These alterations you must discover for yourself. They are a little different for each person. However, most people who are associated with blind rehabilitation on a sincere basis for any length of time get a wider frame of reference from seeing life, if not whole, at least from more than one viewpoint. This in itself frequently touches blind people in a therapeutic manner. This is a goal of major importance, especially with the old and the infirm who are not living with their families, as is the case with the blind domiciliary member.

APPENDIX G

A STUDY OF AN INTENSIVE PHYSICAL MEDICINE AND REHABILITATION PROGRAM FOR LONG-TERM PATIENTS, PRIMARILY GERIATRIC, AT VETERANS' ADMINISTRATION CENTER, LOS ANGELES, CALIF.1

Those who are close to the program of physical medicine and rehabilitation have no doubts about the statement that rehabilitation pays. It pays in patient satisfaction, in conservation of human resources, and in hospital operating costs. Friends of the veteran have frequently chided VA officials for not having more tangible evidence of the economy of medical rehabilitation, and have urged that we appeal to field stations to initiate studies and tabulate results which will help in the expansion of rehabilitation efforts. We hope that the following summary of a study of 105 predominantly neurological patients prior to and following physical medicine and rehabilitation therapy at Veterans' Administration Center, Los Angeles, Calif., will be a stimulus to other stations in making similar studies.

The information presented was published in a pamphlet entitled "It Pays To Rehabilitate," by Robert V. Miller, M. D., Chief, Physical Medicine and Rehabilitation Service; Karl H. Haase, M. D., Assistant Chief, Physical Medicine and Rehabilitation Service; and Cleo B. Nelson, R. R. L., Chief Medical Record Librarian; all of Veterans' Administration Center, Los Angeles, Calif.

While this study was made and published over 2 years ago, it is just as significant as if recently completed. The Director, Physical Medicine and Rehabilitation Service, will appreciate receiving information from hospitals and centers where projects of this nature have been initiated.

During the past 22 years, at Veterans' Administration Center, Los Angeles, several hundred patients have been referred for physical medicine and rehabilitation therapy. While it was easy to know the results of therapy in individual cases, there was no way by which an overall program evaluation could be made. Therefore, a plan was devised for classifying detailed data on patients for whom complete records had been maintained during the period they were actively enrolled in the rehabilitation program.

SELECTION OF PATIENTS

The intensive treatment rehabilitation program was made necessary by an increasing number of long-term patients which was gradually blocking the flow of patients through the acute general medical and surgical hospital. To facilitate rehabilitation, a ward in the proximity of the physical medicine and rehabilitation therapeutic clinics was selected, and patients who were regarded as purely custodial and

1 Source: Veterans' Administration, Department of Medicine and Surgery, Information Bulletin, Physial Medicine and Rehabilitation Service (Washington, October 1954), pp. 6-8.

nursing problems were transferred to it from all wards in the hospital. From among the total number of general medical and surgical hospital patients who were given physical medicine and rehabilitation therapy during 1949 and 1950, a group of 105 were selected for evaluation on the basis of the availability and adequacy of the detail required for this survey.

Although some of these patients have died since therapy was completed or discontinued, the closure date of this study is at time of disposition from the rehabilitation program.

SCOPE OF THE REHABILITATION PROGRAM

A full day's activity program was planned for each patient with emphasis on making him do the maximum amount of which he was capable. Coupled with the exercise program was an equally important phase-remotivation, which was carried out by the doctor, nurse, aide, therapist, and other personnel who came in contact with the patient. Included were some simple psychotherapeutic measures such as reassurance, suggestion, encouragement, and listening to family or emotional problems.

REHABILITATION PROBLEMS AND GOALS

The problems inherent in the motivation and rehabilitation of a predominantly neurological group of patients, most of whom were over 55 years of age, with many having had long periods of hospitalization, were numerous and complex. However, it was felt that some beneficial results could be obtained by every patient. The possibility of restoring all of them to the point of discharge from the hospital on a self-care basis did not exist. The immediate goal, therefore, was to remove as many as possible physically and psychologically, from a dependency status to an independent or semi-independent status with the possibility of eventual discharge from the hospital. The long-range goal was to delay or prevent the necessity for future hospitalization for those discharged.

