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HEARINGS

BEFORE THE

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JOINT SUBCOMMITTEE ON LONG-TERM CARE

OF THE

SPECIAL COMMITTEE ON AGING

UNITED STATES SENATE

EIGHTY-EIGHTH CONGRESS

SECOND SESSION

PART 3

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U.S. GOVERNMENT PRINTING OFFICE

33-257 WASHINGTON: 1964

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Washington, D.C., 20402 - Price 15 cents AUG1964 -O
SPECIAL COMMITTEE ON AGING

GEORGE A. SMATHERS, Florida, Chairman

PAT McNAMARA, Michigan

CLAIR ENGLE, California

HARRISON A. WILLIAMS, JR., New Jersey

MAURINE B. NEUBERGER, Oregon

WAYNE MORSE, Oregon

ALAN BIBLE, Nevada

FRANK CHURCH, Idaho

JENNINGS RANDOLPH, West Virginia

EDMUND S. MUSKIE, Maine

EDWARD V. LONG, Missouri

FRANK E. MOSS, Utah

EDWARD M. KENNEDY, Massachusetts

RALPH YARBOROUGH, Texas

J. WILLIAM NORMAN, Jr., Staff Director

JOHN GMT MILLER, Minority Staff Director

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EVERETT McKINLEY DIRKSEN, Illinois

BARRY GOLDWATER, Arizona

FRANK CARLSON, Kansas

WINSTON L. PROUTY, Vermont

KENNETH B. KEATING, New York

HIRAM L. FONG, Hawaii

E. L. MECHEM, New Mexico

JOINT SUBCOMMITTEE ON LONG-TERM CARE

FRANK E. MOSS, Utah, Chairman

PAT McNAMARA, Michigan

CLAIR ENGLE, California

HARRISON A. WILLIAMS, JR., New Jersey

MAURINE B. NEUBERGER, Oregon

WAYNE MORSE, Oregon

FRANK CHURCH, Idaho

JENNINGS RANDOLPH, West Virginia

EDMUND S. MUSKIE, Maine

EDWARD V. LONG, Missouri

RALPH YARBOROUGH, Texas

FRANK C. FRANTZ, Professional Staff Member

EVERETT McKINLEY DIRKSEN, Illinois

BARRY GOLDWATER, Arizona

FRANK CARLSON, Kansas

KENNETH B. KEATING, New York

HIRAM L. FONG, Hawaii

E. L. MECHEM, New Mexico

NOTE.—Three hearings on nursing homes were held as follows:

Part 1—Washington, D.C., May 5, 1964.

Part 2—Washington, D.C., May 6, 1964.

Part 3—Washington, D.C., May 7, 1964.

II
CONTENTS

CHRONOLOGICAL LIST OF WITNESSES

Page

Jay L. Roney, director, American Public Welfare Association's Project on

Aging 275

Francis W. Stover, national legislative director, Veterans of Foreign Wars;

accompanied by John D. Fagan, assistant director 282

Winborn Davis, director, State Department of Hospitals, Louisiana 286

James M. Ensign, director of professional relations, Blue Cross Association;

accompanied by Steven Sieverts, assistant director, and Bert Tollefson,

Jr., Washington representative, Blue Cross Association 294

Dr. Mitchell Wendell, counsel to the Council of State Governments 300

STATEMENTS

Davis, Winborn E., member, National Association of State Mental Health

Program Directors 287

Wendell, Dr. Mitchell, counsel to the Council of State Governments 300

III

NURSING HOMES AND RELATED LONG-TERM CARE

SERVICES

THURSDAY, MAY 7, 1964

U.S. SENATE,

JOINT SUBCOMMITTEE ON LONG-TERM CARE

OF THE SPECIAL COMMITTEE ON AGING,

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The subcommittee met, pursuant to recess, at 10:25 a.m., in room

4232, New Senate Office Building, Senator Frank E. Moss (chairman

of the subcommittee) presiding.

Present: Senators Moss and Fong.

Also present: Frank C. Frantz and Jay B. Constantine, professional staff members; John Guy Miller, minority staff director, and

Gerald P. Nye, professional staff member (minority) .

Senator Moss. The committee will come to order.

We will proceed now with the hearing.

Our first witness will be Mr. J. L. Roney, the director of the

American Public Welfare Association's Project on Aging.

We are very glad to have you, Mr. Roney, and look forward to your

testimony.

Mr. RONEY. Thank you, Senator.

Senator Moss. Would you like to have your entire statement placed

in the record and speak then emphasizing it or would you care to read

it in full? You may proceed any way you like.

Mr. RONEY. I believe I would like to read it, Senator.

Senator Moss. All right, go right ahead.

STATEMENT OF JAY L. RONEY, DIRECTOR, AMERICAN PUBLIC

WELFARE ASSOCIATION'S PROJECT ON AGING

Mr. RONEY. I am very pleased to appear before your committee,

Mr. Chairman. As director of the American Public Welfare Association's Project on Aging, I am representing that organization here

today.

Prior to accepting the directorship of this project, I was Director

of the Bureau of Public Assistance (now known as the Bureau of

Family Services) of the U.S. Department of Health, Education, and

Welfare from 1954 to 1959. I have been engaged over the years in

social welfare programs in various capacities—as caseworker, case

supervisor, field representative, and State director of public welfare.

The subject of your hearings is of special interest to me

organization I represent. 

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276 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

The American Public Welfare Association is the national voluntary organization of State and local public welfare departments and

of individuals engaged in public welfare at all levels of government.

Its membership includes Federal, State, and local welfare administrators2 welfare workers,

i

and board members from every jurisdiction.

Since its organization n 1930, it has always been concerned with assisting public welfare agencies to administer effectively the proarams for which they have responsibility and to develop programs which are needed to improve the welfare of all citizens and the Nation.

The Public Welfare Project on Aging was inaugurated in August

1959, through a 4-year grant provided by the Ford Foundation to en- able the association—

to help State and local public welfare agencies to establish and operate or ex- pand and improve programs to meet the social, economic, and health needs of aging people.

This Project, through a series of meetings, conferences, institutes, and committees, has made it possible for us to become more aware of the needs of the aging and the variety of services they require, as well as to encourage State and local departments of welfare to expand and improve services. Prior to the termination of this Project early in 1964, the Ford Foundation provided an additional 6-year grant directed to the training of administrative, supervisory, and direct serv- ice personnel in the area of aging.

Our close and continuous working relationships with public welfare

personnel have made us cognizant of the nursing home situation and its attendant problems. State and local public welfare agencies clearly

recognize the importance of the nursing home, particularly as the aged segment in our population increases in numbers and longevity.

Recent testimony before your committee indicated that, in 1962, there

was an expenditure of over $919 million for medical care by public

welfare agencies, of which approximately 34 percent, or $275 million,

was spent for nursing home care. Moreover, public assistance recipients were utilizing about 60 percent of the nursing home beds at that

time.

Because of our awareness of the total medical problems in relationship to the aged, one in a series of seminars conducted by our Project

on Aging was directed to the subject of "Medical Care for the Aging—

Public Welfare's Administrative Role." This seminar, held in October

1962, included, as participants, selected personnel carrying administrative responsibilities for the provision of medical care of the aging

through State and local public welfare departments. About 30 States

were represented. Many problem areas were noted and discussed.

Some of these, I am sure, are familiar to you, but I should like to

focus primarily on those relating to nursing home care. I have left

some copies of this publication for your use, if you are interested.

Senator Moss. Very good. That will be part of our files.

Mr. RONEY. Observations made by this seminar group have pertinence to the subject of nursing home care and related problems:

1. An extensive variety of facilities is grouped under the label

"nursing homes." Some of these are high-powered medical care facilities; others are primarily personal care resources. There is an extensive number of small independent facilities. Changes in ownership or

management frequently complicate relationships with public welfare

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NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 277

departments, while extensive turnover among staff undermines the

effort to sustain high-quality care.

2. There was agreement in this session that in all States standards

for licensure are minimal, although several States have raised these in

the past few years. Welfare departments, this group felt, both could

and should require higher standards for homes approved for placement of welfare recipients.

Clarification and establishment of standards, however, require an

attempt to classify nursing homes by actual inspection of each home.

Such inspection would include facilities and equipment, the qualifications and number of staff, the availability of medical and nursing

records, planned menus and observation of actual services render

Also included in such an assessment would be an evaluation of the

homelike qualities and the efforts made by staff to meet the psychological and social needs of patients. Such classification would also help

determine the rate of pay for each home, based on the maximum potential for service represented by such factors as its facilities, equipment, staff, and so forth.

3. As a parallel to classification of homes, there is need to determine

the initial and continuing evaluation of the needs of each patient to

assure that the home selected best meets his particular requirements.

Such evaluation is also important in order to determine whether other

available and more suitable alternatives exist before a nursing home

placement is made.

4. Public welfare departments which have had experience with

either or both of these classification procedures report that a continuing reassessment of both homes and patients is required because of

changes which can occur.

Public welfare departments face a number of problems in respect to

meeting those recommendations. The large number of small independent facilities frequently change in ownership, turnover, and shortage of personnel, which may result in rapid deterioration in the quality of care provided in any given home. On the other hand, such

changes can result in marked improvement.

Many nursing homes lack cost accounting systems or minimum financial records, although some State welfare departments require these.

Records of patients are sometimes sparse. Initial study of the elderly

patient and periodic review of his condition are highly essential because of rapid physical and mental changes that can occur. To be

aware of the patient's changing needs, both medical and social evaluation must be provided. I am not as aware of the availability,of medical

services as I am of social casework services. To my knowledge, there

is a shortage of casework personnel.

The participants of this seminar discussed progress which had been

made by public welfare departments in helping raise standards of

nursing homes. Various devices have been used, such as joint licensure

of nursing homes, consultation provided by State and local health

departments, use of registered or public health nurses to evaluate and

classify homes, or a joint evaluation by a physician and a medical

social worker. In some States, efforts of health departments and other

voluntary and public agencies have been coordinated to provide training programs for nursing home staffs.
278 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

Some welfare departments, themselves, operate or have responsibility for long-term medical care facilities, but relatively few have become

model nursing homes. Model facilities, if developed, can have certain

values. They can demonstrate the feasibility of providing quality

medical care toward rehabilitation goals; they can provide measures

of cost that can be used to evaluate nonprofit and commercial facilities;

they can offer opportunities for experimentation in the provisions of

services which have not yet been tested.

