Second iniERIID REPORT CONCERNING CARE OF THE CHRONICALLY Ill IN'ILLINOIS JUNE 1947 DWIGHT H. GREEN Governor THE COMMISSION ON THE CARE OF CHRONICALLY ILL PERSONS ESTABLISHED BY ACT OF THE SIXTY-FOURTH GENERAL ASSEMBLY Second menu fit port CONCERNING CARE OF THE CHRONICALLY ILL IN ILLINOIS JUNE 1947 DWIGHT H. GREEN Governor THE COMMISSION ON THE CARE OF CHRONICALLY ILL PERSONS Established by Act of the Sixty-fourth General Assembly TEXT OF ACT CREATING THE COMMISSION ON THE CARE OF CHRONICALLY ILL PERSONS (Senate Bill 436, Sixty-fourth General Assembly, Approved July 18, 1945) An Act creating a commission to investigate the need of developing facilities for the care and treatment of persons who are chroni- cally ill, defining the powers and duties of the commission, and making an appropriation therefor. Be it enacted by the People of the State of Illinois, represented in the Qeneral Assembly: Section 1. There is created a commission, to be known as the Commission on the Care of Chronically 111 Persons, consisting of three members of the Senate to be appointed by the President thereof upon the advice of its Executive Committee, three members of the House of Representatives to be appointed by the Speaker thereof, the Director of the Department of Public Welfare, the Director of the Department of Public Health, and the Public Aid Director of the Illinois Public Aid Commission. The Commission shall select a chairman, secretary and such other officers as it deems advisable from among its members, and may employ such assistants as may be required for the perform- ance of its duties hereunder. The members of the Commission shall receive no compensation but shall be reimbursed for actual expenses incurred in the discharge of their duties. Section 2. The Commission shall make a thorough investigation and study of the hospitalization and other care and treatment facilities available in this State for persons who are chronically ill, the adequacy of such facilities, the need of developing additional facilities for such purpose, the desirability of enacting enabling or corrective legislation to increase or improve such facilities, and all matters germane thereto. The investigation and study shall embrace both governmental and pri- vate facilities and needs and shall relate to all chronically ill persons. The Commission may study and consider the matter of making State contributions for hospitalization and medical needs of chronically ill persons who are destitute and unable to meet such costs. The Commission shall submit a report to the Sixty-fifth General Assembly of the results of its research, together with such recommen- dations for legislative consideration and action as it determines to be necessary or desirable. Section 3. In the conduct of any investigation hereunder the Com- mission may subpoena witnesses and compel the production of rec- ords, books, papers and other data, but no subpoena shall be issued except under the signature of the Chairman of the Commission. Section 4. The sum of $20,000, or so much thereof as may be necessary, is appropriated to the Commission herein created for all or- dinary and contingent expenses incident to the administration of this Act. COMMISSION ON THE CARE OF CHRONICALLY ILL PERSONS MEMBERS SENATOR T. MAC DOWNING, Chairman Macomb SENATOR HUGH M. LUCKEY Potomac SENATOR ALBERT L. SCHWARTZ Chicago REPRESENTATIVE WILLIAM ROBISON Carlinville REPRESENTATIVE ADAM S. MIODUSK1 Chicago REPRESENTATIVE DAN DINNEEN Decatur ROLAND R. CROSS, M.D. Director, Department of Public Health RAYMOND M. HILLIARD, Secretary Public Aid Director, Illinois Public Aid Commission Director, Department of Public Welfare CASSIUS POUST (Represented by Paul Hletko, M.D., Chief Medical Officer, Medical Care and Treatment Division, Department of Public Welfare) STAFF PEARL BIERMAN NORMAN T. PAULSON MARY-CLAIRE JOHNSON ROBERT ROSENBLUTH In JWemoriam Senator Hugh M. Luckey, a member of the Commission on the Care of Chronically 111 Persons, died on December 29, 1946. He had participated actively in the work of the Commission and his passing interrupted the valuable contributions he was making to assist in a solution of the important problem of chronic illness. The sad news came as a profound shock to his associates. Senator Luckey was born near Potomac, Illinois, on November 2, 1873. He attended the Potomac grade and high schools. For more than 50 years he actively engaged in farming. He was a member of the Ver- milion County Board of Supervisors and served as its chairman. In 1922 he was elected a member of the Illinois General Assembly and served seven terms in the State House of Representatives. In 1942 he was elected State Senator to fill a vacancy and in 1944 he was elected Senator for a full term. He was a member of the Potomac Methodist Church, Danville Consistory, and the Modern Woodmen of America. On January 13, 1947, the State Senate adopted a resolution stat- ing, in part, as follows: “His career, both public and private, was marked by selfless and devoted efforts in behalf of those he served. The devotion to his family and his kindness and his concern for their welfare gained him added respect from all who knew him/' The Commission on the Care of Chronically 111 Persons extends its sincere sympathy to Senator Luckey's widow and family and ex- presses deep sorrow at their bereavement. CONSULTANTS TO THE COMMISSION On Research in Chronic Illness and Geriatrics Andrew C. Ivy, M.D., Chicago, Vice President, University of Illinois, in charge of Schools of Medicine, Dentistry, and Pharmacy On Medical Supervision and Care in Institutions for the Chronically 111 Robert S. Berghoff, M.D., Chicago Harold M. Camp, M.D., Monmouth Everett P. Coleman, M.D., Canton Harlan A. English, M.D., Danville Malcolm T. MacEachern, M.D., Chicago John P. O'Neil, M.D., Chicago Walter D. Stevenson, M.D., Quincy On Hospitalization The Reverend John W. Barrett, Chicago Stuart K. Hummel, Joliet C. S. Woods, M.D., Peoria On Minimum Standards for the Care of the Chronically 111 Malcolm T. MacEachern, M.D., Chicago, Chairman Hugo Hullerman, M.D., Chicago Everett W. Jones, Chicago Leo M. Lyons, Chicago Miss Edna Nicholson, Chicago On Nursing Mrs. Madeline Roessler, R.N., Chicago, Chairman Miss Helen Frederick, R.N., Joliet Miss Margery MacLachlan, R.N., Chicago Miss Lorna May, R.N., Chicago Central Service for the Chronically 111 of Chicago William F. Petersen, M.D., Chairman, Administrative Committee Miss Edna Nicholson, Director TO THE SENATE AND HOUSE OF REPRESENTATIVES SIXTY-FIFTH GENERAL ASSEMBLY STATE OF ILLINOIS The Commission on the Care of Chronically 111 Persons, created by the Sixty-fourth General Assembly to carry on in a broader field the investigations of the Committee to Investigate Chronic Diseases Among Indigents, has the honor of presenting for your consideration the accompanying report of its activities and findings and its recom- mendations with respect to needed remedial action by the General As- sembly and the people of Illinois. This Commission has found that the problem is even more exten- sive and serious than estimated in 1945 by the predecessor Committee to Investigate Chronic Diseases Among Indigents. The predecessor committee estimated that there were in the State as a whole 90,900 chronic invalids, that is, persons who had become so handicapped by chronic disease or permanent impairment that they required care by others. This Commission has found that a more probable figure, ex- clusive of the tuberculous and persons with nervous or mental ailments, is 117,679. In any case there are not less than 107,000. Of these, a minimum of 35,000 need care outside their own homes. There is a deficiency of 23,479 institutional beds for this latter group of patients. Home nursing and housekeeping services for the many thousands of chronic invalids who can be cared for in their own homes are prac- tically nonexistent. Nursing services have been established in only 23 communities in the State and these do not have sufficient facilities to serve all chronic invalids in the community who are in need of such services. Beyond any question chronic illness is the major health and wel- fare problem now confronting the State and local governments in Illi- nois, private philanthropic agencies, the medical and nursing profes- sions, and all citizens interested in the general welfare. The problem can be met only by a two-pronged attack: (1) Provision of decent and adequate facilities for the care, treatment, and possible rehabilitation of those now afflicted with chronic disease; and (2) a concerted and co-ordinated program of research into the causes of chronic illness in order that the incidence of chronic disease may be reduced or elimi- nated and methods of treatment improved. From the long-range view only the latter will provide an ultimate solution. Much has been done during the present biennium by State and local officials, private agencies, and interested citizens in beginning an attack on this problem. Of particular value have been: 1. The State-local co-operative plan for converting the former county “poorhouses” into adequately staffed and equipped nursing homes for the infirm and chronically ill. 7. The Illinois Hospital Survey of existing medical and nursing facili- ties. 3. The program for licensing private nursing homes. 4. The development of infirmary facilities in private not-for-profit homes for the aged. 5. The health survey in the Chicago-Cook County area and the survey of chronic disease in Sangamon County. 6. The development of interest in geriatrics and gerontology on the part of physicians. 7. The interest displayed by the medical and nursing profession in standards of care in institutions for the chronically ill. 8. Finally, but perhaps of major importance, the genuine interest and concern on the part of the general citizenry that facilities for care be of the highest type, that the best professional services be avail- able to all those afflicted without any stigma or discrimination be- cause of poverty, and that institutional care be provided close to home where the patient and the care given him may be seen by relatives and friends. Only an alert citizenry can keep present and future institutional facilities for the chronically ill from deteriorating into substandard facilities such as the former county “poorhouses” and some of the present-day nursing homes and hospitals for the mentally ill. Obviously, the steps so far taken constitute only a beginning. Continuous study of the problem on the part of the State of Illinois is vital if planning is to be co-ordinated and the total program directed so as to achieve the goal of adequate care of the afflicted and ulti- mately, through modern research, the conquest of chronic disease itself. The Commission wishes to express its appreciation and indebted- ness to the many citizens and organizations who attended the hearings and, in particular, to the consultant committees of physicians, nurses, and hospital administrators who gave so freely of their busy profes- sional time in providing the Commission with technical information and recommendations. The Commission also wishes to acknowledge with sincere appreciation the assistance given by Dr. Henrietta Her- bolsheimer and the staff of the Illinois Hospital Survey, the staff of the State Department of Public Health, the Illinois Public Aid Com- mission, and the physicians and health and welfare agencies of San- gamon County. Appreciation must also be expressed to the Chicago- Cook County Health Survey for permission to reprint in full their findings with respect to chronic illness in the Chicago-Cook County area. Respectfully submitted, Commission on the Care of Chronically III Persons By T. Mac Downing, Chairman Springfield, Illinois June 3, 1947 TABLE OF CONTENTS PAGE Text of Act Creating the Commission on the Care of Chronically III Persons i Members of the Commission iii In Memoriam: Senator Hugh M. Luckey iv Consultants to the Commission v Letter of Transmittal vi REPORT OF THE COMMISSION: I. Recommendations 1 II. Outstanding Facts Concerning Chronically III Persons in Illinois 10 Number and Age of Persons with Chronic Disease as of 1947 10 Number of Chronic Invalids 10 Dependency _ 10 Other Social Problems 11 Need for Research 11 Possibilities of Rehabilitation 11 Attitudes 11 Need, for Beds 12 Type of Care Required by Chronic Invalids 12 Types of Facilities Needed 12 Standards in Existing Institutions 12 Chronic Invalidism in the General Population 13 III. The Principal Chronic Diseases 14 IV. Most Important Next Step : Research in Chronic Disease and Geriatrics 16 V, Activities of the Commission 19 Organization 19 Field of Investigation as Recommended by Predecessor Committee 20 Method of Conducting Investigations 22 Appointment of Consultant Committees 23 Public Hearings 23 Inspection of County Institutions 23 Surveys 23 VI. Summary of Illinois Developments During the 1945-1947 Biennium.... 25 Illinois Hospital Survey 25 Local Surveys 29 County Homes for the Infirm and Chronically 111 30 Licensing of Private Nursing Homes 34 Not-for-Profit Homes for the Aged 36 Illinois Children’s Hospital-School 40 Hospitalization and Medical Needs Commission 42 Disability Unemployment Compensation Payments Commission 43 Improvement in Medical Programs for the Chronically 111 Receiving Public Assistance 43 Local Activities 44 VII. Developments in Other States, in the Federal Government, and in England 65 California 65 Connecticut 65 Maryland 66 Massachusetts 67 Minnesota 68 New Jersey 68 New York State „ 68 Ohio 73 Wisconsin 73 Federal Government 73 England „ 74 VIII. Current Estimates of the Extent of Chronic Invalidism and the Need for Beds in Illinois 78 Revised Estimate of Chronic Invalidism 78 The Need for Beds 78 Chronic Invalidism Among Persons Receiving Public Assistance 84 Chronic Illiness Among Old Age Pension Recipients 85 IX. Technical Aspects of Sound Future Program Planning as Recom- mended by Technical Consultants to the Commission 86 The Field of Research 86 Medical Supervision and Care in Institutions for the Chronically 111.... 86 Minimum Standards for the Care of the Chronically III 88 Nursing Service for the Chronically 111 88 Basic Considerations in the Development of Facilities and Services 89 X. Current Legislation Bearing on the Care of the Chronically Ili 91 Alcoholism 91 Cancer 91 Poliomyelitis 91 Tuberculosis 92 Mental Illness 93 Medically Indigent 93 County Homes 93 Illinois Children’s Hospital-School 93 Licensing and Regulation of Hospitals 93 Expansion of Public and Nonprofit Hospital Facilities 94 Hospital Authorities 94 APPENDIX: Section I. Persons Attending the Public Hearings 96 Section II. Excerpts from Testimony at Consultants’ Meeting and Public Hearings 101 Need for Research 101 The Chronically III Problem as Seen by Physicians 106 Planning by Voluntary Institutions for the Aged 110 Need for Facilities for the Chronically 111 116 General Hospital Problems in Caring for the Chronically 111 120 County Homes 125 Nursing Problems 129 Comments by Welfare Workers 130 Section III. From a Patient’s Viewpoint 133 Facilities in Rural Counties 134 Rehabilitation 134 Use of Handicapped Persons in Serving the Chronically 111 135 Physiotherapy 135 Homes for the Ambulatory Handicapped 135 Homes for the Handicapped Needing Nursing Care 136 Need for Privacy 136 Section IV. Research Institute for the Study of Chronic Illness and Geriatrics 138 The Problem 138 The Solution 138 A Specific Proposal 139 Explanatory Details 140 Program 140 Expenditure Required 140 Section V. Medical Supervision and Care in Institutions for the Chron- ically III 142 Introduction 142 Medical Direction of Institutions for the Chronically 111 143 Medical Policies of the Institution 143 County Nursing Homes 145 Privately Operated Nursing Homes 146 Construction of New Institutions for the Chronically 111 147 Section VI. Preliminary Report of the Special Committee on Minimum Standards for the Care of the Chronically III 149 General Statement 149 Summary of Current Opinions 150 Recommendations of the Committee 151 Minimum Standards for Institutions Caring for Chronically 111 Patients 152 Section VII. Nursing Service for the Chronically III 158 Home Nursing Service 158 Study of the Problem 160 Supervision of Nursing Personnel 160 Training of Nursing Personnel 161 Licensing of Nursing Personnel 161 Standards Relating to the Duties of Nursing Personnel 162 Licensing of Nursing Homes 162 Section VIII. Chronic Illness in Metropolitan Chicago 163 Foreword 163 Extent and Nature of the Problems of Chronic Illness in Metropoli- tan Chicago 164 Essential Elements of a Comprehensive Community Program 168 Some Basic Considerations Which Should Guide the Development of Facilities and Services 171 Inadequacies in Existing Facilities and Services in the Chicago Met- ropolitan Area and Recommendations for Meeting Them 175 Section IX. Excerpts from the Illinois Hospital Survey and Plan Con- cerning Care of the Chronic and Convalescent 194 Facilities for Chronic and Long-term Convalescent Patients in Gen- eral Hospitals 194 Chronic and Convalescent Hospitals 195 Chronic and Convalescent Institutions 197 Recommendations Concerning Chronic and Convalescent Facilities.. 198 Section X. Chicago-Cook County Health Survey Report on the Chron- ically III 201 Introduction 201 Extent of Chronic Illness in Chicago and Cook County 202 Facilities for the Care of the Chronically 111 207 The Need for Beds for the Chronically 111 211 Quality of the Facilities and Their Services 212 Standards and Licensure 214 Economic Aspects of the Problem 215 Home Care for the Chronically III 218 Rehabilitation - 219 Research and Teaching 220 Summary and Recommendations 221 Section XI. Sangamon County Survey on Extent of Chronic Disease and Other Long-Term Illness as of January 1947 224 Foreword 224 Purpose of Survey 225 Participants 226 Reasons for Selection of Sangamon County 226 Methods Used 229 Chronic Illness in the Nonindigent Population 229 Chronic Invalidism Among Public Assistance (Old Age Pension, Aid to Dependent Children, and Blind Assistance) and General Relief Cases 236 Sangamon County Chronic Invalids Not Included in Survey 240 Summary of Chronic Invalidism Among Persons Assisted by the Sangamon County Department of Public Assistance 240 Summary of Chronic Invalidism Among Indigents 241 Social Factors 241 Economic Factors 242 The Need for Beds 243 Comparison of Results With Other Surveys 245 Section XII. Progress Report on Licensure of Private Nursing Homes 248 Comparison of Data With That of Illinois Hospital Survey 248 Plan Followed in Correcting Hazards 252 Defects Found in Homes Housing Old Age Pension Recipients 252 Defects in Homes Housing Self-supporting Patients 252 Conditions in Not-for-Profit Institutions 252 Difficulties in Homes Located in Rural Areas 253 Future Needs 253 Section XIII. Minimum Standards for Private Nursing Homes 255 Plumbing 255 Heating 256 Lighting 256 Ventilation 257 General Conditions 257 Personnel 258 Water Supply 259 Sewerage 259 Food Handling 259 General Hygiene 261 Diet 262 General Regulations 263 Section XIV. Progress Report on the Development of County Homes for the Infirm and Chronically III 265 Provisions of County Home Legislation 265 Minimum Standards Established 265 State and Local Agencies Co-operate 266 Responsibilities of County Boards 266 Community Interest in Program 266 Homes So Far Converted 267 Counties Nearing Completion of Conversion 267 Counties Having Plan Under Consideration 267 Special Situation with Regard to Oak Forest Infirmary, County Home for Cook County 267 Counties Lacking Plant Facilities 269 Effect of Change in Program on County Home Population 270 Difficulties Hampering Progress of Conversion 270 Factors in Long-range Planning 271 Significance of a Sound Program of Care 271 Personnel Problems 271 Organization and Direction of the Medical Program 272 Adjunct Services 274 Community Support and Participation a Continuing Responsibility 274 Section XV. Rules and Regulations in Regard to Standards for Safeguard- ing Health, Safety and Comfort of Inmates of County Homes for the Destitute, Infirm, and Chronically III, and to Com- pliance Therewith 277 Minimum Requirements 277 Cost of Care 279 Procedure 279 ILLUSTRATIONS, MAPS, AND TABLES PAGE ILLUSTRATIONS Proposed Research Institute for the Study of Chronic Illness and Geriatrics 18 Ward in Illinois County Home Before Conversion 49 Ward in Illinois County Home After Conversion 49 Fayette County Nursing Home 50 Day Room, DeKalb County Home 50 Individual Recreation, Knox County Home and Hospital 51 Group Recreation, Knox County Home and Hospital 51 Bed Room, Rock Island County Home 52 Nurses’ Station, Vermilion County Nursing Home 52 Dining Room, Vermilion County Nursing Home 53 Kitchen, Champaign County Home and Hospital 53 Illinois County Home Program Makes the News 54 Illinois Children’s Hospital-School 55 MAPS General Hospitals in Illinois—1945 56 Counties Having Only Small or No Hospitals in Illinois—1945 57 Tuberculosis Sanatoria in Illinois—1945 58 Nervous and Mental Facilities in Illinois—1945 59 Private Nursing Homes in Illinois—1945 60 Progress of County Home Program for Care of the Chronically III in Illinois —April 1947 61 Private Institutions Caring for Recipients of Old Age Pension and Blind Assistance 62 County Health Departments in Illinois—January 1947 63 Housing and Care of Chronically 111 Persons in the Rockford Area 64 TABLES Type of Hospitals and Beds, by Type, Illinois 1945 27 Beds Available for Certain Types of Patients in Hospitals of 25 Beds or More, by Type of Hospital, Illinois 1945 27 Deficiency in Beds for Chronic Invalids (All Causes)—Illinois 1947 81 Estimated Number of Chronic Invalids (Exclusive of the Tuberculous and the Mentally 111) and Need for Beds in Illinois 1947, by County 82 Chronic and Convalescent Institutions and Beds, by Control, Illinois 1945.... 197 Selected Statistics for Chronic and Convalescent, by Control, Illinois 1945.... 197 Estimated Number of Persons in Specified Age Groups (1) with Chronic Disease or Permanent Impairment and (2) Chronically 111 203 Estimates of Number of Persons 65 Years of Age and Over in Population Projections 1950-1965 (1) with Chronic Diseases or Permanent Impair- ments and (2) Chronically 111, Chicago 204 Average Number of Deaths Annually from Specified Chronic Diseases Ac- cording to Age, Chicago, 1940-1944 206 Type and Number of Agencies Providing Care for the Chronically 111, Con- valescent, and Handicapped and Their Bed Capacities, Cook County and Chicago 207 Minimal Monthly Charges per Patient Reported by 166 Homes and Institu- tions for Care of Chronically 111, Cook County Area, 1946 217 Lump-sum Payments Required as Admission Fees by 20 Homes for the Aged, Cook County Area, 1946 217 Nonindigents with Chronic Disease, Sangamon County 234 Care Required by Old Age Pension Recipients 237 Care Required by Aid to Dependent Children Recipients 238 Care Required by Blind Assistance Recipients 239 Sources of Income or Support of Persons in Illinois 65 Years of Age and Over, Indicating Eligibility for Old Age Pension, December 1944 243 Report from County Welfare Boards on Long-term Patients Receiving Old Age Assistance 245 In Public Institutions—Not Receiving Old Age Assistance 246 Applications for Nursing Home Licenses Received and Acted Upon 250 Number of Unsatisfactory Facilities in the 218 Homes Inspected 251 XV I RECOMMENDATIONS Information assembled as a result of this Commission's studies, investigations, and consultations with interested citizens and compe- tent authorities in the fields of medicine, nursing, and hospital admin- istration has established beyond a doubt that the plight of Illinois citi- zens afflicted with chronic disease is the most pressing health and wel- fare problem now confronting this State. The problem can be met constructively only by a two-pronged attack: (1) by providing adequate facilities and services for those who are now afflicted, using to the greatest possible extent already known and accepted methods of treating chronic disease; and (2) by research into the causes of chronic disease to the end that the incidence may be reduced and better means of treatment provided. From the long-range view the problem will ultimately be solved only through the second approach. In the meantime Illinois is faced with doing something now in be- half of the estimated 118,000 citizens so seriously afflicted with chronic disease that they need care from others. In addition to these 118,000 there are numerous others afflicted with tuberculosis and those condi- tions requiring psychiatric treatment, commonly referred to as "nerv- ous and mental," but not including neurological conditions such as muscular dystrophy, multiple sclerosis, cerebral palsy, and similar dis- orders. For the state as a whole there is a deficiency of 14,937 beds needed by persons with nervous and mental ailments and a deficiency of 3,113 beds for persons afflicted with tuberculosis. But the greatest need of all is for persons incapacitated by other types of chronic dis- ease such as arthritis, cancer, heart conditions, and neurological dis- orders. The studies of this Commission show that there is a deficiency in beds for this group of chronic invalids ranging from 23,500 to a more probable figure of 31,600. During the past biennium, as a result of interest stimulated by the predecessor Committee to Investigate Chronic Diseases Among Indi- gents, there has been wide activity and interest in getting something done to make additional beds available and to improve standards of care and service provided for these afflicted people. Outstanding in terms of concrete action have been the program for converting the former county “poorhouses” into modern nursing homes for the infirm and chronically ill; the attention given by private philanthropic organi- zations toward utilizing homes for the aged as facilities for the infirm; and the program for State licensing of private nursing homes which has laid the groundwork for establishing better standards in all types of medical and related institutions. The basic difficulty in long-time planning for the chronically ill, however, rests in the dilemma that the institutions which are appar- ently so sorely needed today—and these institutions are costly—may not be needed in future years when medical research strikes at the causes of incapacitating chronic diseases and succeeds in reducing or entirely eliminating it. Yet in facing this dilemma the State of Illinois cannot afford to wait out the results of research while those now af- flicted suffer acutely and demand that something be done to help them in their plight. One need only quote from a letter written by a young woman of 30 to Miss Eleanor McClurkin of Aledo, herself crippled by arthritis and confined to a wheel chair for the past 24 years. This af- flicted young woman stated her tragic plight in the following words: “My Mother may have to go for another operation this March or April and I have no place to go but to Oak Forest for three or four months until Mother is sufficiently recovered from her operation. My aunt is in poor health and is unable to care for me as she did last year. “I notice that you have studied about various homes where people with chronic diseases are taken care of. Oak Forest hasn't got treatment rooms where massages and electrical treatments1 are administered to the patient in order to prevent the muscular struc- ture of the patient becoming too weak from disuse of the muscles. If I go to Oak Forest and just lie in bed for a few months, my mus- cles will become too weak to walk as Fm doing now. “Eleanor, isn’t there an institution in Illinois or even other states where I could go and where massages and exercises will be administered while I’m staying there? These treatments will pre- vent my muscles from becoming too weak from disuse. I can’t af- ford to become too weak, or my Mother will have a bedridden pa- tient to care for as long as I live. “Another thing is we can’t afford to pay for my care. I don’t ’Since this letter was written in 1946, Oak Forest has purchased considerable physiotherapy equipment. 2 know if we’ll even manage a small sum to pay as long as I stay there. “I heard through a friend that the Elgin State Hospital may have such facilities in taking care of chronically ill patients. Is this true? “If you can help me, won’t you do so immediately, Eleanor? My doctor will then try to make the necessary arrangements. My malady is Muscular Dystrophy.” The foregoing example can be matched from the files of physi- cians, hospitals, and health and welfare agencies throughout the State. Chronic disease is obviously this State’s foremost health problem. This Commission therefore offers for the consideration of the Sixty-fifth General Assembly and the citizens of this State the following 10-point program: 1. Jhe State of Illinois should authorize immediately the establishment of a State Research Institute for the study of chronic disease and geri- atrics to be operated by the University of Illinois College of "Medi- cine in connection with the research hospitals attached to the Uni- versity. There should be developed between this Research Institute and hospitals throughout the State, public and private nursing homes, and homes for the aged serving the infirm and chronically ill a close re- lationship whereby the patients in these institutions may benefit by improved treatments developed at the Research Institute and where- by patients from these other institutions may be referred to the Re- search Institute for clinical study. It has been estimated that such a State Research Institute will require an initial appropriation of $2,500,000 for the purchase of land, erection of a building, and the acquisition of necessary equip- ment and that annual operating costs will approximate $950,000. On the basis of expenditures now being made for persons requiring pub- lic assistance because of chronic invalidism there is every indication that research and improved treatment will reduce these costs over a period of years and more than pay for itself. 2. Immediate attention should be given by State and local governments working together and by public and private agencies working to- gether, with the active participation of all citizens interested in health and welfare problems, to ways and means of meeting the present acute need for additional beds for chronic invalids who cannot be cared for in their own homes. All planning for additional facilities, however, should be inte- 3 grated with the Illinois Hospital Survey and Plan and addressed to needs as therein revealed through careful study. It cannot be too strongly urged that integrated planning is essential if facilities are to be established where they are most needed and if those which are established are to be of the high standard necessary if costly waste is to be avoided. Information derived through this Commission's studies has indicated that the needed additional beds might be pro- vided through several methods, it being understood that all such additional facilities would undertake to meet the minimum standards recommended by the technical committees consultant to this Com- mission. Additional beds may be provided through several sources: a. Through the addition of chronic care wings or adjunct buildings to general hospitals both public and voluntary [not-for-profit]. This will free beds in the general hospital for acute cases yet will provide chronic care in convenient access to a general hospital to which the patient may be transferred when in need of active med- ical care. Studies indicate that, in general, wings or adjuncts with not more than 20 per cent of the capacity of the general hospital will be assured of sufficient occupants, both private pay patients and patients coming from the public assistance rolls, to justify the cost of erecting the facility. b. “Through extension of the program for converting county homes into public nursing homes for the infirm and chronically ill. All counties having county homes suitable for conversion and of suf- ficient size to permit economical operation should undertake to convert county institutions into county homes for the infirm and chronically ill under the terms of legislation enacted by the Sixty- fourth General Assembly. About one third of the counties having convertible plants have already acted or plan to act under this enabling legislation, but the county boards in other counties ap- pear to be hesitant because of the initial financial outlay and be- cause of unwarranted fears that the State plans to assume control of the institution. This Commission joins with its predecessor Committee to Investigate Chronic Diseases Among Indigents in emphasizing that facilities for the chronically ill are best located in the local communities near the friends and relatives of the patient and that they are best operated under local control with appropri- ate State supervision to provide guidance as to standards and serv- ices. To date, the counties which do not have suitable plants for conversion have not explored fully the possibility of erecting or purchasing a suitable building or of developing a joint county home for the infirm and chronically ill as is permitted by the en- 4 abling legislation. This Commission strongly urges that the coun- ties give consideration to this plan as preferable to the alternative of having the State erect a state-financed and state-controlled nursing home in areas where need is not met by local officials. c. through extension of infirmary facilities in private nonprofit homes for the aged. Private homes for the aged should be encour- aged to carry forward plans begun during the present biennium to adapt their facilities so that an increasing percentage of chronic invalids may receive care in such homes. When endowments or other moneys become available for the erection of new facilities for private homes for the aged, it is urged that these be primarily for chronic invalids and the infirm, preferably located in connec- tion with or convenient to a general hospital. d. Jhrough the establishment of additional private nursing homes of high standard. Additional nursing homes operated for profit should be encouraged in communities where need does not warrant the establishment of larger public or private not-for-profit nursing homes, but such private nursing homes, through the continuation of the State licensing procedure, should be encouraged to develop standards above the minimum now required and operators should be aided in developing understanding of the particular needs of chronically ill patients. Plans should be undertaken at once to es- tablish regular medical supervision for these homes and to arrange for a close relationship with a general hospital in the community in which they are located. 3. Jhe State should enact legislation which will enable the State and local communities to share in federal funds made available for grants- in-aid under the federal "Hospital Survey and Construction Jet (Public Caw 725). The Illinois Hospital Survey and Plan carried out by the De- partment of Public Health with the assistance of an Advisory Coun- cil on Hospitals appointed by Governor Dwight H. Green has laid the groundwork for the State to participate in these federal benefits. The plan for participation will have been completed once enabling State legislation has been enacted. Such legislation will aid the State in expanding its hospital facilities in a co-ordinated manner and in providing facilities in those areas of the State where such facilities are now lacking. i. Jhe development of provisions for rehabilitation, both for persons in hospitals or nursing institutions and in their own homes, is of ut- most importance if the hopelessness of the remaining years of life of 5 chronic invalids is to be ameliorated and as many as possible re- trained so that they may be restored to usefulness, both for their own good and for the good of society. A rehabilitation program, in addition to providing the best cor- rective medical care, should include occupational and recreational therapy, vocational retraining, and social services which will help the afflicted person understand his condition and help his family and friends co-operate with him in his effort to regain a useful role in life consistent with his incapacities. Indications are that through an ade- quate program of rehabilitation dependency among chronic invalids can be reduced by as much as 70 per cent. Intensified effort should therefore be made to institute a program of rehabilitation in all in- stitutions caring for chronic invalids and ways and means should be developed for extending such programs to the greater number of chronic invalids who are cared for in private homes. Since many in- stitutions are too small to permit the employment of full-time spe- cialists in these lines, plans might be developed for several institutions to share the services of specialists. There is also here great oppor- tunity for utilizing the services of volunteer individuals and groups such as were established during the war for service hospitals and camps. Extensive planning in this regard should be developed during the course of the next biennium. 5. 7he State should enact legislation providing for a uniform system of licensing all hospitals and related medical institutions, both public and private. Such a uniform licensing provision is not only necessary as a means of establishing minimum standards for the protection of the patient, but it is also necessary as part of an integrated system of hospitals and nursing institutions. 6. 7he costs of custodial care in an institution could be reduced and the needs of many chronically ill persons met more suitably if pro- vision were made in each and every county of the State for visiting nurse and housekeeping services. At present such services are provided in only 23 communities. Such services should be provided on the principle that those who can pay for the services will do so and those who cannot pay will be aided through public assistance funds to meet such payments. The development of a system of visiting nursing and housekeeping serv- ices, however, must await further study of the needs within each community, existing facilities, and the development of the best plan of division of field as between public and private agencies which 6 are providing or which might provide the service. Such study should be pursued intensively during the next biennium. 7. 'Housing authorities should give attention to developing apartments and accommodations for the aged as part of the normal community which will comprise the housing project. It has been suggested that approximately 10 per cent of the units located on the ground floor might be assigned to ambulant chronic invalids, other factors permitting. This should particularly be the case in housing units located near a general hospital. 8. A register of available facilities which provide care and service at or above minimum standards should be developed in each county so that persons afflicted with chronic illness and the members of their families may be guided to the best care available in terms of the particular patient’s needs. Such a register should be made available to all persons in the community, rich and poor alike, and might well be established by councils of social agencies or other organizations of health and wel- fare groups. In some areas it may be feasible also to establish a register of seriously invalided persons through the co-operation of physicians and health and welfare agencies as an aid in planning the facilities and services required to meet community needs. 9. TVo person afflicted with chronic disease should be denied the care he needs because he is poor or because what resources he has are not sufficient to meet the usually heavy costs of chronic illness. The State of Illinois from the beginning of its history has rec- ognized public responsibility for helping pay the costs of medical care for all persons who cannot pay such costs in whole or in part. In recent years, with the development of the State’s health and wel- fare programs, this principle of public responsibility has been fur- ther refined to include the principle that there shall be no stigma at- tached to persons who must receive public help because of illness or other cause; that such persons should have access to the same fa- cilities as private pay patients and receive the same quality of care; and that they should be free to choose, as any other citizen, the phy- sician and institution which will give them the care needed by their condition. At present persons otherwise needy and qualifying for one of the four major types of assistance (Old Age Pension, Blind Assistance, Aid to Dependent Children, and General Relief) are as- sured of complete medical care whenever they become ill whether from acute or chronic disease. The Illinois laws also provide for meeting at public cost through General Relief funds and State sup- plementation the medical needs of the border line income group 7 known as the medically indigent. It may be assumed that the pre- ponderance of medical indigency in the low income group not oth- erwise in need of public assistance is caused by chronic disease. The State and local program for care of the medically indigent is at present defective in two respects despite the broad coverage intended by the governing law: 1) Adequate moneys for aid to the medically indigent have not been set aside in every area of the State, particularly in local governmental units which are not re- ceiving State grants-in-aid for General Relief; and 2) the present statute makes an exception for medically indigent persons living in the City of Chicago or the Incorporated Town of Cicero. These persons must look to the County of Cook rather than to the Gen- eral Relief agencies in these communities. Furthermore, the County of Cook gives them no choice of care, requiring that they go either to the Cook County Hospital or accept the services of the Cook County physician. Elsewhere in the State a medically indigent per- son goes to the General Relief agency which provides for his care by the hospital and physician of his choice. It is urged that these faults in the present structure for pay- ment of costs through public assistance be studied to the end that uniform provision may be made for the care of the medically in- digent including the chronically ill. 10. 7o bring to a successful conclusion the activity which has developed during the past few years in mobilizing the community to develop sound future plans for the care of the chronically ill, it is necessary that the State of Illinois, through representative members of its gen- eral Assembly in co-operation with citizens and persons competent in the field, continue to study the problem of chronic illness and direct all efforts toward a co-ordinated and well-thought-out plan. There should therefore be created a successor commission to continue the State's responsibilities especially in the following fields: a. To study and make recommendations concerning the proper re- lationships which should be developed between the various types of public and private facilities and the State Research Institute. b. To develop and make recommendations concerning a suitable plan for the extension of home nursing and housekeeping serv- ices including the proper relationship of these services to insti- tutional care for the chronically ill. c. To consider the desirability and feasibility of State grants-in-aid for construction expenses for cnunty nursing homes and other not-for-profit nursing institutions not qualifying as “hospitals” 8 and therefore not eligible for federal-state grants-in-aid under the Federal Hospital Survey and Construction Act. d. To carry out additional first-hand studies of the extent of chronic invalidism and the need for beds for the purpose of seeing that need is met but that unnecessary and costly facilities are not pro- jected should developments in research and other types of serv- ices indicate that they are not needed. e. To analyze State-local relationships and public-private relation- ships in joint undertakings for service to the chronically ill for the purpose of clarifying fields of responsibility and preventing duplication and overlapping. It should be emphasized that sound planning for the chronically ill is the joint responsibility of all levels of government and it is the joint responsibility of pub- lic and private philanthropy. Only through clear understanding of these relationships and full co-operation can there be devel- oped a co-ordinated and efficient plan. 9 II OUTSTANDING FACTS CONCERNING CHRONICALLY ILL PERSONS IN ILLINOIS Number and Age of Persons with Chronic Disease as of 19471 It is estimated that there are 1,483,000 persons in the State, 18.8 per cent of the total population, who have some kind of chronic disease or permanent impairment. Of these, 18,700 are children under five years of age; 273,000 are persons 65 years of age or over; and 1,191,300 are persons between the ages of five and 65. The age groups presenting the greatest numbers with chronic disease are 35-44 years, 263,000 persons; 45-54 years, 288,300 persons; and 55-64 years, 236,100 persons. Thus it will be seen that chronic illness is not a prob- lem of the aged alone. It strikes most devastatingly in the middle years when persons should be at their prime in terms of contribution to the economic and social welfare. Number of Chronic Invalids2 It is estimated that there are in Illinois from 107,000 to 118,000 chronic invalids exclusive of the tuberculous and persons with nervous or mental ailments; the latter number is the more probable figure. The chronic invalid, as distinguished from the total and larger group of persons afflicted with chronic disease or permanent impairment, is one whose condition is so handicapping that he requires care from others. Dependency Chronic invalidism is the greatest single causative factor (other than great economic depressions) in forcing people onto public assist- ance rolls. Assuming that the situation in Sangamon County in Janu- 'The information summarized here is set out in more detail later in this report together with ex- planation of source material and methods used in assembling the data in support of these conclusions. definition of chronic or long-term illness or invalidism: The acute or short-term illness is one which, when recovery is completed after a relatively short period of time, does not result in change of normal adjustments and ways of living which prevailed for the individual before the onset of the disease. The chronic or long-term illness, in contrast to the acute, requires an adjustment of the manner of living for the individual for the remainder of his life or for a very long period after the chronic disease attacks. A chronic invalid is a patient whose chronic illness is of such severity that his condition requires at least the availability of others when need arises; occasional or seasonal care from others is generally needed; and from such minimum degree of affliction the need for care progresses to the point where constant attention needs to be available either from others in the pa- tient’s own home by supplementation to home care by visiting housekeeper or visiting nurse service, and in most advanced stages by care in special nursing homes or institutions. 10 ary 1947 was typical for the State as a whole, 23.2 per cent of all public assistance recipients (Old Age Pension, Blind Assistance, Aid to De- pendent Children, and General Relief) are chronic invalids. Of the aged, 35.6 per cent are chronic invalids requiring care from others; of the blind, 63.6 per cent; of dependent children and the adults caring for them, 5.6 per cent; and of recipients of General Relief, 13.8 per cent. Other Social Problems There are serious social problems in addition to the economic and physical care problems caused by chronic invalidism. Children may have to forego employment to look after chronically invalided parents (or the reverse), leading often to the loss of their own careers or in- terfering seriously with the supervision of their own children. In ad- dition, chronic invalidism often leads to physical or emotional impair- ment of those who have to care for the invalided person in the home. There is a "chain-reaction” effect to chronic invalidism, affecting many others besides the actual invalid. Need for Research While the whole field of geriatrics (diseases of the aged) and of gerontology (the aging process) represents the least known and most neglected areas of medical and sociological science, there is a present awareness of the problem and its great significance. It has been esti- mated that, given needed support, medical research could reduce by 20 per cent the number who would otherwise develop into chronic in- valids and could greatly ameliorate or improve the condition of many others. There is no matter of greater significance than the stimulation of such research. A proposal of such a project has been made to this Com- mission by Dr. Andrew C. Ivy. This proposal has the complete en- dorsement of this Commission and is set out as its first recommenda- tion for future action by the General Assembly and the people of Illinois. Possibilities of Rehabilitation It is estimated that at least 20 per cent of sufferers from chronic invalidism may, by a program of rehabilitation, be restored to a rea- sonably normal and self-sustaining regime of life. Most of the remain- ing sufferers can have the hopelessness of their remaining years greatly altered by adequate programs, understanding, constructive guidance, and help. Attitudes Public and individual attitudes toward chronic invalidism need thorough revision. There seems too often an unwarranted sense of 11 shame, tending to concealment of the presence of a chronic invalid in the home. This concealment, particularly as to a senile parent or a palsied child, minimizes the known extent of the problem and hinders community planning for meeting the problem. This attitude, in part, is intensified by the fact that there is a great dearth of adequate facilities outside the home, either public or private, where care for the chronic invalid might be secured, particularly at a reasonable cost. This intensifies the feeling that anyone who even con- siders having the invalid cared for outside the home (even if only in- adequate care can be given in the home) is "unnatural” or "heartless.” Need for Beds Of the 118,000 chronic invalids, a minimum of 35,000 need care outside their own homes. To meet this need there are only 11,521 beds available, or a deficiency of 23,479 beds. In addition, there is a defici- ency of 3,113 beds for the 7,708 tuberculous requiring care outside their own homes, while the deficiency is 14,937 beds for the 37,741 chronic invalids requiring psychiatric care because of nervous or men- tal conditions. Type of Care Required by Chronic Invalids Of the chronic invalids, slightly over one third can be cared for adequately in their own homes with occasional help from other mem- bers of their household. One third of the chronic invalids can be cared for adequately in their own homes, provided outside assistance, such as visiting nurse or visiting housekeeping service, is available. But approximately 30 per cent of the chronic invalids require more care than their own homes can provide and need special facilities such as care in public or private nursing homes, in general hospitals or in special chronic disease hospitals. Types of Facilities Needed There is need for a great increase in facilities for chronic invalids, particularly in public and private nursing homes and in special institu- tions, the latter preferably connected with large general hospitals. Creation of adequate and satisfactory special facilities for chronic invalids will not only help meet their needs but will most economically serve the need for more adequate facilities for the acutely ill in general hospitals. It has been estimated that as much as 20 per cent of patient- days in general hospitals would be made available for acute cases were there adequate provision for care elsewhere for chronic invalids. Standards in Existing Institutions Every effort must be made to raise standards of nursing homes 12 and of existing public institutions caring for chronic invalids. Much progress has been made in Illinois along these lines, but much still re- mains to be done. Chronic Invalidism in the General Population Chronic invalidism is not by any means confined either to public assistance recipients or to those 65 and over. While the proportion of chronic invalidism in the assistance group is much greater, the number of chronic invalids not on assistance rolls exceeds that in the recipient group. Analysis of the group of chronic invalids, that is, those who require help from others, shows that between 8 per cent and 12 per cent develop into chronic invalids because of lack of treatment or care, par- ticularly in the earlier stages of the disease. 13 Ill THE PRINCIPAL CHRONIC DISEASES Various listings and classifications of chronic disease are given by different authorities. Based on the Sangamon County Survey (see Sec- tion XI of the Appendix), out of 3,296 cases of chronic diseases listed1 by the doctors of that county, the principal chronic diseases are as follows: Disease No. of Cases Per Cent Total 3,296 100.0 Hypertension 587 17.8 Heart disease 520 15.8 Arteriosclerosis 295 9.0 Rheumatism and arthritis 275 8.3 Chest conditions other than tuberculosis 264 8.0 Fractures 187 5.7 Physical senility 169 5.1 Asthma 160 4,9 Urological conditions 129 3.9 Cancer 108 3.3 Diabetes 106 3.2 Nephritis 96 2.9 Orthopedic and crippling conditions other than fractures 93 2.8 Neurological conditions 73 2.2 Mental senility 58 1.7 Epilepsy 56 1.7 Blood dyscrasia 55 1.7 Mental disease and defects other than senility (noncommittable) 42 1.3 Other conditions 23 0.7 tuberculosis is not listed in this group because there are special laws and special facilities provided for sufferers from this disease. (See special section on this subject in the very excellent report of the Illinois Hospital Survey.) For the same reason committable mental defect and mental disease were not included since the State maintains special state institutions for such patients. The National Health Survey, in 1938, found that if all causes of invalidism were counted in- cluding tuberculosis and nervous or mental diseases or defects tuberculosis would account for 5.3 per cent and nervous or mental diseases for 18.2 per cent of an over-all total. 14 In the Interim Report of the predecessor Committee (1945) the same findings with minor variations are reported. If the classification were based on severity of invalidism, some modification would have to be made. Likewise, modification would have to be made if classification were based on knowledge of causes and preventability of progressive disability provided early diagnosis and proper care were given. Thus, the American Cancer Society states that one out of every eight deaths is caused by cancer, which numeri- cally occurred in only 108 of the 3,296 cases of chronic disease re- ported in the Sangamon County Survey. In general, the findings reported in the table above correspond to accepted findings elsewhere as to the relative numerical importance of causes of chronic invalidism with diseases of the heart and circulatory system and rheumatism leading all other causes. 