University of Southern California Dissertations and Theses

Hospital care for home patients

(USC Thesis Other)

Hospital care for home patients

PDF

Download

Open document

Flip pages

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content HOSPITAL CARE PGR HOME PATIENTS
A Thesis
Presented to
the Faculty of the School of Public Administration
University of Southern California
In Partial Fulfillment
of the Requirements for the Degree
Master of Science in Public Administration
by
Donald Walter Mansfield
June 1955
UMI Number: EP64555
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
Dissertation F^»«s»ng
UMI EP64555
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
Microform Edition © ProQuest LLC.
All rights reserved. This work is protected against
unauthorized copying under Title 17, United States Code
ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106 - 1346
This thesis, w ritte n by
DONALD ...........
under the direction of the undersigned Guidance
Committee, and approved by a ll its members, has
been presented to and accepted by the F a cu lty of
the School of P u b lic A d m in istra tio n in p a rtia l f u l
fillm e n t of the requirements fo r the degree of
MASTER OF SCIENCE IN
PUBLIC ADM INISTRATION
Date......J u n e j . . l . 9 . 5 5 .
Guidance Committee :
Chairmi
TABLE OP CONTENTS
CHAPTER PACE
I. INTRODUCTION AND DEFINITION OF THE TERM
HOSPITAL.................................... 1
Introduction................................ 1
Definition of hospital..................... 3
II. EARLY HOSPITALS ........................ 6
III. FACTORS THAT HAVE INFLUENCED THE GROWTH
OF HOSPITALS......................... 8
Religion.......... 8
W a r ........................................ 9
Medical science.......................... 10
Modern nursing................................ 11
Education......................................11
Social organization ..................... 12
Economic conditions............ 12
Public appreciation ....................... 12
IV. STANDARDS OF MEDICAL SERVICE................. ll|
V. FUNCTIONS OF A GENERAL HOSPITAL................19
Organization of the general hospital. . . . 21
The admitting department. ...............22
The medical staff............................ 22
Clinical departments..........................23
Adjunct diagnostic and therapeutic facilities. 2i\.
The clinical laboratory......................2 1 ) .
iv
CHAPTER PAGE
The radiology department.......... 25
Anesthesia......................##..25
Physical medicine department................. 26
The pharmacy department....................26
The dental department. . . 27
The nursing department.....................27
The dietary department ..... . ..... 29
The out-patient department. ................ 30
The medical social service department .... 30
VI. HOSPITAL CARE FOR HOME PATIENTS................ 32
Convalescence ............................... 3Z
Child hygiene................................. 3h
Problems of the aging.........................l ) . 0
Mental health .. ...........................ij-3
The Montefiore Hospital home care program . . l j . 5
Conclusion.................................. . 5^
VII. ADMINISTRATIVE PROBLEMS RELATED TO HOME CARE. . 58
Continuity of medical control................. 63
Physical .facilities required.................. 61|
Living accommodations.........................6I 4
Personnel.............. 65
The visiting nurse............................. 66
The housekeeping service.......................66
Medical social service.........................67
V
CHAPTER PAGE
Property accounting....................... 68
Related problems. ..................... 69
VIII. CONCLUSION.......................................72
BIBLIOGRAPHY . ....................... 86
CHAPTER I
INTRODUCTION AND DEFINITION OF THE TERM HOSPITAL
I. INTRODUCTION
The duties of the public administrator not only
i - ^
encompass the execution of the policy as set by the
legislative body, but also the responsibility of devising j
and introducing methods of improving efficiency and I
1 I
economy. In the field of institutional management, ■
particularly regarding hospital administration, the need
for economy and efficiency is painfully evident.^
i
In both public and private hospitals the cost of
patient care within the confines of the hospital is extreme
ly high, varying from about fifteen to fifty dollars a
day. Coupled with the fact that there is a shortage of
hospital beds for individuals requiring care, there is
an urgent necessity for new and better ways of caring for
the sick.^
Recognizing these problems, Montefiore Hospital
John M. Pfiffner and R. Vance Prestus, Public
Administration (New York; The Ronald press, 1953)> P• 11.
^ "How Are the Bills Paid?" Time, February 8, 195)i, |
P* 57. I
^ Martin Mills, M.D., "Possible Home Care in
Poliomyelitis," California Medicine, 77:31* July, 1952.
2
in New York City began an experiment in hospital care
for home patients soon after World War II. The program,
: briefly, is based upon the premise (aside from economic
i necessity) that a patient is more than just an organic
and spiritual being. He is also a member of society and
therefore should benefit from congenial surroundings
more quickly than in the "sterile" atmosphere of the
hospital.^
The Montefiore plan for hospital care for home
patients has resulted in some interesting facts: from
23,000 days of patient care, the average cost per patient
was less than three dollars versus fifteen dollars in
the hospital itself. However, it has had greater effect
than merely being cheaper.
In a hospital a patient is one of many; he must
give up his little privileges and desires for the group.
At home he is an individual; he can have his breakfast
when he wants it and can sleep when he chooses and listen
to the radio and watch television at his pleasure. There
are numerous cases which would indicate that the patients
get well quicker at home.^
^ Martin Cherkansky, "The Montefiore Hospital Home
Care Program," American Journal of Public Health, 39:^65*
February, 19L|.9#
^ Ibid.. p. 166.
3
To the hospital administrator, both public and
private, stands the challenge of organization and coordina
tion, if the Montefiore Plan becomes widespread in accept
ance. A preliminary survey of the field would indicate
that both geriatric and polio patients are being considered
as possible candidates for the Plan.
It should prove interesting and informative to
investigate this plan and others of a similar nature so
that we may evaluate these efforts in the light of the
public administrator who is concerned with efficiency and
economy in the field of institutional management.
II. DEFINITION OF HOSPITAL
The term "hospital" has more than one definition.
I To some it means only the treatment and care by an or
ganization of the acutely sick, whereas to others it ex-
Itends beyond this to include all types of institutions
/
! where all sick or disabled persons are housed.
The Hospital Licensing Act of the California Health
1
^and Safety Code defines a hospital as meaning:
. . . any institution, place, building or agency
which maintains and operates organized facilities
for the diagnosis, care and treatment of human ill
ness, including convalescence and including care
I ^ Commission on Hospital Care, Hospital Care in the
United States (New York; Commonwealth Fund, 19ÇTTT p.
during and after pregnancy, or which maintains and
operates organized facilities for any such purpose
and to which persons may be admitted for overnight
; stay or longer. "Hospital" includes sanitorium,
I rest home, nursing home, maternity home and lying-in
asylum. 7
As there is no official census of hospitals in
the United States, the facilities of several agencies
must be utilized to obtain a general picture of the
I hospital field.^ The census of 19^0 compiled a list of
institutions in which deaths occur. An attempt was made
to separate hospitals from other institutions; but there
was difficulty encountered in differentiating between a
hospital, a boarding home, a home for the aged and rest
homes. The American College of Surgeons maintains a
record of hospitals, their facilities and service, with
twenty-five beds or more which meet its standards for
approval. Inasmuch as these standards are designed to
set a high level of service and care, it is necessarily
: incomplete as many hospitals do not or cannot maintain
the standard. The American Medical Association maintains
I a registry which is issued annually. It does not include
j
i non-medical organizations, clinics, emergency facilities,
^ or small rest or maternity homes. However, their list
■ is by far the most complete.
^ Hospital Licensing Act, Division 2, Chapters 2-3,
; Sections ll|.00-li).21, California Health and Safety Code,
! 1953, p. 51.
I ® The Sixteenth Census of the United States. 19i|0,
iPppulation,_J V o l u m e ....................... ............
5
There are different categories of hospitals. The
American Medical Association usually refers to them as ;
"General," "Nervous and Mental," "Tuberculosis,"
"Hospital Departments in Institutions," and "Other,
Special."^
; ^ Journal of the American Medical Association,
! 130:1073-ÏoB5, April 20,19W*
CHAPTER II
EARLY HOSPITALS
Hospitals have been in existence here in the
United States since the eighteenth century. The Phila
delphia Almshouse, founded in 1729, had the first build
ing set aside especially for hospital use. However,
provision of hospital care for sick strangers was only
one function of the Almshouse. It also served as a house
of correction, insane asylum, orphanage and workhouse.^
Within a decade the "Publick Workhouse and House
of Correction of the City of New York" was established.
It served the same purposes as did the Philadelphia Alms
house. In l8lj.8, with the development of the science of
medicine, the New York institution became Bellevue
Hospital.^
By the middle of the eighteenth century it became
evident to the leaders of Philadelphia that there was a
need for a hospital in the community. A petition was
submitted in 1751 to the Assembly of the Province of
Pennsylvania for permission to build an institution for
that purpose. By public subscription, the first voluntary
1
James C. Pifield, editor, American and Canadian
Hospitals (Chicago: Physicians Record Company, 1937),
p. 1075.
! ^ Ibid.. p. 8I4.7.
7
hospital in America was established the same year.^
From this modest beginning, the hospitals have
grown steadily through the years. By 1Ô73 the United
States Bureau of Education reported 1,178 hospitals with
a bed capacity of i).0,000. By I909, the American Medical
Association announced that there were if,359 hospitals with
k
a bed capacity of if21,065* At present, there are close
to 7,000 hospitals with a total of nearly 2,000,000
beds."^
o
Ibid., p. 1076. It is interesting to observe
that largely through the efforts of Benjamin Franklin
the petition was submitted to the Assembly. It proposed
that the hospital would be financed by individual contri
butions and a loan from the Provincial Treasury. A re-
quest for the loan was in the petition, however, the
cause was such a popular one that the individual contri-
I butions more than exceeded the L2,750 requested from the
! Treasury.
■ I l
Commission on Hospital Care, Hospital Care in the
United States (New York; Commonwealth Fund, I9I 4 . 7), p. 520.
! n tvrfZjffimaloOf th& Ame.idpan Medi&ai Map-piAtÂ-oa, 121 ;
CHAPTER I I I
FACTORS THAT HAVE INFLUENCED
THE GROWTH OF HOSPITALS
The selection of a single factor responsible for
the growth of hospitals in the United States would be
difficult. In fact, there is an interplay of various in
fluences that have all played a distinct part in the
phenomenon .
A broad and general division of these forces might
be classified as religion, war, medical science, education,
economic conditions and public appreciation.^
I. RELIGION
Medical care was practiced in the ancient temples
of long lost civilizations. From the dust of ancient
cities, scientists have linked the art of healing with re-
p
ligious teaching.
However, it was with Christianity and the tenets
of kindness and peace rather than hate and war that
promoted the widespread care for the sick and injured.
The ethics of the Christians extended care to the poverty-
^ Commission on Hospital Care, Hospital Care in the
■UnllLad States (New York; Commonwealth Fund, 19if7), p. if3,
^ J. L. Rutledge, "Houses of Recovery," Magazine
; Digest, 19;l-if, October, 1939.
9 j
stricken, the victims of disease, the casualties of war
and the friendless stranger alike.
The religious zeal of all Christian faiths carried |
the gospel and church sponsored hospitals to the New World;
The first hospitals on the North American continent were !
' established by the Catholic orders in the colonies of
O ■
Prance and Spain. The first American hospital (Pennsyl- |
vania Hospital) was not, however, church sponsored.
Nevertheless, financial support was rendered by Rev.
George Whitfield*s church.^
II. WAR
The abnormal conditions of war bring disease.
The wounds suffered in combat stress the need for hospital
facilities. With the work of Florence Nightingale empha
sizing cleanliness and sanitation, the modern hospital
; of today was bom.5
!
The Civil War brought about the first attempt in
: this country toward organized treatment of casualties of
iwar. The postwar period brought about the United States
3
Commission on Hospital Care, op. cit., p. I f3.
^ Thomas G. Morton, The History of Pennsylvania
! Hospital, 1751-1695 (Philadelphia: Truger Printing House,
1595), p. 2lf8.
^ Malcolm T. MacEachem, Hospital Organization and
'Management (Chicago: Physicians Record Company, 19lf6),
10
Army Medical Corps, the Medical Department of the Navy
and the Marine Hospital Service (now known as the United
States Public Health Service). Regulations and standards
! 5
were established for guidance of medical officers. In
I
the Spanish American War the ravages of disease were more
devastating than the weapons of war. Research and per
sonal sacrifice solved these problems and instituted the
preventative phase of medicine. World Wars I and II have
brought our hospital system to a high degree of organiza
tion. Modern chemotherapy, blood transfusions and immuni
zation has made it possible for soldiers and civilians
alike to enjoy protection undreamed of a few decades ago.^
I
III. MEDICAL SCIENCE
Advances in medical science have extended the scope
of hospital care to serve larger numbers of patients.
They have made medical care more effective. Advances in
surgery, the discovery of bacterial causes of infection,
; the importance of anesthesia and high standards of nursing
i have contributed toward a finer hospital service.®
^ Commission on Hospital Care, op. cit., p. i f i f ,
7 Ibid.. p. 45.
® Ibid., p. 46.
11
IV. MODERN NURSING
At the time of our Civil War the conditions in
our hospitals were deplorable. Devoted women in our i
country as well as women in other lands investigated, i
demanded and obtained better conditions for hospitals.
Soon schools of nursing were instituted and the graduates
of those first schools have established the fine ideals
and devotion to duty of our modern nursing profession.9
V. EDUCATION
With the turn of the century came a new era of
medical education. Prior to that time, there were few
medical schools of great worth in this country. However,
as medical schools became part of universities with the
: standardization of requirements of admission and curricula,
‘ with new facilities, libraries and coordinated courses
I
of study with hospitals, American medical schools have
: attained the number one position. Internships and
Tdid., p. jf55. During Franklin Pierce's admini
stration (1853-1857)5 Dorothea Lynde Dix promoted the
welfare of the nation's insane. She was instrumental in
1655 in the creation of the first federal hospital for
the insane (St. Elizabeth's Hospital in Washington, D.C.).
She was responsible for getting legislation passed through
