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    "label": "Michigan Non-Profit Homes Association Conference, East Lansing, MI, September 13, 1972 (1)",
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{
    "id": "4526445",
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    "contentType": "document",
    "title": "Michigan Non-Profit Homes Association Conference, East Lansing, MI, September 13, 1972 (1)",
    "citationUrl": "https://catalog.archives.gov/id/4526445",
    "collections": [
        "Gerald R. Ford Congressional Papers",
        "Speeches"
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    "subjects": [
        "Health",
        "Legislation",
        "Medicaid",
        "Medicare",
        "Old age"
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        "logicalDate": "1972-09-30",
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    "ocrText": "The original documents are located in Box D33, folder \"Michigan Non-Profit Homes\nAssociation Conference, East Lansing, MI, September 13, 1972 (1)\" of the Ford\nCongressional Papers: Press Secretary and Speech File at the Gerald R. Ford Presidential\nLibrary.\nCopyright Notice\nThe copyright law of the United States (Title 17, United States Code) governs the making of\nphotocopies or other reproductions of copyrighted material. The Council donated to the United\nStates of America his copyrights in all of his unpublished writings in National Archives collections.\nWorks prepared by U.S. Government employees as part of their official duties are in the public\ndomain. The copyrights to materials written by other individuals or organizations are presumed to\nremain with them. If you think any of the information displayed in the PDF is subject to a valid\ncopyright claim, please contact the Gerald R. Ford Presidential Library.\nDigitized from Box D33 of The Ford Congressional Papers: Press Secretary and Speech File at the Gerald R. Ford Presidential Library\nWednesday, September 13, 1972\nSpeech before Michigan Non-Profit Homes Association Conference\nEast Lansing\nKellogg Center\nProblems the Association is concerned about:\n-- Delay by the State Health Department in dealing with\nviolations of profit-making nursing homes. The\nAssociation feels that such violations are unjustly\nassociated with the non-profit homes.\n-- Delay in reimbursement for public assistance patients.\nTopics the Association would like you to talk about:\n-- H. R. 1.\n-- Prospects for health care legislation.\nPaul has more \"background\" info\nif you would like it\nFORD LIBRARI is GENALD\n1st annual convention -\nmich non. Profit Homes assin )\nBangust Sgot 13 at Kallogg Ch,\nmsu, E.Laweing - 6:30 ?\nTwarly 50 nonprofit nursing have\nf homes fn The ageng in State 8 Mich\n\"Motination for Service-\"\n(616) 382-5033\nProb. Areas-\nStands part i. pat care\nState Health Depthas heen lax\nneed upgrading 2 eufore.\nn polo's on viol 1s. Then all\nI printed my The same frush\nI more ha. yr fr- fin stapt\nnon-propt homes are but more\nand togel phllan gift for\npatishate open defects - hand Pelt to get Askst reinibur\nInter in know. what ma be\nGERAFO FORD NEBARY\nhis Using one! 2x reinturse\nsite in H R.1- -\n- \" \" health progs- what\npropertane In legis\nThe Aden 'ns proz, Jupgrading nurs,\nThat assi cando 2 purther\nhomes = We want take a more\naggress role in sgrading stand\nof put care care.\nWhat one H. progo are -\nBuhing Dear up to date an\nBulkare etc.\naccouplish The adm in of ratives.\nHad the asin can help to\nCould Speedatont 10 mins.\n20 min. on legis. 1 Then\ntalking about H Chira -med. fild.\n5/4021\nH.R.I. = incl. a ho. of proms to\nchange in Made and & Medican\nSome will G\narins such as Reis - others heat\nfealth lyi - - Come\ncruh did not Return to if\nlatefall after 4 the\nhald y twasof leavings in\nThis yr The can occupied m\nMentin a no\nother he 3/4 prinity whis.\nhave been advanced to\ncatastrophic then\nH R.1=\nIn Part B. phys. Fees\nThe prem payments Repat make\n/ seris of proposal would min\nI\nWould liferdize for The\nofthe payments\n- Under paces law The pay. mich.\nperiod when hosp. costs you up -\n- Under HRI-R pay. and only go\nup to the export That Sn Sre. burfits\nI goun How. The deducts under Part B\nR.FORD\ns add In The corpous bruef per\nwouldgofy for 850 to 1860\nBERALD\nin inter pt hosp, stay.\nunder Part A united up postal all\nUnder Parth - Leyef pays deduce\nI $60. to ave. cortof hosp stay e us.\nCo. in sun, Legins 1\nrg to 4 3 the\nWhen H R /- co-ins. would hyri\nmg at rate ig H&B\nI 12 de duct. (3/21 then 60 day)\nRen 6/29 day The pres. rate\nTo require offer This would These be dubld calld when lifetere H.R.\n{fn any spall of ilness - covered for\n90 days rx cept that The benef. has\n60 \"ik coveragething use\nonce lifeten - (150 day).\nfor deduct This L, R. They pay 2 of the\nUnder H.R. L The L.R. would G\ndubld 90 days + 120 2/0 days\ntotal =\nUnder thes. know The States make The\npay. under Medicaid.\nUnder HR. 1. in certifies wouldbe\nprov. TO to get the state du make\nlong stays in\nmy in H.M.O. stitutions. t to discount\n= and of discrictions =\n- replax a in ted, medicaid match.\nper b to after 60 care\na Alceled mers the\nwhile 3atim review prog\ncould show it had an effec\n- Rederse of and 1/3 metch after\n- capa /3 in geila Ded. or TB match hap. after\n90 days in a mental hosp-\n- tavai. of lesser provn's\nEmact: dimfor now#\nH.R. 1 bottled up in Sendte 3in-\nhas made many changes # which zh\nThe Welfare provis -\nCam In 14 no -\nit h tant app El when not taken\ne final votaln Don't know future\nlegis til nextyr - long ferry\nno further consid. of health care\ngoing reveir of Medicare,\nout of is very good, mid. a Phono -\nin yound lean toward The\nadmin Plan + plan rather Then Re townedy\nBERALD FORD LIBRARY\nREMARKS TO THE MICHIGAN NONPROFIT HOMES ASSOCIATION CONFERENCE\nProduct\napdoysis\nfor\nDepan\nA\n9/73/72\nnot.\nGOOD EVENING. IT IS A PLEASURE FOR ME TO BE TALKING WITH A GROUP OF PEOPLE\nWHOSE LIVES ARE INSPIRED BY THE MOTTO, \"MOTIVATION FOR SERVICE.\" LET ME SAY AT\nTHE OUTSET THAT I WISH YOU THEN GREATEST OF SUCCESS AT THIS CONFERENCE, AND I HOPE\nTHIS FIRST ANNUAL\nTHAT\nCONFERENCE SETS A PATTERN OF ACCOMPLISHMENT FOR ALL OF YOUR CONFERENCES\nIN YEARS TOEX COME.\nIT IS INTERESTING THAT YOURS SHOULD BE THE FIRST GROUP OF ITS KIND THAT I HAVE\nADDRESSED SINCE RETURNING FROM A NINE-DAY STAY IN THE PEOPLE'S REPUBLIC OF CHINA.\nTHERE THE MONITION YOU SEE E VERWHERE IS THE SLOGAN, \"SERVE THE PEOPLE.\" WHATEVER\nONE FEELS ABOUT COMMUNISM AS A FORM OF GOVERNMENT, ONE CANNOT ARGUE WITH THAT SIOGAN.\nAS A MATTER OF FACT, THOSE WHO OBEY THAT INJUNCTION ARE MUCH TO BE AIMIRED. IN\nAND\nSO IT IS THAT I BELIEVE YOUR GROUP DESERVES A SPECIAL SALUTE AS YOU PAUSE TO LOOK AT\nTHE FIELD IN WHICH YOU SERVE AND CONSIDER HOW YOU MAY BEST IMPROVE XPON UPON YOUR\nACCOMPLISHMENTS.\nTHIS, I THINK, IS WHAT WE NEED TO SOLVE so MANY OF THE NATION'S PROBIEMS.\nSPIRIT OF SERVICE, A\nSPIRIT OF COOPERATION, SUPPORT OF POLICIES WHICH\nPROMOTE THE GOOD OF THE ENTIRE NATION RATHER THAN THAT OF SELFISH PRESSURE GROUPS.\nIT IS IN THAT\nSPIRIT THAT I SPEAK TO YOU TONIGHT.\nI AM AWARE OF YOUR SPECIAL PROBLEMS. I AM TOLD THAT\nDELAY BY THE STATE\nHEALTH DEPARTMENT IN DEALING WITH VIOLATION OF STANDARDS BY THE \"FOR PROFIT\" NURSING\nHOMES RESULTS IN THE NONPROFIT HOMES BEING TARRED WITH THE SAME BRUSH. I AM ALSO TOLD\nTHAT YOU ARE PLAGUED BY DELAY IN REIMBURSEMENT FOR PUBLIC ASSISTANCERTX PATIENTS.\nTONIGHT I WOULD LIKE TO DISCUSS SOME OF THE CHANGES THAT ARE IN THE OFFING IN\nMEDICARE AND MEDICAID AND THE PROSPECTS FOR IMPROVED HEALTH CARE XNSURANCE LEGISIA TION.\n,TOO,\nI WILL\nALSO TOUCH ON MY EXPERIENCES IN CHINA, SINCE THAT MAY\nINTEREST YOU.\nTHE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED IN NURSING HOME CARE\nO VER THE LAST TWENTY YEARS, PARTICULARLY SINCE THE ENACTMENT OF THE ME DIC ARE AND\nMEDICAID PROGRAMS IN 1965. THIS INVOLVEMENT CARRIES WITH IT A RESPONSIBILITY TO\nWHICH\nMEASURES UP To\nASSURE THAT NURSING HOMES DELIVER CARELAT THE VERY LEAST FEDERAL\nSTANDARDS AND REGULATIONS. THE PRE SI DENT ACCEPTED THIS RESPONSIBILITY IN HIS 8-POINT\nPLAN FOR ACTION TO IMPROVE NURSING HOMES ANNOUN_CED JUST OVER A YEAR AGO IN NEW\nHAMPSHIRE.\nTHE PRESIDENT'S AIMS WERE SIMPLE AND DIRECT:\n-UPGRADE LONGTERM CARE FACILITIES:\n-UPGRADE THE WAYS GO VERNMENT AT ALL LEVELS MONITORS\nTHESE FACILITIES:\n-UPGRADE CHANNELS OF COMMUNICATION BETWEEN THE PATIENT, HIS FAMILY, THE NURSING\nHOME AND GOVERNMENT AGENCIES CONCERNED WITH LONGTERM CARE:\n--2--\n--UPGRADE THE CAPABILITY AND CONSCIOUSNESS OF LONGTERM CARE PERSONNEL:\n--AND, MOST IMPORTANT OF ALL, UPGRADE OUR UNDERSTANDING OF LONGTERM CARE\nFACILITIES. ,LEARN WHAT THEY CAN AND CANNOT DO, AND CONSIDERX WHAT ALTERNATIVE\nMODES AND LEVELS OF CARE MIGHT BE DEVELOPED TO ENSURE OUR OLDER CITIZENS THAT THE\nRIGHT CARE, AT THE RIGHT TIME, AT THE RIGHT PLACE, AND AT THE RIGHT COST WILL BE\nTHERE.\nNOW THIS MAY SOUNDEX LIKE X A LOT OFF UPGRADING AND IT IS. IT HAS BEEN, AND\nIS GOING TO BE, AN UPGRADE BATTLE ALL THE WAY. NOT BECAUSE NO ONE IN THE NURSING\nHOME INDUSTRY OR IN THE GOVERNMENT OR AMONG THE PUBLIC HAS 1 CARED IN THE PAST, BUT\nBECAUSE UNTIL X VERY RECENTLY THERE HAVE NOT BEEN ENOUGH OF THSEX THESE VERY ESSENTIAL\nACTORS ON THELONGTERN CARE STAGE TO CREATE AND MAINTAIN A SYSTEM OF QUALITY THAT OUR\nPEOPLE DEMAND.\nIT WAS TO FULFILL THIS DEMAND THAT THE PRESIDENTE ORDERED THE FEDERAL GOVERNMENT\nTO MOVE BOLDLY AND RAPIDLY ALONG SEVERAL FRONTS. THE EFFECTIVENESS OF THAT ACTION IS\nALREADY BEING FELT.\nWE HAVE SEEN A MARKED IMPROVEMENT IN THE QUALITY OF STATE MEDICAID CERTIFICATION\nPROHRAMS SINCE LAST NOVEMBER WHEN WE FOUND NO FEWER THAN 39 STATES WITH MAJOR\nDEFICIENCIES, TODAY WE CAN BE REASONABLY CONFIDENT THAT EVERY STATE HAS A SOUND XNDX\nSURVEY AND CERTIFICATION PROGRAM. AND THE ADMINISTRATION INTENDS TO CONTINUE TO\nMONITOR THESE PROGRAMS TO MAKE SURE THEY STAY THAT WAY.\nTHE OBJECTIVE OF THIS FEDERAL EFFORT IS THREE-FOLD:\n--TO SERVE NOTICE ON THE STATES THAT FEDERAL STANDARDS ARE TO BE FOLLOWED.\nLETTER;\n--TO SERVE NOTICE ON THE INDIVIDUAL NURSING HOME OPERATOR THAT THE FEDERAL\nPORTION OF HIS PATIENT CARE DOILAR IS GOING TO BE PAID ONLY IF THAT PATIENT IS\nRECEIVING THE QUALITY OF CARE HE OR SHE IS ENTITLED TO;\n--AND, THIRD, TO A SSURE THE INDIVIDUAL PATIENT THAT THE FULL BURDEN OF RESPONSIBILITY\nFOR THE QUALITY AND SAFETY OF HIS OR HER CARE ISNAM NOW TO BE BORNE SQUARELY BY THE\nFEDERAL, STATE ANDKE LOCAL GOVERNMENT AGENCIES SUPERVISING THAT CARE AND BY THE NURSING\nHOME PROVIDING THE SERVICES.\nTHE ADMINISTRATION BELIEVES THESE PURPOSES ARE BEING MET.\nTHE AIMINISTRATION IS ALSO MAKING PROGRESS ON SEVERAL OTHER FRONTS OF THE\nFEDERAL LONGTERM CARE PROGRAM.\nTHERE IS THE PUBLICATION OF FEDERAL MEDICAID STANDARDS FOR INTERNEDIATE CARE\nFACILIT IES WHICH ARE TO BE IMPLEMENTED IN THE FALL.\nTHERE IS THE DEVELOPMENT OF JOINT MEDICARE-MEDICAID NURSING HOME STANDARDS WHICH\nWILL COORDINATE ANDEXER XXXXXX SIMPLIFY VIRTUAL LY ALL COMPLEMENTARY ASPECTS OF THESE\nPROGRAMS.\n-3-\nXEHRE THERE ARE THE H.E.W. TRAINING PROGRAMS, WHICH HAVE NOW REACHED MORE THAN\n700 OF THE 1100 STATE MEDICAID NURSING HOME INSPECTORS IN THE FIELD WITH UNIVERSITY-\nBASED TRAINING COURSES. MAY I INTERJECT AT THIS POINT THAT I HOPE CONGRESS ACTS ON\nTHE PRESIDENT'S PROPOSAL THAT THE FEDERAL GOVERNMENT A SSUME THE FULL COSTS OF STATE\nMEDICAID NURSING HOME INSPECTION PROGRAMS.\nAND, FINALLY, H.E.W.'S TRAINING PROGRAMS NURSING HOME PERSONNEL\nARE MOVING ALONG RAPIDLY.\nJet mr add- impection is important but of\nimpection is not fair of Instruct you At mm how. 2 will not contone nith picters on\nLET ME TURN NOW TO H.R. kg 1, THE AIMINISTRATION'S WELFARE REFORM BILL, WHICH\nCONTAINS MANY PROVISIONS IMPORTANT TO OLDER AMERICANS AND ALL THOSE ENTRUSTED WITH\nTHEIR CARE.\nAS YOU MAY KNOW, H.R. 1 PASSED THE HOUSE MORE THAN A YEAR AGO AND IS STUCK IN THE\nSENATE WELF ARE COMMITTEE. H.R. 1 IS TOP PRIORITY LEGISLATION. CONGRESS WILL HAVE\nFAILED DISGRACEFULLY IN ITS RESPONSIBILITY TO THE NATION IF THIS LEGISLATION IS NOT\nENACTED THISXXEXXX BEFORE CONGRESS ADJOURNS FOR THEYE YEAR.\nH.R. 1 Is IS A COMPLICATED BIIL. ITS PROVISIONS RANGE FROMKEXERAK FEDERAL MATCHING\nFOR MECHANIZED CLAIMS PROCESSING XXX UNDER MEDICAID TO AUTHORITY TO EXPERIMENT WITH\nALTERNATIVE MEDICARE REIMBURSEMENT FORMULAS INTENDED TO PROMOTE ECONOMY AND EFFICIENCY.\nLET ME BRIEFLY DISCUSS HOUSE-APPROVED CHANGES IN THE MEDICARE PROGRAM WHICH SHOULD\nBE OF INTEREST TO YOU.\nONE CHANGE IN MEDICARE CO VERAGE EXTENDS PROTECTION TO THE DISABIED AFTER THEY\nHAVE BEEN RECEIVING SOCIAL SECURITY CASH BENEFITS FOR A PERIOD OF TWO YEARS. THIS MEETS\nA REALBEK NEED IN A MANNER CONSISTENT WITH CAREFUL CONTROL OF MEDICARE COSTS.\nTHE HOU SE ALSO VOTED ТОЕЖХХ CHANGE THE DEDUCTIBELE AND PREMIUM PAYMENT FORMUKLA\nUNDER MEDICARE 'PART B' AND MADE A CHANGE IN THE COINSURANCE PAYMENT FORXM INPATIENT\nHOREXTXX HOSPITAL BENEFITS UNDER 'PART A.'\nUNDER EXISTING LAW, THE PREMIUM A PATIENT PAYS UNDER 'PART B' GOES UP PERIODICALLY\nAS HOSPITAL COSTS GO UP. UNDER H.R. 1, THIS PREMIUM COULD BE INCREASED ONLY TO THE\nEXTENT THAT SOCIAL SECURITY BENEFITS ARE INCREASED. SINCE HEALTH CARE COSTS HAVE\nBEEN RI SING FASTER THAN ANY OTHER COST ITEM IN THE ECONOMY, THIS PROVISION SHOULD BE\nOF SUBSTANTIAL ASSISTANCE TO THE ELDERLY AND DISABLED.\nHOWEVER, H.R. 1 ALSO MEDATES INCREASES THE ANNUAL DEDUCTIBLE UNDER 'PART B' FROM\n$50 TO $60. TH IS DEDUCTIBLE NXXX HAS NOT BEEN INCREASED SINCE THE PROGRAM FIRST WAS\nENACTED IN 1965, ALTHOUGH COSTS OF COVERED SERVICES HAVE INCREASED SHARPLY.\nADDITIONALLY, THE CO INSU RANCE A BENEFICIARY PAYS UNDER 'PART A' WOULD BE IMPOSED\nAT AN EARLIER POINT IN HIS HOSPITAL STAY. UNDER PRESENT LAW, COINSURANCE PAYMENTS\nBEGIN ON THE 61ST DAY OF THE MSX HOSPITAL STAY AND IS EQUIVALENT TO ONE-FOURTH OF THE\nDEDUCTIBELE . UNDER H.R. 1, THE COINSURANCE PAYMENTS WOULD HAVE TO BEGIN WITH THE\n-4-\n31ST DAY BUT XXT AT A RATE EXTXAXEXXX EQUIVALENT TO ONE-EIGHTH OF THED DEDUCTIBLE.\nTHIS WOULD APPLY FROM THE 31ST THROUGH THE 60TH DAY, WHEN THE PRESENT RATE ONCE\nMORE WOULD TAKE EFFECT.\nTO OFFSET THIS INCREASE IN CO INSURANCE PAYMENTS, THE HOUSE DOUBLED THE SO-CALLED\nLIFETIME RESERVE UNDER H.R. 1.\nUNDER PRESENT LAW, A BENEFICIARY IS COVERED FOR 90 DAYS OF HOSPIT ALIZATION IN\nEVERY & 'SPELL OFIE ILLNESS' AND HAS ACCESS TO 60 ADDITIONAL DAYS ON A ONCE-IN-A-LIFETIME\nBASIS. UNDER H.R. 1, ANOTHER NONRENEWABLE 60 DAYS WOULD BE ADDED. THIS GIVES THE\nBENEFICIAIRY A ONE-TIME MAXIUMUM HOSPITALIZATIONE COVERAGE OF 210 DAYS INSTEAD OF THE\nEXISTING 150 DAYS.\nI AM HOPEFUL THAT THE SE CHANGES WILL IMPRO VE THE EFFICIENCY OF THE MEDICARE\nPROGRAM WHILE PROVIDING OUR ELDERLY WITH A MEASURE OF FISCAL RELIEF.\nSINCE WE ARE TALKINGXMER TONIGHT ABOUT THE HEALTH PROBLEMS OF OLDER AMERICANS,\nAND WHAT ALL OF US CAN DO TO HELP RESOLVE THEM, IT SEEMS PRIATE TO QUOTE FROM\nTHE AMERICAN WRITER AMBROSE BIERCE, WHOSE XMX OWN SPECIAL PROBLEM SEEMS TO HAVE BEEN\nA CHRONIC BAD NOX MOOD.\nSAID BIERCE, 'RESPONSIBILITY IS A DETACHABLE BURDEN EASILYXREKKECTEXXKE SHIFTED\nFROM ONE'S OWN SHOULDERS TO THOSE OF GOD, FATE, FORTUNE, LUCK....OR ONE'S XXXXX\nNEIGHBOR.'\nI HAVE JUDGED FROM THE THEME OF THIS CONFERENCE THAT NO ONE LISTENING TO ME\nTHE TONIGHT NEEDS TO BE REMINEDED OF HIS OR HER SHARE OF RESPONSIBILITY FOR LONGTERM\nCARE IN MICHIGAN. AND I SENSE FROM THE SPIIRT OF RESPONSIBILITY IMPLICIT IN YOUR\nCONFERENCEIN AGENDA THAT IF THERE IS ANY SHIFTING OF THAT BURDEN, IT WILL BE TO\nTAKE EVEN MORE OF IT UPON YOUR OWN NX SHULDERS.\nONE COMMENT NOW ABOUT MEDICAIDI. AS YOU KNOW, THE STATES MAKE THE PAYMENTEZI\nMNXER MEDICAID PAYMENTS UNDER EXISTING LAW.\nUNDER H.R. 1, INX INCENTIVES AREXAM PROVIDED TO GET THE STATES TEX TO MAKE\nCONTRACTS WITH HEALTH MAINTENENCE ORGANIZATIONS AND TO DISCOURAGE LONG STAYS IN\nINSTITUTIONS. ONE OF THE DISINCENTIVES IS A REDUCTION IN FEDERAL MEDICAID MA TCHING\nBY ONE-THIRD AFTER 60 DAYS OF CARE IN A SKILIED NURSING HOME. UNLESS THE STATE CAN\nSHOW IT HAS AN EFFECTIVE UTILIZATION REVIEW PROGRAM. THERE WOULD BE A REDUCTION\nOF THE ONE-THIRD MA TCHING AFTER 60 DAYS IN A GENERAL OR TUBERCULOSIS HOSPITAL AND\nA DECREASE BY ONE-THIRD IN E FEDERAL MATCHING AFTER 90 DAYS IN A MENTAL HOSPITAL.\nAS YOU MAY HAVE HEARD, PROSPECTS FORE XEM KN SENATE PASSAGE OF H.R. 1x THIS YEAR\nAPPEAR DIM. IT HAS BEEN BOTTLED UP IN THE SENATE FINANCE COMMITTEE FOR 14 MONTHS NOW.\nHEALTH CARE LEGISLATION IS DEFINITELY ADMITTER A 1973 ACTION ITEM. THE HOUSE\nWAYS AND MEANS COMMITTEE HELD 41 ISI WEEKS OF HEARINGS ON IT TRASXXEXX IN THE LATE FALL\n-5-\nOF 1971 AND THEN LAID IT ASIDE TO DEAL WITH OTHER MATTERS. THEOD COMMITTEE DID NOT\nRETURN TO IT THIS YEAR. MEANTIME A NUMBER OF NEW PROPOSALS HAVE BEEN ADVANCED,\nTHE NEXT\nDEALING WITH CATASTROPHIC ILLNESS. MY PREDICTION IS THAT/CONGRESS WILL PASS HEALTH\nCARE LEGISLATION AND THAT IT WILL RESEMBLE MOST CLOSELY THE ADMINISTRATION PRO POSALS\nIN THIS FIELD. BUILDING ON THE PRESENT HEALTH INSURANCE SYSTEM RATHER THAN\nFEDERALIZING HEALTH CARE. SO THE LONGTERM OUTLOOK IS VERY GOOD, INCLUDING A\nTHEOROUGH-GOING REVIEW OF MEDICARE.\nSINCE WE ARE TALKING TONIGHT ABOUT THE HEALTH PROBLEMS OF OLDER AMERICANS,\nIT SEEMS APPROPRIATE TO QUOTE FROM THE AMERICAN WRITER AMBROSE BIERCE, A ONE-TIME\nOLDER AMERICAN WHOSE OWN SPECIAL PROBLEM X SEEMS TO EXXXXXX HAVE BEEN A CHRONIC BAD\nMOO D.\nSAID BIERCE, 'RESPONSIBILITY IS A DETACHABLE BURDEN EASILY SHIFTED FROM ONE'S\nOWN SHOULDERS TO THOSE OF GOD, FATE, FORTUNE, LUCK...OR ONE'S NEIGHBOR.'\nI HAVE ALREADY JUDGED FROM THE EXX THEME OF THIS CONFERENCE THAT NO ONE LISTENING\nTO ME TONIGHT NEEDS TO BE REMINDED OF HIS OR HER SHARE OF RESPONSIBILITY FOR LONGTERM\nCARE IN MICHIGAN. AND I SENSE FROM THE SPIRIT OF RESPONSIBILITY IMPLICIT IN YOUR\nCONFEREENCE AGEN DA THAT IF THERE IS ANY SHIFTING OF THAT BURIEN, IT WILL BETX TO TAKE\nEVEN MORE OF IT UPON YOUR OWN SHOULDERS.\nX I WOULD LIKE TO NET MENTION AT THIS POINT THAT THE QUALITY OF ANY CIVILIZATION\nCAN BE MEASURED BY THE ATTITUDE OF THE PEOPLE TOWARD THE ELDERLY IN THEIR MIDST. I\nTHINK IT IS NO ACCIDENT THAT ERINKX THE XXXX INCIDENCE OF CRIME HAS ALWAYS BEEN LOW\nIN SOCIETIES WHICH HAVE GREAT REVERENCE FOR FAMILY TIES. MX AND IT SHOULD ALSO BE\nREMARKE D THAT THE SE SAMEXX SOCIETIES THE ME JEWISH AND CHINESE, FOR INSTANCE. HAVE\nALSO HAD GREAT REVERENCE FOR THE ELDERLY IN THEIR MEXX MIDST.\nTHIS REVERENCE FOR AGE CONTINUES IN THE NEW CHINA, AS IN THERED OLD.\nIT MAY BE OF SOME INTEREST TO YOU THAT PEOPLE RETIRE EARLIER IN COMMUNIST CHINA\nTHAN IN THE UNITED STATES. FOR WOMEN THE RETIREMENT AGE IS 55; FOR THE MEN, 60.\nHEALTH CARE IS A TOP PRIORITY IN COMMUNIST CHINA. THIS IS REFLECTED IN\nCREASH PROGRAMS FOR THE TRAINING OF DOCTORS AND NURSES. THE TRAINING PERIOD FOR\nDOCTORS HAS BEEN CUT IN HALF FROM SIX YEARS TO THREE. NURSE\nTRAINING X HAS ALSO BEEN SLICED IN HALF FROM THREE YEARS TO 1½0 AT THE SAME TIME,\nTHE их CHINESE HAVE BEEN TURNING OUT THOUSANDS OF MEDICAL CORPSMEN KNOWN AS 'BAREFOOT\nDOCTORS' WHO ARE SENT OUT INTO THE COUNTRYSIDE TO PROVIDE THE RUDIMENTS OF MEDICAL\nCARE XNXTMXX MAJOR CASES, OR COURSE, ARE SENT TO THE HOSPITALS.\nONLY A FEW YEARS AGO, NO MODERN MEDICAL CARE TO SPEAK OF WAS AVAILABLE TO THE\nLIBRAR\nGREAT PREPONDERANCE OF CHINA'S INHABITENTS. NOW SOMEKX KIND OFCARK CARE IS PROVIDED\nTO EVERY CHINESE IN NEED OF MEDICAL ATTENTION. IN MORE REMOTE REGIONS, IT MAY BE\nELEMENTAL, BUT IT IS AVAILABLE. THERE IS NO CHARGE FOR MEDICAL CARE TO WORKERS IN THE\nCITIES BUT EACH FAMILY XX IN THE COMMUNES PAYS ABOUT 4 CENTS PER MONTH FOR MEDICAL\nSERVICES.\nTHERE IS HERVY EMPHASIS ON PERSONAL CLEANLINESS IN CHINA. AS A RESULT, EPIDEMIC\nAND INTENSTINAL AILMENTS HAVE BEEN SHARPLY REDUCED. THE PEOPLE HA VE BEEN REPEATEDLY\nMOBILIZED TO ERADICATE DISEASE*CARRYING SNAILS, FLIES AND MOSQUITOES.\nSOME OF THE CHINESE HEALTH TECHNIQUES WOULD HAVE EXCHANGE VALUE FOR THIS UNITED\nSTATES. so, TOO, WX DOES THE USE OF ACUPUNCTURE AS ANESTHESIA IN OPERATIONS.\nI WITNESSED THREE OPERATIONS IN PEKING IN WHICH ACUPUNCTURE ANESTHESIA WI WAS\nUSED. so I KNOW THAT IT XX WORKS.\nDR. FREEMAN CARY, A XMXX PHYSICIAN WHO ACCOMPANIED CONGRESSMAN HALE BOGGSTN AND\nME AND OUR PARTY TO CHINA, PREDICTS THAT ACUPUNCTURE ANESTHEXSIA WILLIBE EXTENSIVELY\nXXEEXXXX USED IN THE UNITED STATES WIXHXX WITHIN A YEARXORT OR TWO.\nTHERE ARE STILL MANY HEALTH CARE SHOR TCOMINGS IN CHINA, BOTH IN THE QUALITY OF\nCARE AND IN THE NUMBER AND QUALITY OF FACILITIES AVAILABLE TO THE FEPX PEOPIE. BUT\nTHE CHINESE HAVE MADE TREMENDOUS ADVANCES.\nMEDICINE IN CHINA IS HEAVILY MIXED WITH IDEOLOGY. WHEN THE COMMUNISTS FIRST\nTOOK OVER IN 1949, THE EMPHASIS WAS ON PROVIDING HEALTH CARE IN THE CITIES, THE\nCENTERS OF HEAVY INDUSTRY. AND THE PROFESSORS RAN THE MEDICAL SCHOOLS.\nWITH THE ERUPTION OF THE CULTURAL REVOLUTION IN 1966 AND IN THE YEARS THAT\nFOLLOWED, REVOLUTIONARY COMMITTEES WERE SET UP TO RUN THE MEDICAL SCHOOLS, PROGRAMS\nWERE LAUNCHED TO GREATLY EXPAND MEDICALMX MANPOWER, AND THE EMPHASIS IN HEALTH CARE\nSHIFTED TO THE RURAL AREAS.\nALL IS IN KEEPING WITH THE TEACHINGS OF CHAIRMAN MAO. BUT THIS MUCH MSXTX MUST\nBE SAID. HEALTH CARE IN CHINA HAS BEEN REVOLUTIONIZED.. AND VERY MUCH FOR THE BETTER.\nMAO'S FAVORITE SLOGAN IS A GOOD SLOGAN IN ANY COUNTRY--'SERVE THE PEOPLE.'\n#######\nTHE FEDERAL PROGRAM FOR LONG-TERM CARE\nMARIE CALLENDER\nSPECIAL ASSISTANT FOR NURSING HOME AFFAIRS\nTHIS SEMINAR IS DESIGNED TO INCREASE CONSULTANT SKILLS,\nAND YOU HAVE BEEN ENGAGED IN THE DISCUSSION OF MANY ASPECTS\nOF INSTITUTIONAL CARE AND THE REGULATIONS THAT GOVERN IT.