Two patients one client-revisited

Specialties Private Duty

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I get paid X dollars per hour by an agency. The home that I go to there are two clients. I care for both clients. They both required the same care basically. Originally I was told that they were both approved for 4 hrs each. So, I didn't really argue about more pay.

One patient now gets more hours approved. I am told to chart the X+ hours and that means double assessments for this one. The other one is still only X. The second patient is often home ALL DAY LONG (usually out for things during most of the day), but often I have both all day long. Parents not home and even when they are they busy fighting the good fight for the patients.

When I was told to chart X+, I filled ALL my paper work out with the new hours, including my time sheet. I was paid. Week following, pay dropped to original rate. I am being told that RN's with twins (they are not twins at all) get a flat rate. I am pretty sure it ain't my small rate.

Before I email about this and raise the roof, what IS fair? AGAIN, these are NOT twins.

Specializes in Peds/outpatient FP,derm,allergy/private duty.
Thank you everyone for your replies.

I'll be interested to hear what happens. Since I only worked with Medi-caid (Medi-Cal in my state) patients, I believe they see each family member as an individual and pay the agency accordingly. I don't think the state pays them less for a multi-child discount. If such is the case they are ripping you off. I would not be happy with such a situation.

If you provide nursing care for any client "off the clock" you are also being hung out to dry legally as well. When I cared for two people, I got paid for two people. If I have misunderstood your situation I apologize in advance!

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Specializes in Complex pedi to LTC/SA & now a manager.
I'm not sure why it is necessary to pay more money for more than 1 patient. When I worked in the hospital, there were times my load was light and times it was insanely complex and heavy. The pay never changed based on my assignment.

Most nurses would be thrilled to have just 2 patients!!

In home care & private duty you are focused on a single patient because their condition or diagnosis is severe enough to warrant 1:1 nursing care. Each patient's nursing hours is billed separately and reimbursed separately. Just like if a APN or MD saw 2 children in an office visit each is billed separately and they are paid for both at full rate not at a discounted rate.

In a hospital you are not billing for nursing services like in private duty or home health. Each patient is billed at the same rate and reimbursed at the same rate. In a hospital you are not the only nurse plus you have CNAs, RRTs, security, physicians, radiology, pharmacy and other staff that helps take some of the patient responsibility even if a tiny part such as pharmacy mixing or reconstituting a compounded drug. Respiratory available for trouble shooting a vent or plugged trach. In PDN it's all on the (hopefully qualified nurse)

If you have 2 children with NG/NJ/GT feeds plus trachs you cannot split your attention. There is no back up nurses or ancillary providers like in the hospital. You cannot safely provide emergency care alone to two children at the same time. If there was a fire or weather emergency with. 5 minutes to grab the child, supplies & go bag and it takes 3.5 minutes to exit the home, which patient do you save and which do you leave behind alone. Private duty cannot be compared to hospital or facility nursing in the number of patients per nurse.

Both agencies I work have a policy 2 qualified patients in a home = 2 nurses. It doesn't matter of they are preemie twins or toddler/ preschool siblings.

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That makes sense, JustBeachyNurse, esp. about the reimbursement for each child separately. It makes no sense for the agency to just pocket that money and the nurse to do twice the work with no cut of it.

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Specializes in Complex pedi to LTC/SA & now a manager.

It's both an ethical & safety issue. In a facility one nurse can safely care for two complex patients with ancillary support. Not the same in PDN. Plus if the bill rate is $59/hr for nursing even with Medicaid, they bill $59/hr each patient but only pay $25/hr to nurse.

I know one case in my area that agency m was sending one nurse for two complex siblings. There was an emergency and parent was at work and the care for child 2 suffered plus nurse needed to accompany patient 1 via EMS since parent was not home. So parents rightfully upset, their case manager suggested a simple solution: child 1 is cared by agency A nurse and child 2 cared by agency B nurse.

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When I worked PDN and there was more than one case in the home they had the equal amount of nurses. I had a case that was a foster in a home. This family took in all of the super needy kids that no one else wanted (they were a super sweet family who appreciated us Nurses like crazy). Sometimes they had up to 3 nurses/cases at a time. We each stayed our shift and when the time was over we left. The other nurses were NOT expected to care for these children. If they expect you to care for these kids they better compensate you for it. I'd ask for another (single) case otherwise.

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I have two comments.

1. How is your agency keeping the kids safe with one nurse? When we took two complex kiddos (not vent, though) that were sibs, our agency sent two nurses as per their policy. If one gets X hours and one gets X+Y hours but no one is home for the kid with X hours except for you, how is this allowed? That would be no different than leaving a non-nursing child with the child receiving nursing care. This seems unsafe for the child and unsafe for your license.

2. How is this not fraud? If Medicaid/insurance is paying the agency the regular nursing agency rate for an LPN/RN and the agency is taking that money for services provided but only sending one nurse, how are they not prosecuted for fraud?

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Specializes in Complex pedi to LTC/SA & now a manager.
I have two comments.

1. How is your agency keeping the kids safe with one nurse? When we took two complex kiddos (not vent, though) that were sibs, our agency sent two nurses as per their policy. If one gets X hours and one gets X+Y hours but no one is home for the kid with X hours except for you, how is this allowed? That would be no different than leaving a non-nursing child with the child receiving nursing care. This seems unsafe for the child and unsafe for your license.

2. How is this not fraud? If Medicaid/insurance is paying the agency the regular nursing agency rate for an LPN/RN and the agency is taking that money for services provided but only sending one nurse, how are they not prosecuted for fraud?

^^As usual ventmommy states the important issues so well. ;)

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JustBeachy and Ventmommy, I have no idea, but it is not abnormal in my area. Twins often have one RN assigned to cases, by various agencies. It recently changed from a 1/2 time with X and 1/2 the time with XX, to an overlap in hours.

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follow the money.....

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Specializes in Complex pedi to LTC/SA & now a manager.
JustBeachy and Ventmommy, I have no idea, but it is not abnormal in my area. Twins often have one RN assigned to cases, by various agencies. It recently changed from a 1/2 time with X and 1/2 the time with XX, to an overlap in hours.

I suspect one of the area agencies may have been cited by Medicaid or the case management group, when the special children's health case manager did a home visit and saw one nurse for two complex babies. They were paying for a nurse for each child not a 50% discount for the second child and wanted 2 nurses. Each child had their own policy & authorization and honestly deserves their own nurse.

(I know one nurse complained she was paid time & a half to care for twins or triplets 5+ years ago but not sure which agency. Policy changed quickly)

Current policy for at least the past 3 or so years for these agencies is 1:1 care. Period. Only in exigent circumstances such as natural disaster such as Superstorm Sandy that devastated much of NY & NJ coastlines and physically blocked nursing from getting to/from their cases.

On the same token, If a child doesn't need 1:1 care in the special needs schools then the school nurse team can handle it. This happened recently as an assigned nurse was not doing only1:1 care but assisting other students. Parents(rightfully) went ballistic when they did an unannounced visit and witnessed the scenario. School classroom staff thought "free help".

Consider looking into your state Medicaid regulations regarding private duty nursing for complex children. One of the criteria is often requiring 1:1 care to remain in the home.

a nurse/CHHA

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Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.

I've not been assigned to the case (with two kids) that my agency has, so I don't know what the billing situation is (private insurance, Medicaid, waiver, etc.).

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"...follow the money" LOL! I am, which is why my tummy is in knots.

I am trying to hold on through the summer and then see if I have more options. As of right now, the balls are still in the air. If I were employed directly, the medicaid instructions are clear that my service is to the one patient in the home during that time. There is a whole separate section for Agencies.

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