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A nursing historical perspective on the medical home: Impact on health care policy
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A nursing historical perspective on the medical home: Impact on health care policy Arlene Keeling, PhD, RN, FAANa, Sandra B. Lewenson, EdD, RN, FAANb,* a
Acute & Specialty Care Department, School of Nursing, University of Virginia, Charlottesville, VA b Lienhard School of Nursing, College of Health Professions, Pace University, Pleasantville, NY
article info
abstract
Article history: Received 29 April 2013 Revised 9 July 2013 Accepted 12 July 2013
Background: The idea of a “medical home” is rapidly gaining in popularity in health
Keywords: Primary health care Nursing history Medical homes Health care policy Interprofessional education Provider neutral language Henry Street Settlement American Red Cross Town and Country Nursing Service Frontier Nursing Service
policy circles today. In the face of a shortage of primary care physicians, it has led to a national debate about who should lead the homes, who should deliver care, the kind of care that should be offered, and the location of that care. A historical examination of nurses’ role in primary care can provide evidence to inform the current dialogue. Purpose: This article provides insight into nursing’s role in primary health care during the early 20th century. Methods: Traditional historical methods were used. Discussion/Conclusions: Three historical case studies provide evidence of how nursing and medicine worked together in the past and informs the discussion about using nurses to deliver primary health care today. Policy makers should not overlook the central role nurses have long played in providing access to care for numerous underserved populations. Makers should not overlook the central role nurses have long played in providing access to care for numerous underserved populations. Cite this article: Keeling, A., & Lewenson, S. B. (2013, OCTOBER). A nursing historical perspective on the medical home: Impact on health care policy. Nursing Outlook, 61(5), 360-366. http://dx.doi.org/10.1016/ j.outlook.2013.07.003.
Begun as a model of care to manage the care of children with chronic conditions, the idea of a “medical home” is rapidly gaining in popularity in health policy circles today. In fact, in 2012 the Patient Protection and Affordable Care Act provided for the establishment of patientcentered medical homes (Institute of Medicine, 2012; Patient Centered Primary Care Collaborative, 2013). Along with the recommendation came a debate about who should lead medical homes and who should be involved in providing care within them. Meanwhile, the context in which these would be established is one of a shortage of primary care physicians and uncertainty about the “optimal composition” of the primary care workforce (Blumenthal & Abrams, 2013, pp. 1933-1934).
Since its inception in the 1960s as a model of care for chronically ill pediatric patients, the definition of a “medical home” has evolved. In 2002, the American Academy of Pediatrics defined the medical home as “a model of primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective” (American Academy of Pediatrics, 2002, p. 185). In 2008, it was defined as “a single point of coordination for all health care, including specialists, hospital and acute care” (“Making Medical Homes Work,” 2008, pp. 1-2). Sometimes the definition for the primary care worker includes nurses and nurse practitioners, physician assistants, and practice managers as well as community health centers (Beal,
* Corresponding author: Dr. Sandra B. Lewenson, Lienhard School of Nursing, College of Health Professions, Pace University, 860 Bedford Road, Pleasantville, NY 10507. E-mail address: [email protected] (S.B. Lewenson). 0029-6554/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2013.07.003
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Doty, Hernandez, Shea, & Davis, 2007). At other times, the definition refers only to physicians and medical practice. More recently, the term “medical home” describes a broader health care model that provides adult and children alike with “timely, well-organized care, and enhanced access to providers.[a model in which] racial and ethnic disparities in access and quality are reduced or even eliminated” (Strickland, Jones, Ghandour, Kogan, & Newacheck, 2011, p. 605). Whatever the definition, it seems logical that a patient’s medical home should include an interdisciplinary team of health professionals who can address all of the patient’s health care needs. For over a century, nurses and physicians have worked together to provide patient care in a variety of settings, including the hospital, the home, community clinics, and nursing homes for the elderly. Given the national discussions about medical homes and the policy implications about these homes, including the issues of who will deliver care, to whom, the kind of care that will be offered, and the location of that care, an examination of that collaboration is timely. The purpose of this article is to provide some historical insights into nursing’s role in delivering primary health care during the late 19th and early 20th century, illuminating the current debate on the topic. For nurses, the idea of a “medical home” is not new. The provision of primary health care, especially to underserved populations in rural areas and in lowincome urban settings, has long involved nurses. In fact, many of the attributes of the “medical home” have roots in nursing models in the past that predating the 1960s. This article describes and analyzes the role nurses have played in providing “medical homes” to various underserved populations across the United States in the late 19th and early 20th centuries. It traces the historical roots through 3 case studies, including a discussion of the Henry Street Settlement House, which served as a community-based service to immigrants on the Lower East Side of New York City at the turn of the 20th century; the 1912 to 1948 American Red Cross Town and Country Nursing Service, which reached rural citizens throughout the United States; and the Frontier Nursing Service (FNS), which served as the primary source of nursing and medical care for the underserved rural citizens of Leslie County, KY, from 1920 to 1950. These 3 cases (all ones in which the nurses worked collaboratively with physician advisory boards or linked with the American Red Cross and/or the United States Public Health Service) exemplify the following characteristics of the current medical home: nurses historically enhanced access to care for specific patient populations, provided support for self-care, tracked and coordinated care, kept patient and family records of the care, and gave compassionate and what they considered culturally sensitive care at the time. In short, they were models in which health care was as described in the medical home model todayd “accessible, continuous, comprehensive, family-
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centered, coordinated, compassionate, and culturally effective” (Strickland et al., 2011, p. 605).
