Since Medicare began in 1965, the majority of home care has been delivered by the registered nurse (RN) prepared at the diploma, associate degree, and baccalaureate level. While other professionals such as therapists (physical, occupational, and speech), social workers, and nutritionists have been integral to the care of patients in the home, the largest home care professional workforce continues to be RNs (National Association for Home Care, 2001).

The evolution to an RN workforce has largely resulted from the home care Medicare reimbursement structure. Medicare has restricted the services of other personnel, such as licensed practical nurses (LPNs) can provide to home care patients while also failing to discriminate payment for advanced practice nurses (APNs). This has resulted in providing home care nursing in a "One Size Fits All" structure. Currently, RNs are deployed to provide home care whether the patient needs basic care that could be provided by an LPN or the specialized care that should be provided by an APN.

We are continuing to learn how PPS really works as it transforms clinical data into information with a focus on outcomes. We also know that the new Conditions of Participation (COPs) are scheduled to be released in July of 2003. This means that the Centers for Medicare and Medicaid Services (CMS) are in the process of writing and refining the COPs. The time is now for us to structure the language of the regulations and provide a reimbursement method that is based on what specific nursing professional can best help the patient meet the desired outcomes. How should this be done?

1. The nursing shortage has forced home care organizations to critically examine the way clinical services are provided so that quality care and cost savings are uppermost. Frequently agencies have had to refuse to take admissions because they did not have an RN available. Yet, RNs were performing tasks that could clinically be delegated to other providers such as LPNs, if not prohibited by the reimbursement.

2. The current Medicare COPs allow for LPNs to orient but not supervise home health aides (HHA) in the home. If that regulation was amended to allow LPNs to supervise HHA for those patients whose clinical condition is more long-term or chronic, RNs could be freed up to provide the needed care to patients requiring their expertise. This small change would result in a significant improvement in patients' access to care.

3. Many agencies are using APNs to provide more focused assessments, directly provide care, act as consultants to RNs for individual patients, and provide cutting-edge continuing education opportunities and inservices. Use of APNs in this way has allowed patients to achieve their clinical goals in fewer (although longer time in the home) visits per PPS episode.

Agencies that use the right provider for the right patient at the right time in a patient's clinical course will be much more effective and cost efficient in a system that rewards efficiency, patient satisfaction, and excellent patient outcomes. By effectively using LPNs and APNs, patients, home care organizations, and payers benefit.

We have entered a new era that requires workforce innovation to remain effective and efficient. The nursing shortage, PPS, the diversity of patient conditions and treatments, and the increasing complexity of providing nursing care in the home combine to mandate a new staffing model.

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