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Although there are many deficiencies in present nursing home services, we do not know the maximum level of care that one can expect from a nursing home serving patients at current welfare rates. We equate nursing home care with chronic hospital care, but we pay the nursing home much less than we pay the chronic hospital. This is an unrealistic point of view. We must, through research, learn what is the best care we can expect from a nursing home at any level of payment. Then we can estimate what resources or assistance are needed to meet our desired level of patient care.

In our desire to help nursing homes raise standards, we are often inhibited by the philosophy that nursing homes are proprietary institutions and therefore should not receive any public support. We forget that most of the patients in nursing homes are financed by tax dollars and that a few extra dollars might be a good public investment if better patient care is assured.

Proprietary nursing homes, unlike almost any other type of medical care institution, are isolated from community health resources. This is due to their historical development. Because they originated as commercial enterprises set up by nonmedical entrepreneurs, they were ignored and looked down on by the medical profession and hospitals. As a result of this original rejection they are still insulated from the hospital and the medical profession. They are often regarded by those who could help the most as a necessary evil.

Stricter regulation is often proposed as the only solution. The need for ways to break down this isolation from the mainstream of medical care is quite urgent. Much improvement can be credited to the efforts of the nursing homes themselves and to their association. I do believe, however, that with outside help from governmental and voluntary agencies at all levels (local, State, and National) higher standards of nursing home care can be reached and maintained.

I would like to describe, as an example, what we are doing in Brookline. For the past 5 years we have had an informal committee of local nursing home operators and health department personnel. We met from time to time to try to identify the problems of nursing homes and to see if we could provide solutions, and these were solutions at a local level only.

Our first effort was a failure. We identified the need for recreational programs for patients in nursing homes as an urgent one, but we were unable to obtain the necessary funds. After this we had better luck. With the assistance of the American Red Cross and the visiting nurse service, we gave several courses for nursing home attendants. The nursing homes sent their personnel on paid time. The results were gratifying. We have evidence of improved patient care given by those who took the course.

Although nursing homes are licensed by the State, we inspect for sanitation and safety. We have added a nurse to the inspection team who is available to advise the home on problems she notes during her inspection.

We deliver and loan, without charge, portable dental equipment, including X-ray for use by practicing dentists in treating their shut-in and nursing home patients. Now, for the first time a Brookline dentist can treat a case in a nursing home using adequate equipment.

More recently we were approached by Dr. James E. C. Walter, assistant director of the Peter Bent Brigham Hospital, who was concerned about the current level of patient care in nursing homes and willing to work with us to raise standards. Together with him we have developed a plan for a demonstration program which will be supported for 3 years by the U.S. Public Health Service.

This program envisages a local health department developing an administrative structure that will allow the mobilization of community resources to help raise nursing home standards. The voluntary hospital will help by supplying needed technical, medical, and professional supervision. We hope eventually to involve as many other resources as possible including voluntary health agencies, other hospitals and schools of nursing, social work, medicine, and public health. As our demonstration progresses, we will try to do four things:

(1) Develop continuing training courses for all levels of nursing home personnel.

(2) Provide consultation services to nursing homes. These will include medical care, nursing, nutrition, administration, housekeeping, bookkeeping, purchasing, et cetera. We will lean heavily on the Peter Bent Brigham Hospital for many of these services, but will also utilize personnel from the health department as well as other organizations.

(3) Coordination of community health agencies to help nursing homes develop programs leading to better patent care. Many categorical health agencies such as those interested in diabetes, cancer, heart disease, arthritis, and tuberculosis share an interest in nursing homes along with such general agencies as hospitals, visiting nurse associations, and rehabilitiation groups. We will try to utilize their interests to develop specific demonstration programs in individual homes.