Every State must balance strong competing claims for the limited

welfare dollars among such objects of expenditure as income maintenance, medical care, and special services. As a result of pressures

brought by organizations of nursing home operators, some States have

assigned too large a share of their available funds for nursing home

care. In contrast the ill aged are not organized and cannot bring the

same kind of pressures to promote their own best interests. Many

older persons might still be living in their own homes if enough money

had gone into their assistance grants to prevent malnourishment and

to provide adequate medical care, and if essential community services

had been adequately financed.

Nevertheless, even with recognition that efforts are being directed

in some States and communities toward the improvement of nursing

homes, the reality factor of the low payments made for nursing home

care by a number of States serves as a deterrent in the improvement

of standards, staff, and facilities.

In reviewing the situation today, I should like to make the following

comments from the viewpoint of public welfare:

1. The quantity and quality of facilities to provide for out-of-home

care, both for short- and long-term periods, should be expanded and

improved.

2. Licensing standards should provide for increased adequacy,

greater uniformity, and should reflect the varying classifications of

nursing services.

The various activities of the Federal representatives, recently described to you by previous witnesses, will help considerably in this

area. These include: (a) the development of a suggested model

State code for the licensing of nursing homes; (b) a study of the

entire continuum of care for older people directed to clarifying the

different types of care needed at differing times; and (c) a study of

the costs of various levels or types of nursing home care provided in

different areas of the country.

3. One of the basic public welfare needs is that of increased appropriations, especially from States and counties, to meet the costs of total needs. Recognition must be given as to potentials in each State.

However, such an increase must be directed not to nursing homes

alone but to the adequacy of grants to permit an individual to live

in his own home as long as possible and to provide adequate medical

care whenever needed.

I should like to refer to one aspect of financing. The American

Public Welfare Association has, for several years, strongly supported

the financing of some health costs through the social insurance mechanism, such as is provided in the King-Anderson bill. Enactment of

such a measure would relieve public welfare of some of the medical

care costs they are now meeting. Hopefully, this would enable the

z
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 279

States to divert some of their current expenditures to provide more

adequate income maintenance and improve medical care, which would

include the increased quality of nursing home care.

The 1962 Public Welfare Amendments have been instrumental and

offer great potential by providing increased Federal participation

to improve services to the aging. We believe that, with continued and

increased implementation of these amendments, even further gains

will result.

4. Adequate financing should also be related to the reduction of

caseloads for public welfare caseworkers. Such a reduction indicates funds for increased staff. I believe this device could have a

profound effect on helping to raise nursing home standards. Since

public welfare pays for 60 percent of the nursing home patients, the

close observation afforded by frequent and longer visits to these homes

would serve as a strong potential, in addition to licensing, to improve

the quality of care and, thus, to raise standards. Public welfare staff

must be given adequate time to evaluate each home and the quality

of care provided currently, rather than base its judgment on a visit

made 6 months previously. It must also help evaluate each patient's

needs continuously to determine appropriateness of care afforded and

to keep the physician informed of developments. Observation reflecting continued inadequate care would result in removal of patients.

This cannot be accomplished with current caseloads, which sometimes exceed 250 cases per caseworker.

If frequent visiting were possible by local public welfare staffs, we

believe it would not be a very long time before many inadequate nursing homes would raise their standards or cease to exist. Moreover,

better utilization of nursing homes would be possible. Many patients

now in homes could utilize other living arrangements. Some could return to their own homes, with the help of homemakers and home care

programs some might need foster home care or boarding home care;

others might need hospital care. By the same token, many older persons now in their own homes, by virtue of more frequent visits and a

better understanding of their situation, might require nursing home

care.

The training provisions of the 1962 Public Welfare Amendments

have helped make it possible for a number of caseworkers to secure

professional training, thus improving their capabilities in providing

counseling and other social services. Increased training will serve as

another strengthening device.

5. And finally, and certainly not on an all-inclusive approach, I

should like to call attention to the need for coordination of health and

welfare services on the community level. Currently, many nursing

homes, even of low quality, are being utilized because other alternative

services have not been developed to meet specific and varying needs of

elderly people. Such services include programs of homemakers, organized home care, day care centers, and counseling. We, in public welfare, are fully aware of the importance of the physician, the nurse, the

occupational, recreational, and physical therapist, and their tremendous influence on the quality of care provided in the community, including the nursing home. Their efforts, together with those of us in

public welfare, jointly focused and directed toward the improvement

of care of aging persons, will, I believe, have a beneficial effect.

33-257-64-pt. 3 2
280 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

I thank you, Senator, for the opportunity of appearing before you.

Senator Moss. We stand in recess for 10 minutes and then we will

question you, sir.

(Recess.)

Senator Moss. The hearing will resume.

I apologize to you, Mr. Roney, for running out, but that is the way

things go these days. It had to be done.

I appreciate your statement. It was a very fine statement.

There are two or three questions I would like to ask you.

You pointed out that there were a number of still unlicensed

nursing homes.

Do you have any information on the number of welfare patients

that are in unlicensed nursing homes?

Mr. RONEY. No.

Senator Moss. Do you have a rough estimate?

Mr. RONEY. I do not believe I could even make a guess, Senator.

It would be dangerous for me to even try—the fact that there are

any or some, I guess, is the major concern.

This could well be information that should be secured, I would

imagine. I do not know that it exists in any one place.

Senator Moss. You do not know whether that has been collected

anyplace?.

Mr. RONEY. Not to my knowledge at least.

Senator Moss. A number of our States have licensing, I guess they

all have licensing now, but a great many of them have grandfatherclause licensing.

Do you have any estimate on that? How many would fall in this

grandfather-clause licensing situation?

Mr. RONEY. No; I do not.

Senator Moss. We will try to get it. I thought you might possibly

have that information.

You pointed out that your seminar felt and recommended that welfare departments could and should require higher standards for

welfare recipients, and yet yesterday we heard that if standards in

most areas were raised, or were rigidly enforced, there would be no

accommodations for many patients.

Now, what do you suggest in this dilemma?

Mr. RONEY. Well, hopefully, that welfare departments could secure

enough financing so that they could pay more adequately and thus

demand better facilities.

Along with this additional financing, I would refer to the part of

my testimony of additional social workers as well, so that they can

have more current knowledge of the needs of a patient in terms of

which nursing homes are available. They would have more knowledge of the quality of the various nursing homes since they do vary

considerably.

I mean it is not only a matter of payment, but it is a matter of knowing enough about the patient and his needs and the nursing home

facilities that are available, which takes staff—more staff than most

welfare departments have.

Senator Moss. You mentioned in your testimony that some welfare

departments are doing this continuing evaluation of the individual

patient needs. Can you tell me what States are involved in doing

this
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 281

Mr. RONEY. No, I cannot, Senator.

In this meeting as it was written up, the States who spoke were not

identified as the various proposals were made, and it varies considerably. I do not know that any State is doing it in the nth degree—

and I hesitate to start mentioning any States—

Senator Moss. You might leave some out?

Mr. RONEY. That is right, so I would rather not point out any.

This suggests the possibility that this committee is considering

having hearings over the country in some States. I would think this

would be a very excellent idea for getting some of this kind of

information.

Senator Moss. Would this individual evaluation be done by a caseworker or by specialized inspection staff?

Mr. RONEY. Well, it can be done either way, but it would not be a

caseworker alone; it would be in conjunction with a person who has

medical knowledge as well, usually a nurse rather than a physician,

but a physician's consulting services would also be utilized.

In other words, the combination of the health and the social skills.

Senator Moss. Apropos your suggestion that we hopefully would

have more welfare money, I should point out that many of the States

have difficulty in financing their share of the cost of welfare payments. In my State of Utah, for example, the Kerr-Mills program

originally had very liberal benefits, but in November of 1963, the

Department of Public Welfare out there was obliged to reduce these

benefits because it was overspending its appropriation. This poses

a continuing problem as we deal with the individual States.

Of course, I know the answer but it is a question of how you get

there.

Mr. Roy. That is right. And many States face this same problem and this eventually affects the nursing home situation, too. The

amount they can pay, affects quality, and so forth.

Senator Moss. Would the problem be improved considerably if we

had the King-Anderson bill on some hospitalization for these older

people which in turn would relieve the States of some of their

matching burdens?

Mr. RONEY. We believe it would. I would assume that the States,

under the present arrangement would retain the amount of money

they are now spending. If they were relieved of some of the present

financial costs of hospitalization, they could then provide more adequately for the other aspects of health care as well as maintenance,

which is equally important, whether in a nursing home or elsewhere.

Senator Moss. I understand, welfare payments would extend, of

course, to people in their own homes as well as in long-term care

hospitals.

The fact that the King-Anderson bill would provide for these home

health visits would tend to reduce the number that would be required

to go into nursing homes, too is that not so?

Mr. RONEY. Hopefully, yes.

Senator Moss. My staff indicates there is an estimate that has been

made that at least $200 million in assistance medical payments would

be offset by the King-Anderson program, so under your theory that

much more would be released that could be made available in this

welfare area?

(
282 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

Mr. RONEY. If the appropriation is continued.

Senator Moss. Thank you very much, Mr. Roney. We do appreciate

your testimony. It has been very helpful. We are glad to have you

here today.

Mr. RONEY. Thank you, Senator.

Senator Moss. Mr. Francis Stover, who is the national legislative

director of the Veterans of Foreign Wars, will be our next witness.

We are very glad to have you, Mr. Stover.

STATEMENT OF FRANCIS W. STOVER, NATIONAL LEGISLATIVE

DIRECTOR, VETERANS OF FOREIGN WARS; ACCOMPANIED BY

MEN D. PAGAN, ASSISTANT DIRECTOR, VETERANS OF FOREIGN

WARS

Mr. STOVER. Mr. Chairman, I am accompanied on my right by John

D. Fagan, assistant director of the National Legislative Service of the

Veterans of Foreign Wars.

Mr. Chairman, and members of the subcommittee, thank you for

the courtesy and privilege to appear before this subcommittee to present the views of the Veterans of Foreign Wars of the United States

with respect to the problem of long-term care of our aging veteran

population. My name is Francis W. Stover and I am the Veterans of

Foreign Wars national legislative director.

