of 4.9 percent, and a decrease between the 2 corresponding months of December 1965 and 1966 of 7.2 percent. This is a very significant decrease.

Mr. ROGERS. What year was the turning point?

Dr. YOLLES. 1955.

Mr. ROGERS. Thank you.

Dr. YOLLES. There is one other point. There has been a decrease from the projected number of 702,000 patients to 452,000. In terms of dollars to the State and local governments, this amounts to $4.4 billion of expenditures, both for cumulative cost of care of the patients over these years, as well as the capital improvements, that would have been built to take care of them. Those funds were used for other purposes during these years, and not used for mental hospitals.

I would like now to present three examples of community mental health centers that have been funded under this program. The first of these is purely a construction grant, the second purely a staffing grant, and the last is a combination of both.

This construction grant was awarded to the Swedish-Saint Barnabas Community Mental Health Center. (See fig. 3.) Actually the joint applicants were the Saint Barnabas Hospital and the Swedish Hospital in Minneapolis, across the street from each other. These two hospitals joined to provide community mental health services. They closed off the street and plan to construct the community mental health center between them, uniting the two hospitals.

This new structure will provide to central Minneapolis, which has a population of 200,000, all of these services which were not available to this population before except in fragmented or partial form. They will provide outpatient, inpatient, day and night or transitional services, consultation and education services to schools, courts, welfare departments, and other agencies as well.

In addition, the St. Barnabas hospital and the Swedish hospital will provide emergency services to this total community and by contractual arrangement with private physicians, some patients will be given outpatient care. Further, through a backup arrangement, to be sure that they can serve all of the people in the community when demand is heavy, there is a backup service with the county general hospital to provide outpatient and inpatient services.

The Federal share on this project was $828,000. The total, including local and private financing, was $1,700,000. This project was approved June 27, 1966, and the ground-breaking ceremony was July

10, 1966.

The second example is of a pure staffing grant. This is the Tacoma Mental Health Center in Tacoma, Wash. (See fig. 4.) Prior to the award of this grant, there were some five agencies delivering mental health services within the city and counties surrounding Tacoma, Wash. None of these provided a total service. No total service was available to the city of Tacoma.

By joining together these five agencies to set up the Tacoma Mental Health Center, a total program of services was devised. This is what Mr. Cohen referred to as a program of services with these agencies joining together to provide total services to the city of Tacoma, with a population of 153,000.

FIGURE 4.

Dr. YOLLES. The staffing grant provided funds for the initial partial support of professional and technical personnel for emergency services, day and night services, inpatient services, as well as consultation and educational services. The totality of services provided by the stimulus of this grant was far greater. We have inpatient care being rendered to this total population, as well as for children and adults by the Western State Hospital. We have inpatient services rendered by the St. Joseph Hospital. We have child guidance services available to the total population.

The Department of Public Health has cooperated in providing aftercare services, and the community mental health clinic is now providing consultation and education services to the community, as well as outpatient services.

The Federal share on this project was $78,000 to provide 75 percent of the cost of initial staffing in the first year for St. Joseph Hospital, and the community health center. The others have provided their services without the aid of the Federal grant.

Mr. ROGERS. Mr. Chairman, may I ask a question there for a moment?

It is my understanding that when we passed this bill the concept was to put it all in one building, a community mental health center; to put all five services in one center. It appears that this is not the way you are administering the act. I thought the intention was to require that the services, all five services, be given in one area. I don't know how far it is between these hospitals. Does a person have to go across town? How do they know where to go for which service, and so forth?

Dr. YOLLES. The original intention was to have a single building which would have all of the services as well as for a number of individual services to join together to form a center. The act also calls for agreement by contract to show that the center will render all services to the individual.

The center itself will have a basic or central location in terms of a headquarters operation where patients can be referred. All of the units must be easily accessible to the patient and fairly close together. They may be in different parts of town. However, a patient who is in an inpatient service, and the stage of his illness now suggests that he be in outpatient service, can be moved without any redtape to the outpatient services that are available because of this contractual arrangement between these services. He can move easily and freely, and his records can move as well.

Mr. ROGERS. If this can be arranged, then, anyone could do this with existing facilities and there is not much need for construction. Dr. YOLLES. Some communities have a very definite need for appropriate facilities in which to house these services. A good example of this was in one of the counties in Florida, in your own State, where no services at all were available in a group of counties--no mental health services at all. The hospital had no inpatient psychiatric services. They have asked for and are receiving a construction grant to construct an inpatient psychiatric service. In addition, however, they have joined with other agencies in other communities to provide a totality of services over and above the inpatient services, which may be the only part constructed.

Mr. ROGERS. All right. Thank you.

Mr. COHEN. Might I add-because Mr. Rogers raised quite a fundamental question, and that is why I dealt with it in my testimony-that there was some discussion and perhaps some misunderstanding that the program was sort of a brick-and-mortar program, solely. Of course, the 1963 act authorized construction, and then the 1965 act authorized the staffing grants, but I think the main thrust that we tried to make in 1963, and that we are trying to make now, is that the comprehensive services ought to be available to the people. And if that takes construction, that is desirable. If it takes staffing, that is desirable. And if it takes both of them, of course, they would both be authorized by the law. But I think our concept is a much more flexible one, to adapt the center to the needs of the community.

If a community doesn't need construction but merely needs to broaden the scope of its services, then the staffing money would be available to the community without the construction money.

Mr. ROGERS. I think this is fine because this would cut a lot of construction money that would have to go in. I agree that this is logical but I am not sure that this has been gotten across to communities that are applying because I think many of them feel that all five services must be located in one central area. So you perhaps are getting applications to build because they don't have all of the facilities in one place which, if it were known, many areas might come in to qualify to provide the services that we are concerned with but presently don't think they can because of this concept that the legislation originally held of bringing them all in one central location.

I would hope that perhaps you could make this very clear in some informational bulletins perhaps to the States and societies that might be involved because I think there is a misconception in many areas that there they just can't qualify simply by tying some of their hospitals together.

Dr. YOLLES. We are attempting to do that through informational material as well as consultation through our regional offices.

Mr. ROGERS. I think this could be very helpful.

Dr. YOLLES. The last is the Muskingum County Guidance Center, in Zanesville, Ohio. (See fig. 5.) Here there were both a staffing and a construction grant. Three agencies were involved, the Good Samaritan Hospital, the Bethesda Hospital, and the Muskingum County Guidance Center.

The three joined together to set in motion the construction of the Community Health Center of Muskingum County. The staffing grant would provide for 75 percent of the initial cost of personnel for 12 inpatient beds in the Bethesda Hospital, and 24 inpatient beds in the Good Samaritan Hospital.

It would provide day care in the Community Mental Health Center, outpatient services in the Community Mental Health Center, and consultation and education to professionals and agencies in the community.

These three services would be housed within the new Community Mental Health Center to be constructed and would be provided to five counties in Ohio that have joined together for this purpose.

Dr. YOLLES. The total population of these five counties is 159,800. This third example is one of combining both grants where there was a need for a physical structure and for staffing as well.