15 IV MOST IMPORTANT NEXT STEP: RESEARCH IN CHRONIC DISEASE AND GERIATRICS The outstanding finding of this Commission is that the State of Illinois should take steps immediately to establish a research institute for the study of chronic disease and geriatrics. As the Commission proceeded to work with its consultant com- mittees representing the medical and nursing profession and hospital administrators, as it heard testimony at the hearings conducted in vari- ous points in the State, and as it evaluated statistics concerning pres- ent facilities, it reached the inescapable conclusion that the major at- tack on this problem must be immediate attention to decreasing the in- cidence of chronic illness.1 As this conclusion emerged early in the deliberations of the Com- mission, Dr. Andrew C. Ivy, Vice President of the University of Illinois in charge of the Schools of Medicine, Dentistry, and Pharmacy was asked to submit a concrete proposal. This proposal is set out in detail in Section IV of the Appendix. Dr, Ivy points out the great importance of sound planning for the care of the chronically ill with facilities and services to meet the exist- ing emergency need and research in those diseases which cause chronic illness and premature aging to stem the increasing incidence of chronic illness. He recommends, therefore, a research institute for the study of chronic illness and geriatrics, established as a part of the University ’Henrietta Herbolsheimer, M.D., Director of Study, Illinois Hospital Survey, commented in a letter to the Commission on May 22, 1947 that while research will lessen the incidence of chronic disease, full use of known methods of therapy will also do so. To quote in part from her letter: “Many of the conditions commonly listed in tabulations on chronic diseases include conditions for which considerable amelioration can be accomplished at the present time with facts now well in hand. In asking so much of medical research, the rehabilitation factor seems lost. From the Federal Congress on down to the smallest sociological group the atom bomb has catalyzed widespread use of the word ‘research’ so that the term has almost become a platitude and stripped of its real meanings. Real and fundamental medical research is an inspired activity the end results of which as they apply to man have passed through numerous and time-consuming studies by laboratory scientists. This takes years, decades or centuries. If the case load of the chronically ill is as sig- nificant medically, socially, and economically as the figures indicate, emphasis should be placed on the practicability of using known facts to ameliorate the present circum- stances.” 16 of Illinois College of Medicine, which would study the prevention and improve the treatment of such diseases as arthritis, high blood pres- sure, hardening of the arteries, kidney diseases, chronic cardiorespira- tory diseases, cirrhosis of the liver, and ulcerative colitis. The results of such research would be available to other medical schools in Chicago and could be extended to public and private institutions for the aged. Dr. Ivy's proposal has been endorsed by the Committee of the Illinois State Medical Society Consultant to the Commission and by other technical consultants to the Commission. In current studies made in a number of states there has been a finding in every case that the outstanding need in attacking the prob- lem of chronic invalidism is an organized program, such as a research institute, for the study of the causes of such diseases and to discover better methods of diagnosis and treatment. It has been recognized by each of the states studying the problem that such a research facility should also be located in connection with a medical college or available to all medical colleges so that students of medicine can learn more about diseases of the aged and about chronic disease generally, and so that general practitioners can attend special courses on these dis- eases. It is agreed universally that "geriatrics" or the science of dis- eases of the aged is the least developed field of medicine, and that with the increasing percentage of aged persons in the population, it is the most challenging of all needs in the science of medicine. The research institute proposed by Dr. Ivy for the State of Illinois would require an initial expenditure of $2,500,000 for land, buildings, and equipment and an annual operational expenditure of $950,000. The architect's drawing of the proposed research institute appears on page 18 together with Dr. Ivy's notes as to services by floors. 17 ?sopo»eo INSTITUTE. FOR.THE. STUDY OF chronic illness XNP gERlM~RtC5 200 HOSPITAL bEDS RESEARCH FACILITIES Schedule of Services by Floors Basement—Service Rooms; Mechanical Equipment Space; Storage; Staff Food Service; Locker Rooms. First Floor—Administrative Offices; Outpatient Services; Radiology; Physical Therapy, Occupational Therapy; Conference Rooms; Spec- ial Diet Kitchen; Social Service. Second to Sixth Floors (5 floors)—40 Beds each; Nursing Services; Food Service; Research Laboratories; Offices; Service Rooms. Seventh and Eighth Floors—Long-term Studies on Animals. 18 V ACTIVITIES OF THE COMMISSION The Commission on the Care of Chronically 111 Persons was cre- ated by Senate Bill 436. This Bill was introduced in the Sixty-fourth General Assembly by Senator Arthur J. Bidwill of River Forest and Senator T. Mac Downing of Macomb and signed by Governor Dwight H. Green on July 18, 1945. In accordance with the creating Act (see page i for complete text), the Commission consisted of three members of the Senate, three mem- bers of the House, the Director of the Department of Public Welfare, the Director of the Department of Public Health, and the Public Aid Director of the Illinois Public Aid Commission. The Commission was created to continue in a broader field the studies begun during the pre- ceding two years by the Committee to Investigate Chronic Diseases Among Indigents. It was empowered to investigate and study both gov- ernmental and private facilities and needs as they relate to all chroni- cally ill persons, not only the indigent, and to examine the adequacy of existing facilities, the need of developing additional facilities, and the desirability of enacting enabling or corrective legislation to increase or improve facilities. Organization The Commission held its organization meeting in Chicago on March 90, 1946. Senator Downing was elected Chairman and Ray- mond M. Hilliard, Public Aid Director of the Illinois Public Aid Com- mission, was elected Secretary. The Commission was promised an auspicious start because of the wide public interest in the problem which had been aroused by the Interim Report of its predecessor committee, which was submitted to the Sixty-fourth General Assembly on June 7, 1945. Subsequent to the submission of the Interim Report the Sixty-fourth General Assembly passed bills carrying out several of the major recommendations of the Committee. These included the Rennick-Laughlin Bills enabling coun- ty boards to convert the former "poorhouses” into county nursing homes for the infirm and chronically ill; the Gibbs Bill providing for the licensing of private nursing homes by the Department of Public Health; 19 and the Peters-Ryan Bill providing for the construction of five State tuberculosis sanatoria. During the period between the adjournment of the Sixty-fourth General Assembly and the organization meeting of the Commission on the Care of Chronically 111 Persons in March 1946, state and local agen- cies responsible for the county home conversion program and the nurs- ing home licensing program had these activities well under way. In ad- dition, the Governor had appointed an Advisory Council to the State Department of Public Health to assist that Department in conducting a state-wide survey of hospital and health facilities, in which survey it was planned to assemble data concerning available facilities for the chronically ill as well as the acutely ill. Field of Investigation as Recommended by Predecessor Committee In planning its investigations and studies the Commission had the advantage of conclusions reached by the predecessor Committee to In- vestigate Chronic Diseases Among Indigents. The most significant of these conclusions, as set out in the Interim Report, are quoted here be- cause of their continuing significance and because they provide the background for the detailed activities of the present Commission. Nature of Chronic Disease "Chronic disease has been described by The Surgeon General of the United States Public Health Service as fthe nation's number 1 health problem/ The full effect of the change in the nature of diseases causing death is only beginning to be evident. It is apparent that this change will require increased attention by the medical profession and by hospital management which have in the past given major emphasis to acute illnesses. It is also apparent that chronic disease carries with it serious social and economic implications. These will require imme- diate and careful study, in order that a public policy may be formulated which will keep to a minimum the economic and social losses attendant upon prolonged illness/'1 "All.... factors .... point to the increasing seriousness of the problem of chronic illness. They indicate that chronic invalidism is not confined to the aged or to any one group alone; nor is it confined to the indigent. While the problem of chronic illness bears more heavily on the poor than on others, it is important to keep in mind the fact that the indigent chronically ill constitute only one part of a very large Extent of Chronic Illness interim Report of the Committee fo Investigate Chronic Diseases Among Jndigents, Spring- field, Illinois, June 1945, p. 5. 20 group of invalids in Illinois, all of whom are urgently in need of more and better facilities for care.”1 Possibilities for Additional Facilities . facilities currently available in Illinois for care of the chron- ically ill would indicate that future study should be directed toward the following possibilities for establishing additional facilities for the chronically ill and for co-ordinating all types of facilities so as to as- sure adequate care and service to all residents of the State of Illinois who are afflicted with chronic disease or permanent impairment: 1. “The possibility of setting aside more beds in general hospitals for patients who are chronically ill, or of establishing infirmary facilities in connection with general hospitals. 1. “The possibility of converting County Homes which can be so con- verted into homes for the infirm and chronically ill, with proper re- gard to construction, sanitation, and general hygiene so as to safe- guard the health, safety, and comfort of the patients. 3. “The possibility of establishing additional tuberculosis sanatoria, with attention to their proper distribution so as to provide ready ac- cess to tubercular patients in all parts of the state. 4. "The possibility of establishing additional infirmary facilities in pri- vate institutions for the aged. 5. “The possibility of establishing additional private nursing homes and homes for convalescent care, under competent management and with proper standards, licensed, and supervised by a state agency or by local governments in conformity with state standards. 6. “The possibility of establishing additional home nursing and house- keeping services."1 "Dr. (Herman L.) Kretschmer has ably summarized the funda- mental questions which must be considered in developing a sound pub- lic policy. Dr. Kretschmer says: " "Before any sound program can be instituted, careful and seri- ous consideration must be given to the fundamental questions, as: 1. " "The relative distribution of responsibility which should be main- tained by voluntary, philanthropic and proprietary services for es- tablishing and operating the necessary homes and hospitals. 2. " "The responsibility which should be assumed by the government for the indigent. Fundamental Questions To Be Considered interim Report, p. 9. ’Ibid., p. 18. 21 3. " The desirable size and location of the facilities to be established. 4. " The extent to which beds are needed in hospitals or treatment centers as distinguished from homes for patients who cannot hope to profit from treatment and need only continued personal care and nursing attention. 5. " The most satisfactory method of financing care for patients unable to pay the costs of care, in whole or in part. 6. rf The most effective means of maintaining adequate standards of care in institutions serving these patients, i.e., through licensing laws, periodic inspection by state or local authorities, and so on. ff 'Whether there are to be special institutions for the chronically ill, i.e., chronic disease hospitals separate and apart from those serving acutely ill patients, or whether they are to be separate wings or addi- tions to these hospitals. Much discussion must be given to this ques- tion’.”1 Method of Conducting Investigations The problems, as outlined by the predecessor Committee, made it obvious that the work of the present Commission must necessarily fo- cus on five main lines of inquiry. 1. Assembly of information (through persons competent in the tech- nical and professional fields involved) concerning the medical, hos- pitalization, and nursing needs of chronically ill persons and the standards which should be required of persons and agencies giving care to such persons. 1. Evaluation of existing facilities, as these had developed or not devel- oped subsequent to the appraisal made by the predecessor Com- mittee. 3. Utilization of data assembled by the state-wide Illinois Hospital Sur- vey and by local surveys as a means of providing a current and ac- curate estimate of available facilities and gaps in these facilities, and, if necessary, the execution of additional surveys to provide a com- prehensive current picture of the problem. 4. Consultation with persons in various sections of the State who are interested in the problem of chronic illness to determine from their reports what the problem is locally and what plan for meeting the problem is recommended by persons who know conditions in their own communities. 5. Determination, on the basis of the information assembled, of what is today’s problem and what action should be taken in terms of en- abling or corrective legislation and in terms of endorsing or correct- ing existing programs. 'Interim "Report, p. 17. 22 Appointment of Consultant Committees Since the formulation of sound standards of care and of recom- mendations concerning methods of providing such care required the professional knowledge of physicians, nurses, and hospital administra- tors, the Commission asked the Illinois State Medical Society, the Illi- nois Hospital Association, and the Illinois State Nurses’ Association to designate persons to serve as consultants to the Commission in con- sidering these many technical aspects. The members of these consult- ant committees and of other groups who served the Commission at its request are given on page v. A meeting of all of the technical consult- ant committees was held in Chicago on September 7, 1946 and separate meetings with individual committees in November and December 1946 and in March 1947. Public Hearings Public hearings were held in Urbana on May 8, 1946; in Danville on May 9, 1946; in Carbondale on August 7, 1946; in Springfield on October 10, 1946; and in Rockford on February 14, 1947. In addition, a special meeting was held in Chicago on July 11, 1946 with repre- sentatives of medical schools in the Chicago community, hospital ad- ministrators, and representatives of homes for the aged. Inspection of County Institutions The Commission visited the county homes for the infirm and chronically ill in Champaign, Vermilion, Jackson, and Winnebago Counties. In addition, the Commission sent a small subcommittee to California to inspect county institutions there which had gained nation- wide repute for excellence in care and research. This subcommittee also met with state and local officials in California and representatives of the California medical schools who have been concerned with the problem of the chronically ill and who had been developing a program which it was felt might provide constructive suggestions for future planning in Illinois. Surveys The Commission arranged for access to the findings of the Illinois Hospital Survey which was carried out by the State Department of Public Health, and the Chicago-Cook County Health Survey which was carried out by the United States Public Health Service. Permission has been given to reproduce in this report pertinent findings from these surveys (see Sections IX and X of the Appendix). In order to provide a first-hand study of the extent of chronic dis- eases and other long-term illnesses in a typical downstate county the 23 Commission arranged with the Sangamon County Medical Society, local public officials, private and public health agencies, and the State Department of Public Health to undertake such a survey. The survey was carried out by Robert Rosenbluth of the Public Aid Commission with the co-operation of these Sangamon County agencies. A detailed report of this survey is made in Section XI of the Appendix. Mr. Rosenbluth also assembled for the Commission information concerning activities in other states. 24 VI SUMMARY OF ILLINOIS DEVELOPMENTS DURING THE 1945-1947 BIENNIUM Illinois Hospital Survey On July 23, 1945 Governor Dwight H. Green appointed an Ad- visory Council on Hospitals to assist the Illinois Department of Public Health in making a state-wide study of hospital facilities in Illinois for the purpose of developing a plan for postwar improvement and exten- sion of these facilities. It was contemplated that the plan would em- brace both governmental and nongovernmental institutions and agen- cies, on both state and local levels, and would qualify Illinois for par- ticipation in any federal benefits which it was anticipated would become available to the States for the development of hospital facilities.1 Robert S. Berghoff, M.D., Chicago, President of the Illinois State Medical As- sociation, served as Chairman of the Advisory Council and Henrietta Herbolsheimer, M.D., Springfield, Chief of the Division of Maternal and Child Hygiene, State Department of Public Health, served as Ex- ecutive Secretary. Dr. Herbolshiemer also served as Director of Study for the Survey. The schedule of information prepared by the National Commis- sion on Hospital Care was used. These schedules were sent in Septem- ber 1945 to almost 1,200 institutions listed as hospitals and nursing homes excluding, however, hospitals operated by the federal govern- ment and other institutions not serving the general public such as in- firmaries, prisons, etc. By December 1945 the completed schedules had been collected. Thirty-seven per cent of the institutions were deleted from the study because, on the basis of data submitted, they did not 'Such provision was made by Public Law 725 enacted in 1946 by the 79th Congress of the United States. In a letter dated April 16, 1947 and addressed to Raymond M. Hilliard, Secretary of this Commission, Dr. Henrietta Herbolsheimer, Director of Study, Illinois Hospital Survey, states: “The United States Public Health Service Regulations on the administration of Public Law 725 clarify to some extent the difference between nursing home facilities and chronic and convalescent hospitals. None of the nursing homes listed as such in the tables and portrayed in the maps in the report of the Illinois Hospital Survey can qualify as hospitals for the long-term convalescents or chronically ill, and cannot receive favorable consideration for grants-in-aid under Public Law 725. .... Public Law 725 affects only those institutions for long-term patients wherein there is detailed medical supervision, high level of nursing care, and facilities and programs for occupational, rec- reational, and rehabilitation therapy.” 25 qualify as hospitals or allied institutions. Only five institutions refused to co-operate with the Survey by submitting the desired information. The final report was based on data submitted by 320 hospitals and 362 nursing homes, a total of 682 institutions. The report of the Illinois Hospital Survey and Plan is now under final draft and will be made available in printed form. Through the courtesy of the Illinois Department of Public Health and the Advisory Council on Hospitals, the Commission on the Care of Chronically 111 Persons was given access to the Survey findings as assembled in pre- liminary drafts of the report and has been given permission to repro- duce portions of this material which have bearing on the care of the chronically ill. According to the Illinois Hospital Survey and Plan there were in Illinois, as of 1945, 682 institutions providing hospital or allied services. These institutions were built to accommodate 67,204 persons but at the time of the Survey they actually had set up 80,625 beds. The most serious overcrowding occurred in hospitals for those afflicted with nerv- ous and mental diseases. Although nervous and mental ailments and tuberculosis are types of "chronic disease,” the Illinois Hospital Survey distinguished facili- ties for these patients from facilities for other types of chronic and con- valescent patients because, as stated by Dr. Henrietta Herbolsheimer, "the problems of provision of facilities for tuberculous and psychiatric patients are large enough in themselves to warrant all the special at- tention which they have been receiving and continue to receive, and adding them to the problem of persons chronically ill from other causes only confuses the whole picture.” The same distinction has guided this Commission in pursuing its investigations. In Section IX of the Appendix there are printed by permission excerpts from the Illinois Hospital Survey and Plan which have refer- ence to the care of chronic and convalescent patients. In order that the excerpts regarding the care of the chronically ill may be related to the total picture of medical and nursing facilities in Illinois as of 1945, there is reproduced below a table from the Illinois Hospital Survey indicating the number of institutions of all types and the number of beds. It will be observed from the following table that a little over 53 per cent of all institutions included in the Illinois Survey were devoted to the care of the chronic and convalescent exclusive of specialized facili- ties for the tuberculous and the nervous or mentally ill. Overcrowding was not a problem in the chronic and convalescent institutions to the same extent that it was in the general hospitals and 26 Type of Hospitals and Beds, by Type, Illinois 1945 Type of Hospital Hospitals Beds* Number Per Cent of Total Number Per Cent of Total Normal Complement Normal Complement Total .682 100.0 67,204 80,625 100.0 100.0 General .228 33.4 27,451 28,447 40.8 35.3 Allied special . 37 5.4 2,721 2,590 4.0 3.2 Nervous & mental 25 3.7 21,955 34,414 32.7 42.7 Tuberculosis . 30 4.4 3,556 3,661 5.3 4.5 Chronic & Conva- lescentt .362 53.1 11,521 11,513 17.1 14.3 ♦“Normal” is used to denote the number of beds for which the various institutions were built or the number of beds which normally should be in use. The term “complement” is used to denote the number of beds which were actually set up and in use at the time the survey was made. •{■Mostly nursing homes providing little in addition to domiciliary care. in the hospitals for the nervous and mentally ill probably because chronic and convalescent institutions admit only those patients for whom they have space, requiring those who need care to remain on a waiting list or in the beds of general hospitals. The Survey also re- vealed that existing facilities are poorly distributed as will be noted from the five maps on pages 56 through 60. The Illinois Hospital Survey also undertook to determine the ex- tent to which hospitals of one type provide facilities for patients of other types. Data were assembled for institutions of 75 beds or more and the findings were as set out in the table below: Beds Available for Certain Types of Patients in Hospitals of 25 Beds or More, by Type of Hospital, Illinois 1945 Type of Patient Nervous & Mental Tuberculosis Chronic & Convalescent Type of Hospital Number Per Cent Number Per Cent Number Per Cent Total .32,616 100.0 6,847 100.0 8,104 100.0 General . 549 1.7 357 5.2 168 2.1 Allied special - ........ 51 0.6 Nervous & mental. .32,059 98.3 2,265 33.1 35 0.4 Tuberculosis 3,651 53.3 Chronic & Conva- lescent* 8 574 8.4 7,850 96.9 *Mostly nursing homes providing little in addition to domiciliary care. 27 It will be observed from the above table that only a very small number of beds for chronic patients was provided in facilities other than institutions specializing in caring for chronic and convalescent patients. It is important, however, to note that while general hospitals actually could care for only 168 chronic and convalescent patients without sacrificing beds badly needed for acute cases, many general hospitals actually had 20 per cent of the total beds occupied by chronic disease and other long-term cases.1 Although there has been considerable change since the Illinois Hospital Survey was made in 1945 in the development of facilities for the chronically ill (especially as a result of beds made available through the conversion of the former county "poorhouses” into county nursing homes for the infirm and chronically ill), the Illinois Survey findings with respect to the chronic and convalescent are significant for further planning for the care of the chronically ill. The high lights of Dr. Her- bolsheimer’s report as given in detail in Section IX of the Appendix may be summarized as follows: 1. Of the total of 362 institutions in 1945 which specialized in care of chronic and convalescent patients, 274 or nearly 76 per cent were proprietary or profit institutions. The Survey considered only 20 public institutions or 5.5 per cent of the total. The remaining 68 institutions were not-for-profit institutions operated by religious and fraternal associations or similar voluntary associations. 2. There was slight overcrowding in proprietary and public institutions but the nonprofit institutions actually had set up slightly fewer beds than the institutions were constructed to accommodate. The per cent of occupancy in governmental institutions for the chronic and convalescent was 23.9* as compared with 72.6 per cent occupancy in nonprofit and 60.9 per cent occupancy in the proprietary institu- tions. 3. The average per diem cost of operation in these institutions in 1945 was estimated at $1.81 based on incomplete reporting from the in- stitutions. After evaluating its information on facilities for the convalescent and chronically ill in relationship to its findings with regard to facilities for all types of patients, the Illinois Hospital Survey report recom- mended that: 1. General hospitals should be used only for diagnosis and intensive treatment of chronically ill or convalescent patients. ’See Dr. Henrietta Herbolsheimer’s statement on p. 194. 2Compare this low occupancy of 1945 with the near capacity occupancy in 1947 in county institutions which had been converted into nursing homes tor the infirm and chronically ill under the terms of the Renniclc-Laughlin Bills (see Section XIV of the Appendix). 28 7. The nonacute chronically ill and convalescent patient should be cared for either in a special wing of the general hospital or in a separate institution affiliated with a general hospital. The appoint- ments of such facilities should conform to the type of illness being cared for with provision for occupational, rehabilitative, and recre- ational therapy. 3. There should be established a special hospital affiliated with a teach- ing institution to provide training of physicians and research in the incapacitating diseases. 4. The State should pay or contribute toward the payment of costs of care for persons afflicted with chronic diseases who cannot them- selves pay for needed care. 5. County homes should be converted into facilities for the chronically ill and affiliated with a general hospital. 6. The standards for licensing private nursing homes should be raised and these homes closely supervised. Furthermore, the licensing pro- gram should strengthen its educational and consultation services. 7. Visiting nurse facilities should be extended to each county in the State in order to provide home care for those who would not need institutional care if home care were provided. Local Surveys Supplementing the 1945 State-wide Illinois Hospital Survey and providing more current and detailed information concerning conditions in two counties were the 1946 Chicago-Cook County Health Survey and the survey in Sangamon County on the extent of chronic disease and other long-term illness as of January 1947. Chicago-Cook County Health Survey The need for a survey of health and hospital facilities in Chicago and Cook County was recognized early in 1946 by The Institute of Medicine of Chicago, the Chicago Medical Society, and the Health Division of the Council of Social Agencies. At the invitation of the Mayor of Chicago and the President of the Board of Cook County Commissioners the United States Public Health Service was requested to conduct such a survey. The Survey was carried out during the spring and summer of 1946 and the information gathered assembled in a report during the fall of 1946. The report was released in mimeographed form early in 1947. The Survey was under the direction of Colonel K. E. Miller of the United States Public Health Service. It included a study of public health work and sanitation as well as hospital and medical care and treatment offered by both voluntary and tax-supported agencies. The need for service, the amount and character of services being rendered, 29 the appropriateness of the scheme of organization, the efficiency of operation, the effectiveness of program, and the adequacy of funds, staff, and facilities were studied. Colonel Edward T. Thompson of the United States Public Health Service was in charge of the medical and hospital care section of the Survey. An Advisory Committee (of which Samuel A. Goldsmith, Executive Director of the Jewish Charities of Chicago, was Chairman and Alexander Ropchan, Executive Secretary of the Health Division of the Council of Social Agencies, was Secre- tary) was appointed by the Mayor and the Chairman of the Board of Cook County Commissioners. By permission the Section of the report of the Chicago-Cook County Health Survey which pertains to the chronically ill is repro- duced in full in Section X of the Appendix. The findings of this Survey relative to chronic invalidism and the need for beds have been adapted and utilized in Chapter VIII (see pages 81 through 83) to arrive at a current estimate of the extent of chronic invalidism and the need for beds in the State as a whole. Sangamon County Survey The Sangamon County Survey was carried out under the aus- pices of the Commission on the Care of Chronically 111 Persons in Jan- uary 1947. It was limited to a study of chronic and other long-term illness. The survey was directed by Robert Rosenbluth, Consultant to the Illinois Public Aid Commission. He was assisted by physicians and health and welfare agencies of Sangamon County in collecting the in- formation. A detailed report on the Sangamon County Survey is contained in Section XI of the Appendix. The findings of this Survey have been utilized in assembling the information set out in Chapters II, III, and VIII. County Homes for the Infirm and Chronically 111 The most effective program of the 1945-1947 biennium in terms of actually making available additional beds sorely needed by chronic invalids who could not be cared for in their own homes yet who did not need the extensive care provided by general hospitals was the pro- gram for converting the former county "poorhouses” into county nurs- ing homes for the infirm and chronically ill. The Rennick-Laughlin Bills, which were strongly endorsed by the predecessor Committee to Investigate Chronic Diseases Among Indigents, made this program pos- sible. Full details concerning the progress of this program are given in Section XIV of the Appendix. The standards governing the operation of these homes are set out in Section XV of the Appendix. Because of the importance of the county home program in meet- 30 ing the immediate needs of persons in Illinois who are invalided by chronic diseases, it is well to summarize here the following high lights from the more detailed account given in Section XIV of the Appendix. 1. By April 1947, 15 counties having a total capacity of 916 beds had converted their plants into modern nursing homes for the infirm and chronically ill. These counties were the following: Champaign De Kalb De Witt Fayette Henry Jackson Knox Lee Livingston Menard Mercer Rock Island Vermilion Warren Whiteside 2. Within the next few months Peoria, Ford, Macon, and White Coun- ties will have completed the conversion of the county plant, making available an additional 480 beds. 3. Extensive work is underway in eight other counties with a reported capacity of 500 beds. Conversion in these counties will probably be completed before the end of 1947. 4. An additional 23 counties with buildings of varying adaptability are considering the possibility of conversion. 5. Ten counties with no county plant are giving consideration to the possible purchase of a suitable building for a county nursing home or the erection of a new building for this purpose. 6. The change in function of these county institutions is vividly illus- trated by an analysis of the present population. Whereas the report of the predecessor Committee1 showed that in November 1944 these institutions for the State as a whole were only 59.2 per cent occu- pied and some almost empty, the converted institutions are now almost 100 per cent occupied and many have a long waiting list. Eighty-two per cent of the total patient population in the converted institutions are persons who require nursing care. Significantly, 56 per cent are persons who are paying for their care from Old Age Pension and Blind Assistance grants; 27 per cent are supported by township General Relief funds; and 17 per cent are private pay pa- tients. 7. Progress has been impeded in many counties because of difficulties in obtaining materials and competent personnel. Indications are, however, that these difficulties are being overcome and that the pro- gram will move forward with increasing emphasis on better medical supervision (as exemplified by the program in Vermilion County) and that in time therapeutic services, such as occupational and phy- 1 Interim Report, p. 16. 31 sical therapy and social services, will be established as part of the program. The Illinois program for converting the former county "poor- houses” into modern public infirmaries for the chronically ill has estab- lished a pattern which may result in amendments to the Federal Social Security provisions and in the social welfare laws of other states. At present, because of prohibitions in the Federal Social Security Act against federal contributions toward assistance grants made to persons residing in public institutions, the State of Illinois and local govern- mental units must meet all the costs for financially dependent chron- ically ill persons given care in these county homes.1 The significance of the county home program for Illinois and for the nation as a whole is summarized by Raymond M. Hilliard, Public Aid Director, Illinois Public Aid Commission, in an article entitled, "The Emerging Function of Public Institutions in Our Social Security Structure,”2 Mr. Hilliard says, ". . . the last eleven and one-half years of administering our social security laws and the experiment recently inaugurated in Illinois to convert the former 'poorhouses’ into county institutions for the chronically ill have these implications for the emerg- ing new function of the institution, especially the public institution, in our total planning to meet the present-day health and welfare needs of our people: 1. "Provision for sheltered or institutional care is a necessary part of total planning for the social welfare. Home relief alone is not suffi- cient to meet the needs of people in a modern welfare program, es- pecially in view of the growing problem of chronic disease and other long-term illness. 2. "The public institution has a vital and important part to play in meeting the institutional needs of persons who are sick and infirm or who otherwise cannot adjust to living in the normal community. Such public institutions should be locally placed and locally con- trolled, under proper supervision by an appropriate state agency. Yesterday’s almshouse must be transformed into today’s public in- firmary for the chronically ill. 3. "Public institutions should be conceived of as only one of many units in total community planning for the sick, the infirm, and the chronically ill. The public assistance recipient, as well as the self- 1 According to an article appearing in the March 1947 issue of Public Aid in Illinois (monthly publication of the Illinois Public Aid Commission), the Social Security Administration now “be- lieves that it would be desirable to permit federal matching of the cost of care of persons living in public or private medical institutions other than mental hospitals and tuberculosis sanatoriums.” The American Public Welfare Association has endorsed such change in the Federal Social Security Act in its platforms for 1946 and 1947. 2Social Service Review, Vol. XX, No. 4, December 1946, University of Chicago Press, p. 493. 32 supporting person of moderate means, should have free choice of facility, whether public or private. He should also have freedom to move into or out of the institution, according to whether or not the care and service are satisfactory. 4. "A new function appears to be emerging, for units of government statutorily responsible for maintaining and operating public institu- tions as well as for private philanthropy maintaining and operating private institutions. The governmental body and the board of the private philanthropic institution are now more and more being called upon to establish, maintain, staff, and operate the institution, as a facility at which care can be purchased by rich and poor alike. This system will and should supplant the former system whereby a pau- per or a charity stigma attached to all persons in the institution merely because they were given so-called 'free careJ in the institution. 5. "Rethinking and reshaping the relationship between home relief and institutional care, between public institution and private institution, between local, county, and district or state institution, constitute a challenge for welfare planning in the next decade. It is to be hoped that the same constructive evolution can occur in this field as has occurred during the past decade in the development of federal-state- local and public agency-private agency relationships in the field of home asistance and social services.” Further improvements in the Illinois laws governing the establish- ment and operation of county homes for the chronically ill are contem- plated in the proposed Public Assistance Code of Illinois which was in- troduced in the Sixty-fifth General Assembly on April 2 through Sen- ate Bill 70S and House Bill 328, The proposed Public Assistance Code of Illinois was the result of the work of the Illinois Public Assistance Laws Commission which was created by Act of the Sixty-fourth Gen- eral Assembly. Section 4-17 through Section 4-24 of Article IV of this Code further revise the language of the present Act enabling County Boards to erect and maintain county homes and clarify the County Boards" authority to operate the home, to fix rates, and to control ad- missions. The Code also makes revisions in the language of sections of the Blind Assistance and Old Age Assistance provisions which pertain to recipients of these two types of public assistance who need care in county homes. The Code, however, retains the present provisions whereby the Illinois Public Aid Commission is responsible for prescrib- ing standards for such homes as desire to admit Old Age Assistance and Blind Assistance recipients. The report of the Illinois Public As- sistance Laws Commission comments as follows on this matter: "The present provision whereby . . . regulation is assigned as 33 the responsibility of the Illinois Public Aid Commission with re- spect to county infirmaries for the chronically ill which choose to sell care to recipients of Old Age Assistance and Blind Assistance is a stopgap. This is not properly a function of the State agency assigned responsibility for administering the public aid programs. Regulation of hospitals and nursing institutions, whether public or private, is more properly a function of some other State agency such as the Department of Public Health. The Commission recom- mends that if the General Assembly considers a uniform system of regulating hospital and nursing institutions, that it include all such institutions. Until such action is taken, it is necessary to continue in the Public Assistance Code the standard-approving functions now assigned the Illinois Public Aid Commission."1 House Bill 283 introduced March 12, 1947 by Representatives Homer B. Harris of Lincoln, John W. Lewis of Marshall, and Homer Caton of Stanford provides for licensing and regulation of all public and private hospitals and sanitariums, maternity hospitals, lying-in- homes, rest homes, boarding homes or other institutions and places providing hospitalization or inpatient or nursing care of persons. Re- sponsibility for administration of the Act is placed in the Department of Public Health and other previous separate licensing acts are re- pealed. This Bill, if favorably acted upon by the General Assembly, will include county homes for the infirm and chronically ill. House Bills 281, 282, and 284 by the same sponsors amend other acts in the light of the proposal in the key Bill, House Bill 283. Any necessary amend- ment to the Public Assistance Code will undoubtedly be made should the hospital licensing Bills receive favorable action. Licensing of Private Nursing Homes Paralleling the program for converting county institutions into nursing homes for the infirm and chronically ill, in its immediate prac- tical effect in providing better facilities for the chronically ill, was the program of the State Department of Public Health for licensing private nursing homes. Prior to July 17,1945 when Governor Dwight H. Green' approved House Bill 252 passed by the Sixty-fourth General Assembly,* Illinois did not make provision for state licensing and regulation of such institutions. House Bill 252 defined a nursing home as a "private home, institution, building, residence or other place which undertakes, through its ownership or management, to provide maintenance, per- sonal care or nursing for three or more persons who, by reason of ill- Proposed Public Assistance Code of Illinois: Report of the Illinois Public Assistance Caws Commission, Springfield, April 1947, p. 21. ’House Bill 252 was sponsored by Representatives William F. Gibbs of Quincy, Bernice T. Van der Vries of Winnetka, James L. Wellinghoff of Belleville, and Franklin U. Stransky of Savanna, 34 ness or physical infirmity, are unable properly to care for themselves.” Excluded, however, were state, local, or municipal public institutions, institutions for persons afflicted with mental or nervous diseases, hos- pitals and maternity or lying-in-homes otherwise required to be licensed by the State. Also, only limited state regulation was stipulated for homes or institutions conducted for those who rely upon treatment by prayer or spiritual means. The Act also did not apply within any mu- nicipality which had enacted an ordinance for local licensing and reg- ulation provided the ordinance substantially complied with minimum requirements set out in the State Law. „ Upon the Governor's approval of the Act, the Director of Public Health appointed a Nursing Home Committee consisting of the chiefs of the Divisions of Local Health Administration, Maternal and Child Hygiene, Public Health Nursing, Communicable Diseases, and Sani- tary Engineering. Direct responsibility for administering the Act was placed in the Division of Sanitary Engineering inasmuch as the end in view was largely the improvement of sanitation. Minimum standards were prepared and general policies evolved by the Committee and sub- mitted to the Director of Public Health for approval. Approximately ten days after the Act was approved, copies of the Act, application forms for licenses, and letters explaining in general the provisions of the Act were mailed to all establishments appearing on the nursing home list. All establishments from which no reply had been received by September first were sent a follow-up letter requesting them to inform the Department as to the status of their homes in re- gard to licensure.1 In Section XII of the Appendix there is printed a progress report on licensure of private nursing homes prepared by Mr. C. W. Klassen, Chief Sanitary Engineer, State Department of Public Health, In Section XIII of the Appendix will be found the minimum standards prescribed by the State Department for private nursing homes. The high lights of Mr, Klassen’s report may be summarized as follows: 1. As of February 1947 there were in Illinois 533 private homes or in- stitutions giving nursing services to the infirm or chronically ill. Two hundred and seventy-two of these homes were exempt from the pro- visions of the 1945 State Licensing Act. 2. The State Department received 254 applications for licenses. Two ‘The information contained in this and the preceding paragraphs has been taken verbatim from an article entitled, “State Department of Public Health Assumes Responsibility for Licensing Nurs- ing Homes” by Roland R. Cross, M.D., Director, Illinois Department of Public Health. This article appeared in the November 1945 issue of Public Aid in Illinois. 35 hundred and eighteen homes have been inspected and 163 have licenses in effect. 3. The predominant defects in the homes inspected are inadequate plumbing, improper food handling, insufficient records concerning patients, and poor provisions for general hygiene. 4. Service in the homes operated by religious or fraternal or other non- profit associations is superior to that offered in the other homes. Service in homes catering primarily to self-supporting patients is fairly satisfactory but there is lack of personal interest in the patient other than providing him With fair physical care. The homes hous- ing Old Age Pension and other public aid recipients at present barely meet standards. 5. Postwar difficulties in obtaining equipment and personnel have made it necessary to give temporary acceptance to conditions which nor- mally should not be permitted to continue. The greatest future needs are education of home operators to provide better insight into the needs of chronically ill persons and the strengthening of licensing and regulation, either through the abolition of local licensure or by provision of a closer relationship between the state licensing pro- gram and local licensing programs. Not-for-Profit Homes for the Aged Complete information is not available concerning all not-for-profit homes for the aged now operated in Illinois. Those homes which do provide nursing services for the infirm and thus come under the pro- visions of the Illinois Nursing Home Act were included in the report prepared for this Commission by the Chief Sanitary Engineer of the State Department of Public Health but Mr. Klassen does not list such homes separately in his statistical report. As noted by Mr. Klassen, however, the not-for-profit homes for the aged which do provide nurs- ing facilities for the infirm and chronically ill are in general superior to all other types of nursing homes coming under the Illinois regulatory act. In Section II of the Appendix of this report there is quoted testi- mony by Frank D. Loomis, Executive Director of the Chicago Com- munity Trust, indicating some of the factors which have prevented the full development of homes for the aged as facilities for the chronically ill (see pages 110 through 113). More complete information is available, however, on homes for the aged which are willing to admit recipients of Old Age Pension and Blind Assistance. Information on such institutions is available to the Illinois Public Aid Commission. The private homes for the aged 36 caring for recipients of Old Age Pension and Blind Assistance are listed in the map and chart on page 61. In its Interim Report the predecessor Committee to Investigate Chronic Diseases Among Indigents reported on 49 private homes for the aged admitting public aid recipients as of May 1945. The Com- mittee made this comment in its report: "There is a growing trend among these institutions toward the development of facilities for caring for chronically ill persons. The Chicago Home for Incurables has always cared for chronic patients. Such facilities have more recently been developed by the Home for Aged Jews, the Orthodox Jewish Home, Rosary Hill Convalescent Home, St. Ann’s Home in Cook County and by St. Joseph’s Hospital in Adams County, the I. O. O. F, Home in Coles County and the Eastern Star Sanitorium in Macon County. "It is expected that such facilities will be developed in more of the Institutions of this type as the problem of the chronically ill receives increasing attention and as equitable bases of payment for care in such institutions are developed in co-ordination with payment rates for other types of facilities.”1 At the time of the Interim Report the Illinois Public Aid Commis- sion had a policy whereby the general home income was deducted from per capita costs and Commission payments fixed at the difference. As implied in the report of the predecessor Committee this basis of pay- ment was not considered "equitable” in relationship with payment rates for other types of facilities. In its meeting of June 3, 1946 the Illinois Public Aid Commission adopted a new policy under which the amount of the assistance grant to a resident of a nonprofit private institution was to be based, in most instances, upon the per capita cost to the institution for care and main- tenance of its residents. Information available to this Commission indicates that Illinois is one of the few states in the nation that has made a genuinely liberal provision for assistance grants to needy persons residing in nonprofit institutions. Some states do not permit public assistance to be given to residents of such institutions. Because of its importance in develop- ing this type of facility for the chronically ill, a description of the new Illinois policy (as reported in the August 1946 issue of Public Aid in Illinois') is quoted in full below: "The new policy, which in general permits larger grants to recipients of public aid who are residing in these institutions, re- places the former policy whereby grants were based on the differ- interim Report, p. 15. 37 ence between the per capita cost and the per capita general home income. The old policy operated to the disadvantage of Old Age Pension and Blind Assistance recipients in gaining admission to such institutions, and appeared to have retarded the development of the facilities of such institutions as units in community and state-wide planning for care of the chronically ill. "Observing the effect of the policy then in operation, the Commission began late in 1943 to analyze various aspects of the policy and to explore alternatives which would offer a more prac- tical basis for agreeing on rates with the institutions, for encour- aging these institutions to admit more assistance recipients, and to develop infirmary and other facilities for those who require in- stitutionalization because of chronic illness. As the study pro- gressed, it became obvious that nonprofit private institutions, es- pecially homes for the aged, represented one of the most impor- tant resources for developing high type facilities for care of the chronically ill. "Dissatisfaction with the old policy became more pronounced in 1944. In September of that year the Commission adopted a new policy providing for nursing care of the aged and the blind in private profit nursing homes with a fee schedule allowing for some profit and providing for grants in excess of $40 per month when needed to purchase care in such homes. In December of that year the Commission announced a plan for paying full medical and hos- pital care costs for Old Age Pension and Blind Assistance recipi- ents, with hospital rates to be determined with each hospital at an amount representing a certain percentage of actual cost for ward or comparable accommodations. Both the nursing home and the hospital care plans provided for a fixed rate to be negotiated within Commission standards and did not entail financial scrutiny of the institution's income from patients, endowments, contribu- tions or other sources, as was the case with the private nonprofit institution policy. "These seemingly more equitable and less involved plans for payment for care in private nursing homes and hospitals focused attention anew on the Commission’s policy with respect to non- profit private institutions, especially because of the wide discrep- ancy in the rates paid the nonprofit institutions as compared with the fee schedule allowed for care in nursing homes operated for profit. "The old policy, however, had definite advantages. It was in essence 'deficit financing’ and was thus closely related to the pat- 38 tem used by the Community Fund of Chicago in determining contribution of community fund drive proceeds to such institu- tions. There was also the factor that nearly all such institu- tions followed the practice of conducting independent drives for contributions over and above support received from endowments and from community fund contributions, such drives basing their appeal on the claim that the institution was rendering 'charitable care’ to the aged, the ill, and the unfortunate. "The policy was also similar in principle to the 'individual budget’ method used in determining the amount of the assistance payment to public aid recipients living in their own homes. This principle provides that the assistance grant supplements rather than precedes any other income or resources available to a recipi- ent. "As applied to nonprofit institutions, this principle conceived the assistance grant as being a supplement to endowments and contributions made to the institution for support of residents, and that such endowments and contributions are made for the benefit of public aid recipients as well as other residents of the institution. "Because the old policy was therefore consistent with com- munity patterns and with the assistance budget principle of public aid, careful thought had to be given to the implications in changing it. There were, however, the following disadvantages in the former policy: 1. "It discouraged nonprofit private institutions in making addi- tional openings in the institutions available to Old Age Pension and Blind Assistance recipients who needed the care offered. 