Hospitals have developed into one of the most complex institutions of society with regards to its functions, professional organization, and labor forces. The history of their development extends back many years.

Leper colonies were considered to be the first 'hospitals'. They were not established to serve or aid lepers, but rather to protect society by isolating the diseased individuals.

Pilgrims journeying to Rome would stop at wayside shelters called hospices. Usually those who sought shelter were ill.

The Crusades also added impetus to the formal development of hospitals.  The wounded and sick soldiers needed care which was usually provided by family members.  Since these soldiers were far removed from their families, care shelters staffed by women and directed by physicians and surgeons were established.

Monastic orders of the medieval church were responsible for establishing charitable houses and hospitals. Infirmaries or hostels for pilgrims were centrally located near the city gates. Leper houses were situated outside the city gates.

In England, between 1536 and 1539, the hospital system crumbled with the dissolution of the monasteries. Since church sponsorship was lacking, hospitals were placed under civic authority. They were utilized to house the incurably ill and the homeless.

The humanitarian spirit of the 18th and 19th centuries had its effect on facilities serving the sick. Hospitals became places dedicated to the relief and maintenance of curable poor people. Instead of focusing on the incurable, the emphasis was placed on treating the curable.

The first hospitals established in the United States were Pennsylvania Hospital in Philadephia (1751) and New York Hospital (1773).

During the late 19th and early 20th century, a shift toward scientific medicine occurred. Hospitals utilized medical and surgical intervention and made great advances in care of the sick.  The merging of science with humanitarian motivation has brought us to our modern concepts of health care.

As the field of medicine and technology advanced, the types of patients being treated have changed. Prior to 1923, diabetes was treated as a hospital disease.  After the discovery of insulin, that was no longer the case. The discovery of antibiotics aided in the treatment of infectious diseases and pneumonia, removing patients with these conditions from hospitals. The development of rehabilitation services began to bring more disabled people to the hospital. The 1950's saw chronic illness become more important as a hospital problem and now that has shifted to long term care facilities.

Hospitals are classified according to size, type, mode of ownership, and length of stay. Size is determined by the number or adult or pediatric beds. The four types of hospitals are: (1) mental; (2) tuberculosis; (3) special which includes substance abuse, maternity, rehabilitation, orthopedic, chronic disease, mental retardation, or some combination; and (4) general which includes all other non-special types. There are two basic modes of ownership, private and public. A private hospital is categorized by how income is used. If the hospital is investor-owned for-profit, it is considered proprietary. If it is a not for profit hospital, then it is considered voluntary. A public hospital is categorized by the level of government jurisdiction that owns and operates them, such as at the federal, state, or local level. Hospitals classified according to length of stay are either short term (less than 30 days) or long term (more than 30 days).

Through the years, the health care providers role in hospitals has changed. During the 16th and 17th century, the medical profession included the town leech, the compassionate monk, and the charlatan friars pretending to possess miraculous cures. In 1518, the Royal College of Physicians was established by Henry VIII in England. By the 19th century, physicians found hospitals essential for the care of major illnesses. Nursing, though as old as motherhood, became a profession in medicine through the efforts of Florence Nightingale. Althought the first nursing school was established in 1856, it was not housed in a hospital. It was not until 30 years later, when nursing schools were established in the United States, that nursing became a profession associated with hospital care. During the 20th century, a number of new health care professions developed and found their way to hospitals. The education of health care professionals has shifted from the hospital to community centered facilities in recent years.

One thing which has not changed in hospitals is the stratification of professions. Physicians are traditionally described as a "guest" in a hospital and its primary customer. Physicians use hospitals as "workshops" and the hospital is responsible for the care its staff renders on the physician's order. Even though the physician is considered a "guest", they are very influential in determining hospital policy.

Managed health care involves organizing health care providers and coordinating patient care in order to improve the quality of health care and to lower costs. Health Maintenance Organizations (HMOs) are the most common form of managed care.  There are approximately 56 million members subscribing to HMOs nationwide.

Much has been written about the pros and cons of managed care. Manage care professes to care for ill people just as well as fee-for-service systems. They claim to be better at detecting illnesses.  According to the Center for Disease Control (CDC), women in HMOs are more likely to have yearly examinations, Pap smears, and mammograms. This will allow for early detection of some cancers. The Health Care Finance Administration (HCFA) claim elderly HMO members with cancer are likely to be diagnosed at an earlier stage.

The Robert Wood Johnson Foundation surveyed 4000 MDs under the age of 45.  The results of their survey found young doctors are satisfied with HMOs.

Other surveys have found that HMO members are generally satisfied with the service they receive from their managed care provider. Approximately 87% of HMO enrollees were satisfied with their health plan as opposed to 75% satisfaction from members enrolled in traditional health insurance plans. Only 3% of HMO members decided not to renew membership as compared to 37% of members in traditional plans who chose not to renew.

