We have done a backdoor approach to standards in these reports because we are suggesting minimum forms and procedures to carry on the functions of a home for the aged, medical and nursing services, personnel, dietary, and the all important business of keeping track of your income and expense.

We back all of this up with direct agency consultation.

On my staff in the division on aging, there are three casework consultants, a dietary consultant, a recreation consultant, and we have had part-time nursing consultation and we are expected not to sit on the 14th floor of the building where my agency is housed but to get out and actually see what the problems are and answer the questions. We join our agencies in joy when the accomplishments are theirs, when good things happen and standards are upgraded.

We are aware of the facts that homes for the aged and nursing homes and hospitals and the other group-care facilities serve a very small proportion of the aging but a significant proportion we believe, we know. Actually, as you all know, 4 to 5 to 6 percent of the older aged group are being cared for in these facilities and the homes for the aged that used to be the first resort is now the last resort and this is as it should be.

That is what we do.

Now, as I am limiting my remarks to the things that we know of first hand both from our consultation with agencies from a centralized intake service where we process applications for nine homes for the aged and from our information and referral service, I am limiting my suggestions, and I did not have time to prepare a formal statement, to those things that we believe are needed.

PROBLEMS CONCERNING HOMES FOR THE AGED

We see our homes for the aged, some of them, relaxing their administration requirements and this is as it should be. Some of them do it out of conviction. Some of them do it on an emergency basis. Some of them are doing it because of the pressure of vacancies as the well, the ambulatory, continue to live in the community until high ages as they should."

As we look at the buildings, many of them old, we are appreciative of the fact that capital repairs and replacements and remodeling cost money. We are aware, too, that some of these buildings cannot be remodeled and building costs these days, we know, are high.

Here we feel that the kind of financial support that comes through Hill-Burton money is of inestimable value. The money itself is important and matching basis but almost as important are the standards that go along if you are accepting Federal money, and we have noted with appreciation the fact that the Senate has indicated its awareness of the need for this kind of money and notably in the nursing home field.

Tied to this, I think, is the need for a realistic look at the staffing problems in homes, and here many groups have been concerned about the stretch of the very short professional supply, and I think more effort needs to be spent here.

What should a professional nurse do? Is she supposed to carry on the functions that might perhaps more properly be carried on by an aid? Here I think that in addition to the recruitment programs

that are going on and the many kinds of training programs that are going on, there is need for relaxation of the limits, perhaps elimination of the limits on earnings that are imposed on those in receipt of OASI benefits.

I think of a social worker on my own staff who is going to be employed at the age of 70 and she had a heart attack and she cannot carry on a full-time job. She can work 2 days a week but 2 days a week for $1,199 does not make very much sense, and I think you see this in many spots where the experienced, trained professional worker can be used on a part-time or in a consultation capacity.

I think there is need also for encouragement of our homes for the aged to do an outstretched job, if you will, into the communities. Here I think we need some financing of home-care programs.

There has been a great deal of talk about home-care programs but, as I looked at them recently as a part of a subcommittee activity of the mayors committee in New York City, there was a lot of talk and mighty few people being served under home care and in part this is due to the fact that your voluntary homes for the aged are having to finance this wholly and completely and their budgets are already out of balance in many respects in providing care for those who need the protective and infirmary care of the institution.

EXTENT OF LEGAL LIABILITY OF RELATIVES FOR SUPPORT OF OLDER FAMILY MEMBERS

One other point that I do want to make is in respect to the need for some study being made, and this is notably true as the costs of older people who are ill rise that study needs to be made of the legal liability of relatives for support of the older members in the family.

I think we are in no position at this point to say we are going to eliminate it as has been done in some of the less wealthy States, but it seems to me that here and across the board study needs to be made of the devastating effect of compulsory support on the lives of thousands of families.

Housing is needed, of course, but I am not competent to talk about this in detail except to comment that, in my judgment, it is unrealistic and probably unwise to expect voluntary homes for the aged to take advantage of the HFA money that is available. At this point, it seems to me that this is a wrong step for our homes for the aged to take today. Housing, if it is going to be done under voluntary auspices of this sort, needs to be tied to the full gamut of care that is now available only in limited areas.

Public agencies, as I see it, provide a broad base of service. Voluntary agencies can be expected and should be expected to provide plus services on an individualized basis that is greatly needed.

I think the Senate is to be congratulated on the appointment of this subcommittee. The care with which you are going into the problem is noteworthy and, if there is anything that my agency and some of the great national sectarian agencies can do, I think you have only to call on us.

I will file these reports with you just as a matter of interest and send you along a statement later.

Senator MCNAMARA. Thank you very much. They will be made a part of the record.

We will ask that you stay at the table, if you like, while a couple of others testify. We may have some questions that any of you can

answer.

Thank you very much for your contribution. It will be very helpful, you may be sure, to the comittee.

