The Home Health Primary Nurse cares for a caseload of home health patients by evaluating the patient for appropriateness of home health and developing the home care plan in conjunction with the physician. S/he educates patients, families, caregivers and community providers to safely perform care. S/he provides follow up by evaluating effectiveness of the home care plan, and monitoring patient/family’s response to the plan. Each Home Health Primary Nurse belongs to a geographically organized work team. The Home Health Primary Nurse also identifies performance improvement and home health standard of care initiatives, and assists to design or implement programs to address needed changes.