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But where managed care dictated the number of nursing visits and required nurses to get authorization for everything they did, prospective payment gives nurses more freedom to decide what they want to do to meet the patient's needs with the resources they have, Humphrey said.

Because nurses must exercise their own judgment more than they ever did in the past, proper, up-to-date information on patient care, based on evidence rather than tradition, has become extremely important, say those involved in managed care.

"We need to let go of all the old rules of home care delivery and see what's going to get our patients better quicker," said Paula Milone-Nuzzo, Ph.D., RN, FAAN, professor and associate dean for academic affairs at the Yale University School of Nursing in New Haven, Conn.

Specialized care

Many agencies now use advanced practice nurses, including specialists in wound-ostomy, diabetes, cardiac care, pulmonary care and gerontology, Humphrey said.

Specialists may be used as consultants who stay in the office and work with visiting nurses on specific questions, or they may accompany the visiting nurse on a first visit to set up care, then offer assistance or answer questions as needed.

Milone-Nuzzo also sees a role for LVNs, who could do follow-up routine visits for people with chronic illnesses who are stable but still need some help, freeing the RNs to see more seriously ill patients. "But the LVN has to work in partnership with the RN," she said.

Home health agencies now regularly send out physical therapists, occupational therapists, speech therapists, social workers and home health aides, as well as nurses. Nurses often act as case managers, coordinating a detailed system of care. The documentation for this increasingly complicated system of care also has increased in the last five years, and many nurses find they spend more time on the phone or completing paperwork than they spend with patients.

"There's always been a lot of paperwork in home care, far more than in most other areas of nursing," Suther said. Admissions and discharges are especially tedious, home health nurses said. But because their schedules are so flexible, many say they do the paperwork at home, rather than stay late at the office.

New technologies like handheld computers are helping nurses to complete their documentation in the field, Suther said. Nurses at her agency also use digital cameras to show pictures of wounds to physicians or specialists. Some patients have machines in the home that take vital signs, test lung capacity and monitor glucose. Patients are scheduled to start using home electrocardiograms.

Computers and other monitoring tools are expected to become more important in the future, Suther said, as more people become familiar with them and install the high-speed lines necessary to make them work.

A challenging course

Although many aspects of home care have changed in the last few years, what makes it most different from any other type of nursing care-the uncontrolled environment-has remained a constant. Nurses never know what they will encounter when they go to a home.

Lovejoy has entered houses in dangerous neighborhoods accompanied by a security guard. She has visited homes to find that the patient had been dead for at least a day and no one knew about it.

Evelyn Trone, RN, is the administrator and director of nursing for the Yuma, Ariz., office of Nurses Network, a home care agency. Her small branch agency, just 20 minutes from the Mexican border, treats elderly winter visitors, Mexican farmworkers and American Indians from two nearby reservations.