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Michigan Non-Profit Homes Association Conference, East Lansing, MI, September 13, 1972 (1)
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Michigan Non-Profit Homes Association Conference, East Lansing, MI, September 13, 1972 (1)
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The original documents are located in Box D33, folder "Michigan Non-Profit Homes
Association Conference, East Lansing, MI, September 13, 1972 (1)" of the Ford
Congressional Papers: Press Secretary and Speech File at the Gerald R. Ford Presidential
Library.
Copyright Notice
The copyright law of the United States (Title 17, United States Code) governs the making of
photocopies or other reproductions of copyrighted material. The Council donated to the United
States of America his copyrights in all of his unpublished writings in National Archives collections.
Works prepared by U.S. Government employees as part of their official duties are in the public
domain. The copyrights to materials written by other individuals or organizations are presumed to
remain with them. If you think any of the information displayed in the PDF is subject to a valid
copyright claim, please contact the Gerald R. Ford Presidential Library.
Digitized from Box D33 of The Ford Congressional Papers: Press Secretary and Speech File at the Gerald R. Ford Presidential Library
Wednesday, September 13, 1972
Speech before Michigan Non-Profit Homes Association Conference
East Lansing
Kellogg Center
Problems the Association is concerned about:
-- Delay by the State Health Department in dealing with
violations of profit-making nursing homes. The
Association feels that such violations are unjustly
associated with the non-profit homes.
-- Delay in reimbursement for public assistance patients.
Topics the Association would like you to talk about:
-- H. R. 1.
-- Prospects for health care legislation.
Paul has more "background" info
if you would like it
FORD LIBRARI is GENALD
1st annual convention -
mich non. Profit Homes assin )
Bangust Sgot 13 at Kallogg Ch,
msu, E.Laweing - 6:30 ?
Twarly 50 nonprofit nursing have
f homes fn The ageng in State 8 Mich
"Motination for Service-"
(616) 382-5033
Prob. Areas-
Stands part i. pat care
State Health Depthas heen lax
need upgrading 2 eufore.
n polo's on viol 1s. Then all
I printed my The same frush
I more ha. yr fr- fin stapt
non-propt homes are but more
and togel phllan gift for
patishate open defects - hand Pelt to get Askst reinibur
Inter in know. what ma be
GERAFO FORD NEBARY
his Using one! 2x reinturse
site in H R.1- -
- " " health progs- what
propertane In legis
The Aden 'ns proz, Jupgrading nurs,
That assi cando 2 purther
homes = We want take a more
aggress role in sgrading stand
of put care care.
What one H. progo are -
Buhing Dear up to date an
Bulkare etc.
accouplish The adm in of ratives.
Had the asin can help to
Could Speedatont 10 mins.
20 min. on legis. 1 Then
talking about H Chira -med. fild.
5/4021
H.R.I. = incl. a ho. of proms to
change in Made and & Medican
Some will G
arins such as Reis - others heat
fealth lyi - - Come
cruh did not Return to if
latefall after 4 the
hald y twasof leavings in
This yr The can occupied m
Mentin a no
other he 3/4 prinity whis.
have been advanced to
catastrophic then
H R.1=
In Part B. phys. Fees
The prem payments Repat make
/ seris of proposal would min
I
Would liferdize for The
ofthe payments
- Under paces law The pay. mich.
period when hosp. costs you up -
- Under HRI-R pay. and only go
up to the export That Sn Sre. burfits
I goun How. The deducts under Part B
R.FORD
s add In The corpous bruef per
wouldgofy for 850 to 1860
BERALD
in inter pt hosp, stay.
under Part A united up postal all
Under Parth - Leyef pays deduce
I $60. to ave. cortof hosp stay e us.
Co. in sun, Legins 1
rg to 4 3 the
When H R /- co-ins. would hyri
mg at rate ig H&B
I 12 de duct. (3/21 then 60 day)
Ren 6/29 day The pres. rate
To require offer This would These be dubld calld when lifetere H.R.
{fn any spall of ilness - covered for
90 days rx cept that The benef. has
60 "ik coveragething use
once lifeten - (150 day).
for deduct This L, R. They pay 2 of the
Under H.R. L The L.R. would G
dubld 90 days + 120 2/0 days
total =
Under thes. know The States make The
pay. under Medicaid.
Under HR. 1. in certifies wouldbe
prov. TO to get the state du make
long stays in
my in H.M.O. stitutions. t to discount
= and of discrictions =
- replax a in ted, medicaid match.
per b to after 60 care
a Alceled mers the
while 3atim review prog
could show it had an effec
- Rederse of and 1/3 metch after
- capa /3 in geila Ded. or TB match hap. after
90 days in a mental hosp-
- tavai. of lesser provn's
Emact: dimfor now#
H.R. 1 bottled up in Sendte 3in-
has made many changes # which zh
The Welfare provis -
Cam In 14 no -
it h tant app El when not taken
e final votaln Don't know future
legis til nextyr - long ferry
no further consid. of health care
going reveir of Medicare,
out of is very good, mid. a Phono -
in yound lean toward The
admin Plan + plan rather Then Re townedy
BERALD FORD LIBRARY
REMARKS TO THE MICHIGAN NONPROFIT HOMES ASSOCIATION CONFERENCE
Product
apdoysis
for
Depan
A
9/73/72
not.
GOOD EVENING. IT IS A PLEASURE FOR ME TO BE TALKING WITH A GROUP OF PEOPLE
WHOSE LIVES ARE INSPIRED BY THE MOTTO, "MOTIVATION FOR SERVICE." LET ME SAY AT
THE OUTSET THAT I WISH YOU THEN GREATEST OF SUCCESS AT THIS CONFERENCE, AND I HOPE
THIS FIRST ANNUAL
THAT
CONFERENCE SETS A PATTERN OF ACCOMPLISHMENT FOR ALL OF YOUR CONFERENCES
IN YEARS TOEX COME.
IT IS INTERESTING THAT YOURS SHOULD BE THE FIRST GROUP OF ITS KIND THAT I HAVE
ADDRESSED SINCE RETURNING FROM A NINE-DAY STAY IN THE PEOPLE'S REPUBLIC OF CHINA.
THERE THE MONITION YOU SEE E VERWHERE IS THE SLOGAN, "SERVE THE PEOPLE." WHATEVER
ONE FEELS ABOUT COMMUNISM AS A FORM OF GOVERNMENT, ONE CANNOT ARGUE WITH THAT SIOGAN.
AS A MATTER OF FACT, THOSE WHO OBEY THAT INJUNCTION ARE MUCH TO BE AIMIRED. IN
AND
SO IT IS THAT I BELIEVE YOUR GROUP DESERVES A SPECIAL SALUTE AS YOU PAUSE TO LOOK AT
THE FIELD IN WHICH YOU SERVE AND CONSIDER HOW YOU MAY BEST IMPROVE XPON UPON YOUR
ACCOMPLISHMENTS.
THIS, I THINK, IS WHAT WE NEED TO SOLVE so MANY OF THE NATION'S PROBIEMS.
SPIRIT OF SERVICE, A
SPIRIT OF COOPERATION, SUPPORT OF POLICIES WHICH
PROMOTE THE GOOD OF THE ENTIRE NATION RATHER THAN THAT OF SELFISH PRESSURE GROUPS.
IT IS IN THAT
SPIRIT THAT I SPEAK TO YOU TONIGHT.
I AM AWARE OF YOUR SPECIAL PROBLEMS. I AM TOLD THAT
DELAY BY THE STATE
HEALTH DEPARTMENT IN DEALING WITH VIOLATION OF STANDARDS BY THE "FOR PROFIT" NURSING
HOMES RESULTS IN THE NONPROFIT HOMES BEING TARRED WITH THE SAME BRUSH. I AM ALSO TOLD
THAT YOU ARE PLAGUED BY DELAY IN REIMBURSEMENT FOR PUBLIC ASSISTANCERTX PATIENTS.
TONIGHT I WOULD LIKE TO DISCUSS SOME OF THE CHANGES THAT ARE IN THE OFFING IN
MEDICARE AND MEDICAID AND THE PROSPECTS FOR IMPROVED HEALTH CARE XNSURANCE LEGISIA TION.
,TOO,
I WILL
ALSO TOUCH ON MY EXPERIENCES IN CHINA, SINCE THAT MAY
INTEREST YOU.
THE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED IN NURSING HOME CARE
O VER THE LAST TWENTY YEARS, PARTICULARLY SINCE THE ENACTMENT OF THE ME DIC ARE AND
MEDICAID PROGRAMS IN 1965. THIS INVOLVEMENT CARRIES WITH IT A RESPONSIBILITY TO
WHICH
MEASURES UP To
ASSURE THAT NURSING HOMES DELIVER CARELAT THE VERY LEAST FEDERAL
STANDARDS AND REGULATIONS. THE PRE SI DENT ACCEPTED THIS RESPONSIBILITY IN HIS 8-POINT
PLAN FOR ACTION TO IMPROVE NURSING HOMES ANNOUN_CED JUST OVER A YEAR AGO IN NEW
HAMPSHIRE.
THE PRESIDENT'S AIMS WERE SIMPLE AND DIRECT:
-UPGRADE LONGTERM CARE FACILITIES:
-UPGRADE THE WAYS GO VERNMENT AT ALL LEVELS MONITORS
THESE FACILITIES:
-UPGRADE CHANNELS OF COMMUNICATION BETWEEN THE PATIENT, HIS FAMILY, THE NURSING
HOME AND GOVERNMENT AGENCIES CONCERNED WITH LONGTERM CARE:
--2--
--UPGRADE THE CAPABILITY AND CONSCIOUSNESS OF LONGTERM CARE PERSONNEL:
--AND, MOST IMPORTANT OF ALL, UPGRADE OUR UNDERSTANDING OF LONGTERM CARE
FACILITIES. ,LEARN WHAT THEY CAN AND CANNOT DO, AND CONSIDERX WHAT ALTERNATIVE
MODES AND LEVELS OF CARE MIGHT BE DEVELOPED TO ENSURE OUR OLDER CITIZENS THAT THE
RIGHT CARE, AT THE RIGHT TIME, AT THE RIGHT PLACE, AND AT THE RIGHT COST WILL BE
THERE.
NOW THIS MAY SOUNDEX LIKE X A LOT OFF UPGRADING AND IT IS. IT HAS BEEN, AND
IS GOING TO BE, AN UPGRADE BATTLE ALL THE WAY. NOT BECAUSE NO ONE IN THE NURSING
HOME INDUSTRY OR IN THE GOVERNMENT OR AMONG THE PUBLIC HAS 1 CARED IN THE PAST, BUT
BECAUSE UNTIL X VERY RECENTLY THERE HAVE NOT BEEN ENOUGH OF THSEX THESE VERY ESSENTIAL
ACTORS ON THELONGTERN CARE STAGE TO CREATE AND MAINTAIN A SYSTEM OF QUALITY THAT OUR
PEOPLE DEMAND.
IT WAS TO FULFILL THIS DEMAND THAT THE PRESIDENTE ORDERED THE FEDERAL GOVERNMENT
TO MOVE BOLDLY AND RAPIDLY ALONG SEVERAL FRONTS. THE EFFECTIVENESS OF THAT ACTION IS
ALREADY BEING FELT.
WE HAVE SEEN A MARKED IMPROVEMENT IN THE QUALITY OF STATE MEDICAID CERTIFICATION
PROHRAMS SINCE LAST NOVEMBER WHEN WE FOUND NO FEWER THAN 39 STATES WITH MAJOR
DEFICIENCIES, TODAY WE CAN BE REASONABLY CONFIDENT THAT EVERY STATE HAS A SOUND XNDX
SURVEY AND CERTIFICATION PROGRAM. AND THE ADMINISTRATION INTENDS TO CONTINUE TO
MONITOR THESE PROGRAMS TO MAKE SURE THEY STAY THAT WAY.
THE OBJECTIVE OF THIS FEDERAL EFFORT IS THREE-FOLD:
--TO SERVE NOTICE ON THE STATES THAT FEDERAL STANDARDS ARE TO BE FOLLOWED.
LETTER;
--TO SERVE NOTICE ON THE INDIVIDUAL NURSING HOME OPERATOR THAT THE FEDERAL
PORTION OF HIS PATIENT CARE DOILAR IS GOING TO BE PAID ONLY IF THAT PATIENT IS
RECEIVING THE QUALITY OF CARE HE OR SHE IS ENTITLED TO;
--AND, THIRD, TO A SSURE THE INDIVIDUAL PATIENT THAT THE FULL BURDEN OF RESPONSIBILITY
FOR THE QUALITY AND SAFETY OF HIS OR HER CARE ISNAM NOW TO BE BORNE SQUARELY BY THE
FEDERAL, STATE ANDKE LOCAL GOVERNMENT AGENCIES SUPERVISING THAT CARE AND BY THE NURSING
HOME PROVIDING THE SERVICES.
THE ADMINISTRATION BELIEVES THESE PURPOSES ARE BEING MET.
THE AIMINISTRATION IS ALSO MAKING PROGRESS ON SEVERAL OTHER FRONTS OF THE
FEDERAL LONGTERM CARE PROGRAM.
THERE IS THE PUBLICATION OF FEDERAL MEDICAID STANDARDS FOR INTERNEDIATE CARE
FACILIT IES WHICH ARE TO BE IMPLEMENTED IN THE FALL.
THERE IS THE DEVELOPMENT OF JOINT MEDICARE-MEDICAID NURSING HOME STANDARDS WHICH
WILL COORDINATE ANDEXER XXXXXX SIMPLIFY VIRTUAL LY ALL COMPLEMENTARY ASPECTS OF THESE
PROGRAMS.
-3-
XEHRE THERE ARE THE H.E.W. TRAINING PROGRAMS, WHICH HAVE NOW REACHED MORE THAN
700 OF THE 1100 STATE MEDICAID NURSING HOME INSPECTORS IN THE FIELD WITH UNIVERSITY-
BASED TRAINING COURSES. MAY I INTERJECT AT THIS POINT THAT I HOPE CONGRESS ACTS ON
THE PRESIDENT'S PROPOSAL THAT THE FEDERAL GOVERNMENT A SSUME THE FULL COSTS OF STATE
MEDICAID NURSING HOME INSPECTION PROGRAMS.
AND, FINALLY, H.E.W.'S TRAINING PROGRAMS NURSING HOME PERSONNEL
ARE MOVING ALONG RAPIDLY.
Jet mr add- impection is important but of
impection is not fair of Instruct you At mm how. 2 will not contone nith picters on
LET ME TURN NOW TO H.R. kg 1, THE AIMINISTRATION'S WELFARE REFORM BILL, WHICH
CONTAINS MANY PROVISIONS IMPORTANT TO OLDER AMERICANS AND ALL THOSE ENTRUSTED WITH
THEIR CARE.
AS YOU MAY KNOW, H.R. 1 PASSED THE HOUSE MORE THAN A YEAR AGO AND IS STUCK IN THE
SENATE WELF ARE COMMITTEE. H.R. 1 IS TOP PRIORITY LEGISLATION. CONGRESS WILL HAVE
FAILED DISGRACEFULLY IN ITS RESPONSIBILITY TO THE NATION IF THIS LEGISLATION IS NOT
ENACTED THISXXEXXX BEFORE CONGRESS ADJOURNS FOR THEYE YEAR.
H.R. 1 Is IS A COMPLICATED BIIL. ITS PROVISIONS RANGE FROMKEXERAK FEDERAL MATCHING
FOR MECHANIZED CLAIMS PROCESSING XXX UNDER MEDICAID TO AUTHORITY TO EXPERIMENT WITH
ALTERNATIVE MEDICARE REIMBURSEMENT FORMULAS INTENDED TO PROMOTE ECONOMY AND EFFICIENCY.
LET ME BRIEFLY DISCUSS HOUSE-APPROVED CHANGES IN THE MEDICARE PROGRAM WHICH SHOULD
BE OF INTEREST TO YOU.
ONE CHANGE IN MEDICARE CO VERAGE EXTENDS PROTECTION TO THE DISABIED AFTER THEY
HAVE BEEN RECEIVING SOCIAL SECURITY CASH BENEFITS FOR A PERIOD OF TWO YEARS. THIS MEETS
A REALBEK NEED IN A MANNER CONSISTENT WITH CAREFUL CONTROL OF MEDICARE COSTS.
THE HOU SE ALSO VOTED ТОЕЖХХ CHANGE THE DEDUCTIBELE AND PREMIUM PAYMENT FORMUKLA
UNDER MEDICARE 'PART B' AND MADE A CHANGE IN THE COINSURANCE PAYMENT FORXM INPATIENT
HOREXTXX HOSPITAL BENEFITS UNDER 'PART A.'
UNDER EXISTING LAW, THE PREMIUM A PATIENT PAYS UNDER 'PART B' GOES UP PERIODICALLY
AS HOSPITAL COSTS GO UP. UNDER H.R. 1, THIS PREMIUM COULD BE INCREASED ONLY TO THE
EXTENT THAT SOCIAL SECURITY BENEFITS ARE INCREASED. SINCE HEALTH CARE COSTS HAVE
BEEN RI SING FASTER THAN ANY OTHER COST ITEM IN THE ECONOMY, THIS PROVISION SHOULD BE
OF SUBSTANTIAL ASSISTANCE TO THE ELDERLY AND DISABLED.
HOWEVER, H.R. 1 ALSO MEDATES INCREASES THE ANNUAL DEDUCTIBLE UNDER 'PART B' FROM
$50 TO $60. TH IS DEDUCTIBLE NXXX HAS NOT BEEN INCREASED SINCE THE PROGRAM FIRST WAS
ENACTED IN 1965, ALTHOUGH COSTS OF COVERED SERVICES HAVE INCREASED SHARPLY.
ADDITIONALLY, THE CO INSU RANCE A BENEFICIARY PAYS UNDER 'PART A' WOULD BE IMPOSED
AT AN EARLIER POINT IN HIS HOSPITAL STAY. UNDER PRESENT LAW, COINSURANCE PAYMENTS
BEGIN ON THE 61ST DAY OF THE MSX HOSPITAL STAY AND IS EQUIVALENT TO ONE-FOURTH OF THE
DEDUCTIBELE . UNDER H.R. 1, THE COINSURANCE PAYMENTS WOULD HAVE TO BEGIN WITH THE
-4-
31ST DAY BUT XXT AT A RATE EXTXAXEXXX EQUIVALENT TO ONE-EIGHTH OF THED DEDUCTIBLE.
THIS WOULD APPLY FROM THE 31ST THROUGH THE 60TH DAY, WHEN THE PRESENT RATE ONCE
MORE WOULD TAKE EFFECT.
TO OFFSET THIS INCREASE IN CO INSURANCE PAYMENTS, THE HOUSE DOUBLED THE SO-CALLED
LIFETIME RESERVE UNDER H.R. 1.
UNDER PRESENT LAW, A BENEFICIARY IS COVERED FOR 90 DAYS OF HOSPIT ALIZATION IN
EVERY & 'SPELL OFIE ILLNESS' AND HAS ACCESS TO 60 ADDITIONAL DAYS ON A ONCE-IN-A-LIFETIME
BASIS. UNDER H.R. 1, ANOTHER NONRENEWABLE 60 DAYS WOULD BE ADDED. THIS GIVES THE
BENEFICIAIRY A ONE-TIME MAXIUMUM HOSPITALIZATIONE COVERAGE OF 210 DAYS INSTEAD OF THE
EXISTING 150 DAYS.
I AM HOPEFUL THAT THE SE CHANGES WILL IMPRO VE THE EFFICIENCY OF THE MEDICARE
PROGRAM WHILE PROVIDING OUR ELDERLY WITH A MEASURE OF FISCAL RELIEF.
SINCE WE ARE TALKINGXMER TONIGHT ABOUT THE HEALTH PROBLEMS OF OLDER AMERICANS,
AND WHAT ALL OF US CAN DO TO HELP RESOLVE THEM, IT SEEMS PRIATE TO QUOTE FROM
THE AMERICAN WRITER AMBROSE BIERCE, WHOSE XMX OWN SPECIAL PROBLEM SEEMS TO HAVE BEEN
A CHRONIC BAD NOX MOOD.
SAID BIERCE, 'RESPONSIBILITY IS A DETACHABLE BURDEN EASILYXREKKECTEXXKE SHIFTED
FROM ONE'S OWN SHOULDERS TO THOSE OF GOD, FATE, FORTUNE, LUCK....OR ONE'S XXXXX
NEIGHBOR.'
I HAVE JUDGED FROM THE THEME OF THIS CONFERENCE THAT NO ONE LISTENING TO ME
THE TONIGHT NEEDS TO BE REMINEDED OF HIS OR HER SHARE OF RESPONSIBILITY FOR LONGTERM
CARE IN MICHIGAN. AND I SENSE FROM THE SPIIRT OF RESPONSIBILITY IMPLICIT IN YOUR
CONFERENCEIN AGENDA THAT IF THERE IS ANY SHIFTING OF THAT BURDEN, IT WILL BE TO
TAKE EVEN MORE OF IT UPON YOUR OWN NX SHULDERS.
ONE COMMENT NOW ABOUT MEDICAIDI. AS YOU KNOW, THE STATES MAKE THE PAYMENTEZI
MNXER MEDICAID PAYMENTS UNDER EXISTING LAW.
UNDER H.R. 1, INX INCENTIVES AREXAM PROVIDED TO GET THE STATES TEX TO MAKE
CONTRACTS WITH HEALTH MAINTENENCE ORGANIZATIONS AND TO DISCOURAGE LONG STAYS IN
INSTITUTIONS. ONE OF THE DISINCENTIVES IS A REDUCTION IN FEDERAL MEDICAID MA TCHING
BY ONE-THIRD AFTER 60 DAYS OF CARE IN A SKILIED NURSING HOME. UNLESS THE STATE CAN
SHOW IT HAS AN EFFECTIVE UTILIZATION REVIEW PROGRAM. THERE WOULD BE A REDUCTION
OF THE ONE-THIRD MA TCHING AFTER 60 DAYS IN A GENERAL OR TUBERCULOSIS HOSPITAL AND
A DECREASE BY ONE-THIRD IN E FEDERAL MATCHING AFTER 90 DAYS IN A MENTAL HOSPITAL.
AS YOU MAY HAVE HEARD, PROSPECTS FORE XEM KN SENATE PASSAGE OF H.R. 1x THIS YEAR
APPEAR DIM. IT HAS BEEN BOTTLED UP IN THE SENATE FINANCE COMMITTEE FOR 14 MONTHS NOW.
HEALTH CARE LEGISLATION IS DEFINITELY ADMITTER A 1973 ACTION ITEM. THE HOUSE
WAYS AND MEANS COMMITTEE HELD 41 ISI WEEKS OF HEARINGS ON IT TRASXXEXX IN THE LATE FALL
-5-
OF 1971 AND THEN LAID IT ASIDE TO DEAL WITH OTHER MATTERS. THEOD COMMITTEE DID NOT
RETURN TO IT THIS YEAR. MEANTIME A NUMBER OF NEW PROPOSALS HAVE BEEN ADVANCED,
THE NEXT
DEALING WITH CATASTROPHIC ILLNESS. MY PREDICTION IS THAT/CONGRESS WILL PASS HEALTH
CARE LEGISLATION AND THAT IT WILL RESEMBLE MOST CLOSELY THE ADMINISTRATION PRO POSALS
IN THIS FIELD. BUILDING ON THE PRESENT HEALTH INSURANCE SYSTEM RATHER THAN
FEDERALIZING HEALTH CARE. SO THE LONGTERM OUTLOOK IS VERY GOOD, INCLUDING A
THEOROUGH-GOING REVIEW OF MEDICARE.
SINCE WE ARE TALKING TONIGHT ABOUT THE HEALTH PROBLEMS OF OLDER AMERICANS,
IT SEEMS APPROPRIATE TO QUOTE FROM THE AMERICAN WRITER AMBROSE BIERCE, A ONE-TIME
OLDER AMERICAN WHOSE OWN SPECIAL PROBLEM X SEEMS TO EXXXXXX HAVE BEEN A CHRONIC BAD
MOO D.
SAID BIERCE, 'RESPONSIBILITY IS A DETACHABLE BURDEN EASILY SHIFTED FROM ONE'S
OWN SHOULDERS TO THOSE OF GOD, FATE, FORTUNE, LUCK...OR ONE'S NEIGHBOR.'
I HAVE ALREADY JUDGED FROM THE EXX THEME OF THIS CONFERENCE THAT NO ONE LISTENING
TO ME TONIGHT NEEDS TO BE REMINDED OF HIS OR HER SHARE OF RESPONSIBILITY FOR LONGTERM
CARE IN MICHIGAN. AND I SENSE FROM THE SPIRIT OF RESPONSIBILITY IMPLICIT IN YOUR
CONFEREENCE AGEN DA THAT IF THERE IS ANY SHIFTING OF THAT BURIEN, IT WILL BETX TO TAKE
EVEN MORE OF IT UPON YOUR OWN SHOULDERS.
X I WOULD LIKE TO NET MENTION AT THIS POINT THAT THE QUALITY OF ANY CIVILIZATION
CAN BE MEASURED BY THE ATTITUDE OF THE PEOPLE TOWARD THE ELDERLY IN THEIR MIDST. I
THINK IT IS NO ACCIDENT THAT ERINKX THE XXXX INCIDENCE OF CRIME HAS ALWAYS BEEN LOW
IN SOCIETIES WHICH HAVE GREAT REVERENCE FOR FAMILY TIES. MX AND IT SHOULD ALSO BE
REMARKE D THAT THE SE SAMEXX SOCIETIES THE ME JEWISH AND CHINESE, FOR INSTANCE. HAVE
ALSO HAD GREAT REVERENCE FOR THE ELDERLY IN THEIR MEXX MIDST.
THIS REVERENCE FOR AGE CONTINUES IN THE NEW CHINA, AS IN THERED OLD.
IT MAY BE OF SOME INTEREST TO YOU THAT PEOPLE RETIRE EARLIER IN COMMUNIST CHINA
THAN IN THE UNITED STATES. FOR WOMEN THE RETIREMENT AGE IS 55; FOR THE MEN, 60.
HEALTH CARE IS A TOP PRIORITY IN COMMUNIST CHINA. THIS IS REFLECTED IN
CREASH PROGRAMS FOR THE TRAINING OF DOCTORS AND NURSES. THE TRAINING PERIOD FOR
DOCTORS HAS BEEN CUT IN HALF FROM SIX YEARS TO THREE. NURSE
TRAINING X HAS ALSO BEEN SLICED IN HALF FROM THREE YEARS TO 1½0 AT THE SAME TIME,
THE их CHINESE HAVE BEEN TURNING OUT THOUSANDS OF MEDICAL CORPSMEN KNOWN AS 'BAREFOOT
DOCTORS' WHO ARE SENT OUT INTO THE COUNTRYSIDE TO PROVIDE THE RUDIMENTS OF MEDICAL
CARE XNXTMXX MAJOR CASES, OR COURSE, ARE SENT TO THE HOSPITALS.
ONLY A FEW YEARS AGO, NO MODERN MEDICAL CARE TO SPEAK OF WAS AVAILABLE TO THE
LIBRAR
GREAT PREPONDERANCE OF CHINA'S INHABITENTS. NOW SOMEKX KIND OFCARK CARE IS PROVIDED
TO EVERY CHINESE IN NEED OF MEDICAL ATTENTION. IN MORE REMOTE REGIONS, IT MAY BE
ELEMENTAL, BUT IT IS AVAILABLE. THERE IS NO CHARGE FOR MEDICAL CARE TO WORKERS IN THE
CITIES BUT EACH FAMILY XX IN THE COMMUNES PAYS ABOUT 4 CENTS PER MONTH FOR MEDICAL
SERVICES.
THERE IS HERVY EMPHASIS ON PERSONAL CLEANLINESS IN CHINA. AS A RESULT, EPIDEMIC
AND INTENSTINAL AILMENTS HAVE BEEN SHARPLY REDUCED. THE PEOPLE HA VE BEEN REPEATEDLY
MOBILIZED TO ERADICATE DISEASE*CARRYING SNAILS, FLIES AND MOSQUITOES.
SOME OF THE CHINESE HEALTH TECHNIQUES WOULD HAVE EXCHANGE VALUE FOR THIS UNITED
STATES. so, TOO, WX DOES THE USE OF ACUPUNCTURE AS ANESTHESIA IN OPERATIONS.
I WITNESSED THREE OPERATIONS IN PEKING IN WHICH ACUPUNCTURE ANESTHESIA WI WAS
USED. so I KNOW THAT IT XX WORKS.
DR. FREEMAN CARY, A XMXX PHYSICIAN WHO ACCOMPANIED CONGRESSMAN HALE BOGGSTN AND
ME AND OUR PARTY TO CHINA, PREDICTS THAT ACUPUNCTURE ANESTHEXSIA WILLIBE EXTENSIVELY
XXEEXXXX USED IN THE UNITED STATES WIXHXX WITHIN A YEARXORT OR TWO.
THERE ARE STILL MANY HEALTH CARE SHOR TCOMINGS IN CHINA, BOTH IN THE QUALITY OF
CARE AND IN THE NUMBER AND QUALITY OF FACILITIES AVAILABLE TO THE FEPX PEOPIE. BUT
THE CHINESE HAVE MADE TREMENDOUS ADVANCES.
MEDICINE IN CHINA IS HEAVILY MIXED WITH IDEOLOGY. WHEN THE COMMUNISTS FIRST
TOOK OVER IN 1949, THE EMPHASIS WAS ON PROVIDING HEALTH CARE IN THE CITIES, THE
CENTERS OF HEAVY INDUSTRY. AND THE PROFESSORS RAN THE MEDICAL SCHOOLS.
WITH THE ERUPTION OF THE CULTURAL REVOLUTION IN 1966 AND IN THE YEARS THAT
FOLLOWED, REVOLUTIONARY COMMITTEES WERE SET UP TO RUN THE MEDICAL SCHOOLS, PROGRAMS
WERE LAUNCHED TO GREATLY EXPAND MEDICALMX MANPOWER, AND THE EMPHASIS IN HEALTH CARE
SHIFTED TO THE RURAL AREAS.
ALL IS IN KEEPING WITH THE TEACHINGS OF CHAIRMAN MAO. BUT THIS MUCH MSXTX MUST
BE SAID. HEALTH CARE IN CHINA HAS BEEN REVOLUTIONIZED.. AND VERY MUCH FOR THE BETTER.
MAO'S FAVORITE SLOGAN IS A GOOD SLOGAN IN ANY COUNTRY--'SERVE THE PEOPLE.'
