Interim Report of Gommittee on maryland State Planning Gommission January — /Q47 Interim Report of Committee on Wiedical Gare Maryland State IPlanning Commission January — I PUBLICATIOIN NO. 50 For sale by the Maryland State Planning Commission 104 Equitable Building Baltimore 2, Maryland Price 50 cents Contents Page Page LETTER OF TRANSMITTAL FROM MARYLAND STATE PLANNING COMMISSION TO GOVERNOR LANE vii LETTER OF TRANSMITTAL FROM COMMITTEE ON MEDICAL CARE TO MARYLAND STATE PLAN- NING COMMISSION ix INTRODUCTION xi Specific Problems 11 Problem A—Chronic Disease Flospital for the Baltimore Area 12 Problem B—Medical Care of Indigent and Medically Indigent 12 Recommendations 13 Appendix A 14 A Plan For Organized Medical Care For Welfare Clients Residing in Baltimore City 14 Foreword 14 Outline of’Specific Plan 15 Flow of Services Under the Plan 17 ACTIVITIES OF THE COMMITTEE ON MEDICAL CARE (April 1944 to January 1947) 1 Committee on Mental Hygiene 1 Committee to Study the Medical Care Needs of Baltimore City 2 Hospital Survey Committee 2 Executive Committee 3 The State’s Tuberculosis Program 3 Out-Patient Mental Hygiene Service 3 EXHIBIT B—INTERIM REPORT OF THE HOSPITAL SURVEY SUB COMMITTEE 19 Letter of Transmittal from Hospital Survey Committee to Committee on Medical Care 20 Foreword 21 The Federal Hospital Survey and Construction Act 22 The Hospital Survey Committee 23 The Field Survey 25 Hospitals of All Types and Nursing Homes 25 Public Health Facilities 27 Classification of Institutions 27 Local Plans For Flospital Construction 36 State Legislation 36 Recommendations 37 The Study and Plan 38 RECOMMENDATIONS 4 EXHIBIT A—INTERIM REPORT OF THE COMMITTEE TO STUDY MEDICAL CARE NEEDS OF BALTI- MORE CITY 7 Introduction 9 Organization of the Baltimore Committee 9 Outline of Subjects Reviewed by the Committee 10 Summary of Committee Discussions 11 Cist of Tables and Page Service Flow Chart 18 Table A—Medical Institutions in the State of Maryland 25 Table B—Institutions By Type of Ownership or Control By Counties 26 Table C—Institutions By Type of Service 28 Table D—Beds By Type of Institution By Counties and By Type of Patient 29 Table E—Grouped Institutional Bed Complement from Original Classification 30 Table F—Recapitulation of Beds and Institutions after Reclassification 30 Table G—Normal Bed Capacities By Type of Ownership, Type of Hospital and Bed Assignment By Race 31 Table H—General Hospitals, Bed Complement, Normal Bed Capacity and Bed Assignment By Race 32 Table I—Mental Hospitals, Bed Complement and Normal Bed Capacity By Bed Assignment By Race 33 Table J—Tuberculosis Sanatoria, Bed Complement and Nor- mal Bed Capacity By Bed Assignment By Race 34 Table K—Nursing Homes and Institutions for Chronics 35 Table L—Special Hospitals, Bed Complement and Normal Bed Capacity By Bed. Assignment By Race 36 MARYLAND STATE PLANNING COMMISSION Henry P. Irr, Chairman Memher-at-Large William L. Galvin Robert H. Riley State Board of Public Welfare State Department of Health Robert M. Reindollar Thomas B. Symons State Roads Commission Memher-at-Large I. Alvin Pasarew, Director COMMITTEE ON MEDICAL CARE of the MARYLAND STATE PLANNING COMMISSION George M. Anderson, D.D.S. R. Austrian, M.D. Frederic V. Beitler, M.D. Frank L. Black, M.D. J. W. Bird, M.D. T. Roy Brookes B. Lucien Brun, D.D.S. Robert J. Buxbaum James D. Carr, M.D. Alan M. Chesney, M.D. Louis H. Douglass, M.D. * Allen W. Freeman, M.D. Frank J. Geraghty, M.D. *1 Iarry Greenstein R. C. Lamb G. Carroll Lockard, M.D. Mrs. George V. Lottier Samuel Wolman, M.D. George M. Moffett Leslie Moses Thomas W. Pangborn Walter H. Oakes J. Milton Patterson George H. Preston, M.D. C. Pincoffs, M.D., Chairman *J. Douglas Colman, Secretary Robert H. Riley, M.D. Henry E. Sigerist, M.D. *Winford EE Smith, M.D. Walter Sondheim Harvey B. Stone, M.D. Mrs. Thomas J. Tingley Ralph Truitt, M.D. T. J. S. Waxter Huntington Williams, M.D. *C. E. Wise, Jr. Helen E. Wright members of Executive Committee. COMMITTEE TO STUDY MEDICAL CARE NEEDS OF BALTIMORE CITY Lowell J. Reed, Ph.D., Chairman George M. Anderson, D.D.S. Edwin L. Crosby, M.D. C. Reid Edwards, M.D. Herbert Fallin Frank Geraghty, M.D. L. Edwin Goldman Thomas P. Sprunt, M.D. T. J. S. Waxter Harvey H. Weiss H. Maceo Williams, M.D. Huntington Williams, M.D. Samuel Wolman, M.D. W. H. Woody, M.D. Ross Cameron, M.D., ex officio J. D. Colman, ex officio Maurice C. Pincoffs, M.D., ex officio Dean Roberts, M.D., ex officio W. Thurber Pales, Sc.D., Director of Survey HOSPITAL SURVEY COMMITTEE Walter D. Wise, M.D., Chairman J. D. Colman, Secretary J. David Cordle W. D. Noble, M.D. George D. Preston, M.D. R. H. Riley, M.D. Winford EE Smith, M.D. Ernest L. Stebbins, M.D. I Iarvey B. Stone, M.D. Huntington Williams, M.D. C. E. Wise, Jr. Benjamin W. Wright Herbert G. Fritz, Director of Stirvey Peregrine E. Wroth, M.D. Edwin P. Young, Jr. Ralph Young, M.D. Maurice C. Pincoffs, M.D., ex officio E Alvin Pasarew, ex officio MARYLAND STATE PLANNING COMMISSION WILLIAM L. GALVIN ROBERT M. REINDOLLAR •ROBERT H. RILEY THOMAS B. SYMONS HENRY P. IRR Chairman 104 Equitable Building Baltimore 2, Maryland I. ALVIN PASAREW Director February 1, 1947 Honorable William Preston Lane, Jr, Governor of Maryland Annapolis, Maryland My dear Governor Lane: I take pleasure in transmitting herewith, for your consideration, the Interim Report to January, 1947 of the State Planning Commission’s Committee on Medical Care. Contained therein are several important recommendations, notably: 1. That the responsibilities of the Baltimore City Health Department be extended to make them comparable to those previously approved for the State Health Department, having as the first objective the establishment of a program of medical care for the indigent of Baltimore City comple- menting that already established in the counties of Maryland; 2. That the responsibility for administering the State’s tuberculosis program be transferred from the Maryland Tuberculosis Commission to the State Department of Health; 3. That certain legislation necessary to implement and comply with the provisions of the Federal Hospital Survey and Construction Act be enacted; 4. That certain projects now before the Board of Public Works in the construc- tion programs of the State Board of Mental Hvgiene, the LIniversity of Mary- land, and the State Health Department, be pressed to completion; 5. That the State Board of Health be vested with the responsibilitv for main- taining a program of Mental Hygiene integrated with, but in addition to, the institutional program of the Board of Mental Hygiene; and 6. That the Chronic Disease Hospital, “to be located in or near Baltimore,” as authorized by the last Legislature, be built on the grounds of the Baltimore City Hospitals. The Commission and the State is fortunate in having a group of men, such as that comprised in the Committee on Medical Care, so eminently qualified and so willing, without any hope of personal gain or advantage, to undertake the serious responsibility imposed by the original charge to the Committee “to keep under constant survey the problems of medical care for the citizens of this State and to formulate from time to time recommendations for better utilization and for extension of existing medical facilities and for the institution of such new facilities as are required.” The Commission in approving the recommendations of the Committee, believes that its work is of such caliber as to continue to merit your support, as well as that of the public and the professional groups involved. Respectfully yours, Henry P. Irr, Chairman MARYLAND STATE PLANNING COMMISSION WILLIAM L. GALVIN ROBERT M. REINDOLLAR ■ROBERT H. RILEY THOMAS E. SYMONS HENRY P. IRR Chairman 104 Equitable Building Baltimore 2, Maryland I. ALVIN PASAREW Director January 27, 1947 Mr. Henry P. Irr, Chairman Maryland State Planning Commission Baltimore, Maryland Dear Mr. Irr: I have the honor to transmit herewith the Interim Report of the Committee on Medical Care, recording its activities since the publication of its last report in April, 1944. Despite the limited resources available to the Committee, it has, through the ingenuity and self-sacrifice of its members, been able to complete an impressive agenda out of w'hich have grown some significant recommendations for action. These recommendations are stated herein and deserve careful consideration hv your Commission, the State Administration, the Legislature, and by the public. We trust they will bear such scrutiny and will be translated into action. While important recommendations growing out of the work of our Sub-Committee to Study the Medical Care Needs of Baltimore City, and out of the work of the Hospital Survey Committee are included in this report, both of these Committees are still at work. We may expect further recommendations from them for considera- tion by the Committee on Medical Care and your Commission. You also will note that the Committee hopes to find financial support for a review of the tuberculosis program in Maryland. Such review, it feels, is particu- larly appropriate because of the recommended transfer of the responsibilities in this field from one State agency to another. The continuing support of the work of the Committee by your Commission and its staff is gratefully acknowledged. Sincerely yours, £i£L jjjs Maurice C. Pincoffs, M.D., Chairman Committee on Medical Care INTRODUCTION Tn the two prewar years immediately following the formation of the Committee on Medical Care in Jan- uary 1940, the major efforts of the Committee might be classified as “self-education.” It soon became apparent that the most immediate problem existed in the counties of Maryland, and during 1941 a thorough survey of medical care in the counties of Maryland was undertaken. The coming of war prevented the completion of this program, but a body of data had been accumulated which was to prove of great value. In the war years 1942 and 1943 the activities of the Committee were greatly restricted. I lowever, during this period, the data gathered in the field survey were analyzed and the conclusions presented in the report of the Com- mittee issued in April, 1944. The major recommendation of this report was that there be created a Bureau of Medical Services within the State Department of Health, respon- sible for administering a program of medical care for the indigent and medically indigent in the counties of Mary- land. Legislation establishing such a bureau was passed by the 1945 Legislature. In addition, the data of the Com- mittee gave timely assistance to the staff of the Procurement and Assignment Service in meeting both its local and national problems in providing adequate professional staff for the armed services without crippling essential local services. Since the publication of its report in April, 1944, both during the later war period and since, the Committee has engaged in the study of various aspects of medical care in Maryland. These activities and their results to date are summarized in the present interim report. Early in the war the Chairman of the Committee, Dr. Maurice C. Pincoffs, left for service with the armed forces. He was succeeded by Dr. Allen W. Freeman, who served as acting Chairman of the Committee for a short time, and then by Dr. Victor F. Cullen, who in character- istic fashion gave liberally of his time and energy to the affairs of the Committee. Dr. Pincoffs returned to civilian life in the fall of 1946, at which time Dr. Cullen resigned as acting Chairman and Dr. Pincoffs resumed his activity as Chairman of the Committee. ACTIVITIES OF THE COMMITTEE ON MEDICAL CAKE April 1944 to January 1947 The activities of the Committee in greater part have been carried on through special sub-committees appointed to study specific aspects of medical care in the State. In addition, meetings of the Executive Committee have been held to consider points of policy and future plans. The entire Committee has been called together to receive and consider the reports made to it by the sub-committees. Under separate headings the reports of these special com- mittees and the Executive Committee are summarized together with the action taken by the Committee on Medi- cal Care on each of these reports. Finally, the recom- mendations of the Committee on Medical Care are pre- sented in a separate section. of Maryland. The Committee wishes to point out that the State even now is far behind in its program of construction to meet the expanding needs for the care of the mentally ill. The normal increase in population and the concomitant increase in the number of persons requiring care for mental illnesses will not wait for a board to approve or a legislature to act. Mental illness is not going to decline in incidence—rather will it in- crease as life expectancy increases. Increasing urbaniza- tion also increases the need for State hospital beds. The Committee is convinced that the general program pre- sented by the Board of Mental Hygiene is sound and bv no means an excessive one. Indeed it may well be designated a minimal program designed to meet only the immediate needs and absolutely essential to bring the provisions for care of the mentally ill up to the level where they really should be if the State of Maryland is to discharge its obligations in a proper manner. “The Committee gave some consideration to the ques- tion of the relative values of the specific proposals, but quickly came to the conclusion that it was not in a posi- tion to evaluate one proposal as against another because all of