Henry Street Settlement: A Central Health Care Service In the last decades of the 19th century and well into the 1920s, European immigration to the United States was at its peak, and thousands of Polish, Irish, Italian, Jewish, and Russian immigrants moved into the densely populated cities of the Northeast. There, the rise of an industrial enterprise with its dependence on sweatshops and child labor caused numerous social problems. The streets were filthy, poverty was pervasive, and housing was expensive. Many immigrants crowded whole families into poorly ventilated tenement flats. In this setting, disease and epidemics flourished. Meanwhile, few could afford medical care (Markel, 1999; Keeling, 2007). In an attempt to address some of these issues, Lillian Wald, a well-to-do, young graduate nurse from the New York Training School for Nurses, and her colleague Mary Brewster established a Settlement House at 265 Henry Street on the Lower East Side. From its inception in 1893 until 1944 when the social and nursing activities were separated, the Henry Street Settlement (HSS) linked nursing, social welfare, and the public, serving as a central location where poor immigrants could access nursing care, obtain referrals to physicians, and receive health teaching so that they could manage their own minor illnesses or chronic conditions (Buhler-Wilkerson, 2001; Keeling, 2007). In addition to providing social services, the HSS was unique in that it had visiting nurses who gave skilled, professional nursing care to the thousands of immigrants in neighborhoods on the Lower East side. They did so with physician supervision, while maintaining their professional autonomy, deciding when to make referrals to physicians, the city hospital, or a dispensary. Paul S. Kaplan, an East Side Russian physician who cared for hundreds of Russian immigrants, was among their staunch supporters as were imminent uptown specialists like Henry Koplik, Harry Lorner, Abraham Jacobi, and Henry D. Chapman (Chapman, Jacobi, & Koplik, n.d.). For example, one nurse wrote, “In one room, I found a child with running ears which I syringed, showing the mother how to do it, and directed her to Dr. Koplik of Essex Street Dispensary for further treatment” (“Report of a Day,” 1910, p. 20). In addition to making home visits, the nurses saw patients in the Settlement House’s “First Aid Room,” examining and treating patients after normal work hours and on Saturdays. As the nurses recounted, in the First Aid Room, they cared for patients with minor conditions “hardly important enough to receive attention in the large crowded dispensaries” (BuhlerWilkerson, 2001, p. 109). From the nurses’ perspec-
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tive, accessibility to an appropriate level of care was important. Working among the immigrants, HSS nurses were challenged to understand cultural differences, coming face to face with the health beliefs and cultures of the Irish, Italian, Polish, Russian, Hungarian, blacks, and others. Assignment to specific ethnic groups was one method the nurses used to provide culturally appropriate care. According to 1901 HSS head nurse Jane Hitchcock, “Each nurse’s personal taste is considered and the one who finds herself most in sympathy with the Irish people is sent to an Irish district, the Jewish to a Jewish, the Bohemian to a Bohemian, etc” (Hitchcock, 1907, p. 461). Cultural sensitivity was important in establishing a sense of trust. For example, in one instance, the nurse bathed a newborn in olive oil rather than water to appease the Italian grandmother. In another instance, the nurse allowed the family to keep “bacon fat” hanging around a feverish child’s neck while encouraging the Russian parents to remove the child’s many layers of clothes (Keeling, 2007). Key to the HSS nurses’ work was the provision of affordable care. By 1924, the Henry Street Visiting Nurse Society employed 253 nurses, each averaging 8 visits a day and charging a fee of “$1.15 per visit for those who could afford it and a sliding scale or free service” for those who could not (Henry Street News, 1924, p. 1). By 1926, the Henry Street Visiting Nurse Society was making over 300,000 visits each year (Information Department, 1923) (Figure 1).
Town and Country Nursing Service: Providing Services in Rural Communities Considered one of the first national public health nursing initiatives (Buhler-Wilkerson, 1993), the American Red Cross (ARC) Town and Country Nursing Service (Town and Country) provided family focused,
Figure 1 e 1919 Scalp Treatment. Reproduced with permission from the Visiting Nurse Service of New York.
“continuous service” within towns and rural counties throughout the United States (Clement, 1914, p. 636) (Figure 2). Founded by Lillian Wald in 1912 with the purpose of extending health care access beyond the crowded cities, Town and Country served as the point of contact for families in rural communities where remoteness, isolation, and fewer physicians and nurses created barriers to care. Wald saw a well-organized national structure in the ARC whose initial purpose was to provide care during times of war and emergencies. Building on that structure, Wald envisioned the ARC as a natural conduit for the development of a national plan to deliver primary health care in small towns and rural settings (Dock, Pickett, Clement, Fox, & Van Meter, 1922, p. 1214). The organization would also work in collaborative relationships with other privately funded groups, such as the Metropolitan Life Insurance Company. Working within this framework, Town and Country nurses would visit policyholders and be paid by both Metropolitan and the ARC. Acceptable candidates to Town and Country needed to meet the ARC requirements for enrollment and show successful completion of a minimum of a 4-month course in public health nursing (“Minutes of the Second Meeting,” 1912). The delivery of care required knowledge that extended beyond the training of the typical 2- or 3-year training program of the period. Nurses needed to be educated in the care of families in the rural settings. They learned how to work independently as well as in teams and learned to understand the needs of the community. Aside from their professional training and personal stamina, they also had to be willing to travel the long distances required to visit families living in these settings, and they needed to know how to ride a horse or bicycle in order to succeed (ARC Rural Nursing Service, 1912-1914). Rural communities interested in affiliating with the ARC received a qualified public health nurse who could support the existing community services or assist communities in developing visiting nurse associations when needed. The ARC offered these communities
Figure 2 e 1912 ARC Buggy Public Health Nurse. Reproduced with permission from the American Red Cross. All rights reserved in all countries.
