SUMMARY

In part I the Minneapolis scoring system was described in some detail with an explanation of how scores may be converted into grades.

In part II several tables and graphs illustrate some of the valuable information which can be obtained by an anaysis of the scores. Such analyses serve to reveal the areas where greater emphasis is needed in program planning. Also when identical data are extracted at different times, an accurate measurement of progress is obtained.

The Minneapolis scoring system is particularly valuable as an evaluation method because it is designed to measure performance and as such it is sensitive to changes in the care being given. After all, actual results obtained and actual care given are of more importance to the elderly patient in a nursing home than any amount of potential which remains unused.

In our hands the evaluations made possible by the Minneapolis scoring system have proved invaluable and we still do not think that its usefulness has been entirely explored.

The next witness is Mrs. Irene H. Jacobson, president of the Minnesota Association of County Welfare Directors from Gaylord, Minn., I believe.

STATEMENT OF IRENE H. JACOBSON, PRESIDENT, MINNESOTA ASSOCIATION OF COUNTY WELFARE DIRECTORS

Mrs. JACOBSON. Senator Long and Members of the Senate who may be present, Minnesota is fortunate in having some skilled nursing homes and a larger number of homes for the aged which have some nursing care. Our aged patients needing nursing care have little choice as to what home they may enter, to say nothing of the quality of nursing care they wish, because of the lack of such homes in their respective communities.

Few nursing homes are staffed with qualified geriatric personnel. There is a real need of training of nursing staffs. It is recommended that the Congress give consideration to an appropriation of funds for scholarships earmarked for geriatrics nurses.

Licensing laws of nusing homes must be adequate to protect the public and must be vigorously enforced. The statutes relating to licensing should include the provision to insure staff to do the job adequately by State and local health departments.

Nursing homes should provide more than custodial and sanitary care. Nursing homes must give skilled nursing care, supervise needed medications and treatment as prescribed by qualified physicians, provide services for self-care and self-help in a homelike environment, protect patients' personal possessions and give personal care to maintain for the patient his respect, dignity, and independence. Emphasis here is on nursing service and on home.

This quality of nursing home care is costly but meets need.

A nursing home need not become a permanent home for the aged patient. The skilled nursing home would allow many a patient to return to his own home, enter a home for the aged, a boarding home, or a foster home for elderly.

There is far too much encouragement from relatives and nursing home operators to the aged to remain in a nursing home facility for the patient who pays his own care and for the patient who receives public assistance. Having the elderly person secure within the four walls of a nursing home facility gives his relatives "peace of mind"

regardless of cost or quality of care. This attitude seems widespread and must be changed. Public assistance recipients will increase as private patients expend their last dollars for longtime care. Aged persons have varying needs which require the attention of differing services and facilities and various degrees of intensity of nursing service. Private nursing home patients usually pay a rate not based on amount of nursing care required as the public assistant recipient patient does. The elderly private patient needs protection of such practice of overcharging. When the private nursing home patient runs out of money he applies to the county welfare department for old-age assistance. The county welfare department finds that the patient qualifies for old-age assistance but that he is often not in need of nursing based on a physicians recommendation. The public welfare social worker then plans with the patient to move to a boarding home facility, a foster care home, or home for the aged. This points up the need for a counseling service for the aged person before he enters a nursing home facility if he is going to conserve his financial resources and also conserve the tax dollar. It is evident that the aged person needs preventive, protective, and rehabilitative services before he enters a nursing home facility during the time that he is in this facility and when he leaves the facility. These services should be available, not only to the public assistance recipient, but also to the person who can afford to purchase these services. In rural areas these services are only given by public welfare departments.

The present arrangement of joint financing of public assistance by Federal, State, and county governments is sound and should be continued. There should be one program of public assistance for persons in need of financial assistance and/or social service. The categories of "old-age assistance," "aid to the blind," "aid to dependent children," and "aid to the disabled" should be eliminated. Standards of assistance should be uniform for all ages on a need basis. There are those who recommend that Congress should amend the Social Security Act to provide for Federal participation in general assistance program. In other words, this would be adding another category. If the Congress must continue public assistance on the categorical aid system, then general assistance should be added. County welfare directors and boards are generally agreed that Congress should amend the Social Security Act to provide for one public assistance program. Public welfare social workers are spending their major time with the yearning of and the meaning of the hodgepodge of legal requirements for eligibility for the various programs.