#######
THE FEDERAL PROGRAM FOR LONG-TERM CARE
MARIE CALLENDER
SPECIAL ASSISTANT FOR NURSING HOME AFFAIRS
THIS SEMINAR IS DESIGNED TO INCREASE CONSULTANT SKILLS,
AND YOU HAVE BEEN ENGAGED IN THE DISCUSSION OF MANY ASPECTS
OF INSTITUTIONAL CARE AND THE REGULATIONS THAT GOVERN IT.
I WOULD LIKE TO STEP BACK FROM THOSE SPECIFICS AND DESCRIBE
TO YOU SOME OF THE PROBLEMS IN NURSING HOME CARE, THE SCOPE
nursing home
OF THE PRESIDENT'S COMMITTMENT TO SOLVE THOSE PROBLEMS, AND
SOME FUTURE CONSIDERATIONS WHICH WE ARE STUDYING, I THINK
THIS DESCRIPTION WILL EMPHASIZE THE IMPORTANCE AND THE HIGH
PRIORITY OF THE TASK IN WHICH WE ARE ENGAGED.
THE QUALITY OF ANY CIVILIZATION CAN BE MEASURED BY THE
ATTITUDE OF THE PEOPLE TOWARD THE ELDERLY IN THEIR MIDST.
THEIR VALUE ECONOMICALLY IS EBBING OR IS AT AN END. THEY RE-
QUIRE A DISPROPORTIONATE SHARE OF MEDICAL AND SOCIAL SERVICES,
IN SOME EARLIER CULTURES THEY WERE CUT OFF FROM THE TRIBE AND
FORCED TO WANDER WITHOUT FOOD OR SHELTER UNTIL THEY DIED.
MOST OF US LOOK WITH REVULSION AT SUCH SOCIAL PATTERNS, AND
ACCEPT THE MORAL RESPONSIBILITY OF OUR SOCIETY TOWARD ITS
ELDERLY
To BE PRESENTED AT THE SEMINAR FOR CONSULTANTS, SPONSORED
JOINTLY CHS AND BHI, SSA OF REGION 1X, AT SANTA INEZ INN,
PACIFIC PALLISADES, CALIFORNIA, MONDAY, MARCH 22, 1972,
LIGHTS
2
2
THE MAJORITY OF THOSE OVER SIXTY-FIVE ARE ABLE TO LEAD
ACTIVIE, INDEPENDENT LIVES CONTRIBUTING VIGOROUSLY TO OUR
NATIONAL LIFE. HOWEVER, ALMOST A MILLION OF OUR TWENTY-MILLION
PERSONS OVER SIXTY-FIVE REQUIRE THE CARE AND SUPPORT OF NURSING
HOMES, AND IT IS THESE WHOSE DEPENDENCE MOST ACUTELY TESTS THE
QUALITY OF OUR COMPASSION AND SENSE OF HUMANITY,
THE PRESIDENT HAS APTLY STATED THAT, "FOR THOSE WHO NEED THEM,
THE NURSING HOMES OF AMERICA SHOULD BE SHINING SYMBOLS OF CONFORT
AND CONCERN." MANY OF OUR NURSING HOMES MEET THIS STANDARD. OTHERS
DO NOT, AS TESTIFIED BY RECENT SHOCKING AND TRAGIC NURSING HOME
FIRES, AND LESS DRAMATICALLY BY PRIVATE AND GOVERNMENT STUDIES. IN
MAY, 1971, THE GENERAL ACCOUNTING OFFICE ISSUED A REPORT ON THE EN-
FORCEMENT OF MEDICAID AND MEDICARE STANDARDS IN NINETY NURSING HOMES IN
OKLAHOMA, NEW YORK, AND MICHIGAN, SERIOUS DEFICIENCIES WERE FOUND
IN MORE THAN 50 PERCENT OF THESE HOMES, ALL OF WHICH HAD MEDICAID
PATIENTS AND MANY OF WHICH WERE APPROVED FOR MEDICARE. ON NOVEMBER
30, 1971, SECRETARY RICHARDSON ANNOUNCED THAT 39 STATES WERE OUT
OF COMPLIANCE WITH TITLE 19 CERTIFICATION PROCEDURES, IN HUMAN TERMS,
THESE STUDIES MEAN THAT MANY NURSING HOMES WHICH FAIL TO MEET
STANDARDS ARE UNSANITARY AND UNSAFE, OVERCROWDED AND UNDERSTAFFED--
LONELY AND DEPRESSING PLACES FOR THE ELDERLY TO LIVE AND DIE.
3
THE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED
IN NURSING HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY
SINCE THE ENACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN
1965. IN 1970 THE FEDERAL GOVERNMENT SPENT OVER $2 BILLION
IN SUPPORT OF NURSING HOME PATIENTS, WHILE STATE AND LOCAL
GOVERNMENTS SPENT ANOTHER $700 MILLION, THIS INVOLVEMENT
CARRIES WITH IT A RESPONSIBILITY TO ASSURE THAT NURSING HOMES
DELIVER CARE AT LEAST AT THE LEVELS OF FEDERAL STANDARDS AND
REGULATIONS. THE PRESIDENT ACCEPTED THIS RESPONSIBILITY IN
HIS 8-POINT PLAN FOR ACTION TO IMPROVE NURSING HOMES ANNOUNCED
LAST AUGUST IN NEW HAMPSHIRE.
A MAJOR GOAL OF THE PLAN IS TO IMPROVE FEDERAL ENFORCE-
MENT OF NURSING HOME STANDARDS, As YOU KNOW, THE TERM "NURSING
HOME" IS APPLIED TO A WIDE RANGE OF FACILITIES, FROM THOSE PRO-
VIDING PRIMARILY CUSTODIAL CARE TO THOSE DELIVERING HIGHLY SKILLED
POST-HOSPITAL AND REHABILITATIVE SERVICES. THESE DIFFERENT TYPES
OF FACILITIES ARE ACCREDITED THROUGH DIFFERENT MECHANISMS, AND
FEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES WIDELY, MEDICARE
CERTIFICATION OF EXTENDED CARE FACILITIES IS A FEDERAL PROGRAM
MEDIATED THROUGH STATE SURVEY AGENCIES, MEDICAID IS A FEDERAL-
STATE PROGRAM, FINANCED AND ADMINISTERED THROUGH BOTH FEDERAL
AND STATE FUNDS AND ACTIVITIES. INTERMEDIATE CARE FACILITIES
formarly
UNTIL RECENTLY WERE REQUIRED TO MEET ONLY STATE LICENSING RE-
QUIREMENTS TO RECEIVE FEDERAL FUNDS. THESE DIFFERENCES HAVE COM-
PLICATED THE ENFORCEMENT OF STANDARDS, HOWEVER, BOTH MEDICARE
4
AND MEDICAID HAVE TRADITIONALLY AND STATUTORILY RELIED ON
STATE AGENCY INSPECTION OF FACILITIES, AND THE PRESIDENT HAS
CHOSEN TO RETAIN THIS EMPHASIS ON THE ROLE OF THE STATE AGENCY,
WE BELIEVE THIS APPROACH IS CONSISTENT WITH A HEALTHY FEDERAL-
STATE RELATIONSHIP AND AVOIDS UNNECESSARY EXPANSION OF THE
FEDERAL BUREAUCRACY. BUT THE FEDERAL GOVERNMENT WHICH IS RE-
SPONSIBLE FOR THE QUALITY OF CARE Wilson IT FINANCES MUST AID
IN ENHANCING THE CAPABILITY OF THE STATE AGENCIES TO REGULATE
AND IMPROVE THE QUALITY OF NURSING HOME CARE, To IMPROVE EN-
FORCEMENT OF NURSING HOME STANDARDS, THE PRESIDENT'S PLAN
PLEDGED THE FOLLOWING STEPS:
1. CONSOLIDATION OF RESPONSIBILITY FOR NURSING HOME
AFFAIRS, NURSING HOME ACTIVITIES HAVE BEEN SCATTERED AMONG
SEVERAL BRANCHES OF THE DEPARTMENT OF HEW, INCLUDING THE
SOCIAL SECURITY ADMINISTRATION, THE SOCIAL AND REHABILITATION
SERVICE, AND THE HEALTH SERVICE AND MENTAL HEALTH ADMINISTRATION.
THE PRESIDENT ORDERED THAT ALL FEDERAL ENFORCEMENT RESPONSIBILITY
BE CONSOLIDATED IN A SINGLE OFFICE, AND DR. MERLIN K. DUVAL,
THE ASSISTANT SECRETARY OF HEALTH AND SCIENTIFIC AFFAIRS, WAS
DESIGNATED AS THE RESPONSIBLE OFFICIAL. DR. DUVAL APPOINTED ME
TO WORK WITH HIM ON THESE ACTIVITIES AND TO FUNCTION AS A FULL
TIME COORDINATOR OF NURSING HOME ACTIVITIES.
5
2. ENLARGEMENT OF FEDERAL STAFF FOR ENFORCEMENT OF
NURSING HOME STANDARDS, THE SOCIAL AND REHABILITATION
SERVICE, WHICH ADMINISTERS THE MEDICAID PROGRAM, HAS BEEN
ASSIGNED 142 ADDITIONAL POSITIONS TO CARRY OUT ITS INCREASED
RESPONSIBILITIES. ONE HUNDRED TEN OF THESE POSITIONS WERE
ALLOCATED TO THE REGIONAL OFFICES OF HEW. THE SOCIAL SECURITY
ADMINISTRATION RECEIVED EIGHT NEW POSITIONS, AND HEW's AUDIT
AGENCY RECEIVED THIRTY-FOUR ADDITIONAL POSITIONS TO INCREASE THE
THEIR AUDITS OF NURSING HOME OPERATIONS, THE NATIONAL CENTER
FOR HEALTH SERVICES RESEARCH AND DEVELOPMENT RECEIVED SEVEN
NEW POSITIONS FOR EFFORTS TO IMPROVE NURSING HOME DATA SYSTEMS
AND TO DEVELOP DATA IN SPECIAL FIELDS RELEVANT TO NURSING
HOME CARE.
3. FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID
INSPECTIONS. WE RECOGNIZE THAT AN INCREASED LEVEL OF EN-
FORCEMENT ACTIVITY INVOLVES ADDITIONAL COSTS TO THE STATES.
MEDICARE INSPECTION COSTS HAVE ALWAYS BEEN FULLY PAID FOR BY
THE FEDERAL GOVERNMENT, BUT UNDER THE MEDICAID PROGRAM STATES
HAVE PAID 25 TO 50 PERCENT OF THESE COSTS. SECRETARY
RICHARDSON SUBMITTED TO CONGRESS IN OCTOBER, 1971, AN AMEND-
MENT TO H.R.I. AUTHORIZING THE FEDERAL GOVERNMENT TO ASSUME
100 PERCENT OF INSPECTION COSTS UNDER MEDICAID; THIS STEP WILL
6
PLACE BOTH PROGRAMS ON AN EQUAL FOOTING AND LESSEN THE
FINANCIAL BURDEN TO THE STATES.
4. TRAINING STATE NURSING HOME INSPECTORS, NURSING
HOME SURVEYORS HAVE BEEN TRAINED IN SURVEY AND COUNSELLING
TECHNIQUES UNDER A PROGRAM SPONSORED BY THE HEALTH SERVICES
AND MENTAL HEALTH ADMINISTRATION SINCE MARCH, 1970. SOME -
you HAVE ATTENDED THESE COURSE IN HIS AUGUST SPEECH, THE
PRESIDENT PLEDGED AN EXPANSION OF THIS PROGRAM so THAT 2,000
an
SURVEYORS WOULD BE TRAINED IN THE ENSUING EIGHTEEN MONTH
PERIOD. As A RESULT OF THE PRESIDENT'S ORDER, THE PROGRAM HAS
BEEN ACCELERATED so THAT 475 SURVEYORS HAVE NOW BEEN TRAINED
CONTRACT NEGOTIATIONS ARE IN PROCESS TO ESTABLISH THREE
ADDITIONAL UNIVERSITY CENTERS IN ADDITION, A STUDY WAS PER-
FORMED BY MACRO SYSTEMS, INC., TO EVALUATE THE EFFECTIVENESS
OF THE TRAINING COURSES, AND THESE HAVE NOW BEEN MODIFIED TO
REFLECT THE RESULTS OF THAT STUDY,
THESE EFFORTS TO ACHIEVE COMPLIANCE WITH FEDERAL STANDARDS
AND REGULATIONS ARE NOT DESIGNED TO ELIMINATE FACILITIES AND
THUS TO DEPRIVE PATIENTS OF NEEDED NURSING HOME CARE. WE ARE
WORKING RATHER TO COORDINATE FEDERAL AND STATE PROGRAMS AND
STATE AGENCIES TO SHARE THEIR RESOURCES AND EXPERTISE so THAT
SUBSTANDARD FACILITIES CAN BE UPGRADED, THE FEDERAL PROGRAM
7
TO TRAIN NURSING HOME SURVEYORS, FOR EXAMPLE, EMPHASIZES
THE DEVELOPMENT OF SKILLS TO AID NURSING HOME ADMINISTRA-
TORS IN MAKING NEEDED IMPROVEMENTS. FEDERAL FINANCIAL
ASSISTANCE IS AVAILABLE FOR NURSING HOME MODERNIZATION
AND NEW CONSTRUCTION FROM THE FEDERAL HOUSING ADMINISTRA-
TION AND SUCH PROGRAMS AS HILL BURTON, THE STANDARDS THEM-
SELVES ARE BEING REVISED AND STRENGTHENED. WE ARE DEVELOPING
PROGRAMS TO IMPROVE NURSING HOMES DIRECTLY- SHALL DESCRIBE
THEM IN A FEW MOMENTS
BUT AS THE PRESIDENT WARNED LAST CUCUST,
...
LET THERE
BE NO MISTAKING THE FACT THAT WHEN FACILITIÉS FAIL TO MEET
REASONABLE STANDARDS, WE WILL NOT HESITATE TO CUT OFF THEIR
MEDICARE AND MEDICAID FUNDS." BE TWEEN AUGUST haveneer 6, 1971, AND Anong
FEBRUARY 11, 1972, 13 EXTENDED CARE FACILITIES WERE DECERTI-
FIED FOR MEDICARE PARTICIPATION. ON NOVEMBER 30, 1971, THIRTY-
NINE STATES WERE DECLARED OUT OF COMPLIANCE WITH TITLE 19-
MEDICAID--CERTIFICATION PROCEDURES, By FEBRUARY 1, 1972 IN
RESPONSE TO SECRETARY RICHARDSON'S DEADLINE, ALL BUT ONE OF
THOSE STATES HAD MADE THE IMPROVEMENTS REQUIRED FOR COMPLIANCE,
BY JULY 1 1972, ALL TITLE 19 FACILITIES IN ALL STATES ARE TO
HAVE BEEN INSPECTED AND CERTIFIED THROUGH THE CORRECT PROCEDURES,
THE FEDERAL GOVERNMENT IS PLEDGED TO MEET ITS RESPONSIBILITY
TO ASSURE THAT FEDERAL DOLLARS DO. NOT FINANCE SUBSTANDARD CARE.
8
WHILE WE ARE ENGAGED IN THIS MASSIVE ENFORCEMENT EFFORT,
AND WHILE WE ARE CAUGHT UP IN THE RUSH TO MEET THE JULY 1
DEADLINE, I THINK WE MUST RETAIN A SENSE OF PROPORTION IN
RECOGNIZING ALL THE THINGS FEDERAL REGULATIONS CANNOT DO
TO AFFECT THE QUALITY OF NURSING HOME CARE. THESE LIMITATIONS
CAST A SPECIAL LIGHT ON YOUR ROLE AS CONSULTANTS - FOR YOU ARE
CONSULTANTS NOT ONLY TO SURVEY AGENCIES AND TO SINGLE STATE
AGENCIES, BUT ALSO TO THE NURSING HOMES YOU REVIEW.
FIRST, REGULATIONS OF QUALITY OF CARE TEND TO BECOME A FLOOR
RATHER THAN A CEILING, WHILE WE DEMAND THAT AN EXTENDED CARE
FACILITY NOT FALL BELOW FEDERAL STANDARDS, WE DO NOT WANT TO
DISCOURAGE IT FROM ASPIRING TO ACHIEVE A BETTER QUALITY OF CARE,
AND ALTHOUGH YOU INSPECT FOR COMPLIANCE WITH FEDERAL STANDARDS,
AS CONSULTANTS YOU ARE NOT LIMITED TO WHAT SHOULD BE CONSIDERED
MINIMAL STANDARDS FOR CARE,
SECOND, REGULATIONS TEND TO COVER STRUCTURAL CONSIDERA-
TIONS - THOSE FACTORS IN PROFESSIONAL QUALIFICATIONS, STAFFING,
AND ENVIRONMENT WHICH MAKE GOOD CARE POSSIBLE RATHER THAN THE
ACTUAL QUALITY OF CARE DELIVERED. AND HERE AGAIN, YOU AS
CONSULTANTS CAN IMPROVE THE REGULATORY PROCESS BY EXAMINING
THE MEDICAL AND SOCIAL SERVICES ACTUALLY DELIVERED. THE JOB
IS NOT EASY, IT CANNOT BE DONE IF THE PHARMACIST LOOKS ONLY
AT THE PHARMACY, THE DIETICIAN AT THE KICHEN, THE DOCTOR AT
9
MEDICAL RECORDS, THE NURSE AT NURSING SERVICES, CONSULTANTS
SHOULD CONSIDER ALSO THE PROFESSIONAL COORDINATION IN AN
INSTITUTION, AND HOW IT CONTRIBUTES TO PATIENT CARE,
THIRD, REGULATIONS FREQUENTLY DO NOT CONSIDER THE RE-
LATIVE IMPORTANCE OF DEFICIENCIES, IN THE REAL WORLD, ADMINI-
STRATORS WITH LIMITED BUDGETS--AND FEW HAVE UNLIMITED BUDGETS,
EVEN IN THE FEDERAL GOVERNMENT-MUST OPERATE WITH A LIST OF
PRIORITIES. CONSULTANTS SHOULD BE ABLE TO ASSIST A NURSING
HOME IN ESTABLISHING PRIORITIES, AGAIN, THE JOB IS NOT EASY,
FOR IT REQUIRES THE SPECIALIST TO LOOK BEYOND HIS OWN AREA OF
EXPERTISE TO RECOGNIZE OTHER NEEDS, Is AN IN-HOUSE PHARMACY
MORE IMPORTANT THEN AN -OCCUPATIONAL THERAPY PROGRAM? MIGHT
SUGGEST AN EXERCISE FOR THIS SEMINAR? SPECIALISTS IN THE
VARIOUS FIELDS OF CONSULTION CAN EACH DRAW UP LISTS OF FIVE
MAJOR INSTITUTIONAL DEFICIENCIES IN THEIR AREA OF REGULATION,
THEN IN A GROUP SESSION DEFICIENCIES IN SEVERAL AREAS OF RE-
GULATION BE RANKED ACCORDING TO PRIORITY. THIS PROCESS OF
COMPARING APPLES AND ORANGES-HOWEVER DESPISED IN THE CLASSROOM-
IS AN EVERY DAY EXPERIENCE FOR THE ADMINISTRATOR.
LAST, REGULATIONS ARE SLOW TO RECOGNIZE AND TAKE ACCOUNT
OF CHANGE AND IMPROVEMENT. As CONSULTANTS, YOU SEE AND CAN ASSESS
WHAT IS NEW, AND YOU HAVE THE OPPORTUNITY TO CROSS-POLLINATE
WORTHWHILE IDEAS AND TECHNIQUES. As YOU KNOW, NURSING HOMES HAVE
10
BECOME A VERY COMPLICATED INDUSTRY, AND IN MANY SENSES
HAVE BECOME "BIG BUSINESS." THIS IS NOT ENTIRELY BAD,
NEW MANAGEMENT AND ADMINISTRATIVE SKILLS HAVE BEEN IN-
TRODUCED, AND SOME OF THESE OFFER PROMISE, IF YOU ARE TO
DEAL WITH NURSING HOME ADMINISTRATORS AND ASSESS THEIR
MANAGEMENT, YOU MUST UNDERSTAND THEIR SKILLS so THAT YOU
CAN SERVE MORE EFFECTIVELY YOUR CONSULTANT ROLE,
To RETURN TO THE PRESIDENT'S PLAN, so FAR I HAVE DISCUSSED
IMPROVED ENFORCEMENT OF NURSING HOME STANDARDS, Two OTHER
POINTS IN THE PLAN INITIATED MORE DIRECT STEPS TO IMPROVE
NURSING HOME CARE, THE PRESIDENT DIRECTED THE DEPARTMENT
OF HEW "TO INSTITUTE A NEW PROGRAM OF SHORT-TERM COURSES FOR
PHYSICIANS, NURSES, DIETICIANS, SOCIAL WORKERS AND OTHERS WHO
ARE REGULARLY INVOLVED IN FURNISHING SERVICES TO NURSING
HOME PATIENTS." HEW HAS SUPPORTED SUCH TRAINING FOR SEVERAL
YEARS, AND HAS DEVELOPED CLOSE WORKING RELATIONSHIPS WITH
PROFESSIONAL ASSOCIATIONS AND WITH TRAINING CENTERS. IN RE-
SPONSE TO THE PRESIDENTS' DIRECTIVE, SUCH PROGRAMS HAVE BEEN
EXPANDED UND IR THE LEADERSHIP OF THE COMMUNITY HEALTH SERVICE,
HEALTH SERVICE AND MENTAL HEALTH ADMINISTRATION, AND HIS
ANTICIPATED THAT APPROXIMATELY 20,000 PERSONS
were
TRAINED
IN FISCAL YEAR 1972 AT A COST OF $2.5 MILLION, TRAINING
PROGRAMS WILL FOCUS INITIALLY ON FOUR MANPOWER AREAS SELECTED
BECAUSE OF THEIR DIRECT DAY-TO-DAY RELATIONS WITH NURSING
11
HOME PATIENTS: NURSING HOME ADMINISTRATORS, PHYSICIANS, NURSES,
AND PATIENT ACTIVITIES DIRECTORS, MANY OF THESE TRAINING
PROGRAMS WILL BE OPERATED UNDER CONTRACTS WITH PROFESSIONAL
GROUPS, APPROACHES TO MENTAL HEALTH PROBLEMS OF NURSING
HOME PATIENTS WILL BE DEVELOPED BY NATIONAL INSTITUTE OF
MENTAL HEALTH STAFF WORKING WITH THE GERONTOLOGICAL SOCIETY.
OTHER TRAINING MECHANISMS WILL ALSO BE EXPLORED, SUCH AS
PROGRAMS SPONSORED BY STATE HEALTH DEPARTMENTS AND STATE
AGENCIES, THESE PROGRAMS WILL BE DIRECTED TOWARD MAKING
NURSING HOME STAFF-BOTH PROFESSIONAL AND ALLIED HEALTH-MORE
SENSITIVE AND EXPERT IN THE SPECIAL PROBLEMS OF CARE FOR
GERIATRIC PATIENTS AND THE CHRONICALLY ILL. THE ARE INTENDED
TO BE THE BEGINNING OF "A SYSTEM FOR NATIONWIDE, CONTINUOUS TRAIN-
ING FOR NURSING HOME PERSONNEL WHICH WILL BECOME STANDARD
PRACTICE IN THE NURSING HOME INDUSTRY OF THE FUTURE.
As THE SEVENTH POINT IN HIS PLAN, THE PRESIDENT DIRECTED
THE DEPARTMENT OF HEW "TO ASSIST THE STATES IN ESTABLISHING
INVESTIGATIVE UNITS WHICH WILL RESPOND IN A RESPONSIBLE AND
CONSTRUCTIVE WAY TO COMPLAINTS MADE BY OR ON BEHALF OF IN-
DIVIDUAL PATIENTS." SINCE I ASSUMED MY NURSING HOME RESPONSI-
BILITIES, I HAVE RECEIVED MANY LETTERS FROM NURSING HOME
PATIENTS-TOUCHING IN THEIR. APPEAL FOR CARE OFFERING SIMPLE
DIGNITY AND RIGHTS OF PRIVACY, HARROWING SOMETIMES IN THEIR
DESCRIPTIONS OF PHYSICAL OR PSYCHOLOGICAL ABUSE, THESE
12
PATIENTS ARE OFTEN HELPLESS IN THEIR DEPENDENCE ON THE IN-
STITUTION IN WHICH THEY LIVE. THEY DESERVE A FAIR HEARING,
AND AN ADVOCATE WHEN THEY ARE POWERLESS, THE HEALTH
SERVICES AND MENTAL HEALTH ADMINISTRATION HAS DEVELOPED FIVE
MODELS FOR OMBUDSMAN UNITS TO FILL THIS ROLE, PLACED AT
VARIOUS LEVELS WITHIN THE STATES AND DEMONSTRATING DIFFERENT
MECHANISMS FOR ACTION, CONTRACT PROPOSALS TO TEST THESE
MODELS ARE BEING SOLICITED, AND $600,000 HAS BEEN BUDGETED
FOR FISCAL YEAR 1972 FOR THIS ACTIVITY,
IT WILL TAKE TIME TO TEST AND DEVELOP SUCH AN OMBUDSMAN
SYSTEM, TIME INAPPROPRIATE TO THE URGENCY OF THE PROBLEM,
So AN INTERIM OMBUDSMAN MECHANISM HAS BEEN ESTABLISHED WITH
THE 855 SOCIAL SECURITY ADMINISTRATION DISTRICT OFFICES DE-
SIGNATED TO RECEIVE AND INVESTIGATE COMPLAINTS, THIS MECH-
ANISM IS CURRENTLY IN EFFECT, AND HAS RECEIVED OVER A THOUSAND
RESPONSES.
FOR THESE NURSING HOME INITIATIVES, A SUPPLEMENTAL APPRO-
PRIATION OF $9,572,000 HAS BEEN REQUESTED FOR FISCAL YEAR,
1972. WE FEEL THAT BY MEANS OF THESE PROGRAMS A SIGNIFICANT
IMPROVEMENT IN NURSING HOME CARE CAN BE ACHIEVED IN A RE-
LATIVELY SHORT PERIOD OF TIME.
BERALD LIBRARY
13
WE RECOGNIZE ALSO, HOWEVER, THAT WHILE THESE INITIA-
TIVES CAN RECTIFY SOME OF THE MOST PRESSING PROBLEMS OF
NURSING HOME CARE, THERE ARE OTHER DEFICIENCIES-SOME FUNDA-
MENTAL-THAT REQUIRE FURTHER SOLUTIONS, FROM A BROADER PER-
SPECTIVE, IT IS APPARENT THAT NURSING HOMES ARE ONLY ONE
ELEMENT IN THE SPECTRUM OF LONG TERM CARE-AN ELEMENT WHICH
HAS BEEN FORCED TO BE TOO MANY THINGS TO TOO MANY PEOPLE,
IT IS IN THIS PERSPECTIVE THAT THE LAST POINT IN THE
PRESIDENT'S PLAN IS FRAMED; HE HAS DIRECTED THE SECRETARY OF
HEW TO UNDERTAKE A COMPREHENSIVE REVIEW OF THE USE OF LONG-
TERM CARE FACILITIES AND TO RECOMMEND ANY FURTHER REMEDIAL
MEASURES THAT ARE APPROPRIATE. I HAVE BEEN CHARGED WITH
ORGANIZING AND CHAIRING THAT TASK FORCE ON LONG TERM CARE.
ON ONE LEVEL, THE TASK FORCE WILL EXAMINE ing THE ROLES OF
MEDICARE AND MEDICAID IN NURSING HOME ACTIVITIES, MOST OF
YOU ARE AWARE, AND THE WHITE HOUSE CONFERENCE ON AGING HAS
EMPHASIZED, THAT THESE FEDERAL PROGRAMS HAVE BEEN A MIXED
BLESSING TO THE NURSING HOME INDUSTRY, SOME OF THE PROBLEMS
HAVE BEEN PRIMARILY ADMINISTRATIVE, BUT HAVE PRESENTED
DIFFICULTIES TO NURSING HOME ADMINISTRATORS AND TO STATE PRO-
GRAMS, AN EXAMPLE OF SUCH A PROBLEM IS THE VARIATION IN
STANDARDS FOR EXTENDED CARE FACILITIES UNDER MEDICARE AND
SKILLED NURSING HOMES UNDER MEDICAID. Thetash WE WILL EXAMINE THOSE
is
14
STANDARDS AND DETERMINE WHETHER THESE DIFFERENCES ARE NEC-
ESSARY OR USEFUL,
BUT MORE FUNDAMENTAL ISSUES HAVE ALSO BEEN RAISED WITH
REGARD TO THESE PROGRAMS. FOR HISTORICAL AND STATUTORY REA-
SONS BASED ON THEIR ORIGINS AS HEALTH INSURANCE PROGRAMS,
MEDICARE AND MEDICAID HAVE EMPHASIZED HEALTH ASPECTS OF
NURSING HOME CARE, ACUTE ILLNESS IN WHICH THE PATIENT IS
EXPECTED TO RECOVER AND REGAIN ALL OR MOST OF HIS INDEPEN-
DENCE HAS SERVED AS THE MODEL FOR HEALTH DELIVERY, CON-
SEQUENTLY, THESE PROGRAMS HAVE FAVORED INSTITUTIONAL CARE
OVER NON-INSTITUTIONAL ALTERNATIVES, AND WITHIN INSTITUTIONS,
HEALTH AS OPPOSED TO SOCIAL AND PERSONAL CARE.
IN MANY WAYS, THE CONSEQUENCES OF THIS CARE FOR THOSE
WITH CHRONIC ILLNESS AND FOR THOSE WITH THE INCREASED DE-
PENDENCY OF OLD AGE-HAVE BEEN TRAGIC, COSTS HAVE BEEN IN-
CREASED BY THE SUBSTITUTION OF INSTITUTIONAL.FOR NON-INSTITU-
TIONAL CARE, AND BY SOMETIMES INAPPROPRIATELY HIGH LEVELS OF
MEDICAL SERVICES FOR PATIENTS WHO DO NOT REQUIRE THEM. BUT
EVEN MORE IMPORTANTLY, EPIDEMIOLOGY AND THE SOCIAL SCIENCES
ARE PROVIDING EVIDENCE THAT DEPENDENCY FACTORS - LOWERED
INCOME, DISPLACEMENT, LOSS OF STATUS, ISOLATION - MAY EXACER--
BATE IF NOT PRECIPITATE ACTUAL PHYSIOLOGIC DISEASE, OLDER
15
PERSONS PLACED IN INSTITUTIONS EXPERIENCE SUBSTANTIALLY
HIGHER AGE - SPECIFIC MORBIDITY AND MORTALITY RATES THAN
THOSE WHO REMAIN AT HOME. So THE TRANSFER OF A PERSON
FROM HIS HOME TO AN INSTITUTION, OR FROM AN INSTITUTION
IN WHICH HE IS RELATIVELY AUTONOMOUS TO ONE IN WHICH HIS
DEPENDENCY IS INCREASED, MAY MAKE HIM MORE ILL AND MORE
DEPENDENT.
