Senator LONG. I am about to run out of time on you, but there is one question I would like to ask you before we go on. You mentioned in your prepared statement about the plan of accrediting your nursing home. Are there written standards and regular inspections pro

vided for this?

Mr. SHIELDS. Yes. This program has been established by the American Nursing Home Association in concert and cooperation with the AMA, ADA, American Nursing Association, and other health care associations. It is a voluntary program. The program has been accepted by the association of Minnesota with certain adaptations or certain revisions that would be applicable to our own State. I point out with a certain amount of pride that the welfare program of the State of Minnesota is, we feel, among the top, and I would like to digress a moment. In your television interview yesterday you mentioned that Minnesota has only 2,000 nonacceptable beds, which is lower than the national average, and you said you were interested in finding out why-may I supply an answer?

Senator LONG. If it doesn't take too long.

Mr. SHIELDS. I think, first, it is because in the State of Minnesota the legislators and the welfare department have shown a practical attitude as to what constitutes a fair and equitable fee and to digressyou don't find a homely Cadillac-when you pay a good price, you are bound to get better quality. Conversely, in States which have low welfare rates, you find few good homes.

I think a second point is the desire of the owners themselves— again I speak of private-to improve their homes for competitive reasons and also for the opportunity to qualify for higher rates. Better homes command higher rates.

A third point, I believe, is the result of high standards established by the State board of health in 1951 and also the enforcement of those standards by local welfare authorities

Senator LONG (interrupting). You understand I have been complimenting your people here. I was complimenting them because of the larger percentage

Mr. SHIELDS (interrupting). I won't continue with my prepared address, however, I feel strongly that the private nursing homes have made a significant contribution to the nursing home picture. They first recognized the need and did something about it. There are substantial investments being made in private nursing homes, and a very large program for further expansion exists. I feel that private nursing homes have been a good stabilizing factor in establishing a fair rate for patients. Private nursing homes can provide good service and operate under the limited allocations established by the legislature and welfare department. I maintain that private nursing homes are meeting care problems at a standard that is basically good as attested to by a report made by Dr. Park of the Minneapolis Health Department which states that 70 percent of the nursing homes in Minneapolis now are classified C grade or better, judged by his own standards, the number of nonacceptable homes can be counted on one hand. The big building boom, up until last year, has been proprietary, but now nonprofit and charitable homes have entered into the picture and as they have more funds available they are building faster. However, 60 percent of existing nursing homes are still proprietary; and 53 per

cent of all beds are proprietary. In new construction, however, only 34 percent will be proprietary, and I feel that this ratio may continue for some time.

Senator LONG. Thank you, Mr. Shields.

The next witness is Mrs. Campbell Keith, administrator of Walker Methodist Home, in Minneapolis.

STATEMENT OF MRS. CAMPBELL KEITH, ADMINISTRATOR,

WALKER METHODIST HOME

Mrs. KEITH. Senator Long, members of the subcommittee, I was asked to speak to the relative role or importance of the infirmary facility within the retirement home. The concept, originally, of a retirement home, I feel, was one of a place to which some discarded person might go. The picture has changed entirely. We feel now that the retirement home has a very important part to play in the lives of our entire citizenry and that for the work of a retirement home to meet its commitment it must serve a total program.

We have observed in the past 16 years at the Walker Methodist Home a very definite change in the attitude of people seeking our care. Originally they came, perhaps, looking for an escape from a responsibility, perhaps the idea of a new home was novel to them, however, now the question asked is, "Would you take care of me when I am sick? Will you take care of me if I should lose my mind? What will I do if I can no longer take care of myself in a general way but just need partial support?" The trend is a very healthy one, I feel, toward keeping older people in their own homes, just as long as it can be accomplished, but when the move is made to a retirement home that there should be a five-point program there to completely satisfy the desire of the resident. He is entitled to feel that when he moves to a retirement home that he will remain there so long as he is able to participate in the program of the home and then should he need nursing care, partial or total, it would be provided, and should his mental capacities deteriorate to the point where he needs further support that so long as he is not a menace to those about him, that is the role of the home to meet these needs.

One of the greatest difficulties of any older person, I feel, is the acceptance of change, and should illness become a challenge to us, for the patient to go out for care, very often his convalescence, his general condition, his improvement, is deterred by the fact that he is adjusting to the change of the hospital facility. If he were able to continue in the home, in the infirmary or health center-and the term "health center" is far more acceptable to the old folk than is the term "infirmary"-his recovery will be expedited and there will be far less cost to him or to the agency taking care of his costs.

