the Public Heatlh Service Act, the funds to be earmarked for support of State dental public health activities. The third method that the Federal Government might use more fruitfully in improving dental care for the elderly is the public assistance program. The association recognizes that Federal funds are today earmarked to support State health care programs for the indigent aged. The great need is to stimulate State legislatures and administrative agencies to allocate funds from public assistance grants for dental care. This is a problem which must be solved primarily through dental health information and education programs at the State and local levels. The Federal Government can help by focusing attention on dental health needs. Again, an appropriate device would be through earmarked funds for State dental public health activities. The association has previously presented in summary form an evaluation of the dental health problems of our elderly citizens. We ask that this summary, together with the covering letter, dated May 13, 1959, from Dr. Ralph E. Creig, chairman of the association's council on legislation, and the attachments to our summary be inserted in the record following my statement. In behalf of the American Dental Association, I wish to thank the committee for the opportunity to testify on this important area of national health concern. APPENDIX I AMOUNT OF DENTAL CARE REQUIRED BY PEOPLE 65 AND OLDER COMPARED TO OTHER AGE GROUPS Several national surveys have shown that the percentage of the population' obtaining dental care during a given period of time reaches a peak in early adulthood and declines with each higher age group. In the "Survey of Needs for Dental Care," conducted by the association in 1952, dentists throughout the country submitted data on 38,741 patients, or 0.0247 percent of the U.S. population, seen on a specific date. People in the age group 30 to 34 were most heavily represented, 0.0351 percent of the population in this age group being included among the 38,741 patients. With each higher age group the percentage declined, reaching 0.0200 percent in the 60 to 64 age group; 0.0156 percent in the 65 to 69 age group; 0.0113 percent in the 70 to 74 age group, and 0.0007 percent in the 75-and-over age group. A similar pattern prevailed in the "1950 Survey of the Dental Profession," in which dentists submitted information on 29,703 patients seen during the course of a week. The U.S. National Health Survey, conducting nationwide interviews in August 1957, found that the percentage of people having seen the dentist within a year was highest at ages 15 to 19 (50.3 percent), and declined with each higher age group to 26.5 percent in the 55 to 64 age group and 15.8 percent for the population over 65. These figures do not show a sudden drop in visits to the dentist at age 65; rather the decrease is gradual after the peak is reached in early adulthood. Dental expenditures are perhaps the best single measure of quantity of dental service received. In the "Family Dental Survey," the association gathered data on dental expenditures from 2,443 families, consisting of 8,320 individuals. These data indicated that the annual expenditures for dental care per person seeing the dentist remained nearly constant from age 15 to age 70, at about $27 per person in 1955. For the age group 70 and older, the figure dropped to about $20 per person seeing the dentist. Average annual expenditures based on the entire population, including persons not seeing the dentist, declined with age after early adulthood. From an average of about $17 in the age 15 to 19 bracket, there was a gradual decline to about $10 at ages 60 to 69 and $6 at ages 70 and over. MONTEFIORE-BETH ABRAHAM STUDY, NEW YORK CITY Some possible changes in dental practice are envisioned in studies beginning on needs of the chronically ill and aged by the Division of Dental Public Health, Public Health Service, Department of Health, Education, and Welfare (May 1, 1957). The now-intensified program enters an important phase with the initiation of the cooperative project of the Division with Montefiore Hospital and the Beth Abraham Nursing Home in the Bronx (New York City). The Montefiore-Beth Abraham study is centered on the development of portable dental equipment and techniques for dentists to use in the care of bedfast and homebound patients who now get little or no dental care because they cannot go to a dentist's office. When portable equipment and techniques have been developed, the dentist will be able to treat at home those chronically ill-too ill to be moved. The dentist's treatment of patients will be expanded, to some degree, into the two categories of patients the family doctor has under care-ambulatory patients coming to his office for treatment and the more seriously ill who have to be treated at home. "It is imperative that information be collected on techniques and equipment for treatment of the bedfast and also for persons suffering from unusual conditions," Dr. Norman F. Gerrie, chief of the division of dental public health, said. "The overall effect of such service on rehabilitation must be evaluated and the costs of providing this care must be found. Technical and administrative problems must be ironed out." More than 5 million Americans suffer from chronic illness or the debilities of old age. While this group is growing because of longer life spans and increasing population, there is still very little information on the extent and nature of their dental ailments and needs. Montefiore Hospital, long a leader in care of the chronically ill, was selected as a cooperating agency because of its interest in the dental problems of the chronically ill. The patients in its home care program and those of the Beth Abraham Nursing Home are representative of patients found in many institutions and among the homebound chronically ill population. A Public Health Service dentist and dental hygienist will accumulate data on dental needs of the homebound and institutionalized patients. A three-chair clinic has been set up a Beth Abraham Home in which provision has also been made for treatment of stretcher and bedfast patients. Complete dental service will be provided to the approximately 400 inpatients in the Beth Abraham Home and to the approximately 80 patients in the Montefiore Hospital home care program. STUDY OF DENTAL SERVICE NEEDS OF INSTITUTIONALIZED