nvisioning nursing or intermediate care to this type of patient, the following nel would be required to activate the ward: es (associate grade)....... ing aids (seventh step of GS-3). sician (general) -- ective theraphy aid.. iotherapy aid. 1 secretary or_ en helpers eation specialist_ tence.. llaneous Total cost, including salaries, to activate the ward____. average daily patient load of full occupancy in this ward would add 14,235 ent days to our present assigned load of 255, or a total of 107, 310 inpatient This would represent a 13.2-percent increase in our patient load. We estimated that it would cost approximately $18.11 per diem to activate and is ward on an annual basis. However, this does not cover the apportionof hospital costs for any laboratory work, social work service, professional ils, etc. Inasmuch as this ward would not be separated from the total al appropriation, it would reflect a downward per diem cost of $26.38 as sted with our present per diem of $27.80. EXCESS BUILDINGS AT THE STATION e following information is that requested by the Honorable Ray Roberts for bcommittee on Intermediate Care: rteen buildings, numbers 156 through 168, comprising 61⁄2 wards situated e northwest area of the hospital, were formerly the tuberculosis wards. buildings were originally included in the group of buildings considered to our local needs, but were retained until recently to preclude premature sal should a need arise for their use. They, therefore, represent the last of coup reported to the Assistant Administrator for Construction as excess to eeds. This action has already been taken. 1960, a local study of these buildings was made, and it was determined that, present bed spacing, an additional maximum of 240 beds with necessary istrative areas could be developed if the need arose. Moreover, it was ated that this could be accomplished at a cost of approximately $750,000, ded we could use the station engineer as resident engineer, use purchase and abor, and contract for certain services and installations. The cost would le building service equipment but would not include other ward and portable red equipment such as beds, sterilizers, etc. This was conservatively estid at an additional cost of $75,000. The buildings as they now stand are in lorable condition and would need complete renovation and refurbishing. buildings are of wartime, temporary construction, consisting of 8-inch hollow nd supported above ground by concrete piers. The walls are attached and orted at the base by the floor and at the roof by a trussed ceiling. The at roof would have to be completely replaced and all plumbing within the ngs would have to be replaced. An additional factor that should be coned, not included in the above cost, is complete weatherizing of exterior walls ncrete stucco, or some of the newer plastics. Seepage of moisture through walls constantly lifts interior paints over widespread areas, thus making nued maintenance a costly recurring maintenance and repair item. MEMPHIS, TENN. MARCH 6, 1963. providing the information which you requested relating to nursing-care which could be accommodated and staffed in our existing physical plant, ish to remind you that a replacement facility has been programed for con terim would be contingent upon the selection of a site at another location. The plan for construction at the present site contemplates the renovation and use of all unoccupied buildings to permit the temporary relocation of regular hospital activities. We are taking this opportunity to also point out that 88 beds are included within our present bed complement for intermediate care. This central office, designated intermediate service, is under the direction of a full-time chief of service, and he is assisted by another full-time physician. The staffing pattern for nursing care differs very little, if at all, from that provided our regular medical beds. Currently, we find that 35 patients occupying beds on our intermediate service might be considered suitable for assignment to nursing-care beds. There is considerable diversity of definition of nursing-care beds in the hospital field. As a general rule, we believe that each prospective bed occupant would have to be evaluated in terms of the nursing-care hours per day required and compared with the average hours per patient day provided in the staffing pattern of each nursing-care unit. MOUNTAIN HOME, TENN. MARCH 8, 1963. Your letter of February 25, 1963, directing that certain questions be answered in the space provided at the bottom of your letter, has been received and answered to the best of our ability, using the figures that would treat the 160 veterans as nursing-care patients and as an integral part of our hospital. The problem of providing medical care for the increasing number of veteran patients with long-term illnesses is acute at this station. In 1952, building 8wards 16 and 17—was designated to care for the long-term chronically ill patients, and at the present 127 long-term chronically ill patients occupy these two wards. On September 2, 1953, a space utilization survey was made by VA central office of building 2, which at that time housed some 500 domiciliary members, and it was designated for intermediate care for domiciliary members and, although these plans were never completed, a modern domiciliary medical clinic was established on the ground floor and exterior wheelchair ramps, alterations to water sections, and other work was done in this building. In the clinic a laboratory, X-ray room, pharmacy, office space for five doctors, record office, etc., were provided. Considering the plan as an enlargement of our domiciliary program, it provides adequate care for certain intermediate-type cases that are presently ineligible because they do not meet the ability requirements of VAR 6047 (C) (3) (a) through (e) and (D) (1) through (8). It proposes the use of qualified nonprofessional employees for assistance with daily ablutions, dressing, wheelchair movement, feeding, etc. Cases requiring professional medical care beyond outpatient treatment and substitute self-help in following instructions could not be placed in this setting. Bedridden cases, those not capable of sitting alone in wheelchairs, those without voluntary control over body elimination, and those mentally disturbed would be precluded from this care. At the present time, as part of our domiciliary program, we have 274 nonduty domiciliary beds in buildings 7 and 93. These men are