of hospitals. It is now evident that nursing homes must increase in number, in efficiency, safety, and desirability. Higher standards of modern health care and higher costs of hospitalization have developed the nursing home as a necessary health facility. It is apparent that licensed nursing homes have for years been accepted by the patients and by their families. They are now approved by physicians and health authorities in and out of Government. However, private lending institutions, including banks, savings associations, insurance companies, and similar agencies, because of legal restrictions and lack of appreciation of the need, have not, as I said before, yet recognized the essentiality, economic stability, and ability to meet obligations which now characterize the management of our better licensed nursing homes. For these reasons, existing financing methods for the private nursing home have been and are completely inadequate to take care of the demand for better housing for our nursing homes. The hospitals and medical groups at the present time are experimenting with a changing complex of care in hospitals to include a convalescent or self-care section, somewhat similar to a nursing home. I wish to call your attention to the attached report on the Manchester, Conn., experiment being carried on under the auspices of the Hospital Facilities Section of the United States Public Health Service as reported in the April 26, 1958, issue of the American Medical Association Journal, along with a brief editorial appearing in the same issue on the same subject. A report on a similar study is found in the January 1958 issue of the Kentucky State Medical Journal, which I am also attaching, alongwith the complete report of the study by the Legislative Research Commission of the Commonwealth of Kentucky, Research Publication No. 48, November 1957, entitled "Homes for the Aged." I am submitting also Monograph No. 46, entitled "Nursing Homes, Their Patients, and Their Care," published in 1957 by the United States Public Health Service. I would like to call your attention, Senator, particularly to the table on page 8 of this magazine. This is a survey sponsored by the Commission on Chronic Illness, a national voluntary organization, founded by the American Hospital Association, the American Medical Association, the American Public Health Association, and the American Welfare Association, and assisted by the United States Public Health Service in this study. This study demonstrates clearly the ever-increasing population of the aged, and emphasizes the serious need for increasing the number of modern, new, and efficient nursing and convalescentcare facilities. Mr. Chairman, this study shows that one-quarter of the patients in nursing homes are 85 years or over, two-thirds of them are 75 years or over. They may have no family-they may have a family that cannot take care of them. They do not need to be in expensive hospital beds with a high overhead, but they do need to be in a home where there is some medical supervision and a nurse on duty. This can be provided most economically by a nursing home. These persons may be completely self-sufficient one day and bedfast patients the next, becoming chronically ill and requiring continuing nursing care within their means. These homes are generally not large and there is danger of losing their homelike atmosphere if they become large institutions. In meeting this need for increased facilities for the care of an aged population, we must be very sure that these homes meet the basic health and fire regulations of the various States. Each State has its own such regulations. We have been working with various groups, including representatives of HEW, in developing standards which can be suggested to States in meeting this basic need. Unfortunate disasters to nursing homes, such as fire, can be attributed largely to inadequate State regulations and supervision. Our association, in attempting to prevent such disasters, in 1957 adopted a policy statement which we think would tighten these controls, and I wish to submit it as a part of the record. Senator SPARKMAN. That may go into the record but these longer publications will be placed in the files for the information of the committee. (The policy statement referred to follows:) POLICY STATEMENT The following statement of policy and incorporated recommendations have received the endorsement of the officers, governing council members, and State association presidents of the American Nursing Home Association and are submitted as being representative of the profession as a whole. IRA O. WALLACE, American Nursing Home Association, New Castle, Ky. I. That converted and existing facilities which are below accepted standards and cannot be made adequate, be replaced as rapidly as possible by present owners with modern acceptable facilities; II. That in planning for expansion and new facilities, the SBA recommendations, as accepted in consultation with the ANHA officers, be followed as the minimum whether SBA loans are used or not; III. That the building of more modern and acceptable nursing homes and rapid expansion of facilities now