The home health care delivery system is facing challenges that threaten its survival as well as its very essence. Currently, the federal government provides the threat of disaster for home care patients, staff, and organizations. The dangers are palpable and very real. Although the immediate survival threat is fiscal, there are two other areas which have the potential to be equally devastating. The first is reduced, in some instances absent, patient access to care at home. The second is the flight of professional and paraprofessional personnel from home care.
The origin of "community nursing" can be traced to Charleston, South Carolina, in 1813 where the Ladies Benevolent Society determined that its mission was to feed, clothe, and nurse the less fortunate in the city. The term public health nurse was first used by Lillian Wald in the 1890s when the Henry Street Settlement was founded. Lillian Wald and Mary Brewster are credited with organizing and providing community health care as a professional nursing practice. Today, the settlement is known as The Visiting Nurse Service of New York, the largest home health care organization in the United States (Schulmerich, Riordan, & Davis, 1996).
In 1909 Wald was successful in convincing The Metropolitan Life Insurance Company that it could appreciably reduce the payment of death benefits if it would support home nursing visits to enhance patient recovery and positive outcomes. By 1916, 9.4 million insurance holders in 2,000 cities were the beneficiaries of visiting nurse services as part of their policy
HOSPITAL-SPONSORED HOME CARE
Montefiore Medical Center created the first hospitalsponsored home health agency in 1947. Initially, Montefiore was a home and hospital for the chronically ill (Schulmerich, Riordan, & Davis, 1996). The wait to be admitted to the hospital was sometimes 6 months and the cost of care in 1947 was a staggering $25.00 a day. The leadership of the hospital recognized something had to be done to relieve the bottleneck of patients awaiting admission. One of the solutions was to design and provide home care to patients who met specific criteria. Aside from relieving the bottleneck, there was a distinct financial benefit. The cost of home care was $2.50 per day, one-tenth the cost of a hospital day (Cherkasky, 1948).
Grant funds from the American Cancer Society and the New York Heart Association were used by Montefiore to demonstrate that chronically ill hospitalized patients could be appropriately cared for in their own homes. What came as a stunning surprise was that some patients who had "wasted" in the hospital actually improved significantly at home (Rossman, 1956). Montefiore's experience was the genesis of hospital-sponsored (hospital based) home care departments and has been successfully replicated throughout the United States and in many foreign countries.
THE EFFECTS OF MEDICARE AND MEDICAID ON HOME CARE
The enactment in 1965 of Title XVIII (Medicare) and Title XIX (Medicaid) of the Social Security Act changed home care forever. Medicare home care as a benefit under Part A became a vehicle to allow care for patients at home rather than in a costly hospital bed. A significant limitation in the Medicare benefit was, and continues to be, the lack of a long-term home care provision. In order for a person to utilize home care services under Medicare, only intermittent care with finite limits can be provided. The expectation is that care will be restorative with a defined end point and therefore not chronic in nature. There are a few exceptions to this rule-an example is insulin administration to a blind diabetic.
After the nationwide implementation of diagnosis related groupings (DRGs) in 1985, the expenditures for the home care benefit grew particularly alarming to the federal government. Figure 1, Growth in Home Care by Visit Volume, demonstrates the reason for the government's concern. …