tained through the provision of community participation in the station program and patient and member participation in the community life for enhancement of morale and well-being.

Opportunity is afforded organizations and individuals on a local and national basis to participate in appropriate phases of the VAVS program subject to Veterans' Administration supervision and its need for volunteer assistance. Equal opportunities commensurate with Veterans' Administration needs are provided all organizations to share in the program under their own identities and commensurately with their volunteer resources.

Volunteer aid is supplemental to the essential personnel, buildings, and equipment provided by the Federal Government for the care of patients and members and will be largely represented by assistance through personal services. (For a fact sheet on the Veterans' Administration Voluntary Service, see appendix H.)

A VAVS advisory committee is established at central office level, and at all Veterans' Administration stations in which patients are hospitalized and/or members domiciled, to advise in the planning, integration, and coordination of the VAVS program. A VAVS advisory committee may be established at regional offices with medical facilities, Veterans' Administration out-patient clinics, where established, and the Veterans Benefits Office, following approval of the Chief Medical Director.

VAVS National Advisory Committee: This committee is composed of representatives and alternate representatives of national organizations accepted for membership and assists the Director, Special Service, in an advisory capacity in coordinating on a national level the overall plans and general policies for participation of national and local voluntary service organizations (service, welfare, fraternal, church, veterans, club and civic groups) in the VAVS program.

The VAVS station advisory committee serves, first, in an advisory capacity in coordinating on the local level the established plans and policies for community volunteer participation in programs for the patients and members and for participation of the committee's respective organizations in the VAVS program; and, second, in obtaining from the respective organizations volunteer assistance in accordance with needs for such assistance as expressed by the Veterans' Administration station.

Studies of the role of voluntary community participation in Veterans' Administration programs for aging patients and members are being conducted by special study groups of the VAVS National Advisory Committee.8

11. Planning for the patient's discharge

Most patients who have completed their course of hospital treatment readily return home to resume their respective positions in the community. Even in the case of the severely disabled, the problem of readjustment to home and community living is very often promptly resolved following rehabilitative efforts of greater or lesser degree. However, there are some individuals, comprising, for the most part, patients in the older age groups, who present home and community

Preliminary reports of these studies are published in Veterans' Administration, Depart ment of Medicine and Surgery, Information Bulletin: Special Service (Washington. October 22, 1956), 40 pages.

problems of such serious import, that all normally available efforts to provide adequate care following discharge are to no avail. In such instances, the patient often suffers an unwarranted prolongation of his stay in the hospital to the extent of many months or even years. The plight of these individuals, who have reached a stage where hospitalization is no longer necessary, yet who cannot be discharged because their families or communities are not prepared to accept their return, has become one of the most challenging problems of the Veterans' Administration. It was for the purpose of meeting this challenge that the program of planning for the patient's discharge was conceived and developed.

(a) The team approach. This program is designed to coordinate the resources within Veterans' Administration hospitals and clinics, within the established social and health agencies, and within the Veterans' Administration volunteer groups in behalf of the individual chronic and usually elderly patient who has reached maximum hospital benefit, but still is confronted with an outside situation which prevents his leaving the hospital.

For any patient who gives indication of having a severe, long-term problem, this team approach permits a joint evaluation by all the concerned professional personnel such as nursing, social service, dietetics, physical medicine rehabilitation, psychologists, and so on, under the leadership of the ward physician and the physician who is chief of professional services. In conference, they evaluate the patient's immediate and long-range problems as each specialty sees them and plan the best total way to assist this patient. The doctor presents the health situation and the medical treatment plan. The nurse advises the team as to the need for professional nursing care in the home which she foresees, and the facilities needed for this, as well as the existing community resources for furnishing this nursing care. The social worker contributes a picture of the home situation, the physical setting, the emotional ties, what plans can be worked out with the family, and the help she is securing from the established social and health agencies (community health departments and clinics, public assistance, family welfare, and so forth) in the way of enabling the patient to leave the hospital at the suitable time and maintain the gains made. The other specialists similarly participate with planning.

