During the past 20 years, there has been a profound change in the use of nursing homes in the United States. The residents are older and more frail than ever before. But these institutions are still staffed roughly the same way they have always been -- with full-time nurses and occasional visits from doctors. This needs to change.

Surveys by the National Center for Health Statistics reveal that over half of all nursing home residents have some impairment in thinking and reasoning (most often as a result of Alzheimer's or similar diseases), nearly half are incontinent and fewer than half can walk unassisted. An increasing percentage of these residents are over 85.

The federal government's decision in 1983 to cut Medicare costs by encouraging earlier release from the hospital has further increased the use of nursing homes for "sub-acute" care. Thus, the nursing home today is far from what many of us may remember as a "retirement home."

With nursing home residents increasingly impaired, the level and types of skills required of the staff to provide adequate care have changed markedly. They must be able, for example, to assess the cause of subtle changes in patient functioning that may be a clue to serious acute illness. A slight change in the level of awareness in a person with Alzheimer's might be an early sign of serious infection.

Staff members also must be able to devise multidisciplinary plans to maintain functions, such as the ability to feed oneself. While those needs have altered the demands placed on a variety of professionals, the change has been most critical for nurses. Unlike in a hospital, physician involvement in nursing homes is often limited to a monthly or even less frequent visit to the patient. It is the nurses who care for these patients on a day-to-day basis.

Although there is a core of dedicated individuals working in nursing homes, more often these institutions are a last choice of nursing personnel of all types, from aides to professional nurses with master's degrees. The shortage of persons entering the field of nursing is growing worse, and it affects in particular the chronic undersupply of nurses in long-term care.

The causes of the nursing shortage appear to be numerous, with low pay and lack of respect accorded a career in nursing being most important. This is especially critical now, given the steadily decreasing number of young persons who will be entering the work force in the next decade.

What is needed, it seems to me, is a new type of health specialist -- someone who combines nursing skills with some of the basic diagnostic skills of physicians -- for the aging population. The recent emergence of geriatric nurse practioners is a promising development.

Geriatric nurse practitioners are individuals who have received advanced education, most often at the master's level, in the nursing care of elderly and disabled individuals. In addition to advanced nursing education, they also learn the basic elements of medical diagnosis and management of common problems affecting the elderly.

This combination of skills gives them a unique ability to offer the wide range of services required in nursing homes.

Major university studies, in addition to a recent comprehensive review by the congressional Office of Technology Assessment, found conclusive evidence that services provided by nurse practitioners in general, and geriatric nurse practitioners in particular, are effective and efficient. These studies have found that patients are at least as satisfied with care provided by nurse practitioners as they are with that of physicians; the results of care are equivalent, and the cost of nurse-practitioner care is often less.

Finally, the job satisfaction, opportunities for advancement and self-esteem associated with the role of the nurse practitioner enhance the attractiveness of nursing as a career.

Unfortunately, there are major barriers in federal, state and local regulations and laws, and in the nursing home industry, that severely impede the use of geriatric nurse practitioners. Medicare and Medicaid, for example, do not grant direct reimbursement to nurse-practitioners except in a very few instances. In addition, many states bar them from such basic services as physical examinations, thereby preventing them from using skills that they are clearly capable of performing.

In addition, there has been some uncertainty in nursing itself as to the appropriate role for persons who possess the combination of nursing and medical skills that are embodied in the nurse practitioner.

These barriers need to be broken down. Laws on the federal, state and local level need to recognize the abilities of nurse practitioners. The result will not only enhance the nursing profession but also will improve care for the nearly 2 million people residing in nursing homes in this country.

L. Gregory Pawlson, MD, MPH, is director of the Center for Aging Studies and Services at George Washington University. Second Opinion is a forum for points of view on health policy issus.