(4) Train selected patients for self-help projects within the home. This will not only be beneficial to the patient as a form of occupational therapy, but it will also free trained personnel to carry out other patient care duties in the home. This type of program has been quite successful in veterans' hospitals and

should apply to nursing homes as well. In conclusion, we feel that there are two major areas of activity in which the Federal Government can be of great help. The Community Health Services and Facilities Act of 1961 will be extremely helpful when it gets into operation and should be continued and expanded. We also feel that federally directed programs aimed at encouraging local medical and health resources such as physicians, hospitals, and health agencies to take the leadership and bring nursing homes back into the mainstream of medical care are also urgently needed. Thank you, sir.

Senator SMITH. Thank you very much, Dr. Taubenhaus. We certainly appreciate this testimony. Let me say at this time that I realize the very fine work that Brookline is doing in this field and I urge you to keep up the splendid efforts.

I have just one question that I would like to ask you. What approach is your program taking to the problems of proper placement of patients in homes and the free transfer between nursing homes and acute hospitals?

Dr. TAUBENHAUS. Well, we have built our program primarily around a hospital. We are starting out and we have not got in full operation yet, Senator, but what we have done is to have the hospital people come into the nursing homes and spend some time there so they can see what it is like in a nursing home. It is very easy for the hospital people on one side to say what the nursing home should be doing and the nursing home on the other to say what the hospital should be doing.

We felt the first thing to do was to bring them together. We have had nurses from the hospitals go in and visit nursing patients. We have tried to have nursing home personnel come into the hospital. We hope that the hospital will have some chance to follow their cases when they get within the home. Using the hospital as a resource in this way we feel that we may be able to bridge this gap. The details will have to be worked out by experience.

Senator SMITH. I see. One other question, Doctor, in regard to nutrition. Could you tell me what steps are being taken there?

Dr. TAUBENHAUS. We have already had a nutritionist come in and review the menus in one nursing home. We found out, for example, in this home that they were buying only dietetic foods. This is not necessary. We showed the nursing home, for example, how by bringing the hospital nutritionist in as a consultant, she was able to save them money by setting up their diets more economically, but still providing better diets.

Senator SMITH. I think this is a most important part of it.

Dr. TAUBENHAUS. One of the things we hope will come out of this project is that the nursing home people will learn where and how to Îook for this kind of help. There is plenty of help available, but the communication barrier has been one of the obstructions. This we are trying to break down.

Senator SMITH. One last question, Doctor. Do you suggest any new Federal programs?

Dr. TAUBENHAUS. I don't think so much that new programs are needed as much as strengthening the existing ones, particularly the community facilities. I would like to see the Public Health Service put more emphasis on the responsibility of local medical and professional resources to remember the nursing homes. I think we need leadership more than we need anything else.

Senator SMITH. Thank you very much, Doctor.
Dr. TAUBENHAUS. Thank you.

Senator SMITH. Our next witness will be Mr. Robert P. Curran, deputy commissioner of public welfare, Commonwealth of Massachusetts. He is presenting the testimony of Commissioner Patrick A. Tompkins who will not be here this morning.

Mr. Curran.

STATEMENT OF ROBERT P. CURRAN, DEPUTY COMMISSIONER OF

PUBLIC WELFARE, COMMONWEALTH OF MASSACHUSETTS

Mr. CURRAN. Mr. Chairman and members of the committee, my name is Robert P. Curran, deputy commissioner of public welfare, Commonwealth of Massachusetts. I wish to read the testimony of Mr. Patrick A. Tompkins, commissioner of the department.

It has been my informal understanding that the subject matter of today's hearing is confined to the authorized nursing home program within the Commonwealth of Massachusetts. The State department of public welfare has no official authoritative responsibility with respect to such homes other than its authority to visit, on its own motion, any recipient of public assistance who is a patient in such a home. The department has, however, collaborated with both the official licensing agency of the department of public health, boards and managers of voluntary and charitable nursing homes, and officers and managers of proprietary nursing homes on a variety of matters affecting the interest, health, and welfare of patients in such homes, both patients on public assistance and nonassistance patients.

It is unnecessary at this time to dwell on the fact that responsible governmental and nongovernmental leaders in the health and welfare fields for many years have been concerned about the growing population of aged people and the accelerating numbers of sick aged people in need of continuing medical institutional care. The numbers of such sick aged people receiving either old-age assistance or medical assistance for the aged in Massachusetts have increased markedly in the last 5 years.