7. "The payments rate in these homes compared unfavorably with the fee schedule adopted for private nursing homes, even if al- lowance were made for 'charity’ in the former and for 'profit’ in the latter. This fact was commented on in the Interim Report of the Committee to Investigate Chronic Diseases Among Jndi- gents, submitted to the Sixty-fourth General Assembly of Illi- nois on June 7, 1945. 3. "The policy to some extent deprived the recipient of the 'bar- gaining power’ he had with his grant in similar situations, such as negotiating for board and room in a rooming house. In this respect the policy was a 'restrictive payment’ policy, which criticism was advanced by the Social Security Board in a study made in April 1943, three months before the Commission be- came responsible for administration of the Old Age Pension and related social security programs. The Social Security Board 39 pointed out that the policy was ‘based more on the eligibility of the institution than on the financial situation of the applicant . . . The financial standing of the institution, not consideration of the need of the individual, determined whether the resident was eligible or ineligible for public assistance/ 4. ‘The policy, based as it was on ‘deficit financing’ of private charitable funds, represented a contradiction of the principle that public funds should not subsidize private charity, nor should private organizations administer public funds. 5. ‘The policy became particularly difficult to justify after the Commission adopted in September 1945 a plan for payment for care of Blind Assistance and Old Age Pension recipients in county homes for the chronically ill which provided for nego- tiation of a rate based on per capita cost. ‘‘Prior to the adoption of the new policy, staff of the Com- mission discussed the proposed change with a number of institu- tions throughout the State and with the Illinois Homes for the Aged, Inc. The majority of the homes have approved of the new policy as a distinctly forward step. It is hoped that, as a result of the new policy, private homes for the aged and similar institutions will become important units in Illinois’ facilities for care of the chronically ill.”1 Illinois Children’s Hospital-School Illinois pioneered again when the State established the first state- sponsored institution in the United States equipped to give medical care and education to children who have all types of severe physical handicaps. House Bill 419 was introduced1 in the Sixty-fourth General Assembly by Representatives Bernice T. Van der Vries of Winnetka, W. O. Edwards of Danville, and Anthony Prusinski of Chicago as a result of studies by the Illinois Commission for Handicapped Children and the Division of Services for Crippled Children of the University of Illinois. This Bill was approved by Governor Dwight H. Green on June 99, 1945. An appropriation of $490,000 was made to the Department of Public Welfare, to “establish and maintain services and facilities, in- cluding a hospital-school, for the care and education of physically handicapped but educable children.” Under the statute any child who is a resident of Illinois may be considered for care at the hospital-school ’From article entitled, “Commission Adopts New Policy for Payments for Care in Private In- stitutions,” Public Aid in Illinois, August 1946, p. 3. *This Bill was endorsed by the Committee to Investigate Chronic Diseases Among Indigents. The Committee commented: “It may provide, among other services, some opportunity for the re- habilitation of spastic children for whom facilities are practically nonexistent.” Interim Report, p. 30. 40 if he is educable but so severely handicapped that he cannot take ad- vantage of the system of public school education. The Department of Public Welfare leased the building at 2551 North Clark Street, Chicago, formerly occupied by the North Chicago Community Hospital. Despite the need for structural changes and renovation of the building, which were necessarily delayed by short- ages of labor and material, sufficient progress was made so that 13 children were admitted in September 1946. At the time information was collected for this report (January 1947) there were some 20 children in the institution which will have an eventual capacity of 90 to 100. The professional services provided by the school include the fields of medicine, nursing, education, physical therapy, occupational ther- apy, speech therapy, dietetics, psychology, social work, and religion. In addition, nonprofessional men and women with understanding of children's needs give direct care to the children. A maintenance staff completes the roster of persons required in an institution serving as a home, school, and medical center for handicapped children. Richard Eddy, Superintendent of the Hospital-School, has vividly described the field of service of this unique state institution in an ar- ticle entitled “Give Them a Chance to Learn."1 Mr. Eddy says: “As the fields of public health, education, and welfare ex- panded their facilities to discover and provide opportunities for handicapped children, the Illinois Commission for Handicapped Children and the Division of Services for Crippled Children of the University of Illinois remained alert to evidence of still unmet needs. Children were found who were so physically limited that they could not stand the exertion required to attend even special day schools for the handicapped. There were others whose condi- tion would not respond even to the marvels of modern surgery. Some boys and girls were placed at the end of the waiting lists for care in hospitals for crippled children because only through years of intensive treatment, if then, could physical improvement be expected. With bed space in demand it seemed unfair to be- stow upon one child with a doubtful prognosis the care and atten- tion which might bring complete restoration to three or four who seemed more hopeful. Physical therapy and home teaching were made available to some of these eager though less eligible young- sters, but too often the amount was insufficient or parents were unable or unwilling to lend the necessary co-operation. In some instances parental rejection, frustration, or overburdening made life in the home dismally unpleasant or emotionally deadening for Public Aid in Illinois, February 1947, p. 6. 41 the child, the parents, and other members of the family. Rarely could qualified foster parents be found for the severely handi- capped child for whom removal from the family home was indi- cated. "An important gap in services to crippled children had been discovered. Children with good minds were idling at home without proper physical or mental nurture. Worse yet, some were mistak- enly thought to be mentally as well as physically defective. Super- ficial diagnosis or no diagnosis had led to the hasty conclusion that the imprisoned brain was an enfeebled brain. Reliable esti- mates pointed to the presence in Illinois of thousands of possible educable children suffering from the restricting pressures of cere- bral palsy, muscular dystrophy, spina bifida, postpoliomyelitis, and other physically limiting conditions so severe or so slowly responsive to known methods of treatment that little of real value was being done for them.” The planning for the Hospital-School has progressed with the help and guidance of an Advisory Board of 15 persons established by law and appointed by the Governor and of an especially created Medical Advisory Board. Sound planning has resulted in an institution meeting the needs of children with severe physical handicaps who appear edu- cable, are not being properly served in their present environment, and could not receive appropriate care or educational training through other available resources. When the institution's construction and ren- ovation program is completed, its program will make a substantial con- tribution to meeting the problem of caring for a very special group of the chronically ill. Hospitalization and Medical Needs Commission The Sixty-fourth General Assembly, which created this Commis- sion, also passed Senate Bill 336 creating a Commission to study the hospitalization and medical needs of the State and report findings and recommendations relative thereto to the Sixty-fifth General Assembly together with recommendations concerning the establishment of a State system of hospitalization and medical care. Senate Bill 336 was spon- sored by Senators R. G. Crisenberry of Murphysboro, John T. Thomas of Belleville, and John W. Fribley of Pana and approved by Governor Dwight H. Green on July 18, 1945. The Commission was to consist of three members of the Senate, three members of the House, and three members appointed by the Governor, two of the latter appointments to give consideration to the recommendations of labor groups or organi- zations. Although the work of the Hospitalization and Medical Needs 42 Commission was not limited to the chronically ill, its findings and recr ommendations will have significance for those who are afflicted with chronic disease or permanent impairment. Disability Unemployment Compensation Payments Commission This Commission was created by Senate Bill 553 introduced in the Sixty-fourth General Assembly by Senators Arthur J. Bidwill of River Forest and John T. Thomas of Belleville and signed by Governor Dwight H. Green on July 24, 1945. This Commission consisting of three members of the Senate and three members of the House was to investigate the payment of disability unemployment compensation pay- ments to residents of Illinois, to study the disability unemployment compensation needs of the State, and to report findings and recom- mendations to the Sixty-fifth General Assembly. The findings and recommendations of this Commission should have an important bearing on planning for care of the chronically ill as well as the acutely ill since loss of income through illness often causes persons to neglect conditions which if properly cared for would not result in chronic invalidism. The findings will also have significance because of the close relationship between illness and resulting wage losses, and poverty and dependency. Improvement in Medical Programs for the Chronically 111 Receiving Public Assistance The Illinois Public Aid Commission has taken a number of steps which have resulted in making better facilities available to the chroni- cally ill. In addition to the co-operative county home program and the program for developing additional facilities in nonprofit private homes for the aged (described elsewhere in this report), the Public Aid Com- mission has explored the possibility of encouraging the development of better private nursing homes operated for profit. For several years the Public Aid Commission has worked in close co-operation with the Department of Public Health in relation to stand- ards of care in nursing homes. Prior to the establishment of the state licensing program for nursing homes the Public Aid Commission ob- tained advice from the Department of Public Health on conditions in nursing homes that might constitute hazards to patients there. Since the licensing program became effective in July 1945, the Public Aid Com- mission has relied completely on the decision of the Department of Public Health with regard to homes subject to licensing. From this close working relationship and from the experience which the Commission has had over a period of years it has become evident that, while much improvement has resulted in private nursing home care, there is room 43 for much more. Part of this, it became evident, was due to lack of suffi- cient income in the nursing homes because of the increases in salaries, cost of food and supplies, and other expenses which nursing home op- erators must meet. In January 1947, therefore, the Public Aid Commis- sion increased considerably the allowance authorized for nursing home care of recipients of Old Age Pension, Blind Assistance, and occasion- ally, Aid to Dependent Children parents. The time which has elapsed since this increase does not permit an evaluation of the effect it has had in improving care, but it appears that the increased payments in profit nursing homes will permit more ade- quate staff and should discourage the crowding which has sometimes existed. Local Activities Much activity in planning for care of the chronically ill has been noted in local communities. This activity has been marked by co-opera- tion between public and private agencies, professional and lay citizen groups, and a general recognition of the need for sound planning. It is not possible within the scope of this report to include details of the many projects that are under consideration, have been announced as actual plans or have been completed. The Commission is forced, there- fore, to mention but a few. Belleville (St. Clair County) The Southern Illinois Synod of the Evangelical Church is consid- ering the erection of a home for the aged and a general hospital to be located at Belleville. Some of the beds in each institution would be available for the chronically ill, and the close relationship between the home and the hospital would result in excellent care for such patients. Chester and Ruma (Randolph County) St. Clement’s Hospital at Ruma, Illinois, which is operated by the Sisters Adorers of the Most Precious Blood, is a 12-bed hospital to which is being added a new wing which will provide for 25 additional beds. The institution will then be able to set aside 20 beds for chroni- cally ill patients. The same order is planning to erect a 100-bed hospital at Chester near St. Ann’s Old Folks Home. It is hoped that 30 beds in this institution will be available for convalescent and chronically ill patients. Chicago (Cook County) The past year has brought close to fruition many plans that will improve the care of the chronically ill in Chicago. To quote in part from a report made by Miss Edna Nicholson, Director, The Central 44 Service for the Chronically III of Chicago, at a meeting held by that agency on December 3,1946: 1. "Five general hospitals in Chicago and the suburbs have announced their plans for construction of facilities for the care of long-term patients. And more are now considering it. 7. "One home for the aged has completed construction—and is now using—a new building which provides additional facilities for chron- ic patients. Two homes for the aged have their architects’ plans completed and are ready to start construction of new buildings. Others are now in the process of planning new units and raising funds for this purpose. 3. "The Catholic Charities of Chicago, the Jewish Charities, the Lu- theran Charities, and the Salvation Army, all are thinking and plan- ning actively for the development of new services through their member agencies. Some of the new services already announced for hospitals and homes for the aged are the result of this planning. "There are prospects for very considerable increases in the number of beds available under Catholic auspices for care of chron- ically ill patients. "Plans have been publicly announced by the Jewish Charities for expansion of their present excellent services in their homes for the aged and for erection of new units for long-term care in connec- tion with Michael Reese and Mt. Sinai Hospitals. Mr. Goldsmith, and members of his board and staff, can tell you something of how long it takes to plan wisely and lay a sound foundation for good new facilities. The Jewish Charities Committee on Care of the Aged and Chronic Sick has been working intensively on plans of this kind for almost ten years. They have done excellent work—and there is every reason to believe that when the new facilities become available they will reflect the careful work which has gone into this planning stage. "Homes for the aged affiliated with the Lutheran Charities of Chicago are now planning the development of new facilities. Some of them are well along in their planning and fund-raising. Others are still in the earlier stages. As these facilities develop they, too, will reflect the care which has gone into the planning stages. "One of the first new facilities to develop in Chicago after 1944 —when The Central Service for the Chronically 111 was established —was the Salvation Army Convalescent Home. It is a small, but excellent unit, and it has been highly encouraging to know that there is hope of adding additional stories to the present building, and in- creasing the present capacity of the home. 4. "Other church groups are also actively planning new services. Mr. 45 Munsterman has told us something about the plans of the Evangeli- cal Church in its home and hospital. Methodist, Baptist, and Swedish Covenant groups are working on the problem and there will soon be new facilities resulting from their efforts—including the Bethany Home and Hospital and others. 5. "Under public auspices we have seen the development of additional services of excellent quality for long-term patients in the Chicago Welfare Department's Convalescent Home. "The new State Hospital School for severely handicapped chil- dren was brought into existence largely as a result of the efforts of the Illinois Commission for Handicapped Children, The Hospital School has made an excellent start toward meeting a very real need for constructive program and good facilities for these chronically ill children. "The Cook County Infirmary at Oak Forest has been operat- ing under many handicaps. Its isolated location, and other factors, have made it difficult to staff the institution adequately and to main- tain medical and nursing services at a good level. Some building changes have been badly needed. Construction work is now under way at the Infirmary and some improvements can be expected in the safety and efficiency of the buildings.” Plans for research in Chicago are being undertaken by a number of voluntary hospitals and medical agencies. Among these are St. Luke's Hospital which has established a Department of Research headed by Dr. William F, Petersen; Northwestern University Medical School which is planning for an Institute for the Study of Rheumatic Fever; Mercy Hospital which hopes to have in its new building an elaborate research department which will devote particular attention to polio- myelitis; and the Illinois Division of the American Cancer Society which in March announced grants of $69,115 to 11 Chicagoans for research in the field of cancer. Douglas County Douglas County, which has successfully operated the Douglas County Jarman Memorial Hospital as a real community facility, has considered the possibility of erecting a county nursing home affiliated with the hospital and serving the entire community just as the hospital does. No decision has as yet been made. Springfield (Sangamon County) The Springfield Council of Churches has been intensely concerned with the need for more good chronic care facilities in Springfield which is a medical center for a number of surrounding counties. At the time 46 of this writing no conclusions have been reached as to definite steps to be taken, but it is hoped that the Council’s interest will be the nu- cleus of community action. Wilmette (Cook County) An example of the way in which a local public agency stimulated interest in planning for a voluntary institution for the chronically ill is found in the progress which has been made in the suburbs north of Chicago. The New Trier Township Relief Administration recognized the need for additional chronic care facilities, not only for relief recipi- ents or for the community of Wilmette, but for all the people in the North Shore suburbs. After a number of meetings arranged by Mr. J. Gordon Pegelow, New Trier Township Supervisor, a committee was formed under the chairmanship of Frank D. Loomis, Executive Secre- tary of the Community Trust of Chicago. The committee is exploring the possibility of raising funds for an institution which would be closely affiliated with the Evanston Hospital and which would probably be built near the hospital and perhaps operated by the Evanston Hospital Association. County and Multiple-County Health Departments In 1943 the Searcy-Clabaugh Bills were enacted enabling counties or groups of counties to establish county or multiple-county health departments. There are now in operation nine county health depart- ments and two multiple-county health departments (Alexander-Pu- laski and Lawrence-Wabash). Nine additional counties have by refer- endum authorized the establishment of health departments which will come into existence within the next several months.1 The established and prospective county health departments, as of January 1947, are shown on the map on page 63. The county and multiple-county health departments may have an important role to play in the development of local services for the chronically ill particularly if the recommendations of the United States Public Health Service are followed. In a letter addressed to this Commission on December 17, 1946 the United States Public Health Service stated: "While it is true that many official health agencies do not provide this type (visiting nurse service to the sick at home) of nursing service, the Public Health Service is recommending that as 1For a comprehensive report on the origin and functions of the county and multiple-county health departments see "The Development of Full-Time County Health Departments in Illinois,” by Richard F. Boyd, M.D., Chief, Division of Local Health Administration, Illinois Depart- ment of Public Health, Public Aid in Illinois, March 1947, p. 11. 47 soon as sufficient staff is available, Health Departments should provide this type of service.” The Committee of the Illinois State Nurses" Association, Con- sultant to this Commission, has suggested that "in rural communities all visiting nurse service, including care of the sick at home, is best ad- ministered and supported by the health department/" (See page 159.) 48 Ward in Illinois County Home Before Conversion Ward in Illinois County Home After Conversion 49 Fayette County Nursing Home Day Room, DeKalb County Home 50 Individual Recreation, Knox County Home and Hospital Group Recreation, Knox County Home and Hospital 51 Bed Room, Rock Island County Home Nurses’ Station, Vermilion County Nursing Home 52 Dining Room, Vermilion County Nursing Home Kitchen, Champaign County Home and Hospital 53 Reproduced by permission of the Illinois Public Aid Commission from Public Aid in Illinois June, 1947, p. 14. 54 ILLINOIS CHILDREN’S HOSPITAL-SCHOOL A daily “must”—the 3 R’s Medical examinations can be fun. Making a bird house. Weaving improves muscle co-ordination. Reproduced by permission from Public Aid in Illinois, February 1947 55 GENERAL HOSPITALS IN ILLINOIS—1945 TYPE OF OWNERSHIP O GOVERNMENT HOSPITALS ® NON-PROFIT HOSPITALS • PROPRIETARY HOSPITALS ILLINOIS DEPARTMENT OF PUBLIC HEALTH Reproduced by courtesy of the Illinois Hospital Survey 56 COUNTIES HAVING ONLY SMALL OR NO HOSPITALS IN ILLINOIS—1945 NO HOSPITAL IN COUNTY LESS THAN 25 BEDS 25-50 BEDS ILLINOIS DEPARTMENT OF PUBLIC HEALTH Reproduced by courtesy of the Illinois Hospital Survey 57 TUBERCULOSIS SANATORIA IN ILLINOIS—1945 | ~| TB SANATORIA NO TB SANATORIA ILLINOIS DEPARTMENT OF PUBLIC HEALTH Reproduced by courtesy of the Illinois Hospital Survey 58 NERVOUS AND MENTAL FACILITIES IN ILLINOIS—1945 | [ N&M HOSPITALS [g#|l NAM NURSING HOMES | NO N&M FACILITIES ILLINOIS DEPARTMENT OF PUBLIC HEALTH Reproduced by courtesy of the Illinois Hospital Survey 59 PRIVATE NURSING HOMES IN ILLINOIS—1945 O LICENSED AND PENDING HOMES ® UNLICENSED AND DOUBTFUL HOMES ILLINOIS DEPARTMENT OF PUBLIC HEALTH Reproduced by courtesy of the Illinois Hospital Survey 60 PROGRESS OF COUNTY HOME PROGRAM FOR CARE OF THE CHRONICALLY ILL IN ILLINOIS APRIL, 1947 @ APPROVED PLAN OF OPERATION PLAN UNDER CONSIDERATION Prepared by the Illinois Public Aid Commission. Reproduced by permission. 61 PRIVATE INSTITUTIONS CARING FOR RECIPIENTS OF OLD AGE PENSION AND BLIND ASSISTANCE Adams, Quincy—Methodist Sunset Home, St. Joseph Hospital for the Chronically III, St. Vincent Home. Bureau, Ohio—Mercy Home. Clinton, Aviston—Sacred Heart Home. Carlyle—St. Mary’s Home. Coles, Mattoon—I.O.O.F. Old Folks’ Home. Cook, Argo—Rosary Hill Convalescent Home. Ar- lington Heights—Evangelical Lutheran Old Folks Home. Chicago—Augustana Home for the Aged, Beth- any Home and Hospital, Bohemian Old Peoples Home and Orphan Asylum, Chicago Holland Home for the Aged, The Chicago Home for Incurables, Home for Aged Colored People, Home for Aged Jews, The Nor- wegian Lutheran Bethesda Home, The Norwegian Old People’s Home Society, Orthodox Jewish Home for the Aged, St. Joseph’s Home for the Aged, St. Pauls House, The Swedish Baptist Home for the Aged, The Swedish Covenant Home of Mercy, Western German Baptist Old Peoples Home. Lyons—Illinois Colony Club, Maywood—Baptist Home and Hospital, May- wood Home for Soldiers’ Widows. Techny—St. Ann’s Home. Wheeling—Addalorato Villa. DuPage, Bensenville—The Bensenville Home. Kane, Aurora—Jennings Terrace, Inc., St. Joseph Home. Lake, Gurnee—Viking Horae for the Aged. La Salle, Ottawa—Pleansant View Luther Home. Lee, Dixon—Jacob’s Home. McHenry, Woodstock—Old People’s Rest Home. McLean, Meadows—Mennonite Old Peoples Home. Macoupin, Girard—The Brethren Home. Ogle, Mount Morris—The Brethren Home. Peoria, Peoria—Apostolic Christian Home, St. Jo- seph’s Home. Randolph, Chester—St. Ann’s Home. Rock Island, Rock Island—The Prince Hall Masonic and Eastern Star Home. St. Clair, Belleville—St. Paul’s Evangelical Old Folks’ Home, St. Vincent Home for the Aged. Sangamon, Springfield—St. Joseph’s Home, Mary Bryant Home for Blind Women. Stephenson, Freeport—St. Joseph’s Home for the Aged. Will, Joliet—Salem Home for the Aged. Woodford, Eureka—Mennonite Home for the Aged. Reproduced by permission of the Illinois Public Aid Commission from Public Aid in Illinois, August, 1946, p. 2. 62 COUNTY HEALTH DEPARTMENTS IN ILLINOIS JANUARY 1947 m v COUNTY health departments* aaJL OPERATING J COUNTY HEALTH DEPARTMENTS AUTHORIZED BUT NOT YET OPERATING LEGEND •MULTIPLE-COUNTY HEALTH DEPARTMENTS Prepared by the Illinois Public Aid Commission. Reproduced by permission. 63 HOUSING AND CARE Of CHRONICALLY ILL PERSONS IN THE ROCKfORD AREA O**- HOMES IZZI •••HOSPITALS 64 VII DEVELOPMENTS IN OTHER STATES, IN THE FEDERAL GOVERNMENT, AND IN ENGLAND California The care given at Rancho Los Amigos, the Los Angeles County institution for the chronically ill, is outstanding in the country. More complete reference to this institution is found on page 269. Connecticut Connecticut has had a special Commission on the care of chroni- cally ill persons. In the report submitted to the State Legislature in March 1947, the outstanding recommendation, other than calling at- tention to the great extent of the problem and to the need in develop- ing additional facilities for care, was that the state should provide for a research center for the study of chronic diseases and that such center must be located in connection with a medical college. They also called attention to the fact that "The mildly confused elderly person should not be confined in a hospital for mental illness/' The report of the Com- mission concluded with this summary: "Your Commission believes that more medical studies may be ap- plied to the afflicted and the more enlightened approach to the care of the aged and infirm would be to institute health activities that would help to defer, if not eliminate the rapid deterioration. We therefore recommend: A. "That a central institute for the study and treatment of cancer, arthritis, heart and kidney disease and mild mental deterioration be established. "This hospital to be staffed by a medical group who would be available to examine and prescribe for all the cases under the pro- gram. Refresher studies for the medical practitioner and a focus for the latest methods of treatment could also be had at this institute. The trained scientific staff could do much to spread the knowledge of advances in treating chronic illness to the medical profession of the state. B. "An expansion of the public health activities of the State Depart- ment of Health should be encouraged to prevent or postpone chron- ic disease. 65 C. 'That the activities in the prevention, control and clinic subsidiza- tion for cancer being carried on by the State Department of Health with the co-operation of the Connecticut State Medical Society and hospitals should be expanded to include diagnostic facilities for all chronic diseases. D. “That increases in the chronic bed facilities, by additions to the municipal hospitals and state-aided hospitals be encouraged there- by at the earliest moment relieving the immediate needs. E. "That encouraging and enlarging of the facilities of the fraternal, religious and private homes for the care of both private cases and state wards both by grant and by subsidy be undertaken.” In Connecticut, in 1944, it was shown that about 20,000 assist- ance recipients out of an estimated 100,000 persons were handicapped by chronic illness or disabled; and an additional 13,000 such persons were in special hospitals and institutions. Here again there is proof of the impact of chronic invalidism in enforcing persons in need of public assistance. Maryland The longest and most carefully conducted study of the occurrence and effects of chronic disease was that conducted in the Eastern Health MALES FEMALES FIG. I. PROPORTION OF THE TOTAL POPULATION BY SEX WHO(l) REPORTED NO ILLNESS, C2) REPORTED THE PRESENCE OF CHRONIC DISEASE, ANDO) THOSE WHO REPORTED ONLY ONE OR MORE ACUTE ILLNESSES IN 1,243 CANVASSED WHITE FAMILIES. EASTERN HEALTH DISTRICT OF BALTIMORE. 1938-1939. 66 district of Baltimore where, over a period of five years, careful records were kept of contact between all doctors serving an area with 13,800 families and all cases of illness among those families. Tabulation of the results of that survey are being completed now after interruption dur- ing the war (see chart on page 66 for example of information gathered in this study). The most significant fact brought out is that out of this total of 13,800 families, 381 "chronic disease families had 54 per cent of the total illness and received about 50 per cent of the medical care given to the total population. Persons from these few families also con- stituted almost 40 per cent of the persons hospitalized.” This survey also showed that 90 persons per thousand were afflicted with chronic disease. Massachusetts Massachusetts in 1946 appropriated seven million dollars for an 800-bed institution for the care of chronic invalids in addition to a state institution of similar capacity and in addition to two separate state institutions for cancer patients. The new institution was to feature research. A site was picked by the Governor, about twenty miles out- side of Boston. The medical authorities, however, objected to the selection of such a site because all authorities agreed that research of any real signifi- cance could only be carried on in connection with one or several of the medical colleges of the state, all of which were located in Boston itself. It was felt that without the assistance of the faculties of such medical schools and centers it would be impractical to expect significant results, and therefore, even though money was available and a site chosen, it was felt better to delay the start of the project and to seek amendment to the Act authorizing this research center so that it could be located in Boston in connection with the medical schools and centers. This experience and findings are of great significance, conforming to the judgment and recommendations of the Commission on the Care of Chronically 111 Persons in Illinois, as reported elsewhere in this report. Of considerable interest in Massachusetts is the geriatric clinic at the Peter Bent Brigham Hospital which, with its motto that "life begins at seventy” finds that "old age should not bring the depression that it does * * * Confident living will help reduce the depression that commonly plagues old folks and this depression often is mistaken for senile psychosis.” Many valuable facts have already been developed out of the work of this clinic during the past several years, and they emphasize the importance of a research center for more severe cases and a co-ordinate program of treatment and research extended through- out the state using all available resources. 67 Minnesota A study made by the Wilder Charities of St. Paul, Minnesota, provides an important reference to the study of chronic disease and chronic invalidism. One of the important results of that survey was to establish a ratio of 3.3 beds per thousand population as a basic mini- mum for the care of the chronically ill. New Jersey This state has released a report entitled "The Problem of the Long-Term Patient in New Jersey/" by Emil Frankel, Director, Division of Statistics and Research of the New Jersey Department of Institu- tions and Agencies. The following points are made in the report: A broad research program by the medical profession and al- lied health authorities for the development of measures which defi- nitely may be applied in the prevention of chronic illness. A medical care program whereby physical signs in individuals pointing toward eventual chronic illness are detected at the very incipiency and adequate medical attention afforded at the earliest moment. Recognition that the type and quality of care required by the chronic disease patient practically are the same as those required by any other patient and should be available to rich and poor alike. Recognition that in order to meet the needs of the long-term patient a variegated program of medical, hospital and home nurs- ing care must be built up and adequate funds, public and private, be provided to support such a program. The availability of a Central Information Service in the com- munity to promote public understanding of the problems of chron- ic illness. In addition, New Jersey, for a number of years, has followed a program providing for changing emphasis in the County Welfare Homes, so that these institutions provide care for the chronically ill. For New Jersey’s statistics as to the importance of chronic dis- ease as a causative factor in dependency see page 745. New York State New York State has had a Health Preparedness Commission (New York State Commission to formulate a Long Range Health Pro- gram) which for several years has been making special studies con- cerning chronic invalidism. The final report of this Commission (May 1947) summarizes the findings of several years of study. The Commis- sion found that there were a minimum of 164,000 persons in New York State classified as permanent invalids. Added to these are thousands of 68 others whose disabilities, although not complete, constitute serious de- terrents to economic and social productivity. In more than 70 per cent of the cases these disabling conditions have been caused by chronic diseases. The major recommendations of the New York State Commission include: A State agency for administering a program of education, re- search, rehabilitation, and improvement of facilities and services for the care of chronic illnesses exclusive of tuberculosis and men- tal diseases (the latter were excluded from the report as state pro- grams now exist for the care of such patients). The State should establish a chronic disease hospital center in each of five geographical regions with such centers associated with and administered by general hospitals or medical schools. That provision be made in general hospitals for the care of the chronically ill. That emphasis be placed on rehabilitation in the proposed centers, general hospitals, and public homes. That the expense of such care for those unable to pay be shared by the state with local communities. The Commission's report stresses also the serious social and eco- nomic aspects resulting from the presence of a chronic invalid in the home. (These findings coincide with the findings of our own State Commission and add emphasis to the need for action in creating ad- ditional resources for chronic invalids.) Also noteworthy among the Health Preparedness Commission’s findings are: 1. Whenever possible, convalescent care should be provided in the patient’s own home, supplemented if necessary by such community resources as visiting nurse, housekeeper and rehabilitation training service. Yet a number of factors make it impossible for some homes properly to provide this care .... Under such circumstances care may have to be provided in "between hospital and home facilities.” The "between hospital and home” facilities are either convales- cent or medical domiciliary in type. Convalescent care might be part of the care provided in the long-term care wing of the general hos- pital. It might be provided in a voluntary (nonprofit) convalescent home established contiguous to and as a part of a voluntary general hospital. It might be provided in a public "custodial” or "medical domiciliary” institution such as a county nursing home. It might be provided in a proprietary nursing home. It might be provided in the 69 infirmary of a voluntary home for the aged. It might be provided in the patient’s own home. A wing of the general hospital caring for long-term patients is neither the ideal nor the most economical place for such care. A county nursing home, on the other hand, could provide such care for the chronically ill if its facilities and staff were adequate. How- ever, in utilizing the county nursing home for this purpose it should be stressed and reiterated that the case of each patient should be reviewed periodically to determine the possibility of his discharge either to his own home or to some other more appropriate place of care. Ideally, institutional convalescent care should be given in in- stitutions especially designed for the purpose. Since such care chron- ologically and medically follows that given in general hospitals, the most reasonable development would be that of institutions which would be, in effect, extensions of such hospitals. 1. For purposes of discussion a nursing home is regarded as one pro- viding shelter, board, and nursing care and services under medical supervision to sick, infirm or handicapped persons not in need of hospitalization. Many of the medically indigent, chronically ill are cared for in nursing homes which also admit paying patients. Therefore infor- mation on the homes caring for the indigent gives a general picture of the types of homes available to and used by a majority of the general population. Public welfare officials generally patronize neither the very poor quality nor the very expensive nursing homes but the average homes. 3. Regulation of standards and facilities of nursing homes is needed. Regulation should apply to all nursing homes and should be on the state level to obviate problems of jurisdictional boundaries between counties and within counties and to insure a high quality of inspec- tion service to communities financially or otherwise unable to pro- vide such service. One or two methods suggest themselves: (a) Comprehensive licensure of all institutions caring for ill persons in- cluding nursing homes; or (b) regulation of nursing homes only. Comprehensive licensure seems the desirable method for New York State to adopt as its long-range objective in promoting a high qual- ity of medical and nursing home care. However, if this method of regulation is not established at an early date, it would seem advisable immediately to initiate some method of regulation addressed to nurs- ing homes only; but this is clearly a second choice. 4. A number of persons with whom the subject of Public Nursing Homes has been discussed are convinced that: (a) Each public 70 home which plans to admit or continue to house chronically ill per- sons should, in whole or in part, be converted into a cheerful, home- like nursing home of high quality under public auspices; (b) the converted homes should become community facilities and should admit those able to pay for care as well as the indigent, especially since future admittees may be recipients of Old-Age and Survivors Insurance benefits able to pay for at least part of their care; (c) the care of chronically ill public charges admitted to homes meeting minimum standards should be reimbursed by the State Department of Social Welfare under the same formulae applicable to reimburse- ment for care outside such institutions; (d) every effort should be made to assist the public homes to throw off their social stigma and insure their acceptance as medically related institutions just as state tuberculosis and mental hospitals are regarded; (e) the alcoholic, senile psychotic, and cerebral arteriosclerotic cases should not con- tinue to be part of the general population of the average public home, but should be provided with proper care either in special in- stitutions or specifically designated sections of the larger public homes. The State of New York has for many years maintained a great cancer research institute affiliated with the University of Buffalo Medi- cal College. Appropriations have been made to expand both the bed capacity and the research at this institute. Nassau County Nassau County, New York (suburb of New York City), found 38 per cent of all persons on relief to be chronic invalids. New York City maintains, under the jurisdiction of the Depart- ment of Hospitals, a City Home for Aged and Infirm People as one institution and the Goldwater Hospital for Chronic Invalids as another on Welfare Island. The two institutions are approximately three fourths of a mile apart but work in very close relationship to each other. At the City Home there are both ambulant and bed cases, but any case of serious illness is transferred to the Goldwater Hospital. The City Home, despite the fact that it is an old building (soon to be replaced), has worked out a very excellent program, particularly of therapy and re- habilitation. Goldwater Hospital, with approximately 1,600 beds, is modern in every way. There are three "divisions” to supervise medical care: One under the jurisdiction of the Columbia University Medical Col- lege; the second under the supervision of the New York University New York City 71 Medical College; and the third under General Staff and Consultants. In the two sections under the direction of the medical colleges there are in each 45 beds for intensive research. In February 1947, when visited by Robert Rosenbluth as representative of this Commission, the Su- perintendent stated that the Columbia University group intended to withdraw and that their section would be taken over by New York University. It was particularly interesting to note that intensive research could be conducted in only 90 out of a total basic group of 1,600. The hospital meets the requirements of a Grade A hospital in every way and the entire staff is geared to the idea that they are not a custodial group but a professional and research group.1 The Home for Aged and Infirm Hebrews has worked out a very excellent classified service. For the aged who are well, apartments are rented in regular apartment houses in convenient areas of the city but reasonably close to the parent institution. These apartments are in charge of a registered nurse with doctors from the staff or parent in- stitution on call. If sick over 24 hours or if seriously sick or if diagnosed as more seriously sick, transfer is made to the parent institution or in emergencies to an affiliated general hospital. At the parent institution besides provision for ambulant cases there is an increasing percentage of chronic invalids who are severely afflicted. The facilities at the par- ent institution for all forms of therapy are most excellent. Particular note was given to the fact that arrangement is made not only for the professional therapist but that groups of volunteers serve in this work. These volunteers, however, are not left to haphazard service but are first trained and then their work carried on according to regular plans. (This feature was also noted in other New York City institutions and has much significance, particularly for the public institutions in Illinois where budgets are limited.) Provision is also made for research. Equally significant is the fact that cases requiring major surgery or more in- tensive work than can be given at the parent institution are transferred to a companion institution or general hospital. Again the fact that this general hospital is at some distance from the parent institution for chronic invalids is not deemed any handicap. Montefiore Hospital in New York City has the longest and most conspicuous history in the care of chronic invalidism in the country. Outstanding features of this institution are its program of research, of therapy (physiotherapy, recreational and occupational therapy, and all forms of rehabilitative work). Mentioned elsewhere in this report is the belief of E. M. Bluestone, M.D., Director, Montefiore Hospital, that 1Refer to the February 1947 issue of Hospitals, Journal of the American Hospital Association, for an interesting account of this institution by Chrisman G. Scherf, Superintendent. 72 chronic invalids should be taken care of as part of a general hospital setup.1 St. Barnabas Home has unusual facilities for the care and treat- ment of its patients. Perhaps most significant is the fact that the name of the institution has just been changed from “Home for Incurables/’ The institution contemplates a program of research connected with one of the leading medical schools and arrangements for transfer of its seriously ill patients to its companion institution, St. Luke’s Hospital. There is no doubt in the mind of the medical director of St. Barnabas Home that the fact that the general hospital (St. Luke’s) is at some distance entails no difficulty because of needed transfer or mutual ar- rangement for care between a chronic invalid institution and a general hospital. Ohio There was an excellent study on “Care of the Chronically III in Cuyahoga County” by Mary C. Jarrett, prepared for the Benjamin Rose Institute of Cleveland, Ohio. Under the auspices of this Institute many programs for the care of the aged and the chronically ill have been developed in Cleveland. Wisconsin Reference is made on page 247 to the study in Dane County, Wis- consin. Federal Government Two laws enacted by the 79th Congress should stimulate the states in developing facilities and services for the chronically ill as part of the larger undertaking of developing adequate public health and medical care facilities for all. Public Law 725 The 79th Congress amended the Public Health Service Act by Public Law 725 to authorize grants to states for surveying their hos- pitals and public health centers and for planning construction of ad- ditional facilities and to authorize grants to assist in such construction. Survey and planning grants are available only to states which have designated a single state agency for carrying out these functions. The construction grants, though available for ultimate expenditure for “public and other nonprofit hospitals” will be given only to states which have designated a single state agency to administer or supervise the administration of an approved hospital plan. 1The Journal of the American Medical Association for April 12, 1947 has an article by Dr. Bluestone in which he emphasizes his belief that prevention of long-term illness is most im- portant and that the medical profession must carry major responsibility for prevention. 73 Public Law 487 This law, also enacted by the 79th Congress, amended the Public Health Service Act to provide for research relating to psychiatric dis- orders and to aid in the development of more effective methods of pre- vention, diagnosis, and treatment of such disorders. Upon the request of any state mental health or other state health authority, Federal per- sonnel may be assigned to assist the state. Grants-in-aid may be made to universities, hospitals, laboratories, and other public or private in- stitutions and to individuals for such research projects as are recom- mended by the National Advisory Health Council. The National Health Institute has just embarked on a new series of studies after interruption due to the war. A new development is the co-operative effort between the United States Public Health Service and the City Hospital of Baltimore. A gerontology unit has been started, taking up a study of kidney functions and diseases as a first project. Dr. Floyd S. Daft, Assistant Chief of the physiology division of the institute in which the gerontology unit operates, states, "It is a big if— but if we could understand the aging process, we might be able to slow it down so people could be young at 100.” England This year (1947) in a volume entitled "Old People” the Nuffield Foundation1 reported the findings of an extensive survey in England. These findings are strikingly similar to those reported in this country and because of the thoroughness of the study merit summarization in this report. The English findings are: 1. That the chronic or long-term sick represent an outstanding problem. 2. That many, particularly among the aged, failing to recover their full health after periods of sickness go into a decline resulting in "long- term sickness” because they are unable at the critical moment to take a suitable period of convalescence away from their homes in an atmosphere of care. Even if they desire to do so, there are few places available for their care. 3. That senile dementia cases should be maintained in special institu- tions. (The report cites the London County Council Institution at Tooting Bee where some 2,000 senile dements are housed. Here em- phasis is placed on the adequacy of medical treatment and frequency of examination because "recoveries are not infrequent” and it is essential that recovered persons be removed from among senile de- ments whenever possible.) 4. That those who are "light senile” or otherwise only mildly disturbed 'Old People, Nuffield Foundation, London, 1947. 74 but who are unable to live in an ordinary community without an- noyance to other people are best cared for in private nursing homes when they are able to afford such; otherwise they should be trans- ferred to a public institution where proper facilities exist. 5. With regard to all other long-term sick cases, there are the same two schools of thought as in the United States: a. That special units should be constructed in connection with a gen- eral hospital and for all practical purposes be a part thereof. The advantages are the assurance of a higher level of medical and nurs- ing care, the facilitation of prompt treatment of acute illness, and the furtherance of research into the physical and psychological processes of aging. Its disadvantages lie in the somewhat regi- mented life of the average hospital with its inevitable emphasis on sickness which is unlikely to ensure the contentment of the aged, even when they are sick. b. That the patient should go to a general hospital for diagnosis and treatment but that, when no further specific treatment is consid- ered advisable, he or she should be transferred to an ordinary home. The term "long-term sick” covers a multitude of different conditions and, though many of the patients will obviously need to remain permanently in a nursing home if not in a hospital, others, especially those suffering from disabling diseases, would stand a better chance of being made to feel that they are still part of the general community if they were transferred to an ordinary home under a good matron. In this way they would enjoy as near an approach to ordinary living as possible and would learn not to regard the hospital as the center of their future lives. They would, of course, still need regular visits from their doctor, and it might be necessary for them to spend periods in a hospital from time to time for treatment. Although the homes just described were referred to as ‘"or- dinary” they would need a higher proportion of staff to residents than is usual in homes for the able-bodied aged, and it would be advantageous, though not essential, for them to have special fea- tures such as passenger lifts, easy access to the garden, a sun lounge, and provision for the use of invalid chairs. Where possi- ble a special sick-bay should be provided in these homes so that the old people can remain there until they die, and so avoid the distress and shock of being moved to strange surroundings when they are approaching their end. 6. That institutions and homes providing for the aged should be of the following types: 75 a. Smalt Homes. The Committee agreed with the opinion, which is coming to be held by an ever-growing number of persons who have studied the subject, that all normal old people who are no longer able to live an independent life should be accommodated in small homes rather than in large institutions. Clearly this objective can be attained only gradually, but it is important that the goal to be aimed at should be defined as clearly as possible. Undoubtedly a considerable number of aged persons will continue to be accommodated in homes provided by voluntary agencies, but the majority will have to be accommodated in homes administered by local authorities. It may be thought that, however desirable it may be to replace large institutions by small homes, the cost will be prohibitive. Such, however, is not the case. Ex- perience has shown that quite small homes can be run at costs not appreciably higher per resident than those of well-conducted large institutions. An intimate homey atmosphere can best be created if the number of residents in homes is kept as low as 20, but it is doubtful if this figure is economical. Overheads cease, however, to have an undue influence on the cost per resident when the numbers reach 30 to 35. In some homes of this nature (the exact proportion being determined by experience) provision should be made for the "long-term sick,” at any rate until there is conclusive evidence that some other way of dealing with them is both practicable and preferable. Since, under the new National Health Service the "long-term sick” like all categories of sick per- sons become a responsibility of the central government and as their retention in homes, which is certainly necessary at present and may be permanently desirable, raises substantially the cost of running those homes, it appears reasonable that the central government should pay a subsidy for each "long-term sick” person kept in a home for the aged whether such home is run by a local authority or by a nonprofit-making private body. The amount of such subsidy should be equal to the additional cost incurred by the home over that of maintaining a resident who does not need special nursing care or to the cost of keeping the same patient in a central government hospital, whichever is less. b. Highly Classified Institutions. Although the aim should be to ac- commodate in small homes all normal old people who can no longer lead independent lives, this will certainly not be possible for some time. As an interim measure there is merit in highly classified in- stitutions of medium size, possibly accommodating up to 200 aged 76 residents plus the proportion of “long-term sick” found to be necessary. These institutions should be homelike in their atmos- phere and there should be a large degree of personal liberty. Very few of the old workhouses are suitable for this purpose. In some cases it will be possible to convert buildings erected for other purposes. c. general-purposes Institutions. A small proportion of old people may be permanently unsuited by nature or temperament to either of the foregoing types of accommodation. There will, therefore, have to be accommodation for them in a General-Purposes Insti- tution which should be a mixed institution varying in size accord- ing to the density of the population that it is designed to serve. d. Institutions for Senile Dements. e. Special Dwellings for Old People. Forty-eight thousand small houses, especially designed for old people, were built in England and 27,770 in Scotland. It was believed that five per cent of the houses in any community should be subjected or suited to the special needs of old people. Stress is placed on the fact that loca- tion of such houses should be within easy reach of relatives and friends and accessible to medical care and should permit conven- ient access to the community's institutions of modern life such as shops, postoffice, transportation, library, church, and places of recreation. The best solution seems to be the perfection of small groups of houses for old people interspersed among houses built for other age groups. f. Utilization of Existing Jnstitutions. England reports the need of modernizing the old almshouses wherever these are suitable, esti- mating that in this way accommodations for 20,000 chronic in- valids may be provided. This survey in England confirms the find- ings in Illinois that the existing public institutions, where suscep- tible to conversion, should be utilized. Particlar attention is also called to the need for adequate staff and services. g. Research. The report also stresses the need for research in geri- atrics and gerontology. 