THE ISSUE OF THE BALANCE OF MEDICAL AND PERSONAL SERV-
ICES WITHIN INSTITUTIONS CANNOT BE POSTPONED. ON DECEMBER 28,
1971 PRESIDENT NIXON SIGNED INTO LAW PUBLIC LAW 92-223,
WHICH AUTHORIZES THE TRANSFER OF INTERMEDIATE CARE FACILITIES
INTO THE MEDICAID PROGRAM, AN INTERMEDIATE CARE FACILITY
PROVIDES HEALTH RELATED SERVICES FOR PATIENTS WHO DO NOT RE-
QUIRE CARE IN SKILLED NURSING HOMES, BUT NEED INSTITUTIONAL
CARE BEYOND ROOM AND BOARD, ICF's WERE PREVIOUSLY FINANCED
BY PUBLIC ASSISTANCE PROGRAMS FOR THE AGED, THE BLIND, AND THE
DISABLED, AND WERE SUBJECT ONLY TO STATE LICENSING, TRANSFER
OF FINANCING TO THE MEDICAID PROGRAM MEANS NOT ONLY THAT A
LARGER GROUP OF PEOPLE - INCLUDING THE "MEDICALLY NEEDY" -
MAY POTENTIALLY BE ELIGIBLE FOR BENEFITS, BUT ALSO THAT THE
FEDERAL GOVERNMENT IS EMPOWERED TO SET PHYSICAL AND SAFETY
STANDARDS AND DEFINE THE CARE AND SERVICES THAT MUST BE PRO-
VIDED. THE MEDICAL SERVICES ADMINISTRATION OF THE SOCIAL AND
16
REHABILITATION SERVICE AND MY OFFICE OF NURSING HOME AFFAIRS
ARE CURRENTLY EXAMINING SUCH ISSUES AS WHO SHOULD BE IN THESE
FACILITIES, WHAT SERVICES MUST THEY PROVIDE, AND WHAT SHOULD
BE THE LEVEL OF BENEFITS IN ATTEMPTING TO DEVELOP STANDARDS
cut>
FOR INTERMEDIATE CARE FACILITIES.
JUST AS THE BALANCE BETWEEN MEDICAL AND PERSONAL SER-
VICES WITHIN INSTITUTIONS MUST BE RE-EXAMINED, so MUST THE
ALTERNATIVES TO INSTITUTIONAL CARE BE EXTENDED FOR THOSE
SUFFERING FROM CHRONIC ILLNESS, THE ELDERLY SHOULD HAVE
MORE OPTIONS AVAILABLE. IF A NURSING HOME IS NOT THE MOST
APPROPRIATE PLACE FOR A PERSON'S PARTICULAR NEEDS, THEN
HE SHOULD NOT BE REQUIRED TO GO THERE, IF IT IS PERSONAL
CARE RATHER THAN HEALTH CARE THAT IS REQUIRED, THEN THE
OPTION SHOULD PROVIDE THAT EMPHASIS, IF IT IS APPROPRIATE
HOUSING RATHER THAN INSTITUTIONAL CARE THAT IS NEEDED, THEN
THE EMPHASIS SHOULD BE ON HOUSING,
MANY FEDERAL PROGRAMS HAVE EXPLORED ALTERNATIVES TO IN-
2
STITUTIONAL CARE. THESE ALTERNATIVES HAVE BEEN A PARTICULAR
THRUST OF THE ADMINISTRATION ON AGING, WHICH HAS RECEIVED
NEW SUPPORT AND PRIORITY IN THE PRESIDENT'S BUDGET FOR 1972
IN THE FORM OF A FIVE-FOLD INCREASE IN ITS FUNDING LEVEL.
THE AoA HAS ESTABLISHED PROGRAMS SUCH AS TRANSPORTATION FOR
FORD
THE ELDERLY, SENIOR CENTERS, MEALS-ON-WHEELS, TELEPHONE RE-
LISBARY
17
ASSURANCE, IN-HOME SERVICES, AND OPPORTUNITIES TO SERVE.
THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT HAS DEVELOP-
ING HOUSING PROGRAMS DESIGNED TO MEET THE SPECIAL NEEDS OF
THE ELDERLY, MEDICARE AND MEDICAID PROVIDE HOME HEALTH
BENEFITS,
BUT THE CONCERTED IMPACT OF THESE PROGRAMS HAVE NOT BEEN
ENOUGH, AS WE HEARD ONCE MORE AT THE WHITE HOUSE CONFERENCE
ON AGING. THE PRESSURE FOR INSTITUTIONALIZATION CONTINUES
TO PLACE STRAINS ON NURSING HOMES, WHICH ARE ASKED TO SERVE
TOO WIDE A VARIETY OF FUNCTIONS, AND CONTINUES TO PUSH THE
ELDERLY INTO SOMETIMES PREMATURE DEPENDENCY: THE PROBLEM OF
DEVELOPING A WIDER SPECTRUM OF OPTIONS FOR THE CHRONICALLY
ILL AND FOR THE ELDERLY WILL BE A CENTRAL FOCUS OF THE TASK
FORCE ON LONG TERM CARE.
AN IMPORTANT REASON FOR THE INSUFFICIENT AND SOMETIMES
INAPPROPRIATE IMPACT OF FEDERAL PROGRAMS FOR LONG TERM CARE
HAS BEEN THE LACK OF PLANNING AND COORDINATING BETWEEN FEDERAL,
STATE, AND LOCAL PROGRAMS. PLANNING FOR LONG TERM CARE
SHOULD MOVE FROM IDENTIFICATION OF AN ISSUE OR PROBLEM TO ITS
SOLUTION, WITH IDENTIFIABLE GOALS GUIDING THE PROCESS, MOVE-
MENT TOWARD A GOAL SHOULD NOT BE INTERRUPTED BY CHANGES IN
ADMINISTRATION. WHAT IS TRULY IMPORTANT TODAY SHOULD NOT BE
CAST ASIDE TOMORROW, NEW PROGRAMS SHOULD NOT BE APPENDAGES TO
18
SATISFY THE INTERESTS OF A FEW, NOR SHOULD THEY BE ADDED AS
PACIFIERS TO THE MANY, PROGRAMS DEVELOP THROUGH A RATIONAL
PLANNING PROCESS SHOULD THEN BE ADMINISTERED THROUGH AN
EFFECTIVE AND COORDINATED MECHANISMS,
THE ESTABLISHMENT OF THE OFFICE OF NURSING HOME AFFAIRS
WITHIN HEW WAS A STEP TOWARD IMPROVING COORDINATION. BUT
THE MANDATE FOR THE-TASK FORCE ON LONG TERM CARE IS BROADER:
TO RE-EXAMINE THE ISSUES AND SET NEW GOALS, TO DEVELOP A
NATIONWIDE DATA SYSTEM NECESSARY FOR POLICY FORMULATION,
AND TO RECOMMEND AN ORGANIZATION FOR LONG TERM CARE WITHIN
HEW AND OTHER FEDERAL AGENCIES, AND STATE AND LOCAL PROGRAMS
WHICH CAN ACHIEVE ITS GOALS MOST EFFECTIVELY.
A NATIONAL POLICY COURSE FOR THE CHRONICALLY ILL AND FOR
THE ELDERLY SHOULD BE SET, IT SHOULD BE SET BY GOVERNMENT.
SET BY GOVERNMENT WITH THE FULL AND CREATIVE CONTRIBUTION OF
THOSE IN OTHER AGENCIES AND ORGANIZATIONS, THOSE IN ACADEMIC
TEACHING AND RESEARCH, THOSE IN VOLUNTARY AND UNSALARIED
SERVICE, AND THOSE WHO RECEIVE THAT CARE, AND YOU WHO ARE IN
DIRECT CONTACT WITH HEALTH FACILITIES HAVE A SPECIAL RESPONSI-
BILITY, ON THE ONE HAND, TO TRANSLATE REGULATIONS INTO
AN EFFECTIVE INSTRUMENT FOR CONTROL OF THE QUALITY OF CARE.
ON THE OTHER, TO TRANSMIT TO THOSE OF US IN GOVERNMENT THE
PROBLEMS AND ACHIEVEMENTS OF THESE FACILITIES so THAT WE CAN
PLAN MORE EFFECTIVELY FOR THE CARE OF OUR SICK AND ELDERLY
THE FEDERAL REGULATIONS OF NURSING HOMES
MARIE CALLENDER
SPECIAL ASSISTANT FOR NURSING HOME AFFAIRS
THE QUALITY OF ANY CIVILIZATION CAN BE MEASURED BY THE
ATTITUDE OF THE PEOPLE TOWARD THE ELDERLY IN THEIR MIDST.
THEIR VALUE ECONOMICALLY IS EBBING OR IS AT AN END. THEY
REQUIRE A DISPROPORTIONATE SHARE OF MEDICAL AND SOCIAL
SERVICES, IN SOME EARLIER CULTURES THEY WERE CUT OFF FROM
THE TRIBE AND FORCED TO WANDER WITHOUT FOOD OR SHELTER UNTIL
THEY DIED. MOST OF US LOOK WITH REVULSION AT SUCH SOCIAL
PATTERNS, AND ACCEPT THE MORAL RESPONSIBILITY OF OUR SOCIETY
TOWARD ITS ELDERLY.
THE MAJORITY OF THOSE OVER SIXTY-FIVE ARE ABLE TO LEAD
ACTIVE, INDEPENDENT LIVES CONTRIBUTING VIGOROUSLY TO OUR
NATIONAL LIFE. HOWEVER, ALMOST A MILLION OF OUR TWENTY-
MILLION PERSONS OVER SIXTY-FIVE REQUIRE THE CARE AND SUPPORT
OF NURSING HOMES, AND IT IS THESE WHOSE DEPENDENCE MOST ACUTELY
TESTS THE QUALITY OF OUR COMPASSION AND SENSE OF HUMANITY.
To BE PRESENTED AI THE ANNUAL MEETING OF THE GENERAL CONFERENCE
IN SAN, ANTONIO, TEXAS, MARCH 21, 1972
GERALD LIBRARY R.FORD
2
THE PRESIDENT HAS APTLY STATED THAT, "FOR THOSE WHO
NEED THEM, THE NURSING HOMES OF AMERICA SHOULD BE SHINING
SYMBOLS OF COMFORT AND CONCERN." MANY OF OUR NURSING HOMES
MEET THIS STANDARD, OTHER DO NOT, AS TESTIFIED BY RECENT
SHOCKING AND TRAGIC NURSING HOME FIRES, AND LESS DRAMATI-
CALLY BY PRIVATE AND GOVERNMENT STUDIES, IN MAY, 1971, THE
GENERAL ACCOUNTING OFFICE ISSUED A REPORT ON THE ENFORCEMENT
OF MEDICAID AND MEDICARE STANDARDS IN NINETY NURSING HOMES
IN OKLAHOMA, NEW YORK, AND MICHIGAN, SERIOUS DEFICIENCIES
WERE FOUND IN MORE THAN 50 PERCENT OF THESE HOMES, ALL OF
WHICH HAD MEDICAID PATIENTS AND MANY OF WHICH WERE APPROVED
FOR MEDICARE. ON NOVEMBER 30, 1971, SECRETARY RICHARDSON
ANNOUNCED THAT 39 STATES WERE OUT OF COMPLIANCE WITH TITLE
19 CERTIFICATION PROCEDURES, IN HUMAN TERMS, THESE STUDIES
MEAN THAT MANY NURSING HOMES WHICH FAIL TO MEET STANDARDS
ARE UNSANITARY AND UNSAFE, OVERCROWDED AND UNDERSTAFFED--
LONELY AND DEPRESSING PLACES FOR THE ELDERLY TO LIVE AND DIE.
THE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED
IN NURSING HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY
SINCE THE ENACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN
1965. IN 1970 THE FEDERAL GOVERNMENT UNDER MEDICAID SPENT
OVER $2 MILLION IN SUPPORT OF NURSING HOME PATIENTS, WHILE
3
STATE AND LOCAL GOVERNMENTS SPENT ANOTHER $7 MILLION.
MEDICARE SPENT 247 MILLION. THIS INVOLVEMENT CARRIES WITH
IT A RESPONSIBILITY TO ASSURE THAT NURSING HOMES DELIVER
CARE AT LEAST AT THE LEVELS OF FEDERAL STANDARDS AND REGULA-
TIONS, THE PRESIDENT ACCEPTED THIS RESPONSIBILITY IN HIS
8-POINT PLAN FOR ACTION TO IMPROVE NURSING HOMES ANNOUNCED
LAST AUGUST IN NEW HAMPSHIRE.
A MAJOR GOAL OF THE PLAN IS TO IMPROVE ENFORCEMENT OF
FEDERAL NURSING HOME STANDARDS, THE TERM "NURSING HOME" IS
APPLIED TO A WIDE RANGE OF FACILITIES, FROM THOSE PROVIDING
PRIMARILY CUSTODIAL CARE TO THOSE DELIVERING HIGHLY SKILLED
POST-HOBPITAL AND REHABILITATIVE SERVICES, THESE DIFFERENT
TYPES OF FACILITIES ARE ACCREDITED THROUGH DIFFERENT
MECHANISMS, AND FEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES
WIDELY.
MEDICARE IS A FEDERAL RROGRAM, IT CONTRACTS WITH - STATE
HEALTH DEPARTMENTS TO SURVEY NURSING HOMES FOR COMPLIANCE
WITH FEDERAL STANDARDS, THE RESULTS OF THE SURVEY AND RECOMMEN-
DATIONS ARE THEN PASSED ON TO FEDERAL PERSONNEL IN THE HEW
REGIONAL 0-FICES, WHERE A FINAL DECISION IS RENDERED FOR CERTI-
FICATION OF THE NURSING/AS HOME AN. EXTENDED CARE FACILITY ELIGIBLE
TO RECEIVE MEDICARE FUNDS, THUS, THE FEDERAL ROLE AND THE
FEDERAL ENPORCEMENT POWER ARE CLEAR AND UNEQUIVOCAL,
4
MEDICAID, ON THE OTHER HAND, IS A FEDERAL-STATE PRO-
GRAM, FINANCIED AND ADMINISTERED THROUGH BOTH FEDERAL AND
STATE FUNDS AND ACITIVITIES. To QUALIFY FOR MEDICAID FUNDS
AS A SKILLED NURSING HOME, AN INSTITUTION MUST MEET FEDERAL
STANDARDS. HOWEVER, THE PROCESS OF ENFORCING STANDARDS
DIFFERS FROM THE MEDICARE PROGRAM, UNDER MEDICAID, ADMINI-
STRATION OF STATE PROGRAMS - INCLUDING THE ENFORCEMENT OF
STANDARDS - IS ASSIGNED BY CONTRACT TO A SINGLE STATE AGENCY.
IN THE MAJORITY OF STATES, THE SINGLE STATE AGENCY IS THE
STATE WELFARE DEPARTMENT. THE SINGLE STATE AGENCY, AS IN
MEDICARE, USUALLY CONTRACTS WITH ANOTHER AGENCY TO SURVEY
NURSING HOMES FOR COMPLIANCE WITH FEDERAL STANDARDS, IN MOST
STATES, THE SAME AGENCY SURVEYS FOR BOTH MEDICARE AND MEDI-
CAID. UNDER MEDICAID, THE RESULTS OF THE SURVEY AND RECOM-
MENDATIONS ARE THEN SUBMITTED TO THE SINGLE STATE AGENCY -
STATE RATHER THEN FEDERAL PERSONNEL-WHERE A DECISION IS MADE
WHETHER THE NURSING HOME QUALIFIED AS A SKILLED NURSING HOME
FOR MEDICAID FUNDS, THIS PROCESS DIFFERS FROM MEDICARE, IN
WHICH FEDERAL PERSONNEL REVIEW SURVEY RESULTS TO DETERMINE
WHETHER AN INDIVIDUAL HOME QUALIFIES, IN MEDICAID THE EN-
FORCEMENT OF STANDARDS IS DELEGATED TO THE STATES, WITH THE
FEDERAL MEDICAID PROGRAM RETAINING ONLY THE UTLIMATE NEC-
ESSITY OF FINDING AN ENTIRE OR PART OF A STATE
5
STATE PROGRAM OUT OF COMPLIANCE WITH FEDERAL STANDARDS
AND HENCE INELIGIBLE FOR FEDERAL FUNDS, THESE PROCESSES
REFLECT THE DIFFERENCE IN FUNDING SOURCES BETWEEN THE TWO
PROGRAMS - THE FEDERAL GOVERNMENT BEARS THE ENTIRE BURDEN
OF MEDICARE NURSING HOME FUNDING, WHILE IT PAYS ONLY A
PORTION OF MEDICAID SUPPORT FOR NURSING HOME CARE.
THE MEDICARE PROGRAM, WHILE NOT ENTIRELY ABOVE RE-
PROACH, HAS DONE A CREDITABLE JOB OF ENFORCING NURSING
HOME STANDARDS. MEDICAID HAS BEEN A DIFFERENT STORY.
To SPEAK BLUNTLY, MANY STATES HAVE SIMPLY FAILED TO EN-
FORCE FEDERAL NURSING HOME STANDARDS, WE HAVE BEEN FACED
WITH AN INEQUITABLE SITUATION IN WHICH THE MEDICARE PATIENT
CAN BE ASSURED THAT HIS NURSING HOME IS BEING CAREFULLY
WATCHES; WHILE ANOTHER PERSON WHOSE CARE IS PAID FOR BY
MEDICAID MAY LIVE IN A NURSING HOME WHERE INSPECTIONS ARE
INFREQUENT, INEFFECTIVE, OR ABSENT.
THE PROBLEM OF ENCOURAGING STATES TO ENFORCE FEDERAL
STANDARDS HAS BEEN DIFFICULT. THE BLUDGEON APPROACH OF
DECLARING A STATE OUT OF COMPLIANCE AND HENCE INELIGIBLE
FOR FEDERAL MATCHING FUNDS MAY PENALIZE THE INDIVIDUAL
NURSING HOME PATIENT OR THE GOOD NURSING HOME FOR THE SINS
OF STATE AND
6
FEDERAL MEDICAID PERSONNEL. So THIS CLEARLY IS AN ACTION
OF LAST RESORT. WE RECOGNIZE ALSO THAT SOME STATES - WITH
THE BEST OF INTENTIONS - HAVE FACED REAL PROBLEMS IN EN-
FORCING STANDARDS, ESPECIALLY LACK OF TRAINED PERSONNEL AND
FINANCIAL RESOURCES, FOR THIS REASON, THE PRESIDENT'S
NURSING HOME ACTION PLAN OFFERRED SEVERAL FORMS OF ASSISTANCE
TO THE STATES IN MEETING THEIR RESPONSIBILTIES.
1. THE PRESIDENT PROMISED TO SEEK AUTHORIZATION FOR
FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID INSPECT-
TIONS, WE RECOGNIZE THAT AN INCREASED LEVEL OF ENFORCEMENT
ACTIVITY INVOLVES ADDITIONAL COSTS TO THE STATES. MEDICARE
INSPECTION COSTS HAVE ALWAYS BEEN FULLY PAID FOR BY THE FEDERAL
GOVERNMENT, BUT UNDER THE MEDICAID PROGRAM STATES HAVE PAID
25 TO 50 PERCENT OF THESE COSTS, SECRETARY RICHARDSON
SUBMITTED TO CONGRESS IN OCTOBER, 1971, AN AMENDMENT TO H.R.I.
AUTHORIZING THE FEDERAL GOVERNMENT TO ASSUME 100% OF INSPEC-
TION COSTS UNDER MEDICAID, THIS STEP WILL PLACE BOTH PROGRAMS
ON AN EQUAL FOOTING AND LESSEN THE FINANCIAL BURDEN TO THE
STATES.
2. THE PRESIDENT PLEDGED TO TRAIN 2,000 STATE NURSING
HOME INSPECTIONS IN THE 18 MONTH PERIOD AFTER HIS AUGUST SPEECH,
GERALD
LIBRARY
7
ENTIRELY AT FEDERAL EXPENSE, THIS EFFORT IS WELL UNDER
WAY, AND 475 STATE INSPECTORS HAVE ALREADY ATTENDED THOSE
COURSES,
3. THE PRESIDENT HAS ENLARGED THE FEDERAL STAFF FOR
ENFORCEMENT OF NURSING HOME STANDARDS, ONE HUNDRED NINETY-
ONE PERSONNEL HAVE BEEN ADDED, ONE-HUNDRED TEN OF THESE TO
THE REGIONAL OFFICES OF THE SOCIAL AND REHABILITATION
SERVICE WHICH ADMINISTERS THE MEDICAID PROGRAM, THESE
FEDERAL PERSONNEL WORK CLOSELY WITH STATE MEDICAID PROGRAMS,
4. THE FEDERAL ENFORCEMENT EFFORT HAS BEEN REORGANIZED
TO ACHIEVE IMPROVED COORDINATION AND HIGHER PRIORITY,
NURSING HOME RESPONSIBILITIES HAVE BEEN CONSOLIDATED IN A
SINGLE OFFICE - DR. MERLIN K. DUVAL, THE ASSISTANT SECRETARY
FOR HEALTH AND SCIENTIFIC AFFAIRS IS THE RESPONSIBLE OFFICIAL.
HE HAS INTURN DELEGATED THAT RESPONSIBILITY TO ME TO WORK
WITH HIM TO BE RESPONSIBLE AND ACCOUNTABLE FOR ALL DHEW NURSING
HOME AFFAIRS.
So THE PRESIDENT'S PLAN OFFERS ASSISTANCE TO THE STATES
IN ENFORCING NURSING HOME STANDARDS, BUT AS THE PRESIDENT
WARNED LAST AUGUST, LET THERE BE NO MISTAKING THE FACT
BERALD
8
THAT WHEN FACILITIES FAIL TO MEET REASONABLE STANDARDS,
WE WILL NOT HESITATE TO CUT OFF MEDICARE AND MEDICAID
FUNDS." As A RESULT OF A CRASH PROGRAM TO ASSESS THE
STATE MEDICAID CERTIFICATION AND ENFORCEMENT EFFORT,
SECRETARY RICHARDSON ANNOUNCED ON NOVEMBER 30, 1971,
THAT THIRTY-NINE STATES WERE OUT OF COMPLIANCE WITH
MEDICAID CERTIFICATION PROCEDURES, HE ALSO ANNOUNCED
TWO DEADLINES: BY FEBRUARY 1, 1972, ALL STATES WERE
TO DEMONSTRATE THAT THEIR INSPECTION AND CERTIFICATION
PROCEDURES WERE IN COMPLIANCE WITH MEDICAID REGULATIONS,
ON THAT DATE, THIRTY-EIGHT OF THE THIRTY-NINE STATES CITED
HAD CORRECTED THEIR DEFICIENCIES AND WERE FOUND TO HAVE
IN EFFECT THE CORRECT PROCEDURES, BUT BY JULY 1, 1972,
ALL MEDICAID FACILITIES IN ALL STATES ARE TO HAVE BEEN
INSPECTED AND CERTIFIED THROUGH THE CORRECT PROCEDURES,
THE JULY 1 DEADLINE HAS HIGH HEW PRIORITY, AND WE
ANTICIPATE THAT AS IT NEARS, THE PUBLIC, THE PRESS, AND
THE CONGRESS WILL BECOME INCREASINGLY INTERESTED. THE
NUMBER OF NURSING HOMES WHICH MUST BE SURVEYED AND CERTI-
FIED TO MEET THE DEADLINE VARIES WIDELY FROM STATE TO STATE,
AND IN MANY PRESENTS A MOST FORMIDABLE WORKLOAD, IF THE
DEADLINE IS TO BE MET, AN UNUSUAL CONCENTRATION AND COORDI-
NATION OF HEW REGIONAL OFFICE, SURVEY AGENCY, AND SINGLE
STATE AGENCY RESOURCES MUST BE ACHIEVED IN MOST STATES.
9
To THIS END, A STRATEGY TO ASSIST THE SINGLE STATE
AGENCIES HAS BEEN DEVISED BY MY OFFICE, THE REGIONAL
DIRECTORS OF HEW REGIONAL OFFICES HAVE BEEN NAMED THE
RESPONSIBLE OFFICIALS FOR NURSING HOME INITIATIVES.
THEY ARE RESPONSIBLE FOR DETERMINING THAT SINGLE STATE
AGENCIES DEVELOP REASONABLE TIMETABLES TO ACHIEVE AC-
CREDITATION GOALS AND ADHERE TO THEM; THAT THE REQUIRED
RESOURCES ARE AVAILABLE; THAT CORRECT SURVEY AND CERTI-
FICATION PROCEDURES ARE FOLLOWED; THAT THE PERIODIC
REPORTING REQUIREMENTS ARE MET. WE ANTICIPATE THAT MANY
STATES WILL FACE PROBLEMS OF COORDINATION - FOR EXAMPLE,
SURVEYORS MAY HAVE TO BE "BORROWED" FROM THE MEDICARE
PROGRAM, OR FUNDING MAY HAVE TO BE NEGOTIATED WITH THE
GOVERNOR'S OFFICEES WE WILL MONITOR THEIR PROGRESS
CONTINUOUSLY FROM MY OFFICE, AND WILL OFFER AS MUCH
SUPPORT AS WE CAN, BUT THE TASK PRESENTS A GREAT CHALLENGE
TO THE STATES AND A TEST FOR THE MEDICAID PROGRAM, IF WIDE-
SPREAD ABUSES CONTINUE TO EXIST, WE WILL HAVE NO ALTER-
NATIVE BUT TO FIND WHOLE STATES OUT OF COMPLIANCE - MEANING
THEIR FEDERAL FUNDS CAN BE HELD BACK,
10
THERE IS ANOTHER ISSUE OF MAJOR SIGNIFICANT IN
THE FEDERAL REGULATION OF NURSING HOMES, AN ISSUE WHICH HAS B
HAS BEEN SOMEWHAT OVERSHADOWED BY THE PRESS OF JULY 1 DEAD-
LINE ACTIVITIES, ON DECEMBER 28, 1971, PRESIDENT NIXON
SIGNED INTO LAW PUBLIC LAW 92-223, WHICH AUTHORIZES THE
TRANSFER OF INTERMEDIATE CARE FACILITIES INTO THE MEDICAID
PROGRAM. AN INTERMEDIATE CARE FACILITY PROVIDES HEALTH
RELATED SERVICES FOR PATIENTS WHO DO NOT REQUIRE CARE IN
SKILLED NURSING HOMES, BUT NEED INSTITUTIONAL CARE BEYOND
ROOM AND BOARD. ICF's WERE PREVIOUSLY FINANCED BY PUBLIC
ASSISTANCE PROGRAMS FOR THE AGED, THE BLIND, AND THE DIS-
ABLED, AND WERE SUBJECT ONLY TO STATE LICENSING AND STATE
STANDARDS, TRANSFER OF FINANCING TO THE MEDICAID PROGRAM
MEANS NOT ONLY THAT A LARGER GROUP OF PEOPLE - INCLUDING
THE "MEDICALLY NEEDY" - MAY POTENTIALLY BE ELIGIBLE FOR
BENEFITS, BUT ALSO THAT THIS LARGE GROUP OF NURSING HOMES
WILL FALL UNDER THE UMBRELLA OF FEDERAL STANDARDS, FROM
WHICH THEY WERE PREVIOUSLY EXEMPT. THE MEDICAL SERVICES
ADMINISTRATION OF SOCIAL AND REHABILITATION SERVICE AND
MY OFFICE OF NURSING HoMe AFFAIRS ARE CURRENTLY EXAMINING
SUCH ISSUES AS WHO SHOULD BE IN THESE FACILITIES, WHAT
SERVICES MUST THEY PROVIDE, AND WHAT SHOULD BE THE LEVEL
OF BENEFITS IN ATTEMPTING TO DEVELOP STANDARDS FOR INTER-
MEDIATE CARE FACILITIES.
GERALD
11
I HAVE CENTERED MY REMARKS ON THE ENFORCEMENT OF
FEDERAL NURSING HOME STANDARDS, BECAUSE THESE ISSUES
ARE THE ONES MOST LIKELY TO FIND THEIR WAY TO YOUR DESKS,
BUT I DO NOT WANT TO LEAVE THE IMPRESSION THAT THIS IS
THE SUM SUBSTANCE OF THE PRESIDENTS' PLAN OR OF MY HOPES
FOR THE FEDERAL PROGRAM FOR LONG TERM CARE. WE ARE DEVELOP-
ING IN FULFILLMENT OF THE PRESIDENT'S PLAN PROGRAMS TO TRAIN
NURSING HOME PERSONNEL AND MODELS FOR OMBUDSMAN UNITS TO
SERVE AS ADVOCATES FOR DEPENDENT AND SOMETIMES HELPLESS
NURSING HOME PATIENTS. THE PRESIDENT HAS GIVEN ME A MANDATE
TO HEAD A TASK FORCE STUDYING PROBLEMS OF LONG TERM CARE
FROM A BROAD PERSPECTIVE. THE TASK FORCE WILL MAKE RECOMMENDA-
TIONS FOR CORRECTING DEFICIENCIES IN EXISTING PROGRAMS AND
ORGANIZATIONS AND FOR DEVELOPING NEW ONES. I HAVE BEEN MOST
INTERESTED IN ENCOURAGING ALTERNATIVES TO INSTITUTIONAL CARE
FOR THE ELDERLY, so THAT THEY ARE NOT FORCED PREMATURELY
INTO NURSING HOMES WHEN THE COULD LIVE INDEPENTLY WITH FEA-
SIBLE AND LESS COSTLY SOCIAL SERVICES, WE CAN DO MUCH BETTER
FOR OUR ELDERLY, WE MUST OF COURSE PROTECT THEM FROM
INSTITUTIONAL ABUSE RECOGNIZING THAT SOME ARE WEAK AND
DEPENDENT. BUT WE CAN ALSO MAKE POSSIBLE A WIDE VARIETY OF
SUPPORTING SERVICES AND LIVING ARRANGEMENTS, so THAT THE
VORD
INFIRMITIES OF ADVANCING AGE DO NOT BECOME A PRISON OF THE
SPIRIT, THE ELDERLY WITH OUR HELP CAN HAVE ACCESS TO THE
GERALD
LIBRARY
VARIETY AND FREEDOM WE ASK FOR OURSELVES,
THE FEDERAL PROGRAM TO IMPROVE CARE
OF LONG-TERM PATIENTS IN INSTITUTIONS
MRS. MARIE CALLENDER
SPECIAL ASSISTANT FOR NURSING HOME AFFAIRS
DEPARTMENT OF HEALTH, EDUCATION AND WELFARE*
To BE PRESENTED AT THE NATIONAL CONFERENCE ON SOCIAL WELFARE,
CHICAGO, ILLINOIS, WEDNESDAY MAY 31, 1972
GERAL
THE FEDERAL PROGRAM TO IMPROVE CARE
OF LONG-TERM PATIENTS IN INSTITUTIONS
THE QUALITY OF ANY CIVILIZATION CAN BE MEASURED BY THE ATTITUDE
OF THE PEOPLE TOWARD THE ELDERLY IN THEIR MIDST. THEIR VALUE
ECONOMICALLY IS EBBING OR IS AT AN END. THEY REQUIRE A DIS-
PROPORTIONATE SHARE OF MEDICAL AND SOCIAL SERVICES, IN SOME
EARLIER CULTURES THEY WERE CUT OFF FROM THE TRIBE AND FORCED TO
WANDER WITHOUT FOOD OR SHELTER UNTIL THEY DIED. MOST OF US LOOK
WITH REVULSION AT SUCH SOCIAL PATTERNS, AND ACCEPT THE MORAL
RESPONSIBILITY OF OUR SOCIETY TOWARD ITS ELDERLY,
THE MAJORITY OF THOSE OVER SIXTY-FIVE ARE ABLE TO LEAD ACTIVE,
INDEPENDENT LIVES CONTRIBUTING VIGOROUSLY TO OUR NATIONAL LIFE.
