PREPARED STATEMENT OF GLENN E. HOOPER

611 So. GRANT AVENUE, SPRINGFIELD, Mo.

The retirement and aging programs under Government are presently not effectively workable. The nursing home program under FHA has been, is, and in my opinion, will continue to be a dismal failure. Nonprofit programs under HHFA can never fill the need effectively without overburdening our economy. For an entrepreneur to cooperate with Government now in the best possible development of a retirement community we must consult and work with the following departments and agencies:

(1) Health, Education, and Welfare

(2) Surgeon General's Office

(3) Department of Labor

(4) Department of Commerce

(5) Housing and Home Finance Agency

(6) Federal Housing Administration

(7) Federal National Mortgage Administration

(8) Community Development Administration

(9) Small Business Administration

(10) Department of Revenue (State and Federal)

(11) Securities and Exchange Commission

(12) State, county, and municipal health departments

That is 15. There may be more.

From a reliable source I understand four nursing homes have been built in the United States under FHA since its inception.

One man in Kansas City told me he spent $5,000 for plans that were rejected— 2 years of effort, 30 calls to the FHA Office and 10 to the Jefferson City Health Department. He then did get some plans approved but had a heart attack and the nursing home was never built.

FHA rejected a location largely for reasons that had no basis in fact; the location planned for a retirement community which was approved by the State health department. This department has the responsibility of the lives of the occupants. FHA would have had the responsibility for the loan on the buildings. If the lives in these buildings were safe, surely the loan on the buildings would have been safe together with insurance coverage. Missouri has one of the best nursing home programs for new facilities in the United States.

The very nature of the problem lends itself to very difficult solution. Most people don't want to think about old age or plan for it until they are in it— then it's too late. Their energy and abilities are taxed with infirmities and expenses. They are seasoned to hardship and accept suffering-that is beyond the cooperation of existing meager programs or sympathizers and loved ones.

There is a solution: All of the Federal Government information should be available from one source, perhaps the Health, Education, and Welfare Department. FHA should be relieved of any participation in retirement communities where a nursing home and related housing is planned. They presently require two completely separate utility systems where a public system is not available. This means two wells, two storage tanks, two disposal systems. In small outlying communities where public utilities are not available, or, in areas where they are available some land costs render these developments impossible, in anticipation of any profitable return.

Seemingly the Small Business Administration should have the responsibility of dispensing the Federal funds for communities with nursing homes. Where only housing is involved FHA could continue. In areas where private interests failed to fill the need by developing these communities the General Services Administration is perhaps the best equipped to develop them and as soon as possible turn them over to private investors to purchase and operate or lease with option. Private interests would become interested financially with half the effort and expense after the projects are in operation.

Private enterprise should be able to borrow up to 100 percent or the difference from that available privately, directly from SBA to completely construct nursing homes and related cottages and apartments in a community within the community sufficiently to correct the local need. These Government moneys should have an interest rate of approximately 2 percent lower than the going conventional loans. A 10-year limit should be placed on using this money unless there would be severe hardship to pay it off. Where private money participates the Government should take a second mortgage.

The Internal Revenue Department should lower the minimum 100 people investors requirement in real estate investment trusts to 25 investors as the ownership entity for these retirement communities; permit the ownership to hire the personnel and eliminate any corporation tax on distributed earnings. The Securities and Exchange Commission should establish a separate set of regulation requirements permitting anyone anywhere to purchase stocks in any of these developments. Requirements for the sale of stocks should be based on the need and the ability to operate efficiently and economically.

The Departments of Labor, Commerce, and the Small Business Administration have wonderful programs to assist the occupants in these communities in the production and sale of arts and crafts, hobbies, toys, and many other things. Many of the occupants can assist effectively and efficiently in the routine functional duties and thereby increase their funds for their needs or investment in the ownership securities. The Federal programs should cooperate with the State health programs, decide for each geographic and climatical area what the minimum requirements are to be, then when the State approves of a proposed development it should be largely the deciding factor for Federal participation on the financing, development and operation in cooperation with private interests, from the beginning, or as soon as possible. These should all be on a profit basis. The greatest and quickest improvement could come at the State level and I believe if our very excellent Governor knew personally the acute suffering that exists he would call on special session of the legislature and endeavor to make funds available to match the existing available Federal funds to provide more urgently needed medical facilities for those outside of hospitals.

(Whereupon, at 3:30 p.m., the committee adjourned.)

APPENDIX A

(The Following Document Was Inadvertently Omitted From Part 1 (Portland, Oreg.) of the Hearings on Nursing Homes)

THE NURSING HOME IN OREGON-A PRELIMINARY REPORT

CHAPTER 8, CONCLUSION AND RECOMMENDATIONS

(Prepared as part of the Gerontological Studies sponsored by Mount Angel College, supported by grant HF-RG W-197 from the Hospital Facilities Division, HEW. William T. Liu, Ph. D., project director, assistant professor of sociology, University of Portland, and Sheridan P. McCabe, Ph. D., associate professor of psychology, University of Portland)

From a sociological point of view, the reality of an organization is expressed in the interaction among personnel. Through the pattern of interpersonal relations, functions of the organization are fulfilled; and the structure of the organization becomes crystallized and stabilized. The nursing home, in one sense, is a physical reality; it has a building, beds, and equipment. The nursing home is also a social reality; it has patterned human activities, which are observable and which are expressed through its values, sentiments, and attitudes of individuals, and which play important parts in guiding various activities in the nursing home.