the proposed facilities constitute a single unified system for the care of the mentally ill. Consequently, it does not endorse any particular schedule of construction or recommend that one unit be given preference over another. It does wish to point out, however, that dollars spent in the construction of the proposed psycho- pathic hospital would yield a two fold dividend. They would provide an important link in the State’s system of professional education (medical students, physicians, nurses, technicians) and at the same time make a sub- stantial contribution to the care of the mentally ill. The Committee sees no reason why the construction of this hospital should await the completion of all the other units that have been proposed; it feels that the best interests of the mentally ill will be served if construction of all of the units proceeds at the same time. Following the submission and acceptance of this report, the Special Committee was discharged with thanks by Dr. Victor Cullen, Acting Chairman. Committee on Mental Hygiene During 1944 the State Board of Mental Hygiene, along with other State departments, prepared an exhaustive pro- gram of construction, outlining the major items of new construction and rehabilitation which were to constitute its post-war construction program. These recommendations were referred to the State Planning Commission, which requested the advice of the Committee on Medical Care. Accordingly, on August 11, 1944 a special committee was appointed to review this program. The personnel of the Committee was as follows: Ross McC. Chapman, M.D. J. Milton Patterson Louis H. Douglass, M.D. Robert IT Riley, M.D. Walter N. Kirkman J. C. Whitehorn, M.D. Alan M. Chesney, M.D., Chairman In November 1944 the special committee submitted its report, which was concurred in by the Committee on Medical Care and the State Planning Commission and forwarded to the Board of Public Works. The essential features of this Committee’s report are as follows: “The Committee voted to approve in principle all of the proposals of the State Board of Mental Hygiene de- signed to meet the immediate needs for the care of the mentally ill of the State, including the recommendation that a psychopathic hospital be constructed as an in- tegral part of the School of Medicine of the University 2 Interim Report of Committee on Medical Care Committee to Study the Medical Care Needs of Baltimore City Baltimore City Medical Society, to which all physicians practicing in Baltimore were invited. In both instances the proposed plan was approved by vote of an over- whelming majority. On December 27, 1946, the interim report of Dr. Reed’s Committee was formally presented to the Committee on Medical Care. After discussion, the Committee on Medical Care voted unanimously to approve this report and to include its recommendations in its own report to the State Planning Commission. In accordance with its previously announced intention, the Committee on Medical Care, in 1944, laid plans to undertake the second step of its program, which was to study the complex medical needs of Baltimore City. The Committee was fortunate in securing Dr. Lowell J. Reed to serve as Chairman of this important undertaking. In August, 1944, the appointment of the Committee was announced, with the following personnel: Hospital Survey Committee Lowell J. Reed, Ph.D., Chairman George M. Anderson, D.D.S. Edwin L. Crosby, M.D. C. Reid Edwards, M.D. Herbert Fallin Frank Geraghty, M.D. L. Edwin Goldman Thomas P. Sprunt, M.D. T. J. S. Waxter Harvey H. Weiss H. Maceo Williams, M.D. Huntington Williams, M.D. Samuel Wolman, M.D. W. H. Woody, M.D. Ross Cameron, M.D., ex officio J. D. Colman, ex officio Maurice C. Pincoffs, M.D., ex officio Dean Roberts, M.D., ex officio In anticipation of the passage of Federal legislation pro- viding for grants-in-aid to States for hospital construction, the Committee on Medical Care appointed a I lospital Survey Committee in December, 1945. Later, Congress passed such legislation, now known as the Hospital Survey and Construction Act, P.L. 725-US-1946. Federal funds can be made available to States on a matching basis under certain conditions, the most important of which are that: (a) The State must designate a single State agency with an appropriate advisory council to make an initial inventory of the hospital facilities of the State and to develop therefrom a plan for such expansion and integration of these facilities as may be found to be necessary, and (b) The State must, designate a single State agency which is to administer the construction phase of the program in accordance with the State plan devel- oped as outlined in (a) above. Through the cooperation of the Baltimore City Depart- ment of Flealth and the Maryland State Planning Com- mission, the services of Dr. W. Thurber Fales were secured as Director of Survey. This Committee has been actively at work and has accumulated a vast amount of data concerning many phases of the medical care problem. The understanding of the Committee has been appreciably broadened by many of the unique tabulations of this mate- rial that have been prepared by Dr. Fales and Dr. Reed. Many significant correlations previously unproved, or un- recognized, have been revealed. These studies of the Committee to Study the Medical Care Needs of Baltimore City led to certain specific recommendations which it was felt required immediate attention by the Committee on Medical Care and by the current session of the General Assembly. For this reason an interim report was prepared and presented to the Committee on Medical Care, and is attached hereto as Exhibit A. The recommendations of this interim report, if adopted, materially affect the present organization of medical care in the City of Baltimore. In all instances, responsible authorities of the health agencies concerned were fully consulted by the Committee and their concurrence re- ceived prior to the formulation of the report. The pro- posal of a specific program of medical care for public assistance clients in Baltimore involves the cooperation of the larger out-patient departments of the hospitals of the City as well as that of the practicing physicians. Repre- sentatives of Dr. Reed’s Committee presented these pro- posals to a special meeting of the Baltimore Hospital Conference, and to a special meeting called by the Governor O’Conor designated the Maryland State Plan- ning Commission as the agency in Maryland to under- take the survey phases of this program and the Hospital Survey Committee, previously discussed, was selected as the advisory council to this agency, as provided for under the Federal legislation. Dr. Walter D. Wise, the chief of staff of Mercy Hospital, accepted the chairmanship of this Committee, the entire membership of which is as follows: Walter D. Wise, M.D., Huntington Williams, M.D. Chairman C. E. Wise, Jr. J. D. Colman, Secretary Benjamin W. Wright J. David Cordle Peregrine E. Wroth, M.D. W. D. Noble, M.D. Edwin P. Young, Jr. George H. Preston, M.D. Ralph Young, M.D. R. II. Riley, M.D. Maurice C. Pincoflfs, M.D., Winford II. Smith, M.D. ex officio Ernest L. Stebbins, M.D. 1. Alvin Pasarew, Harvey H. Stone, M.D. ex officio 1 he necessary budgetary assistance was secured through the State Planning Commission, and Mr. FI. G. Fritz was secured as Director of the Survey. The Committee has completed the inventory phase of its work and is now 1 Iospital Survey Committee 3 concerned with the analysis of the data obtained, and with the development of an over-all plan to govern the extension of Maryland's hospital facilities. Attached hereto as Exhibit B is the interim report of this Committee. This interim report was presented to the Committee on Medical Care at its meeting on December 12, 1946. The recommendations made bv the 1 Iospital Survey Commit- tee for legislative action necessarv to enable the State of Maryland to participate fully in the benefits of the I Iospital Survey and Construction Act, were considered carefully and were unanimously approved. In the present report of the Committee on Medical Care to the State Planning Commission these recommendations are included. December 12, 1946, the above information and actions taken were presented. The Committee on Medical Care unanimously agreed to recommend to the State Planning Commission that the transfer be effected. The Committee on Medical Care in its discussion of this subject considered the advisability of a thorough survey of the existing program for the control of tubercu- losis in Maryland. It was the general consensus of the Committee that such a survey would be desirable, espe- cially if its recommendation for the transfer of the sana- toria to the State Department of I lealth were adopted. The Chairman and the Executive Committee were author- ized to explore the possibilities of obtaining funds from private sources to employ a recognized authority to conduct the proposed survey. Executive Committee The State’s Tuberculosis Program Out-Patient Mental Hygiene Service To obtain full information concerning the advantages and disadvantages of the proposed transfer of the State Tuberculosis Sanatoria from the Maryland Tuberculosis Commission to the State Department of Health, the Executive Committee called a special meeting to consider this subject, to which were invited those with specific responsibilities or interests in this field. Those who attended the meeting were as follows: Maurice C. Pincoffs, M.D., Leroy Allen, M.D. Chairman Miriam Brailey, M.D. Charles R. Austrian, M.D. H. Warren Buckler, M.D. Allen W. Freeman, M.D. Walter N. Kirkman I larry Greenstein R. H. Riley, M.D. Winford II. Smith, M.D. G. Canby Robinson, M.D. C. E. Wise, Jr. Huntington Williams, M.D. Very full discussion was held, and there was general agreement on the desirability of coordinating the State’s tuberculosis work, and on the advantages which would accrue if the facilities for case finding, clinics for out- patient care and necessary laboratory facilities were com- bined under the same administration with the sanatoria. Placing of all these responsibilities under the State Depart- ment of Health has the manifest advantage that this State agency has its health officers and nurses already in every county of the State, as well as its regional laboratories, and is already actively engaged in the field of case detection, and prevention of tuberculosis. At the close of the meeting the Chairman polled all those present, and there was unanimous approval of the transfer of the responsibility of administering the State sanatoria to the State Department of Health. The Executive Committee was informed further that by formal action the Maryland Tuberculosis Commission had expressed its approval of the transfer and similar formal action of approval had been recorded by the State Board of Health. At a meeting of the Committee on Medical Care on Prior to the outbreak of war the Mental Hygiene Society of Maryland sponsored clinics held at irregular intervals in various Maryland counties. Phis experience indicated a widespread need for such service, as well as an increasing public demand. It was impossible to con- tinue these clinics during the war, but after the cessation of hostilities the subject of organized provision of mental hygiene clinics throughout the State was taken up, and tentative agreement reached between representatives of the Mental Hygiene Society, the State Board of Health, and the Board of Mental Hygiene, that the administration of such clinics would most effectively be undertaken by the State Board of Health. The Executive Committee, at a meeting on November 15, 1946, invited representatives of the organizations named above to present the details of the project. Those present were: Maurice C. Pincoffs, M.D., Walter N. Kirkman Chairman I. A. Pasarew Charles R. Austrian, M.D. George H. Preston, M.D. J. D. Colman R. H. Riley, M.D. Harry Greenstein Huntington Williams, M.D. Winford H. Smith, M.D. Walter D. Wise, M.D. C. E. Wise, Jr. Peregrine E. Wroth, M.D. It was the consensus of the meeting that the State Board of 1 lealth, through its State-wide organization of county health officers and nurses, was the agency best qualified to administer a non-institutional mental hygiene service utilizing, for professional aspects of the work of the clinics, physicians designated by the Commissioner of Mental Hygiene, as well as those recommended by the Mental Hygiene Society of Maryland. On December 12, 1946, the Executive Committee presented these conclusions to the Committee on Medical Care, which agreed unanimously to recommend such a program to the State Planning Commission. 