available be expedited; IV. That every patient be under medical supervision and someone available who is qualified to carry out physicians' orders for all patients admitted: V. That both existing homes and new facilities plan for greater emphasis on programs for recreation, rehabilitation, and physical therapy and that facilities and personnel be provided for such, wherever practicable; VI. That in licensing, the State agencies require satisfactory character references; VII. That licensing agencies require administrators or prospective administrators to give evidence of satisfactory training and experience, or to avail themselves of the training provided and offered by short periodical institutes and short courses as a prerequsite to licensure; VIII. That referrals by State and local welfare authorities be made only to licensed or approved facilities. IX. Recommended fire safety standards: 1. Fire extinguishers in approved number and type; 3. Enclosed stair wells or automatic closing fire doors; 4. Patients limited to two stories except in fireproof or sprinklered facilities; 5. Unless sprinklered, fire detection and alarm systems for all facilities; 6. Use of fireproof paint; 7. Flameproof treated draperies; 8. Enclosed central heating plants-no space heaters; 9. Monthly fire drills and planned evacuation procedure instructions; 10. Supervised smoking or in designated areas; 11. Approved wiring annually inspected by qualified electrician; 12. Plentiful supply of water and means for immediate use in emergency; 13. Yearly inspection of chimney and heating system; 14. Plan of evacuation by fire department; 15. Fireproof storage of flammable materials; 16. Lighted exit signs; 17. Emergency lighting equipment; 18. Sufficient personnel adequately trained in fire protection at all hours; 19. Exit doors to open outward. X. That to facilitate such policies, we advocate: (a) More liberal terms on loans for expansion and the building of nursing homes by SBA, FHA or other governmental agencies; (b) More liberal payment policies and supplementation by welfare agencies and authorities for the care of indigents and old-age assistance recipients; (c) Patronage by the public of only licensed, approved, and qualified homes capable of properly caring for the type of patient admitted; (d) Greater representation on, and recognition by State and municipal licensing and regulating boards of the nursing home profession's duly appointed spokesmen ; (e) Adequate and qualified licensing agency inspection personnel on local and State levels; (f) Rigid enforcement of existing laws and regulations affecting the profession. IRA O. WALLACE, President, American Nursing Home Association. Mr. MUSTIN. The Hill-Burton grant program meets a need. The proposed Hill-Burton loan program for renovation would meet a need. However, the predominant number of nursing homes are proprietary and are not eligible for this type of financial assistance. We feel that a loan program on a sound, practical, businesslike basis, will allow the homes to provide more beds for the same amount of tax money than will Hill-Burton grants. The loan funds we are requesting should be returned with interest and could be used over and over by other facilities in areas where the need arises. We see no reason why this should result in duplication of facilities and we are confident that in planning these facilities, the overall health facility planning for the area will be considered. This will supplement the Hill-Burton program and meet a definite need so far very inadequately met. The wording of an amendment, we feel, is a matter to be left entirely in the hands of this committee and its staff, who are much more familiar with this law than we are. I would like to read an excerpt from a pamphlet entitled "Health Aspects of Aging." It was written by Dr. H. B. Mulholland, chairman of the American Medical Association's committee on aging, and is based on information developed by that committee: *** It is common knowledge that many general hospitals are now caring for patients who would be better off in the less expensive structure. A committee under the chairmanship of Dr. Howard Rusk recently surveyed the city hospitals of New York City and found that 20 percent of their patients should be in such an institution, where they could be cared for at rate of $6 or $7 per day as compared with the average rate of $21 in New York City hospitals. Not only is the cost less but they are not surrounded with sick people, but live in an atmosphere in which they are stimulated to become self-sufficient * ** In addition to submitting the foregoing pamphlet, Health Aspects of the Aging, I also submit the complete report, Hospital Patient Survey, the New York Foundation, New York City, 1956, referred to in the above quotation. I would like now to summarize very briefly why, in our opinion, the Federal Government should facilitate the building and remodeling of nursing homes. First, proprietary nursing homes at present are caring for the vast majority of nursing home cases, and there is no expectation whatever that nonprofit or public institutions can or ever expect to take over the