10 HEW regional offices, the Office of the Secretary, and with the Social Security Administration (SSA), Social and Rehabilitation Service (SRS), and the Administration on Aging (AoA). Within the Public Health Service, the OLTC monitors and coordinates the long-term care activities, reviews plans and objectives for conformance with HEW long-term care requirements and stimulates needed long-term care programs. In addition, to assure receiving a complete spectrum of opinions, input has been requested from consumer and provider groups. During the past year, regular meetings were scheduled to give consumers and providers the opportunity to provide feedback to consumers on policies and programs. The consumer groups were represented in terms of individual institutions and through national organizations or associations. Areas of consumer involvement included policy advisory and program planning, participation in process of developing regulations, national consumer/provider meetings and consumer education. 2. Consumer feedback and education During 1976, the OLTC employed many methods to provide information to consumers on policies and programs. They included: (a) Testimony at congressional hearings; (b) Formal presentations by key OLTC staff at regularly scheduled national, regional, and State meetings of consumer groups; (c) Preparation and distribution of articles, editorials, booklets, reports, and audiovisual aids; (d) Use of media to present agency concerns; (e) Participation in seminars conducted by consumer groups; (f) Provision of technical assistance to consumers on an individual or small group basis; and (g) Development of short-term training offerings to client and provider consumer groups. These training programs have been carried out since 1971 and have resulted in 100,000 short-term training opportunities for persons engaged in providing care in nursing homes. Among the publications developed by the OLTC for use by the consumers was the introductory report which summarized the findings of the long-term care facility improvement survey. A multimedia publication consisting of a script, a complete set of 35 mm. slides, précis, and presentation suggestions, has been distributed to each regional office and has been used to reach numerous consumer and provider groups. A new HEW booklet, also based on the survey results, "How To Select a Nursing Home: A Guide for Consumer," and three monographs describing the survey's implications in specific health care areas, have been published in 1976. These monographs were : -Assessing health care needs in skilled nursing facilities: Health professional perspectives. -Physicians' drug prescribing patterns in skilled nursing facilities. 3. Consumer correspondence and complaint handling The OLTC received numerous letters and phone calls from consumer groups concerned with regulations and standards. By periodically reviewing the nature of complaints, the OLTC determined if there was a pattern emerging which indicated that regulations needed to be clarified, modified, revised, or revoked. Correspondence from consumers had considerable impact on programs, policy decisions, and the development of proposed regulations and guidelines. In the future, more reliance will be placed on regional operations to respond to consumer requests. Recent changes in staff organization will provide better regional office support and liaison to accomplish this decentralization effort. ITEM 5. LETTER FROM G. DONALD WHEDON, M.D., DIRECTOR, NATIONAL INSTITUTE OF ARTHRITIS, METABOLISM, AND DIGESTIVE DISEASES; TO SENATOR FRANK CHURCH DEAR MR. CHAIRMAN: I am pleased to respond to your letter of November 9, 1976 and to provide updated information to your committee concerning the National Institute of Arthritis, Metabolism, and Digestive Diseases' (NIAMDD) programs that we have identified as having particular relevance to aged persons. The NIAMDD is responsible for the conduct and support of research into a wide array of chronic and disabling diseases as well as some which are associated with a high degree of mortality such as diabetes and kidney disease. Because of the nature of these particular diseases, that is, chronic and disabling, many aged persons suffer from one or more of them by virtue of their longevity. There are in particular, however, several diseases under the purview of this Institute which occur more commonly in aged persons and are of considerable concern because they are crippling, they limit activity and increase dependence on others and often require extended hospitalization. Diseases such as osteoarthritis, osteoporosis and benign prostatic hyperplasia afflict many aged persons and constitute health problems of great magnitude through their social and economic importance. Osteoarthritis.