4 Interim Report of Committee on Medical Care RECOMMENDATIONS I. In order to extend to Baltimore City the benefits of a State-supported medical care program analagous to that already in operation in the counties of Maryland, it is necessary that an agency for administering the City pro- gram be selected. The Health Department of Baltimore City is already engaged in a large program of preventive medicine involving the operation of many special clinics, visiting nurse service, laboratory service and a hospital for communicable diseases. These activities have brought it in close working relation with the practicing physician and the various medical institutions of the City. The success of a medical care program will depend upon the close integration of these existing facilities for preventive medi- cine with those to be provided for the care of the sick. It is the opinion of the Committee, therefore, that the Baltimore City Flealth Department is the logical govern- mental agency to be entrusted with the operation of the medical care program to be developed in the City of Balti- more. Therefore, the Committee on Medical Care recom- mends that: It should be publicly recognized that the conservation of the health of the community and the individuals residing therein is officially the responsibility of the Baltimore City Health Department. In addition to the usual services of public health, which includes sanitation, the prevention of communicable diseases and positive health services in such fields as maternity and child hygiene, the Flealth Department should assume com- munity leadership in the coordination of medical facili- ties in such a manner as will best serve the interests of the citizens of Baltimore City. In carrying out this recommendation there should be established in the City Health Department, at an early date, a Medical Care Section under the direction of a qualified medical administrator. care program to be administered by the Baltimore City Health Department. III. The medical care program outlined in the Interim Report of the Committee to Study the Medical Care Needs of Baltimore City (Appendix A to Exhibit A), which already has been studied and approved by some of the hospitals involved, by the Baltimore Hospital Conference, and by the medical profession, not only will offer to the indigent a more complete form of medical care than any heretofore available, but also will bring into working affilia- tion; practicing physicians, hospital out-patient departments, and the health department clinics. Thus, a most desirable coordination of medical resources will be achieved, which now is seriously lacking. The contacts and conferences between physicians engaged in general practice, those working in hospitals and those associated with the City Health Department will have a distinct educational value and tend thus to raise the level of medical care for the whole community. Therefore, the Committee on Medical Care recommends that: A program as outlined in Appendix A of the attached Exhibit A be adopted to meet the medical care needs of the recipients of public assistance in Baltimore City. IV. From a study of the experience of other States, and out of intimate acquaintance with the problem on the part of many of the committee members, has grown a strong feel- ing in the Committee that, if chronic disease hospitals are to function effectively as curative institutions rather than mere repositories for persons suffering from long term ill- nesses, they must be closely affiliated with and immediatelv adjacent to general hospitals caring for the acutely ill. In addition, there are obvious economies in the avoidance of duplicated service, operating room, laboratory, x-rav and other specialized facilities, inherent in this proposal. Therefore, the Committee on Medical Care recommends that: The grounds of the Baltimore City Hospitals be selected as the site for the proposed State Chronic Disease Hospital to be erected in the Baltimore area, and that this chronic disease hospital be closely integrated as to medical staff and facilities with the Baltimore City Hospitals through appropriate cooperative administrative agreements. II. Since the legislation providing for the medical care of the indigent and medically indigent in Maryland vests the administration of this program with the State Depart- ment of Health, it will be necessary, if the Baltimore City Health Department is to administer a similar medical care program in Baltimore City, to enact legislation permitting the transfer of funds. Therefore, the Committee on Medi- cal Care recommends that: Legislation be enacted necessary to permit the State Board of Health to transfer to the City of Baltimore such State funds as are available for the support of a medical Recommendations 5 V. 1 he State Board of I lealth is now responsible for a program of tuberculosis prevention, for case Ending, for recording reported eases of tuberculosis, and for maintain- ing clinic facilities for ambulatory tuberculosis patients. It is considered that separate responsibility for the care of the tuberculosis patient; (1) during the hospital phase of his illness, and (2) during the longer period in which he lives in the community, is a handicap to an efficient pro- gram of tuberculosis prevention and control. Therefore, the Committee on Medical Care recommends that: The responsibility for the administration of the State tuberculosis sanatoria be transferred from the Maryland Tuberculosis Commission to the State Department of Health, and that the necessary legislation to effect this transfer, along with the necessary transfer of budget and fiscal responsibilities, be enacted. VI. Linder the provisions of the Federal Hospital Survey and Construction Act, P. L. 725-L1S 1946, a single State agency must be designated to administer the construction phases of that Act, as provided for in Sections 621, 622, 623, 624 and 625 of that Act, and in accordance with the State plan developed under Sections 611 and 612 of that Act, now being carried on by the Hospital Survey Com- mittee of the Maryland State Planning Commission. Inasmuch as the responsibility for hospital licensing now is vested with the State Department of Health, along with the responsibility for administering the State’s chronic disease hospital program, it is felt that the State Board of Health is the logical agency in Maryland to charge with the responsibility of administering this program. This pro- posal is in accord with the action taken by the majority of other States and with the recommendations of the Colmcil on State Governments. Therefore, the Committee on Medical Care recommends that: Legislation be enacted necessary to designate the State Board of Health as the agency to administer the con- struction phases of the program outlined in the Federal Hospital Survey and Construction Act, P. L. 725-US 1946; and further such legislation include the authorities necessary to comply with the various provisions of that Act. VII. The clear intent of the Federal Flospital Survey and Construction Act is that first consideration be given to non- urban needs. In Maryland this is particularly appropriate since many of the most urgent institutional needs are in the counties of Maryland. The Committee has no thought of urging the entrance by the State of Maryland into the held of providing hospital care for the acutely ill through the operation and ownership of institutions for this pur- pose. I lowever, the Federal I lospital Survey and Con- struction Act provides that at least two-thirds of the cost of any project undertaken under the Aet must be met from State, local, or private funds before Federal funds are available. Therefore, it is likely that certain counties of Maryland, desirous of facilitating the erection of hospitals, will End themselves unable to participate in this program because of lack of authority to raise funds to match the Federal con- tribution. Since it is expected that Federal funds will shortly be available under this program, and since the Maryland State Legislature will not meet for at least one year, and possibly two, it is felt desirable that some authority be granted to counties and municipalities which would enable them to raise funds in order to participate in this program if they so desired. It is proposed, however, that such legislative authority apply only to funds to be used for participating in a project properly authorized under the provisions of the Hospital Survey and Construction Act and in accordance with the State plan developed for Maryland for which Federal matching funds are available. This would avoid the objec- tion that the authority contained in such legislation might be used to undertake uneconomic or over-expansive projects. Therefore, the Committee on Medical Care recommends that: Legislation be enacted authorizing counties and municipalities to issue bonds, or other evidences of indebtedness in excess of their present statutory debt limits, the proceeds from which can be used only to provide a portion or all of the non-federal share of funds for hospital construction authorized under P. L. 725-US 1946. VIII. The proposal that a hospital for the care of acute psychopathic disorders be erected in conjunction with the University Hospital in Baltimore has been widely approved. An appropriation sufficient for only a part of its cost now is available to the University of Maryland. A sub committee of the Committee on Medical Care, appointed to review the construction program of the State Board of Mental Hygiene, recommended that the construction of this insti- tution be given the highest possible priority in the State’s post-war construction program. Such an institution would give needed stimulus to the training of physicians at the Medical School of the University of Maryland in the care 6 Interim Report of Committee on Medical Care of mental disease. By providing facilities for teaching and research at a graduate level, it would elevate the quality of professional care available to patients in other State institutions for mental patients. To be fully effective, it is imperative that the medical, educational, and administra- tive policies of such an institution be closely integrated with those of the institutions administered by the State Board of Menal Flygiene. Therefore, the Committee on Medical Care recommends that: The additional funds necessary should be allocated for the construction of a hospital for the care of acute psychopathic patients as an addition to the present Uni- versity Hospital in Baltimore; and that the construction of this project be given the highest possible priority and pressed to completion. IX. Late in 1944, a sub-committee of the Committee on Medical Care appointed to review the construction pro- gram proposed by the Board of Mental flygiene for inclu- sion in the State’s post-war construction program said: “Fhe Committee wishes to point out that the State even now is far behind in its program of construction to meet the expanding needs for the care of the mentally ill. The normal increase in population and the concomitant increase in the number of persons requiring care for mental illnesses will not wait for a board to approve or a legislature to act. . . . The Committee is convinced that the program pre- sented by the Board of Mental Flygiene is sound and by no means an excessive one. Indeed it may well be desig- nated as a minimal program designed to meet only the immediate needs and absolutely essential to bring the pro- visions for care of the mentally ill up to the level where they should be if the State of Maryland is to discharge its obligations in a proper manner.” In this view, the Com- mittee on Medical Care wholly concurs. It also endorses the decision of the Board of Mental Flygiene to place first emphasis on the construction of adequate service facilities and housing for personnel so that the quality of care available even to the present patients in such institutions will be improved before any attempt is made to expand the number of patients cared for. Therefore, the Committee on Medical Care recommends that: The requests for funds now before the State Board of Public Works, or included in the budgets of the various State Mental Hospitals’ 1947-1949 biennium, for oper- ating purposes, for rehabilitation of plant, for construc- tion of sendees and personnel housing, and for limited construction of new patients’ facilities, be granted in their entirety. X. Certain Federal funds now are available for matching State and local funds in the support of non-institutional mental hygiene sendee. A service of this type would be very much akin to that now conducted by the State Board of I lealth in other fields of illness, such as tuberculosis, venereal disease, orthopedics, obstetrics, etc. Under existing Maryland legislation, the Board of Mental Hygiene is charged with the responsibility for the care of the mentally ill, and under the provisions governing the Federal funds it is likely that Maryland’s share would necessarily go to the Board of Mental Hygiene, whereas this out-patient program might most logically be administered as a part of the present out-patient service of the State Board of Health. Therefore, the Committee on Medical Care recommends that: A division of mental hygiene be created in the State Department of Health; and further that legislation be enacted necessary to permit the State Board of Health to receive and expend Federal funds to be matched with local funds in the support of a mental hygiene service for out- patients, the professional phases of which are to be integrated as closely as possible with the professional programs of the State mental hospitals. 