77 VIII CURRENT ESTIMATES OF THE EXTENT OF CHRONIC INVALIDISM AND THE NEED FOR BEDS IN ILLINOIS Revised Estimate of Chronic Invalidism The predecessor Committee to Investigate Chronic Diseases among Indigents applied the findings of the 1935-36 National Health Survey to the Illinois population as of 1940 to arrive at an estimate of the number of chronic invalids in Illinois.1 The Committee’s figure was 90,200, On the basis of the study made in Sangamon County in Jan- uary 1947 under the auspices of the present Commission it would ap- pear that the actual number is considerably more (117,679) than the original estimate, assuming that the Sangamon County figures can be projected for the entire State. (See Section XI of the Appendix for a detailed report of the Sangamon County Survey and for a comparison of findings with other studies.) The Need for Beds The need for beds for chronically ill persons has been recognized in every part of the United States. A number of states not only have been conducting current investigations of such need but have appro- priated large sums to provide facilities. For example, the State of Mas- sachusetts has a $7,000,000 appropriation for an 800-bed state institu- tion for chronic invalids to supplement its present institution for chronic invalids and its two special state institutions for cancer cases. Illinois has taken leadership in providing that recipients of public assistance and General Relief may have their grants continued in in- stitutions of their own choice, including county nursing homes, provided these meet standards set by the Public Aid Commission. The Commis- sion requires approval of the county institution by the State Health De- partment and the State Fire Marshal. Under the regulations of the Illi- nois Public Aid Commission there also must be satisfactory arrange- ments for medical care, generally under the supervision of the county medical society. This policy will have the desirable effect of obviating 1Interim Report, p. 6. 78 need for state institutions merely for the care of chronic invalids and in- stead will encourage the development of facilities closer to their homes. The Illinois county home legislation also allows counties to enter into agreements with other counties so that jointly they can create needed facilities where any one of them might either be too small or financially unable to provide necessary facilities. It is believed that, since the state policy assures payment for cost of care of persons in satisfactory institutions, it will be unnecessary for the State to under- take to provide for any special institution merely for the care of chronic invalids. The one State institution should be that for research and teaching as above outlined. The only possible exception to this might arise because of the financial difficulties and economic weaknesses of a group of counties in the extreme southern end of the State. But further investigation and only a finding that the counties themselves could not financially ad- vance such an enterprise provided they joined together for such pur- pose would justify a recommendation for a state institution in that area. Such study and effort to organize by local resources the development of very much needed institutions for that area should be a major con- cern of a successor Commission. Pending reduction of the incidence of chronic disease through adequate research it is, of course, necessary to provide facilities for the care and treatment of those who are now afflicted. Many studies have been made as to the number of beds needed for chronic invalids. It is significant that in no place where a study has been made has there been a finding that there are adequate facilities available. In every case without exception the need for additional fa- cilities has been found to be the greatest single need of the community with respect to provisions for adequate medical care. Since the need has everywhere been found so great, the estimates have been based in almost every case on minimum requirements for urgent immediate need. It is certain, however, that with the develop- ment of adequate facilities at moderate cost and with acceptance of the fact that the social and economic problems posed by chronic in- validism for the other members of the household can be better solved as well as better care given to the chronic invalid if satisfactory special facilities are provided, all present estimates regarding number of beds needed will be found to be too low. In the Chicago-Cook County Survey (see Section X of the Appen- dix) the figure of 3.3 beds for chronic invalids per thousand total pop- ulation was used. This figure was based on the findings of a survey made in St. Paul by the Wilder Foundation. 79 In the table on page 81 the Chicago-Cook County Survey figures have been used with the figures from the Illinois Hospital Survey to arrive at a separate estimate for downstate, Chicago and Cook County, and for the State as a whole. This table shows that chronic invalids, other than the tuberculosis and persons afflicted with nervous or men- tal ailments, need 35,000 beds but only 11,521 are available, that is, there is a deficiency of 23,479 beds. On the basis of the Commission’s study in Sangamon County in January 1947, however, the need would appear to be considerably greater. As a result of the Sangamon County study it was found that 5.5 beds for chronic invalids per thousand total population would be needed. Studies in other states, not yet officially released, also indicate that more beds than have previously been deemed necessary would be required. On the basis of the Sangamon County study there are 118,000 chronic invalids in the State for whom 43,149 beds would be needed as against a finding by the Illinois Hospital Survey of present provisions for 11,521, that is, there is a deficiency of 31,628 beds. The staff has also considered every possibility of reducing the numbers needing care outside their own home which might be effective in the next decade and has concluded that this would still leave a need for at least 4.5 beds per thousand total population for chronic invalids. A conservative figure for the number of beds needed for chronic invalids is 35,000. An absolute minimum would approximate 26,000 and as many as 43,000 might be needed. These figures are set forth for each county in the table on pages 82 and 83, Of course, conditions vary in each county so that for any one area the figures may likewise vary. It is doubtful, however, if in any case there will be found ample provisions even to meet the absolute minimum estimate of requirements to say nothing of the probable mini- mum. The tables should serve a useful purpose in allowing each county to determine how far it must go to meet even minimum need for beds to provide adequately for its chronic invalids. As the incidence of chronic invalidism increases with advancing age and as the proportion of older people in the population increases, it is probable that the need for beds and for adequate provision for chronic invalids will grow as will the need because of the other factors above cited. On the other hand there is hope for effective attack on invalidism through medical research, provision for earlier diagnosis, and for more effective treatment in the initial stages of these diseases providing prop- er care is given. There is also hope, or even better, assurance, as proved 80 Deficiency in Beds for Chronic Invalids (All Causes) — Illinois 1947 Type of Institution Beds Needed Beds Available Deficiency in Beds Chicago-Cook County3 Nervous—Mental 4,563b l,000b 3,563b Tuberculosis 4,915 2,640 2,275 Chronic Invalids 13,000 7,059 5,942 Downstatec Nervous—Mental 33,178d 21,804d 1 l,374d Tuberculosis 2,793 1,955 838 Chronic Invalids 22,000 4,462 17,538 Total State® I Nervous—Mental 37,74lf 22,804f 14,937f Tuberculosis 7,708 4,595 3,113 Chronic Invalids 35,0008 11,521h 23,479h a-See footnote (*), page 83, for number of beds needed for chronic invalids. b-Figures for Nervous—Mental in Chicago—Cook County should really be considered for the area. The Illinois Hospital Survey considers the Chicago, Elgin, Kankakee, and Manteno State Hospitals as serving the Chicago area with 22,527 patients in institutions with normal bed capacity of 13,212 or a deficiency of 9,315 beds for the area. (See also note “f.”) c-Figures for “Downstate” represent the difference between Chicago-Cook County and the totals for the State figures from the Illinois Hospital Survey. The latter figures are authoritative, and any change in the Chicago-Cook County figures will merely represent a difference in distribution of needed facilities, the total remaining the same. d-Referencc should be made to note "b” showing a deficiency of 9,315 beds in the Chicago area which would leave a deficiency of 5,622 beds for the rest of the State outside of the Chicago area as defined in the Illinois Hospital Survey. e-Illinois Hospital Survey and Plan, 1947. f-The defiiciency in beds for Nervous—Mental cases differs from the others in that actually there are 34,4t4 beds in institutions with normal capacity for 21,995. Actually, therefore, the total "deficiency” of 14,937 includes 11,293 for whom beds are "available” in overcrowded institutions with "absolute" deficiency of 3,327. g-See table on page 82 for adjustments in this figure as indicated by findings of the Sangamon County Survey. h-For the “Chronic Invalids” the deficiency of 23,479 beds is "absolute.” By far the great majority of "available” beds for Chronic Invalids are most unsatisfactory, and if even minimum standards were applied, the deficiency would be at least 30,000 beds. 81 ESTIMATED NUMBER OF CHRONIC INVALIDS (EXCLUSIVE OF THE TUBERCULOUS AND THE MENTALLY ILL) AND NEED FOR BEDS IN ILLINOIS 1947, BY COUNTY Population Based on 1940 Census (Ex- cludes Insti- tutional Pop.) County (a) Number of Chronic Invalids (b) Beds Needed for Care of Chronic Invalids Outside Own Home* Absolute Probable Minimum Minimum Probable (c) (d) (e) Total .7,845,300 117,679 25,890 35,304 43,149 (107,000 to 118,000) (30, 000 to 35,304) (34 ,000 to 43,000) Total Downstate Counties.. .3,786,489 56,797 12,4% 17,039 20,826 Adams . 65,229 979 215 294 359 Alexander .. 25,496 383 84 115 140 Bond . 14,540 218 48 65 80 Boone . 15,202 228 50 68 84 Brown 8,053 121 27 36 44 Bureau . 37,600 564 124 169 207 Calhoun 8,207 123 27 37 45 Carroll . 17,987 270 59 81 99 Cass . 16,425 246 54 74 90 Champaign . 70,578 1,059 233 318 388 Christian . 38,564 579 127 174 212 Clark . 18,842 283 62 85 104 Clay . 18,947 284 63 85 104 Clinton . 22,912 344 76 103 126 Coles . 38,470 577 127 173 212 Cook .4,058,811 50,141-60,882 13,394 13,000-18,265 13,000-22,323 Crawford . 21,294 319 70 % 117 Cumberland . 11,698 175 39 53 64 De Kalb . 34,388 516 113 155 189 De Witt . 18,244 274 60 82 101 Douglas . 17,590 264 58 79 97 Du Page . 103,480 1,552 341 466 569 Edgar . 24,430 366 81 110 134 Edwards 8,974 135 30 40 49 Effingham . 22,034 331 73 99 121 Fayette . 28,069 421 93 126 154 Ford . 15,007 225 50 68 83 Franklin . 53,137 797 175 239 292 Fulton . 44,627 669 147 201 245 Gallatin . 11,414 171 38 51 63 Greene . 20,292 304 67 91 112 Grundy . 18,398 276 61 83 101 Hamilton . 13,454 202 44 61 74 Hancock . 26,297 394 87 118 145 Hardin 7,759 116 26 35 43 Henderson 8,949 134 30 40 49 Henry . 43,798 657 144 197 241 Iroquois . 32,496 487 107 146 179 Jackson . 37,920 569 125 171 209 Jasper . 13,431 201 44 61 74 Jefferson . 34,375 516 114 155 189 Jersey . 13,636 204 45 61 75 Jo Daviess . 19,989 300 66 90 no Johnson . 10,727 161 35 48 59 Kane . 124,798 1,872 412 562 686 Kankakee . 51,424 771 170 231 283 Kendall . 11,105 167 37 50 61 Knox . 52,250 784 173 235 287 Lake - . 121,094 1,816 400 545 666 La Salle . 97,801 1,467 323 440 538 ESTIMATED NUMBER OF CHRONIC INVALIDS (EXCLUSIVE OF THE TUBERCULOUS AND THE MENTALLY ILL) AND NEED FOR BEDS IN ILLINOIS 1947, BY COUNTY (a) (b) (c) (d) (e) Lawrence 21,075 316 70 95 116 Lee 31,303 470 103 141 172 Livingston 36,108 542 119 162 199 Logan 25,271 379 83 114 139 McDonough 26,944 404 89 121 148 McHenry 37,311 560 123 168 205 McLean 73,930 1,109 244 333 407 Macon 84,693 1,270 280 381 466 Macoupin - 46,304 695 153 208 255 Madison 147,671 2,215 487 665 812 Marion - 47,989 720 158 216 264 Marshall 13,179 198 44 59 72 Mason 15,358 230 51 69 85 Massac 14,937 224 49 67 82 Menard 10,663 160 35 48 59 Mercer 17,701 266 58 80 97 Monroe . 12,754 191 42 57 70 Montgomery 34,499 517 114 155 190 Morgan 33,166 497 109 149 183 Moultrie 13,477 202 44 61 74 Ogle 29,869 448 99 134 164 Peoria 150,802 2,262 498 679 829 Perry 23,438 352 77 105 129 Piatt 14,659 220 48 66 81 Pike 25,340 380 84 114 139 Pope 7,999 120 26 36 44 Pulaski 15,875 238 52 71 87 Putnam 5,289 79 17 24 29 Randolph 30,138 452 99 136 166 Richland 17,137 257 57 77 94 Rock Island 111,120 1,667 367 500 611 St. Clair 166,899 2,504 551 751 918 Saline 38,066 571 126 171 209 Sangamon .. 117,912 1,769 389 531 649 Schuyler . 11,430 172 38 51 63 Scott 8,176 123 27 37 45 Shelby 26,290 394 87 118 145 Stark 8,881 133 29 40 49 Stephenson 40,646 610 134 183 224 Tazewell 58,362 875 193 263 321 Union 19,341 290 64 87 106 Vermilion ... 86,791 1,302 286 391 477 Wabash ... 13,724 206 45 62 76 Warren 21,286 319 70 96 117 Washington 15,801 237 52 71 87 Wayne ... 22,092 331 73 99 122 White . 20,027 500 66 90 110 Whiteside .. 43,338 650 143 195 238 Will . 108,271 1,624 357 487 595 Williamson 51,424 771 170 232 283 Winnebago 121,178 1,818 400 545 666 Woodford .. 19,124 287 63 86 105 *In determining the number of chronic invalids in Cook County modifications were made because of the facts revealed by a population study of Chicago and Cook County made by the Illinois Public Aid Commission. This showed a great growth in population since the 1940 Census which would indicate a proportionate increase in the number of chronic invalids. Similarly, allow- ances have been made in the above table for the increased percentage of aged persons in 1947 as (Footnote continued at bottom of p. 84.) 83 by the rehabilitation work in Army hospitals and in the very few in- stitutions for chronic invalids where rehabilitation work has been thor- oughly undertaken, that rehabilitation programs can reduce the num- bers who would otherwise be chronic invalids. Chronic Invalidism Among Persons Receiving Public Assistance The Illinois Public Aid Commission, reporting new grants au- thorized for January 1947, shows the following for the entire State: For Old Age Pension, 1,663 grants were authorized, for which 494 were because of illness or disablement of the recipient. This constitutes 29.7 per cent of all authorized grants. For Blind Assistance, of 45 grants authorized 10 or 22.2 per cent were because of illness or disablement of recipient. For Aid to Dependent Children, 773 grants were authorized with 176 or 22.8 per cent because of illness or disablement of par- ent or relative acting in parent’s place. For the three assistance programs, out of 2,481 grants author- ized 680 or 27.4 per cent of the total were for illness or disable- ment as the cause. For General Relief cases, of 3,842 cases 694 or 18.1 per cent of the total were for medical or hospital care. While these figures do not identify the illness or disable- ment as necessarily being chronic invalidism, it can be assumed that a short general illness would not, in most cases, force people to apply for public support. It is surprising how closely these figures correspond to the more detailed analysis revealed in the Sangamon County Survey (see Section XI of the Appendix) and how strongly they support the hypothesis that chronic invalidism is the greatest cause (other than economic) of poverty and dependency. against the 1940 Census figures for age distribution; this results in an increase in the estimated number of chronic invalids. The Federal Hospital Survey and Construction Act stipulates that “. . . the total number of beds required to provide adequate hospital services for chronic disease patients shall not exceed 2 per thousand population.” In 1947 the Hospital Council of Greater New York estimated that there would be needed 3 hospital beds for chronically ill persons per thousand population. The Cleveland Survey in 1944 estimated 4 beds per thousand general population. At least for many years to come the Commission’s staff believes that a majority of beds needed for chronic invalids will have to be provided in nursing homes or special institutions meeting suit- able standards rather than in general hospitals. The number of such beds, therefore, will be in addition to those estimated as needed in general hospitals. NOTE: Referring to the table, column (b), the figure of 1.5 per cent of general population is used to determine the number of chronic invalids. Column (c) is derived by applying 0.33 per cent (this number based on 1945 findings of St. Paul, Minnesota, Survey by Wilder Charities) to gen- eral population figures; column (d) is derived by using the figure 0.45 per cent of general popula- tion (based on modification of 1947 Sangamon County, Illinois, Survey); column (e) by applying the figures of 0.55 percent of general population (based on unmodified 1947 Sangamon County Survey, Appendix, and other recent unpublished studies) to give the number of beds needed. 84 Chronic Illness Among Old Age Pension Recipients During the six-month period from June through November 1946 a survey was conducted by the Illinois Public Aid Commission in seven downstate Illinois counties for the purpose of obtaining detailed data on the cost of medical care to public aid recipients. The counties were chosen so as to present statistical information which might be consid- ered representative of conditions existing throughout downstate Illinois and perhaps, under certain circumstances, of the whole of Illinois. Of particular interest with regard to chronic illness and its cost were the data collected on costs of medical care of Old Age Pension recipients. It is estimated that of the total amount of mony spent for such medical care approximately 95 per cent is spent because of chronic illness. It is also estimated that about 67 per cent of all persons receiv- ing Old Age Pension during a year will require medical care during that year and about 60 per cent of all persons will require care for chronic illness. This would mean that of the 140,793 persons who re- ceived Old Age Pension at some time during 1946 about 94,000 re- ceived the $3,700,000 in medical care. Of this number over 84,000 required about $3,500,000 of the total for the care of chronic illness some time during the year. 85 IX TECHNICAL ASPECTS OF SOUND FUTURE PROGRAM PLANNING, AS RECOMMENDED BY TECHNICAL CONSULTANTS TO THE COMMISSION For competent opinion and suggestions regarding the medical, nursing, and other technical aspects of a sound policy for the care of the chronically ill the Commission sought the assistance of those pro- fessionally qualified to give such advice and recommendations. The reports of these consultant groups are given in full in Sections IV, V, VI, VII and VIII of the Appendix. The high lights of these reports are summarized below. The Field of Research (Dr. Andrew C. Ivy) Provision for custodial care is only one half of the solution of the problem of chronic illness. Research in those diseases which cause chronic illness and premature aging will provide the only hope for ren- dering old age more efficient and for decreasing the future tax burden for the custodial care of the chronically ill. The State of Illinois should therefore establish a research institute to study how to prevent and im- prove the present methods of treatment of such diseases as arthritis, high blood pressure, hardening of the arteries, kidney diseases, chronic cardiorespiratory diseases, cirrhosis of the liver, and ulcerative colitis. A co-operative arrangement should be developed between the Research Institute and county homes for the chronically ill and private homes for the aged whereby the results of research could be extended to these homes. A suitable institute would provide beds for 200 patients, out- patient service for 15,000 patients a year, and suitable facilities for re- search. Medical Supervision and Care in Institutions for the Chronically 111 (Committee of the Illinois State Medical Society) Chronic care institutions other than the chronic disease hospital (which should be as well equipped and staffed as the general hospital) may be defined as those which provide custodial or nursing domiciliary care in homelike surroundings. They include nursing homes (both 86 public and private), private homes for the aged with infirmary sec- tions, and voluntary institutions for the chronically ill. In order that the patients in institutions of this type may have the full benefit of modern medical science and receive the nursing care best suited to their needs, medical supervision must be provided by qualified physi- cians. Minimum requirements for a medical care program in such an institution are as follows: 1. According to the size, program, and location of the institution, medi- cal direction may be provided by one or more of the following: (a) A full or part-time medical director; (b) an organized medical staff; (c) a medical committee representing the local medical society. 2. The medical director should establish and carry out general policies with regard to admission of patients, periodic re-examination of pa- tients, medical treatment of patients, discharge of patients, record keeping, and standing orders and drugs, and the standards estab- lished should be such as will be acceptable to the American Medical Association for registration of the institution as a "related medical institution." 3. It is essential that county nursing homes operated under the pro- visions of the Rennick-Laughlin Bills have competent medical super- vision. In most counties this could best be provided by an advisory committee representing the county medical society. The Oak Forest Infirmary in Cook County (not yet operating under the Rennick- Laughlin Bills) is not comparable with institutions in other counties because of its size. Oak Forest offers unlimited opportunity for de- velopment into an actual chronic disease hospital. The Board of Cook County Commissioners should take necessary action to meet the requirements of the American Medical Association so that this institution may affiliate with the Class A medical schools and thereby become able to offer suitable care and treatment to its patients. 4. There is cause for particular concern with medical care in nursing homes operated for profit. Unless the proprietor retains a physician (done far too seldom) there is no responsibility for medical super- vision nor is there an administrative board to safeguard the patient from possible exploitation or neglect. This should be remedied by particular attention under the licensure program of the State Depart- ment of Public Health. 5. In planning the construction of new institutions for the chronically ill, every possible effort should be made to provide for the closest possible affiliation with a well-staffed and equipped hospital. Wher- ever possible, there should be a joint medical director or an inter- locking medical staff. Where possible, provision should be made for 87 screening patients for research study. The proposal for a State Re- search Institute is endorsed in principle and if established, plans should be made for referral of patients from chronic care institutions and the hospitals with which they are affiliated. As time goes on, physicians responsible for the medical direction of chronic care institutions should enrich the program beyond these minimum standards. For the purpose of rehabilitating the patients to the fullest possible extent there should be provided such adjuvant serv- ices as occupational therapy, recreational therapy, medical social serv- ice, and vocational rehabilitation. Minimum Standards for the Care of the Chronically 111 (Committee Chairmaned by Malcolm T. MacEachern, M.D.) The trend is away from the special hospital and back to the gen- eral hospital for the chronic disease patient in need of active medical care. The patient in need of active medical care should not be relegated to a custodial home but should be placed in the general hospital and affiliation with a nursing home arranged for patients in need of nursing care only. This institution should be in close proximity to the general hospital although there are already many institutions in existence today that could meet minimum requirements by affiliation with a general hospital. County institutions should be of the nursing home type and after having met minimum requirements should be affiliated with an approved community or county hospital which would care for the chronically ill patient in need of active medical care. Two or three such nursing homes might serve and be affiliated with a centrally located hospital. Pay or part-pay patients as well as the medically indigent should be admitted to these nursing homes. A Research Institute would stimulate interest in the prevention of chronic disease and in the chronic disease patient. All voluntary and county hospitals should have the privilege of referring interesting and problem cases of chronic illness to the research center. The Committee outlined minimum standards for institutions caring for chronically ill patients (see Section VI of the Appendix). Nursing Service for the Chronically 111 (Committee of the Illinois State Nurses’ Association) Home nursing service is at present available from voluntary nurs- ing agencies in only 23 communities in Illinois. There is great need for the extension of home nursing service for the acutely ill and the chron- ically ill patient alike. The manner of providing such extension will vary with the community and the existing services, public and private. To provide a complete nursing service, which is most satisfactory for the patient and his family, each nurse in her home visits should combine 88 the functions of health teaching, prevention and control of disease, and care of the sick. In rural communities all visiting nurse service, includ- ing care of the sick at home, is best administered and supported by the health department. In small cities there has been some success with a combination nursing service jointly administered and financed by public and voluntary agencies. In large cities the health department has un- dertaken the preventive services and the voluntary associations have done the bedside nursing. Further study should be given during the next biennium to the best manner of extending and integrating home nursing services throughout the State. Such study should embrace the proper division of responsibility between public and voluntary agency, methods of financing and administration, and other factors. The Com- mittee recommended that a qualified graduate registered public health nurse be retained to study and report on the entire question. Basic Considerations in the Development of Facilities and Services (The Central Service for the Chronically 111, Chicago) The following nine basic principles should guide the development of facilities and services for the chronically ill in any community: 1. There should be a comprehensive program of well-integrated serv- ices directed toward prevention, control, and rehabilitation as well as long-term care of patients. 7. Facilities and services in the community should provide care to pa- tients without economic barriers. 3. Voluntary philanthropy, private initiative, and government should work together on a partnership basis in meeting the problems of chronic illness. 4. The problems of chronic illness, including long-term care of chroni- cally ill people, are primarily medical problems. 5. All chronically ill patients, wherever they may be and in whatever stage their need for treatment may be, should have competent and continuous medical supervision and should have easy access to all of the specialized facilities and services needed in the prevention, diagnosis, and treatment of diseases of any type. 6. Institutions for the long-term care of patients should be so developed, located, and administered that they will provide opportunity and en- couragement for the best possible care and rehabilitation of patients, for medical research, for research into the social and economic fac- tors related to invalidism, and for professional education of physi- cians, nurses, nutritionists, social workers, and others. 7. Specialized institutions are rarely desirable though specialized units, wards or whole buildings operated as part of a general hospital or medical center may be. 89 8. In general, facilities for the long-term care of patients during periods when they do not require intensive treatment should be developed through a series of relatively small institutions spread throughout the community rather than in one or two large centralized units. 9. Adequate financing is the foundation on which good care for pa- tients must rest. 90 X CURRENT LEGISLATION BEARING ON THE CARE OF THE CHRONICALLY ILL Several bills have been introduced in the current Sixty-fifth Gen- eral Assembly of Illinois which will have bearing on planning for care of the chronically ill. These are summarized below.1 Alcoholism Senate Bills 25 and 26 introduced January 28, 1947 by Senators Roland V. Libonati, William G. Knox, and Frank Ryan of Chicago propose to establish an Illinois State Alcoholics Hospital for the care and treatment of persons afflicted with alcoholism. The Hospital would be located in the City of Chicago on a site chosen by a Commission of three persons appointed by the Governor, Supervision, management, and control would be vested in the State Department of Public Welfare. An initial appropriation of $900,000 is proposed. The Hospital would be classified as one of the "State Charitable Institutions.” Cancer Senate Bills 28 and 29 introduced January 28, 1947 by Senators Roland V. Libonati of Chicago, Martin B. Lohmann of Pekin, and Frank Ryan of Chicago propose to establish an Illinois State Cancer Hospital for the care and treatment of persons afflicted with cancer. The Hospital would be located on a site chosen by a Commission of three persons appointed by the Governor. Supervision, management, and control would be vested in the State Department of Public Welfare. An initial appropriation of five million dollars is proposed. The Hospital would be classified as one of the "State Charitable Institutions.” Poliomyelitis House Bill 183 introduced on March 5, 1947 by Representatives Franklin U. Stransky of Savanna, Marvin F. Burt of Freeport, John K. Morris of Chadwick, David Hunter, Jr. of Rockford, and James M. White of Oregon would authorize county boards to levy a tax of not to exceed .075 per cent of the value of local property for the treatment and care of persons afflicted with poliomyelitis. The tax for the Polio- ’This summary includes only bills introduced through April 10, 1947 91 myelitis Fund would be in addition to all other taxes and would not be included within any limitation of rate for general county purposes. Provision is also made whereby the voters of the county might petition the board to make such levy and to submit the proposition for vote at the next general election. If the program is adopted either by action of the county board or by vote in the general election, the county board is to appoint a board of three directors, one of whom is to be a licensed physician and all of whom are to be chosen with reference to their special fitness for such office. Overlapping terms are provided. The board of directors would have exclusive control of the expenditure of moneys in the Poliomyelitis Fund. The board would arrange for the care and treatment of afflicted persons by contract with public and private hospitals in the State. Hospitals under such contract would provide free care for the benefit of all afflicted inhabitants of the county making the contract. Provision is made for the board of directors to receive contributions or donations of money or property toward the Fund. Provision is made that all reputable physicians shall have equal privileges in treating poliomyelitis patients in any hospital with which an agreement has been reached under the Act. Tuberculosis Senate Bill 130 introduced March 11, 1947 by Senator Arthur J. Bidwill of River Forest proposes to establish a State Institute for Tu- berculosis Research and Control to be located in the City of Chicago. The purpose of the Institute is the production, distribution, and appli- cation of methods and materials for prevention of tuberculosis and for conducting research in methods of tuberculosis control. Professional operation and all other management and control would be vested in the Board of Trustees of the University of Illinois which would exercise its authority through appointment of a board of six directors serving for overlapping terms. The board of directors is authorized to hire a managing officer and other necessary personnel. To launch the project appropriations would be made to the State Department of Public Health as follows: $25,000 for purchase of land; $400,000 for con- struction and equipment of a building; and $32,000 for operation and maintenance. House Bill 280 introduced on March 12, 1947 by Representatives Homer B. Harris of Lincoln, John W. Lewis of Marshall, and Homer Caton of Stanford, proposes to establish a series of state tuberculosis sanatoriums for the free care and treatment of residents of the State suffering from tuberculosis. The locations would be selected by the State Department of Public Health in which would be vested responsi- bility for management and control. Provision is made for inpatient and 92 outpatient care and for admission of suspected tuberculosis patients for diagnostic purposes. Counties, municipalities or districts which have established facilities for the tuberculous under other Acts would reim- burse the State for the per diem costs of patients admitted from their communities. If the patient is a resident of a governmental unit which has not provided facilities for the tuberculous, the county board would be required to reimburse the State for per diem costs. No patient would be admitted to a State Sanatorium without prior approval of the gov- ernmental unit responsible for paying for his care and treatment. Mental Illness Senate Bills 116 and 117 introduced March 4, 1947 by Senator William J. Connors of Chicago provide that 25 per cent of all moneys received from the Retailers" Occupation Tax shall be paid into a Wel- fare Institution Fund. Such a fund would be added to the "special funds in the State Treasury"" as set out in the Act in relation to State Finance and the stipulation made that this fund shall be used exclu- sively for the maintenance and operation of the several state hospitals for the mentally ill. Medically Indigent House Bill 420 introduced on April 9, 1947 by Representatives Bernice T. Van der Vries of Winnetka and Vernon W. Reich of Forest Park, would make the General Relief authorities in the City of Chicago and the Incorporated Town of Cicero responsible for meeting medical, nursing, and burial expenses of the medically indigent, that is, persons "not coming within the definition of a pauper.” Under the present law responsibility for the medically indigent residing in these two com- munities rests with the County of Cook whereas responsibility in the other communities of Cook County and elsewhere in the State rests with the General Relief authority. House Bill 420 would also repeal the charge-back provisions for care given medically indigent persons who have residence in some unit other than the unit giving care. County Homes See page 33 for a statement concerning amendments to the County Home Act as provided in the Proposed Public Assistance Code of Illi- nois (Senate Bill 705, House Bill 328). Illinois Children’s Hospital-School Senate Bill 139 introduced March 11, 1947 by Senator T. Mac Downing of Macomb would appropriate $400,000 to the State Depart- ment of Finance to acquire the building now occupied by the Illinois Children's Hospital-School. The state is now renting this building. Licensing and Regulation of Hospitals Two series of Bills have been introduced proposing the licensing 93 and regulation of public and private hospitals and sanatoriums, ma- ternity hospitals, lying-in homes, rest homes, nursing homes, boarding homes, and other institutions and places providing hospitalization or care for persons requiring care, treatment or nursing by reason of ill- ness, injury, physical or mental infirmity or other disability. House Bills 13 and 14 were introduced on January 8, 1947 by Representative Edward A. Welters of Chicago. House Bills 281, 282, 283, and 284 were introduced on March 12, 1947 by Representatives Homer B. Harris of Lincoln, John W. Lewis of Marshall, and Homer Caton ol; Stanford. House Bills 281, 282, 283, and 284 are endorsed by the State De- partment of Public Health as fulfilling the requirements necessary to qualify Illinois for federal grants-in-aid under Public Law 725. (See page 34.) Expansion of Public and Nonprofit Hospital Facilities House Bill 315 introduced on March 18, 1947 by Representatives Homer B. Harris of Lincoln, Calistus A. Bruer of Pontiac, J. Ward Smith of Ottawa, and John E. Miller of Tamms, proposes to give au- thority to the State Department of Public Health to prescribe minimum standards and such other regulations as may be required to qualify hospital construction projects for state and federal grants-in-aid. The Bill proposes to appropriate to the Department of Public Health $5,580,000 for the purpose of making grants-in-aid for the construction of public and nonprofit hospitals as provided in the State plan. Hospital Authorities House Bill 319 (introduced on April 1, 1947 by Representatives John W. Lewis of Marshall, M. E. Lollar of Tuscola, and G. O. Frazier of Marshall) and Senate Bill 111 (introduced on April 3, 1947 by Senators Robert W. Lyons of Oakland, Everett R. Peters of St. Joseph, and R. G. Crisenberry of Murphysboro) would authorize the estab- lishment of a Hospital Authority in any contiguous territory of the State having a population of not less than 5,000. On petition of 500 or more electors, the county judge would be required to order a refer- endum on the proposition to organize a Hospital Authority. If the proposition is approved, the Authority so established is to be governed by a board of commissioners to be appointed in the manner set out in the Act. The Hospital Authority would be empowered to establish and maintain a public hospital and public hospital facilities and to con- struct, develop, expand, extend, and improve any such hospital or fa- cility and to carry out all other functions related to the maintenance of the hospital. A tax not to exceed .075 per cent of the fair value of local property would be authorized for the support of such a hospital. 94 APPENDIX SECTION I PERSONS ATTENDING THE PUBLIC HEARINGS ABERNATHY, ELIZABETH, R.N., Anna, Su- perintendent, Hale Willard Hospital ALKIRE, A. D., Springfield, Relief Adminis- trator, Capital Township, Sangamon County ALTUS, GEORGE, Waterloo, Commissioner, Monroe County ANDERSON, BYRON R., Belvidere, Superin- tendent, Boone County Department of Pub- lic Assistance ARDNER, JOHN F., Urbana, Executive Sec- retary, Champaign County Council of So- cial Agencies ARNOLD, IRENE, Benton, Case Work Super- visor, Franklin County Department of Pub- lic Assistance AUGUSTA, SISTER M., Belvidere, St. Jo- seph’s Hospital BAKER, CHARLES W., Davis Junction, State Senator, 10th District BARNEY, RUTH, Marion, Case Work Super- visor, Williamson County Department of Public Assistance BECK, F. E., Harvard, Chairman, McHenry County Board of Supervisors BERRY, MRS. JAMES, Rockford, League of Women Voters B1ERMAN, PEARL, Chicago, Medical Assist- ance Consultant, Illinois Public Aid Commis- sion. BLOOM, C. H., Rockford, Mayor of Rock- ford BREHM, L. P., Nashville, Superintendent, Washington County Department of Public Assistance BRADFORD, ISABELLA, Springfield, Execu- tive Secretary, American Red Cross BRENNAN, EDMUND J., Chicago, Repre- senting Cook County Board of Commis- sioners BROWN, CHARLES F., Rockford, Chairman, Winnebago County Infantile Paralysis Foun- dation BROWN, GEORGE W., Rockford, Overseer of the Poor, Town of Owen, Winnebago County, and Chairman, Farm Home Com- mittee BRUNK, ARTHUR, Champaign, Regional Rep- resentative, Slate Department of Public Wel- fare BRYAN, W. J., M.D., Rockford, Superintend- ent, Rockford Municipal Tuberculosis Sana- torium BUCHER, C. S., M.D., Urbana, President, Champaign County Medical Society BURTON, COY H., Danville, Superintendent, Vermilion County Department of Public As- sistance BUTCHER, MAXINE, Murphysboro, Jackson County Representative, Illinois Public Aid Commission CAMPBELL, CHARLES, Danville, Assistant Supervisor, Town of Danville, Vermilion County CASS1N, THE VERY REV. MSGR. WIL- LIAM J., Springfield, Diocesan Director of Catholic Charities CAVAN, RUTH SHONLE, Rockford, Lec- turer in Sociology, Rockford College CHARD, EDWIN, Rochester, Overseer of the Poor, Town of Rochester, Sangamon County CHESNUT, NELSON H., M.D., Springfield, Chairman, Sangamon County Medical Ad- visory Committee CLABAUGH, CHARLES W., Champaign, State Representative, 24th District CLINTON, E. M., Oregon, Superintendent, Ogle County Department of Public Assist- ance COLWELL, C. H., Champaign, District Rep- resentative, Illinois Public Aid Commission CONKEY, ELIZABETH, Chicago, Cook Coun- ty Board of Commissioners COWDIN, FRED P., M.D., Springfield, San- gamon County Medical Advisory Committee CRANSTON, CRYSTAL, Kewanee, District Representative, Illinois Public Aid Commis- sion CRISENBERRY, R. G., Murphysboro, State Senator, 44th District CUNNINGHAM, WILLIAM H., M.D., Rock- ford, Winnebago County Medical Advisory Committee 96 DEMETRIA, SISTER M., Belvidere, Account- ant, St. Joseph’s Hospital DIETZ, MARGARET, Danville, St. Eliza- beth’s Hospital D1LLAVOU, ORA D., Urhana, State Repre- sentative, 24th District DIVER, EVELYN L., Woodstock, Acting Su- perintendent, McHenry County Department of Public Assistance DONALDSON, MARTHA J., Waukegan, Lake County Representative, Illinois Public Aid Commission DORN, REV. J., Urbana, Champaign County Ministerial Association DOWNING, MARGARET S., Macomb, Housewife DRAPER, LESTER R., Pawnee, Overseer of the Poor, Town of Pawnee, Sangamon Co. DRISCOLL, REV. THOMAS P., Carbondale, Representative of Belleville Diocese DYE, ROY, Christopher, Overseer of the Poor, Town of Christopher, Franklin County EASTON, BYRON, Rockford, Overseer of the Poor, Town of Harlem, Winnebago County ECKHOFF, WILMA, Danville, St. Elizabeth’s Hospital EDWARDS, W. O., Danville, Stale Represen- tative, 22nd District ENGLAND, R. W., Mounds, Chairman, Pu- laski County Board of Commissioners ENGLISH, HARLAN A., M.D., Danville, Chairman, Vermilion County Medical Ad- visory Committee and District Councillor, Illinois State Medical Society EUGENIA, MOTHER, Red Bud, Superior, St. Clement’s Hospital EVANGELINE, SISTER, Chester, Superior, St. Ann’s Home EVERSMAN, PHIL C., Cairo, Superintendent, Alexander County Department of Public As- sistance FARLEY, WILLIAM H., Harrisburg, District Representative, Illinois Public Aid Commis- sion FARMER, D. MILLARD, Golconda, Superin- tendent, Pope County Department of Pub- lic Assistance FEDER, NAT, Rockford, Child Welfare Worker FETZER, CHARLES E., Springfield, Auditor, Capital Township Relief Administration FETZER, MRS. L. E., Rockford, Board of So- cial Service Index FIELDS, JOHN M., Enfield, Overseer of the Poor, Town of Enfield, White County FIELDS, W. W., Carmi, Superintendent, White County Department of Public Assist- ance FOSTER, JAMES E., Chicago, Chief, Infor- mational Service, Illinois Public Aid Com- mission FRINGER, MRS. WILLIAM R., Rockford, Executive Secretary, Winnebago County Tu- berculosis Association GALVANONI, R. B., Rockford, Field Sani- tarian, Rockford Health Department CARMAN, THOMAS M., Urbana, State Rep- resentative, 24th District GATTON, THE VERY REV. MSGR. J. L., Springfield, Dioceson Director of Hospitals, Springfield Diocese GATTON, L. A., Pawnee, Overseer of the Poor, Town of Pawnee, Sangamon County GIFFIN, D. LOGAN, Springfield, State Sen- ator, 45th District GLEASON, ALICE M., Rockford, Superin- tendent, Winnebago County Department of Public Assistance GREISER, FERD, Danville, Assistant Super- visor, Town of Danville, Vermilion County GRUBER, CARL, Danville, Case Work Su- pervisor, Danville Township, Vermilion County GUNDERSON, IRENE, Rockford, Director, Visiting Nurses Association GUNDERSON, N. O., M.D., Rockford, Rock- ford Commissioner of Health HALL, THAMIE F., Anna, Superintendent, Union County Department of Public As- sistance HAMANN, C. H., M.D., Rockford, Medical Director, Elm Lawn Sanitarium HAMILTON, ROBERT H., McLeansboro, Su- perintendent, Hamilton County Department of Public Assistance HARRISON, ISABEL, Freeport, Acting Super- intendent, Stephenson County Department of Public Assistance HARTMAN, M. L., M.D., Belvidere, Chair- man, Boone County Medical Advisory Com- mittee, and President, Boone County Medi- cal Society HATTEN, VIRGIL, Chatham, Overseer of the Poor, Town of Chatham, Sangamon County HAWN, A. E., Oregon, Overseer of the Poor, Town of Oregon, Ogle County HERBOLSHEIMER, HENRIETTA, M.D., Springfield, Director, Illinois Hospital Sur- vey, State Department of Public Health HILLER, F. B., M.D., Pinckncyville, Super- intendent, Hiller Hospital 97 HINCHLIFF, MRS. EDWARD C., Rockford, Member, Winnebago County Public Aid Ad- visory Committee and Council of Social Agencies HINRICHSEN, ANNE, Springfield, Informa- tional Representative, Illinois Public Aid Commission HOAGLUND, MAX, Champaign, Superin- tendent, Burnham City Hospital HOSK1NSON, C. H., Rockford, Former Township Supervisor HOWARD, LANDO, Springfield, Special Field Representative, Illinois Public Aid Commis- sion HUNTER, EDWARD C., Rockford, State Rep- resentative, 10th District IVY, ANDREW C., M.D., Chicago, Vice President, University of Illinois in charge of Schools of Medicine, Dentistry, and Phar- macy JAMES, DAVID E., M.D., Belvidere, Physi- cian JEREMIAH, CLIFFORD C., Chester, Super- intendent, Randolph County Department of Public Assistance JOHNSON, HENRY V., Capron, Overseer of the Poor, Town of Manchester, Boone Co. JOHNSON, HERBERT F., Rockford, Assist- ant Supervisor, Town of Rockford, Winne- bago County JOHNSON, MARY-CLAIRE, Chicago, Ad- ministrative Assistant, Illinois Public Aid Commission JONES, JOHN R., Springfield, Former San- gamon County Treasurer JORDAN, WILLIAM, Murphysboro, Super- intendent, Jackson County Department of Public Assistance RAPP, JOHN W., Springfield, Mayor of Springfield KELLER, NICK, Waukegan, State Representa tive, 8th District KELLEY, JUANITA, R.N., Anna KELSEY, HAROLD D., Barrington, State Representative, 8th District KIMMEL, ROGER T., Murphysboro, Chair- man, Jackson County Public Aid Advisory Committee K1NZER, ARTHUR, Urbana, Chairman, Champaign County Board of Supervisors KLEIN, E. H., Mt. Vernon, District Repre- sentative, Illinois Public Aid Commission KLOPFENSTE1N, FRIEDA, Springfield, Exe cutive Secretary, Family Welfare Association LANAN, D. J., Kingston, Chairman, De Kalb County Home Committee LAUGHL1N, EDWARD E., Freeport, State Senator, 12th District LIEFER, ALBERT, Red Bud, Commissioner, Randolph County L1ERE, MRS. A., Danville, Child Welfare Nurse LINDSTROM, DR. DAVID E., Urbana, Pro- fessor of Rural Sociology, College of Agri- culture, University of Illinois. L1NNE, ALBERT L., Danville, Overseer of the Poor, Town of Danville, Vermilion County LITTLE, T. N.