(b) Principles underlying the program. The fundamental principle underlying the program of planning for the patient's discharge is the fact that each community-its residents, its social and health agencies, its volunteer groups-must accept a certain share of responsibility in providing for the return and continued well-being of the discharged patient. By bringing into the hospital, the previously insufficiently utilized resource in the form of representatives of various community volunteer groups through the medium of the Veterans' Administration Voluntary Services, the problems of patients coming within the purview of this program are presented and the avenues of needed community assistance beyond that which families and established agencies can supply are explored.

With the community sharing in the responsibility for the rehabilitation of the patient including, where indicated, the pursuit of feasible vocational objectives, we are assured of far greater success in restoring the individual to his family and community, so that he becomes a happier and often a more productive citizen of society.

(c) Role of the physician. It is the physician who is the guiding force in the preparation and development of the discharge plan. However, just as the physician determines the course of medical care within the hospital and guides the course of action out of which arises the plan for the patient's discharge, so must there be medical leadership outside the hospital to ensure the effective realization of this plan which had been so painstakingly developed. Within the community, as within the hospital, the active interest of the physician in his patient is the indispensable keystone of the program of planning for the patient's discharge.

(d) Film, Planning for the Patient's Disharge-From its original establishment at the Veterans' Administration hospital, Aspinwall, Pa., in 1952, the program has gradually been adopted by a number of hospitals throughout the country (for example: Veterans' Administration hospital, Fort Howard, Md.; Veterans' Administration hospital, Indianapolis, Ind.; Veterans' Administration Center, Wood, Wis., and many others). Although the potentialities of this program have not yet been fully realized, the results thus far appear to be very encouraging. A film entitled "Planning for the Patient's Discharge” prepared by the Veterans' Administration was released about 6 months ago for the purpose of depicting the major objectives of the program and various phases of its operation. Its use by representatives of the national VAVS and others has been most gratifying and it is now being shown in Veterans' Administration hospitals and to many community groups. While the concept of cooperation on the part of indidividuals, social and health agencies, and volunteer groups from the community to restore the patient to his rightful place among family and friends is not at all new, this film strives to emphasize the tremendous importance of this joint Planning for the Patient's Discharge in translating into action an appreciation of human values, of happiness and of dignity, to an extent which could not otherwise be accomplished.

H. HOME CARE, OUTPATIENT, OR OTHER SIMILAR SERVICES FOR OLDER VETERANS

1. Veterans' Administration outpatient medical care as it affects the older veteran

The hometown medical care program has been in operation since 1946 in order to provide for veterans who could not be treated conveniently at Veterans' Administration installations. This program has saved veterans many hours they would otherwise have been required to use in traveling to and from Veterans' Administration clinics, some of which would have been lost from their work. The convenience of treatment in their own hometown, together with the privilege of being treated by a doctor of their own choice, has made this plan highly acceptable to the veteran patients. As of June 30, 1956, over 40,000 physicians and a number of osteopaths were participating in the hometown medical care plan. In fiscal year 1956, over 554,000 veterans received hometown medical care at a cost of $6,290,133.

At the end of the fiscal year this type of medical care was contracted for in 34 States and Territories. In 25 of these States and Territories direct agreements between the Veterans' Administration and State

medical societies governed fee payments to participating physicians; in 9 States and Hawaii the plan was operating through intermediary organizations recommended and approved by the State medical societies. Even though a State agreement is in force in the State in which the veteran lives, the veteran may select any reputable physician for his treatment. The physician need not be a member of the State medical society but must be licensed in the State to practice medicine and be in good standing in his community.

The Hoover Commission, in its task-force report on medical service, Veterans' Administration, recommended "Outpatient care following hospitalization for those non-service-connected disabilities for which medical need was established at the time the veteran was hospitalized" (p. 41). Under current regulations the Veterans' Administration is prohibited from furnishing authorized outpatient care to veterans for other than service-connected disabilities. The report also emphasized the need for extending preventive health and rehabilitation programs for domiciled members and also took note of the special geriatric clinic at Veterans' Administration regional office, San Francisco, discussed below, concluding that such programs should be extended both for humanitarian and economy reasons.