So far as the Veterans of Foreign Wars is concerned our remarks

are addressed only to the care of veterans. By veterans it is meant

those citizens who served during wartime and who may be entitled to

medical care by or under the control of the Veterans' Administration.

Generally speaking, there are two kinds of medical care for veterans

of any age, which have been made available by a grateful Congress

in recognition of the service rendered this Nation during wartime.

First and foremost is the care extended to veterans whose disabilities

are service-connected that is, caused by active duty in the Armed

Forces during wartime. Presently, for example, there are approximately 2 million veterans receiving disability compensation payments,

for service-incurred disabilities. There are quite a few more who have

service-connected conditions which are quiescent or are not disabling

enough to warrant at least a 10-percent disability compensation payment. These service-connected veterans, Mr. Chairman, are the ones

who have priority admission to all veterans' hospitals, and the veterans'

hospitals and medical care program is designed primarily to take care

of these service-connected veterans. Not only are they provided outpatient disability treatment, but they are given priority admission to

one of the VA hospitals when needed. The average daily patient load

of the Veterans' Administration is approximately 112,000 a day out of

a maximum of 125,000 beds that have been authorized by the President

to be in operation for the care and treatment of war veterans

Veterans without service-connected disabilities may be admitted to

any one of these Veterans' Administration hospitals provided there is

a bed available or vacant, and the veteran is in need of hospital care

and states that he is unable to defray the cost of the special treatment.

I am now speaking of non-service-connected conditions, for conditions

occurring after active war service. In furtherance of his statement

that he cannot pay for this treatment the veteran is required to fill
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 283

out a detailed form of his income, assets, etc. Even with these strict

limitations, as of the last count, there were approximately 18,000 veterans who were waiting for admission to Veterans' Administration hospitals having certified that they are otherwise eligible, but there were

no beds available. Another statistic is that over half, or about 55,000

of the beds in Veterans' Administration hospitals are occupied by veterans with neuropsychiatric disorders.

The Veterans' Administration also renders other assistance to veterans by its operation of 18 domiciliary homes which take care of approximately 16,000 veterans. The domiciliary is the present-day version of the "old soldiers' home" and has been characterized as taking

care of those veterans who have become dislocated from society. Last,

but not least, the Veterans' Administration renders assistance to 28

States which operate 33 homes for 9,000 veterans by paying up to half

of the veteran's care, not to exceed $2.50 a day. This program is quite

limited and as indicated, only 28 of the 50 States have a State home

for veterans.

Despite the marvelous record established by the Veterans' Administration and the great forward strides and progress it has made since

World War II, the Veterans of Foreign Wars is nevertheless extremely disappointed that this agency has not gone forward with establishing facilities and providing nursing home care for the veteran

who will be an invalid for the rest of his life. Our aims and purposes

are embodied in a bill which has received unanimous approval of

the House and is now pending in the Subcommittee on Veterans' Affairs of the Senate Labor and Public Welfare Committee. I refer to

H.R. 8009, the nursing home care bill in this 88th Congress. Hearings

have been concluded by the subcommittee and the Veterans of Foreign

Wars is extremely hopeful that the Senate will promptly approve

the bill and it will be the signal for the beginning of increased medical

care for a growing number of veterans who are now reaching an age

when this type of care is desperately needed.

What are some of the reasons the Veterans of Foreign Wars is

supporting and working overtime for this legislation—H.R. 8009? The principal reason is found in the statistics which I just referred

to above. What better medical system is there in this land of ours

and is more and better fitted to take the lead in this program than

the Veterans' Administration. Already the Veterans' Administration hospitals by its own count has 9,700 veterans who could be released to a nursing home or to their own home if they had one to go

to, at a greatly reduced cost if such facilities were available. Therefore, the biggest national nursing home program in existence is being

operated by the Veterans' Administration. Just for the purpose of

emphasis, let me repeat just what the VA medical system consists of168 hospitals, 112,000 veterans is the average daily patient load, 18

domiciliaries taking care of 16,000 veterans, most of whom are at an

advanced age; 33 State homes in 28 States with an average daily

member load of 9,000 veterans, and taking care of and paying some

of the cost of 3,000 qualifying veterans who are hospitalized in other

than veterans' facilities. This demonstrates the magnitude and the

depth and the experience which has been gained by this agency and

the Veterans of Foreign Wars is strongly convinced that H.R. 8009

is not only desperately needed by veterans but is the instrument and
284 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

the pilot project which will gain the vital experience necessary to

establish a program of similar nature for all citizens.

At the present time, H.R. 8009, Mr. Chairman and members of the

subcommittee, will do the following in the nursing home care field:

1. It will establish not less than an additional 2,000 nursing home

care beds at existing VA facilities.

2. It will authorize the Veterans' Administration to transfer from

a Veterans' Administration facility to a public or private nursing

home any veteran who has received maximum hospital benefits and

who would require an additional substantial period of nursing home

care. This would be at the cost of the Government, subject, however,

to a limit of 6 months unless in a rare instance the Administrator

determines a longer period is necessary. A further safeguard is that

the cost of such care cannot exceed one-third of the cost of the care

being furnished by the Veterans' Administration in a general hospital.

3. For those States providing nursing home care, their per diem

rate will be increased to $3.50 a day and a matching grants program

is also authorized and provided for at the rate of $5 million a year

to enable States to construct, modernize or renovate facilities for

furnishing nursing home care to war veterans.

The heart of this program is the section which will permit the Veterans' Administration to release veterans from VA hospitals needing

nursing home care to facilities either public or private in or near the

veteran's hometown. This will provide the necessary authority for

the Veterans' Administration to immediately go forward to establish

facilities, standards, criteria, and definitions which will enable all interested and involved in this type of program to greatly benefit. The

Veterans of Foreign Wars has always pointed with great pride to the

magnificent contribution made in the field of education with the first

national education program which you recall as the World War II GI

bill, and the subsequent Korean GI bill. Likewise, this same GI bill

performed another invaluable assist in the field of housing through

the administration of the guaranteed home loan program—a truly national program which brought about warranties, for example, for

homeowners, the first enforceable warranty on a national scale, which

subsequently was adopted by the FHA.

These two programs, of course, have been highly successful and

have laid the foundation and success for other similar Government

programs. The Veterans' Administration can do it again in the nursing care field—establishing a national nursing home care program if

H.R. 8009 is enacted into law.

The problem of taking care of aging veterans was brought to the

attention of the late President Kennedy, who after reviewing the

problem, sent a memorandum to the Veterans' Administrator which

authorized the establishment of 2,000 nursing home beds in the present

Veterans' Administration system. (H.R. 8009 by the way would authorize at least another 2,000 beds, making a minimum total of 4,000

to get this program started.) The President's memorandum eloquently states some of the reasons why he established these 2,000 beds.

I quote from his memorandum of August 12, 1963:

The changing characteristics of our veterans population, particularly those who

served during the First World War, are resulting in an adverse effect on the

acute medical programs administered by the Veterans' Administration. Nearly
4

NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 285

one million war veterans are aged 70 or over. The number will increase 50 percent by 1966.

Older veterans account for one-third of your hospital admissions and they

comprise the bulk of the long-term care patient load. Many have attained maximum benefits of hospitalization but attempts at community placement have been

unsuccessful because of the lack of facilities, inadequate financial resources, absence of family ties, and other reasons. Retention of these patients in facilities

designed for acute care is costly and places an undue strain on the 125,000

hospital-bed limit under which you are now operating.

In order to relieve this situation, I authorize you to activate and operate

facilities and beds for 2,000 nursing-home-type patients in addition to the 125,000

hospital beds presently authorized. This will provide arrangements more

consistent with patient requirements and improve utilization of acute care

facilities. The higher patient turnover will also defer the need for increasing

present bed levels. Existing buildings best suited for this purpose and appropriately located throughout the country according to your judgment, should be

utilized. No construction, other than for necessary conversion of existing facilities, is authorized.

This authorization is to enable the Veterans' Administration to gain firsthand

knowledge and experience in the operation of beds specifially designated for

patients requiring attendant-type services. It will be possible to evaluate a

full range of care form domiciliaries through acute medical care, restoration

centers, and nursing home care where outplacement is not possible.

I am sure that as a part of your administrative studies, cost control systems

will be established so that direct cost comparison will be definitive; also that you

will continue to work toward the development and utilization of community and

private resources in the best interest of veterans and the Nation.

Now the Veterans' Administration has not gone forward with

the speed desired with this program as we had hoped. That is not a

primary concern of this committee, but suffice it to say that the Veterans of Foreign Wars is extremely hopeful that this administration

and the Veterans' Administration will be providing the necessary

funds to implement or more fully implement President Kennedy's

order at the earliest practicable date. Likewise we are equally hopeful that the Senate Labor and Public Welfare Committee and the full

Senate will approve this bill, H.R. 8009, in the same manner as the

House, and that the provision contained therein will be implemented as

rapidly as possible. The Veterans' Administration system, as diverse

and far-flung as it is, is always subject to constructive criticism. The

purpose of H.R. 8009 is to provide congressional approval and

authority for the Veterans' Administration to make available another

phase or type of care which, I am sure this committee will agree after

all the evidence is in, is overwhelmingly needed by the elderly citizens

of this Nation and especially the war veterans.

In summary, Mr. Chairman, the Veterans of Foreign Wars is asking Congress in approving H.R. 8009, to continue its recognition of the

service rendered by war veterans, some of whom unfortunately in

their twilight years are invalids. Nursing care as provided in this

bill will be extremely limited, since only those veterans who are unable

to pay the cost of the care can quality. I think the record should

show that the Veterans of Foreign Wars is asking for this type of

special consideration for only a small group of citizens who were selected by their country to serve in battle and give their lives if need

be for the preservation of this country and its institutions. These are

citizens who wore the uniform and receive an honorable discharge for

service rendered. By providing this type of care, it will encourage

our young men and women of today to serve their country in the present hour of need. It will make war veterans feel that a grateful
286 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

country has further recognized their sacrifice and service by having

this type of care available in the event that their own personal lives

should find themselves in such circumstances.

Again, may I thank you for this opportunity to appear here today.

Senator Moss. Thank you, Mr. Stover. We appreciate the fine

statement and your explanation and position of the Veterans of Foreign Wars.

