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Health - Home Health Care (1)
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Health - Home Health Care (1)
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Sarah C. Massengale Files (Ford Administration)
Sarah Massengale's Health, Social Security and Welfare Files
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Legislation
Medicaid
Health
Old age
Medicare
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1523587
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1976-02-29
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1976
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1972-04-01
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1972
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The original documents are located in Box 12, folder "Health - Home Health Care (1)" of
the Sarah C. Massengale Files at the Gerald R. Ford Presidential Library.
Copyright Notice
The copyright law of the United States (Title 17, United States Code) governs the making of
photocopies or other reproductions of copyrighted material. Gerald R. Ford donated to the
United States of America her copyrights in all of her husband's unpublished writings in National
Archives collections. Works prepared by U.S. Government employees as part of their official
duties are in the public domain. The copyrights to materials written by other individuals or
organizations are presumed to remain with them. If you think any of the information displayed
in the PDF is subject to a valid copyright claim, please contact the Gerald R. Ford Presidential
Library.
HEALTH.
EDUCA
HEW
any DEPARTMENT OF ANY NOID
NEWS
fee
U.S.A.
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
FOR IMMEDIATE RELEASE
John Blamphin - (202) 245-6867
Wednesday, August 25, 1976
HEW Secretary David Mathews announced today a series of public meetings
on home health care activities in keeping with his pledge to involve the
public in HEW's rule-making process.
Mathews said five two-day hearings will be held in September outside
Washington, seeking information on how HEW should regulate the rapidly
growing home health care program for Medicare and Medicaid patients.
Hearings will be held in New York City; Arlington, Texas; Atlanta; Chicago;
and Los Angeles.
"Home health care costs one-half billion dollars annually and touches
the lives of millions of Americans," Secretary Mathews said. "It is too
vast and personal an enterprise to be regulated without broad public
participation."
Home health care has as its broad purpose the treatment and care of
persons in their homes rather than in hospitals or nursing homes. It
covers such services as visiting nurses, nutrition advice, physical and
speech therapy, supplies, and equipment.
The hearings will seek comment from practitioners, patients, their
families, the general public, and others linked to the health industry.
Some of the questions for which HEW wants answers are:
-- How can patients be assured of high quality care?
FORD & LIBRARY QTVU
(More)
-2-
-- Should home health care providers be regulated? If so, by whom?
-- Should Federal fund ceilings be placed on this program?
-- Who should receive home health care?
-- How can services be delivered to remote areas?
Earlier this week, Secretary Mathews announced a $3 million one-year
program to provide demonstration grants to public and non-profit private
agencies for home health care services to the elderly and medically
underserved. HEW expects to award up to 50 of these grants by September 30.
Note to Editors: See attached list of public hearings --
date and location, plus regional contact.
HEW Home Health Care Hearings
September 20-21
Americana Hotel
801 Seventh Avenue
New York City, N.Y.
Time: 9 a.m.
Contact: Robert O'Connell (AC 212/264-3620)
HEW Regional Office
New York City, NY
September 21-22
Arlington Community Center
2800 South Center Street
Arlington, TX
Time: 9 a.m.
Contact: Jerry Stephens (AC 214/655-3338)
HEW Regional Office
Dallas, TX
September 22-23
Atlanta Hilton
Courtland & Harris Street
Atlanta, GA
Time: 9 a.m.
Contact: Joe Juska (AC 404/526-5001)
HEW Regional Office
Atlanta, GA
September 23-24
Holiday Inn
300 East Ohio Street
Chicago, IL
Time: 9 a.m.
Contact: Arline Bredin (AC 312/353-7801)
HEW Regional Office
Chicago, IL
September 30 - -
October 1
Convention Center, Room 217A
1201 South Figueroa Street
Los Angeles, CA
Time: 9 a.m.
Contact: Allen Marer (AC 415/556-1961)
HEW Regional Office
San Francisco, CA
HEW Assistant Regional Directors for Public Affairs
BOSTON
Frank Bucci
AC 617/223-7291
J.F. Kennedy Federal Office Building
Government Center
Boston, Mass. 02203
NEW YORK
Robert B. O'Connell
AC 212/264-3620
26 Federal Plaza
or 3621
New York, New York 10007
PHILADELPHIA
Dave Frankel
AC 212/596-6482
3535 Market Street
Philadelphia, Pa. 19104
ATLANTA
Joseph J. Juska
AC 404/526-5001
50 Seventh St., N.E.
or 2181
Atlanta, Ga. 30323
CHICAGO
Lee Feldman
AC 312/353-5164
300 South Wacker Dr.--35th F1.
or 4640
Chicago, Illinois 60606
DALLAS
William Van Rush
AC 214/655-3311
1200 Main Tower Bldg.--11th F1.
Dallas, Texas 75202
KANSAS CITY
Dick Wall
AC 816/758-3436
601 East 12th Street
Kansas City, Mo. 64106
DENVER
Carl Coleman
GERALO FORD LIBRARY
AC 303/837-2694
Federal Office Building
19th and Stout Streets
Denver, Colo. 80202
SAN FRANCISCO
Robert Fouts
AC 415/556-2246
50 Fulton Street
or 2255
San Francisco, Calif. 94102
SEATTLE
Harvey Chester
AC 206/442-0486
1321 Second Avenue
Seattle, Wash. 98101
THE WHITE HOUSE
WASHINGTON
discuss w/ Sarah
Usue of
FORD is LIBRARY
proprietry home
healthcare
the
Bennett Cloup/
Health Services
407 N Street, SW
Washington, DC 20024
202/484-3344
July 26, 1976
Dr. James H. Cavanaugh, Deputy Assistant
Domestic Affairs
The White House
Room 231
QCRALO FORD
Washington, D. C. 20503
Dear Jim:
I received a copy of a very disturbing memo written by
Marge Lynch pertaining to the Medicaid home health regu-
lations.
It has been my understanding that the regulations have
been held up from being signed primarily because (1)
Senator Moss and Congressman Pepper objected, and (2)
because no decision was forthcoming from the Secretary's
Office.
The Secretary has received numerous letters from know-
ledgeable and important Senators and Congressmen on both
sides of the aisle who are most concerned that these regu-
lations have not been issued.
In May, Planning issued a new position paper which, in
effect, agreed that the regulations should be put into
effect and this memo obviously has been disregarded.
When the discussions first started on this issue earlier
in 1976, there was only one objection as far as I know,
and that from Social Security, and their objection pri-
marily revolved around where medical services leave off
and social services begin. According to Tom Tierney,
they were not objecting to the proprietary issue.
Dr. Cavanaugh
Page 2
July 26, 1976
Marge now comes out with a memo that the regs should go back
to SRS and should eliminate proprietary involvement. She
does not ask for concurrence, but rather, "If any of you have
serious objections, please notify me by Monday, July 19; other-
wise, I shall proceed with the assurance of your full support".
I've never seen this handled this way before.
It hardly seems necessary to closely monitor for another year
an "in-depth evaluation" of the Medicaid regulations. In addi-
tion, the Under Secretary has assigned Region V the responsi-
bility to finalize plans for public hearings on this subject.
If you talk with SRS, H, P, or SSA, I think you 11 find that
they have had "hearings enough" and it would be purely a rehash
and waste of valuable taxpayers' time and money concerning this
subject. I'm enclosing a copy of the memo and would appreciate
any immediate follow-up with Marge or the Secretary on your
part.
Sahilay Best egards,
Berkeley V. Bennett
President
BVB:sg
Enclosures
C:
Mr. William L. Seidman
Mrs. Marjorie Lynch
Mr. Spencer Johnson
Dr. Keith Weikel
Dr. Theodore Cooper
THE UNDER SECRETARY OF HEALTH, EDUCATION, AND WELFARE
WASHINGTON, D.C. 20201
July 13, 1976
TO:
Assistant Secretaries
Principal Operating Components
All Regional Directors
FROM:
The Under Secretaryore Rynh
SUBJECT: Home Health Care
As a result of the extensive discussions and debate of the
past several months with regard to home health care, I plan
to recommend the following course of action to the Secretary.
If any of you have serious objections, please notify me by
Monday, July 19; otherwise, I shall proceed with the assur-
ance of your full support,
1. SRS will submit to the Secretary the revised
final Medicaid regulations on home health
services with the following modifications:
a. The section of the regulations providing
for increased participation by proprietary
home health care agencies will be excluded
from this publication and included as part
of a more general NOI (described below).
The preamble should be revised to explain
this change and reference the NOI.
b. Implementation of these changes in the
Medicaid regulations will be closely monitored
and provide a basis for an in-depth evaluation
of their impact on the utilization and delivery
of home health services at the end of one year.
Based on these findings, the Department at that
time will consider modification of the Medicare
and Medicaid regulations, as well as necessary
legislative proposals, to achieve greater uni-
formity between these two programs. The preamble
to the final Medicaid regulations should be re-
vised to indicate the Department's intent to
consider further changes in both programs at
the end of one year.
Home Health Care
-2-
2. H, with assistance from SRS, SSA, HD and P,
will be responsible for preparing an NOI on
home health care to be published simultaneously
with the Medicaid regulations. This NOI should
explain the broader issues around home health
care with which the Department has been struggling
and frame some of these questions for public dis-
cussion. Such questions should address, among
others, the following:
a. Who should receive taxpayer financed home
health services? (income limits, acute vs.
chronic patients, homebound, etc.);
b. Who should authorize services? (physicians,
professional nurse, etc.);
C, What range of services should be provided?
(health, social, maintenance, etc.);
d. What programs should pay for which kinds
of services?;
e. Who should provide and be reimbursed for
home health services? (proprietary vs. non-
proprietary, single purpose agencies, etc.)
f. How can we assure quality of care and protect
against fraud and abuse? Who is responsible for
providing this assurance?;
g. Are there better ways to finance home health
and other long term care services? (e.g. P's
proposal for separate, community-based long
term care program). What measures should be
taken to contain costs?;
h. What other alternatives to institutional
care should be considered?
The NOI should describe the Department's plans for
conducting public hearings on home health care around the
country,
3. The Regional Director, Region V, will be responsible
for finalizing plans for public hearings based on
the above. The preliminary plan approved by the
Secretary in April should be revised as appropriate
Home Health Care
-3-
to reflect the broader focus of these hearings.
P will be responsible for developing, in con-
junction with the RDs, a suggested agenda and
discussion papers for use at the hearings. Nancy
Porter should provide appropriate notification to
national provider and consumer organizations.
4. Public Affairs should develop a public information
plan for encouraging greater public attention to
the problems and issues surrounding long term care.
Specific emphasis should be placed on inviting
greater media participation in discussion of the
issues related to home health care and other alter-
natives to institutionalization.
5. The Secretary and I will notify the New Coalition
of the Department' plans for public hearings on
these issues and recommend that specific consider-
ation of home health care be included as part of
the Medicaid discussions on the agenda of the
Human Resources Forum. Each RD should contact
the Governors and other appropriate elected
officials in their regions to invite their parti-
cipation in the public hearings.
6. P should prepare an analytic agenda of home health
related issues which require further analysis by
the Department during the next year prior to our
reconsideration of the Medicare and Medicaid reg-
ulations. In addition, P, together with SRS, SSA
and H, should develop an evaluation plan for assess-
ing the impact of the revised Medicaid home health
regulations after one year of implementation.
GERALD FORD
FIN
United States Senate
OFFICE OF
THE ASSISTANT MINORITY LEADER
WASHINGTON, D.C. 20510
June 29, 1976
The Honorable David Mathews
Secretary
Department of Health, Education and Welfare
330 Independence Avenue, S. W.
Washington, D. C. 20201
Dear Mr. Secretary:
It is my understanding that regulations which would
permit the services of proprietary home health care agencies
to be included under the Medicaid program are currently
awaiting your approval.
In view of the need for expanded home health care ser-
vices to the elderly and disabled, I urge that these regulations
receive your approval. I am particularly concerned because the
present law operates to prohibit proprietary home health care
agencies in my State of Michigan from participating in the
Medicaid program, thus effectively cutting off essential ser-
vices to many needy Michigan residents. In fact, the current
law prevents such agencies from Medicaid reimbursement in 34
other States.
I am hopeful that you will give these regulations favor-
able consideration and allow the shortcomings of the present
law to be corrected.
With best wishes, I am
Box Sincerely, Grifin
RALD LIBRARY CERALD R.
Robert P. Griffin
U. S. Senator
RPG:JRj
RUSSELL LONG. LA.. CHAIRMAN
HERMANE TALMARGE GA.
CARL T. CURTIE, NEER.
VANCE MARTNE. IND.
PAUL J. FANNIN, ARIZ.
ABRAHAM RISICOFF. COWN.
CLIFFORD . HANSEN WYO.
HARRY F.B.RD JR., VA.
ROBERT J. DOLE. KANS.
GAYLORD NELSON, WIS.
BCS PACKWOOD. DREG.
WALTER F. MONDALE. MINN.
WILLIAM V. ROTH, JR., DEL
MIKE GRAVEL ALASKA
United States Senate
BILL BROCK, TERN.
LLOYD BENTSEN, TEX.
WILLIAM D. HATHAWAY, MAINE
COMMITTEE ON FINANCE
FLOYD K. HASKELL, COLO.
WASHINGTON, D.C. 20510
MICHAEL STERN, STAFF DIRECTOR
DONALD V. MOOREHEAD. CHIEF MINORITY COUNSEL
June 24, 1976
Honorable David Mathews
Secretary, Department of
Health, Education and Welfare
330 Independence Avenue, S.W.
Washington, D. C. 20201
Dear Secretary Mathews:
I understand that the regulations issued on
Thursday, August 21, 1975, regarding "Home Health
Services" are presently before you. These regula-
tions would establish standards compatible with
Medicare standards for home health aid programs
carried out by private groups.
My own State of Wyoming is a rural state with
a substantial population of older citizens. Home
health care would be a significant benefit to those
citizens, especially if that care could be covered
by Medicare. Moreover, release of these regulations
may have the further beneficial effect of stimulating
growth of these much needed home nurse and visitation
services.
The escalating cost of health service is a well-
known fact. Home health care services can make a
significant impact on health costs by allowing patients
who are kept in hospitals to return home where they may
recover more quickly and more comfortably in familiar
circumstances. I urge you to publish these regulations
as rapidly as possible.
With best regards,
Sincerely,
Clifford P. Hansen
U. S. S.
CPH:1gaw
June 24, 1976
Dear Mr. Secretary:
I am writing to encourage your early finalization
of the proposed Medicaid home health regulations which
were published in the August 21, 1975, Federal Register.
The Title XIX home health benefit is currently
operating with one rather vague regulation, which has
limited utilization of home health care to the param-
eters established by Title XVIII, an institution-
oriented, acute-care oriented philosophy never intended
to be applicable to the Medicaid program.
There have been repeated recommendations in late
years for HEW to encourage development of home health,
to expand the availability of services, and to set
standards.
I feel that your agency has made a solid move in
this direction with the proposed rules, which clarify
that the Medicaid home health program is not bound by
the same skilled care and prior hospitalization require-
ments currently hampering the Medicaid home health Medicare
benefit, which expand the availability of home health
services through inclusion of proprietary home health
agencies as providers, and which set standards for home
health aide training.
I see no reason why the American free enterprise
system shouldn't be encouraged, as long as the propri-
etary agencies meet the standards. In addition, it is
The Honorable David Mathews
June 24, 1976
my understanding that federal monies will not have to
be expended for start-up funding in order to bring in
this additional health manpower resource.
I urge early implementation of this Administration
policy.
Sincerely,
Bob Wilson
Member of Congress
The Honorable David Mathews
Secretary of Health, Education,
and Welfare
Washington, D.C. 20201
bcc: Bobbie Bretsch
MARVIN L. ESCH
DISTRICT OFFICES:
REPRESENTATIVE IN CONGRESS
200 EAST HURON
2D DISTRICT, MICHIGAN
ANN ARBOR, MICHIGAN 48108
PHONE: (313) 605-0618
COMMITTEES:
EDUCATION AND LABOR
Congress of the United States
9 EAST FRONT STREET
SCIENCE AND TECHNOLOGY
MONROE, MICHIGAN 48161
House of Representatives
PHONE: (313) 242-7580
WASHINGTON OFFICE:
2353 RAYBURN HOUSE OFFICE BUILDING
15273 FARMINGTON ROAD
WASHINGTON, D.C. 20515
Mashington, D.C. 20515
LIVONIA, MICHIGAN 48154
PHONE: (202) 225-4401
PHONE: (313) 261-5080
May 6, 1976
Secretary David Mathews
Department of Health, Education and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Secretary Mathews:
I understand that the regulations issued on Thursday, August
21, 1975 regarding "Home Health Services", are presently before
you for issuance.
I have read the joint letter dated December 12, 1975 you re-
ceived from Senator Moss and Congressman Pepper. Before you make
your decision, I would like to set the record straight regarding
the legislative intent of P.L. 90-248. From an inspection of the
legislative history, I find nothing which crystalize the issue as
clearly as the joint letter stated, or even crystalize the issue
at all. In fact, the legislative history in this area is without
any statement of intent.
Therefore, I believe the joint letter, by stating that the
regulations "are not in concert with the Congressional intent"
overstates the legislative history. I appreciate this opportunity
of setting the record straight.
With best wishes, I am
Sincerely,
Marvin L. Esch
Member of Congress
MLE:cv
ROBERT T. STAFFORD
COMMITTEES:
VERMONT
LABOR AND PUBLIC WELFARE
PUBLIC WORKS
5219 SENATE OFFICE BUILDING
VETERANS' AFFAIRS
TEL. (202) 224-5141
United States Senate
SPECIAL COMMITTEE ON AGING
NEAL J. HOUSTON
WASHINGTON, D.C. 20510
ADMINISTRATIVE ASSISTANT
May 27, 1976
The Honorable David Mathews
Secretary
Department of Health, Education, and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Secretary Mathews:
I understand that the regulations issued on Thursday,
August 21, 1975 regarding "Home Health Services", are
presently before you for issuance.
Interested constituents have brought to my attention
the fact that although the Medicaid Home Health Regulations
were proposed back in August of last year and are in a
position to be implemented, no action has been taken
thereon.
Regulations proposed by the Social and Rehabilitation
Service on August 21, 1975, would increase the number of
proprietary home health care providers eligible to partici-
pate in Medicaid programs. The SRS states, in the preface
to these regulations, "The purpose of the proposed regu-
lations is to remove certain restrictions and ambiguities
in current regulations which have prevented full realization
of the benefits of home health services in State Medicaid
"
programs
"Currently, participation under Medicaid as a home
health service provider is restricted to those agencies
which meet the statutory Medicare requirements, i.e.,
they must provide skilled nursing services and one other
service. This has meant that small visiting nurse
associations are unable to participate
"
"A major additional change is removal of the current
limitation which restricts proprietary agencies from
qualifying unless the State licenses such agencies."
The Honorable David Mathews
Page 2
May 27, 1976
Daily we hear reports of the escalating costs of
health services. Considering the urgency of that problem
and the potential for home health care to make a signi-
ficant impact upon health costs, let me urge you to move
these regulations out as rapidly as possible.
Sincerely yours,
Robert T. Stafford
United States Senator
RTS/ee
bcc: Berkeley Bennett
FA:HEW(Re:Medicaid Home Health Regs.)
April 2, 1976
The Honorable F. David Mathews
Secretary
Department of Health, Education, and Welfare
330 Independence Avenue, S. W.
Washington, D. C. 20201
Dear Mr. Secretary:
Interested constituents have brought to my attention the
fact that although the Medicaid Home Health Regulations
were proposed back in August of last year and are in a
position to be implemented, no action has been taken thereon.
From my discussion of these Regulations and the desirability
of their implementátion with those who appear to be in a
position to be able to objectively evaluate them, I feel
such Regulations should be implemented and would accordingly
urge such action.
With best regards,
Sincerely,
GARRY BROWN
GB:dld
April 13, 1976
Honorable David Mathews, Secretary
Department of Health, Education and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Mr. Secretary:
It is my understanding that for some years now the Department
of Health, Education and Welfare has been working toward the pro-
mulgation of regulations for Medicaid home health care.
From my activities and interests, both in Committee and in
my home district, there is a need for expanded services to the
elderly and disabled. The Proposed Regulations published in the
August 21, 1975 Federal Register address several vital issues:
1. the establishment of standards compatible with
Medicare standards;
2. the establishment of home health aide training
standards; and
3. the inclusion of proprietary home health agencies
that meet the above standards.
In particular, I believe that the present exclusion of pro-
prietary home health agencies works to the disadbantagesof both
the patient and the government from the standpoint of accessibility
of services to the patient and lower costs to the government. As
in all other classes of health providers covered by Medicare and
Medicaid, whoever meets the standards is eligible to participate
as a provider, except in the home health program.
Home health care needs to be a significant part of our services
to the elderly and disabled, and soon. Kt is my hope that you will
give consideration to promulgating the regulations I understand are
presently in your office.
Sincerely,
MARILYN LLOYD
Member of Congress
MT./l-h
HARRISON A. WILLIAMS, JR., N.J., CHAIRMAN
JENNINGS RANDOLPH, W. VA.
JACOB K. JAVITS. N.Y.
CLAIBORNE PELL. R.I.
RICHARD S. SCHWEIKER, PA.
EDWARD M. KENNEDY, MASS.
ROBERT TAFT, JR., OHIO
GAYLORD NELSON. WIS.
J. GLENN BEALL. JR., MD.
WALTER F. MONDALE, MINN.
ROBERT T. STAFFORD, VT.
THOMAS F. EAGLETON, MO.
PAUL LAXALT, NEV.
United States Senate
ALAN CRANSTON. CALIF.
WILLIAM D. HATHAWAY, MAINE
JOHN A. DURKIN, N.H.
COMMITTEE ON
LABOR AND PUBLIC WELFARE
DONALD ELISBURG. GENERAL COUNSEL
MARJORIE M. WHITTAKER, CHIEF CLERK
WASHINGTON, D.C. 20510
April 14, 1976
The Honorable F. David Mathews,
Secretary, Department of Health,
Education and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Mr. Secretary:
Regulations proposed by the Social and
Rehabilitation Service on August 21, 1975, would
increase the number of proprietary home health
care providers eligible to participate in Medicaid
programs. The SRS states, in the preface to these
regulations, "The purpose of the proposed regulations
is to remove certain restrictions and ambiguities
in current regulations which have prevented full
realization of the benefits of home health services
in State Medicaid programs
"
"Currently, participation under Medicaid as
a home health service provider is restricted to those
agencies which meet the statutory Medicare require-
ments, i.e., they must provide skilled nursing services
and one other service. This has meant that
small
visiting nurse associations are unable to participate
"
"A major additional change
is removal of
the current limitation which restricts proprietary
agencies from qualifying
unless the State licenses
such agencies. "
LIBRARY
Mr. Secretary, by making funding for medical
care at long last available to the elderly and the
needy, we have greatly increased the demand for such
care. If we simultaneously restrict the supply of
health care providers, either because of a bias
against private suppliers, or by waiting for states
which have not acted on licensing legislation, we
guarantee an increase in the cost of such care. It
is ironic that a program to improve health care seems
to be increasing demand on the one hand and restraining
supply on the other. People who used to be unable to
afford health care may now have the funds, but the
suppliers are forbidden to sell their services.
Secretary Mathews
Page 2
I hope that the proposed regulations of
August 21 can be finalized shortly. If you are
experiencing questions as to the Department's
statutory authority in this area, or other difficulties,
please let me know.
With every good wish.
Sincerely,
Robert Taft, Jr.
United States Senator
JOHN L. MCCLELLAN. ARK., CHAIRMAN
WARREN G. MAGNUSON, WASH.
MILTON R. YOUNG. N. DAK.
JOHN C. STENNIS, MISS.
ROMAN L. HRUSKA, NEBR.
JOHN O. PASTORE. R.I.
CLIFFORD P. CASE, N.J.
ROBERT C. BYRD, W. VA.
HIRAM L FONG, HAWAII
GALE W. MC GEE, WYO.
EDWARD W. BROOKE, MASS.
MIKE MANSFIELD. MONT.
MARK O. HATFIELD, OREG.
United States Senate
WILLIAM PROXMIRE, WIS.
TED STEVENS. ALASKA
JOSEPH M. MONTOYA, N. MEX.
CHARLES MC C. MATHIAS, JR., MD.
DANIEL K. INOUYE, HAWAII
RICHARD S. SCHWEIKER, PA.
COMMITTEE ON APPROPRIATIONS
ERNEST F. HOLLINGS, S.C.
HENRY BELLMON, OKLA.
BIRCH BAYH, IND.
WASHINGTON, D.C. 20510
THOMAS F. EAGLETON, MO.
LAWTON CHILES. FLA.
J. BENNETT JOHNSTON, LA.
April 1, 1976
WALTER D. HUDDLESTON, KY.
JAMES R. CALLOWAY
CHIEF COUNSEL AND STAFF DIRECTOR
Honorable Marjorie Lynch
Under Secretary
Department of Health, Education & Welfare
Washington, D.C. 20201
Dear Marge:
I understand that implementation of the Home Health Care Program
in HEW is moving along very, very slowly. As you know, this committee has
expressed a great deal of support for home health programs and feels that
they should get underway in an expanding effort as soon as possible.
Unfortunately, it appears as though the regulations and guide-
lines for Home Health Care have been written, re-written, and constantly
delayed.
It is time we got this program off the ground and actively moving.
All of the evidence that we have indicates that we can save a large amount
of scarce resources by implementing this program properly. In addition,
with Medicare and Medicaid costs rising so rapidly, it appears as if Home
Health Care could at least be a tool for helping to control these costs.
Your prompt attention to this will be greatly appreciated.
Best personal regards.
Sincerely,
Warren G. Magnuson,
Chairman, Subcommittee on
Labor-Health, Education,
and Welfare
WGM:Dh
PAUL J. FANNIN
OFFICES:
ARIZONA
3121 DIRKSEN BUILDING
WASHINGTON, D.C. 20510
COMMITTEES:
202-224-4521
INTERIOR AND INSULAR AFFAIRS
FINANCE
United States Senate
5429 FEDERAL BUILDING
PHOENIX, ARIZONA 85025
JOINT ECONOMIC
WASHINGTON, D.C. 20510
602-261-4486
301 WEST CONGRESS, ROOM 8-E
TUCSON, ARIZONA 85701
602-792-6336
May 6, 1976
The Honorable David Mathews
Secretary, Department of Health,
Education and Welfare
330 Independence Avenue, S.W.
Washington, D. C. 20201
Dear Mr. Secretary:
My purpose in writing is to urge your approvalof regulations
to permit proprietary home health agencies to participate
under the Medicaid Home Health Care Program.
I am deeply concerned that the Department is failing to
take advantage of proprietary participation in the Home
Health Care Program. Their participation will not only
enhance the scope of home health care, but it will assure
services delivered at a reasonable cost. I have been very
impressed by the level of services that proprietary home
health care programs can deliver at low cost without
sacrificing quality. In view of the obvious need to contain
costs in our federal home health care programs, it would seem
advisable to utilize proprietary home health care programs as
a way to maintain services at reasonable cost levels.
Therefore, I want to urge you to approve the pending regulations
which will permit proprietary home health care agencies to
participate in the Medicaid Home Health Care Program.
With kindest regards.
Sincerely,
Paul Jamin
Paul Fannin
United States Senator
PF:r1m
LLOYD BENTSEN
COMMITTEES:
TEXAS
FINANCE
PUBLIC WORKS
JOINT ECONOMIC
United States Senate
WASHINGTON, D.C. 20510
April 21, 1976
The Honorable David Mathews
Secretary of H.E.W.
U. S. Department of Health, Education
and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Mr. Secretary:
I have been concerned for some time at the delay In the
publication of the regulations on home health care, which
were first proposed by your Department on August 21, 1975.
I recognize that there are many serious Issues involved in
these regulations, but it appears to me that eight months
is more than sufficient time to have these difficulties Ironed
out and finally approved.
Dally we hear reports of the escalating costs of health services,
Considering the urgency of that problem and the potential for home
health care to make a significant impact upon health costs, let
me urge you to move these regulations out as rapidly as possible.
Sincerely,
Lloyd Bentsen
bcc: Mr. Berkeley Bennett
Bennett Group Health Services
407 "N" Street, S.W.
Washington, D.C. 20024
Home dealth care
July 2, 1976
Dear Mr. Duffey:
I appreciated receiving your lettermand followup
to our recent meeting, éncluding your specific
comments about the needs of home health care
agencies.
You may be assured that your views will be taken
into consideration as polisies in this area
develop.
Please extend my thanks and regards to Mr. Payne
as well.
Sincerely,
SPENCER C. JOHNSON
Associate Director of the
Domestic Council
Mr. Leonard E. Duffey, Jr.
Executive Director
Home Health Care Agency of North Alabama
3818 Montclair Road
Suite 120
Birmingham, Alabama
35213
FORD
GERALD R
GERALD
Home Health Care Agency
of North Alabama
3918 Montclair Road
Suite 120
Birmingham, Alabama 35213
Phone (205) 879-0600
June 29, 1976
Mr. Spencer Johnson
White House Associate Director
Concerning Domestic Affairs for
Health and Social Security
Room 237
Old Executive Office Building
Washington, D. C. 20515
Dear Mr. Johnson:
First of all, we would like to thank you for the opportunity of
meeting with you. Our Agency is advocating and urging that Secre-
tary Matthews sign a bill requiring all home health agencies to
obtain a Certificate of Need. Not an 1122, but a "Certificate
of Need to program", an assurance of the need for services pro-
vided by home health agencies. We feel that the criteria for this
Certificate should be stringent to assure not only quality health
care, but comprehensive health care as well.
We also urge that the Secretary sign a bill requiring states to
pass a licensure law by which all home health agencies will be
licensed. If the Federal Government could set minimums concern-
ing this licensure law and allow the individual state to expand
on them as they feel necessary, I think this would be agreeable
with all parts concerned. A licensure law is also essential to
assure quality and comprehensive home health care. In addition,
it would allow home health agencies to determine for themselves
whether to be profit or non-profit. Both of which have advan-
tages and disadvantages, but due to the differences in interpre-
tation from state to state, of Medicare regulations, it would
be more advantageous for home health agencies to make the de-
cision at the state level. Having this option would also elimi-
nate conflict with Internal Revenue Service regulations concern-
ing 501-C-3's.
Thirdly, home health agencies must be regarded
as a separate entity. At present, home health
agencies are regulated partly as if they were
hospitals, and partly as if they were nursing
homes. Home health agencies are neither and
should have separate guidelines, reimbursement
manuals and so forth. It is essential that
BERALD
Page 2
Mr. Spencer Johnson
June 29, 1976
this is done to assure the mere existence, continuance and
expansion of home health agencies. It is virtually impossible
to function as something you're not.
Mr. Johnson, your attention to this matter will be most appre-
ciated, not only by Home Health Care Agency of North Alabama,
but by the some 70,000 over-65 persons we have in our service
area. If additional information is needed or desired, please
do not hesitate to contact us. Also, information that you feel
may be valuable to us will be most welcome.
Sincerely yours,
Loward E. Duffey,Jr.
Leonard E. Duffey, Jr.
EXECUTIVE DIRECTOR
LED:ah
FORD ABRAP
Home Health Care Agency
of North Alabama
3918 Montclair Road
HOME HEALTH CARE OF MISSISSIPPI
Suite 120
Birmingham, Alabama 35213
Leonard E. Duffey, Jr.
Phone (205) 879-0600
Executive Director
W.A. PAYNE
Administrator
P.O. Box 1267, 109 S. 27th Avenue, Hattiesburg, Mississippi 39401
Home Ph. 544-9756
Business Ph. (601) 544-1316
the
Bennett Cloup/
Health Services
407 N Street, S.W.
Washington, DC 20024
202/484-3344
May 10, 1976
Mr. Spencer Johnson, Associate Director
Domestic Council
Room 237
Executive Office Building
Washington, D. C. 20500
Dear Spence:
In communicating with HEW (Secretary, Under Secretary,
Peter Foxx), I would think that the major points to stress
might be:
1. The White House has been concerned for a number
of years about the under-utilization of home health services.
2. The need to "get cracking" on less expensive forms
of care.
3. Recognizing the difference in the needs of patients,
i.e., Medicare beneficiaries and Medicaid clients are differ-
ent kinds of patients with different illnesses.
4. That when establishing policy, the social needs are
often as important as medical needs.
5. Why not sign the Medicaid Home Health Regs now!
I would appreciate your letting me know of any feedback you
receive.
Also, do let me know a convenient date when the "Tuesday Ten"
can meet in the Cabinet Room (original letter to Ted and list
attached).
FORD
Many thanks, and best regards,
Berkeley Shily V. Bennett
is LIBRARY GENALD
President
P.S. Remind HEW that there are many more important Senators
and Congressmen in favor of getting home health "off the dime"
than Senator Moss and Congressman Pepper.
December, 1975
"TUESDAY TEN"
Andrew Cardinal
Ms. Pat McGuire
American Hospital Association
National Association of Blue
1 Farragut Square South
Shield Plans
Washington, D. C. 20006
1730 Pennsylvania Avenue, N.W.
393-6066
Washington, D. C. 20006
785-7990
Paul R.M. Donelan
American Medical Association
Berkeley V. Bennett
1776 K Street, N.W.
The Bennett Group/Health Services
Washington, D. C. 20006
407 N Street, S.W.
833-8310
Washington, D. C. 20024
484-3344
Dr. Thomas G. Bell
American Health Care Association
Ron Kovener
1200 Fifteenth Street, N.W.
Hospital Financial Management
Washington, D. C. 20005
Association
833-2050
1050 - 17th Street, N.W., Suite 550
Washington, D. C. 20036
Hal Christenson
296-2920
American Dental Association
1101 Seventeenth Street, N.W.
Jack MacDonald
Washington, D. C. 20036
National Council of Health Care
833-3036
Services
1200 Fifteenth Street, N.W.
Albert Baker
Washington, D. C. 20005
Federation of American Hospitals
785-4754
1101 Seventeenth Street, N.W.
Washington, D. C. 20036
Steve Sumner
833-3070
Association of American Medical
Colleges
1 Dupont Circle, N.W.
Washington, D. C. 20036
466-5128
"TUESDAY TEN" - BACKGROUND
In January of 1974, a group of ten major health providers gathered
together to discuss health issues and regulations of mutual concern. Since
that date, there have been regular monthly meetings with discussion leaders,
Congressional leaders, HEW officials, and White House personnel.
While not all of the providers are specifically concerned with the
exact same issues, the majority have a great deal in common that can be re-
solved through this discussion mechanism and cooperative effort with the
governmental departments.
The fact that government policy makers meet with a group of providers
at one time offers an additional opportunity for them to discuss issues and
answer questions and, in effect, "kill-ten-birds-with-one-stone". The
meetings are time-saving for all, but most importantly, show a great deal
of solidarity in the industry.
The "Tuesday Ten" has maintained the same organizational size because
its members felt it was important to keep the group small to be manageable
and effective and, more importantly, to get total committments from the
various groups to work closely together and to be specifically helpful to
the government offices involved.
April 7, 1976
Honorable Theodore C. Marrs
Special Assistant to the Peesldent
Old Executive Office Building, Room 103
The White House
Washington, D. C. 20500
Dear Ted:
Following up on our conversation about the "Tuesday Ten"
meeting to be held in the Cabinet Room, there are a number
of issues that we do need briefing on, plus areas that
might be of Interest to discuss with various people at
The White House.
I'm listing these, not in any order of importance, but as
a review of the general areas we feel are Important as they
relate to Congress and to the Department of Health, Educa-
tion and Welfare, and to our varlous constituency.
THe new initiative toward regulatory reform and the
review provess.
Block grants and consolidation of health programs.
Dollar caps on hospital and physician fees.
HEW. Reaction to Senator Talmadge's new bill on reorganizing
Catastrophic coverage.
Prospective reimbursement for providers.
FGRD VIRGANA
Rate regulations.
Council on Price & Wage Stability.
We look forward to an early date, and would hope that perhaps
the first or second week in May might be convenient. I've
Mr. Marrs
Page 2
April 7, 1976
talked with Spence Johnson a couple of times, and
we've had some very preliminary discussions about
this meeting.
We can also get together for you the numbers on the
various provider gropps that we represent if you
need additional background for President Ford or
Secretary Mathews.
Look forward to hearing from you.
Best personal regards,
Berkeley M. Bennett
President
BVB:sg
CC: Mr. Spencer Johnson
Enclosures
HEALTH.
dome Neveth care
ADITION
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
SOCIAL AND REHABILITATION SERVICE
USA
WASHINGTON. D.C. 20201
OFFICE OF THE ADMINISTRATOR
APR 2 9 1976
The Honorable Spencer C. Johnson
Associate Director of the
Domestic Council
The White House
Washington, D.C. 20500
Dear Mr. Johnson:
Your letter of March 1 concerning proposed changes to Medicaid regulations
has been referred to this Agency for reply, as noted by Dr. Andrew S.
Adams, Commissioner of Rehabilitation Services, in his letter to you of
March 10. Please accept my apology for the delay in responding.
You stated that you had been visited by Mr. John Byrne, President of the
National Association of Home Health Agencies, who made several recommenda-
tions regarding home health. Specifically, Mr. Byrne recommended that
this Department withdraw the proposed regulations pertaining to home
health care services under Medicaid and that the Secretary authorize
studies of the quality of home care provided by all types of agencies.
Concerning Mr. Byrne's request to withdraw the proposed regulations, you
may know that Secretary Mathews has committed this Department to the
practice of participatory rule making. The most effective way to ensure
that interested individuals and organizations participate in our decision
making process is through the issuance of proposed regulations. The
interest in this regulation is evidenced by the more than 1,200 comments
received to date. The Secretary is now making a final review of the
comments and suggestions received in response to the proposed regulations.
He is also considering holding public hearings on the home health issue
so that interested persons can engage in personal dialogue with members
of this Department. If such hearings are held, I feel sure that the
matter of dual standards for Medicaid and Medicare will be discussed.
GLRALD FORD LIBRARY
Page 2 - The Honorable Spencer C. Johnson
Studies on home health care are already underway. One task force,
in the Office of Nursing Home Affairs, is reviewing home health
objectives. A second task force, in the Office of Community Health
Services, is responsible for implementing the provision of Public
Law 94-63 making grants available to home health agencies. That
task force is studying geographic areas with high percentages of
aged and medically needy persons so that priority can be given to
those areas when grants for home health are distributed. A demographic
study compiled by the latter group is enclosed for your information.
Mr. Byrne is a member of the task force implementing the grant provision
of Public Law 94-63 (see enclosed list). As Executive Director of the
St. Louis Visiting Nurse Service and as President of the National Association
of Home Health Agencies, he is involved in home health activities both
locally and on the national level.
Mr. Byrne also recommended that a national commission be established to
set up home health care standards for both Medicare and Medicaid programs.
As you may know, several committees in Congress have studied the home
health program for a number of years. An example of their endeavors can
be seen in two reports (also enclosed) published by the Senate Special
Committee on Aging.
Thank you for sharing Mr. Byrne's views with us. If you wish, I shall
be glad to discuss the matter with you further whenever your schedule
permits.
Sincerel Dawnh yours,
Don I. Wortman
Acting Administrator
Enclosures
92d Congress
2d Session
}
COMMITTEE PRINT
HOME HEALTH SERVICES
IN THE UNITED STATES
A REPORT
TO THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
FORD LIBRARY & GLRALD
APRIL 1972
Printed for the use of the Special Committee on Aging
U.S. GOVERNMENT PRINTING OFFICE
74-331 0
WASHINGTON : 1972
For sale by the Superintendent of Documents, U.S. Government Printing Office
Washington, D.C. 20402 - Price 60 cents
PREFACE
Much attention has been given-in the months before and after the
1971 White House Conference on Aging-to the need for developing
"Alternatives to Institutionalization."
Certainly, home health services-when well organized and related to
other components of an overall health delivery system-should rank
SPECIAL COMMITTEE ON AGING
high as a satisfactory alternative.
FRANK CHURCH, Idaho, Chairman
Who, as a person in need of limited but essential services, would not
HARRISON A. WILLIAMS, JR., New Jersey
rather remain in his familiar living quarters if assured that such serv-
HIRAM L. FONG, Hawaii
ALAN BIBLE, Nevada
JACK MILLER, Iowa
ices were available and attractive?
JENNINGS RANDOLPH, West Virginia
CLIFFORD P. HANSEN, Wyoming
Who, as a public official appalled by mounting costs of institutional
EDMUND S. MUSKIE, Maine
PAUL J. FANNIN, Arizona
FRANK E. MOSS, Utah
care, would not welcome services that enable patients to remain at
EDWARD J. GURNEY, Florida
EDWARD M. KENNEDY, Massachusetts
home when it is appropriate for them to do so?
WILLIAM B. SAXBE, Ohio
WALTER F. MONDALE, Minnesota
EDWARD W. BROOKE, Massachusetts
In terms of personal preference on the part of most patients and in
VANCE HARTKE, Indiana
CHARLES H. PERCY, Illinois
terms of public policy, therefore, the arguments for development of
CLAIBORNE PELL, Rhode Island
ROBERT T. STAFFORD, Vermont
home health care networks-providing a range of services to deal with
THOMAS F. EAGLETON, Missouri
temporary or chronic illnesses causing varying degrees of disability-
WILLIAM E. ORIOL, Staff Director
DAVID A. AFFELDT, Counsel
seem irresistible.
JOHN GUY MILLER, Minority Staff Director
And yet, as the report which follows makes all too clear:
-Despite lipservice to the need for home health services, Medicare
and Medicaid have actually fashioned serious roadblocks to the
(Prepared by Brahna Trager, Home Health Consultant)
development of such services.
(II)
-At a time when the "alternatives to institutionalization" psy-
chology is becoming more and more ingrained, the number of
home health service agencies is actually declining, and many more
seem to be in deepening financial jeopardy.
-Less than 1 percent of Medicare expenditures now go to home
health care, and even that small portion appears to be declining.
Surely, these facts point to a fundamental conflict between what is
said to be public policy and what actually exists in the health delivery
nonsystem. But partially because of confusion and partially because of public
unconcern, home health services are vanishing amidst a flurry of
paradoxical Federal regulations, widespread pronouncements about
overreliance on institutional care, and a search for a miracle cure to
the ills of the health industry in the United States today.
This is hardly a promising trend at a time when the Nation is about
to make major decisions on health care policy, including the question
of national health insurance of one kind or another.
The question is: Will home health services become a major com-
ponent in a rational and responsive health care system, or will its
shortcomings of today become even worse tomorrow, in a health
care system grown still more costly and less helpful to people in
need of service?
Fortunately, the answer to the question can be positive, if the
emergency of the present situation is fully understood.
(III)
IV
The Senate Committee on Aging is, of course, concerned primarily
about the effects of the present inadequacies upon the elderly. But as
Americans. is so often the case, action to help older Americans will also help other
CONTENTS
The report which follows documents the shortcomings in public
policy in the home health field. But it does more than this. It also
Page
deficiencies. points the way to an action program that can help remedy these
PART 1
1
The home-An American tradition
2
Immediate and long-term approaches are needed. The report makes
The population "at risk"
these major recommendations:
-Medicare and Medicaid regulations must be interpreted and
PART 2
5
applied so as to promote, rather than restrict, home health
The potential of home health services
5
services.
Home health services of good quality
6
-Home health planning must be based primarily on the professional
Patterns of intensity in home health services
6
judgments of those familiar with consumer needs, rather than
1. Concentrated or "intensive" services
7
2. Intermediate services
7
remote decisionmakers far removed from the problems.
3. "Basic" services
-Institutionalization as a condition for home health care must be
PART 3
eliminated, as well as requirements for co-insurance payments.
-Costly and confusing redtape must be eliminated in providing
The availability of home health services in the United States
9
10
home health services, including, in particular, the practices of
Home health agencies
10
prior authorization and retroactive denials.
Limitations in the Medicare system
14
-Proposals for national health care legislation must include provi-
The definition of a "home health agency"
20
The use of institutions
20
sion for comprehensive home health services.
The problem of "return"
21
-A national approach to the provision of adequate coverage of the
"Coordinated" home care programs
22
population by home health services is essential.
Hospital-based home care programs
These are the action steps that can and must be taken now to bring
Community-based home care programs closely linked to hospitals
22
home health services to the frontlines in the battle for decent medical
PART 4
care in this country. For too long these vital services have been pushed
25
to the sidelines. Their potential has not been realized. And this neglect
Basic components of home health services
25
Nursing services
27
of these services has caused us all to suffer in one way or another. The
Homemaker-home health aide services
32
most unfortunate victim has been the consumer who needs these
Social services
34
services.
Let this report serve as a call to action for all concerned with the
The potential of home health services in health maintenance organizations
Physical therapy, occupational therapy, and speech therapy
34
and ambulatory care facilities
34
health care crisis in this country. There is no need to wait any longer
Health maintenance organization
35
to act. And there is every reason to act now before a bad situation
Ambulatory care facilities
36
becomes even worse.
Cost saving
To the author of this report, Brahna Trager, the committee extends
PART 5
its sincere appreciation for her efforts. We are fortunate to have had
39
European home health services
a person of her distinguished standing in the field as our consultant
in this undertaking. And we are most grateful, too, to those who have
PART 6
43
document. contributed the informative materials in the appendixes in this
Manpower
PART 7
45
FRANK CHURCH,
Summary
46
Chairman, Special Committee on Aging,
Conclusions
EDMUND S. MUSKIE,
PART 8
49
Chairman, Subcommittee on Health of the Elderly.
Recommendations
(V)
VI
APPENDIXES
Appendix 1.-Responses of National Organizations:
Item 1. Letter and material from Kenneth Williamson, deputy
Page
director, American Hospital Association
51
HOME HEALTH SERVICES IN THE
Item 2. Statement by Donald R. Hayes, M.D., Home Health Care
and Service
UNITED STATES
54
Item 3. Statement of the National League for Nursing Department
of Home Health Agencies and Community Health Services
54
(By Brahna Trager*)
Item 4. American Nurses' Association Statement on Home Health
Agencies
57
Item 5. Statement of the National Association of Home Health
Agencies
58
PART 1
Item 6. Statement by the National Council for Homemaker-Home
Health Aide Services, Inc
61
Item 7. Statement by the American Home Economics Association
64
THE HOME-AN AMERICAN TRADITION
Item 8. Letter and material from American Speech and Hearing
Association, to Miss Brahna Trager
68
The word "home", the concept of "home life" has a special impor-
Item 9. Statement by the American Physical Therapy Association
74
Item 10. Statement from the American Occupational Therapy As-
tance to Americans. Our advertising leans heavily upon it. Pictures of
sociation, March 14, 1972
74
happy families together, of white-haired grandmothers and grand-
Appendix .-Excerpts from statement by Senator Alan Cranston, in
fathers "at home", have a deep appeal. The "preservation of family
support of S. 3355, Congressional Record, September 9, 1970
76
Appendix 3.-Excerpts from reports of functioning home health service
life" is a phrase commonly used to strengthen the acceptance of new
programs:
community programs and to protect those which already exist. Insti-
Item 1. Excerpts from report by Blue Cross of Greater Philadelphia
82
tutions frequently use the word as a euphemism to soften the grimmer
Item 2. Excerpts from Home Care Following Hospitalization, As-
aspects of institutional living. "Homes" for aged; nursing "homes",
sociated Hospital Service of New York
112
Item 3. Excerpts from the 10th Annual Report of the Home Care
convalescent "homes", children's "homes" are terms applied to make
Association, Rochester, N.Y., May 11, 1971
115
more palatable a way of life generally unacceptable to a people which has
Item 4. Excerpts from Homemaker-Home Health Aide Services in
culturally and historically guarded the right to a personal way of life,
New Jersey Annual Report
118
118
Appendix 4:
family life, and it is true that the generations in families do not remain
and guarded it fiercely. We hear a great deal about the breakdown of
Item 5. Excerpts from report by San Francisco Home Health Service_
Item 1. Letter from Mary L. Whitacre, M.D., health commissioner,
situation in which large numbers of people live alone. That is, they live
together as they once did. Increased longevity has brought about a
Marietta, Ohio, to Thomas M. Tierney, director, Bureau of Health
Insurance, Social Security Administration, Baltimore, Md
122
"alone" statistically. It is rare, however, to find acceptance of institu-
Item 2. Letter from Francis J. Charlton, M.D., San Francisco, to
Raphael B. Reider, M.D., February 18, 1972
tional life, with all that it means in terms of exclusion from the com-
124
Item 3. Letter from Marilyn Taylor, R.N., home care coordinator,
munity, conformity to institutional rules, separation from an environ-
Visiting Nurse Service, Battle Creek, Mich., to President Richard
ment that is personal, as an adequate substitute for a personal en-
M. Nixon, December 30, 1971
129
vironment, unless that environment is deteriorated or degraded
Item 4. Letter from Mrs. Helen L. Goodwin, R.N., executive director,
because the community offers nothing to support life there. Even
the Greater Lansing Visiting Nurse Association, to Mr. Charles
E. Chamberlain, Washington, D.C., January 27, 1972
130
then, it is more often than not, difficult to persuade the individual
Item 5. Proposed legislation submitted by the California Association
away from what has seemed to be his own shelter, the extension of
of the Home Health Agencies
132
himself, and into an institutional bed.
Appendix 5.-Athens Community Council on Aging: A model for a com-
munitywide home services and training program
134
In one area, the traditional regard for the individual's personal
Appendix 6.-Widespread Home Health Care Named A State Necessity,
choices about his way of life seems to be disappearing. The field of
from Age in Action, West Virginia Commission on Aging, November-
December 1971
health care, in recent years has become increasingly institutionalized.
147
The family physician at the bedside of the patient in his own home is
a vanishing phenomenon. The hospital with its complex of highly
specialized treatment facilities has become the safe, the effective
and the most convenient place for the treatment of acute illness; the
long-term institution has begun to replace a personal environment.
Division of Health Services and Mental Health Administration, Department
*Brahna Trager, consultant and technical writer, Home Health Branch, of
Health, Education, and Welfare; Member, Utilization Review Committee,
Health Aide Services; consultant, San Francisco Home Health Services;
National League for Nursing; Consultant, National Council for Homemaker-Home author
of forthcoming textbook, Homemaker-Home Health Aide Services, Organization,
Administration, and Training, and "Home Health Services and Health Insurance,'
Medical Care, Vol. 9, No. 1, January-February 1971.
(1)
2
3
The effectiveness of medical care has meant that disability and chronic
Growth in the older age group (75+) occurred at a faster rate. About
disease are prevalent in our population, and that those who are so
one-fourth of the population (five million persons) aged 65 and over
afflicted are our problems today. That they are our "problems"
live alone or with non-relatives;² and those in this age range who
rather than a reason for just pride is less a reflection on medical care
live with relatives could reasonably be assumed to be living primarily
than on our ability to create in our communities services which will
with spouses, siblings or other family members in approximately
provide our "saved" population with a decent way of life in terms of
the same age range. The day of the extended family in which the
our own traditions.
generations live together is disappearing, destroyed by economic pres-
We offer the disabled, the chronically ill of all ages but especially
sures which attract young families either to the city and away from
in our aging population one of two choices: helpless isolation "at
the farm, or away from the city to the suburbs, in either case limited
home" or the sterility of an institution.
by the absence of adequate housing, financial security, and com-
munity interest in their ability to maintain older family members in
THE POPULATION "AT RISK"
the multi-generation family. There is a substantial number of persons
in the older age range who no longer have relatives living. There are
To say that we are "confronted" with an aging population implies
also many older persons in the situation described in a recent Senate
that longevity itself is a problem in American life. We appear to con-
Committee on Aging report, in which the question is asked:
sider it a problem in spite of the fact that we have recently seen a
White House Conference on Aging attended by at least 3,400 delegates,
Can we realistically expect the grandparent generation to
assume the responsibility-financial and physical-for the
many of them from this population, actively working to improve
great grandparent generation? A 1962 national survey found
the quality of life for persons of all ages, conference speakers as
well as participants in the special interest sessions. We are surrounded
that among the noninstitutional population 65 and over, 32
in our daily lives by "aging" persons working in their accustomed
percent were great grandparents. That proportion is higher
now.³
way, living much as they have always lived, functioning to the limit
of their capacities which are often considerable. The physician, the
Although the health status in the aging population does not fit a
attorney, the plumber, the electrician, the legislator may have ac-
common stereotype of age as a condition invariably associated with
quired, as he passed the 45-year mark, certain of the chronic dis-
debility, senility, isolation and unhappiness, chronic illness is prev-
abilities which are associated with aging.¹ If he has had access to good
alent in the older persons. About 80 percent of those who are 65 and
health care, has been able to buy those services which he cannot
older are afflicted with one or more chronic conditions,⁴ but in the
undertake to perform for himself; and can afford to relax in a decent
non-institutionalized population in this age group 82.25 percent
living environment, he is not a "problem". He may in fact be a
have no limitation in mobility in spite of the presence of chronic
leader, a full participant in community life and a genial attender of
disease; 12 percent have some limitation in mobility; and of non-
conferences, since, along with his limitations in activity he may have
institutionalized persons 5.75 percent are housebound.⁵ There are,
which in other cultures are considered the basis upon which the
acquired over the years a good deal of wisdom, information and skill
however about five percent of older persons confined to institutions.⁶
future may be built. As the orthopedist said to the man whose X-rays
The use of long-term institutions as an appropriate resource for this
latter group has been questioned:
"
major
medical
looked pretty bad: "It's fortunate we don't walk on our X-rays."
organizations
are burdened with patients they should not have, and, as a last
Those who have worked with less fortunately placed older persons
resort, move them into quasi-medical nursing institutions-that is,
testify to the fact that many of them now in the depersonalizing
nursing homes which 25-50 percent of the patients do not require.'
atmosphere can of institutions or isolated in their homes might also be
A study done in Florida and published in June of 1971 showed that
able to function with greater effectiveness and satisfaction if they,
"85 percent of all nursing home residents would prefer to be at home.
too, had access to health care of good quality and had the essential
Physicians associated with the nursing homes said that nearly 20
compensatory services available to them.
percent of the patients did not belong in institutions. Registered
In 1970 our aging population (65 or over) had reached 20,049,592-
2 Facts and Figures on Older Americans. The Older Population Revisited. First
almost 10 percent of our total population, and the rate of growth in
results of the U.S. Census. U.S. Dept. of HEW. SRS. A.A.
this age group had increased by 21.1 percent in the decade between
3 A Pre-White House Conference on Aging, Summary of Developments and
the 1960 and 1970 census years as compared with a rate of 12.5
Data. A Report of the Special Committee on Aging, U.S. Senate, together with
percent in the under 65 age group. The population of those aged 45
minority and supplemental views. November 1971. p. 25.
and over now accounts for almost one-third of our total population.
4 John B. Martin, Special Assistant to the President for Aging. in: Press release,
January 4, 1971.
1 In the age range 45-64, causes of limitation in activity were heart disease 19%
5 Facts on Aging, A. A. Publication No. 146. Reprint from May 1970.
and arthritis and rheumatism 16.9%. These increased to 21.9 and 20.2 respectively
6 John B. Martin, Special Assistant to the President for Aging. Statement to
in the age group 65 years and over. National Center for Health Statistics Chronic
the Senior Citizens Roundup, Albuquerque, N.M., June 16, 1970.
Conditions and Limitations of Activity and Mobility July 1965-June 1967. USPHS
7 Special Committee on Aging. Alternatives to Nursing Home Care: A Proposal.
Prepared by staff specialists at the Levinson Gerontological Policy Institute.
Dept. of HEW p. 9.
Brandeis University, Waltham, Massachusetts. October, 1971. p. 2.
4
nurses felt that fully 30 percent of these nursing home patients
should have been at home."⁸
The term "at risk" when it is applied to the aging population refers
to the presence of chronic disease, which is characterized by consid-
erable fluctuation; a condition in which optimum health and mobility
PART 2
can at times be affected. The absence of effective preventive and
therapeutic services, of compensatory supports, the use of inappropri-
THE POTENTIAL OF HOME HEALTH SERVICES
ate resources for care, do in fact with depressing frequency produce
debility, senility, deterioration, isolation-the discouraging and SO
Home Health Services-a complex of services which may be
often unnecessary stereotype of old age. The risk is greatest when
brought, when and as needed, into the home-have had a very low
poverty, bad housing, poor nutrition are present, as they are in the
priority in the United States. References to such services in proposals
case of almost five million older Americans ⁹ and is compounded for
to meet growing health and social needs in our population are fre-
those who are poor and near poor and who are also alone. Nearly
quently consigned to the "et cetera" sections. Support for the develop-
six out of every ten in the older age group who live alone or with non-
ment of viable home health services has been minimal and in such
relatives are classified as poor or near poor.¹⁰
government funding as has been available home health services have
The movement into these groups by the well aged is a "risk". The
been limited, with regulatory conditions SO narrow as to make the
cost in dollars of caring for the end product of neglect is a "risk".
product negligible in terms of meeting real need.
The waste in human terms in a culture that in almost all respects is
Such concepts as preference-the right of the individual to remain in
comfort loving, life loving and, in general, generous in its ideals
his own home as a matter of choice; appropriateness-the selection of
is a great "risk".
the home as the most appropriate place for care, when it is appropriate
8 State of Florida Department of Health and Rehabilitation Services, Community
(as against an inappropriate institutional choice or the absence of
service); economy-the use of a less costly service which may be pref-
Care 9 Pre-White for the Elderly, House June Conference 1971. on Aging. Summary of Developments and
erable; concern about the growing costs of institutional care; and the
Data. A Report of the Special Committee on Aging. U.S. Senate. November 1971.
proliferation of institutional facilities (many of them poor in quality,
p. 6.
"one way" facilities with no possibility of rehabilitation or return,
10 Ibid. p. 7.
the best of them frequently used as the only solution rather than the
solution of choice); the growing emphasis upon the necessity for
increased use of ambulatory services, should include, but rarely do, a
forthright approach to the development of home health services of
good quality.
HOME HEALTH SERVICES OF GOOD QUALITY
"Home Health Services of good quality" describes an array of
services which may be brought into the home singly or in combina-
tion in order to achieve and sustain an optimum state of health,
activity, and independence for individuals of all ages who require such
services because of acute illness, exacerbations of chronic illness, long
term or permanent limitations due to chronic illness and disability.
They are an essential component of any system of comprehensive
health care and the absence of such services excludes the possibility
of the most appropriate use of all other health resources.
Such services are therapeutic and preventive. They are flexibly
adapted to meet current need; that is, the selection of those services
which are provided at any given time may change as individual needs
change¹ or they may be effectively maintained in a given combination
1
the first and most important objective of home care is to meet the need of the
individual. I do not deny the value of another, although secondary, objective,
namely, to free precious hospital beds for use by people who need them If
we place major emphasis on the desire to free hospital beds then we may easily
get into a situation where we use home care as a cheap substitute for good hospital
care and this would be a disaster." Goldmann, Franz. Medical Care Programs and
Home Care. In Public Health Nursing of the Sick at Home. Department of Public
Health Nursing. National League for Nursing. New York. 1953.
(5)
7
6
2. INTERMEDIATE SERVICE
for long periods of time. They may be provided permanently, when
they are necessary either therapeutically or to supplement or replace
A less concentrated array of home health services, an "intermediate"
functional limitations which may increase or which are permanent.
level, is most often applicable to those whose needs require services
Coordination of the services is an inherent aspect of their quality.
which correspond to care necessary during convalescence from
Whether the needed combination of services is provided from a single
acute illness or because of temporary disability related to chronic
source or is assembled from a variety of sources, they must be pro-
illness. Such services are often utilized for the establishment of
vided in a context which ensures firm relationships among the various
therapeutic regimes which will accelerate the return to optimum
components of care in order to form a smoothly functioning network of
function. They include, in addition to care given by the physician,
total care.
nursing visits which may involve specific treatment as well as obser-
Continuity of the services is also an inherent aspect of their quality.
vation; they may also include physical therapy, occupational therapy,
In the well organized community, home health services are a part of
speech therapy and they frequently require utilization of substantial
the continuum of care included in the total range. Interruption or
homemaker-home health aide services to support and maintain per-
change is planned and is not imposed by conditions unrelated to indi-
sonal hygiene, adequate nutrition, and an environment which is
vidual need. "Planning" in this sense involves assessment, followed by
conducive to health. Services at this level may vary considerably in
selection of the most appropriate services planned, change in the
intensity and duration. In general this level of care, though of longer
"level" of in-home services, selection of alternative method of care,
duration, is not usually required over extended periods of time.
interruption or discontinuance of services because they are not
currently needed. The movement through the continuum may begin
3. "Basic" SERVICES
at any point in the range, and move flexibly through or between
components of the comprehensive health care system. (See Diagram
These services are described in various ways. The term "preventive"
A, p. 8.)
is broadly used as it is applied in Public Health, to prevent disease or
disability (to promote health); to arrest disease or disability; to sup-
PATTERNS OF INTENSITY IN HOME HEALTH SERVICES
port those who, because of increasing disease or disability, will require
appropriate home delivered services in order to avoid or delay insti-
The utilization of Home Health Services in combinations of varying
tutionalization. The term "minimal" is sometimes applied. Such
intensity are often described as "levels" of care:
services are not "minimal" in terms of their importance. They have
the greatest potential for utilization by large sections of the population.
1. CONCENTRATED OR "INTENSIVE" SERVICE
They are also sometimes described as "custodial". The largest numbers
within the population for whom they could be useful are not candidates
The most concentrated or "intensive" service is considered effec-
for "custodial" care, however, in thesense that they havelost the capacity
tive "for selected patients who otherwise would require admission to
to function without substantial supportive services such as those
hospitals or other health care institutions. It can be equally valid for
provided in an institutional setting. (The absence of such services does,
patients admitted to hospitals or other health care institutions who
however, frequently provide "custodial" candidates.)
no longer need instant availability of full diagnostic and therapeutic
Basic services involve a simple combination: 4 health supervision or
resources of the institution, but do require multiple professional,
the establishment and maintenance of an open channel to health care
diagnostic, therapeutic and supportive services under professional
as needed and the provision of those services which support or maintain
supervision and coordination on an intermittent basis. Patients
activities of daily living or which supplement limited function by
usually need the intensive level of home care for a relatively short
substituting selected services for those which cannot be performed
period of time." 2
independently.
Such concentrated services usually involve the provision in the
The usual combination in addition to medical supervision, includes
home of a complex which may include visits by the physician several
home nursing visits, access to social services, and the services of
times a week, daily nursing visits, frequent physical therapy and
homemaker-home health aides.
occupational therapy treatment, social services, nutrition services,
drugs and medical supplies, the provision of equipment, such as hos-
Basic services may adequately maintain individuals in their homes
pital beds, wheelchairs and commodes, portable diagnostic equip-
at effective levels of health and function over long periods of time or
ment, homemaker-home health aide services, transportation (usually
permanently without recourse to more concentrated care or to
to therapeutic or diagnostic treatment which cannot be provided in the
institutionalization.
home), and "all other diagnostic and therapeutic services which can
4 "For the patient with long-term or chronic illness medical care becomes a way
be safely delivered in the patient's home."
of life-and all too often results in his institutionalization Although the home is not
appropriate for all chronically ill patients in all stages of their illness, it can provide
2 American Hospital Association. Governing Council of the Assembly of Out-
a desirable setting for more patients far more often than at present. Home care
patient and Home Care Institutions. Resolution on Ameriplan April 6-7, 1971.
need not be elaborate in order to meet the requirements of thousands of patients
3 Ibid.
now receiving care in hospitals or chronic disease facilities" American Hospital
Association Statement of the Role and Responsibilities of Hospitals in Home Care-
See Appendix 1, item 2, p. 52.
8
Such services are most effective when chronic disease limits but
does not totally disable, when mobility has been affected SO that full
physical functioning in the essential activities of daily living is not
PART 3
possible for short or long periods of time. Individuals with multiple
diagnostic problems who might, on paper, appear to require institu-
tional care, are very frequently able to continue to live normally in
THE AVAILABILITY OF HOME HEALTH SERVICES IN THE
their own homes, to participate in community life, to continue to work,
UNITED STATES
when such basic services are available to them.
The availability of comprehensive home health services in the
Home Care programs
serve the patient who is already
United States could substantially affect the appropriate utilization
in his own home and needs care but does not require hospital or other
of all health care resources. Such comprehensive services are not
institutional care; they also serve the institutional patient who is
available at the present time.
ready for discharge and now needs only
services of the sort that
can feasibly be provided at home
(they) are diverse and flexible.
The potential of broad community based home health programs
They are not restricted to any one group of patients, but are com-
capable of serving large population groups with varying and fluctuat-
munity wide in their reach. All age groups, all disease entities and
ing needs has barely been demonstrated. Hospital-based programs are
stages of illness, all economic levels are accepted when
indica-
also in short supply and are not being developed in proportion to need.
tions
dictate
care at home as the treatment of choice.' 5
Focused upon short-term concentrated care, they do not have avail-
able in the community those services which can be extended to meet
DIAGRAM A.
long-range need. Home health services, where they do exist are
underfinanced, limited in their capacity to cover the population in
"LEVELS" OF HOME HEALTH SERVICE *
need, frequently lacking in essential components which might make
them an effective resource.
REFERRAL ORIGIN
They are diminishing in numbers.
CONCENTRATED
They are curtailing their services.
SERVICES
They are narrowing their coverage to selected population groups.
HOSPITAL
They are reducing the duration of the care they offer.
The available supply of services includes an assortment of limited
agencies: small home nursing programs which depend upon one or
INTERMEDIATE
two nurses and a few hours of physical therapy or social service-an
SERVICES
COMMUNITY
occasional home health aide-the minimal qualification of "skilled
nursing plus one" required for certification in Medicare legislation.
Such agencies are unable to provide coverage or to meet valid home
care need. Homemaker-home health aide programs which should
supply the essential basic supports when family members are not
I
capable of supplementing care-or when there are no family mem-
<
bers-are rare. They are limited in their ability to meet population
BASIC
SERVICES
demand either for short- or long-term care.
There are geographic areas of the country and large sections of
<
the population which do not have home health services of any kind
available. Services are fragmented, geared to special groups, under-
financed, diminishing as the need increases.
POPULATION UTILIZATION
This situation does not provide a community resource which can be
described as "Home health services of good quality." The auspices
*Source: Ryder, Claire, M.D., Chief of Home Health Branch, Community
Health Service, Health Services and Mental Health Administration, DHEW.
under which the services are provided do not determine their quality.
Whether they are hospital based, community-based, or exist in an
5 Ryder, Claire F. M.D. and Stitt, Pauline G. M.D. Physician Involvement in
assembly of community agencies, each offering the components of
Home Care Inquiry. Volume IV Number 3. Special Issue: Home Care. October,
1967. Blue Cross Association. Chicago, Illinois. Pp. 41-42.
home health care, the essential features which are described in
"good quality" are that all of the needed services must be available
to all of the population. They must be available in a supply which is
adequate for the population. They must be coordinated, whether they
are under a single roof or housed and administered separately. They
(9)
10
11
must provide a network which continuously provides services for as
(1) a beneficiary paralyzed from a stroke who is confined
long as they are needed.
to a wheelchair or who requires the aid of crutches in order
Home health services and "home health agencies" are not con-
to walk; (2) a beneficiary who is blind or senile and requires
sidered synonymous terms. The first is a concept which is based
the assistance of another person in leaving his place of
upon clearly defined standards of excellence, as any health care
residence; (3) a beneficiary who has lost the use of his upper
institution of good quality must be. The second is a legislative title
extremities and, therefore, is unable to open doors, use
which includes only selected and expedient elements of home health
handrails on stairways, etc., and, therefore, requires the
services.
assistance of another individual in leaving his place of
HOME HEALTH AGENCIES
residence; (4) a patient who has just returned from a hos-
pital stay involving surgery who may be suffering from
The title "Home Health Agency" originated in the Home Health
resultant weakness and pain and, therefore, his actions may
Services section of title XVIII-Federal Health Insurance for the
be restricted by his physician to certain specified and limited
Aged (Medicare).
activities such as getting out of bed only for a specified
It has been said that Medicare is not a "program". It is, rather,
period of time, walking stairs only once a day, etc.; and (5)
a mechanism for payment; for reimbursement of the costs of services
a patient with arteriosclerotic heart disease of such severity
specified as benefits in the insurance system which covers a selected
that he must avoid all stress and physical activity.¹
section of the population.
In interpreting these regulations considerable emphasis is placed
Nevertheless, the home health regulations of the Medicare insurance
upon the condition that the patient must not be "custodial". On the
system, which governs the expenditure of the insurance funds have
other hand the severity of limitations, which are indicated in the
had a good deal of influence on the conception of home health services
examples, would appear to apply to the patient who needed consider-
and have had a considerable effect upon the providers of such services
able service in order to be maintained at home.
and the methods by which the services are provided.
Institutional services can readily be defined and understood. The
Services which are reimbursable are not those which are most
needed array of home health services which are comprehensive and
needed by the majority of the insured group.
which must be flexibly utilized is less readily defined.
The definition of the eligible consumer as one who is severely limited
but not custodial does not appear to "fit" with the services which are
LIMITATIONS IN THE MEDICARE SYSTEM
permissible in the system. The requirement that they be "part-time
and intermittent" must either be applied to a patient who is reasonably
As they are applied to the target population-the aged (title XVIII
able to sustain himself in the intervals or who has others available to
parts A and B) and the indigent sick (Title XIX) the features of the
do so. The patient must be sick enough to require "skilled" profes-
system which limit their utilization are these:
sional services but not SO sick that he requires too many visits, visits
Home health services in the Federal Medicare insurance system
which are concentrated numerically, or supportive services which the
are focussed upon acute or short term illness.
system limits sharply.2
The insurance system limits the number of visits (100 for
The regulations which govern the part-time intermittent services
of a home health aide are an illustration:
part A as a post-hospital service and 100 under the supplementary
program for those who can afford co-insurance). Since the number
While the primary need of the patient for home health aide
of visits includes those provided by all personnel in the home
services furnished in the course of a particular visit may be
health agency this in effect allows short-term service and imposes
for personal care services furnished by the aide, the home
upon providers an approach which is limited to acute care.
health aide may also perform certain household services which
The definition of the eligible consumer of home health services
are designated to the home health aide in order to prevent
or postpone the patient's institutionalization.
If
is inherently contradictory as it is applied to the needs of the
insured group.
these household services are incidental and do not sub-
stantially increase the time spent by the home health aide
The eligible consumer of home health services is described in the
the cost of the entire visit would be reimbursable. House-
regulations as follows:
keeping services which would materially increase the amount
An individual does not have to be bedridden to be con-
of time required to be spent by the home health aide to make
sidered as confined to his home. However, the condition
1 Health Insurance for the Aged-Home Health Agency Manual, P. 16c, Section
of these patients should be such that there exists a normal
208.4, U.S. Department of Health, Education and Welfare, Social Security
inability to leave home and, consequently, leaving their
Administration, HIM-11 (6-66), Reprint Date 5-71.
homes would require a considerable and taxing effort.
2 Trager, Brahna, Home Health Services and Health Insurance-Medical Care,
Some examples of homebound patients which are also
Vol. 9, No. 1, Jan.-Feb. 1971.
illustrative of the factors to be taken into account in deter-
mining whether a homebound condition exists would be:
74-331 0-72-2
12
13
the visit above the amount of time necessitated by care for the
patient are not reimbursable.³ [Italics supplied]
ently required three types of service even if not needed, in
order to complete the treatment at home.⁶
The focus on "personal care duties" and the emphasis upon the
fact that housekeeping services should not "substantially" increase
The complexities of administration and reimbursement have
the amount of time required in the home by the home health aide
placed many agencies in financial jeopardy.
are extremely difficult to apply. The assumption that "others" in
Preparation of claims, approval of reimbursement, computation of
the home are available to provide the essential supportive services
visits in the overlapping A and B system have placed considerable
of daily living is not generally applicable to the age and living arrange-
pressure on the administration of home health agencies, many of them
ments of the insured group. It is far more likely that the patient
inadequately prepared to meet these demands.
who lives alone or with an elderly spouse will be able to achieve his
The processes by which claims are submitted, interpretations made,
"personal care" services independently, than that he will be able to
lengthy correspondence initiated over details of wording and differ-
maintain a decent environment; get the laundry in; or carry groceries
ences in visit counts place an enormous burden on providers. The paper
in the "intermittent" periods when services are not provided.
contest over whose judgment shall prevail-the qualified professionals
The definitions of the nature of the services which are reimburs-
in an agency which must meet exacting standards who is looking at
able are susceptible to a wide variety of interpretations.
the patient, his illness and his environment, or the fiscal intermediary
with the paper who is trying to fit the words to the regulations-would
Definitions which apply to the quality of the services which
be ridiculous if it were not SO tragically wasteful. Larger agencies
are reimbursable are extremely difficult to rationalize. The term
watch their administrative costs go up. Smaller agencies watch their
"skilled nursing", for example, has been interpreted to apply to
services go under.
the task itself rather than the assumption that a qualified pro-
fessional person will apply her skills in all aspects of the service
The difficulties in establishing and maintaining services have
that she renders and that her judgment of the nature of the
substantially limited the range of services offered by providers.
services required is the essential professional function. This same
A limited range reduces the usefulness of the services.
approach is common in regulations with respect to physical
Coordinated home care programs which provide a broad range of
therapy services related to restoration with an additional require-
services have demonstrated what must be self-evident: the avail-
ment not compatible with the philosophy of any therapeutic
ability of a variety of professional and supportive services in a home
approach:
health agency encourages utilization, even when the majority of
"there must be a medically appropriate expectation
patients treated do not require all of them. Since the necessity to
that the patient's condition will improve significantly
select differing combinations at different stages in care always exists,
in a reasonably (and generally predictable) period of
physicians will not be encouraged to utilize home health services if
time".⁵ The return to an optimum degree of function
they are not comprehensive and if the patient must be rehospitalized
which is the goal of therapeutic services in other situa-
because services which could reasonably be delivered in the home are
not available.
tions, and particularly in this age group, does not
prevail. [Italics supplied]
Reimbursement from the insurance system is allowed only for
selected services. The relevance of the use of varying combinations
In practice many patients are undergoing an occupational
with different degrees of intensity according to patient need is an
therapy regimen at the time they are discharged from the
aspect of quality care. The regulations as they are interpreted and
hospital or extended care facility and returned to their
applied do not recognize this aspect.
homes for completion of the treatment program there. Under
Home health agencies which offer a reasonable array of services
present law, (Medicare), one of three things must happen: 1)
must look for the support of their development to their own efforts
the patient must be retained in the hospital, at an addi-
and to the communities in which they are placed. This support has
tional cost, until the treatment is completed, or, 2) he must
not been available and the pressure of need for unreimbursed service
be sent home and the needed treatment halted, or 3) some
in the population has strained resources and inhibited development
subterfuge must be found, such as instituting one of the pres-
toward comprehensive services.
3 Nurses
"have a long history of monitoring their activities
better
The system has a very strong institutional bias. Entry into the
utilization has been promoted
nursing staff
in
consultation
with
the
home health services entitlement (Part A) is by way of an insti-
patient's physician, is in the best position to determine the need for care at home.
Such a crucial matter should not be left to the judgment of intermediaries, no
tution (a three-day period of hospitalization unless the insured is
matter how well intentioned," American Nurses' Association. See appendix 1,
able to pay for supplementary insurance).
item 4, p. 57.
4 See appendix 4, item 4, p. 130-Reimbursement was retroactively denied for
In both an acute hospital and an extended care facility the system
nursing visits made to teach a family member to make a dying patient more
reimburses the provider for all services. Regulations do not limit the
comfortable on the score that these were "activities of daily living."
skills of professional personnel nor the number and frequency of
5 Health Insurance for the Aged-Home Health Agency Manual, p. 15-16,
section 205.4, U.S. Dept. Health, Education, and Welfare, S.S. Admin. HIM-11
6 See appendix 1, item 10, p. 74, American Occupational Therapy Association
(6-66), Reprint date 5-71.
Statement on Home Health Care.
14
15
visits. They do not exclude the provision and preparation of food or
any of the maintenance services essential to a hygienic environment.
voluntary or public agencies which offered services in the home
Given a choice between full and coordinated services in the institution
prior to passage of the Medicare insurance legislation; they were not
and the relative insecurity of limited home delivered services which
a substantially new resource for those in need of home health services.
are restricted in the provision of professional care and which view all
Many of these agencies, those which were primarily engaged in
other supportive services very narrowly, consideration for the relative
providing home nursing, added, or contracted for an additional service
safety of the patient must encourage utilization of the institution.
in order to achieve certification. Others providing services which were
The home might be a more appropriate choice, but unless equal
broader in range were able to receive reimbursement for that portion
safety can be insured through the provision of adequate professional
of their care which fit the conditions of the Medicare insurance system.
care and supportive services to compensate for those which the
Those which were established as new agencies in anticipation of sus-
patient can neither provide for himself nor secure from other sources,
taining their services through Federal Medicare Insurance reimburse-
it cannot be in the patient's interest to treat him there.
ment have had the most difficulty; it is not possible to sustain a home
Utilization of home health services in the Medicare insurance
health agency which will provide the care required by those in need
system has remained at less than 1 percent of insurance expend-
when the source of reimbursement is limited to the Medicare insurance
itures and appears to be diminishing. Institutional utilization
system.
and expenditures are increasing.
Certified home health agencies deliver their services under a variety
Increased expenditures for institutional care in the health insurance
of auspices:
system reflect both increased costs and increased utilization. Ex-
As of December 1971, the largest number of certified providers
penditures for home health services in the period 1969-1971 have
1,303 were the official health agencies. Visiting Nurse Associations
decreased.⁷
made up the next largest with 550 agencies certified; 217 of the 243
hospital-based home care programs were certified as providers. The re-
Retroactive denial of payments combined with under
maining agencies were distributed among a variety of auspices, public,
use is resulting in such serious financial difficulties for
voluntary and proprietary. 11
providers of home health care that such provider resources
The range of services provided by these agencies is limited. More
are diminishing steadily.⁸
than half fall into the group "skilled nursing plus one"-the minimum
There has been a decrease in the number of home health agencies
required for certification. Another 26 percent provide two services in
participating in the Medicare insurance system: there were 2,350 par-
addition to nursing. Only 4 percent provide five services in addition
ticipating home health agencies in June of 1970 and in June of 1971,
to nursing. The second service most frequently offered is physical
there were 2,256 participating home health agencies.⁹
therapy. The third most frequently offered is home health aide services.
For these reasons (and others related to the absence of concerted
Services are more numerous in urban areas which, prior to passage
efforts to develop services), contraction of services and personnel have
of the Medicare Insurance legislation, offered bedside nursing serv-
created a prevailing attitude that home health services are not
ices through the official health agencies (departments of Public Health)
generally available and therefore do not serve a useful purpose.
or through well established Visiting Nurse Associations. The distribu-
tion of services in rural areas is thin and in some sections of the country
THE DEFINITION OF A "HOME HEALTH AGENCY"
there are no services available.
