Nursing homes: Past, present and future

Judah L. Ronch, PhD

The ancestors of the modern nursing home were the almshouses of the colonial era. Over time, settings for the care of the dependent and vulnerable elderly had names like “homes for incurables,” “home for the aged and infirm” and “veterans homes” and were often run by fraternal and civic organizations. By the early and mid-20th century, nurse-owned and -operated small convalescent homes were common. In the 1950s, concern about the quality of nursing home care and the desire for healthcare reform led to the passage of the Hill-Burton Act, which funded new nursing home construction with the proviso that in order to get the money, the nursing home had to be affiliated with a hospital. Large nursing homes, like those we know today, became the standard. Because acute-care hospitals were considered the epitome of good, scientifically based medical care, the so-called “medical model” came to be equated with excellence in long-term care.


Now, in 2011, we have reached a point in our history where new directions and innovative models are called for. Multiple stakeholder groups advocate for systems of care for our dependent population that are grounded in more humanistic values and more realistic economics. This is especially an issue as life expectancy at age 65 has grown from an average of 13.7 years in 1940 to 19.25 years in 2010. If this trend continues, by the year 2050, people may reasonably expect to live 25-30 years, on average, past 65.

We in the aging services field are challenged to help larger and larger numbers of dependent elders enjoy the highest quality of life. We’re beginning to see the development of innovative systems of long-term care that allow people to age at home and/or in the community, thus beginning to uncouple the nursing home from its roots in bricks and mortar. If this trend continues into the future, the business of the nursing home may be more virtual than physical, serving to deliver, monitor and coordinate care from a distance for many elders who prefer to remain in the community.


We at the Erickson School at UMBC were invited by LeadingAge executives to engage in a visioning exercise to imagine the LTC environment of 2061-50 years in the future. It was clear that we had to identify technology that would make support possible. We recruited an interdisciplinary team of faculty and students from the wider university and challenged them to develop an answer to the question “what will the nursing home level of care look like in the year 2061?” The team decided to feature technology that would optimize independence, promote greater social integration and enable health management. Our goal was to use technology to add precision and accuracy, and to gather and communicate a comprehensive array of information to result in person-centered decisions. We concluded that one thing technology could do in the future was to release human workers from doing many of these tasks, so they can focus on aspects of care where human engagement is most important for well-being.

The team of students from different backgrounds and majors had 90 days to imagine the environment that would support three people who had varying needs. They were told they must use current technology but could assume that it would be smaller, faster, cheaper and more available. They chose four areas of function: sleeping/rest, eating/dining, hygiene and engagement, in which dependent elders need support. The result is a display of modeling, prototyping and imagining what could be possible with advances in technology. For the students, this exhibit represents the beginning of an ongoing process at UMBC as it relates to a variety of majors, and a university-wide awareness of challenges and opportunities in our aging society.

For all of us at the Erickson School, the project brought home the fact that we might want to consider, on a more regular basis, how important it may be to bring in people from outside the field. As Peter Senge points out in his book, The Fifth Discipline,1 industries that have been characterized only by internal conversations typically come to a crisis point. His example is the automobile industry in the 1980s and ′90s-he points to that set of circumstances and reactions as an example of “groupthink,” a kind of mental limitation where people working in insular situations are reluctant to criticize current models or to take the risk of biting the hand that feeds them. But as we have seen from this work with students, there are passionate people with diverse talents who want to respond to the challenge of what care will look like when they get old. So while we have to continue to operate our services and facilities to remain viable and to serve the needs of those for whom we are responsible, we need to begin to seriously envision what the future will look like.

Even a cursory reading of a book like Physics of the Future2 by Michio Kaku stimulates both curiosity and comfort in that many of the future solutions are already available. His discussion of medical technology, computing, robotics including nanotechnology, genetic manipulation and virtual communities whet the appetite for thinking how we will provide nursing, medical, rehabilitation, social service, dining, housekeeping, pharmacy, activity and other professional skills into the future; how the opportunities and models can change; and how engagement and independence may be more available and easier to support.

So how do we begin to bring others into this solution-finding model? Have conversations about the challenges of the field with your residents who come to you from varied professions, their children who are still out in the world solving problems from their own perspectives and friends and neighbors in other fields. Present your quandaries and see what the models and knowledge from their professions may have to contribute. We can also be more open to taking interns from departments other than those focused on health or aging. In our project, the team includes students not only from Management of Aging Services, but also from Mechanical Engineering, Human-Centered Computing, Design and Interdisciplinary Studies. From their ideas and the synthesis of them, we have learned so much and gained hope.

As Schopenhauer observed, “everyone takes the limits of his own vision for the limits of the world.” Rather than become frustrated by these perceived limits in our field, let’s look outside of it and bring other professions and perspectives to our solutions team. Judah L. Ronch, PhD, is the Dean of and a professor at the Erickson School, University of Maryland Baltimore county, which offers undergraduate and Master’s degrees in Management of Aging Services as well as online and live Executive Education programs and customized industry training. He can be reached at


  1. Senge Peter. The Fifth Discipline: The Art & Practice of the Learning Organization. New York:Doubleday Business, 1994.
  2. Kako Michio. Physics of the Future: How Science Will Shape Human Destiny and Our Daily Lives by the Year 2100. New York:Doubleday, 2011.

Long-Term Living 2011 November;60(11):18-19

Topics: Advocacy , Articles