Our History

The Call to the Nurse: Our history from 1893 to 1943

By Karen Buhler-Wilkerson, Ph.D., RN

Chapter 1

A century ago, American cities were dirty, crowded, and unhealthy places to live. The fluctuating, dramatic, and often frightening presence of infectious disease was a source of great public concern. As popular knowledge of the germ theory of disease spread, urban dwellers began to realize that individual health depended to some extent on the health of the general population. Not only was illness a major cause of destitution, but the infectious diseases contracted by poor people appeared to threaten the well-being of the middle and upper classes as well.

In response to these circumstances, hundreds of community organizations hired trained nurses to care for the sick poor in their homes. The image of the nurse climbing tenement stairs to save the poor from illness struck the fancy of many groups interested in social reform. By the turn of the century, women's clubs, churches, mission societies, hospitals, charity organizations, health departments, settlement houses, and tuberculosis and visiting nurse associations were hiring nurses to care for the sick. In so doing, the members of each group believed they were protecting the public from the spread of infectious disease. Such diversity of private and public sponsorship reflected both upper-class fear of diseases associated with the "dangerous classes" and recognition of the trained nurse as an economical and practical solution to the complex problem of "elevating" poor, often immigrant, families to a more ordered, healthier existence.

Henry Street Nurses Settlement, a visionary experiment, was founded in these socially turbulent times by Lillian Wald. Author of the term public health nursing, Wald was instrumental in securing reforms in health, industry, education, recreation, and housing. Her original ideas led to the establishment of the Federal Children's Bureau, school nursing, insurance payments for home-based nursing care, and a national public health nursing service.

This story begins in the late winter of 1893, when Wald learned that a Sabbath school for immigrants needed a course in home nursing. Unaware of the work of those who had preceded her to New York's Lower East Side and even more ignorant of life's realities for most immigrants, Wald agreed to establish and teach the class. A call for help to the home of one of her immigrant students, Mrs. Lipsky, changed the course of nursing history within an hour. Wald later wrote of being guided by Mrs. Lipsky's young daughter, through crowded "evil-smelling" streets, past open courtyard "closets," up the slimy steps of a rear tenement, and finally into the sickroom:

This experience for Wald was a baptism by fire. Naively convinced that such conditions existed only because "people did not know," Wald committed herself "to know and to tell." Rejoicing that her training in the care of the sick gave her an "organic relationship" to the community, she and Mary Brewster devised a plan to live in the neighborhood as nurses. To support their plans, financial backing was sought from Mrs. Solomon Loeb, who had earlier sponsored the Sabbath School classes. Loeb found Wald to be an extraordinary young woman - a "great genius or mad." Preferring to think she was a genius, Loeb and her son-in-law, Jacob Schiff, agreed to underwrite the salaries of Wald and Brewster for six months. Schiff secured an endorsement by the Board of Health and badges identifying the nurses as "visiting" under its auspices. He also arranged consultation and assistance by the medical staff of the United Hebrew Charities. Two years later, Schiff purchased the house on Henry Street, allowing Wald to have the space necessary to develop many of her unique programs.

Wald's biographer maintains that she moved to the lower east side with "...no theories about economics, sociology or politics, little knowledge as to how people outside her own social group lived, no panacea to try out, no sweeping vision of the future...but she did have an imagination which enabled her -more than that, compelled her - to put herself in other people's places." Her writings are remarkably silent on the subject of her thinking. Nevertheless, Wald repeatedly demonstrated over the next forty years innovative views and pragmatic remedies to seemingly overwhelming problems.

Free from any form of external control or regulation, Wald and Brewster moved to the Lower East Side in July of 1893, "...to do what they could; to see what they could see; and to publicize all that was wrong and remediable..." They arrived at the moment of the country's worst depression. Confronted by the disease, poverty, and the filth of crowded tenement homes, Wald and Brewster immediately recognized that the sickness encountered had to be seen within the context of its social and economic impact on families. They always began by caring for the patient-putting him or her "in nursing condition" and arranging for someone to watch after the patient until the next nursing visit. Recovery, however, required much more than good nursing care.

By the end of a month on the Lower East Side, Wald began to mobilize a vast array of disjointed services to remedy her neighbors' ills, from private relief agencies to the medical establishment itself. Creation of cooperative relationships with organizations as varied as newspapers and hospitals allowed Wald to provide patients with ice, sterilized milk, medicines, and meals. As word of the nurses' work spread, hospitals, dispensaries, relief agencies, and private physicians became "believers," referring neighborhood patients for skilled care, follow-up, and teaching.