HOWEVER, ALMOST A MILLION OF OUR TWENTY-MILLION PERSONS OVER
SIXTY-FIVE REQUIRE THE CARE AND SUPPORT OF NURSING HOMES, AND IT
IS THESE WHOSE DEPENDENCE MOST ACUTELY TESTS THE QUALITY OF OUR
COMPASSION AND SENSE OF HUMANITY,
THE PRESIDENT HAS APTLY STATED THAT, "FOR THOSE WHO NEED THEM, THE
NURSING HOMES OF AMERICA SHOULD BE SHINING SYMBOLS OF COMFORT AND
CONCERN." MANY OF OUR NURSING HOMES MEET THIS STANDARD. OTHER
DO NOT, AS TESTIFIED BY RECENT SHOCKING AND TRAGIC NURSING HOME
FIRES, AND LESS DRAMATICALLY BY PRIVATE AND GOVERNMENTAL STUDIES.
IN MAY, 1971, THE GENERAL ACCOUNTING OFFICE ISSUED A REPORT ON THE
ENFORCEMENT OF MEDICAID AND MEDICARE STANDARDS IN NINETY NURSING
HOMES IN OKLAHOMA, NEW YORK, AND MICHIGAN. SERIOUS DEFICIENCIES
WERE FOUND IN MORE THAN 50 PERCENT OF THESE HOMES, ALL OF WHICH HAD
MEDICAID PATIENTS AND MANY OF WHICH WERE APPROVED FOR MEDICARE.
1
ON NOVEMBER 30, 1971, SECRETARY RICHARDSON ANNOUNCED THAT 39 STATES
WERE OUT OF COMPLIANCE WITH TITLE 19 CERTIFICATION PROCEDURES,
IN HUMAN TERMS, THESE STUDIES MEAN THAT MANY NURSING HOMES WHICH
FAIL TO MEET STANDARDS ARE UNSANITARY AND UNSAFE, OVERCROWDED AND
UNDERSTAFFED--LONELY AND DEPRESSING PLACES FOR THE ELDERLY TO LIVE
AND DIE.
THE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED IN NURSING
HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY SINCE THE EN-
ACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN 1965. IN 1970
THE FEDERAL GOVERNMENT SPENT OVER $2 BILLION IN SUPPORT OF NURSING
HOME PATIENTS, WHILE STATE AND LOCAL GOVERNMENTS SPENT ANOTHER
$700 MILLION, THIS INVOLVEMENT CARRIES WITH IT A RESPONSIBILITY
TO ASSURE THAT NURSING HOMES DELIVER CARE AT LEAST AT THE LEVELS
OF FEDERAL STANDARDS AND REGULATIONS, THE PRESIDENT ACCEPTED
THIS RESPONSIBILITY IN HIS 8-POINT PLAN FOR ACTION TO IMPROVE
NURSING HOMES ANNOUNCED LAST AUGUST IN NEW HAMPSHIRE,
A MAJOR GOAL OF THE PLAN IS TO IMPROVE FEDERAL ENFORCEMENT OF
NURSING HOME STANDARDS. As YOU KNOW, THE TERM "NURSING HOME"
IS APPLIED TO A WIDE RANGE OF FACILITIES, FROM THOSE PROVIDING
PRIMARILY CUSTODIAL CARE TO THOSE DELIVERING HIGHLY SKILLED POST-
HOSPITAL AND REHABILITATIVE SERVICES, THESE DIFFERENT TYPES
OF FACILITIES ARE ACCREDITED THROUGH DIFFERENT MECHANISMS, AND
FEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES WIDELY, MEDICARE
CERTIFICATION OF EXTENDED CARE FACILITIES IS A FEDERAL PROGRAM
MEDIATED THROUGH STATE AGENCIES, MEDICAID IS A FEDERAL-STATE
PROGRAM FINANCED AND ADMINISTERED THROUGH BOTH FEDERAL AND STATE GREATO
LIBRARY
2
FUNDS AND ACTIVITIES. INTERMEDIATE CARE FACILITIES UNTIL
RECENTLY WERE REQUIRED TO MEET ONLY STATE LICENSING REQUIRE-
MENTS TO RECEIVE FEDERAL FUNDS. THESE VARIATIONS HAVE COM-
PLICATED THE ENFORCEMENT OF STANDARDS. THE DIFFERENCES ARE
CURRENTLY BEING RESOLVED TO CREATE A MORE RATIONAL AND EASILY
ADMINISTERED BASIS FOR NURSING HOME STANDARDS.
ON DECEMBER 28, 1971, PRESIDENT NIXON SIGNED INTO LAW PUBLIC
LAW 92-223, WHICH AUTHORIZES THE TRANSFER OF INTERMEDIATE
CARE FACILITIES INTO THE MEDICAID PROGRAM. AN INTERMEDIATE
CARE FACILITY PROVIDES HEALTH RELATED SERVICES FOR PATIENTS
WHO DO NOT REQUIRE CARE IN SKILLED NURSING HOMES, BUT NEED
INSTITUTIONAL CARE BEYOND ROOM AND BOARD. ICF's WERE
PREVIOUSLY FINANCED BY PUBLIC ASSISTANCE PROGRAMS FOR THE AGED,
THE BLIND, AND THE DISABLED, AND WERE SUBJECT ONLY TO STATE
LICENSING. TRANSFER OF FINANCING TO THE MEDICAID PROGRAM MEANS
NOT ONLY THAT A LARGER GROUP OF PEOPLE - INCLUDING THE
"MEDICALLY NEEDY" - MAY POTENTIALLY BE ELIGIBLE FOR BENEFITS,
BUT ALSO THAT THE FEDERAL GOVERNMENT IS EMPOWERED TO SET PHYSICAL
AND SAFETY STANDARDS AND TO DEFINE THE CARE AND SERVICES THAT MUST
3
BE PROVIDED. THE MEDICAL SERVICES ADMINISTRATION OF THE SOCIAL
AND REHABILITATION SERVICE AND MY AFRICE OF NURSING HOME AFFAIRS
ARE CURRENTLY EXAMINING SUCH ISSUES AS WHO SHOULD BE IN THESE
FACILITIES, WHAT SERVICES THEY SHOULD PROVIDE, AND WHAT LEVEL
OF BENEFITS THEY SHOULD OFFER. REGULATIONS FOR INTERMEDIATE CARE
VACILITIES WILL BE AVAILABLE IN THE FEDERAL REGISTER BY JULY 1
THE DIFFERENCE IN THE STANDARDS FOR SKILLED NURSING HOMES UNDER
MEDICAID AND FOR EXTENDED CARE FACILITIES UNDER MEDICARE HAVE
CAUSED CONFUSION TO THOSE PROVIDING SUCH CARE AND FOR THOSE EN-
FORCING STANDARDS, ALTHOUGH THE PHILOSOPHIC INTENT IN THE TWO
PROGRAMS was WERE SOMEWHAT DIFFERENT, IN PRACTICE THE LEVELS OF NURSING
CARE AS DEFINED FOR THE TWO INSTITUTIONS HAVE BEEN ROUGHLY
EQUIVALENT. WE BELIEVE THAT DIFFERENCES IN STANDARDS CAUSE NEEDLESS
CONFUSION. THEREFORE, THE DEPARTMENT OF HEW AND MY OFFICE
OF NURSING HOME AFFAIRS HAVE BEEN MOVING TO ESTABLISH A SINGLE DE-
FINITION AND SET OF STANDARDS FOR EXTENDED CARE FACILITIES UNDER
MEDICARE AND SKILLED NURSING HOMES UNDER MEDICAID. CONGRESS HAS
AMENDED H.R.I. TO CALL FOR THESE CHANGES IN A REDEFINED ENTITY
TO BE CALLED A "SKILLED NURSING FACILITY." IN ANTICIPATION THAT
THAT THESE AMENDMENTS WILL BE ENACTED INTO LAW, WE ARE ALREADY
DEVELOPING A COMMON SET OF STANDARDS, A BASIC PRINCIPLE UNDERLYING
THIS EFFORT IS THAT WHERE STANDARDS BETWEEN THE TWO PROGRAMS DIFFER,
THE HIGHER WILL BE INCORPORATED INTO THE NEW REGULATIONS.
CONGRESSIONAL AMENDMENTS HAVE ALSO INTRODUCED SOME CHANGES IN CERTI-
FICATION PROCEDURES TO MAKE THE TWO PROGRAMS MORE UNIFORM, A
PROVISION HAS BEEN ADDED UNDER WHICH THE SECRETARY OF HEW WOULD
DECIDE WHETHER A NURSING HOME QUALIFIES TO PARTICIPATE AS A "SKILLED
NURSING FACILITY" IN BOTH THE MEDICARE AND MEDICAID PROGRAMS. THE
GERALD LIQUEST FORD
4
SECRETARY WOULD MAKE THAT DETERMINATION BASED PRINCIPALLY UPON
THE APPROPRIATE STATE AGENCY EVALUATION. IT WILL BE REQUIRED
THAT THE SAME STATE AGENCY CERTIFY FACILITIES FOR BOTH MEDICARE
AND MEDICAID. A STATE COULD FOR GOOD CAUSE, REFUSE TO ACCEPT
AS A PARTICIPANT IN THE MEDICAID PROGRAM A FACILITY CERTIFIED
BY THE SECRETARY. BUT A STATE MEDICAID PROGRAM COULD NOT RE-
CEIVE FEDERAL MATCHING FUNDS FOR ANY INSTITUTION NOT APPROVED
BY THE SECRETARY.
ANOTHER ISSUE IN ACHIEVING UNIFORMITY BETWEEN MEDICARE AND
MEDICAID NURSING HOME PROGRAMS IS THE PROBLEM OF REIMBURSEMENT.
WE ARE STUDYING ALTERNATIVE MECHANISMS TO DEVELOP A SYSTEM WHICH
IS UNIFORM AND IS WEIGHTED TO SLOW THE RATE OF "MEDICAL INFLATION.
THE SENATE FINANCE COMMITTEE HAS AMENDED MEDICAID LAWS TO REQUIRE
THAT SKILLED NURSING AND INTERMEDIATE CARE SERVICES BE REIMBURSED
ON A REASONABLE - COST RELATED BASIS, AND THIS IS ONE APPROACH
HEW
s
ARE CONSIDERING.
THE DEPARTMENT OF HEW HAS BEEN WORKING TOWARD THE DEVELOPMENT OF
HIGHER STANDARDS WHICH CAN BE ENFORCED MORE FAIRLY.
S ME OF THE CONGRESSIONAL AMENDMENTS TO H.R.I. REPRESENT PROGRESS
HEW IS
IN THIS DIRECTION, AND DEVELOPING APPROPRIATE PLANS FOR
IMPLEMENTATION. THESE ARE ISSUES WHOSE RESOLUTION WILL BENEFIT
EVERYONE - THE PROVIDER, THE CONSUMER, AND GOVERNMENT OFFICIALS
CHARGED WITH ADMINISTERING THESE PROGRAMS,
BOTH MEDICARE AND MEDICAID WILL CONTINUE TO RELY ON STATE AGENCY
INSPECTION OF FACILITIES.
THIS APPROACH IS CONSISTENT
WITH A HEALTHY FEDERAL-STATE RELATIONSHIP AND AVOIDS UNNECESSARY
EXPANSION OF THE FEDERAL BUREAUCRACY. BUT THE FEDERAL GOVERNMENT
- WHICH IS RESPONSIBLE FOR THE QUALITY OF CARE WHICH IT FINANCES =
MUST AID IN ENHANCING THE CAPABILITY OF THE STATE AGENCIES TO
REGULATE AND IMPROVE THE QUALITY OF NURSING HOME CARE, To IMPROVE
ENFORCEMENT OF NURSING HOME STANDARDS, THE PRESIDENT'S PLAN FOR
ACTION PLEDGED THE FOLLOWING STEPS:
1. CONSOLIDATION OF RESPONSIBILITY FOR NURSING HOME AFFAIRS
NURSING HOME ACTIVITIES HAVE BEEN SCATTERED AMONG SEVERAL BRANCHES
OF THE DEPARTMENT OF HEW, INCLUDING THE SOCIAL SECURITY ADMINISTRATION,
THE SOCIAL AND REHABILITATION SERVICE, AND THE HEALTH SERVICE AND
MENTAL HEALTH ADMINISTRATION. THE PRESIDENT ORDERED THAT ALL FEDERAL
ENFORCEMENT RESPONSIBILITY BE CONSOLIDATED IN A SINGLE OFFICE, AND
DR. MERLIN K. DUVAL, THE ASSISTANT SECRETARY OF HEALTH AND SCIENTIFIC
AFFAIRS, WAS DESIGNATED AS THE RESPONSIBLE OFFICIAL. DR. DUVAL
DELEGATED TO ME THESE RESPONSIBILITIES AND THE FUNCTION OF FULL-TIME
COORDINATOR OF NURSING HOME ACTIVITIES. ALSO, TO AMPLIFY THE VOICE
OF THOSE OUTSIDE GOVERNMENT, AN OLDER AMERICANS ADVISORY COMMITTEE
HAS BEEN NAMED TO ASSIST THE SECRETARY OF HEW.
2. ENI ARGEMENT OF FEDERAL STAFF FOR ENFORCEMENT OF NURSING HOME
STANDARDS,
THE SOCIAL AND REHABILITATION SERVICE, WHICH ADMINISTERS THE
MEDICAID PROGRAM, HAS BEEN ASSIGNED 142 ADDITIONAL POSITIONS TO CARRY
OUT ITS INCREASED RESPONSIBILITIES. ONE HUNDRED TEN OF THESE
POSITIONS WERE ALLOCATED TO THE REGIONAL OFFICES OF HEW. THE
ASSISTANT SECRETARY COMPTROLLER RECEIVED EIGHT NEW POSITIONS, AND
HEW's AUDIT AGENCY RECEIVED THIRTY-FOUR ADDITIONAL POSITIONS TO
INCREASE THEIR AUDITS OF NURSING HOME OPERATIONS. THE NATIONAL
CENTER FOR HEALTH SERVICES RESEARCH AND DEVELOPMENT RECEIVED SEVEN
NEW POSITIONS FOR EFFORTS TO IMPROVE NURSING HOME DATA SYSTEMS AND
TO DEVELOP DATA IN SPECIAL FIELDS RELEVANT TO NURSING HOME CARE,
3. FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID INSPECTIONS.
WE RECOGNIZE THAT AN INCREASED LEVEL OF ENFORCEMENT ACTIVITY INVOLVES
ADDITIONAL COSTS TO THE STATES. MEDICARE INSPECTION COSTS HAVE ALWAYS
BEEN FULLY PAID FOR BY THE FEDERAL GOVERNMENT, BUT UNDER THE MEDICAID
PROGRAM STATES HAVE PAID 25 TO 50 PERCENT OF THESE COSTS, SECRETARY
RICHARDSON SUBMITTED TO CONGRESS IN OCTOBER, 1971, AN AMENDMENT TO
6
H.R.I. AUTHORIZING THE FEDERAL GOVERNMENT TO ASSUME 100 PERCENT
OF INSPECTION COSTS UNDER MEDICAID. THE SENATE FINANCE COMMITTEE
HAS ACCEPTED THIS AMENDMENT. THIS STEP WILL PLACE BOTH PROGRAMS
ON AN EQUAL FOOTING AND LESSEN THE FINANCIAL BURDEN TO THE STATES.
4. TRAINING STATE NURSING HOME INSPECTORS,
NURSING HOME SURVEYORS HAVE BEEN TRAINED IN SURVEY AND COUNSELLING
TECHNIQUES UNDER A PROGRAM SPONSORED BY THE HEALTH SERVICES AND
MENTAL HEALTH ADMINISTRATION SINCE MARCH, 1970. THESE FOUR-WEEK
COURSES HAVE BEEN PRESENTED IN UNIVERSITY CENTERS IN NEW HAMPSHIRE,
LOUISIANA, AND CALIFORNIA. IN HIS AUGUST SPEECH, THE PRESIDENT
PLEDGED AN EXPANSION OF THIS PROGRAM so THAT 2,000 SURVEYORS
COULD BE TRAINED IN THE ENSUING EIGHTEEN MONTH PERIOD. As A RESULT
OF THE PRESIDENT'S ORDER, THE PROGRAM HAS BEEN ACCELERATED so THAT
MORE THAN 700 SURVEYORS WILL HAVE BEEN TRAINED BY JULY OF THIS YEAR.
CONTRACT NEGOTIATIONS ARE IN PROCESS TO ESTABLISH THREE ADDITIONAL
UNIVERSITY CENTERS. IN ADDITION, A STUDY WAS PERFORMED TO EVALUATE
THE EFFECTIVENESS OF THE TRAINING COURSES, WHICH HAVE NOW BEEN
MODIFIED TO REFLECT THE RESULTS OF THAT STUDY,
THESE EFFORTS TO ACHIEVE COMPLIANCE WITH FEDERAL STANDARDS AND RE-
GULATIONS ARE NOT DESIGNED TO ELIMINATE FACILITIES AND THUS TO DEPRIVE
PATIENTS OF NEEDED NURSING HOME CARE. WE ARE WORKING RATHER TO
MAKE GOVERNMENTAL STANDARDS AND PERSONNEL MORE AFFECTIVE RESOURCES
FOR THE UPGRADING OF SUBSTANDARD FACILITIES, THE FEDERAL PROGRAM
TO TRAIN NURSING HOME SURVEYORS, FOR EXAMPLE, EMPHASIZES THE
DEVELOPMENT OF CONSULTANT SKILLS TO AID NURSING HOME ADMINISTRATORS
IN MAKING NEEDED IMPROVEMENTS. FEDERAL FINANCIAL ASSISTANCE IS
AVAILABLE FOR NURSING HOME MODERNIZATION AND NEW CONSTRUCTION FROM
THE FEDERAL HOUSING ADMINISTRATION AND SUCH PROGRAMS AS HILL- BURTON.
THE STANDARDS THEMSELVES ARE BEING REVISED AND STRENGTHENED. WE ARE
DEVELOPING PROGRAMS TO IMPROVE NURSING HOMES DIRECTLY - I SHALL
DESCRIBE THEM IN A FEW MOMENTS.
7
BUT AS THE PRESIDENT WARNED LAST AUGUST," LET THERE BE NO
MISTAKING THE FACT THAT WHEN FACILITIES FAIL TO MEET REASONABLE
STANDARDS, WE WILL NOT HESITATE TO CUT OFF THEIR MEDICARE AND
MEDICAID FUNDS." BETWEEN AUGUST 6, 1971, AND FEBRUARY 11, 1972,
13 EXTENDED CARE FACILITIES WERE DECERTIFIED FOR MEDICARE
PARTICIPATION. ON NOVEMBER 30, 1971, THIRTY-NINE STATES WERE
DECLARED OUT OF COMPLIANCE WITH TITLE 19-MEDICAID--CERTIFICA-
TION PROCEDURES. By FEBRUARY 1, 1972, IN RESPONSE TO SECRETARY
RICHARDSON'S DEADLINE, ALL BUT ONE OF THOSE STATES HAD MADE THE
IMPROVEMENTS REQUIRED FOR COMPLIANCE. By JULY 1, 1972, ALL
TITLE 19 FACILITIES IN ALL STATES ARE TO HAVE BEEN INSPECTED
AND CERTIFIED THROUGH THE CORRECT PROCEDURES, THE FEDERAL GOVERN-
MENT IS PLEDGED TO MEET ITS RESPONSIBILITY TO ASSURE THAT FEDERAL
DOLLARS DO NOT FINANCE SUBSTANDARD CARE.
IN ADDITION TO THESE STEPS FOR IMPROVEMENT IN NURSING HOME STANDARDS
AND THEIR ENFORCEMENT, TWO OTHER POINTS IN THE PRESIDENT'S PLAN
INITIATED MORE DIRECT STEPS TO IMPROVE NURSING HOME CARE. THE
PRESIDENT DIRECTED THE DEPARTMENT OF HEW "TO INSTITUTE A NEW PROGRAM
OF SHORT-TERM COURSES FOR PHYSICIANS, NURSES, DIETICIANS, SOCIAL
WORKERS AND OTHERS WHO ARE REGULARLY INVOLVED IN FURNISHING SERVICES
TO NURSING HOME PATIENTS. HEW HAS SUPPORTED SUCH TRAINING FOR
SEVERAL YEARS, AND HAS DEVELOPED CLOSE WORKING RELATIONSHIPS WITH
PROFESSIONAL ASSOCIATIONS AND WITH TRAINING CENTERS.
IN RESPONSE
TO THE PRESIDENTS' DIRECTIVE, SUCH PROGRAMS HAVE BEEN EXPANDED
UNDER THE LEADERSHIP OF THE COMMUNITY HEALTH SERVICE, HEALTH SERVICE
AND MENTAL HEALTH ADMINISTRATION, AND ANTICIPATED THAT APPROXI-
MATELY 20,000 PERSONS
TRAINED IN FISCAL YEAR 1972 AT A CÔST,
OF $2.5 MILLION, TRAINING PROGRAMS WILL FOCUS INITIALLY ON FOUR
8
MANPOWER AREAS SELECTED BECAUSE OF THEIR DIRECT DAY-TO-DAY
RELATIONS WITH NURSING HOME PATIENTS: NURSING HOME ADMINISTRATORS,
PHYSICIANS, NURSES, AND PATIENT ACTIVITIES DIRECTORS, MANY OF
THESE TRAINING PROGRAMS WILL BE OPERATED UNDER CONTRACTS WITH
PROFESSIONAL GROUPS, APPROACHES TO MENTAL HEALTH PROBLEMS OF
NURSING HOME PATIENTS WILL BE DEVELOPED BY NATIONAL INSTITUTE OF
MENTAL HEALTH STAFF WORKING WITH THE GERONTOLOGICAL SOCIETY,
OTHER TRAINING MECHANISMS WILL ALSO BE EXPLORED, SUCH AS PROGRAMS
SPONSORED BY STATE HEALTH DEPARTMENTS AND STATE AGENCIES, THESE
PROGRAMS WILL BE DIRECTED TOWARD NURSING HOME STAFF-BOTH PRO-
FESSIONAL AND ALLIED HEALTH-MORE SENSITIVE AND EXPERT IN THE SPECIAL
PROBLEMS OF CARE FOR GERIATRIC PATIENTS AND THE CHRONICALLY ILL.
THEY ARE INTENDED TO BE THE BEGINNING OF A SYSTEM FOR NATIONWIDE,
CONTINUOUS TRAINING FOR NURSING HOME PERSONNEL WHICH WILL BECOME
STANDARD PRACTICE IN THE NURSING HOME INDUSTRY OF THE FUTURE.
As THE SEVENTH POINT IN HIS PLAN, THE PRESIDENT DIRECTED THE DEPART-
MENT OF HEW "To ASSIST THE STATES IN ESTABLISHING INVESTIGATIVE
UNITS WHICH WILL RESPOND IN A RESPONSIBLE AND CONSTRUCTIVE WAY TO
COMPLAINTS MADE BY OR ON BEHALF OF INDIVIDUAL PATIENTS.
SINCE
I ASSUMED MY NURSING HOME RESPONSIBILITIES, I HAVE RECEIVED MANY
LETTERS FROM NURSING HOME PATIENTS - TOUCHING IN THEIR APPEAL FOR
CARE OFFERING SIMPLE DIGNITY AND RIGHTS OF PRIVACY, HARROWING
SOMETIMES IN THEIR DESCRIPTIONS OF PHYSICAL OR PSYCHOLOGICAL ABUSE.
THESE PATIENTS ARE OFTEN HELPLESS IN THEIR DEPENDENCE ON THE IN-
STITUTION IN WHICH THEY LIVE. THEY DESERVE A FAIR HEARING, AND AN
ADVOCATE WHEN THEY ARE POWERLESS.
THE HEALTH SERVICES AND MENTAL
HEALTH ADMINISTRATION HAS DEVELOPED FIVE MODELS FOR OMBUDSMAN UNITS
9
TO FILL THIS ROLE, PLACED AT VARIOUS LEVELS WITHIN THE STATES
AND DEMONSTRATING DIFFERENT MECHANISMS FOR ACTION,
CONTRACT
PROPOSALS TO TEST THESE MODELS ARE BEING SOLICITED, AND
$600,000 HAS BEEN BUDGETED FOR FISCAL YEAR 1972 FOR THIS
ACTIVITY.
IT WILL TAKE TIME TO TEST AND DEVELOP SUCH AN OMBUDSMAN SYSTEM,
TIME INAPPROPRIATE TO THE URGENCY OF THE PROBLEM, So AN
INTERIM OMBUDSMAN MECHANISM HAS BEEN ESTABLISHED WITH THE 855
SOCIAL SECURITY ADMINISTRATION DISTRICT OFFICES DESIGNATED TO
RECEIVE AND INVESTIGATE COMPLAINTS. THIS MECHANISM IS CURRENTLY
IN EFFECT, AND HAS RECEIVED OVER A THOUSAND RESPONSES,
FOR THESE NURSING HOME INITIATIVES, A SUPPLEMENT APPROPRIATION
OF $9,572,000 HAS BEEN REQUESTED FOR FISCAL YEAR, 1972. WE
FEEL THAT BY MEANS OF THESE PROGRAMS A SIGNIFICANT IMPROVEMENT
IN NURSING HOME CARE CAN BE ACHIEVED IN A RELATIVELY SHORT PERIOD
OF TIME.
WE RECOGNIZE ALSO, THAT WHILE THESE INITIATIVES CAN RECTIFY SOME
OF THE MOST PRESSING PROBLEMS OF NURSING HOME CARE, THERE ARE OTHER
DEFICIENCIES - SOME FUNDAMENTAL - THAT REQUIRE FURTHER SOLUTIONS,
FROM A BROADER PERSPECTIVE, IT IS APPARENT THAT NURSING HOMES ARE
ONLY ONE ELEMENT IN THE SPECTRUM OF LONG TERM CARE - AN ELEMENT
WHICH HAS BEEN FORCED TO BE TOO MANY THINGS TO TOO MANY PEOPLE.
IT IS IN THIS PERSPECTIVE THAT THE LAST POINT IN THE PRESIDENT'S
PLAN IS FRAMED; HE HAS DIRECTED THE SECRETARY OF HEW TO UNDERTAKE
A COMPREHENSIVE REVIEW OF THE USE OF LONG-TERM CARE FACILITIES AND
TO RECOMMEND ANY FUTHER REMEDIAL MEASURES THAT ARE APPROPRIATE.
10
I HAVE BEEN CHARGED WITH ORGANIZING AND CHAIRING THAT TASK
FORCE ON LONG-TERM CARE.
is EXAMINING
ON ONE LEVEL, THE TASK FORCE WILL THE ROLES OF MEDICARE
AND MEDICAID IN NURSING HOME ACTIVITIES. MOST OF YOU ARE
AWARE, AND THE WHITE HOUSE CONFERENCE ON AGING HAS EMPHASIZED,
THAT THESE FEDERAL PROGRAMS HAVE BEEN A MIXED BLESSING TO THE
NURSING HOME INDUSTRY. SOME OF THE PROBLEMS HAVE BEEN PRIMARILY
ADMINISTRATIVE, AND HAVE BEEN OR ARE BEING CORRECTED AS I
DISCUSSED BEFORE,
BUT MORE FUNDAMENTAL ISSUES HAVE ALSO BEEN RAISED WITH REGARD TO
THESE PROGRAMS. FOR HISTORICAL AND STATUTORY REASONS BASED ON
THEIR ORIGINS AS HEALTH INSURANCE PROGRAMS, MEDICARE AND MEDICAID
HAVE EMPHASIZED HEALTH ASPECTS OF NURSING HOME CARE. ACUTE ILL-
NESS IN WHICH THE PATIENT IS EXPECTED TO RECOVER AND REGAIN ALL
OR MOST OF HIS INDEPENDENCE HAS SERVED AS THE MODEL FOR HEALTH
DELIVERY. CONSEQUENTLY, THESE PROGRAMS HAVE FAVORED INSTITU-
TIONAL CARE OVER NON-INSTITUTIONAL ALTERNATIVES, AND WITHIN IN-
STITUTIONS, HEALTH AS OPPOSED TO SOCIAL AND PERSONAL CARE.