,both houses of Congress to the effect that 12,500,000
acres of land should be set aside for the benefit of the
^ insane. The measure was vetoed by President Pierce with
I the comment, "Begin with doing anything for the insane and
! soon the Federal Government will have on its hands the
I support of e^ery sick man, every vagabond, every drunkard
I ^ l ü .*1^5 . _ J* . ____ ____— _ — -. — ■ ■ — — ——- ....— —...—.— .—— — ■~™~“
12
residencies in hospitals develops within the individual
the ability to put into practice the lessons learned in
the clinics and classroom.
Vi. SOCIAL ORGANIZATION
Urbanization has underlined for modern man the
problems of poverty, malnutrition, housing, sanitation
and disease. Hazards of living have increased with the
proximity that man exists to man. With this comes the
realization that better health practices and facilities
are necessary to protect man and his progeny.
VII. ECONOMIC CONDITIONS
The wealth of our modern society has made it
possible to create the splendid voluntary hospitals that
were built in the early part of the century. With the
depression came the realization that tax support and sub
sidies were necessary to continue their existence.
VIII. PUBLIC APPRECIATION
The discovery of chemotherapeutic agents have all
but eliminated certain types of illness from the beds of
Nathaniel W. Faxon, The Hospital in Contemporary
Life (Cambridge; Harvard University Press, 1%9), P# 168.
Ibid.. p. 2.
Ibid.. p. 269._____________ _ __________
13
our hospitals. Conversely, however, a few short decades
ago, a trip to the hospital was considered only in dire
emergencies or adversity. Yet the use of hospitals for
the delivery of babies is not only expected today but de
manded. This demand for hospital service continues to
expand.13
United States Census, 1950» Housing, Volume II,
Part I; Population, Volume 11, Part I.
I
CHAPTER IV
STANDARDS OF MEDICAL SERVICE
It is not the purpose of this paper to discuss the
' actual techniques of medical service. However, a state
ment of standards and general principles is necessary to
establish a framework for the examination of hospital care
for home patients.
There are eight major tenets of medical practice
according to Lee and Jones.^ Standard number one, they
emphasize, is that good medical practice is the rational
use of medical care based upon the accepted medical
sciences. Surely, cultists, quacks, pseudo-religious
] scientists and racketeers are not to be tolerated in the
healing arts. Diagnosis and therapy is based upon proved
scientific experimentation, observation and astute deduc
tion, not upon the nostrums of charlatans and seers.
The second principle is based upon the belief that
good medical care should stress prevention. The aims to
^ prevent illness and to promote good health should dominate
t all phases of the healing arts * As Lee and Jones point
: out.
1 1
Robert Lee and Lewis Jones, The Fundamentals of
■ Good Medical Care (Chicago: The University of Chicago
Press, 1933)f p. 7.
15
The purpose of treatment is to assist the body
and mind to accomplish restoration of good health,
to interfere with the progress of disease, to pre
vent complication, and to postpone death. Preven
tion, diagnosis, and treatment are inseparable
aspects of the science and art of medicine. They
have a common purpose: the promotion and mainten
ance of health, and they use a common body of know
ledge. ^
The third standard is that good medical care
necessitates intelligent rapport between the lay public
‘ and the practicing physician. Medical care depends upon
; more than the medical profession alone. The uncooperative
patient oftentimes gains little from his treatment. The
patient without the means to comply with his doctor's
instructions also fails to benefit to the maximum. The
hospital, the physician, the patient, his family and the
community all are interrelated in obtaining the optimum
results.
The fourth requirement is that good medical
care should treat the patient as a whole. The patient is
more than an organic creature. He is a physical and social
being as well. Today, medical education includes many of
the aspects of psychology, psychiatry, social influences
and economics, so that every case is an individual. Thus,
; the conscientious physician should treat his patients upon
: a personal basis.3 Of this need for individualizing
2 Ibid.. p. 8.
3 Ibid., p, 9.
l6
treatment for each patient, it is pointed out by another
author that every sick person is an individual and unique
, problem which each physician will treat in a manner that
he deems best. However, unless the need for vigorous
; I
treatment overbalances all other considerations, the i
physician should weigh carefully the prospect of disrupting^
I
the patient's life and ordering treatment that may arrest
the course of the disease. He pointedly demands,
. . . shall he prescribe complete invalidism,
the end of work and life's interest, to add a few
hypothetical months or even years to a man's life,
only that he may dedicate it to the care of his
illness?#-
The fifth guidepost is that in good medical care a
close and continuing personal relationship between physi
cian and patient should be maintained* Lee and Jones point
out that.
The complex nature of a human being, the intri
cate relationship between body and mind and between
the parts and the whole, establish familiarity with
the patient's personality and habits as the first
essential in good medical care.5
The sixth requirement is that good medical care
!
must be coordinated with social welfare work. It is
obvious that the urban physician cannot determine all
the individual social problems of his patients. In the
^ Boaz, op. cit., p. 20,
^ Loc. cit.
17
city, the busy doctor's calls may take him across the
community several times a day. To investigate the finan
cial background of patients would be a monumental and
: . 6
; uncalled for task.^
The seventh standard for good medical care is
' that all types of medical service must be organized,
directed, and fully utilized. The broad spectrum of
medical service from the physician, himself, to the nurse,
the physiotherapist, the bacteriologist, the roentgenolo
gist, the dietitian, the social worker, the pharmacist
and the general personnel involved in patient care must
be coordinated to attain the optimum of performance from
7
each.'
The eighth and final tenet^as outlined by Lee and
Jones, for good medical care is that all of the necessary
services of modern medicine be available to all of the
I
people.
Although not included in the above eight general
requirements, Lee and Jones add that medical treatment
'should continue into the convalescence period in order
® As was pointed out by the White House Conference,
it is imperative that the resources of the community be
properly utilized and protected by trained social workers,
if the continuous and adequate care which will preserve
the health and welfare of our citizens is to be rendered.
"Health and Medical Care for Children," separate from
Preliminary Statements Submitted to the White House Confer
ence on Children in a Democracy, January 18-20, lOliO,
Washington, D.C., p. 18.
T Lee and Jones, op. cit.. p. 9. ............ ....
18 i
8
that benefits already derived may not be lost.
The importance of good medical care cannot be over- ;
emphasized where human lives are concerned. Using the
framework as outlined above we will assess in a later ,
I
chapter the prospects for hospital care for home patients. ;
® Ibid., p. 5.
CHAPTER V
FUNCTIONS OF A GENERAL HOSPITAL*
In order to gain proper perspective in assessing
' what goes on in a hospital, it is necessary to clarify the i
I fact that there are different classifications of hospitals.!
i Hospitals are commonly classified in two different ways ;
' ' I
by ownership or by type of treatment. It follows, natural-|
ly, that hospitals to be correctly classified must be |
* 1 !
described by both methods in order to fully identify them.-^j
As the name implies, a general hospital is devoted
to the treatment of all types of patients. Inasmuch as 1
j
, we are concerned with the general aspects of patient treat-j
ment and care in order to evaluate the possibilities of
hospital care for home patients, we will confine our exami-
! nation of hospital functions to that of a general hospital.
Nevertheles;^ it should prove to be worthwhile to list the
, various types and kinds of hospitals so that we may see
P ' I
' the picture in its entirety. i
i i
Hospitals listed as to clinical or type of treatment:
General
Special
Medicine
Internal Medicine
Malcolm T. MacEachern, Hospital Organization and
' Management (Chicago: Physicians Record Company, 19i|6),
p.
^ Loc. cit.
20
Nervous and Mental
Tuberculosis
Children
Communicable Disease
Venereal Disease
Surgery
Eye, Ear, Nose and Throat
Disea.s es of Women
Cancer
Industrial
Maternity
Convalescent
Chronic
Hospitals listed as to ownership or control:
Governmental
Federal
Army
Navy
Veteran*s Administration
United States Public Health Service
State
County
City
Non Governmental
Church
Fraternal Order
Community
Private— Not for Profit
Private-«For Profit
Functions of a general hospital may be devolved
into four phases: (1) the care of the sick and injured;
(2) education of physicians, nurses and other personnel;
(3) public health--prevention of disease and the promotion
21
of health; and (i|) advancement of research and scientific
3
medicine.
The primary requirement for a hospital is the ser
vice to the sick and injured and it is this responsibility
to which all personnel of the hospital must contribute.
As is pointed out by the Commission on Hospital Care, the
hospital should provide essential services for adequate
treatment of the patients who are admitted for care. In
the treatment of illness, the Commission goes on to say
that the general hospital is responsible to see that a
continuing program for improving service and expanding the
quality of scientific equipment is implemented.
Organization of the general hospital. MaoEachern
points out: "Only by organization in the hospital can
efficiency be produced." Ernest Dale defines organization
as a planning process.^ It is a means to an end, of esta
blishing a pattern of working relationships which constantly
changes as events, personalities and environment require. |
I
There is a defining and grouping of activities which are
3 Ibid.. p. 29. I
^ Commission on Hospital Care, Hospital Care in the |
■ United States (New York: The Commonwealth Fund, I9I 4 .TT» I
■p. 67. I
^ MacEachern, o£. cit., p. 73.
I ^ Ernest Dale, Planning and Developing the Company
Organization Structure (New York: American Management
Association,. I953) P* .1^.— ---- -----------------------
22
logically assigned and efficiently executed. Although the
process of organization is dynamic, the resulting struc
ture (for the movement) is static.
It should prove beneficial, therefore, to examine
the organization of a general hospital, for, in such a
' perusal, we can identify the duties and practices of it.
The admitting department. The admitting department
has as its functions the admission of patients. There
, are several other duties, however, that involve the keep
ing of records of discharges and deaths, transfers of
patients, the scheduling of operations, releasing informa
tion as to the condition of patients and custody of bodies |
I
in the morgue. The admitting department has been described
as the "heart of the hospital" or as the dispatch system
i ■ * ,
of the hospital. It is here that the patient usually gets
his first and lasting impression of the hospital. It is
! important, therefore, that patients and relatives be
. treated with kindness, consideration and tact during the
admission and discharge of patients.
The medical staff. As we pointed out earlier, the
i primary requirement for a hospital is the service to the
I sick and injured. Since actual care cannot be rendered
1 except by physicians legally qualified to practice in the
,state or jurisdiction, it is important that the quality
23
of the medical personnel be of the highest degree attain
able. This is ultimately established by the medical staff
which is a self-governing, self-appraising body of prac
ticing physicians. The medical staff serves as a control
f
of the individual member by establishing certain require
ments of record keeping, meeting attendance, the auditing '
of professional work, educational requirements, staff con-,
I
ferences and participation. Such analysis of clinical worlc
as: mortality rate, autopsy rate, infections and tissue |
committee reports are tremendous levers in elevating
medical standards
Clinical departments♦ The degree of departmentali
zation of clinical departments is closely related to the
extent of specialization of the medical staff.
There are three general divisions within the clini
cal departments. They are : medicine, surgery and ob
stetrics and gynecology. A further refinement of the sub
divisions would be;^
Division of Medicine
General Medicine
Cardiology
Communicable Disease
Dermatology
Endocrinology
* 7
MacEachern, o£. cit., p.
® Ibid.. p. 269.
2 1 ^
Gastroenterology
Metabolism Diseases
Psychiatry
Pediatrics
Tuberculosis
Division of. Surgery
General Surgery
Fractures and Traumas
Neurosurgery
Opthalmology and Otorlinolaryngology
Oral and Maxillofacial Surgery
Orthopedic Surgery
Plastic Surgery
Proctology
Thoracic Surgery
Tumor Surgery
Urology
Division of Obstetrics and Gynecology
Gynecology
Obstetrics
Care of the New Born
Adjunct diagnostic and therapeutic facilities. As
science has advanced and methods of diagnosis and treatment
have developed to a high degree, it is found that some
of these aids to treatment and diagnosis are so costly
and require such highly trained technicians that a con
centration of these facilities in the hospital is good
organizational procedureThe following activities can
be considered as the main functions.
i clinical laboratory. The clinical laboratory
' is invaluable in supplying the physician with information
^ Dale, 0£. cit., p. II3
25
vital to his diagnosis and treatment. Such aids as urin
alysis, blood count, blood coagulation, tissue diagnosis
are important as are the provisions for bacteriology,
parasitology, serology, hematology and biochemistry.
Blood plasma banks and basal metabolism are here as well.
The radiology department. Radiology as defined by
the Council on Medical Education and Hospitals of the
American Medical Association is :
The branch of medicine which deals with the
diagnostic and therapeutic application of radiant
energy, including roentgen rays, radium, ultra
violet rays and other spectral radiation. . . .
A department of radiology is a laboratory or depart
ment of a hospital. . . organized and equipped for |
the diagnostic and therapeutic application of radiant |
energy, in the form of roentgen rays and radium. |
Ultra violet and other spectral radiation may also |
be included,10
The job is a difficult and dangerous one. The equipment
is expensive and soon becomes out-dated. There is need
I
for considerable space (about 1,200 square feet for a
150 bed hospital) with a premium on adequate ventilation
and strategic location.
Anesthesia. Because of the importance of the effect!
upon the future health of the patient as well as being an |
MacEachern, op. cit., p. 362.
26
essential factor in surgery, obstetrics and other pro
cedures, anesthesia has become an important specialty in
itself. There is a need for special equipment and sup
plies and provisions to prevent explosions and fire to
be considered. Certification by the American Board of
Anesthesiology has become an excepted standard of pro
ficiency. Minimum standards for the safety and efficiency
of anesthesia departments has been set by the American
College of Surgeons.
Physical medicine department. Physio-therapy and
occupational therapy is a field in itself. The recogni
tion that rehabilitation of the patient under skilled