During the course of fieldwork, it became obvious to the investigators and interviewers that small homes are quite different from larger homes both in the type of services they render and in the social atmosphere of the home. Additional data may have revealed the idiosyncracy of each home and the use of intraclass correlations may have opened new horizons for future investigations. Based upon the limited amount of data available, it is certain that the work pattern and status relationships in the nursing home have not attained the degree of rigidity and clarity as those found in the hospital. Professionalization of nursing home staff personnel is still in the formative stage. The future development of nursing homes and the future direction of the training of nursing home staff depends upon a number of factors, among which are the size factor, needs and functions recognized, aging trends in the population, and the outcome of the medicare program currently pending in Congress. It is the aim of this chapter to discuss these factors in some detail.

Findings of this study showed that the size factor plays an important role in the nursing home administration, particularly in regard to the perceived role obligations and privileges of staff personnel in various positions. The question being raised is this: What is the best size home? This is by no means a simple question. In light of what is found in the present study, a number of things must be taken into consideration before a tentative answer can be given. The factor of size is directly related to the complexity of the organization. Adequate integration and administration of large numbers of people who have been brought together to accomplish a single goal is a problem that has to be met by application of principles of human organization. One of the most efficient organizational types that has been developed for this purpose is the bureaucracy which, as students of sociology have pointed out, is a series of levels of authority, of initiation and response, and of superordination and subordination. bureaucracy enables people to accomplish functions with a minimum of confusion, but through a system of institutional control, it regulates the behavior of its member according to the position which he holds in the total organiza

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tional structure. A modern hospital, for example, is a bureaucratic structure.1 To insure the maximum degree of work efficiency, the formal control and authority-subordination relationship must be emphasized at the expense of informal relations, even though the two types of relations exist concomitantly. Yet the goal of work efficiency is but only one aspect of the total picture. geriatric ward of a general hospital, for example, has both the advantages of clearly defined status hierarchy and concentration of elaborate facilities and equipment for the care of the aged patients. The geriatric ward seldom fulfills the entire range of functions which a nursing home may offer. A patient in a general hospital finds it quite different from the care rendered to him by a small nursing home. The patient in a hospital ward is frequently overcome by anxiety. His forced passivity, and the functional contacts with doctors and nurses are sufficient to make him suffer from the notion of uselessness." One of the most important contributions that a nursing home makes is the concept of "a home away from home." The fact that a nursing home frequently grows out of a home for the aged makes it possible to retain many features of a home. In this respect, one may view the variety of nursing homes from a shelter home to an all facilities home as polar types of a continuum from a small, homelike care to a larger, complex institutional care.

Since the majority of nursing home patients are aged, with a set of sociomedical problems peculiar and specially pertaining to the older population in an industrial society, the problem of care is neither only medical-therapeutic, nor merely custodial-familial. It is both. Consequently, there is no single answer to the question: "What is the optimal size for an efficient nursing home?" Perhaps the question should be addressed differently: "What is the optimal size for a nursing home with what primary objective(s)?" Researchwise, this is an answerable question. The present study did not start out to investigate the problem of optimal size in nursing home administration. However, the size factor is an important factor in the social structure of nursing homes.

It should be remembered that during the initial stage of the research design it was clear that the primary objective of this study was to find out the nursing home structure; namely, what sort of norms and human activities may exist in nursing homes of various sizes. From our knowledge about the modern organized hospital care, certain norms are particularly conducive to recovery.3 Hospital care, characterized by the specific, rather than the diffuse, relationships, sets universalistic rather than particularistic standards aiming to discourage the "motivational aspects" of illness and disability. Our data show that, in general, nursing home care lacks the element of impersonality. Its norm surrounding interpersonal patient care is generally diffused rather than specific; the standard is particularistic, rather than universalistic. The permissiveness in patient care is obvious: allowing, sometimes even encouraging the patient to express ideas, wishes, and fantasies. As a result, there is a high probability that the nursing home personnel will be inclined to overreact to the passivedependent nature of nursing home patients. In one way, the nursing home personnel may tend to be more sympathetic and supportive of the patient than they ought. Through their indulgent attitude, they characteristically elicit the helplessness on the part of the patient. Hence, the conceptual construct that the patient is totally unable to help himself toward self-sufficiency is shared by both the patient and his nurse. As the practice perpetuates, the "dependency" perpetuates; and both the patient and the service personnel derive satisfaction in such mutually complementary fashion. Our data have partially bore out this conclusion.

Hence, in discussing the social structure of a nursing home, a complete circle of round is made. The permissiveness and the supportive elements found in nursing homes are characteristic of most of the nursing homes studied. But these are the universal characteristics of small groups. The ultimate question is the size of the nursing home. The above analysis has suggested the advantages of small, informal home care for the aged, as well as the disadvantages of such informal, permissive care. To secure a more satisfactory answer to this question,

1 See Harvey L. Smith, "The Modern Hospital," (New York: The Modern Hospital Publishing Co., Inc., 1955); also, "Two Lines of Authority: The Hospital's Dilemma." in Gartley Jaco (ed.), "Patients, Physicians, and Illness" (Glencoe: Illinois Free Press, 1958), pp. 468-491.

See Rose L. Coser, "A Home Away From Home," in Dorrian Apple, "Sociological Studies of Health and Sickness" (New York: McGraw-Hill Book Co., 1960), ch. 12. 3 See Talcott Parsons and Renee C. Fox, "Illness, Therapy, and the Modern American Family," "Journal of Social Issues," 8 (winter, 1952), 31-44.