The number of agencies and the number of services offered provide
The Medicare insurance system defines a "Home Health Agency"
no real indication of their utility as a practical home health resource.
(one which is eligible for certification and consequently for reimburse-
Half of the agencies have fewer than three full time nurses available.
ment of services by the Medicare insurance system) as a public or
The additional services offered are, many of them, only minimally
private agency (or subdivision of such an organization), which, in
available: physical therapy, nutrition, home health aide services may
addition to requirements for sound administration, adequate records,
be available, as are nurses, on an hourly basis, or from one or two
professional supervision, assessment and review, has as its primary
employees. "When an agency's services are too limited, one of two
function the provision of skilled nursing service and at least one
things can occur: (1) it can restrict intake to the few conditions it is
additional therapeutic service (i.e. physical, speech or occupational
equipped to serve; or (2) it may accept patients without having the
therapy, medical social services or home health aide services).
staffing versatility to meet those patients' needs." 12
In January 1969, there were approximately 2,161 certified home
Home health services are not generally available to the population
health agencies in the United States. 10 The majority of them were
in the age group 45-65: a population which should be protected as far
7 See Table A, p. 16.
as possible from arriving on the Medicare health insurance doorstep
8
See appendix, p. 50, American Hospital Association.
in poor condition and consequently slated to be over-utilizers of health
9
Office of Research and Statistics, Social Security Administration.
10 See Table C-1, p. 17.
11 See table C-2, p. 18.
12 Ryder, Claire F.M.D.; Stitt Pauline G.M.D.; and Elkin, William F.M.S.
Home Health Services-Past, Present, Future. Vol. 59, No. 9, American Journal
of Public Health, September 1969, see table B, C-3, pp. 16-18.
16
17
care thereafter. In this group are persons who are disabled but not suffi-
ciently disabled to be eligible for public assistance although they
Percent
18. 2
8. 3
20. 6
15. 7
60. 5
25. 0
60. 0
35. 0
indigent" persons who are not sufficiently indigent to meet public
might be made to become eligible; in this group are "medically
Nutrition
guidance
assistance criteria but who could be reduced to sufficient indigence
Num-
ber
393
45
22
203
104
3
6
7
given the right conditions for deterioration.
The Medicare insurance system has paid for a great deal of good
5
2
quality care, mostly institutional. It has been a resource for older
Number Percent
48. 2
45. 3
50.
45. 5
73.
41. 7
73. 3
persons during periods of acute illness who need no longer fear that
Home health
aide
12 60. 0
there will be no help "when illness strikes" a realistic fear well devel-
1, 042
245
54
589
126
5
11
oped in pre-Medicare days by advertising.
TABLE A.-Medicare reimbursements for home health services and
0
inpatient hospitalization, 1969-71
TABLE C-1.-Number and percent of certified home health agencies providing selected services, by type of agency,
Medical social
ber Percent
20. 0
14. 4
16. 8
16. 5
57. 0
58. 3
33. 3
service
7
12 60.
Reimbursements in millions of dollars
Year
Num-
432
78
18
214
98
5
Home health 1
Hospitalization
I
1969
1970
78. 8
4,039.5
1971 2
4,425.8
ber Percent
22.
25. 9
33. 6
14. 9
47. 7
83. 3
67. 4
Speech
therapy
7 46. 7
0 45.5 6
49. 5
4,538.5
SOURCE: Ryder, Claire F.M.D.; Stitt, Pauline G.M.D.; Elkin, William F.M.S., Home
Num-
477
140
36
193
82
10
Health Services-Past, Present, Future, American Journal of Public Health, Vol. 59,
1 Includes parts A and B.
2 Estimated on the basis of data through Oct. 6, 1971.
Welfare. SOURCE: Social Security Bulletin, January 1972; vol. 35, No. 1. Department of Health, Education, and
TABLE B.-Home health agencies providing specified numbers of services
Occupational
ber Percent
16. 3
20. 7
23. 4
10. 0
36. 0
91. 7
33. 3
40. 0
Services in addition to nursing
January 1969
therapy
September 1969.
352
112
25
62
11
5
8
in addition to nursing service, January 1969
Num-
129
Number
Percent
Percent
72. 7
85. 2
79. 4
64. 1
89. 5
100. 0
80. 0
85. 0
5
4
96
44
3
130
6.0
2
205
9. 5
Physical therapy
1
574
26. 6
Number
1, 571
461
85
830
154
12
12
17
Unknown
1, 155
53. 5
24
Total
Number
2, 161
541
107
1, 294
172
12
15
20
2, 184
100. 0
of agencies
Type of agency
All agencies.
Visiting Nurse Association
Combined government and voluntary.
Official health
Rehabilitation facility based
Extended care facility based
1 Based on 2,161 of the 2,184 certified agencies for which data were available.
SOURCE OF BASIC DATA: Social Security Administration (type of agency and services
Hospital based
Proprietary
provided from application form SSA-1515).
18
19
TABLE C-2.-Number and percentage distribution of participating
destructive practices of retroactive denial of payment on the one
home health agencies by type of agency as of December 1971
hand, "prior approval" policies arriving long after the need is over,
on the other) were eliminated.
Percentage
"It has been demonstrated" means, of course, that many home
Type of agency
Number
distribution
health services have tried to stay afloat and have failed. Some have
closed shop. Many have sharply reduced the range of services that
Total
2, 256
100. 0
make for a useful and constructive resource to physicians, to indi-
Official health
1, 303
57. 8
viduals and families, to communities. Most have tended to offer
Visiting nurse association
550
24. 4
only those services which can be readily provided and readily reim-
Combined Government and voluntary
60
2.7
bursed and have been forced to ignore services which might be "key"
Hospital based
217
9. 6
services in making a home care plan feasible. Some have refused to
Other nonofficial
80
3. 5
accept for care any referral in which third party reimbursement is
Medicare reimbursement. Others have narrowed their acceptance
Extended care facility based
8
4
criteria and have accepted for service only those for whom payment
Rehabilitation facility based
11
5
Miscellaneous
61
2.6
of the full unit cost can be made. There is a tendency to reject re-
cipients insured under Part B because Medicare pays only 80 percent
Proprietary
46
2.0
reimbursement. Certain categories are avoided: long-term care; care
in which the "laying on of hands" (evidence that the care is "health
SOURCE: Social Security Administration, Office of Research and Statistics.
related") cannot be clearly demonstrated. Care policies have been
adopted which are not necessarily related to patient need.
TABLE C-3.-Number and percent of participating home health
Agencies which had previously emphasized the relevance of care
agencies providing selected services as of December 1971
plans to the needs of individual patients have begun to make routine
use of the language of regulations and to make plans which fit that
Percent of all
Selected services 1
Number
agencies
language. (A common one is the refusal to assign a home health aide
for less than four hours even when only two hours are needed by an
All agencies
2, 256
100. 0
elderly gentleman in a one room apartment; a half hour for his "per-
Physical therapy
1, 664
73. 8
sonal care"; a half hour for a bit of cleaning; a half hour alternately
Occupational therapy
447
19. 8
to market, wash two shirts and two sets of underwear; prepare a
Speech therapy
636
28. 2
casserole meal that will last two days. If he is on Medicare he might
Medical social service
494
21. 9
Home health aide
1, 357
60. 2
like the home health aide to come to him for short periods but often;
Other services
514
22. 8
his visits get used up by the requirement that nursing visits must be
made at intervals which neither he, nor the doctor, nor the home
1 All participating agencies must offer nursing services to qualify under the program.
health service may consider appropriate." Hospitalization and the
SOURCE: Social Security Administration. Office of Research and Statistics.
nursing visits are his entree into home health care, without which he
would be compelled to enter a nursing home for as long as the law
Within the age group which Medicare is intended to serve (age 65
allows, which in his case, since he has lived for years in this neighbor-
and over), the Medicare regulations tend to place an impossible
hood might not be for very long-since nursing home patients for a
financial responsibility on providers. The Medicare insurance program
variety of reasons do not have long lives.)
allows reimbursement for the acute or relatively short-term phases
Home health services find it difficult to stay "afloat" economically
of illness (post hospital 100 visits in part A and an equal number in
when they attempt to offer the services that are needed in a way that
part B when the recipient has the funds to participate in costs of the
makes sense for the consumer.
service) but leaves the provider with the alternatives of terminating
Although Medicare is described as a funding device, the policies
service for the long-term service need (which is the commonest
which govern the expenditure of Medicare insurance funds have done
need in this age group), finding the funds for continued service,
a great deal to influence and mold the health delivery system. Policies
suggesting another period of hospitalization as a means of entry
which stress institutional care and which replace the broad concept of
into home health services or avoiding acceptance of such individuals
home health services with a set of complicated isolated services
unless there is clear evidence that the need and the Medicare pay-
labeled "health related," are not going to open the possibility of
ments will terminate at the same time-a difficult assessment in
appropriate choice.
individuals whose chronic illness may prove unpredictable.
The "home health agency" is not a provider of comprehensive home
It has been demonstrated that home health services cannot survive
health services at the present time; as a potential provider of such
on the support of Medicare payments, even if present problems such
as the high costs of paper work required by these programs (and the
13 See appendix 4, item 1, p. 122, Federal requirements for nursing visits deemed
unnecessary by the physician increased costs by one-fourth.
20
21
services it has many advantages. Extended and supported adequately
it can offer services to all sections of the population; all age groups; all
for his return if such return is at all predictable. Individuals who
economic sectors. Whether its components exist under a single ad-
are on public assistance or who are on marginal incomes must
ministration or are developed separately and coordinated SO that
often give up the room or the apartment or even the home in
utilization and progression are effective it offers the possibility of a sys-
which they have lived because there is no way to maintain it.
tem of care which can become a real alternative to institutional care;
Interim funds and services extended from the home health agency
meeting needs as realistically as a good hospital meets them, or as high
to institutionalized patients are necessary to support the expecta-
quality extended care facilities or nursing homes meet them-ex-
tion to return and to maintain the home to which they might
panding the possibility of appropriate choice. This potential effective-
reasonably be expected to return.
ness might be immediately realized by a more realistic approach in the
The family which may have been available has been overwhelmed
Medicare-Medicaid legislation for the groups affected by that legisla-
either by past care or by the prospect of future care. The as-
tion; such a realistic approach would inevitable pave the way for
surance that services in the home will be available when the pa-
broad coverage in the projected health care systems of the future.¹⁴
tient returns must be given at the point of admission and through-
out the period of institutionalization.
THE USE OF INSTITUTIONS
The individual becomes 'institutionalized". He may fear "return"
even when he is unhappy in the institution. The poorer institu-
Institutionalization in extended care facilities, often with a pro-
tions do, in fact, increase this fear by reducing independence and
gressive movement into long-term institutions, has affected large
ignoring the need for services aimed at restoration. The assurance
numbers of Americans who are clear in their minds, often capable of a
that care services at home will be available as needed must be
good deal of self care, and potentially capable of a good deal more with
specific and based upon reliable facts concerning the kind, dura-
aggressive measures of rehabilitation. It has cut them off from their
tion, and reimbursement sources of home delivered services.
communities, their friends, their families, destroyed their privacy-
The physician who might return the patient to his own home is
probably man's most precious possession. No normal, healthy, func-
unwilling to do SO because he has no way of ensuring patient care
tioning human being likes to visit a hospital, an extended care facility,
there. The availability of a reasonable array of services upon
or a nursing home or, over a long period of time. Pointing the finger and
which he can draw for his patient's needs offers him an opportunity
shouting "neglect" at family members and friends increases guilt but
to make an appropriate choice which includes return from the
does nothing to mitigate the reaction of avoidance which is often more
institution.
intense the more loved the "inmate" is. Unlike mercy, the quality of
pity is much strained. It destroys vital relationships.
The fact that some institutions are of poor quality is not a reason
In the words of a physician concerned with geriatric patients:
for the development and utilization of home health services. It is a
shame; a reason to improve the quality of institutional care. Good
We are warehousing thousands of functioning human beings
institutions will be an appropriate choice for those who require good
because they need some relatively inexpensive health care;
institutional care.
they can't change their own bed linen; carry the groceries
The addition to the health care system of good quality home health
upstairs; wash their own hair; occasionally need a little help
services provides the services essential to the return from the insti-
getting in and out of the bathtub and aren't able to take a
tution-even the so-called "long-term" institution. It preserves the
bus ride to the doctor. The same fragile, but psychologically
possibility of choice. It is a continued protection against the danger
and socially functioning individual who is lucky enough to
of assuming that once in, there is no way out.
have a good doctor, a family and friends or is able to buy a
little help for himself doesn't have to give everything up and
"COORDINATED" HOME CARE PROGRAMS
share a hole in the wall with a stranger and become a vege-
table because nobody there is much interested in doing those
All Home Health Agencies and all communities which offer the
things for him either. And the worst of it is, there's no return.
components of home services consider coordination a key element
in the effectiveness of care.
THE PROBLEM OF "RETURN"
The term "coordinated" as it is applied here has traditionally
been included in the title of programs which are either hospital based
Institutional care following hospitalization is sometimes the treat-
or which are closely linked to hospital services.
ment of choice and, provided the institution is a good one, such care
A coordinated home care program is one that is centrally ad-
accelerates recovery. The return of the individual to his own homo
ministered and that, through coordinated planning, evaluation, and
becomes a problem when:
follow-up procedures, provides for physician-directed medical, nurs-
The relationship to his own environment is not carefully guarded,
ing, social, and related services to selected patients at home. Home
prior to or at the point of admission when plans are being made
care programs furnish medical, nursing, and rehabilitative services
14 See "Recommendations," pp. 49-50.
to selected patients in their homes, with a view toward shortening the
length of hospital stay, speeding recovery, and bridging a gap in com-
munity health services for patients who are too ill or otherwise unable
22
23
to visit a physician's office or an outpatient clinic yet do not need
About 216 coordinated home care programs are not hospital based
hospital care.
There have been two avenues of development in home care during into
but are so closely linked to in-patient services that they are included
the past 25 years. In one, the hospital extends some of its services in the
by the American Hospital Association in the second group: "to provide
the community to provide home care under medical direction;
coordinated home care in collaboration with the hospitals of the
other, a community agency such as the visiting nurse association of or
community." 20 Seventy-two of these provide psychiatric foster care
and are based in psychiatric institutions.
ice to provide coordinated home care in collaboration with
the local health department builds upon its existing program serv- the
The importance of the coordinated home care program, whether it
is hospital administered (hospital-based) or whether, as a community
hospitals of the community.15
administered service, it collaborates with or shares services with the
HOSPITAL BASED HOME CARE PROGRAMS
hospital, lies in its focus upon the patient in a hospital bed and in
its potential usefulness for the patient, the institution and the economy
of the hospital-based home-care program as a "hospital without walls", bed
Described by E. Michael Bluestone, who developed the concept
as a means to reduce hospital stay.
The benefits of such programs have been described:
extension of the hospital into the home which added to the been
They offer to the patient, the physician, and the hospital, an
an capacity of the hospital,¹⁷ hospital based home care programs have States.
alternative to the provision of 'progressive' care-to the hospital-
developed in approximately 263 hospitals 18 in the United
extended care facility-nursing home.
About 82 percent of such programs are based in larger about hospitals one-half
The patient is "at home" and this is a factor which has a tre-
(100 beds or more) and offer a complex of services
mendous psycho-social effect; it exerts strong influence upon
the success of treatment.
of the programs providing nine to sixteen selected services.
During the year 1969, about 40,000 patients were admitted to 211
They eliminate the "ping-pong" effect of hospital care in which
hospital home care programs which had been operating for a twelve to
the patient, having received a great deal of care in the hospital
month period. Over-all the median number of patients admitted median
goes home and, without the services, deteriorates and must be
each program for that year was 135. During that same year the
re-admitted to the hospital, frequently in worse condition.
length of stay in the home care programs was 80 days. maintained Hospital
The physician can care for a greater number of patients at
based home care programs offering a wider range of services
home in the home care program; the coordination of the needed
patients in the program for longer periods-the longest (eleven
ancillary services at home is the responsibility of the program.
hospitals) providing services to some patients. Almost sixty percent
He need not individually assemble and coordinate them.
planning to add more staff, to add additional services, to include home-
of these programs, queried in 1969, expected to expand their program-
The patient at home has ready and easy access to medical
advice. Home care staff identifies problems, foresees them and
more patients, to increase geographic coverage, to train more
reduces the possibility of the occurrence of emergency situations.
maker-home health aides. Plans for such expansion were based upon
Home care staff can more readily interpret medical orders,
the anticipation of increased reimbursement and additional insurance
explain treatment regimes, offer reassurance and support.
Where physicians are in short supply, such as urban ghetto
coverage.
areas and areas which do not have ready access to physicians,
COMMUNITY BASED PROGRAMS CLOSELY LINKED TO HOSPITALS
the system is a tremendous plus to the physician.²²
"Whether or not the hospital or community agency is the adminis-
Studies of coordinated home care programs have demonstrated
trator of the home care program, the hospital is a focal point in deter- that
that they do in fact shorten hospital stay and that in spite of the costs
mining the extent of patient needs. It is within the hospital
the utilization of such services.²
of the home delivery of an array of services, there is cost saving in
arrangements are made for patients potentially in need of home care
Studies which have been made of admissions to hospital based home
services.' 19
care programs indicate that increases of admissions to home care
15 Care and The Hospital, Lorraine Richter, Research Associate, Division
Data Home Collection and Alice Gonnerman, Assistant Director for Ambulatory Association,
are related to the number of services provided by the home care
of Care, Division of Continuing Health Care, American Hospital
program; longer stays in the home care program are also related to
the availability of a broad range of services leading to the conclusion
February 1971.
16 "In the 1969 annual survey the American Hospital Association's based definition
that such programs have a greater capability in the care of sick
of a hospital-based home care program was 'an organized hospital program in their
that provides medical, nursing and other treatment services to patients
20 Home Care and the Hospital, p. 12.
21 Home Care and the Hospital, p. 14.
place 17 C. of F. residence'." Ryder, Changing Richter Patterns and Gonnerman. in Home Care, U.S. Department of HEW
Community Health Care of the American Medical Association, Arlington, Va.
Peter Brigham Hospital, Boston, Massachusetts. Report to the Meeting on
22 Jessimen, Bent Andrew G., M.D., Associate Director of Professional Services,
PHS #1657.
18 publication and Gonnerman. Inclusive data concerning admissions and length that
February 4-5, 1972.
of stay Richter apply to 243 programs (some federal hospital programs) indicated
23 See appendix 3, pp. 82-118.
questions relating to these figures were not applicable.
19 Home Care and the Hospital, p. 12.
24
patients and can provide home care patient days in place of hospital
patient days.2⁴
Studies which are in process indicate that the anticipated expansion
of coordinated home care programs is not occurring.
PART 4
Although the benefits for home health services are pro-
BASIC COMPONENTS OF HOME HEALTH SERVICES
vided under the Medicare program it is a limited benefit
program which fragments reimbursement for coordinated
Components of home delivered health services, which provide a
home care services between Parts A and B home health
broad base upon which an effective care system can be built and
services benefits and Part B out-patient benefits. Medicare
extended, are those of nursing, social work, the "therapies" (Occu-
benefits are not allowed for several important services which
pational Therapy, Physical Therapy, Speech) and homemaker-home
are necessary to properly care for patients of a coordinated
health aide services. These services are applicable to every level of
home care program which represents an intensive level of
home health care and fulfill essential requirements for prevention,
care.25
for treatment, and for support of personal, psychosocial and environ-
Rising costs have restricted the extension of the range of services
mental needs in individuals who are acutely or chronically ill or
and their increased utilization. The number of hospitals and com-
disabled, for short or long periods of time, when the selection of the
munity agencies offering such services is not increasing and may be
home as the appropriate site for care is feasible.
diminishing, in spite of the increasing costs of in-patient care. Coor-
dinated home care programs have been established primarily in or
NURSING SERVICES
near urban areas. In communities where there are no facilities for
long-term care or where such facilities are insufficient (and these are
The concept of "skilled" nursing services which has become SO
the majority) the "ping-pong" effect still occurs, and the inappproriate
firmly entrenched in the Medicare insurance system and which is
use of long-term institutions still, after the investment of the home
related almost exclusively to the need for specific bedside tasks
care program, becomes the only available resource.
requiring narrowly defined nursing "skill" does not offer the pos-
sibility of effective home delivery of health care, since such services
The development of increased numbers of such programs is a
are focussed primarily upon acute illness-upon illness in specific
necessity, and the availability of community services to which such
diagnostic categories: those requiring "therapies". These are not
concentrated care programs can refer patients with long-term problems
the major needs of the aging population even in periods of acute
will guarantee the effectiveness of their services.
illness. The "laying on of hands" is not the primary nursing need of
24 Richter and Gonnerman, Table 8.
patients in institutions, and it is not the primary nursing need of
25 Blue Cross of Greater Philadelphia, see appendix 3, item 1, p. 84, p. 71e.
present and potential consumers of effective home health services,
although it must be included as one of the elements in nursing care
in the home. The application of the public health concept of nursing
functions is far more relevant and has, in fact, been the basis upon
which our communicable disease control programs, and our preventive
and care services to the younger "at risk" population have been built.
These functions include:
Case finding-Searching out those individuals whose health
status may constitute a risk to themselves or to the community.
Preventive services.-Providing a necessary link to treatment
facilities and establishing patterns of living with demonstration
and instruction prescribed by physicians for the return to an
optimum state of health.
Assessment and ongoing observation.-Health surveillance which
provides for continuing awareness of fluctuations in health
status; maintaining an open channel to necessary treatment
resources SO that services may be adapted to changing needs.
Direct services.-The use of nursing skills to provide needed
services in the home.
bedside nursing services or to supervise those who provide such
Follow-up.-Identification of individuals who, because of the
nature of their disease, disability or physical limitations, are in
insure continuity of access to needed treatment services.
danger of regressing from an optimum state of health, in order to
(25)
26
27
This range of nursing services has not been available to the aging
agencies, staff cuts were reported by approximately one of every four
population. Historically, home nursing services focussed first upon
agencies. Among voluntary agencies, the proportion was twice as
the nursing care of the indigent sick in their own homes. The develop-
high-approximately one of every two agencies. In over 27 percent
ment of the concepts of prevention and communicable disease control
of the agencies reporting staff curtailment the number of staff nurses
tended to emphasize services in the home to selected disease categories
employed in April 1971 was at least 30 percent below April 1970
(those which threatened the health status of the community) and to
levels with over 7 percent of the agencies experiencing cutbacks of as
those sections of the population which were first considered to be "at
high as 50 percent or more.² Reasons given for cuts were restrictive
risk" (services aimed at the prevention of maternal and infant mor-
and retroactive reinterpretation of Medicare regulations coupled with
tality; the elimination of preventable or correctable crippling in
a lag in reimbursement adjustments for previous years, curtailment
children). Nursing services which focussed upon these problems have
in Medicaid benefits and reimbursement and reductions in voluntary
traditionally been placed in public health departments.
financial support in voluntary agencies.
These clear distinctions no longer exist; public health departments
These reductions, when they are applied to the total number of
have, in many communities, added home nursing of the sick to their
services when such services were not available elsewhere; in some
professional nurses (15,152) and licensed practical nurses (1,409)
communities, Visiting Nurse agencies have merged with the public
employed in Home Health Agencies as of July 1969,³ represent a
health department and in some communities the two services have
"coverage" of the population in need of home nursing services for
which the adjective "thin" is an overstatement.
continued to function separately, each with a different emphasis.
The knowledge that 87 percent of the population resides in counties
Whether they provide the range of services under a single auspice
or divide their activities, both services see their role in the broad
where there is at least one certified home health agency is not im-
context which has been established in public health.
pressive when more than one-half of the agencies have available "less
than three but more than two" 4 nurses to provide the primary
Its application to the field of chronic disease and disability, and
service of a home health agency.
consequently to the older age group has been limited by the failure
of funding sources, both government and voluntary, to recognize that
HOMEMAKER-HOME HEALTH AIDE SERVICES
nursing services have been faced with a new problem: the increased
numbers of older, chronically ill and disabled persons in the population
In all home health services the supportive care which is essential
who are entitled to the full range of public health nursing services
for the total maintenance of the individual in his environment is
but who are unable to receive them because there has not been a
provided ideally by paraprofessional personnel. Homemaker-home
corresponding increase in nursing personnel to meet this new need
health aides are carefully selected for personal aptitudes: emotional
and because the approach to the delivery of nursing services to this
stability; the capacity to adapt to a variety of differing situations;
population has been based upon the misconception that short-term
skills or the capacity to acquire skills; the capacity for observation;
care, directed to acute illness, will meet the need.
discrimination, good sense, judgement; sustained interest in the various
Public health departments which have embarked upon programs
aspects of the work; "maturity" as a combination of these rather than
of home nursing to the older population have found themselves
as an expression of chronological age.
relationships
require
overwhelmed and have been faced with the alternative of sharply
compassion, common sense, self-discipline, optimism and a basic
knowledge of human behavior
The basic training
of
all
limiting such services or of siphoning off the needed services from
individuals
employed
established programs. Voluntary nursing services-whose primary
should be essentially the same. Good ori-
activity is home nursing-anticipating that the health insurance
entation, on-going education and professional supervision should help
system would add the necessary income for this new population, have
develop the variety of special skills necessary to the purpose of the
particular situation.' 5
found instead that the program has served to uncover nursing needs
which the system will not pay for-services which are essential to
The title is not intended to describe casual workers, available in the
the health and safety of the population over sixty-five but which also
open market to the individual employer. Homemaker-home health
have important preventive implications for the sick poor of all ages
aides are always employees of an agency, a service, an administrative
and for the 45-64 age group, in which vulnerability to chronic illness
2 A sample survey of policies and practices of home health agencies and com-
may begin to occur.
munity health services, conducted annually by the Department of Home Health
In the annual reports of home health agencies for 1970-71, there
Agencies and Community Health Services of the National League for Nursing.
3 Number of Professional and Technical Employees (full time equivalents) in
are repeated references to forced staff reductions and curtailed serv-
2,209 Home Health Agencies participating in Medicare as of July 31, 1969.
ices-a situation cited as "untenable at a time when the public has
Source: HEW office of Research and Statistics Health Insurance Statistics, HI 22,
been led to expect increased and expanded services." 1
January, 7, 1971 issue.
In the Yearly Review Survey, staff cuts in the full time nurse force
4 HHSHMA-Community Health Services Data Center Community Health
Services, Community Profile. Data Center Resources Development Branch,
were reported in 38 percent of reporting agencies. Among official
June 1971.
5 National Council for Homemaker-Home Health Aide Services, Inc. Addenda
1 National League for Nursing, Department of Home Health Agencies and
to Standards p. 7.
Community Health Services.
74-331 0-72-3
GERALD FORD ENGRARY
28
29
unit which is responsible for the selection, training, and performance
ing or preventing institutional care where they have been available.
of the worker; in which adequate professional supervision is available,
Public welfare programs during the 1930's began to initiate such
assigned tasks are related to individul skill; protective policies for both
services and there was limited expansion-usually in protective
consumer and worker are established and maintained, and personnel
services for families with children. Amendments to the Social Security
practices provide workers with acceptable working conditions.
Act in 1962, providing 75-25 matching funds for Public Welfare
the homemaker-home health aide is one and the same person.
administered homemaker services, increased the volume of employed
The term 'home health aide' may be required for certain funding or
homemakers from 3000 in 1963 to 5000 in 1965.⁸
legislative purposes; it should not, however, influence the service
Changes in regulations of the Social Security Act with respect to
rendered by the homemaker in the home.' 6
service programs for the aged, blind and disabled, which required
The generic title "homemaker" describes personnel capable of
all State agencies to provide selected services, including the mandatory
performing the full range of activities necessary to the maintenance of
provision of homemaker services (to recipients in the categories
individuals or families in their own homes when long- or short-term
mentioned) by July of 1973. This has been amended to April 1, 1974.
illness, disability, psychosocial crises (or combinations of these)
Data on the number of States which include homemaker services in
require supportive, therapeutic or compensatory services to sustain
State plans does not include the number of homemakers actually
independent living.
employed. The number of States which include such services in their
The title "home health aide" is found in Medicare regulations and
plans has increased from 16 to 39. The term "homemaker" is used.
is intended to describe a somewhat narrower service, sometimes
Adherence to recommended standards of national standard setting
stressed as a service analagous to that of a hospital aide performing
organizations such as the National Council of Homemaker-Home
functions that are primarily related to the "personal care" of the
Health Aides will be required; the range of skills specified in the
patient and excluding, when possible, those services which, in the
standards of the Council combine those specified in Medicare regula-
institution, are provided by other personnel. The introduction of the
tions for the "Home Health Aide" 9 with all other services appropriate
title "home health aide" has occasionally been confusing. It has
to promotion of effective home care.
appeared to reduce the effectiveness of a worker with a range of skills
In January 1972, it was estimated that there were approximately
to the performance of a few-in the home a relatively useless assign-
2,850 agencies providing homemaker-home health aide services
ment-since the home does not have available the variety of ancillary
in the United States: 1,300 serving families with children, 1,200 in
services which are provided by the institution. The combined title
health related programs (both public and voluntary); 175 "single
has been officially adopted⁷ in order to avoid the development of a
service" agencies (i.e. providing supervised homemaker-home health
second group of workers; more important, to avoid a situation which
aide services to meet a variety of community needs) and 175 pro-
began to prevail following the passage of the Medicare health insurance
prietary registries.¹⁰ (See table D, p. 32.)
legislation-in which one paraprofessional-a "home health aide"-
The estimated total number of homemaker-home health aides
was assigned to perform "personal care tasks" and a second parapro-
employed in these programs is 30,000-as against a total estimated
fessional-a "homemaker"-was assigned to perform all other func-
need of 300,000.¹¹
tions related to maintenance of the sick at home. The short supply of
funded personnel in this paraprofessional category made such a division
In July 1969, 4,061 home health aides were employed in those
of labor impressively impractical. Homemaker-home health aides
certified home health agencies which offered the service (an esti-
function appropriately in health settings and in social work programs.
mated 1,042 agencies); (see table E, p. 32); in June 1970 an estimated
It is generally agreed that the predominant need is almost invariably
4,276 home health aides were employed in 1,254 certified home health
health related regardless of age or economic status, and that psycho-
agencies (see table F, p. 32)-an increase of 215 employed home health
social components cannot be separated from health related problems.
aides in the one year period. Staff reductions similar to those in nurs-
Training and supervision stress both aspects of the functions of the
ing staff as a result of continued funding problems have been reported
homemaker-home health aide who is expected to carry out the
in 1971 in homemaker-home health services.
physician-prescribed therapeutic regime as well as to perform all
Experience with Home Help Service in the United Kingdom indi-
tasks which are essential to healthful living in a decent environment.
cates that with "open availability" of home help service, i.e., to all
Homemaker-home health aide services, in the developmental years,
age groups as needed, approximately two-thirds of the consumers are
have been funded entirely from voluntary sources and, as a result,
in the adult population: aging, disabled and chronically ill adults, and
they have not, since the beginnings of such services in the 1920's,
the major reason for referral to the service is a health related problem. 12
had a history of successful growth. In order to recruit, train and
8 Federal Register Volume 5 Number 230 November 26, 1970 Part II Dept. of
adequately supervise such personnel with placement in conditions
HEW; SRS Service Programs for the Aged, Blind and Disabled or Disabled
Persons. Section 222.46.
that protect both worker and consumer, funding from private sources
and from fee-for-service were insufficient to stimulate development,
9 National Council for Homemaker-Home Health Aide Services, N.Y.
10 Ibid.
although the services have demonstrated their effectiveness in shorten-
Office. No. 0-448-917.
11 Report "White House Conference on Aging," U.S. Government Printing
6 National Council for Homemaker-Home Health Aide Services, Inc. Addenda
12 Trager, Brahna, Home Help Abroad in Homemaker-Home Health Aide Services,
to Standards, p. 7.
Organization, Administration, Training. In preparation for U.S.P.H.S. publication.
7 Ibid.
31
30
Recruitment and training of personnel for homemaker-home health
These monies-which were made available by United States Public
aide services is relatively simple. This is a category of employment in
Health Service funded a number of demonstration projects and pro-
which temperament and skill-aptitude play a large part; there is a
vided effective program consultation-were essentially short term. A
large pool of unemployed and underemployed women (and men as well)
training program funded and directed jointly by the Office of Economic
who possess the characteristics and interest essential for the work.
Opportunity-United States Public Health Service focused upon the
Didactic training may be relatively short; professional supervision
training of faculty and the ultimate training of 10,000 homemaker-
provides a continuous source of on-the-job training. Since trainees are
home health aides but did not go beyond the pilot stage, although
drawn from marginal income groups, both the costs of training and the
several State and some local programs did get an effective start as a
result of these efforts.
support of trainees in training must be provided. The personnel pro-
duced has been of good quality.
Homemaker-home health aide services cannot develop or expand
A special project developed in the Kaiser-Permanente group
with voluntary funds, existing third party payments and fees-for-
practice program in Portland, Oregon, to provide home care and
service as the only source of support. Training programs are not being
extended care facilities in the comprehensive system, reported the
maintained because of cost. More important, job placements following
development of a high degree of technical skill in home health aides
training are not available. Staff curtailments are presently more
utilized in the project. Half of the services provided by professional
prevalent in these services than program expansion.
personnel were provided by aides in this project.¹⁴
There is a demand for the services which far exceeds the supply.
"The use of aides served as an integrating factor in the provision of
The demand, however, is for those services that are excluded from
complex medical services in the home. Since any aide might be pro-
reimbursement in the Medicare insurance regulations; supportive
viding various kinds of services to a single patient, greater communi-
services and long-term care. This need, which has been accurately
cation was required among various supervising professionals, thereby
described by Morris 16 exists in that section of the population with
achieving better coordination of patient care. The patients accepted
long-term disability: in "those whose condition is not likely to improve
the services of the home health aide without question and the super-
quickly" estimated 25-50 percent in "quasimedical nursing
vising professionals reported that the aides provided effective service
institutions", the others in the general population:
in the field. There were no reports of services detrimental to the
Some 18 million persons, between the ages of 18 and 64, and
patient, as the aides were able to recognize problems and changes in
another 15 million elderly may be affected. They have some
the patient's status as they developed and obtained supervisory
chronic physical conditions which can limit their freedom of
help." 15
movement or make them dependent functionally in some
Other service programs report similar results, both in the excellence
degree. But, only a small percentage of these large totals, per-
of performance and the wide acceptance by consumers of homemaker-
haps 1½ million adults, require the intervention of any
home health aide services. There appears to be a rapid development of
public program beyond that now available. The larger
rapport and confidence, probably because the homemaker-home
total represents the pool of demand which confronts organized
health aide is in the home for longer periods than the professional, is
health and welfare services. They suffer from the prolonged
integrated into the living routines in the home and has a more natural
consequences of stroke, heart disease, cancer, arthritis,
identification with those she serves.
emphysema, industrial and automobile accidents. Except for
Homemaker-home health aide training programs were funded and
rehabilitation, which is limited to those who can return
"seed" money for program development was provided prior to im-
to work, the medical system is not designed to meet the long-
plementation of the Medicare health insurance system in anticipation
term needs of such disabled.¹
of a greatly increased demand for homemaker-home health aides in
certified home health agencies.
The services proposed by Morris are essentially the application
to our population of a rational approach to basic care-supportive
13 "This vocation is proving a realistic choice for many educationally dis-
services coordinated with health and social services to provide in the
advantaged but capable individuals
in some instances this employment has
enabled a family to become self supporting
thus the community stands to
home what is essential and appropriate to care there-for the long-
gain doubly from this service as previously unemployed persons become self-
term as well as the short-term demand, as a part of a comprehensive
sustaining." National Council of Homemaker-Home Health Aide Services. See
system.
Appendix 1, item 6, p. 61.
14 Hurtado, Arnold V. M.D., Greenlick, Merwyn R. Ph.D, and Saward, Ernest
16 Morris, Robert. Alternatives to Nursing Home Care: A Proposal. Prepared for
W., M.D. The Organization and Utilization of Home Care and Extended-Care-
use by the Special Committee on Aging, United States Senate, By Staff specialists
Facility Services in a Prepaid Comprehensive Group Practice Plan. Medical Care-
at the Levinson Gerontological Policy Institute, Brandeis University, Waltham,
January-February 1969, Vol. VII, No. 2.
Massachusetts. October 1971. U.S. Government Printing Office.
17 Ibid. p. 1.
15 Hurtado, Arnold V., M.D., Greenlick, Merwyn R., Ph.D., McCabe, Marilyn,
18 Ibid. p. 2.
B.A., and Saward, Ernest W., M.D. The Utilization and Cost of Home Care and
Extended Care Facility Services in a Comprehensive Group Practice Program.
Medical Care-January-February 1972, Vol. X, No. 1.
32
33
TABLE D.-Estimated number of homemaker-home health agencies
alone is not the decisive factor. The decision that home care is ap-
by category:
propriate does not guarantee the success of the plan unless, at all
Family and Children's Agencies:
levels and in all phases of care, members of the service program are
(a) Governmental
900
able to understand and utilize psycho-social strengths and compensate
(b) Voluntary
400
for the attitudinal problems which inevitably arise.
Health oriented agencies, including mental health:
(a) Governmental
700
In assessment, in the selection of the home as appropriate for care,
(b) Voluntary
500
in the establishment of treatment plans, these factors are considered
Single service homemaker-home health agencies
175
when competent social work skills are available.
Proprietary registries
175
Social workers must play an important part in the selection,
Total
training and recruitment of homemaker-home health aides. Unless
2, 850
there is careful assessment of temperament in the selection of trainees,
TABLE E.-Number of professional and technical employees (full-
there is considerable danger that the homemaker-home health aide
time equivalents) in 2,209 home health agencies participating in
who is not temperamentally suitable may retard rather than support
Medicare as of July 31, 1969
the home care plan.
Professional skill is essential as interpersonal relationships develop,
Combi-
particularly between the homemaker-home health aide and the
nation
Visiting
Govern-
individual (and his family). The homemaker-home health aide is in
nurse
ment and
Official
Hospital
the home more frequently and for longer periods than any other
Professional and technical
Number of
associa-
voluntary
health
based
employees
employees
tions
agencies
agencies
agencies
Other
member of the home health staff. Her relationship to the consumer
and his family is necessarily an intimate one and as such can influence
Registered professional
the situation in a variety of ways; she in turn is affected by the situa-
nurses
15, 152
4, 818
1, 667
8, 091
364
212
tion in the home and the attitudes of those in the home toward her
Licensed practical nurses
1, 409
657
127
283
241
101
Physical therapists
999
232
53
482
145
87
and her services. The availability of professional skill in the evalua-
Occupational therapists
146
36
7
32
35
36
tion of these changing relationships, enlarges understanding in the
Speech therapists
170
32
6
65
36
31
consumer, the homemaker-home health aide, and in other members
Medical social workers
301
46
9
123
98
25
of the home health staff. Social workers serve as advocates for the con-
Home health aides
4,061
1, 641
524
1, 417
187
292
sumer and his family-assisting them to make maximum use of
resources in the community, and at times representing the consumer's
Source: HEW, SSA, Office of Research and Statistics. Health Insurance Statistics, H122, Jan. 7, 1971 issue.
view, his own estimate of his own best interests or his own personal
TABLE F.-Home health agencies with home health aide service, as of
choices in policy decisions of the services.
June 28, 1970 1
Many homemaker-home health aide services are administered and/
or supervised by professional social workers; those in public welfare
departments almost invariably provide such supervision, using other
Type of facility
Number of facilities
Number aides
components in contractual or consultative arrangements. Voluntary
services are also frequently administered and/or supervised by social
Visiting Nurse Association
300
1, 679
workers.
Combination Government and voluntary agency-
58
489
Official health agency
649
1, 570
Certified home health agencies offered social services in 20 percent
Rehabilitation facility based program
7
54
of all of the agencies in 1969 19 but only 301 workers (full-time equiv-
Hospital based program
151
233
52
alent) were employed. 20 Slightly more than half of the hospital based
Extended care facility based program
16
Proprietary
24
96
home care programs offer social services; 10 percent of those which are
All others
49
104
not hospital based but which collaborate with hospitals offer social
services. Public health agencies occasionally utilize the consultative
Total home health agencies with home
services of a public health social worker.
health aide service
1, 254
4, 276
Social workers who have health care orientation are in short
supply. Schools of social work are beginning to emphasize the health
1 Information obtained from Social Security Administration.
care field in training. An important deterrent to the development of
SOCIAL SERVICES
interest in the field is the shortage of employment opportunities.
19 Social Security Administration. Number and Percent of Certified Home Health
At every level of care, social services are necessary to the effective
Agencies providing selected services by type of Agency, January 1969.
delivery of home health care. The personality of the consumer, his
20 HEW, SSA, Office of Research and Statistics, Health Insurance Statistics
attitudes and those of members of the household; his capacity to
HI 22, January 7, 1971 issue-Number of Professional and Technical Employees
(full-time equivalents) in 2,209 Home Health Agencies Participating in Medicare as
adapt to a treatment program at home play an important part in the
of July 31, 1969.
choice of the home as an appropriate site for care. "Feasibility"
34
35
The requirement that social services must be available in all services
and at every level of home health care would do a great deal to in-
health care. Such organizations will not necessarily deliver the covered
crease the effectiveness and utilization of the services.
population from problems related to the increased need for home health
services.
PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH THERAPY
If the home health services are the same in definition, scope, and
duration as those which are presently available, there is no reason to
Physical therapy takes first place in the series designated as appro-
believe that the situation will improve and there could be some reason
priate after nursing service in the Medicare regulations. It is also
to be apprehensive about costs of institutional services in the future
most frequently indicated as the second service which certified home
of such organizations. Proposals for these, as well as for other systems
health agencies offer.
of health care delivery tend to consider home health services as they
Of the total of professional personnel employed in home health
are presently defined and delivered in the Medicare context.
agencies only 999 "full time equivalent" physical therapists are
Better use might be made of such services as they are presently
involved-about 4.2 percent of the professional personnel who were
defined when they are attached to or available to a Health Mainte-
employed in home health agencies in 1969. 21 This represents a consider-
nance Organization, simply because such an organization will be in a
able thinning of the services. Federal regulations, which restrict dura-
better position to utilize all of its resources to maximum effect in a
tion, limit supervision of regimes and delegate a good deal of the
coordinated system of care. This use will have its major value only
essential services to "others" may inhibit utilization.
for the short-term patient who does not require the full array of serv-
"Data from the National Institute of Neurological Diseases and
ices which are defined in a home health program of good quality.
Stroke indicate that at least 20 percent of those citizens with stroke
If, however, the definition and provision of home health services is
have an associate impairment of language" 22 although speech therapy
considerably broadened to include prevention, an effective array of
is included as a reimbursable service in the Medicare system, regula-
services, and the possibility of extension to serve long-term need, the
tions restrict its use.
health maintenance organization has many built-in features which
While it is true that aspects of many of the therapies-physical
will insure maximum utilization and maximum benefit to the con-
therapy, occupational therapy, and speech-are readily taught, it is
sumer. The availability of high quality home health services to the
also true that of all treatment modalities, the therapies are the most
physician in the organization will encourage the choice of such serv-
difficult to sustain without considerable encouragement and motiva-
ices when they are appropriate and will discourage the choice of less
tion; they are the first to "wander away" technically from established
appropriate care. Economy, which is essential in the choice of services
procedures when the responsibility is left with "others"; the mainte-
when the total funds available are fixed, will encourage the utilization
nance of effective regimes, which, on a daily basis seem uninteresting,
of alternatives to institutional care.
is the most important in the return to optimum function in virtually
all chronic disease diagnostic categories. The enormous investment
Flexibility, coordination, continuity and economy within a system
which institutions make in the return to function of the stroke patient;
which can provide acute hospital, extended care, ambulatory care and
the substantial provision of initial services to those whose limitations
home health service become possible when all are of good quality
fall into one of the largest categories in the aging population-diseases
and all are equally available. Capitation cost must, however, provide
of the bones and joints-are frequently lost when the institutional
for a home health system which is a reliable resource.
effort is no longer available, because aggressive measures are not
AMBULATORY CARE FACILITIES
available or sustained in the home.
The development and maintenance of most of the simplest inde-
The combination of ambulatory care with home health services
pendent human functions involve mobility-physical mobility, mobility
offers the possibility of a community organized replacement for a
in fine movement and mobility in communication. Their presence or
pattern of care which has disappeared. The home as the site of service
absence make the difference between home and institution. Their
and the neighborhood as the supporting environment belong to a
presence requires the initiation and the continuation of aggressive
period wherein the family physician utilizing the family and the
therapy measures in home health care.
neighborhood resources thought of the institution last, rather than
first. Neighborhood health centers, family care centers, outpatient
THE POTENTIAL OF HOME HEALTH SERVICES IN HEALTH
departments and other types of ambulatory group care with their
MAINTENANCE ORGANIZATIONS AND AMBULATORY
linked therapeutic services can extend services into the home as
CARE FACILITIES
an alternative to extension into the hospital in situations of acute
illness or mobility limitation which are not severe enough to require
HEALTH MAINTENANCE ORGANIZATION
institutional care or in situations where the linked therapeutic services
are needed to add the necessary treatment services to a home health
There is considerable emphasis upon the Health Maintenance
plan.
Organization as one of the preferred methods for the provision of
"Ambulatory" in this sense requires that the services of the
center must be made available; special transportation services,
21 HEW, SSA, Office of Research and Statistics, Health Insurance Statistics,
physician home calls, and the appropriate array of home health serv-
HI22, January 7, 1971 issue.
ices can provide care which utilizes the institutional bed only when it is
22 See Appendix 1, item 8, p. 68.
36
37
most essential. Many neighborhood health centers use paraprofessional
hospital care per month, over relatively short periods of time-(aver-
personnel to extend their services into the home; still others are linked
age figures, however including service plans which provided extended
to public health or visiting nurse associations for home care. An innova-
periods of care).²⁵
tive model in Denver links neighborhood health centers to a chain of
The Associated Hospital Service of New York reports that "aggre-
district units staffed to provide physician services and home health
gate hospital stays for the first 5,000 cases admitted to home care was
services as well as traditional public health services to the neighbor-
reduced by more than 113,000 days." 26
hood. Special transportation is available in all levels of care.
The "Early Hospital Discharge Program" of the Denver Depart-
Very few ambulatory care centers, including hospital out-patient
ment of Health and Hospitals reports that admission to the Home
departments, have available to them the needed array of home health
Care Agency of 292 patients dismissed on an early discharge basis
services; their usefulness has not been adequately demonstrated
reduced an average of 19.2 hospital days per patient. (5,629 hospital
to private groups; the Office of Economic Opportunity financed
days for the total group.) 27
neighborhood health centers are limited in their financial ability to
In a special project designed to link a home health service to the
develop services in the home or to utilize them when they are available
extended care facility and hospital in a health maintenance organiza-
in the community. Funding, availability and education could increase
tion program in Portland, it was reported that the average length of
the potential of the combination of ambulatory care and home health
stay in the acute hospital was reduced from 5.4 days to 4.9 days and
services, and provide patterns of care which are innovative and practi-
the use of the acute hospital was only 87 percent of the "expected for
cal.
the over 65 population and 74 percent of the expected for the Medicare
COST SAVING
population." (These results are based on the combined use of the
extended care facility and the home care program.) 28
There is evidence that the utilization of home health services can
Blue Cross of Greater Philadelphia in a study of coordinated home
reduce inappropriate institutional care. Studies which have examined
care reported on an analysis of 3,940 cases admitted to four hospital
costs have been done in a Health Maintenance Organization, in in-
home care departments between November 1961 and July 1970. "An
surance programs which offer home health services as an insurance
average of one and one-half percent of the patients discharged from
benefit, in hospital based home care programs. Reports focus primarily
the medical, surgical and pediatric departments of these hospitals were
on the release of hospital beds as a result of early discharge to home
transferred to home care service an average of 12.9 days earlier than
health services which are less expensive.
would have been likely without the availability of the
service.
The release of hospital beds as a result of early discharge is an im-
This resulted in 6.6 additional beds being available throughout the
portant consideration in cost saving at a time when hospital costs
report period for care of more acutely ill patients at no additional cost
have become a major cause of concern in the health care economy.
to the community". 29 [Emphasis supplied]
Savings of hospital bed days ranging from one day to an average of
All reports emphasize that home health services utilized were sub-
19.2 days is no small item in this economy.
stantially less costly than hospital care.
"If the stay in the hospital of one patient in twenty was shortened
The cost of developing home health services which are available to
by one day-at a daily cost of $70.00 the total hospital cost to the
the total population at risk can be substantially offset by reductions
American people would be reduced by almost 100 million dollars." 23
in the use of institutions of all kinds-acute hospital beds, extended
The prevention of inappropriate institutionalization is however, a
care facilities, psychiatric beds and the current overdevelopment and
larger factor in the computation of costs.
overuse of nursing home beds-costs which are substantial in economic
The annual report for the calendar year 1970 of the Home Care
terms but which are far more significant in terms of the alteration in
Association of Rochester, N.Y., a coordinated, comprehensive service,
the approach to the American way of life which the institutional bias
indicates "a total of 42 hospital beds released, with a total of 1,554
in our present system is effecting. In economic terms the cost of
patients admitted to the service, 653 of whom would have required
developing new services and the upgrading of services which are
hospitalization.
not now adequate will be possible when public policy concerning
The Rochester report underlines this factor. Almost one-half of the
the delivery of health care has been radically altered to include a posi-
patients admitted to the home health service would have required
tive approach to home health services-an alteration which will
hospitalization. Utilization data from programs serving non-hospital-
25 See Appendix 3, items 4-5, pps. 118-121.
ized patients support the conclusion that home health services are
26 Excerpts From Home Care Following Hospitalization, Associated Hospital
utilized by an aging population which, in most respects has problems
Service of New York, 80 Lexington Ave., New York, N.Y. SVN-1965.
similar to those of institutionalized populations: the majority are
27 Department of Health and Hospitals, City and County of Denver, Savings to
Medicare Program as a result of early Hospital Discharge Program 1/1/70-12/31/70.
affected with multiple major diagnostic problems. The level of home
28 The Utilization and Cost of Home Care and Extended Care Facility Services in a
health service hours utilized were equivalent to one or two days of
Comprehensive, Prepaid Group Practice Program. Medical Care, Vol. 10, No. 1,
January-February 1972. (See footnote 15, p. 30.)
23 See Appendix 1, item 5, p. 60.
Hospitals Blue Cross.
29 Coordinated Home Care an Effective Alternative for Patients, Physicians,
24 Tenth Annual Report, Home Care Association, 311 Alexander St., Rochester,
N.Y., May 11, 1971.
Introduction. Blue Cross of Greater Philadelphia. Home Care Department. February, 1972.
38
produce the determination to develop such services and the funds and
personnel which are necessary for analysis of the population which
could feasibly use such services and the need of that population for
home health care as a component of comprehensive services.
Discussing the difficulties of arriving at cost comparisons of home
PART 5
health care vs. the previous kinds of care, the director of an Athens
(Ga.) project said:
EUROPEAN HOME HEALTH SERVICES
"We're dealing with people who-until this service came along-
simply died at home.' 30
Home health services in the United States are not the product of
the current Medicare insurance system. Home health care has been
30 Cook, Thomas, Executive Director, Athens Community Council on Aging,
Inc., Athens, Georgia, see Appendix 5, p. 134.
provided in this country since 1796. Public health nursing services
and the services of the many high quality visiting nurse associations,
and homemaker-home health aide services producing care for the sick
in their own homes, have a long history and are a part of the American
tradition. In contrast with European programs, however, services in
the United States have not been developed, supported or extended as a
matter of public policy, and this situation is paradoxical in the face of
our attachment to ideals of personal independence and personal
choice.
Home-delivered services to the sick and disabled in Western Europe
also have a long history. (Early services date back to the late 18th
century).
Unlike those in the United States, such services have grown
steadily in volume, in scope, and in coverage-almost, but not quite-
keeping pace with need. (The unevenness is not usually related to
unwillingness to fund the services, but is due to diminished pools of
health manpower).
Home health services utilized in most European systems are similar
to those which we consider comprehensive here: physicians, nurses,
social workers, the allied professions and "home helps" working in
teams to provide flexibly planned services in the home. Almost all of
the European countries have a strong anti-institutional bias. Home
health services are therefore one of the most important and firmly based
institutions in the array of available services.
The basic service in almost all European programs is the "home
help." Usually well trained and supervised, the home help functions
as the extension of the professional team into the home. The basic
functions of the home help resemble those which we describe here in
our homemaker-home health aide. They often include as well certain
activities which in the United States are either retained within the
professional purview or which have been assigned to an intermediate
worker: the vocational nurse, the social work assistant, the physical
therapy aide, the nutrition aide, the mental health aide, the community
aide.
It is expected that home helps will perform all tasks which are
essential to the maintenance of a decent environment; those which we
1 "We expect home helps to do whatever is needed. They are sent in to help. This
means unlimited service except for those tasks which cannot be safely undertaken.
It is far better to give unlimited service at home (including medical care and
supportive services), than to put them in hospital or nursing homes." The care of
incontinent bedfast patients is considered a normal part of the home help's
assignment in England. Miss E. Carnegie-Arbuthnot, Organizer. Interview
with B. Trager, London, June 1969.
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40
41
frequently describe as the functions of the housewife-the family
purpose centers are being established with specialized transportation
homemaker; (these include some interesting cultural variations:
facilities as well as the traditional home help program.³
almost all continental home helps are taught flower arrangement;
The other program of major volume is that which exists in the
rural home helps must garden and tend cattle when necessary) in
United Kingdom. Approximately 69,000 home helps were employed
addition to those more closely related to care of the sick. Nutrition,
in 1969 by the Ministry of Health and these workers are expected
food preparation and a very fundamental psychology are very heavily
also to provide a very wide range of services which include personal
stressed. The latter is aimed at the careful preservation of the integrity,
care but which do not include some of the services which are con-
dignity, and personal independence of the consumer of services.
The term "consumer of services" is apt since the services are avail-
ventionally considered closer to nursing.
able to and used by all sectors of the population and there is no
It is impressive in England to note that the types of patients cared
relationship between utilization and poverty.
for at home would, in the United States, be considered institutional
The two countries which offer the largest volume and broadest
candidates. Home help service is not limited to "intermittent part-
range of services-Sweden and the United Kingdom-have been
time care". The home help frequently makes more than one visit in the
strongly affected by the growth of aging populations in the develop-
day and full-time service is not excluded from the entitlement.
ment of their services. Sweden's population over 65 makes up more
In addition to the assignment of the home help there are also mobile
than 13.5 percent of its total population (an increase of 50 percent
services such as meals on wheels and the "Blitzclean" service similar
over the past twenty years.) An increase to 16 percent by the year
to the janitorial services provided in Sweden. A very flexible in-and-out
1980 is anticipated. Although a number of group living approaches
approach to institutional care has been adopted in England, with
(communal housing, villages, homes and nursing homes for aging
families relieved of the responsibility for older family members during
persons) have been developed, the Swedish system acknowledges the
vacation periods, when institutional care is offered, day care, weekend
natural desire of most people to remain in their own homes.
care in institutions, and the establishment of centers which are
In my country we now find it natural for various reasons—
recreational and supervisory and frequently also provide meals.
humanitarian, labor-economic, and social economic-that
The line between health services and social welfare is less distinct in
nobody should stay in an institution if his social or medical
many European programs than in the United States, probably because
problems can be solved in other ways.
of the relatively well developed entitlements to public services in
No old person should live in an old age home just because
both areas. The poor and aged sick are not treated as categorically
he has nowhere else to live, lacks furniture, or cannot clothe,
as they are here. Home help services are firmly linked to both the health
clean or cook for himself. Lodgings can be provided, furniture
system and the social welfare system and our difficulties about what
can be bought, and home help can be found. Thus the
is or is not "health related" are in general not a problem in their
individual's independence, a very precious thing in human
services.
existence, is saved-and always at a lower price than the
In the Western European countries virtually all training of home
cost of institutional care.
helps and home help directors (usually nurses or social workers) is
No one acutely or chronically ill should have to stay in a
funded by the government; most trainees are provided salaries or
hospital if ambulant medical treatment or day hospital care
stipends during training; the administration of all service programs
could be used, often in combination with home help. 2
is usually government funded with, in some countries, incentive
payments to increase the quality of direction, and the funding of
The home help services which are very available, were utilized for
the services themselves is subsidized by the government either in
longer or shorter periods by 11 percent of the aging population in 1969
part or totally.
(in a given week). The services are combined with mobile services
All Scandinavian countries provide free services to pensioners (this
which compensate for a wide variety of limitations: Meals-on-wheels;
is not public assistance but a pension entitlement) and they provide
home delivery of frozen and other foods; physical therapy units;
for fee payments based on a sliding scale in the remaining population.
chiropody; coiffeurs; mobile libraries; "patrols"-units which carry
Some fees for services are charged in most countries but are usually
equipment and provide heavy janitorial work-specialized transporta-
charged only to the economically stable families who can afford them.
tion, and travel to specially developed group and recreation centers.
Almost 60,000 home helps are employed in the program, the majority
In general, countries which provide services to the aging population
of them serving older persons. The ratio of home helps to population
do not limit the duration of such services. They are considered long-
is approximately one to less than one thousand. Rural areas have
term services and are intended to maintain the individual in his own
begun to be a problem in Sweden because of migration of younger
home for as long as this is feasible.
families to suburban communities, leaving large and sparsely settled
Coverage is very good in all countries since the services are es-
sections in which the inhabitants are mostly older persons. Special
tablished by statute and only in rural areas where geographic diffi-
experimental programs have been developed in which regional multi-
culties have occurred is a thin coverage encountered. Most coun-
2 M. Nordstrom, Membre du Parlement, Conseillère à la Direction Nationale
tries are attempting to solve this problem in a variety of ways. France
de la prévoyance sociale, Stockholm. Les Services Sociaux d' Assistance Ménagère
3 Socialstyreisen-The National Board of Health and Welfare. Stockholm,
et Familiale en Suede. Publié dans Revue Internationale du Travaille, Octobre,
Sweden. Byrainspektőr M. Herlin. January 3, 1971.
1963.
42
bases its rural program in agricultural family systems or cooperatives
and the efforts in rural Sweden have already been described.
The range in population ratio in the Western European countries
is from approximately one home help per 760 in Denmark to one
home help to 2,000 population in France. The ratio in France is
considered inadequate-most of the countries which participate in the
International Association consider that a ratio of more than one to
1,500 population constitutes inadequate services.⁴ The ratio in the
PART 6
United States at the present time is less than one to 7,000 population,
with the cluster mostly in urban areas of the Eastern seaboard.
MANPOWER
The description of the British system published in 1948
Planning for the development and expansion of health care services
in a Swedish journal stimulated lively discussion among
the officials, the social workers and the professors of home
which have not previously been available inevitably raises questions
help training
We were not even certain that they (the
about manpower for implementation. This is not a question of major
importance in planning for home health services. Many basic services-
aged) really needed help in their own homes at a time
when homes for the aged were comfortable, modern
nursing, the "therapies" (physical therapy, occupational therapy;
speech therapy), homemaker-home health aide services and social
apartments were being built for pensioners and when we
services have manpower pools available for first steps in development
believed that the majority of older people wanted to care
and expansion. They could produce sufficient manpower in a relatively
for themselves
or to be cared for by their families or
their friends. In fact it was doubtful that we could recruit
short time provided job opportunities could make entry into the field
personnel for this kind of work because of a lack of
attractive and, at least in the paraprofessional field, funded training
facilities could be made available.
employment
It is estimated that, given a more flexible interpretation of reim-
Now, fifteen years after our first tentative approaches,
bursement for nursing services in the present system, staff cutbacks
home help for aging and invalids is so well distributed in our
in nursing could be reversed, The manpower situation could also be
country, with its population of 7.7 million, that in 1965 we
greatly improved with the application of new patterns of utilization
were able to provide (home help) service to approximately
of available nurses using different levels of personnel for services
144,443 aged and incapacitated persons (a total of 17,175,680
requiring different skills. This effort can only become possible when
hours of service). Close to 8 percent of our aged population
tight funding is replaced by incentive and demonstration funds to
received the service. In each municipality aged and in-
implement plans for innovative use of personnel which are already
capacitated persons were helped either by specialized home
available. With these changes, additional nursing personnel will still
helps reserved for the aged or by home helps with diplomas
be necessary. It is estimated that nursing personnel for full imple-
working full time.⁵
mentation of comprehensive home health services could be available
The creation of the first home help service for aged
within a three year period.¹
persons is about a dozen years old. The experience has been
Physical therapy services would be adequate for fuller utilization of
such a positive one that no one can pretend any longer that it
a more flexible use of the Medicare health insurance system at the
is a temporary activity, a palliative dictated by crowded
present time. Additional professional and paraprofessional personnel
hospices, boarding homes or hospitals, since the develop-
can be made available almost as quickly as it is needed. This situation
ment witnesses to the responsibility and to the growing
is not as true of speech therapists. There are 8,160 qualified therapists
respect which society owes to the individual and to his
in the United States. Home health agencies have not been able to
liberty.⁶
fully utilize such services because of limitations in the Medicare
It must be obvious that the investment in home delivered services
regulations. Expansion of services would require increased funds for
is not dictated entirely by cultural attitudes in the European system.
the training of personnel.³
The strong support of these services is evidently based upon the
In the paraprofessional field there is an enormous potential in
realization that it is an economical as well as a rational approach,
home health for those in the reservoir of unskilled, unemployed or
since there have been no reversals in the steady growth of such
underemployed individuals who could be trained quickly and at
services either because of dissatisfaction with their effectiveness
relatively low cost. They can be capable of performing tasks which are
or for reasons of economy.
currently accepted as within the range of the professional. They can
4 Trager, Brahna. Home Help Abroad in "Homemaker Home Health Aide
be helped to move with on-the-job and supplemental training into
Services.'
1 National League for Nursing. Interview with Miss Leah Hoenig 3/13/72.
5 M. Nordstrom, Délegué Chef de Division au Ministère des Affaires Social
2 American Physical Therapy Association Statement before the Senate Finance
Suédoises, Le Service Suédoise d'Aide Aux Veillards à Domicile, Saltsjobaden 12 23
Committee, February 7, 1972, p. 4.
Septembre 1966.
3 See Appendix 1, item 8, p. 72.
6 Ibid.
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74-331 0-72-4
44
work of considerable skill. This will increase the effective use of all
health care professionals and at the same time provide members of
our poor and near poor population with work that is interesting, and
decently paid.
The resurrection and expansion of training programs piloted by the
Office of Economic Opportunity and the United States Public Health
PART 7
Service, implementing training patterns developed to upgrade para-
professionals, could come very close to producing the ratio of home-
SUMMARY
maker-home health aides to the aging population, provided job oppor-
tunities are available as an end goal.4
Although aging itself does not fit a stereotype which is frequently
Innovative approaches to training such as that which has been
patterned on the end product of neglect, large numbers of Americans
demonstrated and abandoned in Kansas could be extended.
who are afflicted with chronic illness and disability are not receiving
Probably more than any other health care institution, home health
preventive and therapeutic services which could maintain them within
services could be brought into the field quickly and effectively; the
their own homes as participants in community life. A significant
availability of manpower will not be a major barrier.
number have been inappropriately cut off from their personal environ-
ment and inappropriately placed in institutions which have proliferated
4 "At a minimum, homemaker-home health aide agencies should have available
300,000 homemaker-home health aides or one homemaker-home health aide per
alarmingly throughout the country.
every one thousand persons in our total population. For older persons, the ratio
The term home health services is broadly applied in quality health
should be approximately one per 100 as a minimum." 1971 White House Con-
care. Such services have application in physical illness, in short- or
ference on Aging Report to the Delegates, December 1971, p. 76.
long-term disability, in emotional illness of short or long duration, in
5 A regional training program adapted to rural areas at Kansas State University
which was discontinued because of lack of funding.
crises which threaten the normal pattern of living and which require
treatment and/or support to prevent disintegration of individual and
family life. The goal of home health services is to provide services
which support personal choice whenever it is feasible and to maintain
a way of life which is as closely related to normal life within the com-
munity as possible.
Home health services are not considered a substitute for institutional
care. They frequently offer an alternative to such care. Adequate
home health services should be considered an essential institution in
the same sense as a hospital, an extended care facility or a nursing
home are institutions.
A review of home health services available in the United States
must lead to the conclusion that they do not constitute a valid
resource for the population which could make appropriate use of them.
They are in short supply; they do not offer the comprehensive range
of services required; they are limited in their capacity to provide
for any significant volume of the population in need; they have no
geographic coverage. Where they do exist the services are fragmented
and are decreasing rather than expanding.
The present system of Medicare health insurance has not stimulated
development of home health services in any appreciable way and may,
in fact, have depressed such development by opening up to the
providers of home health services a caseload which requires a broader
range of services and more appropriate services than those which are
reimbursed. It has considerably influenced the concept of the services
as limited in scope and application. The home health services defined
in the Medicare insurance system do not fit the population they are
intended to serve-the adult population which requires more than the
"nursing plus one" which has, by default, been imposed as the stand-
ard. Application of the regulations has been narrow and inflexible and
subject to wide, and sometimes quixotic interpretation. The services
have been hedged in by a costly paper structure. They have been
overcontrolled and underutilized. Services which are reimbursed by
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46
47
the Medicare insurance system when they are provided in an institu-
Professional manpower could be made available for expanded
tion, are not similarly reimbursed when they are provided in the home
service.
and this has been a factor in inappropriate use of institutional beds.
Homemaker-home health aide services are broad base services and
There is no reason to assume that placement of home health ser-
are essential to all levels of care but most particularly to the third level
vices in health maintenance organizations or their coordination with
which must be utilized by the largest section of the population. De-
ambulatory centers will make any appreciable difference either in
velopment of such services should achieve a ratio of at least one home-
meeting need or encouraging utilization if the services which are offered
maker-home health aide to 1,500 population with good geographic
are defined and reimbursed as they are in the present system. The
coverage.
support of a broader range of services adapted to the home as the site
Unless national health insurance proposals provide for home health
of care services and more realistically directed to long term need
services which ignore the present "nursing plus one" definition and
could, however, make an appreciable difference, enabling appropriate
expand the concept to include the full range of needed services, adding
choice when that choice is available. There is evidence to support the
innovative methods to ensure full use of ambulatory care, they will
conclusion that utilization of home health services is increased in
not fulfill the expectation that national health insurance will improve
proportion to increase in the range of services available. There is
the health status of older persons.
also evidence that appropriate use of home health services can reduce
If comprehensive home health services are to be developed sup-
utilization of institutional beds and that overall costs of care may also
ported and expanded, they must be publicly viewed as an important
be reduced. Costs in human terms where choice, personal identity
health care institution, as all other traditional health care institutions
and integration with family and community life are protected and
are viewed.
preserved must be implicit in any consideration of "cost".
European programs have demonstrated the economy and effective-
ness of very broadly based systems of home health services which
include many features not incorporated in the United States con-
ception of home health care. These include flexible use of institutional
facilities (for day care, weekends, vacations), and full mobility of
both services and consumer, bringing services to the home and the
consumer to the services by means of special transportation. The
base of the European programs is the home help whose services to the
aging, chronically ill and disabled population are virtually unlimited
in volume and duration. Services are developed, and supported or
subsidized, with government funding; all training programs are
government funded and trainees are supported during the period of
training.
Home health services in the United States have been unable to sus-
tain or extend their programs with funds presently available from
voluntary, third party or fee-for-service sources at any of the three
levels of care which are essential to a comprehensive system. Funds
which were available for development, training, leadership and con-
sultation from the Department of Health, Education and Welfare
are no longer available, and there has been no new development in the
field.
CONCLUSIONS
If significant numbers of our aging population are not to be forced
to match the stereotype of aging which is the end product of inappro-
priate care and neglect, health care must include provision for a
comprehensive system of home health services. Such a system must
include an appropriate range of services at all three levels of care.
Some relief from the present inappropriate use of institutional beds
might be achieved with a more realistic application of the home health
services regulations in the Medicare insurance system.
Comprehensive home health systems must be understood to include
preventive services and effective measures to meet the need of chroni-
cally ill and disabled persons for a system of health oriented, supportive
services in the home over long periods, or permanently.
PART 8
RECOMMENDATIONS
Both immediate and long term approaches to the provision of
adequate home health services are necessary:
1. The interpretation and application of present regulations
in the Medicare system must be changed in order to stimu-
late, rather than restrict, utilization of home health services by
allowing full implementation of the regulations as they are
presently stated. Fuller use of more concentrated services, more
flexible approaches to the supportive services of professional and
paraprofessional staff must be reimbursed and encouraged.
The establishment and maintenance of home health plans must
be based upon the professional judgment of personnel in certified
agencies rather than upon the judgments of individuals who are
remote from the consumer.
2. Changes in the system must be made which eliminate entry
into home health services through an institutional bed in part A
and which will eliminate co-insurance payment for home health
services in part B.
3. A revision of the paper structure presently used in submitting
claims, approving service plans, and authorizing payment, must
be made in order to reduce administrative costs and stimulate
prompt payment. Administrative policies which require prior
authorization and allow retroactive denial of claims for services
rendered in good faith must be eliminated in order to encourage
referral to home health services and to support acceptance of such
referrals by home health agencies.
4. A national approach to the provision of adequate coverage
of the population by home health services must be made by:
a. Funding the developmental phases of home health serv-
ices as an essential health care institution through mechanisms
similar to those utilized in the development of institutional
beds (i.e. grants for construction and modernization of
hospital and medical facilities). Emphasis on innovative
approaches to regional facilities for rural and sparsely
populated areas must be included.
b. Funding the expansion of personnel and of the range
of services presently provided in existing agencies by incen-
tive grants to "nursing-plus-one" agencies. Financial sup-
port must be provided for reasonable periods of time, for
an additive approach to the service range in such agencies
to at least six of the required services in order to establish
in such agencies services which offer a reasonable alternative
to institutional care.
c. Amendment of the present Medicare legislation or
introduction of new legislation, providing for basic health
care and supportive maintenance services to those individuals
who require such services for long periods or permanently
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50
when they can be safely and appropriately maintained in
their own homes.
d. Funding the development and maintenance of training
programs for professional and paraprofessional personnel
which is focused upon the organization, administration, and
provision of services in the home utilizing existing training
facilities and providing for the development of additional
facilities for training (with attention to regional facilities in
APPENDIXES
rural or sparsely populated areas). In view of the marginal
status of potential paraprofessional workers, support stipends
will be an essential component of such training facilities.
e. The re-establishment and adequate staffing at the
Appendix 1
Federal level of a corps of personnel qualified to provide
RESPONSES OF NATIONAL ORGANIZATIONS
leadership and consultation in the home-health field, with
funds allocated to: the development of training curricula:
ITEM 1. LETTER AND MATERIAL FROM KENNETH WILLIAMSON,
research and demonstration emphasizing innovative methods
DEPUTY DIRECTOR, AMERICAN HOSPITAL ASSOCIATION
of delivery of home health services; and at reasonable inter-
vals a survey of the field to assess present and future needs
FEBRUARY 28, 1972.
and make reliably based recommendations.
DEAR SENATOR CHURCH As requested, this statement on home health services
is provided for inclusion in the report your Senate Committee on Aging is prepar-
5. All proposals for the provision of national health care
ing on this subject.
services must carefully consider the components of a comprehen-
The American Hospital Association has, for at least fifteen years, actively
sive home health system and include provision for these com-
supported the concept of home health care on an organized, coordinated basis as
ponents. Such proposals must recognize the potential of home
an essential element of comprehensive health care. It has encouraged hospitals
to develop home care programs where needed. Enclosed is a copy of the Asso-
health services in the long-term care of patients included in the
ciation's Statement on the Role and Responsibilities of Hospitals in Home Care.
system.
The home health benefit under Medicare as it is now administered consists
mainly of nursing services in the home rather than fulfilling the concept we
have endorsed-a coordinated multi-disciplinary health service provided the
patient in his home. Interpretations of the benefit promulgated by the Social
Security Administration during recent years have the effect of SO severely re-
stricting the benefit that few patients appear to qualify. Also, as with certain
other Medicare benefits, there is lack of uniformity in the interpretation of the
definition of home health care as a covered service among intermediaries and
even among the regional offices of the Bureau of Health Insurance.
Retroactive denials of payments and restrictive rulings on coverage of
home health services havc had adverse effects on the ability of hospitals to
develop and maintain home health services as well as on physician referrals to
such benefit. services. There is also a lack of consumer belief in the reality of this
The resultant underuse of home health services has been adequately docu-
mented by published reports of the Bureau of Health Insurance. For example,
only one per cent of 1967 reimbursements was for home health services and only
.6% of the beneficiaries received the service. The conclusion reached in this report,
dated December 1971, is that "there has been very little use of the post hospital
alternatives-extended care facilities and home health services."
It is the conclusion of this Association that both legislative and administrative
changes are needed if home health benefits are to provide a truly available alter-
native to long-term institutional care.
1. The provision of home health services under Part A and Part B, especially
with respect to deductibles and co-payments under Part B, has led to excessive
administrative costs, and has often left providers with uncollectable debts. Retro-
active denial of payments combined with underuse is resulting in such serious
financial difficulties for providers of home health care that such provider re-
sources are diminishing steadily. Authority to provide needed home health bene-
bining Parts A and B as this Association has previously recommended.
fits to Medicare beneficiaries in a uniform manner could be accomplished by com-
Social Security Administration should be restudied with the objective of remov-
2. The present Medicare administrative guidelines and interpretations of the
ing unnecessary restrictions that have the effect of denying home health benefits
to those who are appropriate candidates for home health care.
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53
Thank you for the opportunity of submitting the comments of this Association
For the patient with long-term or chronic illness, medical care becomes a way
on this important Medicare benefit-home health services.
of life-and all too often results in his institutionalization. Although the home
Sincerely,
is not appropriate for all chronically ill patients in all stages of their illness, it
KENNETH WILLIAMSON,
can provide a desirable setting for far more patients far more often than at
Deputy Director.
present. Home care need not be elaborate in order to meet the requirements of
thousands of patients now receiving care in hospitals or chronic disease facilities.
STATEMENT ON THE ROLE AND RESPONSIBILITIES OF HOSPITALS IN
HOME CARE
THE HOSPITAL'S ROLE IN HOME CARE
[Approved by the American Hospital Association, May 7-8, 1964]
Whether the hospital or some other community agency will provide the admin-
istrative structure, the hospital has a key role to play in helping to stimulate
INTRODUCTION
development of home care, in fact-finding to determine the extent of need, in
identifying the desirable and appropriate scope of service, and in helping to
The American Hospital Association and its member hospitals recognize home
secure stable financing.
care as an essential component of comprehensive patient care; they accept their
Another basic function of the hospital is to develop and maintain an effective
responsibility to foster the availability of home care services of high quality. This
mechanism for identification of patients potentially suitable for home care
responsibility must be fulfilled at the community level and requires the active
and for their prompt referral to the program. Eligibility for home care should
participation of the Association's member hospitals.
not be related to the patient's financial condition-many patients who can pay
The goal of the Association is "to assure each patient adequate care at the
for the services are either unaware of the service or are denied access to home
right place, at the right time, and at a cost the Nation, each community, and its
care. Involvement of at least the medical and nursing staff is necessary for
citizens can afford." In certain situations and for certain patients, home care
successful performance of this function.
is the mode of patient care that best fulfills this goal.
The hospital must also back up the home care program by assuring that the
Hospitals have long accepted the responsibility to try new approaches to better
patient will be immediately admitted-or readmitted-to the hospital if a change
care and to seek methods of controlling costs, but in the past their attention has
in his condition requires hospitalization. The fear of both patient and family
focused primarily on inhospital services. Home care is no longer a new concept.
that he will need hospital care and not receive it promptly is an important
It is now time to put home care into wide use, permitting its further development
psychological barrier to their acceptance of home care. Technical services and
through flexible planning, experimentation, sharing of knowledge and experi-
equipment usually available only in hospitals should be made available to the
ences, and evaluation of methods and accomplishments. The knowledge thus
patient, either by bringing him to the hospital for these services or by taking
gained will permit the practical realization of home care as an essential compo-
them to the home, as circumstances dictate.
nent of health services.
When the hospital is also the administrative agency for the home care pro-
DEFINITION OF HOME CARE
gram, its role expands to include the direct provision of professional and related
services to the patient at home. Nursing, social services, physical therapy, occu-
In its broadest sense, home care is the provision of health care and/or support-
pational therapy, and, in some programs, physician services are among these.
ive services to the sick or disabled person in his place of residence. It may be
As the coordinating organization, the hospital seeks the involvement of other
provided in a wide range of patterns of organization and service. At one end of
community resources, both of manpower and of financing.
the range is the simplest form, nursing service under physician direction. At the
other end is the coordinated home care program, which fulfills the concept of
THE HOSPITAL'S RESPONSIBILITIES IN HOME CARE
comprehensive patient care. It has been described, in an Association publication
which goes on to explain in detail the terms used in this definition, as a program
The responsibilities of the hospital also vary in relation to its degree of in-
"that is centrally administered and that, through coordinated planning, evalua-
volvement in the administration of the program. Whatever the auspices or
tion, and follow-up procedures, provides for physician-directed medical, nursing,
administrative structure of the program, the hospital must assure that the
social, and related services to selected patients at home."
planning is patient-centered. This requires close cooperation and coordination
The coordinated program is the ideal. In many communities, it is a practical
among the several health care and related services that may be called upon
ultimate objective for programs that begin modestly. In others, particularly in
to share in this responsibility.
very small communities or in large areas with low population density, the prac-
The hospital also has a basic responsibility to the community to assure that
tical objective must remain more limited. Whatever their organization or scope,
services are of acceptable quality, are used efficiently, and are available to
the essential requirements for all home care programs are high quality of service
patients who can pay the full cost of the service as well as to those who
and proper selection of patients.
cannot.
When the hospital administers the program directly, its responsibility for
SELECTION OF PATIENTS FOR HOME CARE
the quality of all services, including those rendered by other agencies, and
for their proper utilization is necessarily greater because it is directly ac-
Successful operation of a home care program demands selection of patients in
countable for all aspects of the program. As the administrative agency, it
accordance with their needs and with the availability of services. The earlier
must recruit competent personnel and provide for their orientation, training,
concept that coordinated home care programs should admit only patients with
and supervision. It must obtain adequate financing; maintain records-admin-
long-term illness requiring multiple services is changing as a result of experi-
istrative, financial, and medical; and establish and maintain effective com-
mental programs extended to a variety of other types of patients. Patients who
munication with other community agencies, both those that participate directly
are convalescing from an illness, those who usually receive treatment on an out-
and those that have a legitimate interest in all services to the community.
patient basis but are temporarily unable to do so, and certain patients with ter-
minal illnesses are being successfully cared for through coordinated home care
CONCLUSION
programs.