' direction can do much to restore the individual as a use
ful member ofi society is important. Physio-therapy is
an important facet in the healing arts.
The pharmacy department. One of the most important
I therapeutic facilities in the hospital is the pharmacy.
Since the development of chemotherapy and other "wonder
! drugs" its prominence cannot be understated. It also
; plays an important role in the out patient department as
many patients who formerly might have been hospitalized
now are spared this experience due to the use of new
' pharmaceutical products.
27
The dental department. There has been a constantly-
growing trend toward a closer relationship between medicine
and dentistry. It has been recognized that good medical
care needs adequate dental diagnosis and treatment. It
has been pointed out that all general hospitals should have
a dental service.
I The adjunct diagnostic and therapeutic facilities
. are essential tools of the physician, however, as im
portant as they may appear, they still do not supplant the
11
doctor. All diagnosis begins with the individual physi
cian’s own physical diagnosis afforded through his senses
of touch, sight, hearing and smell. The adjunct facili
ties confirm or expand his diagnosis but do not supplant
it. If a doctor were to depend entirely upon mechanical
aids, the art of medicine would cease to exist and the
individual patient could no longer be properly cared for.
, The nursing department. The nurse is necessary in
jthe care of patients. In earlier times, the nurse was an
i inferior type— usually from the criminal class. With the
I
^ advent of the religious orders and the establishment of
the Florence Nightingale School of Nursing at St. Thomas
Hospital, London, in 1862, a new era of nursing began.
Today, the standards are high. Nursing schools must meet
Ibid.. p. 339.
28
high requirements as the interdependence of good nursing
education and nursing service is obvious. Contributing to
the personal comfort of the patient and promoting the re
covery by aiding in the treatment is the main function of
the hospital nurse. The ratio of nurses to the number of
patients is hard to establish and is usually arrived at
by empirical methods as follows :
1. Type of Ward Average bedside nurs
ing hours required per patient
each twenty-four hours.
Medical, surgical and mixed, semi-private 3.2
Maternity and semi-private q.2
Newborn and semi-private 2.3
Infants and semi-private Ç.5
Older children and semi-private q..3
Communicable disease and semi-private I 4..7
Mixed, private patients b.q
Maternity, private patients 6.6
2. Type of Ward Relationship of grad
uate bedside nursing hours to
student bedside nursing hours.
Medical, surgical, mixed and semi-private 31^
Maternity and semi-private 51
Newborn and semi-private 6l
Pediatric and semi-private 12
Communicable disease, and semi-private 37
Mixed, private patient
Maternity, private patient
3. Type of Ward Patients per day per
supervisor.
Medical, surgical and mixed, semi-private 70
Maternity and semi-private 67
Newborn and semi-private 82
Pediatric and semi-private f j . 7
Communicable disease
Medical and surgical, private patients 62
Maternity, private patients 50
IMd., p. I 4 . 15» and The Manual of Essentials of
Good Nursing Service.
29
The need for a school of nursing in a general
hospital is determined by the needs of the community it
self. By and large administrators do not want to divert
the necessary funds for educational facilities as the
current experience is that educational costs overshadow
the advantages which might accrue to having the additional
student help.
The hierarchical structure of the nursing depart
ment is interesting to the administrator and the social
anthropologist as well. It will suffice to touch upon
this by mentioning that the director of nurses is head
of the nursing organization. The levels of supervision
below the director are the assistant superintendants, the
1 supervisors of departments or sections, head nurses,
nurses on general duty and adjunct nursing personnel such
as orderlies and attendants.
The dietary department. The therapy of diet is
1 so important to the patient and the hospital personnel
^ that a graduate dietitian is required to be in charge of
the dietary department in any hospital approved by the
American College of Surgeons. Hospital food is a specialty]
Bedridden and convalescent patients alike are sick people.
Good food, appetizingly prepared and tastefully served,
is a must. Even the hospital personnel require exceptional
meals in order to build resistance to infection and revive
30 i
enervated bodies from the tension rife in hospital work.
The out-patient department. Many patients do not
need the in-patient services of the hospital. Ambulatory
patients can apply for diagnosis, care and treatment in |
!
the out-patient department. Oftentimes the hospitalized |
patient can be sent home, returning from time to time for
check-ups and treatment. This relieves the constant pres- |
I
sure for hospital beds and at the same time enables the
i
patient to become at least partially productive in his
home environment.
The medical social service department. Medical
social service has been well described by Lewis, Super
visor of Social Service, Massachusetts General Hospital
who has said:
We are also closely associated with the theories
and developments of a less exact science, sociology,
applying its principles in our daily practice of the
actual needs of the individuals coming to our atten
tion. In its most intimate analysis hospital social
service is an attempt to interpret and adjust in
terms of one another, a patient’s medical liability
to his social assets.13
The purpose of medical social work in the hospital
is to obtain and apply such understanding of the patient
^3 Ibid.. p. 567*
31
as will enable the institution, the physician and the
other agencies concerned to comprehend and treat his
illness more effectively.
The magnitude of the functions of the general
hospital are reflected in a small measure in the brief
survey of the various departments that devote their ef
forts to the care of the sick and injured. In summary,
we can express the beliefs of a leader in the hospital
field:
Hospitals we must have. They are necessary from
the standpoint of self-interest to provide for the
care of the sick. . . if we must have hospitals, we
must support them. • • we are faced with the problem
of financing.I4
It would seem reasonable, in view of this need for
hospitals and the problem of financing, to examine some
plans which might aid in relieving the shortage of hospital
beds and at the same time cut the costs of patient care.
Nathaniel W. Faxon, The Hospital in Contemporary
■ Life (Cambridge: The Harvard University Pressé 19^+9) #
;p. 27I 4 ..
CHAPTER V I
HOSPITAL CARE FOR HOME PATIENTS
As Lee and Jones have pointed out, in addition to
the eight major standards for good medical care is the
importance of maintaining good medical care into the con
valescent period so that benefits already derived may
not be lost
I. CONVALESCENCE
The dictionary defines convalescence as: "The
gradual recovery of health and strength after disease and
weakness; the period during which such recovery takes
2
place; the state of the body during this period."
Sigerist says: "When the disease has reached its climax
: 3
i and a cure is in sight, the invalid becomes a convalescenti]
! Another writer says,
I think of convalescence as beginning physiologi-
I cally when the patient’s, equiliberating forces gain
the ascendancy over the disequiliberating ones. .
convalescence begins psychologically when the patient
overcomes a feeling common to everyone, namely, a
resistance to change of any kind and accepts (1) a
1
Roger I. Lee and Lewis W. Jones, The Fundament als
of Good Medical Care (Chicago: The University of Chicago
Press, 1933), p. 5.
^ Webster ’ s Collegi ate Dictionary, Ij.th edition.
Henry E. Sigerist, Man and Medicine--An Introduc-
!tion to Medical Knowledge (New York: W. W. Norton and
! Company,^ 1932), P. 89. : ___________
33
certain duration of disease as inevitable and
(2) the convalescent state as a necessary one.4
As the New York Academy of Medicine points out,
it is the practice of hospitals to place a time limit on
' the length of time patients may be permitted to remain
within the hospital--usually a month or so. The problem
of those patients who must have longer care is a con
stant one to the hospital. After a certain length of
! time, the administrator ordinarily will begin to inquire
of the medical staff as to the discharge date of the
patient.^ As is often the case, the patient is released
while still in need of medical and hospital care.
It is apparent, then, that there is a time in the
patient’s illness when the possibility of returning home
, must be or should be considered. What are some of the
' factors that should be considered when this point has
' been reached? Also, what can be done? An appraisal of
1 similar programs in various fields related to the general
I hospital should contribute considerably to our appraisal
!
of hospital care for home patients.
Convalescent Care--Proceedings of the Conference
Held Under the Auspices of the Committee on Public Health
Relations of the New York Academy of Medicine (New York;
New York Academy of Medicine, 1939)> p. 9.
■ 5 P. Jensen, Né C. Weiskotten and M. A* Thomas,
Medical Care of the Discharged Hospital Patient (New York:
, The Commonwealth Pund^ Ï9lpîT7~p. 3o.
34
II. CHILD HYGIENE
Regardless of the pros and cons of the individual
' situation, it is often necessary to send the patient home.
In the instance of crippled children, the danger of a
warped personality due to long hospitalization, the need
to gratify the child's desire for affection, plus the
, excessive drain on the financial resources of the family
or of the agency concerned all contribute toward returning
the patient to the home.^ It is important that close
supervision be given by the public health nurse; regular
examination by the attending physician and the parents
should be carefully instructed in proper care, rest and
diet. Care must be taken to insure that the patient does
not get the feeling of undue difference or dependence and
that all members of the family cooperate in creating a
healthy home atmosphere
The State of California Health and Safety Code,
Article 3, Section 300 states; "The Department of Public
Health shall maintain a Bureau of Child Hygiene. ..."
Section 302 continues; "The Bureau, under the direction
and supervision of the department, may investigate and
^ Caroline Smith, "Home Convalescent Care," The
Crippled Child, 9:1].* December, I93I.
35
disseminate educational information relating to conditions
effecting the health of the children of this State."
Recognition of this need for removing patients from
the hospital as soon as possible raises the question of
standards for hospital care for home patients* An investi*
gation of foster homes and their standards reveals;®
1. A responsible person in the home, which is
managed as a family dwelling.
2. Sufficient income to provide a reasonable
standard of living.
3* Housing that provides light, heat, ventilation,
sanitation and adequate sleeping and play space.
[ ] . . Home making that encompasses cleanliness, order,
homelike surroundings, and daily diet sufficient
to build up the child's physical well being.
5# Members of the household free from communicable
disease.
6. Good neighborhood influences.
7. Native intelligence, sympathetic and cheerful
attitude, and ability to understand the patientb
nature and needs with harmonious family rela
tionships .
Harry J. Becker, "Meeting the Needs of the Crippled
'Child— Convalescent and Poster Home Care" (Washington,
ID.C.: U.S. Children's Bureau, mimeographed, 19^0)•
36
Some tests of the effectiveness of the foster home
should be;
1. Improved physical condition of the patient and
continuity of medical care.
2. Improvement of personality in cases of behavior
problems•
3* Home attachments strengthened rather than
weakened.
Former physical and social obstacles removed.
5. Adequate supervision after the patient's re
turn home, to insure continued improvement
In the selection of a foster hom^ the following
requirements should be considered;
1. The foster home should be chosen to meet the
needs of the individual child.
2. The home should offer the patient security,
a feeling of stability and belonging, of count
ing for something in other people's estimation.
3. The home should offer the individual the oppor
tunity to enjoy family life, to live in a normal
family group; to develop natural attachments
and a sense of responsibility.
‘ ^ Georgia Ball, "Poster Home Care for Crippled
; Children," The Child. 3:150-53, January, 1939.
37
I j . * It should offer good nutritious food and ade
quate shelter adapted to the specific needs of
the child's disability.
5# Suitable clothing should be furnished keeping
in mind that certain styles improve the patientfe
appearance.
6. In addition to the usual daily personal hygiene
there is a need to include individual health
habits adapted to the disease or deformity.
7. The essentials of learning must be available.
Vocational training and guidance as well as
occupational therapy are important. If possible
attendance at school or at the very least,
home teachers.
8. The patient's regard for himself as a normal
person of social usefulness rather than as a
handicapped individual is affected by the ex
tent to which he shares the responsibilities
and pleasures of the group.
Another expert points out the fact that there are
special requirements to consider:
1. The house must be accessible to social agencies
and medical facilities.
Ibid.. pp. 150-53
38
2. The home itself must be adapted to the special
needs of the patient--i.e♦, the bathroom on
the same floor as the patient's room#
3* The foster mother should have knowledge of
j
nursing, provide good meals and have sufficient i
help to do the job adequately. '
i|. Occupational therapy, home teaching and medical
supervision are sononomous in need.^^
In the field of child hygiene, it has proved to
be not only desirable but imperative to return the patient
to his home as soon as possible# Where the individual's
home cannot meet the minimum standards for care, the child
should be placed in a foster home where the wholesome in
fluences of family life will speed his recovery* There is
considerable evidence to indicate that the social contacts
; made by the patient has great weight in hastening his
I physical and spiritual recovery# The feeling of partici
pating in the family group and of being wanted tends to
contribute to the patient's well being*
Some of the problems that occur when the patient
returns home should be explored.Is the home adequate to
31 Elizabeth Bissell, "Foster Home Care," The
Crippled Child. August, 1939, pp. 31-32. ---
1^ Edith M. Baker, "Development of Services for
Crippled Children Under the Social Security Act," U.S.
Department of Labor Mimeographed Pamphlet No. 7q88
(Washington, D.C.; United States Printing Office, 1953)•
39 I
properly care for the patient? There is the possibility
of strain on all members of the family. Perhaps the family
will be deprived of things formerly available to it. Per- I
haps the patient will have the feeling of guilt at causing '
I
inconvenience. Home care, even where the family is finan- ■
dally able presents a real hardship.^3 There is a pos
sibility that the needs, desires and suffering of the
patient may affect the work, recreation and development
of the lives of the other members of the family. Of course!,
the family responsibility exists for the patient and the
shouldering of this burden unaided may distort the emo-
ik I
tional development of the entire family. ^ Another problem
is that in homes where economic conditions do not provide
adequate living standards the hope of a healthy recovery