\nI WOULD LIKE TO STEP BACK FROM THOSE SPECIFICS AND DESCRIBE\nTO YOU SOME OF THE PROBLEMS IN NURSING HOME CARE, THE SCOPE\nnursing home\nOF THE PRESIDENT'S COMMITTMENT TO SOLVE THOSE PROBLEMS, AND\nSOME FUTURE CONSIDERATIONS WHICH WE ARE STUDYING, I THINK\nTHIS DESCRIPTION WILL EMPHASIZE THE IMPORTANCE AND THE HIGH\nPRIORITY OF THE TASK IN WHICH WE ARE ENGAGED.\nTHE QUALITY OF ANY CIVILIZATION CAN BE MEASURED BY THE\nATTITUDE OF THE PEOPLE TOWARD THE ELDERLY IN THEIR MIDST.\nTHEIR VALUE ECONOMICALLY IS EBBING OR IS AT AN END. THEY RE-\nQUIRE A DISPROPORTIONATE SHARE OF MEDICAL AND SOCIAL SERVICES,\nIN SOME EARLIER CULTURES THEY WERE CUT OFF FROM THE TRIBE AND\nFORCED TO WANDER WITHOUT FOOD OR SHELTER UNTIL THEY DIED.\nMOST OF US LOOK WITH REVULSION AT SUCH SOCIAL PATTERNS, AND\nACCEPT THE MORAL RESPONSIBILITY OF OUR SOCIETY TOWARD ITS\nELDERLY\nTo BE PRESENTED AT THE SEMINAR FOR CONSULTANTS, SPONSORED\nJOINTLY CHS AND BHI, SSA OF REGION 1X, AT SANTA INEZ INN,\nPACIFIC PALLISADES, CALIFORNIA, MONDAY, MARCH 22, 1972,\nLIGHTS\n2\n2\nTHE MAJORITY OF THOSE OVER SIXTY-FIVE ARE ABLE TO LEAD\nACTIVIE, INDEPENDENT LIVES CONTRIBUTING VIGOROUSLY TO OUR\nNATIONAL LIFE. HOWEVER, ALMOST A MILLION OF OUR TWENTY-MILLION\nPERSONS OVER SIXTY-FIVE REQUIRE THE CARE AND SUPPORT OF NURSING\nHOMES, AND IT IS THESE WHOSE DEPENDENCE MOST ACUTELY TESTS THE\nQUALITY OF OUR COMPASSION AND SENSE OF HUMANITY,\nTHE PRESIDENT HAS APTLY STATED THAT, \"FOR THOSE WHO NEED THEM,\nTHE NURSING HOMES OF AMERICA SHOULD BE SHINING SYMBOLS OF CONFORT\nAND CONCERN.\" MANY OF OUR NURSING HOMES MEET THIS STANDARD. OTHERS\nDO NOT, AS TESTIFIED BY RECENT SHOCKING AND TRAGIC NURSING HOME\nFIRES, AND LESS DRAMATICALLY BY PRIVATE AND GOVERNMENT STUDIES. IN\nMAY, 1971, THE GENERAL ACCOUNTING OFFICE ISSUED A REPORT ON THE EN-\nFORCEMENT OF MEDICAID AND MEDICARE STANDARDS IN NINETY NURSING HOMES IN\nOKLAHOMA, NEW YORK, AND MICHIGAN, SERIOUS DEFICIENCIES WERE FOUND\nIN MORE THAN 50 PERCENT OF THESE HOMES, ALL OF WHICH HAD MEDICAID\nPATIENTS AND MANY OF WHICH WERE APPROVED FOR MEDICARE. ON NOVEMBER\n30, 1971, SECRETARY RICHARDSON ANNOUNCED THAT 39 STATES WERE OUT\nOF COMPLIANCE WITH TITLE 19 CERTIFICATION PROCEDURES, IN HUMAN TERMS,\nTHESE STUDIES MEAN THAT MANY NURSING HOMES WHICH FAIL TO MEET\nSTANDARDS ARE UNSANITARY AND UNSAFE, OVERCROWDED AND UNDERSTAFFED--\nLONELY AND DEPRESSING PLACES FOR THE ELDERLY TO LIVE AND DIE.\n3\nTHE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED\nIN NURSING HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY\nSINCE THE ENACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN\n1965. IN 1970 THE FEDERAL GOVERNMENT SPENT OVER $2 BILLION\nIN SUPPORT OF NURSING HOME PATIENTS, WHILE STATE AND LOCAL\nGOVERNMENTS SPENT ANOTHER $700 MILLION, THIS INVOLVEMENT\nCARRIES WITH IT A RESPONSIBILITY TO ASSURE THAT NURSING HOMES\nDELIVER CARE AT LEAST AT THE LEVELS OF FEDERAL STANDARDS AND\nREGULATIONS. THE PRESIDENT ACCEPTED THIS RESPONSIBILITY IN\nHIS 8-POINT PLAN FOR ACTION TO IMPROVE NURSING HOMES ANNOUNCED\nLAST AUGUST IN NEW HAMPSHIRE.\nA MAJOR GOAL OF THE PLAN IS TO IMPROVE FEDERAL ENFORCE-\nMENT OF NURSING HOME STANDARDS, As YOU KNOW, THE TERM \"NURSING\nHOME\" IS APPLIED TO A WIDE RANGE OF FACILITIES, FROM THOSE PRO-\nVIDING PRIMARILY CUSTODIAL CARE TO THOSE DELIVERING HIGHLY SKILLED\nPOST-HOSPITAL AND REHABILITATIVE SERVICES. THESE DIFFERENT TYPES\nOF FACILITIES ARE ACCREDITED THROUGH DIFFERENT MECHANISMS, AND\nFEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES WIDELY, MEDICARE\nCERTIFICATION OF EXTENDED CARE FACILITIES IS A FEDERAL PROGRAM\nMEDIATED THROUGH STATE SURVEY AGENCIES, MEDICAID IS A FEDERAL-\nSTATE PROGRAM, FINANCED AND ADMINISTERED THROUGH BOTH FEDERAL\nAND STATE FUNDS AND ACTIVITIES. INTERMEDIATE CARE FACILITIES\nformarly\nUNTIL RECENTLY WERE REQUIRED TO MEET ONLY STATE LICENSING RE-\nQUIREMENTS TO RECEIVE FEDERAL FUNDS. THESE DIFFERENCES HAVE COM-\nPLICATED THE ENFORCEMENT OF STANDARDS, HOWEVER, BOTH MEDICARE\n4\nAND MEDICAID HAVE TRADITIONALLY AND STATUTORILY RELIED ON\nSTATE AGENCY INSPECTION OF FACILITIES, AND THE PRESIDENT HAS\nCHOSEN TO RETAIN THIS EMPHASIS ON THE ROLE OF THE STATE AGENCY,\nWE BELIEVE THIS APPROACH IS CONSISTENT WITH A HEALTHY FEDERAL-\nSTATE RELATIONSHIP AND AVOIDS UNNECESSARY EXPANSION OF THE\nFEDERAL BUREAUCRACY. BUT THE FEDERAL GOVERNMENT WHICH IS RE-\nSPONSIBLE FOR THE QUALITY OF CARE Wilson IT FINANCES MUST AID\nIN ENHANCING THE CAPABILITY OF THE STATE AGENCIES TO REGULATE\nAND IMPROVE THE QUALITY OF NURSING HOME CARE, To IMPROVE EN-\nFORCEMENT OF NURSING HOME STANDARDS, THE PRESIDENT'S PLAN\nPLEDGED THE FOLLOWING STEPS:\n1. CONSOLIDATION OF RESPONSIBILITY FOR NURSING HOME\nAFFAIRS, NURSING HOME ACTIVITIES HAVE BEEN SCATTERED AMONG\nSEVERAL BRANCHES OF THE DEPARTMENT OF HEW, INCLUDING THE\nSOCIAL SECURITY ADMINISTRATION, THE SOCIAL AND REHABILITATION\nSERVICE, AND THE HEALTH SERVICE AND MENTAL HEALTH ADMINISTRATION.\nTHE PRESIDENT ORDERED THAT ALL FEDERAL ENFORCEMENT RESPONSIBILITY\nBE CONSOLIDATED IN A SINGLE OFFICE, AND DR. MERLIN K. DUVAL,\nTHE ASSISTANT SECRETARY OF HEALTH AND SCIENTIFIC AFFAIRS, WAS\nDESIGNATED AS THE RESPONSIBLE OFFICIAL. DR. DUVAL APPOINTED ME\nTO WORK WITH HIM ON THESE ACTIVITIES AND TO FUNCTION AS A FULL\nTIME COORDINATOR OF NURSING HOME ACTIVITIES.\n5\n2. ENLARGEMENT OF FEDERAL STAFF FOR ENFORCEMENT OF\nNURSING HOME STANDARDS, THE SOCIAL AND REHABILITATION\nSERVICE, WHICH ADMINISTERS THE MEDICAID PROGRAM, HAS BEEN\nASSIGNED 142 ADDITIONAL POSITIONS TO CARRY OUT ITS INCREASED\nRESPONSIBILITIES. ONE HUNDRED TEN OF THESE POSITIONS WERE\nALLOCATED TO THE REGIONAL OFFICES OF HEW. THE SOCIAL SECURITY\nADMINISTRATION RECEIVED EIGHT NEW POSITIONS, AND HEW's AUDIT\nAGENCY RECEIVED THIRTY-FOUR ADDITIONAL POSITIONS TO INCREASE THE\nTHEIR AUDITS OF NURSING HOME OPERATIONS, THE NATIONAL CENTER\nFOR HEALTH SERVICES RESEARCH AND DEVELOPMENT RECEIVED SEVEN\nNEW POSITIONS FOR EFFORTS TO IMPROVE NURSING HOME DATA SYSTEMS\nAND TO DEVELOP DATA IN SPECIAL FIELDS RELEVANT TO NURSING\nHOME CARE.\n3. FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID\nINSPECTIONS. WE RECOGNIZE THAT AN INCREASED LEVEL OF EN-\nFORCEMENT ACTIVITY INVOLVES ADDITIONAL COSTS TO THE STATES.\nMEDICARE INSPECTION COSTS HAVE ALWAYS BEEN FULLY PAID FOR BY\nTHE FEDERAL GOVERNMENT, BUT UNDER THE MEDICAID PROGRAM STATES\nHAVE PAID 25 TO 50 PERCENT OF THESE COSTS. SECRETARY\nRICHARDSON SUBMITTED TO CONGRESS IN OCTOBER, 1971, AN AMEND-\nMENT TO H.R.I. AUTHORIZING THE FEDERAL GOVERNMENT TO ASSUME\n100 PERCENT OF INSPECTION COSTS UNDER MEDICAID; THIS STEP WILL\n6\nPLACE BOTH PROGRAMS ON AN EQUAL FOOTING AND LESSEN THE\nFINANCIAL BURDEN TO THE STATES.\n4. TRAINING STATE NURSING HOME INSPECTORS, NURSING\nHOME SURVEYORS HAVE BEEN TRAINED IN SURVEY AND COUNSELLING\nTECHNIQUES UNDER A PROGRAM SPONSORED BY THE HEALTH SERVICES\nAND MENTAL HEALTH ADMINISTRATION SINCE MARCH, 1970. SOME -\nyou HAVE ATTENDED THESE COURSE IN HIS AUGUST SPEECH, THE\nPRESIDENT PLEDGED AN EXPANSION OF THIS PROGRAM so THAT 2,000\nan\nSURVEYORS WOULD BE TRAINED IN THE ENSUING EIGHTEEN MONTH\nPERIOD. As A RESULT OF THE PRESIDENT'S ORDER, THE PROGRAM HAS\nBEEN ACCELERATED so THAT 475 SURVEYORS HAVE NOW BEEN TRAINED\nCONTRACT NEGOTIATIONS ARE IN PROCESS TO ESTABLISH THREE\nADDITIONAL UNIVERSITY CENTERS IN ADDITION, A STUDY WAS PER-\nFORMED BY MACRO SYSTEMS, INC., TO EVALUATE THE EFFECTIVENESS\nOF THE TRAINING COURSES, AND THESE HAVE NOW BEEN MODIFIED TO\nREFLECT THE RESULTS OF THAT STUDY,\nTHESE EFFORTS TO ACHIEVE COMPLIANCE WITH FEDERAL STANDARDS\nAND REGULATIONS ARE NOT DESIGNED TO ELIMINATE FACILITIES AND\nTHUS TO DEPRIVE PATIENTS OF NEEDED NURSING HOME CARE. WE ARE\nWORKING RATHER TO COORDINATE FEDERAL AND STATE PROGRAMS AND\nSTATE AGENCIES TO SHARE THEIR RESOURCES AND EXPERTISE so THAT\nSUBSTANDARD FACILITIES CAN BE UPGRADED, THE FEDERAL PROGRAM\n7\nTO TRAIN NURSING HOME SURVEYORS, FOR EXAMPLE, EMPHASIZES\nTHE DEVELOPMENT OF SKILLS TO AID NURSING HOME ADMINISTRA-\nTORS IN MAKING NEEDED IMPROVEMENTS. FEDERAL FINANCIAL\nASSISTANCE IS AVAILABLE FOR NURSING HOME MODERNIZATION\nAND NEW CONSTRUCTION FROM THE FEDERAL HOUSING ADMINISTRA-\nTION AND SUCH PROGRAMS AS HILL BURTON, THE STANDARDS THEM-\nSELVES ARE BEING REVISED AND STRENGTHENED. WE ARE DEVELOPING\nPROGRAMS TO IMPROVE NURSING HOMES DIRECTLY- SHALL DESCRIBE\nTHEM IN A FEW MOMENTS\nBUT AS THE PRESIDENT WARNED LAST CUCUST,\n...\nLET THERE\nBE NO MISTAKING THE FACT THAT WHEN FACILITIÉS FAIL TO MEET\nREASONABLE STANDARDS, WE WILL NOT HESITATE TO CUT OFF THEIR\nMEDICARE AND MEDICAID FUNDS.\" BE TWEEN AUGUST haveneer 6, 1971, AND Anong\nFEBRUARY 11, 1972, 13 EXTENDED CARE FACILITIES WERE DECERTI-\nFIED FOR MEDICARE PARTICIPATION. ON NOVEMBER 30, 1971, THIRTY-\nNINE STATES WERE DECLARED OUT OF COMPLIANCE WITH TITLE 19-\nMEDICAID--CERTIFICATION PROCEDURES, By FEBRUARY 1, 1972 IN\nRESPONSE TO SECRETARY RICHARDSON'S DEADLINE, ALL BUT ONE OF\nTHOSE STATES HAD MADE THE IMPROVEMENTS REQUIRED FOR COMPLIANCE,\nBY JULY 1 1972, ALL TITLE 19 FACILITIES IN ALL STATES ARE TO\nHAVE BEEN INSPECTED AND CERTIFIED THROUGH THE CORRECT PROCEDURES,\nTHE FEDERAL GOVERNMENT IS PLEDGED TO MEET ITS RESPONSIBILITY\nTO ASSURE THAT FEDERAL DOLLARS DO. NOT FINANCE SUBSTANDARD CARE.\n8\nWHILE WE ARE ENGAGED IN THIS MASSIVE ENFORCEMENT EFFORT,\nAND WHILE WE ARE CAUGHT UP IN THE RUSH TO MEET THE JULY 1\nDEADLINE, I THINK WE MUST RETAIN A SENSE OF PROPORTION IN\nRECOGNIZING ALL THE THINGS FEDERAL REGULATIONS CANNOT DO\nTO AFFECT THE QUALITY OF NURSING HOME CARE. THESE LIMITATIONS\nCAST A SPECIAL LIGHT ON YOUR ROLE AS CONSULTANTS - FOR YOU ARE\nCONSULTANTS NOT ONLY TO SURVEY AGENCIES AND TO SINGLE STATE\nAGENCIES, BUT ALSO TO THE NURSING HOMES YOU REVIEW.\nFIRST, REGULATIONS OF QUALITY OF CARE TEND TO BECOME A FLOOR\nRATHER THAN A CEILING, WHILE WE DEMAND THAT AN EXTENDED CARE\nFACILITY NOT FALL BELOW FEDERAL STANDARDS, WE DO NOT WANT TO\nDISCOURAGE IT FROM ASPIRING TO ACHIEVE A BETTER QUALITY OF CARE,\nAND ALTHOUGH YOU INSPECT FOR COMPLIANCE WITH FEDERAL STANDARDS,\nAS CONSULTANTS YOU ARE NOT LIMITED TO WHAT SHOULD BE CONSIDERED\nMINIMAL STANDARDS FOR CARE,\nSECOND, REGULATIONS TEND TO COVER STRUCTURAL CONSIDERA-\nTIONS - THOSE FACTORS IN PROFESSIONAL QUALIFICATIONS, STAFFING,\nAND ENVIRONMENT WHICH MAKE GOOD CARE POSSIBLE RATHER THAN THE\nACTUAL QUALITY OF CARE DELIVERED. AND HERE AGAIN, YOU AS\nCONSULTANTS CAN IMPROVE THE REGULATORY PROCESS BY EXAMINING\nTHE MEDICAL AND SOCIAL SERVICES ACTUALLY DELIVERED. THE JOB\nIS NOT EASY, IT CANNOT BE DONE IF THE PHARMACIST LOOKS ONLY\nAT THE PHARMACY, THE DIETICIAN AT THE KICHEN, THE DOCTOR AT\n9\nMEDICAL RECORDS, THE NURSE AT NURSING SERVICES, CONSULTANTS\nSHOULD CONSIDER ALSO THE PROFESSIONAL COORDINATION IN AN\nINSTITUTION, AND HOW IT CONTRIBUTES TO PATIENT CARE,\nTHIRD, REGULATIONS FREQUENTLY DO NOT CONSIDER THE RE-\nLATIVE IMPORTANCE OF DEFICIENCIES, IN THE REAL WORLD, ADMINI-\nSTRATORS WITH LIMITED BUDGETS--AND FEW HAVE UNLIMITED BUDGETS,\nEVEN IN THE FEDERAL GOVERNMENT-MUST OPERATE WITH A LIST OF\nPRIORITIES. CONSULTANTS SHOULD BE ABLE TO ASSIST A NURSING\nHOME IN ESTABLISHING PRIORITIES, AGAIN, THE JOB IS NOT EASY,\nFOR IT REQUIRES THE SPECIALIST TO LOOK BEYOND HIS OWN AREA OF\nEXPERTISE TO RECOGNIZE OTHER NEEDS, Is AN IN-HOUSE PHARMACY\nMORE IMPORTANT THEN AN -OCCUPATIONAL THERAPY PROGRAM? MIGHT\nSUGGEST AN EXERCISE FOR THIS SEMINAR? SPECIALISTS IN THE\nVARIOUS FIELDS OF CONSULTION CAN EACH DRAW UP LISTS OF FIVE\nMAJOR INSTITUTIONAL DEFICIENCIES IN THEIR AREA OF REGULATION,\nTHEN IN A GROUP SESSION DEFICIENCIES IN SEVERAL AREAS OF RE-\nGULATION BE RANKED ACCORDING TO PRIORITY. THIS PROCESS OF\nCOMPARING APPLES AND ORANGES-HOWEVER DESPISED IN THE CLASSROOM-\nIS AN EVERY DAY EXPERIENCE FOR THE ADMINISTRATOR.\nLAST, REGULATIONS ARE SLOW TO RECOGNIZE AND TAKE ACCOUNT\nOF CHANGE AND IMPROVEMENT. As CONSULTANTS, YOU SEE AND CAN ASSESS\nWHAT IS NEW, AND YOU HAVE THE OPPORTUNITY TO CROSS-POLLINATE\nWORTHWHILE IDEAS AND TECHNIQUES. As YOU KNOW, NURSING HOMES HAVE\n10\nBECOME A VERY COMPLICATED INDUSTRY, AND IN MANY SENSES\nHAVE BECOME \"BIG BUSINESS.\" THIS IS NOT ENTIRELY BAD,\nNEW MANAGEMENT AND ADMINISTRATIVE SKILLS HAVE BEEN IN-\nTRODUCED, AND SOME OF THESE OFFER PROMISE, IF YOU ARE TO\nDEAL WITH NURSING HOME ADMINISTRATORS AND ASSESS THEIR\nMANAGEMENT, YOU MUST UNDERSTAND THEIR SKILLS so THAT YOU\nCAN SERVE MORE EFFECTIVELY YOUR CONSULTANT ROLE,\nTo RETURN TO THE PRESIDENT'S PLAN, so FAR I HAVE DISCUSSED\nIMPROVED ENFORCEMENT OF NURSING HOME STANDARDS, Two OTHER\nPOINTS IN THE PLAN INITIATED MORE DIRECT STEPS TO IMPROVE\nNURSING HOME CARE, THE PRESIDENT DIRECTED THE DEPARTMENT\nOF HEW \"TO INSTITUTE A NEW PROGRAM OF SHORT-TERM COURSES FOR\nPHYSICIANS, NURSES, DIETICIANS, SOCIAL WORKERS AND OTHERS WHO\nARE REGULARLY INVOLVED IN FURNISHING SERVICES TO NURSING\nHOME PATIENTS.\" HEW HAS SUPPORTED SUCH TRAINING FOR SEVERAL\nYEARS, AND HAS DEVELOPED CLOSE WORKING RELATIONSHIPS WITH\nPROFESSIONAL ASSOCIATIONS AND WITH TRAINING CENTERS. IN RE-\nSPONSE TO THE PRESIDENTS' DIRECTIVE, SUCH PROGRAMS HAVE BEEN\nEXPANDED UND IR THE LEADERSHIP OF THE COMMUNITY HEALTH SERVICE,\nHEALTH SERVICE AND MENTAL HEALTH ADMINISTRATION, AND HIS\nANTICIPATED THAT APPROXIMATELY 20,000 PERSONS\nwere\nTRAINED\nIN FISCAL YEAR 1972 AT A COST OF $2.5 MILLION, TRAINING\nPROGRAMS WILL FOCUS INITIALLY ON FOUR MANPOWER AREAS SELECTED\nBECAUSE OF THEIR DIRECT DAY-TO-DAY RELATIONS WITH NURSING\n11\nHOME PATIENTS: NURSING HOME ADMINISTRATORS, PHYSICIANS, NURSES,\nAND PATIENT ACTIVITIES DIRECTORS, MANY OF THESE TRAINING\nPROGRAMS WILL BE OPERATED UNDER CONTRACTS WITH PROFESSIONAL\nGROUPS, APPROACHES TO MENTAL HEALTH PROBLEMS OF NURSING\nHOME PATIENTS WILL BE DEVELOPED BY NATIONAL INSTITUTE OF\nMENTAL HEALTH STAFF WORKING WITH THE GERONTOLOGICAL SOCIETY.\nOTHER TRAINING MECHANISMS WILL ALSO BE EXPLORED, SUCH AS\nPROGRAMS SPONSORED BY STATE HEALTH DEPARTMENTS AND STATE\nAGENCIES, THESE PROGRAMS WILL BE DIRECTED TOWARD MAKING\nNURSING HOME STAFF-BOTH PROFESSIONAL AND ALLIED HEALTH-MORE\nSENSITIVE AND EXPERT IN THE SPECIAL PROBLEMS OF CARE FOR\nGERIATRIC PATIENTS AND THE CHRONICALLY ILL. THE ARE INTENDED\nTO BE THE BEGINNING OF \"A SYSTEM FOR NATIONWIDE, CONTINUOUS TRAIN-\nING FOR NURSING HOME PERSONNEL WHICH WILL BECOME STANDARD\nPRACTICE IN THE NURSING HOME INDUSTRY OF THE FUTURE.\nAs THE SEVENTH POINT IN HIS PLAN, THE PRESIDENT DIRECTED\nTHE DEPARTMENT OF HEW \"TO ASSIST THE STATES IN ESTABLISHING\nINVESTIGATIVE UNITS WHICH WILL RESPOND IN A RESPONSIBLE AND\nCONSTRUCTIVE WAY TO COMPLAINTS MADE BY OR ON BEHALF OF IN-\nDIVIDUAL PATIENTS.\" SINCE I ASSUMED MY NURSING HOME RESPONSI-\nBILITIES, I HAVE RECEIVED MANY LETTERS FROM NURSING HOME\nPATIENTS-TOUCHING IN THEIR. APPEAL FOR CARE OFFERING SIMPLE\nDIGNITY AND RIGHTS OF PRIVACY, HARROWING SOMETIMES IN THEIR\nDESCRIPTIONS OF PHYSICAL OR PSYCHOLOGICAL ABUSE, THESE\n12\nPATIENTS ARE OFTEN HELPLESS IN THEIR DEPENDENCE ON THE IN-\nSTITUTION IN WHICH THEY LIVE. THEY DESERVE A FAIR HEARING,\nAND AN ADVOCATE WHEN THEY ARE POWERLESS, THE HEALTH\nSERVICES AND MENTAL HEALTH ADMINISTRATION HAS DEVELOPED FIVE\nMODELS FOR OMBUDSMAN UNITS TO FILL THIS ROLE, PLACED AT\nVARIOUS LEVELS WITHIN THE STATES AND DEMONSTRATING DIFFERENT\nMECHANISMS FOR ACTION, CONTRACT PROPOSALS TO TEST THESE\nMODELS ARE BEING SOLICITED, AND $600,000 HAS BEEN BUDGETED\nFOR FISCAL YEAR 1972 FOR THIS ACTIVITY,\nIT WILL TAKE TIME TO TEST AND DEVELOP SUCH AN OMBUDSMAN\nSYSTEM, TIME INAPPROPRIATE TO THE URGENCY OF THE PROBLEM,\nSo AN INTERIM OMBUDSMAN MECHANISM HAS BEEN ESTABLISHED WITH\nTHE 855 SOCIAL SECURITY ADMINISTRATION DISTRICT OFFICES DE-\nSIGNATED TO RECEIVE AND INVESTIGATE COMPLAINTS, THIS MECH-\nANISM IS CURRENTLY IN EFFECT, AND HAS RECEIVED OVER A THOUSAND\nRESPONSES.\nFOR THESE NURSING HOME INITIATIVES, A SUPPLEMENTAL APPRO-\nPRIATION OF $9,572,000 HAS BEEN REQUESTED FOR FISCAL YEAR,\n1972. WE FEEL THAT BY MEANS OF THESE PROGRAMS A SIGNIFICANT\nIMPROVEMENT IN NURSING HOME CARE CAN BE ACHIEVED IN A RE-\nLATIVELY SHORT PERIOD OF TIME.\nBERALD LIBRARY\n13\nWE RECOGNIZE ALSO, HOWEVER, THAT WHILE THESE INITIA-\nTIVES CAN RECTIFY SOME OF THE MOST PRESSING PROBLEMS OF\nNURSING HOME CARE, THERE ARE OTHER DEFICIENCIES-SOME FUNDA-\nMENTAL-THAT REQUIRE FURTHER SOLUTIONS, FROM A BROADER PER-\nSPECTIVE, IT IS APPARENT THAT NURSING HOMES ARE ONLY ONE\nELEMENT IN THE SPECTRUM OF LONG TERM CARE-AN ELEMENT WHICH\nHAS BEEN FORCED TO BE TOO MANY THINGS TO TOO MANY PEOPLE,\nIT IS IN THIS PERSPECTIVE THAT THE LAST POINT IN THE\nPRESIDENT'S PLAN IS FRAMED; HE HAS DIRECTED THE SECRETARY OF\nHEW TO UNDERTAKE A COMPREHENSIVE REVIEW OF THE USE OF LONG-\nTERM CARE FACILITIES AND TO RECOMMEND ANY FURTHER REMEDIAL\nMEASURES THAT ARE APPROPRIATE. I HAVE BEEN CHARGED WITH\nORGANIZING AND CHAIRING THAT TASK FORCE ON LONG TERM CARE.\nON ONE LEVEL, THE TASK FORCE WILL EXAMINE ing THE ROLES OF\nMEDICARE AND MEDICAID IN NURSING HOME ACTIVITIES, MOST OF\nYOU ARE AWARE, AND THE WHITE HOUSE CONFERENCE ON AGING HAS\nEMPHASIZED, THAT THESE FEDERAL PROGRAMS HAVE BEEN A MIXED\nBLESSING TO THE NURSING HOME INDUSTRY, SOME OF THE PROBLEMS\nHAVE BEEN PRIMARILY ADMINISTRATIVE, BUT HAVE PRESENTED\nDIFFICULTIES TO NURSING HOME ADMINISTRATORS AND TO STATE PRO-\nGRAMS, AN EXAMPLE OF SUCH A PROBLEM IS THE VARIATION IN\nSTANDARDS FOR EXTENDED CARE FACILITIES UNDER MEDICARE AND\nSKILLED NURSING HOMES UNDER MEDICAID. Thetash WE WILL EXAMINE THOSE\nis\n14\nSTANDARDS AND DETERMINE WHETHER THESE DIFFERENCES ARE NEC-\nESSARY OR USEFUL,\nBUT MORE FUNDAMENTAL ISSUES HAVE ALSO BEEN RAISED WITH\nREGARD TO THESE PROGRAMS. FOR HISTORICAL AND STATUTORY REA-\nSONS BASED ON THEIR ORIGINS AS HEALTH INSURANCE PROGRAMS,\nMEDICARE AND MEDICAID HAVE EMPHASIZED HEALTH ASPECTS OF\nNURSING HOME CARE, ACUTE ILLNESS IN WHICH THE PATIENT IS\nEXPECTED TO RECOVER AND REGAIN ALL OR MOST OF HIS INDEPEN-\nDENCE HAS SERVED AS THE MODEL FOR HEALTH DELIVERY, CON-\nSEQUENTLY, THESE PROGRAMS HAVE FAVORED INSTITUTIONAL CARE\nOVER NON-INSTITUTIONAL ALTERNATIVES, AND WITHIN INSTITUTIONS,\nHEALTH AS OPPOSED TO SOCIAL AND PERSONAL CARE.\nIN MANY WAYS, THE CONSEQUENCES OF THIS CARE FOR THOSE\nWITH CHRONIC ILLNESS AND FOR THOSE WITH THE INCREASED DE-\nPENDENCY OF OLD AGE-HAVE BEEN TRAGIC, COSTS HAVE BEEN IN-\nCREASED BY THE SUBSTITUTION OF INSTITUTIONAL.FOR NON-INSTITU-\nTIONAL CARE, AND BY SOMETIMES INAPPROPRIATELY HIGH LEVELS OF\nMEDICAL SERVICES FOR PATIENTS WHO DO NOT REQUIRE THEM. BUT\nEVEN MORE IMPORTANTLY, EPIDEMIOLOGY AND THE SOCIAL SCIENCES\nARE PROVIDING EVIDENCE THAT DEPENDENCY FACTORS - LOWERED\nINCOME, DISPLACEMENT, LOSS OF STATUS, ISOLATION - MAY EXACER--\nBATE IF NOT PRECIPITATE ACTUAL PHYSIOLOGIC DISEASE, OLDER\n15\nPERSONS PLACED IN INSTITUTIONS EXPERIENCE SUBSTANTIALLY\nHIGHER AGE - SPECIFIC MORBIDITY AND MORTALITY RATES THAN\nTHOSE WHO REMAIN AT HOME. So THE TRANSFER OF A PERSON\nFROM HIS HOME TO AN INSTITUTION, OR FROM AN INSTITUTION\nIN WHICH HE IS RELATIVELY AUTONOMOUS TO ONE IN WHICH HIS\nDEPENDENCY IS INCREASED, MAY MAKE HIM MORE ILL AND MORE\nDEPENDENT.\nTHE ISSUE OF THE BALANCE OF MEDICAL AND PERSONAL SERV-\nICES WITHIN INSTITUTIONS CANNOT BE POSTPONED. ON DECEMBER 28,\n1971 PRESIDENT NIXON SIGNED INTO LAW PUBLIC LAW 92-223,\nWHICH AUTHORIZES THE TRANSFER OF INTERMEDIATE CARE FACILITIES\nINTO THE MEDICAID PROGRAM, AN INTERMEDIATE CARE FACILITY\nPROVIDES HEALTH RELATED SERVICES FOR PATIENTS WHO DO NOT RE-\nQUIRE CARE IN SKILLED NURSING HOMES, BUT NEED INSTITUTIONAL\nCARE BEYOND ROOM AND BOARD, ICF's WERE PREVIOUSLY FINANCED\nBY PUBLIC ASSISTANCE PROGRAMS FOR THE AGED, THE BLIND, AND THE\nDISABLED, AND WERE SUBJECT ONLY TO STATE LICENSING, TRANSFER\nOF FINANCING TO THE MEDICAID PROGRAM MEANS NOT ONLY THAT A\nLARGER GROUP OF PEOPLE - INCLUDING THE \"MEDICALLY NEEDY\" -\nMAY POTENTIALLY BE ELIGIBLE FOR BENEFITS, BUT ALSO THAT THE\nFEDERAL GOVERNMENT IS EMPOWERED TO SET PHYSICAL AND SAFETY\nSTANDARDS AND DEFINE THE CARE AND SERVICES THAT MUST BE PRO-\nVIDED. THE MEDICAL SERVICES ADMINISTRATION OF THE SOCIAL AND\n16\nREHABILITATION SERVICE AND MY OFFICE OF NURSING HOME AFFAIRS\nARE CURRENTLY EXAMINING SUCH ISSUES AS WHO SHOULD BE IN THESE\nFACILITIES, WHAT SERVICES MUST THEY PROVIDE, AND WHAT SHOULD\nBE THE LEVEL OF BENEFITS IN ATTEMPTING TO DEVELOP STANDARDS\ncut>\nFOR INTERMEDIATE CARE FACILITIES.\nJUST AS THE BALANCE BETWEEN MEDICAL AND PERSONAL SER-\nVICES WITHIN INSTITUTIONS MUST BE RE-EXAMINED, so MUST THE\nALTERNATIVES TO INSTITUTIONAL CARE BE EXTENDED FOR THOSE\nSUFFERING FROM CHRONIC ILLNESS, THE ELDERLY SHOULD HAVE\nMORE OPTIONS AVAILABLE. IF A NURSING HOME IS NOT THE MOST\nAPPROPRIATE PLACE FOR A PERSON'S PARTICULAR NEEDS, THEN\nHE SHOULD NOT BE REQUIRED TO GO THERE, IF IT IS PERSONAL\nCARE RATHER THAN HEALTH CARE THAT IS REQUIRED, THEN THE\nOPTION SHOULD PROVIDE THAT EMPHASIS, IF IT IS APPROPRIATE\nHOUSING RATHER THAN INSTITUTIONAL CARE THAT IS NEEDED, THEN\nTHE EMPHASIS SHOULD BE ON HOUSING,\nMANY FEDERAL PROGRAMS HAVE EXPLORED ALTERNATIVES TO IN-\n2\nSTITUTIONAL CARE. THESE ALTERNATIVES HAVE BEEN A PARTICULAR\nTHRUST OF THE ADMINISTRATION ON AGING, WHICH HAS RECEIVED\nNEW SUPPORT AND PRIORITY IN THE PRESIDENT'S BUDGET FOR 1972\nIN THE FORM OF A FIVE-FOLD INCREASE IN ITS FUNDING LEVEL.\nTHE AoA HAS ESTABLISHED PROGRAMS SUCH AS TRANSPORTATION FOR\nFORD\nTHE ELDERLY, SENIOR CENTERS, MEALS-ON-WHEELS, TELEPHONE RE-\nLISBARY\n17\nASSURANCE, IN-HOME SERVICES, AND OPPORTUNITIES TO SERVE.\nTHE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT HAS DEVELOP-\nING HOUSING PROGRAMS DESIGNED TO MEET THE SPECIAL NEEDS OF\nTHE ELDERLY, MEDICARE AND MEDICAID PROVIDE HOME HEALTH\nBENEFITS,\nBUT THE CONCERTED IMPACT OF THESE PROGRAMS HAVE NOT BEEN\nENOUGH, AS WE HEARD ONCE MORE AT THE WHITE HOUSE CONFERENCE\nON AGING. THE PRESSURE FOR INSTITUTIONALIZATION CONTINUES\nTO PLACE STRAINS ON NURSING HOMES, WHICH ARE ASKED TO SERVE\nTOO WIDE A VARIETY OF FUNCTIONS, AND CONTINUES TO PUSH THE\nELDERLY INTO SOMETIMES PREMATURE DEPENDENCY: THE PROBLEM OF\nDEVELOPING A WIDER SPECTRUM OF OPTIONS FOR THE CHRONICALLY\nILL AND FOR THE ELDERLY WILL BE A CENTRAL FOCUS OF THE TASK\nFORCE ON LONG TERM CARE.