For the convalescent patient, home care may be superior to in-hospital care
No longer can a hospital's service program be defined in terms of inpatient
if the home is suitable and if he no longer needs continuous professional atten-
care alone. The hospital is assuming its proper responsibility to assure a con-
tion or use of equipment that cannot practically be provided outside of the
tinuum of acute, rehabilitative, long-term, diagnostic, and preventive health care
hospital.
to the patient wherever he may be. The extension of hospital service to the patient
in his home is both a natural development and a feasible one when his needs can
1 Background Statement on Role of Hospitals in Long-Term Care, American Hospital
be met there and the home is suitable.
Association. September 1962.
2 Hospitals and Coordinated Home Care Programs, American Hospital Association, 1966.
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55
Home care programs are desirable primarily for the benefit of patients; they
advance the goal of adequate care at the right time, at the right place, and at
There are many elderly people who have slim prospects for total recovery,
the most economical cost. In addition, the hospital itself benefits from partici-
but who have the need for part-time intermittent nursing observation, preven-
pating in a program that extends needed services beyond its own walls. Its
tive and restorative services. Changes in the patient's physical or emotional
inpatient beds are utilized more efficiently thereby and in some instances con-
condition may alternate between an acute and stable state, requiring observa-
struction of additional beds can be avoided. Furthermore, the home care pro-
tion, change in regimen and medication.
gram provides concrete evidence that the hospital is no longer concerned only
with the care of the acutely ill today; it is concerned with the health of the
II. PROBLEMS EXPERIENCED BY EXISTING SERVICES AND PROGRAMS OF ALL TYPES
whole community.
While it was expected that Medicare would through Social Security assure
home care to individuals 65 and over, what has occurred is that increasingly
ITEM 2. STATEMENT BY DONALD R. HAYES, M.D.; HOME HEALTH
the regulations have interpreted this care to be restricted to a period of acute
illness and only certain types of care.
CARE AND SERVICE
The focus has thus been on care of illness at a critical stage rather than the
(Donald R. Hayes, M.D., Chairman, Committee on Community Health Care,
more universal need for services which will prevent illness and maintain people
Council on Medical Service, American Medical Association)
at their highest level of health in their homes and communities. Unfortunately
Medicare has perpetuated the problems created by voluntary health insurance
The AMA defines home health care as any arrangement for providing, under
programs that traditionally have given the highest priority to hospitalization
medical supervision, needed health care and supportive services to a sick or dis-
as a covered cost-an emphasis which has increased both the utilization and
abled person in his home surroundings.
costs of hospitals. Under Medicare the financial incentive is for hospitalization
The medical profession has long endorsed the concept of home health care. In
even though care in the home would be more appropriate in the case of count-
December 1960, the AMA House of Delegates recommended that "physicians be
less patients. Thus, the total reimbursements for home health services under
urged to participate in organized home care programs for any patient who can
Medicare have decreased from $79 million in 1969 to $50 million in 1971 while
benefit from the program and to promote such programs in their communities."
hospitalization reimbursements increased from $4 billion to $4.5 billion in
Since that time AMA has produced several reports and publications designed to
1971. See below:
assist the physician in the development and effective utilization of such services
MEDICARE REIMBURSEMENTS FOR HOME HEALTH SERVICES AND INPATIENT HOSPITALIZATION, 1969-71
in his practice.
It has been demonstrated that careful and appropriate instruction to the
[In millions of dollars]
recently discharged hospital patient and his family enhances a smooth conval-
escence and leads to a minimum of home care follow-up.
Reimbursements
The AMA stresses that leadership by physicians is essential to the efficient
and successful provision of home care services. In the past the AMA has stimu-
Home health 1
Hospitalization
lated and encouraged cooperative action by state medical and health groups for
developing home care programs in their communities through regional work-
Year:
shops on home care. The current concern in hospital costs and utilization has
1969
$78.8
$4,042.8
1970
67.5
made physicians increasingly aware of the value of home care as an alternative
4,433.1
1972 2
49.5
4,508.8
mode of patient care. As a result the AMA continues to maintain continuing
liaison with national health and medical groups concerned with effective home
1 Includes pts. A and B.
care programs. It also maintains an ongoing interest in the evaluation of existing
2 Estimated on the basis of data through Nov. 3 and 4, 1971.
coordinated home care programs regarding their proper support by medical care
Source: Social Security Bulletin, February 1972; vol. 35, No. 2, DHEW.
insurance, with a view toward stimulating development and extension of such
programs. Obviously, the needs of the aging population for home health services is increas-
To meet the anticipated need or service provided for in the Federal legislation of
1965, primarily Medicare, Visiting Nurse Associations and nursing units of health
ing and will continue to increase. Difficulties experienced by existing home
departments (home health agencies) were encouraged to and expanded opera-
health care programs include a shortage of qualified and trained health per-
tions for the delivery of services in the home as follows:
sonnel and problems in adequate reimbursement. To meet this expanding need
the AMA recommends that further research and development be undertaken to
1. Employed additional professional and ancillary staff to provide and
evaluate the effectiveness and appropriateness of the utilization of the services
administer service.
provided by home health agencies in the community SO as to ensure optimum
2. Added office staff to meet the need for
patient care.
(a) substantiation, documentation and transcription of records
(b) development of new account and billing systems
3. Purchased additional equipment for both patient care and office use
ITEM 3. STATEMENT OF THE NATIONAL LEAGUE FOR NURSING,
4. Extended staff time needed
DEPARTMENT OF HOME HEALTH AGENCIES AND COMMUNITY
(a) to interpret to patients, their families, physicians, and health
welfare organizations, the continuous modifications in Medicare benefits
HEALTH SERVICES
(b) to mediate between beneficiaries and SSA regarding conflicting
information given about Medicare benefits
I. NEEDS OF THE AGING POPULATION FOR HOME HEALTH SERVICES
(c) to interpret home health services to fiscal intermediaries
In the past three years there has been a net increase of over 1,000,000 people
(d) to assist with audits imposed by various governmental audits
in the United States 65 years of age and over which now comprise approxi-
Since the enactment of amendments to Social Security which legislated Medi-
mately 10% of our population. The 95% of the elderly who live at home could
care with an expectation of increase in financial support from Federal funds, the
be helped to maintain themselves in reasonably good health through provision
percentage of support from United Funds and other private sources decreased
of home health services including assessment of health, health teaching and
for Visiting Nurse Associations. In 1969, as the definition of reimbursable serv-
guidance, prevention of illness, services necessary to maintain or restore health
ices became restrictive by the Social Security Administration, the agencies began
and rehabilitation, health maintenance and long-term care when disability
to experience acute financial difficulties. In 1970-71 the situation reached crisis
occurs.
56
57
proportions. With expensive operations set up, the cutback in Medicare reim-
single organizational unit for the administration and coordination of national
bursement, often applied retroactively, forced many community nursing orga-
health services. Such a unit might be a Department of Health-at the Federal
nizations to reduce staff and limit the services they offer. During this period
level-and it should make provision for consultation from community health
when many agencies are faced with a fight for their actual existence, at the
agencies and other providers. Such a coordinated service should develop proce-
same time there is a greater demand and need for services in the home.
dures to avoid the present expensive duplication of cost finding and audit
The regulations of Social Security have been arbitrary. There is no require-
mechanisms.
ment in the law for consultation from those knowledgeable in the delivery of
Community health service agencies have expertise and the capability to provide
home health care. There is wide variation in the skill and expertise of the fiscal
comprehensive home health services-case finding, prevention of disease, health
intermediary offices and great diversity in their interpretation and administra-
education, and restorative and maintenance care-but cannot do SO without fiscal
tion of the regulations.
support. These agencies have for decades focused on the patient and his environ-
In many areas there have been very limited medical understanding for the
ment with services more comprehensive than therapy for a period of acute illness.
necessity for continuity of care from the institutional setting to the home. This
Present Federal program curbs on the provision of comprehensive health services
lack has also led to over-utilization of hospitals and under-utilization of home
for the elderly in their homes and communities should be withdrawn and the
health services. There is great disparity in this aspect from state to state. In the
focus changed from illness care to health care.
first 18 months after the implementation of Medicare, the "Home Health Starts
of Care per 1000 Medicare Beneficiaries" ranged from 35.2 in one state to 3.2 in
another. The national figure was 15.5. The "Percent of Home Health Starts of
Care to Hospital Admissions" for the United States as a whole was 5.1 with a
ITEM 4. AMERICAN NURSES' ASSOCIATION STATEMENT ON HOME
state's range from 1.0 to 14.8.
HEALTH AGENCIES
Medicaid programs also vary greatly from state to state in the benefits they
provide for the aged and in each state's standard for eligibility.
The American Nurses' Association is the professional organization of reg-
Home health services are a part of the programs of three major administrative
istered nurses in the United States. Its purposes are to foster high standards of
units of the Department of Health, Education, and Welfare. They are the Social
nursing practice and to promote the professional and educational advancement
Security Administration, the Social and Rehabilitation Service and the Health
of nurses to the end that all people may have better nursing care.
Services and Mental Health Administration. There is little coordination among
Home health agencies providing nursing services have existed in the United
the three programs and no provision for obtaining consultation from non-Federal
States for nearly one hundred years. However, not all communities have had such
organizations and agencies in the field of home health services. This further
services available. Originally, the agencies were established under voluntary aus-
compounds administrative costs as professional and business staff of agencies
pices, with boards of directors composed of citizens of the community. Their serv-
struggle with these variables.
ices were offered to all regardless of age, sex, race or ability to pay. Originally,
Home health agencies and community health services-many of them now
their financial support came from client's fees, from endowments and from Com-
barely existing today, cannot continue to provide needed services without
munity Chest and United Fund monies. For a period, two national insurance
financing.
companies paid for home nursing care for certain of their policy holders. Only re-
cently have health insurance programs included coverage for home health
III. SUGGESTIONS FOR MEETING NEED BY INCREASING THE SCOPE AND EXPANDING THE
services.
COVERAGE OF COMMUNITY HEALTH SERVICES IN THE HOME
During the period when health insurance for the aged under the Social Secu-
rity System was being debated in the Congress, the ANA vigorously urged that
To decrease costs and at the same time provide needed care for people, we sug-
home health services be included as a benefit in any program that was enacted.
gest that program efforts be directed toward increased utilization of home health
It contended that nursing care on a part/time basis in cases of acute illness was
agency services. Home health agency reimbursement accounts for only about 1%
often more appropriate than hospitalization, that individuals with chronic ill-
of the total Medicare expenditures.
ness could be maintained in their own homes, rehabilitation measures under-
The need is great for redirection of the health care system from the narrow
taken in familiar surroundings, and serious breakdown avoided. When Medi-
concept of "medical care in institutions during periods of acute illness" to one
care was enacted, the Association was pleased that home care services were in-
of "health care which includes improvement and maintenance of health, pre-
cluded in the program.
vention of diseases, curative and rehabilitative services." In the restructure
However, we have been concerned, in the years since the initiation of Medicare,
necessitated by this change in focus it would be wasteful to encourage the devel-
about the limitations placed on home health services. For example, under Title
opment of agencies or services which parallel or compete in communities with
XVIII, Part A, an individual was only eligible for care at home after a three day
existing agencies who provide quality services. We have seen the results of
stay in a hospital. This requirement was set by law, was rigid and did not allow
funding which encouraged the establishment of agencies whose services dupli-
for an assessment, based on medical and nursing judgment, about where an
cated those provided by existing community agencies. Failure of the new agencies
individual's health care needs could best be met. Health insurance in this coun-
to coordinate with the existing community agencies by contract or similar
try has tended to encourage the use of the most expensive facilities for the pro-
mechanisms has led to overlapping, increase in administrative costs, confusion
vision of care. The requirement of three days hospitalization prior to eligibility
for communities, with insufficient evidence that the new independent services
for home care services perpetuates this practice. Therefore, we believe such a
lead to improved care for people.
requirement should be removed from the law SO that, when appropriate, care
To assure quality care, we recommend that home health agency programs
can be provided at home. The decision about the appropriateness of care at home
meet NLN-APHA accreditation of community health service standards includ-
should be determined by an individual's physician and the home care agency
ing requirement for utilization review process in the agency.
responsible for providing home care services.
We recommend that procedures be developed for advance approval for home
Another concern is that home health benefits have been over-controlled. In-
health benefits. However, we strongly urge that the advance approval standards
termediaries have made arbitrary and questionable decisions with respect to the
be sufficiently flexible to permit coverage for patients who continue to need skilled
nursing care they will approve for payment. To be sure their decisions are based
nursing, physical therapy, or speech therapy services beyond the period initially
on regulations of the Social Security Administration that are perhaps interpreted
approved. We urge provision for the most effective use of existing health care resources
rigidly. For example, crutch walking taught by a nurse is not paid for but is paid
for if taught by a physical therapist. This is unreasonable in view of the fact that
and the elimination of duplication of health care resources. To avoid the exist-
nurses have the competence and have been filling this teaching role for a long
ing duplicating and fragmentation that now exists at the Federal level in the
time. The Social Security regulations regarding the skilled nursing services
case of health care programs under Medicare and Medicaid, we recommend a
that will be paid for focus on the technical and procedure type of nursing care.
58
59
They do not take into account that a client's needs, and those of his family, are
prevention and maintenance at a given level of illness. These services are es-
met as well through counseling, teaching, emotional support and through assess-
sential for keeping aged ill persons in their homes, and money now being ex-
ing, observing and reporting progress or lack of it.
pended for long term institutional care should be channeled to home care serv-
Public health and visiting nurse agencies providing home health services have
ices. It is our opinion that these services can be provided at a savings to the
a long history of monitoring their activities. Unnecessary visiting by nursing
American public and that this is the more humane approach to a way of living
staff has been discouraged and better utilization of the nursing team, which
for the aged. The incentives for remaining self-sustaining are much greater in
includes licensed practical nurses, home health aides and homemakers has been
the home environment.
promoted. Nursing supervision of staff in these agencies is of high caliber. Case
We would recommend that homemaker-home health aide services be provided
conferences on patient needs and evaluation of the care provided is a long
to enable the aged to remain in their homes. We urge that payment be as-
established practice. It is our opinion that the nursing staff in the home health
sured for these services and that payment be assured for professional nurse
agency, in consultation with the patient's physician, is in the best position to
supervision of the personal care when a physical or mental disability is the
determine the need for care at home. Such a crucial matter should not be left
cause for the inability of the aged to maintain themselves independently. Only
to the judgment of intermediaries, no matter how well intentioned.
the professional nurse is capable of identifying early symptoms of deteriora-
Less than one percent of medicare expenditures has been used to pay for
tion and therefore of obtaining early medical intervention. Conversely, the pro-
home health services. There is, therefore, some justification in believing the
fessional nurse can evaluate the patient's progress and make decisions about the
agencies are not given to over visiting for the sake of the Medicare dollar. Yet
necessity for continuing supportive services.
denial of payment after services have been rendered has occurred and this
We urge that payment for drugs and medical equipment be provided for the
creates difficulties for the agency and frustration for the patient, both of whom
care of the patient in his home, when needed.
must go through appeal procedures in an attempt to collect payment.
We urge that money be made available to employ "handy men" to make the
We trust that in the event a national health insurance is enacted ample provi-
home suitable for the handicapped. Many patients could be kept in their homes
sions will be made for home health services. In the meantime, we recommend
if ramps could be built for wheel chairs, doors widened and safety devices
installed.
removal of the limitations placed on these services.
Another tangible need of the aged is transportation. If aged people are to be
maintained in their homes, money must be available for transportation to facil-
ities which provide basic health services, i.e., medical, dental, podiatry, hearing
ITEM 5. STATEMENT OF THE NATIONAL ASSOCIATION OF HOME
centers, rehabilitation centers and the optometrist or ophthalmologist.
HEALTH AGENCIES
RECOMMENDATIONS
HOME HEALTH SERVICES FOR THE AGED
If a Federal Insurance Plan is developed which encompasses all of the needs
listed, there are some basic facts which must be recognized.
STATEMENT OF NEEDS
The problems of what is needed for the individual, where the services can be
It is generally recognized that the majority of the nation's aged population is
obtained and how to get them, poses severe problems for the American public.
economically deprived and, to a large extent, medically indigent. Existing pro-
We recommend that-
grams for home health services are limited in scope and coverage for payment
(1) Local centers be established to screen, plan and co-ordinate health
of services is inadequate.
services to the aged. A qualified home health agency could provide these
The home health agencies experience considerable difficulty in their attempts
services and costly overlap, duplication and gaps in services could be elim-
to secure financing for preventive and maintenance services to the aged in their
inated.
homes.
(2) Equal benefits by way of coverage of payment of services be provided
Preventive services are needed at both primary and secondary levels of care.
for institutional and non-institutional health care services.
At the primary level, certain basic services are essential. For example, nutritional
(3) Criteria for eligibility for coverage be simplified.
services are important to assure an adequate and appropriate diet upon which
(4) Criteria for claim procedures for providers of care be simplified.
good health is dependent. However, good dental health predetermines, to a large
(5) Reimbursement formulae be simplified.
extent, the ability of the patient to eat the foods necessary for a balanced diet.
(6) Utilization review committees determine benefit eligibility and be
Assuming that provisions are made for good nutritional and dental services, the
accountable to the national health insurance carriers.
degree to which the patient can benefit by these services is contingent upon the
(7) Fiscal intermediaries be limited to financial accountability.
ability to market and to prepare the food. Consequently, many aged need assist-
(8) Health maintenance services be covered in the broadest context in-
ance with grocery shopping and meal preparation. The ability to ambulate and
cluding a safe hygiene environment.
perform these duties requires functional feet. As one ages, the need for podiatry
(9) Preventive services be covered and include health surveillance and
services increases, and the ability to pay for such services decreases. The goal
education to maintain physical and emotional well-being.
should be to keep people functional, mobile and healthy, as long as is consistent
(10) Supportive services be covered, i.e., home health aides, homemakers,
with the individual's physical and mental condition. It is commonly recognized
podiatrists, dentists, optometrists, equipment and supplies, prescription
that eyesight changes with the aging process. The need for on-going eye exami-
drugs, laboratory services, transportation and carpentry.
nations and updating of prescriptions for glasses is too obvious to require de-
It is time for this country to stop the emphasis on illness and rewards for
tailed discussion. Coverage for primary preventive services for the aged is
illness as perpetuated by the present system. It is time to reward wellness and
practically non-existent and is an area where agencies experience problems on
to provide coverage for preventive and health maintenance programs.
a daily basis.
At a secondary level of prevention, adequate home health services could pre-
WHAT IS HOME HEALTH CARE?
vent repeated hospitalizations and could prevent placement in long term care
facilities. Many of the aged are afflicted with multiple chronic disease processes.
Home Health Care can be defined as a coordinated system of individualized
Observation and evaluation of the patient's condition at regular intervals could
health care delivered to patients in their homes by professional and allied health
personnel under the direction of a physician. These services are organized and
permit early identification of problems and correction before an acute exacer-
bation of the disease forces the patient into a hospital. Also, it is possible that
provided SO that the patient is either restored to full health or achieves maximal
with the necessary supportive services, the patient could be maintained in his
rehabilitation with the least possible disruption to his usual pattern of daily
home, thus avoiding institutionalization for the rest of his life. The so-called
living.
"custodial" care of an aged individual falls into the categories of secondary
74-331 0-72-5
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61
Home health services include intermittent nursing care, physical therapy,
NEED FOR STANDARDS
occupational therapy, speech therapy, social service, home health aide, house-
keeping services, laboratory investigation, medical equipment and supplies as
We recognize the need to establish standards for home care and to encour-
ordered by the physician.
age agencies to work toward meeting such standards. The Joint Commission for
There are two basic reasons why home health care is not playing a larger and
Accreditation of Hospitals is currently establishing task forces to establish
more important role in the delivery of health care services one,
the
general
standards for home care and a program for accreditation of home health agen-
public does not understand the use of home care, and two, the reluctance of pri-
cies. In order to prevent duplication of effort, our National Association will
vate and public insurers to include home health services on a broad basis as a
work with the Joint Commission on development of standards. Two of the
benefit of insurance policies.
Board Members have accepted an invitation to work on the task forces.
In summary, we believe:
PROPER RECOGNITION AND SUPPORT
(a) Home health care should be a integral part of any health care system.
(b) Home care can drastically reduce the cost of illness.
In the past, lack of recognition and understanding of home care services has
(c) Patients need and want home care-a primary deterrent to patient de-
retarded the Home Health Agency's capacities to function properly and at full
mand for home care is the lack of public and private insurance coverage for
potential.
home health services.
The reluctance of private insurance companies to recognize the Home Health
(d) The advantages of home health services are real, important and undu-
Agency's role and capabilities results in limited coverage for this type of care
plicated.
while the costs of institutional care continue to rise.
(e) Home care is not an "add-on" service, but is an alternative service.
Funds allocated by Federal and State Governments lack long-term commitment
(f) Home care coverage must be broadened beyond the present governmental
to solve the problems that exist. Short-term commitments that stimulate initial
and public insurance plans if any real effect is to be made on the cost of health
planning efforts are prevalent. But with no real follow-up, support of these efforts
care.
has often not reached fruition. Valuable time, talent, and financial resources are
wasted with no real benefits to the patients.
Today's crisis in health care financing demands that the patient be placed at the
ITEM 6. STATEMENT BY THE NATIONAL COUNCIL FOR HOME-
appropriate level of care. The American Hospital Association estimates that 6%
MAKER-HOME HEALTH AIDE SERVICES, INC.
of patients currently hospitalized could be adequately cared for with intermittent
home health services at a drastically reduced per diem cost.
INTRODUCTION
Home care is not a substitute for hospital, extended care or nursing home care.
Home care is a part of the health care continuum which, if used properly, will
The National Council for Homemaker-Home Health Aide Services is a non-
complement the others-meeting the patient's needs in a setting which uses the
profit, tax-exempt membership* organization whose purpose is the development
resources of family, neighbors and friends.
of quality homemaker-home health aide services as an integral part of health
and/or welfare services delivered in the home.
ADVANTAGES OF HOME HEALTH SERVICES
The particular focus of this statement will be on the usefulness of the service
in helping to meet health needs.
It is the position of this Association that full utilization of comprehensive high
quality home health services can have the following advantages:
DEFINITION OF SERVICE
Reduce the length of hospitalization by making early discharge possible.
Diminish the need for readmission to hospitals.
Homemaker-home health aide service helps families to remain together in
Prevent many admissions to nursing homes.
their own homes when a health and/or social problem strikes or helps individuals
Provide a more economical alternative to institutional care.
to return to their homes after specialized care. The homemaker-home health aide,
Increase the efficiency and extend the coverage of the practicing physician.
as a member of the health and/or welfare team providing service in the home,
Decrease capital construction costs by releasing hospital and institutional
carries out assigned tasks in the family's place of residence working under the
beds.
supervision of a professional person who also assesses the need for the service
Provide patient care in the normalcy of the home environment.
and implements the plan of care.
Teach home bound people to live independently.
RECENT DEVELOPMENTS
HOME CARE LESSENS THE COSTS OF ILLNESS
In developing this statement we wish to draw attention to several recent
Here are some dramatic examples of how home care reduces costs:
pertinent developments.
(a) If the stay in the hospital of one patient in twenty was shortened by only
1. In the January 1969 and in the November 1970 isues of the Federal Register,
one day-at daily cost of $70-the total hospital cost to the American people
the National Council for Homemaker-Home Health Aide Services was named
would be reduced by almost 100 million dollars.
by the Social and Rehabilitation Service of the Department of Health, Educa-
(b) During 1970 in Denver, Colorado, a total of 11,019 total hospital days were
tion, and Welfare, as a national standard-setting body for homemaker-home
saved by using home care services. At Denver's $95 per day hospital rate, this is
health aide services. Partly in response to this designation and with the active
a total saving in excess of over one million dollars.
support and assistance of its members and other relevant national organiza-
(c) Because of the shortening of hospital stays for 5,000 Blue Cross patients
tions, the Council has developed and is implementing a national approval pro-
in New York, costs were reduced by an estimated total of $3,648,174.
gram which offers agencies throughout the country, whether under voluntary,
(d) H.E.W. states that just a one-day reduction in hospital stays of Medicare
governmental or proprietary auspices, help in assuring the quality of their home-
beneficiaries in 1968 would have cut program costs by $315,000,000.
maker-home health aide services.
(e) Kaiser Research Foundation-Portland, Oregon, lists the following 1968
2. The National Council was invited by Dr. Arthur Flemming, Chairman, of
per diem comparison:
the 1971 White House Conference on Aging, to plan a Special Concerns Session
Home Care Services
$5.25
on Homemaker-Home Health Aide Services at this important decennial meeting.
Extended Care Services
39.08
This session was held December 1, 1971. An account of this Special Concerns
Hospital Care Services
76. 62
Session appears in the White House Conference on Aging report. Most other
(f) Home care is approximately 3½ times less expensive than hospital care,
*The Council's membership consists of over 300 agencies which provide homemaker-
according to the varied cost studies researched by NAHHA.
home health aide services: 50 health and welfare organizations, both state and national;
200 individuals and several business and industrial corporations which support develop-
ment of the service.
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62
After several months, the homemaker-home health aide was no longer needed.
sessions of the Conference also stressed the need for the development and fund-
The sister had gone to a nursing home, a niece was able to help with some of
ing of this service to help the aging remain in or return to their own homes
the housework, and the wife was able to manage her own personal care. The
rather than be placed in costly institutions.
aged couple had been able to stay together in their own home.
President Nixon, at the closing session of the Conference, specifically stated
"We can give special emphasis to services that will help people live decent and
MEASURES OF NEED
dignified lives in their own homes, services such as home-health aides, home-
maker ad nutritional services, home-delivered meals, transportation assistance."
One home health agency operated for the last ten years in Rochester, New
3. At its clinical Convention held in Boston in 1970, the American Medical
York, reports more visits by homemaker-home health aides than by any of
Association adopted a resolution supporting the development of homemaker-
the other 16 home health services provided. In 1969 there were 21,625 visits by
home health aide services as a part of a medical care plan, and specifically
these homemaker-home health aides. This agency only serves patients who
endorsed the leadership of the National Council for Homemaker-Home Health
would have been in the hospital, otherwise, and its administrator estimates the
Aide Services, Inc.
program saves the community over $1,000,000 each year. Blue Cross subscribers
pay $2.67 per family and $1.27 per individual per year for this home health care
NEED FOR HOME HEALTH SERVICE, INCLUDING HOMEMAKER-HOME
coverage, including homemaker-home health aide service. Despite the need
HEALTH AIDE SERVICE
demonstrated by this agency in this one community, it is estimated that there
are only 30,000 homemaker-home health aides in the entire United States
Home health service, simply stated, is the provision of health care to the
serving all categories of social and health needs the ill, aged, disabled, children
patient in his place of residence. It may be provided through a wide range of
and others with social and/or health problems. At a minimum, homemaker-home
services and organization patterns and delivered under a variety of auspices.
health aide agencies should have available 300,000 homemaker-home health
Homemaker-home health aide service is one of the basic home health services.
aides.
Health service delivered in the home is not a new idea. Recently, however,
A major reason that homemaker-home health aide service is SO underdevel-
much more attention is being paid to this form of health care, and with good
oped is a lack of adequate financing. In a report¹ prepared by the Welfare
reason. Frequently it is not only the form of care strongly preferred by the
Federation of Cleveland in September 1971, it is stated that, "What has come
patient and his or her family, but it is also the most appropriate plan for care.
through to the Committee loud and clear is that here we have a situation
In addition, in many instances it is the least costly form of service to the patient
where (1) home health care is a needed part of the health delivery system; (2)
and/or the community. The National Council has urged in testimony before the
personnel has the knowledge and skill to provide good "care at home and can
Committee on Ways and Means of the House of Representatives that strong
be successfully recruited for this purpose; (3) services are in demand, and
emphasis be placed on provisions for financing home health service in national
are used where costs are fully or partially covered; and where (4) the real
health insurance legislation as an integral part of a continuum of health services,
key to the solution of the problem is more adequate financing."
and that homemaker-home health aide services be specified as one of the covered
services.
WHAT CAN BE DONE REGARDING FUNDING OF SERVICE
PRESENT SERVICE IS INSTITUTION ORIENTED
It is essential that the narrow definitions and restrictive coverage plaguing
Over the last few decades as medical services have become much more special-
the present home health service aspects of the Medicare program be eliminated.
ized and complex, perhaps it was a natural development that health care for the
Far from providing the promised help to the nation's aged, Medicare has been
aged and disabled became almost synonymous with institutional care. For ex-
to many a source of frustration and dashed hopes that needed care would now
ample, less than one percent of the national Medicare expenditures were being
be available where they needed it, when they needed it.
used to provide home health care, according to the Second Annual Report-
National health insurance funding should provide for home health service,
Operation of Medicare Program, dated January 20, 1969. And Federal regulations
not only as an alternative to hospital and nursing home care-although this
relating to home health service, one of the covered benefits under Medicare, have
is very important-but it must also provide home health service for the needi-
consistently been tightened SO that now far too few can qualify for the service
est group of all, the chronically ill and aged. In England, with a population
under Medicare. Yet the National Council hears consistently from doctors, nurses,
markedly below that of the United States, some 71,000 home-helps (homemaker-
social workers, social service departments of hospitals, visiting nurse services,
home health aides) are employed in the health system primarily providing serv-
public welfare and public health departments, homemaker-home health aide
ice to the older chronically ill patients. Such care should be available whether or
agencies, and many other organizations that a service urgently needed to help
not a patient has been in the hospital, if it is to serve the patient and community
people remain in or return to their own homes is homemaker-home health aide
to its optimum extent from the standpoint of efficient service at a lower cost.
service. In fact, this need is SO pressing that proprietary concerns have recognized
In a paper entitled "Home Health Service and Health Insurance," Miss
it and are rapidly springing up throughout the country to make the service avail-
Brahna Trager states: "Home care becomes unreliable if the regulatory and
able on a profit making basis.
funding conditions in the insurance program do not provide for the necessary
Two cases illustrate the role of the homemaker-home health aide in home
continuity of health supervision and a secure environment which is supportive
health care situations A homemaker-home health aide was assigned to care
of optimum health. Without these as a reliable base home care becomes an un-
for a frail, worn mother, 79, crippled with arthritis and her daughter, 56,
stable resource. The institution which will assume the necessary responsibility
terminally ill with cancer. In the two days a week the homemaker-home health
becomes the alternative."
aide was with them, she helped with meals, did the laundry, shopped and gave
We submit that allowing institutional care to continue to be the primary focus
some personal care to both women under the supervision of the public health
for health care is unsatisfactory either in terms of human costs or in terms of
nurse. Besides preventing institutionalization, the lightening of physical burdens
financial costs to families and/or to the community. This concept applies to men-
meant an easing of emotional tensions between mother and daughter. Equally
tal and emotional illness as well as to physical illness.
important, said the caseworker, was the "tremendous mental lift" the homemaker
Home health services, including homemaker-home health aide service, should
gave the family. Both mother and daughter told the nurse and caseworker,
be a part of all forms of health delivery systems, including health maintenance
"You've sent us an angel."
organizations, community and hospital-based health service programs, and any
And in another situation
when a husband, aged 80 visited his wife of
other existing or proposed health delivery systems. Homemaker-home health aide
the same age in the hospital and heard that she had been discharged, he went to
service as an integral part of home health care is provided currently as part of
the floor nurse with tears in his eyes and said, "What am I going to do? I am
not able to take care of her." His wife was completely bedridden as the result
1 "Report of the Exploratory Committee on Public Health Nursing and Related Home
of a fractured hip. They lived with his wife's sister who was an amputee. The
Care Programs."
2 Home Health Services and Health Insurance, Medical Care, Volume IX, No. 1, January-
nurse referred them to the Home Health Agency Coordinator, and homemaker-
February 1971.
home health aide service was planned.
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65
the Harvard Community Health Plan (HMO), the Kaiser Permanente Program
homemaker-home health aide services. Whether the home health or the home-
(HMO), Visiting Nurses Services, Homemaker-Home Health Aide Agencies, Pub-
maker aspect is emphasized when rendering services to individuals depends on
lic Health Departments, Mental Hospitals and many others. Its value has been
the professional orientation of the supervisory agency.
proved over and over in these services around the country. It must also be a vital
part of any new, national, comprehensive health insurance program.
PROFESSIONAL OBSCURANTISM
OTHER IMPORTANT POINTS
One of the major problems confronting the future delivery of service which
meets the whole needs of individuals is that of overcoming over-professionalism
There are several other points which must not be overlooked:
and its tendency to narrow the focus and limit the services rendered. This tend-
1. Professional personnel is in short supply, and it is expensive. Paraprofes-
ency towards over-specialization and limitation of service is accented by restric-
sional or allied professional help must be utilized where and when appropriate
tions on funding, whether source of funding is through health, welfare, education
from the standpoint of safe and effective care. Homemaker-home health aide
or labor agencies. Yet, where the broader concept has been permitted, the result
service is an exemplary utilization of the less expensively prepared individual;
has been most favorable. For example, a home nursing service which utilized
2. All forms of social and health service, including homemaker-home health
women trained as homemakers was very pleased with the quality of service that
aide services, must meet basic standards of quality. The Council strongly endorses
these homemakers offered. The health supervisor was able to direct their work
the concept of assuring quality services through utilization review and other
with respect to the health situation; in addition, the homemakers were able to
standard-setting mechanisms, such as nationally recognized voluntary self-regu-
contribute extras from their understanding of home-related aspects of the
lating programs including that established by the National Council for Home-
health situation. This came from their training and knowledge of housing,
maker-Home Health Aide Services;
food preparation, nutrition, home management, personal family relations, etc.
3. To meet established national standards, homemaker-home health aides must
Likewise when home health training was added to the homemaker's role,
be carefully selected, trained and supervised, but they do not require an extensive
it enhanced the capability and feeling of competency of the women who otherwise
educational background. Therefore, this vocation is proving to be a realistic choice
felt apprehensive about working in homes with a health problem.
for many educationally disadvantaged but capable individuals. As this service
Home economics professionals are uniquely well qualified to work with the
begins to expand consideration should be given to the development of training
related professionals in developing the field of homemaker-home health service.
centers on a local or regional basis located at facilities such as Community
It is our observation that this service should cut across and utilize the several
Colleges, since it might prove difficult for individual agencies to provide suffi-
professional areas involved. The omission of any one tends to limit appreciably
cient training for a rapidly increasing number of homemaker-home health aides.
the quality of the service rendered.
Guidelines and materials would need to be made available to assist these training
centers in developing a curriculum to meet the national standards for training
INADEQUATE NUMBER OF PROGRAMS AND PERSONNEL
of homemaker-home health aides.
Often homemaker-home health aides are middle-aged or older women and men.
No program that we know of even begins to meet the needs of the aging
In many communities, homemaker-home health aides are recruited directly from
population for homemaker-home health services. A research study published in
families whose only source of available income has been public welfare. In some
the April, 1966 issue of the Journal of Home Economics was undertaken to esti-
instances, this source of employment has enabled the family to become self-
mate the demand for homemaker services. It developed a rough estimate of
supporting; in others, a minor amount of subsidization is still required. Grow-
one homemaker for 100 hospital admissions, or about one per 1000 population
ing numbers of agencies are developing career ladders and are providing job
of that county. Thus, the estimated need of over 200,000 homemakers nation-
mobility for many such individuals. Many homemaker-home health aide agencies
ally is conservative, for it is not based on meeting the needs of the non-hospital-
have part-time positions available which enable mothers to work during the
ized aged. Yet, no community meets this minimum standard or even comes close
hours their own children are in school. Thus, the community stands to gain
to it. Using the yellow pages as a simple criterion, it is noteworthy that this
doubly from this service as previously unemployed individuals become self-
direction in most cities does not even include such a service in its index. In those
sustaining.
cities which do, the staff is often much too small and is restricted as to the type
4. Homemaker-home health aide services enable the "breadwinner" to retain
of service offered.
or return to his or her job, knowing that the ill or dependent member(s) of the
LIMITED CONCEPT OF SERVICE
family is well cared for. Some 24 voluntary homemaker-home health aide agencies
in New Jersey report, among other statistics, that in 1970, their services prevented
The concept of homemaker/home health aide is not new in this country and it
2,435 instances of absenteeism from work.
is an accepted service in England, Scandanavia and many European countries.
There may be several reasons why its potential value has not been recognized in
SUMMARY
this country, each of which presents a problem area to be reckoned with in
providing adequate home health services for the aged:
Homemaker-home health aide services are needed by rich and poor alike and
(1) Social Welfare agencies generally have given priority to welfare recipients
must be available when and where they are needed. The community as a whole
and have not solicited its use by those who are able and willing to pay. Thus
stands to gain from a physically and mentally healthy population as well as the
those who can pay a part of the cost and those able to pay full costs are excluded
individuals and families concerned. However, until there is a secure and ade-
from the services, since they are not welfare recipients. This is particularly im-
quate funding base, such as can be provided through National Health Insurance.
portant to the low income but non-welfare aged.
or until the regulations of existing programs such as Medicare and Medicaid
(2) Health agencies have tended to limit the service and view it as an
are appropriate to home health service needs, agencies will not have the fiscal
extension of a nursing service which is primarily concerned with the patient's
security needed to develop the quantity and quality of services required through-
physical problem. Health agencies have been reluctant to include as health re-
out the nation, even for those who can afford to pay for the service.
lated the food buying, meal preparation, home management, household care and
family relations problems of the family. The funding of home health service often
specifically excludes the rendering of any service other than that directly related
ITEM 7. STATEMENT BY THE AMERICAN HOME ECONOMICS
to the patient's physical problem. This leads to the third problem.
(3) Categorical care, that is, the limitation of service to specific categories
ASSOCIATION
of persons, tends to fracture the service into segments of what is really a total
The American Home Economics Association is vitally interested in the home-
living concern for the patient. Specifically, home care when viewed in the con-
related aspects of home health services. And it is because the home-related
text of the problems of the aged or the disabled, the blind, mentally retarded,
aspects are SO interwoven with the health-related aspects, that logic has properly
the welfare client, etc. tends to focus on that category and not on the patient
dicated the joining of these two aspects into one recognized service, namely,
and his family. Admittedly, the home health problems of the aged are some-
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67
what different from those of a younger family confronted with a terminal
that the revenue has been insufficient to provide full and adequate service. Fur-
illness, with a family needing extended care for the return of a family member
thermore, most welfare oriented agencies have limited their service concept to
from a mental institution, or the family with a physically handicapped home-
their own clients, thus denying service to those who would be willing to pay all
maker. Yet, the sameness of the problems of housing, equipment, buying food,
or part of the cost. This is especially important for the middle-class aged who
meal preparation, nutrition, dressing and personal care, transportation, time
could pay partially for the cost of the service.
and money management, family relations, consumer education, and helping the
4. What are the investment requirements to launch a new service in a com-
family relate to the world of forms, credit cards, invoices, appointments, sched-
munity And over how many years must this front-end cost be amortized? Invest-
ules of bureaucratic government and private institutions demands a service which
ment capital is used to establish a motel service, hamburger or fried chicken
has as its focus the meeting of the whole needs of the home resident. Such frac-
outlets across the nation. Likewise, investment capital is needed to launch home-
tionization of services prevents a community from combining services into the
maker service even if launched by a government agency. How, under govern-
most economical unit. Also, it may mean that the patient is served by and often
ment auspices, is it possible to support an advertising and public education
confused by more than one agency. For persons living in the highly metropolitan,
program? Can such costs be assessed as a fixed portion of the costs of operations,
densely populated areas, specialized services may be offered economically. How-
as is often done commercially?
ever, this is not possible in the vast areas of rural America or even in the
suburbs.
MATCHING MONEY GRANTS ARE NOT SUFFICIENT
(4) "Momism" or "Anyone can do it" or "It just takes common sense and
willingness to work"-Such attitudes prevail in the top administration of many
Federal funds for homemaker-home health aide service are available under
educational, health, welfare and manpower programs. Home services tend to
Social Welfare on a three to one matching basis. These funds are unlimited SO
be taken for granted by family members and assumed to be "free". Also, there
that it may properly be asked why states do not make more use of this subsidy,
is no greater reward to the indigenous homemaker for giving excellent rather
particularly in light of the evidence that home health care is less costly than
than poor home care. The work ethic, which is more applicable to the market-
institutional care. One state welfare director answered this by saying that he
place, is peculiarly not SO readily applicable to the homemaker's role. Thus, the
was convinced his state could save many times its cost in reduced payments for
importance of training, professional and occupational orientation, and wage
institutional care by using homemaker-home health aides but, it had never been
scales with fringe benefits is not readily recognized.
possible to get sufficient funds to launch homemaker-home health aide programs
(5) Domestic "hangup"-The tendency to identify the work of a homemaker
and furthermore it did not appear that it would be possible in the near future.
with that of a maid, cook or housekeeper has discouraged people from entering
Funds have also been available under Title III of the Older Americans Act for
the field, retarded the development of a distinctive occupational title, and low-
developing homemaker-home health aide services. However, these require match-
ered the dignity of this worthy profession. The standards recently announced
ing. At least two homemaker-home health aide projects in one state collapsed
by the National Council for Homemaker-Home Health Aide Services, Inc. hope-
because of (1) the matching requirements, (2) failure to develop realistic fee
fully will gain national approval and thereby meet this problem.
schedules, and (3) dedication to provide service to those most needy-thus gen-
(6) Third party buyers of services have been slow to recognize the bargain
erating no income.
inherent in home health services. Instead, the fear of building into insurance
Implementation grants with assurance of funding for at least a five year period
or government programs a service for which there is lacking actuarial experi-
are needed. Such implementation grants should provide for advertising, promo-
ence has been allowed to overshadow the obvious cost saving benefit of home
tion, training, supervision, and subsidization of newly launched programs.
over institutionalized care. The orientation of the HMO concept such as is
described by Representative Bill Roy in the November 11, 1971 Congressional
MYOPIC VIEW OF MANPOWER
Record (H10974) with his introduction of H.R. 11728, should bring into proper
focus the value of homemaker-home health aide in the delivery of health services.
Manpower is customarily measured in terms of prevailing occupations and
(7) Commitment-perhaps the greatest need is for a positive commitment
numbers of persons in the labor force. Unemployment statistics evoke greater
to launch a program that will make the services of competent, trustworthy and
public concern than do situation reports on persons not in the labor force.
professional homemaker-home health aides, working under the supervision of
That is, there is a proper national concern over the labor force, but an inade-
professional agency personnel, available to all persons in need regardless of
quate concern over that population group not counted among the labor force.
Nonparticipation in the labor force by 42 million females in 1971 is the reser-
their age, color, religion, sex or income.
voir of latent talent which can be utilized for homemaker-home health aide
The recommendations of the Homemaker-Home Health Aide Special Concerns
Session, as published in the 1971 White House Conference on Aging report, if
service. (Table A-28, Jan. 1972, Employment and Earnings, USDL) Less than
half of the females 16 years old and older are in the labor force. School and
implemented, will bring this about.
family responsibilities are legitimate reasons for the younger women not par-
ticipating in the labor force. But for those over 45, when child bearing challenges
ECONOMIC ASPECTS HAVE BEEN UNDEVELOPED
are less time consuming, "home responsibilities" was given most frequently as
The commitment to develop and provide a service must be accompanied by
the reason for non participation in the labor force. It increased with age: 40%
economic measures needed to launch this new service. Can it be sold to the nation
of those 45-54 years of age; 44% for those 55-59 years; 55% for the 60-64 year
as a franchise operation? Is franchising the most efficient method of bringing
olds and 76% for those 65 and over in years. Since home making is not a full
into being such a new service? Will this produce desirable results? How can the
time job, it would appear that many of these women are eligible for part time
government health and welfare agencies launch a significant new program such
if not full time employment. It is pathetic that among those who "do not want
as this? What funding systems would be required to develop home health care?
work now", a large proportion gave as their reason for not seeking work "think
And, more basically, if home health care is SO advantageous to the patient and
they cannot get job". (Table A-30, Ibid)
economical to the agency purchasing such service, what is it that has inhibited
Homemaker-home health aide service could tap this reservoir of manpower
its growth? These and other questions need the benefit of serious research, more
not presently in the labor force and thereby have several desirable effects:
specifically:
(1) It could relieve the pressure on the limited supply of professionals
1. Cost data are needed not only on the operations of home health care but on
in the current health system.
alternative methods of providing equivalent service to people.
(2) It would extend the availability, accessibility, and continuity of health
2. Experiments are needed which will generate data useful in assessing the
care services by reducing the communications and transportation gap between
merits of utilizing home health services in lieu of institutional care.
the patient and the physician. For example, most (77%) of the homemakers
3. Experimentation with new and different methods of financing should be ex-
trained in Kansas had drivers' licenses and were able to provide transportation
plored as recommended by the Special Concerns section of the White House Con-
for the elderly. Furthermore, with their being present at the doctor's office or
ference on Aging Report (p. 124). Historically, services have been priced SO low
hospital they were able to assist the elderly in more effective follow-up home
care.
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69
(3) Home care would better utilize the nation's capital outlay in homes
survey, this number is expected to exceed 148,000 by 1980. Data from the Na-
and not require additional capital outlay for the construction of new facilities.
tional Institute of Neurological Diseases and Stroke reveal that at least 20 per-
(4) The money flow would increase the gross national product and increase
cent of those citizens with stroke have an associated impairmen of langauge.
the tax base to support worthy programs.
The National Institute of Neurological Diseases and Stroke estimates there are
(5) Home care would bring a sense of participation and awareness on the
over 600,000 adult Americans with severe language impairment (aphasia).
part of the mature women who now is not fully occupied at home but who could
Data are not available on the prevelance of communicative disorders of those
gain a sense of self-worth and dignity by working and develop a better appre-
aged Americans who, because of poor health or other reasons, are confined to
ciation for how others in America live through serving them as a homemaker.
their places of residence. One can safely assume that the occurrence of com-
municative disorders in the home-bound aged population is no less than the oc-
VOLUNTEERISM
currency of communicative disorders in the general aged population. Indeed, the
The magic of volunteer support may be tarnished when applied seriously in the
incidence may be higher because those debilitating diseases of the aged that re-
area of homemaker-home health aide service. Some of the work of the aides is
sult in confinement to the home (e.g., cancer and stroke) are often accompanied
equivalent to friendly visiting, baby sitting, reading to the blind, helping with
by communicative disorders.
shopping. But much of it is hard work While we support volunteer efforts, we
There are very few home health agencies known to the American Speech and
question whether it can offer a viable solution to the need for the development
Hearing Association that maintain full-time staff speech pathologists and/or
of wage-paying community service.
audiologists. Although many such agencies have consultative services available
to them on a part-time contract basis, the extent to which speech, hearing and
TRAINING-THE DEVELOPMENT OF
language services are being provided to the communicatively handicapped home-
bound aged is not known.
Probably the greatest danger which lies in the immediate future of homemaker-
Current policies of the Medicare program are restrictive SO that rehabilitative
home health aide service is the possibility of its rapid acceptance, this could come
services are often denied those who need them most, i.e., elderly, indigent, home-
quickly with its incorporation in medicare, medicaid or other health programs
bound individuals. Under the Medicare program, speech, hearing and language
which will then make such a great demand that there will be created "instant
services are available to the home-bound aged citizen only when all the follow-
homemakers". It is our conviction that training programs should be instituted
ing conditions are met:
immediately in anticipation of the forthcoming demand. Training is necessary
1. The individual has had prior hospitalization.
because of the technological changes that have taken place with which the older
2. The services are provided through a home health agency.
women are not familiar. Secondly, women find training necessary to prepare them
3. The services are related to a health condition that required prior hospital-
to manage the homes of other people, even though they may have managed their
ization.
own homes well. Thirdly, the trainees need to become aware of specialized pro-
When all the above conditions are met, rehabilitative services (including oc-
blems which have not been part of their own life experiences. They must learn
cupational therapy, physical therapy, nursing, and speech and hearing services)
to be able to organize the work and get it done within a limited time, but yet be
are generally limited to a total of 100 visits during the 12 months immediately
flexible. And finally, training is necessary because one of the valuable services of
following hospitalization.
a homemaker is to work herself out of a job by having educated the patient or
If the patient does meet the above criteria, but fails to meet the definition under
client to serve himself. This is perhaps the most distinguishing feature between
Medicare of what constitutes "home-bound" (primarily physically nonambula-
the role of the homemaker and that of a domestic. The domestic hopes to continue
tory), speech, hearing and language services are obtainable under Medicare only
in the job forever, whereas the homemaker wishes to work out of a job and leave
through out-patient departments of participating hospitals.
the patient self-sufficient.
These restrictions may be better appreciated if the following three hypothetical
The American Home Economics Association has among its membership many
examples are considered:
members in schools, departments and colleges of home economics who would be
1. If a patient is hospitalized for cancer of the larynx, subsequently under-
anxious, able and willing to assist in the training of homemaker-home health aides
goes a laryngectomy, and then is discharged to his home, Medicare will provide
and in the supervision of their work.
speech therapy only if he returns to the hospital as an out-patient. If the hospital
In summary, we see the need:
where the surgery was performed does not provide out-patient speech therapy,
(1) To implement immediately training centers throughout the nation.
the Medicare program will not pay for needed speech therapy even though it
(2) for R&D grants on the economic and manpower problems,
may be available in the community from other resources such as community
(3) for strict adherence to the standards published by the National Coun-
speech and hearing centers, university clinics, or private practitioners. This
cil for Homemaker-Home Health Aide Services, Inc., and
comes about because only the hospital or extended care facility is defined under
(4) for grants to states to initiate services.
the Medicare program as a "primary provider."
2. If a patient is hospitalized for stroke and ait the time of discharge from
the hospital to his home is still handicapped by an impairment of language and
further, he is unable to leave his home because of residual paralysis, he would
ITEM 8. LETTER AND MATERIAL FROM AMERICAN SPEECH AND
be unable to obtain speech and language therapy unless a home health agency
HEARING ASSOCIATION, TO MISS BRAHNA TRAGER
in that community is able to provide therapy. This would maintain even though
rehabilitative services were available to him from other clinical services pro-
DEAR MISS TRAGER: In a statement prepared for the White House Conference
grams in the community that maintain home-bound programs, e.g., community
on Aging the American Speech and Hearing Association described the communica-
speech and hearing clinics, rehabilitation centers, and private practitioners.
tions problems of the aged and significant issues regarding the delivery of hear-
3. If an elderly patient is diagnosed as having a medical disorder sufficient to
'ing, speech and language services to elderly citizens. A copy of that statement is
require him to stay at home but not sufficiently severe to require hospitalization,
enclosed with this letter for your information and for inclusion in the special
and it is determined that home-bound rehabilitative services would improve his
report on home health services now being prepared by your office. We hope this
health or at least maintain it at the current level, he would be ineligible for
letter will be included in that report as well.
rehabilitative services under Medicare because hospitalization was not required.
According to national health surveys, it is conservatively estimated that
Preventive health services are thereby ruled out under current Medicare pro-
between 13 and 25 percent of the population over age 65 have a bilateral hearing
visions.
loss of a magnitude sufficient to seriously restrict understanding of speech and,
The American Speech and Hearing Association supports the concept that a
thus, seriously restrict social efficiency. An estimated 90,000 individuals over
national health care program for the aged must incorporate a delivery system
age 65 are speech handicapped and, according to a United States national health
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tomorrow's aged, having been exposed to today's noise levels, will present hearing
that will assure the distribution of all those health services needed to the home-
disorders in even greater numbers than previously predicted.
bound as well as those able to leave their homes. It is our opinion that any na-
The problem of dysacusis (auditory discrimination deficit resulting in distor-
tional health care program should include a system for preventive care. The
tion of audible speech) must also be taken into account when citing the incidence
American Speech and Hearing Association, therefore, urges that Medicare bene-
of hearing impairment. In a report prepared by the Subcommittee on Human
fits be expanded to permit greater utilization of all rehabilitative services to
Communication and Its Disorders, National Advisory Neurological Diseases and
the home-bound aged. Those benefits should include speech, hearing and language
Stroke Council, the following is stated:
services by qualified speech pathologists and audiologists upon referral of phy-
"The prevalence of dysacusis, or the garbling of audible speech, has not been
sicians or other health related professionals associated with home health agencies
studied systematically on a large enough population to allow any generalizations
or with any other agencies with which the aged citizen comes in contact. It is
regarding its occurrence in the population at large. Methods of determining
essential that all community resources be utilized fully in providing care to the
dysacusis involve tests for speech discrimination which have not been rigorously
aged whether that care is provided in the home or in an out-patient facility.
administered on a mass scale. Thus, only three comments can be made at this
Therefore, we believe that extensions of Medicare programming or new pro-
time. First, dysacusis is often a concomitant of loss in sensitivity. Second, it can
gramming for the aged should permit direct participation by appropriately ac-
also either occur independently thereof or it may appear in conjunction with a
credited agencies and appropriately qualified individuals to provide services to
threshold deficit too mild to be handicapping by itself. Lastly, a great many
the aged at home. Further, we urge that rehabilitation centers, community
elderly persons exhibit a combination of dysacusis and a characteristic high
speech and hearing centers, private practitioners and other such health facilities
frequency loss in sensitivity. If we include this composite presbycusic malady in
be qualified as primary providers in order to fully utilize existing professional
our tabulation, the prevalence of handicapping hearing impairment is probably
manpower.
at least as high as one in four among persons over sixty" (2, p. 15).
For services in speech, hearing and langauge the Medicare regulations already
define qualified individuals as those speech pathologists and audiologists who
Speech
hold the Certificate of Clinical Competence of the American Speech and Hearing
According to a U.S. National Health Survey, an estimated 90,000 individuals
Association or its equivalent. The American Speech and Hearing Association
over age 65 are speech handicapped. By 1980, this number is expected to exceed
also maintains a voluntary national accrediting program for clinical service
148,000. Cancer is a prevalent condition among the elderly. Cancer can require
programs in speech and hearing.
and necessitate the removal of the larynx, resulting in total loss of voice. Cancer
The American Speech and Hearing Association thanks the United States
may also necessitate removal of the lungs and/or of maxillofacial structures
Senate's Special Committte on Aging for this opportunity to express its con-
important to the production of speech. In addition, deterioration of articulation
cerns for the many thousands of elderly speech and hearing handicapped Amer-
proficiency and voice impairments often result from diseases of, or impairment to,
icans it serves.
the central or peripheral nervous system as well as a result of severe hearing
(Enclosure.)
impairment.
COMMUNICATION PROBLEMS OF THE AGING: A POSITION PAPER¹
Language
At the present time, there are no definitive data posting the incidence of lan-
Disorders of communication are an important concern as related to health,
guage disorders in the aging population. Vascular lesions, cerebral trauma or
education and welfare. Communication includes hearing, language comprehen-
tumors are prevalent conditions among the elderly. Often a significant reduction
sion and usage, and speech. Disorders of communication would include hearing,
in language function (aphasia) is a result of such conditions. According to the
speech, language, vision, reading, writing and various combinations of these
National Institute of Neurological Diseases and Stroke, an estimated 600,000
factors. The complexity of communicative impairment is further compounded
adult Americans have aphasia (2, p. 16). The inability to comprehend and use
when the impairment occurs secondary to, in association with, or as a result of,
linguistic symbols as a result of neurological impairment will significantly reduce
other conditions.
the individual's ability to listen, read, write, and/or talk. Loss of the ability to
"In general, various kinds and degrees of hearing and speech problems may
communicate effectively can produce severe concomitant social, emotional and
be associated with a variety of other conditions: all levels of mental subnormal-
vocational handicaps.
ity, emotional stability, psychotic states, cerebral palsy and various forms of
brain injury or disturbances of the central nervous system, problems of anatomic
PROVIDERS OF SPEECH, HEARING AND LANGUAGE SERVICES
development, and various degrees of social deprivation or behavioral maladjust-
ment" (3, p. 7).
Definition of Speech Pathology and Audiology
The effects of communication impairment may profoundly affect the occupa-
Speech pathology and audiology is the professional discipline basically con-
tion, health and psychosocial adjustment of the communicatively impaired adult.
cerned with the systems, structures, and functions that make human communica-
Thus, it is the responsibility of a total health care program to provide evalua-
tion possible; with the causes and effects of delay, maldevelopment or disturbance
tion, treatment and management of communicative impairments in the adult.
in human communication; and with the identification, evaluation, and rehabili-
taiton of individuals with speech, hearing and language disorders.
INCIDENCE OF HEARING, SPEECH, LANGUAGE IMPAIRMENTS IN THE AGING POPULATION
Speech pathology and audiology is thus both a discipline and a profession.
As a discipline, it is concerned with the basic scientific study of the processes of
Hearing
individual communication, with special reference to speech, hearing and lan-
According to National Health Surveys, it is conservatively estimated that be-
guage. It encourages research on disorders of human communication. It aims to
tween 13 and 25 percent of the population over age 65 have a bilateral hearing loss
provide a fund of substantive knowledge as a basis for the practice of the disci-
of a magnitude sufficient to seriously restrict understanding of speech, and, thus,
pline. It therefore concerns itself with the development and evaluation of clinical
seriously restrict social efficiency. Via census translation, there are currently over
tation of individuals with speech, hearing and language disorders.
two and one-half million elderly American citizens who have a significant bilateral
As a profession, its practitioners provide professional services for persons
impairment. The number will increase as the population grows and longevity
whose educational, vocational, personal and social functioning and adjustment
becomes greater. According to census projections for 1980, over three million of
are impaired by disorders of speech, hearing or language. The diagnostic and
the nation's aged population will have bilateral hearing impairments.
therapeutic services needed by persons with such disorders are made available
Hearing loss as a result of aging (presbycusis) is not a condition that neces-
through a variety of clinical settings, rehabilitation centers, programs of special
sarily exists alone. It may be superimposed on other kinds of hearing loss. For
pupil services in schools, and private practice facilities.
example, damaged hearing due to noise is now recognized as a disabling possi-
Descriptions of the duties of the Speech Pathologist and Audiologist are pre-
bility in many industries and trades. There is an increasing probability that
sented in the Dictionary of Occupational Titles (1) as follows:
1 Prepared by the American Speech and Hearing Association.
72
73
"Speech Pathologist (profess. & kin.) 079.103. Diagnoses treats and per-
SIGNIFICANT ISSUES FOR THE DELIVERY OF HEARING, SPEECH AND LANGUAGE SERVICES
forms research related to speech and language problem Diagnoses speech
and language disorders by evaluating etiology. Treats language and speech
The delivery of hearing, speech, and language services to the elderly con-
impairments such as aphasia, stuttering and articulatory problems of organic
sumer is recognized as an integral part of a comprehensive health care system.
and nonorganic etiology. Plans, directs and conducts remedial programs designed
In order for these services to be rendered efficiently and effectively to the
to restore or improve communication efficiency. Provides counseling and guid-
communicatively impaired elderly consumer, the resolution of certain issues
ance to speech and language handicapped individuals. May act as consultant for
is mandated.
educational, medical, and other professional groups. May teach or direct scien-
Issue 1: Manpower Development
tific projects concerned with investigation of biophysical and biosocial phenomena
associated with voice, speech and language. May conduct research related to de-
A significant problem exists in manpower development to provide person-
velopment of diagnostic and remedial techniques or procedures, or design of ap-
nel qualified to render hearing, speech and language services to the elderly
paratus. May be employed in university, hospital, public school, or community or
consumer. The growth of the population, as well as the continuous increase
governmental organization, or may engage in private practice. See Audiol-
in average longevity, will result in an increased number of aged consumers
ogist for one who specializes in diagnosis and treatment of auditory and lan-
having communicative impairments. Since additional personnel must be trained
guage problems.
to meet the demand for delivery of services a substantial increase in funds
"Audiologist (profess. & kin.) 079.108. Specializes in diagnostic evaluation,
to graduate education programs in Speech Pathology and Audiology is vitally
habilitative and rehabilitative services, and research related to hearing: De-
needed.
termines range, nature, and degree of hearing function related to patient's
Issue 2: Manpower Training
auditory efficiency (communication needs), using electroacoustic instrumenta-
Increasing the number of qualified personnel to render hearing, speech and
tion, such as pure-tone and speech audiometers, and galvanic skin response
language services is not the sole solution in meeting manpower needs. Emphasis
equipment. Coordinates audiometric results with other diagnostic data, such as
must be placed upon the training of personnel in type as well as number. The
educational, medical, social and behavioral information. Differentiates between
aging process produces special psychological, physiological and social problems
organic and nonorganic hearing disabilities through the evaluation of total
that mitigate against the direct application of evaluation, treatment and man-
response pattern and use of such acoustic tests as Stenger and delayed speech
agement procedures appropriate for a younger population. Personnel must be
feedback. Plans, directs, and conducts or participated in habilitative and rehabil-
trained to render services as needed for the communicatively impaired geriatric
itative programs including counseling, guidance, auditory, training, speech read-
individual. Thus, substantially increased financial support is necessary for the
ing and speech conservation. May conduct research in physiology, pathology,
training programs to develop curricula and train personnel to serve the needs
biophysics, and psychophysics of auditory systems. May design and develop clini-
of the communicatively impaired adult.
cal and research procedures and apparatus. May act as consultant to educational,
medical and other professional groups. May teach art and science of audiology and
Issue 3: Research
direct scientific projects. May specialize in fields such as industrial audiology,
A dearth of research data exists in relationship to the plethora of research
geriatric audiology, pediatric audiology, and research audiology. See Speech
needs. Hearing, speech and language services have long been directed to the
Pathologist for one who specializes in diagnosis and treatment of speech and
younger populations. Comprehensive information concerning the special prob-
language problems.
lems of the aged in evaluation and treatment of communication impairments
The American Speech and Hearing Association
is not available to the speech pathologist, language pathologist, and audiologist.
A report by the National Institute of Neurological Diseases and Stroke (2) lists
The American Speech and Hearing Association (ASHA) has a membership
fifty-four areas of research needs in audition and its disorders alone.
of almost 13,000 and is the national professional organization to which most
In another federally sponsored report entitled Human Communications: The
speech, hearing and language specialists belong. The basic qualifications for
Public Health Aspects of Hearing, Language and Speech Disorders, the follow-
entrance into the profession have been established by ASHA and include the
ing is essential for comprehensive community health program development:
completion of work for a Master's degree. The American Speech and Hearing
"Further investigation is required into the identification, evaluation, treat-
Association further recognizes the completion of academic and experience re-
ment, of communicative disorders of the aged. Multidisciplined studies of the
quirements for clinical competency by awarding a certificate attesting to the
medical. social and psychological aspects of aging are necessary for specifica-
holder's fulfillment of the requirements. The American Speech and Hearing
tion of the meaning of habilitation in geriatrics and for the development of a
Association has been recognized by both the National Commission on Accrediting
philosophy regarding communicative disorders of the aged (3, p. 24).
and the U.S. Office of Education as the national organization responsible for
accrediting university programs offering graduate education in speech pathology
Issue 4: Education
and audiology.
Information concerning communicative disorders is necessary for both con-
At the present time, there are 8,160 individuals who hold the Certificate of
sumers and public health personnel. One result of Project FIND (5) was the
Clinical Competence in Speech Pathology and 1,627 who hold the Certificate
discovery that many aged individuals were not aware of available services or
of Clinical Competence in Audiology from the American Speech and Hearing
their entitlements to service. All too often agencies wait for the aging to seek
Association. Relative to total manpower, the number of speech pathologists and
them out. Thus, hearing, speech and language services are often not delivered
audiologists who hold the Certificate of Clinical Competence in the United
because the consumer does not know they exist rather than through a lack of
States averages approximately 5.0 per 100,000 population.
need.
Qualifications for Providers of Speech and Hearing Services
The National Institute of Neurological Diseases and Stroke's report strongly
emphasizes the informational need of public health officers regarding services
Services by speech pathologists and audiologists are presented under Medic-
rendered to the communicatively impaired.
aid, Regulation Section 249.10. Services for individuals with speech, hearing
"The broad subject of communicative disorders, their problems and handling,
and language disorders are defined as those diagnostic, screening, preventive, or
should be an integral part of every education program in public health and hy-
corrective services provided by or under the supervision of a speech pathologist
giene. (Just as acquaintance with public health measures should be part of
or audiologist in the practice of his profession. A speech pathologist or audiolo-
the education and training of every student of communicative disorders.) This
gist is defined in the regulations as one who has been granted the appropriate
education may be of three general types: (1) Education in public health meas-
Certificate of Clinical Competence by the American Speech and Hearing Asso-
ures for the specialist in communication, (2) education in the communicative
ciation, or who has completed the equivalent educational requirements and work
sciences for public health officers, and (3) short-course programs to acquaint
experience necessary for such a certificate, or who has completed the academic
service personnel with the public health aspects of communicative disorders"
program and is in the process of accumulating the necessary supervised work
(3, p. 24).
experience required to qualify for such a certificate (4).
74
75
Issue 5: Regulations
person in the home can make the difference between a family member remaining
In a comprehensive health care program, delivery of services to the consumer
at home to provide continuing care for that person or becoming a part of the labor
need not (and should not) be unduly restricted by administrative barriers. Pro-
force outside the home.
visions must allow for comprehensive delivery. Regulations for delivery service
It has long been recognized that patients recovering from acute illnesses and
should provide for multiple entry points into the health care program and direct
receiving restorative care require occupational therapy as an integral part of
reimbursement to the provider for services rendered. In addition, provisions for
their rehabilitation regime. Thus, in the hospital the services of the occupational
service to the communicatively handicapped geriatric should be standardized
therapist who treats the partial paralysis of a stroke patient by designing and
among states SO that service delivery is not determined solely by accident of
fabricating a special arm or leg splint, for example, are provided under the
geography.
Medicare law.
However, when the hospital patient is discharged, any needed home health
services by an occupational therapist can only be provided, under the present
ITEM 9. STATEMENT BY THE AMERICAN PHYSICAL THERAPY
Medicare law, if the patient also needs skilled nursing care or physical therapy
ASSOCIATION
or speech therapy.
This is a critical error in the law, interfering with local professional judgment
POSITION ON PRIORITIES IN THE HEALTH CARE SYSTEM
in providing health care to Medicare patients. The physician should be free to
choose whatever recognized form of treatment he feels will meet the patients'
In concern for the health of the American people, health care is second in prior-
needs most effectively. Interposing artificial requirements that certain treatment
ity only to an environment that contributes positively to human health.
forms must first be instituted before the desired and needed type may be pro-
Within health care, the American Physical Therapy Association advocates
vided interferes with patient care and leads to higher costs rather than savings.
certain priorities which, if adopted by appropriate policy-making bodies, would
In many cases occupational therapy logically comes later in the individual's
promote the right of all persons to have equal access to and equal availability
treatment, translating skills relearned into functional ability.
of high quality health care services.
In practice many patients are undergoing an occupational therapy regimen
These priorities are directed to principles and mechanisms which should per-
at the time they are discharged from the hospital or extended care facility and
vade all elements of the health care system in the United States.
returned to their homes for completion of the treatment program there. Under
The health care system should utilize existing public and private services,
present law, one of three things must happen: 1) the patient must be retained
facilities, and agencies in ways that will economically make comprehensive health
in the hospital, at additional cost, until the treatment is completed, or 2) he must
care available and accessible to all people.
be sent home and the needed treatment halted, or 3) some subterfuge must be
Alternatives to existing methods and organizations for delivering health care
found, such as instituting one of the presently required three types of service
should be encouraged when they demonstrate reasonable predictability of con-
even if not needed, in order to complete the treatment at home.
tributing to the availability and accessibility of comprehensive health care.
This problem has repeatedly been brought to the attention of Congressional
Preventive health care services and public education in personal health care
committees concerned with the Medicare law, but as of this date, no changes have
should be made an integral part of the health care system.
been recommended.
The health care system should be accountable to the public and should include
Chronic illnesses without prior hospitalization are not covered by the Medicare
effective mechanisms for peer review, multidisciplinary review, and consumer
program. Thus the chronically-ill homebound older housewife who might benefit
participation in policy and audit of the system.
from instruction by an occupational therapist in special techniques of preparing
A sufficient number and variety of health care personnel should be educated to
meals and managing a home from a wheelchair cannot receive this service under
meet continuing health care needs, and encouragement should be given to all
Medicare. Nor can the patient over 65 who is losing his sight obtain help and
health care personnel to provide services in areas of the nation where compre-
advice in the arrangement of his room or household from an occupational
hensive health care may not be available.
therapist with Medicare reimbursement. These are but two examples among
The availability of health screening, preventive and early care, and timely
many that might be cited.
referral for more extended care should be expanded by recognizing and enhancing
To overcome this deficiency in the Medicare program, attention should be
the existing competencies of a variety of health care personnel.
given to providing consultation services by occupational therapists to the staff
Methods of financing the health care system should take optimum advantage
members of home health agencies, extended care facilities and nursing homes.
of both public and private funding mechanisms to support the full scope of health
By such consultation the staff members could be instructed in providing this type
care and to remove inequitable barriers to receiving necessary health care
of assistance to chronically ill persons.
services.
Governing boards of health agencies and facilities as well as the utilization
review committees for insurance and government programs should include
representatives of occupational therapy. In this way, their expertise could be
ITEM 10. STATEMENT FROM THE AMERICAN OCCUPATIONAL
effectively utilized both in program management and in decisions involving in-
THERAPY ASSOCIATION, MARCH 14, 1972
dividual cases.
Occupational therapy is the art and science of directing man's engagement in
selected activities in such a way as to promote and maintain his health, diminish
dysfunction and pathology, and enhance his capacity to adapt and to function
with increasing satisfaction to self and others. The occupational therapist is
concerned with the effects of activity upon the whole person, how the individual
responds to the environment in life tasks and adapts his behavior in social rela-
tionships and all the meaningful activity he undertakes.
For more than 50 years, trained occupational therapists have helped speed
recovery for the aged and have made a unique contribution to the care of the
aged who are homebound. Occupational therapists provide services for a wide
range of illnesses, injuries and disabilities, and they function at all levels of
care-in the hospital, nursing home, extended care facility, office, clinic and home.
Adjustment to the home environment and independent of function in the home
are primary occupational therapy goals. The independent functioning of the older
74-331 0-72-6
77
of beds for emergency situations. The result has been the establishment of a
number of hospital-based home health care agencies, as well as agencies affiliated
with one or more hospitals.
Currently, some of the major private third-party insurance plans include in
their coverage the cost of posthospitalization home health care services, and
in a few cases include prehospitalization services. Among prepaid group practice
Appendix 2
plans, Kaiser Permanente in Oregon pioneered in demonstrating the efficacy of
including home care programs among the services provided its membership.
EXCERPTS FROM STATEMENT BY SENATOR ALAN CRANSTON, IN
Home health care services are now included in the benefits provided by about
one-fourth of the prepaid group practices in the United States.
SUPPORT OF S. 3355, CONGRESSIONAL RECORD, SEPTEMBER 9, 1970
Congress at an early date recognized the potential of home health care services
During committee consideration of S. 3355, I also introduced a number of
to meet these new demands on the health care delivery system. In adopting the
amendments which give full recognition to the important role home health care
medicare act, title 18 of the Social Security Act, Congress in 1965 included home
can and should play in the Nation's medical care system. I was very pleased
health care service as a reimburseable service under both part A, "Hospital
that all were accepted by the members of the committee.
Insurance Benefits for the Aged," and part B, "Supplementary Medical Insurance
These amendments, first, include home health care programs as an integral
Benefits for the Aged." These provisions made it economically feasible for in-
dividuals over 65 to utilize home health care services and at the same time pro-
part of regional medical programs; second, place research and demonstration
projects in home health care on an equal priority with those health care
vided some assurance to those wishing to develop such services in the community
methods highlighted as eligible for grants awarded for research and develop-
that there would be a demand from patients with financial ability to pay for
the services SO that investment in home health care systems would be eco-
ment in health services delivery; and third, assure that in planning for the
delivery of health services at both the State and area level, full consideration
nomically viable. At the same time, Congress provided, through special appro-
be given to the potential of home health care services to meet health needs.
priations in 1966 and 1967, seed money to foster the establishment of home health
Because of the importance which I attach to home health care as a means of
care agencies which could meet the certification requirements of medicare.
solving a number of deficiencies in our health care system. I would like to speak
These relatively recent developments have changed the concept of home health
extensively about the history of this medical technique and the unrealized
care and have brought about the creation of new patterns of delivering that care.
opportunities it offers for many, many sick and disabled persons with no alter-
Whereas originally, home health care was limited to the provision of a single
service-such as a visiting nurse, or a homemaker aide-today the emphasis is on
native to becoming institutionalized to receive health care.
Mr. President, among various systems of health care delivery developed and
providing multiple services.
improved upon within the past few years, one of the most promising yet least
Special impetus to the development of a more complex home health care agency
perfected and recognized is the system of home health care. Although home
was provided by medicare through requirements that only those agencies pro-
health care is certainly not a novel program-in the United States, the first or-
viding nursing plus one other service-either physical therapy, occupational
ganized program was established in 1796-several more recent developments
therapy, speech therapy, medical social services, or home health aid services—
have created a demand that these programs provide highly sophisticated, ef-
could be certified for medicare participation. However, of the over 2,100 certified
ficient, medical services as a complementary system to the impatient and out-
home health agencies only 78 provide the full range of services suggested but not
patient services generally thought of as the basic health delivery system.
required by the certification requirements. And over half of the agencies are at
These recent developments include medical advances which have made it
the minimum level, limiting their services to a nurse plus only one of the five
other services.
possible to save many lives that in previous decades would have been lost to dis-
ease and accidents. In addition, the average lifespan has vastly increased due
I wish to note that as with any developing new field, there have been some
to improved medical techniques and increased knowledge in the treatment and
problems and deficiencies in home health care systems. Many existing agencies
prevention of disease. The result has been a much larger population, with a
were hurriedly established in 1966 and 1967 following the enactment of medicare.
higher proportion of elderly individuals who are particularly subject to chronic
Consequently, they were not properly planned and failed to develop close relation-
illness, and an increase in the number of individuals of all ages who are tempo-
ships with other medical services in the community. Recent concerns have been
rarily or permanently disabled. Many of these individuals are not ill to the
expressed by the Social Security Administration about abuses in the home health
extent that an acute care hospital bed or full-time institutional care is needed.
programs, and an instructional release has been issued to their carriers and
intermediaries emphasizing the legislative requirements governing reimburse-
But they are not ambulatory enough to utilize outpatient facilities, and physi-
ment for home health care services. The intent of these provisions is to permit
cian-directed medical care is essential to their recovery.
the reimbursement for home health services only where such services are deter-
A second major development in recent years has been the sharp increase in
mined by the physician to be essential to the patient's recovery and are a less
the cost of hospital care, due partly to the expense of acquiring and staffing
the new equipment and services modern medicine has produced and partly to
expensive alternative to institutional care.
I strongly endorse the principle and requirement in the Social Security Act
increased operating costs and increased construction and renovation costs.
that any treatment program carried out by home health agencies must initially
Unfortunately, the cost of delivery hospital care has increased at a higher
rate than the overall cost of living. These higher hospital expenses are included
be prescribed by a physician after a visit to the homesite and should be actively
in overhead costs and transferred to the patent in the daily charge for his
monitored by a physician through continued personal, direct contact with the
hospital bed. Thus, the hospitalized convalescent or chronically ill patient share is
patient.
An important home care milestone is the development in a few communities
the burden of the cost of expensive acute care even though he is not utilizing it.
of a comprehensive pattern of home health service-called the coordinated home
A third factor encouraging the development of home health care service has
care program. This type of program holds a tremendous potential for meeting
been the increase in the utilization of hospital beds. The growth of third party
many of the deficiencies of existing health delivery systems. These programs
private insurance plans and the enactment of medicare has made hospitaliza-
coordinate a wide range of home services around the needs of an individual
tion possible for many who in previous years were unable to afford it when they
patient as prescribed by his physician; they are centrally administered; and
needed it. At the same time, most of these insurance plans provide reimburse-
ment only for services performed during hospitalization, which restriction has
operate on a team concept in providing multidisciplinary services which can
include medical, dental, nursing, social, educational, or other related services.
served to increase hospital utilization substantially. As a result, many hospitals,
particularly in urban areas, are operating at 95 percent capacity. Accordingly,
Ideally, such a coordinated home care program has relationships with other
services in the community, such as hospitals-to assure immediate availability
communities and hospitals have been pressed to find methods of relieving the
hospital overcrowding and to insure the availability of the necessary number
of hospital inpatient services when needed-laboratory and radiology services,
(76)
GERALD
78
79
occupational and physical therapy services, psychological services, educational
services, and many, many others. Under these circumstances, the program be-
where the transfer of a patient to or from a hospital or other medical facility
comes a full partner in the community system of health and social services and
would be most economical, as well as medically productive, both for the institu-
tion and the patient and his family. These studies need not be confined to the
provides those types of services which can both be provided most efficiently in a
more complex home health care systems. Indeed, the recent report of the staff
home situation and at the same time be closely coordinated with more com-
plex systems for the provision of necessary services beyond the scope of the
to the Senate Committee on Finance on "Medicare and Medicaid, Problems, Issues
home health care program. Unfortunately, the number of home care agencies
and Alternatives," recommended consideration of extending medicare benefits
which have developed this comprehensive, coordinated approach is still very
to include homemaker costs in home health coverage as an alternative to more
costly institutional care. The report stated:
small.
Despite the progress I have outlined, much still needs to be done in this in-
"Many physicians and a number of health insurers have pointed out the pres-
sure for continued hospitalization of a patient for several days more than medi-
creasingly important field:
First. The distribution of home care agencies throughout the country is very
cally necessary because of the lack of someone to assist the patient at home
uneven. Fifty-four percent of the counties in the country have no home health
with food preparation, routine cleaning, etc., during the first week or two fol-
care coverage. Many of these are rural or sparsely populated counties, but
lowing discharge from the hospital. During that period, the patient gradually
among them are 99 counties with populations over 50,000. In these 99 counties
recovers capacity for independent living and ability to meet his routine living
there are many hospitals, extended care facilities, mental health centers, a few
needs. In the absence of assistance at home during that recuperative period,
rehabilitation centers, but not a single home health care agency. Moreover, only
physicians are understandably reluctant to discharge patients and patients are
five States have home health care agencies available for 100 percent of the pop-
reluctant to go home. The present alternative to continued hospitalization is
ulation and only another 13 States have these services available for 90 to 99 per-
to discharge the patient to an extended care facility or skilled nursing home,
cent of their population. Seven have them available for 75 to 90 percent. Seven-
which, while less costly than hospital care, is still quite expensive and often
teen States have these services available for 50 to 75 percent of their popula-
encompasses more care than those patients need." (S. Rept. No. 744, 90th Cong.,
tion, and eight have these services available for less than 50 percent of their
1st Sess. Nov. 14, 1969).)
population. Thus, there is an obvious need to develop these home health care
Sixth. To encourage greater utilization of home health care services, there is
programs in many areas of the United States.
a need to find means of giving recognition and visibility to home care pro-
Second. At the same time, new methods of administration of home health
grams, both in the medical community and in the consumer's community. A
services need to be developed. Each community has its own needs, and each pat-
study undertaken in 1964 under the direction of Dr. Roger Egeberg, now As-
tern of home health care has its particular utility depending on the circum-
sistant Secretary for Health and Scientific Affairs in the Department of Health,
stances of the patient and the circumstances of the health delivery system and
Education, and Welfare, showed that 7 percent of hospital patients were medi-
other related systems of the community. In some communities, the services may
cally suited for home health care. Yet currently only 2½ percent of hospital
be hospital-based or multihospital-based; in others they may be organized inde-
patients are being discharged to home health care programs. This discrepancy
pendently of any existing medical agency in still others they might come un-
is due to the fact that many individuals in communities are unaware of the
der the auspices of a single agency or a multiagency council. A rural community
availability of home care services and many doctors also are equally unaware
may have a very limited base of health services on which a home health care
of the extent of the availability of such services, or are unaccustomed to utiliz-
program can be built, while an urban community may have such a wealth of
ing the services effectively, if at all. Fuller exposure of the medical student
programs that its challenge may lie in utilizing them fully or in overcoming
to home care programs should be included in his medical school training SO
entrenched but outmoded attitudes of providing services. Many communities
that he can learn early in his career the value of such services in the treatment
have found it difficult to break into long standing medical care patterns tradi-
of his patients.