By the end of the first summer, the depression had worsened, and Wald and Brewster spent much of their time "bringing relief or reporting for relief" families who were too proud to ask for charity and who were virtually starving. For those in need, funds were secured to pay others to clean, cook, and provide child care in patients' homes, allowing the wage earner to continue working. In an effort to avoid "pauperizing" their clients, intervention was eschewed. When necessary, however, loans were secured or arrangements made to have rent temporarily paid by United Hebrew Charities. Loans, food, sputum cups, medicines, and car fare were provided from emergency funds and recorded in the nurses' account book. Donations of clothes, bedding, sick room "utensils," surgical dressings, cases of soap, and "some money" arrived on a regular basis as word of the nurses' work spread.

Using the authority given them by the Board of Health, Wald and Brewster began a neighborhood campaign to clean roofs, disinfect "vaults," and clean up tenement hallways, while "greater nuisances" (offensive stables) were referred to the Board of Health in their daily reports. Wald and Brewster, willingly washed dirt from their patients, claiming "the use of scrubbing brush and bath has been frequent - if we can't assert it to be permanent." Any real household or personal "transformations" were rewarded with new clothes or linens.

By November, Wald was reporting an increased number of cases of acute illnesses and surgical procedures at home. By January of 1894, "the tragic condition" in the neighborhood showed no sign of relief.

Wald's practice among those without economic resources quickly taught her that disease resulted most often from cases beyond individual control or escape; that treatment had to be prescribed in an "all around way" with consideration for the social and medical aspects of the case; and that families should not feel outsiders carried the entire burden, but rather shared and consulted them concerning measures to be taken. Seeing daily "enough sorrow and poverty and illness to fill a world with sadness," Wald believed that only employment brought relief to those suffering households.

Anxious for neighborhood residents to experience a life other than that associated with crowded tenement and factory, Wald regularly arranged for amenities and social pleasures, everything from flowers to country excursions, picnics, and concert tickets. Mothers were coaxed to send their children to school (sometimes with the aid of a truant officer) and "little bank accounts" were opened in children's names to save any extra money earned. During the nurses' first holiday season, neighbors reciprocated, coming to "sing to us and some brought...little cards, passed most apparently through more hands than one..."

By providing care for their neighbors' numerous illnesses, assisting in death and "alas many births," as well as making countless visits "for other purposes...as varied as the people," Wald became for the Lower East Side and the country, the first public health nurse. She was what public health leader C.E.A. Winslow would later dub a "community mother" - the trained and scientific representative of the good neighbor, caring for all, sick and well.

Wald chose the term "public health nurse" to emphasize the "community value of the nurse" and the relationship of public health nursing to the social problems that invariably accompany a patient's individual illness. Whether problems were isolated and peculiar, or common to many was, according to Wald, important to determine because the "technique for finding out" often led logically to identification of the remedy. From the beginning, every incident that "seemed to have community bearing" was noted and held in reserve for such time as it could be "broadcast to enable others with facilities for greater publicity to influence and educate public opinion toward pricked consciences and mutual responsibility."

Chapter 3

By Passover of 1895, Wald reported that their neighbors still visited, choosing to take "tea with us as their celebration." She concluded, "We are not tired of them nor they, apparently, of us." The continued welcome, notwithstanding, Wald's desire to create a larger, more formal organization made it necessary to move from the tenement to a nearby house which would become the Henry Street Nurses Settlement. At the May meeting of the National Conference of Charities and Corrections, Wald solicited "zealous women" of talent, personality, ability, and spirit to realize the privilege of joining the "family." She hoped to limit the settlement's members to six nurses representing the training and connections of a variety of nursing schools, and bringing an esprit de corps essential to cooperative work. The settlement nurses would receive a "fellowship," but would share collectively in living expenses.

One room of the settlement was reserved as a dispensary where simple nursing cases could be treated and where physicians could attend to special cases not requiring treatment in the larger clinics scattered throughout the city. An extra bathroom was set aside for regular and emergency use, particularly to prepare neighbors for trips to the country in summer. Finally, classes in home nursing, making of poultices, care of bed patients, elementary first aid to the injured, household hygiene, and child care were conducted for mothers and children from the tenements.

The yard was the "largest playground" on the Lower East Side, with preference given to the need of convalescent and crippled children. To create a social center at the settlement, a portion of the house was comfortably furnished and supplied with books, pictures, musical instruments, and educational materials.

Wald moved to 265 Henry Street with a staff of six in the spring of 1895. Daily rounds for members of the "family" began with breakfast at 7:30 a.m. Mail was read, work and plans for the day organized, new patients assigned, and "knotty problems and difficult situations" discussed. While Wald assigned new patients, mindful of the size of each nurse's caseload, the nurses were free to manage their patients and their time, without restrictions. The nurses customarily returned to the house for lunch. When afternoon visits were completed, they commenced with other special work, such as teaching English or home nursing or leading a group activity, perhaps a club for teenage girls. A cooking class, the Good Time Club, was the most popular course taught by the nurses, despite its cost of a nickel per week to attend.

