selected hospitals to ascertain the number of nursing care beds which would be provided at Veterans' Administration hospitals has already been submitted.

A hearing is being planned for the first week in April with the Administrator of Veterans' Affairs. It is the purpose of this hearing to cover a number of major policy issues before the committee, including the question of intermediate or nursing care. Attached is an extract of the letter I sent to the Administrator requesting his comment and position on an expanded nursing care program.

At the present time the Veterans' Administration pays $2.50 per day to State homes located in 31 States. These homes provide domiciliary care to certain veterans of Federal service. Many of these homes have infirmaries and nursing facilities; however, the program presently operated by Veterans' Administration does not permit payment of the $2.50 per day subsidy if the veteran when he applies for admission to a State home is in need of nursing care exclusively. For several years now the State homes have been seeking a grant program on the basis of matching funds from the States with which to expand facilities. Legislation of this type is pending before the committee now. It is requested that your subcommittee explore the possibility of extending the $2.50 per day allowance to all qualified veterans in State homes particularly those receiving hospital and/or nursing care and consider the possibility of a matching funds program aimed at encouraging the construction of hospital and nursing facilities by the State homes.

It is suggested that the first hearing of the subcommittee be delayed until the Administrator of Veterans' Affairs has made his appearance before the committee during the first week of April.

Sincerely yours,

OLIN E. TEAGUE, Chairman.

The Administrator of Veterans' Affairs has previously testified on this subject as well as others in his appearance before the full committee on April 3, 1963, and without objection I will insert at this point Mr. Gleason's remarks of that date on the subject to nursing care. (The material referred to follows:)

STATEMENT OF THE ADMINISTRATOR OF VETERANS' AFFAIRS BEFORE THE COMMITTEE ON VETERANS' AFFAIRS, HOUSE OF REPRESENTATIVES, APRIL 3, 1963

NURSING HOME AND RELATED TYPES OF CARE

As the committee well knows, we are faced with an ever-growing problem concerning the increasing numbers of our aging war veterans who require a type of care not generally provided by the present system of hospital, domiciliary, and outpatient services. For example, there are now in VA hospitals several thousand veterans who have received maximum hospital benefits and are now in need of a form of care which is provided in nursing homes or similar facilities.

Some of them could get along well in their own homes if competent assistance were available. Others would accommodate well to a foster home environment. The crux of the problem is that despite our efforts to place these patients in suitable community facilities, it is often impracticable to do so, especially where the veteran's income is severely limited. This situation is progressive and is becoming more widespread. Where we are unable to find a place for the chronically ill veteran who has reached the point of maximum hospitalization, we sometimes must retain him as a patient for an indefinite period of time. This limits the availability of beds in our general hospitals for the care of other veterans who require definitive hospital treatment.

We are hopeful that the restoration center plan will produce good results. As you know, this is now being tried out at Hines, Ill., and will be tested at East Orange, N.J. In this efort we concentrate on rehabilitation of chronically ill veterans who have been transferred from the hospital and offer a real prospect of early return and adjustment to their home community. There are other patients who cannot be rehabilitated to this point and need attention in a nursing home or other suitable environment. What to do for this group poses a large question to which we have not found the answer.

In the last Congress, the House of Representatives passed a joint resolution reported by this committee which would have authorized $300,000 for a special study in this field. This would have included a pilot project involving various kinds of services outside VA facilities, coupled with supplemental payments, to test ways and means for meeting the needs of chronically ill patients who have

received maximum hospital benefits. We agree that a suitable study should be made but feel that it should not be as broad as that provided by the resolution which is again before you this year.

Our budget requests for 1964 include an item of $150,000 for initiating a special study of this kind. If this is granted, we will explore carefully the availability and adequacy of community facilities in relation to the needs and circumstances of veterans actually hospitalized in VA facilities in various localities. In developing solutions to this difficult problem it may ultimately be necessary for us to try various approaches.

Your committee is interested in the possibility of placing into service a number of unused beds in the VA system to provide nursing home or intermediate type of care. It has been our practice to intersperse chronically ill patients who continue to need active hospital treatment with other patients and not to set them apart; and we have some serious doubts about the advisability of providing separate facilities for intermediate care, as distinguished from nursing home care.

As to those whose primary need is for attendant type care such as that provided in skilled nursing homes, we are confronted at the outset by a serious question of policy. How far should the Federal Government go in assuming a special responsibility to veterans in this field?

This responsibility is being partially met through existing Federal programs for the aged under which State and local expenditures for nursing home care qualify for Federal matching grants. For example, the Bureau of the Budget tells us it is estimated that during fiscal year 1962 total expenditures from all sources under these programs for nursing home care exceeded $200 million and represented almost 38 percent of all medical care expenditures under these programs. Veterans, of course, may qualify for this assistance. The committee is also aware of the President's recommendations concerning the enactment of a hospital insurance program for the elderly under the social security system. This would include nursing home services immediately following discharge from a hospital.

