North Carolina hospital study.-A special survey of hospital discharges is being conducted in North Carolina through the cooperation of the State medical society; the hospital association; and the State board of health. Completion of this study is scheduled for 6 months hence. Four 1-week periods are being studied on all hospital discharges. One hundred thirty-four member hospitals of the North Carolina Hospital Association are participating in the study, completing survey forms on all discharged patients for the selected study periods. The purpose of the study is to collect factual data as to: 1. Number of patients discharged during each of the 4-week study periods. 2. Identification data as to race, age, length of stay in hospital, total hospital charge, and major cause for hospitalization. 3. Source of payment: patient-family, insurance, Government, and the anticipated "charity writeoff" to be absorbed by the hospital. It is estimated that some 12,000 patients are discharged from these 134 cooperating hospitals per week, so we anticipate having a sampling of some 48,000 records by the end of the study. The following figures representing an advance sample of one-fourth anticipated returns of the first weekly survey points to some important trends as to what the full survey will reveal. Of 37 hospitals sending in returns which have been tabulated there were approximately 3,500 patients discharged. The combined hospital bill for these 3,500 patients was $557,330. For comparison, we determined the number of patients discharged who were 65 and over to be 404 or 11 percent of the total number discharged, with an aggregate hospital charge of $95,659, or 17 percent of the entire hospital charges. The table below gives a further breakdown of 4 contributing methods of hospital payments, comparing the number of patients 65 and over with that of the entire number of discharges: The unpaid balance of hospital cost of the entire 3,500 patients discharged amounted to $108,150 or 19 percent of the combined charge of $557,330 and the unpaid balance of those 65 and over was $19,132 or 20 percent of the combined charge of $95,659. Many of the hospitals returned their survey forms before insurance adjustments had been made and no indication of postponed payments to be made by the patient or family was reported. Hospital authorities report that approximately one-half of the unpaid bill at the time of discharge will be made by the patient or family within a 12-month period. Therefore, we can anticipate that of the unpaid balance of charge amounting to $108,150 uncollected on discharge, including the $19,132 for patients 65 and over, at least one-half will be paid by the patient or family, adding to the percent payment from patient/family in each group. You will note that the patient/family payment for patients 65 and over was 40 percent of the total bill whereas for the entire age groups this was only 27 percent. The combined payment of patient/family and prepaid insurance for the older age group was 64.5 percent as compared to 70 percent of the entire group, pointing to the fact that the older age group was able to take care of the major portion of their hospital charge the same as for other age groups. Other activities In January 1959, a television program sponsored by the State medical society was given outlining the American Medical Association's six-point positive program for the health care of the aging, the various activities of the State medical society's committee on chronic illness, and the programs and services of related agencies and organizations. To further promote the understanding of community and professional leaders of the various services and facilities now available to the aged, as well as those anticipated, programs have been given at State, district community health conferences sponsored by the State medical society, and to other assembled groups throughout the year such as the conference for social service, annual meeting of the North Carolina Boarding and Nursing Home Association, and the medical society officers training workshop. Person County home care demonstration project.-In cooperation with the county medical society and in consultation with the State board of health and the U.S. Public Health Service, the "Person County home care demonstration project" was prepared and approved. It is financed by a grant of $10,000 from the USPHS, $10,000 from the State board of health, and $4,000 from the county commissioners. Through these funds, added personnel was authorized: a medical social worker, a physical therapist, two public health nurses, and a clerk. The program has been integrated into the overall program of the health department and of the many other public and voluntary agencies providing health services in the community. All patients must be referred by a diagnosing family physician and remain under his care. The doctor-patient relationship continues at all times. The services available through the project are: nursing, physical therapy, social service, occupational therapy, rehabilitation, nutritional counseling, medicines and sick room supplies, orthopedic equipment, and health education. No fees are charged for services rendered by the health department workers. Beneficial results accruing to the individual patient in the program have been an accomplishment of a concerted "team effort." The "team" teaches and provides services as requested by the attending physician. The patient and his family are taught the proper care of his disease through actual services offered by the physical therapist, public health nurse, medical social worker, and the nutritionist. Thus, the private physician and this teamwork is, in effect, a unit working toward the achievement of the patient's maximum recovery and physical independence. Evaluation after 6 months' operation, points up certain accomplishments of merit: 1. The project is de facto and in operation. 