You indicated that there is a need for standards in nursing homes.

Do you think that there should be Federal imposition of standards or

publication of standards for nursing homes to met in their services?

Mr. STOVER. I think so far as veterans are concerned that we have

always advocated that the treatment and care of veterans should be

according to a Federal standard. In other words, a veteran, regardless of his situation, regardless of which State he might be in or

which VA facility should receive the same kind and similar treatment

as a veteran would be receiving, as nearly as possible, no matter where

this veteran may be located, and that would be, of course, a Federal

standard laid down by the Veterans' Administration.

Senator Moss. Do you think this same standard, then, could serve

as a standard generally for other nursing homes not confined just to

veterans?

Mr. STOVER. Yes. I think that the Veterans' Administration is extremely qualified to establish national or Federal standards; they

have an abundance of doctors, nurses, social workers, and so forth.

They are one of the biggest agencies, building, constructing, renovating hospitals continuously—year round—all the time. Under President Kennedy's order they have been ordered, of course, to establish

2,000 more nursing home beds and to establish criteria. I think that

any standards that the Veterans' Administration will come up with

will certainly be the product of the best available brains and experience. If there are any experts in this field, if there is a team ready

to make nursing home care a reality I think you will find them in the

Veterans' Administration. H.R. 8009 will provide the VA with an

opportunity to get this nursing care off the ground.

Senator Moss. Thank you, sir. We appreciate your being here and

you, Mr. Fagan, for coming to be at this hearing this morning.

Your testimony has been very helpful.

Mr. STOVER. Thank you very much, sir.

Senator Moss. Our next witness is Mr. Winborn Davis, who is the

director of the State Department of Hospitals of the State of Louisiana. He is representing the National Association of State Mental

Health Program Directors.

We will ask you to proceed, Mr. Davis, as soon as you are ready.

STATEMENT OF WINBORN DAVIS, DIRECTOR, STATE DEPARTMENT

OF HOSPITALS, STATE OF LOUISIANA

Mr. DAVIS. Gentlemen, we appreciate the opportunity to have a

representative of the State Mental Health Program Directors testify.

Unfortunately, the association is meeting at the present time in Los

Angeles, and our president and executive director cannot be here.

They did send me an official statement which with your permission

I would like to read and then make some elaborations on it.
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 287

Senator Moss. All right, will you proceed in that manner?

Mr. DAVIS. The National Association of State Mental Health Program Directors recognizes that certain aged persons suffer from treatable mental illnesses like those that affect younger persons, and that

some aged have such profound deterioration of memory, judgment

and behavior that they must be treated in psychiatric facilities. These

aged are the legitimate concern of State and local mental health

programs.

Other aged persons suffer from physical or neurological disorders

that require general hospital care and treatment.

Others are slightly forgetful, mildly confused, and need various degrees of nursing care of domiciliary care which should be provided in

approved nursing homes or personal care homes. They should not

be required to live in State mental hospitals in 60- to 100-bed wards

with gang bathrooms, and loss of all individuality and personal dignity, even though this type of "human warehousing" is cheaper than

care in nursing homes.

Any infirm person, but especially the aged-infirm, should be kept as

near to home as possible, where family, friends, and familiar surroundings offer the best possible link with his usual life.

Units such as nursing homes and personal care homes should be provided for the aged who need only these services in small and personalized facilities in each town and city.

In the establishment or selection of such units it is important to

keep in mind the fragile health of the patient group and to insure

immediate access to general hospital facilities which can provide

a high caliber of medical and surgical care when it is needed.

The State mental hospitals are already successfully moving to such

units many senile-aged who are sent to them.

Economic dependency should not be a reason for sending physically

ill and socially dependent oldsters to State mental hospitals.

Financial arrangements should be made to give them physical, nursing, and domiciliary care in their own communities.

The State mental hospitals have also been moving into nursing homes

and personal care homes substantial numbers of chronic mental

patients who have grown old in the hospitals, but who no longer require the full range of hospital services.

This is the official statement of the association.

Senator Moss. Thank you, sir.

You have a statement, also, of your own?

Mr. DAVIS. Yes, but I do not think I will read it. I will just make

some comments from it, if I may.

Senator Moss. All right. The entire statement will be placed in

the record and we will ask for your comments.

(The statement follows:)

PREPARED STATEMENT BY WINBORN E. DAVIS, MEMBER, NATIONAL ASSOCIATION OP

STATE MENTAL HEALTH PROGRAM DIRECTORS

AGED PATIENTS AND MENTAL HEALTH

Aged patients in mental hospitals.—For years elderly people who are behavior

problems in their homes have been placed in State mental hospitals and more

often left there for the rest of their lives. Until 1959, State mental hospitals

populations increased year by year, with the aged person making up a considerable portion of the total. As an example, the State of Washington reports that

33-257-64—pt. 3-3
288 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

33.2 percent of all patients in residence in their State mental hospitals are over

65 years of age. Also, 17 percent of their admissions are over 65. Louisiana's

figures are less but still too high. During 1962-63, persons over age 65 made up

19.4 percent of the mental hospital population. Admissions of aged were down

to 9.1 percent only because of a concerted effort beginning in 1960 to reduce admissions of this group. Malcolm W. Thewlis in his book, "The Care of the Aged,"

reports that 23.5 percent of all people in the United States who are over 60 may

have to be hospitalized for mental illness. This is an indictment against our

present handling of the aging person.

State mental health directors recognize that many mental hospitals have

become repositories for the aged. Older people are admitted when they become

senile and difficult to handle in the community. Indeed the aged are often

physically and emotionally fragile so that the family feels they must be placed

in an institution. More often the family circle is then closed to the patient, his

room is turned over to someone else, those who look after him make other

plans, and there is no interest in his return to the family.

Long-term care facilities are needed for the aged, but in their absence mental hospitals often must provide this service. Various approaches to the solution

of this problem have been undertaken, some so recently that adequate evalua- tion of their effectiveness has not been possible.

(1) Private nursing home facilities is one major approach. Their number has

Increased tremendously in recent years. State licensing authorities now insure

that proper standards for construction and for care will be met. In the 1950's nursing home operators, by and large, resisted the admission of aged persons

who were disturbed or who had previously been mental patients. They did

not feel adequate to handle them, other residents of the nursing home were afraid of them, and the community criticized placement of mental patients in the community. Most nursing homes are proprietary, they must make money, and the disturbed person drives others from the home.

More recently some of the State mental health authorities and the nursing

home operators have joined hands in an education and training program. Nurs- ing home operators who are interested in accepting former mental patients are given training in understanding and handling them.

An area needing much attention is education of the public to accept former

mental patients as residents of nursing homes in the community. They need

to know that experience shows a high rate of successful adjustment on the part

of aged mental patients in nursing homes. Again we can refer to a recent survey

made by the State of Washington which shows that of 1,247 former mental patients in nursing homes, only 19 were getting along poorly and another 10 were

said to be not entirely satisfactory. This means 2.3 percent of the total had problems of adjustment.

(2) Foster home placement is another approach to removing aged patients

from the mental hospital. In Louisiana, one mental hospital assigns social

workers to locate private homes that will take a maximum of two aged patients.

They give continuing consultation to these foster homes, and have found the

practice to be highly satisfactory during the short time that it has operated.

(3) The State geriatric hospital is a third approach to removing the aged

from mental hospitals. Both Louisiana and Minnesota currently have facilities

in operation, and the State of Pennsylvania reports that it is setting up a similar program. Nevada, Georgia, and several other States have shown interest in

the geriatric hospital now in operation in Louisiana. The Louisiana facility was

specifically designed to remove from the mental hospitals nonpsychotic patients

who are 65 years and older. Through collaboration with the State department

of public welfare, the hospital utilized the OAA and MAA programs to finance

the project. An attached fact sheet gives a more complete picture of how the

facility was organized and how it operates.

This unit appears to be highly successful as patients discharged from mental

hospitals and admitted to the geriatric hospital have improved considerably in

their attitudes and outlook on life. There is much more concentration on enjoyment of what life has to offer, talking about new things the hospital program

brings to their lives, and playing down the prior focus on their symptoms and

problems.

Prevention in the geriatics field is a term that has not been greatly used. Yet

it appears that much can be done to reduce admissions of the aged to mental

hospitals. Several programs are being tried by the various States. (1) Consultation in comprehensive community mental health centers and regular health
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 289

centers provides more adequate planning for the aged at the local level. The

family, the physician, and the committing authority has a resource to turn to.

Information is available on community resources such as nursing homes to which

the aged can be directed rather than sent away to mental hospitals.

(2) Waiting lists have been established for the aged at mental hospitals in

some States. Previously, most commitments of the aged were reported as

emergencies by local authorities and the family. It has been surprising that

upon placing the patients' names on the waiting list, the emergency often disappears and constructive planning at the community level can begin.

(3) Conditional admissions are being undertaken in some mental hospitals.

An example is the Central Louisiana Hospital, Pineville, where families and

committing authorities must agree to remove the aged patient from the mental

hospital as soon as the staff contacts them indicating the patient is ready for

discharge. Sometimes they are required to sign a statement to this effect.

Many aged people are found to be loaded with various patent medicines and

prescribed drugs which disturb their behavior.

Generally, in these cases, a few days of hospitalization are adequate to dry

the person out and return him to normal functioning. While this treatment is

going on, the hospital makes an effort to plan with the family toward the longrange care of the aged person.

Statement. —It is not possible to speak for all the States, but in Louisiana there

Is the firm belief that long-term care of the aged should be provided in the

community and not in State mental hospitals or public State facilities removed

from the community. It is believed that consultation should be provided by

the local mental health facilities in an effort to reduce mental hospital admissions and to properly place the aged person when this is indicated. Training

programs for nursing home operators, public educational programs in the acceptance of mental patients in the community, and financial assistance to the aged

seem imperative to the promotion of local responsibility.

There is some controversary over whether the State should set up public

geriatric units to remove the nonpsychotic aged patient from mental hospitals.

Some feel an adequate staff to do discharge planning and to work with the

community can return the aged to some community facility. Still others feel

there will always be patients whose behavior is too much of a problem to be

adequately handled even in skilled nursing homes. They believe that the

State should have a facility to which nursing homes may send the aged they

cannot handle and to which mental hospitals may transfer the nonpsychotic

aged who cannot be placed in the community.