Heretofore this has been regarded as chiefly a community responsibility, with such Federal assistance as may be extended under general aid programs. Meeting the problem at the community level also has the practical advantage over regional Federal facilities of keeping the patient in or near his accustomed home surroundings.

I am very doubtful that we can place a limited number of unused facilities in our hospitals into use for nursing home type care without making a heavy commitment to the future. This would doubtless be followed by insistent and quite logical demands for increasing these facilities to meet the mounting requirements for this care from our large and aging war veteran population.

I think we must realize that the initial step in providing nursing home care on a small scale could not be held to those who have received maximum hospital benefits in VA hospitals. This would lay the foundation for an expanded Federal system to furnish this form of care, at the complete expense of the Federal Government, to a large potential group who have not been previously admitted to our hospitals.

In turn, this could lead to the problem of how to establish and maintain sufficient nursing home facilities to meet the ultimate demands to a substantial extent. To do this would require either an additional layer of nursing care facilities at considerable cost to the Government or a sharp change in planning to substitute nursing home beds for either hospital beds or the present type of domiciliary accommodations, or both. It is by no means fanciful to foresee that if we now begin the process of setting up a VA nursing home establishment our planned hospital program may be adversely affected.

As you know, we have a substantial number of chronically ill patients in our hospitals who are receiving a type of care sometimes referred to as intermediate care. Some of these will finally reach the point at which medical attention is merely incidental and their essential needs could be met through nursing home services. As I have indicated, others who were admitted for hospital care have already reached the nursing home stage but cannot be placed in community facilities and we must continue to provide for them.

These groups offer a sufficient basis, I believe, for an intensive study as to the feasibility and soundness of a Federal venture into the operation of nursing home facilities. I have therefore directed that, along with the other study already described, our Department of Medicine and Surgery with other staff elements shall conduct a careful exploration of this matter with a view to de

veloping facts which will better enable us to make a final recommendation on this critical problem, I feel that no actual pilot test of nursing home facilities, as such, should be undertaken pending the results of this study. As was indicated in the President's recent messages on elderly citizens and on health program, the problem of nursing home care which we are discussing is an extensive one affecting all our senior citizens. Successful solution will require the best efforts of all governmental levels and various Federal agencies.

We shall of course persist in our efforts to facilitate the return of hospitalized veterans to their homes or other community facilities wherever it is feasible for them to do so. Through our Social Work Service we have had considerable success in placing those patients who need not remain continuously in the hospital. During the calendar year of 1962 almost 5,600 patients, excluding psychiatric, were assisted in arrangements for placement in homes other than their own homes. Over 3,100 of them were placed in nursing homes, almost 200 in foster homes, and nearly 2,300 in other facilities such as boarding homes and personal care homes. Of these 5.600 veterans, 21 percent had received 6 months' or more hospitalization during their last stay in VA hospitals, and over 72 percent were at least 60 years of age. More than 23,000 patients were helped with planning for their release from the hospital to their own homes during 1962.

The special importance attached to this matter by your committee is shown by the appointment of a subcommittee under the chairmanship of Congressman Everett to consider the needs and type of care required by our older veterans. Emphasis on the nursing care aspect is indicated by the requests recently sent by the subcommittee to various hospital directors for information on available facilities at their installations which could possibly be converted to nursing care beds. We shall be pleased to cooperate with the subcommittee to facilitate its consideration of these matters.

There are several other avenues open to the Federal Government if it were determined that direct Federal assistance should be provided in the area of nursing home and related types of care. Legislation now before you (H.R. 244) would provide assistance to the States in constructing nursing home facilities for veterans. In relation to this approach, I must note the President's recommendation in his recent health message that the Hill-Burton Act be amended to increase the appropriation authorization for assistance to the States in constructing nursing homes from $20 million to $50 million annually. Naturally, our administrative consideration of special assistance of this kind for veterans must take cognizance of what has been proposed by the President on a more general basis.

Another proposal before this committee-H.R. 246-would broaden the program of Federal aid to State soldiers' homes so that payment could be made up to $2.50 per day for war veterans admitted to these homes as nursing care members. Payments are now limited to those State home members who are eligible for hospital or domiciliary care in VA facilities. The Chief Medical Director has heretofore advised me that a veteran who requires only nursing home type care is not in need of hospitalization. Since hospitalization is not involved, the veteran admitted to the State home for nursing care only is not eligible for these payments. Likewise, the veteran is not qualified for the payments as a domiciliary member.

Apart from the basic policy question regarding the appropriateness of extending Federal responsibility in the nursing care area, partial Federal support for this type of care through payments to State homes would be helpful in meeting the problem to the extent that State facilities for this purpose could be made available. Obviously, such a measure would work unevenly since some States do not have State homes and others could not or would not provide nursing home care in these institutions.

The problem which I have been discussing largely involves those with nonservice-connected conditions. Our primary responsibility is to veterans with service-connected disorders and it could well be argued that Federal assistance in providing nursing home or similar type care should be restricted to those whose ailments are of service origin.

