USA > Massachusetts > Middlesex County > Somerville > Report of the city of Somerville 1954 > Part 8
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ANNUAL REPORTS
CLOSURE OF THE OLD CONTAGIOUS HOSPITAL
The astonishing success of "Operation Evacuation" at the City Infirmary, appears more impressive when we recall that just prior to the beginning of this project, the Department was confronted with the problem of transferring some 30 patients from the Hillcrest Nursing Home which had five years pre- viously leased the premises of the old Contagious Hospital, located on the corner of North St. and Broadway. Due to the hazardous conditions prevalent, it was decided not to re-lease the building in which approximately two thirds of the 42 pa- tients were public assistance clients, mostly aged. The old Hospital Building was dismantled shortly after closure of the Hillcrest Home in February.
CHRONIC HOSPITAL CONTEMPLATED
While the City Infirmary traditionally was a hospice for the transient, a haven for the derelict, and a refuge for the evicted, it was also a facility for custodial care of the senile and a retreat for the chronically incapacitated and the terminally ill. Hence, in the course of planning its abandonment, it was but logical that renewed consideration should be given to the erection of alternative accommodations. The possibility of building a Chronic Hospital with a Geriatrics Out-Patient Department, was an objective previously sponsored by the Agent, and considered by the Board of Public Welfare, and the Mayor in 1950. The unavailability of adequate supporting funds from the Federal Government (under the Hospital Survey and Construction Act) to absorb part of the capital outlay costs, necessitated defer- ment of the project at the earlier date, and again in 1954. Con- sultation with the Health Department of the Commonwealth, which clears and channels such Federal grants, revealed that the maximum amount allocatable at the moment, would be $250,000. A "conservative estimate" of the cost of erecting a 100 bed Chronic Hospital was given as $1,250,000 to $1,500,000. Furthermore, a study of the pertinent evidence would seem to indicate that Somerville would need a 200 bed facility. While our experience with ever-mounting commer- cial nursing home expenses would seem to indicate that the initial costs of building a Chronic Hospital would be amortized by the savings affected, over a period of years, the matter of continuing operational costs and the problems of professional personnel staffing are important factors which require careful evaluation. As far as locale is concerned, the grounds of the City Infirmary would certainly seem to offer an excellent site.
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WELFARE DEPARTMENT
THE WELFARE CLINIC
As was mentioned in our Annual Report for the year 1953, the precise role proper to the Welfare Clinic has been a subject demanding periodic review. The recurrence of questions con- cerned with effective inventory methods, and the accurate auditing of accounts complicated by labyrinthine regulations mandatory in the categorical assistance programs in which the Federal Government participates, led to a further study early in 1954.
The findings of a survey which the undersigned had made at the Mayor's request, in the summer of the previous year, were re-examined in the light of ensuing experience, and after considerable deliberation, it was decided to eliminate the Clinic's perennial function of dispensing medication to A.D.C and General Relief recipients. The several conflicting methods of handling the medicinal needs of patients receiving diverse types of public assistance were abolished in favor of a single new procedure whereby clients are referred to pharmacists of their choice for the purchase of prescribed drugs and bio- logicals.
Effective March 1, 1954 the Welfare Clinic became simply a Diagnostic Centre and was relieved of its role as a Dispensary, except in cases of emergency or first aid.
The position of the Welfare Clinic must be regarded in the light of the general Medical Care Program obtaining for the Department. Changes in legislation and shifts in State policy cannot but affect future developments. It is immediately ob- vious that we are far from the ideal insofar as medical care planning is concerned. What the future unfolds remains to be seen. A multiplicity of complex factors crowd the picture at present.
STUDY BY STATE DEPARTMENT
The desire to evolve a plan of systematic staff development which would work to the best interest of the City and the De- partment, together with a realization that efficiency can be enormously increased by modern business procedures, moved the Board to invite the State Welfare Department to undertake an organizational and functional study of the local Department. The State Department has long offered such consultant ser- vices to local Boards.
The request of our Board was despatched to the State offi- cials under date of April 7, 1954. A few weeks thereafter, Mr.
