First, the IOM report (2010) includes the following four main key messages:

1. Nurses should practice to the full extent of their education and training.

2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

3. Nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the United States.

4. Effective workforce planning and policymaking require better data collection and information infrastructure.

All four key messages have implications for home healthcare nurses, although the first key message may have the largest impact. Home healthcare nurses that practice to the full extent of their education and training are not likely to work in what we currently consider as a home healthcare agency (HHA). There are a number of practice models that have been tested that makes it likely that indicate healthcare reform changes will alter the way home healthcare nursing is practiced (Boult et al., 2009). For example, the implementation of a truly patient-centered medical home (PCMH) for persons with chronic illness (many American adults and most older American adults) will require home visits by nurses. At present, PCMHs that are based in primary care offices have difficulty with providing this service, as they are not organizationally structured to do so. This organizational structure issue is going to be a short-term issue, however. HHAs working with PCMHs to provide this service would be only partly effective as long as HHAs insist on continuing with "business as usual." Nimble PCMHs-those that are driven to actually improve care coordination and are paid to do so-are going to want one visit for assessment for patients at highest risk, regardless of payment incentives that encourage more visits. Subsequent visits are likely to be provided one at a time, based on patient response to the visits or health status. Like the current complaints about Medicare-managed care, there will be fewer approved home visits and the visits will require intensive assessment, interventions, and coordination. Think of your current agency's business as being 75% or 80% Medicare-managed care and the implications. (Those who practiced in California in the 1990s may remember this model.) For home healthcare nurses practicing to the full extent of their education and training, this is going to mean upgrading their skill sets to be more astute clinicians for high-level assessment, more knowledgeable about interventions, and better communicators for coordination and collaboration.

I have long worried that my home healthcare nurse colleagues focused so much of their continuing-education activities on correctly answering Outcome and Assessment Information Set (OASIS) questions and placed so little focus on the more contemporary approaches to clinical care. Have you been trained in such techniques as motivational interviewing? Do you know the most current effective approaches to patient self-management and how to tell which patients are prime candidates for your interventions? If not, now is the time to learn those skills.

Thinking more broadly about a truly seamless approach to care for home healthcare nursing would incorporate components of the existing transitional care models (Coleman & Berenson, 2004; Naylor et al., 2011) but be broader. For example, a "neighborhood nurse" (NN) could be responsible for a specific geographic area and provide primary prevention (think influenza vaccines) as well as secondary and tertiary care. Practicing to the full extent of his or her education and training, the NN would receive information electronically when one of the persons in his or her neighborhood was hospitalized with an exacerbation of chronic obstructive pulmonary disease. The NN would view the hospital record and make a visit to the hospital to assess the patient and the patient's further needs once back home. When the patient returns home, the NN would be notified electronically and schedule a home visit within 2 days of hospital discharge. At this point, the NN would calibrate what he or she saw of the patient in the hospital with the reality of the home environment, caregiver availability, and the patient's status. As part of the discharge planning, the patient would already have a follow-up visit scheduled with his or her primary care provider for which the NN would provide an electronic report of the key findings from the home visit. At this point, the NN would decide, in conjunction with the primary care provider, whether more home visits are needed or whether telehealth or telephonic care is sufficient. Perhaps there could be a network of NNs supported by a nurse practitioner who assists with managing the most complicated patients. Note that this approach captures IOM Key Messages 1, 3, and 4.

Although this approach sounds overly optimistic in light of how the current system operates, current healthcare reform is driving a number of demonstration projects to determine how to best provide the care that will attain the best possible patient outcomes. Boult and colleagues (2009) provide an overview of 15 models of care that have been tested. There are also models that are being tested for which we do not yet have results (Windel et al., 2011). The current approaches to providing home healthcare are clearly not going to be sustainable without more coordination with the rest of the healthcare system. The days of "But I'm just a home care nurse, I don't have any influence" are about to end and must end!

This leads then to the second key message: "Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression." Nursing's national academic leadership groups are forcing serious discussions with their academic colleagues about how to make this happen. For home healthcare nurses in particular, now is the time for you to push your academic colleagues to recognize the importance of home healthcare nursing practice and to push them to design educational and training programs that meet your needs. We are constrained by our history as home healthcare nurses. Home healthcare nursing "lost" its certification examination, primarily because there were so few home healthcare nurses who were interested in certification, professional autonomy, and a representative voice for specialty nursing organizations. Although certification in OASIS completion is critically important at present, at what point will clinical certification in home healthcare nursing assume comparable importance? Home healthcare nurses, many of whom were educated at diploma and associate's degree levels, are strong clinicians, but the changes in the healthcare system are going to demand additional training (think continuing education) and education (think RN-BSN or RN-MSN programs).

Am I optimistic about the future of home healthcare nursing? Absolutely! Home healthcare nurses are the only group who can put "feet on the ground" and can understand and manage the complexities of providing care to some of the most vulnerable Americans. We have a rich knowledge base about how to do this work, but we have not been very successful at telling our story. Our focus in the past decades has been short-term: fighting the government regulations, focusing on payment-all important issues. However, it has left us vulnerable to being victims of decisions made by others. Although home healthcare practices interdisciplinary care in ways that other parts of the healthcare system need to learn (our work with physical, occupational, and speech therapists; social workers; nutritionists; and pharmacists is to be emulated), home healthcare is very much a nursing practice environment. Thus our call to action, based on the IOM report, is to make our contributions clear so that the healthcare system and the patients served, all benefit from our experience andexpertise. As Bob Dylan reminds us, "the times, they are a-changing."

To read the IOM report, see http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-H.

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