7 EXHIBIT A INTERIM REPORT to the COMMITTEE ON MEDICAL CARE of the MARYLAND STATE PLANNING COMMISSION from the COMMITTEE TO STUDY THE MEDICAL CARE NEEDS OF BALTIMORE CITY December, 1946 9 INTRODUCTION 4 t the request of the Medical and Chirurgical Faculty of Maryland, the Committee on Medical Care was established early in 1940 as a standing committee of the Maryland State Planning Commission. Because of the urgent problems of medical care in the counties of Mary- land, the Committee turned its first attention to a study of these needs. A field survey of the medical facilities available in the counties was conducted during 1941. The analysis of these data, however, was delayed by the exi- gencies of the war. A “Report on Medical Care in the Counties of Maryland” was finally published by the Maryland State Planning Commission in April, 1944. The principal recommendation called for the establish- ment of a program by the State of Maryland for the medical care of the indigent and the medically indigent. The report recommended that the formulation of the program and its administration should be the responsibility of the State Department of Health. In order to implement this recommendation, the report advocated that the State Board of Health be authorized to establish a Council of Medical Care to act in an advisory capacity and a Medical Care Section within the State Department of Health. The report further recommended that the county health officer should administer the local aspects of the medical care program in cooperation with the county medical societies. In February, 1945 the General Assembly of Maryland passed a law authorizing the State Board of Health to establish a Bureau of Medical Services that should begin its work on July 1, 1945. The law provides that: “The Bureau of Medical Services, under the direction of the Director of Health, shall administer a program of medical care in the State of Maryland for indigent and medically indigent persons, or either of such classes; for the purpose the Bureau of Medical Services is hereby authorized to contract with physicians, dentists and hos- pitals for the medical, dental, surgical and hospital treat- ment of eligible persons; within the provisions of the budget the said Bureau is hereby authorized to provide bedside nursing care for eligible persons.'’ The program for the first two years under this legislation was limited to the counties of Maryland in accordance with the recommendation in the Report on Medical Care in the Counties of Maryland. The Committee on Medical Care in this report, however, recognized that a program should be developed to accomplish similar results in Baltimore City, but considered that such a program should be the subject of a separate inquiry and report by a local com- mittee. Organization of the Baltimore Committee On August 5, 1944, Dr. Victor F. Cullen, Acting Chair- man of the Committee on Medical Care, appointed the following Committee to study the medical care needs of Baltimore City: Lowell J. Reed, Ph.D., Chairman George M. Anderson, D.D.S. Edwin L. Crosby, M.D. C. Reid Edwards, M.D. Herbert Fallin Frank J. Geraghty, M.D. L. Edwin Goldman Thomas P. Sprunt, M.D. T. J. S. Waxter Harvey H. Weiss H. Maceo Williams, M.D. Huntington Williams, M.D. Samuel Wolman, M.D. W. H. Woody, M.D. In a letter to the Chairman dated September 21, 1944, Dr. Cullen charged the committee as follows: "It is the privilege and the responsibility of your Com- mittee: to take a broad view of the work of all these medical care resources of Baltimore; to outline a pattern of relationship among them and to suggest any intensification or curtailment of the activi- ties of any of them which will make their efforts most productive; and to suggest the means for translating modern health and medical knowledge most fully into service available to citizens—both sick and well.” Ihe first meeting of the Committee was held on Sep- tember 27, 1944 and was devoted to a discussion of the objectives as stated in the above charge. The Committee agreed to review the activities of all the private, voluntary and governmental agencies which are connected with the problem of medical care, with a view to suggesting means for the integration of all these activities into a program of medical care as beneficial as possible to all the people of the city. To enable the Committee to review these activities in a systematic manner, the chairman was authorized to organize a small staff to prepare the factual material required in the 10 Interim Report of Committee on Medical Care committee’s study of the problem. Dr. I luntington Williams, Commissioner of Health of Baltimore City, made available to the committee the services of Dr. W. Thurber Fales, Director of the Statistical section of the Baltimore City Health Department, to have charge of the collection and analysis of these data. Dr. Fales was also selected to serve as secretary of the Committee. Well baby clinics Immunization clinics Other Health clinics Babies’ Milk Fund Association Industrial I lospitals Public Baltimore City Hospitals Sydenham Hospital Private General Special Auxiliary Facilities Laboratories Hospital Health Department Private X-Ray Other D. Distribution of sickness load E. Adequacy or inadequacy of facilities to meet needs F. Financial problems involved Cost of services Individual aspects Institutional aspects Public participation Hospital and other forms of health insurance G. Outstanding problems requiring special study Domiciliary and ambulatory care Welfare clients Population in general Dental care Convalescent care Home Institutional Hospitalization and home care of chronic ill Nursing homes Correction of remedial defects Rehabilitation H. Possible solutions The discussions of the Committee have followed this outline in a systematic fashion with the exception that the financial aspects of the problem have not as yet been studied in detail. Later deliberations of the Committee will deal more fully with this phase and also will cover more Outline of Subjects Reviewed by the Committee During the last two years, the Committee has met at frequent intervals to study the material assembled by the working staff under the direction of the chairman. The wide range of subjects covered in this review is illustrated by the following outline that is modified but slightly from that presented at an early meeting of the Committee. OUTLINE A. Population Composition Race, age, income, family size, geographic dis- tribution • Trends Changing age composition, aging of the popula- tion, increase in Negro component B. Estimates of illness Prevalence and incidence Distribution Race, sex, age, income Causes of illness and disability Geographic distribution Source of data—Eastern Health District Studies Other studies Selective Service examinations C. Facilities for medical care Physicians Number and distribution General practitioners—specialists Trend Dispensaries—out-patient departments General and special Public dispensaries of Department of Public Welfare Health Department clinics Tuberculosis Venereal disease Prenatal Exhibit A 11 completely those aspects of the problem that the com- mittee has so far considered in only a general way. The Committee is not prepared at the present time to submit a final report giving the detail evidence that has been collected around this outline and the conclusions that follow from this evidence. There are, however, sev- eral urgent issues that should be brought to the attention of the Committee on Medical Care of the State Planning Commission; hence this interim report. Summary of Committee Discussions As the Committee proceeded in the study of medical care in Baltimore City, the complexities of the problem stood out more and more clearly. It became apparent that the medical care program for an urban community like Baltimore City has many different facets. It could not con- fine itself to the physician’s care of individual patients even though this included provisions for hospital care, dental care or nursing care. The Committee's study of the distribution of illness revealed clearly that it is erroneous to consider the popu- lation as separated- into two groups—the ill and the well. Health or its converse, illness, is a graded matter for every individual. In a very true sense it may be said that each person is ill to a certain degree and well to a certain degree. Thus the individuals in the population may be graded into ordered classes such as, essentially well, ill to a minor degree, more seriously ill, ill to the extent of calling for highly specialized services. A person’s need for medical services depends upon his position within this classifica- tion and his passage from one category to another. Thus the problem of medical care involves a constant screening process that is carried out partially by the individual him- self, partially by the physician, and partially by the various agencies and organizations that are concerned with main- taining or restoring health. With the tremendous advances in the science of medi- cine, the interest of a larger and larger share of the medical profession is focused on illnesses that require special diag- nostic and therapeutic facilities. A decreasing proportion of the time and energy of the medical profession is avail- able for problems of medical care related to the treatment of minor illness and the maintenance of health. This lack of balance in medical effort is at variance with the objec- tives of a medical care program for a community, which are to maintain its population in health, to prevent minor illnesses from developing into major ones, and to restore to health as rapidly as possible those who have become ill. To correct this we need to develop preventive services that will be integrated with our present diagnostic and therapeutic facilities. This calls for the creation of medical centers offering comprehensive medical care. Although such a program is not yet available to the population, much can be accomplished by a better coordination of the services offered by physicians, hospitals, clinics, the City 1 lealth Department and the many other public and private agencies. That this is the case is well illustrated by the achieve- ments in the fields of maternity, infant and child care where the Baltimore City Health Department, in coopera- tion with the physicians of the city, has provided better organization of medical services for both well and ill. This cooperation has expressed itself in such ways as; (1) the continuous campaign for diphtheria toxoid inoculation for infants, in which the physicians of the city play an impor- tant role by giving an ever-increasing proportion of the inoculations, and (2) the investigation of every maternal death and its subsequent review, at the monthly meeting of the Joint 1 lealth Department and City Medical Society’s Committee on Maternal Deaths, for the purpose of deter- mining which ones of these are preventable. These are but instances of a number of cooperative efforts that have led to a striking improvement of health and to a consider- able conservation of life in the maternity and infancy groups. Consideration of the needs previously expressed for more comprehensive medical services with an increased emphasis on preventive medicine, and realization of the accomplish- ments obtained in certain fields through cooperative efforts, led the Committee to its first major recommendation, which is as follows: That the responsibility for coordination of all the Health Services for the population of the city should be publicly acknowledged as a proper function of the City Health Department. In carrying out this responsibility, the City Health Department should utilize the services of a qualified full-time medical administrative officer who will, under the Commissioner of Health, be responsible for planning and executing the program of a new Medical Care Section within the City 1 lealth Department. Specific Problems The Committee’s study of the various factors influencing the problems of medical care in Baltimore revealed numer- ous shortcomings in specific facilities and programs. Many of these have been reviewed in the past and recommenda- tions for remedial measures have been made. In some instances action has been taken to correct deficiencies, but 12 Interim Report of Committee on Medical Care in recent years war conditions have delayed implementation of recommendations already accepted by governmental authorities. In order that certain deficiencies may receive immediate attention by the Committee on Medical Care and by the coming session of the General Assembly, rec- ommendations on two specific problems are presented in this interim report. Problem A—Chronic Disease Hospital for the Baltimore Area The population of Baltimore is steadily aging. The proportion of the population over 45 years of age increased from 20.5 percent in 1910 to 26.5 percent in 1940. The relative increase in the population 65 years of age and over has been even greater, rising from 4.2 percent in 1910 to 6.8 percent in 1940. In the future the proportion of elderly persons will continue to increase. A recent survey of illness in 1,500 families living in the Eastern Health District of Baltimore revealed that twenty percent of the population over 40 years of age suffers from chronic disease. Approximately three-fourths of the sick days for persons over 40 years of age in these families were due to chronic disease. The Committee found that these illnesses present one of the most pressing medical problems facing the community. Between 500 and 600 chronically ill persons are continually on waiting lists for hospital beds. The last session of the General Assembly provided for the construction of three chronic disease hospitals in the State. The law provides that one should care for long- term patients from Baltimore City and the five counties— Anne Arundel, Baltimore, Carroll, klarford and Howard. In discussing the location of these State Hospitals for Chronic Disease, the original report of the Governor’s Com- mission on Chronic Diseases recommended that these insti- tutions should be built in proximity to general hospitals, in order that the special facilities of such hospitals might be