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When Denise Lovejoy, RN, rings the bell of a tidy stucco house in San Francisco's Sunset district, a wizened man in his 90s buzzes her in. Lovejoy, a home care nurse for the Visiting Nurses and Hospice of San Francisco, is making a final visit to the man's wife. The 92-year-old woman recovering from surgery is the sort of patient that home health care professionals are seeing more often these days.

The woman had a hip replacement and spent a few days in the hospital, followed by a month in a skilled nursing facility. She is receiving physical therapy to help regain mobility and nursing care for pressure sores she developed during her recovery.

After eight visits spanning about a month, the sores are healing well, Lovejoy notes. "You have delicate skin," she tells the thin, white-haired woman, who had greeted her in an elegant, red dressing gown and earrings.

"It's just old," the woman insists, her eyes twinkling.

Lovejoy takes her blood pressure and pulse, then listens to her lungs. She tells the patient's husband what a great job he is doing taking care of his wife. She tells them what to watch for and insists that they call if they have any concerns. Physical therapists will continue to visit, she explains, but this will be her last time.

"I'll miss you," the woman says.

Later, driving through Golden Gate Park, Lovejoy says she feels confident discharging the patient. She has to be. As a home care nurse, she knows there will be no new shift to follow up on her assessment, no call button the patient can push if something goes wrong, no physician to summon if some minor condition becomes worse.

"There's nobody else to follow up but you," she said. "You can't just go and do the task. You have to be open to what else is going on."

On their own

As field workers, away from direct supervisors and hospital physicians, home care nurses have always had a certain amount of autonomy. But recent changes in the system of reimbursement for home visits have forced them to become careful case managers, working as a team with the patient, the patient's family and other nurses, as well as therapists, social workers and physicians. They must fill out reams of paperwork. They must plan from the beginning how many visits they will need to meet the health goals they set with patients. They must help the patient find and use community resources like meal services, if needed. They must teach the patient and family members how to do much of the health care for themselves.

Home care or visiting nurses have been caring for the sick in their homes since the 1880s, when wealthy people hired private duty nurses and the poor crowded into hospitals, where many died of infectious diseases. Visiting nurse associations began caring for the poor in their homes. Most of these early patients were new mothers or young people with communicable diseases like tuberculosis.

As contagious diseases disappeared and people began living longer, home care gradually shifted its focus to the elderly and people with chronic illnesses, such as heart disease, lung disease and diabetes. Medicaid and Medicare began covering expenses. Technology such as portable ventilators allowed nurse specialists to set up mini-hospital rooms in patients' homes. Therapists and social workers began visiting patients at home to help them with needs other than nursing care. Visiting nurses began working with community agencies to make sure homebound patients were fed and properly cared for.

Early discharges from hospitals gave home care nurses a new role as continuing care providers, taking over where acute care left off. As more elderly people opted to stay at home for as long as possible and nursing home stays became more temporary, home care nurses began seeing older and sicker patients.

The two fastest-growing age groups for her home care agency are people older than 85 and people older than 100, said Mary Suther, MPH, RN, president and CEO of the Visiting Nurse Association of Texas and chairwoman of the board of the National Association for Home Care. Suther's nurses routinely treat people with heart failure, high blood pressure, diabetes, fractures, strokes and injuries from accidents. "Most of our patients have more than one problem," she said.