths into several small hospital units. This unit system involves decentralizing patient treatment organizational elements into smaller, more workable, semiautomonous hospital units in which patients are provided comprehensive treatment and care from admission to discharge. The continuity of treatment which results from this so-called "small hospital" concept evokes favorable responses from patients and enables the staff to make and carry out reasonably effective plans for patients' treatment. The psychiatric and nursing staff's are thus afforded a renewed challenge to remotivate longer term patients while carrying out treatment for the newly admitted patient. As part of the continuity of treatment program, all small hospital units have outpatient clinics which aid patients to adjust to community life when they leave the hospital on convalescent leave. Day center programs have also been established for patients who are able to move from the hospital but who still are in need of structured activity.

The process of decentralization to “small hospital" units has not yet been completed.

PHYSICAL AND PSYCHIATRIC REHABILITATION

Second, the hospital has placed increasing emphasis upon physical and psychiatric rehabilitation through the development and use of programs and activities designed to provide patients with the opportunity to live a life that is personally, socially, and economically productive. An example of an important part of the hospital's overall endeavor to prepare patients to live fuller lives both in the hospital and in the community has been an attack on the problem of deafness. Through improved equipment and staff realinement, deaf patients are receiving better diagnostic and therapeutic attention. Not only does hearing improvement increase a person's social acceptance and acceptability but may play a role in the specific treatment of some mental illness.

FOSTER CARE PROGRAM

Third, the hospital is now operating an increasingly successful foster care program under which patients are placed in supervised homes throughout the community and given an opportunity to take their first steps toward effective living outside a hospital setting. There were 268 such placements in 1965, a number double that of the preceding year.

Much more could be said, for example, concerning the rehabilitation of prisoner patients, our work in occupational and recreational therapy, pioneering efforts in the field of psychodrama, the establishment and operation of our youth center, and the invaluable contributions of hundreds of volunteer workers. All these activities have contributed substantially to the general improvement of treatment programs, the value of which is perhaps best attested to by the patient population statistics of the hospital.

PATIENT POPULATION DATA

During the past decade, the average daily resident patient load of St. Elizabeths Hospital was reduced approximately 14 percent. The rate of decrease in the latter part of the decade, however, was most pronounced, the load declining an average of 230 patients, or approximately 3.5 percent annually during the past 3 years. Most significantly, this reduction was achieved despite continued increases in the number of admissions, which rose from 1,692 in 1964 to 1,965 in the past fiscal year. During the last decade, the length of time patients remained in the hospital was substantially shortened. Of the patients admitted in 1955, only 36 percent were returned to the community by June 30 of that year; in 1965, the comparable figure was 57 percent, a most gratifying improvement. Approximately 50 percent of newly admitted patients are currently being returned to the community within 4 months and 80 percent within 12 months of their admission.

A significant recent development in the treatment of the mentally ill was the passage of the District of Columbia Hospitalization of the Mentally Ill Act (Public Law 88–597) which became effective in September 1964. Along with provisions for separating the issue of legal competency from that of commitment for treatment, the act has facilitated voluntary admissions and provides for admission of nonprotesting and emergency patients without a prior judicial order. This act

has had a substantial impact on admissions, particularly by increasing voluntary admissions. Despite this, the hospital expects to effect continued reductions in the average resident patient load from an actual level of 6,148 in 1965 to 5,936 in 1966 and 5,722 in 1967. This anticipated further decrease of over 400 patients reflects to a large extent (1) the probable continued effect of the intensification of treatment programs made possible by staffing and materiel improvements authorized by the Congress over the past several years, (2) organizational changes initiated in the past few years, and (3) the increasing efforts of the hospital to transfer to other facilities those patients who no longer require treatment in a mental hospital.