Underutilization of home health care services is also caused to some extent
tionally around institutional care. Many existing home health care agencies
were established without adequate community planning and support and as
by the limitations of private third-party insurance plans in including such
a result or inadequate to the particular needs of that community. Thus, con-
services in their coverage. In those cases where it is covered, it usually is re-
siderable study is still necessary to develop further the various methods and
imbursable only following hospitalization. And even where covered in private
scope of delivery of home health care services and to determine means of
third party insurance plans and in medicare there is considerable under-utiliza-
matching particular models to a particular community's needs and resources.
tion of the services. A study of medicare beneficiaries who were hospitalized
Third. There is a need for adapting treatment procedures for additional dis-
during 1 year, indicated that the rate of utilization of home health care per
eases to the home health care delivery method. Significant opportunities exist
State ranged from 3.2 individuals per 1,000 hospitalized to 37.8 per 1,000, with
for treatment at home in the area of the premature infant, the mentally ill, the
the individual State average being 13.2 individuals per 1,000 hospitalized.
chronically ill, especially in the area of renal or respiratory diseases, and the
When the expensive daily costs of hospital care are considered, this wide
spinal cord injured. The child of working parents who becomes ill may require a
differential in the use of home health care services indicates that considerable
parent to stay home from work to supervise him. Home care services offer re-
savings might have been realized had home health care services been fully
sponsible care for such a child without jeopardizing the parent's job career or
utilized. For example, a Blue Cross study of some 2,500 Blue Cross, medicare,
financial stability. Home health care can be provided the terminal patient, giving
and other patients in Philadelphia indicated that by utilizing home care serv-
him the psychological boost of familiar surroundings and warm loving attention
ices for these patients, some 33,000 hospital days were saved. For each patient
SO essential to maintaining his spirits. Finally, a great potential exists in the
the saving represented an average of 13 days of inpatient hospital care, and
provision of home health care services prior to hospitalization, particularly in
the cost of home health care on the average was roughly one-half that of the
the case of elective surgery, where the first days of hospitalization may be de-
same care provided in a hospital.
voted to undergoing a battery of tests which could be provided at home at con-
Underutilization of home care services following hospital treatment can also
siderably less expense.
be attributed to a lack of adequate hospital patient-discharge planning due partly
Fourth, Experiments and demonstrations in the innovative use of allied health
to inertia in changing established patterns of care and partly to the lack of
personnel in home health care programs need to be developed. Opportunities also
financial motive for the hospital, the physician, and the family. The hospital, if
exist for the development of programs to train the nonprofessional health aide
not operating at capacity, loses revenue; the physician's reimbursable services
as an extension of the professional worker in the home setting. A special poten-
are not covered as fully as in the case of a hospitalized patient and the family
tial for expanding health manpower resources offered by home care programs is
may find home care more expensive in terms both of utilization of their own time,
the opportunity they provide to utilize on a part-time basis the professional who
and financially in that only limited coverage or none may be available-for ex-
is unable to meet the rigid schedule of a full-time job in an institutional setting.
ample, after the initial benefits are used up in the case of medicare, reimburse-
Fifth. Studies need to be undertaken in the area of cost effectiveness to de-
ment is limited to 80 percent of the costs.
velop a formula which could determine with reasonable precision the moment
80
81
In sum the potential for improvement and development of home health care
Furthermore, in the development of State plans for the utilization of section
programs is almost unlimited. Experience and recent research findings have
314(d) formula money. I believe that each State should be strongly encour-
shown that home health care programs can accelerate the rate of recovery from
aged to devote a portion of its funds to encourage the establishment of home
illness, can prevent or postpone disability, can reduce the time of hospitalization,
health services and to the support of one or more individuals whose function
can prevent rehospitalization, and can achieve these results at lower cost than
would be to provide guidance and counsel to existing home health care agencies
the same services provided in an institutional setting. Benefits to the patient are
in methods of improving their utilization within the community and meeting
considerable, economically in terms of reduced cost of care and psychologically
the specific health needs of the community. Section 1902(a) (24) of the Social
in terms of a comfortable recovery in a noninstitutional, familiar, home environ-
Security Act requires that each State provide consultative services to home health
ment. The amendments made to S. 3355 will encourage the development of new
agencies, among other types of facilities, to assist them in qualifying for reim-
and the improvement of existing home health care agencies and services.
bursement under the provisions of medicaid. Thus a nucleus already exists for
The amendments to title IX of the Public Health Service Act-sections 102
these additional counseling functions.
(b) and 104(a) of the bill-are intended to emphasize that home health care is
Greater emphasis must also be placed in the allocation of section 314(e) funds
an important method of care to be utilized in regional medical programs. The
on the establishment of home health agencies or the provision of home health
critical diseases which are the major concern of regional medical programs are
services. In particular, I recommend to the Secretary of Health, Education, and
particuarly appropriate for home care treatment. Three instances applicable to
Welfare that in granting funds for the establishment of comprehensive health
RMP are described in an article "Home Health Service-Past, Present, Future,"
care programs, such programs in all cases include the delivery of home health
in the September 1969 issue of the American Journal of Public Health, as follows:
care services. Currently, I understand, 33 primary health care projects are being
"1. In one community, program evaluation had revealed that not a single
funded by section 314(e) grants. Of these 33 projects funded for the purpose of
patient with terminal cancer had been admitted to the home although many
providing comprehensive health care to a select group or to a community, 12 fail
cancer patients had remained in hospitals until death. The following year, a con-
to mention the provision of home health care services; eight plan to refer cases
certed effort by hospital and home care staffs resulted in home care for selected
which require home care to other existing agencies, in many instances, the Visit-
patients with terminal cancer. Patient and family response was encouraging. The
ing Nurse Association; and only 13 include home health care services as a com-
patients were more at ease and required fewer sedatives and drugs for pain;
ponent of their program. My proposal would insure that in all these projects, due
the families were better able to cope with grief. In general, these terminal patients
consideration would be given to the feasibility of including home health care
were better off, both physically and mentally, in the home setting.
services among those provided by the program.
"2. Growing concern in the health field over the restricted number of patients
Considerable opportunity exists in the Hill-Burton program-support of hos-
who can receive intermittent renal dialysis in hospital centers suggests the need
pital and other health facilities construction-for encouraging such facilities
for dialysis at home. The development of a portable dialysis unit, and evidence
to utilize both prehospitalization and posthospitalization home health care serv-
that continuing intermittent renal dialysis can be carried on at home makes
ices. In awarding of grants or other forms of support for these facilities, re-
utilization of home care programs particularly pertinent to treatment of kidney
cipients should be encouraged to provide such services either directly or through
disease. (The Veterans' Administration is already carrying out home dialysis
arrangements with an existing home health care agency.
in ten areas.)
As a member of the Health Subcommittee of the Labor and Public Welfare
"3. St. Luke's Hospital in New York City has instituted a home health nursing
Committee over the past 20 months since I entered the Senate, I have become
program for outpatients with heart disease. The addition of public health nurs-
greatly concerned about the impending crisis in our total health delivery sys-
ing visits as follow-up to the outpatient cardiac program has reduced the rate
tem-if a system it is-and about the need to prod the medical community to
of hospitalization for congestive heart failure. The staff feels that an anticipatory
move far faster in adjusting to today's needs, yesterday's means of caring for
home care program based in a community hospital 'has great potential both for
the sick, rehabilitating the disabled, and preventing injury and disease. I believe
improving the health status of patients with chronic illness and for bringing
that S. 3355 can provide some of that necessary impetus by giving home health
the hospital closer to its community."
care the full recognition it requires as an important functioning part of a health
These examples, I believe, are clear evidence of the need to include home
care delivery system suited to today's needs and by encouraging full utilization
health care programs as an integral part of procedures utilized in regional medi-
of these services in plans for improving the delivery of comprehensive and spe-
cal programs.
cialized health services in our communities.
An amendment to section of the Public Health Service Act-section
Mr. President, at the same time, as chairman of the Subcommittee on Vet-
203(2) of the bill-would place research in home health care in its proper per-
erans Affairs of the Labor and Public Welfare Committee and in line with my
spective as a full member of a comprehensive health care delivery system.
particular interest in the Veterans' Administration medical program, I plan to
There is a continuing need for research in this special means of health care de-
introduce amendments to section 612(a) and (f) of title 38, United States Code,
livery to, first, find better methods of delivering home health care; second,
which will give impetus to the provision of home health care services as part of
find additional medical fields in which home health care can be utilized; third,
the outpatient medical services provided a veteran for a service-connected disabil-
develop innovative uses of new types of allied health professionals; and fourth,
ity, before, after, and independent of hospitalization. These same home health
undertake studies to enable the doctor to determine the most effective way of car-
care services would also be made available to a veteran eligible for hospitaliza-
ing for the individual patient-home care or institutional care-and when the
tion and treatment even though his injury or illness is not service connected.
transition should occur. This amendment would give research in home health
These new authorities would enable the Veterans' Administration more ef-
care the same priority as research in other modes of health services delivery.
ficiently to perform its vital function of providing first quality modern health
care for our veterans.
The amendments to section 314(a) and (b) of the Public Health Service Act-
sections 220(d) and 230(b) of the bill-would encourage the utilization of home
health care services in the community and would encourage the development of
additional agencies and programs by identifying home health care as a serv-
ice that should be included in health services planning at both the State and area-
wide level. To meet community needs adequately, home health agencies must be
planned and developed with the full cooperation and counsel of the areawide
comprehensive health planning agency (314(b)). This participation would be
assured by these amendments in S. 3355.
I also feel special efforts should be made by the 314(a) and 314(b) agencies
to seek representation on their advisory councils of representatives of substantial
home health care programs to insure that this kind of service is given full con-
sideration in the planning of community and State health services.
83
4. Physicians did not refer private patients to "organized" home care programs
in which the home care department medical director and his "team" of allied
health professionals assumed responsibility for the medical management of
patients. Therefore, the organized hospital home care programs were used for
medically indigent patients almost exclusively.
5. Innovative work in some programs suggested that departures from tradi-
Appendix 3
tional administrative patterns and service programs might stimulate private
physicians and their patients to use home care.
EXCERPTS FROM REPORTS OF FUNCTIONING HOME
6. Coordinated home care represents a level of care appropriate for patients
of all ages, and without regard to sex, diagnosis, and the patient's financial
HEALTH SERVICE PROGRAMS
status. However, such services were not generally available.
7. Convincing data was not available from existing programs to demonstrate
ITEM 1. EXCERPTS FROM REPORT BY BLUE CROSS OF GREATER
a reduction in the use of inpatient facilities resulting from the use of coordinated
PHILADELPHIA
home care but there were some cases which indicated that this might be
anticipated.
COORDINATED HOME CARE AN EFFECTIVE ALTERNATIVE
8. Utilization controls applicable to the use of home care services were almost
nonexistant.
[By Helen L. Rawlinson]
9. The appropriate use of professionally coordinated home care services would
This report documents a decade of experience which has demonstrated that
probably result in an improved quality of medically required continuity of care.
a skillfully administered array of professionally coordinated nursing, therapeutic
10. If skillfully administered and appropriately used, coordinated home care
and ancillary medical services represents a concentrated level of patient care
could contribute to fuller use of existing services and facilities and possibly lessen
which is valuable to patients, physicians, hospitals and Blue Cross. Patients
the cost of individual episodes of illness.
11. Coordinated home care appeared to represent a valid level of health care
generally respond more rapidly and fully to care at home, physicians' services
which hospitals, other community health agencies and Blue Cross should investi-
can be expanded to more patients when this level of home care service is avail-
able to their patients (more than 800 private physicians have used the service),
gate cooperatively through the development of pilot programs. For if home care
potentially offered an alternative to unnecessary hospitalization or other insti-
hospitals can increase the use of existing facilities and enlarge their services to the
community without a corresponding capital investment, and Blue Cross sub-
tutional care it would be essential for the provider and financing sectors to work
together to develop a medically acceptable service with appropriate financial
scribers can be provided a broader range of benefits for medically required health
care services without a related increase in subscription rates.
support.
PROGRAM DEVELOPMENT
An average of one and one half percent of patients discharged from medical,
surgical and pediatric departments of the participating hospitals included in
In preparing the Program Plan special care was taken to develop adminis-
this report were transferred to home care service an average of 12.9 days earlier
trative and reimbursement principles which would apply effectively to the
than would have been likely without the availability of the coordinated home
operation of a coordinated home care service administered by any general hos-
care service. This resulted in 6.6 additional hospital beds being available through-
pital or other community agency. Decisions which were made regarding the
out the report period for care of more acutely ill patients at no additional cost
following issues are reflected in the Home Care Program Plan included with
to the community. Expressed in other terms, the value of the inpatient days
this report:
saved on 3,940 home care cases amounted to $2,495,267. The net value after
1. How to structure and administer a home care service which would be
deducting the cost of providing services to patients and the related administra-
most acceptable and useful to private physicians and their patients?
tive costs amounted to $1,298,381 or $330 per case.
2. How to develop and implement patient care planning activities which would
In 1958, Pennsylvania Insurance Commissioner Smith held hearings in connec-
encourage the timely transfer of patients to appropriate levels of care?
tion with a request by Blue Cross for subscription rate increases. Evidence de-
3. The range of services which should and could be delivered to patients in
veloped in the hearings indicated the alarming escalation of hospital costs was
their homes.
due in part to the use of inpatient services for patients whose medical needs did
4. What methods of coordinating the delivery of home care services to patients
not require around-the-clock nursing care and supervision nor the instant avail-
and keeping the responsible physician informed regarding his patient's condi-
ability of hospital services. In his adjudication Commissioner Smith directed
tion would be most effective and efficient?
Blue Cross to undertake initiatives to reduce inappropriate utilization of hospital
5. Personnel required to adminster the home care service and to coordinate
facilities, including the exploration of benefit programs which would provide
patient services.
acceptable alternatives to inpatient care. One of several actions taken by Blue
6. The uses and design of home care medical record forms.
Cross pursuant to this directive was an indepth study of coordinated home care.
7. Utilization controls which would assure appropriate use of home care
Available literature was studied. Physicians, nurses, and administrators of visit-
services.
ing nurse organizations and hospitals operating home care programs were inter-
8. How to monitor the quality of patient care provided through the home care
viewed, home care programs in distant cities were visited and home care related
service?
workshops and sessions of professional organizations were attended. These
9. Development of effective functional relationships between the home care
activities led to the following conclusions.
department and other departments of the hospital and participating community
1. The concept of coordinated home care was endorsed by all professional or-
organizations.
ganizations concerned with the provision of health care, by the American Hospital
10. Administrative and professional policies for the admission of patients and
Association and the Public Health Service.
delivery of services.
2. Home care, both single service (VNA) and multiple services (coordinated
11. Blue Cross benefits to be allowed and how third party financing could
home care), was used mostly for elderly, chronically ill, indigent or medically
stimulate appropriate and optimum use of home care within the context of an
indigent persons and female patients outnumbered male patients fifty to sixty
insurable risk.
percent.
12. Statistical and financial record systems which would produce reliable
3. Hospitals were not prepared to organize home care programs and thus to
medical, cost and actuarial data efficiently.
assume additional responsibility for long-term care of patients out of the hos-
All hospitals participating in the Blue Cross Home Care Program have used
pital without assurance that reimbursement would be available to cover the costs
the Program Plan when organizing their home care departments. The participat-
of such care.
ing hospitals include a metropolitan medical center which serves an older urban
(82)
84
85
population, a pediatric hospital, general hospitals located in affluent and less
privileged suburban communities, hospitals associated with university medical
The impact of medicare benefits for extended care facility services on the previ-
schools, and a general hospital which serves an area severely depressed financially
ously steady growth of coordinated home care utilization is shown in Exhibit 11
and socially. All of the hospitals, except one, purchase nursing and therapeutic
which charts home care admissions and transfers to extended care facilities.
services from community home health agencies and provide directly the hospital
Medicare benefits for "home health services" also produced a temporary in-
ancillary medical services such as laboratory, X-ray, electrocardiogram, and
crease in the number of patients referred to community home health agencies.
other special diagnostic treatment services, medical supplies and equipment, medi-
This intermediate level of home care which represents an additional service in
cations, and all other services of the hospital as feasible.
the continuum of patient care was rarely included in Blue Cross or commercial
Blue Cross home care benefits include all medical and related services ordered
health insurance benefit schedules prior to 1966. As medicare rulings became more
by the responsible physician which would be covered if the subscriber were an
restrictive, the number of referrals to community home health agencies declined.
inpatient, including nursing and therapeutic services on a visiting basis, all
In 1969 Blue Cross extended its home care benefit program to include nursing
ancillary medical services supplied by the hospital and medically required patient
and physical therapy visits when this level of continuing care was medically
transportation between hospital and home provided by commercial carriers.
necessary and was planned through the participating hospital home care depart-
These benefits are allowed for treatment of the condition for which the patient
ments. Again the number of referrals to community home health agencies
was hospitalized or would be hospitalized if coordinated home care services were
increased.
not available. Benefits are not provided in cases of normal obstetrical deliveries
The fact that the medicare statute does not recognize the special characteristics
or for food, housing, homemakers, home health aides or for supplementary diet
of coordinated home care presents problems in the promotion and development
assistance.
of this level of care which offers an effective alternative to institutional health
Blue Cross reimbursement to participating hospitals for covered home care
care. The experience of Hospital D presented in this report reflects this influence.
services includes the cost of nursing, therapeutic and related ancillary medical
services plus a proportionate share of the direct and indirect administrative
AGE AND SEX OF HOME CARE PATIENTS
costs incurred by the hospital in operating the home care department. Various
The census records of both hospital home care services and community home
reimbursement methods have been used. Experience indicates that payment for
health agencies generally indicate that women represent a substantial majority
direct patient services according to a negotiated schedule of charges plus semi-
of home care patients. A different experience is demonstrated in Table III. In
annual settlements for approved administrative costs is the most efficient and
the 65 and over age group during the four years 1966-1970 (1,254 cases) female
mutually satisfactory method.
patients outnumbered male patients by 56.4%, however, among the patients
under 65 years of age who were admitted during the same period (1,392 cases)
EXPERIENCE ANALYSIS
male patients outnumbered female patients by 19%. In the hospital which serves
An analysis of 3,940 home care cases is presented in a series of tables which
a younger population, male patients represented 52% of the total home care
are a part of this report. These cases represent all admissions to four hospital
census; in the hospitals serving older populations, female patients (56%) out-
home care departments between November 1961 and July 1970. The hospitals
numbered male patients (43%).
included are most similar organizationally and administratively and with one
The average age of all home care patients was 61 years. It is important to
exception had been in operation more than five years. However, the hospitals
note, however, that 51% of the patients were under 65 years of age. This experi-
present considerably different characteristics in terms of size and the population
ence was consistent during the four years before and after implementation of
served. The number of medical, surgical, and pediatric beds in the smallest hospi-
the medicare program. Patients under 22 years of age accounted for 6% of the
tal has averaged about two hundred during the report period, the largest about
cases, 12% were between 22 and 45, and 33% of all patients were between 46 and
seven hundred. The other two hospitals averaged about four hundred beds. One
65 years of age. During the periods before and after medicare 49% of the home
hospital is located in a predominately industrial suburban community with a
care patients were 65 years of age or older (Table IV).
younger population. One is situated on the boundary of a depressed urban area
The use of coordinated home care for male patients in 47% of the cases and
and a more stable and moderately prosperous suburban community. Another
for patients under 65 years of age in 51% of the cases suggests that health care
hospital is a division of an urban medical center which serves an older popula-
planners, legislators, financing agencies and health care providers should take a
tion with a varying financial and social characteristics. The fourth hospital serves
new view of the patient universe which can be served by coordinated home care
a generally affluent suburban community.
services. It also indicates that providers of home care services should evaluate
their service programs to see if they are prepared to meet the scope of health
UTILIZATION EXPERIENCE
care services required by non-geriatric and male patients.
The goal is establishing a coordinated home care service is dichotomous-the
PRIOR HOSPITALIZATION LENGTH OF STAY
quality of continuing care must be maintained, if not improved, and the cost
of medically required care should be lowered through the timely use of an
The period of hospitalization which precedes transfer of patients to home
acceptable alternative to more costly institutional care.
care service is influenced by several factors: the traditional patterns of medical
practice, hospital administrative policies and practices, patient care planning
procedures used in the hospital, or the absence of such procedures, the size of
HOME CARE ADMISSIONS
the institution, the patient's clinical status, his socio-economic situation, the
The synergistic values achieved by participating hospitals and Blue Cross were
availability of supportive services in the community, to name a few. Numerous
disturbed when the medicare benefit program emphasized transfer of patients to
studies have demonstrated that substantial numbers of patients are hospitalized
extended care facilities as the primary alternative to unnecessary inpatient hos-
inappropriately or remain in hospitals longer than medically necessary. Not all
pital care. Although benefits for "home health services" are provided under the
such patients need coordinated home care either. The problems of patient care
medicare program it is a limited benefit program which fragments reimbursement
planning must be studied carefully to identify procedures which can be applied
for coordinated home care services between Part A and Part B "home health
effectively to all patients. Although a great amount of attention has been given
services" benefits and Part B outpatient benefits. Medicare benefits are not
to this problem in the planning and operation of the hospital home care depart-
allowed for several important services which are necessary to properly care for
ments, results have been uneven and, to some extent, disappointing. Neverthe-
patients of a coordinated home care program, which represented an intensive level
less, it should be remembered that patients who require this intensive level of
of home care.
coordinated home care generally have a very serious illness which usually re-
quires prolonged care, or have experienced an unusual recovery from serious
86
87
illness. For this reason arbitrary parameters are not appropriate and are often
misleading when applied to home care patients or potential home care patients.
the acute exacerbation category unless the medical record indicated that read-
The average period of hospitalization prior to home care admission averaged
mission was part of the therapeutic plan. During the two years ending June 30,
31 days, the median was 27 days. Within reimbursement categories, the average
1970 the reasons causing readmission were analyzed more accurately and it
ranged from 20 to 48 days and the median from 19 to 37 days. It is significant
was determined that of the total unplanned readmissions, 43% were caused
that 39% of all home care patients were hospitalized 21 days or less, 349 patients
by expected physical deterioration due to the disease process and 16% were
(9%) were hospitalized less than 10 days, 1,171 patients (30%) were hospitalized
caused by superimposed illnesses with diagnoses unrelated to the original home
between 10 and 21 days. Direct admissions, instances of hospitalization being
care diagnosis. Upon adjusting the readmission experience according to this
avoided through use of coordinated home care services, accounted for 151 cases
analysis, the readmission figure shown in Table VIII would appear as follows:
(4%) (Table V). The prevalence of certain diagnoses affects the period of hos-
Admitted to hospital due to-
pitalization before transfer to home care service. This influence is evident when
Percent
the distribution of diagnoses (Table VII) is compared to the periods of hos-
Acute exacerbation
6
pitalization shown in Table V. However, the distribution of diagnoses is much
Planned
5
less variable. The possibility that non-medical considerations influenced the
Disease progression
6
length of time patients were hospitalized prior to admission to the home care
Unrelated diagnosis
2
service must be acknowledged.
HOME CARE SERVICES PROVIDED TO PATIENTS
HOME CARE LENGTH OF STAY
Twenty-one different medical and related services were provided to home
Only the intensive level of coordinated home care is represented in the cases
care patients. The number and percentage of all patients who used each service
included in this study. This is to say that the responsible physician determined
are listed in Table X. The following tabulation indicates the percentage of
the medical status of his patient to require centralized professional coordina-
patients who received each service and the corresponding percentages of usage
tion of a range of services provided through the hospital home care depart-
within the three payment categories.
ment. When this level of care is no longer necessary, patients are either dis-
charged, transferred to continuing care by a community home health agency,
HOME CARE SERVICES PROVIDED TO ALL PATIENTS, 1966-70
or other appropriate arrangements are made for the needed level of continuing
[In percent]
care.
The average home care length of stay for all patients was 39 days, the
All
Blue Cross
Other
Medicare
median was 26 days. Blue Cross subscriber patients remained on home care
Home care services
cases
cases
cases
cases
service an average of 31 days (median 24 days) medicare patients averaged 47
days (median 30 days) and all other patients used an average of 38 days
Nursing
97.0
98.0
98.0
96.0
(median 27 days) per case. (Table VI.)
Laboratory procedures
48.0
57.0
46.0
44.0
Medications
42.0
78.0
64.0
10.0
Medical equipment
42.0
38.0
33.0
50.0
DIAGNOSES
Medical supplies
38.0
32.0
44.0
38.0
Physical therapy
23.0
15.0
19.0
30.0
Coordinated home care was used in the treatment of all classifications of
Laboratory technician
22.0
31.0
16.0
21.0
disease (Table VIII). Variations in the frequency home care was used for
Electrocardiogram
13.0
15.0
15.0
10.0
X-ray (diagnostic)
4.0
4.0
5.0
4.0
patients experiencing different diagnoses reflect to some degree characteristics
Oxygen
4.0
4.0
4.0
4.0
of the population served by the hospital, particularly age, sex and social fac-
Inhalation therapy
3.0
4.0
3.0
3.0
tors. For example, a higher percentage of injuries, exclusive of fractures, were
Speech therapy
2.0
.8
1.0
2.0
Home health aide
1.0
.1
.7
3.0
treated in the hospital which serves a relatively younger population in an in-
Occupational therapy
.7
.3
1.0
.6
dustrial community. Patients with strokes and other circulatory illness repre-
Outpatient Department visits
.6
.7
.3
.2
sented a higher percentage of the patients in the hospital which serves an
Operating room
.6
1.0
1.0
.07
Clinic visits
.4
.6
.4
.3
older population. Other variations can be identified with different character-
Other
.3
.4
.4
.2
istics of the hospital medical staffs. For example, a physician in one hospital
X-ray (therapeutic)
.2
.1
.4
transferred his patients with hip fractures to home care as promptly following
Patient transportation
.2
.4
.3
Social service
.0007
.2
surgery as possible while in another hospital orthopedic surgeons did not use
home care at all for his fractures.
Although the four most prevalent diagnoses, heart, cancer, fractures, and
The level of illness of coordinated home care patients usually presents a need
circulatory conditions other than cardiovascular accidents, accounted for 58%
for medication therapy. The lack of medicare benefits for medications, which
of all cases, it is important to resist the tendancy to associate coordinated
are covered when supplied as an inpatient service, interferes with the ability of
home care with a limited number of disease categories. Such identification
the professionals responsible for coordination and delivery of services to super-
tends to interfere with the use of this level of care for all patients for whom
vise the prescribed medication regimen. This is of special concern at a time when
it is appropriate which, in turn, diminishes its potential value and usefulness.
the physical, mental and financial capabilities of patients to be personally re-
sponsible for observing medication orders are usually impaired. When the medi-
PATIENT SITUATION ON DISCHARGE FROM HOME CARE
care home care patient elects to obtain ordered medications privately, rather
than to have them supplied through the home care department, the coordinator
The majority of home care patients do not require an organized program
of patient services is unable to exercise effective control over this important as-
of health care services following discharge from the coordinated home care
pect of the patient's treatment. This is an example of the potential influence of
service. Continuing medical supervision was the only care needed by 70% of
financing arrangements on the quality of patient care.
the patients discharged. (Table VIII.) Three percent of the patients were
When the scope of home care services provided is considered with the high
transferred to continuing care by community home health agencies, 4% ex-
percentage of patients (70%) who require only continuing medical supervision
pired while on home care, 2% were transferred to nursing homes or extended
following discharge from coordinated home care, the comparatively short dura-
care facilities.
tion of home care services (27 days median) and the full range of diagnoses
Readmission to the hospital occurred in 19% of the cases. The number of
treated, the dynamic character and the therapeutic values of this intensive level
cases readmitted to the hospital due to acute exacerbations is misleading be-
of coordinated home care are evident.
cause until 1969 all patients readmitted to the hospital were counted as in
88
89
FINANCIAL EXPERIENCE
Levels of patient care have been more appropriately defined and experience has
demonstrated that it is feasible and desirable to provide an intensive level of
Express related to providing home care services are detailed in Tables XI,
care to patients in their own homes when medical and environmental conditions
XII, XIII and XIV. Expenses include the costs of direct patient services, the
are suitable. This has lead to broader recognition and use of the intermediate
administrative costs of coordinating the direct patient services and administer-
level of nursing and therapeutic services which community home health agencies
ing the home care department and the related overhead costs.
have provided traditionally. It is estimated that five percent of all hospitalized
The average per diem costs, including all direct and indirect expenses, during
patients could be transferred to coordinated home care earlier in their illnesses
the period 1962 through 1965 was $6.30, the average per diem cost during the
with a corresponding reduction in the use of inpatient facilities.
period 1966 through 1970 was $8.73, an increase of 38.6% for home care com-
Coordinated home care has been used for the continuing care of patients with
pared to an average increase of 78.9% for inpatient hospital care during the same
all types of illnesses and in 4% of the cases, hospitalization was avoided or de-
periods.
layed through use of the hospital home care departments.
Direct patient services represented 57.8% of total costs, direct and indirect ad-
ministrative costs represented 42.2% of total costs. Financial experience is ex-
PHYSICIAN COMMENTS
pressed in terms of per diem and per case costs in this report because these cost
units reflect the continuous character of a coordinated home care service. Al-
This report would be incomplete if the views of physicians who have used
though some patients are not visited by a nurse or therapist every day their care
coordinated home care for their patients were not mentioned.
is under continuing professional supervision and patients are supplied with all
One hundred and fifty-eight randomly selected physician responses to a ques-
ancillary medical services needed for their daily care. The cost of professional
tionnaire were reviewed. Three questions were asked: (1) Was the home care
coordinating services are included in direct administrative costs.
department able to provide all the services you considered necessary for your
patient? (2) What medical considerations influenced you to transfer your patient
VALUE OF COORDINATED HOME CARE
to the home care service? (3) How many times did you see the patient during the
home care period? Space was provided for additional comments. All but three
The financial value of coordinated home care service can be expressed in various
physicians stated that the home care service provided all needed services, two
ways. The most common is to estimate the number of days patients would have
did not answer the question and one replied negatively. A wide variety of medical
remained hospitalized if home care services were not provided. Such estimates
considerations which prompted use of coordinated home care was given, the
are usually based on the physician's opinion when he referred his patient to the
majority indicated that the availability of professionally coordinated nursing
coordinated home care service. These are of questionable reliability for various
and ancillary hospital services which would meet their patients' needs at home
reasons, the most significant being that physicians have no sure knowledge at
prompted use of the home care service. Physicians saw their patients at home
the time of referral what patients' continuing responses to treatment and their
or in private offices as the medical situation warranted. Generally the physicians
illnesses will be. The only reasonably reliable guide to the potential affect of co-
did not have to see patients as frequently as they would have been obliged to
ordinated home care on the use of inpatient service is obtained from an objective
see them without the home care service. As one physician put it, "The home care
professional analysis of the home care medical record following discharge of pa-
department saves me inestimable house calls."
tients from home care service. The professional analysis should take into con-
Considering the well known fact that physicians weary of filling out forms,
sideration the services ordered and provided and the patient's progress. The
it was surprising that 115 responses had additional comments noted. For
estimated number of inpatient days saved due to use of coordinated home care
example:
service shown in Table XV were based on such an analysis of each patient's
"I was able to obtain pertinent information regarding my patient's condition
medical record. An estimated average of 12.9 inpatient days were saved on each
and vital signs, and to get necessary lab work at home."
home care case, a total of 50,800 inpatient days. At this rate 6.6 additional hos-
"A great service to the patient and hospital."
pital beds were made available throughout the report period without a correspond-
"The value of this service is unlimited and it should be expanded. M.D.'s need
ing capital investment.
more information regarding details of the service on a regular basis."
The monetary value of the estimated inpatient days saved (Table XVI) is
The final comment is included here as a tribute to the dedicated directors of
based on the average inpatient per diem cost in each hospital during each of the
all the participating home care departments, as it was intended by the responding
report years multiplied by the number of estimated days saved during the corre-
physician for the director who assisted in the care of his patient. The physician's
sponding years. The result is a gross value of $2,495,267.
comment-How does one describe a masterpiece?"
The direct and indirect cost of providing home care services was $1,196,886
Dr. Cecil G. Sheps, Director, Health Service Research Center and Professor of
which leaves an estimated net value of $1,298,381 or $330 per home care case.
Social Medicine at the University of North Carolina, stated the following in a
During the year ending June 30, 1970, the estimated net value per case was $473,
paper delivered in September, 1970:
a figure which does not appear in the tables included with this report.
"As central as hosiptals are to the provision of health services, most of them
are characterized by important deficiencies in term of their functional connection
CONCLUSION
with the chronic care system and with ambulatory care. Both of these linkages
need to be developed much more strongly as continuous programs.
Blue Cross objectives in supporting coordinated home care have been substan-
"Beginnings are being made. In various parts of the country, general hospitals
tially realized through the nine hospitals which have participated in the home
have merged with or developed extended care facilities and rehabilitation pro-
care program. There has been no concentrated effort to encourage all hospitals to
grams, in addition, of course, to the more substantial, though still very inade-
establish home care programs. Hospitals which have indicated an interest have
quate, development of home care programs."
been encouraged and assisted to develop home care services and this experience
has provided a variety of opportunities to test and refine the Program Plan and
administrative methods. In all situations the basic concepts have been applicable
to the solution of special problems.
Private physicians, more than 800, have used the hospital home care depart-
ments for their patients who, with few exceptions, have indicated they preferred
coordinated home care to continued hospitalization.
Hospitals and community home health agencies have developed new cooperative
relationships, service programs and the professional skills of community home
health agencies have been expanded and upgraded.
BLUE CROSS OF GREATER PHILADELPHIA COORDINATED HOME CARE STUDY 1962-70
TABLE I.-HOME CARE CASES DISTRIBUTION BY SOURCE OF PAYMENT, 1962-70
A
B
C
D
Total 1962-70
Total 1962-65
Total 1966-70
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Source of payment:
Blue Cross, Philadelphia
416
32
800
48
285
32
30
44
1,531
39
780
60
751
28
Blue Cross, other
24
2
2
1
29
1
2
24
1
06
Self-pay
251
19
87
5
135
15
10
15
483
12
185
14
298
11
Insurance, including Blue Cross major
104
8
106
6
45
5
14
21
269
7
77
6
192
7
service, free care
43
3
38
2
10
1
91
2
79
6
12
1
Pennsylvania medical assistance
185
14
261
16
38
4
5
7
489
12
227
18
262
10
Medicare
336
25
578
35
483
54
9
13
1,406
36
1,406
53
More than 1 of above
-11
-1
-39
-2
-20
-2
-70
-2
-18
-1
-52
-2
Open cases from previous year
-31
-2
-166
-10
-88
-9
-285
-7
-38
-3
-247
-9
Admissions this year
317
100
1,665
100
890
100
68
100
3,940
100
1,294
100
2,646
100
HOSPITAL(A)
10
20
30
40
50
60
OL
08
90
100
110
120
130
140
150
160
170
180
190
200
74-331
HHA Refer
ECF Transfers
H.C. Admi
rals
(c)
1961 12 3 1962 12 3 1963 12 3 1964 12 3 1965 1969 12 3 1469 12 3 1967 12 3 1969 12 3 12 3 1979
ssions
(B)
EXHIBIT =
HOME CARE ADMISSIONS
91
D
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
TABLE III.-HOME CARE CASES BY SEX
A
B
C
D
Total, 1962-70
Total, 1962-65
Total, 1966-70
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Blue Cross cases:
Male
236
57
368
49
135
50
17
57
756
51
355
47
401
57
Female
180
43
390
51
133
50
13
43
716
49
408
53
308
43
Total
416
100
758
100
268
100
30
100
, 472
100
763
100
709
100
Other cases except medicare:
Male
309
53
180
44
87
45
13
45
589
49
234
44
355
52
Female
270
47
233
56
106
55
16
55
625
51
297
56
328
48
Total
579
100
413
100
193
100
29
100
214
100
531
100
683
100
92
Medicare cases:
Male
139
43
201
41
148
34
1
11
489
39
489
39
Female
183
57
293
59
281
66
8
89
765
61
765
61
Total
322
100
494
100
429
100
9
100
1,254
100
1,254
100
All cases:
Male
684
52
749
45
370
42
31
46
1,834
47
589
46
1, 245
47
Female
633
48
916
55
520
58
37
54
2,106
53
705
54
1,401
53
Total
1, 317
100
1,665
100
890
100
68
100
3,940
100
1,294
100
2,646
100
TABLE IV.-HOME CARE CASES, AGE DISTRIBUTION
A
B
C
D
Total 1962-70
Total 1962-65
Total 1966-70
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Blue Cross cases:
Under 22 years
44
11
17
2
35
13
96
7
36
5
60
8
22 to 45 years
101
24
93
12
43
16
8
27
245
17
110
14
135
19
46 to 64 years
198
48
406
54
145
54
22
73
771
52
264
35
507
72
65 and over
73
17
242
32
45
17
360
24
353
46
7
1
Total cases
416
100
758
100
268
100
30
100
1, 472
100
763
100
709
100
Average age
50
59
52
53
55
60
50
Median age
51
57
55
57
55
62
54
Other cases except medicare:
Under 22 years
84
14
28
7
23
12
7
24
142
12
38
7
104
15
22 to 45 years
140
24
58
14
34
18
6
21
238
19
72
14
166
24
46 to 64 years
228
39
181
44
97
50
16
55
522
43
143
27
379
55
65 and over
139
23
146
35
39
20
93
324
26
278
52
34
6
Total cases
591
100
413
100
193
100
29
100
1,226
100
531
100
683
100
Average
50
56
53
41
52
60
46
Median age
49
55
54
45
51
64
52
Medicare cases: 65 years and over
310
100
494
100
429
100
9
100
242
100
1,254
100
Average age
75
74
75
73
76
76
Median age
74
73
74
75
74
74
All cases:
Under 22 years
128
10
45
3
58
7
7
10
238
6
74
6
164
6
22 to 45 years
241
18
151
9
77
9
14
21
483
12
182
14
301
11
46 to 64 years
426
32
587
35
242
27
38
56
1,293
33
407
31
886
34
65 and over
522
40
882
53
513
57
9
13
1,926
49
631
49
1,295
49
Total cases
1,317
100
1,665
100
890
100
68
100
3,940
100
1,294
100
2,646
100
Average age
56
63
63
51
61
60
61
Median age
58
65
67
56
63
62
63
TABLE V.-HOME CARE CASES, INPATIENT DAYS PRIOR TO HOME CARE ADMISSION
A
B
C
D
Total 1962-70
Total 1962-65
Total 1966-70
Inpatient days
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Blue Cross cases:
Under 10 days
69
17
34
4
41
15
2
7
146
10
10 to 21
73
10
176
73
10
42
225
30
79
29
9
31
489
33
22 to 28
267
34
222
32
98
24
149
20
40
15
7
23
294
20
29 to 35
144
19
150
21
38
9
141
19
19
7
4
13
202
14
110
36 to 42
14
92
13
15
4
72
9
27
10
3
10
117
8
60
43 to 56
8
57
8
10
2
71
9
12
5
1
3
94
6
44
6
50
7
Over 56 days
8
2
66
9
10
4
3
10
87
6
43
6
44
6
Direct admissions
2
40
15
1
3
43
3
22
3
21
3
Total cases
416
100
758
100
268
100
30
100
1,472
100
763
100
709
100
Average days
20
30
24
27
26
26
27
Median days
19
28
21
23
24
21
24
Other cases except medicare:
Under 10 days
89
15
27
7
12
6
4
14
132
11
52
10
80
12
10 to 21
225
39
75
18
47
24
10
34
357
29
160
30
197
28
94
22 to 28
119
21
60
15
29
15
6
21
214
18
90
16
124
18
29 to 35
53
9
64
15
25
13
2
7
144
12
65
12
79
12
36 to 42
25
4
35
8
17
9
4
14
81
7
36
7
45
7
43 to 56
21
4
41
10
22
12
1
3
85
7
41
8
44
6
Over 56 days
27
5
111
27
20
10
2
7
160
13
78
15
82
12
Direct admissions
20
3
21
11
41
3
9
2
32
5
Total cases
579
100
413
100
193
100
29
100
1,214
100
531
100
683
100
Average days
23
48
34
26
33
35
32
Median days
21
37
27
22
27
33
26
Medicare cases:
Under 10 days
40
12
7
1
24
6
71
6
71
6
10 to 21 days
127
39
86
17
108
25
4
45
325
26
325
26
22 to 28 days
60
19
72
15
79
18
2
22
213
17
213
17
29 to 35 days
28
9
92
19
67
16
1
11
188
15
188
15
36 to 42 days
15
5
60
12
54
12
2
22
131
10
131
10
43 to 56 days
11
3
68
14
44
10
123
10
123
10
Over 56 days
3
1
109
22
24
6
136
11
136
11
Direct admissions
38
12
29
7
67
5
67
5
Total cases
322
100
494
100
429
100
9
100
1,254
100
1,254
100
Average days
20
47
29
25
34
34
Median days
21
34
28
26
29
29
All cases:
Under 10 days
198
15
68
4
77
9
6
10 to 21 days
9
349
528
9
125
40
386
10
23
224
234
8
26
22 to 28
23
35
277
1,171
30
427
21
33
281
744
17
28
148
17
15
29 to 35 days
22
721
18
119
234
9
18
297
487
18
18
111
12
36 to 42
7
10
534
14
55
175
4
14
167
359
10
14
98
11
9
43 to 56 days
13
329
8
42
96
3
7
180
233
11
9
78
9
2
3
Over 56 days
302
7
85
38
7
3
217
286
8
17
54
6
5
Direct admissions
7
383
10
121
60
9
5
262
10
90
10
1
1
151
4
31
2
120
5
Total cases
1, 317
100
1,665
100
890
100
68
100
Average days
3,940
100
22
1,294
100
40
2,646
100
30
26
31
Median days
27
20
31
35
26
23
27
26
27
95
TABLE VI.-HOME CARE CASES, NUMBER OF HOME CARE PATIENT DAYS
Total
Total
A
Total
A
C
D
1962-70
1962-65
1966-70
Patient days
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Blue Cross cases:
10 or less
98
24.0
96
13
64
24
7
22
265
18
11 to 20
107
14
158
22
145
35.0
122
16
49
18
6
22
322
21 to 30
22
137
18
185
128
26
31.0
188
25
67
25
10
34
393
26
31 to 60
212
27
181
26
43
10.0
283
36
75
28
7
22
408
61 to 90
28
236
31
172
24
7
2.0
82
11
19
7
108
7
91 to 120
70
9
38
5
21
3
7
3
28
2
17
121 to 150
2
11
2
1
7
1
5
2
13
1
4
151 to 180
1
9
1
Over 180
Open cases from previous report per
-6
-2
-41
-5
-17
-6
-64
-4
-19
-2
-45
-6
96
Cases transferred to other permanent
source
-1
-1
-1
Total
416
100.0
758
100
268
100
30
100
1,472
100
763
100
709
100
Average days
18
37
33
23
31
32
29
Median days
15
29
25
21
24
25
22
Other cases except medicare:
10 or less
196
34.0
48
12
45
23
6
21
295
24
100
19
195
29
11 to 20
183
32.0
75
18
36
19
13
45
307
25
95
18
212
31
21 to 30
119
20.0
69
17
40
20
3
10
231
19
117
22
114
17
31 to 60
75
13.0
138
33
59
30
6
21
278
23
121
23
157
23
61 to 90
15
3.0
70
17
28
15
1
3
114
9
54
10
60
9
91 to 120
7
1.0
48
12
5
3
60
5
37
7
23
3
121 to 150
1
16
4
6
3
23
2
13
2
10
1
151 to 180
1
17
4
6
3
24
2
19
4
5
1
Over 180
7
2
3
2
10
1
7
1
3
1
Open cases from previous report per
-15
-3.0
-61
-15
-15
-8
-91
-7
-19
-4
-72
-11
Cases transferred to other permanent
source
-3
-14
-4
-20
-10
-37
-3
-13
-2
-24
-4
Total
579
100.0
413
100
193
100
29
100
1,214
100
531
100
683
100
Average days
19
62
45
22
38
44
56
Median days
17
56
28
18
27
39
25
Medicare cases:
10 or less
80
25.0
64
13
11 to 20
70
16
2
122
22
37.0
216
94
17
19
21 to 30
59
14
216
3
34
17
67
20.0
278
89
23
18
64
15
2
278
45
22
23
31 to 60
14.0
222
186
18
38
61 to 90
147
35
222
2
16
22
18
5.0
380
70
30
14
91 to 120
69
16
380
30
4
1.0
155
28
12
6
40
9
155
12
121 to 150
2
1.0
72
15
6
3
151 to 180
13
3
72
6
2
1.0
30
2
2
0
8
2
30
2
Over 180
2
1.0
12
1
12
2
13
Open cases from previous report per
3
12
1
-17
-5.0
27
-65
2
-13
-54
-13
27
Cases transferred to other permanent
-136
-11
-136
-11
source
-1
-1
-2
-2
Total
322
100.0
494
100
429
100
9
Average days
100
26
51
1,254
100
58
19
1,254
100
Median days
17
47
34
36
47
23
30
30
All cases:
10 or less
374
28.0
208
13
179
20
15
11 to 20
22
776
450
34.0
20
291
207
16
17
569
144
16
22
21 to 30
22
33
907
314
23
232
24.0
346
22
18
171
675
18
15
26
31 to 60
22
846
163
21
12.0
329
607
25
36
281
517
32
15
19
61 to 90
22
1,066
26
38
357
3.0
222
13
28
116
709
13
1
27
91 to 120
1
377
11
1.0
10
124
97
10
6
52
253
9
6
121 to 150
160
4
4
.5
38
54
4
2
24
106
4
3
151 to 180
66
2
3
17
.5
1
19
1
49
14
2
2
Over 180
36
1
2
.5
19
1
19
1
17
16
1
2
37
Open cases from previous report per
1
7
-3.0
1
30
97
-38
-150
-9
1
-86
-10
Cases transferred to other permanent
-274
-7
-38
-3
-236
-9
source
-4
-.5
-32
-2
-21
-2
-57
-1
-14
-1
-43
-2
Total
1,317
100.0
1,665
100
890
100
68
100
Average days
3,940
100
21
1,294
100
48
49
2,646
100
22
39
Median days
37
17
39
34
30
18
26
31
26
TABLE VII.-HOME CARE CASES, CLASSIFICATION OF DISEASE
Total
A
B
C
D
1962-70
1962-65
1966-70
Disease classification
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Blue Cross cases:
Cancer
42
10.0
83
11
42
16
11
36
178
12
90
12
88
12
Diabetes
43
10.0
45
6
16
6
2
7
106
7
52
7
54
8
C.V.A
12
3.0
34
4
5
2
3
10
54
4
40
5
14
2
Heart
170
41.0
175
23
54
20
2
7
401
28
187
25
214
31
Circulatory, other
11
3.0
107
14
12
4
2
7
132
9
69
9
63
9
Respiratory
2
.5
66
9
7
3
3
10
78
5
49
6
29
4
98
Digestive
20
5.0
64
8
18
7
3
10
105
7
62
8
43
6
G.U.-gyn
35
8.0
13
2
13
4
1
3
62
4
45
6
17
2
Fractures
24
6.0
50
7
40
15
2
7
116
8
53
7
63
9
Other orthopedic
2
.5
32
4
31
12
65
4
25
3
40
6
Injuries excluding fractures
13
3.0
4
1
17
1
17
2
Other
42
10.0
89
12
26
10
1
3
158
11
91
12
67
9
Total
416
100.0
758
100
268
100
30
100
1,472
100
763
100
709
100
Other cases except medicare:
Cancer
65
11.0
41
10
28
15
11
39
145
12
61
11
84
12
Diabetes
74
14.0
31
8
5
3
110
9
55
10
55
C.V.A
13
2.0
36
8
8
4
3
10
60
5
33
6
27
com
Heart
187
32.0
60
15
29
15
2
7
278
23
117
22
161
24
Circulatory, other
14
2.0
68
16
13
7
4
14
99
8
39
7
60
9
Respiratory
1
18
4
2
1
21
2
10
3
11
2
Digestive
43
7.0
26
6
12
6
1
3
82
7
40
8
42
6
G.U.-gyn
33
6.0
6
1
7
4
1
3
47
4
28
5
19
3
Fractures
41
7.0
52
13
51
26
4
14
148
12
61
11
87
13
Other orthopedic
12
2.0
23
7
18
9
53
4
18
4
35
5
Injuries excluding fractures
35
6.0
1
1
1
37
3
37
5
Other
61
11.0
51
12
19
9
3
10
134
11
69
13
65
10
Total
579
100.0
413
100
193
100
29
100
1,214
100
531
100
683
100
Medicare cases:
Cancer
49
15.0
49
10
Diabetes
73
17
2
22
173
40
12.0
14
16
3
173
C.V.A
12
14
3
17
68
5.0
5
66
13
68
24
Heart
6
5
100
107
31.0
71
9
14
107
72
17
9
Circulatory, other
1
11
244
34
11.0
19
99
20
244
44
19
Respiratory
10
5
177
2.0
14
19
4
177
15
14
Digestive
4
39
21
7.0
3
19
4
39
G.U.-gyn
32
7
3
1
11
73
20
6
6.0
11
2
6
73
6
Fractures
1
37
11
3
3.0
78
17
37
88
3
Other orthopedic
21
4
45
181
2
14
.5
16
3
181
31
14
7
Injuries excluding fractures
1
11
50
2
4
.5
5
50
4
Other
1
7
1
21
7.0
50
10
7
27
1
6
98
8
98
8
Total
322
100.0
494
100
429
100
9
100
1,254
100
1,254
100
All cases:
Cancer
156
12.0
172
10
143
16
Diabetes
24
36
495
157
13
12.0
151
92
12
6
344
33
13
4
C.V.A
2
3
284
7
42
3.0
107
135
8
177
8
7
37
4
Heart
6
9
220
442
6
34.0
73
6
306
147
18
155
17
5
Circulatory, other
5
7
908
74
23
5.0
304
273
16
23
604
69
23
8
6
Respiratory
9
422
11
8
1.0
108
8
103
6
314
24
12
3
3
Digestive
4
138
4
84
59
7.0
5
109
7
79
62
3
7
5
G.U.-gyn
7
260
7
88
7.0
30
102
8
158
2
6
26
3
Fractures
2
3
146
3
76
5.0
73
180
6
11
73
179
3
20
10
Other orthopedic
15
445
16
11
114
1.0
74
9
331
4
13
80
9
1
Injuries excluding fractures
1
171
3
50
43
4.0
3
128
1
4
10
1
66
Other
61
124
2
9.0
190
61
12
2
72
8
4
6
390
10
160
12
230
9
Total
1,317
100.0
1,665
100
890
100
68
100
3,940
100
1,294
100
2,646
100
TABLE VIII.-HOME CARE CASES, PATIENT SITUATION AT TERMINATION OF HOME CARE
A
B
C
D
Total, 1962-70
Total, 1962-65
Total, 1966-70
Patient situation
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Blue Cross cases:
Medical followup
340
84.0
512
72
181
74
18
64
1,051
76
542
77
509
74
Admitted to hospital:
Acute exacerbation
31
7.0
80
11
25
10
3
11
139
9
79
11
60
9
Planned
16
4.0
48
7
15
6
2
7
81
6
37
5
44
6
Disease progression
2
.5
10
1
4
2
4
14
20
1
20
3
Unrelated diagnosis
7
1
3
1
10
1
10
1
Admitted to nursing home/ECF
2
.5
5
1
4
2
11
1
7
1
4
1
Visiting nurse followup
3
1.0
20
3
2
1
25
2
18
3
7
1
Patient expired
12
3.0
28
4
12
4
1
4
53
4
18
3
35
5
Closed cases
406
100.0
710
100
246
100
28
100
1,390
100
701
100
689
100
Other cases except medicare:
100
Medical followup
474
83.0
239
60
140
69
15
56
868
72
356
71
512
73
Admitted to hospital:
Acute exacerbation
44
7.0
79
20
18
9
3
11
144
12
77
15
67
10
Planned
17
3.0
28
7
16
8
1
4
62
5
18
4
44
6
Disease progression
4
.7
10
3
2
1
5
18
21
2
21
3
Unrelated diagnosis
3
.6
2
1
5
1
5
1
Admitted to nursing home/ECF
12
2.0
8
2
8
4
1
4
29
2
17
3
12
2
Visiting nurse follow-up
4
.7
9
2
11
5
24
2
12
2
12
2
Patient expired
16
3.0
21
5
9
4
2
7
48
4
24
5
24
3
Closed cases
574
100.0
396
100
204
100
27
100
1,201
100
504
100
697
100
Medicare cases:
Medical followup
234
75.0
340
69
237
56
1
50
812
66
812
66
Admitted to hospital:
Acute exacerbation
37
12.0
72
15
59
14
167
14
167
14
Planned
6
2.0
15
3
11
3
32
3
32
3
Disease progression
9
3.0
18
4
14
3
41
3
41
3
Unrelated diagnosis
3
1.0
8
2
4
1
15
1
15
1
Admitted to nursing home/ECF
6
2.0
8
2
18
4
33
3
33
3
Visiting nurse followup
5
1
47
11
52
4
52
4
Patient expired
17
5.0
20
4
35
8
1
50
73
6
73
6
Closed cases
312
100.0
486
100
425
100
2
100
1,225
100
1,225
100
All cases:
Medical followup
1,048
81.0
1,091
69
558
64
34
Admitted to hospital:
60
2,731
71
898
75
1,833
70
Acute exacerbation
112
9.0
231
15
102
11
6
Planned
11
451
39
11
3.0
91
156
6
13
42
5
295
11
3
5
Disease progression
175
15
5
1.0
38
55
5
2
20
102
2
5
9
Unrelated diagnosis
16
82
6
2
.5
17
1
7
82
1
3
Admitted to nursing home/ECF
30
20
2.0
1
21
1
30
30
3
1
1
2
Visiting nurse followup
72
7
2
.5
24
34
2
2
48
60
7
2
Patient expired
101
45
3
3.0
30
69
2
4
71
56
3
6
4
6
174
5
42
3
132
5
Closed cases
1,292
100.0
1,592
100
875
100
57
100
3,816
100
1,205
100
2,611
100
101
TABLE IX.-HOME CARE DAYS AND NURSING VISITS
Total
Total
Total
A
B
C
D
1962-70
1962-65
1966-70
Blue Cross cases:
Case admitted
416
758
268
30
1,472
763
709
Total home care patient days
7,601
28,521
8,835
678
45,635
24,875
20,760
Average patient days per case
18.3
37.6
33.0
22.6
31.0
32.6
29.3
Total nursing visits
3,279
6,662
3,088
282
13.311
7,597
5,714
Average number nursing visits per case
7.9
8.8
11.5
9.4
9.0
10.0
8.1
Average number days between nursing visits
2.3
4.3
2.9
2.4
3.4
3.3
3.6
Other cases except medicare:
Cases admitted
579
413
193
29
1,214
531
683
Total home care patient days
11,293
25,579
9,246
636
46,754
23,597
23,157
Average patient days per case
19.5
61.9
47.9
21.9
38.5
44.4
33.9
Total nursing visits
5,088
4,238
2,761
266
12,353
591,6
6,437
Average number nursing visits per case
8.8
10.3
14.3
9.2
10.2
11.1
9.4
Average number days between nursing visits
2.2
6.0
3.4
2.4
3.8
4.0
3.6
102
Medicare cases:
Cases admitted
322
494
429
9
1,254
1,254
Total home care patient days
8,339
25,340
24,302
167
58,148
58,148
Average patient days per case
25.9
51.3
56.6
18.6
46.4
46.4
Total nursing visits
3,298
4,151
338
72
15,859
15,859
Average number nursing visits per case
10.2
8.4
19.4
8.0
12.7
12.7
Average number days between nursing visits
2.5
6.1
2.9
2.3
3.7
3.7
All cases:
Cases admitted
1,317
1,665
890
68
3,940
1,294
2,646
Total home care patient days
27,233
79,440
42,383
1,481
150,537
48,472
102,065
Average patient days per case
20.7
47.7
47.6
21.8
38.2
37.5
38.6
Total nursing visits
11,665
15,051
14,187
620
41,523
13,513
28,010
Average number nursing visits per case
8.9
9.0
15.9
9.1
10.5
10.4
10.6
Average number days between nursing visits
2.3
5.3
3.0
2.4
3.6
3.6
3.9
TABLE X.-DIRECT SERVICES PROVIDED HOME CARE PATIENTS
A
B
C
D
Total 1962-70
Total 1962-65
Total 1966-70
Services
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Blue Cross cases
416
758
268
30
1,472
763
709
Nursing
414
99
680
90.0
264
99.0
30
100
1,388
94.0
690
90.0
698
98.0
Physical therapy
8
2
216
28.0
48
18.0
5
17
277
19.0
170
22.0
107
15.0
Social service
16
2.0
1
.4
17
1.0
17
2.0
Speech therapy
8
1.0
5
2.0
13
1.0
7
.9
6
.8
Occupational therapy
1
.4
1
3
2
.1
2
.3
Inhalation therapy
85
11.0
85
6.0
56
7.0
29
4.0
Nutritionist
Home health aide
1
4
1
.1
1
.1
Laboratory technician
417
55.0
29
11.0
446
30.0
227
30.0
219
31.0
Drugs and medications
318
76
694
92.0
187
70.0
23
77
1,222
83.0
667
87.0
555
78.0
Laboratory procedures
231
56
425
56.0
99
37.0
13
43
768
52.0
364
48.0
404
57.0
Electrocardiograms
145
35
17
2.0
20
7.0
3
10
185
13.0
82
11.0
103
15.0
X-ray:
Diagnostic
15
4
22
3.0
31
12.0
1
3
69
5.0
38
5.0
31
4.0
Therapeutic
1
3
1
.1
1
.1
Medical/surgical supplies
168
40
141
19.0
106
40.0
15
50
430
29.0
202
26.0
228
32.0
Medical equipment rental
56
13
400
53.0
93
35.0
6
20
555
38.0
287
38.0
268
38.0
Oxygen
1
.2
47
6.0
7
3.0
55
4.0
27
4.0
28
4.0
OPD/emergency room
3
.4
2
1.0
5
.3
5
.7
103
Operating room
9
3.0
9
1.0
2
.3
7
1.0
Clinic visits
4
1.0
4
.3
4
.6
Patient transportation
3
1.0
3
.2
3
.4
Other
5
.6
2
.7
7
.5
4
.5
3
.4
Other cases except medicare
579
413
193
29
214
531
683
Nursing
577
99
370
90.0
186
96.0
28
97
1,161
96
493
93.0
668
98
Physical therapy
12
2
188
46.0
62
32.0
7
24
269
22
138
26.0
131
19
Social service.
130
31.0
130
11
130
24.0
Speech therapy
13
3.0
8
4.0
1
3
22
2
12
2.0
10
1
Occupational therapy
4
1.0
3
2.0
2
7
9
.7
9
1
Inhalation therapy
41
10.0
41
3
20
4.0
21
3
Nutritionist
Home health aide
1
2
4
2.0
5
4
5
7
Laboratory technician
199
48.0
13
7.0
212
17.0
106
20.0
106
16
Drugs and medications
358
62
271
66.0
112
58.0
21
72
762
63.0
328
62
434
64
Laboratory procedures
253
44
205
50.0
53
27.0
3
10
514
42
200
38
314
46
Electrocardiograms
131
23
5
1.0
11
6.0
147
12
43
8
104
15
X-ray:
Diagnostic
14
2
37
9.0
24
12.0
75
6
42
8
33
5
Therapeutic
3
10
3
2
3
4
Medical/surgical supplies
288
50
91
22.0
95
49.0
13
45
487
40
187
35.0
300
4
Medical Equipment rental
63
11
285
69.0
82
42.0
11
38
441
36
218
41.0
223
33
Oxygen
2
.3
33
8.0
3
2.0
2
7
40
3
16
3.0
24
4
OPD/emergency room
1
.2
6
3.0
7
.6
5
.9
2
.3
TABLE X.-DIRECT SERVICES PROVIDED HOME CARE PATIENTS-Continued
A
B
C
D
Total 1962-70
Total 1962-65
Total 1966-70
Services
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Number
Percent
Operating room
12
6.0
12
0.9
5
0.9
7
1
Clinic visits
6
3.0
6
.5
3
.6
3
.4
Patient transportation
2
1.0
2
.2
2
.3
Other
1
0.2
1
0.2
1
.5
3
.2
3
.4
Medicare cases:
322
494
429
9
254
254
Nursing
322
100
449
91.0
424
99.0
9
100
1,204
96
1,204
96
Physical therapy
4
1
261
53.0
112
26.0
4
44
381
30
381
30
Social service
2
.5
2
2
2
2
Speech therapy
20
4.0
5
1.0
25
2
25
2
Occupational therapy
5
1.0
2
.5
7
6
7
6
Inhalation therapy
39
8.0
39
3
39
3
104
Nutritionist
Home health aide
11
2.0
26
6.0
37
3
37
3
Laboratory technician
242
49.0
23
5.0
265
21.0
265
21
Drugs and medications
49
15
27
5.0
49
11.0
125
10
125
10
Laboratory procedures
174
54
243
49.0
135
31.0
3
33
555
44.0
555
44.0
Electrocardiograms
102
32.0
5
1.0
20
5.0
127
10.0
127
10.0
X-ray:
Diagnostic
2
.6
1
.2
50
12.0
53
4.0
53
4.0
Therapeutic
Medical and surgical supplies
164
5
97
20.0
209
49.0
2
22
472
38.0
472
38.0
Medical equipment rental
41
13.0
337
68.0
244
57.0
5
56
627
50.0
627
50.0
Oxygen
28
6.0
20
5.0
48
4.0
48
4.0
OPD/emergency room
3
1.0
3
.2
3
.2
Operating room
1
.2
1
.07
1
.07
Clinic visits
4
.9
4
.3
4
.3
Patient transportation
Other
1
.3
1
.2
1
.2
3
.2
3
.2
All cases
317
1,
665
890
68
940
294
646
Nursing
1,313
99
1,499
90.0
874
98.0
67
99
3,753
95
1,183
91.0
2,570
97
Physical therapy
24
2
665
40.0
222
25.0
16
24
927
24
308
24.0
619
23
Social service
146
9.0
3
.3
149
4
147
11.0
2
Speech therapy
41
2.0
18
2.0
1
1
60
2
19
1.0
41
2
Occupational therapy
9
.5
6
1.0
3
4
18
5
18
7
Inhalation therapy
165
10.0
165
4
76
6.0
89
3
Nutritionist
Home health aide
12
1.0
31
Laboratory technician
3.0
43
1
858
52.0
65
43
7.0
1
Drugs and medications
725
923
23
55
333
992
60.0
26.0
348
590
39.0
44
22
Laboratory procedures
65
658
50
2,109
54
873
995
52.0
77.0
287
32.0
1,114
42
Electrocardiograms
19
28
378
1,837
47
29
27
564
2.0
44.0
51
1,273
X-ray:
6.0
48
3
4
459
12
125
10.0
334
13
Diagnostic
30
2
60
4.0
105
12.0
Therapeutic
1
1
196
5
80
6.0
116
4
4
Medical/surgical supplies
6
4
1
620
47
329
20.0
4
410
46.0
2
30
Medical equipment rental
44
1,389
35
160
12
389
1,022
30.0
61.0
419
1,000
38
47.0
22
Oxygen
32
1,623
41
3
.2
505
108
39.0
6.0
30
1,118
42
3.0
2
3
OPD/emergency room
143
4
1
43
.07
3
3.0
100
.2
11
4
1.0
Operating room
15
.4
5
.4
10
18
4
2.0
Clinic visits
18
.5
2
.2
16
14
.6
2.0
Patient transportation
14
.4
3
.2
11
5
.4
1.0
Other
5
.1
2
.2
5
7
.2
.4
4
.4
13
.3
4
in
9
.3
105
106
107
TABLE XI.-DIRECT PATIENT SERVICES, AVERAGE CHARGE PER CASE
TABLE XI.-DIRECT PATIENT SERVICES, AVERAGE CHARGE PER CASE-Continued
Services
A
B
C
D
1962-70
1962-65
1966-70
Services
A
B
C
D
1962-70
1962-65
1966-70
Blue Cross cases
416
758
268
30
1,472
763
709
Patient transportation
$0.18
$0.07
$0.07
Other
$0.02
$0.15
.06
.06
Nursing
$39.70
$57.77
$86.85
$106.99
$58.96
$47.85
$70.92
Physical therapy
.47
17.11
17.17
10.13
12.28
14.02
10.41
Total charges
85.68
122.69
273.12
$133.12
204.12
204.12
Social service
.13
.01
.07
.13
.01
Speech therapy
2.23
.87
1.31
.92
1.73
All cases
1,317
1,665
890
68
3,940
$1,294
2,646
Occupational thrapy
.18
.80
.05
.10
Inhalation therapy
1.43
.74
.98
.48
Nursing
$46.35
$72.22
$124.81
$102.67
$76.03
$51.90
$87.84
Nutritionist
Physical therapy
.34
22.60
30.00
12.31
16.66
16.14
16.91
Home health aide
.50
.09
.19
Social service
.64
.01
.27
.83
Laboratory technician
8.04
1.10
4.34
3.97
4.74
Speech therapy
6.94
1.02
.32
3.17
2.14
3.67
Drugs and medications
10.20
44.18
19.89
31.56
29.90
31.92
27.73
Occuptational therapy
.31
.38
.35
.22
.33
Laboratory procedures
8.78
41.49
11.29
17.53
26.26
16.20
37.09
Inhalation therapy
1.23
.52
.79
.39
Electrocardiograms
14.63
.93
1.73
3.83
5.01
4.34
5.73
Nutritionist
X-ray:
Home health aide
.93
3.44
1.13
1.19
1.77
Diagnostic.
1.04
.82
2.95
1.00
1.27
1.17
1.38
Laboratory technician
7.96
.99
3.59
3.76
3.51
Therapeutic
9.60
.20
.41
Drugs and medications
7.75
33.50
10.76
22.70
19.58
31.68
13.66
Medical/surgical supplies
4.46
2.20
6.38
10.40
3.77
2.80
4.81
Laboratory procedures
7.86
41.74
12.37
11.40
23.27
14.72
27.45
Medical equipment rental
1.39
20.74
14.60
3.99
13.81
12.36
15.37
Electrocardiograms
11.11
.63
2.31
1.69
4.54
3.82
4.89
Oxygen
.12
1.37
.41
.81
.87
.75
X-ray:
OPD/emergency room
.08
.01
.02
Diagnostic
.67
.93
2.99
.44
1.30
1.37
1.27
Operating room
.77
.14
.08
.20
Therapeutic
11.38
.20
.30
Clinic visits
.15
.03
.06
Medical and surgical supplies
5.20
2.93
10.60
6.62
5.49
3.07
6.67
Patient transportation
.34
.06
.12
Medical equipment rental
1.35
28.82.
22.33
11.60
17.89
16.81
18.42
Otner
.10
.42
.25
.28
.18
.39
Oxygen
.06
1.96
1.99
4.54
1.37
.88
1.61
OPD/emergency room
.10
.02
.03
Total charges
80.90
198.86
165.52
195.83
159.39
137.79
182.64
Operating room
.47
.11
.10
.11
Clinic visits
.01
.10
.02
.01
.02
Other cases excluding medicare
579
413
193
29
1,214
531
683
Patient transportation
.05
.14
.05
.07
Other
.06
.20
.18
.15
.11
.17
Nursing
$46.11
$81.26
$99.72
$106.96
$68.03
$57.74
$76.04
Physical therapy
.32
29.68
37.28
11.76
16.46
19.18
14.35
Total charges
80.76
223.59
224.99
187.15
175.64
148.13
189.09
Social service
2.36
.80
1.83
Speech therapy
6.13
2.62
.76
2.52
3.89
1.45
Occupational therapy
.59
.85
.34
.60
TABLE XII.-AVERAGE PER DIEM CHARGE
Inhalation therapy
1.29
.44
.53
.37
Nutritionist
Home health aide
.46
2.17
2.66
.57
1.01
Services
A
B
C
D
1962-70
1962-65
1966-70
Laboratory technician
8.10
.82
2.89
3.46
2.45
Drugs and medications
9.15
52.07
14.20
20.55
24.83
31.35
19.76
Laboratory procedures
6.31
37.57
9.58
3.03
17.39
12.59
21.12
Blue Cross cases:
Electrocardiograms
8.98
.36
1.37
4.62
3.08
5.82
Number of home care days
7,601
28,521
8,835
678
45,635
24,875
20,760
X-ray:
Diagnostic
.76
2.22
2.72
1.55
1.65
1.47
Nursing
$2.17
$1.55
$2.63
$4.73
$1.91
$1.47
$2.43
Therapeutic.
16.76
.40
.71
Physical therapy
.03
.45
.52
.45
.39
42
.35
Medical/surgical supplies
5.05
3.30
9.85
4.57
5.21
3.46
6.57
Social service
.005
.005
0.
.01
Medical equipment rental
1.10
41.71
17.78
17.23
17.95
23.20
13.87
Speech therapy
.06
.03
.04
.03
.05
Oxygen
.06
2.95
.13
10.65
1.31
.88
1.64
Occupational therapy
.01
.04
.005
.01
OPD/emergency room
.19
.03
.05
Inhalation therapy
.04
.02
.03
.01
Operating room
.90
.14
.13
.15
Nutritionist
Clinic visits
.01
.13
.02
.01
.03
Home health aide
.02
.005
.01
Patient transportation
.17
.03
.05
Laboratory technician
.21
.03
.14
.12
.16
Other
.06
.02
.12
.05
.09
Drugs and medications
.55
1.18
.60
1.40
.97
.98
.96
Laboratory procedures
.48
1.10
.34
.78
.84
.50
1.25
Total
77.91
270.07
200.60
194.93
165.58
162.98
167.60
Electrocardiograms
.81
.02
.05
.17
.16
.13
.20
X-ray:
Medicare cases
322
494
429
9
1,254
1,254
Diagnostic
.06
.02
.09
.04
.04
.04
.04
Therapeutic
.42
.01
.02
Nursing
$55.22
$86.80
$159.83
$74.44
$103.59
$103.59
Medical/surgical supplies
.25
.06
.19
.46
.12
.09
.16
Physical therapy
.21
25.12
34.73
21.33
21.98
21.98
Medical equipment rental
.07
.55
.44
.18
.44
.38
.51
Social service
.01
.01
.01
Oxygen
.01
.04
.01
.03
.03
.03
Speech therapy
14.85
.40
5.99
5.99
OPD/emergency room
.005
.005
.01
Occupational therapy
.56
.30
.32
.32
Operating room
.02
.005
0.
.01
Inhalation therapy
.89
.35
.35
Clinic visits
.01
.005
.01
Nutritionist
Patient transportation
.01
.005
.01
Home health aide
2.75
5.84
3.08
3.08
Other
.01
.01
.005
.01
.01
Laboratory technician
7.70
1.00
3.38
3.38
Drugs and medications
2.08
1.59
3.51
2.36
2.36
Total charges
4.43
5.29
5.02
8.67
5.15
4.23
6.25
Laboratory procedures
9.50
45.62
14.29
17.89
25.43
25.43
Electrocardiograms
10.42
.36
3.11
3.88
3.88
X-ray:
Diagnostic
.04
.03
3.13
1.09
1.09
Therapeutic
Medical/surgical supplies
6.41
3.76
13.59
67
7.78
7.78
Medical equipment rental
1.78
30.43
29.22
18.80
22.58
22.58
Oxygen
2.05
3.79
2.10
2.10
OPD/emergency room
.09
.03
.03
Operating room
.07
.02
.02
Clinic visits
.06
.02
.02
74-331 0-72-8
108
109
TABLE XII.-AVERAGE PER DIEM CHARGE-Continued
TABLE XIII.-AVERAGE CHARGE FOR EACH SERVICE AS A PERCENTAGE OF TOTAL DIRECT SERVICE CHARGES
Services
A
B
C
D
1962-70
1962-65
1966-70
Hospitals
Other cases excluding medicare:
Number of home care days
11,293
25,579
9,246
636
46,754
23,597
23,175
Direct services
A
B
C
D
1962-70
1962-65
1966-70
Nursing
$2.37
$1.30
$2.08
$4.87
$1.76
$1.29
$2.24
Physical therapy
.02
.48
.78
.54
43
.42
43
Blue Cross Cases:
Social service
.04
.02
.04
Nursing
49.1
29.1
52.5
54.6
37.0
34.7
38.8
Speech therapy
10
.05
.03
.07
.09
.04
Physical therapy
.6
8.6
10.4
5.3
7.7
10.2
5.7
Occupational therapy
.02
.02
Social service
.01
.01
.1
.1
.1
.1
Inhalation therapy
.02
.01
.01
.01
Speech therapy
1.1
.5
.8
.7
.9
Nutritionist
Occupational therapy
.1
.4
.1
.1
Home health aide
.01
.05
.12
.01
.03
Inhalation therapy
.7
.4
.7
.3
Laboratory technician
.13
.02
.08
.08
.08
Nutritionist
Drugs and medications
.47
.84
.30
.93
.65
.71
.58
Home health aide
.3
1
1
Laboratory procedures
.33
.61
.20
.14
.45
.28
.63
Laboratory technician
4.0
.6
2.7
2.9
2.6
Electrocardiograms
.47
.01
.03
.12
.07
.17
Drugs/medications
12.6
22.2
12.0
16.1
18.7
23.2
15.2
X-ray:
Laboratory procedures
10.9
10.9
6.7
9.0
16.5
11.8
10.4
Diagnostic
.04
.04
.06
.04
.04
.04
Electrocardiograms
18.1
.5
1.1
2.0
3.1
3.1
3.1
Therapeutic
.76
.01
.02
X-ray:
Medical/surgical supplies
.26
.05
.21
.21
.14
.08
.19
Diagnostic
1.3
.4
1.7
.5
.8
.8
.8
Medical equipment rental
.06
.67
37
.79
.47
.53
.41
Therapeutic
4.9
.1
.2
Oxygen
.05
0
.49
03
.02
.05
Medical/surgical supplies
5.5
1.1
3.8
5.3
2.4
2.0
2.6
OPD/emergency room
0
0
0
Medical equipment rental
1.7
10.4
8.8
2.0
8.7
9.0
8.4
Operating room
02
0
0
0
Oxygen
.1
.7
.3
.5
.6
.4
Clinic visits
0
0
0
0
OPD/emergency room
.1
Patient transportation
0
0
0
0
Operating room
.5
.1
.1
.1
Other
0
0
0
0
Clinic visits
.1
Patient transportation
.2
.1
Total charges
4.02
4.36
4.19
8.89
4.30
3.67
4.94
Other
.1
.2
.2
.2
.1
.2
Medicare cases:
Total direct service
100.0
100.0
100.0
100.0
100 0
100.0
100.0
Number of home care days.
8,339
25,340
24,302
167
58,148
58,148
Other cases excluding medicare:
Nursing
59.2
30.1
49.7
54.9
41.1
35.4
45.4
Nursing
$2.13
$1.69
$2.82
$4.01
$2.23
$2.23
Physical therapy
.4
11.0
18.6
6.0
9.9
11.8
8.6
Physical therapy
.01
.49
61
1.15
47
47
Social service
9
.5
1.1
Social service.
0.
0.
0.
Speech therapy
2.3
1.3
.4
1.5
2.5
.8
Speech therapy
29
.01
.13
.13
Occupational therapy
.2
.4
.2
.4
Occupational therapy
.01
.01
.01
.01
Inhalation therapy
.5
.3
.3
.2
Inhalation therapy
.02
.01
.01
Nutritionist
Nutritionist
Home health aide
.2
1.1
1.4
.3
6
Home health aide
.05
.10
.07
.07
Laboratory technician
3.0
.4
1.7
2.1
1.5
Laboratory technician
.15
.02
.07
.07
Drugs/medications
11.7
19.3
7.1
10.5
15.0
19.3
11.8
Drugs and medications
.08
.03
.06
.05
.05
Laboratory procedures
8.1
13,9
4.7
1.6
10.5
7.7
12.6
Laboratory procedures
.37
.90
.25
.96
.55
.55
Electrocardiogram
11.5
.1
.7
2.8
1.9
3.5
Electrocardiograms
.40
.01
.05
.08
.08
X-ray:
X-ray:
Diagnostic
1.0
.8
1.4
.9
1.0
.8
Diagnostic.
0.
0.
.06
.02
.02
Therapeutic
8.6
.2
.4
Therapeutic
Medical/surgical supplies
6.5
1.2
4.8
2.3
3.1
2.1
3.9
Medical/surgical supplies
.25
.07
.24
04
.17
.17
Medical equipment rental
1.4
15.4
8.9
8.8
10.8
14.2
8.3
Medical equipment rental
.07
.59
.59
1.01
.49
.49
Oxygen
.1
1.1
.1
5.5
.8
.5
1.0
Oxygen
.04
.07
05
.05
OPD/emergency room
.1
.1
OPD/emergency room
0.
0.
0.
Operating room
.4
.1
.1
.1
Operating room
0.
0.
0.
Clinic visits
.1
Clinic visits
0.
0.
0.
Patient transportation
.1
Patient transportation
0.
0.
0.
Other
.1
.1
.1
.1
Other
0.
0.
0.
0.