available to the chronic ill as required. The Committee’s study of this problem led to the same conclusion, and the Committee has already submitted on January 7, 1946, to the Committee on Medical Care and the State Board of Health the following resolution on the location of the insti- tution for the Baltimore area: “The Committee recommends that the Baltimore City Hospitals grounds be selected as a site for the chronic hospital for the Baltimore area and that the chronic hospital be closely integrated as to medical staff and facilities with the Baltimore City Hospitals through appropriate cooperative agreements.'' The Committee reaffirms this resolution and incorporates it in this report as one of the items that needs immediate action. In taking this action, the Committee realizes that adequate provision for hospitalization for the chronic ill represents but one phase of the problem. The final report will contain the Committee’s recommendations for handling other aspects of this growing problem. Problem B—Medical Care of Indigent and Medically Indigent The second pressing problem is one for which the State has recognized its responsibility and is one of the specific items which led to the appointment of the present Baltimore Committee. This problem is concerned with the provision for medical care to recipients of public assistance and other persons in low economic groups. As the Com- mittee reviewed the medical services for these groups as now provided by the Department of Public Welfare of Baltimore City, it found many deficiencies that have devel- oped because of the lack of any organized plan of medical service to individuals in these groups. A program for providing medical care to corresponding groups in the counties of the State was inaugurated on July 1, 1945. While the program for a similar service in Baltimore City should be an extension of that already inaugurated in the counties, the pattern of service will be different in order that the greater medical facilities of the city may be utilized. The program, however, should be acceptable to the State Bureau of Medical Services and the State Council on Medical Care which are charged by law with the formulation of programs for such medical service throughout the State. The Committee’s third recommendation is that a specific plan be adopted to meet the medical care needs of the welfare population of Baltimore City. The essential ele- ments of such a plan are presented in Appendix A. Although the suggested plan is directed at welfare clients, it is the belief of the Committee that it could be extended to pick up the problem of the medically indigent as soon as the service is sufficiently well organized to handle the load of individuals now on direct public assistance. The development and administration of the program should be the responsibility of the Commissioner of Health of Balti- more City, but would require the creation of a Medical Care Section in the Health Department for its specific administration. Exhibit A RECOMMENDATIONS In the present interim report, the Committee submits to the Committee on Medical Care of the State Planning Commission, the following three recommendations: 1. It should be publicly recognized that the conservation of the health of the Community and the individuals residing therein is officially the responsibility of the Baltimore City I lealth Department. In addition to the usual services of public health, which includes sanitation, the prevention of communicable diseases and positive health services in such fields as maternity and child hygiene, the Health Department should assume community leadership in the coordination of medical facilities in such a manner as will best serve the interests of the citizens of Baltimore City. In carry- ing out this recommendation there should be estab- lished in the City Health Department at an early date, a Medical Care Section under the direction of a qualified medical administrator. 2. The Committee recommends that the Baltimore City Hospitals grounds be selected as a site for the chronic hospital for the Baltimore area and that the chronic hospital be closely integrated as to medical staff and facilities with the Baltimore City Hospitals through appropriate cooperative agreements. 3. 1 he Committee recommends the adoption of an organized plan for meeting the medical care needs of the recipients of public assistance. Such a pro- gram should meet emergency medical needs of this group and should also provide a comprehensive medi- cal service for their long-term needs. The specific elements of such a plan are presented in Appendix A of this report. 14 Interim Report of Committee on Medical Care APPENDIX A A PLAN FOR ORGANIZED MEDICAL CARE FOR WELFARE CLIENTS RESIDING IN BALTIMORE CITY FOREWORD rp he following outline presents the essential elements of a plan for medical care of public assistance clients of Baltimore City. It has been prepared by the Committee to Study the Medical Care Needs of Baltimore City for submission to the Committee on Medical Care of the Maryland State Planning Commission. While it forms a part of an interim report to the State Committee on Medical Care, it will be included as an appropriate section of the final report of the Committee. The ultimate objective is to provide for the welfare group in the city, continuous medical care comprising preventive, diagnostic, and therapeutic services, and such auxiliary services in the fields of dentistry, nursing, and rehabilitation as are feasible. The program suggests the organization of medical centers associated with existing hospitals in order to provide a system of home and ambulatory medical care through the integration of the facilities of the hospital dispensary and the services of the physicians practicing in the area. Exhibit A 15 OUTLINE OF SPECIFIC PLAN 1. The planning and administration of medical care for welfare clients of the Department of Public Welfare of Baltimore City should be the responsi- bility of the Commissioner of Health of Baltimore City. For this purpose there should be created in the Baltimore City Health Department, a Medical Care Section. An Advisory Committee on Medical Care composed of representatives of participating pro- fessions and groups should be appointed by the Com- missioner of Health to assist in the planning and to advise on administrative policy. 2. Each family or individual accepted for public assist- ance by the Department of Public Welfare of Balti- more City will be certified to the proposed Medical Care Section as eligible for medical care. The Depart- ment of Public Welfare will furnish the Medical Care Section with a statement as to the assistance classification of the client and such other information contained in the welfare records as may be required, to plan for appropriate medical care. The Medical Care Section will furnish the Department of Public Welfare upon request, reports of the physical status of public assistance clients assigned to it. 3. The Medical Care Section will formulate two plans of medical service; (a) a plan for emergency medi- cal service for those clients of the Department of Public Welfare that are given only temporary public assistance, and (b) a plan for comprehensive medical service for those clients who will be given public assistance over a considerable period of time. The program for emergency medical care will be an exten- sion of the current program to provide that physician services and hospitalization shall be available 24 hours of the day. The program for comprehensive medical service will be outlined below. 4. Each welfare client certified to the Medical Care Section will be assigned to plan (a) or (b) and will be instructed as to the medical services available to him. If his service is to be under plan (b), he will be instructed to register promptly at the medical center to which he is assigned by the Medical Care Section, even though he has no immediate medical care needs. 5. The Medical Care Section will sponsor in appropriate sections of the city, the organization of a number of medical centers. Insofar as practical, the medical center should be a part of the out-patient department of a hospital in the area. These centers will assume responsibility for home and ambulatory medical care for the families referred to it. 6. The medical center will appoint a competent medical administrator whose duty would be to organize and administer a program of comprehensive medical serv- ice for welfare clients assigned to the center. The medical facilities, services, and staff of each medical center participating in the program shall conform to certain minimum standards established by the Medi- cal Care Section in consultation with its Advisorv Committee on Medical Care. 7. In arranging for comprehensive medical service, the medical center will explain the nature of the program to the physicians practicing in the area and invite their cooperation in furnishing home and office care to welfare clients. The center will keep a register of physicians who express a willingness to participate in the medical care of these families. 8. The Medical Care Section will assign the welfare client to the medical center in accordance with the residence of the family. Upon registering at the medical center, the welfare client will be given spe- cific information as to what he should do in case of illness in his family. If the welfare client has a family physician, he will be instructed to continue the physician's services. If the client has no physician, he should choose one from the list of participating physicians. In both instances the medical center will inform the selected physician of the client’s registra- tion with the medical center and ask the physician’s cooperation in furnishing comprehensive medical service to the family. The medical center will be responsible for seeing that an adequate initial exam- ination of the physical status of each welfare client is made and that the medical center and the client’s physician have a copy of the findings of this exam- ination. 9. The personal physician chosen by the welfare client will be the important keystone in furnishing medical service to this group. He should have general super- vision of the health of those who select him. He will be expected to provide these families with those services that may be considered within the field of general practice. The physician will keep a record of all services rendered the client and periodically will furnish the center with a summary report. When the physician decides that the client requires diag- nostic and therapeutic services not ordinarily pro- vided by a general practitioner, he will refer the client to the medical center. He will consult with the center on any medical problems of the family while under his care. The center in every such instance shall furnish the physician with a complete report. 16 Interim Report of Committee on Medical Care 10. While the medical center may render medical care in emergency cases, it will ordinarily refer the patient to his physician for all care of a routine nature. The center will inform the client’s physician of any medi- cal service rendered at any time by the center. Horn time to time, the medical center will arrange for consultations and conferences with participating physicians relative to the program in general and the medical care needs of particular families and indi- viduals. 11. The success of the program will depend upon the teamwork developed between the medical center and the participating physicians. In order to make such cooperation effective, each medical center will appoint an advisory committee composed of physicians se- lected from the staff of the center, the register of participating physicians, and of individuals repre- senting other professional groups participating in the program. The committee will advise on the plans for organizing the services proposed and will develop through experience minimum standards for handling certain classes of cases. The committee will review from time to time the services of the medical center, the participating physicians and other professional personnel and make recommendations for improving the service. 12. The medical center and participating physicians shall utilize fully the preventive, special diagnostic, and nursing services of the Baltimore City Llealth Depart- ment. The bureau directors and district health officers of the Health Department will cooperate with the Medical Care Section in making these facilities avail- able on a referral basis to the centers and to the par- ticipating physicians. The medical center will not be expected to develop for welfare clients, clinic services in such fields as venereal disease, tuberculosis, prenatal care, etc., which services are available through already established clinics of the f lealth Department. 13. When the physician finds that the condition of a welfare client requires hospitalization, he will notify the medical center which will then arrange with the Medical Care Section for hospitalization, under the program already in operation. The hospital will fur- nish the medical center and the physician with a report of the hospitalization that should include recommendation as to subsequent handling of the case. 14. A limited dental service for welfare clients will be organized by each medical center in order to provide for emergency dental service. 