Nursing Footcare Scope of Practice
I am frequently asked if providing foot care is within the nursing practice act. Please remember that I am not an attorney or a government official. This is my personal interpretation of the statutes on this topic. Please check with your local officials or regulators for information.
I am most familiar with the practice act from the State of Washington. My understanding is that most states have similar statutes. If a nurse wishes to provide a service which is not part of her formal nurse training ...
Answer these questions: 1. Was the skill/task taught in your basic nurse program? 2. If a task has become routine in the nursing literature and in nursing practice, it can reasonably and prudently be assumed within scope. 3. Is the task/skill in your hiring agency policy and procedure manual? 4. If it was not included in your basic nursing education, have you since completed a comprehensive training program, which included clinical experience. Has this training been documented in your personnel file? 5. Does carrying out the duty pass the "reasonable and prudent" standard for nursing? 6. Is the action reflective of the consumer's desires and is it appropriately authorized? If you can answer "yes" to all the above questions, the task is within your scope of practice and you do not need to seek an advisory opinion from the commission. So if you have received additional training beyond your basic nursing training, the care procedures are generally permitted. This section of the law does not just relate to foot care, but to any task you may wish to take on that is generally with in limits of normal nursing, but may require extra training. ____________________________________________ Employment vs Independent If you will be performing routine foot care as part of your employment, your employer may have additional requirements for you to fulfill. And they should have policies and procedures in place covering necessary training, competencies, and issues such as infection control. If you are planning to provide this care as an independent practitioner, I definitely recommend that you maintain the same standards. You should have your own policies and procedures in place. Even if it is just in a notebook in your home office. We'll cover many of these issues in a future Newsletter. If you're starting an independent practice, consider a web page as part of your marketing. An excellent example of this is provided by Mary Carraway, RN, CWCN. She's had a successful footcare practice for quite a while. Her website is a great example since it includes information about the care she provides as well as general foot care information and resources for her patients. Check it out at: http://www.footnurseofvirginia.com __________________________________________________________________ Foot Care Certification I also receive questions about certification for foot care. As you know, the WOCN offers a certification examination for foot care. This certification demonstrates that you have obtained the additional experience and training. While it is not technically necessary to have the WOCN certification to comply with the law above, I believe it is an important credential to add to your license. The specific requirements for certification can be found at www.WOCNCB.org. __________________________________________________________________
Nursing Malpractice Insurance Malpractice insurance is definitely necessary if you are practicing on your own. You can obtain that for approximately $100 per year from many sources. One in particular is the Nurse Service Organization at www.NSO.org. Many of the patients we will work with are high risk with multiple comorbidities. While we may only be performing routine care, such as nail and callous trimming, the potential for problems is always present. Please don't ever practice these skills without appropriate malpractice coverage in place. It is affordable and absolutely necessary. __________________________________________________________________ Reimbursement
Reimbursement for "routine foot care" Is a complicated topic. If you are a physician or an advanced practice nurse, you must bill this to Medicare. There are "Advance Beneficiary Notice of Noncoverage" forms that must be filled out by the patient if you are billing to Medicare. This advises them that while it is being billed to Medicare, that it most likely will not be a covered service. This is a required form by Medicare and is form number CMS-R-131. If you are not an advanced practice nurse and you are performing these services on your own (outside of the clinic) you cannot bill it to Medicare. That is actually a good thing since it is much less complicated that way. You are free to collect cash for the services provided. The common rates that I have seen charged in community practices range from $25 in senior centers to $65 in a person's private home. Some nurses charge more on initial visit and less after that. There are many strategies for pricing. None of them are fixed or recommended anywhere. You are free to set your own reimbursement rates when you are performing the services privately as a nurse. If you are working independently, I strongly recommend that you get an informed consent from the patients stating that they acknowledge that the fees for this service will not be billed to Medicare and that they cannot send it in for reimbursement after they pay you. There are several private forms that serve this function. I am in the process of posting this on the website. I will let you know when it is up there for your use. _________________________________________________________________ Places of Service If you are performing foot care services out in the community, there are a number of possible locations for you to try to work in. One of the most common is senior centers. It is very common for senior centers to have a nurse in on a monthly basis to perform routine foot care. This is nice because all the patients come to you. But typically you can only charge $25 per patient.
Another venue are "family group homes". They are also called "adult family homes". These are private homes that can house up to six people. The residents can range from developmentally disabled adults to senior citizens. It is often an option to a retirement home or other institutional setting. This can be a nice option because there are as many as six patients in one home. That again maximizes the number of patients you can see in a given time period. The rate I have generally seen in that environment is $45 per patient.
Some nurses are going out to patient's homes individually. This is certainly very time-consuming and it is difficult if you are trying to enhance your income with the practice. A typical charge for a home visit to a single person is $65. Although as I said, this is totally your choice. I know nurses who have charged time and travel charges as well as the visit charge if they have to go some distance to see the patient. I think this is perfectly appropriate since you are providing a service which is difficult if not impossible for the patient to receive any other way. I don't mean for a moment that we will take advantage of anyone. But remember that you have paid for your training and experience and you provide a high level of medical care for them. I think this is an appropriate charge for profesional care.
You probably won't get very far approaching long-term care or skilled nursing facilities. Most of those have podiatrists on staff who go out monthly to provide care. They will not want to share the patient load with you. But another type of facility, a rehab center, would be a good place to try. These are facilities that typically do not have podiatrists on staff but still need to provide the care. They have long-term residents who are weaning from vents and similar rehab services. In a situation like that, you can bill the facility directly for the patients you see. A common charge there would be $45 per patient. You would see the patients that they indicate and send them one bill for the entire day's work. That's a very clean way to go.
Sometimes approaching podiatrists in your area is a good idea. You will find that some of them are not open to a nurse performing the services at all. On the other hand, many do not wish to perform the services themselves and would be just as glad to have someone competent to refer their patients to for that care. You may even consider the possibility of renting a treatment room from them once a week or so, so that you can provide care there. This would be excellent since it would be an automatic referral of patients to you and you would have an instant ability to refer patients back to the podiatrist with any problems that you find. Additionally, it is certainly better to perform this work with the proper treatment chair and other facilities rather than sitting on the floor or on a folding chair. (As is often the case in senior centers and other venues.)
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Final Thoughts Well, I think I've probably worn you out for this newsletter. I've thrown a lot of information at you which mostly will help those of you planning to perform this service on your own. In the next newsletter, I'll cover some of the protocols and useful forms that you need to provide a professional medical service in foot care. So watch for the next newsletter. Until then, Take care and keep clipping! Dr. Julia Happy New Year!!
Dr. Julia Overstreet, DPM, FAPWCA
Podiatric Physician & Surgeon
Wound Care Specialist
High Risk Foot Care Specialist
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