Nurses from Henry Street Settlement were available throughout the city seven days a week between the hours of 8:30 a.m. and 5 p.m. Patients were usually visited on a daily basis and night nurses, along with cleaning and laundry services, were provided for the critically ill. As a rule, new cases were seen first, morning and afternoon. Patients with elevated temperatures or in poor condition were usually seen twice a day, often with the second visit to make them comfortable for the night.

While referrals came most often from the patient's family, some were from charitable organizations, clergy, and physicians. A visit by the nurse usually preceded the physician. The nurse decided whether to seek medical care at a dispensary, call upon "uptown specialists," or advise services from a hospital.

During its early years, no public or formal reports were issued by the settlement, nor was it necessary to make appeals for money. Patients were encouraged to pay what they could, but most of the care provided was free. Money received from patient fees was placed in an emergency fund to be used for expenses incidental to the nursing service-items such as car fare and supplies. With moderate success, Wald contracted with several Lower East Side lodges and benefit societies to provide nursing care for members; an annual retainer was paid for these services.

Chapter 4

By 1909, Wald was convinced that nursing care could be a cost effective investment for insurance companies and proposed to the Metropolitan Insurance Company (now MetLife) that this proposition be tested. Armed with data documenting that nursing care saved lives, Wald urged MetLife to hire visiting nurses to care for policyholders during illness. For a modest fee per policy, Wald believed that MetLife could reduce the number of death benefits paid, and that without additional fund raising by the settlement, services of the visiting nurses could be extended to more of the working classes. Arguing that mutual advantages were readily apparent, Wald recommended a brief experiment to test the idea.

MetLife agreed to test Wald's proposal by having nurses from Henry Street Visiting Nurse Service visit sick policyholders referred by MetLife agents in one section of the city, and comparing results with similar policyholders in another section of the city. The experiment began in New York on June 1, 1909, with a visit to a policyholder on Hudson Street who had an ulcerated leg. After three months, the result were good enough for the "wise directors" to authorize extending the program to cover policyholders throughout the city.

By 1911, the company had decided to extend its nursing service across the country and by the close of 1916, had made the services of the visiting nurse available to over 90% of its 10.5 million industrial policyholders living in 2,000 cities. Wald's New York City experiment initiated more than one billion home visits nationwide for MetLife between 1909 and 1952 and resulted in establishment of the first national system of insurance coverage for home based care. While visiting nurse associations and patients across the country were the beneficiaries of MetLife's services, so too was Henry Street, which received 30-40% of its income over the next 20 years from insurance payments.

By 1910, with a phenomenal increase in demand, the nursing service quickly outgrew 265 Henry Street. Several other houses were opened throughout the city and eventually the nurses began to live in flats of their own in neighborhoods where they worked. In addition to twelve posts across the city, the staff of 54 nurses ran a milk station, a convalescent home known as "The Rest," three country homes with a total capacity of 75 beds, and first aid stations for the treatment of burns, infections, and injuries. The nurses conducted health consultations for mothers and babies and a maternity service. Caring for 15,492 patients, the staff made 143, 589 home visits and gave 18,934 first aid treatments.

A number of programs grew from Wald's belief that illness also had underlying social causes. Three kindergartens, as well as classes in carpentry, sewing, art, diction, music, and dance were instituted. Boys' and girls' clubs had a combined membership of 2,500. In addition, staff and volunteers oversaw men's, young women's and mothers' clubs, a dramatic group with its own theater, two large scholarship funds, and numerous informal activities. In December 1912, attendance for all programs reached 28,000.

While the nursing service retained its original aim to care for the sick and to solve related social and economic problems, growth required creating an institutional structure insuring consistency in all programs throughout the city. Inevitably, the "family council" was replaced by an increasingly complicated and expensive system of communication and administration: a Board of Directors, Committee on Nursing, supervisors, rules, "Bulletin of Instruction," and extensive "carefully kept" records.

Although there were impressive campaigns to raise money, rapid growth of the settlement reached the point where expenses at year's end significantly exceeded income. Despite regular "retrenchments to the bone" and Wald's devotion to keeping "the main enterprise solvent," finances became a chronic problem. By 1917, with a caseload of 32,753 patients requiring 266,078 nursing visits and 8,880 social service visits, the deficit reached $31,456. In desperation, Wald hired a specialist to initiate a Million Dollar Fund Drive to place the work of the visiting nurses on a less "hazardous basis." Unfortunately, Wald's pacifist stand during World War I and inclusion on government lists as a "radical" caused some longtime donors to withdraw their usual contributions. While raising money remained a terrible struggle, Henry Street Settlement still represented an irresistible "stewardship" among many supporters, allowing the visiting nurse service to come into its maturity.