VILLA FELICIANA GERIATRIC HOSPITAL, JACKSON, LA.

Background: Villa Feliciana Geriatric Hospital was created August 1, 1961,

by the State Department of Hospitals. "Operation Old Age" began on that date

at East Louisiana Hospital (mental) by screening all patients 65 and older. The

geriatric hospital was formally opened March 1, 1962, with 59 patients, and now

has 525.

Purpose: Villa Feliciana was created to remove from the State mental hospitals aged people who are no longer psychotic but are in need of continued

medical and nursing care. It is designed to house indigent aged who qualify for

some public assistance and the Federal MAA benefits.

Physical plant: Three buildings at East Louisiana Hospital were separated

from the mental institution and a new facility created. Each building has 4

wards and the total capacity is 750. The villa has its own geographical boundaries and is administered as a separate facility from the mental hospital.

Program and staff: The villa is considered a geriatric hospital rather than

a nursing home. There are two full-time physicians on the staff and a part-time

physician in each medical specialty needed. Recreational, occupational, and

other forms of activity therapy are provided. Menus and special diets are

supervised by a registered ADA dietitian. Catholic and Protestant chaplains

hold regular religious services and are available for individual counseling. A

coordinator of volunteers brings the facility and the community as close

as possible. A beauty parlor and barber shop, along with nursi

promote personal grooming. Social service assists with proble op #b adjustment to the hospital and maintains contact with patients' relati . Men and

women are housed separately but participate in activities together.

4ua 20
290 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

Financing: The villa is operated by the State Department of Hospitals but is

a joint project with the Louisiana State Department of Public Welfare. Hospitals determine that the patient is nonpsychotic but in need of continued medical and nursing care. DPW determines financial eligibility and makes payment to each individual at the villa. Payments are from the OAA and MAA

programs, representing 73 percent Federal and 27 percent State funds, all

provided by the Department of Public Welfare. There is no State appropriation to the villa. Quarterly audits of the villa are made by DPW and monthly

rates determined on the basis of actual cost of operation, currently amounting

to $183 monthly per person. Additionally, DPW provides each patient with $17

monthly for personal incidentals.

Admission criteria: In the beginning admission was from a State mental hospital only. A person had to be aged 65 or over, nonpsychotic, in need of continued medical and nursing care, and eligible for public assistance. Some have

small private or social security income, in which ease DPW provides the difference between their income and monthly cost of operation. Recently the villa

began to accept from private nursing homes eases which they could not handle.

Though senescent or senile, they are not psychotic and are sent to the villa

rather than a mental hospital. Some of these are self-pay and are charged the

regular monthly rate.

For further information write to: Winborn E. Davis, acting director, State

Department of Hospitals, Capitol Building, Baton Rouge, La., 70804.

Mr. DAVIS. I would like to point out that we as mental health directors have become acutely aware that mental hospitals have become repositories for aged people. Though I could not obtain for you in the

brief time available national statistics, I quote from a survey made by

the State of Washington, which indicates 33.2 percent of their patient

population in State mental hospitals are over age 65. Our own State

of Louisiana has 19.4 percent of the resident population over 65.

Admissions to the Washington hospitals run 17 percent, age 65 or over.

In Louisiana, admissions of aged are down to 9.1 percent mostly because we have had a concerted program since 1960 to reduce admission

of this particular group.

I would like to point out that 9.1 percent of the population in the

United States are 65 years and older as of the 1960 census. This

means Louisiana admits just about the number expected on a ratio

basis.

The problem is that more often, when the aged are admitted to the

hospital the family circle is closed to the patient. They turn the room

over to somebody else, the person who takes care of them makes other

plans, and there is little or no interest in the family to return the

patient.

We know long-term care facilities are needed and you have heard

the description of some of them earlier. We subscribe wholly to the

idea of private nursing home facilities as one of the major approaches

to removing the mentally ill oldster from the State mental hospital.

There are problems in this area. Nursing home operators have been

afraid to accept mental patients; the other oldsters in the homes have

objected because they are afraid of mental patients; the community

has objected because they do not like to see an ex-mental patient walking down the street. We often get calls saying that persons from a

hospital, now in a nursing home, are walking up and down the streets.

We often reply by asking if anybody else is walking up and down the

street? There should be little or no difference, but the community is

afraid if people have the tag of an ex-mental patient.

We believe, too, that another move in the direction of getting the

oldster out of mental hospitals is the education of the public. They
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 291

should know, as an example, that so far the few projects that have been

undertaken to remove the oldster from the mental hospital and put him

in the nursing home have been quite successful. I refer again to Washington where they placed 1,247 former mental patients in nursing

homes. Of this number, only 19 were not getting along well, and 10

were not entirely satisfactory. That means only 2.3 percent were

having any kind of difficulty.

Another 'approach to getting aged out is foster home placement

in which mental hospital personnel find homes that will take—in

Louisiana—a maximum of two. If they take more than two, by law

they are a nursing home and will have to be licensed. Staff gives

continuing consultation to operators of the home, the private home,

caring for the aged mental patient.

A third approach is the setting up of a specific geriatric hospital.

In Louisiana, and in Minnesota, this has been done and we hear

that the State of Pennsylvania contemplates the same thing. In

the last 2 weeks we have had inquiries from Nevada, Georgia, and

several other States to know how this has been done, and attached

to this statement is a brief fact sheet showing how we did it in

Louisiana. We literally cut off three buildings from a mental hospital and set up a new institution. Oldsters who were no longer

psychotic, but had no place to go, were placed in the new institution.

You might be interested to know one of them was admitted to the

mental hospital in 1899 and he was transferred to the geriatric hospital at the age of 103. He celebrated his 104th birthday yesterday.

There was no place for him in the community.

We set up this institution in the absence of an adequate number of

private facilities. Today we have 525 oldsters who are nonpsychotic,

though they have some mental aberrations. They have a continuing

medical and nursing care need. This was done jointly with the

Department of Public Welfare, and all of the patients are supported by OAA and MAA funds. There is no State appropriation

to the geriatric hospital.

The Department of Public Welfare pays each person on the basis

of the actual per monthly cost of operating the institution.

Another more important approach, is prevention of admission of

oldsters to State mental hospitals. This can be done, first, by setting

up consultation in community mental health centers, the new and

rather fascinating approach to mental health that we have heard

so much about. We are doing this as are several other States. The

family, the physician, and the committing authorities will have a

place to turn to, a place that will have information on all the community resources that might be available to take care of aged people.

In this way we think that many of them will never go to the hospital because, after all, they are generally not psychotic; they have

behavior difficulties that make it extremely difficult to take care of

them in the home or in the nursing home.

Another gimmick, and it is just that, is being used by some of

the State mental hospitals. They set up waiting lists, for the admitting

of the aged even though they may have a bed for them. In the past

everyone had thought admission of aged to a hospital was an emergency. When we set up a waiting list the emergency situation seems
292 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

to disappear, and plans are made on a local level which often presents

hospital admission.

Another approach is conditional admissions, and this is something

new that we have just recently begun. A lot of aged are loaded up

on patent medicines, if I may mention a few—Nervine, Peruna, and so

on, and they do begin to behave peculiarly. But, if you can put them in

the hospital for a week or so, they will usually dry out and return to

their normal behavior. I don't mean like they act as they did when

they were 25, but as they did before they got too loaded up on drugs.

This is not just patent medicines, but prescribed drugs also. They are

getting regular checkups and are really having toxic reactions to the

drugs

Upon admission the family will sign a statement agreeing to pick

up the patient when we call and say he is ready. We have found this to

be a highly successful means of getting them back into the community.

To complete my own statement, we believe that in the case of the

aged person in the mental hospital, there is a twofold approach: (1)

to prevent their admission, and (2) the development of private nursing homes and other domiciliary facilities for their care. State mental

health authorities should assist these resources by training their personnel, and by educational programs for the community so people can

know the ex-mental patient does just about as well in the community as one who has never been labeled as mentally ill.

Thank you.

Senator Moss. Thank you very much for that most interesting testimony, Mr. Davis. Your description of moving a number of the older

people from the mental institution into a domiciliary nursing home

type of care is very interesting. Are there still a number of elderly

patients in this situation yet to be moved in Louisiana?

Mr. DAVIS. Yes, we know that in one hospital there are 600 we could

move if we had the personnel and the private nursing home facilities to

move them to.

Senator Moss. I understand that a number of States have indicated

they have rather large numbers that certainly could be moved.

Do you have any national figures on the number of people who

could be adequately cared for or even better cared for in nursing homes

rather than retaining them in our mental hospitals?

Mr. DAVIS. That would have to be a rather wild guess.

Senator Moss. Give us an estimate, a ball park estimate, as we learn

to say around here.

Mr. DAVIS. There are approximately 750,000 mental beds in the

United States at any given time and the occupancy is 85 percent or

more. I do not have national percentages on how many are 65 and

over. But I would say, based on our own experience in Louisiana,

that 75 percent of the people who are 65 and over sent to mental hospitals should either not go there in the first place or could be returned

to the community with adequate facilities.

Senator Moss. What is your estimate on percentages?

Mr. DAVIS. I would say 75 percent. Now, if you ask me how many

are in our hospitals 65 or over, that we could move out, it would be a

higher percentage, I would say 85 percent of those 65 and over in our

mental hospitals now could be removed to the community with adequate

facilities.
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 293

Senator Moss. That is an astonishing figure, and I am glad to get it

in the record. It gives us something to think about.

Mr. DAVIS. It will be challenged, you may be sure.

Senator Moss. It certainly is a challenge.

In your statement, the one made for the association, you pointed

out that it is necessary to insure immediate access to general hospital

facilities when these patients are placed in nursing homes. From that,

would you say it is desirable to have a formal affiliation between the

nursing home and the hospital for this type of patient placed in the

nursing home?

Mr. DAVIS. Definitely. In fact, we encourage the construction of

nursing-home facilities in conjunction with a general hospital, and if

not, before we will license them they must have some agreement with

a general hospital for the transfer of patients.

Mr. FRANTZ. Do I understand correctly that in your State licensing,

you require a formal agreement with a hospital?

Mr. DAVIS. Yes. We have quite a number of nursing homes that

are built in conjunction with general hospitals. Twelve of the 155

licensed nursing homes in Louisiana are a part of a general hospital.