Total direct service
100.0
100.0
100.0
100.0
100.0
100.0
100.0
Total charges
3.32
4.34
4.82
7.17
4.40
4.40
Medicare cases:
Nursing
64.4
39.0
58.6
55,9
50.8
50.8
All cases:
Physical therapy
.2
11.3
12.7
16.0
10.8
10.8
Number of home care days
27,233
79,440
42,383
1,481
150,537
48,472
102,065
Social service
Speech therapy
6.6
.1
2.9
2.9
Nursing
$2.24
$1.51
$2.62
$4.71
$1.99
$1.39
$2.28
Occupational therapy
3
.1
.1
.1
Physical therapy
.02
.47
.63
.57
.44
.43
.44
Inhalation therapy
.4
.2
.2
Social service
.01
0.
.01
.02
Nutritionist
Speech therapy
.15
.02
.01
.08
.06
.10
Home health aide
1.2
2.1
1.5
1.5
Occupational therapy
.01
.01
.02
.01
.01
Laboratory technician
3.5
.4
1.7
1.7
Inhalation therapy
.03
.01
.02
.01
Drugs/medications
2.4
.7
1.3
1.2
1.2
Nutritionist
Laboratory procedures
11.1
20.4
5.3
13.4
12.5
12.5
Home health aide
.02
.07
.05
.03
.05
Electrocardiograms
12.2
.2
1.1
1.9
1.9
Laboratory technician
.17
.02
.09
.10
.09
X-ray:
Drugs and medications
.37
.70
.23
1.04
.51
.85
.35
Diagnostic
.1
1.1
.5
.5
Laboratory procedures,
.38
.87
.26
.52
.61
.39
.71
Therapeutic
Electrocardiograms
.54
.01
.05
.08
.12
.10
.13
Medical/surgical supplies
7.5
1.7
5.0
5
3.8
3.8
X-ray:
Medical equipment rental
2.1
13.7
10.7
14.2
11.1
11.1
Diagnostic
.03
.02
.06
.02
.03
.04
.03
Oxygen
.9
1.4
1.0
1.0
Therapeutic
.52
.01
.68
OPD/emergency room
Medical/surgical supplies
.25
.06
.22
.30
.14
.08
.17
Operating room
Medical equipment rental
.07
.60
.47
.53
.47
.45
.48
Clinic visits
Oxygen
0.
.04
04
.21
04
.02
.04
Patient transportation
.1
OPD/emergency room
0.
0.
0.
Other
.1
Operating room
01
0.
0.
0.
Clinic visits
0.
0.
0.
0.
Total direct service
100.0
100.0
100.0
100.0
100.0
100.0
Patient transportation
0.
0.
0.
0.
0.
Other
0.
0.
0.
0.
0.
0.
Total charges
3.90
4.69
4.72
8.59
4.60
3.95
4.90
Other
Pt. transportation
Clinic visits
Operating room
OPD/emergency room
Oxygen
X-ray:
Laboratory procedures.
Drugs/medications
Laboratory technician
Nutritionist
All cases:
Total direct service
Medical equipment rental
Medical/surgical supplies
Therapeutic
Diagnostic
Electrocardiograms
Home health aide
Inhalation therapy
Occupational therapy
Speech therapy
Social service
Physical therapy
Nursing
Direct services
100.0
1"
1.7
6.4
8'
13.8
9.7
9.6
57.4
A
100.0
.1
12.8
18.7
10.1
1
9.
1.3
.4
4
3
15.0
3.6
4
9'
.1
3.1
3
32.3
B
CHARGES-Continued
TABLE XIII.-AVERAGE CHARGE FOR EACH SERVICE AS A PERCENTAGE OF TOTAL DIRECT SERVICE
110
Hospitals
100.0
1
2
1"
is
9.8
4.7
1.3
1.0
5.5
4.8
4
1.5
52
13.3
55.5
C
100.0
2.4
6.2
3.5
6.1
2
is
6.1
6.
12.1
6.6
54.9
6
22
D
100.0
.1
.1
8'
10.2
1
3.1
.7
2.7
13.2
11.1
2.0
7
3
1.8
2
9.5
43.3
1962-70
100.0
1
.1
1
6
11.3
2.1
.9
2.6
9.9
21.5
2.5
is
5
1.4
6
10.9
35.0
1962-65
100.0
is
9.7
3.5
2
.7
7
2.6
14.6
7.2
1.9
9
.2
1966-70
2
1.9
8.9
46.5
TABLE XIV.-DIRECT SERVICE CHARGES AND INDIRECT COSTS
Direct service charges
Indirect costs
All cases
Blue Cross
Blue Cross
Blue Cross
Total expenses
cases
Other cases
All cases
cases
Other cases
All cases
cases
Other cases
1962-70
1962-65
1966-70
Hospital:
A
$33,656
$72,699
$106,355
$24,971
$52,360
$77,331
$58,627
B
$125,059
150,734
221,547
$183,686
372,281
$66,385
106,930
$117,303
178,078
285,008
C
257,664
399,625
44,359
155,884
657,289
200,243
209,666
31,050
447,623
92,790
123,840
75,400
248,674
D ²
324,083
5,875
29,504
6,851
12,726
8,406
294,575
10,698
19,104
14,281
17,549
31,830
31,830
Total
234,624
456,981
691,605
171,357
333,926
505,283
405,981
790,907
1,196,888
305,555
891,331
Average per case: Hospital:
A
80.90
80.69
80.70
60.03
58.11
58.72
140.93
138.80
139.48
B
149.18
134.52
198.86
244.26
223.59
141.07
196.34
171.18
339.93
440.60
C
394.77
299.52
165.52
463.86
111
250.62
224.99
115.86
149.18
139.15
281.38
399.80
D 2
364.14
198.02
195.83
397.55
180.29
185.15
280.20
281.53
280.94
476.03
461.82
468.09
468.09
Average all cases
159.38
185.16
175.53
116.41
135.30
128.25
275.80
320.46
303.78
236.13
336.86
Average per home care pa-
tient day: Hospital:
A
4.43
3.70
3.90
3.28
2.67
2.84
7.71
6.37
6.74
7.51
6.38
B
5.29
4.35
4.69
3.74
3.50
3.59
9.03
7.85
8.28
6.29
9.71
C
5.02
4.65
4.72
3.51
2.77
2.92
8.53
7.42
7.64
4.69
8.16
D 2
8.67
8.53
8.59
12.40
13.32
12.90
21.07
21.85
21.59
21.49
Average all cases
5.14
4.36
4.59
3.75
3.18
3.36
8.89
7.54
7.95
6.30
8.73
1 Unaudited figures.
2 Indirect costs estimated.
112
113
TABLE XV.-ESTIMATED NUMBER OF INPATIENT DAYS SAVED DUE TO USE OF HOME CARE SERVICE
The continuing goal of the Home Care program is to provide outstanding
and highly individualized post-hospital care at home for many thousands of
A
B
C
D
1962-70
1962-65
1966-70
patients. Progress toward that goal is summarized in this report.
The report includes data on the entire group of Home Care patients and more
Estimated members of inpatient days saved:
detailed information about experience gained in the first five thousand cases.
Blue Cross cases
5,122
7,528
3,592
369
16,611
6,953
9,658
The aggregate hospital stays for these first 5,000 cases were reduced by more
Other cases excluding medicare
7,661
7,322
3,253
296
18,532
9,311
9,221
than 113,000 days, and illness costs were reduced by over $3.6 million dollars.
Medicare cases
3,994
6,197
5,364
102
15,657
15,657
This amount includes patient savings of $2.1 million dollars and Blue Cross
All cases
16,777
21,047
12,209
767
50,800
16,264
34,536
savings of $1.5 million dollars.
The Home Care program offered by a participating hospital develops at a
Estimated average days saved per case:
Blue Cross cases
12.3
9.93
13.4
12.3
11.3
9.1
13.6
controlled pace; full use is attained in from two to three years. Experience
Other cases excluding medicare
13.2
17.73
16.9
10.2
15.3
17.5
13.5
to date confirms earlier estimates that at least ten percent of any general hos-
Medicare cases
12.4
12.54
12.5
11.3
12.5
12.5
pital's medical, surgical, and pediatric patients are at one time or another
All cases
12.7
12.64
13.7
11.3
12.9
12.6
13.1
candidates for Home Care instead of continued hospital confinement.
Number of hospital beds made available due to
For the 5,000 cases, combined hospital and home care averaged 90 days at a
estimated inpatient days saved
5.6
9.1
6.5
1.5
6.6
5.3
7.4
per diem cost of $10.24. The average per diem Blue Cross payment for the in-
hospital portion of the combined care was $31.28: for Home Care portion, $3.05.
The combined care costs were higher for older age groups.
TABLE XVI.-VALUE OF ESTIMATED INPATIENT DAYS SAVED BASED ON AVERAGE PER DIEM COSTS
The older the age group, the higher the costs of both in-hospital and Home
Care.
A
B
C
D
1962-70
1962-65
1966-70
5,000 CASES: BLUE CROSS PAYMENTS FOR IN-HOSPITAL AND HOME CARE, BY AGE GROUP
Blue Cross cases
$175,679
$378,044
$210,156
$32,103
$795,982
$219,960
$576,022
Other cases
276,214
327,050
304,488
8,874
916,626
299,981
616,645
Medicare cases
185,891
365,417
205,599
25,752
782,659
782,659
Average per case payment
All cases
637,784
1,070,
720,243
66,729
2,495,267
519,941
1,975,326
Number
In-hospital
Home
Combined
Less home care service charges and
Age group in years
of cases
care
care
care
indirect costs
183,688
657,289
324,079
31,830
1,196,886
305,555
891,331
Estimated net value
454,096
413,222
396,162
34,899
1,298,381
214,386
1,083,995
345
248
445
513
330
Total
Estimated net value per case
166
410
5,000
$717.08
$204.69
$921.77
Per diem average:
1 Unaudited figures.
Under 12
148
569.03
136.
705.
TABLE XVII.-BLUE CROSS EXPERIENCE
13 to 19
100
640.7
147. 10
787. 83
20 to 34
180
624.49
166.2 23
790. 72
35 to 49
747
624.24
193. 45
817. 69
A
B
C
1962-70
1962-65
1966-70
50 to 64
D
866
723.1
211.
935. 04
65 to 74
1,374
760.
214.
974.98
75 and over
576
795. 47
214.73
1,010.20
Value of estimated inpatient days saved_
$175,679
$378,044
$210,156
$32,103
$795,982
$219,960
$576,022
Not given
9
602.
83.10
685.
Less home care service charges and in-
direct costs
58,627
257,664
75,408
14,281
405,980
163,331
242,649
Estimated net value
117,052
120,380
134,748
17,822
390,002
56,629
333,373
Estimated net value per case
281
159
529
594
265
74
470
For the 5,000 cases, combined hospital and home care averaged 90 days at a
per diem cost of $10.24. The average per diem Blue Cross payment for the in-
hospital portion of the combined care was $31.28; for Home Care portion $3.05.
1 Unaudited figures.
The combined care costs were higher for the older age groups. The older the
age group, the higher the costs both in-hospital and Home Care.
ITEM 2. EXCERPTS FROM: HOME CARE FOLLOWING HOSPITALIZA-
PATIENT AND FAMILY REACTIONS
TION, ASSOCIATED HOSPITAL SERVICE OF NEW YORK
In considering patient and family reactions to Home Care, it should be real-
INTRODUCTION
ized that the program is designed to provide high quality individualized care
Pre-planned post-hospital Home Care sponsored by Associated Hospital Serv-
to selected patients, that use of Home Care is voluntary, and that it is available
ice of New York has gained wide acceptance among patients, their families,
only when recommended by the attending physicians.
attending physicians and participating Home Care hospitals.
The first reaction to Home Care by patients and their families is satisfaction
This Greater New York area program was started in 1960, following a five-
because it shortens hospital confinement while providing continuity of care under
year study conducted by Associated Hospital Service of New York in the pro-
direct supervision of the attending physicians.
vision of pre-planned post hospital visit-nurse care at home.
When Home Care ends. Blue Cross requests patient and family appraisals
This study showed that remarkable improvement in patient health and well-
of the service. In the 2.000-case group, 1.720 (85 percent) replied. Those not
being resulted from use of pre-arranged visiting nurse care for hospital pa-
replying either could not be located, or used Home Care again at a later date,
tients carefully selected by their own physicians. It also showed that these
or had died. Of those replying. 1,708 evaluations were favorable, with strong
patients' hospital stays were shortened and their over-all costs of illness re-
and common emphasis on the feelings of security that Home Care gave to pa-
duced.
tients and families. The individualized Home Care approach seems to be highly
In addition, the study led to understanding of the kind of structure, stand-
prized by patients and families.
ards and controls which would be needed for an effective permanent program
Frequently mentioned points pertaining to overall satisfaction with Home
of post hospital care at home for large numbers of patients.
Care include: belief that recovery or improvement is hastened; gratification with
Associated Hospital Service of New York designed such a program and then
the earlier return to the home; comfort in the observed close working relation-
requested changes in the New York State Insurance Law to permit coverage
ship between public health nurse and attending physician; the conviction that
by Blue Cross of the Home Care services now provided. The Law was changed
in 1959. The first participating hospital started Home Care one year later.
114
115
much has been learned about self-care or the care of a family member; elimina-
ITEM 3. EXCERPTS FROM THE 10TH ANNUAL REPORT OF THE HOME
tion of the need for family members to visit the patient in the hospital; saving
CARE ASSOCIATION, ROCHESTER, N.Y., MAY 11, 1971
of Blue Cross coverage for later use; reduction in costs of care; and freeing
a hospital bed for other sick people. Much praise and many blessings are be-
ADMISSIONS
stowed upon the hospitals, the physicians, the public health nurses and Blue
10 YEAR GROWTH
Cross.
1961-70 CALENDAR YEARS
Patient and family judgments are important in evaluating Home Care; favor-
1554
able appraisals indicate that patients and their families make personal as-
1970
sessments of professional competence. It seems logical to assume that unless
1555
1969
patients and families were favorably impressed as to competence, they would
not express feelings of security with such unanimity and enthusiasm.
1331
1968
Nevertheless, overwhelmingly favorable patient and family response in no
1234
way lessens professional obligation for evaluation of the quality of care pro-
1967
vided under Home Care and work toward ever higher performance standards.
1131
1966
811
PHYSICIAN REACTIONS
1965
661
In these 2,000 cases 1,606 (80 percent) of the attending physicians responded
1964
to Blue Cross requests for medical appraisals of Home Care. It is significant
545
that among Home Care patients are physicians themselves and members of their
1963
386
families.
1962
Physicians approve of Home Care because it is voluntary and because they
141
are responsible for the final selection and continuing management of their
1961
patients.
HOME CARE COSTS VERSUS HOSPITAL COSTS FISCAL YEARS 1961-1971
15.58
$92.00
1970-71
13.68
76.37
1969-70
11.95
69.07
1968-69
12.05
59.83
1967-68
11.90
51.17
1966-67
11.32
45.80
1965-66
10.78
42.17
1964-65
8.99
40.15
1963-64
8.44
38.09
1962-63
$ 7.53
$36.07
1961-62
HOSPITAL
HOME CARE
116
117
AVERAGE COST OF CARE
FISCAL YEARS
HOME CARE ASSOCIATION
PER PATIENT DAY
ESTIMATED SAVINGS RESULTING FROM HOME CARE
CALENDAR YEAR 1970
1968-69
1969-70
1970-71
Total Patients Admitted
1554
Home Care Administration
$ 1.72
$ 1.80
$ 2.01
Purchased Health Services
9.95
11.58
13.22
(1) Total Patients who would have
Medical Social Casework
.28
.30
.35
received hospital care as an
alternative to Home Care
653
$11.95
$13.68
$15.58
Patient days hospital care
saved by Home Care, average
per patient
21
Total hospital patient days
saved
13,713
Average hospital cost per day
MAJOR DIAGNOSTIC CATEGORIES
in Monroe County
$
92.00
1970 CALENDAR YEAR
BY PERCENTAGE DISTRIBUTION
Average Home Care cost per day
$
15.10
Net savings per day
$
76.90
Diagnostic Category
All Admissions
Under age 65
Over age 65
Total savings per year
$1,054,529.70
Cancer
22%
54%
46%
(2) Total hospital beds released
Cardiac
15%
32%
68%
42
CVA
8%
32%
68%
Orthopedic
32%
62%
38%
General Surgery
7%
57%
43%
Other
16%
49%
51%
(1) Estimated from a 1970 survey of physicians who reported that 42% of 297 patients studied
would have required an average of 21 additional hospital days care. This figure is conservative
since 83% of responding physicians agreed that further hospitalization would have been required
ALL ADMISSIONS
100%
but 57% of these physicians declined to estimate the number of days.
(2) Based on approximately 90% utilization, i.e., 325 patient days per hospital bed per year.
Average length of stay
40 days
44 days
36 days
Median length of stay
31 days
34 days
29 days
118
119
ITEM 4. EXCERPTS FROM HOMEMAKER-HOME HEALTH AIDE
SERVICES IN NEW JERSEY ANNUAL REPORT
Most patients served had marginal incomes; over 70 percent had cate-
gorical aid or Social Security as their principal source of income.
Almost two-thirds had multiple diagnoses. The most frequently reported
HI-LITES OF 1970
were heart conditions (28 percent), arthritis (21 percent), orthopedic con-
New Jersey's twenty-four homemaker agencies received 14,211 applications
ditions (19 percent), neoplasms (15 percent), and cerebral vascular acci-
for service.
dents and their residuals (14 percent).
9380 patients received, 1,362,677 hours of service this year.
In a given admission, approximately one-half of the group used in-home
80 percent of the patients accepted for service this year were female.
services for less than six months. One-third were still receiving services a
The Placement of a homemaker-home health aide prevented hospitalization for
year after admission (Table 2).
One-third of the patients studied averaged less than ten hours' home-
2465 persons in 1970.
65 percent of the patients were sixty-five years of age or older; 23 percent were
maker/aide service a month; one-third required 10 to 19 hours; the other
between 19 and 49; 11 percent were between 50 and 64; one percent were younger
one-third, 20 hours or more (Table 3).
Over a period of time, intermittent service was provided to one-third
than 19.
2435 instances of employment absenteeism were prevented by the placement
of the study group; these persons had other admissions to agency service
during the ten-year period, either before or after the study admission.
of a homemaker-home health aide.
1334 homemaker-home health aides were employed in December 1970.
The individual who is fairly typical of the candidates for home health services
25 training courses were held and 443 new homemakers trained.
under Title XVIII usually lives alone in a small apartment, a rooming house,
Hospital discharge was facilitated for 2228 persons because of the availability
or, less frequently, a single dwelling. He rarely has assistance available from
family or relatives. He is able to get along with part-time assistance, usually
of a homemaker-home health aide.
averaging less than 20 hours per month (often in larger volume during the first
weeks of illness and tapering off with convalescence) provided that such assist-
TOTAL PATIENTS SERVED AND HOURS OF SERVICE BY DIAGNOSIS
ance is realistically geared to his circumstances. This means that he is provided
with planned care during those hours, in that amount, and of the kind that he
Number of
Number of
Diagnosis
patients
Percentage
hours
Percentage
particularly needs while he is too ill to maintain himself. Plans may change
from day to day during his period of illness and recovery.
Virtually all plans for service include maintenance of bathroom and food
Heart and circulatory
2,721
29
434,350
32
Bones
1,111
12
177,384
13
preparation areas and preparation of linens for laundry. Almost invariably food
Cancer
896
10
105,674
8
shopping is essential, either in the pattern of providing a supply of food which
Accidents and injuries
747
8
103,959
8
can be prepared ahead and used by the patient in the absence of assistance or,
Nervous system
548
6
97,122
7
6
28,115
2
where refrigeration and storage are limited (as is often the case), on a more
Pregnancy
561
Aging
487
5
115,093
8
frequent basis.
Digestive system
492
5
47,333
3
The provision of limited household maintenance and food are SO inextricably
Genitourinary
342
4
37,805
3
Respiratory
296
3
29,663
2
bound up with bathing, bed-changing, assistance with ambulation and retraining
Neuropsychiatric
244
2
31,197
2
that "costing them out" of the reimbursable charge becomes difficult and unreal-
Infectious diseases
79
1
8,774
1
istic (as is surveillance which shifts eligibility on the basis of how many visits
Other
856
9
146,208
11
outside the home are made by the patient for treatment in any given week).
Total
9,380
100
1,362,677
100
Neither does it appear to be feasible in these predominantly single unit dwellings
to provide one subspecialist for personal care and another subspecialist for the
maintenance and support services that are essential to most older patients
Average hours per patient 145.
during periods of illness.
TABULATIONS
ITEM 5. EXCERPTS FROM REPORT BY SAN FRANCISCO
HOME HEALTH SERVICE
Data given is drawn from a study of case characteristics and service patterns
based upon a single admission (ignoring later admissions during a study
The following data is drawn from statistical compilations during a study
year) during two years following admission to service. Patients studied were
period in an agency which has provided in-home services (the range of personal
admitted 8/64 to 7/65. Over the ten-year period 1957-1966 this agency received
care, rehabilitation in activities of daily living, environmental maintenance,
9411 referrals for service and accepted 3024 for in-home services.
assistance in reaching medical resources, and assistance in planning health care
The study group consisted of 359 patients admitted to service in the year
and allied services) to older individuals. Data has been gathered over a ten
August, 1964, to July, 1965; information was recorded for the two years after
year period during which approximately 10,000 referrals were received.² Services
admission. (Length of service and hourly data given are based on this single
are provided in approximately 700 households per month in an urban community
admission, although 25 of the patients were readmitted during the year.) The
well supplied with medical resources: 3
age, living arrangement, income source and diagnoses reported at admission
More than 70 percent of the persons admitted were aged 65 and over;
were similar to those of 3024 admissions to agency service over a ten-year
one-fourth were 80 or over.
period. (Table 1)
Two-thirds were persons living alone.
Of those having other persons in the household, in 39 percent of the
cases there were other ill persons in the home.
1 1957-1966.
2 See tabulations.
3 Refers to basic level of care.
120
121
TABLE 1.-CHARACTERISTICS OF PATIENTS SERVED BY SAN FRANCISCO HOME HEALTH SERVICE COMPARISON
TABLE 3.-SAN FRANCISCO HOME HEALTH SERVICE, HM/HHA SERVICE PROVIDED DURING 2 YEARS FOLLOWING
OF 1964-65 STUDY GROUP AND ALL ADMISSIONS, 1957-66
ADMISSION, PATIENTS ADMITTED AUGUST 1964 TO JULY 1965
1964-65 study group
All 1957-66 admissions
Average monthly hours in 2 years following admission
Patient characteristics
Number
Percent
Number
Percent
Under 10
10 to 19
20 hours
Diagnosis, age at admission
Under 10
10 to 19
20 hours
Total
hours
hours
or more
Total
hours
hours
or more
Total patients admitted
359
100.0
3,024
100. 0
Sex, age at admission:
Male
67
18.6
639
20.9
All diagnoses
359
121
121
117
100
33.8
33.8
32. 6
Under 65
18
4.0
186
6.1
Arthritis
77
24
22
31
100
31.1
28.5
40.5
65-79
21
5.8
264
8.7
80 and over
28
7.8
186
6.1
Under 65
12
6
2
4
65 and over
100
(2)
(2)
Not stated
3
(3)
65
18
(2)
20
27
100
27.6
30.7
41.5
Female
292
81.3
2,385
78.6
Heart
101
34
33
34
100
33.6
32.6
33.6
Under 65
82
22.8
710
23.4
65-79
141
39.2
1,144
37.6
Under 65
18
6
8
4
80 and over
64
17.9
511
65 and over
100
(2)
(2)
81
(2)
16.9
27
25
29
Not stated
100
33.3
30.8
35.8
Not stated
5
1.4
20
.7
2
1
1
100
(2)
Living arrangement:
(2)
Person living alone
245
68.0
1,806
59.8
Neoplasms
52
17
13
22
100
32.7
25.0
42.4
Person living with others
114
32.0
1,218
40.2
Percent of persons living with others where there are
Under 65
27
8
7
12
100
65 and over
29.6
26.0
44.5
other ill persons in household
38.6
37.9
23
7
6
10
Not stated
100
(2)
Principal source of income: Categorical aid
200
2
(2)
55.6
1,403
46.5
2
(2)
100
(2)
Not categorical aid
159
44.4
1,621
53.4
CVA and residuals
49
13
20
16
100
26.6
40.8
32.7
Social security
57
15.9
549
18.1
Pension, disability insurance
32
9.0
239
8.0
Under 65
11
4
5
2
100
(2)
(2)
(2)
Wages or other
70
19.3
832
27.3
65 and over
38
9
15
14
100
23.7
39.4
36.8
Diagnoses most often reported:
Arthritis
77
21.4
452
14.9
Orthopedic
69
19
22
28
100
27.6
31.9
40.5
Heart conditions
101
28.0
799
26.2
Neoplasms
52
14.5
374
12.4
Under 65
22
8
5
9
13.6
10.6
65 and over
100
(2)
49
321
46
(2)
(2)
Cerebral vascular accidents and residuals
11
17
18
19.2
470
Not stated
100
23.9
37.0
39.0
Orthopedic
69
15.5
1
1
100
(2)
(2)
1 First admission during study period only.
2 Each admission counted separately; total referrals for period, 9,411.
1 1st admission during year only.
3 Less than .01.
2 Percents not computed for fewer than 25.
4 Same patient may be counted under more than one diagnosis.
Note: Diagnostic groups include patients with this diagnosis as 1 of 3 possible recorded conditions; the same person
TABLE 2.-SAN FRANCISCO HOME HEALTH SERVICE, HM/HHA SERVICE PROVIDED DURING 2 YEARS FOLLOWING
may be shown under more than 1 group: Arthitis, ICD 720-727; Heart, ICD 410-443; Neoplasms, ICD 140-205, 210-239
ADMISSION PATIENTS ADMITTED AUGUST 1964 TO JULY 19651
dystrophy), 758; Fractures or absence of limbs.
(or mention of colostomy, mastectomy); CVA, ICD 330-334, 352; Orthopedic, ICD 730-738, 740-749 (excluding muscular
Length of service in 2 years following admission
24
24
Diagnosis age at
Under 6
6 to 11
12 to 23
months
Under 6
6 to 11
12 to 23
months
admission
Total
months
months
months
or more
Total
months
months
months
or more
All diagnoses
359
181
63
61
54
100
50.0
17.5
17.0
15.
Arthritis
77
32
12
16
17
100
41.6
15.6
20.8
22.
Under 65
12
8
4
100
(2)
(2)
(2)
(2)
65 and over
65
24
18
16
17
100
37.0
12.3
24.6
26.2
Heart
11
51
18
17
15
100
50.5
17.8
16.8
148
Under 65
18
10
4
2
2
100
(2)
(2)
(2)
(2)
65 and over.
81
39
14
15
13
100
48.1
17.3
18.5
16.
Not stated
2
2
100
Neoplasms
52
38
6
5
3
100
73.0
11.6
9.6
5.8
Under 65
27
22
4
1
100
81.5
14.8
3.7
65 and over
23
14
2
4
3
100
(2)
(2)
(2)
(2)
Not stated
2
2
100
(2)
CVA and residuals.
49
25
7
8
9
100
51.0
14.3
16.3
18.3
Under 65
11
6
2
1
2
100
(2)
(2)
(2)
(2)
65 and over
38
19
5
7
7
100
50.0
13.2
18.4
18.4
Orthopedic
69
33
13
14
9
100
47.9
18.8
20.3
13.0
Under 65
22
12
5
4
1
100
(2)
(2)
(2)
(2)
65 and over
46
20
8
10
8
100
43.5
17.4
21.7
17.4
1 1st admission during year only.
2 Percents not computed for fewer than 25.
Note: Diagnostic groups include patients with this diagnosis as 1 of 3 possible recorded conditions; the same person
may be shown under more than 1 group: arthritis, ICD 720-727; heart, ICD 410-443; neoplasms, ICD 140-205, 210-236
(or mention of colostomy, mastectomy); CVA, ICD 330-334, 352; orthopedic, ICD 730-738, 740-749 (excluding muscular
dystrophy), 758; fracture or absence of limb.
123
Additional cost to program for this added call-
Month of November, 1969
County Home Nursing Service
Appendix 4
Total number of patients-15
Number of patients seen by Home Health Aide-8
ITEM 1. LETTER FROM MARY L. WHITACRE, M.D., HEALTH COMMIS-
SIONER, MARIETTA, OHIO, TO THOMAS M. TIERNEY, DIRECTOR,
[Time in hours]
BUREAU OF HEALTH INSURANCE, SOCIAL SECURITY ADMINISTRA-
TION, BALTIMORE, MD.
Round trip
Visit time
Location
Number
(miles)
1/2 hour per
patients
Traveltime
Time per
patient
Writeup
2 weeks
JANUARY 9, 1970.
New Matamoras
Little Hocking
64
DEAR SIR: I am enclosing a copy of a recent study I have made concerning
4
2
60
2
Rinard Mills
1
2
2
6
the recent Social Security regulations which affect two Home Health Agencies
Williamstown
64
1
2
1/2
3
which are operated out of the Marietta City Health Department. I am the
Devola
10
1
1/2
3
10
Director of these agencies and I run them as efficiently and economically as possi-
1
1/2
11/2
Total
½
1½
ble to give the greatest amount of service to the patients involved. I am quite
208
8
7
4
4
concerned with the amount of money the Federal Government is spending with
15
no appreciable return to the patient or to the taxpayer.
I do general practice in association with my father in Chesterhill, a village of
Total number of patients-45.
City Home Nursing Service-Month of November, 1969-
400 people. I am also part-time Health Commissioner for the city of Marietta.
In our general practice my father and I charge $5.00 for a house call within
Number of patients seen by Home Health Aide-16.
the village limits. In my Home Nursing Services it costs $7.00 to send out a
nurse to make a home nursing visit. This cost is going up 25% in 1970 due to
Round trip
the reasons stated on the enclosed study. This means a home nursing visit is
Location
mileage
Travel time
Visit time
Write-up
Total time every
going to cost $8.75.
2 weeks
Secretary Finch recently announced that the monthly rate of Medicare Part
Marietta
2 miles per pt.
B-Co-Insurance would be raised from $4.00 to $5.25 per month due to the rising
(16 2)
Do
20 minutes.
1/2 hour per pt
(20 minutes) X
1/2 hour per pt
costs of doctors' fees and other services of the program. I take this as a personal
(16 X 1/2 hour)
insult. I have practiced medicine for 14 years and never in my life have I come
16 pts.
(16 X 1/2 hour)
across such an obvious waste of money and inefficient, un-coordinated operations
Total
32 miles.
5 hours
8 hours
8 hours
as that of the total Medicare program.
21 hours.
I realize that all this added cost is re-imbursable to my Nursing program but
to spend $18,000,000 and get nothing in return is more than I can stomach. It's
Total number of nurse hours and travel time 36 hrs.
hard earned taxpaying citizens' money they are squandering and I don't like it.
I've always felt that the elected officials in Washington had a contract with us
of take 4 hours, which is 1 week's time. She previously was spending 1 week it will out
The 40 total number of nursing hours spent is 36 but realistically I feel
home folks. As proof of that contract I received my income tax bill every 3
months. I'm a "naive hill country gal" who feels that the politicians in Washing-
won't send my money. I may get a needed long vacation at federal expense if
tered nurse and to 2 weeks making supervisor visits, therefore I have to hire a Nurs-
ing 1 visits with the new regulation she will spend 2 weeks making a supervisor Home visits
week. Previously Now the nurse made Home Nursing visits 3 weeks and
making supervisor visits but now she spends 2 weeks out of 4.
ton should fulfill their part of the contract and spend my money wisely or I
I persist in this delusion. So I am asking you and the politicians and super
geniuses in Washington to justify the need of these recent (maybe old)
making supervisor make visits. the nursing visits for the week the Supervisor Nurse regis- is
regulations.
(Enclosure.)
Annual nurse's salary=$6,000.
52 weeks-4=13 weeks 13 weeks=1/4 time employee;
1/4 time nurse's salary
THE COMMUNICATION GAP IN GOVERNMENT OR ONE HAND DOESN'T KNOW
WHAT THE OTHER HAND IS DOING
12% PERS and Workmen's Comp
$1,500
180
In an attempt to reduce costs and make Home Nursing Services more efficient
Total
Social Security has recommended and put into effect the following.
1. Reduce the number of patients eligibile for Home Nursing Services making
need month 1/4 of our supervisor nurse is $17.000 per month. The additional nurse pay will per
Now for this additional nurse will be paid travel also. The average travel
1,680
the eligibility requirements more stringent.
this (as she works 1 week out), which is:
2. Require a full page of information to be submitted on each patient being
$4.50 travel pay per week weeks=$58.50
served in the Home Health Agency every 2 months.
(This information will be reviewed by a physician or physicians at the inter-
We pay 10 cents a mile for travel therefore added travel costs are:
mediary's office. It will be his decision as to whether the patients are or are not
City miles=32 times 10 cents times 12 months
eligible and then our agency is notified.)
County miles=208 times 10 cents times 12 months
$38.40
3. Raised from 1 to 2 number of supervisory visits per month the nurse makes
249.60
Total
with the Home Health Aide on each patient the Home Health Aide serves.
The following statistics are based on the actual number of patients served in
288. 00
November, 1969 in the 2 Home Nursing Services I now run. I have calculated
the expense that these regulations will cost my Home Nursing agencies.
(122)
74-331 0-72-9
124
125
tion The to added be made out and mailed to the intermediary every 2
cost for the required clerical work (the 1 page of months-and patient informa- we
to say that I am anything but pleased and enthusiastic with the
ments that of the Committee during the year, and with some positive contributions accomplish-
have a total of 60 patients) is:
1/4 time clerk for City Home Nursing Service.
1/4 time clerk for County Home Nursing Service.
folder papers and documents, which will come in two packages. One will be by a
other on file at Society headquarters. This letter to you will be accompanied the
letters as reference to unfinished business, will be found in the minutes and as
well I did manage to make. Most of the history and work of the Committee,
½ time clerk.
Annual clerk's salary=$4,218.00.
$2,109.00
of communications between Blue Cross,
½ time clerk's salary
253.08
and You me, and I'll summarize my action and thoughts up to the end of the
Home Health Service,
Plus 12% PERS and Workmen's Comp
may feel that I took the easy way out, and may wish to year.
2,362.08
that negotiations. I can If you do decide this, I shall be very glad to help reopen in those
Total Total actual cost added to the Home Nursing program for the forthcoming
understanding of the disagreement between the
as a member of the Committee, and as one who now has a considerable any way
envelope full of items received during the year-requests, complaints, and an
and their fiscal intermediary, Blue Cross. The second package Home Health consists Service of
year is:
Annual additional travel pay for Supervising Nurse making supervisory
$288.0
forth-arranged in chronological order and about which I shall make SO
Annual visits additional 1/4 R.N. salary plus Pers., Workmen's Compensation- 1,680.00
should file at Society headquarters, and which you feel that the you Committee simply
wish running to commentary, which will help you to decide which items some
58.50
Annual Annual additional clerk salary plus Pers., Workmen's Compensation
additional travel pay for 1/4 time nurse
2,362.08
do something about.
finishing folder, starting with that dated July 29, 1971, to me from Blue Cross, and
of SFHHS the VS. Blue Cross, and read over the seven numbered letters in the front 1,
If you will now direct your attention to the manilla folder labelled number
4,388.58
Total is only 9 months old and the number of patients will served prob- in
Blue with the Dec. 27, 1971, letter from HHS to me, you will
1970 The will county double program and may triple. The city program is 2½ years old and
tion an agreement, and requested the assistance of our Committee. In could
not reach Cross rejected some claims from the Home Health Agency, that they see that
ably The increase total budget by 10% for this both year. county and city programs for 1970 before this addi-
cases to things, that it would take perhaps several months to prepare the among nine
other to the letters there were several phone calls, in which I was told, addi-
tional cost was:
$23,530
1970 city budget
dated Nov. 5, 1971, in which Mr. A
protocols until Nov. 8, 1971, together with the letter from Blue Cross to me,
be presented. This prediction was correct in that we did not receive the
13,000
1970 county budget
maries of Blue and then have a preliminary meeting with him and other sum-
proposed that I review the
36,530
Social Total Security in an attempt to reduce the cost and make the program more
review Cross. He thought that this perhaps would eliminate the need representatives of
cost has of the physician and clerk hired by the intermediary to admitted review and the
around of nine cases, and that upon finding that controversy seemed reviewing to two
the dated Nov. 15, 1971, that I spent one and one-half hours
by the whole Committee. You will note in document 5, my letter a special to Mr.
efficient added one-fourth of the total budget to the cost.
The determine eligibility or ineligibility of each new patient not in-
in of their position, that my patience was finally exhausted, which explana-
tions Blue Cross' use of meaningless form letters, rather than clear revolve
forms then notify to the agency, I won't even attempt to estimate but this is an
letter a somewhat petulant quality in my letter. Nevertheless, I think it was resulted
significant Home item. Health agency is one of the smallest ones in the state of Ohio. There X 100
Our 100 such agencies in the state. Just projecting take $9,000 the other
only unrealistic but also rude for them to demand of the "vendor" detailed not
Omaha, and SSA need very much to be reminded from time to time that it is of
and that what I said needed saying, in as much as Blue Cross, Mutual a good
agencies there are 2,000 Home Health agencies (I am figuring in
are over which equals $900,000. To go one step further assume that that in Ohio is a
when reports and meaningful explanations of services delivered and bills
49 states and am assuming that there are not 100 Home Health estimated agencies 4,900
as the they themselves communicate almost exclusively by such barbaric presented, means
big state of the 49 states.) If I take 49 x 100 which would give an is too high.
odious form letter. Mr.
moted, from Mr. or B put out to pasture, the next letter from Blue Cross on Dec. 8, 1971, pro-
having apparently been vaporized,
each Health agencies in the other 49 states which figure I know in 50
Therefore Home I am estimating that there are 2,000 Home Health agencies
ber 395, and number made 71-10. some important references to intermediary letters num-
states. $900,000-100 agencies =$18,000,000.00 for 2,000 agencies.
The next items in the folder, after a final letter from HHS, are these
Now In our these regulations have not reduced the cost. They have that not an
important stand documents, which I recommend that you read in order to fully under- two
in agency more effective, efficient service. The total end results are and
mediary letter number 395 goes into some detail as to what was considered
the heart of the dispute. They may be summarized as follows: Inter-
additional resulted cost of 25% of our total budget has been added to the program
that fewer people over 65 will be eligible for the service.
nursing Medicare care in August of 1969, and the principle that in order to be covered skilled
ITEM 2. LETTER FROM FRANCIS J. CHARLTON, M.D., TO RAPHAEL B.
the really change or refute anything in the prior document, but does does
not therapy. The later document headed "Part A Intermediary Letter 71-10" or speech
needing skilled nursing care on an intermittent basis or physical as
payment for home health services, the patient had to be certified for
REIDER, M.D., SAN FRANCISCO, CALIF., FEBRUARY 18, 1972
denials explanation somewhat and makes the important point that "while enlarge
others flow from the guidelines set out in Intermediary Letter 395, many
AGING AND CHRONIC ILLNESS COMMITTEE
second are unrelated to these guidelines and are based on other factors." many (See
DR. REIDER: First, my congratulations to you on becoming the breaking chair-
Mr. B's paragraph of 71-10). Careful reading of the last three paragraphs of
DEAR of the Committee. You have probably heard by this time about my for a
their to table with a closed mind, and that we were going to be used to come
the letter of Dec. 8, will reveal that Blue Cross was planning to
man leg on the last day of 1971. I had decided to beg off being chairman professional
second my even prior to that time, because of certain personal and work of the
a position, or were to be ignored if we disagreed with their position. support This is
year, which prevented my devoting sufficient attention to the which
very revealing document and should not be misplaced.* Letter number 7 from
problems, and which therefore resulted in my neglecting certain things This is not
Committee, I should have done as chairman of the Committee during the year.
mittee regarding these cases.
*Excerpts from the Fiscal Intermediary to the Chairman of the Chronic Disease Com-
126
127
HHS to me, dated Dec. 27, 1971, concludes with the statement that they would
like to meet with our Committee to clarify differences between the law, the
an Interpretations effort from Blue Cross of the Social Security Administration possible. in
community and be interpreted by physicians in the community wherever
regulations, and the interpretation of those regulations. You of course should make of
your own decision, but the idea of a meeting sometime between representatives
HHS, Blue Cross, our Committee and SSA of HEW to discuss the principles
sentatives sary there is an individual interpretation of medical facts made by repre- neces-
when to clarify a point, be more restrictive than would otherwise be may,
of the medical community.
involved might help to clear the air, particularly if all participants were provided
Very truly yours,
with an agenda which included such items as pointlessness of review by a Medical
Society Committee which is impotent at the outset by the rules of the game.
RALPH THOMAS,
This letter being quite long enough, I'll close it and discuss the other items
Assistant Director, Medical Utilization Review.
mentioned above in a supplementary letter.
BLUE CROSS,
Mr. RALPH THOMAS,
San Francisco, Calif., September 16, 1971.
San Francisco, Calif., July 29, 1971.
Assistant Director,
FRANCIS J. CHARLTON, M.D.,
Medical Utilization Review,
Chairman, Aging and Chronic Disease Committee, San Francisco Medical Society,
Blue Cross, Oakland, Calif.
San Francisco, Calif.
DEAR DR. CHARLTON We have met with the
Home Health Agency
to resolve Medicare cases where skilled nursing services, plus home health
last is to be taken. It is my understanding that the committee meets when
action not review our disputed Medicare cases, I would like to know will
or and will Illness Committee of the San Francisco Medical Society either Aging
DEAR Chronic MR. THOMAS: Since we have not yet received notice that the
services, have been provided over an extended period of time. We were unable
to arrive at a reasonable solution as the question related to the interpretation
of medical fact based upon usual and customary practices in the community.
and Friday of the month and considerable time has elapsed since our agreement on the
your letter of August 17, 1971.
The Aging and Chronic Disease Committee in the past has assisted us and
home health agencies by reviewing such questions and furnishing us with a
These patients were all homebound, under definitive medical
recommendation. We would appreciate your Committee assisting us again. There
and plan of treatment. In terms of the types of medical part the
medical required skilled nursing, with Home Health Aide care as an integral care of and
are nine cases, however, the medical information which requires review is not
voluminous and the resolution of a few of the cases will probably set the pattern
ments treatment for here, we fail to understand the rationale of discontinuing problems
with regard to the balance. We can prepare these cases in the usual manner,
has keep been the patient relatively stable than it would be logical if, once the physician cardiac
to successful care plans as not being "reasonable." helping the pay-
including a summary of the medical facts for Committee members and a state- will
ment of the questions which are raised under the Medicare Program. We addi-
Sincerely, stabilized on digitalis, that medication were discontinued.
furnish the Committee with three sets of the full medical information and
tional sets can be made available upon request. We will furnish the summary
information to the Home Health Agency SO that they know what information
Director of Nursing.
has been presented in case they wish to supplement that information.
SAN FRANCISCO MEDICAL SOCIETY,
Very truly yours,
RALPH THOMAS,
Mr. DONALD W. BOWDEN, Jr.,
San Francisco, Calif., November 15, 1971.
Assistant Director, Medical Utilization Review.
Manager Medical Review,
San Francisco, Calif., August 4, 1971.
Blue Cross Medicare Fiscal Intermediary,
Oakland, Calif.
Mr. RALPH THOMAS,
Assistant Director, Medical Utilization Review, Blue Cross,
DEAR MR. BROWN: I have this morning reviewed two of the nine
each referred file to in your letter of Nov. 5, 1971. Forty-five minutes time spent cases
Oakland, Calif.
DEAR MR. THOMAS: We are pleased that you have arranged to have the Aging
tions revealed to me that your denials were reasonable based on the clarifica- on
and Chronic Disease Committee of the San Francisco Medical Society review the
It is SO well presented in HEW Intermediary Letter No. 71-10, dated Nov. 1971.
equally clear to me that the long impasse and many needless letters between
nine we discussed on July 20, 1971.
We cases that the summaries of medical information you have agreed to which send
cite your the organization and the HHS resulted from failure to properly and
will include assume a copy of the "questions raised under the Medicare Program"
appropriate regulations, but rather to resort to that most promptly offensive
We also hope that there soon will be clarification from either Blue mentioned Cross or
from "specific Mrs. reasons H for denial of coverage" they received a comprehensive letter
weapon, the irrelevant form letter. When HHS finally persuaded you to submit
you plan to send to Dr. Charlton's committee.
Social Security regarding the subject of "reasonableness", which you
had ments but, unfortunately, did not refer to the principles in I.L. NO. 71-10, which,
which quoted amply from your medical consultant's com-
at our meeting.
they been used, might well have ended the appeal.
Sincerely,
Because, in my opinion, the members of my committee appear to be better
Director of Nursing.
mediary, I am forced to ask the following questions:
acquainted with the law and with pertinent documents than is the fiscal inter-
BLUE CROSS,
San Francisco, Calif., August 17, 1971.
hours court preparation on the part of each member of my committee involved, as a
Do you see the proposed conference, which will require from four to eight
to of appeal in which your opinion will be binding? If so, I shall be willing
Director of Nursing, San Francisco Home Health Service,
deliberation. If such is not the case, then I cannot impose upon the committee
review the other cases and in due time to submit them to a subcommittee for
San Francisco, Calif.
: Thank you for your letter of August 4, 1971. If the Aging
better and more honest to inform the appealing agency that it is without further
become thoroughly acquainted with each case. In the latter event necessary it would be
members to the extent of asking them to spend the many hours to
which and we will send to you and to that Committee will include "the questions
DEAR Chronic Disease Committee is able to review your cases, the information
a valid court of appeal.
recourse or at least that this committee lacks the authority necessary to make it
ableness". I believe This is an area of medical interpretation which should stay
raised that the review by the Committee will clarify the subject of "reason- in the
under the Medicare Program" for your review.
Sincerely yours,
FRANCIS J. CHARLTON, M.D.,
Chairman, Chronic Illness and Aging Committee.
128
129
BLUE CROSS,
San Francisco, Calif., December 8, 1971.
FRANCIS J. CHARLTON, M.D.,
San Francisco, Calif., December 27, 1971.
J. CHARLTON, M.D.,
Chairman, San Chronoic Illness and Aging Committee, San Francisco Medical Society,
FRANCIS Chairman, Chronic Illness and Aging Committee, San Francisco Medical Society,
Francisco, Calif.
San Francisco, Calif.
ing the cases review. from We share your Home concern about the time involved in those reviewing
yourself. surprised that you had spent considerable time reviewing some of these records
we would be invited to the meeting and review of the records, we were somewhat that
ber 15, 1971 to Mr. Donald Bowden of Blue Cross. Since we had understood Novem-
DEAR MR. CHARLTON Thank you for sending us a copy of your letter of
DEAR DR. CHARLTON Thank you for Health your letter Services of November submitted 15, for 1971 the regard- Com-
mittee's such as these and endeavor to submit, for the Society's review, that cases the
cases Blue Cross, as a Medicare Fiscal Intermediary, is of the opinion decision
comments where and opinions of the Committee would allow a more favorable
related time these patients received services and we were demanding reasons published which
at major the complaint, however, is that Intermediary Letter 71-10 was not other
strate an excellent grasp of some of our complaints to Blue Cross. The
Your statements to Mr. Bowden regarding the specific denial reasons demon-
for beneficiary.
the comments concerning the method of notifying the provider as need to the to
Your for the denial are well taken. Blue Cross recognizes the on-
to the Medicare Law (89-79) or to the two Federal publications which
exact reason communicate at all levels and devotes considerable time the to an under-
which enumerate the required standards of care provided and the conditions
standing case is essential, although the use of exact denial reasons is used occasionally
going of the Medicare levels of care and their application to an for
effectively training program for providers of services. We believe that individual
11). (conditions of participation-HIM-2 and Home Health Agency Manual-HIM-
a licensed Home Health Agency can expect Medicare reimbursement under
additional educational value.
Some of the nine cases you received were, indeed, appealed due to
Intermediary Letter #395 was issued by the Bureau of Health Insurance in
vant denial reason which did not relate to the regulations, cited above, an which irrele-
of 1969. The instructions contained in Intermediary Letter #395 bene- were
August effect at the time the services were rendered to those Medicare Health
tient's a care plan requiring the skills of a professional nurse to assess the clearly
were indicate privy to at that time. The majority, however, are examples which we
those in whos files you have. Those instructions were released to all Home Blue
ficiaris in December of 1969. Just prior to the release of these instructions. time to the
treatment. lizing a Home Health Aide) which was an integral part of the physician's plan (uti- of
condition between physician examinations and to continue a care plan pa-
education Cross and problems of Home Health Agencies. In January of 1970, Insurance,
Agencies added a Licensed Public Health Nurse to its staff to devote full there was
Congress was to meet some of the needs of the chronically ill elderly in
visits need not be linked to a hospital. This seems to indicate that the intent SO of
The Medicare Law includes 100 visits under the Supplementary Benefits that
a meeting in Los Angeles under the auspices of the Bureau of Health benefits.
to discuss covered levels of care under Home Health Medicare
During devoted to Home Health benefits under Medicare as they are Letters.
April of 1971, Blue Cross conducted four Home Health Workshops outlined that in
and by our fiscal intermediary is that care is to be related only to acute episodes
prevention tion and/or postponement of institutionalization." The current interpreta- the
were the Medicare Law and pertinent Medicare Regulations and Intermediary June
must cease once relative stability is reached.
30th These of this year. The June 30th meeting covered all items contained
items were again covered at a State-wide workshop in Los Angeles in on Inter-
differences ulations between the Law, the regulations, and the interpretations of the
We would very much like to meet with you or a subcommittee to clarify the
mediary Letter #71-10, which had been issued in May of 1971.
patients. which severely restrict the physician in providing therapeutic care to reg- his
addition to these general meetings to discuss Medicare Home Health bene- to
fits, discuss and answer questions pertaining to the Medicare Law, Regulations
In numerous personal meetings were held with the Home Health Services and
Sincerely,
Director of Nursing.
Intermediary Letter #395 and #71-10.
Cross views the education of all providers as an important function and of
will Blue continue to schedule workshops in utilization review and Medicare issues. levels
ITEM 3. LETTER FROM MARILYN TAYLOR, R.N., HOME CARE COORDI-
care throughout 1972. As before, such meetings will focus on Medicare
NATOR, VISITING NURSE SERVICE, BATTLE CREEK, MICH., TO PRES-
It is agreed that, at this point, the nine cases referred to your Committee all claims for
IDENT RICHARD M. NIXON, DECEMBER 30, 1971
have been reviewed extensively within Blue Cross. As with of
Blue Cross' a Medical Consultants. Each review has resulted in a determination
where review denial action is necessary, the claim has also been reviewed by one
President RICHARD M. NIXON,
The White House.
that the care provided each patient did not meet Medicare coverage criteria.
Contractually, Blue Cross must apply those coverage exclusions in the Medi- and
years of age citizen.
know the real situation as it relates to health services available to our over may 65
DEAR PRESIDENT NIXON I request you take time to read this SO that you
care Blue Cross' Medical Review policies and procedures consider all reviewed
Law, Regulations and instructions, such as Intermediary Letters #395 avail-
able #71-10. medical information in review of those Medicare claims that are
I am a registered nurse, have been involved with visiting nurse agencies in
as one capacity or another off and on for the past 30 years. I am presently serving
medically. nine cases referred to your Committee for review, we are of the opinion
agency co-ordinator to five acute care hospitals in our area. We have
In all the information has been carefully evaluated and a fair and just decision cannot
instituted a Co-ordinated Home Care program. I work closely with a nurse recently
that been reached on each case. In reply to your specific question, we will
consider has the opinion of your Committee as binding. The appealing agency
to their skilled or basic, a rehabilitation center, and in many cases it logically is
either discharge planning. This planning may result in a transfer to a nursing home,
ordinator in each of these hospitals and we assist families and patients with co-
be
We notified. do, however, feel that with your Committee's excellent understanding each of
out their nursing needs.
own home with the assistance and support of the visiting nurse to carry
the Medicare Law and Regulations, the Committee's recommendation on
In our area we are fortunate to have the team of Health Professionals to
case would, in all likelihood, have been the same as our decision.
forward We to a continued your working relationship in the future with you and your
appreciate time spent in the review of these particular cases, and look
our rigid efforts restrictions of Medicare guidelines regarding eligibility are hampering
the effectively deliver the needed services to patients in their homes. Unfortunately,
alternative is to cut services.
and when we cannot recover payment for such services, the only
Committee.
Sincerely,
RICHARD D. KLINE,
Medical Review Department Manager.
130
131
The write this letter goes like this. On August 3, 1971 we received Mr. a B was
specific case for which we recently were denied payment and prompted referral
Interpretation of covered care is based on procedure only and inconsistent
me to 79 old Mr. B from one of our local acute care hospitals. could
even then. Knowledge, judgment, assessment skills though considered funda-
on a year from cancer of the stomach and his surgeon felt nothing man more needed
suffering surgically as he was in the terminal stage of his illness. This to manually
cian is reimbursed for such skills, the hospital is reimbursed for its care to a
mental to a physician are apparently less fundamental to the nurse. The physi-
a daily feces from the rectum. His disease naturally, interfered nor- the
be done enema and on many days it was necessary for the nurse with
terminally ill patient and yet a community agency caring for the patient and
exercising assessment and judgmental skills is not reimbursed. What a paradox
remove the and his diet consisted mostly of dairy products as his this home was with
that the very service designed to maintain the patient in the community when-
mal digestion of food he could tolerate. Mr. B was to be discharged to Mrs.
ever possible and to lessen the high cost of medical care is the service, offered
only type old wife if the nurse could go in daily to supervise and extremely support un-
on a non profit basis, that is being forced out of business by the restrictive in-
his B and 81 year give the enema. Without this daily evacuation Mr. B was
terpretation of covered care (about 1%+ of the cost of Medicare and Medicaid
is attributable to Home Care services).
comfortable and the developed referral severe and assisted abdominal with distention. the arrangements to allow Sundays) Mr. B.
We must somehow help our leadership, our law-makers, our communities to
to go 3, 1971 through August 23, 1971. Mrs. B was not able teach. On
We accepted home. We had a nurse visit daily (including Saturdays and to perform
it is too late.
understand what is happening to patient care on the community level before
from August and there were no other family members we could died the fol-
Examples from several agencies of denial of coverage by fiscal intermediary
the August procedure 24, 1971 Mr. B was readmitted to the hospital where he
Patient I:
lowing
certainly day. without my saying that this elderly man was more $12.00 content per
Diagnosis: Congestive Heart Failure, Arthritis, Old Hip Fracture.
It for goes these last days than in a hospital. Our charge was $110.00.
Physician's Orders: Observation of symptoms and side effects relative to
in his Currently home in our area, the average cost per day in the hospitals visits is by the
change in medical regime-increase or decrease in edema, respiratory diffi-
visit. economic view it was a charge of $252.00 for 21 hospital.
culty, vital signs, etc. Techniques to reduce edema. Report to physician.
So, from a pure compared to $3310.00 for the same period in the Detroit. I
Reimbursement denied No specific procedures involved for the ten nursing
visiting nurse discussed as this case with our Medicare representatives in of have this
visits. If the doctor had made the visits or the patient hospitalized would
reimbursement also have been denied?
furnished We notified December 23, 1971 that after reconsideration have not been
I have them with additional information documenting the needs they
Patient II:
patient. were maintaining were their original position. In other words we
Diagnoses: Diabetes. Terminal Carcinoma of the esophagus (Cobalt therapy), Mild
able for even one visit to this man.
to collect might add I am familiar with the regulation that forced them to to take so-
Physician's Orders: Check for fecal impaction-relieve as necessary. Obser-
this stand. They patient. Again and again much needed services basic care.
Now, I clearly state they will not pay for cleansing enemas are denied a
vation and assessment of patient-report to physician. Support to patient
and family during terminal stages of illness.
called basic this care unfair, unreal, unworkable definition of skilled and the ill
Five nursing care visits made: Admitted to hospital-Expired. Reimburse-
because of Mr. President, the situation is deteriorating daily for what is over hap-
ment denied. If the doctor had made the visits would reimbursement have
Believe me, great country. There is no way you could know elected
been denied? Was the hospital denied?
65 citizen to these of our senior citizens unless you personally and other the of our regulations
Patient III
pening officials begin to listen to those of us attempting to live within
and the needed services.
Diagnoses: Hypertension-Cerebral Vascular Accident, Urinary Retention.
Care of Home Health Agencies represents only 1.5% of total paid continue to be
still deliver the sick at home is without question the most economical. Reimburse- out under
Physician's Orders: Teach care of patient to housekeeper-vital signs, force
fluids, catheter care, intake and output, etc. Supervise care.
ment to benefits. It is inconceivable that such agencies must cited in this
Patient expired Six visits-Reimbursement being questioned.
Medicare for services by a professional nurse, such in as cases less
Patient IV:
letter denied when repayment the alternatives are much more costly and many
Diagnoses: tention Cerebral Vascular Accident-Behavioral Changes, Urinary Re-
satisfactory. Your personal attention to this matter would be greatly appreciated by citizens
Physician's Orders: Check for impaction-Manual removal (enemas not ef-
throughout our country.
fective). Catheterization as necessary-Observe for signs of retention.
Patient admitted to hospital Expired.
LETTER FROM MRS. HELEN L. GOODWIN, R.N., ASSOCIATION, EXECUTIVE
Reimbursement denied.
ITEM 4. THE GREATER LANSING VISITING NURSE JANUARY 27,
Patient V.-Age 66:
TO DIRECTOR, MR. CHARLES E. CHAMBERLAIN, WASHINGTON, D.C.,
Diagnoses: Sarcoma-(Terminal), Old Cerebral Vascular Accident with left
1972 CHAMBERLAIN : The Secretary of H.E.W.'s Committee and to recom- Study
hemiplegia, Rheumatic Heart Disease Arteriosclerotic Heart Disease.
DEAR MR. Role for Nurses "has arrived at certain conclusions have respon-
This 90 pound woman was rapidly deteriorating as evidenced by continued
Extended broad of action as guides to all who seek and of health
incontinence. She needed constant care and medication.
rapid weight loss, dehydration, increased pain, poor to no appetite, beginning
mends sibility some for achieving courses improvement in the availability and effectiveness
The VNA's purpose of four visits was to teach her husband and an auxiliary
care American people."
for the from the report of the Committee to Secretary Richardson and at
person how to provide skillful care to a dying patient. She was under close medi-
cal care.
This statement to indicate a concern for meeting needs of people wherever to an idea but
This service as provided was referred to by the fiscal intermediary as "Activi-
would seem level is necessary. It is one thing to give lip service This is where the
ties of daily living" and four teaching visits were rejected.
whatever actually implement it at the grass roots. result
quite billions another of dollars to spent in formulating "Ivory Tower" concepts fail to
Patient VI.-Age 91:
in of services to people.
Diagnoses-Carcinoma of breast: Metastasis to lungs and skin.
improved about health the care health care delivery system-the need for innovation needed with to
This frail, debilitated lady, with draining area on breast needing careful
(We talk provide the care wherever and whenever service
dressing changes, and several other growths on chest and back that were in-
a improve humanitarian the system-to approach and yet what is actually happening at the
flammed and painful, was admitted for care on Medicare B. She needed assist-
level is denial of necessary care.
ance with hygiene of skin, mouth and particular care to draining and painful
132
133
areas. She had poor vision due to glaucoma and was extremely feeble SO was for
Institutions are offered many financial programs that assist with construction
most part bed bound. Visiting Nurse made one visit to teach her to billed care for to
of facilities, purchase of equipment, training of personnel, and expansion of
the
service programs as well as direct grants and guaranteed loans. None of these
She lived and alone encourage and the hiring an auxiliary person. This one for visit the one was visit.
should be offered.
devices is currently available to Home Health Services and financial support
herself Medicare documentation of service was requested even and she
and visits made due to her increasing needs finan- was
Several that additional Medicare would were not cover the nursing care she needed visit without and a cut-
Sec. 1. The development of new home health agencies
advised done showing she could pay $10.00 per be paid
Section Grants-in-aid for the development of new home health agencies as defined in
cial investigation into her savings. was She became angry with the nurse and died said a it few should weeks later.
ments:
shall be made available in accordance with the following require-
ting refused to let the nurse return. She would not
for Telephone by Medicare persuasion and by the supervisor was to no avail. If Medicare
a. Development funds shall be provided in grants for periods of from one to
three years.
pay
she would do without. reimbursement after services have been offered Manual) in good
b. Preference shall be given to communities or areas where such services are
Retroactive that they denial will be of covered (according to criteria in the Home and must Care somehow
not sufficiently available.
faith is devastating to an Agency who has incurred the liability
c. Funds may be provided to a public or private, non-profit agency which has
a governing body on which there is substantial representation of qualified health
contend budget deficit.
with the these concerns of Home Health Agencies in consider Michigan health will
and social welfare professionals as well as representation from consumer groups.
be We helpful sincerely to you hope in your deliberations in the coming year as you
d. The agency must present plans which provide for on-going community serv-
ices upon termination of the grant.
care needs of people.
e. Plans must include provision by the agency, directly or through arrange-
ments, of all elements of professional and supportive personnel and services
ITEM 5. PROPOSED LEGISLATION SUBMITTED BY THE CALIFORNIA
considered essential to home care.
ASSOCIATION OF THE HOME HEALTH AGENCIES
f. Agencies established by such grants must demonstrate effective liaison and
planning community. activities with existing health care facilities and resources in the
HOME HEALTH SERVICES
Sec. 2. Funds for the expansion of existing home health agencies
1. a. A if home it is health an agency agency or is organization a qualified provider: or a subdivision of such an agency or
Funds for the expansion of existing home health agencies shall be made avail-
able to home health agencies as defined in Section - in order to add new areas
organization; b. if it is primarily engaged in providing therapeutic services in the homes of
of service or to increase the range and effectiveness of services in the home. Such
patients who services are under the provided care of a under physician; the direct professional supervision which has of
funds shall be provided to add personnel in new areas of competence or to pur-
chase equipment essential to diagnosis or treatment in the home or to increase
the effectiveness of services through the provision of mobile equipment. The
trained health restoration to health, full or partial rehabilitation, which will
c. if the care personnel are in accordance with a plan of treatment the initiation
following provisions shall apply to such funds:
as and its maintenance objectives, of a treatment program for the patient in the home
three years.
a. Funds to develop new services may be made available for periods of one to
be
safe and feasible. services must be directly related to the health problem for which might
b. New services may be funded when evidence indicates a need.
the patient singly in combination in an institution or out-patient provided
Home health is under the physician's care and include all services which facility if
C. Preference in the funding of new services shall be given to agencies when
similar services are not provided elsewhere in the community.
be provided offered or effectively in the home. Such services shall be full time on
d. Funds for expansion may not be provided to subsidize or expand case load
an intermittent regime for brief periods, if care of the patient is served. services
they can be basis but may, in exceptional circumstances, become Home a Health
or geographic coverage.
Sec. 3. Funds for the training of home health personnel
treatment Services shall not be used as a substitute for appropriate out-patient or
Section 1. Home health training facilities which provide approved training to
institutional care.
professional and non-professional personnel in the field of home health care may
health agency shall:
be provided:
2. A home written policies developed and reviewed from time to time by a group more
a. have personnel associated with the agency, including representatives one or
cility. a. As an extension of the training curriculum in an existing educational fa-
of professional and or more registered professional nurses, and for super-
physicians consumers to one govern the services which it furnishes, and provide nurse. Op-
home health agency.
b. As an organized training program attached to a health care facility or a
vision erational matters, related to professional activities, shall be handled by an
of of such services by a physician or a registered professional appro-
Section 2. Training facilities for home health personnel must be closely linked
to home health agencies and must demonstrate that training is realistically linked
priate subcommittee of the governing group;
to home health service needs. It is highly desirable that basic training be in
b. c. maintain meet all applicable adequate clinical requirements records of on the all law patients; of the State in which it furnishes
"traditional" school settings and existing institutions wherever possible.
Section 3. Training subsidies may be made available for faculty, facilities,
services; written policies and procedures, which provide for a systematic evalua-
equipment and for maintenance of trainees when it has been demonstrated that
tion d. have of its program at appropriate intervals in order to assure the appropriate
employment will be available for trainees upon completion of training.
Section 4. Grants for curriculum planning and the training of faculty may be
utilization of services;
e. provide a planned program of continuous in-service training for all of its
made to a training facility or to a qualified home health agency or to a non-
implementation of training programs.
profit health or educational facility as sponsor or coordinator of planning and
staff.
FUNDS FOR THE DEVELOPMENT AND EXTENSION OF HOME HEALTH SERVICES
The These funds have been insufficient in amount and too narrow health care.
government has appropriated some funds for the training of home in health scope
personnel. to help us solve the problems or meet the existing needs of home
135
AUXILIARY HOME SERVICES
Handyman service assists in small minor repairs to eliminate hazards and pro-
mote safety and well-being for those unable to do or have done such maintenance.
Assistance in moving to better housing. Chore services, such as housework, lawn
care, shopping, errands, etc. not requiring a trained Homemaker/Home Health
Aide, will be provided eligible persons who because of frailty cannot do for them-
selves. Loan of wheel-chairs, walkers, sick-room supplies, etc. for those who need
them on a temporary basis or have no other way to secure these items for self-
care in the home are provided on request.
Appendix 5
INFORMATION, REFERRAL AND FOLLOW-THROUGH
COMMUNITY COUNCIL ON AGING: A MODEL FOR PROGRAM, A COM-
This service provides a community-wide source of information and counsel to
ATHENS MUNITY-WIDE HOME SERVICES AND TRAINING
all aged, blind or disabled and their families without regard to any eligibility
ATHENS CLARKE COUNTY, GEORGIA
requirements. A Telephone "Life-line" is the central point for incoming inquiries
and for outgoing "Telephone Reassurance" calls to isolated, homebound persons.
I. INTRODUCTION
Assessment of requests and interpretation of need will be made in reacting to
The Athens Community Council on Aging and churches, (ACCA), in a philosophy, private-non-profit accepts asso- the
these requests. Referral to the appropriate resource in the agency or community
follows. Community Service Aides assist with necessary home visits, escort
ciation worth and of service dignity agencies, of all citizens, civic groups and feels a major healthy, responsibility dignified and to assist to the older de-
service to needed services and with follow-through to determine if the individual
received adequate care.
citizens possible, in pursuing independent a worthwhile, life and life-style meaningful, has attempted befitting to our develop older a citizens. multiple It services is long, with
COMMUNITY AND VOLUNTEER SERVICES
gree system a sense to of urgency provide assistance that the ACCA for our who older in citizens their declining, some of whom, and to for considerable too
Staff organizational and coordination assistance will be rendered to established
and new groups of older adults in the community. Program services related to
have degree, been helpless a major conditions, neglected are group deserving increasing of more population than mere of existence. older citizens,
now
consumer protection, money management, improved opportunities for social and
community participation, and information essential to providing individuals with
over The 10 ACCA percent accepts of the total the fact population. of the The acute by need a majority for coordinated of older assistance citizens and
alternatives for independent living in times of stress or illness, are arranged for
both individuals and groups. Transportation assistance is also provided when
programs cannot be or questioned specific services in light of of such recent programs, Congressional Hearings, research
available. Staff coordination of Volunteers is made for nursing home visits,
residential home visits, transportation and delivery of hot meals and commodities.
experiences The only by real agencies questions such remaining as ACCA. to be answered be determined are: (1) What among is these the magni- needs
Location of isolated, needy, frail elderly is a function of "Finder" staff personnel.
tude and what of specific are they? service (3) needs? In terms (2) of Can organization priorities and finance, how will to the become priority a
HOME DELIVERED MEALS
services be provided?
MODEL It is from for this the base organization and background and delivery that needed the of ACCA services services is to attempting located older citizens not only and in the an
The agency prepares or secures nutritious meals and delivers one or more hot
meal daily to the home of eligible persons who are unable to obtain or prepare
nourishing meals.
integral Athens area, linkage but between throughout them and Georgia. other ACCA. The following section provides a brief
DAY CARE SERVICES
overview of current operations of the
Day care services will be provided during the day to eligible persons in protec-
II. COMPREHENSIVE HOME CARE AND COMMUNITY PERSONS SERVICES FOR OLDER ADULTS,
tive settings for purposes of personal care and to promote the social, health, and
emotional well-being of clients through opportunities for companionship, self-
BLIND OR DISABLED
education and other satisfying leisure time activities.
PURPOSE AND BENEFICIARIES
TIME TABLE
The purpose of this service is to provide a range and private of interlocking services, to services, maintain, co-
Expanded services under the provisions of Title XVI were not activated until
ordinated strengthen, and improve inter-linked and safeguard with other home public and will family be those life, individuals especially in where the service older
the sixth month of the current project year. Thus a number of objectives will not
be reached until well into the next project year. It is anticipated that three Day
adults who are demonstrate involved. Primary a need for beneficiaries Homemaker/Home will be Health those Aide able-bodied, and the mature related
Care units will be operational by the beginning of the third project year. Staffing
for positions indicated should be nearly complete by that time. Training and
area services adults, primarily listed below. from Secondary the MNA, beneficiaries who will receive specialized training and full or
Upgrading will occur on a continuing schedule and new Aides will be trained and
placed as vacancies occur, services demand and resources dictate.
part-time employment.
SOURCES OF FUNDING
SUMMARY OF PROGRAM SCOPE AND CONTENT
The following components comprise the currently Act, and funded the CDA) expanded aimed services toward
Major funding for the project is provided through a contract with the Georgia
Department of Family and Children Services under Title XVI of the Social
maintaining (under Titles older XVI & adults IV-A in of their the Social own homes Security or chosen residence as self-directing, those
Security Act entitled "Service Programs for Aged, Blind & Disabled" with provision
for Title IV-A of the same act where families with dependent children qualify for
active
Home participants management, in the home community: maintenance and to personal need this care service. service Homemaker/ to
Homemaker services. This contract is made possible through matching "Donor"
funds from Model Cities. The Agency also will receive about $8,200 through the
individuals Home Health who Aides are determined will be trained by and the agency supervised organizations by professionals as The National under Council recom-
United Fund which with local in-kind is used as matching for a small grant under
Title III of the Older Americans Act through the Georgia Commission on Aging
mended for Homemaker-Home standards set by Health such recognized Aide Service (134) (of which the agency is a member).
136
137
which offers additional technical support in the development of the range of
service basis. programs not otherwise available either on a demonstration or continuing
services offered by the Council on Aging. Contributed consultant services through
the University of Georgia School of Social Work and the Institute of Community
and Area Development are utilized for matching purposes.
and year the Council's operation. The Board was reorganized and its
In of 1969, the present Director, Thomas C. Cook, Jr., arrived during the third
The above resources provide a mix of both categorical and noncategorical
survival activities were strengthened. At the time the Council was going programs
services to assure that persons in both the MNA and the entire Athens residential
Athens crisis involving fiscal and operational difficulties, but the people through of a
area may receive the care they need based upon their individual circumstances.
Fees for services will have a negligible part with the more generous provisions of
meet on Aging together with the Athens Model Cities designed a program which would
community support has been building ever since. In late 1969, the Athens Council
and Clarke County area rallied to the support of the Council and the
Title XVI and will be employed when unallowable expenditures are not otherwise
covered under other resources.
Continuation of support from Model Cities, the Georgia Dept. of Family and
strengthen family life by providing Homemaker/Home Health Aide services,
the needs of older persons living in their own homes and which would
Children Services, the Georgia Commission on Aging and an increase in community
starting with elderly persons in the Model Cities area.
input is an indication of the recognition of the needs of older citizens and confidence
needs addition to the supplemental Model Cities Grant, indicated a concern that the
Funding from Title III money through the Georgia Commission on Aging, in
for these services which have been now written into the State plan. (Underwriting
in the planning and implementation capacity of the agency as well as the future
of Homemaker provisions becomes mandatory for States in 1974) the ACCA,
given (Typically, staff 75% of the clients are elderly.) The Georgia Commission on Aging has
of older Georgians be met in both opportunities to be employed and served.
through this project is developing models for training and day care guidelines
demonstrated time to assist in developing and initiating the project. The project has
under Title XVI.
duplicated in similar cities or areas in the State.
the potential for becoming a model service entity which can be
SUMMARY STATEMENT OF OBJECTIVES
As the ACCA developed its proposal for expanded services under Title XVI the
the have unable to meet the increasing requests for service that have programs to
Five been training sessions have been completed. The aides trained in these
following objectives were identified as important to the long range development of
Expanded Cities geographic area, in terms of both employment and service.
the Model generated by Model Cities Funds, the service has been predominately are to
largely agency. (See p. 145, service growth record.) Since funds for this project come
an adequate service delivery system for the community:
1. To determine what is a reasonable cost per unit of service for each category.
Based on this experience it is hoped a mechanism for third party payments from
made services to the entire service area of the ACCA is one objective
both public and private sources will be developed. It is recognized that these
services will be mandated by 1974 for public assistance recipients and demands
need problems to is not one peculiar to one geographic area, and there is a compelling
possible with Title XVI Social Security Funds. Aging and all its related now
from private sources will be increasing.
expand home services to the total community.
services according to accepted and established standards as set forth by such
2. To develop and provide homemaker/home health aide and related home
enabled of City of Athens and local and State department of Health and Welfare has
Cooperation the with the Georgia Commission on Aging, Model Cities Department
organizations as the National Council on Homemaker/Home Health Aide Service. health
older us to provide what has been described as a model service to promote
3. To design, implement and refine a model training of homemaker/home
In people being able to remain in their own homes as long as possible.
aides related to Georgia and rural America adaptable to potential operations of a
1972, the Council on Aging together with Model Cities as donor of matching
similar nature, including pre-service and in-service classes of varying sizes.
and funds was able to initiate the first Title XVI service program for aged, blind
4. To develop a model service operation manual to use as a guide for other
increased through the matching quality of Model Cities funds and services were not only
disabled in the State of Georgia. This meant that services were multiplied
potential home services in the State.
5. To increase the number of career opportunities for individuals in all helping
where demonstrated to this target need area, exists but for have such spilled services. over into the entire city and county
professions. 6. To measure the extent to which the promotion of jobs for older adults (50 and
to be is indicative of the broad support for its many programs which have proved
inclusion Chest of the Council on Aging into the Athens-Clarke County Community
Increased visibility, increased support through these city resources plus the
over) can be effective in the home service field.
7. To evaluate the impact of home services in the total needs of the community. and
8. To enlist, coordinate and bring to bear appropriate existing resources
a success in meeting the needs of older adults. This creative combination of
services within the community which would reinforce the home services.
9. To document and test existing guidelines for eligibility for delivery of home
through Christian a joint committee of the Athens Community Council on Aging and the
resources, programs and commitment as evidenced by the plans being generated
College of Georgia to promote a learning service center and the broadened
services.
BACKGROUND: ATHENS COMMUNITY COUNCIL ON AGING
mation, referral and follow-through, "telephone lifeline", broader
scope of direct services including Homemaker/Home Health Aide services; infor-
The Athens Community Council on Aging was formally organized on January and 9,
churches. Through the five years of its existence the Council on Aging has depended
and Gerontology, the increasing number of clubs and organizations for older people on
planning for elderly, the involvement of the University of Georgia's community Council
1967 as a private-non-profit association of service agencies, civic groups
largely upon the local church community including the Ministerial Alliance, and
tangible of evidence of the concern of a city for its older citizens and the quality and
now our proposed Day Care for Elderly soon to become operational, gives
the churches themselves and Church Women United for resources, direction, and
range alternatives they may choose.
volunteer services. The Council was initially begun with a mix of local under
the Older Americans Act of 1965. Concerned individuals and representatives of
meaning for people in our town "Making Life More Meaningful for Older
We believe that the motto of the Athens Community Council on Aging has real
Title III funds administered through the Georgia Commission on Aging,
Adults-Building a Brighter Future for All".
the above mentioned groups and agencies created the Council to develop "more
large, staff and has the involvement and backing of the city Fathers and community at
The work of our local Council on Aging, including its board of membership and
effective means of providing services for older adults in the Athens area" and as
well as to promote means whereby our older adults can find challenging
meaningful ways to become involved in the life of the community and to serve
Senior Council on Aging will soon be submitting a proposal for our own local Retired
as The Recommendations for Developing Retired Senior Volunteer Programs", etc.
reached a point of national recognition and inclusion in such publications
throughout the rich retirement years.
The Athens Community Council on Aging has conducted community surveys needs,
determine the needs of the aging, what services are available to meet such available
Christian Center, which also is backed and sponsored by both the Council on Aging and the
Volunteer Program which will interlink with the Athens Voluntary Action
what to additional services should be developed, and what resources are and
College of Georgia.
improved to programs and activities essential to the health and well-being wise
support needed services. It has served as the community planner for new of older
of they the are unable to contribute actively in the way they always have to the life
Athens, Georgia cares for its older citizens, not only that they be cared for when
adults. It has sought to coordinate existing services to promote efficient and needed
use of community resources. The council on Aging operates and generates
fully in the life of the city in which they live.
community, but also that they have dignity and become involved meaning-
138
139
HOME SERVICES
Mrs. H. A.: October 27, 1970-current
DEFINITION
Age 84. Owns her own home but has no near relatives. A distant cousin
her. nearby and can check on her occasionally but cannot assume responsibility lives for
Why do we need Home Services and what do we mean by this term? It has often
been emphasized that home life is the highest and finest product of civilization.
for care home alone. Recently she reached the point where she would not
for Mrs. her A. is mobile and can care for her bodily needs but cannot adequately
In every field of social work, and now in the medical field, the emphasis on main-
build herself. Her nutrition was so poor the caseworker put her in the hospital cook to
taining persons in their own home is receiving more and more attention. Not only
her hemoglobin up.
is the home the place where people can live with greatest peace of mind, but it is
axiomatic that it is the most economical for the community. The recent national
nutritious meal before she leaves. Oh the two days a week that the aide doesn't a
week. The aide cleans house, shops, does laundry, and sees that Mrs. A. has hot a
Homemaker Health Aide Service increased Mrs. A's time to 4 hours, 3 times
concern for Health Maintenance Organizations (HMO) reinforces the prevention
and primary level of this service.
go in, Hot Meals deliver a noon day meal.
We have, therefore, initiated in our community a flexible program available
Mrs. A. has been kept out of a nursing home and living in her own home for
to individuals, agencies, physicians and others which will provide services in
long time.
over a year due to this help. She is in better health now than she had been for a
a variety of ways designed to maintain people in their own homes. Our agency
administers a program with a two-pronged approach-one developed to cope
Mrs. D. M.: February 2, 1971-current
with social needs of a family, and the other focused to meet the supportive health
maintenance needs necessary to maintain an individual in his home.
in and a able wheel to chair. care for her own needs until a broken hip and a kidney infection put active her
Mrs. M. is 83 years old. She is alert mentally and had physically remained
WHO NEEDS THESE SERVICES?
The types of problems are many and varied that a service such as we are
combination of Social Security and D.F.C.S.