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supervision as well as some financial support for the rural nurses until they were able to operate on their own (ARC Rural Nursing Service Scope, 1912-1914). They worked with a variety of agencies that already existed in the community such as visiting nurse associations, health departments, boards of education, industrial companies, antituberculosis associations, and woman’s clubs (Cannon, 1921, p. 131). The needs of the community; the kinds of organizations that existed; and the sociopolitical, economic, religious, ethnic, racial, and geographic location impacted the work of these public health nurses. Where needed, they provided care at the bedside and in well-baby clinics, schools, and industrial settings and participated in public health educational and publicity campaigns. A visit to a patient’s home meant a visit to that family. In the case of one public health nurse’s experience, she visited a family that was referred to their service because a “child [was] suffering from results of infantile paralysis, crawling on hands and knees and not in school.” (Fox, 1921a, p. 52). The record of her subsequent home visits showed a description of the condition of the farm and the home and a detailed account of the family members living in that home including a father; a mother; a 12-year-old daughter; the child who had been disabled by polio and was now 10 years old but not attending school; 3 younger children ages 7, 5, and 4; a 9-month-old baby (who appeared to have “spots” on his face that the family attributed to bed bugs); and an aunt who was 83 years old and a “pipe smoker.” During the home visit, the 10-year old was found to have an elevated temperature along with respiratory symptoms. He was referred to the physician for treatment for pneumonia and had to have his tonsils and adenoids removed. Later both feet were operated on (gratis) to correct the deformity. One of the girls needed glasses and was referred to the “oculist.” The record showed the status of each visit and the care coordination for that family (Fox, 1921a). Town and Country lasted from 1912 until 1948. In that time, there were over 3,100 public health nursing services covering 1,800 counties, providing a full range of services (Kernodle, 1949, p. 469). It served as a central organizing and coordinating mechanism that took care of a broad array of needs. It was a nursing model that incorporated community issues, family assessments, and individual needs. Indeed, Town and Country nurses “fill[ed] the gaps in the health organization of the country,” serving as trailblazers in areas where no care of any kind existed (Fox, 1921b, p. 108).
The FNS: A Primary Source of Health Care in Appalachia In the early 20th century, attracting physicians to Leslie County, KY, a remote mountainous region of hills and valleys, was practically impossible. The 373esquare
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mile area had a population of less than 11,000 and was one of the poorest and most inaccessible areas in the United States. The few physicians who worked there resided in Hazard or Lexington, which was some distance away. Access to Leslie County was first by train and then by horse or on foot (Willeford, 1932; Breckenridge, 1952; Dye, 1983). Since the early 1900s, Leslie County had also had one of the highest maternal/infant mortality rates in the United States, 12.4 deaths per 1,000 live births; the national maternal death rate was 7.0 per 1,000 live births in 1929. Faced with this unacceptable situation, the Kentucky State Board of Health formed the Bureau of Maternal and Child Health in 1922 and charged it with the protection and promotion of the health of mothers and children in the state. Mary Breckinridge, a member of a distinguished and well-connected Kentucky family, was also interested in the problem. Breckenridge, a graduate of St. Luke’s Hospital School of Nursing, had lost two children to childhood diseases. As a result, she resolved to improve maternal and child care in the United States. After serving as Director of Child Hygiene and Public Health Nursing from 1919 to 1922 and then studying public health at Teachers College in New York City, Breckenridge went to Appalachia to work with physician Arthur McCormack, the State Health Officer. After traveling the area on horseback and studying the state of obstetric services in three mountain counties, where distances and road conditions were formidable, Breckenridge concluded that the creation of a decentralized nurse-midwifery service would be necessary to reach the mountain people and provide them with a higher quality of care. In 1925, she founded the FNS working out of the main house Wendover, which nurses used as their home base. Over the next 10 years, Breckenridge established a series of 8 clinics; the main one was at Wendover, and the others were at Beech Fork, Red Bird, Flat Creek, Brutus, Oneida, Bob Fork, and Wooton. All were accessible by creek beds. Serving families in 3 counties altogether, each clinic provided services to an area covering 78 square miles of the rugged Appalachian territory (Cockerham & Keeling, 2012; Ettinger, 1999; Keeling, 2007). Each served as a point of care, much like the medical home of today, for the Highland people (Figure 3). At the same time, Kentucky physicians, long aware of the problem of high maternal-infant mortality, took a particular interest in addressing the problem. In 1926, the State Medical Society and the Louisville Obstetrical Society requested a “thorough study of every maternal death,” after which they concluded that every pregnant woman should place herself “under the care of a competent physician at once” (Keeling, 2007, p. 54). Although the physicians meant well, the recommendation was unrealistic. In fact, in Leslie County, there were only 5 “state-registered physicians who could see patients and all of them (with the exception of 1 employed by the mission settlement school), charged
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Figure 3 e Clinic Day at Frontier. Reproduced with permission from the Frontier Nursing University.
In addition to maternity cases, the FNS nurses gave “over 68,000 inoculations and vaccination for such diseases as typhoid, diphtheria, influenza, pneumonia smallpox and tetanus. Three-thousand and fifty-four sick cases (not including midwifery) were cared for in their homes and all except 166 recovered” (Gay, 1978 as cited in Keeling, 2007, p. 68). At the close of the ninth fiscal year, the FNS was caring for 1,146 families, including 256 babies, 1,139 preschool children, 2,243 school-aged children, and 2,337 adults (Keeling, 2007). Clearly, the FNS nurses were providing care to thousands of patients in the impoverished community. Combining public health nursing with standard home nursing care and primary medical care, these nurses used their clinics as “medical homes” for thousands of rural patients.