Mr. FRANTZ. Are a part?

Mr. DAVIS. And much of your Hill-Burton money that comes to

Louisiana for nursing homes goes to those that are affiliated with a

hospital. We make it pretty difficult for them to build with HillBurton money unless it has that affiliation.

Mr. FRANTZ. For the others that are not actually part of the hospital, is there a standard form of agreement which the State prescribes?

Mr. DAVIS. At present we do not have a specific form, but they must

have an agreement satisfactory to our inspectors. You heard earlier

about inspection. We have regular inspectors going to every nursing

home to study every aspect from sanitation, fire control, diet, and nursing care to see that they are up to standard.

Senator Moss. Do you think there ought to be stricter standards

applied to these nursing homes that take patients who have been

moved out of the mental hospitals?

Mr. DAVIS. If we made them any stricter in Louisiana we would

put them out of business. I do not think they should be any different from nursing homes that care for the regular aged person. We

would like to remove this mental illness tag and reduce its connotations as much as possible, because it does not belong there.

Senator Moss. Mr. Frantz has one other question he would like

to ask.

Mr. FRANTZ. You emphasized the private nursing home as a resource for the placement of these people and just for the record, I

wanted to clarify whether you included nonprofit and church-related

homes along with this?

Mr. DAVIS. Yes, proprietary and nonprofit; we have no real preference in the matter, except we like to see people build nursing

homes that they personally are going to operate. Absentee ownership is not the best means of providing good nursing home care.

It should not be a thing to go into to make money out of, in that

sense. We find that people who own and operate their own nursing

homes do the best job.
294 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

Senator Moss. That is an interesting point. We have asked this

a number of times of other witnesses and I do not think we have

ever had as direct a statement of opinion and speaking from experience that you have given us.

Thank you, Mr. Davis. We appreciate this very much.

Our next witnesses represent the Blue Cross Association: Mr.

James M. Ensign, director of professional relations; Mr. Steven

Sieverts, who is the assistant director, and Mr. Bert, Tollefson, Jr.,

who is the Washington representative.

I am glad to have you gentlemen with us and we look forward to

receiving your statement.

Mr. ENSIGN. Thank you, sir.

STATEMENT OF JAMES M. ENSIGN, DIRECTOR OF PROFESSIONAL

RELATIONS, BLUE CROSS ASSOCIATION, ACCOMPANIED BY

STEVEN SIEVERTS, ASSISTANT DIRECTOR, AND BERT TOLLEFSON,

JR., WASHINGTON REPRESENTATIVE, BLUE CROSS ASSOCIATION

Mr. ENSIGN. My name is James M. Ensign. I am director of

professional relations for the Blue Cross Association, the national

organization of nonprofit Blue Cross hospital service plans. I

appear before you today as the representative of these plans, which

collectively provide hospital service benefits to some 59 million

American citizens of all ages. With me today is Mr. Steven Sieverts,

assistant director of professional relations and Mr. Bert Tollefson,

Washington representative for the Blue Cross Association. We

appreciate this opportunity to present Blue Cross views on the financing of long-term care.

Blue Cross initially focused on the acute general hospital. Our concern for many years dealt primarily with the financing of care in the

hospital for episodes of acute illness. With the passage of time, however, our communities have demanded broader coverage of services

within and without the hospital, so that today, in addition to the

purely inpatient aspects of care in general and special hospitals, Blue

Cross covers emergency room services, outpatient services, skilled nursing facility (or nursing home) services, and services in the home

( visiting nurse or coordinated home care services) in many or most

areas of the country. The public, having become accustomed to voluntary nonprofit prepayment of acute hospital care, has come to

desire equivalent protection on a broader front.

The phrase, "long-term care" describing your subcommittee's interest, encompasses an extremely complex area of concern. Health problems do not separate neatly into chronic disease and acute disease;

one can be chronically ill and need little medical care for short periods

of time, or be acutely ill for an extended period of time. It is the financing of expensive services over periods of months and years that presents serious problems, not the question of whether the diseases requiring long-term care are technically "chronic" or "acute."

Treatment of long-term conditions takes place in many settings:

the doctor's office, the home, the acute general hospital, the outpatient department, the chronic disease hospital, the mental institution,

the tuberculosis sanitarium, the nursing home, the convalescent home,

the home for the aged and its infirmary. Most often these are sepa-
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 295

rately owned and administered and sometimes located in separate communities. A major problem lies in bringing these facilities, programs,

and personnel into a continuum of coordinated care for the patient

with proper reference to quality and economy. We in Blue Cross

are well aware that the benefits which we select and how we administer them with particular reference to standards will help shape the

patterns of care which develop in the future.

In the general hospital setting Blue Cross has frequently found itself financing long-term care. Often the acute general hospital is the

most appropriate locus for a long-term patient who requires its comprehensive or acute services. It has been estimated that some 10 percent

of Blue Cross subscribers admitted to the hospital for illness or accident stay 15 or more days and utilize nearly 40 percent of hospital

days for all subscribers. It is common for Blue Cross contracts to cover

up to 120 days of hospital care; maximum benefits of 365 or 730 days

are not uncommon.

It is also true, however, that some persons who are presently patients

in hospitals for extended periods of time would be better cared for in

facilities more specifically attuned to their needs and conditions. The

exact numbers of persons fitting this description has not been determined accurately. The very lack of professionally sound long-thrincare facilities in a community may make the hospital the treatment

location of choice by default. Many other factors may contribute to

the choice of the hospital for care of long-term patients. Convenience

for the physician who may be used to working in the hospital setting,

remote location of appropriate facilities beyond the hospital, and the

existence of coverage for in-hospital services only, are but a few of

factors which may be involved.

Serious questions are raised about whether the fact of prepayment

is acting as an inducement for some patients to remain hospitalized

because transfer to postacute facilities or programs such as chronic

disease facilities, nursing homes, or other postacute programs might

mean extra financial burdens for these patients. We in Blue Cross are

deeply concerned with this problem, and not only for the obvious reason

that hospital care costs considerably more per day than does care in

settings which may be more appropriate for certain long-term-care

conditions. Our community sponsorship and our close cooperation

with the community's hospitals give us a profound interest in the

quality of care available in the community. We are quite aware of the

fact that there is a range in quality from the excellent to the shockingly poor in postacute facilities and programs; we are not willing to

commit our subscriber's purchasing power to the support and perpetuation of inferior or inappropriate facilities and services.

Individual Blue Cross plans in their development of postacute

benefits recognized the problems of inferior care in substandard institutions by seeking quality standards adequate to protect their subscribers. At the national level the development of a professionally

sound accreditation program for skilled nursing homes is one of the

most troublesome of postacute care problems. Forty-five percent of

the nursing homes listed as "skilled" by the U.S. Public Health Service

do not have a registered nurse in attendance at all. More than 40 percent of the total "skilled" nursing home beds are listed as "unacceptable" under the State Hill-Burton program standards. State
296 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

nursing home licensure laws are often so loose or permissively administered as to allow homes with less than professionally acceptable or

physically safe standards to obtain licensure.

With reference to national programs of standards, 2 years ago Blue

Cross Association, in developing guidelines for its member plans, urged

the Joint Commission on Accreditation of Hospitals to assume the

accreditation of skilled nursing facilities as an ongoing program. The

joint commission has a time-honored and widely accepted professional

reputation in measuring adequacy of hospital facilities and applying

standards of care. This agency is multilateral in its membership,

bringing the knowledge and reputation of the American Hospital Association, the American Medical Association, the American College of

Physicians, and the American College of Surgeons with the skills and

talents of full-time doctor of medicine surveyors to bear on this important task. However, as you have heard from others, the joint

commission members reached an impasse on the logical extension of

accreditation into skilled nursing facilities.

Having already endorsed the American Hospital Association's listing (now registration) program for inpatient care institutions other

than hospitals as a desirable prerequisite to accreditation or as an acceptable alternative until joint commission action, the Blue Cross Association went on record in support of strengthened AHA registration and

continued efforts by the AHA to work toward accreditation. The

American Hospital Association standards and program format were

felt to be essentially sound in differentiating among acceptable and

unacceptable facilities. The Blue Cross Association will continue to

support the AHA registration program until a successful breakthrough occurs in returning to the concept of a multilateral accreditation program such as that originally proposed by the Joint Commission

on Accreditation of Hospitals.

In more than half of the Blue Cross plans, some skilled nursing facility benefits are now available under certain subscriber contracts,

especially the special contracts written for the aged. We do not pretend that the arrangements under which these benefits are being

delivered are fully satisfactory in all areas. Blue Cross has stepped

in to fill a need and has provided benefits on a limited scale to gradually gain experience in this field of coverage. Our collective experience reinforces our conviction that there is need for a professionally

administered, sound program to define adequate standards for skilled

nursing facility care.

In many instances long-term care is most appropriately administered

in the patient's own home. Blue Cross has helped to pioneer in the

development of coordinated home care in the United States. Major

home care efforts are being supported by Blue Cross. Programs in

Michigan, New Jersey, Greater New York City, Greater Rochester,

New York, and Delaware are notable examples.

Let me stress our conviction concerning the necessity of careful

planning in the next steps in improving the availability and the

quality of long-term care facilities and programs. It is apparent that

more and more funds from State and Federal Government will be

directed toward expanded health services for the older citizens who

are most in need of long-term care of all kinds. We have already seen

the proliferation of substandard nursing homes built and operated at
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 297

levels dictated by meager governmental financing for old-age assistance recipients; the infusion of fresh money will not by itself guarantee

better standards. What will be needed is a strong, yet flexible, control

mechanism with quality standards set high to assure adequate care.

We will face the dilemma, as I mentioned earlier, of keeping these

standards adequate and working toward an adequate supply of services at the same time, in order to meet the substantial needs of those

requiring long-term care. If an error is made in balancing needed

quality and needed quantity, we would submit that it would be preferable to err on the side of quality, and to allow time and the existence

of expanded purchasing power to fill the gaps.

Further, we would urge that the planning for long-term care be

carried on within regions or on an areawide basis, with reference

to the need for an active coordinating role on the part of hospitals,

to include physicians, and all health services, facilities, and personnel. Hospitals, for example, might extend their purview to "adopt"

skilled nursing facilities through affiliation agreements, or build

long-term care units in order to achieve continuity of care for the

long-term patient. Other programs for long-term patients must be

coordinated within the community to extend this continuity into

the home, the doctor's office and the outpatient departments. Here,

again, we feel the community hospital has a strong role to play.