\nAN IMPORTANT REASON FOR THE INSUFFICIENT AND SOMETIMES\nINAPPROPRIATE IMPACT OF FEDERAL PROGRAMS FOR LONG TERM CARE\nHAS BEEN THE LACK OF PLANNING AND COORDINATING BETWEEN FEDERAL,\nSTATE, AND LOCAL PROGRAMS. PLANNING FOR LONG TERM CARE\nSHOULD MOVE FROM IDENTIFICATION OF AN ISSUE OR PROBLEM TO ITS\nSOLUTION, WITH IDENTIFIABLE GOALS GUIDING THE PROCESS, MOVE-\nMENT TOWARD A GOAL SHOULD NOT BE INTERRUPTED BY CHANGES IN\nADMINISTRATION. WHAT IS TRULY IMPORTANT TODAY SHOULD NOT BE\nCAST ASIDE TOMORROW, NEW PROGRAMS SHOULD NOT BE APPENDAGES TO\n18\nSATISFY THE INTERESTS OF A FEW, NOR SHOULD THEY BE ADDED AS\nPACIFIERS TO THE MANY, PROGRAMS DEVELOP THROUGH A RATIONAL\nPLANNING PROCESS SHOULD THEN BE ADMINISTERED THROUGH AN\nEFFECTIVE AND COORDINATED MECHANISMS,\nTHE ESTABLISHMENT OF THE OFFICE OF NURSING HOME AFFAIRS\nWITHIN HEW WAS A STEP TOWARD IMPROVING COORDINATION. BUT\nTHE MANDATE FOR THE-TASK FORCE ON LONG TERM CARE IS BROADER:\nTO RE-EXAMINE THE ISSUES AND SET NEW GOALS, TO DEVELOP A\nNATIONWIDE DATA SYSTEM NECESSARY FOR POLICY FORMULATION,\nAND TO RECOMMEND AN ORGANIZATION FOR LONG TERM CARE WITHIN\nHEW AND OTHER FEDERAL AGENCIES, AND STATE AND LOCAL PROGRAMS\nWHICH CAN ACHIEVE ITS GOALS MOST EFFECTIVELY.\nA NATIONAL POLICY COURSE FOR THE CHRONICALLY ILL AND FOR\nTHE ELDERLY SHOULD BE SET, IT SHOULD BE SET BY GOVERNMENT.\nSET BY GOVERNMENT WITH THE FULL AND CREATIVE CONTRIBUTION OF\nTHOSE IN OTHER AGENCIES AND ORGANIZATIONS, THOSE IN ACADEMIC\nTEACHING AND RESEARCH, THOSE IN VOLUNTARY AND UNSALARIED\nSERVICE, AND THOSE WHO RECEIVE THAT CARE, AND YOU WHO ARE IN\nDIRECT CONTACT WITH HEALTH FACILITIES HAVE A SPECIAL RESPONSI-\nBILITY, ON THE ONE HAND, TO TRANSLATE REGULATIONS INTO\nAN EFFECTIVE INSTRUMENT FOR CONTROL OF THE QUALITY OF CARE.\nON THE OTHER, TO TRANSMIT TO THOSE OF US IN GOVERNMENT THE\nPROBLEMS AND ACHIEVEMENTS OF THESE FACILITIES so THAT WE CAN\nPLAN MORE EFFECTIVELY FOR THE CARE OF OUR SICK AND ELDERLY\nTHE FEDERAL REGULATIONS OF NURSING HOMES\nMARIE CALLENDER\nSPECIAL ASSISTANT FOR NURSING HOME AFFAIRS\nTHE QUALITY OF ANY CIVILIZATION CAN BE MEASURED BY THE\nATTITUDE OF THE PEOPLE TOWARD THE ELDERLY IN THEIR MIDST.\nTHEIR VALUE ECONOMICALLY IS EBBING OR IS AT AN END. THEY\nREQUIRE A DISPROPORTIONATE SHARE OF MEDICAL AND SOCIAL\nSERVICES, IN SOME EARLIER CULTURES THEY WERE CUT OFF FROM\nTHE TRIBE AND FORCED TO WANDER WITHOUT FOOD OR SHELTER UNTIL\nTHEY DIED. MOST OF US LOOK WITH REVULSION AT SUCH SOCIAL\nPATTERNS, AND ACCEPT THE MORAL RESPONSIBILITY OF OUR SOCIETY\nTOWARD ITS ELDERLY.\nTHE MAJORITY OF THOSE OVER SIXTY-FIVE ARE ABLE TO LEAD\nACTIVE, INDEPENDENT LIVES CONTRIBUTING VIGOROUSLY TO OUR\nNATIONAL LIFE. HOWEVER, ALMOST A MILLION OF OUR TWENTY-\nMILLION PERSONS OVER SIXTY-FIVE REQUIRE THE CARE AND SUPPORT\nOF NURSING HOMES, AND IT IS THESE WHOSE DEPENDENCE MOST ACUTELY\nTESTS THE QUALITY OF OUR COMPASSION AND SENSE OF HUMANITY.\nTo BE PRESENTED AI THE ANNUAL MEETING OF THE GENERAL CONFERENCE\nIN SAN, ANTONIO, TEXAS, MARCH 21, 1972\nGERALD LIBRARY R.FORD\n2\nTHE PRESIDENT HAS APTLY STATED THAT, \"FOR THOSE WHO\nNEED THEM, THE NURSING HOMES OF AMERICA SHOULD BE SHINING\nSYMBOLS OF COMFORT AND CONCERN.\" MANY OF OUR NURSING HOMES\nMEET THIS STANDARD, OTHER DO NOT, AS TESTIFIED BY RECENT\nSHOCKING AND TRAGIC NURSING HOME FIRES, AND LESS DRAMATI-\nCALLY BY PRIVATE AND GOVERNMENT STUDIES, IN MAY, 1971, THE\nGENERAL ACCOUNTING OFFICE ISSUED A REPORT ON THE ENFORCEMENT\nOF MEDICAID AND MEDICARE STANDARDS IN NINETY NURSING HOMES\nIN OKLAHOMA, NEW YORK, AND MICHIGAN, SERIOUS DEFICIENCIES\nWERE FOUND IN MORE THAN 50 PERCENT OF THESE HOMES, ALL OF\nWHICH HAD MEDICAID PATIENTS AND MANY OF WHICH WERE APPROVED\nFOR MEDICARE. ON NOVEMBER 30, 1971, SECRETARY RICHARDSON\nANNOUNCED THAT 39 STATES WERE OUT OF COMPLIANCE WITH TITLE\n19 CERTIFICATION PROCEDURES, IN HUMAN TERMS, THESE STUDIES\nMEAN THAT MANY NURSING HOMES WHICH FAIL TO MEET STANDARDS\nARE UNSANITARY AND UNSAFE, OVERCROWDED AND UNDERSTAFFED--\nLONELY AND DEPRESSING PLACES FOR THE ELDERLY TO LIVE AND DIE.\nTHE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED\nIN NURSING HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY\nSINCE THE ENACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN\n1965. IN 1970 THE FEDERAL GOVERNMENT UNDER MEDICAID SPENT\nOVER $2 MILLION IN SUPPORT OF NURSING HOME PATIENTS, WHILE\n3\nSTATE AND LOCAL GOVERNMENTS SPENT ANOTHER $7 MILLION.\nMEDICARE SPENT 247 MILLION. THIS INVOLVEMENT CARRIES WITH\nIT A RESPONSIBILITY TO ASSURE THAT NURSING HOMES DELIVER\nCARE AT LEAST AT THE LEVELS OF FEDERAL STANDARDS AND REGULA-\nTIONS, THE PRESIDENT ACCEPTED THIS RESPONSIBILITY IN HIS\n8-POINT PLAN FOR ACTION TO IMPROVE NURSING HOMES ANNOUNCED\nLAST AUGUST IN NEW HAMPSHIRE.\nA MAJOR GOAL OF THE PLAN IS TO IMPROVE ENFORCEMENT OF\nFEDERAL NURSING HOME STANDARDS, THE TERM \"NURSING HOME\" IS\nAPPLIED TO A WIDE RANGE OF FACILITIES, FROM THOSE PROVIDING\nPRIMARILY CUSTODIAL CARE TO THOSE DELIVERING HIGHLY SKILLED\nPOST-HOBPITAL AND REHABILITATIVE SERVICES, THESE DIFFERENT\nTYPES OF FACILITIES ARE ACCREDITED THROUGH DIFFERENT\nMECHANISMS, AND FEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES\nWIDELY.\nMEDICARE IS A FEDERAL RROGRAM, IT CONTRACTS WITH - STATE\nHEALTH DEPARTMENTS TO SURVEY NURSING HOMES FOR COMPLIANCE\nWITH FEDERAL STANDARDS, THE RESULTS OF THE SURVEY AND RECOMMEN-\nDATIONS ARE THEN PASSED ON TO FEDERAL PERSONNEL IN THE HEW\nREGIONAL 0-FICES, WHERE A FINAL DECISION IS RENDERED FOR CERTI-\nFICATION OF THE NURSING/AS HOME AN. EXTENDED CARE FACILITY ELIGIBLE\nTO RECEIVE MEDICARE FUNDS, THUS, THE FEDERAL ROLE AND THE\nFEDERAL ENPORCEMENT POWER ARE CLEAR AND UNEQUIVOCAL,\n4\nMEDICAID, ON THE OTHER HAND, IS A FEDERAL-STATE PRO-\nGRAM, FINANCIED AND ADMINISTERED THROUGH BOTH FEDERAL AND\nSTATE FUNDS AND ACITIVITIES. To QUALIFY FOR MEDICAID FUNDS\nAS A SKILLED NURSING HOME, AN INSTITUTION MUST MEET FEDERAL\nSTANDARDS. HOWEVER, THE PROCESS OF ENFORCING STANDARDS\nDIFFERS FROM THE MEDICARE PROGRAM, UNDER MEDICAID, ADMINI-\nSTRATION OF STATE PROGRAMS - INCLUDING THE ENFORCEMENT OF\nSTANDARDS - IS ASSIGNED BY CONTRACT TO A SINGLE STATE AGENCY.\nIN THE MAJORITY OF STATES, THE SINGLE STATE AGENCY IS THE\nSTATE WELFARE DEPARTMENT. THE SINGLE STATE AGENCY, AS IN\nMEDICARE, USUALLY CONTRACTS WITH ANOTHER AGENCY TO SURVEY\nNURSING HOMES FOR COMPLIANCE WITH FEDERAL STANDARDS, IN MOST\nSTATES, THE SAME AGENCY SURVEYS FOR BOTH MEDICARE AND MEDI-\nCAID. UNDER MEDICAID, THE RESULTS OF THE SURVEY AND RECOM-\nMENDATIONS ARE THEN SUBMITTED TO THE SINGLE STATE AGENCY -\nSTATE RATHER THEN FEDERAL PERSONNEL-WHERE A DECISION IS MADE\nWHETHER THE NURSING HOME QUALIFIED AS A SKILLED NURSING HOME\nFOR MEDICAID FUNDS, THIS PROCESS DIFFERS FROM MEDICARE, IN\nWHICH FEDERAL PERSONNEL REVIEW SURVEY RESULTS TO DETERMINE\nWHETHER AN INDIVIDUAL HOME QUALIFIES, IN MEDICAID THE EN-\nFORCEMENT OF STANDARDS IS DELEGATED TO THE STATES, WITH THE\nFEDERAL MEDICAID PROGRAM RETAINING ONLY THE UTLIMATE NEC-\nESSITY OF FINDING AN ENTIRE OR PART OF A STATE\n5\nSTATE PROGRAM OUT OF COMPLIANCE WITH FEDERAL STANDARDS\nAND HENCE INELIGIBLE FOR FEDERAL FUNDS, THESE PROCESSES\nREFLECT THE DIFFERENCE IN FUNDING SOURCES BETWEEN THE TWO\nPROGRAMS - THE FEDERAL GOVERNMENT BEARS THE ENTIRE BURDEN\nOF MEDICARE NURSING HOME FUNDING, WHILE IT PAYS ONLY A\nPORTION OF MEDICAID SUPPORT FOR NURSING HOME CARE.\nTHE MEDICARE PROGRAM, WHILE NOT ENTIRELY ABOVE RE-\nPROACH, HAS DONE A CREDITABLE JOB OF ENFORCING NURSING\nHOME STANDARDS. MEDICAID HAS BEEN A DIFFERENT STORY.\nTo SPEAK BLUNTLY, MANY STATES HAVE SIMPLY FAILED TO EN-\nFORCE FEDERAL NURSING HOME STANDARDS, WE HAVE BEEN FACED\nWITH AN INEQUITABLE SITUATION IN WHICH THE MEDICARE PATIENT\nCAN BE ASSURED THAT HIS NURSING HOME IS BEING CAREFULLY\nWATCHES; WHILE ANOTHER PERSON WHOSE CARE IS PAID FOR BY\nMEDICAID MAY LIVE IN A NURSING HOME WHERE INSPECTIONS ARE\nINFREQUENT, INEFFECTIVE, OR ABSENT.\nTHE PROBLEM OF ENCOURAGING STATES TO ENFORCE FEDERAL\nSTANDARDS HAS BEEN DIFFICULT. THE BLUDGEON APPROACH OF\nDECLARING A STATE OUT OF COMPLIANCE AND HENCE INELIGIBLE\nFOR FEDERAL MATCHING FUNDS MAY PENALIZE THE INDIVIDUAL\nNURSING HOME PATIENT OR THE GOOD NURSING HOME FOR THE SINS\nOF STATE AND\n6\nFEDERAL MEDICAID PERSONNEL. So THIS CLEARLY IS AN ACTION\nOF LAST RESORT. WE RECOGNIZE ALSO THAT SOME STATES - WITH\nTHE BEST OF INTENTIONS - HAVE FACED REAL PROBLEMS IN EN-\nFORCING STANDARDS, ESPECIALLY LACK OF TRAINED PERSONNEL AND\nFINANCIAL RESOURCES, FOR THIS REASON, THE PRESIDENT'S\nNURSING HOME ACTION PLAN OFFERRED SEVERAL FORMS OF ASSISTANCE\nTO THE STATES IN MEETING THEIR RESPONSIBILTIES.\n1. THE PRESIDENT PROMISED TO SEEK AUTHORIZATION FOR\nFEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID INSPECT-\nTIONS, WE RECOGNIZE THAT AN INCREASED LEVEL OF ENFORCEMENT\nACTIVITY INVOLVES ADDITIONAL COSTS TO THE STATES. MEDICARE\nINSPECTION COSTS HAVE ALWAYS BEEN FULLY PAID FOR BY THE FEDERAL\nGOVERNMENT, BUT UNDER THE MEDICAID PROGRAM STATES HAVE PAID\n25 TO 50 PERCENT OF THESE COSTS, SECRETARY RICHARDSON\nSUBMITTED TO CONGRESS IN OCTOBER, 1971, AN AMENDMENT TO H.R.I.\nAUTHORIZING THE FEDERAL GOVERNMENT TO ASSUME 100% OF INSPEC-\nTION COSTS UNDER MEDICAID, THIS STEP WILL PLACE BOTH PROGRAMS\nON AN EQUAL FOOTING AND LESSEN THE FINANCIAL BURDEN TO THE\nSTATES.\n2. THE PRESIDENT PLEDGED TO TRAIN 2,000 STATE NURSING\nHOME INSPECTIONS IN THE 18 MONTH PERIOD AFTER HIS AUGUST SPEECH,\nGERALD\nLIBRARY\n7\nENTIRELY AT FEDERAL EXPENSE, THIS EFFORT IS WELL UNDER\nWAY, AND 475 STATE INSPECTORS HAVE ALREADY ATTENDED THOSE\nCOURSES,\n3. THE PRESIDENT HAS ENLARGED THE FEDERAL STAFF FOR\nENFORCEMENT OF NURSING HOME STANDARDS, ONE HUNDRED NINETY-\nONE PERSONNEL HAVE BEEN ADDED, ONE-HUNDRED TEN OF THESE TO\nTHE REGIONAL OFFICES OF THE SOCIAL AND REHABILITATION\nSERVICE WHICH ADMINISTERS THE MEDICAID PROGRAM, THESE\nFEDERAL PERSONNEL WORK CLOSELY WITH STATE MEDICAID PROGRAMS,\n4. THE FEDERAL ENFORCEMENT EFFORT HAS BEEN REORGANIZED\nTO ACHIEVE IMPROVED COORDINATION AND HIGHER PRIORITY,\nNURSING HOME RESPONSIBILITIES HAVE BEEN CONSOLIDATED IN A\nSINGLE OFFICE - DR. MERLIN K. DUVAL, THE ASSISTANT SECRETARY\nFOR HEALTH AND SCIENTIFIC AFFAIRS IS THE RESPONSIBLE OFFICIAL.\nHE HAS INTURN DELEGATED THAT RESPONSIBILITY TO ME TO WORK\nWITH HIM TO BE RESPONSIBLE AND ACCOUNTABLE FOR ALL DHEW NURSING\nHOME AFFAIRS.\nSo THE PRESIDENT'S PLAN OFFERS ASSISTANCE TO THE STATES\nIN ENFORCING NURSING HOME STANDARDS, BUT AS THE PRESIDENT\nWARNED LAST AUGUST, LET THERE BE NO MISTAKING THE FACT\nBERALD\n8\nTHAT WHEN FACILITIES FAIL TO MEET REASONABLE STANDARDS,\nWE WILL NOT HESITATE TO CUT OFF MEDICARE AND MEDICAID\nFUNDS.\" As A RESULT OF A CRASH PROGRAM TO ASSESS THE\nSTATE MEDICAID CERTIFICATION AND ENFORCEMENT EFFORT,\nSECRETARY RICHARDSON ANNOUNCED ON NOVEMBER 30, 1971,\nTHAT THIRTY-NINE STATES WERE OUT OF COMPLIANCE WITH\nMEDICAID CERTIFICATION PROCEDURES, HE ALSO ANNOUNCED\nTWO DEADLINES: BY FEBRUARY 1, 1972, ALL STATES WERE\nTO DEMONSTRATE THAT THEIR INSPECTION AND CERTIFICATION\nPROCEDURES WERE IN COMPLIANCE WITH MEDICAID REGULATIONS,\nON THAT DATE, THIRTY-EIGHT OF THE THIRTY-NINE STATES CITED\nHAD CORRECTED THEIR DEFICIENCIES AND WERE FOUND TO HAVE\nIN EFFECT THE CORRECT PROCEDURES, BUT BY JULY 1, 1972,\nALL MEDICAID FACILITIES IN ALL STATES ARE TO HAVE BEEN\nINSPECTED AND CERTIFIED THROUGH THE CORRECT PROCEDURES,\nTHE JULY 1 DEADLINE HAS HIGH HEW PRIORITY, AND WE\nANTICIPATE THAT AS IT NEARS, THE PUBLIC, THE PRESS, AND\nTHE CONGRESS WILL BECOME INCREASINGLY INTERESTED. THE\nNUMBER OF NURSING HOMES WHICH MUST BE SURVEYED AND CERTI-\nFIED TO MEET THE DEADLINE VARIES WIDELY FROM STATE TO STATE,\nAND IN MANY PRESENTS A MOST FORMIDABLE WORKLOAD, IF THE\nDEADLINE IS TO BE MET, AN UNUSUAL CONCENTRATION AND COORDI-\nNATION OF HEW REGIONAL OFFICE, SURVEY AGENCY, AND SINGLE\nSTATE AGENCY RESOURCES MUST BE ACHIEVED IN MOST STATES.\n9\nTo THIS END, A STRATEGY TO ASSIST THE SINGLE STATE\nAGENCIES HAS BEEN DEVISED BY MY OFFICE, THE REGIONAL\nDIRECTORS OF HEW REGIONAL OFFICES HAVE BEEN NAMED THE\nRESPONSIBLE OFFICIALS FOR NURSING HOME INITIATIVES.\nTHEY ARE RESPONSIBLE FOR DETERMINING THAT SINGLE STATE\nAGENCIES DEVELOP REASONABLE TIMETABLES TO ACHIEVE AC-\nCREDITATION GOALS AND ADHERE TO THEM; THAT THE REQUIRED\nRESOURCES ARE AVAILABLE; THAT CORRECT SURVEY AND CERTI-\nFICATION PROCEDURES ARE FOLLOWED; THAT THE PERIODIC\nREPORTING REQUIREMENTS ARE MET. WE ANTICIPATE THAT MANY\nSTATES WILL FACE PROBLEMS OF COORDINATION - FOR EXAMPLE,\nSURVEYORS MAY HAVE TO BE \"BORROWED\" FROM THE MEDICARE\nPROGRAM, OR FUNDING MAY HAVE TO BE NEGOTIATED WITH THE\nGOVERNOR'S OFFICEES WE WILL MONITOR THEIR PROGRESS\nCONTINUOUSLY FROM MY OFFICE, AND WILL OFFER AS MUCH\nSUPPORT AS WE CAN, BUT THE TASK PRESENTS A GREAT CHALLENGE\nTO THE STATES AND A TEST FOR THE MEDICAID PROGRAM, IF WIDE-\nSPREAD ABUSES CONTINUE TO EXIST, WE WILL HAVE NO ALTER-\nNATIVE BUT TO FIND WHOLE STATES OUT OF COMPLIANCE - MEANING\nTHEIR FEDERAL FUNDS CAN BE HELD BACK,\n10\nTHERE IS ANOTHER ISSUE OF MAJOR SIGNIFICANT IN\nTHE FEDERAL REGULATION OF NURSING HOMES, AN ISSUE WHICH HAS B\nHAS BEEN SOMEWHAT OVERSHADOWED BY THE PRESS OF JULY 1 DEAD-\nLINE ACTIVITIES, ON DECEMBER 28, 1971, PRESIDENT NIXON\nSIGNED INTO LAW PUBLIC LAW 92-223, WHICH AUTHORIZES THE\nTRANSFER OF INTERMEDIATE CARE FACILITIES INTO THE MEDICAID\nPROGRAM. AN INTERMEDIATE CARE FACILITY PROVIDES HEALTH\nRELATED SERVICES FOR PATIENTS WHO DO NOT REQUIRE CARE IN\nSKILLED NURSING HOMES, BUT NEED INSTITUTIONAL CARE BEYOND\nROOM AND BOARD. ICF's WERE PREVIOUSLY FINANCED BY PUBLIC\nASSISTANCE PROGRAMS FOR THE AGED, THE BLIND, AND THE DIS-\nABLED, AND WERE SUBJECT ONLY TO STATE LICENSING AND STATE\nSTANDARDS, TRANSFER OF FINANCING TO THE MEDICAID PROGRAM\nMEANS NOT ONLY THAT A LARGER GROUP OF PEOPLE - INCLUDING\nTHE \"MEDICALLY NEEDY\" - MAY POTENTIALLY BE ELIGIBLE FOR\nBENEFITS, BUT ALSO THAT THIS LARGE GROUP OF NURSING HOMES\nWILL FALL UNDER THE UMBRELLA OF FEDERAL STANDARDS, FROM\nWHICH THEY WERE PREVIOUSLY EXEMPT. THE MEDICAL SERVICES\nADMINISTRATION OF SOCIAL AND REHABILITATION SERVICE AND\nMY OFFICE OF NURSING HoMe AFFAIRS ARE CURRENTLY EXAMINING\nSUCH ISSUES AS WHO SHOULD BE IN THESE FACILITIES, WHAT\nSERVICES MUST THEY PROVIDE, AND WHAT SHOULD BE THE LEVEL\nOF BENEFITS IN ATTEMPTING TO DEVELOP STANDARDS FOR INTER-\nMEDIATE CARE FACILITIES.\nGERALD\n11\nI HAVE CENTERED MY REMARKS ON THE ENFORCEMENT OF\nFEDERAL NURSING HOME STANDARDS, BECAUSE THESE ISSUES\nARE THE ONES MOST LIKELY TO FIND THEIR WAY TO YOUR DESKS,\nBUT I DO NOT WANT TO LEAVE THE IMPRESSION THAT THIS IS\nTHE SUM SUBSTANCE OF THE PRESIDENTS' PLAN OR OF MY HOPES\nFOR THE FEDERAL PROGRAM FOR LONG TERM CARE. WE ARE DEVELOP-\nING IN FULFILLMENT OF THE PRESIDENT'S PLAN PROGRAMS TO TRAIN\nNURSING HOME PERSONNEL AND MODELS FOR OMBUDSMAN UNITS TO\nSERVE AS ADVOCATES FOR DEPENDENT AND SOMETIMES HELPLESS\nNURSING HOME PATIENTS. THE PRESIDENT HAS GIVEN ME A MANDATE\nTO HEAD A TASK FORCE STUDYING PROBLEMS OF LONG TERM CARE\nFROM A BROAD PERSPECTIVE. THE TASK FORCE WILL MAKE RECOMMENDA-\nTIONS FOR CORRECTING DEFICIENCIES IN EXISTING PROGRAMS AND\nORGANIZATIONS AND FOR DEVELOPING NEW ONES. I HAVE BEEN MOST\nINTERESTED IN ENCOURAGING ALTERNATIVES TO INSTITUTIONAL CARE\nFOR THE ELDERLY, so THAT THEY ARE NOT FORCED PREMATURELY\nINTO NURSING HOMES WHEN THE COULD LIVE INDEPENTLY WITH FEA-\nSIBLE AND LESS COSTLY SOCIAL SERVICES, WE CAN DO MUCH BETTER\nFOR OUR ELDERLY, WE MUST OF COURSE PROTECT THEM FROM\nINSTITUTIONAL ABUSE RECOGNIZING THAT SOME ARE WEAK AND\nDEPENDENT. BUT WE CAN ALSO MAKE POSSIBLE A WIDE VARIETY OF\nSUPPORTING SERVICES AND LIVING ARRANGEMENTS, so THAT THE\nVORD\nINFIRMITIES OF ADVANCING AGE DO NOT BECOME A PRISON OF THE\nSPIRIT, THE ELDERLY WITH OUR HELP CAN HAVE ACCESS TO THE\nGERALD\nLIBRARY\nVARIETY AND FREEDOM WE ASK FOR OURSELVES,\nTHE FEDERAL PROGRAM TO IMPROVE CARE\nOF LONG-TERM PATIENTS IN INSTITUTIONS\nMRS. MARIE CALLENDER\nSPECIAL ASSISTANT FOR NURSING HOME AFFAIRS\nDEPARTMENT OF HEALTH, EDUCATION AND WELFARE*\nTo BE PRESENTED AT THE NATIONAL CONFERENCE ON SOCIAL WELFARE,\nCHICAGO, ILLINOIS, WEDNESDAY MAY 31, 1972\nGERAL\nTHE FEDERAL PROGRAM TO IMPROVE CARE\nOF LONG-TERM PATIENTS IN INSTITUTIONS\nTHE QUALITY OF ANY CIVILIZATION CAN BE MEASURED BY THE ATTITUDE\nOF THE PEOPLE TOWARD THE ELDERLY IN THEIR MIDST. THEIR VALUE\nECONOMICALLY IS EBBING OR IS AT AN END. THEY REQUIRE A DIS-\nPROPORTIONATE SHARE OF MEDICAL AND SOCIAL SERVICES, IN SOME\nEARLIER CULTURES THEY WERE CUT OFF FROM THE TRIBE AND FORCED TO\nWANDER WITHOUT FOOD OR SHELTER UNTIL THEY DIED. MOST OF US LOOK\nWITH REVULSION AT SUCH SOCIAL PATTERNS, AND ACCEPT THE MORAL\nRESPONSIBILITY OF OUR SOCIETY TOWARD ITS ELDERLY,\nTHE MAJORITY OF THOSE OVER SIXTY-FIVE ARE ABLE TO LEAD ACTIVE,\nINDEPENDENT LIVES CONTRIBUTING VIGOROUSLY TO OUR NATIONAL LIFE.\nHOWEVER, ALMOST A MILLION OF OUR TWENTY-MILLION PERSONS OVER\nSIXTY-FIVE REQUIRE THE CARE AND SUPPORT OF NURSING HOMES, AND IT\nIS THESE WHOSE DEPENDENCE MOST ACUTELY TESTS THE QUALITY OF OUR\nCOMPASSION AND SENSE OF HUMANITY,\nTHE PRESIDENT HAS APTLY STATED THAT, \"FOR THOSE WHO NEED THEM, THE\nNURSING HOMES OF AMERICA SHOULD BE SHINING SYMBOLS OF COMFORT AND\nCONCERN.\" MANY OF OUR NURSING HOMES MEET THIS STANDARD. OTHER\nDO NOT, AS TESTIFIED BY RECENT SHOCKING AND TRAGIC NURSING HOME\nFIRES, AND LESS DRAMATICALLY BY PRIVATE AND GOVERNMENTAL STUDIES.\nIN MAY, 1971, THE GENERAL ACCOUNTING OFFICE ISSUED A REPORT ON THE\nENFORCEMENT OF MEDICAID AND MEDICARE STANDARDS IN NINETY NURSING\nHOMES IN OKLAHOMA, NEW YORK, AND MICHIGAN. SERIOUS DEFICIENCIES\nWERE FOUND IN MORE THAN 50 PERCENT OF THESE HOMES, ALL OF WHICH HAD\nMEDICAID PATIENTS AND MANY OF WHICH WERE APPROVED FOR MEDICARE.\n1\nON NOVEMBER 30, 1971, SECRETARY RICHARDSON ANNOUNCED THAT 39 STATES\nWERE OUT OF COMPLIANCE WITH TITLE 19 CERTIFICATION PROCEDURES,\nIN HUMAN TERMS, THESE STUDIES MEAN THAT MANY NURSING HOMES WHICH\nFAIL TO MEET STANDARDS ARE UNSANITARY AND UNSAFE, OVERCROWDED AND\nUNDERSTAFFED--LONELY AND DEPRESSING PLACES FOR THE ELDERLY TO LIVE\nAND DIE.\nTHE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED IN NURSING\nHOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY SINCE THE EN-\nACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN 1965. IN 1970\nTHE FEDERAL GOVERNMENT SPENT OVER $2 BILLION IN SUPPORT OF NURSING\nHOME PATIENTS, WHILE STATE AND LOCAL GOVERNMENTS SPENT ANOTHER\n$700 MILLION, THIS INVOLVEMENT CARRIES WITH IT A RESPONSIBILITY\nTO ASSURE THAT NURSING HOMES DELIVER CARE AT LEAST AT THE LEVELS\nOF FEDERAL STANDARDS AND REGULATIONS, THE PRESIDENT ACCEPTED\nTHIS RESPONSIBILITY IN HIS 8-POINT PLAN FOR ACTION TO IMPROVE\nNURSING HOMES ANNOUNCED LAST AUGUST IN NEW HAMPSHIRE,\nA MAJOR GOAL OF THE PLAN IS TO IMPROVE FEDERAL ENFORCEMENT OF\nNURSING HOME STANDARDS. As YOU KNOW, THE TERM \"NURSING HOME\"\nIS APPLIED TO A WIDE RANGE OF FACILITIES, FROM THOSE PROVIDING\nPRIMARILY CUSTODIAL CARE TO THOSE DELIVERING HIGHLY SKILLED POST-\nHOSPITAL AND REHABILITATIVE SERVICES, THESE DIFFERENT TYPES\nOF FACILITIES ARE ACCREDITED THROUGH DIFFERENT MECHANISMS, AND\nFEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES WIDELY, MEDICARE\nCERTIFICATION OF EXTENDED CARE FACILITIES IS A FEDERAL PROGRAM\nMEDIATED THROUGH STATE AGENCIES, MEDICAID IS A FEDERAL-STATE\nPROGRAM FINANCED AND ADMINISTERED THROUGH BOTH FEDERAL AND STATE GREATO\nLIBRARY\n2\nFUNDS AND ACTIVITIES. INTERMEDIATE CARE FACILITIES UNTIL\nRECENTLY WERE REQUIRED TO MEET ONLY STATE LICENSING REQUIRE-\nMENTS TO RECEIVE FEDERAL FUNDS. THESE VARIATIONS HAVE COM-\nPLICATED THE ENFORCEMENT OF STANDARDS. THE DIFFERENCES ARE\nCURRENTLY BEING RESOLVED TO CREATE A MORE RATIONAL AND EASILY\nADMINISTERED BASIS FOR NURSING HOME STANDARDS.\nON DECEMBER 28, 1971, PRESIDENT NIXON SIGNED INTO LAW PUBLIC\nLAW 92-223, WHICH AUTHORIZES THE TRANSFER OF INTERMEDIATE\nCARE FACILITIES INTO THE MEDICAID PROGRAM. AN INTERMEDIATE\nCARE FACILITY PROVIDES HEALTH RELATED SERVICES FOR PATIENTS\nWHO DO NOT REQUIRE CARE IN SKILLED NURSING HOMES, BUT NEED\nINSTITUTIONAL CARE BEYOND ROOM AND BOARD. ICF's WERE\nPREVIOUSLY FINANCED BY PUBLIC ASSISTANCE PROGRAMS FOR THE AGED,\nTHE BLIND, AND THE DISABLED, AND WERE SUBJECT ONLY TO STATE\nLICENSING. TRANSFER OF FINANCING TO THE MEDICAID PROGRAM MEANS\nNOT ONLY THAT A LARGER GROUP OF PEOPLE - INCLUDING THE\n\"MEDICALLY NEEDY\" - MAY POTENTIALLY BE ELIGIBLE FOR BENEFITS,\nBUT ALSO THAT THE FEDERAL GOVERNMENT IS EMPOWERED TO SET PHYSICAL\nAND SAFETY STANDARDS AND TO DEFINE THE CARE AND SERVICES THAT MUST\n3\nBE PROVIDED. THE MEDICAL SERVICES ADMINISTRATION OF THE SOCIAL\nAND REHABILITATION SERVICE AND MY AFRICE OF NURSING HOME AFFAIRS\nARE CURRENTLY EXAMINING SUCH ISSUES AS WHO SHOULD BE IN THESE\nFACILITIES, WHAT SERVICES THEY SHOULD PROVIDE, AND WHAT LEVEL\nOF BENEFITS THEY SHOULD OFFER. REGULATIONS FOR INTERMEDIATE CARE\nVACILITIES WILL BE AVAILABLE IN THE FEDERAL REGISTER BY JULY 1\nTHE DIFFERENCE IN THE STANDARDS FOR SKILLED NURSING HOMES UNDER\nMEDICAID AND FOR EXTENDED CARE FACILITIES UNDER MEDICARE HAVE\nCAUSED CONFUSION TO THOSE PROVIDING SUCH CARE AND FOR THOSE EN-\nFORCING STANDARDS, ALTHOUGH THE PHILOSOPHIC INTENT IN THE TWO\nPROGRAMS was WERE SOMEWHAT DIFFERENT, IN PRACTICE THE LEVELS OF NURSING\nCARE AS DEFINED FOR THE TWO INSTITUTIONS HAVE BEEN ROUGHLY\nEQUIVALENT. WE BELIEVE THAT DIFFERENCES IN STANDARDS CAUSE NEEDLESS\nCONFUSION. THEREFORE, THE DEPARTMENT OF HEW AND MY OFFICE\nOF NURSING HOME AFFAIRS HAVE BEEN MOVING TO ESTABLISH A SINGLE DE-\nFINITION AND SET OF STANDARDS FOR EXTENDED CARE FACILITIES UNDER\nMEDICARE AND SKILLED NURSING HOMES UNDER MEDICAID. CONGRESS HAS\nAMENDED H.R.I. TO CALL FOR THESE CHANGES IN A REDEFINED ENTITY\nTO BE CALLED A \"SKILLED NURSING FACILITY.