1.2: History of Home Care

In 1813, the Ladies Benevolent Society, (LBS), a group of women volunteers in Charleston, South Carolina, began the first efforts at providing home care services (Buhler-Wilkerson, 2001). These untrained women were the first to provide direct care services within people’s homes. The LBS visited the sick poor in their homes, helped them to obtain medicines, food, and supplies such as soap, bed linens, and blankets. They also helped to supply them with nurses, although these nurses were untrained.

According to Buhler-Wilkerson (2001), in the North, women from wealthy families volunteered with the sick poor to establish “friendships” in which to help the sick overcome disease and poverty. These women quickly realized that trained nurses were needed to help the sick poor, as establishing friendships alone could not help prevent or cure disease (Buhler-Wilkerson). They began to hire trained nurses, who they called “visiting nurses.” This idea came about based on the “district nurse” model which was established in England (Buhler-Wilkerson).

The National Nursing Association for Providing Trained Nurses for the Sick Poor was created in England in 1875 (Buhler-Wilkerson, 2001). This organization trained, organized, and created standardized practices for district nurses who worked within people’s homes. In addition to attending to the physical needs of their patients, these visiting nurses worked to teach the sick poor about how disease is spread and how to maintain a clean home in order to prevent the spread of infection.

Based on this model, Visiting Nurse Societies were established in major cities throughout the Northern United States (Buhler-Wilkerson, 2001). By 1890, there were 21 home care visiting nursing associations (Buhler-Wilkerson). The need for nursing care within the home continued to grow. This need grew to not only caring for the sick poor, but also to provide preventative services to babies, children, mothers, and to care for patients with infectious diseases such as tuberculosis. Although the death rate for infectious diseases had declined, there was a growing concern for prevention and good hygiene. By 1909, the Metropolitan Life Insurance Company began to send nurses into their policyholders’ homes to provide nursing services (Buhler-Wilkerson). Their hope was that providing home nursing care would reduce the amount of death benefits claimed. They were the first organization to provide reimbursement for home care nursing services.

Lillian Wald, a nurse, is credited for establishing the Henry Street Settlement and with defining the term “public health nursing”. The nurses who worked at the Henry Street Settlement visited the sick in their homes, and also provided social services for people throughout the city. In addition to the Henry Street Settlement house, the organization grew to include numerous nursing houses throughout the city to meet the growing need for nurses within communities. These nurses also held classes for their neighbors to teach carpentry, sewing, cooking, English, and home nursing (Buhler-Wilkerson, 2001). They established kindergartens and various social clubs to meet the needs of their neighborhoods. By the time of Lillian Wald’s retirement, her nurses were making 550,000 home visits to 100,000 patients (Buhler-Wilkerson).

In the late 1920s, many of the home care agencies closed due to the poor economy and the nursing shortage during World War II (Buhler-Wilkerson, 2001). The establishment of hospitals resulted in a model where patients moved from receiving care in the homes to into hospitals. Despite experiments by The Health Insurance Plan of Greater New York and Blue Cross to include home care services, coverage for visiting home care was not universally provided at that time (Buhler-Wilkerson). By the late 1950s and early 1960s, however, it became clear that there was again a growing need for home care services. People with chronic illnesses did not necessarily need to be hospitalized. The cost of hospitalizations began to be apparent, and the long-term effects on lengthy institutionalizations began to be studied (Buhler-Wilkerson).

In the U.S., it was not until 1965, when Medicare was established for people over 65 years of age, that home care services were once again covered by insurance (Buhler-Wilkerson, 2001). Medicare is a federal health insurance program. Medicare now also pays for patients with kidney failure and certain disabilities. According to the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services (2010), patients who receive home services through Medicare must be under the care of a physician who certifies the need for skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy. Patients must also be certified to be home-bound by their doctors. This means that it is either unsafe for the patients to leave their home or they have a condition that makes leaving the home difficult. Medicare provides “intermittent” home care, meaning home care is not needed on a full-time basis. While Medicare will often pay the full cost of most covered home health services, they do not pay for 24 hour a day care. Medicare may also cover up to 80% of special equipment the patient needs, such as a wheelchair or walker (U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services).

Medicaid is a joint state and federal health insurance program. Coverage for patients will vary from state to state, and states may call it different names, such as “Medi-Cal” or “Medical Assistance” (U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services, 2010). Medicaid provides coverage for low-income patients and families. Eligibility for this program depends on income, number of people in a household, and other circumstances. It is important to remember that not everyone is eligible to receive Medicare or Medicaid, and home care services may not be covered in full. Agencies who receive reimbursement through Medicare or Medicaid must meet certain guidelines, including the requirement that HHAs receive formal training and pass certification exams. Due to the growing need for home care services, and in an effort to reduce costs to insurance programs such as Medicare, the need for home health aides (HHAs) and personal care aides (PCAs) continues to increase.