old, crippled, blind, and in wheelchairs, etc., and are not able to be cared for in the domiciliary-duty program. If building 2 could be renovated and used as part of our domiciliary program, it would mean that we would have another step in the domiciliary care of the veteran, slowing down his eventual admission to the hospital and keeping free our hospital beds for acutely ill patients. Dr. J. C. Neale, chief, outpatient department, which includes the domiciliary clinic, has submitted a statement for my information concerning intermediate care versus domiciliary care, which is attached for your perusal. Your attention is called to the cost where we have used the highest figures for renovation on the theory that if it becomes necessary to change this proposed building into part of the hospital, it could be done without further expenditure other than for increased personnel and some additional equipment. THE PLACE OF INTERMEDIATE NURSING CARE IN DOMICILIARY By whatever name they may be called or whatever the type of care may be designated, the senile, debilitated, chronically incapacitated old veteran is the major problem faced in domiciliary today. He is not acutely ill to the extent e should be hospitalized, and yet he requires so much care, medical, nursing, eneral custodial, that it is impossible for the family, if any, to accept respony for him. Furthermore, the routine medical, nursing, and custodial care ble in a domiciliary is not geared to provided the special and extensive care he needs. ring a certain percentage of the time he not only can care for himself but s upon this privilege. Suddenly and for varying periods of time he may e almost total nursing care because of physical or medical situations which developed. ese old veterans cannot be cared for in their homes, if they have such, because ies and personal time of the family is not available. Again in most instances, f families are available, finances are inadequate to meet the problem. These terans are not wanted in the general hospitals, since they are not sufficiently y ill to justify hospitalization on an active medical ward. Little can be plished to improve their overall physical condition and their stay in the al is usually indefinite, thereby freezing beds for acutely ill medical and al patients. Domiciliaries usually have limited facilities to care for this of member and, therefore, must maintain a waiting list for admission. ically, those domiciliaries connected with general medical and surgical als avoid accepting these cases for admission when they are not in their sal areas, since admission to the domiciliary is another back-door method of admission to a hospital for an indefinite period, thereby freezing additional or acutely ill medical and surgical patients. Unless their terminal illness is short-duration type such as myocardial infarction, pneumonia, etc., these iliary members often become long-term, chronically ill hospital patients. s obvious that all chronically incapacitated domiciliary members cannot be ied in one group but must be placed in several categories depending on their al and physical capabilities. It would, therefore, seem highly desirable his be recognized in providing domiciliary medical, nursing, and custodial o the end that provision be made to care for these patients at several diffierent . Specifically, the long-term, chronically, seriously ill patient is a hospital nd should be so cared for. Immediately below this patient is the chronically ividual who requires a limited amount of medical care, a relatively large nt of nursing care, and almost total custodial care. This individual may be cared for in domiciliary surroundings staffed realistically to meet the of the veteran. In this situation the member would be moved to hospital nly when his medical condition became such that he was considered acutely eriously ill, requiring more medical facilities than should be made available omiciliary-care setup. s domiciliary facility would, of course, be staffed by physicians, nurses, and lly trained auxiliary personnel as may be required. › next step would be the domiciliary member who could care for himself normal conditions providing adequate facilities were available, close at and some assistance in the form of semiskilled or unskilled attendants ble. These would include wheelchair members in reasonably good physical ion, blind individuals, compensated cardiac cases, and all such cases requirnstant medical and custodial care but a minimum of nursing care. In this ›nment special emphasis should be placed upon custodial care and the ishing of sufficient medical safeguards to insure adequate medical attention times. › remaining domiciliary population might still be subdivided depending upon al needs, physical handicaps requiring special environmental conditions ustodial needs. Such classifications might easily vary in different locations ding upon the predominant type of domiciliary members being cared for he overall housing facilities available. Each facility might well solve its roblems after reasonable study of the needs and facilities available. nursing-care beds can be provided now without displacing M. & S. patients. -bed replacement hospital is programed for completion in 1966. At that approximately 600 beds in the existing ward buildings would be available nversion. A considerable amount of renovation would be required, the f which would be from $500,000 to a million dollars, depending upon the of the remodeling. The estimated per diem cost for this type patient .be $15. MARCH 4, 1963. This hospital is of cantonment type, built by the Army in 1943. It contains five permanent buildings and many temporary structures. Several of our temporary buildings could conceivably be put to use as nursing-care units, containing 30 to 40 beds each, but I would not recommend this step for the following reasons: (1) These temporary buildings contain much flammable material in their construction, and I do not believe that they could be made fireproof short of almost complete rebuilding. (2) The accumulated deterioration of aging would require extensive modernization if these buildings are to be put to any long-time use. (3) The cost of renovating and modernizing each of these buildings could be up to $75,000 each, depending upon the standards to be met, and even this expenditure would not provide a fireproof building. (4) The single-story construction of these buildings makes them very hot and uncomfortable in the summer unless completely