(The statement referred to follows:)

PREPARED STATEMENT BY MRS. JEAN WALLACE CAREY, DIRECTOR, DIVISION ON AGING, FEDERATION OF PROTESTANT WELFARE AGENCIES

The Federation of Protestant Welfare Agencies notes with appreciation and satisfaction the appointment of a Senate subcommitee charged to submit a report to the Senate in 1960 on the all-important subject of the problems of the aged and aging.

We welcome the opportunity to submit a statement on conditions and needs of the older-age population as observed by a central coordinating agency. The summer season precluded consideration of this statement by the federation's advisory committee on aging; fall meetings make this review possible. Under four general headings, this statement follows the pattern suggested by Senator Pat McNamara, subcommittee chairman, in his invitation dated July 20, 1959. 1. Summary description of agency interest and work in the field of aging

The Federation of Protestant Welfare Agencies is a central coordinating agency. Affiliated or associated with the federation are 219 Protestant or nonsectarian agencies serving people of all ages through 391 health and welfare programs in the Greater New York area.

The division on aging, estabilshed in 1936, renders a threefold service: (1) agency consultation to 64 agencies including 54 voluntary homes for the aged and 2 nursing homes; (2) a centralized intake service handling the inquiries and applications for admission to 9 homes for the aged (1958 vol. 1,007); and (3) a specialized information and referral service for older people (1958 vol. 733). Service is given by a professional division staff of six: division director, three casework consultants, a dietary consultant, and an institutional recreation consultant. Other staff specialists include consultants on purchasing, fundraising, and public relations. Additional service is given by a division on group work and youth services to 18 Golden Age Clubs and day centers for older people and to 8 summer camps for older people.

2. Some analytic evaluation of agency activities with an indication of additional responsibilities that might logically be undertaken

The core of federation service is agency consultation. In its broadest sense, this is provided through advisory committees and conference groups, through sponsorship of meetings and forums, through publications, through discussions with agency board and staff members, through grants-in-aid to expand or to upgrade services, through continuing contacts and close working relations with communitywide agencies, both public and private. Federation resources include an informed lay leadership, professional staff competence, and collected file information.

Committees include (1) an advisory committee on aging under the strong leadership of Edward K. Warren, composed of 40 lay people, holding 10 regularly scheduled meetings a year; and (2) a special project committee chaired by Albert Pleydell, composed of experts responsible for issuing a series of manuals on forms and procedures for use by homes for the aged.

Conference groups, each meeting from 4 to 10 times a year, provide a meeting place for the exchange of experience and joint action for administrators for homes for the aged, institutional activity workers, and social workers.

Two major meetings a year on varied and timely subjects in the field of aging, are enormously popular with lay and professional workers.

The most recent publications are four sections of a "Manual on Forms and Procedures for Use by Homes for the Aged," devoted to "Dietary Service," "Medical and Nursing Services," "Noncapital Financial Recordkeeping," and "Personnel Policies and Practices." Reissued is a "Menu-Maker." (Copies of these submitted to Senator McNamara). In immediate prospect are two other sections of the "Manual on Budgeting and Social Services." Close to 500 copies of each of the sections have been distributed locally and nationally. These are practical helps for the harassed administrators of homes for the aged and nursing

homes. Additionally they represent, if you will, a back-door approach to standards.

Direct discussion with board and staff members of homes for the aged and nursing homes is focused on a host of problems: Increased operating costs; need for more staff and more specialized personnel; need for revision of board and staff organization; remodeling existing facilities and provision of new facilities to care for the physically and mentally frail and ill; outstretched service to enable older people to live happily, safely, and comfortably in the community in accord with today's thinking and obvious trends.

The division on aging is acutely aware of the fact that great social forces make changed functioning of homes for the aged well-nigh inevitable. Homes for the aged were once the first resort for the older person. Today homes tend to be the last resort-but they represent potentially a strong and significant link in a chain of community services for the aging. To serve the frail and the ill constitutes a major change from the service heretofore rendered by homes for the aged to the young-old who were ambulatory and relatively well. The change provides an opportunity to rethink agency programs and imposes a responsibility to refocus agency programs.

The federation is geared and equipped to work with community leaders and responsible board members of agencies in the field of aging to interpret changed needs and to acquaint agencies with new programs, new ways of work and new opportunities to take advantage of community resources. Specifically, as new programs are developed under local, State, or Federal auspices, it is a staff responsibility to apprise the boards of directors and administrators of our member agencies of the development and about the ways that this ties in to established services. And in this connection, our approach is direct, pointed, and practical.

3. Specific problems of aging as seen out of our own organizational experience At least since 1950, we have been saying that the needs of older people are not new needs, nor are they all unique to the age group. They are intensified by the sheer increase in the absolute and proportionate numbers of older people and by the mobility of the population as a whole.

Underlying the specific needs is a basic need for change in community and individual attitudes about the capacities and potentialities of older people. Here the Senate subcommittee, through its hearings and publications, renders a highly useful service.