We commend you Senators as Members of Congress for your concern for the citizens of our fine country. Your first concern of human welfare was proven by the passage of the Social Security Act in 1935. This act created for the first time a nationwide public welfare policy, and created local public welfare agencies covering all counties in every State. In Minnesota, as our public welfare manual states, this resulted in a single comprehensive county welfare agency system within. which basic public assistance and child welfare programs were combined, a step which made these agencies a central factor in the community's local social service network.

You are to be doubly commended for the 1956 amendments to the Social Security Act in which you charge the public welfare depart

ments to develop services for recipients of public assistance. In your meaning from the 1956 amendments to the Social Security Act you specify self-care as the major aim for those recipients of advanced age, self-support and self-care as special goals for the blind and disabled and your major charge of strengthening family life. In order to carry out these goals in a meaningful, economical, and efficient manner, we need your leadership in making it possible for us to resolve the causes of dependency and family dissolution. We need your leadership in developing communitywide prevention and control programs. By the elimination of the categories in the present public assistance program which would mean amending the Social Security Act to provide for one public assistance program on the same arrangement of joint financing by Federal and State Governments, you would help us accomplish your goals. By so doing, you will release the talent of the public welfare personnel in helping people. There will be time for us to focus on the family rather than on the extra paperwork by our present system of categories under different formulas and requirements. As someone said long ago, "The human family does not live in separate compartments." We must stop classifying people in these rigid categories and improve the capacity of the family as a whole. Many an aged person today is in the nursing home because his family fell to pieces long ago. He needed help as an aging person. Aging begins at birth.

In the rural areas of Minnesota our good nursing homes provide skilled nursing care and provide dietary services. Other required services to maintain a homelike atmosphere are social services, psychological services, medical services, housekeeping services, recreational and education services, rehabilitation services, occupational therapy, speech and hearing services, spiritual services, vacation services, day center services, and services for the blind. Few nursing homes in rural areas, or for that matter, anywhere in Minnesota, can provide all of these services, so rightfully needs to look to the community resources. In some of our communities there is some duplication of services but generally there is a lack of services. Many of these services could be provided and/or developed if the county public health, education, welfare, and agricultural extension agencies made a concerted effort with the medical societies, church, and community organizations to make their services available in an organized manner to meet need on a continuing basis.

By the elimination of categories in the present public assistance program, the county welfare departments would have time to assist the local communities to coordinate the local public and private resources and do some much needed community organization. You have charged us with the development of these services and since every county in the United States has a public welfare department, there the responsibility may well remain.

Training of volunteers to assist patients in nursing homes is one of the many services that could be developed locally. Volunteers can add life to the added years of our aged with no Federal dollars involved. There is a place for everyone who has a concern for his fellow man. A friendly visiting program ought to be available to every nursing home. Surveys made in Minnesota reveal that persons in nursing homes pre

ferred the following services in this order: Friendly visiting programs, free or low-priced health clinics, movies, and social organization.

Services must be coordinated on the county or local level. It is fine for the consultant from St. Paul or Washington, D.C. to give technical assistance and inspiration at the local level, but it is the local machinery that keeps the community "on the ball" day by day. Thank you. Senator LONG. Thank you. Is that a State position?

Mrs. JACOBSON. Yes, it is.

Senator LONG. Thank you very much. Dr. Frank H. Krusen.

STATEMENT OF DR. FRANK H. KRUSEN, DIRECTOR, SISTER KENNY INSTITUTE, MINNEAPOLIS

Dr. KRUSEN. Senator Long, I have presented you with four exhibits I have here for the committee as a whole, additional copies of which I can give to your committee.

I would like to call your attention first to exhibit A and just after the heading at the middle of the first paragraph of this item from the Congressional Record appears this statement by our senior Senator of this State (Senator Humphrey), that the voluntary health agency is needed more vitally than ever before and that is thanks to the wise decision of Congress to expand Federal teamwork in cooperation with health groups.