She lives with a single daughter in a low rent project. Her only income is a
developing may help solve the following life situations illustrate both the acute
needs and the scope of services required.
reported work. their jobs were in jeopardy because they were losing SO much time from
A married daughter was driving across town to share in her care. Both daughters
PREVENTION
Service cided to quit work altogether and apply for welfare. Homemaker Health Aide
They refused to consider a nursing home and the single daughter had de-
Mrs. Y, age 80 years, with only partial vision, is unable to prepare adequate
provides an aide 8 hours a day to care for Mrs. M. and to see that her meals
meals for herself. To prevent physical breakdown meals should be prepared for
a are prepared. Both family members have been kept on the job for over a year as
result of the service.
her. With some rehabilitation help she could be taught to deal with her partial
vision and keep herself and her home.
Mr. E. T.: November 19, 1971-current-Age 29
Mr. G., age 70, is physically fit but since retirement has been unable to find
Mr. T. has 4 children, ages 3-8.
a role for himself. He is depressed and needs some outside stimulation. Referral
He had no one to help him except an elderly mother who was an invalid. Mr. T.
Mr. T. wife deserted him and the children and left him in a serious situation.
to an activities center should be arranged.
A mother of one child has just had her second. This five weeks old baby has
had to be admitted to a hospital for lack of proper care and nourishment. This
with invalid mother could not continue to sleep away from her own home to ever, be
the was trying to work an evening shift and keep the children in school. Ho
happened with her first child as well. The doctor on the case indicated that all
this woman needed was some instruction on how one feeds a newborn and how
children to and from school and cares for the house. Mr. T. has been able to
the children at night. Homemaker Health Aide goes in daily, takes the
one gives a baby the tender, loving care that is SO essential to proper growth
order. remain on the day shift and is slowly getting his and the children's life back in
and development. A teaching homemaker visiting this family once or twice
a week might very well have prevented a costly stay in the hospital.
Mr. & Mrs. L.: November 16, 1970-current-ages 40 and 28
PRESERVATION OF HOME LIFE
Both Mr. and Mrs. L. were blind. They had a baby 3 months old at the be-
ginning of service. A teen age son was of great help but needed to be in school.
An older woman with terminal cancer is anxious to return to her home and
her husband. They live alone in a small apartment. Medically, there is no reason
things were difficult. Homemaker Health Aide Service went in and bathed the
This couple did many things for themselves but with the advent of a baby some
for her to remain at the hospital. Her husband, although anxious to have her home,
Aides baby, arranged the food situation to help her prepare what food she could. The
fears that he will be unable to care for her alone. After investigation by a social
for the next days meals. This couple has remained independent in their own home
always prepared a meal on the day they were there and prepared Mrs. L.
worker it was decided that they could have gotten along very well with the help
of aide two to three hours a week and a nurse's visit once a week.
and the son has been able to continue school.
A an mother about to have a new baby needs someone to care for her other
Mrs. P. B.: January 1972-current
children young while she is in the hospital. Her husband is employed but if he is unable
to find help at home, he will have to stay at home and care for his children.
A mother in a one parent home needs to be hospitalized for surgery. If help is
the Day Nursery for the 3 year old but the nursery refuses to care for a child
Mrs. B. has 2 children which she supports. Her husband is in prison. She used
not available to care for her children they will have to be placed with foster
who is on medication. Since this child has suspected cepter fibrosis she is often
parents.
much out ill. The mother's job was in jeopardy and the oldest child, a son, was missing
UTILIZATION OF HOME SERVICES
Health Aide Service goes in intermittently when the child is ill. The mother
time from school in an effort to keep the mother working. Homemaker
An older woman has been hospitalized with a cracked pelvis. She is able to
leave the hospital earlier with daily home help involving 4 hours of service each
required to be out of school to help.
has been kept on the job and the boys grades have improved as he is no longer
needs daily help with meal preparation, laundry, shopping and housekeeping. if
day. She is able to walk with a walker and take care of her personal needs, but
Mr. C. W.: December 10, 1970-current-age 71
his elderly wife can have help. There is need for physical therapy as well as
An elderly male stroke patient can be returned to his home setting earlier
Mr. W. is semi-invalid with a heart condition who has rapidly deteriorated
Homemaker Health Aide Service goes in to help her with her duties and sit for
mentally. His wife wants very much to keep him at home as long as possible.
assistance with personal care of the patient. With an aide to assist 4 hours a day,
5 days a week, the patient can be maintained at home.
her to get out occasionally. A male aide goes in twice weekly to give Mr. W. a
74-331 0-72-10
140
141
care for other personal needs. Mr. W. is one of several clients in similar Health
following a study in 1969-70, that the future delivery of health service in the
bath condition and who would of necessity be in a mental hospital if Homemaker
United States would include home services as an acceptable level of care and that
Aide Service did not serve them.
this would be included in our future health insurance packages.
With this as background it is wise to base fees for the field service on the costs
Mrs. M. H.: December 11, 1970-current
Lived independently in a low rent project on an income limited of $110.00 income SS
that are incurred for placing the aide in the field (wages plus fringe benefits) plus
Age 85. She had a daughter who lived across town on a very not have the
administration. This fee should not include the training costs nor any expensive
and and D.F.C.S. crowded conditions. She is willing to help but does day week
professional or para-professional overhead that the agency has on its staff.
in Mrs. very H. was able to care for herself and remain active with one 1971 she a broke
Fees must be realistic and competitive. The commercial firms will use the
means. Homemaker Health Aide Service. On December 19, with this
existing training facilities, graduates, schools, agencies, hospitals, and place the
service from and forced to move in with her daughter. She kept contact under
person in the field. Their fees will be based on costs, plus administration, which
her office arm by telephone. was Eventually she became severely depressed at living
will include a margin for profit. If the non-profit voluntary sector is to take ad-
vantage of third party payments, they must be in a position to present their costs
such
conditions. allowed to return home on condition that the Homemaker Health to care Aide for
on the same basis the commercial agency does and take advantage of not having
She was would in daily to help her. She has since become more able happy to
to plan for a margin for profit. In this manner the non-profit organization should
be a force to reckon with.
herself Service and now go only needs 4 hours instead of 8 hours a day. She is very
At this time there are 50 trained homemaker/home health aides functioning in
be independently again.
living Rochester, Syracuse and Binghamton in New York State could have have
Athens-Clark County. These aides have provided home services predominantly
Studies that in about 20% of the patients in hospitals and nursing homes home settings.
for people needing assistance in the Model Cities Area. In the first 18 months of
shown cared for at less expensive levels of care, many of them in demonstrated
operation, the needs of the elderly have been so great and acute that the staff
been Coordinated Home Care Program in Rochester, New York has patient
has had to concentrate its efforts in meeting the most urgent needs. However,
The its can save an average of 21 patient days of hospital in care 1970. per
there are many gaps in service that have been identified and should be met in
that admitted use to the program. This resulted in a saving of $890,000
other areas, e.g., child care. The aides have served in emergency situations in
homes with children where mothers have been unable to care for their families,
HOW WE HOPE TO MEET THE PROBLEM
but due to lack of an adequate number of aides, the most urgent requests are the
only ones that have been served. We are now in the process of modifying our
that a Home Services Program be set up along the lines of suggested develop-
staff pattern to include one full-time placement assistant to coordinate and place
in We proposed 144. This expanded program, now in its fifth month Directors of the
these aides. A registered nurse is being hired to coordinate health services. Her
the chart, under p. the supervision and direction of the Board of for
responsibilities will include the three functions of health training for aides, the
ment, Athens is Community Council on Aging. The Executive Director is responsible
supervision of health services, and the provision of direct skilled nursing to day
care clients.
carrying Chart out the shows policies the of functions the board we and plan services. to carry out. The director services: is directly
3. Auxiliary Home Services
responsible The for all programs and their evaluation. There are six defined
The third program area being developed is Auxiliary Home Services. During
1. Community and Volunteer Services
these first months of operation the need for teaching home management, child
has rendered catalytic services for the older adult since of staff its incep- time.
rearing practices and budgeting has been documented. The agency has four field
This Its agency service in this area has been less than desirable due to lack are:
counselors and four community service aides on the staff. We are augmenting our
tion. Some of the activities in which the staff has been involved in the last year
staff with several home maintenance aides and two handyman drivers.
Within this function, a Telephone Life Line Service has been initiated. This is
Organizing Cooperation of with groups University and activities. of Georgia Human Services Disciplines.
an answering and phoning service which eventually will operate on a 24 hour
basis. The types of functions that can be performed in this area are:
Workshops on activities.
Sponsoring Stimulation of existing agencies to initiate or improve services 1971. to elderly.
seminars on Aging.
Daily phone contact with older persons living alone.
Information and referral.
Cooperation Planning with Christian College of Georgia for "National adults Institute and
on Pre-White House Conference on Aging
Emergency life line or "Hot line".
Answering service for other related agencies.
for Joint Life Enrichment"-a learning service center for older
To further this type of service two persons will be hired to cover the phone out-
side the regular working hours. These could be handicapped or elderly persons.
practitioners. Comprehensive Health Planning (with NEGAPDCO).
There should be some flexibility for growth and change allowed in this function.
activities not complete. With additional staff the services in have this been area
It can be expected that the field counselors and community service aides will
could concentrate greatly on this program. This coordinator with the assistance functions of
These be enhanced. are A full-time coordinator and a field worker of the
listen to the residents they are serving, and where needs are identified, provision
hired to Committee, recruits and trains volunteers that assist in all and
tion. can be made to meet the needs as they are brought to the staff and board's atten-
Volunteer Volunteers are used in a number of different ways valuable and are
The agency has acquired three vehicles for service use: a 12 passenger van, and
the agency of program. good experience personally in addition to rendering is made to
two 9 passenger station wagons for client and staff mobility and the delivery of
assured needed services, a with staff assistance when needed. A major effort
meals and equipment to homes.
effectively use this volunteer assistance.
4. Training and Upgrading
2. Field Service
Training of homemaker/home health aides has been a function of this agency.
the future for home services is one of expansion and growth, The the home- future
Five courses have been conducted by professional staff personnel with nurses,
maker/home third party payments for aide service is bright. This can be Inc., has
Since health aide service should be in a free standing position. documented by
social workers, and home economists on a contractural and consultant basis. These
courses will be continued intermittently to train the additional personnel needed
for large commercial pharmaceutical company, UpJohn and plans
to expand and replenish the field service.
the fact that a franchise a operation formerly known as Homemakers, Inc., more than
A training manual for the course is being developed that can be used locally or
purchased offices the nation. At this time they are operating in all
with equal effectiveness in surrounding counties. (It is wise to recruit and train
to operate and by across 1974, when homemaker services become mandatory homes of
in areas where the service will be used and needed.) The Athens Community
States, our country on a fee for service basis. It was the conclusion
100 offices 400 offices will be opened. They plan to deliver aide service of to this the company,
Council on Aging's aide service has had experience in training of aides and could,
with adequate financial support complete the development of such a manual and
1,42
143
transport the course to other communities. While some material is already avail-
able from other States, our experiences have shown that a tailoring of coarse ma-
prorated the to has been allocated to administration or management centers,
When amount income that and expense items have been placed in the proper cost
terials to fit the characteristics of the area of service (here, basically non-metro-
politan urban with rural fringes) is a must.
proration is all the service cost centers. The percentage figure that is must be
In addition, there should be additional training developed for any personnel
for that cost balance center. figure for each cost center is the operational surplus cost or center. deficit
The net the percentage of personnel time that has gone into each used for
who might be upgraded to the positions that will become available in the Auxil-
iary Home Service. If upgrading is not possible, training must be developed for
new personnel who may be coming into the agency to fill vacant positions. In-
DEVELOPMENT AND EVALUATION
service training on a monthly basis for all staff is another area that must be
developed. A full-time coordinator of training has been hired to develop and conduct
evaluations functions, and to be involved in the development of the expanded existing
The agency recently hired a full-time coordinator for evaluation of
training whenever needed. There is a budget for consultants for training to be
provided responsibility of the executive director. Clerical or secretarial assistance is is a
direct of all components of the agency. The staff of this department services and
used by the coordinator to meet the needs of expanded training.
plus a budget for consultants.
5. Day Care
STAFFING PATTERN
Identified early in the project as a needed service for more effective care of
many individuals now receiving individual care in the home, is day care. Because
of this and in response to requests from model neighborhood residents to include
ment policy and procedures for the agency. They hire the Executive Director to imple- sets
The and Board of Directors of the Athens Community Council on Aging, Inc.
day care, it was added to the proposal now funded through the Title XVI program
The carry out the policies and procedures approved by the
under contract between the ACCA and the Georgia Department of Family and
Children Services. At present, a pilot unit adjacent to the offices of the ACCA
Administration, direct supervisory responsibility of the Director are: functions
that may delegate will be a responsibility for portions of the agency program. Those Director
Executive Director is responsible for hiring all other staff. Board. The
is being furnished in an extensively remodeled old home. A variety of services
and activities is being developed, including nutrition, health, recreational, edu-
Community Development, Evaluation, Technical Services, Volunteer General and
cational and social services. Projections of plans include two additional units,
Services, and Training and Upgrading.
one to be placed in East Athens and one in West Athens. These will be operated
and Community is directly responsible to the Executive Director. Since Supervisor of
supervising Home Services Field Service and Auxiliary Home Services. The coordinating and
The Supervisor the of Home Services is responsible for directing,
as satellite units sharing certain staff services with the central day center. We
are hopeful that a modular unit can emerge and be reproducible in other areas
as we gain experience.
conferences of these three areas in particular have to cooperate and meet Services, in staff
the personnel and Volunteers Services may provide staff to the Home Training
6. Nutrition Services (Home delivered meals)
on a regular basis.
Inserted in the project out of demonstrated need and as a means whereby a
greater number of clients could be served, hot meals delivered to the client's
WHY A VOLUNTARY AGENCY?
home are now a most effective function of the ACCA. Expansion of this program
will accelerate when our demonstration kitchen is completed. Located in the pilot
2. 1. With It is a free agent to purchase services wherever and whenever the
Day Care Center, the kitchen will serve as preparation point for both day care
no political ties, it is able to serve the total community and need not arise. be
meals and to dispatch volunteers and staff personnel with nutritious meals to
totally 3. In subject to administrative or legislative restrictions.
those unable to prepare them at home or where an aide is needed only for nutrition
made: concerning participation in home care programs, the following statement Cross) in 1964 was
a report their prepared by the Michigan Hospital Service (Blue
service and can be released for serving another client. We are utilizing the surplus
meals of the College Avenue Day Center for Children and the Pattie Hillsman
School. These meals are purchased for a nominal fee, packaged in insulated
containers and delivered hot to the client. Additional meals and special diets
service there available more than one hospital, community-wide planning be done to where
"From is the Blue Cross standpoint, it is preferred that in communities
are prepared by staff daily and on holidays when school cafeterias are closed. At
rather than to all Blue Cross subscribers of the area in need of such make service, the
present we are serving from 40-50 clients one meal a day, five days a week.
4. A to those discharged from only one of the hospitals."
The six functions described above are the major direct services that the agency
clients
with voluntary ease. agency may administer a fee schedule of payments from its
delivers. These are the cost centers identified for functional budgeting.
Functional Budgeting
adjust ing to professions changing situations. and interested public, can be more viable and board, more includ- readily
5. the Policy direction in a voluntary agency with a representative
All services in the field of social welfare should consider the advisability of
the business community for years.) It is imperative that the social welfare field
being able to tell what each service costs. (Cost accounting has been a must with
patient, 7. physician, welfare agencies and insurance carriers.
6. A voluntary agency is more likely to marshall the full support it needs from
consider it a must at this time. For the first time in its history, third party pay-
private Public agencies generally have a greatly restricted clientele, whereas the
ments will be available for the services. The cost of service must then be a true
Our older agency may utilize public and private resources to open services
that if we are to charge for aide service we must know the cost of placing that
cost (including administration) as well as being a realistic one. It follows, then,
their needs largely been schooled not to ask because they, personal services.
silent They have of the population when it comes to speaking up for comprise a
10% citizens are not in the habit of asking for services. They to all.
aide in the field plus per unit costs of administration. It is not realistic to include
in this cost the costs of training the aide, nor the cost of all the social services
and medical services that may also be part of the agencies program.
able segment hence, of our we society. must find, develop, and extend new services to this meeting vulner-
their needs, adequately met. Now we have National policy directed as a group, toward never had
To functionalize one program, is to know what the various services are that
an agency delivers. When these are identified and defined the number of cost
centers will correspond to the number of services identified.
wide of must from be indigenous to the needs of the older population) sense and package
These services services must be comprehensive (in the specialized that the
Upon identifying the cost centers, the professional and para-professional staffs
person-e.g. range those needed by the self-directing to the totally cover a
identified services. Based on these time sheets, the salaries of the personnel are
of the agency must keep a time sheet if they are working in more than one of the
nursing and health aides, homemaker services, prescriptive main-
tenance, home pre-retirement, retirement, life enrichment activities, health dependent
charged to each of the cost centers. All other costs that can be charged to the
alternative. care, finally institutional care, when, and only when it hospital is the only and
specific centers should be so charged. All other costs are placed in management
or administration.
mix Aging of provide "barrier free" services to the extent now possible on
The seeks model to currently being developed by the Athens Community Council
center. As one instance, if the agency is reimbursed for training costs, such income
Any income that the agency derives should also be placed in the proper cost
services resources and programs available to it. What is most important with the
should be placed in that cost center.
are now being provided where once (not long ago) none such existed. is that
144
145
leasurement of effectiveness, cost/benefit ratio etc. is not done easily. What we
HOMEMAKER/HEALTH AIDE SERVICE-SUMMARY OF PATIENT/CLIENT FILES
know is that many elderly persons are alive and well cared for where once they
died unattended for lack of appropriate help-institutional or otherwise.
Number
Visits
Month
Hours
of clients
per week
Number
per week
Visits
Month
Hours
'hey were invisible to the community.
of clients
per week
per week
December 1970
PLANNING vs. DELIVERY?
75
191
Inactivated
401
-13
August 1971
-58
-27
103
244
Gains
818
11
One of the new combinations possible because of new re-formulation of health
40
81
December bal-
nd social services is the possibility of testing new original patterns for the planning
ance
62
Total
133
374
114
284
Inactivated
899
delivery of social and health services. In the past, it has been considered a
-12
-33
-112
January 1971
62
olicy guideline to separate out operational and planning services because of the
133
374
Gains
14
27
August net
115
102
251
787
xperiment with "vertical linkage" whereby the various services of prevention
endency for operations to swamp the planning function. It is now possible to
Total
76
160
September 1971
489
102
251
Gains
787
Inactivated
nd rehabilitation of aged can be brought into the administrative purview of one
-6
-17
-86
4
14
41
which would necessarily have a planning function in order to maintain of
January net
70
143
Total
403
106
265
Inactivated
828
terlinkage gency of services and would have the capacity of assuming the role
-1
-2
February 1971
-6
70
lanning advocate for developmental and remedial services for the aged. Specifi-
143
Gains
403
8
28
123
September net
105
263
822
ally, this unites the traditional planning function of the Athens Community
Total
78
October 1971
Council on Aging with the operating responsibility of the direct service agency.
171
526
105
263
Gains
822
Inactivated
-5
rganizational differentiation along the vertical axis will involve a management-
-13
-38
22
57
187
esource allocation system that will be attuned to the needs of the older population
February net
73
158
Total
488
127
320
nd therefore, perhaps be better prepared to contribute to full scale community
Inactivated
1,009
-3
-10
March 1971
-25
73
lanning since it will represent sources of need and data whose absence has led to
158
Gains
488
8
24
97
October net
124
310
984
inevitable distortion of community planning.
Total
81
182
585
November 1971
124
310
Inactivated
984
-2
-3
-9
Gains
11
25
95
BOARD OF DIRECTORS
March net
79
Athens Community Council on Aging
179
576
Total
135
335
Inactivated
1,079
-14
April 1971
-40
-125
79
179
Executive
Gains
576
15
34
167
November net
121
295
954
Director
Total
94
213
Development
Inactivated
743
December 1971
121
295
954
Administrative
-2
Evaluation &
-10
-50
Gains
16
48
136
Services
Technical Services
April net
92
203
693
Total
137
343
Inactivated
1,090
-3
May 1971
-11
-32
92
203
Gains
693
10
32
139
December net
134
332
1,058
Supervisor of
Total
102
235
832
January 1972
134
Home Services
Inactivated
332
-1
-5
-40
Gains
1,058
28
84
320
May net
101
230
792
Total
162
416
Inactivated
1,378
June 1971
-2
-8
-32
101
230
Gains
792
8
34
107
January net
160
408
1,346
Total
109
264
899
February 1972
Inactivated
160
408
-2
-50
Gains
1,346
-10
18
63
230
June net.
107
254
849
Total
178
471
Inactivated
1,576
July 1971
-1
-2
-8
Training and
107
254
Auxiliary
Gains
849
Community and
Field
Upgrading
1
2
4
February net
177
469
1,568
Volunteer Services
Service
Home Services
Total
108
256
STAFF MEMBERS IN EACH SERVICE
Inactivated
853
-5
-12
-35
Development, Evaluation &
Community &
July net
103
Volunteer Services
244
Administrative Services
818
Assistant for Administrative Services
Technical Services
Administrative Ass't for
Coordinator
Fiscal Manager
Development & Evaluation
Secretary
Clercial staff
Clerk-Typist
Consultants
for etc. March 1972. This represents assistance with doctors' appointments, paying bills, grocery shopping, and
Note: the month In addition of to homemaker health aide service: Community Service aides-260 clients received 918 hours of service
Auxiliary Home Services
Training and Upggading
Field Service
Assistant for Field Service
4 Field Counselors
Supervisor & Coordinator
30 full time Addes
4 Community Service Aides
Consultants
30 part time Aldes
2 Telephone Life Line Staff
2 Home Maintenance Aides
1 Driver
1 Handyman
146
SEPTEMBER 1971-CLIENTS SERVED BY SOCIAL SERVICE WORKERS ("COMMUNITY
SERVICE AIDES")
93
Beadie Alexander
83
Ruby Howard
73
Viola Galloway
249
Visits for month of September 1971
OCTOBER 1971-SERVICES RENDERED BY SOCIAL SERVICE WORKERS
97
Beadie Alexander
102
Appendix 6
Ruby Howard
72
Viola Galloway
Services rendered for clients in October 1971
271
WIDESPREAD HOME HEALTH CARE NAMED A STATE NECESSITY
NOVEMBER 1971-SERVICES RENDERED BY SOCIAL SERVICE WORKERS
[From Age in Action, West Virginia Commission on Aging, November-December, 1971]
Clients
Services
West Virginia Commission on Aging, feels that " *** the most neglected area of
Dr. N. H. Dyer, Director, West Virginia Department of Health and member,
health service is home care.
32
45
Beadie Alexander
34
62
19
28
dealing with their health problems," he wrote in the November 25, 1971, State
we will have helped greatly in meeting some of the real needs the elderly face in
"If adequate health services to patients in their home could be made available,
Viola Galloway
30
43
24
35
of the State's Health.
Ruby C. Howard
28
32
7
13
Thousands of the State's senior citizens spoke out in more than 300 Older
Joe L. Sorrells
3
3
health care and transportation.
Americans Community Forums, naming their main needs as adequate income,
177
261
Total
The regional White House Conferences on Aging and the State Conference
emphasized the need for improved health care for the elderly.
DECEMBER 1971-SERVICES RENDERED BY SOCIAL SERVICE WORKERS
of our counties have home health services, yet such care is essential if older
One of West Virginia's proposals on health care states: "Fewer than 25 percent
87
113
and women are to remain in their homes. These services should be extended men
Beadie Alexander
45
77
throughout the State, and physicians should be encouraged to make referrals.
Viola Galloway
52
103
Ruby c. Howard
47
large part by Medicare."
Without home health care, our people are being deprived of services covered in
47
Joe L. Sorrells
231
340
home health services. Sixteen home health agencies in local health departments
In 1966, legislation was passed authorizing health departments to provide
Total
were certified to provide care to patients covered by Medicare in 21 counties.
JANUARY 1972-SERVICES RENDERED BY SOCIAL SERVICE WORKERS
"Seed money" for this effort was available from the Public Health Service.
77
health agencies are discontinuing the program. These agencies offered services in
However, due to financial problems and lack of patient referrals, two home
102
Beadie Alexander
49
86
Viola Galloway
44
108
Ruby C. Howard
departments serving 11 counties.
an eight-county area. There are presently 11 home health agencies in local health
102
136
Joe L. Sorrells
Many people working with the elderly have misconceptions about the health of
272
432
Total
percent are in health care facilities and 14 percent of the noninstitutionalized
older persons, Dr. Dyer feels. The aged enjoy reasonably good health-only 5
elderly are totally unable to work or keep house due to a chronic condition.
FEBRUARY 1972-SERVICES RENDERED BY SOCIAL SERVICE WORKERS
"This may look like a rosy picture," he continued, "but when several variables
122
are added, the picture becomes out-of-focus. One variable of significance is that
62
Beadie Alexander
44
90
those 65 and over are the fastest growing poverty-stricken age group in our
Viola Galloway
70
141
services society. Other factors influence the health care problems of the elderly: (1) Are
Joe Lanier Sorrells
36
67
Myrtice Strickland
48
102
but available to meet the needs of the 14 percent who live in the community,
Ruby Howard
who have major health problems that prevent functioning within their
260
522
normal limits? (2) Are there services available to maintain the relatively healthy
Total
aging who are able to function with few or no limitations? All too often, the answers
to these questions are a qualified 'no.'
coordinated and continuous. Comprehensive service is a total range of service
In general, he wrote, the aging need health services that are comprehensive,
his family. Coordinated service is a service that is assembled into an appropriate
that is available and accessible to meet all known needs of the older person and
his package for each individual and is available to fit the needs of the individual and
The need for this type of service is reflected in another of the State's proposals
family. Continuity of service is a service that is provided without interruption.
for the White House Conference on Aging: "We need a coordinated health service
system at the Federal, State, and local levels which would provide both long-term
and short-term care for the physically and mentally ill aged * * Such
health system would stress, (among other things) home health care as a necessary a
health aides, homemakers, and volunteers."
means of helping older people stay out of institutions and would involve home
(147)
93d Congress
1st Session
}
COMMITTEE PRINT
PREFACE
HOME HEALTH SERVICES IN THE
UNITED STATES:
A WORKING PAPER ON CURRENT STATUS
(Together with Recommendations
and
A Summary of Proceedings from a Conference:
"In-Home Services: Toward a National Policy,"
Columbia, Md., June 1972)
PREPARED BY THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
GERALD
LIBRARY
JULY 1973
Printed for the use of the Special Committee on Aging
U.S. GOVERNMENT PRINTING OFFICE
96-867
o
WASHINGTON : 1973
For sale by the Superintendent of Documents,
U.S. Government Printing Office, Washington, D.C. 20402
Price 50 cents Domestic postpaid or 30 cents GPO Bookstore
Stock Number 5270-01874
B abam stanqioitraq
to
to borlism bib
PREFACE
to
bas
to
"We must provide the older adult with better op-
portunities for choice than is presented to him at the
И SERVICES HTJAIH
present time. One of the messages that has come
through to me, quite loud and clear, from older adults
NULLED
is: 'We want to be put in a position where we can make
our own decisions relative to our own lives. We don't
A
want other persons making these decisions for us.' So
it seems to me that it is important for us to provide
older adults with a variety of choices."
-Dr. Arthur Flemming, Chairman of
the 1971 White House Conference on
B
Aging and now U.S. Commissioner of
Aging, in his closing address to the
Conference: "In-Home Services: To-
ward a National Policy."
SPECIAL COMMITTEE ON AGING
FRANK CHURCH, Idaho, Chairman
HARRISON A. WILLIAMS, JR., New Jersey HIRAM L. FONG, Hawaii
Perhaps the need for the "choices" mentioned by Dr. Flemming are
ALAN BIBLE, Nevada
CLIFFORD P. HANSEN, Wyoming
nowhere more vital than in the health care resources available to
JENNINGS RANDOLPH, West Virginia
EDWARD J. GURNEY, Florida
older Americans.
EDMUND S. MUSKIE, Maine
WILLIAM B. SAXBE, Ohio
And yet it has become commonplace to observe that the elderly of
FRANK E. MOSS, Utah
EDWARD W. BROOKE, Massachusetts
CHARLES H. PERCY, Illinois
our Nation are especially hard-hit by overreliance upon institutions—
EDWARD M. KENNEDY, Massachusetts
WALTER F. MONDALE, Minnesota
ROBERT T. STAFFORD, Vermont
hospitals, as well as nursing homes-and intensive "crisis" treatment
VANCE HARTKE, Indiana
J. GLENN BEALL, JR., Maryland
rather than sustained treatment to maintain health or keep chronic
CLAIBORNE PELL, Rhode Island
PETE V. DOMENICI, New Mexico
illnesses in check.
THOMAS F. EAGLETON, Missouri
Clearly, in-home health services would play a major role in any com-
JOHN V. TUNNEY, California
LAWTON CHILES, Florida
prehensive system capable of providing the options that older persons,
WILLIAM E. ORIOL, Staff Director
as well as members of other age groups, should have.
DAVID A. AFFELDT, Chief Counsel
For that reason, the Senate Special Committee on Aging last year
VAL J. HALAMANDARIS, Associate Counsel
published a report, written by Miss Brahna Trager, on Home Health
JOHN Guy MILLER, Minority Staff Director
Services in the United States. An authority of long-standing in this
area, Miss Trager concluded that home health service agencies in the
(Prepared by Brahna Trager, Home Health Consultant)
United States are laboring under serious difficulties, including re-
(II)
strictive Medicare policies.
Miss Trager, asked by this committee to update last year's findings,
has written the following brief report.
Unfortunately, she must conclude that the difficulties still exist.
In fact, the number of home health agencies in the United States has
actually declined within the past year, and Medicare still causes seri-
ous problems for present or potential providers of in-health services.
In direct response to the regrettable situation described in this com-
по
mittee's home health report last year, a group of specialists in the field
of home health care convened at Columbia, Md., for a conference on
in-home health services. The recommendations, printed in part 2 of
this report along with a summary of the proceedings, should have
challenged the Federal Government and private resources to awaken
to the desperate need for broader and better in-home services.
(III)
IV
Furthermore, the Columbia conference participants made a vital
agaibescorq to
point worthy of national note. They emphatically declared that they
did not consider in-home services an "alternative" method of care. The
community, rather than the institution, was seen as the primary site
of care, and the array of services provided in the community are in-
tended to make appropriate choices possible rather than to substitute
CONTENTS
one method of care, necessarily, for another.
The Columbia recommendations and Miss Trager's latest findings
are worthy of careful attention at a time when considerable lip serv-
ice is paid to the concept of "alternatives to institutionalization."
PART 1
To help the Committee on Aging to arrive at its own findings and
Page
recommendations, the following report is therefore printed as a work-
Preface
III
Home health services in the United States: Current status
1
ing paper and source book of helpful information.
The Columbia conference
5
FRANK CHURCH,
Exhibits (see appendix 1, page 53-74)
10
Chairman, Special Committee on Aging.
PART 2
EDMUND S. MUSKIE,
Chairman, Subcommittee on Health of the Elderly.
Summary of proceedings and text of recommendations:
Conference on "in-home services: Toward a national policy," Co-
lumbia, Md., May 31-June 2, 1973
11
I. Frontispiece
12
II. Introductory statement
12
III. The need for a national policy
13
IV. "In-home services"
14
V. The conference opens:
Keynote address: Carroll Witten, president, board of
aldermen, mayor pro tem, city of Louisville, Ky
16
Legislative proposals regarding home health care:
David Affeldt, chief counsel, U.S. Senate Special
Committee on Aging
17
Health care becoming increasingly institutionalized
18
The challenge
18
Recommendations
19
100-visit limitation
19
Elimination of 3-day hospitalization requirement
19
Protection against retroactive denial of payments.
20
Expansion of home health services under Medicare.
20
Manpower requirements
20
Other proposals
21
Conclusion
21
VI. The working conference
21
VII. Quotes from the working groups:
What is policy?:
The "right" to health care
24
Planning
25
Barriers to acceptance
26
Services
26
Funding
26
VIII. The conclusions-conference recommendations:
"Toward a national policy":
Preamble
27
Implementation
28
Legislative recommendations
28
IX. Closing address:
The administration's plan for action: Dr. Arthur Flemming,
Chairman, White House Conference on Aging, 1971
32
(V)
VI
Summary of proceedings and text of recommendations-Continued
Conference on "in-home services"-Continued
X. Participant organizations speak:
Page
Mr. Richard Schlesinger, executive vice president, areawide
and local planning, American Association of Comprehen-
sive Health Planning
37
Miss Alice Gonnerman, assistant director, division of ambu-
latory care, American Hospital Association
38
Dr. Patrick Storey, American Medical Association, Professor
of medicine and community medicine, University of
Pennsylvania
38
Mrs. Manuel Bergnes, women's auxiliary of the American
Medical Association
39
HOME HEALT
Mr. John J. McManus, assistant director, department of
community services, AFL-CIO
40
Malcolm U. Dantzler, M.D., M.P.H., assistant State health
officer, South Carolina State Board of Health, Association
of State and Territorial Health Officers
40
Miss Ann Cohlan, Blue Cross Association, Federal Programs
Concern about in
Contract Operation, Senior Director of Claims Service
40
States can be expres
Miss Helen Rawlinson, director, home care department, Blue
One is the dollar
Cross of Greater Philadelphia
41
Mr. William Reinertson, associate director, Health Insurance
discussion about me
Council
42
Another approac
Mr. Lowell Norling, National Consumer Health Council
42
by the "human" as
Miss Margaret Lewis, president, National Association of
who face inconven
Home Health Agencies
42
Mrs. Helen Burr, consultant on national organizations,
at the worst.
National Council on Aging
43
Starting from t
Mr. Berkeley Bennett, executive vice president, National
"human" facts, the
Council of Health Care Services
43
Mrs. Florence Moore, executive director, National Council
are becoming increa
for Homemaker-Home Health Aide Services, Inc
44
delivery of health
Mrs. Katherine Ellickson, National Council for Senior
needs where they e
Citizens
45
those services that
Mr. Peter Meek, executive director, National Health Council
46
Dr. Dorothy McMullen, National League for Nursing
46
Incongruities in
Working Conference: "In-Home Services-Toward a Na-
more and more on s
tional Policy", Urban Life Center, Columbia, Md., May
A recent General
31, June 1 and 2, 1972
48
criticism of present
Conference Agenda
49
Conference Participant List
50
There is a c
about 25 perce
APPENDIX 1
facilities which
Exhibit A. Bed disability days per person per year by family income,
system is orien
July 1965-June 1967
53
phase of illnes
Exhibit B. Days of disability per person per year by sex and age, 1969
53
Exhibit C. Medicare reimbursements for home health services and in-
health care by
patient hospitalization, 1969-1972
54
financing for tl
Exhibit D. Memorandum from Helen L. Rawlinson, director home care
patients in acce
department, Blue Cross of greater Philadelphia, January 19, 1973
55
Exhibit E. Report of the council on medical service, Home Health Care,
Noninstitutional
AMA, 1972
58
aggressive approacl
Exhibit F. Memorandum from Helen L. Rawlinson, February 20, 1973
66
priate, least costly
Exhibit G. Fact Sheet, National Association of Home Health Agencies
68
Exhibit H. Study of health facilities construction costs, enclosure C,
systems that result il
Chapter 3, Home Care, Comptroller General of the United States,
Among these "alt
November 20, 1972
70
Home care ad
care delivery a
1 Miss Trager was the
published in April 1972 by
2 "GAO Report." Study
by the Comptroller Genera
2
3
Home care can be viewed as meritorious by itself in that it
The situation remains one in which new home health services can-
provides the most appropriate care to the patient at the level
not be developed in communities or areas where they are not now avail-
which best fits his needs. Patients on home care also pay a
able because no funding mechanism exists for their development. Agen-
good deal less than the rate they would have to pay in a gen-
cies which have already been organized are unable to expand the area
eral hospital, and there is a growing sentiment among med-
of services which would make them effective as "alternative" commu-
ical economists that a well-conceived home care program
nity care systems without funding assistance. Agencies and commu-
could make unnecessary the construction of a substantial
nities have been forced to conclude that however desirable home health
number of new general hospital beds. One source estimated
services might be and however effective they might be in reducing the
that a home care program with a caseload of 50 patients
cost of inappropriate institutional care they cannot exist entirely on the
could be an adequate substitute for construction of an equiva-
basis of third party reimbursement. They cannot maintain their pres-
lent number of hospital beds occupied by patients who require
ent status nor can they expand when much of that third party reim-
home care but not hospital care.
bursement is bound up in a frustrating and expensive set of paper
In the report "Home Health Services in the United States",³ home
procedures.⁴ Fee-for-service by which full cost may be reimbursed from
health services of "good quality" are described:
the "private sector" is not reliable as a financial base either for program
development or expansion, and reimbursement from the private sector
'Home health services of good quality' describes an array
does not solve the problem for that part of the population which has
of services which may be brought into teh home singly or
the greatest need for the services.
in combination in order to achieve and sustain an optimum
state of health, activity, and independence for individuals of
It has been demonstrated that however much communities might
all ages who require such services because of acute illness, ex-
see the need for the development of home health services, funding
acerbations of chronic illness and disability. They are an es-
from voluntary sources cannot be secured in any significant
sential component of any system of comprehensive health care
amounts because equally imperative pressures from other areas
and the absence of such services excludes the possibility of the
of the community draw on available funds. In any case, a com-
most appropriate use of all other health resources. (Author's
munity system which intends to meet the needs which have be-
come evident for those inappropriately institutionalized, or for
emphasis.)
those who are at home whose disability is limiting, cannot rely
It was pointed out in the same report that such services were limited
in their availability; many communities had not developed home
upon casual, or charitable, or sporadic funding sources. Just as
the "bricks and mortar" approach was developed with hospital
health programs at all; many offered only those services required as
a condition for certification by the Medicare insurance system; those
funding, SO must the community network which will provide home
which participated in the Federal insurance system (Titles XVIII and
care and ambulatory care be seriously tackled with the idea of
XIX, Social Security Act) had experienced serious difficulty in pro-
building an important component of the health care system.
viding services because the requirements of the system with respect to
Fiscal intermediaries and home health agencies, excerpt from American Hospital Asso-
eligibility for home health service were unrealistic and interpreted
ciation, Minutes, Committee on Home Health Services Assembly of outpatient and home
care institutions, meeting of June 27, 1972:
in a variety of approaches by claims reviewers in various areas;
"Some home health agencies continue to experience many difficulties with the fiscal
paper work, retroactive denials, delays in claims approval had driven
intermediary process. Some of the committee question whether the administrative
structure for claims review which has evolved under Medicare is not overly cumber-
many community service programs from the field, had forced them to
some, expensive and inadequate.
reduce staff and services, or had resulted in refusal to serve recipients
when the third party payor was the insurance system.
"Some fiscal intermediaries are paying only a part of the prescribed treatment and
are thus reversing physician-ordered treatment which the agency had carried out. Some
During the period since the report was issued, the situation as
intermediaries ask for medical information in addition to what is sent in on claim
forms. Variations between different Blue Cross Plans in their determination on home
described has continued. The number of "certified" home health
health agency claims persist as a major problem. Many plans lack professionally
trained and experienced claims reviewers. Miss Brown stated that when intermediary
agencies at the end of 1972 is reported to be 2,221; the figure given
operations are reviewed a prime area of interest is the intermediary's rate of claims
as of 1970 was 2,350, and as of December 1971, 2,256. The situation
denied. i.e. billings VS. non-payments. This is seen as being an indication of the ade-
quacy of the intermediary's administrative controls when in fact, the intermediary may
with respect to Medicare expenditures still indicates a marked
have educated the agencies about what are covered services so the agencies are billing
only for covered services. The chairman was advised by the Blue Cross Plan in Denver
increase in hospitalization (an estimated 9.4 in 1972 over 1971)
that she must have some claims denied. She questioned the need to file claims knowing
with no significant increase in expenditures for home health serv-
they would be ineligible for payment, in order to increase denial rate. The committee
would like information on the number of retrocative denials of claims which are
ices or the percentage of over-all expenditures for home health
reversed after rehearings.
services. (See exhibit C, appendix 1, page 54.) Agencies also report
a steady attrition of staffs and services because of fiscal problems,
"The Secretary has brought the problems agencies were having with intermediaries
to the attention of the Medicare Division of Blue Cross Association, since BCA is the
many, but not all, of them related to the insurance system.
prime contractor for the plans. There was staff recognition that too little attention
had been paid to helping plans do a better job with home health agency claims review.
Written materials, educational programs for the Plans and use of personnel from
3 Home Health Services in the United States, a report, April 1972, U.S. Senate Special
Plans with good experience in home health agency claims review as consultants to
Committee on Aging, p. 5, prepared by Brahna Trager, Home Health Consultant.
other Plans were identified as ways of improving the situation."
4
5
In the immediate future there does not appear to be action which
increase need; reducing utilization of health care in times of need
will improve the present situation. Among the major recent legislative
can only produce more serious need. It is an approach which sug-
(H.R. 1, P.L. 92-603) and regulatory changes:
gests the use of alternative patterns of care without offering the
possibility that such alternative care can be made available. It
(Sec. 203)
suggests culpability in a number of groups: Physicians, institu-
tions, providers of such "alternative" care as is available; con-
1. Medicare premiums will be increased.
sumers. In fact the delivery system itself is the culprit; all other
groups have been forced to make use, appropriately or inappro-
(Sec. 204)
priately, of what was available in time of need, and there is very
good evidence that large numbers in the population are going
2. Increased individual financial participation will be required for
without care because what they need is not available at all.
the Part B (Supplementary Medical Insurance) deductibles.
THE COLUMBIA CONFERENCE
(Sec. 208)
On May 31, 1972, at Columbia, Maryland, a group of specialists in
3. The medically indigent will be subject to monthly premium
the field of home health care convened for a conference entitled "In-
charges under Medicaid.
Home Services-Toward a National Policy".⁶ The title "In-Home
Services" was intended to broaden the approach to care in the com-
FED. REGISTER, SEC. 222.46; FED. REGISTER, VOL. 35, No. 230, Nov. 26,
munity, extending it beyond the very limited, narrowly interpreted
1970; ELIMINATED
"health related services" which has become a minimal approach to care.
4. Homemaker/home health aide services, an important component
The "In-Home Services" approach emphasizes the development of an
of non-institutional community care will not, as previously provided,
array of services which could provide care in a continuous, coordinated
be maintained as one of the special services which must be provided
fashion offering to both professional and consumer a broad enough
by the Social and Rehabilitation Services. They will become "op-
range of options SO that viable care in the community could be made
available for individuals at all three levels of need when it is indicated,
tional".
The stipulation that quality must be assured through the require-
desirable or preferred.
ment that such programs meet those of national standard setting or-
During the course of this conference, a significant approach was
made to the problem of developing a community network of services
ganizations has disappeared.5
which does not eliminate the need for institutional care but which is
effectively coordinated with all health and social resources to provide
(P.L. 92-603; SECTIONS 213, 228)
the kind of "appropriateness" that has been referred to in the General
5. The "assurance" of payment section (section 228) and "limita-
Accounting Office report.
tion on liability" section (section 213) will place an additional finan-
The conference group did not confine itself only to the rights and
cial and administrative burden on agencies whose existence is already
the problems of providers of care. It recognized the fact that the ab-
threatened by financial and administrative problems related to titles
sence of community resources for non-institutional care does not in
XVIII and XIX. (See exhibit D, appendix 1, page 55, for comment.)
fact deprive members of the American population of their personal
6. The requirement that entry into the home health service benefit
rights and deprives ethical providers of the opportunity to select not
via the 3 days of hospitalization has been retained in the insurance
only the most effective method of care but one which is adapted to the
preference of the individual.
system.
In-home services, as described in the recommendations of the Co-
The contradictions in this approach are immediately apparent:
lumbia conference, suggest an administrative framework, a well-de-
It is an approach which expects to reduce costs by increasing pre-
veloped, linked set of services, coordinated with existing institutions
miums. It is an approach which penalizes those sectors of the
and resources, with a funding base which allows for constant and reli-
population whose need for medical care is the greatest. It is an
able delivery of good quality care in the community and in the per-
approach based upon the expectation that financial penalties im-
sonal environment. Such services could make maximum use of ambu-
posed upon the most vulnerable population groups will deter
latory care facilities, family care centers, neighborhood care centers,
utilization of health facilities when such deterrent action can only
private physicians, health maintenance organizations, a real possibil-
ity. In fact, the organized components of a well-developed in-home
5 "Dr. Weinstein stated his opinion that the only criteria for controlling abuses should
be (1) medical necessity as attested to by physician orders. (2) responsible agency admin-
services system could then make of the community itself a "health
istration, and (3) utilization review." Harry Weinstein. M.D., M.E.D., Director of Mt. Zion
Home Care Program, San Francisco. Minutes. committee on Home Health Services, Assem-
bly of outpatient and home care institutions, AHA, meeting of June 27, 1972.
6 See part II of this report for a summary of proceedings and the full text of the recom-
mendations.
6
7
maintenance organization", and since the under-one-roof pattern of
in the recommendations of the Columbia conference with respect to
HMO's will not, in the foreseeable future, become available to the
home health care:
whole population, such an approach to community care seems to offer
The changing age composition of the U.S. population and
the most practical method of reversing both dollar costs and human
the proportionate increase in long-term illness and disability
costs in the present institutionally oriented delivery pattern.
have resulted in the medical profession's increased recogni-
Members of the conference were quite clear about the fact that
tion of the neeed for examining and improving traditional
they do not consider in-home services an "alternative" method of
methods of delivering health care services.
care since the community rather than the institution is seen as the
Over the past half century, the increase in prevalence of
primary site of care (see also exhibit F, appendix 1, page 66) and
such chronic diseases as hypertensive and arteriosclerotic
the array of services provided in the community are intended to
heart disease, cerebrovascular disease, arthritis, neurological
make appropriate choices possible rather than to substitute one
disorders, malignancies, and pulmonary disorders has ex-
method of care for another.
panded demand for long-term medical and supportive care.
Although it is possible and even probable that after initial develop-
mental costs have been incurred community centered care might show
Home care is of benefit for many categories of patients-
cost savings, there was no intention on the part of the conference to
the acutely ill, the convalescent, and those recovering from
eliminate appropriate optional use of, nor was there any intention to
surgery. In December 1960, the AMA house of delegates
substitute a "cheaper" method of care for one which was more expen-
recommended that "physicians be urged to participate in or-
sive. Savings would be those involved in making the best use of the
ganized home care programs for any patient who can benefit
whole range of needed services.
from the program and to promote such programs in their
The preamble to the conference's recommendations clearly states
communities.' A 1972 report, Home Health Services in the
the objectives which should include in-home services as a part of our
United States, prepared for the U.S. Senate Special Com-
national policy in the range of services to which the population is en-
mittee on Aging verifies the fact that many patients in nurs-
titled. This preamble and its recommendations might be said to repre-
ing homes could better utilize home care services.
sent a bill of rights for consumers and providers.
It is the right of every individual to live his life in circum-
The benefits of effective home health care programs can be sum-
stances which enable him to make the fullest use of his ca-
marized as follows:
pacities. This right is protected when the society in which he
1. Patients prefer care that can be provided in the nor-
lives provides these safeguards which ensure his basic eco-
malcy of their home environment.
nomic security in a decent environment and the services which
2. Home-bound people can be taught to live in a relatively
are necessary to promote his physical, mental and emotional
independent status.
health. These services are only effective when they are avail-
3. The need for initial admission or readmission to in-
able in a comprehensive system which includes all of the
patient institutions can be diminished.
skills and facilities essential to the promotion and mainte-
4. For the necessary institutional admission, unnecessary
nance of optimum health.
days can be eliminated through early discharge to home care.
In-home services are a major component in this system.
5. Unnecessary capital construction costs for inpatient
They ensure appropriate utilization of all other components
facilities can be decreased.
in the system; they utilize the home and the family as a valu-
6. The efficiency of the practicing physician can be in-
able resource; they prevent the unnecessary displacement of
creased by expanding the team approach. The physician can
persons which occurs when services are lacking; they guar-
care for a greater number of patients through a home care
antee the right of the individual to remain in the place of his
program because he does not have to assemble and coordinate
choice. In the absence of in-home services, no system may
individually the services needed for his patients in their
be considered either comprehensive or effective. They must,
home settings.
therefore, be an integral part of this system and top national
7. Home care staff can readily interpret medical orders,
priority must be given to the development of a rational sys-
explain treatment regimes, and offer reassurance and support.
tem of comprehensive in-home services for the whole
8. Home care staff can identify day-to-day problems and
population.
thus help to reduce the possibility of emergency situations
In 1972, also, the Committee on Community Health Care of the
arising.
American Medical Association submitted a report on home health
The report stresses the need for recommendation of these benefits by
care (see exhibit E, appendix 1, p. 58) which takes much the same ap-
the practicing phyisican, the need for concern and leadership in the
proach as that expressed in the General Accounting Office report and
community medical society and the role of institutional medical
staffs in recognizing "the important community problems and needs
8
9
of patients and the utilization patterns of care that can most appro-
priately answer those needs." (See exhibit F, appendix 1, page 66.)
they intend to establish as a part of their professional respon-
Throughout the year in regional conferences concerned with com-
sibilities. It was a nurse at Columbia who suggested that entry
prehensive health planning, health care delivery, home health serv-
into the in-home services system need not invariably be
ices and homemaker services, across the country, the need for in-home
through physician or nursing services but through the need
health services has been repeatedly stressed and the hardship which
of any service which promotes health in its broadest sense.
the absence of such services imposes on large sections of the popula-
It was a social worker who said "health care is ancillary to
social functioning." In a group which included representa-
tion have been repeatedly described.
At one of these conferences the following comments were made:
tives from every field and from every organization-volun-
tary, proprietary, consumer-related to the fields of human
It would be very difficult at this time to point to any major
services, there was general agreement concerning the "right
public effort which has been made to support the development
of every individual to receive good care in the place of his
and expansion of in-home services with hard cash. There has
choice" and the "responsibility of society to meet his needs.
been no move comparable to the funding of our many excel-
There is also a broad concern with our present delivery sys-
lent and expensive acute care facilities. Prior to the imple-
tem. The current interest in health maintenance organizations
mentation of titles XVIII and XIX, there were some very
does not grow out of cost considerations alone. We are looking
good but limited project grants directed to the development
at them as a possible method to provide an organized con-
of home health agencies. There were limted funds made
tinuum of services which makes maximum use of facilities
available for the training of paraprofessionals, many of
and resources because they are all tied together and must be
whom could not be placed in employment because there were
appropriately used if they are to sustain themselves. We are
no jobs available for them. There are some funded "home-
hearing about ambulatory care facilities which are a socially
maker" programs in public welfare departments. A few
organized and potentially effective effort to replicate the serv-
communities have succeeded in establishing good to excel-
ices which were available in the days when people considered
lent networks of services through the consortium approach.
the institution last. We are hearing more about family cen-
In general, however, it would be accurate to say that our
tered care. The realization is growing that care in the commu-
services have been left to generate themselves and to be-
nity for the mentally ill, the massively disabled, the mentally
come self-sustaining.
retarded, the alcoholic, the drug addicted can be more effec-
I do not need to say to this group that the self-generating,
tively provided when concern with personal ties and attach-
self-sustaining approach has not been successful, and I know
ments are included in therapeutic considerations.
there is no need, here, to stress the problems which have arisen
We are also, at long last, coming to the conclusion that
out of the administration of the Federal insurance system as
health care for the whole population and a minimally decent
it relates to services in the home. It is focussed on two impor-
standard of living for the whole population may, in the long
tant segments of our population, but however important they
run, be the best cost savers of all.
are, that system leaves a large portion of the population un-
These concerns stress, as never before, the necessity for
covered. There is no way to defend this absence of concern be-
home-centered services. It does not require any great amount
cause it is indefensible.
of intelligence to understand that the health maintenance or-
We cannot therefore truthfully say that "in-home" services
ganization will be in the same position in the future as the
are not available because they are not accepted. We can only
private physician is in today if it must rely for care at home
say that they cannot be accepted if they are not available. We
upon a few nursing visits plus an hour or two of "one other
cannot expect the user or the provider to "accept" what he has
service". If it has not been possible to keep people out of in-
not known or to "utilize" what is not realistic in terms of the
stitutional beds by providing these limited services in the past
needs that exist.
it will be equally impossible in the future. Ambulatory care
There is now a growing belief that the institutional
services will not serve a real purpose unless those who could
pattern of services is not effective. It is not only the cost in
use them effectively are found and helped to reach and use
dollars which concerns us. There is emerging a set of new con-
them. Real "health" and "social welfare" objectives are those
cerns. We are hearing about dissatisfaction with "the quality
which insist upon a decent environment, access to health care
of life". We are seeing developments which stress the impor-
which is both preventive and therapeutic, good nutrition,
tance of individual life styles. We are facing the fact that
psycho-social support, the availability of special skills to meet
children do not invariably have well-heeled families to pro-
special needs, and assistance which enables individuals to
vide all of their needs. We are facing the fact that our rapidly
participate as fully as possible in community life, in recrea-
growing population of older persons do not have the "fam-
tion and in appropriate occupations.
ilies" to care for them which we liked to believe they had. We
None of our visions about new approaches which stress
are hearing young physicians talk about new traditions which
appropriate use of facilities and resources, or which look
10
hopefully to humanized individual care for those members
of the population who really belong in their homes and in
their communities, are going to become at all possible through
magical processes. Without the same careful planning, with-
out the same development and organization of services, with-
out the same precise approach to the best, the most effective
PART 2
methods that we find in our major medical institutions, in-
home services will continue to be the least used and the least
useful of community resources.⁷
SUMMARY OF PROCEEDINGS AND TEXT OF
In spite of this increased verbal interest, the necessary impetus
toward implementation of a national policy with respect to home
RECOMMENDATIONS
health services is still absent. "It has been said that delay is the worst
form of denial." [See exhibit F, appendix 1, page 66.]
Conference on "In-Home Services: Toward A National Policy,"
This delay and this denial has begun to significantly affect our
Columbia, Md., May 31-June 2, 1972
national economy in terms of dollars. It more significantly, how-
I. Frontispiece
12
ever, affects the health, the personal freedom and to a serious ex-
II. Introductory Statement
12
tent the future well-being of the whole population.
III. The Need for a National Policy
13
The implementation of the recommendations of the Columbia
IV. "In-Home Services"
14
conference, therefore, become less and less an option and more
V. The Conference Opens:
and more a necessity.
Keynote address: Carroll Witten, M.D., president,
board of aldermen, mayor pro tem, city of Louis-
EXHIBITS
ville, Ky
16
(See appendix 1)
Legislative proposals regarding home health care:
A. Bed-Disability Days Per Person Per Year By Family Income.
David Affeldt, chief counsel, U.S. Senate Special
July 1965-June 1967.
Committee on Aging
17
B. Days of Disability Per Person Per Year By Sex and Age, 1969.
VI. The Working Conference
21
C. Medicare Reimbursements For Home Health Services And In-
(Consolidation of discussion-end of the first day)
VII. Quotes from the Working Groups
24
patient Hospitalization, 1969-72.
D. Memorandum from Helen L. Rawlinson, Director Home Care
VIII. The Conclusions-Conference Recommendations
27
Department, Blue Cross of Greater Philadelphia, January 19,
IX. Closing Address:
1973.
The administration's plan for action: Dr. Arthur
E. Report of the Council on Medical Service, Home Health Care,
Flemming, chairman, White House Conference on
Aging, 1971
32
AMA, 1973.
F. Memorandum from Helen L. Rawlinson, February 20, 1973.
X. Participant Organizations Speak
37
G. Fact Sheet, National Association of Home Health Agencies.
H. Study of health facilities construction costs, enclosure C, Chap-
The report which follows was prepared for the Department of Health, Education, and
Welfare and was released for publication as part of this working paper. The official status
ter 3, Home Care, Comptroller General of the United States.
of the report is described in the following letter :
Nov. 20, 1972.
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE,
PUBLIC HEALTH SERVICE,
In-Home Services-Present and Future, Brahna Trager, presented at the Conferences
HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION,
"In-Home Services-Strategies for Community Planning,' International Hotel, Los An-
Rockville, Md., June 19, 1973.
geles, July 24-25, and Hilton Inn, San Francisco, July 26-27, 1972.
Mr. WILLIAM ORIOL,
Staff Director,
U.S. Senate Committee on Aging.
DEAR MR. ORIOL: I am pleased to release the manuscript prepared by Ms. Brahna
Trager entitled "In-Home Services Toward a National Policy," a report of the
Columbia, Maryland meeting on In-Home Services held May 30-31, June 1, 1972,
for publication as a committee document.
It is suggested that the foreword or preface carry the following: "This confer-
ence was attended by those in leadership roles in Home Health Services throughout
the country, who, acting as a committee, evolved a series of ideas and recommenda-
tions which were put together by Ms. Trager into these proceedings under Purchase
Order PLD-11046-72, HSMHA, DHEW. While much of the material will be ex-
tremely helpful to the Government in future program planning and implementation,
the report does not necessarily reflect the policy or views within HSMHA today.
This should and does not detract from the proceedings which we are pleased to
publish."
Sincerely yours,
EDWARD L. KELLY,
Acting Director.
(11)
96-867 O 73 3
13
during meals and in the informal sessions after the close of the work-
ing day.
The diversity of representation, all of it knowledgeable, encouraged
and supported the broadest view of in-home services and the need
for such services in our population. The result is a statement which
I. FRONTISPIECE
ignores established boundaries and compartmentalized interests. It
recognizes "The right of every individual to live a full life in the place
It is the right of every individual to live his life in
of his choice" and stresses in-home services as "a major compo-
circumstances which enable him to make the fullest use of
nent
in a comprehensive system which includes all of the skills
his capabilities. This right is protected when the society in
and facilities essential to the promotion and maintenance of optimum
which he lives provides those safeguards which ensure his
health.
basic economic security in a decent environment and the serv-
ices which are necessary to promote his physical, mental and
III. THE NEED FOR A NATIONAL POLICY
emotional health. These services are only effective when they
are available in a comprehensive system which includes all
The use of the phrase "a national policy" as it relates to in-home
of the skills and facilities essential to the promotion and main-
services bears some resemblence to the established definition of a public
tenance of optimum health.
health problem. Public concern and public action are necessary in
In-home services are a major component in this system.
relation to service needs when those needs have been demonstrated
They ensure appropriate utilization of all other components
to be general, in the sense that they are evidenced in significant num-
in the system; they utilize the home and the family as a valu-
bers of the population, when they are dangerously evident and unmet,
able resource; they prevent the unnecessary displacement of
when the remedy is specific and when measures to meet them cannot
persons which occurs when services are lacking; they guaran-
be effectively undertaken by sporadic or voluntary efforts.
tee the right of the individual to remain in the place of his
The need for in-home services has become increasingly apparent in
choice. In the absence of in-home services, no system may
recent years. There has been accumulated evidence that institutional
be considered either comprehensive or effective. They must,
facilities are being inappropriately used. The rights of individuals to
therefore, be an integral part of this system and top national
choose where they will be cared for, and of concerned helping pro-
priority must be given to the development of a rational
fessionals to select the most effective method of care, have been limited
system of comprehensive in-home services for the whole
because the available choice oftentimes is: Care in an institution
population.
or no care at all. "Alternatives" to institutional care, usually defined
(Preamble-"In-Home Services-Toward a National Pol-
as high quality services provided in the home, are SO limited that
icy," The Columbia conference, May 31-June 2, 1972,
they do not at present constitute a practical resource. Hopeful be-
Columbia, Md.)
ginnings in the development of needed services have been frustrated
and defeated in the absence of the support which is essential to devel-
II. INTRODUCTORY STATEMENT
opment, extension and continuity of such services. The result has been
a dismal situation for the sick, the disabled, the crisis ridden sections
"In-Home Services-Toward a National Policy" describes the
of the population; young and old, economically disadvantaged and
central focus of a conference which took place May 31, June 1 and
economically secure.
2, 1972 in Columbia, Md. The conference was sponsored by the Home
The statement made to participants in the Columbia conference
Health Branch, Division of Health Resources, Community Service,
summarized the situation:
HSMHA, in the Department of Health, Education, and Welfare.
Participant representatives from 20 national organizations, 11 State
Expressions of interest in the potential of in-home services
and local organizations, the Office of the Administrator of HSMHA,
have been increasing in all areas of our health and welfare
the Special Committee on Aging of the U.S. Senate, the White House
systems. They are stressed as an "alternative to institutional
Conference on Aging, the General Accounting Office, 13 Federal
care" in health programs, and as an essential component in
programs and regional office staff came together in a working con-
ambulatory care systems. They are cited as the means of
ference to formulate a national policy and to plan strategy for its
producing a way out of the mental hospital-or of offering
implementation.
the possibility of a more normal way of life for the mentally
The term "working conference" is an apt description. It was a con-
ill who are still in the community. They are described as key
ference devoted almost entirely to the deliberations of working groups.
services in preventing family disintegration in periods of
Presentations by speakers were sharply centered on the subject at
family crisis, where the physical and psychological health
hand and the environment encouraged discussions which continued
of children is threatened. They are considered a valuable
resource in the development of health patterns of family life
(12)
14
15
for the economically and culturally deprived. They are
There is also a comparable sophistication in available skills. In
repeatedly referred to as the most needed services for the
medical skill, in nursing skill, in social services, in rehabilitation, in
aging population, for the chronically ill, for the disabled.
the organization of institutional services to meet the most complex
They are beginning to be considered an important therapeutic
needs, there is ample evidence of a traditional competence. In the de-
supplement to community treatment services for special prob-
livery of services, and most particularly in what should almost be a
lem groups-in drug addiction and alcohol abuse.
garden variety of service delivery-that which is provided in the
These expressions of interest have produced a variety of
home-a common place-the implementation of theory and skill in
approaches, many of them underlining or demonstrating the
effective service programs has not been achieved in the United States.
potential value of such services. But-they have not yet pro-
This retardation in the development of an essential community re-
duced a national policy.
source may be attributed primarily to the absence or insufficiency of
In the absence of such a policy, the stimulus for the real
financial support. Since community institutions are rarely self gener-
development of needed services also is lacking. Without a
ating and only infrequently self supporting, the money problem has
policy, without a legislative and financial base, broad com-
undoubtedly been central in the very slow development of community
munity in-home services for the whole population cannot be
in-home services. Unlike other community institutions, in-home serv-
developed and the potential of such services cannot be
ices have been poorly understood. In the absence of a clear view of
what is needed and for whom, those services which have been devel-
realized.
IV. "IN-HOME SERVICES"
opèd have been fragmented in their scope and provided only to meet
that part of community need which has appeared to be most pressing.
The term "in-home-service" reflects the changes which have been
The efficiency of institutions-the under-one-roof provision of serv-
taking place in philosophy, in concepts, in approaches to the develop-
ices-has been reassuring and attractive in a culture which places effi-
ment and organization of home delivered services. It represents a
ciency high on the scale of what is most desirable.
natural progression from the "whole patient" to the "whole person";
There is, however, another standard of desirability which must be
from the category to the group; from concern with the individual
equally influential. If services are to be efficient they must also be
"agency" to concern with effective relationships between agencies;
effective. The growing concern about the effectiveness of institutional-
from comprehensiveness within the individual service to comprehen-
ization on most individuals are not desirable. The effects of institu-
siveness within a network of community services.
tional care on children were observed in England during World War
In broadening the base, responsibilities are also broadened. "High
II. At its best such care, it was discovered, produced children who
quality" agencies are diminished in their effectiveness if concern for
were physically healthy but lacking in emotional capacities-those of
quality does not extend beyond the agency to related concerns: to the
developing deep relationships, of learning to love or to understand
environment in which the services are delivered; to what has hap-
the quality and durability of love and concern for others. This dis-
pened before a specific set of services has been delivered; to what is
covery has had a profound effect on child care theory in most coun-
needed from sources outside the specific service area during the period
tries in the western world and has stimulated a strong system of in-
when services are being delivered, and to what will happen after the
home services for the childhood population as an alternative to in-
recipient of services has moved from the aegis of the specific service
stitutional care-except in the United States where the result has been
area. They are diminished in their effectiveness if their concern does
a rather haphazard combination of juvenile halls and poorly supported
not extend to those who are relegated to the "not appropriate for
foster homes. The effects of institutional care upon adults have also
service" category because of limitations within the service area and/or
been observed-both at home and abroad. In the United States we are
limitations in what the community is providing. In a narrow context,
hearing new language: "sensory deprivation," "depersonalization" are
such terms as "assessment," "care plan," "evaluation" are a comfort;
terms used to describe the effects of isolation from a personal environ-
they are apt to encourage the acceptance of a static situation with
ment, from accustomed social communication from participation in a
respect to what is being provided-even excellently provided-rather
viable way of life in the community as opposed to the artificial life of
than to what could and should be provided.
the institution.
The broadening of perspectives inherent in the new title, the in-
The value of institutional care cannot be questioned. When there
creased concept of responsibility is supported by some of the most
is need for complex facilities and skills, there can be no substitute
sophisticated theory in the world.
for the modern hospital. Institutions such as extended care facilities,
The terms "community planning for comprehensive care," "progres-
rehabilitation centers, nursing homes of good quality, hospitals for
sive patient care," the carefully developed schema of the "stages of
the mentally ill, and (more questionably) child-care institutions, serve
prevention," the concept of "levels of care" have become common
their purpose with excellent effect when they have been selected as the
verbal coinage. Well developed theory concerning human psycho-
most appropriate resource to meet clearly defined need. The absence
social needs, and concerning all aspects of community organization, is
of an equally effective complex of services, which can be delivered in
an accepted part of the armenentarium of every professional in the
the home when institutional care is not appropriate, creates a situation
field. Theory is not lacking.
in which there is no opportunity for appropriate choice. Inefficient use
16
17
of institutional resources is the inevitable result. Appropriateness and
minimal qualifications of 'skilled nursing plus one' required for cer-
the economic use of community resources are desirable objectives. They
tification in Medicare legislation."
become pejorative terms when they are applied without reference to
Persently only 4 percent of the agencies provide for services in
the preferences of the individuals. We may be, as a culture, attracted
addition to nursing. We are truly warehousing human needs. There is
by efficiency, but we are also the culture which has strongly adhered
no one at home to look after the patient. We should get more and
to the concepts of personal right, of personal independence, of that
adequate home health services.
"freedom-of-choice" which is almost a cliche in our modern approach
The American Medical Association will not accept all the blame.
to the development of national institutions.
The Federal, State and local governments should share part of it and
The approach to services provided in the home, which is implied by
initiate bold programs.
the term "in-home services," is intended to include all of the care and
We Americans are crisis-oriented toward receiving health services
all supportive services which make care in the home practical and
(look at our hospitals). It is old fashioned to be sick at home. In sud-
effective when it is the appropriate and accepted environment for such
den illness (although for thousands we know what is required), people
care.
prefer to remain institution-oriented. If the hospital stay of one out of
The statement made to the participants in the Columbia conference
twenty patents could be reduced one day, we could save $20 million a
defined such services as follows:
year. Reduction of institutional care means an increase in money-
The term "in-home services" is used as an inclusive term in
saving.
order to broaden the concept of such services. It is meant to
There are 30,000 homemaker-health aides-a large pool for employ-
describe an array of services which can be brought into the
ment. In one institution 20 percent of the patients do not belong there.
home, singly or in combination, and which can be adapted to
Eighty-five percent of our hospital residents prefer to be at home but
meet the needs of persons in all age groups, in all diagnostic
we have locked the door to their home!
categories and in all economic and psychosocial situations
The solution Home-health services, defined, are
when such services can be used therapeutically, or to prevent
(1) Intensive-doctor daily and nursing services; nutrition
or arrest illness and disability, to supplement limited function
for short periods.
and to protect and support those whose capacities for opti-
(2) Intermediate-chronic illness, physical therapy.
mum development, function and participation in family and
(3) Basic (or preventive) delay or avoid institutional serv-
community life are threatened. In this context, many services
ices; help in activities of daily living; open channel to health care.
which have been considered innovative possibilities but not
Here, are the alternatives to the institutional approach (compare
yet developed, are included. The concept is not tied to existing
Trager report* recommendations, pp. 49-50).
payment sources, to regulations which limit the scope and
Summary: Why favor home health care?
duration of services, or to auspices. It is intended to describe
(1) People get well faster in familiar surroundings.
a community-wide, coordinated network of services, a com-
(2) Home health care is less expensive than hospital care.
plex which can be considered a community institution and
Therefore, we could keep down rising cost of health care.
an essential component of the health and welfare system.
(3) Home care can relieve hospital bed shortage and even the
need for construction of additional hospitals.
V. THE CONFERENCE OPENS
Conclusion: We need leadership at Federal and private sector level.
We must provide example of workable programs. Compare the Phila-
Keynote address: Carroll Witten, M.D., president, board of alder-
delphia program (good, but can be improved). Home health care is
men, mayor pro tem, city of Louisville, Ky.
a community concern and must be on a par with hospitals.
In regard to home care programs, there is a fragmentation of
services. We lack home-health care national policy. In measuring the
effectiveness of our Nation, we have failed. Recall the Brahna Trager
LEGISLATIVE PROPOSALS REGARDING HOME HEALTH CARE
report (released in April, 1972), part 2, "The Potential of Home
Health Services":
(Address by David Affeldt, Chief Counsel, U.S. Senate Special
Committee on Aging.)
Support for the development of viable home health services
has been minimal and in such Government funding as has
A few weeks ago, Brahna Trager-a nationally known home health
been available home health services have been limited, with
consultant-prepared a hard-hitting report on the status of home
regulatory conditions SO narrow as to make the product
health services in the United States for the Committee on Aging.
Her basic theme was brief, and blunt. And in a nutshell, it could be
negligible in terms of meeting real need.
summed up this way: Despite the strong support oftentimes expressed
Agencies providing home health services are diminishing in num-
bers. Again, "the available supply of services includes an assortment
*See footnote 1, p. 1.
of limited agencies: small home nursing programs (with)
the
18
19
for home health and other related services, many serious roadblocks
cording to the physicians associated with the nursing homes-did not
still exist.
belong in institutions.
It is rather ironic that at a time when the "alternatives to institu-
Second, besides being a more appropriate form of care in many
tionalization" psychology is gaining further momentum, the number
cases, home health care is substantially cheaper than institutionaliza-
of home health service agencies participating in Medicare is actually
tion. And remember this: If we could shave one hospital day off the
declining. However, the number dropped from 2,350 in 1970 to about
Medicare national average, we could possibly provide a savings
2,250 in 1972.
amounting to approximately $300 million.
What are the reasons for this alarming trend? Well, a key factor is
the problem of retroactive denial of payments, which has not only
RECOMMENDATIONS
caused hardships for elderly Medicare patients but for home health
agencies as well.
These are compelling reasons for initiating action now to meet the
Additionally, the complexities of administration and reimbursement
immediate and long-range needs in the field of home health care. In
have placed many agencies in financial jeopardy. As a result, the larger
her report, Brahna provided an excellent blueprint for action to
agencies watch helplessly as their administrative costs shoot upwards,
achieve this goal. In fact, her proposals will serve as a springboard
while smaller agencies watch their services go under.
for my discussion with you today.
Now I would like to outline some of these recommendations, which
HEALTH CARE BECOMING INCREASINGLY INSTITUTIONALIZED
the committee hopes to incorporate in a comprehensive legislative
package. At the outset, I wish to emphasize that our proposals will
Another major theme developed in the report is that our health care
focus on the elderly population because we are the Committee on
system is becoming increasing institutionalized. The family physician
Aging. However, many of these measures would be applicable for all
at the bedside of a patient in his own home is largely a relic of yester-
age groups.
year-a vanishing phenomenon.
We are now in the process of preparing appropriate memoranda for
Moreover, as I am sure you are well aware, home health services
legislative counsel to draft this proposal. And we also welcome your
have, to a very large degree, had a very low priority in the United
suggestions for perfecting this omnibus program.
States. Less than 1 percent of Medicare expenditures, for example,
now go to home health care. And even that small proportion appears
100 VISIT LIMITATION
to be declining.
Today, as in the past, support for the development of viable home
One of our key proposals will deal with the number of reimbursable
health services has fallen far short of the need. Our funding policies
visits under Medicare. As I am sure most of you are aware, Medicare
have been limited. And regulatory conditions have been SO narrowly
limits the number to 100 under Part A as a posthospital service and
defined to make the end product negligible in terms of meeting the
also 100 under Part B, Supplementary Medical Insurance.
real need.
At present, we are considering a three-prong approach to improve
Equally significant, the range of services provided by home health
the existing law:
agencies is limited. More than half fall into the category of "skilled
1. The number of reimbursable visits would be increased from
nursing plus one," which is the minimum requirement for certifica-
100 to 200.
tion under Medicare. Only about 4 percent provide about five serv-
2. For persons who require further care, there would be a "life-
ices in addition to nursing.
time reserve"-similar to the lifetime reserve for hospitaliza-
tion-of 50 visits.
THE CHALLENGE
3. Further care could be authorized, where appropriate, upon
the certification of a utilization review committee.
Despite Brahna's sober assessment of the existing situation, her
basic message was not pessimistic. Instead, it was one of a challenge to
ELIMINATION OF THREE-DAY HOSPITALIZATION REQUIREMENT
develop a national policy to bring home health services to the fore-
front in the battle for decent medical care in our Nation.
Another measure would deal with the existing requirement that a
And it seems to me that we have two key forces to aid in this
patient must be hospitalized for 3 days to be eligible for home health
objective.
services under Part A. Our proposal would eliminate this requirement.
First, most older Americans would prefer to remain in their own
Today many patients are unnecessarily institutionalized for the sole
homes, rather than be prematurely institutionalized. A classic example
purpose to become eligible for home health care. The net impact is that
of this strong feeling was revealed in a recent study in Florida, which
this is an improper use of institutionalization.
found that 85 percent of all nursing home residents would prefer to be
And it can create a ping-pong effect where a patient goes to a hos-
at home. Many of them undoubtedly could remain at home if they
pital for 3 days to be eligible for home health care. Then he returns
were provided with appropriate services. Another important revela-
for another 3 days after exhausting his home health benefits.
tion from this study was that nearly 20 percent of these patients-ac-
96-867 O 73 4
20
21
PROTECTION AGAINST RETROACTIVE DENIAL OF PAYMENTS
OTHER PROPOSALS
Earlier, I discussed the problem of retroactive denial of payments.
The Trager report also suggests a number of other far-reaching
A year ago, Senator Church-Chairman of the Committee on Aging-
actions, which we hope to translate into legislation. In the interest
introduced legislation, S. 1827, to help remedy this situation.
of time, I shall discuss these measures very briefly.
Under this proposal, the Secretary of HEW would be authorized to
-The establishment of a program to develop home health and
designate certain periods after hospitalization during which a patient
homemaker services in areas where none currently exist.
would be presumed to require home health care. This measure was
Moreover, funding would be available to "add on" to services to
incorporated in H.R. 1, which passed the House of Representatives last
bring existing agencies up to our proposed minimum requirement
June. We are also considering broadening this measure to cover other
of skilled nursing plus four.
forms of care. And I will have more to say about that in just a moment.
-A demonstration program to simplify administrative proce-
dures and eliminate red tape for homemaker-home health
EXPANSION OF HOME HEALTH SERVICES UNDER MEDICARE
agencies.
-A merger of Parts A and B of Medicare.
Another important recommendation of the Trager report called for
-Congruent eligibility age for Social Security and Medicare.
the expansion of home health and other related services under Medi-
Finally, we are considering a proposal not mentioned in the Trager
care. This has been a major concern of the Committee on Aging. In
report, but one which we believe has a great deal of merit. This
fact, our former Chairman, Senator Harrison Williams, has intro-
measure would establish an eligibility age for Medicare which would
duced a bill (S. 882) to broaden Medicare coverage to include services
coincide with the eligibility age for Social Security.
performed by a household aide.
This is crucial, we strongly believe, because many Social Security
We are considering a number of other proposals to expand the con-
recipients are without hospital or medical insurance-particularly
cept to include a full range of needed services.
those who have received actuarially reduced benefits. And this is
Today the limited Medicare coverage of home health services di-
likely to become even more intense as pressures for earlier retirement
minishes the possibility of appropriate choice. Moreover, the concept of
continue to mount.
"skilled" nursing services has become firmly entrenched in Medicare.
Even when the Social Security beneficiary becomes eligible at age
As a result, home health services have focused to a substantial degree
65, this may still become a problem-especially if the wife is 2 or
upon acute cases.
3 years younger than her husband.
Ideally speaking, we would like to develop an array of services
which would establish as a minimum requirement skilled nursing plus
CONCLUSION
four, instead of skilled nursing plus one. These therapeutic and sup-
portive services should be sufficiently flexible to cover the three levels
In conclusion, these are some of the proposals that the committee
of care mentioned in the Trager report: Intensive, intermediate, and
plans to incorporate into a legislative package to implement the rec-
basic. And examples of these services would include nursing, environ-
ommendations of the Trager report. Quite clearly, this will not be the
mental support (homemaker-home health), the various therapies
final word on what ultimately emerges. We expect to make perfecting
(physical, speech, and occupational), and other levels of appropriate
changes. We will probably add new proposals. And we may even
care.
change the basic thrust of these measures.
In any event, we welcome your suggestions and counsel. And hope-
MANPOWER REQUIREMENTS
fully, we can submit a legislative package within a few weeks which
has the strong support of organizations in the field of aging.
A key problem in the field of homemaker-home health services is the
serious manpower shortage.
VI. THE WORKING CONFERENCE
At the White House Conference on Aging, the delegates called for
300,000 homemaker-home health aides as a minimum requirement. Ac-
Consolidation of discussion at the end of the first day:
cording to Miss Trager, development of these services should achieve
The definition of a national policy with respect to in-home services
a ratio of at least one homemaker-home health aide for each 1,500 per-
is difficult in the absence of national policy in the broader areas of
sons, and with good geographic distribution.
health care and social welfare. Nevertheless it is necessary to develop
To meet these demands, we are considering proposals to beef up our
such a policy which must then become an important consideration
present training efforts by providing new or increased funding to:
in all legislation, in planning and development of broader systems.
-Home health agencies;
Basic to such a definition are the fundamental principles:
-Nursing schools;
The right of the individual to good care and
-State departments of health;
The obligation of society to provide the means to achieve it.
