Background And Historical Development Of Nursing Homes In The United States
From Almshouses to Nursing Homes

Nursing home policy was developed from social welfare issues regarding care of the poor. A strategy known as ''indoor relief" was developed in Elizabethan England when social planners used almshouses to care for the poor, who were divided into the "deserving poor" (those who were unable to work) and the "undeserving poor" (those who were perceived as morally corrupt because they were able to work). The poor elderly were housed in almshouses and exempt from moral judgments because of their age and inability to work (Hall and Buckwalter, 1990).

In the United States in the 1920s, almshouses were funded by the states and were used to continue the policy of providing indoor relief for the deserving poor who were unable to be employed in the factories, as well as providing care for the blind, chronically ill, mentally ill, and frail and old individuals. In 1923, about half of the 78,000 residents of almshouses were elderly and infirm. Society began to protest the housing of the infirm elderly with the poor and insane and Congress, because of this public pressure, stipulated that persons in public institutions should not receive old age funds; people in boarding houses, however, were eligible. Not surprisingly, this legislation prompted a sharp increase in the number of boarding homes in which nurses were hired to care for the frail and chronically ill. Thus, many boarding homes became known as nursing homes (Kalisch and Kalisch, 1978; Vladeck, 1984). Also in the early 20th century, private care homes emerged for elderly widows of various ethnic or religious groups (e.g., Lutheran homes, Jewish homes), which served as the precursors for today's charitable and nonprofit nursing homes (Vladeck, 1984).

Nursing homes really began to develop following passage of the Social Security Act of 1935, which provided payment to individual beneficiaries and thus turned indoor relief into "outdoor relief." That is, community-based services began to emerge that prevented the need for almshouse placement (Kalisch and Kalisch, 1978; Vladeck, 1984). With passage of the Kerr-Mills Medical Assistance to the Aged Act in 1950, which allowed for direct payment to care providers, and with increases in the number of older adults in the population, the nursing home industry boomed.

In 1954, the American Nursing Home Association lobbied for and won the right for nonprofit nursing homes to be built in conjunction with hospitals using Hill-Burton funds. Thus, nonproprietary homes were moved into the medical-surgical domain where, after passage of the Medicaid and Medicare Acts in 1965, they were required to meet strict federal nursing standards, creating the skilled-level facilities of today. Standards of care relaxed somewhat during the Nixon administration, and proprietary homes could apply for small business develop-



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