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stay, or prevents his readmission in times of physical and emotional crisis. The emotional problems of the totally disabled veterans are often rooted in the emotional and physical state of the members of his family. It can be stated categorically that the emotional problems of a family are so deeply inter-related that piecemeal treatment of one member without simultaneous and coordinated treatment of other members almost assures failure.

The totally disabled veterans or the family of a veteran who died from a service-connected disability have the greatest moral claim on all of us. They should receive optimal care at least equivalent to the best standards of care extant for the non-veteran population. Care of the family as a unit is an aim of the best medical care today and its availability should be assured to those veterans who have made the greatest sacrifices for the welfare of their fellow citizens.

Care of the total family is also important if we examine the mandated educational function of the veterans administration hospitals. These institutions have made, and will in the future, make very significant contributions to the development of health manpower of all kinds. The veterans administration hospitals and the nation are beneficiaries of this effort. The absence of provisions for the care of women and children and of family units has always been a serious deterrent to the optimal use of veteran's facilities for education in the health professions-especially, today in terms of the understanding of the need for comprehensive care. The new provision for the care of the families of certain categories of veterans will materially improve the utility of the veterans hospitals as settings for clinical education in the following ways:

(a) Care of the total family is an important experience for all students of medicine, nursing, allied health, dentistry, and social welfare. The availablity of such experiences at veterans hospitals will make it possible for students to take more or all of their clinical training in such institutions.

(b) The veterans hospitals are now at a disadvantage in competing for interns and residents because of their inability to provide experiences in the care of women and children. With the new provisions, they will be able to compete more effectively for the best house staff candidates. Providing a more complete experience in all the clinical specialities in turn, enhances the quality of care provided in all departments of the veterans hospitals.

(C) The veterans hospitals will now be able to extend the range of their training to include family practice residencies, physician assistants, and family nurse practitioners and pediatric nurse practitioner programs. These new categories of health workers are needed in veterans hospitals as well as in civilian life. They represent the new reservoir of manpower we must train if we are to provide for the neglected types of care; primary care, long term care and preventive medicine.

(d) In the case of our Health Sciences Center at Stony Brook, there is an additional advantange. We have developed a new mode of affiliation-called the clinical campus. In this arrangement the VA Hospital at Northport functions as an extension of the Stony Brook campus and provides extended clini. cal experiences for students in the Schools of Medicine, Dentistry, Nursing, Allied Health and Social Welfare. To maintain an equal position with reference to the other clinical campus, in the Stony Brook consortium, the Northport VA Hospital should be able to provide the full spectrum of clinical experiences available at the civilian hospital. Enactment of S 59 with its provisions for care of families will greatly enhance the utility of the Northport Veterans Hospital as a true clinical campus.1

(e) The pattern of clinical campuses being developed at Stony Brook can serve as a pattern for other regions if P.L. 92–541 is funded and veterans hospitals enter even more extensively into the system of medical education. With th retrenchment of other federal funds and the continuing ne for health manpower output to serve the needs of the veterans hospital and the nation, the veterans administration hospital system will, in many parts of the country, become the major clinical resource for new and even existing medical schools. This role will be markedly compromised if the care of women and children and of family units is not a part of the spectrum of care offered to veterans in these institutions.

1 E. D. Pellegrino: The Regionalization of Academic Medicine: The Metamorphosis of a Concept, Journal of Medical Education, vol. 48 : 119 1973.

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(2) PROVISIONS OF OUTPATIENT AND AMBULATORY SERVICES This amendment of Title 38 for the first time, permits the provision of outpatient and ambulant services for certain categories of veterans and for the wives and families of veterans who die from service connected disabilities, as well as for the families of veterans totally disabled. This provision would remove another of the major limitations to the optimal care of the veteran treatment. It is also in keeping with the national trend to greater emphasis on ambulatory care. We are all seeking to avoid unnecessary hospitalization wherever possible in the interests of cost reduction. But out-patient care also allows for better treatment of many illnesses where hospitalization can slow down diagnostic evaluation and treatment schedules and impede eventual recovery.

This amendment on ambulatory services is just as important as the forego ing one in enhancing the service and educational validity of the veterans hospitals for the following reasons :

(a) Outpatient and ambulant care is the essential link between any hospital with its community. It serves to interrelate hospital care and home care to the advantage of each. By extending and liberalizing their ambulant services, veterans hospitals will enjoy a closer relationship with the veteran in the community and thereby improve the totality of his care. Truly comprehensive and continuous care cannot be practiced without this articulation between community and home on the one hand and hospital on the other, which the outpatient department serves to link most effectively.

(b) Ambulant care is an essential feature of the education of all health professionals. No institution can be a complete clinical educational instrument today without offering opportunities for experiencing this kind of care.

(c) While important for all the specialties, ambulant and outpatient care is absolutely essential for the preparation of primary care physicians, family care physicians, family nurse practitioners, physician assistants and most of the allied health personnel.. Without the opportunity to care for individuals and families as total units on an ambulant basis clinical educational programs will be compromised. Again the veterans hospital will be at a disadvantage in competing for high quality students, house staff and career health professions.