Beyond creating new approaches to fund raising, financial problems required constant analysis of overhead, cost, productivity, and efficacy of programs. The dilemma of having to cut programs without destroying the real effectiveness of the service produced numerous strategies for efficiency, retrenchment, ad quotas of visits/day by the nurses.

Despite financial and personal difficulties, the nursing service continued to grow through the 1920s. With 18 nursing centers throughout the city, staffed by 164 field nurses and 28 supervisors, the service was able, in 1926, to care for over 49,000 patients and to make nearly 347,000 home visits. Prenatal and preschool clinics, mothers' clubs, and well-baby consultations provided 10,567 clinic hours and 1,546 consultations for 18,330 patients. Almost 50% of the nurses' visits were made in connection with the maternity program, double the proportion of such cases in the previous decade. Half of their patients were under 5 years of age, over 70% were women, and one-third MetLife policyholders. Despite the decrease in immigration in the 1920's, one-quarter of the service's work remained focused on "Americanizing our foreign born population" through health teaching. Henry Street nurses had been caring for the black community since 1906, and by 1925 fifteen percent of the patients were black. With death rates twice that in the rest of the city, members of the black community were the recipients of "special attention" by the service during the 1920's, and the black nursing staff increased from one supervisor and four nurses to two supervisors and eighteen nurses.

Chapter 5

In 1933, after 40 years on the lower east side, Lillian Wald retired as head of Henry Street Settlement. By now, her staff of 265 annually climbed 24,750 tenement stairs, drove 140,000 miles and took 120,000 subway rides to make 550,000 home visits to 100,000 patients. The nurses cared for one-fourth of the cases of pneumonia, one-third of the maternity patients, and one-fifth of the "reportable" diseases in the city.

Wald's chosen successors were the respected social worker Helen Hall as overall head of the settlement, and Marguerite Wales, a nurse, as director of the nursing service. Wald and the board hoped to preserve the original structure of the settlement, with its interplay between social services and nursing care, through retention of a single head for all programs. By the spring of 1936, however, Wald saw the coming of conflict over power and control. Hall assumed her authority extended to all professional matters, including hiring and removing the director of nursing without the advice and consent of the Committee on Nursing. Not surprisingly, the nurses were reluctant to have a "lay person" speak for them. Hall had the stronger personality, however, and in June of 1936, Marguerite Wales resigned. Wald always believed this to be a conflict over terms rather than principles, but an acceptable compromise was never found.

Wald's goal was for social services and nursing care to be united in such a way that neither absorbed the other. She wished that these trials of transition were an opportunity to see relationships more clearly, but she acknowledged that a difficult plan had been created for any successor who did not possess the dual "personality" of administrator of social services and director of nursing. In the end, with the development of more separated social and health agendas, the united programs of the settlement simply could not continue in the absence of Lillian Wald's leadership. The original vision of an "organic structure" uniting the two had come to an end.

Lillian Wald died in 1940 at her home in Westport, Connecticut, after a long illness. In 1944, social services and nursing activities were separated into distinct entities. The nursing service moved its headquarters farther uptown, becoming Visiting Nurse Service of New York, while Henry Street Settlement has remained focused on the neighborhoods of the Lower East Side.

The Promise and the Reality: Our history from 1944 to 1993

By Shirley H. Fondiller, EdD, RN

Chapter 1

In May 1944, the Visiting Nurse Service of New York (VNSNY) became a freestanding agency committed to meeting an important community need. Fifty years earlier, its mission "to find the sick and poor and nurse them" was the impetus for the creation of the Henry Street Visiting Nurse Service. But as World War II approached, VNSNY and the Henry Street Settlement were evolving along different paths in relation to their aims, administrative concerns, needs, and community focus. When the separation occurred in the mid 1940's, both could take pride in leaving a legacy of rich experiences that would guide them into the decades to come.

Following the war, health care in the United States assumed new directions, which greatly influenced the public health arena. Extraordinary advances in medical science, increasing numbers of hospital beds, and the expansions of public health and industrial services intensified the need for professional nurses.

Americans began to exhibit considerable interest in the normal growth and development of children, problems of exceptional children, emotional aspects of pregnancy, natural childbirth, and care of geriatric patients. Venereal disease still continued, but the use of penicillin and the discovery of other "miracle drugs" signaled the advent of a new era in health care.