2. There has been public acceptance of the program as participants and beneficiaries. 3. There has been a gradual increase of patients admitted to the program (a total of 39 patients admitted with a present patient load of 33). 4. There has been a harmonious working relationship with the physicians (referral, review, and evaluation of each patient, is made by the attending physician with the health department team on regular appointments). 5. There has been added to the county hospital an organized and equipped physical therapy department. (The local National Polio Foundation chapter gave $4,800 for the purchase of some 40 items of equipment. The hospital provided a room and limited supplies, and the citizen's committee has augmented needed supplies and volunteer services.) 6. The community has joined together to support and promote the project, (Five committees with some 40 volunteers are cooperating in the program, rendering services not otherwise provided by the demonstration funds.) 7. The project has provided an avenue of health education in control of disease. The anticipated results of the Person County project include major aims: 1. To provide information about the cost of home care in a rural area. 2. To shorten the period of hospital stay for patients with long-term illness. (This has been accomplished on several of the patients.) 3. To extend into the home, services ordinarily restricted to hospitals. (This is being done presently.) 4. To reduce, through supplementary services in the home, the number of chronic disabling conditions of young and older people alike. (Results now available.) 5. To effect a reduction of cost to the county for hospital and welfare care for persons with long-term illness. 6. To provide more adequate medical care for the people of Person County. We are proud of the fact that this is the first project of its kind to be carried on in a rural area in the United States. It is showing desired results, further proving that the Federal, State, and local official and voluntary agencies in the community can coordinate their efforts in an organized program for the home care and restoration of the chronically ill in a rural area with economical end results. Two other counties are taking similar steps toward a home care program as an integrated part of the public health program. Alamance and Guilford Counties have two nurses each, trained or being trained at the Bellevue Rehabilitation Center, who will be able to extend their specialized services to outpatient cases. These nurses will make home visits and render direct nursing services to patients under physicians' orders, and with the special training will be better equipped to help in restorative practices and exercises based upon individual needs and recommendations by their family physician. This is another step forward in helping to keep the patient in his own home and out of the hospital by extending services heretofore characteristic of hospitals to the home by qualified and specially trained personnel. We have other demonstration projects which are "pioneering" in rural areas for the first time. One of these is a homemaker service program in three rural North Carolina counties. This project is being financed, as a demonstration, by the Doris Duke Foundation and is limited to category public welfare recipients, since some additional county funds are being used. In each of the three counties, one white and one colored homemaker has been added to the county welfare staff, who work under the direction of the casework supervisor. As of March 1959 a total of 1,199 home visits had been made to some 85 cases, which averages about 2 visits per week in the 3 demonstration counties. The homemakers are not nurses, nor are they domestic helpers, but they do assist with planning and in the management of the family while the adult member is disabled by a longterm illness or injury. They are able to follow physician orders as to home care procedures prescribed, excluding injections or other skilled nursing services. In North Carolina we have nine homemaker programs in urban areas and these services are made available to any family or older people needing this type of help, regardless of their ability to pay. These are open market services with the homemakers working under the supervision of welfare caseworkers. We look with favor upon this type of service program and hope to see it broaden to be available to all income groups and duplicated in all counties in the State, under official agency or volunteer auspices. We have other home care service programs, affiliated with Duke Hospital and the UNC Memorial Hospital, demonstrating the value of having physical therapists assigned to their staffs to make home visits to discharged patients for the continuation of treatment and supervision, thus reducing the hospital stay and many times avoiding a return trip to the hospital. The physical therapists give professional assistance in restorative and health maintenance care. Again, the medical profession looks with favor on this type of extended service into the home to reduce costs and use of hospital beds for chronic illnesses and prolonged injury recoveries. The organization of Golden Age Clubs over the State is providing opportunities for older people to meet and plan together various activities which meet their own special interests. Activities of these clubs provide members with recreational outlets, development of creative hobbies, and continued education and occupational programs. These clubs also provide avenues for individual expression and leadership which are vital to all persons regardless of age. Red Cross training course for employed nurses aids.