Another very important advantage of an infirmary or health center within a retirement home is the relationship to the rehabilitation program. The emphasis placed on rehabilitation in the geriatric field is well taken and Dr. Krusen certainly spoke to that. We have witnessed in our home tremendous gains and restoration of self-confidence, physical capacity, and emotional adjustment through our rehabilitation program. It is encouraging to the older patient in the rehabilitation program to be able to measure his progress against that of his neigh

bors. We feel that the nursing staff is better able to evaluate his progress because he knows his patient better. He is an inspiration to others, to his neighbors who are loath to accept a rehabilitation service, and in every way we recommend strongly, from our point of view, the rehabilitation program in a retirement home.

The cost of a rehabilitation program is high at first, but when one considers what it means to the ultimate cost of patient care, it is much lower. It is our considered judgment that an infirmary is an integral part of a good retirement home. It gives security to every resident that knows should he become ill, he will be given care in familiar surroundings. The costs are less than those in acute hospitals and nurshomes. The infirmary is available at all times and the fearful, discouraged older person will find the support he needs.

I do not presume to hold a brief for a retirement home to compete with the acute hospital by way of having facilities for surgical intervention, et cetera, but where the resident is well oriented in the services his home provides, he will realize that possibly for diagnostic study and surgical treatment he will need to go out to an acute hospital, but with the assurance that for the convalescence he will return to his home. He will accept the change and will not rebel against it. (The prepared statement of Mrs. Keith follows:)

PREPARED STATEMENT OF MRS. CAMPBELL KEITH, ADMINISTRATOR, WALKER METHODIST HOME, MINNEAPOLIS, 9, MINN.

To evaluate infirmary facilities within a retirement home, one must first clarify his concept of a retirement home. Should a retirement home be all embracive of services required by those older people within it or should it be limited to the policies and practices of the home in question, be they restricted to domiciliary care or limited nursing care. It would appear that there has emerged from the various conclaves and convocations within the field of geriatrics a picture of the ideal retirement home as the facility with the total program. This means that many of our fellow citizens needs must revise their thinking and redefine their conception of a retirement home.

The term, "total services," covers a broad area, and which should be paramount in order of value is problematical. Briefly and historically speaking, a retirement home was a place, not necessarily a haven for those within it, and perhaps was well described when it was designated as the poor house. Among the possible facets, however, that they might have had in common with the ideal retirement home as I would interpret it is that terminal care is given in both. It has been an interesting experience throughout the past 16 years to have observed how inquiries relative to admission to the Walker Methodist Home have changed. The Walker Methodist Home opened its doors in 1945. At that time and for several years later many of the inquiries seemed to be based on the applicants' desire to be relieved from responsibility. He wanted to escape, or so it seemed in many instances, from the many demands made upon him-the male applicant perhaps wishing to be relieved of the storm window project, and the woman from the dishwashing or what have you. There has been a gradual and increasing emphasis, however, placed on the need for care. One of the first questions has become, "Do you take care of me when I am sick?"; another "What happens to me if I get queer or lose my mind?" followed by the comment, "I am just fine now, of course, and I would like to stay where I am until I need to move." It might well be that this change of attitude on the part of the applicant should be an important factor in our determination of what the services of a retirement home should include. Emphasis at the Walker Methodist Home has now come to be placed on what we would term a five-point program: domiciliary, limited nursing care, total care, custodial supervision, and outpatient services.

With the increased longevity of our people and the toll that time takes mentally from some, we feel that a retirement home can do a great deal to give care for the so-termed senile in the atmosphere to which he has become ac

customed. I do not suggest that the senile patient be admitted directly to the home, but I strongly recommend that the one who becomes in need of special love and care, as we so describe it, for his sake and that of his family and friends, that they be provided for him at the home. It has been our observation that to have a special area for this type of patient does not serve as a reminder to the resident body that senility is a threat, but rather does it give the assurance that should it come, his home is still where he had chosen to live when he was in possession of his faculties. Further we have noted in some instances what appears to be a stabilization of the retrogression process.

We would like to use the term "health center" as an all-embracive one, to cover every service provided other than the domiciliary, although we are qualifying, of course, that those in the domiciliary section are eligible for health center services. Terminology is very important, and we have found a rejection of the term "infirmary" as such, but an acceptance of the health center. Going back to our original premise that infirmary facilities within a retirement home are not only to be recommended but are essential, we accept as fact the concept that by far the greater number of residents within a retirement home have outlived most of their friends and relatives. Then too we must recognize that friendly visitation has therapeutic value at any age level. If the resident with the home requires acute nursing care, chronic or otherwise, and is moved to facilities beyond the campus of the retirement home, he in many instances is going to be denied the encouragement and strength that comes from contact with the new friends he has made since he entered the retirement home.