Implications for Health Policy Today $1.00 per mile for every mile spent in travel to the case, as well as an additional basic charge of $5.00” (Willeford, 1932, p. 15). Needless to say, families with average incomes of $183.53 a year could not afford these prices. Moreover, the treacherous mountain terrain and the lack of roads and bridges made access to physicians difficult even for those who could afford the fees. Instead, the FNS nurses worked with a medical advisory committee made up of 9 physicians, all of whom were located in Lexington, which was some distance from Wendover (Medical Advisory Committee, 1928). Despite the distance, these physicians supervised the FNS nurses in delivering not only midwifery services but also what was essentially primary medical care. Sometimes contact was made by telephone; more frequently, the nurses requested consultation and received responses through handwritten notes sent by a messenger. However, in most instances, the nurses had to see patients alone. To cover the nurses’ actions in those situations, a medical advisory committee wrote standing orders called routines or medical routines for the nurses to follow. In the preface to the 1928 manual, the physicians acknowledged the realities of the nurses’ practice, recognizing that they worked “under extremely difficult conditions in very remote areas.in many instances when physicians can never be had, owing to impossible seasons of ice and ‘tides,’ as well as great distances and heavy mileage costs” (Medical Advisory Committee, 1928, p. 1). Using the standing orders, the Frontier nurses not only provided midwifery services but also treated everything from snakebites, gunshot wounds, sore throats, and earaches to acute abdominal pain, diphtheria, and typhoid fever (Medical Advisory Committee, 1928, pp. 5-8). In addition, they sutured lacerations; applied salve to boils, shingles, and burns; and treated elderly patients for pneumonia, chest pain, and congestive heart failure. By May 1934, the FNS nurses had made “161,832 home visits and seen 115,601 in the clinics” (Keeling, 2007, p. 67; Willeford, 1935, pp. 7-8).
In the past, the agency in which public health nurses worked, whether private or government funded, whether in rural or urban settings, or whether during financially stable times or during depressions, influenced the extent of their scope of practice (Lewenson, 2013). Within various settings and in collaboration with physicians and pharmacists, nurses were key players in providing primary health care. In doing so, they attempted to provide culturally sensitive cared not to be judged by today’s standards of cultural competence but considered in the context of a society in which assimilation into the American culture was revered. Moreover, nurses bridged the gaps in the health care system, working cooperatively with physicians at the grass-roots level to provide access to care to those to whom it would otherwise be denied (Keeling, 2007; Fairman, 2008). Although the term “medical home” was not used during the period of time that the HHS, Town and Country, or FNS existed, these three examples illustrate the comprehensive and interdisciplinary care goals that policy makers hope to create in the medical home model today. These early nursing models successfully brought health care to underserved populations living in both urban and rural settings. Working within these models, nurses coordinated what was then culturally sensitive and timely care, provided families a central point of access, and supported community health initiatives. As the role of nurses continues to evolve, their place within the broader discussions about medical homes and the delivery of care is critical. Including nurse practitioners in the 2011 National Committee for Quality Assurance accreditation standards for medical homes, in the Institute of Medicine’s 2012 report, and more importantly in the Patient Protection and Affordable Care Act speaks to the value of these practitioners in this evolution. Yet, the need to be more inclusive in the policy arena cannot happen
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without the depth and perspective that historical analysis can give. D’Antonio and Fairman (2010) implore the use of a historical perspective “that places nurses and nursing at the center of longstanding debates about health services delivery, knowledge formation, patient safety, technology, and education for practice” (p. 114). The three case studies offer a historical perspective of nurses’ work within health care models of the past that legitimizes nursing’s place within the debates taking place today. Much has changed since the early 20th century, but the care Americans are seeking has not. What they need and want is safe, effective, affordable, and timely care that is culturally sensitive. Today, registered nurses, public health nurses, and advanced practice nurses (particularly family nurse practitioners) collaborate with physicians to provide primary health care services through various agencies in various settings; yet, perceptions of the quality of that care differs between the professions of medicine and nursing (Blumenthal & Abrams, 2013; Chen, 2013; Donelan, desRoches, Dittus, & Buerhaus, 2013). However, time and time again, nurses have demonstrated the expertise and experience that makes make them poised to be valuable partners and leaders of the new developing models. Federal funding should support nursing education and nursing practice initiatives as well as interprofessional models. What is needed is a unified interprofessional comprehensive service that includes, among others, nurses as leaders. Therefore, the new model should use neutral provider language such as “health care homes” rather than language that directs us to just physicians. It behooves health policy makers to examine what was successful in the past and what needs to be changed to adapt to the present social, political, and economic health care environment. Most importantly, policy makers today should not overlook the central role nurses have long played in providing access to care for numerous underserved populations. Including nurses in decision-making policy venues today can ensure that nurses will continue to play an active role in providing primary health care to these populations in the future.