-The Older Americans Act; and
Our concern in the establishment of policy must therefore be broad-
-Other appropriate institutions and agencies.
ened. It must describe a pattern of care based on individual needs. It
22
23
must include prevention of disease, promotion of health, rehabili-
respect to home health services since an available multidisciplin-
tation in its broadest sense and must eliminate artificial restrictions
ary team would, in fact, increase and extend his resources.
which limits access to and availability of care. It must eliminate the
The dependence of other professionals upon the physician for
schism between "health" and "social welfare" and between physical
the "brand" or "stamp" of professional approval.
health and mental health. It must include all population groups. It
The "brake" imposed upon other professionals by this system
must establish the principle that the system must be available to
with a corresponding absence of professional "egalitarianism"
everyone.
which could enable appropriate professionals to assume "team"
Although the home as a natural site of care has been largely ignored
leadership based upon the changing need.
in our service system in favor of extensive development of institutional
The broad approach to these and other problems, which inhibit the
facilities, it remains an important resource. It must not be considered
development and maintenance of a rational system of in-home services,
an "alternative" to institutional care. This concept must be reversed
will involve:
SO that the institution becomes the "alternative" to care in the home.
A national mandate which supports the development and main-
We must switch our thinking and our approach. The home is the
tenance of this system as essential to the population. Such a man-
"vital coordinating link" in the planning of services for the individual.
date must incorporate the provision of in-home services to the
The home and family provide support which is essential to personal
population in all communities and in all areas.
security. To the extent that this resource is ignored we deprive the
The development of a concept of the "system" which can be
care system of a part of its capability. The absence of in-home serv-
generally understood and accepted.
ices "excludes the possibility of the most appropriate use of all other
Careful scrutiny of every piece of legislation related to the pro-
resources."
vision of services and unified efforts to include in-home services
The problem of moving in-home services into the mainstream of
in all of them.
community services is a difficult one but it must be dealt with. A "blue
Recognition of the fact that while fragmented funding such as
print" for a rational system of in-home services must be developed.
that provided by Medicare, by insurance benefits, by labor health
Impediments to the development and utilization of such services
and welfare plans, and by possible funding sources in Federal,
have been attributed to a number of factors.
State and local programs, must be utilized to the maximum, a
The absence of a rational funding mechanism.
broader financial base must be provided.
A relatively unsophisticated approach to community planning
More immediate and specific action will be essential in developing
and service administration.
the system. Such action must involve consumers, planners, providers,
The absence of developed relationships to community services
payors, and politics. Home health services and allied programs must
and institutions which would ensure continuity.
work hand in hand with community health planning and other plan-
The absence or spotty development of the range of services needed
ning structures, so that they are familiar with the concept and the
for a rational in-home service system.
need and are prepared to develop and support effective proposals for
Community apathy, variously attributed to the lack of "outreach,"
in-home services.
the absence of a coordinated system which can be a single resource
Effective community structures must be developed which will:
for the prospective user of services, and frustration when the need
provide for efficient centralized administration;
for services cannot be met.
coordinate services;
The narrowness of the present approach to service which focuses
maintain continuity between all services;
only upon acute care and virtually ignores all other aspects of
eliminate duplication;
need.
provide mechanism for collecting information concerning com-
Emphasis on the provision of reimbursable or profit producing
munity need;
services.
involve the consumer at all levels of planning, both in program
Competition and duplication within existing services.
and policy, and as an individual participant in the planning of
The reluctance of community services and institutions to share
care for himself and his family;
information, to coordinate efforts, to eliminate fragmentation and
provide the community with an effective center of information;
duplication, to build needed services. (This reluctance is at-
concerning sources and availability of services-one is data, the
tributed to the present competitive environment which is imposed
other is information;
by the absence of a rational approach to the support of needed
provide for patient outreach and follow-up;
services and to the planning of such services.)
Activities which are immediately necessary involve the coordina-
The "problem" of the physician: This is variously described as
tion of those services which are presently available so that they will
indifference, frustration because of his difficulty in putting to-
present a "base" for the building of the in-home services system. This
gether a needed service package from a variety of sources.
will involve forging effective linkage between existing home health
The problem of the physician's "unwillingness" to make addi-
services, acute care institutions, long-term care institutions, rehabilita-
tional home visits A misconception which must be tackled with
tion facilities, outpatient services, public and voluntary social serv-
24
25
ices and all other resources which can be pulled together to provide
'team' is only qualified to decide what's appropriate when the 'user'
the coordinated continuum of care which is needed.
of services and the family are members of the team."
VII. QUOTES FROM THE WORKING GROUPS
PLANNING
(The content of the following sections reflects the flavor of discus-
"What we need are comprehensive systems of care based on indi-
sion in the working groups which led to the development of the
vidual needs for the prevention of disease and the promotion of health;
statement of policy; recommendations concerning service principles,
without artifical limitations-and for the whole population."
service needs and structure; strategies for implementation. Quota-
"Our present system deals only with the narrowest part of home
tions are drawn verbatim from the discussion.)
care. It is concerned with the period after acute care and before the
long pull. Because it is tied to providers and to a constricted payment
WHAT Is POLICY?
mechanism it deals with what is profitable. People return to institu-
tions because there is nothing in the community to maintain them
THE "RIGHT" TO HEALTH CARE
there."
"The system must be planned SO that there is mandatory linkage be-
"National policy"-a large concept-was developed in all working
tween all of the needed services and this includes institutional services
groups along very much the same lines, the broadest consideration
and services in the home which are not included in the present system
related to the concept of human rights: Are there basic needs which
of home care. They have been frozen at the minimum level in the pres-
exist in the whole population? Is the need for health care one of these?
ent system. They must be expanded and accepted as a part of the
The conclusion that the population is entitled to health care was
continuum."
general.)
"The planning process should be limited. It should not go on ad
"If health care is a right in any population what are the implica-
infinitum."
tions? Who is responsible for the personal health care of that popu-
"In-home services should be an integral part of a coordinated de-
lation? Society must provide the means to meet those needs"
livery system. In order to utilize this system every community should
"Health care is ancillary to social functioning."
have an identified administrative structure."
"In our society we have traditionally accepted responsibility for
"Program designs should not be constructed simply to follow fund-
those who have been unable to care for themselves."
ing sources. They must be coordinated and not parallel or duplicating."
"Every individual must have the right and opportunity to live a
The concept of a consortium-linking services together and adding
full life. We must provide all services which are necessary to keep
to the base services."
the individual in the mainstream of his society."
"Let's emphasize the concept of a network of services to include all
"Policy involves the avoidance of the displacement of the individual
of the services needed to maintain people in the community. We are
because of the absence of facilities."
less concerned with agencies-which may be multiple-we are talking
"This is more than a problem of services for the aging. It involves
about a system of services."
the problem of comprehensive care for the whole population."
"The way to make the system available to everyone is to start plan-
"If in-home services are not understood, if they are not developed,
ning at the community level."
they may be ignored when the health care system 'shakes down'. We
The in-home facility can be the focus of all out-of-hospital
must have a national policy concerning this segment of the system."
services."
"It is perfectly logical to talk about the direction of care from
"How can in-home services become an institution The hospital be-
the home. That is where the need for care begins."
comes an institution because:
"There are more people, served or unserved, in need of services in
It provides an array of services which are readily accessible from
their own homes than there are in institutions."
professionals and others as needed.
"In-home services have been considered something which is intended
It is supported financially.
to take the place of hospital care. A comprehensive system makes use
It is demanded by the consumer.
of all modalities. Such a system must make the full range of in-home
Its services are accepted by reimbursement sources (insurance).'
services available. It must include case-finding and extend to long
"An institution must have relationships with other institutions.
term care."
These factors can be applied to in-home services. They could become a
"Home health care is the vital, coordinating link. It is more than
part of this continuum."
an alternative. In-home services could become the assessor of the total
"In addition to regional and rural planning, emphasis should be
health care plan."
placed upon combining duplicating services in urban areas."
"If there are 16 services needed as a part of the in-home system,
"What is needed is a combination of providers, consumers, payors
all of these services must be available."
and politics."
"The decision about what is 'appropriate' depends upon the indi-
"If the consumer doesn't demand comprehensive planning we won't
vidual choice of the person who's getting the service. A coordinated
have it."
27
26
"Unless the consumer is involved at all levels of decisionmaking the
"Funds must be made to flow to where the need for developing serv-
system will not be responsive to need."
ice is. This means redirecting funds from existing programs into in-
home services."
"Services follow dollars."
BARRIERS TO ACCEPTANCE
"There is always a lag between legislation and the funding ability
Physicians-"they don't accept in-home services readily. They have
to reimburse the new services that you know have to come."
not had much opportunity to use the services."
"You can't ask communities to develop services for which there is
"The usual scapegoats are physicians. This is not true."
no funding."
"One of the misconceptions-that the physician will have to
"We are always seeking the cheapest, the lowest level of care. Every-
make more home visits if these services were developed-is not
one is working their way down."
valid."
"What we have now is nickel and dime programs."
Providers-"there is resistance to exchange of meaningful informa-
"The minimum becomes the maximum and funds get frozen at that
tion-to contribute to the continuity of care. They limit services to
level."
funding sources."
"There is no funding for the organization of services-to support
Health and professional facilities-"they are not interested in co-
coordination."
operative action.
"There must be funding-for development, for maintenance, for
Public acceptance-"the exposure has been limited. Union mem-
growth in these services.'
bers decide what they want in their insurance package. Others get
"We need a rational funding mechanism."
what the present services provide. Very little."
VIII. THE CONCLUSIONS-CONFERENCE
SERVICES
RECOMMENDATIONS
"We need a new professional approach. Professional assessment has
"TOWARD A NATIONAL POLICY"
become inflexible. Administrative mechanisms defeat professional flex-
ibility when it comes to care in the home. The assessment methods
PREAMBLE
should consider the change in need and the role as 'team leader' of the
best person to meet that need. This is not necessarily the physician."
It is the right of every individual to live his life in circumstances
'Professional leadership means any or all the disciplines. At any
which enable him to make the fullest use of his capacities. This right
point in time, depending on need, there can be a different professional
is protected when the society in which he lives provides those safe-
leader.
guards which ensure his basic economic security in a decent environ-
"One of the major problems is having to fund through catastrophic
ment and the services which are necessary to promote his physical,
insurance.'
mental and emotional health. These services are only effective when
"We don't have real social legislation."
they are available in a comprehensive system which includes all of
"Half the personnel in rehabilitation centers are doing the job over
the skills and facilities essential to the promotion and maintenance
again because the gains are lost when there are no services in the
of optimum health.
home-there is nothing to support the therapy that's been provided
In-home services are a major component in this system. They en-
in the institution."
sure appropriate utilization of all other components in the system;
"A coordinated 'team' is only qualified to decide what's 'best' when
they utilize the home and the family as a valuable resource; they
the patient and his family are members of the 'team'.
prevent the unnecessary displacement of persons which occurs when
"Services must be focused on prevention-on case finding-and
services are lacking; they guarantee the right of the individual to re-
maintenance. We are oriented now to crisis care."
main in the place of his choice. In the absence of in-home services,
"Professional judgment must be more clearly defined."
no system may be considered either comprehensive or effective. They
"We must remove the 'brake' on the other professionals in the team
must, therefore, be an integral part of this system and top national
without removing the responsibility of the physician in health care."
priority must be given to the development of a rational system of
"We are talking about all of the modalities-the institutions and
comprehensive in-home services for the whole population.
other community facilities are a part of the rational service system.
A national policy must provide:
The ability to move from one to the other is what's needed."
-that in-home services which are comprehensive will be available,
accessible, and acceptable to every member of the population who
FUNDING
needs them.
-that they will be available without restrictions as to diagnosis,
"It should be required that funding for all programs be coordinated
race, religion, or ethnic origin, age or sex.
and not parallel or duplicating.'
-that they will be based on the needs of the consumer rather than
the provider.
96-807 73 5
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29
they will be provided without financial barriers.
Phat comprehensive health planning agencies should be charged
-that they will be provided in circumstances which guarantee high
with the responsibility for developing programs of comprehensive
quality.
in-home services.
-that they will be provided without barriers between health and
-that funds be provided for the development of
social services, but as a coordinated blend which promotes and
legislative models for use at the Federal, State and local levels
supports optimum health in the broadest sense.
for inclusion of in-home service.
that they will be based upon a philosophy which recognizes the
systems models directed at organization and coordination of
right of the individual to participate with professionals in mak-
services.
ing decisions about the place, type, and extent of care and serv-
a massive educational process directed at consumers, legislators,
ices he needs and receives.
providers, payors and professionals involved in the delivery of
services which describe comprehensive in-home services, stress
IMPLEMENTATION
their value and provide guidelines for the development and inte-
gration of such services in order to establish integrated and effec-
This policy must be implemented through action at all levels of
tive services for the population.*
government and in all public and private efforts.
that funds be provided for
development, maintenance and expansion of training programs
LEGISLATIVE RECOMMENDATIONS
to meet the health manpower needs of an accelerated program
of in-home health services.
It was recommended
-that Federal policy require significant provision for the inclusion
development of broadly based training programs, including pro-
of comprehensive in-home services in all legislation directed at
fessional schools.
the establishment of a health security system.
State health department educational efforts for technical and
-that voluntary and commercial insurance plans be required to
operational improvement of agency personnel.
cover comprehensive in-home services.
emerging community college programs and other educational
It was recommended that Federal funds be made available:
facilities in order to establish a reliable manpower pool and to
-for the development of in-home services in areas which do not
provide all individuals engaged in the delivery of human services
have them.
with understanding of the content and value of in-home services
-to expand existing service programs in both range * of services
and to develop skills which will support the effective organization
provided and capacity to serve the population in need.
and delivery of such services.
-to coordinate services.
At State, regional and local levels.
-to maintain services through funding on a reimbursement for-
It is recommended
mula which would provide for growth and economic stability.
-that planning for in-home services be assumed as a responsibility
-for training in order to implement expanded services-training
in comprehensive health planning agencies and in all other groups
to be directed at all types of manpower and to include training
involved in planning delivery systems of health and social
focused upon the organization, administration and provision of
services.
in-house services.
-that planning be directed to elimination of duplication and un-
At the national level it is also recommended:
necessary construction of facilities for institutional care.
-that a National Advisory Commission on IHS be established with
dil-that all planning should support legislation and systems designed
representation from consumers and providers-with consumer
to blend social and health services.
representation in the majority.
that planning for in-home service should be accomplished by a
-that the National Advisory Commission should provide leader-
consortium of total community involvement, consisting of con-
ship in the development of standards and policies to insure:
sumers of service, third-party payers, providers, planners, labor,
the quality of IHS
industry, and government.
national organization and administration of IHS
-that planning must include recognition of the need in every
economy in the provision of services
community (or area) for an effective administrative and care
effective delivery of IHS
faciliting mechanism (a "community based continuum").
coordination with all other IHS health and social service
Effective administration must:
systems.
Assure the receipt of appropriate care for the individual and
his family.
*The range of comprehensive in-home services to include Home health services, home-
maker-home health aide services, home maintenance services, social services, meals-on-
*It was recommended that a synopsis of the report "Home Health Services in the United
wheels, transportation, telephone reassurance, friendly visitors, services which make pos-
States," prepared for the Special Committee on Aging of the United States Senate (No. 74-
sible meaningful participation in community and family life.
331, April 1972) be supplied to other provider groups.
30
31
Provide for "outreach" activities in order to assure that all in-
priate personnel such areas as the comprehensive health planning proc-
dividuals in need of services are found and provided with ap-
ess at the national, State and local levels, the functions of the regional
propriate services.
medical programs and similar programs, in order to develop a co-
Provide for a sufficiently wide range of in-home services to meet
ordinated approach to the development of in-home services within
the need appropriately.
those programs.
Assure proper utilization of services through direct delivery or
Legislative recommendations related to the Medicare-Medicaid in-
arrangement with existing community services.
surance system:
Provide for the continuum of services through the development
It was recommended that:
of strong linkage between all services, through established sys-
Medicare coverage with respect to home health services be ex-
tems of communication within planning areas, through the de-
panded to include at least "skilled nursing plus four" additional
velopment of contracts and agreements and through other similar
services in order to provide therapeutic, supportive, and environ-
arrangements.
mental services at the three levels of care (intensive, intermediate,
Establish quality performance standards as seen by both provider
and basic). (Home health agencies would be required to have
and consumer (user
available at least this range of services a condition for par-
Assure that services be organized, developed, provided and main-
ticipation.)
tained by qualified interdisciplinary personnel in qualified serv-
Parts A (Hospital Insurance) and B (Supplementary Medical
ice systems. ("Qualified" service standards to be established by
Insurance) of Medicare be merged and the deductible and co-
the appropriate national standard-setting organizations.)
insurance features for in-home services be eliminated.
Assure that an evaluation component is present in every in-home
Present Federal legislation and regulations be revised to remove
service system.
barriers such as 3-day hospital stays as a requirement for ad-
Identify unmet community service needs and take responsibility
mission to home health services.
for initiating plans to meet these needs.
Payment for 10 in-home health services visits for covered condi-
Provide for a program of continuing community education con-
tions be guaranteed at the start of care.
cerning the function and value of in-home services.
Home health coverage, with respect to the number of reimbursable
Assure effective financial management and accountability
visits, be increased two-fold with an added life time reserve of
through development and use of functional budget practices and
50 visits on the recommendation of the utilization committee.
cost analysis.
Eligibility for home health services be changed to permit entry
Make available reliable information concerning costs and
on the basis of need for any service, or for any combination of
statistics.
home health services.
Assure full participation by users of service in all decisions and
The practice of retroactive denials be eliminated.
plans for care.
Congruent eligibility ages for Medicare and Social Security be
For research and development in such areas as:
established. (The expanded home health benefits under Medicare
a. Average length of stay by diagnostic categories in the three
would not be available to people on early retirement unless there
levels of home care.
is congruent eligibility.)
b. Prepayment and capitalization plans for home health.
To simplify Federal administration of home health services under
c. Regionalization of home health services.
Medicare:
d. Management in incentive programs within home health
It is recommended that action be taken to establish providers
agencies.
appeals for home health agencies.
e. Viable patterns of service for rural areas, for complex urban
Demonstration program must be established to explore effective-
centers and for the new systems of service which are being
ness of audit patterns in relation to fiscal administration, utiliza-
developed.
tion and patient care.
To broaden the scope of Hill-Burton to include funding for con-
Policies and standards for professional personnel and related serv-
struction, renovation, and modernization of facilities furnishing
ices should only be established by the appropriate professional
coordinated home health services.
personnel on an ongoing basis.
It was recommended that Federal health care funds be denied to
A simplified claims processing system must be developed together
communities without coordinated home health services.
with a uniform claims form and uniform reporting system which
It was recommended that the Home Health Branch, DHR, Com-
would be applicable to the Federal insurance system and to all other
munity Health Services of DHEW be strengthened in order to provide
third party payors.
effective leadership, consultation and research to explore with appro-
The focus of Medicare coverage must be shifted from the need
for skilled professional services to the needs of the individual.
*It was suggested that the term "patient" does not accurately describe the individual
who uses "in-home services" and that the term "user" be substituted. The terms "user" and
All concerned professional organizations should recommend to their
"consumer" were referred to throughout the discussions.
governing bodies the adoption of this national policy.
32
33
IX. CLOSING ADDRESS
persons making those decisions for us." So it seems to me that it is very
important for us to provide older adults with a variety of choices.
THE ADMINISTRATION'S PLAN FOR ACTION
Now, we do have, as you recognize, 900,000 older adults living in
(Remarks by Dr. Arthur Flemming, Chairman, White House Con-
institutions. Sometimes I've heard that expressed in this way, "After
ference on Aging, 1971, and former Secretary of DHEW, at the "In-
all, we have only 900,000 living in institutions." And sometimes people
Home Service-Toward a National Policy" Conference, Columbia,
will say that it is only 5 percent of the persons 65 years of age and
older. I don't like to deal with it in that way-900,000 human beings
Md., June 2, 1972.)
is a very, very large number of human beings. As the President
Thank you very much. I appreciate the opportunity of participat-
said in his special message on aging on March 23, "These older men
ing in what seems to me to be a very significant follow-up to the
and women require the assistance provided by skilled nursing homes
White House Conference on Aging.
and other long-term care facilities. For them, a dignified existence
I am a staff person on the President's staff with a job description
depends upon the care and concern which are accorded them in such
that the President has given me which is fairly specific. He has asked
settings."
me to continue as Chairman of the White House Conference on Aging
After all, any policy changes which might enable a larger percent-
during the post conference year of 1972. He has asked me to serve
age of older persons to remain in their homes or other places of resi-
as one of the members of the Cabinet-level Committee on Aging. The
dence will have very little impact on the lives of the 900,000 persons
committee is chaired by the Secretary of Health, Education, and
who are now in these institutions. Furthermore, they will have very
Welfare-Elliot Richardson. He has also charged me with function-
little impact on the lives of those who will be moving into these homes
ing as an advocate within the Government in the field of aging. The
today, tomorrow, and the day after tmorrow. Therefore, there isn't any
final thing the President has asked me to do is to serve as his repre-
question in my mind but that the quality of care in these homes must
sentative in an effort to bring about more effective coordination of
continue to be one of our primary concerns.
programs for older adults that cut across departmental lines. In some
There is momentum in this area. The President, just a year ago, in
respects, as I look down the road to the next few months, I think that
his address in the city of Chicago, set forth a policy which has made
possibly this could prove to be the most interesting aspect of my
it very clear he wants to have it implemented. He said there that
assignment. So it is within the frame of reference of my responsibilities that I
Medicare and Medicaid funds should not be used for the purpose of
subsidizing substandard nursing homes. You may be interested in the
will endeavor to address myself to some of the issues that you have
fact that that particular sentence was not in the text of the speech
been looking at. As I do so, I will be reflecting points of view that
that was released to the press prior to the time the President spoke.
have been expressed to me throughout the country by many persons.
There was a section of the address that was devoted to nursing homes,
I decided that when I came on the job, just a year ago on a full-time
but apparently, as he went through that particular section, he decided
basis, that I was going to spend a good deal of my time in the field. As
that it needed to be strengthened; therefore, he added the sentence to
a member of the Civil Service Commission and as a Secretary of
which I have referred. He made it very clear to me on the trip back
HEW, I learned that this is a wise thing to do. First of all, if you are
that he expected the executive branch of the Government to do every-
in the field, you will pick up ideas that you won't pick up in Washing-
thing possible to implement that particular policy.
ton, and in the second place, if you are in the field, you will learn
You know that that was followed by an eight-point program, which
about things that have happened in Washington that you'll never learn
the President announced in New Hampshire in August. The Secre-
about if you stay in Washington. After all, the people in the field are
tary of HEW has been in the process of implementing that program
on the receiving end of what Washington decided to do, and in most
since then. And I feel that some very significant developments have
cases they are not at all hesitant in giving expression to their
taken place as a result of the steps that have been taken to implement
convictions.
that eight-point program. For example, it seems to me that the es-
As we discuss some of the issues that you have been looking at, some-
tablishment of the office of nursing home affairs in the Department of
time we refer to alternatives to institutional care. Personally, I do
Hew constitutes a constructive development. I think we are all indebted
not thnik that this is a very happy choice of words. I like to think in
to the kind of leadership we are receiving from Dr. Marie Callender,
terms of institutional care and services to older adults in their own
who was recruited by the Secretary to head up this particular office.
homes as parallel services for older adults. It seems to me that, in
There is a great deal of work that remains to be done in this whole
both of these situations, our society must render better services than
area of institutional care. I know that those who are participating in
we are now rendering. We must provide the older adult with better
this conference recognize this. The President in his special message on
opportunities for choice than is presented to him at the present time.
aging of March 23, said we must place emphasis, and I now quote
One of the messages that has come through to me, quite loud and clear,
him, "on public and private services which can help older persons live
from older adults is-"We want to be put in a position where we can
dignified, independent lives in their own homes and other places of
make our own decisions relative to our own lives. We don't want other
residence." In reality, this was a reiteration of a statement that he in-
cluded in his address at the concluding session at the White House
34
35
Conference on Aging, when he was referring to the fact that he was
available for grants to States and communities to support programs
going to request an increase for Title III funds, under the Older
which provide service to older persons, with the emphasis on services
Americans Act to $100 million for fiscal year 1973. Then he went on
that will enable them to continue to live in their homes or other places
to say, "Now let us see what will help people live decent and dignified
of residence. That's $200 million in 1973 as contrasted with $20 million
lives in their own homes, services such as home health aides, home-
in the beginning of 1972. This to me represents momentum that has
maker and nutritional services, home delivered meals, and transporta-
led to significant action. I feel that the spirit created by the White
tion assistance." I am confident that the Secretary of HEW, and the
House Conference on Aging has had a good deal to do with the
Commissioner of Aging regard that as a directive SO far as the utiliza-
establishment of that momentum.
tion of the $100 million is concerned. I believe that this will be
Now, there is no reason at all why some of the funds that will be
reflected in the guidelines which go to the States.
made available to the Administration on Aging could not be utilized
Personally, I believe that helping in the development of a national
for the purpose of moving forward in this area of the in-home serv-
policy that will make it possible to achieve the kind of objectives that
ices. Whether or not it is used in this way depends to a very large de-
the President has identified is one of the major opportunities con-
gree on the kind of proposals initiated at the community level. This
fronting us in the field of aging. This is an objective in which the
in turn, of course, will depend on the kind of leadership available at
President has a deep-seated personal interest. He recognizes that we
the community level. This is one area where we can see some signifi-
can't possibly meet the needs of our older adults by putting emphasis
cant developments as the result of grass roots initiative. You are
solely on institutional care. He knows that if the kind of objectives
aware that there are now around 150 national organizations which
that he has set forth are to be achieved, it is going to be necessary for
are members of a steering committee chaired by Ellen Winston. The
us to work out a national policy in this particular area and to work out
purpose of the steering committee is to stimulate the development of
ways and means for the implementation of that policy.
comparable steering committees at the local level. The primary ob-
What is happening as far as the Older Americans Act is concerned
jective of the local committees is to support services that will enable
represents momentum in this particular area. As you know, the part
older adults to continue to live in their own homes or in other places
of the Act which authorizes appropriations for the programs that are
of residence. It seems to me that this is a significant development
identified under the Act, expires on June 30, of this year. The Presi-
on the part of the private sector. Here again, success will depend to
dent, in his special message on aging, stated that he would like to have
a considerable degree, on the quality of leadership at the local level.
these authorizations extended on an indefinite basis. Also, the Presi-
Of course, once these committees get under way, they will make
dent has proposed some amendments to the Older Americans Act
vigorous recommendations as to what should be going on in the public
which are designed to bring about a more effective coordination of the
sector, at the local level and what kind of support those programs
delivery of services at the community level. In addition, some mem-
should have at the State and national levels.
bers of the Congress have also proposed amendments. At the moment.
I have the feeling that we have really not made as effective use as
these amendments are being considered by both the House committee
we could of the adult services title under the Social Security Act. I
and the Senate committee. I think, however, that the most significant
would certainly like to see us utilizing this title to a much greater
development in this area relates to appropriations. When the President
extent than we have up to the present time in connection with in-home
told the delegates to the White House Conference that he was going
services.
to ask the Congress to increase the appropriations for title III to
In the area of nutrition, we have as one of our major resources food
$100 million, he did so knowing that as of that particular moment the
stamp and surplus food programs. That resource has been expanded
appropriations for title III for the fiscal year 1972 were around $20
considerably over the past few months until today the benefits are
or $22 million. The day after the conference adjourned the Senate
valued at about $2.5 billion a year. It is assumed that around 2.5 mil-
was considering a supplemental appropriation bill. Some members
lion older adults will utilize these benefits during the present fiscal
of the Senate said, "Well, if we are going to go to $100 million in
year, in the amount of roughly $350 million. I was talking about this
1973 why don't we make a real move in that direction in 1972?" So
to a group of Governors not long ago, and I was telling them about a
they offered amendments to increase the appropriations for title III
project that we are going to launch to locate older adults who are SO
in such ways as to bring them up to approximately $42 or $44 million.
lost in society that they are totally unaware of the existence of food
This was accepted by the House conferees and, of course, became law.
stamp and surplus food programs. After the meeting, one of the Gov-
Then, as you also know, a few weeks ago, the Congress passed a law
ernors came up to me and he said, "Look, did you ever think of the
which authorizes the expenditure of funds in the fiscal year 1973 and
possibility of utilizing the stamp concept in the field of transporta-
fiscal year 1974, for grants to States and communities, which they in
tion I said, "No, I haven't." He said, "I've talked to Secretary Volpe
turn can use for the purpose of supporting programs in the field of
about this a number of times, and he sees some possibilities in this."
nutrition. The amount authorized for 1973 is $100 million, for 1974 it
Well does it have any possibilities in the area of in-home services?
is $150 million. When the President signed the law, he said that he
I think it might be worth looking at.
was going to ask for an amendment to his 1973 budget in the amount
There is another area which is related to your concerns, where there
of $100 million. So, in fiscal year 1973 we will have about $200 million
is significant momentum, and that is the area of making it possible for
FORD
LIBRARY
36
37
older adults to continue to be involved in life. Older persons are saying
health maintenance organizations passes, this whole concept is going
to our society: "We want to continue to be involved in life, we don't
to be given quite a shot in the arm.
want to be put on the shelf." And you will recall that in his address
As some of you know, I did have 10 regional meetings prior to the
at the White House Conference on Aging, the President put a good
White House Conference on Aging. Since the White House Confer-
deal of emphasis on this area. At that time, he announced, for example,
ence, I've spent a large part of my time in the field and I am about to
that he was going to ask for a doubling of the appropriations for pro-
have 10 more regional meetings that will really be follow-up meet-
grams such as foster grandparent programs, senior aide programs,
ings to the White House Conference. Let me just summarize the mes-
Green Thumb programs. He also announced that he was going to ask
sages: Older adults have said to me that society has put them in an
for a tripling of the appropriations for the retired senior volunteer
inferior or secondary position. They don't like it. The second thing
program. It seems to me that many of the persons who will be par-
they've emphasized is that society has been pretty long on promises
ticipating in these programs can be trained to play a significant role
but short in delivery. Obviously they don't like that. The third is that
in the area of in-home services. If this is done, we're accomplishing a
they want to be in a position where they can make their own decisions
number of things. We are contributing to the physical and mental
relative to their own lives. They want freedom of choice. The fourth
health of those who are trained to participate and they in turn can be a
is that they want to continue to be involved in life; they don't want
very real help to those older adults who need services in their own
to be put on the shelf. The final one, and the one that overrides all
homes. For example, it is my understanding that there are 30,000
the rest, is "We want to be treated with dignity." As I think of these
trained homemaker-health aides in the Nation at the present time,
messages, then as I think of the opportunities presented to us in the
and the need is for 300,000. I think that we have to keep in mind
area of in-home services, it seems to me that if we take advantage of
that not all persons who want to be involved are looking for full-time
the opportunities that exist in this area we will be responding in a
employment or even part-time employment. Many of them want the
positive and affirmative manner to the messages that I have just
psychic compensation that comes from being involved in a systematic
identified.
way in community service activity.
Personally I am grateful for the time and thought that you have
I recognize that we could move much more rapidly in achieving
put into your deliberations during the last few days, and, as I indi-
some of our objectives in the area of in-home services if we obtained
cated at the beginning, I look forward to getting the results of those
amendments to the Medicare legislation which would liberalize the use
deliberations. I can assure you that my own convictions are such that
of Medicare funds for such services. This would put an additional
I will pick up your recommendations and see what I can do as an
burden on the Medicare trust fund but I believe that we can demon-
advocate, particularly within the executive branch of the Govern-
strate that if we are willing to make that kind of investment it would
ment. Thank you.
pay tremendous dividends in terms of the overall objectives of the
Medicare legislation.
X. PARTICIPANT ORGANIZATIONS SPEAK
I think it is likewise very important for us to watch the national
health insurance legislation from the point of view of in-home serv-
Mr. RICHARD SCHLESINGER,
ices. It seems to me that this country has accepted the fact that the
Executive Vice President, Areawide and Local Planning, American
time has come for a national health insurance program. The ques-
Association of Comprehensive Health Planning.
tion is what method is going to be used or what combination of meth-
"For those of you who may not know what the association is, I'd
ods are going to be used. This will be one of the major issues confront-
better explain, since we are fairly new. The American Association
ing the Congress in its next session. Those of us who believe in this
for Comprehensive Health Planning is a new national organization
concept of in-home services should try to make sure that the legisla-
which was just formed last December. It is as the title implies, com-
tion that finally emerges from the Congress makes a contribution in
posed of people who are engaged in, or being trained for comprehen-
the direction of institutionalizing the concept of in-home services.
sive health planning.
As I have talked with older adults about national health insurance,
"The executive committee of the association met last Friday, and
I find that they are very unhappy over the fact that proposals pend-
had before it a recommendation from the long-range planning com-
ing before the Congress do not come to grips with the issues of long-
mittee of the association, which was: "That the association consider
term care, at any level of care. They are right in identifying that par-
national health planning program and policy development as a sig-
ticular weakness.
nificant thrust of its efforts. Special emphasis should be placed on
H.R. 1 has some provisions that can have an impact on the evolution
matters that transcend State and community boundaries. Examples
of policy in the field of in-home services, particularly that part which
might include planning for improvement from the utilization and dis-
would make it possible for Medicare beneficiaries to join HMO's. Now
tribution of health manpower, assessing the impact of national health
this, of course, raises another issue: Are the health maintenance or-
insurance on the existing and future capabilities of this Nation to
ganizations going to be established in such a way as to give adequate
respond, and how to harness our Nation's resources into establishing
recognition to in-home services? If that part of H.R. 1 that deals with
and maintaining a healthy environment for all our population. The
38
39
association would assume these community activities under the guid-
"So
we
have
a
dilemma"
" a princple in operating which under
ance, participation, and active involvement of its member agencies.
other circumstances I call Storey's law i.e. that there are two problems
Furthermore, all efforts would be made to enlist the resources and
for every solution."
experience of other organizations in reaching these objectives. The
"The AMA has in the past-as part of the image of the American
emphasis of these efforts must be founded on public accountability in
doctor-and does at present-as part of its obeisance to the demands
achieving tangible and effective results.' That recommendation, from
of advanced technology-support completely the concept of need for
the long-range planning committee, I was informed by telephone,
an elaborate, smoothly functioning, system of home care for the chroni-
yesterday, was accepted by the executive committee, and will be rec-
cally ill, the disabled, the elderly, and the young."
ommended to the full board at its meeting later in June, and I assume
"It pledges its support as an organization, and has consistently
will be adopted. This is a fairly broad statement, obviously, and leaves
urged physicians to recognize their responsibility in this regard to
a great deal of leeway. However, I think that the majority of my col-
their patients and to their community. It has encouraged physicians
leagues who are involved in the association would generally accept
to actively seek a leadership role in the development of the home care
the statement of purpose and goals for comprehensive health plan-
resources of their communities, and to exploit such resources in the
ning, the development in our communities and our own States of more
interests of their individual patients."
rational systems of health care services delivery. From that point of
"
the last two meetings of AMA's committee on community
view it seems to me we would all accept the fact of the development of
health care
came up with three recommendations: (1) that the
in-home services as the crucial part of what we are aiming to achieve,
AMA council on medical services urge the council on legislation
and a part that largely has been missing."
that home health care and homemaker services-as important com-
ponents of health care delivery systems-be included in AMA's Medi-
credit and other national health care programs;
Miss ALICE GONNERMAN,
(2) sponsor a conference for physicians on home health care;
Assistant Director,
Division of Ambulatory Care,
(3) Review and up-date all present material on home health care."
American Hospital Association.
"The American Hospital Association really does have a history that
Mrs. MANUEL BERGNES,
it can be proud of in terms of support of home care."
Our official
Women's Auxiliary of the American edical Association.
policy statement
which came out in 1971, has a number of refer-
"
I represent a volunteer group, the women's auxiliary to the
ences to the fact that home care services must be included in any kind
AMA. It is an organization
with a membership of around 90,000,
of comprehensive care package, and we are interested in the concept
with component state and county auxiliaries."
of health care corporations which also need to have home care as
"Since the early '50's, the women's auxiliary has actively pro-
one of their benefits."
moted in-home services, such as: homemaker-home health aide serv-
"The American Hospital Association has had a membership cate-
ices, home delivered meals, and the volunteer friendly visitors pro-
gory for home care institutions since 1968. In 1969 an Assembly of
gram."
Outpatient and Home Care Institutions was formed to serve these
"Some auxiliaries have begun the services themselves, such as: the
members."
initial 'meals on wheels' program begun by the San Francisco medi-
"This assembly has been meeting with the other national member-
cal auxiliary; the Knosha, Wis., County Homemaker Service, and
ship organizations for home health agencies to determine in what areas
the Milwaukee, Wis., meals service. Others have worked actively with
they could work productively together for the benefit of their respec-
other community leaders to begin their services."
tive memberships."
"Home centered health care has been a priority project for several
Dr. PATRICK STOREY,
years. We've used the slide film, "Home Fires", on the use of the home-
American Medical Association,
maker-home health aid in Illinois in conjunction with the AMA.
Professor of Medicine and Community Medicine,
We've developed a skit on the role of the friendly visitor. This was
University of Pennsylvania.
used in conjunction with the promotion of the volunteer visitors train-
(We are) "caught in the cycle of advancing technology which re-
ing program and auxiliaries were urged to sponsor the course as well
as train their own members to act as volunteers. The telephone reas-
quires management of the sick patient in a facility where expensive
surance program was also included as an added service for those con-
equipment and highly skilled personnel are available-which saves
fined to their home."
and prolongs life-which means more prolonged convalescent care for
"The women's auxiliary continues to work closely with the AMA
the previously lethally ill, more chronic disability, longer life span,
more aged-which in turn requires more home care-and the resur-
on any programs needed to be developed for in-home care. With 50
State medical auxiliaries, made up of component county auxiliaries,
gence of the frontier picture of the physican at the bedside-which is
there is a 90,000 member potential for promotion of whatever com-
imposible because of the increase in longevity and constant advances
in medical technology."
prehensive program that is devised."
40
41
Mr. JOHN J. McManus,
concept, including peer review grouping, as well as other methods of
Assistant Director,
delivery such as home health."
Department of Community Services,
"We need the same kind of feedback we will get from this group
AFL-CIO.
as we need in most communities, the reaction of the various home
"Thank you. Probably this is the first time in history that the AMA
health agencies and institutions, to the local Blue Cross plan SO that
and the American Hospital Association have preceded the AFL-CIO.
it will recognize that such a benefit is needed."
For an encore I have the following statement. The AFL-CIO is com-
mitted to the full implementation of a national health security pro-
Miss HELEN RAWLINSON,
gram. An in-home service program could be of considerable value, and
Director, Home Care Department,
is of critical importance to the preventive and direct service aspects
of a full and comprehensive national health security system. The AFL-
Blue Cross of Greater Philadelphia.
CIO Community Services Department, of which I am a part, is there-
"Blue Cross of Greater Philadelphia has been directly engaged in
fore vitally interested in participating and learning from the con-
the promotion of home care services since 1956 when we granted a
ference, and we will be glad to assist in drafting a policy proposal that
substantial sum of money to a member hospital to assist it to es-
could be forwarded without commitment to the AFL-CIO for review
tablish the first hospital based home care program in southeastern
and further consideration. This ends the gospel for today, but what I
Pennsylvania."
wanted to say is that as a professional I am intrigued that it requires
"Since 1960 full time staff has been responsible for encouraging
a national conference to bring us all together on this very important
greater availability and use of the intensive level of coordinated home
thing that I felt we'd accepted SO very long ago."
care. In addition to a comprehensive benefit program we provide con-
sultation and administrative assistance to hospitals and other com-
munity health agencies interested in planning and implementing serv-
MALCOLM U. DANTZLER, M.D., M.P.H.,
(8)
ice programs to provide this level of home health care. In 1969 we
extended our home care program to selected patients referred di-
Assistant State Health Officer, South Carolina State Board of Health,
rectly from hospitals to community home health agencies-the inter-
Association of State and Territorial Health Officers.
mediate level of home health services. This benefit is available to pa-
"As you know, State health agencies are very concerned with health
tients of all ages when continuing care is planned through participat-
services in the home for many, many years. Their efforts in developing
ing hospitals home care departments."
home health services were given a major boost in 1965, with the enact-
"All of our participating coordinated home care programs are hos-
ment of Medicare and Medicaid. Over 50 percent of home health
pital based. This is to say the hospital has the same responsibility for
agencies are now directly affiliated with official health agencies and
home care patients as it does for patients of its inpatient or outpatient
the remainder have an indirect relationship. The State health officers
services."
are strong supporters of home health services and are allocating major
"We endorse Miss Trager's statement in the report on 'Home Health
segments of their resources to development of home health services. A
Services in the United States' that home health services
'are an
number of States have established specific bureaus or division of home
essential component of any system of comprehensive health care and
health services, and many include home health services in their units
the absence of such service excludes the possibility of the most appro-
of nursing, community health services or medical care."
priate use of all other health resources. However, we do not believe
the establishment and acceptance of home care as an essential com-
Miss ANN COHLAN,
ponent of the health care system will be accomplished simply by mak-
ing dollars available. Providers, financers, and consumers of health
Blue Cross Association. Federal Programs Contract Operation, Senior
and health related services must work together to plan, develop and
Director of Claims Service.
implement programs and procedures which will encourage appro-
"The Blue Cross Association
is
a federation of 75 Blue
priate utilization of our total health care resources and will also guar-
Cross plans across the country. This is one of our strengths, but also
antee the availability of needed services to all at a cost our society can
one of our weaknesses; that we have 74 autonomous groups or plans in
support. Implicit in this is the enforcement of reasonable, construc-
74 communities or regions in the country that have to respond to
tive, and effective controls which will promote a high quality of care
regional differences, medical practice, pressures and delivery systems."
delivered economically and consistently. Our home care benefit pro-
"The Blue Cross Association of America, in the past year, has taken
gram, claims administration and reimbursement policies are designed
a firm position to move into the area of quality control in affecting the
to support these objectives."
delivery and organization of such services as home health."
"We sense a considerable need for increased innovation which will
"The division of research and development is currently staffed
lead to new and better methods of patient care planning and the
with a group of health experts who are looking into HMO develop-
delivery of health and social services at the lowest acceptable organi-
ment and encouraging Blue Cross plans to get involved in this area.
zational level of the health care and human delivery systems. We
The HMO expert is also looking at home care as part of an HMO
42
43
believe both the voluntary and official agencies which pay for these
services have a great responsibility to carry out their trusteeship in
"An example of what we've done in the first year: For one of our
a manner which will contribute to the achievement of the essential
board meetings we came to Washington, D.C.; we spent 4 days in
goals I have mentioned. Therefore, we will continue our endeavors in
which we contacted every legislator with whom we could make a con-
support of the appropriate and effective development and use of in-
tact. We had a hearing with Senator Long's staff members and with
home services."
Senator Mills' staff members. We have had a formal protest on the
regulations which have been SO difficult for us to live with.
We
Mr. WILLIAM REINERTSON,
have also tried to meet
with all of the professions which are en-
Associate Director,
gaged in home health care. One of the concepts which we had when
Health Insurance Council.
we began this organization was that it should be representative of
"The Health Insurance Association of America, on behalf of its
all the disciplines who are engaged in the delivery of services."
300 plus members, believes that a major thrust in the improvement
"We have had an ongoing communication with HSMHA, Social
of health care delivery systems should be to shift the emphasis from
Security Administration, with legislators, and private agencies, and
high cost in-patient hospital care to a more accessible ambulatory
we are hoping of course to eventually get involved with the labor
home care type. To achieve this goal, we feel, requires the expansion
groups."
of present major medical and basic hospital contracts. The home care
Mrs. HELEN Burr,
relations committee of HIAA is presently preparing guidelines, with
Consultant on National Organizations,
the help of many of the provider organizations. Today I am here to
National Council on Aging.
learn, as are the Blue Cross people, and we support the need for a
"
national policy."
one of the great consumers of in-home services are those who
are most needy, the aging, of course. Our organization started first as
Mr. LOWELL NORLING,
a committee in 1950 and then was incorporated as a council in 1960.
National Consumer Health Council.
The National Council on Aging is a membership organization of
"Primarily we are a grass roots organization, having just organized
individuals; local, regional, and Federal organizations interested in
in October of 1969, and we do have some active participants. Basically,
programs on the aging, in delivery of services, in the consumer input
our organization is set up around health centers but it has extended
into the services to be given. However, it does not itself give direct
out into many areas. I feel that our organization must have a voice,
services. It does work on a planning and coordinating level with
primarily SO that poor people and people whose voice can't be heard,
other organizations and it does publish and disseminate information,
will be heard. It is an organization dealing with all ethnic groups.
presently has a number of publications and a bibliography of library
Retroactive denial is one of the real problems that we have run across.
references that comes out periodically."
One of the things we are interested in is getting home care to the
"We feel that we have a vested interest in the support of this kind
people who need it, at the time that they need it, and also SO that
of conference and the establishment of a national policy for in-home
they won't be denied because of Government regulations."
services for obvious reasons."
Mr. BERKELEY Bennett,
Miss MARGARET LEWIS,
Executive Vice President,
President,
National Council of Health Care Services.
National Association of Home Health Agencies.
"The National Council of Health Care Services is made up of a
"The National Association of Home Health Agencies may be a
select group of owned or managed companies, including hospitals,
very new title to many of you in the audience. We are only a year
nursing homes, clinics, home health care agencies and pharmacies.
and a half old. The assoication was formed because many of us felt
They are involved in a broad range of health care services. They are
that home health services in terms of the health care system and also
all taxpaying companies, and as a condition for membership in the
because we felt that we needed a single purpose organization. One
National Council, any companies owning hospitals or nursing homes
sole aim was to promote home health care. Of course, we would hope
must be accredited by the joint commission. Consequently, we are as
that in the process of promoting it we did not neglect the other aspects
involved and interested in standards in the home health service area as
of care that were important for patients but we did feel that we were
anyone possibly could be. I do feel that all of our members are inter-
on the low part of the totem pole."
ested in in-home services, they are interested in the whole concept of
"We are encouraging all of our State associations and our regional
the continuum of care."
representatives on our board to conduct seminars and workshops in
"We are interested in legislation that would deal with the difficulties
their areas not only to promote home health care in their communi-
with Medicare and Medicaid restrictions and also relate to coverage in
ties, but also hopefully to sharpen the skills of the agencies in terms
HMO's and national health insurance. I believe now is an appro-
of administration, accountability, and all the other things which are
priate time for a group of this type to really get involved in convincing
important in any business administration."
people that home health care and homemaker services are not add-on
benefits, but that they are alternatives."
44
45
"There is a need to put the patient in the proper level of care. I
thing that is absolutely imperative in terms of it being implemented
don't look at it strictly from the viewpoint of getting the patient out
and developed, and that is that we've got to work at this thing together.
of the hospital or the nursing home into home health care, but the
Individually, I can't really promote homemaker-home health aide
other way around; I like to think of keeping them out of the hospital
services. Individually, perhaps you can't do a whole lot in terms of
or the nursing home. I will add the significant factor that 20 to 30
home health care, but together we can really move a mountain."
percent of patients who are in nursing homes don't need to be there.
One problem is that a lot of those people don't have any other place
Mrs. KATHERINE ELLICKSON,
to go.
"We are very interested in the conference, we want to contribute,
National Council for Senior Citizens.
and we look forward to a really increased interest on the part of the
"The last speaker gave the same tone I wanted to give to it, the mat-
legislature, on the part of Congress, and on the part of our agencies."
ter of how we implement what we do here. The National Council of
Senior Citizens has 3 million members, organized in 3,000 local groups
throughout the country. Many of these are union members still, or were
Mrs. FLORENCE MOORE.
for many years while they were working. While they are all senior
Executive Director, National Council for Homemaker-Home Health
citizens now, they are not interested in programs just for themselves,
Aide Services, Inc.
but also for their families, SO that there is no limitation in the kinds
"The purpose of the National Council for Homemaker-Home
of comprehensive home health services that they want. Now these peo-
Health Aide Services is to promote the development of quality home-
ple whom I have the responsibility of representing are the veterans of
maker-home health aide services throughout the country. It is a mem-
three catastrophic events: first, the great depression, which kept many
bership organization, incorporated 10 years ago, under the name,
of them in poverty or injured them physically then, World War I and
National Council for Homemaker Services, and about a year ago the
World War II. Part of our program is to get the Nation to accept
membership voted to change the name to the National Council for
more responsibility for assuring that these people have the kind of
Homemaker-Home Health Aide Services. This symbolizes the fact that
life, including health care, which they are entitled to, and which they
this service is equally useful in the health and in the welfare fields."
cannot provide from their own depleted resources.
A national
"I am very pleased to tell you that in 1971 the board of directors
convention of the organization will be held next week, and I said to
gave top priority to the development of an accreditations system
Nelson Cruikshank, the president of the organization, when he asked
for homemaker-home health aide services. That program has been de-
me to represent us here, what would the convention do about home
veloped, approved by the board of directors, and is now being imple-
health services? He said, that depends on what report you can bring
mented. At our annual meeting in April of this year, we gave out first
us as to what is going to happen, and I do hope that there can be a
certificates to agencies who were in substantial conformity with the
focus from this conference what will enable me to say, 'Well this is
standards that the National Council has developed. I think you should
what we hope can be accomplished, and that it will therefore deserve
know that the standards were based on a code of standards developed
the attention of this national convention. Obviously, the National
in 1965, and both the code of standards and the standards subsequent
Council of Senior Citizens has to deal with many other problems be-
to that code and the current standards being used for accreditation
sides this one, and they tend to focus on those where action can result
purposes were developed by groups very broadly representative of
from their efforts. They are still supporting changes in the Medicare
health and welfare interests at the national, State, and local level.
regulations and in the legislation that would bring some of the kinds
"When you hear statistics like Dr. Whitten gave us earlier, about
of improvements that have been talked about. Particularly, the matter
the fact that we have 30,000 homemaker-home health aides and we
of removing the restriction to the original illness, and preventing
need 300,000 homemaker-home health aides, you know we have a long
retroactive denials. The National Council of Senior Citizens, like the
way to go in this field. I'd like to just say though that I think that we
AFL-CIO, believes in a comprehensive national health service."
are on our way. We estimate that during the last 6 years, when the
"In addition, we lobby for things like the nutrition bill (Administra-
last national survey of this field was done, we have had something like
tion on Aging) that was passed, which provides us $100 million, rising
a 400 percent increase in the units of homemaker-home health aide
to $200 million, for meals for people, including the aged, which are
service. This includes a large number of one and two homemaker-
provided in schools and churches, and in some cases to meals on wheels.
home health aid agencies, but nevertheless that is a substantial in-
The National Council of Senior Citizens, is strongly supporting the
crease. It does mean that although some of these agencies are small,
20 percent increase in basic Social Security benefits which has now
there is an administrative base there and they can expand from these
been sponsored by 55 members of the Senate. In the field of home
bases."
health services the National Council brought over Dr. Lionel Cosins,
"I would perhaps just close by saying that
I really liked the
who is a British expert in this field, and he testified in favor of com-
first speaker's reference to the 'untapped potential.' It's just begin-
prehensive home health services before the Senate Finance Committee
ning to have its potential felt and understood. It does seem to me,
and also gave many lectures on the subject. So there is no question of
though, that if we come up with something in this meeting, there is one
where we stand on this, and of the awareness of our organization of
46
47
the need for great expansion in this field. However, may I say that I
think we need to consider home health services, not nesessarily
neighborhood health centers. In the interest of improving the quality
as an economy, because we have to be prepared to invest the necessary
of community health services, the NLN and the American Public
funds in this area. True, you can get savings on hospital bills or nurs-
Health Association co-sponsored a national accreditation program for
ing home bills, but you also need a great deal more financial invest-
community health agencies. The criteria are more comprehensive than
ment in the home health services."
those required for certification under Medicare. A staff of experts is
"Our State and local groups take part in a great variety of activities.
employed to administer this voluntary accreditation program, which
This is not a highly centralized organization. This is important to
aims to help agencies to evaluate and improve their policies and prac-
know SO that when you want cooperation at the local level, from some
tices. The staff also provides consultation services through field visits,
of these senior citizens' groups, it will be necessary to contact the ap-
meetings of the council, correspondence and phone calls, and includes
propriate group locally, which may or may not carry the name that
program evaluation and development, extension of services, continuity
identifies it as one of our affiliates. I would hope you would include
of care from hospital to home, administrative practices, budget and
these groups in your planning, because some of these senior citizens do
finance, personnel policy, in-service education, board participation, the
have time to take part in trying to get support for necessary steps.
agency's role in comprehensive health planning, and related areas."
They have tended, these local groups especially, to do home visiting,
"This year testimony has been given to the Senate Committee on
to work for free or low fares on buses, and to get homestead exemp-
Finance, and in November to the Committee on Ways and Means at
tions in tax measures, SO that the aged can stay in their homes, or pay
the House of Representatives. It is prepared currently to testify on
low rent."
HMO's before the House Committee on Public Health and Environ-
"May I close on the sense of urgency. The people I represent can't
ment.'
wait 10 and 20 years for something to be developed. For these
"In 1969, a multidisciplinary advisory committee of the council
senior citizens, veterans, and in many cases victims of the past, time is
was formed, which includes the following organizations: The Ameri-
urgent. We hope increasingly they can be beneficiaries rather than vic-
can Speech and Hearing Association, the AMA, ANA, the American
tims of our health system."
Occupational Therapies Association, American Physical Therapy As-
sociation, National Council of Hearing and Speech Agencies, the Na-
Mr. PETER MEEK,
tional Association of Social Workers, and the National Council for
Executive Director,
Homemaker Services. The councils and staffs of the NLN are much
National Health Council.
concerned with the need to improve and increase the care of people in
"I was asked to talk for a minute or two about what the National
their homes and on an ambulatory basis."
Council has done in the field of services in the home, and as I listen
to a recital, one after another of our member agencies, has been at
this podium, SO I could practically say you have heard it from either
our member agencies or organizations with which we are involved or
who could be members in the Health Council."
After describing the function and organization of the National
Health Council, Mr. Meek told of his experiences with previous at-
tempts to develop services in the home. He emphasized the importance
of the steering committee at the White House Conference on Aging
and the implications of the new Kennedy bill and the HMO's. He con-
cluded by cautioning against efforts to "re-invent the wheel" and
pointed out the importance of constructive planning and joint action.
DR. DOROTHY McMullen,
National League for Nursing.
"The National League for Nursing has six councils on nursing serv-
ice and nursing education, one of which is the council of home health
agencies and community health services. It is a descendant of the
National Organization of Public Health Nursing which was originally
founded in 1911. The council has in its membership over 1,400 home
health and community health agencies and includes the majority of
the large community health agencies across the country. These agen-
cies provide services to people in their homes, in schools, ambulatory
centers, and other community services such as senior centers, and other
49
PURPOSES OF THE CONFERENCE
Conference participants represent organizations and agencies whose interest
in the development of effective in-home services has been expressed and who are
aware of the need for such services as a part of our community institutions.
From the varied experience of the participants, it is hoped that the conference
WORKING CONFERENCE
deliberations will produce:
1. A clear statement of a proposed national policy concerning in-home
"IN-HOME SERVICES-TOWARD A NATIONAL POLICY"
services in the United States.
2. A proposed strategy for the implementation of this national policy, in-
cluding proposals and recommendations for immediate and long-term action.
URBAN LIFE CENTER, COLUMBIA, MD.
More specifically, participants will be asked to work toward these goals through
the tasks of
May 31, June 1 and 2, 1972,
1. Identifying conceptual, attitudinal, and operational barriers to optimal
development and utilization of in-home services of several types including:
To: Conference participants.
a. Administrative.
From Program coordinator.
b. Legislative.
Subject Background information.
C. Professional.
The attached materials are suggested as a working basis for the deliberations of
d. Economic.
the conference. They should be considered only as a framework on which can be
2. Establishing immediate and long-term objectives to overcome such
built the understandings and experience of all participants.
barriers.
3. Preparing recommendations for specific action (short and long-term)
THE NEED FOR A NATIONAL POLICY
to achieve the established objectives at:
a. National.
Expressions of interest in the potential of in-home services have been increas-
b. State.
ing in all areas of our health and welfare systems. They are stressed as an "alter-
C. Local levels.
native to institutional care" in health programs, and as an essential component
in ambulatory care systems. They are cited as the means of producing a way out
THE CONFERENCE-BEFORE AND AFTER
of the mental hospital-or of offering the possibility of a more normal way of
life for the mentally ill who are still in the community. They are described as
The status of home health services today has been fully identified in the report
key services in preventing family disintegration in periods of family crisis, where
to the Special Committee on Aging by Brahna Trager. To conserve time in the
the physical and psychological health of children is threatened. They are con-
discussions for a forward look, it is expected that all participants will be familiar
sidered a valuable resource in the development of health patterns of family life
with its content and thus be able to be involved more readily in planning for a
for the economically and culturally deprived. They are repeatedly referred to as
national policy and strategy statement.
the most needed services for the aging population, for the chronically ill, for the
It is presently planned to video-tape the general sessions of the meeting, to edit
disabled. They are beginning to be considered an important therapeutic supple-
them, and to provide this audio-visual tool to the regional offices for their use at
ment to community treatment services for special problem groups-in drug
State and local levels. In addition, written proceedings are to be prepared and will
addiction and alcohol abuse.
be widely distributed to all interested persons.
These expressions of interest have produced a variety of approaches, many
Finally, as an evaluative procedure, participants will be contacted, 3 months,
of them underlining or demonstrating the potential value of such services. But-
6 months, and 1 year following the conference to learn what steps have been
they have not yet produced a national policy.
taken or are planned by the represented organizations to implement the findings
In the absence of such a policy, the stimulus for the real development of
and recommendations of the "Expert" Meeting.
needed services also is lacking. Without a policy, without a legislative and finan-
cial base, broad community in-home services for the whole population cannot be
CONFERENCE AGENDA
developed and the potential of such services cannot be realized.
WEDNESDAY, MAY 31
DEFINITION OF IN-HOME SERVICES
9-9:30 a.m.: Registration and coffee.
The term "in-home services" is used as an inclusive term in order to broaden
9:30-11 a.m.: First general session.
the concept of such services. It is meant to describe an array of services which
Greetings: Dr. Paul Batalden, Director, Community Health Service.
can be brought into the home, singly or in combination, and which can be adapted
Keynote address: Carroll Witten, M.D., president, board of aldermen, mayor
to meet the needs of persons in all age groups, in all diagnostic categories and in
pro tem, city of Louisville, Ky.
all economic and psychosocial situations when such services can be used thera-
Legislative proposal: Mr. David Affeldt and Mr. Kenneth Dameron, staff of
peutically, or to prevent or arrest illness and disability, to supplement limited
Senate Special Committee on Aging.
function and to protect and support those whose capacities for optimum develop-
Goals of conference Claire F. Ryder, M.D., M.P.H., Chief, Home Health Branch.
ment, function and participation in family and community life are threatened.
11:30-12 noon Small group discussions-Session I.
In this context, many services which have been minimally demonstrated in the
12-1: p.m. Lunch-continuation of Session I.
United States, or which have been considered innovative possibilities but not yet
1:30-4 p.m. Small group discussions-Session II.
developed, are included. The concept is not tied to existing payment sources, to
6-8 p.m. : Social hour and dinner.
regulations which limit the scope and duration of services, or to auspices. It is
8-10 p.m.: Meeting of chairpersons, recorders, and staff-Session A (all other
intended to describe a community-wide, coordinated network of services, a com-
participants free for evening).
plex which can be considered a community institution and an essential component
of the health and welfare system.
THURSDAY, JUNE 1
(48)
8-9 a.m.: Breakfast.
9-12 noon Small group discussions-Session III.
12-1 :30 p.m. Lunch.
1:30-4:30 p.m. Small group discussions-Session IV.
*All sessions to be held at the Urban Life Center, Columbia, Md.
50
51
4:30-6 p.m.: Meeting of chairpersons, recorders and staff-Session B.
National Council for Senior Citizens: Mrs. Katherine Ellickson, National
6-8 p.m. Social hour and dinner.
Council for Senior Citizens, 1511 K Street N.W., Washington, D.C. 20005.
8-10 p.m.: Second general session-agreements and disagreements-chair-
National Health Council Mr. Peter Meek, Executive Director, National Health
person: Dr. Claire Ryder.
Council, 1740 Broadway, New York, N.Y. 10019.
FRIDAY, JUNE 2
National League for Nursing Dr. Dorothy McMullen, National League for
8-9 a.m. : Breakfast.
Nursing, 10 Columbus Circle, New York, N.Y. 10019.
9-12 noon : Third general session
United Way of America: Mr. John Tierney, Director of Health Affairs, United
Conference summary: Dr. George Pickett, director, San Mateo Public Health
Way of America, 801 North Fairfax Street, Alexandria, Va. 22313.
and Welfare Department.
Reactor panel Legislative point of view Mr. Affeldt and Mr. Dameron; Pro-
STATE AND LOCAL
fessional viewpoint: Dr. Patrick Storey, representing the American Medical
Association; the people speak Mrs. Katherine Ellickson, representing the Na-
Mr. James Bergman, Director of Program Development, State Council on
tional Council for Senior Citizens.
Aging, 141 Milk Street, Boston, Mass. 02109.
Closing address: The Administration's Plan for Action Mr. Arthur Flemming,
Mr. Richard Brown, Executive Director, Home Health Services of Louisiana,
Chairman, White House Conference on Aging, 1971.
Inc., 2115 Caronoehet Street, New Orlean, La. 70115.
Mr. Thomas Cook, Executive Director, Athens Community Council on Aging,
CONFERENCE PARTICIPANT LIST
230 South Hull Street, Athens, Ga. 30601.
Professor Lester Davis, Chairman, Department of Human Resources, West-
chester Community College, 75 Grasslands Road, Valhalla, N.Y.
NATIONAL
Mrs. Shirley DeMott, Director, Home Health Services, West Nebraska General
American Association of Comprehensive Health Planning Mr. Richard Schle-
Hospital, 4021 Avenue B, Scottsbluff, Nebr. 63961.
singer, Executive Vice President, Area-Wide and Local Planning, 1010 James
Mr. Alan Fite, Executive Director, Nassau-Suffolk Home Care Council, 1200
Street, Syracuse, N.Y. 13202.
Stewart Avenue, Garden City, N.Y. 11530.
AFL-CIO: Mr. John J. McManus, Assistant Director, Department of Com-
Miss Jean Keating, Southeastern Kentucky Regional Demonstration, Inc., P.O.
munity Service, 815 Sixteenth Street N.W., Washington, D.C. 20006.
Box 4238, 1718 Alexandria Drive, Lexington, Ky. 40504.
American Hospital Association: Miss Alice Gonnerman, Assistant Director,
Mr. Edward Lindsey, State Communities Aid Association, Buffalo Office-810
Division of Ambulatory Care, American Hospital Association, 840 North Lake
Genesse Biulding, Buffalo, N.Y. 14202.
Shore Drive, Chicago, III. 60611.
Miss Helen Rawlinson, Director, Home Care Department, Blue Cross of Greater
American Medical Association Dr. Patrick Storey, Professor of Medicine and
Philadelphia, 1333 Chestnut Street, Philadelphia, Pa. 19107.
Community Medicine, University of Pennsylvania, 36th Street and Hamilton
Dr. Hugh Rohrer, Director, City Health Department, 2116 North Sheridan
Walk, Philadelphia, Pa. 19104.
Road, Peoria, Ill. 61640.
Women's Auxiliary of the American Medical Association: Mrs. Manuel Berg-
Mrs. Dorothy Watts White, Administrator, Home Care Administration, 311
nes, 1735 West Main Street, Norristown, Pa. 19401.
Alexander Street, Rochester, N.Y. 14604.
American Nursing Home Association: Dr. Thomas Bell, American Nursing
Home Association, 1025 Connecticut Avenue, N.W., Washington, D.C. 20036.
FEDERAL
Association of State and Territorial Health Officers Malcolm U. Dantzler,
HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION
M.D., M.P.H., Assistant State Health Officer, South Carolina State Board of
Health, Association of State and Territorial Health Officers, 26 Bull Street,
Office of the Administrator Mrs. Ruth Knee.
Columbia, S.C. 29201.
Community Health Service: Office of the director, Donald P. Conwell, M.D.:
Blue Cross Association: Miss Ann Cohlan, Blue Cross Association, Federal
Division of Health Resources, Paul D. Pedersen, M.D.; Division of Medical
Programs Contract Operation, Senior Director of Claims Service, 840 North Lake
Care Standards, Mrs. Mary Frances Hilton.
Shore Drive, Chicago, Ill. 60611.
Comprehensive Health Planning Service: Mr. James Williams.
Group Health Association of America Mr. Jeffrey Cohelan, Executive Director,
Maternal and Child Health Service: Dr. Alice Chenoweth.
Group Health Association of America, 1717 Massachusetts Avenue N.W., Wash-
National Center for Health Statistics: Mrs. Gloria Hollis.
ington, D.C. 20036.
National Institutes of Mental Health: Miss Dorothy Collard, R.N.
Health Insurance Council Mr. William Reinertson, Associate Director, Health
Regional Medical Programs Service: Mr. Walter C. Levi.
Insurance Council, 750 Third Avenue, New York, N.Y. 10017.
National Institutes of Health, Bureau of Health Manpower Education, Miss
National Association of Home Health Agencies: Miss Margaret Lewis, Presi-
Geri Piper.
dent, National Association of Home Health Agencies, 659 Cherokee Street, Denver,
Social Rehabilitation Service, Administration on Aging, Mrs. Stephanie
Colo. 80204.
Stevens; Community Services Administration, Mr. James Burr; Medical Serv-
National Association of Neighborhood Health Centers: Dr. James Shepperd,
ices Administration, Mr. Joseph Manas.
Vice President, 924 Nineteenth Street N.W., Washington, D.C. 20036.
Social Security Administration, Bureau of Health Insurance, Mr. Bruce
National Consumer Health Council Mr. Lowell Norling, National Consumer
Edemy Bureau of Health Insurance, Miss Sue Jenkins.
Health Council, Palo Alto, Calif.
Office of Child Development, Home Start, Dr. Ann O'Keefe ; Health Start, Mrs.
National Council on Aging: Mrs. Helen Burr, National Council on Aging, Con-
Olive Burner.
sultant on National Organizations, 1828 L Street N.W., Suite 504, Washington,
Veterans Administration, Extended Care Services, Dr. William Klein.
D.C. 20036.
Senate Special Committee on Aging, Mr. David Affeldt and Mr. Kenneth
National Council of Health Care Services: Mr. Berkeley Bennett, Executive
Dameron.
Vice President, National Council of Health Care Services, 407 N Street S.W.,
General Accounting Office, Mr. Allen Elliot.
Washington, D.C. 20024.
Regional Office, Community Health Service, Region III, Miss Marie Herold;
National Council for Homemaker-Home Health Aide Services, Inc. Mrs. Flor-
Community Health Service, Region VII, Miss Helen Epp; Community Health
ence Moore, Executive Director, National Council for Homemaker-Home Health
Service, Region IX, Miss Esther Gilbertson.
Aide Services, Inc., 1740 Broadway, New York, N.Y. 10019.
Conference staff, Home Health Branch, Division of Health Resources, Com-
munity Health Service, Claire F. Ryder, M.D., M.P.H.; William E. Cox; Miss
52
Nina Lee; Miss Marcile Backs; Mrs. Melver Hodgson; Miss Cybthia M. Palank;
Special Assistant, Mr. Hector Sanchez.
PROGRAM PARTICIPANTS
Dr. Paul Batalden-Speaker, Director, Community Health Service, Health
services and Mental Health Administration, Rockville, Md.
APPENDIX 1
Frank Ellis, M.D.-Conference Summarizer, Regional Health Director, Region
V, Chicago, Ill.
Mr. Arthur Flemming-Speaker, Chairman, White House Conference on Aging,
(Exhibits submitted by Brahna Trager)
1971.
Miss Brahna Trager-Special Consultant for Conference, San Geronimo, Calif.
EXHIBIT A
Carroll Witten, M.D.-Speaker, President, Board of Aldermen, Mayor Pro
Tem, City of Louisville, Louisville, Ky. 40205.
Chart 5 - Bed-Disability Days Per Person Per Year By Family Income, July 1905-June 1967
NUMBER OF BED
DISABILITY DAYS
PER PERSON
15
14 -
13
12
11
10
9
8-
7-
6-
WHITE
NON-WHITE
5-L
4--
10.2
9.3
WHITE
NON-WHITE
WHITE
3.L
NON-WHITE
2-
5.8
5.4
4.9
3.5
1.
FAMILY INCOME
UNDER $3,000
$3,000-$6,999
$7,000 and OVER
Source: Table 8
EXHIBIT B
TABLE 9.-DAYS OF DISABILITY PER PERSON PER YEAR BY SEX AND AGE, 1969
Days of disability per person per year
Restricted-
Bed-
Sex and age
activity
disability
Work-loss 1
to
Both sexes-all ages
14.8
6.1
5,2
Under 17 years
9.8
4.7
17 to 24 years
9
4
3.6
25 to 44 years
12,8
5.1
4.8
45 to 64 years
20
7.6
6,3
65 years and over
33.5
12.9
5.8
Male-all ages
13.4
5.3
5.1
Under 17 years
9.6
4.4
17 to 24 years
8
2.7
3.6
25 to 44 years
10.8
3.8
4.5
45 to 64 years
19.1
7.4
6.5
65 years and over
30.9
11.9
6.7
Female-all ages
16
6.8
5.2
Under 17 years
10
5
17 to 24 years
9.8
5.1
3.7
25 to 44 years
14.6
6,2
5.4
45 to 64 years
20.9
7.7
6.1
65 years and over
35.5
13.7
4
1 Work loss reported for currently employed persons aged 17 years and over.
Source: 14.
(53)
EXHIBIT C
EXHIBIT D
MEDICARE REIMBURSEMENTS FOR HOME HEALTH SERVICES AND INPATIENT HOSPITALIZATION, 1969-72
To: D. Ann Cohlan, senior director, Federal Programs-Health Care Services,
Blue Cross Association.
[In millions of dollars]
From Helen L. Rawlinson, director home care department, Blue Cross of
Greater Philadelphia.
Reimbursements
Date: January 19, 1973.
Year
Home health
1
Hospitalization
Copy to Howard W. Baker, M.D., vice president, Blue Cross of Greater
Philadelphia.
1969
79.7
4,088.6
Subject Social Security Act-1972 Amendments (P.L. 92-603). Section 213-
1970
68.7
4,514.7
Limitation on Liability of Beneficiary and Provider Where Services Furnished
1971
56.6
5,026.0
Are Not Medically Necessary or not of a Covered Level of Care; Section
1972 ²
58.5
5,550.6
228-Assurance of Payment for Skilled Nursing Care Facility and Home Health
Services.
1 Includes pts. A and B.
I have studied the sections of the amendments noted above and various state-
2 Estimated on the basis of claims received through Dec. 7, 1972 (first 6 months multiplied by 2).
ments of criteria and procedures that have been drafted regarding their imple-
Source: Monthly Benefit Statistics, Feb. 15, 1972; No. 1-1973, DHEW/SSA/Office of Research and Statistics.
mentation. It is clear that the Congress included these amendments to authorize
administrative procedures that would help to resolve problems and inequities ex-
1971 medicare reimbursements
perienced previously in the administration of the Medicare program. I am con-
Thousands
cerned, however, because enforcement of these sections of the law in relation
Hospital insurance
$5, 234, 630
to home health services will significantly increase both providers' and inter-
mediaries' costs. It is particularly important to recognize that procedures re-
Inpatient hospital
5, 026, 025
quired for enforcement will inevitably reduce the productivity of provider pro-
Home health
40,771
fessional personnel, which is in short supply. Therefore, the following comments
Extended care facility
167, 834
and suggestions are submitted for your consideration with the hope you will
bring the recommendations to the attention of appropriate officials.
Medical insurance
1 1, 956, 423
SECTION 213-LIMITATION ON LIABILITY OF BENEFICIARY AND PROVIDER
Physicians
1, 748, 270
Home health
15,824
Effective enforcement of this amendment will require documentation that the
Outpatient hospital
104, 778
provider advised the beneficiary the services supplied were, in the provider's
Independent laboratory
12, 398
judgment, considered to be not covered and the beneficiary accepted the services
All other
75, 062
regardless of this fact. This requirement will result in severe problems for home
health providers and, more important, for their patients.
Total
7, 191, 053
Such mandatory documentation has serious implications that will impact not
only on home health providers' administrative procedures and costs, but also on
Includes some reimbursables for which type of service is unknown.
the quality of care they can provide. Nurses and therapists establish care plans
Source: (Same as above.)
based on professional judgments related to the physician's therapeutic plan and
Home Health (pts. A and B) reimbursements for 1971, total $56,595 (in thousands) or
the medical goals established for the patient; also on the patient's nursing and/or
0.787 percent of the total Medicare reimbursement for services in 1971.
therapy needs and the type of services and frequency of visits required to achieve
Prepared by Department of Home Health Agencies and Community Health Services,
NLN, Feb. 20, 1973.
the medically desired results. Unlike services provided in an institutional envi-
ronment where patient care plans are carried out under circumstances and in an
(54)
atmosphere that does not require patients to make decisions regarding their
willingness or ability to assume financial responsibility for each service provided,
the unit of service and cost under a home health plan is a visit to the patient's
home. Therefore, the home health agency staff would be obliged to discuss with
every patient who is a potential Medicare beneficiary each non-covered visit and
to obtain the patient's acceptance or rejection of the service to document the
beneficiary's liability and the agency's exercise of "due care". It should also be
noted that it is not always possible to know in advance of a visit whether a
covered or non-covered level of care will be provided because of the frequent
fluctuations in the physical status of older persons with chronic or long term
illnesses.
An average of 45 percent to 50 percent of all visits provided by home health
agencies in the five county southeastern Pennsylvania area to persons over 65
years of age are now determined by providers to be for a non-covered level of
care by Medicare definitions, and Medicare billings are not submitted to the
intermediary for such visits. Notwithstanding the lack of Medicare coverage,
home health agencies make every possible effort to provide services they deter-
(55)
56
57
mine their patients to need. If the patient can pay for all or part of the cost
hospital or skilled nursing facility for at least 3 days and no more than 14
of non-covered visits, he is billed. If the agency concludes, often without dis-
days prior to establishment of the home health plan or treatment. Therefore,
cussing the issue with the patient, that he is financially unable to pay for the
these patients' conditions and their need for home health services are documented
services provided, no bill is submitted and the agency seeks financial support for
and easier to assess than is generally the case with beneficiaries eligible only
such costs from charitable and other sources. The provider's primary concern
for Part B coverage.
is to meet the patient's needs and voluntary HHA providers try to avoid patients
The number of Part B home health claims is almost equal to the number of
declining their services because of financial considerations. This amendment
Part A claims. Therefore, the assurance of payment amendment will, at the most,
would force HHA providers to discuss the payment status of all non-covered
apply to only about one-half of all home health claims and these represent the
visits with patients who are financially able to pay either part of the visit charge
least controversial in terms of coverage eligibility.
or the total charge, and to obtain a signed statement from such patients accepting
This amendment represents little value if providers have been adequately
the non-covered services provided. Although patients for whom the provider
instructed by their intermediary regarding the rules and regulations governing
voluntarily assumes liability do not represent a problem under the amendment,
covered and non-covered services. There is little, if any, justification for manda-
full pay and especially the part pay patients will present serious problems,
tory implementation of this amendment.
complicated by the fact that patient care plans often call for covered visits to
Therefore, we strongly urge that, if permissible under the law, guidelines per-
be interspersed with visits that by Medicare definitions represent a non-covered
taining to Sec. 228 specify that implementation of assurance of payment be vol-
level of care. As noted previously, visits are made on the basis of professional
untary on the part of providers and/or intermediaries as now is the case with
judgments related to patients' medical needs. Professional nurses and therapists
periodic interim payment provisions. That is to say, the assurance of payment
should not be obliged to discuss the medical implications of the need for non-
procedures for home health services need not be implemented unless requested
covered visits with patients to obtain documentation of the beneficiary's accept-
by the home health provider.
ance of non-covered services when to do SO would not be in the best interest of the
patient.
It is apparent this amendment, although intended to protect beneficiaries from
unreasonable financial obligations resulting from unpredictable and/or improper
decisions and/or actions on the part of responsible Government agencies and
fiscal intermediaries, may instead create an unanticipated and unintended situa-
tion in relation to proper and full use of home health services as an alternative
to more costly institutional care. At the same time, it offers precious little pros-
pect of serving a significantly useful purpose in connection with home health
services because (1) the problem it is intended to deal with is not prevalent in
the home health field: (2) judging from experience over the past five and one-
half years, its enforcement, because of the necessary documentation required, will
escalate administrative costs of home health providers and intermediaries while
adversely affecting the quality of care and patient's willingness to accept needed
services, and (3) it will interfere with the professional management of patient
care and the delivery of medical services.
SUGGESTIONS AND RECOMMENDATIONS
1. We suggest the rulings regarding procedures for implementation of Sec. 213
applicable to home health providers be written independently of procedures for
institutional providers and after consultation with persons experienced in the
area of home health administration.
2. We recommend that procedures promulgated for enforcement of Sec. 213 in
relation to home health providers be implemented at the discretion of inter-
mediaries or BHI regional offices. Implementation would be required only and
during the period a provider is determined to be functioning unsatisfactorily in
exercising "due care" in (1) making consistent and accurate decisions regarding
covered levels of care, and (2) advising beneficiaries appropriately of the financial
obligations they incur upon acceptance of the home health services provided.
SECTION 228-ASSURANCE OF PAYMENT FOR HOME HEALTH SERVICES
I am concerned that this section, which applies to Part A home health claims
only, will create unreasonable and unnecessary problems in processing home
health claims and provider and intermediary costs will be significantly increased.
Again, the documentation required for effective enforcement by intermediaries
will lessen the productivity of the provider's professional staff because of the
duplication of time and effort in writing clinical records that will be required.
This view is shared by all local home health providers who have discussed the
matter with me.
If it were conceded that an assurance of payment procedure would serve a use-
ful purpose, it is impossible to rationalize its application to Part A claims only
since eligibility for Part A home health coverage can usually be determined with
more confidence than eligibility for Part B coverage. This is due to the fact that
Part A benefits are allowable only after beneficiaries have been treated in a
59
Obviously, during the acute phase of illness the complex and costly services of
the general hospital are often necessary. In the period of continued disability,
however, hospital stay on a continuous basis frequently is neither necessary nor
desirable. The patient may be moved from the hospital to a skilled nursing
home. At any time when part-time services are needed, the patient may well
benefit from the provision of medical and other needed services at home. In addi-
EXHIBIT
E
tion to those patients who are referred from an institution, many patients are
ill in their own homes, and they may need the same kind of services. Although
REPORT OF THE COUNCIL ON MEDICAL SERVICE
not currently needing an institutional setting, they need home care as preventive
and therapeutic measure. Home care is of benefit for many categories of pa-
American Medical Association Report: C (C-73)¹
tients-the acutely ill, the convalescent, and those recovering from surgery. In
December 1960, the AMA House of Delegates recommended that "physicians be
Subject Home health care.
urged to participate in organized home care programs for any patient who can
Presented by William B. Hildebrand, M.D.
benefit from the program and to promote such programs in their communities."
