(e) Full-time Veterans' Administration personnel and residents may not care for patients outside the Veterans' Administration. hospital.

The need to balance instruction in the characteristics and treatment of short-term illness by placing equal emphasis on long-term illness is becoming recognized. This is an educational experience that is being advocated for basic school curriculum. As was pointed out in the comments relative to paragraph 45, educational opportunities pertaining to the care of long-term patients are being made available to Veterans' Administration nurses.

APPENDIXES

APPENDIX A

GERIATRIC MAINTENANCE THERAPY PROGRAM 1

3

Walter C. Matheny, M. A.; 2 Worth J. Randall, B. S.; and Leo Rosenberg, M. D.*

This center [Dayton, Ohio] has a domiciliary section of 2,100 beds and a so-called geriatric (Patrick) hospital with about 150 custodial beds. Both of these units have large numbers of veterans with disabling, chronic disease, residual of severe accidents or surgery, and infirmities of old age. In a survey of the age and disability characteristics of 250 patients being transferred from hospitals to the domiciliary section, we found that (1) 28 percent were past 65 years of age and 86 percent were past 55; (2) 42 percent had permanent progressive disabilities. A survey of the geriatric hospital at the same time showed 41 percent to be over 65 years old and 94 percent to be over 55 years old and suffering from severe disabling illness.

Some time ago the need for a physically sustaining type of treatment became apparent. Patients who had reached the conclusion of their definitive treatments and had a great deal of residual disability were often transferred to the geriatric hospital or domiciliary section where many deteriorated noticeably in the absence of directed exercise. With a small staff and a large potential load of this type superimposed on the regular therapy needs of the center, we sought a mass type of treatment that would provide for minimal patient needs and require minimal therapist time. We eventually developed a plan of maintenance therapy which has proven successful beyond our expectations.

Let us first define what we mean by maintenance therapy. It is a program of minimal activity required to maintain the physical condition of a patient with a poor prognosis for improvement at his maximum feasible level. This objective is usually established for the patient by the physiatrist under the following conditions: (1) After the patient has undergone intensive restorative therapy and has reached the point of maximum treatment benefit and it appears likely that he cannot maintain his own physical condition; (2) where a geriatric patient has deteriorated in the absence of physical medicine and rehabilitation therapy, and maintenance therapy is necessary to prevent contractures, disuse atrophy, decubiti, incontinence, weakness of musculature, and loss of self-care ability.

1 Source: Veterans' Administration, Department of Medicine and Surgery, Information Bulletin, IB 10-72, Physical Medicine and Rehabilitation Service (Washington, February 1955), pp. 14-18.

Executive assistant, physical medicine and rehabilitation service, Veterans' Administration Center, Dayton, Ohio.

3 Chief, corrective therapy, Veterans' Administration Center, Dayton, Ohio.

Chief, physical medicine and rehabilitation service, Veterans' Administration Center, Dayton, Ohio.

Patients often fail to maintain themselves physically because of mental confusion and disorientation. We believe that activity, physical and mental, retards mental deterioration. Our program, therefore, makes a twofold attack on the problem of maintenance: (1) It provides exercise to maintain the patient physically; (2) it retards mental deterioration so the patient retains his interest in self-activity. The primary objectives of the program are as follows: 1. To continue self-care ability as long as possible.

2. To delay the necessity for maximum nursing care. 3. To improve morale of geriatric patients.

4. To fill a distinct need for sustaining therapy by a mass-treatment technique, where possible. The mass approach enables us to do more maintenance therapy with present personnel.

5. To screen the large group of geriatric patients for those with the will and capacity to improve under intensive therapy.

6. To provide social outlets for patients of similar current social status in clinics.

Faced with the problem, and accepting the concept of maintenance therapy as the maximum feasible rehabilitation for certain individual patients, we established a recognized treatment objective-maintenance therapy. In each individual case, this objective is determined by the physiatrist when the need is apparent and the prospects of improvement are negligible.

The program was launched by the corrective therapy section at the geriatric hospital. About 15 patients, who were receiving no physical medicine and rehabilitation treatments, were selected by the ward physician and physiatrist on the basis of their need for a sustaining type of therapy and self-care training. The patients are brought to the clinic from 10: 45 to 11: 45 daily, which is normally a slack period for the therapist, due to hospital routine.

During this hour, the therapist trains and assists each patient to learn and carry on a specified activity. He assists and encourages each patient, moving from one to another as required. Parallel bars, wall pulleys, bicycle, punching bag, shoulder wheel, reciprocal overhead pulleys, etc., are used simultaneously as scheduled. Each patient uses one or more pieces of apparatus, getting a total of 5 to 20 minutes of exercise according to his tolerance.

Member detail men assist the therapist in getting the patients started on the equipment, moving them from one piece of equipment to another as scheduled, serving as ambulation escorts, moving them in and out of the clinic, and standing by to assist patients as required. A second part of the corrective therapy maintenance program is to schedule patients with maintenance objectives throughout the day for individual work in Patrick and Brown Hospital clinics. After their routine is learned, they require little therapist attention and can use the equipment not then in use by other patients. Many patients can get good sustaining results by this means with a minimum of supervision.

The maintenance therapy objective is in effect for several blind geriatric patients in Patrick Hospital. Due to their age and physical and mental condition, a program of orientation and cane ambulation is not feasible, but they do need a physical sustaining therapy. Their treatment is essentially a corrective therapy type of treatment using the corrective therapy facilities.

Occupational therapy has prescriptions on a few geriatric patients and domiciliary members with maintenance objectives. They utilize crafts and activities suited to the patient's physical or mental need, and in which he is interested. For the most part, they are the same activities given to other patients and on an individual basis. It is usually a repetitive activity which does not require too much learning ability and which can be carried on without much supervision. Training in some of the activities of daily living is given, if necessary. An excellent rapport is not difficult with the geriatric patient in all phases of our maintenance therapy program. The occupational therapy clinic is especially conducive to socializing while working, reminiscing, and developing common interests in some project. Successes in completing projects and getting expressions of admiration from therapist and patients encourage a feeling of achievement and selfworth which is very stimulating and satisfying to the geriatric patient. Physical therapy has a very few maintenance cases which are multiple physical rehabilitation problems. They require an individual approach toward stabilizing muscular imbalance and arresting degenerative processes of disease.

Although we have a limited objective in these so-called maintenance cases, we get some beneficial physical results beyond mere maintenance. The following are observed:

1. Increases joint mobility.

2. Reduces minor aches, pains, stiffness, and soreness.

3. Improves remediable postural defects and personal appearance. 4. Increases muscular strength, endurance, and coordination.

5. Reduces symptoms of dizziness (on standing or sudden exertion), constipation, and incontinency. It improves appetite and ability to sleep.

6. Improves motor skill.

7. Reduces chronic fatigue.

8. Increases patient's confidence in his ability to be active. Our experience has shown that a considerable number of geriatric patients, admitted to the program for maintenance therapy, have been able to make substantial progress toward self-care and ambulation. The immediate reason for starting treatment is to maintain the patient's physical condition, and his capacity for improvement would probably not be discovered except for the screening effect of the maintenance program. The treatment objective in such cases is changed to self-care and ambulation, preparation for discharge to his home, or other suitable objective.

There have also been demonstrable financial savings from this program. Aside from the savings in nursing and medical care, which are difficult to measure but are substantial, patients and domiciliary members have progressed to other objectives and to discharge. Known cases of discharge from this program in the past year are as follows:

1 The difference between $17.05 per diem cost in hospitals and $2.86 per diem cost in the domiciliary ection.