full responsibility for the aged. Second, because of the one-purpose design of nursing homes and their equipment, the usual community lending facilities either cannot or will not provide the needed financial credit. Third, the nursing home is a small, private, taxpaying business that is providing a vital service to the community and is a part of the economy on which America's growth and prosperity is based. Fourth, the nursing homes are not asking for subsidies either in principal or interest; they will pay the going rate of interest and will repay money advanced to them so it can be used over and over again. Fifth, the nursing home that meets realistic standards, and that has the proper arrangements for nursing and physicians' services, serves hundreds of thousands of elderly patients who otherwise would be forced to enter general hospitals and pay the relatively high prices that hospitals are forced to charge. That concludes my statement. Mr. Bateman and I will be happy to attempt to answer any questions. Senator SPARKMAN. Thank you very much, Mr. Mustin. It has been a very good and helpful statement. Let me ask you this: You mentioned there that such loans are available through the Small Business Administration. If they are available from the Small Business Administration, then why would you want them included under housing? Mr. MUSTIN. Senator, they are limited to 10 years. You must repay the loan in 10 years, and that is beyond the means of our people. Senator SPARKMAN. The small business loans are short-term loans, and the loans are more difficult as a result. Mr. MUSTIN. Yes, sir. Mr. BATEMAN. The matching funds required, set the participation on the part of SBA too low. Senator SPARKMAN. You made some reference there to nonprofit corporations which may operate these homes. You say they are eligible now. Is that under the Hill-Burton Act? Mr. MUSTIN. Yes, sir. Senator SPARKMAN. Do you have anything in mind with reference to housing? Is there any eligibility under housing for them? Mr. MUSTIN. For the nonprofit people? Senator SPARKMAN. Yes. Mr. MUSTIN. Yes. They have the opportunity for religious and fraternal homes to obtain some money for nonprofit institutions on a loan basis. Senator SPARKMAN. For the organization? Mr. MUSTIN. Yes. Senator SPARKMAN. They are able to obtain it on a local basis, you say? Mr. MUSTIN. Yes, sir. I believe that is true. Under section 207 of the FHA bill. Senator SPARKMAN. Under what? Mr. MUSTIN. Under section 207 of the FHA act. Senator SPARKMAN. Mr. Mustin, I am not sure you said this in your statement. You said something about the American Medical Association, or the medical fraternity as such. I am not sure whether you said they approved this kind of program or not. Mr. MUSTIN. You mean a loan program? Senator SPARK MAN. For the nursing home. Mr. MUSTIN. We believe they do, sir, but I believe they will give testimony themselves. Senator SPARK MAN. You were in my office one day and there were some representatives of the American Medical Association with you. at that time. Mr. MUSTIN. Yes, sir. Senator SPARKMAN. As I recall it, they did approve of it orally and they said, I believe, they would be glad to write a letter to that effect, did they not? Mr. MUSTIN. I believe they will give testimony before your committee at a little later date. I think their board of trustees have approved it and they are prepared to give testimony favoring loans, but they will speak for themselves. (See p. 676.) Senator SPARKMAN. I wonder if for the benefit of the record you would explain what a nursing home is. Mr. MUSTIN. Yes, sir. Senator, a nursing home is a home which offers skilled care, that is, it offers care for persons who are chronically ill, as opposed to those who are acutely ill, and persons who cannot be cared for in their homes by reason of the fact that the families are not trained to take care of this particular person. So they go into a nursing home, where they have not only care by persons who are trained to do so, but they also have a homelike atmosphere. When they go into a nursing home it is for total care, usually, for the remainder of their lives. Senator SPARK MAN. These are individuals who are either chronically ill or who are aged and unable to care adequately for themselves, or who, through some enfeeblement or some other reason, cannot care for themselves? Mr. MUSTIN. That is right, sir. Senator SPARKMAN. And they receive skilled care and nursing care which is available in the home? Mr. MUSTIN. Yes, sir. Senator SPARKMAN. I believe you bring out the point in here that your thought is they are better when they are operated as residential units, rather than institutional construction? Mr. MUSTIN. Not necessarily residential-type of construction, but we speak here of smaller units rather than those housing hundreds of people. There is always a tendency to regiment people when they are housed in large numbers. Senator SPARKMAN. You probably know that this committee has for some time been concerned with trying to work out a solution for elderly persons, detached persons, persons who do not constitute the usual, average American household. 25834-58--23 |