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Public health nursing: Practicing population-based care. Burlington: Jones & Bartlett Learning. Making medical homes work: Moving from concept to practice (2008, December). Policy Perspective: Insight into Health Policy Issues, Center for Studying Health System Change: Mathematica Policy Research, 1-2. Retrieved from http://www.hschange.org/ CONTENT/1030/1030.pdf. Markel, H. (1999). Quarantine: East European Jewish immigrants and the New York City epidemics of 1892. Baltimore: Johns Hopkins University Press. National Committee for Quality Assurance (NCQA). (2011). Standards for patient-centered medical home. Washington, DC: NCQA. Medical Advisory Committee. (1928). Medical routine for use of the Frontier Nursing Service. Lexington, United Kingdom: Frontier Nursing Service, Inc. Minutes of the second meeting of the Committee on Rural Nursing. (1912, December 10). Rockefeller Sanitary Commission
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www.nursingoutlook.org
A nursing historical perspective on the medical home: Impact on health care policy Arlene Keeling, PhD, RN, FAANa, Sandra B. Lewenson, EdD, RN, FAANb,* a
Acute & Specialty Care Department, School of Nursing, University of Virginia, Charlottesville, VA b Lienhard School of Nursing, College of Health Professions, Pace University, Pleasantville, NY
article info
abstract
Article history: Received 29 April 2013 Revised 9 July 2013 Accepted 12 July 2013
Background: The idea of a “medical home” is rapidly gaining in popularity in health
Keywords: Primary health care Nursing history Medical homes Health care policy Interprofessional education Provider neutral language Henry Street Settlement American Red Cross Town and Country Nursing Service Frontier Nursing Service
policy circles today. In the face of a shortage of primary care physicians, it has led to a national debate about who should lead the homes, who should deliver care, the kind of care that should be offered, and the location of that care. A historical examination of nurses’ role in primary care can provide evidence to inform the current dialogue. Purpose: This article provides insight into nursing’s role in primary health care during the early 20th century. Methods: Traditional historical methods were used. Discussion/Conclusions: Three historical case studies provide evidence of how nursing and medicine worked together in the past and informs the discussion about using nurses to deliver primary health care today. Policy makers should not overlook the central role nurses have long played in providing access to care for numerous underserved populations. Makers should not overlook the central role nurses have long played in providing access to care for numerous underserved populations. Cite this article: Keeling, A., & Lewenson, S. B. (2013, OCTOBER). A nursing historical perspective on the medical home: Impact on health care policy. Nursing Outlook, 61(5), 360-366. http://dx.doi.org/10.1016/ j.outlook.2013.07.003.
Begun as a model of care to manage the care of children with chronic conditions, the idea of a “medical home” is rapidly gaining in popularity in health policy circles today. In fact, in 2012 the Patient Protection and Affordable Care Act provided for the establishment of patientcentered medical homes (Institute of Medicine, 2012; Patient Centered Primary Care Collaborative, 2013). Along with the recommendation came a debate about who should lead medical homes and who should be involved in providing care within them. Meanwhile, the context in which these would be established is one of a shortage of primary care physicians and uncertainty about the “optimal composition” of the primary care workforce (Blumenthal & Abrams, 2013, pp. 1933-1934).
Since its inception in the 1960s as a model of care for chronically ill pediatric patients, the definition of a “medical home” has evolved. In 2002, the American Academy of Pediatrics defined the medical home as “a model of primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective” (American Academy of Pediatrics, 2002, p. 185). In 2008, it was defined as “a single point of coordination for all health care, including specialists, hospital and acute care” (“Making Medical Homes Work,” 2008, pp. 1-2). Sometimes the definition for the primary care worker includes nurses and nurse practitioners, physician assistants, and practice managers as well as community health centers (Beal,
* Corresponding author: Dr. Sandra B. Lewenson, Lienhard School of Nursing, College of Health Professions, Pace University, 860 Bedford Road, Pleasantville, NY 10507. E-mail address: [email protected] (S.B. Lewenson). 0029-6554/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2013.07.003
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Doty, Hernandez, Shea, & Davis, 2007). At other times, the definition refers only to physicians and medical practice. More recently, the term “medical home” describes a broader health care model that provides adult and children alike with “timely, well-organized care, and enhanced access to providers.[a model in which] racial and ethnic disparities in access and quality are reduced or even eliminated” (Strickland, Jones, Ghandour, Kogan, & Newacheck, 2011, p. 605). Whatever the definition, it seems logical that a patient’s medical home should include an interdisciplinary team of health professionals who can address all of the patient’s health care needs. For over a century, nurses and physicians have worked together to provide patient care in a variety of settings, including the hospital, the home, community clinics, and nursing homes for the elderly. Given the national discussions about medical homes and the policy implications about these homes, including the issues of who will deliver care, to whom, the kind of care that will be offered, and the location of that care, an examination of that collaboration is timely. The purpose of this article is to provide some historical insights into nursing’s role in delivering primary health care during the late 19th and early 20th century, illuminating the current debate on the topic. For nurses, the idea of a “medical home” is not new. The provision of primary health care, especially to underserved populations in rural areas and in lowincome urban settings, has long involved nurses. In fact, many of the attributes of the “medical home” have roots in nursing models in the past that predating the 1960s. This article describes and analyzes the role nurses have played in providing “medical homes” to various underserved populations across the United States in the late 19th and early 20th centuries. It traces the historical roots through 3 case studies, including a discussion of the Henry Street Settlement House, which served as a community-based service to immigrants on the Lower East Side of New York City at the turn of the 20th century; the 1912 to 1948 American Red Cross Town and Country Nursing Service, which reached rural citizens throughout the United States; and the Frontier Nursing Service (FNS), which served as the primary source of nursing and medical care for the underserved rural citizens of Leslie County, KY, from 1920 to 1950. These 3 cases (all ones in which the nurses worked collaboratively with physician advisory boards or linked with the American Red Cross and/or the United States Public Health Service) exemplify the following characteristics of the current medical home: nurses historically enhanced access to care for specific patient populations, provided support for self-care, tracked and coordinated care, kept patient and family records of the care, and gave compassionate and what they considered culturally sensitive care at the time. In short, they were models in which health care was as described in the medical home model todayd “accessible, continuous, comprehensive, family-
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centered, coordinated, compassionate, and culturally effective” (Strickland et al., 2011, p. 605).