\" IN ANTICIPATION THAT\nTHAT THESE AMENDMENTS WILL BE ENACTED INTO LAW, WE ARE ALREADY\nDEVELOPING A COMMON SET OF STANDARDS, A BASIC PRINCIPLE UNDERLYING\nTHIS EFFORT IS THAT WHERE STANDARDS BETWEEN THE TWO PROGRAMS DIFFER,\nTHE HIGHER WILL BE INCORPORATED INTO THE NEW REGULATIONS.\nCONGRESSIONAL AMENDMENTS HAVE ALSO INTRODUCED SOME CHANGES IN CERTI-\nFICATION PROCEDURES TO MAKE THE TWO PROGRAMS MORE UNIFORM, A\nPROVISION HAS BEEN ADDED UNDER WHICH THE SECRETARY OF HEW WOULD\nDECIDE WHETHER A NURSING HOME QUALIFIES TO PARTICIPATE AS A \"SKILLED\nNURSING FACILITY\" IN BOTH THE MEDICARE AND MEDICAID PROGRAMS. THE\nGERALD LIQUEST FORD\n4\nSECRETARY WOULD MAKE THAT DETERMINATION BASED PRINCIPALLY UPON\nTHE APPROPRIATE STATE AGENCY EVALUATION. IT WILL BE REQUIRED\nTHAT THE SAME STATE AGENCY CERTIFY FACILITIES FOR BOTH MEDICARE\nAND MEDICAID. A STATE COULD FOR GOOD CAUSE, REFUSE TO ACCEPT\nAS A PARTICIPANT IN THE MEDICAID PROGRAM A FACILITY CERTIFIED\nBY THE SECRETARY. BUT A STATE MEDICAID PROGRAM COULD NOT RE-\nCEIVE FEDERAL MATCHING FUNDS FOR ANY INSTITUTION NOT APPROVED\nBY THE SECRETARY.\nANOTHER ISSUE IN ACHIEVING UNIFORMITY BETWEEN MEDICARE AND\nMEDICAID NURSING HOME PROGRAMS IS THE PROBLEM OF REIMBURSEMENT.\nWE ARE STUDYING ALTERNATIVE MECHANISMS TO DEVELOP A SYSTEM WHICH\nIS UNIFORM AND IS WEIGHTED TO SLOW THE RATE OF \"MEDICAL INFLATION.\nTHE SENATE FINANCE COMMITTEE HAS AMENDED MEDICAID LAWS TO REQUIRE\nTHAT SKILLED NURSING AND INTERMEDIATE CARE SERVICES BE REIMBURSED\nON A REASONABLE - COST RELATED BASIS, AND THIS IS ONE APPROACH\nHEW\ns\nARE CONSIDERING.\nTHE DEPARTMENT OF HEW HAS BEEN WORKING TOWARD THE DEVELOPMENT OF\nHIGHER STANDARDS WHICH CAN BE ENFORCED MORE FAIRLY.\nS ME OF THE CONGRESSIONAL AMENDMENTS TO H.R.I. REPRESENT PROGRESS\nHEW IS\nIN THIS DIRECTION, AND DEVELOPING APPROPRIATE PLANS FOR\nIMPLEMENTATION. THESE ARE ISSUES WHOSE RESOLUTION WILL BENEFIT\nEVERYONE - THE PROVIDER, THE CONSUMER, AND GOVERNMENT OFFICIALS\nCHARGED WITH ADMINISTERING THESE PROGRAMS,\nBOTH MEDICARE AND MEDICAID WILL CONTINUE TO RELY ON STATE AGENCY\nINSPECTION OF FACILITIES.\nTHIS APPROACH IS CONSISTENT\nWITH A HEALTHY FEDERAL-STATE RELATIONSHIP AND AVOIDS UNNECESSARY\nEXPANSION OF THE FEDERAL BUREAUCRACY. BUT THE FEDERAL GOVERNMENT\n- WHICH IS RESPONSIBLE FOR THE QUALITY OF CARE WHICH IT FINANCES =\nMUST AID IN ENHANCING THE CAPABILITY OF THE STATE AGENCIES TO\nREGULATE AND IMPROVE THE QUALITY OF NURSING HOME CARE, To IMPROVE\nENFORCEMENT OF NURSING HOME STANDARDS, THE PRESIDENT'S PLAN FOR\nACTION PLEDGED THE FOLLOWING STEPS:\n1. CONSOLIDATION OF RESPONSIBILITY FOR NURSING HOME AFFAIRS\nNURSING HOME ACTIVITIES HAVE BEEN SCATTERED AMONG SEVERAL BRANCHES\nOF THE DEPARTMENT OF HEW, INCLUDING THE SOCIAL SECURITY ADMINISTRATION,\nTHE SOCIAL AND REHABILITATION SERVICE, AND THE HEALTH SERVICE AND\nMENTAL HEALTH ADMINISTRATION. THE PRESIDENT ORDERED THAT ALL FEDERAL\nENFORCEMENT RESPONSIBILITY BE CONSOLIDATED IN A SINGLE OFFICE, AND\nDR. MERLIN K. DUVAL, THE ASSISTANT SECRETARY OF HEALTH AND SCIENTIFIC\nAFFAIRS, WAS DESIGNATED AS THE RESPONSIBLE OFFICIAL. DR. DUVAL\nDELEGATED TO ME THESE RESPONSIBILITIES AND THE FUNCTION OF FULL-TIME\nCOORDINATOR OF NURSING HOME ACTIVITIES. ALSO, TO AMPLIFY THE VOICE\nOF THOSE OUTSIDE GOVERNMENT, AN OLDER AMERICANS ADVISORY COMMITTEE\nHAS BEEN NAMED TO ASSIST THE SECRETARY OF HEW.\n2. ENI ARGEMENT OF FEDERAL STAFF FOR ENFORCEMENT OF NURSING HOME\nSTANDARDS,\nTHE SOCIAL AND REHABILITATION SERVICE, WHICH ADMINISTERS THE\nMEDICAID PROGRAM, HAS BEEN ASSIGNED 142 ADDITIONAL POSITIONS TO CARRY\nOUT ITS INCREASED RESPONSIBILITIES. ONE HUNDRED TEN OF THESE\nPOSITIONS WERE ALLOCATED TO THE REGIONAL OFFICES OF HEW. THE\nASSISTANT SECRETARY COMPTROLLER RECEIVED EIGHT NEW POSITIONS, AND\nHEW's AUDIT AGENCY RECEIVED THIRTY-FOUR ADDITIONAL POSITIONS TO\nINCREASE THEIR AUDITS OF NURSING HOME OPERATIONS. THE NATIONAL\nCENTER FOR HEALTH SERVICES RESEARCH AND DEVELOPMENT RECEIVED SEVEN\nNEW POSITIONS FOR EFFORTS TO IMPROVE NURSING HOME DATA SYSTEMS AND\nTO DEVELOP DATA IN SPECIAL FIELDS RELEVANT TO NURSING HOME CARE,\n3. FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID INSPECTIONS.\nWE RECOGNIZE THAT AN INCREASED LEVEL OF ENFORCEMENT ACTIVITY INVOLVES\nADDITIONAL COSTS TO THE STATES. MEDICARE INSPECTION COSTS HAVE ALWAYS\nBEEN FULLY PAID FOR BY THE FEDERAL GOVERNMENT, BUT UNDER THE MEDICAID\nPROGRAM STATES HAVE PAID 25 TO 50 PERCENT OF THESE COSTS, SECRETARY\nRICHARDSON SUBMITTED TO CONGRESS IN OCTOBER, 1971, AN AMENDMENT TO\n6\nH.R.I. AUTHORIZING THE FEDERAL GOVERNMENT TO ASSUME 100 PERCENT\nOF INSPECTION COSTS UNDER MEDICAID. THE SENATE FINANCE COMMITTEE\nHAS ACCEPTED THIS AMENDMENT. THIS STEP WILL PLACE BOTH PROGRAMS\nON AN EQUAL FOOTING AND LESSEN THE FINANCIAL BURDEN TO THE STATES.\n4. TRAINING STATE NURSING HOME INSPECTORS,\nNURSING HOME SURVEYORS HAVE BEEN TRAINED IN SURVEY AND COUNSELLING\nTECHNIQUES UNDER A PROGRAM SPONSORED BY THE HEALTH SERVICES AND\nMENTAL HEALTH ADMINISTRATION SINCE MARCH, 1970. THESE FOUR-WEEK\nCOURSES HAVE BEEN PRESENTED IN UNIVERSITY CENTERS IN NEW HAMPSHIRE,\nLOUISIANA, AND CALIFORNIA. IN HIS AUGUST SPEECH, THE PRESIDENT\nPLEDGED AN EXPANSION OF THIS PROGRAM so THAT 2,000 SURVEYORS\nCOULD BE TRAINED IN THE ENSUING EIGHTEEN MONTH PERIOD. As A RESULT\nOF THE PRESIDENT'S ORDER, THE PROGRAM HAS BEEN ACCELERATED so THAT\nMORE THAN 700 SURVEYORS WILL HAVE BEEN TRAINED BY JULY OF THIS YEAR.\nCONTRACT NEGOTIATIONS ARE IN PROCESS TO ESTABLISH THREE ADDITIONAL\nUNIVERSITY CENTERS. IN ADDITION, A STUDY WAS PERFORMED TO EVALUATE\nTHE EFFECTIVENESS OF THE TRAINING COURSES, WHICH HAVE NOW BEEN\nMODIFIED TO REFLECT THE RESULTS OF THAT STUDY,\nTHESE EFFORTS TO ACHIEVE COMPLIANCE WITH FEDERAL STANDARDS AND RE-\nGULATIONS ARE NOT DESIGNED TO ELIMINATE FACILITIES AND THUS TO DEPRIVE\nPATIENTS OF NEEDED NURSING HOME CARE. WE ARE WORKING RATHER TO\nMAKE GOVERNMENTAL STANDARDS AND PERSONNEL MORE AFFECTIVE RESOURCES\nFOR THE UPGRADING OF SUBSTANDARD FACILITIES, THE FEDERAL PROGRAM\nTO TRAIN NURSING HOME SURVEYORS, FOR EXAMPLE, EMPHASIZES THE\nDEVELOPMENT OF CONSULTANT SKILLS TO AID NURSING HOME ADMINISTRATORS\nIN MAKING NEEDED IMPROVEMENTS. FEDERAL FINANCIAL ASSISTANCE IS\nAVAILABLE FOR NURSING HOME MODERNIZATION AND NEW CONSTRUCTION FROM\nTHE FEDERAL HOUSING ADMINISTRATION AND SUCH PROGRAMS AS HILL- BURTON.\nTHE STANDARDS THEMSELVES ARE BEING REVISED AND STRENGTHENED. WE ARE\nDEVELOPING PROGRAMS TO IMPROVE NURSING HOMES DIRECTLY - I SHALL\nDESCRIBE THEM IN A FEW MOMENTS.\n7\nBUT AS THE PRESIDENT WARNED LAST AUGUST,\" LET THERE BE NO\nMISTAKING THE FACT THAT WHEN FACILITIES FAIL TO MEET REASONABLE\nSTANDARDS, WE WILL NOT HESITATE TO CUT OFF THEIR MEDICARE AND\nMEDICAID FUNDS.\" BETWEEN AUGUST 6, 1971, AND FEBRUARY 11, 1972,\n13 EXTENDED CARE FACILITIES WERE DECERTIFIED FOR MEDICARE\nPARTICIPATION. ON NOVEMBER 30, 1971, THIRTY-NINE STATES WERE\nDECLARED OUT OF COMPLIANCE WITH TITLE 19-MEDICAID--CERTIFICA-\nTION PROCEDURES. By FEBRUARY 1, 1972, IN RESPONSE TO SECRETARY\nRICHARDSON'S DEADLINE, ALL BUT ONE OF THOSE STATES HAD MADE THE\nIMPROVEMENTS REQUIRED FOR COMPLIANCE. By JULY 1, 1972, ALL\nTITLE 19 FACILITIES IN ALL STATES ARE TO HAVE BEEN INSPECTED\nAND CERTIFIED THROUGH THE CORRECT PROCEDURES, THE FEDERAL GOVERN-\nMENT IS PLEDGED TO MEET ITS RESPONSIBILITY TO ASSURE THAT FEDERAL\nDOLLARS DO NOT FINANCE SUBSTANDARD CARE.\nIN ADDITION TO THESE STEPS FOR IMPROVEMENT IN NURSING HOME STANDARDS\nAND THEIR ENFORCEMENT, TWO OTHER POINTS IN THE PRESIDENT'S PLAN\nINITIATED MORE DIRECT STEPS TO IMPROVE NURSING HOME CARE. THE\nPRESIDENT DIRECTED THE DEPARTMENT OF HEW \"TO INSTITUTE A NEW PROGRAM\nOF SHORT-TERM COURSES FOR PHYSICIANS, NURSES, DIETICIANS, SOCIAL\nWORKERS AND OTHERS WHO ARE REGULARLY INVOLVED IN FURNISHING SERVICES\nTO NURSING HOME PATIENTS. HEW HAS SUPPORTED SUCH TRAINING FOR\nSEVERAL YEARS, AND HAS DEVELOPED CLOSE WORKING RELATIONSHIPS WITH\nPROFESSIONAL ASSOCIATIONS AND WITH TRAINING CENTERS.\nIN RESPONSE\nTO THE PRESIDENTS' DIRECTIVE, SUCH PROGRAMS HAVE BEEN EXPANDED\nUNDER THE LEADERSHIP OF THE COMMUNITY HEALTH SERVICE, HEALTH SERVICE\nAND MENTAL HEALTH ADMINISTRATION, AND ANTICIPATED THAT APPROXI-\nMATELY 20,000 PERSONS\nTRAINED IN FISCAL YEAR 1972 AT A CÔST,\nOF $2.5 MILLION, TRAINING PROGRAMS WILL FOCUS INITIALLY ON FOUR\n8\nMANPOWER AREAS SELECTED BECAUSE OF THEIR DIRECT DAY-TO-DAY\nRELATIONS WITH NURSING HOME PATIENTS: NURSING HOME ADMINISTRATORS,\nPHYSICIANS, NURSES, AND PATIENT ACTIVITIES DIRECTORS, MANY OF\nTHESE TRAINING PROGRAMS WILL BE OPERATED UNDER CONTRACTS WITH\nPROFESSIONAL GROUPS, APPROACHES TO MENTAL HEALTH PROBLEMS OF\nNURSING HOME PATIENTS WILL BE DEVELOPED BY NATIONAL INSTITUTE OF\nMENTAL HEALTH STAFF WORKING WITH THE GERONTOLOGICAL SOCIETY,\nOTHER TRAINING MECHANISMS WILL ALSO BE EXPLORED, SUCH AS PROGRAMS\nSPONSORED BY STATE HEALTH DEPARTMENTS AND STATE AGENCIES, THESE\nPROGRAMS WILL BE DIRECTED TOWARD NURSING HOME STAFF-BOTH PRO-\nFESSIONAL AND ALLIED HEALTH-MORE SENSITIVE AND EXPERT IN THE SPECIAL\nPROBLEMS OF CARE FOR GERIATRIC PATIENTS AND THE CHRONICALLY ILL.\nTHEY ARE INTENDED TO BE THE BEGINNING OF A SYSTEM FOR NATIONWIDE,\nCONTINUOUS TRAINING FOR NURSING HOME PERSONNEL WHICH WILL BECOME\nSTANDARD PRACTICE IN THE NURSING HOME INDUSTRY OF THE FUTURE.\nAs THE SEVENTH POINT IN HIS PLAN, THE PRESIDENT DIRECTED THE DEPART-\nMENT OF HEW \"To ASSIST THE STATES IN ESTABLISHING INVESTIGATIVE\nUNITS WHICH WILL RESPOND IN A RESPONSIBLE AND CONSTRUCTIVE WAY TO\nCOMPLAINTS MADE BY OR ON BEHALF OF INDIVIDUAL PATIENTS.\nSINCE\nI ASSUMED MY NURSING HOME RESPONSIBILITIES, I HAVE RECEIVED MANY\nLETTERS FROM NURSING HOME PATIENTS - TOUCHING IN THEIR APPEAL FOR\nCARE OFFERING SIMPLE DIGNITY AND RIGHTS OF PRIVACY, HARROWING\nSOMETIMES IN THEIR DESCRIPTIONS OF PHYSICAL OR PSYCHOLOGICAL ABUSE.\nTHESE PATIENTS ARE OFTEN HELPLESS IN THEIR DEPENDENCE ON THE IN-\nSTITUTION IN WHICH THEY LIVE. THEY DESERVE A FAIR HEARING, AND AN\nADVOCATE WHEN THEY ARE POWERLESS.\nTHE HEALTH SERVICES AND MENTAL\nHEALTH ADMINISTRATION HAS DEVELOPED FIVE MODELS FOR OMBUDSMAN UNITS\n9\nTO FILL THIS ROLE, PLACED AT VARIOUS LEVELS WITHIN THE STATES\nAND DEMONSTRATING DIFFERENT MECHANISMS FOR ACTION,\nCONTRACT\nPROPOSALS TO TEST THESE MODELS ARE BEING SOLICITED, AND\n$600,000 HAS BEEN BUDGETED FOR FISCAL YEAR 1972 FOR THIS\nACTIVITY.\nIT WILL TAKE TIME TO TEST AND DEVELOP SUCH AN OMBUDSMAN SYSTEM,\nTIME INAPPROPRIATE TO THE URGENCY OF THE PROBLEM, So AN\nINTERIM OMBUDSMAN MECHANISM HAS BEEN ESTABLISHED WITH THE 855\nSOCIAL SECURITY ADMINISTRATION DISTRICT OFFICES DESIGNATED TO\nRECEIVE AND INVESTIGATE COMPLAINTS. THIS MECHANISM IS CURRENTLY\nIN EFFECT, AND HAS RECEIVED OVER A THOUSAND RESPONSES,\nFOR THESE NURSING HOME INITIATIVES, A SUPPLEMENT APPROPRIATION\nOF $9,572,000 HAS BEEN REQUESTED FOR FISCAL YEAR, 1972. WE\nFEEL THAT BY MEANS OF THESE PROGRAMS A SIGNIFICANT IMPROVEMENT\nIN NURSING HOME CARE CAN BE ACHIEVED IN A RELATIVELY SHORT PERIOD\nOF TIME.\nWE RECOGNIZE ALSO, THAT WHILE THESE INITIATIVES CAN RECTIFY SOME\nOF THE MOST PRESSING PROBLEMS OF NURSING HOME CARE, THERE ARE OTHER\nDEFICIENCIES - SOME FUNDAMENTAL - THAT REQUIRE FURTHER SOLUTIONS,\nFROM A BROADER PERSPECTIVE, IT IS APPARENT THAT NURSING HOMES ARE\nONLY ONE ELEMENT IN THE SPECTRUM OF LONG TERM CARE - AN ELEMENT\nWHICH HAS BEEN FORCED TO BE TOO MANY THINGS TO TOO MANY PEOPLE.\nIT IS IN THIS PERSPECTIVE THAT THE LAST POINT IN THE PRESIDENT'S\nPLAN IS FRAMED; HE HAS DIRECTED THE SECRETARY OF HEW TO UNDERTAKE\nA COMPREHENSIVE REVIEW OF THE USE OF LONG-TERM CARE FACILITIES AND\nTO RECOMMEND ANY FUTHER REMEDIAL MEASURES THAT ARE APPROPRIATE.\n10\nI HAVE BEEN CHARGED WITH ORGANIZING AND CHAIRING THAT TASK\nFORCE ON LONG-TERM CARE.\nis EXAMINING\nON ONE LEVEL, THE TASK FORCE WILL THE ROLES OF MEDICARE\nAND MEDICAID IN NURSING HOME ACTIVITIES. MOST OF YOU ARE\nAWARE, AND THE WHITE HOUSE CONFERENCE ON AGING HAS EMPHASIZED,\nTHAT THESE FEDERAL PROGRAMS HAVE BEEN A MIXED BLESSING TO THE\nNURSING HOME INDUSTRY. SOME OF THE PROBLEMS HAVE BEEN PRIMARILY\nADMINISTRATIVE, AND HAVE BEEN OR ARE BEING CORRECTED AS I\nDISCUSSED BEFORE,\nBUT MORE FUNDAMENTAL ISSUES HAVE ALSO BEEN RAISED WITH REGARD TO\nTHESE PROGRAMS. FOR HISTORICAL AND STATUTORY REASONS BASED ON\nTHEIR ORIGINS AS HEALTH INSURANCE PROGRAMS, MEDICARE AND MEDICAID\nHAVE EMPHASIZED HEALTH ASPECTS OF NURSING HOME CARE. ACUTE ILL-\nNESS IN WHICH THE PATIENT IS EXPECTED TO RECOVER AND REGAIN ALL\nOR MOST OF HIS INDEPENDENCE HAS SERVED AS THE MODEL FOR HEALTH\nDELIVERY. CONSEQUENTLY, THESE PROGRAMS HAVE FAVORED INSTITU-\nTIONAL CARE OVER NON-INSTITUTIONAL ALTERNATIVES, AND WITHIN IN-\nSTITUTIONS, HEALTH AS OPPOSED TO SOCIAL AND PERSONAL CARE.\nIN MANY WAYS, THE CONSEQUENCES OF THIS CARE FOR THOSE WITH CHRONIC\nLLNESS - AND FOR THOSE WITH THE INCREASED DEPENDENCY OF OLD AGE -\nHAVE BEEN TRAGIC. COSTS HAVE BEEN INCREASED BY THE SUBSTITUTION\nOF INSTITUTIONAL FOR NON-INSTITUTIONAL CARE AND BY SOMETIMES\nINAPPROPRIATELY HIGH LEVEL OF MEDICAL SERVICES FOR PATIENTS WHO\nDO NOT REQUIRE THEM. BUT EVEN MORE IMPORTANTLY, EPIDEMIOLOGY AND\nTHE SOCIAL SCIENCES ARE PROVIDING EVIDENCE THAT DEPENDENCY FACTORS -\nLOWERED INCOME, DISPLACEMENT, LOSS OF STATUS, ISOLATION - MAY\nEXACERBATE IF NOT PRECIPITATE ACTUAL PHYSIOLOGIC DISEASE, OLDER\n11\nPERSONS PLACED IN INSTITUTION EXPERIENCE SUBSTANTIALLY HIGHER\nAGE SPECIFIC MORBILITY AND MORTALITY RATES THAN THOSE WHO\nREMAIN AT HOME. So THE TRANSFER OF A PERSON FROM HIS HOME\nTO AN INSTITUTION, OR FROM AN INSTITUTION IN WHICH HE IS RE-\nLATIVELY AUTONOMOUS TO ONE IN WHICH HIS DEPENDENCY IS INCREASED,\nMAY MAKE HIM MORE ILL AND MORE DEPENDENT. WE MUST REEXAMINE\nTHE BALANCE BETWEEN MEDICAL AND SOCIAL SERVICES WITHIN INSTITUTIONS\nTO MEET THE NEEDS OF LONG-TERM PATIENTS. THE RESTRUCTURING OF\nTHE INTERMEDIATE CARE FACILITY PROGRAM IS A STEP IN THIS DIRECTION,\nJUST AS THE SERVICES WITHIN INSTITUTIONS MUST BE RE-EXAMINED, so\nMUST THE ALTERNATIVES TO INSTITUTIONAL CARE BE EXTENDED FOR THOSE\nSUFFERING FROM CHRONIC ILLNESS, THE CHRONICALLY-ILL AND ELDERLY\nSHOULD HAVE MORE OPTIONS AVAILABLE. IF A NURSING HOME IS NOT\nTHE MOST APPROPRIATE PLACE FOR A PERSONS PARTICULAR NEEDS, THEN\nHE SHOULD NOT BE REQUIRED TO GO THERE, IF IT IS PERSONAL CARE\nRATHER THAN HEALTH CARE THAT IS REQUIRED, THEN THE OPTION SHOULD\nPROVIDE THAT EMPHASIS, IF IT IS APPROPRIATE HOUSING RATHER THAN\nINSTITUTIONAL CARE THAT IS NEEDED, THEN THE EMPHASIS SHOULD BE\nON HOUSING,\nMANY FEDERAL PROGRAMS HAVE EXPLORED ALTERNATIVES TO INSTITUTIONAL\nCARE, THESE ALTERNATIVES HAVE BEEN A PARTICULAR THRUST OF THE\nADMINISTRATION ON AGING, WHICH HAS RECEIVED NEW SUPPORT AND\nPRIORITY IN THE PRESIDENT'S BUDGET FOR 1972 IN THE FORM OF A FIVE-\nHOLD INCREASE IN ITS FUNDING LEVEL, THE AoA HAS ESTABLISHED PROGRAMS\nSUCH AS TRANSPORTATION FOR THE ELDERLY, SENIOR CENTERS, MEALS-\nON-WHEELS, TELEPHONE REASSURANCE, IN-HOME SERVICES, AND OPPORTUNITIES\nTO SERVE, THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT HAS\n12\nDEVELOPING HOUSING PROGRAMS DESIGNED TO MEET THE SPECIAL NEEDS\nOF THE ELDERLY. MEDICARE AND MEDICAID PROVIDE HOME HEALTH BENEFITS.\nBUT THE CONCERTED IMPACT OF THESE PROGRAMS HAVE NOT BEEN ENOUGH,\nAS WE HEARD ONCE MORE AT THE WHITE HOUSE CONFERENCE ON AGING.\nTHE PRESSURE FOR INSTITUTIONALIZATION CONTINUES TO PLACE STRAINS\nON NURSING HOMES, WHICH ARE ASKED TO SERVE TOO WIDE A VARIETY\nOF FUNCTIONS, AND CONTINUES TO PUSH THE ELDERLY INTO SOMETIMES\nPREMATURE DEPENDENCY THE PROBLEM OF DEVELOPING A WIDER\nSPECTRUM OF OPTIONS FOR THE CHRONICALLY ILL AND FOR THE ELDERLY\nWILL BE A CENTRAL FOCUS OF THE TASK FORCE ON LONG TERM CARE,\nAN IMPORTANT REASON FOR THE INSUFFICIENT AND SOMETIMES INAPPROPRIATE\nIMPACT OF FEDERAL PROGRAMS FOR LONG TERM CARE HAS BEEN THE LACK OF\nPLANNING AND COORDINATION BETWEEN THOSE PROGRAMS. PLANNING FOR\nLONG TERM CARE SHOULD MOVE FROM IDENTIFICATION OF AN ISSUE OR\nPROBLEM TO ITS SOLUTION, WITH IDENTIFIABLE GOALS GUIDING THE\nPROCESS, MOVEMENT TOWARD A GOAL SHOULD NOT BE INTERRUPTED BY\nCHANGES IN ADMINISTRATION. WHAT IS TRULY IMPORTANT TODAY SHOULD\nNOT BE CAST ASIDE TOMORROW, NEW PROGRAMS SHOULD NOT BE APPENDAGES\nTO SATISFY THE INTERESTS OF A FEW, NOR SHOULD THEY BE ADDED AS\nPACIFIERS TO THE MANY. PROGRAMS DEVELOPED THROUGH A RATIONAL\nPLANNING PROCESS SHOULD THEN BE ADMINISTERED THROUGH EFFECTIVE\nAND COORDINATED MECHANISMS.\nTHE ESTABLISHMENT OF THE OFFICE OF NURSING HOME AFFAIRS WITH HEW\nWAS A STEP TOWARD IMPROVING COORDINATION. BUT THE MANDATE FOR\nTHE TASK FORCE ON LONG TERM CARE IS BROAD TO RE-EXAMINE THE\nISSUES AND SET NEW GOALS, TO DEVELOP A NATIONWIDE DATA SYSTEM\n13\nNECESSARY FOR POLICY FORMULATION, AND TO RECOMMEND AN ORGANI-\nZATION FOR LONG TERM CARE WITHIN HEW, OTHER FEDERAL AGENCIES,\nAND STATE AND LOCAL PROGRAMS WHICH CAN ACHIEVE ITS GOALS MOST\nEFFECTIVELY.\nA NATIONAL POLICY COURSE FOR THE CHRONICALLY ILL AND FOR THE\nELDERLY SHOULD BE SET, IT SHOULD BE SET BY GOVERNMENT. SET\nBY GOVERNMENT WITH THE FULL AND CREATIVE CONTRIBUTION OF THOSE\nIN OTHER AGENCIES AND ORGANIZATIONS, THOSE IN ACADEMIC TEACHING\nAND RESEARCH, THOSE IN VOLUNTARY AND UNSALARIED SERVICE, AND\nTHOSE WHO RECEIVE THAT CARE.\nA START HAS BEEN MADE.\nWE CAN DO MUCH BETTER FOR OUR ELDERLY. WE MUST OF COURSE\nPROTECT THEM FROM INSTITUTIONAL ABUSE, RECOGNIZING THAT SOME\nARE WEAK AND DEPENDENT. - BUT WE CAN ALSO MAKE POSSIBLE A WIDE\nVARIETY OF SUPPORTING SERVICES AND LIVING ARRANGEMENTS, so THAT\nTHE INFIRMITIES OF ADVANCING AGE DO NOT BECOME A PRISON OF THE\nSPIRIT. THE ELDERLY WITH OUR HELP CAN HAVE ACCESS TO THE VARIETY\nAND FREEDOM WE ASK FOR OURSELVES,\nGLANTO FORD LIBRARY\nLONG TERM CARE: WASHINGTON IS LISTENING, TOO\nBy MARIE CALLENDER\nSPECIAL ASSISTANT FOR NURSING HOME AFFAIRS\nDEPARTMENT OF HEALTH, EDUCATION AND WELFARE\nPRESENTED AT ANNUAL CONVENTION, IDAHO HEALTH FACILITIES, INC.\nCOEUR D'ALENE, IDAHO, JULY 25, 1972\nLONG TERM CARE: WASHINGTON IS LISTENING, TOO\nTHE THEME OF THIS CONFERENCE -- \"WE ARE LISTENING\" -- COULD\nNOT HAVE BEEN BETTER CHOSEN. NOR COULD THIS GATHERING HAVE\nBEEN MORE APPROPRIATELY TIMED IN LIGHT OF THE ANNOUNCEMENT\nLAST FRIDAY THAT THE STATE OF IDAHO WILL BE ONE OF FIVE TO\nTEST A MODEL NURSING HOME PATIENT OMBUDSMAN PROJECT UNDER A\nHARD-WON FEDERAL CONTRACT.\nI SAY HARD-WON BECAUSE IT WAS -- IN COMPETITION WITH MORE THAN\nA DOZEN STATES AND NATIONAL ORGANIZATIONS EAGER TO TRY OUT THEIR\nIDEAS ON OPENING UP NEW CHANNELS OF COMMUNICATIONS AMONG THE\nNURSING HOME PATIENT, THE NURSING HOME, AND THE GOVERNMENT AGENCIES\nRESPONSIBLE FOR SUPERVISING LONG TERM CARE FACILITIES.\nI CONGRATULATE THE STATE PEOPLE RESPONSIBLE FOR DEVELOPING THE\nINNOVATIVE IDEAS WHICH RANKED THE PROJECT HIGH AMONG THE\nAPPLICANTS. THE IDAHO PLAN IS PARTICULARLY IMAGINATIVE IN THE\nWAY IT WILL LINK AN ASSISTANT ATTORNEY GENERAL WITHIN THE\nDEPARTMENT OF SPECIAL SERVICES WITH REPRESENTATIVES OF OTHER\nSTATE AGENCIES, NURSING HOME OPERATORS AND PATIENTS, AND THIS\nPROJECT IS TO BE FURTHER COMMENDED FOR ITS PLAN TO CALL ON LOCAL\nORGANIZATIONS TO PROVIDE VOLUNTEER HELP. THIS IS THE KIND OF\nCITIZEN-INVOLVEMENT WITH LONG TERM CARE THAT WE HOPE WILL BE\nENCOURAGED AS THE OMBUDSMAN IDEA CATCHES ON THROUGHOUT THE\nHEALTH CARE SYSTEM,\n- 2 -\nTHREE OTHER STATES--PENNSYLVANIA, SOUTH CAROLINA AND WISCONSIN--\nAND THE NATIONAL COUNCIL OF SENIOR CITIZENS WHICH WILL WORK WITH\nTHE STATE OF MICHIGAN, HAVE ALSO RECEIVED DEMONSTRATION CONTRACTS\nAND WILL BE TESTING OTHER KINDS OF LINKAGES AND COMMUNICATIONS\nCHANNELS.\nWE HAVE HIGH HOPES FOR THESE FIVE TESTS AND WE ARE CONFIDENT\nTHAT OUT OF THIS YEAR-LONG EXPERIMENT WILL EVOLVE A WORKABLE\nPLAN FOR CREATING A NATIONAL PROGRAM OF REAL VALUE TO THE\nPATIENT, THE INDUSTRY, AND THE GOVERNMENT,\nI AM ALSO CONFIDENT THAT THE NURSING HOMES OF IDAHO WILL COOPERATE\nFULLY IN THIS EXPERIMENT IN \"LISTENING\" TO THEIR PATIENTS, AGAIN,\nTHE THEME OF THIS CONFERENCE BESPEAKS YOUR OBVIOUS CONCERN FOR THE\nPATIENTS ENTRUSTED TO YOUR CARE,\n\"LISTENING,\" AS ANYONE WHO HAS EVER WORKED IN OR AROUND HEALTH\nCARE KNOWS ONLY TOO WELL, IS A TOO-SELDOM PRACTICED ART. INDEED,\nTHERE CAN BE NO MORE SALIENT SYMPTOM OF WHAT MAY BE WRONG WITH\nANY ASPECT OF ANY HEALTH CARE FACILITY THAN THE INABILITY--OR\nUNWILLINGNESS--OF THOSE WHO SERVE PATIENTS TO HEAR THOSE PATIENTS\nWHEN THEY CALL OUT FOR HUMAN CONCERN,\nJUST AS THIS IS TRUE FOR HEALTH PROFESSIONALS AND ADMINISTRATORS,\nso IS IT TRUE FOR THOSE IN GOVERNMENT CHARGED WITH OVERSEEING THE\nQUALITY AND SAFETY OF CARE PROVIDED TO AMERICAN CITIZENS, AND IT\nIS ESPECIALLY TRUE FOR THOSE AT ALL LEVELS OF GOVERNMENT WHO ARE\nCONCERNED WITH THE LONG-NEGLECTED AREA OF LONG TERM CARE,\n- 3 -\nTHE PEOPLE WE ARE LISTENING TO IN WASHINGTON ARE THE VERY SAME\nPEOPLE YOU ARE TALKING ABOUT HERE TODAY-THE OLDER AMERICANS OF\nIDAHO AND THE OTHER 49 STATES, THE 21 MILLION OVER 65, AND MOST\nPARTICULARLY, THE MORE THAN ONE MILLION CONFINED TO LONG TERM\nCARE INSTITUTIONS.\nTHE PRESIDENT FIRST ARTICULATED HOW STRONGLY THEIR VOICES WERE\nBEING HEARD IN WASHINGTON NEARLY A YEAR AGO WHEN HE ANNOUNCED\nA COMPREHENSIVE ACTION PLAN ON LONG TERM CARE, His AIMS WERE\nSIMPLE AND DIRECT:\n-- UPGRADE LONG TERM CARE FACILITIES;\n-- UPGRADE THE WAYS GOVERNMENT AT ALL LEVELS MONITORS\nTHESE FACILITIES;\n-- UPGRADE CHANNELS OF COMMUNICATION BETWEEN THE PATIENT,\nHIS FAMILY, THE NURSING HOME AND GOVERNMENT AGENCIES\nCONCERNED WITH LONG TERM CARE;\n-- UPGRADE THE CAPABILITY AND CONSCIOUSNESS OF LONG\nTERM CARE PERSONNEL;\n-- AND, MOST IMPORTANTLY, UPGRADE OUR UNDERSTANDING\nOF LONG TERM CARE FACILITIES--LEARN WHAT THEY CAN\nAND CANNOT DO, AND CONSIDER WHAT ALTERNATIVE MODES\nAND LEVELS OF CARE MIGHT BE DEVELOPED TO ENSURE OUR\nOLDER CITIZENS THAT THAT RIGHT CARE, AT THE RIGHT\nTIME, AT THE RIGHT PLACE, AND AT THE RIGHT COST\nWILL BE THERE,\n- 4 -\nNow THIS MAY SOUND LIKE A LOT OF UPGRADING--AND IT IS, AND\nIT HAS BEEN, AND IS GOING TO BE, AN UPGRADE BATTLE ALL THE\nWAY. NOT BECAUSE NO ONE IN THE NURSING HOME INDUSTRY OR IN\nTHE GOVERNMENT OR AMONG THE PUBLIC HAS CARED IN THE PAST,\nBUT BECAUSE UNTIL VERY RECENTLY THERE HAVE NOT BEEN ENOUGH\nOF THESE ESSENTIAL ACTORS ON THE LONG TERM CARE STAGE TO\nCREATE AND MAINTAIN A SYSTEM OF THE QUALITY THAT OUR PEOPLE\nDEMAND.