is doubtful.Where hospital care for home patients
could be effected, the possibility of returning these lower
income patients to the home is increased.It is evident
even with all the difficulties presented that where home
care can be effected it is a great aid to the physician
in his treatment and to the patient and his family in
13
Boaz, 0£. cit., p. Ik.
I ^4 Leon J. Saul, Emotional Maturity (Philadelphia:
|J. B. Lippincott Company19k?), p. 299.
I Convalescent Care, p. 79.
I 16 I b i d . . p . 82.
ko
improved morale•
III. PROBLEMS OP THE AGING
The family problems of having an elderly person in
: the home presents a strained relationship. There is a
question as to whether young children should be subjected
to the pattern of conforming to the restricted activity
necessary to accommodate the old person. However, it
should be pointed out that the tendency to relegate these
ailing oldsters to an institution where they degenerate
by disuse and atrophy is not right either. It is sug
gested that family problems would be considerably relieved
by the assistance of counseling services, the provision
of better home nursing facilities, the use of house-
: keepers and social workers to help smooth over some of
the difficulties and to maintain a happier home environ-
i
ment.
I
; At the present time there is a shortage of 20,000
beds for chronically ill in the state of California alone.
How can it be remedied? At the Governor's Conference,
home care for the aged was explored* The discussion
centered around the fact that the home is generally recog
nized as the most important place in which to center the
1?
"Proceedings of the Governor's Conference on
! Problems of the Aging" (Sacramento: California State
.Printing Office, October lk-l6, 1951), a pamphlet, p. 150.
kl
care of the individual. "Home is the logical place to
find affection, happiness and serenity.
It was further pointed out that the medical social
. worker is indispensable in this situation.
Experience has shown that where adequate home
care services are provided, many elderly sick per
sons do not need hospital accommodations and further,
many who are already in hospitals may be sent home,
if adequate facilities are provided at home. The
wisdom of this course of action in terms of lower
cost and increased happiness seems obvious.19
The medical social worker is in a position to verify the
■ individual conditions surrounding each patient or old
person. Assessing the individual's needs is as important
in many cases as the diagnosis is to the physician.
The needs for old people can be summed up as
'follows:
1. Information and counseling services.
2. Diagnostic and investigation facilities such
as laboratory. X-ray and other special tests.
3. Specialists of all types, including those in
!
internal medicine, general surgery, opthal- i
mology, dental, ear, nose and throat, orthopedic]
neurological and others,
k# Treatment services to carry out the recommenda
tions after diagnosis and specialists consulta- :
' I
tions.
18 Ibid.. p. 151.
^9 Ibid.. ,p. 152,
42
5* Nutrition consultation service,
6. Physical medicine and therapy services.
7* Occupational therapy facilities.
8. General medical supervision.
9- General nursing supervision.
10. Medical social service facilities.
11. Recreational facilities.
12. Sheltered workshops associated with industry.
13. Home nursing service,
ill* Housekeeper service.
The summary and recommendations of the Conference
placed the emphasis on the home as being the most suitable
21
place for the elderly sick person. By providing better
home services, especially home nursing, medical social
service, housekeepers and mobile rehabilitation facilities
many elderly sick persons need not be admitted to hospitals
at all.
Why is it that hospital care for home patients is
not being implemented here in the state of California for
the benefit of the aging? Apparently it would be cheaper
in operation than sending the old folks to an institution.
20
Ibid., p. 154*
Ibid.. p. 156.
43
Also, it is better for the patient. In an institution he
is one of many. The patient is left to his own devices
and, in such an enervating atmosphere, he soon becomes dis
interested with his surroundings. Degeneration and atrophy
are his lot# Since it is agreed that such a program would
be worthwhile both economically and socially why doesn't
it exist? To start, there is a shortage of the key per
sonnel necessary to even attempt such a program. There
is a shortage of doctors, nurses, medical social workers,
housekeepers, physiotherapists and nutritionists not to
mention the almost complete lack of qualified administra
tors needed to organize, coordinate and direct such a
worthwhile program.
IV. MENTAL HEALTH
In the field of mental hygiene it has been found
that family or home care enables the patient to become an
individual in the home and community.Thus, instead of
remaining one of hundreds of inmates in a certain hospital,
the patient becomes a part of an environment that aids him
toward a normal existence. Where the institution has about
it only a few overworked staff members and hundreds of
patients with common experiences of neglect, illness and
Hester B. Crutcher, Foster Home Care for Mental
Patients (New York: The Commonwealth Fund, 1944)* p. S.
xmîiappiness, the patient is removed from these oppressing
surroundings to a home. In the home he is restored to
a normal life in a friendly world, away from the monotony
and frustrations of the institution. Gone are the rigid
rules and the petty requirements that are necessary in a
large institution but not needed in the home. He is able
to watch television and listen to his favorite programs
at his pleasure. He is able to eat the things of his
fancy rather than being required to partake of institution-^
al meals. But^ most of al], he is one of the family. To
be able to participate in the tiny triumphs, the satisfac
tions of home life and the joys of belonging all contribute
23
to his return to a normal life.
The placement of home patients has been an effec
tive administrative procedure for the following reasons ;
1. It releases space for other patients in need
of specialized treatment and for those from
whom the community needs to be protected.
2. It provides care at less than hospital mainten
ance .
3. A large proportion of patients so placed make
a relatively permanent and satisfactory
adjustment.
23
Ibid., p. 11.
k5
In the state of New York where the foster home
care has been in effect for the past two decades, there
has been a significant growth of the service* In fact,
in the period of I938-I9I 42 alone the growth was from 1*1
patients in one hundred placed in 1938 to 3*8 patients per
hundred in 1942*^^
The actual savings in cash alone, the expenses were
cut from fourteen dollars per week down to seven dollars
per week* This is to mention the actual cash savings*
Just imagine the salvage of human resources and lives as
well as the happiness that has been afforded*
V. THE MONTEPIORE HOSPITAL HOME CARE PROGRAM
Dr* Martin Cherkansky, home care executive for the
Montefiore Hospital in New York City, stated in an address
that the philosophy of hospital care for home patients has
25
developed the concept of medical care to a finer degree*
He goes on to explain that the medical profession has
progressed from the original premise of treating only the
limb or the eye to treating the patient as a whole * Now,
however, he advocates an even broader approach that the
Ibid.. p. 12.
Presented before a Joint Session of the Public
Health Nursing and Medical Care Sections of the American
Public Health Association at the seventy-sixth Annual
Meeting in Boston, Mass*, November 10, 19i|8*
1 ^ 6
practitioner should consider the patient not only as an
organic and spiritual whole, but also as a whole in
society. **It is no more fair or useful to separate a
man from his environment than it is to divide him into
separate and independent parts.
Cherkansky develops this thought further by point
ing out that our hospitals, despite their stress on
scientific medicine, including diagnostic machines, labor
atory examination, therapeutic procedures and the like,
have held back from the understanding of sick human beings
as social human beings. As an example, he cites the case
of the patient who enters the hospital with certain symp
toms. He enters as a stranger, his Illness is diagnosed,
and he is relieved of his condition. Unfortunately,
more often than not, he returns to the same situation that
may have given rise to his illness. Actually, to under
stand what has caused this patient to become sick in the
first place, it would be necessary to know what sort of
a family he has, where he lives, what type of clothing he
wears and what are his relations to these factors. Such
things as this and other facts of life comprise the in
gredients that make up man as a social being. Dr. Cherkan
sky asks, therefore, if it could be possible that these
26
Martin Cherkansky, **The Monteflore Hospital Home *
Care Program,’ * American Journal of Public Health, 38:103. I
February, 1949* I
kl
facts could be even.more provocative in the origin than
the germ which has been isolated from his sputum in the
bacteriology laboratory. It is as much the responsibility
of the hospital to seek knowledge, he insists, in this
field, as in the field of scientific medicine#
The Montefiore plan for hospital care for home
patients in extending its services into the home has placed
itself in a position to learn many things about the patient
which could only be learned as a participant in the
patient’s family life. The physicians who have participat
ed in this plan have discovered the importance of the
social factors of disease. They find that it is true of
any disease, but particularly in the case of long term
disease. Here the stress of the illness brings about many
changes in the relationship of the patient to his family,
both emotionally and economically. They have found new
reasons why a patient becomes sick and why his illness
is prolonged.
In order to illustrate the plan and what can be
done for a patient, the following is a report of a typical
case :
John J. was admitted to the hospital with some
undetermined abdominal disease, and after thorough
investigation by clinicians and by the laboratories
of the hospital, it was found that he had cancer of
the colon. He was subjected to major surgery, at
which time it was found that the disease had pro
gressed so far that the entire cancer could not be
kQ
removed and he was left with a colostomy.^7
Here was a patient who will ultimately die of his
disease, but he may have six months, a year, two years or
more to live. He requires nursing care, colostomy irriga
tions, watchful attention for complications, medication
and someone to help him with his food. He may be sdmi-
ambulatory or bedridden. In any case he is a sick man.
But he may no longer require the special facilities of the
hospital. Indeed, even if there were plenty of room for
him in the hospital, he might do much better in some other
environment.
The department of home care was notified about this
patient, and the doctor saw him for the purposes of deter
mining whether we could provide him with the level of
care at home which would be in conformity with the best
hospital standards.
In addition to being medically eligible, the
patient was investigated and determined to be socially
eligible. Every patient who is admitted to Montefiore
Hospital has a social service work up. When he is
evaluated for home care, the social service worker reviews
the patient’s record, interviews him, interviews members
of his family, and investigates the home. Since no
Ibid.. p.
k9
patient is returned to his home unless this is in his
best interests, it is obviously important that the family
situation, the physical facilities of the home, and the
patient’s relationship with other members of his family
28
should be such as to encourage the return to his home.
Dr. Cherkansky then goes on to point out that
many of us think of families and just naturally assume--
at least when we were younger-—that all parents love
their children and that all children love their parents.
Most people live long enough to find out that this is
not necessarily so. When return of a patient to his home
is contemplated, it is important to know what bonds exist
between him and his family. Are they still strong, after
the disrupting effects of a long illness? These questions
must be answered before it can be decided that it is best
ibr a patient to return to his home. Some families seem
not to want the patient back, but closer investigation
reveals that the reason is not lack of love, but fear--
fear of illness, fear of impending disaster, fear of in
ability to do what is required. If the fundamental
attitudes are sound, all of these fears can be overcome
by careful handling and good service.. Some of the fami
lies who were doubtful proved to be among the best in
the experience of the doctor.
Ibid.
50
When it is decided that a patient is medically
and socially eligible, the patient goes on home care and
receives the following services:
1. Medical service--Medical service around the
clock, seven days a week. Specialists are available for
the patient in his home, such as orthopedists, opthal-
mologists and surgeons. Many medical procedures such as
abdominal taps and blood transfusions can readily be done
in the home.
2. Social service--The social worker who cared
for the patient on the ward follows him into the home to
help him and his family with any problem that may arise
and interprets the program to the family.
3. Nursing--The visiting nurse service of New York,
by contracts with the hospital, visits each patient at
least once, even in those cases where a need for visiting
nurse service is not forseen, since their experience in
the home will provide a good evaluation of the patient
and of the patient’s need for nursing. In addition, the
nurses have two other important functions, they provide
nursing and they teach. The teaching is, in some respects,
the most important part of their job. They often teach
a member of the family to become an expert nurse in the
care of the particular patient.
4$ Housekeeping service--Housekeeping service
51
is provided five to ten hours per week. It is found to
be very helpful since many of the patients who would other
wise have to remain in the hospital can well be taken care
of at home if there is someone to help with the heavy
house work. It has been discovered that a woman is more
than just a housekeeper in the home--that the mother,
when she returns to the home, even though she no longer is
able to do the dishes and wash the floors, can still be
the rallying point for the entire family.
5* Transport ati on--Transport ation to and from
the hospital is provided, and there is a free interchange
of patients between the hospital and the home. Dr. Blue-
29
stone pointed out that home care is, in essence, an ex
tension of the hospital into the home. There are none of
the facilities of the hospital to which patients cannot
be brought by ambulance. The inconvenience to the patient
is little greater than moving him from the fourth floor
of the hospital to one of its laboratories.
6. Medication— The patient is supplied with all
medications, with hospital beds, wheelchairs, special
mattresses, braces, in fact, anything that contributes to
the welfare of the patient and which can be transported.
^ E. M. Blue8tone. Director, Montefiore Hospital,
Lecturer, School of Public Health, Columbia University,
New York.
52
7* Occupational therapy--A full time occupational
therapist who visits the patient in the home is employed.
This serves several purposes: first, it is a morale
builder and certain corrective procedures can be taught
to the patient ; and, second, for some patients it may in
a small way alleviate the ever present financial difficul
ties.
8. Physical therapy--The physical therapist also
