Caring for the chronically ill: Philadelphia, 1945-1965

Changing patterns of illness in the United States modified the context for sick care during the first half of the twentieth century, presenting both dilemma and challenge to policy makers and professionals. Philadelphia\u27s community leaders promoted several approaches to long-term care services between 1945 and 1965. Denied an adequate source of financing, and confronted with persistent societal ambivalence toward the long-term sick, chronic care remained unavailable and of poor quality. In this historical inquiry, four historical case studies establish the context and unifying features of local long-term care prior to Medicare and Medicaid. Public institutional care at Riverview Home for the Aged, the contemporary descendent of the original almshouse, highlights the politicized nature of municipal care during Philadelphia\u27s Reform Movement. The Philadelphia Home Care Plan of the Visiting Nurse Society, the first nurse-controlled, community-based, long-term home care project, gained minimal acceptance by transferring technology and professionals into the home, particularly to reduce hospital overcrowding by unwanted, long-stay patients. A comparison with Montefiore Hospital\u27s Home Care Program demonstrates the conflicting roles of nurses and physicians in long-term care. Local conflicts between central planning agencies, such as the Health and Welfare Council, and direct service agencies, such as the Lighthouse Settlement\u27s Meals-on-Wheels program and various homemaker programs, illustrate possibilities and limitations in the construction of an extra-institutional, community-based, long-term care system. Resistance to internal structural change and inter-agency collaboration, fragmentation of services, and containment of expenditures combined to limit extension of innovative voluntary services. Federal, state, and local efforts to improve quality of care in long-term institutions were inadequate, highlighting the failure of government policy for the aged and chronically ill. Lacking the will to implement necessary economic and structural improvements, and in the absence of home-based alternatives, a poor system of institutional long-term care evolved which provided minimal care for the middle to lowest classes. While long-term care was significantly medicalized during the 1950s and early 1960s, evaluations of the moral worthiness of the long-term sick suggest explanations for continued neglect of long-term care services