How do cases qualify for skilled nursing?

by jsilva89 (New) New

Does anyone know how exactly insurances agencies determine how patients qualify for skilled nursing private duty? I got hired by an agency that currently has about 40 cases. One trach/vent case, maybe 15 higher acuity cases, and the majority of the rest are just seizure precautions, GT, or just PO feeds or a combo of these. I was surprised how many babysitting type cases there are.

The four cases I've gone out to already are so low acuity that a regular baby sitter could've done them. Two with CP both with PO feeds, one-two meds, where working the hoyer was the biggest skill performed. One was a 3 year old with down syndrome, no skills at all, one multivitamin given and mom expected me to play with and entertain him for 12 hours while she went to the beach and got pedicures. A developmentally delayed 14 year old with seizure disorder and no documented seizure in two years years where mom expected me to peel, dice, and mash potatoes all shift to ensure meal prep for two weeks (every time I go to this case, I peel, dice, and mash potatoes) and fold all the laundry since that's "the day nurses job"... She was home all day too watching TV and performed any actual care that needed to be done like meds or daily care.

Most of them have had nursing care for years despite everyone knowing there's no actual skilled care. Also, in almost every home the mom is home all day hanging out. So how are they approved for private duty? I know the agency likes to push the notes are what gives or takes away hours from families based on what nurses write, but I've yet to see that be true because there's no way an insurance company sees "peeled and diced potatoes for pt PO feeds", "pt actively walking around, feeding self, toileting, nurse gave PO vitamin",  or "all  care performed by mom, nurse engaged in play with pt" and still give like 12+ hours of skilled care.

So how do insurance companies approve these hours?


38,332 Posts

Insurance companies approve these hours because agencies ensure that appropriate charting is submitted, not necessarily the truth.  Raise issues and you can ensure that you will at some point become persona non grata with this agency, if not, even other prospective agency employers.  You probably should tell the agency that you only want to work with the cases that will more properly use your skills.  Specifically tell them that peeling, cooking, and mashing potatoes is not what you consider appropriate.  As for the general gist of it, yes, a great deal of, if not most, extended care is nothing more than glorified babysitting.  How to cope with that fact?  All patients need some level of "skilled observation".  That is what I tell myself when nothing more than my diaper changing skills are expected.  If you can't accept this, then extended care nursing is not for you.

LeChien, BSN, RN

Specializes in Emergency Nursing, Pediatrics. Has 10 years experience. 277 Posts

I have no idea how some patients get approved for hours! ?

I would personally speak to your agency and tell them that you don't feel you are utilizing your skills enough with your case(s). They will most likely find you something more challenging.


5 Posts

IDK how insurance judges need for private nursing. I've recently returned to private duty after a long break and there definitely seems to be a big increase in low acuity cases. Low acuity used to mean GT/seizures at the least, now low acuity typically means autism or behavioral issues, eating by mouth with a CP dx ("aspiration precautions"), or just having a  diastat order even if there hasn't been seizure activity in years. Also, I guess hoyers can only be operated by nurses these days. Agency calls me all the time and when I ask what skills the case requires they say just hoyering... yeah no thanks. 

I personally like school/day program cases with hours that just cover school. Gets you out of the house, away from the parents, away from house chores, and around other people with whom you can interact with. Keeps my mind busy enough that I don't start to build up resentment towards the case for various reason. Also, school cases are usually a little more high acuity hence the need for a private nurse at a place already staffed with nurses.

Don't be afraid to turn down cases, also don't be afraid to call the agency and say you won't return after you've gone out. They likely have tons of cases and sending you to the difficult to staff cases first. 



Has 10 years experience. 3 Posts

It's actually that overseeing physician that has a lot of say in cases keeping private duty nursing. I imagine most doctors sign the 485 for re-certification without even reading it, I also imagine a lot of families when visiting the doctor play everything up and make it seem like private nursing is still necessary when it's not. There's tons of fraud in private duty and tons of cases that have private nursing, but don't need it. I've ran into many cases where apparently the kid only has bad seizures when nursing isn't around, but absolutely none with the nurse for years. I've also encountered wealthy families who pay out of pocket for nursing, when their kids have CP diagnoses and just want a nurse around to help. 

I tell agencies that I'm no where near retirement and need to keep up on my skills so I need cases with actual medical care. I refuse cases with patient who eat by mouth, who just need transferring, or are just seizure precautions. I'm not a babysitter, maid, or personal companion for entertainment/stimulation/conversation for patient or parents. In the beginning of my career, I stayed at a basic case that was really pretty much babysitting for a year. When I left and tried to find a new job I found that I gained no skills and pretty much wasted my time for an entire year spoon feeding, playing legos, and changing diapers. Advocate for yourself, its your career. Demand higher skilled cases. 

Leader25, ASN, BSN, RN

Specializes in NICU. Has 39 years experience. 1,239 Posts

Where do I send resume,could use a break.


16 Posts

This is something I’ve always wondered!

But in my neck of the woods, nurses actually turn down the higher acuity cases, in part because the agencies do not pay nurses extra for high acuity cases . My agency is starving for trach and vent nurses right now. The low acuity cases find nurses easily. 

Why work a trach and vent case when you can play leggos and hang out with a kid on seizure precautions?