15. Such drugs as are required will be dispensed through the medical centers and retail druggists upon a par- ticipating physician’s prescription. The policies for furnishing drugs should be determined by the Medi- cal Care Section in cooperation with the local Advisory Committee on Medical Care. Biological products should be furnished the medical center and the participating physicians by the Laboratories of the Baltimore City 1 lealth Department in accordance with the current plan for general distribution of such products to the physicians of the city. 16. The principal financial support of the proposed plan for medical care of welfare clients should come from the State appropriation to the Bureau of Medical Services of the State Department of Health for pro- viding medical service to the indigent and medically indigent of the State. Legislation should be secured at the next session of the Maryland Assembly author- izing the transfer of funds to the Mayor and City Council so that the plan may be administered bv the Baltimore City Health Department. Payment for services of the medical center will be based on the number of public assistance clients assigned to it. Payment to the participating physicians will follow the same principle and will be based on the number of clients selecting the physician for service. This capitation concept of payment is recommended by the Committee for several reasons, among which are (a) that this plan will permit greater freedom in the referral of any individual to his personal physician by the medical center, and by the physi- cian to the center as the medical condition of the patient requires; and (b) that this plan simplifies the administra- tion of the program and reduces to a minimum, the paper work that the general practitioner will be called upon to undertake. Hie proposed tentative budget, which is based on an estimated load of 20,000 individuals on public assistance, covers the funds recommended for the operation of the plan for the first two years: 1947-48 1948-49 Services of physicians $150,000 $165,000 Services of medical centers 150,000 165,000 Emergency dental care 22,000 25,000 Drugs 40,000 48,000 Administration 14,000 15,000 Total $376,000 $418,000 Exhibit A 17 FLOW OF SERVICES UNDER THE PLAN The accompanying diagram indicates the organization and flow of essential services as follows: 1. The family (client) applies to Department of Public Welfare for public assistance. If accepted, the welfare client is referred to the Medical Care Section for inclusion in the program of medical care. 2. The welfare client is referred to the medical center for comprehensive medical service. The Medical Care Section notifies the medical center of the client’s eligibility for medical service under the plan. 3. The client registers with the medical center and selects a physician. The medical center sets up a record of medical services for each client. 4. The medical center then notifies the physician of his selection as personal physician for the client. After this, the welfare client will receive such home and ambulatory care as is required from the physician. 5. The physician of his choice refers the welfare client to the medical center for special diagnostic and thera- peutic services. 6. The physician and medical center exchange records of all services rendered the client. 7. The medical center arranges for conferences and consultations with the physician concerning the medi- cal care needs of the welfare client. 18 Interim Report of Committee on Medical Cari BUREAU OF MEDICAL CARE CITY HEALTH DEPARTMENT DEPARTMENT OF PUBLIC WELFARE REFER FOR , MEDICAL CARE REPORTS AND cCONFERENCES SERVICE FLOW CHART PROPOSED MEDICAL CARE PROGRAM FOR WELFARE CUENTS OF BALTIMORE CITY FAMILY UNIT HOSPITAL MEDICAL CENTER GENERAL MEDICAL EXAMINATION AND HISTORY^ FAMILY REGISTERS FOR MEDICAL CARE AND SELECTS PHYSICIAN NEIGHBORHOOD PHYSICIAN EXHIBIT B SURVEY OF THE HOSPITAL AND HEALTH FACILITIES OF THE STATE OF MARYLAND INTERIM REPORT of the HOSPITAL SURVEY SUB COMMITTEE of the COMMITTEE ON MEDICAL CARE of the MARYLAND STATE PLANNING COMMISSION December, 1946 20 MARYLAND STATE PLANNING COMMISSION HOSPITAL SURVEY COMMITTEE WILLIAM L. GALVIN ROBERT M. REINDOLLAR ■ ROBERT H. RILEY THOMAS B. SYMONS HENRY P. IRR Chairman I. ALVIN PASAREW Director 104 Equitable Building Baltimore 2, Maryland Maurice C. Pincoffs, M.D., Chairman Committee on Medical Care University Hospital Redwood and Greene Streets Baltimore 1, Maryland December 17, 1946 Dear Dr. Pincoffs: I take pleasure in transmitting herewith the first interim report of the Hospital Survey Committee for submission to the State Planning Commission. Included is a history of the Hospital Survey Committee, its program, and a sum- mary of the accomplishments to date, along with some recommendations for imme- diate action considered too important to be delayed until the work of the Committee is completed. Yet to be done is the important work of studying the findings of the field survey and planning a long-range program for the expansion of hospital and clinical facilities to meet determined needs, as well as the preparation of a plan for the integration of these facilities. However, the recommendations made at this time are amply supported by the facts already available to the Committee. When this Committee was appointed, it was intended that its work would comply with the requirements of Senate Bill 191 then pending in Congress and at the same time continue with the original work of the Committee on Medical Care which was “continuously to survey the problem of medical care for the citizens of the State.” With the passage of the Hospital Survey and Construction Act (Public Law 725) the State’s Attorney General ruled that the State Planning Commission, in the light of existing statutes and the charge by the Governor, at the time of making funds available for the work of this Committee, was legally qualified and designated as the single State agency for the survey and planning work under the Act. The Survey Committee has functioned, therefore, and will continue to function in the role of the Advisory Council to the State Planning Commission in this effort for the duration of the survey and planning as defined in the Act. A composite report at the end of the Committee's work is contemplated, which will fully comply with the charge under which it was established. It is expected that the work will have been completed and the report ready for submission by June 30, 1947. Sincerely yours, Walter D. Wise, M.D., Chairman Hospital Survey Committee Exhibit B 21 FOREWORD rri ms interim report has been prepared at the request of the Committee on Medical Care and the State Planning Commission under whose auspices the I lospital Survey Committee was established. Included is a history of the Hospital Survey Committee and its program and a summary of the work to date, along with some recommendations for action considered too important to he delayed until the work of the Committee is completed. Yet to be done is the important w'ork of studying the findings of the field survey and planning a long-range program for the expansion of hospital facilities to meet determined needs, as well as the preparation of a plan for the integration of these facilities. However, the recom- mendations made at this time are amply supported by the facts already available to the Committee. A composite report at the end of the Committee’s work is contemplated, which will fully comply with the charge under wdhch the Committee was established. 22 Interim Report of Committee on Medical Care THE FEDERAL HOSPITAL SURVEY AND CONSTRUCTION ACT Congress passed the Hill-Burton Bill, known as Senate Bill 191, or the Hospital Survey and Construction Act, as one of the last acts of the 2nd Session of the 79th Congress. President Truman signed it on August 13, 1946, and it became known as Public Law 725. Under the Law, the work is divided into two phases named in its title. The first phase is the survey and prep- aration of a plan. The second phase is the administration of the construction of facilities under the plan. The Law is so written that this work may be done as two separate efforts or as one continuous project. It is required that a “single State agency” be responsible for the survey and planning and that another “single State agency” be respon- sible for the administration of the construction. This may be the same agency. For the State of Maryland, the present Hospital Survey Committee under its charge is limiting its work to the first phase of the Law and will complete its work with the preparation of a State plan. As a part of its final report, the Committee will recommend a State agency to be charged with the responsibility for the administration of the construction program. The Law authorized the appropriation of $3,000,000 to be allotted to the States as grants to be expended for survey purposes in the amount of one-third of the total expendi- tures for such purposes by the States. It also authorized the appropriation of $75,000,000 annually for a period of five years for the construction of medical facilities. The grants are applicable to projects which are within the scope of the approved State plan and are based on one- third of the total costs of such projects. Funds were appro- priated for the survey but, while authorized to be appro- priated, no funds were appropriated for construction. It is assumed that this appropriation will be made by the new Congress when it convenes. The funds to be appropriated will be allotted to the various States on the basis of a formula contained in the Law. On the basis of the formula, the State of Maryland is entitled to a sum of $46,158 for survey purposes and an annual allotment of $870,300 for a period of five years for construction. If all of the funds available were utilized, it would be necessary that Maryland set up $92,316 for survey pur- poses, making a total of $138,474 available for this pur- pose. It is quite apparent that such sums are not necessary for the work of the present Committee; however, the State agency designated for the administration of the construc- tion program will probably find it necessary to review the program from time to time and will no doubt utilize some of this money. If all of the Federal construction funds available are utilized and if these funds are limited to the present amounts stipulated in the Law, the construction program will entail expenditures of $2,610,900 per year, or $13,054,500 for the five-year period. It is required that each State wishing to participate in this program make formal application for such part of the Federal funds allotted to it as it may need for carrying out the purposes of the Act. The State Planning Commission, on October 24, 1946, filed with the United States Public Flealth Service such application, completed and accom- panied by such documents as were required to establish the statutory authority for the State Planning Commission to function as the “single State agency” for the making of the survey and the preparation of the State plan. Cor- respondence with the United States Public Health Service relative to the details of the application indicate that, as of this date, the application is acceptable with the excep- tion of the representation on the Survey Committee, which corresponds to the advisory council as required in the Law. On November 25, 1946, Governor O’Conor appointed, as additional members of the Hospital Survey Committee, three persons nominated by the Committee for the pur- pose of broadening its representation. It is presumed that with these additions to the Committee, this single defect in the application will have been rectified and Federal funds will be forthcoming for the continuation of the work of the Committee. Under the Law, the United States Public Health Service is required to prepare a set of general regulations to define the Law and implement its operations. A preliminary draft of these regulations has only recently become available. It is expected that when these regulations are finally set up, the work of the Committee will be more clearly defined and a more rapid approach to the final plan will be made. Under the Law, certain bed maximums for the State are established in the various categories of medical facilities. Under the final regulations, hospital areas will be defined which will be classified on the basis of population content and graduated bed maximums will be established for the various types of areas. Exhibit B 23 The State plan is intended to make a determination of the differential between existing facilities and those estab- lished as needed. As a part of this plan, these needs will be established on a priority basis according to their urgency. The plan is also supposed to include a design for the integration of the various types of facilities between the areas so that adequate services may be established in or be available to every part of the State. After the plan has been prepared, it is required that it be submitted to the Surgeon General for approval. Once having obtained the approval of the Surgeon General, the work of the Survey Committee will have been completed. The administration of the construction phase of the program will then be undertaken by the “single State agency” given such authority. This agency may from time to time review the State plan for the purpose of adjusting it to changing conditions. THE HOSPITAL SURVEY COMMITTEE On November 2, 1945, the Executive Committee of the Committee on Medical Care of the State Planning Com- mission met at the Medical and Chirurgical Faculty Build- ing for the express