AGE OF PATIENTS AT TIME OF REFERRAL TO PHYSICAL MEDICINE AND REHABILITATION SERVICE

The ages of the patients ranged from early adult to late old age, with the majority (81 percent) over 45 years of age. The mean age was 55 years.

In general, the characteristics were those of a group of early-old-age persons with declining or nonexistent economic potentials. All were physically disabled; a great number were chronically ill, with many having histories of long periods of hospitalization prior to referral for rehabilitation.

FIRST ENTRY AND REENTRY OF 105 PATIENTS

Of the 105 patients surveyed, 67 were initial admissions to the hospital and 38 were readmissions. The group of 67 initial admissions, together with 17 readmissions, or a total of 84 persons, were receiving physical medicine and rehabilitation therapy for the first time. The

remaining 21 patients not only had had previous hospital experience but also had received previous physical medicine and rehabilitation therapy for their present disability.

MULTIPLE DIAGNOSES OCCURRING AMONG 105 PATIENTS

The largest diagnosis group consisted of 37 persons suffering from some form of brain damage resulting in paralysis, approximately onehalf of which was hemiplegia. Of the 37 paralytic patients, 27 were over 55 years of age.

The influence of age upon the number of diseases present is apparent. Among patients under 45 years of age, 2 diseases were diagnosed, while after the age of 45 years an average of 4 diseases per person were diagnosed.

THERAPY STATUS OF 105 PATIENTS AS DISPOSITION FROM PHYSICAL

MEDICINE AND REHABILITATION PROGRAM

Of the 105 patients included in the survey, only 76 completed therapy. Four were uncooperative, although three of these showed improvement by entering a class of disablement which permitted them to practice greater self-care. The treatment of another 20 patients was discontinued because of illness; of these, 9 had shown improvement at the termination of treatment while 11 showed no improvement. For two patients, treatment was discontinued because they were not benefiting therefrom. One patient was maintained on morale therapy and two died during the period of therapy.

DISPOSITION OF 26 PATIENTS FOR WHOM THERAPY WAS DISCONTINUED

Of the 26 patients who did not complete therapy, 4 were discharged from the hospital and 22 remained, only 2 of whom were able to meet the requirements of self-care in the domiciliary unit. Seven patients, all above the age of 55 years, were transferred to the psychiatric hospital. Of the original 105 patients, there remained only 13 who continued to require general medical and surgical hospital care.

DISPOSITION OF 76 PATIENTS COMPLETING REHABILITATION THERAPY

An average of 185 days per person was required to rehabilitate 76 patients completing therapy. The largest diagnostic group, 54 patients with disorders of the nervous system, were under therapy for the greatest length of time or, on the average, 210 days each. All 76 patients were discharged from the general medical and surgical hospital-either to the domiciliary unit or to the community. The approximate cost per patient day for all physical medicine and rehabilitation activities was $1.302 or a total rehabilitation cost of $18,287 for those completing therapy.

Of the 76 patients who completed rehabilitation therapy, 34 were discharged home and 42 were able to assume the responsibilities of self-care in the domiciliary unit on an ambulatory basis. From cost standpoint, 45 percent of the total number rehabilitated were com

2 Based on the patient per diem cost of $1.30 for all physical medicine and rehabilitation during June 1949, Veterans' Administration Center, Los Angeles.

3

pletely removed from the Los Angeles center, and the cost of maintaining the other 55 percent was reduced from $15.08 per day to $3.04 per day.

4

AREAS OF IMPROVEMENT AMONG 76 PATIENTS COMPLETING THERAPY

The 76 patients who completed the prescribed course of treatment demonstrated a marked improvement by moving out of their original degrees of disablement to positions of greater self-reliance.

Of the 14 persons who were ambulatory with mechanical aid, 12 became ambulatory without any aid whatsoever. Of the initial 44 wheelchair patients, 14 of whom were not self-sufficient, there remained only 13 with continued need of a wheelchair, all on a selfsufficient basis. The 14 bed patients all responded to therapy, 6 becoming ambulant and 8 becoming wheelchair patients, 7 of whom were self-sufficient. It can be said, therefore, that the objectives of the rehabilitation program were realized in that the patients completing therapy developed increased self-care abilities and ambulation to the greatest degree of which they were physically capable.