( McLeansboro, Overseer of the Poor, Town of South Crouch, Hamilton County LOEWENBERG, I. S., Chicago, Chairman, Council for the Aged and Chronic Sick, Jewish Charities LOGAN, A. D., Rockford, Secretary, Civic League LOGAN, JAMES A., Benton, Superintendent, Franklin County, Department of Public As- sistance LOOMIS, FRANK, Chicago, Executive Di- rector, Chicago Community Trust LOVEL, E. J., Springfield, District Repre- sentative, Illinois Public Aid Commission LOY, HILDA, Rockford, Manager, Nursing Home LYONS, LEO M., Chicago, Director, St. Luke’s Hospital McDONALD, W. J., Murphysboro, State Representative, 44th District MclNNES, R. J., Rockford, Winnebago Coun- ty Representative, Illinois Public Aid Com- mission MAASBERG, IRMA R., Rockford, Assistant District Representative, Illinois Public Aid Commission MacEACHERN, M. T., M.D., Chicago, Di- rector of Hospital Activities, American Col- lege of Surgeons, and President, Chicago Medical Society MAHER, J. T., M.D., Danville, Director, Vermilion County Tuberculosis Sanatorium MARLIN, JOHN M., Vienna, Superintendent, Johnson County Department of Public As si stance MARSHALL, MRS. HELEN, Danville, Vis- itor, Vermilion County Department of Public Assistance MARTIN, IVA A., Rockford, Manager, Mar- tin Rest Home MEEKER, CHARLES R,, Rockford, Regional 98 Representative, State Department of Public Welfare MEYER, FRED, E. St. Louis, District Repre- sentative, Illinois Public Aid Commission MODGLIN, L. E., Ava, Overseer of the Poor, Town of Ora, Jackson County MORRIS, JOHN K., Chadwick, State Repre- sentative, 12th District MYERS, CHARLES W., Danville, Superin- tendent, Vermilion County Home NELSON, A. R., Chicago, President, Illinois Homes for the Aged, and Superintendent, Swedish Covenant Home of Mercy NOBLES, C. D., M.D., Anna, Superintend- ent, Anna State Hospital NORMAN, L. D., Carbondale, Regional Rep- resentative, State Department of Public Wel- fare O’BRIEN, JAMES, Coulterville, Commission- er, Randolph County ORTSCHE1D, DORIS M., Galena, Superin- tendent, Jo Daviess County Department of Public Assistance OTTEN, HARRY, M.D., Springfield, Sanga- mon County Medical Advisory Committee OWENS, J. W., Buffalo, Overseer of the Poor, Town of Buffalo, Sangamon County OWENS, RAY, Harrisburg, Superintendent, Saline County Department of Public Assist- ance OXTOBY, MRS. FRIEDA B., Rockford, Case Worker, Family Consultant Service PALMER, D. H., Danville, Relief Administra- tor, Town of Georgetown, Vermilion Coun- ty PAULSON, NORMAN T., Chicago, County Home Consultant, Illinois Public Aid Com- mission PFLEIDERER, E. R., Springfield, Lions Club PIERCE, CHARLES M., Belvidere, Overseer of the Poor, Town of Belvidere, Boone County POOLE, SUSANNAH, DuQuoin, Superin- tendent, Marshall Browning Hospital RAHN, Mrs. ROSE, Springfield, Relief Of- fice, Town of Capital, Sangamon County RIFE, Berry V., M.D., Anna, President, Union County Medical Society RIGGS, GORDON, Elizabethtown, Superin- tendent, Hardin County Department of Pub- lic Assistance RIPPELMEYER, ARMIN, Waterloo, Superin- tendent, Monroe County Department of Pub- lic Assistance ROPCHAN, A. L., Chicago, Executive Sec- retary, Health Division, Council of Social Agencies ROSENBLUTH, ROBERT, Chicago, Consult- ant, Illinois Public Aid Commission ROSS, PRUDENCE, Rockford, Consultant, Illinois Division of Child Welfare RUDDICOMBE, MRS. EDITH V., Rockford, Manager, Ruddicombe Convalescent Home SCHLUETER, C. H,, Nashville, Overseer of the Poor, Town of Nashville, Washington County SCHULTZ, OTTO R., Danville, Credit Man- ager, Lakeview Hospital SERBIAN, ANDREW, Cairo, Chairman, Alexander County Board of Commissioners SETZKORN, VERNE, Pinckneyville, Superin- tendent, Perry County Department of Pub- lic Assistance SHEEHE, MRS. NORMAN L., Rockford, As- sistant Supervisor, Town of Rockford, Win- nebago County SHIELDS, CLIFFORD, Danville, Chairman, Vermilion County Board SHONTZ, VERNON L., Springfield, Presi- dent, Council of Churches SISSON, R1X A., De Kalb, Superintendent, De Kalb County Home SPORE, RUE, Metropolis, Superintendent, Massac County Department of Public As- sistance STENERSON, O. H., Poplar Grove, Chair- man, Boone County Board of Supervisors STEVENSON, DR. MARIETTA, Urbana, Di- rector of Graduate Curriculum in Social Welfare Administration, University of Illi- nois STOCKHUS, MERYLE, Rockford, Board of Illinois Children’s Convalescent Home and Cottage SWANK, HAROLD, Chicago, County Home Consultant, Illinois Public Aid Commission TAIT, FLORENCE, Rockford, Manager, Tail Nursing Home TAYLOR, R. A., Carbondale, Member of Jackson County Public Aid Advisory Com- mittee THOMPSON, COL. E. T., M.D., Chicago’ Director of Medical Care, Chicago-Cook County Health Survey THORNTON, THOMAS J., Chester, State Representative, 44th District TOBIN, MRS. MARGARET, Urbana, Cham- paign County Family Service Bureau 99 TRUTTER, Ann, R.N., Springfield, Director, Public Health Nursing and Tuberculosis As- sociation of Sangamon County VAN METER, KATHERINE, Springfield, Illinois Public Aid Commission VEIRS, W. L., M.D., Urbana, Chairman, Champaign County Medical Advisory Com- mittee VENARDOS, ELIZABETH, Springfield, As- sistant District Representative, Illinois Pub- lic Aid Commission VIRTUE, MRS. BETH, Rockford, Ward nurse in charge, Winnebago County Hospital WAKERLIN, GEORGE E., M.D., Chicago, Assistant Dean, University of Illinois Med- ical School WALKER, M. R., Danville, State Representa- tive, 22nd District WALSH, JAMES M., Springfield, Overseer of the Poor, Town of Capital, Sangamon County WATSON, ISABELL H., Riverton Overseer of the Poor, Town of Clear Lake, Sanga- mon County WEEKS, J. M., Rochelle, Overseer of the Poor, Town of Flagg, Ogle County WESTFALL, HOWARD F., Mounds, Super- intendent, Pulaski County Department of Public Assistance WESTON, MAX A., Rockford, States Attor- ney, Winnebago County WHEATLEY, M. J., Sparta, Relief Adminis- trator, Randolph County WHITE, JAMES M., Oregon, State Repre- sentative, 10th District WHITE, LEON H., Springfield, Superin- tendent, Catholic Charities WINSTON, G. B., Springfield, Urban League Executive WISE, LEONA B., Harvard, Relief Officer, Town of Durham, McHenry County WITTE, THE VERY REV. MSGR. F., Ruma, General Manager of Hospitals for Sisters Adorers of the Most Precious Blood WOOD, HARL1NGTON, Springfield, Sang- amon County Judge WOOD, PEGGY, Carbondale, Child Welfare Regional Supervisor, State Department of Public Welfare YATES, KATHERINE, Metropolis, Relief Ad- ministrator, Massac County YOUNGBERG, JAMES A., Springfield, As- sistant Secretary, Springfield Council of Social Agencies ZAUN, DONALD R., St. Charles, Juvenile Parole Officer, State Department of Public Welfare ZOLD, A. E., llliopolis, Overseer of the Poor, Town of llliopolis, Sangamon County ZUROWESTE, THE RT. REV. MSGR. AL- BERT R., E. St. Louis, Diocesan Director of Charities, Belleville Diocese 100 SECTION II EXCERPTS FROM TESTIMONY AT CONSULTANTS’ MEETING AND PUBLIC HEARINGS Need for Research Malcolm T. MacEachern, M.D., Chicago Director of Hospital Activities, American College of Surgeons, and President, Chicago Medical Society Public Hearing, Chicago, July 11, 1946 “For many years I have felt that the chronically ill person has been forgotten. He has been left in his physical condition without much consideration. Nor has adequate effort been made to cure it, or at any rate to rehabilitate him into a productive and happy life. We also can do that. “I believe that the medical profession has not done as much as it should for retarding old age diseases in the long-term patient which we call "chronic’ or "incurable’. We don’t like these words in our medical language. They are discouraging. We like the designation "long-term illness’ better. ""I have always favored special consideration in connection with treating patients with long-term illnesses, that is, providing some of the pleasantries of life to make them happy—give them work if they can do it—and open to them an enjoyable existence. They can never be brought to a fully rehabilitated state but medicine has had good re- sults in the use of occupational therapy, recreational therapy, hydro- therapy, electrotherapy, and other forms of physical therapy. Since the war large sums of money have been given for the advancement of this work and has made it possible to develop departments of physical medicine and research in old age diseases. ""We must not forget research in this connection because I feel there is a great deal we should know and a great deal we should do that will help materially in the proper care of long-term illnesses and the diseases of old age. I believe that there is much thought which should be given to these subjects; we must find out why diseases become chronic or long-term; why did they become that way; what can be 101 done to counteract such conditions and avoid reaching this state. Here is a wonderful field for research. The University of Illinois College of Medicine has developed a fine program of research. This institution is most fortunate in having Doctor Ivy with them now—his work in re- search is known the world over. Under his inspiring enthusiasm and leadership much will be accomplished. The Government of the United States has recognized his work in the war. The State is very fortunate to have such a man. This State institution, the Illinois University Col- lege of Medicine, is attracting to its staff the best men in the country to be a part of the great medical center. "There are two things we can do in this field, and I have very definite ideas on this: first, we can relieve these patients, rehabilitate them; secondly, there is research. Therefore, we have before us a great challenge which is not to be set aside. We need money to do it. In the end we would be contributing toward making people self-sustaining, and this would be better than having them become charges on the State or the county . .. George E. Wakerlin, M.D., Chicago Assistant Dean, University of Illinois Medical School Public Hearing, Chicago, July 11, 1946 "I don't think there is any question of the need for hospital space for care of the chronically ill of Illinois. Since we must make a begin- ning, I think a State research facility for chronic illness should be lo- cated in the new West Side Medical Center where it will be in close association with other medical institutions and medical schools, includ- ing the University of Illinois. Such a research hospital would be the nucleus of the several hospitals for the care of the chronically ill which I hope the Legislature will establish throughout the State. "Here in Chicago, I think, the proposed hospital for the chroni- cally ill should be in a teaching center where students from the various medical schools will obtain valuable experience for subsequent medical practice. This should apply to the students of all medical schools, not only the University of Illinois. "Research in the fields of the aging processes and the diseases of older years is in its beginning. There is a great deal to be learned es- pecially from the standpoint of preventing the aging processes from setting in prematurely and from the standpoint of preventing, delay- ing, and treating such diseases as hardening of the arteries, high blood pressure, arthritis, and cancer. "I think that one chronic hospital in the West Side Medical Cen- ter in Chicago is the first and most important need. Later on it might be desirable to have more distributed throughout the State. “I would like to emphasize again that I am here merely as a private citizen and as such I am of the opinion that the research hospital for the chronically ill to be located in the West Side Medical Center should be under the jurisdiction of the University of Illinois College of Medi- cine. I feel also that the other medical schools in the Chicago area should participate in the medical teaching and research that would be afforded by such a hospital. It would be unfair not to give the other schools this opportunity. "It is my opinion that the patient should always be informed of any contemplated experimental procedure and his consent obtained. Most patients are very glad to cooperate. Furthermore, I believe all doctors in conducting medical research on human subjects are gov- erned by the Golden Rule—they won't do anything that they wouldn't want done to themselves." Andrew C. Ivy, M.D., Chicago Vice President, University of Illinois In charge of Schools of Medicine, Dentistry and Pharmacy Public Hearing, Chicago, July 11, 1946 "Some of you may know that in the last century of our existence the span of life has increased from 30 to 65 years. That has been due chiefly to reducing infant mortality in maternal cases and improved means of preventing and curing acute diseases: for example, the pre- vention of deaths from diphtheria, pneumonia, typhoid, and more re- cently the use of the sulfa drug and penicillin in penumonia and other types of acute infections. "Several years ago I analyzed this increase in life expectancy and I concluded that only about five years of this increase could be credited toward an increase in the years of active life in the older age groups. "We are now confronted with a marked increase in the number of people above the age of 30 in our population, and the range of clinical investigation in the field of medicine must be directed toward the older age groups in making the life of older people more comfortable and more efficient. Obviously, if we are going to extend life spans up to the possible extent of 75-80 years, we will not be serving our people properly unless at the same time we direct our attention to making the added years more comfortable and more efficient. That is why throughout the country at the present time persons interested in the field of public health are giving attention to chronic illnesses, their prevention 103 and alleviation, in what is called the science of geriatrics. Geriatrics is just the opposite of pediatrics. “In this field of chronic diseases, I have in mind cancer, heart disease, hardening of the arteries, nephritis, rheumatism, and peptic ulcers—the diseases which kill so many people too early and which make life less efficient and comfortable for a great number of people. “Before we can expect to prevent, alleviate, or delay the onset of these diseases, we must direct our research efforts toward them. That is going to require patients for clinical study, scientists, and facilities. In regard to the location of a research hospital, I should like to direct attention to the policy adopted by the Veterans' Administration in lo- cating hospitals for veterans near an existing institution for medical re- search and education. That question has been up in Washington be- fore the National Research Council, of which I am a member and the question has also been before Surgeon General Parran of the United States Public Health Service in relation to the national cancer programs. It has seemed to be most advisable to start this plan for research in re- lation to medical institutions. In these institutions we have the advan- tage of men trained in the field of research and at the same time we have the doctors of the future so that we can impress upon them the importance of this field of research and the prevention of chronic dis- eases, which in the past was not considered very important. As it was pointed out by a previous speaker, we will make our young doctors alert regarding chronic disease only when we are doing research on those diseases in our medical schools. The medical schools which pro- duce the most alert physicians are those schools where every teacher is doing research and has the facilities for doing research. By locating this first research institution, your major institution, in association with a medical center, you will be not only taking advantage of the research facilities but at the same time you will be stimulating the doctors of the future to become more interested in those illnesses. “I should like to say, in connection with the point raised by Dr. Wakerlin about research being done on patients and their reactions, that I have done clinical investigations on our veterans in the veterans' hospitals and we tell them just exactly what we are after and we haven't had a veteran turn us down yet. In fact, they deeply appreciate the extra attention and without exception are anxious to help increase knowledge which would help themselves and others." 104 Everett P. Coleman, M.D., Canton Chairman, Fulton County Medical Advisory Committee Chairman, Illinois State Medical Advisory Committee to Illinois Public Aid Commission Consultants1 Meeting, Chicago, September 7, 1946 "I am interested in the research angle of chronic illness because I believe we should work toward keeping people from developing these illnesses. If something can be done to keep them from these illnesses for even 15 or 20 years more, I am all for it. But it is one of those things where I think we have to be a little bit skeptical. There are a number of things that one can prevent but the difficulty is that we get them too late. Many of these people are victims of high blood pressure or hard- ening of the arteries and are no longer able to work. Yet, if they are hospitalized for a period of two, three, or four months, many of them can go back and get on the job again. You know that keeping a person hospitalized or not working for too great a period of time never has done any good. Reasonable periods of hospitalization are better. Many heart cases have gone back to work and have continued to work for a long period of time. "In our own county of Fulton in our 151-bed hospital, I don't know the percentage of chronically ill persons, but we have quite a few. There are a great many cases of fractured hips among old people and it used to be that there was nothing that could be done for them. Now, we have partly solved that problem by a routine of treatment that gets them up and reduces the time of inactivity. They are able to be up and about and some go home in a short time. It used to be that we had to use the rollers and weights and keep the patient in traction for a long time. Now, they don't all get along that well; nevertheless, a decidedly greater number can take care of themselves. "The same is true in the cases of some old men who are often afflicted with prostatic trouble rendering them incapacitated. Now, with the proper treatment we are restoring them to usefulness and many of them are going back to work. Many of these old men take care of farms. "There are some cases not so fortunate. In cases of arthritis they are not able to get around and do anything for themselves. Some of these people can't get any help from the children who have grown up and moved away from the home and they are a rather pitiable group to watch. Something should be done so that the children realize their responsibility to their parents. They should be made to assist these old folks. This condition is getting to be the greatest disgrace to the human 105 race in this section of the country and in the entire Mississippi Valley region.” The Chronically 111 Problem as Seen by Physicians Everett P. Coleman, M.D., Canton (See previous testimony for complete identification) Consultants’ Meeting, Chicago, September 7, 1946 "Frequently you hear of cases where families are looking for a place for some member of the family who is unable to properly care for himself while they go away for a while—ones who are apt to set the house on fire or fall down stairs and break a leg. After a while they discover it is nice to be without that person and they leave him in a nursing home. It is seemingly heartless, but there is the viewpoint that he may live another ten years and disrupt the entire family and they feel they have certain rights themselves and that the “nursing home’ is the answer. "I might mention the question of nursing home care as we have seen it. That varies from very good to very bad. In my community there is a very old building which could be a regular fire trap. I will say, however, that the patients there do receive the best of food and care. This place is being closed now because of the death of one of the operators. It is being succeeded by two or three smaller homes which I fear are ill-equipped and not properly supervised. In the case of a nursing home it is so important that it be properly managed and reg- ularly inspected. It is also important that proper facilities are available and that a certain amount of privacy is given to the patients. It is all right to have wards but they shouldn’t all be in wards. "There are two or three factors a number of us have thought of in my community. First of all, we have thought that we might build a wing to the hospital, and then we could use the surplus in beds tq care for the old people or the chronically ill where they could have the facilities of the hospital available for their use when they needed them. We have thought, too, that from time to time they vary in numbers because of the high death rate among the aged, and if necessary we would use part of that wing for general hospital cases. In that way, it would not be a one-sided affair. It would help both the general hos- pital and the chronically ill patients.” Harlan A. English, M.D., Danville Chairman, Vermilion County Medical Advisory Committee District Councillor, Illinois State Medical Society Public Hearing, Danville, May 9, 1946 "In view of the fact that county homes are supported largely by 106 taxes, we feel that whatever taxes are levied for that purpose in Ver- milion County should be spent here. In times past, the people of the county had considered the county home as a place called the 'Poor Farm/ This county home has gradually been converted into a con- valescent type of home. "As a medical society, we have been most interested in seeing that the quality of care is of the very best for the type of case present in the building. During the war we will admit we were not as exacting as we would like to have been, but many things have been done that will be changed along in November (1946) when we get a more com- plete staff back from service and can run a rotating physician service out at the county infirmary. We are one group which is certainly try- ing to make Illinois one of the few states where recipients of public assistance can be taken care of properly and not in some flop house where there is very little food of poor quality .., About November we hope to have four men working on medicine, surgery, orthopedics, and geriatrics. "The staffs of the hospitals have warned the hospitals that they had better be very careful in the chronically ill care business for the reason that our population is getting older all the time. If they start making that a big item now, they are going to end up in 1957 needing another infirm section in the general hospitals. General hospitals aren’t particularly interested in this type of work. "It is my opinion that those people who are in the home on a pension and for just custodial care should not pay as much as those who are there for bed care and nursing attention. I would decide be- tween bed care and custodial care and stop right there. "You are not going to find the physician trained in diseases of the aged—easily. You will find it very difficult to pick a man whose practice consists of older aged groups to serve in a consultant capacity. We have about four or five who grew up with these people and are accustomed to treating their diseases. We will use their knowledge and background in Vermilion County.” F. B. Hiller, M.D., Pinckneyville Superintendent Hiller Hospital Public Hearing, Carbondale, August 7, 1946 "I believe it is quite possible that patients are having difficulty with doctors because doctors now are like the hospitals. They would rather not take care of patients who are chronically ill and very little can be done. "There are a number of chronic disease patients in the hospitals, 107 I will admit, that are hard to care for. Nurses can tell you that and they don't like to take care of them. In one hospital in Perry County the nurses went on strike. They won't take care of old people because they take too much care. Now, I find that in these hospitals are chron- ically ill who have no control of their bodies. Some grow better—but, say a paralyzed person is a patient from now on, where are you going to put him? The people in his home are not able to care for him. That kind of a person has got to be in a hospital, just as much as a surgical case, and he requires more care ... "Now, another thing, the State sends out literature on the care of the child. We have been giving this literature to mothers in our hos- pitals. I believe the State should furnish similar literature on the care of old people and distribute it to the homes. I think part of the trouble is that there is no educational information on the care of old people...” C. S. Bucher, M.D., Champaign President Champaign County Medical Society Public Hearing, Urbana, May 8, 1946 "There was a point made that so many of our mental patients are mentally ill first and then physically ill. Generally it is just the opposite. The mental condition follows the physical condition. "I know it has been the intention of hospitals and doctors, as soon as possible, to increase the size of hospitals in order to have a place for convalescents and chronically ill. That will give laboratory and X- ray facilities and anything else they may need. Laboratory and X-ray equipment add quite an overhead. It is more economical to have one good laboratory and X-ray department manned with well-trained technicians than several small units. "In the aged, keeping them occupied is a most important thing.” C. H. Hamann, M.D., Rockford Medical Director Elm Lawn Sanitarium Public Hearing, Rockford, February 14, 1947 "I am the director of a privately owned sanatorium and have been in the field of psychiatry for a number of years. I think that all chroni- cally ill are potentially mentally ill. It is necessary that they have good psychiatric help. Unfortunately, we have only too few well-trained phychiatrists. There are too few psychiatrists trained in the field of good mental hygiene for these people. "I certainly agree that the private selection of a physician most desirable for the maximum benefit to every patient (young or elderly) 108 and the preservation of this responsibility should be shared by the family of the afflicted as well as by directors of all public institutions. "It is necessary that the local community feels an obligation to- ward the care of these people. They need the aid of larger groups, of state and national resources, to aid them in discharging their responsi- bility. .. We have to have further widespread education in the schools, in the Legislature, and in the law, if we are going to attack the problem. That also applies to the mental health problem of any person who is ill and particularly those who are chronically ill." W. J. Bryan, M.D., Rockford Superintendent Rockford Municipal Tuberculosis Sanatorium Public Hearing, Rockford, February 14, 1947 "We are finding that tuberculosis is not so much a disease of in- fancy as of adulthood. Fewer cases are being found among the very young. The greater percentages of tuberculosis entering our sanatoria today are among the older age group, ranging from 45 to 60; even pa- tients between 70 and 80 are being admitted. "The problem of disease among older people is a big one and one which requires much thought. In the next few years, I believe we will find more and more physicians specializing in chronic diseases of older people. It is my opinion that in the not too distant future the chronically ill (exclusive of tuberculosis) will be a bigger problem than that of tuberculosis. "Most of these people will need hospital care for at least a short period of time. Then, when they are able, they may be moved into nursing homes. I believe there are none of you who would not be dis- appointed if you were assigned to some doctor you did not know, want, or trust. I think we all want to have our own selection of doctors in any plan. "In our sanatorium, practical nurses handle only daily routine care of the patients. The registered nurses direct the work of the prac- tical nurses and are the only nurses permitted to give medication. I would be in favor of establishing training courses for nurses in the care of chronically ill patients; similar courses might also be given for prac- tical nurses." J. T. Maher, M.D., Danville Director Vermilion County Tuberculosis Sanatorium Public Hearing, Danville, May 9, 1946 "All of our people at the Tuberculosis Sanatorium are, of course, 109 chronically ill. We have a capacity of 60 beds at the present. We av- erage 44 patients in the hospital and at present some 13 are from counties other than Vermilion and are paid for by their home counties. As long as I have been here, we have had no problem in admitting any patient who needed care. "The patient does not receive as much occupational therapy treat- ment as you would find in orthopedic cases because very few of the tuberculosis patients are able to get up and about and most of them just want to read or listen to the radio. If they were up and around it would be advantageous to have some occupational therapy. At the present time we have five cases which could stand occupational therapy so far as returning them to normal living. We have to wait for the Illinois Tuberculosis Association and the doctors to develop something like that. There are some cases that could stand more than reading and writing and radio listening/" (On May 7, 1947 Dr. Maher reported that beginning October 1, 1947 the sanatorium will have the services of an occupational therapist who will also provide vocational counseling.) Planning by Voluntary Institutions for the Aged Mr. Frank D. Loomis, Chicago Executive Director Chicago Community Trust Public Hearing, Chicago, July 11, 1946 "I shall not attempt to present statistics or proofs as to how serious and acute is the need for planning for the chronically ill. You doubtless have in your possession already or easily available to you reports and estimates of the Illinois Public Aid Commission as to the needs of pa- tients in their care, particularly those of the old age group now depend- ent on Old Age Assistance, For several years it has been my privilege to serve as a member of the Cook County Bureau of Public Welfare Advisory Committee and its subcommittee on Care of the Aged where we have discussed this problem again and again at numerous meetings and we know how difficult and often impossible it is to find safe and wholesome homes where homeless chronics can live at a cost which they can pay even after liberal public monthly allowance. "The Central Service for the Chronically 111, a private agency operating under The Institute of Medicine and affiliated with the Coun- cil of Social Agencies of Chicago, has prepared estimates and other data on the general needs in this field. Doubtless you have their reports. I would only add that the need is great not only among the very poor or the general population made up mostly of middle-class people of 110 limited means, but is acute among the well-to-do and even the rich who have ample funds to pay for adequate service were it available. It is often not available even in institutions operating on a de luxe scale at exorbitant and unreasonable costs. “The Illinois Public Aid Commission, acting under authority of the Legislature, is to be heartily commended for the steps it is taking to meet such needs. The plan to make over or convert the ancient county poor infirmaries into modern homes for the care of chronics is one of the most constructive steps which has been taken for the care of the infirm in many generations. These institutions are maintained, of course, by taxation. Efforts of the Illinois Public Aid Commission to encourage extension and improvement of facilities in institutions privately operated as voluntary tax exempt charities, are likewise to be commended. I wish to speak briefly concerning possible improve- ments in these institutions. “We have in the State a large number of old people's homes and some sanitariums, hospitals or agencies with boarding-home services for the chronically ill, operated by charitable corporations, “In Chicago and near vicinity alone we have 44 institutions op- erating under the general title of Homes for the Aged. They are re- ported to have 4,021 beds. Twenty-eight of these homes are endorsed by the Subscriptions Investigating Committee of the Chicago Associa- tion of Commerce—27 under this classification. (Chicago Home for Incurables is classified as a hospital. Sanatoriums for tubercular pa- tients are not included in the list.) Concerning the 27 Homes for the Aged, published reports of the Association of Commerce show that they had for the last fiscal year total current income of $1,617,000 and current expenses of $1,395,000, or excess income for the year of $222,- 000. In addition to this excess current income of $222,000, they re- ceived within the year capital gifts and bequests of $796,000, or total increased assets of $1,118,000. “Examination of reports running back for ten years and more show that this is not an unusual situation. The reports show substantial gains each year, both in current and in capital income. The combined balance sheet for the 27 institutions at the end of the last fiscal year (up to March 31, 1945) showed total institutional property of $6,145,- 000, and invested capital (i.e. invested for profit) of $13,392,000. In- vested capital or endowment equal to plant investment is for institu- tions of this kind generally regarded as quite adequate. Some have less. Some have a good deal more. “How do these institutions get that way? “The general pattern under which these homes are established 111 and operated calls for an admission fee or permanent contract by which desirable inmates may gain admission. The usual minimum admission fee is $1,000. But there is the further requirement in the policies of most of these homes that the incoming resident turn over to the home any other property he may possess. This is turned over by gift or be- quest which is labeled as voluntary. In many cases these gifts or be- quests are quite substantial. “Operations under this policy have proven quite profitable. Once the home is paid for, the well-managed institution makes money. The well-situated home, restricted in its service to socially privileged and ordinarily well-to-do people may make a great deal of money. One could commend such good management and rejoice in such accumu- lation of wealth if it resulted in increased service even to the well-to-do. But regrettably it usually does not. Whether the home has property of half a million or has risen to five or ten millions it still continues to care for its selected family of a hundred old people. Perhaps one of the elements of attractiveness in such charitable institutions is their ex- clusiveness. “Or one could recognize the desirability of and rejoice in a service available to old people which enables them to spend their declining years with people congenial to them, people of the same basic culture, whatever it is, racial, religious, nationalistic, intellectual, economic, ar- tistic; but when there are people of that same culture who have fallen into real misfortune, or perhaps never rose above it, or when even there are people of a different culture lying sore and afflicted at the gate, and the charitable institution has ample money to help them, cer- tainly it ought to find some way to make its charity effective. “The case is even worse with the highly endowed memorial char- ity. Established as a monumental institution, with large or excessive en- dowment even before it is built, to be operated on a highly restrictive basis for the benefit of a limited few, such charities may rise to great wealth while they render service of little special value. We have two or three charitable homes in this country (they are east of here) which began at a modest level many years ago but now are reported to be worth in the neighborhod of a hundred million or more each, while they still continue to care for only a few individuals. There are others whose endowments are probably half that much. We have no institu- tions of any such wealth in Chicago. We are young. We do have some homes which are moving in that direction, and more are projected in bequests not yet operating. “I do not mean to criticize any institution or the managers of any institution personally. Many of them would like to do differently but 112 they are tied by customs and often by the explicit letter of some will which the courts insist on interpreting according to the explicit letter. I believe we will eventually come to the opinion, just as they did in England a hundred years ago, that the public welfare and the usefulness of charitable wealth in our capitalistic system are more important than the letter of ancient wills. In England, long burdened by the accumu- lation of useless charities, wills today are being broadly interpreted in the light of present-day needs. “So the rule recently adopted by the Illinois Public Aid Commis- sion that the current income of old people’s homes shall be currently used as a condition precedent to any contract with the Illinois Public Aid Commission for compensation for the care of the wards of the State is a sound and wholesome rule. It will help these institutions to modernize their methods and increase their usefulness. Many of the homes are trying to do just that. There is a tendency to abolish the contract rule for admissions, to base charges on what the patient can afford to pay, to accept also at cost wards from the State to the limits of their capacity, and to use capital resources to increase their capacity whenever possible in order that the chronically ill of the State may be cared for ...” Mr. A. R. Nelson, Chicago President, Homes for the Aged, and Superintendent, Swedish Covenant Home of Mercy Public Hearing, Chicago, July 11, 1946 “As you know, I am President of the Illinois Homes for the Aged, which is an organization covering the recognized homes in Cook Coun- ty and neighboring counties. “There are some remarks which Mr. Loomis made on which I should like to comment. I don’t have the figures with me in the mat- ter of home income but I assume those he gave are correct. In many homes a larger part of the income is from contributions from public or private organizations, I know that is true of many homes. It is true of my own, the Swedish Covenant Home of Mercy. Our normal in- come is around $40,000, but of that about half, $90,000, is in the form of donations from our churches, tag days, and benefits run for the maintenance of the home. In other words, what we receive from each individual is not sufficient to meet the needs of that individual and we must maintain an active campaign through the years in our churches so that at the end we can come out in the black. Many homes are sup- ported by churches and lodges in that manner. “It is true that most homes require a set fee for admission of $500 113 or $1,000, or some such sum. But let us consider how many patients there are who are in the home for a considerable length of time. A re- cent study disclosed that the average length of residence is 7.9 years —approximately 8 years. If you will figure that the cost of keep is $45.00 a month, it would amount to $540 a year for the care of one patient, and you will see that the $500 paid on admission will not near- ly cover the cost of his care. Take for instance a case I had of a woman who had been a resident of the home for 28 years and paid $800 when she came. It takes a lot of contributions to care for such a person. . , "Length of life is increasing and the number of persons 65 years of age or older is much greater now than it was ten years ago, to say nothing of 20 or 30 years ago. The results of a recent survey which have been released indicate that by 1980, which isn't too far away, one out of every six people will be over 65 years of age. So, you see, it is very much a problem for the future and not only the present. This problem of caring for the chronically ill is perhaps the most important that we have facing us, not only in this State but throughout the entire country. "Mr. Loomis stated that there are 50,000, which figure I presume to be correct, people who are in need of care as chronically ill. I wonder if everybody appreciates this particular situation. Can I give a personal experience just to illustrate this point. "Just today I received from the Civilian Production Administra- tion a denial to build a building on my premises which would provide for from 50 to 60 chronically ill persons. We have the Swedish Cove- nant Hospital there with a capacity of 200 beds and the Swedish Cove- nant Home of Mercy, or old people's home, with a capacity of 100. Then in an old hospital building we have a nurses' home. It was our plan that when we could secure authority to build our new nurses' dormitory we would convert the present dormitory into a home for chronically ill which would relieve the strain on the hospital and the old people's home. This new building would cost us about three or four hundred thousand dollars, but the government will not permit it. We can't get authority to go ahead. This new building would do two things: It would provide a space for the care of persons who are not now in any institution, and it will also relieve the hospital of perhaps 20 or 25 chronically ill who are taking bed space that should be used for those acutely ill. This building would have facilities for that par- ticular kind of care. "From the hospital standpoint, the hospitals are not in a position to take care of chronics—there are too many who are acutely ill—too many emergency cases have to wait because the beds are tied up with 114 chronics and convalescents. These beds should be released for those who need them. How we are going to do it, I don't know. “So far as the home is concerned, those admitted must be in fairly good health, but they don't stay that way. They become chronics and we have to take care of that kind of patient. “Now then, we have a lot of folks not in either hospitals or homes that require care, and those are the ones we are concerned with. It seems to me that in public institutions we should provide for that par- ticular situation. From what I have heard discussed here, I can't help but feel that in a city like Chicago we should provide facilities for car- ing for chronic illness and research into the causes of these ailments, especially in the field of geriatrics which today is in its infancy. Thirty or forty years ago the field of pediatrics was in its infancy but today is a well-established field. We have to give lots of study to geriatrics and the best place would be around a medical center. I feel that this should be near the County Hospital or the Illinois Research Hospital so that some real work could be done on it and at the same time provide for a great many who need care. “There are many, many institutions taking over care of chronics by installing infirmaries. For instance, the Baptist Home in Maywood and the Swedish Baptist Home out in Morgan Park, and some others. Many of them are giving this care through agencies, plus trying to give them something to do to keep them mentally active. “It would be a tremendous help to have a building program. This problem has been neglected because of the fact that we have not seen very much of it, but it is the future that we have to look out for." Sister Evangeline, Chester Superior St. Ann's Home Public Hearing, Carbondale, August 7, 1946 “We have a 34-bed institution at St. Ann's Home in Chester. We accept only such persons who are up and about at the time they enter our Home. However, it is my opinion that nearly all aged persons re- quire at least some nursing care, even if they are not completely bed- fast. Applications for admission far exceed the number we can accept. In 1945, we admitted four out of 159 applications. In 1946, the dis- proportion between the two figures will be even greater," 115 Need for Facilities for the Chronically 111 Dr. David E. Lindstrom, Urbana Professor of Rural Sociology College of Agriculture University of Illinois Public Hearing, Urbana, May 8, 1946 "I am hopeful that the Commission won't overlook the chroni- cally sick in rural areas. Chronic illness is higher in rural areas than in urban areas. . . Therefore, I assume you are going to take full cog- nizance of that kind of treatment which is inadequate, or almost com- pletely lacking, in some rural areas, . . I may add that in these areas are many old people who are chronically ill and try to get along on farms or in little villages not understanding that anything can be done for them. That is the general attitude of the rural sick. . . "Now, if I am correct, you are looking for a way of caring for such people. This has to be given to them as something they can pay for. It must be clear that it is not a charity. Many of these people feel that if they go to an agency they are lowering themselves in the eyes of their fellow men. I think something needs to be done to overcome that mistaken idea. I think reports should be submitted for the benefit of these people showing what facilities are available and that they can be purchased, and try to see if we can erase this feeling that prevails in rural areas." C. D. Nobles, M.D., Anna Superintendent, Anna State Hospital Public Hearing, Carbondale, August 7, 1946 “There is almost a daily call to Anna State Hospital from some one asking how they can care for some individual who is ill, whether or not it is an individual of 15 or 90 or 90 years of age. There are many people in the Anna State Hospital who would not need to be there if they could find a nursing home. . . “There is a possibility, to my way of thinking, that many of the poorer counties may have to go together and build modern homes that would house quite a number of people. You can secure in this day and age in Southern Illinois plenty of attendant help." Berry V. Rife, M.D., Anna President, Union County Medical Society Public Hearing, Carbondale, August 7, 1946 “The State Hospital certainly isn't the place for the chronically ill. We need a place for them. We have some 16 or 90 in our county we can't take care of. We have one nursing home and they have quite 116 a number who need that kind of care for heart disease, arteriosclerosis, etc. We have a lot who will live a long time and will get by, but they don’t get the proper care. They need a place with proper housing. A good many could be up and around but they need that kind of a place. We have no facilities.” N. O. Gunderson, M.D., Rockford Rockford Commissioner of Health Public Hearing, Rockford, February 14, 1947 "As far as the Rockford area is concerned it appears that the chronically ill need to be cared for locally and not sent to district or state institutions, should these latter be considered in drafting new legislations. "Caring for these individuals locally, however, requires an envi- ronment, (if the building, fire, electrical, plumbing, and health codes are to be complied with) that cannot be met with the money allocated for this purpose at the present time. "Evidence of this fact is exemplified in the records on file of the City Department of Public Health, covering the official, semiofficial, and private institutions, and homes where the chronically ill are housed in the Rockford area at the present, as shown on this chart,1 which is specifically made a part of this report. "Nursing care of the chronically ill likewise needs to be met in terms of qualified personnel, which again increases the cost care per individual, as does the medical care, which should be on the basis of the "patient’s free choice of physician,’ which is not too difficult to arrange. "Rockford citizens appreciate the courtesy extended by coming to this area to get first-hand information confronting us in the proper sym- pathetic, individual care of the chronically ill.” Mrs. Alice M. Gleason, Rockford Superintendent, Winnebago County Department of Public Assistance Illinois Public Aid Commission Public Hearing, Rockford, February 14, 1947 "I am inclined to agree with Dr. Gunderson that we do have a problem here in providing care for the chronically ill. We have local nursing homes, private nursing homes, and at the present time we have 30 patients in fC Ward at the county hospital. We have 12 patients in the county hospital at regular hospital rates. We have 24 patients who could be cared for in a nursing home if facilities were available. 1See chart on p. 64 of text of this report. 117 One of the greatest problems is to convince the individual that he should leave his home and family and go into a nursing home some distance away. "We have 52 recipients of assistance living in the community whose health is such that they should have some help. Now, in addi- tion to that, there are some who are being cared for in the hospital proper who could be cared for adequately in a nursing home, but are not because of lack of facilities. Then, there are 25 who should have some kind of convalescent care. If we had some means of caring for these people who could be placed either in the county or a private hos- pital until such time as they had regained their health sufficiently to be placed in a home for the chronic or convalescent, we could then begin to expand our facilities for care of the acutely ill people. "We are being pushed day after day to find a place for someone but there are no facilities available. This is a real problem which we are facing in our department every day in the week, and our visitors are constantly on the spot in an attempt to work out a plan. It's a bad situation and the visitor must carry the responsibility for it.” Mr. William Jordan, Murphysboro Superintendent, Jackson County Department of Public Assistance Illinois Public Aid Commission Public Hearing, Carbondale, August 7, 1946 "We have a number of cases in Jackson County. They are getting by because friends or relatives are taking time to care for them. There is quite a number of these cases. When they get so bad that friends or relatives are unable to care for them, we put them in the hospital. If we could put them in a home for chronically ill, we could give them care within the range allowable made for such care and release the limited general hospital beds, which are needed for emergent cases. A county institution will really be a God-send to this county. It will re- lieve most conditions in every sense of the word.” Mr. R. W. England, Mounds Chairman Pulaski County Board of Commissioners Public Hearing, Carbondale, August 7, 1946 "I came here to learn. We don't have any facilities in our county and if you would ask us just how we get along I doubt if we could answer. We do have chronically ill and are badly in need of facilities. Just what can be done I am not in a position to say. "We would be willing to join with other counties as we are rather 118 poor now. We are hardly able to set up and maintain our own institu- tion. I would suggest that two, three, or four counties go together and build a hospital. It is just impossible to take care of these people with- out some kind of a building plan. They will just lay there and suffer.” M. L. Hartman, M.D., Belvidere Chairman, Boone County Medical Advisory Committee President, Boone County Medical Society Public Hearing, Rockford, February 14, 1947 "I believe the Sister from St. Joseph's Hospital (Belvidere) has made our problem clear. As she has told you, when a doctor comes to the hospital with a surgical patient, the hospital must have room for that patient. I believe our problem is a local one and that it is up to us to iron it out.” David E. James, M.D., Belvidere Public Hearing, Rockford, February 14, 1947 "I am from Boone County. We have had quite a problem over there on many occasions in obtaining hospitalization for patients. In many instances we have had to turn away other patients in favor of emergency cases because of lack of bed space. "At the time of the meeting of our Medical Board we discussed this problem and passed a resolution that the Board of Supervisors turn our county home into a convalescent or nursing home. This has not as yet been presented to the Board but we feel as though it would satisfy the definite need in our county . . . The patients have got to be taken care of some way. We have to make some arrangements. In the future we had in mind not only handling old age pension recipients, but mak- ing available facilities for all people not on old age assistance.” The Rt. Rev. Monsignor Albert R. Zuroweste, East St. Louis Diocesan Director of Charities, Belleville Diocese Public Hearing, Carbondale, August 7, 1946 "Most of our calls are into homes of people who are chronically ill and who cannot get into the hospitals because they are too crowded. Some may have been patients in a hospital for a time, but they were moved out to make room for someone else. We do have some older men and women who are chronically ill. "We have had quite a few calls from brothers, sisters, or children of chronic invalids asking us to give them some information as to where they can put these patients. The hospitals and the institutions are too crowded. My only answer is, ‘I don't know.' ” 119 General Hospital Problems in Caring for the Chronically 111 The Rev. John W. Barrett, Chicago Director, Catholic Hospitals, Archdiocese of Chicago; Chairman of Committee on Legislation and Governmental Relations, Illinois Hospital Association Consultants" Meeting, Chicago, September 7, 1946 “I have listened with a great deal of interest and I cannot help but think that the basic answer to the problem might be what a friend of mine answers when asked how he is—There is nothing wrong with me that money won’t cure." I think that providing adequate beds for the chronically ill is primarily one of money, certainly that is the situ- ation here in Chicago. “I would like to observe, too, that it is eminently important that this Commission and the Hospital Survey Committee work together on the application of Public Law 775 in Illinois. This Federal law enacted by the 79th Congress will allocate next year $1,750,000 to Illinois for hospital construction. would like to answer in so far as I can the challenge to the col- lective thinking of the Illinois Hospital Association with regard to care of the chronically ill in general hospitals. It is my judgment that hos- pital people are tending more and more to think that long-term illnesses of old age amenable to therapy should be treated in general hospitals. There is, of course, a lack of beds and the problem of how to get more. Until such time as general hospitals can spend—it all goes back to money—we must think in terms of other facilities for long-term or chronic cases. "I am not too familiar with the trend of thinking on this problem among medical people, but obviously hospital administrators are di- rected and influenced by trends in the medical profession. I am sure that hospitals will become increasingly interested in therapy of long- term cases as more and more medical men become interested in the field of geriatrics and look to the general hospitals to provide modern methods for treatment. Td like to get back to this idea of money—The Illinois Public Aid Commission and the State Department of Public Health have taken a step forward in endeavoring to help hospitals in the State develop facilities for the care of the chronically ill. These agencies are to be congratulated. I am sure that the members of the Illinois Hospital As- sociation which I represent here tonight will be willing in every way possible to assist in the study this Commission is making. There is scarcely a general hospital in Illinois that isn’t struggling with this prob- lem of long-term illness. How much the enactment of Public Law 775 120 helps this situation remains to be seen. May I conclude by referring to my opening observation that financing the facilities for adequate care of the chronically ill is one of our primary problems.” Col. Edward T. Thompson, Chicago Director of Medical Care Chicago-Cook County Health Survey Public Hearing, Chicago, July 11, 1946 “The Chicago-Cook County Health Survey realizes that chronic illness is the number one health problem of this community. We are surveying the entire field and we hope to come out with a report which will have some bearing on the things you are discussing today. “I would like to supplement something Mr. Lyons said. He has made the statement, and correctly so, that the community is not in a position to take care of acutely ill. The survey while not completed is definitely bearing that out. “I would like to say that a survey conducted in New York City several months ago showed that about fourteen per cent of all the beds in the hospitals were devoted to taking care of chronically ill. While I don’t know the exact figures for Chicago, my impression is that about ten per cent of the beds are being used to care for chronics. The ques- tion has been asked of all hospitals: cHow many beds in your hospital at the present time are occupied by patients who could better be taken care of in an institution for long-time illnesses?’ From answers received I would say that at least ten per cent are devoted to the care of chron- ically ill.” Mr. Leo M. Lyons, Chicago Director, St. Luke’s Hospital Public Hearing, Chicago, July 11, 1946 "I have only a few comments to make which, in all probability, are repetitions of this matter by earlier speakers. “Certainly in state-wide planning we must be sure to include in our consideration all groups—the State Medical Society, Chicago Medi- cal Society, Illinois Hospital Association, Chicago Hospital Council, State Nursing Association and the Visiting Nurse Association, all of which will provide manpower in the handling of all cases. “We should also consider whether people should be isolated, des- ignated as chronically ill and cared for in separate buildings, or whether care should be provided in general hospital programs. I am one who believes that they should be cared for in a general hospital. “In Chicago there are not sufficient beds for the acutely ill; there- fore, whether it be in a wing, or in a ward, where possible, provision 121 should be made in order that duplication of facilities be kept at a minimum. "The State Hospital Survey should point out the weaknesses of our present facilities, and should be the basis of a building program so that the needs of the people can be met where the people are. "I am of the opinion these needs should be provided so that pa- tients can be visited with a minimum of inconvenience. This means locating facilities accessible to friends and relatives. "At present there is no planned program for the care of the chron- ically ill, and general hospitals have made no concerted effort in this direction due to the pressure for beds for the acutely ill.” Mr. I. S. Loewenberg, Chicago Chairman, Council for the Aged and Chronic Sick Jewish Charities of Chicago Public Hearing, Chicago, July 11, 1946 "The Jewish Charities of Chicago has a Council on the Care of the Aged and Chronic Sick which is a co-operative organization of agencies in the Jewish community which deal with the problems of old age and chronic illnesses; the Home for Aged Jews, Orthodox Jewish Home for the Aged, and The Jewish Social Service Bureau having pri- mary responsibility for the care of old people; Michael Reese and Mt, Sinai Hospitals concerned with chronic illnesses; the Jewish community centers interested in leisure-time activities. The Council provides a channel for joint thinking and action towards the goal of serving the needs of the Jewish community. "The Jewish Charities, working together with the Council on the Care of the Aged and Chronic Sick, has formulated a definitive pro- gram for the care of the chronic sick in the Jewish community. In or- der to integrate all of the facilities it was decided that a full-time Medi- cal Director for the chronic sick in the Jewish community shall be em- ployed. In this way not only would the medical staffs working in the different facilities be interrelated, but also stimulus would be given to a comprehensive research program. "The chronically ill person requiring active medical care would be served in a hospital facility. This would include service for (1) pa- tients for whom no therapeutic aid is possible but who require the type of nursing which can best be given in a well-equipped hospital and (2) for patients in the terminal stages of disease who cannot be cared for elsewhere. It is intended that each hospital have a separate unit of approximately 100 beds set apart either in the hospital proper or in a separate building in close proximity to the hospital for use of the chronic sick patients. 