Henry Street Settlement: A Central Health Care Service In the last decades of the 19th century and well into the 1920s, European immigration to the United States was at its peak, and thousands of Polish, Irish, Italian, Jewish, and Russian immigrants moved into the densely populated cities of the Northeast. There, the rise of an industrial enterprise with its dependence on sweatshops and child labor caused numerous social problems. The streets were filthy, poverty was pervasive, and housing was expensive. Many immigrants crowded whole families into poorly ventilated tenement flats. In this setting, disease and epidemics flourished. Meanwhile, few could afford medical care (Markel, 1999; Keeling, 2007). In an attempt to address some of these issues, Lillian Wald, a well-to-do, young graduate nurse from the New York Training School for Nurses, and her colleague Mary Brewster established a Settlement House at 265 Henry Street on the Lower East Side. From its inception in 1893 until 1944 when the social and nursing activities were separated, the Henry Street Settlement (HSS) linked nursing, social welfare, and the public, serving as a central location where poor immigrants could access nursing care, obtain referrals to physicians, and receive health teaching so that they could manage their own minor illnesses or chronic conditions (Buhler-Wilkerson, 2001; Keeling, 2007). In addition to providing social services, the HSS was unique in that it had visiting nurses who gave skilled, professional nursing care to the thousands of immigrants in neighborhoods on the Lower East side. They did so with physician supervision, while maintaining their professional autonomy, deciding when to make referrals to physicians, the city hospital, or a dispensary. Paul S. Kaplan, an East Side Russian physician who cared for hundreds of Russian immigrants, was among their staunch supporters as were imminent uptown specialists like Henry Koplik, Harry Lorner, Abraham Jacobi, and Henry D. Chapman (Chapman, Jacobi, & Koplik, n.d.). For example, one nurse wrote, “In one room, I found a child with running ears which I syringed, showing the mother how to do it, and directed her to Dr. Koplik of Essex Street Dispensary for further treatment” (“Report of a Day,” 1910, p. 20). In addition to making home visits, the nurses saw patients in the Settlement House’s “First Aid Room,” examining and treating patients after normal work hours and on Saturdays. As the nurses recounted, in the First Aid Room, they cared for patients with minor conditions “hardly important enough to receive attention in the large crowded dispensaries” (BuhlerWilkerson, 2001, p. 109). From the nurses’ perspec-
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tive, accessibility to an appropriate level of care was important. Working among the immigrants, HSS nurses were challenged to understand cultural differences, coming face to face with the health beliefs and cultures of the Irish, Italian, Polish, Russian, Hungarian, blacks, and others. Assignment to specific ethnic groups was one method the nurses used to provide culturally appropriate care. According to 1901 HSS head nurse Jane Hitchcock, “Each nurse’s personal taste is considered and the one who finds herself most in sympathy with the Irish people is sent to an Irish district, the Jewish to a Jewish, the Bohemian to a Bohemian, etc” (Hitchcock, 1907, p. 461). Cultural sensitivity was important in establishing a sense of trust. For example, in one instance, the nurse bathed a newborn in olive oil rather than water to appease the Italian grandmother. In another instance, the nurse allowed the family to keep “bacon fat” hanging around a feverish child’s neck while encouraging the Russian parents to remove the child’s many layers of clothes (Keeling, 2007). Key to the HSS nurses’ work was the provision of affordable care. By 1924, the Henry Street Visiting Nurse Society employed 253 nurses, each averaging 8 visits a day and charging a fee of “$1.15 per visit for those who could afford it and a sliding scale or free service” for those who could not (Henry Street News, 1924, p. 1). By 1926, the Henry Street Visiting Nurse Society was making over 300,000 visits each year (Information Department, 1923) (Figure 1).
Town and Country Nursing Service: Providing Services in Rural Communities Considered one of the first national public health nursing initiatives (Buhler-Wilkerson, 1993), the American Red Cross (ARC) Town and Country Nursing Service (Town and Country) provided family focused,
Figure 1 e 1919 Scalp Treatment. Reproduced with permission from the Visiting Nurse Service of New York.
“continuous service” within towns and rural counties throughout the United States (Clement, 1914, p. 636) (Figure 2). Founded by Lillian Wald in 1912 with the purpose of extending health care access beyond the crowded cities, Town and Country served as the point of contact for families in rural communities where remoteness, isolation, and fewer physicians and nurses created barriers to care. Wald saw a well-organized national structure in the ARC whose initial purpose was to provide care during times of war and emergencies. Building on that structure, Wald envisioned the ARC as a natural conduit for the development of a national plan to deliver primary health care in small towns and rural settings (Dock, Pickett, Clement, Fox, & Van Meter, 1922, p. 1214). The organization would also work in collaborative relationships with other privately funded groups, such as the Metropolitan Life Insurance Company. Working within this framework, Town and Country nurses would visit policyholders and be paid by both Metropolitan and the ARC. Acceptable candidates to Town and Country needed to meet the ARC requirements for enrollment and show successful completion of a minimum of a 4-month course in public health nursing (“Minutes of the Second Meeting,” 1912). The delivery of care required knowledge that extended beyond the training of the typical 2- or 3-year training program of the period. Nurses needed to be educated in the care of families in the rural settings. They learned how to work independently as well as in teams and learned to understand the needs of the community. Aside from their professional training and personal stamina, they also had to be willing to travel the long distances required to visit families living in these settings, and they needed to know how to ride a horse or bicycle in order to succeed (ARC Rural Nursing Service, 1912-1914). Rural communities interested in affiliating with the ARC received a qualified public health nurse who could support the existing community services or assist communities in developing visiting nurse associations when needed. The ARC offered these communities
Figure 2 e 1912 ARC Buggy Public Health Nurse. Reproduced with permission from the American Red Cross. All rights reserved in all countries.