Referred to Reference Committee D (G. E. Collentine, Jr., M.D., chairman).
A 1972 report, Home Health Services in the United States, prepared for the U.S.
The Committee on Community Health Care reviewed the AMA position on
Senate Special Committee on Aging, verifies the fact that many patients in
home health care and prepared this report, which consolidates information
nursing homes could better utilize home care services.
previously contained in several different publications. The report includes dis-
cussion on:
2. PATTERNS AND LEVELS OF HOME CARE
1. Background.
2. Patterns and Levels of Care.
Home care services are available from a variety of sources. They may be pro-
3. Homemaker-Home Health Aide Services.
vided through: (1) A single service agency such as a homemaker-home health
4. Financing of Home Health Care.
aide services program or a meals-on-wheels program; (2) a multiple-service
A. Private Insurance Programs.
agency that arranges for two or more types of services, such as home nursing
B. Federal Programs.
care, physical therapy, and homemaker-home health aide, or (3) a coordinated
5. Benefits of Home Care Services.
home care program that arranges for a wide range of home services designated to
6. The Role of the Practicing Physician.
meet the patient's individual needs through one centralized administration. The
7. The Role of the Medical Society.
coordinated home care program also is responsible for planning, evaluation, and
8. The Role of the Institution Medical Staff.
follow-up procedures to provide physician-directed medical, nursing, social, and
The American Medical Association defines home health care as: Any arrange-
related services to selected patients at home.
ment for providing, under medical supervision, needed health care and sup-
Home care is generally considered to be categorized into three component
portive services to a sick or a disabled person in his home surroundings. The
levels: (1) Concentrated or intensive care; (2) intermediate service; and (3)
provision of nursing care, social work, therapies (such as diet, occupational,
basic services.
physical, psychological, and speech), vocational and social services, and home-
The most concentrated or intensive service is for patients who would ordinarily
maker-home health aide services may be included as basic components of home
require admission to inpatient institutions. Some patients require complex pro-
health care. The provision of these needed services to the patient at home con-
fessional services on a coordinated and continuing basis for brief periods of time.
stitutes a logical extension of the physician's therapeutic responsibility. At the
They do not require full-time resources and can benefit from intensive home
physician's request and under his medical direction, personnel who provide these
health care services.
home health care services operate as a team in assessing and developing the
Intermediate services are those needed on a less intensive basis. Patients re-
home care plan.
quiring intermediate services may have long-term problems or may have been
1. BACKGROUND
recently discharged from an acute care facility.
Basic services are those that provide an effective level of health care for an
The changing age composition of the U.S. population and the proportionate
individual within that person's home. Basic service should be sufficient to sustain
increase in long-term illness and disability have resulted in the medical profes-
patients adequately SO that they can remain relatively independent. Assuming
sion's increased recognition of the need for examining and improving traditional
they have stabilized physical conditions, they do not have to return to an in-
methods of delivering health care services.
patient facility for more intensive care.
Over the past half century, the increase in prevalence of such chronic diseases
Home health services, including follow-up, can be provided by many different
as hypertensive and arteriosclerotic heart disease, cerebrovascular disease, arthri-
kinds of private and public agencies, including visiting nurse associations
tis, neurological disorders, malignancies, and pulmonary disorders has expanded
(VNA's), departments of public health, and hospital-based programs. VNA's are
demand for long-term medical and supportive care. Many of these diseases, after
voluntary nonprofit groups that deliver nursing services in the home. The public
a dramatic acute phase, are followed by long periods of convalescence, rehabili-
health departments are governmental units that may provide, in addition, a
tation, and supportive care often punctuated by additional acute episodes. Other
variety of services such as case finding, preventive services, observation, and
medical problems have a less acute onset phase that requires definitive diagnosis
follow-up. Hospital-based home care programs serve as an extension of hospital
followed by a long course of definitive therapy. Congenital defects (in structure
services and can provide nursing care plus a variety of other supportive services
or metabolism) and disabilities resulting from accidents also contribute their
to noninstitutionalized and post-hospital patients.
share of long-term care problems.
Since enactment of the Medicare law, programs that were previously providing
Such diseases or disabilities present difficult problems of medical, social. and
nursing care of the sick at home have expanded their functions to include other
economic significance. The long periods of time involved in treatment and rehabil-
services, such as physical therapy, homemaker-home health aide services, and
itation, with the resulting social and financial burdens placed on the individual.
social services. Whether a VNA, a public health department, or a hospital-based
the family, and society in general, necessitate that physicians become concerned
program, a home health agency certified under Medicare must receive referrals
with optimal methods by which needed services and facilities can be furnished to
from physicians. It provides services for both noninstitutionalized and the post-
the patient.
hospital patients.
Whatever the organizational mechanism, home care services at any of the
1 Past House Action C-70 : 146, 176-117 A-67 63-65 A-62 118-119 C-61 170,
described levels should be viewed as an alternative to hospital, nursing home,
182; C-60 : 155, 157, 163-164.
or other institutional care and as part of a total medical care plan. As such,
(58)
96-867 O 73 2
60
61
home care can enable the patient to remain in, or return to, a home environment
believes that home health services should be an integral part of any health
that may be psychologically therapeutic and probably result in a cost saving.
insurance program.
The patient must want to receive care in the home environment and family
The appropriate use of home health care services can reduce unnecessary uti-
relationships should be conducive to care.
lization of institutional services. Earlier discharges from hospitals release more
Training of the patient in self-care and instruction of family members are of
hospital beds and can reduce the costs of hospital stays. The National Association
prime importance in achieving maximum effective utlization of available pro-
of Home Health Agencies has reported that if the average hospital stay were
fessional health personnel. For example, institutional efforts devoted to careful
shortened by one day for only five precent of all hospital patients, the potential
instruction of a diabetic or a post-coronary patient and his family before the
cost savings would be about $100 million annually. However, this figure does not
patient goes home provides for continuity of care and reinforcement of the edu-
include the operating cost of maintaining empty institutional beds that must also
cational process in the setting of the patient's home. Home care will be enhanced
be assumed by communities. Also, it must be understood that home care programs
by having instructions start in the hospital because they will then be reinforced
may merely shift a portion of the total health care costs from the inpatient cate-
in the home.
gory to the outpatient category. This outpatient home care service can normally
3. HOMEMAKER-HOME HEALTH AIDE SERVICES
be provided at a fraction of the inpatient costs and thus an overall savings can be
expected. This shift in costs from the inpatient category has usually resulted in
Homemaker-home health aide service programs offer a type of home health
out-of-pocket expenses for the patient because the inpatient care was reimburs-
care to a variety of patients, Homemaker services originated in the 1920's. Serv-
able whereas home care or ambulatory services are frequently not covered.
ices are provided by homemaker-home health aides who are mature and specially
trained persons with skills in both homemaker and personal care. They help main-
A. PRIVATE INSURANCE PROGRAMS
tain and preserve a family environment that is threatened with disruption by
illness, death, ignorance, social maladjustment, and other problems. They can
Third party payors, including Blue Cross-Blue Shield and commercial insur-
assume full or partial responsibility for child or adult care, for household man
ance companies, are recognizing that effective utilization of home health care
agement, and for maintaining a wholesome atmosphere in the home. Their ac-
services potentially can result in significant cost savings. As a result, a greater
tivities are performed under the general supervision of a nurse, social worker.
number of health insurance policies are beginning to include coverage of home
or other appropriate health professional.
health care services. Insured home care programs in two areas-Philadelphia,
Home health aide services is a term that refers to the personal care services
Pennsylvania, and Rochester, New York, have been in operation for several years
for the patient. This term was first used in the Medicare regulations to describe
and have reported significant cost savings.
the services eligible for reimbursement under that program. Home health aide
The Blue Cross of Greater Philadelphia Home Care Program was developed
services can be broadened to include certain functions of homemaking directed
to serve as an effective alternative to institutional care for patient and physician
toward maintaining the environment of the patient.
use. Blue Cross of Greater Philadelphia worked with selected member hospitals
Homemaker-home health aides can perform a number of routine duties: light
and community home health agencies in a collaborative effort to develop an
housekeeping, light laundry, preparation and serving of meals, shopping, simple
administrative mechanism to facilitate coordinated home health care delivery
errands, teaching of household routine and skills to well members of the family,
as an alternative to inappropriate and unneeded institutional care. Under this
and general supervision of the children of the patient. There is a need for the
program, Blue Cross subscribers were provided a broader range of benefits.
expansion and extension of this service in new and imaginative ways.
The patients who have made use of the home care have generally accepted the
The AMA and its women's auxiliary have long promoted the use of effective
opportunity for care. They have been released from hospitals an average of
homemaker-home health aide services. The AMA supports the appropriate de-
13 days earlier than they would have been without the availability of the coordi-
velopment of homemaker-home health aide services. Physicians and medical so-
nated home care service. Expressed in the value of inpatient days saved on
cieties as well as hospital administrators and other health professionals should
3,940 home care cases, this amounted to a gross savings of approximately $2.5
appreciate and understand the important role that the homemaker-home health
million. Net savings amounted to approximately $1.3 million, or $330 per case
aide can play in the proper oneration of a coordinated home care program.
after deducting the cost of providing home care services and the related program
The National Council for Homemaker-Home Health Aide Services, Inc., is a
administrative costs. More than 800 private physicians have participated and
nonprofit, tax-exempt, voluntary membership organization whose purpose is the
referred patients to the home care service. Most of the physicians indicated
development of quality homemaker-home health aide services as an integral part
they preferred coordinated home care to continued hospitalization. Better coop-
of health and welfare services delivered in the home. In 1969, it was named as
erative relationships, high quality programs, and professional skills have been
the national standard-setting body for homemaker-home health aide services for
developed within the participating hospitals and community home health
the program administered by the Social and Rehabilitation Service of the De-
agencies.
partment of Health, Education, and Welfare. In this role, the National Council
The Rochester (New York) Home Care Association Program is also under-
has developed and is implementing a national approval program that can offer
written through the Rochester Blue Cross Program. Home care services are
help in assuring the quality of homemaker-home health aide services. The AMA
purchased primarily from the VNA and the public health nursing department.
has actively supported the National Council since its beginning and, in Novem-
Direct social services are also provided in this well organized program that
ber 1970, the AMA urged support and extension of homemaker-home health aide
offers continuing care. Patients are referred to the home care program in many
services.
ways and from a variety of providers, including practicing physicians, and
Homemaker-home health aides help a community maintain and improve its
organizations within the community. The program grew from a total of 141
physical and mental health by providing high quality homemaker-home health
referrals in 1961 to over 1,500 referrals in 1970.
aide services. The medical profession should cooperate with and support indi-
The national inpatient per diem cost rose from $36 in 1961 to $92 in 1971.
viduals and organizations that are capable of delivering these high quality home-
In 1961, the Rochester home care cost per day was about $8 and in 1971 it was
maker-home health aide services in communities where they are needed.
$16, and it offered approximately a $76 saving over charges for a patient day
in the hospital in 1971. The average hospital length of stay for the type of
4. FINANCING OF HOME HEALTH CARE
patient served by the program was about 40 days. However, through utiliza-
The financing and the cost of home health care services are complex subjects.
tion of home care services a savings of 21 inpatient days per case was realized.
From the standpoint of coverage and reimbursement, home health services have
For the calendar year 1970, the Rochester Home Care Program achieved a net
been almost ignored by most third parties in the past. In recent years, however,
savings of over $1 million.
home care coverage is more available as a result of patient and provider satis-
Both of these programs illustrate that effective programs of home care services
faction and the recognition by all parties of the potential cost savings. The AMA
can reduce costly inpatient stays and thus achieve significant savings.
62
63
Blue Cross, Blue Shield, and other insurance companies will underwrite almost
a physician and paid for under the program, but each would be paid and reported
any service for which the insured group is willing to pay the premium. It must
under the category of the specific individual service such as nursing, speech
be remembered that labor and management play a large part in determining
therapy, physical therapy, etc, rather than as organized home health services.
what goes into an insurance contract.
CHAMPUS will pay for home care by registered nurses, and by licensed practical
nurses, as well as by other health providers.
B. FEDERAL PROGRAMS
4. Federal Employees Health Benefits Program (FEHB)
Government programs generally provide for reimbursement of home health
services to the extent that such coverage is specifically included in the law. Thus
The Federal Employees Health Benefits Program (FEHB) has no statutory
in Medicare and Medicaid, in which home health services are identified in the
mention of home health service. Enabling legislation, P.L. 86-382, speaks of
statutes as reimbursable, the service is generally provided. In the Civilian
"general care rendered in the patient's home," "ambulatory patients' benefits," and
Health and Medical Program for the Uniformed Services (CHAMPUS) and the
"other medical supplies and services" but makes no statutory requirement for
Federal Employees Health Benefits Program (FEHB), home care is normally
specific coverage of home health services. Statistical reports on the program do
provided and reimbursed as an adjunct to physician services.
not identify utilization of such services but generally combine all hospital bene-
fits. It is estimated that approximately 95 percent of those enrolled in the high
1. Medicare-Title XVIII
option FEHB program are covered for home nursing, but the patient often pays
a deductible or has some other limitation, such as a coinsurance payment. Cov-
Medicare reimburses for home health services under both Parts A and Part B
erage by the two largest plans-the Blue Cross-Blue Shield and Aetna (the
of Title XVIII. After a minimum of 3 days' stay in a hospital or after a dis-
contractor for the other insurance companies)-includes a variety of home health
charge from an ECF, Part A pays for up to 100 hospital-related home health
care services.
visits within a 12-month period. These visits must be ordered by a physician
There are limitations in most of the Federal programs. Some limitations in
according to a plan established within two weeks after institutional discharge.
home health service under the Medicare program are: (1) Focus is on acute or
The home health agency must be a participant in the Medicare program and the
short-term illness (2) there are inherent contradictory definitions of the eligible
patient must be treated for the same condition for which he was hosptialized.
home health service patient as applied to the insured group's need (3) reim-
Part B of Medicare pays the providing home care agency for up to 100 home
bursable services are not necessarily those most needed by the majority of the
health care visits each year when a patient has no prior hospital stay if such
insured group; (4) definitions of reimbursable services are susceptible to a
services are provided according to a plan of treatment approved by a physician.
great degree of interpretations; (5) many agencies have been placed in financial
Part B of Medicare also may be used if the patient's Part A visits have been
jeopardy by delays in reimbursement resulting from administrative complexities;
exhausted.
(6) difficulties are encountered in establishing and maintaining comprehensive
It should be emphasized that Part A pays reasonable costs of home health
services because reimbursement from the insurance system is limited to selected
services, while Part B pays 80 percent of the reasonable cost of services after the
services; (7) strong institutional bias exists with a 3-day hospital stay required
patient has met the overall annual $50 deductible for Part B services.
prior to entitlement for home health services under Part A, and non-hospital
Medicare cost data for fiscal year 1971 indicate that both the number of claims
related home health services under Part B are dependent on the individual's
and the amount paid comprise an extremely small portion of the total expendi-
paying the insurance premium and 20 percent of the cost of service (8) cost of
tures for the program. Home health services accounted for less than 20 percent
home health services under Medicare has remained at less than 1 percent of
of the number of claims and less than 1 percent of the dollars paid out under
insurance expenditures and appears to be diminishing while expenses for insti-
Medicare.
tutional services are increasing. Similarly, many of these criticisms have been
leveled against the State-administered Meidcaid program.
2. Medicaid-Title XIX
The United States Senate's Special Committee on Aging's 1972 report, Home
Medicaid statutes list services that are eligible for Federal matching, including
Health Services in the United States, stated that there were minimal Federal
home health care services. Home health care services are defined in Medicaid reg-
resources allocated for the creation of appropriate home health service programs
ulations to include nursing and therapy services, as well as other services provided
and that, where there were resources, strict regulations had hampered the
through a home health agency under direct supervision of the physician. About
success of such programs in meeting the needs for home care. A question might also
80 percent of the individual State Medicaid programs have included home health
be raised as to what degree any open-ended need for home health services can
services either for the categorically indigent or the medically indigent. As of
realistically be met.
July 1, 1970, all States were required to provide home health services for eligible
individuals entitled to skilled nursing home services. All home health agencies
5. BENEFITS OF HOME CARE SERVICES
participating in the Medical program must meet Medicare standards.
The benefits of effective home health care programs can be summarized as
Unlike Medicare, the Medicaid program does not require payment of reasonable
follows:
costs or reasonable charges but rather the law states that payments may not be in
1. Patients prefer care that can be provided in the normalcy of their home
excess of reasonable charges. There is no minimum payment level set. In general,
environment.
the method of determining payment levels is a state option.
2. Home-bound people can be taught to live in a relatively independent
In the overall Medicaid program, home health expenditures again are a small
status.
part, totalling less than a half percent of the dollars paid out.
3. The need for initial admission or readmission to inpatient institutions
can be diminished.
3. Civilian Health and Medical Program Uniformed Services (CHAMPUS)
4. For the necessary institutional admission, unnecessary days can be
The Civilian Health and Medical Program for the Uniformed Services
eliminated through early discharge to home care.
(CHAMPUS) is one of the most comprehensive Federal health programs, and it
5. Unnecessary capital construction costs for inpatient facilities can be
is administered through a number of private insurance carriers and/or State
decreased.
medical societies. There is no specific listing of home health services in the
6. The efficiency of the practicing physician can be increased by expanding
enabling legislation or in descriptive materials issued by the program. The pro-
the team approach. The physician can care for a greater number of patients
gram attempts, where feasible, to pay for any appropriate legitimate services
through a home care program because he does not have to assemble and
ordered by the physician for treatment of a patient. Apparently most, if not all,
coordinate individually the services needed for his patients in their home
of the individual services provided by home health agencies could be ordered by
settings.
64
65
7. Home care staff can readily interpret medical orders, explain treatment
regimes, and offer reassurance and support.
such services and show what significant economic benefit can be reaped by a
8. Home care staff can identify day-to-day problems and thus help to reduce
community.
the possibility of emergency situations arising.
2. Measure the capability of the community to provide home care from the
standpoint of manpower, financial, transportation, and institutional re-
6. THE ROLE OF THE PRACTICING PHYSICIAN
sources, and any other necessary resources.
3. Stimulate the development and use of home health care programs in the
Depending upon the needs of the patient, home health care may require many
community in whatever setting is considered most appropriate.
persons and organizations to combine their efforts and form a health care team
4. Identify expected sources of income for the program and urge expansion
under physician direction. Leadership by physicians is essential to the efficient
of existing insurance payment mechanisms for appropriate types of home
and successful provision of home care services. This leadership role can be ex-
care.
pressed in many ways. Examples are as a: (1) medical director in a hospital (2)
5. Make use of medically and ethically sound promotional and educational
medical director of a community-based home health agency; (3) member of a
material on available home care programs.
board or advisory committee of a home health agency; (4) coordinator of a hos-
6. Provide technical advice and assistance in developing and operating
pital-based home care program; (5) a member of a home care committee or
home care programs.
similar body of a hospital, health center, medical society, etc., or as (6) a private
7. Encourage the public to demand insurance coverage for a needed home
practitioner who makes appropriate use of home health services in his patient
care alternative.
care management.
The medical society should also urge the medical directors in hospitals and
Whatever the role, some suggestions for physicians are:
other health facilities to develop continuing professional education programs on
1. The physician should be aware of the home care services available in
the utilization of home care services. Communitywide public education programs
his community and the various methods by which they can be developed or
should be initiated as a means of promoting community acceptance.
improved.
The medical society should emphasize the need for medical schools and intern-
2. The physician should assist in initiating innovative ways in his com-
ship programs to educate medical students, interns, and residents in the value and
munity that encourage the delivery of more efficient, more economical, and
proper use of home care programs.
more appropriate care in the natural home setting of the patient.
The medical society should emphasize in all of its deliberations concerning
3. The physician should become familiar with the various financing alter-
home care that effective home care programs can offer high quality medical care
natives that can be used in paying for home health services.
and can be an extension of the physician's services at very little cost and effort
4. When referring patients for home care, the physician should establish
to him.
a plan of treatment for each patient and should periodically review this plan
Each medical society should create a home care committee to coordinate the
and the patient's progress with the home health personnel providing the
medical society's activities on the subject of home care.
care. Special efforts (or arrangements) may be needed to maintain this
communication when a patient is cared for at home because of the sep-
8. ROLE OF THE INSTITUTIONAL MEDICAL STAFFS
aration in time and distance between the different services and personnel
involved. The physician may, therefore, wish to support the establishment
As an integral part of a health care institution, the organized medical staff
of coordinated home care programs that can fulfill this role.
should be particularly sensitive not only to that institution's specific needs and
5. The physician should ensure that he receives regular reports, observa-
goals but also to the important community problems of the needs of the patients
tions, and progress notes from the health personnel or home care program
and the alternative patterns of care that can most appropriately answer those
providing the services.
needs. Because the medical staff's decisions affect the general utilization of in-
stitutional beds and services, it is important that the hospital medical staff be
7. THE ROLE OF THE MEDICAL SOCIETY
fully aware of the value and proper use of home care programs. The medical
staff's primary concern is to ensure that all patient care is appropriate and of
The medical society has a proper concern with the availability and adequacy
high quality. These concerns should lead the medical staff to seek active and
of health care services for the population in its service area. The medical society,
involved representation on the institution's home care committee. If there is
therefore, should stimulate physician interest in and acceptance of home care
not a home care committee, the medical staff should stimulate its development.
as an integral part of the overall continuum of care. Along with this, the society
The interests of an institutional home care committee should extend beyond
should provide community leadership in both improving the coordination of exist-
acute inpatient care and they should determine the appropriate and effective use
ing home care services and stimulating the development of new services where
of home care programs for the patients served by the institution. The home care
they are needed.
committee should coordinate its efforts with the activities of the medical society,
Adequate community home care services will be dependent not only upon the
the community planning agency, other appropriate community agencies, and
actions of the local medical society but also upon the sound cooperative planning
organizations concerned with home care services.
efforts of many public and private health and service agencies in the community,
The medical staff and the home care committee should urge the medical direc-
especially the community health planning agency. In addition to the medical
tor of the institution to develop and offer continuing professional education pro-
society and its women's auxiliary, other agencies that might properly become
grams on the use of home care services. The home care committee should ensure
involved in the overall community planning for home care include local and State
that any interns, residents, and other health professional students in the in-
health departments (particularly their bureaus of nursing) local visiting nurse
stitution are trained in the value and use of the home care program. The com-
associations or community nursing services; local or State nurse, hospital, and
mittee should also encourage the development of appropriate professional review
nursing home associations; local or State health professional provider organiza-
and evaluation of home care programs. The effective use of the home health care
tions: health financing organizations; chambers of commerce; and other impor-
services can only be realized when well designed criteria for selection of patients
tant community business and government leaders.
for home care and standards for evaluating the effectiveness of home care are
Medical societies should help to ensure that the community health planning
used.
agency has broad representation from all organizations concerned with providing
home care. The medical society, in particular, can stimulate the involvement of
physicians in these planning activities. Some of the activities that the community
planning agency may want to consider in the development of adequate community
home care services are:
1. Measure the need for such services in the community by making in-
patient population analyses and demographic studies that show who can use
67
health services is dependent on correction of the unreasonable raises of the
agencies financial instability.
Assuming adequate financial resources can be made available, providers of
home health services could take initiatives through cooperation and structural
relationships with physicians and institutional providers to deal with some of
the most acute deficiencies of our health care system-providing care, under
medical direction, to individuals in their places of residence when institutional
EXHIBIT F
care is not medically required, assessing individuals' health needs, and assisting
To: Brahna Trager.
those who require active medical treatment and/or institutional care to reach
From: Helen L. Rawlinson, Director Home Care Department, Blue Cross of
promptly the appropriate sources of needed care. For example: Professionally
Greater Philadelphia.
qualified and supervised home health agency personnel could be regularly as-
Date: February 20, 1973.
signed as an on-site primary care resource in housing complexes for the aging
Home care, its potential values and the problems that have impaired its
and in other areas where an aging population is concentrated. These practitioners
growth and utilization were carefully stated and well documented in "Home
would provide primary care screening, health education and maintenance serv-
Health Services in the United States," the report you prepared for the Special
ices, morbidity care and access to supportive services required incident to illness
Committee on Aging of the United States Senate. Although there is some evi-
of either an acute or chronic nature. They would provide a continuance of medi-
cally directed care following hospitalization or other institutional care.
dence that more recognition is being given to the need to effectively incorporate
A program as described would contribute significantly to resolution of the
home care in the main stream of the health care delivery system, there is
problems associated with the absence of primary care in the community while
precious litle evidence of action in this direction. It has been said that delay
relieving the need for physicians to make time-consuming visits to patients'
is the worst form of denial with respect to enhancing the quality of patient
homes. The proper use of qualified home health agency professional personnel
care, and reducing related costs, through expanded and appropriate use of
could be one of the most effective steps toward building a primary care system.
home care services, we have witnessed the validity of this statement. Expressed
Home health agencies would provide in the community setting needed and appro-
opinion is generally in favor of home care, but action to establish it as a
priate levels of health and related services as hospitals provide the required
viable component of the health care delivery system is afforded a priority SO
levels of care in an institutional setting.
low that the resulting delay in effective action threatens the capability of
Implementation of this concept would require home health agencies to expand
organized providers of home care to maintain even the services they have sup-
their staffs to include clinicians and practitioners in nursing and the allied health
plied in the past.
professions. To accomplish the objectives, new relationships with physicians and
Several reasons for this decline could be stated but, in my view, the three most
health care institutions would have to be achieved new administrative concepts
important causes are:
and practices would have to be developed; there would have to be relief from
1. Absence of physician understanding and interest.
inappropriate and unreasonable financial restraints; financial support would
2. Emphasis on health services provided in institutional facilities.
have to be provided for well conceived and managed demonstration projects; and
3. Isolation of home care providers from the "main stream" of the health
logical thinking would have to prevail among planners and persons formulating
care system and the absence of innovation in development, delivery and ad-
reimbursement policies. Home health services would become an integral part of
ministration of home care services.
the organizational infrastructure of the health care delivery system.
These issues can only be dealt with by casting aside thinking that is cir-
As stated SO well in the Senate Committee Report of April 1972, "They (home
cumscribed by historical burdens and moving forward vigorously to replace
health services) are an essential component of any system of comprehensive
traditional concepts with decisive action toward new administrative and service
health care and the absence (or the failure to use appropriately) such services
patterns that will be responsive to countemporary problems and needs. A pre-
excludes the possibility of the most appropriate use of all other health resources."
requisite to change in correction of the erroneous understandings and thinking
In an article in the March 1971 issue of "Inquiry", Anne R. Somers wrote, "The
that associate the financing, administration and delivery of home care services
guiding principle of the Swedish planners is that 'care should be provided at the
with institutional providers of health care.
lowest acceptable organizational level of the medical care system'."
There is little comparability between economic forces related to institutional
In terms of the needs of the aging, it is not an "alternative" service that is
and physician services and home health services. Except for a history of casual
needed, but a whole new organization of services that will assure accessibility
utilization controls in providing prolonged periods of health supervision and
and effectiveness when they are required and delivered where they are needed.
maintenance levels of care, home health agencies have enforced extraordinary
A system that would provide ready availability of services, coordination of
economy in their operation. They have in no way contributed to the escalation of
services under professional supervision, channels to other levels of care, and
health care costs. Nevertheless, they have had to absorb the problems of increas-
helpful counseling. Such a system would be an alternative to the bewildering
ing costs, especially salary costs which they have been obliged to meet to compete
fragmentation and the inaccessibility of entry to the system that now prevails.
with institutional providers for qualified professional personnel. More recently
they have had to incur substantial increases in administrative costs to comply
with Medicare provider certification and reimbursement regulations. Concur-
rently, charitable and local government financial support has been reduced drasti-
cally on the assumption that Medicare cost reimbursement would eliminate the
deficits previously covered by these sources of financial support. This has not
been the case, however, because Medicare coverage of home health services is
defined narrowly while voluntary (nonprofit) agencies have continued to try
to provide the services their patients need regardless of the availability of Medi-
care or other third party reimbursement. More recently, rulings of the Economic
Stabilization Program have compounded home health agencies' financial prob-
lems by ruling out the possibility of obtaining reimbursement of their costs
related to providing covered services to Medicare beneficiaries. Many agencies,
as a result, have depleted their modest endowment funds that were accumulated
from gifts over the years and others have had to reduce their services to pa-
tients. Many are facing total financial insolvency. Therefore, the future of home
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69
Have established policies, reviewed and approved by a committee of
health professionals and consumers.
Provide health services under the direct supervision of appropriate
health care personnel.
EXHIBIT G
Maintain appropriate clinical records.
Conduct periodic peer reviews and utilization reviews.
NATIONAL ASSOCIATION OF HOME HEALTH AGENCIES
Establish policies and procedures for systematic evaluation and revision
of their programs.
FACT SHEET
SUMMARY
N.A.H.H.A.
In the past, price has been the least important consideration in health care
purchases. However, we must solve the current dilemma of too many people
The National Association of Home Health Agencies believes that The inclusion
requiring care, not enough manpower, (doctors, nurses, etc.) and not enough
of in-home health services as an integral part of a rational health system should
money. The home must be re-established as to the center of care SO that resources
result in a reversal of a trend toward institutionalization, increased consumer
will go where they can do the most good for all; the taxpayer, the poor, the
satisfaction and moderation of rising costs.
elderly, the children, the handicapped, and the disadvantaged. Greater utilization
of in-home health services will help develop a high quality health care delivery
DEFINITION
system that uses the institution as the last alternative.
In-home health services are the activities and services provided to individuals
and families in their places of residence for the purpose of promoting, maintain-
ing or restoring health, or minimizing the effects of illness and disability.
ADVANTAGES
Home care produces greater results in relieving human misery. Various studies
have revealed that:
1. 84-90 percent of the patients preferred home health care to institu-
tionalization.
2. 84-95 percent of physicians felt that home care could satisfactorily meet
the needs of their patients.
3. Home care was the service of choice.
4. Home care enables patients to retain independence.
Home care extends services to residents of ghetto, rural and suburban areas.
It increases efficiency in utilization of manpower.
COST
In-home health services lessens the cost of illness:
1. Home care is 3½ times less expensive per case than hospitalization.
2. Home care is 4-5 times less expensive per day than skilled nursing home
care. (E.C.F.)
In-home health services reduces the high health care costs:
1. Home care saves community funds.
2. Reduces the length of hospitalization.
3. Decreases hospital re-admissions.
4. Makes many nursing home admissions unnecessary.
5. Reduces capital construction costs of new institutional beds.¹
In-home care insures that given amounts of money will accomplish more:
1. Maximizes each individual's potential for self-care.
2. Extends the efficiency and coverage of practicing physicians.
3. Home environment is more conducive to patient learning than the
hospital.
QUALIFIED PROVIDERS
In-home health services must be furnished by only organizations that meet the
following qualifications:
Primarily engaged in providing in-home health services.
Have a readily identifiable governing body accountable for the manage-
ment of the agency.
1 New Jersey in 1970 saved Medicare an estimated $3.5 million through selective and
proper use of home health services, extended care services, and hospitals.
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71
1967, 1,800 home care providers had been certified under Medicare with about
10 percent under hospital auspices. The number of certified providers under
Medicare had increased to 2,256 as of December 1971.
The AHA annual survey of registered hospitals for 1970 disclosed that 523, or
8 percent of the reporting hospitals, had home care departments. A special study
of 547 hospitals reporting home care programs in 1969 disclosed, however, that
only about half these hospitals actually administered programs. Hospitals re-
EXHIBIT H
porting programs not administered by them usually referred patients to com-
munity program.
EXCERPT FROM STUDY OF HEALTH FACILITIES
A substantial majority of patients with long-term illnesses could best be treated
at home with suitable supervision and assistance and environmental adaptations.
CONSTRUCTION COSTS
Analysis of general hospital use shows that from 20 to 30 percent of the extended-
stay patients have been retained because of social rather than medical reasons,
(General Accounting Office, Nov. 20, 1972)
and surveys of nursing homes show that many patients do not need the con-
tinuous nursing services of the facility but could be adequately cared for in home
CHAPTER 3-HOME CARE
settings if some type of nursing and related care were available.
Home care advocates have long cited this method of health care delivery as
Home care, in the broadest sense, is the provision of health care and/or sup-
a mechanism for reducing hospital costs. Home care can be viewed as meritori-
portive services to the sick or disabled person in his place of residence. It may be
ous by itself in that it provides the most appropriate care to the patient at the
provided through a broad range of service and organizational patterns from
level which best fits his needs. Patients on home care also pay a good deal less
nursing service under physician direction to a coordinated home care program
than the rate they would have to pay in a general hospital, and there is a growing
which is centrally administered, planned, and evaluated to provide for physician-
sentiment among medical economists that a well-conceived home care program
directed medical, nursing, social, and related services to selected patients at home.
could make unnecessary the construction of a substantial number of new general
Coordinated home care should include visiting nurse, home aide, and laboratory
hospital beds. One source estimated that a home care program with a caseload
services; physical therapy; drugs; and sick room equipment and supplies. The
of 50 patients could be an adequate substitute for construction of an equivalent
purpose of such programs is to shorten the length of hospital stay, to speed re-
number of hospital beds occupied by patients who require home care but not
covery, and to bridge the gap in community health services for patients who are
hospital care.
too ill or otherwise unable to visit a physician's office or an outpatient clinic yet
A study by the Rochester, New York, Regional Hospital Council in 1966 indi-
do not need hospital care.
cated that 5.2 percent of the acute patient days could be eliminated by transfer
There have been two areas of development in home care during the past 25
of patients to an adequate home health program. A cost-effectiveness analysis
years, the hospital-based service and the community-based service. In the one
of health care facilities prepared by the Health Economics Branch of the Bureau
area the hospital extends some of its services into the community in the other
of Health Services of PHS, to be conservative, cut this rate in half and projected
a community agency, such as the visiting nurse association or the local health
that in 1970 about 5.8 million hospital days, equivalent to about 20,000 beds,
department, builds on its program of service to provide coordinated home care.
could be saved. Our study noted similar examples, as follows:
One study found that the hospital-based programs tend to specialize in relatively
-A Blue Cross plan in New York initiated a home care program in March 1960.
dynamic conditions which required a good deal of medical management, while
By 1967 there were 27 community nursing service agencies and 40 member hospi-
community-based programs tend toward more static chronic conditions which
tals providing preplanned, coordinated services at home. From March 1960 to
require rehabilitation more than therapeutic services. Whether or not the
May 1967, there were 15,261 registered home care cases. A study of the first 5,000
hospital or community agency is the administrator of the home care program, the
closed cases disclosed that the average number of inpatient days was about 23
hospital and the physician are the focal points in determining the extent of
while about 85 percent of the hospital stays were shortened by 1 to 4 weeks, or
patient needs. It is within the hospital that arrangements are made for patients
an average of about 23 days. According to the study, the home care program re-
potentially in need of home care. The physician plays the major role in identify-
duced the inpatient stay for the 5,000 patients by 50 percent.
ing and appraising need, establishing a care plan, delivering services, reapprais-
-In February 1960 a Michigan Blue Cross plan also undertook a 1-year dem-
ing the care, and discharging the patient.
onstration project for home care, involving 300 cases. These 300 cases showed an
Under earlier concepts of home care, only patients with long-term illnesses
average of 27 days of hospitalization prior to home care and an estimated 20 hos-
requiring multiple services were considered acceptable. A study of organized
pital days saved per case. The results of the program were SO impressive that the
home care in New York City and adjoining counties found that the home health
program was subsequently adopted on a permanent basis and, as of January 1972,
care population was (1) predominantly in the upper age bracket and (2) pre-
there were 78 hospitals participating in the program. During the period January
dominantly chronically ill or permanently disabled with little or no expectation
1963 through December 1969, there were about 9,800 discharged cases with an
of ultimate recovery or significant improvement. However, there has been some
average of 16.3 days of inpatient hospital days saved per case. A representative of
change in the earlier concept and patients who are convalescing from illnesses,
the plan advised us that these cases and days saved are applicable only to non-
those who usually receive treatment on an outpatient basis but are temporarily
Medicare patients. Data was not available for Medicare at the time of our
unable to do so, and certain patients with terminal illnesses can now be success-
contact.
fully cared for through coordinated home care programs. Other studies of small
-A Pennsylvania Blue Cross plan initiated a home care program in November
community home care programs disclosed that, although home care programs
1961. An analysis of 3,940 admissions to four participating hospitals' home care
are primarily involved with aged and chronically ill patients, often home care
departments between November 1961 and July 1970 showed that patients were
is used intermittenly only for one short period in the course of a patient's
transferred from the hospitals' medical, surgical, and pediatric departments to
illness.
the home care department an average of 12.9 days earlier than would have been
Though home care has a longstanding history, growth has been slow. The
likely without available home care. This amounted to a reduction of about 30 per-
familiar prototype of hospital-centered organized home care was established at
cent in inpatient days and resulted in 6.6 additional beds being made available
the Montefiore Hospital in New York City in 1947, but by 1966 PHS had identified
without a corresponding capital investment. Blue Cross concluded that its objec-
fewer than 70 home care programs. The implementation of the Medicare law
tives in supporting home care had been substantially realized. These objectives
(42 U.S.C. 1395) provided a sudden stimulus toward implementation of this
included improvement in the continuum of patient care and promotion of more
system of medical care. Under Parts A and B of Medicare, reimbursement is
economical use of existing hospital and other health care facilities through an
possible for home health services provided to eligible beneficiaries. By early
acceptable alternative method of delivering care.
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73
One specialty hospital, an institution for treating crippled children, has also
use of the program, the number of dialyses performed, and professional per-
demonstrated that home care could save inpatient days. The average length
sonnel required.
of stay at the institute has been reduced-from 49 days in 1962 to about 19 days
Technology, however, has produced an artificial kidney which can be used
in 1971. The reduction is due to many factors, including changes in treatment
in the home for long-term treatment of chronic kidney disorders. Home dialysis
procedures and a waiting list for admission, but also to a change in the attitude
has the advantage of being cheaper for the patient through the elimination of
of the doctors who recognize that the home is the best treatment place for the
both hospital costs and professional manpower. The average annual cost of home
patient. One specific item which contributed to the reduction is a special program
dialysis to 413 Veterans Administration (VA) patients in fiscal year 1971 was
instituted in June 1969 to train mothers of patients who had spinal fusions for
about $9,000 per patient. A person with a totally nonfunctional kidney is re-
scoliosis to care for the patients at home. A limited test comparing patients
quired to have three treatments weekly. The cost of each treatment at the VA
admitted prior to the training program with patients admitted after showed a
hospital was about $160. Thus, the annual inpatient program cost for a chronic
reduction in length of stay of about 5 days. In addition, the program has sig-
patient could total $25,000, or a difference of $16,000.
nificantly reduced the readmission of scoliosis patients for treatment of pressure
These statistics are further borne out by data from a Florida hospital. The
sores from body casts. Because of the decrease in average length of stay the
hospital reported that for fiscal year 1970 the average charge per inpatient treat-
hospital was able to admit 966 patients in 1971 compared with 366 admissions in
ment was about $113. About the same time the average charge for home dialysis
1962.
for the Florida Division of Vocational Rehabilitation was about $30, representing
-Another study, sponsored by HEW, to determine potential benefits of home
a savings of as much as $13,000 per year to a patient.
care, was conducted by a health research center located in Portland, Oregon. The
With improvements in, and simplification of, home dialysis equipment, home
study concerned the integration of home health services into a prepaid com-
dialysis is preferred for those patients who can manage such a program. Hospital
prehensive group practice plan. However, the services were added to a medical
facilities are thus made available to teach patients being prepared for home
care system with a history of very low hospital use and the study concluded that
dialysis and for backup care of home dialysis patients and for other patients
there was very little reduction in acute hospital days attributable to home care
not suitable for home programs.
services. A Kaiser-Permanente representative advised us that the benefits of home
Since home care has the apparent advantages of reducing the need for ex-
care are considered to be more social than economic.
pensive acute hospital beds and a lower cost of operation, why has the health
The significance of the benefits of home care programs can be illustrated by the
care delivery system failed to jump at an opportunity that can save money?
potential savings in days of hospital care on a national basis for diagnoses for
Though strongly endorsed, organized home care has not taken hold. We identified
which home care is applicable. Heart disease, cancer, and stroke are always
numerous explanations for this paradox, but the most common was lack of third-
numerically important diseases among patients on home care, along with diseases
party reimbursement of one aspect or the other of the care provided. For example,
of the nervous and digestive systems, diabetes, and injuries. We noted that these
although the Michigan Blue Cross plan has a home care program which has been
types of diseases accounted for an estimated 136 million inpatient days of care
demonstrated to save acute inpatient days, the actual number of patients which
for 1970. We recognize that not all patients with a particular diagnosis are can-
use the program is small, less than 1 percent of acute admission in participating
didates for home care. However, since our study noted that acute inpatient days
hospitals. One reason for this limited use is that Michigan Blue Shield does not
were reduced from 5 to 50 percent for patients in home care programs, we
pay for physician services in a home care program. A representative of Michigan
believe that additional bed use possible through even a 5-percent reduction in
Blue Shield advised us that this lack of coverage has merely been a matter of
acute inpatient days should help reduce the need to construct new acute beds.
priorities. Other types of coverage in their insurance package have been con-
Home care programs have been found to result in lower costs to patients,
sidered more important.
third-party payers, and the community as a whole. Home care costs are offset
Another example of the reimbursement problem is the experience of a New
by the shortening of the hospital stays and an apparent reduction in the fre-
Mexico hospital. The hospital instituted a home care program several years ago
quency and duration of home care patient readmission. We found specific data
but had to drop it because those individuals that needed the care could not afford
on the cost benefits of home care to be sketchy but noted several examples which
a $10 charge per visit and health insurance was not available. The administrator
demonstrate this point. Home care programs use various measurements in re-
advised us that the demand for home care still exists.
porting costs, such as cost per visit, cost per day, or total costs per case. In the
In addition, when home care is offered as a benefit in an insurance program, it
Michigan Blue Cross home care program, the average cost per day for home
is often offered on the basis of providing entitlement to a number of days of home
care in 1967 was $3.96 compared with an average cost of inpatient care of
care in exchange for one inpatient day. Therefore patients who anticipate re-
$51.34. The average number of acute hospital days saved at the $51.34 per day
admission to the hospital may be reluctant to forego hospital benefits.
rate due to home care resulted in a savings of about $550 per home care case.
Coverage of home care by insurance has been somewhat extended by its inclu-
The Pennsylvania Blue Cross coordinated home care study for the period
sion as a Medicare benefit. However, this coverage is limited to persons over age
November 1961 through July 1970 disclosed an average cost per patient day of
65, and, although a large percentage of home care patients are over age 65, there
$7.95. The value of the inpatient days saved from the home care program for
remains a large group of persons under 65 who could benefit from home care.
this period was estimated at $1.3 million, or $330 per case. While the national
Moreover, the Social Security Administration (SSA) reported in 1967 that less
average of hospital expenditures per patient day was rising from $38.91 in
than 1 percent of the persons ever enrolled for Medicare had used home care
1963 to $70.03 in 1969, the per day cost of the various home care programs noted
services. This is due, in part, to the stringent requirements governing the receipt
in our study ranged between $3 and $8.
of care under the program. We found that several authorities have attributed
A more significant example of the costs of home care as opposed to inpatient
the lack of home care programs to the complex requirements of such a program,
care is in the area of renal dialysis. Renal dialysis is a process of artificially
such as the degree of organization and inflexible application of definitions.
cleansing the body's blood when the kidney becomes incapable of doing SO. This
The physician is most important in instituting home care. A study of 83 physi-
can be done by means of an artificial kidney machine. In most cases when the
cians by research staff of Pennsylvania State University, in conjunction with a
kidney is totally nonfunctional, treatment is required three times weekly.
Pennsylvania hospital, found that among users and nonusers alike there was a
Inpatient renal dialysis programs are costly to operate in terms of space,
generally favorable attitude toward home care. Other studies indicate, however,
equipment, and manpower. For example, in 1971 the cost to construct a unit
that some physicians are highly resistant to home care. For example, a survey
capable of handling at least 10 patients simultaneously was estimated at $275,000.
of organized home care by the Columbia University School of Public Health and
Moreover, a study of dialysis services and facilities in the Philadelphia-South
Administrative Medicine found that there are some physicians who will not per-
Jersey metropolitan area showed that the annual cost to operate a dialysis bed
mit their patients to even be told of the existence of such programs.
ranged between about $13,000 and $64,000 per bed depending on the extent and
Several reasons for the physician's attitude were reported in studies by the
Blue Cross Association and in a study by a task force on health facilities by the
74
American Institute of Architects, as well as by various hospital officials. These
include:
1. Preference for the convenience of the hospital or clinic.
2. The physician's method of treatment does not often require an organized
home care program.
3. Physicians are unaware of the existence and value of home care.
4. Home care is seen as a disrupting influence on the doctor-patient rela-
tionship.
5. Physicians see home care as primarily a social welfare program.
There are also indications of resistance to home care by hospital administrators
because of low occupancy in some hospitals and time and staffing problems. We
were advised that low occupancy in hospitals is a problem that seriously affects
use of any type of outpatient service. Other problems affecting home care
include:
1. The fact that home care is restricted to those discharged from acute
care.
2. The physical condition of the home and the family situation.
3. The process of care may be disorganized.
After a decade of experience, home care programs have been found to effect
a reduction in the length of acute inpatient stays for specific ages and diagnostic
categories of patients. Columbia University's study of the many problems restrict-
ing home care programs concluded that home care is a valuable health care
resource and suggested to various authorities, including the different levels of
government, that:
1. Community-based home health agencies enlarge their scope and be-
come multiservice, health-related home care agencies.
2. It is time to penalize hospitals which relegate home care program of-
fices to some inaccessible and invisible location in the hospital.
3. Medical staffs be prohibited from barring patients from access to home
care services
4. Additional education of family members in how to care for the sick
and aged at home is needed.
5. Because much unnecessary institutional placement of the aged results
from lack of relatives or others to help with simple activities of daily living,
local governments study tax incentives to encourage families to care for the
aged sick at home or in small, group-living arrangements.
6. Medicare provide for approved, multiservice, home health agencies to
accept patients directly in lieu of unnecessary hospital or ECF admission.
Over 11 percent of the population are limited in their activities due to chronic
conditions. In addition, science and technology are causing the average age of
population to increase and thereby are also increasing the proportion of the
population susceptible to chronic illness. The AHA Report of a Conference on
Care of Chronically Ill Adults concluded that the high cost of hospital care,
changing housing and family patterns, the inability of the medical profession to
deal effectively with chronic diseases, and a significant increase in the number
of old people should stimulate the growth of various forms of community care.
HOME HEALTH ACTIVITIES TRAINING SESSION
LIBRARY
GERALD
April 20 - 21, 1976
OUTSIDE FACULTY AND RESOURCE PERSONS
OFOS
Mr. John P. Byrne
President
National Association of Home Health Agencies
St. Louis, Missouri
Ms. Margaret Lewis
Executive Director
National Association of Home Health Agencies
Denver, Colorado
Dr. Hugh H. Rohrer
Director of Health
Peoria Health Department
Peoria, Illinois
Mr. Tommy L. Kubach, Jr.
Division of Health
State of Missouri
Jefferson City, Missouri
Ms. Joan E. Caserta
Director
Department of Home Health Agencies and
Community Health Services
National League for Nursing
New York, New York
Ms. Nancy L. Tigar
Assistant Director
Department of Home Health Agencies and
Community Health Services
National League for Nursing
New York, New York
Ms. Elsie Griffith
Executive Director
Visiting Nurse Association
Dallas, Texas
Mr. Donald Christ
Associate Director
Visiting Nurse Association
Rochester, New York
Mr. Richard DeVito
Head, Cost Reimbursement Department
Simione & Simione
Certified Public Accountants
Hamden, Connecticut
1970 Data
UTA PREFERENCE ATION RY STATE AND HFW REGION
Preference
Population
% of Total Pref. Pop.
TOTALS
of Total
State
Region
State
Region
U.S. Population
REGION I
aged medically Indigent
137
234,799
.91
5.83
Connecticut
112,091
.44
1.49
Maine
104,274
.40
.49
Massachusetts
18,434
.07
2.80
New Hampshire
.36
Rhode Island
.47
Vermont
.22
REGION II
529,558
2.05
12.50
New Jersey
436,987
1.69
3.53
New York
92,571
.
.36
8.57
Puerto Rico } H4:
Virgin Islands
1-H-
REGION III
1,125,143
4.36
11.52
Delaware
.27
Dist. of Col.
.37
Maryland
41,881
.16
1.93
Pennsylvania
45,059
.17
5.30
Virginia
530,285
2.06
2.29
West Virginia
507,918
1.97
.86
REGION IV
10,383,996
40.25
15.67
Alabama
868,853
3.37
1.69
Florida
2,658,311
10.30
3.34
Georgia
992,983
3.85
2.26
Kentucky
1,151,801
4.46
1.58
Mississippi
1,629,370
6.32
1.09
North Carolina
1,322,890
5.13
2.50
South Carolina
849,684
3.29
1.26
Tennessee
910,104
3.53
1.95
REGION Y
2,139,735
8.30
21.68
Illinois
795,343
3.08
5.47
Indiana
170,082
.66
2.56
Michigan
149,715
.58
4.37
Minnesota
512,483
1.99
1.57
Ohio
147,312
.57
5.24
Wisconsin
364,800
1.42
2.17
REGION VI
5,655,785
21.92
10.01
Arkansas
1,268,219
4.91
.95
Louisiana
944,029
3.66
1.79
New Mexico
167,962
.65
.50
Oklahoma
936,027
3.63
1.26
Texas
2,339,548
9.07
5.51
REGION VII
3,891,036
15.08
5.53
Iowa
730,664
2.83
1.39
Kansas
721,163
2.80
1.11
Missouri
1,976,270
7.66
2.30
Nebraska
462,939
1.79
.73
REGION YIII
558,532
2.17
2.74
Colorado
89,824
.35
1.09
Montana
69,869
.27
.34
North Dakota
129,293
.50
.30
South Dakota
220,639
.86
.33
Utah
23,963
.09
.52
Ivoming
24,944
.10
.16
REGION IX
1,109,962
4.30
11.31
American Samoa
Arizona
115,488
.45
FORD
.87
California
994,474
3.85
9.82
Guam
Hawaii
UBRARY
.38
Nevada
.24
Trust Territory
REGION X
170,743
.66
3.21
Alaska
29,945
.12
.15
Idaho
22,774
.09
.35
Oregon
89,154
.34
1.03
Washington
28,870
NUMBER OF
PREFERENCE COUNTIES
PERCENT OF PREFERENCE
COUNTIES
TOTALS
With H.H.A.
Without H.1
A.
TOTAL
% With
Without
TOTAL
REGION I
5
3
8
.36
.22
.57
Connecticut
Maine
2
2
4
.14
.14
.29
Massachusetts
2
1
3
.14
.07
.22
New Hampshire
1
0
1
.07
--
.07
Rhode Island
Vermont
REGION II
5
1
6
.36
.07
.43
New Jersey
3
0
3
.22
.22
New York
2
1
3
.14
.07
.22
Puerto Rico
Virgin Islands
REGION III
51
25
76
3.66
1.79
5.45
Delaware
Dist. of Col.
Maryland
2
0
2
.14
--
.14
Pennsylvania
3
0
3
.22
--
.22
Virginia
40
1
41
2.87
.07
2.94
West Virginia
6
24
30
.43
1.72
2.15
REGION IV
211
244
455
15.13
17.49
32.62
Alabama
35
4
39
2.51
.29
2.80
Florida
14
26
40
1.00
1.86
2.87
Georgia
1
91
92
.07
6.52
6.59
Kentucky
19
59
78
1.36
4.23
5.59
Mississippi
73
2
75
5.23
.14
5.38
North Carolina
11
38
49
.79
2.72
3.51
South Carolina
15
11
26
1.08
.79
1.86
Tennessee
43
13
56
3.08
.92
4.01
REGION V
61
71
132.
4.37
5.09
9.46
Illinois
16
28
44
1.15
2.01
3.15
Indiana
2
S
10
.14
.57
.72
Michigan
3
10
13
.22
.72
.93
Minnesota
16
17
33
1.15
1.22
2:73
Ohio
7
1
8
.50
.07
.57
Wisconsin
17
7
24
1.22
.50
1.72
REGION VI
134
203
337
9.61
14.55
24.16
Arkansas
62
4
66
4.44
.29
4.73
Louisiana
27
12
39
1.94
.86
2.80
New Mexico
2
12
14
.14
.86
1.00
Oklahoma
37
19
56
2.65
1.36
9.01
Texas
6
156
162
.43
11.18
11.61
REGION VII
51
220
271
3.66
15.77
19.43
Iowa
16
36
52
1.15
2.58
3.73
Kansas
19
48
67
1.36
3.44
4.80
Missouri
14
79
93
1.00
5.66
6.67
Nebraska
2
57
59
.14
4.09
4.23
REGION YIII
16
66
82
1.15
4.73
5.88
Colorado
3
9
12
.22
.65
.86
Montana
1
10
11
.03
.72
.78
North Dakota
1
16
17
.07
1.15
1.22
South Dakota
9
27
36
.65
1.94
2.58
Utah
0
3
3
1
---
.22
.22
Wyoming
2
1
3
.14
.07
.22
REGION IX
4
7
11
.29
.50
.79
American Samoa
Arizona
1
2
3
.07
.14
.22
California
3
5
8
.22
.36
.57
Guam
J
Hawaii
Nevada
Trust Territory
REGION X
3
14
17
.22
1.00
1.22
Alaska
0
8
8
.57
.57
--
Idaha
0
3
3
.22
Oregon
3
0
3
22
22
-
HEALTH.
OF
DELICATION
AMERICA AND
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
S
OFFICE OF THE SECRETARY
U.S.A.
WASHINGTON, D.C. 20201
Office of Human Development
Rehabilitation Services Administration
MAR 10 1976
The Honorable Spencer C. Johnson
Associate Director of the
Domestic Council
The White House
Washington, D.C. 20500
Dear Mr. Johnson:
Thank you for your letter of March 1, 1976, concerning the proposed
changes to the Medicaid regulations published in the Federal Register,
August 21, 1975.
The matters you mentioned pertain to the Social and Rehabilitation
Service of this Department. I am, therefore, referring your letter to
Mr. Don I. Wortman, Acting Administrator of that office.
I feel sure that you will be hearing from Mr. Wortman shortly.
Very sincerely,
andrew S. adams
Dr. Andrew S. Adams
Commissioner of Rehabilitation Services
FORD & LIBRARY CERALD
4/8
sent copies of emesponderee as they had no
record of to letter wortman (Attn, Bernice gibbs 245-0373)
soc & Rehab service
HEW
Rm 5217 S. Bldg
DC 20201
of Home HealthCare medicaid
leg.
THE WHITE HOUSE
WASHINGTON
March 1, 1976
Dear Mr. Adams:
I was visited recently by Mr. John Byrne, President
of the National Association of Home Health Agencies
concerning the proposed changes to the Medicaid regu-
lations published in the Federal Register, August 21,
1975.
Mr. Byrne made the following recommendations regarding
this issue:
1. That the Department of Health, Education and
Welfare withdraw its proposed regulations
related to home health care services under
Medicaid.
2. That a national commission be established
under the President's Domestic Council
for the purpose of establishing standards
for home health care to be applicable
to both Medicare and Medicaid programs. This
would include examination of the appropriate
role of home health services in the health
delivery system.
3. That the Secretary of HEW authorize appropriate
studies of the quality of home care provided
by all types of agencies.
I would appreciate it if you could provide me with
a status report as it relates to this issue and
any comments you might have about the recommendations
mentioned.
Sincerely, Spencer John
SPENCER C. JOHNSON
Associate Director of the
Domestic Council
Mr. Andrew S. Adams, Administrator
Rehabilitation Services Administration
Department of Health, Education and Welfare
GERALD FORD LIBRARY
Switzer Building, 330 C Street, S.W.
Washington, D.C. 20201
NAHHA
National Association of Home Health Agencies
John P. Byrne, M.H.A.
President
1129 Macklind Avenue
St. Louis, Missouri 63110
314-533-9680
February 5, 1976
Mr. Spencer Johnson
The Domestic Council
Room 237
Old Executive Office Building
The White House
Washington, D. C.
Dear Mr. Johnson:
We are pleased that your schedule will permit you to see us on
behalf of the National Association of Home Health Agency membership. The
issue which we wish to discuss is the proposed changes to the Medicaid
regulations published in the Federal Register, August 21, 1975. It is my
understanding they may be soon signed out by Secretary Matthew's office.
Fundamental problems inherent to the proposed changes:
1. Pre-emption of state law - i.e., for-profit home health
agencies need not be licensed to be a Medicaid provider;
2.
Double standard level will be introduced, one for Medicare
provider, another for Medicaid;
3. Proliferation of single service agencies.
Accompanying me to our 1:45 p.m. meeting on February 10, 1976,
will be:
Mr. Dan MacDonald
Consultant to Visiting Nurse Association of Greater St. Louis
(Social Security No. 302-16-9019)
Mr. John Grupenhoff
Consultant to N.A.H.H.A.
(Social Security No. 268-28-4099)
We will be entering through the 17th Street N.W. Gate.
-2-
Mr. S. Johnson
February 5, 1976
A more detailed packet of background information on this matter
will be sent tomorrow.
Look forward to meeting you on Tuesday.
Sincerely,
Maxm John P. Byrne, M.H.A.
President
JPB:rp
(Soc.Sec. # 294-28-9306)
CC: Mr. J. Grupenhoff
GERALD FORD (VBRARY
the
Bennett (Troup/
Health Services
407 N Street, SW
Washington. DC 20024
2O2/484-3344
April 21, 1976
Honorable Frank E. Moss
Dirksen Senate Office Building
Room 3121
Washington, D.C. 20510
Dear Ted:
For many years now, you, your staff, and my clients
and I have worked closely together on common problems
in the field of aging. I'm concerned right now be-
cause someone is being led down the primrose path
(undoubtedly the elderly and the taxpayer) of what
are purported to be "issues" in home health care
delivery.
I refer specifically to your "undated" recent joint
memorandum to Secretary David Mathews concerning the
"Proposed Regulations Mandating the Participation of
For-Profit Home Health Agencies in Medicaid" (hereafter
referred to as Moss/Pepper Letter #2).
Someone should be brought up to date on the real issue:
"How will this nation's elderly ever receive home ser-
vices provided appropriately, accessibly and at a price
the people and government can afford under the present
uncontrolled, unregulated cottage industry?" I say
"cottage industry" because it is a small and declining
industry - from 2,248 certified agencies in December,
1974 to 2,209 in February, 1976 - figures which I trust
your staff receives regularly.
Let's face the facts
home health care has never been
a viable mode of health delivery and the attempt to
hold up the final Medicaid regulations is only delaying
services to those in need.
It would seem that your Subcommittee and your staff
should look into a number of vital facts recently
brought to light that tell the true story not a lop-
sided memorandum ("taken from the transcript") produced
FORD NERARY
Senator Moss
page 2
April 21, 1976
at taxpayer's expense and intended to present a
biased viewpoint of the wrong issues in home health
care.
#1. Perhaps your staff is not aware of a recently
published study by one of your October 28 witnesses,
Amitai Etzioni, entitled "Profit in Not-for-Profit
Institutions.' As Dr. Etzioni states: "A closer
look at current regulations of the financial dealings
of not-for-profit corporations suggests, however, that
a decision to bar for-profit corporations in the human
services would not suffice to eliminate profit-making
abuses. The reason is that omissions, ambiguities
and loopholes in the laws and regulations governing
not-for-profit corporations presently make it possible
for the trustees and staff of not-for-profit corpora-
tions to engage in a variety of financial practices
which bring them personal profits over and above fees,
salaries and fringe benefits due them for work performed."
He goes on to point out four avenues for profit-
making in not-for-profit corporations: (1) staff
income tied to entrepreneurship rather than to work,
(2) self-dealing, (3) real estate transactions, and
(4) unreasonable and uncustomary fees, salaries and
fringe benefits. The report makes interesting reading!
(Unbiased, because Dr. Etzioni before your Joint Commit-
tee presented testimony of an entirely different nature.)
#2. Having checked first with you, Senator Lawton Chiles
chaired a hearing in Tampa, Florida, last week for the
Senate Government Operations Subcommittee on Federal
Spending Practices on the subject of Medicare-only
agencies in that state. Private non-profit home health
agencies (proprietaries have not yet attained Medicare
status in Florida) are accused of "ripping off" the
Medicare program through limiting their services to
Medicare eligibles only, since the Medicare program
reimburses all "costs". The "costs" that Medicare is
reimbursing to the private non-profits are inflated
salaries ($49,000 to a husband-wife-daughter partnership),
employee pension funds, overutilization of visits, large
expense accounts. Medical directors of some of these
non-profit agencies are variously earning $12,000 for
an eight hour week ($60,000 yearly full time equivalent)
and $19,200 for a ten hour week ($76,800 yearly full
time equivalent). It is interesting to note that a
large nursing association recently formed a special
interest committee which, in effect, put the seal of
approval on so-called "private non-profit" offices -
some of which are being formed by former Blue Cross
auditors. These are not illegal practices as the terms
Senator Moss
page 3
April 21, 1976
"non-profit" and "cost reimbursement" are currently
defined. In fact, it is the current law that has
motivated this kind of "rip off".
#3. And while we're about it, what about the defi-
nition of not-for-profit? The Internal Revenue Ser-
vice says: In a booklet entitled, "How to Apply for
Recognition of Exemption," the IRS defines a 501 (c) (3)
organization as one organized and operated exclusively
for one or more of the following purposes: charitable,
religious, scientific, testing for public safety, lit-
erary, educational, or prevention of cruelty to child-
ren or animals. A 501 (c) (4) organization is one organ-
ized and operated exclusively for the promotion of
social welfare, to further the common good and general
welfare of the people of the community, or to improve
the welfare of mankind. In both cases, state law
must be adhered to.
All non-profits can also be classified as:
501 (c) (5) - Labor agricultural and horticultural
organizations.
501 (c) (6) - Business leagues, chambers of commerce,
real estate boards, boards of trade.
501 (c) (7) - Social and recreation clubs, and
501 (c) (19), 501 (c) (8), 501 (c) (10), etc.
You pays your money and you takes your choice -- what
kind of a non-profit would you like to be?
As most taxpayers believe and probably as the Church
of Latter Day Saints defines it, not-for-profit means
church-sponsored or community-based agencies using
both charity and tax dollars in a judicious, effective,
necessary manner.
#4. Justifiably, the public expects quality services.
VNA's (the true non-profits) testified in the February
24 hearings before Mr. Pepper's Committee that there
is no difference in the quality of services delivered
by not-for-profits and the for-profits. The same
statement was made before Senator Chiles' April 12
hearing.
One of your Committee's favorite witnesses writes that
even in the nursing home field, there is a widespread
belief that the difference in quality is not linked to
the tax status of the facility (see Adelaide Mendelson:
Tender Loving Greed, page 195).
Senator Moss
page 4
April 21, 1976
The running battle that Representative John Moss of
the House Commerce Oversight Subcommittee has with
Secretary Mathews on implementing utilization control
in state Medicaid programs will not be successfully
resolved until home health care is made a viable part
of that program. (Already, there has been a District
Court ruling that a patient institutionalized for lack
of definitive post-hospital plans may not have this
institutionalization reimbursed by Medicare.)
Why not check with the nearby PSRO in Anne Arundel
County, Maryland, where there is not home health
agency availability (there is a nurses' registry
opening up); the physician has no place to place the
patient after the UR Committee completes its evalua-
tion. Great way to appropriately treat the elderly!
#6. It now seems that few candidates for office this
November would deny that "fiscal responsibility in
government" is the byword, so let's look at a few dol-
lar figures.
The fact that services are unavailable without proprie-
tary inclusion is documented. In fiscal 1974, Medicaid
home health expenditures totalled $31,000,000 out of a
total Medicaid expenditure of $10.6 billion, or three-
tenths of one percent. (Comparable figures for the
Medicare program are $98,500,000 out of a $10.7 billion
total, or nine-tenths of one percent.) Without inclusion
of proprietaries, the federal government would have to
fork over millions of dollars for startup and expansion
of non-profit home health agencies. (And before that,
the definition of a non-profit would have to be clarified.)
Two home health care providers alone could save the federal,
state, and local taxpayers millions upon millions of dollars.
Homemakers Home and Health Care Services, Inc. with 52,000
employees (not 30,000 as erroneously stated in the Moss/
Pepper Letter #2) and Medical Personnel Pool with 30,000
employees could make your Committees heroes with the Budget
and Appropriations Committees! All of these quality ser-
vices at the right price are available to the government
at absolutely no cost.
#7. The title of the Moss/Pepper Letter #2 is misleading.
These proposed regs do not mandate inclusion of proprie-
taries. (And the Congress never intended to exclude them.)
It merely removes the federal restriction of licensure by
the state in order for the proprietary agency to participate.
Senator Moss
page 5
April 21, 1976
The non-profits are already participating without
licensure, so that this proposal equalizes what has
been a discriminatory practice. It should be noted
that, while the states ought to retain the right to
allow or disallow for-profit participation, the states
have abrogated their responsibilities to their popula-
tions by allowing agencies to deliver health care with-
out licenses! The private sector of home health care is
totally unregulated. The for-profits have had to set
up their own standards in the absence of state licensure
laws. It should be up to the state to elect to certify
a licensed provider for participation in Medicaid, but
all providers must, at the least, be licensed. There
are, today, after ten years, only fourteen states with
home health agency licensure laws. A paltry number!
Barber shops, plumbers, hairdressers, must be licensed,
but unlicensed home health agencies can drop IV's into
people.
#8. What is so secretive about the October 28 hearing
report? Why is it not available after six whole months?
Why are the testimonies of only one side presented in
the Moss/Pepper Letter #2 and no testimony was included
of any for-profit home health agency representatives on
the issue of proprietary participation, leaving that
advocacy role entirely to the Commissioner of Medicaid?
Can this be a biased memo clothed in the legitimacy of
being an "analysis of issues
taken from the transcript?"
In fact, for the first time, Medicaid is proposing to
have regulations that will give the home health program
some impetus and remove it from the shackles of Medicare
regulations, which were adopted by the state Medicaid
programs, by default, absent definitive federal Medicaid
regs. One simple example: these proposed regs mandate
training for home health aides, something which should
have been done a long time ago. We hope you will give
this some thought. And then one of your witnesses has
the naivete to declare that these regulations would set
up a "two-tiered delivery system." Well, I should hope
they would -- if your witnesses would care to research
the difference between the needs of a Medicare benefi-
ciary and a Medicaid client. Never was Medicaid intended
to restrict home care to purely "skilled" services. Ap-
propriate services to the elderly have been held back
and delayed. Is this fair to those in need? (While we'me
correcting your memo, page 8 states that the physician
decides which agency should provide treatment. Not so.
Senator Moss
page 6
April 21, 1976
The hospital social services director and discharge plan-
ning director make the decisions.)
Your Committee and staff may or may not be aware of a
number of home care experimental programs (under Section
222 of P.L. 92-603) successfully contracting with for-
profit agencies. To quote from Mrs. Joan Quinn, Director
of the Triage Project in Connecticut, "We could not run
this experiment without the inclusion of Homemakers-Upjohn
and Medical Personnel Pool." And while we're at it, I'm
attaching what might be considered "unsolicited testimon-
ials" from Salt Lake City, Utah (Salt Lake Community Nurs-
ing Service, Primary Children's Medical Center and Latter
Day Saints Hospital) that surely you or your staff could
easily confirm.
Over the years in our working together, Ted, I've always
prided myself in bringing before you constructive, inno-
vative approaches to providing quality care for the el-
derly. I would hope that you and your Committee will
continue to look for better ways of serving our citizens
and not be sidetracked because of an attractive political
issue that has no factual basis and which has, in fact,
undermined this program to the extent of hurting the
elderly in this country.
Sincerely,
Babily Berkeley V. Bennett
President
BVB:km
Attachments
P.S. At the hearings, staff commented that you had a (1)
list of questions for Mr. Wilsmann which would be mailed
to him to be answered in writing. Six months later, no
letter, no questions. (2) We were also requested to
supply information on all offices via a pending question-
naire from your staff. We agreed to comply. To date, no
questionnaire, whatever its nature may have been. (3)
Our offer to expose your staff to how a home health agency
is operated via visits to offices any where in the country.
Truly an opportunity to learn. No takes, however.
CC: Sec. of DHEW; Major Congressional Distribution; All HEW
Assistant Secretaries; State Governors; Regional HEW Offices;
State Medicaid Directors; Other HEW Interested Persons; AARP/
NRTA; National Council of Sr. Citizens; Washington Post;
Washington Star; N.Y. Times; Wall Street Journal; National
Journal; National Home Health Asso.
JOHN L MC CLELLAN, ARK., CHAIRMAN
WARREN G. MAGNUSON, WASH.
MILTON R. YOUNG, N. DAK.
JOHN C. STENNIS, MISS.
ROMAN L HRUSKA, NEBR.
JOHN 0. PASTORE. R.1.
CUFFORD P. CASE, N.J.
ROBERT C. BYRD, W. VA.
HIRAM L FONG, HAWAII
GALE W. MC GEC, WYO.
EDWARD W. BROOKE, MASS.
MIKE MANSFIELD, MONT.
MARK O. HATFIELD, OREG.
Mnited States Senate
WILLIAM PROXMIRE, WIS.
TED STEVENS, ALASKA
JOSEPH M. MONTOYA. N. MEX.
CHARLES MC C. MATHIAS, JR., MD.
DANIEL K. INDUYE, HAWAII
RICHARD S. SCHWEIKER, PA,
COMMITTEE ON APPROPRIATIONS
ERNEST F. HOLLINGS, S.C.
HENRY BELLMON, OKLA.
BIRCH BAYH, IND.
WASHINGTON, D.C. 20510
THOMAS F. EAGLETON, MO.
LAWTON CHILES, FLA.
J. BENNETT JOHNSTON, LA.
April 1, 1976
WALTER D. HUDDLESTON, KY.
JAMES R. CALLOWAY
CHIEF COUNSEL AND STAFF DIRECTOR
Honorable Marjorie Lynch
Under Secretary
Department of Health, Education & Welfare
Washington, D.C. 20201
Dear Marge:
I understand that implementation of the Home Health Care Program
in HEW is moving along very, very slowly. As you know, this committee has
expressed a great deal of support for home health programs and feels that
they should get underway in an expanding effort as soon as possible.
Unfortunately, it appears as though the regulations and guide-
lines for Home Health Care have been written, re-written, and constantly
delayed.
It is time we got this program off the ground and actively moving.
All of the evidence that we have indicates that we can save a large amount
of scarce resources by implementing this program properly. In addition,
with Medicare and Medicaid costs rising so rapidly, it appears as if Home
Health Care could at least be a tool for helping to control these costs.
Your prompt attention to this will be greatly appreciated.
Best personal regards.
Sincerely,
Warren G. Magnuson,
Chairman, Subcommittee on
Labor-Health, Education,
and Welfare
WGM:Dh
FA:HEW(Re:Medicaid Home Health Regs.)
April 2, 1976
The Honorable F. David Mathews
Secretary
Department of Health, Education, and Welfare
330 Independence Avenue, S. W.
Washington, D. C. 20201
Dear Mr. Secretary:
Interested constituents have brought to my attention the
fact that although the Medicaid Home Health Regulations
were proposed back in August of last year and are in a
position to be implemented, no action has been taken thereon.
From my discussion of these Regulations and the desirability
of their implementation with those who appear to be in a
position to be able to objectively evaluate them, I feel
such Regulations should be implemented and would accordingly
urge such action.
With best regards,
Sincerely,
GARRY BROWN
GB:d1d
LLOYD BENTSEN
COMMITTEES:
TEXAS
FINANCE
PUBLIC WORKS
JOINT ECONOMIC
United States Senate
WASHINGTON, D.C. 20510
April 21, 1976
The Honorable David Mathews
Secretary of H.E.W.
U. S. Department of Health, Education
and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Mr. Secretary:
I have been concerned for some time at the delay in the
publication of the regulations on home health care, which
were first proposed by your Department on August 21, 1975.
I recognize that there are many serlous issues involved In
these regulations, but it appears to me that eight months
is more than sufficient time to have these difficulties Ironed
out and finally approved.
Dally we hear reports of the escalating costs of health services,
Considering the urgency of that problem and the potential for home
health care to make a significant impact upon health costs, let
me urge you to move these regulations out as rapidly as possible.
Sincerely,
Lloyd Bentsen
bcc: Mr. Berkeley Bennett
Bennett Group Health Services
407 "N" Street, S.W.
Washington, D.C. 20024
HARRISON A. WILLIAMS, JR., N.J., CHAIRMAN
JENNINGS RANDOLPH, W. VA.
JACOB K. JAVITS, N.Y.
CLAIBORNE PELL, R.I.
RICHARD S. SCHWEIKER, PA.
EDWARD M. KENNEDY MASS.
ROBERT TAFT, JR., OHIO
GAYLORD NELSON, WIS.
J. GLENN DEALL, JR., MD.
WALTER F. MONDALE, MINN.
ROBERT T. STAFFORD, VT.
THOMAS F. EAGLETON, MO.
PAUL LAXALT. NEV.
United States Senate
ALAN CRANSTON. CALIF.
WILLIAM D. HATHAWAY, MAINE
JOHN A. DURKIN, N.H.
COMMITTEE ON
LABOR AND PUBLIC WELFARE
DONALD ELISBURG. GENERAL COUNSEL
MARJORIE M. WHITTAXER, CHIEF CLERK
WASHINGTON, D.C. 20510
April 14, 1976
The Honorable F. David Mathews,
Secretary, Department of Health,
Education and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Mr. Secretary:
Regulations proposed by the Social and
Rehabilitation Service on August 21, 1975, would
increase the number of proprietary home health
care providers eligible to participate in Medicaid
programs. The SRS states, in the preface to these
regulations, "The purpose of the proposed regulations
is to remove certain restrictions and ambiguities
in current regulations which have prevented full
realization of the benefits of home health services
in State Medicaid programs
"
"Currently, participation under Medicaid as
a home health service provider is restricted to those
agencies which meet the statutory Medicare require-
ments, i.e., they must provide skilled nursing services
and one other service. This has meant that small
visiting nurse associations are unable to participate
:
"A major additional change
is removal of
the current limitation which restricts proprietary
agencies from qualifying
unless the State licenses
such agencies.'
Mr. Secretary, by making funding for medical
care at long last available to the elderly and the
needy, we have greatly increased the demand for such
care. If we simultaneously restrict the supply of
health care providers, either because of a bias
against private suppliers, or by waiting for states
which have not acted on licensing legislation, we
guarantee an increase in the cost of such care. It
is ironic that a program to improve health care seems
to be increasing demand on the one hand and restraining
supply on the other. People who used to be unable to
afford health care may now have the funds, but the
suppliers are forbidden to sell their services.
Secretary Mathews
Page 2
I hope that the proposed regulations of
August 21 can be finalized shortly. If you are
experiencing questions as to the Department's
statutory authority in this area, or other difficulties,
please let me know.
With every good wish.
Sincerely,
Robert Taft, Jr.
United States Senator
MARVIN L. ESCH
DISTRICT OFFICES:
REPRESENTATIVE IN CONGRESS
200 EAST HURON
20 DISTRICT, MICHIGAN
ANN ARBOR, MICHIGAN 48108
PHONE: (313) 605-0618
COMMITTEES
EDUCATION AND LABOR
Congress of the United States
9 EAST FRONT STREET
SCIENCE AND TECHNOLOGY
MONROE, MICHIGAN 48161
House of Representatives
PHONE: (313) 242-7580
WASHINGTON OFFICE:
2353 RAYBURN HOUSE OFFICE BUILDING
15273 FARMINGTON ROAD
WASHINGTON, D.C. 20515
Mashington, D.C. 20515
LIVONIA, MICHIGAN 48154
PHONE: (202) 225-4401
PHONE: (313) 261-6080
May 6, 1976
Secretary David Mathews
Department of Health, Education and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Secretary Mathews:
I understand that the regulations issued on Thursday, August
21, 1975 regarding "Home Health Services", are presently before
you for issuance.
I have read the joint letter dated December 12, 1975 you re-
ceived from Senator Moss and Congressman Pepper. Before you make
your decision, I would like to set the record straight regarding
the legislative intent of P.L. 90-248. From an inspection of the
legislative history, I find nothing which crystalize the issue as
clearly as the joint letter stated, or even crystalize the issue
at all. In fact, the legislative history in this area is without
any statement of intent.
Therefore, I believe the joint letter, by stating that the
regulations "are not in concert with the Congressional intent"
overstates the legislative history. I appreciate this opportunity
of setting the record straight.
With best wishes, I am
Sincerely,
Marvin L. Esch
Member of Congress
MLE:cv
April 13, 1976
Honorable David Mathews, Secretary
Department of Health, Education and Welfare
330 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Mr. Secretary:
It is my understanding that for some years now the Department
of Health, Education and Welfare has been working toward the pro-
mulgation of regulations for Medicaid home health care.
From my activities and interests, both in Committee and in
my home district, there is a need for expanded services to the
elderly and disabled. The Proposed Regulations published in the
August 21, 1975 Federal Register address several vital issues:
1. the establishment of standards compatible with
Medicare standards;
2. the establishment of home health aide training
standards; and
3. the inclusion of proprietary home health agencies
that meet the above standards.
In particular, I believe that the present exclusion of pro-
prietary home health agencies works to the disadbantagesof both
the patient and the government from the standpoint of accessibility
of services to the patient and lower costs to the government. As
in all other classes of health providers covered by Medicare and
Medicaid, whoever meets the standards is eligible to participate
as a provider, except in the home health program.
Home health care needs to be a significant part of our services
to the elderly and disabled, and soon. Kt is my hope that you will
give consideration to promulgating the regulations I understand are
presently in your office.
Sincerely,
MARILYN LLOYD
Member of Congress
MI./l-h
Home Health Cae
70x- decise puper
on H HC policy for DHEW
FORD LIBRARY
gr.
The Science & Health Communications Group, Inc.
A Subsidiary:
Science & Health Publications
John T. Grupenhoff, President
March 5, 1976
Mr. Spencer Johnson
The Domestic Council
The White House
Washington, D. C.
Dear Spencer,
Just a note to thank you for your marvelous courtesy you extended
to me, John Byrne, and Dan McDonald at the meeting about home health
care. I deeply appreciated your asking Gene Haislip to attend.
Obviously, whatever you did after the meeting had a quick and profound
effect. We've been told that the regulations have been withdrawn, and
"sent back to the drawing board".
Good luck in your new job--if I can be helpful in any way, please
don't hesitate to call on me.
Sincerely,
G John T. Grupenhoff
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1740 N Street, N.W., Washington, D.C. 20036, Area Code 202-659-1336