REDUCTION IN COST OF CARE

Based on the 1950 Veterans' Administration per diem inpatient operating expense for general medical and surgical hospitals, the cost of providing care for the group of 105 patients at time of referral to physical medicine and rehabilitation was approximately $1,583 per diem. At disposition from physical medicine and rehabilitation the per diem cost of caring for those remaining at Los Angeles center amount to $378, a cost reduction of 300 percent, or an annual saving of approximately $440,000.

SUMMARY

The patients included in this study were all in the general medical and surgical hospital at time of referral to the physical medicine and rehabilitation program. Later, a ward was set up in the proximity of the physical medicine and rehabilitation clinics to which the patients were transferred to permit more effective utilization of rehabilitation services.

A marked improvement was obtained in the self-care capabilities of a group of 105 severely disabled aging persons, who are generally considered permanent hospital patients. As a result of an intensive activity and emotionally supportive psychotherapy program, many have been retired to their homes. Of those remaining at the Los Angeles center, all except 13 have been transferred to a less expensive type of care. As a group, they are permitted to live more comfortably because of improved health and function. The costs of care and maintenance have been materially reduced.

Based upon these criteria, it can be said that a physical medicine and rehabilitation service is an effective instrument in the motivation and restoration of the disabled individual to a more useful life.

31950 per diem cost for all Veterans' Administration general medical and surgical hospitals, Veterans' Administration Budget Service, PEBA-8, July 1951.

1950 per diem cost for all Veterans' Administration domiciliary units, Veterans' Administration Budget Service, PEBA-11, July 1951. 5 Veterans' Budget Service Reports Control Symbol PEBA-8-11, September 1951.

APPENDIX H

FACT SHEET, VETERANS' ADMINISTRATION VOLUNTARY SERVICE

(VAVS)

Citizen Participation With Government in Serving Hospitalized Veterans

BRINGING THE COMMUNITY TO THE HOSPITAL

The whole community helps in VA's plan for volunteer participation in hospital programs for sick and disabled veterans.

The major purpose behind bringing the community to the hospital is the theapeutic effect of keeping the patient surrounded with normality.

Long-term hospitalization for the mentally ill or tuberculous patient may result in a tendency toward permanent hospitalitis. It may widen the gulf between the protective life of the hospital community, where the patient must depend on others to do for him, and the community outside the hospital, where the individual must largely do for himself.

By assisting the staff in keeping the patient surrounded with normality, the volunteer workers help in assuring that this gulf between will not become too wide for the patient to overcome when he has received maximum hospital benefit and is ready for his return to a normal and productive life in the community.

Another and very serious aspect of this gulf between, however, faces the patient who is necessarily separated from his home by the communicable nature of his disease.

For him Voluntary Service must and does abridge the gulf between the normal and abnormal until he is safe to return to his home.

BACKGROUND OF VA VOLUNTARY SERVICE

There has long been a tradition of community volunteer participation in activities for veteran-patients and domiciliary members.

Veterans' Administration Voluntary Service (VAVS), inaugurated in April 1946, has given added significance to this long-time volunteer effort by incorporating the work of the volunteers into hospital-approved and staff-supervised programs for the care and treatment of patients.

The volunteers function as part of the hospital team at the request of and under the direction of the hospital's professional staff.

WHAT VETERANS' ADMINISTRATION THINKS ABOUT THE VOLUNTEERS Mr. Harvey V. Higley, Administrator of Veterans' Affairs, paid this tribute to the volunteer workers on the occasion of the 10th anniversary of Veterans' Administration Voluntary Service:

"How can I possibly find words to thank you today for your countless acts of kindness in behalf of your fellow men *** the ill and disabled in our hospitals and homes?

"What words are there to match the hope you have instilled in their hearts? The faith you have given them that they are not alone in

1 Source: Veterans' Administration.

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