\nIT WAS TO FULFILL THIS DEMAND THAT THE PRESIDENT ORDERED THE\nFEDERAL GOVERNMENT TO MOVE BOLDLY AND RAPIDLY ALONG SEVERAL\nINTEGRAL FRONTS, THE EFFECTIVENESS OF THAT ACTION IS ALREADY\nBEING FELT\nOTHER\nYou ARE, OF COURSE, WELL AWARE OF THE MILESTONE WE HAVE JUST\nPASSED IN OUR EFFORTS TO UPGRADE STATE MEDICAID NURSING HOME\nINSPECTION PROGRAMS AND THROUGH THEM, NURSING HOMES THEMSELVES,\nREPORTED TO THE PRESIDENT AND THE PUBLIC IN JULY:\nTHAT\nFULLY 88 PERCENT OF THE NATION'S 7,000\nMEDICAID NURSING HOMES HAD PASSED RIGOROUS MUSTER AGAINST\nFEDERAL STANDARDS, WITH 24 PERCENT OF THESE MERITING FULL\nTWELVE-MONTH PROVIDER AGREEMENTS, INDICATING FULL CONFORMITY\nWITH THE MEDICAID STATUTE AND REGULATIONS. SLIGHTLY OVER 600\nDID NOT MAKE THE GRADE--AND, WERE EITHER DECERTIFIED BY THE STATES\nOR VOLUNTARILY WITHDREW FROM THE MEDICAID PROGRAM RATHER THAN\nATTEMPT TO MEASURE UP.\n217\nAND\nGERALD\n- 5 -\nYou ARE ALSO AWARE THAT WE HAVE SEEN A MARKED IMPROVEMENT IN\nTHE QUALITY OF STATE MEDICAID CERTIFICATION PROGRAMS SINCE\nLAST NOVEMBER WHEN WE FOUND NO FEWER THAN 39 STATES WITH MAJOR\nDEFICIENCIES. TODAY WE ARE REASONABLY CONFIDENT THAT EVERY\nSTATE HAS A SOUND SURVEY AND CERTIFICATION PROGRAM--AND WE\nINTEND TO CONTINUE TO MONITOR THESE PROGRAMS TO ENSURE THAT\nTHEY STAY THAT WAY.\nTHE OBVIOUS OBJECTIVE OF THIS PHASE OF THE NEW FEDERAL EFFORT\nWAS THREE-FOLD:\n-- To SERVE NOTICE ON THE STATES THAT FEDERAL STANDARDS\nARE FOREVERMORE TO BE FOLLOWED TO THE LETTER AND\nSPIRIT;\n-- To SERVE NOTICE ON THE INDIVIDUAL NURSING HOME\nOPERATOR THAT ANY FEDERAL PORTION OF HIS PATIENT\nCARE DOLLAR IS GOING TO BE PAID ONLY IF THAT\nPATIENT IS RECEIVING THE QUALITY OF CARE HE OR SHE\nIS ENTITLED TO;\n-- AND, MOST IMPORTANTLY, TO ASSURE THE INDIVIDUAL\nPATIENT THAT THE FULL BURDEN OF RESPONSIBILITY\nFOR THE QUALITY AND SAFETY OF HIS OR HER CARE IS\nNOW TO BE BORNE SQUARELY BY THE FEDERAL, STATE\nAND LOCAL GOVERNMENT AGENCIES SUPERVISING THAT\nCARE AND BY THE NURSING HOME PROVIDING THE SERVICES,\nWE BELIEVE THESE PURPOSES HAVE BEEN MET. AND WE TRUST THEY WILL\nCONTINUE TO BE MET BECAUSE WE DO NOT INTEND TO LET THE BUCK STOP\nHERE. JULY 1. HAS COME AND GONE, BUT THE FEDERAL PRESENCE WILL\nLINGER ON IN THE ONGOING PROCESS OF KEEPING THE STATES, AND THROUGH\nTHEM MEDICAID NURSING HOMES, UP TO THE LEVEL OF QUALITY CARE THAT\nTHE FEDERAL DOLLAR IS INTENDED TO HELP PROVIDE.\n- 6 -\nSOME OF THE MOST IMPORTANT RESULTS OF THIS MASSIVE CERTIFICATION\nEFFORT ARE NOT SO IMMEDIATELY OBVIOUS IN THE STATISTICS ON HOW\nMANY HOMES IN HOW MANY STATES DID OR DID NOT MEET THE MARK, I\nREFER HERE TO THE GREAT MASS OF DATA THAT HAS BEEN ENGENDERED BY\nTHIS NATIONWIDE EFFORT,\nWE NOW HAVE, FOR THE FIRST TIME IN THE HISTORY OF GOVERNMENT\nCONCERN WITH LONG TERM CARE, THE MAKINGS OF A TRUE PICTURE OF\nTHE LONG TERM CARE SYSTEM, WE KNOW WHAT'S RIGHT WITH IT--AND\nWE KNOW WHAT'S WRONG, WE CAN CATALOG DEFICIENCIES AND WE CAN\nDISCERN ANY PATTERNS WHICH MAY BE REFLECTED IN THEM. WE CAN\nCOMPARE FACILITIES IN SINGLE STATES WITH THE NATIONAL PICTURE\nAND PERHAPS LEARN WHERE AND HOW IDIOSYNCRACIES IN STATE PROGRAMS\nAND LAWS MAY REFLECT ON THE QUALITY OF THEIR FACILITIES.\nAND MOST IMPORTANTLY, WE CAN LOOK FORWARD TO DEVELOPING FROM\nTHIS DATA IDEAS ON HOW GOVERNMENT REGULATIONS AND REIMBURSEMENT\nPOLICIES MIGHT BETTER HELP THE LONG TERM CARE SYSTEM UPGRADE\nITSELF,\nTHIS KIND OF INFORMATION -- AND THESE KINDS OF IDEAS -- WILL PRO-\nVIDE A MAJOR SEGMENT OF THE INPUT WE NEED FOR THE STUDY OF LONG\nTERM CARE WE NOW HAVE UNDERWAY IN WASHINGTON, OUT OF THIS STUDY,\nWHICH WE EXPECT TO COMPLETE BY THE END OF NEXT YEAR, WILL COME\nANOTHER FIRST FOR FEDERAL CONCERN WITH LONG TERM CARE: THE\nDEVELOPMENT OF A TRULY COMPREHENSIVE FEDERAL PHILOSOPHY TOWARD\nTHE DAY-TO-DAY HEALTH AND HEALTH-RELATED NEEDS OF OLDER AMERICANS,\nA PHILOSOPHY FOUNDED IN AN ENLIGHTENED ATTITUDE TOWARD AGING AND\nGROUNDED IN INNOVATIVE APPLICATIONS OF THE FULL SPAN OF RESOURCES\n- 7 -\nAVAILABLE TO US FROM THE ORGANIZATIONAL, SOCIAL, BEHAVIORIAL AND\nBIO-MEDICAL SCIENCES, I NEED NOT DWELL HERE ON THE NEED FOR SUCH\nA BREAKTHROUGH IN WASHINGTON. WE ARE SUFFERING TODAY FROM THE\nABSENCE OF SUCH A POLICY OVER THE PAST SEVERAL DECADES WHEN TOO\nFEW IN WASHINGTON WERE LISTENING, AND NOT ENOUGH WAS BEING DONE\nTO HELP MEET THE REAL NEEDS OF OUR LONG TERM CARE POPULATION.\nTHIS BEING OUR CONTEXT, THE WORK BEING DONE NOW REPRESENTS A\nHISTORIC OPPORTUNITY TO HELP FASHION THE FUTURE SHAPE OF LONG\nTERM CARE IN AMERICA.\nWE ARE FOCUSING OUR STUDIES ALONG THREE PRIMARY LINES WHERE TOO\nLITTLE -- AND IN SOME CASES NOTHING AT ALL --- IS KNOWN ABOUT\nEITHER LONG TERM CARE OR THE POTENTIAL IMPACT THAT GOVERNMENTAL\nPOLICY AND REIMBURSEMENT PROCEDURES MAY HAVE ON THAT CARE,\nTHE FIRST OF THESE FOCAL POINTS INVOLVES POTENTIAL ALTERNATIVES\nTO INSTITUTIONAL CARE OF THE ELDERLY AND CHRONICALLY ILL AND\nINCLUDES EVALUATION OF THEIR EXPECTED IMPACT OF THE HUMAN NEEDS\nOF THE PATIENT, ON BED NEEDS, AND ON COSTS,\nTHE SECOND CONCERNS THE QUALITY OF ALL MODES OF LONG TERM CARE,\nHERE, WE ARE HOPING TO DEVELOP WORKABLE METHODS OF QUANTIFYING\nINDICATORS THAT WILL TELL US QUICKLY AND SURELY WHICH FACTORS\nHAVE WHAT EFFECT ON THE QUALITY OF PATIENT SERVICES,\nTHE THIRD INVOLVES DATA COLLECTION AND ANALYSIS, WITH PARTICULAR\nSTRESS ON DEVELOPING INNOVATIVE WAYS TO ENABLE HEALTH PROFESSIONALS,\nTHE INDUSTRY, AND GOVERNMENT TO READILY MONITOR PROGRESS AND\nINDENTIFY PROBLEM AREAS.\n- 8 -\nGROUNDWORK FOR THE STUDY IS BEING DONE BOTH WITHIN AND WITHOUT\nTHE FEDERAL GOVERNMENT. IN THE STUDY, AS IN ALL OTHER ASPECTS\nOF THE LONG TERM CARE PROGRAM, WE ARE WORKING CLOSELY WITH ALL\nFEDERAL OFFICES AND AGENCIES WITH RESPONSIBILITY FOR OR INTEREST\nIN THE PROBLEMS OF THE AGING RANGING FROM THE ADMINISTRATION ON\nAGING TO THE VETERANS ADMINISTRATION AND THE DEPARTMENT OF HOUSING\nAND URBAN DEVELOPMENT.\nI CANNOT STRESS TOO MUCH THAT THE DEVELOPMENT OF THIS PROJECT WILL\nNOT TAKE PLACE IN A FEDERAL ECHO CHAMBER. WE ARE TAKING GREAT\nPAINS TO ENSURE THAT THE VOICES OF EXPERIENCE AND EXPERTISE FROM\nALL POSSIBLE POINTS ARE LISTENED TO IN THE COURSE OF OUR WORK.\nAMONG THE MOST ARTICULATE VOICES SHOULD BE THOSE OF THE LONG TERM\nCARE INDUSTRY ITSELF -- THE VOICES OF NATIONAL AND STATE ASSOCIA-\nTIONS, AND THE VOICES OF INDIVIDUAL FACILITY OPERATORS. WE WANT\nTO HEAR WHAT YOU HAVE TO SAY AND WE ARE NOW DEVELOPING THE\nCAPABILITY WITHIN MY OFFICE TO ENSURE THAT YOU WILL HAVE OUR EAR.\nTo FACILITATE YOUR COMMUNICATION WITH US, AND TO ACTIVELY SOLICIT\nYOUR IDEAS, I HAVE ASSIGNED MY ASSISTANT FOR HEALTH POLICY,\nPAUL B. SIMMONS, TO WORK WITH NATIONAL AND STATE NURSING HOME AS-\nSOCIATIONS AND WITH OTHER GROUPS INVOLVED IN LONG TERM CARE. I\nURGE YOU TO GET IN TOUCH WITH HIM AT ANY TIME. HE WILL BE\nRESPONSIBLE FOR OPENING -- AND KEEPING OPEN -- DIRECT LINES INTO\nTHE FEDERAL GOVERNMENT FOR ANYONE WITH. ANYTHING TO SAY ABOUT LONG\nTERM CARE.\n- 9 -\nIN CLOSING I WANT TO TOUCH BRIEFLY ON THE PROGRESS WE HAVE BEEN\nMAKING ALONG SEVERAL OTHER FRONTS OF THE FEDERAL LONG TERM CARE\nPROGRAM,\nYou WILL SOON BE SEEING THE FIRST PUBLICATION OF FEDERAL MEDICAID\nSTANDARDS FOR INTERMEDIATE CARE FACILITIES, WE EXPECT THESE\nWILL BE READY FOR COMMENT BY LATE SUMMER AND TO BE READY FOR\nIMPLEMENTATION IN THE FALL.\nWE ALSO EXPECT TO FINISH UP SOON ON THE DEVELOPMENT OF JOINT\nMEDICARE-MEDICAID NURSING HOME STANDARDS WHICH WILL COORDINATE\nAND SIMPLIFY VIRTUALLY ALL COMPLEMENTARY ASPECTS OF THESE PROGRAMS,\nOUR TRAINING PROGRAMS ARE ALSO RUNNING AT HIGH MOMENTUM. WE HAVE\nNOW REACHED MORE THAN 700 OF THE 1100 STATE MEDICAID NURSING HOME\nINSPECTORS IN THE FIELD WITH UNIVERSITY-BASED TRAINING COURSES,\nWE HOPE TO REACH THE REMAINING 400 BEFORE THE END OF THE YEAR,\nAND WE FURTHER HOPE THAT THE CONGRESS WILL ACT ON THE PRESIDENT'S\nPROPOSAL THAT THE FEDERAL GOVERNMENT ASSUME THE FULL COSTS OF\nSTATE MEDICAID NURSING HOME INSPECTION PROGRAMS, SUCH A MOVE WOULD\nENCOURAGE THE STATES TO EXPAND AND UPGRADE THEIR ENFORCEMENT\nCAPABILITIES,\nAND FINALLY, OUR TRAINING PROGRAMS FOR NURSING HOME PERSONNEL ARE\nALSO MOVING ALONG RAPIDLY. WE EXPECT TO REACH UPWARDS OF 20,000\nADMINISTRATORS, PHYSICIANS, NURSES AND ACTIVITIES DIRECTORS DURING\nEACH OF THE FIRST TWO FULL YEARS OF THIS EFFORT. AND FOR THE LONG\nRUN, WE ARE WORKING NOW ON DEVELOPING WHOLLY NEW METHODS OF BRINGING\nCRITICALLY NEEDED TRAINING DIRECTLY TO THE 500,000 PEOPLE WORKING\nIN THE LONG TERM CARE FACILITY SETTING, THROUGHOUT THE DEVELOPMENTAL\n- 10 -\nAND TRAINING ASPECTS OF THIS PROGRAM, WE ARE RELYING HEAVILY ON THE\nEXPERTISE OF FOUR MAJOR GROUPS UNDER CONTRACT WITH US: THE AMERICAN\nNURSING HOME ASSOCIATION; THE ASSOCIATION OF UNIVERSITY PROGRAMS IN\nHOSPITAL ADMINISTRATION; THE AMERICAN MEDICAL ASSOCIATION; AND THE\nAMERICAN NURSES' ASSOCIATION.\nSINCE WE ARE TALKING HERE TODAY ABOUT THE SPECIAL HEALTH PROBLEMS\nOF OLDER AMERICANS, AND WHAT ALL OF US CAN DO TO HELP RESOLVE THEM,\nIT SEEMS A PROPOS TO LEAVE YOU WITH A THOUGHT ASCRIBED TO AMBROSE\nBIERCE, A ONE-TIME OLDER AMERICAN WHOSE OWN SPECIAL PROBLEM SEEMS\nTO HAVE BEEN A CHRONIC BAD MOOD.\n\"RESPONSIBILITY,\" HE SAID, \"IS A DETACHABLE BURDEN EASILY SHIFTED\nFROM ONE'S OWN SHOULDERS TO THOSE OF GOD, FATE, FORTUNE, LUCK --\nOR ONE'S NEIGHBOR.\"\nI JUDGE FROM THE TONE AND THRUST OF THIS CONFERENCE THAT NO ONE IN\nTHIS ROOM NEED BE REMINDED OF HIS OR HER SHARE OF RESPONSIBILITY\nFOR THE FUTURE OF LONG TERM CARE IN IDAHO, AND I SENSE FROM THE\nSPIRIT OF RESPONSIBILITY IMPLICIT IN YOUR AGENDA THIS WEEK THAT\nIF THERE IS ANY SHIFTING OF THAT BURDEN, IT WILL BE TO PLACE EVEN\nMORE OF IT UPON YOUR OWN SHOULDERS,\nTEXT OF REMARKS BY UNDER SECRETARY\nJOHN G. VENEMAN\nDEPARTMENT OF HEALTH, EDUCATION, AND WELFARE\nBEFORE THE\nAMERICAN NURSING HOME ASSOCIATION\nANAHEIM, CALIFORNIA\nNOVEMBER 5, 1971\nTwo years ago, it was my privilege to address\nyour Annual Convention in Houston, and I have not\nforgotten in those two years that many of the\nmembers of your Association, the proprietary nursing\nhome industry, provide most of the institutional\ncare of the aging in America.\nPrivately owned homes care for nearly 67\npercent of all the aging receiving institutional\ncare. This is a solemn responsibility, and I know\nthat you bear it with a great sense of honor and\npride. I also know that you share the anguish of\nyour fellow Americans at the tragic nursing home\nfire at Honesdales, Pennsylvania this month. A fire\nthat resulted in the death of 15 aged and helpless\nAmericans.\nIt would be easy to find in this home a\nready scapegoat for the problems that beset the\nnursing home industry, and certainly there are\nlessons to be learned from this and similar recent\ntragedies. But I am not going to indulge in\nscapegoating today. That would be too easy. It\nwould also be all too wrong.\nThe fact is, there is blame enough to go\naround for everyone in the nursing home fires and\nother incidents that have made headlines in the\npast. The problem is not to find the scapegoats,\nit is to reform the system that produces the scapegoats.\nSolutions do not lie in hand-wringing\ndeclarations, or pious finger-pointing. Solutions\nlie in acting to right the wrongs of the present\nsystem for administering, regulating and enforcing\nstandards of safety and patient care. Those\nsolutions have to be realistic. They cannot be based\nupon the flimsy paper of publicity releases and\npanic solutions.\nAs you know, President Nixon has announced\nhis firm intention of assuring that our aging receive\ngood care in safe institutions. His speech in New\nHampshire on August 6th was not just words. Nor was\nit just a call to action. It was action.\nIn that speech the President issued eight\naction directives and charged the Department of\nHealth, Education, and Welfare with carrying them\nout, and we are carrying them out. Last week, I\nreported in public testimony before Senator Moss's\n-3-\nSubcommittee on Long Term Care of the Aging what\nHEW is doing to implement those eight directives.\nOne big problem that we had already begun to\nact on is the indifferent performance of many\nstates in enforcing Medicaid standards. The record\nis not a good one.\nLast May, the General Accounting Office looked\ninto the Medicaid enforcement effort of 90 homes in\nthree states: Michigan, New York and Oklahoma. That\nstudy found deficiencies in over half of these homes,\nand discovered that 44 of them failed even to meet\nfire safety standards. That should tell us one\nthing. The clock may already be ticking toward\nthe next tragic nursing home fire. HEW is acting\nto stay the hands of that clock. Last week, final\nfire and safety regulations for Medicare were published.\nThese new regulations require extended care facilities\nand hospitals to comply with the Life Safety Code.\nThis will make Medicare fire safety standards the\nsame as Medicaid's.\nHEW conducted its own enforcement survey\nrecently. Among the 15 States surveyed, Medicaid\nstandards were not even: being used to certify homes.\nContrary to law, State Licensure Standards were\nbeing used to certify homes. Your Association has\n-4-\nrepeatedly pointed out that there is no uniformity\namong state licensure standards. So one of the\nfirst things we have to do is to bring about uniformity.\nThis month, a special HEW survey team launched\na crash effort to find out how well each State is\nenforcing Medicaid rules. This team has already\ngone into 34 States, and it will visit the remaining\n16 by November 15th.\nQuite frankly, we aren't expecting to find\nany miraculous improvements since the recent spot\nsurveys, but we expect to find out where the problems\nare, what the problems are, and what we at the\nFederal level can do to solve them.\nThe Administration and enforcement of Medicaid\nsafety and patient care regulations is still a state\nresponsibility, as the law requires. However, an\nincreasing Federal presence among state regulatory\nagencies is clearly needed. That's why the President\nhas asked Congress to appropriate funds to finance an\nadditional 150 Federal positions for nursing home\nenforcement. When these funds become available, most\nof those 150 persons will be assigned to work directly\nwith the States, out of HEW's regional offices.\nI suppose you could characterize this as looking\nover the States' shoulders, and I suppose you would\nbe right. But the law gives us this responsibility\nand we will soon have the additional personnel needed\nto fully discharge it.\nWe know, and you know, that monitoring the\nenforcement efforts of the States isn't going to\nproduce instant miracles. The actual enforcement\nof Medicaid standards has to be done by the States\nthemselves. That's why the President is going to\nask Congress to authorize the Federal Government\nto pick up the full cost of state nursing home\ninspection programs, and also why the President has\ndirected that an additional 2,000 state nursing\nhome inspectors be trained at Federal expense over\nthe next 18 months. HEW has already begun that\ntraining. Over half of these 2,000 state inspectors\nwill be trained within a year, and all 2,000 will be\ntrained within 18 months.\nSomething else your Association has called for\nis the training of more personnel serving the aged\nin facilities. We fully agree with you. The\nPresident has called for 'short-term' training\ncourses for 20,000 health personnel now serving\nthe aging in institutions, and we intend to see\nto it that these people get that training within\nthe next 18 months. These, as you know, are solutions\nthat will bear fruit in the future. But meanwhile,\n-6-\nthere is today, and one of the biggest 'today'\nproblems to be faced is money.\nAs you have pointed out, a tougher enforcement\neffort means that nursing homes will have to spend\nmore money to improve their facilities. We have\na uniform fire safety code now. That code calls\nfor things like firewalls, sprinkler systems and\nflame-resistant materials. To make that code\nenforceable, a way must be found to finance the\ncost of these capital improvements.\nI know you are concerned about this, and you\nhave suggested a solution.\nWe in HEW are aware of your proposal to have\nthe Federal Government offer low-cost guaranteed\nloans of up to $50,000 to nursing homes that need\nto make capital improvements in order to meet\nstandards.\nI wish I could have come here today with the\nnews that your proposal has been favorably received,\nbut I can't. But I can tell you this -- your proposal\nis being actively considered, and although this news\nmay not make your pulse quicken, I hope that it conveys\nto you that we understand your problem, and that we\ntoo appreciate the need to help you find a solution\nto your fiscal problem.\nBut meanwhile, while you are awaiting decisions,\nthere are several misconceptions about the Admini-\nstration's initiatives in the nursing home field\nthat I want to try to clear up.\nOne misconception is that the crackdown is\ngoing to mean wholesale withdrawal of Federal\ncertification. Another misconception - quite the\nopposite - is that the President's firm language\nis just so many words.\nFirst, let me assure you on this second point;\nAnyone who assumes that we aren't going to withdraw\nfunds from institutions that won't meet standards\nis attaching a false and dangerous interpretation\nto the President's remarks. The President has told\nit like it is, \"We are not going to pay for substandard\nsubhuman care for our aging.\"\nNow as to the first misconception, that we plan\na wholesale purge of institutions that don't measure\nup in every way. That's wrong too. It would serve\nno purpose to force the wholesale withdrawal of\nFederal funds to facilities that are visibly trying\nto measure up, but we intend to develop a monitoring\nand enforcement system that will apply selective\npressure. Selective pressure does not mean withdrawing\ncertification from every institution that fails to\nmeet every minor rule. It does mean that inspectors\nwill be around to visit and to spot deficiencies,\nand to come back again, perhaps unannounced, to\nsee with their own eyes whether a facility has\nmade visible progress toward correcting those\ndeficiencies.\nRight now, a handful of states have a fair\neyeball enforcement program. The President's\nintention is to ensure that every state gets that\nkind of enforcement machinery.\nAnother kind of misconception has also sprung\nup since the President said he would cut off Federal\nfunds to substandard homes. There are some who\nsimply don't believe that's going to happen. Where\nwould they put the patients if homes are forced to\nclose their doors for lack of funds? So goes reasoning.\nAs far as Medicare patients are concerned,\nthat's no problem. Any Medicare patient currently\nhoused in a facility that loses its Medicare certi-\nfication remains in that home until the issue is\nresolved, or until their condition no longer requires\nthem to remain in that institution.\nThe States, however, do possess the authority\nto close down any facility that they have decertified\nfor Medicaid. In the past, states have been under-\nstandably reluctant to take that action, fearing that\nthey would create real hardships among patients displac\nby the closing of a facility. And indeed, credible\nenforcement cannot be achieved by the threat of\nincredible actions.\nNo one would put up with having aging patients\nthrown into the streets. That would only punish\nthe victims. It would be like blowing up the bridge\nto relieve the traffic jam, but we in HEW are taking\nsteps to make the incredible threat a credible\npossibility.\nWe are keeping close track of how many beds\nare available in certain Federal hospitals, such\nas those operated by the Public Health Service.\nThis is being done with the view of making empty\nbeds available for the prompt use of Medicaid patients\nwho would be displaced by the impending closing of an\ninstitution that a state had decertified for reimbursement.\nWe will also work closely with state certification\nagencies to pinpoint other facilities that can be used\nto house and care for these patients, and we are prepared\nto take whatever action is needed to ensure that no\naging patient suffers hardship because an institution\nfaces Medicaid decertification. We hope that further\nclosings will not occur, but if they do, we will see\nto it that facilities are standing by to handle the\npatient population involved.\n-10-\nSome of what I've said to you today may sound\nlike tough talk. Maybe it is, but it is also honest\ntalk. Frankly, I don't think that anything I've\nsaid is very far opposed to what your organization\nstands for.\nI've read your President's recent speeches,\nand I've read that part of your Association's\nconstitution that says; \"The object of this Association\nshall be to improve the standards of service and\nAdministration of member nursing homes, to secure\nand merit public and official recognition and approval\nof the work of nursing homes\n\"\nThat's a good\nstatement, and I know you plan to live up to it.