Access to Medicaid Private Duty Nursing Services Governor’s Commission on Medicaid Managed Care December 10, 2015

Who is the Granite State Home Health Association? A non-profit membership association representing 39 home care agencies licensed in NH. Most members are Medicare-certified agencies that provide a full range of skilled nursing and therapy services. Members also care for Medicaid enrollees, including intermittent care, private duty nursing care, and long term services and supports. Members include non-profit Visiting Nurse Associations (VNAs); and locally-owned private businesses such as Interim Healthcare, statewide; Silver Touch, Merrimack; Benda Home Care, Portsmouth

What is Medicaid Private Duty Nursing? Skilled nursing services for recipients who require more individual and continual nursing observation, judgement, assessment and interventions than available from a visiting nurse, in contrast to part-time or intermittent care, such as wound care (He-W 540) Inherently complex service or patient’s condition requires services that can only be provided a licensed nurse (as opposed to a LNA or Personal Care Service Provider) Requires continual skilled nursing services for more than 2 hours, provided by a RN or LPN Often referred to as “block time nursing” Private Duty Nursing Patients Any Medicaid recipient who has the medical necessity for private duty nursing services Most patients have complex medical needs and are technology-dependent

Medicaid Private Duty Stats Currently, 7 Association members provide Medicaid PDN services As of 12/4/2015, these agencies serve 104 patients. 32 patients are currently covered by MCOs; others will transition in February. 3609 authorized hours of service per week 769 hours (21%) are unfilled (as of 12/4) due to lack of qualified staff Medicaid PDN reimbursement to agencies: RN services -- $41.80/hour LPN services -- $38.29/hour Reimbursement rates have not been updated since July 1, 2006.

Challenges for Home Care Agencies Agencies must cover all costs associated with care with limited reimbursement. Costs Nursing wages Supervision and support of nurses Staff education and training for individual patients’ clinical and equipment needs Discharge planning – visits to hospital prior to discharge/ visits home prior to home care admission Administrative time for authorizations (4 hours +) and billing Payroll taxes, Workers’ Comp and Liability Insurance ACA employer health insurance mandate, if applicable Other overhead Poor reimbursement affects agencies ability to pay competitive wages RN pay for PDN care - $21-25/hour LPN pay for PDN care - $19-23/hour

Challenges for Nurses Private Duty Nursing is ICU work in a home setting. Nurses must be qualified, competent and confident to work independently. Each new patient requires individualized training for the nurses. PDN is usually a per diem job. Hours cannot be guaranteed. If patient is hospitalized, the nurse does not work. Home/family dynamic can be stressful. Wages are lower than other nursing positions. Other nursing jobs offer better pay and less stress.

Public Policy Issues The current low reimbursement limits the ability for home care agencies to recruit and retain private duty nurses. Reimbursement should be raised to $58-60/hour for RN care and $55-58/hour for LPN care to enable agencies to raise hourly pay for nurses. Reimbursement should be higher for overnight care. False sense of network adequacy MCOs currently contract with home care agencies that offer PDN care. But if agencies cannot cover all authorized hours, access to care is limited Rate transparency disappears when all clients move to care management. Rates are no longer published Rates are confidentially negotiated between MCOs and providers. Limits the ability of families, providers and organizations to advocate for patients Without meaningful increases to reimbursement, access to care for vulnerable patients will continue to be compromised. Patients will have no choice but to seek care in higher cost institutional settings.

Contact Information Gina Balkus, CEO, Home Care Assn of NH gbalkus@homecarenh.org 603-225-5597