AND HOMEGROUND CHRONI- Background Little factual information is available concerning the nature and extent of the dental service needs of the institutionalized and homebound chronically ill or aged person, or about the problems, both technical and administrative, which would be involved in providing the required dental services. It is imperative that a body of information be collected to provide the basis for planning programs to care for these people. In order to obtain the necessary information and experience, a dental clinic will be established in the Beth Abraham Home and staffed with a full-time dentist and auxiliary personnel. Clinical dental services will be provided to all inpatients of Beth Abraham (approximately 400 persons) and to all patients in the Montefiore home care program (approximately 80 average daily census). Objectives of the proposed project 1. To determine the extent and nature of the dental needs of chronically ill patients in a nursing home and in a home care program. 2. To develop clinical techniques and methods for providing dental care services to both bedfast and ambulatory institutionalized and homebound chronically ill individuals. 3. To determine the cost of providing the dental services needed by chronically ill patients in a nursing home and in a home care program. 4. To develop and evaluate specialized equipment for providing dental services under unusual conditions. 5. To determine the effect of dental services in the overall rehabilitation of the chronically ill. Dental services to be provided Complete dental service will be given all patients in the program, provided the treatment is determined to be in the best interest of the patients' total health. The decision that dental services are in the best interest of the patients' total health will be made following existing procedures for determining appropriateness of other supportive health services. Priority of service will be to patients in the home care program and nursing home. If time permits, dental services may be provided to hospital outpatients selected for their value as study cases. Any patient in the home care program, whose health status permits his being transported to a central point for service, will receive dental care at the Beth Abraham dental clinic. The others will be treated at home. Beneficiaries All patients in the Beth Abraham Home and all patients of the Montefiore Home care program, regardless of age or medical diagnosis, wil lbe eligible for service at no cost to them. Data to be collected The objective of the Public Health Service in participating in this project is to obtain a body of information which will serve as a basis for planning communitywide programs to meet the dental needs of institutionalized and homebound chronically ill and aged persons, and to evaluate selected types of fixed and mobile dental equipment. Consequently, the following types of information will be needed: (a) Measurements of dental needs, age, sex, medical diagnosis, social evaluation. (b) Measurements of time and cost required to provide dental services in clinic and to bedfast patients in nursing home and private homes, both by dentists and auxiliary staff. (c) Determination of effectiveness of various kinds of fixed and mobile dental equipment. (d) Determination of the value of dental services in improving the health and social well-being of the patients. Period of agreement It is suggested that the project cover a minimum of 2 years and a maximum of 4 years. The minimum period of time would be required to obtain experience and data required for planning other programs. It may be appropriate to consider extension or modification of the project whenever warranted by unfore seen developments. Administrative relationships The success of a project such as this is dependent upon the complete integration of the dental service as a part of the overall health program. It would seem appropriate, therefore, to define certain administrative responsibilities. The project dentist will be responsible administratively to the director of Montefiore Hospital. Auxiliary dental personnel will be responsible to the project dentist. The chief of the dental department of Montefiore Hospital will act in an advisory capacity to the project dentist upon the request of the project dentist or director of Montefiore Hospital. He can serve a particularly important role in regard to insuring continuity of dental services for individuals transferred from one service to another; e.g., hospital to home care. The Public Health Service also will provide advisory assistance through the Chief of Dental Services, New York area. Continuing review will be made of study progress in order that appropriate modifications or additions be made. A complete review of the project will be made within 3 to 6 months after its initiation. Any modifications in study plans will be discussed and agreed upon jointly by the appropriate professional representatives of the cooperating agencies. The Montefiore staff will serve as authorities on matters involving the medical and social aspects of the project; the Public Health Service, on matters involving methods and techniques for providing dental services and the scope and quality of such services. All publications will be presented under the institutional titles of the agencies involved: Montefiore Hospital, Beth Abraham Home, and the Public Health Service. Individuals involved in the project will retain the right to make general references to the project in independent publications concerned with such matters as the health problems of the chronically ill or the need for dental services by special groups. All study forms, including dental examination and treatment records, will be designed and provided by the Public Health Service. Contributions of cooperating agencies Public Health Service: One dentist. One dental hygienist. Two dental assistants. Dental equipment and supplies. Laboratory fees. Consultant dental services. Records (including design). Analysis of data. Transportation for home care. Montefiore Hospital and Beth Abraham Home: Clinical space and utilities. Remodeling and installation of equipment. Consultant services: dentist, physician, social worker, nurse. (If requested to provide clinical dental services, the dentist will be paid a consultant's fee by the Public Health Service.) Ambulance and other transportation