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Did you know that today’s nursing homes trace their history all the way back to the days of poor houses in the 18th century? We’ve come a long way! I hope you enjoy reading these highlights in the history of U.S. nursing homes.
Prior to the 1800’s
Families generally took responsibility for the care of elderly relatives who could no longer fend for themselves. Wealthy older people with no family assistance ended up hiring servants to provide care. But elders with no family and no means of support lived in poor houses (also know as almshouses).
There was no age distinction in these institutions, so the elderly lived alongside orphans, unwed mothers, alcoholics, and the mentally ill. Almshouses were run by the government and paid for through taxes. Conditions in most of these homes were dreadful.
Concerns about the terrible reputation of almshouses led to charitable and fraternal organizations building homes for the aged. People admitted to these facilities were often restricted to the ethnic or religious background of the founders. Moreover, potential residents were often required to pay an entrance fee, and they were sometimes asked to present a letter verifying their good character.
Over time, specialized institutions were built for groups such as orphans and the mentally ill. As a result, the almshouses became largely filled with elderly people. (Does anyone know when the final almshouse closed? I was able to trace them into the 1950’s.)
The Social Security Act of 1935 provided a federal system of monthly payments known as Old Age Assistance to people over the age of 65. However, in an attempt to shut down the almshouses, money was not given to people living in public facilities. This resulted in many people leaving these institutions. Some were now able to afford to live on their own, while others could pay for care in private facilities. However, these private facilities were unregulated and many provided substandard care.
The Hill-Burton Act of 1946 made construction loans and grants available to communities to help build healthcare facilities, including nursing homes. In order to receive the money, a nursing home was required to be affiliated with a hospital. As a result, nursing homes developed a medical model of care. In other words, they were run like hospitals with a focus on treating illness.
The creation of Medicare & Medicaid in 1965 greatly increased federal funding for nursing homes and set standards for nursing homes that received these funds. This resulted in the first real federal regulation of nursing homes.
If you’ve ever worked at a nursing home during a state survey (inspection), then you know what a stressful experience this can be. I often wondered who on earth ever came up with such a terrible idea. In reality, regular inspections came about due to legitimate concerns about substandard care during the 1970’s. This resulted in a significant increase in government oversite of nursing homes. Other changes included the development of an ombudsman program, guidelines for the training of nursing home staff, and penalties for failure to comply with regulations.
In 1987 the Nursing Home Reform Act specified national standards for the services a nursing home must provide for all residents. Requirements for nursing home surveys were strengthened. A nursing home resident’s Bill of Rights was also created: (This has since been updated.)
- The right to freedom from abuse, mistreatment, and neglect.
- The right to freedom from physical restraints.
- The right to privacy.
- The right to accommodation of medical, physical, psychological, and social needs.
- The right to participate in resident and family groups.
- The right to be treated with dignity.
- The right to exercise self-determination.
- The right to communicate freely.
- The right to participate in the review of one’s care plan, and to be fully informed in advance about any changes in care, treatment, or change of status in the facility.
- The right to voice grievances without discrimination or reprisal.
The Patient Self-Determination Act of 1990 assured nursing home residents the right to make decisions regarding their own health care.
Creative new concepts in nursing home care are being developed. The focus is no longer on medical care, but rather on a more homelike, person-centered environment. Check these links to see how leaders in the field are envisioning alternatives to traditional nursing homes:
What do you see as the nursing home of the future? Please let us know in the comment section. (Remember, this is where you and I may be living someday!)