purpose of discussing the activities of the Commission on Hospital Care and the advisability of instituting a State-wide survey of hospital facilities. The activities of the Commission on I lospital Care were reviewed. It was pointed out that the Commission was established to stimulate State-wide hospital surveys which, when completed in all States, would produce the first com- plete survey of hospital and public health facilities in the Elnited States and, at the same time, would conform to the requirements of Senate Bill 191, then pending in Congress. The contents of Senate Bill 191, as then written, were discussed and it was revealed that, under the provisions of the Bill, funds would be made available for surveys and hospital construction, but only to States having completed surveys and having prepared plans for the expansion of hospital and public health facilities where the needs were found to exist. A resolution was then passed to the effect that the Executive Committee would advise the entire Committee on Medical Care of this development and secure authority from it to form and appoint a Hospital Survey Committee. Dr. Victor F. Cullen, Acting Chairman of the Committee on Medical Care, addressed a letter to this group, as follows: "In accordance with the responsibilities of the Com- mittee on Medical Care of the Maryland State Planning Commission, ‘to keep under constant survey the problems of medical care for the citizens of this State, and to formulate recommendations for better utilization and for extension of existing facilities and for the institution of such new facilities as are required, and in view of the physical additions presently contemplated by many of our Maryland hospitals, the establishment of a Hospital Survey Committee has been considered imperative. The following persons have been selected as members of the Committee: J. Douglas Colman W. D. Noble, M.D. George 11. Preston, M.D. Robert H. Riley, M.D. Winford H. Smith, M.D. Harvey B. Stone, M.D. 1 luntington Williams, M.D. C. E. Wise, Jr. Walter D. Wise, M.D. Benjamin W. Wright Peregrine E. Wroth, M.D. Ralph Young, M.D. “The Committee shall elect its own chairman. "Hospitals do not achieve their fullest usefulness if their interests are limited to their primary function of restoring to health those disabled by illness or injury. In addition, hospitals have opportunities to maintain and improve health; to provide educational opportunities and encouragement for the members of the medical, dental, nursing and allied professions; contribute to the advance- ments of science through research; and to serve more actively in the education of the public in matters per- taining to the maintenance of health. Therefore, the functions of the Committee are: 1. To survey existing institutional facilities for the care of the sick and for the rendering of public health service. 2. To analyze the facts governing the availability and use of these facilities. 3. To define the need for additional facilities. 4. To develop a long-range program whereby existing facilities and such additional facilities as are recom- mended may operate to provide a comprehensive and integrated hospital service for the citizens of Maryland. “In performing its function, the Committee should recognize the provisions of the several contemplated fed- eral public works programs, under which, funds may be available for, hospital construction. It is imperative that the work of this Committee should be pursued with all 24 Interim Report of Committee on Medical Care possible dispatch and upon its completion, a report of its findings and recommendations presented to the Com- mittee on Medical Care of the Maryland State Planning Commission. Any interim reports which may seem indi- cated will, of course, be welcomed. “Through the interests of Governor Herbert R. O’Conor, funds have been made available to the State Planning Commission, which should provide for the technical assistance necessary for the Committee effec- tively to perform its functions." At a meeting held Friday, February 22, 1946, Dr. Walter D. Wise was unanimously elected Chairman of the Com- mittee. The Hospital Survey Committee, at the outset, recognized in its assignment three definable phases and several limit- ing factors. The initial phase would be the taking of an inventory of the existing medical facilities. The second stage of the work would entail the compilation of the data thus gathered and an analysis of these facilities quantita- tively, qualitatively, geographically, and in relation to popu- lation trends. The third phase would consist of the estab- lishment of the actual need for the various types of facilities, a determination of the differential between exist- ing facilities and those considered adequate to meet the need, and the preparation of a long-range plan for the installation of the facilities required to meet the established need, giving special consideration to the urgency of the need from the standpoint of type of service and location. The limiting factors were funds and time. The fund of $8,500 made available by the Board of Public Works was sufficient for the employment of only a small staff and for the payment of only minimum inci- dental expenses. The time element imposed a need for expeditious action. There was a generally recognized immediate need for addi- tional medical facilities in all categories. The Hospital Survey and Construction Act, then pending in Congress, contained clauses stipulating that grants would be made for hospital construction, but required that a State plan for such expansions must have been completed and approved by the Surgeon General before funds for construction could be released. The limited personnel which could he employed with the modest appropriation for this purpose would be required to work with dispatch to complete the work before the survey funds were exhausted. At its meeting April 16, 1946, the Survey Committee adopted a working program, as follows; 1. Use the Hospital Schedule of Information to cover hospitals, and Public Health Department Facilities Schedule of Information to cover public health facili- ties. Both of these forms were prepared by and are available through the Commission on I lospital Care. 2. Have schedules completed by the local health officers and hospital administrators. 3. The health officers should return their forms when completed, but the administrators should hold theirs until representatives of this Committee had audited them. 4. One copy of the completed schedules would be held for study and the other submitted to the Commis- sion on Hospital Care for tabulation. The Commis- sion should return this copy along with a set of punch cards when the tabulations are complete. 5. One copy of the Hospital Schedules will be returned to the administrators. 6. At the completion of the work, the files, including the schedules, with the deletion of Section G, entitled Financial Data, will be turned over to the State Department of Flealth. 7. Since the Bureau of Medical Services of the State Department of Health is seeking the same informa- tion as the basis for licensing medical institutions, cooperation should be accepted from and given to this Bureau. For the purpose of giving the Committee broader repre- sentation and in order to have the benefit of their own thinking and the thinking of the groups they represent, the following were nominated for membership on the Survey Committee: Dr. Ernest L. Stebbins, Director of the School of Hygiene and Public Health of The Johns Hopkins University. Mr. J. David Cordle, Secretary-! reasurer of the Brotherhood of Railway Clerks of the Baltimore and Ohio Railroad. Mr. Edward T. Young, Jr., City Editor of The Eve- ning Sun. These nominations were presented to the Committee on Medical Care for approval. On November 25, 1946, the Governor announced the appointments, thus bringing the membership of the Committee to sixteen. Exhibit B 25 THE FIELD SURVEY Hospitals of All Types and Nursing Homes The field survey was undertaken for the purpose of com- piling data as to the total number of medical institutions, beds and ancillary departments and public health facilities available in the State. Hie first work to be done was the compilation of a com- plete list of all institutions in the State maintaining facili- ties for the care of patients. This was simplified by reason of the fact that the Legislature had enacted a hospital licensing law in 1945 (Annotated Code of Maryland 1939, Sections 496A to 496K), and the Bureau of Medical Services of the State Department of Health had alreadv compiled such a list. A copy of the list was supplied to the survey office. Since the Bureau of Medical Services had planned to use for its basic files on the licensed institutions data similar to that required for the completion of the Schedules of Information to be used in the survey, the survey work was complementary to the field work necessary for State licensing purposes. The Bureau of Medical Services, in line with its work of inspecting prior to licensing hospitals, made its facilities and personnel available to assist with the survey work. The hospital consultant of that Bureau, at the time of inspecting institutions for licensing purposes, on numerous occasions, completed the survey Schedule of Information on the institution. This cooperation was very valuable to the survey throughout the period of the field work. Additions and deletions were made to the list as new institutions were found and others discontinued in service. These changes were almost entirely in the category of nursing homes. The original list, along with additions made during the period of the field work, included 231 institutions. Of those listed, 31 had either not followed through with their plans to open or had closed. The balance of 200 institutions were included in the survey. (Table A.} Table B is a tabulation of the institutions by tvpe of ownership and by counties. Every institution on the list was mailed two copies of the Schedule of Information. These schedules contained forty pages of questions, covering the following headings: A. General Data B. Area Served C. Physical Plant D. Patient Service Data E. Medical Staff F. Administration G. Financial Data H. Educational Activities J. Research Activities The recipients of these schedules were requested to com- plete them and keep them available pending the visit of a field worker. Because of the comprehensiveness of the schedules and the recognized difficulty in preparing the statistics requested for their completion at a time when most medical institutions were very busy and experiencing per- sonnel shortages, a period of thirty days was allowed to MEDICAL INSTITUTIONS IN THE STATE OF MARYLAND TABLE A County Original Deleted Due to Included Totals Closing, Etc. in Survey Allegany 9 9 Anne Arundel 5 1 4 Baltimore 29 4 25 Baltimore City 81 9 72 Calvert 1 1 Caroline 1 1 Carroll 9 2 7 Cecil 6 3 3 Charles 1 — 1 Dorchester 4 — 4 Frederick 8 — 8 Garrett 1 — 1 Harford 4 1 3 Howard 2 — 2 Kent 3 — 3 Montgomery 30 6 24 Prince George’s 7 — 7 Queen Anne’s 4 — 4 St. Mary’s 1 — I Somerset 1 — 1 Talbot 7 2 5 Washington 9 — 9 Wicomico 8 3 5 Worcester Total 231 31 200 Infirmaries in Jails, etc. 4 4 — Grand Total 235 35 200 Interim Report of Committee on Medical Care 26 INSTITUTIONS BY TYPE OF OWNERSHIP OR CONTROL AND BY COUNTIES County Governmental* N on-Go vern mental Totals State City County City- County Non-Profit Proprie- tary Church Non-Profit Allegany 1 2 1 1 4 9 Anne Arundel 1 — — — , — 1 2 4 Baltimore City 1 2 — — 16 21 32 72 Baltimore County 3 — — — 3 5 14 25 Calvert — — — — — 1 — 1 Caroline — — — — — — 1 1 Carroll 2 — — — 1 — 4 7 Cecil — — — — — 1 2 3 Charles — — — — — 1 — 1 Dorchester 1 — — — — 1 2 4 Frederick 1 — 2 — — 3 2 8 Garrett — — — — — — 1 1 Harford — — — — — 1 2 3 Howard — — — — — — 2 2 Kent — — — — — 1 2 3 Montgomery — — — — 2 3 19 24 Prince George’s — — — — 1 1 5 7 Queen Anne’s — — — — — — 4 4 St. Mary’s — — — — — 1 — 1 Somerset — — — — — 1 — 1 Talbot — — — — — 2 3 5 Washington — — 1 — 2 2 4 9 Wicomico 1 — — — — 2 2 5 Worcester Totals 11 2 5 1 26 48 107 200 TABLE B * No Federal institutions included. elapse between the mailing of the schedules and the visit of the field worker. Preceding the mailing of the schedules, a letter was sent by Dr. Merrill L. Stout, Director of the Hospital for the Women of Maryland, who was President of the Maryland- District of Columbia Hospital Association. This letter por- trayed the survey as something apart from the usual ques- tionnaire, so many of which hospital administrators receive. Accompanying the Hospital Schedules at the time of mailing was a letter from Dr. Walter D. Wise, Chairman of the Hospital Survey Committee, requesting that the information be entered promptly in preparation for the later visit by the field worker. Visits were made to all of the 200 institutions and to some of those which were later deleted from the list when they were found to have discontinued their work. The administrators of the institutions, with few excep- tions, were willing to cooperate with the survey effort but were universally seriously handicapped due to shortages of personnel and excessive utilization of their institutions and other current problems. A number of administrators made such comments as, "Problems are greater now than during the war”; or, “This is the most difficult year ever experi- enced.” In only a very small number of institutions was the schedule completed at the time of the field worker’s visit. In