At mid-century, the urbanization of America and a steadily expanding population beginning with the "baby boom" of the 1940's, markedly affected the delivery of health care in the nation. Specialization emerged as a characteristic of scientific medicine, which opened the door to new knowledge and technical skills. Medical care became more efficient, complex, and expensive.

A notable trend was the rise in chronic illnesses, such as heart disease, cancer, diabetes, and arthritis. In 1950, Marian Randall, VNSNY's first executive director and a prominent public health nurse reported that approximately 16 to 20% of its home care patients were elderly people with these conditions. A few years later, she observed a new trend: "Our statistics show that grandpa is receiving a larger part of the services than in former years. Every day we are called on for more and more nursing to patients suffering from chronic diseases of middle and later life, diseases which cripple and disable." By the end of the decade, 50% of home care recipients fell within this category.

Chapter 2: The Post War Challenges

The VNSNY nursing staff provided home care to thousands of men, women, and children during the forties and fifties. They conducted classes for expectant parents, checked in on youngsters in day care centers (a function of the Advisory Service), and made visits to workers employed in industrial settings. The VNSNY also served as a learning and field site for nursing and medical students from schools in the New York area.

One of the early ventures after World War II was the agency's participation in the Montefiore Hospital Home Care Program. This pioneer project demonstrated that many services of a modern hospital could be effectively and economically implemented in the patient's home setting.

Recognizing that many of its patients experienced emotional problems, largely related to coping with their illnesses, VNSNY employed its first mental health nurse consultant in 1957. This forward looking move was not surprising in light of mental health reform in the country, viewed by experts as the new frontier in public health.

During that same period, VNSNY suffered a major disappointment when the Metropolitan Life Insurance Company terminated its contract of long standing. In citing the main reason for its withdrawal, MetLife expressed its belief that voluntary sickness insurance plans would increasingly include nursing benefits. The fact was, however, that even with the proliferation of private prepaid health insurance plans in the forties, few companies considered home services essential. Nevertheless, the participation of VNSNY in an experimental effort with Blue Cross in the early 1950s produced positive outcomes, and resulted in expanding the amount of service through hospital home care plans. The MetLife departure was offset by the City of New York, which began to purchase increasing amounts of services for sick people at home through its Department of Health, Welfare and Hospitals.

During the 1950s, certain changes became necessary in the nature of the agency's services. Nursing visits were greatly affected by emerging medical advances, such as the introduction of the Salk vaccine to prevent poliomyelitis, new drugs and other therapeutic measures for tuberculosis patients, and oral medication and improved equipment for people with diabetes. Although polio cases decreased, home visits still continued with 20% of them made to orthopedic patients over age 21 requiring rehabilitation.

In addition, the closing of specialized hospitals where many tuberculosis patients had been housed tended to add to the home caseload, but these visits eventually declined. Diabetic patients followed a similar pattern and with the number of visits dropped to half of what they had been. Although people with heart disease and circulatory disorders constituted the largest number of cases seen, some decrease was observed with oral medication replacing hypodermic injections.

At the end of the fifties, Miss Randall announced her retirement. For fourteen years she had successfully directed VNSNY through its nascent period as an independent body.

Chapter 3: The Great Society: Impact on VNSNY

On June 1, 1959, Anna M. Fillmore began her new post as executive director. Fresh from the National League for Nursing where she was its first general director, this well-known nursing leader and former VNSNY assistant director arrived on the verge of a decade that would see some of the greatest social change in history.

During the 1960's, continued population growth, technological advances, and new social values created changes in the health professions. The public had become increasingly health conscious and more acutely aware of the social and economic penalties resulting from illness. Additionally, the concept of the patient's right to health care assumed new significance with the passage of the Comprehensive Health Planning Act of 1960, which recognized that the "fulfillment of our national purpose depends on promoting and assuring the highest level of health attainable for every person." Two years later, the Manpower Development and Training Act authorized funding for training auxiliary workers for health care services.

At VNSNY headquarters, Anna Fillmore observed a resurgence of interest in the care of patients in their own homes. She cited as the main reason the rapid growth of the elderly population and their ability to maintain themselves through social security.

In 1962, the agency received a three-year grant from the U.S. Public Health Service (USPHS) to establish a Home Aide Program. The project's purpose was "to provide, in conjunction with nursing care, those additional personal housekeeping services which would permit patients to cope with their afflictions more effectively in their own homes." Designed to aid the aged and chronically ill, the program began in Queens and was extended to the Bronx and Manhattan by the mid-1960s. Although auxiliary personnel had been employed in hospitals for some years, the home aide (later changed to home health aide) represented a new type of worker in public health.

