No Place Like Home: A History of Home Care in the U.S.
Updated: Oct 6, 2022
In early 19th-century America, care for the sick was part of domestic life guided by family traditions and the advice found in the medical or nursing manuals of the era. When families hired physicians or nurses, professional care was delivered in the patient’s home, most often with the help of female assistants, or occasionally a servant. Yet, for those without family or financial resources, few healthcare options were available.
The earliest U.S. efforts to care for the sick at home (1813) were motivated by a tradition of religious benevolence among wealthy ladies of Charleston, SC, who entered homes of the poor and dependent to provide care and domestic comfort.
Although caring for the poor was an obligation of their class, the ladies were nevertheless confronted by the customary challenges and questions regarding home care:
Who was worthy to receive care?
Who was responsible for that care?
What type of care should be provided and for how long?
Since nursing’s origins, records kept by the Ladies Benevolent Society (LBS) demonstrated these central dilemmas of caring for the sick at home.
Along with these three critical questions, the LBS also struggled with family circumstances and chronic illness. Families and their home life were unpredictable and often uncontrollable, yet they were a vital determinant of the outcomes of care. First and foremost, the chronically ill challenged both the mission and economics of the LBS.
They quickly discovered that discharging the needy chronically ill violated a sense of benevolent duty, while maintaining such patients as part of the caseload threatened the longevity of the organization. Even worse, the LBS found it impossible to distinguish who were the most deserving among the chronically ill. Ultimately, care was limited to the acute phase of illness and eventually the LBS resorted to medical certification of necessity.
The ladies were forced to conclude that some problems simply should not be cared for at home. The mid-century opening of Charleston’s first hospital offered an alternative to the complexities of care at home and demand for home care began to decline. Charleston’s efforts to determine how best to deliver home care, especially to the poor and chronically ill, remains an excellent prototype for issues that would loom larger and longer on the healthcare landscape of the United States.
By the end of the 19th century, urbanization, industrialization, immigration, and the constant danger of infectious diseases were transforming most large cities into increasingly unhealthy places to live. The relationship between poverty and illness was indisputable and popularization of the germ theory of disease provided further motivation to protect society from uncontrolled disease.
Florence Nightingale (1820-1910), known as “The Lady With the Lamp,” was a British nurse, social reformer and statistician best known as the founder of modern nursing. Her experiences as a nurse during the Crimean War were foundational in her views about sanitation. She established St. Thomas’ Hospital and the Nightingale Training School for Nurses in 1860. Her efforts to reform healthcare greatly influenced the quality of care in the 19 and 20 centuries.
Guided by Nightingale precedent, introduction of the visiting nurse in the United States was a logical extension of religious convictions and social obligations dominating the activities of an earlier generation of citizens, such as the women of Charleston. Nightingale’s popular allure, combined with the growing availability of trained nurses, provided a practical solution to the urban threats of disease and disorder.
The image of the nurse climbing tenement stairs to care for the indigent and protect society from diseases of the “dangerous” classes appealed to numerous turn-of-the-century reformers. Motivated by a shared vision of the good society, wealthy ladies in New York, Philadelphia, Boston, Buffalo, and Chicago began to hire nurses to bring care, cleanliness, and character to the homes of the sick poor. By 1909, nearly 600 organizations across the country were sponsoring the work of visiting nurses.
Visiting nursing also appealed to a newly emerging nursing leadership striving for recognition as a profession. Such work promised to satisfy womanly desires for social uplift and to enhance the status of nursing. Working alone in homes of the poor, nurses occupied center stage and attained a distinct importance within society.
Nurses who frequently found themselves alone in patient’s homes without direct medical oversight simply took charge. Protected by standing orders and nursing procedures endorsed by the local medical group, nurses in the home exercised considerable authority. They saw their role as service to the patient, rather than to the physician. On daily rounds, visiting nurses attended to the patient’s environment, nourishment, and medicines. They alleviated distressing symptoms, intervened in emergencies, gave necessary treatments, brought the latest in portable medical technology, provided health education to all ages, and were welcomed visitors. Their patients were women, men, children, mothers and their newborns, school children, workers, the elderly, and the injured. In addition to general care, these nurses often found it necessary to contribute clothes, food, equipment, child care, housekeeping services, and assistance to exhausted family income providers in need of relief from caregiving responsibilities.
Eventually, the growing availability and acceptability of hospital care solved the problem of patients requiring continuous care, surgery, or having certain “dangerous” illnesses. But what to do about patients who failed to get well, or to die, persisted as a chronic dilemma.
Building on knowledge gained as part of an agenda of social reform during the Progressive Era, along with the public health movement of the late 19th and early 20th centuries, Lillian Wald further advanced the concept of healing at home. Hoping to demonstrate a new paradigm for nursing, Lillian Wald invented the term public health nurse to describe nursing practice that considered sickness within its social and economic context. Her charge to the nurse was not only to provide bedside care of the sick, but also to identify and correct the underlying causes of illness and misery so there would be less sickness to nurse and cure in the future. Wald truly can be credited with professionalizing visiting nursing.
Her ability to analyze and to describe the essence of overwhelming problems resulted in innovative and pragmatic remedies. Like her colleagues, Wald discovered that to care for the sick successfully at home required much more than medicines. As the definitive public health nurse, she was instrumental in securing reforms in health, industry, education, recreation, and housing.
Among Wald’s most impressive innovations was establishment of insurance coverage for home care. Relying on documentary evidence of the visiting nurses practical value, Wald convinced the Metropolitan Life Insurance Company (MLI) to examine the cost effectiveness of their policies. For a modest fee, MLI could include a visiting nurse benefit, and in the long term, reduce the number of death benefits paid. The experiment was a great success and initiated the first of 100 million home visits to MLI policy holders across the country between 1909 and 1952.
Source: Karen Buhler-Wilkerson’s No Place Like Home: A History of Nursing and Home Care in the United States (Baltimore: The Johns Hopkins University Press, 2001).