-In its report to the Congress (April 1976), the National Arthritis Commission, of which I am a member, stated that more than 40 million Americans (survey date 1960-62) had some manifestation of osteoarthritis. The severity of the disease varied from symptom-free to bedridden. The Commission went on to make specific recommendations for research activity needed to help alleviate this situation which we are proceeding to implement in a stepwise manner within the limitations of the resources available. Our major research efforts in this area involve the use of biochemical and bioengineering methods to advance fundamental understanding of the chemical and structural alterations that occur in the joints with aging and to develop improved and longer wearing artificial joints to replace those destroyed by the disease. New initiatives concerning arthritis are underway within the Institute following passage of the National Arthritis Act (Public Law 93-460). I am pleased to report that we have published an announcement of our intent to establish multipurpose arthritis centers, resources which will consist of the facilities of a single institution or a consortium of cooperating institutions through which cooperating health personnel can demonstrate and foster prompt and effective application of available knowledge and develop urgently needed new knowledge. Each center will have or will develop a program in education, research and community-related activities. Osteoporosis.-This bone-thinning condition occurs frequently in elderly, postmenopausal women. Our research activities are aimed primarily at the production of new knowledge about bone formation, structure and metabolism that can form the rational basis for devising new means of therapy and, hopefully, prevention of osteoporosis. The possibility that bone formation might be stimulated in the thinned bores of patients by fluoride salts is being examined in a clinical study supported by the Institute. My own personal research interests in mineral metabolism of bony tissues have led to studies on the effects of prolonged bedrest in promoting the loss of calcium from bones. As previously reported, the Institute continues to distribute a pamphlet on osteoporosis written for the general public and the regularly published Endocrinology Index, which contains references on the latest research information on osteoporosis for investigators and physicians. Benign prostatic hyperplasia (BPH).-Last year we reported on a workshop that the Institute held in February 1975, to review, evaluate and identify and thereby stimulate new directions in BPH research. The proceedings of that workshop have now been published and I am pleased to enclose a copy for each member of your committee. The Institute is distributing this publication widely with 3.700 copies going to members of the American Urological Association, 360 copies to all medical school and hospital libraries in this country and abroad and copies sent to young research investigators identified at training centers across the country. Additional copies are on sale through the Government Printing Office. Your attention is directed in particular to the preface and introductory remarks and the summary of the workshop's findings which begins on page 269. Benign prostatic hyperplasia is a benign growth of the prostate gland that encroaches upon the urethra and produces bladder outlet obstruction. Recent studies have suggested that more than 80 percent of men over the age of 40 have some degree of bladder outlet obstruction secondary to BPH, and it is estimated that more than 10 percent of these men will eventually require a major surgical procedure for its correction. Secondary infection may result from bladder outlet obstruction which in turn could lead to chronic prostatitis and inflammation of the bladder and upper urinary tract with accompanying urinary incontinence of varying degrees. Complications of the condition include infection with possible damage to the kidneys and a predisposition to urinary stone formation. Interdisciplinary studies have been stimulated by the workshop and the Institute is presently supporting integrated clinical and basic research involving both animals and man. Recent exciting findings of research have strengthened the belief that development of BPH is under hormonal control since this condition has now been shown to be associated with an abnormal accumulation af potent androgen (male hormone). In addition, it has been found that BPH can be produced in animals by treating them with hormones. The experimental animal model thus produced will be studied in the coming months to help provide insight into the pathogenesis of this disorder. In addition, the Institute will initiate a program of specialized centers of research this year on urolithiasis (kidney stone formation) which should have impact on dealing with one of the complications which occurs in BPH. Insofar as funding levels for these areas of research are concerned, there have been only minor changes from fiscal year 1975, primarily because NIĄMDD'S overall budget did not change, having about a 21⁄2 percent increase in fiscal year 1976. Internal budgetary shifts saw a small gain (about 7 percent) for support of activities in arthritis and related musculoskeletal disorders while the kidney and urology area remained at about the same level. We in NIAMDD are acutely aware of the tremendous public health problems these diseases represent and of the considerable social and economic burden they place on our aged citizens. There will continue to be considerable commitment on the Institute's part to sustaining the long-term efforts required to make significant improvements in the outlook for these diseases of such importance to the aged. Sincerely yours, G. DONALD WHEDON, M.D., ITEM 6. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT CONSUMER AFFAIRS AND REGULATORY FUNCTIONS DEPARTMENTAL ADVISOR, ELDERLY AND HANDICAPPED POLICY The Office of the Departmental Advisor for Elderly and Handicapped Policy, located in the immediate office of the Assistant Secretary for Consumer Affairs and Regulatory Functions, serves as the focal point within HUD for matters pertaining to housing and related facilities and services for the elderly or the handicapped, and advises the Assistant Secretary on such matters. In order to give added emphasis to housing programs for the elderly and the handicapped and provide a visible contact point for the public, elderly and handicapped housing coordinators are located in all HUD field offices. Major responsibilities assigned to the Office include participating in the development or revision of all HUD policies, programs and procedures affecting the elderly or handicapped; coordinating HUD Elderly/Handicapped initiatives and responses; and representing HUD in activities with other Federal, State, and municipal or private organizations relating to the elderly and handicapped. To help carry out its responsibilities, the Office chairs two intradepartmental working groups: one on the elderly and the other on the handicapped. Members of each group represent all of the operating divisions of the Department, and meet on a regular basis to surface and discuss various issues relating to the elderly or the handicapped. In addition, the Office is an active participant on the Interdepartmental Working Group of the Domestic Council Committee on Aging. As a result, working agreements between this Department and other Federal agencies have been developed and the effectiveness of their implementation monitored by the Elderly and Handicapped Policy Staff and other elements of the Office of the Assistant Secretary for Consumer Affairs and Regulatory Functions. During 1976, the Departmental Advisor worked with the Department of Health, Education, and Welfare in a successful effort to resolve differences in the minimum property standards used by the two departments for housing the elderly or handicapped. Moreover, during the year this Office actively participated in the development of the new section 202 program and played a substantial role in the screening and evaluation of applications for direct loans under this program. Funds totaling $750 million were awarded to sponsors for the construction or rehabilitation of over 25,000 units of housing for the elderly or the handicapped. Throughout the year, the Office arranged numerous meetings and discussions between HUD executives and representatives of various major organizations representing older Americans and handicapped citizens. The sessions served to bring to the attention of the Department the immediate concerns of these organizations regarding elderly/handicapped housing and to suggest ways in which the Department could respond to them. In turn, the Department was afforded an opportunity to explain its programs and policies with respect to housing the elderly and handicapped. In working toward the goal of a more barrier-free environment, the Office has acted as liaison and provided staff support to the Architectural and Transportation Barriers Compliance Board since its inception in March of 1974. It also advises the Assistant Secretary for Consumer Affairs and Regulatory Functions who serve as HUD's representative on the Board. As life expectancy increases and the awareness of the need to make our environment accessible to all persons, the Office of the Department Advisor will continue its attempts to provide a life of greater quality, dignity and independence for all citizens who are elderly or disabled. HOUSING CONSUMER PROGRAMS DIVISION Current agreements between HUD and AoA, HUD and DOT, and HUD and HEW continue to produce programs and services. Another HUD/AoA agreement for services under section 202/8, housing for the elderly, was completed. A member of the staff serves on the Administration on Aging Task Force on Nutrition, as well as on its Task Force on Information and Referral. Some 700 local housing authorities have provided facilities for the meal program over the past year, with some housing agencies providing additional services as grantees. In several instances, the nutrition program has added other programs in recreation, health education, referral, and transportation. Nearby elderly residents of housing projects are thereby benefitted. HOUSING SECTION 8-IMPLEMENTATION The problems of aging and particularly the housing needs of the elderly are continual concerns of the Department. The implementation of the new section 8 housing assistance payments program will both assist the construction of elderly housing projects and provide an alternative for those who prefer to avoid living in projects housing only elderly persons. The section 8 housing assistance payments program authorized by the U.S. Housing Act of 1937, as amended, replaces and considerably expands and improves upon the section 23 leasing program which enabled low-income families to rent privately owned housing. Section 8 will provide the flexibility necessary to allow lower-income families including elderly families to occupy existing standard rental units, as well as to permit a family to shop for and choose its own dwelling, rather than leaving the selection to HUD or the local housing authority. The section 8 program provides assistance to encourage the construction of new units, the substantial rehabilitation