Despite inferences and allegations to the contrary, this concern of both governmental and nongovernmental leaders has resulted in a number of progressive and salutary efforts to improve the quality of nursing home care and guarantee both to the community and to the relatives of the sick aged that skilled nursing care, plus kindly, sympathetic, and understanding treatment of the sick aged person will, in fact, be available in all such nursing home facilities within the Commonwealth.

Let me cite some of these efforts:

(1) Many years ago the General Court of the Commonwealth of Massachusetts, to be specific in 1948, enacted legislation establishing the State department of public health as the standard setting and licensing agency for all nursing homes offering nursing home care to more than two paying patients.

(2) The problem of adequate staffing of the division of licensing has been continuously brought to the attention of a succession of chief executives and a succession of different sessions of the General Court with moderate successful results.

(3) Some years ago, the general court vested in the division of hospital costs and finances of the Commonwealth the responsibility for determining reasonable, equitable, and adequate payments for public assistance recipients who needed and received nursing home care in an authorized and licensed nursing home. The per diem payment for such public assistance patients has been increased three times in the last several years.

(4) The Boston College School of Nursing is conducting a research study, supported by a grant from the National Institutes of Health, to estimate the nursing needs of nursing home patients in Massachusetts. This project was undertaken initially at the request of the Massachusetts Department of Public Health and the Massachusetts Federation of Proprietary Nursing Homes.

(5) The Massachusetts Federation has also sponsored a series of seminars at Northeastern University in the city of Boston for improv

care.

ing management techniques and services to patients in such nursing homes.

(6) The great Peter Bent Brigham Hospital, in collaboration with Brandeis University and the Brookline Public Health Department, has sponsored a research project for purposes of evaluating quality of care in proprietary nursing homes.

(7) The Greater Boston Jewish community has under construction at the immediate moment a new nursing home which has, as its objective, the finest such facility in the country. Other denominations—Unitarian, Episcopalian, Baptist, and Lutheran groups—for long years past managed outstanding homes for the aged, most of which have been converted, because of the prolongation of age, into nursing homes of the finest type for the aged of their denominations. The several Roman Catholic dioceses within the Commonwealth of Massachusetts have a multiple number of outstanding homes for the aged, virtually all of which are licensed also to provide nursing home

Many of these religious groups admit patients irrespective of creed, color or national origin. Many have contemplated expansion plans, either in action or under consideration and, in turn, are supplemented by a number of eleemosynary charitable nonsectarian institutions. The department of public health has also instituted a regulation that all new nursing home facilities must be of original construction, rather than the traditional conversion of old mansions no longer usable for home or family into nursing home facilities.

All of these collective individual efforts augur well for the professional protection and care of the sick aged, the improvement of the quality of such care, and the continued interest of both governmental and nongovernmental leaders concerned with the adequate provision of a variety of services to our aging population.

Since other witnesses have a greater competence to testify and comment on specific problems with respect to such nursing homes and the quality of care presently provided, I shall conclude my testimony by stating that I believe that the organized community of Massachusetts and the organized leadership of the several metropolitan areas, wherein the great majority of our aged people are located, are alert to, and progressively planning for, protective medical and nursing services for

the aging population of the Commonwealth. Senator SMITH. Thank you very much, Mr. Curran.

I have a question, Mr. Curran. How difficult are the problems of your staff in finding the appropriate placements for their clients in nursing homes? How difficult is that? How much of a problem is that for your people now?

Mr. CURRAN. I am not able to answer that, being on the State level. That is handled by the local board of public welfare.

Senator SMITH. It does not affect you, that problem?

Mr. CURRAN. They have that problem. We help if we can but generally they do it.

Senator Sšith. Tell me, Mr. Curran, when you find a situation in a nursing home that is not up to your standards, what action do you take?

Mr. CURRAN. We bring it to the attention of the department of public health. They are the licensing authority for those homes.

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