Private duty and private pay: care by the shift, paid by the hour.

1. Two different ways to nurse at home

Most home nursing is intermittent. A nurse drives to the home, performs a defined skilled task such as a wound dressing, an infusion or a teaching visit, documents it and leaves. Medicare-certified home health and home infusion nursing are built on that model.

Private duty nursing is the other model. The patient needs a nurse present, so care is ordered by the hour and delivered in shifts of eight or twelve hours, sometimes around the clock. The federal Medicaid regulation at 42 CFR 440.80 defines private duty nursing services as nursing for beneficiaries who require more individual and continuous care than is available from a visiting nurse or routinely provided by hospital or nursing facility staff, furnished by a registered nurse or licensed practical nurse under the direction of the beneficiary’s physician, in the home, a hospital or a skilled nursing facility at the state’s option.

“Private pay” answers a different question. It says who is paying, not what kind of care is given. A family can pay privately for a skilled visit, a twelve-hour nursing shift or an aide. Keeping the care model and the payer separate lets an agency run every combination on one set of records, as described on payer and program models.

2. The patients

The largest group is medically complex children and adults who live at home with technology: a tracheostomy, a ventilator, a feeding tube, a central line, a seizure disorder that needs a nurse’s judgment through the night. Many of these cases run for years, with the same small team of nurses.

A second group is post-acute: an adult coming home from a hospital or rehabilitation stay who needs more than a visit for a few weeks. A third is the worker with a catastrophic injury whose care is directed by a workers’ compensation carrier. The fourth is concierge care, where a family buys nursing or aide hours because they want them.

3. Who pays

The payer decides what must be authorized, what the record must contain and what document asks for the money.

Medicaid treats adults and children differently. Medicaid.gov lists home health services as a mandatory benefit and private duty nursing services as an optional one, so each state chooses whether to cover private duty nursing for adults, and how. The Early and Periodic Screening, Diagnostic and Treatment benefit, which is mandatory, covers enrolled children under age 21, and Medicaid.gov states that a state must provide any service coverable under section 1905(a) of the Social Security Act that is found medically necessary, regardless of whether the state plan covers it.

The federal EPSDT guide for states, issued in June 2014, names private duty nursing among those services. It says medical necessity is determined case by case for the individual child, that hard limits based on a monetary cap or budget are not consistent with EPSDT, and that a state may require prior authorization if it is decided for each child individually and does not delay needed treatment. Pediatric hours are therefore won and kept with clinical evidence about one child, renewed on a schedule.

The VA describes its skilled home health care as care delivered by a community-based home health agency that has a contract with VA, for enrolled veterans who are eligible for community care and meet the clinical criteria. Commercial plans and workers’ compensation carriers write their own terms, and the pattern is the same: a number of hours authorized over a period. See VA Community Care.

4. Orders, the plan of care and authorization in hours

A case starts with a nursing assessment in the home and physician orders naming the equipment and settings, medications, feeding, emergency procedures and the parameters that require a call to the physician. Together they become the plan of care the nurse on shift works from. Payers and state licensing rules set how often the plan is reviewed and re-signed, so the agency holds the interval as a dated rule for each payer.

Authorization is expressed in hours: so many hours per day or per week, for a period with an end date, sometimes split by skill level. Three numbers then matter every week. Hours authorized, hours scheduled and hours worked. Hours worked above the authorization are not paid. Hours authorized and not staffed are care the patient did not receive.

For private pay the service agreement takes the place of the authorization. For skilled nursing the physician’s orders still govern the care, whoever is paying.

5. Staffing a case: orientation, competencies and continuity

A license is necessary and not sufficient: a nurse who has never managed a ventilator is not sent to a ventilator case. Agencies keep two layers of qualification. The first is general: license, CPR, health records, background check, and validated skills such as tracheostomy care, ventilator management and enteral feeding. The second is specific to the patient: orientation in that home, with that equipment, that emergency plan and that family, signed off by a supervising nurse.

The result is a short list of nurses oriented to each patient. Families want the same few faces, and payers and surveyors ask who was oriented before working alone.

A case is a weekly pattern of shifts, maintained by exception: a call-off, a hospitalization that suspends the case, a nurse who leaves. On a call-off the first question is who else is oriented to this patient and available without overtime. If nobody is, the family covers the shift and the missed hours are recorded with the reason.

6. RN supervision of LPN and LVN practice

Much private duty care is delivered by licensed practical or vocational nurses, and their practice is supervised. State nurse practice acts set the rule, and the pattern is consistent: a registered nurse performs the comprehensive assessment, establishes the plan of care and supervises the practical nurse who carries it out.

Texas is a clear example. The Texas Board of Nursing states that the LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist or podiatrist, citing section 301.353 of the Nursing Practice Act and Board Rule 217.11. The Board’s guidance adds that an LVN may not practice in a completely independent manner, and that the proximity of supervision is not defined in rule.

