Do We Need a Surgeon General's Report on Home and Community Based Services? A Personal and Policy Journey

During my career, my attention became focused on elder community care policy after reading a Commonwealth Fund-supported report of the Commission on Chronic Illness (1956) Care of the Long-Term Patient. The report described the problems of coordination and integration of services for the patient with multiple needs, which required simultaneous solutions. It argued for some type of community-based central organization to oversee and plan for the needs of long-term patients. (Note the focus on the long term patient , not the long-term care system.) The Community Welfare Council of Schenectady, where I held my first professional job, issued a report in 1964 detailing the chronic illness needs in Schenectady County, New York. I wrote that report with technical assistance from the State Charities Aid Association of New York and the New York State Department of Health. This report was written in the time before the establishment of Medicare. It was a time when Visiting Nurse Association nurses returned to their offices at 4 p.m. each day, filled out their records and sharpened their hypodermic needles in a needle sharpener (similar to the one used for pencils). The report listed a number of radical recommendations such as: (a) acute care hospitals should establish stroke rehabilitation programs, (b) married couples residing in the gender-segregated county nursing home should be able to visit each other, (c) nursing homes should have at least one registered nurse available to oversee care, (d) a community-wide home-care program should be created, (e) Blue Cross/Blue Shield should reimburse for in-home care, and (f) a new homemaker program should be established. That report is almost 40 years old. director of the Massachusetts Medicaid Program. Morris wanted to do a study of elders on Old Age Assistance and asked for my help in getting access to records and people. These were the years when the Harvard Community Health Plan (HCHP), a prepaid staff model group practice, had been established. Medicaid actually had a contract with HCHP for 1,200 Aid to Families With Dependent Children recipients in the Mission Hill area of Boston. Morris produced a report calling for the creation of a prepaid organization (like HCHP) to provide social services to elders, for which he had found a great need. Services would include homemaking, chores, transportation, meals, legal services, etc. It would be called the Personal Care Organization (PCO). We moved ahead, received one of the early 1115 waivers, and …