122 “The two Jewish old people’s homes will care for the custodial patients who require institutional care in homelike surroundings, nurs- ing services, religious, recreational, and social activities with a mini- mum of medical care. Each of the homes will provide facilities to care for approximately 65 to 75 custodial patients. “There will be a separate Outpatient Clinic in association with the chronic sick hospital services to which ambulatory patients may be referred for follow-up care and to which other patients not requiring hospital care may be referred. "It is also intended that a more adequate home medical service be developed by The Jewish Social Service Bureau under hospital aus- pices; also, care of the custodial patients in the community either through housekeeping service or boarding house facilities. “We realize that our program can only care for a very small por- tion of the chronic sick in the community and that tax-supported agen- cies would need to carry the major responsibility for care of the chronic sick person. We would strongly urge, therefore, that a new chronic sick hospital be built by the State, preferably on the hospital campus on the West side of Chicago. This new hospital should be of sufficient capacity to adequately care for the chronic sick in our community.” Mr. Max Hoagland, Champaign Superintendent, Burnham City Hospital Public Hearing, Urbana, May 8,1946 “Our beds are inadequate to take care of emergency, critically ill, and surgical cases without thinking of taking care of the chronically ill patients. We need a convalescent hospital right now of at least 150 beds. With good co-operation from the nurses and doctors we could transfer such patients from the general hospital. The logical course would be for persons 80 years old with a fractured hip which would need a pin or some surgery to be brought to a hospital such as ours, and when the patient becomes a convalescent transferred to a nursing home which we do not have. “We have 13 who have been there more than 45 days. This is 10 per cent of our census today. They could be in one of those nursing homes providing convalescent care. Some of these are people of means. I don’t think we have any long-term patients who are old age pension recipients. If we did not work at getting that type of patient out, we would have our hospital 50 per cent filled with them all the time. “My personal opinion is that in the cities of Champaign and Ur- bana we need at least 150 more general hospital beds, and an addi- tional 100 beds for long-term patients; so that our rate of occupancy 123 would approximate 80 per cent instead of the 105 per cent now expe- rienced, with some people not yet receiving needed hospitalization.” Sister M. Demetria, Belvidere Accountant, St. Joseph's Hospital Public Hearing, Rockford, February 14, 1947 "Our problem is that we do not have the room in our hospital to care properly for chronically ill patients. We would be only too gladf to take them if we had the room. We have only a 55-bed hospital and we feel that we are not able to care for chronically ill. When a doctor calls in and tells us he is sending in a surgical case, we must absolutely have a bed for that patient. "Most of the old age assistance patients will require two or three months' stay. That is taking up a lot of inpatient days that we might use for surgical and medical cases that do not require so much time. I feel that in Boone County we have a very great need for good nursing and old people homes to take care of the chronically ill, rather than having them take up space and time in general hospital.” Mr. Otto R. Schultz, Danville Credit Manager Lakeview Hospital Public Hearing, Danville, May 8, 1946 "It is the opinion of our Board of Directors that chronically ill pa- tients should not be cared for in a general hospital. The available beds are needed for acute cases. There should be some provision made for the care of these patients either as an adjunct to the hospital or by the County or private sources. These patients are not happy in the general hospital nor do they need the type of nursing care offered.” Monsignor F. Witte, Ruma General Manager of Hospitals for Sisters Adorers of the Most Precious Blood Public Hearing, Carbondale, August 7, 1946 "At the present time we are planning on building a $400,000 ad- dition to the hospital. Mr. Hilliard has asked us to consider the advis- ability of creating facilities for just the people we are discussing. I can assure Dr. Cross and Mr. Hilliard that we intend to have it in operation by March or April of 1948. There is a great need for care of this kind.” 124 County Homes Mr. Rix A. Sisson, De Kalb Superintendent, De Kalb County Home Public Hearing, Rockford, February 14, 1947 “We have converted our old county home. Our building was in need of a little repair and work, and I found out that after inspections were made, and through the co-operation of the Board, it wasn’t such a difficult matter to get it set up and run. Now we have, I believe, 31 getting pensions who are paying their own way. Right now, our per capita cost is $60.00 a month. We have had to stretch that $60.00 per month over repairs due to depreciation, and then we did a little redec- orating and things like that. We have practical nurses in our county home. We have used a county doctor, but he was quite an elderly man and had to give up the work. We then discontinued that practice and call any doctor that is available or any doctor the patient might want.” Mr. George W. Brown, Rockford Overseer of the Poor, Town of Owen, Winnebago County; Chairman, Farm Home Committee Public Hearing, Rockford, February 14, 1947 “I am a member of the Board of Supervisors and Chairman of the Farm Home Committee. I think that for some time back we have been reading the handwriting on the wall. The people from the local office are all the time asking us for more room in the convalescent ward. With that in mind, we are at the present time having an architect draw plans that will give us 120 more beds. That will mean a bond issue for Winnebago County, and we could use some funds from the State to re- lieve that condition we have at the county hospital. We have at the county hospital six or seven graduate nurses and about six or seven practical nurses. Every bed is full and people are in the halls and it is impossible to take in any more patients. We are just doing all we can and we are trying to do a good job and take care of them.” Mr. F. E. Beck, Harvard Chairman, McHenry County Board of Supervisors Public Hearing, Rockford, February 14, 1947 “Our experience in McHenry County is probably different from that of the State as a whole because we have a plant which has been adequate for the county up to the present time and we are able to fi- nance it satisfactorily. We are practically up to capacity. Two floors are used as a home and one floor is used as a hospital for the chroni- cally ill. “There was some mention of nursing staff in the earlier discussion. 125 We have one registered nurse at the head of the institution. During the last few years we couldn't find enough registered nurses to staff the place, but with the one registered nurse, we have done very well with the practical nurses under the supervision of the one registered nurse. We had a county physician up until a few years ago and then we dis- pensed with him. We have found it more satisfactory to let the institu- tion be open to all physicians. We find it more practical to let the pa- tient choose his own physician and he attends him at our county home. "This question of paying patients—we adopted a policy sometime ago that people who were able to pay for part of the medical care and unable to pay for all of it, might go there and pay a fee which we fixed at $1.00 a day. We had to dispense with that because we found too many people who wanted to get in on the cheaper rate—far more than we could handle. There were too many people who could afford to pay for all the care but who wanted to get into the county institution because they could do it more cheaply. We dispensed with that. We would have the same problem if we admitted people receiving old age pensions ... "I don't know whether it would be practical to work out a district plan. More than one county could be included in a district for the use of a nursing home or a T.B. Sanatorium. However, I do maintain that the legislature should leave the final authority to the local people .. Mr. A. E. Hawn, Oregon Overseer of the Poor, Town of Oregon, Ogle County Public Hearing, Rockford, February 14, 1947 "For some reason or other at a meeting over a year ago the Board turned the question of conversion over to the county home committee and they never really have adopted it. They seem to be very much scared about whether they would lose control of the home. The county home has gone along and done a good job. They have made many im- provements and are considering the building of a disposal station. We have been approved by the Fire Marshal... "A great many people, as long as they arc able to get around and care for themselves to a certain degree, can be taken in private homes and boarding houses. But as soon as they become a care, they are turned out again and there is no place we have to put them, and the only thing we can do is put pressure on the county home. "We have met with a good many committees on the plan, and many are afraid that if we say we will accept, we will lose the county farm. During the last six or seven months we have done a good many of the things that have been recommended and we are going to continue to do them. I will say that there are a great many things we could do if 126 we received some assistance from the State. I am not hostile to the pro- gram as long as the operating authority is being left with the Board of Supervisors/1 Mr. L. E. Modglin, Ava Overseer of the Poor, Town of Ora, Jackson County Public Hearing, Rockford, February 14, 1947 "I am on the committee which has started to reconvert our county home, a splendid fire-proof building that does credit to the State of Illinois. But it had been poorly kept, and until recently had been just a home for 'paupers/ as we called them. "When I came here the institution cared for five, shall I say 'pau- pers1? You would, if you saw the institution as I saw it when I first came on the Board. Well, it wasn't kept up-to-date. It wasn't kept well. It had been neglected. We redecorated and painted. It still lacks a few of the comforts and services which we hope to provide. If you could see the home at its best, it is a very inviting place. If we couldn't make it so, I should worry about my old age, about having a decent and beautiful place to go .. /' Representative W. R. Walker, Danville State Representative, District T1 Public Hearing, Danville, May 9, 1946 ''I think the County Board of Supervisors feel a little independent. They don't want any help from the State or Federal Governments un- less they are going to retain control of the operation. There might be a time to come when they would need some help. I think it would be received only if there wasn't any supervision by the State or Federal Government and they would still maintain control over the operation of the institution/' Mr. N. T. Paulson, Chicago County Home Consultant Illinois Public Aid Commission Public Hearing, Urbana, May 8, 1946 "In rural areas we have found exceptionally active interest in the county homes on the part of community organizations. For example, in Menard County, the County Farm Bureau has undertaken the com- plete furnishing of two rooms. The various Kiwanis, Rotary, and church clubs have also furnished rooms completely or have supplied other essential equipment and furnishings. Every doctor in the county has visited the institution and all have a keen interest in the develop- ment of the program. One doctor who visited the Home for the first time to examine a patient was so favorably impressed that he made 127 arrangements for one of his regular patients to be accepted for care. On a later visit he brought out a wheel chair which he had bought for his patient. “One of the local newspapers sponsored a contest to get a name for the institution as remote as possible from anything which might suggest a "poor farm' or an almshouse. They offered a small prize of $5.00 and ran the contest for two weeks. In that time 200 names were submitted by residents of Menard County and by former residents of the county in ten other states besides Illinois. The woman who selected the winning name "Sunny Acres/ was from Ohio. She returned her $5.00 prize with the request that it be used to buy something for the home.” Mrs. Margaret Tobin, Urbana Champaign County Family Service Bureau Public Hearing, Urbana, May 8, 1946 ""As a family social worker, I look at the program of changing over the county homes with mixed feelings. Because of the severe hous- ing shortage our organization has been endeavoring to find homes for people. We tried to secure space in the county hospital but were told it was full of chronically ill. That is how severe our housing shortage is. ""Several of the people who have come to our agency regarding resources for care are not necessarily on old age pension. They ask, "May I go to that county nursing home for care at the same rate as an old age assistance recipient"? There are many who are not 65 years of age but who need such a resource. ""I think this whole conversion program is something to be watched very closely because I think the approach is easy but the continued surveillance of the community will be necessary if the program is to be successful. ""Another point I would like to mention is that brought out by Dr. Lindstrom that there are many people who still look at these homes as almshouses and "poor farms." I am glad to see some effort has been made to eliminate this connotation. ""Another point which Mr. Hilliard mentioned is the matter of licensing nursing homes. This seems to be very important to me. There are many places needed—and they should be good—to help the old age recipient or similar needful persons by taking him in and giving him care. There are many families unhappy because of an elderly per- son who is chronically ill and in need of such care. Their recourse to such homes is certainly growing. ""I don"t have any questions about what has been done. I only want to say that the efforts being made here are grand but we must 128 keep on practicing these things. It is not enough that the program is good; it must keep up that way/" Nursing Problems Mrs. Madeline Roessler, Chicago Chairman, Cook County Health Department Consultant's Meeting, Chicago, September 7, 1946 “... Out of the classifications of chronic illness the involuntary case is the most difficult to manage. These sick people are helpless and need more nursing care than other types of chronically ill. The un- tidy case is also difficult and needs close supervision. These patients have very careless personal habits and create problems of nursing care, hospital personnel and equipment. “As I have listened to the discussion on providing nursing home and hospital care in the community, I have been thinking that if more of these types of patients could be cared for adequately in their own homes, the problem would be less serious. “Of course, in the nursing home some care is provided by gradu- ate nurses and the care of this type of patient is a real challenge to the nursing profession. I do not understand how these persons in charge of operating nursing homes can profit with the cost of personnel and care of patient. They are not making money and I do not see how they can give adequate standard care or are financially able to provide the necessary needs to patients. “The nurse in the community has a challenge also. I believe that if provisions were made for more adequate personnel to the health de- partments, a plan could be devised to provide supervision of care in the patients' own homes. Provisions have been made for child care, tuberculosis, communicable disease and crippled children. The chronic invalid is always the last to be given consideration and the problem has not been met in any way to date. “My suggestion would be to meet with representatives from the various nursing organizations, State and local, the hospitals and the Public Aid Commission to plan a solution.” Miss Ann Trutter, R.N., Springfield Director Public Health Nursing and Tuberculosis Association of Sangamon County Public Hearing, Springfiield, October 10, 1946 “Every nursing association usually carries a long list of chroni- cally ill patients whom it tries to care for in their own homes. That is the 129 situation here. We have many such cases. Some of them have been under our care for a period of eight years and some a little longer. "Now, the care of these people does not necessarily require skilled nursing service; neither does it require any definite plan for health edu- cation. It does, however, require a little feeling of sympathy and un- derstanding on the part of the nurses who perform this feat day after day. We find too often that there is a feeling of insecurity on the part of some of these people into whose homes we go. This may be due to a crowded situation or the economic condition or of older adults liv- ing with younger people where there is a conflict of ideas, etc. "Aside from the nursing care we are very often baffled as to what to do in some cases where the chronic illness extends over a long period of time. We feel definitely that we would welcome any plan that would help us to be able to give these individuals the type of care and service that would make their remaining years comfortable. At the present time we have 32 patients, all in their own homes. The person who has been cared for the longest is one who has been paralyzed for six years." Mrs. Florence Tait, Rockford Manager, Tait Nursing Home Public Hearing, Rockford, February 14, 1947 "I have both trained and practical nurses in my nursing home, and while I think it is well to have a trained nurse at the head, the practical nurses are quite capable. They are usually middle-aged ex- perienced people and better qualified to do the work than the younger nurses because they can use their judgment.. Comments by Welfare Workers Mr. John F. Ardner, Urbana Executive Secretary Champaign Council of Social Agencies Public Hearing, Urbana, May 8, 1946 "From 1918 to 1938, as a nation, we shelved the aged. With the war we placed them back into industry and into agriculture. Now that the war is over, what are we going to do with them? I am referring to persons over 50, both men and women. If they can live socially useful lives, if we can gear them into our peace economy, the number of hos- pital beds required for their care will not be as great as if we again shelve them. Already there is a trend for our personnel departments to be concerned in the main with employment of persons under 45. What we do with the aged from now on will largely determine, in my opinion, the need for facilities for the chronically ill." 130 Dr. Marietta Stevenson, Urbana Director of Graduate Curriculum in Social Welfare Administration University of Illinois Public Hearing, Urbana, May 8, 1946 “It seems to me very proper that the State have supervision and control over the standards and fiscal set-up of county homes and that adequate supervision be exercised over all types of service available to those in the institutions .,. “In New York, the New York City Welfare Committee concluded that at least one third of the group requiring hospital care are chroni- cally ill. They emphasize the fact that there is great need for more intensive study of this problem to provide care for chronically ill else- where in order to make room in hospitals for those emergency cases and acutely ill, most of whom need major operations. “They point out that chronic illness is on the increase partly be- cause our resistance is low because there is more strain in living. Over half of the people who needed care were under 45, which is rather sur- prising, and seventy per cent were under 55—so that chronic illness isn't simply a disease of old age. “Another authority is the Texas Survey which pointed out that most chronic illness occurs in low income groups. Naturally that would be the case, and it is more difficult to provide care for these groups." Mrs. Florence I. Hosch, Urbana Associate Professor in Social Welfare Administration, University of Illinois Public Hearing, Urbana, May 8, 1946 “What I have to say may seem academic but I think maybe the doctors here will agree. We have been very enthusiastic about the pos- sibility of institutions for the chronically ill and are holding very high hopes for the development of this new program. The illustration of Menard County shows what can be done. The important thing is that we keep it up. All too often after the first glamour of the undertaking wears off we sink into a routine and let it deteriorate. I would like to see the Commission and the State of Illinois do something in the way of research in this field of the chronically ill. We are going to meet this problem more and more in the future and we are going to have more and more people applying for care. I think prevention is the key word. “There is one other thing I should like to mention and that is the problem of eligibility. We have to determine at what level of income persons can afford to pay. “I would like to stress for the record that I hope there will be 131 proper supervision in areas where the Illinois Public Aid Commission does not reach. I hope that we will be able to encourage such care in places not now under its jurisdiction for all persons including those under 65 years of age.” 132 SECTION III FROM A PATIENT’S VIEWPOINT While it is assumed that health and welfare agencies, physicians, nurses, and hospital administrators must necessarily have major roles to play in the development of sound planning for the chronically ill, it has seldom occurred to students of the problem that persons who are themselves severely afflicted might have suggestions of particular ap- plicability and significance. In the November and December 1945 and the January 1946 is- sues of Jhe "Modern Hospital there appeared a series of three articles on chronic illness written "from the patient’s viewpoint” by Miss Eleanor McClurkin of Aledo, Illinois (Mercer County). In a letter dated Jan- uary 25, 1946 to Raymond M. Hilliard, Secretary of this Commission, Miss McClurkin, who helped organize the Illinois Wing of the Na- tional Shut-In Society, wrote: "Ultimately I hope to acquire the skill necessary to make the pub- lic more aware of the present plight of the severely handicapped, and I feel that they should have a voice in the plans made for their care. So I am glad to have you use my articles, if the magazine gives its consent. "I don’t know what personal details will interest your readers. My life has been one of great contrasts: from the active life of a kinder- garten teacher in a social settlement to a hospital ward to fight a losing battle with arthritis. Then from those crowded Chicago streets to a rural village, and several years on the farm. Thus I feel qualified to speak from personal knowledge on handicapped problems, both city and rural. "Economically speaking I’ve had a view from both sides of the fence, too. For I paid up my college loans just in time and passed abruptly from social worker status to a charity patient—thanks to arthritis! "After leaving the hospital I experimented with various home businesses, and finally succeeded in building up a mail-order business in hand-made greeting cards. I am not far up the financial ladder, but I am now able to pay my own bills. "During the twenty-four years I have lived in a wheel chair both my parents died. Depression and bank failure wiped out my savings 133 and family illness often incapacitated those who cared for me. Being completely helpless, I have a personal stake in future plans for the hand- icapped.” Miss McClurkin has made available to this Commission the man- uscript for her three articles in 7he CWodern Hospital. Excerpts are quoted below by permission of Miss McClurkin and the Managing Editor of The Modern Hospital Publishing Company. Facilities in Rural Counties “Many rural counties have co-operative arrangements for sani- tarium care of tuberculous patients. It seems that a practical method of caring for other chronic diseases could be planned on the same basis ... Such a plan for the less spectacular and noncontagious chronic diseases would require more publicity on present needs. It also calls for proof that community health would benefit by establishing centers for care and study of crippling diseases ... A rural health center of this type would serve many community needs. And if adequate grounds were provided many of the patients could help in its maintenance. I am thinking of the possibilities of gardening, poultry and dairy farm- ing, small fruits and orchards, as therapeutic aids in rehabilitation. Many individuals have found these activities possible in spite of crip- pling conditions. There should be further experimentation and demon- stration of these activities as a source of support for disabled rural citizens.” Rehabilitation “Although actual life is not at stake in all chronic diseases, many serious complications and crippled conditions could be avoided by a new conception of the hospital as an educational institution. Planned primarily to study chronic disease, such a hospital would serve both medical research and the patient... Army hospitals are working out new techniques in rehabilitation of service men. They find it best to begin reorienting the patient at once. Light exercise, mental occupa- tion, recreation, begin as soon as possible. All facilities are co-ordinated to re-educate the seriously disabled. Recovery and readjustment to life are greatly hastened by this plan. The civilian patient faces a similar shock and readjustment which frequently is overlooked in treating physical symptoms. Mental attitudes must also be considered. Ade- quate diagnosis is the first essential and the treatment must cover as long a period as necessary in the hospital. But if former living or work- ing conditions are a contributing factor the patient should be prepared for different activities while undergoing treatment. This means a much broader conception of occupational therapy than the present general 134 hospital provides. New skills can be gained which have both thera- peutic and educational value. But mental as well as physical needs must be considered. The patient will co-operate in the more tedious repeti- tive activities for muscle building, if they are fitting him for a useful job later. Co-operation with state employment and rehabilitation agen- cies will be part of the integrated program. With some of the insecurity and worry over loss of job and income removed, the patient should respond faster to treatment." Use of Handicapped Persons in Serving the Chronically 111 "In the hospital which is geared to longer periods of treatment, the staff undoubtedly will develop greater personal interest and a more informal attitude toward patients. It will miss a great opportunity if capable well-educated patients are not enlisted in research projects. Why not use former teachers, social service workers, nurses and their like, who have acquired physical handicaps, to assist busy staff mem- bers? They could aid in counseling, occupational therapy, compiling statistics, etc. If this seems visionary, consider the demonstrations which are arranged in veterans" facilities by amputees, the blind, and other handicapped persons, as morale builders. It would encourage the educated patient to feel that there were openings for his previous training. Frustrated problem patients might disclose their worries to one who had been 'through the mill" when they distrust an able-bodied counselor. *Ward life" often discloses this tendency. I have seen unco- operative patients aroused by a 'bull session" or by thoughtful advice from a more experienced roommate."" Physiotherapy "One of the crying needs of the homebound patient today is for information and guidance in the selection of appliances for home exer- cise. Few of us ever see a physiotherapist and must devise our own gadgets. Commercial appliances often need special adaptation or are financially out of reach. The physiotherapy department could render valuable aid in testing appliances and in adapting simple devices to home conditions. Clinical demonstrations for doctors and nurses would enlarge this service for slight injuries treated in the home."" Homes for the Ambulatory Handicapped "... consider the more active section—the ambulatory who are now employed, or could be if transportation and living facilities per- mitted. Even during the present man power shortage there are many un- employed who could be usefully occupied. Employed handicaps living in rooming houses, students wishing further education in city schools and colleges, the newly rehabilitated waiting placement on jobs would 135 all welcome a location where their needs had been considered. Since nursing care and medical treatment are not required, the building and its location are most important... it must be near many employment opportunities where real estate values are high. On the the other hand, the individuals of this class pride themselves on their financial inde- pendence so that large maintenance endowments would be unnecessary. In fact, there is undoubtedly enough business and executive experience among them to run a co-operative establishment. Desires they have mentioned point to a combination hotel and club house with recrea- tional opportunities for leisure hours ... The setting need not be ex- travagant. Comfortable, sanitary rooms, or apartments with ramp en- trances and elevator service to prohibit falls, community dining room, recreation rooms and library are essentials. Possibly some plan for group transportation could also be devised/" Homes for the Handicapped Needing Nursing Care ",.. the very nature of their own struggle for independence often makes the ambulatory person overconfident so that he misunderstands his more helpless contemporary. Our second group which really dif- fers only in physical condition from the first has its own desire for in- dependence. Each must work harder for it, in a more circumscribed area. Therefore, I think their need is for an institution developed to give physical care, useful employment, and the mental and spiritual and recreational life of normal people. Accepting this basic need for physical care such a home in either city or country surroundings will first provide conveniences for all possible self-help. Lifting devices for bedside and bathroom use, wide doorways and easily opened doors with no threshold for all rooms will make wheel chair navigation easier and also save work for attendants. The routine daily care which is es- sential to good health should not consume too much of the day. There- fore any aids which increase self-help should be utilized. Treatments or periodic checkups should be scheduled in advance not to interfere continually with the primary occupation of the resident of the home/" Need for Privacy "It is assumed that cleanliness and balanced diets are part of any modern institutional plan. So I will not dwell on that aspect here. But let me emphasize the need for private rooms. Several consultants, in such homes or hoping for accommodations in a future one, have stressed the need for privacy in which I heartily concur. For short periods in a hospital the ward has definite advantages. How many normal persons would care to be constantly surrounded by roommates not of their own choosing? And no matter how congenial one's friends, or how 136 gregarious his nature, there is a need for periods of personal privacy. This is particularly true in a permanent location where the individual is encouraged to have a definite aim in life. My hypothetical Home would be permeated by this ideal. An immediate effort would be made to help each new resident find his talent and develop it. Perhaps some of the handicapped members of the home who show aptitudes for leadership could be trained as counselors. Many of the duties of the Home could be done by the more active members. Every possible po- sition should be filled by a handicapped person.” The foregoing suggestions from a citizen of Illinois who knows first-hand what chronic invalidism means should be of wide interest, especially to local governments planning the development of facilities within the local communities. 137 SECTION IV RESEARCH INSTITUTE FOR THE STUDY OF CHRONIC ILLNESS AND GERIATRICS A Proposal By Dr. Andrew C. Ivy, Vice President, University of Illinois The Problem Care of the chronically ill and aged is a vital problem in the State of Illinois. The Governor and General Assembly have officially recog- nized this fact by the appointment of a special commission to make a survey of present and future needs. This body is known as the Com- mission on the Care of Chronically 111 Persons. In addition, The In- stitute of Medicine of the City of Chicago has sponsored a Central Service for the Chronically III under the organization of the Council of Social Agencies of Chicago. The Solution Provision for Custodial Care It is obviously necessary to provide custodial care to meet the existing emergency demand. But this represents only one half of the solution of the problem. It constitutes the emotional and temporizing rather than the well-con- sidered solution of the problem. Provision for Research Research on those diseases which cause chronic illness and pre- mature aging obviously provides the only hope for: 1. Rendering old age more efficient and comfortable, and 2. Decreasing the future tax burden for the custodial care of chroni- cally ill persons by: a. decreasing the number requiring custodial care, and b. decreasing the time that custodial care is required. Relatively little is now known regarding the prevention and man- agement of those diseases which cause prolonged illness. The same is true of factors which may retard aging and render old age more effi- 138 dent. And we cannot afford to ignore the fact that due to our increased knowledge regarding the prevention and management of acute dis- eases the percentage of the population above 45 years of age is rapidly increasing. 7rom the humanitarian viewpoint, time and money should be spent to decrease the incidence of those diseases which disable and which render old age less efficient and enjoyable. from the material viewpoint, it appears to be ill-advised to build more and more institutions and to spend more and more money on the care of the chronically ill, and at the same time to devote nothing to research—to the study of how to prevent and better manage chronic illness. Knowledge regarding the prevention and treatment of chronic illness and how to delay the onset of disabling conditions associated with aging will decrease the need for custodial care and add to the income-producing activities of the individuals of the State and Nation. A Specific Proposal It is proposed to study how to prevent and improve the present methods of treatment of such diseases as arthritis, high blood pressure, hardening of the arteries, kidney diseases, chronic cardiorespiratory diseases, cirrhosis of the liver, and ulcerative colitis. In addition to these diseases, assuming that a desirable co-operat- ing working service could be made available to county homes and to private homes for the aged, the results of the research could be ex- tended to these homes. For example, a co-operative study on senility might be made at Oak Forest, the county home for Cook County or the results of research be applied there. Specifically, it is proposed to create a Research Institute for the Study of Chronic Illness and Geriatrics in the Medical Center Area on Chicago's Near West Side, to be operated by the University of Illinois College of Medicine in connection with the group of special hospitals now attached thereto (the Research and Educational Hos- pital, Eye and Ear Infirmary, Neuropsychiatric Institute, and Institute for Juvenile Research). Creation of such an institute offers the hope that as many as 20 per cent of the causative factors leading to commitment to state in-* stitutions might be obviated. Nowhere in the world is there such an institute. Illinois could well be proud to take the leadership in this field, not only for the sake of leadership, but because it offers the most constructive attack on an ever-increasing menace to the growing percentage of aged in our pop- ulation. 139 Explanatory Details A suitable Research Institute1 would provide beds for 200 pa- tients, an outpatient service for 15,000 patients a year, and suitable facilities for research. Forty patients would be hospitalized on each of five floors. Adjoining each bed area, research facilities in a particular specialty would be provided. For example, 40 patients with essential hypertension or high blood pressure could be housed on one floor. A physician-scientist and two assistants would study methods for controlling this disease. They would work in the research laboratory adjoining their patients on the same floor. The same general arrangement would be followed on each of five floors. The two upper floors would be devoted to research on animals. All the basic and important leads which have advanced medicine in the last century have come directly or indirectly from such studies. In- formation on the effect of diet, exercises, hormones, heredity, and other factors on the longevity of humans can be obtained best by studying, under controlled conditions, the effects of these factors on the longevity and health of animals. Program 1. A Research Institute for Study of Chronic Illness and Geriatrics, 2. Beds for 200 patients. 3. Outpatient services for a maximum load of 15,000 patient visits per year (50 per day). 4. Adjunct services in Radiology, Physical Therapy, Occupational Therapy, and Nutrition. 5. Administrative offices. 6. Research space on each floor adjoining the patient space. 7. Provision for long-term studies of factors which prolong the life of animals. 8. Conference and classroom space. 9. Laundry and power to be secured from central plant not in this building. Other service areas will be included. Expenditure Required A suitable Research Institute to carry on the research and treat- ment described above would require an initial expenditure of $2,500,000 for land, buildings and equipment. Its operation would require an annual expenditure of $950,000. ’See p. 18 of this report for architect’s drawing of the proposed Research Institute. 140 SPACE REQUIRED Ground Floor Area 16,600 S.F. 10 Ft. 166,000 C.F. First Floor Area 16,600 13 215,800 2nd to 8th Floors 7 floors at 12,600 88,200 11 970,200 121,400 S.F. 1,352,000 C.F. AREA OF LAND 16,600 S.F. x 4 (25% coverage) 66,400 S.F. equals 200'x332' CAPITAL COSTS Land 66,400 S.F. at $2.00 $ 132,800 Building 1,352,000 C.F. at $1.55 2,095.600 Equipment 271,600 $2,500,000 ANNUAL COSTS Patients Care (22 at $7.00 per day) $500,000 Building Operation and Maintenance1 100,000 Academic Staff, Administration and Assistants 350,000 $950,000 determined on the basis of 80c per square foot per year: 121,400 square feet totals cost of $100,000. 141 SECTION V MEDICAL SUPERVISION AND CARE IN INSTITUTIONS FOR THE CHRONICALLY ILL Report by The Committee of the Illinois State Medical Society Consult- ant to the Commission on the Care of Chronically 111 Persons. Everett P. Coleman, M.D., Canton (Chairman); Robert S. Berghoff, M.D., Chicago; Harold M. Camp, M.D., Mon- mouth; Harlan A. English, M.D., Danville; Malcolm T. Mac- Eachern, M.D., Chicago; John P. O’Neil, M.D., Chicago; and Walter Stevenson, M.D., Quincy. Introduction Institutions for the chronically ill vary in size and type from the chronic disease hospital to the small private nursing home. The chronic disease hospital should be as well equipped and staffed as the general hospital, and medical supervision and care in such hospitals should be subject to the same medical staff authority found in the general hospital. Other chronic care institutions with which this report is concerned include nursing homes, both private and public, private homes for the aged with infirmary sections, and voluntary institutions for the chroni- cally ill. This entire group of institutions provides custodial or nursing domiciliary care in homelike surroundings. The term "custodial” is used to describe a sheltered or protected environment in which pa- tients may receive the type of nursing care required because of chronic illness, handicaps or infirmity caused by senescence. Medical super- vision of the institution’s treatment program and medical care of the individual patient in order that he may have the full benefit of modern medical science and receive the nursing care best suited to his needs must be provided by qualified physicians. This report outlines those areas in the administration of the institution’s program and the care of the individual patient for which the medical profession should be responsible. Institutions for the chronically ill in Illinois vary in size, progress in program development, proximity to adequate hospital facilities, avail- ability of physicians, and management. Certain general requirements 142 for a medical care program in an institution can be described, however, which, with minor adaptations, would be generally suitable. The committee in the following generally applicable recommenda- tions has kept in mind the need for completeness and continuity of care of institutionalized chronically ill patients. The committee be- lieves that the plan outlined provides minimum requirements for a medical care program in an institution for the chronically ill and that the physician or physicians responsible for the medical direction should enrich the program as time goes on for the purpose of rehabilitating the patients to the fullest extent possible. Such adjuvant services as oc- cupational and recreational therapy, medical social service, and voca- tional rehabilitation would become part of this fuller program. Medical Direction of Institutions for the Chronically 111 The first responsibility of the institution's board and of the medi- cal director, staff, or board is for the care of the patient because of whose needs the institution exists. Efficient business management of the institution, although important, is secondary to consideration of the patient's requirements. In this consideration the medical director of the home has a specialized focus on the patient and is responsible for the quality of the patient's day-by-day treatment through the for- mulation of the over-all medical policies of the institution. General medical direction may be provided according to the size, program, and location of the institution by one or more of the fol- lowing: 1. A full-or part-time paid medical director. 2. An organized medical staff. 3. A medical committee or board representing the local medical soci- ety; such board should, if possible, represent those specialties par- ticularly related to care of the type of patients in the institution. Medical Policies of the Institution The medical director of the institution should establish and carry out general policies with regard to the following: Admission of Patients There should be a review of a patient's medical history before he is admitted. This may, in many instances, require diagnostic examina- tion in a hospital to determine whether the patient has had the full benefit of active medical treatment or whether he should remain in the hospital for a time before admission. In other cases a full report by the attending physician or an examination by the medical director or a member of the board or staff may be sufficient to determine whether the institution can provide the type of care required by the patient. The 143 admission review should be used for classification of the patient with regard to treatment and nursing care and also with regard to his place- ment in the institution. Indiscriminate jumbling together of such pa- tients as senile dements, arthritics, and terminal cancer patients would certainly not add to the comfort or happiness of any group. It should be determined by proper tests that patients to be admitted do not have tuberculosis, are not typhoid carriers, and do not have any other dis- ease which can be transmitted to fellow patients or to the staff of the institution. Periodic Re-examination of Patients Each patient in the institution should have a complete physical examination not less often than once a year even though he is under regular medical care for a particular illness. This will permit a full in- ventory of his physical condition, and will lead to better and more individualized care of the patient. Even among the chronically ill who are so often considered by lay persons to be only "on the downgrade” there are peaks and valleys of physical fitness and sometimes marked and lasting improvement. Medical Treatment of Patients Whenever possible the patient should continue to be attended by his own physician who may call at regular intervals or may visit ir- regularly as needed. It is recognized, however, that some institutions may be located in a community distant from the patient's own home town so that the services of his personal physician are not available to him. Under these circumstances or when the institution is somewhat distant from any town so that all physicians are not able to call, the medical policy may provide for a staff physician to provide necessary treatment. Institutions for the chronically ill should be open to all qual- ified physicians who wish to care for patients there subject to whatever rules and regulations may be established as over-all medical policy. It is not possible to establish standards with regard to the fre- quency of physicians' visits to chronically ill patients since their con- ditions vary so greatly. With suitable medical direction of the institu- tion, however, and adequate and qualified nursing staff a patient in need of a visit from his physician will receive such care. There should be a well-established and understood procedure for obtaining the serv- ices of a physician in an emergency. Discharge of Patients The medical policies of the institution should provide through review of the medical record by the medical director, staff or board for discharge to other facilities of patients who no longer require the particular type of care provided by the institution. Such patients may 144 be found to need general hospital care, state hospital care, tuberculosis sanatorium care or may be able to return to their homes or other living arrangements in the community. Record Keeping An individual record of medical and nursing care should be main- tained for each patient in the institution and should contain the ad- mission report and examinations, periodic examination reports, the physician's orders, the nurse's record, and additional findings by the attending physician. The record system should be simple but complete. If a patient is hospitalized and is to be under the care of a physician other than the one attending him in the institution, a summary of his medical history should be provided the attending physician in the hos- pital. Likewise, when the patient returns from the hospital the institu- tion's medical record should have added to it a report concerning the hospital diagnosis and treatment. Standing Orders and Drugs General medical policy of the institution should provide for in- structions to the nursing staff with regard to standing orders for cer- tain kinds of routine treatment and administration of medication. Ex- cept as provided in standing orders, no treatments or medications should be given to patients by nurses except upon the physician's instructions. Hospital Affiliations Each institution should have an arrangement with one or more nearby hospitals that will accept patients when they require hospital care. Hospitalization should be arranged on the recommendation of a physician. Registration by the American Medical Association It is recommended that institutions for the chronically ill establish standards of medical care acceptable to the American Medical Associa- tion so that they may be registered by the American Medical Associa- tion as related medical institutions. County Nursing Homes The committee believes that it is particularly important for county nursing homes in Illinois operating under the provisions of the Rennick- Laughlin Bills to have competent medical direction of their medical programs. A county board which constitutes the governing board for the county nursing home is made up of elected officials, and is the gov- erning body for all other county affairs. By law the county board is 145 responsible for the administration of the county home, but it must be recognized that members are not selected as are boards of private in- stitutions solely because of their particular interest in and knowledge of the institution's program. Despite this fact many county boards have developed programs that show considerable understanding of the needs of chronically ill persons. This understanding, of itself, should encour- age county boards to arrange for good medical direction. In most counties this could best be provided by an advisory committee repre- senting the county medical society. Although county boards of super- visors are responsible for the creation, maintenance, and administration of county nursing homes, it is entirely within the law for responsibility for medical direction to be delegated to the medical profession, and such delegation assures both the county board and the patient that the best possible care is provided. The committee is not including in this report detailed recommen- dations with regard to Oak Forest Infirmary, the county institution in Cook County, since its size precludes its consideration jointly with the very much smaller downstate county nursing homes. But the com- mittee does wish to point out that Oak Forest's location near Chi- cago with its four Class A medical schools offers unlimited opportunity for development of this particular institution into an actual chronic disease hospital. The committee recommends strongly that the Cook County Board of Commissioners take necessary action to meet the re- quirements of the American Medical Association for intern and resident training so that this institution may affiliate with the Class A medical schools and thereby become able to offer suitable care and treatment to the patients in Oak Forest. Privately Operated Nursing Homes The committee is particularly concerned with medical care in nursing homes that are operated for profit. In such homes there is no one to take responsibility for medical supervision unless the proprietor retains a physician, which is done far too seldom, nor is there an ad- ministrative board to safeguard the patient from possible exploitation or neglect. While most nursing home proprietors give care to the best of their ability, there are some who require considerable supervision. The committee recognizes that the State Department of Public Health through its licensure program has done much to raise standards. The committee recommends, however, that as the licensure program con- tinues, particular attention be given by the department in accordance with the principles outlined in this report to the quality of medical care in these homes. 146 Construction of New Institutions for the Chronically 111 The great need for additional beds for the chronically ill has in- terested many philanthropic groups in planning for construction of new institutions for the chronically ill. The federal and state funds which will be available for hospital construction under the Hospital Survey and Construction Act (Public Law 715) have also stimulated interest. The committee recommends that in planning for new institu- tions every possible effort be made by planning groups, whether they be private or public, to provide for the closest possible affiliation be- tween the institution and a well-staffed and equipped hospital. Wher- ever possible, consideration should be given to having a joint medical director for both medical institutions or an interlocking medical staff so that the services of specialists and technicians will be readily avail- able. Such affiliation with a general hospital will provide, in addition to better care for patients in institutions for the chronically ill, a greater possibility of screening patients for study as research material. If the State establishes a research institute for the study of chronic disease and geriatrics as has been proposed, plans should be made for referral of patients from institutions and the hospitals with which they are affiliated. It is only through study of chronic disease and the knowledge of prevention and control which will thereby result that the increasing burden of caring for the chronically ill can be lessened. The committee has approved, in principle, the proposal by Dr. Andrew C, Ivy for the development of a Research Institute. 