some cases, even though the notice had been sent of the planned visit, there had not been a single entry made prior to the arrival of the field worker. Exhibit B 27 Some schedules, especially in the cases of nursing homes, were completed by the field worker from the meager records available. In the larger institutions, where consider- able time was required to prepare the statistical data, the administrator was assisted with the factual data and urged to complete the balance of the work by the time of a later visit. Many institutions had to be visited more than once and, in some cases, as many as four repeated visits were necessary before the schedule was completed and ready for audit. The individualism of medical institutions was effectively demonstrated in the effort to reduce the statistics of their work and the functioning of their departments to a uniform set of questions. On frequent occasions, the ambiguous answers “Yes and No" had to be reduced to a “Yes" or “No.” By a gradual process, the number of completed sched- ules in the office increased and the unfinished list decreased. On September 8, 108 completed Hospital Schedules were shipped to the Commission on Hospital Care for tabula- tion and the preparation of punch cards. By the end of October, the field work was completed, there remaining out only a few schedules which had been audited and were in the process of being typed by the institutions. Public Health Facilities Schedules of Information covering Public Health Depart- ment facilities were sent to the health officers in each of the counties and the City of Baltimore. Dr. Robert H. Riley, Director of the State Department of Health, and Dr. Huntington Williams, Commissioner of the Baltimore City Department of Health, urged their respective staffs to complete and return these schedules promptly. The responsible persons, in each county and in each district in the City of Baltimore, performed this duty and returned the schedules completed, with the result that this phase of the survey was completed with a minimum of effort on the part of the survey staff. The field work was started early in April and completed by the end of October. Classification of Institutions The Hospital Survey and Construction Act was intended to include General Hospitals, Tuberculosis Sanatoria, Men- tal Hospitals, Chronic Disease Hospitals, and Public Health Facilities. The survey, because of the State Chronic Dis- ease Hospital Program, included in addition; nursing homes, homes for the aged, and other special tvpes of institutions. This was done for the purpose of gathering data on the number of patients being cared for in places other than their homes, and determining the potential load which would fall on institutions of the various types once they became available. Because of the inclusive nature of the survey, it was necessary to group the types of institutions under twelve headings. The original grouping included the following categories: 1. General 2. Nervous and Mental 3. Tuberculosis 4. Contagious 5. Obstetrics 6. Pediatrics 7. Orthopedics 8. Eye, Ear, Nose and Throat 9. Convalescent 10. Skin and Cancer 11. Chronic 12. Others, including aged In Table C they are shown by categories and by county. The institutions were requested to report their bed complement, which is the “number of beds actually set up and in use for in-patients, excluding bassinets for new- born infants." They were also asked to report their normal bed capacity, which is “the number of beds for which the institution was designed or, in lieu of this information, the number of beds which could be set up allowing 80 square feet of floor space per bed." The differential between the bed complement and the normal bed capacity is indicative of the expansion of capacity or crowding which the insti- tution had permitted without adding space for beds. The original tabulation of the bed complement by coun- ties and by type of institution is shown in Table D. After the bed complement for the State by counties and by type of service had been completed, it became necessary to group them under the four main headings referred to in the I lospital Survey and Construction Act; that is, General Hospitals, Tuberculosis Sanatoria, Mental Hospitals, and Chronic Disease Hospitals. The Act specifi- cally excludes institutions giving only domiciliary care. In the first grouping, before the institutions which give only domiciliary care and others which it was felt fall outside the scope of the Act were set aside, the twelve categories were reclassified under four main headings of the Act. General hospitals included those institutions caring for acutely ill medical and surgical patients. Hos- pitals admitting patients having conditions which fall in the category known as the specialties were grouped sepa- rately. In this group were contagious disease, obstetrical, pediatric, orthopedic; and eye, ear, nose and throat hos- 28 Interim Report of Committee on Medical Care INSTITUTIONS BY TYPE OF SERVICE TABLE C Totals Allegany Anne Arundel Baltimore Baltimore City Calvert Caroline Carroll Cecil Charles Dorchester Frederick Garrett Harford Howard Kent Montgomery Prince Goerge’s Queen Anne’s St. Mary’s Somerset Talbot Washington Wicomico Worcester COUNTY co i H H H M M | 0) W H i tO | CO )-> (-» I-* | j 00 | (-* CO General to to 1 1 1 1 1 1 1 CO to | to I 1 h- M 1 H 1 1 (0 « M H Nervous and Mental Oi IhMMMMMIhIMhMUM Tuberculosis - 1 II 1 1 1 M ! 1 II 1 1 1 It 1 M - 1 1 1 Contagious 00 1 1 M.0 l-U | | | | 1 M | 1 H- I M | M | Obstetric 1 111 1 1 11II 1 1 1 1 1 1 1 1 1 1 II 1 1 1 Pediatric to 1 1 1 II 1 1 1 1 1 1 1 II 1 1 1 1 1 1 to I I I Orthopedic 1' 1 - 1 I 1 1 II II 1 1 1 1 1 1 1 1 1 to | 1 M Eye, Ear Nose and Throat o 5 16 2 1 12 2 2 Convalescent - 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ~ M I Skin and Cancer cn o 3 1 5 23 1 1 2 7 4 3 Chronic 23 200 1 H M 10 1 1 to 1 1 I 1 Icoto' I CO I 1 oi eo 1 | Others, Including Aged 9 4 25 72 1 1 7 3 1 4 8 1 3 2 3 24 7 4 1 1 5 9 5 Totals pitals. Mental hospitals included primarily those for the care of the mentally ill. Tuberculosis sanatoria included those institutions where admissions are limited to patients having tuberculosis. One hundred beds maintained at Springfield State Hospital for the care of mental patients having tuberculosis were counted as beds for mental pa- tients. Chronic disease hospitals included nursing homes, institutions for the care of convalescent patients, chronics, incurables, and aged. The inclusive totals under the four broad headings are shown in Table E. More detailed analyses of the institutions and their constituent departments were made to determine which institutions should be excluded from the survey and which categories would be credited with certain groups of beds. Under general hospitals during the period of the survey, the Schnauffers Flospital at Brunswick in Frederick County had closed, taking 30 beds out of the total. The Leland Memorial Flospital had included in its report 21 beds which are in a separate building and are used entirely for chronics and aged. Johns Hopkins Hospital had included in its total 87 beds in the Phipps Psychiatric Clinic which beds, it was decided, should be credited to the mental hospital bed total. The Baltimore City Hospitals had included 280 beds for tuberculosis patients, 451 beds for chronics, and 705 beds for ambulatory aged, all of which were removed from the general hospital bed total. From the category of mental hospitals, it was considered proper to exclude Rosewood State Training School for feeble-minded. It has reported 1,386 beds. Also excluded were the Bowditch Hospital School, with 24 beds; the Silver Cross Home, with 21 beds, both institutions for epileptics; and the Marine Home for Retarded Children, with a bed complement of 12. There were no deletions from the number of beds available for tuberculosis patients; however, the 280 beds for tuberculosis patients at the Baltimore City Hospitals were added. 1 he groups included in the category giving care to chronics, convalescents, aged and others, ranged all the way from institutions bordering on the luxurious to places operated under conditions not fit for human habitation. In the final analysis this group should be sharply dis- Exhibit B County General Nervous and Mental T.B. Conta- gious Disease Obstet- rics Pediatrics Ortho- pedies Eye, Ear, Nose and Throat Convales- cent Skin and Cancer Chronic Others, Including Aged Total Grand Total Number of Insti- tutions W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW Allegany 391 2 96 6 17 48 558 2 560 9 Anne Arundel 70 1234 3 9 79 1237 1316 4 Baltimore 4112 453 11 126 89 182 4962 11 4973 25 Calvert 15 11 15 11 26 1 Caroline 8 8 8 1 Carroll 3011 357 11 37 3059 357 3416 7 Cecil 62 10 4 13 79 10 89 3 Charles 23 8 23 8 31 1 Dorchester 57 18 492 22 571 18 589 4 Frederick 175 33 30 523 234 22 962 55 1017 8 Garrett 24 24 24 1 Harford 78 11 20 98 11 109 3 Howard 51 51 51 2 Kent 25 6 13 38 6 44 3 Montgomery 323 20 100 141 141 705 20 725 24 Prince George’s 206 97 114 417 417 7 Queen Anne’s 31 31 31 4 St. Mary’s 35 10 35 10 45 1 Somerset 30 8 30 8 38 1 Talbot 83 25 8 6 26 117 31 148 5 Washington 185 4 26 54 54 22 345 345 9 Wicomico 147 30 60 39 64 310 30 340 5 W orcester 0 0 County—Total, White 1905 7989 1036 30 43 391 422 701 12517 14342 128 County—Total, Negro 192 1234 368 9 22 1825 Baltimore City 5730 514 425 100 8 172 47 79 26 343 21 884 18 566 32 8328 637 8965 72 State—Total, White 7635 8414 1036 100 38 172 122 734 21 1306 1267 20845 State—Total, Negro 706 1234 368 9 47 26 18 54 2462 23307 200 _____ BEDS BY TYPE OF INSTITUTION BY COUNTIES AND BY TYPE OF PATIENT TABLE D Interim Report of Committee on Medical Care 30 GROUPED INSTITUTIONAL BED COMPLEMENT FROM ORIGINAL CLASSIFICATION TABLE E RECAPITULATION OF BEDS AND INSTITUTIONS AFTER RECLASSIFICATION TABLE F Type of Institution Number of Institutions Bed Complement General Hospitals 43 8,341 Tuberculosis Sanatoria 6 1,404 Mental Hospitals Including institutions limiting admissions to: Epileptics Feeble-Minded Mental 22 9,648 Special Hospitals Including institutions limiting admissions to: Contagious 1 Obstetrical 8 Orthopedic 2 E. E. N. & T. 4 15 514 Chronic Hospitals Including institutions limiting admissions to: Chronics \ 90 Convalescents / Aged and Others 24 114 3,400 Totals 200 23,307 Type of Institution Number of Institutions Bed Comple- ment Normal Bed Capacities ♦Standard Under P. L. 725 Differential Between Normal and Standard in P. L. 725 General 42 6,874 6,566 8,923 -2,357 Special 7 300 300 — + 300 Tuberculosis 6 1,684 1,883 3,177 -1,294 Mental 18 8,292 7,453 9,915 -2,462 Chronic 89 2,391 2,391 3,966 -1,575 Totals 162 19,541 18,593 25,981 -7,388 ♦Population estimate 11/1 P-46, No. 3). /43—-1,982,947 (U. S. Bureau of Census—Series Using the population data prepared by the United States Census Bureau from Ration Book registration as of Novem- ber 1, 1943, which shows the population for Maryland as 1,982,947, the following standards were set up: General hospital beds 8,923 Mental hospital beds 9,915 Tuberculosis sanatoria beds 3,177 Chronic disease hospital beds 3,966 Total 25,981 The 1943 census estimate was used for illustration. The census base for application of Public Law 725 will be prescribed by Federal regulation. The standards in each of the categories were compared with the existing normal bed capacities in Table F, show- ing the following resultant differentials: Standards Existing „ r . per Public Normal Deficlen' Law 725 Count General hospital beds 8,923 6,566 —2,357 Mental hospital beds 9,915 7,453 —2,462 Tuberculosis sanatoria beds 3,177 1,883 —1,294 Chronic disease hospital beds 3,966 2,391 —1,575 Beds in special hospitals 300 300 Totals 25,981 18,593 —7,388 It was found that the over-all shortage of beds in all categories, when compared with the standards set up in the Act, was 7,388. Detailed tabulations of the four cate- gories are shown in Tables H, 1, J, K, and L. counted because few of them offer more than domiciliarv care and such institutions were supposed to be excluded from the survey. However, for the immediate purposes of the study, it was determined to remove from this group those institutions caring only for aged persons and those giving only domiciliary care. The results of this reclassification of institutions and departments within institutions are shown on Table F. The normal bed capacities were determined from the reports and are also shown on Table F. An analysis of normal bed capacities by type of owner- ship, tvpe of hospital, and assignment by race is shown on Table G. Having established the net normal bed capacities, com- parisons were made with the maximum for each category as set up in the Hospital Survey and Construction Act. The standards in Public Law 725 are: General hospital beds 4.5 per 1000 population Mental hospital beds 5.0 per 1000 population Tuberculosis sanatoria beds 2.5 times the average an- nual deaths from tu- berculosis in the State over the 5-year period from 1940 to 1944* Chronic disease hospital beds.. . 2.0 per 1000 population * Deaths from tuberculosis in the State of Maryland from 1940 to 1944, inclusive were; 1940—1,302; 1941— 1,256; 1942—1,263; 1943—1,250; 1944—1,285. Exhibit D 31 County General Mental Tuberculosis Special Chronic State County1 and/or City- Voluntary Proprietary State County1 and/or City- Voluntary Proprietary State County1 and/or City-’ Voluntary Voluntary Proprietary Proprietary W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW W NW Allegany 49 2 2181