of units, and the use of standard existing units. It encourages the participation of both private developers and housing agencies. And importantly, section 8 can maximize the use of the existing housing stock, while inducing production of additional units in markets where the supply of existing units is inadequate to meet all housing needs, including those of the elderly. The legislation requires that section 8 projects serve lower-income and very low-income families. Further, some projects may be developed with a mix of assisted and unassisted families. In addition, the act recognizes that the elderly have special housing needs. The preference for projects with 20 percent or less of the units subsidized under section 8 does not apply in cases of projects for the elderly. No family assisted under section 8 may pay more than 25 percent of its income for rent, but the rental payment may be as low as 15 percent, depending on family income, size, and medical or other unusual expenses. In fiscal year 1976 (including the transition quarter), 49 percent of the contract authority reserved was for units for occupancy by the elderly. Contract authority was reserved for 181,881 units for occupancy by the elderly; 105,143 units were in preliminary proposals for units to be newly constructed; 7,979 units in preliminary proposals for units to be substantially rehabilitated; and 68,759 units under the existing housing program. Several other features of the section 8 program should be of special advantage to older Americans: Eligibility for section 8 assistance has been expanded to include two or more unrelated elderly, disabled, or handicapped persons, who are living together, or one or more such individuals living with another person who is essential to their care or well being; FHA multifamily mortgage insurance programs will be made available to both section 8 developers and nonprofit sponsors to provide the project financing they need for new construction or substantial rehabilitation. Public housing agencies also may use FHA's section 221(d)(3) market rate multifamily insurance program to finance construction or rehabilitation of section 8 assisted units. (Development for profit-motivated mortgagors will generally use the section 221(d) (4) program or conventional financing.) Another program feature of particular relevance to elderly citizens is the provision of congregate facilities. The term “congregate housing" generally refers to projects in which some or all of the dwelling units do not have full kitchens, where the residents are served by a central kitchen and dining facility. This arrangement permits some of the conveniences and economics of communal living to be built into rental projects. Assistance for such housing will be available under the public housing, section 202 and section 8 programs. However, there is a statutory limit of 10 percent on the amount of annual contributions contract authority which may be used for this purpose in any fiscal year. SECTION 202-DIRECT LOANS FOR HOUSING FOR THE ELDERLY OR HANDICAPPED The section 202 program was first introduced as a part of the Housing Act of 1959 to provide direct Federal long-term loans for the construction of housing for the elderly or handicapped. The program was intended to serve elderly persons whose income was above public housing levels but still insufficient to secure adequate housing on the private market. The section 202 program was amended by the 1974 Housing and Community Development Act to change the method of determining the interest rate (previously set at 3 percent) and to provide for the use of section 8 housing assistance payments for projects constructed or substantially rehabilitated under the program. The current interest rate, applying to all loans closed through September 30, 1977, is 7% during the construction period and 6% thereafter. HUD was authorized to lend $750 million in fiscal year 1976. The first group of reservations was announced in April 1976. Two additional groups were approved prior to September 30, 1976, the end of the transition quarter, for an aggregate of 285 projects totaling more than 29,000 units. The first project started construction in September 1976. Regulations are being amended to provide for a decentralized program in fiscal year 1977. Funds totaling $750 million have been assigned to the 10 regional offices on a fair share basis. When final regulations and processing instructions have been issued, the field offices will issue Notices of Fund Availability within their respective jurisdictions and new applications will be accepted. We expect to be able to accept new applications by the end of April 1977. OTHER SUBSIDIZED HOUSING PROGRAMS FOR THE ELDERLY RENTAL ASSISTANCE-SECTION 236 (f) (2) AND RENT SUPPLEMENT Section 236 (f) (2) also was added to the National Housing Act by the Housing and Community Development Act of 1974. It is designed to assist tenants in section 236 projects who cannot afford to pay basic rents within 25 percent of their income. It provides that HUD will make rental assistance payments to project owners on behalf of such tenants. The program has been structured along lines similar to those for the rent supplement program. Generally, rental assistance payments are not made with regard to more than 20 percent of the units in a project. However, in the case of projects for the |