I happen to be the president of the Minnesota State Board of Health, of which Dr. Barr, who testified previously, is executive officer, and I happen also to have served as chairman of one of the work committees of the Rehabilitation Section of the White House Conference on Aging. In exhibit B, which I have presented to you, on page 8 I have made reference to nursing homes and some of the problems of the people in nursing homes. The American Medical Association, I have pointed out, has realized the need for rapid expansion of the number and quality of nursing homes in this country. It is estimated that we have, as you know, I am sure, better than I do, about 25,000 nursing homes containing 450,000 beds; 180,000 of these beds are in skilled nursing homes and 80,000 in personal care homes that provide some skilled nursing care. The point that I think is important is that the average age of the persons in these homes is 80 years and two-thirds of those are over 75 years of age. Only onethird are men, less than half can walk with assistance, and more than half have periods of disorientation.

One of the most important things, we think, in nursing homes is to provide training of nurses in rehabilitation nursing services and we believe this is extremely important.

In exhibit C, on page 8, I point out that the opportunity to see and evaluate the number of chronically ill and handicapped persons will enable us to arrive at more accurate projections of our needs in the field of our aging and handicapped and the possibility of their needing services. I have felt particularly the need for a disability detection program and the need to do everything we can to lessen the number of beds in nursing homes by providing adequate rehabilitation services. There is a natural tendency to discuss this problem in terms of present and future needs for approved facilities for housing of the chronically ill. Requirements for nursing home beds are constantly

in our minds. Perhaps more attention should be given to the question of how to reduce these needs by keeping our aged citizens out of these beds. Perhaps, in brief, we should give less emphasis to habilitation and more emphasis to rehabilitation. How can we give our aging citizens the ability to live outside of the nursing home? And failing this, how can we give them the ability to live with greater dignity, independence, and hope inside the nursing home? One answer to both of these questions, I am certain, lies in developing fuller awareness and fuller application of present-day rehabilitation concepts and techniques. Initially rehabilitation is three to four times as costly as routine care, but in the long run it is considerably less expensive. Rehabilitation may take many months, but passive institutional care can go on and on indefinitely in nursing homes. In addition, rehabilitation offers benefits which cannot be measured in terms of dollars; among them, hope, a chance of obtaining some degree of independence, and the prospect of returning a disabled person to his own home rather than remaining in a nursing home.

In

The long ranges which can be effected through rehabilitation were well illustrated in a San Mateo, Calif., study reported last year. this community a group of citizens were given thorough examination at the time they applied for welfare assistance and half of these people required rehabilitation services, and social retraining. The program was financed by welfare funds. The cost of supplying these services increased initially the welfare expenditures. However, 5 years later it was found that the total medical care bill for this group was 10 times lower than that group which did not receive rehabilitation. For those provided services the need for long-term nursing home care was much diminished.

In St. Louis, Steinberg has studied the ability of aging patients to live at home. In this program, out of 43 patients discharged, 30 were returned home.

In New York intensive economic evaluation of 95 chronic hospital patients showed that only 27 were in need of continuing hospital care, 11 were adjudged to have a better than 50-50 prospect of successful rehabilitation.

These studies suggest that rehabilitation can keep many patients out of the nursing home or defer the need for this care. It is also important and a largely unfulfilled function to perform inside the nursing home. At the Kenny Institute in conjunction with the State department of health here in Minnesota we are constantly conducting courses in rehabilitation nursing, especially to help the nurses in nursing homes to know how to train these people to live in the homes with as much dignity and with as much self-sufficiency as possible.

We have progressed a long way from the attitude of regarding the nursing home as a mere way station on the way to the grave. At the same time, rehabilitation has progressed past the stage where its exclusive object is reemployment of these people. To be sure, many nursing home occupants may never be returned to independent living, but rehabilitation can give greater dignity and emotional and physical well-being to those who are living dependent lives. The establishment of nursing homes and self-care facilities in proximity to comprehensive rehabilitation centers offers a very promising area for research.