As private duty nursing (PDN) providers and advocate representatives in Virginia, we respectfully submit our concerns and recommendations for you to consider allocating federal funding provided through the American Recovery Plan Act (ARPA) to states to support Medicaid home and community based services (HCBS) to providers of skilled and private duty nursing services.

Prior to the COVID-19 pandemic, private duty nursing providers have always been instrumental in ensuring medically fragile patients have access to quality care. The care provided by these nurses enables patients, many of whom are Medicaid beneficiaries, with complex medical conditions to remain at home where studies show, and experience proves, they have a better quality of life and often remain healthier than if they were cared for an institutional setting.

The delivery of medical care in the home by nurses also creates a cost-savings to the Commonwealth. The spread of COVID-19 in institutional and congregate living settings, has made home care an even safer model of care for these incredibly vulnerable patients. Throughout the pandemic, private duty nursing providers have collaborated with hospital systems to bring patients home sooner and have worked hard to keep this population at home to reduce exposure to COVID-19.

The need for access to care has not changed in Virginia during the pandemic, yet the risk and costs to provide this care continue to place additional challenges on providers. The challenges include providing additional and new types of PPE which are not reimbursable; convincing nurses to continue to provide in-home care where they work longer hours in a setting less controlled, and less regulated than a hospital, and must do so at a hourly rate far lower than hourly rates paid by hospitals and others.

As you know, the hourly rate paid to Medicaid private duty nurses is determined using a benchmark rate that was established in 2016 through an actuarial study. The hourly rate paid today is just 80% of a 2016 benchmark rate that is well below the private and Medicare rate. Medicaid private duty nurses are being recruited by hospitals, nursing homes and now vaccination clinics. The differential in the hourly rate paid to private duty nurses has been exacerbated during the pandemic with the addition of hazard pay and/or retention bonuses that hospitals and others are offering to nurses. Private duty nursing providers simply cannot compete.

Our inability to compete has impacted patient care. In central Virginia, a 62-patient waitlist for PDN services exists. Patients on the waitlist are either receiving none of or a portion of the PDN authorized services because a nurse is not available to provide all authorized hours. A provider reported 60% of authorized hours are staffed in Richmond and 70% of authorized hours are staffed in Charlottesville. The lack of nurses also impacts the discharge of patients from PDN. Recently 8 of 13 patients discharged by a provider were due to insufficient staffing.

While we understand and recognize that the pandemic has impacted all health care providers, we respectfully ask that you consider using federal funds to provide a rate enhancement to private duty nurses caring for Medicaid patients, as you did for other home care providers including home health care workers and personal care attendants.

On May 13, 2021 we reviewed guidance from CMS articulating how state could use the 10% FMAP increase for home and community-based services and noted that the guidance explicitly states that the funds can be used to support private duty nursing services. Further, the Biden Administration has proposed an ongoing increase in funding for Medicaid home and community-based services. The availability of federal funds enables the state to provide a rate enhancement for a service that is now underpaid and creates cost-savings to the state.

We ask that as you consider our request to use federal funds to enhance the rate paid to the skilled in-home providers of nursing that care for Medicaid’s most medically fragile patients that you remember:

• Private duty nurses are jeopardizing their own and their family’s health because they are committed to ensuring their patients have the care that they need
• Nurses providing care in patient homes reduced the number of patients in nursing homes and assisted living facilities where we know COVID-19 has killed many vulnerable Virginians
• Other states, including our neighbor state, North Carolina, Washington state and others are using the 6.2% FMAP and the HCBS 10% increase to enhance private duty nursing rates. Washington state has increased the rate paid to PDN providers by $6.00/hour.
• A domino effect occurs when patients are unable to access PDN care. Without access to a nurse, family members are forced to stop working to care for their medically fragile loved ones. Unable to work, many families are forced to use other state provided social services and financial assistance programs.

We will continue to work to ensure Virginia’s most medically fragile population has access to in-home care to avoid hospital admission and nursing home placement that could create increased exposure to COIVD-19. We respectfully ask that you help us meet the unexpected and increasing cost of caring for the population.

Please feel free to reach out to us for further information or questions/discussion.

Respectfully Submitted,
Jim Melancon, Aveanna Healthcare
Tracy Colvard, Maxim Healthcare
Roberta Verville, Thrive Skilled Pediatric Care