In conclusion, we accept the fact that the financing mechanisms

should permit and encourage the use of the most appropriate treatment modalities at the right time, and we accept an active role in

behalf of the aged, as well as all members of the community, in

promoting standards and the growth of public oriented and effect.ively operated facilities.

Blue Cross Association is pleased to offer these comments. If we

can assist the subcommittee further, we will be happy to do so.

Senator Moss. Thank you very much. It was a very fine statement, Mr. Ensign.

I noticed in your statement you indicated there were contracts

covering up to 120 days, some were as many as 365 or 730 days.

Are these in common use now?

Mr. ENSIGN. 120-day contracts are very common now; yes, sir.

Senator Moss. And what percentage of your contracts do you

think would fall in that area?

Mr. ENSIGN. We do not have that here available at the present

time.

Our most common national contract is the 120-day contract. This

is one serving national accounts; that is, employed groups of multiState corporations.

Senator Moss. The others, though, the 365 would be a rather unusual one?

Mr. ENSIGN. Not unusual, I would say, in some of the highly,

industrialized areas. Michigan, for example, offers a 365-day contract which is quite commonly in use in that State.

Senator Moss. Many of the Blue Cross plans pay the hospitals

on the basis of audited. costs. Do these plans offering nursing home

benefits specify the type of costs on which reimbursement would be

based?
298 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

Mr. ENSIGN. The benefits in nursing homes have not reached the

sophisticated point where Blue Cross plans are paying on the baths

of audited costs to nursing homes. There is some thought and experimentation going on in this area. However, the practice is one

of providing, at the present time, indemnified benefits in nursing

homes. That is the pattern in reimbursement to nursing homes, so

that often there is an indemnified payment, for example, of 60 percent of the daily charge or $8 per day.

Now, we are convinced that probably the earliest steps in providing

reimbursement based on nursing home costs will take place in nursing

homes that are either affiliated closely with hospitals or are actually

owned and operated by hospitals. One reason is that the hospitals over

the years have reached the point of sophistication in accounting and

administration which permits this, whereas in most of the nursing home

facilities audited costs are difficult to obtain.

Senator Moss. Do you feel you get a higher level of care in hospitalaffiliated nursing homes than you do in the unaffiliated?

Mr. ENSIGN. I would say the organized medical staff, medical records committee, and many of the other organizational aspects of a

hospital which promote high quality care would necessarily rub off on

the nursing home which becomes affiliated with an acute general hospital ; yes, sir.

Senator Moss. In your experience has the availability of the skilled

nursing home benefits significantly reduced the average length of stay

in the hospital?

Mr. ENSIGN. No, sir. This is largely because the benefit is not yet

widely enough available, and because of the lack in many years of

skilled nursing home facilities which could effectively take on the load

of patients which they might assume were they to meet high standards.

The use of these facilities by physicians at the moment is limited and

would be expanded if there were higher quality facilities closely related

to the hospitals so that the process of discharge from hospital to nursing home would become a sort of routine thing rather than being an

exceptional case.

Senator Moss. Does Blue Cross experience any significant difference

in the services rendered in the proprietary homes and those available

in nonprofit institutions?

Mr. ENSIGN. I can only speak of isolated instances. We have no

general statement to make on that point.

But based on personal observations, I can say that one of the types

of facilities where we see high standards of quality adhered to to a

greater extent than in the proprietary institution is the home for the

aged with an infirmary. These are largely nonprofit, and the programs for the elderly patients who find themselves in need of medical

services tend to be of a higher quality than we have seen in a broad

range of other skilled nursing facilities or nursing homes around the

country.

Senator Moss. In talking about accreditation, which you strongly

urge, I wondered why the Blue Cross Association urges its member

plans to use the American Hospital Association's registration program

as a standard rather than the accreditation of the American Medical

Association-American Nursing Home Association?
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 299

Mr. ENSIGN. Well, we feel that it is important to have an organization do the accrediting job which has standards that focus on medical

staff organization, the requirement of certain level of nursing care

around the clock, the provision of adequate medical records and a,

number of other things which are characteristic of the American Hospital Association registration program.

Now, the existence of the AMA—ANHA accreditation program is of

such recent vintage that we have not fully been able to evaluate the

standards and the administration of this program. We have as I indicated in my statement, supported the American Hospital Association

registration program for more than 2 years. It has, in fact, registered

a significant number of skilled nursing facilities

'

as I am sure you

heard from the American Hospital Association. I believe the figure is

1,221 facilities registered to date.

We feel that the American Hospital Association program by urging

affiliation with hospitals, by setting a standard which requires medical

staff organization, by requiring registered nurses for supervision of the

care in the institution, has a program which will have to be adequate for

the moment. It is the one that we have elected to support as an

association.

Senator Moss. You think it is adequate in the present instance and

as far as you see will be adequate in the future?

Mr. ENSIGN. As I indicated in my testimony, I would hope that

accreditation by a multilateral agency such as the joint commission

will return to the scene as the agency for accreditation.

We find in some areas, in California, for example, that this kind of

program is in existence. We hope that a national program comparable to the California program will develop.

Senator Moss. All right. Mr. Frantz has one more question, he

says, on this.

Mr. FRANTZ. You mentioned that the National Council on Accreditation program was very recent and I believe that only 279, I think is the

figure, homes have received their accreditation.

Do you have any information to the effect that even of this number

many of those may have received their accreditation before the standards were adopted which would actually be a grandfather clause

accreditation?

Mr. ENSIGN. Yes; we have that information.

Mr. FRANTZ. Could you tell us how many such instances have

occurred?

Mr. ENSIGN. I imagine this would be considered entirely hearsay.

However, I would say a substantial majority of those that are now

listed as being accredited by the National Council on Accreditation

had formerly been accredited by the ANHA program which was

a unilateral program prior to the formation of the AMA—ANHA

Council.

Senator Moss. Thank you, Mr. Ensign, Mr. Sieverts, and Mr.

Tollef son. We appreciate your coming and giving us this testimony.

It has been most helpful and we appreciate it.

Mr. ENSIGN. Thank you, sir.

Senator Moss. Our next witness is Dr. Mitchell Wendell, who is

counsel for the Council of State Governments. I am very glad to

have you, Dr. Wendel; glad to see you again2 and have you before the

committee on which I sit. We appreciate having your testimony.
300 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

STATEMENT OF DR. MITCHELL WENDELL, COUNSEL TO THE

COUNCIL OF STATE GOVERNMENTS

Dr. WENDELL. Thank you very much.

Mr. Chairman, since you have received the prepared statement in.

advance in multiple copies, I would ask permission to have it included in its entirety in the record and I will simply highlight it

and summarize it here this morning and respond to such questions

as Tou may have.

Senator Moss. Thank you. The entire statement will be placed

in the record and you can go ahead with your comments or highlighting of it as you care to.

(The statement follows:)

PREPARED STATEMENT OF DR. MITCHELL WENDELL

My name is Mitchell Wendell. I appear in my capacity as counsel to the

Council of State Governments, a joint agency of the 50 States and the Commonwealth of Puerto Rico for Federal-State and interstate relations.

In the early 1940's the Council of State Governments organized what is

now its committee of State officials on suggested State legislation. This committee is composed of State legislators, attorneys general, legislative service

personnel, and uniform law commissioners. Its purpose is to draw upon the

experience of all the States in calling to the attention of State governments

problems of new or urgent concern and suggesting, frequently in draft bill

form, specific avenues which may be employed in dealing with the problems.

Sometimes such suggested legislation is modeled closely on an enactment of a

particular State, sometimes it is a blending of relevant statutes in several

States, and sometimes it is a new product developed either by the committee of State officials itself or by one or more groups known to have expertise

in the field of the proposal.

At the present time, the committee of State officials on suggested State

legislation is working on a comprehensive nursing home statute. The project

was begun last fall after the wide variation in the scope of State laws on

the subject was called to our attention by staff members in the Department of

Health, Education, and Welfare who have been doing research in the nursing

home field for some time. As the result of a subsequent meeting with the

President's Council on Aging, the cooperation of that group in our undertaking

also has been secured.

A first draft of our projected nursing home statute has been prepared.. In addition to a subcommittee of the committee of State officials on suggested State

legislation, an advisory group has been constituted to review the draft with an

eye to making criticisms of it which can form the basis of a revised document.

This advisory group and the subcommittee will hold a first meeting on May 20.

This process of comment and revision will be repeated until we are satisfied that

we have as good a product as we can develop. The draft will then be submitted to

the full membership of the committee of State officials. If approved by the full

committee, it will become part of one of the "Programs of Suggested State Legislation" of the Council of State Governments. These programs are annual publications of the Council of State Governments which are furnished to all State legislators, legislative drafting and research agencies, and to many other groups of

State officials as well. Items appearing in them are not necessarily intended to

be enacted by all States in exactly the form that they appear in the publication.

It is inevitable that each State should examine these models with a view toward

their own existing laws, the scope of the problem which they face, and their own

policy judgments. Nevertheless, the "Programs of Suggested State Legislation"

have had substantial influence, and the substance of draft bills contained in them

has found its way into the laws of many States.

Since the first revision of our draft statute will not be made until after the

meeting of May 20, it is not possible at this time to set forth the ultimate contents of the final product in specific terms. The principal purposes of my appearance before you today are to inform you that we are at work, to tell you something of the group which is to serve with us, and to provide whatever
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 301

information we can. It is probably true that at this stage of its work the

committee of State officials can learn as much from you as it can tell you.

In forming our advisory group we have been conscious that a good suggested

State act is most likely to be developed by calling upon those with professional

training and experience in the several aspects of the nursing home problem, as

well as those with competence in the drafting of legislation. Consequently, our

group consists of a number of Federal and State officials, and representatives of

the leading medical, nursing, and related associations, as well as of several

individuals who have been asked to serve because of their personal qualifications

in the nursing home field.

