The "Re-Invention" of Personal Assistance Services

No doubt the origin of personal assistance services (PAS) dates to prehistoric times, the first time a cave man got injured and his hunting buddy helped him hobble home. There his mate took over tending the wounds, nurturing him back to health and full participation in the various activities of the daily life of the clan. 2 If, perchance, the injury was life-threatening, our fellow was totally out of luck. And the same if it involved recuperation over a period of time, in the absence of long-term care. Morris, Caro, and Hansan (1998) pretty much pick up the trail from there in their survey of the historical context of home and community-based long term care. 3 Their story begins with the total reliance on family and individual charity in early Western civilization, continues through the local public authority embodied in the poorhouses established by the late 16th century Elizabethan Poor Law, and brings us up to the present social welfare system. Throughout history home care has been defined as a medical need and provided in a social welfare context. 4 Ironically, 20th century Medicaid long-term care was a program originally designed to meet the health care needs of the poor, but it has become a middle-class entitlement. Medicaid now provides publicly funded nursing home care (or home and community-based care) once individuals have divested themselves of assets and "spent down" to indigent status. The combination of the aging trend in the general population, which actually began with the Industrial Revolution, recent medical advances that allow greater numbers of younger persons to survive devastating injury or illness with severe disabilities, and the family fracturing effects of modern day geographic mobility have conspired to expand the need for home care and to make its provision more problematic. In the early 20th century scientific advances in knowledge of disease, new therapeutic interventions, increasing medical specialization, and the evolution of the hospital as primary health care institution contributed to the redefinition of health care throughout the industrialized world in the late twentieth century. 5 But it was the economics of the health care industry itself that ultimately led to the development of in-home personal assistance services. And this happened long before the recent health care trends toward managed care and cost containment efforts in the newborn conservative political climate. Gini Laurie traced "The Origins of Attendant Care Programs in the U.S." to a deinstitutionalization …