As the drama inherent in a new administration and congress unfolds, it is important that visiting nurse agencies (VNAs) remain front and center. In fact, with a healthcare delivery system on the brink of near collapse, front and center is where VNAs must be, providing the very best in healthcare.

Last year, the Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey (Shea et al., 2008) indicated that 90% of the respondents called the healthcare delivery system broken and in dire need of a major overhaul. To the idea that incremental tinkering would forestall the waiting catastrophe of runaway costs and diminishing value, these key leaders gave a huge "thumbs down."

But, really, a major overhaul? Didn't we learn in the early 1990s that Americans would only digest incremental change? At that time, health spending was only 12% of our economy. Today, it's at 18% and well on its way to 20% within the next decade-well over $4 trillion in healthcare spending. This trajectory may well force huge, not incremental, change. Pocketbooks are being squeezed, more people are uninsured, and we are failing to meet the value promise-health outcomes are suboptimal, patient satisfaction is middling, and unexplained racial, ethnic, and geographic disparities in treatment are staggering.

In response, some call for universal coverage, whether through a single-payer or a market-driven approach. Still others demand more cost or price controls of the variety that made managed care such a villain in the 1990s. More often now than ever before, many experts point to the need to focus on the minority of patients, namely those with multiple chronic conditions, who drive the majority of costs. It's a complex series of choices, and the debates ahead will be fierce.

But, the Commonwealth Fund survey points to a key area of agreement-that more patient-centered primary and preventive care has to be the future focus of our healthcare system. While that seems obvious, lobbyists supporting institutional-based care are formidable advocates, and re-tooling the system will be extremely difficult to achieve. I should know; prior to joining the VNA family, much of my career was spent in these parts of the system-Medicaid, hospitals, and managed care. That might make eyes squint with suspicion, but be assured, having traveled the country, meeting VNAs, and seeing agencies in action, I am a convert-the born-again type who embraces what he sees with wonder, admiration, and inspiration.

I truly believe VNAs can help drive the fundamental reforms that Americans are demanding. After all, who are better than VNAs-the people who helped develop community-based public health and prevention-to make the case that a devotion to patient-centered home and community-based care improves results? It's what VNAs do everyday. VNAs provide front-line community-based primary care, even when Medicare, Medicaid, or anyone else won't pay for it. Who better than VNAs and their clinical teams to step forward and take even more responsibility for, and receive the recognition for, managing the care of chronically ill Americans?

When the policymakers look around for a resource to build a stronger primary care delivery system, whom should they trust? Clearly, primary care physicians need to be part of the equation. But we know that even the best efforts to expand their supply will leave us short of physicians. If we're going to improve primary and preventive care, and build significant capacity cost-effectively, we are going to have to pull in the universe of family caregivers and physician-extenders and, more importantly, pull them in through existing organized entities that already have the infrastructure to deliver care and family caregiver support and training in our communities and in our homes-entities such as VNAs.

Home-centered healthcare, and the patient empowerment that goes with it, is clearly on the horizon as a way to deliver a wide continuum of care cost-effectively-from primary and preventive care through to postacute and chronic and rehabilitative care. Again, who are better than VNAs to be at center stage in implementing the home-centered care concept?

As bullish as I am on the central role that VNAs must play in a restructured healthcare system, I'm not naive about the work we must do to win and keep the coveted role of "community health superstar." To get there, we'll have to speak out more often and with sound and solid data in Washington about all we have to offer. While of course we'll keep fighting for what we already have from Medicare, we must also, and with equal if not greater vigor, push Washington to expand its investment in what VNAs do-to look beyond the narrow view of the current home health benefit to a more comprehensive benefit that truly responds to the broad needs of the chronically ill patients that VNAs serve with such distinction.

We have to be prepared to demonstrate that our unmatched capacity for care coordination and prevention can help save the system hundreds of millions of dollars, and that in exchange, a federal investment in our agencies, nurses, and technology, will pay for itself many times over.

We have to help Washington understand that we embrace nonprofit status for a reason-because we are driven as charitable organizations to serve communities in ways that no one else does-that VNAs take all patients, and that without us, hundreds of thousands of Americans would lose access to vitally needed healthcare.

Our work in Washington is necessary, but it's not sufficient to capture the limelight. We also have to continue thriving as diversified, broadly supported community organizations. VNAs are already venturing into a wider range of healthcare and related services-into immunization programs, private-duty nursing, corporate health programs, hospice services, even federally qualified health centers, and more. Communities are reaping the benefits of these extended services, and as more people are reached, the more indispensable VNAs become and the more often communities turn to them to meet healthcare needs.

As the show continues, I fully expect that the VNAs will continue to outperform their counterparts in the healthcare system in the quality and value of the care they provide, that communities will continue to applaud VNAs' efforts to provide high-quality care, and that they continue to draw on their services for strength, healing, and comfort.

REFERENCES