IN MANY WAYS, THE CONSEQUENCES OF THIS CARE FOR THOSE WITH CHRONIC
LLNESS - AND FOR THOSE WITH THE INCREASED DEPENDENCY OF OLD AGE -
HAVE BEEN TRAGIC. COSTS HAVE BEEN INCREASED BY THE SUBSTITUTION
OF INSTITUTIONAL FOR NON-INSTITUTIONAL CARE AND BY SOMETIMES
INAPPROPRIATELY HIGH LEVEL OF MEDICAL SERVICES FOR PATIENTS WHO
DO NOT REQUIRE THEM. BUT EVEN MORE IMPORTANTLY, EPIDEMIOLOGY AND
THE SOCIAL SCIENCES ARE PROVIDING EVIDENCE THAT DEPENDENCY FACTORS -
LOWERED INCOME, DISPLACEMENT, LOSS OF STATUS, ISOLATION - MAY
EXACERBATE IF NOT PRECIPITATE ACTUAL PHYSIOLOGIC DISEASE, OLDER
11
PERSONS PLACED IN INSTITUTION EXPERIENCE SUBSTANTIALLY HIGHER
AGE SPECIFIC MORBILITY AND MORTALITY RATES THAN THOSE WHO
REMAIN AT HOME. So THE TRANSFER OF A PERSON FROM HIS HOME
TO AN INSTITUTION, OR FROM AN INSTITUTION IN WHICH HE IS RE-
LATIVELY AUTONOMOUS TO ONE IN WHICH HIS DEPENDENCY IS INCREASED,
MAY MAKE HIM MORE ILL AND MORE DEPENDENT. WE MUST REEXAMINE
THE BALANCE BETWEEN MEDICAL AND SOCIAL SERVICES WITHIN INSTITUTIONS
TO MEET THE NEEDS OF LONG-TERM PATIENTS. THE RESTRUCTURING OF
THE INTERMEDIATE CARE FACILITY PROGRAM IS A STEP IN THIS DIRECTION,
JUST AS THE SERVICES WITHIN INSTITUTIONS MUST BE RE-EXAMINED, so
MUST THE ALTERNATIVES TO INSTITUTIONAL CARE BE EXTENDED FOR THOSE
SUFFERING FROM CHRONIC ILLNESS, THE CHRONICALLY-ILL AND ELDERLY
SHOULD HAVE MORE OPTIONS AVAILABLE. IF A NURSING HOME IS NOT
THE MOST APPROPRIATE PLACE FOR A PERSONS PARTICULAR NEEDS, THEN
HE SHOULD NOT BE REQUIRED TO GO THERE, IF IT IS PERSONAL CARE
RATHER THAN HEALTH CARE THAT IS REQUIRED, THEN THE OPTION SHOULD
PROVIDE THAT EMPHASIS, IF IT IS APPROPRIATE HOUSING RATHER THAN
INSTITUTIONAL CARE THAT IS NEEDED, THEN THE EMPHASIS SHOULD BE
ON HOUSING,
MANY FEDERAL PROGRAMS HAVE EXPLORED ALTERNATIVES TO INSTITUTIONAL
CARE, THESE ALTERNATIVES HAVE BEEN A PARTICULAR THRUST OF THE
ADMINISTRATION ON AGING, WHICH HAS RECEIVED NEW SUPPORT AND
PRIORITY IN THE PRESIDENT'S BUDGET FOR 1972 IN THE FORM OF A FIVE-
HOLD INCREASE IN ITS FUNDING LEVEL, THE AoA HAS ESTABLISHED PROGRAMS
SUCH AS TRANSPORTATION FOR THE ELDERLY, SENIOR CENTERS, MEALS-
ON-WHEELS, TELEPHONE REASSURANCE, IN-HOME SERVICES, AND OPPORTUNITIES
TO SERVE, THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT HAS
12
DEVELOPING HOUSING PROGRAMS DESIGNED TO MEET THE SPECIAL NEEDS
OF THE ELDERLY. MEDICARE AND MEDICAID PROVIDE HOME HEALTH BENEFITS.
BUT THE CONCERTED IMPACT OF THESE PROGRAMS HAVE NOT BEEN ENOUGH,
AS WE HEARD ONCE MORE AT THE WHITE HOUSE CONFERENCE ON AGING.
THE PRESSURE FOR INSTITUTIONALIZATION CONTINUES TO PLACE STRAINS
ON NURSING HOMES, WHICH ARE ASKED TO SERVE TOO WIDE A VARIETY
OF FUNCTIONS, AND CONTINUES TO PUSH THE ELDERLY INTO SOMETIMES
PREMATURE DEPENDENCY THE PROBLEM OF DEVELOPING A WIDER
SPECTRUM OF OPTIONS FOR THE CHRONICALLY ILL AND FOR THE ELDERLY
WILL BE A CENTRAL FOCUS OF THE TASK FORCE ON LONG TERM CARE,
AN IMPORTANT REASON FOR THE INSUFFICIENT AND SOMETIMES INAPPROPRIATE
IMPACT OF FEDERAL PROGRAMS FOR LONG TERM CARE HAS BEEN THE LACK OF
PLANNING AND COORDINATION BETWEEN THOSE PROGRAMS. PLANNING FOR
LONG TERM CARE SHOULD MOVE FROM IDENTIFICATION OF AN ISSUE OR
PROBLEM TO ITS SOLUTION, WITH IDENTIFIABLE GOALS GUIDING THE
PROCESS, MOVEMENT TOWARD A GOAL SHOULD NOT BE INTERRUPTED BY
CHANGES IN ADMINISTRATION. WHAT IS TRULY IMPORTANT TODAY SHOULD
NOT BE CAST ASIDE TOMORROW, NEW PROGRAMS SHOULD NOT BE APPENDAGES
TO SATISFY THE INTERESTS OF A FEW, NOR SHOULD THEY BE ADDED AS
PACIFIERS TO THE MANY. PROGRAMS DEVELOPED THROUGH A RATIONAL
PLANNING PROCESS SHOULD THEN BE ADMINISTERED THROUGH EFFECTIVE
AND COORDINATED MECHANISMS.
THE ESTABLISHMENT OF THE OFFICE OF NURSING HOME AFFAIRS WITH HEW
WAS A STEP TOWARD IMPROVING COORDINATION. BUT THE MANDATE FOR
THE TASK FORCE ON LONG TERM CARE IS BROAD TO RE-EXAMINE THE
ISSUES AND SET NEW GOALS, TO DEVELOP A NATIONWIDE DATA SYSTEM
13
NECESSARY FOR POLICY FORMULATION, AND TO RECOMMEND AN ORGANI-
ZATION FOR LONG TERM CARE WITHIN HEW, OTHER FEDERAL AGENCIES,
AND STATE AND LOCAL PROGRAMS WHICH CAN ACHIEVE ITS GOALS MOST
EFFECTIVELY.
A NATIONAL POLICY COURSE FOR THE CHRONICALLY ILL AND FOR THE
ELDERLY SHOULD BE SET, IT SHOULD BE SET BY GOVERNMENT. SET
BY GOVERNMENT WITH THE FULL AND CREATIVE CONTRIBUTION OF THOSE
IN OTHER AGENCIES AND ORGANIZATIONS, THOSE IN ACADEMIC TEACHING
AND RESEARCH, THOSE IN VOLUNTARY AND UNSALARIED SERVICE, AND
THOSE WHO RECEIVE THAT CARE.
A START HAS BEEN MADE.
WE CAN DO MUCH BETTER FOR OUR ELDERLY. WE MUST OF COURSE
PROTECT THEM FROM INSTITUTIONAL ABUSE, RECOGNIZING THAT SOME
ARE WEAK AND DEPENDENT. - BUT WE CAN ALSO MAKE POSSIBLE A WIDE
VARIETY OF SUPPORTING SERVICES AND LIVING ARRANGEMENTS, so THAT
THE INFIRMITIES OF ADVANCING AGE DO NOT BECOME A PRISON OF THE
SPIRIT. THE ELDERLY WITH OUR HELP CAN HAVE ACCESS TO THE VARIETY
AND FREEDOM WE ASK FOR OURSELVES,
GLANTO FORD LIBRARY
LONG TERM CARE: WASHINGTON IS LISTENING, TOO
By MARIE CALLENDER
SPECIAL ASSISTANT FOR NURSING HOME AFFAIRS
DEPARTMENT OF HEALTH, EDUCATION AND WELFARE
PRESENTED AT ANNUAL CONVENTION, IDAHO HEALTH FACILITIES, INC.
COEUR D'ALENE, IDAHO, JULY 25, 1972
LONG TERM CARE: WASHINGTON IS LISTENING, TOO
THE THEME OF THIS CONFERENCE -- "WE ARE LISTENING" -- COULD
NOT HAVE BEEN BETTER CHOSEN. NOR COULD THIS GATHERING HAVE
BEEN MORE APPROPRIATELY TIMED IN LIGHT OF THE ANNOUNCEMENT
LAST FRIDAY THAT THE STATE OF IDAHO WILL BE ONE OF FIVE TO
TEST A MODEL NURSING HOME PATIENT OMBUDSMAN PROJECT UNDER A
HARD-WON FEDERAL CONTRACT.
I SAY HARD-WON BECAUSE IT WAS -- IN COMPETITION WITH MORE THAN
A DOZEN STATES AND NATIONAL ORGANIZATIONS EAGER TO TRY OUT THEIR
IDEAS ON OPENING UP NEW CHANNELS OF COMMUNICATIONS AMONG THE
NURSING HOME PATIENT, THE NURSING HOME, AND THE GOVERNMENT AGENCIES
RESPONSIBLE FOR SUPERVISING LONG TERM CARE FACILITIES.
I CONGRATULATE THE STATE PEOPLE RESPONSIBLE FOR DEVELOPING THE
INNOVATIVE IDEAS WHICH RANKED THE PROJECT HIGH AMONG THE
APPLICANTS. THE IDAHO PLAN IS PARTICULARLY IMAGINATIVE IN THE
WAY IT WILL LINK AN ASSISTANT ATTORNEY GENERAL WITHIN THE
DEPARTMENT OF SPECIAL SERVICES WITH REPRESENTATIVES OF OTHER
STATE AGENCIES, NURSING HOME OPERATORS AND PATIENTS, AND THIS
PROJECT IS TO BE FURTHER COMMENDED FOR ITS PLAN TO CALL ON LOCAL
ORGANIZATIONS TO PROVIDE VOLUNTEER HELP. THIS IS THE KIND OF
CITIZEN-INVOLVEMENT WITH LONG TERM CARE THAT WE HOPE WILL BE
ENCOURAGED AS THE OMBUDSMAN IDEA CATCHES ON THROUGHOUT THE
HEALTH CARE SYSTEM,
- 2 -
THREE OTHER STATES--PENNSYLVANIA, SOUTH CAROLINA AND WISCONSIN--
AND THE NATIONAL COUNCIL OF SENIOR CITIZENS WHICH WILL WORK WITH
THE STATE OF MICHIGAN, HAVE ALSO RECEIVED DEMONSTRATION CONTRACTS
AND WILL BE TESTING OTHER KINDS OF LINKAGES AND COMMUNICATIONS
CHANNELS.
WE HAVE HIGH HOPES FOR THESE FIVE TESTS AND WE ARE CONFIDENT
THAT OUT OF THIS YEAR-LONG EXPERIMENT WILL EVOLVE A WORKABLE
PLAN FOR CREATING A NATIONAL PROGRAM OF REAL VALUE TO THE
PATIENT, THE INDUSTRY, AND THE GOVERNMENT,
I AM ALSO CONFIDENT THAT THE NURSING HOMES OF IDAHO WILL COOPERATE
FULLY IN THIS EXPERIMENT IN "LISTENING" TO THEIR PATIENTS, AGAIN,
THE THEME OF THIS CONFERENCE BESPEAKS YOUR OBVIOUS CONCERN FOR THE
PATIENTS ENTRUSTED TO YOUR CARE,
"LISTENING," AS ANYONE WHO HAS EVER WORKED IN OR AROUND HEALTH
CARE KNOWS ONLY TOO WELL, IS A TOO-SELDOM PRACTICED ART. INDEED,
THERE CAN BE NO MORE SALIENT SYMPTOM OF WHAT MAY BE WRONG WITH
ANY ASPECT OF ANY HEALTH CARE FACILITY THAN THE INABILITY--OR
UNWILLINGNESS--OF THOSE WHO SERVE PATIENTS TO HEAR THOSE PATIENTS
WHEN THEY CALL OUT FOR HUMAN CONCERN,
JUST AS THIS IS TRUE FOR HEALTH PROFESSIONALS AND ADMINISTRATORS,
so IS IT TRUE FOR THOSE IN GOVERNMENT CHARGED WITH OVERSEEING THE
QUALITY AND SAFETY OF CARE PROVIDED TO AMERICAN CITIZENS, AND IT
IS ESPECIALLY TRUE FOR THOSE AT ALL LEVELS OF GOVERNMENT WHO ARE
CONCERNED WITH THE LONG-NEGLECTED AREA OF LONG TERM CARE,
- 3 -
THE PEOPLE WE ARE LISTENING TO IN WASHINGTON ARE THE VERY SAME
PEOPLE YOU ARE TALKING ABOUT HERE TODAY-THE OLDER AMERICANS OF
IDAHO AND THE OTHER 49 STATES, THE 21 MILLION OVER 65, AND MOST
PARTICULARLY, THE MORE THAN ONE MILLION CONFINED TO LONG TERM
CARE INSTITUTIONS.
THE PRESIDENT FIRST ARTICULATED HOW STRONGLY THEIR VOICES WERE
BEING HEARD IN WASHINGTON NEARLY A YEAR AGO WHEN HE ANNOUNCED
A COMPREHENSIVE ACTION PLAN ON LONG TERM CARE, His AIMS WERE
SIMPLE AND DIRECT:
-- UPGRADE LONG TERM CARE FACILITIES;
-- UPGRADE THE WAYS GOVERNMENT AT ALL LEVELS MONITORS
THESE FACILITIES;
-- UPGRADE CHANNELS OF COMMUNICATION BETWEEN THE PATIENT,
HIS FAMILY, THE NURSING HOME AND GOVERNMENT AGENCIES
CONCERNED WITH LONG TERM CARE;
-- UPGRADE THE CAPABILITY AND CONSCIOUSNESS OF LONG
TERM CARE PERSONNEL;
-- AND, MOST IMPORTANTLY, UPGRADE OUR UNDERSTANDING
OF LONG TERM CARE FACILITIES--LEARN WHAT THEY CAN
AND CANNOT DO, AND CONSIDER WHAT ALTERNATIVE MODES
AND LEVELS OF CARE MIGHT BE DEVELOPED TO ENSURE OUR
OLDER CITIZENS THAT THAT RIGHT CARE, AT THE RIGHT
TIME, AT THE RIGHT PLACE, AND AT THE RIGHT COST
WILL BE THERE,
- 4 -
Now THIS MAY SOUND LIKE A LOT OF UPGRADING--AND IT IS, AND
IT HAS BEEN, AND IS GOING TO BE, AN UPGRADE BATTLE ALL THE
WAY. NOT BECAUSE NO ONE IN THE NURSING HOME INDUSTRY OR IN
THE GOVERNMENT OR AMONG THE PUBLIC HAS CARED IN THE PAST,
BUT BECAUSE UNTIL VERY RECENTLY THERE HAVE NOT BEEN ENOUGH
OF THESE ESSENTIAL ACTORS ON THE LONG TERM CARE STAGE TO
CREATE AND MAINTAIN A SYSTEM OF THE QUALITY THAT OUR PEOPLE
DEMAND.
IT WAS TO FULFILL THIS DEMAND THAT THE PRESIDENT ORDERED THE
FEDERAL GOVERNMENT TO MOVE BOLDLY AND RAPIDLY ALONG SEVERAL
INTEGRAL FRONTS, THE EFFECTIVENESS OF THAT ACTION IS ALREADY
BEING FELT
OTHER
You ARE, OF COURSE, WELL AWARE OF THE MILESTONE WE HAVE JUST
PASSED IN OUR EFFORTS TO UPGRADE STATE MEDICAID NURSING HOME
INSPECTION PROGRAMS AND THROUGH THEM, NURSING HOMES THEMSELVES,
REPORTED TO THE PRESIDENT AND THE PUBLIC IN JULY:
THAT
FULLY 88 PERCENT OF THE NATION'S 7,000
MEDICAID NURSING HOMES HAD PASSED RIGOROUS MUSTER AGAINST
FEDERAL STANDARDS, WITH 24 PERCENT OF THESE MERITING FULL
TWELVE-MONTH PROVIDER AGREEMENTS, INDICATING FULL CONFORMITY
WITH THE MEDICAID STATUTE AND REGULATIONS. SLIGHTLY OVER 600
DID NOT MAKE THE GRADE--AND, WERE EITHER DECERTIFIED BY THE STATES
OR VOLUNTARILY WITHDREW FROM THE MEDICAID PROGRAM RATHER THAN
ATTEMPT TO MEASURE UP.
217
AND
GERALD
- 5 -
You ARE ALSO AWARE THAT WE HAVE SEEN A MARKED IMPROVEMENT IN
THE QUALITY OF STATE MEDICAID CERTIFICATION PROGRAMS SINCE
LAST NOVEMBER WHEN WE FOUND NO FEWER THAN 39 STATES WITH MAJOR
DEFICIENCIES. TODAY WE ARE REASONABLY CONFIDENT THAT EVERY
STATE HAS A SOUND SURVEY AND CERTIFICATION PROGRAM--AND WE
INTEND TO CONTINUE TO MONITOR THESE PROGRAMS TO ENSURE THAT
THEY STAY THAT WAY.
THE OBVIOUS OBJECTIVE OF THIS PHASE OF THE NEW FEDERAL EFFORT
WAS THREE-FOLD:
-- To SERVE NOTICE ON THE STATES THAT FEDERAL STANDARDS
ARE FOREVERMORE TO BE FOLLOWED TO THE LETTER AND
SPIRIT;
-- To SERVE NOTICE ON THE INDIVIDUAL NURSING HOME
OPERATOR THAT ANY FEDERAL PORTION OF HIS PATIENT
CARE DOLLAR IS GOING TO BE PAID ONLY IF THAT
PATIENT IS RECEIVING THE QUALITY OF CARE HE OR SHE
IS ENTITLED TO;
-- AND, MOST IMPORTANTLY, TO ASSURE THE INDIVIDUAL
PATIENT THAT THE FULL BURDEN OF RESPONSIBILITY
FOR THE QUALITY AND SAFETY OF HIS OR HER CARE IS
NOW TO BE BORNE SQUARELY BY THE FEDERAL, STATE
AND LOCAL GOVERNMENT AGENCIES SUPERVISING THAT
CARE AND BY THE NURSING HOME PROVIDING THE SERVICES,
WE BELIEVE THESE PURPOSES HAVE BEEN MET. AND WE TRUST THEY WILL
CONTINUE TO BE MET BECAUSE WE DO NOT INTEND TO LET THE BUCK STOP
HERE. JULY 1. HAS COME AND GONE, BUT THE FEDERAL PRESENCE WILL
LINGER ON IN THE ONGOING PROCESS OF KEEPING THE STATES, AND THROUGH
THEM MEDICAID NURSING HOMES, UP TO THE LEVEL OF QUALITY CARE THAT
THE FEDERAL DOLLAR IS INTENDED TO HELP PROVIDE.
- 6 -
SOME OF THE MOST IMPORTANT RESULTS OF THIS MASSIVE CERTIFICATION
EFFORT ARE NOT SO IMMEDIATELY OBVIOUS IN THE STATISTICS ON HOW
MANY HOMES IN HOW MANY STATES DID OR DID NOT MEET THE MARK, I
REFER HERE TO THE GREAT MASS OF DATA THAT HAS BEEN ENGENDERED BY
THIS NATIONWIDE EFFORT,
WE NOW HAVE, FOR THE FIRST TIME IN THE HISTORY OF GOVERNMENT
CONCERN WITH LONG TERM CARE, THE MAKINGS OF A TRUE PICTURE OF
THE LONG TERM CARE SYSTEM, WE KNOW WHAT'S RIGHT WITH IT--AND
WE KNOW WHAT'S WRONG, WE CAN CATALOG DEFICIENCIES AND WE CAN
DISCERN ANY PATTERNS WHICH MAY BE REFLECTED IN THEM. WE CAN
COMPARE FACILITIES IN SINGLE STATES WITH THE NATIONAL PICTURE
AND PERHAPS LEARN WHERE AND HOW IDIOSYNCRACIES IN STATE PROGRAMS
AND LAWS MAY REFLECT ON THE QUALITY OF THEIR FACILITIES.
AND MOST IMPORTANTLY, WE CAN LOOK FORWARD TO DEVELOPING FROM
THIS DATA IDEAS ON HOW GOVERNMENT REGULATIONS AND REIMBURSEMENT
POLICIES MIGHT BETTER HELP THE LONG TERM CARE SYSTEM UPGRADE
ITSELF,
THIS KIND OF INFORMATION -- AND THESE KINDS OF IDEAS -- WILL PRO-
VIDE A MAJOR SEGMENT OF THE INPUT WE NEED FOR THE STUDY OF LONG
TERM CARE WE NOW HAVE UNDERWAY IN WASHINGTON, OUT OF THIS STUDY,
WHICH WE EXPECT TO COMPLETE BY THE END OF NEXT YEAR, WILL COME
ANOTHER FIRST FOR FEDERAL CONCERN WITH LONG TERM CARE: THE
DEVELOPMENT OF A TRULY COMPREHENSIVE FEDERAL PHILOSOPHY TOWARD
THE DAY-TO-DAY HEALTH AND HEALTH-RELATED NEEDS OF OLDER AMERICANS,
A PHILOSOPHY FOUNDED IN AN ENLIGHTENED ATTITUDE TOWARD AGING AND
GROUNDED IN INNOVATIVE APPLICATIONS OF THE FULL SPAN OF RESOURCES
- 7 -
AVAILABLE TO US FROM THE ORGANIZATIONAL, SOCIAL, BEHAVIORIAL AND
BIO-MEDICAL SCIENCES, I NEED NOT DWELL HERE ON THE NEED FOR SUCH
A BREAKTHROUGH IN WASHINGTON. WE ARE SUFFERING TODAY FROM THE
ABSENCE OF SUCH A POLICY OVER THE PAST SEVERAL DECADES WHEN TOO
FEW IN WASHINGTON WERE LISTENING, AND NOT ENOUGH WAS BEING DONE
TO HELP MEET THE REAL NEEDS OF OUR LONG TERM CARE POPULATION.
THIS BEING OUR CONTEXT, THE WORK BEING DONE NOW REPRESENTS A
HISTORIC OPPORTUNITY TO HELP FASHION THE FUTURE SHAPE OF LONG
TERM CARE IN AMERICA.
WE ARE FOCUSING OUR STUDIES ALONG THREE PRIMARY LINES WHERE TOO
LITTLE -- AND IN SOME CASES NOTHING AT ALL --- IS KNOWN ABOUT
EITHER LONG TERM CARE OR THE POTENTIAL IMPACT THAT GOVERNMENTAL
POLICY AND REIMBURSEMENT PROCEDURES MAY HAVE ON THAT CARE,
THE FIRST OF THESE FOCAL POINTS INVOLVES POTENTIAL ALTERNATIVES
TO INSTITUTIONAL CARE OF THE ELDERLY AND CHRONICALLY ILL AND
INCLUDES EVALUATION OF THEIR EXPECTED IMPACT OF THE HUMAN NEEDS
OF THE PATIENT, ON BED NEEDS, AND ON COSTS,
THE SECOND CONCERNS THE QUALITY OF ALL MODES OF LONG TERM CARE,
HERE, WE ARE HOPING TO DEVELOP WORKABLE METHODS OF QUANTIFYING
INDICATORS THAT WILL TELL US QUICKLY AND SURELY WHICH FACTORS
HAVE WHAT EFFECT ON THE QUALITY OF PATIENT SERVICES,
THE THIRD INVOLVES DATA COLLECTION AND ANALYSIS, WITH PARTICULAR
STRESS ON DEVELOPING INNOVATIVE WAYS TO ENABLE HEALTH PROFESSIONALS,
THE INDUSTRY, AND GOVERNMENT TO READILY MONITOR PROGRESS AND
INDENTIFY PROBLEM AREAS.
- 8 -
GROUNDWORK FOR THE STUDY IS BEING DONE BOTH WITHIN AND WITHOUT
THE FEDERAL GOVERNMENT. IN THE STUDY, AS IN ALL OTHER ASPECTS
OF THE LONG TERM CARE PROGRAM, WE ARE WORKING CLOSELY WITH ALL
FEDERAL OFFICES AND AGENCIES WITH RESPONSIBILITY FOR OR INTEREST
IN THE PROBLEMS OF THE AGING RANGING FROM THE ADMINISTRATION ON
AGING TO THE VETERANS ADMINISTRATION AND THE DEPARTMENT OF HOUSING
AND URBAN DEVELOPMENT.
I CANNOT STRESS TOO MUCH THAT THE DEVELOPMENT OF THIS PROJECT WILL
NOT TAKE PLACE IN A FEDERAL ECHO CHAMBER. WE ARE TAKING GREAT
PAINS TO ENSURE THAT THE VOICES OF EXPERIENCE AND EXPERTISE FROM
ALL POSSIBLE POINTS ARE LISTENED TO IN THE COURSE OF OUR WORK.
AMONG THE MOST ARTICULATE VOICES SHOULD BE THOSE OF THE LONG TERM
CARE INDUSTRY ITSELF -- THE VOICES OF NATIONAL AND STATE ASSOCIA-
TIONS, AND THE VOICES OF INDIVIDUAL FACILITY OPERATORS. WE WANT
TO HEAR WHAT YOU HAVE TO SAY AND WE ARE NOW DEVELOPING THE
CAPABILITY WITHIN MY OFFICE TO ENSURE THAT YOU WILL HAVE OUR EAR.
To FACILITATE YOUR COMMUNICATION WITH US, AND TO ACTIVELY SOLICIT
YOUR IDEAS, I HAVE ASSIGNED MY ASSISTANT FOR HEALTH POLICY,
PAUL B. SIMMONS, TO WORK WITH NATIONAL AND STATE NURSING HOME AS-
SOCIATIONS AND WITH OTHER GROUPS INVOLVED IN LONG TERM CARE. I
URGE YOU TO GET IN TOUCH WITH HIM AT ANY TIME. HE WILL BE
RESPONSIBLE FOR OPENING -- AND KEEPING OPEN -- DIRECT LINES INTO
THE FEDERAL GOVERNMENT FOR ANYONE WITH. ANYTHING TO SAY ABOUT LONG
TERM CARE.
- 9 -
IN CLOSING I WANT TO TOUCH BRIEFLY ON THE PROGRESS WE HAVE BEEN
MAKING ALONG SEVERAL OTHER FRONTS OF THE FEDERAL LONG TERM CARE
PROGRAM,
You WILL SOON BE SEEING THE FIRST PUBLICATION OF FEDERAL MEDICAID
STANDARDS FOR INTERMEDIATE CARE FACILITIES, WE EXPECT THESE
WILL BE READY FOR COMMENT BY LATE SUMMER AND TO BE READY FOR
IMPLEMENTATION IN THE FALL.
WE ALSO EXPECT TO FINISH UP SOON ON THE DEVELOPMENT OF JOINT
MEDICARE-MEDICAID NURSING HOME STANDARDS WHICH WILL COORDINATE
AND SIMPLIFY VIRTUALLY ALL COMPLEMENTARY ASPECTS OF THESE PROGRAMS,
OUR TRAINING PROGRAMS ARE ALSO RUNNING AT HIGH MOMENTUM. WE HAVE
NOW REACHED MORE THAN 700 OF THE 1100 STATE MEDICAID NURSING HOME
INSPECTORS IN THE FIELD WITH UNIVERSITY-BASED TRAINING COURSES,
WE HOPE TO REACH THE REMAINING 400 BEFORE THE END OF THE YEAR,
AND WE FURTHER HOPE THAT THE CONGRESS WILL ACT ON THE PRESIDENT'S
PROPOSAL THAT THE FEDERAL GOVERNMENT ASSUME THE FULL COSTS OF
STATE MEDICAID NURSING HOME INSPECTION PROGRAMS, SUCH A MOVE WOULD
ENCOURAGE THE STATES TO EXPAND AND UPGRADE THEIR ENFORCEMENT
CAPABILITIES,
AND FINALLY, OUR TRAINING PROGRAMS FOR NURSING HOME PERSONNEL ARE
ALSO MOVING ALONG RAPIDLY. WE EXPECT TO REACH UPWARDS OF 20,000
ADMINISTRATORS, PHYSICIANS, NURSES AND ACTIVITIES DIRECTORS DURING
EACH OF THE FIRST TWO FULL YEARS OF THIS EFFORT. AND FOR THE LONG
RUN, WE ARE WORKING NOW ON DEVELOPING WHOLLY NEW METHODS OF BRINGING
CRITICALLY NEEDED TRAINING DIRECTLY TO THE 500,000 PEOPLE WORKING
IN THE LONG TERM CARE FACILITY SETTING, THROUGHOUT THE DEVELOPMENTAL
- 10 -
AND TRAINING ASPECTS OF THIS PROGRAM, WE ARE RELYING HEAVILY ON THE
EXPERTISE OF FOUR MAJOR GROUPS UNDER CONTRACT WITH US: THE AMERICAN
NURSING HOME ASSOCIATION; THE ASSOCIATION OF UNIVERSITY PROGRAMS IN
HOSPITAL ADMINISTRATION; THE AMERICAN MEDICAL ASSOCIATION; AND THE
AMERICAN NURSES' ASSOCIATION.
SINCE WE ARE TALKING HERE TODAY ABOUT THE SPECIAL HEALTH PROBLEMS
OF OLDER AMERICANS, AND WHAT ALL OF US CAN DO TO HELP RESOLVE THEM,
IT SEEMS A PROPOS TO LEAVE YOU WITH A THOUGHT ASCRIBED TO AMBROSE
BIERCE, A ONE-TIME OLDER AMERICAN WHOSE OWN SPECIAL PROBLEM SEEMS
TO HAVE BEEN A CHRONIC BAD MOOD.
"RESPONSIBILITY," HE SAID, "IS A DETACHABLE BURDEN EASILY SHIFTED
FROM ONE'S OWN SHOULDERS TO THOSE OF GOD, FATE, FORTUNE, LUCK --
OR ONE'S NEIGHBOR."
I JUDGE FROM THE TONE AND THRUST OF THIS CONFERENCE THAT NO ONE IN
THIS ROOM NEED BE REMINDED OF HIS OR HER SHARE OF RESPONSIBILITY
FOR THE FUTURE OF LONG TERM CARE IN IDAHO, AND I SENSE FROM THE
SPIRIT OF RESPONSIBILITY IMPLICIT IN YOUR AGENDA THIS WEEK THAT
IF THERE IS ANY SHIFTING OF THAT BURDEN, IT WILL BE TO PLACE EVEN
MORE OF IT UPON YOUR OWN SHOULDERS,
TEXT OF REMARKS BY UNDER SECRETARY
JOHN G. VENEMAN
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
BEFORE THE
AMERICAN NURSING HOME ASSOCIATION
ANAHEIM, CALIFORNIA
NOVEMBER 5, 1971
Two years ago, it was my privilege to address
your Annual Convention in Houston, and I have not
forgotten in those two years that many of the
members of your Association, the proprietary nursing
home industry, provide most of the institutional
care of the aging in America.