for home care patients. Joint: Planning. Review. Evaluation. Publication of findings. APPENDIX III KANSAS CITY STUDY A 4-year pilot study of an entire community will be made to identify the problems and to develop solutions to the problems of making dental services available to the institutionalized and homebound chronically ill and aged persons, the Public Health Service has announced. Kansas City, Mo., has been chosen for the study and demonstration by the Service's Division of Dental Public Health, which will conduct the study. The project will serve as a pattern to be followed by other cities. The Kansas City metropolitan community, represented by Community Studies, Inc., will cooperate in conducting the project. The University of Kansas City School of Dentistry is the first community agency to participate in the project. As a major contribution, it will remodel an existing structure to provide space for the study clinic. "In most communities, there are many institutionalized or homebound individuals who are in need of dental services but are not able to obtain them," Dr. Norman F. Gerrie, Division Chief, said. "The reasons are many and include lack of funds to pay for dental services and inability of the patient to come to the dentist's office. It is a health department and community responsibility to make necessary dental services available to those individuals. It is also the responsibility of the health department and community to make a real effort to encourage the utilization of such services, once they are available." Dr. Donald J. Galagan, Assistant Division Chief, who has specialized in studying the problems associated with providing dental care for the chronically ill, said the group with long-term illness now numbers more than 5 million. He said "They are the forgotten in dental care. The fact must now be faced that many individuals will live for long periods of time with chronic, incapacitating illnesses." A sample of the institutionalized and homebound chronically ill and aged population in the Kansas City metropolitan area will be studied from a standpoint of dental needs, and a selected group of patients will be provided with dental service. One phase of the project will focus attention on the community potential for providing dental service and stimulating acceptance of responsibility and appropriate action on the part of the community agencies. Community groups, official and nonofficial, will be brought together to consider what each can contribute to the solution of the problem. PROPOSED COMMUNITYWIDE PROGRAM FOR PROVIDING DENTAL SERVICES FOR INSTITUTIONALIZED AND HOMEBOUND CHRONICALLY ILL AND AGED PERSONS (A cooperative project of the U.S. Public Health Service, Division of Dental Public Health, and the Kansas City metropolitan community represented by Community Studies, Inc.) Background In most communities, there are many institutionalized or homebound individuals who are in need of dental services but are not able to obtain them. The reasons are many and include: lack of acceptance of this type of patient by the dental profession; lack of funds to pay for dental services, inability of patient to come to the dentist's office. It is a health department and community responsibility to make necessary dental services available to these individuals, even if they cannot pay for the services. It is also the responsibility of the health department and community to make a real effort to encourage the utilization of such services, once they are available. It is proposed, therefore, to carry out a combination study and demonstration in a community to identify some of the problems and to develop solutions to the problems which are involved in making dental services available to institutionalized and homebound chronically ill and aged persons. Objectives 1. To determine the nature and extent of the dental service needs of all nursing home and long-term (over 30 days) hospital patients and of some segments of the homebound chronically ill and aged population in the community. 2. To identify resources in the community which might be brought to bear on the problem. 3. To demonstrate how existing community resources can be marshaled for partially meeting dental service needs of the institutionalized and homebound chronically ill and aged. 4. To determine the technical, dental, and administrative feasibility, and to obtain information upon which to base estimates of the cost of providing, within a community wide framework, dental services to supplement those already available in the community so that dental services will be available to the entire chronically ill study population. Study site The site for the study is the Kansas City metropolitan area consisting of the four counties: Johnson, Wyandotte (Kans.), Jackson, and Clay (Mo.). Study population The size of the study site restricts the study group to only part of the institutionalized and homebound chronically ill and aged persons in the community. Generally speaking, the entire institutionalized chronically ill and aged population will be studied from a standpoint of dental needs, but the dental service aspect of the project will be concerned with patients in a particular group of institutions-probably selected on the basis of size of institution. The study group of homebound will be selected primarily by using known case lists. study group will not be a representative sample of chronically ill and aged persons in the Kansas City metropolitan area, but since the prevalence of chronically ill in the area is known, it will be possible ultimately to describe the study population in terms of the total known chronically ill and aged population. Method The The components of the proposed study-demonstration will be fairly distinct entities, but more than one aspect of the study may be underway at a given time. There are three major study and demonstration areas. Each will be described briefly : A. Problem and resources survey.-A precise determination will be made of the dental service needs and the resources available in the community to meet the dental needs of the study population. Information obtained through the survey will include: 1. Number of institutions in the community having chronically ill and aged, according to size of institutions, types of medical and dental services provided, and types of institution (public or private, profit or nonprofit). |