In a home, where the supervisor is not down the hall, the agency meets this with a named RN supervisor for each case, an on-call RN reachable during every shift, supervisory visits at the interval the state or payer sets, and review of the shift records, each dated and signed.

7. Documenting a shift

A visit note describes one encounter. A shift record describes eight or twelve hours, and it is built from several documents that run in parallel.

The timesheet, the clinical record and the schedule must agree; a shift billed to 7 a.m. with a last entry at 3 a.m. is an audit finding. Where a Medicaid program requires electronic visit verification, the clock-in and clock-out join the same set of facts. See Medicaid home and community care.

8. Private pay: agreements, rates, invoices and collections

With a family there is no adjudication, so the service agreement does the work of a payer contract. It names the client and the person financially responsible, the services, the schedule, the rates, the minimum shift length, cancellation notice, holiday charges, invoice frequency and due date, and how either side ends the arrangement.

The rate schedule usually varies by discipline and by time (weekday, weekend, night, holiday). Many agencies take a deposit before the first shift and apply it to the final invoice. Invoices go out weekly or every two weeks, listing each shift with its date, hours, caregiver and rate. Families often pay by card or bank transfer on file, so the agency also needs a signed payment authorization, receipts and a clean way to refund.

Collections in private pay are personal, because the person who owes the money is often the relative the scheduler speaks to every day. Agencies that do this well invoice promptly, keep the balance visible and stop extending credit at a threshold the agreement states.

9. Long-term care insurance

The National Association of Insurance Commissioners’ consumer guide describes how long-term care insurance works. Benefits begin when the insured meets the policy’s benefit trigger: most commonly an expected inability to perform two of six activities of daily living (bathing, continence, dressing, eating, toileting and transferring) without assistance for 90 days, or a cognitive impairment. For a tax-qualified policy the insured must be chronically ill in that sense and the care must follow a plan that a licensed health care practitioner prescribes.

Benefits do not start on the first day. The elimination period chosen at purchase, which the guide gives as 20, 30, 60, 90 or 100 days, must pass first, and the family pays during it. Insurers count it in one of two ways: by calendar days on which the trigger is met, or by service days on which paid care is actually received. Under the second method, three paid days a week satisfy the period more slowly than five.

Once benefits begin they are paid up to a daily, weekly or monthly limit, by the expense-incurred method (the lesser of the charge and the limit), by indemnity (a set amount regardless of cost) or by a disability method. The guide notes that a policy may require care from a licensed agency and that most policies do not pay family members. For the agency, the claim means proving its license, supplying the plan of care, and sending invoices and care notes in the form the insurer wants. The family owes what the limit does not cover, so one shift can be split between two payers.

10. Agency licensure

Providing nursing or personal care in the home generally requires a state license for the agency, separate from the licenses of its nurses, and states divide the categories differently. In Texas, for example, the Health and Human Services Commission licenses home and community support services agencies under Health and Safety Code Chapter 142 and rules at Title 26, Chapter 558 of the Texas Administrative Code. The Commission lists the categories a license may carry: personal assistance services, licensed home health services, licensed home health services with a home dialysis designation, and licensed and certified home health services. A state surveyor reads the same shift records and personnel files the agency uses daily.

11. Overtime

Twelve-hour shifts and call-offs make overtime a constant cost risk in private duty. Under the Fair Labor Standards Act a nonexempt employee is paid at least one and one-half times the regular rate for hours over 40 in a workweek. The Department of Labor defines the workweek as a fixed, recurring period of 168 hours and does not permit averaging hours across two or more weeks. Four twelve-hour shifts in one workweek is therefore eight hours of overtime, whatever the following week looks like.

Nurses are not automatically exempt. The Department’s fact sheet on nurses, revised September 2019, says registered nurses may be classified as exempt learned professionals if they are paid on a salary or fee basis of at least $684 per week, that registered nurses paid on an hourly basis should receive overtime pay, and that licensed practical nurses generally do not qualify as exempt and are entitled to overtime. Private duty nurses are almost always paid by the hour.

For aides, federal regulations in effect since January 1, 2015 say third-party employers such as home care agencies may not claim the companionship or live-in exemptions, so under the regulation agency-employed aides are owed minimum wage and overtime. On July 2, 2025 the Department published a proposal to return to its 1975 regulations on this point, and on July 25, 2025 its Wage and Hour Division issued Field Assistance Bulletin 2025-4 suspending its own enforcement of the 2013 rule while that rulemaking is pending. As read on October 11, 2026, the Department’s home care page still presents the change as a proposed rule and the regulation itself remains in the Code of Federal Regulations. State wage laws can be stricter, so the rule in force is a dated fact to check for each state.

What goes wrong when the work is spread across systems

A private duty agency typically has a scheduling tool, paper flow sheets, a payroll service, an accounting package and a spreadsheet of authorizations. The failures happen between them.