The specific needs as we see them from our own organizational experience

are

(a) Health facilities made available and appropriately used for the physically and mentally frail, ill, or invalided. Additional and restructed facilities for prevention, diagnosis, and treatment of chronic illness head the list. (b) Flexible living arrangements including safe, comfortable, and convenient independent quarters at low rental, with auxiliary services like housekeeping and shopping available when needed; semi-independent arrangements such as foster homes.

(c) Income maintenance at a level to meet daily needs and to cover emergencies, notably health emergencies.

(d) Counseling services to meet crises and everyday problems of adjustment which are often many sided.

(e) Recreation and adult education programs for all economic groups to provide social contacts and stimulation and to overcome isolation and loneliness.

(f) Opportunities for spiritual growth.

Below we note even more specifically what would be helpful from our vantage point of work with homes for the aged and with older people who tend still to turn first to homes for the aged as a solution to vexing problems.

First, homes for the aged need encouragement to serve the old old and the ill. Some homes for the aged are revising their admission policies to serve this group out of conviction, on an exception basis, or under the pressure of vacancies. On an across-the-board basis this is not happening. Encouragement is needed to speed up the process and the most helpful and effective encouragement carries a dollar sign. Physical plants are old and ill devised to care for the sick. Endowment and contributory income often represents a light cushion to balance an ever-rising operating and maintenance budget. Outside capital funds are

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needed to remodel and to build new facilities. Hill-Burton type grants on a matching basis are important. Here we have observed with appreciation that the Senate is favorably disposed to an increased appropriation with funds earmarked for nursing home construction. This kind of money-admittedly small in relation to the need-is helpful in its own right, but perhaps even more important is the imposition, if you will, of desirable standards. As of now, it seems unrealistic and unwise to expect voluntary homes for the aged to take the lead in utilizing FHA money for housing as such. Housing is needed, of course, but the great majority of homes for the aged are in no position to enter the housing field, when the gamut of care is limited. In connection with the foregoing point, realistic fixing of rates of payment for care of old-age assistance recipients in voluntary homes for the aged, is vital. In New York City, we are fortunate in that the New York City Department of Welfare sets rates that take into account per capita costs and level of service. Generally, however, there is a patchwork payment for care. Low rates of payment for care make a responsible board of directors cautious about contemplating capital expansion 100 percent borne by private funds.

Secondly, good staff and particularly competent professional staff, is in short supply. In addition to the recruitment and training efforts, attention should be directed to retaining or recalling into active employment the older skilled worker. Here raising or eliminating the ceiling on earnings for those eligible for OASI benefits would serve a practical end. Benefits need to be raised, too, but of equal importance is the freedom to continue to work and to contribute skills badly needed and in short supply.

Third, encouragement needs to be given to the extension of home care or nonresident aid programs under institutional auspices. These have been widely discussed and applauded as socially desirable and comparatively inexpensive programs providing security and as-needed service to older men and women living in the community until such time as protective institutional care is needed. Homes for the aged are hard pressed to balance institutional operating budgets in the face of ever-increasing costs. Presently confronted with the problem of 100-percent coverage of the cost of administering a home-care program, the development has been understandably slow. Financial coverage by public welfare departments of part of these administrative costs-on a contract or purchase basis-would extend such programs at small cost and defer entrance to increasingly expensive institutional facilities. Here, the trial period is past for demonstration of the value of home-care programs.

Finally, and we make only four points, it is important for continuing an objective study of the need for broadly based prepayment plans to meet the expenses of long-term illness. Tied to this or perhaps as an independent inquiry is needed for the Federal Government to give leadership to study of the effect on family of existing State laws on the legal liability of relatives for the support of the aged. The latter is fraught with difficulties, but the files of social agencies and probably the desks of legislators bulge with evidence of the devastating effect of compulsory support particularly when long-term illness occurs.

4. Relative responsibility of volunteer groups, local community, the State and Federal Government in meeting these problems

Time does not permit a detailed answer. In general, public agencies must provide the broad base of health and welfare services largely directed to maintain other people in the community as long as this is possible and desirable, with supporting health, recreation, and counseling services made widely available. Obviously, when the need for 24-hour and 7-day-a-week service is required primarily for reasons of failing health, government must provide the basic service either directly or through subsidy. The enormity of the problem makes this necessary.

Voluntary agencies can be expected to provide plus services on an individualized basis. Additionally, local and national voluntary agencies supported by citizen interest and concern provide an enormous reservoir to interpret the great public programs and policies. This Senate subcommittee has clearly shown its awareness of the interpretive role of voluntary agencies at a grassroots level and may assuredly count on this in the future.

Senator MCNAMARA. Next on our list is Dr. Joy Elmer Morgan, president of the Senior Citizens of America.

We are glad to have you here this morning, Doctor.
Proceed in your own manner, sir.