a State nursing home to move these people back to their own homes? Dr. HABER. That is the way the program is being developed. Mr. EVERETT. Go right ahead. Dr. HABER. It behooves us, therefore, as I said, to seek increases in the authorized rates in order to maintain a free access to community nursing home beds. The 80 contracts that we lost are only part of the problem. I have figures here which show that in many instances we cannot even begin to draw contracts because a recent rate survey indicated that in some communities the nursing homes won't even consent to drawing contracts with the VA. Thus in the Metropolitan New York area 93 percent of the contracts which we sought could not be consummated at our rates. Mr. EVERETT. That is the highest percentage you have, or is the State of California higher? Dr. HABER. California in Los Angeles is not quite as bad as that, only 47 percent. In other words, out of every two contracts we sought only one could be drawn at our rates in Los Angeles. In Connecticut 70 percent of the contracts we sought could not be consummated at our rates. In Dearborn, Mich., it was 83; in Buffalo, N.Y., 74 percent of the contracts we sought could not be drawn. Now, despite these difficulties, the program has shown a steady increase in the number of placements. A look at some of the pertinent statistics would be helpful. We find that one out of three patients must return to the VA hospital for an acute intercurrent illness during his 6-month nursing home stay. We find that about 13 percent are discharged with maximum benefits from nursing homes, and that another 33 percent of all veterans either move to another private nursing home under their own or other resources or else continue to say at the same nursing home after VA benefits have expired. Recent developments have indicated the Social Security Administration has seen fit to add on entitlement under title 18 (extended care benefits) to our 180 days nursing home stay, thus providing a total of 280 days under combined VA and medicare benefits. We have had requests for exactly 135 extensions. The law provides that the administrator may extend the 6 months if special circumstances warrant. Of the 135 requests, we have granted 113. Mr. EVERETT. People had better start applying. Dr. HABER. That might be the solution, Mr. Chairman. One facet does deserve comment, and this is our quality control system. This system permits an inspection of the facility indirectly by cross accrediation with the Joint Commission on Accrediation of Hospitals of the American Hospital Association or directly by our own teams of inspectors when the hospital or clinic director has the need and opportunity to do so. What this would require is that if the director doesn't want to take somebody's word for it, he has the right to send out a team, usually consisting of a social worker or public health nurse or physician, or a combination, to inspect the nursing home and see whether they meet our standards. We are using a new form (VA form 1204) to refer patients to the nursing home, which will simultaneously give us a baseline on which to judge future progress of the patient and inform the nursing home of the patient's condition and recommended treatment, so that we don't drop the ball. We receive from the nursing home a short but vital report at monthly intervals which serves to check on the progress of the patient in certain important patient care areas. We don't want a lot of paperwork. They just have to make a few X's in a few boxes, but it gives us a conviction that the veteran is getting the care we wanted. We are now evaluating a more standardized approach to our own visitation followup (VA Form 10-1204a) and hope to be able to improve uniform guidelines for visitation which will result in uniform quality control at minimal costs. We are working with our department of data management in trying to automate as much of this information as possible, beginning with a simple listing of nursing homes and gradually expanding it to include patients' and nursing home characteristics. Benefits accruing to this program are seen on chart XVII. Mr. EVERETT. Have you had to void any contracts because of mistreatment of veterans? Dr. HABER. Yes, sir; but very few. At my last look at this, I think there were about three or four that we had to void. We are now currently evaluating a more standardized approach to our own visitation. We go out and look at these veterans. Usually it is a social worker or occasionally a public health nurse. We hope to possibly indicate a more uniform approach to visitation. We feel that we have responsibilities, even though we are paying for the cost of care, to see that the veteran is getting the care. One facet is that when the veteran becomes ill, we take him back to our own hospital with very little demurrer on the part of anybody. Mr. EVERETT. Can he go directly back or does he have to get on the waiting list? Dr. HABER. No. If this man is acutely ill, has appendicitis, the usual priorities are voided, and we take him back right away. Incidentally, if he cannot get back to the VA hospital because distance or time is not propitious, he may be hospitalized in a community hospital with the VA paying the bill. Mr. EVERETT. These are on nonservice connected cases? Dr. HABER. Yes, sir. This is only where the situation would be threatening to his life and where prior authorization with the VA exists, and this could be accomplished in 72 hours. Mr. EVERETT. What percentage of service-connected cases are in nursing homes, 10 percent? Dr. HABER. It is about 20 percent. Mr. EVERETT. That is the same as the hospitals? Dr. HABER. Except that in our own VA nursing homes we run a higher percentage of service-connected, about 30 or 35 percent. We like to keep the service-connected veteran in our own VA nursing home so we can avoid the 6-month limitation in community nursing homes. Mr. EVERETT. About 20 percent of the hospital beds are serviceconnected, aren't they? Dr. HABER. Closer to 30 percent. We are working with our own department of data management in trying to automate as much of this information as possible beginning with a simple listing of nursing homes and monthly reviews of how many beds they have and what kind of care they can have and so on. The next chart (chart XVII, page 1545), summarizes the benefits of our community nursing home program. We have— 81-439 0-67- -5 (1) Provided 1.5 million days of nursing home care. (3) Raised nursing home standards. (4) Trained and taught nursing home personnel. The next program of helping the States operate and construct nursing homes has also continued with gratifying steadiness, and has shown consistent increases in the numbers of veterans treated. Chart XVIII shows the State homes which have nursing home care