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supervision as well as some financial support for the rural nurses until they were able to operate on their own (ARC Rural Nursing Service Scope, 1912-1914). They worked with a variety of agencies that already existed in the community such as visiting nurse associations, health departments, boards of education, industrial companies, antituberculosis associations, and woman’s clubs (Cannon, 1921, p. 131). The needs of the community; the kinds of organizations that existed; and the sociopolitical, economic, religious, ethnic, racial, and geographic location impacted the work of these public health nurses. Where needed, they provided care at the bedside and in well-baby clinics, schools, and industrial settings and participated in public health educational and publicity campaigns. A visit to a patient’s home meant a visit to that family. In the case of one public health nurse’s experience, she visited a family that was referred to their service because a “child [was] suffering from results of infantile paralysis, crawling on hands and knees and not in school.” (Fox, 1921a, p. 52). The record of her subsequent home visits showed a description of the condition of the farm and the home and a detailed account of the family members living in that home including a father; a mother; a 12-year-old daughter; the child who had been disabled by polio and was now 10 years old but not attending school; 3 younger children ages 7, 5, and 4; a 9-month-old baby (who appeared to have “spots” on his face that the family attributed to bed bugs); and an aunt who was 83 years old and a “pipe smoker.” During the home visit, the 10-year old was found to have an elevated temperature along with respiratory symptoms. He was referred to the physician for treatment for pneumonia and had to have his tonsils and adenoids removed. Later both feet were operated on (gratis) to correct the deformity. One of the girls needed glasses and was referred to the “oculist.” The record showed the status of each visit and the care coordination for that family (Fox, 1921a). Town and Country lasted from 1912 until 1948. In that time, there were over 3,100 public health nursing services covering 1,800 counties, providing a full range of services (Kernodle, 1949, p. 469). It served as a central organizing and coordinating mechanism that took care of a broad array of needs. It was a nursing model that incorporated community issues, family assessments, and individual needs. Indeed, Town and Country nurses “fill[ed] the gaps in the health organization of the country,” serving as trailblazers in areas where no care of any kind existed (Fox, 1921b, p. 108).
The FNS: A Primary Source of Health Care in Appalachia In the early 20th century, attracting physicians to Leslie County, KY, a remote mountainous region of hills and valleys, was practically impossible. The 373esquare
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mile area had a population of less than 11,000 and was one of the poorest and most inaccessible areas in the United States. The few physicians who worked there resided in Hazard or Lexington, which was some distance away. Access to Leslie County was first by train and then by horse or on foot (Willeford, 1932; Breckenridge, 1952; Dye, 1983). Since the early 1900s, Leslie County had also had one of the highest maternal/infant mortality rates in the United States, 12.4 deaths per 1,000 live births; the national maternal death rate was 7.0 per 1,000 live births in 1929. Faced with this unacceptable situation, the Kentucky State Board of Health formed the Bureau of Maternal and Child Health in 1922 and charged it with the protection and promotion of the health of mothers and children in the state. Mary Breckinridge, a member of a distinguished and well-connected Kentucky family, was also interested in the problem. Breckenridge, a graduate of St. Luke’s Hospital School of Nursing, had lost two children to childhood diseases. As a result, she resolved to improve maternal and child care in the United States. After serving as Director of Child Hygiene and Public Health Nursing from 1919 to 1922 and then studying public health at Teachers College in New York City, Breckenridge went to Appalachia to work with physician Arthur McCormack, the State Health Officer. After traveling the area on horseback and studying the state of obstetric services in three mountain counties, where distances and road conditions were formidable, Breckenridge concluded that the creation of a decentralized nurse-midwifery service would be necessary to reach the mountain people and provide them with a higher quality of care. In 1925, she founded the FNS working out of the main house Wendover, which nurses used as their home base. Over the next 10 years, Breckenridge established a series of 8 clinics; the main one was at Wendover, and the others were at Beech Fork, Red Bird, Flat Creek, Brutus, Oneida, Bob Fork, and Wooton. All were accessible by creek beds. Serving families in 3 counties altogether, each clinic provided services to an area covering 78 square miles of the rugged Appalachian territory (Cockerham & Keeling, 2012; Ettinger, 1999; Keeling, 2007). Each served as a point of care, much like the medical home of today, for the Highland people (Figure 3). At the same time, Kentucky physicians, long aware of the problem of high maternal-infant mortality, took a particular interest in addressing the problem. In 1926, the State Medical Society and the Louisville Obstetrical Society requested a “thorough study of every maternal death,” after which they concluded that every pregnant woman should place herself “under the care of a competent physician at once” (Keeling, 2007, p. 54). Although the physicians meant well, the recommendation was unrealistic. In fact, in Leslie County, there were only 5 “state-registered physicians who could see patients and all of them (with the exception of 1 employed by the mission settlement school), charged
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Figure 3 e Clinic Day at Frontier. Reproduced with permission from the Frontier Nursing University.