The passage of the Public Law 791, 81st Congress, permitted outpatient treatment accorded to veterans of the Spanish-American War, including the Boxer Rebellion and Philippine Insurrection, to be extended to cover treatment of any disability as being service-connected on a presumptive basis. For this reason, special cognizance is being taken of the needs of these older veterans through the avenues of the hometown medical care program, which includes home nursing and dental care, and the pilot geriatric clinic at the Veterans' Administration regional office, San Francisco. While all beneficiaries eligible for fee-basis medical care are also eligible for home nursing care, the latter is stressed particularly in the case of Spanish-American War veterans, many of whom require this type of care to enable them to remain at home with families and friends while receiving treatment. The types of home nursing care, of course, vary. For example, community home nursing service is obtainable under contract with community public health agencies of which the Veterans' Administration has 524. In addition, visits are arranged for by county public health nurses, registered public health nurses, and practical nurses. Of the above-noted total number of veterans furnished hometown care in fiscal year 1956, 62,761 were veterans of the Spanish-American War, who were treated at a cost of $699,735.

In addition to the treatment for Spanish-American War veterans which permits outpatient medical care for any illness, the Veterans' Administration regional office, San Francisco, has a geriatric clinic. which is under the direction of a physician who currently has approximately 100 elderly patients under his medical supervision. Only those veterans who are in need of multiple services from various disciplines available in the clinic are referred to the geriatric clinic. All others are referred to the specialty in which their particular illness falls. Twelve to 15 patients are scheduled for each clinic session, and all such

For a more detailed account of the San Francisco clinic see Veterans' Administration regional office. San Francisco, Calif., Coordinated Approach to Geriatrics, 1953 (San Francisco, 1954), 26 pp.

patients must have a medical workup prior to their referral to the special clinic. The geriatric clinic is part of and integrated with the basic medical program of the entire office, which, in turn, carries out the recommendations of the geriatric clinic. This clinic has demonstrated its effectiveness from the standpoint of health and improved morale of older patients. The current staffing pattern of the clinic is as follows: 1 medical officer, 1 public-health nurse, 1 psychiatrist, 1 physiotherapist, 1 social worker, 1 clinic secretary, 1 dietitian.

2. Continuity of care

There is considerable continuity of treatment between the hospital and outpatient programs for those patients with service-connected tuberculous and psychotic conditions through the well-established tuberculosis clinics and through mental hygiene clinics wherever they exist. Such continuity is fostered also by the general medical, surgical, dental, paraplegia, and various other clinics. Further, in the case of referrals to fee-basis physicians, the Veterans' Administration outpatient physicians stand temporarily in the role of a personal physisian handling the diagnostic, laboratory, and other preliminary work and preliminary planning of treatment of veterans. Community nursing care, dietetic services, and social service all contribute to continuity of treatment.

3. Outpatient nursing-care program

The Veterans' Administration, aware of its responsibility for the medical care of the ever-increasing number of older veterans and those with extended illness, is also aware of the importance of effectively utilizing the medical and nursing resources of regional office clinics in treating and maintaining their health. With the increased number of aging patients requiring health care, there has been a corresponding increase in the amount and kinds of nursing service required. Nurses, as members of the medical-care team, have a responsibility to assist the veteran patient in achieving a maximum level of self-care in order that he may take his rightful place as an effective member of society. In line with the Veterans' Administration standards of nursing care, nurses qualified by preparation and experience in the special field of public-health nursing are assigned to regional office duties. To insure maximum value to the patient during his clinic visit and followup nursing care at home, nursing assistance is provided each patient on an individualized basis to meet his particular needs. The clinic nurse interprets to the patient the Veterans' Administration facilities available to help him. She teaches him the principles of healthful living and what his contribution to the prevention of illness and maintenance of health can be. The nurse also teaches the patient and family how to carry out the physician's orders for the patient in his home. She gives him detailed written instructions as a reminder, making certain that he clearly understands his health-care plan. In the event the patient's condition prevents him from attending the clinic for needed nursing care, the nurse will plan with the phyisician to arrange for continuity of professional nursing care in the home through the facili ties of a community public-health nursing agency.

The community nursing program, an extension of the hometown medical-care plan, is a medical resource for the continued nursing care and rehabilitation of the patient at home. It serves to bridge the