facilities and their various capacities. Chart XIX shows the growth of the program since its inception. There are 33 State homes in 28 States; 15 of those homes operate nursing home beds, and these have all been inspected by the VA and authorized to operate these as nursing home beds. These are separate and distinct parts of the domiciliary facility that the States operate. Sometimes that separateness may mean only that they have set aside a ward, but our regulations have required that they differentiate clearly between running the State home and the State nursing home which have all been located within the State. Mr. EVERETT. Doctor, I notice you have Hot Springs there. Do you have a State home there in addition to the hospital we have there? We have a VA hospital? Dr. HABER. Yes, sir. Mr. EVERETT. The State home is separate and apart? Dr. HABER. Yes, sir. Hot Springs, S. Dak., is very proud of the fact that it has two veterans' installations, one run by the State and one by the Federal Government. This next chart (chart XIX page 1546), shows the growth of the program since its inception. You can see how the number of beds is going up. The next chart (chart XX, page 1547), indicates the relationship of the increasing nursing home care to the decreasing domiciliary load in State homes with an increasing amount of Federal participation to the States. This shows that as the State beds are going down, the nursing home beds are going up, but we are helping to support both programs with more money. Mr. EVERETT. Do you have any figures about how much we are spending on State homes all together and how much the States are spending? Dr. HABER. Yes, sir. Mr. EVERETT. Will you supply that for the record? Dr. HABER. Yes, sir; I shall. (The information to be supplied follows:) Cost for member and nursing home care in State homes Cost for member and nursing home care in State homes, by State, July 1966 through March 1967 1 Estimated. Based on the experience of the past 5 years the State home contributes 70 percent and the VA contributes 30 percent of the cost care of veterans in the State homes. Dr. HABER. The next chart (chart XXI, page 1547), shows that a total of eight State construction projects in seven States have been approved consisting of 824 beds at a cost of over $11 million with the VA participating almost to the extent of 50 percent. Mr. EVERETT. Do you approve the plans? Dr. HABER. Yes, sir. Mr. EVERETT. Do you have pretty close supervision over it? Dr. HABER. Yes, sir. We are trying to act again in accordance with our general philosophy to be of most help and least redtape. I think this is succeeding well. Mr. EVERETT. I am glad to hear one bureaucratic organization say that. Go right ahead. Dr. HABER. Our next chart shows the projects which are under review and are planned by the various States. This is one of the reasons we are asking for an extension of the $25 million for another 5 years. We have reason to believe that the States are going to come in with more projects. The next chart indicates some of the benefits ew have derived from the State home program. We have assisted the States or will have assisted them with 824 nursing home beds, $11 million, of which we have paid almost half. We have clarified by prescribing construction standards. These are going to be very good facilities. We have helped develop, with the General Counsel, more formal procedures in recognition of the State homes and defined the levels of care to make clear what the veterans are entitled to. We have helped the States to pro vide almost a million days of nursing home care and feel we have helped this Federal-State partnership of which Dr. Engle spoke. Now, with respect to a question asked, I believe, by Mr. Roberts; may we have the next chart please? This indicates the nursing home care summary in terms of the actual loads of patients, and I think the next chart will show you the total number of beds that we expect to operate by 1970. You will note here that this implies 4,000 beds for the VA program, 3,600 beds for the community nursing homes, and about 3,700 beds in the State nursing homes, for a total of 11,300 beds available for veterans requiring nursing home care. Mr. EVERETT. Mr. Roberts. Mr. ROBERTS. So that all of the beds you are talking about would be outside the VA, then. You are not planning on any additional beds above 4,000 which we set as a floor? Dr. HABER. Yes, sir. At this point our total within the VA is estimated at 4,000 beds within the VA. Mr. EVERETT. That is what it is now. Mr. ROBERTS. That is the least you can do to comply with the law? Dr. HABER. That is right, sir. Mr. EVERETT. In 1970 you are not going to have any more? Dr. HABER. That is right, sir. I wouldn't say that we are going to have any more. I would say that our definitive planning has not provided for it at this point. With respect to the domiciliary and restoration program there is increasing evidence of our determination and ability to convert the formerly static domiciliary custodial program into a progressive dynamic therapeutic modality. Emphasis has been focused increasingly upon restoration, by which we mean return to the community in whole or in part, self-supporting for those individuals who do not require long-term maintenance-type benefits of a domiliciary program. This chart (chart XXVI, page 1551), shows there are now 699 restoration center beds located at five centers, and that the total beds including those for domiciliary care is still substantially lower than the domiciliary beds in operation in 1960. A most interesting item in this chart is the change in turnover rate where a dramatic increase has been shown in the restoration centers amounting to 16.7 percent as compared to the domiciliary of only 9.1 percent. I note in our latest issue it is 17.3 percent as compared to the domiciliary of only 9.1 percent. We feel that we are successful in returning these people to the community either to jobs or independent living. This is not just discharges, Mr. Chairman, this is successful restoration. Fifty-four percent of the cases are working out. Part of our increase in efficiency here is due to the fact that our screening methods are better and part is that we are learning better the business we are in and I think both will show progressive increase as we go along. Mr. ROBERTS. I like this term "independent living,” and I think you have a philosophy that is going to be really helpful. It seems to be that our idea is to provide that the veteran can be in his own home if possible. I am not sure I can get my thinking across, but have we started any investigation as to how many could be in their own homes, if we provided adequate pensions? Obviously if we keep them in a hospital for a week we are talking about $200 or $250. If we could keep |