air conditioned. (5) The location of these temporary buildings, remote from laboratory, X-rays, clinics, and kitchens, would create additional transportation and communication expense. (6) This hospital is scheduled for modernization or replacement, and I do not anticipate that the temporary buildings I have in mind would be included in any such program. The cost of equipping these buildings would be up to $13,000 each. Staffing of additional nursing units of this sort would be extremely difficult. It has been my experience that it is hard to recruit good qualified physicians who are willing to work in nursing-care units. Insofar as nurses are concerned, we have not been able to recruit our full complement of nurses in recent months, and it is quite doubtful that we would be able to recruit enough nurses to staff additional units. Per diem cost for nursing-care units can vary according to the standards of care to be provided and the type of patients to be cared for. However, highest quality care for patients who are entirely helpless could be quite expensive. I would estimate that it would require about 6 months after bids for modernization contracts have been let before the first building could be activated if we could successfully recruit necessary personnel by that time. ROSEBURG, OREG. FEBRUARY 25, 1963. We could not provide any nursing-care beds unless additional buildings are constructed. Presently, we are operating 598 psychiatric beds and 56 general medical and surgical beds, or a total of 654 beds, within space which should accommodate no more than 500 beds. All of our 654 beds are required to satisfy psychiatric and general medical and surgical needs. RUTLAND HEIGHTS, MASS. MARCH 5, 1963. In April 1962, during a visit by a representative of the Joint Commission on Accreditation of Hospitals, it was recommended that one of our buildings, which was used for the care of 64 patients, be vacated and closed until alterations, acceptable to them, could be completed. This building, constructed in 1923, is structurally sound. However, objections to the use of the building for patient care was that the corridors were too narrow and the doorways to the rooms were to narrow to permit wheelchairs or beds to be removed without dismantling them. This building, known as building No. 21 on our plot pan, could be utilized and would provide an excellent nursing-care building for 50 patients. Our engineering staff has determined that renovation and alterations costs for the interior would approximate $230,000. Cost of necessary equipment, technical, medical, and dietetic, would be $30,000. Professional personnel have determined that the staffing requirements for this building would require an estimated per diem cost of $27 and the building could be activated for nursing care 15 months after award of the contract for renovation and alterations. The costs involved are far less for the renovation of this structurally sound building than would be required for a new building of like capacity. THOMASVILLE, GA. domiciliary is in a fortunate position of having a number of vacant cannt-type buildings. There is adequate space available for 400 such beds. ost could be multiplied for each additional 100 units with the exception of nent which would be $25,000 rather than $60,500 as it was with the first its. $10 per diem cost is predicated on the fact that we get nursing-care cases; er, if these veterans deteriorate to the condition they need total bed care e do not have a place to move these men, the cost would almost double. timate approximately $18 per day. There is a possibility, however, we solate them total-bed-care cases and would reduce the average to about $15 y overall. TUPPER LAKE, N. Y. MARCH 7, 1963. estimated per diem cost, projected on an annual basis for 64 nursing-care mounts to $201,383. This is the amount we would need annually in addio our present recurring primary fund allocation for these additional beds. ajor item in cost of renovation and equipment is the installation of an Dr. WALLA WALLA, WASH. MARCH 1, 1963. nk you for your letter inviting questions in regard to nursing-care beds. In ing your first letter in which you requested information in regard to the er of nursing-care beds we could provide and staff, the question arose among aff as to the definition of "nursing-care beds.' It was felt that there could wide variance in interpretation which would have a definite effect upon ons which would have to be made regarding equipment and staffing needs. ents occuping such beds could range from the fully ambulatory patient, g custodial type care, to the nonambulatory and totally helpless patient. ese patients would need nursing care of varying degrees. In thinking of pe of patients ordinarily referred from VA hospitals to a nursing home, we zed a patient who would usually not require any kind of intensive nursing He might or might not be a bed patient but would require minimal nursing nd no acute episodes would be anticipated. finally decided that the term would include patients for the most part needoportive nursing care, i.e., those who need to be kept clean and comfortable heir nutritional needs adequately met. This would eliminate cases where nursing service would be required such as those requiring special posig, care of decubitus ulcers, Stryker frame patients, those who must receive enous medication, complicated irrigations, catheters, etc. ce some of the patients would not be ambulatory, it would be necessary to levators between floors and porto-lifts, walkers, and other equipment of this è available for use on the ward when needed. Even though a physician not be required on full-time duty on such a ward, it would be expected that sician would provide supervision through scheduled visits to the ward. We ontemplate that the ward would be supervised by a registered nurse and that ed practical nurses and nursing assistants would give the necessary bedside liscussing the answers to the questions posed in your letter, we are assuming he pateints occupying the nursing-care beds will be of the type mentioned We would appreciate knowing if our interpretation is in conformance with deas on this subject. MARCH 8, 1963. s is to provide you with our answers to the questions raised in your letter of ary 25, 1963, relative to the establishment of nursing-care beds at this al. The answers to your specific questions are set forth below: per of nursing-care beds which can be provided_ 64 $47, 300 $28, 838 $7.65 5 |