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Charles F. Clancy, Manager of the Greater Boston District of the State Department reviewed with the Agent and the Board an outline of the proposed study. Eventually, several weeks later, the actual survey work began under the direction of Mr. Clancy who assigned two Field Representatives, namely, Miss Dorothy Johnson and Mr. John Grady, to the task.
As originally projected, the findings of the Study were to be available to the local Board by the first weeks of October, but no report was filed before the end of the year and it appeared that the new year would be well along before the results of the Study would become known. Meanwhile the Board which con- siders this venture as a cooperative enterprise of the two Departments (the State and the Local) is looking forward hope- fully to some objective appraisals and practical recommenda- tions.
NEW MEDICAL PLAN
The State Welfare Department in January, inaugurated a new Medical Plan, the operation of which became effective by mandate in local communities not later than July 1, 1954. The implementation of the Plan has manifold consequences includ- ing a tremendous increase in detail work both for the Social Workers and the regular clerical staff. The writing, mailing, filing, return from physicians and vendors, scrutiny, approval, processing for payment and recording of thousands of author- izations for services and supplies in quadruplicate, continues to tax the time, patience and energy of all concerned.
Our experience to date warrants the conclusion that the procedures involved in the Plan, are unreasonably costly, sense- lessly time-consuming, vexatious for professional persons, and generally futile. It is eminently clear to any administrator that they were prefabricated by theorists far removed from the realities of practical case administration. The idea of control- ling medical costs by multiplying paper-work and by perpetual harassment of physicians and vendors is the sheerest sort of folly. It should be jettisoned completely without resorting to gradual "strategic withdrawals." We have little doubt that eventually the entire Plan will necessarily be supplanted. The early abandonment of the provisions affecting druggists pre- sages ultimate dissolution. The startling abruptness with which this section of the front capitulated under the vociferous protests of the organized pharmacists was a disillusioning phenomenon not easily forgotten.
The main feature of the new Plan from the aspect of prin- ciple, is that of direct payment to physicians and vendors,
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instead of indirect payment whereby clients were formerly re- imbursed for payments made or to be made.
The concept originally embodied in the Federal Social. Security Act and carried over into State policy was that of pre- serving the client's sense of responsibility and the provision of personal purchasing power to meet his medical needs. The new approach made possible by the recent Social Security Amendments, and incorporated in the new State Plan, puts the local agency in a contractual relationship with the vendor, and consequently emancipates the beneficiary of assistance from the burden of responsibility.
The first view when reduced to method, was found imper- fect, especially because of the difficulty involved for the indigent in advancing cash and waiting for reimbursement, and also because of problems associated with senility and invalid- ism. The new program however, also falls short of the desideratum. Once the sluice-way of government funds is left open to merchandisers of goods and services, it becomes in- finitely difficult to prevent syphoning by the unscrupulous. Once it becomes known that "the City will pay for it" or the State, or Uncle Sam, stratospheric charges result, and the public treasury is raided, however respectably the action is disguised. The dangers remain frightful even though we realize that the plurality of professional persons and business managers abide by some code of ethics.
Under the terms of the new Plan we changed our method of paying licensed Nursing Homes. Previously the patient was paid in advance so that he could "purchase the care needed." We now pay the Homes in arrears, on a billing basis. We re- gard this particular phase as a definite improvement, although, here too, we perceive the advantages accruing to the proprie- tors, who recognize the contractual character of the new relationship. The fact is of course, that because of the in- capacity characteristic of the patients placed in these homes, some sort of contractual relationship was apparently always implicit.
From the legal viewpoint, we foresee the possibility of several questions eventually arising which may result in a more exact definition of the responsibility of the Public assistance agency, in respect to persons whom it places in institutions, or, for whom it pays. Ordinarily, the concept of a public agency discharging the responsibility of a competent adult citizen, is abhorrent to the enfranchised. The agency by the mere fact
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ANNUAL REPORTS
of financing and arranging needed care, does not ipso facto, become a custodian or conservator. Therefore, what precisely are the limits of the agency's duties and responsibilities, and relevantly, its privileges? What are the boundaries between the agency's role and that of sons and daughters and other relatives, especially in regard to the placement itself, and to the transfer of patients? Does the legal liability of children enter into the matter?
