OBJECTIVE: To use process and structural measures to evaluate the quality of Private Duty Nursing (PDN) services provided to individuals with complex medical needs in the Rare and Expensive Case Management (REM) program in the state of Maryland. The results will form the basis for recommendations for legislative changes regulating Private Duty Nursing provider agencies.

BACKGROUND: Individuals with defined complex medical needs diagnosed before age 21, may receive skilled nursing level of care at home under the Maryland Medicaid REM program. The REM and similar programs have been shown to be cost effective, providing cost-savings to both state Medicaid programs and private insurance companies as the beneficiaries avoid long stays in short-term and/or long-term care facilities. Unfortunately, the quality of care in the REM program is not consistent. Thus, there is a need to evaluate REM program services to understand the reasons for these inconsistencies and make recommendations for fixes to the State and PDN provider agencies.

TARGET POPULATION: Individuals with complex medical needs receiving REM program services and PDN provider agencies in the state of Maryland.

DATA: Results of audits of client and personnel records of PDN provider agencies performed by the Division of Nursing Services (DONS) in the Maryland Department of Health were reviewed and analyzed.

ANALYTICAL METHOD: This was a mixed-methods study, utilizing both qualitative and quantitative methods for data analyses. A descriptive study method with a retrospective analysis was also employed. Frequencies, percentage scores, and means with confidence intervals were generated in Google Sheets and Stata software. Finally, qualitative content analysis was used to analyze the DONS auditors’ comments, to find themes from key words or phrases.

RESULTS: The study found major deficiencies in the client and employee records. Out of 99 employees and 30 client records from about 13 PDN provider agencies, 100 % of the records had deficiencies of one kind or the other, the most prevalent being discrepancies between the physician orders and the medication administration records.

CONCLUSION: Study findings indicate that improvements to the quality of nursing services to REM program participants can be implemented at provider agencies as well as the executive and legislative levels of state government.