This is an important factor in appraising a proposal, such as you have before you-H.R. 224-to assist veterans entitled to the higher rates of pension based on the need for regular aid and attendance in purchasing drugs and medicine prescribed by licensed physicians. We can defray the cost of medicines for outpatient treatment of service-connected conditions. This cannot be done for non-service-connected disabilities since the outpatient program has traditionally been restricted to those whose injuries and ailments resulted from service.

An

exception is when we furnish medical services in preparing the veteran for hospital admission or to complete treatment following hopsitalization. Even though we feel a special concern for the needs of those requiring regular aid and attendance, I would think any move to reimburse these pensioners for the cost of drugs and medicines would lay the foundation for providing outpatient assistance on a wider basis and to additional groups.

I believe that enough has been said to demonstrate that further intensive study must be given to the question of what should be done for the disabled veteran who must receive care and attention not provided within the range of our existing medical, hospital, and domiciliary programs. We are struggling here with a most complex and far-reaching issue of Government policy which, as I have said, is receiving increased attention on a Government-wide basis. I hope that our planned administrative study will contribute toward restoration of patients who have received maximum hospital benefits to the community and community facilities. In this endeavor we believe we are also serving the objectives of this committee.

Mr. EVERETT. This committee has conducted two surveys involving the question of nursing care, a portion of which appears in the biennial questionnaire and has been since reprinted as a separate document. This shows the number of nursing care eligibles in Veterans' Administration hospitals as of last fall. The more recent survey involves 50 selected Veterans' Administration hospitals as to the possibility of the construction of new nursing care facilities, the cost of renovation, the time required to activate, and the per diem cost.

Without objection, these two surveys will be included in the record at this point.

(The material referred to follows:)

Nursing-care beds availability in selected VA hospitals based on subcommittee

ASPINWALL, PA.

MARCH 7, 1963. The buildings which we propose are part of the Old Aspinwall Hospital, and photographs are attached so that you can be aware of the sound basic construction available. These buildings are attached by corridors to the main hospital facilities, and have wheelchair runs to the outside lawn and recreation areas for use during summer months.

The cost actually figured is based upon many of these cases needing full care and the utilization of hospital facilities for their continued maintenance, i.e., laboratory services, radiology services, and physical medicine services.

The care could be provided at a lesser cost and renovation at a lesser cost if the quality desired were to be reduced. I strongly urge that your committee consider the highest quality available for our deserving veteran population.

BATH, N.Y.

MARCH 15, 1963.

In reply to your telegram of March 11, 1963, relative to nursing-care beds, you are informed that there are two domiciliary buildings at this station of modern construction which could be converted to nursing-care beds to provide an estimated 300 beds. The cost of renovation is estimated at $500,000 and the cost of equipment at $150,000. The per diem would be $15.00. It is believed that these nursing-care beds could be activated within 12 months after authority, funds, and final plans are made.

Over the years since this installation was opened in 1877, there has been developed a staff of dedicated people which can be augmented without difficulty, except in a few scarce category positions.

While these buildings can be renovated and will give far better accommodations than a majority of nursing homes, there have been, as you know, rapid advances in nursing-care institutions during the recent past, a good example of which is the Pavilion Nursing Home adjacent to Genesee Hospital in Rochester, N.Y., which was opened on March 3, 1963. We are taking the liberty of forwarding a fairly complete description of this institution which appeared in the March 3 issue of the Rochester Democrat and Chronicle. Construction of this type, adjacent to and connected with our modern 273 G.M. & S. hospital, would be more efficient and more in line with present-day trends in nursing-home and convalescent-care facilities.

BATAVIA, N.Y.

MARCH 4, 1963.

Your letter of February 25 requesting information regarding the establishment of nursing-care beds has been discussed with appropriate members of our staff. The thoughts we have on this idea do not lend themselves to proper expression if the format at the bottom of your letter is completed.

This is a hospital with 257 authorized beds, of which we are presently operating 240 beds, divided among 5 wards. The nonoperating beds are distributed among three different wards.

Our discussion has led us to one common conclusion: to establish nursing-care beds, there must be a somewhat separate and identifiable area in which these beds would be located and which would not be part of the regular hospital operating beds. Were such nursing-care beds scattered throughout the hospital and intermingled with the otherwise active beds, a differentiation would not be possible, particularly in the area of the medical attention devoted to the bed occupants and the level of nursing attention provided to them.

For the above reasons, it is my opinion that there are no beds at this hospital which could properly and productively be converted to a nursing-care type of operation. There is no one ward or any portion of one ward which could be so designated and continue to maintain the order beds at the present level of activity and turnover rate.

Therefore, it is our feeling that there are no beds which could be provided for a nursing-care type of operation, and this would lead to negative answers in the other four questions that you also asked.

Our interest and that of your committee in the continuing study of the needs of our eligible veteran population, and in providing adequate plans to provide for those needs, is an objective well worthy of our mutual understanding and cooperation.