When HMO members are asked what they like best about managed care, their responses include the attention given to preventive care, the coordination of services, and the accessibility of information when they need it. And of course, there is criticism of managed care. Such criticism includes the refusal for managed care to pay for investigational therapies (i.e., bone marrow transplants), early discharges from hospitals, dictating to physicians how they must practice, and regulating physicians' communications with patients. Gag rules prevent physicians from mentioning bonuses or other financial rewards they receive if they contain costs. Some physicians are limited in what they can tell patients about which treatments are covered by the HMO plan.

Managed care organizations have similar stratifications as hospitals with regard to health care providers. Some smaller HMOs have a tendency to hire personnel with minimal qualifications to contain costs.  Many services, such as pharmacy, x-ray, and laboratory, are contracted to outside vendors. This relinquishes control of the HMO over these services.  It also dictates to the physician and the patients which health care vendors they will be allowed to use.

Long term care is defined as the wide range of services provided over a long period of time to people of all ages who need assistance with regular, everyday activities. It generally does not involve the hospital and services are provided in the home, community, and residential settings ranging from small board and care homes for assisted living to traditional nursing homes.

Health care providers involved with long term care in institutional settings have roles similar to health care providers in hospitals and managed care settings. Health care providers involved in long term care in the home setting or community usually work as interdisciplinary teams.

For more information on the composition of the long term care population, who pays for long term care, and long term care as a family issue, click on the web-site below.

What Is Long Term Care?

The American Hospice System is based on the ideas of British physician Cicely Saunders, director of the St. Christopher's Hospice in London. Hospices consist of a set of services intended to improve the quality of life for terminally ill patients and to help these patients die with dignity. Patients make decisions about pain relief using a polypharmacy approach to pain management.  The overall goal of the hospice is to help patients avoid suffering and "heroic" interventions as much as possible, while offering support to the patient and family during the process of dying. Usually teams of therapists are available to provide bereavement counseling to family members as well. The care setting can be institutional or at home. Health care providers in the hospice setting using work as interdisciplinary teams.

For more information, double click on hospice.

Ambulatory care is a personal or combined healath care service given to a person who is not a bed patient in a health care institution. Ambulatory care covers all health services other than community health services and personal and combined services given to the institutionalized patient.  Two categories of ambulatory care are private practice and ambulatory care in organized settings.

A private practice is composed of health care workers who provide a range of health care services limited only by the licensing laws of the state in which they operate as an independent entrepreneur. Physicians and dentists are usually the primary health care provider in primary practice, however this has changed over the years.  Therapists and other health care workers have been establishing their own independent practices lately. Private practices also include independent pharmacies, laboratories, and radiology groups.

The emergence of managed care and HMOs have led to a decrease in private practices in the past few years.  Increased malpractice insurance has been another influence in decreasing the number of private practices.

Ambulatory care in organized settings consist of hospital ambulatory settings, emergency medical services, health department services, and group practices, including HMOs. Hospital ambulatory services are comprised of outpatient services, hospital clinics, and emergency services.  The four functions of emergency services are as follows: (1) take care of the critically ill and injured patient; (2) serve as a secondary physician's office; (3) admitter of patients to the hospital; and (4) provisions of care to people who are not injured or critically ill, who do no have or cannot reach a physician, and/or who do not use the clinic. Emergency medical services are responsible for ambulance services and emergency prehospital care; emergency medical care provider at the hospital; and disaster medical services.

Rural health care is somewhat hard to define since even government bodies cannot come to a consensus on what is rural health care.  The Census Bureau defines rural as a community with less than 2500 residents while the Department of Health and Human Services defines rural as less than 99 persons per square mile and frontier areas with fewer than six people. Rural health care allows rural residents access locally to achieve goals of primary and preventive care to prevent illness whenever possible.

For more information, click here on Rural Health Care.

A wide variety of health and social services can be provided at home to recovering, disabled, or chronically ill persons in need of medical, nursing, social, or therapeutic treatment and/or assistance with the essential activities of daily living. Home health care is appropriate whenever a person prefers to stay at home but needs ongoing care which cannot be provided solely by family members or friends.

Providing home health care requires a team effort. Registered nurses can provide skilled nursing care while physical, occupational, and speech therapists provide needed and appropriate therapies. Medical social workers evaluate personal and financial needs of patients and link them with sources of help. They also provide counseling to patients and family members.  Registered dieticians counsel patients on nutritional needs. Home health aides assist with personal care and provide companionship. Medical equipment is made available by home suppliers. High-tech infusion nurses offer home infusion services. Other health care providers are also capable of providing services to patients at home.

There are numerous benefits of home health care. Health care is provided in the privacy of one's home giving the patient a feeling of personal care, comfort, and control in familiar surroundings. To some patients, there is no place like home with all its comforts as well as the presence of friends and family members. Home health care is viewed as being convenient for the patient.  They do not have to worry about transportation problems and disruptions in their schedule.

Research has shown people recover more quickly at home. Also, home health care results in lower costs to the patient, especially if the care rendered is based in a hospital or long term care facility.

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References:

French, Ruth M. (1979). Dynamics of Health Care. McGraw-Hill.

Jonas, Steven (1981). Health Care Delivery in the United States. Springer.