\nAny other course of action would be disastrous, not\nonly for our aging, who depend upon you, but also\nfor the nursing home industry itself. Because unless\nthe American people see continued and visible progress\nin upgrading the institutions for our aging, there\nwill be calls for tougher and tougher legislation.\nYou don't need me to tell you that fires in\nnursing homes move us closer to that possibility.\nI hope and trust that your Association takes an\naggressive stand in self-policing. It's worth a\nton of legislation.\nI see some signs that you plan to move on\nthe self-regulation route. The fact that your\nPresident, David Mosher, wrote President Nixon to\nexpress your Association's support of his\ninitiatives is refreshing. We in HEW are also\nhappy that you are keeping your lines of communication\nopen with us.\nLast month, your representatives sat down with\nsome of our people and held a good brass-tacks\ndiscussion about the Administration's nursing home\ninitiatives. That's another good sign. Our\ncommunications with you will continue to improve\nrapidly.\nAs you know, Dr. Merlin K. DuVal, Assistant\nSecretary for Health and Scientific Affairs is\nthe man charged with success of failure of our\nhursing home initiatives. But he won't be alone\nin this responsibility.\nSecretary Richardson has named one of the\nNation's top experts in nursing homes to assist\nDr. DuVal. Her name is Mrs. Marie Callender.\nShe served recently as Assistant Professor of the\nDepartment of Clinical Medicine and Health Care at\nthe University of Connecticut School of Medicine.\nFew people know their way around the nursing home\nfield any better than Mrs. Callender. So your\ndiscussions with her are sure to be - shall we\nsay -- 'meaningful. I\nIn any case, my present feeling is that your\nAssociation -- and you as individuals -- are not\nfar away from what the President, the Congress\nand HEW want to see happen soon in the nursing\nhome field. That's a good feeling, and with your\nconcurrence, that's the message I plan to take\nback with me when I return to Washington.\nThank you.\n# # #\nREMARKS FOR THE UNDER SECRETARY\nDEDICATION OF THE METROPOLITAN HOSPITAL FOR EXTENDED CARE\nWashington, D.C.\nNovember 19, 1970\nAt a time when we are all searching for new ways to solve our\nhealth care problems, and when health promises to be a significant political\nissue in future campaigns, I am very happy to be able to represent the\nAdministration in dedicating this extended care center.\nThe extended care facility has taken its place, during recent\nyears, as an important component in the continuum of medical care. The\nstrengthem\ncooleme\nwinton\nopening of each new institituion, such as this one, stregthens the implica-\ntion of comprehensive community he alth planning and meets a clearly\nestablished health need.\nBut amid such great expectations, there has developed in recent\nmonths a liturgy of criticism of facilities such as this. There are many\nmembers of the medical community who sincerely believe that we are\non the road to the tot al depersonalization of medical care, toward a\nstate of affairs in which patients and physicians alike will be reduced\nto numbers, to be processed through computers, with virtually no regard\nfor the personal interactions that are at the heart of the practice of medicine.\nOne Congressman has gone so far as to refer to nursing homes\nas \"human junkyards\" and a Washington Post article last week speculated\nLIDERAY\nThe American system of care is passing through a difficult\nperiod, a period of change, of re-evaluations, of innovation, and frankly\nof a crisis of confidence. If we view this period as a time to dig in and\nhold onto things as they are, we will face an overwhelming demand for\nuprooting of the whole national system of health care.\nIf, on the ot her hand, we accept the need for change and take\nadvantage of the opportunities for orderly evolution based on the great\nstrengths. that are to be found in the pluralistic American health enterprise,\nthen I think we will move into annera of unmatched excellence in health\ncare.\nA critical ingredient of a scheme such as this is the involvement\nof all segments of the society. It is essential that the innovative business\nskills that characterize the American free enterprise system be brought\nto bear upon the health care delivery system.\nAnd this is another of the criteria for effective care which this\nextended care facility satisfied. In this sense, it is truly a model for\nthe nation and we intend to encour age the development of other models\nalong the same lines.\nAll of the components of an effective comprehensive health\nstrategy have a difficult task ahead of them and that is to combat the\ncynicism of the American people when it comes to the quality of health\n-2-\nupon the use of potent tranquilizers in nursing homes as effective\n\"chemical strait-jackets\" for the aging.\nRecognining only the as say Indian that I do between not share nursinghomes such apprehensions, and extended Plans care\nyour plans\nfor this facility\nemphasize the pleasant atmosphere and careful attention\nthat patients will receive. And so, I think, on the contrary that as health\ncare for individuals becomes more continuous, as the emphasis moves\ntoward health maintenance and away from acute care, that physicians\nwill develop a rapport with their patients much mor e conducive to the\nbest of health care. And that is what the doctor-patient relationship\nis all about.\nLast year, the Federal Government spent $500 million on\nMedicare reimbursements to extended care facilities. Obviously, we\nhold responsibility for insuring that the care that our Medicare beneficiaries\nreceive is high quality, comprehensive care at the lowest possible cost.\nAnd that is why I am so happy, and the Administration is so willing, to\nencourage the establishment of facilities such as this one which offer\npatients just such care as this,\n\"Overuse of high cost acute facilities is one of our most\ncrucial health care problems. There is a growing need for lower cost\nalternatives, including extended care facilities\" These are the words\nof former Secretary Finch, and they characterize the attitude of the entire\nAdministration.\n-4-\ncare they are able to obtain.\nsuch\nA recent Harris survey gives evidence of this widespread\ndiscontent.\nConducted in over 1500 households around the country, the\nsurvey came up with some significant findings, and some startling ones,\nhave\nin spite of the fact that we, in government, had long been aware of a\ndeep-seated resentment and concern among the American people.\n- 63 per cent of the people questioned felt that doctors try\nto jam so many patients into office hours that they don't give enough\ntime and attention to anyone.\n- 62 per cent of the people agree that, since Medicare and\nMedicaid have come in, doctors have jumped their fees to take advantage\nof it.\n53 per cent of the people questioned felt that, if doctors paid\nmore attention to preventive medicine, their patients could avoid a lot\nof illness.\nThese, and other significant findings all tend to reinforce a\nfeeling we in the government have had for a long time\nthat there\ndoes exist this \"crisis in confidence\" as regards medical care and the\nmedical profession.\n-5-\nOf course, we feel that we have some responsibility for dealing\nwith this trend, but I must emphasize that we cannot do it alone. Doctors\nwill have to look closely at these statistics and even more closely at\ntheir own habits and procedures.\nMedical schools will have to weigh the benefits of their\nresearch programs against the long-term benefits to the public of larger\nteaching programs. We face very critical manpower shortages, and yet\nmany of our medical schools continue to pursue irrelevant research\nobjectives at the expense of turning out more doctors.\nI am happy to see that this facility will be dealing with this\nproblem of manpower by offering teaching and training programs, especially\nto the under employed.\nI suppose the point of all this is that we must work together\nif we are to confront and conquer the very severe problemSof costs,\nmanpower and resources. We will have to explore a variety of routes\ntoward the same goal\nthat is to enable every person in the United\nStates to benefit equally in the tremendous national investment in health\nand health care.\nThe Metropolitan Hospital for Extended Care will offer the\npeople of the District of Columbia low cost care, ideally located, and\n-6-\nin pleasant surroundings. It will offer doctors in this area the opportunity\nof reaching their patients at least once, if not twice a day, and they\nwill be able to work in modern, convenient facilities with ample support\nstaff.\nWe in the government are committed to the development\nof this facility and others like it. We believe it is truly an essential\ningredient in whatever health scheme we should settle upon to solve\nthe nation's health problems.\nAnd I know that everyone involved in the planning and\nproviding of health care within the Administration joinsme in thanking\nyou for helping us through the establishment of the Metropolitan Hospital\nfor Extended Care.\nPARTIAL TEXT OF REMARKS BY\nUNDER SECRETARY JOHN G. VENEMAN\nDEPARTMENT OF HEALTH, EDUCATION, AND WELFARE\nBEFORE THE\nGOVERNOR'S CONFERENCE ON COMMUNITY HEALTH SERVICES\nOKLAHOMA CITY, OKLAHOMA\nTHURSDAY, MARCH 12, 1970\nI am pleased to be here tonight, to bring greetings from\nSecretary Finch, and to represent the Department of Health, Education,\nand Welfare at this important conference.\nI would like to thank Governor Bartlett for asking me to\naddress this distinguished group and for calling attention to the health\nproblems we face.\nOklahoma has an active and effective State Health Planning\nAgency, reaching about 60 percent of the State's population. I see from\nyour brochure that recent \"quality of life\" studies ranked Oklahoma 17th\namong the 50 States in achievement of health goals, and I know your\nPlanning Agency is outlining priorities and choices for achieving even\nbetter health for all citizens of your State. Their comprehensive approach\ncovering all areas of physical, mental and environmental health with\nthe commitment and dedication exemplified by groups like yours, can\nmeet the growing challenge of effective health care in Oklahoma. The\nsituation is not so encouraging in other parts of the country.\nFORD LIBRARY is GERALD\nparts of the system are private and largely autonomous organizations.\nIt is an industry which lacks to a large degree competition, which is\nalmost completely lacking in organizational relationships and community-\nwide linkages, and which is unable to organize itself to meet an increas-\ning demand for services. The question for the governmental authorities\nFederal, State and local\n.therefore is, how can we develop a compre-\nhensive system of health care delivery without massive Federal inter-\nvention and regulation?\nLast July Secretary. Finch warned that \"what is ultimately\nat stake is the pluralistic, independent, voluntary nature of our health\ncare system\" and that \"We will lose it to pressures for monolithic,\ngovernment-dominated medical care unless we can make that system\nwork for everyone in this Nation. =\nLet me outline some of the problems we face in accomplish-\ning this goal.\nThe escalation of health care costs is perhaps our most\npublicized problem for the immediate future.\nIn 1955, total expenditures for health services were just\nover $17 billion. By 1965, they had risen to over $37 billion. The\nlatest estimates for 1969 show that health care is now a $60 billion\nenterprise. By 1975, estimates indicate that we will be spending\nbetween $90 and $100 billion on health services.\nIn spite of the great increase in expenditures for health,\nthe indicators of health status show us as lagging behind other nations.\nIn world ranking, we have slipped to fifteenth in infant mortality and\n22nd in life expectancy for men.\n:\nThe implementation of Medicare and Medicaid have multiplied\nthe stresses and strains on this fragile system. The great increases\nin numbers of patients demanding and receiving health care, as well\nas the rise in the proportion of total funds for health provided from\npublic sources, have not been accompanied. by a rise in equitable\nutilization of health care resources for all members of society.\nFirst, there are vast shortages of resources. For example,\nunder the current conditions, we are short about 50,000 physicians,\nand a recent study shows that modernization of our decaying hospital\nfacilities would cost at least $6 billion.\nSecond, we are not only short on resources, they are also\npoorly distributed. For example, in one area of Harlem, there were\n50 physicians to serve 25,000 people 25 years ago; today, there are\nORD\n5 physicians for 50,000.\nGERALD\nLIDRANY\n4\nWhat these problems represent is an area of social\nwelfare in which, more than in any other, we have derived limited\nresults from vast amounts of money and an abundance of facilities.\nThe problem is clearly not one of availability of funds.\nI\nThe stake of the Federal Government in this area is\nreflected in the fact that it is currently purchasing more than 25 per-\ncent of the output of the health care system, while State and local\ngovernments are purchasing another 12 percent for a total of 37 percent.\nThe three levels of government combined now purchase more than half\nof the hospital care in this Nation.\nThese figures indicate that the use of its purchasing\npower is probably the government's primary source of leverage to\ninitiate changes in the organization and delivery of health care.\nHow are we to use this leverage? To what extent should\nit be used to change present patterns in an essentially private system\nand to preserve that system?\nLet me talk about some of the initiatives the government\nhas already taken\nand then mention the long range picture.\nSome of these initiatives do deal with the financing of\nhealth services. I happen to feel that these are the most immediate\nchanges we can make. The Health Cost Effectiveness Amendments\nof 1969, and the preliminary recommendations of the Medicaid Task\nForce, for example, are intended to improve the effectiveness of\nhealth care financing mechanisms.\nThey reflect the feeling of the Administration that it is\nnow time to make some fundamental changes in the law which governs\nMedicare and Medicaid reimbursement. We need an incentive system\nof institutional reimbursement and we need changes in the law that\nwill help control the increases in the amount that the Medicare pro-\ngram will recognize in the charges of individual practitioners.\nIn the case of hospitals and other institutional providers,\nreimbursement is now on a retroactive basis. Consequently, facilities\ndo not have : strong economic reasons for trying to improve the\nefficiency of their operation.\n:\n:\nI think we should move as quickly as possible in the\ndirection of prospective rather than retroactive reimbursement. With\nrates set in advance, a provider would be challenged to stay within\nthe limits of the known reimbursement and would share in savings\nthat come from economies achieved through effective management.\nFurthermore, our programs would no longer have only a\npassive role in responding to costs incurred by providers. They would\nhave an active role in influencing in advance the amounts which will\nbe made available for institutional health care.\n-6-\nI would not want to minimize the difficulty that would\naccompany the introduction of this prospective approach to reimburse-\nment. Implementation will take time, but I believe that the benefits\nmerit such an effort.\nWe have also recommended that the law should be changed\nso as to limit further the rate at which increases in physicians fees\nwould be recognized by Medicare.\nRealistically, charges under the current program and the\nfees recognized by carriers reflect whatever physicians choose to\n3\ncharge the public generally\nin a market where growing demand is\npressing increasingly on the limited supply of health personnel.\nWe are also proposing for the Medicaid program modifi-\ncations in the rate of Federal participation with incentives for the use\nof long term institutional care. Unfortunately, statistics show that\na significant factor in skyrocketing costs can be traced to the practice\nof needlessly retaining patients in costly hospital beds simply because\nthe government is around to pay the bills. We have all heard it said\nthat you cannot legislate morality, but limitations on the length of\nstay for which there will be full Federal participation and a system of\n\"utilization review\" would go a long way toward curbing the practice.\nWe will not reach our objectives through solutions which\ndeal solely with financial problems. Our efforts must represent a\nstrategy for solution to all aspects of the total health problem.\nWith this in mind, the Administration has introduced revisions in\nother health programs which would improve the organization and\ndelivery of health care. We would encourage the development of\nambulatory care programs. The proposed Health Services Improvement\nAct of 1970 focuses sharply on improving the efficiency and effective-\nness of our health systems and targets the efforts of the Comprehensive\nHealth Planning and SErvices program, the Regional Medical Programs\nand the efforts in health services research and development toward\nthese ends. We are linking the reimbursement policies under Medicare\nand Medicaid to mesh with these programs.\nWe will be moving in the direction of improvement of the\norganization of health services at the community level. Our responsi-\nbility will be to assist in the development of new social institutions\nat the community level which will draw together the health resources,\nthe providers of health care, and the consumers into a community\ntrusteeship for health. The need for such an nstitution was\nrecognized five years ago by the National Commission on Community\nHealth Services chaired by a distinguished former Secretary of HEW,\nMarion Folsom. The time has come to initiate these measures in\neach community in the Nation and the Administration stands ready to\nassist such community efforts.\nWe have proposed redirections in the Hill-Burton con-\nstruction program. When the program was launched 23 years ago, the\nUnited States had less than 60 percent of the hospital beds it needed.\nToday, despite the rapid growth of the population, we have about\n90 percent of the acute hospital beds we need.\nWe will move to reorder our priorities under Hill-Burton\naway from inpatient care toward outpatient care and from sickness\nto preventing sickness. We propose a program of bloc grants to\nencourage the states to expand such facilities as outpatient clinics,\nneighborhood health centers, skilled nursing homes and extended care\nfacilities. We believe that these measures would provide a better\nbalanced health structure and would enable more people to get more\ncare at less cost.\nIt is obvious that prevention is cheaper in the long run,\nboth to the individual and to society in general.\nThat is when we have such high hopes for our\nprograms for rubella vaccination and our campaign against hunger and\nmalnutrition. The difficult situation we face in the area of hunger\nwas emphasized by the convening of the White House Conference on\nHunger held in December. We are presently conducting a national\nnutrition survey system as well as support for community nutrition\nFORD\n''d\nLIBRARY\nprograms.\nGERALD\nIn addition, we are giving a great deal of attention to\nthe first few years of life and to the health needs of mothers and\nchildren. We hope to expand such programs as family planning,\nmaternal and child health services, day care and other prevention\nservice.\nSupport will also be provided for specific activities\nwhich improve the quality and productivity of health services, includ-\ning the utilization of new types of health manpower such as returning\nmedics from the Armed Services.\nAll of these efforts look forward to a time when ability\nto pay for medical care will no longer be an important barrier to receipt\nof care. This situation will be brought about largely through the\nextension of health insurance, whether required by government or\nprovided through government or in part subsidized by government.\nJust about everyone is going to be under a health insurance plan,\npublic or private, covering a major part of individual health costs\nincluding low income people who will one day participate in the same\nsystems that cover the rest of the population. This situation could\ncreate more severe strains on the delivery of care.\nWith this in mind, it is important to recognize that many\nof the solutions to the problems will be found only in changes within\nthe private health industry and with their cooperation. The Federal\nGovernment clearly needs to safeguard the public interest in administer-\n-10- -\ning the public programs. We must consider interface between the\npublic and private sectors, and the methods of influencing the private\nsector to look at their policies which may impede improvements.\nPrivate employers and consumers need to reevaluate\ntheir health insurance policies to provide incentives to the use of\nlower cost alternative modes of care.