Privately owned homes care for nearly 67
percent of all the aging receiving institutional
care. This is a solemn responsibility, and I know
that you bear it with a great sense of honor and
pride. I also know that you share the anguish of
your fellow Americans at the tragic nursing home
fire at Honesdales, Pennsylvania this month. A fire
that resulted in the death of 15 aged and helpless
Americans.
It would be easy to find in this home a
ready scapegoat for the problems that beset the
nursing home industry, and certainly there are
lessons to be learned from this and similar recent
tragedies. But I am not going to indulge in
scapegoating today. That would be too easy. It
would also be all too wrong.
The fact is, there is blame enough to go
around for everyone in the nursing home fires and
other incidents that have made headlines in the
past. The problem is not to find the scapegoats,
it is to reform the system that produces the scapegoats.
Solutions do not lie in hand-wringing
declarations, or pious finger-pointing. Solutions
lie in acting to right the wrongs of the present
system for administering, regulating and enforcing
standards of safety and patient care. Those
solutions have to be realistic. They cannot be based
upon the flimsy paper of publicity releases and
panic solutions.
As you know, President Nixon has announced
his firm intention of assuring that our aging receive
good care in safe institutions. His speech in New
Hampshire on August 6th was not just words. Nor was
it just a call to action. It was action.
In that speech the President issued eight
action directives and charged the Department of
Health, Education, and Welfare with carrying them
out, and we are carrying them out. Last week, I
reported in public testimony before Senator Moss's
-3-
Subcommittee on Long Term Care of the Aging what
HEW is doing to implement those eight directives.
One big problem that we had already begun to
act on is the indifferent performance of many
states in enforcing Medicaid standards. The record
is not a good one.
Last May, the General Accounting Office looked
into the Medicaid enforcement effort of 90 homes in
three states: Michigan, New York and Oklahoma. That
study found deficiencies in over half of these homes,
and discovered that 44 of them failed even to meet
fire safety standards. That should tell us one
thing. The clock may already be ticking toward
the next tragic nursing home fire. HEW is acting
to stay the hands of that clock. Last week, final
fire and safety regulations for Medicare were published.
These new regulations require extended care facilities
and hospitals to comply with the Life Safety Code.
This will make Medicare fire safety standards the
same as Medicaid's.
HEW conducted its own enforcement survey
recently. Among the 15 States surveyed, Medicaid
standards were not even: being used to certify homes.
Contrary to law, State Licensure Standards were
being used to certify homes. Your Association has
-4-
repeatedly pointed out that there is no uniformity
among state licensure standards. So one of the
first things we have to do is to bring about uniformity.
This month, a special HEW survey team launched
a crash effort to find out how well each State is
enforcing Medicaid rules. This team has already
gone into 34 States, and it will visit the remaining
16 by November 15th.
Quite frankly, we aren't expecting to find
any miraculous improvements since the recent spot
surveys, but we expect to find out where the problems
are, what the problems are, and what we at the
Federal level can do to solve them.
The Administration and enforcement of Medicaid
safety and patient care regulations is still a state
responsibility, as the law requires. However, an
increasing Federal presence among state regulatory
agencies is clearly needed. That's why the President
has asked Congress to appropriate funds to finance an
additional 150 Federal positions for nursing home
enforcement. When these funds become available, most
of those 150 persons will be assigned to work directly
with the States, out of HEW's regional offices.
I suppose you could characterize this as looking
over the States' shoulders, and I suppose you would
be right. But the law gives us this responsibility
and we will soon have the additional personnel needed
to fully discharge it.
We know, and you know, that monitoring the
enforcement efforts of the States isn't going to
produce instant miracles. The actual enforcement
of Medicaid standards has to be done by the States
themselves. That's why the President is going to
ask Congress to authorize the Federal Government
to pick up the full cost of state nursing home
inspection programs, and also why the President has
directed that an additional 2,000 state nursing
home inspectors be trained at Federal expense over
the next 18 months. HEW has already begun that
training. Over half of these 2,000 state inspectors
will be trained within a year, and all 2,000 will be
trained within 18 months.
Something else your Association has called for
is the training of more personnel serving the aged
in facilities. We fully agree with you. The
President has called for 'short-term' training
courses for 20,000 health personnel now serving
the aging in institutions, and we intend to see
to it that these people get that training within
the next 18 months. These, as you know, are solutions
that will bear fruit in the future. But meanwhile,
-6-
there is today, and one of the biggest 'today'
problems to be faced is money.
As you have pointed out, a tougher enforcement
effort means that nursing homes will have to spend
more money to improve their facilities. We have
a uniform fire safety code now. That code calls
for things like firewalls, sprinkler systems and
flame-resistant materials. To make that code
enforceable, a way must be found to finance the
cost of these capital improvements.
I know you are concerned about this, and you
have suggested a solution.
We in HEW are aware of your proposal to have
the Federal Government offer low-cost guaranteed
loans of up to $50,000 to nursing homes that need
to make capital improvements in order to meet
standards.
I wish I could have come here today with the
news that your proposal has been favorably received,
but I can't. But I can tell you this -- your proposal
is being actively considered, and although this news
may not make your pulse quicken, I hope that it conveys
to you that we understand your problem, and that we
too appreciate the need to help you find a solution
to your fiscal problem.
But meanwhile, while you are awaiting decisions,
there are several misconceptions about the Admini-
stration's initiatives in the nursing home field
that I want to try to clear up.
One misconception is that the crackdown is
going to mean wholesale withdrawal of Federal
certification. Another misconception - quite the
opposite - is that the President's firm language
is just so many words.
First, let me assure you on this second point;
Anyone who assumes that we aren't going to withdraw
funds from institutions that won't meet standards
is attaching a false and dangerous interpretation
to the President's remarks. The President has told
it like it is, "We are not going to pay for substandard
subhuman care for our aging."
Now as to the first misconception, that we plan
a wholesale purge of institutions that don't measure
up in every way. That's wrong too. It would serve
no purpose to force the wholesale withdrawal of
Federal funds to facilities that are visibly trying
to measure up, but we intend to develop a monitoring
and enforcement system that will apply selective
pressure. Selective pressure does not mean withdrawing
certification from every institution that fails to
meet every minor rule. It does mean that inspectors
will be around to visit and to spot deficiencies,
and to come back again, perhaps unannounced, to
see with their own eyes whether a facility has
made visible progress toward correcting those
deficiencies.
Right now, a handful of states have a fair
eyeball enforcement program. The President's
intention is to ensure that every state gets that
kind of enforcement machinery.
Another kind of misconception has also sprung
up since the President said he would cut off Federal
funds to substandard homes. There are some who
simply don't believe that's going to happen. Where
would they put the patients if homes are forced to
close their doors for lack of funds? So goes reasoning.
As far as Medicare patients are concerned,
that's no problem. Any Medicare patient currently
housed in a facility that loses its Medicare certi-
fication remains in that home until the issue is
resolved, or until their condition no longer requires
them to remain in that institution.
The States, however, do possess the authority
to close down any facility that they have decertified
for Medicaid. In the past, states have been under-
standably reluctant to take that action, fearing that
they would create real hardships among patients displac
by the closing of a facility. And indeed, credible
enforcement cannot be achieved by the threat of
incredible actions.
No one would put up with having aging patients
thrown into the streets. That would only punish
the victims. It would be like blowing up the bridge
to relieve the traffic jam, but we in HEW are taking
steps to make the incredible threat a credible
possibility.
We are keeping close track of how many beds
are available in certain Federal hospitals, such
as those operated by the Public Health Service.
This is being done with the view of making empty
beds available for the prompt use of Medicaid patients
who would be displaced by the impending closing of an
institution that a state had decertified for reimbursement.
We will also work closely with state certification
agencies to pinpoint other facilities that can be used
to house and care for these patients, and we are prepared
to take whatever action is needed to ensure that no
aging patient suffers hardship because an institution
faces Medicaid decertification. We hope that further
closings will not occur, but if they do, we will see
to it that facilities are standing by to handle the
patient population involved.
-10-
Some of what I've said to you today may sound
like tough talk. Maybe it is, but it is also honest
talk. Frankly, I don't think that anything I've
said is very far opposed to what your organization
stands for.
I've read your President's recent speeches,
and I've read that part of your Association's
constitution that says; "The object of this Association
shall be to improve the standards of service and
Administration of member nursing homes, to secure
and merit public and official recognition and approval
of the work of nursing homes
"
That's a good
statement, and I know you plan to live up to it.
Any other course of action would be disastrous, not
only for our aging, who depend upon you, but also
for the nursing home industry itself. Because unless
the American people see continued and visible progress
in upgrading the institutions for our aging, there
will be calls for tougher and tougher legislation.
You don't need me to tell you that fires in
nursing homes move us closer to that possibility.
I hope and trust that your Association takes an
aggressive stand in self-policing. It's worth a
ton of legislation.
I see some signs that you plan to move on
the self-regulation route. The fact that your
President, David Mosher, wrote President Nixon to
express your Association's support of his
initiatives is refreshing. We in HEW are also
happy that you are keeping your lines of communication
open with us.
Last month, your representatives sat down with
some of our people and held a good brass-tacks
discussion about the Administration's nursing home
initiatives. That's another good sign. Our
communications with you will continue to improve
rapidly.
As you know, Dr. Merlin K. DuVal, Assistant
Secretary for Health and Scientific Affairs is
the man charged with success of failure of our
hursing home initiatives. But he won't be alone
in this responsibility.
Secretary Richardson has named one of the
Nation's top experts in nursing homes to assist
Dr. DuVal. Her name is Mrs. Marie Callender.
She served recently as Assistant Professor of the
Department of Clinical Medicine and Health Care at
the University of Connecticut School of Medicine.
Few people know their way around the nursing home
field any better than Mrs. Callender. So your
discussions with her are sure to be - shall we
say -- 'meaningful. I
In any case, my present feeling is that your
Association -- and you as individuals -- are not
far away from what the President, the Congress
and HEW want to see happen soon in the nursing
home field. That's a good feeling, and with your
concurrence, that's the message I plan to take
back with me when I return to Washington.
Thank you.
# # #
REMARKS FOR THE UNDER SECRETARY
DEDICATION OF THE METROPOLITAN HOSPITAL FOR EXTENDED CARE
Washington, D.C.
November 19, 1970
At a time when we are all searching for new ways to solve our
health care problems, and when health promises to be a significant political
issue in future campaigns, I am very happy to be able to represent the
Administration in dedicating this extended care center.
The extended care facility has taken its place, during recent
years, as an important component in the continuum of medical care. The
strengthem
cooleme
winton
opening of each new institituion, such as this one, stregthens the implica-
tion of comprehensive community he alth planning and meets a clearly
established health need.
But amid such great expectations, there has developed in recent
months a liturgy of criticism of facilities such as this. There are many
members of the medical community who sincerely believe that we are
on the road to the tot al depersonalization of medical care, toward a
state of affairs in which patients and physicians alike will be reduced
to numbers, to be processed through computers, with virtually no regard
for the personal interactions that are at the heart of the practice of medicine.
One Congressman has gone so far as to refer to nursing homes
as "human junkyards" and a Washington Post article last week speculated
LIDERAY
The American system of care is passing through a difficult
period, a period of change, of re-evaluations, of innovation, and frankly
of a crisis of confidence. If we view this period as a time to dig in and
hold onto things as they are, we will face an overwhelming demand for
uprooting of the whole national system of health care.
If, on the ot her hand, we accept the need for change and take
advantage of the opportunities for orderly evolution based on the great
strengths. that are to be found in the pluralistic American health enterprise,
then I think we will move into annera of unmatched excellence in health
care.
A critical ingredient of a scheme such as this is the involvement
of all segments of the society. It is essential that the innovative business
skills that characterize the American free enterprise system be brought
to bear upon the health care delivery system.
And this is another of the criteria for effective care which this
extended care facility satisfied. In this sense, it is truly a model for
the nation and we intend to encour age the development of other models
along the same lines.
All of the components of an effective comprehensive health
strategy have a difficult task ahead of them and that is to combat the
cynicism of the American people when it comes to the quality of health
-2-
upon the use of potent tranquilizers in nursing homes as effective
"chemical strait-jackets" for the aging.
Recognining only the as say Indian that I do between not share nursinghomes such apprehensions, and extended Plans care
your plans
for this facility
emphasize the pleasant atmosphere and careful attention
that patients will receive. And so, I think, on the contrary that as health
care for individuals becomes more continuous, as the emphasis moves
toward health maintenance and away from acute care, that physicians
will develop a rapport with their patients much mor e conducive to the
best of health care. And that is what the doctor-patient relationship
is all about.
Last year, the Federal Government spent $500 million on
Medicare reimbursements to extended care facilities. Obviously, we
hold responsibility for insuring that the care that our Medicare beneficiaries
receive is high quality, comprehensive care at the lowest possible cost.
And that is why I am so happy, and the Administration is so willing, to
encourage the establishment of facilities such as this one which offer
patients just such care as this,
"Overuse of high cost acute facilities is one of our most
crucial health care problems. There is a growing need for lower cost
alternatives, including extended care facilities" These are the words
of former Secretary Finch, and they characterize the attitude of the entire
Administration.
-4-
care they are able to obtain.
such
A recent Harris survey gives evidence of this widespread
discontent.
Conducted in over 1500 households around the country, the
survey came up with some significant findings, and some startling ones,
have
in spite of the fact that we, in government, had long been aware of a
deep-seated resentment and concern among the American people.
- 63 per cent of the people questioned felt that doctors try
to jam so many patients into office hours that they don't give enough
time and attention to anyone.
- 62 per cent of the people agree that, since Medicare and
Medicaid have come in, doctors have jumped their fees to take advantage
of it.
53 per cent of the people questioned felt that, if doctors paid
more attention to preventive medicine, their patients could avoid a lot
of illness.
These, and other significant findings all tend to reinforce a
feeling we in the government have had for a long time
that there
does exist this "crisis in confidence" as regards medical care and the
medical profession.
-5-
Of course, we feel that we have some responsibility for dealing
with this trend, but I must emphasize that we cannot do it alone. Doctors
will have to look closely at these statistics and even more closely at
their own habits and procedures.
Medical schools will have to weigh the benefits of their
research programs against the long-term benefits to the public of larger
teaching programs. We face very critical manpower shortages, and yet
many of our medical schools continue to pursue irrelevant research
objectives at the expense of turning out more doctors.
I am happy to see that this facility will be dealing with this
problem of manpower by offering teaching and training programs, especially
to the under employed.
I suppose the point of all this is that we must work together
if we are to confront and conquer the very severe problemSof costs,
manpower and resources. We will have to explore a variety of routes
toward the same goal
that is to enable every person in the United
States to benefit equally in the tremendous national investment in health
and health care.
The Metropolitan Hospital for Extended Care will offer the
people of the District of Columbia low cost care, ideally located, and
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in pleasant surroundings. It will offer doctors in this area the opportunity
of reaching their patients at least once, if not twice a day, and they
will be able to work in modern, convenient facilities with ample support
staff.
We in the government are committed to the development
of this facility and others like it. We believe it is truly an essential
ingredient in whatever health scheme we should settle upon to solve
the nation's health problems.
And I know that everyone involved in the planning and
providing of health care within the Administration joinsme in thanking
you for helping us through the establishment of the Metropolitan Hospital
for Extended Care.
PARTIAL TEXT OF REMARKS BY
UNDER SECRETARY JOHN G. VENEMAN
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
BEFORE THE
GOVERNOR'S CONFERENCE ON COMMUNITY HEALTH SERVICES
OKLAHOMA CITY, OKLAHOMA
THURSDAY, MARCH 12, 1970
I am pleased to be here tonight, to bring greetings from
Secretary Finch, and to represent the Department of Health, Education,
and Welfare at this important conference.
I would like to thank Governor Bartlett for asking me to
address this distinguished group and for calling attention to the health
problems we face.
Oklahoma has an active and effective State Health Planning
Agency, reaching about 60 percent of the State's population. I see from
your brochure that recent "quality of life" studies ranked Oklahoma 17th
among the 50 States in achievement of health goals, and I know your
Planning Agency is outlining priorities and choices for achieving even
better health for all citizens of your State. Their comprehensive approach
covering all areas of physical, mental and environmental health with
the commitment and dedication exemplified by groups like yours, can
meet the growing challenge of effective health care in Oklahoma. The
situation is not so encouraging in other parts of the country.
FORD LIBRARY is GERALD
parts of the system are private and largely autonomous organizations.
It is an industry which lacks to a large degree competition, which is
almost completely lacking in organizational relationships and community-
wide linkages, and which is unable to organize itself to meet an increas-
ing demand for services. The question for the governmental authorities
Federal, State and local
.therefore is, how can we develop a compre-
hensive system of health care delivery without massive Federal inter-
vention and regulation?
Last July Secretary. Finch warned that "what is ultimately
at stake is the pluralistic, independent, voluntary nature of our health
care system" and that "We will lose it to pressures for monolithic,
government-dominated medical care unless we can make that system
work for everyone in this Nation. =
Let me outline some of the problems we face in accomplish-
ing this goal.
The escalation of health care costs is perhaps our most
publicized problem for the immediate future.
In 1955, total expenditures for health services were just
over $17 billion. By 1965, they had risen to over $37 billion. The
latest estimates for 1969 show that health care is now a $60 billion
enterprise. By 1975, estimates indicate that we will be spending
between $90 and $100 billion on health services.
In spite of the great increase in expenditures for health,
the indicators of health status show us as lagging behind other nations.
In world ranking, we have slipped to fifteenth in infant mortality and
22nd in life expectancy for men.
:
The implementation of Medicare and Medicaid have multiplied
the stresses and strains on this fragile system. The great increases
in numbers of patients demanding and receiving health care, as well
as the rise in the proportion of total funds for health provided from
public sources, have not been accompanied. by a rise in equitable
utilization of health care resources for all members of society.
First, there are vast shortages of resources. For example,
under the current conditions, we are short about 50,000 physicians,
and a recent study shows that modernization of our decaying hospital
facilities would cost at least $6 billion.
Second, we are not only short on resources, they are also
poorly distributed. For example, in one area of Harlem, there were
50 physicians to serve 25,000 people 25 years ago; today, there are
ORD
5 physicians for 50,000.
GERALD
LIDRANY
4
What these problems represent is an area of social
welfare in which, more than in any other, we have derived limited
results from vast amounts of money and an abundance of facilities.
The problem is clearly not one of availability of funds.
I
The stake of the Federal Government in this area is
reflected in the fact that it is currently purchasing more than 25 per-
cent of the output of the health care system, while State and local
governments are purchasing another 12 percent for a total of 37 percent.
The three levels of government combined now purchase more than half
of the hospital care in this Nation.
These figures indicate that the use of its purchasing
power is probably the government's primary source of leverage to
initiate changes in the organization and delivery of health care.
How are we to use this leverage? To what extent should
it be used to change present patterns in an essentially private system
and to preserve that system?
Let me talk about some of the initiatives the government
has already taken
and then mention the long range picture.
Some of these initiatives do deal with the financing of
health services. I happen to feel that these are the most immediate
changes we can make. The Health Cost Effectiveness Amendments
of 1969, and the preliminary recommendations of the Medicaid Task
Force, for example, are intended to improve the effectiveness of
health care financing mechanisms.
They reflect the feeling of the Administration that it is
now time to make some fundamental changes in the law which governs
Medicare and Medicaid reimbursement. We need an incentive system
of institutional reimbursement and we need changes in the law that
will help control the increases in the amount that the Medicare pro-
gram will recognize in the charges of individual practitioners.
In the case of hospitals and other institutional providers,
reimbursement is now on a retroactive basis. Consequently, facilities
do not have : strong economic reasons for trying to improve the
efficiency of their operation.
:
:
I think we should move as quickly as possible in the
direction of prospective rather than retroactive reimbursement. With
rates set in advance, a provider would be challenged to stay within
the limits of the known reimbursement and would share in savings
that come from economies achieved through effective management.
Furthermore, our programs would no longer have only a
passive role in responding to costs incurred by providers. They would
have an active role in influencing in advance the amounts which will
be made available for institutional health care.
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I would not want to minimize the difficulty that would
accompany the introduction of this prospective approach to reimburse-
ment. Implementation will take time, but I believe that the benefits
merit such an effort.
We have also recommended that the law should be changed
so as to limit further the rate at which increases in physicians fees
would be recognized by Medicare.
Realistically, charges under the current program and the
fees recognized by carriers reflect whatever physicians choose to
3
charge the public generally
in a market where growing demand is
pressing increasingly on the limited supply of health personnel.
We are also proposing for the Medicaid program modifi-
cations in the rate of Federal participation with incentives for the use
of long term institutional care. Unfortunately, statistics show that
a significant factor in skyrocketing costs can be traced to the practice
of needlessly retaining patients in costly hospital beds simply because
the government is around to pay the bills. We have all heard it said
that you cannot legislate morality, but limitations on the length of
stay for which there will be full Federal participation and a system of
"utilization review" would go a long way toward curbing the practice.
We will not reach our objectives through solutions which
deal solely with financial problems. Our efforts must represent a
strategy for solution to all aspects of the total health problem.
With this in mind, the Administration has introduced revisions in
other health programs which would improve the organization and
delivery of health care. We would encourage the development of
ambulatory care programs. The proposed Health Services Improvement
Act of 1970 focuses sharply on improving the efficiency and effective-
ness of our health systems and targets the efforts of the Comprehensive
Health Planning and SErvices program, the Regional Medical Programs
and the efforts in health services research and development toward
these ends. We are linking the reimbursement policies under Medicare
and Medicaid to mesh with these programs.
We will be moving in the direction of improvement of the
organization of health services at the community level. Our responsi-
bility will be to assist in the development of new social institutions
at the community level which will draw together the health resources,
the providers of health care, and the consumers into a community
trusteeship for health. The need for such an nstitution was
recognized five years ago by the National Commission on Community
Health Services chaired by a distinguished former Secretary of HEW,
Marion Folsom. The time has come to initiate these measures in
each community in the Nation and the Administration stands ready to
assist such community efforts.
We have proposed redirections in the Hill-Burton con-
struction program. When the program was launched 23 years ago, the
United States had less than 60 percent of the hospital beds it needed.
Today, despite the rapid growth of the population, we have about
90 percent of the acute hospital beds we need.
We will move to reorder our priorities under Hill-Burton
away from inpatient care toward outpatient care and from sickness
to preventing sickness. We propose a program of bloc grants to
encourage the states to expand such facilities as outpatient clinics,
neighborhood health centers, skilled nursing homes and extended care
facilities. We believe that these measures would provide a better
balanced health structure and would enable more people to get more
care at less cost.
It is obvious that prevention is cheaper in the long run,
both to the individual and to society in general.
That is when we have such high hopes for our
programs for rubella vaccination and our campaign against hunger and
malnutrition. The difficult situation we face in the area of hunger
was emphasized by the convening of the White House Conference on
Hunger held in December. We are presently conducting a national
nutrition survey system as well as support for community nutrition
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LIBRARY
programs.
GERALD
In addition, we are giving a great deal of attention to
the first few years of life and to the health needs of mothers and
children. We hope to expand such programs as family planning,
maternal and child health services, day care and other prevention
service.
Support will also be provided for specific activities
which improve the quality and productivity of health services, includ-
ing the utilization of new types of health manpower such as returning
medics from the Armed Services.
All of these efforts look forward to a time when ability
to pay for medical care will no longer be an important barrier to receipt
of care. This situation will be brought about largely through the
extension of health insurance, whether required by government or
provided through government or in part subsidized by government.
Just about everyone is going to be under a health insurance plan,
public or private, covering a major part of individual health costs
including low income people who will one day participate in the same
systems that cover the rest of the population. This situation could
create more severe strains on the delivery of care.
With this in mind, it is important to recognize that many
of the solutions to the problems will be found only in changes within
the private health industry and with their cooperation. The Federal
Government clearly needs to safeguard the public interest in administer-
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ing the public programs. We must consider interface between the
public and private sectors, and the methods of influencing the private
sector to look at their policies which may impede improvements.
Private employers and consumers need to reevaluate
their health insurance policies to provide incentives to the use of
lower cost alternative modes of care.
It is this kind of organizational "put together" that will
make the difference not only in the cost but in the organization of
delivery of better health care
and not just to Medicare and Medicaid
recipients, but to all of our citizens. We at HEW are giving the highest
priority to the exercise of the discretion and leverage that we have in
our various programs to enhance and make more rational the organization
and delivery of medical care.
As Secretary Finch has pointed out, "what is at stake is the
pluralistic, independent, voluntary nature of our health care system."
We must move now to assure a leadership role for government and to
avoid any move toward the direct Federal assumption of responsibility
for the Nation's health system.
I hope you will work with us toward these ends and to
make good health a reality throughout the country. Your influence in
these areas can be considerable.
ADDENDUM TO SPEECH:
I am delighted to publically commend Oklahomans, the Oklahoma
Health Science Foundation, and Dr. James Dennis for the innovative,
health program which has become known as the Oklahoma Health
Center -- the "Oklahoma Plan."
This program promises to put into actual practice a concept which
many of us in the health field still dream about. It combines the
considerable resources of academic medicine, practicing medicine,
voluntary agencies, and public health agencies into a single operat-
ing health continuum.
In the present space age, the word "spinoff" has become routine.
So, I would mention that the spinoff from the "Oklahoma Plan" will
be felt outside of Oklahoma. The experiences gained in this pro-
gram will most surely guide and benefit the entire Nation.
And certainly the program at the University of Oklahoma School of
Health to train health planning personnel for 13 states will have a
national impact.
ADDENDUM TO SPEECH:
Subject: Oklahoma's Unusually Successful Effort in Raising
Immunization Levels Against Rubella
In a cooperative team effort combining resources from both public
and private agencies, a statewide "Rubella Sunday" was conducted
on February 1, 1970. Joining the Oklahoma state and local health
departments in this massive campaign were the State Medical
Association, Oklahoma Nurses Association, Pharmaceutical
Association, Osteopathic Association and Oklahoma Jaycees.
255, 000 doses of rubella vaccine were administered reaching 51%
of the total susceptible population in the age group 1 through 11.
Oklahoma is one of the first states in the nation to conduct such
a community-wide campaign.