It is one thing when minor children are entrusted to the State as wards, and the State acts "in loco parentis" that is, "in place of the parent." It is something vastly different when an adult who has not been pronounced mentally defective, or, "non compos mentis", but who is physically incapable, be- comes a charge of the community via its public assistance agency, and the agency is maneuvred as it were, into assuming the moral responsibility of available children, as well as the financial burden of support.
It is postulated of course, that the agency should extend service as well as monetary support. But a question worth pondering arises. Should the legal liability of children extend beyond financial frontiers? Should their moral responsibilities be defined in detail by Statute? In other words, what are the limitations on the agency's role, for example, in placement and arranging the details of care, medical and otherwise, if respon- sible adult children are conveniently at hand, but choose to shunt the duty of filial devotion over to the social agency? The implications are particularly meaningful when an aged parent is senile but not considered committable.
We raise these points here simply to illustrate the observa- tion that medical social case work is no superficial process, but is pregnant with far-reaching consequences. Hence, the urgent need for clearly understood and well thought out basic principles.
FINANCING PROBLEMS
Early in the year we expressed to the Mayor our misgivings as to the adequacy of the appropriations made for the Depart- ment in the Annual Budget, and our experience during the first half of the year verified our unfavorable anticipations. It became clear at the half-way mark that additional monies would be needed. We formally advised the Mayor to this effect in an explanatory communication under date of August 4, 1954. The fact that overly optimistic estimates of revenues receivable had conditioned the projected costs for the year, the failure of
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the A. D. C. caseload to taper off appreciably during the sum- mer season, as it had in 1953, a rise in unemployment, the elimination by local industries of overtime and Saturday work to the detriment of marginal income families, steadily spiral- ling medical and advancing rental expenses were the chief factors contributing to the urgency for a supplementary ap- propriation.
After a careful study of the situation, the Mayor decided to borrow $250,000 by means of a bond issue, to meet the Department's needs for the balance of the year. After pro- longed debate, and without objection from the Executive Department, the figure was eventually reduced to $225,000 and the money became available in September, after the legis- lation was finally passed by the Board of Aldermen.
In order to meet the day to day requirements of the various categories of assistance, several money transfers were effected within the Department, pending and subsequent to the Bond issue. A table of these transactions is recorded below.
CIVIL SERVICE EXAMINATION
The Civil Service examination requested by the Board to fill the vacancy created by the death of Mr. Willwerth, was held on Friday July 30, 1954. It was a competitive promotional examination open to all Supervisors of Social Work in the De- partment.
The marks were made known to the individual candidates under date of September 22, 1954, but a series of appeals de- layed the designation of an Agent beyond the end of the year.
SOCIAL SECURITY CHANGES
Important changes in the Social Security Act influencing directly or indirectly the divers programs of public assistance were legislated by Congress during 1954. Of particular sig- nificance financially, was an increase across the board, in Old Age and Survivors Insurance Benefits which became effective on October 1, 1954. The Insurance increase roughly approxi- mated $5.00 per beneficiary, and necessitated the reduction of assistance payments correspondingly. Some 700 Old Age As- sistance cases were re-budgeted accordingly, and a compara- tively small number of D. A. and A. D. C. cases.
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ANNUAL REPORTS
In notifying the assistance clients of the reduction, care was taken to point out that Federal and State Laws required the action in question. As a result, the number of complaints was negligible.
HIGHER RATES FOR PHYSICIANS AND NURSING SERVICES
A delegation of five physicians representing the Somerville Medical Society conferred with Mayor Donovan and the Agent on the subject of a higher fee schedule, for home calls and night visits, on November 16, 1954. As a result of this con- ference, it was agreed to pay the prevailing rates outlined in the new State Medical Plan, effective as of January 1, 1955.
