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When hospitals emerged as centers of technologically based care in the mid-twentieth century, public access was uneven. In response, the federal government poured billions of dollars into hospital expansion through the Hill-Burton Act of 1946, putting hospital care within the geographic reach of most Americans and substantially increasing the industry’s size. The governmenttransformed the industry even more fundamentally though Medicare, enacted in 1965. That program funded another expansion spurt and supplied close to half the revenues of many institutions. It fostered a technological revolution in care and formed the financial base for the rise of national for-profit chains and academic medical centers. The prospective payment system that it adopted in 1983 also altered the operational paradigm of many hospitals, rearranged relationships with physicians, and transformed the nature of medical care. Without Medicare, hospitals would still exist, but they would be smaller, less numerous, and less technologically capable.

This chapter describes the contraction of social work as intrinsic to understanding the story of nursing's expansion. The Forest Grove Elder Services' mandate of coordination and comprehensive management seemed like the perfect setting to showcase social work's expertise. Moreover, the Grove was mandated to hire social workers—a rarity in outpatient health care. Despite its having all the right organizational conditions, the doors of legitimacy never seemed to open for social work. Exploring how this occurred provides an opportunity to consider the relationship between nursing's professional gains and social work's losses. The chapter then shows how the logics and structural conditions that legitimate nursing's expansion are related to those that justified social work's contraction. Physician absence is undoubtedly a necessary condition for nursing's expansion; however, it is not a sufficient one. One must also understand how the NPs' incorporation of social and organizational problems into the clinic came to make more sense than having them resolved within social work.

During the course of illness, many patients move between care settings. They may be hospitalized to receive some forms of medical treatment or to treat pain, symptoms, treatment side effects, or acute episodes of illness. They may also receive care in nonhospital settings, such as a nursing home, the home of the patient or a loved one, or a residential hospice. This section discusses guidelines for care transitions. It covers general guidelines for hand-offs between professionals and transfers across care settings; guidelines on care transitions for nursing home residents; guidelines on portable medical orders; guidelines on discharge planning and collaboration with nursing homes, home care, hospice, and outpatient care; and guidelines on care transitions for patients who will die in the hospital.

This chapter examines the life and writings of Superintendent John M Galt, and argues that the experience of heading an asylum in the United States South and the example of slaves hiring out prompted institutional innovation. Galt was the only American Superintendent to publicly endorse total non-restraint, reject racial segregation, and promote the cottage system of outpatient care. By showing that slavery provided the impetus for cost-saving initiatives that also maximized patients’ rights, this chapter connects the history of psychiatry with recent scholarship on slavery and modernity. Shunned by his peers in the Association of Medical Superintendents of American Institutions for the Insane, Galt tried to establish a transnational network with superintendents in Brazil and Russia, two societies that were also shaped by systems of coercive labor.

The conclusion opens with discussion of Edgar Allen Poe’s “The System of Dr. Tarr and Prof. Feather,” a satire of moral treatment. Poe was a distant cousin of Superintendent John M. Galt, and he might have based his fictional institution on the Eastern Lunatic Asylum, particularly his depiction of the attendants as African apes. This story provides an opportunity to review the ideals and shortcomings of moral therapy, and to connect the history of psychiatry to analysis of race. It is asserted that racial antipathy undermined humane asylum care and stalled implementation of successful outpatient care models. Instead, moral medicine gave way to moral hygiene and eugenics as asylum and prison moved closer together. The conclusion ends with a brief discussion of psychiatrist Franz Fanon, who drew upon his professional experiences to outline a different asylum nightmare than that envisioned by Poe.

This chapter looks at the transformation of asylum care that was initiated by the Civil War. At the Eastern Lunatic Asylum, the biggest change came after the suicide of Superintendent John M. Galt during Union occupation of Eastern Virginia. Ultimately, Galt’s death created opportunities for his professional rivals in the Association of Medical Superintendents of American Institutions for the Insane to end his experiments with outpatient care and to insist upon the creation of segregated institutions for black and white patients. In the interim, the asylum was run by a series of Union doctors and civilians with the aid of former staff, including enslaved attendants. Operating during wartime was especially difficult for enslaved staff because their legal status was in limbo, and they were liable to seizure by raiding Confederates. Wartime shortages further compounded these challenges.