THE OUTLOOK ON NURSING HOMES
IT IS WITH SOME HUMILITY THAT I APPROACH A TOPIC AS BROAD
AS "THE OUTLOOK ON NURSING HOMES." FOR NOT ONLY ARE YOU, OF
THE VIRGINIA NURSING HOME ASSOCIATION INVOLVED IN THE IMMEDIATE,
PERSONAL JOB OF CARING FOR PATIENTS IN NURSING HOMES, BUT ALSO AS
VIRGINIANS YOU ARE TOO CLOSE TO WASHINGTON TO HARBOR ILLUSIONS
ABOUT THE WISDOM OR GRANDEUR OF FEDERAL POWER. You CAN GAZE ACROSS
THE PoToMac AND WITNESS THE LEGISLATIVE JUNGLE THROUGH WHICH A
PROGRAM MUST PASS IN CONGRESS TO BECOME LAW, AND YOU CAN OBSERVE
THE DIFFICULTY IN TRANSLATING AN ADMINISTRATIVE POLICY CONCEIVED
IN THE HEW NORTH BUILDING INTO A REALITY IN ARLINGTON COUNTY. So
YOU KNOW THAT THOSE OF US WHO SERVE THE FEDERAL GOVERNMENT TODAY
DO NOT COME EQUIPPED WITH ALL THE ANSWERS - READY TO DISPENSE
THE BALM OF GREAT PERSONAL WISDOM TO HEAL ALL WOUNDS AFFLICTING
A TROUBLED SOCIETY,
I COME BEFORE YOU TODAY THEN NOT TO OFFER READY-MADE PRE-
SCRIPTIONS OR ROCK-HARD CERTAINTIES, BUT TO DESCRIBE TO YOU SOME
OF THE PROBLEMS WE SEE AND THE ANSWERS WE HAVE DEVISED. AND I WANT
TO ENLIST YOUR AID IN HELPING US FIND AND REALIZE SOLUTIONS TO THE
PROBLEMS FACING THOSE WHO NEED OR ARE RECEIVING NURSING HOME CARE,
THE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED IN
NURSING HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY SINCE
THE ENACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN 1965. IN
1970 THE FEDERAL GOVERNMENT SPENT OVER $2 BILLION IN SUPPORT OF
NURSING HOME PATIENTS, WHILE STATE AND LOCAL GOVERNMENT SPENT
ANOTHER $700 MILLION,
GERALD FORD VIBRASK
2
THE DIFFICULTY WITH SUCH MASSIVE INVOLVEMENT IS IN ASSURING
THAT DESIRED AND DESIRABLE IMPACT IS ACHIEVED, WITH RESPECT TO
CONTINUITY OF CARE BETWEEN HOSPITAL AND ENTENDED CARE FACILITY,
I BELIEVE THE FEDERAL ROLE HAS BEEN USEFUL AND IMPORTANT. THE
PRESIDENT'S 8-POINT PLAN FOR ACTION TO IMPROVE NURSING HOMES,
ANNOUNCED LAST AUGUST IN NEW HAMPSHIRE, IS DESIGNED TO STRENGTHEN
AND IMPROVE THAT ROLE. THE IMPLEMENTATION OF THAT PLAN HAS ABSORBED
MOST OF MY TIME SINCE I ASSUMED MY NURSING HOME RESPONSIBILITIES
LAST DECEMBER - MORE OF MY TIME THAN I HAD IMAGINED, I MIGHT ADD -
AND I WOULD LIKE TO DESCRIBE FOR YOU SOME OF THESE EFFORTS, BUT I
WOULD ALSO LIKE TO DESCRIBE FOR YOU THE PROBLEMS AT THE OPPOSITE
END OF THE SPECTRUM - CONTINUITY BETWEEN INSTITUTIONAL CARE AND THE
HOME. I BELIEVE THAT THE FEDERAL ROLE HAS BEEN LESS CONSTRUCTIVE
IN THAT AREA, WHICH REPRESENTS TOMORROW'S CHALLENGES. AND THESE
CHALLENGES FACE US ALREADY IN WAYS I SHALL DESCRIBE,
THE EXTENDED CARE FACILITY PROGRAM UNDER MEDICARE WAS DESIGNED
TO COVER THE EXTENSION OF CARE FOR A PATIENT WHO NO LONGER REQUIRES
THE FULL MEDICAL RESOURCES OF A HOSPITAL, BUT STILL NEEDS RELATIVELY
INTENSIVE MEDICAL SERVICES, THE SKILLED NURSING HOME PROGRAM UNDER
MEDICAID, ALTHOUGH THE PHILOSOPHIC INTENT WAS SOMEWHAT DIFFERENT,
ADOPTED VERY SIMILAR STANDARDS, ACUTE ILLNESS, IN WHICH THE PATIENT
IS EXPECTED EVENTUALLY RECOVER, IS THE BASIC MODEL FOR WHICH THIS
SYSTEM IS DESIGNED, AND THE EMPHASIS HAS BEEN ON MEDICAL RATHER THEN
SOCIAL AND PERSONAL SERVICES, THIS APPROACH HAS LED TO VERY REAL
PROBLEMS WHEN APPLIED TO PATIENTS WITH CHRONIC ILLNESS, WHO MAKE UP
A LARGE PROPORTION OF THE ELDERLY NURSING HOME POPULATION - I SHALL
DISCUSS THESE PROBLEMS LATER,
3
THE PRESIDENT'S PLAN FOR NURSING HOMES ACCEPTED THE RESPONSI-
BILITY TO ASSURE THAT NURSING HOMES DELIVER CARE AT LEAST AT THE
LEVELS OF FEDERAL STANDARDS AND REGULATIONS. A MAJOR GOAL OF THE
PLAN IS TO IMPROVE FEDERAL ENFORCEMENT OF NURSING HOME STANDARDS,
As YOU KNOW, THE TERM "NURSING HOME" IS APPLIED TO A WIDE RANGE OF
FACILITIES, FROM THOSE PROVIDING PRIMARILY CUSTODIAL CARE TO THOSE
DELIVERING HIGHLY SKILLED POST-HOSPITAL AND REHABILITATIVE SERVICES,
THESE DIFFERENT TYPES OF FACILITIES ARE ACCREDITED THROUGH DIFFERENT
MECHANISMS, AND FEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES
WIDELY, MEDICARE CERTIFICATION OF EXTENDED CARE FACILITIES IS A
FEDERAL PROGRAM MEDIATED THROUGH STATE AGENCIES. MEDICAID IS A
FEDERAL-STATE PROGRAM, FINANCED AND ADMINISTERED THROUGH BOTH FEDERAL
AND STATE FUNDS AND ACTIVITIES. INTERMEDIATE CARE FACILITIES UNTIL
RECENTLY WERE REQUIRED TO MEET ONLY STATE LICENSING REQUIREMENTS TO
RECEIVE FEDERAL FUNDS, THESE DIFFERENCES HAVE COMPLICATED THE ENFORCE-
MENT OF STANDARDS. IF H.R. 1 AS CURRENTLY AMENDED BY THE SENATE FINANCE
COMMITTEE IS PASSED, THEM SOME OF THESE DIFFERENCES WILL BE MINIMIZED
AND MORE UNIFORM STANDARDS AND CERTIFICATION PROCEDURES WILL BE ADOPTED
FOR MEDICARE AND MEDICAID. IN ANTICIPATION OF THESE CHANGES, A COMMON
SET OF STANDARDS FOR BOTH PROGRAMS IS BEING DEVELOPED UNDER THE
AUSPICES OF MY OFFICE, BUT THE STATE AGENCY WILL RETAIN ITS INSPECTION
ROLE, AND THE FEDERAL GOVERNMENT, WHICH IS RESPONSIBLE FOR THE
QUALITY OF CARE WHICH IT FINANCES, MUST AID IN ENHANCING THE CAPABILITY
OF THE STATE AGENCIES TO REGULATE AND IMPROVE THE QUALITY OF NURSING
HOME CARE, To IMPROVE ENFORCEMENT OF NURSING HOME STANDARDS, THE
PRESIDENT'S PLAN PLEDGED THE FOLLOWING STEPS:
4
1. CONSOLIDATION OF RESPONSIBILITY FOR NURSING HOME AFFAIRS
NURSING HOME ACTIVITIES HAVE BEEN SCATTERED AMONG SEVERAL BRANCHES
OF THE DEPARTMENT OF HEW, INCLUDING THE SOCIAL SECURITY ADMINI-
STRATION, THE SOCIAL AND REHABILITATION SERVICE, AND THE HEALTH
SERVICE AND MENTAL HEALTH ADMINISTRATION. THE PRESIDENT ORDERED
THAT ALL FEDERAL ENFORCEMENT RESPONSIBILITY BE CONSOLIDATED IN A
SINGLE OFFICE, AND DR. MERLIN K. DUVAL, THE ASSISTANT SECRETARY
OF HEALTH AND SCIENTIFIC AFFAIRS, WAS DESIGNATED AS THE RESPONSIBLE
OFFICIAL, DR. DUVAL APPOINTED ME TO WORK WITH HIM ON THESE ACTIVITIES
AND TO FUNCTION AS A FULL-TIME COORDINATOR OF NURSING HOME ACTIVITIES.
2. ENLARGEMENT OF FEDERAL STAFF FOR ENFORCEMENT OF NURSING HOME
STANDARDS.
THE SOCIAL AND REHABILITATION SERVICE, WHICH ADMINISTERS THE MEDICAID
PROGRAM, HAS BEEN ASSIGNED 142 ADDITIONAL POSITIONS TO CARRY OUT
ITS INCREASED RESPONSIBILITIES, ONE HUNDRED TEN OF THESE POSITIONS
WERE ALLOCATED TO THE REGIONAL OFFICE OF HEW. THE SOCIAL SECURITY
ADMINISTRATION RECEIVED THIRTY-FOUR ADDITIONAL POSITIONS TO INCREASE
THEIR AUDITS OF NURSING HOME OPERATIONS. THE NATIONAL CENTER FOR
HEALTH SERVICES RESEARCH AND DEVELOPMENT RECEIVED SEVEN NEW POSI-
TIONS FOR EFFORTS TO IMPROVE NURSING HOME DATA SYSTEMS AND TO DEVELOP
DATA IN SPECIAL FIELDS RELEVANT TO NURSING HOME CARE,
3. FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID INSPECTIONS.
WE RECOGNIZE THAT AN INCREASED LEVEL OF ENFORCEMENT ACTIVITY IN-
VOLVES ADDITIONAL COSTS TO THE STATES. MEDICARE INSPECTION COSTS
HAVE ALWAYS BEEN FULLY PAID FOR BY THE FEDERAL GOVERNMENT, BUT UNDER
THE MEDICAID PROGRAM STATES HAVE PAID 25 TO 50 PERCENT OF THESE
COSTS, SECRETARY RICHARDSON SUBMITTED TO CONGRESS IN OCTOBER, 1971,
5
AN AMENDMENT TO H.R. 1. AUTHORIZING THE FEDERAL GOVERNMENT TO
ASSUME 100 PERCENT OF INSPECTION COSTS UNDER MEDICAID; THIS STEP
WILL PLACE BOTH PROGRAMS ON AN EQUAL FOOTING AND LESSEN THE FINAN-
CIAL BURDEN TO THE STATES.
4. TRAINING STATE NURSING HOME INSPECTORS,
NURSING HOME SURVEYORS HAVE BEEN TRAINED IN SURVEY AND COUNSELLING
TECHNIQUES UNDER A PROGRAM SPONSORED BY THE HEALTH SERVICES AND
MENTAL HEALTH ADMINISTRATION SINCE MARCH, 1970. THESE FOUR-WEEK
COURSES HAVE BEEN PRESENTED IN UNIVERSITY CENTERS IN NEW HAMPSHIRE,
LOUISIANA, AND CALIFORNIA, IN HIS AUGUST SPEECH, THE PRESIDENT
PLEDGED AN EXPANSION OF THIS PROGRAM SO THAT 2,000 SURVEYORS WOULD
BE TRAINED IN THE ENSUING EIGHTEEN MONTH PERIOD. As A RESULT OF
THE PRESIDENT'S ORDER , THE PROGRAM HAS BEEN ACCELERATED SO THAT
MORE THAN 700 SURVEYORS WILL HAVE BEEN TRAINED BY JULY 1.
CONTRACT NEGOTIATIONS ARE IN PROCESS TO ESTABLISH THREE ADDITIONAL
UNIVERSITY CENTERS. IN ADDITION, A STUDY WAS PERFORMED BY MACRO,
SYSTEMS, INC., TO EVALUATE THE EFFECTIVENESS OF THE TRAINING COURSES,
AND THESE HAVE NOW BEEN MODIFIED TO REFLECT THE RESULTS OF THAT
STUDY,
THESE EFFORTS TO ACHIEVE COMPLIANCE WITH FEDERAL STANDARDS
AND REGULATIONS ARE NOT DESIGNED TO ELIMINATE FACILITIES AND THUS
TO DEPRIVE PATIENTS OF NEEDED NURSING HOME CARE, WE ARE WORKING
RATHER TO COORDINATE FEDERAL AND STATE PROGRAMS AND STATE AGENCIES
TO SHARE THEIR RESOURCES AND EXPERTISE so THAT SUBSTANDARD FACIL-
ITIES CAN BE UPGRADED. THE FEDERAL PROGRAM TO TRAIN NURSING HOME
SURVEYORS, FOR EXAMPLE, EMPHASIZES THE DEVELOPMENT OF SKILLS TO
AID NURSING HOME ADMINISTRATORS IN MAKING NEEDED IMPROVEMENTS,
FEDERAL FINANCIAL ASSISTANCE IS AVAILABLE FOR NURSING HOME
MODERNIZATION AND NEW CONSTRUCTION FROM THE FEDERAL HOUSING
6
ADMINISTRATION AND SUCH PROGRAMS AS HILL BURTON. THE STANDARDS
THEMSELVES ARE BEING REVISED AND STRENGTHENED. WE ARE DEVELOPING
PROGRAMS TO IMPROVE NURSING HOMES DIRECTLY-I SHALL DESCRIBE THEM
IN A FEW MOMENTS,
BUT AS THE PRESIDENT WARNED LAST AUGUST,"
LET THERE BE
NO MISTAKING THE FACT THAT WHEN FACILITIES FAIL TO MEET REASONABLE
STANDARDS, WE WILL NOT HESITATE TO CUT OFF THEIR MEDICARE AND
MEDICAID FUNDS." BETWEEN AUGUST 6, 1971, AND FEBRUARY 11, 1972,
13 EXTENDED CARE FACILITIES WERE DECERTIFIED FOR MEDICARE PARTICI-
PATION. ON NOVEMBER 30, 1971, THIRTY-NINE STATES WERE DECLARED
OUT OF COMPLIANCE WITH TITLE 19-MEDICAID--CERTIFICATION PROCEDURES,
By FEBRUARY 1, 1972, IN RESPONSE TO SECRETARY RICHARDSON'S DEADLINE,
ALL BUT ONE OF THOSE STATES HAD MADE THE IMPROVEMENTS REQUIRED FOR
COMPLIANCE. By JULY 1, 1972, ALL TITLE 19 FACILITIES IN ALL STATES
ARE TO HAVE BEEN INSPECTED AND CERTIFIED THROUGH THE CORRECT PRO-
CEDURES, THE FEDERAL GOVERNMENT IS PLEDGED TO MEET ITS RESPONSI-
BILITY TO ASSURE THAT FEDERAL DOLLARS DO NOT FINANCE SUBSTANDARD
CARE,
IN ADDITION TO IMPROVED ENFORCEMENT OF NURSING HOME STANDARDS,
TWO OTHER POINTS IN THE PRESIDENT'S PLAN INITIATED MORE DIRECT STEPS
TO IMPROVE NURSING HOME CARE. THE PRESIDENT DIRECTED THE DEPARTMENT
OF HEW "TO INSTITUTE A NEW PROGRAM OF SHORT-TERM COURSES FOR
PHYSICIANS, NURSES, DIETICIANS, SOCIAL WORKERS AND OTHERS WHO ARE
REGULARLY INVOLVED IN FURNISHING SERVICES TO NURSING HOME PATIENTS."
HEW HAS SUPPORTED SUCH TRAINING FOR SEVERAL YEARS, AND HAS DEVELOPED
CLOSE WORKING RELATIONSHIPS WITH PROFESSIONAL ASSOCIATIONS AND
WITH TRAINING CENTERS. IN RESPONSE TO THE PRESIDENTS' DIRECTIVE,
SUCH PROGRAMS HAVE BEEN EXPANDED UNDER THE LEADERSHIP OF THE
COMMUNITY HEALTH SERVICE, HEALTH SERVICE AND MENTAL HEALTH ADMINI-
STRATION, AND IT IS ANTICIPATED THAT APPROXIMATELY 20,000 PERSONS
7
WILL BE TRAINED IN FISCAL YEAR 1972 AT A COST OF $2.5 MILLION,
TRAINING PROGRAMS WILL FOCUS INITIALLY ON FOUR MANPOWER AREAS
SELECTED BECAUSE OF THEIR DIRECT DAY-TO-DAY RELATIONS WITH NURSING
HOME PATIENTS: NURSING HOME ADMINISTRATORS, PHYSICIANS, NURSES,
AND PATIENT ACTIVITIES DIRECTORS. MANY OF THESE TRAINING PROGRAMS
WILL BE OPERATED UNDER CONTRACTS WITH PROFESSIONAL GROUPS.
APPROACHES TO MENTAL HEALTH PROBLEMS OF NURSING HOME PATIENTS WILL
BE DEVELOPED BY NATIONAL INSTITUTE OF MENTAL HEALTH STAFF WORKING
WITH THE GERONTOLOGICAL SOCIETY. OTHER TRAINING MECHANISMS WILL
ALSO BE EXPLORED, SUCH AS PROGRAMS SPONSORED BY STATE HEALTH
DEPARTMENTS AND STATE AGENCIES, THESE PROGRAMS WILL BE DIRECTED
TOWARD MAKING NURSING HOME STAFF-BOTH PROFESSIONAL AND ALLIED HEALTH-
MORE SENSITIVE AND EXPERT IN THE SPECIAL PROBLEMS OF CARE FOR
GERIATRIC PATIENTS AND THE CHRONICALLY ILL. THEY ARE INTENDED TO
BE THE BEGINNING OF A SYSTEM FOR NATIONWIDE, CONTINUOUS TRAINING
FOR NURSING HOME PERSONNEL WHICH WILL BECOME STANDARD PRACTICE IN
THE NURSING HOME INDUSTRY OF THE FUTURE,
As THE SEVENTH POINT IN HIS PLAN, THE PRESIDENT DIRECTED THE
DEPARTMENT OF HEW "TO ASSIST THE STATES IN ESTABLISHING INVESTI-
GATIVE UNITS WHICH WILL RESPOND IN A RESPONSIBLE AND CONSTRUCTIVE
WAY TO COMPLAINTS MADE BY OR ON BEHALF OF INDIVIDUAL PATIENTS."
SINCE I ASSUMED MY NURSING HOME RESPONSIBILITIES, I HAVE RECEIVED
MANY LETTERS FROM NURSING HOME PATIENTS-TOUCHING IN THEIR APPEAL
FOR CARE OFFERING SIMPLE DIGNITY AND RIGHTS OF PRIVACY, HARROWING
SOMETIMES IN THEIR DESCRIPTIONS OF PHYSICAL OR PSYCHOLOGICAL ABUSE,
THESE PATIENTS ARE OFTEN HELPLESS IN THEIR DEPENDENCE ON THE IN-
STITUTION IN WHICH THEY LIVE, THEY DESERVE A FAIR HEARING, AND AN
ADVOCATE WHEN THEY ARE POWERLESS, THE HEALTH SERVICES AND MENTAL
HEALTH ADMINISTRATION HAS DEVELOPED FIVE MODELS FOR OMBUDSMAN
8
UNITS TO FILL THIS ROLE, PLACED AT VARIOUS LEVELS WITHIN THE
STATES AND DEMONSTRATING DIFFERENT MECHANISMS FOR ACTION,
CONTRACT PROPOSALS TO TEST THESE MODELS ARE BEING SOLICITED,
AND $600,000 HAS BEEN BUDGETED FOR FISCAY YEAR 1972 FOR THIS
ACTIVITY,
IT WILL TAKE TIME TO TEST AND DEVELOP SUCH AN OMBUDSMAN
SYSTEM, TIME INAPPROPRIATE TO THE URGENCY OF THE PROBLEM, So
AN INTERIM OMBUDSMAN MECHANISM HAS BEEN ESTABLISHED WITH THE
855 SOCIAL SECURITY ADMINISTRATION DISTRICT OFFICES DESIGNATED
TO RECEIVE AND INVESTIGATE COMPLAINTS, THIS MECHANISM IS CURRENTLY
IN EFFECT, AND HAS RECEIVED OVER A THOUSAND RESPONSES.
FOR THESE NURSING HOME INITIATIVES, A SUPPLEMENTAL APPRO-
PRIATION OF $9,572,000 HAS BEEN REQUESTED FOR FISCAL YEAR, 1972.
WE FEEL THAT BY MEANS OF THESE PROGRAMS A SIGNIFICANT IMPROVEMENT
IN NURSING HOME CARE CAN BE ACHIEVED IN A RELATIVELY SHORT PERIOD
OF TIME.
I WOULD LIKE TO EXAMINE NURSING HOMES NOW IN A DIFFERENT
PERSPECTIVE, I HAVE MENTIONED THAT MEDICARE FINANCES NURSING
HOME CARE AS AN EXTENSION OF HOSPITAL CARE - THE PRIOR HOSPITALI-
ZATION REQUIREMENT AND THE TIME LIMITATIONS PER SPELL OF ILLNESS
ARE MANIFESTATIONS OF THIS PRINCIPLE, MEDICAID REQUIREMENTS FOR
SKILLED NURSING HOMES, WHILE THEY ARE NOT BASED ON THE SAME CONCEPT
OF EXTENDED CARE TEND TO EMPHASIZE AND PROVIDE COVERAGE FOR MEDICAL
SERVICES AS OPPOSED TO SOCIAL AND PERSONAL CARE,
9
THE ELDERLY OF COURSE SUFFER FROM ACUTE DISEASE, BUT THEY
ARE MUCH MORE SUBJECT THAN YOUNGER PEOPLE TO THE DEPENDENCY OF
CHRONIC ILLNESS, THE TERM "SPELL OF ILLNESS" MAKES LITTLE SENSE
WHEN APPLIED TO A DISEASE PROCESS WHICH WILL NEVER BE CURED,
MOREOVER, ALTHOUGH THE CHRONICALLY - ILL PATIENT MAY BENEFIT FROM
INTENSIVE MEDICAL SERVICES, HE IS MORE LIKELY TO REQIRE LESS IN-
TENSIVE BUT CONTINUOUS MEDICAL CARE IN COMBINATION WITH SOCIAL AND
PERSONAL SERVICES TO HELP HIM LIVE WITH HIS CHRONIC DISABILITY,
So THE HEALTH FACILITY WHICH CAN BEST SERVE HIM MAY BE VERY DIFFERENT
FROM THE EXTENDED CARE FACILITY WHICH IS IDEALLY SUITED TO A PATIENT
RECUPERATING FROM A MYOCARDIAL INFARCTION OR A BROKEN HIP, OR HE
MIGHT NOT REQUIRE INSTITUTIONAL CARE AT ALL - HE MIGHT BE PERFECTLY
ABLE TO LIVE IN HIS OWN HOME WITH THE AID OF HOMEMAKING AND HOME
HEALTH SERVICES,
THESE PATIENTS WITH CHRONIC ILLNESSES - WHICH INCLUDE A DIS-
PROPORTIONATE SHARE OF THE ELDERLY - AND THOSE SUFFERING THE IN-
CREASED DEPENDENCY OF OLD AGE ITSELF-DEMONSTRATE THE WEAKNESSES OF
LONG TERM CARE AS SUPPORTED BY THE FEDERAL GOVERNMENT.
FIRST, MEDICARE AND MEDICAID TEND TO BE MORE CONCERNED IN
TERM OF STANDARDS AND COVERAGE WITH THE MEDICAL COMPONENT OF NURSING
HOME CARE, THIS HAS BEEN TRUE FOR BOTH STATUTORY AND HISTORICAL
REASONS BASED ON THEIR ORIGIN AS HEALTH INSURANCE PROGRAMS, I DO
NOT THINK IT IS HELPFUL TO SEPARATE THE PHYSICAL, EMOTIONAL, SOCIAL,
AND ENVIRONMENTAL COMPONENTS OF CARE, PARTICULARLY FOR THE ELDERLY,
THESE ARE IMPERMANENT SEPARATIONS OF INTEREST, EMPHASIS, ORGANIZATION
AND PREFERENCE; THEY REST MORE UPON TRADITION AND ARBITARY BOUNDARIES
THEN THE APPLICATION OF KNOWLEDGE TO LONG TERM CARE.
10
SECOND THE PRESENT HEALTH FINANCING SYSTEM OFFERS MORE
COMPLETE COVERAGE FOR PATIENTS INSIDE INSTITUTIONS THAN FOR
THOSE WHO REMAIN OUTSIDE, So OUR FINANCING STRUCTURE TENDS
TO PUSH THE ELDERLY INTO NURSING HOMES, SOMETIMES PREMATURELY.
SOCIETY PAYS A PRICE FOR THIS, INSTITUTIONAL CARE IS MORE
COSTLY THEN HOME HEALTH CARE, MORE IMPORTANT, THERE IS IN-
CREASING EVIDENCE THAT THE DISPLACEMENT, LOSS OF STATUS,
AND ISOLATION CAUSED BY INSTITUTIONALIZATION MAY EXACERBATE
IF NOT PRECIPITATE ACTUAL PHYSIOLOGIC DISEASE. THE TRANSFER
OF A PERSON FROM HIS HOME TO AN INSTITUTION MAY MAKE HIM
MORE ILL AND MORE DEPENDENT.
IF A NURSING HOME IS NOT THE MOST APPROPRIATE PLACE FOR
A PERSON'S PARTICULAR NEEDS, THEN HE SHOULD NOT BE REQUIRED
TO GO THERE. IF IT IS PERSONAL CARE RATHER THEN HEALTH
CARE THAT IS REQUIRED, THEN THAT SHOULD BE AVAILABLE. IF IT
IS APPROPRIATE HOUSING RATHER THEN INSTITUTIONAL CARE THAT
IS NEEDED, THEN THE EMPHASIS SHOULD BE ON HOUSING. THE ELDERLY
SHOULD HAVE MORE OPTIONS AVAILABLE,
THESE SEEM TO ME BASIC AND VALID CRITICISMS OF OUR PRESENT
SYSTEM - THE SEPARATION BETWEEN MEDICAL AND PERSONAL CARE AND THE
FAILURE TO PROVIDE ADEQUATE ALTERNATIVES TO INSTITUTIONAL CARE,
AND IN THESE AREAS, FEDERAL PROGRAMS HAVE HAD AN UNFORTUNATE IF
UNINTENDED IMPACT. THESE ISSUES CANNOT BE POSTPONED, ON
DECEMBER 28, 1971, PRESIDENT NIXON SIGNED INTO LAW PUBLIC LAW
92-223, WHICH AUTHORIZES THE TRANSFER OF INTERMEDIATE CARE FACIL-
ITIES INTO THE MEDICAID PROGRAM. AN INTERMEDICATE CARE FACILITY
PROVIDES HEALTH RELATED SERVICES FOR PATIENTS WHO DO NOT REQUIRE
CARE IN SKILLED NURSING HOMES, BUT NEED INSTITUTIONAL CARE BEYOND
11
ROOM AND BOARD. As YOU KNOW, ICF's WERE PREVIOUSLY FINANCED
BY PUBLIC ASSISTANCE PROGRAMS FOR THE AGED, THE BLIND, AND THE
DISABLED, AND WERE SUBJECT ONLY TO STATE LICENSING, TRANSFER
OF FINANCING TO THE MEDICAID PROGRAM MEANS NOT ONLY THAT A LARGER
GROUP OF PEOPLE - INCLUDING THE "MEDICALLY NEEDY" - MAY POTENTIALLY
BE ELIGIBLE FOR BENEFITS, BUT ALSO THAT THE FEDERAL GOVERNMENT IS
EMPOWERED TO SET PHYSICAL AND SAFETY STANDARDS AND DEFINE THE
CARE AND SERVICES THAT MUST BE PROVIDED. THE MEDICAL SERVICES
ADMINISTRATION OF THE SOCIAL AND REHABILITATION SERVICES AND
MY OFFICE OF NURSING HOME AFFAIRS ARE CURRENTLY EXAMINING SUCH
ISSUES AS WHO SHOULD BE IN THESE FACILITIES, WHAT SERVICES MUST
THEY PROVIDE, AND WHAT SHOULD BE THE LEVEL OF BENEFITS IN ATTEMPT-
ING TO DEVELOP STANDARDS FOR INTERMEDIATE CARE FACILITIES. So
THESE FACILITIES ARE FORCING A RE-EXAMINATION OF COVERAGE ISSUES,
AND THE BALANCES OF MEDICAL AND PERSONAL SERVICES WITHIN IN-
STITUTIONS, THE "PROBLEMS TO COME" ARE HERE ALREADY,
I WOULD LIKE TO MENTION ONE MORE PROBLEM THAT HAS DEMANDED
ATTENTION, AND THAT IS THE PLANNING PROCESS ITSELF. AN IMPORTANT
REASON FOR THE INSUFFICIENT AND SOMETIMES INAPPROPRIATE IMPACT OF
FEDERAL PROGRAMS FOR LONG TERM CARE HAS BEEN THE LACK OF PLANNING
AND COORDINATION BETWEEN FEDERAL, STATE, AND LOCAL PROGRAMS,
PLANNING FOR LONG TERM CARE SHOULD MOVE FROM IDENTIFICATION OF AN
ISSUE OR PROBLEM TO ITS SOLUTION, WITH IDENTIFIABLE GOALS GUIDING
THE PROCESS, MOVEMENT TOWARD A GOAL SHOULD NOT BE INTERRUPTED BY
CHANGES IN ADMINISTRATION. WHAT IS TRULY IMPORTANT TODAY SHOULD
NOT BE CAST ASIDE TOMORROW. NEW PROGRAMS SHOULD NOT BE APPENDAGES
TO SATISFY THE INTERESTS OF A FEW, NOR SHOULD THEY BE ADDED AS
PACIFIERS TO THE MANY, PROGRAMS DEVELOPED THROUGH A RATIONAL PLANNING
PROCESS SHOULD THEN BE ADMINISTERED THROUGH AN EFFECTIVE AND COORDI-
NATED MECHANISMS.
12
THE ESTABLISHMENT OF THE OFFICE OF NURSING HOME AFFAIRS
WITHIN HEW WAS A STEP TOWARD IMPROVING COORDINATION. THE EIGHTH
POINT OF THE PRESIDENT'S PLAN IS A MANDATE FOR A TASK FORCE ON
LONG TERM CARE. THIS TASK FORCE WILL RE-EXAMINE ISSUES AND SET
NEW GOALS, DEVELOP A NATIONWIDE DATA SYSTEM NECESSARY FOR POLICY
FORMULATION, AND RECOMMEND AN ORGANIZATION FOR LONG TERM CARE WITHIN
HEW AND FEDERAL STATE AND LOCAL PROGRAMS WHICH CAN ACHIEVE ITS
GOALS MOST EFFECTIVELY.
A NATIONAL POLICY COURSE FOR THE CHRONICALLY ILL AND FOR
THE ELDERLY SHOULD BE SET, IT SHOULD BE SET BY GOVERNMENT, WITH
THE FULL AND CREATIVE CONTRIBUTION OF THOSE IN OTHER AGENCIES
AND ORGANIZATIONS, THOSE IN ACADEMIC TEACHING AND RESEARCH, THOSE
IN VOLUNTARY AND UNSALARIED SERVICE, AND THOSE WHO RECEIVE THAT CARE,
WE CAN DO MUCH BETTER FOR OUR ELDERLY, WE MUST OF COURSE
PROTECT THEM FROM INSTITUTIONAL ABUSE, RECOGNIZING THAT SOME
ARE WEAK AND DEPENDENT, BUT WE CAN ALSO MAKE POSSIBLE A WIDE
VARIETY OF SUPPORTING SERVICES AND LIVING ARRANGEMENTS, SO THAT
THE INFIRMITIES OF ADVANCING AGE DO NOT BECOME A PRISON OF THE
SPIRIT. THE ELDERLY WITH OUR HELP CAN HAVE ACCESS TO THE VARIETY
AND FREEDOM WE ASK FOR OURSELVES,
THE OUTLOOK ON NURSING HOMES
MRS. MARIE CALLENDER
SPECIAL ASSISTANT FOR NURSING HOME AFFAIRS
DEPARTMENT OF HEALTH, EDUCATION AND WELFARE*
*To BE PRESENTED AT THE ANNUAL SPRING CONVENTION OF THE COLORADO
ASSOCIATED NURSING HOMES, INC., ON TUESDAY, MAY 16, L972,
THE OUTLOOK ON NURSING HOMES
IT IS WITH SOME HUMILITY THAT I APPROACH A TOPIC AS BROAD
AS
THE OUTLOORS ON NURSING HOMES,
A lha llenae from the White douse
FOR NOT ONLY ARE YOU, OF
THE COLORADO ASSOCIATED NURSING HOMES INVOLVED IN THE IMMEDIATE,
PERSONAL JOB OF CARING FOR PATIENTS IN NURSING HOMES, BUT ALSO AS
COLORADANS YOU ARE DISTANT ENOUGH FROM WASHINGTON TO UNDERSTAND
THE DIFFICULTY IN TRANSLATING AN ADMINISTRATIVE POLICY CONCEIVED IN
THE HEW NORTH BUILDING INTO A REALITY IN DENVER. So YOU KNOW THAT
THOSE OF US WHO SERVE THE FEDERAL GOVERNMENT TODAY DO NOT COME
EQUIPPED WITH ALL THE ANSWERS - READY TO DISPENSE THE BALM OF GREAT
PERSONAL WISDOM TO HEAL ALL WOUNDS AFFLICTING A TROUBLED SOCIETY.
I COME BEFORE YOU TODAY THEN NOT TO OFFER READY-MADE
PRESCRIPTIONS OR ROCK-HARD CERTAINTIES, BUT TO DESCRIBE TO YOU SOME
OF THE PROBLEMS WE SEE AND THE ANSWERS WE HAVE DEVISED. AND I
additional
WANT TO ENLIST YOUR AID IN HELPING US FIND AND REALIZE SOLUTIONS
TO THE PROBLEMS FACING THOSE WHO NEED OR ARE RECEIVING NURSING
HOME CARE.