A new fee schedule was also negotiated with the Somerville Visiting Nursing Association effective as of November 1, 1954. In accordance with an agreement reached with the Massachusetts Organization of Public Health Nurses by the State Welfare Department, the local per call rate was increased on a cost basis, from $1.67 to $1.89.
OLD AGE ASSISTANCE
The Old Age Assistance caseload fluctuated to some slight extent, during the year, but remained in the neighborhood of the 2100 mark. On January 1, 1954 there were 2130 active cases and on December 31, there were 2083 on the rolls. The number of recipients who receive payments in any particular month differs somewhat from the number actually on the rolls because of suspension of payments due to hospitalization or for other transitory reasons. This latter figure showed a very gradual decline from 2102 in February to 2037 in December. We mention this fact because it is on the latter statistic that the per capita case cost is based. In December the per person payment averaged $73.65. This single fact indicates the impact of medical care when we bear in mind that more than a third of the recipients are also beneficiaries of Old Age and Survivors' Insurance, which is the largest single source of other income, but not the only one.
It should be borne in mind that the average caseload does not suffice to attest the activity of the Bureau, since, during the year, 2405 different persons received assistance.
The average age of new applicants was 71.7 years, of re- cipients transferred from other Cities and Towns 72.7 years,
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WELFARE DEPARTMENT
and of reinstated cases 74.2 years. Thus the general average age of enrollees was 72.8 years. Since the eligibility age is 65, we regard this evidence as very significant. In the first place, it demonstrates the weakness of the position held by those who ceaselessly agitate for a lowering of the eligibility age. Further- more, it tends to buttress once again, our long cherished con- viction, based on more than two decades of experience, that our aged in general, do not seek public assistance until their economic resources are depleted, and their physical ability is near exhaustion. The impressiveness of this fact is further enhanced in view of the evidence that two thirds of the re- cipients are women, the preponderance of whom are widows, or, individuals who never married.
In passing, it may be worth recording that a study of cog- nate import made by John J. Griffin, Supervisor of Old Age Assistance, in 1953, was published in the April 1954 number of the Journal of Gerontology, under the title: "Financial Sig- nificance of Longevity in Public Assistance."
The total cost of the Old Age Assistance program in 1954 was $1,929,605.27 which represented 65.7 per cent of the aggregate expenditures of the entire Department. The total operating cost of the Bureau was $17,944.73 more in 1954 than in the preceding year.
It is worth recalling that Massachusetts had an Old Age Assistance program some five years before the Social Security Act became effective. The Commonwealth's statute became operative on July 1, 1931 and the program started in Somer- ville on August 17 of the same year.
Since the date of its inception until the end of 1954, the Somerville Bureau has expended $20,217,876.67. How infla- tion, liberalization, and caseload augmentation has affected development, is made manifest by the fact that of the total of over $20,000,000, almost half, or, $9,500,420.24 equalling 47 per cent of the gross amount, was disbursed in the past five years, 1950-1954, inclusive, and three quarters of all, or $15,072,787.49 representing exactly 75 per cent, was ex- pended in the latest 10 years.
AID TO DEPENDENT CHILDREN
During 1954 the A. D. C. Division, the second largest of the Department, expended a gross total of $501,500.21 or 17.1 per cent of the Department's aggregate disbursements. While
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ANNUAL REPORTS
the caseload did not vary significantly from that of the previous year, hovering in the vicinity of the 300 mark throughout the year, the per capita cost climbed and this Division spent some $44,612.53 more than in 1953. Percentagewise the increase represented a rise of over 9.5. The per case cost of course, varies unpredictably with the size of the families aided. More- over, it is worth noting that the "average" monthly caseload figure does not provide a true index to the turnover of clients, since during the twelve month period under review, 452 dif- ferent families received assistance from the Division.
Early in the year the intensified case work program newly inaugurated under the auspices of the State Welfare Depart- ment, was placed in operation. The State authority made monthly visits mandatory. Whatever the efficacy of "the new approach" may be on a State-wide basis, it has not proven par- ticularly fruitful locally.