(d) If preventive medicine is to be practiced—and this unfortunately is not the case now on any extensive basis-it will be practiced in the ambulant and not the hospital services. The veteran, along with the civilian population of this country are in need of a more coordinated attack on the preventable disorders. Preventive medicine requires careful health counselling, psycho-social behavioral modification and alterations in diet, smoking and exercise patterns. Such measures are impractical unless ambulatory care is permissible. The veterans should enjoy the benefits of preventive medicine for his own welfare. But preventive medicine can also cut, or diminish, the cost of his care by avoiding certain disorders entirely, or at least mitigating their presence. We are not yet applying the knowledge we already possess to prevent or delay costly disability and disease.

The veterans administration hospital system could lead the nation in this respect if it were to provide ambulant service as proposed and tie this in with the education of new health care personnel specifically trained to provide preventive services.

(3) THE PROVISIONS OF SUBCHAPTER III OF 92-541 WHICH PROPOSES TO EXPAND

THE ROLE OF THE VETERANS ADMINISTRATION HOSPITALS IN EDUCATION OF
HEALTH MANPOWER INCLUDING THE DEVELOPMENT OF NEW HEALTH CAREERS AND
INTER-DISCIPLINARY APPROACHES

Like the other two provisions I have commented upon, this provision is as Important for the improved care of the veterans as it is to help meet future manpower needs of the veterans administration and the nation.

(a) A continuing source and a rational distribution of skilled health manpower must be provided to meet present and future health needs of veterans. In many hospitals there are deficits in numbers and kinds of health manpower; especially in the areas of health related professions trained to provide the newer types of medical care. The training of allied health personnel is essential in civilian and veterans hospitals if comprehensive care is to be provided adequately and its practice extended throughout the country. This is especially true in the neglected types of care; primary health care, family

medicine, long term care, and preventive medicine. Allied health workers developed specifically to assist the physicians and the dentists with these modalities of care can function with great efficiency and safety. They take a shorter period to train and they are less costly to produce. With their assistance, each physician and dentist can serve more veterans than before and thus expand his own utility.

(b) The provision calls specifically for the development of inter-disciplinary approaches. One of the major problems facing the organizers of health care systems today is the central difficulty of deploying health care personnel in the most efficient fashion-so that each profession can make a maximal contribution to the production of health care which is effective, efficient, less costly and more personalized than is now the case. Much experimentation is needed in redeploying the manpower we now possess and in devising new categories when necessary.

In this respect, the veterans hospitals have a unique opportunity to develop new models for the use of all health manpower. The system is a large one; it is well organized, and it is possible to set up carefully studied models of patient care to explore the new uses of health professionals much more effectively than is possible in community or university hospitals. Many of the obstacles of self-interest and conflicting prerogatives which stand in the way of newer patterns of manpower utilization in the civilian sector are obviated in the veterans hospital system. With the new provision, the veterans hospitals could use their unique potential to the fullest for the benefit of the veterans they serve and for the improvement of health manpower utilization for the entire nation.

(4) SOME GENERAL COMMENTS ON THE VETERANS' ADMINISTRATION HOSPITALS

AS NATIONAL RESOURCES FOR EDUCATION OF HEALTH MANPOWER

I would like to emphasize that my support for the specific provisions of S 59 I have discussed and elements of 92–541 now awaiting funding is based on my conviction that they will improve the care of veterans and especially those veterans in the category for which we have the greatest moral responsibility as a nation. These measures if enacted and funded as the case may be

will bring certain aspects of medical care delivered to all veterans closer to optimal than is now the case. Surely, the veteran should not receive inferior care when a comprehensive pattern is available (to the non-veteran) in the community. But these measures will also enable the veterans hospitals to develop and provide improved methods of care. Thus, in selected areas of care, the veterans hospitals can take a role of leadership for the benefit of those they serve and all others, as well.

It happens also that these measures will also enhance the already great contributions of the veterans hospital system to the production of health manpower for its own future needs of the nation at large. Our veterans hospitals constitute a unique resource for medical, dental and health professional education of all types. They are now assuming an ever greater importance for the universities with which they are affiliated. They have a mandate to participate in education as well as patient care; they provide examples of settings in which good care must be the prime objective. But good care is also the first requirement for good education. The veterans hospitals also permit easier and better controlled opportunities for developing newer kinds of health manpower, for better models and patterns of delivery of care, and utilization of personnel.

The veterans hospitals provide an economical means for enlarging the number of students who can be educated in any university. In some communities they are or can become the major clinical base for new medical and health professional schools. The return in benefits to patient care and education for the money expended for certain types of education can be higher in a veterans hospital than in comparable institutions under private auspices.

Current recommendations for federal expenditures for education of health professionals impose considerable restraint to health manpower production. This may not have dire results immediately. If some form of national health insurance is enacted—then the demands for medical care will surely increase. With the demands will come the requirement for more health manpower of all types. The actualization of the full potentialities of the veterans hospitals for education and patient care can and will provide a resource for clinical education ready to respond to future expanded needs and to provide a steady flow of health manpower at a time when other systems will be forced to curtail their efforts.