-The American Red Cross has developed a demonstration training program designed to give nursing home operators and aids training in improved techniques of nursing care. These courses are to be given by special trained Red Cross registered nurses. In North Carolina we have such trained personnel, with others receiving training, who will be able to give this nursing course to employed aids in our nursing and boarding homes. An inquiry made to the boarding and nursing homes by the department of public welfare indicated that 104 operators and 236 aids in 52 counties would like to have this course made available to them. We are aware of the need to improve the type of care now given in our boarding and nursing home, and this is an indication that we can expect such improvements by proper training of employees. This is anothe rstep in self-help for the care of our older and chronically ill patients. Report from study commissions Governor's Commission on Aging.-This 15-member study group appointed by Governor Hodges in 1956 has three basic objectives: 1. To review (quarterly) current activities within the State to meet the needs of older people. 2. To evaluate growing or unmet needs and plan together how best to meet these needs. 3. To report from time to time on matters in this area which affect the economic and social progress of the State. Major areas which have been reported upon include: 1. Special programs for placement of older people in employment. 2. Plans for expanding adult education programs. 3. Increased activity in stimulating recreation among older people. 4. A wider range of public health programs and services for older people, including a new division on chronic illness in the State board of health. 5. More attention and emphasis on the training of medical students to cope with the needs of older people. 6. Courses in geriatrics at the North Carolina School of Public Health Nursing. 7. Increasing the wide range of services through the public welfare program in terms of subsistance grants for older people, increased hospitalization, more adequate provision of domiciliary facilities, and other specialized services, including a demonstration of homemaker services for the aged. 8. Emphasis by the State mental hospitals, working with local agencies, especially welfare departments, as to home placement programs. 9. Strengthening the State retirement system. 10. Helping to bring information to rural people about services needed by and available for the aging through the auspices of the Agriculture Extension Service. The coordinating committee serves as a clearinghouse for all activities in this field of interest and work. Two other major accomplishments are: 1. Organization of county workshops on aging: I have already mentioned the fact the some 51 of our 100 counties have held such meetings at the local level, and to the fact that these groups are cooperating with the county medical society chronic illness chairmen. 2. Proclamation of a special week by the Governor: The week of July 12th has been set for 1959 and will provide opportunities for wide coverage of various programs conducted throughout the State in the interest of the aged. The Governor has designated this commission to plan for the State conference on aging for 1960 and for the 1961 White House Conference on Aging. The medical society has been requested to work very closely with this group at both State and local level for study, evaluation, and for recommendations as to present and future needs of our older citizens. The commission for cancer control.-The general assembly renewed its appropriation to this study commission and requested it to continue its study of improvements made and those needed for the next 2 years. A report of this commission has been prepared, reported to, and approved by the general assembly this year. The commission on nursing and boarding homes.-This commission and the Nursing and Boarding Home Association were primarily interested in getting the mandatory licensing law passed for all boarding and nursing homes. This law was passed and becomes effective as of January 1, 1960. Basic research at Duke Medical Center Under the able leadership of Dr. Ewald Busse, the Duke University Council on Gerontology was formally established by President Edens in 1955. A panel on interdisciplinary research was formalized and received its first grant September 1, 1957, from the U.S. Public Health Service, through the National Heart and Mental Health Institutes in the amount of $12 million. This grant is to be used over a 5-year period to set up a pilot regional center for research on aging. The panel is charged with the responsibility: (1) of determining the policies of the research program; (2) of collaborating with the project director in major decisions in regard to the areas of research activity, the selection of key personnel, and the coordination of the investigation. The center for the study of aging has as its aims: (1) encouragement and support of fundamental research concerned with the phenomenon