\nIt is this kind of organizational \"put together\" that will\nmake the difference not only in the cost but in the organization of\ndelivery of better health care\nand not just to Medicare and Medicaid\nrecipients, but to all of our citizens. We at HEW are giving the highest\npriority to the exercise of the discretion and leverage that we have in\nour various programs to enhance and make more rational the organization\nand delivery of medical care.\nAs Secretary Finch has pointed out, \"what is at stake is the\npluralistic, independent, voluntary nature of our health care system.\"\nWe must move now to assure a leadership role for government and to\navoid any move toward the direct Federal assumption of responsibility\nfor the Nation's health system.\nI hope you will work with us toward these ends and to\nmake good health a reality throughout the country. Your influence in\nthese areas can be considerable.\nADDENDUM TO SPEECH:\nI am delighted to publically commend Oklahomans, the Oklahoma\nHealth Science Foundation, and Dr. James Dennis for the innovative,\nhealth program which has become known as the Oklahoma Health\nCenter -- the \"Oklahoma Plan.\"\nThis program promises to put into actual practice a concept which\nmany of us in the health field still dream about. It combines the\nconsiderable resources of academic medicine, practicing medicine,\nvoluntary agencies, and public health agencies into a single operat-\ning health continuum.\nIn the present space age, the word \"spinoff\" has become routine.\nSo, I would mention that the spinoff from the \"Oklahoma Plan\" will\nbe felt outside of Oklahoma. The experiences gained in this pro-\ngram will most surely guide and benefit the entire Nation.\nAnd certainly the program at the University of Oklahoma School of\nHealth to train health planning personnel for 13 states will have a\nnational impact.\nADDENDUM TO SPEECH:\nSubject: Oklahoma's Unusually Successful Effort in Raising\nImmunization Levels Against Rubella\nIn a cooperative team effort combining resources from both public\nand private agencies, a statewide \"Rubella Sunday\" was conducted\non February 1, 1970. Joining the Oklahoma state and local health\ndepartments in this massive campaign were the State Medical\nAssociation, Oklahoma Nurses Association, Pharmaceutical\nAssociation, Osteopathic Association and Oklahoma Jaycees.\n255, 000 doses of rubella vaccine were administered reaching 51%\nof the total susceptible population in the age group 1 through 11.\nOklahoma is one of the first states in the nation to conduct such\na community-wide campaign.\nTHE OUTLOOK ON NURSING HOMES\nIT IS WITH SOME HUMILITY THAT I APPROACH A TOPIC AS BROAD\nAS \"THE OUTLOOK ON NURSING HOMES.\" FOR NOT ONLY ARE YOU, OF\nTHE VIRGINIA NURSING HOME ASSOCIATION INVOLVED IN THE IMMEDIATE,\nPERSONAL JOB OF CARING FOR PATIENTS IN NURSING HOMES, BUT ALSO AS\nVIRGINIANS YOU ARE TOO CLOSE TO WASHINGTON TO HARBOR ILLUSIONS\nABOUT THE WISDOM OR GRANDEUR OF FEDERAL POWER. You CAN GAZE ACROSS\nTHE PoToMac AND WITNESS THE LEGISLATIVE JUNGLE THROUGH WHICH A\nPROGRAM MUST PASS IN CONGRESS TO BECOME LAW, AND YOU CAN OBSERVE\nTHE DIFFICULTY IN TRANSLATING AN ADMINISTRATIVE POLICY CONCEIVED\nIN THE HEW NORTH BUILDING INTO A REALITY IN ARLINGTON COUNTY. So\nYOU KNOW THAT THOSE OF US WHO SERVE THE FEDERAL GOVERNMENT TODAY\nDO NOT COME EQUIPPED WITH ALL THE ANSWERS - READY TO DISPENSE\nTHE BALM OF GREAT PERSONAL WISDOM TO HEAL ALL WOUNDS AFFLICTING\nA TROUBLED SOCIETY,\nI COME BEFORE YOU TODAY THEN NOT TO OFFER READY-MADE PRE-\nSCRIPTIONS OR ROCK-HARD CERTAINTIES, BUT TO DESCRIBE TO YOU SOME\nOF THE PROBLEMS WE SEE AND THE ANSWERS WE HAVE DEVISED. AND I WANT\nTO ENLIST YOUR AID IN HELPING US FIND AND REALIZE SOLUTIONS TO THE\nPROBLEMS FACING THOSE WHO NEED OR ARE RECEIVING NURSING HOME CARE,\nTHE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED IN\nNURSING HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY SINCE\nTHE ENACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN 1965. IN\n1970 THE FEDERAL GOVERNMENT SPENT OVER $2 BILLION IN SUPPORT OF\nNURSING HOME PATIENTS, WHILE STATE AND LOCAL GOVERNMENT SPENT\nANOTHER $700 MILLION,\nGERALD FORD VIBRASK\n2\nTHE DIFFICULTY WITH SUCH MASSIVE INVOLVEMENT IS IN ASSURING\nTHAT DESIRED AND DESIRABLE IMPACT IS ACHIEVED, WITH RESPECT TO\nCONTINUITY OF CARE BETWEEN HOSPITAL AND ENTENDED CARE FACILITY,\nI BELIEVE THE FEDERAL ROLE HAS BEEN USEFUL AND IMPORTANT. THE\nPRESIDENT'S 8-POINT PLAN FOR ACTION TO IMPROVE NURSING HOMES,\nANNOUNCED LAST AUGUST IN NEW HAMPSHIRE, IS DESIGNED TO STRENGTHEN\nAND IMPROVE THAT ROLE. THE IMPLEMENTATION OF THAT PLAN HAS ABSORBED\nMOST OF MY TIME SINCE I ASSUMED MY NURSING HOME RESPONSIBILITIES\nLAST DECEMBER - MORE OF MY TIME THAN I HAD IMAGINED, I MIGHT ADD -\nAND I WOULD LIKE TO DESCRIBE FOR YOU SOME OF THESE EFFORTS, BUT I\nWOULD ALSO LIKE TO DESCRIBE FOR YOU THE PROBLEMS AT THE OPPOSITE\nEND OF THE SPECTRUM - CONTINUITY BETWEEN INSTITUTIONAL CARE AND THE\nHOME. I BELIEVE THAT THE FEDERAL ROLE HAS BEEN LESS CONSTRUCTIVE\nIN THAT AREA, WHICH REPRESENTS TOMORROW'S CHALLENGES. AND THESE\nCHALLENGES FACE US ALREADY IN WAYS I SHALL DESCRIBE,\nTHE EXTENDED CARE FACILITY PROGRAM UNDER MEDICARE WAS DESIGNED\nTO COVER THE EXTENSION OF CARE FOR A PATIENT WHO NO LONGER REQUIRES\nTHE FULL MEDICAL RESOURCES OF A HOSPITAL, BUT STILL NEEDS RELATIVELY\nINTENSIVE MEDICAL SERVICES, THE SKILLED NURSING HOME PROGRAM UNDER\nMEDICAID, ALTHOUGH THE PHILOSOPHIC INTENT WAS SOMEWHAT DIFFERENT,\nADOPTED VERY SIMILAR STANDARDS, ACUTE ILLNESS, IN WHICH THE PATIENT\nIS EXPECTED EVENTUALLY RECOVER, IS THE BASIC MODEL FOR WHICH THIS\nSYSTEM IS DESIGNED, AND THE EMPHASIS HAS BEEN ON MEDICAL RATHER THEN\nSOCIAL AND PERSONAL SERVICES, THIS APPROACH HAS LED TO VERY REAL\nPROBLEMS WHEN APPLIED TO PATIENTS WITH CHRONIC ILLNESS, WHO MAKE UP\nA LARGE PROPORTION OF THE ELDERLY NURSING HOME POPULATION - I SHALL\nDISCUSS THESE PROBLEMS LATER,\n3\nTHE PRESIDENT'S PLAN FOR NURSING HOMES ACCEPTED THE RESPONSI-\nBILITY TO ASSURE THAT NURSING HOMES DELIVER CARE AT LEAST AT THE\nLEVELS OF FEDERAL STANDARDS AND REGULATIONS. A MAJOR GOAL OF THE\nPLAN IS TO IMPROVE FEDERAL ENFORCEMENT OF NURSING HOME STANDARDS,\nAs YOU KNOW, THE TERM \"NURSING HOME\" IS APPLIED TO A WIDE RANGE OF\nFACILITIES, FROM THOSE PROVIDING PRIMARILY CUSTODIAL CARE TO THOSE\nDELIVERING HIGHLY SKILLED POST-HOSPITAL AND REHABILITATIVE SERVICES,\nTHESE DIFFERENT TYPES OF FACILITIES ARE ACCREDITED THROUGH DIFFERENT\nMECHANISMS, AND FEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES\nWIDELY, MEDICARE CERTIFICATION OF EXTENDED CARE FACILITIES IS A\nFEDERAL PROGRAM MEDIATED THROUGH STATE AGENCIES. MEDICAID IS A\nFEDERAL-STATE PROGRAM, FINANCED AND ADMINISTERED THROUGH BOTH FEDERAL\nAND STATE FUNDS AND ACTIVITIES. INTERMEDIATE CARE FACILITIES UNTIL\nRECENTLY WERE REQUIRED TO MEET ONLY STATE LICENSING REQUIREMENTS TO\nRECEIVE FEDERAL FUNDS, THESE DIFFERENCES HAVE COMPLICATED THE ENFORCE-\nMENT OF STANDARDS. IF H.R. 1 AS CURRENTLY AMENDED BY THE SENATE FINANCE\nCOMMITTEE IS PASSED, THEM SOME OF THESE DIFFERENCES WILL BE MINIMIZED\nAND MORE UNIFORM STANDARDS AND CERTIFICATION PROCEDURES WILL BE ADOPTED\nFOR MEDICARE AND MEDICAID. IN ANTICIPATION OF THESE CHANGES, A COMMON\nSET OF STANDARDS FOR BOTH PROGRAMS IS BEING DEVELOPED UNDER THE\nAUSPICES OF MY OFFICE, BUT THE STATE AGENCY WILL RETAIN ITS INSPECTION\nROLE, AND THE FEDERAL GOVERNMENT, WHICH IS RESPONSIBLE FOR THE\nQUALITY OF CARE WHICH IT FINANCES, MUST AID IN ENHANCING THE CAPABILITY\nOF THE STATE AGENCIES TO REGULATE AND IMPROVE THE QUALITY OF NURSING\nHOME CARE, To IMPROVE ENFORCEMENT OF NURSING HOME STANDARDS, THE\nPRESIDENT'S PLAN PLEDGED THE FOLLOWING STEPS:\n4\n1. CONSOLIDATION OF RESPONSIBILITY FOR NURSING HOME AFFAIRS\nNURSING HOME ACTIVITIES HAVE BEEN SCATTERED AMONG SEVERAL BRANCHES\nOF THE DEPARTMENT OF HEW, INCLUDING THE SOCIAL SECURITY ADMINI-\nSTRATION, THE SOCIAL AND REHABILITATION SERVICE, AND THE HEALTH\nSERVICE AND MENTAL HEALTH ADMINISTRATION. THE PRESIDENT ORDERED\nTHAT ALL FEDERAL ENFORCEMENT RESPONSIBILITY BE CONSOLIDATED IN A\nSINGLE OFFICE, AND DR. MERLIN K. DUVAL, THE ASSISTANT SECRETARY\nOF HEALTH AND SCIENTIFIC AFFAIRS, WAS DESIGNATED AS THE RESPONSIBLE\nOFFICIAL, DR. DUVAL APPOINTED ME TO WORK WITH HIM ON THESE ACTIVITIES\nAND TO FUNCTION AS A FULL-TIME COORDINATOR OF NURSING HOME ACTIVITIES.\n2. ENLARGEMENT OF FEDERAL STAFF FOR ENFORCEMENT OF NURSING HOME\nSTANDARDS.\nTHE SOCIAL AND REHABILITATION SERVICE, WHICH ADMINISTERS THE MEDICAID\nPROGRAM, HAS BEEN ASSIGNED 142 ADDITIONAL POSITIONS TO CARRY OUT\nITS INCREASED RESPONSIBILITIES, ONE HUNDRED TEN OF THESE POSITIONS\nWERE ALLOCATED TO THE REGIONAL OFFICE OF HEW. THE SOCIAL SECURITY\nADMINISTRATION RECEIVED THIRTY-FOUR ADDITIONAL POSITIONS TO INCREASE\nTHEIR AUDITS OF NURSING HOME OPERATIONS. THE NATIONAL CENTER FOR\nHEALTH SERVICES RESEARCH AND DEVELOPMENT RECEIVED SEVEN NEW POSI-\nTIONS FOR EFFORTS TO IMPROVE NURSING HOME DATA SYSTEMS AND TO DEVELOP\nDATA IN SPECIAL FIELDS RELEVANT TO NURSING HOME CARE,\n3. FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID INSPECTIONS.\nWE RECOGNIZE THAT AN INCREASED LEVEL OF ENFORCEMENT ACTIVITY IN-\nVOLVES ADDITIONAL COSTS TO THE STATES. MEDICARE INSPECTION COSTS\nHAVE ALWAYS BEEN FULLY PAID FOR BY THE FEDERAL GOVERNMENT, BUT UNDER\nTHE MEDICAID PROGRAM STATES HAVE PAID 25 TO 50 PERCENT OF THESE\nCOSTS, SECRETARY RICHARDSON SUBMITTED TO CONGRESS IN OCTOBER, 1971,\n5\nAN AMENDMENT TO H.R. 1. AUTHORIZING THE FEDERAL GOVERNMENT TO\nASSUME 100 PERCENT OF INSPECTION COSTS UNDER MEDICAID; THIS STEP\nWILL PLACE BOTH PROGRAMS ON AN EQUAL FOOTING AND LESSEN THE FINAN-\nCIAL BURDEN TO THE STATES.\n4. TRAINING STATE NURSING HOME INSPECTORS,\nNURSING HOME SURVEYORS HAVE BEEN TRAINED IN SURVEY AND COUNSELLING\nTECHNIQUES UNDER A PROGRAM SPONSORED BY THE HEALTH SERVICES AND\nMENTAL HEALTH ADMINISTRATION SINCE MARCH, 1970. THESE FOUR-WEEK\nCOURSES HAVE BEEN PRESENTED IN UNIVERSITY CENTERS IN NEW HAMPSHIRE,\nLOUISIANA, AND CALIFORNIA, IN HIS AUGUST SPEECH, THE PRESIDENT\nPLEDGED AN EXPANSION OF THIS PROGRAM SO THAT 2,000 SURVEYORS WOULD\nBE TRAINED IN THE ENSUING EIGHTEEN MONTH PERIOD. As A RESULT OF\nTHE PRESIDENT'S ORDER , THE PROGRAM HAS BEEN ACCELERATED SO THAT\nMORE THAN 700 SURVEYORS WILL HAVE BEEN TRAINED BY JULY 1.\nCONTRACT NEGOTIATIONS ARE IN PROCESS TO ESTABLISH THREE ADDITIONAL\nUNIVERSITY CENTERS. IN ADDITION, A STUDY WAS PERFORMED BY MACRO,\nSYSTEMS, INC., TO EVALUATE THE EFFECTIVENESS OF THE TRAINING COURSES,\nAND THESE HAVE NOW BEEN MODIFIED TO REFLECT THE RESULTS OF THAT\nSTUDY,\nTHESE EFFORTS TO ACHIEVE COMPLIANCE WITH FEDERAL STANDARDS\nAND REGULATIONS ARE NOT DESIGNED TO ELIMINATE FACILITIES AND THUS\nTO DEPRIVE PATIENTS OF NEEDED NURSING HOME CARE, WE ARE WORKING\nRATHER TO COORDINATE FEDERAL AND STATE PROGRAMS AND STATE AGENCIES\nTO SHARE THEIR RESOURCES AND EXPERTISE so THAT SUBSTANDARD FACIL-\nITIES CAN BE UPGRADED. THE FEDERAL PROGRAM TO TRAIN NURSING HOME\nSURVEYORS, FOR EXAMPLE, EMPHASIZES THE DEVELOPMENT OF SKILLS TO\nAID NURSING HOME ADMINISTRATORS IN MAKING NEEDED IMPROVEMENTS,\nFEDERAL FINANCIAL ASSISTANCE IS AVAILABLE FOR NURSING HOME\nMODERNIZATION AND NEW CONSTRUCTION FROM THE FEDERAL HOUSING\n6\nADMINISTRATION AND SUCH PROGRAMS AS HILL BURTON. THE STANDARDS\nTHEMSELVES ARE BEING REVISED AND STRENGTHENED. WE ARE DEVELOPING\nPROGRAMS TO IMPROVE NURSING HOMES DIRECTLY-I SHALL DESCRIBE THEM\nIN A FEW MOMENTS,\nBUT AS THE PRESIDENT WARNED LAST AUGUST,\"\nLET THERE BE\nNO MISTAKING THE FACT THAT WHEN FACILITIES FAIL TO MEET REASONABLE\nSTANDARDS, WE WILL NOT HESITATE TO CUT OFF THEIR MEDICARE AND\nMEDICAID FUNDS.\" BETWEEN AUGUST 6, 1971, AND FEBRUARY 11, 1972,\n13 EXTENDED CARE FACILITIES WERE DECERTIFIED FOR MEDICARE PARTICI-\nPATION. ON NOVEMBER 30, 1971, THIRTY-NINE STATES WERE DECLARED\nOUT OF COMPLIANCE WITH TITLE 19-MEDICAID--CERTIFICATION PROCEDURES,\nBy FEBRUARY 1, 1972, IN RESPONSE TO SECRETARY RICHARDSON'S DEADLINE,\nALL BUT ONE OF THOSE STATES HAD MADE THE IMPROVEMENTS REQUIRED FOR\nCOMPLIANCE. By JULY 1, 1972, ALL TITLE 19 FACILITIES IN ALL STATES\nARE TO HAVE BEEN INSPECTED AND CERTIFIED THROUGH THE CORRECT PRO-\nCEDURES, THE FEDERAL GOVERNMENT IS PLEDGED TO MEET ITS RESPONSI-\nBILITY TO ASSURE THAT FEDERAL DOLLARS DO NOT FINANCE SUBSTANDARD\nCARE,\nIN ADDITION TO IMPROVED ENFORCEMENT OF NURSING HOME STANDARDS,\nTWO OTHER POINTS IN THE PRESIDENT'S PLAN INITIATED MORE DIRECT STEPS\nTO IMPROVE NURSING HOME CARE. THE PRESIDENT DIRECTED THE DEPARTMENT\nOF HEW \"TO INSTITUTE A NEW PROGRAM OF SHORT-TERM COURSES FOR\nPHYSICIANS, NURSES, DIETICIANS, SOCIAL WORKERS AND OTHERS WHO ARE\nREGULARLY INVOLVED IN FURNISHING SERVICES TO NURSING HOME PATIENTS.\"\nHEW HAS SUPPORTED SUCH TRAINING FOR SEVERAL YEARS, AND HAS DEVELOPED\nCLOSE WORKING RELATIONSHIPS WITH PROFESSIONAL ASSOCIATIONS AND\nWITH TRAINING CENTERS. IN RESPONSE TO THE PRESIDENTS' DIRECTIVE,\nSUCH PROGRAMS HAVE BEEN EXPANDED UNDER THE LEADERSHIP OF THE\nCOMMUNITY HEALTH SERVICE, HEALTH SERVICE AND MENTAL HEALTH ADMINI-\nSTRATION, AND IT IS ANTICIPATED THAT APPROXIMATELY 20,000 PERSONS\n7\nWILL BE TRAINED IN FISCAL YEAR 1972 AT A COST OF $2.5 MILLION,\nTRAINING PROGRAMS WILL FOCUS INITIALLY ON FOUR MANPOWER AREAS\nSELECTED BECAUSE OF THEIR DIRECT DAY-TO-DAY RELATIONS WITH NURSING\nHOME PATIENTS: NURSING HOME ADMINISTRATORS, PHYSICIANS, NURSES,\nAND PATIENT ACTIVITIES DIRECTORS. MANY OF THESE TRAINING PROGRAMS\nWILL BE OPERATED UNDER CONTRACTS WITH PROFESSIONAL GROUPS.\nAPPROACHES TO MENTAL HEALTH PROBLEMS OF NURSING HOME PATIENTS WILL\nBE DEVELOPED BY NATIONAL INSTITUTE OF MENTAL HEALTH STAFF WORKING\nWITH THE GERONTOLOGICAL SOCIETY. OTHER TRAINING MECHANISMS WILL\nALSO BE EXPLORED, SUCH AS PROGRAMS SPONSORED BY STATE HEALTH\nDEPARTMENTS AND STATE AGENCIES, THESE PROGRAMS WILL BE DIRECTED\nTOWARD MAKING NURSING HOME STAFF-BOTH PROFESSIONAL AND ALLIED HEALTH-\nMORE SENSITIVE AND EXPERT IN THE SPECIAL PROBLEMS OF CARE FOR\nGERIATRIC PATIENTS AND THE CHRONICALLY ILL. THEY ARE INTENDED TO\nBE THE BEGINNING OF A SYSTEM FOR NATIONWIDE, CONTINUOUS TRAINING\nFOR NURSING HOME PERSONNEL WHICH WILL BECOME STANDARD PRACTICE IN\nTHE NURSING HOME INDUSTRY OF THE FUTURE,\nAs THE SEVENTH POINT IN HIS PLAN, THE PRESIDENT DIRECTED THE\nDEPARTMENT OF HEW \"TO ASSIST THE STATES IN ESTABLISHING INVESTI-\nGATIVE UNITS WHICH WILL RESPOND IN A RESPONSIBLE AND CONSTRUCTIVE\nWAY TO COMPLAINTS MADE BY OR ON BEHALF OF INDIVIDUAL PATIENTS.\"\nSINCE I ASSUMED MY NURSING HOME RESPONSIBILITIES, I HAVE RECEIVED\nMANY LETTERS FROM NURSING HOME PATIENTS-TOUCHING IN THEIR APPEAL\nFOR CARE OFFERING SIMPLE DIGNITY AND RIGHTS OF PRIVACY, HARROWING\nSOMETIMES IN THEIR DESCRIPTIONS OF PHYSICAL OR PSYCHOLOGICAL ABUSE,\nTHESE PATIENTS ARE OFTEN HELPLESS IN THEIR DEPENDENCE ON THE IN-\nSTITUTION IN WHICH THEY LIVE, THEY DESERVE A FAIR HEARING, AND AN\nADVOCATE WHEN THEY ARE POWERLESS, THE HEALTH SERVICES AND MENTAL\nHEALTH ADMINISTRATION HAS DEVELOPED FIVE MODELS FOR OMBUDSMAN\n8\nUNITS TO FILL THIS ROLE, PLACED AT VARIOUS LEVELS WITHIN THE\nSTATES AND DEMONSTRATING DIFFERENT MECHANISMS FOR ACTION,\nCONTRACT PROPOSALS TO TEST THESE MODELS ARE BEING SOLICITED,\nAND $600,000 HAS BEEN BUDGETED FOR FISCAY YEAR 1972 FOR THIS\nACTIVITY,\nIT WILL TAKE TIME TO TEST AND DEVELOP SUCH AN OMBUDSMAN\nSYSTEM, TIME INAPPROPRIATE TO THE URGENCY OF THE PROBLEM, So\nAN INTERIM OMBUDSMAN MECHANISM HAS BEEN ESTABLISHED WITH THE\n855 SOCIAL SECURITY ADMINISTRATION DISTRICT OFFICES DESIGNATED\nTO RECEIVE AND INVESTIGATE COMPLAINTS, THIS MECHANISM IS CURRENTLY\nIN EFFECT, AND HAS RECEIVED OVER A THOUSAND RESPONSES.\nFOR THESE NURSING HOME INITIATIVES, A SUPPLEMENTAL APPRO-\nPRIATION OF $9,572,000 HAS BEEN REQUESTED FOR FISCAL YEAR, 1972.\nWE FEEL THAT BY MEANS OF THESE PROGRAMS A SIGNIFICANT IMPROVEMENT\nIN NURSING HOME CARE CAN BE ACHIEVED IN A RELATIVELY SHORT PERIOD\nOF TIME.\nI WOULD LIKE TO EXAMINE NURSING HOMES NOW IN A DIFFERENT\nPERSPECTIVE, I HAVE MENTIONED THAT MEDICARE FINANCES NURSING\nHOME CARE AS AN EXTENSION OF HOSPITAL CARE - THE PRIOR HOSPITALI-\nZATION REQUIREMENT AND THE TIME LIMITATIONS PER SPELL OF ILLNESS\nARE MANIFESTATIONS OF THIS PRINCIPLE, MEDICAID REQUIREMENTS FOR\nSKILLED NURSING HOMES, WHILE THEY ARE NOT BASED ON THE SAME CONCEPT\nOF EXTENDED CARE TEND TO EMPHASIZE AND PROVIDE COVERAGE FOR MEDICAL\nSERVICES AS OPPOSED TO SOCIAL AND PERSONAL CARE,\n9\nTHE ELDERLY OF COURSE SUFFER FROM ACUTE DISEASE, BUT THEY\nARE MUCH MORE SUBJECT THAN YOUNGER PEOPLE TO THE DEPENDENCY OF\nCHRONIC ILLNESS, THE TERM \"SPELL OF ILLNESS\" MAKES LITTLE SENSE\nWHEN APPLIED TO A DISEASE PROCESS WHICH WILL NEVER BE CURED,\nMOREOVER, ALTHOUGH THE CHRONICALLY - ILL PATIENT MAY BENEFIT FROM\nINTENSIVE MEDICAL SERVICES, HE IS MORE LIKELY TO REQIRE LESS IN-\nTENSIVE BUT CONTINUOUS MEDICAL CARE IN COMBINATION WITH SOCIAL AND\nPERSONAL SERVICES TO HELP HIM LIVE WITH HIS CHRONIC DISABILITY,\nSo THE HEALTH FACILITY WHICH CAN BEST SERVE HIM MAY BE VERY DIFFERENT\nFROM THE EXTENDED CARE FACILITY WHICH IS IDEALLY SUITED TO A PATIENT\nRECUPERATING FROM A MYOCARDIAL INFARCTION OR A BROKEN HIP, OR HE\nMIGHT NOT REQUIRE INSTITUTIONAL CARE AT ALL - HE MIGHT BE PERFECTLY\nABLE TO LIVE IN HIS OWN HOME WITH THE AID OF HOMEMAKING AND HOME\nHEALTH SERVICES,\nTHESE PATIENTS WITH CHRONIC ILLNESSES - WHICH INCLUDE A DIS-\nPROPORTIONATE SHARE OF THE ELDERLY - AND THOSE SUFFERING THE IN-\nCREASED DEPENDENCY OF OLD AGE ITSELF-DEMONSTRATE THE WEAKNESSES OF\nLONG TERM CARE AS SUPPORTED BY THE FEDERAL GOVERNMENT.\nFIRST, MEDICARE AND MEDICAID TEND TO BE MORE CONCERNED IN\nTERM OF STANDARDS AND COVERAGE WITH THE MEDICAL COMPONENT OF NURSING\nHOME CARE, THIS HAS BEEN TRUE FOR BOTH STATUTORY AND HISTORICAL\nREASONS BASED ON THEIR ORIGIN AS HEALTH INSURANCE PROGRAMS, I DO\nNOT THINK IT IS HELPFUL TO SEPARATE THE PHYSICAL, EMOTIONAL, SOCIAL,\nAND ENVIRONMENTAL COMPONENTS OF CARE, PARTICULARLY FOR THE ELDERLY,\nTHESE ARE IMPERMANENT SEPARATIONS OF INTEREST, EMPHASIS, ORGANIZATION\nAND PREFERENCE; THEY REST MORE UPON TRADITION AND ARBITARY BOUNDARIES\nTHEN THE APPLICATION OF KNOWLEDGE TO LONG TERM CARE.\n10\nSECOND THE PRESENT HEALTH FINANCING SYSTEM OFFERS MORE\nCOMPLETE COVERAGE FOR PATIENTS INSIDE INSTITUTIONS THAN FOR\nTHOSE WHO REMAIN OUTSIDE, So OUR FINANCING STRUCTURE TENDS\nTO PUSH THE ELDERLY INTO NURSING HOMES, SOMETIMES PREMATURELY.\nSOCIETY PAYS A PRICE FOR THIS, INSTITUTIONAL CARE IS MORE\nCOSTLY THEN HOME HEALTH CARE, MORE IMPORTANT, THERE IS IN-\nCREASING EVIDENCE THAT THE DISPLACEMENT, LOSS OF STATUS,\nAND ISOLATION CAUSED BY INSTITUTIONALIZATION MAY EXACERBATE\nIF NOT PRECIPITATE ACTUAL PHYSIOLOGIC DISEASE. THE TRANSFER\nOF A PERSON FROM HIS HOME TO AN INSTITUTION MAY MAKE HIM\nMORE ILL AND MORE DEPENDENT.\nIF A NURSING HOME IS NOT THE MOST APPROPRIATE PLACE FOR\nA PERSON'S PARTICULAR NEEDS, THEN HE SHOULD NOT BE REQUIRED\nTO GO THERE. IF IT IS PERSONAL CARE RATHER THEN HEALTH\nCARE THAT IS REQUIRED, THEN THAT SHOULD BE AVAILABLE. IF IT\nIS APPROPRIATE HOUSING RATHER THEN INSTITUTIONAL CARE THAT\nIS NEEDED, THEN THE EMPHASIS SHOULD BE ON HOUSING. THE ELDERLY\nSHOULD HAVE MORE OPTIONS AVAILABLE,\nTHESE SEEM TO ME BASIC AND VALID CRITICISMS OF OUR PRESENT\nSYSTEM - THE SEPARATION BETWEEN MEDICAL AND PERSONAL CARE AND THE\nFAILURE TO PROVIDE ADEQUATE ALTERNATIVES TO INSTITUTIONAL CARE,\nAND IN THESE AREAS, FEDERAL PROGRAMS HAVE HAD AN UNFORTUNATE IF\nUNINTENDED IMPACT. THESE ISSUES CANNOT BE POSTPONED, ON\nDECEMBER 28, 1971, PRESIDENT NIXON SIGNED INTO LAW PUBLIC LAW\n92-223, WHICH AUTHORIZES THE TRANSFER OF INTERMEDIATE CARE FACIL-\nITIES INTO THE MEDICAID PROGRAM. AN INTERMEDICATE CARE FACILITY\nPROVIDES HEALTH RELATED SERVICES FOR PATIENTS WHO DO NOT REQUIRE\nCARE IN SKILLED NURSING HOMES, BUT NEED INSTITUTIONAL CARE BEYOND\n11\nROOM AND BOARD. As YOU KNOW, ICF's WERE PREVIOUSLY FINANCED\nBY PUBLIC ASSISTANCE PROGRAMS FOR THE AGED, THE BLIND, AND THE\nDISABLED, AND WERE SUBJECT ONLY TO STATE LICENSING, TRANSFER\nOF FINANCING TO THE MEDICAID PROGRAM MEANS NOT ONLY THAT A LARGER\nGROUP OF PEOPLE - INCLUDING THE \"MEDICALLY NEEDY\" - MAY POTENTIALLY\nBE ELIGIBLE FOR BENEFITS, BUT ALSO THAT THE FEDERAL GOVERNMENT IS\nEMPOWERED TO SET PHYSICAL AND SAFETY STANDARDS AND DEFINE THE\nCARE AND SERVICES THAT MUST BE PROVIDED. THE MEDICAL SERVICES\nADMINISTRATION OF THE SOCIAL AND REHABILITATION SERVICES AND\nMY OFFICE OF NURSING HOME AFFAIRS ARE CURRENTLY EXAMINING SUCH\nISSUES AS WHO SHOULD BE IN THESE FACILITIES, WHAT SERVICES MUST\nTHEY PROVIDE, AND WHAT SHOULD BE THE LEVEL OF BENEFITS IN ATTEMPT-\nING TO DEVELOP STANDARDS FOR INTERMEDIATE CARE FACILITIES. So\nTHESE FACILITIES ARE FORCING A RE-EXAMINATION OF COVERAGE ISSUES,\nAND THE BALANCES OF MEDICAL AND PERSONAL SERVICES WITHIN IN-\nSTITUTIONS, THE \"PROBLEMS TO COME\" ARE HERE ALREADY,\nI WOULD LIKE TO MENTION ONE MORE PROBLEM THAT HAS DEMANDED\nATTENTION, AND THAT IS THE PLANNING PROCESS ITSELF. AN IMPORTANT\nREASON FOR THE INSUFFICIENT AND SOMETIMES INAPPROPRIATE IMPACT OF\nFEDERAL PROGRAMS FOR LONG TERM CARE HAS BEEN THE LACK OF PLANNING\nAND COORDINATION BETWEEN FEDERAL, STATE, AND LOCAL PROGRAMS,\nPLANNING FOR LONG TERM CARE SHOULD MOVE FROM IDENTIFICATION OF AN\nISSUE OR PROBLEM TO ITS SOLUTION, WITH IDENTIFIABLE GOALS GUIDING\nTHE PROCESS, MOVEMENT TOWARD A GOAL SHOULD NOT BE INTERRUPTED BY\nCHANGES IN ADMINISTRATION. WHAT IS TRULY IMPORTANT TODAY SHOULD\nNOT BE CAST ASIDE TOMORROW. NEW PROGRAMS SHOULD NOT BE APPENDAGES\nTO SATISFY THE INTERESTS OF A FEW, NOR SHOULD THEY BE ADDED AS\nPACIFIERS TO THE MANY, PROGRAMS DEVELOPED THROUGH A RATIONAL PLANNING\nPROCESS SHOULD THEN BE ADMINISTERED THROUGH AN EFFECTIVE AND COORDI-\nNATED MECHANISMS.\n12\nTHE ESTABLISHMENT OF THE OFFICE OF NURSING HOME AFFAIRS\nWITHIN HEW WAS A STEP TOWARD IMPROVING COORDINATION. THE EIGHTH\nPOINT OF THE PRESIDENT'S PLAN IS A MANDATE FOR A TASK FORCE ON\nLONG TERM CARE. THIS TASK FORCE WILL RE-EXAMINE ISSUES AND SET\nNEW GOALS, DEVELOP A NATIONWIDE DATA SYSTEM NECESSARY FOR POLICY\nFORMULATION, AND RECOMMEND AN ORGANIZATION FOR LONG TERM CARE WITHIN\nHEW AND FEDERAL STATE AND LOCAL PROGRAMS WHICH CAN ACHIEVE ITS\nGOALS MOST EFFECTIVELY.