Focusing on future as well as present needs, Miss Fillmore deliberated over new challenges in health care and attempted to find ways to streamline agency operations. The pervasive nursing shortage greatly affecting staffing, which continued to be unstable at the time. Many public health nurses were young women who left for marriage and motherhood. Nurses who developed specialized skills in research, mental health, maternal and child health, or rehabilitation nursing often moved to other agencies or the universities.

One effort in Miss Fillmore's plan to cope with the continuing nursing shortage was a study, also USPHS funded, to determine how nursing personnel were utilized in VNSNY. The results revealed that visiting nurses spent an average of 12.5 minutes for travel, 19.1 minutes in preparing and following up on telephone calls and paper work, 31.9 minutes with a sick patient, and 37.4 minutes with a new mother and baby.

In 1964, VNSNY's nurses operated out of six district offices in Manhattan, four in the Bronx, and three in Queens. Miss Fillmore's productive five-year tenure had come to a close, and Eva Reese, a national figure in public health nursing, was appointed to the top administrative position. At the time, the field staff consisted of 169 full-time nurses and therapists, which represented the highest number in fifteen years. Visits had increased as well due to the rapidly growing elderly population and the early discharges of new mothers from the hospital. The service recorded a total of 264,699 annual visits.

Mrs. Reese characterized 1965 as a "transition year" because of the pending impact of the nation's most important health legislation. The recent passage of the Social Security Amendments was a major legislative milestone in giving the federal government responsibility in the financing of health care for its citizens.

Title 18 established the Medicare program for persons 65 years and over. Benefits were available to all citizens who qualified under that program, regardless of their income or need for medical care. In some ways, Title 19, which established the Medicaid program for low-income persons in need of medical care, showed an even greater sense of responsibility on the part of government. Five years after it was introduced, Medicaid required states to include home care activities.

Once implemented, Medicare and Medicaid (through the New York State program) proved to be a financial as well as social blessing because benefit payments helped to reduce the serious gap between income and expenditures that had plagued the agency for several years. By 1969, the agency showed an excess in non-operating income to offset the previous deficit. Within a few years, however, government cutbacks reversed the trend and agency deficits reappeared.

As a result of Medicare, home health aides became a familiar part of the health care team. Their growth was remarkable, showing a rise in visits from 45,636 in 1967 to 106,568 the following year. Medicare affected about 80% of home health aide hours and 53% of all nursing visits.

During the late sixties, VNSNY also sought patients through non-traditional approaches. Mothers' and parents' classes and visits to day care centers were discontinued. In an experimental hospital program, an agency staff nurse visited each new mother on the maternity unit, taught infant care, and identified families for follow-up visits.

Another initiative was the single-room occupancy hotel project, which gave care to a large group of needy people, many elderly, who were unable to look after themselves. Within a few years, VNSNY provided services in six such living quarters, with nurses working side by side with social workers, physicians, psychiatrists, home health aides, and many caring volunteers.

Chapter 4: Expanding Roles and Services

During the seventies, cost containment became the watchword. New patterns of health care delivery emerged, with health maintenance organizations replacing the regional medical programs introduced a few years earlier. In 1973, federal requirements for HMOs mandated the provision of home health care. Health professionals also experienced changing or expanded roles. In the nursing field, the nurse practitioner in primary health care came on the scene and, in time, this worker became a significant force in community nursing.

The evolution of the nurse practitioner movement was consistent with beliefs expressed in an important statement of the federal government on extending the scope of nursing practice. Eva Reese supported this concept, pointing out that staff nurses at the agency had requested further training to expand the range of their duties and responsibilities. Increasingly, these nurses, in the tradition of the Henry Street pioneers, were drawn to helping people whose lives were circumscribed by illness, poverty, fear, and ignorance.

In 1972, two VNSNY nursing administrators collaborated with Cornell University-New York Hospital in designing an intense and practical one-year program for federally-funded family nurse practitioner training project called PRIMEX. Four agency staff members were appointed to the faculty and three staff nurses participated in the first group of students. By the end of 1974, nine Primex-trained family nurse practitioners were serving on the agency's staff. Currently, nurse practitioners in New York State perform in a specialty area of practice in collaboration with a physician. They provide primary care in the community, diagnosing illness and physical conditions. Most nurse practitioners are prepared in university graduate programs.

In light of the changing health care picture and the anticipated trends, Mrs. Reese saw the need to assess the agency's status and define its direction for the future. She envisioned a multi-service organization, requiring a substantial expansion of programs and an expert staff of health professionals. She projected the following services that were eventually realized: skilled nursing, social work, rehabilitation services (physical therapy, speech therapy), mental health consultation, maternal and child health, nutrition, a more comprehensive home health aide program, and sources for equipment and facilities for transporting patients to clinics and hospitals.