147 SECTION VI PRELIMINARY REPORT OF THE SPECIAL COMMITTEE ON MINIMUM STANDARDS FOR THE CARE OF THE CHRONICALLY ILL By Malcolm T. MacEachern, M.D., (Chairman), Hugo Hul- lerman, M.D., Everett W. Jones, Leo M. Lyons, and Miss Edna Nicholson General Statement Medical facilities for the care of a particular segment of the popu- lation are usually provided when society recognizes that need. Many forward-looking physicians, sociologists, and social workers have been cognizant of the medical and social problems presented by the aging population and have been thinking for years in terms of provisions for the aged and the chronically ill. Recently these thoughts have crystal- lized into definite recommendations for the care of these people and still more recently the governing bodies of a few states have recognized the chronically ill patient as a definite social problem and one that must be met by the concerted action of the state. We believe that society is becoming more and more conscious of the problem in each community. We are all aware that the economic structure of our society has changed. An agrarian society has given way to a highly industrialized society; the large home has been replaced by the small city apartment. Mechanized household equipment and cleaning service by the day or hour have replaced the family servant. There is no room to care for the bedridden chronically ill patient or even the wheel chair patient at home and even if there were, it would be difficult to obtain sufficient household help to carry the extra burden. Along with the change in our economic structure has gone prog- ress in medical science. At the same time that industrialization of so- ciety condemned to the past large dwellings and family servants, med- ical progress advanced the life expectancy from 40 to 65 years. The population as a whole is familiar with the situation through in- ability to obtain admission for old people in homes for the aged and the difficulty in securing adequate care for the chronically ill patient, be he 149 young or old, either in the general hospital, the occasional home for the incurables or the nursing home. Unless provision is made for the care of disorders which afflict the chronically ill, society will have failed in its responsibility for the well-being of a large segment of the population and in addition will have to bear a large financial burden due to lack of foresight in pro- viding treatment which might have rendered many members of society self-supporting. Society is ripe for the establishment of a co-ordinated state-wide system of all types of agencies for the care of the chronically ill. The fact that the Governor of this State has appointed a Commission to study provisions for the care of these patients in the State of Illinois is proof of this. Summary of Current Opinions In establishing standards for institutions caring for the chroni- cally ill it is necessary to define our terms and to decide upon the type of care to be provided. The thinking of current leaders in this field must be considered and factors which must be taken into account critically evaluated be- fore formulating minimum standards for institutions caring for chronic disease patients. There seem to be two main schools of thought regard- ing hospitalization for the chronically ill patient. Dr. Ernst P. Boas, formerly Director of Montefiore Hospital and at present a member of the staff of Mount Sinai Hospital, New York City, the leader of one school, separates the chronic disease patient into three categories: 1. Those in need of active medical care for diagnosis and treatment. 1. Those chiefly in need of skilled nursing care. 3. Those in need of custodial care. He feels, and many agree with him, that the first two classes should be cared for in the chronic disease hospital while for the third class a custodial home affiliated with the chronic disease hospital is sufficient. The chronic disease hospital would provide facilities for di- agnosis and treatment; the custodial home, domiciliary care. Dr. E. M. Bluestone, Director of Montefiore Hospital, New York City, a voluntary hospital for the care of patients with chronic diseases, leader of the other school, contends that the chronic disease patient in need of active medical care should be cared for in the general hospital where all the diagnostic and therapeutic facilities are available. He feels, and again many agree with him, that a duplication of these facilities in a separate hospital for the chronically ill is an unjustifiable expense. There is universal agreement regarding the chronically ill patient 150 in need of active medical care. It is felt that he should not be relegated to a custodial home and whether he is placed in a special hospital for chronic diseases or a general hospital, the same diagnostic and thera- peutic facilities necessary for the care of the acutely ill patient in the general hospital should be available for his care. The trend is away from the special hospital and back to the gen- eral hospital, and it would seem best to think of the care of the chronic disease patient as a part of the function of the general hospital. The advantages to this arrangement are well known to those in the hospital field. Briefly these are economy of operation and the services of a skilled and well-rounded staff. The disadvantages are few compared to the advantages if we consider that the chronic disease patient in need of active medical treatment is generally not in the hospital more than a few weeks or months at a time. Recommendations of the Committee The Committee on Standards recommends that the chronically ill person in need of active medical care be placed in the general hospital and affiliation with a nursing home arranged for patients in need of nursing care only. This institution should be in close proximity to the general hospital although there are already many institutions in exist- ence today that could meet minimum requirements for institutions of this type by affiliation with a general hospital. Location in a suburban or country district should not serve as a deterrent to their approval. Reference here should be made to the situation in the State of Illinois, Many county homes throughout the State have been or are in the process of being converted into nursing homes for the infirm and the chronically ill. This would appear to be a simple solution to the problem of caring for the chronically ill. However, a good many of the county homes will require extensive alterations as well as changes in equipment, personnel, and management before they can meet the mini- mum requirements for nursing homes for the care of chronically ill patients. The Committee recommends that if a survey of county homes es- tablishes the fact that a sufficient number of them could meet minimum requirements as hereinafter laid down, these institutions should be of the nursing home type and the State divided into sections, two or three nursing homes serving a centrally located, approved community or county hospital prepared to care for the chronically ill patient in need of active medical care. Pay or part-pay patients as well as the medically indigent should be admitted to these nursing homes and the proper state-supported 151 agency asked to underwrite the care of the indigent chronically ill in need of active medical care in the voluntary general hospital. Such pay- ment should be based on cost and patterned after the Emergency Ma- ternity and Infant Welfare Care Plan. The Commission on the Care of Chronically 111 Persons has under consideration a proposal for the erection of A Research Institute for the Study of Chronic Illness and Geriatrics in conjunction with the Re- search and Educational Hospitals of the University of Illinois College of Medicine. This is most commendable. Such an institution would stimulate interest in the prevention of chronic disease and in the chronic disease patient. All voluntary and county hospitals should have the privilege of referring interesting and problem cases of chronic illness to the research center. Minimum Standards for Institutions Caring for Chronically 111 Patients 1. Physical Plant—a physical plant adequate in size, construction, and equipment to meet the needs of the patients accepted for care, a. A building free from fire and sanitation hazards with safety and self-help devices to meet the needs peculiar to chronically ill pa- tients, These shall include facilities available to all patients for easily summoning an attendant at any time; handrailings in the corridors; grip bars in the bathrooms, and other rooms used by patients; hanging wash basins for the accommodations of wheel chair patients; water closets with curtains in place of doors; wide doorways without thresholds; wide corridors; elevators large enough to accommodate stretchers and equipped with wide doors and handrailings; ramps leading from the first floor to the ground; etc. b. A sufficient number of solaria, balconies or porches, small day rooms, dining rooms for ambulant and wheel chair patients to- gether with a large hall for recreation, a library, and a storage room for patients" trunks. c. Space sufficient to afford adequate light, ventilation, and reason- able privacy for patients. There should be private, semiprivate, and ward accommodations, the latter not to exceed six beds. These accommodations should include easily accessible storage facilities for patients" clothing and personal possessions in bureaus, closets, lockers or other suitable form. d. Decorations and furnishings of a type consistent with physical needs of the patients and with a homelike, cheerful atmosphere. e. Allotted space, plumbing, and equipment necessary for house- 152 keeping, maintenance, and nursing activities. These should in- clude on each patient floor a serving pantry, a nurses" station, bath- rooms, one or more utility rooms equipped with bedpan flushers and other nursing equipment, janitor closets, and space for stor- ing wheel chairs, walkers, crutches, and other appliances. 2. Cocation—a location readily accessible to the patients it is to serve and to their families and friends; and to the specialized staff and facilities needed in their care, especially physicians, nurses, and gen- eral hospital facilities. Efforts should be made also to provide an at- tractive neighborhood and pleasant surroundings. 3. governing Board—a carefully selected governing board having com- plete authority and final responsibility for the operation of the in- stitution. a. Board members should be selected to include representative, re- sponsible persons in the community with sincere interest in the care of chronically ill people. b. Provision for including, in the formulation of policy and in other activities of the governing board, the particular knowledge of the various specialists directly concerned in the problems of chronic illness and the management of institutions for the care of the sick including medicine, nursing, law, hospital administration, business and finance, public health, social welfare, government, etc. This provision may take the form of membership on the governing board of persons competent in the specialties or of advisory com- mittees working with the board on the special problems. In no in- stance, however, should physicians, nurses, social workers or other persons employed or practicing in the institution or in agen- cies or professional practice working directly with the institution or in competition with it serve as members of the governing board, 4. Organization—clearly stated written constitution, charter, law or similar document setting forth the purpose, scope, duties, responsi- bilities, form of organization, financing, and administrative relation- ships of the institution. a. If the institution is not operated as an integral part of a general hospital, reciprocal relations with a general hospital should be established in order to provide patients with the services of a skilled medical staff and hospital facilities in case of acute illness or in case of the return of an active phase of a chronic disorder. b. Clearly defined, written policies covering the operation of the in- stitution. These policies should be formulated by or with the help of persons competent in the various specialized fields and should be officially defined and adopted by the governing board. They 153 should include, among others, policies governing admission and discharge of patients; medical attention; standing orders and other aspects of nursing care; control of drugs and medications; business management and financing including charges for the care of patients; relationships with the general hospital and other institutions, agencies, and governmental units, c. Admission policies should be developed in conference with rep- resentatives of the affiliated general hospital, and of other medical, public health, and welfare agencies in the community. 5. financing—financing adequate to provide and maintain on a stable basis the plant, furnishing, equipment, supplies, and services needed to meet the standards outlined in this statement. a. Fees charged for care should be maintained at a level which, when added to the institution's other sources of income, if any, are suf- ficient to cover the cost of maintaining and operating the institu- tion. Welfare agencies and government agencies referring indi- gent patients to the institution should be charged the minimum rates established for other low-income patients in the institution. 6. Administration—a competent, well-trained executive officer or ad- ministrator with authority and responsibility to carry out the policies of the institution as authorized by the governing board. a. The administrator must possess executive ability; a knowledge of the fundamentals of institution management including business procedures, administrative organization and relationships; and at least a superficial acquaintance with the problems and general methods of caring for the sick including an ability to work effec- tively with physicians, nurses, and other professional staff. b. In addition to the above qualities the administrator must possess sympathy and understanding of sick and helpless people and must be able to instill the same feeling in those associated with him in the care of such patients. 7. TAedicai Staff—a medical staff adequate in its numbers, qualifica- tions, and organization to assure that there will be good medical su- pervision of all aspects of patient care and that all patients will re- ceive competent medical attention at regularly scheduled times and promptly in emergencies. a. Responsibility for participation in the formulation of medical pol- icy and of other policies of the institution directly affecting the care of the patient should be clearly placed upon an individual physician or a designated committee of physicians. This physician should also be responsible for the application of medical policies 154 and for the quality of medical care provided within the institution. This responsibility may be placed on designated officers of an organized medical staff or on a competent medical director em- ployed by the institution. He should work closely with the medi- cal staffs of the hospital or hospitals referring patients to the in- stitution, preferably through a co-ordinating or advisory commit- tee composed of representatives of these staffs. b. There should be provision for a sufficient number of competent physicians to meet the needs of all patients accepted for care. These needs include, in addition to emergency medical attention, physical examination of all patients at regularly scheduled inter- vals in accordance with a clearly defined policy and procedure. c. The medical staff should include a dentist, a pathologist, a radi- ologist, and a psychiatrist in addition to general practitioners and other recognized specialists. Services of the various specialists may be obtained through the affiliated general hospital; on a part- time or consulting basis; or by special arrangement with approved hospitals, laboratories or practitioners. An inter-locking medical staff with the affiliated general hospital is highly desirable. d. There should be definite provision for obtaining these services of the physician promptly in emergencies. Large institutions or those located in rural areas should have one or more resident physicians. Smaller institutions in more favorable locations may arrange with medical staff members in the immediate vicinity of the institution to handle emergency calls. e. All physicians serving on the medical staff should be graduates of approved medical schools and have served internships and resi- dencies or have equivalent experience. f. Physicians serving on the staff, particularly the medical director or resident physician, should be selected not only on the basis of medical training but also for understanding of the psychic and emotional problems of long-term illness. 8. Adjunct TAedical facilities—adjunct medical facilities sufficient to make available at all times, as needed, laboratory service, physical therapy, occupational therapy, dental care, and emergency treat- ment. An emergency treatment room should be provided in every institution. In large institutions space, equipment, and personnel should be provided in the institution for all of these adjunct services. Smaller institutions may provide them through the affiliated general hospital or by arrangement with approved hospitals, laboratories or practitioners in the community. Provision should be included, under any of these arrangements, for bringing each of these adjunct serv- 155 ices to the bedside when the patient cannot easily be transported to the facilities provided. a. Laboratory facilities should be equipped to do routine urine ex- aminations, blood counts, sedimentation rate determinations, and simple cultures and smears. b. The treatment room should be equipped for superficial physical examinations, dressings, and minor outpatient procedures. All patients acutely ill should be transferred to the affiliated general hospital. c. A physical therapy department should have adequate equipment to carry out treatments prescribed by the medical staff, both resi- dents and consulting. d. The occupational therapy department should be equipped and supplied to provide services for the mental and emotional health of the patients as well as for the restoration of physical function. These might include facilities for music therapy, etc. 9. Auxiliary facilities—auxiliary facilities, including a dietary depart- ment, a social service department, and a recreation department. a. The dietary facilities should include space and equipment for re- frigeration and storage of food; a modern kitchen; serving pan- tries for the preparation of trays for bedridden patients; space allotted and equipped for preparation and serving of special diets; dining rooms for ambulatory and wheel chair patients; and din- ing rooms for employees. b. The social service department should be easily accessible to pa- tients and their families and to the members of the medical staff. c. The recreation department should be so located and equipped that it can provide services to bedridden patients as well as to those who are ambulant; and should provide regularly scheduled activi- ties in which there is active participation by the patients as well as passive entertainment such as movies, concerts, etc. 10. Personnel—an adequate number of efficient personnel, properly organized and under competent supervision should be provided, a. The nursing personnel and service should be in charge of a reg- istered nurse who has had supervisory experience. The nursing personnel must be of sufficient number and ability to meet the patients' requirements and to maintain standards of good nurs- ing care. From 15 to 30 per cent of the total nursing staff should consist of graduate nurses in order to provide sufficient super- vision for the attendants and in order to care for medications, temperatures, and treatments requiring nursing skill. Attendants giving personal care or nursing service to patients must be suf- 156 ficiently trained and experienced and should work under super- vision of graduate nurses at all times. b. Laboratory service should be under the supervision of a com- petent pathologist. c. If drugs are compounded and prescriptions filled in the institu- tion, the drug room should be under the supervision of a regis- tered pharmacist. d. The dietary, physical therapy, occupational therapy, social serv- ice, and recreation departments should be staffed by qualified personnel. Staff in these departments should be supervised by persons with recognized training and experience in their respec- tive fields. Small institutions may obtain the services of dietitians, physical therapists, occupational therapists, social workers, etc., through the affiiliated general hospital or on a part-time or visit- ing basis if arrangements for full-time trained staff are not prac- ticable. 11. Medical Records—accurate and complete medical records and nursing notes must be maintained and filed in an accessible manner, available for follow-up, for study, and for reference, a. An adequate resume should accompany the patient in his passage from and to the general hospital and should include a social serv- ice report on the pertinent environmental and psychosomatic factors. 157 SECTION VII NURSING SERVICE FOR THE CHRONICALLY ILL Report by The Committee of the Illinois State Nurses' Association Con- sultant to the Commission on the Care of Chronically 111 Per- sons. Mrs. Madeline Roessler, R.N., Chicago (Chairman) ; Miss Helen Frederick, R.N., Joliet; Miss Margery MacLach- lan, R.N., Chicago; and Miss Lorna May, R.N., Chicago. Home Nursing Service A survey of home nursing service (visiting nurse service) in Illi- nois indicates that such care is available from voluntary nursing agen- cies in only 73 communities in Illinois: Alton (Madison County) Alton Associated Charities Alton Catholic Charities Aurora (Kane County) Aurora Public Health Associa- tion Chicago (Cook County) Chicago Infant Welfare Society Chicago Visiting Nurse Asso- ciation Danville (Vermilion County) Danville Visiting Nurse Asso- ciation Decatur (Macon County) Decatur Visiting Nurse Associ- ation East St. Louis (St. Clair County) East St. Louis Visiting Nurse Association Elgin (Kane County) Elgin Health Center Evanston (Cook County) Evanston Visiting Nurse Asso- ciation Freeport (Stephenson County) Freeport Child Welfare Associ- ation Galesburg (Knox County) Galesburg Visiting Nurse Asso- ciation Joliet (Will County) Joliet Public Health Council Kewanee (Henry County) Kewanee Visiting Nurse Asso- ciation La Grange (Cook County) La Grange Community Nurse and Service Association Marseilles (La Salle County) Marseilles Public Health Cen- ter 158 Oak Park (Cook County) Infant Welfare Society Family Welfare Visiting Nurse Service Ottawa (La Salle County) Ottawa Public Health Nursing Association Peoria (Peoria County) Peoria Visiting Nurse Associa- tion Quincy (Adams County) Quincy Visiting Nurse Associ- ation Rockford (Winnebago County) Rockford Visiting Nurse Asso- ciation Rock Island (Rock Island County) Rock Island Visiting Nurse As- sociation Upper Rock Island Visiting Nurse Association Springfield (Sangamon County) Public Health Nursing and Tu- berculosis Association Waukegan (Lake County) Barwell Settlement House Wilmette (Cook County) Wilmette Health Center The Metropolitan Life Insurance Nursing Service provides serv- ice to insured persons in three of the above communities and nine ad- ditional ones. In all other parts of Illinois patients requiring nursing care in their homes are dependent, if friends or relatives can not care for them, on nursing service from whatever professional or nonprofessional person- nel may be available. Visiting nurse service can not be supplied by offi- cial health agencies because of limited staff and funds. These facts illustrate the great need for extension of home nursing service for the acutely ill and the chronically ill patient alike. The manner in which home nursing service may be extended varies with the community and the existing services, public or private. A basic principle in any plan should be that "each nurse, in her home visits, combine the principle functions of health teaching, prevention and control of disease, and care of the sick whether in a given situa- tion she works under the direction of a private physician or a health officer. This is important to provide a complete nursing service that is most satisfactory for the family/'1 Possible patterns of nursing organi- zation are: 1. In rural communities all visiting nurse service including care of the sick at home is best administered and supported by the health de- partment. The United States Public Health Service in a letter ad- dressed to the Commission on the Care of Chronically 111 Persons on December 17,1946 stated: "While it is true that many official health agencies do not ’Desirable Organization of Public Health Nursing for Family Service, Public Health Nursing, August 1946. 159 provide this type of nursing service, the Public Health Service is recommending that as soon as sufficient staff is available, Health Departments should provide this type of service” 2. Small cities have had some success with a combination nursing serv- ice jointly administered and financed by public and voluntary agen- cies with service given by a single group of nurses. 3. In large cities preventive services in the nursing field are frequently the responsibility of the health department while a voluntary nursing organization does the bedside nursing usually, although not always, in close co-operation with the health department. Recommendation: The committee recommends to the Com- mission that further study be given during the next biennium to the manner in which home nursing service may be extended and in- tegrated throughout the State of Illinois. Study of the Problem Factors to be considered in studying the extension of home nurs- ing service involve not only consideration of the above-mentioned var- iations of a basic plan but such considerations as: 1. whether existing voluntary nursing agencies can extend the area in which they give service; 2. how the nursing service, if not to be administered by the official health agency, is to integrate its services with those of the health department; 3. what sources of funds are available such as payment from the pa- tient's own resources or from assistance funds and to what extent these need to be supplemented by private and community contribu- tions or by local or state subsidies ; 4. whether public agencies can accept service contracts from insurance companies. Recommendation; Because of these factors and the complex- ity of the problem the committee recommends to the Commission that a qualified graduate registered public health nurse be retained to study and report on this entire question. The committee recom- mends further that an advisory committee of nurses be appointed to work with the above-mentioned nurse, and that the Illinois De- partment of Public Health, Division of Public Health Nursing, be represented on the advisory committee. Supervision of Nursing Personnel Since the nursing care of chronically ill patients in nursing homes and in their own homes in the community is often provided by persons 160 known as practical nurses, nursing assistants or nursing aides, provi- sions should be made for the supervision of these persons by a profes- sional registered nurse. Supervision by a professional nurse would in- sure that persons giving the nursing care would have adequate super- vision; this would also be a protection to the chronically ill patient. Supervision of the nursing staff of the nursing home, if there is no reg- istered nurse in the home, might be provided through local or state health agencies who are responsible for the inspection of these homes for licensing. In the community the nursing supervision of the private home might be provided by the local health agency. Provisions for nursing supervision to the chronically ill patient should be under the general direction of the Illinois Department of Public Health. Recommendation: The committee recommends to the Com- mission that the nurse whose appointment was recommended above include in her study the problem of providing nursing supervision to the chronically ill, whether they are cared for in their own homes or in public or private institutions. Training of Nursing Personnel Nursing service is dependent upon leadership of the medical pro- fession and the type of treatment recommended by physicians. Simi- larly, interest in nursing care of any particular group of patients or dis- eases can best be stimulated by physicians who are working with such patients and diseases. Recommendation: The committee recommends to the Com- mission that research in the prevention, control, and treatment of chronic disease be undertaken at the earliest possible moment. Such research would benefit the patient group and would provide training for physicians and nurses interested in the care of the chronically ill. Licensing of Nursing Personnel The Illinois Nurses' Practice Act, until this time, has licensed only the professional or graduate nurse. A new act which has been prepared and is to be introduced at the Sixty-fifth General Assembly will pro- vide for the licensing of all nursing personnel including the group known by such titles as practical nurses, nursing assistants or nurses' aides. Licensing of this type would insure that persons giving nursing care for compensation would have had suitable training under super- vision and would constitute a protection not only to chronically ill persons but to all other persons who are dependent upon this group for nursing service. 161 Recommendation: The committee recommends to the Com- mission that it endorse the passage of the new Nurses" Practice Act. Standards Relating to the Duties of Nursing Personnel The American Nurses" Association has already studied the nursing needs, standards for nursing care, and analysis of time required for the care of the obstetrical, surgical, and other specialized types of pa- tients. The nursing care of the chronically ill patient is a major national problem, one in which there has been widespread interest. It is the opinion of the committee that standards should be established. Recommendation: The committee recommends to the Com- mission that it be suggested to the American Nurses" Association that a study of the nursing needs of the chronically ill patient, simi- lar to their other studies, be initiated. Licensing of Nursing Homes Much of the nursing care of chronically ill persons is given in pri- vate nursing homes which are now subject to licensing. Certain changes are needed in the law licensing nursing homes. At present the Illinois Department of Public Health does not have jurisidiction in those com- munities where there is local provision for licensing nursing homes. While the state law requires that such local provision be comparable to the state law, there are some communities in Illinois where the local licensing procedures do not operate effectively. Recommendation: The committee recommends to the Com- mission that action be taken so that the Illinois Department of Pub- lic Health has jurisdiction with regard to licensing in all communi- ties in the State, superseding all local licensing authority. The Illi- nois Department of Public Health should be commended for the excellent job which has been done in licensing nursing homes and should be given all support in continuing this much needed program. 162 SECTION VIII CHRONIC ILLNESS IN METROPOLITAN CHICAGO A preliminary report on the nature and extent of the problem of chronic illness in the Chicago metropolitan area and the general type of community program which should be developed to meet it, including some specific recommendations. April 1947 Prepared by THE INSTITUTE OF MEDICINE OF CHICAGO—THE CENTRAL SERVICE FOR THE CHRONICALLY ILL 343 South Dearborn Street, Chicago 4, Illinois William F. Petersen, M.D., Chairman, Administrative Committee Edna Nicholson, Director Foreword The Institute of Medicine of Chicago, through its Central Service for the Chronically 111, hopes to make available within the coming year a detailed report on the extent and nature of the problems of chronic illness in the Chicago area; facilities and services now available to meet these problems; changes and additional services needed; and recom- mendations for developing them. In the meantime, at the request of the Illinois Legislative Commission on the Care of Chronically 111 Persons, this preliminary report is presented. It constitutes a preliminary state- ment of the steps which the Central Service for the Chronically 111 be- lieves should be taken in the Chicago area and outlines the plan which the Service will follow in its work directed toward meeting the prob- lems of chronic illness in this community. For the past three years The Institute of Medicine of Chicago through its Central Service for the Chronically 111 has given intensive study to the problems of chronic illness. In the course of this study it has had the help of national and local leaders in the various pro- fessional fields directly concerned in the different aspects of these prob- lems. These have included physicians; hospital administrators; nurses; public health personnel; voluntary health agencies; social workers; di- 163 etitians; administrators of homes for the aged; persons experienced in community organization and financing of community groups; church organizations; and others. In addition to its other duties the staff of The Central Service has worked intensively in assembling factual in- formation on such points as: 1. The approximate number of persons affected; their age; sex; finan- cial status; diagnosis; degree of disability; and amount and type of care needed. 2. The total facilities needed in the community for the prevention and control of the chronic diseases; for the rehabilitation of patients handicapped by them; and for the long-term care of persons for whom prevention, control, and rehabilitation are no longer possible, including the number, type, quality, and approximate costs of the various services and institutions needed. 3. The total facilities now available in the Chicago metropolitan area, including the number, type, quality, and current costs. 4. The general characteristics of the additional facilities and services which can and should be developed in the Chicago area, taking into consideration the importance of the most effective use of existing facilities and the ideas and preferences of community leaders with respect particularly to such points as methods of financing; relation- ship between government, voluntary philanthropy, and private in- itiative; specialization of services, etc. In assembling this information the staff has investigated the meth- ods in use in other communities and states throughout the United States and Canada. Various aspects of the problem have been discussed, also, with persons working with it in England, Sweden, and Brazil. There is marked similarity between the problems facing Chicago and the State of Illinois and those confronting other communities throughout the United States and other nations. It is not possible to include in this report complete statistical and other detailed information relating to the various points outlined above. This information is, however, on file in the office of The Institute of Medicine, The Central Service for the Chronically 111. It forms the ba- sis for the proposals presented in this report. Extent and Nature of the Problems of Chronic Illness in Metropolitan Chicago Chicago and the State of Illinois are facing serious problems as a result of the rapidly increasing numbers of people disabled for long periods of time by chronic illness. These problems are shared by other communities throughout the United States, and other nations. They are serious everywhere. 164 Medical science and practice have made rapid progress in the past half century. Advances are continuing. They have occurred, however, almost entirely within the field of prevention and control of the acute diseases, chiefly those which are infectious in origin. As a result the na- ture of the diseases which predominate as causes of illness and death has shifted. The diseases which strike quickly and terminate rapidly are no longer the chief health hazards. Their place has been taken by the chronic diseases which characteristically are insidious in onset and bring slowly progressive invalidism over long periods of time. For the majority of people who die each year the length of time during which they are ill and require care is no longer a week or ten days. For more than half of all people who died in 1946 this period of illness lasted weeks, months or years. During 1946 heart disease caused more than ten times as many deaths in Illinois as were caused by pneumonia and influenza combined. The four leading chronic diseases—heart disease, cancer, cerebral hemorrhage, and nephritis—accounted for two thirds of all deaths which occurred in the Chicago metropolitan area during 1946. This experience was consistent with that of the State and the nation as a whole.1 The chronic diseases are serious in the extent to which they cause death. From the point of view of human suffering and economic loss, they are equally serious in the long-continued illness and disability which precede death. Some of the chronic diseases—notably rheuma- toid arthritis—frequently strike during the young adult years of life. They rarely cause death; but they leave their victims crippled and helpless for years. In this group should be included also some of the neurological disorders such as paralysis agitans, multiple sclerosis, mus- cular dystrophy, and others. Estimated Number of Persons Affected It is estimated that there are in Chicago and Cook County more than 750,000 people who suffer from chronic diseases sufficiently seri- ous to be recognized as constituting some degree of handicap in nor- mal living. Of these, more than 50,000 are so seriously disabled that they are unable to carry on normal activities and may be described as invalids. The remaining 700,000 people have some chronic disease but are still able to continue fairly normal activity and to care for themselves.1 Most of the 700,000 people who are still "on their feet” are in the early stages of heart disease, circulatory disorders, cancer or ’See Health Statistics Bulletin, Division of Vital Statistics and Records, Illinois State De- partment of Public Health, 1946 series, number 3. Estimate based on rates established in National Health Survey, United States Public Health Service, applied to population figures for Cook County. 165 other conditions which, unless checked, will progress with steadily increasing seriousness until the patient reaches the stage of complete invalidism. These 700,000 people constitute the chief source from which the invalids of the immediate future will develop. Among the 50,000 persons who are already invalids the serious- ness of their conditions and the amounts of care which they require show considerable variation. Some of the patients are still able to move around and care for most of their own personal needs provided there is someone available to look after their homes, prepare meals, and be available in case help is needed. For the entire group of 50,000 invalids the degree of care required ranges all the way from this group which requires the minimum of service to those whose illness and disability are increasingly severe to a point where death is imminent. In general, it may be said that with respect to the amount of care required all in- valids move along a course which begins with a need for minor care and proceeds through gradually increasing helplessness to the terminal period of illness and death. The immediate aspect of the problem of chronic illness which is pressing so heavily upon the public consciousness at the present time is the lack of services and facilities to care for patients who are already invalids as a result of chronic disease. There is desperate need for more and better services and facilities of this type. The need must be met. The immediate urgency of this need, however, must not be permitted to overshadow the equal need for constructive efforts to prevent and control the particular chronic diseases and to rehabilitate patients hand- icapped by them. Advances in the control of the acute, infectious diseases during the past half century have provided dramatic illustrations of what can be accomplished when the full powers of medical research, professional education, public health education, and preventive medicine are fo- cused upon particular diseases. Until recently, comparatively little had been done to direct forces of this kind at diseases of the heart, circu- latory disorders, arthritis, kidney disorders, and the other chronic dis- eases. The surface has barely been scratched in efforts at prevention and control of these conditions. Enough has been accomplished, how- ever, to demonstrate tremendous opportunities which have not previ- ously been recognized nor used. It has demonstrated, also, the impor- tance of approaching the problems of chronic illness with a construc- tive attitude. It is true that, in the present stage of medical knowledge, there are many cases of circulatory disorders, disease of the nervous system, cancer, and other chronic conditions which can not be cured or markedly relieved. Progress is being made, however. More can be fore- 166 seen. Many patients whose condition seemed hopeless in the past are being cured today. Many of those who seem hopeless now may be cured in the future. Advances of this kind can not be expected as a result of fortunate scientific accidents, however. If they are achieved it will be as the re- sult of well-planned, practical steps which make them possible. Large amounts of money will be needed to support the work. Good physical facilities will be needed for research in the basic medical sciences and at the bedside. Adequate numbers of competent personnel will be need- ed for research, for professional education, and for care of patients. Chronic illness has been described as "the Nation's Number One Health Problem." It is almost overwhelming, both in its size and in its seriousness. Constructive efforts to deal with it have been too long de- layed. As a result the need for effective action is extreme. The amount of money which will be required and the number and quality of per- sonnel and facilities needed are tremendous. This is not a problem which can be met by patching up old buildings no longer suitable for other uses. Nor can it be conquered by piecing together the scraps left over from other health, medical, and welfare services regarded as of greater immediate importance. The problems of chronic illness must be faced squarely. The community must be realistic in accepting the fact that they will not be solved easily nor cheaply. The costs will be large. The costs of any further delay in dealing with these problems, however, will be even larger. The steadily and rapidly increasing invalidism re- sulting from chronic disease has already brought appalling financial burdens to patients, to their families, and to the tax-paying public. Money and effort intelligently spent in prevention and control of the chronic diseases and in rehabilitation of patients disabled by them offers the only hope of stemming the increasing burdens of invalidism. The expenditures required, therefore, great as they are, will constitute a sound investment. Any further delay in providing them can result only in continued increases in the number of helpless people in the population requiring long-continued and expensive care. Failure to meet these problems realistically represents, at best, a tragic example of a "penny-wise and pound-foolish" policy. Constructive action for prevention, control, and rehabilitation must be undertaken. The immediate pressure for adequate care of the thousands of patients who are already rfhopeless" invalids must also be met. Adequate provision for long-continued care of those patients who have little hope of recovery is essential. It is vitally important, however, that provisions for care of these patients be an integral part of a comprehensive community program which includes provisions for 167 prevention and control of the particular chronic diseases and rehabilita- tion of patients in all possible cases as well as continuing care of "hope- less" patients. The hospital facilities, nursing homes, rest homes, and infirmaries needed for long-term care of patients should be developed with full consideration of the part which they can play in medical re- search, professional education, general health education, and rehabili- tation as well as in the daily care of long-term patients. Essential Elements of a Comprehensive Community Program A complete program designed to meet the problems of chronic illness must include well co-ordinated activities in three broad fields: 1. The prevention and control of the chronic diseases and of the in- validism associated with them. 2. Rehabilitation. 3. Long-term care of patients. Specifically, an effective community program must include at least the following activities: 1. ‘Medical research into the causes and methods of prevention and treatment of the particular chronic diseases including diseases of the heart; arteriosclerosis and hypertension; cancer; neurological dis- orders including paralysis agitans, multiple sclerosis, etc; nephritis and other kidney disorders; and other chronic conditions. Research should include efforts to clarify and deal with the currently ill-de- fined condition commonly described as "senility," especially as it may result from circulatory disorders and as it may be related to nu- trition. Provision should be included for research in the basic sci- ences as well as for clinical research. 2. Social and economic research into the causes and methods of pre- vention and relief of factors other than physical damage which con- tribute to invalidism. This should include investigation into the ef- fect of emotional factors, the possibilities of rehabilitation, selective placement of handicapped people in industry, etc. 3. Professional education which will assure a supply of professional personnel competent to meet the problems of prevention and con- trol of the chronic diseases and the rehabilitation and care of patients disabled by them. This should include physicians, nurses, public health personnel, nutritionists and dietitians, occupational therapists, physical therapists, social workers, hospital administrators, and other professional persons needed to provide the various services required. 4. Wealth education directed toward educating people on nutrition and other aspects of health promotion, and including information which will promote early recognition of disease symptoms and prompt seeking of competent medical attention. 168 5. Public health services including good vital statistics; well-balanced administration of public health services to take into account the chronic diseases as well as the control of communicable disease, in- fant welfare services, etc. These should include consistent activities which will keep the public intelligently informed on the nature and type of health problems in the community including the chronic diseases. They should also include effective licensing, registration, and other means of control over the quality of professional person- nel offering services to the sick; and of institutions including hos- pitals, nursing homes, sanatoria, homes for the aged, and other places offering shelter and care. 6. Provisions for meeting the costs of care for persons unable to do so from their own resources. Public assistance programs, voluntary wel- fare agencies, "free” and "part pay” medical services, should be adequate to assure that no one in the community will, for want of funds, be unable to obtain promptly and whenever needed the medi- cal services, hospitalization, care through protracted or terminal ill- ness and other attention necessary for: a. Prevention or early detection of disease. b. Diagnosis and treatment of existing illness. c. Rehabilitation including partial or complete restoration of phy- sical function which may have been lost or damaged. d. Control of the progress of disease and prevention of further dis- ability. e. Relief of pain. 7. Personnel and facilities adequate in Quality and amount to meet the needs of all persons in the community for diagnosis, treatment, re- habilitation, and care. These should include all professional services and hospital and other institutional facilities needed for early detec- tion of disease and for prompt diagnosis and treatment. Specifically, they should include adequate numbers of well-qualified: a. Physicians including the specialists. b. Nurses including competent practical nurses as well as registered nurses. c. Hospitals. d. Laboratory and X-ray personnel and equipment. e. Dentists. f. Nutritionists and dietitians for instruction of patients as well as management of diets in hospitals and institutions. g. Occupational therapy technicians. h. Physical therapy technicians. i. Social workers. 169 j. Sources of medications and prosthetic and therapeutic appliances. 8. Rehabilitation services comprehensive in scope and constructive in approach. They should include well co-ordinated services for: a. Physical restoration. b. Education of the patient in how to care for his personal needs and live intelligently with his handicap. c. Instruction in performance of useful work. d. Vocational guidance. e. Selective placement in industry. The services should be available to all who can profit from them and should not be limited to persons who can become fully self-supporting. They should include such services as instruction of handicapped women in the performance of household duties and education of parents of handicapped children in how to meet their needs constructively. 9. facilities and services for long-term care of patients. These should include services to help families caring for patients in their own homes; and community facilities for care of patients who can not re- main in homes of their own. Adequate provision should be made in both groups for all patients needing care regardless of economic sta- tus. It is usually preferable for the same agencies and institutions to serve both rich and poor. The costs of care for the poor can be met from public funds while payment is made from their own resources by patients able to pay for their care. Services for patients in their own homes should include adequate provision for: a. Physicians. b. Nurses including visiting nurses and also registries and other means by which families can obtain part-time or full-time service from both registered and competent practical nurses. c. Services of other specialists on a visiting or part-time basis in- cluding nutritionists and dietitians. d. Housekeepers. e. Occupational therapy. f. Physical therapy. g. Social case work. h. Religious activities. i. Rehabilitation, particularly instruction of patients in how to live with their handicaps. j. Recreation. Facilities for the care of patients outside their own homes will include units for long-term care affiliated with general hospitals; nursing homes; infirmary units in homes for the aged; etc. 170 10. Co-ordination of facilities and services. This should include ade- quate provision for maintaining accurate information on the nature and extent of community needs; gaps and overlapping in services; and community attitudes. Provision should be included, also, for a central place where persons needing care can obtain reliable in- formation on how and where to obtain it. Some Basic Considerations Which Should Guide the Development o£ Facilities and Services The Central Service for the Chronically 111 believes that the fol- lowing basic considerations should guide the development of additional facilities and services to meet the problems of chronic illness in the Chi- cago metropolitan area. This belief is based upon extensive study of the problems and possible methods for meeting them including an anal- ysis of opinions expressed by approximately 200 leading persons in the community with particular competence and experience in dealing with various aspects of chronic illness. These persons included phy- sicians; public officials; hospital administrators; representatives of civic organizations and church groups; nurses; social workers; business men; persons experienced in management and financing of community health and welfare agencies; managers of homes for the aged; superin- tendents of institutions now caring for chronically ill patients; and a selected number of chronically ill patients. The Service believes that the following statements are sound; are workable in practice; and are consistent with the desires of the com- munity. They are not all now being met in practice. Considerable time may be required to bring existing facilities into conformity with some of these statements of principle. Consistent efforts should be made in this direction, however, and each new development in the community should be in the directions indicated by these statements. 1. fhere should be a comprehensive program of well-integrated services directed toward prevention, control, and rehabilitation as well as long-term care of patients. No one segment of this program should be developed apart from the total plan and without full considera- tion of its relationship to other elements in the program and of the part which it is to play in meeting the community’s total need. 2. facilities and services in the community should provide care to pa- tients without economic barriers. There should not be established nor maintained separate personnel, community services, and institu- tions to provide care for the poor apart from those which serve fi- nancially independent people. The same professional personnel, hos- pitals, and other services and institutions should serve both rich and 171 poor. Persons financially able to pay for their own care should do so. For those financially unable to pay for the care which they need, including "part-pay” patients, costs which they are unable to meet should be met through public assistance payments or similar meth- ods of distribution of public funds on a fee-for-service basis. 3. Voluntary philanthropy, private initiative, and government should work together on a partnership basis in meeting the problems of chronic illness. There is a need for joint efforts of all these groups. Methods of dealing with the various aspects of chronic illness have not yet been fully tested. Experimentation and flexibility in programs are essential. A wide variety of facilities and services are needed. In general, government's part in meeting the problem should lie chiefly in its established responsibilities for regulation and licensing; in pro- viding financial assistance to meet the costs of care for patients un- able to do so for themselves; and in providing funds for construc- tion of institutions under the general plan outlined in the Hospital Construction Act of 1946. Voluntary philanthropy and private ini- tiative should establish and operate the new institutions and other facilities needed, collecting reasonable fees for service. These fees should be adequate to cover operating costs and would include both those paid by financially independent patients and those paid by or on behalf of patients dependent upon public assistance for part or all of the costs of their care. 4. 7he problems of chronic illness, including long-term care of chroni- cally ill people, are primarily medical problems. They should be ap- proached in the best tradition of medical practice and should have as their constant objective the greatest possible restoration of the pa- tient to health and well-being. It is recognized that the nature of the problem is such that there may be a high percentage of failure to re- store patients to full health. Recent experience has demonstrated, however, that for some patients cure is possible; for many there is a possibility of . control of the progress of the disease and of improve- ment in physical function; for many more medical science can do much to relieve suffering; and from all these patients, physicians and others can learn much which may help to prevent other patients from suffering similar helplessness and pain. Institutions caring for these patients should therefore emphasize treatment and rehabilitation. They should not be regarded as "shelters,” "infirmaries,” or "cus- todial institutions.” 