Moreover, the largest capital and operating cost of establishing a new medical school is the university hospital. The veterans hospitals, if they can extend their roles as S 59 and P.L. 92–541 and their provisions promise to do, can compete in quality with university hospitals and obviate the attendant costs of building and maintaining a whole new set of university hospitals.

All of us in medical education now realize that we must tie education more closely to health care delivery. It is only through our impact on production of adequate numbers and kinds of health care personnel and through our efforts to improve the patterns of health care delivery that we can justify our educational and research efforts. This close inter-penetration of service, education and research is a feature of the mandate of the veterans administration hospi. tals which will make them progressively more important resources for the welfare of all citizens as well as the veteran population.

The funding of 92-541 should be considered a necessary adjunct to the pas sage of $ 59. The veterans administration system can thereby extend its capacities in clinical education and by doing so to facilitate the care of more veterans. These measures will further encourage the essential mix of patient care, education, and research which provides the best ground for the development of newer types of health personnel and patterns of health care delivery the veteran and the entire nation need.

Senator CRANSTON. Our next witness, changing the order, is Col. Herbert M. Houston, director, National Legislative Service, Veterans of World War I.

We are delighted to have you with us and we appreciate your patience in waiting.

STATEMENT OF COLONEL HERBERT M. HOUSTON, DIRECTOR, NA

TIONAL LEGISLATIVE SERVICE, VETERANS OF WORLD WAR I
OF THE U.S.A., INCORPORATED
Colonel Houston. Thank you very much, Mr. Chairman.

For the sake of the pressure of time, I would like to submit the written statement.

Senator CRANSTON. Thank you very much. That will go in the record. We appreciate that.

Colonel HOUSTON. I would also like to submit five letters as a part of this, with three appendices.

Senator CRANSTON. They will go in the record following your prepared statement at the conclusion of your testimony.

Colonel HOUSTON. I can state briefly, in summary, the objectives we have, Mr. Chairman, and that is to get our people into a Veterans Hospital for post-hospital care, which is nursing homes. Those are the two critical areas to which I would summarize the written statement.

Turning briefly to some of the appendix letters that we have referred to, we have sought to get some information for you on particular cases and instances that we could point out to you the need for hospitalization for our aging veterans.

We continue to receive letters of individuals who sought to get admittance, who are put on a waiting list or were sent home without hospitalization. So, we sent out some inquiries to get some letters back or cases back. We didn't have time to receive them before this hearing, so I called some service offices to get some letters and statements from them.

We have been trying to get patients in the hospitals or nursing homes to get their reactions from them. There are two letters in this group from individual cases.

I would like to address myself now to some of these letters from the service offices, and I will just quote a few sentences from some of these letters.

This particular one is from a county service officer, where he states that he had a number of cases where the hospitalization was refused to the veteran, but he did not have time to go into his record and get this to me to present the names for you.

Now, he raises a problem that I have not heard raised in any of this testimony. The sentence "Our problem in Cleveland is the doctors will not accept a service-connected patient, because they say the VA will not pay the fees."

This has reference to the outpatient care. With this letter is a letter from the medical association of that county, which is very critical. It may be found in the record. He apologizes for not being able to give us names—I was restricted as to time, I had 2 days to get this for you.

Another case in another county, another service officer makes this complaint with regards to getting veterans in the hospital:

The complaints that I have for the Veterans' Administration Hospital is that when a veteran makes application for hospitalization, it will take the Doctor 10 days to review this application and then he will be scheduled for hospitalization from 30 to 40 days in the future.

The VA tells us that there is no waiting list. I think this man is on a waiting list until he is admitted to the hospital. These are quotations from the service officer.

Another complaint is the VAH will notify a veteran to report to the VAH for admission, when he arrives he is examined and told to go

home and come back for admission next week. The veterans in the community where this gentleman lives to which he is referring, is 150 miles from the Veterans' Administration hospital. These veterans are on a limited retirement income and do not have the funds to go to these hospitals. If it is an ambulance case, it will cost the community from $110 to $125 in ambulance fees to travel and transport him to the hospital.

If he is able to ride in a car, that means that someone must donate his time and a car or send him in a taxicab, which will cost $50. This is very critical, a very critical indictment of that situation.

He goes on to state, “If this man needs hospitalization next week, why does he not need it now?"

Just briefly, I have a letter here from an individual who said he made application to go to the Veterans' Administration hospital three times unsuccessfully, and the reason given him, no beds.

Senator CRANSTON. Do you know what his problem was, do you know what his health problem was?

Colonel HOUSTON. He had been in the VA hospital on three previous occasions at different places, and he had moved to this place.

Senator CRANSTON. What was his illness, do you know?

Colonel Houston. He just says serious ailments, he does not classify it.

Those are the hospital cases. Our problem there is getting our people in the hospital.

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