In sharing her thoughts with the board of directors, Mrs. Reese pointed out that a comprehensive approach "may service far more patients as a reasonable alternative to institutionalization." The plan, she continued, would free hospitals for the acutely ill, reduce costs to patients and taxpayers, and give people the assurance and comfort of the family circle. The agency's grasp of the future was mirrored in 1973 by two pieces of New York State legislation: the Lombardi Bill and the Cook Bill. Under the Lombardi Bill, the responsibility for establishing and regulating home health agencies was placed within the state department of health. The law required insurance carriers to make home health services available to purchasers of hospital insurance.

The Cook Bill classified homemaker or housekeeper services as reimbursable items under Medicaid when ordered by a physician and supervised by a registered nurse. This legislation also created a shared responsibility between nurses and social workers, which VNSNY viewed as a fine opportunity to strengthen community health services.

In the same year, the agency contracted for the first time with a New York hospital to make VNSNY the primary provider of services needed by discharged patients. By 1993, VNSNY reported agreements with 23 New York hospitals for home care. In some of the institutions, hospital-based agency nurses assist in discharge planning and coordinate follow-up care in the home.

In the mid-seventies, a project was initiated with New York City's Comprehensive Planning Agency to determine the services needed at home by the chronically ill, the costs, and reimbursement under existing third party arrangements. Another project, funded by the City's Human Resources Administration, aimed to explore the social and financial needs of the elderly at home.

Chapter 5: New Programs, New Health Programs

In his state of the health message in 1980, New York's Governor Hugh L. Carey called for a continuing effort to "humanize treatment through such programs as home health care." The new decade heightened the stature of VNSNY when it received approval from the state department of health to launch a pilot project. "Nursing Home Without Walls." Made possible by the Lombardi legislation, the effort aimed to show that comprehensive long-term home care could be provided at 75% of the average cost of a skilled or intermediate care facility.

Within a few years, the Long Term Home Health Program (or the Lombardi Program) was well established, with teams of health workers giving medical and skilled nursing care and supervision, personal day care, housekeeping services, social day care, social transportation, and home improvement and maintenance. The program took many elderly people out of the nursing home, giving them a new lease on life instead of "waiting in fear of being put away."

The agency also began participating in a novel family-centered demonstration program of the Maternity Center Association's Childbearing Center. In this homelike atmosphere, mother and infant were discharged after 12 hours. On January 15, 1976, Ian Sipher Freedman officially became the center's first birth. On hand to provide care at home was VNSNY's Bernadette Turner, a public health nurse who made follow-up visits to Baby Ian and his mother in their home. VNSNY nurses are still involved with this program.

In 1976, Eva Reese handed over leadership to Anne-Marie Thom, a former public health nurse and supervisor with the agency, and she, in turn, announced her retirement in 1982. VNSNY celebrated its millionth visit in the same year. During her term, the agency expanded its rehabilitative and social services, and developed long-range planning assisted by the executive committee of the board.

Mr. Thom's successor, Elsie J. Griffith, assumed her new position as chief executive officer, coming to the agency with a long track record in public health nursing. Prior to her new position she was executive director of the Dallas Visiting Nurse Association. From the outset, she cited one of her concerns as "working children" with aged parents at home. "Our country is growing older," she said, adding that statistics are meaningless when "it's your mother who needs help."

During this period VNSNY was faced with many key issues, but none more critical than cost-effective care. These concerns intensified with the implementation of the Social Security Amendments of 1983, affecting the entire health care industry. Under the law, a prospective payment system (PPS) would be established based on 467 diagnosis related group (DRG) categories that allowed pretreatment diagnosis billing categories for almost all hospitals reimbursed by Medicare. Although the effect of DRGs on acute care settings was thought to be great, some experts believed that the greatest impact would be on home health agencies.

Three years after the Medicare PPS was implemented, the U.S. Senate Special Committee on Aging noted that hospital discharges to home health agencies increased by 37%, while some slowing of home health services occurred. In 1987, cutbacks in Medicare coverage of home care services compounded the effects on DRGs. While hospitals sent patients home sicker and quicker, Medicare was denying the more intensive care they needed. The PPS continues to leave its mark on VNSNY, which has to assess its services in light of earlier hospital discharges and more acutely ill people.

The reimbursement policies that developed in the early 1980s also contributed to patients' anxiety about whether they were receiving quality care in the home. As a result, minimum safety standards for home care providers were enacted by the federal government. In 1987, the National League for Nursing created the Community Health Accreditation Program (CHAP) and charged it with establishing the highest standards in the industry. Agencies accredited by CHAP meet all the conditions of participation in the Medicare program. Since the program began, VNSNY is the only CHAP-accredited, certified home health care agency in New York State.