5. All chronically ill patients, wherever they may be and in whatever stage their need for treatment may be, should have competent and continuous medical supervision and should have easy access to all 172 of the specialized services and facilities needed in the prevention, diagnosis, and treatment of disease of any type. The amount of medi- cal attention required will vary between patients and for the same patient at different times. Some patients during some periods of their illness may need only occasional visits from the physician. Others or the same patient at different times may require daily attention. The quality of care which the patient needs, however, does not vary. And his need for having constantly accessible all types of specialized facilities and services is constant since his condition may change at any time. Facilities through which the patient receives medical su- pervision should be such that the continuity of his care will not need to be interrupted as his condition may grow better or worse or as he moves from his home to an institution or back again. The patient who has been bedridden and has improved to a point where he can be up and about should continue under the same medical supervi- sion. It should not be necessary to transfer him to new doctors and new institutions, breaking the continuity of his care each time he improves to the point of becoming ambulant or grows worse and is bedridden. 6. Institutions for the long-term care of patients should be so developed, located, and administered that they will provide opportunity and en- couragement for: a. The best possible care and rehabilitation of the patients, includ- ing provisions for continuity of medical care. b. Medical research. c. Research into social and economic factors related to invalidism and to the possibilities of rehabilitation. d. Professional education especially of physicians; nurses; nutrition- ists and dietitians; physical therapists; occupational therapists; so- cial workers; and other personnel needed in the prevention and control of the chronic diseases and the rehabilitation and care of patients. Institutions should be so located that they are easily accessible to the patients they are to serve and to the professional personnel, specialized medical facilities, and other staff and facilities needed in the daily operation of the institution. Rural surroundings usually offer the advantage of cheaper land values and quieter surroundings. These can rarely compensate, however, for the disadvantages of an isolated location in terms of the possibility of getting and keeping good staff to operate the institution; having the patients easily ac- cessible for visiting by their families and relatives; making use of 173 specialized facilities and utilities more readily accessible in urban locations; and being available for teaching and research. 7. Specialized institutions are rarely desirable though specialized units, wards, or whole buildings operated as part of a general hospital or medical center may be. This is true with respect to specialized “chronic disease hospitals” apart from general hospitals or medical centers. It is also true of independent institutions for particular diag- nostic groups such as cancer, orthopedics, etc. It is particularly true of the chronic diseases that they frequently occur in combinations. The patient suffering from cancer may also have heart disease, hy- pertension or arthritis. The diabetic may also have arteriosclerosis or any number of other conditions. The patient suffering from a chronic disease may develop an intercurrent acute illness or an acute exacerbation of his chronic disease. For these reasons all of these patients must have access at all times to all of the facilities and serv- ices which are included in a good general hospital or medical center. A specialized hospital, operating independently of any general hos- pital or medical center, will have to duplicate all of these facilities within its own organization. This is expensive and unnecessary. Separate, specialized hospitals present an added disadvantage and expense in administrative difficulties particularly in the admis- sion process. Admission to the specialized hospital makes it neces- sary to determine not only that the patient is ill and requires hospital care but also to determine the diagnosis in advance and eliminate those patients who do not fall within the specific category served by the particular hospital. If this can not be done in advance and is accomplished only after admission, it may mean transfer of the pa- tient to another institution with consequent administrative difficulty and expense as well as delay and inconvenience for the patient. It is sometimes assumed that specialized, independent hospitals have advantages with respect to the possibility of obtaining public and professional interest and support. Such advantages as there may be in this respect, however, usually can be retained and many of the disadvantages avoided if the necessary facilities are established as specialized units or services within the general hospital or as specialized units which are integral parts of a complete medical center. 8. In general, facilities for the long-term care of patients during periods when they do not require intensive treatment should be developed through a series of relatively small institutions spread throughout the community rather than in one or two large centralized units. Fa- cilities for long-term care of patients during periods when they do 174 not require intensive treatment can operate efficiently with 25 pa- tients and with even fewer if the facility is an integral part of a gen- eral hospital. The optimum size of facilities of this type varies with a number of factors. In most instances, however, such facilities should not be less than 20 beds in size nor more than 300. If it is essential that institutions larger than 300 beds be operated, they should be broken down into a series of smaller units or subdivisions. 9. Adequate financing is the foundation on which good care for patients must rest. Money alone will not assure good care. Without adequate funds, however, good care is impossible. This fact must be faced clearly both in evaluating existing facilities and in planning new ones. It is unwise to attempt to develop facilities for care of long- term patients on the premise that this is to be an immediate money- saving device. Good care for long-term patients can be provided at a little lower operating cost and with less expensive equipment than can care in a general hospital serving acutely ill patients. If complete care of good quality is provided, however, the costs are not as much lower as is usually supposed. Dr. E. M. Bluestone of Montefiore Hospital for Chronic Diseases in New York City, has estimated the cost of care for the long-term patient at about two thirds of that of caring for the acutely ill patient. This can be regarded as a minimum figure. As better techniques and equipment are developing for the care and rehabilitation of long-term patients, they are being reflected in increased costs. It must be kept in mind that the very considerable differences in costs of care in many so-called infirmaries for long-term patients now operating as compared with general hos- pitals are usually related to incomplete and low-quality care of pa- tients. It is not safe to assume that good care can be provided for these patients at less than two thirds to three fourths of the cost of general hospital care. With respect to construction costs of new buildings or the re- modeling of existing buildings for this purpose, there is little basis for assuming that they will be significantly lower than the costs of constructing new buildings or remodeling old ones for general hos- pital use. Equipment costs will be lower. But actual construction costs will not be markedly different since with respect to size, safety, and similar construction factors the needs are essentially the same. Inadequacies in Existing Facilities and Services in the Chicago Metropolitan Area and Recommendations for Meeting Them It is not possible in this preliminary report to mention, by name, all of the work which is now being done in the Chicago area to meet 175 the various aspects of the problems related to chronic illness. In ad- dition to the services being provided by individual professional persons practicing in the community there are more than 400 agencies and in- stitutions in the Chicago metropolitan area now providing services es- sential in meeting the problems of chronic illness. Many of these indi- viduals, agencies, and institutions are at the present time engaged in the effort to develop more and better facilities and services to meet these problems. Institutions offering professional education, charitable foundations and trusts, hospitals, health agencies, social agencies, homes for the aged, public assistance agencies, physicians, nurses, pro- fessional organizations, public officials, church groups, civic tions, and women's clubs are actively participating in planning and developing the necessary additional services needed in the community. Significant progress is being made. New and more adequately supported research projects are being undertaken in medical schools and hospitals. Increasing interest is being shown by the various pro- fessional personnel involved and by educators in the different profes- sional fields. Health education services relating to particular chronic diseases are expanding. Rehabilitation services are receiving intensified practical interest and support and planning for some additional service is well under way. Public assistance agencies are giving intelligent study to ways in which they can meet their responsibilities more adequately and are taking definite steps toward doing so. The confusion surround- ing the licensing of nursing homes and institutions has been clarified though the problems in the City of Chicago, Oak Park, and some smaller municipalities in the metropolitan area have not yet been elim- inated. There is increasing interest and some progress in strengthening and expanding the services needed in caring for patients in their own homes. Development of additional facilities for long-term care of pa- tients in hospitals, nursing homes, homes for the aged, and other insti- tutions necessarily requires considerable time for planning, fund-rais- ing, and construction of buildings. Significant developments are oc- curring in this direction. A number of hospitals and homes for the aged are actively planning new facilities for long-term care and expansions in existing ones. Some of them have completed their fund-raising cam- paigns and have money available for construction of buildings in the immediate future. There have been noticeable improvements in the quality of care being provided in privately operated nursing homes. Significant progress has been made in public understanding of the problems and in the development of intelligent public support for good services. Reliable technical information is now available on such mat- ters as staff needs, reasonable costs of construction and operation of 176 facilities, and other practical problems involved in building and operat- ing institutional facilities. The needs of the community are known and possible methods of meeting them have been explored. In the current emergency period of extreme lack of facilities in the community, social agencies, visiting nurse associations, and other community services are continuing to stretch their facilities to the utmost in helping patients and their families to the best compromise possible between their urgent immediate need for care and the tragic lack of adequate facilities to provide it. The community can not rely on these agencies to continue the struggle against this overwhelming need indefinitely. Their serv- ices are an extremely valuable asset, however, in the present emergency period until facilities can be developed more nearly equal to the need. The Central Service for the Chronically 111 regrets exceedingly that it is not possible in this report to mention by name the many indi- viduals, agencies, and institutions now providing these highly important services. These existing facilities and services are of fundamental im- portance because they are now bearing the burden of caring for pa- tients in the community and must continue to do so until sufficient ad- ditional ones can be brought into existence. They are equally impor- tant because they form the nucleus from which additional facilities and services can be developed. Practical limitations, however, make it im- possible to include individual mention of them and the good work which is being done. This final section of this preliminary report, there- fore, is limited to a summary of inadequacies in the community and some recommendations regarding ways in which the inadequacies can be met. Prevention and Control of the Particular Chronic Diseases 1. ‘Medical Research. Chicago is fortunate in having four medical schools of excellent quality; a large and representative group of out- standing physicians and related scientists; and a number of well- operated, progressive hospitals. There are now in process in these medical schools and hospitals many individual research projects on the particular chronic diseases. These include, among others, cancer, circulatory disorders, diseases of the heart, rheumatic fever, arthritis, metabolic disorders, and orthopedic conditions. There are research projects, also, on nutrition in relation to the various diseases. Work is already being done both in the basic sciences and in clinical re- search, Too many of these individual research projects, however, are handicapped by lack of sufficient funds, staff, equipment, and clinical material. Recommendations: Definite efforts should be made to strength- en, co-ordinate, and expand this research on the various chronic 177 diseases and on the relationship between nutrition and disease and invalidism. These efforts should include such activities as those listed below. a. Work now in process (in The Institute of Medicine of Chicago, The Central Service for the Chronically 111) should be continued and expanded in an effort to maintain centralized information re- garding research now being done, gaps and overlapping in the work, and areas in which new developments are needed; to facili- tate co-ordination of activities; and to promote effective use of facilities needed in research work. b. Continued efforts should be made to publicize the importance of prevention and control of the chronic diseases in an effort to: (1) stimulate the interest of competent professional personnel in undertaking research of this type; and (2) develop a broader base of public interest and support for such work. c. Efforts should be made to encourage foundations, government, and individuals to provide funds for the support of research projects on subjects not now adequately covered. d. Additional clinical facilities should be made available by: (1) arranging affiliations between medical schools and the hos- pitals and other institutions caring for chronically ill pa- tients; and (2) promoting the development of new facilities for care of pa- tients under such auspices and in such locations that research can be an active part of their programs, e. Plans are already under consideration for the establishment of a co-ordinated program of research in chronic diseases at the Uni- versity of Illinois Research and Educational Hospitals. An ade- quate research program including the necessary physical facilities and provisions for continued maintenance should be established as a part of the program of the University of Illinois Medical School and the Research and Educational Hospitals. The pro- gram should cover all phases of the chronic diseases and should not be limited to any one age group. Similar programs might well be established in one or more of the other approved medical schools in the city. 2. Social and Economic Research. Some work is being done in isolated places in Chicago and Cook County on investigation of the possibili- ties for rehabilitation of handicapped people in industry and in meth- ods and possibilities for rehabilitation of handicapped patients. Some large industrial firms are experimenting in this area and at least one 178 large general hospital has begun work on rehabilitation directed to- ward teaching patients with chronic disabilities to live with their handicaps. There is no co-ordinated research program in this field at the present time, however. Recommendations: Research in this field should be under- taken as follows: a. Definite efforts should be made to bring into reality the proposed rehabilitation center for which plans have recently been devel- oped through a committee of the Council of Social Agencies of Chicago and to encourage research on various aspects of reha- bilitation, vocational guidance, and selective placement in industry of patients handicapped by chronic disabilities. b. Provision for research of this kind including publication of re- ports should also be included in the program and appropriations for the Illinois Hospital School. c. Experimental work on the possibilities of rehabilitation should be encouraged in all institutions caring for chronically ill patients. 3.Professional Education. Chicago is unusually fortunate in the num- ber and quality of its educational facilities. There are in Chicago and Cook County approved schools of good quality for the training of physicians, graduate nurses, nutritionists and dietitians, social work- ers, occupational therapy technicians, physical therapy technicians, medical record librarians, and hospital administrators. There are no schools of public health and no approved facilities for the training of practical nurses in the Chicago area. So far as can be ascertained at this time there are no schools anywhere for training persons skilled in rehabilitation as a special field of service. Nor are there any specialized facilities for the training of personnel competent to administer homes and institutions for long-term care of chronically ill patients. As expansions occur in facilities and services in both these fields the need for training will be more definitely recognized and the possibilities for practical training of personnel will expand. In the facilities which now exist in the Chicago area for train- ing of professional personnel there is an almost universal lack of sufficient emphasis upon the chronic diseases, their importance, and methods for prevention, control, and rehabilitation. The lack of sat- isfactory facilities for training practical nurses and practical nurse- housekeepers is an immediately serious obstacle to providing ade- quate care for patients. Recommendations: Immediate efforts should be made to in- crease the emphasis on chronic diseases in the curricula of existing 179 professional schools and to develop the additional educational facili- ties needed in the community. Such steps as the following should be taken: a. Efforts should be made through national professional organiza- tions and directly with local schools to provide more adequate training of students in the various professional schools now in ex- istence. These efforts should include, among others: (1) promoting understanding of the importance of this subject matter; (2) assisting in the development of teaching material; and (3) facilitating teaching affiliations between agencies and institu- tions caring for long-term patients and the educational in- stitutions. b. Immediate efforts should be made to develop adequate training courses for practical nurses and practical nurse-housekeepers. c. Efforts should be made to develop facilities for the training of per- sonnel competent to administer homes and institutions for long- term care of chronically ill patients. These facilities probably should be developed in connection with existing courses for the training of hospital administrators. 4, Health Education. Well-established voluntary health agencies exist in the Chicago area in the specialized fields of heart disease, cancer, tuberculosis, prevention of blindness, promotion of hearing, cerebral palsy, mental hygiene, and infantile paralysis. Agencies have re- cently been established in the fields of nutrition, the control of epi- lepsy, and the treatment and control of alcoholism. All of these agen- cies maintain health education services within their own fields and in most of these fields health education material emanating from na- tional organizations is also available in Chicago. With the exception of infantile paralysis, however, and possibly tuberculosis and cancer all of these agencies are now handicapped in their health education efforts by insufficient funds and personnel. The same factors handi- cap the work which should be done in health education in the pub- lic schools and through the public health departments in the Chicago area. The chief source of hope in controlling most of the chronic diseases at the present time lies in early detection of symptoms and prompt, competent treatment. These can not be achieved unless the public is educated to the importance of regular, competent medical attention. Recommendations: Health education services of existing agen- cies should be strengthened and expanded and new services should 180 be developed in areas not now covered. Health education services should be more widely diffused through other education, health, and medical activities including hospitals. Specifically, there should be such steps as the following: a. Voluntary health agencies now in the field should be encouraged to develop their health education services to the fullest possible degree. b. Health education services in the schools should be greatly strength- ened particularly on such points as the importance of healthful living, good nutrition, periodic physical examinations, and prompt seeking of competent medical advice in the early stages of illness. c. More emphasis should be given to health education in relation to chronic diseases through public health departments. d. Services should be developed through voluntary health agencies or public health departments or both to cover the particular dis- eases and subject matter not now covered. These should include, particularly, emphasis on the importance of recognizing disease entities in older people; dealing with them as definite disease rather than accepting them as inevitable concomitants of advancing age; and clarifying the nature of so-called "senility.” e. General hospitals should be encouraged to develop their services as true health centers including health education services. Basic Community Provisions Affecting the Quality and Quantity of Services in the Community 1. Licensing, Registration, and Other Tdeans of Control Over the Qual- ity of Professional Services and Institutions. Present provisions for licensing and registration of most of the professional personnel con- cerned with chronic illness appear to be relatively satisfactory. There are no controls at present, however, over schools purporting to train! practical nurses and there are no provisions for regulating the prac- tice of persons serving as practical nurses. Present legal provisions for licensing of nursing homes in the City of Chicago are unrealistic and unworkable. This fact plus the division of authority and responsibility for interpretation and en- forcement of the requirements constitute a serious obstacle in the way of improving services of this kind in the community. The solu- tion of this problem will not be easy. It is important, however, that persistent efforts be made to improve both the legal requirements and the way in which they are enforced. The chief points on which problems arise are zoning, require- ments related to fire prevention, and the detailed nature of the re- 181 quirements in the building code. Since all of these are points on which the municipality must have certain regulatory powers, there is some doubt as to whether the present difficulties could be signifi- cantly relieved by making the State licensing law applicable within the City of Chicago. Work is now in progress on a revision of the Chi- cago Building Code. This should result in considerable improvement in relation to licensing of nursing homes. Efforts are also being made to bring about better co-ordination between city departments in the formulation and enforcement of licensing requirements. Recommendations: Continued efforts should be made to find adequate solutions for the current problems related to licensing and registration especially as they relate to schools for training of prac- tical nurses, to regulation of the practice of "practical nursing,” and to licensing of nursing homes in the City of Chicago. a. The proposals made by the Illinois State Nurses' Association in the current session of the State General Assembly regarding changes in the requirements affecting graduate nurses should be adopted. b. Provisions should be adopted as soon as possible for regulation by the State of schools for practical nurses. c. Provision should be made as soon as possible for voluntary State registration or licensing of practical nurses. Plans should be made for compulsory registration or licensing in the future. Provisions of this kind should not be adopted at the present time, however. d. Revisions now in process on the Chicago Building Code should take into account the importance of sound, realistic requirements affecting nursing homes. e. Efforts of the Metropolitan Housing Council and other organiza- tions to promote centralization of city inspection services and to strengthen them by more and better staff should be supported. 2. Public Assistance as 11 Relates to Chronic Illness. The adequacy of services received by financially dependent people can never be any better than the adequacy of public assistance programs including standards governing the amount of financial assistance which can be provided; the flexibility of policies and procedures under which as- sistance is given; and the adequacy of case work services provided to persons dependent upon public assistance for support. This is true of people suffering from chronic illness as well as others in the population. Adequate amounts of assistance and sound, flexible ad- ministrative policy and procedure are essential if the necessary serv- ices and supplies are to be provided for the prevention and control of the chronic diseases and the rehabilitation or continuing care of 182 patients disabled by them. There have been marked improvements in recent years in the administration of public assistance in Illinois and there have been some improvements in the adequacy of assist- ance payments. There are, however, serious inadequacies still exist- ing from the point of view of prevention and control of the chronic diseases and of care for patients permanently disabled by them. Persons dependent upon Aid to Dependent Children, Aid to the Blind, and Old Age Pension are financially unable to purchase many of the services essential for health promotion and early detection of disease. As a result it frequently happens that their chronic diseases have reached an advanced stage before medical attention is obtained. In spite of recent revisions in the amount of assistance provided to Old Age Pensioners who are invalids, the increases over the past three years have little, if any, more than kept pace with increases in the costs of living and the costs of providing care for them. Conse- quently, such increases as have been made do not support signifi- cantly better care than was available to these patients five years ago. The amount of assistance now being paid to Old Age Pensioners who are invalids is not sufficient to cover the actual cost of providing adequate care. Large numbers of invalids who are dependent upon Old Age Pension are receiving seriously inadequate care and are unable to obtain care which can by any reasonable standard be re- garded as satisfactory. There have been significant improvements in the past three years in the public aid policies and procedures affecting the care of chronically ill patients. Regulations have recently been adopted per- mitting greatly improved flexibility in adjusting the amount of the assistance payment to the amount of care needed by the individual patient. These regulations have not yet been made fully effective by the adoption of realistic standards for determining the amount of money needed to cover the cost of the varying amounts of care. The adoption of this method, however, represents a significant improve- ment in procedure. Case work services, particularly for recipients of Old Age Pen- sion, are seriously inadequate. Case loads are so high that many pen- sioners rarely see a case worker. The serious physical, social, and emotional problems which they and their families face in connection with the chronic illness and care rarely receive adequate attention. Their case workers are so burdened with unreasonably large case loads that it is impossible for them to deal with problems in their early stages when something might be done to prevent family break- downs. There are many times when patients are unable to get in 183 touch with their case workers promptly even in emergencies such as sudden illness of a family member who has been responsible for the care of the invalid pensioner. Recommendations: The Illinois Public Aid Commission is to be commended for improvements which have already been made in relation to the provision of assistance for chronically ill patients de- pendent upon them for support. Consistent efforts should be made, however, to bring about further improvements: a. Realistic standards to replace those now in operation should be adopted as soon as possible to govern the amount of assistance which can be paid to invalids requiring personal care and nursing services. b. Present case loads, particularly in Old Age Pension cases, should be decreased as soon as possible to a point where adequate in- dividual attention can be given to chronically ill patients and to other recipients whose problems may contribute to the develop- ment of disability and invalidism. Services and Facilities Needed for Continuing Care of Chronically III Patients in Their Own Homes It is estimated that there are in Chicago and Cook County at least 35,000 invalids being cared for by their families in their own homes. A high proportion of these patients remain in their homes because they and their families prefer this arrangement. Some of the 35,000 patients now living in their homes, however, could pay for the necessary care and would prefer to be in nursing homes if enough good facilities of this kind were available. There may be as many as 5,000 such patients among the 35,000 invalids now living with their families in their own homes. This number is at least partially offset, however, by the con- siderable numbers of patients now in nursing homes and institutions who could and would prefer to be in homes of their own if they could obtain the household and professional help needed to care for them there. Considering both of these groups of patients it is estimated that approximately two thirds of all invalids are now in their own homes and that well over half of all invalids can and will probably always pre- fer to remain in homes of their own. These persons would not make use of nursing homes and institutions, even if plenty of such facilities were available. In planning community services and facilities for long- term care of chronically ill patients, therefore, it is important to provide for the needs of these persons as well as those who are in institutions. 184 The visiting nurse associations in Chicago, Evanston, and other communities are the chief sources of help now available for families caring for invalids in their own homes in the Chicago metropolitan area. They are giving excellent service. Because of limitations in fi- nances and staff, however, they have not been able to meet the full needs of all patients requiring care, even within the communities which they serve, and there are some areas in Cook County in which little or no service of this type is available from any source. Services of visiting nurses are now available almost exclusively to the low-income families and to those who are dependent upon public assistance for support. Large numbers of families in the middle-income groups also need serv- ices of this kind and are able and willing to pay reasonable fees for them. There are practically no sources now available in the communi- ty, however, from which they can obtain them. There is an almost total lack of sources from which any patients, rich or poor, can obtain professional services of dietitians, occupational therapists or physical therapists in their homes. There is an urgent need among patients in all economic groups for sources from which they can obtain competent practical nurse-housekeepers to help in house- hold management and the care of patients in their homes. There are no schools in the Chicago area for the training of persons competent to perform this combination of services. There are practically no com- munity organizations nor privately operated employment agencies to which chronically ill patients and their families can turn for help in obtaining such personnel even though they may be able to pay for it. There has been very little help available to families and patients needing rehabilitation services in their homes. The "Home-Bound” services provided by the Illinois Association for the Crippled give ex- cellent help to some patients in learning to live with their handicaps and carry on useful activities in spite of them. Limitations of the agen- cy’s staff and finances, however, have made it impossible for more than a very small number of patients to obtain these services. Illness of all kinds may be aggravated by physical surroundings, living conditions, fear or worry, lack of understanding or unsympa- thetic attitudes on the part of the patient’s family, and other social problems. This is especially true of such diseases as heart conditions, high blood pressure, diabetes, and other chronic diseases. Not only do social problems aggravate the illness. The illness and the burdens placed on the family in caring for the patient create new and serious social and economic difficulties. Families previously living happily may suffer serious strain, even to the point of complete breakdowns in the form of separation or divorce, when confronted with months or years 185 of caring for a "difficult” invalid in the home. Serious problems of re- adjustment of the family's way of living and serious emotional prob- lems on the part of both the patient and his family are common. These problems are not limited to families who are financially dependent. They occur with equal seriousness in families of all economic groups. Good social case work can go far toward relieving these strains and helping patients and families through the difficult personal adjustments which must be made. Social case work service is being used in slowly increasing amounts by financially independent people in the Chicago area. There is still widespread lack of understanding of its value, however, and many families suffer through very difficult and sometimes disastrous efforts to "muddle through” their problems without help because of the mis- taken idea thdt social case work is useful only for "paupers” and so- cial misfits. Recommendations: Services and facilities in the homes of chronically ill patients should be extended by such steps as the fol- lowing : 1. Consistent efforts should he made to increase the financial re- sources and staff of existing organizations providing visiting nurse services to a point where it is possible to meet the full needs of all long-term patients including those able to pay for their care. Areas in which such service is not now available should be encouraged and helped to develop it through voluntary agencies whenever this is possible. In some areas service might be developed through ex- tension of existing agencies now working in adjacent communities. In areas where services can not be developed satisfactorily through voluntary agencies the need should be met by expansion of the rural nursing service of the Cook County Department of Public Health. Fees covering the costs of the services should be collected by the nursing agencies from patients and families able to pay for them, and from public assistance agencies to meet the costs of care for patients who are dependent upon public assistance for support. 2. Steps should be taken as rapidly as possible to develop agencies or centers in the community from which families in need of such service can obtain competent practical nurse-housekeepers. De- velopment of such centers will necessarily go hand in hand with the development of the educational facilities mentioned above for training of such personnel. Service should be available on both 186 part-time and full-time arrangements to meet varying needs of the patients and families to be served. Preferably the same agen- cies or centers should serve all economic groups. Patients able to pay for service should do so. For patients unable to pay for nec- essary service, costs should be met by public assistance agencies and voluntary welfare agencies. The possibility should be investigated of developing these new services in connection with existing community agencies such as Visiting Nurse Associations. If this is not feasible, they might be developed in connection with the educational institutions for the training of personnel or as independent agencies. They should, however, be operated on a not-for-profit basis similar to the vol- untary hospitals which serve all economic groups. 3. Jhe services of competent nutritionists and dietitians should he made available as soon as possible for consultant service on a visit- ing basis to patients and their families in their own homes. These services should include help to families in meal planning and man- agement of good normal diets and special help in the planning and management of therapeutic diets as needed. Like other services related to care and treatment of the pa- tient, the services of the nutritionists and dietitians should be car- ried out in accordance with the directions of the patient's attend- ing physician. Services of this type should be available to patients in all eco- nomic groups, preferably through a single agency. Fees should be collected from patients able to pay and from assistance agencies to cover the costs of services to patients dependent upon such agencies. These services might be developed in connection with exist- ing organizations such as visiting nursing associations; or they might be developed as a part of the agency providing practical nurse-housekeeper service. Some services of this type might be de- veloped as extensions of diet therapy departments in hospitals, par- ticularly those in which there are training courses for dietitians. In whatever particular form the necessary organization may be developed, it should be operated on a not-for-profit basis and should include affiliation with educational institutions responsible for training of nutritionists and dietitians. 4. Consistent efforts should be made to provide adequate occupa- tional therapy and physical therapy services on a visiting basis to patients in their own homes. In general, occupational therapy and physical therapy services should be provided by the same agency 187 with close correlation between them. Like the services mentioned above these services should be provided through a not-for-profit agency serving all economic groups and collecting fees from pa- tients and assistance agencies. The services should, of course, be provided under the direction of the attending physician in all cases. Such services should be developed, if possible, as an expan- sion of the existing services provided by the Visiting Nurse As- sociation and the Illinois Association for the Crippled. Arrange- ments should be included for affiliation with the training courses for occupational and physical therapy technicians. 5. 'Rehabilitation services should he made available to patients in their own homes as rapidly as possible. These should include educational services for patients and their families designed to help patients to learn to live with their handicaps and perform useful activities in caring for their own personal needs as well as those activities designed to help them become self-supporting. Consistent efforts should be made to increase the financial resources and staff of the Illinois Association for the Crippled to a point where the type of services now being provided in their homes for cerebral palsied children and a few other patients can be made available to all patients in need of them. Such services might be developed also as an extension of the proposed new Rehabilitation Center in Chicago and other not- for-profit agencies; the State Division of Rehabilitation; the Divi- sion of Services for Crippled Children; and the Illinois Children’s Hospital-School; or similar agencies or organizations. Wherever such services are developed they should be in agencies which also provide physical and occupational therapy and social case work and should be closely correlated with these services. They should, like other specialized services, be provided in all instances in accordance with the directions of the patient’s physician. Services of this kind are needed by patients able to pay as well as those in the lower financial brackets and should be equally accessible to all economic groups on a reasonable fee-for-service basis. Fees for such service for recipients of public assistance should be recognized as constructive and appropriate expenditures of public assistance funds. There should be provision for affiliation between agencies providing these services and schools for training of occupational and physical therapy technicians and those offering training for 188 social workers, especially child welfare, psychiatric, and medical social work. 6. Efforts should be made to develop more social case work service for financially independent families and wider public understand- ing and more intelligent use of such service by these families. Services now being provided to financially independent families through voluntary social agencies should be more widely publi- cized and made more easily available to financially independent people. Provision should be made for making good social case work service available on a fee basis in attractive surroundings where financially independent families will find the atmosphere less suggestive of social failure and stigma. If possible, this should be accomplished by extension of services of existing agencies. If it can not be done in this way, an experimental service should be es- tablished entirely independent of those serving the poor and should be operated until such time as the value of its service has been demonstrated to the general public. Long-term Care of Patients in Hospitals, Nursing Homes, and Other Institutional Facilities Approximately two thirds of all invalids are cared for by their families in their own homes. The remaining one third, however, can not be cared for in homes of their own either because they are single or widowed people with no relatives to care for them, or because the only relatives they have are, themselves, ill or for other reasons unable to give them the nursing and other care they need. It is estimated that there is a total need in Chicago and Cook County for at least 15,000 beds for patients of this kind. In addition there are significant numbers of patients, now in their own homes, who would like to have care in good nursing homes and are able to pay for it but can not obtain it be- cause of the lack of sufficient good facilities in the community. Characteristics of Patients Pecfuiring Long-term Care in 'Nursing Homes, Hospitals, and Other Institutional facilities. The 15,000 peo- ple who require care outside their own homes include people in all age and economic groups. There are variations, also, in the amounts of care they require and the illnesses from which they suffer. Reliable estimates indicate that a majority of all invalids are peo- ple in the middle and young age groups. Less than one third of the total number of invalids are 65 years of age or older. There are definite variations, however, between the total group of invalids and the smaller group which includes only those requiring care outside of their own homes. A high proportion of children and young adult invalids remain 189 in their own homes. The ability of families to care for an invalid at home, however, decreases as the age of the patient increases. Conse- quently a relatively high proportion of invalids in the younger age re- main in their own homes; and comparatively fewer of them need care in other facilities. The situation is reversed, however, among invalids in the older age group. A recent analysis of approximately 4,000 cases handled by The Central Service for the Chronically 111 showed that 66 per cent of all the patients needing care outside their own homes were 65 years of age or older. Twenty-seven per cent were between 35 and 65 years of age; 5 per cent from 15 to 35 years; and 2 per cent were under 15 years of age. A review of the same records indicated that more than half of all these patients are fully able to pay for their care; less than 10 per cent are unable to pay anything toward the cost of their care; and the remaining 40 per cent can pay part but not all of the costs of the care they need. The amounts these “part-pay” patients could pay ranged from as little as $10.00 to as much as $75.00 per month. Approximately one fourth of this entire group of patients were invalids as a result of hardening of the arteries, high blood pressure, and “strokes” with resulting paralysis. Fourteen per cent of the total number of patients were reported to be “senile” or suffering from the mild mental confusions commonly attributed to “old age.” In actual Diagnoses Percentage of Total Cases Total 100.0 Arteriosclerosis and hypertension including cerebral hem- orrhage and resulting paralysis 24.8 "Senility” and "mild mental confusion” 14.3 Orthopedic impairments, blindness, and deafness including old fractures and injuries 11.9 Diseases of the heart 10.0 Cancer and other malignancies 8.7 Diseases of the nervous system including Parkinson’s Dis- ease, multiple sclerosis, cerebral palsy, etc 7.1 Rheumatism and arthritis 6.3 Mental illness 7.4 Diabetes 7.4 Ulcers of the stomach and duodenum, and other nonmalig- nant diseases of the gastro-intestinal tract 1.7 Vague and ill-defined disorders 4.7 Other miscellaneous conditions 6.7 190 fact, in a very high proportion of these cases the mental confusion is not due to the number of years the patient has lived but to hardening of the arteries. In others, severe nutritional deficiencies are contributing in large measure to these symptoms which are mistakenly regarded as inevitable results of advancing age. These deficiencies, incidentally, are not limited to poor people. They probably result at least as much from poor food habits and lack of good health education for the entire pop- ulation as they do from poverty. The distribution of the various diagnoses among the 4,000 cases studied is shown below. Existing facilities. The 15,000 invalids in the Chicago area who can not receive care in homes of their own are now scattered through a variety of places in the community. Some of these facilities are well equipped and offer good services. Others are not intended for the care of patients of this type; they object to the presence of such patients in their institutions and, while giving them adequate care, are con- stantly trying to "unload” them. These include, particularly, the gen- eral hospitals and some homes for the aged. Some privately operated nursing homes and "boarding homes,” are giving the best service pos- sible within the limits of the low fees being paid them but are never- theless far from adequate. In general, services in these homes can not be markedly improved until realistic provisions are made to meet the costs of satisfactory care for financially dependent people. Many Old Age Pensioners are in homes of this kind and can not obtain better services because they do not receive sufficient money to cover the cost of them. An extremely small number of homes offer low-quality care because of lack of conscience or bad intentions on the part of the op- erator. Of the 15,000 patients now in need of care, approximately 1,500 are in the Cook County Infirmary at Oak Forest; about 4,000 are being cared for in not-for-profit institutions including the infirmary sections of homes for the aged; about 2,000 are in recognized nursing homes or "boarding homes;” 1,500 to 2,000 are backed up in general hospitals against the wishes of the hospitals which need their beds for acutely ill patients; and the remaining 5,000 to 6,000 are scattered through hotels, rooming houses, and other places not equipped to care for the sick. Exclusive of the beds needed for treatment of tuberculo- sis and of mental illness, the Chicago area needs at least 6,000 new beds for long-term care in addition to the total number now in exist- ence. Many of those now available are in buildings which are not safe nor well adapted to this purpose. These beds should be replaced as rapidly as possible. Including additional beds and replacements the Chicago area needs a total of at least 10,000 new beds for long-term 191 care of patients now disabled. Unless effective efforts are made to prevent and control the chronic diseases, this number can be expected to rise steadily in the future. Recommendations: The Central Service for the Chronically 111 believes that these beds should be developed in accordance with the following plan. 1. Consistent emphasis should be placed upon treatment and rehabili- tation of patients. 7o this end efforts should be made to develop in connection with every approved general hospital a unit for long- term treatment and rehabilitation. Each hospital should have in its unit for long-term patients, roughly, two beds for every five beds in its section caring for the acutely ill. The research and educa- tional functions of the hospital should be fully extended into the unit for long-term patients. 2. Privately operated nursing homes and institutional homes for the aged should be regarded as substitutes for or extensions of the care of patients in their own homes. Adequate provisions should be made in these institutions for the same type of care and serv- ice as is carried on in patients* own homes. Intensive treatment, such as can best be given in hospitals, should not be attempted in institutions of this type. These institutions should have close working relationships with hospitals, preferably administrative affiliations or actual man- agement by the hospital. Efforts should be made to bring about such affiliations between existing homes for the aged and hospi- tals as rapidly as possible. 3. 7he total number of privately operated nursing homes should not be significantly increased, but the level of duality should be raised by fostering improvements in existing homes and encouraging the development of good new ones to replace those whose duality of care can not be maintained at an adeduate level. Efforts to im- prove quality of care must include better financing of services and development and use of more practical educational material for the use of persons operating nursing homes or planning to open them. 4. Efforts should be made to remove present restrictions which limit the facilities of the Convalescent Home operated by the City of Chicago “Welfare Department to patients dependent upon the city or county for support. The high quality of care available in this institution should be made available to the greatest possible num- ber of patients. 5. 7he character of the County Infirmary at Oak 7orest should be 192 changed to make it primarily a medical institution. The size of the institution should be reduced and the quality improved. Staff should be added, sufficient in number and qualifications to pro- vide constructive medical attention and rehabilitation. At least half of its total bed capacity should be converted into a general hos- pital serving the southern section of the county. Efforts should then be made to arrange affiliation with a teaching institution. 193 SECTION IX EXCERPTS FROM THE ILLINOIS HOSPITAL SURVEY AND PLAN1 CONCERNING CARE OF THE CHRONIC AND CONVALESCENT By Henrietta Herbolsheimer, M.D., Director of Study, Illinois Hospital Survey Facilities for Chronic and Long-term Convalescent Patients in General Hospitals2 Modern medical science has shortened the convalescence of a great many diseases. There are, however, some notable conditions which require long periods of care with varying degrees of medical, nursing, and custodial services. With the gradual aging of our popula- tion and the growing relative importance of chronic illness of varying grades of disability and seriousness, the medical, social, and economic aspects of this problem merit all the consideration which they are ob- taining at this time. Ever increasing demands are being made of the general hospital in many institutions to the extent of 20 per cent of all beds for care of this group of long-term cases whose stay frequently runs into years. This is a critical problem for the general hospital, the purpose and destiny of which is to provide care and early rehabilitation for the acutely ill. The provision of elaborate equipment and highly trained personnel and the architecture peculiar to general hospitals make for expensive cost of operation. This high cost of care is especially noteworthy be- cause the medical and surgical sections of the general hospital building are not designed to really meet the physical and emotional needs of long-term cases. When full and dispassionate considerations are given to the fact that general hospitals as we understand them today have plants which are attuned to the care of acute illness with large staffs of highly trained nurses and other personnel required for care of pa- Reproduced by permission from draft copy as submitted to the Executive Committee of the Advisory Council on Hospitals, February 25, 1947. 2Ibid, page 10, Section I, “Principle Concepts of Hospital Planning,” Chapter I, Sub- topic 5. 194 dents whose condition may change decisively hour by hour and have preventive medical responsibilities, it seems unwise to permit the mis- use of these highly expert facilities by cases which do not have imme- diate need for such equipment and personnel. To be sure, there is a shortage of beds for the chronic and long-term convalescent and tem- porary expedients will have to be arranged. But vision should not be turned from the fact that the acute units of general hospitals in com- munities of all sizes are constituted both to care for short-term cases amenable to treatment and to afford the principles of prevention to the challenges of chronic illness. These are equal needs of the people. In the past general hospitals have been reluctant to admit long-term patients because of the shortage of hospital beds, the length of stay of these cases, the nonemergent nature of their disease, and the frequent additional obstacle of f