The vision statement of the International Home Care Nurses Organization (IHCNO) is: Develop and support a vibrant world-wide network of nurses who promote excellence in providing equitable care for optimal health and well-being to patients living in their homes. What is "excellent home health nursing that provides optimal health and well-being to patients living in their homes?" To better answer this question, let's start with a brief historical analysis of home healthcare nursing.

The historical origins of home-based nursing in the United States began late in the 19^th century with the advent of the Visiting Nurse Associations (VNAs). Supported mainly by women philanthropists who cared about immigrant families living in poverty, groups of nurses banded together to bring care to these families. They developed a nursing model of care to meet the needs of this population. Each geographic location had its own nurse. Nurses developed caring relationships with their families. These relationships enabled families to trust the nurse's recommendations. The same nurse usually managed the patient's care and provided almost all the procedures and education the patients needed, which supported continuity of care.

With the advent of the 1965 Medicare Home Health Care Benefit and its requirement for physician-certified Plans of Care based on medical diagnoses, the nursing model of care was replaced with the medical care model. Since home healthcare was now supported by Medicare instead of voluntary donations, another trend emerged. Entrepreneurs went into the "business" of home healthcare and some of these agencies morphed into large corporate entities. Some of the home health agencies and corporations instituted models of care delivery to increase profits, such as increased productivity requirements, pay-for-visit compensation, and fragmented models of care in which continuity of care for patients was replaced by the efficiencies of splitting care, so different nursing tasks are assigned to least expensive caregiver.

During this trend, Medicare policy makers found they needed additional regulations to rein in costs and prevent Medicare fraud. An unintended effect of these regulatory burdens was it became harder and harder for small community-based agencies, like the VNAs, to meet the regulations and provide the care. In the 21^st century, most VNAs have been acquired or merged into for-profit agencies. Many of these agencies institute business models of care, which may be undermining the humanitarian service of healthcare. Home healthcare nurses around the world have difficulty maintaining their caring values and principles because they do not know how to maintain them within these new models of care. They are having difficulty providing the quality patient-centered care that home healthcare nurses found so rewarding.

Yet, change is inevitable. Everything evolves. Home healthcare nursing needs to evolve along with the home health industry to address societal trends and economic realities. Home healthcare nurses are professionals with the responsibility of defining standards for their practice. It is unprofessional to hand over our standards of practice to Medicare, corporations, or agencies. We need to work collaboratively with these entities to find ways to meet our nursing values/principles while addressing their needs. We need to advocate for "excellent home-based nursing practice."

This is impossible for individuals to do alone. The professional organization for professional home healthcare nurses is the IHCNO and one of its current missions is to give nurses the opportunity to reinvigorate the scope and standards for home-based nursing practice. These standards will support nurses advocating that nursing values and principles be honored by their home health agencies and Medicare. You can be part of this effort by becoming an IHCNO member (https://ihcno.org/join-us) and signing up for the Policy & Advocacy Committee.