\nA NATIONAL POLICY COURSE FOR THE CHRONICALLY ILL AND FOR\nTHE ELDERLY SHOULD BE SET, IT SHOULD BE SET BY GOVERNMENT, WITH\nTHE FULL AND CREATIVE CONTRIBUTION OF THOSE IN OTHER AGENCIES\nAND ORGANIZATIONS, THOSE IN ACADEMIC TEACHING AND RESEARCH, THOSE\nIN VOLUNTARY AND UNSALARIED SERVICE, AND THOSE WHO RECEIVE THAT CARE,\nWE CAN DO MUCH BETTER FOR OUR ELDERLY, WE MUST OF COURSE\nPROTECT THEM FROM INSTITUTIONAL ABUSE, RECOGNIZING THAT SOME\nARE WEAK AND DEPENDENT, BUT WE CAN ALSO MAKE POSSIBLE A WIDE\nVARIETY OF SUPPORTING SERVICES AND LIVING ARRANGEMENTS, SO THAT\nTHE INFIRMITIES OF ADVANCING AGE DO NOT BECOME A PRISON OF THE\nSPIRIT. THE ELDERLY WITH OUR HELP CAN HAVE ACCESS TO THE VARIETY\nAND FREEDOM WE ASK FOR OURSELVES,\nTHE OUTLOOK ON NURSING HOMES\nMRS. MARIE CALLENDER\nSPECIAL ASSISTANT FOR NURSING HOME AFFAIRS\nDEPARTMENT OF HEALTH, EDUCATION AND WELFARE*\n*To BE PRESENTED AT THE ANNUAL SPRING CONVENTION OF THE COLORADO\nASSOCIATED NURSING HOMES, INC., ON TUESDAY, MAY 16, L972,\nTHE OUTLOOK ON NURSING HOMES\nIT IS WITH SOME HUMILITY THAT I APPROACH A TOPIC AS BROAD\nAS\nTHE OUTLOORS ON NURSING HOMES,\nA lha llenae from the White douse\nFOR NOT ONLY ARE YOU, OF\nTHE COLORADO ASSOCIATED NURSING HOMES INVOLVED IN THE IMMEDIATE,\nPERSONAL JOB OF CARING FOR PATIENTS IN NURSING HOMES, BUT ALSO AS\nCOLORADANS YOU ARE DISTANT ENOUGH FROM WASHINGTON TO UNDERSTAND\nTHE DIFFICULTY IN TRANSLATING AN ADMINISTRATIVE POLICY CONCEIVED IN\nTHE HEW NORTH BUILDING INTO A REALITY IN DENVER. So YOU KNOW THAT\nTHOSE OF US WHO SERVE THE FEDERAL GOVERNMENT TODAY DO NOT COME\nEQUIPPED WITH ALL THE ANSWERS - READY TO DISPENSE THE BALM OF GREAT\nPERSONAL WISDOM TO HEAL ALL WOUNDS AFFLICTING A TROUBLED SOCIETY.\nI COME BEFORE YOU TODAY THEN NOT TO OFFER READY-MADE\nPRESCRIPTIONS OR ROCK-HARD CERTAINTIES, BUT TO DESCRIBE TO YOU SOME\nOF THE PROBLEMS WE SEE AND THE ANSWERS WE HAVE DEVISED. AND I\nadditional\nWANT TO ENLIST YOUR AID IN HELPING US FIND AND REALIZE SOLUTIONS\nTO THE PROBLEMS FACING THOSE WHO NEED OR ARE RECEIVING NURSING\nHOME CARE.\nTHE FEDERAL GOVERNMENT HAS BECOME INCREASINGLY INVOLVED IN\nNURSING HOME CARE OVER THE LAST TWENTY YEARS, PARTICULARLY SINCE\nTHE ENACTMENT OF THE MEDICARE AND MEDICAID PROGRAMS IN 1965. IN\nL970 THE FEDERAL GOVERNMENT SPENT OVER $2 BILLION IN SUPPORT OF\nNURSING HOME PATIENTS, WHILE STATE AND LOCAL GOVERNMENT SPENT\nANOTHER $700 MILLION,\n2\nTHE DIFFICULTY WITH SUCH MASSIVE INVOLVEMENT IS IN ASSURING\nTHAT DESIRED AND DESIRABLE IMPACT IS ACHIEVED. WITH RESPECT TO\nCONTINUITY OF CARE BETWEEN HOSPITAL AND ENTENDED CARE FACILITY,\nI BELIEVE THE FEDERAL ROLE HAS BEEN USEFUL AND IMPORTANT. THE\nPRESIDENT'S 8-POINT PLAN FOR ACTION TO IMPROVE NURSING HOMES,\nANNOUNCED LAST AUGUST IN NEW HAMPSHIRE, IS DESIGNED TO STRENGTHEN\nAND IMPROVE THAT ROLE. THE IMPLEMENTATION OF THAT PLAN HAS ABSORBED\nMOST OF MY TIME SINCE I ASSUMED MY NURSING HOME RESPONSIBILITIES\nLAST DECEMBER - MORE OF MY TIME THAN I HAD IMAGINED, I MIGHT ADD -\nAND I WOULD LIKE TO DESCRIBE FOR YOU SOME OF THESE EFFORTS, BUT I\nWOULD ALSO LIKE TO DESCRIBE FOR YOU THE PROBLEMS AT THE OPPOSITE\nEND OF THE SPECTRUM - CONTINUITY BETWEEN INSTITUTIONAL CARE AND THE\nHOME. I BELIEVE THAT THE FEDERAL ROLE HAS BEEN LESS CONSTRUCTIVE\nIN THAT AREA, WHICH REPRESENTS TOMORROW'S CHALLENGES. AND THESE\nCHALLENGES FACE US ALREADY IN WAYS .I SHALL DESCRIBE.\nIn part the shall engs stem from the fact that\nTHE EXTENDED CARE FACILITY PROGRAM UNDER MEDICARE WAS DESIGNED\nTO COVER THE EXTENSION OF CARE FOR A PATIENT WHO NO LONGER REQUIRES\nTHE FULL MEDICAL RESOURCES OF A HOSPITAL, BUT STILL NEEDS RELATIVELY\nINTENSIVE MEDICAL SERVICES. THE SKILLED NURSING HOME PROGRAM UNDER\nMEDICAID, ALTHOUGH THE PHILOSOPHIC INTENT WAS SOMEWHAT DIFFERENT,\nADOPTED VERY SIMILAR STANDARDS. ACUTE ILLNESS, IN WHICH THE PATIENT\nIS EXPECTED EVENTUALLY RECOVER, IS THE BASIC MODEL FOR WHICH THIS\nSYSTEM IS DESIGNED, AND THE EMPHASIS HAS BEEN ON MEDICAL RATHER THEN\nSOCIAL AND PERSONAL SERVICES. THIS APPROACH HAS LED TO VERY REAL\nPROBLEMS WHEN APPLIED TO PATIENTS WITH CHRONIC ILLNESS, WHO MAKE UP\nA LARGE PROPORTION OF THE ELDERLY NURSING HOME POPULATION - I SHALL\nDISCUSS THESE PROBLEMS LATER.\n3\nTHE PRESIDENT'S PLAN FOR NURSING HOMES ACCEPTED THE RESPONSI-\nBILITY TO ASSURE THAT NURSING HOMES DELIVER CARE AT LEAST AT THE\nLEVELS OF FEDERAL STANDARDS AND REGULATIONS. A MAJOR GOAL OF THE\nPLAN IS TO IMPROVE FEDERAL ENFORCEMENT OF NURSING HOME STANDARDS.\nAs YOU KNOW, THE TERM \"NURSING HOME\" IS APPLIED TO A WIDE RANGE OF\nFACILITIES, FROM THOSE PROVIDING PRIMARILY CUSTODIAL CARE TO THOSE\nDELIVERING HIGHLY SKILLED POST-HOSPITAL AND REHABILITATIVE SERVICES.\nTHESE DIFFERENT TYPES OF FACILITIES ARE ACCREDITED THROUGH DIFFERENT\nMECHANISMS, AND FEDERAL LEVERAGE IN ENFORCING STANDARDS VARIES\nWIDELY. MEDICARE CERTIFICATION OF EXTENDED CARE FACILITIES IS A\nFEDERAL PROGRAM MEDIATED THROUGH STATE AGENCIES, MEDICAID IS A\nFEDERAL-STATE PROGRAM, FINANCED AND ADMINISTERED THROUGH BOTH FEDERAL\nAND STATE FUNDS AND ACTIVITIES. INTERMEDIATE CARE FACILITIES UNTIL\nRECENTLY WERE REQUIRED TO MEET ONLY STATE LICENSING REQUIREMENTS TO\nRECEIVE FEDERAL FUNDS. THESE DIFFERENCES HAVE COMPLICATED THE ENFORCE-\nMENT OF STANDARDS. IF H.R. 1 AS CURRENTLY AMENDED BY THE SENATE FINANCE\nCOMMITTEE IS PASSED, THEM SOME OF THESE DIFFERENCES WILL BE MINIMIZED\nAND MORE UNIFORM STANDARDS AND CERTIFICATION PROCEDURES WILL BE ADOPTED\nFOR MEDICARE AND MEDICAID. IN ANTICIPATION OF THESE CHANGES, A COMMON\nSET OF STANDARDS FOR BOTH PROGRAMS IS BEING DEVELOPED UNDER THE\nAUSPICES OF MY OFFICE. BUT THE STATE AGENCY WILL RETAIN ITS INSPECTION\nROLE. AND THE FEDERAL GOVERNMENT, WHICH IS RESPONSIBLE FOR THE\nQUALITY OF CARE WHICH IT FINANCES, MUST AID IN ENHANCING THE CAPABILITY\nOF THE STATE AGENCIES TO REGULATE AND IMPROVE THE QUALITY OF NURSING\nHOME CARE. To IMPROVE ENFORCEMENT OF NURSING HOME STANDARDS, THE\nPRESIDENT'S PLAN PLEDGED THE FOLLOWING STEPS:\n4\n1. CONSOLIDATION OF RESPONSIBILITY FOR NURSING HOME AFFAIRS\nNURSING HOME ACTIVITIES HAVE BEEN SCATTERED AMONG SEVERAL BRANCHES\nOF THE DEPARTMENT OF HEW, INCLUDING THE SOCIAL SECURITY ADMINI-\nSTRATION, THE SOCIAL AND REHABILITATION SERVICE, AND THE HEALTH\nSERVICE AND MENTAL HEALTH ADMINISTRATION. THE PRESIDENT ORDERED\nTHAT ALL FEDERAL ENFORCEMENT RESPONSIBILITY BE CONSOLIDATED IN A\nSINGLE OFFICE. AND DR. MERLIN K. DUVAL, THE ASSISTANT SECRETARY\nOF HEALTH AND SCIENTIFIC AFFAIRS, WAS DESIGNATED AS THE RESPONSIBLE\nOFFICIAL. DR. DUVAL inturn DELEGATED TO ME THESE RESPONSIBILITIES AND\nTHE FUNCTION OF FULL-TIME COORDINATOR OF NURSING HOME ACTIVITIES.\n2. ENLARGEMENT OF FEDERAL STAFF FOR ENFORCEMENT OF NURSING HOME\nSTANDARDS.\nTHE SOCIAL AND REHABILITATION SERVICE, WHICH ADMINISTERS THE MEDICAID\nPROGRAM, HAS BEEN ASSIGNED 142 ADDITIONAL POSITIONS TO CARRY OUT\nITS INCREASED RESPONSIBILITIES. ONE HUNDRED TEN OF THESE POSITIONS\nWERE ALLOCATED TO THE REGIONAL OFFICE OF HEW. THE ASSISTANT\nSECRETARY COMPTROLLER RECEIVED THIRTY-FOUR ADDITIONAL POSITIONS TO\nINCREASE THEIR AUDITS OF NURSING HOME OPERATIONS. THE NATIONAL CENTER\nFOR HEALTH SERVICES RESEARCH AND DEVELOPMENT RECEIVED SEVEN NEW POSI-\nTIONS FOR EFFORTS TO IMPROVE NURSING HOME DATA SYSTEMS AND TO DEVELOP\nDATA IN SPECIAL FIELDS RELEVANT TO NURSING HOME CARE. These positions\nwill strengthen our assistant to StAte Agencies,\n3. FEDERAL SUPPORT OF 100% OF THE COST OF STATE MEDICAID activities INSPECTIONS.\nWE RECOGNIZE THAT AN INCREASED LEVEL OF ENFORCEMENT ACTIVITIY IN-\nVOLVES ADDITIONAL COSTS TO THE STATES. State MEDICARE INSPECTION COSTS\nHAVE ALWAYS BEEN FULLY PAID FOR BY THE FEDERAL GOVERNMENT, BUT UNDER\nTHE MEDICAID PROGRAM STATES HAVE PAID 25 TO 50 PERCENT OF THESE\nCOSTS. SECRETARY RICHARDSON SUBMITTED TO CONGRESS IN OCTOBER, 1971,\n5\nAN AMENDMENT TO H.R. 1. AUTHORIZING THE FEDERAL GOVERNMENT TO\nhome\nASSUME 100 PERCENT OF INSPECTION COSTS UNDER MEDICAID; THIS STEP\nWILL PLACE BOTH PROGRAMS ON AN EQUAL FOOTING AND LESSEN THE FINAN-\nCIAL BURDEN TO THE STATES.\n4. TRAINING STATE NURSING HOME INSPECTORS,\nNURSING HOME SURVEYORS HAVE BEEN TRAINED IN SURVEY AND COUNSELLING\nTECHNIQUES UNDER A PROGRAM SPONSORED BY THE HEALTH SERVICES AND\nMENTAL HEALTH ADMINISTRATION SINCE MARCH, 1970. THESE FOUR-WEEK\nCOURSES HAVE BEEN PRESENTED IN UNIVERSITY CENTERS IN NEW HAMPSHIRE,\nLOUISIANA, AND CALIFORNIA. IN HIS AUGUST SPEECH, THE PRESIDENT\nPLEDGED AN EXPANSION: OF THIS PROGRAM so THAT 2,000 SURVEYORS COULD\nBE TRAINED IN THE ENSUING EIGHTEEN MONTH PERIOD. As A RESULT OF\nTHE PRESIDENT'S ORDER, THE PROGRAM HAS BEEN ACCELERATED so THAT\nMORE THAN 700 SURVEYORS WILL HAVE BEEN TRAINED BY JULY 1.\nCONTRACT NEGOTIATIONS ARE IN PROCESS TO ESTABLISH THREE ADDITIONAL\nUNIVERSITY CENTERS. IN ADDITION, A STUDY WAS PERFORMED, TO\nEVALUATE THE EFFECTIVENESS OF THE TRAINING COURSES, AND THESE HAVE\nNOW BEEN MODIFIED TO REFLECT THE RESULTS OF THAT STUDY.\nTHESE EFFORTS TO ACHIEVE COMPLIANCE WITH FEDERAL STANDARDS\nAND REGULATIONS ARE NOT DESIGNED TO ELIMINATE FACILITIES AND THUS\nTO DEPRIVE PATIENTS OF NEEDED NURSING HOME CARE, WE ARE WORKING\nRATHER TO COORDINATE FEDERAL AND STATE PROGRAMS AND STATE AGENCIES,\nTO SHARE THEIR RESOURCES AND EXPERTISE so THAT SUBST\nmore pubstancial FACIL assistant\nand consul Astion ean be offered,\nITIES\nCAN\nBE\nUPGRADED.\nTHE FEDERAL PROGRAM TO TRAIN NURSING HOME\nSURVEYORS, FOR EXAMPLE, EMPHASIZES THE DEVELOPMENT OF SKILLS TO\nand personnel\nchanges\nAID NURSING HOME ADMINISTRATORS IN MAKING NEEDED IMPROVEMENTS.\nin addition\nEDERAL FINANCIAL ASSISTANCE IS AVAILABLE FOR NURSING HOME\nMODERNIZATION AND NEW CONSTRUCTION FROM THE FEDERAL HOUSING\n6\nthe\nProgram\nADMINISTRATION AND SUCH PROGRAMS AS HILL BURTON, THEMSTANDARDS\nTHEMSELVES ARE BEING REVISED AND STRENGTHENED. WE ARE DEVELOPING\nPROGRAMS TO IMPROVE NURSING HOMES DIRECTLY- SHALL DESCRIBE THEM\nIN A FEW MOMENTS.\nBUT AS THE PRESIDENT WARNED LAST AUGUST,\" LET THERE BE\nNO MISTAKING THE FACT THAT WHEN FACILITIES FAIL TO MEET REASONABLE\nSTANDARDS, WE WILL NOT HESITATE TO CUT OFF THEIR MEDICARE AND\nMEDICAID FUNDS.\" BETWEEN AUGUST 6, 1971, AND FEBRUARY 11, 1972,\n13 EXTENDED CARE FACILITIES WERE DECERTIFIED FOR MEDICARE PARTICI-\nPATION. ON NOVEMBER 30, 1971, THIRTY-NINE STATES WERE DECLARED\nOUT OF COMPLIANCE WITH TITLE 19-MEDICAID--CERTIFICATION PROCEDURES.\nBy FEBRUARY 1, 1972, IN RESPONSE TO SECRETARY RICHARDSON'S DEADLINE,\nALL BUT ONE OF THOSE STATES HAD MADE THE IMPROVEMENTS REQUIRED FOR\nthis coming\nCOMPLIANCE. By JULY 1, 1972, ALL TITLE 19 FACILITIES IN ALL STATES\nsurveyed\nassist against Title 19 need, standards\nARE TO HAVE BEEN INSPECTED AND CERTIFIED THROUGH THE CORRECT PRO\nCEDURES, THE FEDERAL GOVERNMENT IS PLEDGED TO MEET ITS RESPONSI-\nBILITY TO ASSURE THAT FEDERAL DOLLARS DO NOT FINANCE SUBSTANDARD\nCARE. and that the velderly of this country have assurance not\nthese standards are met,\nIN ADDITION TO IMPROVED ENFORCEMENT OF NURSING HOME STANDARDS,\nTWO OTHER POINTS IN THE PRESIDENT'S PLAN INITIATED MORE DIRECT STEPS\nTO IMPROVE NURSING HOME CARE. THE PRESIDENT DIRECTED THE DEPARTMENT\nOF HEW \"TO INSTITUTE A NEW PROGRAM OF SHORT-TERM COURSES FOR\nPHYSICIANS, NURSES, DIETICIANS, SOCIAL WORKERS AND OTHERS WHO ARE\nREGULARLY INVOLVED IN FURNISHING SERVICES TO NURSING HOME PATIENTS.\"\nHEW HAS SUPPORTED SUCH TRAINING FOR SEVERAL YEARS, AND HAS DEVELOPED\nCLOSE WORKING RELATIONSHIPS WITH PROFESSIONAL ASSOCIATIONS AND\nWITH TRAINING CENTERS. IN RESPONSE TO THE PRESIDENTS' DIRECTIVE,\nSUCH PROGRAMS HAVE BEEN EXPANDED UNDER THE LEADERSHIP OF THE\nCOMMUNITY HEALTH SERVICE, HEALTH SERVICE AND MENTAL HEALTH ADMINI-\nSTRATION, AND IT IS ANTICIPATED THAT APPROXIMATELY 20,000 PERSONS\n7\noffered\nWILL BE TRAINED IN FISCAL YEAR 1972 AT A COST OF $2.5 MILLION.\nTRAINING PROGRAMS WILL FOCUS INITIALLY ON FOUR MANPOWER AREAS\nSELECTED BECAUSE OF THEIR DIRECT DAY-TO-DAY RELATIONS WITH NURSING\nHOME PATIENTS: NURSING HOME ADMINISTRATORS, PHYSICIANS, NURSES,\nAND PATIENT ACTIVITIES DIRECTORS, MANY OF THESE TRAINING PROGRAMS\nWILL BE OPERATED UNDER CONTRACTS WITH PROFESSIONAL GROUPS.\nAPPROACHES TO MENTAL HEALTH PROBLEMS OF NURSING HOME PATIENTS WILL\nBE DEVELOPED BY NATIONAL INSTITUTE OF MENTAL HEALTH STAFF WORKING\nWITH THE GERONTOLOGICAL SOCIETY. OTHER TRAINING MECHANISMS WILL\nALSO BE EXPLORED, SUCH AS PROGRAMS SPONSORED BY STATE HEALTH\nDEPARTMENTS AND STATE AGENCIES. THESE PROGRAMS WILL BE DIRECTED\nhelping you\nTOWARD MAKING NURSING HOME STAFF-BOTH PROFESSIONAL AND ALLIED HEALTH-\nMORE SENSITIVE AND EXPERT IN THE SPECIAL PROBLEMS OF CARE FOR\nGERIATRIC PATIENTS AND THE CHRONICALLY ILL. THEY ARE INTENDED TO\nBE THE BEGINNING OF A SYSTEM FOR NATIONWIDE, CONTINUOUS TRAINING\nFOR NURSING HOME PERSONNEL WHICH WILL BECOME STANDARD PRACTICE IN\nTHE NURSING HOME INDUSTRY OF THE FUTURE,\nAs THE SEVENTH POINT IN HIS PLAN, THE PRESIDENT DIRECTED THE\nDEPARTMENT OF HEW \"TO ASSIST THE STATES IN ESTABLISHING INVESTI-\nGATIVE UNITS WHICH WILL RESPOND IN A RESPONSIBLE AND CONSTRUCTIVE\nWAY TO COMPLAINTS MADE BY OR ON BEHALF OF INDIVIDUAL PATIENTS. \"\nSINCE I ASSUMED MY NURSING HOME RESPONSIBILITIES, I HAVE RECEIVED\nMANY LETTERS FROM NURSING HOME PATIENTS-TOUCHING IN THEIR APPEAL\nFOR CARE OFFERING SIMPLE DIGNITY AND RIGHTS OF PRIVACY, HARROWING\nSOMETIMES IN THEIR DESCRIPTIONS OF PHYSICAL OR PSYCHOLOGICAL ABUSE.\nTHESE PATIENTS ARE OFTEN HELPLESS IN THEIR DEPENDENCE ON THE IN-\nSTITUTION IN WHICH THEY LIVE. THEY DESERVE A FAIR HEARING, AND AN\nADVOCATE WHEN THEY ARE POWERLESS, THE HEALTH SERVICES AND MENTAL\nHEALTH ADMINISTRATION HAS DEVELOPED FIVE MODELS FOR OMBUDSMAN\n8\nUNITS TO FILL THIS ROLE, PLACED AT VARIOUS LEVELS WITHIN THE\nSTATES AND DEMONSTRATING DIFFERENT MECHANISMS FOR ACTION.\nCONTRACT PROPOSALS TO TEST THESE MODELS ARE BEING SOLICITED,\nAND $600,000 HAS BEEN BUDGETED FOR FISCAY YEAR 1972 FOR THIS\nACTIVITY.\nIT WILL TAKE TIME TO TEST AND DEVELOP SUCH AN OMBUDSMAN\nSYSTEM, TIME INAPPROPRIATE TO THE URGENCY OF THE PROBLEM. So\nAN INTERIM OMBUDSMAN MECHANISM HAS BEEN ESTABLISHED WITH THE\n855 SOCIAL SECURITY ADMINISTRATION DISTRICT OFFICES DESIGNATED\nTO RECEIVE AND INVESTIGATE COMPLAINTS. THIS MECHANISM IS CURRENTLY\nIN EFFECT, AND HAS RECEIVED OVER A THOUSAND RESPONSES,\nFOR THESE NURSING HOME INITIATIVES, A SUPPLEMENTAL APPRO-\nPRIATION OF $9,572,000 HAS BEEN REQUESTED FOR FISCAL YEAR, 1972.\nWE FEEL THAT BY MEANS OF THESE PROGRAMS A SIGNIFICANT IMPROVEMENT\nIN NURSING HOME CARE CAN BE ACHIEVED IN A RELATIVELY SHORT PERIOD\nOF TIME.\nI WOULD LIKE TO EXAMINE NURSING HOMES NOW IN A DIFFERENT\nPERSPECTIVE. I HAVE MENTIONED THAT MEDICARE FINANCES NURSING\nHOME CARE AS AN EXTENSION OF HOSPITAL CARE - THE PRIOR HOSPITALI-\nZATION REQUIREMENT AND THE TIME LIMITATIONS PER SPELL OF ILLNESS\nARE MANIFESTATIONS OF THIS PRINCIPLE, MEDICAID REQUIREMENTS FOR\nSKILLED NURSING HOMES, WHILE THEY ARE NOT BASED ON THE SAME CONCEPT\nOF EXTENDED CARE TEND TO EMPHASIZE AND PROVIDE COVERAGE FOR MEDICAL\nSERVICES AS OPPOSED TO SOCIAL AND PERSONAL CARE.\n9\nTHE ELDERLY OF COURSE SUFFER FROM ACUTE DISEASE, BUT THEY\nARE MUCH MORE SUBJECT THAN YOUNGER PEOPLE TO THE DEPENDENCY OF\nCHRONIC ILLNESS. THE TERM \"SPELL OF ILLNESS\" MAKES LITTLE SENSE\nWHEN APPLIED TO A DISEASE PROCESS WHICH WILL NEVER BE CURED.\nMOREOVER, ALTHOUGH THE CHRONICALLY - ILL PATIENT MAY BENEFIT FROM\nINTENSIVE MEDICAL SERVICES, HE IS MORE LIKELY TO REQIRE LESS IN-\nTENSIVE BUT CONTINUOUS MEDICAL CARE IN COMBINATION WITH SOCIAL AND\nPERSONAL SERVICES TO HELP HIM LIVE WITH HIS CHRONIC DISABILITY,\nSo THE HEALTH FACILITY WHICH CAN BEST SERVE HIM MAY BE VERY DIFFERENT\nFROM THE EXTENDED CARE FACILITY WHICH IS IDEALLY SUITED TO A PATIENT\nRECUPERATING FROM A MYOCARDIAL INFARCTION OR A BROKEN HIP. OR HE\nMIGHT NOT REQUIRE INSTITUTIONAL CARE AT ALL - HE MIGHT BE PERFECTLY\nABLE TO LIVE IN HIS OWN HOME WITH THE AID OF HOMEMAKING AND HOME\nHEALTH SERVICES.\nTHESE PATIENTS WITH CHRONIC ILLNESSES - WHICH INCLUDE A DIS-\nPROPORTIONATE SHARE OF THE ELDERLY - AND THOSE SUFFERING THE IN-\nCREASED DEPENDENCY OF OLD AGE ITSELF-DEMONSTRATE THE WEAKNESSES OF\nLONG TERM CARE AS SUPPORTED BY THE FEDERAL GOVERNMENT.\nFIRST, MEDICARE AND MEDICAID TEND TO BE MORE CONCERNED IN\nTERM OF STANDARDS AND COVERAGE WITH THE MEDICAL COMPONENT OF NURSING\nHOME CARE. THIS HAS BEEN TRUE FOR BOTH STATUTORY AND HISTORICAL\nREASONS BASED ON THEIR ORIGIN AS HEALTH INSURANCE PROGRAMS. I DO\nNOT THINK IT IS HELPFUL TO SEPARATE THE PHYSICAL, EMOTIONAL, SOCIAL,\nAND ENVIRONMENTAL COMPONENTS OF CARE, PARTICULARLY FOR THE ELDERLY.\nTHESE ARE IMPERMANENT SEPARATIONS OF INTEREST, EMPHASIS, ORGANIZATION\nAND PREFERENCE; THEY REST MORE UPON TRADITION AND ARBITARY BOUNDARIES\nTHEN THE APPLICATION OF KNOWLEDGE TO LONG TERM CARE,\n10\nSECOND THE PRESENT HEALTH FINANCING SYSTEM OFFERS MORE\nCOMPLETE COVERAGE FOR PATIENTS INSIDE INSTITUTIONS THAN FOR\nTHOSE WHO REMAIN OUTSIDE. So OUR FINANCING STRUCTURE TENDS\nTO PUSH THE ELDERLY INTO NURSING HOMES, SOMETIMES PREMATURELY.\nSOCIETY PAYS A PRICE FOR THIS. INSTITUTIONAL CARE IS MORE\nCOSTLY THEN HOME HEALTH CARE. MORE IMPORTANT, THERE IS IN-\nCREASING EVIDENCE THAT THE DISPLACEMENT, LOSS OF STATUS,\nAND ISOLATION CAUSED BY INSTITUTIONALIZATION MAY EXACERBATE\nIF NOT PRECIPITATE ACTUAL PHYSIOLOGIC DISEASE. THE TRANSFER\nOF A PERSON FROM HIS HOME TO AN INSTITUTION MAY MAKE HIM\nMORE ILL AND MORE DEPENDENT,\nIF A NURSING HOME IS NOT THE MOST APPROPRIATE PLACE FOR\nA PERSON'S PARTICULAR NEEDS, THEN HE SHOULD NOT BE REQUIRED\nTO GO THERE. IF IT IS PERSONAL CARE RATHER THEN HEALTH\nCARE THAT IS REQUIRED, THEN THAT SHOULD BE AVAILABLE, IF IT\nIS APPROPRIATE HOUSING RATHER THEN INSTITUTIONAL CARE THAT\nIS NEEDED, THEN THE EMPHASIS SHOULD BE ON HOUSING. THE ELDERLY\nSHOULD HAVE MORE OPTIONS AVAILABLE.\nTHESE SEEM TO ME BASIC AND VALID CRITICISMS OF OUR PRESENT\nSYSTEM - THE SEPARATION BETWEEN MEDICAL AND PERSONAL CARE AND THE\nFAILURE TO PROVIDE ADEQUATE ALTERNATIVES TO INSTITUTIONAL CARE.\nAND IN THESE AREAS, FEDERAL PROGRAMS HAVE HAD AN UNFORTUNATE IF\nUNINTENDED IMPACT. THESE ISSUES CANNOT BE POSTPONED. ON\nDECEMBER 28, 1971, PRESIDENT NIXON SIGNED INTO LAW PUBLIC LAW\n92-223, WHICH AUTHORIZES THE TRANSFER OF INTERMEDIATE CARE FACIL-\nITIES INTO THE MEDICAID PROGRAM. AN INTERMEDICATE CARE FACILITY\nPROVIDES HEALTH RELATED SERVICES FOR PATIENTS WHO DO NOT REQUIRE\nCARE IN SKILLED NURSING HOMES, BUT NEED INSTITUTIONAL CARE BEYOND\n11\nROOM AND BOARD. As YOU KNOW, ICF's WERE PREVIOUSLY FINANCED\nBY PUBLIC ASSISTANCE PROGRAMS FOR THE AGED, THE BLIND, AND THE\nDISABLED, AND WERE SUBJECT ONLY TO STATE LICENSING. TRANSFER\nOF FINANCING TO THE MEDICAID PROGRAM MEANS NOT ONLY THAT A LARGER\nGROUP OF PEOPLE - INCLUDING THE \"MEDICALLY NEEDY\" - MAY POTENTIALLY\nBE ELIGIBLE FOR BENEFITS, BUT ALSO THAT THE FEDERAL GOVERNMENT IS\nEMPOWERED TO SET PHYSICAL AND SAFETY STANDARDS AND DEFINE THE\nCARE AND SERVICES THAT MUST BE PROVIDED. THE MEDICAL SERVICES\nADMINISTRATION OF THE SOCIAL AND REHABILITATION SERVICES AND\nMY OFFICE OF NURSING HOME AFFAIRS ARE CURRENTLY EXAMINING SUCH\nISSUES AS WHO SHOULD'BE IN THESE FACILITIES, WHAT SERVICES MUST\nTHEY PROVIDE, AND WHAT SHOULD BE THE LEVEL OF BENEFITS IN ATTEMPT-\nING TO DEVELOP STANDARDS FOR INTERMEDIATE CARE FACILITIES. So\nTHESE FACILITIES ARE FORCING A RE-EXAMINATION OF COVERAGE ISSUES,\nAND THE BALANCES OF MEDICAL AND PERSONAL SERVICES WITHIN IN-\nSTITUTIONS. THE \"PROBLEMS TO COME\" ARE HERE ALREADY.\nI WOULD LIKE TO MENTION ONE MORE PROBLEM THAT HAS DEMANDED\nATTENTION, AND THAT IS THE PLANNING PROCESS ITSELF. AN IMPORTANT\nREASON FOR THE INSUFFICIENT AND SOMETIMES INAPPROPRIATE IMPACT OF\nFEDERAL PROGRAMS FOR LONG TERM CARE HAS BEEN THE LACK OF PLANNING\nAND COORDINATION BETWEEN FEDERAL, STATE, AND LOCAL PROGRAMS.\nPLANNING FOR LONG TERM CARE SHOULD MOVE FROM IDENTIFICATION OF AN\nISSUE OR PROBLEM TO ITS SOLUTION, WITH IDENTIFIABLE GOALS GUIDING\nTHE PROCESS, MOVEMENT TOWARD A GOAL SHOULD NOT BE INTERRUPTED BY\nCHANGES IN ADMINISTRATION. WHAT IS TRULY IMPORTANT TODAY SHOULD\nNOT BE CAST ASIDE TOMORROW. NEW PROGRAMS SHOULD NOT BE APPENDAGES\nTO SATISFY THE INTERESTS OF A FEW, NOR SHOULD THEY BE ADDED AS\nPACIFIERS TO THE MANY. PROGRAMS DEVELOPED THROUGH A RATIONAL PLANNING\nPROCESS SHOULD THEN BE ADMINISTERED THROUGH AN EFFECTIVE AND COORDI-\nNATED MECHANISMS.\n12\nTHE ESTABLISHMENT OF THE OFFICE OF NURSING HOME AFFAIRS\nWITHIN HEW WAS A STEP TOWARD IMPROVING COORDINATION. THE EIGHTH\nPOINT OF THE PRESIDENT'S PLAN IS A MANDATE FOR A TASK FORCE ON\nLONG TERM CARE. THIS TASK FORCE WILL RE-EXAMINE ISSUES AND SET\nNEW GOALS, DEVELOP A NATIONWIDE DATA SYSTEM NECESSARY FOR POLICY\nFORMULATION, AND RECOMMEND AN ORGANIZATION FOR LONG TERM CARE WITHIN\nHEW AND FEDERAL STATE AND LOCAL PROGRAMS WHICH CAN ACHIEVE ITS\nGOALS MOST EFFECTIVELY.\nA NATIONAL POLICY COURSE FOR THE CHRONICALLY ILL AND FOR\nTHE ELDERLY SHOULD BE SET, IT SHOULD BE SET BY GOVERNMENT, WITH\nTHE FULL AND CREATIVE CONTRIBUTION OF THOSE IN OTHER AGENCIES\nAND ORGANIZATIONS, THOSE IN ACADEMIC TEACHING AND RESEARCH, THOSE\nIN VOLUNTARY AND UNSALARIED SERVICE, AND THOSE WHO RECEIVE THAT CARE.\nWE CAN DO MUCH BETTER FOR OUR ELDERLY. WE MUST OF COURSE\nPROTECT THEM FROM INSTITUTIONAL ABUSE, RECOGNIZING THAT SOME\nARE WEAK AND DEPENDENT. BUT WE CAN ALSO MAKE POSSIBLE A WIDE\nVARIETY OF SUPPORTING SERVICES AND LIVING ARRANGEMENTS, so THAT\nTHE INFIRMITIES OF ADVANCING AGE DO NOT BECOME A PRISON OF THE\nSPIRIT. THE ELDERLY WITH OUR HELP CAN HAVE ACCESS TO THE VARIETY\nAND FREEDOM WE ASK FOR OURSELVES,"
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