enters the home to treat the patients.
Dr. Cherkansky asks: “What are the results of
this program?First, to consider the financial bene
fits, even though they may not be the most important:
in the first twenty months of the program, there were
provided over 23,000 days of patient care. The average
cost per patient per day was less than three dollars com
pared with the present cost of hospital care of twelve
dollars to fifteen dollars per day in the hospital wards.
It is, however, not of importance to have a product which
is only cheaper. It must be as good or better than other
products on the market. The home care patient would still
do much better in his home, the author insists, than he
could possibly do in a hospital. In the hospital, a
30 Ibid.
53
patient is one of many. He has to give up many of his
own little private privileges and desires for the bene
fit of the group as a whole. In home care, the patient
has been provided the best of scientific medicine and the
best environment. He is an individual in his own bed
with his own type of bed-clothes, and he can have the win
dow up or down as he sees fit. He can have his break
fast yien he wants it and not when the dictates of hos
pital discipline compel. A patient on the ward in a hos
pital may be looked at every day by a doctor, but he not
always is “seen." When a doctor visits a patient in his
home two, three, or four times a week, he is the sole re
cipient of the doctor’s attention and care. A doctor on
the ward may find greater interest in some patient three
beds down the ward vho is clinically more exciting or more i
interesting. Where the special facilities of the hospital
are no longer needed, the rigidity and chilliness of a
hospital can be profitably exchanged for the flexibility
and warmth of the home.
Cherkansky then goes on to cite a case which il
lustrates the individualization of medical care and the
well organized team which can be brought to bear on the
patient in the home:
..... ' 5k
Jean J. had a growth involving her spine. An
operation was performed and a large bony segment was
removed. This happened about six years ago. Dur
ing the intervening time Jean spent more than one
year in a body cast and because of the defect in her
spine, was told that she could never walk. She was
seen in some of the best hospitals, but here was a
patient permanently consigned to bed, a hard fate
for a twenty-nine year old girl to endure.
Eight months ago Jean came on the home care pro
gram. She lived in a third story apartment with her
widowed mother. The doctor seeing this young woman
in her home, developed a much clearer insight into
her hopes and desires than could a doctor on the
ward where she was just one of a dozen patients bed
ridden for life. An orthopedist was called in, and
after reviewing all the x-ray films, a special back
brace was made for the patient. One day the visit
ing nurse met the doctor at Jean’s home and helped
her out of bed with under-the-arm crutches, and so
began a long period with the doctor visiting three
or four times a week, the physical therapist four
times a week, massage, encouragement, new Swiss
crutches, leg brace and one day Jean got out of bed
and walked to the bathroom for the first time in
over five years. By using telephone books as an im
provised stair, she was taught to walk up and down
stairs. More than six months after coming on home
care, Jean walked down two flights of stairs, got
into a cab, came to our hospital and was presented
to our clinical conference. Many of the doctors were
surprised to see this “bedridden* patient come in
under her own steam. Jean is now progressing toward
walking without any supports. We have salvaged a
human being and this by individualizing her care and
by coordinating all the facilities of the hospital
and community in their joint fight for health and
against disease.31
VI. CONCLUSION
As has been pointed out above, there is a time in
Ibid., p. 167.
55
the patient’s illness when the possibility of returning
home must be considered. In the case of child hygiene,
particularly with crippled children, the danger of a
warped personality due to long hospitalization, plus the
. need to gratify the child’s desire for affection besides
! the excessive drain on the financial resources of the
!
family or of the agency concerned all contribute toward
; returning the patient home. It is also emphasized that
close supervision by the public health nurse as well as
regular examinations by the attending physician must be
effected besides the teaching of the parents in the pro
per care, rest and diet of the patient* The importance
of a healthy home atmosphere has been stressed. In child
hygiene we may conclude that there are many obstacles
toward returning the patient to his home, but that even
with all the difficulties, where home care can be effected
g it is a great aid to the physician in his treatment and
to the patient and his family in improved morale.
Again, in the problems of the aging, we find that we
have much the same problems: there is a shortage of
proper hospital beds, there can be acute resistance on
the part of the patient’s family toward his returning
home, but to overshadow all of these obstacles is the
; importance to the patient himself. It appears that
: institutional life tends to cause these old people to
I
56
!
degenerate by disuse and atrophy. There is an indication
thal^ wherever family problems do exist, that these problems !
would be considerably relieved by counseling services,
the provision of better home nursing facilities, the use
; of housekeepers and social workers. It is apparent that
, home is. the logical place to find affection, happiness '
and security. One of the greatest reasons for this pro- |
I
gram's not being in effect at the present time is the I
shortage of qualified personnel. '
In the case of mental hygiene, as in the above
fields, home care actually contributes toward the patient's
improvement. Not only is it less expensive, it releases
space for other patients in need of specialized treatment
and for those from whom the community needs to be pro
tected. Also, a great majority of the patients so placed
make a relatively permanent and satisfactory adjustment.
The Montefiore Hospital Home Care Program represents
the most positive and dynamic plan for treating the sick
in the home. As pointed out above, the fourth require
ment for good medical practice is that good medical care
! should treat the patient as a whole. He is more than an
organic creature. He is a physical and social being as
well. The physician should treat his patient upon a
personal basis. The fifth standard of good medical care
stresses a close relationship between the physician and
57
the patient. The complex nature of a human being, the
intricate relationship between body and mind and between
the parts and the whole, establish familiarity with the
' patient’s personality and habits as the first essential
' of good medical care. This is echoed by Cherkansky, when
' he states: “It is no more fair or useful to separate
man from his environment than it is to divide him into
32
separate and independent parts."
From this discussion, it is reasonable to conclude
that it is consistent with the best medical practice to
place the individual patient in a wholesome atmosphere as •
nearly like a normal home as possible. Not only does the
patient improve more quickly and his family benefit from
his presence, it also enables the attending physician to
observe him in his own environment and thus aids him in
further diagnosis and treatment. Further, we have seen
I that the proposition of hospital care for home patients is
hot only a desirable, but also a possible plan. In addi-
■ tion to being a workable program, it is much less expen-
; sive in operation than institutional care. Why, then, is
it not in widespread use?
Further study is necessary to discover all of the
. reasons, however, an analysis of the administrative prob
lems appears to be in order.
I Ibid., p. i^2.
CHAPTER V I I
ADMINISTRATIVE PROBLEMS RELATED TO HOME GARE
It is proper that a careful delineation be made
' when we discuss the administrative aspects of our subject
Dr. Haven Emerson, as editor of Administrative Medicine,
I hastens to point out that there is a broad distinction
' between those activities which are carried on by the in-
: dividual physician for his own private patients for pay
and between those which involve a number of persons re
lated to each other by authorized organizations, either
as an institution or agency, for the delivery of service
to individuals and groups, or to whole communities or
populations. This latter group is what may be termed ad
ministrative medicine to include the broad sub-divisions
of public health and organized care for the sick.
He further refines the term, organized care for
I
the sick as including those special functions provided
: by institutions and agencies generally found in a mature
urban society of today, and recognized as necessary to
, meet our ambition for humane, competent and economical
care of the sick, namely:
^ Haven Emerson, editor. Administrative Medicine
(New York: Thomas Nelson and Sons, 1 9 5 1 p. 11.
59
Hospital care for bed patients.
Out patient care for ambulatory sick.
Convalescent homes to complete recovery.
Care of the chronically ill.
Visiting nurse service for the sick at home.
Medical social service.
Home medical care.
Rehabilitation.2
Public health, as defined by Dr. Emerson, is a
community service applying the sciences of preventive
medicine through civil government for social ends.
I
I Dr. Emerson draws attention to the principle that
^ administrative medicine for the care of the sick, through
I
its social instruments, its agencies and institutions,
: seeks to increase the utility and economy, and to expand
for universal availability the sciences of those trained
in medical arts and science, without loss of that quality
of personal excellence and competence which the law re
quires of the doctor of medicine as an individual practi-
: tioner. He cautions, however, that while experimentation
! by the government, the laity and by the medical profes-
i sion itself is to be encouraged, it should be remembered
; that what is good, enduring and constructive existing at
i present must not be sacrificed for visionary benefits,
hoped for by persons or groups unfamiliar with and ir
responsible in the field of medical care.
^ Ibid.
6o
The measure of value of any particular administra
tive procedure in the medical field can be Judged on its
competence, results and the cost of its performance*
Since administrative medicine is coneorned with the health
of persons as a social asset or value, society and govern
ment are interested in the delivery of services in a way
to reach the largest number of people at the least expense
consistent with good quality*
It has been pointed out in the preceding pages the Î
advantages of returning the patient to a desirable environ
ment after the specialized services of the hospital have
been completed* Prom this point, what are some of the |
considerations necessary to implement the hospital care
for home patients plan?
With the advances of preventive and curative medi
cine and the results of the discoveries in the field of
! chemotherapy, chronic disease presents a more serious
problem of medical care than acute disease* In a study
made by Bailey and Weiskotten, it was found that 90 per
cent of the cost of the.hospitalization of patients on
I general medical wards was expended for chronic illnesses
and that only one third of the patients received what was
considered satisfactory medical supervision after their
discharge from the hospital. Also, that the "duration of
I many patient's stay in the hospital could have been
6i
shortened and many need not have been returned to the
hospital if intelligent medical supervision after dis
charge had been provided."^
Subsequent to the study made by Bailey and Weis
kotten, Syracuse University Medical School established a
' home care service. The first and perhaps the most im
portant factor to be determined is the eligibility of the
j patient for home care. Does the disease or condition lend
' itself to home care treatment? Will the patient and his
i
,family cooperate in the patient’s best interests? Are
there special problems peculiar to an individual patient
I
that will prejudice the entire program? The following
report illustrates some of the considerations to be ex
pected:
During the period of the experiment, l65 patients
required home care by the Extramural Resident follow
ing their discharge from the hospital. The primary
concern in undertaking their treatment was to deter
mine how best they could be assured of adequate medi
cal care following their stay in the hospital. How
ever, the principles which guided the planning of
their medical care were of such pragmatic value that
the hospital staff eventually realized that one sig
nificant remedy for overcrowded wards had presented
itself. Patients who had previously been treated in
the hospital over a period of weeks or months were
discharged earlipr to the Extramural Resident’s ser
vice.
^ A. A. Bailey and N. G. Weiskotten, “The Problem
of the Discharged Hospital Patient,“ Hospitals, August,
1939» p. 13.
62
In the beginning, the ward physicians were re
luctant to accept this new concept of earlier dis
charge. For instance, a patient with a coronary
I vessel occlusion remained usually from six to ten
i weeks in the hospital without the possibility of
good medical care at home being investigated. When
the service had become established and recognized
as valuable, a number of cases of coronary disease
with myocardial infarcation were discharged at the
end of two to three weeks and their treatment con
tinued at home with no difficulty whatsoever. On
the other hand, skillful handling of the patients
themselves was sometimes necessary before they
would acquiesce in an early discharge. For example,
cardiac patients who had had numerous previous ad
missions expressed surprise when told that they
could go home even thought all subjective symptoms of
heart failure had not disappeared. Usually, their
comment was that previously they had spent six weeks
in the hospital and they could not understand why,
after two or three weeks, they were allowed to go
home. The new program puzzled them at first, but
when the home care plan was explained they willingly
accepted it. The patient was told that the physician
who would visit him was in every sense his private
doctor. Without exception, the patient expressed
satisfaction with this arrangement and in nearly
every instance showed evidence of having found a new
sense of security.
Before undertaking the home care of the discharged
ward patient, it was necessary to have first hand in
formation concerning the patient as a person, to con
sider him in the light of both the psychic and somatic
factors of his illness and, indeed, few of the
patients with organic disease were free from accompany
ing emotional disturbances. It was also extremely
important to make a social study of the patient’s
resources and home environment before home care could
be contemplated. During his daily rounds on the
wards, the Extramural Resident devoted his time to
the study of the nature of the patient’s illness,
his daily progress, and treatment, and in this way
he soon came to know the patient more intimately
and was in a position to lay the foundations for a
mutually satisfactory physician-patient relationship.
He had, in most instances, foreknowledge of the
patient’s date of discharge and could, therefore,
j prearrange the suitable cooperation of the relief
I agency, public or private, interested in the patient,
i These agencies were asked for such material help as
63
bedding, increases in food allowance, special diets
and medicines.
Experience taught the Extramural Resident to in
vestigate the home environment for himself whenever