THE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED IN
NURSING HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY SINCE
THE ENACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN 1965. IN
L970 THE FEDERAL GOVERNMENT SPENT OVER $2 BILLION IN SUPPORT OF
NURSING HOME PATIENTS, WHILE STATE AND LOCAL GOVERNMENT SPENT
ANOTHER $700 MILLION,
2
THE DIFFICULTY WITH SUCH MASSIVE INVOLVEMENT IS IN ASSURING
THAT DESIRED AND DESIRABLE IMPACT IS ACHIEVED. WITH RESPECT TO
CONTINUITY OF CARE BETWEEN HOSPITAL AND ENTENDED CARE FACILITY,
I BELIEVE THE FEDERAL ROLE HAS BEEN USEFUL AND IMPORTANT. THE
PRESIDENT'S 8-POINT PLAN FOR ACTION TO IMPROVE NURSING HOMES,
ANNOUNCED LAST AUGUST IN NEW HAMPSHIRE, IS DESIGNED TO STRENGTHEN
AND IMPROVE THAT ROLE. THE IMPLEMENTATION OF THAT PLAN HAS ABSORBED
MOST OF MY TIME SINCE I ASSUMED MY NURSING HOME RESPONSIBILITIES
LAST DECEMBER - MORE OF MY TIME THAN I HAD IMAGINED, I MIGHT ADD -
AND I WOULD LIKE TO DESCRIBE FOR YOU SOME OF THESE EFFORTS, BUT I
WOULD ALSO LIKE TO DESCRIBE FOR YOU THE PROBLEMS AT THE OPPOSITE
END OF THE SPECTRUM - CONTINUITY BETWEEN INSTITUTIONAL CARE AND THE
HOME. I BELIEVE THAT THE FEDERAL ROLE HAS BEEN LESS CONSTRUCTIVE
IN THAT AREA, WHICH REPRESENTS TOMORROW'S CHALLENGES. AND THESE
CHALLENGES FACE US ALREADY IN WAYS .I SHALL DESCRIBE.
In part the shall engs stem from the fact that
THE EXTENDED CARE FACILITY PROGRAM UNDER MEDICARE WAS DESIGNED
TO COVER THE EXTENSION OF CARE FOR A PATIENT WHO NO LONGER REQUIRES
THE FULL MEDICAL RESOURCES OF A HOSPITAL, BUT STILL NEEDS RELATIVELY
INTENSIVE MEDICAL SERVICES. THE SKILLED NURSING HOME PROGRAM UNDER
MEDICAID, ALTHOUGH THE PHILOSOPHIC INTENT WAS SOMEWHAT DIFFERENT,
ADOPTED VERY SIMILAR STANDARDS. ACUTE ILLNESS, IN WHICH THE PATIENT
IS EXPECTED EVENTUALLY RECOVER, IS THE BASIC MODEL FOR WHICH THIS
SYSTEM IS DESIGNED, AND THE EMPHASIS HAS BEEN ON MEDICAL RATHER THEN
SOCIAL AND PERSONAL SERVICES. THIS APPROACH HAS LED TO VERY REAL
PROBLEMS WHEN APPLIED TO PATIENTS WITH CHRONIC ILLNESS, WHO MAKE UP
A LARGE PROPORTION OF THE ELDERLY NURSING HOME POPULATION - I SHALL
DISCUSS THESE PROBLEMS LATER.
3
THE PRESIDENT'S PLAN FOR NURSING HOMES ACCEPTED THE RESPONSI-
BILITY TO ASSURE THAT NURSING HOMES DELIVER CARE AT LEAST AT THE
LEVELS OF FEDERAL STANDARDS AND REGULATIONS. A MAJOR GOAL OF THE
PLAN IS TO IMPROVE FEDERAL ENFORCEMENT OF NURSING HOME STANDARDS.
As YOU KNOW, THE TERM "NURSING HOME" IS APPLIED TO A WIDE RANGE OF
FACILITIES, FROM THOSE PROVIDING PRIMARILY CUSTODIAL CARE TO THOSE
DELIVERING HIGHLY SKILLED POST-HOSPITAL AND REHABILITATIVE SERVICES.
THESE DIFFERENT TYPES OF FACILITIES ARE ACCREDITED THROUGH DIFFERENT
MECHANISMS, AND FEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES
WIDELY. MEDICARE CERTIFICATION OF EXTENDED CARE FACILITIES IS A
FEDERAL PROGRAM MEDIATED THROUGH STATE AGENCIES, MEDICAID IS A
FEDERAL-STATE PROGRAM, FINANCED AND ADMINISTERED THROUGH BOTH FEDERAL
AND STATE FUNDS AND ACTIVITIES. INTERMEDIATE CARE FACILITIES UNTIL
RECENTLY WERE REQUIRED TO MEET ONLY STATE LICENSING REQUIREMENTS TO
RECEIVE FEDERAL FUNDS. THESE DIFFERENCES HAVE COMPLICATED THE ENFORCE-
MENT OF STANDARDS. IF H.R. 1 AS CURRENTLY AMENDED BY THE SENATE FINANCE
COMMITTEE IS PASSED, THEM SOME OF THESE DIFFERENCES WILL BE MINIMIZED
AND MORE UNIFORM STANDARDS AND CERTIFICATION PROCEDURES WILL BE ADOPTED
FOR MEDICARE AND MEDICAID. IN ANTICIPATION OF THESE CHANGES, A COMMON
SET OF STANDARDS FOR BOTH PROGRAMS IS BEING DEVELOPED UNDER THE
AUSPICES OF MY OFFICE. BUT THE STATE AGENCY WILL RETAIN ITS INSPECTION
ROLE. AND THE FEDERAL GOVERNMENT, WHICH IS RESPONSIBLE FOR THE
QUALITY OF CARE WHICH IT FINANCES, MUST AID IN ENHANCING THE CAPABILITY
OF THE STATE AGENCIES TO REGULATE AND IMPROVE THE QUALITY OF NURSING
HOME CARE. To IMPROVE ENFORCEMENT OF NURSING HOME STANDARDS, THE
PRESIDENT'S PLAN PLEDGED THE FOLLOWING STEPS:
4
1. CONSOLIDATION OF RESPONSIBILITY FOR NURSING HOME AFFAIRS
NURSING HOME ACTIVITIES HAVE BEEN SCATTERED AMONG SEVERAL BRANCHES
OF THE DEPARTMENT OF HEW, INCLUDING THE SOCIAL SECURITY ADMINI-
STRATION, THE SOCIAL AND REHABILITATION SERVICE, AND THE HEALTH
SERVICE AND MENTAL HEALTH ADMINISTRATION. THE PRESIDENT ORDERED
THAT ALL FEDERAL ENFORCEMENT RESPONSIBILITY BE CONSOLIDATED IN A
SINGLE OFFICE. AND DR. MERLIN K. DUVAL, THE ASSISTANT SECRETARY
OF HEALTH AND SCIENTIFIC AFFAIRS, WAS DESIGNATED AS THE RESPONSIBLE
OFFICIAL. DR. DUVAL inturn DELEGATED TO ME THESE RESPONSIBILITIES AND
THE FUNCTION OF FULL-TIME COORDINATOR OF NURSING HOME ACTIVITIES.
2. ENLARGEMENT OF FEDERAL STAFF FOR ENFORCEMENT OF NURSING HOME
STANDARDS.
THE SOCIAL AND REHABILITATION SERVICE, WHICH ADMINISTERS THE MEDICAID
PROGRAM, HAS BEEN ASSIGNED 142 ADDITIONAL POSITIONS TO CARRY OUT
ITS INCREASED RESPONSIBILITIES. ONE HUNDRED TEN OF THESE POSITIONS
WERE ALLOCATED TO THE REGIONAL OFFICE OF HEW. THE ASSISTANT
SECRETARY COMPTROLLER RECEIVED THIRTY-FOUR ADDITIONAL POSITIONS TO
INCREASE THEIR AUDITS OF NURSING HOME OPERATIONS. THE NATIONAL CENTER
FOR HEALTH SERVICES RESEARCH AND DEVELOPMENT RECEIVED SEVEN NEW POSI-
TIONS FOR EFFORTS TO IMPROVE NURSING HOME DATA SYSTEMS AND TO DEVELOP
DATA IN SPECIAL FIELDS RELEVANT TO NURSING HOME CARE. These positions
will strengthen our assistant to StAte Agencies,
3. FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID activities INSPECTIONS.
WE RECOGNIZE THAT AN INCREASED LEVEL OF ENFORCEMENT ACTIVITIY IN-
VOLVES ADDITIONAL COSTS TO THE STATES. State MEDICARE INSPECTION COSTS
HAVE ALWAYS BEEN FULLY PAID FOR BY THE FEDERAL GOVERNMENT, BUT UNDER
THE MEDICAID PROGRAM STATES HAVE PAID 25 TO 50 PERCENT OF THESE
COSTS. SECRETARY RICHARDSON SUBMITTED TO CONGRESS IN OCTOBER, 1971,
5
AN AMENDMENT TO H.R. 1. AUTHORIZING THE FEDERAL GOVERNMENT TO
home
ASSUME 100 PERCENT OF INSPECTION COSTS UNDER MEDICAID; THIS STEP
WILL PLACE BOTH PROGRAMS ON AN EQUAL FOOTING AND LESSEN THE FINAN-
CIAL BURDEN TO THE STATES.
4. TRAINING STATE NURSING HOME INSPECTORS,
NURSING HOME SURVEYORS HAVE BEEN TRAINED IN SURVEY AND COUNSELLING
TECHNIQUES UNDER A PROGRAM SPONSORED BY THE HEALTH SERVICES AND
MENTAL HEALTH ADMINISTRATION SINCE MARCH, 1970. THESE FOUR-WEEK
COURSES HAVE BEEN PRESENTED IN UNIVERSITY CENTERS IN NEW HAMPSHIRE,
LOUISIANA, AND CALIFORNIA. IN HIS AUGUST SPEECH, THE PRESIDENT
PLEDGED AN EXPANSION: OF THIS PROGRAM so THAT 2,000 SURVEYORS COULD
BE TRAINED IN THE ENSUING EIGHTEEN MONTH PERIOD. As A RESULT OF
THE PRESIDENT'S ORDER, THE PROGRAM HAS BEEN ACCELERATED so THAT
MORE THAN 700 SURVEYORS WILL HAVE BEEN TRAINED BY JULY 1.
CONTRACT NEGOTIATIONS ARE IN PROCESS TO ESTABLISH THREE ADDITIONAL
UNIVERSITY CENTERS. IN ADDITION, A STUDY WAS PERFORMED, TO
EVALUATE THE EFFECTIVENESS OF THE TRAINING COURSES, AND THESE HAVE
NOW BEEN MODIFIED TO REFLECT THE RESULTS OF THAT STUDY.
THESE EFFORTS TO ACHIEVE COMPLIANCE WITH FEDERAL STANDARDS
AND REGULATIONS ARE NOT DESIGNED TO ELIMINATE FACILITIES AND THUS
TO DEPRIVE PATIENTS OF NEEDED NURSING HOME CARE, WE ARE WORKING
RATHER TO COORDINATE FEDERAL AND STATE PROGRAMS AND STATE AGENCIES,
TO SHARE THEIR RESOURCES AND EXPERTISE so THAT SUBST
more pubstancial FACIL assistant
and consul Astion ean be offered,
ITIES
CAN
BE
UPGRADED.
THE FEDERAL PROGRAM TO TRAIN NURSING HOME
SURVEYORS, FOR EXAMPLE, EMPHASIZES THE DEVELOPMENT OF SKILLS TO
and personnel
changes
AID NURSING HOME ADMINISTRATORS IN MAKING NEEDED IMPROVEMENTS.
in addition
EDERAL FINANCIAL ASSISTANCE IS AVAILABLE FOR NURSING HOME
MODERNIZATION AND NEW CONSTRUCTION FROM THE FEDERAL HOUSING
6
the
Program
ADMINISTRATION AND SUCH PROGRAMS AS HILL BURTON, THEMSTANDARDS
THEMSELVES ARE BEING REVISED AND STRENGTHENED. WE ARE DEVELOPING
PROGRAMS TO IMPROVE NURSING HOMES DIRECTLY- SHALL DESCRIBE THEM
IN A FEW MOMENTS.
BUT AS THE PRESIDENT WARNED LAST AUGUST," LET THERE BE
NO MISTAKING THE FACT THAT WHEN FACILITIES FAIL TO MEET REASONABLE
STANDARDS, WE WILL NOT HESITATE TO CUT OFF THEIR MEDICARE AND
MEDICAID FUNDS." BETWEEN AUGUST 6, 1971, AND FEBRUARY 11, 1972,
13 EXTENDED CARE FACILITIES WERE DECERTIFIED FOR MEDICARE PARTICI-
PATION. ON NOVEMBER 30, 1971, THIRTY-NINE STATES WERE DECLARED
OUT OF COMPLIANCE WITH TITLE 19-MEDICAID--CERTIFICATION PROCEDURES.
By FEBRUARY 1, 1972, IN RESPONSE TO SECRETARY RICHARDSON'S DEADLINE,
ALL BUT ONE OF THOSE STATES HAD MADE THE IMPROVEMENTS REQUIRED FOR
this coming
COMPLIANCE. By JULY 1, 1972, ALL TITLE 19 FACILITIES IN ALL STATES
surveyed
assist against Title 19 need, standards
ARE TO HAVE BEEN INSPECTED AND CERTIFIED THROUGH THE CORRECT PRO
CEDURES, THE FEDERAL GOVERNMENT IS PLEDGED TO MEET ITS RESPONSI-
BILITY TO ASSURE THAT FEDERAL DOLLARS DO NOT FINANCE SUBSTANDARD
CARE. and that the velderly of this country have assurance not
these standards are met,
IN ADDITION TO IMPROVED ENFORCEMENT OF NURSING HOME STANDARDS,
TWO OTHER POINTS IN THE PRESIDENT'S PLAN INITIATED MORE DIRECT STEPS
TO IMPROVE NURSING HOME CARE. THE PRESIDENT DIRECTED THE DEPARTMENT
OF HEW "TO INSTITUTE A NEW PROGRAM OF SHORT-TERM COURSES FOR
PHYSICIANS, NURSES, DIETICIANS, SOCIAL WORKERS AND OTHERS WHO ARE
REGULARLY INVOLVED IN FURNISHING SERVICES TO NURSING HOME PATIENTS."
HEW HAS SUPPORTED SUCH TRAINING FOR SEVERAL YEARS, AND HAS DEVELOPED
CLOSE WORKING RELATIONSHIPS WITH PROFESSIONAL ASSOCIATIONS AND
WITH TRAINING CENTERS. IN RESPONSE TO THE PRESIDENTS' DIRECTIVE,
SUCH PROGRAMS HAVE BEEN EXPANDED UNDER THE LEADERSHIP OF THE
COMMUNITY HEALTH SERVICE, HEALTH SERVICE AND MENTAL HEALTH ADMINI-
STRATION, AND IT IS ANTICIPATED THAT APPROXIMATELY 20,000 PERSONS
7
offered
WILL BE TRAINED IN FISCAL YEAR 1972 AT A COST OF $2.5 MILLION.
TRAINING PROGRAMS WILL FOCUS INITIALLY ON FOUR MANPOWER AREAS
SELECTED BECAUSE OF THEIR DIRECT DAY-TO-DAY RELATIONS WITH NURSING
HOME PATIENTS: NURSING HOME ADMINISTRATORS, PHYSICIANS, NURSES,
AND PATIENT ACTIVITIES DIRECTORS, MANY OF THESE TRAINING PROGRAMS
WILL BE OPERATED UNDER CONTRACTS WITH PROFESSIONAL GROUPS.
APPROACHES TO MENTAL HEALTH PROBLEMS OF NURSING HOME PATIENTS WILL
BE DEVELOPED BY NATIONAL INSTITUTE OF MENTAL HEALTH STAFF WORKING
WITH THE GERONTOLOGICAL SOCIETY. OTHER TRAINING MECHANISMS WILL
ALSO BE EXPLORED, SUCH AS PROGRAMS SPONSORED BY STATE HEALTH
DEPARTMENTS AND STATE AGENCIES. THESE PROGRAMS WILL BE DIRECTED
helping you
TOWARD MAKING NURSING HOME STAFF-BOTH PROFESSIONAL AND ALLIED HEALTH-
MORE SENSITIVE AND EXPERT IN THE SPECIAL PROBLEMS OF CARE FOR
GERIATRIC PATIENTS AND THE CHRONICALLY ILL. THEY ARE INTENDED TO
BE THE BEGINNING OF A SYSTEM FOR NATIONWIDE, CONTINUOUS TRAINING
FOR NURSING HOME PERSONNEL WHICH WILL BECOME STANDARD PRACTICE IN
THE NURSING HOME INDUSTRY OF THE FUTURE,
As THE SEVENTH POINT IN HIS PLAN, THE PRESIDENT DIRECTED THE
DEPARTMENT OF HEW "TO ASSIST THE STATES IN ESTABLISHING INVESTI-
GATIVE UNITS WHICH WILL RESPOND IN A RESPONSIBLE AND CONSTRUCTIVE
WAY TO COMPLAINTS MADE BY OR ON BEHALF OF INDIVIDUAL PATIENTS. "
SINCE I ASSUMED MY NURSING HOME RESPONSIBILITIES, I HAVE RECEIVED
MANY LETTERS FROM NURSING HOME PATIENTS-TOUCHING IN THEIR APPEAL
FOR CARE OFFERING SIMPLE DIGNITY AND RIGHTS OF PRIVACY, HARROWING
SOMETIMES IN THEIR DESCRIPTIONS OF PHYSICAL OR PSYCHOLOGICAL ABUSE.
THESE PATIENTS ARE OFTEN HELPLESS IN THEIR DEPENDENCE ON THE IN-
STITUTION IN WHICH THEY LIVE. THEY DESERVE A FAIR HEARING, AND AN
ADVOCATE WHEN THEY ARE POWERLESS, THE HEALTH SERVICES AND MENTAL
HEALTH ADMINISTRATION HAS DEVELOPED FIVE MODELS FOR OMBUDSMAN
8
UNITS TO FILL THIS ROLE, PLACED AT VARIOUS LEVELS WITHIN THE
STATES AND DEMONSTRATING DIFFERENT MECHANISMS FOR ACTION.
CONTRACT PROPOSALS TO TEST THESE MODELS ARE BEING SOLICITED,
AND $600,000 HAS BEEN BUDGETED FOR FISCAY YEAR 1972 FOR THIS
ACTIVITY.
IT WILL TAKE TIME TO TEST AND DEVELOP SUCH AN OMBUDSMAN
SYSTEM, TIME INAPPROPRIATE TO THE URGENCY OF THE PROBLEM. So
AN INTERIM OMBUDSMAN MECHANISM HAS BEEN ESTABLISHED WITH THE
855 SOCIAL SECURITY ADMINISTRATION DISTRICT OFFICES DESIGNATED
TO RECEIVE AND INVESTIGATE COMPLAINTS. THIS MECHANISM IS CURRENTLY
IN EFFECT, AND HAS RECEIVED OVER A THOUSAND RESPONSES,
FOR THESE NURSING HOME INITIATIVES, A SUPPLEMENTAL APPRO-
PRIATION OF $9,572,000 HAS BEEN REQUESTED FOR FISCAL YEAR, 1972.
WE FEEL THAT BY MEANS OF THESE PROGRAMS A SIGNIFICANT IMPROVEMENT
IN NURSING HOME CARE CAN BE ACHIEVED IN A RELATIVELY SHORT PERIOD
OF TIME.
I WOULD LIKE TO EXAMINE NURSING HOMES NOW IN A DIFFERENT
PERSPECTIVE. I HAVE MENTIONED THAT MEDICARE FINANCES NURSING
HOME CARE AS AN EXTENSION OF HOSPITAL CARE - THE PRIOR HOSPITALI-
ZATION REQUIREMENT AND THE TIME LIMITATIONS PER SPELL OF ILLNESS
ARE MANIFESTATIONS OF THIS PRINCIPLE, MEDICAID REQUIREMENTS FOR
SKILLED NURSING HOMES, WHILE THEY ARE NOT BASED ON THE SAME CONCEPT
OF EXTENDED CARE TEND TO EMPHASIZE AND PROVIDE COVERAGE FOR MEDICAL
SERVICES AS OPPOSED TO SOCIAL AND PERSONAL CARE.
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THE ELDERLY OF COURSE SUFFER FROM ACUTE DISEASE, BUT THEY
ARE MUCH MORE SUBJECT THAN YOUNGER PEOPLE TO THE DEPENDENCY OF
CHRONIC ILLNESS. THE TERM "SPELL OF ILLNESS" MAKES LITTLE SENSE
WHEN APPLIED TO A DISEASE PROCESS WHICH WILL NEVER BE CURED.
MOREOVER, ALTHOUGH THE CHRONICALLY - ILL PATIENT MAY BENEFIT FROM
INTENSIVE MEDICAL SERVICES, HE IS MORE LIKELY TO REQIRE LESS IN-
TENSIVE BUT CONTINUOUS MEDICAL CARE IN COMBINATION WITH SOCIAL AND
PERSONAL SERVICES TO HELP HIM LIVE WITH HIS CHRONIC DISABILITY,
So THE HEALTH FACILITY WHICH CAN BEST SERVE HIM MAY BE VERY DIFFERENT
FROM THE EXTENDED CARE FACILITY WHICH IS IDEALLY SUITED TO A PATIENT
RECUPERATING FROM A MYOCARDIAL INFARCTION OR A BROKEN HIP. OR HE
MIGHT NOT REQUIRE INSTITUTIONAL CARE AT ALL - HE MIGHT BE PERFECTLY
ABLE TO LIVE IN HIS OWN HOME WITH THE AID OF HOMEMAKING AND HOME
HEALTH SERVICES.
THESE PATIENTS WITH CHRONIC ILLNESSES - WHICH INCLUDE A DIS-
PROPORTIONATE SHARE OF THE ELDERLY - AND THOSE SUFFERING THE IN-
CREASED DEPENDENCY OF OLD AGE ITSELF-DEMONSTRATE THE WEAKNESSES OF
LONG TERM CARE AS SUPPORTED BY THE FEDERAL GOVERNMENT.
FIRST, MEDICARE AND MEDICAID TEND TO BE MORE CONCERNED IN
TERM OF STANDARDS AND COVERAGE WITH THE MEDICAL COMPONENT OF NURSING
HOME CARE. THIS HAS BEEN TRUE FOR BOTH STATUTORY AND HISTORICAL
REASONS BASED ON THEIR ORIGIN AS HEALTH INSURANCE PROGRAMS. I DO
NOT THINK IT IS HELPFUL TO SEPARATE THE PHYSICAL, EMOTIONAL, SOCIAL,
AND ENVIRONMENTAL COMPONENTS OF CARE, PARTICULARLY FOR THE ELDERLY.
THESE ARE IMPERMANENT SEPARATIONS OF INTEREST, EMPHASIS, ORGANIZATION
AND PREFERENCE; THEY REST MORE UPON TRADITION AND ARBITARY BOUNDARIES
THEN THE APPLICATION OF KNOWLEDGE TO LONG TERM CARE,
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SECOND THE PRESENT HEALTH FINANCING SYSTEM OFFERS MORE
COMPLETE COVERAGE FOR PATIENTS INSIDE INSTITUTIONS THAN FOR
THOSE WHO REMAIN OUTSIDE. So OUR FINANCING STRUCTURE TENDS
TO PUSH THE ELDERLY INTO NURSING HOMES, SOMETIMES PREMATURELY.
SOCIETY PAYS A PRICE FOR THIS. INSTITUTIONAL CARE IS MORE
COSTLY THEN HOME HEALTH CARE. MORE IMPORTANT, THERE IS IN-
CREASING EVIDENCE THAT THE DISPLACEMENT, LOSS OF STATUS,
AND ISOLATION CAUSED BY INSTITUTIONALIZATION MAY EXACERBATE
IF NOT PRECIPITATE ACTUAL PHYSIOLOGIC DISEASE. THE TRANSFER
OF A PERSON FROM HIS HOME TO AN INSTITUTION MAY MAKE HIM
MORE ILL AND MORE DEPENDENT,
IF A NURSING HOME IS NOT THE MOST APPROPRIATE PLACE FOR
A PERSON'S PARTICULAR NEEDS, THEN HE SHOULD NOT BE REQUIRED
TO GO THERE. IF IT IS PERSONAL CARE RATHER THEN HEALTH
CARE THAT IS REQUIRED, THEN THAT SHOULD BE AVAILABLE, IF IT
IS APPROPRIATE HOUSING RATHER THEN INSTITUTIONAL CARE THAT
IS NEEDED, THEN THE EMPHASIS SHOULD BE ON HOUSING. THE ELDERLY
SHOULD HAVE MORE OPTIONS AVAILABLE.
THESE SEEM TO ME BASIC AND VALID CRITICISMS OF OUR PRESENT
SYSTEM - THE SEPARATION BETWEEN MEDICAL AND PERSONAL CARE AND THE
FAILURE TO PROVIDE ADEQUATE ALTERNATIVES TO INSTITUTIONAL CARE.
AND IN THESE AREAS, FEDERAL PROGRAMS HAVE HAD AN UNFORTUNATE IF
UNINTENDED IMPACT. THESE ISSUES CANNOT BE POSTPONED. ON
DECEMBER 28, 1971, PRESIDENT NIXON SIGNED INTO LAW PUBLIC LAW
92-223, WHICH AUTHORIZES THE TRANSFER OF INTERMEDIATE CARE FACIL-
ITIES INTO THE MEDICAID PROGRAM. AN INTERMEDICATE CARE FACILITY
PROVIDES HEALTH RELATED SERVICES FOR PATIENTS WHO DO NOT REQUIRE
CARE IN SKILLED NURSING HOMES, BUT NEED INSTITUTIONAL CARE BEYOND
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ROOM AND BOARD. As YOU KNOW, ICF's WERE PREVIOUSLY FINANCED
BY PUBLIC ASSISTANCE PROGRAMS FOR THE AGED, THE BLIND, AND THE
DISABLED, AND WERE SUBJECT ONLY TO STATE LICENSING. TRANSFER
OF FINANCING TO THE MEDICAID PROGRAM MEANS NOT ONLY THAT A LARGER
GROUP OF PEOPLE - INCLUDING THE "MEDICALLY NEEDY" - MAY POTENTIALLY
BE ELIGIBLE FOR BENEFITS, BUT ALSO THAT THE FEDERAL GOVERNMENT IS
EMPOWERED TO SET PHYSICAL AND SAFETY STANDARDS AND DEFINE THE
CARE AND SERVICES THAT MUST BE PROVIDED. THE MEDICAL SERVICES
ADMINISTRATION OF THE SOCIAL AND REHABILITATION SERVICES AND
MY OFFICE OF NURSING HOME AFFAIRS ARE CURRENTLY EXAMINING SUCH
ISSUES AS WHO SHOULD'BE IN THESE FACILITIES, WHAT SERVICES MUST
THEY PROVIDE, AND WHAT SHOULD BE THE LEVEL OF BENEFITS IN ATTEMPT-
ING TO DEVELOP STANDARDS FOR INTERMEDIATE CARE FACILITIES. So
THESE FACILITIES ARE FORCING A RE-EXAMINATION OF COVERAGE ISSUES,
AND THE BALANCES OF MEDICAL AND PERSONAL SERVICES WITHIN IN-
STITUTIONS. THE "PROBLEMS TO COME" ARE HERE ALREADY.
I WOULD LIKE TO MENTION ONE MORE PROBLEM THAT HAS DEMANDED
ATTENTION, AND THAT IS THE PLANNING PROCESS ITSELF. AN IMPORTANT
REASON FOR THE INSUFFICIENT AND SOMETIMES INAPPROPRIATE IMPACT OF
FEDERAL PROGRAMS FOR LONG TERM CARE HAS BEEN THE LACK OF PLANNING
AND COORDINATION BETWEEN FEDERAL, STATE, AND LOCAL PROGRAMS.
PLANNING FOR LONG TERM CARE SHOULD MOVE FROM IDENTIFICATION OF AN
ISSUE OR PROBLEM TO ITS SOLUTION, WITH IDENTIFIABLE GOALS GUIDING
THE PROCESS, MOVEMENT TOWARD A GOAL SHOULD NOT BE INTERRUPTED BY
CHANGES IN ADMINISTRATION. WHAT IS TRULY IMPORTANT TODAY SHOULD
NOT BE CAST ASIDE TOMORROW. NEW PROGRAMS SHOULD NOT BE APPENDAGES
TO SATISFY THE INTERESTS OF A FEW, NOR SHOULD THEY BE ADDED AS
PACIFIERS TO THE MANY. PROGRAMS DEVELOPED THROUGH A RATIONAL PLANNING
PROCESS SHOULD THEN BE ADMINISTERED THROUGH AN EFFECTIVE AND COORDI-
NATED MECHANISMS.
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THE ESTABLISHMENT OF THE OFFICE OF NURSING HOME AFFAIRS
WITHIN HEW WAS A STEP TOWARD IMPROVING COORDINATION. THE EIGHTH
POINT OF THE PRESIDENT'S PLAN IS A MANDATE FOR A TASK FORCE ON
LONG TERM CARE. THIS TASK FORCE WILL RE-EXAMINE ISSUES AND SET
NEW GOALS, DEVELOP A NATIONWIDE DATA SYSTEM NECESSARY FOR POLICY
FORMULATION, AND RECOMMEND AN ORGANIZATION FOR LONG TERM CARE WITHIN
HEW AND FEDERAL STATE AND LOCAL PROGRAMS WHICH CAN ACHIEVE ITS
GOALS MOST EFFECTIVELY.
A NATIONAL POLICY COURSE FOR THE CHRONICALLY ILL AND FOR
THE ELDERLY SHOULD BE SET, IT SHOULD BE SET BY GOVERNMENT, WITH
THE FULL AND CREATIVE CONTRIBUTION OF THOSE IN OTHER AGENCIES
AND ORGANIZATIONS, THOSE IN ACADEMIC TEACHING AND RESEARCH, THOSE
IN VOLUNTARY AND UNSALARIED SERVICE, AND THOSE WHO RECEIVE THAT CARE.
WE CAN DO MUCH BETTER FOR OUR ELDERLY. WE MUST OF COURSE
PROTECT THEM FROM INSTITUTIONAL ABUSE, RECOGNIZING THAT SOME
ARE WEAK AND DEPENDENT. BUT WE CAN ALSO MAKE POSSIBLE A WIDE
VARIETY OF SUPPORTING SERVICES AND LIVING ARRANGEMENTS, so THAT
THE INFIRMITIES OF ADVANCING AGE DO NOT BECOME A PRISON OF THE
SPIRIT. THE ELDERLY WITH OUR HELP CAN HAVE ACCESS TO THE VARIETY
AND FREEDOM WE ASK FOR OURSELVES,