In addition to maternity cases, the FNS nurses gave “over 68,000 inoculations and vaccination for such diseases as typhoid, diphtheria, influenza, pneumonia smallpox and tetanus. Three-thousand and fifty-four sick cases (not including midwifery) were cared for in their homes and all except 166 recovered” (Gay, 1978 as cited in Keeling, 2007, p. 68). At the close of the ninth fiscal year, the FNS was caring for 1,146 families, including 256 babies, 1,139 preschool children, 2,243 school-aged children, and 2,337 adults (Keeling, 2007). Clearly, the FNS nurses were providing care to thousands of patients in the impoverished community. Combining public health nursing with standard home nursing care and primary medical care, these nurses used their clinics as “medical homes” for thousands of rural patients.
Implications for Health Policy Today $1.00 per mile for every mile spent in travel to the case, as well as an additional basic charge of $5.00” (Willeford, 1932, p. 15). Needless to say, families with average incomes of $183.53 a year could not afford these prices. Moreover, the treacherous mountain terrain and the lack of roads and bridges made access to physicians difficult even for those who could afford the fees. Instead, the FNS nurses worked with a medical advisory committee made up of 9 physicians, all of whom were located in Lexington, which was some distance from Wendover (Medical Advisory Committee, 1928). Despite the distance, these physicians supervised the FNS nurses in delivering not only midwifery services but also what was essentially primary medical care. Sometimes contact was made by telephone; more frequently, the nurses requested consultation and received responses through handwritten notes sent by a messenger. However, in most instances, the nurses had to see patients alone. To cover the nurses’ actions in those situations, a medical advisory committee wrote standing orders called routines or medical routines for the nurses to follow. In the preface to the 1928 manual, the physicians acknowledged the realities of the nurses’ practice, recognizing that they worked “under extremely difficult conditions in very remote areas.in many instances when physicians can never be had, owing to impossible seasons of ice and ‘tides,’ as well as great distances and heavy mileage costs” (Medical Advisory Committee, 1928, p. 1). Using the standing orders, the Frontier nurses not only provided midwifery services but also treated everything from snakebites, gunshot wounds, sore throats, and earaches to acute abdominal pain, diphtheria, and typhoid fever (Medical Advisory Committee, 1928, pp. 5-8). In addition, they sutured lacerations; applied salve to boils, shingles, and burns; and treated elderly patients for pneumonia, chest pain, and congestive heart failure. By May 1934, the FNS nurses had made “161,832 home visits and seen 115,601 in the clinics” (Keeling, 2007, p. 67; Willeford, 1935, pp. 7-8).
In the past, the agency in which public health nurses worked, whether private or government funded, whether in rural or urban settings, or whether during financially stable times or during depressions, influenced the extent of their scope of practice (Lewenson, 2013). Within various settings and in collaboration with physicians and pharmacists, nurses were key players in providing primary health care. In doing so, they attempted to provide culturally sensitive cared not to be judged by today’s standards of cultural competence but considered in the context of a society in which assimilation into the American culture was revered. Moreover, nurses bridged the gaps in the health care system, working cooperatively with physicians at the grass-roots level to provide access to care to those to whom it would otherwise be denied (Keeling, 2007; Fairman, 2008). Although the term “medical home” was not used during the period of time that the HHS, Town and Country, or FNS existed, these three examples illustrate the comprehensive and interdisciplinary care goals that policy makers hope to create in the medical home model today. These early nursing models successfully brought health care to underserved populations living in both urban and rural settings. Working within these models, nurses coordinated what was then culturally sensitive and timely care, provided families a central point of access, and supported community health initiatives. As the role of nurses continues to evolve, their place within the broader discussions about medical homes and the delivery of care is critical. Including nurse practitioners in the 2011 National Committee for Quality Assurance accreditation standards for medical homes, in the Institute of Medicine’s 2012 report, and more importantly in the Patient Protection and Affordable Care Act speaks to the value of these practitioners in this evolution. Yet, the need to be more inclusive in the policy arena cannot happen
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without the depth and perspective that historical analysis can give. D’Antonio and Fairman (2010) implore the use of a historical perspective “that places nurses and nursing at the center of longstanding debates about health services delivery, knowledge formation, patient safety, technology, and education for practice” (p. 114). The three case studies offer a historical perspective of nurses’ work within health care models of the past that legitimizes nursing’s place within the debates taking place today. Much has changed since the early 20th century, but the care Americans are seeking has not. What they need and want is safe, effective, affordable, and timely care that is culturally sensitive. Today, registered nurses, public health nurses, and advanced practice nurses (particularly family nurse practitioners) collaborate with physicians to provide primary health care services through various agencies in various settings; yet, perceptions of the quality of that care differs between the professions of medicine and nursing (Blumenthal & Abrams, 2013; Chen, 2013; Donelan, desRoches, Dittus, & Buerhaus, 2013). However, time and time again, nurses have demonstrated the expertise and experience that makes make them poised to be valuable partners and leaders of the new developing models. Federal funding should support nursing education and nursing practice initiatives as well as interprofessional models. What is needed is a unified interprofessional comprehensive service that includes, among others, nurses as leaders. Therefore, the new model should use neutral provider language such as “health care homes” rather than language that directs us to just physicians. It behooves health policy makers to examine what was successful in the past and what needs to be changed to adapt to the present social, political, and economic health care environment. Most importantly, policy makers today should not overlook the central role nurses have long played in providing access to care for numerous underserved populations. Including nurses in decision-making policy venues today can ensure that nurses will continue to play an active role in providing primary health care to these populations in the future.
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