During the eighties, the agency took a dramatic step when it instituted a corporate structure forming four subsidiaries: VNS Home Care, Partners In Care, Family Care Services, and the National Center for Home Care Education and Research (later discontinued). VNS Home Care was designed to provide acute and long-term care, maternal/child and pediatric care, hospice care, and prevention. Through a case management approach, a primary care nurse working with the patient's physician coordinates a range of services with a medical social worker, rehabilitation therapists, and other specialists. Home health aides and housekeepers take care of patients' routine needs, while an active cadre of volunteers offers companionship to patients.

Toward the end of the decade, the maternal/child health and pediatric care program (MCHP) developed "First Steps," a project coordinated with Harlem Hospital to deal with substance abuse problems of mothers and their babies. Before long, the MCHP became the fastest growing service within VNS Home Care.

In 1989, the VNS Hospice Program, also part of VNS Home Care, reported that 263 patients were admitted that year, with 98% of all care provided in the home. VNSNY's concept of "hospice" focuses on the comfort and support of the terminally ill, rather than on the physical setting itself. The emphasis is on care designed to meet medical, social, and spiritual needs.

Partners In Care, a for-profit subsidiary, was established to integrate a home health aide service that had been provided through contract arrangements into one controlled internally. Through a computer scheduling system, it matched the particular skills and experiences of certified home health aides with patients' needs. Today, VNSNY employs nearly 1,400 certified home health aides.

Another subsidiary, Family Care Services, was established to manage a contract with New York City's Human Resources Administration. Later, it added Meals-On-Wheels to the list of services. Under a contract with NYC Department of the Aging, the program provides meals to residents in Astoria, Queens, and neighboring communities. Today, Family Care Services also provides home attendant services to residents of the Bronx and Brooklyn.

Sophisticated technology is one of the many comprehensive services now offered by expert teams for complex home care needs. VNSNY nurses also work in the home with special equipment to care for critically ill patients, such as ventilator-dependent children.

The AIDS epidemic escalated sharply during the 1980s and, by 1989, visiting nurses were seeing almost 600 adults and children on a daily basis. Within four years, the number soared to a census of almost 1200. VNSNY is the largest home health care provider for AIDS patients in the country. Through VNS Home Care, various programs have been initiated to assist people with AIDS and HIV-related illnesses, including the At-Home Options Program, which offers a full range of clinical and personal services. Another effort, funded by the United Hospital Fund and the New York Community Trust, is the AIDS Mental Health Demonstration Project, which provides psychiatric services to HIV-infected persons.

Chapter 6: Prospects and Retrospect

In its centennial year, VNSNY can marvel at the phenomenal growth of the health care industry while reflecting on its own contribution over many decades of service. In 1991, Board President Carl H. Pforzheimer III noted that access to health care as well as quality care could be assured for a disparate population. He said: "One measure of the agency's success in meeting the health care needs of children, adults, frail elderly, and people with AIDS and TB...is the dramatic expansion of services to the poor, the uninsured, and underinsured."

Today, VNSNY continues to be financially stable. Carol Raphael, a former executive deputy commissioner with the New York City Human Resources Administration, joined the agency as its chief executive officer in September 1989 on Elsie Griffith's retirement. Keeping pace with the latest developments in health care, Ms. Raphael has maintained a busy agenda, giving testimony on home care before congressional committees, addressing a subcommittee of Hillary Rodham Clinton's task force on health care reform, and working closely with staff to advance the agency's goals.

Created in the agency's centennial year, the Center for Home Care Policy and Research will add to knowledge about home and community-based care. Ms. Raphael points out that the center will develop new areas for study as well as build on various research in progress, such as pediatric asthma, AIDS, and mental health among the homeless.

Another project recently instituted is the development of a model for a community nursing organization (CNO), made possible through a grant from the federal Health Care Financing Administration. In 1992, the VNSNY was selected as one of four sites in the nation. The CNO will blend the concepts of community health nursing and managed care into one model, to test whether nurses managing and coordinating care of Medicare-enrolled beneficiaries will be able to contain health costs and improve health outcomes on a fee-per-patient payment system. Nurse practitioners and clinical specialists will be available around the clock to answer questions, as well as have ongoing personal contact with patients in homes, churches, shelters, or wherever they live. This can be viewed as traditional public health nursing with the look on the nineties.

The history of the Visiting Nurse Service of New York has been told through its unwavering mission and the performance of a visionary leadership. The promise of bringing health care services into the home and community to people in need has become a reality in an ever-changing world.

If Lillian Wald was alive today, what would her thoughts be a hundred years after she began her remarkable quest? Carol Raphael considered the question recently: "Lillian Wald would be proud of our ability to be flexible and to adapt to a fast-changing environment."

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