North Carolina does not have enough private duty nurses to provide home-based services to Medicaid participants with complex medical needs, creating a crisis for many working families who cannot single-handedly manage their loved ones鈥� care.
The shortage is expected to worsen over the next decade. Demand for registered nurses in home health and hospice settings is predicted to surpass the state鈥檚 supply by nearly 18 percent in 2033, generated by the Cecil G Sheps Center for Health Research at the University of North Carolina.
Home health advocates say low pay has been the biggest barrier to recruiting and retaining nurses. The state鈥檚 Medicaid program currently reimburses employers for private duty nursing at .
The state budget approved last month by the North Carolina General Assembly includes a long-requested increase that, once implemented, will raise the hourly rate to $52. But state Sen. Gale Adcock believes an even bigger investment is needed.
Adcock, a Democrat whose District 16 covers a portion of Wake County, knows how demanding the job can be. A nurse by trade, she worked in home health as an employee of the Wake County Health Department in the 1980s.
鈥淣one of the budgets actually gave the increase that the industry is saying it鈥檚 going to take to make sure they have not just the supply of nurses they need but also the trained nurses that they need,鈥� she said, adding that advocates had lobbied for a rate of $65 an hour. 鈥淭his is a special kind of care that people get at home. It鈥檚 not like working at a hospital.鈥�
More than 1,800 North Carolinians receive private duty nursing services through Medicaid. Many of them, Adcock said, are unable to walk, talk or feed themselves.
鈥淭hey鈥檙e on ventilators or they need nebulizer treatments,鈥� she said. 鈥淭hey have very complicated medicines to take that have to be timed just right and have to be given in certain ways. They鈥檙e not able to communicate because they may have had a stroke, or maybe they鈥檝e had a tracheostomy or they鈥檙e on oxygen.鈥�
Some patients, she added, will 鈥渘eed this kind of support for the rest of their life.鈥�
Toll on parents
Children make up nearly half of the state鈥檚 private duty nursing patients.
Jenny Hobbs, co-founder of the nonprofit , said the shortage has taken a financial toll on parents, some of whom have been fired from their workplaces or forced to quit their jobs.
鈥淚f you don鈥檛 have reliable nursing, you can鈥檛 reliably show up for work,鈥� she said.
In 2022, the advocates鈥� group surveyed 54 parents and caregivers whose children receive in-home care. Forty-seven percent of respondents said they were unable to work because of the nursing shortage, while 17 percent said they had lost their jobs.
The shortage has also affected parents鈥� health. Many suffer from sleep deprivation because their children require around-the-clock monitoring, Hobbs said.
鈥淎 lot of these parents are providing 24/7 care, so they鈥檙e not getting sleep,鈥� she said. 鈥淲hen you鈥檙e overtired because of chronic lack of sleep, you鈥檙e gonna make mistakes.鈥�
Those mistakes, she said, can have grim consequences.
鈥淎sk any of the children鈥檚 hospital complex care teams, and they鈥檒l tell you that there have been deaths related to the nursing shortage,鈥� said Hobbs, who has three medically fragile children of her own. 鈥淚t鈥檚 unfair and sad, and it breaks my heart.鈥�
Recruitment woes
Erin Fraher, director of the , said the overall scarcity of nurses across the state has created a situation where 鈥渁ll employers in the ecosystem are competing for registered nurses and licensed practical nurses.鈥�
Hospitals often have the edge when it comes to recruitment. They usually offer better pay, Fraher said, and are generally considered by nurses to be more appealing places to work.
鈥淗ome health, long term care and mental health have typically had a harder time recruiting nurses than hospitals,鈥� she said. 鈥淣urses would rather go into a hospital or would rather go into ambulatory care than they would in home health or long term care.鈥�
In conducted last fall by the, eight out of 12 home health providers said they were experiencing 鈥渆xceptionally long vacancies鈥� for open positions. In one anonymous comment, a respondent wrote that the starting pay for nurses was $45 an hour at their local hospital.
While that鈥檚 the same amount the state currently pays for at-home nursing, private duty nurses earn far less because their employers take a percentage of that money to cover their overhead and administrative costs. Jessica Britton, a private duty nurse who works for the nonprofit BAYADA Home Health Care, that she makes $22.50 an hour.
The new rate approved by the General Assembly is higher than what is offered in South Carolina, which pays $42 to $45 an hour for private duty nursing. A registered nurse could make even more in neighboring Virginia, where the rate is $71 to $81 depending on the location.
While Hobbs is in support of North Carolina鈥檚 new rate, she worries that the additional money will never reach the pockets of private duty nurses. She said several nurses did not receive a raise from their employers after a in 2020.
鈥淭he point is to incentivize them to come into home health or to stay in home health,鈥� Hobbs said. 鈥淏ut if it鈥檚 not getting to their paycheck, then it鈥檚 not actually doing what it鈥檚 intended to do.鈥�
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