he was contemplating treatment of a patient at home.
Often he would be assured by patients anxious to re
turn home that they could be adequately cared for
only to find when the home was visited that the neces
sary medical treatment could not be properly carried
out .4
Continuity of medical control. The best interest
of the patient must be protected at all times and to as
sure the best results there must be a continuity of treat
ment. Inasmuch as the patient is actually receiving care
directly from the staff of the hospital itself, medical
records can be kept up to date much better than might be
done if the patient had been shipped off to some nursing
home where the staff might not be as well trained or
conscientious.^ The close relationship of the patient
with the hospital actually eliminates much of the duplica
tion of service which would probably occur if a nursing
or convalescent home were used. Also, should the patient,
for any reason, be returned to the hospital, the records
and charts would be available immediately. With the home
care plan,the patient has the same medical social service
^ P. Jensen, H. G. Weiskotten, and M. A. Thomas,
Medical Care of the Discharged Hospital Patient (New York;
The Commonwealth Pund^ 1 9i }. I | . y , p. 21.
5
Ibid., p. 12.
6 i | .
worker, the same physicians, technicians and other per
sonnel. The atmosphere of “familiarity" so desirable for
■ 6
; tranquility and peace of mind is maintained.
Physical facilities required. A general hospital |
■
already in existence has the basic equipment and personnel ^
necessary to contemplate instituting the hospital care
for home patients plan. Rolling stock in the form of
! j
; specialized motor equipment would of course be needed. i
It would be necessary to consider the location of the |
home care patients in relation to the hospital. Space is
a factor to be reckoned with and a patient requiring al
most constant attention in a poorly located home would
7
prove to be a burden.' However, as has already been
pointed out, the patient does not leave the hospital unless
. his individual situation meets the standard of furnishing
as good or better hospital care in the home.
Living accommodations. Living conditions should be !
: O
: given considerable attention. It should be remembered j
. that the primary purposes of returning the patient home j
are to improve his physical comfort, raise his morale and
^ Ibid., p. 79.
^ Ibid., p. 17.
® Emerson, op. cit., p. I08.
65 I
change his attitude from that of an ill person to one j
with normal interests. The room should avoid as much
as possible the appearance of a hospital ward or room.
It is suggested that color be used to good effect. Some j
. . ■ j
people associate white bedspreads with illness; colored |
ones with a normal healthy life. It would be desirable !
that there be facilities for sitting, sunning and watch- ;
ing the outside world. The homes themselves would have ;
to meet the minimum requirements of healthy living con- >
taining adequate bathing, cooking and treatment facili-
. ties.
!
, Personnel. An institution offering hospital care
for home patients would need an administrator skilled in
organization, coordination and control. Not only would
he need the conventional skills of a hospital administrator^
I he would be required to supervise the method of dispatching
I the constant flow of vehicles. The life's blood of the
i
I
> hospital care for home patients plan lies in the mobility ^
i
of its technical personnel. Doctors must be at the
■ patient's home on time. Specialists, needed in two
'different locations would require scheduling. Valuable
I equipment such as x-ray machines and physio-therapy appara-
!tus would necessitate careful attention and trained tech-
j 9
:nicians. Careful scheduling, again would be imperative.
I 9 E. H. L. Corwin, The American Hospital (New York;
I The Commonwealth Fund, 19^6), p. 132.
66
The plan would require full time physicians or residents
who would be dedicated to the program and skilled in deal
ing with patients and their families. Specialists would
be needed for consultation and specialized procedures.
A medical director who would be responsible for the general!
medical care policy and skilled in human relations is a I
must
The visiting nurse. The visiting nurse is distinct
from the public health nurse in that the major program
of the Visiting Nurse Association is bedside nursing care
for the sick, whereas, the major program of the public
health nurse is family health counseling. The National
; Organization for Public Health Nursing advocates an inclu
sive public health nursing service in which both curative
. and preventive functions are carried out by the same
, nurse, and when feasible under one administrator. The
I hospital care for home patients plan has the ingredients
* 1 1 1
: Of care and training incorporated in it.*^"*- The nurse is |
I
necessary to assist and train the patient's family in j
special techniques and care of the patient. j
: I
! j
The housekeeping service. The housekeeping service I
Emerson, op. cit., p. 110.
National Organization for Public Health Nursing,
I “Public Health Nursing Care of the Sick," a booklet, 19l|3,
1 p. 54.
6?
is a very necessary adjunct to the home care program* The
time required for patient care by the family would subtract
^ from the time necessary to maintain the home in good order.
I A housekeeping crew, equipped with the necessary materials
' and implements should be scheduled for housekeeping duties.
' Personnel for this work would have to be physically cap
able of moving heavy objects of furniture as well as being
meticulous in rendering the home spotlessly clean. Five
to ten hours a week has been found to be economically
feasible. More housekeeping time than this raises the
question of the advisability of home care for the particu-
12
lar patient.
Medical social service. The social investigation
of the hospital patient by the medical social service
worker is invaluable to the physician. In formulating
his plan for satisfactory home care of a patient, the
: findings as reported to him are of great benefit. It has
been pointed out that since a social investigation is in
, a sense interperative, and in order to be of greatest
, value, the medical social service worker should be the
I
: same one who has been working with the patient in the
hospital.It is desirable that the social worker be
■ Jensen, op. cit., p. 29
! ^3 Ibid.. p. 56.
68 I
in a position to take into account the point of view of
, the physician regarding home care treatment and also the
limitations of the service. An obstacle which has deve]cped|
in the experiments here has been the extreme shortage of i
I 14
: qualified medical social service workers.
I
I Property accounting. The special needs of each
’ patient must be met. A special type bed, a traction ap- j
pliance, a wheel chair or almost any kind of sick room i
i
supplies might be required. These items, whether singly
or in a group represent a tremendous investment. Damaged
equipment would need repair or replacement. Items no
longer needed would have to be returned, sterilized and
placed in storage. Property accounting showing the loca
tion and individual charged would have to be kept constant
ly up to date. It should be pointed out, however, that
these items used by the patient in the home would likewise
be used by him in the hospital. The difference here is
that the items are now out of the confines of the hospital.
Experience of the Los Angeles County Auditors Department
has been that it is often extremely difficult to persuade
the patient to relinquish a particularly comfortable bed
M. Field and B. Schlus, “Extension of Medical
Social Services into the home," Journal of Social Casework,
32:29, July, 1948.
69
or a favorite wheel chair.
Related problems. In Jensen's report discussed
above are factors which need our attention. Dr. Jensen
I mentions that the patient offers an obstacle to the pro
position of home care. In some cases, it was pointed out,
the patient could not understand why he was required to
return home so soon. The author goes on to state that
proper explanation obtained concurrence and cooperation
of the patient with an accompanying "evidence of the feel
ing of security." Although the literature available to
us would indicate that such is the case, a further search
along this avenue seems in order.
In England, where the National Health Service has
been in effect for over six years, there has been an ap-
^preciable expansion of hospital services. However, the
demands for hospital services have been so great that there
are long waiting lists. In order to remedy this, the
Board of Governors of the United Liverpool Hospitals gave
jconsideration to the possibility of expanding the hospital
i
! service to "recovery homes." This is not in the true
: sense a home care plan where the patient actually is in
ihis own home. A "recovery home" would compare more closely
'to our convalescent or nursing home. Nevertheless, cer-
:tain administrative problems would be the same. It was
!
jdiscovered that the cost could be materially reduced by
70
transferring the patients to a recovery home after the
immediate services of the hospital were no longer needed.
I However, the major disadvantage seemed to be the inter
ruption in the management of the individual patient. Many
patients believed that under the National Health Service
Î they were entitled to the care of a first class hospital
and resented the transfer to what they felt, rightly or
■ wrongly, an inferior unit. A further line of thinking,
where the service is sponsored by the state, is the com
ment, “if simple facilities for rest in bed were augmented,
the demand on hospitals would certainly increase.** The
problem facing the state planners, after six years, is
the difficulty of determining what constitutes a reason
to enter a free hospital. Should the admission be mainly
on the basis of complications and surgery, or should
patients be admitted, for example, with “anxiety** symp
toms? The conclusion of the Liverpool Hospital study
would indicate that recovery homes could be a partial
answer.It would appear that there is considerable
resistance on the part of the patient to being placed
I in what he feels to be an inferior unit. The report ends
with the suggestion that the expansion and improvement of
hospital care needs further study, especially during the
“Recovery Homes,** The Lancet. 26g:2l|.-2$, July 1^,
1953*
71
recovery or out-patient phase of treatment
It is significant to us in our study of hospital
care for home patients to remember that the patient and
his family must be conditioned to the desirability of
home care.
Another problem facing the plan is the overlapping
of activities of the various welfare agencies. Consider
able time and attention was required by the physicians
and social workers in this area to get proper help and
17
accommodations for the patient.
Ibid.. p. 2I 4 ,.
17
Jensen, 0£. cit., p. 71#
CHAPTER VIII
CONCLUSION
It is important to re-examine the frame of reference
I within which this study was undertaken# The duties of the |
i public administrator not only encompasses the execution
of the policy as set by the legislature, but also the re- i
!
; sponsibility of devising and introducing methods of im- j
; I
, proving efficiency and economy. It is particularly true |
in the field of Institutional management that there is a
need for economy and efficiency. Not only are the costs
of hospitalization increasing, the demand for hospital
care is growing at even a greater rate. The need for addi
tional hospital beds is mounting, but the tremendous cost
of creating new units, plus the lack of adequate funds has
retarded the fulfillment of the need. It is in this area,
that the hospital administrator should explore new and
ipossibly better ways of caring for the sick.
The principle is brought out in the organized care
of the sick that through the social instruments available
to us we should seek to increase the utility and economy
and to expand for universal availability the sciences of
those trained in the art of healing, but without the loss
'of that quality of personal competence required of the
professions. The measure of value that is employed to
judge an administrative procedure is on its competence.
73
results and cost of performance. In administrative medi
cine the health of an individual as a social asset or
value is of vital concern, as is the delivery of services
I
. that will reach the largest number of people at the least
' expense consistent with good health.
It has been found in this study that the terra
“hospital** can have many meanings and therefore the
inquiry has been limited to the broadest type of hospital
known as the general hospital.
In order to become oriented with the cultural forces
that influence attitudes toward hospital care it has been
discovered that these forces can be classified as : re
ligion, war, medical science, education, economic condi
tions and public appreciation. From the potpourri of these
, forces have evolved the attitudes which provide the pre-
■ sent day hospitals and the social expectations of what is
j to be expected of them.
I It is desirable to examine the standards of medical
i
I service so that the comparative values of hospital care
'for home patients can be assessed. The eight tenets of
I '
good medical practice may be listed as:
I
I 1. Good medical practice is the rational use of
i
! medical care based upon the accepted medical
sciences.
i
, 2. Good medical care should stress prevention.
Ik
3* Good medical care necessitates intelligent
rapport between the lay public and the
physician.
i j , . The patient must be treated as a whole.
I
i
5. There must be a close and continuing personal i
relationship between the physician and the ;
i
patient. j
I
6. It is important to coordinate the efforts of |
the social welfare agencies. i
7. All types of medical service must be organized, |
directed and fully utilized.
8. All the necessary services of modern medicine
must be available to all of the people.
It should be added that it was also found to be important
that medical care should continue into the convalescence
in order that benefits already derived may not be lost.
The functions of a general hospital have been in-
I vestigated and it has been found that the major considéra-
i tions include four phases to be considered: the care of
the sick and injured; the education of physicians, nurses
I and others; public health in the prevention of disease
^ and promotion of health; and the advancement of research
I and scientific medicine. The primary requirement of the
'hospital is the service to the sick and injured and it
is this responsibility to which all personnel of the
75
hospital must contribute. In the course of this study,
the author found that the operation of a general hospital
' is a tremendous undertaking. The general hospital is an
i
I extremely costly necessity. Care for the sick, even if
I
examined in the light of self interest, must be provided* j
,Hospitals are a necessity, and they must be supported. i
i
: Since the problem of financing is faced by the community, j
^ it is reasonable to examine some of the possibilities which^
might aid in relieving the shortage of hospital beds.
At the same time, it is necessary to be alert to the oppor
tunity of reducing the costs of patient care.
Convalescence is the period during which the body
,makes a gradual recovery of health and strength from
disease and weakness. Physiologically, it can be termed
as the time when the patient's equiliberating forces gain
, the ascendency of the disequiliberating ones, whereas,
, psychologically, convalescence is the time when the
'patient overcomes a feeling common to everyone, namely, a
: I
I resistance to change of any kind and accepts a certain j
i duration of disease as inevitable and that the convalescence
