(This is part 1 of our 5-part series on the history of nursing homes. Other parts: Part 2Part 3, Part 4, and Part 5.)

The concept of  ‘traditional’ nursing homes is undergoing rapid change and the industry is consolidating. Discussions about ‘skilled nursing’ are often complicated by confusing and misused terminology.

Think of ‘skilled nursing’ as dealing with 3 kinds of patients: (1) Long-term, acutely ill ‘custodial care’; (2) Transitional Care; (3) Rehabilitation.

Currently, chronically ill patients are not usually housed in facilities operated as ‘transitional care and rehabilitation’  units.  These ‘rehab’, short-stay units have a goal:  GET OUT OF HERE!   ‘Transitional Care’  is designed to help patients build strength and skills to transition into the next phase of recovery—hopefully, from the hospital to back home. ‘Rehabilitation care‘ crosses all age lines and “retrains patients to compensate for specific lost functions”. 

This ‘re-skilling’ is directed at the ‘skills’ of walking, talking, even breathing.  But again, transition and rehabilitation care are not ‘maintenance’, which is defined as: “no improvement expected, skilled care needed for continuation purposes” i.e., to prevent or slow a further decline in condition.  (May I make a personal observation at this point?  Not dying (continuing), isn’t necessarily the same as living.)

With all the changes, improvements, and discoveries in health care (hip/knee replacements, etc.), is there any wonder the function of the ‘Nursing Home’ is changing?  As pointed out earlier,  simply using the nomenclature ‘Nursing Home’ can cause confusion.

Before Nursing Homes, There Were Almshouses


To put this all in context, let me take a minute to review the early history of Nursing Homes in America. Before the nineteenth Century,
old people who were incapacitated and/or broke lived in Almshouses.
 Many older Americans had been displaced by the Industrial Revolution—unable to hold mechanized jobs. The Civil War decimated some families’ ability to care for their elderly members. Local governments of the time favored ‘group housing’ as opposed to what was called ‘outdoor welfare’ consisting of donations
of food, clothing, wood, etc., to individuals living independently.  As a result, all kinds of people—the physically incapacitated, orphans, the mentally ill and insane, etc. ended up living in Almshouses.

As the nineteenth century began to unwind, women and church groups began founding Homes for the Aged out of concern for worthy individuals of their own ethnic or religious background who might have to spend their last days alongside the most despised in society in an Almshouse.  The big concern then—as now—is that “foreigners have taken possession of the public charities . . . including the houses where our less privileged classes formerly resided.”

Not only were ‘more worthy’ elderly people moved from the Almshouses, but other groups started providing for young people, the blind, the insane, etc. By the 1920’s nearly 70% of all residents in Almshouses were the elderly poor.

More in Part 2 tomorrow!