To accept change is a very difficult part of the lives of older folk, and it would then follow that ground would be lost in adjusting to an acute facility in lieu of a health center if a resident is transferred out for nursing care. During his residency in the home he has come to look upon the nursing staff as part of his own neighborhood. They are not creatures in white uniforms, but rather personal friends from whom concern and affection radiate, not to mention professional skills. We know and the patient will know, should he be transferred to an acute hospital (and there are times when this is indicated) and his associates within the home who may be older and less able than is he will be unable to make the journey to see him, perhaps due to physical limitations or maybe financial, and there will be a resultant lag in his convalescence.

Another advantage of having an infirmary or health center within a retirement home is its relationship to the rehabilitation program. The emphasis placed on rehabilitation in this geriatric field is well taken. We have witnessed tremendous gains and restoration of self-confidence, physical capacity, and emotional adjustment through our emphasis on rehabilitation. Among the advantages is that of being able to measure progress. The nursing staff within the home has a more accurate picture of the patient and his needs, as well as his capacities, than can the nurse with whom he comes in contact for a very limited time within the acute facility. His friends and neighbors within the home are a means of encouragement to him, as he in turn is an inspiration to others, and his true progress can be measured far more satisfactorily here than elsewhere. The support of an infirmary program within a retirement facility can, in part, be absorbed by that portion of the budget allocated to administrative expense. A well-trained, experienced administrator of a retirement home is in a position to evaluate her nursing staff and to work intelligently and constructively with her supervisor of health services.

It is our considered judgment that an infirmary is an integral part of a good retirement home. It gives security to every resident who knows that should he become ill he will be given care in familiar surroundings and by people in whom he has confidence. The costs are less than those in acute hospitals and nursing homes. The infirmary is available at all times, and the fearful, discouraged older person will find in his familiar area the support he needs. I would indeed be a hostile witness (with all apologies to Perry Mason) if I were to designate as a good retirement home one that was not equipped to give general care to the ill. I do not presume to hold a brief for a retirement home to compete with the acute hospital by way of having facilities for surgical intervention, etc., but where the resident is well oriented in the services his home provides, he will realize that possibly for diagnostic study and surgical treatment he will need to go out to an acute hospital, but with the assurance that for his convalescence he returns to his home.

Senator LONG. Thank you. Dr. Leo Nash.

STATEMENT OF DR. LEO NASH, CHAIRMAN, COMMITTEE ON AGING, MINNESOTA STATE MEDICAL ASSOCIATION, ST. PAUL

Dr. NASH. Senator Long and members of the subcommittee, I am Dr. Leo Nash, of St. Paul, Minn., representing the Minnesota State Medical Association's Committee on Aging. I am a radiologist and one of the 3,650 Minnesota doctors who comprise the State Medical Association. One statement I have submitted to your committee outlines in detail many of the pertinent facts concerning our Minnesota nursing homes, the cost of caring for persons in these homes, and the obvious need for additional facilities within these homes.

But first, on behalf of the association, I wish to take this opportunity to welcome you to Minnesota. We appreciate the valuable time you are taking to consider our recommendations to help all of us who are, or will soon be, senior citizens. We are proud that you have chosen to hold hearings on our Minnesota nursing home program, a program which has been developed by the Minnesota Department of Health, the Minnesota Nursing Home Association, the Minnesota Hospital Association, churches and fraternal organizations, and the Minnesota State Medical Association.

As we physicians care for our aging population, we soon become aware of the fact that the only thing these people have in common is that they are over 65. They are not a homogeneous group. Hence, as doctors, we treat each person individually. We feel, also, that any programs instituted to help those over 65 must also be geared to the individual.

In Minnesota we know that 3.5 percent of our population over age 65 resides in licensed nursing homes. This does not include boarding homes. The average age of these people is 80 years, and they spend an average of 2 years in the homes. According to a recent study of persons living in congregated housing in the State, 90 percent were widows, widowers, or persons who never married. Of the approximate 12,000 nursing home beds in Minnesota, about 52 percent are occupied by recipients of old-age assistance. This study also pointed up the fact that people living in congregated housing have a much smaller net worth, and more of them spend their time just sitting and thinking, than those who live in noncongregated housing. It was noted that those in congregated homes regard their health problems as more serious than others.

These, and many other statistics contained in my statements lend emphasis to the fact that we should help elderly people remain in their own homes as long as they are able. Hence, we support the Federal Housing Act of 1956 and its 1959 amendments, and we urge that this act be strengthened to: (1) Facilitate the purchase of housing by older persons; (2) facilitate the financing of rental housing projects both profit and nonprofit-designed specifically for the elderly; (3) facilitate the financing of proprietary nursing homes; (4) make public, low-rent housing more readily available to older persons; and (5) make direct loans to sponsors of nonprofit rental housing projects who are otherwise unable to obtain financing.

We have always supported, and will continue to support, the use of the Hill-Burton Construction Act for building new nursing homes. Builders, whether public or private, must be encouraged to take into