Perhaps the best way to offer our substantive comments on the nursing home

problem and on the more important provisions of a comprehensive State law is

to reproduce the major portion of the explanatory memorandum which was sent

to the members of our advisory group along with the first draft of the suggested

act. The memorandum in relevant part is as follows:

EXPLANATORY STATEMENT TO ACCOMPANY SUGGESTED NURSING HOME ACT

An ever-increasing number of persons require the services of nursing homes.

On the whole, it is probable that the demand for nursing home care in connection

with convalescence remains relatively constant and any upward trend is to be

explained as merely a reflection of the Nation's increasing population. On the

other hand, the number of elderly persons in our society is undergoing a marked

increase.. In part, this is due to an ever-larger population, but even more it results from greater longevity among our people and to the consequently greater

significance of the degenerative diseases as causes of infirmity.

States have undertaken to regulate nursing homes, both by statute and by

administrative action. However, the extent of the laws in the individual States

varies widely from jurisdiction to jurisdiction. The suggested legislation is

designed to serve as a comprehensive statute dealing with all of the phases of

nursing home regulation which are appropriate for treatment in statute. It

should be noted that many matters are more appropriate for administrative regulations. In such areas, the suggested legislation provides for the objectives

to be attained by such administrative action and confers the necessary rulemaking power on an appropriate State agency. A number of matters do lend

themselves to direct statutory treatment. They are covered specifically.

1. Licensing.—The basic public concern with nursing homes is to see that they

offer facilities and services appropriate to and adequate for the health and comfort of their patients. As an enforcement problem, this involves passing upon

qualification of personnel and inspecting facilities to see that they meet desirable

standards. Licensure can serve as the central element in approaching this part

of the governmental task. In order to cover both the facilities and personnel

aspects, the act provides for a nursing home license which is actually a facilities

license, and a nursing home administrator's license, which is the license to be

required of the person in charge of the home. The qualifications of other personnel, including medical and nursing personnel, are described in broad terms

and left for supplementation by administrative rules and regulations.

2. Patients to be accommodated.—The question of classification for nursing

homes can be a difficult one. In some respects, these institutions are like hospitals; but since they are not intended to cater to the completely disabled, and since

It is desirable to produce as cheerful and normal an atmosphere in a nursing

home as possible, it would be improper to think of a nursing home as a hospital

and to regulate it as though it were one. At the other end of the scale—particularly where elderly persons are concerned—the nursing home has some of the

characteristics of a hotel or boardinghouse. Yet it is not accurate to regulate

it as though it were such an establishment, because much more specialized services are required. Consequently the suggested act attempts to steer a middle

course. It provides for the exclusion of patients who really need hospital services. While it does not expressly forbid the admission of persons who are well

enough to live in hotel-type residences, it may be assumed that such individuals

normally would not seek out the nursing home as a place of abode and that no

provision of law is necessary to discourage them.

3. Substandard homes.—The principal provision of the suggested act in its

present form which relates to substandard homes is the provision for revocation

of a nursing home license. It is probable that the only satisfactory way to deal

with substandard facilities, or facilities so poorly operated that they fall below

minimum permissible standards, is to require discontinuance of the establish-
302 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

ment. On the other hand, many other violations of the act's provisions should

be the occasion for the imposing of legal penalties. At this stage of the work

on the draft, no attempt has been made to write such penalty sections.

Dr. WENDELL. As you know, Mr. Chairman, the Council of State

Governments is a joint official organization of all the States and

Commonwealth of Puerto Rico. It has a number of separate functions

which it carries on on behalf of the States, only one of them is of

direct concern here this morning, and that is in the province of the

committee of State officials on suggested State legislation which is a

committee of the Council of State Governments and for all of its

forbidding title, what it actually does is to pool the experience of the

States in legislation which they may be developing to handle new or

urgent problems. The committee itself consists of a number of

State legislators, for that matter virtually every State in the country

has at least one State official representative on the committee on suggested State legislation, sometimes more than one; it consists of State

legislators, of State attorneys general, of legislative reference and other

legislative service people, of bill drafters, and we in the Council of

State Governments staff act as secretariat to this committee as we do

to other committees and affiliates of the Council of State Governments.

Sometimes the committee also in a new field does break new ground

and does develop its own legislation which it then makes available to

the States for such use as they might wish to make of it.

A project in which we are currently engaged is the development

of a comprehensive model State nursing home act. The legislation

in the regulation of nursing homes for all of the standards, of

course, which the Federal Government provides through its various

agencies in respect of those programs that can be federally aided,

legislation in this field is, of course, State legislation. It was called

to our attention rather forcefully and rather pointedly back last

fall that this legislation from State to State was, of course, widely

varying in content and in scope and it would be desirable to improve

and perhaps even to get a more common core into the State legislation in this particular field.

This is the reason for our having undertaken the project.

We have drafted in preliminary first draft fashion a model nursing home act and we have also recruited an advisory group to work

with a subcommittee of the committee of State officials on suggested

State legislation, to help us go over this draft and successive drafts

of this comprehensive model nursing home act and what we propose

to do is repeat this drafting and review procedure with our advisory

groups and the members of the subcommittee as many times as

necessary until we are satisfied that we have as good a product as

we can recommend to the States.

At that point it will be offered to the full committee of State

officials and hopefully, if we do not go too far wrong, why, they will

adopt it and carry it in the program of suggested legislation which

is an annual publication made available to all State legislators and

to many other State officials in all of the States calling to their

attention the desirability of perhaps updating and improving what

they may now have in the individual States by way of law on this

particular subject.

We are in a very preliminary stage, as I have just indicated: The

first meeting of our subcommittee and advisory group is going to
NURSING HOMES AND RELATED LONG-TERM CARE SERVICES 303

be held on the 26th of this month at our offices here in Washington,

and the makeup of that advisory group consists of a number of

Federal and State officials with experience and responsibility in this

particular field, and also representation of the leading medical and

nursing •and other organizations with responsibilities or interests

or knowledge in this particular field.

We have also, Mr. Chairman, invited your committee to be represented on our advisory group and to assist us, and if you find that

possible, why, we will be very glad to cooperate with you and to

also receive the help of the knowledge that you and your staff have

developed in the course of your work in this particular subject and

in putting our act together.

Senator Moss. We appreciate the invitation to participate in formulating this model act that the Council of State Governments has set

about to work upon and I will be most happy to ask Mr. Frantz, our

professional staff member here on the subcommittee to meet with your

group and to render such assistance and advice as he can give to this

committee.

Dr. WENDELL. Thank you very much. That will be most

appreciated.

Senator Moss. The drafting of model codes, I think, represents a

real service by the Council of State Governments. We have a diversification that exists among our 50 States and a need for some greater

degree of uniformity in many areas of regulation.

I am aware that the Public Health Service, of course, has recommended standards already to the States in these nursing homes and

homes for the aged. I wondered to what degree a model code would

follow this recommendation or vary from it or supersede the recommendations of the Public Health Service?

Dr. WENDELL. Well, the Public Health Service is one of the Federal

agencies with which we are cooperating and their people are part of our

advisory group as well as the others. We have been over the Public

Health Service standards and some other materials that they have

developed over the course of the past couple of years. Most of what

they developed is really not statutory material, it has to do on the

whole with the mechanical and physical measurements for nursing

home facilities, with certain other requirements that are more appropriate for administrative rules and regulations than for a statute.

I have been guided by those standards in preparing the first draft.

to the extent that they did constitute statutory material rather than

administrative rule and regulation.

In its first draft form what the statute proposes to do is to set out,

and does set out, those things that we feel can specifically be handled

by statute and then within the framework of the statute the draft

presently confers rulemaking power on the State agency that would

administer the act and I am sure that much of the material, either

verbatim or similar to what the Public Health Service recommends,

would be expected to be incorporated into these implementing rules

and regulations.

Senator Moss. Does the model code in any way call for additional

inspection and enforcement? We have heard that one of the problems we have is the inadequacy of enforcement of any licensing

features that we have now and I am wondering about that next step.

Dr. WENDELL. Well, you understand, Mr. Chairman, that anything
304 NURSING HOMES AND RELATED LONG-TERM CARE SERVICES

I say about this rough draft in its present form does not at this stage

represent anything other than what is in the first draft and what will

be reviewed and the policy for which may be changed, depending on

what our advisory group and our committee thinks.

With that caveat, I can say what is in the rough draft.

The rough draft proceeds basically on the licensure principles; it

does provide that in order to get a license, in order to keep a license—

and there are two types of licenses involved in the rough draft as it

now stands: One for the physical facility, that is the nursing home,

and the other for the chief person who is in charge of operating it,

whom the draft calls a nursing home administrator—in order to get

and to keep such licenses the draft does provide for initial inspections,

for then a probationary period while the facility is just getting into

operation; another inspection before it becomes a permanently going

licensed facility; annual inspection at least thereafter, and with respect

to the personnel, to the nursing home administrator, why, I am suggesting in this first draft that he be examined prior to licensure and

that a minimum course of training be required, in either hospital administration or nursing home administration or some such allied field.

Then, of course, his continuance, his license, could be revoked if it

were demonstrated that he did not continue to perform satisfactorily.

As for other types of inspection to see that there are proper facilities and that there are proper personnel on the premises, the draft

specifically provides at the present stage, that all of the necessary building codes and other applicable codes such as the codes the Departments

of Health may have for the preparation of serving food and so

on, remain applicable and must be complied with and evidence that

they are being complied with must be submitted as prerequisites to the

initial obtaining of a nursing home license and then of the annual

renewals of such licenses.

With respect to other professional personnel, such as medical and

nursing personnel, the first draft provides that there shall be such

persons available and such services available, but it leaves up to rules

and regulations how many because this is bound to vary with the size of

the institution and the conditions in the institution and perhaps even

with its location.

Senator Moss. Thank you, Dr. Wendell. I think this is a very significant step in finding a solution to the problem that we are examining

and it is most helpful to us to know that the Council of State Governments is proceeding in this way. We will be most happy to cooperate in

every way that we can to assist in recognition of the role of the State

and the need for States to improve these standards and bring some

uniformity to the improvements.

We appreciate your coming today and bringing us this statement,

giving us your testimony and answering our questions.

Thank you, sir.

Dr. WENDELL. Thank you very much, Mr. Chairman.

Senator Moss. This has now completed the list of witnesses for the

hearings and the hearings will now be adjourned.

(Whereupon, at 12:25 p.m., the hearings were adjourned.)

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