Why has there been a shift of focus in health care from hospitals to the community?

Answer 1

The shift from exclusive hospital care to at home and community care occurred in the early 1980s. Prior to that, it was believed that all patients fared better when receiving in-hospital care.

Pre-1950, women after delivery stayed an average of 7-8 days. By the 1970s, women after delivery stayed an average of 4 days. Now, women after delivery stay an average of 2 days if there are no complications.

Pre-1950, abdominal surgery meant anywhere from 10-14 days in the hospital. By the 1970s, abdominal surgery shifted to a 4-6 day in-hospital recovery. Use of laproscopy using "stab" incisions cut hospital stays to 1 to 3 days. Today, most laproscopy surgery patients are home the next day. Abdominal surgery patients go home within a few days if the wound shows no sign of infection.

These shifts occurred in part because of a change in procedures, a shift in how patients and society viewed doctors as less than the previous "God-like" impressions, and lastly, because of cost-cutting by insurance companies. In the early 1980s, most "home care companies" were just beginning to take hold, replacing the "private duty nursing care" prevalent before the 1950s. Doctors in the 1980s still were not convinced that home care was good enough for patients; some doctors fought home care nurses and sometimes even refused or delayed signing the necessary orders. However, as more patients were dumped back to their own homes, "home care" grew and doctors slowly accepted that a patient could recover just as well at home.

The biggest negative in this transition was that almost all "terminally ill" patients were simply sent home to die, often without adequate pain medication. As "home care companies" became established, "hospice care" also began to be created; "hospice care" companies and residences had not yet been widespread in the 1980s. Pre-1985, home care nurses had to daily fight with doctors to get adequate pain control for terminally ill cancer patients; doctors stated they didn't want their patients "to become addicted", while home care nurses argued back that "the patient is dying--what difference would it make if the patient became addicted!" Sadly, many at home cancer patients only received morphine during the last 24 hours of their lives, making the "dying at home" slogan seem rather cruel. Luckily physicians' attitudes changed, especially as they became more comfortable with hospice and terminal care delivered at home by qualified Registered Nurses. Now, "dying at home" is a choice many patients and families embrace.

The fact that no patient is *required* to stay in the hospital for a predetermined number of days is now accepted, but when these changes first began it felt like a breath of life was finally instilled into medical and nursing care. The changes were on the one hand frightening but on the other hand, exciting-- like one feels when first learning to ride a bike! Home care experienced some falls and mishaps as professionals deliniated their roles in this new regime, but over the last 20 years, everyone has become more comfortable with patients being at home sooner than before. Now, professionals feel comfortable riding this "bike" and in teaching new patients and families that they are smart enough to handle a patient's general recovery and chronic illness needs at home.