When Stephen Holt came to Philadelphia to run the Visiting Nurse Association of Greater Philadelphia nearly a quarter-century ago, home health care was a "land of paper and pencil."

His staff had no GPS systems, laptops, or cellphones. Nurses did all their records and billing by hand, and had to call coworkers by landline.

Now, as Holt prepares to retire Dec. 31, his nurses carry laptops, and can easily see what therapists and other practitioners have done with patients. "The nurse admits the patient at the bedside and pushes a button, and the billing starts," said Holt, 66.

He is still so remarkably enthusiastic about his work that it's reasonable to wonder if he's ready to retire.

He sees more technological transformation ahead, along with growing respect for the role of home care, as private insurers and the government seek more ways to keep chronically ill patients from going into the hospital or returning there after an admission.

"Just in the last two years," he said, "there has been more of an alignment of interests" between insurers and providers. The agency also has a lot more competition - about 100 home-health companies in the Philadelphia area, compared with 30 when he began here. That reflects a greater need for home care as the population ages and families are less able to care for aging relatives.

Responding to those trends will now fall to longtime CFO Walter Borginis III, who will take over as president and CEO. He'll have a tough act to follow.

Mark Baiada, who founded Bayada Home Health Care 40 years ago, is both a collaborator and a competitor for VNA. He praised Holt as an energetic and innovative leader who was "always trying to do the right thing."

The two have worked together to lobby for better funding and regulation of home-health care. Both think it's too easy for new firms to enter the market.

Holt insists he is ready to retire. "It's time to do other things that interest me," he said. He is active in hereditary societies, including the Pennsylvania Society of Sons of the Revolution - his ninth great-grandfather was a Philadelphia physician who died in 1709.

Holt, a minister's son, grew up in Dallas and studied government at Southern Methodist University. He soon gravitated to human services, which led to his first home-health job with the VNA of Dallas.

He called being the CEO a "beautiful combination of intellectual stimulation and emotional reward. I can't think of a better way to spend one's career."

Founded in 1886, Philadelphia's VNA is the nation's oldest. Some others, Baiada said, have not survived.

When Holt came here from New York City in 1990, the VNA had an average daily caseload of 300. It's now about 2,300.

Ninety-five percent of the agency's clients live in Philadelphia. Many are elderly, female, poor, and alone. Only about 5 percent of clients have private insurance; the rest are on Medicare and Medicaid.

Under Holt, the agency established a hospice service and developed programs in wound care, mental health, disease management, and chronic care. His was the first to add visiting doctors and nurses to provide in-home primary care.

Today, patients are much sicker with chronic ailments. The big five diseases - diabetes, stroke, heart failure, coronary artery disease, and cancer - used to be quick killers.

"In 1965, those were acute care. You died in six months," he said. "Guess what. Today, those patients are living 30 years."