and health programs of aging; (2) training of investigators for research in the problems of aging; (3) development of a source of scientific knowledge in the field of aging for State and local government as well as for private groups and individuals. The Public Health Service funds will support a teamwork approach to aging problems by workers in the fields of psychology, sociology, and economics as well as medicine. During the past 12 years, 19 separate research projects have been initiated by means of these funds. Additional support of the work of the center has come from Duke University as well as from other granting agencies. The Ford Foundation (February 1959) has granted $200,000 for a 31⁄2 years of basic research in the areas of social and behavioral sciences to complement the activities of the health and health-related areas. The research to date has involved a great many disciplines, including psychiatry, medical psychology, internal medicine, electroencephalography, anatomy, dermatology, ophthalmology, neurology, anthropology, and socio economics. Projected institute training program.-Another proposal being made by Duke University, which is still in the formative and discussion stage of development, is the possibility of establishing a continuing training institute designed to bring together from local areas physicans representatives of all agencies concerned with health, paramedical services, hospitals and the public for special instruction and training. The methodology and text content of such an institute would undergo continual evaluation in order that changing conditions might be met. Such an institute would be expected to coordinate all health endeavors with the center of aging at Duke University thereby merging their energies to focus on the problem of total patient care. Conclusion.-From this report of programs and activities now being conducted in the State of North Carolina, I feel that you will agree with me, representing the Medical Society of the State of North Carolina, that: (1) We are aware of the increasing numbers of older people and their needs; (2) we know our own resources and are combining our efforts to meet present needs and we are increasingly meeting the needs, as well as anticipated needs of the next few years; and (3) through basic research we expect to learn shortly some of the causes and effects of aging so that we may develop services, facilities, and trained personnel to meet these newly defined needs as they are discovered and identified. Financial assistance in the areas under consideration is but a single part of the total problem of the aging, and trying to solve one portion, in largess while neglecting the minute factors involved in the practical and adequate care of the aged, is not the answer to the total need. I would like to close with the results of a sample survey of the adult population conducted by the Opinion Research Corp., Princeton, N.J., for the American Medical Association. "More than threefourths of the population of the United States want to choose their own physician. In addition, they want to assume all or part of the responsibility for paying their doctor bills." I make this point to emphasize that the attainment of health and human happiness involves a great many choices which the individual must make for himself and that these choices involve the interplay of personal relationships out of which the whole may develop. Therefore, goals of the Forand-type legislation may well miss these important factors, even for the aging population, by removing factors of choice and self-participation which are so essential in a life such as we have so notably founded by experience here in America. At this time, I would like to recognize other representatives of the Medical Society of the State of North Carolina, President John C. Reece of Morgantown, N.C.; J. P. Rousseau, M.D., Winston-Salem, N.C.; and Mr. James T. Barnes, executive director, headquarters office, Raleigh, N.C. Thank you for your kind attention. STATEMENT OF OMAR B. KETCHUM, DIRECTOR, VETERANS OF FOREIGN WARS OF THE UNITED STATES JULY 31, 1959. Senator PAT MCNAMARA, DEAR SENATOR MCNAMARA: Thank you for the invitation to present the views of the Veterans of Foreign Wars concerning the problems of the aged and aging. The legislative efforts of the Veterans of Foreign Wars are controlled in the main by the resolutions adopted at our annual national conventions. Over the past several years the delegates to our conventions have expressed their concern with the problems of the aging in several fields, such as pensions, medical care, employment, and housing. Generally speaking, the members of our organization who participated in World War I have reached or are approaching the retirement age. These veterans are faced with the problems common to all citizens who must adjust to a life of retirement. One of the most vexing problems reaching the national level of our organization is the problem of inadequate pension payments. The second most pressing problem is the lack of adequate medical care with its high cost, particularly on an outpatient basis. On the inpatient basis more VA hospitals are reporting longer and longer waiting lists for qualified veterans desperately in need of treatment but must wait because of a lack of beds available. For these veterans without funds for medical care, it is a case of desperation and despair. In the employment field there seems to be a general consensus of opinion that after age 45 it is increasingly more difficult to obtain employment. By the |