FINANCING

Budget estimates of St. Elizabeths Hospital are set forth under two appropriation headings. The “Salaries and expenses” appropriation provides funds for the general operation and maintenance of the hospital, including research and training activities. Operating funds for this account are obtained through annual direct appropriations covering most Federal beneficiaries and reimbursements for care rendered other patient groups, principally residents of the District of Columbia. Appropriations under this heading are of the indefinite type, under which the hospital receives in appropriated funds the difference between the amount of reimbursements received during the year and the total program costs for the year as approved by the Congress. The “Buildings and facilities appropriation account covers capital outlay for major alterations and improvements of existing facilities and for new construction. The account is financed by direct Federal appropriations. However, in accordance with Public Law 83-472, the District of Columbia bears a proportionate share of the cost of the program, such share being collected over a period of years following completion of projects and deposited to the credit of ihe miscellaneous receipts of the Treasury. With your permission, I would like briefly to summarize the 1967 requests for both appropriation accounts, starting with "Salaries and expenses."

SALARIES AND EXPENSES APPROPRIATION

We are requesting a total "Salaries and expenses" operating budget authorization of $30,683,000 for the coming year. This sum represents an increase of $70,000 over the amount anticipated in the current fiscal year. The direct appropriation required to cover the Federal share of the proposed 1967 budget, however, is estimated at $2,202,000 less than that expected in 1966, the additional operating funds coming from increased reimbursements for treatment and care rendered certain patient groups, principally residents of the District of Columbia. The proposed budget provides basically for continuation of existing programs and activities at current vear levels. The additional $70,000 requested for hospital operations is required to cover mandatory cost increases totaling $264,000, as partially offset by a downward adjustment in program costs amounting to $194,000, the latter figure a reflection principally of reductions in supply and equipment requirements attributable in large measure to the anticipated decrease in patient population. Mandatory cost increases covered by the re

60-627-66-pt. 2-67

quest are (1) annualization of Federal employee salary increases authorized under Public Law 89–301, (2) annualization of five new positions authorized in 1966, and (3) electricity costs related to the hospital's ongoing rewiring program.

The budget provides for continuation of employment in 1967 at the current fiscal year levels. When applied to the projected lower patient load, this will result in an upward adjustment in the employee/patient staffing ratio from 64 employees per 100 patients in 1966 to an estimated 66 per 100 in 1967. In summary then, the 1967 “Salaries and expenses” budget will enable the hospital to meet unavoidable cost increases related to its current operations and improve slightly the quality of patient treatment, the latter to be achieved by means of the better employee/patient ratio to be achieved entirely by a reduction in the patient load.

BUILDINGS AND FACILITIES APPROPRIATION

Funds requested for the buildings and facilities account in fiscal year 1967 will provide for the development of plans and specifications for a new security facility and for 10 projects involving improvements to existing facilities of the hospital. Total cost of the work proposed for 1967 is estimated at $2,138,000, an increase of $161,000 over the sum appropriated for construction and facility improvement activities in the current fiscal year.

SECURITY FACILITY

An amount of $25,000 was appropriated in 1966 for the development of a program statement leading to the construction of patient treatment facilities having appropriate security features. To avoid any unnecessary delay in completion of this urgently needed structure, the hospital requests in 1967, as the second phase of the project, the sum of $450,000 for preparation of plans and specifications for the new facility which will serve as a replacement for two antiquated treatment buildings built in 1879 and 1899, and provide adequate housing for prisoners and other patients requiring treatment and care under security conditions. The number of patients in St. Elizabeths requiring treatment of this type is well in excess of the 396 beds available in the John Howard Pavilion, the hospital's only maximum security building. As a consequence, there are a substantial number of “prisoners" as well as disturbed and potentially assaultive civil patients housed in areas which lack the security and other facilities necessary for the proper treatment of patients of this type. Authorization of the sum requested in 1967 will enable the hospital to move forward without delay with the planning of a facility which will provide greater safety for its patients and the public, replace obsolete treatment buildings, and provide the best in curative treatment for an area of mental illness that constitutes a major social problem of the time.

MISCELLANEOUS IMPROVEMENTS OF EXISTING FACILITIES

The balance of the 1967 buildings and facilities request, $1,688,000, is required for 10 essential improvement projects, all of which are part of the hospital's continuing program of restoration, modernization and improvement of existing facilities. The major portion of these funds is for the following three projects:

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