state is a necessary one. The convalescence period can
t
I be thought of as a period of recovery, but as has been
j pointed out, there is a need for continuing medical care
j during this period. The practice in the past has been
I that the patient spend the recovery period in the hospital.
76
or, in the case of those less fortunate, to send them
home# This latter practice has frequently proved un
satisfactory, however, as the patient or his family often
1
failed to understand the true nature of the disease or " |
\ I
the importance of following the prescribed program. All ;
!
of this, together with adverse social and economic factors |
I and lack of medical supervision, has tended to nullify |
the benefits of hospitalization. There are innumerable I
instance;^ where patients must be re-admitted to the hospital,
that could have been prevented had satisfactory medical^
supervision continued. With this type of experience, it
is little wonder that the conscientious practitioner hesi- j
tates to return his patient, especially a needy one, back
to the conditions that probably contributed to the original
illness.
Does this mean, therefore, that the home as a
possibility for convalescent care should be rejected?
In the field of child hygiene, it has been found, especial
ly in the instance of crippled children, that the danger
of a warped personality is so great due to prolonged
i
hospitalization, plus the child’s desire for affection,
.that it is necessary to return the child home for its
own good. It is emphasized, however, that medical super
vision be continued at the home. Environment is stressed
I as important. In fact, good home environment is pointed
77
out as a great therapeutic agent in returning the child
to normal living. The importance of the home is consider
ed so great, that in the case of children particularly,
foster homes are used where the patient’s own homo does j
not meet the desired standards. i
! In the case of elderly persons, again it has been !
I I
found that the home is the logical place to find affection,)
happiness and serenity. The experience in this area is |
that where adequate home care services are provided, many !
elderly sick persons do not need hospital accommodations.
In fact, not only does it lower the cost, and improve theirj
physical well being, but the old people are immeasurably
more contented. Again, the importance of maintaining j
• an adequate standard of environmental factors, plus medical
supervision is stressed.
In the area of mental health, it has been found
! that the family or home care enables the patient to become
' an individual in the home and community. Instead of
i
' remaining one of hundreds of inmates in an institution,
1 the patient becomes a part of an environment that aids
' him toward a normal existence. In the mental institution,
which usually has only a few overworked staff members and
hundreds of patients with common experiences of neglect,
; illness and unhappiness, the desirability of removing
I the patient from these oppressing surroundings to a home
I
I
78
is obvious. Where placement in homes has been followed,
it has been found that it is an effective administrative
procedure. Not only does it release space for other
patients in need of specialized treatment and for those j
from vhom the community needs protection, it provides
care at less than hospital maintenance and most important
and significant is that a large proportion of the patients j
so placed make a relatively permanent and satisfactory j
. adjustment. ■
Are we, then faced with an impasse? On one hand
we find that after the critical stage of the illness is
passed and the convalescent period begins, there is a time
to consider removing the patient from the urgently needed
hospital bed. Since the patient no longer needs the
: special facilities and emergency attention available at
the hospital, there is the possibility of placing the con
valescent elsewhere. Experience has demonstrated, however,
. that the patient may return to an environment which might
' have caused the original condition. If this is the case
and medical care is not continued, the patient often must
I be re-admitted to the hospital for further treatment and
care. Nevertheless, it has also been found that the best
place for a convalescent patient is in his familiar sur
roundings. He finds peace, tranquility and happiness in
Ihis home. Home is associated with a normal life, whereas,
i
79
the hospital, with its strict routine and impersonal ef
ficiency, represents illness and expense. In many cases
the patient, regardless of all other factors, must be re
turned home in order to prevent a warped personality and
> to implement psychological rehabilitation.
Since we have found that it is desirable and some-
: times necessary to return the patient home, and also that
‘ continuing medical care and supervision is a necessity as
well, it should prove worthy of inquiry to determine the
desirability of hospital care for the patient in the home.
The Montefiore Hospital Home Care Program is pre
dicated on the principle that the patient should be treated
as a whole human being. Although the medical profession |
has progressed from treating not only the infected part
of the body to treating the body as a whole, the home
care program emphasizes the importance of remembering the
social importance of disease to the patient. It is no
more fair or useful to separate a man from his environment
than it is to divide him into separate and independent
; parts.
The Montefiore Hospital maintains that it is the
responsibility of the hospital to explore the social
aspects of disease and this can be done by figuratively
expanding the walls of the hospital to encompass the home.
The home care program has revealed that social factors
80
are extremely important in long term disease.
The Montefiore Hospital Home Care Program is based
upon the idea that when the patient no longer needs the
■ special facilities of the hospital, it is possible that
he might do better in some other environment.
When a patient is considered for the home care
) program, the physician determines whether proper care
I
could be provided at home in conformity with the best
hospital standards. Besides being medically eligible,
the patient is investigated and must be determined to be
socially eligible as well. No patient is returned to his
home unless this is in his best interests. The medical
social service worker reviews his record, interviews his
family and inspects the physical facilities of the home
before encouraging the patient to return to his home.
One problem which has arisen is the relationship
of the patient with his family. Are the bonds of family
relationship still strong after the disrupting effects of
a long illness? Some families appear not to want the
patient back. This reluctance on his family’s part ap
pears not to be a lack of love, but fear, fear of illness,
fear of impending disaster, fear of inability to do what
is required. If the fundamental attitudes are sound, all
. of these fears can be overcome by careful handling and
good service.
81
The patient who goes home can expect and receive
the following services:
1. Medical service around the clock, seven days
a week.
2. The medical social service worker who has
cared for the patient on the ward follows him
into the home to help him and his family with
any problem that may arise.
3. The visiting nursing service instructs the
family in the care of the patient and provides
any necessary home nursing service.
1 4 .. Housekeeping service on the basis of five to
ten hours a week is provided which is an ex
tremely important factor in the success of the
entire program.
5. Transportation to and from the hospital when
ever necessary is still another service avail
able to the patient.
6. Medication, medical supplies, equipment, in
fact, anything that contributes to the welfare
of the patient and which can be transported is
available to him in his home.
7* A full time occupational therapist visits the
patient in the home which serves the purpose
of building morale and teaching him certain
82
necessary corrective procedures where indicated*
8# The physical therapist enters the home to
treat the patient.
The advantages of hospital care for home patients
I are many. It is consistent with the best medical practice
to place the individual patient in a wholesome atmosphere
as nearly like a normal home as possible. Not only does
the patient improve more quickly and his family benefit
from his presence, it also enables the attending physician
to observe him in his home environment and thus aids him
in further diagnosis and treatment. The plan is not only
possible, it is workable.
The measure of value of any administrative procedure
, in the medical field can be judged on its competence,
iresults and cost of its performance. Since administrative
medicine is concerned with the health of people as a
social asset, society and government are interested in
the delivery of services in a way to reach the largest
number of people at the least expense consistent with
good quality. Where these measures of value can be main
tained, without the loss of personal excellence and com
petence required of the doctor of medicine, exploration
to increase utility and economy is to be encouraged.
We have found that the home care program of the
^Montefiore Hospital follows the tenets of good medical
83
practice. Indeed, in many cases, the patient is far bet
ter off in the hospital care for home patients program
than he could be under the conventional methods of treat
ment# In addition, the home placement of patients makes
available the urgently needed beds in the hospital itself.
Also, the costs are materially lower in the home care pro
gram. It would be reasonable to state that the hospital
care for home patients program can measure up in administra
tive procedure when judged on its competence, results and
cost of performance.
The success of such a program would depend upon
the service which would integrate the hospital, out patient^
home treatment plus the assistance of the social welfare
agency concerned. Effective integration of all these
community resources can be accomplished only by the
physician who knows the patient as a whole, who is familiar
with the records of his hospital stay and the social and
economic factors which influence his illness and who can
formulate a plan for continuous treatment. He must be
assisted by a medical social worker who can furnish per
tinent data and.work along with him. Only in this way
can the patient be treated as a whole, by considering all
the medical and social factors influencing his illness.
Hospital care for home patients points the way
toward more economical and beneficial use of the hospital
81^
in the organized care of the sick. As the costs of
hospitalization continue to rise, it will be interesting
to see whether this plan will gain broader application.
BIBLIOGRAPHY
BIBLIOGRAPHY
A. BOOKS
Bachmeyer, Arthur G. and Gerhard Hartman, editors, The
Hospital in Modern Socieby. New York: The Common
wealth Fund, Ï9I43. 763 pp.
, Hospital Trends and Developments, 19^0-19^6.
York: The Commonwealth Fund, I9I 48. 8I9 pp. New
Commission on Hospital Care, Hospital Care in the United |
States. New York: The Commonwealth Fund, 1914-7 • i
631 pp. ' ;
Corwin, E. H. L., The American Hospital. New York: The !
Commonwealth Fund, 1914. 6, 226 pp. |
Crutcher, Hester B., Foster Home Care for Mental Patients. i
New York: The Commonwealth Fund, I9I 4 . I 4. 199 PP*
Dale, Ernest, Planning and Developing the Company Organiza- }
tion structure. New York; The American Management
Association, 1953* 2 i | . 2 pp. j
Emerson, Haven, editor. Administrative Medicine. New York:
Thomas Nelson and Sons, 195l* 1007 PP*
Faxon, Nathaniel W., The Hospital in Contemporary Life.
Cambridge: The Harvard University Press, 1949»
288 pp.
Fifield, J. C., editor, American and Canadian Hospitals.
Chicago: Physicians Record Company, 1937* 1127 PP*
Jensen, F., N. G. Weiskotten and M. A. Thomas, Medical
Care of the Discharged Hospital Patient. New York:
The Commonwealth Fund, I9I 4 . 4» 9k PP*
Joint Commission on Education, Problems of Hospital Ad
ministration. Chicago: Physicians Record Company,
1914- 6. 10i| pp.
Lee, Roger I. and Lewis W. Jones, The Fundamental3 of Good
Medical Care. Chicago: The University of Chicago
Press, 1933. 678 pp.
MacEachern, Malcolm T., Hospital Organization and M^age-
ment. Chicago: Physicians Record Company, I9I 16.
1052 pp.
87
Morton, Thomas G., The History of the Pennsylvania Hospital^
1751-1895* Ph
lo95* 3Ç8 pp.
1751-1895. Philadelphia: The Truger Printing House,
“ ~^8
Pfiffner, John M. and R. Vance Prestus, Public Administra- I
tion. New York: The Ronald Press, 1953♦ 626 pp.
, Saul, Leon J., Emotional Maturity. Philadelphia: J. B. |
Lippincott Company, 1947* 338 PP* ^
Sigerist, Henry E., Man and Medicine--An Introduction to |
Medical Knowledge. New York; W. W. Norton and Company,
: Inc., 1933% 74° PP- I
; I
! Stone, Joseph Er, Hospital Organization and Management. i
I London: Faber, 1939# 920 pp. !
; I
Urwick, L., The Elements of Administrât!on. New York:
Harper and Brothers, 1943* 132 pp.
B. PERIODICAL ARTICLES
Bailey, A. A. and N. G. Weiskotten, “The Problem of the
Discharged Hospital Patient,“ Hospitals, 13:13-17,
August, 1939*
Ball, Georgia, “Foster Home Care for Crippled Children,’ *
The Child, 3:7, January, 1939#
Bissell, Elizabeth, “Foster Home Care,“ The Crippled
Child, August, 1939» PP# 31-32.
; Cherkansky, Martin, “The Montefiore Hospital Home Care
Program,“ American Journal of Public Health, 38:163-66,
' February, 1949*
Field, M., and B. Schlus, “Extension of Medical Social
Services into the Home,” Journal of Social Casework,
I July, 1948, pp. 22-31#
I
Maletz, Leo, “Family Care; A Method of Rehabilitation,“
Ment al Hygiene, 26;594"^^5, October, 1942.
j McPherson, George E., “Family Care--An Experiment in Place
ment,” American Journal of Mental Deficiency, 55:588-
93, April, 1941#
88
Mills, Martin, “Possible Home Gare in Poliomyelitis,”
California Medicine, 77:1, July, 1952.
Rutledge, J. L., “Houses of Recovery,” Magazine Digest,
19:4-5, October, 1939#
Smith, Caroline, “Home Convalescent Care,” The Crippled
Child, December, 193^, PP* 109-117*
C. PUBLICATIONS OP LEARNED ORGANIZATIONS
A Hospital Plan for Los Angeles County, California.
Minneapolis; James A. Hamilton and Associates,
Hospital Consultants, 1946-1947, 52 pp.
Baker, Edith M., “Development of Services for Crippled
Children under the Social Security Act.“ U. S.
Department of Labor, U. S. Children’s Bureau, Pamphlet
#7488, Washington, D.C. 57 PP#
Becker, Henry J., “Meeting the Needs of the Crippled Childr4
Convalescent and Poster Home Care.” Ü. S. Department
of Labor, U. S. Children’s Bureau, Mimeographed
pamphlet, 194o* 22 pp.
Better Hospital Care for the Ambulant Patient. Harrisburg;
Hospital Association of Pennsylvania, 1946* 184 PP#
Better Care in Mental Hospitals. Washington; American
Psychiatric Association, 1949# 208 pp.
Convalescent Care. New York Academy of Medicine, Proceed
ings of the Conference held under the auspices of the
Committee on Public Health Relations. New York; The
New York Academy of Medicine, 1939* 108 pp.
Hospital Administration. Chicago: The American College of
Hospital Administrators, 1948# 82 pp.
“Hospital Licensing Act,” Division 2, Chapter 2, Sections
1406-1941* California Health and Safety Code, 1953#
Hospital Personnel Administration. Chicago: American
Hospital Association, 1949# l4l PP*
J ournal of the American Medical Association. 130:1073-85,
April 20, 1946#
89
Proceedings of the Governor’s Conference on Problems of
the Aging. Sacramento: California State Printing
Office, October l5-l6, 1951. l55 PP*
Public Health Nursing Care of the Sick. New York:
National Organization of Public Health Nursing, 1943,
ll).6 pp ,
"Recovery Homes," The Lancet, 265*53» London : July i | . ,
1953.
UntversKv of Southern California Library