The basic moral and social problems which protrude with such appalling starkness from the picturesque pages of A.D.C. case histories, cannot, it seems to us, be solved or even essen- tially ameliorated by mere resort to novel applications of professional social work techniques. Wind-mill theorizing, festooned platitudes and sheer naivete may conspire to indulge such costly experimentation, but the concrete results demon- strate beyond cavil, that the substantial realities of everyday family life remain unaffected. The foundational principles and implementing policies upon which the entire A. D. C. formula is projected, urgently demand scrutinizing analysis and objective re-evaluation in the light of the traditional norms of the Natural Law and the historical experience of administer- ing public agencies. Dependent children do not exist in a vacuum. Nor can their parents be considered as simply the irresponsible prey of environmental pressures and emotional energies.
Rationality is the primary characteristic which distin- guishes the human person from the brute animal. Rationality and responsibility are the first elements around which all pro- fessional social work and public welfare administrators should be constructed. A relief program primarily and ostensibly de- signed to preserve, protect and promote family stability cannot hope to succeed unless there is sustained practical emphasis on the full scope and significance of parental responsibility. In plain language, this means that any statute, judicial interpreta- tion, enforcement negligence, administrative policy or pro- cedure which in fact becomes equivalent to placing a premium on promiscuity, concubinage, continued desertion, or repeated
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WELFARE DEPARTMENT
delinquency on the part of the parent or parents, should be effectively repudiated as prejudicial to the immediate welfare of the child and the ultimate purpose of human life. This is not to attempt the legislation of personal morality. It is sheer common sense, and the preference of the child's well-being and the good of the community to the blind selfishness of un- controlled license.
DISABILITY ASSISTANCE
The average Disability Assistance caseload remained fairly steady throughout the year. On January 1, 1954 there were 243 active cases and 239 on December 31, 1954. During the year 315 different persons received assistance. The number of cases actually receiving monthly payments vacillated from a low of 208 in March and April to a high of 236 in October.
During the calendar period under review, this Division ex- pended a total of $261,034.06 which was tantamount to 8.9 per cent of the aggregate spending by the Department as a whole. The 1954 costs were but $3,877.72 greater than those in 1953, despite the sizable influx of applicants resulting from closure of the City Infirmary. The turnover of cases in this particular category is remarkably high. This is easily under- standable since "permanent and total disability" is a pre- requisite.
The very character of the program also explains in great part, the fact that almost one half of the total money disbursed for assistance is expended for medical care. Thus in 1954 of the total $239,648.37 distributed for assistance, some $102,579.66 or 42.8 per cent was for medical, hospital, and nursing home care.
The work of processing applications in this Division is par- ticularly onerous. The medical documentation of alleged incapacity sometimes takes months to complete, and clearance with the State Department likewise extends over prolonged periods. The number of cases which finally prove eligible represent less than 50% of the applications processed. In 1954 only 106 of the 230 applicants for this type of assistance, eventually were found to be both medically and financially eligible.
GENERAL RELIEF
The General Relief (or Miscellaneous Welfare) caseload climbed sharply during 1954. While the average caseload during January was 132, it was exactly 50 higher or 182 in
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December. During the twelve months there was a total of 705 different cases aided. The overall rise in costs however, was not alarming. The 1954 gross was $216,902.70 or just $8,610.35 above the 1953 sum of $208,292.35. The General Relief costs were equivalent to 7.4 per cent of the Depart- ment's budget.
It is especially interesting to note that the expenses for medical care in this Division, despite the rise in fee schedules, were somewhat less than in the prior year. In 1953 the charges for medical care totalled $42,334.06 or 35.5 per cent of the $119,000 expended directly for assistance, while the compara- tive figures in 1954 were $39,390.77 or approximately 29.8 per cent of the direct assistance outlay of $132,317.17.
DOMESTIC RELATIONS
The Domestic Relations Bureau was intensely active during the year 1954. The grave social and legal problems which preoccupy the attention of this Division, namely, divorce, de- sertion, abandonment, non-support, and illegitimacy, are ob- viously precipitating dependency in an ever increasing number of instances.
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