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

The development of a comprehensive health service (314E) program at Red Lake, Minnesota

PDF

Rural health care delivery systems with emphasis on the health maintenance organization concept

PDF

An analysis of the theory and practice of contemporary corrections as a professional activity

PDF

Legal aspects in the development of health maintenance organizations

PDF

A comparison of the attitudes of selected groups toward the provision of dental care by the federal government with compulsory individual wage deductions, including provision for voluntary accept...

PDF

A study of the Los Angeles medical agencies providing care for certain classes of low income groups

PDF

Local governments' role in consumer protection

PDF

Controlled-interview study of "the therapeutic team" in selected hospitals of Southern California evaluated from the standpoint of the Christian Church

PDF

A suggested program for consumer health education for the health services delivery centers in the San Luis Valley

PDF

The evolution of a multicounty air pollution control district

PDF

Orthodontics: A new field in public health

PDF

The role of the psychiatric social worker in psychiatric hospitals and clinics

PDF

A study of the feasibility of merit rating and merit pay for teachers

PDF

A study of councilmanic backgrounds, interests, and attitudes in California council-manager cities

PDF

A comparative study of attitudes related to turnover in civil service and non-civil service hospital personnel

PDF

Guidelines for special care units for dementia patients: An analysis of three case studies

PDF

History of the organization and functions of the Office of the Auditor General of the State of California

PDF

The chemistry and physiopharmacology of the various toxins found in Latrodectus hesperus

PDF

The social worker's approach to schizophrenic patients in the Veterans Administration Mental Hygiene Clinic

PDF

The chronic male patient in a mental hospital: Hospital services in his behalf

Asset Metadata

Creator Mansfield, Donald Walter (author)

Core Title Hospital care for home patients

School School of Public Administration

Degree Master of Science

Degree Program Public Administration

Degree Conferral Date 1955-06

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health and environmental sciences,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c39-96930

Unique identifier UC11311607

Identifier EP64555.pdf (filename),usctheses-c39-96930 (legacy record id)

Legacy Identifier EP64555.pdf

Dmrecord 96930

Document Type Thesis

Format application/pdf (imt)

Rights Mansfield, Donald Walter

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA